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LEPTOSPIROSIS - PHILIPPINES (05)
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[1]
Date: Mon 26 Oct 2009
Source: INQUIRER.net [edited]
<http://newsinfo.inquirer.net/breakingnews/metro/view/20091026-232379/Leptospirosis-deaths-climb-to-167--DoH>
Leptospirosis deaths climb to 167: DoH
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Almost a month after storm Ondoy flooded Manila and Rizal, about 167
Filipinos have died from leptospirosis, a health official said Monday
[26 Oct 2009].
The country's total number of leptospirosis cases related to the
Ondoy floods alone hit 2158 with 167 recorded deaths -- a 3-fold
increase from last year's [2008] total cases of 769, said Dr Lyndon
Lee Suy, program manager for emerging and re-emerging infectious
diseases division of the Department of Health (DoH).
From 177 leptospirosis cases reported between 1 and 12 Oct 2009, the
department's tally rose to 1000 cases on 15 Oct and leaped to 1963 on
21 Oct 2009.
Lee Suy said the number of cases will continue to rise over the next
weeks but not in the hundreds as seen in previous weeks after the
floods have subsided in Metro Manila Manila and Rizal province.
"We project that the number of leptospirosis cases will continue to
rise but not as high as before where we report a rise of 400 cases
per day immediately after storm Ondoy. After the floods have
subsided, the risk of exposure to the bacteria was drastically
reduced, too," said Lee Suy.
Presently, DoH has not declared that the disease was contained in
flood-hit areas like Marikina although it was moving toward
containment after the increase in cases as reported daily have
dropped from 400 or 500 to below 100, he added.
Lee Suy warned Filipinos, even those who have been cured of
leptospirosis not to wade in murky flood waters because they are not
immune from the leptospirosis bacteria.
"Exposure to the bacteria previously is not a guarantee that a person
will not get infected again. Even if you have been cured of the
disease, you are not immune and you are at risk to get infected again
once you get exposed to the bacteria in floods or from contaminated
water or food," he said.
"But we are not saying that those exposed to the bacteria are doomed
to die. Once you have flu-like symptoms and have recently waded in
floods, consult a doctor immediately," said Lee Suy.
Common symptoms [are] flu-like and include fever, red skin rash,
general weakness, headaches, muscle and joint pains, vomiting, and
fatigue, he added.
Leptospirosis is caused by swallowing the bacteria directly from
water, absorbing them through cuts in the skin, or through food.
Although the disease is commonly associated with rat urine, infection
can also come from animals like cattle, pigs, horses, dogs and wild
animals, said Lee Suy [see commentary below].
[Byline: Anna Valmero]
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[2]
Date: Mon 26 Oct 2009
Source: Time [abridged & edited]
<http://www.time.com/time/printout/0,8816,1932199,00.html>
A month after the floods, Manila battles 'rat fever'
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[The man] swerves his tricycle taxi to a stop just before the
floodwater, lapping over a speed bump in the road. He knows the
mud-colored water could be contaminated with a potentially deadly
rat-borne disease that is still threatening communities in and around
Manila a month after tropical storm Ketsana hit the Philippines'
capital. "I saw the warnings on TV," says the lanky 19-year-old,
watching pedestrians wade through the knee-high water covering part
of a road in the capital's Pasig district, one of the worst flood-hit
areas.
Nearly 860 people were killed in flooding and landslides after
Ketsana and typhoon Parma tore into Luzon, the country's largest
island, in late September and early October [2009]. 4 weeks later,
sections of the city and some surrounding provinces are still
underwater, and state-run hospitals have been overwhelmed by an
outbreak of leptospirosis, a bacterial disease spread from the urine
of infected rats and other animals. (In Sri Lanka, where there was a
large outbreak in 2008, leptospirosis is known as "rat fever.") The
bacterium is transmitted by the standing floodwater through cuts in
the skin and by people swallowing contaminated water. This month's
leptospirosis outbreak -- the worst by far that doctors [in Manila]
can remember -- has swollen the disaster's death toll, claiming 157
victims from mostly poor communities [for updated figures see article
1 above].
National health authorities have been trying to contain the unusually
virulent outbreak of the common disease since the 1st cases appeared
around a week after the storm. They are distributing antibiotics to
some 1.3 million people living in still-flooded areas in the capital
and 2 nearby provinces. But last week [week of 19 Oct 2009], the
country's top epidemiologist sent out an "SOS" to the global health
authorities. A medical mission from the World Health Organisation's
(WHO) Global Outbreak Alert and Response Network was set to arrive in
Manila today [26 Oct 2009] and Tuesday. WHO officials in Manila said
the 4-person team will comprise 2 epidemiologists and an expert each
in clinical management and leptospirosis.
Part of its task will be to evaluate the government's response in
tackling the disease, and draw up recommendations for future
large-scale leptospirosis outbreaks, said Eric Tayag, head of the
Department of Health's National Epidemiology Center. "They will also
be looking at why there have been such high mortality rates" in the
current outbreak, he said. Between 5 and 10 percent of the cases in
this outbreak have been resulted in death -- the highest level of
mortality for leptospirosis by WHO's measures.
The Philippines overstretched and underfunded public health system is
poorly equipped to deal with large-scale disease outbreaks, even for
diseases like leptospirosis that are seasonally common across the
archipelago. Several large government hospitals were damaged in the
flooding, and have struggled to cope with the influx of patients. A
week after Ketsana, much of Pasig General Hospital was under water,
including its laboratory. According to reports, staff initially only
had dextrose to give flood victims seeking medical attention. In
flood-ravaged Marikina, one of 16 cities that make up Metropolitan
Manila, only 4 out of 21 public health facilities were in operation
as of 24 Oct 2009. San Lazaro Hospital, the main government hospital
specializing in infectious diseases, has treated 451 leptospirosis
cases since the storm hit on 26 Sep 2009 -- nearly double the number
of cases in the span of just a month than for the whole last year
[2008]. "We expected cases to rise because of the unusually heavy
flooding, but we were not prepared for the numbers and we eventually
ran out of testing kits," said Eumelia Salva, head of San Lazaro's
public health services.
Ketsana dropped more rainfall on greater Manila's 14 million
residents in a 9-hour deluge than in an average month of the
country's rainy season from July to November. At the height of the
storm, 80 percent of the capital was underwater. The rainfall was
exceptional, but the severity of the flooding was intensified by the
city's garbage-clogged drainage system, partly from the shanties of
informal settlers living along waterways and decades of skewed urban
planning.
Authorities quickly issued health warnings about waterborne diseases
after the storm. For leptospirosis, people were told to cover cuts
and abrasions with waterproof bandages, and thoroughly wash after
wading in floodwater. Early symptoms of the disease include fever,
rash, vomiting and jaundice; renal failure, hemorrhaging, and liver
disease are among its life-threatening complications. An average of
680 leptospirosis cases and 40 deaths from the disease are reported
every year in the Philippines. And while its incidence is far higher
in tropical than temperate regions, global surveillance of the
disease is generally poor, said Adam Craig of WHO's Western Pacific
regional office in Manila.
The worst of the outbreak, it appears, is over. Since its peak around
mid-October [2009], the number of confirmed cases has steadily
declined, a likely reflection of its incubation period and the
receding floodwater. But with some areas expected to remain
underwater for months due to still flood-swollen rivers and
waterways, "the potential for more outbreaks is still there," warns
Tayag. Last week [week of 19 Oct 2009] the Philippine health
authorities began distributing the antibiotic doxycycline in flooded
communities, a procedure recommended by the WHO. Plans are now being
readied for a large-scale spraying of saltwater into still-flooded
areas to kill the leptospirosis bacterium, which only lives in
freshwater. The timing to ask for help from the global health
authorities -- as well as other decisions such as the distributing of
antibiotics and the saltwater spraying -- were "judgment" calls, says
Tayag.
But for those living in flooded areas, the specter of swarms of rats
on the loose after being flushed from their lairs by storm waters is
obviously still alarming. "We told our children not to go in the
water and we check them every day for cuts," said a 45 year-old
father of 5 and a member of the security detail of Pasig's mayor.
"The people here now know about leptospirosis, but many have no money
to buy protective clothing like rubber boots, but we're taking no
chances."
[Byline: Alastair McIndoe]
--
Communicated by:
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[Both items mention that leptospirosis can also come from other
animals like cattle, pigs, horses, dogs, and wild animals. Most
likely, and in line with the media-derived reports, the bacteria were
secreted by rats, the species traditionally known as related to
flooding situations. Identification of the serogroup/serovar involved
in the current Philippines epidemic will enable the confirmation of
the animal source.
All mammals appear to be susceptible to at least one species of
_Leptospira_. Disease is rare in cats, and less common in sheep than
cattle. The primary reservoir hosts for most _Leptospira_ serovars
are wild mammals, particularly rodents. Reservoir hosts among
domestic animals include cattle, pigs, sheep, and dogs.
The specific reservoir host(s) vary with the serovar and the
geographic region. Disease in reservoir hosts is more likely to be
asymptomatic, mild, or chronic. Reservoir hosts include:
- rats: serogroups _icterohaemorrhagiae_ and _ballum_
- mice: serogroup _ballum_
- cattle: serovars _hardjo_, _grippotyphosa_, and _pomona_
- sheep: serovars _hardjo_ and _pomona_
- pigs: serovars _pomona_, _tarassovi_, and _bratislava_
- dogs: serovars _canicola_ and _bataviae_.
According to the following information from Gideon (Global Infectious
Disease & Epidemiology Network -- <http://www.GideonOnline.com>),
kindly abstracted and provided by Dr Steve Berger (Geographic
Medicine, Tel Aviv Medical Center, <mberger@post.tau.ac.il>), the
largest past leptospirosis outbreak on record is the 2008 Sri Lanka
outbreak (4500 cases, 1150 fatal), followed by Kazakhstan 1998 (2000,
7), Nicaragua 1995 (2419, 48), and Brazil 1996 (1425, 22). This puts
the current outbreak as 2nd on record.
A noteworthy event was recorded in Japan in 2005, when 2 human cases
were ascribed to contact with squirrels that had been imported from
the United States (see
<http://origin.cdc.gov/ncidod/EID/vol12no07/06-0370.htm>). The
causative agent was identified as _L. kirschneri_ serovar
_grippotyphosa_. - Mod.AS]
[The chronic problems that Metro Manila has had with its public
health infrastructure mentioned in the above news reports (e.g.,
garbage disposal, sanitation, rat infestation) and the devastation
that has occurred to some of Metro Manila's medical facilities after
the 2 recent typhoons that hit Luzon is astounding. The destruction
of hospital facilities by flooding is reminiscent of the destruction
of hospitals in New Orleans after hurricane Katrina. The situation in
New Orleans though was flooding with salty seawater, an unlikely
environment for survival of leptospira, whereas flooding in Metro
Manila is with freshwater. To prevent future outbreaks of
leptospirosis and other water-borne diseases, Manila will have solve
its chronic problems with public health infrastructure. - Mod.ML]
[see also:
Leptospirosis - Philippines (04) 20091023.3643
Leptospirosis - Philippines (03) 20091019.3591
Leptospirosis - Philippines (02): background 20091018.3579
Leptospirosis - Philippines: (MM,RI) 20091016.3561
Leptospirosis - India (02) 20090404.1296
Leptospirosis - India: (north), 2007 20090403.1292
Leptospirosis - Fiji (03) 20090225.0772
Leptospirosis - Fiji (02) 20090207.0554
Leptospirosis - Fiji 20090204.0502
2008
----
Leptospirosis - Guyana (coastal) 20081231.4131
Leptospirosis - Sri Lanka (07): (NW) 20081231.4127
Leptospirosis, fatal - UK (02) 20081010.3210
Leptospirosis, fatal - UK: rodent scratch 20081007.3173
Leptospirosis, sea mammals - USA: (CA) 20081003.3125
Leptospirosis - Sri Lanka (06) 20080927.3058
Leptospirosis - Sri Lanka (05) 20080922.2984
Leptospirosis - Sri Lanka (04) 20080909.2810
Leptospirosis - Philippines: (Davao Region) 20080626.1967
Leptospirosis - Sri Lanka (03): background 20080610.1836
Leptospirosis - Sri Lanka (02): hantavirus also susp. 20080606.1808
Leptospirosis - Sri Lanka: RFI 20080605.1801
Leptospirosis - New Caledonia (02): background 20080408.1291
Leptospirosis - New Caledonia 20080407.1281
Leptospirosis - Peru: (Loreto), new species 20080407.1279
Leptospirosis - Jamaica 20080125.0312
2007
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Leptospirosis - Dominican Republic 20071124.3804
Leptospirosis - Jamaica (02) 20071018.3409
Leptospirosis - Ukraine (Lvov, Kiev, Kherson) 20071018.3401
Leptospirosis - Jamaica 20071016.3383
Leptospirosis, fatal - Sri Lanka (Matara) 20070914.3051
Leptospirosis - China (Hong Kong) 20070821.2725
Leptospirosis - Argentina (Santa Fe) 20070429.1395
2006
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Leptospirosis - India (Gujarat): not hantavirus 20060831.2476
Leptospirosis - India (Kerala) 20060609.1612
Leptospirosis - India (Karnataka) 20060123.0226]
...................................arn/mj/lm
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