PRISMA flowchart.

<p>Selection of eligible articles for study inclusion.</p

<i>Leptospira</i> species^a reported in acute human leptospirosis and animal carrier hosts by African country.

<p>Footnotes</p><p>^a methodology includes genetic typing of isolates, DNA sequencing following PCR detection, extrapolation of serovar data with species determined by reference to KIT <i>Leptospira</i> library.</p><p>^b<i>Miniopterus</i> spp. include <i>Miniopterus gleni</i>, <i>Miniopterus goudoti</i>, <i>Miniopterus griffithsi</i>, <i>Miniopterus mahafaliensis</i>, <i>Miniopterus majori</i>, <i>Miniopterus soroculus</i></p><p>^c<i>Microgale</i> spp. include <i>Microgale longicaudata</i>, <i>Microgale majori</i>, <i>Microgale principula</i></p><p>^d Described as <i>L</i>. <i>borgpetersenii</i>-like,[<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003899#pntd.0003899.ref035" target="_blank">35</a>] <i>L</i>. <i>borgpetersenii</i> Group B[<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003899#pntd.0003899.ref086" target="_blank">86</a>] and recently re-classified as <i>L</i>. <i>mayottensis</i>[<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003899#pntd.0003899.ref134" target="_blank">134</a>]</p><p><i>Leptospira</i> species<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003899#t005fn002" target="_blank">^a</a> reported in acute human leptospirosis and animal carrier hosts by African country.</p

Case definitions for study inclusion: Acute human leptospirosis and confirmed animal carrier hosts.

<p>Footnotes</p><p>* Culture in any of the following media: Ellinghausen-McCullough-Johnson-Harris (+/- 5’Fluorouracil), Fletcher, Korthoff, Stuart, Vervoot or Noguchi culture media.</p><p>Case definitions for study inclusion: Acute human leptospirosis and confirmed animal carrier hosts.</p

Geographic distribution of acute human leptospirosis and confirmed animal <i>Leptospira</i> spp. infection in Africa.

<p>Geographic distribution of acute human leptospirosis and confirmed animal <i>Leptospira</i> spp. infection in Africa.</p

Summary of eligible cohort and surveillance studies reporting human acute leptospirosis in Africa, 1930–2014.

<p>Footnotes</p><p>*Figures reported here are based on the number of reported acute leptospirosis cases that met our review case definitions (see <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003899#pntd.0003899.t001" target="_blank">Table 1</a> for case definitions) and therefore may vary from the values reported in the original citations.</p><p>** All cases met probable case definitions. An unspecified proportion of positive cases also met the case definition for confirmed cases but exact numbers could not be determined from the available data.</p><p>^a Patients who refused hospital admission were not investigated.</p><p>^b Methods describe a change to a case-finding survey partway through the study, but full details not available</p><p>^c MAT performed in a subset of participants only</p><p>^d Clinical diagnosis defined as ≥3 of the following: headache or fever (temperature not defined), evidence of liver inflammation (defined as jaundice, tender liver, and/or abnormal liver function tests), evidence of renal inflammation (haematuria and/or abnormal renal function), or evidence of muscle inflammation (tenderness and/or elevated creatine phosphokinase)</p><p>^e All tested negative for <i>Salmonella enterica</i> serovar Typhi, <i>Brucella</i> spp., and <i>Rickettsia</i> spp.</p><p>^f All tested negative for Hepatitis A, B, and C.</p><p>^g In setting of outbreak of acute febrile illness in a well-defined population</p><p>^h 187 patients were diagnosed with selected co-infections out of a total cohort of 1510 patients with non-specific febrile illness.</p><p>ϖ Taken ≥ 9 days of onset of illness</p><p>^k Also report two imported cases from Comoros and Madagascar respectively</p><p>Summary of eligible cohort and surveillance studies reporting human acute leptospirosis in Africa, 1930–2014.</p

Full search strategies for database searches (in alphabetical order).

<p>Full search strategies for database searches (in alphabetical order).</p

Reported health care seeking behavior among household survey respondents and calculated multipliers, Moshi Urban and Moshi Rural Districts, Tanzania, 2011.

<p>KCMC = Kilimanjaro Christian Medical Centre, MRH = Mawenzi Regional Hospital.</p>*<p>Number of respondents who chose KCMC as their first or second choice for health care in response to respective questions.</p>†<p>Number of respondents who chose MRH as their first or second choice for health care in response to respective questions.</p>‡<p>Inverse of proportion of respondents who select KCMC for care in response to respective questions.</p>§<p>Inverse of proportion of respondents who select MRH for care in response to respective questions.</p

Surveillance pyramid.

<p>Multipliers were applied to account for incomplete assessments at various levels of the surveillance pyramid.</p

Confirmed and probable leptospirosis cases, Moshi Urban and Moshi Rural Districts residents, Kilimanjaro Christian Medical Center (KCMC) and Mawenzi Regional Hospital (MRH), Tanzania 2007–2008.

<p>KCMC = Kilimanjaro Christian Medical Centre, MRH = Mawenzi Regional Hospital.</p>*<p>Confirmed or probable cases based on testing of paired sera. For adjusted case calculations these cases were multiplied by a ‘MAT sensitivity multiplier’ of 1.00.</p>†<p>Probable cases based on testing of acute serum only. For adjusted case calculations these cases were multiplied by a ‘MAT sensitivity multiplier’ of 2.05.</p

Leptospirosis incidence estimates, Moshi Urban and Moshi Rural Districts, Tanzania 2007–2008.

<p>KCMC = Kilimanjaro Christian Medical Centre, MRH = Mawenzi Regional Hospital, MAT = microscopic agglutination test.</p>*<p>Cases adjusted by ‘MAT sensitivity multiplier,’ MAT specificity, ‘KCMC multiplier,’ and KCMC referral adjustment.</p>†<p>Cases adjusted by ‘MAT sensitivity multiplier,’ MAT specificity and ‘MRH multiplier’.</p>‡<p>No. for the ≥15 years age group represents the mean of the KCMC adjusted case no. and MRH adjusted case no. No. for the 0 to <5 years and 5 to <15 years age groups equal the KCMC adjusted case no. since fever surveillance was not conducted in these groups at MRH.</p>§<p>‘Paired sera multiplier’ applied to estimates using confirmed cases only.</p>¶<p>Only KCMC data used for this estimate since MRH data represents a limited age range.</p>#<p>(Annual estimated cases/population) *100,000.</p