Community Behaviors That Affect the Incidence of Leptospirosis in West Jakarta,Indonesia

Abstract

Background:

Leptospirosis is an infectious disease caused by a pathogenic Leptospira species transmitted directly or indirectly from animals to humans. It is endemic in Southeast Asia in several countries, including Indonesia and Thailand. Therefore, this study aimed to determine the effect of community behavior on the incidence of leptospirosis in West Jakarta in 2019.

Methods:

The study used a case–control design, and data were obtained from the West Jakarta Health Office. The sample included 140 respondents, consisting of 70 leptospirosis patients (cases) and 70 participants who did not suffer from the disease (controls) in a 1:1 ratio.

Results:

In the bivariate analysis, there were significant effects on leptospirosis incidence from knowledge (odds ratio [OR] = 18.789), occupation (OR = 31.875), injury history (OR = 20.842), and recreation (OR = 0.294). Multivariate analysis showed significant effects based on occupation, present wounds, and recreation records. Occupation was a dominant factor in leptospirosis in West Jakarta (OR 54.116: 95% confidence interval: 4.435–660.372).

Conclusion:

The dominant factors for leptospirosis were risky occupations, followed by a history of injuries.

Introduction

Leptospirosis is an infectious disease transmitted directly or indirectly from animals to humans, caused by a pathogenic Leptospira species (Centers for Diseases and Control and Prevention [U.S.], 2018; World Health Organization, 2003). The number of leptospirosis cases in humans is estimated to be 0.1–1 per 100,000 people per year in temperate climates, 10–100 per 100,000 in humid climates, and >100 per 100,000 people during an outbreak, with a 5–30% case fatality rate (CFR) for those populations exposed to high-risk factors (World Health Organization, 2003). In Asia, it is an endemic disease in various countries, including Indonesia, Thailand, and Sri Lanka (World Health Organization, 2003).

In 2015, there were 366 cases of leptospirosis in Indonesia spread over six provinces—Daerah Khusus Ibukota (DKI) Jakarta or the Special Capital Region of Jakarta (37 cases), West Java (2 cases), Central Java (149 cases), the Special Region of Yogyakarta (144 cases), East Java (3 cases), and Banten provinces (31 cases). In 2017, most cases occurred in Central Java (316), with a CFR of 16.14% (Kementerian Kesehatan Republik Indonesia, 2018). Based on data collected by the Provincial Health Office of DKI Jakarta from 2016 to August 2019, 94 cases of leptospirosis were found in the DKI Jakarta area. The majority of cases (70) were in the West Jakarta area, with a CFR of 5.56–20% (Suku Dinas Kesehatan Jakarta Barat, 2019).

The leptospirosis problem is affected, directly and indirectly, by the environment, community behavior, access to health care services, and the topography and demography of an area. These factors can exacerbate the incidence of leptospirosis in the categories of injury history (odds ratio [OR] = 12.16, 95% confidence interval [CI]: 2.99–49.37), contact with rat carcasses (OR = 4.99, 95% CI: 1.59–15.70), and living in poor housing conditions according to the Clean and Healthy Lifestyle index (OR = 4.6) (Aulia, 2014; Suratman, 2006). People in these categories are at a higher risk of leptospirosis (Aulia, 2014; Suratman, 2006).

Other risk factors for leptospirosis that relate to community behavior include habitually walking barefoot in the fields and not covering open wounds (Pratamawati et al, 2018). Determining the magnitude of behavioral risk factors may help policy makers and minimize the spread of leptospirosis in the region. This study aimed to determine community behaviors affecting the incidence of leptospirosis in West Jakarta.

Methods

This study used a case–control design, and was conducted in West Jakarta between October and November 2019. The case population included all leptospirosis patients diagnosed by clinicians through clinical examinations and laboratory tests reported and recorded in the West Jakarta Health Office from January 2016 to August 2019. The total sample included 140 respondents, comprising 70 cases and 70 controls (a 1:1 ratio).

Sampling was carried out according to the inclusion criteria—respondents registered and recorded as leptospirosis patients, diagnosed by clinicians through laboratory examinations, and living in West Jakarta. The control group had not been diagnosed with leptospirosis, but their other characteristics were similar to those of the case group. The exclusion criteria were respondents in a problematic situation (sick, grieving), or unwilling/unable to be interviewed and respond to the questionnaire.

Data collection

The data obtained were limited to the respondents' health and characteristics, including age, gender, knowledge of leptospirosis, occupation, and injury history. The behavioral data collected were bathing habits, recreational activities, and history of contact with rodent carcasses. Responses to these variables were categorized into two categories: age (economically inactive and productive), sex (female and male), knowledge (good and poor), occupation (not risky and risky), injury history (absent and present), bathing habits (no and yes), recreation history (absent and present), and history of contact with rat carcasses (absent and present). This study showed information bias, especially for respondents suffering from leptospirosis in 2016. The respondents were given instructions or clues to minimize potential bias.

Data analysis

The data obtained were analyzed using univariate, bivariate, and multivariate methods. The bivariate analysis used chi-square, whereas the multivariate analysis used multiple logistic regression. The statistical significance level for all tests was set at a p value <0.05.

Results

Table 1 shows the effect of individual characteristics on the incidence of leptospirosis. The variable knowledge of leptospirosis and occupation was associated with leptospirosis (p < 0.05), while variables of age and gender were not associated with the incidence (p value >0.05). Respondents with poor knowledge of leptospirosis had a risk 18.789 times higher than those with good knowledge of leptospirosis (95% CI: 2.367–149.168). Those with risky occupations had a risk 31.875 times higher than those with no occupational risk (95% CI: 4.077–249.199). The respondents with a history of injuries had a risk 20.842 times higher than those with good knowledge (95% CI: 6.496–66.869).

Table 1.

Effect of Individual Characteristics on the Incidence of Leptospirosis in West Jakarta in 2019

Characteristic and health of respondent	Group				Total		OR (95% CI)	p
	Case		Control		Total
	n	%	n	%	n	%
Age
Productive	49	94.2	51	98.1	100	96.2	0.320 (0.032–3.184)	0.618
Unproductive	3	5.8	1	1.9	4	3.8	0.320 (0.032–3.184)	0.618
Sex
Male	39	75.0	33	63.5	72	69.2	1.727 (0.743–4.018)	0.288
Female	13	25.0	19	36.5	32	30.8	1.727 (0.743–4.018)	0.288
Knowledge
Poor	51	98.1	38	73.1	89	85.6	18.789 (2.367–149.168)	0.001^*
Good	1	1.9	14	26.9	15	14.4	18.789 (2.367–149.168)	0.001^*
Occupation
Risky	20	38.5	1	1.9	21	20.2	31.875e (4.077–249.199)	0.0005^*
Not risky	32	61.5	51	98.1	83	79.8	31.875e (4.077–249.199)	0.0005^*
Injury record
Presence	33	63.5	4	7.7	37	45.6	20.842 (6.496–66.869)	0.0005^*
Absence	19	36.5	48	92.3	67	64.4	20.842 (6.496–66.869)	0.0005^*

p < 0.05.

CI, confidence interval; OR, odds ratio.

The results of the community behavior analysis showed that bathing habits and a history of contact with rat carcasses had no significant relationship with leptospirosis incidence. Recreation history was a protective factor for leptospirosis, OR 95% CI (0.294: 0.110–0.783) (Table 2). The bathing habits variable could not be analyzed as a behavior variable due to homogeneous data.

Table 2.

Effect of Behavioral Factors on the Incidence of Leptospirosis in West Jakarta, in 2019

Behavioral factor	Group				Total		OR (95% CI)	p
	Case		Control		Total
	n	%	n	%	n	%
Washing habit
Yes	14	26.9	18	34.6	32	30.8	0.698 (0.301–1.608)	0.524
No	38	73.1	34	65.4	72	69.2	0.698 (0.301–1.608)	0.524
Recreation record
Presence	7	13.5	18	34.6	25	24.0	0.294 (0.110–0.783)	0.022^*
Absence	45	86.5	34	65.4	79	76.0	0.294 (0.110–0.783)	0.022^*
Record of contact with rat carcasses
Presence	36	69.2	28	53.8	64	61.5	1.929 (0.864–4.303)	0.158
Absence	16	30.8	24	46.2	40	38.5	1.929 (0.864–4.303)	0.158

p < 0.05.

Multivariate analysis results showed that occupation, injury history, and recreation records were significantly correlated with leptospirosis incidence. Occupation was the dominant factor in leptospirosis incidence in West Jakarta in 2019. Respondents with risky occupations were 54.116 times more likely to contract leptospirosis than those without risk of injury on the job (95% CI: 4.435–660.372) (Table 3).

Table 3.

Results of Multiple Logistic Regression Modeling (Multivariate Final Model)

Variable	B	p	OR	95% CI
Variable	B	p	OR	Lower limit	Upper limit
Occupation (risky)	3.991	0.002	54.116^*	4.435	660.372
Injury record (presence)	3.690	0.000	40.031	7.782	205.935
Recreation record (presence)	−2.265	0.009	0.104	0.019	0.570
Constant	−9.787	0.000	0.000

p < 0.05.

Discussion

Knowledge of leptospirosis

The statistical analysis showed a p-value of 0.0005 with an OR of 95% CI (18.789: 2.367–149.168), meaning that lack of knowledge was significantly associated with leptospirosis. Respondents with poor leptospirosis knowledge (source, mode of transmission, symptoms, risk factors, and prevention) had 18.789 times greater risk of leptospirosis than those with adequate information (95% CI: 2.367–149.168). These results are in line with a study conducted in Malaysia, which reported that 57% of respondents had poor knowledge of leptospirosis. The respondents with poor knowledge of leptospirosis had a lower prevention attitude toward leptospirosis than those with good knowledge (Nozmi et al, 2018).

In contrast, a study conducted in the Philippines found no difference in knowledge between workers in the agricultural and nonagricultural sectors—both groups had good knowledge of leptospirosis. Workers in the nonagricultural sector had a better attitude than those in the agricultural sector (Arbiol et al, 2016). Knowledge is a factor that influences human health behavior; therefore, the manner of transmitting knowledge—symptoms, risk factors, and prevention of leptospirosis—should focus on exposing all workers to preventive measures to improve their health-related behaviors (Notoadmodjo, 2003).

Occupation and leptospirosis

Statistical analysis returned a p-value of 0.0005, meaning that work significantly affects leptospirosis incidence. Likewise, the value of OR = 31.875 means that respondents with risky occupations had 31.875 times the risk of leptospirosis than those in less risky occupations (95% CI: 4.077–249.199). The multivariate analysis showed that occupation was a dominant factor that increased the incidence of leptospirosis (OR = 54.116). Previous studies have found that those working as animal feeders are 3.9 times more likely to develop leptospirosis than those in other occupations. Workers in the agricultural sector are 3.3 times more likely to contract leptospirosis than those in nonagricultural jobs. Workers' exposure to livestock urine was significantly related to leptospirosis (Maze et al, 2018). Agricultural areas with standing water were found to be suitable habitats for Leptospira and rodents (Sumanta et al, 2015).

Regarding occupational risk factors for leptospirosis, a study in Malaysia showed that the presence of cattle was associated with seropositive leptospirosis, indicating that those raising cattle on their farms were at 4.78 times greater risk of developing leptospirosis than those who did not have these animals. In addition, landfills around the plantation area increased leptospirosis among plantation workers (Meny et al, 2019; Mohd Ridzuan et al, 2016). Therefore, the nature of one's occupation can be a risk factor for acquiring leptospirosis (Meny et al, 2019).

Risky occupations are those involving contact with water, mud, or soil, which supports leptospirosis transmission, since Leptospira survive in water and moist soil (Centers for Diseases and Control and Prevention [U.S.], 2018; World Health Organization, 2003). Respondents with risky occupations include sugar cane farmers, breeders, cleaning, and abattoir workers, fish and poultry-processing, butchers, laboratory assistants, miners, waste managers in endemic areas, market workers, veterinarians, and those in other occupations related to the environment suspected of being contaminated with Leptospira (Kementerian Kesehatan Republik Indonesia, 2017; Meny et al, 2019).

According to the data obtained from this study, in West Jakarta, the number of respondents who engage in various occupations was as follows: private employees (24), garbage collectors (5), laborers (11), housewives (17), motorcycle taxidrivers (4), janitors (1), traders (16), nine janitors (9), one student (1), household assistants (4), security guards (6), pensioners (1), drivers (4), and farmers (1). Therefore, most respondents with leptospirosis had risky occupations, including scavengers, workers handling public facilities and infrastructure (better known as “orange troops”), those who clean sewage disposal sewers, and garbage collectors.

Injury history and leptospirosis

Statistical tests showed that a history of injuries significantly affected leptospirosis incidence (p = 0.0005). An OR value of 20.842 means that respondents with a history of injuries had 20.842 times greater risk of leptospirosis than those without a history of injuries (95% CI: 6.496–66.869). This result was in line with a study conducted in India (Kamath et al, 2014), which reported a significant relationship between wounds or scratches on the body and acquiring leptospirosis. Respondents with wounds or scratches at work had a 4.88 times greater probability of developing leptospirosis than those without wounds.

Another study showed that having more than two wounds on the body was independently associated with infection (Phraisuwan et al, 2002). A study in the Bantul District showed that injury history was a risk factor for leptospirosis (p = 0.001). Respondents with a history of injuries were at 10 times greater risk of contracting leptospirosis than those without a history (Prastiwi, 2012).

Almost all previous studies found injury history to be an influential risk factor, increasing the chance of developing leptospirosis. Furthermore, a history of injuries has a significant role in leptospirosis transmission, since Leptospira can penetrate the human body through an open wound. Therefore, an injured person who comes in direct contact with an environment contaminated with Leptospira has a higher chance of becoming infected with leptospirosis (World Health Organization, 2003). The most common location of wounds was the feet and hands, resulting from the respondent's occupation.

The slightest injury or skin abrasion allows Leptospira to penetrate into the body (Centers for Diseases and Control and Prevention [U.S.], 2018), and the incubation period is 10 days before initial symptoms appear (World Health Organization, 2003). In this study, respondents with leptospirosis had a history of injuries resulting from minor scratches, such as needle punctures, but the most prevalent injuries were those caused by rat bites. The respondents injured while working outside the home (n = 37) reported not using personal protective equipment at work. Most ignored the injury and considered it harmless, especially those whose injuries were caused by rat bites (n = 7).

Recreational activities and leptospirosis

The findings in this study demonstrated that recreational activities significantly affected leptospirosis incidence as a protective factor with an OR of 0.294 (95% CI: 0.110–0.783). These results differ from research conducted in Malaysia (Garba et al, 2018; Nizal et al, 2018), Japan (Narita et al, 2005), and Wisconsin (Morgan et al, 2002). A survey conducted by Garba et al (2018) in Malaysia found that recreation affected and increased leptospirosis incidence. In Malaysia, a study showed that a sampling performed in several water-recreation areas in Johor, Malaysia, had Leptospira in 18.2% of the samples, which presents a risk for water-recreation users (Nizal et al, 2018).

In Japan, results revealed an increased leptospirosis incidence associated with water sports; 71% of respondents had participated in water sports before being diagnosed (Narita et al, 2005). In mid-July 1998, three Wisconsin athletes were hospitalized for acute febrile illness after participating in triathlon in which one of the activities included swimming competition. They experienced headaches, myalgia, elevated liver enzymes, and hematuria. A laboratory test conducted using the enzyme-linked immunosorbent assay method returned a positive result for leptospirosis in one sample (Morgan et al, 2002).

This study's results differed from those of previous studies that found more links between sportspeople who had contact with water. Here, the recreational activities performed by respondents were fishing and swimming on weekends, particularly spending free time with family. The recreational activities performed among beloved families enhanced respondents' happiness; rather than a risk factor, they were protective variables.

Nevertheless, transmission of leptospirosis during recreational activities was monitored closely. Water is an intermediary medium for Leptospira penetration into the human body. Although the variable recreation was a protective factor in West Jakarta, this does not mean that swimming pool water, for instance, is free from Leptospira, since no laboratory tests were conducted. Thus, these results from other regions suggest that future research should test water from swimming pools in Jakarta.

With regard to the OR 95% CI in the multiple logistic regression modeling, it can be seen that the range of the OR was too wide, between 54.1 (4.435–660.372) for occupation and recreation records 40.031 (7.782–204.93, rounded). This wide range may be due to a lack of samples, because the ratio between cases and controls was 1:1. Therefore, if the comparison between cases and controls is enlarged, for example, 1:2, 1:3, or 1:4, it is possible that the results will be better; namely, the OR range is narrower. We suggest that future research be conducted using more comparison of controls.

Conclusion

Lack of knowledge, risky occupations, and a history of injuries are associated with leptospirosis in West Jakarta, Indonesia, while recreational activity may be a protective factor. The dominant factors for leptospirosis are risky occupations, followed by a history of injuries.

Providing information and education on leptospirosis to the public may minimize the occurrence of leptospirosis. The results also suggest the need to disseminate public information and provide outreach regarding leptospirosis. Further studies are recommended on other factors affecting leptospirosis incidence, such as the environment and topography, since a wider range of those factors were impractical in this study, which focused only on community behavior.

Footnotes

Authors' Contributions

D.S. contributed to acquisition of the financial support for the project leading to this publication; conceptualization ideas; formulation or evolution of overarching research goals and aims; oversight and leadership responsibility for the research activity planning and execution, including mentorship external to the core team. R.I.T.N. assisted with application of statistical test to analyze and synthesize the data; preparation of the published work, revising it critically for important intellectual content; D.S., R.I.T.N., and L.R. provided final approval of the version to be published.

Ethical Approval and Consent to Participate

All procedures performed in studies involving human participants and animals were under the ethical standards of the national research committee approved by The Research and Community Engagement Ethical Committee of Faculty of Public Health Universitas Indonesia no. 650/UN2.F10/PPM.00.02/2019.

Informed Consent

Written informed consent was obtained from a legally authorized representative for anonymized patient information published in this article.

Availability of Data and Materials

The data used to support the findings of this study are available in Dryad: Ectoparasites in rats and shrews data related to leptospirosis in West Jakarta. https://doi.org/10.5061/dryad.t4b8gtj18 (Susanna et al ).

Author Disclosure Statement

No conflicting financial interests exist.

Funding Information

The authors thank the Directorate of Research and Community Engagement Universitas Indonesia for providing the grant through the International Collaboration for Publication in the Indexed International Journal or the Publikasi Terindeks Internasional (PUTI) Kolaborasi Internasional (2Q2) grant no. NKB-772/UN2.RST/HKP.05.00/2020; We also thank all the staff of the Public Health Center in West Jakarta who assisted with the data collection.

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