Knowledge, Attitude and Practice towards Leptospirosis among municipal workers in Tiruchirapalli, India

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1 e-issn: Iteratioal Joural of Pharma Research ad Health Scieces Available olie at Origial Article Kowledge, Attitude ad Practice towards Leptospirosis amog muicipal workers i Tiruchirapalli, Idia Prabhu N 1 *, Meera J 1, Bharaidhara G 1, Natarajaseeivasa K 2, Ismail M 1, Uma A 1 1 Departmet of Microbiology, Cheai Medical College Hospital ad Research Cetre (SRM Group), Tiruchirapalli , Tamiladu, Idia 2 Departmet of Microbiology, School of Life Scieces, Bharathidasa Uiversity, Tiruchirapalli , Tamiladu, Idia. A R T I C L E I N F O A B S T R A C T Received: 23 May 2014 Accepted: 27 Jue 2014 A cross sectioal study was coducted to assess the kowledge, attitude ad practice (KAP) o leptospirosis amog 106 muicipal workers i Tiruchirapalli, Tamiladu. Workers were iterviewed usig a validated questioaire cosist of demographic data, kowledge, attitude ad practice questios. The collected data were statistically aalyzed usig SPSS versio software. All respodets were muicipal workers with the mea age of 42.1 ( 8.38) years old. The mea duratio of employmet was 15.6 ( 8.62) years. Majority of workers had poor kowledge (87.2%) ad usatisfactory practice score (64.5%); but showed, 64.9% of satisfactory attitude score. I coclusi o, kow weakess was oted i kowledge as well as i practice level. The fidigs of this study recommed that health promotio for muicipal workers could be improved ad ecessitate for further ad uique cosideratio. 1. Keywords: Muicipal workers, leptospirosis, kowledge, attitude, practice Correspodig author * Dr. N. Prabhu, Departmet of Microbiology, Cheai Medical College Hospital ad Research Cetre (SRM Group), Tiruchirapalli , Tamiladu, Idia. E Mail: leptoprabhu@gmail.com 1. INTRODUCTION Leptospirosis is the most widespread re-emergig zoootic disease i the world, particularly i tropical ad subtropical regios where climatic coditios provide a optimal eviromet to support the survivability of leptospires. The disease presets as mild febrile illess ad subsides without complicatios i the majority of patiets. Trasmissio of leptospires 246

2 may follow direct cotact with urie, blood ad tissue form a ifected aimal or exposure to a cotamiated eviromet durig occupatioal or recreatioal use. 1,2,3 Accordig to World Health Orgaizatio from their curretly available reports, the icidece of leptospirosis rages from 0.1 to1 per 1,00,000 per year i temperate climates ad per 1,00,000 i the humid tropics. The icidece may reach over 100 per 1,00,000 i high-exposure risk groups ad durig outbreaks 4,5. A umber of leptospirosis outbreaks have bee reported i the last few years i various coutries icludig Idia. I spite of this, leptospirosis remais a grossly eglected disease ad suffers for uawareess. Most cases, this disease is ot cosidered by the cliicia; eve they are ot suspected. 6 Huma leptospirosis is edemic ifectio i Idia ad it has great potetial for outbreaks to occur, so the disease surveillace as well as awareess programs should be stepped up ad sustaied. It has a cosiderable public health ad ecoomic impact, primarily, a occupatioal disease affectig may labourers icludig farmers, field workers, muicipal workers, fisherme, sugarcae cutters etc. 7,8 Muicipal workers were chose as a study populatio because they pose risk for leptospiral ifectio i every step of the draiage cleaig as well as other risk orieted works related to aimal cotact. Some studies also reported that the prevalece of seropositive amog muicipal workers up to almost 18%. Surveys of kowledge, attitudes, ad practices (KAP) are a commo strategy for collectig iformatio ad to assess the safe work practice amog populatios at risk. 9 The surveys also provide a suitable format to evaluate existig programs ad to idetify effective strategies for behavior chage. Ideed, a good KAP amog muicipal workers at risk is essetial i esurig successful prevetio ad cotrol of the disease. Ufortuately o research has bee coducted so far i this area i Idia. This study presets the results of a study o KAP o leptospirosis amog populatios at risk of ifectio i Tiruchirapalli, Idia. The study will also provide a baselie data to assist policy makers i developig appropriate evidece based strategies to prevet ad cotrol leptospirosis i Idia. 2. MATERIALS AND METHODS 2.1 Study Desig ad Selectio of Participats A cross sectioal study was coducted amog muicipal workers employed by Tiruchirapalli Corporatio i Jauary March They were comprised of three mai job categories amely garbage collector, draiage cleaer ad septic tak cleaers. The objective was to assess their kowledge, attitude ad practice o leptospirosis. Up to the study date, there is o health educatio program for muicipal workers regardig the awareess of their risk ad the related prevetive measures that ca be practiced i order to reduce the risk of ifectio. Sample size was calculated based o pilot study usig a sigle mea formula. The largest ad the most feasible sample size were determied from stadard deviatio () of the practice score which was 8.6. With the precisio of 1.0, the estimated sample size calculated was 120. With a aticipated 10% o-respose rate, the total sample size required was 106. The total list of muicipal workers i the corporatio was the samplig frame. We icluded selected area muicipal workers i this study who had served cotiuously for at least six moths so as to make sure that they were really egaged with work activities. However, permaet workers i the corporatio area icluded ad cotract workers ad those doig part time jobs elsewhere were excluded from this project. There were a total of 106 workers who met the iclusio ad exclusio criteria for this research. I view of that, o samplig was carried out ad all of 247

3 them were take as study subjects to meet the required sample size. 2.2 Questioaire ad Iterview The muicipal workers were subjected to a iterviewer guided questioaire which probed ito demographic data ad iformatio o kowledge, attitude ad practice. It was desiged to be completed withi 20 miutes for a average participat. The laguage used was Tamil i which the mothers togue of the muicipal workers. Ay techical terms were traslated ad explaied by the iterviewer. The iterview was coducted by oe of the researchers throughout to avoid the problem of iter-iterviewer variatios. A pilot study was coducted amog 106 muicipal workers i four major areas of Tiruchirapalli to validate the KAP questioaire before the actual study was coducted. The questioaire was developed i stages which icluded literature search, discussio with experts ad pre-testig the questioaire to esure good cotet validity. Sixty (60) fial items were selected out of 123 costructed items which are eed based ad required for the survey aalysis. Kowledge questios started askig whether the respodets had ever heard of leptospirosis ad they were asked to specify the source of their iformatio. Oly those who had ever heard of the disease were allowed to proceed to aswer the rest of kowledge questios which were desiged to solicit correct, icorrect ad do t kow aswers. 2 marks were give for a correct respose, 1 mark for do t kow ad 0 mark for icorrect respose. There were 24 kowledge questios which covered causes, sigs, symptoms, complicatios, treatmet, prevetio ad risk factors of leptospirosis. There were a total of 12 questios o attitude which covered safe work practices, persoal protective equipmet (PPE) ad geeral practices. Questios o attitude were desiged to be aswered usig a Likert scale (strogly agree/ agree/ ot sure/ ot agree/ strogly ot agree). For positive attitude items, scores of 4, 3, 2, 1, ad 0 for strogly agree, agree, ot sure, ot agree ad strogly ot agree were give respectively. For egative attitude, the above scorig system was reversed. Te (10) questios o practice were also desiged to be aswered usig a Likert scale (ever / seldom / sometimes / ofte / always). For good practice items, scores of 4, 3, 2, 1, ad 0 for always, ofte, sometimes, seldom ad ever were give respectively. For bad practices items, the above scorig system was reversed. A total of 14 questios o prevetive practices were asked cotaiig questios o safe work practice, PPE ad geeral practices. 2.3 Statistical aalysis Data was etered ad aalyzed usig SPSS Versio All cotiuous variables were described usig mea () whereas the categorical data were preseted as frequecies. The mea () for each item of the KAP was also aalyzed. The proportio of respodets who gave the correct aswer for each item i the kowledge domai was expressed as a correct percetage. The proportios for positive attitude ad good practice for each item of the KAP were also displayed. Those who aswered strogly agree or agree for the attitude that they should have ad disagree or strogly disagree for the attitude that they should ot have are cosidered as havig positive attitude. The proportios for good practice iclude those who aswered always or ofte for the practice that they should adopt ad ever or seldom for the practice that they should avoid. The scores for kowledge, attitude, ad practice were trasformed ito percetage scores by dividig the scores obtaied by the respodets with the possible maximum scores ad multiplied by 100. The percetage score was used i the aalysis rather tha the raw score because it is easier to appreciate the level of scores i the scale of zero to 100. The 248

4 categories of kowledge, attitude ad practice scores were decided by cosesus amog the researchers. For the kowledge category, the participats who had ever heard of leptospirosis are cosidered to have poor kowledge. Those who scored <72% are cosidered to have moderate kowledge ad those who scored 72% are cosidered to have good kowledge. The differece betwee moderate ad good kowledge depeds o the mea percetage of total kowledge score amog those who had ever heard of the disease. Cosiderig the maximum possible score of four poits for each item i the attitude ad practice domais, the total maximum scores for attitude ad practice domai were 48 ad 56 respectively. Allowig the miimum average of three poits for each item, a total score of less tha 36 (3 poits x 12 items) out of 48 idicates usatisfactory attitude while a total score of less tha 42 (3 poits x 14 items) out of 56 idicates usatisfactory practice. If we covert them ito percetages, a score from zero to <75% may be cosidered usatisfactory whereas a score of 75 to 100% may be take as satisfactory attitude ad practice scores. 3. RESULTS AND DISCUSSION 3.1 Demographic characteristics The respose rate was 95.8%: 106 muicipal workers out of the 120 eligible workers were recruited ito the study because 14 workers refused to participate. All participats were ative of Tiruchirapalli ad workig i this area for three geeratios with the mea age of 42.1 ( 8.38) years old. The age rages from 21 to 57 years old. Most of the respodets were married (90.5%). A majority of them had lower secodary school educatio ad below (46.2%): o schoolig (7.5%), primary school (33%) ad upper secodary school educatio (13.3%). The mea duratio of employmet was 15.6 ( 8.62) years with a rage of 2.5 to 35.0 years. 3.2 Kowledge o leptospirosis Study subjects aswered a total of 24 questios about leptospirosis. A large majority of the participats had ever heard about the disease leptospirosis. Thus they were cosidered to have poor kowledge (81.1%). Oly 20 workers (18.9%) had ever heard of leptospirosis. Amog them, 11 (55%) kew about it from televisio, 4 (20%) obtaied the iformatio from ewspapers ad 5 (25%) kew about the disease from both i televisio ad ewspapers. The mea percetage score for kowledge was 72.0 ( 8.48). Based o that, 6.7% had good kowledge ad 6.1% had moderate kowledge (Table 1). However, the aalysis for each kowledge item was carried out oly for those who had ever heard about leptospirosis (=20). The mea score () ad the percetage of correct aswer for each items are displayed i Table 2. Table 1: Category of kowledge, attitude ad practice score amog participats (=106) Category Frequecy Kowledge Good (score 72%) 7 (6.6) Moderate (score <72%) 13 (12.3) Poor (ever heard about leptospirosis) 86 (81.1) Attitude Satisfactory (score 75%) 74 (69.8) Usatisfactory (score <75%) 32 (30.2) Practice Satisfactory (score 75%) 45 (42.4) Usatisfactory (score <75%) 61 (57.6) Figures i paretheses are i percetage 3.3 Attitudes towards leptospirosis Regardig the attitudes towards leptospirosis, all participats obtaied a mea percetage score of 76.8 ( 10.96). The attitude towards leptospirosis was geerally good as 69.8% of the participats had satisfactory attitude score ad 30.2% had usatisfactory score (Table 1). For each item o attitude, the majority of participats had positive attitudes. There were, however, 34 (32.1%) of the participats who showed some cocer regardig 249

5 followig the uiversal safety precautios especially wearig footwears ad 62 (58.4%) participats showed doubts about drikig while workig. The detailed aalysis of attitudes towards leptospirosis amog muicipal workers is described i Table 3. Table 2: Kowledge with mea score () ad percetage of correct aswers ( = 20) Kowledge items Mea Correct aswers i Causes Leptospirosis is caused by a microorgaism () 1.8 (0.37)* % 17 (85)** It is trasmittig by aimals 1.8 (0.46) 17 (85) Leptospires ca eter our body through cuts Leptospires ca eter our body through cotamiated foods 1.6 (0.60) 13 (65) 1.7 (0.55) 16 (80) It is a mosquito bore disease 0.8 (0.83) 5 (25) Huma to huma ifectio is possible 1.3 (0.77) 9 (45) Sigs, Symptoms ad Complicatios Patiet may have fever ad headache 1.6 (0.55) 13 (65) Patiet may have myalgia ad arthralgia 1.3 (0.70) 9 (45) Patiet may have jaudice 0.9 (0.70) 4 (20) Cause death 1.7 (0.53) 14 (70) Cause cacer 0.9 (0.70) 4 (20) Cause liver damage 1.4 (0.60) 9 (45) Cause kidey failure 1.4 (0.59) 8 (40) Cause ocular maifestatios 1.2 (0.80) 8 (40) Risk factors Hadlig aimals i bare hads cause ifectio Eatig ad drikig while workig cause ifectio 1.2 (0.83) 9 (45) 1.1 (0.88) 9 (45) Bare foot ad bare hads are high risk 1.2 (0.89) 10 (50) Muicipal workers is cosider as risk group Therapy ad prevetio Blood ivestigatio is better diagostics 1.4 (0.79) 12 (60) 1.8 (0.41) 16 (80) Easily treatable 1.9 (0.34) 18 (90) Preveted by takig bath after workig 1.5 (0.69) 12 (60) Uiversal safety precautios may help to prevet the ifectio Fever is the primary idicator of this disease; early diagosis ad prompt therapy reduce the mortality risk Earliest disposal of dead aimals icludig rodets may reduce the commuity risk 1.9 (0.39) 19 (95) 1.5 (0.73) 12 (60) 1.8 (0.49) 16 (80) Figures i paretheses are i *stadard deviatio ad **percetage Table 3: Attitude with mea score () ad percetage for positive attitude ( = 106) Attitude items Mea Positive attitude i () Safe work practice ad persoal protective measures Drikig while workig is ot a problem Need safe work practice to get rid from disease 2.8 (1.45)* % 60 (56.6)** 3.1 (0.64) 98 (92.4) Glovig is importat durig work 3.0 (1.00) 90 (84.9) Glovig durig workig is igglig 3.5 (0.97) 88 (83) Glovig durig workig make work slower Glovig durig workig make discomfort Bootig durig workig make discomfort Geeral practice (Off work) Kowig about the disease is iterestig Follow uiversal safety precautio is must Make my eviromet free from rodets Disposig the dead aimals is importat 3.6 (0.97) 92 (86.8) 3.3 (1.15) 85 (80.2) 3.5 (1.04) 88 (83) 3.1 (0.66) 97 (91.5) 1.8 (1.27) 36 (33.9) 2.8 (0.95) 94 (88.7) 3.6 (0.85) 97 (91.5) Worry by walkig through flood 2.9 (1.17) 76 (71.7) Figures i paretheses are i *stadard deviatio ad **percetage Table 4: Practice with mea score () ad percetage for good practice ( = 106) Practice items Mea Correct aswers i () Safe work practice ad create the ifectio free eviromet Eat while workig 3.5 (0.75)* % 94 (88.7)** Drik while workig 3.1 (1.06) 69 (65.1) Smoke while workig 3.4 (1.00) 85 (80.2) Always isist my colleagues to follow proper workig procedure Ecourage my colleagues to follow uiversal safety precautios Isist myself ad my colleagues for proper had washig Persoal protective measures (PPE) 2.1 (1.31) 36 (33.9) 3.6 (0.75) 39 (36.8) 2.2 (1.31) 48 (45.3) Wearig gloves while workig 1.9 (1.69) 38 (35.8) Wearig boots while workig 2.5 (1.50) 47 (44.3) Wearig log sleeves shirt while workig 3.7 (0.94) 91 (85.8) Wearig mask while workig 1.0 (1.55) 21 (19.8) Verify the quality of the gloves before wearig 1.7 (1.72) 35 (33.0) Had washig with mild atiseptics 3.6 (0.97) 74 (69.8) 250

6 Geeral practice My eviromet is free from rats ad 2.8 (1.26) 60 (56.6) rodets Eter ito the sewage without 2.5 (1.39) 54 (50.9) protectio Cover always the prepared foods 3.8 (0.55) 104 (98.1) Lookig after the cattles 3.6 (1.19) 94 (88.7) Hadlig the dogs ad cats i home 3.1 (1.48) 79 (74.5) Figures i paretheses are i *stadard deviatio ad **percetage 3.4 Practice regardig leptospirosis prevetio The mea percetage score o prevetive practices agaist leptospirosis was 69.0 ( 13.31). I cotrast with attitude, 42.4% of the respodets showed satisfactory practice score while 57.6% showed usatisfactory score (Table 1). The aalysis for each item o practices showed that the use of PPE while the workers are i workig was relatively poor: oly 21 (19.8%) wore mask ad mask like clothes ad 12 (11.3%) wore rubber gloves while workig. Table 4 shows the mea () score for each item as well as the percetage of muicipal workers who adopted good prevetive practices o leptospirosis. 3.5 Relatioship of job characteristics with kowledge, attitude ad practice There were o differece betwee kowledge, attitude ad practice with educatio level, age, duratio of employmet ad job category. Table 5 highlighted the sigificat differece betwee kowledge, attitude ad practice level with job category. I this ivestigatio, there were a low percetage of participats who had ever heard about leptospirosis (18.9%). Of those who did, they heard about it from either the televisio or ewspaper or both. This is probably due to the fact that the govermet as well as the media reported extesively o the recet outbreaks of the disease that were exposed to flood water. I cotrast, a report o leptospirosis i Kelata (2012) ad i Queeslad oted that 12.8% ad 52% of leptospirosis cases have heard about the disease respectively. 4,10 Some of the participats clearly metioed that they received the iformatio through the posters ad word of mouth. Similarly aother study amog the caoeist i North Wales, (1991) revealed a very high proportio (95%) of respodets who had ever heard of the disease because they were exposed to a good health promotio program. 11 With disparity to our preset ivestigatio, such studies probably foud a higher percetage of participats ever heard about the diseases because they were either carried out amog leptospirosis cases or the subjects were exposed to systematic if ot itesive iformatio whereas our study was focused o asymptomatic subjects who were exposed to iformatio o leptospirosis o ad hoc ad volutary basis. As like other studies, i our ivestigatio also it was showed that the Tiruchirapalli is a weakest area of kowledge amog those who had ever heard of leptospirosis. It must be oted here that there were workers who eve obtaied zero percet score. Ideed, without kowig the risk factors, it is very tough for the iterviewers ad commuity surveyors for givig the awareess about leptospirosis ad expectig the workers to be aware of the disease ad as a corollary it is almost impossible for them to be motivated to adopt good prevetive work practices. The kowledge received by the muicipal workers o cause ad treatmet ad prevetio of leptospirosis was relatively better compared to risk factors. This may imply that the workers kow that the disease is caused by a microorgaism ad it is related to rat s urie but they have little kowledge o the factors that cotributed to the disease. The kowledge score o the sigs, symptoms, ad complicatio was also relatively very poor. Approximately 20% of the participats kew about the cliical maifestatios. This fact idicates that the majority of people are ot aware of the disease as most of the ifected persos are asymptomatic. I additio to this, our participats were all asymptomatic ad healthy durig this iterview. 251

7 Table 5: Relatioship of job category with kowledge, attitude ad practice levels Variables Kowledge (=20) Attitude (=106) Practice (=106) Good Poor p Satisfactory Usatisfactory p Satisfactory Usatisfactory p Mea Mea value Mea Mea value Mea Mea value Job Category Garbage collector Draiage cleaer Septic cleaer tak - 3 (15.0) - 13 (65.0) - 4 (20.0) - 23 (26.7) - 28 (32.5) - 35 (33.0) a - 17 (24.6) - 28 (40.6) - 24 (34.8) - 8 (21.6) - 14 (37.8) - 15 (40.5) a - 16 (42.1) - 15 (39.5) - 7 (18.4) - 9 (13.2) - 22 (32.3) - 37 (54.4) <0.01 a Educatioal category Lower secodary school below Upper secodary school above ad ad - 12 (60.0) - 8 (20.0) - 58 (67.4) - 28 (32.6) a - 49 (71.0) - 20 (29.0) - 27 (72.9) - 10 (27.1) a - 26 (68.4) Age 41.7 (7.58) (8.50) b 41.6 (8.35) (8.39) b 41.4 (8.54) Duratio of b b 16.2 employmet (8.92) (8.59) (8.66) (8.55) (8.67) a Chi square; b idepedet test; Figures i paretheses are i stadard deviatio (Mea ) ad percetage - 12 (31.6) (8.29) (8.60) - 53 (77.9) - 15 (22.1) a b b Kowledge of the sigs, symptoms ad complicatios amog the workers are ideed crucial because it will help them to recogize the dager of leptospirosis at a early stage ad this may lead to proper case maagemet, for early diagosis, prompt treatmet to reduce the mortality. 12,13 It is iterestig that the most of participats i this study had false belief that leptospirosis ca be trasmitted through mosquito bites ad it may also cause lug cacer. This wrog belief may spread to other workers as well as the commuity ad may fially cotribute to poor disease cotrol. To some extet, wrog belief about the disease also implies that the workers had gross miscoceptios about leptospirosis ad they may cofuse it with some other diseases which are more familiar to them such as typhoid, malaria, degue ad other PUOs that may cosider as a importat issue which eeds to be emphasized to them 3,7. The results of this ivestigatio suggest that muicipal workers eeds special attetio by providig awareess ad pamphlets. It seems crucial that to create awareess amog them should be carried out immediately may reduce the risk i the followig seasos. Geerally, a majority of the workers had positive attitude with oly 30.2% of them havig usatisfactory attitude score. This is a good startig poit to carry out a successful prevetio ad cotrol programs because there still exist difficulties i covicig people to take all the ecessary uiversal safety precautios eve though they may be well aware of the disease. This ivestigatio is also suggestig that the attitude towards the o use of PPE ad takig a drik while workig are importat risk areas i their attitude that eed to be corrected. The workers may ot appreciate the importace of such practices as disease prevetios because they simply lack kowledge o the disease ad the prevetios agaist it. I compariso to attitude, a majority of workers, (61%) had usatisfactory practice score. This was probably because they failed to see the beefits of a give 252

8 behavior. It is possible that the iformatio provided by media was ot sufficiet to address the iformatio for uderstadig the disease prevetio. The attitude ad practice regardig the leptospirosis revealed that very less percetage of workers practiced wearig of proper boots, rubber gloves, as well as wearig of mask while workig i the draiage ad garbages. May studies demostrated that PPE are importat ad remaied the mai predictors for leptospiral ifectio. 14,15 Evidetly ad i spite of the majority of the workers havig poor kowledge ad usatisfactory prevetive practices, the participats had relatively satisfactory attitude level. This suggests the importace of practical ways to prevet leptospirosis by educatioal campaigs with theater, pamphlets ad performig drama related to risk factors ad pathogeesis of leptospirosis. Other tha lack of kowledge, it is also possible that the participats caot fid time to coduct activities that relate to disease prevetio, lack of skills or some their factors hiderig prevetive practices. Further studies should actively look ito other factors hiderig prevetive practices agaist leptospirosis such as their health behavior ad beliefs. It is possible that the participats might ot tell the truth especially questios o attitude ad practice which may itroduce to social desirability bias. It was miimized by assurig participats of their aoymity ad cofidetiality of idividual reports. 16 Our preset study may be applicable to other populatio with similar characteristics i the muicipalities which have the same settigs as like this study. 4. CONCLUSION This ivestigatio demostrated a iterestig patter i the kowledge, attitude ad practice of the muicipal workers i this prevalet area ad hit at the shortcomigs of the cotrol program. Cosiderable weakess was idetified i the kowledge which obviously affects the practice. Examiig the kowledge, attitudes ad practice of the muicipal workers ad the strategies that recommeds will help health professioals to better uderstad the barriers to actio ad factors that facilitate the adoptio of recommeded prevetive actios. This highlighted the importace of the itervetioal awareess programmes required to this group of people. More over the public should be iformed about the hazards via ewspapers, televisio ad alertess of otably cliicias, healthcare workers ad decisio makers should be created by targeted educatio ad campaigs. 5. REFERENCES 1. Natarajaseeivasa K, Raja V, Narayaa R. Rapid diagosis of leptospirosis i patiets with differet cliical maifestatios by 16s rrna gee based ested PCR. Saudi J Biol Sci 2012; 19: Prabhu N, Joseph PID, Chiaswamy P. Case capsules of leptospirosis prevalece amog childre, Coimbatore, Idia. Bomb Hosp J 2009; 51: Prabhu N, Natarajseeivasa K, Uma A, Thirumalaikoludusubramaia P. Leptospirosis ow: epidemiology, progress, challedges ad research gaps. Elix Hum Physiol 2014; 67: Rahim M, Aziah BD, Nazri MS, Azway YN, Habsah H, Zahiruddi WM, Zahila I, Rusli MA. Tow service workers kowledge, attitude ad practice towards leptospirosis. Bru Darus J Hlth 2012; 5: WHO. Huma leptospirosis: Guidace for diagosis, surveillace ad cotrol. R_EPH_ pdf. Accessed o Jauary 25,

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