Table of content 1.

Dengue fever a public health problem 2

2. The Dengue fever outbreak at Lahore (Pakistan) and role of Department of Health . 3 3. Responses at different levels to cope with dengue fever outbreak .. 4

a. Response at the government level 4 b. c. d. 4. 5. 6. Evaluation of the role played by the government of Punjab 5 Response by armed forces of Pakistan . 7 Response by International Community 7 Potential effects of such incidents on Public health . 7 Dengue fever controlling measure failure . 8 Measures for effective control of Dengue outbreak 10

References 13

1.

Dengue fever a public health problem

Dengue fever has become a public health challenge and is on the rise around the world in the recent times. According to World Health Organisation there are over 2.5 billion people which makes about 40% of the world population are having a risk of dengue fever. WHO has estimated 50-100 million dengue infections globally every year. Dengue fever is endemic in Asia and Africa and is common in other parts of the world as well such as Central America, South America and the Caribbean and the World Pacific (Health Protection Agency 2011). Dengue fever has become a serious and important cause of mortality and morbidity in different parts of the world especially South Asia and South East Asia and due to its severe form of illness it is a challenging subject (Kuran and Takasaki, 2001). There have been social impacts and direct economic impacts in the regions where dengue virus is endemic (Beaute and Vong, 2010). Indian subcontinent has an important history regarding mosquito-borne diseases such as malaria and dengue fever. After 1990s the there was quite a big decline in the rate of malarial infection because of preventative measure but contrary to this, there was an increase in the rates of dengue fever and dengue haemorrhagic fever in this region. There has been regular history of outbreaks of dengue fever in Pakistan, Sri Lanka, India and Bangladesh. The most dominant and lethal serotypes DEN2 and DEN3 are named to be the cause of outbreaks (Raheel et al. 2011). There are many factors which are responsible for expanding transmission area such as increased travel, global warming and urban sprawl (Racloz et al. 2012).

2. The Dengue fever outbreak at Lahore (Pakistan) and role of Department of Health According to National Statistics of Pakistan 2011 the total population of Lahore is 9 million with 9 towns and 150 union councils. Being the capital of Punjab Lahore has got a better health care system as compared to the other districts in Punjab which is shown in the figure given below

(MS: Medical Superintendent, DHQ: District Headquarter Hospital, THQ: Tehsil Headquarter Hospital, EDO: Executive District Officer, DO: Director OF Health).

The dengue fever has now become familiar with population of Pakistan, every year people of Pakistan come across with dengue viral infection. According to World Health Organisation 2012 it was 1994 when Pakistan reported its first epidemic of dengue fever, but sudden increase in the incidence and annual epidemic trend started in Karachi in November 2005. In 2010 there was seen a greater rise in the dengue viral infection compared to previous fiver years. After the monsoon of 2011 Lahore was hit by dengue

virus and this time it was so severe that it claimed many lives. This time it came out to be a bigger challenge as compared to other challenges such terrorism in Pakistan. This outbreak posed a greater threat to public health protection because of prolonged exposure to dengue viral infection. On 30th September 2011 CNN reports that more than 12,000 have been infected and more than 125 have died and most of them have died in Lahore and 300 cases are being reported daily. This outbreak not only claimed the lives of poor people but some of the government official also died. This showed that government did not manage the situation properly and was not prepared to cope with dengue virus outbreak. 3. Responses at different levels to cope with dengue fever outbreak a. Response at the government level Government of Punjab asked the federal government to cope with this situation and contain the speed of the epidemic. The government of Punjab arranged a telephonic hotline service which was known as Punjab Health Line Project for Dengue which could be accessed by dialling 0800-99000. This was to help the community regarding signs and symptoms of dengue and ultimately to identify the genuine cases. The government of Punjab also directed the educational institutions to be closed otherwise a strong action would be taken against those who had not followed the government directions. The News newspaper reported that government of Punjab was so desperate that they even had to take some unnecessary steps to reduce the spread of dengue virus. In short, government of Punjab took following steps to contain outbreak Ban on swimming pools Ban on morning school assembly Closing of school for 10 days
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Article 144 was imposed in Lahore for the containment of the spread of dengue An appeal was made by the government of Punjab to private hospitals provide free treatment for dengue patients

An awareness campaign was started by the government of Punjab headed by the Chief Minister of Punjab Mr Shahbaz Shareef.

Service stations were closed for indefinite period of time. Fishes were released into open ponds b. Evaluation of the role played by the government of Punjab

The government of Punjab should have been prepared earlier as it was expected by the year of 2011 as dengue fever has become endemic in Pakistan and the annual trend of the incidences of dengue fever is on the rise. So knowing the previous year data the government must have done something to contain the spread of the dengue virus. Some of the steps taken by the government of Punjab were having no logic behind them such as ban on morning school assemblies. The dengue fever has nothing to with ban on morning school assemblies. The mosquitoes always or mostly bite when the human are in the stationary state or there is not that much movement such as sleeping times and there is no risk of bite during morning assemblies and secondly there is minimum risk of bite of bite of dengue mosquitoes in open areas and there is least risk of getting bitten by dengue virus during that time and in open places like playgrounds of school and colleges where morning school assemblies take place. Another recommendation was ban on swimming pools as there is no role of swimming pools in breeding of the mosquitoes responsible for dengue fever and is known as AEDES AJEPTI. Water in swimming pool has got heavy tides on its surface due to human activities. The mosquito larvae have got their breathing tubes outside the water surface and due to movement of the water surface the larvae will dive down in to the water and will come onto

the surface later. If there is regular activity in the swimming pool the larvae cannot survive because of the constant disturbances caused by the activities in the swimming pool. Even adult female are not able to lay eggs in the swimming pools because of the constant disturbance there. Secondly the swimming pools are constructed with concrete tiles without vegetation along its surface and larvae cannot survive without vegetation (Jeron and Mukhtar, 2007). The swimming pools are constructed in such a way that they have perpendicular walls which further prevent its breeding because mosquitoes cannot survive in such habitats (Mukhtar et al. 2006). Closing of the schools for 10 days was the most surprising step taken by the government of Punjab, because if the educational institutions are kept closed for a period of 10 days, the student would sleep at home and would get up till late in morning and would make the students to have a maximum chance of getting bitten by the mosquito. If the students are at educational institutions there would be a considerable movement of the human body and would have minimum chances of getting bitten by the mosquito. This step which was taken by the government of Punjab cannot stop the spread the disease and would rather increase its spread. Service stations were closed for unknown time, which are mostly present in the busiest centres of the city, where water coming out of those service stations is contaminated with detergents. The vector responsible for dengue fever and dengue haemorrhagic fever in Pakistan is A. aegypti and breeds in clean domestic water. So there was no need to close service stations because the water coming out of the service stations is mixed with detergents where the mosquito cannot breed (Nathaly and Mukhtar, 2001). There was another astonishing step taken by the government of Punjab where fishes were released into the open ponds. In South-East Asia including Pakistan where the vectors

responsible for the dengue fever and dengue haemorrhagic fever are associated with clean domestic water and shaded places in human dwellings. The investigations conducted during a period of 2005-2010 by WHO, Ministry of Health and National Institute of Health across the different parts of the country (Hyderabad, Lahore, Karachi, Faisalabad), it was found that 100% of the samples were positive which were collected from inside of the houses and households were the most preferred sites for breeding (Mukhtar et al. 2011). Overall most of the recommendation made by government of Punjab were not based on evidence and ultimately failed to achieve the desire impacts and moreover these actions taken by the government of Punjab produced a panic situation among the masses of Lahore. The policy makers should have evidence based health needs assessment of the community and should introduce community friendly interventions which could benefit the population. c. Response by armed forces of Pakistan Pakistani armed forces have been kept busy by various activities in Pakistan whether it comes to terrorism or natural disasters. During this crisis of the dengue outbreak, the armed forces were also involved to cope with the situation. Pakistan army was involved to increase public awareness and established medical camps in various parts of Lahore to help government of Punjab in treating dengue patients d. Response by International Community Sri Lankan government promised to assists government of Punjab to tackle this crisis in the form of providing staff and medicine. Indonesian government also sent a medical team consisting of 20 experts regarding assisting government to fight against dengue outbreak. WHO has already been working with government officials to fight against dengue outbreak. 4. Potential effects of such incidents on Public health
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To secure populations health, there should be proper monitoring (National Academy of Sciences 2000). According to El-Ansari and his colleagues 2005 infectious diseases such dengue fever are a major concern for the society. Public health risks can be minimised, if the warning signs are identified earlier and are acted upon in time (Hayward, 2003). To recognise a risk factor is important to initiate emergency action to deal a crisis (National Audit Office 2002) and Suckling and his colleagues 2003 consider this a basis for public health protection. Public health protection can further be improved by a process of surveillance which can be a source of early investigation and controlling an infectious disease in time (DoH 2000a). The potential effects or risks identified are as follows Great number of people were hospitalised and resulted in loss of huge amount of public funds Those people who were saved suffer mental instability A panic was created among the masses of Lahore and resulted in mass displacement A disbelief was created regarding healthcare system 5. Dengue fever controlling measure failure There should have been an educational approach by the government of Punjab rather than a restrictive approach. As dengue virus is endemic in Pakistan and especially in Lahore, the government needs to make firm policies to prevent the community from such disaster. There must be proper guidelines which could be implemented easily. The government must be prepared for such infectious disasters. As a result of globalisation the outbreaks of such infectious diseases produce inevitable effects (National Academy of Science 2000, pp26). If the health authorities are unprepared for events like these, it may result in devastating effects on the health of the community (Hayward, 2003). The Daily Times Pakistan reported on 26 September 2011, that government of Punjab was unprepared for this expected disaster and it

also reported that in 2006 there were 50 deaths, 289 deaths in 2007, 55 deaths in 2008, over 100 deaths in 2009, and in 2010 dengue outbreak claimed more than 100 live, and still government was unprepared for dengue outbreak in 2011. Pakistan has Ministry of Health at federal level and each of the four provinces have health ministry at provincial level. Health is a provincial matter and policies and guidelines are to be made at provincial level. Health structure of Pakistan if considered overall is fragmented without any proper coordination among the health sectors of all the provinces. The provinces have got a rudimentary preventive health structure. The funding for preventive measure is not there most of the time and source of major funding is always done by WHO. There has not been an effective development of the policies regarding dengue outbreak. Proper planning and application of surveillance and preventative measures are missing at federal and provincial level. Public health agencies have not been that much active or developed, so they have a minimal role. There has been lack of intra-provincial coordination which has resulted in the spread of the disease and also leads to the failure of developing effective dengue control policies. There is always ambiguity in assessing the burden of disease as there is lack of effective data collection and its sharing with other provinces. There is minimal or non-existing data collection in rural areas and difficult to assess the burden of the disease. There is nothing like effective mosquito controlling measures as emphasis is mainly put on ultra-low volume insecticide air sprays. There is unhygienic housing and lack of water, sewer, and there is not a proper waste management system due to increase in population growth and uncontrolled urbanisation. There is increased use of non-biodegradable packaging compounded by non-existent of ineffective trash control services. A large number of Aedes aegypti larvae are imported and exported within used tyres. There is phenomenon of

continuous exchange different pathogens and dengue viruses due to increased air travel. The government has been always been in a crisis mentality which is always based on emergency measures to contain outbreaks rather than establishing an effective guidelines to prevent such outbreaks 6. Measures for effective control of Dengue outbreak There should be a proper epidemiological and entomological surveillance system to cope with the this kinds of outbreaks at the earliest stages There must be advocacy and implementation of intersectoral actions. Community has an important role to play so their participation must be mandatory The basic health services must be addressed properly. There should be proper data collection and case reporting The subject of dengue/health must be incorporated into formal education Professionals related to medical or social sciences should have formal training The government should be prepared for all emergency situations Lahore city should be divided in to 10 different zones. The dengue patients should not be treated at central hospitals like Mayo Hospital, Ganga Ram Hospital, Service Hospital and other hospitals, as it makes the case identification difficult and the dengue patients should be admitted in the hospital in their locality. Each zone should be provided with a field hospital to identify the number of cases in one cluster. Aedes Agypti can only fly for 100 meters from the place of its breeding. The proliferation point can be indicated by identifying two or more cases from a single point and focus should be made on the particular locality along with instructions to the people to check for water gathering spots like air conditioners, plant pots and any other area where water can accumulate.

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Government should look for house based industries located among residential areas which use water for carpet manufacturing and cleaning industries like that.

Patients should be treated by medical professionals trained in dengue fever treatment. Hydration is an important point in the treatment of dengue fever cases. Medicines required at the initial stage are Paracetamol and Ponstan. No NSAIDs should be used as they cause bleeding and these patients are prone to bleeding due to low platelet count.

Platelet count should be checked twice daily in all the patients who are found to have lower than the normal platelet count.

There should be inter and intra-departmental coordination like education department. School children can be involved in compaigns like Have You Clean Your Backyard Today by going to each house in the school vicinity.

Media should be responsible and should avoid creating any dengue-hype. If properly treated it is not fatal

Dont be afraid of dengue virus, get properly dressed to avoid being bitten by the mosquito

An effective strategy should be prepared at federal level with involving provincial health ministries. These strategies must be implemented with sincerity and goodwill.

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References
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