DENGUE A SUCCESS IN PAKISTAN

Prof. Dr. Waseem Akram Head of Research and Development Program on

Dengue, CM Secretariat, Punjab,

WORST EPIDEMIC

• Pakistan faced one of the worst epidemic that started in the month of August 2011.

• In a very short span of time cases started emerging with deaths increasing day by day.

• No previous experience of facing the disease and knowing the vector along with its habitat was there.

• All efforts were based on simple mosquito control.

DENGUE OUTBREAK IN PAKISTAN

Statistics of Disease in Punjab Year First

Case

Last

Cases

Total

Cases/t

o date

Deaths Duration

of the

disease

(Days)

Potential

number

of days

Peak

Season

Month

Peak Season cases

2011 Unknown 3rd Dec

2011

22000 375 198 72 August-Oct ALL CASES

2012 Year

of Success

29 May

2012

20th Dec

2012

(FSD)

265 1 206 62 Sept-Oct

Jan to Jul = 0

173+52=265

2013 13-May-

2012

26th Dec

2013

(RWP)

2661 18 238 114 August- Dec

Jan to Jul = 8

50+248+650+1514+233

= 2661

2014 17

March

2014

28 Dec

2014

1440 01 210

Continuing

80

Continuing

Sept-Oct-Nov

Jan to Jul = 9

3+105+784= 1440

2015 9th

August

Continuin

g

4234 7 120days August to

Nov

4234

Circulating Serotype

DENV- 1 7%

DENV- 2 25%

DENV- 3 68%

Total Samples: 28

Serotyping of Dengue Cases at Lahore Serotyping of Dengue Cases at Rawalpindi

DENV- 2, 286

DENV- 3, 109

DENV-4, 24 DENV-1, 5

Expansion of Dengue Boundaries

District Confirmed 2012 Confirmed

2013

Confirmed

2014 ATTOCK 0 3 12

BAHAWALNAGAR 4 4 0

BAHAWALPUR 4 17 1

Chakwal 0 4 3

CHINIOT 2 2 0

FAISALABAD 38 22 2

DG Khan 0 3 1

GUJRANWALA 1 6 4

GUJRAT 2 2 3

HAFIZABAD 4 2 1

JHANG 5 0 0

Jhelum 0 0 2

KASUR 1 13 1

KHANEWAL 1 3 0

Khushab 1 0

LAHORE 119 1512 97

LAYYAH 1 1 0

Lodhran 2 0

MANDI BAHUDDIN 1 4 3

MIANWALI 1 0 1

MULTAN 1 9 2

MUZAFFARGARH 2 2 0

NANKANA SAHIB 1 1 1

NAROWAL 0 6 0

OKARA 1 3 2

Outside Punjab 2 19 13

PAKPATTAN 4 4 1

RAHIMYAR KHAN 3 3 1

RAJANPUR 0 0

RAWALPINDI 0 904 1212

SAHIWAL 1 6 1

SARGODHA 1 5 3

SHEIKHUPURA 30 81 60

SIALKOT 1 5 1

T.T.SINGH 1 4 0

VEHARI 1 5 0

TOTAL 265 2661 1440

Weekly Comparison of Dengue Cases

2011, 2012, 2013 and 2014

0 0 0 0 5 1 0 0 0 1 0 10 23

91

28 28 26 14

8 4 5 7 4 1 2 0 0 0 1 2 4 1 1 10 8 15

15

30 38

74 56 81

111

108 116

356 375

510 545

2013, 405

307

189 233

0 0 0 0 0 0 2 9 33

305

682

1336

3219

3554

2878

2168

1758 1719

1271

785

366 312 206 236

0

500

1000

1500

2000

2500

3000

3500

0

100

200

300

400

500

600

700

800

900

1000

Jan Mar May Jul W 32

W 34

W 36

W 38

W 40

W 42

W 44

W 46

W48 W50

Ca

se

s 2

01

2,

20

13

an

d 2

01

4

Aug Sept Oct Nov 7

Cases

2011

Is the Future with Vaccines or the Vector Control

•Global Disease Burden •Delhi •Malaysia •Thailand •Indonesia •Philippine •Brazil

Vector Control

RESPONSES THAT MADE THE SUCCESS

Preventive Strategy Adapted During the Worst Epidemic 2011

• ROAD MAP TO SUCCESS

ROAD MAP TO SUCCESS

• Phase 1: Initial Dengue control started with the heavy use of chemical application that included

• Carpet untargeted fogging

• Heavy application of chemicals in the forms of IRS + Larviciding

•Phase 2: Enforcement of IVM strategy and Major emphasis on inter- sectoral collaboration and Public awareness.

• The system included the development of complete monitoring system of dengue prevalence in all parts of Lahore and the next worst areas of Punjab.

• The System was facilitated by the use of PITB and android phone with complete dengue

monitoring software installed in it. • Expertise's from Sri Lanka, Thailand and Indonesia

Success of the System • Disease was managed on war footing with Chief Minister Personally involved. • Man power was increased and technical experts were appointed in the system . • Mega Vector Source Elimination days celebrated. • System extended to Union Council Level . • Use of WHO recommended chemicals promoted and no local allowed. • Mass training and awareness lectures organized • Distribution of Sachets (KITS)

Legislation Introduced

• FIR AGAINST THE VOILATORS INTRODUCED

• Strict laws for the destruction of automobile tires imposed

• Movement of old tires within the province completely banned

• All swimming pool closed

• Fountains dried

• Biological agents like the locally available fish introduced in all ponding areas after water analysis

• Solid waste disposal system developed

• WASA efficiency monitored and improved

• Large scale clearing of grave yards

“HOW WILL WE DO IT,

TOGATHER WE WILL DO IT” AND HAVE DONE IT

A STRONG ADVOCATIVE STYLE FOR ENFORCEMENT

Preventive Strategies Adapted During the Worst Epidemic Continued to date

Development of SOPs for each and every department along with strict compliance and monitoring

Master training of 118 professionals at AIT, Thailand and Sri Lanka (DEC 2011)

Off season management and source identification and removal of breeding spots

Extensive surveillance activities • First Phase Started from 15 February till Mid

May • Second Phase started from June (Onset of

monsoon) and ended In November

Pest Engineers recruited for Second Phase (LG&CDD)

• Formation of Macro and Micro Plans for vector management.

• Establishing PITB DASH BOARD • Formation of DEAG for clinical management of the patients • Formation of TERC • Case Response as the most powerful tool in dengue

management • Use of WHO approved PHI • Third Party validation • Uploading of case response on Dash board • Training Programs

Success Indicators

Macro Plans

Political Involvement as key Indicator

Preventive Strategy Adapted During the Worst Epidemic 2012

Major IVM based training programs

Distribution of more than 1600 android phones

Anti dengue days throughout the province

Comprehensive surveillance programs for most vulnerable UC

Research studies on various chemicals and bioassay trial on the field efficacy of recommended products.

International Conference

With CM monitoring all meetings

and activities

Macro Plans

WE HAVE FOUGHT AGAINST THIS DISEASE “SOCIAL MOBILIZATION”

Door to Door Campaigns

Micro Plans

• Administrative Tools for meeting the targets – Daily Meetings (DERC) on 24 hrs performance by

various departments throughout the season

• Operational Tools – Split up of Towns to Zones and engagement of HR

• IDST Indoor Surveillance Teams (Female) • ODST Outdoor Surveillance Teams • CRT Case Response Teams

– Evaluation of field work and case response (CR), vector surveillance and left over (TERC)

– Cross checking CR by visits to hospitals and individual patients.

Provincial Implementation Committee

District Implementation

Alerts and Disease outbreak informing

Health Department

City District

Responsible for enforcement of decisions

and main controlling body of entire professionals. Placed 3200 additional field staff during 2014 for active surveillance.

Town Committee TERC Meetings 1

DDOH = 1

Med. Ento = 1

Environ Insp = 9 2

Tehsil Sanitary Insp. = 2

CDC Supervisors = 10

3

Sanitary Male = 18

Sanitary Female = 24

4

LHW

Union Council Level Responsible for implementation and monitoring

of decision Represented by Political electives

Third Party evaluation Teams

Special Branch

Field men 20 LHS 3 Each town committee is

composed of 1+2+3+4

Bodies formed to combat Dengue

Recommendations Enforced

SURVEILLANCE AND PREVENTION

– Strategy – Surveillance should be carried out with 07 DAYS INTERVAL

– However with regular onset of rainfall this period be reduced to FIVE DAYS.

– Those areas which remain negative during the monsoon season as against others a few ovitraps may be installed to monitor breeding activity.

– Removal of traps as they become positive.

– Strict monitoring of the ROOM COOLERS , roof tops and all artificial breeding sites both indoor as well as out door.

– Fountains be monitored regularly if operational

– Swimming pools opened

Measures • Mechanical removal based on the size of the breeding area • Fish stocking • Dewatering • Chemical treatment more focused and target defined • As of previous years strategy all departments taken on board Railways, PIA, local

transportation and other departments for compliance of the SOPs.

PRE-PREPARATION OF DENGUE SEASON

• Following steps provoked at provincial level:

• Spray Machinery

– Safe storage of equipments at the end of the season

– Proper stock taking of spray machinery with information on those needing repair.

– Calibration of all spray machinery to ensure actual quantity of pesticide required

– Vehicles maintenance used in dengue brigade.

Chemical used in Dengue program

• Stock taking of chemicals left over in the last season • Rationalizing actual chemical requirement during the

current season – Ware house inspection for storage – Tendering of pesticide and purchase of chemicals for larviciding,

IRS and fogging. – Pretesting of chemicals on larval and adult stages of Aedes

albopictus/aegypti populations which must be completed at least ONE MONTH BEFORE THE PURCHANSE OF CHEMICALS AND START OF DENGUE SEASON.

– Safe transportation of chemicals to different districts with proper quantity requirement and storage.

– Regular inspection of the purchased chemicals for labels, seals, leakage, shelf life, storage conditions and stacking.

Capacity Building

– Extensive training programs for all categories of manpower attached with the dengue control program initiated at various time intervals between the heavy disease burden periods.

Training of Trainee

Dengue Seminars & Exhibitions | iph.punjab.gov.pk www.iph.punjab.gov.pk/news_events_activities_seminars Cached Anti-dengue Day (September 2, 2012) Dengue Awareness seminars At IPH 3 In Educational Institutions 27 Community 10. A seminar was arranged at IPH, Lahore Dengue Seminar deferred - thenews.com.pk www.thenews.com.pk/article-39722-Dengue-Seminar-deferred Cached FAISALABAD: Water and Sanitation Agency (WASA) dengue awareness seminar... Dengue seminar www.nation.com.pk/.../lahore/14-Sep-2012/dengue-seminar Cached LAHORE (PR) – A dengue awareness seminar was held at the Government Ayesha Degree College, Timber Market, Ravi Road on Thursday. PML-N MPA Dr Asad Ashraf

December to January:

Selection of master trainers for the training program. • Synopsis of training program to be prepared for

these workshops that will include • Vector identification • Habitat and seasonal abundance of mosquitoes • Surveillance methods and its field application • Use of android phones and data uploading • Using the ECRS-Punjab and Dengue Tracking system

and knowing the status of your data uploads • Training on chemical use and dose calculation

• Measurement of the target area to be treated • Spray techniques used in IRS, swath formation

and pattern. • Fogging patterns • Insecticidal Residual studies under field

conditions • Effective psi in spray programs

Dengue Capacity Building Workshops (DCBW)

• Dengue Capacity Building Workshops (DCBW) • Entomologists

• Environment Inspectors

• Sanitary workers

• Spray men

• Leady Health Workers

February March to May

June to July August to November

Meteorological studies and forecasting

X X X X

dengue surveillance season and monitoring of the vector population from 15th February

X X X X

Installation of Ovitraps to observe the adult Aedes population activity and egg laying

X X

IVS Integrated Vector Surveillance should be carried out with 10 days interval in the month of February to the time when first Aedes population is visible

X

All surveillance activities should follow destruction of breeding spots X X X X

Extensive training workshops and real time capacity building survey of the dengue staff should be ensured

X X X

Monitoring of dengue cases and vector population X X X X

Regular monitoring of rainfall and humidity pattern. X X X

SOP for indoor and outdoor surveillance should be followed. X X X X

Field trials with chemicals being used in the dengue program must be initiated and mortality percentage should be recorded to measure the residual activity of the material being used.

X X X X

Identify the breeding places both indoor as well as outdoor X X X X

Identify the peak exposure times and places during these days and observe the mosquito density

X X X

Monitoring of rain pattern with measurement of rainfall in millimeters X X X

Removal of breeding spots through intensive outdoor surveillance activities and vigilance campaigns in the houses.

X X X

Public awareness should go side by side during this season X X X X

Activities of indoor will be the responsibility of the household owner and no negligence in its compliance will be accepted

X X X X

Protocol 1 IVM Approach

Protocol 2 IVM Approach

Protocol 3: IVM Approach

SAFETY MEASURES • Use of long-sleeved shirts and garments like

shalwar kameez, pants and jumpers.

• Proper scrubbing of pots /open empty containers after every ten days from February to November.

• Cover water drums , gahras and matkas at all times.

• Regularly change water from coolers, plant pots, flower vases, open drains, small ponds, bird baths, pets' dishes, and other pools of standing water.

• All stagnant water be treated

ADDITIONAL MEASURES

• Cleaning roof pipes.

• Ensure that there are no old tires as these will collect water.

• Dispose all unusable tin cans, jars, bottles and other items that can hold water.

• Solid waste management with regular collection and disposal.

• Ensuring free flow of sewerage line.

• Monitoring the mosquito population in the already sprayed area for residual life of the product.

Interventions

• Release of Tilapia @800/acre

• Public awareness campaigns

• TV Discussions

• Inclusion of dengue chapter in curriculum

• Zero period in schools, Colleges followed by

• Special big cleaning days throughout the season.

SOP FOR CHEMICAL APPLICATION

• Based on the Alerts the SOPs for chemical application are followed

• Incase of patients reported the SOP followed include – 12 houses on each side are surveyed for

• larval sites, adults population and water stagnant areas along with patients

Patient Houses

12 Houses

12 Houses

12 Houses

12 Houses

Dengue Prevention • Generation of Alerts

– Three types of alerts are generated

• Vector Based Alerts

• WHO Based Alerts

• GIS Based Alerts

• Vector Alerts

– Generated on the basis of stages of mosquitoes present these alerts mark the beginning of potential dengue season.

WHO Based Alerts Alert Threshold=

03 suspected and probable cases of dengue +1 laboratory confirmed cases

FORMULA AT= 3SC/PC+ILCC

Out Break Threshold =

01 Confirmed case and 6 Probable + Suspected cases

FORMULA BT=01+6PC/SC

GIS Based Alerts • Developed by DEAG

– If three circles with 1Km radius overlap with one another then GIS based alert is generated

Circles overlapping

Introduction of Surveillance System

Epidemiological Reporting of Dengue

PITB Punjab Information Technology Board created

• http://ecrs.punjab.gov.pk/phl_cms/login.php Electronic Complaint Routing System

• These sites provide detailed information on the over all situation of dengue in Punjab.

• The system is operated/linked through 1600 android phones

• http://www.tracking.punjab.gov.pk/

DIFFERENT ACTIVITY PAGES ON THE ANDROID PHONE

ACTIVITY RELATED TO PRESENCE OF ADULTS IN

THE AREA COVERAGE INCLUDES THE PUNJAB

Parameters used

Main page

http://ecrs.punjab.gov.pk/phl_cms/login.php

Epidemiological Reporting of Dengue

Patient Reporting

All hospital covered

and included

in the system

GP very

few

included

in the

system

and

• http://www.tracking.punjab.gov.pk/

SERIOUS CONCERNS

• 2011 LIMITED TO 6 CITIES IN PUNJAB • 2012 EXPANED TO 28 CITIES IN

PUNJAB

• 2013 REACHED 34 DISTRICTS IN PUNJAB

• 2014 REACHED 29 DISTRICTS IN PUNJAB

• 2015 REACHED 30 DISTRICTS IN PUNJAB

• OUT BREAKS IN SWAT (KPK) • HIGH NUMBER OF CASES IN

KARACHI • ISLAMABAD (395) A

GROWING CONCERN WITH DISEASE OUT BREAK

SUMMARY OF CONCERNS

• LIMITED TRENDS TOWARDS RESEARCH

• MULTIPLE CIRCULATING SEROTYPES

• CLIMATIC CONCERNS

• HEAVY PESTICIDE APPLICATION

• MINIMUM DEPENDENCY ON IVM

• GAPS IN APPLICATION PROCEDURES

• NO SAFTY MEASURES

• INTER PROVINCIAL DENGUE THREATS

• NATIONAL POLICEY NOT DEVELOPED

Road Map Pakistan

• Taking Urban Forum as a tool to development and following the road map of dengue

– We have pointed out

• Water storage is the prime concern in dengue

• Soild waste and its removal is a key to clean living

• Unplanned urbanization is a vital issue and requires a that our systems are properly designed

• Education and Health Parah Lekha Pakistan

OUR GENERAL LIVING STYLE

NON-RESPONSIVE BEHAVIOUR OF PEOPLE

Water being drained

Thanks