Chapter 1: statement of the problem

Leptospirosis is a zoonosis of worldwide distribution, endemic mainly in

countries with humid subtropical or tropical climates and has epidemic
potential. It often peaks seasonally, sometimes in outbreaks, and is often
linked to climate changes, to poor urban slum communities, to occupation or
to recreational activities. The clinical course in humans ranges from mild to
lethal with a broad spectrum of symptoms and clinical signs. Leptospirosis is
underreported in many countries because of difficult clinical diagnosis and
the lack of diagnostic laboratory services.
Causal agent: Pathogenic leptospires belong to the genus Leptospira (long
corkscrew-shaped bacteria, too thin to be visible under the ordinary
microscope); dark-field microscopy is required. The more than 240
pathogenic serovars cannot be differentiated on the basis of morphology.
Main modes of transmission: Feral and domestic animals constitute the
reservoir of the agent, transmitted through contact of mucous membranes or
(broken) skin with water (swimming or immersion), moist soil or vegetation
contaminated with the urine of infected animals; occasional infection occurs
through ingestion/inhalation of food/droplet aerosols of fluids contaminated
by urine. The incubation usually lasts about 10 days (2 to 30 days).
Clinical description and recommended case definition
Clinical description: The usual presentation is an acute febrile illness with
headache, myalgia (particularly calf muscle) and prostration associated with
any of the following symptoms/signs:
Conjunctival suffusion, Anuria or oliguria , Jaundice , Cough, haemoptysis
and breathlessness Haemorrhages (from the intestines; lung bleeding is
notorious in some areas) , Meningeal irritation , Cardiac arrhythmia or
failure , Skin rash. Other common symptoms include nausea, vomiting,
abdominal pain, diarrhoea, arthralgia. The clinical diagnosis is difficult where
diseases with symptoms similar to those of leptospirosis occur frequently.A
positive result of a rapid screening test such as IgM ELISA, latex
agglutination test, lateral flow, dipstick etc. Isolation from blood or other
clinical materials through culture of pathogenic leptospires. A positive PCR
result using a validated method (primarily for blood and serum in the early
stages of infection). Fourfold or greater rise in titre or seroconversion in
microscopic agglutination test (MAT) on paired samples obtained at least 2

weeks apart. A battery of Leptospira reference strains representative of local

strains to be used as antigens in MAT. Suspected: A case that is compatible
with the clinical description and a presumptive laboratory diagnosis.
Confirmed: A suspect case with a confirmatory laboratory diagnosis.
Awareness about the prevalence of this disease has been noticed by many
people , but as observed by the researchers, people in the flooded areas of
San Pedro Laguna has not been aware of the fact that roaming around in
flooded areas can be a source of infection that may lead to the development
of Leptospirosis
Statement of the Problem

This study is designed to assess the level of awareness of the residents

of the selected flood prone areas in san pedro laguna.

Specially, this study sought to answer the following questions:

1. What is the profile of the participants with respect to the following

demographic variables:
1.1
1.2
1.3
1.4
1.5
2.
3.
4.
5.

Age,
Gender,
Civil status,
Educational attainment
Occupation

Who are the people mostly susceptible to get Leptospirosis?

What are the factors that affect their perception of leptospirosis?
What are the ways that can help the people avoid getting leptospirosis?
Is awareness regarding leptospirosis affected by the educational
attainment of an individual?

Hypothesis

People in flood prone areas are more aware about the dangers bought by
Leptospirosis rather than people in non flood prone areas

Significance of the Study

The results of this study aims to benefit the following:

Nurses.
Results of this study will provide information to the people
about the dangers and demise that Leptospirosis can bring

Nursing Profession.

This will further help the profession to

Researchers. This study will enable the researcher to identify the

peoples awareness about Leptospirosis and aid them by rendering client
education.

Future Researchers.
This study will serve as a reference for future
studies related to the degree of awareness of people regarding Leptospirosis.

Scope and Limitations

This study is focused on determining the level of Awareness of people

regarding Leptospirosis in flood prone areas in San Pedro Laguna
The respondents are 50 residents of randomly selected flood prone
baranggays in San Pedro Laguna.
This study was conducted from August 2012 to March 2013.

Definition of Terms

To facilitate a better understanding and clarity of the study, the

following terms are defined operationally;

Case Finding An activity to discover or find TB case

Case Holding An activity to treat TB cases through proper treatment
regimen and
health education
Cure A treatment outcome wherein a sputum smear positive patient who
has
completed treatment and is sputum smear negative in the alst month of
treatment and on at least one previous occasion.
Cure Rate Cure rate is the proportion of the number of smear positive TB
cases
who are smear negative in the last month of treatment and on at least
one previous occasion.
CXR Chest x-ray
Defaulter A treatment outcome wherein a patient whose treatment was

interrupted for two consecutive months or more.

Died A treatment outcome wherein a patient dies for any reason during the
course of treatment.
DOH Department of Health
DOT Directly Observed Treatment. This is an activity wherein a trained
health worker or treatment partner personally observes the patient to
take anti-TB medicines every day during the whole course of the
treatment of smear positive case.
DOTS Directly Observed Treatment Short-Course. This is a comprehensive
strategy to control TB, and is composed of five components. These are:
1. Government commitment to ensuring sustained, comprehensive
TB control activities
2. Case detection by sputum-smear microscopy among symptomatic
patients self-reporting to health services. (passive case finding)
3. Standard short course chemotherapy using regimens of six to eight
months, for at least all confirmed smear positive cases. Complete
drug taking through DOT by health workers during the shole
course of treatment for all smear positive cases.
4. A regular uninterrupted supply of all essential anti-tuberculosis
drugs and other materials
5. A standard recording and reporting system that allows assessment
of case finding and treatment results for each patient and of the
tuberculosis control programs performance overall.
Doubtful A treatment outcome that occurs when a 3-sputum-smear
examinations
has only one positive result out of three smear examinations
Extra-pulmonary TB A patient with at least one mycobacterial
smear/culture positive from
an extra-pulmonary site (organs other than the lungs: pluera, lymph
nodes, genito-urinary tract, skin, joints and bones, meninges, intestines,
peritoneum and pericardium, among others), or a patient with
histological and/or clinical evidence consistent with active TB and
there is a decision by a physiciaan to treat the patient with anti-TB
drugs
ii
Failure Case A patient who, while on treatment, is sputum smear postivie at
five
months of later during the course of treatment.
MDR-TB Multiple drug resistant TB. A condition which is resistant against at
least isoniazid and rifampicin.
MT Medical technologist
New Case A patient who has never had treatment for TB or who has taken
antituberculosis
drugs for less than one month
NTP National Tuberculosis Control Program

Other Case A patient who is starting treatment again after interrupting

treatment for
more than two months and has remained or became smear-negative or a
sputum smear-negative patient initially before staring treatment and
became sputum smear-positive during the treatment or a chronic case: a
patient who is sputum positive at the end of a re-treatment regimen
PhilHealth Philippine Health Insurance Corporation
PTB Pulmonary tuberculosis
Relapse Case A patient previously treated for tuberculosis who has been
declared
cured or treatment completed, and is diagnosed with bacteriologically
positive (smear or culture) tuberculosis
Return after default (RAD) Case A patient who returns to treatment with
positive bacteriology (smear or
culture), following interruption of treatment for two months or more.
Smear negative, PTB A patient with at least three sputum specimens
negative for AFB with
radiographic abnormalities consistent with active TB, and there has
been no response to a course of antibiotics and/or symptomatic
medications, and there is a decision by a physician to treat the patient
with anti-TB drugs
Smear Positive, PTB A patient with at least two sputum speciments for
AFB, with or without
radiographic abnormalities with active TB, or a patient with one
sputum specimen positive for AFB and with radiographic abnormalities
consistent with active TB as determined by a clinician or a patient with
one sputum speciment positive for AFB with sputum culture positive
for M. tuberculosis
Sputum Microscopy for Diagnosis The sputum smear examination done
to TB symptomatic to establish a
diagnosis of TB. Three sputum specimens should be collected
Sputum Microscopy for Follow-up The sputum smear examination done
to monitor the sputum status of a
patient after treatment is initiated. Only one sputum specimen is
collected, preferably the early morning phlegm.
TB Tuberculosis
TB-DOTS Centers Accredited facilities by the Philippine Health Insurance
Corporation to
provide services for TB-DOTS.
TB Symptomatic Any person who presents with symptoms or signs
suggestive of
tuberculosis, in particular cough of long duration (for two or more
weeks duration).
Transfer-in Case A patient who has been transferred from another facility
with proper
referral slip to continue treatment.

iii
Transfer out A treatment outcome wherein a patient who has been
transferred to
another facility with proper referral/transfer slip for continuation of
treatment.
Treatment Completed A treatment outcome wherein a patient who has
completed treatment
but does not meet the criteria to be classified as cure of failure. This
group includes: a) a sputum smear-positive patient initially who has
completed treatment without follow-up sputum examinations during the
treatment, or with only one negative sputum examination during the
treatment, or without sputum examination in the last month of
treatment or b) a sputum smear positive patient who has completed
treatment.
Treatment Failure A treatment outcome wherein a patient who is sputum
smear-positive at
five months or later during the treatment or a sputum smear-negative
patient initially before starting treatment and becomes smear-positive
during the treatment.
Tubercle Bacillus Mycobacterium tuberculosis which causes tuberculosis. It
is acid-fast
stained with Ziel-Nielsen staining method.

Chapter 2 : Review of related literature

Tuberculosis continues to be a large disease burden in the Philippines. The

2005
WHO global TB report placed the country at number nine in the top ten
countries in the
world with the highest cases of TB. On that same year, TB ranked 6th in the
top 10
leading cause of morbidity and mortality in the country taking a death toll of
78 people
per day and afflicting 293 for every 100,000 Filipinos (DOH,2006).
To combat the disease, tuberculosis control programs in the world and
Philippines
had been emphasizing the Directly Observed Therapy Scheme, which was
promoted by
the WHO and International Union against TB and Lung Disease, in the
management of
the disease. The current goals are to achieve 85% treatment success rate
and 70% case
detection among communities. To meet these goals, TB control institutions
are faced
with the challenge of decreasing treatment non-completion and increasing
case detection.

In view of this fact and the recent documentation of extremely drug resistant
TB in the Philippines, it becomes imperative that all patients undergoing
therapy complete their treatment.
Defaulting from treatment is a multi-factorial issue that has organizational
and
socio-economic implications (Chang et al, 2004). The researcher therefore
looked into
and examined through logistic regression the socio-demographic, treatment
related, and
personal patient characteristics to find out whether any of these
characteristics can be
used to predict treatment defaulting under the existing service and social
settings in
San Antonio San Pedro Laguna in the hope of improving the rate of treatment
compliance in the said area.
TB DOTS program
Available literature identified several factors associated with defaulting from
DOTS which range from socio-demographic and personal to treatment
related factors.
The following review summarizes the materials available to the researcher.
Knowledge has been cited as one of the major factors contributing to default
by
most of the studies. The studies in Ethiopia implicated poor awareness about
the disease
(Belachew et al, 2004) and inadequate knowledge about treatment duration
(Ali et al,
2002) as reasons for defaulting. In Zambia, patients were noted to become
non-adherent
to treatment once they feel better (Kaona et al, 2004) while in Gambia, high
rates of
defaulting were found among those who were uncertain that their treatment
will work
(Bah et al, 2005). Uncertainty about treatment success was found to be a
very critical
factor for defaulting in the first 90 days of treatment. In the Philippines,
Blumfeld et al
(1999) looked into the correlations between socio-demographic and service
factors and
the rate of incomplete treatment and found out that when the infectious
nature of the
disease and the requisite treatment regimen were explained clearly to the
patient, default
rates were decreased as much as 50%. Edding (1998) who conducted an
interventional

study in Sibuco, Zamboanga del Norte likewise found higher compliance in

those who
received TB education. The study of the PRICOR project of USAID in 1999
also noted
that compliers tend to know more about the drug regimen particularly
treatment duration
compared to defaulters.
Another factor implicated with defaulting among DOTS enrolled TB patients
is
the distance of the residence of the patient from the treatment facility
(Belachew et al,
2004). Those who incurred significant time and money costs traveling to
receive
treatment are most likely to default. Distance of residence from the facility
was noted to
be critical 90 days after initiation of treatment (Bah et al, 2005).
The relevance of social support to defaulting was also tackled in the
literature.
The lack of family support was found to be strongly predictive of default in
the study of
Chan et al (2000) in Singapore and Ali et al (2002) in Ethiopia. In Nepal, Bam
et al
(2006) noted compliance behavior to be closely associated with the social
support from
family and friends. Social support from health workers however was found to
be
insignificant.
The contribution of treatment side effects to defaulting has been evaluated
by
studies and there has been conflicting results. Chang et al (2004) in Hong
Kong and Ali
et al (2000) in Ethiopia find treatment side effects to be associated with
default. Soriano
(2002) in a qualitative study in Mutia, Zamboanga del Norte likewise stressed
that most
4
of those who defaulted did so because of inability to deal with drugs adverse
effects.
She further stressed that defaulters perceived that the health benefits of
undergoing
treatment were not worth suffering the negative side effects of the medicine.
That long
term goals of cure and recovery were disregarded by defaulters for the
immediate goal of
seeking relief from the discomfort brought about by the side effects of
medication. Chan

et al (2004) in Singapore and Burman (1997) in Denver USA, however, did

not find an
association between toxic reactions to drug and default.
In Bangalore India, Vijay et al (2003) conducted a retrospective case control
study on defaulting among Category 1 and Category 2 patients and found
out that male
sex and alcoholism are predictive of default. Alcoholism and homelessness
were
likewise found to be predictive of default in the Denver USA retrospective
study by
Burman et al (1997) while smoking was found to be significant in Hong Kong.
In Nepal, Hansen et al (2005) examined the contribution of socio-economic
status
to non-adherence to treatment. Results of their study revealed that
unemployment, low
status occupation, low annual income, and cost of travel to the TB treatment
facility are
significantly associated with non-adherence to treatment. They concluded
that low socioeconomic status and particularly lack of money are important
risk factors for nonadherence to treatment in a poor country as Nepal. Chan
et al (2004) in Singapore however did not find significant association
between employment status and defaulting.
In sum, there seems to be a strong support in the literature regarding the
predictive value of inadequate knowledge and lack of social support for
default. Data on
the role of gender, socio-economic status and treatment side effects as
predictors of
default were conflicting. Distance of residence from the treatment facility
and cost of
traveling seem to be important in less developed countries while alcoholism,
homelessness and smoking seem to be important in urban areas as
predictors of treatment default.