Awareness and Practices Regarding Leptospirosis in Andaman and Nicobar Islands, Union Territory of India

Background Leptospirosis is a worldwide prevalent zoonotic infection and re-emerging disease caused by the bacterium of genus Leptospira transmitted by infected animals in the environment. Andaman and Nicobar Islands has one of the highest incidence rates of leptospirosis in India with a seroprevalence of 52.7%. This study examined the knowledge, attitudes, and practices (KAP) regarding leptospirosis among the urban and rural populations of the Union Territory (UT) of India. Aim and objective This study aims to assess the knowledge, attitude, and practices regarding leptospirosis in a rural and an urban community of Andaman and Nicobar Islands. Materials and methods This community-based cross-sectional study was conducted at rural and urban field practice areas under the aegis of the Department of Community Medicine, Andaman and Nicobar Islands Institute of Medical Sciences (ANIIMS), Port Blair, for a period of three months. A semi-structured interview schedule was administered to 450 participants in community settings selected from a list of households obtained from the municipal council using a systematic random sampling method. All interviews were conducted face-to-face by the investigators to collect data on the sociodemographic variables of the study participants and their knowledge, attitudes, and practices regarding the disease. The data was analyzed using Statistical Package for the Social Sciences (SPSS) version 27.0 (IBM SPSS Statistics, Armonk, NY, USA). Results The knowledge and attitude regarding leptospirosis and henceforth the likelihood of individuals using preventive practices were evaluated. The majority of respondents (97%) had previously heard about leptospirosis; however, specific knowledge regarding its risk factors, causative agent, and complications was limited among the participants. Although more than 90% of them had a favorable attitude toward seeking treatment for the disease and adopting specific preventive measures and general hygiene, they did not practice these hygiene habits nor used self-protective equipment in their day-to-day lives. Less than 50% of participants wore protective clothing, boots, and gloves while cleaning cattle sheds, and only 40% of them used rodenticides despite the presence of rodents in their houses. Most of the owners (60%) had not vaccinated their pets. We also found a significant association between the male gender and urban residence with a good knowledge score (p=0.05). Conclusion Despite having knowledge of and a positive attitude toward the disease, the participants did not practice preventive measures. We recommend that health interventions in endemic communities should focus on the implementation of protective measures by raising awareness in the susceptible population on multiple dimensions of leptospirosis in order to attain and ensure better compliance.


Introduction
Andaman and Nicobar Islands, being a part of a tropical belt, leaves its population highly vulnerable to contracting leptospirosis, a zoonotic disease favored by humid climate, heavy rainfall, and occasional flooding and characterized by multi-organ failure as one of its complications [1][2][3].Despite its high

Study period
The study was conducted from January to March 2023.

Study population
The study population consisted of adults (18 years and above) residing in both study areas.

Inclusion Criteria
All males and females 18 years and above who had been residing in the study area for at least one year.

Exclusion Criteria
All those diagnosed with leptospirosis by any healthcare facility or had any family member treated for the disease.

Study tool
A pre-tested, semi-structured interview schedule was administered to all the participants after obtaining their written consent.The pre-testing was carried out in Ferrargunj and Haddo, which are rural and urban areas, respectively.
The interview schedule comprised four sections: sociodemographic characteristics and knowledge, attitudes, and practices regarding leptospirosis.The sociodemographic section gathered details such as name, age, gender, address, educational qualifications, occupation, and socioeconomic class.The knowledge section comprised a set of questions addressing the epidemiology, transmission, clinical features, diagnostic methods, outcomes, prevention, and treatments available for leptospirosis.The attitude of the population regarding the disease was assessed thoroughly by questions on vaccines for domestic animals and chemoprophylaxis and adopting preventive measures to avoid infection and transmission of the disease.Practices regarding prevention were assessed through questions based on adherence to preventive measures, frequency of handwashing, eating habits, prevention of food and water contamination, protection of domesticated animals, and use of personal protective equipment.Multiple responses were allowed in suitable questions to gather detailed perceptions of the study participants regarding the disease.

Sample size
For the calculation of sample size, the following formula was used: N = Z 2 (1-α/2) * P(1-P)/d 2 , where N is the sample size, Z (1-α/2) is 1.96 value of the standard normal variate corresponding to the level of significance α of 0.5, d is the specified precision on either side of the mean, and P is prevalence.
The sample size was calculated assuming a 95% confidence level, a 5% margin of absolute error, and a 50% proportion for prevalence.Since there has been no similar study conducted in Andamans previously, we have taken the prevalence to be 50% [5].Taking into account a 10% non-response rate, a total of 450 subjects were enrolled in the study.

Methodology
The list of households was taken from Port Blair Municipal Council for the designated rural and urban areas, and the total number of eligible households based on inclusion criteria was short-listed.Systematic random sampling was used to select the households out of a total number of eligible households.The first household was selected by simple random sampling using a random number generator in Microsoft Excel software (Microsoft Corporation, Redmond, WA, USA).After selecting the household, one study participant was selected by a simple random sampling technique using a random number method and enrolled in the study.If a particular house was found locked on three consecutive visits, then that household was dropped from the study and the next eligible household was chosen.All interviews were conducted at participants' homes through face-to-face interaction with the investigator to collect data on sociodemographic details and knowledge, attitudes, and practices related to leptospirosis.

Ethical considerations
The study protocol was approved by the Institutional Scientific Research Committee (ISRC) and the Institutional Ethics Committee, ANIIMS, Port Blair.Written informed consent was obtained from the study participants after explaining to them the nature and purpose of the study.

Data analysis
Data was entered in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA), and analysis was done using Statistical Package for the Social Sciences (SPSS) version 27.0 (IBM SPSS Statistics, Armonk, NY, USA).Quantitative variables were expressed as means and standard deviations.Categorical variables were expressed as frequencies and percentages.The chi-square test was used to test differences in proportions.A two-tailed p-value of <0.05 was considered statistically significant.

Sociodemographic characteristics
The age of the study participants ranged from 18 to 80 years, and their mean age was 43.36±5.7 years.There was nearly an equal proportion of male (51.3%) and female (48.7%) participants in our study.Most of the participants were either graduates (22.2%) or had completed middle school (22%), followed by high school (18%).More than two-thirds of the participants belonged to nuclear families (72.7%) comprising parents and children (Table 1).

Knowledge
Among the total participants, almost 97% of the participants had heard about leptospirosis, while 3.1% were completely unaware of the disease.While 24% of the people considered bacteria to be the causative organism, followed by viruses (19.6%), 2.9% of the participants thought rats, rodents, and mosquitoes as the causative organism, while 37.1% of the participants were not aware of the cause of the disease.Animals (65.3%) were mostly considered to be the mode of transmission, followed by mosquitoes (48.9%), contaminated water (39.1%), and food (36%).Nearly 61% of the people thought walking barefoot was the most significant risk factor, followed by contact with contaminated animal carcasses (48.9%) and water bodies (47.1%), while only four (0.9%) participants specifically mentioned contact with infected rat's urine as a risk factor.More than 75% of the participants considered floods to be the most potential natural calamity responsible for disease transmission.
Fever (74.7%), headache (54.7%), vomiting (43.8%), muscle pain (43.3%), weakness (40.4%), and redness of the eyes (21.3%) were thought to be the most common symptoms, and jaundice (42.9%) and liver damage (26.9%) as the most common complications of leptospirosis.Blood tests (69.1%) followed by urine examination (13.6%) were most commonly thought of as the methods of diagnosis, but 1.1% of the participants were also of the opinion that this disease cannot be diagnosed.While 72.4% of the people considered leptospirosis to be a fatal disease, about 2.5% disagreed, and the rest were unaware of its outcome.
More than 86% of the participants were of the opinion that leptospirosis can be prevented with the use of protective equipment, proper hand hygiene, avoiding direct contact with animals and flooded areas, and anti-rodent measures, but only 3.1% and 10.2% of them were aware of the availability of chemoprophylaxis and vaccines for domestic animals against leptospirosis, respectively (Table 2).

Attitude
More than 90% of the participants had a positive attitude toward treatment seeking, adopting specific preventive measures against leptospirosis, and general hygiene measures such as handwashing.However, 4.4% of the population did not consider it necessary to seek medical help if one develops symptoms of leptospirosis, while 10.22% and 3.1% of people, respectively, refused the need to take preventive measures such as vaccines for domestic animals and chemoprophylaxis against the same.A small segment of the study subjects did not deem the following measures as necessary to prevent leptospirosis: making the environment free of rodents (12%), wearing protective equipment while cleaning cattle sheds/kennels/sty, vaccinating their domesticated animals and disposing of the remains of animals properly (1.3%), covering household drains (0.7%), and cleaning them frequently (1.3%).The remaining participants had a favorable attitude toward all these preventive measures (Table 3).

Practices
Although 88% of the participants had a positive attitude toward making their environment rodent-free, only 40% of them used rodenticides in their homes despite the presence of rodents.Less than 50% of those owning a domestic animal had them vaccinated.While more than 65% of cattle owners cleaned the cattle shed/kennel/sty daily, among them only two-fifths wore boots and gloves while cleaning them.
While 57.1% of the people threw the leftover food or kitchen waste in a separate bin for wet waste, others preferred to throw them in a nearby drain (32.7%) or in an open area (9.6%).About 55% of the people interviewed disposed of their household waste daily, whereas 32.2% disposed biweekly, and 9.1% did it once weekly.More than 36% of the participants did not keep the drains in their vicinity covered.Around 41.6% of the participants cleaned the drains as required, while 12.2% of them never cleaned the drains (Table 4).

Association between demographic factors and knowledge score
The demographic variables gender (chi-square=11.886,p=0.008) and residence (chi-square=35.823,p<0.001) are significantly associated with the knowledge score.No significant association between knowledge and age, marital status, religion, education, and family type was observed (p>0.05)(Table 5).

Discussion
Although several serological studies to establish the association of leptospirosis with certain high-risk occupations have been carried out, studies to explore awareness and preventive practices are still lacking.Andaman and Nicobar Islands, being a highly endemic pocket, require robust data on existing awareness and practices for initiating effective control measures.
The present study demonstrated that 96.9% of the participants were aware of the disease, but they recognized it by the name of "Andaman fever."Animals (65.3%) were mostly considered to be the mode of transmission, followed by mosquitoes (48.9%), contaminated water (39.1%), and food (36%).Similar findings were observed in a study conducted by Sukeri et al. among the rural and urban communities in Malaysia in 2018, in which the findings revealed that almost all the participants had heard of leptospirosis or rat urine disease but lacked basic knowledge regarding the disease [6].This was in contrast to the findings of a cross-sectional study conducted in Tamil Nadu by Prabhu et al. among municipal workers, where it was found that only 18.9% of the workers had heard about leptospirosis, while most of the participants had false beliefs that leptospirosis can be transmitted by mosquitoes as well and can cause lung cancer in later stages [7].The findings in our study are heartening as even the general community here is familiar with the disease against the municipal workers of Tamil Nadu who are at high risk for it.
Nearly 61% of the people thought walking barefoot was the most significant risk factor, followed by contact with contaminated animal carcasses (48.9%) and water bodies (47.1%)However, only 0.9% of the participants specifically mentioned infected rat urine as a risk factor for leptospirosis.This was in contrast with the findings of a cross-sectional study conducted by de Araújo et al. in the urban slums of Salvador, Brazil.where 72.7% of the participants were aware that leptospirosis is a disease spread by rats [8].The difference in the findings can be attributed to the high literacy rate (99.2%) and health awareness among the Brazilian population [9].
Over 70% of the people were of the opinion that leptospirosis is a fatal disease.Similar conclusions were drawn from a cross-sectional study conducted by Ricardo et al. in 2017 among the residents of riverside settlements in Santa Fe, Argentina, where nearly 80% of the participants agreed that leptospirosis can cause death if not treated.More than 80% of the participants also considered leptospirosis to be a preventable disease in corroboration with 86% of the participants of our study [10].
More than 90% of the participants had a positive attitude toward treatment seeking, adopting specific preventive measures against leptospirosis, and general hygiene measures such as handwashing.Of the participants, 88% considered making their environment free of rodents as an effective method to prevent leptospirosis.This was consistent with the findings observed in a cross-sectional study conducted by Nair et al. in 2020 in Thiruvananthapuram, Kerala, where 85.63% of the respondents expressed a positive attitude toward keeping their houses rat-free [11].
Surprisingly, despite the majority of participants having knowledge and positive attitudes regarding the disease, only 40% of them practiced the use of rodenticides.This corroborated the findings of the study conducted in 2011 by Mohan and Chadee in Trinidad, in which 68.9% of the participants did not spend any money on rodent control [12].Less than 50% of those owning domestic animals got them vaccinated.
Although more than 65% of cattle owners cleaned the cattle shed/kennel/sty daily, only around 40% took preventive measures and wore boots and gloves while cleaning them.Similar findings were seen in a crosssectional study conducted by Arulmozhi et al. in 2017 among the risk populations of South Chennai, in which 39% of the participants did not use any protective equipment while engaging in high-risk activities [13].
We found the demographic variables gender (chi-square=11.886,p=0.008) and residence (chi-square=35.823,p<0.001) to be significantly associated with the knowledge score.However, no significant association between knowledge and age, marital status, religion, education, and family type was observed (p>0.05).This was in contrast to the study conducted by Rathinam et al. from March 2017 to March 2018 in Madurai, in which none of the factors such as age, gender, and residence were found to be significantly associated with awareness of preventive measures against leptospirosis [14].

Limitations
This was a cross-sectional study in which the responses were self-reported and hence prone to recall bias, and also, the risk of social desirability is anticipated to be high.Moreover, the changes especially in attitude and practices could not be evaluated further as it was a cross-sectional study.

Strengths
Nevertheless, this study is the first of its kind to be conducted in the Union Territory with high endemicity and seroprevalence of leptospirosis.The study involves both urban and rural populations of the islands, providing us with a scope to assess a difference in sociodemographic determinants of the disease.Also, the findings of our study can be extrapolated to both urban and rural settings.It was conducted in community settings in the participants' own households without the time constraints of a facility-based survey, enabling interactive and active participation, henceforth improving the quality of responses.

Conclusions
A community-based cross-sectional study was conducted at rural and urban field practice areas under the aegis of the Department of Community Medicine, Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, in which 450 participants were enrolled.Around 52.89% of the participants in the study belonged to a rural area, while 47% of them were urban residents.Almost all the participants had heard about leptospirosis; however, when probed further about the specificities of the disease, such as modes of transmission, risk factors, complications, and outcome, the knowledge gap was revealed.Very few participants were aware of chemoprophylaxis and the availability of vaccines for domestic animals against leptospirosis.The majority of participants had a positive attitude toward adopting preventive measures in their day-to-day lives involving personal hygiene, environment hygiene, and kitchen hygiene.Although the

TABLE 1 : Distribution according to demographic variables
INR: Indian rupee

TABLE 5 : Association between demographic factors and knowledge score
*Statistically significant