Dengue Fever

A situation analysis in Pakistan DENGUE CONTROL STRATEGY IN PAKISTAN

Shahid Yusuf
MD, MPH (Student) Walden University
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Purpose of this presentation

Barely able to recuperate after the devastating earthquake of 2006 the worlds most populous region went into another crisis of dengue fever. In 2006 alone Pakistan had over 4000 cases of dengue fever and more than 50 deaths. Later years are being more daunting as the number of dengue fever cases are increasing each year. The dengue scare is gripping the public while little or no efforts are being done by the government to ameliorate the situation. This presentation walks-through the perils of dengue fever, its burden, causes of failure and methods to ameliorate the situation.
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The audience for this presentation are intended but not limited to: Public Health Professionals at the federal and provincial levels of Pakistan. Public Health Nursing community at the federal and provincial levels.

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AGENDA
Agenda of this presentation is aimed at: Profile of Pakistan. Clinical manifestation of Dengue fever.

Burden of the disease in Pakistani population.

Measures adopted by governmental and public health agencies to reduce the incidence and prevalence of the disease. Tracing the causes of failure and discussing options to adopt an effective strategy for controlling dengue fever in Pakistan
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GOVERNMENT SECRETARIAT ISLAMABAD

THE FEDERAL CAPITAL

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SHAHLAMAR GARDENS
PUNJAB PROVINCE

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Karachi's Mazar-e-Quaid Mausoleum SINDH PROVINCE

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MOUNTAINOUS NWFP KHYBER PROVINCE

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BLAUCHISTAN PROVINCE

OFFICIAL INSIGNIA OF MINISTRY OF HEALTH PAKISTAN

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MAP OF PAKISTAN

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WHO Maps http://www.who.int/countries/en

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PROFILE OF PAKISTAN
Situated in South Asia Pakistan borders India on its East, Afghanistan and Iran on its West, and China in the North.
Total area of the country is 796,095 sq km Total population of the country as in July 2011 is estimated at 187,342,721.
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HEALTH DEVELOPMENT IN PAKISTAN

Poor maternal and child health profile
High maternal mortality rate 276/100,000 live births Low ante-natal coverage (61%) High under five, infant, and neonatal mortality ( 94, 78, and 54/1000 live births respectively).

Double burden of disease

The burden of disease is heavily dominated by communicable diseases, reproductive health problems, and malnutrition which together account for about 50% of the total.

world health organization, May 2011 http://www.who.int/country focus

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HEALTH DEVELOPMENT .. Cont.

Low health expenditures and low public investment in health sector; low focus on prevention; main expenditures for salaries an inequity in allocation of resources.

Insufficient health district mapping and planning, Inadequately planned human resources for health. Transfer of critical responsibilities from federal to provincial level. Health referral pyramid not respected.

World health organization, May 2011 http://www.who.int/country focus

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DENGUE FEVER :entomology

Dengue fever is caused by an arthropod-borne virus which is transmitted to humans through a mosquito Aedes Aegypti. Dengue is the most common mosquito-borne viral disease of humans that is recently becoming a major international public health concern.

Globally 2.5 billion people live in areas where dengue viruses can be transmitted (WHO Dengue/dengue hemorrhagic fever, 2011)

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Aedes Mosquito

Aedes Aegypti

Aedes Albopictus

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A mosquito sucking blood

courtesy of National Geographic

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DENGUE FEVER:

world distribution

2006
Red: Epidemic dengue (wikipedia, www.wikipedia.org) 4/17/2012 18

DENGUE FEVER: endemicity

Dengue is endemic in more than 100 countries. It infects 50-110 million people worldwide a year, leading to a half a million hospitalizations, and approximately 12,500 to 25,000 deaths. This disease has a burden estimated to be 1600 disability-adjusted life years per million population, similar to tropical diseases like Tuberculosis. WHO counts dengue as one of the sixteen neglected tropical diseases.

(WHO Dengue/dengue hemorrhagic fever, 2011). (Wikipedia, Dengue).

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DENGUE FEVER :

Clinical manifestations

Dengue fever is also known as break bone fever or dengue hemorrhagic fever. Majority of the cases (80%) with dengue remain asymptomatic having mild fever, a small proportion develop life threatening illness termed as dengue hemorrhagic fever. Occurs when a mosquito carrying an arbovirus bites a human, passing the virus to the new host. The virus travels to various glands in the body where it multiplies. Acute viremia is manifested by bleeding, low levels of blood platelets, and blood plasma leakage resulting in dengue shock syndrome, where dangerously low blood pressure occurs.

Wikipedia, dengue, http://en.wikipedia.org/wiki/Dengue_fever

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Clinical manifestationscont.

Incubation of the diseases ranges from 4-7 days. The course of infection is divided into three phases: febrile, critical and recovery.

Febrile phased is spanned by a fever over 40

C (104 F), associated with generalized pains and headache, flushed skin, measles like rash, and small petechiae. The fever is classically biphasic in nature, breaking than returning for one or two days.

Critical phase of the disease is manifested by

high grade fever which lasts for one or two days, fluid accumulation in chest and abdominal cavity due to capillary permeability. Shock (dengue shock syndrome) and hemorrhage (dengue hemorrhagic fever) may occur in less than 5% of cases.

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Clinical manifestations.. cont.

The recovery phase is
heralded by resorption of the leaked fluid into the blood stream. This lasts for two-three days.

A typical rash seen in dengue fever

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Hemorrhages in the eyes

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DENGUE FEVER :

with mild form of disease

High fever , up to 105 F (40.6 C) A rash over most of the body, which may subside after a couple of days, then reappear. Severe headache, backache or both. Pain behind the eyes Severe joint and muscle pain Nausea and vomiting Mild bleeding manifestations (e.g. nose or gum bleed, petechiae, or easy bruising).
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DENGUE FEVER with severe form of disease

Severe abdominal pain or persistent vomiting Red spots or patches on the skin Bleeding from nose or gums Vomiting blood Black tarry stools ( feces, excrement) Drowsiness or irritability Pale, cold or clammy skin Breathing difficulty

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LABORATORY CRITERIA FOR DIAGNOSIS

Isolation of dengue virus from serum, plasma, leukocytes, or autopsy samples Demonstration of a 4-fold or greater change in reciprocal immunoglobulin G (IgG) or immunoglobulin M (IgM) antibody titers to one or more dengue virus antigens in paired serum samples.

Demonstration of dengue virus in tissue via immunohistochemistry or immunofluorescence or in serum samples via enzyme immunoassay (EIA) .
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CLASSIFICATION OF DENGUE CASES

Cases are classified as suspected if they are
compatible with the clinical description.

Cases are classified as probable if they are

compatible with the clinical definition and satisfy one or more of the following criteria:

Occurrence at the same location and time as other confirmed cases of dengue fever Supportive serology: antibody titer greater than 1280, comparable IgG EIA titers, or positive IgM antibody test in late acute or convalescent-phase serum specimen.

A confirmed case is one that is compatible with the

clinical definition and is confirmed by the laboratory.
Shepherd, S. M. & Cunha, B. A. 2009 emedicine.medscape.com

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DIAGNOSIS CRITERIA
DENGUE HEMORRHAGIC FEVER A positive result from the tourniquet test Petechiae, ecchymoses, or purpura Bleeding from the mucosa, gastrointestinal tract, injection sites, or other sites Hematemesis or melena, thrombocytopenia (< 100,000 cells/L) and evidence of plasma leakage due to increased vascular permeability
Shepherd, S. M. & Cunha, B. A. 2009 emedicine.medscape.com

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BURDEN OF DISEASE IN PAKISTAN

2006 DENGUE OUTBREAK IN PAKISTAN A significant increase in dengue was reported in Pakistan reported as countrys worst health crisis. More than 4,800 cases were reported as diagnosed with more than 50 deaths. It was the first time that such an outbreak in Pakistan was reported. 2007 DENGUE FEVER More than 3500 cases were reported from all over the country with more than 289 deaths
http://www.dailytimes.com.pk/default...-8-2008_pg12_8

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BURDEN OF DISEASE
2008 DENGUE FEVER CASES
More than 4,000 cases were reported in the press with number of deaths ranging to 55.

2009 DENGUE FEVER CASES

More than 5,500 cases were reported in the press throughout the four provinces with number of deaths ranging over 100.

2010 DENGUE FEVER CASES

News reports quoted Pakistan National Health Department confirming more than 5,050 cases. Province of Sindh reported 2.350, Punjab reported 1,885 and more than 200 cases in Khyber Pakhtoonkhaw province with 31 reported deaths.
http://www.upi.com/Health_News/2010/11/03/Dengue-fever

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DENGUE FEVER
CONTROLLING MEASURES FAILURE Pakistan has a ministry of Health at the federal level and each of the four provinces have health ministries at the provincial level. Health is a provincial matter solely Policy guidelines are not issued by the federal government, provinces enjoy autonomy in all matters concerning health.

A health worker fogging a residence for mosquito control

Overall health structure of the country is fragmented, with poor or no coordination among provinces
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CONTROLLING MEASURES
Provinces have rudimentary preventive health services structure. Major funding in preventive health is done through WHO and other world funding agencies. Lack of an effective policy development on dengue fever is one of the important causes culminating in failure of control. Vector control techniques mainly consist of fogging and spraying costly organophosphates and pyrethroid insecticides on ponds and other stagnant water sites.

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Failure to control dengue fever year after year

Pakistani health authorities at the federal and at the provincial levels are failing to control dengue fever outbreaks since 2006. Proper planning and application of surveillance and preventive measures are missing at the federal and provincial levels. Role of public health agencies is minimal in disease prevention, such platform is either ineffective or has not been developed.
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FAILURE
Lack of intra-provincial coordination results in a failure to develop consistent dengue control policies. Lack of effective data sharing among the provinces results in considerable ambiguity in assessing the burden of disease in the country. Data collection from rural areas is minimal or non-existing making it difficult to assess the exact prevalence of disease.
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Factors leading to increased numbers of Ae. aegypti larval habitats

Effective mosquito control is virtually non-existent and emphasis is being placed on ultra low-volume insecticide space sprays. Uncontrolled urbanization and concurrent population growth is resulting in sub-standard housing and inadequate water, sewer, and waste management systems.
Increased use of nonbiodegradable packaging compounded by non-existent or ineffective trash control services.
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FACTORS
Ongoing large scale import and export of used tires infested with Ae. aegypti larvae.
Increased air travel is resulting in constant exchange of dengue viruses and other pathogens. The reality of limited financial and human resources has resulted in a crisis mentality with emphasis on emergency control methods in epidemics rather than developing programs to prevent epidemic transmission.
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STRATEGIES FOR EFFECTIVE CONTROL

Integrated epidemiological and entomological surveillance Advocacy and implementation of intersectoral actions. Effective community participation Environmental management and addressing basic services. Patient care within and outside of the health system

Lloyd. S. Linda, 2003, Best practices for dengue control in the Americas, http://www.ehproject.org.

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STRATEGIES FOR EFFECTIVE CONTROL

Case reporting Critical analysis of the use and function of insecticides. Incorporation of the subject of dengue / health into formal education. Formal training of health professionals and workers both in the medical and social sciences. Emergency preparedness.
Lloyd. S. Linda, 2003, Best practices for dengue control in the Americas, 4/17/2012 http:www.ehproject.org

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DENGUE CONTROL STRATEGY

FOR LAHORE
Most immediate measure should be to divide the city into eight or ten different zones. Dengue patients should not be admitted and treated at a central location like Mayo hospital, services hospital, Gangaram hospital and other hospitals. This makes case identification difficult. Patients from their localities should be admitted in hospitals close to the area cordoned out.

DENGUE CONTROL STRATEGY (2)

Establish field hospitals in each zone and identify the number of cases in one cluster. Aedes Aegypti can only fly for 100 meters from the place of its breeding. Two or more cases from a single point indicate the proliferating point of the mosquito. Focus all insecticide spray on that particular locality along with instructions to the people to check for water gathering spots like air conditioners, plant pots and any other place where water can accumulate.

DENGUE CONTROL STRATEGY (3) The government should look for house-based industries located among residential areas which use water for carpet manufacturing and cleaning and industries like that. The owners of these industries often escape attention through bribing officials but they are the worst culprits.

DENGUE CONTROL STRATEGY (4)

Patients should be treated by medical doctors and nurses trained in dengue fever diagnosis and treatment. Hydration of patients is very essential and all patients should be kept properly hydrated. Medicines required in the initial cases are Paracetamol and Ponstan. No NSAIDs should be used as they invoke bleeding earlier than expected.

DENGUE CONTROL STRATEGY (5) Platelet count should be sought twice daily in all cases who are considered serious and thrombocytopenia of < cells/ L is found. Do not wait for lowering of platelets from 100,000 otherwise complications of DHF will set in and culminate in death.

DENGUE CONTROL STRATEGY (6) Seek community participation for dengue control. Seek interdepartmental and intradepartmental coordination like education department. School children can be involved in Have You Cleaned Your Backyard Today campaign by going to each house in the school vicinity.

DENGUE CONTROL STRATEGY (7) Finally, control dengue-scare, ask media to cut dengue-hype. If properly treated dengue is not fatal.
There is no point in being scared, keep yourself properly clothed to avoid being bitten by the mosquito.

FINAL WORD
An effective dengue control strategy should be prepared at the federal level with consultation of the all provincial health authorities. Intensify disease surveillance and case management. Community and school-based dengue preventive activities should be intensified. Inter and intra-sectoral approach through involvement of other departments in dengue control activities.
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 Training of doctors and nurses to improve management of dengue cases. Effective data management and data sharing between provinces. Strengthening capacity to undertake prevention and control of dengue and research related to epidemiology, disease and vector management and behavioral changes.

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References
Alam, M. (2011, January 2, 2011). 2010 saw stakeholders` complete failure to control dengue. Dawn. COM. Retrieved from http://www.dawn.com/2011/01/02/2010-saw-stakeholderscomplete-failure-to-control-dengue.html Balochistan (technical). (2011). Retrieved from http://www.balochistan.gov.pk/index.php?option=com_content& task=view&id=38&Itemid=67: http://www.balochistan.gov.pk
Islamic News Dengue fever. (2010). In 31 dead, 5000 infected by dengue. Retrieved July 8, 2011, from http://theislamicnews.com/pakistan-31-dead-5000-infected-by-dengue/

Llyod, L. S. (2003, February 2003). Best practices for dengue prevention and control in the Americas (technical). Retrieved from http://www.ehproject.org/PDF/Strategic_papers /SR7-BestPractice.pdf: http://www.ehproject.org 4/17/2012

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References
Llyod, L. S. (2003, February 2003). Best practices for dengue prevention and control in the Americas (technical). Retrieved from http://www.ehproject.org/PDF/Strategic_papers /SR7-BestPractice.pdf: http://www.ehproject.org Shepherd, S. M. & Cunha, B. A. (2009, October 23, 2009). Dengue Fever Clinical Presentation (technical). Retrieved from http://emedicine.medscape.com/article /215840-clinical#a0217: http://emedicine.medscape.com

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References
WHO Dengue/dengue hemorrhagic fever (technical). (2011). Retrieved from http://www.who.int/csr/disease/dengue/en/index.html: http://www.who.int

Wikipedia. (2011). In Punjab, Pakistan. Retrieved July 19, 2011, from http://en.wikipedia.org/wiki/Punjab,_Pakistan
Wikipedia, Sindh. (2011). In Wikipedia, Sindh. Retrieved 20 July, 2011, from http://en.wikipedia.org/wiki/Sindh Worldfactbook Pakistan. (n.d). In Pakistan. Retrieved 7 July, 2011, from https://www.cia.gov/library/publications/the-worldfactbook/geos/pk.html 4/17/2012

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