“scenario of leptospirosis in gujarat public health scenario of leptospirosis in gujarat &...
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““Scenario of Leptospirosis in Gujarat Scenario of Leptospirosis in Gujarat &&
Public Health InterventionsPublic Health Interventions””
DR.S.J.GANDHIDeputy Director (Epidemic)
Commissionerate of Health,Gandhinagar,Gujarat.
INTRODUCTION
• Leptospirosis is a contemporary zoonosis affecting all warm and cold blooded vertebrates.
• It prevailed through out the world however their distribution is concentrated in tropical and sub tropical countries where the soil pH and moistureare favourable for their survival .
• It produces acute, sub acute and chronic infections especially in livestock's with varied manifestations.
• Leptospirosis is an economically important disease especially in livestock industry due to the mortality, reduction in milk yield, abortion, repeat breeding and infertility.
INTRODUCTION Contd...• In Human beings most of the infections go mildly as
influenza like symptoms and only virulent strains are capable of producing severe illness with icterus and hemorrhagic signs.
• The domestic animals may act as carrier and disseminator to their own species and also to other species of animals and man.
• Rodents plays important role in the continuous maintenance of Leptospira and disseminate them in the surroundings.
• It is an occupational disease in man who acquires the infection by virtue of his association with the work related to animal industries.
MODE OF TRANSMISSION• Leptospira enters the body through intact
mucous membranes and abraded skin.• Conjunctival, oral and nasal mucous
membranes are the major routes of entry in susceptible hosts through food, inhalation or contact with infected water and other materials.
• Direct contact may occur when handling infected animals or their tissues after slaughter or death and the mopping of urine during husbandry practices.
Spectrum of Leptospirosis
Anicteric Leptospirosis
90%
Icteric Leptospirosis
10%
• Clinical Types---1 Anicteric Leptospirosis--- 90%2 Icteric Leptospirosis --- 10%
Clinical types of LeptospirosisAnicteric Leptospirosis• It is the milder form of the
diseases• Patients have
fever,Myelgia but do not have Jaundice
• Almost 90% of patients have this type of illness.
Icteric Leptospirosis• It is the severer form of
the diseases• Almost 5-10% of patients
have these type of manifestations.
• It is characterized by jaundice.
• It may or may not be associated with involvement of other organs.
Clinical profileFever, Headache, Myalgia, Conjunctival suffusion, Jaundice,
Renal failure, Acute respiratory distress, Meningism, Cardiac disturbances
16.8 %26.8 %
38.7%
67%
0
10
20
30
40
50
60
70
Percentage of Patients
1999 2002 2007 2008
Year
LUNG HAEMORHAGE
35
26
31
0
5
10
15
20
25
30
35
Percentage of Patients
2005 2006 2007 2008
Year
No. of Dialysis Performed
Change Is Global
• India• Andaman
• 1931 First case of leptospirosis • 1994 First case of lung involvement
detected• 1997 28 out of 58(48%)
? Immune Pathogenesis Of Hemorrhage
• Two phases of the disease.septicemic and immune
• Infectious vasculitis
• Majority of other lung haemorrhages are of immune origin
Standard Treatment Protocol
• Antibiotics• Mechanical ventilation with PEEP• Correction of thrombocytopenia
Year wise Scenario of Leptospirosis in,2006& 2007, & Up to 30/8/08in Gujarat
No of Affected Taluka
No.of Affected PHCS No. of Affected Villages
2006 2007 2008 2006 2007 2008 2006 2007
37 92
Tapi - - 3 - - 14 - - 36
74
33
-
-
5
202
152
105
61
3
6
6
329
32
16
0
0
1
86
48
34
23
3
0
0
107
2008
Surat 11 11 7 27 79
Navsari 5
5
0
0
1
22
5 29 59
Valsad
5
5
2
1
2
5 24 36
Bharuch 0 0 0
SMC 0 0 5
Other 1 2 2
TOTAL 26 21 96 217
AffectedDistricts/
Years
YEAR DISTRICT1 2 3 4 >5
2003 SURAT 34 11 8 2 3NAVSARI 61 14 8 5 2VALSAD 48 2 5 2 0
2004 SURAT 39 19 7 5 3NAVSARI 68 36 17 8 4VALSAD 42 10 2 3 1
2005 SURAT 48 14 3 5 2NAVSARI 50 16 5 2 0VALSAD 54 11 1 1 1
2006 SURAT 48 16 2 1 1NAVSARI 62 16 5 1 0VALSAD 31 1 1 1 0
2007 SURAT 110 19 12 5 5NAVSARI 65 25 5 4 3VALSAD 44 14 3 2 2
NO OF CASESYEAR & NO OF LEPTO-CASE WISE AFFECTED VILLAGES
Year wise Trend of Affected Villages
4
41
238
362
256
203
334
217
0
50
100
150
200
250
300
350
400
2001 2002 2003 2004 2005 2006 2007 2008 (Up to30/8/08)
YEAR
No
of A
ffect
ed V
illag
es
NIZAR
CHORYASI
Affected Villages—24Suspected Case—39Death--7
Affected Villages—22Suspected Case—29Death--3
Affected Villages—19Suspected Case—44Death--7
Affected Villages—9Suspected Case—9Death--1
Affected Villages—14Suspected Case—22Death--6
Affected Villages—2Suspected Case—2Death--2
Affected Villages—29Suspected Case—37Death--13
Affected Villages—4Suspected Case—4Death--1
Affected Villages—23Suspected Case—38Death--10
Affected Villages—1Suspected Case—1Death--0
Affected Villages—2Suspected Case—2Death--0
Affected Villages—1Suspected Case—1Death--0
Affected Areas—6Suspected Case—6Death--4
Taluka wise Map of Affected Villages, Cases & Deaths Dist.Surat (As on 19/10/2007)
Status of Affected Villages, Cases & Deaths of last three years : Surat Municipal Corporation
5
379
6 5
43
4 10
50
100
150
200
250
300
350
400
2006 2007 2008 ( Up to 30/8/08)
No of Affected Zones No of Cases No of Deaths
Spot Map of Cases
Taluka wise Map of Affected Villages, Cases & Deaths Dist.Navasari (As on 19/10/2007)
Affected Villages--35Case :- 68Death :- 12
Affected Villages--26Case :- 44Death :- 14
Affected Villages--7Case :- 9Death :- 1
Affected Villages--10Case :- 10Death :- 4
Affected Villages--22Case :- 26Death :- 12
Affected Areas-1Case-3Death-1
Navsari City
Spot Map of CasesValsad
City
DharampurPardi
KaparadaUmargam
Affected Villages-20Case-28Death-6
Affected Areas-4Case-6Death-1
Affected Villages-11Case-19Death-8Affected Villages-8
Case-15Death-4
Affected Villages-1Case-1Death-0
Affected Areas-13Case-26Death-5
Taluka wise Map of Affected Villages, Cases & Deaths Dist.Valsad (As on 19/10/2007)
Cases & Deaths status in other Leptospirosis endemic states
Sr.No
Name of State Situation on
No Of Cases No of Deaths
1 Gujarat 31/10/2007 521 135
2 Maharashtra 6/10/2007 1016 70
3 Karnataka 23/8/2007 62 4
4 Kerala 30/6/2007 294 15
5 Andaman Year-2006 218 22
Year & Taluka wise comparison of Surat DistrictFrom 2006 to 2008 (30/8/08)
Sr.No. Taluka 2006 2007 2008
Cases Deaths Cases Death Cases Death4202800391
2
12 SMC 379 43 6 4 5 132
1 Mahuva 26 9 40 7 202 Valod 25 4 44 7 73 Mandvi 9 5 22 6 104 Choryasi 3 0 2 2 55 Bardoli 18 9 38 13 366 Kamrej 9 4 4 1 67 Nizar 1 0 0 0 08 Palsana 6 5 39 11 279 Vyara 18 4 29 3 53
10 Songadh 3 2 10 1 4
11 Olpad 1 0 1 0 5
Total 498 85 238 55 178
Year & Taluka wise comparison of Navsari DistrictFrom 2006 to 2008(30/8/08)
Sr Taluka 2006 2007 2008Cases Deaths Cases Death Cases Death
5201715
1 Navsari 30 10 14 5 142 Jalalpore 18 6 32 16 133 Gandevi 21 4 46 16 134 Chikhali 31 7 68 12 245 Vansda 9 2 10 2 18
TOTAL 109 29 170 51 82
Year & Taluka wise comparison of Valsad DistrictFrom 2006 to 2008 (30/8/08)
Sr.No. Taluka 2006 2007
2008 (30/8/08)
Cases Deaths Cases Death Cases Death
1
4
1
1
2
1
10
1 Valsad 4 0 29 7 12
2 Pardi 23 6 21 8 13
3 Dharampur 3 0 26 5 7
4 Kaparada 2 0 1 0 2
5 Umargam 5 1 19 5 6
6 Valsad City 3 0 6 1 1
TOTAL 40 7 102 26 41
Trends of Disease• Changes in Disease Profile: It has been observed over last few years
that earlier patients use to report with hepatic & renal complications.
• But over last two to three years numbers of patients are reporting with pulmonary (respiratory) complications in which patients become critically ill within a short span of life so very less time is available for their survival even at the level of well equipped Medical College Hospital.
• Even in the affected districts newer areas are getting involved in Leptospirosis and even in the same village more numbers of cases are occurring.
Trends of Disease
• It is also observed that few cases of Leptospirosis are being reported in the neighboring districts like Bharuch, Ahmedabad etc and probably the disease is also shifting in few urban areas too.
• In spite of the best available laboratory methods applied, diagnosis of Leptospirosis could not be established in more than 50% of suspected Lepto cases and we are dealing with problem at field level with a very broad case definition which is used by paramedical field staff.
Trends of Disease
• It is observed that Leptospirosis is also occurring amongst the persons who are not engaged in theagriculture activities, cattle rearing or dairy activities which are usually considered as high risk population.
• The role of rodents (rats), cows, buffalo, sheep, goats and other animals has to be explored and defined by Sero surveillance by Department of Animal Husbandry.
Age & Gender wise Distribution of Case & Deaths in Surat, Navsari, & Valsad(2007)
Cases DeathsMale Female Male Female
=<20 39 18 1056 13
151313108
17
99
596350392449
379
621-25 17 326-30 12 131-35 26 336-40 20 841-45 11 246-50 7 1>50 14 5
Total 125 29
Age Group
Comparison of Age wise distribution of cases & deaths due to Leptospirosis in year 2006 & 2007 in Surat Navsari & Valsad.
Age Group2006 2007 2006 2007
=<20 22 57 3 1621-25 36 73 10 1626-30 47 71 11 1631-35 44 89 13 1636-40 36 70 13 2141-45 31 50 11 1246-50 24 31 11 9>50 28 63 6 22Total 268 504 78 128
Cases Deaths
Sex Wise Distribution-Surat, Navsari, Valsad2006
Sex Cases Death CFR%
Male 210 69 32.8
Female 58 9 15.5
Total 268 78 29.1
210
69
32.8
58
9 15.5
0
50
100
150
200
250
Male Female
Male 210 69 32.8Female 58 9 15.5
Case Death CFR
Sex Wise Distribution-Surat, Navsari, Valsad2007
Sex Cases Death CFR%
Male 379 99 26.12
Female 125 29 23.2
Total 504 128 25.4
379
99
26.12
125
29 23.2
0
50
100
150
200
250
300
350
400
Male Female
Male 379 99 26.12Female 125 29 23.2
Case Death CFR
Sex Wise Distribution-Surat, Navsari, Valsad2008 (As on 22/8/08)
Sex Cases Death CFR%
Male 150 24 16
Female 37 10 27.02
Total 187 34 18.18
150
2416
37
10
27.02
0
20
40
60
80
100
120
140
160
Male Female
Male 150 24 16Female 37 10 27.02
Case Death CFR
Occupation wise Distribution-Surat, Navsari, Valsad2006
Occupation Cases Death Occupation Cases Death
Farm Lab 197 59 Other Labour 16 5
Ani.Hus. 20 5 Banana-Lari 1 0
Diamond Lab. 4 2 LT 1 0
Driver 1 1 Mechanic 1 0
Dying Lab 1 0 Quarry labor 2 1
House Wife 10 4 Student 2 0
Kadiakam 3 0 Vegetable Merchant 2 1
Kariyana Lab 2 0 Data NA 2 0
Black-Smith 1 0 Tea-Lari 1 0
Electrc Wireman 1 0
Total Cases -268, Total Deaths - 78
Occupation wise Case & Death PrevalenceSurat, Navsari & Valsad 2007
Surat Navsari TOTAL
D D
47 38
0
0
13
51
0
0
4
51
C
123
0
0
47
170
C
211
1
5
15
232
ValsadOccupation/
Case & Death C D C D
418 109
0
0
19
128
1
5
80
504
Farm Labour&AnimalHandler
84 24
House Wife 0 0Student 0 0
Others 18 2
Total 102 26
Month wise Cases and Deaths in affected districts--2007
Surat Navsari Valsad TotalCase Death Case Death Case Death Case Death
July 41 8 13 1 2 1 56 10August 76 11 80 20 22 10 178 41
Sept. 90 22 46 18 48 13 184 53Oct. 25 10 31 12 30 2 86 24Total 232 51 170 51 102 26 504 128
Month
Month wise Graph of CASES in affected districts of South Gujarat--2007
0
41
76
90
25
0
13
80
46
31
0 2
22
48
30
0102030405060708090
100
JUNE JULY AUGUST SEPTEMBER OCTOBER
SURAT NAVSARI VALSAD
Month wise Relationship between Rainfall (In mms)& Cases of Leptospirosis in Surat From YEAR 2005 to 2007
2005 2006 2007
Rain Fall Cases Rain Fall
Cases Rain Fall Cases
June 11958 0 5074 0 0
25 49
78
83
22
0
65
24
4
1
17
85
53
30
0
2453
July 7929 15936 6918
August 6150 6638 7101
September 6733 1404 4657
October 00 00 00
November 00 00 00
Month
Month wise Relationship between Rainfall (In mms)& Cases of Leptospirosis in Surat From YEAR 2005 to 2007
YEAR 2005
05000
1000015000
June
July
Aug
ust
Sep
tem
ber
Oct
ober
Nov
embe
r
Rai
n Fa
ll (M
ms)
020406080100
Case
s
Rain Fall Cases
Year 2006
0
5000
10000
15000
20000
Jun Jul Aug Sep Oct Nov
Rain
Fal
l (M
ms)
0
20
40
60
80
Case
sRain Fall Cases
Year 2007
0
1000
2000
3000
4000
5000
6000
7000
8000
Jun Jul Aug Sep Oct Nov
Rain
Fal
l (M
ms)
0
10
20
30
40
50
60
70
80
90
Case
s
Rain Fall Cases
Month wise Relationship between Rainfall (In mms)& Cases of Leptospirosis in Navsari From YEAR 2005 to 2007
Month 2005 2006 2007
Rain Fall Cases
Rain Fall
Cases Rain Fall Cases
June 6876 0 1103 0 15
26 79
45
31
0
0
54
25
4
0
21
37
38
18
0
799
July 9805 6520 3941
August 11915 9451 7044
September 14322 10231 8663
October 00 10433 0
November 00 1893 0
Month wise Relationship between Rainfall (In mms)& Cases of Leptospirosis in Navsari From YEAR 2005 to 2007
YEAR 2005
05000
100001500020000
June
July
Aug
ust
Sep
tem
ber
Oct
ober
Nov
embe
r
Rain
Fal
l (M
ms)
010203040
Case
s
Rain Fall Cases
Year 2006
0
5000
10000
15000
Jun Jul Aug Sep Oct Nov
Rain
Fal
l (M
ms)
0
20
40
60
Cas
esRain Fall Cases
Year 2007
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
Jun Jul Aug Sep Oct Nov
Rain
Fal
l (M
ms)
0
10
20
30
40
50
60
70
80
90
Case
s
Rain Fall Cases
Month wise Relationship between Rainfall (In mms)& Cases of Leptospirosis in ValsadFrom YEAR 2005 to 2007
Month 2005 2006 2007
Rain Fall Cases Rain Fall
Cases Rain Fall Cases
June 1378 0 383 0 0
5 3
32
52
15
0
18
17
0
0
4
38
38
8
0
350July 608 1028 669August 538 813 759September 580 199 467October 9 0 0November 0 0 0
Month wise Relationship between Rainfall (In mms)& Cases of Leptospirosis in Valsad From YEAR 2005 to 2007
YEAR 2005
0
500
1000
1500
Jun Jul Aug Sep Oct Nov
Rain
Fal
l (M
ms)
0
10
20
30
40
Case
s
Rain Fall Cases
Year 2006
0
500
1000
1500
Jun Jul Aug Sep Oct Nov
Rain
Fal
l (M
ms)
0
5
10
15
20
Cas
es
Rain Fall Cases
Year 2007
0
100
200
300
400
500
600
700
800
Jun Jul Aug Sep Oct Nov
Rai
n Fa
ll (M
ms)
0
10
20
30
40
50
60
Cas
es
Rain Fall Cases
Preventive Actions:• An International Leptospirosis Conference was organized at Medical
College Surat in the 20th to 22nd January 2005 in which ICMR centre for Leptospirosis & NICD Delhi played lead role and during thisworkshop various experts, researchers, treating physicians, Microbiologists, epidemiologists were invited from affected States of the country as well as delegates from international level.
• An Inter- departmental training workshop was organized in January 2006 at Surat by involving Agriculture, Veterinary, Health officials, Surat Municipal Corporation as well as delegates from sugar & dairy cooperatives to discuss implementation of anti- rodent measures in a scientific way at field level to prevent transmission of Leptospirosis.
Preventive measures for Leptospirosis- 2007
Details Surat Navsari ValsadTotal Houses 502776 274360 322264No of Houses visited 2616694 1842140 160266
Total Population 2339591 1371800 1611285Surveyed Population 12051216
(Five Rounds)8691082
(Six Rounds)692493
(Five Rounds)
NO. Susp.Lepo cases found 232 170 102No .of fever cases found 100487 90100 64850No. of cases found +ve for Malaria 109 273 372Chloriquin Tab. distributed 410858 331755 264174
Primaquin Tab. distributed 1738 2194 28336Cap. Doxy. as Chemoprophylaxis 2796572 2361689 1102934Cap. Doxy. as Therapeutic 00 1498 27573No. of meetings 31173 33414 3813IEC activities 4404935 4427989 212407
Preventive measures for Leptospirosis- 2008 (30/8/08)Details Surat(21/8/08) Tapi(21/8/08) Navsari(23/8) Valsad(23/8)
Total Houses 312864 127845508004
(4th Round)
7724682340050(4th Round)
51No of Deaths 18 11 15 10
2130920
157819
1700205484
45121025723
274360 322264No of Houses Surveyed 1152732
(4th Round)1108120(4th Round)
829919(3rd Round)
Total Population 1540139 1371800 1613325Surveyed Population 5260175
(4th Round)5527462(4th Round)
4470900(3rd Round)
NO. Susp.Lepto cases found 97 82 41
No .of fever cases found 42878 48038 51697No. of cases found +Ve for Malaria.
17 53 224
Chloriquin Tab. distributed 356678 398875 369139
Primaquin Tab. distributed 278 3389 68244Cap. Doxy given to presumptive case
362460 433398 533868
No. of meetings 15949 17691 2049IEC activities 1838237 2260135 536214
Antirodent Activities:- Surat District:-
YearTaluka Covered
Village covered
Rodenticide Used
No. of Rats killed
Name of Rodenticide
Lepto. Case
Death
2000 9 330 5436 Kg. 446621 78 10
2001 11 330 7431 Kg. 244515 0 0
2002 14 1062 9149 Kg. 389955 23 2
2003 14 1043 9756 Kg. 321689 154 22
2004 0 0 0 0 0 285 34
2005 14 4118 kg 133783 185 43
2006 14 905 4305 kg 138338 119 42
2007 No Anti-Rodent Activities Carried Out 238 55
Bromadiolin 0.005
Bromadiolin 0.005
Antirodent Activities:- Navsari District:-
YearTaluka Covered
Village covered
Rodenticide Used
No. of Rats killed
Name of Rodenticide
Lepto. Case
Death
2000 5 388 705008 Tab.2115kg
524619 56% 50 2
2001 5 387 882388 Tab.8823Kg
615268 Brmadiolin 0.005 2 0
2002 5 387 1618700 Tab.6214 kg
290686 Brmadiolin 0.005 25 1
2003 5 384 7352 kg 488741 Brmadiolin 0.005 154 27
2004 246 43
2005 2 146 4122 kg 288600 Brmadiolin 0.005 114 26
2006 5 385 4100 Kg. 137330 Brmadiolin 0.005 109 29
2007 No Anti-Rodent Activities carried out. 170 51
Antirodent Activities:- Valsad District:-
YearTaluka Covered
Village covered
Rodenticide Used
No. of Rats killed
Name of Rodenticide
Lepto. Case
Death
2000 5 465 484380 Tab. 286419 Bromadiolin 0.005 28 4
2001 5 465 484326 Tab.8073 Kg.
81576 Bromadiolin 0.005 0 0
2002 5 465 484344 Tab.8073 kg
115858 Bromadiolin 0.005 12 0
2003 5 90 1360652268 kg
30355 Bromadiolin 0.005 72 9
2004 5 106 140734 Tab.2352 kg
15332 Bromadiolin 0.005 98 15
2005 5 107 158820 Tab.2347 kg
26057 Bromadiolin 0.005 88 11
2006 5 106 175248 Tab.2920 kg
127664 Bromadiolin 0.005 40 7
2007 5 131 175041 Tab.2917.35 Kg
57897 Bromadiolin 0.005 102 26
Criteria for selection of villages for Chemoprophylaxis
• Those villages which were affected for more then one year with Leptospirosis during last five years.
• Those villages which reported >1 case of Leptospirosis in the previous year.
• Those villages in which Death occurred even in single case of clinically suspected Leptospirosis
• Those villages in which cases of Leptospirosis are reported for the first time during current year
(This criteria will be invariably added from 2008 after consultation with NICD)
Specific Preparedness for Leptospirosis for Year 2008
• An international training workshop was organized on10 to12 Dec 2007 and 13 to 15 Dec 2007 respectively for laboratory techniques for diagnosis of leptospirosis and it’s practical demonstration, at Microbiologydepartment, Government Medical College Surat.
• International experts participated and provided their valuable directives.
• Assistant professors (Microbiology) and laboratory technicians of all Govt medical colleges took the advantage of this workshop.
Specific Preparedness for Leptospirosis for Year 2008
• A meeting was held on 22/01/2008 under the chairmanship of respected Commissioner Health atGandhinagar to discuss out the modalities of controlling Leptospirosis in Endemic Districts of South Gujarat, by isolating circulating Lepto Serovars amongst cattle population & co-relation or them, if any, to increasing mortality & extension of Human Leptospirosis in newer areas of South Gujarat.
• Rs 25 Lakhs has been allotted to Microbiology department GMC Surat for this project.
Culture PCR
Total Result Tested Positive Negative Pending
Rat Kidney 359 UnderProcess
278 32 165 81
Animal Urine 503 UnderProcess
359 24 283 108
Animal Serum
168 UnderProcess
142 20 96 26
Goat Kidney 6 UnderProcess
6 1 5 NIL
Samples
As per the latest information regarding the status of Cattle Serovars project till 30/8/08
Specific Preparedness for Leptospirosis for Year 2008
• Soil samples are also taken for the pH analysis from high risk villages of south Gujarat by Agriculture department as per recommendation by NICD Delhi.
• List of 84 high risk villages of Surat, 43 of Navsari and 31 villages of Valsad districts are given to Agriculture Department for soil collection and analysis from Health Department.
• Total 292 soil samples are collected and tested by Agriculture Dept and results of tests have been sent to Krishi University Navsari.
• No recommendations for Gypsum or Bio Fertilizers are given by Krishi University Navsari.
Specific Preparedness for Leptospirosis for Year 2008
• An Interdepartmental meeting was organized on 22nd April 2008 under the chairmanship of Principal Secretary involving senior officers of Health, Agriculture, Animal Husbandry, Irrigation, etc from State and expert from ICMR Andaman to discuss about important issues pertaining to the prevention and control of Leptospirosis in Gujarat State.
• Minutes and specific task to be taken by respective department was sent.
Specific Preparedness for Leptospirosis for Year 2008
• IEC activities were carried out during ‘Krishi Rath Mahotsav’ to educate and inform community regarding leptospirosis during 7/5/08 to 6/6/08 in the Surat , Navsari and Valsad districts.
• Grant of Rs.10 Lakhs has been allotted to HEB for IECactivities.
• Guidelines are prepared and distributed to all districts for prevention and control of Leptospirosis for the year 2008 for implementation in districts which was prepared by PSM Department, Medical College Surat on 19/06/2008 after multiple meetings with experts.
Specific Preparedness for Leptospirosis for Year 2008
• An active surveillance has been started from 1st June 2008 in leptospirosis endemic districts like Surat, Navsari and Valsad. All fever cases (> 15 years of age) surveyed are given CapsuleDoxycycline 100 mg./ twice a Day for 7 days along with antimalarial treatment as per the decided guidelines.
• The 24 hours working control room has been started from 15/6/2008 at district Panchayat of Surat, Navsari, Valsad and Regional Deputy Director Office Surat.
• Modular Training was given to Block Health Officers, Medical officers and paramedical staffs of Surat, Navsari and Valsad districts in last week of June 2008.
• Sarpanchs, Talatis, Gram sevaks, TDOs, elected representatives and members of milk cooperative societies of Surat, Navsari and Valsad districts are given training in the first week of July 2008.
Specific Preparedness for Leptospirosis for Year 2008
• Following 5 treatment centers are established in South Gujarat to provide comprehensive treatments to all suspected cases of leptospirosis.
– New Civil Hospital Surat– Civil Hospital Navsari– Civil Hospital Valsad– CHC Bardoli– CHC Vyara
Specific Preparedness for Leptospirosis for Year 2008
• An inter-state meeting was held on 2/5/2008 at NICD Delhi for a pilot project to be initiated as a ‘New Initiative’ in the 11th Five year plan to prevent morbidity and mortality due to Leptospirosis by GOI, in which Surat, Navsari, and Valsad districts of Gujarathave been taken as pilot districts.
• This pilot project will be completed in a span of two years from January 2008-December 2009.
• The pilot project is budgeted at an estimated total cost of Rs.2,05,18,000/-.
• Out of this amount State of Gujarat will be allotted Rs.1,17,10,000/-for the period 2008 and 2009.
Specific Preparedness for Leptospirosis for Year 2008
• A training for core group trainers under this project is held on 19/6/2008 at PSM Department, Government Medical College Surat, and training had been given to officers of health, medical services, medical college Surat, and Animal Husbandry department involved in leptospirosis preventive activities by National experts Dr. U V S Rana from NICD Delhi.
• The focus of the project will be on :– Strengthening diagnostic laboratories in pilot project areas– Strengthening of patient care management facilities in pilot project areas
and supplementary provision of drugs for chemoprophylaxis.– Development of trained manpower.– Create awareness regarding timely detection and appropriate treatment of
patients.– Sensitization of Animal Husbandry and Agriculture personnel.– Information, Education.
Specific Preparedness for Leptospirosis for Year 2008
• Anti-rodent activities are to be done by Agricultural Department of State and budget of Rs 30 Lakhs have been prepared by them. 10% of this budget i.e. Rs 3 Lakhs has been allotted by Health Department.
• For the current year (2008-09)Budget provision and allotment of funds of Rs 300 Lakhs (Rs150 Lakhs under Tribal Head, Rs. 50 Lakhs under Non-Tribal head and Rs. 100 Lakhs under Special Components) have been done by State Government to control and prevent Leptospirosis.
Specific Preparedness for Leptospirosis for Year 2008
• With reference to deaths reported due to Leptospirosis a request had been sent to the Director EMR Delhi on 14/8/08 for deputing a ‘Central Team’ ofexperts to investigate and guide, case management protocols to Head of Department of Medicine, Govt Medical College Surat in serious patients developing acute pulmonary hemorrhage. Central Team from GOI visited Lepto affected district during 26/8/08 to 29/8/08 with Deputy Director (Epidemic).
• As a result of such phenomena percentage of occurrence of pulmonary hemorrhage has been found increasing from 39% (Year-2007) to 60% in the current year and patients are observed to expire within a short span of time after onset of disease.
Patient Management in hospitals• If there is a scope of patient care with alternative regimes with
steroids or other antibiotics ,they require to be explored and suggested to us.
• It is a humble submission that if agreed , a separate meeting may be called at National level for treating physicians of affected states for recent advances & interactions on these aspects.
District Opening Balance (District & Pipeline 30/ 6/07)
Supplied through CMSO in Year 2007
TOTALStock
Consumption up to 31/10/07
Balance on 31/10/07
Surat 840000 2500000 3340000 2796515 543485
Navsari 1614000 1500000 3114000 2363187 750813
Valsad 1443000 1000000 2443000 1130507 1312493
TOTAL 3897000 5000000 8897000 6290209 2606791
Balance sheet of Supply & Consumption of Cap. Doxycycline in Year 2007
Alternative drugs for chemoprophylaxis?
• Cap Doxy. has been in use in south Gujarat for many years.
• Possibility exisists for its resistance in population.
• Possibility of long term toxicity has to kept in consideration.
• Other less toxic and more effective drugs may be suggested in coming years.
• Studies on chemotherapeutic efficacy of Doxycycline are requested from current year by NICD or ICMR as field research.
Strategy for rest of Gujarat• Suggestions are welcome for rest of the districts and municipal
corp. and other urban areas of the state which may report sporadic cases of Lepto. in current year since there may be fancy .since it is a new subject for them.
• As a matter of precaution National guidelines on Lepto. Published by NICD & WHO have been provided to all districts & have been requested to follow the same
• Training lectures had been covered in IDSP trainings as a state specific subject
• Still diagnostic protocols are requested to be provided from GOI/NICD for low endemic areas
• Problems are anticipated as per last years experience from private sector as well as corporate hospitals
Issues on Chemotherapy• Whether it is indicated for all fever cases occurring throughout the
district or requires to be limited?
• If we have to restrict, then who are the priority groups: high risk group of persons or identified endemic villages of Leptospirosis, may pl. be clarified.
• Whether such a cap. Doxy. chemotherapy is also applicable to high risk group of persons residing in low or non endemic districts of the state, requires to be clarified
Which strategy is a priority?• Many a times due to various administrative problems and situations
beyond our control the massive requirement of cap. Doxy (roughly3-3.5 crores) may not be available locally during the rainy months
• In that case which mode of prevention is likely to provide better results and should be considered in field operations, chemoprophylaxis or chemotherapy?
• Whether chemotherapy with cap.Doxy. For all cases of fever for 7days is also indicated in endemic area of Surat Municipal Corporation is to be made clear pre-monsoon ,since during 2006 it had been debated seriously during heavy floods
Consumption Of Cap. Doxycycline2006 & 2007 (31/10/2007)
Chemoprophylaxis Chemotherapeutic Total
2006 2007 2006 2007 2006 2007
Surat 1939657 2796512 1220141 0 2796512
1498 2363187
1130507
2290
6292556
27573
0
29071
2361689
1102934
2290
6263485
3159798
Navsari 1870186 810548 2680734
Valsad 987167 544922 1532089
Bharuch 0 0 2290
Total 4797010 2575611 7374911
District
NB: Chemotherapy with Cap Doxy. Of all fever cases was discontinued in 2007as per revised NICD Guidelines.
Consumption Of Cap. Doxycycline2007 & 2008 (8/9/08)
Chemoprophylaxis Chemotherapeutic Total
2007 2008 2007 2008 2007 2008
Surat 2796512 - 0 399028 399028
498544 498544
593452
390824
1881848
593452
390824
1881848
-
-
-
2796512
Navsari 2361689 1498 2363187
Valsad 1102934 27573 1130507
Tapi
Total 6263485 29071 6292556
District
NB: Chemotherapy with Cap Doxy. Of all fever cases was discontinued in 2007as per revised NICD Guidelines.
Associated Laboratory Findings
• Other Diagnostic Tests were found positive in 57 patients who were admitted as suspected Leptospirosis in New Civil Hospital, Surat as shown in table.
Malaria 23
Hepatitis 14
Dengue 10
Hepatitis E 10
Different Departmental Role in Control of Leptospirosis
Socialscientists
AnimalHusbandry
Agriculture
Laboratory
Medical
Health
Leaders
Administration
Stakeholders
ACTION PLAN BY AGRICULTURE DEPARTMENT OF LEPTOSPIROSIS FOR THE YEAR 2008-2009
SR.NO
.
STAKEHOLDER
ISSUES TO BE DISCUSSED BY STAKE HOLDER
ACTION PLAN
1 DirectorAgricultureDepartment
• Action Plan of Agriculture Department For Anti-rodent activities and its planning, implementation, time frame, funding, monitoring & interdepartmental.
• Detail Action plan prepare by District Agriculture officer in month of Feb/March to control rat.
• Purchase of Rodent control material in month of April.• Rodent material use in month of May to first week of June.• Implementation done by Garam-sevak with the help of
farmer.• Generally fund comes from MACRO MANAGEMENT
SCHEME. A provision of Rs. 30 Lakh is made for the year 2008-09.
• Monitoring Done by Extension officer, Assistant Director of Agriculture, District Agriculture Officer.
• Co-operation with Agriculture, Animal Husbandry and Health Department
• Rodent mapping. • Manually calculated by Gram-sevak
• Result of Soil Samples collected from Lepto endemic villages & their implications.
• In the year 2007-08, total 292 Soil Samples collected from 73 Lepto endemic villages.
• Extension Education activities of farming community against Leptospirosis
• Various camps arrange by Agriculture Department before Rodent activities start.
• During Krishi Mahotsav-2008, awareness programme will be carried out in the Lepto endemic villages.
Result of Soil Samples collected from lepto endemic villages & their implications in District ,Valsad
Sr. no. No.of villages
No. ofSamples
Item Total
Low Medium High1 2 3 4 5 6 7 8
PH 84 4 75 5EC 84 84 0 0N 84 52 32 0P 84 19 65 0K 84 0 8 76
Samples Reading Position
1
Local situations• Lot of problems are being raised in PRESS as well as under RTI
ACT for above issues ,which have to be addressed satisfactorily and with authenticity
• South Gujarat districts have large no. of tribal population & Leptospirosis is emerging as more & more sensitive issue
• Hon .C.M. of Gujarat has recently covered Lepto under his priority programme Vanbandhu Kalyan Yojna for all the actions to reduce morbidity & high CFR due to leptospirosis
• Sickle Cell Anaemia Diagnosis & Control Programme across the state under GOG-NGO partnership is also covered under above scheme & it is a time for undertaking an active field research to establish any links, if at all they exist in above two conditions among tribal population.
Year wise (1995 to 2008 (30/08/08) )Trend of CASE FATALITY RATE (%) amongst Leptospirosis cases
in Gujarat State
14.3
22.5
11.5
7.88.7
10.2
0
3.4
15.3614.6
20.51
18.55
25.91
19
0
5
10
15
20
25
30
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
Up
to 3
0/8/
08
CFR % Linear (CFR %)