dengue part 2- emerging public health problem

Dengue : Emerging Public Health Problem

PRESENTER : Dr Kaushik K NGUIDE : Dr Jayanth Kumar

Date : 19-2-2014

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DENGUE : AN EMERGING HEALTH PROBLEM

PART

2 2

Previous presentation

• Introduction

• Dengue epidemiology

• Problem statement - World

• Problem statement - India

• Dengue case classification

• Burden of disease

• Transmission

• Clinical management, laboratory diagnosis and delivery of clinical services

• Case management

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Contents Of Today’s Presentation

• Long term action plan for Prevention and control of Dengue (2007-2010)

• Mid Term Plan for Prevention & Control of Dengue (2011-2013)

• Dengue emergency outbreak response / containment of dengue epidemic

• Dengue vaccine• Reasons/underlying causes for the worsening

Dengue situation• References

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PURPOSE OF THE LONG TERM ACTION PLAN

• Vellore (1956) - Dengue first reported

• 1963-1964 - initial epidemic of dengue fever - Eastern Coast of India

• Spread northwards to reach Delhi in 1967 and Kanpur in 1968.

• Simultaneously - southern part of the country and gradually the whole country involved

• 1991- 2006 – 31 out of 35 states dengue cases reported

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PURPOSE OF THE LONG TERM ACTION PLAN

• Dengue transmission has shown substantial increase over years

• Government of India has Developed a Long Term Action Plan for Prevention and Control of Dengue in the country and sent to the State(s) on January 2007 for implementation.

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LONG TERM ACTION PLAN FOR PREVENTION AND CONTROL OF

DENGUE

• Dengue Fever & Dengue hemorrhagic fever – ever increasing endemicity in India.

• Both Dengue and Chikungunya are Vector Borne disease and are caused by viruses carried by same Mosquito [Aedes aegypti].

• Dengue/ DHF is being managed as a part of National Vector Disease Control Programme (NVBCDP).

• Chikungunya fever has occurred in epidemic form in the year of 2006 after about 30 years.

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DENGUE• Chikungunya was not a part of the National Vector

Borne Disease Control but the strategies for its prevention and control is similar to that of Dengue prevention and control strategies as both the disease are caused by the same Vector (Mosquito) i.e. Aedes aegypti.

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DENGUE• The long term strategies for prevention and

control of DF/DHF/DSS and Chikungunya in India is three-pronged : (2007-2010)

1.Early case reporting & management

2.Integrated Vector Management

3.Supporting Interventions

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EARLY CASE REPORTING & MANAGEMENT

• Early case reporting – – fever alert surveillance

– Sentinel surveillance sites with laboratory support

– Strengthening of referral services

– Involvement of Private Sector in sentinel surveillance

• Case management – • Case management

• Epidemic preparedness & Rapid response10

INTEGRATED VECTOR MANAGEMENT

• Entomological surveillance including larval surveys

• Anti - larval measures • Source reduction

• Chemical larvicide

• Larvivorous fish

• Environmental management

• Anti – adult measures • Indoor space spraying

• Fogging

• Personal protection measures

• Protective clothing

• ITBN & repellents

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SUPPORTING INTERVENTIONS

• Human resource development through capacity building

• Behavioral change communication

• Inter – sectoral collaboration

• Supervision & monitoring

• Coordination committees

• Legislative support

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FEVER ALERT SURVEILLANCE

– Early capture of suspected Dengue outbreak

– ASHA, Anganwadi worker (AWW) & Fever treatment depot (FTD) trained – indentifying & reporting

– Fever syndrome reported to District Vector Borne Disease Control Officer (respective PHC/CHC)

– Information on disease shared • District Health Mission

• Rogi Kalyan Samiti

• Village Health & Sanitation Committee

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ESTABLISHMENT OF SENTINEL SURVEILLANCE

– Epidemics at peak transmission before recognition & confirmation of Dengue – Dengue surveillance needs to be Proactive

– Programme employs proactive surveillance to predict Dengue outbreak

– Serological/ virological surveillance important – monitor transmission during inter – epidemic periods

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• Network of sentinel surveillance hospital – Regional & District levels

– One sentinel surveillance site – each district in India

– 110 sentinel sites in the country

– 50,000 contingency grant

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• Function of Sentinel Surveillance Hospital – Blood sample collection

–Maintain line listing of Dengue positive case

– Capacity building of PHC/CHC

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DENGUE CASE CONFIRMED & THEN WHAT?

• Dengue confirmed by serological test – IgM MAC Elisa kits (NIV Pune)

• District Vector Borne Disease Control Officer intimated

• He/she initiate remedial measure – 24 hours

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INVOLVEMENT OF PRIVATE SECTOR IN SENTINEL SURVEILLANCE

• Private health centers – clinics, nursing homes in endemic district – sentinel surveillance site

• Avail existing lab facility from public sector

• Line listing

• Physician / MO – training programme

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STRENGTHENING OF REFERRAL SERVICES

• PCR, Virus isolation – 13 apex referral lab

• Capacity building

• Have advanced diagnostic facilities

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APEX LABS

National Institute of Virology, Pune.

National Institute of Communicable Diseases, Delhi.

(National Institute of Mental Health & Neuro-Sciences, Bangalore.

Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow.

Post- Graduate Institute of Medical Sciences, Chandigarh.

All India Institute of Medical Sciences, Delhi.

ICMR Virus Unit, Kolkata

Regional Medical Research Centre (ICMR), Dibrugarh, Assam.

King’s Institute of Preventive Medicine, Chennai.

Institute of Preventive Medicine, Hyderabad.

B J Medical College, Ahmedabad.

State Virology Institute, Allappuzha, Kerala

DRDE, Gwalior, Madhya Pradesh

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INTEGRATED VECTOR MANAGEMENT

• Prevention and reduction in disease burden – control of mosquito vectors

• Activities to control transmission – target vector in the habitats of its immature 7 adult stages in households and immediate vicinity

• Integrated vector management – strategic approach to control vector - promoted by WHO

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INTEGRATED VECTOR CONTROL• Key elements –

1. Advocacy, social mobilization & legislation

2. Collaboration within the health sector and with other sectors

3. Integrated approach to disease control

4. Evidence based decision making

5. Capacity building

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METHODS OF VECTOR CONTROL• Environmental management – 1. Environmental modification-piped water supply 2. Environmental manipulation-street cleansing,

recycling, planning of construction• Chemical control : larvicides1. Target area2. Insecticides3. Application procedure4. Treatment cycle

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METHODS OF VECTOR CONTROL

• Chemical control : Adulticides

1.Residual treatment – space sprays and their application

2.Target area

3.Insecticides

4.Application procedure

5.Treatment cycle

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• Monitoring of insecticide susceptibility –

1.Insecticide resistant Aedes aegypticus – organophosphates, pyrethroids, carbamates

2.Routine monitoring of insecticide susceptibility

3.WHO kits for testing the susceptibility of adult and larval mosquitoes – standard method

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• Biological control –

1.Fish

2.Predatory copepods – mesocyclops – vietnam

• Improved tools for vector control –

1.Insecticide treated materials

2.Lethal ovitraps

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DENGUE SURVEILLANCE

• Disease surveillance

• Entomological surveillance

• Monitoring environmental risk

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DENGUE SURVEILLANCE

• 3 components of dengue surveillance – Disease surveillance – • Critical component • Provide information necessary for risk assessment,

epidemic response & program evaluation• Utilize both passive & active data collection processes• Event based surveillance• Case based surveillance• Active and passive surveillance• Sentinel surveillance

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DENGUE SURVEILLANCE

– Entomological surveillance • Larval & pupal surveillance

• Pupal/demographic surveys

• Passive collection of larvae/pupae

• Adult mosquito population survey

• Landing collections

• Resting collections

• Trap collections

• Frequency of sampling

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DENGUE SURVEILLANCE

– Monitoring environmental & social risks • Various factors have been determined to influence a

community’s vulnerability to dengue epidemics• Distribution and density of population• Settlement characteristics• Conditions of land tenure• Housing styles• Education• Socio economic status• Water supply services• Knowledge of domestic water storage practices• Solid waste disposal services

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SUPPORTING INTERVENTIONS

• Human resource development through capacity building

• Behaviour change communication

• Inter sectoral collaboration

• Operational reasearch

• Supervision, monitoring & evaluation

• Geographical information system

• Legislation support32

MID TERM PLAN FOR PREVENTION & CONTROL OF DENGUE

• Purpose of this document-– Intensity of dengue transmission shows substantial

increase over the years in spite Of Long Term Action Plan

– To revisit the current strategies of Long Term Action Plan

– Develop a programmatic & comprehensive Mid Term Plan for prevention and control of Dengue in India

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• Objectives – To reduce the incidence of dengue to bring down

the disease burden

– To reduce the case fatality rate due to dengue

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• Elements – Disease & vector surveillance

– Case management

– Laboratory diagnosis

– Vector management

– Outbreak response

– Capacity building

– Behavior change communication

– Inter sectoral co ordination

– Monitoring & supervision36


• Implementation period – 2011 to 2013

• Surveillance concept – –Monitor trends in distribution & spread of disease

– Early case detection for timely intervention

–Measure disease burden

– Assess social & economic impact

– Evaluate effectiveness of prevention & control

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MID TERM PLAN FOR PREVENTION & CONTROL OF DENGUE - LARVAL

SURVEILLANCE

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MID TERM PLAN FOR PREVENTION & CONTROL OF DENGUE –

ENVIRONMENTAL MANAGEMENT

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DENGUE VACCINE

OVERVIEW

• Significant progress made.

• Researchers, funding agencies, policy makers and vaccine manufacturers – attracted by unchecked spread of dengue worldwide

• Public private partnerships facilitated the process of product development

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DENGUE VACCINE

PRODUCT & ITS DEVELOPMENT

• Primary immunological mechanism – virus neutralization through circulating anti bodies

• Vaccine – needs to protect against all 4 serotypes of virus strain

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DENGUE VACCINE

• 4 types of vaccines under development – – Live attenuated vaccine

– Chimeric live attenuated vaccine

– Inactivated or sub unit vaccine

– Nucleic acid based vaccine

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LIVE ATTENUATED - DENGUE VACCINE

• Induce durable humoral & cellular immune response

• Pr M & E (structural genes) of each of 4 dengue virus inserted into yellow fever 17D vaccine

• 2 doses required for high rates of tetravalent neutralizing antibodies

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CHALLENGES FOR LIVE ATTENUATED VACCINE• Major problem - Need to develop not one but

four immunogen

• Interefence between 4 vaccine virus must be avoided

• Lack of validated correlate of protection – mechanism of protective immunity not fully understood

• Antibody dependant immune enhancement - DHF

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VACCINE UTILIZATION

• Cost effectiveness, outcome of financial & operational analysis

• Infants – need to carry out vaccination on a schedule compatible with others

• Research to be continued

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INDIA UPDATE ON DENGUE VACCINE• Indian scientists have achieved an important

breakthrough in their efforts to develop a vaccine to prevent the deadly dengue. Supported by the Department of Biotechnology under the Ministry of Science & Technology, scientists at International Centre for Genetic Engineering and Biotechnology (ICGEB) in New Delhi have developed a non-infectious dengue vaccine from yeast.

India today, New Delhi, September 20, 2013

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INDIA UPDATE ON DENGUE VACCINE• "Search for a dengue vaccine has been going on

across the world for past several decades. We, at our centre, started experiments seven years ago. The new technology we have used, i.e. recombinant DNA technology, to develop the dengue vaccine is a breakthrough," said Dr Navin Khanna, group leader of Recombinant Gene Products Group, ICGEB.

– PUBLISHED: 00:01 GMT, 20 September 2013 | UPDATED: 00:01 GMT, 20 September 2013

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REASONS FOR RE EMERGENCE OF DENGUE FEVER

• Demographic & Societal Changes – – Unplanned & uncontrolled urbanization

– Population growth

– Restraints on civic amenities – water supply, solid waste disposal

– Increase in breeding potential of vector species

– Improved communication facilities- rapid transporatation – establish in rural area

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• Effective mosquito control based on source reduction – non existent in endemic areas

• Solid waste management – – Increase in use of plastics, paper cups, tyres

– Facilitate breeding

– Insufficient solid waste collection & management

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• Increased population management –

• Significant increase in plantations – – Increased demand for rubber

– Rubber plantation increased

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REASONS FOR RE EMERGENCE OF DENGUE FEVER• Uncontrolled urbanization

• Inadequate environment management

• Population movements• Growth in global air traffic

• Increase in maritime passenger and cargo traffic

• Climate change

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REASONS FOR RE EMERGENCE

• Unrestrained production and use of non biodegradable food and drink packaging like plastic, tetra packs

• Unmonitored use and abandoning of containers, drums (construction site)

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RE EMERGENCE OF DENGUE: INADEQUATE ENVIRONMENTAL MANAGEMENT

• Inefficient waste collection and management

• Non biodegradable containers

• Improper tyre disposal

• Insufficient and inadequate water distribution

• Inadequate management of water storage & disposal

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RE EMERGENCE OF DENGUE: POPULATION MOVEMENTS• Migration : > 750 million people annually

cross international borders

• Increase in rural migration to urban areas

• Ever increasing international travelers across the globe

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GROWTH IN GLOBAL AIR TRAFFIC

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INCREASE IN MARITIME PASSENGER & CARGO TRAFFIC

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CLIMATE CHANGE

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CLIMATE CHANGE

• Viral incubation in mosquito quickens

• Shorten mosquito breeding cycle

• Increase mosquito feeding frequency

• More efficient transmission of dengue/chikungunya virus from mosquito to man

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OBSTACLE IN AEDES CONTROL

• Community participation in dengue prevention & control is limited.

• Local health services are politically driven now and are not sufficiently established

• Water supply and solid waste management are limited in high risk areas

• Lack of inter sectoral co ordination

• Insufficient operational research on individual and community based strategies

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A FEW SUGGESTIONS – MAINTENANCE OF WATER SUPPLY SYSTEMS

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A FEW SUGGESTIONS – ESTABLISHING PROPER DRAINAGE SYSTEM

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BBMP and BWSSB should formulate an integrated approach programme for water supply, sewerage, drainage and waste management so as to keep the environment free from the risks of vector breeding/growth

Storm water drains should be invariably be covered and be maintained by the way ofRegular cleaning, de-silting etc to prevent stagnation of water

Large storm water drains should be suitably channeled and cleaned regularly to facilitate adequate velocity for flow of waste water

A FEW SUGGESTIONS – CONSTRUCTION SITE

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Water stagnation in construction areas should be cleared

Clearance of garbage in vacant sites at proper intervals of time to avoid breeding of Aedes mosquito

A FEW SUGGESTIONS – MODEL CIVIC BYELAWS

63Standard design for lids for over head tanks and cisterns

CONCLUSION

• Dengue virus has become a fatal disease

• Small creatures (mosquito) is posing a big threat of late

• Re emergence and spread of dengue is a serious issue

• Role of vaccine is still a question though many advancements in vaccine manufacture is promising

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REFERENCES

• Dengue guidelines for diagnosis, treatment, prevention and control, a joint publication of the world health organization (WHO) and the special programme for research and training in tropical diseases (TDR)

• Long Term Action Plan for prevention & control of Dengue & Chikungunya. Directorate of NVBDCP : Delhi; 2007.

• Mid Term Plan for Prevention & Control of Dengue & Chikungunya. Directorate of NVBDCP : Delhi; 2011.

• Global strategy for Dengue prevention & control 2012-2020. World Health Organization. Publication Data: Geneva ; 2012

• Guidelines for clinical management of Dengue fever, Dengue hemorrhagic fever & Dengue shock syndrome. Directorate of NVBDCP : Delhi; 2008

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THANK YOU

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APEX REFERRAL LABORATORIES

1. National Institute of Virology, Pune.2. National Center for Disease Control (former NICD), Delhi.3. National Institute of Mental Health & Neuro-Sciences, Bangalore.4. Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow.5. Post- Graduate Institute of Medical Sciences, Chandigarh.6. All India Institute of Medical Sciences, Delhi.7. ICMR Virus Unit, National Institute of Cholera & Enteric Diseases,Kolkata.8. Regional Medical Research Centre (ICMR), Dibrugarh, Assam.9. King’s Institute of Preventive Medicine, Chennai.10. Institute of Preventive Medicine, Hyderabad.11. B J Medical College, Ahmedabad.12. State Public Health Laboratory, Thiruvananthapuram, Kerala13. Defence Research Development and Establishment, Gwalior14. Regional Medical Research Centre for Tribals, (ICMR) Jabalpur,

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Stagnant water sources (heavy rainfall) – vector breeding- increased incidence of dengue - indicate that preventive measures against dengue infection should probably come into full-swing during the post-monsoon months.Presence of some dengue IgM positive cases even during dry months - reflective of the year-round activity of the mosquito vector. Minimal collections of water sources (like stagnating water within indoor plants) – favour breeding of the vector thereby helping in the maintenance of the vector population throughout the year.

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• Curtailment of outdoor playing activities (especially during the post-monsoon months) by children could be done.

• As the mosquito vector exhibits activity during the dusk, this could reduce probably to a great extent the chances of children getting exposed to the vector.

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Govt.of Karnataka guidelines – original document

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Govt of Karnataka guidelines- original document

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Dengue vaccine

• the pathogenesis of DHF is not fully known• Animal model – absent• a tetravalent vaccine that prevents infection with all

four DV serotypes - needed.• Natural• DV infection induces long-lasting protective immunity-

same serotype. • A tetravalent formulation that retains the

immunogenicity of all four serotypes has proven difficult, requiring the use of more complicated, multiple dose immunization regimens.

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Epidemics Of Dengue-like Illness In India

Year Places1780 Madras

1824–1925 Rangoon to Madras

1844–1949 Kanpur, Calcutta

1852–1956 Wide spread

1870–1973 Bombay, Calcutta, Madras

1897–1999 Bombay

1901–2007 Madras

1907–1913 Calcutta, Pune, Meerut

1920–1926 Lucknow, Bombay, Calcutta

1927–1928 Coimbatore

1930–1933 Madras

1934–1936 Madras

1940–1945 Calcutta

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• Rapid Action Team should be constituted with the aim to undertake urgent epidemiological investigations and provide on the spot technical guidance required and logistic support

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dengue part 2- emerging public health problem

Health & Medicine