On 7 September 2000, CDC was notified by Idaho Department of Health about
a case of acute febrile illness in a 35-year-old man; the illness was characterized
by acute onset of high fever, chills, headache, and myalgias. The patient had
participated in the EcoChallenge Sabah 2000 Expedition Race, a multisport event held
during August 20 - September 3, at various sites in Sabah in Malaysian Borneo.
This report presents preliminary findings of an ongoing investigation to
identify cases of acute febrile illness among athletes who participated in the
EcoChallenge Race in Borneo during August 2000. Preliminary laboratory test results indicate
the probable cause of illness to be leptospirosis, a spirochete infection. The event
involved jungle trekking, open water swimming, river and ocean paddling, mountain
biking, canyoneering, scuba diving, and spelunking. Participating were 76 four-person
teams from 26 countries, including 37 teams from the United States. Subsequently,
nine other EcoChallenge participants who became ill were identified in California (five
in San Diego County, two in Orange County, and two in Los Angeles). To
identify additional athletes with febrile illness, an EcoChallenge participant list was
obtained from race organizers, and a telephone survey was administered by CDC with
the assistance of several state public health departments. As of September 13, 82 (53%)
155 U.S.-based athletes have been contacted; 37 (45%) reported having fever and
12 (15%) were hospitalized. No deaths have been reported.
On September 12, serum specimens obtained from two hospitalized athletes
from Los Angeles were tested at CDC for leptospirosis using the Dip-S-Ticks*
assay (Leptospira INDX Dip-S-Ticks; Integrated Diagnostics, Baltimore, Maryland) and
the Pan-Bio* enzyme-linked immunosorbent assay (ELISA) IgM test (PanBio,
Brisbane, Australia). One athlete tested positive with both tests on an acute-phase
serum specimen obtained 4 days following onset of fever. The second athlete tested
negative with both tests on the acute-phase specimen but positive with both tests on a
follow-up specimen obtained 4 and 6 days following onset of fever.
On the basis of laboratory test results and the clinical features of illness,
CDC advises the following to clinicians caring for EcoChallenge participants.
First, asymptomatic athletes that were taking chemoprophylaxis for leptospirosis (i.e.,
200 mg oral doxycycline weekly) should ensure that their final weekly dose was
taken following completion of the race (1). Second, although the merits of one dose
of postexposure chemoprophylaxis with 200 mg oral doxycycline are unknown,
asymptomatic athletes who participated in the race and who were not
taking chemoprophylaxis for leptospirosis may wish to discuss the single-dose option
with their physician. Third, for athletes with mild symptoms consistent with
leptospirosis, treatment should include 7 days of oral doxycycline, 100 mg twice daily
(2). Finally, for hospitalized patients with severe illness (e.g., persistent high-grade fever,
impaired hepatic or renal function, or severe neurologic disturbances, including
coma, hemiplegia, or transverse myelitis), treatment should include 7 days of
intravenous penicillin G, 1.5 million units every 6 hours
(3). As with other spirochete infections, a Jarisch-Herxheimer reaction can develop following the initiation of penicillin
therapy for leptospirosis (4). Although these reactions serve as an indicator of
therapeutic efficacy, they can be associated with increased morbidity and mortality;
patients receiving intravenous penicillin should be monitored for shocklike symptoms.
On September 13, CDC issued an advisory (http://www.cdc.gov/travel/other/lepto-malaysia.htm) about the probable leptospirosis outbreak associated with
the EcoChallenge event to raise awareness among health-care workers and participants
of the event in Borneo. The Meningitis and Special Pathogens Branch (MSPB) at CDC
is interested in receiving reports through state and local health departments of
additional participants who have been ill or have had fever since August 21. In addition,
MSPB will test clinical specimens for leptospirosis received through state and local
Reported by: California Dept of Health. Idaho Dept of Health. Council of State and
Territorial Epidemiologists, Atlanta, Georgia. Meningitis and Special Pathogens Br, Div of Bacterial
and Mycotic Diseases, National Center for Infectious Diseases; and EIS officers, CDC.
- Takafuji ET, Kirkpatrick ET, Miller JW, et al. An efficacy trial of doxycycline
chemoprophylaxis against leptospirosis. N Engl J Med 1984;310:497500.
- McClain BL, Ballou WR, Harrison SM, Steinweg DL. Doxycycline therapy for
leptospirosis. Ann Intern Med 1984;100:6968.
- Watt G, Padre LP, Tuazon ML, et al. Placebo-controlled trial of intravenous penicillin for
severe and late leptospirosis. Lancet 1988;8563:4335.
- Tappero JW, Ashford DA, Perkins BA.
Leptospira species (Leptospirosis) 5th ed. In:
Mandell GL, Bennet JE, Dolin R, eds. Principles and practice of infectious diseases. New York,
New York: Churchill Livingstone, 1999;2495--501.