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Indian Journal of Community Medicine

Vol. 32, No. 2 (2007-04 - 2007-06)

Editorial

Editorial

Dengue outbreak in 2006: Failure of public health system?

Singh Bir
All India Institute of Medical Sciences, New Delhi - 110 029, India
Date of Submission 23-Apr-2007

Correspondence Address:
Singh Bir
All India Institute of Medical Sciences, New Delhi - 110 029
India

Source of Support: None, Conflict of Interest: None
How to cite this article:
Singh B. Dengue outbreak in 2006: Failure of public health system?. Indian J Community Med 2007;32:99-100
How to cite this URL:
Singh B. Dengue outbreak in 2006: Failure of public health system?. Indian J Community Med [serial online] 2007 [cited 2007 Nov 30];32:99-100. Available from: http://www.ijcm.org.in/text.asp?2007/32/2/99/35643

We stand on the brink of an era in which millions of people are likely to be safer from some of the most terrifying killer and maiming diseases. It is expected that very soon obituary will be written for diseases like tetanus neonatorum, poliomyelitis, leprosy and onchocerciasis; and these will join diseases like small pox and guinea worm disease as diseases found only in the textbooks of medicine.

The flip side is that some of the communicable diseases, once thought to be conquered (e.g., poliomyelitis resurgence in northern India), have come back with a vengeance while some have developed stubborn resistance to antibiotic drugs. The pandemic threat for influenza is looming large on the horizon. Some new and previously unknown diseases continue to emerge. These are often labeled as 're-emerging' diseases. Thus all these trends are almost amounting to a crisis that is a challenge for the public health systems in many parts of the world.

In India, dengue fever has struck again. Some states of northern India felt the heat, the capital being the worst hit. There are reports that the infection had also spread to Maharashtra and Kerala. To compound the problem, a sister disease of dengue fever called chikungunya fever has also ravaged the southern peninsula and also affected north since August 2006. The Japanese encephalitis has visited the eastern parts of the country in 2005 and 2006 with a high number of cases and death.

It is not that diseases like dengue fever, JE, malaria and chikungunya are being reported only in the last 2-3 years. If one looks at the data released by the Union Ministry of Health and Family Welfare, it is clear that since 1996, these communicable diseases have been occurring regularly with periodic surges in a number of cases.[1] All these diseases are grouped under 'vector-borne' diseases; the vector happens to be mosquito. It hardly matters whether the mosquito is Aedes (dengue fever, chikungunya fever), Anopheles (malaria) or Culex (JE, filariasis).

In India, DF/DHF outbreaks have been reported in various parts of the country during the last four decades.[2] Delhi has been endemic for DF/DHF for quite some time now and still maintains high vulnerability due to the high influx of international tourist traffic into the metropolis and the extensive breeding potential of Aedes aegypti. [3] Delhi recorded epidemics of dengue fever during the years 1967, 1970, 1982, 1988, 1991, 1992 and 1996. [2][4] During the 1988 outbreak of DF/DHF, about 33% mortality was reported among children admitted in a hospital; [5] while during 1996, 10,252 cases were hospitalized and 423 deaths were recorded.[4] This epidemic peaked in September when an Aedes aegypti larval house index of 43.7% was recorded. In the year 2001, there were 3,306 cases with 53 deaths; in 2002, the number was 1,926 cases and 33 deaths. In 2003, there was a huge outbreak with 12,754 cases and 215 deaths. [1] The outbreak in 2006 started in August and peaked in October. As of end of November 2006, it was estimated that 10,344 cases and 162 deaths due to severe forms of dengue (i.e., DHF/ DSS) had taken place. Since dengue fever is under focus currently, let us examine why the country has to undergo this annual torture. Almost all of the factors discussed below can safely be presumed to be applicable to most of the other re-emerging infections, especially the mosquito-borne diseases.

Mosquitoes breed in water - be it clean or stagnant water in and around the homes (Aedes) or clean stagnant water in larger water bodies (Anopheles) or collections of dirty water (Culex). As regards the issue of bites by mosquitoes, it is directly related to the phenomenon of increased breeding and larger density of mosquitoes as well as bites by them. To my mind, the underlying causes for this are improper management of water: shortage or wastage; lack of public awareness about breeding, and protection from bites of mosquitoes; and inadequate drainage system and poor sanitation.

If there is a shortage of water in an area, as is the case in most parts of India, especially in metropolis, people tend to store water in whatever manner possible. Often these storage containers are left uncovered, thus inviting the mosquitoes to breed in them. If there is wastage of water due to leaking taps and water supply lines or around wells and hand pumps, as again is quite common, the water tends to get collected, making it a fertile breeding ground for mosquitoes. This process is clearly aided by a poor or often nonexistent water drainage system - more so in urban slums and villages.

Water shortage and wastage, as well as poor drainage systems, are directly related to the phenomena of ever increasing population; rapid urbanization and industrialization; unplanned and under-planned towns, cities and villages; unchecked and unplanned construction activities; poor sanitation facilities; deforestation; so on and so forth. Imbalances in nature created by the ever increasing human greed have led to extinction of 'mosquito' feeders, thus allowing them an unhindered flight.

Poor water management is often coupled with lack of awareness in general public about breeding of mosquitoes and protection from their bites.

As public health education is largely the responsibility of the governmental public health system, the obvious conclusion is that the health care workers, as well as the state health departments, are not really tuned very finely to meet this need. A health education poster here or an occasional newspaper advertisement there really serves no purpose. In a country where only about 20% of health services are provided by the public health sector (the rest are provided by private sector), these activities are obviously not given the importance they deserve. In our country, where less than 0.9% of GNP is spent on health and which stands at a dismal position in Human Development Index, these figures are not really surprising.

Poor or delayed response to outbreak or epidemic threats can be attributed clearly to poor health infrastructure (personnel and facilities) and monitoring of communicable diseases, including mosquito-borne diseases. A National Vector-Borne Diseases Control Program (NVBDCP) exists.[5] The mission of the program is an integrated and accelerated action towards reducing mortality on account of malaria, dengue, JE by half; and elimination of kala-azar by 2010 and elimination of lymphatic filariasis by 2015. The NVBDCP strategies comprise early case detection and prompt treatment; integrated vector management, including promotion of personal protection; biological control measures like larvivorus fish and minor environmental engineering; communication for behavioral impact; capacity building through integrated training of all tiers of health care service delivery system; operational research; monitoring and evaluation through regular field visits; and management information system. Despite this near-perfect and 'ideal' components as part of its strategy, the health care providers are not trained enough and often have neither the eyes and ears of an 'epidemiologist' nor an attitude that is required of a public health person. Clearly, the fault lies with the training and refresher training of doctors, nurses and all levels of health care workers - more notably those working at the village and sub-center levels. This inadequate training also includes sub-optimal ability in instituting adequate and prompt curative treatment.

As prevention is definitely a better, cheaper and more effective method to control any disease, the issues raised above need to be addressed as part of a comprehensive response to management of health. Health is not the responsibility of health department alone. A multi-sectoral, multifaceted and comprehensive response will be required to meet the challenges of frequently occurring outbreaks. A segmented or isolated approach will not succeed. While the disease surveillance has to be strengthened, the training of health care providers in medical and paramedical schools has to be tailored as per community health needs. The Integrated Diseases Surveillance Project launched in November 2004 to develop capacity of early identification of outbreak of important communicable diseases such as cholera, typhoid, polio, measles, malaria, TB, HIV/ AIDS needs to be made functional at the ground level.

As a long-term strategy, the health infrastructure has to be strengthened so that the outbreaks can be managed even by smaller, peripheral hospitals. In the 2006 outbreak, a premier medical institute like the All India Institute of Medical Sciences (AIIMS) could have been saved from a large rush only if smaller-area hospitals in and around Delhi were more responsive. The civic agencies have to be more sensitive to the basic needs of the citizens. Rather than adopting a callous attitude and passing the buck, their workers have to 'really work.' Need for enhancing government-citizen partnership through well-coordinated community participation efforts can't be overemphasized. Involving resident welfare associations in urban areas and the Panchayats will help tremendously.

The public health education strategies have to be streamlined. Rather than ad hoc, knee-jerk reactions on occurrence of an outbreak, they have to be implemented through innovative, client-friendly approaches throughout the year on a regular and sustainable basis.

In short, unless India really tones up the basic public health system, it will continue to suffer every now and then. Its dream of becoming a superpower will remain a pipe dream only.

References

1. Annual Report 2005-06. Ministry of Health and Family Welfare, Govt. of India. p. 59-74.
2. Yadava RL, Narsimham MV. Dengue/dengue haemorrhagic fever and its control in India. Dengue Newsletter 1992;17:3-8.
3. Kalra NL, Kaul SM, Rastogi RM. Prevalence of Aedes aegypti and Aedes albopictus - Vectors of dengue and dengue haemorrhagic fever in north, north-east and central India. Dengue Bull 1997;21:84-92.
4. Kaul SM, Sharma RS, Sharma SN, Panigrahi N, Phukan PK, Lal S. Preventing dengue/dengue haemorrhagic fever outbreaks in the National Capital Territory of Delhi--the role of entomological surveillance. J Commun Dis 1998;30:187-92. [PUBMED]
5. Kabra SK, Verma IC, Arora NK, Jain Y, Kalra V. Dengue haemorrhagic fever in children in Delhi. Bull World Health Organ 1992;70:105-8. [PUBMED]

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