































 

 Epidemiology and Society Health Review | ESHR 
Vol. 6, no. 1, 2024, pp. 1-12 ISSN 2656-6052 (online) | 2656-1107 (print) 
      http://journal2.uad.ac.id/index.php/eshr/index                                                   eshr@ikm.uad.ac.id 

 

 

      10.26555/eshr.v6i1.9031 

 
 
1 

 
 

  

Review Articles 
 
Environmental Risk Factors of Leptospirosis: Systematic 
Review 
 
Muchsin Maulana1,2, Devi Stefani1, Ratu Matahari1,3, Wan Karmida Wulandari1* 
 1Faculty of Public Health, Ahmad Dahlan University, Yogyakarta, Indonesia 
 2Internasional Health Program, Institute of Public Health, National Yang Ming Chiao Tung 

University, Taiwan, Province of China 
3Institute for Population and Social Research, Mahidol University, Salaya, Thailand 
 
* Correspondence: wankarmida @gmail.com Phone: +6282137554729 
 
Received 13 September 2023; Accepted 23 January 2024; Published 29 January 2024 
 

ABSTRACT 

Background: Leptospirosis is a zoonotic disease caused by the bacteria Leptospira sp. 
The incidence of Leptospirosis ranges from 0.1 to 10 per 100,000 per year globally. GIS is 
a tool to visualize data that considers effectiveness and efficiency when determining the 
priority areas of particular disease control. 
Method: This systematic review was based on some databases, Google Scholar, PubMed, 
and the BASE, for articles published from 2010 to 2020. PRISMA guideline was used during 
data screening.  
Results: Eight articles were reviewed that showed a pattern of distribution of cases of 
Leptospirosis: clustered, evenly, and randomly. We also found 15 environmental factors that 
influence Leptospirosis distribution:  the existence of the river, precipitation, sunshine, a 
history of the flood, the existence of the gutter, the condition of the garbage disposal, the 
existence of rice fields, the presence of vegetation, trap success, the existence of the road, 
the ownership of the pet, the presence of rats, altitudes, and land-use.  
Conclusion: 15 identified environmental risk factors influence the incidence of 
Leptospirosis, namely the existence of rivers, history of flooding, the existence of gutters, 
waste disposal conditions, rainfall, the existence of rice fields, population density, 
the existence of vegetation, the success of traps, the existence of ponds, the existence of 
roads, livestock ownership, presence of rats, altitude, and land use. 

Keywords: Geographic Information Systems; Spatial Analysis; Mapping; Leptospirosis; 
Environment. 

 

 

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https://doi.org/10.26555/eshr.v3i1.3629


 
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INTRODUCTION 

Leptospirosis is acknowledged as a public health issue, with several outbreaks 
attributed to natural catastrophes and the presence of unsatisfactory sanitary 
conditions. Globally, the prevalence of Leptospirosis varies from 0.1 to 10 cases per 
100,000 individuals annually. In the event of an outbreak and significant exposure 
among vulnerable populations.1 In Indonesia, nine provinces experienced cases of 
Leptospirosis in 2019; they are DKI Jakarta, West Java, Central Java, DI Yogyakarta, 
East Java, Banten, North Kalimantan, South Sulawesi, and Maluku. The 2020 
Indonesian Health Profile states that 920 cases of Leptospirosis occurred in 2019, with 
122 deaths (CFR = 13.26%).2 

Leptospirosis is a zoonotic disease caused by spiral-shaped and actively moving 
microorganisms from the pathogenic genus Leptospira, which is Leptospira sp. 
bacterial.3 Humans can accidentally become infected by the Leptospira bacteria, which 
naturally resides in mice as their definitive hosts. This infection is considered incidental 
because humans are not the primary target of this bacteria. There are two main ways 
humans can get infected: first, through contact with environments contaminated by 
mouse urine containing this bacterium, such as water or soil; second, through direct 
contact with tissues or organs of mice infected with the Leptospira sp. bacteria. In both 
cases, the infection occurs due to indirect interaction between humans and mice, 
making this process an incidental event in the life cycle of the bacteria.4 

One step to reduce leptospirosis incidence can be utilizing geographic information 
systems (GIS). GIS are computerized instruments for storing, visualizing, analyzing, 
and interpreting geographic data.5 The use of GIS is presented in a spatial form to make 
it easier to display and compare the distribution of relationships between the locations 
of objects so that you can get a picture of the points or locations of the distribution of 
diseases and other health conditions.6 The environment plays a vital role in transmitting 
Leptospira sp. bacteria, so it is necessary to know the spatial description of leptospirosis 
cases, which is expected to identify environmental factors that influence the spread of 
Leptospirosis. The Geographic Information System is used to improve the health 
surveillance system because by using this system, it can visualize disease in space and 
time in the form of a map. Besides that, GIS can also be used to identify patterns of 
disease spread, the distance between cases, the outbreak, how long cases can spread, 
and which areas are included in disease-prone areas.7  

Knowing the past research that discussed the environmental risk factor of Leptospirosis 
using GIS is beneficial to understanding the potential community at risk. Accordingly, it 
can alarm the policymaker while planning the control program. A systematic review is a 
research method that uses review, analysis, structured evaluation, classification, and 
categorization of evidence-based evidence from previous researchers. This research 
aimed to study the last article that addresses the environmental risk factor of 
Leptospirosis and analyze it using GIS. 

 

 

 



 
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METHOD 
Search Strategy 
Google Scholar, PubMed, and Bielefeld Academic Search Engine (BASE) were the 
primary source databases accessed in January-March 2021 to extract studies published 
in English and Bahasa that discussed the Leptospirosis Indonesian context. A set 
combination of keywords was used: "Geographical Information System," "Spatial 
Analysis," "Geographical Mapping," "Leptospirosis," and "Environment," and the 
keywords in English are: "Geographical Mapping," "Spatial Analysis," "Leptospirosis" 
and "Environment." We observed research papers published from 2010 to 2020. Title, 
keyword, and abstracts were screened for the first step for the relevant article, and the 
full paper that met our criteria inclusion was included in our analysis. Inclusion criteria: 
original research article, articles are published in English or Indonesian, the article aims 
to understand the spatial distribution, pattern of case spread, and environmental factors 
affecting the spatial occurrence of Leptospirosis and have published 2010-2020. 

 
 

Figure 1. PRISMA Diagram 
 



 
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RESULTS  

The final result of screening using the PRISMA diagram yielded eight articles that aligned with 
the predetermined topic and criteria. The last stage of the systematic review was extracting 
data into Microsoft Excel. Table 1 shows the search results after going through several stages. 

Table 1. Extraction results 

 
No 

 
Author and Year 

 
Title 

 
Research 
Location 

Pattern 
Distribution  
Of Cases 

 
Method 

Environme
ntal factor 

(1) Isnaini Alfazcha 
Zukhruf and 
Dyah 
Mahendrasari 
Sukendra 
(2020) 

Spatial Analysis of 
Leptospirosis Cases 
Based on 
Epidemiological 
Factors and Risk 
Factors 
Environment 

Demak 
District, 

Central Java 

Clumped ANN history, gutter 
conditions, and 
conditions 
garbage dump 

(2) Annisa 
Rahim and 
R. Yudhastuti 
(2015) 

Mapping  and 
Analysis of  Risk 
Factors for 
Leptospirosis Based 
on Geographic 
Information Systems 
In Sampang Regency 

Sampang 
Regency 

Clumped Not 
stated 

Rainfall, altitude, 
history of flooding 

(3) Dewi Puspita 
Ningsih and 
Sunaryo 
Sunaryo (2014) 

Spatial Distribution of 
Leptospirosis in 
Districts 
Gresik, East Java 

Gresik 
Regency, 
East Java 

Equally Not 
stated 

Trap success, 
Land use, 
rainfall, 
Vegetation 
density 

(4) Widya Hary 
Cahyati and Lia 
Diah Kumalasari 
(2020) 

Spatial Analysis of 
Environmental Factors 
of Leptospirosis in 
Bonang District, 
Demak Regency 

Demak 
District, 
Central Java 

Random 
 

ANN History of floods, 
waste storage, 
rivers, rice fields, 
ponds, and 
population 
density 

(5) Maftuhah 
Nurbeti, Hari 
Kusnanto and 
Widagdo Sri 
Nugroho (2016) 

Cases of 
Leptospirosis in the 
Border Districts of 
Bantul, Sleman, and 
Kulon Progo: Analysis 
Spatial 

Bantul, 
Sleman and 
Kulonprogo 
Regencies, 
Yogyakarta 

Clumped NNA Rice fields, rivers, 
roads, population 
density, rainfall, 

(6) Lirih Setyorini, 
Nurjazuli and 
Hanan Lanang 
Dangiran (2017) 

Analysis of 
Leptospirosis 
Distribution Patterns in 
City Semarang 

Semarang 
City, Central 

Java 

Clumped NNA The existence of 
rivers, rubbish 
dumps, 
Drain, 

(7) Ferry Febrian 
and Solikhah 
(2013) 

Spatial Analysis of the 
Incidence of 
Leptospirosis in 
Sleman Regency, 
Yogyakarta Special 
Region Province 
the year 2011 

Sleman 
Regency, 

Yogyakarta 

Clumped Not state Pet ownership, 
presence of rats, 
presence of 
vegetation, 
presence of ditches 

(8) Hasnan Arwit 
Hassan, et al 
(2018) 

A Geographical 
Information System on 
Related Environmental 
Factors of 
Leptospirosis in 
Northeastern State 
Malaysia 

Northeastern 
State Malaysia 

Clumped ANN Existence of rivers, 
land use 

 
 



 
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Based on the results of the systematic review analysis that was carried out, a total of 8 
articles were obtained that discussed the distribution patterns of leptospirosis cases and 
environmental factors that influence the spatial incidence of Leptospirosis. Articles 
discussing the distribution pattern of Leptospirosis cases include six articles number 
1,2,5,6,7,88–13  with a clustered pattern of case distribution, one article14 with an even 
pattern of case distribution and one article15 with a random case pattern. Of the eight 
articles, 5 mentioned the causes of the pattern of distribution of cases, namely due to 
rainfall,9 the presence of rice fields and ponds,10,15 history of flooding,9,15 and river 
flow.10,11 In comparison, three articles 8,12,13 others did not mention the cause.  

The method most frequently used to detect case distribution patterns from the eight 
articles studied, namely Nearest Neighbor Analysis (NNA), used in 2 articles, Average 
Nearest Neighbor (ANN) in 3 articles, Nearest Neighbor Index (NNI) method used in 1 
article, and three articles did not mention the type of method used. Fifteen 
environmental factors play a role in the occurrence of Leptospirosis. Some of these 
factors include rivers,10,11,13,15  flood history,8,9,11,15  the existence of sewers,8,11,12 

condition of waste disposal. 8,11,15 The other result yield from the review was the 
presence of rice fields,10,15 precipitation,9–11,14 population density,10,15 presence of 
vegetation,12 trap success,14 presence of ponds,15 presence of roads,10 pet ownership,12 
presence of mice,12 altitudes,9 and land use.13 

DISCUSSION  

Leptospirosis has been acknowledged as a public health concern, with several reported 
pandemics attributed to natural disasters and the prevalence of inadequate sanitation 
conditions. An estimated ten or more individuals per 100,000 are affected by this 
disease annually in tropical regions. The incidence can escalate to 100 cases per 
100,000 people in a pandemic. Based on the systematic review results, GIS could 
recognize the distribution pattern of leptospirosis cases. The cause of this pattern 
formation is due to exposure to risk factors, including river flow, high rainfall, history of 
flooding, and the presence of rice fields and ponds. According to previous research, a 
spatial pattern shows the placement or arrangement of objects on the earth's surface.16 
Any changes in spatial patterns will illustrate spatial processes directed by 
environmental and cultural factors. This aligns with another research study, which states 
that the pattern formed is clustered, where the same exposure to environmental risk 
factors, such as rice fields and puddles, causes the pattern.15 

The results of the systematic review analysis show that the use of Geographic 
Information Systems (GIS) to detect distribution patterns of leptospirosis cases has 
been widely implemented in various regions in Indonesia. Despite this widespread 
implementation, many areas still need to utilize GIS fully in the health sector. This 
underutilization is partly due to the need for more human resources skilled in operating 
and using GIS.17 Environmental Factors that Influence the Distribution Pattern of 
Leptospirosis Cases can vary and are unique from one region or event to another. 
Spatial analysis is one method for identifying risk factor points that influence the 
incidence of Leptospirosis, making it easier to prevent and control areas at risk. 



 
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Existence of Rivers10,11,13,15 

Rivers are at risk of exposure to Leptospira bacteria due to the possibility of contact with 
the urine of infectious reservoir animals. Leptospira bacteria enter through the soft pores 
of the skin, which become permeable when in contact with water, mucous membranes, 
skin on the feet, hands, and any areas with abrasions or wounds.18 The distance 
traveled by mice is influenced by the availability of food, and the migration distance of 
mice reaches a distance of 1 -2 km to obtain food, so that if the distance from the house 
to the case's home is at that distance, there is a risk of Leptospirosis transmission. This 
is when compared with the research results, three articles have a distance of 1 - 2 km 
between the case house and the presence of a river, where this distance is the cruising 
range of mice, so there is a risk of Leptospirosis transmission. In contrast, 1 article 
shows the case house is at a distance of 3000 meters or 3 km, which means it exceeds 
the distance traveled by mice, suggesting that other environmental risk factors can 
cause this. 

Flood History8,9,11,15 

The study showed that 8 These results align with research conducted by Pramestuti in 
Pati Regency, showing that 75.7% of leptospirosis sufferers live in environments with a 
history of flooding.19 Flooding is a disaster that can disrupt health services and 
infrastructure, cause dirty water and sanitation, and damage houses. It can increase 
environmental exposure to pathogens.20 The research results show that the research 
location is a coastal area, and water channels overflow when it rains, resulting in 
flooding and lots of standing water, which triggers the transmission of Leptospirosis. 
However, Leptospirosis can occur outside flood areas, where the area has experienced 
standing water and contains Leptospira bacteria. Apart from that, it can be influenced 
by other risk factors that influence the incidence of Leptospirosis. 

Existence of gutters8,11,12 

Fifty-four percent of Leptospirosis cases are spread in areas with poor sewer 
conditions.12 It happened when gutters in the respondents' homes did not flow smoothly, 
there was a lot of rubbish piling up in the gutters, the gutters overflowed when it rained, 
the gutters were not cleaned routinely and regularly, the gutters were made of concrete 
which reduced their ability to absorb water, and there were often rats—visiting the 
house. Previous research said that 51.4% of cases had a sewer distance of ≥ 2 meters 
while observed using buffer analysis. 11 This indicates that the distance is unrelated to 
Leptospirosis. The research of Priyanto et al. showed no relationship between the 
distance from the house and the presence of sewers on the incidence of Leptospirosis 
(p = 0.789).21 The proximity of a sewer to a case of Leptospirosis sufferers does not 
cause Leptospirosis because it depends on the condition of the sewer itself. In essence, 
Leptospirosis is transmitted through the sewer route if the sewer water is infected with 
Leptospira bacteria, and the respondent comes into contact with the water. 

Waste disposal conditions8,11,15 

97.5% of Leptospirosis cases have poor waste disposal sites.22 This is reinforced by 



 
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Rusmini, who states that poor rubbish dumps are a risk factor for Leptospirosis because 
the intermediary vector of Leptospira bacteria, especially rats, really like places with 
piles of rubbish. 23 Meanwhile, research stated that a distance radius between case 
houses with rubbish dumps shows that 91.8% of cases are located at a distance of less 
than 500 meters. 11 This is in line with research, which showed that 90% of cases were 
at a distance of ≤ 500 meters. 24 The research results show that respondents still use 
open rubbish bins such as buckets, plastic, and sacks, and some don't have rubbish 
bins at home, resulting in rubbish strewn all over the yard. This will undoubtedly invite 
the presence of mice, making the place a food source and shelter for mice. The 
proximity of a house to a rubbish dump means that mice can enter the house and urinate 
everywhere. If a rat is infected with Leptospira bacteria and excretes infective urine, the 
waste likely contains Leptospira bacteria. 

Rainfall9–11 

Leptospirosis often occurs with rainfall above 177.6 mm, nine while others say that 
Leptospirosis often occurs in areas with rainfall of 2000 mm/year, 10 and 101 – 300 
mm/month.11 According to Sunaryo and Marbawati, the incidence of Leptospirosis will 
increase with high rainfall. 25 Several studies have shown that the rainfall index is a risk 
factor influencing the incidence of Leptospirosis. High rain causes flooding and is a good 
and optimal condition for mice to reproduce, thereby increasing the risk of transmission 
of Leptospira bacteria. 

The existence of rice fields8,10,15 

38% of cases reside in residences more than 200 meters from rice fields. One study 
found that 7 cases were documented, while another found that all cases occurred in 
dwellings within a 0-1 km radius of rice fields.15 The validity of these findings is 
enhanced by buffer analysis measures, which indicate that 52.5% of the cases reside 
in dwellings within a range of 0 - 1 km from rice fields. These two research findings 
suggest a correlation between the proximity of a house to rice fields and the incidence 
of Leptospirosis. Specifically, the chance of acquiring Leptospirosis increases as the 
distance between the house and the rice fields decreases. The findings of this study 
are consistent with the research carried out in Banyumas Regency, which indicates that 
all reported cases were within a range of 0 - 1 km from rice fields. 26 

Population Density10,15 

Villages with high density have several cases of 4%, villages with medium density have 
several cases of 80%, and low density have several cases of 16%.15 Meanwhile, the 
research using an overlay of a population density map with a map of Leptospirosis 
cases showed that population density was not accompanied by an increase in the 
number of cases, and the most significant number of cases was not found in areas with 
high population density. 10 This shows that population density does not necessarily 
affect the incidence of Leptospirosis. These results do not align with Stein, C. et al. that 
population density is one factor influencing the transmission of Leptospirosis in 
Southeast Asia.27 Densely populated environments tend to be dirty and have a high rat 



 
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population due to poor sanitation, making it easier for Leptospira bacteria to spread. 
Other environmental factors may influence these differences. The research results 
stated that at the research location, the land used was not only for residential areas but 
also for agricultural land, plantations, and ponds, which were quite extensive. Thus, it 
can increase the risk of transmitting Leptospirosis apart from population density. If the 
population density is high but the sanitation conditions are reasonable, it can minimize 
the occurrence of leptospirosis transmission. 

Presence of vegetation12 

100% of Leptospirosis incidents occur in locations with three or more vegetation types.12 
These results align with previous research, which found that 53.8% of Leptospirosis 
cases had vegetation ≥ 3 types around the house.28 The diversity and density of 
vegetation are a source of food and shelter for mice. Several plants that contribute to 
the existence of mice include bushes, shrubs, and plants with branches. An 
environment that is dirty and covered with grass or bushes is a place that mice like. 

Trap success14 

The results of the research show that most of the five sub-districts have a trap success 
percentage value of > 7% inside and outside the house, meaning that there are a lot of 
mice in that area, and this is a potential location for mouse habitat as a reservoir for 
Leptospira bacteria. Research mentioned that the criteria for successful trapping in the 
house are if >7% is categorized as having lots of mice and <7% is classified as having 
few mice. 29 The success of catching mice can describe the density of mice in a place 
or environment. High trap success can be caused by several things, such as lack of 
cleanliness, poor sanitation, scattered or piled-up rubbish, and sewer water that does 
not flow. 

Existence of ponds15 

The research using buffer analysis shows that the highest number of houses with cases 
are located within a distance of > 2 km from the pond, with a percentage of 62%. This 
is in line with research showing that the distance between the case house and the pond 
is > 700 meters with a percentage of 85.3%.30 The research results are inversely 
proportional to Mwacui's statement that low-lying areas along riverbanks, ponds, or 
beaches are highly vulnerable to flooding during the rainy season. 31 This difference can 
be caused by other supporting environmental risk factors. This research explains that 
the research location is a slum and densely populated, and rubbish is piling up. This 
triggers the presence of a reservoir (rodent). 

Road Existence10 

The buffer analysis research shows that the highest number of houses with leptospirosis 
sufferers are within a distance of 0 - 50 m from the road at 82.97%. In this study, it 
needs to be explained in detail why this distance influences the incidence of 
Leptospirosis. However, it was explained that there are still many wastewater disposal 
facilities along the road, and people still have the habit of throwing rubbish or dead rats 



 
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at that tunnel. Most of the disposal tunnels are still open.  

Pet ownership12 

The research showed that 59.1% of Leptospirosis cases occurred in locations where 
animals, such as dogs, cows, pigs, goats, cats, or others, were owned. This research is 
in line with research conducted by Ramadhan in determining the condition of the homes 
of leptospirosis sufferers, showing that 95% of cases have pets.32  Pets that can become 
intermediate hosts and transmit Leptospirosis to humans are dogs, goats, cats, cows, 
pigs, or birds.33 Leptospirosis exposure is primarily in tropical countries, including 
developing countries, but it is most likely in humans due to infection from livestock, 
domestic animals, and wild animals.34 

Presence of mice12 

The study results showed that 85.2% of cases of Leptospirosis occurred in locations 
where rats were in the house. This is in line with previous research showing that 73.3% 
of cases occurred in places where rats were present.35 Rats are essential in transmitting 
Leptospirosis because >50% of rats can continuously excrete Leptospira bacteria 
through urine without symptoms.23 Apart from that, it is closely related to environmental 
conditions. Rats in or around the house are caused by rubbish that is not managed 
correctly, lack of lighting, and poor environmental conditions. 

Altitudes9 

The study results showed that Leptopsirrhosis occurred frequently in Sampang District 
from 4 sub-districts with altitudes below 47 meters above sea level, with a total of 103 
cases. This aligns with Sunaryo's research that Leptospirosis cases are more common 
in altitude areas below 47 meters above sea level.36 This low altitude has the potential 
for flooding, which can become a medium for transmitting Leptospira bacteria. Areas 
that have a low altitude of 5m to 10m above sea level are unlikely to have cases of 
Leptospirosis; this is because, in these conditions, there are areas where there is 
seawater/brackish water with a high level of salinity, which is not liked by Leptospira 
bacteria. Meanwhile, a height between 31m and 50m above sea level is the ideal height 
area for the life of Leptospira bacteria. 

Land use14 

The research results show that most cases live on agricultural land with a percentage 
of 67.1%, including horticulture, rubber, rice, gardens, and other crops. These results 
are reinforced by the fact that 35.4% were included in the high-risk occupational group 
in the research area, including farmers. Land use is closely related to the spread of 
Leptospirosis because it can indicate the potential places for Leptospira bacteria to 
survive under certain conditions and the residence and breeding place for the reservoir 
itself. 

 



 
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CONCLUSION 

This study aims to identify the environmental risk variables that influence leptospirosis 
incidence based on previously published publications that used GIS as the research 
method. It is known that 15 identified ecological risk factors influence the incidence of 
Leptospirosis, namely the existence of rivers, history of flooding, the existence of 
gutters, waste disposal conditions, rainfall, the existence of rice fields, population 
density, the existence of vegetation, the success of traps, the existence of ponds, 
the existence of roads, livestock ownership, presence of rats, altitude, and land use. It 
is clear that when one or more of these risk variables exist in a location, there is a risk 
of Leptospirosis happening, allowing local authorities to design prevention initiatives. 

Declarations 

Authors' contribution 

DS and SS were responsible for the research design and data collection, MM provided a 
data analysis review, and WKW reviewed the manuscript. 

Funding statement 

This research received no specific grant from any funding agency in the public, commercial, 
or not-for-profit sectors. 

Conflict of interest 

There is no conflict of interest in this research. 

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