Dengue part 2- emerging public health problem

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Dengue part 2- emerging public health problem

  1. 1. Dengue : Emerging Public Health Problem PRESENTER : Dr Kaushik K N GUIDE : Dr Jayanth Kumar Date : 19-2-2014 1
  2. 2. DENGUE : AN EMERGING HEALTH PROBLEM PART 2 2
  3. 3. 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 3
  4. 4. 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 4
  5. 5. 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 5
  6. 6. 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. 6
  7. 7. 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. 7
  8. 8. LONG TERM ACTION PLAN FOR PREVENTION AND CONTROL OF 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. 8
  9. 9. LONG TERM ACTION PLAN FOR PREVENTION AND CONTROL OF 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 9
  10. 10. 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 response 10
  11. 11. 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 11
  12. 12. SUPPORTING INTERVENTIONS • Human resource development through capacity building • Behavioral change communication • Inter – sectoral collaboration • Supervision & monitoring • Coordination committees • Legislative support 12
  13. 13. 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 13
  14. 14. 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 14
  15. 15. ESTABLISHMENT OF SENTINEL SURVEILLANCE • 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 15
  16. 16. ESTABLISHMENT OF SENTINEL SURVEILLANCE • Function of Sentinel Surveillance Hospital – Blood sample collection – Maintain line listing of Dengue positive case – Capacity building of PHC/CHC 16
  17. 17. 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 17
  18. 18. 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 18
  19. 19. STRENGTHENING OF REFERRAL SERVICES • PCR, Virus isolation – 13 apex referral lab • Capacity building • Have advanced diagnostic facilities 19
  20. 20. 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 20
  21. 21. 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 21
  22. 22. 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 22
  23. 23. METHODS OF VECTOR CONTROL • Environmental management – 1. Environmental modification-piped water supply 2. Environmental manipulation-street cleansing, recycling, planning of construction • Chemical control : larvicides 1. Target area 2. Insecticides 3. Application procedure 4. Treatment cycle 23
  24. 24. 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 24
  25. 25. METHODS OF VECTOR CONTROL • 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 25
  26. 26. METHODS OF VECTOR CONTROL • Biological control – 1.Fish 2.Predatory copepods – mesocyclops – vietnam • Improved tools for vector control – 1.Insecticide treated materials 2.Lethal ovitraps 26
  27. 27. 27
  28. 28. DENGUE SURVEILLANCE • Disease surveillance • Entomological surveillance • Monitoring environmental risk 28
  29. 29. 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 29
  30. 30. 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 30
  31. 31. 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 31
  32. 32. SUPPORTING INTERVENTIONS • Human resource development through capacity building • Behaviour change communication • Inter sectoral collaboration • Operational reasearch • Supervision, monitoring & evaluation • Geographical information system • Legislation support 32
  33. 33. 33
  34. 34. 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 34
  35. 35. MID TERM PLAN FOR PREVENTION & CONTROL OF DENGUE • Objectives – To reduce the incidence of dengue to bring down the disease burden – To reduce the case fatality rate due to dengue 35
  36. 36. MID TERM PLAN FOR PREVENTION & CONTROL OF DENGUE • Elements – Disease & vector surveillance – Case management – Laboratory diagnosis – Vector management – Outbreak response – Capacity building – Behavior change communication – Inter sectoral co ordination – Monitoring & supervision 36
  37. 37. MID TERM PLAN FOR PREVENTION & CONTROL OF DENGUE • 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 37
  38. 38. MID TERM PLAN FOR PREVENTION & CONTROL OF DENGUE - LARVAL SURVEILLANCE 38
  39. 39. MID TERM PLAN FOR PREVENTION & CONTROL OF DENGUE – ENVIRONMENTAL MANAGEMENT 39
  40. 40. 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 40
  41. 41. 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 41
  42. 42. DENGUE VACCINE • 4 types of vaccines under development – – Live attenuated vaccine – Chimeric live attenuated vaccine – Inactivated or sub unit vaccine – Nucleic acid based vaccine 42
  43. 43. 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 43
  44. 44. 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 44
  45. 45. 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 45
  46. 46. 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 noninfectious dengue vaccine from yeast. India today, New Delhi, September 20, 2013 46
  47. 47. 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 47
  48. 48. 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 48
  49. 49. REASONS FOR RE EMERGENCE OF DENGUE FEVER • 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 49
  50. 50. REASONS FOR RE EMERGENCE OF DENGUE FEVER • Increased population management – • Significant increase in plantations – – Increased demand for rubber – Rubber plantation increased 50
  51. 51. 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 51
  52. 52. 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) 52
  53. 53. 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 53
  54. 54. 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 54
  55. 55. GROWTH IN GLOBAL AIR TRAFFIC 55
  56. 56. INCREASE IN MARITIME PASSENGER & CARGO TRAFFIC 56
  57. 57. CLIMATE CHANGE 57
  58. 58. 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 58
  59. 59. 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 59
  60. 60. A FEW SUGGESTIONS – MAINTENANCE OF WATER SUPPLY SYSTEMS 60
  61. 61. A FEW SUGGESTIONS – ESTABLISHING PROPER DRAINAGE SYSTEM 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 of Regular 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 61
  62. 62. A FEW SUGGESTIONS – CONSTRUCTION SITE 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 62
  63. 63. A FEW SUGGESTIONS – MODEL CIVIC BYELAWS Standard design for lids for over head tanks and cisterns 63
  64. 64. 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 64
  65. 65. 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 65
  66. 66. THANK YOU 66
  67. 67. 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, Kerala 13. Defence Research Development and Establishment, Gwalior 14. Regional Medical Research Centre for Tribals, (ICMR) Jabalpur, 67
  68. 68. Stagnant water sources (heavy rainfall) – vector breedingincreased 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. 68
  69. 69. • 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. 69
  70. 70. Govt.of Karnataka guidelines – original document 70
  71. 71. Govt of Karnataka guidelinesoriginal document 71
  72. 72. 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 immunitysame 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. 72
  73. 73. Epidemics Of Dengue-like Illness In India Year Places 1780 1824–1925 1844–1949 1852–1956 1870–1973 1897–1999 1901–2007 1907–1913 1920–1926 1927–1928 1930–1933 1934–1936 1940–1945 Madras Rangoon to Madras Kanpur, Calcutta Wide spread Bombay, Calcutta, Madras Bombay Madras Calcutta, Pune, Meerut Lucknow, Bombay, Calcutta Coimbatore Madras Madras Calcutta 73
  74. 74. 74
  75. 75. 75
  76. 76. • 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 76

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