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Environmental and Behavioural Determinants of Leptospirosis Transmission a Systematic Review

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Abstract

Leptospirosis is a zoonotic disease that globally spreads and has the potential to become an epidemic. In Indonesia, the incidence of leptospirosis tends to increase with case fatality rate ranged from 5 to 12%. Ponorogo is one regency in Province of East Java, Indonesia that has loftier incidence of leptospirosis. The objective of this study was to place sociodemographic, behavioral, and environmental factors associated with incidence of leptospirosis in highlands of Ponorogo regency. The study used example control design conducted in 15 villages in the highlands of Ponorogo regency. The sample was equanimous of 28 cases of leptospirosis and 112 nonleptospirosis. The variables of this study were sociodemographic, behavioral factors, ecology factors, and incidence of leptospirosis. Data was collected past interview using questionnaire and observation of ecology conditions. Data was analyzed using chi square and logistic regression. The result showed that factors associated with the incidence of leptospirosis were education (p = 0.019), occupation (p = 0.003), health practise (p = 0.007), house density (p = 0.013), livestock ownership (p = 0.004), distance from house to cowshed (p = 0.024), cow ownership (p = 0.010), and the presence of rats in the house (p = 0.050). The result of logistic regression assay showed that the variables dominantly associated with the incidence of leptospirosis were livestock buying, educational activity (depression), firm density (crowded), and distance from house to cowshed (less than ten k). In determination, sociodemographic, behavioral, and environmental factors were associated with the incidence of leptospirosis in highlands of Ponorogo Regency.

Keywords

  • Behavioral
  • Environmental
  • Highlands
  • Leptospirosis
  • Sociodemographic

one. Introduction

Leptospirosis is a zoonotic affliction that is widespread in the world, can attack humans or animals, and has the potential to go an epidemic that has a significant bear on on health.

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This disease is acquired by a screw-shaped bacterial infection of the genus Leptospira pathogens that can naturally exist transmitted from vertebrate animals to humans or vice versa.

Information technology can be transmitted through direct contact of mucous membranes or opened skin with a source of infection or through intermediary media such every bit h2o, soil and food. I of the near important reservoirs that tin transmit leptospirosis are mammals including rats, cattle, dogs, and cats.

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The incidence of leptospirosis in the world is estimated at 320,000 per twelvemonth,

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by and large in tropical and subtropical areas, both in the highlands and lowlands.

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Leptospirosis cases in Indonesia tend to increase in the number of cases and deaths in the menses 2004–2013. The highest incidence occurred in DKI Djakarta due to heavy flooding in 2007 with 113 cases and 20 people died (CFR = nineteen.iv%).

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In Ponorogo Regency the number of leptospirosis cases until 2015 was 92 with v deaths. The highest number of cases was in 2011 with 30 cases and iv deaths (CFR 13.3%), 74 cases (80%) occurred in the highlands that were not flooded areas. The distribution of leptospirosis cases in Ponorogo Regency until 2015 was spread over 10 subdistricts and there are 4 subdistricts that accept height of more than than 500 thousand.

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The high cases of leptospirosis in the tropics and subtropics areas tin can be associated with unfavorable environmental atmospheric condition. This makes Leptospirosis leaner grow and reproduce.

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The wide spread of leptospirosis that attacks the customs can potentially cause outbreaks. Therefore, it is of import to behave out cross-sectoral outbreak control efforts in assisting health workers in conducting epidemiological investigations, coordinating the formation of fast-moving teams, empowering communities, and carrying out community control.

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According to the Directorate General of P2PL, Ministry of Health, RI, the type of occupation is an important risk factor for humans.

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The results of an epidemiological investigation of the Ponorogo District Wellness Office showed that leptospirosis cases were often institute in farmers (60.5%) both farmers in rice fields and farmers in clove and pine plantations, cattle farmers, and sand miners in rivers (17.4%). Most cases were male person with productive historic period between 30 and 55 years and 79% cases accept cattle.

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Ponorogo Health Office
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This occupational risk cistron fits within the adventure groups, merely there are other occupational factors for the Ponorogo expanse, namely sand mining in the river.

Environmental risk factors related to the incidence of leptospirosis included housing and workplace sanitation atmospheric condition. These weather condition include open sources of wastewater disposal and the presence of rats. Semipermanent houses and buildings that exercise non have ceilings make it easier for rats to enter the house. The presence of garbage around the house besides makes the rat population around the house increase. Other environmental gamble factors are history of flooding, the presence of water around the house, the waterways that are not smooth, the sanitation of the business firm that is not practiced, and high rainfall.

,

The hazard in the highlands in Ponorogo is the factors of unhealthy settlement such as semi-permanent business firm walls, house floors fabricated of soil, cowshed in the house, the presence of potential disease vectors, namely the presence of rats within and outside the house.

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These conditions indicate that the potential for the spread of leptospirosis cases is still high and requires more comprehensive control in terms of wellness, farming, and agriculture.

,

In addition to individual and environmental characteristics, beliefs is an important factor in the incidence of leptospirosis. Knowledge, attitudes, and private practice in the prevention of leptospirosis play important function for the incidence of leptospirosis. The objective of this study was to analyze the influence of sociodemographic characteristics, behavior and ecology factors on the incidence of leptospirosis in the highlands of Ponorogo Regency, East Java Province.

2. Materials and methods

This research was analytic observational with instance command design. The report was conducted in 15 villages of 4 subdistricts in the highlands of Ponorogo Regency, East Java Province, Indonesia in the catamenia March 2016 to February 2017. Cases were populations who had suffered from leptospirosis i-twelvemonth menses prior to the data collection menses. Information of cases were obtained from the Chief Health Cares. Controls were populations that had never suffered from leptospirosis, living in the aforementioned village with the leptospirosis cases. Sample of case were all cases of leptospirosis in 15 villages as many every bit 28 people. Sample of controls were neighbors of leptospirosis cases drawn past unproblematic random technique with the ratio of case and control is 1–4. So 112 people were taken as controls. The variables studied in this inquiry were socio-demographic characteristics, including age, gender, education, and occupation; behavior, including noesis near leptospirosis, attitudes, practices for preventing leptospirosis, and mobility; ecology factors, including house density, livestock ownership, distance from business firm to cowshed, sewerage, puddle, source of clean water, the presence of rats in the business firm and effectually the business firm, trash cans, vegetation, and road conditions. Data was nerveless by interview using questionnaire and ascertainment of ecology weather. Data was analyzed descriptively by tabulating the distribution of information, bivariate analysis using Chi Square test or Fisher's exact test, and multivariate assay using multiple logistic regression.

3. Results

This research was conducted in 15 villages from 4 sub-districts in Ponorogo Regency, Eastward Coffee Province. One hundred and forty respondents consisting of 28 cases of Leptospirosis and 112 controls were interviewed. The distribution of respondents is described as follows.

  • 1

    Sociodemographic Characteristics

The average age of the respondents is 45.86 ± nine.41 years. The hateful age in the example grouping was 47.86 ± 7.18 years while in the control group is 45.36 ± 9.86 years. There was no pregnant deviation in mean historic period between case and control groups (p > 0.05). The distribution of respondents by age, sex, didactics, and occupation is described in Table 1.

Table 1 Distribution of respondents based on sociodemographic characteristics.

Characteristics Category Example (n = 28) Command (due north = 112) P
Age (years) 30 0 (0.0%) seven (vi.3%) 0.258
31–40 4 (14.iii%) 26 (23.2%)
41–50 12 (42.nine%) forty (35.7%)
51–60 12 (42.9%) 34 (xxx.4%)
>sixty 0 (0.0%) 5 (iv.5%)
Gender Male 17 (sixty.seven%) sixty (53.half dozen%) 0.640
Female 11 (39.3%) 52 (46.four%)
Education Low 24 (85.vii%) 67 (59.8%) 0.019
Medium to High 4 (14.three%) 45 (twoscore.2%)
Occupation Farmers/breeders 23 (82.one%) 54 (48.2%) 0.003
Some other v (17.9%) 58 (51.eight%)
  • Open table in a new tab

Table i shows that the historic period of cases ranged from 31 to 60 years, well-nigh of the them were male (60.vii%), had low education (85.7%), and worked as farmers or breeders (82.1%). At that place was no meaning departure in age and gender distributions between the instance and control groups (p > 0.05), simply there were meaning differences in the distribution of education and occupation betwixt the case and control groups (p < 0.05). It seems that low didactics and employment as farmers or breeders have a relationship with the incidence of leptospirosis.

  • two

    vBehavioral Factors

There are 4 behavioral aspects observed in this written report, namely the respondent'south knowledge about leptospirosis, attitudes, leptospirosis prevention practices, and mobility. The score of each aspect is classified into two categories, skillful and poor. The distribution of each behavioral attribute is described in Table 2.

Table 2 Distribution of respondents based on behavioral factors.

Behavior Category Case (due north = 28) Control (n = 112) P
Knowledge Good 13 (46.4%) 62 (55.4%) 0.525
Poor 15 (53.6%) 50 (44.vi%)
Attitude Good nineteen (67.9%) 85 (75.9%) 0.530
Poor 9 (32.1%) 27 (24.i%)
Practice Expert 13 (46.4%) 84 (75.0%) 0.007
Poor 15 (53.half-dozen%) 28 (25.0%)
Mobility Low 25 (89.3%) 97 (86.6%) 1000
Loftier 3 (x.7%) 15 (13.4%)
  • Open table in a new tab

In Table 2 information technology can be seen that the exercise of leptospirosis prevention is the only aspect that has a human relationship with the incidence of leptospirosis. Respondents who had poor practise had a college probability of suffering from leptospirosis (p < 0.05). Noesis about leptospirosis, attitude, and mobility had no relationship with the incidence of leptospirosis (p > 0.05).

  • 3

    Environmental Factors

There are 13 environmental aspects discussed in this report, namely: firm density, livestock ownership, altitude from house to cowshed, cow ownership, goat ownership, sewerage, puddle, source of clean water, the presence of rats in the business firm, the presence of rats around the house, vegetation, trash can, and road conditions. Each aspect is categorized based on the aspects presented in Table 3.

Table 3 Distribution of respondents by environmental factors.

Environment Category Instance (n = 28) Control (north = 112) P
Business firm density Non crowded thirteen (46.4%) 82 (73.2%) 0.013
Crowded (<8m2/prs) 15 (53.6%) 30 (26.8%)
Livestock buying No 1 (three.vi%) 37 (33.0%) 0.004
Yes 27 (96.iv%) 75 (67.0%)
Distance from business firm to cowshed 10 chiliad or more 10 (35.7%) 69 (61.6%) 0.024
Less than 10 m 18 (64.3%) 43 (38.four%)
Moo-cow ownership No 8 (28.half dozen%) 65 (58.0%) 0.010
Yes 20 (71.four%) 47 (42.0%)
Goat ownership No 6 (21.4%) 39 (34.8%) 0.258
Yes 22 (78.half dozen%) 73 (65.ii%)
Sewerage Eligible 21 (75.0%) 101 (ninety.two%) 0.053
Not eligible seven (25.0%) 11 (9.8%)
Puddle No 11 (39.3%) 65 (58.0%) 0.117
Aye 17 (60.vii%) 47 (42.0%)
Source of clean water Boreholes 1 (3.6%) 11 (9.eight%) 0.134
Dug well 5 (17.9%) 36 (32.1%)
Water springs 22 (78.vi%) 65 (58.0%)
The presence of rats in the house No ii (seven.i%) 30 (26.viii%) 0.050
Yes 26 (92.ix%) 82 (73.2%)
The presence of rats around the business firm No 6 (21.4%) 30 (26.eight%) 0.735
Yes 22 (78.6%) 82 (73.ii%)
Vegetation No 5 (17.9%) 31 (27.vii%) 0.411
Yes 23 (82.ane%) 81 (72.3%)
Trash can Yes, well managed 18 (64.iii%) 82 (73.ii%) 0.483
No, scattered 10 (35.7%) 30 (26.8%)
Road conditions Dry 17 (threescore.7%) 58 (51.8%) 0.525
Watery x (39.three%) 54 (48.ii%)
  • Open table in a new tab

Based on the results of the bivariate examination of ecology factors with cases and controls, it is known that, environmental aspects related to the incidence of leptospirosis are: house density (0.013), livestock ownership (0.004), distance from house to cowshed (0.024), cow buying (0.010) and the presence of rats in the house (0.050) with a value of p < 0.05.

  • 4

    Result of Multivariate Analysis

Based on the results of bivariate analysis, aspects of teaching, practice of prevention, firm density, livestock ownership, and the distance from the business firm to the cowshed, and the presence of rats in the house accept significant human relationship with the incidence of leptospirosis. Furthermore, multivariate analysis of these variables was carried out using multiple logistic regression tests in analyzing the dominant aspect and the magnitude of run a risk (OR) described in Tabular array four.

Table iv Results of multiple logistic regression in analyzing leptospirosis risk factors.

Contained Variable B P OR 95% CI for OR
Lower Upper
Instruction (Low) 1.463 0.019 4.319 ane.278 14.594
House density (Crowded) 1.300 0.008 3.671 ane.398 ix.638
Livestock ownership (Yeah) two.627 0.014 thirteen.830 1.702 112.382
Distance from house to cowshed (Less than ten m) 1.146 0.019 3.146 1.206 viii.210
Constant −5.836 0.000
  • Open table in a new tab

Based on the results of the multivariate assay in Table 4, it is known that livestock ownership was the dominant aspect associated with the incidence of leptospirosis, followed by education, house density, and distance from firm to cowshed. Livestock buying had OR 13.830 (with 95% CI of 1.702–112.382), means that respondents with livestock ownership had a 13.830 times greater take chances of developing leptospirosis compared to respondents with no livestock ownership. Teaching had an OR value of 4.319 (with 95% CI of ane.278–14.594), means that respondents with low instruction were at risk of developing leptospirosis 4.329 times than respondents with higher teaching. Furthermore, house density had an OR of 3.671 (with 95% CI of 1.398–9.638). This ways that respondents lived in a crowded house were at risk of leptospirosis 3.671 greater than those lived in uncrowded house, while the distance from house to cowshed had OR iii.146 (with 95% CI of i.206–8.210), ways that respondents who had firm close to the cowshed had a 3.146 times greater take chances of developing leptospirosis compared to respondents who had a house far from the cowshed.

This upshot shows that environmental factors and educational activity have chief role in the transmission of leptospirosis. House and environmental sanitation should receive more attention in efforts to prevent and control leptospirosis. Community behavior, especially practise of prevention, must be improved so that efforts to control leptospirosis can provide the expected results.

four. Discussion

Based on the results of the study, the most of leptospirosis cases were 41–60 years sometime and male. This is in line with the results of inquiry conducted in Brazil which stated that leptospirosis sufferers were found in the adult male group (over 35 years) which was as much as 80%.

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This effect occurred because near of the male population in the historic period group of 40 years piece of work as farmers and cattle breeders also equally sand miners in rivers. This is evidenced by the results of this study that almost of the sufferers likewise work as farmers or breeders. In addition, the results of this study are in line with research conducted by Pramestuti et al., in 2015 which stated that well-nigh leptospirosis set on men of productive age who work outside the home.

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The high risk of farmers getting leptospirosis occurs because the animals or mammals called reservoirs that announced good for you merely are actually infected and can transmit leptospirosis to humans.

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Reservoirs that are in contact with the community can increase the risk of leptospirosis transmissions. Direct or indirect contact between farmers or breeders and reservoirs can exist the reason for the spread of leptospirosis transmissions.

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Furthermore, based on the level of education, most people with leptospirosis have depression level of educational activity. The results of statistical tests too showed that respondents with a low level of education had a 4.319 times greater risk of developing leptospirosis than respondents with a high level of teaching. The low level of teaching is related to the level of knowledge virtually leptospirosis.

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The depression level of cognition and pedagogy nearly the dangers of leptospirosis can lead to a subtract in the level of awareness nigh leptospirosis, and then that leptospirosis can easily spread amongst the community.

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Human behavior factors are aspects that determine human activeness. Based on the results of the written report in Tabular array 2, it is known that the bulk of leptospirosis sufferers take a lower level of knowledge, and poor practice of leptospirosis prevention. A low level of knowledge tin can cause a low level of public awareness of leptospirosis. Based on Table 2, it is known that leptospirosis prevention exercise is associated with the incidence of leptospirosis. The results of this study mean that the incidence of leptospirosis is closely related to customs behavior, specially efforts to prevent disease, particularly leptospirosis. The level of instruction can affect the incidence of leptospirosis; people who have high level of teaching accept an event on disease prevention behavior which is also high by applying the importance of clean and healthy living beliefs in daily life. Practices of leptospirosis prevention behavior that tin can exist carried out include maintaining individual hygiene afterward activities outside the home, especially in areas or activities with a loftier risk of exposure to leptospirosis such as breeders and farmers.

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In addition, using personal protective equipment is also recommended for people who directly contact with livestock that tin can be a reservoir of leptospirosis.

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Environmental factors are one of the main factors that cause the spread of leptospirosis transmission. The house component is one of the environmental factors related to the spread of leptospirosis. House components that do not come across the requirements can lead to the presence of disease-conveying vectors, namely rats.

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Firm density is one aspect associated with the incidence of leptospirosis. Business firm density is defined as the floor area in the business firm compared to the number of residents in the house. Based on Regulation of the Minister of Health of the Democracy of Indonesia Number 829 of 1999 apropos Housing Health Requirements, the standard for business firm density is the unit of square meters per person under 8 square meters per person. Based on the results of the study, respondents with high housing density (crowded) had a iii.671 times greater adventure of developing leptospirosis than respondents with low firm density. The majority of leptospirosis sufferers in Ponorogo Regency live with a large number of family members in 1 house. A narrow firm with a large number of residents will cause many diseases, especially infectious diseases that will easily spread to all members of the house such as leptospirosis.

Customs ownership of livestock is also a source of disease transmission. Based on the multivariate logistic regression test, it yielded information that respondents who own livestock were at risk of contracting leptospirosis xiii,830 times than respondents who did not own livestock (Tabular array 4). Leptospirosis can be transmitted through livestock or mammals such as cattle or goats. This is caused past infection with pathogenic bacteria directly through the urine of infected animals or indirectly due to contact between humans and h2o or soil that has been contaminated with urine from infected animals.

The results of this written report were in line with the research which stated that the almost of leptospirosis cases occurred in areas with ownership of pets and livestock such as dogs, buffalo, and cows.

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Also, Noach and Noach in their enquiry institute that the prevalence of leptospirosis in cattle was 20%. Furthermore, the area where people alive with livestock tend to be close to the cage, with the reason that they tin monitor their livestock.

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The distance between the cowshed and house that are shut (less than ten m) can increase the risk of leptospirosis transmission past 3146 times. This is because infected livestock do non ever show symptoms. Infected livestock manure will pollute the environment effectually the house such as sewerages, make clean water sources, and vegetation.

Furthermore, puddles of water, sewerage, and waste direction are also factors associated with disease manual, one of which is leptospirosis. Just, based on the results of this study, puddles of water, sewerage, and trash tin can were non related to the incidence of leptospirosis in highlands of Ponorogo Regency. This happens considering based on the results of interview and observations, the aspects of environmental weather of cases and controls were the same. This finding differs from the enquiry result of Cahyati & Kumalasari

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that garbage storage and the beingness of puddy fileds and sewerage were risk factors of leptospirosis. Their research was conducted in lowlands. Other environmental factor associated with the incidence of leptospirosis in this study was the presence of rats in the firm. Most of the respondents stated that in their house, specially in leptospirosis cases, rats were found. This can be the reason for the spread of leptospirosis that can occur in some people in Ponorogo Regency. Rats every bit the main reservoir of leptospirosis can transmit leptospirosis bacteria direct to humans through rat droppings, or through rat tracks in trash cans, sewerages, puddles, and vegetation.

Different from several studies that accept been carried out, which more often than not accept one aspect or factor to be analyzed, this study comprehensively analyzed individual characteristics, behavior, and environmental factors to identify risk factors for leptospirosis in highland areas. Likewise, the selection of locations in rural areas in the highlands is related to geographical weather and the risk factors studied exercise non change rapidly or relatively stable. However, several variables that are theoretically associated with the occurrence of leptospirosis have not been analyzed in this written report, such every bit the type of firm edifice, permanent or semi-permanent, flooring material, and climate.

In the future, in add-on to examining variables that have non been studied in this study, it is recommended to conduct farther inquiry past conducting laboratory examinations of the urine of livestock (cow or goat) or the kidneys of rats to detect the presence of leptospirosis bacteria.

5. Conclusion

Sociodemographic factors, namely the level of educational activity and occupation, behavioral cistron, namely practise of leptospirosis prevention, and environmental factors, namely business firm density, livestock ownership, altitude from firm to cowshed and the presence of rats in the business firm are associated with the incidence of leptospirosis in highlands of Ponorogo Regency.

Acknowledgements

Authors would similar to admit the heads of Health Office and Primary Health Centers of iv subdistricts in the highlands of Ponorogo Regency for providing secondary data on Leptospirosis.

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Article Info

Publication History

Published online: November 30, 2021

Accepted: November xiv, 2021

Received in revised class: November 2, 2021

Received: October 2, 2021

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DOI: https://doi.org/10.1016/j.cegh.2021.100911

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