Flooding along the East coast of Guyana has resulted in an increase in reported human cases of leptospirosis. This is being reported widely. A statement issued by the Guyana Medical Association on 04 Feb 2005 has caused concern for residents and the aid community, and the LIC has issued this statement in response to the current situation.
The Ministry of Health of the Cooperative Republic of Guyana has begun prophylactic treatment of all those exposed to flood waters and has indicated a possible need to evacuate certain areas due to the risk of waterborne infections including leptospirosis. This has led to some panic and concern as to the causes, symptoms and spread of the disease. All cases of flooding will lead to an increased risk of human leptospirosis, especially those where the areas affected include dwellings and farmland, and where the water remains present for several days. This is also the case with other waterborne diseases and pathogens. We at the LIC consider the infection rates reported for Guyana to be expected given the level of flooding and population styles, and although precautions will be required to address the outbreak, this is not an epidemic and the infection is not out of control. At the time of issue of this statement, seven fatalities have been attributed to leptospirosis. The serovar of infection is as yet unknown, however CDC Atlanta is analysing samples.
The LIC supports the decision by Guyanan authorites to issue doxycycline to those exposed to floodwater and wishes to make the following points clear to those in the affected areas:
- The dose of 200mg per week of doxycycline issued by the authorities is sufficient and should not be exceeded. Increased doses will not offer significant additional protection and may result in adverse reactions.
- Each 200mg capsule provides a medical effect for up to 7 days. Should the flood waters persist, further weekly doses will be issued. There is NO shortage of medication.
- The medication is being issued to all those over eight years of age. It should NOT be given to young infants or pregnant mothers, both of whom should be given different treatment directly by the medical staff on scene.
- The incidence of infection is very low, and the medicine is being issued as a preventative and protective measure, but it is not a vaccine, and does not make the user immune to infection. It will however minimise the probability of serious illness developing. Taking doxycycline does not make the user able to ignore basic hygiene and health precautions as described below.
- There is no human vaccine for leptospirosis available for use in Guyana.
- The infection is expected to subside within 21 days of the waters receding.
- Human to human transfer is extremely rare
Risks of infection
For all those living and working in the flooded areas, the information on our website gives a complete list of risks and infection routes, which we summarise here:
- The infection is caused by swallowing the bacteria directly from water, absorbing it through cuts in the skin, or via food. IT IS NOT AIRBORNE and cannot be passed by normal human contact.
- The bacteria lives in freshwater and is killed instantly by heat, disinfectants, acids and alkalis. Normally cooked food and boiled water will be safe. It is also killed by being dried out, which is why floods increase the infection rates even when the bacteria is normally present in an area.
- The bacteria originates in rats, and is spread by the urine of rats entering water, or food stores. It can cause illness in humans, dogs, cats and all large mammals but it is rare for them to pass the illness directly from animal to animal (or from human to human)
- Anyone working in flood water should protect any broken skin with a waterproof dressing, and should ensure they do not allow water to enter their mouth (via the hands, or via food or clothing)
- Doxycycline offers some protection against severe illness and is the best and normal medication to be given in these situations, but it cannot guarantee protection and a mild illness may still occur.
- All food and drinking water should be protected against contamination. Fresh vegetables and fruit should be washed in CLEAN water and then cooked or peeled. The bacteria will only contaminate the outside of food items, and animals infected with the bacteria will be safe to eat if thoroughly cooked.
Symptoms and signs
The early signs of infection occur between 4 and 10 days after exposure, and usually begin with a fever, a red skin rash and a general influenza-like feeling. Headaches, reaction to light, muscle and joint pains, vomiting and fatigue are also common. Most cases recover after a mild illness of a few days, but some progress into a severe illness over 5-7 days. The patient gradually becomes more fatigued and will report headaches, fevers, generalised pain, bruising of the skin, bleeding from the nose, eye pain and gastrointestinal discomfort. In some but not all cases, the liver is affected and the patient shows jaundice (yellow skin pigment). Very similar early symptoms can be caused by a number of other waterborne diseases, and the usual diagnostic method is isolation of the bacteria from blood samples.
The treatment for infection is by antibiotic therapy (doxycycline and others) and management of the symptoms of each case as they appear. A low dose of doxycycline can act to reduce the chance of severe illness but there is no generally-accepted human vaccine and previous exposure cannot guarantee immunity, due to the large number of bacterial strains involved.
Full text of the GPHC Statement
Here is the text of the Minister’s statement:
“Since the flood started the Ministry of Heath’s surveillance system has been tracking a number of clinical conditions and diseases that are associated with flood conditions. These include, but are not limited to, the following:
- Fever (>100F or 38C)
- Fever, vomiting and abdominal pain
- Cold
- Fever and Cough
- Water diarrhoea/bloody diarrhoea
- Conjuntivitis (pink eye)
- Rash
- Fungal Infection
- Injuries – mild, moderate and severe
- Bites – dog, snakes, caiman, rats
- Burns
- STIS
- Hepatitis A
- Leptospirosis
- Dengue
Because the surveillance system worked well and medical teams have been in all the communities since the first day, the health sector has been able to reduce morbidity and mortality associated with these conditions.
All persons with certain conditions are automatically referred to the Georgetown Public Hospital Corporation (GPHC) or to private hospitals (if they choose that option). The Ministry of Health is monitoring all patients admitted to hospitals from flooded areas to determine the exact cause of their ailments. Special surveillance and laboratory staff are working with the GPHC so as to have effective laboratory support.The GPHC has been tasked with following up with private hospitals to include persons from the private sector in the surveillance net.
In addition, we are following up on all mortalities of persons from flooded areas to determine if any of the deaths are due to any of the above conditions. There have been reports of deaths due to Leptospirosis in the hospitals. Several persons have been treated for Leptospirosis, based on a high suspicion index for Leptospirosis due to the flooded conditions and based on clinical presentation (since the symptoms of Leptospirosis were present). But the symptoms present in these persons are also consistent with other disease conditions. Confirmatory tests are being done in order to obtain differential diagnosis. These confirmatory tests are to be done at CAREC and CDC (Atlanta).Leptospirosis was one of the serious conditions we had anticipated. We had maintained from the first day a high suspicion index for Leptospirosis.
It is for this reason that a prophylactic treatment programme was included as part of the package of services we would provide to the population of the affected area.This treatment programme was intended to begin today.
The prophylactic treatment was based on the presumption that Leptospirosis was part of the expected clinical conditions associated with flooding. It included providing a single treatment with 200 mg doxycycline to all persons above eight years old. This treatment has a prophylactic efficacy for one week. Should the flood waters persist beyond one week from this date, the Ministry of Health will continue to administer doxycycline on a weekly cycle.
This prophylactic treatment is not to be used by pregnant women and children under eight years old. Pregnant women and children under eight years old are to be treated by medical personnel. This prophylactic programme would assist us in reducing the impact of any possible outbreak of Leptospirosis. Similar surveillance work is being done with other diseases, but no indication of any unusual and unexpected outbreak has presented itself.
The Ministry of Health’s surveillance team is keeping a 24-hour watch on the health situation and the Ministry of Health is prepared to act aggressively in order to minimise the effects of any disease outbreak. PAHO/WHO has been working with the Ministry of Health in this respect from the first day. The surveillance team has been strengthened this week with support from the CDC (US) and CAREC/PAHO/WHO and epidemiologists from the Cuban Medical Brigade. The Ministry of Health commends the dedicated work of all the health workers from the public sector and the private sector and all the volunteers who have ensured that any adverse health effect resulting from the flood would be minimised.
We acknowledge the outstanding work being done by the hundreds of health care volunteers.”