{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,6]],"date-time":"2026-05-06T16:17:43Z","timestamp":1778084263101,"version":"3.51.4"},"reference-count":92,"publisher":"American Society of Tropical Medicine and Hygiene","issue":"5","license":[{"start":{"date-parts":[[2026,5,6]],"date-time":"2026-05-06T00:00:00Z","timestamp":1778025600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,5,6]]},"abstract":"<jats:title>ABSTRACT.<\/jats:title>\n                  <jats:p>\n                    Leptospirosis is a zoonotic infection with significant mortality, yet its burden is underestimated due to diagnostic limitations. The dynamics of naturally acquired anti-\n                    <jats:italic>Leptospira<\/jats:italic>\n                    antibodies, particularly during pregnancy, remain poorly understood. This study examined the seroincidence of leptospiral infection among a cohort of pregnant women and characterized longitudinal antibody kinetics in an endemic setting. Paired sera were collected from a population-based pregnancy cohort in Anuradhapura, Sri Lanka. Women were enrolled before 12 weeks of gestation and followed up between 25\u201328 weeks. Data on sociodemographics, self-reported febrile illness, and hospital admissions were collected. Microscopic agglutination testing (MAT) was performed against 11\n                    <jats:italic>Leptospira<\/jats:italic>\n                    serovars. Seroincidence was defined as seroconversion from non-reactive (&lt;1:50) to reactive (\u22651:50). Antibody kinetics were assessed using Gaussian accelerated failure time and proportional odds logistic regression models. Among 3,374 recruited women, 1,338 had paired samples. Of 1,245 seronegative at baseline, 22 (1.8%) seroconverted, yielding a seroincidence rate of 52.8\/1,000 person-years (95% CI: 31.2\u201376.8), using the \u22651:50 definition; using a \u22651:100 cutoff, the seroincidence rate was 14.4 per 1,000 person-years (95% CI: 5.3\u201331.4). No significant differences in pregnancy outcomes were observed between seroconverts and non-seroconverts. Among 93 women with baseline antibody titers \u22651:50, 14 (15.1%) seroreverted to &lt;1:50, 12 (12.9%) showed a decline in titers but remained \u22651:50, 56 (60.2%) remained unchanged, and 11 (11.8%) showed an increase in antibody titers. Antibody decay rates ranged from +0.353 to \u20130.789 log\n                    <jats:sub>2<\/jats:sub>\n                    units\/30 days (mean: \u20130.074), with faster decay at higher baseline titers. This study reveals frequent, asymptomatic\n                    <jats:italic>Leptospira<\/jats:italic>\n                    exposure and rapid antibody decline during pregnancy, highlighting substantial silent transmission and the limitations of current surveillance tools in endemic settings.\n                  <\/jats:p>","DOI":"10.4269\/ajtmh.25-0553","type":"journal-article","created":{"date-parts":[[2026,3,19]],"date-time":"2026-03-19T15:32:53Z","timestamp":1773934373000},"page":"848-856","source":"Crossref","is-referenced-by-count":0,"title":["Subclinical Leptospiral Infections and Antibody Waning During Pregnancy: A Population-Based Cohort Study from Rural Sri Lanka"],"prefix":"10.4269","volume":"114","author":[{"given":"Suneth","family":"Agampodi","sequence":"first","affiliation":[{"name":"Innovation, Initiatives & Enterprise Development, International Vaccine Institute, Seoul, Republic of Korea;"},{"name":"Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dinesha","family":"Jayasundara","sequence":"additional","affiliation":[{"name":"Department of Microbiology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Janith","family":"Warnasekara","sequence":"additional","affiliation":[{"name":"Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thilini","family":"Agampodi","sequence":"additional","affiliation":[{"name":"Epidemiology, Public Health, Impact Unit, International Vaccine Institute, Seoul, Republic of Korea;"},{"name":"Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Indika","family":"Senavirathna","sequence":"additional","affiliation":[{"name":"Department of Biochemistry, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Dilrukshi","family":"Menike","sequence":"additional","affiliation":[{"name":"Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Digantha","family":"Aswaddumage","sequence":"additional","affiliation":[{"name":"Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Madushika","family":"Sewwandi","sequence":"additional","affiliation":[{"name":"Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chamila","family":"Kappagoda","sequence":"additional","affiliation":[{"name":"Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anuruddhi","family":"Premalal","sequence":"additional","affiliation":[{"name":"Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hwa Young","family":"Kim","sequence":"additional","affiliation":[{"name":"Epidemiology, Public Health, Impact Unit, International Vaccine Institute, Seoul, Republic of Korea;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shashanka","family":"Rajapakse","sequence":"additional","affiliation":[{"name":"Department of Physiology, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka;"},{"name":"Department of Public Health & AI, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang-si, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Rapha\u00ebl M.","family":"Zellweger","sequence":"additional","affiliation":[{"name":"Epidemiology, Public Health, Impact Unit, International Vaccine Institute, Seoul, Republic of Korea;"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"2795","reference":[{"key":"b1","series-title":"PLoS Negl Trop Dis","first-page":"e0010331","article-title":"Diagnostic method-based underestimation of leptospirosis in clinical and research settings; An experience from a large prospective study in a high endemic setting","volume":"16","author":"Warnasekara","year":"2022"},{"key":"b2","series-title":"Emerg Infect Dis","first-page":"2079","article-title":"Leptospirosis, diagnostic challenges, American Samoa","volume":"18","author":"Lau","year":"2012"},{"key":"b3","series-title":"Pathology","first-page":"387","article-title":"Leptospirosis: A global disease. The diagnostic and public health challenges","volume":"44","author":"Craig","year":"2012"},{"key":"b4","series-title":"Clin Infect Dis","first-page":"322","article-title":"Fool\u2019s gold: Why imperfect reference tests are undermining the evaluation of novel diagnostics: A reevaluation of 5 diagnostic tests for leptospirosis","volume":"55","author":"Limmathurotsakul","year":"2012"},{"key":"b5","series-title":"Am J Trop Med Hyg","first-page":"471","article-title":"Leptospirosis outbreak in Sri Lanka in 2008: Lessons for assessing the global burden of disease","volume":"85","author":"Agampodi","year":"2011"},{"key":"b6","series-title":"PLoS Negl Trop Dis","first-page":"e0009565","article-title":"Optimizing the microscopic agglutination test (MAT) panel for the diagnosis of Leptospirosis in a low resource, hyper-endemic setting with varied microgeographic variation in reactivity","volume":"15","author":"Jayasundara","year":"2021"},{"key":"b7","series-title":"Am J Trop Med Hyg","first-page":"531","article-title":"Redefining gold standard testing for diagnosing leptospirosis: Further evidence from a well-characterized, flood-related outbreak in Sri Lanka","volume":"95","author":"Agampodi","year":"2016"},{"key":"b8","series-title":"PLoS Negl Trop Dis","first-page":"e0009876","article-title":"Comparison of the Serion IgM ELISA and Microscopic Agglutination Test for diagnosis of Leptospira spp. infections in sera from different geographical origins and estimation of Leptospira seroprevalence in the Wiwa indigenous population from Colombia","volume":"16","author":"Dreyfus","year":"2022"},{"key":"b9","series-title":"Diagnostics (Basel)","first-page":"1455","article-title":"Diagnosis of human leptospirosis: Comparison of microscopic agglutination test with recombinant LigA\/B antigen-based in-house IgM Dot ELISA dipstick test and latex agglutination test using Bayesian latent class model and MAT as gold standard","volume":"12","author":"Behera","year":"2022"},{"key":"b10","series-title":"Int J Infect Dis","first-page":"135","article-title":"Development of in-house ELISAs as an alternative method for the serodiagnosis of leptospirosis","volume":"105","author":"Niloofa","year":"2021"},{"key":"b11","series-title":"Sci Rep","first-page":"19785","article-title":"Evaluation of a genus-specific rGroEL(1-524) IgM-ELISA and commercial ELISA kits during the course of leptospirosis in Thailand","volume":"11","author":"Maneewatchararangsri","year":"2021"},{"key":"b12","series-title":"Am J Trop Med Hyg","first-page":"1777","article-title":"Evaluation of the Panbio Leptospira IgM ELISA among outpatients attending primary care in Southeast Asia","volume":"104","author":"Dhawan","year":"2021"},{"key":"b13","series-title":"Vet Immunol Immunopathol","first-page":"109960","article-title":"Development of antibody ELISA specific of Leptospira interrogans serovar Grippotyphosa, Canicola, and Icterohaemorrhagiae to monitor vaccine immunogenicity","volume":"219","author":"Cariou","year":"2020"},{"key":"b14","series-title":"Trop Biomed","first-page":"1071","article-title":"Evaluation of IgM LAT and IgM ELISA as compared to microscopic agglutination test (MAT) for early diagnosis of Leptospira sp","volume":"36","author":"Zin","year":"2019"},{"key":"b15","series-title":"Biomedica","first-page":"673","article-title":"Evaluation of three qPCR for the detection of pathogenic leptospires in domestic animals in Nicaragua","volume":"40","author":"Flores","year":"2020"},{"key":"b16","series-title":"Mol Cell Probes","first-page":"1","article-title":"Development and validation of pan-Leptospira Taqman qPCR for the detection of Leptospira spp. in clinical specimens","volume":"38","author":"Mohd Ali","year":"2018"},{"key":"b17","series-title":"Methods Mol Biol","first-page":"257","article-title":"Detection of pathogenic Leptospira spp. through real-time PCR (qPCR) targeting the LipL32 gene","volume":"943","author":"Stoddard","year":"2013"},{"key":"b18","series-title":"Clin Infect Dis","first-page":"1249","article-title":"Utility of quantitative polymerase chain reaction in leptospirosis diagnosis: Association of level of leptospiremia and clinical manifestations in Sri Lanka","volume":"54","author":"Agampodi","year":"2012"},{"key":"b19","series-title":"Deutsches Archiv f\u00fcr Klinische Medizin","first-page":"209","article-title":"\u00dcber eine eigenth\u00fcmliche, mit Milztumor, Icterus und Nephritis einhergehende, acute Infektionskrankheit","volume":"39","author":"Weil","year":"1886"},{"key":"b20","series-title":"Elife","first-page":"e73120","article-title":"Linking rattiness, geography and environmental degradation to spillover Leptospira infections in marginalised urban settings: An eco-epidemiological community-based cohort study in Brazil","volume":"11","author":"Eyre","year":"2022"},{"key":"b21","series-title":"Front Med (Lausanne)","first-page":"862378","article-title":"Biannual and quarterly comparison analysis of agglutinating antibody kinetics on a subcohort of individuals exposed to Leptospira interrogans in Salvador, Brazil","volume":"9","author":"Cruz","year":"2022"},{"key":"b22","series-title":"Am J Epidemiol","first-page":"893","article-title":"Effects of accounting for interval-censored antibody titer decay on seroincidence in a longitudinal cohort study of leptospirosis","volume":"190","author":"Owers Bonner","year":"2021"},{"key":"b23","series-title":"PLoS Negl Trop Dis","first-page":"e0004275","article-title":"Spatiotemporal determinants of urban leptospirosis transmission: Four-year prospective cohort study of slum residents in Brazil","volume":"10","author":"Hagan","year":"2016"},{"key":"b24","series-title":"PLoS Negl Trop Dis","first-page":"e0009747","article-title":"Leptospirosis in pregnancy: A systematic review","volume":"15","author":"Selvarajah","year":"2021"},{"key":"b25","series-title":"Anuradhapura Med J","first-page":"31","article-title":"Cohort profile: The Rajarata Pregnancy Cohort (RaPCo)","volume":"17","author":"Agampodi","year":"2023"},{"key":"b26","series-title":"PLoS Negl Trop Dis","first-page":"e2927","article-title":"Prospective study of leptospirosis transmission in an urban slum community: Role of poor environment in repeated exposures to the Leptospira agent","volume":"8","author":"Felzemburgh","year":"2014"},{"key":"b27","series-title":"Res Sq","first-page":"rs.3.rs-3760267","article-title":"Eco-epidemiological study of seropositivity against Rickettsia and Leptospira agents in rural areas of Uraba, Colombia","author":"Torres-Bustamante","year":"2024"},{"key":"b28","series-title":"Emerg Infect Dis","first-page":"1016","article-title":"Environmental exposure and leptospirosis, Peru","volume":"10","author":"Johnson","year":"2004"},{"key":"b29","series-title":"Int J Antimicrob Agents","first-page":"249","article-title":"Randomized controlled trial of doxycycline prophylaxis against leptospirosis in an endemic area","volume":"13","author":"Sehgal","year":"2000"},{"key":"b30","series-title":"Mil Med","first-page":"802","article-title":"Leptospirosis and rickettsial diseases sero-conversion surveillance among U.S. military personnel in Honduras","volume":"187","author":"Chao","year":"2022"},{"key":"b31","series-title":"Eur J Epidemiol","first-page":"257","article-title":"Prospective serological study of leptospirosis in southern Spain","volume":"12","author":"Dastis-Bendala","year":"1996"},{"key":"b32","series-title":"Int J Environ Res Public Health","first-page":"1756","article-title":"Sero-prevalence and risk factors for leptospirosis in abattoir workers in New Zealand","volume":"11","author":"Dreyfus","year":"2014"},{"key":"b33","series-title":"Acta Trop","first-page":"128","article-title":"Seroepidemiology and serological follow-up of anti-leptospiral IgG in children in southern Vietnam","volume":"106","author":"Thai","year":"2008"},{"key":"b34","series-title":"Ann Trop Med Parasitol","first-page":"255","article-title":"Leptospiral infection: A household serosurvey in urban and rural communities in Barbados and Trinidad","volume":"84","author":"Everard","year":"1990"},{"key":"b35","series-title":"Curr Top Microbiol Immunol","first-page":"65","article-title":"Leptospirosis in humans","volume":"387","author":"Haake","year":"2015"},{"key":"b36","series-title":"Eur J Clin Microbiol Infect Dis","first-page":"2491","article-title":"Leptospirosis in pregnancy","volume":"31","author":"Puliyath","year":"2012"},{"key":"b37","article-title":"National Maternal Mortality Review Report 2008.","year":"2008"},{"key":"b38","article-title":"National Maternal Mortality Review Report 2010.","year":"2010"},{"key":"b39","series-title":"Medico-Legal J SL","first-page":"20","article-title":"A death of a pregnant mother following leptospirosis","volume":"1","author":"Rathnaweera","year":"2015"},{"key":"b40","series-title":"J Ruhunu Clin Soc","first-page":"50","article-title":"Fulminant leptospirosis leading to shock lung & severe coagulopathy in a pregnant patient: A case report and review of the literature","volume":"25","author":"Tharanga","year":"2020"},{"key":"b41","series-title":"PLoS Negl Trop Dis","first-page":"e0003898","article-title":"Global morbidity and mortality of leptospirosis: A systematic review","volume":"9","author":"Costa","year":"2015"},{"key":"b42","series-title":"J Gynecol Obstet Biol Reprod (Paris)","first-page":"418","article-title":"[Leptospirosis and pregnancy. Eleven cases in French Guyana]","volume":"24","author":"Carles","year":"1995"},{"key":"b43","series-title":"Asian Pac J Trop Med","first-page":"390","article-title":"Etiological agents causing leptospirosis in Sri Lanka: A review","volume":"9","author":"Naotunna","year":"2016"},{"key":"b44","series-title":"PLoS Negl Trop Dis","first-page":"e0009272","article-title":"12 Novel clonal groups of Leptospira infecting humans in multiple contrasting epidemiological contexts in Sri Lanka","volume":"15","author":"Jayasundara","year":"2021"},{"key":"b45","series-title":"Eur J Epidemiol","first-page":"601","article-title":"Persistence of anti-leptospiral IgM, IgG and agglutinating antibodies in patients presenting with acute febrile illness in Barbados 1979-1989","volume":"17","author":"Cumberland","year":"2001"},{"key":"b46","series-title":"PLoS Glob Public Health","first-page":"e0002400","article-title":"Quantifying the relationship between climatic indicators and leptospirosis incidence in Fiji: A modelling study","volume":"3","author":"Rees","year":"2023"},{"key":"b1","series-title":"PLoS Negl Trop Dis","first-page":"e0010331","article-title":"Diagnostic method-based underestimation of leptospirosis in clinical and research settings; An experience from a large prospective study in a high endemic setting","volume":"16","author":"Warnasekara","year":"2022"},{"key":"b2","series-title":"Emerg Infect Dis","first-page":"2079","article-title":"Leptospirosis, diagnostic challenges, American Samoa","volume":"18","author":"Lau","year":"2012"},{"key":"b3","series-title":"Pathology","first-page":"387","article-title":"Leptospirosis: A global disease. The diagnostic and public health challenges","volume":"44","author":"Craig","year":"2012"},{"key":"b4","series-title":"Clin Infect Dis","first-page":"322","article-title":"Fool\u2019s gold: Why imperfect reference tests are undermining the evaluation of novel diagnostics: A reevaluation of 5 diagnostic tests for leptospirosis","volume":"55","author":"Limmathurotsakul","year":"2012"},{"key":"b5","series-title":"Am J Trop Med Hyg","first-page":"471","article-title":"Leptospirosis outbreak in Sri Lanka in 2008: Lessons for assessing the global burden of disease","volume":"85","author":"Agampodi","year":"2011"},{"key":"b6","series-title":"PLoS Negl Trop Dis","first-page":"e0009565","article-title":"Optimizing the microscopic agglutination test (MAT) panel for the diagnosis of Leptospirosis in a low resource, hyper-endemic setting with varied microgeographic variation in reactivity","volume":"15","author":"Jayasundara","year":"2021"},{"key":"b7","series-title":"Am J Trop Med Hyg","first-page":"531","article-title":"Redefining gold standard testing for diagnosing leptospirosis: Further evidence from a well-characterized, flood-related outbreak in Sri Lanka","volume":"95","author":"Agampodi","year":"2016"},{"key":"b8","series-title":"PLoS Negl Trop Dis","first-page":"e0009876","article-title":"Comparison of the Serion IgM ELISA and Microscopic Agglutination Test for diagnosis of Leptospira spp. infections in sera from different geographical origins and estimation of Leptospira seroprevalence in the Wiwa indigenous population from Colombia","volume":"16","author":"Dreyfus","year":"2022"},{"key":"b9","series-title":"Diagnostics (Basel)","first-page":"1455","article-title":"Diagnosis of human leptospirosis: Comparison of microscopic agglutination test with recombinant LigA\/B antigen-based in-house IgM Dot ELISA dipstick test and latex agglutination test using Bayesian latent class model and MAT as gold standard","volume":"12","author":"Behera","year":"2022"},{"key":"b10","series-title":"Int J Infect Dis","first-page":"135","article-title":"Development of in-house ELISAs as an alternative method for the serodiagnosis of leptospirosis","volume":"105","author":"Niloofa","year":"2021"},{"key":"b11","series-title":"Sci Rep","first-page":"19785","article-title":"Evaluation of a genus-specific rGroEL(1-524) IgM-ELISA and commercial ELISA kits during the course of leptospirosis in Thailand","volume":"11","author":"Maneewatchararangsri","year":"2021"},{"key":"b12","series-title":"Am J Trop Med Hyg","first-page":"1777","article-title":"Evaluation of the Panbio Leptospira IgM ELISA among outpatients attending primary care in Southeast Asia","volume":"104","author":"Dhawan","year":"2021"},{"key":"b13","series-title":"Vet Immunol Immunopathol","first-page":"109960","article-title":"Development of antibody ELISA specific of Leptospira interrogans serovar Grippotyphosa, Canicola, and Icterohaemorrhagiae to monitor vaccine immunogenicity","volume":"219","author":"Cariou","year":"2020"},{"key":"b14","series-title":"Trop Biomed","first-page":"1071","article-title":"Evaluation of IgM LAT and IgM ELISA as compared to microscopic agglutination test (MAT) for early diagnosis of Leptospira sp","volume":"36","author":"Zin","year":"2019"},{"key":"b15","series-title":"Biomedica","first-page":"673","article-title":"Evaluation of three qPCR for the detection of pathogenic leptospires in domestic animals in Nicaragua","volume":"40","author":"Flores","year":"2020"},{"key":"b16","series-title":"Mol Cell Probes","first-page":"1","article-title":"Development and validation of pan-Leptospira Taqman qPCR for the detection of Leptospira spp. in clinical specimens","volume":"38","author":"Mohd Ali","year":"2018"},{"key":"b17","series-title":"Methods Mol Biol","first-page":"257","article-title":"Detection of pathogenic Leptospira spp. through real-time PCR (qPCR) targeting the LipL32 gene","volume":"943","author":"Stoddard","year":"2013"},{"key":"b18","series-title":"Clin Infect Dis","first-page":"1249","article-title":"Utility of quantitative polymerase chain reaction in leptospirosis diagnosis: Association of level of leptospiremia and clinical manifestations in Sri Lanka","volume":"54","author":"Agampodi","year":"2012"},{"key":"b19","series-title":"Deutsches Archiv f\u00fcr Klinische Medizin","first-page":"209","article-title":"\u00dcber eine eigenth\u00fcmliche, mit Milztumor, Icterus und Nephritis einhergehende, acute Infektionskrankheit","volume":"39","author":"Weil","year":"1886"},{"key":"b20","series-title":"Elife","first-page":"e73120","article-title":"Linking rattiness, geography and environmental degradation to spillover Leptospira infections in marginalised urban settings: An eco-epidemiological community-based cohort study in Brazil","volume":"11","author":"Eyre","year":"2022"},{"key":"b21","series-title":"Front Med (Lausanne)","first-page":"862378","article-title":"Biannual and quarterly comparison analysis of agglutinating antibody kinetics on a subcohort of individuals exposed to Leptospira interrogans in Salvador, Brazil","volume":"9","author":"Cruz","year":"2022"},{"key":"b22","series-title":"Am J Epidemiol","first-page":"893","article-title":"Effects of accounting for interval-censored antibody titer decay on seroincidence in a longitudinal cohort study of leptospirosis","volume":"190","author":"Owers Bonner","year":"2021"},{"key":"b23","series-title":"PLoS Negl Trop Dis","first-page":"e0004275","article-title":"Spatiotemporal determinants of urban leptospirosis transmission: Four-year prospective cohort study of slum residents in Brazil","volume":"10","author":"Hagan","year":"2016"},{"key":"b24","series-title":"PLoS Negl Trop Dis","first-page":"e0009747","article-title":"Leptospirosis in pregnancy: A systematic review","volume":"15","author":"Selvarajah","year":"2021"},{"key":"b25","series-title":"Anuradhapura Med J","first-page":"31","article-title":"Cohort profile: The Rajarata Pregnancy Cohort (RaPCo)","volume":"17","author":"Agampodi","year":"2023"},{"key":"b26","series-title":"PLoS Negl Trop Dis","first-page":"e2927","article-title":"Prospective study of leptospirosis transmission in an urban slum community: Role of poor environment in repeated exposures to the Leptospira agent","volume":"8","author":"Felzemburgh","year":"2014"},{"key":"b27","series-title":"Res Sq","first-page":"rs.3.rs-3760267","article-title":"Eco-epidemiological study of seropositivity against Rickettsia and Leptospira agents in rural areas of Uraba, Colombia","author":"Torres-Bustamante","year":"2024"},{"key":"b28","series-title":"Emerg Infect Dis","first-page":"1016","article-title":"Environmental exposure and leptospirosis, Peru","volume":"10","author":"Johnson","year":"2004"},{"key":"b29","series-title":"Int J Antimicrob Agents","first-page":"249","article-title":"Randomized controlled trial of doxycycline prophylaxis against leptospirosis in an endemic area","volume":"13","author":"Sehgal","year":"2000"},{"key":"b30","series-title":"Mil Med","first-page":"802","article-title":"Leptospirosis and rickettsial diseases sero-conversion surveillance among U.S. military personnel in Honduras","volume":"187","author":"Chao","year":"2022"},{"key":"b31","series-title":"Eur J Epidemiol","first-page":"257","article-title":"Prospective serological study of leptospirosis in southern Spain","volume":"12","author":"Dastis-Bendala","year":"1996"},{"key":"b32","series-title":"Int J Environ Res Public Health","first-page":"1756","article-title":"Sero-prevalence and risk factors for leptospirosis in abattoir workers in New Zealand","volume":"11","author":"Dreyfus","year":"2014"},{"key":"b33","series-title":"Acta Trop","first-page":"128","article-title":"Seroepidemiology and serological follow-up of anti-leptospiral IgG in children in southern Vietnam","volume":"106","author":"Thai","year":"2008"},{"key":"b34","series-title":"Ann Trop Med Parasitol","first-page":"255","article-title":"Leptospiral infection: A household serosurvey in urban and rural communities in Barbados and Trinidad","volume":"84","author":"Everard","year":"1990"},{"key":"b35","series-title":"Curr Top Microbiol Immunol","first-page":"65","article-title":"Leptospirosis in humans","volume":"387","author":"Haake","year":"2015"},{"key":"b36","series-title":"Eur J Clin Microbiol Infect Dis","first-page":"2491","article-title":"Leptospirosis in pregnancy","volume":"31","author":"Puliyath","year":"2012"},{"key":"b37","article-title":"National Maternal Mortality Review Report 2008.","year":"2008"},{"key":"b38","article-title":"National Maternal Mortality Review Report 2010.","year":"2010"},{"key":"b39","series-title":"Medico-Legal J SL","first-page":"20","article-title":"A death of a pregnant mother following 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