Risk Factors Affecting the Incidence of Leptospirosis in Indonesia:
Literature Review
Siti Hajar Husni1, Martini Martini2, Suhartono Suhartono3
1,2,3Environmental Health Department, Universitas Diponegoro, Semarang Indonesia
*Corresponding email : sitihajarhusni21@gmail.com
Received: November 6, 2022 Accepted: November 23, 2022
Abstract
Leptospirosis is a disease of animal origin or zoonoses that most commonly occurs in tropical countries. Rats are the main reservoir of Leptospira and have an important role in the incidence of leptospirosis in humans. Leptospirosis transmission is related to host factors, disease agent factors, and environmental factors. The purpose of this study was to find out the risk factors that influence the incidence of Leptospirosis. The method used in writing this article is a literature review. The source of the library used in writing this literature review is a journal article from 2017-2021 with from search process through Google Scholar and Garuda Portal. The results showed the presence of rats, the presence of livestock, the presence of standing water around the house, the condition of the living environment, and the type of work of respondents were the dominant factors that influenced the incidence of leptospirosis in Indonesia. The community is expected to maintain the cleanliness of the environment around the house and use PPE when doing risky work.
Keywords: rats, leptospirosis, risk factors, rodentia, zoonosis
Abstrak
Leptospirosis ialah penyakit yang berasal dari hewan atau zoonosis yang paling sering terjadi di negara- negara tropis. Tikus merupakan reservoir utama Leptospirosis dan mempunyai peranan penting pada kejadian Leptospirosis pada manusia. Penularan Leptospirosis berkaitan dengan faktor host, faktor agen penyakit dan faktor lingkungan. Tujuan dari penelitian ini adalah mengetahui faktor risiko yang mempengaruhi kejadian Leptospirosis. Metode yang digunakan dalam penulisan artikel ini adalah literatur review. Sumber pustaka yang digunakan dalam penulisan literatur review ini adalah artikel jurnal tahun 2017-2021 dengan proses pencarian melalui Google Scholar dan Portal Garuda. Hasil penulisan menunjukkan keberadaan tikus, keberadaan ternak, adanya genangan air di sekitar rumah, kondisi lingkungan tempat tinggal, dan jenis pekerjaan responden adalah faktor dominan yang mempengaruhi kejadian leptospirosis di Indonesia. Masyarakat diharapkan dapat menjaga kebersihan lingkungan sekitar rumah dan menggunakan Alat Pelindung Diri (APD) saat melakukan pekerjaan berisiko.
Kata Kunci: tikus, leptospirosis, faktor risiko, rodensia, zoonosis
1. Introduction
Leptospirosis is a disease caused by the bacterium Leptospira sp. Sources of infection in humans are usually the result of direct or indirect contact with the urine of an infected animal. Many cases of leptospirosis unreported due to the difficulty of clinical diagnosis and the high cost of laboratory examinations.[1] Leptospirosis is all over the world with a spectrum of animals as its hosts. Infection that occurs can be through contact with water or other materials that have been contaminated with animal host’s feces [2].
The disease is particularly at risk in outdoor workers with animals, such as ranchers, farmers, tailors, veterinarians, and military personnel. In addition, leptospirosis is also at risk for individuals exposed to water that has been contaminated with Leptospirosis bacteria. Endemic areas have a peak incidence of leptospirosis, especially during rains and floods [3]. Rats are the main reservoir of Leptospirosis and play an important role in the incidence of Leptospirosis in humans [4].
The clinical action of Leptospirosis is very much the beginning of the flu to kidney failure and pulmonary bleeding accompanied by breathing failure. Leptospirosis can also cause meningitis, difficulty breathing, and until death if without treatment [5]. Leptospirosis transmission is related to environmental factors, including biotic and abiotic contexts. Abiotic environmental factors include rainfall index, air temperature, water temperature, air humidity, light intensity, water pH, and soil pH. Biotic environmental factors include vegetation, trap success and the prevalence of Leptospirosis in mice [2].
The risk factor for the spread of leptospirosis that predominantly occurs in Indonesia, especially Semarang City, is poor environmental conditions, especially during the rainy season when there are a lot of puddles around the house, overflowing gutters, and scattered garbage as well as the presence of rats around the house. In addition, leptospirosis is also at risk for individuals exposed to water that has been contaminated with Leptospirosis bacteria. [6]
Environmental changes such as puddles, muddy surroundings, and the amount of garbage that is buried can be caused by flooding in the area where the situation causes Leptospira bacteria to multiply.
Flooding contaminated with rat urine will enter the human body through wounds on the exposed surface of the skin, and mucous membranes of the eyes and nose. Animals such as cows, goats, dogs, and pigs can develop leptospirosis, but the potential to transmit it to humans is not as great as that of rats. Leptospirosis in Indonesia has a high mortality rate of 2.5-16.4%, and is found at the age of 50 years and above to have a mortality rate of 56% [7].
The provinces of DKI Jakarta, West Java, Central Java, Banten, North Kalimantan, and South Sulawesi have reported cases of leptospirosis in 2020. Nationally, there were 906 cases of Leptospirosis reported in Indonesia in 2020. Over the past 10 years, there has been an upward trend in leptospirosis cases, especially in the last three years. Deaths from leptospirosis in 2020 at the provincial level were much lower than in 2019 and none of the provinces with a CFR of 30%, even the highest CFR of 16.4% occurred in West Java [1].
2. Material and Methods
The method used in this writing is a literature review. Library sources used in the preparation of literature reviews using journal articles from 2017-2021 the article search process through Google scholar and the Garuda portal. Journal articles found using Indonesian and English and using keywords when searching for journals are the risk factors of leptospirosis in Indonesia, behavioral and environmental factors that influence the incidence of leptospirosis, risk factor of leptospirosis, environmental risk factor of leptospirosis in Indonesian. The journal articles found are 15 journals that discuss specifically risk factors with leptospirosis in Indonesia. The published research article has a case-control and cross-sectional research design.
The first step in the study selection is to screen the title and abstract followed by the full text. Non- conforming articles can be issued taking into account their suitability for research purposes
3. Results and Discussion
Based on Table 1, from 15 journals included in this writing, 43 variables were found in total 30 variables of which are statistically meaningful with the incidence of leptospirosis in Indonesia.
Table 1. Results of literature review
No. Writer Purpose Method Sample Variable Result
1. Hajar Camelia Dewi, Ririh Yudhastuti (2019)
Aims to find out what risk factors influence the incidence of leptospirosis in
Gresik county
The design of this study is
observationa l with a case-control design
The number of case samples was 14 people and the control samples were 14 people spread across 7 sub-districts
The variables in this study are age, gender, type of work, presence of puddles, sewer conditions, flood history, presence of vegetation, use of PPE (Personal Protective Equipment) when doing risky work, the habit of washing feet and hands with soap, a habit of closing food
There is a relationship between the presence of standing water with the values of p=0.001 and or= 22. There is a sewer relationship with the incidence of leptospirosis with values of 0.053 and OR=0.205. there is a relationship between the use of PPE with a value of p=0.000 and there is a relationship between hand and foot washing habits with values of p=0.000 and or=0.031 2. Isnaini
Alfazcha Zukhruf, Dyah Mahendras
The purpose of this study is to determine the spatial
The design of this study is
descriptive quantitative.
The number of samples in this study was 13 samples
Gender, occupation, employment history, flood history, rice
The pattern of distribution of leptospirosis cases in the Karang Tengah health center is clustered pattern. Risk factors that are widely found
ari Sukendra (2020)
picture of leptospirosis cases based on
epidemiologi cal and environment al factors
field presence, sewer
conditions, and landfill
conditions
are gender, flood history, sewer conditions, and landfill conditions
3. Diana Andriyani Pratamawati, Ristiyanto, Farida Dwi Handayani, Revi Rosavika Kinansi (2017)
The purpose of this study was to determine the
relationship between community behavioral risk factors and the incidence of leptospirosis and the magnitude of the factors in the Kebumen district
This study uses a type of analytical descriptive research with a control case design
The sample taken in this study was 44 people, consisting of 22 cases and 22 controls.
Gender, age, last education, type of work, going to the yard barefoot, activities in the rice fields, open wounds,
Behavior in the yard barefoot has a 0.25 greater risk of developing leptospirosis.
Activities in the rice fields have an OR of 0.16 and if there is an open wound of 0.12. These three behaviors have an OR value of < 1, meaning they have a small risk value for leptospirosis.
4. Maya Sofiyani, Ruben Dharmawan, Bhisma Murti (2018)
This study aims to analyze the risk factors for
leptospirosis in Klaten, Central Java
This research is an analytical and
observationa l study with a case- control design
Samples from 49
leptospirosis sufferers and 101 controls were
selected.
Work, wound history, water tourism history, education, PPE
use, the
physical condition of the house, living environmental conditions, presence of rats or livestock, history of rain/flooding
Water tourism, open wounds, poor condition of the environment, and poor physical condition of the house indicate an increased risk of leptospirosis. The use of PPE, and knowledge of the home environment reduces the risk of leptospirosis. The presence of mice in the home environment increases the risk of leptospirosis.
5. Patria Sari Dewi, Setyo Sri Rahardjo, Bhisma Murti (2020)
This study aims to analyze the environment al risk factors for the incidence of
leptospirosis in Klaten regency, Central Java
This is a case-control study conducted at the Klaten Health Center, Central Java
Each health center was taken 10 people, for a total of 210 research subjects.
With 39
leptospirosis patients
The house's condition, the settlement's condition, the presence of rats, livestock,
the area
bordering the river, the flooded area, age, gender, and occupation.
The risk of leptospirosis increases directly with the presence of rodents and flooded areas. The risk of leptospirosis decreases at the age of 20 to <60 years and the female sex. The risk of leptospirosis is indirectly influenced by the presence of rodents, the presence of livestock, flooded areas, poor settlement conditions, the poor physical condition of the house through the area adjacent to the river, and the poor physical condition of the house, and work in wet areas.
6. Hari Baruki Notobroto, Yudied Agung Mirasa,
The purpose of this study is to identify sociodemogr aphic,
This study used a case- control design conducted in
Samples consists of 28 cases and 112 controls
The variables of this study are education, work, healthy living, house
The results of logistic regression showed that the dominant variables associated with the incidence of leptospirosis were
Firman Suryadi Rahman (2021)
behavioral, and
environment al factors related to the incidence of leptospirosis in the highlands of the Ponorogo district
15 villages in Ponorogo.
density, livestock ownership, the distance of the house to the
pen, cow
ownership, the presence of rats in the house
livestock ownership, low education, crowded house density, and a distance from the house to the cage of fewer than 10 meters.
7. Marek Samekto, Suharyo Hadisaputro, Mateus Sakundarno, Suhartono, Bagoes Widjanarko (2019)
This study aims to determine the factors that
influence the occurrence of
leptospirosis in starch districts
Types of observationa l and analytical research. A descriptive study with a control case study design.
The samples in this study consisted of 44 cases and 44 controls with
consecutive sampling techniques
The presence of puddles around the house, the presence of garbage near the house, the characteristics of the
impermeability of the house, the condition of the sewers, the presence of rats, work, income, the habit of wearing footwear, the habit of bathing and washing in the river, and socialization related to leptospirosis.
The presence of rats in the house, the characteristics of the house are not
impermeable to rats, and the habit of wearing footwear has been shown to affect the incidence of leptospirosis.
The presence of standing water around the house, the presence of garbage in the house, poor sewer
conditions, risky work, low income, bathing and washing habits in the river, and no socialization of leptospirosis disease have been shown to not affect the incidence of leptospirosis.
8. Hanifah Agda Nursitasari (2019)
The purpose of this study was to analyze environment al risk factors and individual characteristic s of the incidence of leptospirosis in Ponorogo Regency
This
research was conducted using the design of the control case
The sample in this study had a ratio of 1:3 with a comparison of the number of cases of 9 people and control of 27 people.
Respondent’s behavior, the physical environment of home
conditions (temperature, humidity, and lighting) rat- proofing, and the biological environment.
Bad habits such as rinsing hands and feet in puddles after work are 10 times more at risk of causing leptospirosis and installing SPAL as a protective factor against the incidence of leptospirosis.
9. Raysha Afiff, M Sakundarno Adi, Lintang Dian Saraswati, M. Arie Wuryanto
This study aimed to describe the risk factors of
leptospirosis in the highlands.
This type of research is descriptive with survey and observation methods using a cross- sectional design, that
The total sample was 300 cadre houses divided into 5 sub-districts in Semarang.
Temperature, humidity, the height of the premises, condition of the walls of the house,
ownership of farm animals, the presence of rodents, means
Favorable environmental factors coupled with the majority of people's work in farming and raising livestock are one of the increasing risks of leptospirosis. Farm animals are a risk factor for leptospirosis because they can be a medium for the transmission of leptospirosis bacteria
is, research methods that are carried out only in a certain period.
of disposal of garbage, vegetation, and sources of provision of clean water.
10. Widya Hary Cahyati, Lia Diah Kumalasari (2020)
This study aims to spatially analyze the environment al factors of leptospirosis in Bonang District.
This researcher has a cross- sectional design.
The samples in this study were 24 people spread across Bonang District.
The variables studied in this study are flood / tidal history, the state of individual landfills, the distance of rivers, rice fields, and ponds to residential housing, and population density associated with leptospirosis events.
The pattern of distribution of leptospirosis cases in Bonang District is unevenly
distributed. The poor state of individual TPS and the presence of rice fields and rivers close to the case house can increase the risk of leptospirosis events.
11. Ragil Andriani, Dyah Mahendras ari Sukendra (2019)
The purpose of this study was to determine the
relationship between environment al factors and leptospirosis prevention behavior to the incidence of
leptospirosis in the endemic area of
leptospirosis Puskesmas Bonang I, Demak Regency
The design of this study is cross- sectional
Sample of 68 houses with cluster sampling technique
The variables in this study were the distance between the house and the sewer, the presence of ponds, the presence of garbage around the house, the presence of puddles, a history of participation and activities at risk of
leptospirosis, risky work, and preventive behaviors.
There is a relationship between the distance of the house and the sewer, the presence of standing water, the history of participation and activities at risk of leptospirosis, and the type of work against the incidence of leptospirosis.
12. Dessy Elva Listianti, Suryono, Wartini (2017)
The purpose of this study was to determine the risk factors for leptospirosis in Boyolali Regency, Central Java 2017
This study is an analytical survey with a Case- Control design
The samples in this study were 26 patients as cases and 26 samples as control. So that a total of 52 samples
The variables in this study are behavior, the presence of standing water, the availability of clean water, the presence of rats, the presence of domestic animals, the type of work, the level of education, the
There was a significant association between behavior and leptospirosis (p=0.012) OR (3.068) and CI (0.982- 9.591) values, there was a significant association between the presence of standing water, the availability of clean water, the presence of rat
populations, the presence of animals with the incidence of leptospirosis
level of knowledge 13. Siti
Thomas Zulaikhah, Ratnawati, Adithya Khalimurro syid (2020)
The purpose of this study was to analyze the most dominant risk factors related to leptospirosis in Semarang City
This type of research is analytical and
observationa l with a case- control design.
Sampling technique using proportional random sampling
The sample was calculated based on the sample size formula and obtained 24 cases and 24 controls.
Age, gender, education, occupation, the physical environment of the house, knowledge of leptospirosis, and behavior against leptospirosis.
The results of the bivariate analysis showed a knowledge significance value of 0.001;
home environment = 0.001;
behavior = 0.021. The results of the multivariate analysis obtained knowledge p = 0.04;
Odd ratio = 6.376; CI = 1,092-37,210, home physical environment p = 0.254; Odd Ratio = 2.553 CI = 0.509- 12.797.
The most dominant risk factor associated with leptospirosis is knowledge.
14. Sulistyawati, Righa Pradana, Sandheep Sugathan (2020)
This study aims to investigate the
relationship between human behavior and leptospirosis
The design used is case- control from December 2017 to January 2018
The sample used 24 cases and 24 controls with a total of 48 respondents
Work, history of wounds, bathing and washing in the river, use of PPE, work, and the presence of livestock around the house.
It was found that a history of wounds, bathing and washing habits in the river, not using PPE, and the presence of livestock around the house carried the risk of leptospirosis, but were not significantly related.
15. Novie Ariani, Tri Yunis Miko Wahyono (2019)
To find out the factors that
influence the incidence of leptospirosis in 2
district location of sentinel leptospirosis surveillance in Banten in 2017-2019
The study plan is cross- sectional
The sample population is suspected of leptospirosis found in sentinel leptospirosis in Tangerang district, Serang. Data used secondary data from sentinel leptospirosis surveillance results in zoonotic subsites
Gender, age, occupation, the presence of rodents, uncovered feeding storage, the presence of pets, the presence of farm animals, flooded houses of the last 2 weeks, there is an activity in the river, cleaning waterways without PPE, cleaning garbage without PPE.
From all the variables studied after the multivariate test, six variables were found to be significantly
meaningful, namely, the variables of sex, age, closed food storage, the presence of rats, the presence of pets, and contact with stagnant water.
The most influencing variable was the rat presence variable with a p-value of 0.001 95%CI 1.738-9.566
The entire variable of statistically related articles is the most influential factor in the incidence of leptospirosis in Indonesia based on the similarity of results between researchers. Such factors are the presence of mice (5 articles), the presence of livestock (5 articles), the presence of standing water around the house (4 articles), the environmental conditions of the dwelling (3 articles), and the type of work (3 articles).
3.1. The presence of mice
The physical condition of the house that does not meet the health requirements makes it easier for rats to enter the house, thereby increasing the presence of rats in the house. The presence of rats can also be caused by the presence of garbage that is not managed properly and poor lighting because rats’ nest in dark places. The presence of rats around the house has the potential for leptospirosis transmission [8].
Frequent types of rats as a reservoir for the occurrence of leptospirosis are rius rats (R.norvegicus), house mice (R.diardii), garden mice (R.exulans), house moles (Suncus murinus) [9].
Research by [10] showed that the response that there was a rat population in their neighborhood had a risk of 3,167 times greater than respondents who did not have rats in their homes. This is reinforced by [11] in 2020 that the response to rats in their homes has a risk of 4 times compared to respondents who do not have rats in their homes at 2020 [12]. Leptospirosis in Indonesia is mainly spread by mice that release bacteria through urine into the environment [9]
3.2. The existence of livestock
Most tropical countries including developing countries are likely to be the greatest exposure to leptospirosis in humans, one of which is due to infection with farm animals [9]. The presence of livestock has a role in increasing the incidence of leptospirosis in humans.
Based on the research [13], it’s known that livestock ownership is the dominant aspect associated with the incidence of leptospirosis by having a 13,830 times greater risk of increasing the incidence of leptospirosis compared to respondents who do not have livestock. This is in line with research conducted by [14] showing that most of the houses in the Semarang highlands (67%) studied have risky livestock such as cows, goats, and chickens. This is a favorable environmental factor for leptospirosis crossing because farm animals can be a medium for transmitting leptospira bacteria.
3.3. Waterlogging around the house
Puddles around a house are water that stagnates above ground level that can potentially be reached by rats and passed by humans. Waterlogging is one of the risk factors for the physical environment of leptospirosis. Some respondents who have standing water around the house have a greater risk of developing leptospirosis. Based on research by [15] showed that there is a relationship between the presence of waterlogging and the incidence of leptospirosis in Gresik Regency. There were 12 people with leptospirosis who had waterlogging around their homes, especially during the rainy season, while in the control group only 3 people had standing water in their home environment. The results of research by [11]
showed that respondents who had contact with stagnant water had a 2 times risk of developing leptospirosis compared to respondents who had no contact with stagnant water.
3.4. Environmental conditions of residence
Poor living environmental conditions can increase the risk of leptospirosis. Some risk factors of the residential environment with unhealthy physical conditions of the house, sewers near the house that do not apply, and garbage around the house are not managed properly [9].
According to the results of the research of [16] that there is an indirect effect of the poor physical condition of the home environment on the incidence of leptospirosis, the effect of poor home physical conditions on the presence of rats is positive and statistically significant [16]. Based on the research of [17]
that a poor physical environment increases the risk of leptospirosis up to 6,023 times compared to a good environment.
3.5. Types of work
Work is an important risk factor. The main occupational groups at risk of contact with the source of infection are farmers or plantation workers, pet shop workers, breeders, sewer cleaners, slaughter workers, meat processors, veterinarians, the military, etc [9]. Based on the results of research by [3] that leptospirosis disease that occurs in Kebumen is closely related to activities in rice fields with the characteristics of the group of patient cases showing the majority as farmers. The results of the analysis showed that respondents who were active in rice fields were 0.16 times more affected by Leptospirosis. This is in line with the research of [18] that Leptospirosis sufferers in Bonang District show the largest percentage of respondents working as farmers and fishermen/laborers increased by 37.5% and 30%.
4. Conclusion
The main factors that can influence the incidence of Leptospirosis in Indonesia are disease agent factors, host factors, and physical environmental factors. Based on a literature study from 15 articles studied, there are dominant factors as the cause of leptospirosis in Indonesia, namely the presence of rats, the presence of livestock, standing water around the house, environmental conditions, and types of work.
It is hoped that people in leptospirosis endemic areas will be able to maintain the cleanliness of the home environment and its surroundings, clean puddles at home, wear PPE (Personal Protective Equipment) when carrying out risky activities, and maintain the cleanliness of livestock pens and their surroundings.
5. Acknowledgments
Thank you to Martini (first supervisor) and Suhartono (second supervisor) at Universitas Diponegoro, who have provided direction and guidance in the preparation of this literature review article.
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