dengue

Dr.G.C.Sahu/ROHFW/GoI/Ahmedabad/[email protected]

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Pan AmericanHealthOrganization

Integrated Strategy

for Dengue Prevention and

Control

Integrated Strategy

for Dengue Prevention and

Control


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The Global Impact of Dengue VirusThe Global Impact of Dengue Virus

Dengue Fever & Dengue Fever & Dengue Hemorrhagic FeverDengue Hemorrhagic Fever

Endemic in more Endemic in more than 100 countriesthan 100 countries

50 million cases 50 million cases each yeareach year

Areas infested with Aedes aegypti

Areas with Aedes aegypti and dengue epidemic activity


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Examples of Emerging and Re-Emerging Infectious Disease: past 10 years A Fauci,

NIAID/NIH, 2005


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2

HIV

Dengue

H Papilloma v

Ebola

Hanta virus

West Nile virus

Tobacco

Malaria

Non-HIV tuberculosis Road accidents

3

55

6

Influenza

Polio

SARS

vCJD

Measles HBV + HCV

4

Log 10

RSV, Rota virus

7

Hospital infection

Suicide

Major and minor killers: global impact viewed on a ‘Richter’ (logarithmic) scale

Weiss & McMichael, 20041

Viruses

Infant/child ARI & diarrhoeal dis

10,000-fold difference in impact


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Reemergence of Dengue Environmental

FactorsClimate change

Alteration of ecosystems

Alteration ofGeographical distribution

of pathogensand vectors

Increase in Increase in vector-borne diseasesvector-borne diseasesDengue Yellow

Fever

Ideal Ideal conditions for conditions for Dengue:Dengue:Latitude: 350 north 350 southAltitude: 2,200 mTemperature: 15-40 °CRelative humidity:

high-moderate

Changes in transmission

Ecological changes

Socio-economic changes


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Sequential steps necessary for a mosquito to transmit an Sequential steps necessary for a mosquito to transmit an ArbovirusArbovirus

(1)(1) A female mosquito ingests an infectious blood meal and virus enters the mesenteron. A female mosquito ingests an infectious blood meal and virus enters the mesenteron.

(2)(2) Virus infects and multiplies in mesenteronal epithelial cells. Virus infects and multiplies in mesenteronal epithelial cells.

(3)(3) Virus is released across the basal membrane of the epithelial cells and replicates in other tissues. Virus is released across the basal membrane of the epithelial cells and replicates in other tissues.

(4)(4) Virus infects salivary glands. Virus infects salivary glands.

(5)(5) Virus is released from the epithelial cells of the salivary glands and is transmitted in the saliva during feeding. [From Monath Virus is released from the epithelial cells of the salivary glands and is transmitted in the saliva during feeding. [From Monath (1988, p 91).](1988, p 91).]


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ParadigmParadigm Large-scale factors are strongly acting upon the

issue of dengue.

The dimensions of Dengue go beyond the scope of

the health sector.

The health sector is not solely responsible for

dengue prevention and control.

To limit its effects, it is necessary to join the efforts

of all sectors (public, private, and communities).


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Population Growth

Reemergence of Dengue Socio-Economic Factors

Reemergence of Dengue Socio-Economic Factors

• Unprecedented population growth.

• Urbanization neither planned nor controlled.

• Increase in poverty.

• Inadequate environmental management.

• Unprecedented population growth.

• Urbanization neither planned nor controlled.

• Increase in poverty.

• Inadequate environmental management.

0

1,000,000,000

2,000,000,000

3,000,000,000

4,000,000,000

5,000,000,000

6,000,000,000

1830 1930 2000


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Reemergence of Dengue Uncontrolled Urbanization

Reemergence of Dengue Uncontrolled Urbanization

• Rapid unplanned urbanization.

• Informal settlements proliferate due to poverty.

• Absence of basic services: electricity, running water, sewer systems, garbage collection.

• High population density.

• Rapid unplanned urbanization.

• Informal settlements proliferate due to poverty.

• Absence of basic services: electricity, running water, sewer systems, garbage collection.

• High population density.

Sources: Gubler, 1998; PAHO, 1997.


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Pan AmericanHealthOrganization Source: Vilas, 1995.


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Reemergence of Dengue Inadequate Environmental Management

Reemergence of Dengue Inadequate Environmental Management

• Insufficient waste collection and management.

• Non-biodegradable containers.

• Improper tire disposal.

• Insufficient waste collection and management.

• Non-biodegradable containers.

• Improper tire disposal.

• Insufficient and inadequate water distribution.

• Increased number of water storage containers.

• Inadequate septic system conditions.

• Insufficient and inadequate water distribution.

• Increased number of water storage containers.

• Inadequate septic system conditions.

Increase in breeding sites for the vector


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Reemergence of Dengue Population Movements

Reemergence of Dengue Population Movements

• MigrationMigration

• International International tourismtourism

• MigrationMigration

• International International tourismtourism

• More than 750 million people annually cross international borders.

• Increase in rural migration into urban areas.

• 1.4 billion international travelers in 1999.

• 697 million international tourist arrivals in 2000 and 715 million in 2002 (up 3.1%).

• More than 750 million people annually cross international borders.

• Increase in rural migration into urban areas.

• 1.4 billion international travelers in 1999.

• 697 million international tourist arrivals in 2000 and 715 million in 2002 (up 3.1%).

Source: OMT data.

Traffic of microorganisms


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— — continued and frequently unplanned urbanization;continued and frequently unplanned urbanization;— — inadequate municipal services such as water supply and solid waste inadequate municipal services such as water supply and solid waste disposal;disposal;— — the escalating rate and geographical range of virus transmission brought the escalating rate and geographical range of virus transmission brought aboutaboutby intercontinental travel;by intercontinental travel;— — the circulation of multiple strains and serotypes in one area;the circulation of multiple strains and serotypes in one area;— — the adaptability of the vectors (Aedes aegypti and, to a lesser extent, Aedesthe adaptability of the vectors (Aedes aegypti and, to a lesser extent, Aedesalbopictus mosquitoes);albopictus mosquitoes);— — the unrestrained production and use of non-biodegradable food and drinkthe unrestrained production and use of non-biodegradable food and drinkpackaging, and drums and other water storage vessels that often becomepackaging, and drums and other water storage vessels that often becomelarval habitats;larval habitats;— — the importation of used tyres by developing countries at risk for dengue; the importation of used tyres by developing countries at risk for dengue; andand— — non-existent, inconsistent, or fragmented national programmesnon-existent, inconsistent, or fragmented national programmes

The reasons for dengue’s emergence as a major global health problem have beenThe reasons for dengue’s emergence as a major global health problem have beenwell documented and include:well documented and include:


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Receding – then Resurging?Receding – then Resurging?

1950s-60s: Infectious diseases apparently receding in developed countries

• Antibiotics and vaccines

• Pesticides to control mosquitoes

• Improved surveillance and control measures – internationally coordinated

Early 1970s: Authorities proclaimed end of infectious disease era. Premature!

• >30 new or newly-discovered human IDs over past 30 yrs

• We overlooked the ecological/evolutionary dimensions

1950s-60s: Infectious diseases apparently receding in developed countries

• Antibiotics and vaccines

• Pesticides to control mosquitoes

• Improved surveillance and control measures – internationally coordinated

Early 1970s: Authorities proclaimed end of infectious disease era. Premature!

• >30 new or newly-discovered human IDs over past 30 yrs

• We overlooked the ecological/evolutionary dimensions


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• Microbial adaptation and changeMicrobial adaptation and change

• Human susceptibility to infection Human susceptibility to infection ageing, HIV, IV drugs, transplantation, transfusionageing, HIV, IV drugs, transplantation, transfusion

• Population growth and densityPopulation growth and density

• Urbanization, crowding – social and sexual relationsUrbanization, crowding – social and sexual relations

• Globalization of travel and trade Globalization of travel and trade

•Misuse of antibiotics (humans & domestic animals)Misuse of antibiotics (humans & domestic animals)

• Changes to ecosystems (deforestation, biodiversity loss) Changes to ecosystems (deforestation, biodiversity loss)

• Global climate changeGlobal climate change

Factors in Emerging/Re-emerging Infectious Diseases


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Integrated Strategy Integrated Strategy Integrated Strategy Integrated Strategy

SocialSocialCommunicationCommunication

SocialSocialCommunicationCommunication

EpidemiologicalEpidemiologicalSurveillanceSurveillance

EpidemiologicalEpidemiologicalSurveillanceSurveillance

EntomologyEntomologyEntomologyEntomology

Patient CarePatient CarePatient CarePatient CareLaboratoryLaboratoryLaboratoryLaboratory

Integrated Integrated StrategyStrategy

Integrated Integrated StrategyStrategy

ComponentsComponentsComponentsComponents


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Social Communication • Strengthen the effectiveness and sustainability of

national strategies through social communication and community participation.

Epidemiologic Surveillance• Ensure that public health policies have a

multisectorial, intersectorial, and interdisciplinary focus.

Entomology• Establish a system of entomologic surveillance

for integrated vector management (intersectoral, involving the education, environment, academic, public-works, local/regional government, NGO and private sector).

Social Communication • Strengthen the effectiveness and sustainability of

national strategies through social communication and community participation.

Epidemiologic Surveillance• Ensure that public health policies have a

multisectorial, intersectorial, and interdisciplinary focus.

Entomology• Establish a system of entomologic surveillance

for integrated vector management (intersectoral, involving the education, environment, academic, public-works, local/regional government, NGO and private sector).

Expected Results


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Patient Care• Ensuring that health workers are trained in the

diagnosis and treatment of the disease, that the network of institutions be prepared to treat the ill, and that the community is well informed as to warning signs.

Laboratory• Ensuring that the surveillance system has a

laboratory or an integrated network of laboratories available, that is capable of generating reliable and timely information for clinical diagnosis and the design of interventions.

Patient Care• Ensuring that health workers are trained in the

diagnosis and treatment of the disease, that the network of institutions be prepared to treat the ill, and that the community is well informed as to warning signs.

Laboratory• Ensuring that the surveillance system has a

laboratory or an integrated network of laboratories available, that is capable of generating reliable and timely information for clinical diagnosis and the design of interventions.

Expected Results cont.


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Promote the methodology of the integrated strategy, strengthening state/ National Programs.

Incorporate the Dengue Task Force into vector borne disease control programmes.

Implement the COMBI Plan: Communication for Behavioral Impact.

Promote and implement intersectoral activities between the Health, Environment, Education, and other sectors.

Promote the methodology of the integrated strategy, strengthening state/ National Programs.

Incorporate the Dengue Task Force into vector borne disease control programmes.

Implement the COMBI Plan: Communication for Behavioral Impact.

Promote and implement intersectoral activities between the Health, Environment, Education, and other sectors.

Where are we going?


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UNDIFFERENTIATED FEBRILE ILLNESS * With Rash. * With Resp symp.

* Both * With none.

CLASSICAL DF

BREAKBONE FEVER

DHF

DSS


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UNDIFFERENTIATED FEBRILE ILLNESS.

CLASSICAL DF

DHF

DSS


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There are two general pathways through which hyperendemicity may increase the probability of DHF:

First, as we see on the left, in a situation of hyperendemicity, where several virus serotypes are circulating at high levels, the probability of virulent strains occurring is increased, which increases the probability of DHF.

In addition, as is presented on the right, in a situation of hyperendemic transmission, the probability that an individual will experience a secondary infection is increased, which increases the likelihood of immune enhancement and DHF.

There are two general pathways through which hyperendemicity may increase the probability of DHF:

First, as we see on the left, in a situation of hyperendemicity, where several virus serotypes are circulating at high levels, the probability of virulent strains occurring is increased, which increases the probability of DHF.

In addition, as is presented on the right, in a situation of hyperendemic transmission, the probability that an individual will experience a secondary infection is increased, which increases the likelihood of immune enhancement and DHF.


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THE GLOBAL STRATEGY FOR PREVENTION AND CONTROL OF DF/DHFTHE GLOBAL STRATEGY FOR PREVENTION AND CONTROL OF DF/DHF

Selective, integrated mosquito control with community and inter sectoral participation, in Selective, integrated mosquito control with community and inter sectoral participation, in which control is directed towards geographical areas at highest risk of transmission, which control is directed towards geographical areas at highest risk of transmission, integrating all appropriate methods in the most cost-effective and economical manner;integrating all appropriate methods in the most cost-effective and economical manner;

Active disease surveillance based on strong health information systems, involving Active disease surveillance based on strong health information systems, involving clinical and laboratory-based dengue surveillance for early detection of epidemics and clinical and laboratory-based dengue surveillance for early detection of epidemics and vector surveillance for monitoring and evaluation of control programmes;vector surveillance for monitoring and evaluation of control programmes;

Emergency preparedness, necessitating development of emergency and contingency Emergency preparedness, necessitating development of emergency and contingency plans, including education of the medical community, hospitalization plans, case plans, including education of the medical community, hospitalization plans, case management, and emergency vector control;management, and emergency vector control;

Capacity building and training, in surveillance, laboratory diagnosis, case management, Capacity building and training, in surveillance, laboratory diagnosis, case management, and vector control at professional, supervisory, technical, and field levels; andand vector control at professional, supervisory, technical, and field levels; and

Vector control research, including studies on vector biology and control, disease Vector control research, including studies on vector biology and control, disease relationships, design and management of control programmes, including social and relationships, design and management of control programmes, including social and economic approaches, and cost–benefit analyses.economic approaches, and cost–benefit analyses.


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PERSONAL PROPHYLACTIC MEASURES-PERSONAL PROPHYLACTIC MEASURES-PREVENTION OF MOSQUITO BITESPREVENTION OF MOSQUITO BITES

PERSONAL PROPHYLACTIC MEASURES-PERSONAL PROPHYLACTIC MEASURES-PREVENTION OF MOSQUITO BITESPREVENTION OF MOSQUITO BITES

WEAR FULL SLEEVED CLOTHS, LONG DRESSES THAT COVER WEAR FULL SLEEVED CLOTHS, LONG DRESSES THAT COVER THE ARMS AND LEGS DURING THE OUTBREAKSTHE ARMS AND LEGS DURING THE OUTBREAKS

USE INSECT REPELLENTS WHILE SLEEPING AT NIGHTUSE INSECT REPELLENTS WHILE SLEEPING AT NIGHT

TAKE ADDITIONAL CARE OF CHILDREN AND ELDERLY.TAKE ADDITIONAL CARE OF CHILDREN AND ELDERLY.

USE MOSQUITO COILS/ELECTRIC VAPOUR MATS.USE MOSQUITO COILS/ELECTRIC VAPOUR MATS.

USE MOSQUITO NETS ESPECIALLY TO PROTECT BABIES AND USE MOSQUITO NETS ESPECIALLY TO PROTECT BABIES AND OLD PEOPLE.OLD PEOPLE.

KEEP PATIENTS PROTECTED FROM MOSQUITO BITES IN KEEP PATIENTS PROTECTED FROM MOSQUITO BITES IN ACUTE PHASE WHICH WILL REDUCE NO.OF INFECTIVE ACUTE PHASE WHICH WILL REDUCE NO.OF INFECTIVE MOSQUITO POPULATION.MOSQUITO POPULATION.

WEAR FULL SLEEVED CLOTHS, LONG DRESSES THAT COVER WEAR FULL SLEEVED CLOTHS, LONG DRESSES THAT COVER THE ARMS AND LEGS DURING THE OUTBREAKSTHE ARMS AND LEGS DURING THE OUTBREAKS

USE INSECT REPELLENTS WHILE SLEEPING AT NIGHTUSE INSECT REPELLENTS WHILE SLEEPING AT NIGHT

TAKE ADDITIONAL CARE OF CHILDREN AND ELDERLY.TAKE ADDITIONAL CARE OF CHILDREN AND ELDERLY.

USE MOSQUITO COILS/ELECTRIC VAPOUR MATS.USE MOSQUITO COILS/ELECTRIC VAPOUR MATS.

USE MOSQUITO NETS ESPECIALLY TO PROTECT BABIES AND USE MOSQUITO NETS ESPECIALLY TO PROTECT BABIES AND OLD PEOPLE.OLD PEOPLE.

KEEP PATIENTS PROTECTED FROM MOSQUITO BITES IN KEEP PATIENTS PROTECTED FROM MOSQUITO BITES IN ACUTE PHASE WHICH WILL REDUCE NO.OF INFECTIVE ACUTE PHASE WHICH WILL REDUCE NO.OF INFECTIVE MOSQUITO POPULATION.MOSQUITO POPULATION.


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PREVENTION OF MULTIPLICATION OF MOSQUITOPREVENTION OF MULTIPLICATION OF MOSQUITO

DRAIN WATER FROM COOLERS.TANKS,BARRELS,DRUMS AND DRAIN WATER FROM COOLERS.TANKS,BARRELS,DRUMS AND BUCKETS ETCBUCKETS ETC

COOLERS SHOULD BE EMPTIED OF WATER WHEN NOT IN USECOOLERS SHOULD BE EMPTIED OF WATER WHEN NOT IN USE

UNUSED WATER CONTAINING OBJECTS/HOLDING OBJECTS SHOULD UNUSED WATER CONTAINING OBJECTS/HOLDING OBJECTS SHOULD BE REMOVED FROM HOUSE HOLDS.BE REMOVED FROM HOUSE HOLDS.

WATER SHOULD BE REMOVED FROM REFRIGERATER DRIP OPANS WATER SHOULD BE REMOVED FROM REFRIGERATER DRIP OPANS EVERY OTHER DAY.EVERY OTHER DAY.

ALL USABLE AND STORED WATER COINTAINERS SHOULD BE KEPT ALL USABLE AND STORED WATER COINTAINERS SHOULD BE KEPT KEPT COVERED ALLTHE TIME.KEPT COVERED ALLTHE TIME.

CLEAN UP THE TERRACE, DISCARD SOLID WASTE FROM THECLEAN UP THE TERRACE, DISCARD SOLID WASTE FROM THE SORROUNDINGS.SORROUNDINGS.

DRAIN WATER FROM COOLERS.TANKS,BARRELS,DRUMS AND DRAIN WATER FROM COOLERS.TANKS,BARRELS,DRUMS AND BUCKETS ETCBUCKETS ETC

COOLERS SHOULD BE EMPTIED OF WATER WHEN NOT IN USECOOLERS SHOULD BE EMPTIED OF WATER WHEN NOT IN USE

UNUSED WATER CONTAINING OBJECTS/HOLDING OBJECTS SHOULD UNUSED WATER CONTAINING OBJECTS/HOLDING OBJECTS SHOULD BE REMOVED FROM HOUSE HOLDS.BE REMOVED FROM HOUSE HOLDS.

WATER SHOULD BE REMOVED FROM REFRIGERATER DRIP OPANS WATER SHOULD BE REMOVED FROM REFRIGERATER DRIP OPANS EVERY OTHER DAY.EVERY OTHER DAY.

ALL USABLE AND STORED WATER COINTAINERS SHOULD BE KEPT ALL USABLE AND STORED WATER COINTAINERS SHOULD BE KEPT KEPT COVERED ALLTHE TIME.KEPT COVERED ALLTHE TIME.

CLEAN UP THE TERRACE, DISCARD SOLID WASTE FROM THECLEAN UP THE TERRACE, DISCARD SOLID WASTE FROM THE SORROUNDINGS.SORROUNDINGS.


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TAKE LONG TERM MEASURESTAKE LONG TERM MEASURES

INITIATE RECOMMENDED VECTOR CONTROL MEASURESINITIATE RECOMMENDED VECTOR CONTROL MEASURES

IDENTIFY AND MAP OUT THE HIGH RISK AREAS FORIDENTIFY AND MAP OUT THE HIGH RISK AREAS FOR PRIORITISATION OF AREA SPECIFIC STRATEGIES.PRIORITISATION OF AREA SPECIFIC STRATEGIES.

PATIENTS SHOULD BE TREATED IN NEARBY HEALTH PATIENTS SHOULD BE TREATED IN NEARBY HEALTH /HOSPITALS WHERE FACILITIES OF PLATELET COUNT AND /HOSPITALS WHERE FACILITIES OF PLATELET COUNT AND HAEMATOCRIT VALUE ESTIMATION IS AVAILABLE.HAEMATOCRIT VALUE ESTIMATION IS AVAILABLE.

PANICKY MEASURES LIKE ISOLATION OF PATIENTS ANDPANICKY MEASURES LIKE ISOLATION OF PATIENTS AND DISINFECTION OF SECRETIONS ARE NOT REQUIRED ASDISINFECTION OF SECRETIONS ARE NOT REQUIRED AS DF/DHF VIRUS IS NOT TRANSMITTED FROM PERSONS TODF/DHF VIRUS IS NOT TRANSMITTED FROM PERSONS TO PERSONSPERSONS

EFFECTIVE HEALTH EDUCATION CAMPAIGNS AND EFFECTIVE HEALTH EDUCATION CAMPAIGNS AND FIELD SUPERVISIONFIELD SUPERVISION

INITIATE RECOMMENDED VECTOR CONTROL MEASURESINITIATE RECOMMENDED VECTOR CONTROL MEASURES

IDENTIFY AND MAP OUT THE HIGH RISK AREAS FORIDENTIFY AND MAP OUT THE HIGH RISK AREAS FOR PRIORITISATION OF AREA SPECIFIC STRATEGIES.PRIORITISATION OF AREA SPECIFIC STRATEGIES.

PATIENTS SHOULD BE TREATED IN NEARBY HEALTH PATIENTS SHOULD BE TREATED IN NEARBY HEALTH /HOSPITALS WHERE FACILITIES OF PLATELET COUNT AND /HOSPITALS WHERE FACILITIES OF PLATELET COUNT AND HAEMATOCRIT VALUE ESTIMATION IS AVAILABLE.HAEMATOCRIT VALUE ESTIMATION IS AVAILABLE.

PANICKY MEASURES LIKE ISOLATION OF PATIENTS ANDPANICKY MEASURES LIKE ISOLATION OF PATIENTS AND DISINFECTION OF SECRETIONS ARE NOT REQUIRED ASDISINFECTION OF SECRETIONS ARE NOT REQUIRED AS DF/DHF VIRUS IS NOT TRANSMITTED FROM PERSONS TODF/DHF VIRUS IS NOT TRANSMITTED FROM PERSONS TO PERSONSPERSONS

EFFECTIVE HEALTH EDUCATION CAMPAIGNS AND EFFECTIVE HEALTH EDUCATION CAMPAIGNS AND FIELD SUPERVISIONFIELD SUPERVISION


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AEDES CONTROL METHODSAEDES CONTROL METHODS Environmental sanitation measures to reduce mosquito breeding sites, such Environmental sanitation measures to reduce mosquito breeding sites, such as the physical management of water containers (e.g. mosquito-proof covers for as the physical management of water containers (e.g. mosquito-proof covers for water storage containers, polystyrene beads in water tanks), better designed water storage containers, polystyrene beads in water tanks), better designed and reliable water supplies, and recycling of solid waste such as discarded and reliable water supplies, and recycling of solid waste such as discarded tyres, bottles, and cans.tyres, bottles, and cans.

Biological methods (e.g. fish, copepods – small crustaceans that feed on Biological methods (e.g. fish, copepods – small crustaceans that feed on mosquito larvae) to kill or reduce larval mosquito populations in water mosquito larvae) to kill or reduce larval mosquito populations in water containers.containers.

Chemical methods against the mosquito’s aquatic stages for use in water Chemical methods against the mosquito’s aquatic stages for use in water containers (e.g. temephos sand granules).containers (e.g. temephos sand granules).

Chemical methods directed against adult mosquitoes, such as insecticide Chemical methods directed against adult mosquitoes, such as insecticide space sprays or residual applications.space sprays or residual applications.

Personal protection through use of repellents, vaporizers, mosquito coils, Personal protection through use of repellents, vaporizers, mosquito coils, and insecticide-treated screens, curtains and bednets (for daytime use against and insecticide-treated screens, curtains and bednets (for daytime use against Aedes).Aedes).


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URBAN BREEDINGSITES

URBAN BREEDINGSITES


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PROTECTION OF ELDERLY AND CHILDREN IS OF VITAL IMPORTANCE

PROTECTION OF ELDERLY AND CHILDREN IS OF VITAL IMPORTANCE


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ELIMINATION ELIMINATION OF OF

BREEDING BREEDING SITES---SITES---

THE INITIATIVE THE INITIATIVE MOSTLY LIES MOSTLY LIES

WITHWITHINDIVIDUALSINDIVIDUALS


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……..And..And……..And..And


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GOVT EFFORTSGOVT EFFORTS COUPLED WITH COUPLED WITH

THE THE PUBLIC PUBLIC PARTICIPATIONPARTICIPATION……

. IS THE . IS THE KEYKEY. .

………….. THANKS.. THANKS………….. THANKS.. THANKS

AcknowledgementsAcknowledgements::• WHOWHO• CDCCDC• NVBDCPNVBDCP• NICDNICD• JD(m&f),G.nagarJD(m&f),G.nagar• Dr.Kapse,SuratDr.Kapse,Surat

AcknowledgementsAcknowledgements::• WHOWHO• CDCCDC• NVBDCPNVBDCP• NICDNICD• JD(m&f),G.nagarJD(m&f),G.nagar• Dr.Kapse,SuratDr.Kapse,Surat


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Knowing is not enough; we must apply.Knowing is not enough; we must apply.Willing is not enough; we must do.Willing is not enough; we must do.

(Goethe)(Goethe)

dengue

Health & Medicine

dengue prevention

dengue epidemic

growthreemergence of

dimensions of dengue

issue of dengue

rota virus

inadequate water distribution

water supply