Features
Leptospirosis – no longer the rural farmer’s disease
Making a breakthrough in the study of leptospirosis, a bacterial infection transmitted from animals, a team of Sri Lankan researchers in a collaborative endeavour has discovered six new genotypes of this largely undermined tropical disease. In an exclusive interview with the Sunday Island, they throw light on the findings of their research which are now in international literature enabling new knowledge on the world’s commonest zoonotic disease.
by Randima Attygalle
No longer considered the ‘rural farmer’s disease’, leptospirosis, commonly called rat fever or mee una in Sinhala, is changing its dynamics, urging clinicians, health policy-makers and the public to revisit this common tropical disease of both humans and animals. The bacterium that causes leptospirosis is spread through the urine of infected animals, which can get into water or soil and can survive there for weeks or months. Many different kinds of wild and domestic animals carry the bacterium including cattle, pigs, rodents, dogs, horses and wild animals.
Humans can become infected with the bacterium either through contact with urine of an infected animal or with water or soil contaminated with the urine of infected animals. The bacteria can enter the body through skin, eyes, nose or mouth. Outbreaks of leptospirosis are usually caused by exposure to contaminated water, such as floodwaters. It is a serious occupational hazard for those working outdoors such as farmers, miners etc. and professionals such as veterinarians in close contact with animals. According to global research findings, around one million cases of leptospirosis and 58,900 deaths are estimated to occur worldwide each year. More than 70% of the deaths are reported from the tropical, poorest regions of the world.
A re-merging disease here at home, leptospirosis has gained much attention since the large outbreak in 2008. “The annual incidence of leptospirosis that had required hospitalization from 2008 to 2015 was 52.1 per 100,000 people, with an estimated case fatality rate of 7.0% according to National Health Bulletin data. In 2018 there was another resurgence in numbers. The disease is no more a ‘seasonal’ one as it was conventionally known to be, resulting in multiple outbreaks per year, notably during rainy seasons. Manifestations of the disease have also changed, with a wide array of new clinical entities such as pulmonary haemorrhage (bleeding into the lungs), pancreatitis, and myocarditis coupled with high case fatality. These shifts in the disease call for new strategies, new interventions and the need to reorganize ourselves as the health care sector,” says Dr. Panduka Karunanayake, Senior Lecturer from the Department of Clinical Medicine, University of Colombo.
The purpose of this research project between researchers from several local institutions (Medical Research Institute and Base Hospital Elpitiya under the Ministry of Health, and University of Peradeniya and University of Colombo) and Japan (National Institute of Infectious Diseases in Tokyo, and Graduate School of Infectious Diseases and Institute of Genetic Medicine of Hokkaido University) had been to identify the serogroups and genetic groups of Leptospira organisms that are found here at home. “This knowledge is important to better understand the new clinical manifestations for their early diagnosis and treatment, and to know the carrier animal for specific control measures, as this disease is carried by animals,” explains Dr. Karunanayake.
A laborious process, first, the organisms need to be ‘isolated’ (grown) in artificial culture, and thereafter artificially ‘maintained’ (kept alive) in culture media. This needs specialized laboratories with biosafety measures. The National Reference Laboratory (NRL) for Leptospirosis at the MRI offers this service to hospitals routinely. “Organisms were isolated from blood of patients affected by the 2015-2017 leptospirosis outbreak from the Base Hospital in Elpitiya and animal kidney tissue from Kandy. Once they were successfully grown and maintained in culture, they were sent to Japan for the genetic characterization which was done for us by the Japanese collaborator (Dr. Nobuo Koizumi, National Institute of Infectious Diseases (NIID), Japan),” says Dr Karunanayake.
The genetic characterization and serogroup analyses were done in NIID, Japan which demonstrated that these strains belonged to three genetically-defined species. “When their genotypic strains were analyzed, it was found that the isolates belong to 15 different strains, of which six were not described before in the world literature, hence treated as ‘novel genotypes’. Of these, three were from patients treated at the Base Hospital in Elpitiya. They were causing multiple complications such as kidney, liver, heart and lung involvement and septic shock. However, all of these patients survived,” says Dr. Karunanayake.
Although leptospirosis had been prevalent in our country since the 1950s, it has been changing its nature in the last decade. “While the number of cases are increasing alarmingly, the clinical picture too is changing, with the identification of new and troublesome complications including pulmonary haemorrhage, pancreatic involvement, heart involvement, community-acquired sepsis, etc.” he said. The disease is also affecting a wider group of people, such as those living in urban areas and people exposed only briefly to stagnant waters or floods.
“After 40 years since Dr. K. Nityananda’s work in the 1960s and 1970s at the NRL, we have been able to introduce new strains for the first time to the world literature on leptospirosis, again from the NRL,” observes Dr. Lilani Karunanayake, Consultant Clinical Microbiologist and Head/National Reference Laboratory for Leptospirosis at the Medical Research Institute. The emergence of new genotypes, as she points out, imply the importance of strict quarantine of imported cattle as well as other imported domestic animals that are potential reservoirs of leptospirosis. “Unintentional introduction of rodent reservoirs through improper garbage disposal and the existence of unidentified reservoir animals in the country also call for attention,” says the senior microbiologist who further says that new knowledge from this study will be valuable in future research for patient management and specifically-targeted control approaches for reservoir hosts in the prevention and control of leptospirosis in Sri Lanka. She extended her thanks to the clinicians from various hospitals who sent in samples, which enabled these discoveries in the best interest of people.
The National Reference Laboratory (NRL) for Leptospirosis at the MRI which serves as the central referral laboratory in the country performs certain specific leptospirosis tests, samples for which are sent from hospitals island-wide. “Although certain tests could be performed at peripheral levels, some of the advanced cases need to be referred to the central lab,” notes Dr. Karunanayake, adding that the Teaching Hospitals at regional level should be strengthened with testing facilities for early detection.
Non-specific features of the patients such as fever, headaches, body aches, diarrhea which could mimic other conditions such as dengue has rendered early detection of leptospirosis very challenging, says Dr. Sajiv De Silva, Consultant Physician, Base Hospital, Balapitiya. “Hence kidney complications and the lung involvement are two specific features we give attention to in our investigations which often require intensive care. We also take serious account of the patient’s exposure to paddy fields and muddy water. In the Elpitiya patient cluster which we took as our research sample, the kidney complications and pulmonary haemorrhage were very severe which enabled us to add the new genotypes from this cluster to the world literature on leptospirosis.” He further remarks that these genotypes are more virulent than those found in the Western Province. Similar to the cluster in Elpitiya, more recent samples from patients in Galle, Balapitiya and Udugama in the Southern Province have reflected more severe complications, particularly lung and kidney complications which trigger rapid deterioration of the patient.
Patient demographic changes are also significant as the research reveals, points out Dr. De Silva. “Apart from farmers and miners who were traditionally identified as the most vulnerable to the disease, today we find a considerable percentage of young patients who had contacted it by merely visiting a paddy field or bathing in a river.” Diagnosing leptospirosis has become a “dilemma” for the physicians at the peripheral level, observes the Consultant who adds that, blurring lines between dengue and leptospirosis makes it more challenging. “In both situations platelets will drop. However in the treatment of dengue, while fluids need to be administered proportionate to the urine output, in the case of leptospirosis, fluids cannot be administered to mitigate pulmonary hemorrhage.”
Reiterating on the urgency of seeking early hospital care, the physician notes, “the earlier they come, faster the laboratory diagnosis would be.” Although clinical diagnosis of leptospirosis was not possible in the first few days of symptoms, today the availability of the PCR test (free in the state health sector) makes this possible, he adds. The toll the disease takes on families and the national health budget cannot be undermined. In a bid to create awareness on prevention of it by promoting safety footwear and early detection among the communities at rural level, a programme is now in place facilitated by the MOHs and PHIs says Dr. De Silva.
The breakthrough research is also a reflection of the validity of the ‘One Health’ concept where collaborative health efforts of multiple disciplines working nationally and globally can attain optimal health for people, animals and the environment, observes Dr. Chandika Gamage, Veterinarian and Senior Lecturer from the Department of Microbiology, Faculty of Medicine, University of Peradeniya. “Pathogens isolated from rats and humans in a molecular study during the research had revealed same genetic strain types which have enabled us to enlarge our knowledge on leptospirosis,” explains Dr. Gamage.
Although traditionally leptospirosis had been considered a disease spread by rats (‘natural reservoirs’), it is now becoming clear that there are other animals, such as cattle, that harbour the bacteria and spread it, points out Dr. Gamage. The research had further thrown light on dairy cattle as a potent reservoir of the disease. They are often grazed on grassland infected with rat urine and can can set off a vicious cycle, says the Veterinarian. “One excretion of cattle urine can be an amplifier pathogen of leptospirosis.”
Concurrent studies in humans, animals and environmental sampling can determine how these interact to bring about disease in humans which validates the One Health approach, says the Veterinarian. Furthermore, diverse sero groups were found in this study to cause both human disease and that present in animals like cattle and buffalo, pointing towards the need for new preventive strategies to control human leptospirosis in Sri Lanka, he says. Research will also be extended to the study of domestic animals such as dogs and cats as potential carriers of the disease.
“It is imperative that we contribute to the control of leptospirosis through One Health perspective through preventive measures such as safe garbage disposal which would otherwise become breeding grounds for rats, vaccination of cats and dogs, use of preventive footwear in agrarian and other outdoor pursuits. While a patient infected with the disease may be treated, unless we adopt a holistic approach towards prevention, the environment around us could still be a catalyst of the disease hindering the control or even elimination of the disease.”
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There’s an ill more dangerous and pervasive than the Coronavirus that’s currently sweeping Sri Lanka. That is the fear to express one’s convictions. Across the public sector of the country in particular many persons holding high office are stringently regulating and controlling the voices of their consciences and this bodes ill for all and the country.
The corrupting impact of fear was discussed in this column a couple of weeks ago when dealing with the military coup in Myanmar. It stands to the enduring credit of ousted Myanmarese Head of Government Aung San Suu Kyi that she, perhaps for the first time in the history of modern political thought, singled out fear, and not power, as the principal cause of corruption within the individual; powerful or otherwise.
To be sure, power corrupts but the corrupting impact of fear is graver and more devastating. For instance, the fear in a person holding ministerial office or in a senior public sector official, that he would lose position and power as a result of speaking out his convictions and sincere beliefs on matters of the first importance, would lead to a country’s ills going unaddressed and uncorrected.
Besides, the individual concerned would be devaluing himself in the eyes of all irrevocably and revealing himself to be a person who would be willing to compromise his moral integrity for petty worldly gain or a ‘mess of pottage’. This happens all the while in Lankan public life. Some of those who have wielded and are wielding immense power in Sri Lanka leave very much to be desired from these standards.
It could be said that fear has prevented Sri Lanka from growing in every vital respect over the decades and has earned for itself the notoriety of being a directionless country.
All these ills and more are contained in the current controversy in Sri Lanka over the disposal of the bodies of Covid victims, for example. The Sri Lankan polity has no choice but to abide by scientific advice on this question. Since authorities of the standing of even the WHO have declared that the burial of the bodies of those dying of Covid could not prove to be injurious to the wider public, the Sri Lankan health authorities could go ahead and sanction the burying of the bodies concerned. What’s preventing the local authorities from taking this course since they claim to be on the side of science? Who or what are they fearing? This is the issue that’s crying out to be probed and answered.
Considering the need for absolute truthfulness and honesty on the part of all relevant persons and quarters in matters such as these, the latter have no choice but to resign from their positions if they are prevented from following the dictates of their consciences. If they are firmly convinced that burials could bring no harm, they are obliged to take up the position that burials should be allowed.
If any ‘higher authority’ is preventing them from allowing burials, our ministers and officials are conscience-bound to renounce their positions in protest, rather than behave compromisingly and engage in ‘double think’ and ‘double talk’. By adopting the latter course they are helping none but keeping the country in a state of chronic uncertainty, which is a handy recipe for social instabiliy and division.
In the Sri Lankan context, the failure on the part of the quarters that matter to follow scientific advice on the burials question could result in the aggravation of Islamophobia, or hatred of the practitioners of Islam, in the country. Sri Lanka could do without this latter phobia and hatred on account of its implications for national stability and development. The 30 year war against separatist forces was all about the prevention by military means of ‘nation-breaking’. The disastrous results for Sri Lanka from this war are continuing to weigh it down and are part of the international offensive against Sri Lanka in the UNHCR.
However, Islamophobia is an almost world wide phenomenon. It was greatly strengthened during Donald Trump’s presidential tenure in the US. While in office Trump resorted to the divisive ruling strategy of quite a few populist authoritarian rulers of the South. Essentially, the manoeuvre is to divide and rule by pandering to the racial prejudices of majority communities.
It has happened continually in Sri Lanka. In the initial post-independence years and for several decades after, it was a case of some populist politicians of the South whipping-up anti-Tamil sentiments. Some Tamil politicians did likewise in respect of the majority community. No doubt, both such quarters have done Sri Lanka immeasurable harm. By failing to follow scientific advice on the burial question and by not doing what is right, Sri Lanka’s current authorities are opening themselves to the charge that they are pandering to religious extremists among the majority community.
The murderous, destructive course of action adopted by some extremist sections among Muslim communities world wide, including of course Sri Lanka, has not earned the condemnation it deserves from moderate Muslims who make-up the preponderant majority in the Muslim community. It is up to moderate opinion in the latter collectivity to come out more strongly and persuasively against religious extremists in their midst. It will prove to have a cementing and unifying impact among communities.
It is not sufficiently appreciated by governments in the global South in particular that by voicing for religious and racial unity and by working consistently towards it, they would be strengthening democratic development, which is an essential condition for a country’s growth in all senses.
A ‘divided house’ is doomed to fall; this is the lesson of history. ‘National security’ cannot be had without human security and peaceful living among communities is central to the latter. There cannot be any ‘double talk’ or ‘politically correct’ opinions on this question. Truth and falsehood are the only valid categories of thought and speech.
Those in authority everywhere claiming to be democratic need to adopt a scientific outlook on this issue as well. Studies conducted on plural societies in South Asia, for example, reveal that the promotion of friendly, cordial ties among communities invariably brings about healing among estranged groups and produces social peace. This is the truth that is waiting to be acted upon.
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By Sanjeewa Jayaweera
It was on 3rd January 1972 that our family arrived in Karachi from Moscow. Our departure from Moscow had been delayed for a few weeks due to the military confrontation between Pakistan and India. It ended on 16th December 1971. After that, international flights were not permitted for some time.
The contrast between Moscow and Karachi was unbelievable. First and foremost, Moscow’s temperature was near minus 40 degrees centigrade, while in Karachi, it was sunny and a warm 28 degrees centigrade. However, what struck us most was the extreme warmth with which the airport authorities greeted our family. As my father was a diplomat, we were quickly ushered to the airport’s VIP Lounge. We were in transit on our way to Rawalpindi, the airport serving the capital of Islamabad.
We quickly realized that the word “we are from Sri Lanka” opened all doors just as saying “open sesame” gained entry to Aladdin’s cave! The broad smile, extreme courtesy, and genuine warmth we received from the Pakistani people were unbelievable.
This was all to do with Mrs Sirima Bandaranaike’s decision to allow Pakistani aircraft to land in Colombo to refuel on the way to Dhaka in East Pakistan during the military confrontation between Pakistan and India. It was a brave decision by Mrs Bandaranaike (Mrs B), and the successive governments and Sri Lanka people are still enjoying the fruits of it. Pakistan has been a steadfast and loyal supporter of our country. They have come to our assistance time and again in times of great need when many have turned their back on us. They have indeed been an “all-weather” friend of our country.
Getting back to 1972, I was an early beneficiary of Pakistani people’s love for Sri Lankans. I failed the entrance exam to gain entry to the only English medium school in Islamabad! However, when I met the Principal, along with my father, he said, “Sanjeewa, although you failed the entrance exam, I will this time make an exception as Sri Lankans are our dear friends.” After that, the joke around the family dinner table was that I owed my education in Pakistan to Mrs B!
At school, my brother and I were extended a warm welcome and always greeted “our good friends from Sri Lanka.” I felt when playing cricket for our college; our runs were cheered more loudly than of others.
One particular incident that I remember well was when the Embassy received a telex from the Foreign inistry. It requested that our High Commissioner seek an immediate meeting with the Prime Minister of Pakistan, Mr Zulifikar Ali Bhutto (ZB), and convey a message from Mrs B. The message requested that an urgent shipment of rice be dispatched to Sri Lanka as there would be an imminent rice shortage. As the Ambassador was not in the station, the responsibility devolved on my father.
It usually takes about a week or more to get an audience with the Prime Minister (PM) of a foreign country due to their busy schedule. However, given the urgency, my father spoke to the Foreign Ministry’s Permanent Sectary, who fortunately was our neighbour and sought an urgent appointment. My father received a call from the PM’s secretary around 10 P.M asking him to come over to the PM’s residence. My father met ZB around midnight. ZB was about to retire to bed and, as such, was in his pyjamas and gown enjoying a cigar! He had greeted my father and had asked, “Mr Jayaweera, what can we do for great friend Madam Bandaranaike?. My father conveyed the message from Colombo and quietly mentioned that there would be riots in the country if there is no rice!
ZB had immediately got the Food Commissioner of Pakistan on the line and said, “I want a shipload of rice to be in Colombo within the next 72 hours!” The Food Commissioner reverted within a few minutes, saying that nothing was available and the last export shipment had left the port only a few hours ago to another country. ZB had instructed to turn the ship around and send it to Colombo. This despite protests from the Food Commissioner about terms and conditions of the Letter of Credit prohibiting non-delivery. Sri Lanka got its delivery of rice!
The next was the visit of Mrs B to Pakistan. On arrival in Rawalpindi airport, she was given a hero’s welcome, which Pakistan had previously only offered to President Gaddafi of Libya, who financially backed Pakistan with his oil money. That day, I missed school and accompanied my parents to the airport. On our way, we witnessed thousands of people had gathered by the roadside to welcome Mrs B.
When we walked to the airport’s tarmac, thousands of people were standing in temporary stands waving Sri Lanka and Pakistan flags and chanting “Sri Lanka Pakistan Zindabad.” The noise emanating from the crowd was as loud and passionate as the cheering that the Pakistani cricket team received during a test match. It was electric!
I believe she was only the second head of state given the privilege of addressing both assemblies of Parliament. The other being Gaddafi. There was genuine affection from Mrs B amongst the people of Pakistan.
I always remember the indefatigable efforts of Mr Abdul Haffez Kardar, a cabinet minister and the President of the Pakistan Cricket Board. From around 1973 onwards, he passionately championed Sri Lanka’s cause to be admitted as a full member of the International Cricket Council (ICC) and granted test status. Every year, he would propose at the ICC’s annual meeting, but England and Australia’s veto kept us out until 1981.
I always felt that our Cricket Board made a mistake by not inviting Pakistan to play our inaugural test match. We should have appreciated Mr Kardar and Pakistan’s efforts. In 1974 the Pakistan board invited our team for a tour involving three test matches and a few first-class games. Most of those who played in our first test match was part of that tour, and no doubt gained significant exposure playing against a highly talented Pakistani team.
Several Pakistani greats were part of the Pakistan and India team that played a match soon after the Central Bank bomb in Colombo to prove that it was safe to play cricket in Colombo. It was a magnificent gesture by both Pakistan and India. Our greatest cricket triumph was in Pakistan when we won the World Cup in 1996. I am sure the players and those who watched the match on TV will remember the passionate support our team received that night from the Pakistani crowd. It was like playing at home!
I also recall reading about how the Pakistani government air freighted several Multi Barrell artillery guns and ammunition to Sri Lanka when the A rmy camp in Jaffna was under severe threat from the LTTE. This was even more important than the shipload of rice that ZB sent. This was crucial as most other countries refused to sell arms to our country during the war.
Time and again, Pakistan has steadfastly supported our country’s cause at the UNHCR. No doubt this year, too, their diplomats will work tirelessly to assist our country.
We extend a warm welcome to Mr Imran Khan, the Prime Minister of Pakistan. He is a truly inspirational individual who was undoubtedly an excellent cricketer. Since retirement from cricket, he has decided to get involved in politics, and after several years of patiently building up his support base, he won the last parliamentary elections. I hope that just as much as he galvanized Sri Lankan cricketers, his political journey would act as a catalyst for people like Kumar Sangakkara and Mahela Jayawardene to get involved in politics. Cricket has been called a “gentleman’s game.” Whilst politics is far from it!.
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Believe me, seeing certain videos, on social media, depicting action, on the dance floor, at some of these entertainment venues, got me wondering whether this Coronavirus pandemic is REAL!
To those having a good time, at these particular venues, and, I guess, the management, as well, what the world is experiencing now doesn’t seem to be their concerned.
Obviously, such irresponsible behaviour could create more problems for those who are battling to halt the spread of Covid-19, and the new viriant of Covid, in our part of the world.
The videos, on display, on social media, show certain venues, packed to capacity – with hardly anyone wearing a mask, and social distancing…only a dream..
How can one think of social distancing while gyrating, on a dance floor, that is over crowded!
If this trend continues, it wouldn’t be a surprise if Coronavirus makes its presence felt…at such venues.
And, then, what happens to the entertainment scene, and those involved in this field, especially the musicians? No work, whatsoever!
Lots of countries have closed nightclubs, and venues, where people gather, in order to curtail the spread of this deadly virus that has already claimed the lives of thousands.
Thailand did it and the country is still having lots of restrictions, where entertainment is concerned, and that is probably the reason why Thailand has been able to control the spread of the Coronavirus.
With a population of over 69 million, they have had (so far), a little over 25,000 cases, and 83 deaths, while we, with a population of around 21 million, have over 80,000 cases, and more than 450 deaths.
I’m not saying we should do away with entertainment – totally – but we need to follow a format, connected with the ‘new normal,’ where masks and social distancing are mandatory requirements at these venues. And, dancing, I believe, should be banned, at least temporarily, as one can’t maintain the required social distance, while on the dance floor, especially after drinks.
Police spokesman DIG Ajith Rohana keeps emphasising, on TV, radio, and in the newspapers, the need to adhere to the health regulations, now in force, and that those who fail to do so would be penalised.
He has also stated that plainclothes officers would move around to apprehend such offenders.
Perhaps, he should instruct his officers to pay surprise visits to some of these entertainment venues.
He would certainly have more than a bus load of offenders to be whisked off for PCR/Rapid Antigen tests!
I need to quote what Dr. H.T. Wickremasinghe said in his article, published in The Island of Tuesday, February 16th, 2021:
“…let me conclude, while emphasising the need to continue our general public health measures, such as wearing masks, social distancing, and avoiding crowded gatherings, to reduce the risk of contact with an infected person.
“There is no science to beat common sense.”
But…do some of our folks have this thing called COMMON SENSE!
