Laboratory capacity building and implementation of enhanced surveillance for leptospirosis and melioidosis in Puerto Rico

CDC Partner Project – Technical Assistance for Response to Public Health (CDC-RFA-OT18-1804)

Leads: Amy Kircher, akircher@umn.edu, Claudia Munoz-Zanzi, munozzan@umn.edu

This project is developing and planning to implement a surveillance system in Puerto Rico to identify and treat cases of leptospirosis and melioidosis earlier, better define at-risk areas and predominant local risk factors, and inform prevention recommendations. It is creating both epidemiologic and laboratory capacity to complement existing leptospirosis and melioidosis passive surveillance. Utilizing active surveillance methods and protocols throughout the territory, researchers will be able to investigate the local ecology of leptospirosis in hurricane-affected jurisdictions thereby creating a protocol to implement and activate surveillance post disaster. The project goals include building and improving laboratory capacity and disease awareness to support patient diagnosis and surveillance for leptospirosis and melioidosis in US territories.

Project Approach:

Leptospirosis is a bacterial disease caused by pathogenic bacteria of the genus Leptospira. This zoonotic pathogen is transmitted directly or indirectly from animals (wild and domestic) to humans. The incidence of infection is exacerbated during periods of drastic environmental disturbance, such as heavy rains and floods. Environmental factors are also thought to be important for infections acquired through daily activities as a result of contact with a Leptospira-contaminated environment. Typical risk factors include agricultural practices, animal or sewage contamination of water, poor housing and waste disposal, and changes in the density of animal reservoirs, namely rodents. In September 20, 2017 the island of Puerto Rico was hit by hurricane Maria causing one of the largest natural disasters in recent history. The nearly category 5 storm devastated the electric grid, severely disturbed access to all health services, interrupted water services and access to clean water, disconnected communities, blocked and destroyed roads, and paralyzed the functioning of all systems on the island. As a result, there has been an increase in leptospirosis cases and deaths. Between the challenging conditions and the need for laboratory testing to diagnose cases, underdiagnosis and underreporting is expected which leads to underestimation of risk areas. This, together with misinformation and technical challenges, impedes proper surveillance and, therefore, implementation of timely and effective public health responses. Well-built and -maintained public health infrastructure geared toward both prevention and preparedness is the first line of defense against health threats. Furthermore, activities related to prevention, epidemic investigation, and control require a sophisticated level of decision making and resource coordination. Objectives of this project are:

• To improve leptospirosis and melioidosis epidemiological capacity and knowledge to identify and treat cases of leptospirosis and melioidosis earlier,
• To define at-risk areas and predominant local risk factors
• To inform prevention recommendations.
• To complement existing leptospirosis and melioidosis passive surveillance by building active surveillance sites
• To investigate the local ecology of leptospirosis

We will first set up a robust hospital/clinic-based surveillance program for leptospirosis and melioidosis under the umbrella of laboratory testing of patients seeking for febrile illness. A critical component of this program is to establish a process for improved access to diagnosis including confirmation. We will implement this program in 3-5 sites selected based on prior information on leptospirosis occurrence, on the health system network, and the information to be gained to understand the epidemiology of these diseases. Subsequently, data and findings provided by the surveillance program will inform additional investigation into specific risk factors at the community and individual level, animal reservoirs and community education and public health response.