In Kerala, leptospirosis spread faster than the health department's warnings after floods

Even as flood waters started receding in Kerala in the second and third weeks of August, the state’s health authorities were preparing for a possible outbreak of leptospirosis. The Directorate of Health Services released an action plan for prevention and control of communicable diseases that includes protocol for the control of leptospirosis. Yet, many leptospirosis deaths have occurred in what can only be called epidemic conditions.

The Integrated Disease Surveillance Programme or IDSP data shows that as of September 11, there have been 1,318 confirmed cases and 53 confirmed deaths this year while the number of suspected cases is 2,598 and number of suspected deaths is 95. Most of these cases and deaths have occurred after the floods. The State Health Department’s statistics indicates that since September 1 alone there have been 1,107 suspected cases and 33 suspected deaths while there have been 570 confirmed cases and 18 confirmed deaths.

Leptospirosis is a bacterial disease that is transmitted from animals – in this case rats – to humans. The disease is also called rat fever or “eli pani” in Malayalam. There is always an increased threat of the disease after floods as urine of infected rats and other rodents contaminate water and the Leptospira bacteria can pass on to humans who come in contact with the water. Elderly people and those suffering from kidney or liver ailments are more vulnerable to the disease. Its symptoms include high fever, headache, chills, abdominal pain and rashes.

When Kerala sounded an alert for leptospirosis on August 28, health authorities mentioned Thrissur, Palakkad, Kozhikode, Malappuram and Kannur as districts facing high risk of infection. In the week of September 1-7, Thrissur and Palakkad did not report deaths, but three deaths were reported in new districts, Thiruvananthapuram and Pathanamthitta where leptospirosis is endemic and the floods enabled the transmission of the parasite from rats to humans.

Gaps in communication

The Directorate of Health Services’ detailed action plan for the post-flood control of leptospirosis named organisations and individuals responsible for control measures and indicated the timeline of specific actions to be taken – that is, what needed to be done during the floods, after the water receded and during the post-flood cleaning process. Health authorities made efforts to prevent outbreaks by providing prophylactic drugs in flood-affected areas. Yet, directorate’s follow-up reports indicate that many of those who died had not taken the prophylactic doses for various reasons, including inaccurate public perception of the leptospirosis risk and weak communication of this risk in the immediate aftermath of the floods.

Rescue workers, including from the Army and Navy, distributed doxycycline to flood-affected people. Doxycycline is a prophylactic medicine used to prevent the incidence and spread of leptospirosis. Health authorities also supplied relief camps with doxycycline to be given to anyone who had to wade through knee deep water. Health and other relief and rescue volunteers were told about the importance of these prophylactic doses. Even with supplies of doxycycline being used up quickly, especially in places like Kozhikode, and some taluks having their drug stores flooded and their stocks ruined, health authorities say that they have been able to replenish supplies.

However, grassroots health workers and volunteers engaged in rescue efforts on the ground may not have understood the seriousness of the threat of leptospirosis. When they handed out the prophylactic drug doxycycline to groups of flood-affected people, they may not have clearly communicated the exact doses required for individuals – adults, adolescents and children. In addition, many fake WhatsApp messages about the effectiveness of various preventive measures have been circulated in Kerala in the weeks after the floods, which could have undermined the risk perceptions.

Moreover, not all health professionals may have been aware of the specific treatment protocols for infectious diseases in general and leptospirosis in particular. There is a need to get the treatment protocols to treating physicians across the state, and all resources including social media have been used for this purpose.

Damage control

The directorate has since issued specific guidance for prophylactic doses and treatment options. The state’s health experts from its government medical colleges have been working to adapt existing treatment protocols for use in relief camps and during rehabilitation. Health authorities also marked out special sites within hospitals to isolate and treat leptospirosis patients.

Hospitals have also played an important in reporting leptospirosis cases and deaths, which enables authorities to better implement disease control measures. While at most times, private hospitals sometimes hesitate to report deaths due to infections fearing that they might be blamed for poor treatment, they have been more proactive in reporting cases in the aftermath of the floods.

All told, the state health machinery seems better prepared to deal with the leptospirosis outbreak now than it was when the floods began receding.

Mala Ramanathan is professor and Ravi Prasad Varma is associate professor at the Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum.