Management of Leptospirosis Outbreaks. Irmingarda P. Gueco, MD, FPCP, FPSN, MBA

Management of Leptospirosis Outbreaks Irmingarda P. Gueco, MD, FPCP, FPSN, MBA

Objective : To discuss the handling of Leptospirosis outbreaks with specific reference to Philippine experience.

Outline : a. Definition of Epidemic b. Leptospirosis c. Philippine Experience d. Summary and Conclusion

Epidemic : The occurrence in a community or area of cases of a disease that are clearly in excess of what is expected. Lucas, A. (1989). Manual of Epidemiology for District Health Management. In Controlling of Epidemic (p. 202). WHO

Cases of Leptospirosis 6000 5000 4000 3000 2000 1000 0 2007 2008 2009 2010 2011 Philippine DOH Data

Review routine information, surveillance, clinical cases, community information and reports Investigation Information regarding possible epidemic Criteria for establishing presence of an epidemic Is there an epidemic Check records and seasonal incidence Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence Lucas, A. (1989). Manual of Epidemiology for District Health Management. In Controlling of Epidemic (p. 202). WHO

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Review routine information, surveillance, clinical cases, Criteria for establishing Check records presence community of an epidemic information seasonal incidence and reports Is there an epidemic Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Is there an epidemic Information regarding possible Check records and seasonal incidence epidemic Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Confirm diagnosis Criteria for establishing presence of an epidemic Is there an epidemic Isolate and Treat cases Criteria Check records for and seasonal incidence establishing presence of an epidemic Disease control Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Check records and Criteria for establishing seasonal presence incidence of an epidemic Check records and seasonal incidence Investigation Is there an epidemic Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Confirm diagnosis Criteria for establishing presence of an epidemic Is there an Is there an epidemic epidemic? Isolate and Treat cases Check records and seasonal incidence Disease control Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Check records and seasonal incidence Investigation Confirm diagnosis Is there an epidemic Investigation Isolate and Treat cases Disease control Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Is there an epidemic Check records and seasonal incidence Disease control Confirm diagnosis Conduct case finding Isolate and Treat cases Confirm diagnosis Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Is there an epidemic Check records and seasonal incidence Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Attack source and transmission Conduct case finding Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Is there an epidemic Check records and seasonal incidence Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Trace contacts Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Is there an epidemic Check records and seasonal incidence Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Institute prevention Conduct environmental assessment Process and analyse data Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Disease control Is there an epidemic Check records and seasonal incidence Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Check records and seasonal incidence Investigation Isolate and Treat cases Confirm diagnosis Is there an epidemic Isolate and Treat cases Disease control Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Check records and seasonal incidence Investigation Confirm diagnosis Attack source and transmission Conduct case finding Is there an epidemic Isolate and Treat cases Attack source and transmission Disease control Trace contacts Conduct environmental assessment Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Is there an epidemic Check records and seasonal incidence Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Trace contacts Conduct environmental assessment Institute prevention Compile information concerning epidemic Process and analyse data Attack source and transmission Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Is there an epidemic Check records and seasonal incidence Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Continue surveillance Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Check records and seasonal incidence Investigation Confirm diagnosis Conduct case finding Trace contacts Conduct environmental assessment Compile information concerning epidemic Is there an epidemic Compile information concerning epidemic Process and analyse data Isolate and Treat cases Attack source and transmission Institute prevention Disease control Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Is there an epidemic Check records and seasonal incidence Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Process and analyse data Compile information concerning epidemic Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Is there an epidemic Check records and seasonal incidence Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Communicate findings Process and analyse data Institute prevention Continue surveillance Communicate findings Institute health plans to prevent recurrence

Investigation Review routine information, surveillance, clinical cases, community information and reports Information regarding possible epidemic Criteria for establishing presence of an epidemic Is there an epidemic Check records and seasonal incidence Disease control Confirm diagnosis Isolate and Treat cases Conduct case finding Attack source and transmission Trace contacts Conduct environmental assessment Compile information concerning epidemic Institute health plans to prevent recurrence Process and analyse data Communicate findings Institute prevention Continue surveillance Institute health plans to prevent recurrence

Epidemic management will differ depending on : Type of illness / condition Rapidity that it develops Case fatality rates Locality that it happened Available technology More

Outline : a. Definition of Epidemic b. Leptospirosis c. Philippine Experience d. Summary and Conclusion

Leptospirosis Zoonotic disease Epidemics often occur during seasonal heavy rainfall and flooding; and are associated with extreme weather events

The transmission cycle of leptospirosis Ko AI. et al. (2009). Ko AI, Goarant C, Picardeau M. Leptospira: the dawn of the molecular genetics era for an emerging zoonotic pathogen. Nature Reviews Microbiology, 7, 736 747. doi:10.1038/nrmicro2208.

Leptospirosis is clinically defined as an illness with : Fever Headache Myalgia Report of the First Meeting of the Leptospirosis Burden Epidemiology Reference Group. (2010). WHO.

Leptospirosis May cause : Meningitis Uveitis Myocarditis Bleeding (pulmonary hge syndrome) Jaundice Acute Kidney Injury Report of the First Meeting of the Leptospirosis Burden Epidemiology Reference Group. (2010). WHO.

Working disease model for leptospirosis Susceptible Acute Febrile Illness Acute Kidney Injury Acute Lung Injury Death Report of the First Meeting of the Leptospirosis Burden Epidemiology Reference Group. (2010). WHO p. 14

Outline : a. Definition of Epidemic b. Leptospirosis c. Philippine Experience d. Summary and Conclusion

September 25 27, 2009 Typhoon Ondoy (Ketsana)

Leptospirosis Data 2500 2000 1500 1000 500 0 Oct 09 16 19 23 25 28 30 Cases 1,073 1,231 1,461 1,463 1,627 2,025 Collated by the Philippine Society of Nephrology

Collaborative efforts : Philippine Society for Microbiology and Infectious Disease (PSMID) Philippine Society of Nephrology (PSN) Philippine College of Chest Physicians (PCCP)

Collaborative efforts PSMID - Diagnosis and Antibiotics PSN - Fluids, Management of Acute Kidney Injury PCCP - Management of Pulmonary Hemorrhage / Adult Respiratory Distress Syndrome

Predictors of Mortality in Leptospirosis 40 years or older Oliguria Creatinine > 3 mg / dl Hyperkalemia Metabolic Acidosis Hypotension * Visith S. et al, J Postgrad Med 2005; 51: 184 188. * Tantitanawat S. et al, J Med Assoc Thai 2003; 86: 925 931. * Dupont H. et al: Clin Infect Dis 1997; 25: 720 724. *Panaphut T. et al, Thailand. Int J Infect Dis 2002; 6: 52 59. *Brady HR. et al, Acute renal failure; in: Brenner & Rector s The Kidney, ed 7. London, Elsevier, 2004, pp 1215 1292. Spichler AS. et al, Am J Trop Med Hyg.: 79 (6): 911-914; December 2008

Predictors of Mortality Cardiac Abnormalities Respiratory Insufficiency Thrombocytopenia Hyperbilirubinemia Pulmonary Involvement * Visith S. et al, J Postgrad Med 2005; 51: 184 188. * Tantitanawat S. et al, J Med Assoc Thai 2003; 86: 925 931. * Dupont H. et al: Clin Infect Dis 1997; 25: 720 724. *Panaphut T. et al, Thailand. Int J Infect Dis 2002; 6: 52 59. *Brady HR. et al, Acute renal failure; in: Brenner & Rector s The Kidney, ed 7. London, Elsevier, 2004, pp 1215 1292. Spichler AS. et al, Am J Trop Med Hyg.: 79 (6): 911-914; December 2008

Guidelines for the management of leptospirosis But

The guidelines were shared with implementors : Department of Health Philippine Medical Association Philippine Hospital Association Philippine College of Physicians Philippine Academy of Family Physicians Frontline doctors

Vehicles : Short Message Service (SMS) E-mail Newspapers Media

As a result, the Department of Health : Gave out free Doxycycline to individuals in high risk areas Financed dialysis in some private hospitals

Leptospirosis wards : Advantages : Concentration of expertise Shorten learning curve Sharing of resources

Case Fatality Rate : 6 % 6000 5000 4000 3000 2000 1000 0 2007 2008 2009 Cases Deaths

Predictors of Mortality (Phil experience) Jaundice Platelet Count <100,000 ph <7.2 SCrea >3 mg/dl K > 5 meq/dl Na < 135 meq/dl ARDS/Pulm Hge Weil Syndrome PSN Leptospirosis Study Group

Subsequent occurrence of super typhoons with potential leptospirosis outbreak, the following steps are undertaken : The public is sensitize and made aware of the possibility of the outbreak through media i.e., radio and television. The different specialty societies concerned with implementation of guidelines are galvanized into action through a meeting.

Subsequent occurrence of super typhoons Information campaign to appropriate frontline doctors: SMS Distribution of booklets Additional concerns were monitored.

Some hospitals crafted leptospirosis management protocols (administrative and technical) for outbreaks. For influx of > 10 leptospirosis cases in 12 hours, a special ward will be created. Processes and procedures are put in in place to address the influx.

Cases of Leptospirosis 6000 5000 4000 3000 2000 1000 0 Cases Deaths 2007 2008 2009 2010 2011 CFR 6.3 5.0 6.0 6.6 6.1 Philippine DOH Data

Lessons Learned Importance of : a. Collaboration among specialty societies b. Creation of guidelines that are properly situated in the area of occurrence c. Application of up-to-date technology in the context of the locality d. Coordination with implementing societies / units

Importance of e. Creation of opportunities for optimum implementation of guidelines f. Responsive and dynamic systems g. Timely intervention h. Private and government sector role in outbreaks

Outline : a. Definition of Epidemic b. Leptospirosis c. Philippine Experience d. Summary and Conclusion

Conclusion : Outbreaks of leptospirosis can be truly a disease burden. While we cannot control the environment and its natural disasters, leptospirosis epidemic usually presents with a triggering event.

Conclusion With concerted efforts and appropriate strategic moves we can perhaps keep the case fatality rate at the non-epidemic level.