Spatial analysis of Leptospira infection in muskrats in Lower Saxony, Germany, and the association with human leptospirosis

Linking rattiness, geography and environmental degradation to spillover Leptospira infections in marginalised urban settings: An eco-epidemiological community-based cohort study in Brazil

Background

Zoonotic spillover from animal reservoirs is responsible for a significant global public health burden, but the processes that promote spillover events are poorly understood in complex urban settings. Endemic transmission of Leptospira, the agent of leptospirosis, in marginalised urban communities occurs through human exposure to an environment contaminated by bacteria shed in the urine of the rat reservoir. However, it is unclear to what extent transmission is driven by variation in the distribution of rats or by the dispersal of bacteria in rainwater runoff and overflow from open sewer systems.

Methods

We conducted an eco-epidemiological study in a high-risk community in Salvador, Brazil, by prospectively following a cohort of 1401 residents to ascertain serological evidence for leptospiral infections. A concurrent rat ecology study was used to collect information on the fine-scale spatial distribution of 'rattiness', our proxy for rat abundance and exposure of interest. We developed and applied a novel geostatistical framework for joint spatial modelling of multiple indices of disease reservoir abundance and human infection risk.

Results

The estimated infection rate was 51.4 (95%CI 40.4, 64.2) infections per 1000 follow-up events. Infection risk increased with age until 30 years of age and was associated with male gender. Rattiness was positively associated with infection risk for residents across the entire study area, but this effect was stronger in higher elevation areas (OR 3.27 95% CI 1.68, 19.07) than in lower elevation areas (OR 1.14 95% CI 1.05, 1.53).

Conclusions

These findings suggest that, while frequent flooding events may disperse bacteria in regions of low elevation, environmental risk in higher elevation areas is more localised and directly driven by the distribution of local rat populations. The modelling framework developed may have broad applications in delineating complex animal-environment-human interactions during zoonotic spillover and identifying opportunities for public health intervention.

Funding

This work was supported by the Oswaldo Cruz Foundation and Secretariat of Health Surveillance, Brazilian Ministry of Health, the National Institutes of Health of the United States (grant numbers F31 AI114245, R01 AI052473, U01 AI088752, R01 TW009504 and R25 TW009338); the Wellcome Trust (102330/Z/13/Z), and by the Fundação de Amparo à Pesquisa do Estado da Bahia (FAPESB/JCB0020/2016). MTE was supported by a Medical Research UK doctorate studentship. FBS participated in this study under a FAPESB doctorate scholarship.

Muskrats are greater carriers of pathogenic Leptospira than coypus in ecosystems with temperate climates

Knowledge on the possible sources of human leptospirosis, other than rats, is currently lacking. To assess the distribution pattern of exposure and infection by Leptospira serogroups in the two main semi-aquatic rodents of Western France, coypus (Myocastor coypus) and muskrats (Ondatra zibethicus), results of micro-agglutination testing and renal tissue PCR were used. In coypus, the apparent prevalence was 11% (n = 524, CI95% = [9% - 14%]), seroprevalence was 42% (n = 590, CI95% = [38% - 46%]), and the predominant serogroup was Australis (84%). In muskrats, the apparent prevalence was 33% (n = 274, CI95% = [27% - 39%]), seroprevalence was 57% (n = 305, CI95% = [52% - 63%]), and the predominant serogroup was Grippotyphosa (47%). Muskrats should therefore be considered an important source of Grippotyphosa infection in humans and domestic animals exposed in this part of France.

[Leptospirosis in Germany: current knowledge on pathogen species, reservoir hosts, and disease in humans and animals]

Leptospirosis is a zoonotic disease with a wide spectrum of clinical symptoms in humans and animals, ranging from subclinical infections to severe signs of multiorgan dysfunction. In Germany, laboratory confirmation of acute human infection is notifiable based on the Protection Against Infection Act. Disease or occurrence of the pathogen in pigs and sheep must be reported according to the regulation on reportable animal diseases. Transmission occurs via direct and indirect contact with the urine of infected animals, with rodents acting as the main reservoir. With an average annual incidence of 0.1 notified cases per 100,000 inhabitants, leptospirosis is a rare disease in Germany.This review article presents the current knowledge on leptospirosis in Germany in the framework of the project "Improving public health through a better understanding of the epidemiology of rodent-transmitted diseases" (RoBoPub) funded by the Ministry of Education and Research. In a One-Health approach, information about clinical manifestation, available prevalence data in humans and animals, knowledge of pathogen distribution, host association, mode of transmission, and survival in the environment is summarized. Preliminary findings on the influence of fluctuations in rodent populations on the occurrence of leptospirosis are also discussed. The aim of the article is to increase the awareness of this currently neglected disease in Germany.In future, higher temperatures and more frequent heavy rainfalls, which could occur due to climate change, should be taken into account.

An outbreak of leptospirosis among kayakers in Brittany, North-West France, 2016

In September 2016, a cluster of seven kayakers with clinical symptoms of leptospirosis with onset since July 2016 was reported to French health authorities. Human and animal investigations were undertaken to describe the outbreak, identify the likely place and source of infection and implement necessary control measures. We identified 103 patients with clinical symptoms of leptospirosis between 1 June and 31 October 2016 who lived in the Ille-et-Vilaine district in Brittany. Of these, 14 (including the original seven) reported contacts with the river Vilaine during the incubation period and were defined as outbreak cases: eight were confirmed by serology tests or PCR and six were probable without a laboratory confirmation for leptospirosis. All 14 cases were kayakers. Three distinct contamination sites were identified on a 30 km stretch of the river Vilaine. Nine cases reported having skin wounds while kayaking. None were vaccinated against leptospirosis. The outbreak was attributed to Leptospira kirschneri serogroup Grippotyphosa. Animal investigations did not allow identifying the possible reservoir. Leptospirosis outbreaks associated with freshwater sports are rare in temperate climates. The prevention of such outbreaks requires control of potential animal reservoirs in zones such as the Vilaine valley and that kayakers adopt the recommended individual prevention measures.

Spatial epidemiological approaches to inform leptospirosis surveillance and control: A systematic review and critical appraisal of methods

Leptospirosis is a global zoonotic disease that the transmission is driven by complex geographical and temporal variation in demographics, animal hosts and socioecological factors. This results in complex challenges for the identification of high-risk areas. Spatial and temporal epidemiological tools could be used to support leptospirosis control programs, but the adequacy of its application has not been evaluated. We searched literature in six databases including PubMed, Web of Science, EMBASE, Scopus, SciELO and Zoological Record to systematically review and critically assess the use of spatial and temporal analytical tools for leptospirosis and to provide general framework for its application in future studies. We reviewed 115 articles published between 1930 and October 2018 from 41 different countries. Of these, 65 (56.52%) articles were on human leptospirosis, 39 (33.91%) on animal leptospirosis and 11 (9.5%) used data from both human and animal leptospirosis. Spatial analytical (n = 106) tools were used to describe the distribution of incidence/prevalence at various geographical scales (96.5%) and to explored spatial patterns to detect clustering and hot spots (33%). A total of 51 studies modelled the relationships of various variables on the risk of human (n = 31), animal (n = 17) and both human and animal infection (n = 3). Among those modelling studies, few studies had generated spatially structured models and predictive maps of human (n = 2/31) and animal leptospirosis (n = 1/17). In addition, nine studies applied time-series analytical tools to predict leptospirosis incidence. Spatial and temporal analytical tools have been greatly utilized to improve our understanding on leptospirosis epidemiology. Yet the quality of the epidemiological data, the selection of covariates and spatial analytical techniques should be carefully considered in future studies to improve usefulness of evidence as tools to support leptospirosis control. A general framework for the application of spatial analytical tools for leptospirosis was proposed.

Spatiotemporal dynamics and risk factors for human Leptospirosis in Brazil

Leptospirosis is an emerging neglected tropical disease with a worldwide significant global health burden. Between 2000 and 2016, there were 63,302 cases of human leptospirosis and 6,064 deaths reported in Brazil. We modeled the spatiotemporal risk dynamics of human leptospirosis morbidity and lethality, and attributed an easily interpretable risk-based priority index (PI) for all Brazilian federative units to suggest improvements to the national surveillance system. We also developed a conceptual framework of causality and estimated the effects of environmental and socioeconomic determinants of morbidity and lethality. Spatiotemporal risk patterns of morbidity and lethality differed. For morbidity, the pattern was mainly spatial, whereas lethality was mainly explained by the spatiotemporal interaction. The hypothesized causal model explained a relevant fraction of the heterogeneity in the spatial and spatiotemporal interaction patterns. The increase in soil moisture, precipitation, poverty, and the decrease in the proportion of urban households, acted as risk factors. The increase in the proportion of households in which waste is directly collected and in temperature were preventive factors. The structured temporal trend was increasing for morbidity and decreasing for lethality. In terms of morbidity, it was clear that the prioritization should be focused in a couple of states, mainly Acre. In terms of lethality, the allocation of resources need not be as asymmetric, but there was nonetheless a prioritization order. The proposed approach can be used to characterize spatiotemporal dynamics of other diseases and to inform decision makers.