GUIDELINES FOR THE DIAGNOSIS, MANAGEMENT,

PREVENTION AND CONTROL OF LEPTOSPIROSIS IN

MALAYSIA

DISEASE CONTROL DIVISION

DEPARTMENT OF PUBLIC HEALTH
MINISTRY OF HEALTH MALAYSIA
2011
1ST edition

i
FOREWORD
Leptospirosis occurs worldwide and can be a serious public health issue in a humid
tropical and subtropical country such as Malaysia. Although leptospirosis cases have
been reported in Malaysia since the 1920s, the actual disease burden in the country
is unknown due to it not being a notifiable disease under the Prevention and Control
of Communicable Diseases Act 1988 until recently.

Leptospirosis is also known as the Great Mimicker and may be overlooked and
underdiagnosed due to its varied clinical presentations. It is important for our
healthcare personnel to recognize the various presentations and thus take the
opportunity to provide early treatment with the appropriate antibiotics to patients and
prevent complications.

I would like to commend the Zoonosis Sector for bringing together a multidisciplinary
group of health professionals in developing this guideline which will serve as a
guiding tool in creating awareness and assisting healthcare personnel in the
diagnosis, management, prevention and control of leptospirosis in Malaysia.

I also encourage constructive comments and feedback from the implementers at all
levels to further improve this guideline in order to control this disease in the most
effective, coordinated and organized manner.

Dr. Lokman Hakim B. Sulaiman

Director of Disease Control

Ministry of Health, Malaysia

2011

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ADVISORS
Dato Dr. Hasan Abdul Rahman
Deputy Director General of Health (Public Health)

Dr. Lokman Hakim B. Sulaiman

Director of Disease Control

CHIEF EDITOR

Dr. Khebir bin Verasahib

Head of Zoonosis Sector

EDITORIAL BOARD

Dr. Husna Maizura Bt. Ahmad Mahir

Cik Ong Chia Ching

Tn Hj. Abdul Jamil B. Ali

iii
CONTRIBUTORS
Disease Control Division Dr. Noraini Bt Ismail
Hospital Sultanah Bahiyah, Alor Setar
Dr. Khebir B. Verasahib
Dr. Shaari B. Ngadiman Dr.Chow Ting Soo
Dr. Hj. Daud Abdul Rahim Hospital Pulau Pinang
Dr. Balachandran A/L Satiamurti
Dr. Rosemawati Bt. Ariffin Dr. Kan Foong Kee
Dr. Husna Maizura Bt. Ahmad Mahir Hospital Sultanah Aminah, Johor Bahru
Dr. Junaidi B. Djoharnis
Dr. Muhamad B. Ismail Encik Alex Francis
Tn Hj. Abdul Hamid B. Osman Hospital Raja Permaisuri Bainun, Ipoh
Cik Ong Chia Ching
Tn Haji Wagimon B. Amat Dr. Zulhizzam B. Hj. Abdullah
Tn Hj. Abdul Jamil B. Ali Perlis State Health Department

National Institutes of Health Dr Uma Salmah Bt. Abd. Kadir

Institut of Medical Research Dr. Shareh Azizan Shareh Ali
Kedah State Health Department
Dr. Norazah Bt. Ahmad
Dr Fairuz Amran Dr. Saraswathi Bina Rai
Pulau Pinang State Health Department
National Public Health Laboratory
Dr. Puvaneswari a/p Subramaniam
En. Khairul Azan B. Hashim Perak State Health Department

Medical Development Division Dr. Anita Bt. Sulaiman

Selangor State Health Department
Dr. Inderjeet Kaur Gill
Dr. Maznieda Bt. Mahjom
Family Health Development Division WP Kuala Lumpur State Health Department

Dr. Aizuniza Abdullah Dr. Hamizar Iqbal B. Abdul Halim

Negeri Sembilan State Health Department
Planning and Development Division
Dr. Hashimah Bt. Hassan
En.Ahmad Jessren Kamaruddin Melaka State Health Department
Dr. Fathullah Iqbal Ab. Rahim
Dr. Zuraidah Bt. Mokhtar
Engineering Services Division Johor State Health Department

En. Nazri B. Salleh Dr. Hj. Mohamed Sapian B. Mohamed

Siti Asma Bakar Pahang State Health Department

Health Education Division To' Puan Dr. Rahmah Bt. Elias

Terengganu State Health Department
En. Sasitheran K.Nair
Dr. Suhaiza Bt. Sulaiman
Hospital Kuala Lumpur Kelantan State Health Department

Dr. Kamarul Azahar Mohd Razali, Dr. Maria Bt. Suleiman

Sabah State Health Department
State Health Departments

Dr.Benedict Sim Lim Heng

Hospital Sg. Buloh

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Table of Contents

Foreword

1. Introduction

2. Epidemiology

3. Factors Responsible For The Emergence Of Leptospirosis

4. Modes of Transmission

5. High Risk Groups

6. Clinical Manifestations

7. Case Classifications
7.1 Suspected case
7.2 Probable case
7.3 Confirmed case

8. Notification

9. Treatment

10. Prophylaxis

11. Surveillance

11.1 Hospital Based Surveillance

11.2 Serosurveillance (Laboratory Based Surveillance)
11.3 Active Surveillance

12. Outbreak Response

13. Prevention and Control

14. References

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List Of Annex

Annex 1 Collection and Transportation of Sample (Clinical & Environmental) and

Criteria for Water Sampling
1a - Laboratory Request Form from IMR
1b - Laboratory Request Form from MKAK (MKAK-BPUI-U01)
1c - Laboratory Request Form from MKAK (MKAK-PER-104B-02/1)
Annex 2a Rev/2010 Form (Notification Form) in National Language
Annex 2b Rev/2010 Form (Notification Form) in English
Annex 3 Leptospirosis Case Investigation Form
Annex 4 Example of Leptospirosis database format
Annex 5 Outbreaks Preliminary Report BKP/WABAK/01/2005
Annex 6 Flow Chart of Notification of cases/outbreak
Annex 7a Example of Risk Assessment Form (Man made Recreational
Park)
Annex 7b Example of Risk Assessment Form (Natural Recreational Park)
Annex 8a Example of Health Hazard Signage In National Language
Annex 8b Example of Health Hazard Signage In English

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1. INTRODUCTION

Leptospirosis is a common public health problem worldwide with an estimated anuual

incidence ranging from 0.1 to 1 per 100 000 per year in temperate climates to 10 or
more per 100 000 per year in the humid tropics (1). The estimated case-fatality rates in
different parts of the world have been reported to range from <5% to 30% (1). These
figures however are probably grossly underestimated because in many countries
especially those where the disease is highly endemic, diagnostic capabilities are not
readily available resulting in significantly poor surveillance and reporting of leptospirosis
(2).

Leptospirosis is an infectious disease with broad range of clinical manifestations,

ranging from mild flu-like illness to very severe disease with haemorrhagic
manifestations and multiorgan failures. Severe leptospirosis commonly resulted in case
fatalities if aggressive managements are not instituted at an early stage (1).

In Malaysia, an increasing number of reported cases and outbreaks which had resulted
in significant number of deaths have been observed over the past decade. There is a
great need for improvement is case surveillance, in order to define strategies in control
and prevention of case morbidity and mortality related to this disease. Thus, under the
Prevention and Control of Infectious Diseases Act 1988 leptospirosis has been gazetted
as a notifiable disease on 9 December 2010.

This guideline is drawn up through joint efforts of various Ministry of Health experts to
provide information on the disease and guides on diagnostic criteria, management of
diagnostic samples and notification procedures.

The aims of this guideline include:

To increase awareness among the healthcare personnel on the

importance of leptospirosis.
To guide in diagnostic procedures in order to obtain early diagnosis so
that prompt and appropriate management can be instituted and
prevention and control measures can be carried out at the earliest
possible stage to reduce morbidity and mortality.
To quantify and monitor leptospirosis disease burden and its distribution
throughout the country.
To obtain good epidemiological and clinical data on leptospirosis which is
important for improving strategies in prevention and control of the disease.

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2. EPIDEMIOLOGY

Leptospirosis is an infectious disease caused by pathogenic spirochete bacteria of the

genus leptospira that are transmitted directly or indirectly from animals to human (i.e., a
zoonotic disease). Pathogenic leptospires belong to the species Leptospira
interrogans, which is subdivided into more than 200 serovars with 25 serogroups (3).
The leptospiral serovars are naturally carried in the renal tubules of rodents, wild and
domestic animals.

Leptospirosis is usually a seasonal disease that starts at the onset of the rainy season
and declines as the rainfall recedes. Sporadic cases may occur throughout the year with
outbreaks associated with extreme changing weather events such as heavy rainfall and
flooding (2).

The incidence of Leptospirosis was not well documented in Malaysia due to it not being
a notifiable disease, previously. Currently available leptospirosis country data for
Malaysia is based on the Report of Morbidity and Mortality for Ministry of Health
Hospitals. Since these cases were from hospital records, it is not known whether they
were sporadic cases or related to clusters (epidemiological link).

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 Table 1 showed an apparent increase in leptospirosis cases which could be due to
several reasons such as an actual rise in the number of cases, increased awareness
and diagnosis, reporting, and laboratory capacity.

Table 1: CASES OF LEPTOSPIROSIS IN MINISTRY OF HEALTH HOSPITALS,

MALAYSIA FROM YEAR 2004 TO 2009

No State Year
2004 2005 2006 2007 2008 2009
1 Perak 29 (4) 71(4) 93 (9) 149 (3) 289 (16) 280 (19)
2 Selangor 16 (5) 20(3) 37 93 97 (2) 208 (7)
3 Pahang 29 (1) 24 51(3) 184 (3) 198 (7) 184 (5)
4 Kelantan 15 (1) 38 (1) 17 (1) 81(1) 180 (4) 138 (4)
5 Terengganu 7(1) 17 42(1) 55(3) 107 (4) 126 (9)
6 Kedah 15 (1) 27 31 28 (1) 52 (2) 106 (9)
7 N. Sembilan 27(1) 41 24 49 59 91
8 Sarawak 32 (2) 42 (2) 37 (3) 46 (1) 58 (5) 70 (4)
9 Johor 30 (1) 29 (6) 31 (2) 115 (2) 87 (3) 59 (3)
10 WP KL 31 20 (1) 27 (1) 31 45 54
11 Sabah 13 (1) 12 (1) 19 41 (2) 34 (2) 35 (1)
12 P. Pinang 9 25 (1) 28 37 25 (2) 32
13 Melaka 7 (1) 9 (1) 79 (2 ) 32 (1) 25 20 (1)
14 WP 1 1 7 3 1 14
Putrajaya
15 Perlis 2(1) 2 4 5 6 1
16 WP Labuan 0 0 0 0 0 0
Total 263 (20) 378 (20) 527 (22) 949 (22) 1263 (47) 1418 (62)
( ) Death

Source:

Report of Morbidity and Mortality for Patients For The Year 2004 to 2009, Health
Management Information System, Medical Care Subsystem, Health Informatics Centre,
Planning and Development Division, Ministry of Health, Malaysia

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3. FACTORS RESPONSIBLE FOR THE EMERGENCE OF LEPTOSPIROSIS

The conditions that are favourable for maintenance and transmission of Leptospirosis
are:

a) Reservoir and carrier hosts

Leptospirosis has a very wide range of natural rodent, and non-rodent reservoir
hosts especially rats, cattle, dogs, foxes, rabbits, etc. The animals act as carriers
of the leptospires and excrete large number of leptospires in their urine, thus
responsible for the contamination of large and small water bodies as well as soil.

b) Flooding, drainage congestion

Flooding and drainage congestion may be risk factors for contamination of water
bodies with infected animal urine. Water logged areas may force rodent
population to abandon their burrows and contaminate the stagnant water by their
urine.

c) Animal-Human Interface

The potential for infection increases through exposure from occupational or

recreational activities without proper protection. Poor cleanliness/sanitation in
recreational areas may attract animal host such as rodent thus increases the risk
of contamination. These may be due to poor maintenance of facilities, improper
disposal of waste and public attitude/ apathy.

d) Human host risk factors

Several sections of the population are more susceptible to infection such as

those not previously exposed to the bacteria in their environment (nave
immunities), and those with chronic disease and open skin wounds.

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4. MODES OF TRANSMISSION

Infection is acquired from contact through skin, mucosa/ conjunctiva with water or soil
contaminated with the urine of rodents, carrier or diseased animals in the environment.
Ingestion of contaminated water may also cause infection. There is no documentation of
human to human transmission.

5. HIGH RISK GROUPS

Exposure depends on chance contacts between human and infected animals or a

contaminated environment through occupational and/or recreational activities. Some
groups are at higher risk to contract the disease such as:

Workers in the agricultural sectors

Sewerage workers
Livestock handlers
Pet shops workers
Military personnel
Search and rescue workers in high risk environment
Disaster relief workers (e.g. during floods)
People involved with outdoor/recreational activities such as water recreational
activities, jungle trekking, etc.
Travelers who are not previously exposed to the bacteria in their environment
especially those travelers and/or participants in jungle adventure trips or outdoor
sport activities
People with chronic disease and open skin wounds.

6. CLINICAL MANIFESTATIONS

The incubation period is usually 10 days, with a range of 2 to 30 days (3).

The clinical manifestations are highly variable. Typically, the disease presents in four
broad clinical categories (1):

(i) a mild, influenza-like illness (ILI);

(ii) Weil's syndrome characterized by jaundice, renal failure, haemorrhage
and myocarditis with arrhythmias;
(iii) meningitis / meningoencephalitis;
(iv) pulmonary haemorrhage with respiratory failure.

Clinical diagnosis is difficult because of the varied and non-specific presentation.

Confusion with other diseases, e.g. dengue and other haemorrhagic fevers, malaria,
typhoid, melioidosis, influenza, etc. is particularly common in the tropics. Presentations
may also overlap as the infection progresses.

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7. CASE CLASSIFICATION

Leptospirosis is difficult to distinguish from a number of other diseases on clinical

grounds alone. History of possible exposure is paramount to aid clinical diagnosis.

7.1 Clinical case

A case that is compatible with the following clinical description:

Acute febrile illness with history of exposure to water and/or environment

possibly contaminated with infected animal urine with ANY of the following
symptoms:
Headache
Myalgia particularly associated with the calf muscles and lumbar region
Arthralgia
Conjunctival suffusion
Meningeal irritation
Anuria or oliguria and/or proteinuria
Jaundice
Hemorrhages (from the intestines and lungs)
Cardiac arrhythmia or failure
Skin rash
Gastrointestinal symptoms such as nausea, vomiting, abdominal pain,
diarrhea

7.2 Probable Case

A clinical case AND positive ELISA/other Rapid tests.

7.3 Confirmed case:

A confirmed case of leptospirosis is a suspected OR probable case with any

one of the following laboratory tests:

Microscopic Agglutination Test (MAT),

For single serum specimen - titre 1:400
For paired sera - four fold or greater rise in titre

Positive PCR (samples should be taken within 10 days of disease onset)

Positive culture for pathogenic leptospires (blood samples should be taken

within 7 days of onset and urine sample after the 10th day)

Demonstration of leptospires in tissues using immunohistochemical staining

(e.g. in post mortem cases)

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 In places where the laboratory capacity is not well established, a case can be
considered as confirmed if the result is positive by two (2) different rapid
diagnostic tests.

Cases that require confirmation are:-

Hospitalized cases
All suspected leptospirosis death cases

Notes on Laboratory Diagnosis

In cases which needed to be confirmed (hospitalized and suspected death

cases), serum samples should be sent for confirmation by MAT. The MAT is
considered the "gold standard" or cornerstone of serodiagnosis because of its
unsurpassed diagnostic (serovar/serogroup) specificity in comparison with other
currently available tests. Second serum samples must be taken to detect fourfold
or greater rise in titre.

Simple serological screening method can be done using the rapid test kit for
Leptospira. Reminder: any leptospirosis rapid test kit to be used must be
validated/approved by IMR.

The ELISA/other rapid tests detect IgM antibodies. The presence of IgM
antibodies may indicate current or recent leptospirosis. A patients serum may be
positive 5 to 10 days after onset of symptoms but not usually before this.
Reminder: IgM-class antibodies may remain detectable for several years.

If the initial sample was taken at an early stage in the infection, the ELISA test
may be positive but MAT negative. Therefore a follow-up sample is required.
Test may be negative if the serogroup of the infecting strain does not react with
the Patoc 1 serovar strain used as the antigen. If antibiotics are given from the
beginning of the illness, the immune and antibody response may be
delayed.

The diagnosis is also confirmed by isolation of Leptospires from blood (first 7

days) or CSF (days 4-10) during the acute illness, from urine (days 7) and from
tissue samples, by using special media. Inoculation of young guinea pigs,
hamsters or gerbils can also be carried out for isolation of leptospires.
Leptospires die quickly in urine. Clean urine sample should be inoculated into
appropriate culture medium not more than 2 hours after voiding. Survival in acid
urine may be increased by making it neutral.

For postmortem diagnosis, in addition to serology and culture, leptospires can be

demonstrated in tissues using PCR or immunohistochemical staining, notably by direct
immunofluorescence.

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Figure 1: Leptospiremic phases in conjunction with the laboratory methods of
diagnosis (4).

Note: Biphasic nature of leptospirosis and relevant investigations at different stages of

disease. Specimens 1 and 2 for serology are acute-phase specimens, 3 is a
convalescent-phase sample which may facilitate detection of a delayed immune
response, and 4 and 5 are follow-up samples which can provide epidemiological
information, such as the presumptive infecting serogroup (4).

Refer to Annex 1 for collection and transportation of clinical and environmental

samples for leptospirosis and criteria for water sampling.

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8. NOTIFICATION

For the purpose of notification, all probable and confirmed cases must be notified to
the nearest Health District Office within 1 week of the date of diagnosis.

Notification of cases can be done using Rev/ 2010 form (Annex 2).

All notified cases must be investigated using the Investigation Form (Annex 3).

9. TREATMENT

Early treatment with antibiotics is essential.

Adults

Severe cases are usually treated with high doses of IV C-penicillin (2 M units 6
hourly for 5-7 days). Less severe cases treated orally with antibiotics such as
doxycycline (2 mg/kg up to 100 mg 12-hourly for 5-7 days), tetracycline,
ampicillin or amoxicillin.

Third generation cephalosporins, such as ceftriaxone and cefotaxime, and

quinolone antibiotics may also be effective. Jarisch-Herxheimer reactions may
occur after the start of antimicrobial therapy.

Monitoring and supportive care as appropriate, e.g. dialysis, mechanical

ventilation.

Pediatrics

Preferred Alternative Comments

Penicillin G >8yrs: Penicillin:
100 Doxycycline use in moderate to severe disease
000U/kg/dose 4mg/kg/dose oral caution in impaired renal function
IV 6hourly x 12hourly x 7days Jarisch-Herxheimer reaction has been
7days <8yrs: described in patients with leptospirosis
Ampicillin
75-100mg/kg/dose oral Doxycycline:
6hourly x 7days used for only mild disease
or can cause permanent discoloration of teeth
Amoxicillin
50mg/kg/dose oral 6- Ampicillin/Amoxycillin:
8hourly x 7days 2nd line agent or for pts < 8yrs

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10. PROPHYLAXIS

The cost effectiveness and risk versus benefits of antibiotic prophylaxis for
leptospirosis remains unclear. If prophylaxis is considered, the possible options
include:

Pre-exposure Prophylaxis

May be considered for people at high risk of exposure to potentially contaminated

sources e.g. soldiers going into jungles, rescue team, persons involved in
activities in possible high risk areas e.g. adventurous sports.

Dose:

Doxycycline 200mg stat dose then weekly throughout the stay

OR
Azithromycin 500mg stat dose then weekly throughout the stay (For pregnant
women and those who are allergic to Doxycycline)

However the benefit of pre-exposure prophylaxis remains controversial where

possible benefits need to be balanced with potential side effects (e.g. doxycycline
induced photosensitivity, nausea, etc.)

Empirical treatment for Post-Exposure

In an outbreak, there may be a role for post exposure prophylaxis for those
exposed to a common source as the index case. Dose:

Doxycycline 200mg stat dose then followed by 100mg BD for 5 7 days for
those symptomatic with the first onset of fever.
OR
Azithromycin 1gm on Day-1, followed by Azithromycin 500mg daily for 2 days
(For pregnant women and those who are allergic to Doxycycline)

Note:
The role of prophylaxis in children has not been adequately studied.

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11. SURVEILLANCE

Reliable data on the incidence and prevalence of leptospirosis in many parts of the
world are scarce and most probably overlooked and underreported (1). Studies may be
performed on selected groups (rice farmers, meat workers, etc.) in a population that is
likely to be exposed to leptospires. While the incidence rate for the whole of the
population in an area may be low, it may be very high in a selected risk group.
Preventive methods may be focused on selected risk groups.

In order to obtain the actual disease burden leptospirosis is made a notifiable disease in
Malaysia under the Prevention and Control of Communicable Diseases Act 1988 since
2010. For the purpose of surveillance, the State Health Departments must compile a
database for Leptospirosis. This database must have information on possible source of
infection (Annex 4).

11.1 Hospital-based surveillance

The diagnosis should be confirmed by laboratory tests as the clinical manifestations of

leptospirosis are often atypical. Leptospirosis should be suspected in patients
presenting with symptoms such as fever, severe headache, prostration, aching muscles
or conjunctival suffusion, or patients presenting with signs of aseptic meningitis, adult
respiratory distress syndrome with pulmonary haemorrhage, kidney failure or jaundice.
Data should be collected on the age, sex, occupation and exposure history (place, date,
conditions of animal contact or contact with contaminated environment) of the patient.

Laboratory methods are required to confirm the diagnosis. Isolation followed by typing is
essential for surveillance as it provides information about the leptospires circulating in a
certain area. In addition, typing data can be compared with the clinical manifestations of
the disease in the area concerned. Serology is also important but, because of cross
reactions, the information obtained is of limited value in terms of causative serovars.
Mild cases may not be admitted to hospital, so hospital-based surveillance may result in
a bias towards severity in assessing the public health importance of leptospirosis.

Very severe cases may also be missed as patients may die at an early stage of the
disease before the diagnosis can be established. Especially in these cases, culture,
PCR and immunohistochemistry may be useful methods of demonstrating the
leptospiral aetiology in post-mortem samples.

11.2 Serosurveillance (Laboratory based surveillance)

The detection of persisting antibodies by the microscopic agglutination test (MAT) may
give an indication of the prevalence of leptospirosis in an area. It is best to carry out the
MAT using a panel of antigens that is representative of the locally circulating
leptospires. If the local strains are not fully known, a broad panel with representative
strains of all currently known serogroups should be used. Persisting antibodies from a
past infection are usually serogroup-specific. Titres to serovars used as antigens and

11
their frequency of distribution may give information on the prevalence of these serovars
or on antigenically similar serovars belonging to the same serogroup.

ELISA tests provide information only on recent or current cases and no information on
the circulating serovars because they use a broadly reactive so-called genus-specific
antigen to check for IgM antibodies.

11.3 Active Surveillance

In certain circumstances, active surveillance can be carried out and helpful in

determining the incidence of leptospirosis in a community. Such active surveillance may
provide valuable information on the "normal" incidence of leptospirosis in a community
and may identify serovars present in the area. Arrangement with public health
laboratories may enable samples to be analysed.

12. OUTBREAK RESPONSE

Definition:

An outbreak is defined as more than one probable or confirmed cases of

leptospirosis with an epidemiological link within one incubation period.

All cases must be investigated and control measures taken wherever

possible. During an outbreak, the District Health Office should also investigate
the clinical cases. All symptomatic cases in an outbreak should be admitted to
hospital for laboratory confirmation and treatment.

All outbreaks must be notified to National Crisis Preparedness and Response

Centre (CPRC) KKM by phone or text/sms to on-call surveillance at 013-6699700
or email to cprc@moh.gov.my

Send all outbreak preliminary reports to the CPRC, Disease Control Division by
e-mail, text/sms, and fax using the BKP/WABAK/01/2005 Form (Annex 5) within
24 hours.

A final report must be produced after 1 month the outbreak ends and sent to
CPRC, Disease Control Division.

Refer Annex 6 for Flow Chart of Notification of cases/outbreak.

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13. PREVENTION & CONTROL

Because of the large number of serovars, variety of infection sources and the wide
differences in transmission conditions, the prevention and control of leptospirosis is
complex. Effective prevention and control can be achieved by controlling the reservoir
or reducing infection in animal reservoir populations such as dogs or livestock via
treatment or vaccination of the animals. Control of wild animals may be difficult.
Preventive measures must be based on knowledge of the groups at particular risk of
infection and the local epidemiological factors.

Prevention and control should be targeted at:

(a) The infection source;

(b) The route of transmission between the infection source and the human host;
or
(c) Prompt and proper treatment of infection.

13.1 Preventive and Control Measures

Health Education: Health education activities are to be carried out to create

awareness among the public about the disease and motivate them to take
preventive actions. This needs to be done through multiple strategies in order to
reach the specific target groups. This could be done by using the electronic,
printed and interpersonal means. It is important to ensure that messages
delivered are relevant, timely and culturally acceptable to the target groups. A
proper needs assessment has to done to ascertain the target groups needs in
order to alleviate their fear and concerns.

Risk assessment of possible contaminated water sources/bodies. Examples of

risk assessment forms used by Perak State Health Department are attached in
Annex 7a & 7b.
Reminder: The formats are flexible and changes can be made according to
the situation in respective states.

Alert public or users regarding the hazards of possible contaminated areas.

Health hazard warning signage (examples as in Annex 8a & 8b) should be
posted in areas found to be contaminated through environment risk assessment
(co-operation with local authorities).

Persons with occupational or recreational exposure to potentially contaminated

water or soil should:-

o Wear waterproof protective clothing such as rubber boots and gloves.

o Cover skin lesions with waterproof dressings.
o Wash with clean water immediately after exposure.

13
 o Seek immediate medical treatment if develop symptoms within the
incubation period.

Advise public to keep their homes and premises free from rodents.

Advise people to vaccinate their pets against leptospirosis.

Promote cleanliness at the recreational areas, food premises as well as housing

area.

Promote interagency collaboration such as with local authorities, Wildlife

Department (PERHILITAN), Department of Veterinary Services (JPV), National
Training Service Department (JLKN), etc. to maintain cleanliness in the
respective environmental settings, especially rodent control.

14
REFERENCES

1. World Health Organization. Human leptospirosis: guidance for diagnosis,

surveillance and control; 2003.

2. World Health Organization. Report of the First Meeting of the Leptospirosis

Burden Epidemiology Reference Group. Geneva; 2010

3. Heymann DL, editor. Control of Communicable Diseases Manual. 18th ed.

Washington, DC: American Public Health Association; 2004.

4. Levett PN. Leptospirosis. Clinical Microbiology Reviews. 2001;14(2):296-326.

15
 Annex 1
COLLECTION AND TRANSPORTATION OF CLINICAL AND ENVIRONMENTAL SAMPLES FOR LEPTOSPIROSIS

1. Clinical Sample

Table1: Clinical sample Collection and Transportation

Test Specimen Container Storage & Where to send

Transport
condition
ELISA or any Serum Plain tube (3 mL) Ambient. 1. Hospital with
other rapid If delay is facilities or
immune unavoidable store 2. IMR or
diagnostic kit at 4-8C. 3. MKAK (for
community outbreak)

MAT Serum (same sample for ELISA can be used Plain tube (3 mL) Ambient or 4-8C 1. IMR
for MAT) if delay is 2. MKAK (for
A repeat convalescent sample (at least 1 week unavoidable community outbreak)
later) is necessary to confirm cases.
a
PCR Whole blood EDTA tube (2mL) Ambient or 4-8C 1. IMR
if delay is 2. MKAK (for
unavoidable community outbreak)
b
Mid stream Urine
Sterile plain leak Ambient.
proof container.
c
Culture Blood Heparin tube Ambient IMR
(4-5 mL)

CSF / body fluids Sterile container Ambient

Tissue Sterile container Ambient

16
 Notes:
a-Best done during first week of symptoms. Sensitivity is low once seroconversion has occurred
b. only useful if taken 7 days after onset prior to antibiotics.
c. Best sensitivity during first week of symptoms and prior to antibiotic administration. Culture is done mainly for
epidemiological surveillance. Sensitivity is usually less than 30%. This test is not useful for guide in management.
Identification of the isolated leptospiral strain is important in future understanding of disease transmission, knowledge on
reservoir hosts, pathogenesis of disease and useful in decision making regarding use of vaccines for prevention of
disease.
- Clinical sample for community outbreak to MKAK should use form MKAK-BPU-UO1
- Each sample should be properly labeled and sent to laboratory as early as possible. In case of delay, the samples
should be stored at 4-8 C (except samples for culture) before transporting to the laboratory.

Contact numbers:

1. IMR 03-26162504 (Leptospirosis lab); 03-26162658 (Bacteriology Unit)

2. MKAK 03-61261329/1330 (Bacteriology Unit)

Table 2: Post-mortem samples Collection and Transportation (Post-mortem should be performed under strictly
aseptic technique)

Test Specimen Container Transport condition Where to send

PCR Intracardiac blood EDTA Ambient temperature IMR
or 4-8C if delay
Tissues (brain, lung, liver, heart, kidneys) Sterile container unavoidable

CSF
Sterile container
Culture Blood Heparin tubes. Ambient temperature IMR

Tissues, CSF Sterile container

Immunohistochemistry Tissues Paraffin Blocks or slides with mounted Ambient temperature IMR
tissue sections (microtomised tissues 4-40 uM)

17
2. Environmental Sample

Table 3: Environmental Sample Collection and Transportation

Type of Quantity Container Transport condition Where to send

samples
Water 100 250mL Sterile whirl pack or sterile Ambient temperature or 4-8C MKAK Sg. Buloh
bottle if delay unavoidable

Soil (moist soil) 200 gram Sterile whirl pack or sterile Ambient temperature or 4-8C MKAK Sg. Buloh
bottle if delay unavoidable

Notes:
- Use form MKAK-PER-104B-02 / 1 Environment sample.
- Completed laboratory form request and specimen should be sent to MKAK within 48 hours

Viability and reproducibility of pathogenic leptospira reduces at temperature below 10oC. Best to transport environmental
samples only at ambient temperature.

18
3. Animal sample

Trapped rodents or animals to be sent alive to Veterinary Research Institute (VRI). Prior
arrangement must be made before sending of animals.

Contact Number: 05-5457166 ext 138 (Serology Unit, VRI)

19
NOTA:
KRITERIA PEMILIHAN KAWASAN PENSAMPELAN AIR UNTUK UJIAN
LEPTOSPIROSIS

1. Kawasan persampelan air yang sesuai adalah:

i. Kawasan Teduh
ii. Kawasan yang disyaki terdapat kehadiran haiwan (ie: bekas tapak kaki)
iii. Celah- celah Batu

2. Sampel air diambil satu kaki di bawah permukaan air.

NOTA: Penyampel diminta untuk melakarkan bentuk tasik/kolam dengan
melabelkan 4 kawasan persampelan (beserta petunjuk) di ruagan yang disediakan
dalam borang MKAK PER-104B-02 /1

3. Bacaan fizikal : pH, suhu, kekeruhan, clarity dan warna air perlu diambil dan
dicatatkan dalam borang MKAK PER-104B-02 /1 sebelum pensampelan .

TATACARA PENGAMBILAN SAMPEL AIR DARIPADA SUNGAI/TELAGA/ KOLAM/

TASIK/ LOMBONG UNTUK UJIAN LEPTOSPIROSIS

1. Bersihkan baldi logam/aluminium daripada sebarang kotoran.

2. Tuangkan sedikit alkohol 70% ke dalam baldi, nyalakan dan biarkan terbakar
dindingnya (sebelah dalam)untuk pembasmian kumam.

3. Tuangkan alkohol 70% ke dalam dulang dan letakan baldi ke dalamnya. Bakar
dindingnya untuk membasmi kuman di permukaan luar.

4. Turunkan baldi ke dalam sungai/telaga/kolam/tasik dan pastikan talinya tidak masuk

tersentuh ke dalam baldi. Kalau boleh bilas baldi dengan air
sungai/telaga/kolam/tasik pada kawasan yang hendak disampel. Apabila baldi
penuh, naikan ke atas dengan berhati-hati.

5. Buka penutup beg steril/botol steril. Isikan air ke dalam beg steril/botol terus
daripada baldi.

6. Masukkan thiobeg/botol yang telah diisi air ke dalam cool box dalam susunan
menegak Sampel air yang telah dikumpulkan perlu dihantar ke MKAK dengan kadar
segera (48 jam) bersama borang MKAK PER-104B-02 /1 dan disimpan pada suhu
sekitar 4 -8C sekiranya kelewatan tidak dapat di elakkan.

7. Baldi aluminium hendaklah dibasuh dengan air bersih selepas digunakan. Ulang
tatacara ini untuk persampelan di kawasan yang lain.

NOTA: Baldi aluminium perlu dibersihkan dengan air bersih (air paip atau air suling)
sebelum diguna untuk pensampelan di tempat pensampelan yang lain. Baldi hendaklah
dikeringkan untuk disimpan selepas diguna.

20
KRITERIA PEMILIHAN KAWASAN PENSAMPELAN TANAH UNTUK UJIAN
LEPTOSPIROSIS

1. Kawasan tanah persampelan adalah pada jarak kurang dari 5 meter daripada tepi
sungai/kolam/tasik.

NOTA: Penyampel diminta untuk melakarkan bentuk tasik dan kawasan tanah dengan
melabelkan kawasan persampelan (beserta petunjuk) di borang yang disediakan.

2. Proses pengambilan sampel digalakkan pada waktu pagi. Keadaan kawasan

persampelan tanah yang sesuai adalah:
i. Kawasan yang lembap atau basah (terdapat lopak-lopak air)
ii. Kawasan yang teduh
iii. Kawasan yang disyaki kehadiran haiwan (terdapat bekas tapak kaki)

3. Sampel tanah diambil pada area 15-20 cm x 4-8 cm. Kuantiti tanah yang diperlukan
adalah 100-200g. Catatkan suhu dan pH tanah tersebut pada borang permohonan.

4. Sampel tanah dimasukkan ke dalam whirl pack dan dihantar dengan segera ke MKAK
pada suhu ambient dalam tempoh 24 jam atau pada suhu 4-8C sekiranya berlaku
kelewatan.

21
 Annex 1a
LEPTOSPIROSIS LABORATORY REQUEST FORM
BACTERIOLOGY UNIT
INSTITUTE FOR MEDICAL RESEARCH KUALA LUMPUR
Hospital :________________________
R/N:_____________________________
Date of Admission:________________

Sample Type:_____________________
(Please note that blood sample has to be taken using aseptic technique. Whenever
possible, 10 mls of sample is taken, 3 mls in plain tube, 2 mls in EDTA tube and 5 mls in
Heparin tube. If not possible, please send in plain tube only)

Sample No: 1st 2nd 3rd

Sample Date: _____________________
Test Request

Name:____________________ Age:____________
Gender: Male Female
Race : Malay Chinese Indian Others:___________
I/C/ ID No. :____________________________
Address: ______________________________________________
Occupation : ________________
Number of Days of illness prior to admission:__________________ :
History of activities that may predispose to infection: Please state locality where activities
was done and when (days or week before onset symptoms):
__________________________________________________________________
Bathing Fishing
Hunting Camping
Others (State) _____________ Days/weeks before onset illness:_____________
Contact with animals (eg rodents, cows etc) : _____________________________
Underlying disease/s : ________________________
Antibiotic
therapy: ___________________ Date started:___________________
Dialysis: Date/s done: _________________________

Clinical features
Fever Jaundice
Chills and rigors Diarrhoea
Anorexia Rash
Headache Convulsion
Retroorbital pain Lymphadenopathy
Calf pain Hepatomegaly
myalgia Splenomegaly
Conjunctival redness Altered mental status
arthralgia Nausea/Vomiting
Abd. Pain:Which area
Cough OTHER FEATURES
Haemoptysis
Severe pulmonary haemorrhage
22
CXR : __________________

Respiratory failure: Yes/No

ECG abnomalities : ____________________

CSF :____________________

Admitted to ICU : Yes/No

Passed away: Yes/No

Laboratory Results:

Dates

ALT
ALP
Ser. Dir. Billirubin
Ser. Indir. Bilirubin
Albumin
Ser. Creatinine
Urea
K+
Na+
Cl-
Hb
TWC
Neutrophils
Platelets
Creatine Kinase
Ser. Amylase
Prothrombin time
CT
BT
PO2
PCO2
Na Bicarbonate
Urine protein
Urine RBC
Urine Pus cells
CSF cells
CSF protein
CSF sugar

Name of requesting Doctor:_________________________________________

Signature:______________________

23
 Laboratory Request Form MKA (Clinical) Annex 1b
MKAK-BPU-U01
REQUESTOR INFORMATION
Name : Lan No. (for lab use):
Post :
Address : MAKMAL KESIHATAN AWAM
District : State : KEBANGSAAN
Tel. No. : Fax No. : KEMENTERIAN KESIHATAN MALAYSIA
Email : Lot 1853, Kg Melayu Sungai Buloh,
47000 Sungai Buloh, Selangor Darul Ehsan
Tel:03-61565109 Fax:03-61402249/61569654
LABORATORY REQUEST FORM
A. PATIENT'S INFORMATION
Name : Age : Date of Birth :
IC No : Sex : Male Female
Your Reference No. : Marital Status: Single Married
Address : Nationality : Malaysian
Non Malaysian :
District : Postcode :
State : (Please state country of origin)
Tel. No : Occupation :
B. CLINICAL SUMMARY C. PURPOSE OF SAMPLING
Sign and Symptoms : Outbreaks / Cluster Cluster Code:
Diagnostic
Surveillance Specimen Category :
Programme/Projects Case
Others : Contact

D. FOR VACCINE PREVENTABLE DISEASE

Date of onset : Immunisation status (for the specified disease)
Clinical/Provisional Diagnosis : Yes Number of
Doses : Date
of last dose :
No
E. SPECIMEN INFORMATION
Type of Specimen Date and Time of Collection Date Specimen Received
(for lab use)

F. TYPE OF TESTS
Bacterial identification : Serology (Specify) :
(culture sensitivity)
Viral Identification : Others (Specify) :
Isoation / Antigen Detection / Nucleic acid

G. RESULTS (for laboratory use only) :

Verified By : Date :
..
NB : Please send request form in duplicate

24
Laboratory Request Form MKA (Environmental Sample) Annex 1c

MAKMAL KESIHATAN AWAM KEBANGSAAN,

Lot 1853 Kg. Melayu Sg.Buloh
47000 Sg.Buloh, Selangor Darul Ehsan
No. Tel: 03-61261200 No. Faksimili: 03-64102249 / 61569654
---------------------------------------------------------------------------------------------------
BORANG PEMOHONAN PENYIASATAN/PEMANTAUAN LEPTOSPIRA
Institusi yang memohon: Tarikh/ masa pengambilan sampel:

No Faks: Lokasi Persampelan:

Jenis sampel:
Tandatangan/ cop rasmi: Maklumat kes:

Lakaran Kawasan Persampelan/ Kolam:

Petunjuk:

Analisa Parameter Fizikal

ID Masa Suhu pH Kekeruhan Clarity Warna Catatan
Sampel Persampelan (oC)

Tarikh/masa terima sampel:

Nama dan Tandatangan penerima:

25
 Annex 2a
Borang Notis: Rev/2010
No. Siri:

NOTIFIKASI PENYAKIT BERJANGKIT YANG PERLU DILAPORKAN

(Seksyen 10, Akta Pencegahan Dan Pengawalan Penyakit Berjangkit 1988)
A. MAKLUMAT PESAKIT

1. Nama Penuh (HURUF BESAR):

Nama Pengiring (Ibu/Bapa/Penjaga):

(Jika belum mempunyai Kad Pengenalan diri)

2. No. Kad Pengenalan Diri / Dokumen Perjalanan Sendiri Pengiring

(Untuk Bukan Warganegara)

No. Daftar: Nama Wad:_______________ Tarikh Masuk Wad: / /

3. Kewarganegaraan: 4. Jantina: Lelaki Perempuan

Warganegara:
Ya Keturunan: 5. Tarikh Lahir: / /

Sukuketurunan:
(Untuk Orang Asli, Pribumi Sabah/Sarawak) 6. Umur: Tahun Bulan Hari
Tidak Negara Asal:
Status 7. Pekerjaan:____________________________________________
Kedatangan: Izin Tanpa Izin Penduduk Tetap (Jika tidak bekerja, nyatakan status diri)

8. No. Telefon: Rumah Tel. Bimbit Pejabat -

(Untuk dihubungi)
9. Alamat Kediaman 10. Alamat Tempat Kerja / Belajar:

B. DIAGNOSIS PENYAKIT

1. Poliomyelitis 16. Hand, Food and Mouth Disease 31. Syphilis - Acquired
2. Viral Hepatitis A 17. HIV 32. Tetanus Neonatorum
3. Viral Hepatitis B 18. Influenza 33. Tetanus - Lain-lain
4. Viral Hepatitis C 19. Leprosy (Paucibacillary) 34. Typhus - Scrub
5. Viral Hepatitis - Lain-lain 20. Leprosy (Multibacillary) 35. Tuberculosis - PTB Smear Positive
6. AIDS 21. Leptospirosis 36. Tuberculosis - PTB Smear Negative
7. Chancroid 22. Malaria - Vivax 37. Tuberculosis - Extra Pulmonary
8. Cholera 23. Malaria - Falciparum 38. Typhoid - Salmonella typhi
9. Dengue Fever 24. Malaria - Malariae 39. Typhoid - Paratyphoid
10. Dengue Haemorrhagic Fever 25. Malaria - Lain-lain 40. Viral Encephalitis - Japanese
11. Diphtheria 26. Measles 41. Viral Encephalitis - Nipah
12. Dysentery 27. Plague 42 Viral Encephalitis - Lain-lain
13. Ebola 28. Rabies 43. Whooping Cough / Pertussis
14. Food Poisoning 29. Relapsing Fever 44. Yellow Fever
15. Gonorrhoea 30. Syphilis - Congenital 45. Lain-lain - nyatakan: ________________

Selain dari notifikasi bertulis, penyakit berikut perlu dinotifikasi melalui telefon dalam tempoh 24 jam iaitu:- Acute Poliomyelitis, Cholera,
Dengue, Diptheria, Ebola, Food Poisoning, Plague, Rabies dan Yellow Fever.
11. Cara Pengesanan Kes: 12. Status Pesakit: 13. Tarikh Onset:
Kes Kontak FOMEMA Hidup - -

Ujian Saringan ______________________ Mati - -

14. Ujian Makmal: 15. Keputusan Ujian Makmal: 16. Status Diagnosis:

Nama Ujian: (i)_____________________ Positif (_____________________________) Sementara (Provisional/Suspected)

(ii)_______________ (iii)________________ Negatif Disahkan (Confirmed)

Tarikh Sampel Diambil: Belum Siap Tarikh Diagnosis

- - - -

17. Maklumat Klinikal 18. Komen:

Yang Relevan:

C. MAKLUMAT PEMBERITAHU

19. Nama Pengamal Perubatan:

20. Nama Hospital / Klinik dan Alamat:

21. Tarikh Notifikasi: - - .

Tandatangan
Pengamal Perubatan
26
 Annex 2b
Notification Form: Rev/2010
Serial No:
NOTIFICATION OF COMMUNICABLE DISEASES TO BE REPORTED
(Section 10, Prevention And Control Of Communicable Diseases Act, 1988)

A. PATIENT INFORMATION

1. Full Name (CAPITAL LETTER):

Accompany by(Mother/Father/Guardian):
(If under age/without Identity Card)

2. Identity Card Number / Travelling Document: Self Accompany by

(For Non Citizen)

Registration Number: Ward:_______________ Date of Admission: / /

3. Citizenship: 4. Gender: Male Female

Citizen
Yes Race/Ethnic: 5. Date of birth: / /

Sub Ethnic:
(For Aborigines, Native of Sabah/Sarawak) 6. Age: Year Month Day
No Country of origin:
Status of 7. Occupation:____________________________________________
Entry: Legal Illegal Permanent Resident (If unemployed, please state self reference)

8. Telephone No.: Resident H.phone Office -

(Contact purposes)
9. Current Address: 10. Address of Employer/School/College/University:

B. DISEASE DIAGNOSIS
1. Poliomyelitis 16. Hand, Food and Mouth Disease 31. Syphilis - Acquired
2. Viral Hepatitis A 17. Human Immunodeficiency Virus Infection 32. Tetanus Neonatorum
3. Viral Hepatitis B 18. Influenza 33. Tetanus (Others)
4. Viral Hepatitis C 19. Leprosy (Multibacillary) 34. Typhus - Scrub
5. Viral Hepatitis (Others) 20. Leprosy (Paucibacillary) 35. Tuberculosis - PTB Smear Positive
6. AIDS 21. Leptospirosis 36. Tuberculosis - PTB Smear Negative
7. Chancroid 22. Malaria - Vivax 37. Tuberculosis - Extra Pulmonary
8. Cholera 23. Malaria - Falciparum 38. Typhoid - Salmonella typhi
9. Dengue Fever 24. Malaria - Malariae 39. Typhoid - Paratyphoid
10. Dengue Haemorrhagic Fever 25. Malaria - Others 40. Viral Encephalitis - Japanese
11. Diphtheria 26. Measles 41. Viral Encephalitis - Nipah
12. Dysentery 27. Plague 42. Viral Encephalitis - (Others)
13. Ebola 28. Rabies 43. Whooping Cough / Pertussis
14. Food Poisoning 29. Relapsing Fever 44. Yellow Fever
15. Gonorrhoea 30. Syphilis - Congenital 45. Others: please specify: __________________

Besides by written notification, the following diseases must be notified by telephone within 24 hours, such as:- Acute Poliomyelitis,
Cholera, Dengue, Diptheria, Ebola, Food Poisoning, Plague, Rabies and Yellow Fever.
11. Case detection classification: 12. Status of patient: 13. Date of Onset:
Case Contact FOMEMA Live/alive - -

Screening Test ______________________ Died - -

14. Laboratory investigation: 15. Laboratory investigation result: 16. Diagnosis Status:

Investigation: (i)_____________________ Positive (_____________________________) Provisional/Suspected

(ii)_______________ (iii)________________ Negative Confirmed

Date of specimen taken: Pending Date of Diagnosis

- - - -

17. Relevant Clinical 18. Comment:

Information:

C. NOTIFIER

19. Name of Medical Practitioner:

20. Name and address of Hospital/Clinic:

21. Date of Notification: - - .

Signature of
Medical Practitioner

27
 ANNEX 3
KKM/BKP/ZOONOSIS/LEPTO/1/2011

BAHAGIAN KAWALAN PENYAKIT

KEMENTERIAN KESIHATAN MALAYSIA
BORANG SIASATAN KES LEPTOSPIROSIS
Daerah :
Negeri :
Tarikh Siasatan :
A. DATA DEMOGRAFI
1. Nama :____________________________
2. Umur :___________
3. Jantina : Lelaki Perempuan
4. No. ID (S/B,K/P,Passport) :____________________________
5. Ethnik :________________
6. Kewarganegaraan:_______________
7. No. Tel :________________
8. Alamat Rumah :________________________________________
________________________________________
9. Pekerjaan :________________
10. Alamat Tempat Kerja/ Sekolah* :____________________________
____________________________
B. RIWAYAT KLINIKAL
11. Tarikh onset :____________
12. Tarikh masuk wad* :____________ Hospital:______________RN:_______
13. Simptom & gejala klinikal : (Tandakan yang berkaitan)
Simptom: Gejala Klinikal:

Demam, Ruam
Sakit kepala Jaundis
mengigil Radang mata (Conjunctival suffusion)
Sakit otot Lain-lain, nyatakan:_____________
Sakit otot betis (Calf pain)
Sakit Sendi
Malaise
Sakit abdomen
Loya
Muntah
Diarrhea
Batuk
Sesak nafas
Lain-lain, nyatakan:_____________

28
14. Adakah kes ini berkaitan dengan wabak ? Ya Tidak Tidak diketahui
15. Ujian Diagnostik makmal:
Nama Ujian Tarikh Nama Keputusan Catatan
Pensampelan Makmal Disahkan Probable
(Confirme
d)
MAT
PCR
ELISA
Rapid test

Nota:
Kes Probable (diagnosa Klinikal+ ujian makmal seperti rapid test dan/ atau ELISA )
Kes disahkan (melalui ujian makmal MAT atau/dan PCR)

16.Adakah pesakit dirawat dengan antibiotik ? Ya Tidak

17. Status Pesakit: Sedang dirawat Sembuh Mati
Tarikh Keluar wad*:_________________
Tarikh mati* :_________________
C. FAKTOR RISIKO

18. Adakah jangkitan ini berkaitan dengan pekerjaan ? Ya Tidak

Jika ya, nyatakan bidang pekerjaan:______________________

19. Adalah jangkitan ini berkaitan dengan aktiviti rekreasi (Contoh: berkhemah, berenang,
berkayak, berkelah dll) ? Ya Tidak

Jika Ya, nyatakan jenis aktiviti:__________________

Tempat :__________________
Tarikh pendedahan :__________________

20. Adalah jangkitan ini berkaitan hubungan langsung (direct contact) dengan haiwan?

Ya Tidak
Jika ya, nyatakan jenis haiwan:__________________
Tempat :__________________
21. Adakah jangkitan ini berkaitan dengan air untuk kegunaan harian ? Ya Tidak
Sumber air:______________

22. Adakah jangkitan ini berkaitan dengan kejadian banjir ? Ya Tidak

23. Lain-lain maklumat yang berkaitan dengan risiko jangkitan, nyatakan:

_______________________________________________________________________

________________________________________________________________________

29
24. Adakah anda mengenali sesiapa yang mempunyai simptom yang serupa ?

Ya Tidak Tidak diketahui

Jika ya, senaraikan:

Nama Hubungan No. Tel Catatan

(Guna lampiran yang lain sekiranya ruangan tidak cukup)

*jika berkenaan
D. KOMEN/ TINDAKAN SUSULAN

Komen Pegawai Penyiasat:

Tandatangan & cop :

Nama penyiasat :_________________________________
Jawatan :_________________________________
No. Tel :(Pej) ________________________
(HP) ________________________
Tarikh :____________________________

Komen PPKP Kanan/Pegawai Kesihatan Daerah

Tandatangan & cop :

Nama Pegawai :________________________________
Jawatan :________________________________
No. Tel :(Pej) ________________________
(HP) ________________________
Tarikh :_____________________________

30
Example of Leptospirosis database format Annex 4
CONTOH DATABASE KES POSITIF LEPTOSPIROSIS TAHUN ..
NEGERI: Annex 4

M AKLUM AT PESAKIT Ke m asuk k an Ke Hos pital JENIS KES*

SPORADIK
NAMA STATUS Klasifik as i k es

WABAK
Tarik h PUNCA

Yidak
WARGA HOSPITAL /KLINIK Tarik h Tarik h Notifik as i M AKMAL JENIS PESAKIT (Pr obable /

Ya
NO NAMA UM UR JANTINA BANGSA DAERAH Ons e t JANGKITAN
NEGARA KESIHATAN Ke m as ukk an * UJIAN UJIAN (HIDUP/ M ATI) confirm e d)
DIBUAT

1
2
3
4
5
6
7
8
9
10
11
12
13

Dis e diak an ole h: Dis e m ak ole h:

Jaw atan: Jaw atan:
Tarik h: Tarik h:

Kes Positif bermakna :

1. kes Probable (diagnosa Klinikal+ ujian makmal seperti rapid test dan/ atau ELISA )
2. kes disahkan (melalui ujian makmal MAT atau/dan PCR atau disahkan oleh 2 jenis rapid test)

31
 Annex 5
BKP/WABAK/01/2005

BORANG LAPORAN AWAL WABAK PENYAKIT

Sumber laporan wabak: Tarikh terima:

1. Penyakit:

2. Tarikh Onset/ 3. Tarikh /Masa Notifikasi:

Masa
4. Tempat Berlaku:

5. Definisi kes:

6. Bilangan orang terlibat:

a) Status Kes b) Kumpulan Jumlah Kes

Umur

-bilangan terdedah: - bilangan dirawat: 0-1 tahun Lelaki Perempuan

- Bilangan kes - bilangan masuk wad: 1-5 tahun

i) suspect:
-bilangan mati: 6-18 tahun
ii) probable:
19-50 tahun
iii) confirmed:
>50 tahun

Jumlah
keseluruhan

7. Gejala klinikal : (secara ringkas yang merangkumi majoriti pesakit)

8. Hasil siasatan:

a) Epid Curve (masukkan major event):

b) Faktor risiko:

c) Kes indeks/ punca wabak disyakki:

d) Agen etiologi disyakki:

9. Tindakan pencegahan dan kawalan yang diambil:

10. Ulasan Pegawai Kesihatan Daerah:

11. Ulasan Pegawai Epid Negeri:

12. Pegawai Pelapor (Daerah) 12. Pegawai Penerima (Negeri)
Nama: Nama:
Jawatan: Jawatan:
Alamat Pejabat: Alamat Pejabat:
Tarikh: Tarikh:

32
 Annex 6
CARTA ALIR PENGENDALIAN NOTIFIKASI KES/ WABAK LEPTOSPIROSIS

Notifikasi kes (Probable/confirmed) diterima

Siasat:
Verifikasi kes (Probable/confirmed)

Ya
Tidak
Kes ?
Tidak Tamat

Ambil Langkah Pencegahan dan Kawalan

Daftar Kes dalam E-notis

Tidak
Wabak? Tamat

Ya

Notifikasi wabak ke CPRC KKM melalui tel atau Kawalan wabak

sms on call CPRC KKM: 013-6699700

Hantar Laporan awal wabak (BKP/WABAK/01/2005) dalam

masa 24 jam ke CPRC, KKM
No. Tel:03-88810 600/700
No. Fax:03-88810 400/500
e-mel:cprc@moh.gov.my

Hantar Laporan Harian/ Progress report

Hantar Laporan akhir wabak Leptospirosis ke CPRC, KKM

dalam tempoh masa sebulan setelah wabak diisytiharkan
tamat
33
 Annex 7a

BORANG PENILAIAN RISIKO LEPTOSPIROSIS

DI PUSAT-PUSAT REKREASI (BUATAN)
Pejabat Kesihatan Daerah:_________________ Tahun:___________
Pengurus Pusat Rekreasi : Majlis Daerah/Jabatan Perhutanan/Swasta/ Lain:_____________
Tarikh pemeriksaan :_________________

Jenis Pusat Rekreasi:

Nama Taman Rekreasi / Taman Tema/ Kolam Renang: __________________________
Lain-lain.Nyatakan : ___________________________
Lokasi :______________________

PERKARA Setiap Soalan

YANG DIPERIKSA Membawa 1 Markah
YA TIDAK KRITIKAL*
(mematuhi) (tidak
mematuhi)
A. PENCEGAHAN SUMBER JANGKITAN LEPTOSPIROSIS (INTERVENTIONS AT INFECTION
SOURCES)
1. HALANG RODENT MEMASUKI PUSAT REKREASI (yang ada pagar dan bangunan
sahaja) **
1.1 Pagar adalah berkeadaan baik, tidak rosak dan 1 1
rodent proof
1.2 Bangunan premis adalah rodent proof 2 2
2. HALANG RODENT MEMASUKI PREMIS MAKANAN ATAU TEMPAT MINUMAN
2.1 PREMIS MAKANAN JENIS STATIK (GERAI /
RESTORAN)
a.Stor simpanan makanan:
Tempat penyimpanan makanan berkeadaan 3 3
bersih, teratur, tersusun dan tidak terlalu padat
Terdapat jadual pembersihan yang baik dan 4 4
pengendalian keluar masuk barang yang baik
Ada sistem rodent- proof. 5 5
b.Terdapat aktiviti kawalan rodent 6 6
c.Tiada kesan rodent 7 7
d.Tidak mempunyai barang yang tidak diperlukan 8 7
e.Pengurusan sisa makanan yang baik dan tidak 9 8
mengundang rodent

2.2 PREMIS MAKANAN BERGERAK

a.Sisa makanan tidak ditinggalkan merata-rata 10 9

34
 PERKARA Setiap Soalan
YANG DIPERIKSA Membawa 1 Markah
YA TIDAK KRITIKAL*
(mematuhi) (tidak
mematuhi)
b.Sisa makanan dimasukkan ke dalam plastik sampah 11 10
c.Plastik sampah yang penuh dihantar ke tempat 12 11
pengumpulan sampah setiap hari
3. CEGAH PEMBIAKAN RODENT SEKITAR PUSAT REKREASI
3.1 Secara umum, persekitaran pusat rekreasi adalah 13 14
berkeadaan bersih
3.2 Rumput adalah pendek di sekitar pusat rekreasi 14 15
3.3 KEMUDAHAN SANITASI:
a. Ada Tandas 15
Tiada kesan rodent 16 16
Berkeadaan bersih 17 17
Sistem pembuangan yang bersih 18 18
Jadual pembersihan yang baik dan kerap 19 19
Sisa tidak melimpah atau backflow tidak 20 20
berlaku
b. Ada Bilik Mandi 21
Bilangan mencukupi 22 21
Berkeadaan bersih 23 22
3.4 PENGURUSAN SISA MAKANAN DAN SAMPAH
SEKITAR PUSAT REKREASI
a. Bilangan tong sampah;
Mencukupi, 24 23
Tidak Rosak, 25 24
Bertutup, 26 25
Mempunyai Plastik Sampah, 27 26
Sampah Tidak Berselerak/Bersepah, 28 27
Terdapat Jadual Pengutipan Sampah 29 28
b. Tempat pengumpulan sampah;
Bersih 30 29
Berkeadaan baik dan terurus 31 30
Tiada longgokan sampah di lantai 32 31
Mempunyai paip air dan parit bagi urusan 33 32
pembersihan
Pengurusan air leachate yang baik dan tidak 34 33
bertakung
Pembersihan dan pembuangan sampah yang 35 34
kerap

35
 PERKARA Setiap Soalan
YANG DIPERIKSA Membawa 1 Markah
YA TIDAK KRITIKAL*
(mematuhi) (tidak
mematuhi)
3.5 KEADAAN PERSEKITARAN PUSAT REKREASI
a.Sumber utama air (inlet) bukan dari punca yang 35 35
tercemar dan berisiko.
b.Tiada pengaliran air masuk dari punca lain ke pusat 36 36
rekreasi
c.Pusat rekreasi adalah tidak terdedah kepada matahari 37 37
[ tiada rintangan daripada daun/ pokok/ rumput atau
lalang sekitar pusat rekreasi ]
d.Aliran air tidak tersekat atau bertakung 38 38
e.Terdapat perparitan di sekeliling pusat rekreasi bagi 39 39
mengelakkan pengaliran air permukaan masuk ke
dalam pusat rekreasi
f.Sampel air mematuhi parameter fizikal (pH, 40
kekeruhan dan warna)- jika sampel air diambil dan diuji
- optional
3.6 PENGURUSAN AIR DI PERMUKAAN (SURFACE
WATER)
a.Sistem pengaliran air di permukaan tidak mengalir 41
masuk ke kawasan air di pusat rekreasi
b.Keadaan parit dan saliran termasuk parit di tepi jalan
yang masuk ke kawasan pusat rekreasi (jika ada)
Tidak rosak/ pecah/ 42
Tidak memerangkap sampah 43
Tidak tersekat aliran atau bertakung 44

3.7 PENGURUSAN SISA AIR LIMBAH (SULLAGE)

a.Sistem pengumpulan sisa yang bersih (Septik atau 45
lubang serapan)
b.Perangkap lemak yang bersesuaian dan berfungsi 46
dengan baik
c.Tempat pengumpulan air limbah yang bersih 47
d.Tidak berbau busuk 48

B. PENCEGAHAN TRANSMISI JANGKITAN LEPTOSPIROSIS

(INTERVENTIONS AT THE TRANSMISSION ROUTE)
1. Ada bilik mandi atau shower [ berdekatan pusat 49 40
rekreasi untuk membasuh badan selepas aktiviti
rekreasi]
Bilangan mencukupi 50 41
2. Sumber Air Minum Yang Selamat Disediakan
Air Lembaga Air Perak (LAP) yang telah 51 42

36
 PERKARA Setiap Soalan
YANG DIPERIKSA Membawa 1 Markah
YA TIDAK KRITIKAL*
(mematuhi) (tidak
mematuhi)
dimasak atau air botol
3. Ada bahan pendidikan kesihatan mengenai 52
pencegahan Leptospirosis disediakan untuk
pengunjung seperti pamplet, poster dan sebagainya.
JUMLAH / 52 /52 /42*

PERATUS

Catatan:
. i. Faktor-faktor kritikal bergantung kepada situasi di negeri masing-masing
ii.Faktor-faktor yang dianggap sebagai faktor kritikal. Pelanggaran 42 faktor kritikal boleh
meningkatkan risiko pembiakan rodent, pembiakan bakteria Leptospira serta
meningkatkan risiko penularan Leptospirosis.
iii.** Jika tiada pagar dan bangunan di pusat rekreasi, jumlah maksima markah faktor
kritikal ialah 40 faktor sahaja.
iv. Catatkan T.B. atau Tidak Berkaitan jika perkara dinilai, tiada di pusat rekreasi tersebut.

Ulasan:

Cadangan Langkah-Langkah Penambahbaikan (guna helaian tambahan, jika perlu):

Disediakan oleh: Disemak/ disahkan oleh:

................................................... ...........................................................
Tandatangan Pegawai Pemeriksa Tandatangan Peg. Kesihatan Daerah/Peg.
Epid. Daerah/PPKPKanan
Tarikh: Tarikh:

Adaptasi daripada:
1. World Health Organization: Human Leptospirosis: Guidance For Diagnosis, Surveillance &
Control; Control of Leptospirosis, 2003.
2. Borang Pemeriksaan Persekitaran PLKN Bagi Kemudahan Aktiviti Kolam
3. Borang Penilaian Risiko Leptospirosis Di Pusat Rekreasi (Buatan) Jabatan Kesihatan Negeri
Perak.

37
 Annex 7b

BORANG PENILAIAN RISIKO LEPTOSPIROSIS

DI PUSAT-PUSAT REKREASI (SEMULAJADI)

Pejabat Kesihatan Daerah:___________________ Tahun: ____________

Pengurus Pusat Rekreasi:Majlis Daerah/Jabatan Perhutanan/ Swasta /Lain_____________
Tarikh pemeriksaan:_________________

Pusat Rekreasi:
Nama : _____________________________
Lokasi :
Jenis : ( ) Air terjun ( )Sungai
Lain-lain.Nyatakan: ___________________________

PERKARA Setiap Soalan

YANG DIPERIKSA Membawa 1 Markah
YA TIDAK KRITIKAL*
(mematuhi) (tidak
mematuhi)
A. PENCEGAHAN SUMBER JANGKITAN LEPTOSPIROSIS (INTERVENTIONS AT INFECTION
SOURCES)
1. HALANG RODENT MEMASUKI PREMIS MAKANAN ATAU TEMPAT MINUMAN
1.1 PREMIS MAKANAN JENIS STATIK (GERAI /
RESTORAN)
a.Stor simpanan makanan:
Tempat penyimpanan makanan berkeadaan 1 1
bersih, teratur, tersusun dan tidak terlalu padat
Terdapat jadual pembersihan yang baik dan 2 2
pengendalian keluar masuk barang yang baik
Ada sistem rodent- proof. 3 3
b.Terdapat aktiviti kawalan rodent 4 4
c.Tiada kesan rodent 5 5
d.Tidak mempunyai barang yang tidak diperlukan 6 6
e.Pengurusan sisa makanan yang baik dan tidak 7 7
mengundang rodent

1.2 PREMIS MAKANAN BERGERAK

a.Sisa makanan tidak ditinggalkan merata-rata 8 8
b.Sisa makanan dimasukkan ke dalam plastik sampah 9 9
c.Plastik sampah yang penuh dihantar ke tempat 10 10
pengumpulan sampah setiap hari

2. CEGAH PEMBIAKAN RODENT SEKITAR AIR TERJUN / SUNGAI

2.1 Secara umum, persekitaran pusat rekreasi adalah 11 11

38
 PERKARA Setiap Soalan
YANG DIPERIKSA Membawa 1 Markah
YA TIDAK KRITIKAL*
(mematuhi) (tidak
mematuhi)
berkeadaan bersih
2.2 Rumput adalah pendek di sekitar air terjun / sungai 12 12
2.3 KEMUDAHAN SANITASI:
a. Tandas
Tiada kesan rodent 13 13
Berkeadaan bersih 14 14
Ada jadual pembersihan 15 15
Sistem pembuangan yang bersih 16 16
Sisa tidak melimpah atau backflow tidak 17 17
berlaku
2.4 PENGURUSAN SISA MAKANAN DAN SAMPAH
SEKITAR PUSAT REKREASI
a. Bilangan tong sampah;
mencukupi, 18 18
tidak rosak, 19 19
bertutup, 20 20
mempunyai plastik sampah, 21 21
sampah tidak berselerak/bersepah, 22 22
terdapat jadual pengutipan sampah 23 23
b.Tempat pengumpulan sampah;
Bersih 24 24
Berkeadaan baik dan terurus 25 25
Tiada longgokan sampah di lantai 26 26
Mempunyai paip air dan parit bagi urusan 27 27
pembersihan
Pengurusan air leachate yang baik dan tidak 28 28
bertakung
Pembersihan dan pembuangan sampah yang 29 29
kerap
B. PENCEGAHAN TRANSMISI JANGKITAN LEPTOSPIROSIS
(INTERVENTIONS AT THE TRANSMISSION ROUTE)
1. Ada tandas atau bilik mandi [ berdekatan kawasan 30 30
air terjun / sungai untuk membasuh badan selepas
aktiviti rekreasi]
Bilangan mencukupi 31 31
2. Sumber Air Minum Yang Selamat Digunakan
Pengunjung
Air botol atau air yang telah dimasak 32 32
Ada bahan pendidikan kesihatan mengenai 33
pencegahan Leptospirosis disediakan untuk
pengunjung seperti pamphlet, poster dan sebagainya.
JUMLAH / 33 /33 / 32*

PERATUS

39
 Catatan:
i. Faktor-faktor kritikal bergantung kepada situasi di negeri masing-masing
ii. Faktor-faktor yang dianggap sebagai faktor kritikal. Pelanggaran 32 faktor kritikal boleh
meningkatkan risiko pembiakan rodent, pembiakan bakteria Leptospira serta
meningkatkan risiko penularan Leptospirosis.
iii. Catatkan T.B. atau Tidak Berkaitan jika perkara dinilai, tiada di pusat rekreasi
tersebut.

Ulasan:

Cadangan Langkah-Langkah Penambahbaikan (guna helaian tambahan, jika perlu):

Disediakan oleh: Disemak/ disahkan oleh:

................................................... ...........................................................
Tandatangan Pegawai Pemeriksa Tandatangan Peg. Kesihatan Daerah/Peg.
Epid. Daerah/PPKPKanan
Tarikh: Tarikh:

Adaptasi daripada:
1. World Health Organization, Human Leptospirosis: Guidance For Diagnosis, Surveillance &
Control; Control of Leptospirosis, 2003.
2. Borang Pemeriksaan Persekitaran PLKN Bagi Kemudahan Aktiviti Kolam
3. Borang Penilaian Risiko Leptospirosis Di Pusat Rekreasi (Semula Jadi) Jabatan Kesihatan
Negeri Perak.

40
Example of Health Hazard Signage In National Language Annex 8a

AMARAN!
RISIKO KESIHATAN
RISIKO PENYAKIT BERJANGKIT
SUNGAI, KOLAM, AIR TERJUN DAN LUMPUR MUNGKIN
DICEMARI BAKTERIA ATAU VIRUS ATAU PARASIT
JANGAN MINUM AIR YANG TIDAK DIMASAK ATAU
DIRAWAT
ELAKKAN BERENANG ATAU BERMAIN AIR SEKIRANYA
ANDA LUKA ATAU ADA PENYAKIT KULIT
BERENANG ATAU BERMAIN AIR ATAS RISIKO SENDIRI
DAPATKAN RAWATAN SEKIRANYA TIDAK SIHAT DALAM
TEMPOH 2 MINGGU DARI SEKARANG
JAGA KEBERSIHAN PERSEKITARAN. PERSEKITARAN
YANG KOTOR MENGUNDANG KEHADIRAN PERUMAH
HAIWAN YANG MENINGKATKAN RISIKO PENCEMARAN
KUMAN
UNTUK MAKLUMAT LANJUT, HUBUNGI:
PEJABAT KESIHATAN DAERAH BERHAMPIRAN
(##-#########)
41
 Example of Health Hazard Signage In English Annex 8a

WARNING!
HEALTH RISK

RISK OF COMMUNICABLE DISEASES

FRESH WATER STREAMS, PONDS AND MUD POSSIBLY
CONTAMINATED WITH BACTERIA OR VIRUSE OR
PARASITES
DO NOT DRINK UNBOILED OR UNTREATED WATER
DO NOT SWIM OR WADE IF YOU HAVE CUTS OR
ABRASIONS
SWIM OR WADE AT YOUR OWN RISK
SEEK TREATMENT IF YOU ARE NOT WELL WITHIN 2
WEEKS FROM NOW
KEEP THE ENVIRONMENT CLEAN AS UNCLEAN
ENVIRONEMNT ATTRACT NATURAL ANIMAL HOSTS
WHICH INCREASES THE RISK OF GERM CONTAMINATION
FOR MORE INFORMATION, PLEASE CALL:
THE NEAREST DISTRICT HEALTH OFFICE
(##-#########)

42