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UNIVERSITI PUTRA MALAYSIA

KNOWLEDGE, ATTITUDE AND PREVENTIVE PRACTICE TOWARDS LEPTOSPIROSIS AND SEROPREVALENCE OF LEPTOSPIRA

ANTIBODIES AMONG MARKET WORKERS IN SELANGOR, MALAYSIA

SUHAILAH BINTI SAMSUDIN

FPSK(M) 2017 16

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By


Thesis Submitted to the School of Graduate Studies, Universiti Putra Malaysia, in

Fulfilment of the Requirements for the degree of Master of Science

March 2017

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All material contained within the thesis, including without limitation text, logos, icons,

photographs and all other artwork, is copyright material of Universiti Putra Malaysia

unless otherwise stated. Use may be made of any material contained within the thesis for

non-commercial purposes from the copyright holder. Commercial use of material may

only be made with the express, prior, written permission of Universiti Putra Malaysia.

Copyright © Universiti Putra Malaysia

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Abstract of thesis presented to the Senate of Universiti Putra Malaysia in fulfillment of

the requirement for the degree of Master of Science

KNOWLEDGE, ATTITUDE AND PREVENTIVE PRACTICE TOWARDS

LEPTOSPIROSIS AND SEROPREVALENCE OF LEPTOSPIRA ANTIBODIES

AMONG MARKET WORKERS IN SELANGOR, MALAYSIA

By


March 2017

Chairman : Associate Professor Malina Binti Osman, MD Faculty : Medicine and Health Sciences

Objective: The aim of this thesis is to identify and investigate the knowledge, attitude

and practices towards leptospirosis prevention along with seroprevalence of leptospira

antibodies. Methodology: A cross sectional study was conducted among 120 market

workers in four urban markets in Selangor. Questionnaire surveyed and blood sampled

were two important methods used in the study. A questionnaire consists of respondent’s

background, risk factors, knowledge, attitude and practice questions related with

leptospirosis. The blood sample was collected from market workers with consent in

purpose of seroprevalence study. The sera were obtained and Microscopic Agglutination

Test (MAT) was used to determine seropositivity of leptospira antibodies among market

workers. Validation and reliability of the questionnaire were carried out and proper

procedure in the laboratory was done according to standard protocol. Result: The

result showed majority of respondents have poor knowledge (91.7%), have unacceptable

attitude (60.8%) and have unacceptable practice (72.5%). This study has found that there

are 44.2% serum samples positive of leptospiral antibodies. Regression analysis was

conducted and the result showed that the respondents who were Malaysian and

undertook gardening activity have more likely to have good knowledge. Furthermore,

this study showed that respondents who have formal education, undertook cleaning

outside house, have exposed to contaminated water having more likely to have good

attitude. An adjusted odd ratio shows that respondents who were female, undertook

gardening activity, went for travelling, undertook cleaning of business premises and have

unacceptable practice score have more likely of having seropositive of leptospiral

antibodies. Conclusion: The evidence from this study suggests that comprehensive

health education should be conducted among market workers regarding leptospirosis and

its prevention as majority of them scored poor knowledge, unacceptable attitude and

unacceptable practice.

Keywords : seroprevalence, leptospirosis, knowledge, attitude, practice, market

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Abstrak tesis yang dikemukakan kepada Senat Universiti Putra Malaysia sebagai

memenuhi keperluan untuk ijazah Sarjana Sains

PENGETAHUAN, SIKAP DAN AMALAN PENCEGAHAN TERHADAP

PENYAKIT KENCING TIKUS DAN SEROPREVALEN ANTIBODI

LEPTOSPIRA DI KALANGAN PEKERJA PASAR DI SELANGOR, MALAYSIA

Oleh


Mac 2017

Pengerusi : Profesor Madya Malina Binti Osman, MD Fakulti : Perubatan dan Sains Kesihatan

Objektif: Tujuan tesis ini adalah untuk mengenal pasti dan menyiasat pengetahuan,

sikap dan amalan ke arah pencegahan leptospirosis bersama-sama dengan seroprevalen

antibodi Leptospira. Metodologi: Kajian irisan lintang telah dijalankan di kalangan

120 pekerja pasar di empat buah pasar di kawasan bandar di Selangor. Borang soal

selidik dan pengambilan darah adalah dua kaedah penting yang digunakan dalam kajian

ini. Soal selidik mengandungi informasi latar belakang, faktor-faktor risiko, pengetahuan,

sikap dan amalan responden berkaitan dengan leptospirosis. Sampel darah untuk tujuan

kajian seroprevalen telah berjaya dikumpul dengan kebenaran pekerja-pekerja

pasar.Ujian mikroskopik agglutinasi (MAT) telah dijalankan ke atas sera yang telah

diperolehi bagi menentukan seropositif antibodi leptospira di kalangan pekerja pasar.

Validasi dan kebolehpercayaan soal selidik telah dijalankan dan prosedur di dalam

makmal mengikut protokol yang ditetapkan. Keputusan: Hasil kajian menunjukkan

majoriti responden mempunyai pengetahuan yang lemah (91.7%), sikap yang kurang

baik (60.8%) dan mempunyai amalan yang kurang baik (72.5%).Kajian ini telah

mendapati bahawa terdapat 44.2% sampel serum positif antibodi Leptospira. Analisis

regresi telah dijalankan dan hasilnya menunjukkan bahawa responden yang

berwarganegara Malaysia dan menjalankan aktiviti berkebun adalah lebih cenderung

untuk mempunyai pengetahuan yang baik. Tambahan pula, kajian ini menunjukkan

bahawa responden yang mempunyai pendidikan formal, menjalankan pembersihan di

luar rumah, terdedah kepada air tercemar mempunyai kecenderungan yang lebih untuk

mempunyai sikap yang baik. Nisbah odds menunjukkan bahawa responden wanita,

menjalankan aktiviti berkebun, pergi melancong, melaksanakan pembersihan premis

perniagaan dan mempunyai skor amalan yang kurang baik mempunyai lebih

kecenderungan dalam mempunyai seropositif antibodi Leptospira. Kesimpulan: Bukti-

bukti daripada kajian ini menunjukkan bahawa pendidikan kesihatan yang komprehensif

hendaklah dilaksanakan di kalangan pekerja pasar mengenai leptospirosis dan

pencegahannya.

Kata kunci: seroprevalen, kencing tikus, pengetahuan, sikap, amalan, pasar

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ACKNOWLEDGEMENTS

Bismillahirrahmannirrahim. Alhamdulillah, thank you to Allah the almighty of the

universe for the entire blessing. I would like to thank my project supervisor, Associate

Profesor Dr Malina Osman for her patiently guidance and supervision to me throughout

the completion of this project. I also give her deepest appreciation of her sincere

helpfulness and co-operation in giving out ideas as well as providing transport and

financial aids.

I would like to extend my sincerest gratitude to my co-supervisor, Dr Siti Norbaya

Masri for sharing ideas, suggestion, financial aids and transportation in order to

complete this project.

I am happy to give my very special appreciation to my beloved parents and family who

always give their blessing, moral support and financial along my journey in this

project. I feel gratitude to have friends (Sakinah, Naqibah, Husna) as they always by

my side as friends make good times better and hard times easier.

Thank you and appreciation are also extended to Kajang Municipal Council, Subang

Jaya Municipal Council and Perbadanan Kemajuan Pertanian Selangor for their

approval and support to carry out research in their area. Lastly, I would like to send my

gratitude to respondents who involved in my study and to people who involved directly

and indirectly throughout my research progress.

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This thesis was submitted to the Senate of Universiti Putra Malaysia and has been

accepted as fulfilment of the requirement for the Master of Science. The members of

the Supervisory Committee were as follows:

Malina Osman, MD

Associate Professor

Faculty of Medicine and Health Sciences

Universiti Putra Malaysia

(Chairman)

Siti Norbaya Masri, MD

Senior Lecturer

Faculty of Medicine and Health Sciences


(Member)

________________________

ROBIAH BINTI YUNUS, PhD

Professor and Deputy Dean

School of Graduate Studies


Date:

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Declaration by graduate student

I hereby confirm that:

this thesis is my original work;

quotations, illustrations and citations have been duly referenced;

this thesis has not been submitted previously or concurrently for any other degree at any other institutions;

intellectual property from the thesis and copyright of thesis are fully-owned by Universiti Putra Malaysia, as according to the Universiti Putra Malaysia

(Research) Rules 2012;

written permission must be obtained from supervisor and the office of Deputy Vice-Chancellor (Research and Innovation) before thesis is published (in the form

of written, printed or in electronic form) including books, journals, modules,

proceedings, popular writings, seminar papers, manuscripts, posters, reports,

lecture notes, learning modules or any other materials as stated in the Universiti

Putra Malaysia (Research) Rules 2012;

there is no plagiarism or data falsification/fabrication in the thesis, and scholarly integrity is upheld as according to the Universiti Putra Malaysia (Graduate

Studies) Rules 2003 (Revision 2012-2013) and the Universiti Putra Malaysia

(Research) Rules 2012. The thesis has undergone plagiarism detection software.

Signature: ________________________ Date: __________________

Name and Matric No.: Suhailah binti Samsudin, GS38891

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Declaration by Members of Supervisory Committee

This is to confirm that:

the research conducted and the writing of this thesis was under our supervision;

supervision responsibilities as stated in the Universiti Putra Malaysia (Graduate Studies) Rules 2003 (Revision 2012-2013) are adhered to.

Signature:

Name of Chairman of

Supervisory

Committee:

Signature:

Name of Member of

Supervisory

Committee:

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TABLE OF CONTENTS

Page

ABSTRACT i

ABSTRAK ii

ACKNOWLEDGEMENT iii

APPROVAL iv

DECLARATION vi

LIST OF TABLES xiii

LIST OF FIGURES xvi

LIST OF ABBREVIATIONS xvii

LIST OF APPENDICES xviii

CHAPTER

1 INTRODUCTION

1.1 Background of study 1

1.2 Problem Statements 2

1.3 Research Justification 3

1.4 Research Objective 3

1.5 Research Hypothesis 4

1.6 Definition of Variables 4

1.7 Conceptual Framework 5

2

LITERATURE REVIEW

2.1 Overview of Leptospirosis

2.1.1 Definition of Leptospirosis 6

2.1.2 Epidemiology of Leptospirosis 8

2.1.3 Signs and Symptoms of Leptospirosis 11

2.1.4 Diagnosis of Leptospirosis 13

2.1.5 Management of Leptospirosis 14

2.1.6 Control and Prevention of Leptospirosis 15

2.2 Demographic and Socio-economic Indicators 15

2.3 Risk Factors of Leptospirosis 17

2.4 Knowledge of Leptospirosis 18

2.5 Attitude towards Leptospirosis Prevention 20

2.6 Practices towards Leptospirosis Prevention 21

2.7 Seropositivity of Leptospira antibodies and Distribution of Serovars 23

3

METHODOLOGY

3.1 Study Design 25

3.2 Study Location 25

3.3 Study Duration 26

3.4 Sampling

3.4.1 Study population 26

3.4.2 Sampling population 26

3.4.3 Sampling frame 27

3.4.4 Sampling method 27

3.4.5 Sample size 27

3.5 Instrument and Data collection

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3.5.1 Instruments 27

3.5.2 Questionnaires 28

3.6 Data Collection

3.6.1 Sample Collection 29

3.6.2 Serology of Leptospira Antibodies by

Microscopic Agglutination Test

30

3.7 Quality Control

3.7.1 Part: Questionnaire 30

3.8 Data Analysis 31

3.9 Study Ethics 31

3.10 Variables 32

4

RESULT

4.1 Response rate 34

4.2 Descriptive of Demographic and Socioeconomic Indicators,

Risk Factors, Knowledge, Attitude and Preventive Practice

Items towards Leptospirosis

4.2.1 Distribution of Demographic and Socioeconomic

Indicators

35

4.2.2 Distribution of Behavioural, Occupational and

Environmental Risk Factors

35

4.2.3 Distribution of Respondents According to Awareness

of Leptospirosis

37

4.2.4 Description of Knowledge Items among Respondents 37

4.2.5 Distribution of Respondents according to Knowledge Score 40

4.2.6 Description of Attitude Items toward Prevention

of Leptospirosis

41

4.2.7 Distribution of Respondents according to Attitude Score 44

4.2.8 Description of Preventive Practice Items among

Market Workers

44

4.2.9 Distribution of Preventive Practice according to

Practice Score

47

4.3 Seropositive of Leptospira Antibody and Distribution of Serovar

Culture

4.3.1 Seropositive of Leptospira Antibody 48

4.3.2 Distribution of Serovar among Seropositive Sera Sample 48

4.3.3 Serovar Positivity among Positive Sera Sample Reaction

to Serovar among Seropositive Respondents

49

4.4 Relationship between Demographic and Socioeconomic Indicators

with Level of Knowledge, Attitude, and Preventive Practice

4.4.1 Association between Demographic and Socioeconomic

Indicators with Knowledge on Causative Agent

of Leptospirosis

50

4.4.2 Association between Demographic and

Socioeconomic Indicators with Knowledge on Modes

of Leptospirosis Transmission

52


Socioeconomic Indicators with Knowledge on Signs,

Symptoms and Complication of Leptospirosis

53

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Socioeconomic Indicators with Knowledge on Risk Factors

of Leptospirosis

55


Socioeconomic Indicators with Knowledge on

Treatment, Diagnosis and Prevention

57

4.4.6 Predictor Influencing Knowledge of Respondents

towards Leptospirosis

58


Socioeconomic Indicators with Attitude on Prevention

of Leptospirosis

59

4.4.8 Predictor Influencing Attitude of Respondents


61


Socioeconomic Indicators with Preventive Practice

on Personal Hygiene

63



on Environmental Hygiene

64



on Specific Protection

66



on Isolation

67



on Eradication at Source

68

4.4.14 Predictor Influencing Practice of Respondents

towards Prevention of Leptospirosis

70

4.4.15 Relationship between Knowledge with Attitude

of Leptospirosis

72

4.4.16 Relationship between Knowledge with Preventive Practice

of Leptospirosis

72

4.4.17 Relationship between Attitude and Preventive Practice

of Leptospirosis

73

4.5 Relationship among Demographic and Socioeconomic Indicators,

Risk Factors, Knowledge, Attitude, and Practice with Seropositivity

of Leptospira Antibody

4.5.1 Relationship between Demographic and Socioeconomic

Indicators with Seropositivity of Leptospira Antibody

73

4.5.2 Relationship between Risk Factors (Behavioural Risk,

Occupational Risk, Environmental Risk) with

Seropositivity


74

4.5.3 Relationship between Knowledge with Seropositivity of

Leptospira Antibody

77

4.5.4 Relationship between Attitudes with Seropositivity of

Leptospira Antibody

78

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4.5.5 Relationship between Practices with Seropositivity of

Leptospira Antibody

79

4.5.6 Predictor Influencing Seropositivity of Leptospira

Antibody

among Market Workers

81

5

DISCUSSION

5.1 Descriptive of Demographic and Socioeconomic Indicators, Risk

Factors, Knowledge, Attitude, and Preventive Practice Items


5.1.1 Distribution of Demographic and Socioeconomic

Indicators

83

5.1.2 Distribution of Behavioural, Occupational and

Environmental Risk Factors

84

5.1.3 Distribution of Knowledge regarding Leptospirosis


84

5.1.4 Distribution of Attitude Regarding Prevention of

Leptospirosis among Market Workers

86

5.1.5 Distribution of Practice Regarding Prevention of


90

5.2 Seropositive of Leptospira Antibody and Distribution of Serovar

Strain

5.2.1 Seropositive of Leptospira Antibody and Distribution of

Serovar

91

5.3 Association between Demographic and Socioeconomic Indicators

with Knowledge, Attitude and Preventive Practice

5.3.1 Relationship between Demographic and

Socioeconomic Indicators with Knowledge of


93

5.3.2 Predictor Influencing Knowledge of Market Workers


94


Socioeconomic Indicators with Attitude towards

Prevention

of Leptospirosis among Market Workers

95

5.3.4 Predictor Influencing Attitude of Market Workers


95


Socioeconomic Indicators with Practice of Prevention

of Leptospirosis among Market Workers

96

5.3.6 Predictors Influencing Practice of Market Workers


97

5.3.7 Relationship between Knowledge, Attitude and Preventive

Practice of Leptospirosis among Market Workers

97

5.4 Relationship among Demographic and Socioeconomic Indicators,

Risk Factors, Knowledge, Attitude and Practice with Seropositivity



Socioeconomic Indicators with Seroprevalence of

Leptospira Antibodies among Market Workers

98

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5.4.2 Relationship between Risk Factors with Seropositivity

of Leptospira Antibody among Market Workers

98

5.4.3 Relationship between Knowledge, Attitude and Practice

with Seroprevalence of Leptospira Antibodies among

Market Workers

99

5.4.4 Predictor Influencing Seropositivity of Leptospira

Antibody


99

6 SUMMARY, CONCLUSION AND RECOMMENDATIONS

FOR FUTURE RESEARCH

6.1 Summary, Conclusion and Recommendations 101

REFERENCES 104

APPENDICES 109

BIODATA OF STUDENT 129

LIST OF PUBLICATIONS 130

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LIST OF TABLES

Table Page 2.1 Clinical Manifestation of Leptospirosis among 559 Cases in

Malaysia

12

3.1 Sample size calculation according to objective 27

3.2 Lists of statistical analysis according to objectives 31

3.3 Lists of independent and dependent variables according to

objectives

32

4.1(a) Descriptive of socio demographic and socioeconomic indicators

among market workers in Selangor

34

4.1(b) Descriptive of socio demographic and socioeconomic indicators

among market workers in Selangor

35

4.2 Descriptive of behavioural, occupational and environmental risk

factors exposure among market workers

36

4.3 Distribution of respondents (%) according to level of awareness 37

4.4(a) Description of knowledge items among market workers 39

4.4(b) Description of knowledge items among market workers 40

4.5 Distribution of market workers according to knowledge level 40

4.6 Distribution of respondent (%) according to overall score of

knowledge items

41

4.7(a) Description of attitude items among market workers 42

4.7(b) Description of knowledge items among market workers 43

4.8 Distribution of respondent (%) according to attitude score 44

4.9 Distribution of preventive practice items among market workers 46

4.10 Distribution of preventive practice level within five sections of

items among market workers

47

4.11 Distribution of respondent (%) of practice score on prevention of

leptospirosis

48

4.12 Distribution of respondents according to seropositivity of

leptospira antibody among market workers

48

4.13 Distribution of serovars among seropositive sera sample

obtained from market workers (n= 53)

49

4.14 Serovar positivity among positive sera sample 50

4.15(a) Association between demographic and socioeconomic indicators

with knowledge level on causative agent of leptospirosis among

market workers

51

4.15(b) Association between demographic and socioeconomic indicators

with knowledge level on causative agent of leptospirosis among

market workers

51


with knowledge on modes of leptospirosis transmission among

market workers

52


with knowledge on modes of leptospirosis transmission among

market workers

53


with knowledge on signs, symptoms and complications of

leptospirosis among market workers

54

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with knowledge on signs, symptoms and complications of

leptospirosis among market workers

55

4.18 Association between demographic and socioeconomic indicators

with knowledge level on risk factors among market workers

56


with knowledge on treatment, diagnosis and prevention among

market workers

57


with knowledge on treatment, diagnosis and prevention among

market workers

58

4.20 Predictor influencing knowledge of respondents towards

leptospirosis

59


with attitude towards leptospirosis prevention among market

workers

60

4.22 Predictors influencing attitude of respondents towards

leptospirosis

62


with preventive practice on personal hygiene among market

workers

63


with preventive practice on personal hygiene among market

workers

64


with preventive practice on environmental hygiene among

market workers

65


with preventive practice on specific protection among market

workers

66


with preventive practice on specific protection among market

workers

67


with preventive practice on isolation among market workers

68


with preventive practice on eradication at source among market

workers

69


with preventive practice on eradication at source among market

workers

70

4.28 Predictors influencing practice of respondents towards

leptospirosis

71

4.29 Relationship between knowledge with attitude of leptospirosis 72

4.30 Relationship between knowledge with preventive practice of

leptospirosis

73

4.31 Relationship between attitude and practice of leptospirosis 73

4.32 Relationship between demographic and socioeconomic

indicators with seroprevalence of leptospira antibody

74

4.33(a) Relationship between risk factors with seropositivity of


75

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4.33(b) Relationship between risk factors with seropositivity of


76

4.33(c) Relationship between risk factors with seropositivity of


77

4.34 Relationship between knowledge with seropositivity of

leptospira antibody

78

4.35 Relationship between attitudes with seropositivity of leptospira

antibody

79

4.36 Relationship between practices with seropositivity of leptospira

antibody

80

4.37 Distribution of predictors influencing seropositivity of leptospira

antibody among respondents

82

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LIST OF FIGURES

Figure Page

2.1 Leptospira interrogans 7

2.2 Leptospirosis in Malaysia from 2004 – July 2015 9

2.3 Leptospirosis cases in Selangor from year 2005 until year 2015 10

2.4 Leptospirosis cases according to district in Selangor from year 2011

until 2015

10

3.1 Districts in Selangor 25

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LIST OF ABBREVIATIONS

CDC Communicable Disease Control

CSF Cerebral Spinal Fluid

ELISA Enzyme-linked Immunosorbent Assay

g gram

IMR Institute of Medical Research

kg kilogram

MAT Microscopic Agglutination Test

mg milligram

ml milliliter

PCR Polymerase Chain Reaction

PPE Personal Protective Equipment

RM Ringgit Malaysia

SPFL Severe Pulmonary Hemorrhagic Form Leptospirosis

UPM Universiti Putra Malaysia

WHO World Health Organization

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LIST OF APPENDICES

Appendix Page

A Definition of Variable 109

B Sample size calculation 113

C Gantt Chart 115

D Ethical Approval Letter 116

E Respondents Information Sheet 118

F Questionnaire 121

G Health Program Poster 126

H Health Program Poster 127

I Data Collection Picture 128

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CHAPTER 1

INTRODUCTION

1.1 Background of study

Leptospirosis is an infectious disease caused by pathogenic organisms belonging to the

genus Leptospira, which are transmitted directly or indirectly from animals to humans.

Leptospirosis is a major direct zoonosis (World Health Organization, 2003).Genus of

Leptospira can be classified into two which are Leptospira interrogans (pathogenic

leptospires) and Leptospira biflexa (saprophytic leptospire). Pathogenic Leptospira

have a potential to cause disease whilst saprophytic Leptospira are free-living bacteria

and do not cause disease (WHO, 2003).

Pathogenic leptospires are survived in the renal tubules and genital tracts of certain

animals which are rodents, cattle, dogs, and pigs appear to be the predominant animal

hosts in many countries (WHO, 2003). In the Asia-Pacific region, countries with high

incidence rates (> 10 per 100,000 populations) are Bangladesh, Cambodia, Fiji, French

Polynesia, the Andaman, and Nicobar Islands in India, Laos, Nepal, New Caledonia,

Sri Lanka, Thailand and Vietnam. Countries like China, mainland India, Malaysia,

New Zealand, the Philippines and Mongolia have moderately high incidence rates (1 –

10 per 100,000 population) while low incidence rates (< 1 per 100,000 population) are

seen in countries like Australia, Hong Kong, Japan, South Korea and Taiwan

(Victoriano, A., Smythe, L., Gloriani-Barzaga, N., Cavinta, L., Kasai, T.,

Limpakarnjanarat, K.,…Adler, B., 2009). In the developing countries of the Asia

Pacific region, leptospirosis is largely a water-borne disease and climate change may

further aggravate the extent of the problem (Lim, J. K., Murugaiyah, V. A., Ramli, A.,

Abdul Rahman, H., Mohamed, N. & Shamsudin, N., 2011).

Leptospirosis occurs in many countries but the incidence varies considerably and

marked underreporting is common. Generally, there is a higher incidence in tropical

countries (Sarkar, Chopra, Katageri, Raj, & Goel, 2012). Persons of all ages and sexes

are susceptible to infection. Besides, it is also considered to be an occupational disease

of individuals, who come in direct contact with infected animals, such as farmers,

veterinarians, and abattoirs workers, and may also affect persons who have contact

with the urine of animals having the disease for example sewer workers and sugarcane

field workers. Occupational exposure towards leptospirosis probably accounts for 30-

50% of human cases ( Sapian, M., Khairi, M. T., How, S. H., Rajalingam, R., Sahhir,

K., Norazah, A.,…Jamaludin, A. R., 2012). The main occupational groups at risk

include farm workers, veterinarians, pet shop owners, field agricultural workers,

abattoir workers, plumbers, meat handlers, coal miners, and workers in the fishing

industry, military troops, and sewer workers (Sapian et al., 2012).

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1.2 Problem statements

Market or pasar in Malaysia serves an important role in the modern urban environment

and recreating industry, and has become one of important tourism resources. Night

markets are popular destinations among locals where it can be found easily in almost

every small town and city in every state including Selangor (Aziz, K. A. & Yeng, L.

W., 2011). Other than night market, Malaysia also has a wet market which also known

as a fresh food market. The market is the place which provides a variety of food

although their cleanliness status is well known uncertain. According to a study by

Subramaniam (2011) on rodents and human health risks at the wet market shows the

majority of food workers and hawkers had symptom on health related problem.

Furthermore, the outcome of the study shows about 72% rodent infestation and rodent

species which had been identified exist in the study environment (Subramaniam, Abdul

Hafiz, & Chandrakant, 2011). Wet market workers might pose a risk to acquire

leptospirosis through exposure to Leptospira contaminating watery environment of the

market. Furthermore, the risk not limited to leptospirosis, the previous study showed

that 60 respondents had symptoms of health related problems are reported

(Subramaniam et al., 2011).

Besides in Kuala Lumpur, Selangor also was known has the high-density population,

especially in Klang Valley. Rampant urbanization of cities has been known can lead to

improper garbage management system in urban areas, probably created favourable

conditions for animal carriers (Benacer, D., Woh, P.Y., Mohd Zain, S.N., Amran, F. &

Thong, K.L., 2013).Perhaps the most important animals associated with human

leptospirosis are peridomestic rodents which are rats and mice (Mohan, A. & Chadee,

D., 2011; World Health Organization, 2003). This may pose a health risk for

leptospirosis as infected animals and carriers might contaminate environmental waters

and soils via their excreta and urine (Doudi Benacer et al., 2013).

It is a norm to observe abundant of semi-solid and solid waste left at the site of the

market after their operation ended during that specific day. Variety types of wastes

such as solid, food and sometimes watery waste can be found in market areas when

their closed. This will create favour environment to animal carriers such as rats and

mice. The study shows solid waste accumulations become an important factor for

urban rodent feeding and sheltering strategies. A study from Barcellos and Sabroza in

2011 shows densely populated urban areas displayed an excess of leptospirosis cases

around waste accumulation sites (Barcellos, C. & Sabroza, P. 2001).

Previous study among local market seller towards leptospirosis showed that majority of

them had moderate knowledge (51.4%), unsatisfactory attitude (90.0%) and

satisfactory practice (64.3%). Thus, it is showed that the sufficient information on

leptospirosis was not made available to the community especially among market

workers (Ismail, Ahmad, Sarker, Lim, Ishak, Husin & Johari, 2016). Furthermore,

previous study only focused on local market seller while recently lots of foreign were

hired to become a worker in the market. This study included both Malaysian and

immigrant workers who involved in this type of occupation.

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1.3 Research Justification

Based on statistic cases reported by Jabatan Kesihatan Negeri Selangor (JKNS)

showed there are two districts of Selangor which have a high number of cases in 2015

were Hulu Langat and Petaling. Both districts are located in urban areas of Selangor.

High rodent infestation in urban Selangor causes a high risk of having leptospirosis

among the population. A variety of occupations may easily expose towards

leptospirosis in order to fulfill their job, they need to have contact with the

environment.

Leptospirosis not only infects population who working with infected animals. It also

gives risk to the population who has contact with the urine of animals having the

disease (Shafei, MN., Mohd Rahim, S., Azwany, Y.N., Habsah, H., Zahiruddin, W.M.,

Aziah, B.D.,…Rusli,M.,2012). In an example, markets and hawker centres would

attract rats if the waste is not disposed of properly (Henry, 2013). Thus, working as

market workers and food handlers may pose a risk to have leptospirosis from the

environment.

Market workers have a proneness to have leptospirosis if the location of the market had

precarious sanitation conditions which attract infestation of rats and vulnerable to

flood. Besides, a serious menace at wet markets and food courts was proved as rats are

not just damaging electrical wires and food items but also transmitting dangerous

diseases like leptospirosis (Henry, 2013). Hence, it is importance to have knowledge in

leptospirosis especially on a transmission of the disease, the prevention and also

treatment which can be implemented among market workers to avoid any cases occurs

among them. In order to address this issue, the study of knowledge, attitude and

preventive practice towards leptospirosis and seroprevalence of Leptospira antibodies

among market workers in Selangor is important to be done. Furthermore, the data

from this study will be a good baseline for market workers population to determine the

seroprevalence among them and their level of knowledge, attitude and practices

regarding leptospirosis since there is no study had been done.

1.4 Research Objective

1.4.1 General Objective

To study knowledge, attitude and preventive practice towards leptospirosis along with

seroprevalence of Leptospira antibodies and associations between variables among

market workers.

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1.4.2 Specific Objectives

1. To determine demographic (age, gender, race, nationality) and socioeconomic indicators (education level, monthly income), risk factors, knowledge, attitude

and preventive practices distribution towards leptospirosis among market

workers.

2. To determine seropositivity of Leptospira antibodies and distribution of serovars among market workers.

3. To determine associated factors (demographic and socioeconomic indicators) to the level of knowledge, attitude and preventive practices towards

leptospirosis among market workers.

4. To determine associated factors (demographic and socioeconomic indicators, risk factors, knowledge, attitude, and practice) to seropositivity of Leptospira

antibodies among market workers.

5. To determine predictors influencing knowledge, attitude, practice and seropositivity of leptospirosis among market workers.

1.5 Research Hypothesis

1. There is a significant association between associated factors (demographic and socioeconomic indicators) with the level of knowledge, attitude and

preventive practice towards leptospirosis among market workers.

2. There is a significant association between associated factors (demographic and socioeconomic indicators, risk factors, knowledge, attitude and preventive

practice) with seropositivity of Leptospira antibodies among market workers.

3. There is a probability of a predictors is associated with the knowledge, attitude, practice and seropositivity of leptospirosis among market workers.

1.6 Definition of variables

The conceptual definition of variables and operational definition of variables are in

Appendix A.

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