MILITARY MEDICINE, 162,2:101,1997

Leptospirosis on Oahu: An Outbreak among Military Personnel

Associated with Recreational Exposure
Alan R. Katz, MD, MPH* CAPT Joel Escamilla, MSC USN§
David M. Sasaki, DVM MPHt Charles R. Middleton, MSt
COL Alan H. Mumm, MC USA* Sofia E. Romero, BSq[

In December 1992, a common-source waterborne outbreak of
leptospirosis occurred on the island of Oahu in the state of
Hawaii. Two male service persons were hospitalized with cul-
ture-confirmed leptospirosis. Eighteen others had similar his-
tories of exposure to the same freshwater swimming site. Al-
majority ofreported cases were work related, involving sugar, taro,
and macadamia nut farmers and cattle ranchers. The proportion
ofleptospirosis casesin Hawaii related to occupational exposures
dropped from 56% in 1971-1975 to 29% in 1986-1990, whereas

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though six men developed signs and symptoms comparable to cases related to exposures that were recreational, habitational
those of the two confirmed cases, none manifested culture or (activities around thehome), oravocational increased from 43% in
serologic evidence of leptospirosis. The increased incidence of 1971-1975 to 71% in 1986-1990. 13
leptospirosis in Hawaii coupled with an increased risk in The State of Hawaii is a subtropical archipelago comprising
young males characterize the military population in Hawaiias seven major inhabited volcanic islands in the northern Pacific
a high-risk population with respect to leptospirosis. Ocean: Hawaii, Maui, Oahu, Kauai, Molokai, Lanai, and Niihau.
Themajority ofleptospirosis cases have beenreported from the
Introduction islands ofHawaii, Kauai, and Oahu."
Thisreportdescribes a common-source outbreakofleptospi-
A lthough it is an uncommon disease in humans, leptospiro- rosis from recreational exposure to a contaminated freshwater
sis is considered the most widespread zoonosis in the source, and suggests public health interventions to prevent/
world. 1 From 1970 through 1992, the annual reported rate of limit future outbreaks.
leptospirosis in the United States varied from 0.02 to 0.05 per
100,000 population.f Since the Hawaii State Department of
Health (DOH) began collecting detailed statistics on leptospiro- The Outbreak
sis in the early 1970s, Hawaii has consistently had the highest On December 6, 1992, two male marines were admitted to
annual incidence rates ofleptospirosis nationally," In 1992, the Tripler Army Medical Center, Honolulu, with suspected lepto-
DOH reported a leptospirosis incidence rate of2.97per 100,000 spirosis. Bothhad a history ofrepeated exposures to contami-
population compared withthe national rate of0.02per 100,000 nated freshwater via swimming at Kapena Falls on consecutive
population. 4 weekends: November 21 and 22, and 28 and 29, 1992. Onsetof
Awide assortment of domestic and feral animals, including symptoms occurred 3 and 5 daysaftertheir last exposure. This
cattle, dogs, and swine, may serve as a reservoir for infectious area, a small waterfall with an associated swimming hole, is
leptospires. Rodents such as rats and mice act as the normal located in Honolulu within the NuuanuValley on the island of
carrier hosts." The etiologic bacteria infect the host animal's Oahu. Rats and mice are abundant in this locale.
renal tubules and are transmitted via contactwiththe urine of
an infected animal. Thismaybethroughdirect contact," contact Methods
witha contaminated freshwater source,7,8 or contactwithcon-
taminated moistsoilor vegetation. 9 Interviews were conducted withthe two hospitalized marines
Historically, leptospirosis has been classified as an occupa- in an attemptto identify otherswho had been swimming at the
tional disease affecting mainly rice, sugar, and taro farmers, same site during the same time interval. Twenty male marines
veterinarians, ranchers, abattoirworkers, and military troops. 10 were identified and sampled (including the two hospitalized
Recent national and local trends, however, show a predomi- men) who swam at this site duringthe two consecutive week-
nance of infection acquired through exposures during avoca- ends ofNovember 21 and 22, and 28 and 29, 1992.
tionaljrecreational activities. 11-14 An outbreak-associated possible casewasdefmed as an indi-
In Hawaii, leptospirosis wasfirst recognized as an occupational vidual who had a recreational exposure to Kapena Falls between
disease of sugar plantation farmers in 1907. Prior to 1970, the November 21 and 29, 1992, with a positive history of flu-like
illness (headache, fever, nausea, myalgia, etc.). A confirmed
·Department of Public Health Sciences, School of Public Health, University of casewas defmed as an individual withrecreational exposure to
Hawaii, Honolulu, HI 96822. Kapena Falls during the samedates,and eitherpositive cultures
tCommunicable Disease Division, Hawaii State Department ofHealth, Honolulu,
HI 96801. for leptospires or serologic evidence ofa recentleptospiral infec-
*Preventive Medicine Service, TripIer Army Medical Center, Honolulu, HI 96859. tion manifested by a minimal 4-fold increase in microscopic
§U.5. Navy Environmental andPreventive Medicine Unit Number 6, Pearl Harbor, agglutination test (MAT) titers in paired acute and convalescent
HI 96860-5040. sera.15 Acute serum specimens were drawn on December 11,
m.s. Naval Medical Research Institute Detachment, Lima, Peru. 1992 (12-20 days post-exposure). Convalescent serum speci-
This manuscript was received for review inFebruary 1996. The revised manuscript
was accepted for publication inAugust 1996. mens were drawn on January 5, 1993 (37-45 days post-expo-
Reprint & Copyright ©byAssociation ofMilitary Surgeons ofU.S., 1997. sure). Serumspecimens were sent for MAT analysis to the U.S.

101 Militaxy Medicine, Vol. 162, February 1997

102 Leptospirosis on Oahu

Navy's Medical Research Institute Detachment Laboratory in
Lima, Peru. Seventeen serovars were included in the battery of
testingantigens.
Ellinghausen McCullough Johnson Harris(EMJH) semi-solid
medium was inoculated with patients' blood 3 and 7 days after
symptom onset.Thecultureswere incubatedat room tempera-
ture and examined forleptospiral growth at weekly intervals. 15
Rodents were trappedat and above the exposure siteby DOH
personnel. Following euthanasia, kidneys were aseptically ex-
tracted and inoculated into EMJH semi-solid medium and in-
cubated at room temperature for up to 6 weeks.
Results
high index of suspicion and obtain the appropriate laboratory
testa/cultures.F'!" In this investigation, only 2 of 20 exposed
persons (2 of8 with reported symptoms) demonstrated labora-
tory-confirmed leptospirosis. Theinitialcase definition used in
this investigation was developed to maximize sensitivity, hence
specificity was compromised to some extent.
Itis possible that leptospirosis waspresent but went undetected
in some or allofthe 18exposed menwith negative MAT results. A
negative MAT resultdoes not ruleout the presence ofinfection. A
false-negative resultmayoccur either if a serumspecimen is ob-
tained prior to seroconversion or if an individual is infected with a
serogroup missing from the battery of MAT testing antigens. 15
False-negative resultsmayalso occur when patients receive anti-
biotic therapy early in the course of their illness or if they are

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In addition to the two hospitalized patients, 6 of the 20 ex-
posedmarinesreported nonspecific flu-like symptoms, withthe placed oncorticosteroid therapy. Although none ofthe menin this
onset ofsymptoms occurring 2 to 21 days afterexposure (Table outbreak were treated with corticosteroids, 2 of 6 unconfirmed
I). MAT results confirmed the diagnosis of leptospirosis in the symptomatic individuals and 11 of 12 asymptomatic individuals
two hospitalized patientsonly (Table II). Blood culturesfrom the were given early antibiotic treatment withoraldoxycycline (100 mg
two hospitalized patientsobtained at the timeofadmission were twice daily) for 14days. The two hospitalized patients were treated
positive for Leptospira interrogans serovar bangkok (Australis initially with intravenous ceftriaxone (1 gevery 12hours) and then
serogroup). Isolates from the two patientswere examined using switched to oral doxycycline (100 mg twice daily) to complete a
polymerase chain reaction analysis. The isolates demonstrated 14-day treatment regimen.
100% homology, indicating that a single strain was responsible Most untreated infected individuals will have demonstrable
forillness in both cases.16 Kidney culturesfrom 5 of85 rodents antibodies within 6 to 12dayspost-infection, withpeaktitersby
trapped in the Kapena Falls area were culture positive for lep- the 3rd or 4th week; however, aRproximately 10°;6 ofcasesfail to
tospira. The results by species were as follows: 4 of 77 Rattus manifest positive MAT results. 9
rattus (2 from the Ballum serogroup; 2 from the Icterohaemor- The two culture-positive cases were initially diagnosed by the
rhagtae serogroup); 1 of2 Rattus norwegicus (Icterohaemorrha- MAT. The MAT uses live antigens, representing eachofthe known
gtae serogroup); and 0 of6 Rattus exultans. serogroups, with the expectation that antibodies produced against
the infecting serovar will cross-react with the representative anti-
Discussion genofthat serogroup inthetest.The MAT is considered a reference
test for the serologic diagnosis ofleptospirosis, although it is only
The nonspecific symptoms associated with leptospirosis
partially serovar-specific. Cross-reactivity is well documented be-
makeit a difficult illness to recognize. Oneneeds to maintaina
TABLE I
tween serovars inthesameserogroup as well as inrelated serovars
from different serogroups. 15 The reaction between sera from sub-
REPORTED SIGNS AND SYMPTOMS FOR '!WO LABORATORY- ject 2 and Djasiman serogroup antigen reflects cross-reactivity.
CONFIRMED CASES AND SIX "SUSPECT' CASES WITHOUT
LABORATORY CONFIRMATION IN A LEPTOSPIROSIS OUTBREAK,
Low-agglutinin titerssuch as those measured bythe MAT in sera
KAPENA FALLS, 1992 from subject 3 (Table II) may represent either the presence of
persistent antibodies from a previous infection or possible false-
Percent positive test results.
Percent (No./Total) of Although 5 of85 cultures ofrodentkidneys were positive for
(No./Total) of "Suspect" Cases, Leptospira, none demonstrated the serovar or serogroup that
Laboratory- Lacking Laboratory caused disease in the two cases. Hence, none of the trapped
Confirmed Cases, Confirmation, rodents appeared to be related to the outbreak.
Sign/Symptom with Findings with Findings
Only the two confirmed (hospitalized) patients missed work
Documented fever ;:::40°C 100 (2/2) 0(0/6) due to their illness. Subject 1 was hospitalized for 6 days and
Undocumented fever 50 (3/6) missed 10 days ofwork; subject 2 was hospitalized for 4 days
Chills 100 (2/2) 50 (3/6)
and missed 6 daysofwork. All othermenhad resolution oftheir
Headache 100 (2/2) 67 (4/6)
Backache 100 (2/2) 33 (2/6)
symptoms within 3 to 17 days.
Myalgtas 100 (2/2) 33 (2/6) Clinical illness withleptospirosis maylast from a few daysto
Conjunctival suffusion 100 (2/2) 17 (1/6) 3 weeks or longer; in untreated illness, recovery may take sev-
Nausea 100 (2/2) 50 (3/6) eralmonths. Thecasefatality rate is generally low, but increases
Vomiting 100 (2/2) 33 (2/6) withincreasing ageand mayexceed 20% in patientswith renal
Diarrhea 100 (2/2) 33 (2/6) or hepaticmanlfestattons." Early intervention withoraldoxycy-
Jaundice 50 (1/2) 0(0/6) cline, within 3 days ofsymptom onset, has shown efficacy in mod-
Abdominal pain 100 (2/2) 33 (2/6) ifying the course ofillness in individuals with anicteric disease, 20
Syncope 50 (1/2) 0(0/6) andparenteral penicillin Ghas demonstrated efficacy in modifying
Delirium/mental 100 (2/2) 0(0/6)
illness in patients with severe icteric disease even when therapy
confusion
wasinstituted 7 to 19days aftersymptom onset."

Military Medicine, Vol. 162, February 1997

Leptospirosis on Oahu 103

TABLE n
MATRESULTS FOR EIGHT SYMPTOMATIC, EXPOSED SUBJECTS IN A LEPTOSPIROSIS OUTBREAK, KAPENA FALLS, 1992

Days after Convalescent Days after Presumptive Leptospira Antibiotic

Subject Number Acute Titer Symptom Onset Titer Symptom Onset interrogans Serogroup Given
la 1:800 9 1:3200 34 Australis Yes
2a 1:100 7 1:200 32 Djasiman Yes
1:800 Australis
3 1:100 0 Negative 25 Grippotyphosa No
4 Negative 13 Negative 38 Yes
5 Negative 0 Negative 25 No
6 Negative 0 Negative 25 Yes
7 Negative 17 No
8 Negative 43 No

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aLaboratory-confirmed leptospirosis.

Animal leptospirosis vaccines fordomestic livestock and dogs
havebeenin use formanyyears to protectboth animalsand the
humans that come in contactwith them. Immunity is, to a large
part, serovar-specific, and there are more than 200 known se-
rovars, each of which can independently infect a wide array of
animal hosts. As regional variation in enzootic serovars is well
documented, knowledge of the specific regional enzootic sero-
vars, as well as the animal hosts, is necessary to develop an
effective vaccine. Polyvalent vaccines may be needed where
more than one serovarinfectsthe same animal species. Annual
"boosters" are also needed to maintain an adequate immune
response. Although animals given a vaccine produced from re-
gionally specific serovarswill be protectedfrom clinical disease,
vaccination may not prevent infection or urinary shedding of
leptospires.' Vaccination of feral host animals, including rats
and mice, is not possible. Human vaccines have been used in
Vietnam, China, and Japan to immunize high-risk populations
such as ricefarmers or sewer workers. Reported sideeffects, such
as pain, fever, and nausea, haveoccurred in a highproportion of
recipients, and the challenges posed by the wide variety ofregion-
allyenzootic serovars would need to be addressed before human
vaccines could be utilized in a cost-efficient manner.f Chemopro-
phylaxis withoraldoxycycline (200 mgperweek) has been shown
to be an effective leptospirosis prevention strategy for military per-
sonnel engaged in short-term (up to 3 weeks) exposures to high-
risk environments.23
The majority of reported leptospirosis cases both nationally
and in Hawaii havebeen sporadicand unrelated.11-14 However,
cluster outbreaks are reportedinfrequently. 19,24-28 Bermanand
colleagues recognized leptospirosis as a significant cause of
morbidity amongU.S. servicemen in Vtetnam.i" The epidemio-
logic investigation of a recent leptospirosis outbreak involving
22 male U.S. military personnel in Okinawa, Japan, revealed
twoseparate sources ofinfection. Fifteen men had been exposed
during training drills that included negotiating an underwater
obstacle course. Seven men were exposed recreationally via
swimming in a freshwater stream."? A recent case report of
leptospirosis in a 19-year-old military recruit from the United
Kingdom, exposed occupationally during military exercises,
stressed that physicians in the Royal Army Medical Corps
should be awareofthe inherent risk ofleptospirosis forsoldiers
from both recreational and occupational exposures."
In Hawaii in 1986, two of two sailors swimming in another
stream in Honolulu were hospitalized and subsequently con-
firmed to have contracted leptospirosis (Icterohaemorrhagiae
serogroup). One of the two developed Weil's syndrome and was
hospitalized for more than 2 months. Since 1986, two of five
leptospirosis outbreaks in Hawaii havebeen military associated
(Table III). Between 1990 and 1993, seven patients (including
twofrom this outbreak) were admitted to TripIer Army Medical
Centerwith the diagnosis of leptospirosis.
Epidemiologically, young males are at greatest risk for con-
tracting leptospirosis. This is true not onlybecause of age and
gender, but because ofassociatedoccupational and recreational
activities. As the military populationis composed predominately
ofyoungmen, and Hawaii has the highest reportedincidence of
leptospirosis in the U.S., the military population in Hawaii is
considered a high-riskgroup with respect to leptospirosis.
Kapena Falls has beenthe single mostfrequently identified site
ofexposure forrecreationally acquired leptospirosis on the island
ofOahu. From 1985through 1992, 10 confirmed cases were as-
sociated with swimming at this site, including 1 fatality.32 It is
likely that others escaped detection due to lack of recognition
and/ orlackofappropriate laboratory testing. In orderto minimize
exposures, DOH personnel haveposted warning signs at Kapena
Falls and otherfreshwater swimming sites.Thesignswere present
and clearly visible duringthe exposure period in the current out-
break. As a result ofthe recentoutbreak, several additionallepto-
spirosis prevention strategies are being planned. They will include
providing a brochure on leptospirosis in the information packets
given to newmilitary members reporting fordutyin Hawaii as well
as periodic coverage of leptospirosis-related information in local
military newspapers. Astate-wide Leptospirosis Ad Hoc Commit-
tee, comprising military and civilian public health professionals,
has been meeting monthly to discuss surveillance, prevention,
education, and researchissues.
TABLEm
LEPTOSPIROSIS OUTBREAKS, STATE OF HAWAII, 1986-1992
Number
Year Island of Cases Exposure Circumstances
1986 Oahu 2 Recreational Swimming in streams"
1987 Kauai 8 Recreational Swimming in streams
1987 Oahu 2 Occupational Com farming
1987 Oahu 2 Occupational Pig farming
1992 Oahu 2 Recreational Swimming in streams"
aMilitary associated.

Military Medicine, Vol. 162, February 1997

104
Although there were no further leptospirosis outbreaks in
Hawaii during the first 6 months of 1996, Hawaii continues to
leadthe nationin reported annualincidence rates.Arecentcase
involving a marine swimming at Kapena Falls was used as an
opportunity to educate the military population about leptospi-
rosisand its prevention. Thisinformation was published in the
local military newspaper.f
Leptospirosis posesa significant risk to military personnel in
Hawaii. Its potential impact on military readiness should notbe
underestimated.
Acknowledgments
We thank the following personnel for technical support: CDR R.P.
Williams, HM-l M.E. Bish, and HM-l C. Stringer of the U.S. NavyEnvi-
ronmental and Preventive Medicine Unit Number 6; HM-l J. River of lst
Battalion, 3rd Marine Division; and the Hawaii State Department of
Health Vector Control Branch workers and laboratory staff.
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