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Leptospirosis Hawaii's dry conditions from a lack of rain the past two years have an upside: leptospirosis cases have declined.
cases dwindle, but
isles rank first
in nation
People catch the disease
Facts and figures
by contact with urine
from infected animalsBy Helen Altonn
Star-BulletinThe disease is transmitted to people through fresh water -- such as streams, rivers, falls and even water-catchment basins -- that is contaminated by urine from infected animals.
Leptospirosis made worldwide headlines recently because many athletes who participated in the EcoChallenge Race in Malaysian Borneo, including two from Hawaii, became ill, apparently from the disease.
Without proper treatment, it can cause kidney damage, meningitis, liver failure, breathing problems and, in some cases, death.
The number of cases diagnosed in Hawaii has dropped significantly since 1996. There were 52 cases in 1996; 72 in 1997; 65 in 1998, 38 last year, and 16 so far this year, according to the state Department of Health.
The DOH also is waiting for results from more than 40 patient blood samples sent to the Centers for Disease Control and Prevention, said Dr. David M. Sasaki, veterinary medical officer with the Epidemiology Branch.
400 warning signs posted
Regardless of how it's calculated -- by numbers alone or by population -- Hawaii has more cases of leptospirosis than any other state, he said. "On the mainland they would see it more in summer and fall but we get it year-round" because of the tropical climate, he said.The Centers for Disease Control and Prevention in Atlanta stopped collecting national data in 1994, but in the five preceding years, Hawaii accounted for about two-thirds of all cases reported nationally.
Sasaki noted, however, that it may not be an accurate picture.
"It's the kind of disease, if you don't pay any attention to it, you will never know what you're dealing with."
There are many risk factors, Sasaki said, but about two-thirds of Hawaii's cases involve people with abrasions or cuts on the skin exposed to contaminated water.
He believes island physicians and residents probably are more aware of leptospirosis than elsewhere because of posted signs, brochures and a videotape in all libraries.
About 400 signs are posted in county and state parks warning that fresh-water streams and mud possibly are polluted with leptospirosis.
Hawaii is the only state that closely tracks the disease, Sasaki said, explaining that the DOH tries to interview all patients who test positive to determine how they were exposed.
The DOH conducts a screening test on blood samples sent by physicians in suspected cases but it isn't as sensitive as the CDC test, he said. "They run a confirmatory test, which is very labor-intensive."
However, the CDC recently suspended such tests at least through the end of this year. "So we're going to be backlogged until the next year as far as getting final results on a lot of these people," Sasaki said.
"That's absolutely incredible," said Kauai's Dr. Jeffrey Goodman, who is credited with diagnosing more leptospirosis than any other doctor in the country. "They'll essentially have no cases for the rest of the year."
Most cases in Hawaii occur on the Big Island but, based on population, Kauai has the greatest number. Despite a lot of rain on the northern and eastern half of Maui, it has the fewest cases, "and we don't know why," Sasaki said.
Goodman, with Kauai's North Shore Clinic, is closely following leptospirosis test results of the recent EcoChallenge Race, which had 76 four-person teams from 26 countries.
As of Sept. 13, the CDC had contacted 82 -- only 53 percent -- of the 148 American EcoChallenge participants to warn them of the possible illness.
Difficult to diagnose
Of those contacted, 37 (45 percent) reported having fever; 12 (15 percent) were hospitalized. Ten sent blood samples to CDC and seven tested positive for leptospirosis."There are a lot more cases out there and a lot more are going to occur," Goodman said, noting the disease has an incubation time of two to 21 days.
Sasaki sent blood samples to CDC from the two islanders believed to have contracted the disease during the 500-mile race involving swimming, hiking, spelunking, biking, scuba-diving and boating.
Both Mike Trisler, 32, a lifeguard on Oahu's North Shore, and Edward Bugarin, 50, a retired Army sergeant-major and founder of STREND Fitness Challenge, Inc., were hospitalized after returning.
There is no quick test for leptospirosis and it's difficult to diagnose, Sasaki said. Symptoms vary and are similar to flu, malaria, dengue and other infections.
The first samples are often negative so the DOH asks doctors to send a second sample two weeks later, he said. The second sample may be positive in DOH lab tests and a negative sample many times will be positive in a CDC confirmatory test, he said.
"In that respect, diagnosis is challenging because it's slow." Also, he said, "The clinical pattern is not classic. It is highly variable, so a doctor can't look at a patient presenting certain kinds of symptoms and say, "You have leptospirosis.'"
Goodman said the first patient he had with leptospirosis was in 1974.
"I didn't know what this was. I started digging around in books. An internist friend was also digging in books. We met in the hall the next morning and said, "It's got to be leptospirosis.' We did blood tests and it was."
Goodman began getting other cases that "were notoriously misdiagnosed as hepatitis and flu," he said. "The problem is the variety of symptoms, physical findings and lab findings. A potpourri of many small things that fit together make leptospirosis more likely."
About three years ago after a heavy rainfall period, he said his little clinic saw more than half the cases in Hawaii. It hasn't had any cases this year because of the dry weather, but he expects some to emerge after it starts raining.
Second phase can be deadly
Leptospirosis is a "very dangerous" disease because it has several phases, Goodman said. It has an initial episode of five to seven days, a respite period of one to two days when the patient feels normal, then "a second phase which can be deadly," he explained.A patient must be treated in the first five days, even though the disease can't be definitely diagnosed, Goodman emphasized.
It usually takes a week after the illness begins before antibodies produced by the immune system to fight the disease are detectable, he said. If the doctor waits for the illness to go away, or for other symptoms, the patient may move into the respite period and cancel further medical appointments, then get severely ill two or three days later.
"This has troubled me," Goodman said, noting that he wrote to the CDC, urging that doctors be alerted that the respite period may fool them.
"They should over-treat rather than under-treat for leptospirosis. You never find out what the result is until three or four weeks after being sick. That's why it's critical for doctors to be keen about what to look for."
Hawaii facts and figures
Two-thirds of local cases occur in the last six months of the year, possibly because of more outdoor activity during the summer.
Source: State Department of Health