Once bitten, twice shy! | Daily News
Dengue prevention and control: State gets its act together:

Once bitten, twice shy!

The prevalence of dengue has grown dramatically across the globe in recent years and the burden has expanded for decades. Population growth, unplanned urbanisation, and suboptimal mosquito control in urban centres have immensely contributed to the rapid spread of dengue, a mosquito-borne viral disease.

The World Health Organisation has recognised dengue as a major public health concern throughout tropical and sub-tropical regions of the world. The organisation estimates that 50-100 million dengue infections occur each year and that almost half the world’s population lives in countries where dengue is endemic. WHO reveals that while dengue is a global concern, with a steady increase in the number of countries reporting the disease, currently close to 75 per cent of the population exposed to dengue is in the Asia-Pacific region.

There has been concerted action against dengue and in the year 1995, WHO’s Global Strategy for Dengue Prevention and Control (2012-2020) concentrated action against dengue and affirmed revision in the light of the new advances.

The goal of the global strategy is to reduce the burden of dengue. The specific objectives are to reduce mortality and morbidity from dengue by at least 50 per cent and 25 per cent respectively by 2020. WHO says these objectives can be achieved by applying existing knowledge. Dengue mortality can be reduced by implementing early case detection and appropriate management of severe cases, reorienting health services to identify early cases and manage dengue outbreaks effectively, and training health personnel along with appropriate referral systems at primary health care levels.

Surveillance, prevention and control

Organisation says research will continue to play an important role in reversing the trend in dengue which is a neglected tropical disease by improving methods and systems for surveillance, prevention and control.

Director General of Health Services Dr. Anil Jasinghe said dengue cases have reduced this year and the situation is under control. “Last year was extraordinary there was a severe endemic. The outbreak situation in 2017 warranted extensive and regular removal of possible mosquito breeding sites from the environment, along with strengthened patient education on management of fever which resulted in a relatively low mortality,” Dr Jasinghe said.

He added that it is very important to seek medical attention in the event of fever and to do relevant laboratory investigations at least by day three of the illness.

“When the situation gets better people tend to forget the gravity of it they get lenient. Every establishment, public, organisations, tri forces, police Divisional Secretariats should engage in cleaning up the premises and removing mosquito breeding sites constantly,” Dr. Jasinghe stressed.

He revealed that the Health Ministry has newly recruited staff to handle the task of inspecting all areas, organising clean-up campaigns and creating awareness. He assured with a collective effort the country can overcome this issue.

National Dengue Control Unit, Consultant Community Physician, Dr. Preshila Samaraweera said from January to date around 27,478 dengue cases have been reported.

“This year we saw a downward trend in dengue cases compared to last year’s outbreak. However there was an increase during the months of April and May. As there is no vaccine for dengue, preventive methods are the best. In that view our unit launched the ‘Premise Inspection Programme’ with a labour force of 1,200 mobilized in Kalutara, Gampaha and Colombo districts in the Western Province. They also have been sent to other provinces including Jaffna, Batticaloa, Ratnapura, Kurunegala and Puttlam. Under the programme they will inspect religious places, schools and construction sites alongside homes. As the PHI will also accompany the team, public can receive chemicals to clean water and if necessary they will fumigate the area. If there are repeated offenders legal action will be taken,” Dr. Samaraweera explained.

She said teams are also advised to find out the places where recent dengue patients have been reported to inspect the surroundings.

“At the same time health education workshops will also be held. The unit continuously creates awareness through posters, pamphlets, booklets and leaflets. Dengue Control Unit takes all steps to increase the capacity of health sector to monitor trends and reduce dengue transmission, strengthen the capacity to implement effective integrated vector management and increase health workers’ capacity to diagnose and treat patients and improve health-seeking behaviour of communities,” Dr. Samaraweera added.

Promoting collaboration among national health agencies and major stakeholders to implement dengue programmes and increasing the capacity to predict, detect and respond to dengue outbreaks early also falls under Unit’s purview.

Local governments’ role in dengue fight

However she stresses the need of the unvarying support of the public in this effort.

“It is not only the general public but the whole society should shoulder the responsibility of keeping dengue at bay. If people separate garbage for disposal but if they are not collected the issue will remain the same. Local Governments need a lot of support to clean the places where water gets collected. Even a small place with water is enough for mosquitoes to breed. Schools, government offices, public places with construction sites have to be weekly inspected which we alone cannot handle. Head of the institutions have to take the responsibility. If there is a place that cannot be cleaned we will take steps to use chemicals to prevent mosquitoes breeding,” Dr. Samaraweera explained.

She pointed out the delay in seeking medical attention as another reason for deaths due to dengue.

“When you have high fever with symptoms such as severe joint pains, vomiting, nausea and fatigue you should be alert and take a dengue antigen test. Testing once is not sufficient and should be repeated. May be people face financial difficulties but when they delay seeking medical attention they risk their lives,” Dr. Samaraweera said.

Chief Epidemiologist Dr. Anil Dissanayake of Health Ministry’s Epidemiology Unit said after monsoons and recent flooding dengue unit expected an increase in the number of dengue patients.

“The consumption of plastic containers has increased among people. Especially as those affected by recent floods took refuge in schools and religious places, they left the garbage behind. People have to be responsible as their behaviour will affect the whole nation,” he advised.

“Still there is no vaccine or preventive drug for dengue. Therefore the best way to avoid dengue infection is to prevent mosquito bites and remove mosquito breeding places. Hence, people specially children have to wear protective clothing during day time, use mosquito nets when sleeping (both day and night), get rid of mosquito breeding sites regularly in and around your household usually discarded tyres, plastic containers, coconut shells, leaf axils, blocked roof gutters, bird baths, flower vases, or any other place where rain water collect to avoid an outbreak of dengue,” Dr. Dissanayake added.

He also pointed out if an adult or a child develops dengue fever the person should be protected from exposure to mosquito bites in order to avoid further spreading of the infection.

“Especially children should stay at home during the illness, ideally under a mosquito net when resting,” he added.

Dengue Control committee

Meanwhile, Education Ministry took several measures to control the spread of Dengue outbreak in the island. School Nutrition and Health Services Branch, Education Director, Renuka Peiris said under the initiative a Dengue control committee was established in each school chaired by the Principal.

“A teacher is appointed to Dengue Control committee as the coordinator of school and the committee should hold a cleaning programme with the participation of all students, teachers, past pupils, parents or any other volunteers on every Friday for an hour. School site map is divided in to several parts and each part is allocated for a class/classes for cleaning. School cleaning programmes are also conducted on Sundays and special school cleaning programmes will be conducted by school development society with help of parents, students and past pupils and their organisations at the end of each academic term and before a new school term is commenced,” she explained.

Peiris added that growing mosquito repellent plants such as Maduruthala, Sera, Dahaspethiya in the school premises especially near the class rooms are encouraged.

“The Ministry will also see the establishment of proper waste management systems and provide separate bins for paper waste, polyphone, glass with colour codes. Removal of abandoned toilets as they act as breeding places for mosquitoes is also concentrated on or they will be renovated. Rain gutters of multistoried buildings will also be inspected,” she said.

Education Director noted that water drain system of the schools will be improved to minimize spots where water gets collected.

“Ministry officials will conduct continuous awareness programmes through School Media Society, Prefect Guild, Environmental society or by other organisations of the school whilst Health Inspector-PHI of the MOH will inspect at least once a month to ensure the premises is clean,” Peiris said.

Education Ministry has also introduced Dengue Free Child App in collaboration with Mobitel to fast report dengue affected children to take quick actions.

[WHO’s advice]

WHO promotes the strategic approach known as Integrated Vector Management (IVM) to control mosquito vectors, including those of dengue. The proximity of mosquito vector breeding sites to human habitation is a significant risk factor for dengue virus infection.

Prevention and control relies on reducing the breeding of mosquitoes through source reduction (removal and modification of breeding sites) and reducing human–vector contact through adult control measures. Both control measures need to implemented simultaneously for effective control.

This can be achieved by reducing the number of artificial water containers that hold water (cement tanks for water storage, drums, used tyres, empty bottles, coconut shells, etc.) in and around the home and by using barriers such as insect screens, closed doors and windows, long clothing and use of insect repellents, household insecticide aerosol products, mosquito coils etc. and space spraying with insecticide can be deployed as an emergency measure. As protection from the Aedes mosquitoes (the primary vector for transmission), it is recommended to sleep (particularly young children, the sick or elderly) under mosquito bed nets, treated with or without insecticide.

WHO does not recommend that any general travel or trade restrictions be applied on Sri Lanka based on the information available for this event.

[Public health response]

World Health Organization (WHO) is supporting the MoH Sri Lanka to ensure an efficient and comprehensive health response and the following response measures include:

* Support from the military forces has been requested by the MoH to increase the number of beds as the health care facilities are overwhelmed. Three temporary wards in a hospital 38 km north of Colombo have now been completed.

* The MoH launched an emergency response including vector control activities that is also supported by the mobilization of defense forces. The army, police and civil defence forces have been mobilized to conduct house-to-house visits in the high-risk areas with health staff. In addition, they are involved in mobilizing the community for garbage disposal, cleaning of vector breeding sites, and in health education.

* The Regional Office for South-East Asia (SEARO) has constituted a Task Force to guide the response.

* WHO/ SEARO deployed an epidemiologist, an entomologist and two dengue management experts from the WHO Collaborating Center for case management of Dengue/Dengue Haemorrhagic Fever (Queen Sirikit National Institute of Child Health, Thailand) and Ministry of Public health (MoPH) Thailand. The triage protocol was updated in June 2017 to assist with better management of the patients in the health facilities.

* The WHO Sri Lanka country office has purchased 50 fogging machines to support vector control activities.

* MoH and WHO have worked together to prepare a strategic and operational plan for intensive measures to control dengue outbreak in next few weeks.

The current dengue fever outbreak occurs in a context of massive heavy rains and flooding and is currently affecting 15 out of 25 districts in Sri Lanka where almost 600,000 people have been affected. Heavy monsoon rains, public failure to clear rain-soaked garbage, standing water pools and other potential breeding grounds for mosquito larvae attribute to the higher number of cases reported in urban and suburban areas.


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