WHOSouth-East Asia Journal of Public Health (World Health Organization, Regional Office for South-East Asia) ISSN 2224-3151 E-ISSN 2304-5272 EDITORIAL BOARD Advisory Board Samlee Plianbangchang (Chair) Richard Horton David Sanders Lalit M Nath Hooman Momen Fran Baum Chitr Sitthi-amorn Editorial Board Poonam K Singh (Chair) Sattar Yoosuf Nyoman Kumara Rai Aditya P Dash Athula Kahandaliyanage Nata Menabde Mahmudur Rahman Chencho Dorji Hasbullah Thabrany Nay Soe Maung Suniti Acharya Phitaya Charupoonphol Kenneth Earhart Sangay Thinley Quazi Munirul Islam Maureen E Birmingham Rohini de A Seneviratne Mariam Cleason Jacques Jeugmans Editorial Team Sarah Ramsay (Chief Editor) Jennie Greaney (Coordinator) Rajesh Bhatia (Associate Editor) Nyoman Kumara Rai Sudhansh Malhotra Nihal Abeysinghe Renu Garg Prakin Suchaxaya Roderico Ofrin Leonard Ortega Aditya P Dash Sunil Senanayake Richard Brown WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) i WHO South-East Asia Journal of Public Health (World Health Organization, Regional Office for South-East Asia) GENERAL INFORMATION The WHO South-East Asia Journal of Public Health (WHOSEAJPH) (ISSN 2224-3151, E-ISSN 2304-5272) is a peer-reviewed, indexed (IMSEAR), open access quarterly publication of the World Health Organization, Regional Office for South-East Asia. The Journal provides an avenue to scientists for publication of original research work so as to facilitate use of research for public health action. Information for Authors There are no page charges for submissions. Please check http:// www.searo.who.int/publications/journals/seajph/about/en/ for details. Manuscripts should be submitted online at www.searo.who.int/ publications/journals/seajph © World Health Organization 2014. All rights reserved. Permissions Editorial Process All manuscripts are initially screened by editorial panel for scope, relevance and scientific quality. Suitable manuscripts are sent for peer review anonymously. Recommendations of at least two reviewers are considered by the editorial panel for making a decision on a manuscript. Accepted manuscripts are edited for language, style, length etc. before publication. Authors must seek permission from the copyright holders for use of copyright material in their manuscripts. Submissions are promptly acknowledged and a decision to publish is usually communicated within three months. Disclaimer The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area ii or its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for the damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Requests for permission to reproduce or translate WHO publications – whether for sale or for non-commercial distribution should be addressed to Information Management and Dissemination Unit, World Health Organization, Regional Office for South-East Asia. We encourage other users to link to articles on our web-site, provided they do not frame our content; there is no need to seek our permission. Editorial Office WHO South-East Asia Journal of Public Health World Health Organization, Regional Office for South-East Asia, Indraprastha Estate, Mahatma Gandhi Road, New Delhi 110 002, India. Tel. 91-11-23309309, Fax. 91-11-23370197 Email:
[email protected] Website: www.searo.who.int/publications/journals/seajph WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) WHO South-East Asia Journal of Public Health (World Health Organization, Regional Office for South-East Asia) January-March| Volume 3 | Issue 1 Contents Foreword ........................................................................................................................................ 1 Editorial Vector-borne diseases in South-East Asia: burdens and key challenges to be addressed Rajesh Bhatia, Leonard Ortega, A P Dash, Ahmed Jamsheed Mohamed............................................................... 2 Perspective Expediency of dengue illness classification: the Sri Lankan perspective Hasitha Tissera, Jayantha Weeraman, Ananda Amarasinghe, Ananda Wijewickrama, Paba Palihawadana, LakKumar Fernando............................................................................................................................. 5 Reviews Highly infectious tick-borne viral diseases: Kyasanur forest disease and Crimean-Congo hemorrhagic fever in India Devendra T. Mourya, Pragya D Yadav, Deepak Y Patil..................................................................................... 8 Current status of dengue and chikungunya in India Dayaraj Cecilia..................................................................................................................................22 Original research Vector-borne diseases in central India, with reference to malaria, filaria, dengue and chikungunya Neeru Singh, Manmohan Shukla, Gyan Chand, Pradip V Barde, Mrigendra P Singh..................................................28 Co-circulation of dengue virus serotypes with chikungunya virus in Madhya Pradesh, central India Pradip V Barde, Mohan K Shukla, Praveen K Bharti, Bhupesh K Kori, Jayant K Jatav, Neeru Singh..............................36 Barriers to malaria control in rural south-west Timor-Leste: a qualitative analysis Penny E Neave, Maria L Soares...............................................................................................................41 Dengue fever in a rural area of West Bengal, India, 2012: an outbreak investigation Dilip K Biswas, Rama Bhunia, Mausumi Basu...............................................................................................46 Dengue vectors in urban and suburban Assam, India: entomological observations V Dev, K Khound, GG Tewari..................................................................................................................51 An evaluation of the surveillance system for dengue virus infections in Maldives Aishath Aroona Abdulla, Fathimath Rasheeda, Ibrahim Nishan Ahmed, Maimoona Aboobakur...................................60 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) iii .....................................Research briefs Atypical presentation of visceral leishmaniasis (kala-azar) from non-endemic area Yatendra Singh............... challenges and the way forward Thar Tun Kyaw....... NR Adhikar.... Leonard Ortega... Galappaththy..... Thaung Hlaing......... BR Marasini...... Subhash Chandra Joshi.....................90 Economic burden of malaria in India: the need for effective spendings Indrani Gupta.......... Gawrie N.................... SK Pant..... MP Upadhyay................................. YR Pokhrel........................................ Kala-azar....... Malaria....................... 122 iv WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .............. 103 Report from the field The National Academy of Vectors and Vector Borne Diseases in India: two decades of progress Neena Valecha and M.. Mala Sinha..95 Towards universal health coverage: an example of malaria intervention in Nepal Shiva Raj Adhikari..................................... Prakash S Gelotar..R....... Ri Kwang Chol. P Ghimire................ Khin Mon Mon....... L Ortega................. 121 Dengue Bulletin..................85 Containing artemisinin resistance of Plasmodium falciparum in Myanmar: achievements............... 121 Bibliography on Vector-borne Diseases from the South-East Asia Region... Krongthong Thimasarn.................................................... KR Rijal........................................69 Profile of dengue infection in Jamnagar city and district.. Volume 37....... N Singh......... Valaikanya Plasai................................................................................................... Ranjit.......... 2009–2013. Naresh Makwana.................................72 Policy and practice Mass primaquine preventive treatment for control of Plasmodium vivax malaria in the Democratic People’s Republic of Korea: a country success story Shushil Dev Pant..... Kamini N Mendis...................81 Malaria elimination in Sri Lanka: what it would take to reach the goal Risintha Premaratne..................................................... Samik Chowdhury..................................................... 117 Recent WHO Publications Aide-mémoires – Dengue.......................................... Yonas Tegegn............. Lymphatic filariasis.............................. Partha Pratim Mandal..... Navaratnasingam Janakan...................75 Monitoring the durability of long-lasting insecticidal nets in field conditions in Nepal J Hii. Paramjeet Singh................................................... Kim Yun Chol............................................. GD Thakur.... 2013. west India Krunal D Mehta.................................. 113 Public health classic On some peculiar pigmented cells found in two mosquitos fed on malarial blood Ronald Ross..................................... Leonard Ortega.................... L....... Swati C Vachhani.......................................................................... Mohammad Khalil.............. The 18 articles cover a range of current research and policy aspects of vector-borne diseases. vector-borne diseases have emerged as serious public-health problems worldwide. dengue. The World Health Assembly in its first meeting in 1948 decided to celebrate 7 April of each year. The articles are from different countries in the Region including the Democratic Republic of Korea.searo. as World Health Day. In recent years. would go on to receive the Nobel Prize in Physiology or Medicine in 1902 “for his work on malaria.who. The day marks the founding of the World Health Organization. Population growth. with effect from 1950. limited capacity exists to apply that knowledge. insecticide resistance and concerns about environmental pollution. While we have gained considerable insights into the transmission biology and management of certain vectorborne diseases over the past few decades. faces several publichealth challenges and high disease burdens with relatively weak health systems.int/ publications/journals/seajph DOI: 10. home to a quarter of the global population. In 2009. cultural and economic situations in the Region are quite distinct and demand innovative solutions suited to local communities. The social. Vector-borne diseases have not only adversely affected human health but also impeded overall socioeconomic development. Maldives and Timor-Leste. Lessons learned need to be rapidly disseminated within the Region to stimulate adaptation and application. whose research was done in the South-East Asia Region. Kyasanur forest disease and Crimean-Congo haemorrhagic fever. Ross. each year a theme is selected that highlights a priority area of public health. including malaria. high cost. The theme for 2014 is vector-borne diseases – illnesses to which more than half of the world’s population are at risk. We conclude this special issue by reproducing the classic article by Sir Ronald Ross published in the British Medical Journal in 1897. in disease management but the effectiveness of the available vector-control methods is limited by logistic problems. the WHO South-East Asia Advisory Committee on Health Research endorsed the recommendation of the regional meeting on research priorities in communicable diseases that the WHO South-East Asia Regional Office should facilitate sharing and dissemination of research by various means. including a public-health journal. this special issue of the WHO South-East Asia Journal of Public Health is devoted to vector-borne diseases. migration and poor environmental sanitation are some of the major causes of the emergence and re-emergence of vectorborne diseases. To mark World Health Day 2014.4103/2224-3151. particularly in the SouthEast Asia Region. Control of vectors remains a major component WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) Dr Poonam Khetrapal Singh World Health Organization Regional Director for South-East Asia 1 . urbanization.Access this article online Foreword Website: www. These diseases still represent a significant threat to human health despite considerable national and international efforts. These factors prompted the Regional Office to begin quarterly publication of the WHO South-East Asia Journal of Public Health in 2012.115828 Quick Response Code: Foreword The South-East Asia Region of the World Health Organization (WHO). by which he has shown how it enters the organism and thereby has laid the foundation for successful research on this disease and methods of combating it.” I sincerely hope that readers will find this special issue very informative and useful. Access this article online Editorial Website: www. which has been malaria-free since 1984. lymphatic filariasis and schistosomiasis – are among the 17 neglected tropical diseases. These include.10 The South-East Asia Region has become hyperendemic with regular reporting of dengue cases since 2000. The higly infectious and fatal tick borne viral diseases.11 In 2012. fleas. The maximum number of cases (355 525) and deaths (1982) were recorded during 2010.5 It is therefore 2 Malaria is endemic in all countries in the Region except Maldives. 60 million are in the Region.4 In 2012. World Health Day 2014 focuses on vector-borne disease with the following aims: (a) families living in areas where diseases are transmitted by vectors know how to protect themselves. of whom 297 million (34%) are children. Estimates indicate about 100 000 cases of kala-azar per year in this Region. flies. Of the 120 million infected people globally. a total of 257 204 cases and 1229 deaths were reported from the Region. mainly the poor and marginalized populations. lymphatic filariasis). a small focus of kala-azar has been identified in Bhutan.9 Schistosomiasis in the Region is limited to small areas in two districts in Indonesia where the number of schoolage children requiring preventive chemotherapy in 2012 was only 2998 compared with 114 348 387 globally. and (d) in countries where vector-borne diseases are an emerging threat. Human infections in Africa have been at relatively low levels for a number of years. Indonesia. Each year a theme is selected that highlights a priority area of public health.12 Chikungunya occurs in Africa. (b) travellers know how to protect themselves from vectors and vector-borne diseases. sandflies.4 billion people are at risk.1 Many vector-borne diseases are prevalent in the SouthEast Asia Region.5 In India. human African trypanosomiasis. ministries of health put in place measures to improve the protection of their populations. This special issue of the WHO South-East Asia Journal of Public Health focusing on vector-borne diseases is one of the highlights of World Health Day 2014 activities in the WHO Regional Office for South-East Asia. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . the total economic burden from malaria could be around $1940 million. sandfly-borne disease (kalaazar) and snail-transmitted disease (e.115828 Vector-borne diseases in South-East Asia: burdens and key challenges to be addressed Quick Response Code: WORLD HEALTH DAY AND ITS SIGNIFICANCE fitting that the theme of World Health Day 2014 focuses on vector-borne diseases. The Region thus accounts for about 65% of the global population at risk and 50% of the infected people. putting almost half of the world’s population at risk. Mosquitoes are the best known disease vector.2 Yet. Japanese encephalitis. schistosomiasis). India.3 The incidence of dengue has increased 30-fold over the last 50 years. Others include ticks. 871 million reside in the South-East Asia Region. dengue/severe dengue. India and Nepal) are at risk of kalaazar. WHO estimated that there were 27 million cases and 42 000 deaths due to malaria in 2012 in the Region. there were an estimated 207 million cases and an estimated 627 000 deaths due to malaria. Asia and the Indian subcontinent.7 Of the 1. among others.2 Vector-borne diseases account for more than 17% of all infectious diseases.1 World Health Day is celebrated on 7 April every year to mark the anniversary of the founding of the World Health Organization (WHO) in 1948. VECTOR-BORNE DISEASES Vectors are living organisms that can transmit infectious diseases between humans or from animals to humans. five vector-borne diseases – Chagas disease.g. Up to 50–100 million infections are now estimated to occur annually in over 100 endemic countries. mostly (90%) in sub-Saharan Africa. triatomine bugs and some freshwater aquatic snails. dengue. Kyasanur forest disease and Crimean Congo hemorrhagic fever are present in India6 but not much is known about these in the Region probably due to poor surveillance and very limited diagnostic facilities to detect it. Maldives. mainly from lost earnings (75%) while 24 percent comes from treatment costs. causing more than 1 million deaths annually.3 billion people globally at risk of lymphatic filariasis.int/ publications/journals/seajph DOI: 10.searo. mosquitoborne diseases (e.who. mainly in Africa.8 About 147 million people in three countries (Bangladesh. health authorities work with environmental and other authorities locally and in neighbouring countries to improve integrated surveillance of vectors and to take measures to prevent their proliferation. Recently. It provides an opportunity for individuals in every community to get involved in activities that can lead to better health. leishmaniasis.4103/2224-3151. A major outbreak occurred in the islands of the Indian Ocean in 2005 and since then.g. where around 1. (c) in countries where vector-borne diseases are a public-health problem. malaria. chikungunya. multisectoral collaboration and community participation are needed to prevent and control outbreaks of these diseases. Geneva: WHO. and poor housing. possibly related to increasing population movement. WHO is coordinating the emergency response to artemisinin resistance28 that is being implemented by ministries of health and nongovernmental organizations.20 and in Sri Lanka21. http://www. World Health Organization.int REFERENCES 1.accessed 28 March 2014. 2014. political will and sustainable financing are essential to achieve universal coverage to control and.5 including in Asia Pacific.who. with support from development partners. 4. Dengue control. improve procurement and supply chain management and develop and maintain the right mix of expertise at different levels of the health system to reach the goal of elimination. These include difficult access to health services. 2014.accessed 28 March 2014. http://www. Leonard Ortega. innovative delivery mechanisms. schistosomiasis and malaria – are being targeted for elimination at least in some countries. While success in malaria control is noted globally. Efficient. http://www. including integrated vector management. Outbreaks of dengue. Insecticide resistance is widespread. families and the communities at risk are necessary to eliminate these diseases and to contain the spread of dengue.22 The emergence of artemisinin resistance in some areas in the Greater Mekong subregion is a major threat to the progress in malaria control and elimination. The case-fatality rate among those with encephalitis can be as high as 30%.accessed 28 March 2014. 2013. Geneva: WHO.13 Japanese encephalitis is endemic in 24 countries in the WHO South-East Asia and Western Pacific regions. Neglected tropical diseases. World Health Organization. Rajesh Bhatia. Email: bhatiaraj@who. World Health Day 2014 is another opportunity to call for action against vector-borne diseases. sanitation and water supplies. World Health Organization.14 with delayed parasite clearance in patients treated with artemisinin has been identified. kala-aazar. World Health Organization. eliminate vectorborne diseases. India. A P Dash. Additional tools. schistosomiasis and malaria and to prevent reintroduction of transmission in areas freed from these diseases. much more needs to be done to eliminate lymphatic filariasis. India Address for correspondence: Department of Communicable Diseases. Geneva: WHO.int/campaigns/world-health-day/2014/ event/en/ .7 April 2014. Mahatma Gandhi Marg.who.who. lymphatic filariasis. the pathway to accelerate malaria control towards elimination is being seriously threatened by vector resistance to insecticides and parasite resistance to drugs.who.23–25 Recently a molecular marker associated CONCLUSION Vector-borne diseases are major public-health problems in the South-East Asia Region.: Vector-borne diseases in South-East Asia Myanmar and Thailand have reported over 1.int/ campaigns/world-health-day/2014/en/ . indicates several challenges should be addressed to improve further the achievements in containing artemisinin resistance. New Delhi 110 002. sustainable financing and community participation are essential. A recent report from Myanmar29. 5. World malaria report 2013. Among them is the need to scaleup further the use of existing strategies. It affects all major vector species and all classes of insecticides.Bhatia et al. 2014.19 and put in place innovative delivery mechanisms to help ensure that everyone at risk or with the disease can easily access evidence-based interventions. However. most of these diseases share common socioeconomic determinants. http:// www. ADDRESSING KEY CHALLENGES Most vector-borne diseases have unique epidemiological features as described in some of the articles in this special issue of the WHO South-East Asia Journal of Public Health6.int/ denguecontrol/en/ .22. Strong political will. In addition to effective systems for surveillance and rapid response. While progress is notable. Geneva: WHO. poverty. Investments are needed to generate strategic information for decision-making. World Health Organization Regional Office for South-East Asia. http://www. chikungunya and Japanese encephalitis. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 3 . Permanent neurological or psychiatric sequelae can occur in 30–50% of those with encephalitis.int/neglected_diseases/diseases/en/ . 2. Ahmed Jamsheed Mohamed Department of Communicable Diseases. chikungunya and Japanese encephalitis are becoming common. whenever feasible.26 There is an urgent need for all stakeholders to work together to address insecticide resistance and drug resistance in accordance with WHO-recommended strategies. Geneva: WHO. World Health Organization. globalization of trade and urbanization without adequate measures to prevent vector breeding.accessed 28 March 2014. It is the main cause of viral encephalitis in many countries of Asia with nearly 68 000 clinical cases every year. Some key challenges to be addressed to accelerate progress towards elimination are common to these diseases. New Delhi. Treatment is focused on relieving severe clinical signs and supporting the patient to overcome the infection.15–18. which could help improve global surveillance of artemisinin resistance.int/malaria/publications/world_malaria_ report_2013/en/ .accessed 28 March 2014. World health day . 3. Safe and effective vaccines are available to prevent the disease. 27 In the Greater Mekong Subregion.9 million cases. globally it is now reported in nearly two thirds of 97 countries with ongoing malaria transmission.who. Well-coordinated multisectoral actions as well as active participation of individuals. effective and sustainable prevention and control of vector-borne diseases requires not only the application of biomedical tools but also interventions to address those factors that are beyond the domain of the health sector. The parasitic vector-borne diseases – kala-azar. World Health Organization Regional Office for South-East Asia. World health day: protect yourself from vector-borne diseases. int/publications/ 2010/9789241500470_eng. searo.who. Singh MP. 2012: an outbreak investigation. WHO South-East Asia J Public Health 2014.accessed 28 March 2014. Emergence of artemisininresistant malaria on the western border of Thailand: a longitudinal study. Amaratunga C. WHO South-East Asia J Public Health 2014. Witkowski B. N. pdf. Thar Tun Kyaw. Galappaththy GNL. 2013.89(2):21-28. Regional strategic framework for elimination of Kala-azar from the South-East Asia Region. 3(1): 36-40. accessed 28 March 2014. 24.379: 1960–1966. Barde PV.accessed 28 March 2014. 2012. et al.Bhatia et al. http://www. Mendis KN. Biswas DK. Mohamed AJ. Chikungunya. 25. Vector-borne diseases in central India with reference to malaria. Ortega L. World Health Organization. Geneva: WHO. 14.int/entity/world_health_day/2014/KA_CD239.searo. 3(1): 22-27. How to cite this article: Bhatia R.who.pdf accessed 28 March 2014. 20.int/entity/world_ health_day/2014/Adde_memoire_Dengue. Vector-borne diseases in South-East Asia: burdens and key challenges to be addressed. 16. Basu M. Malaria successes and challenges in Asia. World Health Organization. Premaratne R. Krongthong Thimasarn. Fact sheet. Singh N. et al. http://www. Lancet.accessed 28 March 2014. 2011.who. 2010. Malaria elimination in Sri Lanka: what it would take to reach the goal. Dengue in South-East Asia: an appraisal of case management and vector control. 28.int/ entity/world_health_day/2014/Chikungunya_Factsheet_ A4. Cocirculation of dengue virus serotypes with chikungunya virus in Madhya Pradesh.accessed 28 March 2014. Cecilia D. http://www. Integrated vector management (IVM). WHO South-East Asia J Public Health 2014. Patil DY. Regional Office for South-East Asia. Current status of dengue and chikungunya in India. http://apps. who. Chand G. Med. Aide memoire dengue. 18. Barde PV. Kalra NL. 23. Global report on antimalarial efficacy and drug resistance: 2000-2010.int/wer/2014/wer8902. Thaung Hlaing. challenges and the way forward. Yadav PD. Economic burden of malaria in India: the need for effective spending. Dash AP. Engl.361:455–467. World Health Organization. Regional Office for South-East Asia. World Health Organization. Shukla MK.who. 2012. Khin Mon Mon. WHO South-East Asia J Public Health 2014. who. Dengue fever in a rural area of West Bengal.int/ malaria/publications/atoz/ artemisinin_resistance_containment_2011. 29.int/iris/ bitstream/10665/79940/1/9789241505321_ eng.accessed 20 March 2014.searo. http://whqlibdoc. Geneva: WHO. Highly infectious tick borne viral diseases: Kyasanur forest disease and Crimean-Congo hemorrhagic fever in India. Bhatia R.pdf .pdf . 2012. 15. 2014 Jan 2. A molecular marker of artemisinin resistant Plasmodium falciparum malaria. 3(1): 28-35. Bharti PK.who.searo. Global plan for insecticide resistance in malaria vectors (GPIRM). 26. 17. 3(1): 2–4 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . central India. Rastogi R.accessed 28 March 2014. 13. 2014 Jan. Dengue Bulletin. India. J Vector Borne Dis. Kori BK. Global plan for artemisinin resistance containment (GPARC). Geneva: WHO. Japanese encephalitis. 8. Emergency response to artemisinin resistance in the Greater Mekong subregion: regional framework for action 2013-2015. 10. New Delhi: WHO-SEARO. Shukla M. World Health Organization. Nkhoma S. Phyo AP. 12. World Health Organization. World Health Organization.accessed 28 March 2014. The regional strategic plan for elimination of lymphatic filariasis. WHO South-East Asia J Public Health 2014. Geneva: WHO. dengue and chikungunya.int/ malaria/publications/ atoz/gpirm/en/ . 3(1): 90-94. WHO SouthEast Asia J Public Health 2014.who. 4 Mourya DT. Bhatia R. WHO South-East Asia J Public Health 2014.50:239–247. 22. J. 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A study done in Sri Lanka in 2011.searo.4103/2224-3151. Colombo 01000. this physical sign typically presents late and. In this revised classification. Sri Lanka. dengue was considered an incapacitating but largely non-fatal illness.2 Historically. respectively. complications and mortality – whatever the classification used. outbreaks of fatal haemorrhagic fever in children in Thailand and several other South-East Asian countries changed this perception. This finding indicates that the warning signs are rather nonspecific.9 To address concerns. Ananda Wijewickrama2. brain or heart (isolated organopathy). The guidelines for prevention and control of dengue and DHF published by the WHO South-East Asia Regional Office (SEARO) in 2011 further revised the 1997 classification. Furthermore. the main pathophysiological change differentiating DHF from DF in clinically suspected febrile patients is evidence of progressive and selective plasma leakage lasting 24–48 hours (the “critical period”) denoted by haematological. Paba Palihawadana1.115828 Quick Response Code: Expediency of dengue illness classification: the Sri Lankan perspective Hasitha Tissera1.7. by the time it is clinically detectable. An informal expert consultation on case management of dengue was held in August 2013 in Colombo. surveillance and clinical management. Jayantha Weeraman1. DHF was subdivided into non-shock and shock replacing Grades I and II and Grades III and IV. the WHO Special Programme for Research and Training in Tropical Diseases (WHO TDR) classification was proposed in 200910 and apparently further updated in 2012. since these patients 1 Address for correspondence: Dr Hasitha Tissera. which were subsequently updated in 1997. 231 De Saram Place. patients with warning signs require strict observation. This predicament has possibly created confusion among clinical practitioners in many countries including Sri Lanka. entitled “Dogma in classifying dengue disease”.lk. 2Infectious Disease Hospital. Two perspective articles were published recently. Ananda Amarasinghe1. LakKumar Fernando3 Epidemiology Unit. However.3-6 Clinical information gathered during these early outbreaks was the basis for dengue clinical classification published in the 1975 World Health Organization (WHO) guidelines.12 which used the 2009 WHO TDR classification because it was more user friendly.8 Dengue illness was classified as two distinct clinical entities: dengue fever (DF) and dengue haemorrhagic fever (DHF). From a clinical standpoint it is essential to make all efforts to reduce substantially the morbidity. The overall objective of the meeting was to appraise the current status of the use of case classifications in the region.14 The authors argued over a number of important issues pertaining to dengue illness classification faced today. inutility of the 2009 WHO case definition”. regarding application of the 1997/2011 WHO classification. associated with dengue illness were classified as expanded dengue syndrome or unusual manifestations. Ministry of Health. District General Hospital Negombo. compliance with the WHO TDR guidance would probably overburden clinical facilities.uk form the majority. kidney. In addition. 3Centre for Clinical Management of Dengue/DHF. Therefore. found that the majority of DF patients had warning signs. Sri Lanka Email: chepid@sltnet. During the late 1950s. According to the WHO TDR classification. In this classification. It is important to note that this classification served a dual purpose.11 This classification defines three different levels of clinical dengue illness: Dengue. the patient may already have progressed to impending shock. Sri Lanka. dr_korelege@yahoo. particularly in clinical settings. Ministry of Health. Epidemiology Unit. such as liver. radiological and clinical evidence in that order of appearance. Here. in the 2009/12 WHO TDR classification “clinical” accumulation of fluid is categorized as a warning sign.Access this article online Perspective Website: www.co. Ministry of Health.13 and “Dengue: syndromic basis to pathogenesis research. Sri Lanka organized by the WHO SEARO with the participation of country representatives and experts from the region.int/ publications/journals/seajph DOI: 10. unusual manifestations seen among only a minority of patients with severe organ involvement. we briefly describe the best use of these classifications and their challenges in application in the Sri Lankan perspective. Sri Lanka DENGUE CLASSIFICATION South-East Asia is the region with the highest burden of dengue. we note that the 2009/12 WHO TDR classification has not given clinicians the anticipated ease of application for successful case management. Ministry of Health. Dengue with Warning Signs and Severe Dengue. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 5 .1 and has been in the forefront of the development of case classification and management.who. We encounter two conflicting clinical practice scenarios.16. Most clinicians have realized the importance of detecting plasma leak that is preceded by a drop in platelet count around the time of defervescence. warning signs of severe illness10 are considered when admitting patients to hospital from day 3 onwards. some clinicians continue to struggle to classify dengue illness effectively for case management. by contrast. institutionalization of mandatory patient monitoring charts. coinfections or unusual manifestations such as massive bleeding (without leaking). unpublished data). National surveillance data are based on timely. which has helped to guide clinicians to manage patients without allowing complications of severe dengue to arise. Furthermore. we are yet to find many cases where the primary cause of death was not related to prolonged and repeated shocks as a consequence of delayed and inappropriate treatment or fluid overload due to over treatment with intravenous fluids without proper monitoring (Epidemiology Unit. approximately a quarter of whom were children younger than 15 years.9. training of all levels of clinical staff based on these guidelines.28% in 2013 (from 5% in 1996) against a background of a very high dengue incidence.22 Therefore. hands-on training for clinical staff. This observation supports what Scott Hastead 14 has referred to as clinicians having varying degrees of experience.21 Among other criteria. with the first outbreak reported in1965. two centres of excellence were recently established to allow closer observation of children and adults undergoing treatment. As rightfully mentioned by Halstead. Over the past several years a number of activities were initiated in Sri Lanka to strengthen and standardize early detection and management of DHF.Tissera et al. and research. based on the haemodynamic status of each patient. the appearance of leukopenia and subsequent thrombocytopenia aids the diagnosis. and regular clinical and death audits.20. This high fatality probably 6 reflects late detection of plasma leakage and therefore delayed initiation of appropriate fluid therapy. DHF was first reported as a public health problem in Sri Lanka in 1989. Furthermore. diagnose severity according to clinical end-points and manage cases accordingly. A minority of clinicians largely depend on warning signs as predictors of severe disease. Notably. we reiterate that the main challenge for clinicians is timely decision-making to guide management to handle the fluctuating spectrum of clinical syndrome using the classifications appropriately. multiple outbreaks of DF were reported with only occasional reporting of DHF. In Sri Lanka. the 2009/12 WHO TDR classification considers that “dengue is one disease entity with different clinical presentations and often with unpredictable clinical evolution and outcome”. The key activities were: development and dissemination of national guidelines. This observation has helped in early differentiation of DHF. The relation between the drop in platelet count towards and below 100 000 mm3 with concurrent and consistent haemoconcentration evidenced by a rapid rise in haematocrit towards 20% from the baseline appears to be unique to DHF and helps to distinguish DHF from DF and other acute febrile illnesses. Despite this success. in a minority of patients with no comorbidities. Having reviewed the 1237 dengue-related deaths reported over the past decade in Sri Lanka. In Sri Lanka. The main objective of surveillance is to have a sensitive tool to identify possible dengue cases early for public health intervention. it is noteworthy that a substantial proportion of patients who develop potentially severe features do not show any of the warning signs described in 2009/12 WHO TDR classification during the febrile phase. lowering mortality is a clinician’s top priority and has been handled effectively in Sri Lanka in recent years. The highest-ever total of 44 461 dengue cases (220 cases/100 000 population) was notified in 2012.19 Classification of dengue illness is important for surveillance and clinical diagnosis and management.17 Since early 2000. In all parts of Sri Lanka. the case-fatality rate remains proportionately higher. making DHF a “predictably treatable illness”.15 Thereafter. capacity building by establishing high-dependency units in major hospitals. training and clinical skills that probably influence the disease outcome. The progressive nature of plasma leak in DHF warrants close clinical and laboratory evaluations and proactive action. progressively larger epidemics of dengue with more cases of DHF have occurred at regular intervals. We believe Sri Lanka has invested wisely to reach the lowest-ever case-fatality rates of 0. high-yield reports that capture symptomatic dengue patients classified by use of the 1997/2011 system. In our opinion. DHF is reported among all age groups from most parts of the country. We have observed that the 2009/12 WHO TDR classification provides severity-based end-points (whether natural or iatrogenic) and enables better classification of clinically severe cases. unpublished reports). : Dengue illness classification in Sri Lanka THE SRI LANKAN EXPERIENCE Dengue was first serologically confirmed in Sri Lanka in 1962. dengue illness is now considered as a differential diagnosis in patients presenting with acute onset of fever with or without classical features of dengue. Heavy reliance on warning signs in anticipation of worsening clinical status without a proper monitoring regime has repeatedly been found to result in unwarranted consequences. Most practising clinicians actively look for plasma leak among “potential leakers” (patients with fever beyond two days with a platelet count dropping towards and below 100 000 mm3) and provide fluid therapy judiciously.2. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . DHF cases are more common in urban areas with hyperendemic transmission and tend to be younger than DF patients (Epidemiology Unit. an integrated surveillance system of communicable diseases includes dengue and has island-wide coverage through trained and dedicated clinical and public health staff.18 A major upward shift to a high incidence of dengue has been reported since 2009. a potentially life-threatening condition. The 1997/2011 WHO classification identifies DF and DHF as two distinct entities. thereby minimizing disease severity and the occurrence of complications needing adjunctive therapy. When there is a mandatory complete blood count done on day 3 of illness onwards. with a markedly high DHF proportion of 10–15%.2 This is the major advantage of the 1997/2011 WHO classification. not all patients as well as treatment centres do equally well. Dengue: the syndromic basis to pathogenesis research. World Health Organization. Drake JM. Bhatt S. Rothman AL. 1962-1964. Kiatpolpoj S. 1966. Both classifications were born and do exist under the auspices of the WHO. 1975. 1998. Usefulness of World Health Organization (WHO) dengue case classifications in a Sri Lankan clinical setting. Farlow AW. 3(1): 5–7. Farrar JJ. World Health Organization. Lum L. 1997. Geneva: WHO. 20. Wijewickrama A. Tomashek KM. 2002. Southeast Asian Journal of Tropical Medicine and Public Health. Kanakaratne N. 1969. New York: CAB International. WHO/HTM/NTD/DEN/2009. How to cite this article: Tissera H.496(7446):504-7. Tissera HA. However. 1982. treatment. Western Pacific Regional Office. Suntayakorn S. Junghanns T. pp. Martinez E. Shahani A. 1987. doi:1038/nature 12060. Messer WB. Handbook for clinical management of dengue. Halstead SB. Special report: dengue fever/dengue haemorrhagic fever surveillance 2011. Wahala MPBW. 2003-2006. prevention and control. Scott TW. Palihawadana P. countries with limited logistics and human resources struggle to identify what is best for their own use. 22. The global distribution and burden of dengue. Hoen AG. Dengue Bulletin. Cohen SN.88:212-215. Simmons CP. Gubler DJ. Validation of these classifications as a tool for clinical management should be focused to study the impact of their use in changing the course of the disease and its related outcome. Gubler DJ. Wanigasuriya K. Simmons CP. Seneviratne SL. Emerging Infectious Diseases. Editor. Bull World Health Organ. Geneva: WHO. 1966. 2012. Messina JP. treatment. New Delhi: WHO-SEARO. Myers MF. 1–22. 1997. Mackenzie JS. Dengue and Dengue Hemorrhagic Fever. 2013. Hay SI. 198-204. Epidemiological Bulletin. Gunatilake SB. 1997. Kuno G. Geneva: WHO. Dengue Bulletin. Asian-Oceanian Journal of Pediatrics and Child Health. Vaughn DW. Weeraman J. 14. In: Gubler DJ. De Silva AM. Wallingford: CAB International. Wijewickrama A. 53(3):17-19. Innis BL. : Dengue illness classification in Sri Lanka The intention of this Perspective was not to do an exhaustive comparison of the two classifications. 9.42:21-27. World Health Organization. Am J Trop Med Hyg.Tissera et al. Guruge P. Dengue guidelines for diagnosis. Amarasinghe A. 16. 8. Nimmannitya S. Early clinical and laboratory indicators of acute dengue illness. Halstead SB. 2013 Aug. Brandy OJ. Am J Trop Med Hyg.176:313-321. WHO South-East Asia J Public Health 2014. Margiotta MR. 5. 2.18:954-71. Viral diseases in Sri Lanka: a national overview. Wint GRW. Brownstein JS. editors.1. Nature. Special Program for Research and Training in Tropical Diseases (TDR). Tami A. Sankoh O. I. 1997. World Health Organization. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 7 . Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. The clinical and physiologic manifestations of dengue hemorrhagic fever in Thailand. Kroeger A. Dengue hemorrhagic fever: diagnosis and management. 2013 Apr 25. pp. 21. 7. Regional Offices for South-East Asian.1(1):1-22. 18. REFERENCES 1.15(2):192199. Halstead SB. 15. Jayakuru WS. 2012. prevention and control of dengue haemorrhagic fever. Document No. Special Programme for Research and Training in Tropical Diseases (TDR).68:448–456. Source of Support: Nil. Technical guidelines for diagnosis. pp. Ministry of Health. Expediency of dengue illness classification: the Sri Lankan perspective. Control of dengue/dengue haemorrhagic fever in Sri Lanka. 2013. Shock associated with dengue infection. Dengue haemorrhagic fever: current issues and future research. Editors.35:3–15. 12. Hien TT. Jayakuru WS.22: 53-9. 10. in terms of surveillance as well as diagnosis and management both classifications have their own advantages and disadvantages. Kunentrasai N. Journal of the Ceylon College of Physicians. J Pediatr. Dengue and dengue hemorrhagic fever: its history and resurgence as a global public health problem. Abeysinghe N. treatment. Jaenisch T. Dengue hemorrhagic fever: diagnosis. 2011.18(3):392-397. Green S. prevention and control. Historical account of dengue haemorrhagic fever in Sri Lanka. 133-145. 13. In: Dengue and dengue hemorrhagic fever. Fernando L. 2009. 2011. 2013. Nimmannitya S. 4.89(2):198-201. Halstead SB. 11. Gunasekera M. Ratanachu-eke S. Ennis FA. Kalayanarooj S. World Health Organization. Nimmannitya S. surveillance. 19. It is now time to create a formal platform for both groups to sit around one table together with representatives from countries and develop a common guideline classifying dengue illness best applicable to all. New Delhi: WHO-SEARO. Moyes CL. Clinical spectrum and management of dengue haemorrhagic fever. Am J Trop Med Hyg. 6. Viramitrachai W. No doubt. Farrar JJ. Hung NT. Nimmannitya S. Severe dengue epidemics in Sri Lanka. Laksono IS. Wills BA. Conflict of Interest: None declared. 17. London: Academic Press. 3. Contributorship: All authors have contributed to this paper and have read and approved the final version submitted. 1997. Vitarana T. Horstick O. Regional Office for South-East Asia. Dogma in classifying dengue disease. Cohen SN. Jaenisch T.21:117-8. Dengue and chikungunya virus infection in man in Thailand. Gething PW. Nimmannitya S. Nisalak A. Journal of Infectious Diseases. In: Viral diseases in south east asia and the western pacific. Kuno G. 2009. George DB. Kulatilaka TA. Withane N. inutility of the 2009 WHO case definition. Vitarana T. Mosquito borne haemorrhagic fevers of South and SouthEast Asia. Sri Lanka. I: observations on hospitalized patients with hemorrhagic fever. Walling ford UK. com Key words: Crimean–Congo haemorrhagic fever. Most tick-borne diseases are caused by tick-borne viruses. Maximum Containment Laboratory. is transmitted by Dermacentor spp. Kyasanur forest disease (KFD) and Crimean–Congo haemorrhagic fever (CCHF). Generally. depending on the association of the tick species and host. reptiles and amphibians. 20-A. European tick-borne encephalitis and the severe Russian spring–summer encephalitis are transmitted by Ixodid spp. a non-nosocomial CCHF outbreak in Amreli district. There are several other rickettsial infections like rickettsioses and Boutonneuse fever (caused by Rickettsia conorii found in Europe).3 Ticks suck host blood during their lengthy attachment period (7–14 days).6 Rocky Mountain spotted fever. Microbial Containment Complex. Among viral infections. which are responsible for causing the fatal tick-borne WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . this may extend. KFD virus was first identified in 1957 in Karnataka state.8 Hyalomma anatolicum anatolicum and Haemaphysalis spinigera are the two important species of ticks present in India. The emergence of KFD and CCHF in various Indian states emphasizes the need for nationwide surveillance among animals and humans. ticks are the important arthropod vectors for transmission of numerous infectious agents and are responsible for causing human and animal diseases. Ambedkar Road. Two major tick-borne virus zoonotic diseases.3 Tick-borne diseases are prevalent only in specific risk areas where favourable environmental conditions exist for individual tick species. and implementation of thorough tick control in affected areas during epidemics.7. Kyasanur forest disease. are notifiable in India and are associated with high mortality rates. caused by Rickettsia rickettsia.searo. Pune. cases were reported from previously unaffected areas in Karnataka. and newer areas of Kerala and Tamil Nadu states. the tick Haemaphysalis spinigera is the main vector. India. These reports may be the result of improved active surveillance or may reflect altered virus transmission because of environmental change. India Email: directorniv@gmail. National Institute of Virology.3 Eighty per cent of the world’s tick fauna are hard ticks and the remaining 20% are soft ticks.4.5 Human tick-borne diseases have been recognized since the discovery of Lyme borreliosis. haemorrhagic fevers. more containment laboratories. pets and humans. National Institute of Virology. In 2013. CCHF is distributed in Asia. tick-borne diseases.who.115828 Highly infectious tick-borne viral diseases: Kyasanur forest disease and Crimean– Congo haemorrhagic fever in India Quick Response Code: Devendra T Mourya. Deepak Y Patil Abstract Ticks are distributed worldwide and can harbour and transmit a range of pathogenic microorganisms that affect livestock and humans.3 Worldwide increases in the 8 incidence of tick-borne diseases have been reported. birds. as well as positive tick.2 Ticks are obligatory bloodsucking ectoparasites that infest mammals. India. During 2012–2013.int/ publications/journals/seajph DOI: 10. suggested that the virus is widespread in Gujarat state. India Address for correspondence: Dr DT Mourya. Africa and some part of Europe. ticks Introduction Globally. better public awareness. Director. Pragya D Yadav. There is a need for improved diagnostic facilities. transmitted by Rhipicephalus sanguineus and other tick species.1 Various wild and domestic animals are reservoir hosts for tick-borne pathogens of livestock. which is transmitted by Ixodid ticks.4103/2224-3151.Access this article online Review Website: www. only 10% of the total hard and soft tick species are known to be involved in disease transmission to domestic animals and humans. in the United States of America (USA). ticks are the main vectors. Hyalomma spp. animal and human samples in various areas of Gujarat state. Maharashtra. However. The existence of CCHF in India was first confirmed in 2011 in Gujarat state. tick-borne viral diseases manifest three different clinical conditions: encephalitis. and acute febrile illness. Pune-411001. bats viral diseases of Crimean–Congo hemorrhagic fever (CCHF) and Kyasanur forest disease (KFD). revealing gaps in many areas in understanding these diseases. isolated from many Ixodid spp. including India (see Figure 1 and Table 1). rodents. respectively. shrews.Mourya et al. Table 1: Association of virus isolation from ticks (Hyalomma and Haemophysalis) and arboviral zoonotic diseases (KFDV and CCHFV) of India Virus name Family/Genus Tick species CCHFV Bunyaviridae/ Nairovirus Hyalomma marginatum. India monkeys (Semnopithecus entellus. Macaca radiata). many other Ixodid spp. and current policies for management of their control and for raising public awareness. India 1957: langur monkey (Semnopithecus entellus) moribund adult organs and tissues.11. India emerged in comparatively new areas. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 9 . India First isolation in India 2011: Hyalomma anatolicum pool of ticks collected from domestic animals from Gujarat state.13. the role of ticks as vectors. These viruses have Karnataka.10 The tick species are widely distributed in different parts of world. active surveillance programmes among humans and animals. Kyasanur Forest near Baragi village.9. clinical and epidemiological features of the diseases.14 This paper focuses particularly on the Indian scenario of KFD and CCHF infections. KFDV Flaviviridae/ Flavivirus/ Haemaphysalis spinigera. Natural vertebrate Geographical host distribution in India Hare Gujarat.: Tick-borne viral diseases in India Figure 1: The distribution of predominant Hyalomma anatolicum anatolicum and Haemaphysalis spinigera tick species of ruminants in India. 27/03/1957.12 The highly infectious nature of KFD and CCHF causes sporadic outbreaks among humans. the main focus activity was in Shimoga District (NIV unpublished data). papuana kinneari.29 Geographical distribution of KFD virus in India and its detection in newer areas After the discovery of KFD. The ticks are small (unfed adults <4. wellingtoni and H. an outbreak of KFD was reported for the first time in December 2012 in Chamrajanagar district of Karnataka. 823 were laboratory confirmed. The epidemic period begins in November or December and peaks from January to April.11 A large number of isolations have been obtained from ticks. Kerala (Figure 2). then declines by May and June. namely Chikmagalur. Subsequently. until 1972. with the increase in the number of foci. However. thereby generating hotspots of infectious ticks that further spread the virus (Table 1). monkey necropsy samples and tick pools from the Kannangi and Konandur areas in Thirthahalli taluk. through the bites of infected H.15 The virus was initially suspected as a Russian spring–summer (RSS) complex of viruses.10 Owing to the large number of KFD laboratory-associated infections at the National Institute of Virology (NIV). Transmission of KFDV in the laboratory has been demonstrated in a number of Haemaphysalis and Ixodes species. an outbreak of KFD has been confirmed by screening human samples. of these. which appear to be more anthropophilic than mature ticks. As far as spread in new areas is concerned. spinigera is the main vector of KFD. bispinosa.31. H. and the Andaman Islands.5 mm long). NS3.10 In 2013. Thereafter.29 The finding that immature stages of H. The genus Haemaphysalis includes 177 species. monkeys. KFDV was detected in autopsy of dead monkeys in Nilgiris District. and feed on their hosts.18–27 Humans become infected through the bite of infected unfed nymphs. In Karnataka state. Phylogenetic relation and ancestry of KFD virus in India The positive-sense RNA genome of the KFDV is about 11 kb in length and encodes a single polyprotein that is cleaved posttranslationally into three structural (C. are H. more than 100 human cases have been reported in the past while working on the virus. are three-host ticks. Infection causes severe febrile illness in some monkeys. cattle and buffaloes. West Bengal state. it was mainly confined to three taluks (Sagar. this year. Kyasanur forest disease The KFD virus (KFCV) is a member of the genus Flavivirus and family Flaviviridae. the ticks drop from their body. rodents. These facts suggest that constant changes in the ecobiology. They are easy to differentiate from other genera by the characteristic lateral projection of a palpal article 2 beyond the margins of the basis capituli. KFDV is transmitted to other ticks feeding on the infected animals. NS2a. while. since isolates from monkeys and human showed relatedness to this virus. which include parts of the the Saurashtra region in Gujarat state. Adult fed female ticks lay eggs. KFD was thought to be endemic in the Shimoga district. the activity of nymphs is very high during November to May. and that these hosts are highly susceptible to the virus. H. Tamil Nadu and in a human case from Wayanad district.4 × 10–4 substitutions/site/year with WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .16 Mode of transmission of KFD virus KFDV is transmitted to the wild monkeys Semnopithecus entellus and Macaca radiate. serological evidence obtained in the past during different studies. kyasanurensis. H.33 The frequency of cases can be correlated with the number of confirmed KFD-infected nonhuman primates. brownish or reddish. revealed a rate of evolution of ~6. NS4a. foci were reported from four additional areas. India.32 Since 1957. and have very short mouthparts. Large numbers of human infections were reported in 2003–2004. the geographic area affected was small and the number of cases was relatively low. cuspidata. work on this virus was stopped for 30 years.17 After infection. Data indicate that. Shikaripur and Sorab) of the Shimoga district of Karnataka. and H. when an illness occurred concomitantly in monkeys (Semnopithecus entellus and Macaca radiata) and in humans. Among other susceptible species of Haemaphysalis. it was found that animal handlers became infected while handling sick monkeys. as well as accidentally infesting humans. H. thus also acting as a reservoir for the virus. M and E) and seven non-structural (NS1. might have led to the spread of this disease to newer localities. NS2b. minuta. forested regions west of Kolkata. based on Bayesian molecular clock analysis (partial E and NS5 gene sequences of ~50 KFD viruses). and eyeless. and the cycle is repeated.: Tick-borne viral diseases in India Highly infectious tick-borne viral diseases in India 1. but a significant decline occurred in 2007 and again in 2010–2011. such as birds. This is the predominant tick species found in the forest. spinigera ticks. All Haemaphysalis spp. It was first recognized in 1957. When infected monkeys die. H. however NIV started working on the virus again after establishment of a Biosafety Level-3 (BSL-3) laboratory. the estimated incidence of KFD in India has been 400–500 cases per year.10 Already in 2014. Dakshina Kannada. which hatch to larvae under the leaves. They further infest small mammals and monkeys. which is endemic in Karnataka state.30 For a long time. turturis. Udipi and Uttar Kanada districts of Karnataka state. In earlier years. NS4b and NS5) proteins. including deforestation and new land-use practices for farming and timber harvesting.33 Between 2003 and March 2012. Pune. suggests that KFD virus or related viruses are present in other areas of India. correlating with a higher transmission rate of KFD at this time of year.28 Ticks have also been found to transmit this virus transstadially. they mature to nymphs. aculeate. there were 3263 reported human cases and. suggests that this species of tick might indeed be an important vector for the disease. H.Mourya et al. the incidence has increased. spinigera. spinigera infest a variety of hosts. Nymphs and adults also transmit the disease to rodents and rabbits by bite.29 Although human-to-human transmission is not known. and this rodent–tick cycle continues for more than one life-cycle.18. During a recent outbreak of KFD (2013) 10 in Bandipur Tiger Reserve forest. spinigera contributed about 95% of these isolations. H. Evolutionary studies undertaken earlier for KFDV.10. in addition to H. but no skin eruption has been noted.34.2 × 10–5 substitutions/site/year) and a much older ancestry of KFDV. which is reminiscent of dengue. There is usually conjunctival suffusion and photophobia. There is severe myalgia. as are the axillary epitrochlear lymph nodes in some cases. Physical examinations during the first few days of illness reveal an acutely ill. Kerala and Tamil Nadu and CCHF positivity in Gujarat State. Gastrointestinal bleeding is evidenced by haematemesis or fresh blood in the stools. but the majority of cases run a full course without any haemorrhagic symptoms. This raised temperature is continuous and lasts for 5–12 days. it appears that the analysis of full-length genomes might have provided a more accurate estimate of an older ancestry and also suggests that the evolution of tickborne viruses was more gradual than that of rapidly evolving mosquito-borne viruses.34 However. and abnormality of reflexes are noted. mental disturbance. Fever soon follows headache and rapidly rises to 104°F.: Tick-borne viral diseases in India Figure 2: Pictorial presentation of KFD activity in Karnataka.Mourya et al. with blood-tinged sputum and occasionally substantial haemoptysis. giddiness. Neck stiffness. It is initiated by headache and by this time abnormalities of the central nervous system are generally present. Body pains are of high intensity at the nape of the neck. febrile patient with a severe degree of prostration. The cervical lymph nodes are usually palpable. with chills followed by severe frontal headache. The fever lasts from 2 to 12 days (Table 2). Often. Bleeding from the nose. a recent study based on analysis of full-length sequences (KFDV n = 3 and Alkhurma haemorrhagic fever virus n = 18 – a variant of KFDV in Saudi Arabia) revealed a slower rate of evolution (9. Clinical signs and symptoms In humans. coarse tremors.35 Though the number of KFDV isolates that were available at the time of the study was limited. The onset is sudden. the divergence of KFDV estimated to have occurred 62 years ago. the second phase occurs after a febrile period of 1 to 2 weeks. A very constant feature is the appearance of papulovesicular lesions on the soft palate.29. the disease runs a biphasic course. or even longer. the incubation period of KFD is estimated to be about 2 to 7 days after tick bites or exposure.30 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 11 . lumbar region and calf muscles. Diarrhoea and vomiting occur by the third or fourth day of illness. Some patients have persistent cough. gums and intestines begins as early as the third day. The convalescent phase of the disease is prolonged.35 Phylogeography studies for KFDV are also important to genetically characterize the recently circulating KFDVs and understand the dispersal pattern of the virus within Karnataka and to newer geographical areas. hepatomegaly. mucosal hemorrhage. myalgia. Hospital laboratory testing: The following tests should be performed on blood samples from enrolled patients.: Tick-borne viral diseases in India Table 2: Clinical phases of Kyasanur forest disease virus and Crimean-Congo hemorrhagic fever virus infection and tests used for diagnosis. hemorrhagic rash. Confirmed case: a confirmed case of KFD is defined as a case that fulfils the criteria for a probable KFD case and. neutropenia. elevated liver enzymes • isolation of KFDV in cell culture or in a mouse model. the differential diagnosis should include consideration of influenza. RT-PCR and Real-Time RT-PCR IgM ELISA RT-PCR and RealTime RT-PCR (1 to 10 days). • liver function tests (aspartate aminotransferase (AST)/ alanine aminotransferase (ALT). oral and intestinal hemorrhage. bradycardia. in addition. • smear for malaria parasite or malaria rapid diagnostic test.Mourya et al. from blood or tissues. eosinopenia. with sudden onset of high fever and one of headache or myalgia. Standardized. 2–10% thrombocytopenia. increased pro-inflammatory cytokines/ chemokines. and platelet counts. For surveillance purposes. alkaline phosphatase). Personal protective equipment should be used by the collecting technician or care provider in all cases. by venipuncture with an aseptic techniquee. epistaxis. elevated liver enzymes Leukocytopenia. Diagnosis In the KFD-endemic area of Karnataka state. haemoglobin level. 3–60% thrombocytopenia. it should cover any of the following: • exposure to secretions from a confirmed acute or convalescent case of viral haemorrhagic fever (VHF) within 10 days of that person’s onset of symptoms. cephalalgia.33 Probable case: a clinically compatible illness that does not meet the SOPs for a confirmed definition. splenomegaly. In cases of fatality. KFD resembles Omsk hemorrhagic fever (OHF). particularly forest in Karnataka. increase clotting times. Disease KFD CCHF Phase of illness Acute phase Post onset days 2–7 days Convalescent phase 8–12 days Acute phase 1–7 days Convalescent phase 7–12 days months can extend up to 4 month Diagnostic test IgM ELISA. arthralgia. for example. and then 10 days after initial specimen collection or at the time of discharge from the hospital (if less than 10 days). a KFD-endemic area. according to standard hospital procedures: • complete blood count (CBC): total leukocytic count (TLC)/ differential leukocytic count (DLC). cough. and malaria and leptospirosis in moderate to severe cases. • serum electrolytes. blood urea. myalgia. it is essential to emphasize the importance of laboratory confirmation of the disease. headache and myalgia. diarrhea. Blood samples should be collected from the hand or antecubital fossa by the treating physician. malaise. serum creatinine. IgM ELISA (4 days-4 months). and the lack of data available on clinical diagnosis of KFD. Virus isolation (In vitro): 1 to 7 days IgM ELISA. • detection of KFDV-specific genetic sequence by reverse transcription-polymerase chain reaction (RT-PCR) or realtime RT-PCR from blood or tissues. • positive result on testing of clinical serum specimens using the immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA). disseminated intravascular coagulopathy Hematologic Case changes fatality Leukopenia. The other tickborne viral disease antigenically related to KFD and OHF is tick-borne encephalitis. The following case definitions are proposed: Case definition: a patient of any age presenting with acute fever. the second specimen should be collected at the time of death. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . typhoid and rickettsial group of fevers. 12 Disease signs and Symptoms Fever. Virus isolation (In vitro and In vivo). to ensure proper collection of each of the specimens. detailed SOPs should be provided to each of the hospital wards and laboratories. meningoencephalitis Fever. this should be done on two separate occasions – initially at the time of enrolment/ admission. dizziness.33 Suspected case: a patient. but with one of the following: • epidemiological link to a documented exposure to a KFDaffected area (one or more of the following exposures within the 3 weeks before onset of symptoms). multi-organ failure. Q fever and mite-borne typhus in mild cases. within a radius of 5 km surrounding the villages reporting recent monkey deaths or laboratoryconfirmed KFD cases. India. and a history of exposure to ticks and/or a visit to a forest area and/or living in. IgG ELISA (7 days onwards) Clinically. which occurs in the Omsk Oblast in Siberia. serum bilirubin.29 Case definition Owing to the variability in clinical illness associated with KFD infection. or the blood or viscera of monkeys by inoculation into infant mice. the level of viraemia reaches up to 3 × 106 within 3–6 days and remains high for as long as 10–14 days of infection. The trend of increasing numbers of patients infected with KFD in Karnataka state warrants development of a new vaccine – either recombinant. KFD cases are recorded annually. potent. Suspected samples should be shipped according to international regulations for the shipment of infectious agents. rats. Continuous information. collection of specimens for diagnosis of monkey samples. The role and responsibilities of health-care providers at different levels of health facilities are explained. hemagglutination (HA). Pune. For better organization of the health-care-delivery system.Mourya et al. there were no studies done on KFD. Therefore. to provide health care to critically ill patients. vaccines based on inactivated viruses as antigens have shown a certain level of adverse reactions. Government has made provision for well-equipped ambulances for transfer of critically ill patients from community to PHC or from PHC to secondary health-care facilities. This includes maintenance of hydration and the usual precautions for patients with bleeding disorders. and proper disposal of dead monkeys. Improper storage of vaccine and lack of maintenance of the cold chain result in ineffectiveness of the vaccine and could be another reason for the emergence of KFD despite routine vaccination. vaccination of human subjects should be carried out in those areas. hemagglutination inhibition (HI). or in vitro using Vero E6. Guidelines for management of KFD cases In recent years.: Tick-borne viral diseases in India Diagnostic laboratory testing: For a long period. and the use of spray insecticides has been recommended in a 50-m radius around a dead monkey. After establishment of the first BSL-3 laboratory of India at NIV.38 The vaccine was found to be immunogenic. Whenever monkey deaths are reported. and probably a few birds that form enzootic foci. However. Education has been provided in local languages every year. following triple container criteria. Under these circumstances. blood and viscera of infected monkeys. infant mice are found to be the most susceptible for virus isolation.38 Control Infected nymphs and larvae are shed in the forest.33 Prevention The formalin-inactivated KFDV vaccine produced in chick embryo fibroblasts is currently in use in the endemic areas in Karnataka state of India. undertake training of staff. an early and effective diagnosis strategy is essential. As association of human infections in the vicinity of dead monkeys has been shown. real-time RT-PCR can detect the virus in human samples after onset of febrile illness up to the 10th day (NIV data). or a virus-like-particlebased vaccine – which will help in controlling the disease. hence. State government educates the villagers and tourists who visit the forest in Karnataka state about using repellent and gum boots and having prior vaccination. the prevention of tick bites by the use of repellents should be considered. porcupines. the period of higher viraemia coincides with the time at which patients usually report to hospital and collection of a blood sample for laboratory diagnosis. and this has to be carefully balanced with their efficacy and durability. once focus of this disease becomes established in any biotope. supportive therapy is important.36 KFDV can be isolated from the blood of patients (in acute phase 2–5 days). As soon as suspected cases are notified they are referred to NIV. and medical officers are trained to identify the suspected KFD cases. for better understanding and preparedness for KFD disease. education and communication activities with regard to early recognition of suspected KFD cases are carried out among newly recruited medical officers and other relevant populations. squirrels. RT-PCR and detection of IgM and IgG antibodies by ELISA were developed and standardized. state public health agencies in the affected districts have made efforts to ensure adequate staff and infrastructure at primary health-care (PHC) and secondarylevel health facilities. shrews. the interrelationship of IgM and IgG antibodies. If a monkey is found positive for KFDV. During KFDV infection. however. or tissues of ticks.7 Therefore.37 Treatment No specific treatment for KFD is available. Economic and logistical problems associated with regular insecticide spray in a large area makes implementation of a control programme difficult. real-time RT-PCR. In all these systems. rapid action is taken to transmit information to health officers and veterinary staff for necropsy of monkeys.29 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 13 . mainly by the monkeys. positive tick pools. The production of inactivated vaccines carries the inherent risk of utilizing large quantities of potentially highly pathogenic viruses and the possibility of incomplete inactivation of viruses. it cannot be eliminated easily.29 The front-line test for KFD is real-time RT-PCR and RT-PCR from blood/serum of humans. Destruction of infected ticks would necessitate control of ticks throughout the entire forested area. thereby monitoring the annual disease burden at all the health facilities. mapping of primary. but is not technically and economically feasible. secondary and tertiary care health facilities in high-risk areas has been made available. and minimize the frequency of transfer of trained staff. This is the main reason why. it is technically difficult in certain inaccessible areas to transport the large volumes of water needed for the spray. KFD anti-IgM antibodies can be detected using ELISA during the acute phase (4 days onward) (see Table 2). although recommendations have been made for spraying of insecticides around the place of monkey death. stable and safe. complement fixation and in vivo inoculation of patients’ sera into suckling mice were the tests of choice for diagnosis. Clear information about the KFD viraemia phase. Pune for investigation and confirmation. especially in children.36 According to what is known. In addition. and the duration of persistence of these antibodies in naturally infected patients remains to be understood (Table 2). BHK-21 or chick embryo cells. the western border districts. High tick activity is associated with warm winters and hot summers.51 Among these. and persons who come in close contact with CCHF patients. while in the northern half of Africa H. apart from some serological evidence recorded in the past. blood or tissues from viraemic livestock. This is medically important. domesticated and laboratory mammals.46–50 The CCHF cases coincide with the life-cycle of Hyalomma ticks.Mourya et al.9 The history of exposure revealed that the treating physician had an accidental contact with the patient (the index case. attended the funeral of a person who had died due to CCHF. 15 are important vectors of infectious agents of veterinary and public health importance. Secondly.9 CCHFV circulates in nature in the enzootic “tick–vertebrate– tick’’ cycle. antibodies against CCHFV have been detected in the sera of variety of animals. They effectively withstand diverse habitats ranging from warm. marginatum rufipes. since. during the developmental cycle. the risk of CCHFV being passed to the Indian subcontinent was recognized.76. marginatum turanicum and H. CCHFV has been reported in over 30 countries covering Africa. The virus was first isolated from ticks in Pakistan in the 1960s and the first reported human case occurred in Rawalpindi in 1976. CCHF was first isolated in 1965 from a human case and later. ticks infest a variety of hosts – smaller to larger mammals. with long hypostomes and eyes located in sockets. Amreli district. in 1973. lived in the same house. Pune. stables and weedy or fallow fields. birds or reptiles. to examine livestock from abattoirs in the northern adjoining state of Rajasthan WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .44.75 Until 2011. no virus isolation could be achieved and hence no clear evidence of this virus could be obtained. The average case-fatality rate is 30–50%.44 Risk groups include individuals who are exposed to ticks (mainly farmers.72. and the virus was subsequently isolated in 1956 from a human case. had reported the presence.67 Since then. asiaticum ticks from the same region of Xinjiang province in north-western China. Hyalomma species of ticks are medium to large sized.54–56 Viraemia does not develop in birds. who had similar symptoms of haemorrhagic fever and had died a week earlier. mainly those of the Hyalomma genus.57 Geographical distribution of CCHF virus in India CCHF is transmitted to humans and animals by the bite of Ixodid ticks. or by contact with secretions. the existence of CCHF was not known in India. Once a human was infected. harsh lowland. CCHF was first isolated in 1978 and the disease re-emerged in 1999. 14 and this species has wide distribution in India.73 In China. the geographic distribution of CCHF is closely related to the global distribution of Hyalomma spp. from H. in hospital settings. resulting in high case fatality. in the West Crimean region of the former Soviet Union.52 Nymphs and unfed adults remain hidden in the dry and winter season in crevices in stone walls. or came in contact with infected body fluids. this varies between 5% and 80 % in various outbreaks.58–65 India has always been considered at high risk for CCHF. owing to its wide distribution and ability to cause disease in humans. CCHF was recognized for the first time in 1944. During the CCHF outbreak of 2013 in Karyana village. Thus. anatolicum anatolicum). another episode of nosocomial infections recorded from Ahmadabad city resulted in two fatalaties. During December 2010.51 H. blood samples were collected by NIV.45 Ticks of the Hyalomma genus have been reported to be associated with the incidence of the disease and found to play a key role in transmission of CCHFV to mammals. which are distributed throughout Eurasia.76 Serological evidence of the presence of CCHF in India was reported by screening for HI antibodies in animal sera from Jammu and Kashmir. owing to its borders with affected countries such as China and Pakistan.66. the disease was transferred to other close family relatives who either accompanied the infected individual to hospital. arid and semi-arid. marginatum isaaci) predominate. South-Eastern Europe. of CCHFV-specific antibody in nine human samples from Kerala and Pondicherry and in goats from South India. Ahmadabad). The predominance of tick species as vectors of CCHFV differs geographically and includes H. the main reason for transmission of virus was infected Hyalomma ticks infested on domestic animals. family or nosocomial outbreaks are observed. many sporadic outbreaks have occurred in Pakistan every year. H. shepherds and veterinarians).71 In Iran. resident of Bawla Taluka. it has the potential to cause nosocomial cases/outbreaks.39–42 It is a member of the genus Nairovirus of the family Bunyaviridae. where it causes a high mortality rate. Crimean–Congo haemorrhagic fever The Crimean–Congo haemorrhagic fever virus (CCHFV) is also considered as an important zoonotic virus.70 Since this episode.74. southern regions and Maharashtra state.: Tick-borne viral diseases in India 2. H.68. the Middle East and Western Asia. They are mainly found in semi-arid zones. Because of the long association of India with these adjoining countries and the possible trade of animals across the border.44 During June 2012. with high case fatality. marginatum subspecies (H. an outbreak with 19 cases and 12 deaths (case-fatality rate 63. anatolicum subspecies (H. The life-cycle involves three hosts. in 1984. anatolicum anatolicum is known to transmit virus to humans.2%) was reported from Takhar Province in the northern part of Afghanistan. migratory species could carry infected ticks and play a role in disseminating the virus over long distances.77 Shanmugam et al. as reported earlier. Thus.43 Mode of transmission of CCHF virus Humans become infected through tick bites. marginatum marginatum. and started with an index case history of tick bites and close contact with animals. Hyalomma anatolicum anatolicum is important. and infest domestic and wild mammals as well as birds. by contact with a CCHF-infected patient during the acute phase of infection. just prior to the CCHF outbreak.53 CCHFV has a wide host range and can cause a transient viraemia in many wild. and long dry seasons. Afghanistan has seen many outbreaks of CCHF in subsequent years.. ticks. Of the 25 known Hyalomma spp. which is considered to be the most CCHF-affected area in the country. during a large outbreak.69 In March 1998. Observation of CCHF transmission in India during the year 2011 showed it was mainly nosocomial.77 All these studies were based on serological findings only. however. and infection mainly occurs during the period when immature ticks are active. a total of 198 human samples were processed by real-time RT. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 15 . 43. a cluster of suspected VHF cases were reported in Karyana village.44 After its confirmation in India. in Ahmadabad district. Kutch. for the presence of CCHFV-specific IgG antibodies. Amreli district and. IgG antibody positivity was recorded in animals from Karyana. Patan. sporadic cases were recorded from Surendra Nagar. Surprisingly. Nilwada and Khambhala village from Amreli distrct and Kundal village.44 Samples from three suspected cases. unpublished data). earlier than this outbreak (see Figure 2). samples from two medical professionals and the husband of an index case were positive for CCHFV. 83 contacts. were found to be positive for IgG antibodies against CCHFV. Rajkot and Surendranagar were found to be positive for CCHF viral RNA. anatolicum anatolicum ticks were positive by PCR and virus isolation. Surveillance of anti-CCHF IgG in domestic animals showed a number of animals from 15 districts that were positive (see Figure 3) (NIV.78 During the period of 23 June to 25 July 2013. goat and sheep from Sirohi district. Ahmadabad district. Hyalomma ticks and livestock were screened for CCHFV by real-time RT-PCR. Gujarat state. sheep and goats) showed IgG antibodies but only one of the buffalo was positive for CCHFV. Patan district and Kutch district. in southern Rajasthan. The H.Mourya et al.PCR and 19 samples were found to be positive for CCHFV. Figure 3: Pictorial presentation of different outbreaks and spread of CCHF in Gujarat State. during the year 2010. of these. About 17. This emphasizes the necessity of continuous monitoring and screening of syndrome-based cases for CCHF. Ahmadabad were positive for IgG antibodies. sporadic cases of CCHF were reported in 2011–2012. simultaneously.: Tick-borne viral diseases in India and some more distant areas of Maharashtra and West Bengal states. Serum samples of buffalo. cattle. while only two cattle and a goat showed positivity by real-time RT-PCR. Gujarat state.44 The presence of CCHF disease was confirmed for the first time in India during a nosocomial outbreak. in the adjoining village of Jivanpara.0% of domestic animals (buffalo.0% of domestic animals from Kolat.9 Owing to high alertness over 2 months. Retrospective screening of suspected human samples revealed that the virus was present in Gujarat state. Human suspected cases from Amreli. nausea.14 Laboratory investigations during the first 5 days of the CCHF disease mostly show leukopenia. involving neurological symptoms like delirium and convulsions. the first signs that the central nervous system has been compromised start appearing. neck and chest.13.13. In more serious cases. Q fever and other haemorrhagic fevers. with a history of exposure to a suspected. tiredness. Europe in group V and Greece in group VI. headache. temporary complete loss of hair.45 The following are the case definitions for CCHF infection: Suspected case: a patient with abrupt onset of high fever >38. both tick isolates shared 100% nucleotide identity with one of the Indian human isolates of 2011. or other biological fluids from a possibly infected animal (e. urinary tract. Patients with serious illness can show signs of shock or coma. Notably. including nosocomial outbreaks of this high-risk group of viruses. approximately 5 to 7 days after the onset of the disease. including meningitis. Bleeding. South-Africa and West Africa in group III. ears and vagina. Hyperaemia of the face. vomiting. as in other CCHF viruses. while the M segment was of type M2. on the basis of the S segment. there is bleeding under the skin or in internal organs. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .13.79–83 The molecular clock of Indian isolates has revealed the ancestry of these viruses is not very recent and dates back to about 33 years. partial thromboplastin time 60 s or more. Complete genome analysis of Indian CCHFV isolates not only revealed high genetic diversity but also showed recombination and reassortment. loss of hearing and loss of memory. probable. blood. M and L gene segment products. whereas it is about 15 years based on the M segment. The haemorrhagic period is short. West-Africa in group I. or history of contact with tissues. nausea. The disease is milder in children and in secondary or tertiary cases.5% nucleotide identity) and was of South-Asia 2 type. Patient history is very informative. tiredness. within 14 days prior to the onset of symptoms. poor vision. diarrhoea and sore throat. The clinical signs and symptoms are observed between 1 and 3 days (maximum 9 days) after a tick bite. these signs and symptoms may be seen from 5 to 6 days later (maximum 13 days). epistaxis. headache and muscle pain. It is characterized by labile pulse.85. malaise. haematomas and vaginal bleeding. nausea and vomiting. They include abrupt high fever.14. dizziness. thrombocytopenia.44 After a tick bite. Group IV may split into two distinct groups. followed by a long asymptomatic period.43. dizziness and further symptoms of diarrhoea. or bleeding out of the mouth. After that phase. and/or diarrhoea and a history of tick bite within 14 days prior to the onset of symptoms. gastrointestinal system. even death. while survivors show progressive improvement (see Table 2). abattoir workers.Mourya et al. Middle-East and Asia in group IV. Phylogenetic analysis based on the S segment demonstrated that the Indian CCHFV isolates formed a distinct cluster in the Asian–Middle East group IV of CCHF viruses. In most cases. The complete genome was found to be 19. this disease needs to be differentiated from other infections such as dengue. elevated liver enzymes and prolonged blood coagulation times. The convalescence period begins 10–20 days after the onset of disease. leptospirosis. The CCHFV strains cluster into 6–7 distinct groups. Both M and L segments were closest to an Afghanistan strain Afg09-2990 of 2009 (93% and 98% nucleotide identity) respectively. rickettsiosis. vomiting. Information on the time of appearance of symptom of VHF has varied. especially when tick bite or travel to currently known endemic areas in Gujarat is evident.85 In severe 16 cases.2 kb in length. or laboratory-confirmed CCHF case. The S segment of the six Indian CCHFVs showed 99. gingival bleeding.8% nucleotide identity. or health-care workers in health-care facilities. rapidly progresses and typically begins at the third to fifth day of the illness. severe headache.5°C and one of the following symptoms: severe headache. however. in a few cases. ranging between 1 and 21 days after exposure to the virus. muscle pain. Typically.84 Clinical signs and symptoms The initial nonspecific symptoms of CCHF can mimic other common infections that occur in India.86 Case definition: Defining a case is an important aspect of a surveillance system. the incubation period is of short duration (3–7 days). The haemorrhagic signs vary from petechiae to the appearance of large haematomas on the mucous membranes and skin. which may lead to misdiagnosis. The first phase includes a few days of fever. AST 700 U/L or more. myalgia. The average period of incubation is around a week. polyneuritis. encephalitis and myelitis. which can lead to neurological sequelae and. commonly from the nose. The delay of proper treatment and precautionary measures may result in outbreaks.43.: Tick-borne viral diseases in India Ancestry of CCHF virus in India Sequence-based molecular characterization of the Indian CCHFV has shown that the virus possesses the functional motifs known to occur in the S. and conjunctivitis are also noted. The case definition of the disease will be more accurate when it is combined with laboratory confirmation with clinical manifestations. myalgia. which resulted in more complicated evolutionary routes of the virus than mutation-based selective forces.44 Haemophagocytosis is also one of the consistent features in many cases. livestock owners. brucellosis. Asia 1 and Asia 2. however.43. pre-haemorrhagic and haemorrhagic phases. when infection is contracted from direct contact with viraemic livestock or CCHF patients. increased serum ferritin levels caused by haemophagocytosis is also one of the consistent features related to the severity of disease.g. The pre-haemorrhagic period is characterized by sudden onset of fever. Central Africa in group II. haemorrhagic manifestations are observed – mainly petechiae.52 In India. ALT 900 U/L or more. The S segment was closest to a Tajikistan strain TADJ/HU8966 of 1990 (98. difficulty in breathing. and bleeding from unexpected sites has been reported. the disease follows a fourphase course: incubation.44 High viral load is also associated with a fatal outcome. Symptoms also depend on the viral species involved and may include fever. cerebral haemorrhage. Death usually occurs between 5 and 7 day of illness. and fibrinogen 110 mg/dL or less are suggestive of a fatal outcome. congested sclera. tachycardia. veterinarians) within 14 days prior the onset of symptoms. weakness and exhaustion. platelets 20 × 109/L or less. eyes. and convalescence. respiratory tract and other sites including the vagina. or BSL-2-compliant laboratories can be carried out following good microbiological practices with standard protocol. • The ambulance/transport vehicle should also be disinfected after use. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 17 . • The dead body should be sprayed with 1:10 liquid bleach. has been used in Bulgaria and the former Soviet Union.93–97 the drug has not been approved for the treatment of CCHF by the FDA. • clinical procedures that are likely to cause spraying of bodily fluids should be avoided.13. CCHF–venin. for onset of a febrile illness. In suspected secondary bacterial infection. haematemesis. at present.90. Confirmed case: a confirmed CCHF case is defined as a case that fulfils the criteria for probable CCHF and. Real-time RT-PCR for rapid diagnosis of CCHFV infections is the test of choice in the acute phase.: Tick-borne viral diseases in India Probable case: a probable CCHF case is defined as a suspected CCHF case fulfilling the following additional criteria: thrombocytopenia <50 000 cells/mL and two of the following haemorrhagic manifestations: haematoma at an injection site. is laboratory confirmed with one of the following assays: detection by ELISA or immunofluorescence assay of specific IgM antibodies against CCHFV. haemoptysis. Some of these fevers can be transmitted from person to person. to avoid direct contact with the patient. fluid supplements (crystalloids/colloids) and ionotropic support. gastrointestinal haemorrhage. patients should be treated according to standard guidelines/practice for community-acquired/nosocomial infections. patients should be carefully monitored during therapy for signs and symptoms of toxicity. and for ticks.45 Diagnosis Haemorrhagic fevers are contracted through contact with the blood of infected animals. A 1:100 dilution of bleach should be used to clean surfaces. while viral RNA detection combined with serology for laboratory diagnosis in BSL-3. with proper biosafety precautions and handling of these samples. • medical staff handling the patient should wear gloves and a gown. 5% Lysol may be used. • after handling the patient.93 The effect of ribavirin is still controversial. and the bite of infected ticks (CCHF and KFD) and mosquitoes (dengue fever). It was observed that CCHF cases in India supported the use of ribavirin. there is no specific treatment for CCHF. in addition. an immunoglobulin preparation particularly from the geographical areas where this disease is endemic. It should then be wrapped with a winding sheet. • bleach can be used for disinfection.98 Ribavirin is contraindicated in patients with chronic anaemia and haemoglobin levels below 8 g/dL. The drug may accumulate in patients with impaired renal function. confirmed by sequencing of the PCR product or CCHFV isolation. Alternatively. purpuric rash. If ribavirin is administered. medical staff should thoroughly wash their hands. which is then sealed with adhesive tape before transport. rhinorrhagia.Mourya et al. and bedding and clothes. Laboratory diagnosis of the disease is established by molecular methods.93–97 Guidelines for management of CCHF cases In the hospital setting The following precautions are recommended:13 • isolate the patient in a room that is separate from other patients in the hospital. which include resuscitation. which is not yet approved by the Food and Drug Administration of the USA (FDA) . or a 4-fold increase in specific IgG antibodies against CCHFV in two specimens collected in the acute and convalescence phases. Patients with hypotension or haemodynamic instability should be managed following standard guidelines for the treatment of shock. or any other haemorrhagic manifestation in the absence of any known precipitating factor for haemorrhagic manifestation. The persons handling the dead body in hospitals should also wear a mask and use personal protective equipment. may be useful by the intravenous route for treatment of patients with severe CCHF. fresh frozen plasma and erythrocyte preparations. if administered before the fifth day of the disease. but is. which is then sprayed with bleach solution. petechiae. medical equipment. or detection by RT-PCR of CCHF viral RNA in a clinical specimen. A 1:10 dilution of bleach should be used to clean up bodily fluids. • The wrapped and bleached body should be placed in a plastic bag.91 The isolation of CCHFV requires a high-containment BSL-4 laboratory.92 Since no specific treatment is available. using soap and water. Dead body disposal • Rubber gloves or double surgical gloves should be used for handling the dead body.87–89 However. or a mask and eye goggles. or only performed by medical staff wearing a face shield. as well as any other parts of their body that came into contact with the patient. after training and acquisition of all the required biosafety equipment. while IgM and IgG antibodies become detectable by indirect immunofluorescence assay or ELISA after the fifth day (see Table 2). the only antiviral agent with promising effect. and in patients with severe renal impairment (creatinine clearance <30 mL/min). A vaccine based on formalin-inactivated suckling mouse brain. supportive treatment includes careful fluid and electrolyte balance. The Gujarat Government has planned to upgrade laboratories to provide CCHF diagnosis. monitoring and replacement with platelets. there are reports that in severe cases no antibody response is observed. such as anaemia. Treatment So far. gingival haemorrhage. In the family/community setting • Family members and friends who had direct contact with the patient should be monitored for 14 days. A network of laboratories. as well as IgG antibody screening of domestic animals and viral RNA detection in infested ticks. With the diagnostic support of NIV. vector-borne diseases have emerged as a serious public health problem in countries of the South-East Asia. Increased population. • undertake tick control in infected animals. Control After confirmation of the CCHF outbreak in Gujarat state.99–101 However.9 The recent sero-survey study by NIV.77 Strengthening of public health system networking for WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .57. urbanization. Pune in the last 3 years.13.97–101 Prevention and control with regard to disease-affected animals: • segregate the animal from other livestock. resistance of ticks to acaricides poses an increasing risk to livestock.44. is recommended for prevention. with contact tracing and monitoring of contacts. control measures should be mainly focused on tick control in outbreak areas and on personal protective measures for persons caring for CCHF patients. Many emerging zoonoses have spread globally at the human–animal interface. Spraying is another method used to apply the chemical acaricides that kill ticks. Owing to proper precautions and quick preventive measures. for reporting and sending samples to NIV. • these procedures should be followed for at least 2 weeks and blood samples should be drawn and confirmed to be free of viraemia Tick bites are best prevented by people avoiding tick-infested areas or by wearing long trousers that are tucked into boots. deforestation. and help in monitoring the contacts and family members was activated. United Kingdom.104 All these have impact not only on public health but also on the livelihood and economy of affected countries.Mourya et al. international travel. • cattle sheds should be properly disinfected. but there is now evidence of its spread. environmental factors.103 Risk factors for emergence reside in multiple sectors. similarly. Thus. along with researchers from Georgia and New York. spraying human dwelling with residual sprays. Pune for confirmation. and areas of high rainfall.9. modern equipment and trained medical professionals are required in order that the country is prepared to deal with this kind of emergency situation. Barrier nursing techniques are essential while treating confirmed and suspected cases of CCHF.78 An awareness programme is conducted in different government and private hospitals.98 The individuals in outbreak areas who are vulnerable to tick bites. change in lifestyle. spraying cattle in the affected area with anti-tick agents. animal and entomological surveillance. including India. Tick bites can be prevented by application of a topical repellent to exposed skin and treatment of clothing with insecticide. has revealed that domestic animals are positive for anti-IgG antibody in at least 15 districts of Gujarat state (NIV unpublished data).76. 18 • if animals are slaughtered. temperate regions and desert. Pune. KFD was originally assumed to be restricted only to Karnataka state. every suspected case has been referred to NIV for a quick diagnosis.: Tick-borne viral diseases in India Prevention The main means of CCHF outbreak control. and communicating the risk to the public. on a global map. Isolation and treatment of cases following universal precautions is carried out. CCHF is not restricted to one district but human positivity has now been recorded in seven districts. • the left-over feed should be sprayed with 3% bleach and should be disposed of. the milk should not be used for human consumption. in consultation with the animal husbandry department. Dipping is the primary method of tick control for livestock and has been found to be highly effective for controlling several tick-borne diseases. a highly efficient network of hospital reporting of admissions of suspected cases. and a porous international border make this country a high-risk area for outbreaks of emerging and new diseases. change in agricultural practices. Though the main endemic foci are in Gujarat state. immediate surveillance is conducted for members of the community. India is considered a “hot spot” for emerging infectious disease.102 In recent years. Health-care workers should take all the necessary precautionary measures to prevent occupational exposure. surveillance programmes. Animal diseases health officials and national vector-borne diseases (NVBCD) officials are on alert for sampling of ticks and domestic animal samples from the area of any suspected case in Gujarat state. namely breaking the transmission chains by avoiding/minimizing exposure to the virus-infected material. to ensure that other animals do not feed on it. to avoid the spread of infection. Discussion According to a recent study from the Zoological Society of London. avoidance of nosocomial infection in humans is optimized. or health-care and laboratory workers are considered to be at risk of contracting CCHF. which gives nearly 100% protection. thick evergreen forest. more highcontainment diagnostic laboratories. close contact of animals.14. USA. CCHF has been suspected in other parts of the country. The strategic actions taken by the state government included active human. for unusual fever symptoms. Whenever any deceased CCHF-positive patient is reported. causing considerable morbidity and mortality. proper disposal of carcasses should be performed. Close contacts of the infected patient should be followed up with daily temperature recording and monitoring of symptoms for at least 15 days after the putative exposure. • if milking an animal. based on earlier serology data. India has extremes of climatological and geographical conditions: temperatures that vary from extremely low to high. trained laboratory staff.102 Vector-borne zoonoses now occur in epidemic form on an almost annual basis. or exposed to infected animals or animal tissues. Experiment.47:133–138.56:589–593. Acad. 1957. 1933. 2010. Transmission of Kyasanur Forest disease virus by the soft tick. 216:1317– 1319. Int. Med. 1968. In view of the “One health concept” put forward by WHO. a joint initiative has been taken up by ICMR and the Indian Council of Agricultural Research (ICAR) to conduct a survey of IgG antibodies against CCHF in domestic animals in different states of India. Isolation of Kyasanur forest disease virus from naturally infected ticks of the genus Haemaphysalis. Raoult D. Emergence of viral hemorrhagic fevers: is recent outbreak of Crimean-Congo hemorrhagic fever in India an indication? J. Karnataka. with special emphasis on livestock farming systems in India: present and future possibilities for integrated control—a review. Sci. Med. Isolation of Kyasanur Forest disease virus from ixodid ticks: 1961–1964. Work TH. Department of Health Research. Singh KR. 1968. Ind. Work TH. which have diverse and often overlapping. Ind. Infect. Mistry M. Anderson CR. clinical presentations. J. Clin. Med. Med. Allen KE. India. Med. 2013. 1960. Elsevier Pub.56:610–613. Davis JP. Ind. Mysore. Hoogstraal and Rajagopalan.doi. Preliminary studies on experimental transmission of Kyasanur Forest disease virus by nymphs of Ixodes petauristae Warburton. Ministry of Health and Family Welfare. 1975. Patil DY. Reddy S. Rajagopalan PK. Acknowledgements 10. In general. Haemaphysalis ticks of India. 2011. Sreenivasan MK. Majumdar TD. Studies on the transmission of Kyasanur Forest disease virus by Haemaphysalis spinigera Newman. Pavri K. Varma MG. 16. Uilenberg G. Parasitol. Barbour AG.1016/j. 1963. Trends Parasitol. 17.Mourya et al. 1964. Nature. J. Bhatt PN. Dis. Res. 2. Science.40:49-66. Indian J. Bhat UK. 18. as cases are observed almost every year in Karnataka and Gujarat states. org/10.59:213–218.1007/s40011-013-0197-3 . Raval DK. 2014 Mar. Res. Prevention of tick-borne diseases. 25. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 19 . respectively. McQuiston JH. Argaspersicus (Ixodoidea: Argasidae). VIII. 1968. Experimental transmission of Kyasanur forest disease virus to small mammals by Ixodes petauristae. 2012–2013. Biology of ticks. Pavri K. Secretary. Shimoga.56:594–609. Yadav PD. Infect. Mishra AC. Human babesiosis: an emerging tick-borne disease.63:879–887. We also gratefully acknowledge the cooperation of the Directorate of Health Services. Dis. 2013 Jan. Yadav PD. 19:1540-1541. Summary of preliminary report of investigations of the virus research centre on an epidemic disease affecting forest villagers and wild monkeys in Shimoga district. Bhat UK. Postgrad. 7. Unadkat VB. Mysore. 2004. Kyasanur Forest disease: a new infection of man and monkeys in tropical India by a virus of the Russian spring summer-complex. Appl.1973. 19. Summary of preliminary report of investigations of the virus research centre on an epidemic disease affecting forest villagers and wild monkeys in Shimoga district. I. Res. Shete AM. 12. 2012. Karnataka.84(1):9-18. Benach JL.52:566–573. 1971. Gurav YK. 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Hooshmand B: Seroprevalence of Crimean-Congo hemorrhagic fever in Sistan-va-Baluchestan province of Iran. et al. Isolation of Thogoto. Infect. Benjiang Ma. Longson M. Padbidri VS. Josse R. 86. 2012. Chinikar S. 115828 Quick Response Code: Current status of dengue and chikungunya in India Dayaraj Cecilia Abstract National Institute of Virology. National Institute of Virology 20-A. Both viruses are believed to have originated in Africa about 200–300 years ago 22 as shown by molecular clock analysis. shortly after the identification and naming of the disease in 1779 by Benjamin WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . The number of cases reported is increasing. chikungunya. DENV belongs to the Flaviviridae family and CHIKV belongs to the genus Alphavirus of Togaviridae. the Malay Peninsula is also considered as a possible place of origin. Address for correspondence: Dengue Group. a Flavivirus and chikungunya. by virtue of being arthropod-borne viruses and having singlestranded positive-sense RNA genomes.com Key words: dengue. although the clinical profiles differ as the infection progresses.dayaraj@gmail. group-A and group-B. For chikungunya. The review ends with a short summary of the most recent vector-control studies. Before the genome organization and replication strategy was discovered the two viruses were placed in arboviruses. young adults are the major group affected. The first recognized epidemics occurred almost simultaneously in Asia. For dengue. thousands of individuals are affected and contribute to the burden of health care. Dengue outbreaks have continued since the 1950s but severity of disease has increased in the last two decades. all age groups are affected but severe manifestations are more often seen in children. Aedes aegypti and share spatiotemporal territories. Dengue virus (DENV) and chikungunya virus (CHIKV) are transmitted by the same species of mosquito. Chikungunya outbreaks started in the 1960s and dwindled to sporadic cases until a resurgence in 2006. for DENV. Maharashtra. Maharashtra.4103/2224-3151.who. Pune-411001. The first probable case of dengue fever (DF) was recorded during the Jin Dynasty (265–420 AD) in China. Dr Ambedkar Road. Based on the data of National Vector Borne Disease Control Programme (NVBDCP). the severity of disease in India is still lower than that reported elsewhere in South-East Asia. India. evolution INTRODUCTION Dengue and chikungunya are two mosquito-borne viral diseases of great public health concern in India. and paediatric cases of dengue haemorrhagic fever have a high mortality.1 GLOBAL DISTRIBUTION Dengue The name dengue originated from the Swahili word for “bonebreaking fever” or the word for “the walk of a dandie” in Spanish. outbreaks. the number of cases reported in 2013 was about 74 454 for dengue with 167 deaths and 18 639 for chikungunya. India Dengue.searo. probably because of the availability of IgM detection kits produced and distributed by National Institute of Virology through NVBDCP and better reporting. transmitted by Aedes mosquitoes. Both viruses are known to cause acute febrile illness with almost identical symptoms in the early phase of infection. symptoms. neurological syndromes and non-neurological manifestations are recorded. are a cause of great concern to public health in India. In the absence of wellstructured epidemiological studies. Every year.int/ publications/journals/seajph DOI: 10. India Email: cecilia. this review attempts to summarize reports on dengue and chikungunya outbreaks from various regions of India. an Alphavirus. Persisting arthralgia. However. Changes in the genotype and mutations in the genome have been detected for both dengue and chikungunya viruses.Access this article online Review Website: www. Africa and North America in the 1780s. 910 D&N Haveli. 161 Tamil Nadu.40 70000 1. During 2010– 2012.25% in 2013. including Madagascar. 5432 Madhya Pd. 7132 Maharashtra. It was first described by Robinson and Lumsden in 1953. there has been a resurgence of chikungunya outbreaks in the islands of the Pacific Ocean. 2007–2013 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 23 . Delhi and Puduchery.11 DISTRIBUTION IN INDIA Since 2007.20 60000 1. dengue encroached into the remaining states. 0 Andhra Pradesh. in 1965 in Pondicherry (formerly Pondicherry). which are supplied with DENV. 198 Assam. Andhra Pradesh. The programme has 347 sentinel centres in 35 states and 14 apex referral laboratories.5% of those affected die. In the early 1900s.Cecilia: Dengue and chikungunya in India Rush.and CHIKV-specific IgM detection kits produced by the National Institute of Virology (NIV).2 The presence of four serotypes has become one of the complex challenges presented by dengue. A second infection after this period often results in severe disease.00 0 The history of dengue outbreaks in India has been recently reviewed. compared with 41. 61 Puduchery. The execution of well-designed epidemiological studies has been difficult. Tamil Nadu. India was one of the major areas affected.13 Resurgence of chikungunya has been attributed to various factors including globalization. 0 Manipur. 6408 Sikkim. 1409 Tripura. 1246 Chattisgarh. crosssectional dengue prevalence study in collaboration with Vadu Rural Health Programme.15 Daman & Diu. Rajasthan. about 40% of the world’s population is at risk and there are 50–100 million cases every year. 86 J & K. 7911 Punjab. The overall mortality rate of 1. An estimated 500 000 people with severe dengue require hospitalization each year and about 2.60 30000 0. sporadic cases continued to be recorded in Maharashtra during 1983 and 2000. West Bengal. 4526 Delhi. Although the number of dengue cases has shown a steady rise with every passing year.9 Thereafter.6 Chikungunya Chikungunya was first detected in 1952 in Makonde. dengue is widespread and endemic in most major cities. 4413 Kerala. the Swahili word for the contorted posture of patients because of their arthritic symptoms. Karnataka.12 Almost 1.3 Presently. Protective immunity against the infecting serotype is lifelong but lasts for only 3–4 months against the other serotypes. 6122 Karnataka. 46 Nagaland.. Compared with the rest of South-East Asia.2% for the rural village. This reduction is probably the result of the cumulative effects of better patient management.00 50000 0.20 10000 0. 52 Goa. Madhya Pradesh. Figure-1 shows the distribution of dengue cases among the states of India in 2013. Madhya Pradesh and Maharashtra and again in 1973 in Maharashtra. Uttar Pradesh. 1255 Meghalaya. 107 A& N Island. there was a very large epidemic in Reunion Island followed quickly by the one in India. dengue has re-emerged in the United States of America and has made inroads into Europe. Viet Nam.2% in 2007 dropped to 0. 2007 2008 2009 2010 No. 7 Figure 1: Distribution of dengue cases in Indian states in 2013 (based on NVBDCP data)6 80000 1. 5920 Uttar Pradesh. diagnosis and data assimilation for dengue and chikungunya in India have been facilitated by the National Vector Borne Disease Control Programme (NVBDCP). Punjab. increased diagnostic capabilities and better reporting. 6170 Uttrakhand.14 More recent and systematic data are now available because of the NVBDCP.10 Since 2003. 38 Rajasthan. Thailand. Kerala. the mortality has reduced (Figure-2). Dengue prevalence was determined in two villages that differed in the level of urbanization and population density. Mauritius and Reunion Island. We carried out a pilot age-stratified.4 In the last few years. of cases 2011 2012 2013 % Mortality Figure 2: Total dengue cases reported to NVBDCP (left axis) and percentage mortality (right axis) in India. Cambodia. loss of herd immunity and the mutation A226V in the E1 gene causing a significant increase in CHIKV infectivity for Ae. KEM Hospital Pune.8 In India. increase in the mosquito population. India.7 Epidemics were subsequently noted in the Philippines (1954.5 In India. Haryana. 67 Bihar. albopictus. 9 Mizoram. the Comoros. 190 Chandigarh. the number of dengue shock syndrome (DSS) cases in India remains low. 4114 Orissa. 1837 Jharkhand.5% for DENV was found in the urbanized village. spread of dengue was explosive and accompanied the movement of people across continents because of the slave trade and the two World Wars. United Republic of Tanzania (formerly Tanganyika) and derives its name from kungunyala. major epidemics of chikungunya were reported in 1963 in Kolkata. 1784 West Bengal.3 million suspected chikungunya fever cases were reported in India. A significantly higher seropositivity of 58.80 40000 0. 2215 Arunachal Pradesh. 5574 Gujarat. 54 Haryana.. The data on the web site of NVBDCP6 and earlier publications by NIV3 show that dengue has been endemic in 16 states since the beginning: Andhra Pradesh. Tamil Nadu. Goa. 1956 and 1968).11 In January 2006.40 20000 Dengue 0. Maharashtra. Chandigarh. 0 Himachal Pd. Gujarat. Myanmar and Sri Lanka. Lakshadweep had a chikungunya outbreak only in 2007.3% in a study that included 19 children older than 1 year in 1990 in the North Arcot district and the adjoining areas of Tamil Nadu and Andhra Pradesh. During 2009–2010. The cumulative number of cases observed per month during the 6-year period showed that the largest numbers were observed in the month of October with a positivity of 57. Maharashtra.13 The year 2011 was exceptional in that cases were reported from all states except Punjab. Karnataka.23 CHIKV then seems to have disappeared from India. well-designed epidemiological studies in demographically defined populations are required.18 Based on the symptoms presented the cases. This was followed by a large outbreak in Tirunelveli district. Tamil Nadu.24 In 2008 almost 100 000 people in different villages of Kasargodu district.Cecilia: Dengue and chikungunya in India in Delhi. 61 Figure 4: Distribution of chikungunya cases in Indian states in 2013 (based on NVBDCP data)13 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . The A226V mutation was found to occur only in the 2007 isolate from India.9% (Figure-3).15% positivity in 7846 samples and circulation of all four serotypes in 2003 followed by DENV-3 in 2004–2006. 5295 Goa. 646 A& N Island. the proportion dropped to 6.45%. 2006 and 2008. DENV-4 was poorly represented with just one case each in 2009 and 2010.17 We carried out a longitudinal study for a period of 6 years (2005–2010) in Pune city involving 24 private and government clinics/hospitals. Each year was characterized by the predominance of one of three serotypes. Rajasthan. DENV-1 was dominant in 2005 and 2007. Gujarat and Kerala.23 The A226V shift in the E1 protein that was detected with progression of the epidemic in Reunion Island was absent in all of the Indian isolates. In 2010 both DENV-2 and DENV-3 were co-dominant. reported three deaths in 38 DHF/DSS cases in the paediatric intensive-care unit with a mean age of 4. Dadra and Nagar Haveli and Lakshadweep.. This was followed by epidemics in Tamil Nadu. it is evident that to get accurate data. 859 Rajasthan.19 This fall probably reflected improved diagnosis and better reporting of non-hospitalized dengue cases. West Bengal. 202 Delhi. Co-circulation of all four serotypes was observed in 2003 and emergence of DENV-3 as the dominant serotype in 2005. DENV2 in 2007 and DENV-1 in 2008. DHF or DSS according to World Health Organization (WHO) 2007 criteria. 146 Tamil Nadu. A study on samples received at the All India Institute of Medical Sciences. The CHIKV isolate was found belong to the Eastern Central Southern African genotype (E1:226A). in Mumbai in 2003. DENV-2 was dominant in 2008 and DENV-3 was dominant in 2009. Andaman & Nicobar Islands and Puducherry.5% (n=235) cases were categorized as DHF.23 In the subsequent years. 2000 1800 1600 1400 1200 1000 800 600 400 Chikungunya 200 0 J F M A M J No tested J A S O N D No positive Figure 3: Seasonality of dengue during 2005–2010 in Pune city15 There have been a few longitudinal studies based on single/ multiple hospital data. Cherian et al. The 21–30 years age group was most affected by dengue throughout the 6 years. which belonged to the Asian genotype. Year-wise analysis revealed that the proportion of DHF cases was about 20% in 2005. There have been isolated reports on mortality in paediatric DHF/DSS cases which are much higher than the cumulative mortality reported by NVBDCP. Orissa.9 years. Madhya Pradesh. New Delhi.5% (n=2239) of the patients were classified as DF and 9. 18 Puduchery. 742 Karnataka. 139 Kerala.15 On testing 5106 samples we observed a positivity of 48. during 2003–2005 reported 44. During the 5-year period.8% in 2007.6% was reported in DHF/DSS patients from a single hospital where the mean age was 25. In the 1996 outbreak 24 The first recorded chikungunya outbreak was in Kolkata in 1963. a mortality rate of 6. 4827 Assam.21 Another study. 219 Maharashtra. 2890 Jharkhand. Tamil Nadu in 2009–2010. 2009 and 2010.20 reported a casefatality rate of 26. All four serotypes were found to be circulating in Pune. 76 Orissa. reported 30.12.22 Therefore. Distribution of cases in 2013 is shown in Figure 4.56% positivity in 1820 samples. Andhra Pradesh and Maharashtra in 1964–65 and in Barsi in 1973. All ages and both sexes were affected. The virus isolates belonged to the African genotype different from the viruses circulating in 1963–1973. The virus re-emerged in 2006 after a gap of 32 years and caused an explosive outbreak affecting 13 states. DHF was seen with low severity despite the circulation of multiple serotypes. West Bengal. CHIKV spread to other states: Goa. Kerala were affected by chikungunya.6 years. both cases were dengue haemorrhagic fever (DHF). The maximum number of cases belonged to the 21–30 years age group and the peak was in October. 90. 1049 Gujarat.16 Another study from a tertiary care hospital in Delhi covering 7 years (2002–2008). 35 Madhya Pd. The states first affected were Andhra Pradesh. cases were also reported from Maharashtra. 1432 Andhra Pradesh. were classified into DF. 19 Similar observations were reported from Delhi. hepatic. systemic complications – encephalopathy. which has been well documented in DHF. During a 5-year study conducted by our group on clinical profiling of patients. Liver involvement. Melaena and haematemesis were the most common haemorrhagic manifestations in DHF. Neurological syndromes in cases from Ahmadabad and Pune included encephalitis. rash and conjunctival congestion was found to be a possible prognostic marker of progression towards severe disease due to the strong association of these symptoms with DHF cases.26 SYMPTOMS Dengue DENV causes self-resolving DF in the majority of cases.9 Genotype III of DENV-3.41 The Indian isolates obtained over a span of 50 years by NIV were sequenced and analysed with global data. blindness due to retrobulbar neuritis and acute flaccid paralysis. Several groups have tried to identify prognostic symptoms for progression to severe disease. the excess deaths that occurred during the outbreak period was attributed to CHIKV and a mortality rate of 4. was evident in about 85% of the DHF patients tested. characterized by severe body ache.38 CHIKV infection in neonates is very rare. meningitis. based on death records during previous years in Ahmadabad.42–44 The phylogenetic analysis of the E gene sequence revealed that the Indian viruses formed clusters that were temporally distinct. oral ulcers and encephalitis. According to the new terminology recommended by WHO in 200915 dengue cases can be classified into dengue without warning signs. cardiac and haematological manifestations together with atypical manifestations including lymphadenopathy.36 Children are at maximum risk for severe manifestations of the disease.31. headache. joint pain. among 90 laboratory-confirmed chikungunya cases hospitalized in Ahmadabad. i. altered levels of consciousness.34 Optical abnormalities have also been associated with CHIKV infections. Complete genome sequence analyses have confirmed these results for DENV-145and DENV-2. retro-orbital pain and itching were seen in a significantly higher proportion of DF cases. seizures. Non-neurological systemic syndromes included renal. vomiting. dengue with warning signs (abdominal pain/persistent vomiting/mucosal bleed/increase in HCT with decrease in platelet count) and severe dengue (severe plasma leakage.28 Kerala29 and West Bengal.35. retro-orbital pain.3 million cases in 2006 but no data on mortality were available except for two reports – one on a subset of patients and one deductive. For all four serotypes. DENV4 serotype seems to have its origin in India.Cecilia: Dengue and chikungunya in India India reported 1.40 VIRUS EVOLUTION Dengue When dengue first emerged in India during 1950–60s.47 The Indian 2006 isolates were closer WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 25 . rash and myalgia. The clinical triad of abdominal pain. The neurological manifestations of dengue infection can be grouped into three categories: neurotropic effect of the virus – encephalitis.30 Although dengue is considered a non-neurotropic virus. high fever.32 Chikungunya Symptoms generally start 4–7 days after the mosquito bite. The circulation of serotypes in different parts of the country and changes in the circulating serotypes in consecutive years has been reviewed recently. headache and at times rash. is more virulent and has caused haemorrhagic outbreaks in many countries. In the chronic phase. B.25 The other report was deductive. optic neuritis and GuillainBarré syndrome. Genotype shifts for DENV-2 (American to Cosmopolitan) and DENV-4 (genotype V to I) and lineage changes for DENV-1 (India III to India I and II of American African genotype) and DENV-3 (F to A. hypokalaemic paralysis and papilloedema. 18 deaths were recorded of which 15 were aged 60 years or older and five had comorbidities. stroke. The acute phase is characterized by painful polyarthralgia. myositis and myelitis. Phylogenetic analysis based on partial sequences of NS4 and E1 genes showed that all earlier isolates (1963–1973) were Asian genotype. whereas the 2006 and 2000 isolates were African genotype. neuromyelitis optica. respiratory. myelitis. the viruses circulating in India in the 1950s and causing mild disease were either replaced or evolved into lineages/genotypes with greater virulence and/or transmissibility. the disease was mild despite circulation of all four serotypes. which originated in India.37 Another report on CHIKV infection in infants younger than 12 months old indicated that the most characteristic features of the infection in infants were acrocyanosis. encephalopathy and myelopathy or myeloneuropathy. asthenia. The evolution of genotype I of DENV-4 in India could be associated with an event of recombination of a genotype V Indian isolate of 1961 with a genotype I Sri Lankan isolate of 1978.46 Chikungunya The evolutionary timescale of CHIKV was estimated to be in the last 300 years under a constant-population relaxed-clock model.9% was reported. incapacitating arthralgia persists for months. Some of the clinical features in children include neurological manifestations. abdominal pain and nausea. C and D of genotype III) were observed.33. severe bleeding and severe organ involvement. neurological complications have been reported in dengue cases. encephalomyelitis. The progenitor of the 2005–2007 viruses was found to have existed around 9 years ago and may have originated from Uganda. In one report. and postinfection – acute disseminated encephalomyelitis. symmetrical superficial vesicobullous lesions and erythematous asymmetrical morbiliform rashes.39 Vertical transmission of CHIKV from mother to child has been documented. one case presented with severe thrombocytopenia and features of multisystem involvement.e. The disease profile changed and greater severity was reported from the late 1980s. female-specific lethality. The transgenic strain. N. allows genetic sexing resulting in male-only releases and permits the release of eggs instead of adult mosquitoes. 1998. Emerg. Indian J Med Microbiol. In: NIV Commemorative Compendium National Institute of Virology. Portugal.30(2):222-226. http://www.3:92. Raghupathy P. 1–10. 1955. 2013.in/chikun-status. AD. resistance to infection was found to persist in transinfected mosquitoes which were released in a field trial for a year. Res.accessed 16 March 2014. 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Schuffenecker I. 2008. Bhakdeenuan P. Shetty R. Molecular characterization of Chikungunya virus isolates from clinical samples and adult Aedes albopictus mosquitoes emerged from larvae from Kerala. Bandyopadhyay T.88:1967-76. Narayana KM. Sharma P. 2009. Mourya DT. Mahendradas P. Indian J Pediatr.42(4):255-61. Verma R. 40. 2007. Systemic involvements and fatalities during Chikungunya epidemic in India. Am J Ophthalmol. Ocular manifestations associated with chikungunya. 3(1): 22–27. Maheshkumar S.Cecilia: Dengue and chikungunya in India 23. Cherian S. 36. Sathe PS. 59. Thavara U. Ophthalmology. Overall. 59% (DENV-1) and 34% (DENV-3) respectively. the control of VBDs remains difficult. Key words: Chikungunya. Regional Medical Research Centre for Tribals Campus.4103/2224-3151. Nagpur Road.0001).0. Madhya Pradesh. while for chikungunya very few samples were found to be positive. Madhya Pradesh. Madhya Pradesh. and show year-to-year variation. filaria.com Conclusion: Despite recent advances in potential vaccines and new therapeutic schemes. Regional Medical Research Centre for Tribals (Indian Council of Medical Research). P<0. dengue.0. India 1 Address for correspondence: Dr Neeru Singh. A coordinated. at 5% (odds ratio [OR] = 3. The slide vivax rate was highest among infants. with reference to malaria. Gyan Chand1.7%) as compared to females 6.4. Methods: The studies were carried out at the request of Government of Madhya Pradesh. in the years 2011. malaria. microfilaria rates were higher in males (8. filaria. This age-related pattern was not seen in other VBDs.5%.Access this article online Original research Website: www.com. India. dengue and chikungunya Neeru Singh1. Mrigendra P Singh2 Abstract Background: Vector-borne diseases (VBDs) caused by parasites and viruses are a major cause of morbidity and mortality in Madhya Pradesh (MP). Jabalpur Madhya Pradesh. For dengue and chikungunya. 2012 and 2013 among referred samples. 16. Pradip V Barde1. divided by the total number of blood smears made) was 18. Manmohan Shukla2.5 to 9. in three locations where many VBDs are endemic. 2012 and 2013. 95% CI 1.6% and 7. dengue and chikungunya. vectorborne diseases 28 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . suspected cases were referred to the research centre.who. rmrctjabalpur@rediffmail. filaria.05) and the highest slide falciparum rate was 20% in children aged 1–4 years (OR = 2. except on malaria. The microfilaria rate was 7. Therefore. 95% confidence interval [CI] = 1. P < 0.115828 Quick Response Code: Vector-borne diseases in central India.singh@gmail. Jabalpur. India 2 National Institute of Malaria Research Field Station. 7. interruption of transmission still relies on vector-control measures. Regional Medical Research Centre for Tribals (Indian Council of Medical Research). Email: neeru.5.int/ publications/journals/seajph DOI: 10. These diseases are malaria. Data on malaria/filaria prevalence were collected by repeatedly undertaking cross-sectional parasitological surveys in the same areas for 3 years. P<0. lymphatic filariasis.8. Jabalpur 482003.4% (372/2266) and 20.1 to 2.searo.7.8% in the years 2010. consistent. Epidemiological information is lacking on different VBDs that are commonly prevalent in rural-tribal areas of MP.4% (OR = 1.5 to 2. falciparum.4% (104/509) respectively in the years 2011. central India. Post Garha. integrated vector-management approach is needed to control malaria. There was a strong age pattern in both Plasmodium vivax and P. Jabalpur. The prevalence of dengue was 48% (dengue viruses 1 and 4 – DENV-1 and DENV-4). Results: Monitoring of results revealed that all the diseases are commonly prevalent in the region. dengue and chikungunya.01).7% (190/1018). 95% CI = 1. 2012 and 2013. Malaria slide positivity (the number of malaria parasitaemic cases. respectively. The area is under two rounds of indoor residual spray (IRS) with dichlorodiphenyltrichloroethane (DDT) for vector control.11 It is estimated that 34% of the global cases are from India10 and the country is known to be endemic. evidence-based strategies for curbing these diseases. Study area Madhya Pradesh is situated in the centre of India and comprises 50 districts. Orissa and Rajasthan. summer (April to June). Statewide analysis of chikungunya was also carried out. before apparently disappearing for a period of several years to decades. dengue and chikungunya are important VBDs.and middleincome countries.4 Lymphatic filariasis is endemic in 81 countries in tropical and subtropical regions of Asia.17 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 29 . with all four serotypes (DENV-1.6 In India about 600 million people. residing in 250 districts. has an area of 3701 km2 and one third of the area is under forest. The study area is on the border of the Bilaspur and Korea districts of Chhattisgarh state. The inhabitants spend most of their time outside their dwellings and sleep outdoor during hot and humid seasons. are at risk.1 One hundred and four countries and territories are endemic for malaria. with an average elevation of 505 m. MATERIALS AND METHODS The study has the approval of the ethics committee of the Regional Medical Research Centre for Tribals (RMRCT). The district is about 300 km from RMRCT. Anuppur district Anuppur is located at 23. fluviatilis. lymphatic filariasis.: Vector-borne diseases in central India Introduction Vector-borne diseases (VBDs) caused by parasites and viruses are major cause of mortality and morbidity across the world. Malaria is a major public health problem.473 to 0.5. after 32 years.13 Chikungunya virus (CHIKV) is a mosquito-transmitted singlestranded RNA alpha virus belonging to the family Togaviridae.16 The villages are located off road and the terrain is inaccessible. In all. especially in tropical and subtropical low. In 2005. North Eastern States. of which nearly 100 million require medical attention. monsoon (July to September). encircled by perennial streams and their tributaries. DENV-2. A. and over 1. the studies on malaria. Spleen examination was carried out in children aged between 2 and 9 years.3 million cases of chikungunya are estimated to have occurred in India. The population of the district is 749 237. for Madhya Pradesh and Chhattisgarh.7 India alone contributes 40% of global cases of lymphatic filariasis. and India alone contributes about 50% of the 2 million reported cases in the World Health Organization (WHO) South-East Asia Region. spring (February to March). stephensi and A. throughout the year.68°E.15 The disease is overshadowed by dengue.627 (range 0. causing an estimated 390 million infections every year worldwide. Jharkhand. with a major contribution to the overall global disease burden every year. Africa.1 The majority of malaria cases and deaths in India are reported from Chhattisgarh. of which three are common in central India.3. The results reported fill some knowledge gaps with regard to the burden associated with these VBDs in Madhya Pradesh.14 A characteristic feature of CHIKV is that it causes explosive outbreaks. Malaria. using Hackett’s method. This study aims to describe the characteristics of VBDs that are commonly prevalent in central India.10 and more than 500 000 require hospitalization.789) million deaths throughout the world in 2012. fluviatilis. with or without fever.1°N 81. culicifacies and A. Madhya Pradesh. the disease re-emerged in the Indian Ocean.Singh et al. which has similar symptoms and is transmitted by same vector.9 Lymphatic filariasis is caused mainly by W.2 There are six efficient vectors of malaria. lymphatic filariasis and dengue were carried out in the districts of Anuppur. Dengue fever is a most important re-emerging arboviral disease. These streams supports numerous breeding sites for A. Panna and Narsinghpur respectively (see Figure 1). 12 cross-sectional parasitological surveys were carried out for malaria during 2011–2013. covering all seasons i. as a result chikungunya is neglected because the symptoms are milder in comparison to dengue. of whom 48% are ethnic tribes. to help policy-makers to commence appropriate. Jabalpur is the WHO collaborative centre for the health of the indigenous population and the National Vector Borne Disease Control Programme (NVBDCP) designated apex referral laboratory for dengue and chikungunya. The inhabitants of the villages are of the primitive Baiga tribe and the local economy is mainly forest based.e. At the request of the Government of Madhya Pradesh. post monsoon (October to November) and winter (December to January).6 An estimated 25 million have genital disease and 15 million have lymphoedema or elephantiasis caused by Wucheraria bancrofti or Brugia malayi. causing 207 (range 135 to 287) million cases and 0. Jabalpur. or in agricultural fields for crop protection. Jabalpur.34 billion people at risk of infection. central and south America and Pacific Island nations. namely Anopheles culicifacies. Most tribal villages are formed of three to eight scattered hamlets. There is historical evidence that CHIKV originated in Africa and subsequently spread to Asia. RMRCT. with more than 120 million people infected and 1.8 There are about 31 million microfilaria carriers and 23 million chronic clinical cases. bancrofti (>99%) and transmitted by mosquito – Culex quinquefasciatus.12 Aedes aegypti is regarded as the principal vector for this virus in India. DENV-3 and DENV-4) circulating throughout the year in different parts. 17°E.6% of the geographical area and the inhabitants of the study area belong to a low socioeconomic group and are employed in agricultural practices. mass drug administration (MDA) started in the district. dengue and chikungunya For malaria. with a population of 1 091 854 and is about 90 km from RMRCT. showing study districts Anuppur (C).4% ethnic tribe) and they are engaged mainly in agricultural activities. For lymphatic filariasis. Among these.Singh et al. Narsinghpur district Narsinghpur is located at 22. Blood samples of patients in Madhya Pradesh state with suspected chikungunya during 2011 to 2013 were referred to RMRCT for laboratory testing. artemisinin-based combination therapy (ACT) + primaquine for Plasmodium falciparum and chloroquine + primaquine for P. after obtaining written informed consent. of which 49% is under forest. The population of the district is 1 016 520. The district has an area of 5125. with an average elevation of 410 m.: Vector-borne diseases in central India Figure 1: Map of India (A) and Madhya Pradesh (B). Blood samples from patients with suspected dengue in Narsinghpur during 2011 to 2013 were referred to RMRCT for laboratory testing. filaria.55 km2.19 Treatment was provided as per national drug policy on malaria. Panna has an area of 7135 km2. thick and thin blood smears were made from all fever cases and cases with a history of fever in the past 14 days. Jabalpur. Panna district is highly endemic for filarisis and about 200 km from RMRCT. with an average elevation of 347 m. Microfilaria surveys were carried out in randomly selected villages that historically had clinical cases related to filarial disease.2°E. sentinel villages under NVBDCP were also surveyed. data from the district in previous years were obtained from the district malaria officer Anuppur. along with details of the insecticide used for spray and the population covered (see Table 1). 30 Sample processing for malaria.27°N 80.20 Pregnant women and infants were not given primaquine. Blood smears were stained with Jaswant singh and Bhattacharji stain18 and examined under a microscope as described earlier. 2012 and 2013. Jabalpur. and by June 2013 eight rounds were completed. vivax. Jabalpur Panna district Madhya Pradesh state Panna is located at 24. Forest covers 26. of whom about 88% live in rural areas (only 15. 40 µL of blood was taken from a finger prick and a thick smear was prepared and WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .9. blood slides were prepared by conducting night blood surveys between 8 pm and 11 pm. from a randomly selected population. From 2004.e.95°N 79. Panna (D) and Narsinghpur (E) RMRCT: Regional Medical Research Centre for Tribals. A total of three surveys were carried out in the years 2010.21 Before undertaking this investigation. i. 7% (190/1018).0001). Study definitions The slide positivity rate (SPR) was defined as the number of malaria parasitaemic cases.7) as compared to adults (P < 0. Pvt.3%. and >14 years.11 0. falciparum (1.48 0. Odds ratios (ORs) and 95% confidence intervals (CIs) were also presented for 2 × 2 contingency tables.3.2%.61 0.4% and 19.22 Treatment to microfilaria carriers was provided by the district medical officer.8).1. >4 years to 8 years. Young children between 1 and 4 years of age showed the highest rate of parasite positivity. For lymphatic filariasis.Singh et al. The gametocyte rate was 20. vivax and P. BSE: blood slide examined. RESULTS Malaria slide positivity was 18. though the difference was not statistically significant. Analysis of the distribution of malaria cases by species of parasite and season revealed (data not shown) that P. Statistical analyses were performed using STATA 12 for Windows (StataCorp LP.82. The proportion of P. vivax (16. The average spleen enlargement was 1.0). 95% CI = 2. using a kit manufactured by NIV. dengue-negative samples were also tested for the presence of CHIKV IgM and the PCR products were sequenced.5% (338/950) in 2012.6% and 7. SFR: slide falciparum rate.8% respectively in the WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 31 .8%. The samples collected in the acute phase of illness were subjected to RT-PCR. The age-specific and species-specific data on malaria are shown in Table 2. For dengue.97 1. 11.9% in 2011 to 20. as described by Naresh et al. 7. followed by winter (24%. respectively. 95% CI = 2. Pune.26 A few.9. Ltd. An additional decrease in malaria positivity was seen in older children and adults (>14 years). Texas. which increased to 40. 2012 and 2013. divided by the total number of blood smears made. >8 years to 14 years. API: annual parasite incidence.9%. stained as described earlier.25 The PCR products were sequenced to identify genotypes.5 to 9. 95% CI = 1. 16.0 to 1.23 All the samples collected after the fifth day of illness were tested for the presence of DENV-specific immunoglobulin M (IgM).1%. In adults.7% and 14. The samples collected in the acute phase of illness (in the first 5 days) were tested either for the presence of nonstructural (NS1) protein by using the dengue day 1 diagnostic test (DENGUE DAY1 TEST.78 1. Both P. ABER: Annual Blood Examination Rate. Pune.: Vector-borne diseases in central India Table 1: Epidemiological situation of malaria in Anuppur district and the population under DDT spray (2011 to 2013) Year Target population 2011 2012 2013 681 862 764 511 779 801 Population Sprayed with DDT 126 431 156 014 174 178 BSE Positive Pf Pv ABER API SPR SFR 81 868 85 734 76 331 1211 834 846 650 520 447 561 314 399 12.79 0. The microfilaria rate was calculated as the number of microfilaria-positive cases out of the total number of blood smears examined. the blood samples from suspected patients were collected by the treating physician and referred to the laboratory in the cold chain.79 1.08 1. malariae were found. United States of America). These samples were tested for the presence of CHIKV IgM antibodies. The SFR was highest (25%) in the post-monsoon season (OR = 3. 21.2% in the age groups <1 year. samples were referred from all over the state.59 Source: District malaria officer.25 For diagnosis of chikungunya. divided by the total number of blood smears made. New Delhi.05 and at 95% confidence level. India) and/ or by nested reverse transcription polymerase chain reaction (nRT-PCR).4% (104/509) respectively in the years 2011. SPR: slide positivity rate.21 9.05). 3016 individuals were screened during three surveys carried out in Panna district (see Table 3). by enzyme-linked immunosorbent assay (ELISA). 548/666) were prevalent in all age groups.6% and 4.0 to 4. 10. and lowest in monsoon (10 %).1%.0. the SFR was highest in young children >1 year to 4 years (OR = 2. OR = 2. Only three cases of P. the gametocyte rate was significantly lower than in other age groups (see Table 2). >1 year to 4 years. All records were validated and all inconsistencies and differences were resolved before analysis. India as per the manufacturer’s protocol. 95% CI = 1.4% (372/2266) and 20.9). The significance level was considered alpha = 0. Categorical data are presented as frequency counts (%) and compared using the χ2 or Fisher’s exact statistic as appropriate. as per NVBDCP guidelines. Anuppur district. falciparum increased from 80% in 2011 to 93% in 2013 (OR = 1. The microfilaria rate was 7. 95% CI = 1. using a kit developed by the National Institute of Virology (NIV).5 to 2. with information in a predesigned format.4) when compared with adults (P < 0. 8/666).01 11.6% in 2013 (67/165). 107/666) and P. A decrease in malaria positivity was recorded in relatively older children in the age groups >4 years to 8 years and >8 years to 14 years. randomly picked. J Mitra and Co.09 1. Further analysis revealed that the SVR was highest in infants (<1 year. Positive: positive for malaria. Pf: Plasmodium falciparum. (2007).1% in 2013.5%. Year-wise analysis revealed that SPR and SFR increased from 18.24 with minor modification. Data analysis The demographic and clinical information of patients was double-key entered into Microsoft Excel 2007. DDT: dichlorodiphenyltrichloroethane. However.8. The slide falciparum rate (SFR) and slide vivax rate (SVR) were defined as the number of falciparumand vivax-infected cases respectively. OR = 3. with a few cases of mixed infection with P. falciparum (82. The prevalence of splenomegaly was 35. using the basic local alignment search tool.1 to 4. falciparum was the dominant species in all surveys. 7) 1 (reference) CI: confidence interval. while in 2013.3 (1.2) 2. In the years 2011 and 2012. 20 were found to be positive. as compared to other age groups.9)a 1 (reference) 1 (reference) PfG 6.5.0001.6 to 47.7) 135/1097 (12.5)b 1.1 (1.2 Malaria 2. years 2010. a total of 123 samples were referred and.9)a 2. of which 34% were positive (DENV-3).4 %).9)a 1.5 (2.4 (1.1 11.8 to 46.6) 120 (10.1) 228d/1289 (17.7 to 6.6 (1.2 to 56. 2012 and 2013.1 (1.9) 7 (5.9)c 3. Both sexes were infected but the overall microfilaria rate was higher in males (8. 95% CI = 1. Table 3: Microfilaria rates from Panna district (2010–2013) Year 2010 2012 2013 Odds ratio (95% CI) Male +ve/screened Female +ve/screened 36/394 56/659 66/759 15/281 25/416 33/507 Microfilaria positivity rate (95% CI) Male Female 9.9 10. of these.5 to 10.0) 1 (reference) 1. of which 48% were positive (DENV-1 and DENV-4).1 to 1. a Age of one patient is not known.1 (13.1 to 2.0) 90 (19.9) 6.: Vector-borne diseases in central India Table 2: Malaria positivity in the study area of Anuppur district (2011–2013).2 to 2.1 (0.1 (15. b P < 0.5) 37 (2. This difference was statistically significant (OR = 1.4 to 4.0 (0.0 (1.7 (1.01.0 to 2. two chikungunya cases were detected in the samples referred from Mandsaur district of west Madhya Pradesh.0 (1. For CHIKV infection.0) 162/807 (20.7)c 3.8 (1.6 (1.4) 1. 59% were positive (DENV-1).3 to 3.6 4.0.3) 24 (17. in this extremely heterogeneous epidemiological landscape.2 to 1. a P < 0. Studies such as the current one are crucial for understanding the dynamic nature of malaria.6) 8.4 to 4. SFR: slide falciparum rate.9)b 1 (reference) Odds ratio (95% CI) P. CI: confidence interval.8 (1.4)a 2.1 to 8. vivax 1.2 (1. BSE: blood slide examined. Pf: Plasmodium falciparum.4) 5. all the positive cases reported were from Jabalpur district. Further analysis revealed that adults in the age groups 26–45 years had the highest numbers of dengue cases.0 (3.5 (4. Pfg rate: Plasmodium falciparum gametocytes rate.5 to 24.3) 42.0)c 1. Analysis further revealed that 32 the DENV-1 (genotype III) in 2011 and 2012 and DENV-3 (genotype III) in 2013 were circulating in the area.1)b 2. although this was not statistically significant (see Table 4). WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .5 to 9.8 to 10. CI: confidence interval.4) 28 (3.0) 20 (4.1 to 2.3)c 1.4 to 2. Monitoring of drug distribution and compliance revealed that coverage was 43% and the compliance rate was 19%.5 (1.0)b 6. 31 samples were referred from Narsinghpur district in 2011.0)a +ve: microfilaria positive.5 (6.0 (1.5 to 9. Table 4: Dengue cases detected from Narsinghpur district in 2013 Age groupa (years) 0–15 16–25 26–45 46 and above +ve/sample tested 9/32 9/28 23/54 7/26 Positivity rate (95% CI) 28.7) 8. out of 364 tested samples.6 )a 1 (reference) +ve: malaria parasitaemic cases. while two cases were among travellers returning from the southern part of India.9 to 8.5 to 2.5 to 12.1 (2.3 (0. DISCUSSION The morbidity and mortality associated with VBDs pose a growing problem for global public health.7 (6.1 to 17.2 to 3.7 to 5. SPR: slide positivity rate.0 to 7.7 (1. c P < 0.4) 20.8) Odds ratio (95% CI) 1. according to age and species Age group (years) +ve/BSE (SPR) Pf (SFR) Pv (SVR) PfG rate ≤1 >1–4 >4–8 >8–14 >14 years 31/141 (22. P < 0.6) 188 (14.01.9) 6. odds ratio: odds ratio.9 to 52. 141 samples were tested. d 3 Plasmodium malariae.9) 15 (1.05.8 21.8)b 2.1 (6. It was interesting to note that about 5% of dengue-positive cases were admitted to the tertiary care government hospital at Jabalpur (referral hospital) in 2011 and 2012 when DENV-1 and DENV-4 were detected.7 to 3. SVR: Slide vivax rate.6) 134 (16. lymphatic filariasis. dengue and chikungunya.3 to 3.0 to 8. a P < 0. while 50% of dengue patients were admitted to tertiary care for treatment when DENV-3 was detected.0) 110/459 (24.9 (11. whereas in 2013. Pv: Plasmodium vivax. Nine samples were found positive by nRT-PCR.7%) as compared to females (6.1)b 2.3 (3. falciparum P.01). The sequencing and phylogenatic analysis revealed that the virus belonged to the East Central South African genotype.8) 26.7)a 3.Singh et al. For dengue. In 2012.8) 32.6 (29. in particular the development of insecticide resistance in the vectors and the drastic reduction of chemicals available for public health. owing to the complexities of human behaviour and of scaling up malaria-control measures. it is important to monitor the virus activity.22 Historically. as transmission intensity increases. increasing urbanization. which is a rational decision-making process for optimal use of available resources. the microfilaria rate of Panna district is ≤1%. these methods face several obstacles. which are not approachable throughout the year and which are dominated by socioeconomically disadvantaged people of tribal origin. the insecticide-treated nets (ITNs)/LLINs are not distributed. CHIKV too has been documented to be circulating in central India for over half century and the virus was isolated from both human and mosquitoes from Nagpur city in 1965. conducted over the last 3 years. which favors man–mosquito contact. However.38 Overall.10 There are many reasons for the increase in reported cases: the spread of disease is enhanced by frequent international travel. vivax and P. with more than 60% compliance. which was non-endemic earlier.35. ineffective vector-control measures.31 Amidst this progress.40 The four antigenically distinct dengue viruses (DENV-1 to -4) cause a wide range of signs and symptoms. Only 20% of infections were found in older children and adults.41 The incidence of dengue is increasing worldwide. with both P. This suggests the need for a better coordinated. particularly in remote areas. as several distinct malaria ecotypes exist. it underlines that the ECSA genotype of CHIKV is in circulation in Madhya Pradesh. Records revealed that four rounds of mass drug administration were carried out with diethylcarbamazine (DEC) alone.4 In this study area. Available literature reveals that five or more rounds of a good compliance rate of mass drug administration reduce the microfilaria rate to below 1%. a large proportion of people are sleeping in the forest unprotected. Only two rounds of DDT were sprayed. Although this study has the limitation of small sample size and a low number of referred samples. nor is the area sprayed with synthetic pyrethroid. and.39 Moreover. with marked differences in clinical severity. The number of malaria cases and age groups indicated that the risk for the age group under 8 years was two times greater than in older age groups.40 The four serotypes of DENV showed wide variation over time in epidemiology and clinical presentation. More than 45% of cases were reported in children aged less than 8 years and 34% cases were reported in children aged between 8 years and 14 years. and resistance to this insecticide is common among vectors. education and communication (IEC) and behaviour-change communication (BCC) for better drug compliance.44 The present study.45 Despite recent advances for potential vaccines and new therapeutic options. However. Several independent studies have reported that the incidence of malaria in the country is grossly underestimated. from where it can spread to areas that are currently free of filaria transmission. lymphatic filariasis. evidence of lymphatic filariasis was also found in this district. including India. 16 samples were referred for dengue.37.36 This is mainly due to lack of proper surveillance. Panna district is also endemic for malaria19 and. One of the key features of integrated vector WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 33 .4 Malaria control remains difficult if foci are located in forested areas.33 or may be at higher risk of infection because of behavioural factors. according to the state VBD control programme. as CHIKV is known to spread very fast.43 It is worth mentioning here that Narsinghpur is not only endemic for dengue. dengue fever. Moreover. thereby increasing the movement and exposure of viraemic people. foci and hot spots for filaria are still present. in terms of both the number of reported cases42 and the number of countries where the disease is emerging or re-emerging.Singh et al.40 Therefore.32 These high-risk populations may carry infection from their workplace to their villages.4 There is evidence that. earlier studies have revealed that vectors bite both indoors and outdoors. WHO encourages adoption of the integrated vector-management strategy. especially in immunologically naive populations. ranging from asymptomatic infections to undifferentiated fever. Dengue is the fastest re-emerging arboviral infection transmitted by Aedes mosquitoes. these diseases can be potentially controlled by the same interventions or strategies. biological and chemical methods is an important component of prevention of VBDs. particularly during October to December. multi-disease strategy for vector control. other factors such as sequence variation and primary and secondary infections are known to influence the clinical manifestations. wherever these diseases are endemic.30 It is worthwhile to mention that tremendous progress has been made in some countries in reducing malaria-related morbidity and many countries are striving for elimination of malaria. dengue hemorrhagic fever and dengue shock syndrome. interruption of transmission still relies on vector-control measures.29 In spite of high malaria positivity. a major challenge is in forested areas. where it is expected that transmission ceases. To conclude. malaria transmission is perennial.27. malaria. Moreover. the age of peak morbidity decreases. with a further four rounds with DEC + albendazole. as recorded earlier. the mass drug administration should be with DEC + albendazole. in areas where more than one disease is endemic. dengue and chikungunya are all transmitted by mosquitoes and. Forest malaria is a wellcharacterized ecotype associated with high transmission of malaria. falciparum present in all surveys. the rates of microfilaria recorded in this study showed that this area is still highly endemic for filariasis after the eighth round of mass drug administration. Lymphatic filariasis is in the elimination phase in several countries. recently. the control of VBDs remains difficult.34 Although the feeding behaviour of vectors was not studied in this area. besides differences in serotypes. of which 56% were positive for DENV-3. However. above all.: Vector-borne diseases in central India The risk of malaria within the country varies dramatically. The present study shows the need to improve the delivery system of drugs and to strengthen information.45 Vector control through the use of physical. confirms the circulation of CHIKV in the central part of India. when falciparum transmission is highest. To stop transmission.28 Interestingly. and can cause long-lasting arthritis resulting in clinical complications. a recent study reported a shift in the mean age of malaria cases after introduction of intervention measures in Orissa (long-lasting insecticidal nets [LLINs] + ACT). Shukla MM. Guidelines on filariasis control in India and its elimination. 23. Sinton JA. J Gen Virol.searo. 7.html . National drug policy on malaria 2013. http://www. 1958. Ind J Med Res. Greenwood BM. http://www. Vorndam AV. World Health Organization. Rapid detection and typing of dengue viruses from clinical samples by using reverse transcriptase-polymerase chain reaction. Rapid staining of malarial parasites by a water soluble stain. Chikungunya fever: facts. Chand G. Casals-Pascual C. 15. India & phylogenetic relationship with Central African isolates. Chaturvedi UC.gov. To improve the coverage and utilization of interventions. prevention and control .gov. New Delhi: Directorate of Health Services. 2013. Farrar JJ. George DB. Chapter 1. 11.in/pca/default. New Delhi: Directorate General of Health Services. 9. Ministry of Home Affairs. Bojang KA.gov. Indian J Med Res. Singh Neeru. Trans R Soc Trop Med Hyg.35(86):377–388. Changes in malaria indices between 1999 and 2007 in The Gambia: a retrospective analysis. Sankoh O.pdf .assessed 26 February 2014.81:471–9. Messina JP. Sey O.0073730. J Postgrad Med. 10. Anthony Johnson AM.103:1202–3. Geneva: WHO. Moyes CL. Indian Medical Gazette. comprehensive and sustained national advocacy (IEC/BCC) campaign is required. Palmer A. treatment. Updated September 2013. Sesay SS. Epidemiology of malaria transmission in an area of low transmission in Central India. 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Etiology of the 1965 epidemic of febrile illness in Nagpur city. Ebol A. World malaria report 2008.rmrct. 37. 2 Four antigenically related serotypes of dengue virus (DENV).4 Chikungunya re-emerged in 2005. Key words: Central India. which may lead to more complex clinical outcomes such as dengue hemorrhagic fever (DHF).2 India contributes about 34% of these cases. Dengue viruses 1 and 4 were found co-circulating with chikungunya virus in Jabalpur.4 Infection with the chikungunya virus is generally self-limiting but in a few cases it may cause severe incapacitating arthralgia in small joints. Conclusion: Accurate and timely diagnosis would help in patient management and use of resources. co-circulation. lasting up to 6 months or more. This will also aid in understanding the epidemiology of chikungunya. The samples collected in acute phase of illness were tested by nested reverse transcription polymerase chain reaction (nRT-PCR). Email: neeru. 6 Dengue-confirmed and chikungunya-suspected cases have been reported from this part of the country in the recent past.1 It is estimated that about 100 million dengue cases and over 390 million infections occur worldwide annually. Jabalpur. Chikungunya virus (CHIKV) sequences were analysed to determine their genotype.int/ publications/journals/seajph DOI: 10. Madhya Pradesh. Chikungunya WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .9%) were positive. The incidence of dengue has increased more than 30-fold in the last 50 years. and of 119 samples screened for chikungunya. with different genotypes. both diseases present with a similar set of clinical symptoms. Bhupesh K Kori1.4 with a predominance of the East Central South African genotype of virus. such as sudden onset of high-grade fever. Madhya Pradesh. Regional Medical Research Centre for Tribals (Indian Council of Medical Research). dengue Introduction Arthropod-borne viral infections cause major disease burden in tropical and subtropical countries worldwide. India.searo. Materials and methods: Samples from suspected dengue cases were subjected to dengue immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) and dengue-negative samples were tested with chikungunya-specific IgM ELISA. Post Garha. 1 Address for correspondence: Dr N Singh. dengue shock syndrome (DSS) or death. Neeru Singh1 Abstract Background: Dengue and chikungunya present with very similar signs and symptoms in the initial stage of illness and so it is difficult to distinguish them clinically. This study was conducted with the aim to explore the co-circulation of dengue and chikungunya viruses in central India.4 million cases.1.com. and rash. Praveen K Bharti1.Access this article online Original research Website: www.who.3 All four serotypes can cause simple febrile illness (DF). India. Nagpur Road. headache. The chikungunya virus detected belonged to the East Central South African genotype. muscle and joint pain. 21 (15. nausea and vomiting. It is advocated to simultaneously test samples for these two diseases in endemic areas. 2 Netaji Subhash Chandra Bose Medical Collage.115828 Quick Response Code: Co-circulation of dengue virus serotypes with chikungunya virus in Madhya Pradesh. Mohan K Shukla1.4103/2224-3151.4 DENV and CHIKV are both transmitted by Aedes aegypti and Aedes albopictus mosquitoes. 13 (10.singh@gmail. India. are known to be circulating in India. rmrctjabalpur@rediffmail. Jabalpur 482003. with about 1. Madhya Pradesh.4 making differential diagnosis difficult clinically. Both are transmitted by Aedes aegypti and Aedes albopictus mosquitoes. central India.2%) were positive. Jayant K Jatav2. In the initial stage of illness. after a gap of 32 years. chikungunya. and 36 continues to circulate in India. central India Pradip V Barde1.5. Regional Medical Research Centre for Tribals (ICMR). Jabalpur.com Results: Of 138 samples screened for dengue. chikungunya is overshadowed by dengue in outbreak situations and in dengue-endemic areas. Jabalpur is recognized as the Apex Referral Laboratory by the National Vector Borne Disease Control Program (NVBDCP) for dengue and chikungunya. in turn.9 Upon receipt.7 However. CHIKV: chikungunya virus. as defined by NVBDCP. Ethical approval Samples were referred to this virology laboratory for diagnosis of diseases and thus considered as part of the public health response. using kits manufactured by the National Institute Total sample n=138 Acute phase sample n=25 DEN nRT-PCR DENV IgM ELISA n=138 n=19 Positive n=119 Negative n=06 Positive n=19 Negative CHIK RT-PCR n=19 CHIK IgM ELISA n=119 n=06 Positive n=113 Negative n=09 Positive n=10 Negative Figure 1: Flowchart depicting the methodology of processing the samples ELISA: enzyme-linked immunosorbent assay. Materials and Methods The virology laboratory of the Regional Medical Research Centre for Tribals (RMRCT). DENV-ELISA-negative samples were tested by chikungunya IgM ELISA. Samples and testing This year-round (April 2011 to March 2012) study was conducted in Madhya Pradesh.5 This study sought to confirm the co-circulation of the two viruses in central India.8 Diagnosis of chikungunya is equally important.: Co-circulation of dengue and chikungunya viruses has low/no mortality.Barde et al. are the best tools for controlling or avoiding outbreaks in endemic areas. The testing sequence for the samples is shown in Figure 1. Jabalpur. timely intervention by prompt accurate diagnosis. serum was separated by brief centrifugation at 4oC and was preferably tested on same day by immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA) or nested reverse transcription polymerase chain reaction (nRT-PCR). nRT-PCR: nested reverse transcription polymerase chain reaction WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 37 . India. mortality may go up to 3–5% in outbreak situations and serious cases. help with designing intervention strategies. IgM: immunoglobulin M. for Madhya Pradesh and Chhattisgarh. as it would help to estimate the disease burden and. using serological and molecular tools.4 were collected by clinicians and referred for diagnosis to the virology laboratory of RMRCT. along with clinical and demographic information in the World Health Organization’s (WHO’s) predesigned format. In the absence of any licensed vaccine for either of these diseases. All the samples were tested by dengue-IgM-specific ELISA. Blood samples of patients reporting to health-care units of Jabalpur and the adjoining 14 districts. Chikungunya can spread with ease and causes a high percentage of clinical cases with a very high attack rate in an immunologically naive population. with symptoms of dengue and chikungunya. the project “Establishment of Grade II Virology Laboratory” had ethical clearance from the institution ethics committee of RMRCT. DENV: dengue virus. Cocirculation and coinfections of these two viruses are reported. nonetheless. though early referral and good management can reduce this. along with mosquito control. whereas for dengue. odds ratio [OR] = 31.13 The data were double-key entered into Microsoft Excel. two samples were positive on both tests. dengue epidemiology is continually changing. Most of the patients. though the difference was not statistically significant. joint pain. DENV-4 identified in this study had sequence homology with DENV-4 identified in 2010 (GenBank: JF929180). which were collected in the acute phase of illness. this difference was not significant (OR = 1. a Dengue-negative (n = 119) samples were tested for chikungunya by ELISA and 19 by RT-PCR. Results One hundred and thirty-eight samples from 15 districts of Madhya Pradesh were screened for dengue (see Figure 1). 13 (10. Single-sample testing confirmed that there was no significant difference between these two proportions (P = 0.Barde et al. with very few studies focusing on these infections. A subset of samples. Discussion DENV-3 was detected during an outbreak that occurred at Jabalpur in 1966. 38 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . DENV-1 was first identified in central India and the sequence showed that it was closely related to the DENV identified from New Delhi (JF 815209. where infection was suspected – 112 (81%) – had fever (100–103oF) for more than 2 days.5. It was noted that. The partial nucleotide sequence of CHIKV envelop gene 1 (E1) was compared with 14 sequences of CHIKV strains from the National Center for Biotechnology Information (NCBI) database from Asia and Africa. with application of 1000 bootstrap replicates.4. nRT-PCR: nested reverse transcription polymerase chain reaction. CHIKV re-emerged in 2005. Hepatomegaly was seen in 18 (13%) cases. Katni (DENV-4). sex and screening tests for diagnosis of dengue and chikungunya are given in Table 1.11 with minor modifications. body ache.1. posing challenges to clinicians and health authorities.2%) were found to be positive for dengue. No cases of DHF. All chikungunya-positive samples (n = 13) were from Jabalpur district.5. India. 95% confidence interval [CI] = 6. Single-sample proportion testing and logistic regression were done using SPSS version 20. Of these. see Table 1). in the case of dengue. with close sequence homology with isolate from Delhi (GenBank: JN048826). samples for which the DENV nRT-PCR result was negative were subjected to CHIKV-specific RT -PCR. 21 (15.8 to 142. Pune. DSS or death were noted. Panna and Narsinghpur (DENV-4). In the case of chikungunya. A total of 15. Most of the confirmed cases of dengue and chikungunya were detected in the monsoon and postmonsoon periods. and representative sequences were submitted to GenBank.2% (21/138) were positive for dengue and 10.9% (13/119) were positive for chikungunya. 85 (62%) were male and 53 (38%) were female. two were only RT-PCR positive and four samples were positive on both tests. the positivity of dengue was significantly higher among adults (age 16 years and above) when compared to children (≤15 years. The phylogenetic analysis carried out using nucleotide sequences established that CHIKV from Jabalpur belonged to the East Central South African (ECSA) genotype (see Figure 2). The nRT-PCR and sequencing results confirmed that DENV-1 (n = 1) and DENV-4 (n = 6) were circulating in and around Jabalpur. were also subjected to DENV nRT-PCR.12 The sequences were analysed for their homologies.1).01) but in the case of chikungunya.14 However.8. P < 0. T: total. with associated symptoms such as headache. namely Jabalpur (DENV- 1 and DENV-4). 15 were only IgM ELISA positive.9%) were positive for chikungunya. using the basic local alignment search tool. fatigue and nausea. 95% CI = 0. from four districts. as described by manufacturer. version 5.12. central India. of whom 26% had thrombocytopenia (platelet count <105/mm3). The PCR products were extracted and sequenced as described earlier.10 for detection of DENV RNA and the DENV serotype.44 to 5. Six samples were IgM ELISA positive and nine were RT-PCR positive. dengue and chikungunya remained neglected diseases in this part of country. the positivity was higher among males (16/85. Multiple sequence analysis was done using CLUSTAL W software and the p-distance Neighbor Joining phylogenetic tree was generated using Molecular Evolutionary Genetics Analysis (MEGA).: Co-circulation of dengue and chikungunya viruses of Virology.117). The results for age. Of the 21 dengue-positive cases. M: male. Table 1: Age and sex distribution of the suspected and confirmed cases of dengue and chikungunya Age group (years) 0 to 15 16 and above Total Suspected casesa M 54 31 85 F 38 15 53 T 92 46 138 Dengue positive by sex M F 0 2 16 3 16 5 Dengue positive by screening method ELISA nRT-PCR T 2 nil 2 17 6 23 19 6 21b Chikungunya positive by sex M F 4 5 3 1 7 6 Chikungunya positive by screening method T ELISA RT-PCR 3 6 9 3 3 6 6 9 13b ELISA: enzyme-linked immunosorbent assay. Out of 138 samples tested. The platelet count was available for 42 patients. b Four samples of dengue and two samples of chikungunya were positive by both tests. After adjusting for the sex of cases. no such difference was observed. of these. 9%). 19%) as compared to females (5/53. F: female.12 Out of 119 dengue-negative samples. Of these. 63 (46%) patients were from rural areas.15 Because of the emergence of different serotypes and their genotypes. Statistical analysis revealed no significant difference in initial symptoms such as fever in confirmed cases of dengue and chikungunya. and to conduct characterization studies on CHIKV.05 0. it emphasizes the importance of chikungunya diagnosis.4 and also seen in this study. It is known that. for the first time. or coinfection with other pathogens. In an endemic area like India.Barde et al. Probably because of the severity of dengue. may produce a severe outcome of the disease. There is some evidence that infection with multiple DENV serotypes.4 An earlier study reported the presence of DENV serotype 4 in central India.25 0.: Co-circulation of dengue and chikungunya viruses India-06-HQ702750 64 India-11-JQ740183 India-10-JN048826 94 India-11-JX911895 India-06-FJ000068 83 68 Reunion-06-AM258993 Central Africa-84-HM045784 100 99 India-63-EF027140 Thailand-58-HM045810 Thailand-95-HM045787 84 92 Indonesia-10-AB678693 } } ECSA Genotype Asian Genotype } West African Genotype Onyong-nyong-96-AF079456 } Outgroup Senegal-66-AF192891 0. In contrast. where multiple DENV serotypes are circulating with CHIKV. Serological tests (ELISA) have demonstrated the presence of dengue and chikungunya from central India in the recent past.12 detection of another serotype (DENV-1) is alarming. Ministry of Health and Family Welfare.17 An early and accurate diagnosis can help clinicians to decide the course of treatment. Tree showing chikungunya virus detected in this study (▲) belonging to East Central South African genotype. although based on a small sample size. the initial symptoms of chikungunya are similar to those of dengue and both are transmitted by same vectors Aedes aegypti and Aedes albopictus. The presence of IgM for DENV and CHIKV can only be detected around the fifth day of infection.15 0. as there is no significant difference in the positivity of samples for the two diseases. before 1973. the early symptoms cannot clinically distinguish between dengue and chikungunya.10 0. It will be interesting to isolate and further characterize these circulating viruses for better epidemiological understanding. the Asian genotype was circulating in India and was subsequently replaced by the ECSA genotype.15 With establishment of the Viral Diagnostic Laboratory. both clinicians and public health officials focus on this disease.2 As reported earlier.16. circulation of the ECSA genotype in this part of India. As apparent in the present study.00 Figure 2: Phylogenetic tree of chikungunya viruses generated by the NJ method. and samples are sent to laboratories with requests for diagnosis of dengue only. Each strain is labelled with the country and year of isolation followed by GenBank accession number. and there is no significant difference in the positivity for the two diseases. for financial support under the project “Establishment of Grade II Virology Laboratory”. after the epidemic. Indian Council of Medical Research. O’nyong’nyong virus was used as the outgroup after a gap of almost 32 years. it was possible to provide molecular diagnosis of DENV. Acknowledgements The authors are grateful to the Secretary to the Government of India. we advocate early and simultaneous testing of samples for DENV and CHIKV.4 However.5 This study documents. and made its presence felt in India with more than one million cases.20 0. the tests such as nonstructural protein (NS1) detection for DENV and RT-PCR for both these viruses to detect virus antigen/RNA should be preferred. and The Director-General. Although this study has a limited number of samples. the medical fraternity neglected CHIKV infections. Department of Health and Research. probably because chikungunya is considered to be a disease with mild morbidity and no mortalities. the possibility of concurrent infection occurs.4. dengue is a disease with significant morbidity and mortality and is endemic in the country.12. 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New Delhi: Directorate General of Health Services. data analysis. Hewson R.61:1462–70.accessed 27 February 2014. Trends in Microbiology. 3. Konde J. Madhya Pradesh. data interpretation and writing.78:333–337. Am J Trop Med Hyg. 15. Rapid detection and typing of dengue viruses from clinical samples by using reverse transcriptase-polymerase chain reaction. 327. 5. India. Bondade S. Peterson D. Njenga MK. Myers MF. Wint GR. Bharaj P. Singh N. Dandawate CN. India & phylogenetic relationship with Central African isolates. D’ Agaro P. 2012. Logue CH. Kori BK. 16. BKK and PVB did data collection.Barde et al.25:504–7. New Delhi: WHOSEARO. How to cite this article: Barde PV. Regional Office for South-East Asia. Paunipagar P. 17. Jacob GP. Ministry of Health & Family Welfare. Chakravarti A. J of Trop Medicine. Gubler DJ. 3(1): 36–40. Agarwal M. Lewis J. Sergon K. 2012. 2010. Sudeep AB. Jatav JK. Seroprevalence of Chikungunya virus (CHIKV) infection on Lamu Island. National Vector Borne Disease Control Program. Peterson N. Kenya. All authors read and agreed upon the manuscript. Contributorship: PVB and NS designed the study and did literature search and writing. Abdulmaleek H. Baba M. 2011. Broor S. Barde PV. 10. 2012. New Delhi provided kits for diagnosis of dengue and chikungunya. Pavri KM. George DB. docstoc. Bharti PK.accessed 27 February 2014. Vorndam AV. 1992 Mar. India in 2010. Dumilla AM. Source of Support: The study was funded by the Indian Council of Medical Research (ICMR). 2014. Jaenisch T. Key words: Access to treatment.2 There are nine species of anopheles mosquito that can transmit malaria to humans in Timor-Leste. Self-diagnosis and home treatment were common. and better access to treatment are recommended if the incidence of malaria is to be reduced throughout the country. focus groups and semi-structured interviews. New Zealand 2 Childfund. Research methods included transect walks. and over three quarters of the population live in areas of high transmission.who.int/ publications/journals/seajph DOI: 10. and belief in the power of traditional healers. Although funding has been provided to reduce the burden of this disease. limiting the distribution of bed nets to pregnant women and children aged under 5 years had resulted in some focus group respondents believing that only those in these groups could be affected by malaria. Introduction Malaria is endemic throughout Timor-Leste.and communitybased education about malaria. sanitation. makes an accurate estimation of the incidence of this disease problematic.nz Results: The location of the hamlets near rice fields.Access this article online Original research Website: www.ac. Laserda de Maia. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 41 . and treatment in rural communities. Dili.3 Underreporting of cases. Conclusion: Improvements in infrastructure. particularly in rural areas. The two most common are Anopheles barbirostris and Anopheles vagus genotype B. Timor-Leste. New Zealand. and was the only intervention undertaken by the National Malaria Control Programme.4 With the help of international funding. Auckland University of Technology. AUT University. Northcote. management of symptoms. Timor-Leste 1 Background: Malaria is an important health problem in Timor-Leste. Timor-Leste’s Ministry of Health established the National Malaria Control Programme in 2003. Auckland. Methods: A qualitative study was undertaken in two rural hamlets in Timor-Leste. Akoranga Drive. one priority was to establish and strengthen health services that had suffered significant disruption during the war with Indonesia. malaria. inadequate water supplies and dumping of waste from the local hospital provided opportunities for mosquitoes to breed. Most participants were aware of the link between mosquitoes and malaria.1 The majority (81%) of infections are caused by Plasmodium falciparum and 19% by Plasmodium vivax. Content analysis was used to identify themes. leaking taps.2 there are local and seasonal variations. Treatment for unresolved infections depended on access to transport funds. Rua Governador.1 Although the parasite prevalence may be in the range of 19%. but a lack of control over their environment was a major barrier to preventing malaria. and providing school. Email: pneave@aut. Interventions undertaken were both “top-down” (led by government agencies) and “bottom up” (community led). The aim of this study was to explore the perceptions and practices undertaken in relation to all aspects of malaria control by members of two rural communities in Timor-Leste.searo.4103/2224-3151. Vila Verde. However. empowerment. tyres and concrete drains. Address for correspondence: Penny Neave. and small plastic containers. few studies have investigated whether this has improved malaria-related knowledge.3 The preferred breeding habitats of the latter are fresh and brackish swamps. Among the former interventions.115828 Quick Response Code: Barriers to malaria control in rural southwest Timor-Leste: a qualitative analysis Penny E Neave1. The distribution of bed nets had occurred once. The former breeds in large permanent bodies of water with permanent vegetation. Others included the wide distribution of bed nets to pregnant women and children aged under 5 years. Maria L Soares2 Abstract Department of Community Health Development. empowerment of rural communities. Study participants were subsistence farmers. spoke Tetum (the national language) fluently. and knowledge about the national malaria-control programme. with the help of health volunteers working in the community”. with and to the community”. Focus groups and interviews were carried out in Tetum. One was attended by three women and four men and the other was attended by five women and two men.6 and the other discussed the implementation of the grant given by the Global Fund to Combat AIDS. regional and local government officials. One was approximately 8 km. The aim of this study was to explore the perceptions and practices undertaken in relation to all aspects of malaria control by members of two rural communities in Timor-Leste. the aim was “to mobilise community members to access basic healthcare services. Before data collection commenced. Maps of each hamlet were drawn. Health volunteers informed community members about the study and encouraged participation. It was set in two hamlets in a rural area of south-west Timor-Leste. and appropriate treatment. Interviews were recorded using a digital recorder.5 Only two previous studies have investigated how malaria is managed in Timor-Leste following the implementation of the National Malaria Control Programme. One focus group was conducted in the local school. actions taken to diagnose and treat malaria. Previous work undertaken by this researcher in this region had suggested that knowledge of malaria in the community was poor. With a slogan of “from. who would be asked to facilitate the research. Most family houses consisted of three bedrooms. who requested written notes to be taken instead. prevention of mosquito bites. One village had approximately 60 households. During the walk. using content analysis: malaria transmission sites in each hamlet.3. The age of the participants of this study ranged from 20 to 70 years. knowledge of malaria transmission. focus groups and semi-structured interviews were carried out in July 2012 and each lasted about an hour. Topics covered in the interviews and focus groups comprised: knowledge about malaria transmission and symptoms. transcribed verbatim and translated into English by one of the authors. and the head of each hamlet. meetings were arranged with national. and the other 12 km away from the nearest health clinic. They provided details of local health volunteers.Neave et al. the data from the transect walks. it is not known whether these improvements have been experienced throughout the country. who also answered questions. Three semi-structured interviews were conducted and these were carried out in respondent’s homes. Results Transect walks. where individuals with suspected malaria could be tested and receive treatment.7 However. transect walks were carried out with the assistance of a guide.6. All responses that corresponded to one of these themes were collated by one author. focus groups and semi-structured interviews were categorised into five main themes.5 and in the second hamlet was 5. One researcher chose the area in which to carry out the study. and the other in the home of the hamlet head. Semi-structured interviews The hamlet leaders (one from each hamlet) and the traditional healer from one hamlet were invited to take part in semistructured interviews. For the analysis. with the exception of the interview with one head of hamlet. Transect walks To evaluate the potential for mosquito breeding in the community. Tuberculosis and Malaria. methods Ethical approval to carry out the study was obtained from the Auckland University of Technology Ethics Committee. or individuals who gained an income from selling firewood or from making and selling traditional clothes. was familiar with local customs and had previously worked on malaria-control campaigns in the country. and accepted by the District Health Service Ethics Committee in the area of Timor-Leste in which the study was conducted. and the other about 80 households. and can be used to explore local sanitation conditions.7 The latter study reported that there had been an increase in knowledge about malaria transmission in the country. and reviewed by the other to ensure agreement. to demonstrate how bed nets were hung and their state of repair. The other hamlet did not have a traditional healer working there. Transect walks are journeys taken through a community. Each was given a week to decide whether they wished to take part. to gain support for the study. Interested participants contacted the hamlet leader or health volunteer. to ensure anonymity of the respondents. but regional reported malaria data suggested that the incidence rate was lower in this area than in other districts in the country. symptoms of malaria. photographs were 42 taken of the local environment and the bedrooms of some houses. The exact location of the study is not provided. Focus group discussions Focus groups were organized in each hamlet. the Ministry of Health “Integrated Community Health Services” (SISCa) was introduced throughout Timor-Leste. This researcher was native to Timor-Leste. showing potential mosquito breeding sites. All study participants gave written informed consent before participating. based on her familiarity with this district.7 One of these focused predominately on the use of bed nets. and greater awareness of the need for maintaining high levels of sanitation.: Malaria in Timor-Leste As part of its “bottom up” approach. The average number of occupants per household in the first hamlet was 4. and their contact details were passed to the researcher. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . The distribution of bed nets was the only awareness participants had of the National Malaria Control Programme. as it was believed that the bitter taste would be effective. Disposal of rubbish In the first hamlet. resulted in some focus group respondents believing that only those in these groups could be affected by malaria. Others buried their rubbish or burned it. as well as by the local hospital.Neave et al. although the sporadic income that many received meant that creams and mosquito coils could not be used throughout the year. therefore we go to the hospital to get it tested . Some would purchase analgesics or antibiotics from the nearby shop (within walking distance) if they could afford it. a distance of several kilometres away. or not caring for an ancestor. as they did not believe they had personal experience of these. including one of the hamlet heads. in both hamlets. Some people who could afford to do so would also purchase anti-mosquito creams and mosquito coils. Others. and on the banks of the river there were pools of stagnant water. recognized that other family members could also become ill with malaria. Knowledge about malaria transmission Some focus group members referred to their lack of education to justify why they did not know in detail how malaria was transmitted. No participant mentioned a hospital visit as a first course of action. He considered pregnant women as being particularly susceptible because they had stopped menstruating. Some believed they could self-diagnose. some households used a nearby rubbish tip. rice fields were located close to households. but all respondents recognized the importance of avoiding mosquitoes and were aware of the link between stagnant water and malaria. Eating boiled papaya leaves with noodles was popular. covering of the body in the evening. if we stayed at home then we didn’t know. dry cassava and cow dung to create smoke. Many participants explained that an initiative to clean the local environment must be made directly from the hamlet head. In the second hamlet. Treatment seeking Initial treatment of malaria-type symptoms would most typically be carried out by the individual. and argued that nets should have been distributed more widely. and the hamlet heads had played a role in their distribution.: Malaria in Timor-Leste Sites suitable for malaria transmission Rice fields From the transect walks. This was confirmed by the heads of each hamlet. as it could not be turned off. claimed not to know the symptoms. There were some discussions among participants about whether it was possible to self-diagnose malaria from clinical symptoms. there was an acknowledgement among participants that there was a lack of space to hang them. The village guide explained that some farmers irrigated their rice field during the night. However. which used an area near to one of the hamlets as a dumping site for hospital waste. Most houses contained three bedrooms but were occupied by four to seven people. . by community members and by residents of other hamlets. which he said resulted from current or past misdeeds. water provided for the community ran from a communal tap continuously. Slow-moving water. one well served nearly 400 people. Nets had been given free of charge to pregnant women and children aged under 5 years. provided sites for mosquitoes to breed. to wash clothes or collect water. when many mosquitoes were prevalent. or burning tyres. Despite wanting more nets. so go to hospital to get blood tested then we will know . while others recognized that a blood test was necessary for an accurate diagnosis: We got this disease but we don’t know. Many individuals from both hamlets used the river. such as cans and bottles. Symptoms and diagnosis Most participants could name some common symptoms of malaria. as well as the head of one hamlet. Some houses lacked toilets. it was observed that. no action would be taken. in both hamlets. Rubbish was scattered along the side of the road. necessitating the use of outdoor areas near to mosquito-breeding sites. Prevention of mosquito bites Common measures to prevent mosquito bites were killing them by hand. Some families who received more nets than others had shared them with others. Others. but others threw them away if they became torn or damaged. unintentionally. Some repaired holes in nets. limiting the distribution of bed nets to pregnant women and children under 5 years of age had. There was some confusion about whether and how often nets should be washed. Lack of suitable water supply and drainage systems In the first hamlet. although the head of one hamlet explained he had made repeated requests for the tap to be mended. Without this. The transect walks revealed that irrigation channels along the river path provided sites for mosquitoes to breed. if it’s malaria disease (focus group respondent). . . The traditional healer attributed spiritual reasons for malaria infections. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 43 . All participants understood that sleeping under nets would help to protect against being bitten by mosquitoes. However some noncombustible items. algae and small irrigation channels connecting river water to these channels provided sites for mosquitoes to breed. 2 or 3 years previously. . so that spiritual barriers that might be preventing its success could be overcome. Efforts to reduce the incidence of malaria in other areas of the same region have shown that full community engagement and commitment is a key component to success. for example of receptacles in which mosquitoes could breed. was also noted by Lover et al. However. remains outside the scope of people who are not able to access it. A lack of trust of outsiders may make this difficult. A lack of available cash for transport (the cost ranged from between US$ 2 and US$ 4) was the reason voiced by many.: Malaria in Timor-Leste If symptoms persisted. then we will not get it again (traditional healer). He also explained that people might come from other hamlets to be treated by him. including to remote rural areas. financial difficulties alone could not explain why some people resorted to supernatural treatments for malaria. despite these being a specific aim of the National Malaria Control Programme. However. and this is in line with the findings of Lover and colleagues. and were reluctant to discuss issues freely. respondents appeared to be reliant on interventions from outside. then it will get healed. Responses to questions about the most effective diagnosis and treatment of malaria also suggested perceptions of powerlessness among some respondents. Only bed net distribution was mentioned as an intervention by the National Malaria Control Programme. who had been admitted to hospital but had not recovered. The poor sanitary conditions were confirmed during the transect walks. Access to money was described as particularly difficult at times of the year when there were few crops to sell. while the use of a transect walk by a research team member with malaria expertise meant that an independent evaluation could be made of the potential for mosquitoes to breed in the vicinity. implemented in Timor-Leste in 2007. the options available were either to visit the local hospital (where treatment was provided free of charge) or to seek help from a traditional healer. and two parallel beliefs in malaria etiology appeared to be common. The spiritual healer confirmed he had been asked by a male nurse to treat his wife. The finding that a belief in supernatural causes of malaria was reported to be held by some medically trained staff highlights the need to reinforce the importance of medical treatment with these individuals. While Martins and colleagues have noted that some success has been made by the first Global Fund grant to reduce 44 malaria-related morbidity and mortality in Timor-Leste. and could also be used to provide information about the requirements for washing nets. Although the researcher who carried out the fieldwork was born in Timor-Leste. They might advise patients to visit one if their symptoms did not resolve in a few days after treatment had started. in particular. Kill a chicken and feed the spirit of the dead people. to explain why the latter action might be taken. the traditional healer mentioned that some people would access his treatments by paying similar sums of money to those they would spend on biomedical treatment.1 Thus. a lack of control over managing the sanitation in their local environment appeared to be the predominant factor that limited the ability of respondents to protect themselves against mosquito bites. Treatment by the traditional healer involved carrying out a ceremony while sharing food and cigarettes. or killing animals: Malaria can be treated through bringing betel nuts and giving them to the spirit of the dead. including hamlet heads. and/or for a local hospital to be built. accurate diagnostic testing and treatment.9 The results of this study suggest that WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . the provision of free diagnostic tests and treatment for malaria. to ensure that information is understood and trusted. Some could not seek a parasitological diagnosis and drug treatment because of a lack of funds. Thus. she noted that several respondents described her amongst themselves as an “outsider” or “foreigner”. the priority is to reduce the morbidity and mortality caused by this disease. Despite being aware of the risks within their local environment. Further research using quantitative methodologies would be necessary to determine whether the results could be extrapolated to other rural populations. Thus. The qualitative methodology employed allowed exploration of concepts that might be a barrier to malaria control. There is also a need to involve community members more in efforts to reduce malaria.8. and that they might pay him between US$ 2 and US$ 5. This is in order that other causes of presenting symptoms can be ruled out. a few said that some hospital doctors they had received treatment from did believe in the power of traditional healers. as well as the fact that this had taken place on one occasion with no followup. Interviewing a range of respondents enabled a diversity of views to be included.6 The confusion about who malaria could affect.7 the results of the research presented here suggest that a priority for the country is still the strengthening of infrastructure. or treated. and. Discussion The aim of this study was to investigate knowledge. and the lack of response to repeated requests for improved water supplies. an unintended consequence of targeting pregnant women and children aged under 5 years. Not all respondents believed that traditional healers had a role to play in the treatment of malaria.Neave et al. attitudes and practices relating to malaria transmission. Interventions focusing on increasing malaria-related knowledge without providing the means to prevent mosquito bites are unlikely to be effective.6 Ongoing educational sessions with local communities may overcome this confusion. the need for laboratory confirmation of suspected malaria. the provision of waste disposal services and improved water supply. and no respondent mentioned any “bottom-up” approaches to malaria control. Specific problems mentioned were the dumping of rubbish by the local hospital. The heads of the hamlets had made unsuccessful requests to regional health officers for a mobile clinic to make regular visits. The heads of hamlets could be a useful interface between community members and health workers from outside these areas. by preventive measures.9 and could be replicated in Timor-Leste. Timor Leste is still in the malaria “control” phase. Many respondents recognized the usefulness of bed nets. Rather than poor knowledge about malaria transmission. symptoms and treatment in one small rural area of Timor-Leste after the implementation of malaria programmes carried out in this country to reduce the burden of this disease. and explaining how nets can be maintained correctly. 2013. WHO South-East Asia J Public Health 2014. Malaria journal. Asian Pacific Journal of Tropical Medicine. Cooper RD. Timor Leste. 7. 2002. carried out the fieldwork and contributed to writing the paper.who.3:283287. Annals of Tropical Medicine and Parasitology. An exploratory study of treated-bed nets in TimorLeste: patterns of intended and alternative usage. 5. Soares ML. 2012. 2002. advised on the study design.96(7):739-743. Did the first global fund grant (2003– 2006) contribute to malaria control and health system strengthening in Timor-Leste. 8. Rainy-season prevalence of malaria in Bobonaro district. Kaneko A. http://www.accessed 27 February 2014. Malaria epidemiology in the Democratic Republic of East Tim or.accessed 27 February 2014. A community-directed strategy for sustainable malaria elimination on islands: short-term MDA integrated with ITNs and robust surveillance. jointly carried out data analysis and co-wrote the paper. Acta tropica. 2012.80(8):660-66. How to cite this article: Neave PE. Geneva: WHO. 2010.int/malaria/areas/elimination/overview/ en/ . Source of Support: Maria Soares received a scholarship from the New Zeland AID Programme. Control of malaria: a successful experience from Viet Nam.pdf . et al. et al.: Malaria in Timor-Leste there is still much progress to be made in rural areas. East Timor. www. et al.who. doi:10.1186/1475-2875-9-40. and providing access to accurate diagnostic tests and treatment. 10. de Almeida A. MLS jointly conceived the study. et al. 4. Lover AA. Martins JS. References 1. “bottom-up” approaches could focus more on enabling the community to take control of improving sanitation within their local environment. 3.11: 237. basicsorg/documents/13-SISCa-Guidilines. Contributorship: PEN jointly conceived the study. Geneva: WHO.Servisu Integradu da Saude communitaria (Integrated Community Health Services). Preventing rubbish entering the hamlets from other areas. With respect to prevention. 2009. 2010. Bragonier R. World Health Organization Overview of malaria elimination. contributed to formulating the study design.9:40. Bulletin of the World Health Organization. Zwi AB. http://www. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 45 . Kelly PM.accessed 27 February 2014. 2011. Malaria Journal. Hung LQ. World Health Organization. Malaria vectors of Timor-Leste. SISCa. as well as ongoing training of clinicians are important “topdown” priorities.int/malaria/publications/world_malaria_ report_2012/report/en/ . 2010.114(3): 177-183.Neave et al. Mnistry of Health. 9. Barriers to malaria control in rural south-west Timor-Leste: a qualitative analysis. ensuring they understand the rationale for targeting particular groups with bed nets. 2. 3(1): 41–45.10:199. Conflict of Interest: None declared. et al. Malaria Journal. World malaria report 2012. 6. and retro-orbital pain – 73%. are at risk of dengue fever. rural area. West Bengal.Access this article online Original research Website: www. subgenus: Stegomyia. as Aedes aegypti mosquito. the highest number of cases was from Gopalpur 37% (37/100). 10% and 5%. Mausumi Basu3 Abstract Deputy Chief Medical Officer of Health-II. district Purba Medinipur. improvement of transport facilities such as railway and roads. Among the four villages studied.4 Dengue 46 fever and dengue haemorrhagic fever are prevalent in urban areas.5 billion people. 2012: an outbreak investigation Dilip K Biswas1. All the cases had history of fever (100%). outbreak.2 According to the National Vector Borne Diseases Control Programme (NVBDCP). 3%. The study led to a recommendation to destroy water containers and use mosquito nets.3 In West Bengal. West Bengal 3 Department of Community Medicine. Ramchandrapur.115828 Quick Response Code: Dengue fever in a rural area of West Bengal. 13%. genus: Aedes. Key words: dengue. The values for Household Index. Gopalpur. Container Index and Breteau Index of the four villages were: Badalpur. then gradually declined and no further cases were noted after 28 September 2012. of which nearly 2000 cases were recorded from the Kolkata Metropolitan Corporation areas. of which 56% (56/100) were men. Results: There was a total of 100 cases. Kolkata. Materials and Methods: The clinical features. deaths have risen from 53 in 2001 to 242 in 2012. 2%. followed by myalgia – 82%. and 13%. 23% and 18%. Institute of Post Graduate Medical Education and Research.who. 11%. The majority of cases were in age group 15–45 years – 52% (52/100).7. from 3306 in 2001 to 50 222 in 2012. Welcome Housing. 3306 confirmed dengue cases were reported from 1 January 2012 to 30 September 2012. and Tajpur.searo.1 Over 2. West Bengal. peaked on 18 September. 228 Ashokegarh. Blood specimens were collected from affected patients and sent for serological examination.5 Outbreaks of dengue fever have also been reported from rural areas of India.6 The rapid growth of industries and building activities. India. an increased number of fever cases was reported from Ramnagar-II block. West Bengal Introduction Dengue is a mosquito-borne viral disease found in tropical and subtropical regions. West Bengal 2 Lady Duffrin Victoria Hospital. Rama Bhunia2. to determine the risk factors and to recommend preventive measures. usually breeds in urban and peri-urban areas. followed by the age group >45 years – 28% (28/100). 9%. Address for correspondence: Dr Dilip Kumar Biswas. India 1 Background: During September 2012. India Email: dilipbiswas29@gmail. 40% of the world population. with the following objectives: to describe the distribution of fever cases. followed by Badalpur 26% (26/100). Seventy-nine per cent (79/100) of cases were NS1 test positive (non-structural antigen-1) and 72% (13/18) cases were positive on a dengue monoclonal antibody (IgM) capture enzyme-linked immunosorbent assay (MAC-ELISA) test. The outbreak started on 7 September 2012. species: Aedes aegypti). All recovered except one (case-fatality ratio: 1%). increased movement of people from urban to rural areas. The outbreak was controlled. Purba Medinipur district. 19% (19/100) of cases had a history of migration from dengue-endemic areas. the vector of dengue (family: Culicidae. This study investigated the outbreak. An epidemic curve was plotted and environmental and entomological surveys were carried out.int/ publications/journals/seajph DOI: 10. headache – 78%. date of onset and outcome of all cases of fever were listed. 8 An increase in the number WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . and environmental changes have all favoured the spread of dengue in rural as well as urban areas. 2% and 2%. (IPGME&R) Kolkata. Kolkata-700108.4103/2224-3151. the number of cases in India has escalated steadily.com Conclusion: The outbreak was probably due to dengue fever. The highest number of affected patients was reported from the village of Gopalpur 37% (37/100). retro-orbital pain (73). They were mainly farmers and labourers by occupation and some of them moved for work to dengue-endemic areas and visit their houses frequently. There was no reported case after 28 September 2012 (see Figure 1). Environmental study The investigation team observed the sanitation practices. water containers for mosquito breeding. were considered as breeding sites. Analysis and calculation of the standard Aedes larval indices. bleeding manifestations (e. for confirmation of dengue virus. breathlessness (47). An entomological investigation was carried out to understand the density of vectors responsible for viral transmission.Biswas et al. Use of the NS1 ELISA and IgM ELISA (MAC ELISA) tests was recommended by the West Bengal Government for confirmation of dengue at public health laboratories. rainfall and humidity. using the single larval survey (SLS) technique. retro-orbital pain. The proportion of cases by age group and sex was calculated. namely Badalpur. headache (78). abdominal pain (16).g. watercollection habits.12 For epidemiological purposes. vomiting (47). since it was an outbreak investigation. Unused wells. etc. There was no history of dengue cases over the previous 5 years. A value of HI greater than 5% and/or of BI greater than 20% for any locality are indications that the locality is prone to dengue. MATERIALS AND METHODS Ethical permission was not required for this research. It was recognized that the movements of villagers to the dengueendemic area might spread the outbreak. Entomological investigation A demographic map of the study villages and surveyed houses was prepared. Dengue fever (suspected dengue case) was defined as acute febrile illness of 2–7 days’ duration. peaked on 19 September 2012 and declined gradually. A total of 100 affected patients were identified in the four villages. (iii) to determine the etiology of the outbreak. by the district public health specialist/epidemiologist. comparable immunoglobulin G (IgG) enzymelinked immunosorbent assay (ELISA) titre. and a confirmed case of dengue was also associated with one or more of the following: supportive serology (reciprocal haemoagglutination–inhibition antibody titre. followed by Badalpur 26% (26/100). blood samples were also sent to Midnapore Medical College Hospital for MAC-ELISA test. The environmental investigation was carried out with the help of records of temperature. drainage systems and personal protection measures against mosquitoes. These two hospitals were the referral hospitals for these villages. arthralgia. The majority of cases – 52% (52/100) – were in the age group of 15–44 years. broken earthen pots. such as House Index (HI). or positive monoclonal IgM antibody capture (MAC-ELISA) test in a serum specimen from the late acute or convalescent phase. Gopalpur. were carried out. myalgia. rash. in four villages. and an epidemic curve was drawn to observe the dynamic of the outbreak. The outbreak started on 7 September 2012.10 Larvae were identified by visual inspection of their appearance and movement in water. plastic cups and packets. place and person. Data collection and analysis Trained health workers worked with the primary investigator to collect data in a predesigned format. while only 3% (3/100) of cases were aged under 5 years (see Table 1). and altered WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 47 . Febrile illness was associated with myalgia. diarrhoea (17). The total population of these affected villages was 5381.: Dengue outbreak in West Bengal. to estimate the prevalence and infestation level of vectors in the locality. from the meteorological department. A larval survey was conducted by searching mosquito breeding sites inside and outside houses. The data were analysed using coded numbers instead of individual names. skin rash (14). and (iv) to recommend measures to control the outbreak. empty coconut shells. nose or gum bleeding. All 100 cases had fever. Container Index (CI) and Breteau Index (BI). Descriptive epidemiology Health workers informed the researchers about a sudden increase of fever cases that occurred during September 2012. Other signs and symptoms were: myalgia (82 patients). of which 56% (56/100) were men. the HI indicates potential spread of virus through an area once an infected case becomes established. (ii) to describe the outbreak in relation to time. mosquito breeding sites. place and person. The outbreak was described in terms of time. This investigation was carried out with the following objectives: (i) to confirm the existence of an outbreak. under Ramnagar-II block of Purba Medinipur district. arthralgia.9 Clinically suspected dengue cases were tested with a rapid test kit such as NS1 antigen (nonstructural antigen 1 rapid diagnostic) test kit. and 19% (19/100) of affected patients had a history of migration from dengue-endemic areas. Lawns and grounds around the houses were considered as peri-domestic sites. They conducted houseto-house surveys to identify fever cases in the affected villages and also looked for any affected patients from the four villages admitted at the Ramnagar-II Block Primary Health Centre and Contai Subdivisional Hospital. West Bengal. with two or more of the following: headache. headache. India of fever cases was reported from Ramnagar-II block of Purba Medinipur district on 7 September 2012. Ramchandrapur and Tajpur. haemorrhagic manifestations. RESULTS The affected block is one of the coastal blocks of the district. petechiae or easy bruising) (6). Since a dengue referral laboratory was not available at the outbreak district. or leukopenia. retro-orbital pain. rash and haemorrhagic manifestations suggestive of dengue fever. discarded tyres. tree holes. The inhabitants used to take tea in plastic and earthen pots and throw these used pots away in their yards. at Ramnagra-II block. 2% to 23% and 2% to 18% respectively. 208 houses in Badalpur.9. except one female patient aged 43 years. India during September 2012.12 26. these coconut shells. Laboratory tests Of 100 affected patients.12 14.12 6. West Bengal.12 4. they were 8.5% respectively. The case-fatality ratio (CFR) was therefore 1%.12 28. CFR: case-fatality ratio cognitive function (2). An average of 8% (89/1137) of houses 48 showed the presence of Aedes aegypti larvae. which favoured mosquito breeding.9.9. coconut shells and tyres. 13.1% and 9. The maximum HI. After careful examination.9.12 16. 23% and 18% (see Table 2).9. Purba Medinipur district. Water also accumulated in broken flower vases. All the patients recovered.9.12 22. of which 72% (13/18) were tested positive.9. of which one had multi-organ failure and two had pneumonia.9. during September 2012 Badalpur Age group (years) Male 1–4 5–14 15–44 >45 Total Gopalpur Total Female (%) 1 2 (8) 0 2 (8) 7 14 (54) 2 8 (31) 10 26 (26) 1 2 7 6 16 40 Male 1 2 11 4 18 Total Female (%) 0 1 (3) 6 8 (22) 8 19 (51) 5 9 (24) 19 37 (37) Ramchandrapur Total Male Female (%) 0 0 0 (0) 2 1 3 (21) 5 1 6 (43) 2 3 5 (36) 9 5 14 (14) Notification Tajpur Male Female 0 2 7 4 13 0 2 6 2 10 Total (%) 0 (0) 4 (17) 13 (57) 6 (26) 23 (23) Total (%) 3 17 52 28 100 Control measure taken 35 No.9. earthen pots.9.12 24. after rain. Water accumulated in these containers. tyres.12 0 Date of onset Figure 1: Epidemic curve of outbreak of suspected dengue fever at four villages of Ramnagar-II block.12 10.9. it was observed that water accumulated in drums. by age and sex.: Dengue outbreak in West Bengal. Entomological survey A total of 989 water-holding containers from the four villages were searched for breeding sites of Aedes larvae. India Table 1: Distribution of suspected cases of dengue fever. earthen pots.9. Purba Medinipur district.9. 468 houses in Gopalpur.0%. CI and BI were calculated in the four villages. Three patients had complications. both indoors and outdoors. West Bengal. flower tubs and plastic containers were found to be positive for Aedes aegypti larvae. ponds and other containers of water.12 8.12 20.Biswas et al. with ranges of 2% to 13%. and were 13%. 79% (79/100) were positive for NS1 antigen test and 18 blood specimens were sent for MACELISA test. 172 houses in Ramchandrapur and 289 houses in Tajpur were surveyed.9. There was no scarcity of water in WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . The average HI.12 12. of cases 30 CFR=1 25 20 15 10 5 30. CI and BI values were observed in Gopalpur village. Environmental study During the researchers’ visit. Of these. drains. India.12 18. most of the patients were men and young. social workers (ICDS workers).6 Climatic factors such as temperature. local nongovernment organization workers and other departments. India Table 2: Entomological survey at four villages of Ramngar-II block.13 DISCUSSION This epidemiological investigation showed that the outbreak was probably dengue fever. chips packets. for his kind permission to conduct the study. The total rainfall in the district during September 2012 was 302 mm. humidity and rainfall would have contributed to the abundance of Aedes mosquitoes and virus transmission. Mosquitoes were found to be breeding there. etc. Acknowledgements The authors would like to acknowledge Dr Sukumar Das. coconut shells. A dengue-referral laboratory was not available at the district and the nearest laboratory facilities (at Midnapore and the School of Tropical Medicine. but water for cattle was collected and stored water in earthen containers without cover. India. respectively. the BI was <5% in three out of four villages.15 but dissimilar to another study at Kanyakumari of Dharmapuri district. in the month of September. Larvae were identified by visual inspection alone and not confirmed by a laboratory. CONCLUSION It was revealed from the epidemiological. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 49 .6 where more women and children (6–15 years) were affected. panchayat workers. Ex Chief Medical Officer of Health. So. However the HI was not <1% in the other three villages. Kolkata) were 150–175 km away from the place of outbreak. water bottles. the MAC-ELISA test was only done for 18.15 South India. 72% (13/18) of affected patients were positive on the MAC-ELISA test. Purba Medinipur district. The health authority. It is suggested that regular training of health workers. and mosquitoes bred there . so this could not be considered a low risk of transmission.16 Western India. whereas a study at two villages at Dharampuri district revealed that 42% (13/31) and 27% (14/52) tested positive. Limitations A pupal index survey was not carried out and involvement of a qualified entomologist would have added value to the investigation. which was consistent with the findings of other studies.1 6 In this study. Newly constructed buildings and concrete roads in the villages indicated urbanization. especially reduction of breeding sources by destroying unnecessary and discarded water containers. which was not considered a low risk of transmission. but water for cattle was collected and stored in earthen pots without a cover. were present in these villages. In this study. Purba Medinipur. Small water containers such as plastic tea cup.14 Though dengue outbreaks had previously been reported from urban areas. The relative humidity and temperature of the district was 75–90% and 27–37 °C respectively. On the other hand. a high risk of transmission was not considered. took joint initiatives to increase awareness of dengue fever and its signs and symptoms. Young and active age groups were most affected. the HI of Gopalpur village was >10%. entomological and serological investigations that suspected fever outbreaks were probably due to dengue virus infection. during September 2012 Villages Gopalpur Ramchandrapur Badalpur Tajpur House Index (%) 13 9 3 2 Container Index (%) 23 11 10 2 Breteau Index (%) 18 13 5 2 the villages. Adverse meteorological conditions and unplanned urbanization favoured the breeding of Aedes mosquitoes in the study villages. and early referral of severe cases to hospital was conducted. Department of Microbiology. on dengue and other vector-borne diseases.19 The spread of dengue fever in the villages needed preventive actions. along with local administration. Associate Professor. this finding was similar to that of a study in Upadi district.18 as well as in this outbreak. earthen pots. Midnapore Medical College and Hospital. tyres.17 and West Bengal. in the recent past outbreaks had also been reported from semi-urban and rural areas of North India. Involvement of government sectors and community youth groups to clean up the discarded tyres and containers in the neighbourhoods. Similarly. out of 100 affected patients.: Dengue outbreak in West Bengal. Minapore. and raise awareness among the villagers addressed the dengue outbreak. The communities were also taught about personal protective measures against mosquito bites. There was no scarcity of water in the villages. They also acknowledge the health workers of Ramnagar-II block for helping with data collection and Dr TK Pathak. in the age group of 15–45 years. and those with a history of migration from dengue-endemic areas. will reduce the incidence of outbreaks in the future. Environmental conditions and larval indices favoured an explanation of Aedes aegypti and dengue virus transmission.6. It was also evident that movement of villagers to dengueendemic areas had contributed to this outbreak. The BI was less than 50% in all four villages. for helping with serological tests.Biswas et al. Vector-control measures were carried out. which was considered a high risk of transmission. West Bengal. The logistic challenges meant that. which favored mosquito breeding. Victor TJ. World Health Organization. New Delhi: Director General of Health Services.Biswas et al.accessed 27 February 2014. India.116:133–39.: Dengue outbreak in West Bengal.136(4):649–55. 15.com/doc/ 41670075/Lecture-10-Aedes-Index .Outbreak of dengue virus serotype-2 (DENV-2) of Cambodian origin in Manipur. Indian J Med Res.gov.scribd. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . Epidemic dengue/dengue hemorrhagic fever as a public health.27 February 2014. 12. Issued on 18. 2001.33(4):274–81.acponline. Katyal R. 2011. 11. 50 13.nvbdcp. J. Directorate of National Vector Borne Disease Control Program. Gurusamy D. Kolkata: Regional Meteorological Center.21:93–95. http://www. www. 2012: an outbreak investigation. Singh TB. Datta KK. with editing and critical editing.int/ mediacentre/factsheets/ fs117/en/ . Conflict of Interest: None declared. Dengue and severe dengue.gov. WHO South-East Asia J Public Health 2014. http://pier. Anjan JK. Dengue fever in a rural area of West Bengal. 10. Basu M. RB was involved in designing the study. Epidemiological and entomological investigation dengue outbreak area of Ahmedabad district.10(2):100–3.32 (1):22–27.in/sites/ default/files/val%20add%2025–9-12. social and economic problem in the 21st century. Indian J Med Res. Dengue Fever & Dengue Haemorrhagic Fever.imdagrimet. 1996. Thenmozhi V. Kumar K. 7. Macdonald WW. Studies on dengue and dengue haemorrhagic fever (DHF) in West Bengal State. Trends in Microbiology.in/Dengue_Updates/d_01_10. Indian J Med Res. 2006. 2002 Feb. http://www.pdf – accessed 27 February 2014.pdf – accessed 27 February 2014. For prevention and control of dengue & chikungunya: mid term plan 2011–2013. Bull World health Organ. New Delhi: WHO-SEARO. Regional Publication.accessed 27 February 2014. 19. revision and critical editing the study. National Institute of Communicable Diseases. Padbidri VS. Delhi-110054. 3(1): 46–50. West Bengal.(40):467–8. 2010. 18. National Vector Borne Disease Control Programme. Guidelines for integrated vector management for control of dengue/dengue hemorrhagic fever. An outbreak of dengue fever in rural areas of northern India. World Health Organization. 2000. Investigation & Control of Outbreaks.pdf – 27 February 2014. 1999. Dengue fever caused by dengue virus serotype . 2. India-Association with meteorological factors. 2001:13. Shanmuqavel J. Department of Health & Family Welfare. Chaudhuri M. Ministry of Health and Family Welfare.wbhealth. 9. Tonn RJ. Ministry of Health & Family Welfare. Bhunia R. 6. 2010. Nizam K. 5. http://www. 2012. 17. MB was involved in editing. Dengue updates. Sheppard PM. Tamil Nadu. http:// www. Dis. India. Geneva: WHO. WHO-SEARO Dengue Bulletin.html – accessed 27 February 2014. Dengue hemorrhagic fever prevention and control activities in South-East Asia Region.09.gov.2012. Thakare JP.38 (2):124–129.who. Pests and vector management: aedes index.3 (subtype-III) in a rural area of Madurai district. Paramasivan R. India Meteorological Department.%20Director_Desk%20DGHS%20meeting%20OCT%20 06. Dengue Bulletin. 1997. Jain DC. Multimodel ensemble based district level whether forecast. Leo SV. Sharma SK. New Delhi: Directorate General of Health Services. 2002. data entry. DKB is the guarantor of the paper. Pandya AP. Directorate General of Health Services. Sankari T. 16. Regional Office for South-East Asia.20:24-30.org/physicians/ public/d068/references/d068-r3.in/Doc/ Mid-Term-Plan-Dengue-Chikungunya-%202011-13. Desai A. 22. 1st October’2012.346:1643 4. Narayanasamy G et al. Sham Nath Marg. 29. J Commun Dis. analysis and manuscript writing. India. Dhananjeyan KJ. Hoti SL. SEARO No. 117.gov. All authors read and finally approved the final manuscript. Dengue fever outbreaks in two villages of Dharmapuri district in Tamil Nadu. Malathi M. Commun.nvbdcp.132:339–342 Joshi PT. J Commun Dis. Ravi V. Rajendran R et al. Contributorship: DKB conceived the study with data collection. 14. 3. Prevention and control of dengue and dengue haemorrhagic fever: comprehensive guidelines. Source of Support: Nil. Kumar A. Hati AK. Breeding of Aedes aegypti and its impact on dengue/DHF in rural areas. A new method of measuring relative prevalence Aedes Aegypti. 1969. 2013. Gubler DJ.2012. India REFERENCES 1.pdf . Gill KS. How to cite this article: Biswas DK. November 2012. India. http://www. What can India do about dengue fever?: BMJ. 8. Andjaparidze AG. Alipore. Chusak P.in/ Doc/ dengue_1_. Muniara M. Fact sheet No. Email: mrcassam@hotmail. but susceptible to malathion (5%). reported 237 confirmed cases of dengue for the first time in 2010. with 1058 and 4526 cases recorded.5–7 The state of Assam. was the predominant mosquito species in suburbs. and to ascertain the status of their susceptibility to adulticides and larvicides. Assam. However. north-east India.who.4103/2224-3151. Address for correspondence: Dr V Dev.int/ publications/journals/seajph DOI: 10. 4%). Aedes albopictus.05 mg/L). National Institute of Malaria Research (Field Station). breeding predominantly in discarded tyres. mosquito breeding habitats. Both Aedes aegypti and Aedes albopictus were resistant to dichlorodiphenyltrichloroethane (DDT. Guwahati. seasonal abundance Introduction There has been dramatic increase in dengue cases globally and nearly half of the world’s population is estimated to be living at risk of the disease. Guwahati – 781022. Aedes aegypti was the most common in the city.1 Dengue is endemic in India.2–4 However. with increased urbanization and population movement.1 The World Health Organization (WHO) estimates that there are 50 to 100 million cases every year in tropical and subtropical countries. the disease is reportedly spreading to other metropolitan areas or cities that were hitherto free from disease. situated in north-east India. with reported morbidity and attributable death cases. Conclusion: Given the seasonal abundance and case incidence in city areas.Access this article online Original research Website: www. Assam. India 1 Background: Dengue is rapidly becoming established in north-east India and spreading. including malathion (1.searo. it is highly probable that Aedes aegypti is the predominant mosquito vector transmitting dengue virus. insecticide susceptibility status. dengue. temephos (0. India: entomological observations V Dev1.115828 Quick Response Code: Dengue vectors in urban and suburban Assam. with reported disease outbreaks in large metropolis cities. and exhibited a varied response to pyrethroids. and subsequently there was a significant increase in 2012 and 2013. using World Health Organization standard diagnostic concentrations and test procedures. GG Tewari1 Abstract National Institute of Malaria Research (Field Station). the WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 51 . The study results have direct relevance for the state dengue-control programme. Government of Assam. Assam. larval populations of both these mosquito species were susceptible to larvicides. breeding preferentially in flower vases. Assam. respectively. K Khound2.02 mg/L) and fenthion (0. The insecticide susceptibility status of mosquito adults and larval populations of both Aedes aegypti and Aedes albopictus was ascertained. however. India. for targeting interventions and averting outbreaks and spread of disease.com Results: The study revealed that both Aedes aegypti and Aedes albopictus are widely abundant in Guwahati city and suburbs. This study aims to determine the seasonal abundance of Aedes (Stegomyia) albopictus and Aedes (Stegomyia) aegypti in Guwahati metropolis and suburban settlements. to characterize the breeding resources for these mosquitoes.0 mg/L). Guwahati. India 2 National Vector Borne Disease Control Programme. cut-bamboo stumps and leaf axils. and breeding in a wide variety of resources.3 Of the total confirmed cases for each year in the state. Methods: Mosquito larval surveys were carried out in different localities in both Guwahati city and adjoining suburbs from January to December 2013. to determine the seasonal abundance of disease vectors and their breeding preferences. at much lower dosages than diagnostic concentrations. cement tanks and used battery boxes. Aedes albopictus. on account of rapid urbanization and population movement. Key words: Aedes aegypti. and grouped into four zones (East.43–80) 31.19 million).5) 55. most of the year is hot and humid and. South and Capital zone). situated on the southern bank of the mighty river Brahmaputra (54 m above sea level).40 (2.86 (0. topography and climate Guwahati city (26°11’10 N. but no data on the relationship of seasonal abundance and the member species composition of the Aedes albopictus subgroup. Aedes aegypti (renamed as Stegomyia aegypti) and Aedes albopictus (renamed as Stegomyia albopicta) are reportedly prevalent in the north-east region of India.34–40) 26.: Dengue vectors in Assam. The study site comprised Guwahati city and its adjoining suburban Sonapur block (see Figure 1).5 million. political. with large tribal concentrations and vast forest cover. BI: Breteau Index. with many structures made of split bamboo with thatched roofing.43 (2. of dengue cases HI CI BI West Zone 238 13. India majority (70–90%) were recorded in the largest metropolitan area.Dev et al. the general population live in houses/apartment complexes made of brick and cement but drainage is still open in many areas.05 (4.67 (13. under the jurisdiction of Guwahati Municipal Corporation for administrative purposes. often with an attached cattle shed.8–10 This study aims to determine the seasonal abundance of Aedes albopictus and Aedes aegypti in Guwahati metropolis and suburban settlements. 91°45’3 E). with many cases undiagnosed and additional cases reported in public/private sectors. HI:House/premise Index.39 (1. to characterize the breeding resources for respective species. The actual disease burden is estimated to be much higher.5 Recent occurrences and increased case incidence of dengue in north-eastern states warrant detailed investigations of the seasonal prevalence of these two mosquito species.36 (3. with a population of 1. yet many households store potable water in cement tanks or plastic/tin containers for domestic use.4) 40.1) Capital Zone 819 14. housing is mixed. which offers ideal conditions for proliferation of these mosquito vectors and the spread of disease.17–62. Typically. and is a principal centre of socialcultural. It is the largest city in north-east India. The city is densely populated.19–57. during Mean mosquito breeding indices (range) City Zone No. 52 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .76 (5. Study site.34–1200 Sonapur block Figure 1: Diagrammatic sketch map of Guwahati city and adjoining suburban Sonapur block.19–61. In Sonapur block (population 0.41 (4. spread over 264 km2. for formulation of suitable interventions at specific places and times.5) 36.07–38. and table giving distribution of dengue cases in different zones and corresponding entomological indices of disease vectors. Guwahati city.5) 23.34 (20.31 (8–160) East Zone 2863 12. In this region.22–28.17–27.39 (2. and to ascertain their susceptibility to adulticides and larvicides. industrial. Aedes aegypti is the predominant mosquito species in the city (total cases = 4121) and Aedes albopictus in the suburban Sonapur block (total cases = 2). There have been sporadic informal reports of mosquito surveys in north-eastern states. There is a piped water supply in most areas of the city. This block is sparsely populated.85–60) 62.5) South Zone 201 No data No data No data 2 20. showing mosquito larval survey locations (yellow circles) in different zones. trade and commerce for the entire north-east of India.04–30) 34. is a fast-growing metropolis in Assam state and a gateway to the north-east of India for economic activities. West. Inset is the map of India showing location of the study site. however. to improve understanding of their bionomics. CI: Container Index. including HI.13. mosquito larval surveys were conducted in different localities in both Guwahati city and the adjoining suburban Sonapur block. Mortality was recorded 24 h after exposure (24 hM). The experiments were completed at ambient room temperature of 27 ± 2°C and relative humidity of 70–80%. a species-specific diagnostic character. leaf axils and small plastic/tin/earthenware containers of <200 mL capacity. however. coconut shells. aided by a dipper (200 mL capacity) in tyres and cement tanks. Aedes pseudalbopictus (Borel). The relative humidity is high (>70%) for most of the year and the total annual rainfall ranges from 1.4%). the monthly mean maximum and minimum temperatures range from 30°C to 34°C and 20°C to 25°C respectively. Container Index (CI) and Breteau Index (BI). Aedes downsi (Bohart and Ingram). and are implicated in transmission of dengue and chikungunya/ arboviruses. Mosquitoes were identified using taxonomic keys primarily based on male genitalia for claspette. Knocked-down and dead mosquitoes were recorded after this time (1 hKD) before being transferred into the holding tubes.02 mg/L). industrial areas and other landmark locations. keeping appropriate control for corrected percentage mortality. including larvae and pupae. including market places. flower vases. 532/3013). Aedes patriciae (Mattingly). Following the WHO test protocol. i. and by direct pipetting of larvae and pupae from cut-bamboo stumps. Collections of immature populations. Ten per cent sugar-soaked cotton was provided to the females during the 24-h holding period.12 Insecticide susceptibility status The insecticide susceptibility status of mosquito adults as well as larval populations of both Aedes aegypti and Aedes albopictus was ascertained using WHO standard diagnostic dosages and test procedures.or fourth-instar larvae (20–40 per replicate) were evaluated against larvicides. Aedes seatoi (Huang) and Aedes subalbopictus (Barraud). During the remainder of the season (April to December). such as the railway yard. malathion (1.0 mg/L) and temephos (0. namely fenthion (0.14 Batches of unfed.11 These include Aedes albopictus (Skuse). with pre-monsoon showers during April to June. India the summer (April to September). Data from larval bioassays were subject to probit analysis. the House/premise Index (HI). NIMR/ IDVC/2011/139. the majority of the containers searched were dry (82. organophosphorous (5% malathion). until emergence.e. and plastic/tin/earthenware containers were searched for larval/pupal breeding.05% deltamethrin). all were devoid of mosquito breeding. and seasonal abundance was monitored by conventional indices.75% permethrin. Each test was replicated five to eight times (10–20) mosquitoes per replicate.05 mg/L).5 m to 2 m and many areas get inundated due to flash flooding. nurseries. and of those recorded wet (17. Based on monthly breeding surveys. there are no data on the abundance of member species of this subgroup specific to north-eastern states. Methods The study protocol was approved by the Institutional Scientific Advisory Committee and bears the project ID No. followed by heavy downpours during July to September. 0. city zoo and airport. Entomological sampling techniques Larval breeding surveys To determine the seasonal abundance of Aedes albopictus and Aedes aegypti and species-specific breeding habitats. using SPSS software version 22 for determining the 50% and 95% lethal concentrations (LC50 and LC95).Dev et al. with a batch of 10 unfed females per replicate against each insecticide.14 two to four batches of third. Aedes novalbopictus (Barraud). The rainy season is extended. and synthetic pyrethroids (0. Appropriate controls were tested as described above. namely organochlorine (4 % dichlorodiphenyltrichloroethane [DDT]). in both urban and suburban settings. for accurate species identification. For rest of the year (October to March). A mosquito was recorded as knockdown if it was lying on its back or side and was unable to maintain flight after a gentle tap. cutbamboo stumps. CI and BI are given in Table 1. from each type of container were kept separately in small water-filled containers. Adult mosquitoes were identified using available taxonomic keys and related publications. 27% (2039/7651) of wet WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 53 . the monthly mean maximum and minimum temperatures range from 24°C to 32°C and 9°C to 22°C respectively. namely discarded tyres. The first filial generation of each mosquito species was exposed to serial dilutions of discriminating dosages. the rainfall is comparatively less. during January to December 2013 (see Figure 1). it was observed that during the winter season (January to March). Aedes flavopictus (Yamada). Larval collections were made. Some of these member species Monthly data on the houses/premises inspected and containers searched for seasonal changes in breeding indices. (but not all) have been recorded in India. Results Entomological observations Species composition of the Aedes (Stegomyia) albopictus subgroup Seasonal abundance of Aedes aegypti and Aedes albopictus Aedes (Stegomyia) albopictus is a species subgroup.6%. members of which are known to coexist in south-east Asia.: Dengue vectors in Assam. 2–3-dayold female mosquitoes (emerged from field-collected larval populations) were introduced into holding tubes for 1 h and then transferred into the exposure tube and placed vertically for 1 h to the test insecticides. in the post-monsoon months (October to March). The number of dead/ moribund and alive mosquito larvae post 24-h exposure was recorded. Different breeding resources were searched in various localities. All possible mosquito breeding resources. household heads provided informed verbal consent. with 95% confidence intervals. houses (exterior premises only). 2. 408 (20%) containers were positive for mosquito breeding.5 14. for each mosquito species. mosquitoes with dark scales (type form) and pale scaled mosquitoes (variety queenslandensis) were recorded breeding WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . During April to December.1 33. 172 (8.5 15.70 to 28.5 25 43 58.Dev et al.0 65 107 61. i. The CI ranged from 1.8 60 231 25.3 30.5. There was a parallel rise in BI. HI. 100 Mosquito breeding indices 90 80 70 60 50 40 30 20 10 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2013 HI CI BI Figure 2: Seasonal cumulative larval breeding indices of Aedes aegypti and Aedes albopictus mosquito species in Guwahati city and adjoining suburbs.5 Number of containers searched 97 172 263 205 192 140 285 226 237 587 75 92 CI 0 0 0 2.05 to 9. Assam. CI: Container Index. was first detected at the beginning of April and Aedes aegypti was first recorded in May. The CI.9 18. Assam.0 42 122 34.19%) containers were positive for Aedes albopictus and Aedes aegypti 54 respectively. BI: Breteau Index containers searched were positive for Aedes immature stages.9 and 58.4 65 133 48. CI and BI ranged from 3.52 to 26.6 25. Similarly. 2013 January February March April May June July August September October November December Number of positive premises 0 0 0 4 12 14 19 14 22 31 8 14 Number of premises inspected 44 141 212 119 107 122 133 103 231 195 43 65 CI (number of positive containers/ number searched × 100) Number of positive containers 0 0 0 6 65 42 65 40 60 77 25 28 HI 0 0 0 3. however.43%) and 167 (8. and for mixed breeding it varied from 1.e. the CI combined for both Aedes aegypti and Aedes albopictus was observed rising from 2. and the extent of mixed breeding.1 during June to December.8. Of these.0 22.67 for Aedes albopictus and Aedes aegypti respectively.8 for rest of the season.38%) were positive for mixed breeding comprising both species (see Table 2).6 21. i. the HI was observed rising gradually and peaked during November and December (post-monsoon season). varied during the months investigated. dengue vector mosquito species in Guwahati metropolis and suburbs.9 in April and then fluctuated between 13.1 and 33.9 33.e.8 40 103 38. and 5.: Dengue vectors in Assam.4 to 21.9 to 33. India.78 for the months observed. Both varieties of Aedes aegypti.1 28 65 43. At the onset of the rainy season in April. HI: House/premise Index.4 BI (number of positive containers/ number of premises inspected × 100) Number of Number of positive premises BI containers inspected 0 44 0 0 141 0 0 212 0 6 119 5.5 9.0 in April to 61. Aedes albopictus.3 13.8 30. however.0 to 61.0 in May and it then varied between 25. however. BI: Breteau Index.12 and 0. CI: Container Index.0 HI: House/premise Index.9 77 195 39. from 5.8 17. monthly entomological indices.4 11. India Table 1: Monitoring seasonal abundance of Aedes albopictus and Aedes aegypti mosquito breeding. Both these mosquito species are morphologically separated by the presence of a distinct lyre marking covered with white scales on the scutum (Aedes aegypti) or a prominent median stripe of white scales on the scutum (Aedes albopictus).3 13. and the remaining 69 (3.0 respectively (see Figure 2).2 11. India HI (number of positive premises/ number inspected × 100) Month. of a total of 2039 breeding sources searched in both urban and suburban areas. 5) 0 0 0 0 10 (5. Breeding habitat surveys During April to December 2013.67) 16 (17. Assam. It was relatively less abundant in city areas in all habitats.20) 0 3 (1. it is concluded that Aedes albopictus is the only member species of the Aedes albopictus subgroup that is prevalent in Guwahati and suburbs. a breeding source for Aedes albopictus in rural areas. lower right: a flower vase. During April to December. during the months investigated Species composition of the Aedes (Stegomyia) albopictus subgroup Mosquito adult males that emerged from larval collections from various breeding resources in different localities were dissected for male terminalia/claspette.67) 3 (3.: Dengue vectors in Assam. on the other hand. lower left. a species-specific diagnostic Figure 3: Breeding habitats of Aedes aegypti and Aedes albopictus in Guwahati city and adjoining suburbs.6 0 0 1661.85) 42 (30. of a total 2039 containers searched for mosquito breeding. 17. the latter was the predominant collection in pre-monsoon and monsoon months (April to September). 2013 January February March April May June July August September October November December Total a Total rainfall (mm) 0 11.86) 26 (4. Assam. in which Aedes aegypti and Aedes albopictus occurred in approximately 60:40 proportions.7) in urban areas.7 464.80) 40 (17. cut-bamboo stumps.1) 25 (33. dengue vector mosquito species in Guwahati metropolis and adjoining suburbs. Upper left: a discarded tyre. Aedes aegypti.7 94. albopictus Ae.70) 5 (6. a leaf axil. as they possess (i) a claspette – mushroom like with numerous scales and several widened specialized setae on the mesal aspect.92) 54 (28. Thus. all of which were confirmed to be true morphotype Aedes (Stegomyia) albopictus (Skuse). flower vases and leaf axils. plastic/tin containers and coconut shells.04% (148/591) were positive in urban and semi-urban areas respectively.9 Total number of wet containers searched for mosquito breeding 97 172 263 205 192 140 285 226 237 587 75 92 2571 Number (%) of containers positive for mosquito breeding 0 0 0 6 (2. and occasionally in cut-bamboo stumps.7 214.3 336.57) 45 (15. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 55 . with a conspicuous horn-like median projection. Both Aedes aegypti and Aedes albopictus were observed breeding in a variety of natural and artificial habitats (see Figure 3). aegypti Mixed Number of reported dengue casesa 0 0 0 6 (2.69) 60 (25.43) 408 (15. a breeding source for Aedes albopictus.26) 172 (6.4 122.52) 30 (21.39) 41 (6.98) 20 (26.92) 65 (33.4 21. India. a preferred breeding source for Aedes aegypti in urban areas (written permission to reproduce this image was provided by the individual portrayed). however. plastic/tin containers.39) 167 (6.42) 0 9 (9.00) 65 (22.7) and used battery boxes (CI = 14. the exclusive collection in flower vases and leaf axils in both in urban and suburban areas.9).43) 17 (5. predominantly breeding in discarded tyres (CI = 15.31) 77 (13. and a few widened specialized curved setae on an apical angle of the expanded distal part. 290 male mosquitoes were dissected for male genitalia.9) Number (%) of containers positive for species Ae. and the former was the exclusive collection during post-monsoon months (October to December). It was.3) 28 (30.3). in Guwahati city. Aedes albopictus was recorded breeding in tyres. Mixed breeding of both mosquito species was largely recorded in tyres in both urban and suburban areas.7) 0 0 0 0 1 (0.96) 15 (6. in both urban and suburban areas but the CI varied between habitats and ecotype (see Table 3).95% (260/1448) and 25.78) 69 (2.12) 12 (8.05) 0 21 (8. India Month.7) 0 0 0 0 1 0 2 75 1635 1395 827 188 4123 Data based on reported cases in the study area (source: State Health Directorate of Assam).3). compared to Aedes aegypti (CI = 3.78) 25 (11. and was the exclusive collection in cement tanks (CI = 43. and was predominant in plastic/tin containers (CI = 8. India Table 2: Seasonal container positivity of Aedes albopictus and Aedes aegypti.5 260.06) 10 (1. and in coconut shells it was observed only in suburbs. and (ii) a tergum IX. upper right: a cut bamboo stump.06) 12 (5.Dev et al. was the most common species in the city.6 135. a preferred breeding habitat for Aedes albopictus characteristic of the Aedes albopictus subgroup.63) 27 (11. temephos (0.7) 0 1 (14.7) 10 (20. S: susceptible (mortality 98–100%). susceptible to deltamethrin: 1 hKD = 100%. and for fenthion WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . and for permethrin 1 hKD ranged from 57% to 100% and 24 hM was <97%.9) 4 (11.0) 14 (9.75%). dengue mosquito vector species in Assam.: Dengue vectors in Assam. Aedes aegypti was observed to be resistant to deltamethrin (0.0) 14 (9.3) Number of containers positive for species (Container Index) Aedes albopictus Aedes aegypti Mixed breeding 17 (2.1) 26 (12. at much lower dosages than given diagnostic concentrations.3) 25 (12.5) 29 (8. Both Aedes aegypti and Aedes albopictus were resistant to DDT (4%). thus. Insecticide susceptibility status of mosquito adult and larval populations Adult bioassay The results of the susceptibility test of Aedes aegypti and Aedes albopictus females to various insecticides are presented in Table 4. April to December 2013 Breeding habitat Tyres Bamboo stumps Tin/plastic containers Flower vases Leaf axils Cement tanks Battery boxes Coconut shells Ecotype Urban Semi-urban Urban Semi-urban Urban Semi-urban Urban Semi-urban Urban Semi-urban Urban Semi-urban Urban Semi-urban Urban Semi-urban Number of wet containers searched for mosquito breeding 799 194 75 132 334 50 154 202 35 7 16 2 28 1 7 3 Number (%) of containers positive for mosquito breeding 172 (21.000059 mg/L to 0. For larvicide assay of Aedes aegypti.1) 13 (17.3) 37 (28. India. However.0) 46 (13.02 mg/L) and fenthion (0. for temephos 0. Assam. the LC50 to LC95 values for malathion were 0.3) 0 0 0 33 (4.4) 2 (28. the susceptibility status was borderline (verification required) according to the given WHO criterion.75%) Mosquito species Aedes aegypti Susceptibility status R R: resistant (mortality <80%). a Mortality in control replicates was <5%.6) 0 0 0 0 0 1 (33.9) 0 0 0 0 0 7 (43. but fully susceptible to malathion (5%) at the given diagnostic concentrations.0 mg/L).05%) as well as permethrin (0.5) 5 (1. with a mortality of <80%.05 mg/L).3) 122 (15.6) 7 (43.9) 4 (11.3) 0 Table 4: Insecticide susceptibility status of Aedes aegypti and Aedes albopictus.5) 72 (37.4) 2 (2.7) 0 3 (10.8) 10 (20. VR: verification required (mortality 81–97%). India Table 3: Major breeding habitats and relative abundance of Aedes albopictus and Aedes aegypti in Guwahati metropolis and adjoining suburbs. India.7) 2 (1.000317 mg/L.05%) Aedes aegypti 101 (8) 96 (95) 81 (80) R Aedes albopictus 100 (7) 100 (100) 100 (100) S Aedes aegypti 110 (6) 28 (25) 24 (22) R Aedes albopictus 101 (8) 88 (87) 97 (96) VR Insecticide (diagnostic concentration) DDT (4%) Permethrin (0.7) 0 4 (14. including malathion (1.0707 mg/L.8) 11 (14.9) 0 0 13 (3.Dev et al.3) 1 (33.5) 0 0 0 0 0 0 0 0 0 1 (14.7) 35 (26.0199 mg/L to 0.1) 21 (10. both these species exhibited a varied response to pyrethroids (deltamethrin and permethrin). July to October 2013 Number of mosquitoes exposed (number of replicates)a 70 (5) Number (%) of mosquitoes knockdown in 60 minutes 1 (1) Number (%) of mosquitoes dead post 24 h exposure 2 (2) Aedes albopictus 60 (5) 7 (12) 8 (13) R Malathion (5%) Aedes aegypti Aedes albopictus 70 (5) 80 (6) 69 (99) 78 (98) 70 (100) 80 (100) S S Deltamethrin (0.1) 26 (13.1) 26 (12. but Aedes albopictus was 56 Larval bioassay Larval samples of both Aedes aegypti and Aedes albopictus were susceptible to all three larvicides.4) 2 (28. for temephos 0. The seasonal prevalence of both mosquito species occurs from the onset of rains in April until December.00374 mg/L to 0.00579 (0. mg/L LC95 (95% confidence interval).000047 to 0. India Table 5: Summary statistics of susceptibility test results of mosquito larvae of Aedes aegypti and Aedes albopictus to various larvicides in Assam.17 The present study has revealed that both Aedes aegypti and Aedes albopictus (the only member species of the Aedes albopictus subgroup) are widely abundant in Guwahati city and suburbs. With only two dengue cases recorded in the suburban Sonapur block.43) and there was negative correlation for HI (r = –0. LC95: concentration that is lethal to 95% of the population. Given the variable distribution of confirmed dengue cases in different zones of the city.91x 0. competitively displacing Aedes albopictus. a CI of 0. the CI was observed to be the highest in the East zone. and for fenthion 0. P = 0. Capital zone.1562) 0. owing to socioeconomic and developmental changes. but correlation was very weak (r = 0. unevenly distributed in different zones of the city. however. P = 0.90).5. Similarly.000183) 0.218) and BI (r = 0. P = 0.0199 (0.000058 (0. The cases were. evidenced by the CI.029 Aedes albopictus 160 y = 5. Similar study results have been reported in Thailand.20.891) and BI (r = –0. as evidenced by higher relative abundance in tyres in both urban and suburban areas (see Table 3). where populations of Aedes aegypti have been found to be resistant to both deltamethrin and permethin.410 Aedes aegypti 200 y = 9. Dengue is spreading rapidly and becoming established in north-east India.02) Fenthion (0. it seemingly outnumbered Aedes albopictus.00374 (0.: Dengue vectors in Assam. and an increase in reported morbidity and attributable death.00226 mg/L to 0. Aedes aegypti is reportedly invading the suburbs and other town areas in the state.5 In the state of Assam. Given the fact that populations of both mosquito species were resistant to DDT.52 (for Aedes aegypti). it is highly unlikely that Aedes albopictus is an efficient vector. mg/L Aedes aegypti 280 y = 4.00283) 0.67 + 2. breeding predominantly in discarded tyres.000018 to 0. with a dramatic increase in urbanization and population movement. breeding in a wide variety of resources (see Table 3).427 Aedes aegypti 160 y = 28. was the predominant mosquito species in the semi-urban area. Instead. it is argued that.16 In 2013.00226 (0. cut-bamboo stumps and leaf axils.0271) 0. although most cases have been recorded in Guwahati city itself.01292 to 0.00294 (0.48 + 3.000031) 0.230. and high values of CI for Aedes aegypti were maintained in the city premises during July to December. with large concentrations in the East zone. it is projected that dengue will emerge as a major public health issue in northeast India. 0.00699) Mosquito species LC50: concentration that is lethal to 50% of the population. with increased urbanization and depletion of forest cover. preferentially in flower vases.557) were also insignificant statistically.01747 mg/L to 0. which corresponded Even though both Aedes aegypti and Aedes albopictus are the suspected vectors and implicated in dengue transmission in the north-east region of India.Dev et al.000023 to 0.27x 0.0415 to 0.000083) 0. and showed a variable response to pyrethroids.3.01747 (0. West zone and South zone. see Table 2). However. India.1x 0.00216 to 0. with increased case incidence. mg/L ) Malathion (1. June to July 2013 Larvicide (diagnostic concentration. the role of Aedes albopictus in dengue transmission in this region needs to be elucidated.05) Number of larvae assayed Regression equation Pearson X2 goodness of fit LC50 (95% confidence interval). given the seasonal abundance and case incidence in city areas.15.000128 to 0.61 + 7. evidenced by underlying Discussion WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 57 . corresponding to a record number of cases. and the mosquito breeding indices varied between the months observed (see Figure 2). correlation of dengue cases with HI (r = 0.00272 to 0. in decreasing order (see Figure 1).0518 mg/L.0138 to 0. For Aedes albopictus.000317 (0. breeding in variety of habitats.00294 mg/L.0707 (0.000027 (0. malathion should be the insecticide of choice for control. confirmed cases have also been reported from other district towns. supported by serological evidence for circulating strains of dengue virus.91 + 2.204 Aedes albopictus 160 y = 17.02108) 0.5x 0. was associated with the first reported dengue case in May.0764) 0. Aedes aegypti was the most common species in urban areas.5883) 0. although correlation with CI and the number of cases was very weak (r = 0. 91% (4121/4526) of the total reported dengue cases were recorded in Guwahati city alone and only two cases in the suburban Sonapur block. on the other hand.28x 0. respectively.00404) 0.00519 to 0.0474 to 0.000058 mg/L.00342) 0. and combined CI of 5.348. Interestingly.0518 (0.76 + 10.52 + 4.5 Similar observations have also been documented in other countries of south-east Asia.000059 (0. the LC50 to LC95 values for malathion were 0.192 0.248.455. and was recorded exclusively in cement tanks and used battery boxes (see Table 3).00340 to 0.010 Aedes albopictus 120 y = 20.0) Temephos (0. With the increasing distribution range of Aedes aegypti and evidence of virus activity.85x 0. and the data analysed for mosquito breeding indices for respective zones.00579 mg/L respectively (see Table 5). Aedes albopictus. it is highly probable that Aedes aegypti is the predominant mosquito vector transmitting dengue virus.000027 mg/L to 0. Abeyewickreme W. Vol. Thailand. with particular reference to identification of high-risk areas. TDR/IDE/Den/03.accessed 28 February 2014. Kroeger A. Yaumphan P. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . Das NG. namely. seasonal variation & dengue transmission prediction in Sisaket. Document No. Geneva: WHO. Sarkar PK.2011. Wattanachai P. Belkin JN. J Environ Biol.0 mg/L). The subgenus Stegomyia of Aedes in Southeast Asia. John VM. Gokhale MD. Paeporn P. Culicidae). temephos (0. Eco-biosocial determinants of dengue vector breeding: a multicountry study in urban and periurban Asia.20–22 However.25:209–212. Sharma SN. Srisawat R. Mahanta J.24–26 There is scope for further research on the subject to generate similar data for other districts/states of north-east India. Thenmozhi V. Barua HC. Chaturvedi UC. Biosci. Ragu K. and DK Srivastava. 1987. Nam VS. Lenhart A. Chaturvedi C. 20. Tyagi BK. Tropical Biomedicine. Tana S. Srivastava S. 1996. Mosquito survey in Tirap and Subansiri districts of Arunachal Pradesh. and to the India Meteorological Department. Ministry of Health and Family Welfare. Gupta N. for providing meteorological data.int/ hq/2003/ TDR_IDE_DEN_03. Madurai for confirmation of mosquito species identification. World Health Organization. India. XIV. Khan AM. Dengue Bulletin. Geneva: WHO. Contrib Am Entomol Inst. J.136: 373–390. WHO/VBC/81–806. Barbazan P. for targeting interventions and averting outbreaks and spread of disease. Insectcide susceptibility status of certain populations of Aedes aegypti mosquito from rural areas of Maharashtra state. 5. Midega J. continuous monitoring of insecticide susceptibility against dengue vectors is imperative for effective control and containment of disease spread. 22. Jaroensutasinee M. 1987.who. Khan SA. 14. 1996.48:116–118. http://www. Sommerfeld J. Entomological observations on dengue vectors mosquitoes following a suspected outbreak of dengue in certain parts of Nagalnad with notes on susceptibility to insecticides. Singh RK.who. 18.19 For anti-larval operations. 2013.28:210–212. Savanpanyalert P. Lal S. Supaphathom K. Tun-Lin W. Instructions for determining the susceptibility or resistance of mosquito larvae to insecticides. Document No. Kabilan L. 608 and 412. Tewari P. Thailand. World Health Organization.23 This study has provided data on the prevalence of both disease vectors and some bionomic characteristics. Tropical Biomedicine. 2009. A review of entomological sampling methods and indicators for dengue vectors.1.accessed 28 February 2014. 2012. Petzold M. Pegu DK. India. Morrison AC. New Delhi: Directorate General of Health Services. Kerala. 2004. Geneva: WHO.30:234–242. Mohapatra PK. J Vector Borne Dis. Hazarika S. but lack of data on the pupae-per-person index in the given locality remains the limitation of the study. Mahanta J. India. 1&2. 1962.88:173–184. 11. http://www. 2003. India. Wongkoon S. Thailand. Geneva: World Health Organization. pp. Hemorrhagic manifestations associated with dengue virus infection in Nagaland.14(9):1143–1153. Huang YM.: Dengue vectors in Assam. 2010. Natural and vertical transmission of dengue virus in Aedes albopictus in southern India. Mittal PK.gov. similar study results have been reported for mosquito adult and larval population in other regions of India. Mourya DT. Jain A. Bacillus thuringiensis israelensis (Bti) and insect growth regulator compounds. Chakraborti S. Sharma CK. organophosphates and carbamate insecticides diagnostic test. 2004. Barua HC.18.25:84–87. Petzold M. Manrique-Saide P. Susceptibility status of dengue vectors against various insecticides in Koderma (Jharkhand). updated September 2013. 17. 4. Indian J Med Res. 15.05 mg/L). To overcome insecticide resistance. Mahanta J. Trop Med Int Health.21:1–6.1. 16. 1981. Reducing costs and operational constraints of dengue vector control by targeting productive breeding places: a multi-country non-inferiority cluster randomized trial. Jaroensutasinee K. NG Das and the project staff for technical assistance.The Scutellaris group of species. enforced by civic bye-laws. WHO/VBC/81. Nathan MB. Detection of dengue virus in wild caught Aedes albopictus (Skuse) around Calicut Airport. Supaphathom K.807. 13. Samuel P.accessed 30 December 2013.60:245–249. 1972.02 mg/L) and fenthion (0. Indian J Med Res. 23. Document No.97:87–91.pdf . 1993. Ya-umphan P. Apart from the variable response of mosquito adults to pyrethroids. National vector borne disease control programme. Instructions for determining the susceptibility or resistance of adult mosquitoes to organochlorines. 7. Mahadev PVM. Banerjee K. References 2. Paeporn P. Rahman SJ. J Commun Dis. as well as chikungunya virus infection and co-infection of various dengue serotypes.138:347–353. Biochemical detection of pyrethroid resistance mechanism in Aedes aegypti in Ratchaburi province. Meheus F. Centre for Research in Medical Entomology.in/ . Dhiman RC. 2006. Kumar K. Japanese J Infect Dis.24:143–149. Potential vectors of dengue and the profile of dengue in the north-eastern region of India: an epidemiological perspective. 25. Espino Fe. Sawat SL. 12. Fact sheet No 117. Malhotra PR.33:429–441 Dutta P.nvbdcp. and community participation to prevent mosquito breeding. including Delhi and Jharkhand. Kroeger A. Dutta P. malathion (1. Dengue and dengue haemorrhagic fever: Indian perspective. Dua VK. Hiryan J. and has been duly endorsed by WHO. Indian J Med Res. Gill KS. Arunachalam N. Kerala.Dev et al. Bull World Health Organ. district officer for data access on reported cases and coordinated efforts for vector breeding surveillance. Dengue Bulletin. should all be considered. Sharma VP. Dengue and severe dengue. 21.21:145–151. The Mosquitoes of the South Pacific (Diptera. Dengue Bulletin. vector incrimination and seasonal infectivity of dengue. 2008. Acknowledgements 3. Nagar R. 24.24:151–158. 2001. 1. 10. Nagpal BN. Mahanta J. 9. Komalamisra N. Saxena VK. Rebollar-Téllez E. The authors are grateful to Dr BK Tyagi. Deesin V. 2013.28:301–303. 2007. Kittayapong P. Susceptibility status of immature and adult stages of Aedes aegypti against conventional insecticides in Delhi. Pajni HR. 58 8. Survey of mosquito fauna of northeastern region of India. 2004.28:56–58. Thanks are also due NR Choudhury. 1981. Tiwari SC. an appropriate mix of technologies.9(1): 109. Fock DA. int/ . Indian J Malariol. Dengue in India. sustained efforts for community awareness. repeated applications seemed inappropriate given the diversity of breeding resources and selection pressure for resistance. Indian J Malariol. Distribution. http://whqlibdoc. 2004. Sanchez F. Kire M. Maslapurum district. India biochemical mechanisms. Insecticide susceptibility and selection for resistance in a population of Aedes aegypti from Ratchaburi Province. even though larval populations of both species were susceptible to all three larvicides. Contributions to the mosquito fauna of Southeast Asia. I. The pupal/demographic survey has been proven to be an effective tool for assessing risk and targeting the most productive containers for reducing operational costs. Wai KT. Das BP. J Commun Dis. Serologcial evidence of DEN-2 activity in Assam and Nagaland. Katyal R. Cote M. including application of bio-larvicides. World Health Organization. Guwahati. Berkeley and Los Angles: University of California Press. 6. Patimaprakorn R.27–29 The study results have direct relevance for the state dengue-control programme. 19. KK coordinated the study. Mahanta J. 2001. 03/2014. Pradhan SK. J Vector Borne Dis. intermediate supervision. Maharashtra state. Gokhale MD. WHO South-East Asia J Public Health 2014. Source of Support: This study was funded by the Indian Council of Medical Research. All authors have read the final version and approved it for submission. Document No. Khan AM. First evidence of chikungunya virus infection in Assam. 27.43:151– 160. 2006. India: entomological observations. How to cite this article: Dev V.1. Contributorship: VD developed the concept proposal. Acta Virol. Emergence of chikungunya virus in Indian subcontinent after 32 years: a review. Tewari GG. 28.Dev et al. 2011. 3(1): 51–59. Powers AM. Isolation of chikungunya virus from Aedes aegypti mosquitoes collected in the town of Yawar. Hundekar Sl. Mourya DT.105:355–357. Alexander N. Dengue vectors in urban and suburban Assam. and drafted the manuscript. Chowdhury P. Fock DA. mosquito dissections and identification. 29. data collation and analysis. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 59 . This submission has been reviewed by the Institute Publication Screening Committee and bears the approval No.: Dengue vectors in Assam.TDR/IDE/ DEN/06. Multicountry study of Aedes aegypti pupal productivity survey methodology: findings and recommendations. India 26. Thakare JP. New Delhi (File No. Khan SA. Geneva: World Health Organization. India. 2006. Chandrakant L.45:305–309. Conflict of Interest: None declared. conducted overall supervision. data compilation. Dutta P. Jaykumar PC. GGT undertook data collection. provided intermediate supervision and developed portions of the manuscript.5/8-7 (306) V-2011-ECD-II). Khound K. Northeast India. Pune district. Trans R Soc Trop Med Hyg. Borah J. Maldives. Information is disseminated as annual communicable disease reports to health facilities and uploaded onto the official website.mv. E-mail: aroona@health. environmental management and community mobilization are important for effective prevention and control. Ministry of Health and Family. Address for correspondence: Dr Aishath Aroona Abdulla. Maldives. 1 Background: Dengue is endemic in Maldives. Malé. using an evaluation tool based on United States Centers for Disease Control and Prevention (US CDC) guidelines. where the responsibility of notifying was also assigned to ward in-charge and support staff. Center for Community Health and Disease Control. surveillance.7%). The largest epidemic to date was in 2011. and doctors expected to notify. Indira Gandhi Memorial Hospital (IGMH). Maldives. The World Health Organization (WHO) currently estimates that there may be 50–100 million dengue infections worldwide annually. where only doctors were given the responsibility. and surveillance data from the Health Protection Agency (HPA) were compared by use of an independent database of the country’s national referral hospital in Malé. owing to central and peripheral resource limitations. Health Protection Agency. Over 40% of the world’s population is currently at risk from dengue. but with early detection and good clinical management. Standard case definitions were published. Maldives.4103/2224-3151. 4 Director. Acceptability by clinicians was poor.com Conclusion: This evaluation shows the performance of the dengue surveillance system was good overall. Maldives. the usefulness for early warning of outbreaks was limited. Severe dengue is a leading cause of serious illness and death among children in some Asian countries. mostly in urban and 60 semi-urban areas. 2 Public Health Program Officer for Surveillance. 3 Senior Public Health Program Officer for Surveillance. dengue shock syndrome. Vector control. Maldives Introduction Dengue is a mosquito-borne disease with significant morbidity and mortality. Maimoona Aboobakur4 Abstract Senior Medical Officer. but it was extremely low from the medical ward (1. Maldives. Malé. legislature and assigning the responsibility of surveillance in hospitals to ward managers in addition to doctors. Indira Gandhi Memorial Hospital.int/ publications/journals/seajph DOI: 10. Public Health Programs.54. Ibrahim Nishan Ahmed3. Methods: This evaluation of the national surveillance system for dengue was done in September to October 2012. Roashanee Building. Ministry of Health and Family. were interviewed. Data were useful for planning. Dengue is found in tropical and subtropical countries worldwide. dengue haemorrhagic fever. This study evaluates the surveillance system for dengue during 2011. identifies gaps and suggests ways to improve. clinicians need more regular feedback. Sensitivity was 0. doctors’ role. Results: National surveillance is conducted by HPA. Fathimath Rasheeda2. Epidemiologist.who. the case-fatality rate can be reduced to less than 1%. to assess sensitivity and timeliness. The timeliness of reporting was good (median 2 days). However.gov. Surveillance is crucial for early detection of outbreaks and timely control.searo. The performance could be improved significantly by written protocols. Center for Community Health and Disease Control.115828 Quick Response Code: An evaluation of the surveillance system for dengue virus infections in Maldives Aishath Aroona Abdulla1. There is no specific treatment to cure dengue. Ministry of Health and Family. However. iaroona@hotmail. Center for Community Health and Disease Control.Access this article online Original research Website: www. evaluation. The reporting rate was high from the paediatric ward in IGMH (85%). The quality of data was acceptable. Staff involved in surveillance of different levels. owing to the lack of feedback reaching them. Ministry of Health and Family. which collects information daily from a network of health facilities. Key words: dengue.1 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . but they were not easily accessible to clinicians. while it was hoped to reduce bias from increased reporting after official declaration and media publicity.6 There was some criticism regarding the inadequacy of public health measures related to this outbreak. with perennial occurrence and seasonal peaks during the months of June to August each year. Thereafter. DHF or DSS from the national-level referral hospital Indira Gandhi Memorial Hospital (IGMH) that were detected by the surveillance system. to detect epidemics and take control measures. The last epidemic in June 2011 was the worst experienced. The flow of data is shown in Figure 1.e. This included a policylevel person. Aggregate data in the form of daily counts and individual casebased information are collected. and to plan and prioritize efforts to control the disease in Maldives. • simplicity – assessed by method of notification. a staff member of the Medical Records Unit of IGMH. surveillance for dengue began in the year 2000. Results The national surveillance system for dengue covered a population of approximately 317 000.3 The central public health authority – the Health Protection Agency (HPA) is responsible for surveillance as well as public health services. it is expected that the forms will be completed by treating clinicians. Standard case definitions were used and a case definition booklet was published in 2008 and disseminated.4%. Approximately one third of the population lives in the capital Malé. positive predictive value calculated using the proportion of patients diagnosed with dengue fever (DF). Doctors in hospitals in Malé and Hulhumalé were interviewed using a separate questionnaire to assess the acceptability of the system and identify how data are collected at the hospital level (see Supplementary Online Annex 3 for questionnaire). Usually WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 61 . Data for a one-month period in May in 2011 were selected for comparison because. i. • sensitivity – the proportion of individuals given the final diagnosis of DF. Methods A qualitative evaluation of the national-level indicator-based surveillance system for dengue infections was conducted in September to October 2012. but surveillance staff were not aware of any written documentation of the objectives. Staff involved in surveillance at different levels of the surveillance system were interviewed. Surveillance is conducted by the Communicable Disease Surveillance Unit of the Communicable Disease Division. the case-fatality rate was maintained low at 0.5. fax and email (see Table 1). with good clinical management nationwide.Abdulla et al.7 This study reports on the following attributes: • data quality – assessed by the completeness of core data fields and proportion of duplicates and proportion of confirmed cases. Dengue was first reported in Maldives in 1979. using a real-time online software database (SIDAS). However.: Dengue surveillance in Maldives Maldives is a small country. with clinical or laboratory confirmation. as the first dengue outbreak. and suggest ways to improve the functioning of the system. Who notifies? Although there are no written procedures or legislation indicating who is responsible for notifying. with 2909 cases and 12 deaths. dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). The surveillance system of Maldives had not been formally evaluated in the recent past. There are 21 administrative divisions (20 administrative atolls and Malé city). Dengue is now an endemic disease in Maldives. using an evaluation tool based on the United States Centers for Disease Control and Prevention (US CDC) Updated guidelines for evaluating public health surveillance systems. the ideal assessment by time from the date of consultation to the date of inclusion in the database could not be done because the date of receipt of notification to HPA and date of entry into the database were not recorded. • timeliness – assessed by the time taken from the date of onset to date of notification. Information is collected on a daily basis from all health facilities. identify gaps in the surveillance system. a staff member of the Communicable Disease Surveillance Unit.4–6 The objectives of the dengue surveillance are to characterize seasonal patterns of dengue infections. scattered over approximately 200 inhabited islands as estimated for 2011. data on dengue patients reported to HPA from IGMH were accessed with the necessary permissions and compared with data in an independent patient database maintained by the Medical Records Unit of IGMH for the hospital’s use.2. there were more cases. A semi-structured questionnaire consisting of 16 main questions was used. It was the fourth most commonly notified disease in 2011.8 but case definitions were not easily accessible by the users (reporting clinicians) at the time of the evaluation. with a population of about 330 000 dispersed over 194 inhabited islands. interventions and planning for disease control and health promotion. After a major outbreak in 1998 and 1999. Case-based data were collected and are available from 2005. This study was conducted to evaluate the surveillance system during the year of the epidemic. The surveillance system for dengue is mainly indicator based. • acceptability – assessed by the reporting rate and views of doctors. outbreaks were reported intermittently. To assess sensitivity and timeliness. Objectives were defined for the communicable disease surveillance system. and a laboratory staff member of IGMH. as this was the month before the epidemic was declared.2 HPA collects information from a network of atoll hospitals and from the tertiary hospital and other hospitals and clinics in Malé. Daily inpatient lists compiled by nurses were compared with the list of reported cases prepared by the hospital Medical Statistics Unit. cl inical assistants). Ministry of Health. hospitals – atoll. PHU: Public Health Unit.: Dengue surveillance in Maldives Councils. DSS: dengue shock syndrome. MNDF: Maldives National Defense Force. health workers. IGMH. clinical support staff (ward clerks. clinics (MNDF. regional. WHO Occurrence of DF /DHF/DSS cases Case goes to health facility Case confirme by treating doctor Feedback and dissemination of information for public health action Reporting sources Health cent res. laboratories. public . DF: dengue fever. doctors. 62 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . ADK. health posts. private). laboratory technicians Reporting : · sending notifications · confidentiality maintained Data recipients Primary level Health centre in charge Data management (from secondary level and above) · collection Secondary level Atoll (13)/regional (6)/tertiary hosp ital medical records or PHU · entry · editing · storage · analysis · report generation Tertiary level HPA s urveillance unit · report dissemination · confidentiality maintained Figure 1: Data flow through the national surveillance system of Maldives ADK : .Abdulla et al. DHF: dengue haemorrhagic fever. IGMH: Indira Gandhi Memorial Hospital. stakeholders. nurses. HPA: Health Protection Agency. WHO: World Health Organization. conversely.7) 142 (54. patient confidentiality may not be a major problem at present. is used though the surveillance network. There were some gaps in the notification forms. as they require a higher degree of confidentiality of patient information. because of the lack of restrictions to edit and access individual patient data on the system. and thus can be used at peripheral locations. which is important for control measures. except in islands where primary health-care workers are the only clinicians.8) 22 (8. The notification forms had slight variations from one hospital to another.8 as hospitals printed their own forms. In the medical ward of IGMH. Villingili private hospitals (ADK) and clinics Other centres sometimes fax data when they have disruption of internet connection or software malfunction.: Dengue surveillance in Maldives Table 1: Methods of receiving notifications during the month of May 2011 Method Web – entered directly or onto Excel sheets uploaded Email Fax Number (%) in May 2011 95 (36. However. As there is no stigma associated with dengue infection. where internet facilities are available. and patient confidentiality. At the time of the evaluation. and surveillance officers at HPA. case classification. Data can be entered offline and uploaded. in-charge nurses and ward clerks are also given the responsibility of ensuring notification. are protected by password-protected access to the SIDAS system. despite a template being provided in the case definition booklet. and assist in completing forms. the easy availability of identifiable names and addresses with little restriction could threaten individual confidentiality. 1 these are doctors. while the island of Thulhusdhoo is the administrative centre for the rest of the atoll. This allows it to be used by individual healthcare providers to report data online. However. rather than individual health-care providers. and doctors sign them. DHF and DSS).5) Telephone Post Total None in May None (not used) 259 (100%) Remarks From atoll and regional hospitals From IGMH Hulhumalé. and can be accessed from any computer by a person with an authorized username and password. Therefore use of SIDAS is restricted to atoll-level and central-level data entry by HPA. forms are completed by doctors. the entire responsibility of notification is left to doctors. and laboratory confirmation. age. all reports from K Atoll1 (Thulhusdhoo is the administrative centre) are generally faxed. However. The central-level policy is that responsibility has been given to institutional.9 Security of the system. The data-entry officers at the statistics units in atoll and regional hospitals.Abdulla et al. The same username and password give access to entering new data as well as accessing and editing individual patient information. and indicator of disease burden (whether outpatient or admitted). clinical assistants or ward clerks complete forms. In the wards of IGMH. This system is used for all notifiable infectious diseases. The present system saves each patient’s name. However. A SIDAS user manual is available at all atoll hospital surveillance units. as it may threaten data quality and confidentiality. and. which did not cover outcome (death or discharged) clearly. Hulhumalé and Villingili are under Malé city and suburbs. the practice of informing all deaths from dengue by telephone to the surveillance unit was maintained. two in June. Receiving and storing data An online electronic system. In the paediatric ward. for administrative purposes. this facility is not used. but no telephone contact number. However. Trained medical records officers or community health workers enter data into SIDAS from atoll hospital level. the islands of Malé. download WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 63 . — K Atoll is where the capital Malé is situated. who enter and edit data. including tuberculosis. Box 1 details the information collected by the notification form. Owing to internet problems. and centrally for reference. despite having access to the SIDAS system Deaths were informed by telephone as well – one in February. at the reporting level. all hospitals. relevant to person. clinicians and hospital staff were of the opinion that that it is the responsibility of doctors. but excluding HIV and sexually transmitted infections. The approved users can also edit patient information online or locally and upload into the system. health centres and clinics (government owned and private) had been instructed to report cases of dengue infections. Data management and analysis Data can be edited at atoll level and at central level by HPA. place and time. The field for address was also not worded to capture the address of residence. sex and address. diagnosis (DF. In many peripheral hospitals. However. the system is not sensitive to IP address. the WHO South-East Asia Regional Office Integrated Data Analysis System (SIDAS). What information is collected? Case-based information was collected. are provided a username and password by HPA. the core field “date of onset” was incomplete for 69% of entries. the staff at CCHDC has changed. was used for analyses. there were limitations in the SIDAS software used. These data have been saved. Patients initially diagnosed with DF may later be diagnosed as having DHF or DSS. including active surveillance for dengue and other priority communicable diseases.) •• Date of onset of illness (not printed in IGMH form) •• Date of admission (for admitted patients) •• Date of consulting the doctor (for outpatients) •• Names of the doctor who diagnosed. and this is not updated on the reporting forms. Dissemination Surveillance information is disseminated as annual communicable disease surveillance reports. There are 11 mandatory core data fields (see Box 1). (Forms in IGMH and Hulhumale hospital specify this field as “reporting doctor”. who have a diploma-level training. Public health activities are carried out by primary health-care workers. usually between one and three staff. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . by saving a default system date for the incomplete cases. were available. the atoll stations maintain reporting by faxing information to HPA. such as biweekly reports. if these are not complete. Data were analysed manually. the doctor who referred. However. particularly in the atolls. •• The reporting hospital or institution – is not included in the template. This is printed as “Address in Malé” in reporting forms of IGMH. owing to a malfunction of the online SIDAS system. which was duly completed. Editing is generally done following cross-checking of the address of residence. as individual hospitals prints their own forms. Atoll-level public health or medical record units analyse and prepare annual reports.: Dengue surveillance in Maldives Box 1: Information collected in the communicable disease notification form •• Name of patient. as the population is too high in Malé and main city islands to trace addresses.and regional-level units have varying staff numbers in hospital medical record units. However. and. and could not keep up with targets. blank templates and updated Excel spreadsheets to the local computer. Atoll. Characteristics of the surveillance system evaluated Quality of data The quality of data was generally acceptable but there were some gaps. (hospital registration number – added by hospitals) •• Address. or when the diagnosis or case classification is revised – following revised reports by notifying health-care providers. it cannot generate graphs or maps. the software is designed to not save the case details. Resources HPA had two full-time surveillance officers and a programme manager for the unit. •• The fax number of CCHDC is given at the bottom of the form for faxing reports. (The instructions in the form do not specify to record the address where the patient lived at the time of contracting the disease. analysing regularly for timely detection of outbreaks and appropriate dissemination of data for action. particularly for data analysis. The reports were uploaded onto the Ministry of Health website. separate fields for: –– atoll –– island •• and two addresses: –– permanent address –– temporary address (in the island where the patient is hospitalized). but identified by the logo at the top of the form. The estimate according to past performance is that about six officers are required for efficient functioning of the unit. Also. but the majority of doctors interviewed were not aware of this.Abdulla et al. They were overworked. finally. and alert functions cannot be set-up. In such a case. such as computers and communication equipment. Two names and land phone numbers of contact persons to be called in non-official hours are also given in the form. the date of consultation or admission. as it could only analyse proportions. for patients from atolls outside main cities. Cross-checks for 64 data quality are only done on address at island level (required for prevention activities). Therefore. However. The equipment required. The maximum outage was when some atolls were unable to upload data online for a period of about two weeks. The surveillance unit attempts to produce more frequent reports. which focus more on the regional hospital’s own patient data than peripheral data (information from three surveillance unit staff in regional hospitals). but their ability to keep up with this is highly limited. internet and internal network connections are not stable. the doctor or person reporting (3 separate fields) •• Diagnosis – 2 fields: –– preliminary or clinical diagnosis –– confirmed diagnosis supported by laboratory tests •• Case classification: suspected/probable/confirmed (not printed in IGMH form) •• Condition of the patient •• Comments •• Reporting person’s name and signature and date. age and sex. and disease burden analyses. and localizing pockets of outbreak. as IGMH enters data into a different format and emails them. Data flow from the peripheries to HPA is relatively simple using the online SIDAS database. The island of residence of an identified case could be verified without much difficulty. It has helped in quantifying the burden of disease in various areas for planning resources.06%). as experienced in the epidemic declared from 1 June. it is not so easy to verify data from the reporting person. recovered or was very sick. this added to the workload of both IGMH and the surveillance unit at HPA. and surveillance case classification. and there is no automatic early warning built in. and found it a little cumbersome. unreported outpatients were not documented.: Dengue surveillance in Maldives Core data fields that may be inaccurate include: address of residence. As data analysis is not possible using the SIDAS system. policy decisions and concentrating efforts in improving clinical treatment. or tiers. The data have provided some useful information. as they only needed to write the diagnosis and sign the form. virus isolation and quantitative dengue serology tests required by the WHO case definition are not available in Maldives. but the usefulness in early detection was highly limited at the time. dengue data have been updated and checked for outbreaks on a weekly basis. In order to detect circulating dengue virus (DENV) serotypes during an epidemic. owing to the absence of an automated early warning of outbreaks and the difficulty of the surveillance unit checking the dengue data of all atolls on a daily basis. Fifty-three per cent of patients were notified from Malé. Addu and Fuvamulah. Therefore. Thailand. calculated using the proportion of patients diagnosed with DF. as seen in the weekly time trend graph (see Figure 2). The two doctors interviewed from the medical unit in IGMH completed forms themselves. so it was not possible to calculate sensitivity for outpatients. but not for cases from Malé. who are non-medical support staff. Addresses of residence were verified for cases from atolls. However. However. Laboratory confirmation was not available for the majority (91%) of patients. The system had not been adequately sensitive in detecting outbreaks early. Clinical outcome was not included in the core data field. Seroprevalence studies have not been done to date. from nine samples obtained. As clinical assistants or ward clerks. DHF and DSS with clinical or laboratory confirmation. as their interpretation was left to the person completing the form. reflecting the higher tendency to report severe illness. Data are checked for duplicates and cleaned. The forms are in a format that requires most of the requested information to be written. There was no formal event-based surveillance system during this period. Only DENV-1 virus serotype was detected during the 2011 epidemic. According to surveillance staff. the data files have to be downloaded and analysed separately. are not yet possible. This was not a new serotype to Maldives.54 for inpatient notifications (n = 154). A data field named “Clinical condition” was used in the system. these doctors found the process simple. but doctors were not clear what was required from this field. except that of providing early warning of outbreaks. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 65 . The confirmatory tests such as polymerase chain reaction (PCR). There is no automatic alert to warn of an outbreak. This is because serology is neither a requirement for treating dengue. Usefulness The dengue surveillance data are useful to detect outbreaks of dengue. which affected the quality of data. adding more data fields. The doctors interviewed had different experiences. such as analysis of data by incidence rather than case numbers. Fuvamulah or Malé). However. complete the forms for most doctors. and laboratory confirmations and outcomes updated by the medical records units of hospitals and the surveillance unit in HPA. while 100% of DSS cases were reported. Thus. Surveillance staff had to look at disease patterns manually by creating graphs each time. and more complex analyses. which could have been detected about three weeks earlier (in the week of 8–14 May). The surveillance system is flexible enough to accommodate changes in case definition. particularly construction sites in Malé. Simplicity and flexibility Dengue surveillance is part of the infectious disease surveillance system. Since then. Sensitivity Sensitivity was 0. as these data accounted for more than half of the notifications. the surveillance unit obtains samples from a cluster of 10–20 patients and tests them from a reference laboratory in another country – the Armed Forces Research Institute of Medical Science (AFRIMS).58. that require preventive measures. it was meant to record whether a patient died.Abdulla et al. unless the individual lived in a major city (Addu City. However. the positive predictive value was 0. Forty-one outpatient cases of DF and DHF were reported. this resulted in variation in information such as diagnoses. This sometimes resulted in postponing notification. it seems to meet most of the objectives of the surveillance system. date of onset of illness. as dengue serology was often not tested. There were only 16 repetitions out of 2680 cases entered in the last database by 13 October 2011 (0. This presents an additional burden to the surveillance unit. nor the most useful confirmatory test according to the case definition. using MS Excel. They were not used to checking on a regular basis until after the epidemic occurred. The breakdown by diagnosis showed that reporting rates were similar for DF (40%) and DHF (38%). particularly in Malé. including detecting the seasonal pattern of dengue infections. and even as early as February for control measures. and had been detected in previous years as well. Dengue was diagnosed mainly clinically and the case definition was not strictly followed. They also claimed that clinicians do not report on time. support staff such as clinical assistants or ward clerks help in initiating and completing reporting forms. and it is assumed that inpatients will be reported during their stay. where it is too busy to report outpatients. They were not aware of surveillance reports uploaded on the Ministry of Health website. More recently. the average and median time from onset to reporting was 4 days. in September. public health units and councils were yet to be added to the mailing list for receiving epi-reports.9% of health stations did not notify at the time of the study. In all units other than internal medicine. The doctors interviewed were not aware of the usefulness and functionality of the surveillance system. was 3 days (median 2 days). They found 66 patients admitted with dengue from daily census sheets that were not reported. and were rather delayed at the time of the study. overlaid on trends for 2009 and 2010 Acceptability A total of 126 centres were required to report dengue infections. The most appropriate measure for timeliness (difference between the date of seeking treatment and the date of entering the case in the surveillance WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . This would be acceptable given the natural history. Medical officers in the emergency room said that reporting is often not done there. The average time between the date of consultation and date of reporting was half a day for May and 2 days for September. 8.11 The average time from onset of illness to reporting during the month of May 2011.10 Reporting rates from paediatric versus medical inpatient units showed that 85% of paediatric patients were reported in May. Sometimes they forget to report. and did their best to keep up. doctors carry out the entire process. were aware of the epidemiological reports.: Dengue surveillance in Maldives Figure 2: Weekly dengue cases reported from Maldives in 2011. after the frenzy of the epidemic had calmed down. such as patient management. The majority of doctors interviewed claimed that they are too busy and have to prioritize other work. before the epidemic was declared. while only one adult patient (1. but very dedicated. Atoll hospitals. Most thought that surveillance data were not published. while doctors only write the diagnosis. Timeliness It is expected that an outbreak will be investigated within two weeks of first being reported. In medical wards. However. This includes the paediatric ward and general outpatient department. None of the doctors interviewed. For the month of June. whether local areas or from another country. as the majority of data for onset of illness were missing (70% for May and 59% for September 2011). 56% and 30% of data were missing for May and September respectively. it may still not be accurate. They felt that prevention activities were not carried out with urgency. Surveillance staff at IGMH Medical Records Unit claimed that the workload was too much to keep up with. the mean time was 10 days. but were not actively requesting clinicians to report them. Surveillance staff at the central level were also overworked.7%) was reported. owing to unavailability of staff.Abdulla et al. over reporting. The paediatric unit treated almost twice as many patients with dengue infections as the medical unit. Acceptability to the clinicians reporting was poor. support. and these varied across forms in different facilities. After the epidemic. by displaying the dengue case definition as posters in wards. as dengue would generally be diagnosed about 3–5 days from the onset of fever. as instructed by HPA. particularly in detecting outbreaks early. Discussions are under way to improve laboratory surveillance. The delay in detection and declaration of the outbreak suggests the advisability of setting alert levels and incorporating an automated alert in the system. there were confusions in noting address. with specific instructions for completion. The marked difference between medical and paediatric wards showed that delegating responsibility to nurses and clinical support staff helped to improve the reporting rates greatly. HPA is also in the process of compiling a legal regulation for disease surveillance under the Public Health Protection Act 7/2012. with instructions to ask directly for the address of residence at the time the patient became ill. The case definitions were not utilized. with reporting institutions. health facilities printed and used their own notification forms. some changes were made to the surveillance system. our opinion is that the institutional responsibility policy helps to maintain some degree of reporting. Head of Communicable Disease Division for granting permission to interview staff and access the surveillance system for conducting this study. This is particularly important because of the high turnover of clinicians in Maldives. including staff of the surveillance unit at CCHDC. and uploaded onto the Ministry of Health website. in addition to policy-makers at the Ministry of Health.Abdulla et al. and patients are referred from various places. DHF and DSS were updated. as well as clinical. in the process of disease surveillance. staff should continue to check dengue trends at least on a weekly basis. Ministry of Health and Family for granting permission to conduct this evaluation and providing vital information by interview. Discussion The dissemination of reports needs to be improved. However. central-level staff now continue to check on dengue trends on a weekly basis. and further training is planned to improve the functioning of the system. and also posted on the Ministry of Health website. The reporting rate of 54% of inpatients from IGMH was mainly due to the poor reporting from the medical ward. Since the epidemic. and guidelines for disease surveillance to be used by health-care facilities. despite the fact that booklets had been printed. The fields for recording address in notification forms was difficult for the reader to understand – there were two addresses – permanent address and “Address in Malé” or “address in island”.11 The high variation with a delay of 10 days may be a bias induced by the increased workload during the peak of the epidemic. with instructions to use only this template and no other forms. Maldives has a well-functioning surveillance system for dengue. at that time. Case definitions for DF. unless the patient or accompanying person was directly asked for it. finalized and sent to all health facilities. compared to giving the responsibility solely to the doctors. this study identified some gaps that should be improved in order to improve the sensitivity. and included answers that could be selected by tick-marks rather than writing. as the date of receipt to HPA and date of entry were not noted. medical records WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 67 . atoll public health units and councils. This may have been due to the fact that. in keeping with the WHO Regional Office for South-East Asia 2011 guidelines. over reporting. medical records and public health staff. the hospital medical records staff also began the practice of calling wards to retrieve dengue notifications that doctors had missed the previous days. it was suggested that this field should be revised to “address of present residence”. and addresses showed some inaccuracy. in order to gain acceptability and improve reporting rates. The unusual timeliness with a median time of only 2 days in May may reflect some inaccuracy of recording the date of onset. As many doctors claim that they are too busy and have to prioritize other work. We emphasize the need to have good written protocols defining staff and institutional roles and responsibilities that are available and accessible to the surveillance staff and clinical staff expected to notify diseases. These will define the roles and responsibilities of health facilities. with a gap of 5 months for the last report. Therefore. Acknowledgements Our heartfelt appreciation for their time and support in conducting this evaluation go to: Ms Geela Ali. as the population of Maldives is highly mobile.: Dengue surveillance in Maldives database) could not be calculated. If this is not possible. Also.11 printed and sent out to all health facilities to display in the doctor’s rooms and wards. In conclusion. Permanent Secretary of Health. the Director Public Health Programs. It was suggested that the field with the confusing term “clinical condition” was replaced by “outcome”. Dissemination of data for action was also very late. and all those who participated in this evaluation by interviews. such as patient management. The communicable disease notification form was revised to enable collection of mandatory information with greater ease. The large proportion of missing data also reduces the representativeness of this calculation. Case definitions should be more widely available to reporting clinicians. Staff capacity-building by expanding HPA and training for atolls is being conducted. The forms in IGMH did not have “date of onset” printed on them. The quality of data showed significant gaps in date of onset. thus. The new template was pre-tested. this field would be unlikely to be completed for over a half of the notifications received from IGMH. as the time reduced during the later months. Reports should be shared on a regular basis. acceptability and usefulness of the system. After sharing the findings and recommendations of this evaluation with HPA. as other hospital staff are also given the role of initiating the process of notification. The surveillance unit in HPA has communicated with WHO to improve the SIDAS online data-management system. March 2014. Republic of Maldives. Aboobakur M. World Health Organization. 3(1): 60–68. World Health Organization. Male: Centre for Community Health and Disease Control. 2012. 7. Republic of Maldives. Regional Office for South-East Asia.html . Ministry of Health and Family.health. 2011. New Delhi: WHO-SEARO. Ahmed IN. Analytical report 2006: population and housing census 2006. Regional Office for South East Asia. 2001. 2011. 11. Guidelines Working Group. Conflict of Interest: None declared. Male: MOH&G. SIDAS: an instant reference for atoll users . Regional Technical Advisory Group (RTAG) on Dengue: report of the second meeting. emergency rooms and out-patient departments of IGMH and Hulhumalé hospital. 68 World Health Organization. Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. 17. References 1. 2013. The Maldives health statistics 2009. Bali. 8. An evaluation of the surveillance system for dengue virus infections in Maldives. 9.accessed 19 March 2014. WHO South-East Asia J Public Health 2014.int/mediacentre/ factsheets/fs117/en/index. 2007. World Health Organization. Revised and expanded. 2006.instructions manual. 2009. Morbidity and Mortality Weekly Report. Male: MOP&ND. Regional Office for South-East Asia. FR contributed to a significant part of data collection and some analysis. New Delhi: WHO-SEARO. 5. Case definition for notifiable disease in Maldives 2008. 6. 10. New Delhi: WHOSEARO. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . Indonesia. 4. Male: CCHDC.mv . Fact sheet no. Dengue and severe dengue. Updated guidelines for evaluating public health surveillance systems: recommendations from the Guidelines Working Group. Male: MOH&F. Rasheeda F. Ministry of Planning and National Development. 27–29 November 2012.: Dengue surveillance in Maldives staff of IGMH and Hulhumalé Hospital and doctors working in wards. Geneva: WHO. and wrote the major part of the report. Minsitry of Health and Gender. INA contributed to data analysis. Republic of Maldives.who. Epidemiology and Disease Surveillance Unit. 3.gov. Republic of Maldives. Minsitry of Health and Family. http://www.Abdulla et al. http://www. collected data for. Dengue epidemiological report 29th September 2011. Republic of Maldives. Source of Support: Nil. Annual communicable disease report 2011.accessed 20 March 2014. Contributorship: AAA is the principal author who designed.Male: Center for Community Health and Disease Control. 2. 2011.50(RR13):1–35. How to cite this article: Abdulla AA. 2008. MA contributed to data collection and writing the report. Republic of Maldives. Minsitry of Health. Visceral leishmaniasis (VL) is endemic in various parts of India. This paper presents an atypical presentation of kala-azar. pancytopenia. Room no. with multiorgan failure in the absence of splenomegaly or fever. B. On physical examination. Haldwani 263139. Uttarakhand. India Abstract Leishmaniasis is a major public health problem in various part of world.115828 Atypical presentation of visceral leishmaniasis (kala-azar) from non-endemic area Quick Response Code: Yatendra Singh. India. Others tests. serum glutamic pyruvic transaminase [SGPT] – 555 IU). She was admitted to hospital with a 4-week history of weakness. with mild jaundice and severe pallor.72 µmol/L and serum creatinine was 291. West Bengal and Orissa. India Email:
[email protected]. were in the normal range. Case History The patient gave written informed consent for publication. Haldwani. the patient was tachypnoeic and tachycardic. 32 Sr Hostel Government Medical College. Atypical presentations can be challenging to the clinician. dengue. as well as neighbouring countries such as Nepal and Bangladesh.4103/2224-3151. multi-organ failure. Paramjeet Singh. malaria. The patient was a 32-year-old woman. who may present atypically. or visceral leishmaniasis (VL). The remaining systemic examination was normal.7 µmol/L. presents as fever. C and E) were negative.searo. with an acute. depending upon the Leishmania species and immune responses of the hosts.int/ publications/journals/seajph DOI: 10. including arterial blood gas analysis. HIV and viral hepatitis (A. She was severely anaemic and two units of packed red blood cells had been transfused prior to admission. abdominal pain. Ultrasonography of the abdomen revealed early medical renal disease and mild hepatomegaly. No significant past history was present. Address for correspondence: Dr Yatendra Singh. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 69 . Government Medical College. but brought no symptomatic relief. A chest radiograph was normal. with tenderness in the right hypochondrium.com Key words: kala-azar without splenomegaly. in the form of visceral. Tests for enteric fever. who did not smoke or consume alcohol and who worked as a labourer in her native region. The transaminases were raised (serum glutamic oxaloacetic transaminase [SGOT] – 766 IU. Mohammad Khalil Department of Medicine. visceral leishmaniasis Introduction Leishmaniasis is a vector-borne zoonosis with variable clinical presentations. Subhash Chandra Joshi. The thyroid profile. This paper reports VL in a patient from a nonendemic region of India. Abdominal examination revealed mild hepatomegaly. pancytopenia and hypergammaglobulinaemia. Total serum proteins were 65 g/L and albumin was 15 g/L. vomiting. it has also emerged in new geographic areas and host populations. total serum bilirubin was 54. She had never visited any area endemic for VL.1 Atypical presentation of VL in an nonendemic area can lead to a diagnostic dilemma. mainly Bihar. who presented with pancytopenia and multi-organ failure in the absence of splenomegaly or fever. progressive dyspnoea. Visceral infection can remain subclinical or become symptomatic. Kala-azar. Intravenous ceftriaxone at 1 g twice a day had been administered by her general practitioner for the past 5 days. Absence of splenomegaly is rare in immunocompetent patients. loss of appetite and weight loss.Access this article online Research brief Website: www. though it may occur in the early stages. cutaneous (of localized or diffuse types) and mucocutaneous types. It may be absent in immunocompromised patients. The presence of splenomegaly is characteristic of VL. Laboratory investigations revealed that haemoglobin was 38 g/L and normocytic normochromic anaemia with pancytopenia was observed on peripheral smear examination. subacute or chronic course. Recent increases in the number of cases have been reported from nonendemic areas of India. Involvement of the renal function in patients with visceral leishmaniasis (Kalaazar). much of which is probably due to parasite-released substances. Yaibuki K. J Clin Pathol. Discussion VL ranges over the intertropical zones of America and Africa. Ferreira TMAF. 1972. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . a rK39 strip test and bone marrow examination were carried out. To confirm the diagnosis of VL. 2003. In : Hunter’s tropical medicine.7 Several authors have described renal pathological changes in VL. el Hasan AM. in the absence of splenomegaly and fever. Nepal. Leishmaniasis. 9. Sudan and Brazil. Habib A. can also be found in kala-azar. 2. which appears to increase the mortality rate in this group of patients. Boura E.4. 70 VL misdiagnosed as connective tissue disorders is well reported in the literature . Gulati V. The development of acute kidney injury is an important clinical complication in individuals with VL. so Napier’s aldehyde test was done and found to be positive.14:51. Haematological abormalities found in systemic lupus erythematosus. 10.46:303–6. the patient in this study was also investigated for these biochemical markers and antibodies. As a consequence of B-cell hyperactivity. Edited by GT Strickland. Voulgari PV. 4. VL is a chronic infectious disease caused by Leishmania donovani and characterized by irregular fever. 3. Malatesha G. Sharma A. Elisaf M. which act as B-cell mitogens. chemokines and reactive oxygen and nitrogen species. There is infiltration of the reticuloendothelial system with amastigotes. Delayed diagnosis due to atypical manifestations can lead to fatal outcomes for patients. 11. simple laboratory findings like pancytopenia. Skopouli FN. Antinuclear antibodies (ANA). Gupta D . Rev Inst Med Trop São Paulo. Visceral leishmaniasis resembling systemic lupus erythematosus.11:12–16. 2006.26:245–6. The most frequent pathologies found are proliferative glomerulonephritis and interstitial nephritis. Ahasan H. Clinical and infective outcome of Parasitologicaly confirmed KalaAzar patients treated with sodium antimony gluconate . Indian Journal of Gastroenterology. The patient had a working diagnosis of pyrexia with pancytopenia.21(1):235–236. Pathophysiologically. 7. Salgado Filho N. thereby reducing the mortality of VL.3 but it may be absent in immunocompromised patients. The Nephropathy of Kala-azar. liver involvement in VL is typically self-limiting and involves a mononuclear celldominated granulomatous inflammation mediated by cytokines. Singh N K. weight loss. 2009.36:217–221. Rev Soc Bras Med Trop. The rK39 immunochromatographic strip was positive for anti-K39 antibody. In one series.47(6):547–51.11–13 This may cause confusion in diagnosis.2 Ninety per cent of the VL cases in the world are in Bangladesh. For this reason. hepatosplenomegaly. Hossain A.10 The patient in this study had both hepatic and renal involvement. 1999. Renal involvement in a patient with visceral leishmaniasis. cytoplasmic and perinuclear antineutrophil cytoplasmic antibodies (c-ANCA and p-ANCA) and direct Coombs’ tests were negative. There are an estimated 12 million cases worldwide. Kaul R. those with haematological malignancies and those on long-term steroids. Intracellular and extracellular amastigotes (Leishman–Donovan bodies) were visualized directly in Giemsa-stained bone-marrow aspirate. leukopenia or lymphocytopenia and thrombocytopenia due to the presence of auto-antibodies. such as those who are HIV positive. Ann Rheum Dis. For similar reasons. owing to the hyperplasia of the reticuloendothelial cells that are filled with parasites.1213–45. 7th ed. Leishmania donovani infection induces nonspecific and specific antibody production. and extends into temperate regions of South America. Bryceson ADM. even in atypical cases. 8. at a dose of 0. Leishmania donovani infection may cause hypergammaglobulinaemia and production of auto-antibodies such as ANA. 638–55. pp. with one and a half to two million cases occurring each year. Costa JML. Visceral leishmaniasis: acute liver failure in an immunocompetent Asian-Indian adult.Liver morphology and function in visceral leishmaniasis (Kalaazar).5 Milder forms of liver involvement occur in 17% of individuals with VL. The patient is under regular follow-up and is asymptomatic. Instead of relying solely on the classical clinical features of VL. pancytopenia and hypergammaglobulinaemia. At discharge. or in the early stages of the disease.5 mg/ kg/day after 1 week and this was continued for 3 weeks. Splenomegaly is an important feature of the clinical presentation.Singh et al. Efstratiadis G. References 1. Satinder SK. Pappas GA. In: Manson’s tropical diseases.6 and are structurally and functionally reversible after treatment. 1996. Homeida M. 1991. Southern Europe and Asia. 2004. which gives rise to the clinical and biochemical features. splenomegaly was reported to be present in 100% of patients. Hashim FA. India.63:1348-9. 2007. J Vector Borne Dis. Azad AH. which is an unusual presentation of kala-azar. Clin Dermatol.17:317–25. 5. el Tom IA. 20th ed. namely anaemia. Drosos AA. Andrade ZA. renal transplant recipients. pp.8. Philadelphia: WB Saunders. Mahesh DM.9 The main pathophysiological mechanism responsible for renal impairment in VL probably includes the deposition of immune complexes. altered albumin/globulin ratio and positive aldehyde and rK39 strip tests can help make an early diagnosis. WB Saunders. Conclusion The case is presented to highlight the atypical presentation of VL in a nonendemic region where the index of suspicion is low.: Atypical presentation of visceral leishmaniasis iron profile and vitamin B12 values were normal. a careful clinical approach is required to reach a definitive conclusion. the spleen tip was just palpable and the liver was not palpable. Leishmaniasis. A new focus of visceral leishmaniasis in the Himalayas. et al. Rarely. Raina S. Desjeux P. Global control and Leishmania HIV co-infection. el Kalifa M. 1994 Jun. it may be absent in acute cases. India. 6. Giamalis P. Liberopoulos EN. 2010. J Medicine. Nephrol Dial Transplant. Islam QT. The patient presented with pancytopenia and multi-organ failure. Siddiqui Rehman MM. By the seventh day of treatment. she had improved symptomatically as well as biochemically. Three units of whole blood were also transfused to maintain her haemoglobin levels. Jeffrey D Chulay. The patient was started on amphotericin B. el Hag IA. di Vico B. Joshi SC. Skopouli FN.Singh et al. How to cite this article: Singh Y. Drosos AA. Casato M. Mixed cryoglobulinemia secondary to visceral Leishmaniasis. et al. Clin Rheumatol. Visceral leishmaniasis resembling systemic lupus erythematosus. WHO South-East Asia J Public Health 2014. Source of Support: Nil. Conflict of Interest: Nil. Voulgari PV. Singh P. Ilardi I. PS – introduction and discussion. SCJ – case history.42:2007–11. Epub 2003 Oct 31. 2003. Voulgarelis M.Contributorship: YS – introduction and discussion. de Rosa FG.: Atypical presentation of visceral leishmaniasis 12. 3(1): 69–71. Arthritis Rheum. Serelis J. Atypical presentation of visceral leishmaniasis (kala-azar) from non-endemic area. Khalil M. 13.22:452–5. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 71 . Pucillo LP. Zorzin LR. MK – data collection. 1999. India Email: krunaldmehta@yahoo. Mala Sinha1 Department of Microbiology. The incidence of dengue peaked in October and slowly tapered by December. ethical approval was not necessary. west India Krunal D Mehta1.1 In India. and health centres in the surrounding district.co. Jamnagar. India 1 Abstract Background India is one of the countries in the World Health Organization South-East Asia Region that regularly reports outbreaks of dengue fever (DF)/dengue hemorrhagic fever (DHF).in Results A total of 903 serum samples were tested. The majority were males (72%) and in the age group of 16–30 years. Shri MP Shah Government Medical College. Department of Microbiology.2 In the last decade. Tamil Nadu and Karnataka. This retrospective study was carried out to assess the seasonal variation in dengue cases in a tertiary care hospital. Methods The laboratory records of clinically suspected dengue patients from July 2008 to June 2011 were analysed retrospectively for the results of immunoglobulin M (IgM) anti-dengue antibodies.searo. dengue has become a major global public health concern.4103/2224-3151. Jamnagar.4 Since there is no specific treatment or vaccine for dengue.int/ publications/journals/seajph DOI: 10. western states of Gujarat and Rajasthan. young adult age group. Gujarat. are estimated to be at risk of acquiring dengue infection. Shri MP Shah Government Medical College. living mainly in urban areas of tropical and subtropical regions. Western India. This observation is useful for planning special preventive strategies. As effective control and preventive programmes depend upon improved surveillance data. Variations in disease incidence by sex. Punjab and Uttar Pradesh. tested by dengue monoclonal antibody (IgM) capture enzyme-linked immunosorbent assay (MAC ELISA). southern states of Andhra Pradesh. Jamnagar. Prakash S Gelotar1. thus. age group and season were assessed. thereby helping implementation of effective vector-control measures. Shri MP Shah Government Medical College. vector Introduction In recent years. Swati C Vachhani1. prevention and control of the disease mainly depend upon epidemiological surveillance that provides reliable estimates of the disease. and the eastern state of West Bengal.5 billion people. Mehta. Key words: Dengue. in the post-monsoon season.who. The study draws attention to the susceptibility of the male.115828 Quick Response Code: Profile of dengue infection in Jamnagar city and district. unplanned urbanization and migration of the population from rural to urban areas with lack of proper sanitation facilities are important factors that have resulted in an increased burden of dengue in recent times. to inform control measures and preventive programmes. Approximately 2. Naresh Makwana2. The casefatality rate has been less than 1% in recent years.3 but a 72 major outbreak associated with haemorrhagic manifestations occurred in Calcutta in 2004. India 2 Department of PSM. this study was carried out to report the seroprevalence of dengue virus infection in an area around Jamnagar city. India. outbreaks and deaths have been reported from northern states of Haryana. Address for correspondence: Dr Krunal D. seasonal variation. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .Access this article online Research brief Website: www. Conclusion Dengue cases were higher during September to December. MATERIALS AND METHODS This was a retrospective analysis of routine laboratory diagnostic work. of which 253 were positive. Gujarat. dengue has been occurring regularly in India. 4%). Pune. 32%). The correlation between occurrence of dengue and the monsoon season is clearly evident in this study. The proportion of dengue cases 2009 2010 2011 Number of postivie cases 35 30 25 20 15 10 5 0 Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Figure 1: Month-wise distribution of dengue cases Note: the monsoon season in west India is from the end of July to the start of November each year. Fig. 46– 60 years (10/253. using dengue monoclonal antibody (IgM) capture enzyme-linked immunosorbent assay (MAC ELISA) kit of the National Institute of Virology. 49%).8 Ludhiana. over each of the 4 years studied. and emphasizes that preventive measures against dengue infection should come into full swing during water stagnation periods after the initial bouts of rainfall and at the end of the monsoon period. Gujarat. 1 shows that there were few dengue cases from January to July each year. at the Government Hospital. RESULTS A total of 903 acute-phase blood samples were collected from clinically suspected cases of dengue virus infection. 2008 DISCUSSION In the past decade. Data on the beginning and end of the annual monsoon season in Jamnagar district were taken from the sample-collection register for dengue. The year-round occurrence of dengue infection. following the initial epidemic and the availability of diagnostic tools in the hospital. analysis of the data on a monthly basis was carried out. as seen in this study.Mehta et al.10 This may be because this season is very favourable for breeding of the vector. 14%). with a peak in the rainy season. with a peak in September and October. has contributed to the increased detection of cases. 31–45 years (36/253. peaked in October and slowly tapered by December. i. and ≥60 years (1/253. it is also true that an increased alertness to the disease among the medical fraternity. for effective control measures.11 This seasonal outbreak of disease transmission is very important at a local level. Jamnagar. Out of these. A gradual increase in cases was noted from August.: Dengue in west India Age and sex data on all patients who presented with signs and symptoms of fever.4%). WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 73 .9 and Karachi. Out of the total 253 laboratory-confirmed dengue cases.7 To identify the seasonal variation of the disease. is consistent with reported patterns of dengue transmission.e. The most affected age group was 16–30 years (125/253. headache and joint pain that were suggestive of dengue virus infection. and is from the end of July to the start of November each year. Aedes aegypti and Aedes albopictus.6 Analysis of the year-wise distribution of dengue cases revealed an unsteady increase in the number of dengue patients over the past few years. This shows a seasonal trend of dengue. GG Hospital. World Health Organization (WHO) criteria were followed for inclusion or exclusion of a case of dengue infection. available from the Department of Microbiology.14 The presence of some dengue IgM-positive cases even during dry months. 182 were in males (72%) and 71 were in females (28%). This may be partially attributed to the rapid unplanned urbanization. Jamnagar. the incidence started to increase in August to September. 0.5 Serum samples were tested for the presence of antidengue immunoglobulin M (IgM). or at the primary and community health centres in Jamnagar district between July 2008 and June 2011 were recorded. 28% of symptomatic patients were serologically positive for dengue infection. India. with periodic surges in the number of cases. 253 samples (28%) were positive for dengue virus infection. and is further supported by similar findings from Kerala. In this study. dengue haemorrhagic fever (DHF) or dengue shock syndrome (DSS). followed by 0–15 years (81/253. India. probably reflects the year-round activity of the mosquito vector. India. with unchecked construction activities and poor sanitation facilities contributing fertile breeding grounds for mosquitoes. which correlates with the monsoon season in west India. Mehta et al.: Dengue in west India for the age group 16–30 years was highest, similar to the results noted in a study by Kumar et al.;7 the order of prevalence was followed by the age group 0–15 years. However, in several international studies, dengue has been reported to be mainly a paediatric public health problem.12,13 Dengue infection occurred in most active age groups, i.e. children and adults, who were out of the house most of the time, either playing or at work. This observation is noteworthy, because true endemicity of dengue is reached when adult infection declines and only the new entrants into the population, i.e. children, are affected more by the disease.8 In the present study, males were found to be more affected than females. From the high incidence of dengue IgM seropositivity, it appears that dengue is fast emerging as a major health concern in this part of India. In the absence of specific treatment for dengue, management is mainly supportive; further, there are no vaccines currently available in market, thus early diagnosis and vector control is the only method by which dengue can be controlled. The number of dengue cases was higher during September to December in the post-monsoon season; this information is useful for planning special preventive strategies. The study draws attention to the male, young adult age group. The results of this study indicate that dengue infection is unlikely to wane, but is going to stay and will play havoc if immediate control measures are not taken. There is an urgent need for a long-term vector-control strategy, to prevent outbreaks. At the same time, this will solve the problem of other mosquito-borne diseases like chikungunya, Japanese encephalitis, malaria and filaria. REFERENCES 3. 74 5. 6. 7. 8. 9. 10. 11. 12. CONCLUSION 1. 2. 4. Halstead SB. Dengue. Lancet. 2007 Nov 10;370(9599):1644–52. Bennett SN, Holmes EC, Chirivella M, Rodriguez DM, Beltran M, Vorndam V, Gubler DJ, McMillan WO. Selection-driven evolution of emergent dengue virus. Mol Biol Evol. 2003 Oct;20(10):1650–58. India, Ministry of Health and Family Welfare. Dengue cases and deaths in the country since 2007. New Delhi: National Vector Borne Disease 13. 14. Control Programme, Directorate General of Health Services, 2013. http://www.nvbdcp.gov.in/den-cd.html - accessed 24 February 2014. National Institute of Communicable Diseases. CD Alert.Dengue/ Dengue Haemorrhagic Fever, Delhi, India. 2004;8:2–4. World Health Organization. Clinical diagnosis. In: Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. 2 nd ed. Geneva: WHO, 1997. pp. 12–23. Singh B. Dengue outbreak in 2006: failure of public health system? Indian J. Community Med. 2007;32:99–100. Kumar A, Rao CR, Pandit V, Shetty S, Bammigatti C, Samarasinghe CM. Clinical manifestations and trend of dengue cases admitted in a tertiary care hospital, Udupi district, Karnataka. Indian J Community Med. 2010;35:386–90 Kavitha R. Dengue fever: the rise and the establishment of a new disease in Kerala, India with special references to the capital, Thiruvananthapuram. J Acad Clin Microbiol. 2007;9:65–70. Lal M, Aggarwal A, Oberoi A. Dengue fever: an emerging viral fever in Ludhiana, North India. Indian J Public Health. 2007;51:198–9. Khan E, Siddiqui J, Shakoor S, Mehraj V, Jamil B, Hasan R. Dengue outbreak in Karachi, Pakistan, 2006: experience at atertiary care center. Trans R Soc Trop Med Hyg. 2007;101:1114–9. Reiter P. Climate change and mosquito-borne disease. Environ Health Perspect. 2001 Mar;109(Suppl 1) :141–61. Shah GS, Islam S, Das BK. Clinical and laboratory profile of dengue infection in children. Kathmandu University Med. J. 2006;13:40–4. Anderson KB, Chunsutiwwat S, Nisalak A, Mameen P, Libarty D, Rothman AL. Burden of symptomatic dengue infection in children at primary school in Thailand: a prospective study. Lancet. 2007;369:1452– 59. Yukiko Higa. Dengue vectors and their spatial distribution. Trop Med Health. 2011 Dec;39(Suppl 4):17–27. http://www.ncbi.nlm.nih.gov/ pmc/articles/PMC3317606/ - accessed 24 February 2014. How to cite this article: Mehta KD, Gelotar PS, Vachhani SC, Makwana N, Sinha M. Profile of dengue infection in Jamnagar city and district, west India. WHO South-East Asia J Public Health 2014; 3(1): 72–74. Source of Support: Nil. Conflict of Interest: None declared. Contributorship: KDM – concept and design of study, data collection and data analysis; PSG – data collection; SCV – data entry; NM – analysis of data, discussion writing; MS – analysis of data. Acknowledgements: The authors thank all the GG civil hospital, Jamnagar Clinic staff for providing support for recruitment of patients and collection of samples, and also acknowledge the Department of Microbiology, Shri MP Shah Government Medical College, Jamnagar, for extending support for the study. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) Access this article online Policy and practice Website: www.searo.who.int/ publications/journals/seajph DOI: 10.4103/2224-3151.115828 Mass primaquine preventive treatment for control of Plasmodium vivax malaria in the Democratic People’s Republic of Korea: a country success story Quick Response Code: Shushil Dev Pant1, Kim Yun Chol3, Yonas Tegegn2, Partha Pratim Mandal1, Ri Kwang Chol3 Office of the WHO Representative, 14-Munsudong, Pyongyang, Democratic People’s Republic of Korea 2 Office of the WHO Representative, Bangkok, Thailand 3 Ministry of Public Health, Democratic People’s Republic of Korea Abstract In 1998, the resurgence of Plasmodium vivax malaria in the Democratic People’s Republic of Korea quickly increased to an epidemic, with 601 013 cases reported during 1999–2001. The introduction of mass primaquine preventive treatment (MPPT) in 2002 was followed by a rapid reduction of malaria disease burden. The intervention has been well accepted by the community. Doctors were part of a strong functional health system with the ability to deliver interventions at the household level. MPPT was considered for control of malaria after a study conducted in two neighbouring endemic villages (ris) involving 320 healthy adults demonstrated that presence of parasitaemia was significantly lower among those receiving MPPT than those who did not. Similarly, in a mass blood survey conducted in the study sites during May, 2002 involving 5138 persons in study and 4215 in comparison areas, the total positive results were 7–10 times rarer in the treatment group both before and after the malaria transmission season. In addition, the number of malaria cases in the MPPT treatment ris was strikingly lower than control ris in every month during the malaria transmission season of 2002. The prevalence of G6PDD deficiency in DPR Korea is low, haemolytic events are rare and deaths due to MPPT have not been reported. MPPT in itself is a powerful intervention and the decision to deploy it depends on the epidemiology of malaria, urgency of malaria control and resources available in the country. 1 Address for correspondence: Dr Shushil Dev Pant, Office of the WHO Representative, 14-Munsudong, Pyongyang, Democratic People’s Republic of Korea. Email:
[email protected] Key words: Malaria, Democratic People’s Republic of Korea, mass primaquine preventive treatment, Plasmodium vivax Background The resurgence of Plasmodium vivax malaria in the Democratic People’s Republic of Korea followed the outbreak in 1998, when 2100 malaria cases were reported. This outbreak occurred after the country had been malaria free for more than 25 years.1 At the time, there was no outbreak-response plan, and limited national expertise had been retained for malaria programme management. Entomologists, microscopes, and people with the skills to read malaria slides were scarce. There were limited resources and capacity to scale up vector-control interventions. In the absence of a rapid and appropriate response, the outbreak soon spread nationwide. A total of 601 013 cases were reported over 1999–2001. Most of the people affected were adults and only 7–12% of cases were children aged under 15 years. Agriculture workers were the predominant occupational group affected. However, no mortality associated with malaria was reported.2 In this setting, the World Health Organization (WHO) assisted the Ministry of Public Health to introduce mass primaquine preventive treatment (MPPT), starting with pilot studies in 2002. The decision to deploy MPPT was also strongly influenced by the encouraging experiences of other countries that had prevalent P. vivax infection, with dual strains of short and long incubation periods – notably neighbouring China, where about 30 million people were treated between 1973 and 1983.3 Introduction of MPPT in the Democratic People’s Republic of Korea contributed to significant reduction of P. vivax malaria in subsequent years. This review describes the evolution of the intervention and its contribution to malaria control in the country. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 75 Pant et al.: Mass presumptive primaquine treatment in DPR Korea Materials and methods International publications citing studies or reviews of diseasecontrol programmes in the Democratic People’s Republic of Korea are limited. This paper aims to share the country’s success story, based on the limited documentation available. The majority of references for development of the document came from the assignment reports of the WHO malaria experts. These experts worked in the country and were supported to review the epidemiology of malaria after its resurgence there; to design the study to assess the effectiveness of MPPT; to develop the plan of implementation; and to monitor the progress made in malaria control from 1998 to 2012. Information shared during detailed discussion with the manager of the National Malaria Programme and malaria experts in the country has also been used as reference to enrich the document. Where possible, the information provided by the national programme has been verified against the documents in WHO archives. Publications from neighbouring countries and experiences of countries that have also successfully implemented MPPT to control malaria have also been included, to improve understanding of the MPPT concept, in an attempt to make this document more comprehensive and useful for policy decisions. The hypothesis: MPPT reduces malaria transmission Malarial infections in the Democratic People’s Republic of Korea during January to April (winter) are dormant and rarely reported. In addition, the vectors of malaria begin to hibernate from the end of November and mosquitoes are rarely spotted until the end of April. Thus, malaria transmission is extremely rare during winter months.2 According to the Ministry of Public Health, based on a research conducted in 2000, P. vivax malaria parasites that are prevalent in the Democratic People’s Republic of Korea exhibit two different durations of incubation period. For 20–30% of the P. vivax infections the incubation period is 2–3 weeks, while for 70–80% of infections it is 6–12 months.4 The report of this research has not been shared, but the national programme is confident of the reliability of the data. However, in the absence of means for parasite genotyping, these conclusions are open to debate. Infections with short-incubation parasites manifest in the same transmission season and the majority of infections (caused by long-incubation parasites) are therefore asymptomatic in the respective winter and manifest at the beginning of malaria transmission season (May to August). In other words, in a given year, 70–80% of reported cases were infected in the previous year and 20–30% of cases are new infection or relapse of the short-incubation type. Infections with long-incubation parasites, and cases that will relapse in the transmission season, were dormant during the immediate preceding winter. Mass treatment with primaquine during winter will thus reduce the number of individuals in the community who are harbouring hypnozoites, thereby reducing the local parasite reservoir. Despite an increase in vector density and human bite rate in June to August, most anopheles bites are non-infectious. As a result, the entomological inoculation rate becomes low and malaria transmission decreases.[5] Study of the hypothesis A study was conducted in 2001 to test the above hypothesis. The study aimed to evaluate the effectiveness of MPPT in reducing reinfection or the relapse rate among treated and non-treated cases.6 Two neighbouring endemic villages (ris) were selected as the treatment and control sites. A total of 320 healthy adults without patent disease or contraindications to primaquine administration (pregnancy, patients with lupus, arthritis, leukaemia or hepatitis, or with a history of haemolysis/ hypersensitivity after taking primaquine) were selected for the treatment arm. Other details of the characteristics of the sample are not documented. Each case in the treatment arm received 15 mg primaquine per day for 14 days in the month of March. They were followed up for parasitaemia in subsequent months. The results were compared with 320 adult controls who did not receive primaquine. Owing to limited laboratory capacity, the cases could not be reclassified into new, recrudescence or relapse. Table 1 shows the results of the prospective study. The presence of parasitaemia was significantly lower (P < 0.0001) among those receiving MPPT. The study demonstrated strong evidence that MPPT was an effective intervention to reduce malaria transmission. Piloting of MPPT in malaria transmission areas MPPT was introduced during February to April 2002 in seven malaria-endemic counties of five provinces. The counties selected for the piloting were: Kangnam, Sukchon, Sonchon, Sinchon, Hwangju, Anbyon and Panmum.7 Malaria outbreaks Table 1: Study of the effectiveness of primaquine prophylactic treatment for reducing reinfection or relapse Infections detected during follow-up Number Malaria cases Relapse/ reinfection rate, % April May June July August September October Primaquine 320 9 2.9 0 0 0 3 3 2 1 None 320 98 36.0 0 8 24 34 28 3 1 Regimen Month, 2001 Relative risk = 10.9 (95% confidence interval = 5.6 to 21.2, P < 0.0001, Yates corrected χ2 test). 76 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) or a history of haemolysis/hypersensitivity after taking primaquine were excluded from MPPT. a total of 391 357 people from 91 ris of seven malaria counties were targeted for MPPT. at the onset of MPPT. arthritis.04 3 716 1 0. The overall reported rate of side-effects was slightly lower in the first group (4.8%) as compared to the second one (6. The total number of positive results was 7–10 times lower in the treatment sample both before and after the malaria transmission season. the villages are isolated and cross-border contamination of control areas is unlikely. In treatment ris. The control ris were represented by 421 875 people above the age of 5 years. In the Democratic People’s Republic of Korea.37 1000 900 800 700 600 500 400 300 200 100 0 Kangnam Sukchon Sonchon Sinchon Study Hwangju Anbyon Panmun Control Figure 1: Malaria incidence per 100 000 population in study and control sites WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 77 . Assessment of side-effects and safety The prevalence of glucose-6-phosphate dehydrogenase (G6PD) enzyme deficiency in the Korean peninsula has historically been reported as low.7 The first group (10 022 persons) received primaquine 0.8 In 2002. These cards were filled in for each individual receiving The total number of malaria cases in the pilot areas was studied every month after the introduction of MPPT. 2994 persons in control areas).03 Control 4 215 14 0. Children under the age of 5 years. primaquine was administered to all eligible 391 357 inhabitants. the trait of G6PD deficiency has a prevalence between 0. each selected county was further divided into treatment ris (total 91 ris in seven counties) and control ris (total 85 ris in seven counties). the totals in this table also show that there are 90% fewer cases of malaria in treatment ris compared to control ris. hepatitis. For a pilot study. According to a WHO report. pregnant women. 4215 in comparison areas) and September (3716 persons in study areas. a study was conducted in the Democratic People’s Republic of Korea to assess the safety of different durations and doses of primaquine treatment. The intervention was undertaken from 18 April to 3 May 2002.Pant et al. as shown in Table 3. The result from the survey are shown in Table 2. the government conducted a mass blood survey in the study sites during May (5138 persons in study areas. In 2002. season of 2002.5 mg/kg/day in two divided doses for 14 days. Nearly 400 000 follow-up cards to record probable sideeffects were printed in Korean language and distributed to ri levels. and patients with lupus. however the source of this information is not quoted directly in the WHO report.: Mass presumptive primaquine treatment in DPR Korea were reported from all of the ris of the seven counties in the preceding year.25 mg/kg/ day for 7 days and a secondr group (10 033 persons) received primaquine 0.9 % in Korea. The results of the assessment also concluded that the likelihood of being infected with malaria in MPPT areas was 4–17 times lower than in untreated areas (see Figure 1).7 In 2002. The number of cases of malaria in the treatment ris was strikingly lower than in the control ris in every month during the malaria transmission Table 2: Slide-positive rate (SPR) amongst primaquine-treated and control population Population May 2002 September 2002 Slides examined Slides positive SPR (%) Slide examined Positive SPR (%) Treated 5 138 2 0. leukaemia. 33 2 994 11 0.5%).5 and 2. No severe side-effects or deaths were reported. 4 Treatment 30 000 45 56 61 142 148 42 6 0 0 1 501 15. HH doctors/volunteers were trained on recording and reporting. Any such observation was recorded and all individuals with suspected haemolytic or any other serious side-effects were immediately excluded from treatment and referred for appropriate care.25 mg/kg was administered after breakfast for 14 consecutive days. Prior to implementation of MPPT. A task force plans and delivers MPPT in each ri.: Mass presumptive primaquine treatment in DPR Korea Table 3: Malaria cases and incidence by counties among treatment and control ris. In every ri of the Democratic People’s Republic of Korea. Table 4: Prevalence of side-effects among persons treated with primaquine.Pant et al. people with a history of side-effects with primaquine. calculation of dose. All of them recovered in the subsequent 3–5 days and were excluded from future rounds of MPPT. Most importantly. The task force consists of a supervisor from province or county level and all the HH doctors of the target ri. Delivery of MPPT primaquine treatment. as shown in Table 4.10 Cases with suspected haemolytic symptoms discontinued the drugs and were referred to higher centres for treatment.2 Sinchon Treatment 72 857 13 19 57 239 158 24 1 0 0 0 511 6. there is at least one ri hospital with about 6–10 doctors. The national programme has confirmed that no death related to MPPT has been reported in the country so far. 2002 Side-effects Number of people with symptoms Proportion of side-effects (%) Headache 4 291 32.20 Control 83 670 241 307 312 322 119 14 1 0 0 0 1 316 15.3 Nausea and vomiting 1 801 13. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .10 under direct observations.1 1 098 8. A daily primaquine dose of 0. The HH doctors/volunteers visit house to house.12 Control 87 000 104 451 654 529 490 32 3 1 2 0 2 266 25. ensuring drug compliance and monitoring of side-effects of the drugs. Before ingestion of the daily dose.7 Control 56 455 52 705 1 207 936 490 76 6 3 2 2 3 479 60. 2011 and 2012.2 13 365 100. pregnant women. MPPT was completed each year before April. to identify and record inhabitants eligible for the mass treatment in the respective year.0 Encouraged by the results of the studies on the effectiveness and safety of MPPT.8 Control 51 964 68 257 407 368 169 74 14 1 0 1 1 359 22.2 Treatment 86 000 3 8 10 51 24 4 1 0 0 0 101 1.04 Control 74 250 136 367 566 439 141 11 2 1 0 1 1 664 22.1 Epigastric pain 2 451 18.0 Treatment 74 030 9 11 14 39 16 0 0 0 0 0 89 1.1 Anorexia 1 702 12.5 Dizziness 1 753 13. The health care of all members of a unit of about 150–250 households (HH) is a primary responsibility of each doctor. by their respective doctors. the country could not conduct the mass campaign in 2008. 2002 County Ris Pop May June July Aug Sept Oct Nov Dec Jan Feb Total Malaria incidence per 1000a Kangnam Treatment 33 030 1 2 5 4 0 0 0 0 0 0 12 0. the doctors inquired about the symptoms of side-effects of the drugs and looked for any signs of haemolysis. Owing to limited resources. the national programme implemented MPPT every year from 2002 to 2007.4 Sukchon Hwangju Anbyon Panmun a Malaria incidence was calculated by using the total population of the village as denominator.7 254 1. An analysis of the content of these cards revealed that the prevalence of various side-effects was very low and did not exceed 4%.6 Sonchon Treatment 54 470 3 3 13 13 19 5 1 0 0 1 58 1. Volunteers from the community are an integral part of the planning and delivery process.5 Treatment 40 970 5 5 33 35 37 7 1 8 0 0 131 2. and people with a history of liver or blood disorder. The target excludes children aged under 5 years.9 Changed urine color Black-coloured urine Others Total 78 15 0. no cases of severe haemolysis were reported.36 Control 27 581 17 76 58 42 34 15 0 0 0 0 242 8.1 Control 40 955 646 584 979 834 699 166 16 2 2 2 3 930 91. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 79 . The microscopy confirmation improved to 70–90% among suspected cases in subsequent years. However.5 mg primaquine tablet to provide a dose of 0. 40–60% of suspected malaria cases were tested annually and those with a positive result received radical treatment. vivax strain prevalent in the Democratic People’s Republic of Korea . Artemisia leaf) to repel mosquitoes away from the communities. as individuals with suspected haemolytic symptoms were excluded from further treatment. The proportion of people completing a full course of primaquine in the mass campaign was always over 94%. A similar trend was observed in the subsequent years. Artemisia vulgaris. expansion of malaria microscopy centres started from the year 2001. and capacitybuilding in malaria microscopy was a high priority for the government. An increase in the number of malaria cases was observed when MPPT could not be conducted in a particular year. there are no data available on coverage and use to make conclusions on the effect the nets had to contain the outbreak. 711 960 long-lasting insecticidal nets have been distributed to malaria-affected communities in the Democratic People’s Republic of Korea from 2010 to 2012. In an effort to confirm cases before treatment. Presumptive treatment with chloroquine for all fever cases also contributed to reduction of malaria transmission. 2011. The contribution these efforts have made to reduce malaria transmission is under study. Irrespective of the coverage of other malaria-control interventions. Table 5 also demonstrates that the number of malaria cases increased in the years MPPT was not conducted (2008. the total malaria burden had decreased by 90% in 2012. MPPT is essential to reduce the burden of malaria disease in the Democratic People’s Republic of Korea. it is difficult to measure their contribution to reducing the burden of malaria. 2012). Impact of MPPT The burden of malaria began to decline after introduction of MPPT in 2002. it was difficult to achieve 100% coverage of the targeted population. A drug-effectiveness study conducted in 2005 and 2012 confirmed that chloroquine is effective against the existing P. and because they are effective against malaria vectors. Malaria microscopy services have been expanded to 1023 centres and about 90% of suspected cases are being confirmed. Table 5: Reduction in the number of malaria cases after introduction of MPPT Percentage decrease of case burden compared to previous year 241 000 19 19 425 475 60 559 80 75 Number of cases treated with MPPT Cases of malaria reported 2001 0 296 540 2002 396 644 2003 2004 392 829 33 803 89 44 2005 449 700 11 507 96 66 2006 378 366 9 353 97 19 2007 4 904 261 7 436 97 21 2008 0 23 409 92 –215 (increase) a 2009 826 344 16 679 94 29 2010 968 818 15 392 95 8 2011 0 17 518 94 –14 (increase) 0 23 537 90 –26 (increase) a 2012 a Percentage decrease of case burden compared to 2001 Year a MPPT not conducted in this year. In addition. during 2002–2009. however. With support from the Global Fund Round 8 Malaria grant. there were attempts to improve coverage of vector-control interventions. more than 450 000 households and 90 000 agriculture and night-time workers have been protected with insecticide-treated clothes each year.7 There are reports that bed nets (insecticide treated and untreated) were also widely used. the interventions were only rolled out to selected areas and were inadequate to control malaria transmission in the country. Compared to 2001. Details of the impact of MPPT during 2002–2012 are shown in Table 5. The total number of cases was reduced by 80% following two round of MPPT in 2002 and 2003.: Mass presumptive primaquine treatment in DPR Korea It was a major challenge to break a 7.25mg/kg/day to a child. there was a difference between baseline data and the actual size of household numbers. Up to 2004. In addition. the HH doctors and volunteers tried to adhere to the national guideline as far as practical. During the same period.Pant et al. data on the accuracy of the results of microscopy are not available. However. Communities were encouraged to reduce vector breeding sites and burn moxa (mugwort. The pyrethroid group of insecticides was preferred for ease of operation. DDT was used from 2001 to 2003 and only 10 000 people benefited from indoor residual spraying. owing to death or migration of members. In the absence of data and studies on the effectiveness of traditional vector-control interventions. Owing to limited resources. DPR Korea. Regional Office for South-East Asia. Malaria control in DPR Korea: assignment report: 3-25 July 2001. Malaria Mass Prophylaxis with Primaquine in DPR Korea: assignment report 17 April – 15 June 2002. WHO Short-term consultant. 36(3):565–71. 2007. Evaluation of a malaria control project in DPR Korea.12:383.(4):24–8. MPPT needs to be complemented by other interventions to eliminate P. Howteerakul N. Bennett A. 2011 and 2012. Tegegn Y. 3(1): 75–80. Suwannapong N. 7. Liu Y. Widespread use of primaquine for control of Plasmodium vivax epidemics in a population with varying degrees of G6PD deficiency. Chol RK. and for drug compliance and monitoring of the side-effects. to ensure the intervention is effective. National malaria treatment guideline. 6. Ministry of Public Health. New Delhi: World Health Organization. Further resources need to be mobilized to ensure continuity of MPPT to achieve further gains in malaria control. WHO Working Group. The contraindications and compliance to the long regimen of primaquine treatment are the major limitations to the ability of MPPT to have an impact. Nguyen Hoan Phu. Dr AV Kondrashin. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . 2001-2003. New Delhi: World Health Organization. 1989. Bulletin of the World Health Organization. Inadequate resources interrupted MPPT in 2008. Regional Office for South-East Asia. Conflict of Interest: None declared. New Delhi: WHO Regional Office for SouthEast Asia. Mandal PP. 2010 Oct-Dec. China. Kondrashin AV. 2013 Nov 1. Hwang J. WHO South-East Asia J Public Health 2014. need to be carefully considered before a decision is made to implement MPPT. Arbani PR. Assignment Report: 1 – 30 June 2007. A strong health system is essential for proper planning of the mass campaign. et al. Source of Support: Nil. and an increase in malaria cases was observed in each of these years. Pinyowiwat V. Hsiang MS1. as well as the resources available in the country and ethical issues related to mass primaquine administration. resistance of the local P. a drastic decrease in malaria burden has been observed in the country. vivax strain to primaquine needs to be studied at intervals. 2001. Med Parazitol (Mosk). Southeast Asian J Trop Med Public Health. Chol KY. 2003. with monitoring and achievement of high coverage. At the same time. Mass drug administration for the control and elimination of Plasmodium vivax malaria: an ecological study from Jiangsu province. Mass primaquine preventive treatment for control of Plasmodium vivax malaria in the Democratic People’s Republic of Korea: a country success story. 2. 5. Outcome and impact of mass chemoprophylaxis with primaquine on Vivax malaria in the DPR Korea. World Health Organization. Kondrachine AV. 2002.Pant et al. vivax among individuals with contraindications to primaquine treatment. New Delhi: WHO Regional Office for South-East Asia. 8. 10. Mission report to DPR Korea.: Mass presumptive primaquine treatment in DPR Korea Conclusion 3. References 1. 9. Regional Office for South-East Asia. 2005 May. 80 Chol PT. Schapira A. Shanks GD. Since the introduction of the intervention. vivax malaria. MPPT is a success story of the Democratic People’s Republic of Korea’s programme to control P. Baranova AM. Malaria control in DPR Korea: experiences on primaquine prophylaxis. New Delhi. Malar J. Glucose-6-phosphate dehydrogenase deficiency. 2002 How to cite this article: Pant SD. 4. Sergiev VP. 2002. 67: 601–611. The urgency of malaria control. Tao AR. 4VectorBorne Disease Research and Training Center. physical integrity and bioefficacy of three polyester LLIN products that were distributed during 2010 to 2013 in Nepal. 3. Department of Population Health. BR Marasini2. Using the recently published guidelines from the World Health Organization (WHO) some progress has been made in the monitoring and assessment of performance of nets in the field. YR Pokhrel2. Tropical Medicine and Rehabilitation Sciences. textile laboratory testing is also urgently needed. The procurement and distribution of LLINs in Nepal was mainly managed by Population Services International (PSI-Nepal). GD Thakur2. P Ghimire5 School of Public Health.115828 Quick Response Code: Monitoring the durability of long-lasting insecticidal nets in field conditions in Nepal J Hii1. 6 Recently. Similar studies should be done in other countries to (i) track LLIN durability to support management of resupply.and moderate-risk areas. this requires an overall ratio of one LLIN for every 1. in line with World Health Organization (WHO) recommendations. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 81 . Email: hiijk1@gmail. Department of Population Health.7 in order to achieve and sustain the goal for universal coverage.int/ publications/journals/seajph DOI: 10. QLD 4811. as well as contributing to procurement decisions based on the number of years of protection.1–3 and the regional malaria-control strategy. Hetauda. adjusted for the effect of odd-numbered households. For procurement purposes. MP Upadhyay2. 5 Country Office and South-East Regional Offices. Kathmandu. this is based on an allocation of one LLIN per two persons.4 Distribution and promotion of the use of LLINs is an integral component of the National Malaria Control Programme. World Health Organization. this was later changed in 2009 to one LLIN for two persons. James Cook University. Since 2005. Since 2007. complemented by continuous distributions through antenatal-care facilities and child immunizations. It is hoped that robust and auditable data on net survival (physical integrity and bioefficacy) of these three brands in different environments will assist the Nepal National Malaria Control Programme in planning future LLIN-replacement strategies. WHO has promoted universal coverage with effective methods of vector control for everyone at risk of malaria. more predictive. SK Pant4. New. and all other activities of malaria prevention and control activities are implemented by the Epidemiology and Disease Control Division (EDCD).searo. malaria transmission. Nepal and India 1 Abstract Understanding and improving the durability of long-lasting insecticidal nets (LLINs) in the field is critical for the success of malaria prevention using mosquito nets. This paper describes the protocol of an ongoing retrospective study of the attrition rate. Kathmandu. malaria. WHO has also recommended free distribution of nets through mass campaigns.Access this article online Policy and practice Website: www.com Key words: Bioefficacy. and (ii) inform procurement decisions at the global level. 3Kantipur College of Medical Sciences. Australia. Nepal. Address for correspondence: Dr Jeffrey Hii. NR Adhikar3.1. 2Epidemiology and Disease Control Division. School of Public Health. Nepal. including behaviourchange communication about LLIN care and maintenance. Nepal. with the long-term goal of malaria elimination. KR Rijal3. the estimated LLIN coverage was 100% of target population in high. long-lasting insecticidal nets. L Ortega5. rather than the current practice of unit cost. The advantages and disadvantages of prospective and retrospective cross-sectional approaches are discussed.5 The national LLIN distribution policy 2005 recommended one LLIN per household in endemic districts in stratum 1. malaria control. James Cook University. By the end of 2013.8 people in the target population.4103/2224-3151. Australia.8 LLINs were developed in the 1990s and first approved by the WHO Pesticide Evaluation Scheme in 2003.who.3 million LLINs have been distributed with support from the Global Fund. including appropriate strategies to validate the timing for mass distribution of nets. Tropical Medicine and Rehabilitation Sciences. physical integrity BACKGROUND AND RATIONALE The National Malaria Control Programme in Nepal is using indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) to reduce the transmission of malaria. N Singh5. and the number of holes in each category were recorded. (i) Terai plain rice (2 districts). and (iv) hills and river valleys (3 districts). which has direct implication for the success of malaria control. Each LLIN sampled was hung up from the four corner points and examined. there is a significant paucity of information on LLIN survival time. As far as the authors are aware. avoiding holes and repairing them early to prevent deterioration. local washing and drying techniques and storage. on LLINs washed not more than twice. 2–10 cm. four subsamples per LLIN were assembled as one sample. labelled and stored at room temperature for chemical analysis at Walloon Agricultural Research Centre. Morang and Nawalparasi districts.12 Villagers in Nepal generally wash clothes and LLINs with detergent powder and soap and dry them in sunlight for 4–5 hours. under field conditions?” Current budgeting for LLINs is based on an assumption that LLINs have an average useful life of at least 3 years. Similar studies in other countries where the use of LLINs is one of the key strategies for malaria prevention and control are also advocated. This was based on the assumption of one measurement for each of the nets per time point. For chemical assays.5–2 cm. (ii) to determine the attrition rate of LLINs and factors that have contributed to attrition in four eco-zones since 2010. and GPS points available from PSI were used to validate the identity of household locations including interviews with household heads by district/health facility staff. if the householder was absent.14 a sample of 40 LLINs per village development committee (VDC) was considered sufficient. bioassay tests carried out in Banke.11 However. or if the house was no longer in the VDC.10 resulting in a rapid increase in bednet ownership and utilization (in addition to largely used conventional nets) in the target population.13 From each of the LLINs collected. that is. four pieces 25 × 25 cm in size were cut from four sides of the net as per WHO guidelines. Household rosters showing dates of LLIN distributions. After the fourth washing. clean aluminium foil. (iii) Inner Terai forest fringe (3 districts). 196 and 578. also showed 100% mosquito mortality. VDCs were selected on the basis of LLIN distribution dates. Dang. Kanchanpur. and the general environment in which the net is being used (climate. the variation in performance between LLINs of different textiles. In reality.9 However. Acknowledging this gap. sleeping place and washing patterns). bioefficacy and attrition in local conditions was collected using a standardized questionnaire. and (iii) to compare the use of LLINs distributed since 2010. that is.5 In 2009. power of 80%.13 Field data on LLIN survival are not currently available to inform the National Malaria Control Programme on the timing and nature of future LLIN replacement strategies.Hii et al. the Ministry of Health and Population requested WHO to give guidance on this question. this is the second study of this type in the WHO South-East Asia Region. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .13 using sharp scissors. Global Fund financing helped provide over 310 million LLINs for malaria control between 2002 and 2012. Using the method of Kilian for estimating the necessary sample size. Information on physical integrity (holes).5 cm. divided into the categories <0. remains: “How long does an LLIN last in serviceable condition. the next house on the list was selected. rolled up and placed in a new. Dhanusha. there is considerable variation in LLIN durability in relation to their conditions of use. bioassays tests conducted in Dhanusha. Households were randomly selected from this list prior to the follow-up surveys. rendering them wash resistant and extending insecticide residual effectiveness to at least 3 years without the need for retreatment. A total of 440 households were randomly selected from VDCs of the above districts. 82 STUDY PROTOCOL: OBJECTIVES AND METHODS The objectives of this ongoing study are: (i) to assess the physical integrity and bioefficacy of three polyester LLIN products.: Durability of long-lasting insecticidal nets in Nepal LLIN technology is based on the slow release of pyrethroid insecticides. having >50 households. an alpha error of 0. (ii) Terai foothill (3 districts). and analysed to allow the programmes to gather scientific evidence related to the study objectives. housing. and to assist in the planning and implementation of a retrospective study of LLINs that were distributed during 2010 to 2013. Kavre and Makwanpur districts. Hole categories are designed to be easily and accurately measured under field conditions and were weighted as 1. with LLINs washed up to three times.1. there was a sharp decline in mortality to 42% in Kanchanpur district. In 2008. for example. and being representative of the major ethnic tribes. not durable and not effective like previous LLIN”. showed 100% mosquito mortality. After getting informed consent.5 The report concluded that “LLIN distributed in 2010 had many public comments like: it was weak. with a range of 30–50 households per district. For these reasons. their position on the LLIN.0. the interview was conducted and one randomly selected LLIN was collected and replaced with a new LLIN.1. The size of holes. The study was conducted in 11 districts representative of the four ecological zones. a critical question. and standard deviation of 8. respectively. 23. These factors may partly explain the observed variations. 10% of randomly selected LLINs were selected. 0. Kanchanpur. The number of holes in each category was multiplied by the category weight and expressed as a proportionate hole index (PHI). a recent publication by WHO provided guidance on how to estimate the longevity of nets using durability data from the field.9 As the largest funder for malaria programmes. and >10 cm diameter. including changing people’s behaviour with respect to care and repair of nets.05. This paper summarizes the protocol of this study and the progress to date. which is a major concern in South-East Asia. Geneva: WHO. 2013. An orientation workshop was conducted to finalize the survey protocol with EDCD. It should be noted that there is an urgent need for the development and validation of novel vector-control strategies. TB and Malaria. 7. Kantipur College of Medical Sciences research team. and (vi) recall by users of what happened more than 12 months previously may be unreliable. Global malaria programme: insecticide treated nets: a position statement. Kathmandu: MOH&P.13 pretested and adjusted for any issues arising from the piloting in Kavre and Sindhupalchowk districts. Hetauda and Kasetsart University.13 Protocol development for comparing different products is required to test the “true” performance of some brands.un. 2013. 9. 440 LLINs (4 triplicate pieces from 440 nets) were collected by the end of January 2014. WHO/HTM/NTD/WHOPES/2013. a similar study should be carried out in other countries. (Revised version-December 2011).3. The field survey in 11 districts representing four different ecological zones were completed.int/malaria/publications/atoz/itnspospaperfinal. Document no. Epidemiology and Disease Control Division. more predictive textile laboratory testing. 2010.accessed 17 March 2014. Malaria J. 2011. 25 April 2012. World Health Organization.: Durability of long-lasting insecticidal nets in Nepal WHO Collaborating Centre for Quality Control of Pesticides. New Delhi: WHOSEARO. 2. How many mosquito nets are needed to achieve universal coverage? Recommendations for the quantification and allocation of long-lasting insecticidal nets for mass campaign. http://www. DISCUSSION AND RECOMMENDATIONS In this study protocol. there is no other malaria vectorcontrol tool that could be easily scaled up to help accelerate progress in malaria control towards elimination. Nepal. World Health Organization. 10. 15 and the fact that. STUDY IMPLEMENTATION: UPDATE The study was approved by the National Health Research Council. Kilian A.Nepal for funding the study channeled through WHO Nepal. Data collection commenced in December 2013. Thailand. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 83 . Geneva: WHO.com/storage/ countrypartner/Nepal%20Strategic%20Plan%202011-1016. The results from the analysis are expected to be available soon. Strategic investment for Impact: global fund results report 2012.org/gmap/gmap. http://apmen. Secretary-General’s message on world malaria day. TGF / PSI. which may reach 4 years or more in some environments. This would support management of resupply. World Health Organization. Belgium. cross-sectional studies. The global malaria action plan – for a malariafree world. REFERENCES 1. together with some selected alternatives (e.9:330. 2012. Global Fund to Fight AIDS. structured questionnaire was adapted from the WHO guidelines. Teku. The LLIN pieces are undergoing bioassay at the Vector Borne Disease Research and Training Centre. Roll Back Malaria. Document no. in conjunction with urgently needed new. brands and years of distribution are being tested at the WHO collaborating centre in Belgium. http://www. Another two sets of four subsamples were similarly rolled up in clean aluminium foils and tested using standard WHO cone bioassay methods. (v) labels on LLINs fade or are lost over time. prospective studies obviate some of the disadvantages listed above.pdf . to track LLIN durability.squarespace. United Nations. WHO recommendations for achieving universal coverage with long-lasting insecticidal nets in malaria control.int/iris/ bitstream/10665/80270/1/9789241505277_eng. 3.pdf . and enumerators. World Health Organization. and will provide the National Malaria Control Programme with scientific evidence for policy review.g. the following possible limitations were considered: (i) the survival of LLINs cannot be estimated in most settings.int/malaria/ publications/atoz/who_recommendation_coverage_llin/en/ . Kathmandu. procurement decisions. SEA-MAL 243 (Rev 1). (ii) LLINs available may be a biased sample. compared with retrospective.accessed 17 March 2014. Indoor residual spraying: an operational manual for indoor residual spraying (IRS) for malaria transmission control and elimination. The revised malaria control strategy 2006 – 2010. (iii) a significant and unknown portion of the local population has moved into or out of the study area. Thailand. Department of Health Services.asp?nid=6023 accessed 17 March 2014. with the exception of IRS. who. September 2013. http://www. and inform. (iv) the number of opportunities for follow-up are limited.11. Geneva: WHO. Nepal. amounting to USD 500 million every year. In view of the huge investments on LLINs for malaria control. 6. Gembloux. Roll Back Malaria Partnership. and the chemical content of 10% of the samples representing different locations. 4. World Health Organization. The information collected through survey questionnaires and reports of cone bioassay and chemical analysis13 will be entered in a Microsoft Access database and analysed using SPSS statistical software.who. Nepal malaria strategic plan 2011–2016. rollbackmalaria. Ministry of Health and Population. A precoded. making identification difficult. Boulay M. 2008.14 This may include the one or more products that are already in large-scale use in that setting. at the Vector Borne Disease Research and Training Centre Hetauda and Kasetsart University.org/sg/statements/index. at global level. Geneva: WHO. 2007. Koenker H.pdf .accessed 17 March 2014.who. www. as worn-out LLINs may no longer be present. Geneva: GFATM. since LLINs and IRS are not sufficient to combat outdoor and early-biting transmission of malaria.Hii et al. Guidelines for laboratory and field testing of long-lasting insecticidal nets. MoHP/DOHSNational Malaria Program for programmatic support for the study and WHO for technical support. Villagers are informed about the aims and objectives of the study through house-to-house visits. However. some of those that bid for the last tender but were not selected). Lynch M. 8.accessed 17 March 2014. Regional Office for South-East Asia.pdf – accessed 17 March 2014. 5. 2013. Information on various aspects of the study was read in the local language and written consent was obtained from each household before the start of the interview. http://www. Acknowledgements The authors acknowledge Nepal Health Research Council for permission to conduct the study. Guidelines for monitoring the durability of long-lasting insecticidal mosquito nets under operational conditions. Marasini BR. KRR. Networks document.int/malaria/ publications/atoz/gmpllin_effective_coverage_concept_note. http://whqlibdoc. World Health Organization. Contributorship: JH and LO designed the study. GDT and BRM facilitated the training workshop and ethical review. WHO global malaria programme: a system to improve value for money in LLIN procurement through market competition based on cost per year of effectuive coverage. 3(1): 81–84.pdf accessed 17 March 2014.who. Rijal KR. 84 World Health Organization. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .accessed 17 March 2014. Geneva: WHO. accessed 17 March 2014. World malaria report 2012.Hii et al.int/malaria/publications/atoz/who_ guidance_longevity_llins/en/ . Conflict of Interest: None declared. Upadhyay MP. http://www. who coordinated the field and laboratory activities and drafted the manuscript. Ortega L. 2011. Concept Note. Estimating the potential gains and savings from increased mosquito net durability. Source of Support: This study was financially supported by the World Health Organization and the Global Fund. 2012. 13. Adhikar NR. Geneva: Global Malaria Programme. 15.pdf . How to cite this article: Hii J. Monitoring the durability of long-lasting insecticidal nets in field conditions in Nepal. 2013. Ghimire P. MPU. Networks. Kilian A.who.int/malaria/publications/world_malaria_ report_2012/report/en/ . NRA. World Health Organization. World Health Organization. Singh N.int/ publications/2011/9789241501705_eng.accessed 17 March 2014. YRP.: Durability of long-lasting insecticidal nets in Nepal 11. 12. WHO Guidance note for estimating the longevity of long-lasting insecticidal nets in malaria control. http://www. All authors contributed to the final version of the text and have read and approved the manuscript. SKP and NS supervised the field studies with the assistance and inputs from students of Kantipur College of Medical Sciences. September 2011.who. 14. Pokhrel YR. Geneva: WHO. Thakur GD. with inputs from PG. Geneva: WHO.who. Pant SK. WHO South-East Asia J Public Health 2014. http://www. Kamini N Mendis4 Abstract Anti-Malaria Campaign. to make the country both receptive and vulnerable to the reintroduction of malaria.Access this article online Policy and practice Website: www.5 million cases and 80 000 reported deaths. Bauddhaloka Mawatha. which led to an estimated 5. Sri Lanka 1 Fifty years after narrowly missing the opportunity to eliminate malaria from Sri Lanka in the 1960s.Leonard Ortega2. Colombo 5.3 There have now been no indigenous malaria cases in the country among its 20 million inhabitants for over a year (see Figure 1). a global momentum to eliminate malaria. and the influx of labour and refugees from neighbouring malarious countries combine with the continued presence of malaria vectors in formerly endemic areas. New Delhi. 4141 Jawatta Road. achieved a steady reduction in malaria transmission rates in the country. of sustaining a malaria-free country and preventing the reintroduction of malaria to Sri Lanka.115828 Quick Response Code: Malaria elimination in Sri Lanka: what it would take to reach the goal Risintha Premaratne1. Sri Lanka. Colombo 7. The challenge now. sustained funding for the Anti-Malaria Campaign and for implementation research and technical guidance on elimination. imported malaria. the opportunity to eliminate the disease from Sri Lanka presents itself against a background of postwar developments in the country that impose high risks for malaria resurgence. Narahenpita. Navaratnasingam Janakan3.2 and near elimination of malaria during the Global Malaria Eradication Programme of the 1960s. Sri Lanka.4103/2224-3151. prevention of reintroduction. elimination. the national malaria control programme of Sri Lanka. The absence of indigenous malaria has led to a loss of awareness among the medical profession. the Anti-Malaria Campaign (AMC). vulnerability Introduction Sri Lanka’s protracted history of malaria is studded with some landmark events in global public health. receptivity. Sri Lanka. with many of these being imported infections (see Figure 1). malaria. 141 Jawatta Road. These have been sustained for more than 10 years over a period that spanned a 30-year separatist war that raged in the north and east of the country – areas that were previously highly malarious. the WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 85 . resulting in delayed diagnosis of malaria despite the availability of an extensive malaria diagnosis service. and advocacy to maintain awareness among the medical profession and at high levels of government. the country has now interrupted malaria transmission and sustained this interruption for more than 12 months – no indigenous malaria cases have been reported since October 2012.int/ publications/journals/seajph DOI: 10. India. such as the severe malaria epidemic of the 1930s. vector-borne diseases.who. This time. South-East Asia. businesses and a booming tourist industry. Address for correspondence: Kamini N Mendis. Interventions that are necessary at this critical time include sustaining a state-of-the-art surveillance and response system for malaria.1 which reduced the number of cases from 91 990 in 1953 to a mere 17 in 1963. Email: kaminimendis@gmail. has. Sri Lanka. Sri Lanka. Colombo 5. The malaria-elimination effort should be supported by rigorous analyses to demonstrate the clear economic and health benefits of eliminating malaria. which exceed the cost of a surveillance and response system. is examined here in the context of rapid postwar developments in the country. Colombo 5. This was achieved through a period overlapping with a 30-year separatist war in areas that were endemic for malaria. 3Country Office of the World Health Organization.searo. Highly prevalent vector-borne diseases such as dengue are competing for health-service resources. 2 World Health Organization SouthEast Asian Regional Office. Increased travel to and from the country to expand development projects. once again.1. In the past decade.com Key words: delay in diagnosis. An annual World Health Organization review of the programme may also be required. Sri Lankan peacekeeping forces returning from service in malaria-endemic countries. and the even greater challenge of preventing its reintroduction to the country. 2008–2013 86 Foreign nationals 3 Professional 6 Student 4 Tourist 3 Pilgrim 3 5 Asylum seeker 19 Social worker 1 59 36 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . and the vast majority of the rest was of Pakistani and Indian origin (see Figure 3). all of which are bringing a steadily increasing proportion of imported malaria cases into the country (see Figure 2). and nationals travelling for business or leisure. In 2013. 2 2 11 11 1 10 Figure 1: The reported annual incidence of malaria since 1999 presented with the annual malaria incidence in the period 1949– 1969 to illustrate the near elimination in the earlier years and the resurgence that followed 17 59 odds of a persisting vulnerability and receptivity to malaria in the country. Sri Lanka 2013 Occupation category Armed forces/police Sri Lankan nationals 4 Business/trade 20 2 Seaman 13 2 6 4 Technician/skilled labourer Manual labourer Figure 2: The number of microscopically confirmed malaria cases reported from Sri Lanka (indigenous and imported).Premaratne et al. postwar developments continue at an accelerated pace. irregular migrants. imported labour from malaria-endemic countries – particularly India and China. entomological surveillance and vector control have contributed to interrupting local transmission in the country since October 2012. business travellers and boat people voyaging the Indian Ocean and making landings in Sri Lanka have been the main contributors to imported malaria being reported with increasing frequency in Sri Lanka over the past few years (see Table 1). Sri Lankan expatriates returning home. refugees from neighbouring endemic countries. Sri Lankan Indian Ugandan Indonesian Tajik Challenges for sustaining interrupted transmission and preventing reintroduction While intense surveillance-based operations of case detection. and enormous challenges of sustaining a focus on a disease that is no longer endemic . nearly 60% of imported malaria was among travellers of Sri Lankan origin Pakistani Burmese English Korean Ukraine Figure 3: Number of patients with imported malaria in Sri Lanka in 2013. This paper critically examines the prospects of eliminating malaria from Sri Lanka.: Malaria elimination from Sri Lanka who had contracted malaria overseas. These have resulted in an influx of tourists. by nationality Table 1: Occupational categories of imported malaria cases among foreign and national patients. management. This. at a provincial level. Clinical awareness of malaria has plummeted to the extent that in 2012 there was an unacceptable delay in the diagnosis of patients with malaria (see Figure 5).4 Although evidence is unavailable on current vectorial capacities of these mosquito species. including in areas that were previously endemic for malaria. rates of referral by medical practitioners for a malaria diagnosis remain persistently low. in 10% and 20% of these patients respectively. Furthermore. all of which are associated with increased travel of foreign nationals. this programme is implemented by the provincial ministries of health. The malaria control programme in 2003. culicifacies has reportedly diversified its breeding habitats from previously clear. Figure 5: Number of days from onset of illness to blood testing for malaria among indigenous (yellow) and imported (red) malaria patients in Sri Lanka in 2012 Figure 4: Geographical distribution of A. the principal vector of malaria. Ongoing construction projects are leading to the creation of new vector breeding sites.Premaratne et al. unpolluted slowflowing waters to more polluted and still sources of water. including human resources. almost certainly points to a sustained high risk of malaria reintroduction unless rigorous measures are taken to prevent it. although diagnostic services for malaria are adequately and widely distributed in all parts of the country. 2013 Malaria control and elimination continues as a priority of the Ministry of Health. In nearly half of indigenous cases. and introduction of foreign labour into the country. zero malaria mortality has been sustained in the country since 2007 owing to a high standard of clinical management of severe malaria patients. Despite this. An external evaluation of the malaria-elimination programme in 2013 found that. increasing global business investments. and the elimination programme from 2008 onwards has been supported additionally by three successive grants from the Global Fund to fight AIDS. Anopheles culicifacies.5 As a result. subpictus. including in previously endemic areas. and secondary vectors such as A. providing technical guidance to the elimination programme. In the currently decentralized health system. Meanwhile.: Malaria elimination from Sri Lanka Since the end of the separatist war. respectively. the AMC. A. amounting to USD 2 077 223. 2 159 122 and 2 159 122 for the periods 2003 to 2008. and a rapidly growing tourist industry. competing fiercely for the attention of public health services. Tuberculosis and Malaria. the disease had even progressed to severe and complicated malaria in some patients. 2005 to 2009 and 2009 to 2013. five or more days elapsed from the time the patient sought treatment until a malaria diagnosis was made. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 87 . and 66% of imported malaria patients. the construction of several highways traversing the country. with the directorate of the national malaria control programme. it took more than 10 days for a malaria diagnosis to be made. increasing the number of imported malaria cases. culicifacies (principal vector) during the high-density season in Sri Lanka. are as prevalent in the country as previously (see Figure 4). when combined with the increasing reports of imported malaria from diverse parts of the country. Sri Lanka has been on a steep development trajectory with the building of new air and sea ports. their prevalence implies a continuing high receptivity to malaria in previously endemic areas. Compounding these risks are some inevitable challenges associated with sustaining health services and surveillance for a non-prevalent disease. Other vector-borne diseases such as dengue are highly prevalent (see Figure 6) and currently feature as one of the greatest public health challenges. through Regional Malaria Officers. Given the cost of malaria to the country over the years. supported by mobile malaria units. through in-service training. Rigorous economic analysis to demonstrate the cost effectiveness of preventing malaria 88 Reflection on the previous near-eradication effort of the 1960s dictates two critical interventions to achieve and sustain elimination of malaria. should be a priority.9. the country stands today at a pivotal point in its malaria history. The necessary policy and strategy adjustments to act within the recently adopted Sri Lanka National Migration Health Policy7 will need to be developed to deal with the influx of labour and migration from neighbouring highly malarious countries. A focus on malaria elimination at the highest levels of government is now needed. Ports of entry to the country by both sea and air. free-trade zones. Sri Lanka reached the leprosy-elimination target stipulated by the World Health Organization (WHO). Steps for this are already being taken at a national level – the Sri Lankan research funding agencies will earmark modest funds for research on malaria for the next several years. In 1996.6. supported by eloquent policy arguments and a seemingly sound structural basis for integration. trade and tourism. of less than one case per 10 000 population.10 suggest massive economic benefit would be gained by malaria elimination. is not beyond the affordability of Sri Lanka’s health system. new sea ports and industrial parks. such as those for the accelerated building of highways. on the basis of an extensive national research effort on malaria. 13 making the estimated cost of malaria to Sri Lanka a gross underestimate. and shifting its geographical focus on the strict basis of receptivity and vulnerability in different parts of the country. vastly strengthening its entomological and infection and disease surveillance and response arm. even though the methodology used in these studies barely broached the economic opportunities lost to commerce. thereafter. Exactly 50 years after a missed opportunity to eliminate malaria. to be reprogrammed. particularly with hindsight of a failed effort in the 1960s. Singapore.12. to seek the cooperation of sectors beyond health.6 the effort and resource investment required for a rigorous surveillance and response system would be entirely justified. which is known to deliver an equitable and effective health service. building construction sites. improving the quality of diagnostic services. the goal of sustaining a malaria-free country after the cessation of the war appears well within the capacity of its health system. A highquality malaria diagnostic service needs to be meticulously maintained by the AMC. and. and other imported-labour-intensive activities will need to be the focus of enhanced surveillance for malaria. The price of an outstanding surveillance and response system which is now essential. rather. Therefore. One is for the Ministry of Health to ward off complacency and to refrain from shifting resources from malaria to other high-burden vector-borne diseases such as dengue. district-level anti-leprosy services were integrated into the general health services in 2001/20028 – a move that has resulted in a resurgence of leprosy. The AMC needs. which govern and regulate major development efforts in the country. One example is to allow compulsory screening of migrant labour. with similar environmental risks for malaria as Sri Lanka.11 or the cost of malaria to human development. despite large volumes of labour migration into the country and small WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . Sri Lanka’s recent experience with a failed leprosy elimination serves as a stark reminder that proposals on integration of malaria services with health services for any other disease must not be considered for at least the next 5 years. Recent attempts to estimate the cost of malaria to Sri Lanka. Such a strong research and technical basis would well serve the elimination and prevention of resurgence of malaria now. has sustained a malaria surveillance and response system to keep the country malaria free. with a system of externally accredited microscopists. competitive economies and higher standards of living.Premaratne et al. Discussion The cost of malaria to Sri Lanka has been enormous over centuries and would be more so now in the context of globalization. Figure 6: The reported annual number of malaria and dengue cases in Sri Lanka 1999–2013 What does success depend on? Sri Lanka has achieved and sustained interrupted malaria transmission during the last stages of an intense separatist war that gripped the country and its health services and economy.: Malaria elimination from Sri Lanka reintroduction would help as an advocacy tool for the muchneeded continuation of national and international investments for malaria elimination and prevention of reintroduction. One of the many factors that are widely believed to have contributed to the decline of malaria in Sri Lanka during the past few decades is the deployment of evidencebased control operations by the AMC at all level of the health system. Sustaining awareness of malaria among public-health medical practitioners. Surveillance with 24-hour compulsory notification and rapid response for malaria now needs to be the singular focus of Sri Lanka’s elimination programme. and continued collaboration with medical educators and professional medical associations and colleges. The second is to sustain a focus on and investment in research and technical guidance for malaria elimination and prevention of reintroduction. Rajendram S. Jayewickreme SH. 4. Wijeyerathne P. Sri Lanka national migration health policy. Yi P. London: London School of Hygiene and Tropical Medicine. 1951. are all factors that would support the feasibility of achieving and sustaining malaria elimination. Fernando D. reported in 2009 . How to cite this article: Premaratne R. Dondorp AM.accessed 25 March 2014. Trans R Soc Trop Med Hyg. Poverty of resources if often cited as a legitimate reason for failure of disease-control efforts. The control and prevention of epidemic malaria by residual spraying houses with DDT. more recently. Bhutan. alluding to muliple demands on restricted health budgets and competing health priorities as making such goals unachievable. such as it’s island nature and thus not being as prone to unregulated human migration as countries with contiguous land borders. 3.12:285. Mendis KN. It would also risk the country facing the globally growing problem of insecticide resistance in vector mosquitoes. Mendis KN. 2012. Fairmed Foundation. it has a highly performing and equitable health system. Am J Trop Med Hyg. Given the achievements so far. de Silva D. 13. Lee KS.pdf . which has now extended from its point of origin at the Thailand–Cambodia border. Malar J. JN provided the data on other vector-borne diseases in Sri Lanka. Conflict of Interest: None declared.pdf . Nosten F. 11. 1994.361(5):455–67. Fernando T. Sri Lanka. Anti Malaria Campaign.lk/sri_ lanka_national_migration_health_policy. Ng LC. and that the international support required to sustain this achievement is forthcoming. Although the WHO Region of South-East Asia . Artemisinin resistance in Plasmodium falciparum malaria. All authors reviewed and edited the final text. 8. Hapugoda M. Lin R. It would place the country at risk of artemisinin-resistant malaria. 2013. Wickremasinghe R.Premaratne et al. Wickremasinghe R. Sacs JD. Sri Lanka: report of the WHO external in-depth country review: malaria control and elimination programme. http:// www.Malariology.malariajournal. and help validate the sustained high investments for the global fight against malaria. serve as a much-needed boost to the concerted global malaria-elimination efforts. Attanayake N. Malaria elimination in Sri Lanka: what it would take to reach the goal. 2011.columbia. Tarning J. Sri Lanka. several countries within the region have made significant achievements in either eliminating malaria (Maldives in 1984) or. 1998. having achieved and sustained more than a year of arrested malaria transmission in Sri Lanka. Ruberu PS. this may not be such a limiting factor at present. PhD Thesis. Oo PL. placebo-controlled. Carter R. Tan CH. Harvard: Centre for international Development.7(8):e43162. Malaria in Ceylon. 2003. and bearing in mind that international support for malaria elimination is accessible and forthcoming. Bhatia R. 2006. Ind. Rastogi RM. Gunathilaka N. Kahn JG. 3(1): 85–89. Economic justification of intensive malaria control programme in Sri Lanka 1977/81. Anopheles culicifacies breeding in polluted water bodies in Trincomalee District of Sri Lanka. and sustaining a malaria-free status. J. Part I.Hyg. 15. Ortega L. J Vector Borne Dis. Malaria successes and challenges in Asia. Some of Sri Lanka’s characteristics. et al. 10. A failure to sustain malaria elimination at this stage is more likely to reflect poor judgement and planning on the part of health and national authorities rather than of lack of resources. which would jeopardize its development efforts. Malaria control and elimination in Sri Lanka: documenting progress and success factors in a conflict setting. Source of Support: Nil. 2. clinical trial of the impact of malaria prevention on the educational attainment of school children. http://www.15 India and Myanmar still harbour considerable case incidence rates of malaria.migrationhealth. Sri Lanka. significantly reducing their levels of endemicity (Bangladesh. 9. Galappaththy GNL. Report of meeting on elimination of malaria from and preventing its reintroduction to Sri Lanka: identifying gaps in operational research. WHO South-East Asia J Public Health 2014.accessed 25 March 2014.97(6):633–9.62:79–85. Malaria Journal. Feachem RGA.16 as far west as Myanmar. Nepal. Gueye CS. 2012. Plos ONE. 2010. Fernando D. Gallup JL. contributing the most by far to the region’s disease burden. 7. de Silva D. N Engl J Med. KM drafted the overall paper. 10 December 2013. Ortega L.74(3):386–93.Trop. would be an important regional milestone. Das D. despite the country’s intrinsically high receptivity and vulnerability to malaria. A randomized. 6. The corollary – the cost of failure to achieve and sustain malaria elimination in Sri Lanka – would be far greater than the mere return of malaria. and thus confront an escalating cost of malaria control. 16. LO reviewed and provided the malaria data from the Asian region. The economic burden of malaria.5:1–73 Abeyasinghe R R. 12. to which Sri Lanka belongs. 1959. Yet. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 89 . Phyo A. Cost-effectiveness of anti-malaria activities in Sri Lanka. LamPhua SG. Anti malaria campaign. et al. Abeyewickreme W.accessed 25 March 2014. References 1.: Malaria elimination from Sri Lanka local outbreaks. 5.com/content/9/1/305 .earth. it is imperative that national investment of resources and effort continue unabated. Karunaratne WA. 2013. 14. Report of the evaluation of the anti leprosy programme in Sri Lanka. double-blind. Entomologic and molecular investigation into Plasmodium vivax transmission in Singapore.Med. and it has a high literacy rate. Janakan N.14 which must reflect an assumption that the investments are well below the cost of a malaria resurgence. Lwin KM. Eliminating malaria from Sri Lanka. Contributorship: RP reviewed and analysed the data from the AntiMalaria Campaign.edu/ sitefiles/file/about/director/ pubs/mal_wb. and Timor-Leste). The influence of malaria control on vital statistics in Ceylon. Short-term impact of an acute attack of malaria on the cognitive performance of schoolchildren living in a malaria-endemic area of Sri Lanka. its land extent and terrain are not unwieldy. bears the second largest burden of malaria in the world. 18–28 February 2013. (unpublished). 2009. Colombo: MOH.50:239–247. second only to Africa. Ministry of Health. 2009. 2013.J. http://www.9:305. Wickremasinghe R. from July 2011 to 2012. namely.4 The Myanmar Ministry of Health endorsed the framework in April 2011. 4Former National Malaria Control Programme Manager. as recommended by the World Health Organization’s Global Malaria Programme (GMP) relies heavily on the effectiveness of a few tools.who.9 Later on. WHO Office of the Representative to Myanmar. and activities started in July 2011.1 and in Myanmar as first-line treatment since 2002. India Abstract Artemisinin resistance is a major threat to global malaria control and elimination efforts. With financial assistance from the Bill and Melinda Gates Foundation (BMGF). Thaung Hlaing2.3. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . outcomes and early impact on malaria from July 2011 to December 2013. the western border of Cambodia and Thailand and the western border of Thailand bordering Myanmar’s Tanintharyi and Bago regions and Mon state. Since 2010. Leonard Ortega6 Department of Health.Access this article online Policy and practice Website: www.7 The Myanmar national malaria programme has joined the global community in the containment of artemisinin resistance since April 2011 by initiating the Myanmar artemisinin resistance containment (MARC). Myanmar. WHO Office of the Representative to Myanmar. financial resources for MARC rolling out came primarily from the Three Diseases Fund (3DF). no next-generation antimalarials are on the horizon. even though artemisinin resistance was not confirmed until 2011. WHO has played a vital role in ensuring that a comprehensive programme on the containment of the resistance is in place. L. which later became Three Millennium Development Goals (3MDG) Fund in 2013. Myanmar.115828 Containing artemisinin resistance of Plasmodium falciparum in Myanmar: achievements.searo. New Delhi. bordering Thailand. two locations in the world have confirmed artemisinin resistance “hotspots”. Key words: malaria.4103/2224-3151. thus artemisinin resistance is a major threat to progress made in the past decade. 6 WHO Regional Office for SouthEast Asia. Malaria Unit.4 Both foci are located in the GMS.int Background The malaria elimination goal. Artemisinin has been used widely in the Greater Mekong Subregion (GMS) since 1995. 2 While the therapeutic efficacy of artemisinin-based combination therapy (ACTs) remains at satisfactory level globally. WHO Myanmar’s Malaria Unit has been one of the major forces behind the initiation of artemisinin-resistance containment in Myanmar since early 2010. current achievements. Myanmar. At the outset. Ministry of Health. Valaikanya Plasai5. Myanmar detected the first indication of the resistance in 2009 in the eastern part of the country. This paper documents achievement made in terms of output. Gawrie N. the framework also benefited from technical guidance from the Global Plan For Artemisinin Resistance Containment (GPARC). 90 MARC – Strategic framework for artemisininresistance containment in Myanmar8 Efforts to contain the spread of artemisinin resistance in Myanmar started since its first indication in 2009. artemisinin resistance 1 Address for correspondence: Dr Krongthong Thimasarn. most importantly. among them antimalarials.int/ publications/journals/seajph DOI: 10. with possible serious global implications for malaria elimination. Ministry of Health. as well as lessons learned during early implementation of the programme. 3Malaria Unit. the MARC framework was developed in 2010 through consultation and brainstorming sessions of the Malaria Technical and Strategy Group (TSG). MARC specific objectives are shown in Box 1. This paper documents the process. 2National Malaria Control Programme. enabling factors. Myanmar. challenges awaiting the national programme and its partners. Khin Mon Mon4.5 and confirmed in 2011. Galappaththy3. Myanmar. building on the Cambodia–Thai containment project with the strategy developed in 2008. Ministry of Health. Krongthong Thimasarn3. A total of US$ 9 million was mobilized through the 3DF to roll out MARC from July 2011 to 2012 and another US$11 million from 3MDG for MARC activities in 2013. Email: thimasarnk@who. evidence of suspected artemisinin resistance was reported in 2009. challenges and the way forward Quick Response Code: Thar Tun Kyaw1. 5independant consultant. In Myanmar. It also identifies enabling factors to success and.6 To date. as well as LLIN distribution. 6) To conduct studies. both in villages and at worksites. and improved access to quality treatment and malaria prevention among targeted population groups. particularly mobile populations. • Training activities to support the above activities: microscopists at state or region level. and migrant mapping. or other sources of funding. MARC aims at delaying the spread of artemisinin-resistant parasites. as well as day 3 parasitaemia studies. but results in the containment areas along the eastern border of Myanmar are still inconclusive due to high population movement across this border and inaccessibility in conflict areas. coordination among implementing partners is vital to success. Key strategies include a multisectoral approach and integrated interventions in scaling up of case management. • Activities to advocate for the support of containment of artemisinin resistance among partners and stakeholders. BHS. • A monotherapy replacement programme using affordable or free-of-charge quality ACTs through the private sector. MARC targets 52 townships. LLIN/ITN distribution. 7) To provide effective management and coordination to enable rapid and high-quality implementation of the containment strategy. Eight implementing partners (IPs)a—implement MARC activities with funding from 3DF. World Vision. guidelines for the treatment and prevention of malaria among mobile/migrant populations. but bordering Tier 1 area). volunteers at villages and at worksites for case detection and treatment.: Containment of artemisinin resistance in Myanmar Box 1: MARC Objectives 1) To improve access to and use of early diagnosis and quality treatment according to the national treatment guidelines. and. morbidity and mortality of falciparum malaria. An additional four partnersb implement MARC activities with either their own funding. and artemisinin monotherapy replacement. Out of 330 townships of Myanmar. malaria mortality and morbidity has declined in MARC’s target areas in the two years (Table 1). • Public-private partnerhsip initiation for: migrant mapping. the project has achieved its two goals. Tier 3 refers to areas endemic to Plasmodium falciparum with no evidence of artemisinin resistance and limited contact with Tier 1 areas. reduction of drug pressure. and the affected community. volunteers. MARC achievements during 2011–2013 While it has been merely 30 months since the first implementation of MARC. 2011–1013 • Set up of screening points along the Thai–Myanmar and Myanmar–China border areas to detect malaria among migrants. 21 in Tier 1 (strong evidence of suspected resistance). 5) To support containment of artemisinin resistant parasites through advocacy and BCC/IEC. Myanmar Medical Association. Japan International Cooperation Agency. International Organization for Migration. and public–private partnership. health facilities and private vendors. in certain areas. • Therapeutic efficacy studies (TES) and day 3 parasitaemia studies for evidence-based policy and strategic development. and reducing transmission. especially operational research to support the development of evidence-based containment policies and strategies. b Medicin san Frontieres-Switzerland. Myanmar Health Assistant Association. and WHO Myanmar. Population Services International. 4) To increase migrant/mobile population access to and use of malaria diagnosis. • Insecticide-treated nets and long-lasting insecticidal nets (ITNs/LLINs). Two new IPs in 2013 includes Friend for Health and Medical Action Myanmar. including private practitioners. other governmental agencies. These activities are for example. and second. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 91 . as well as a network of private physicians and clinics in the 52 townships. meetings with the affected communities. Because MARC relies on a multisectoral approach.Kyaw et al. local committees. This mechanism ensures strong public– private partnership in MARC implementation. The TSG coordinates among partners at higher levels. detected no new suspected resistance in Tier 3. CPI/GHAP and USAID/PMI CAP-Malaria a MARC major activities and outputs. and at implementing level. indoor residual spraying together with personal protection measures to limit transmission in containment areas. Significant outcomes of MARC in containment areas since July 2011: • improved access to quality diagnosis and treatment through volunteers. World Concerns. education and communication (IEC) material and behaviour change communication (BCC) material for different target populations such as private practitioners. IP in 2011–2012 included Community Development Association. VBDC staff. • System strengthening for timely and improved information: epidemiological and entomological surveillance. case management. treatment and vector control measures including personal protection. Surveys of households. and 31 in Tier 2 (unclear evidence of suspected resistance. TES results. and the private sector. national drug policy. 3) To limit the transmission of malaria by vector control and personal protection. First. 2) To decrease drug pressure for selection of artemisinin resistant malaria parasites by stopping the use of artemisinin monotherapies and sub-standard/fake drugs. and mobile malaria clinics to reach hard-to-reach areas to improve access to quality treatment. • Documentation: information. 93 12.95 0.84 0. four of 18 townships are covered.11 4.57 3.37 3.02 0.67 9.06 0.54 5.55 1.62 1.37 12.34 18.07 16.75 2.19 6.80 7.36 13.33 2.87 44.70 1.20 0.71 8.46 16.03 9.70 20.75 1.70 0.18 45.59 0.51 0.76 10.90 6.22 9.09 0.37 3.72 2.55 0. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .71 0.71 1.54 3.39 1.60 3.43 Kayah 26.25 0.50 24. • national drug policy.14 1.72 10 Shan (South) 8.41 3.91 70.48 21.00 1.30 4.20 8.82 3.82 2.68 0.81 9.75 32.35 30.73 1.74 35.94 26.38 9.33 9 Shan (North) 12.88 13.57 MARC area 14. In the latter.20 6.: Containment of artemisinin resistance in Myanmar Table 1: State and region wise malaria morbidity and mortality.16 5 Mandalay 2.33 11.37 22.59 Kayin 12.70 6 7 8 Non-MARC 1 Non-MARC Bago (East) 11. MARC/ NonMARC State/ Region 2008 2009 2010 2011 2012 Morbidity rate* Mortality rate** Morbidity rate Mortality rate Morbidity rate Mortality Rate Morbidity rate Mortality Rate Morbidity rate Mortality Rate Ayarwaddy 3.47 9.07 2.41 0.84 10.28 0.19 7.04 3.96 4.61 0.80 34. including a policy to ban artemisinin monotherapy.58 0. • increased coverage of personal protection through increased use of LLINs.21 4 Magway 7.30 3.33 37.98 1.46 3.66 4.17 0.74 46.61 0.34 0.16 9. • improved compliance of private sector to national drug policy.98 0.86 2.77 13 Kachin*** 23.19 19.17 8.33 3.01 16.10 2.09 5.62 0.89 6.46 9.91 37.49 2.75 2.75 2.53 1.68 1.30 27. • a system for early detection of artemisinin resistance along the border.14 8.36 0.64 1.09 1.20 24.26 0.22 3.58 4.12 2.90 2. • standardized and computerized surveillance system strengthened and expanded into township level in Tier 1.37 1.Kyaw et al.76 3 Chin 44.55 0.68 0.36 0.65 4.25 0.83 1.67 0.11 6.64 1.18 7.89 1. The four townships contribute around 1/3 of total cases in the State.12 3.45 3.03 0.64 11. reintroduction of IRS and improved knowledge of target populations through IEC and BCC activities.48 1.64 2.29 0.08 Rakhine 42.80 11.08 14.70 0. 92 • mapping of migrants at local level for microplanning of malaria control.62 2 Bago (West) 6.39 2.42 4.20 0.30 22.71 6.45 0.13 8.02 14.78 4.69 16.50 3.14 1.07 0.08 9.98 Shan (East) 5.54 1.28 0.30 4.95 8.09 3.27 7.44 3.22 44.72 0.22 0.79 1.74 Sagaing 18.83 14 15 MARC 12 *Morbidity rate/1000 population **Mortality rate/100 000 population *** MARC covers all townships in the State/Regions mentioned except in Kachin.75 22.85 2.05 16 Mon 9.13 3.77 1.68 1.13 2.84 1.51 1.47 1.24 2.68 2.70 2.02 0.54 8.22 0.67 0.37 Nationwide 10.53 11 Yangon 1.00 4. 2008–1012 No. Myanamar.70 17 Tanintharyi 24.32 20. from national to state/ region. Successes from Myanmar that can be repeated elsewhere are. as well as confusion among workers under different implementing partners. 3. as well as increased technical issues. 3. 4.40:674-91. multiple donors together with multiple implementing partners requires careful planning and adequate coordination. job descriptions. This factor together with outdoor transmission in the forest continues to pose technical challenges to MARC’s future achievement. Overlapping of areas of activity at lowest level of implementation due to many IPs has caused confusion among staff. focusing on two main activities: (1) improved access to diagnosis and treatment to target populations in containment areas. This had led to fragmentation of implementation and reporting. Ministry of Health. such as Myanmar Health Assistant Association in Myanmar and many others. and imposed significant difficulties to its implementation.: Containment of artemisinin resistance in Myanmar MARC’s enabling factors First. and training manuals and process. 2009. and fund transferring require much attention and energy. National strategic plan. and to village levels. Burkholder B. and later 3MDG. et al. enhanced public–private partnerships in implementation of malaria activities. 6. strong political will to support malaria control and elimination efforts of the Ministry of Health has played a vital role in the success of MARC as well as regular malaria control achievements. these are mobile population and migrants. Finally. continues to pose challenges to Myanmar NMCP and WHO. however. Enhanced economic opportunities due to several reasons.44(Suppl. Southeast Asian J Trop Med Public Health. Donors were not adequately coordinated. Several important outcomes and two early impacts were achieved in containment areas according to MARC’s two goals: reduced morbidity and mortality. Smooth transition of MARC as project activities to become an integral part of malaria control remains a challenge. Christophel E. for example. 1):201-230. From 2014 onwards. It also contributed to high turnover of trained staff posted in villages or work sites inflict additional cost of recruiting and training of new ones. the Mekong economic corridor. for example. have fostered the control efforts. malaria prevention and control 2010-2015 (Annex 3). 2013. 3MDG will continue to provide additional funding for artemisinin-resistance containment activities in Myanmar beyond 2013. possibly until 2016. both positive and negative. 2012. Tuberculosis and Malaria (GFATM) and BMGF.10 thus posing further challenges for artemisinin-resistance containment in GMS. 7. Southeast Asian J Trop Med Public Health. and with funding from 3DF. Conclusions and the way forward Implementation of MARC started 30 months ago. thus they faced different recruitment. Bustos MD.11 The donor community can work together to ensure that the technical implementing partners are not unnecessarily burdened by administrative requirements. Delacollette C. containment of artemisinin resistance in Myanmar will become an integral part of the efforts under the GMS regional artemisinin resistance initiative (RAI). It is imperative for all parties to embrace lessons learned. While it is good news that funds continue to pour into Myanmar. and replacement of artemisinin monotherapy due to concerted efforts among multisectoral partners. were implemented by several partners. 2. as well as the Asian Economic Community (AEC). not-for-profit local professional organizations. and no further artemisinin resistance were detected outside know foci. Challenges in implementing MARC While MARC has tremendous success since its inception in April 2011. Maintaining what was achieved in the face of rapid changes in administrative and finance mechanisms. Malaria trends and challenges in the Greater Mekong Subregion. Second. the programme continues to face challenges in the coming years: 1. Grant agreement signing. 5. external financial and technical supports from numerous partners made it possible for the programme to conceive and implement such an ambitious project. including the supportive political environment in Myanmar. Long and cumbersome processes of grant negotiation and administration delayed the commencement of containment activities by several months. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 93 .Kyaw et al. How MARCimplementing partners overcame challenges encountered during its 30-month implementation can also be beneficial elsewhere. MOH . Monitoring antimalarial drug efficacy in the Greater Mekong Subregion: an overview of in vivo results from 2008 to 2010. While increased coverage of LLIN and ITN among target populations is one of MARC’s major objectives. Myanmar. resulted in ineffective management of programme activities. 9. Inadequate coordination at all levels. Myanmar’s NMCP was able to capitalize on the strong networks of private physicians in Myanmar in the provision of quality assured antimalarials. focusing on using a multisectoral and integrated approach in implementing various antimalarial interventions in containment areas. with funding from the Global Fund to Fight AIDS. Yangon: Department of Health. Communication barriers due to cultural and language difference between malaria service providers and recipients have impeded the effectiveness of the programme. as well as among national level and sub-recipients. 2. Civil unrest in some containment areas have limited access. References 1. to township. D’Souza C. Third. Delacollette C. Volunteers for case management in villages and at worksites. Wongsrichanalai C. will contribute to increased non-immune population movement into malarious areas. 8. This phenomenon is not unique to Myanmar. and (2) provision of locally appropriate vector control measures and personal protection. Bangkok. TH provided information. New Delhi: WHO-SEARO. SEA-MAL 257. 12-13 June 2012. 3(1): 90–94. LO reviewed the paper. 2009. KMM provided information. 9. Galappaththy GNL. Ministry of Health Myanmar. 2011. Global plan for artemisinin-resistance containment (GPRAC). http://csis. Myanmar.org/files/publication/131107_ Daniel_DrugResistantMalaria_ Web. Development of a strategy towards elimination of plasmodium falciparum parasites with altered response to artemisinins: report of an informal consultation.Kyaw et al. Thailand. http://whothailand.org/ bitstream/123456789/1460/10/SEA-MAL-270. Arlington.pdf . Containing artemisinin resistance of Plasmodium falciparum in Myanmar: achievements. challenges and the way forward. Document No. Yangon: MOH. 5. Hlaing T. Strategic framework for artemisinin resistance containment in Myanmar (MARC). VP wrote the paper. vivax resistance to anti-malarial drugs in the Greater Mekong Sub-region. 13-14 February 2008. Kunming. KT wrote the paper. World Health Organization. Document No. Rieffel L. 2011. March 2013. falciparum and P. Daniel JC. 2011-2015.accessed 28 March 2014. Thimasarn K. VA: Nathan Associates Inc. The People’s Republic of China. DC: Center for Strategic & International Studies. 10. New Delhi: WHO-SEARO. Geneva: WHO. Fox JW. 8. SEA-MAL-270. 2013. Yangon: MOH. Drug-resistant malaria: a generation of progress in jeopardy. http://whothailand. September 30-October 2. Nay Pyi Taw. Mon KM. Ministry of Health Myanmar.: Containment of artemisinin resistance in Myanmar 4. 2010. too soon? The dilemma of foreign aid to Myanmar/Burma. 7. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . Regional Office for South-East Asia. Mandalay. Regional Office for South-East Asia. Myanmar. Source of Support: Nil. Plasai V. Report of the workshop to review and plan therapeutic efficacy studies to monitor P. SEA-MAL-263. Conflict of Interest: None declared. 2013. World Health Organization. Myanmar.pdf – accessed 28 March 2014. Ortega L. New Delhi: WHO-SEARO. Too much. Document No. 6. Contributorship: TTK provided information. Annual report 2011: vectorborne diseases control programme. 2013. Reviewing and planning therapeutic efficacy studies (TES) to monitor antimalarial drug resistance in the Greater Mekong Subregion (GMS): report of a workshop.org/bitstream/123456789/1015/1/ SEA-MAL-263-%20TES%20in%20Mandalay%202009.healthrepository. How to cite this article: Kyaw TT. Washington. World Health Organization.accessed 28 March 2014. WHO SouthEast Asia J Public Health 2014. 2008.healthrepository. 11.pdf . 94 World Health Organization. Regional Office for South-East Asia. GNLG wrote the paper. by presenting two alternative scenarios of deaths. Also. Email: ig. Children and pregnant women have low immunity to vector-borne diseases like malaria. While there continue to be debates and discussions around the prevalence.com. Using a nationally representative sample. specifically. there is a paucity of studies on the economic burden on households and likely cost of these illnesses. they exist for other surveillance data as well. India Address for correspondence: Professor Indrani Gupta. and such a nationally representative sample should be used for a better understanding of the malaria situation in the country. which impact mostly the poor and vulnerable sections of the population. The NSS 60th round is useful in this context because. Vectorborne diseases contribute to widespread disease. The results indicate that the total economic burden from malaria in India could be around US$ 1940 million. 1 Despite the significant presence of vector-borne diseases in India. while 24% comes from treatment costs. Subsequently. indrani@iegindia. leading to maternal deaths. Institute of Economic Growth. This paper. the data are analysed to understand the distribution of the burden of malaria across sex.who. malaria.06 million (provisional). residence (rural/urban areas). according to the Directorate of the National Vector Borne Disease Control Programme (NVBDCP).org Key words: Economic burden. education and consumption categories. in terms of morbidity and mortality. kala-azar and lymphatic filariasis have considerable impact. and are especially vulnerable. it also seeks responses on missed days of work and earnings foregone. University Enclave. While severe a decade ago.4103/2224-3151. vector-borne diseases such as malaria. there has been a declining trend in the overall endemicity of malaria in the country. this study has estimated the economic burden of malaria in India by applying the cost-of-illness approach. The major burden of vector-borne disease in India comes from malaria. Institute of Economic Growth.115828 Economic burden of malaria in India: The need for effective spending Quick Response Code: Indrani Gupta. Japanese encephalitis (JE). While limitations exist. Delhi 110007. and low birth weight in infants. therefore. A sensitivity analysis was carried out. 80% of malaria reported in the country is confined to populations residing in tribal. and economic. dengue. allocation of financial resources among states does not reflect the burden of malaria. India. chikungunya. days lost and earnings foregone. on account of ecology. uses unit-level data from the NSS 60th round on health. An analysis of the trend and patterns in public expenditure by the National Vector Borne Disease Control Programme shows a declining focus of the central government on vector-borne diseases.1 Residents of rural and tribal areas as well as urban slums are most at risk from such diseases. stillbirths. The major burden comes from lost earnings (75%). about 95% of the population in the country resides in malaria-endemic areas. New Delhi. to analyse the direct and indirect costs of malaria.indrani@gmail. public spending Introduction In India. vector bionomics. according to government sources. incidence and deaths from malaria. the last health round (60th round) of the National Sample Survey2 of India (NSS) – which is a nationally representative survey – is yet to be utilized to understand the treatment burden of malaria and the profile of those affected.int/ publications/journals/seajph DOI: 10. using nationally representative data.searo. India.Access this article online Policy and practice Website: www. especially among the poor. the major vector-borne disease in the country. difficult and inaccessible areas. Since mortality is low. The epidemiology of these vectorborne diseases varies considerably. this is not a major source of economic burden of malaria. the analysis focuses on direct and indirect costs of treatment for outpatients and hospitalizations. disability and deaths in India. Health Policy Research Unit. using the information on cost of treatment. with a reported number of cases in 2012 of around 1. in addition to costs of treatment. Alternative estimates of deaths WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 95 . The NSS has the potential to independently validate the various estimates of malaria burden. hilly. sociocultural and behavioural factors. Samik Chowdhury Abstract About 95% of India’s population resides in malaria-endemic areas and. from the National Sample Survey data. who have limited access to timely and effective treatment. Also.3 Other analyses point out that it is indeed a challenge to estimate the true case burden of malaria in India. compared to only 4. Rajasthan and West Bengal.1 of the reported 1. cases of malaria occurred seasonally and were concentrated in an important agricultural season. While the survey pertains to 2004. though the number could be higher due to lower treatment-seeking behaviour in general. According to the NVBDCP.8 which reported 15 000 deaths per year due to malaria. The NSS data contain information on the direct costs of treatment for both outpatient and hospitalization episodes in rural and urban areas respectively. with lower and upper limits of 125 000 and 277 000.to high-income categories. numerous studies have focused on the economic burden on households. The most affected states are the north-eastern ones: Andhra Pradesh. data from WHO and the more recent Lancet study were used for the lower and upper range of possible deaths from malaria. Maharashtra. This season saw the bulk of the economic impact in terms of loss in working days and loss in school days. with 32% of their annual household income being lost as a result of the direct and indirect costs of malaria. Thus. However. The survey also asks about the kind of illness suffered by the respondent. The findings indicate that malaria eradication resulted in improvements in income for males. Karnataka. despite a significant burden of malaria in India. surveillance is a key area that needs further policy focus to refine estimates of cases and deaths because the economic burden of malaria is entirely driven by the case-load and mortality.9 Finally.3 indicating the need for constant vigilance and prevention.01% are due to P. METHODS The study used NSS data for the last available health round on India. In the mid-1970s. a widely quoted study in The Lancet estimated that 205 000 deaths per year could be attributed directly to malaria. The direct and indirect costs for both inpatients and outpatients were calculated from NSS data. Odisha. The paper also highlights certain key issues on the patterns in public financing of the NVBDCP in general. and therefore. respectively. the estimates are used in conjunction with more recent estimates of malaria cases in India. especially among adults. the weights given in the NSS data were used to estimate nationally WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . it is safe to assume that the malaria numbers from the NSS are indeed malaria.06 million cases in 2012. Wherever required. for example. For the total number of deaths. The findings showed that the costs of treatment for malaria accounted for almost half of expenditure on curative care costs incurred by the households.4 million new cases in 1976.11 Another study from Sri Lanka indicated that.7 These figures differed significantly from the 2008 World Health Organization (WHO) World malaria report. there is as yet no study that has used a nationally representative database to assess the total economic burden of illness and deaths from malaria in India. Chhatisgarh. though there are some that have looked at chikungunya14 and lymphatic filariasis. which pertains to 2004. about 95% of the country’s population resides in malaria-endemic areas.17 In the absence of more recent data.12 A study from Nigeria compared the financial and economic costs of malaria with other illness episodes for households in five malaria holoendemic rural communities.4 Non-reporting of mortality causes a serious problem with data on the medical cause of certification of death. Economic impact of malaria: global evidence A number of studies have looked at the economic impact of malaria globally. and also from the numbers reported by the NVBDCP. Gujarat. It is possible that the actual number of malaria cases is higher because a large number of infected individuals might be seeking treatment from private health providers. difficult and inaccessible areas. and 80% of malaria reported in the country is confined to regions that have more than 20% of their population residing in tribal. current available estimates of cases and deaths are used for analysis and discussion of economic burden. Malaria in India The case-load of malaria in India has reduced and reported deaths are declining. few studies have looked at the economic impact of malaria on households.5 A more recent article indicates that global malaria mortality may be much higher than previously estimated. While self-reported morbidities may not be accurate generally.10 However. compounded by the lack of medical certification of deaths as well as issues with the attribution of specific cause of death. the analysis contended that cases due to Plasmodium falciparum might represent only a fraction of the total malaria disease burden in India. would not be counted in any reporting system.: Economic burden of malaria in India are used to calculate the burden from loss of earnings and years of productive lives.Gupta et al. Research also confirms that the majority of deaths from malaria were not in any formal health-care facility.13 However. to assess the economic burden of the disease on the country.16 While the consensus from such studies is that malaria imposes significant burden on households. Some have estimated the impact of malaria 96 on economic growth and there is some evidence for a belief that regions that have been able to reduce malaria have subsequently registered higher economic growth. who do not report to NVBDCP. Madhya Pradesh. although the overall economic impact was limited. hilly.15 One paper examined the effects of a large-scale eradication programme that drastically reduced malaria over a short period of time. with 6. the epidemiology of malaria remains complex. Jharkhand. owing to the geographical and ecological diversity. falciparum. an early study from Malawi showed that households with a very low income bore a disproportionate share of the economic burden of malaria.2% for households in the low. in addition to the usual direct costs.6 For India. anyone who stated malaria as his/her illness has certainly had a diagnosis. malaria re-emerged in India. indicating declining endemicity. Clearly. 50. The EAG states comprise about 45% of India’s population. Rajasthan. and the economic value of lost earnings due to death. that 60% of the total deaths are of adults (age 15 years and above).18 and the upper range of deaths from the Lancet study (277 000). even though the lowest quartile has 10% more cases than the other three quartiles.92 million cases for 2004. 60th round2 Table 2 presents the distribution of cases between the Empowered Action Group (EAG) of states. Overall. These costs are re-estimated for 2012 by using a suitable deflator. For deaths.2 While slightly higher for the EAG states. Madhya Pradesh. The stepwise methodology to calculate costs of illness from malaria for adults is given next. 5. 6. 7. 1. Since the WHO estimates are ranges. Table 1: Profile of malaria-affected individuals Characteristic Sex. Total economic burden from malaria has three components: treatment costs due to illness. (prevalence of 0–1 and greater than 1). the cases are significantly higher for the nonEAG states. This is somewhat higher than the NVBDCP’s reported 1. and more consistent with other views discussed above about the true burden of malaria in the country. 89% of the population is affected. and the present value of number of years of life lost due to malaria. Since one component of the cost of illness is productive work days lost. Odisha. 2. and the remaining 22% live in high-transmission areas (greater than 1 case per 1000 population).5 Non-EAG 38. malaria comprised 2. Other statistics indicate that slightly more males are affected than females. Uttar Pradesh and Uttarakhand versus other major states. which shows that slightly more than 60% of malaria cases occurred among adults. 67% reside in low-transmission areas (0–1 case per 1000 population). using a discount rate of 5%.1% in low.5% and 1. and. RESULTS Profile of malaria-affected individuals The data indicate that in 2004 there were a total of 2. and an average age of retirement as 60 years.2 47.5% of the total cases occurred in the EAG states. 7 This number is independently validated from the NSS study. days lost and earnings foregone. and to that extent.9% of the cases in rural and urban areas respectively. productivity loss due to foregone earnings emanating from lost days of work. the case-load between these two groups seems similar for rural India. The distribution across consumption quartiles is somewhat more. 3. In all therefore. if the fact that these are the socioeconomically weaker states and contribute mostly to the adverse Millennium Development Goal (MDG) outcomes is taken into account. in conjunction with estimated cases.3 8. Table 2: Malaria cases across EAG and non-EAG states Residence/states Rural Urban Total EAG 39. 60th round. the average earnings foregone are used to arrive at the potential loss of earnings. The majority of malaria cases are in rural areas (78%) and about 75% of the cases occur among individuals who are illiterate or have less education. the gross domestic product (GDP) deflator was used to arrive at expenditure figures for 2012. the analysis was restricted to adults only. Treatment costs are calculated using the costs of outpatient treatment and hospitalization from NSS 60th round.5 and 1 per 1000 or 0.4 Source: NSS unit level data.Gupta et al. Jharkhand. Two inputs are important in these calculations: the total number of cases of malaria and total number of deaths due to malaria. This is done to get a range within which the true economic burden might lie. Overall.05% and 0. these were assumed to be 0. using the information on cost of treatment. It is also assumed. rural Education Illiterate Primary and less Consumption quartile First Second Third Fourth Percentatge (total n = 2 396 194) 54 78 48 27 33 23 24 22 Source: NSS unit level data. male Residence. Thus. in conjunction with the total days lost due to illness and death 8. The EAG states are prioritized for special focus in government programmes. 4. A cost-of-illness approach was used to calculate the economic burden of malaria. based on the Lancet study. Assuming 45 years as the average age of death due to malaria among adults. while the number of cases remains the same. However.4 million cases of malaria (see Table 1).: Economic burden of malaria in India representative numbers. the distribution seems logical. two alternative estimates of economic costs are arrived at. two alternative estimates are used: WHO estimate of 15 000 per year. for urban India. Since the NSS pertains to 2004. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 97 . the present value of earnings foregone can be estimated. In fact. 47. The total burden due to treatment costs is calculated by using the unit costs of treatment. with the assumption that relative treatment costs remain the same. of all ailments reported. with two different assumptions regarding total deaths from malaria. comprising Assam. the potential number of life-years lost can be calculated.4 14.0 52. WHO estimates that in India about 11% of the population is malaria free. From NSS. such a distribution of case burden becomes a cause for concern.and hightransmission areas respectively. Bihar. this section attempts to understand the level and patterns of public spending on the malaria programme. the EAC consists primarily of funding from the Global Fund to Fight AIDS. along with the introduction of rapid diagnostic test kits. which has another five components dealing with leprosy. Earnings loss per day were 213 rupees and the total work days lost is assumed to the same (10 days). Overall. 2004 Categories Sector Rural Urban Quartiles Poorest Second Third Richest All Treatment cost (average per capita per month). control and treatment. owing to the lack of data that might indicate the true prevalence and incidence of malaria in the country. Hospitalization care lodging etc) Total Work days lost Loss of earnings (average per capita per day). The NVBDCP is an umbrella programme for prevention and control of vector-borne diseases. while the remaining 24 % comes from treatment costs. rupees 191 119 53 149 28 19 272 286 10 9 107 171 167 154 173 210 175 46 75 58 135 75 28 25 24 26 26 241 254 256 370 275 11 11 9 8 10 91 131 119 158 124 Source: NSS unit level data. Tuberculosis and Malaria and the World Bank (GFATM). The relative costs have. while malaria may not lead to many deaths.2 98 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . While the average work days lost was similar across residence. Overall. That is because the major burden comes from lost earnings (75%). the estimates would change dramatically. by residence and consumption quartiles. Mortality and value of lives foregone is not a major source of economic burden of malaria. and the current value of lives lost. The results do not change much when varying the total number of deaths. Clearly. The costs of illness for outpatient treatment. 60th round. with higher quintiles spending more on malaria treatment. The average total cost of treatment was 475 rupees in 2012. Other than a brief period between 2005–2006 and 2008–2009. it imposes a great burden via illness and missed days of work. and ultimately would also play out at the macro level by impacting national productivity and income. and calculated for 2012 by applying the appropriate GDP deflator. a part of the National Disease Control Programme (NDCP). derived from the NSS study. which marked the initiation of the World Bankassisted Enhanced Malaria Control Project (EMCP). There also seems to be a positive correlation between economic status and cost of treatment.19 Actual expenditure has trailed budgetary outlay for the entire period and reached a peak Table 3: Direct and indirect cost of illness from malaria. the DBS has exceeded the EAC. rupees Outpatient Others (Transport. Figure 1 shows the trend in allocation and actual expenditure on the NVBDCP. the NVBDCP has a 43% share of expenditure under the NDCP and malaria accounts for more than half of the central government expenditure on vector-borne diseases. Public financing of vector-borne disease control in India High economic burden warrants significant spending on prevention. The results indicate that the total economic burden from malaria in India could be around US$ 1940 million and varying the death rate does not make much difference. tuberculosis. This jump in EAC coincides with the GFATM-assisted Intensified Malaria Control Project (IMCP) in 94 districts of 10 states. Economic burden of malaria in India Table 4 presents estimates of the economic burden of malaria from treatment costs. which in turn has implications for households’ welfare. However. therefore. though this exercise is not attempted here. loss of earnings was higher in urban areas. the loss of earnings would be a substantial part of the total economic burden. the value of earnings foregone because of work days lost. While the DBS represents the central government contribution. blindness. The two sources of financing NVBDCP expenditure are the Domestic Budgetary Support (DBS) and the Externally Aided Component (EAC). an average of 175 rupees was spent for each outpatient treatment and 75 rupees on each hospitalization for malaria in 2004.: Economic burden of malaria in India Treatment costs and loss of work days and earnings due to malaria Table 3 presents the average expenditure on malaria for outpatient treatment and hospitalization. and is. in turn. if the prevalence figures were varied. and loss of earnings. The DBS and EAC have been supplementing each other since 1997–1998. hospitalization and other costs are based on the estimates given in Table 3. drug de-addiction and iodine deficiency. The disease required more outpatient expenditure generally.Gupta et al. Public expenditure on malaria prevention and control forms a part of the NVBDCP of the Government of India. if the prevalence was assumed to be double. been assumed to be the same with respect to each other. work days lost. Currently. though hospitalization expenses in urban India were relatively much higher than in rural India. 0 0. Such a low rate of utilization could be indicative of weak absorptive capacities.22 Although health is constitutionally a state subject.49 11. the central government provides technical. This is important because a major chunk of the plan expenditure is in the form of direct transfer of central plan assistance to state/district-level autonomous bodies/implementing agencies.: Economic burden of malaria in India Total economic costs due to malaria (millions of rupees) Total economic costs due to malaria (millions of US dollars. lower absorption leads to efficiency loss. insecticides and larvicides) and financial assistance to the states and UTs.7 XIth plan (2007–2012) 31. in 100 districts of eight states.0 3. Source: Strategic plan for malaria control in india.9 19.21 Plan expenditure (the blue line) demonstrates a clearly increasing trend over the years. 2012–201719 Note: scenarios I and II are based on alternative estimates of deaths from malaria. Plan financing of anti-malaria programme Plan expenditure on NVBDCP Approved outlay (billion rupees) Actual expenditure (billion rupees) Expenditure as % of outlay 2006-07 116 194 2007-08 116 093 2005-06 115 2004-05 14 2003-04 Current value of lives lost (millions of rupees) 2001-02 87 739 2002-03 Value of earnings foregone (millions of rupees) 2000-01 28 340 1999-00 Total costs of treatment (millions of rupees) Scenario II 1998-99 Scenario I 5.0 2. 1045 PHCs predominantly inhabited by tribal people have been provided full support. Nagaland and Tripura) have been provided 100% central assistance for programme implementation since December 1994. Assam.0 1. When this trend is juxtaposed with the significant burden of malaria analysed in the previous section. Maharashtra.Gupta et al. as well as administrative issues. namely Andhra Pradesh.5 2. commodity (drugs. North-eastern States (Arunachal Pradesh. 2012. in absolute terms. since 1997. Figure 2 shows the trends in plan expenditure on NVBDCP by the central government. Gujarat. the red line). which affects all public health programmes.97 88. but actual expenditure has grown by only 13%. Meghalaya.53 61. Chhattisgarh. US$ 1 = 60 rupees) 1935 1937 2010-11 2009-10 2008-09 Budget Allocation -. Whatever the reasons. Mizoram. which was followed by a reduction in budgetary outlay itself.5 1. Additionally.5 4.3 12.5 3. Madhya Pradesh. Further. 2 also plots plan expenditure on NVBDCP. and needs proper analysis. It is important to note that plan expenditure comprised 96% of the total expenditure on the programme in the year 2011–2012.5 0. It is observed that this share steadily declines from 4% in 2002–2003 to 2. It has more than doubled during the 10-year period. during 2008–2009. The operational costs for Table 5. the rate of absorption – measured by the proportion of outlay actually spent – has declined by more than 25 percentage points between the two plan periods. it says little about the significance of this programme within the central government budget for the health sector. Orissa and Rajasthan. when viewed in isolation.0 4. including operational expenses under the EMCP. with a slight decline during 2007–2009. Fig.2 Average annual growth (%) 27. but as a percentage share of total plan expenditure of the Ministry of Health and Family Welfare (MOHFW. it emerges as a cause for concern. plan expenditure on the NDCP as a share of the total plan expenditure of the MOHFW has also registered a decline from 9% in 2002–2003 to 5% in 2011–2012. In fact. it is observed that the aggregate approved outlay has grown by 27% between the two plan periods.DBS Budget Allocation -. Jharkhand.2% in 2011–2012. Manipur. The new World Bank-supported “Malaria control and kala-azar elimination project” for a period of 5 years has also been implemented since 2008–2009.EAC Budget Allocation -. with World Bank assistance.Total Actual Expenditure Figure 1: Budgetary allowance and expenditure under NVBDCP DBS: Domestic Budgetary Support. EAC: Externally Aided Component. Comparing the previous two plan periods (see Table 5). Central Bureau of Health Intelligence.0 1997-98 Parameters Rs Billion Table 4: Economic burden of malaria under alternative assumptions of mortality Xth plan (2002–2007) 13. To examine this. While this is encouraging.20 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 99 . This is indicative of the general decline in health spending of the government.6 Source: Health profile of India. Government of India.2 3. 2012–2011 Source: data on financial allocation from Lok Sabha unstarred question No. Jharkhand. some interesting observations can be made. Comparing with the estimated economic burden calculated from the cost-of-illness approach. the share of allocation falls short of the share in malaria cases in the country. Central Bureau of Health Intelligence. for the year 2010–2011. these figures for economic burden should be treated as being on the lower side.0 Arunachal Pradesh 1. Under these circumstances.2 30. and treatment costs.1 3.0 Percent 6.0 3.0 20. including the estimates of cost of illness and deaths. as well as other social costs of morbidity and deaths of children that have not been included in the analysis.19 Figure 3 shows the distribution of central allocations for NVBDCP for selected states with a share of malaria cases greater than 1%. and thereafter funds are allocated under the NVBDCP. For more than half of these states. MOHFW.24 Overall. States that receive the highest share of central allocation for NVBDCP are Odisha. being driven by cases of morbidity resulting in loss of productive days.20 and Demand for grant no 47.4 Percent Rs Billion 5. The percentage share of malaria cases for the same year is also plotted alongside. The centre also meets the requirement of states during emergency situations.1 West Bengal 2.0 Rajasthan 2.0 15.21 implementation of the NVBDCP and certain commodities are met from state funds. rather than mortality. Also. CONCLUSIONS AND DISCUSSION While a proper surveillance system would remain a key to assessment of the economic impact of malaria and require global cooperation and consensus regarding the methodology of estimation. Ministry of Finance. Funding will remain the most important policy concern for the control.0 10. and possibly declining as a percentage of total health spending in the country.1 3. Bihar and Chattisgarh. If this is combined with the states’ share of malaria cases. the amount remains much lower than the potential economic burden imposed by the disease. which is around US$ 1940 million for only adults.0 Jharkhand 3.0 Percent share of Malaria cases Figure 3: Share of allocation under NVBDCP and malaria cases for selected states.0 2.Gupta et al.0 Uttar Pradesh 2. While a major part of this will be on malaria.4 3.5 4.5 2. the states are required to submit their project implementation plan every year. the distribution across states does not seem commensurate with the disease burden.5 1. Union Budget.0 4.25 the analyses in this study.2 Meghalaya 2.0 Chhattisgarh 4. the economic burden of malaria may be much higher. the loss of work days is quite high for malaria and is likely to impose a high economic impact at the household level as well.6 2.0 25.1 4. Gujarat. the true impact may be much higher.0 Percent share of Allocation Karnataka Tamil Nadu Gujarat Manipur Mizoram 0. Being under the umbrella of the National Rural Health Mission.0 3. 5008. the expenditure analysis indicates that there is a need to step up spending on malaria. indicating the possibility of improving resource allocation for spending to be more effective. and enable comparison with current disease-control expenditures. The profile of those affected clearly indicates that such work-day losses are going to be felt more severely by the most vulnerable.5 3.1 3. Government of India. 100 5.0 Madhya Pradesh 2. Assam. MOHFW. The current surveillance is clearly inadequate.0 Bihar 3.9 Tripura 2.9 5.8 Assam 3.0 Nagaland 2011-12 2010-11 2009-10 2008–09 2007-08 2006–07 2005–06 2004–05 2003–04 2002–03 0. Especially significant are the cases of Chattisgarh. since it mostly captures data from the public sector.0 1.23 data on malaria cases from NVBDCP website.0 Andhra Pradesh 2.3 Odisha 3.: Economic burden of malaria in India Plan Expenditure on NVBDCP Expenditure on NVBDCP as % of Total Plan Expenditure of MOHFW Figure 2: Trends in plan expenditure on NVBDCP Source: Health profile of India. yield useful insights into the magnitude of the problem. analysts have WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .0 3. prevention and treatment of malaria. Jharkhand. In particular. dated on 2 September 2011. which are also known to be the states with relatively greater burden of malaria. which is appraised in the MOHFW. especially since a significant percentage of the population does not seek care. This analysis raises the possibility of reallocation of central resources and aligning these with disease burden across states. in 2012. about 5410 million rupees or US$ 86 million was spent on the entire vector-borne disease programme of the country.5 0. Also.0 Maharashtra 1. There are significant costs involved for treatment. Maharashtra and Odisha. The states are ordered by their share in total allocation for the NVBDCP. which is very low compared to the potential burden it is imposing in the country.0 0. While domestic funding for malaria is augmented by international funding from sources like the GFATM and the World Bank. India. 19. asp?slid=1256&sublinkid=1163 . Kyle J Foreman. Mukherjee Anit N. Raju M Jotkar.mrcindia. New Delhi: National Sample Survey Organisation. For the million death study collaborators adult and child malaria mortality in India: a nationally representative mortality survey. December 2007. Gallup John Luke & Effrey D. January 2001. editors. Ashis Das.who. 14.accessed 22 March 2014. 2000 Jun 1. Morbidity. Winnie Fung. human resources and monitoring and evaluation. actual expenditure has fallen far short of approved outlay for vector-borne diseases. The Lancet. 2012.accessed 22 March 2014. Malaria in India: the center for the study of complex malaria in India.doi. Photini Sinnis.ncbi. Ettling M. Anupkumar R. the country has to find additional resources from its domestic sources for a sustainable programme of control and elimination of malaria. Robert W Snow. 15. and coordination with international agencies such as the World Bank and other partners. Monica Singhal. http://globalhealthcenter.376(9754):1768-1774.in/index2. would require funding. Measuring the economic cost of malaria to households in Sri Lanka. Mohsen Naghavi. Sharma. India’s invisible malaria burden. thereadgroup. 10. Simon I Hay.56(6):656660.pdf .gov/books/NBK2624/ accessed 22 March 2014. Kamaraju Raghavendraa. Burden of Malaria in India: retrospective and prospective view.Tom Vogl. The Economic Burden of Malaria. United States Agency for International Development. Arlington. 2010 Apr:2(2):72–94. India. Patrick L. Ministry of Statistics and Programme Implementation.nih. int/malaria/world_malaria_report_2010/en/ accessed 22 March on 2014. Directorate General of Health Services.nlm.16(6):251-253.accessed 22 March 2014. American Economic Journal: Applied Economics. Economic burden of malaria illness on households versus that of all other illness episodes: a study in five malaria holo-endemic Nigerian communities. Strategic plan for malaria control in India. Malaria: magnitude of the problem. 4. Sutton. Nutan Nanda. Explaining the Global malaria mortality between 1980 and 2010: a systematic analysis.accessed 22 March 2014. as well as scaling up interventions.accessed 22 March 2014. http://cbhidghs. Vineeta Singh. Murray Christopher J L. Alan D Lopez.121(3):267-273. int/malaria/publications/atoz/9789241563697/ en/index.pdf . Ramanan Laxminarayan. Bhupinder N. health care and the conditition of the aged: NSS 60th round (January – June 2004). 2008 Nov 15. Ministry of Health and Family Welfare. Michael Kremer. http://www. http://dx. Ministry of Health and Family Welfare. Economic impact of malaria in Malawian households.princeton. Jane M. 1994. Untreated morbidity and demand for healthcare in India: an analysis of national sample survey data.in/malaria3. 18. with states with higher prevalence of malaria not necessarily receiving higher funding from the central government In addition to scaling up effective interventions.Gupta et al. Read. 1997.46:57– 64. Edwin Michael. 2010 Nov 20-26. India. VA. Helen L Guyatt. Thomas. 2010 Nov 20-26. The economic burden of lymphatic filariasis in India.pdf . 379. 2000 Nov 17. New Delhi: Central Bureau of Health Intelligence. The Lancet. Cator. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 101 .gov.net/wp-content/uploads/Das-et-al-India-ICEMR-2012. 16.edu/~tvogl/malaria_ cfksv. Editors. http://www. For resource mobilization. Furthermore. http://nvbdcp. Onwujekwe Obinna.html . a two-pronged strategy visualized by GMAP includes setting up resource-mobilization processes at country level. Nancy Fullman.pdf . India. Singh. World malaria report 2010. http:// dx. Van der Hoek W. India. pdf . Neelima Mishra.gov. Diana Haring.27. 2004. http://www. McFarland DA. Ministry of Health and Family Welfare. Krishanu Karmakar. 2009 Mar.1016/S0140-6736(10)61084 – accessed 22 March 2014. Ramesh C. 2008. even at the domestic level. The American Journal of Tropical Medicine and Hygiene. J Vector Borne Dis. supply chain.edu/documents/globalmalaria-lancet0212. Konradsen F. Keusch GT. http:// planningcommission.org/10. World Health Organization. Chitsulo L. Das Aparup. Directorate General of Health Services. 6. Acta Tropica. Vector Biology and Control Project. Household economic impact of an emerging disease in terms of catastrophic out-of-pocket health care expenditure and loss of productivity: Investigation of an outbreak of chikungunya in Odisha. Economic and Political Weekly. The Lancet. nvbdcp. Parasitology Today.45(1):74-79. There also seem to be horizontal imbalances in the distribution of these funds across states. Surya K.1016/S01694758(00)01643-4 – accessed 22 March 2014. by developing a fully fledged country-level financing plan. World malaria report 2008. New Delhi: Directorate of National Vector Borne Disease Control Programme. 2012-2017.accessed 22 March 22 2014. Nagpala. Steven A. Vinod P Sharma. strengthening health systems remain a cornerstone of a successful strategy of malaria control. 20.html . 2012 Feb 4. Alex Eapen.who. Reginald Chima.54(2):143–159. Stephen S Lim. Kathryn G Andrews. The intolerable burden of malaria: a new look at the numbers: Supplement to Volume 64(1) of the American Journal of Tropical Medicine and Hygiene. Report of the working group on disease burden for the 12th Five Year Plan. Cutler David.pdf . Alan A Cohen. Lisa C Rosenfeld. Kapa D Ramaiah. Anvikar. as evidenced by the declining share of this component in the plan expenditure of the MOHFW. Gopalan Saji Saraswathy. et al. 2. White NJ. Interventions can be effective only if there is an effective system of. Northbrook (IL): American Society of Tropical Medicine and Hygiene. Diego G Bassani. Schultz LJ.376(9754):1716-1717. Amerasinghe FP.doi. Om P. Rafael Lozano. Geneva: WHO. Early-life malaria exposure and adult outcomes: evidence from malaria eradication in India.umn. 5.accessed 22 March on 2014. Defining and defeating the intolerable burden of malaria III: progress and perspectives: supplement to volume 77(6) of American Journal of Tropical Medicine and Hygiene. 2010. Egan A. for example. Peter S Rodriguez. Prabhat Jha.in/aboutus/committee/wrkgrp12/ health/ WG_3_1communicable. Andrew F. Amerasinghe PH. Health Policy. New Delhi. http://www. Priority accorded to vector-borne disease seems to have declined over the years. Northbrook (IL): American Society of Tropical Medicine and Hygiene. New Delhi: National Vector Borne Disease Control Programme. XLIII(46):71-77. Carlton. National health profile of India – 2012.: Economic burden of malaria in India pointed out that global funding has not been adequate so far and it is unlikely that MDG goals to halve the disease burden by 2015 will be achieved without significant increases in funding. Lauren J. World Health Organisation. India. Peter W Gething.accessed 22 March on 2014.org/10. Dhingra Neeraj. Sullivan. Paul Okonkwo.accessed 22 March 2014. Harish C. Dhiman. http://www.gov. Geneva: WHO. Tropical Medicine and Parasitology : Official Organ of Deutsche Tropenmedizinische Gesellschaft and of Deutsche Gesellschaft fur Technische Zusammenarbeit (GTZ). Sachs. Breman JG. 13. 17. 12. Srivastava. Kumar A. http://www. 7. 9. While international funding has been a major part of India’s funding for malaria. Jain T. Strengthening health systems. Alilio MS.in/Doc/StrategicAction-Plan-Malaria-2012-17%20.org/journal/issues/461057. 2011. In: Breman JG.26 The gap in funding need remains a critical global concern and it could be almost four times the funds currently available. Matthew B. 11. 8. References 1. Planning Commission. The Roll Back Malaria Partnership has developed The Global Malaria Action Plan. Wilson Suraweera. Neena Valecha. Pradeep K Das. which can be viewed as a document around which other partners can coordinate their efforts. Valecha N. http://www. Richard Peto. nic. 3. Gupta et al.: Economic burden of malaria in India 21. 22. 23. 24. 25. 102 India, Ministry of Health and Family Welfare. Notes on demands for grants, 2013-2014. Demand No. 47. New Delhi: Department of Health and Family Welfare. http://indiabudget.nic.in/ ub2013-14/eb/sbe47.pdf accessed 22 March on 2014. Gupta Indrani, Chowdhury S. Scaling up health expenditure for universal health coverage: prospects and challenges. Delhi: Health Policy Research Unit, Institute of Economic Growth, 2013. Unpublished Mimeo. Lok Sabha questions. http://164.100.47.132/LssNew/psearch/qsearch15. aspx - accessed 22 March 2014. India, Ministry of Health and Family Welfare. Malaria Situation in India. New Delhi: National Vector Borne Disease Control Programme, Directorate General of Health Services, 2013. http://nvbdcp.gov.in/Doc/ mal-situation-Nov13.pdf - accessed 22 March 2014. Hay Simon I, Peter W Gething, Robert W Snow. India’s invisible malaria burden, The Lancet. 2010 November 20-27;376(9754):1716–1717. 26. Snow Robert W, Carlos A. Guerra, Juliette J. Mutheu, Simon I. Hay. International funding for malaria control in relation to populations at risk of stable plasmodium falciparum transmission. PLoS Medicine. 2008 Jul;5(7):e142. http://www.plosmedicine.org/ article/fetchObject.action?uri=info%3Adoi%2F10.1371%2Fjournal. pmed.0050142&representation=PDF - accessed 22 March 2014. 27. The Roll Back Malaria Partnership. Executive summary: the global malaria action plan. Geneva: GMAP, 2008. http://www.rollbackmalaria. org/gmap/0-5.pdf. - accessed 22 March 2014. How to cite this article: Gupta I, Chowdhury S. Economic burden of malaria in India: the need for effective spending. WHO South-East Asia J Public Health 2014; 3(1): 95–102. Source of Support: Nil. Conflict of Interest: None declared. Contributorship: Both authors were responsible for conceptualization, analysis and writing this paper. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) Access this article online Policy and practice Website: www.searo.who.int/ publications/journals/seajph DOI: 10.4103/2224-3151.115828 Towards universal health coverage: an example of malaria intervention in Nepal Quick Response Code: Shiva Raj Adhikari Abstract A comprehensive and integrated assessment of health-system functioning requires measurement of universal health coverage (UHC) for disease-specific interventions. This paper aims to contribute to measurement of UHC by utilizing locally available data related to malaria in Nepal. This paper utilizes the elements of UHC as outlined by the World Health Organization (WHO). The concept of UHC represents both improvements in health outcomes and protection of people from poverty induced by health-care costs. Measuring UHC focusing on a tropical disease highlights the progress made towards elimination of the disease and exhibits health-system bottlenecks in achieving elimination of the disease. Several bottlenecks are found in the Nepalese health system that strongly suggest the need to focus on health-system strengthening to shift the health production function of malaria intervention. The disaggregated data clearly show the inequality of service coverage among subgroups of the population. Analysis of effective coverage of malaria interventions indicates the insufficient quality of current interventions. None of households faced catastrophic impact due to payment for malaria care in Nepal. However, the costs of hospital-based care of malaria were not captured in this analysis. The paper provides the current status of UHC for malaria interventions and reveals system bottlenecks on which policy-makers and stakeholders should focus to improve Nepal’s malaria control strategy. It concludes that financial coverage of the malaria intervention is at an acceptable level; however, service coverage needs to be improved. Department of Economics, Tribhuvan University, Nepal Address for correspondence: Dr Shiva Raj Adhikari, Associate Professor of Economics, Department of Economics, Patan Multiple Campus, Tribhuvan University, Lalitpur, Nepal Email:
[email protected] Key words: universal health coverage, malaria, Nepal, health-systems strengthening Introduction There are considerable debates on how to assess whether a country has achieved universal health coverage (UHC).1,2 There is no straightforward or defined way to achieve UHC; many paths towards UHC are found in the literature and no particular path to reach UHC is endorsed.3,4 There is no doubt, however, that UHC is desirable because it makes the current health achievements sustainable. It also improves health outcomes through greater access to health services and provides financial protection against the cost associated with illness. UHC is a means to achieving better health status and to sustaining economic and social development. It is associated with better health, equity and financial protection.3 Achieving UHC is a long journey and requires a huge investment to design health systems that allow universality in health care. A movement for UHC is now in progress after being endorsed by the World Health Assembly through a resolution in 2005. UHC is being considered as the umbrella health goal in the post2015 development agenda. In December 2012, the movement prompted the United Nations General Assembly to call on governments to “urgently and significantly scale-up efforts to accelerate the transition towards universal access to affordable and quality health-care services.” Universal indicates equality and for everyone to have the opportunity. Coverage may be the outcomes of the intervention. UHC means that all people can use health services, while being protected against financial hardship associated with paying for them.3 Nepal has made remarkable achievements in health outcomes and poverty reduction over the past two decades. International development partners are providing technical and financial support to work on elements and issues related to UHC; WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 103 Adhikari: Universal health coverage and malaria in Nepal however, designing the path of UHC is not straightforward and national average data hide the inequality in progress at the local level. In this situation, more evidence is needed at local level to find ways to improve the coverage of existing interventions and to design a health-care financing system.5 Building evidence in support of UHC is more important than measuring the relative achievement of UHC. In addition, we need to know how to increase access, coverage, and utilization of quality services, and how to address obstacles that hinder success of interventions. Specifically, this paper aims to answer two questions from a UHC perspective. (1) What are the important elements of UHC at the local level? (2) How we can measure UHC, particularly related to tropical diseases using the example of malaria? The analysis aims at assessing the effective coverage of malaria interventions and the catastrophic and impoverishing impact from the use of these interventions in Nepal by utilizing the data from health information systems and national representative household surveys. This paper contributes to the aforementioned literature with discussion of how to measure UHC by utilizing the locally available data related to tropical diseases. Tropical diseases, such as malaria in Nepal, are linked to progress towards the Millennium Development Goals (MDGs). In Nepal, we have made good progress in terms of national averages; however, there may be inequalities and disparities among population groups. Measuring UHC focusing on tropical diseases highlights the progress made towards elimination of diseases and exhibits health-system bottlenecks in achieving the goal of elimination of diseases. The World malaria report 2013 indicated such possible gaps; for example, worldwide, between 2000 and 2012, estimated malaria mortality rates decreased by 45% in all age groups and by 51% among children under 5 years of age; however, millions of people at risk of malaria still do not have the access to interventions such as an insecticide-treated bednets, indoor residual spraying (IRS), diagnostic testing and artemisinin-based combination therapies.6 The concept of UHC represents both improvements in health outcomes and protection of people from poverty induced by health-care costs. Progress against malaria provides evidence of the tangible benefits of population-wide access to life-saving interventions. Analysis of financing strategies for tropical-disease care is needed in order to know the impact of health-care cost on household economies. METHODS AND MATERIALS Several studies have suggested that there is a lack of consideration of the health-system context in interventions for tropical-disease control since factors of health systems can constrain the success of programmes such as tuberculosis control and malaria control.7–9 A comprehensive and more integrated assessment of health-system functioning requires measurement of UHC for disease-specific interventions. It is important for the country to know the relative status of UHC. For example, the Nepal health sector implementation plan 2010–2015 has set an objective to improve the health system to achieve universal coverage of essential health services.10 The Sixty-fourth World Health Assembly Resolution WHA64.17 on malaria adopted in May 2011 focuses on developing strategic and operational plans for achieving and maintaining universal coverage of malaria interventions. As a Member State, Nepal has a strategic vision of a “malaria-free Nepal by 2026”; however, situation analysis and programme evaluation were primarily based on epidemiological data. Analysis of the situation of malaria intervention from a health-system approach is a major missing element despite the importance of better understanding the sustainability of programmes and the current status of UHC for malaria interventions in Nepal. 104 Conceptual framework This paper focuses on the elements of UHC as outlined by the World Health Report 2010: providing all people with access to needed health services of sufficient quality to be effective and ensuring that the use of these services does not expose the user to financial hardship.3 The Report provided a threedimensional conceptual framework for UHC – breadth, depth, and height of coverage – to demonstrate population coverage, service coverage and financial coverage. In this context, breadth is defined as the proportion of the population covered across various population subgroups, which highlights equity in coverage across consumption quintile groups, gender, age, and place of residence among others. The service coverage dimension captures the character of services covered and need of range of services. The financial coverage dimension ensures that people do not suffer financial hardship linked to paying for these services at the time they need them. Although the conceptual framework is clear, operationalizing measurable indicators for tracking a country’s level of coverage is not straightforward; for example, what are the indicators for service coverage or financial coverage? Several studies have suggested approaches to measure coverage: for example, the Piot–Fransen model for sexually transmitted infections;11 the Tanahashi model for health services;12 and the model for environment and access to health care.13After rigorous review of various concepts based on the available literature in order to measure service coverage, we concluded that the concept developed by Tanahashi may be a better fit for measuring the elements of UHC. There are numbers of reasons behind reaching this conclusion, for example: (a) the model focused on effectiveness of coverage as an output indicator; (b) the model allows us to assess potential capacity of a health system and the utilization of that capacity; (c) it allows assessment of the capacity of the health system to deliver the full effect of interventions and quality of services; (d) some organizations such as UNICEF and The World Bank have used this concept to show health-system bottlenecks in marginal budgeting bottleneck analysis or investment cases; (e) it can be applied to national or decentralized health systems; (f) it is easy to apply to scaled-up health care. Coverage can be defined as the proportion of the population who receive an intervention among those who need it. Coverage is influenced by supply (provision of services) and demand WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) rapid malaria diagnosis and artemisinin-based combination treatment. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 105 . Coverage is measured as the ratio of services in relation to the target population. Choices of tracer intervention and service delivery modes are primarily determined by the availability of indicators.Quality/impact People who receive effective care Continuous coverage . They show that almost 30% of people with acute illness did not consult any health-care providers. rural/urban residence. human resources for functioning of the health system. continued utilization. no difference is found between rural–urban categories. Malaria diagnosis and treatment are provided free of cost at public health facilities.Adhikari: Universal health coverage and malaria in Nepal by people in need of services. however. and effective coverage level. age group and consumption quintile. The paper uses financial coverage indicators of catastrophic payments and impoverishment that reflect the concept of hardship to utilize malaria interventions. This analysis used indicators of financial coverage as suggested by the literature to measure the capacity of current financial coverage to provide protection from financial risk due to malaria illness. This analysis disaggregated the types of illness by gender. analysis of population coverage in relation to other types of illness may be interesting because it gives some idea about the burden of malaria relative to other illnesses. The top three coverage indicators are related to the demand perspective and the remaining three coverage indicators are the supply perspective.Physical access of services People who can use services Availability Coverage . The recent microstratification based on village development committees (VDCs) suggested that only 52% of the population is at risk.Essential commodities and equipment People for whom service is available Target Population Figure 1: Tanahashi model dimensions of service access and coverage. Health-system goals are not only improving health due to malaria interventions but also protecting people from the financial consequences of malaria. Therefore. long-lasting insecticide-treated nets (LLIN) stocks. Availability of critical health-system inputs. Initial utilization describes preconditions for clients such as availablity of at least any type of bednets or the first contact with services to continue the utilization of services. The private sector uses a variety of rapid diagnostic tests including antibody-based tests and treatment with artemisinin monotherapy as well as other forms of malaria combination treatment.15 The dimensions of access and coverage of services that are derived from the Tanahashi model are shown in Figure 1. This is followed by inequality in coverage in development regions. Effective coverage is a critical indicator that measures health-system performance and quality of care. The highest inequality was found between different age groups. A tracer intervention is representative of other similar indicators within the service delivery mode. Malaria care may be different from other health care. malaria and other health services are provided under the same roof by health providers. however. with the support of external development partners has executed malaria control interventions: IRS. such as drugs. acceptability.Continuous coverage People who use the services Target Population who don't have continuous coverage Initial utilization . The Government of Nepal. development region.16 Data from the NLSS 2010– 2011 also indicate the percentage of health consultations for acute illnesses by status and practitioner type across various population subgroups. There may be financial consequences of out-of pocketpayments (OOP) for malaria care on households. Data from the NLSS 2010–2011 indicating the percentage distribution of acute illness by type show that the burden of malaria illness is around 1%. Consultations of malaria care are conditional on need or illness. RESULTS Population coverage { Effective Coverage . and quality of health services on utilization and coverage of malaria services among vulnerable populations.Proportion of service capacity used People who will to use services Accessibility Coverage . Malaria is a focal disease in Nepal.Human resources of correct skills mix People for whom service is available Availability Coverage . Table 2 shows the calculated inequalities within population subgroups. and accessibility of malaria interventions to clients are the important elements while assessing the service coverage. initial utilization. Indicators of UHC and sources of data The indicators in Table 1 were used to measure UHC for malaria interventions.14. To assess financial coverage requires total expenditures from different sources on malaria interventions. accessibility. geographical accessibility. however the Nepal Living Standard Survey (NLSS) 2010–2011 suggested that people had paid some amount of money for malaria care. The Tanahashi health-servicedelivery framework has been applied to evaluate the effect of the availability. Continuous utilization indicates adequate coverage such as percentage of households having at least one LLIN. It is an impact indicator based on given interventions such as percentage of children younger than 5 years sleeping under a LLIN the previous night. the services do not cover almost 30% of the population for some reason. indicating that in aggregate. LLIN. Tracer interventions that represent the service coverage are selected only if data are available for each of its six coverage indicators: availability of commodities and human resources. however.16 There is an almost 10 percentage point difference between rural and urban in adequacy of health services.2 and 3 above Indicators of Financial coverage Out-of-pocket payment for malaria care and distribution by consumption quintile Catastrophic payment and impoverishment impact Data sources and analysis NLSS 2010– 201116 Methods used as suggested in O’Donnell (2008). where there is no microscopy facility. 106 Diagnosis and treatment A microscopy facility is available in available at the district hospital. MOHP (2012). These results suggest that minimum population coverage in terms of just and more than adequate services was 67%. Malaria interventions can be broadly categorized into two groups – curative and preventive –although the roles of promotion and rehabilitation services are significant in providing health outcomes.16 MOHP (2010). Antimalarial drugs are provided free of charge from all the public sector health facilities. primary health care centre (PHCC) and some of the health posts (HPs) in endemic districts. the aim is to ensure prompt and effective treatment of malaria.26 Adhikari et al. only 68% of the poorest quintile people perceived services to be “just adequate”. In the NLSS 2010– 2011.4 MOHP (2010). residence. (2006)6 Total malaria expenditure Estimated using data from NLSS 2010–201116 and various other sources MOHP = Ministry of Health and Population Self-reported adequacy of health services can be used as an indicator for population coverage in UHC.18 In malaria endemic areas.18 Mehata et al (2012). treatment of severe malaria with antimalarials as per national guidelines is 66% although 92% of people show willingness to use diagnosis and treatment services. Effective coverage of a malaria intervention indicates the quality of the intervention. respondents were asked about adequacy of health-care services (which included malaria care). Service coverage The service coverage dimension of UHC for malaria interventions includes availability of services.23 MOHP (2012). shown in Table 3. Antimalarial drugs are provided free of charge through the female community health volunteer (FCHV) network in high-risk areas according to national treatment guidelines.17 WHO (2011)20 Composite effective coverage index From 1.16 MOHP (2010). 2010–20111 2 Gender. (2009).17 WHO (2011)5 3 Service coverage by population subgroups Consulted any type of health providers and not consulted of services after illness. The indicators shown in the figures WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . Availability and accessibility of malaria interventions are the preconditions for willingness to use and utilization of these interventions. MOHP (2011)23 Data sources and analysis 1 Population coverage measures service and financial coverage across population subgroups NLSS data (nationally representative). for example. Figure 2 shows coverage of diagnosis and treatment of malaria. highlight that 90% of the richest quintile experienced “just adequate” health services. The results. while rapid diagnostic tests are available in HPs and sub-health post (SHPs) where a microscopy facility is not available. (2006)21 Methods used Concentration index (who suffer as suggested from catastrophic in O’Donnell (2008) and van payment) Doorslaer et al. consumption quintile and age groups Category of illness: malaria and others Effective coverage of LLIN intervention at the targeted malaria risk areas and malaria risk areas MOHP (2011). For diagnosis and treatment interventions. rapid diagnostic tests are made available for the diagnosis.Adhikari: Universal health coverage and malaria in Nepal Table 1: Indicators and data sources Indicators of population coverage Data sources and analysis Indicators of service coverage Effective coverage of diagnosis and treatment intervention NLSS 2010– 2011.27 and van Doorslaer et al. utilization of services and quality of services that are captured by the facilitybased as well as household survey data. An assessment of service coverage is based on diagnosis and treatment and prevention of malaria. percentage of not consulted is the proxy indicator of not covered Effective coverage of IRS at the targeted risk areas NLSS 2010– 2011. 7 100 Fourth 69.4 30.7 20.0 1.4 30.6 100 Poorest 71.6 1.7 100 Age groups Consumption quintile Rural/ Urban Development regions Gender Population sub-groups Nepal Western 75.3 100 60+ years 61.7 32.1 1.5 82.7 77.5 100 Female 68.7 0.36 1.0 100 46-59 years 63.3 100 6-14 years 69. Health consultations for acute illnesses across population subgroups16 Percentage of service consultation Consulted any types of health providers Not consulted Total Male 70.4 2.0 0.2 87.0 29.3 31.0 Urban Ratio of highest and lowest value 1.1 10.6 100 Table 3: Self-reported adequacy of health services16 Population sub-groups Consumption Urban/ Development quintile Rural regions Inequality Eastern Central Western Mid-west Far west Less than adequate 16.5 30.4 1.92 82.3 24.3 100 Urban 69.1 22.2 1.7 0.7 1.9 1.5 100 Poorest Second Third Fourth Richest 30.8 100 0-5 years 79.2 83.3 100 15-44 years 68.00 1.4 68.9 17.6 100 Third 68.07 1.8 75.4 100 Richest 69.6 32.6 0.7 36.9 100 Second 69.7 30.2 30.9 100 Total 69.7 0.5 0.7 27.3 0.10 1.2 24.1 28.3 33.1 38.4 100 Central 66.5 0.1 0.2 More than adequate 0.2 100 Rural 20.2 73.5 31.6 30.8 0.6 100 100 100 100 100 107 .5 100 Eastern 67.8 80 68.4 0.7 100 100 100 100 100 Just adequate WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) Not applicable Total 0.0 32.7 100 Mid-western 71.2 7.6 2.9 66.8 0.4 30.4 100 Rural 69.Adhikari: Universal health coverage and malaria in Nepal Table 2.6 30.4 2.0 100 Far western 72.3 90.4 12.4 15.5 29. however. A total population of 985 636 (3. in the endemic districts. as shown in Figure 3. more than 80% people are agreeable to use an LLIN. only 76% people utilized the LLIN.52%) live in low-risk VDCs. On the other hand. The efficacy of IRS is about 12 weeks. two rounds of IRS campaigns are conducted in a year in villages at risk. A total population of 14 139 920 (52. Data availability and choice of appropriate tracer intervention are critical issues while analysing the depth of service coverage.18 Without improving supply-side indicators such as availability of essential commodities and drugs and human resources. Some of the VDCs achieved more than 90% coverage. at the same time. Different processes should be followed in the different services delivery mode. the results from the demand side suggest that there are some problems with LLINs reaching the household level or problems in LLIN distribution. For example. it indicates that 92% clients are willing to use services but not why the percentage of treatment with antimalarials (both severe and complication) as per national guidelines is lower by at least 20%.20 but such a problem is indicated by the 82% available human resource with correct skill mix at the facility. The major problems. such as facility-based or community-based. and (b) determinants of system bottlenecks of the intervention. As mentioned previously.36%) came under the no-risk category. LLINs are distributed according to the existing LLIN distribution guidelines. i. and 9378 735 (34. however.05%) live in norisk VDCs. the second round IRS is crucial.79%) live in moderate-risk VDCs. and accessibility of malaria care. out of laboratory confirmed cases of malaria only 92% of clients received treatment indicating the gap in service coverage.22 % of patient treatment provided out of laboratory confirmed cases of Malaria 92 % Households having access PHCCs and hospitals within one hour distance 54 % of filled posts at PHCCs and district hospitals by doctors and staff nurses 82 % of in district facilities have no stock outs of tracer drugs/commodities for more than a month 77 0 10 20 30 40 50 60 70 80 90 100 Per cent Figure 2: Coverage of diagnosis and treatment of malaria provide at least two views: (a) the situation of availability or utilization of interventions. 2660 692 (9. Figure 2 shows the problems in the supply side. The recent national household survey shows that effective coverage in the endemic districts is only 10%. irrational use of rapid diagnostic tests and malaria microscopy against national protocols. The literature suggest that IRS coverage is very poor and effective coverage is found to be zero because the second round of spraying was not conducted for some reasons in 2009. The Annual Report of the Department of Health Services 2010–2011 also indicated problems or constraints in the supply side such as irregular and inadequate supplies of antimalarial drugs.18 LLINs are distributed through a campaign with the strategy of one third target VDCs per year in each district so as to cover the entire high-risk VDCs by the end of the third year. a field survey report suggested 80% coverage with at least one LLIN in the targeted intervention areas. Two rounds of routine IRS are carried out annually in each high-risk VDC unless LLIN population coverage in that VDC exceeds 80%.62% of the 108 The Ministry of Health and Population (MOHP) with the support of external development partners has implemented a malaria control programme including IRS and LLIN. Preventive intervention A recent microstratification report on malaria risk in Nepal demonstrated that 54 VDCs came under the high-risk category. 201 VDCs came under the moderate-risk category. LLIN and IRS are complementary interventions. it means that sometimes two rounds of the IRS campaign do not happen on time or do not cover all households of that the first round is also covered in the second round.e. Reported data used different denominators such as targeted population or total population. are in the supply side such as lack of equipment or commodities. the coverage is very low. increasing the effective coverage (or impact indicator) such as percentage of severe malaria treatment may not be possible. Figure 2. the proportion of children younger than 5 years who children slept under an LLIN the previous night is only 61%. such as the huge gap between clinically suspected malaria and laboratory confirmed cases. however. however. one LLIN per two persons in a house. The first round is undertaken during May–June and the second round in August–September. the aim is to increase the coverage of LLINs and to reduce IRS. 999 came under the low-risk category and 2718 (68. Survey-based data are more reliable than reported data.Coverage indicators Adhikari: Universal health coverage and malaria in Nepal % of severe malaria treated with antimalarials as per national guidelines 66 % of confirmed cases of uncomplicated malaria treated with antimalarials as per national guidelines 70 population) live in high-risk VDCs. and lack of coordination between the microscopic networks and collection centres. Different sources report different coverage of LLINs. however. coverage indicators do not show satisfactory results. to make IRS more effective.17 Effective coverage. therefore.20 In other words. lack of orientation on the malaria programme for all health workers. as indicated by the results shown in Figure 5.20 This does not mean that the second round IRS campaign is in the guideline but not in the practice. LLIN coverage in targeted areas is found satisfactory. does not provide a comprehensive picture with regard to diagnosis and treatment of malaria. Willingness to use IRS is also less than willingness to use LLINs. survey-based data are not frequently available. Figure 2 indicates the situation of coverage of diagnosis and treatment of malaria. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . however. while providing diagnosis and treatment services. From the point of view of UHC.19 The demandside barriers in use of LLINs in endemic districts are shown in Figure 4. The effective coverage indicator indicates that the behaviour change communication strategy is not very effective. This analysis used the composite coverage index (CCI) as suggested Boerma et al. The data suggest that OOP including for the private sector was 5% of total expenditure on malaria. demand-driven activities exert sufficient pressure to improve supply-side efficiency. national representative survey data suggest that people have paid some amount of money to different types of providers such as public or private providers. Information can be used to make financial projections of a country’s health-system requirements and compare their own experiences with the past or with those of other countries. Nepal does not have an insurance system and public facilities provide the services at free of cost or a heavily subsidized price. Nepal does not yet produce national disease accounts. In Nepal. 10 % of households in endemic districts with at least one LLIN 15 % of households in endemic districts with at least one any type of bed net 56 % households living near distribution point or reached by annual campaigns 100 Financial coverage % active Female Community Health Volunteer (FCHVs) at the community 100 Disease account % of receiving LLIN through annual campaign as per national guidelines 100 20 0 40 60 80 100 120 Per cent Figure 4: LLIN coverage in endemic districts Coverage indicators 10 20 30 40 50 60 70 80 90 100 Per cent Per cent % of households with effective coverage of IRS 0 % of households IRS second round sprayed at the same risk VDCs as per national guidelines 0 % of households IRS first round sprayed at the risk VDCs as per national guidelines 17 % households having access Health Post/Sub-health Post within one hour distance 83 % of filled posts at PHCCs and district hospitals by doctors and staff nurses 82 % of in district facilities have no stock outs of tracer drugs/commodities for more than a month 77 0 10 20 30 40 50 60 70 80 90 Per cent Figure 5: IRS coverage in village development committees National health accounts provide evidence to monitor trends in health spending for all sectors – public and private – different health-care activities. diseases. malaria preventive. The remaining 95% is jointly covered by the Government of Nepal and external development partners. however. The data on public expenditure24 and number of malaria cases and OOP for malaria from the survey data and estimation methods as suggested by the 2011 OECD report25 were used to estimate the total expenditure on malaria. Survey data suggest that average OOP (drug and consultation WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 109 .Adhikari: Universal health coverage and malaria in Nepal % of under five children in the targeted intervention areas slept under LLIN in the previous night 61 76 % of at least one LLIN in the targeted intervention areas % of households used the services 80 Coverage indicators Coverage indicators % of people living in the targeted intervention areas slept under the LLIN in the previous night 100 % active Female Community Health Volunteer (FCHVs) at the community 100 % of filled posts at the facility % of receiving LLIN through annual campaign as per national guidelines 100 % of availability of drugs/essential commodities/equipment 20 40 60 80 100 40 % of households willing to use service % households living near distribution point or reached by annual campaigns 0 34 % of households received effective care 61 % households having access health facility 84 91 88 0 120 Figure 3: LLIN coverage in the targeted areas % of children under five in endemic districts who slept under a LLIN the previous night Coverage indicators Figure 6: Composite coverage index On occasion. population groups and regions in a country. for some years. With providing equal weight to all tracer interventions. diagnostic and curative services are free of charge in all health facilities. such as in Australia. CCI is presented in Figure 6. although the approach has been popular in other countries.23 This composite index aggregates malaria intervention coverage indicators. providers. They help in developing national strategies for effective health financing and in raising additional funds for health. Secondly. As malaria is concentrated in the certain areas of the country. The approach allows us to update the capacity of the health system to achieve effective coverage by assessing both the potential capacity and the utilization of that capacity. for example UHC can mean greater than 80% coverage of LLINs for those at risk of malaria. this means missing values for a national representative survey. however. care and treatment are changing.1. hospitalization costs were not included. The negative sign indicates malariacare payment is higher among the poor. The service coverage dimension captures issues related to availability of services and use of these services. malaria in Nepal is in pre-elimination phase. but with limited data on malaria care. There not yet global consensus on service coverage measurement. and prompt and effective treatment of malaria with an effective antimalarial within 24 hours of onset of fever. however. As mentioned previously. considering different types of health care together to assess a service package could be highly misleading due to the aggregation of many different types of health intervention with widely different efficacy. This analysis used the Tanahashi approach of six coverage indicators to measures service coverage. and a number of national and international experts and stakeholders are engaged to develop updated strategies. The NLSS 2010–2011 reported an average per person consumption NRs 34 829 for all Nepalese citizens. The average consumption for the first poorest decile group was NRs 11 093.28 The widely accepted method for measuring the incidence and intensity of the catastrophic payments is to use a threshold range from 5% to 40% of household total consumption and nonfood consumption.3 UHC can be defined for the disease-specific situation. effectiveness and duration of treatment and prevention. Average transportation cost. Financial coverage shows the financial hardship to use these services. making these virtually independent medical commodities and definition of effective coverage differs. a number of tropical diseases have their own peculiarities that require specific interventions for their control or elimination. is found to be –0. however.1043. It is challenging to get significant results with limited data sets.29 The impoverishment impact of a health-care payment is measured in terms of its poverty incidence and intensity. Population coverage focuses on population subgroups such as gender and quintile group. is far below this baseline indicator of UHC. however. OOP payments are also impoverishing when they are sufficient to dip a low-income household into poverty. Nevertheless. Analysis of disease-specific UHC has a number of advantages. in most cases an artemisinin-based combination therapy. which summarizes the information on the relationship between total cost of malaria care paid by the household and the rank of their living standards. Thirdly. and subsidized cost of care. Narrowly defined or disease perspective strategies may not be sufficient to achieve the desired outcomes. gives an estimate of the poverty impact of health care payment on incidence and intensity. The concentration index (CI).27 From the NLSS 2010–2011 data on consumption and cost of malaria care it is seen that the poorest and eighth groups shared almost an equal percentage in the distribution of total cost for malaria care while the sixth or richest groups shared the highest percentage. This finding suggests that the richest group paid relatively less of their affordable capacity for malaria care. was NRs 88 (US$ 1. the reported cost in the survey did not capture the hospital cost of malaria care. Distribution of OOP Household consumption that includes food and nonfood consumption is used as a living standard measure as suggested by O’Donnell and colleagues. the CI is not significant at the 5% level. OOP payments can be categorized as catastrophic when they exceed a given threshold. say 10% of household consumption. This paper focuses on malaria interventions where services packages are relatively clear and the interventions are globally acceptable. comprehensive benefit packages. Due to limitation of measurement of catastrophic payment.Adhikari: Universal health coverage and malaria in Nepal cost) for malaria care was Nepalese Rupees (NRs) 1624 for 2010–201126 (approximately US$ 22). it fails to capture those individuals who do not seek malaria care. These three dimensions ensure priority of population groups. The drug cost of OOP for malaria was almost 90%. no one was pushed due to malaria care payment to below the poverty line. Comparing the current coverage situation of malaria interventions with the given baseline coverage for UHC suggests that Nepal. Patterns of disease. especially on issues such as an essential versus comprehensive service package for UHC and criteria for selecting particular indicators.2). the third to sixth groups paid more. For example. which indicates the geographical access to services. The difference between the pre-payment and post-payment income poverty. We measured systematically catastrophic and impoverishment impact using national representative data. adopting a comprehensive service package creates more challenges to achieving UHC. 110 DISCUSSION AND CONCLUSION A three-dimensional framework for UHC as suggested by WHO (2010) was used to analyse the status of UHC for malaria interventions in Nepal. Similarly. while for the richest decile it was NRs 102 772. several bottlenecks are found from the results in the Nepalese health system. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . This paper adopted the methods suggested by Adhikari and colleagues to measure catastrophic payments and the impoverishment impact of OOP for malaria care. through focusing some of the indicators. Patterns of malaria illness and epidemiology can suggest movement towards preelimination. however. which strongly suggest a need to focus on health-system strengthening to shift the health production function of malaria interventions. they are focusing on a disease perspective rather than a health-system perspective. These changes demand new delivery systems. firstly. None of households faced a catastrophic impact due to payment for malaria care in the given range of thresholds in the literature.2 An essential or narrow service package within the limited fiscal space can ensure UHC. Adhikari: Universal health coverage and malaria in Nepal Financial coverage indicators show the financial burden or shocks due to payment for malaria care on households. The literature has frequently suggested that the costs of malaria care are above 10% of household income;30,31 total household costs of malaria per year have been reported to be as much as 18% of annual income in Kenya and 13% in Nigeria.32 The financial shocks or catastrophic payment discourages use of services not only for other household members but also other members of society. The results suggest that OOP for malaria in Nepal does not create financial hardship or discourage use of services. None of patients faced catastrophic payment and an impoverishment impact due to malaria care. This paper does not capture the hospital-based care of malaria. Clients have to pay more for hospital*based care although services are provided free of cost at the public hospital, for example, OOP for hospital-based treatment of kala-azar care was catastrophic for the household since it extracted 17% of annual household income and pushed more than 20% of non-poor people below the poverty line.28 Both the strengths and shortcomings of the key indicators of UHC for malaria interventions are discussed. There are some limitations in the paper while measuring service coverage and financial coverage. The paper tried to use the indicators from same year, 2010–2011; however, very limited data were available to measure the service coverage indicators that did not permit measurement of depth of service coverage based on service delivery mode, such as facility-based service delivery, community-based service delivery and populationbased service delivery. However, the paper is able to contribute to the existing literature on how to measure UHC for malaria interventions using available indicators in lowincome countries such as Nepal, and to provide the current status of UHC for malaria interventions and to reveal system bottlenecks on which policy-makers and stakeholders should focus to improve the malaria control strategy of Nepal. REFERENCES 1. 2. 3. 4. 5. 6. 7. Scheil-Adlung, Florence B. 2011. Beyond legal coverage: assessing the performance of social health protection. International Social Security Review. 2011 Jul-Sep; 64(3):21-38. DOI: 10.1111/j.1468246X.2011.01400.x International Labour Organization. World social security report 2010/11: providing coverage in times of crisis and beyond. Geneva: ILO, 2010. World Health Report. Health systems financing: the path to universal coverage. Geneva: WHO, 2010. Barros AJ, Ronsmans C, Axelson H, Loaiza E, Bertoldi AD, França GV, Bryc J, Boerma JT, Victora CG. 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Littrell MM, Ndhlovu JM, Hamainza MB, Hawela M, Kamuliwo M, Hamer DH, Steketee RW. Documenting malaria case management coverage in Zambia: a systems effectiveness approach. Malaria Journal. 2013 Oct 25;12(1):371. Nepal, Ministry of Health and Population. Nepal health sector support programme implementation plan 2010-2015. Kathmandu: MOPH, 2010. p. 107. Hudson CP. Community-based trials of STD treatment: repercussions for epidemiology and HIV prevention. Bulletin of the World Health Organization. 2001;79:48–58. Tanahashi T. Health service coverage and its evaluation. Bulletin of the World Health Organization. 1978;56(2):295-303. Phillips KA, Morrison KR, Andersen R, Aday LA. Understanding the context of healthcare utilization: assessing environmental and providerrelated variables in the behavioral model of utilization. Health Serv Res. 1998;33(3):571-96. Carrera C, Azrack A, Begkoyian G, Pfafmann J, Ribaira E, O’Connell T, Doughty P, Aung KM, Prieto L, Rasanathan K, Sharkey A, Chopra M, Knippenberg R. The comparative cost-effectiveness of an equityfocused approach to child survival, health, and nutrition: a modelling approach. The Lancet. 2012 Sep 13;380(9850):1341-1351. http://www. thelancet.com/journals/lancet/ article/PIIS0140-6736(12)61378-6/ fulltext - accessed 30 March 2014. O’Connell A, Sharkey A. Reaching universal health coverage through District Health System Strengthening: using a modified Tanahashi model sub-nationally to attain equitable and effective coverage. Maternal, Newborn and Child Health Working Paper December 2013. Knowledge Management and Implementation Research Unit, Health Section, Program Division. New York: UNICEF, 2013. http://www. unicef.org/health/files/DHSS_to_reach_UHC_121013.pdf - accessed 30 March 2014. Nepal, Central Bureau of Statistics. 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Am. J. Trop. Med. Hyg. 2004;71(Suppl 2):147–155. 31. 32. Onwujekwe OE, Chima R, Okonkwo PO. The economic burden of malaria illness versus that of a combination of all other illnesses: a study in five malaria holo-endemic communities. Health Policy. 2000;54:143– 159. Leighton C; Foster R. Economic impacts of malaria in Kenya and Nigeria. Bethesda, Maryland, Abt Associates, Health Financing and Sustainability Project, 1993 Nov. 98 p. (Major Applied Research Paper No. 6; USAID Contract No. DPE-5974-Z-00-9026-00). http://www. popline.org/node/335331#sthash. v2d4kuz2.dpuf – accessed 30 March 2014. How to cite this article: Adhikari SR. Towards universal health coverage: an example of malaria intervention in Nepal. WHO South-East Asia J Public Health 2014; 3(1): 103–112. Source of Support: Nil. Conflict of Interest: None declared. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) Access this article online Report from the field Website: www.searo.who.int/ publications/journals/seajph DOI: 10.4103/2224-3151.115828 Quick Response Code: The National Academy of Vectors and Vector Borne Diseases in India: two decades of progress Neena Valecha1 and M.R. Ranjit2 Director, National Institute of Malaria Research, New Delhi, India and Vice President of the National Academy of Vector Borne Diseases 2 Deputy Director, Regional Medical Research Centre, Bhubaneswa, India and Secretary General of the National Academy of Vector Borne Diseases 1 Abstract The National Academy of Vector Borne Diseases (NAVBD) was founded at Bhubaneswar in 1994, by Dr AP Dash, along with 15 like-minded scientists from all over India. NAVBD is a non-profit academic organization in India, dedicated to advancing and promoting knowledge on vectors and vector-borne diseases, and encouraging scientists and members of the academy to conduct research on vectors and vector-borne diseases. NAVBD convenes national and international seminars, symposia and workshops to exchange knowledge on recent advances in the field of vectors and vector-borne diseases and raise public awareness. Plans are under way to expand the Academy’s activities to the rest of the SouthEast Asia Region. Key words: India, National Academy of Vector Borne Diseases, vector-borne diseases, vectors Background Vectors are organisms that transmit pathogens and parasites from one infected person (or animal) to another, causing serious diseases in human populations. These diseases are commonly found in tropical and subtropical regions. Vector-borne diseases (VBDs) account for 17% of the estimated global burden of all infectious diseases.[1] Mosquito-borne diseases threaten the lives and livelihoods of millions of people worldwide.[2] Vector-borne diseases have not only adversely affected the health of the people in the region but also impeded overall socioeconomic development.[3–5] At the same time, developmental activities without adequate environmental concerns have increased the scope and scale of transmission of these diseases. VBDs such as malaria, dengue fever, chikungunya, Japanese encephalitis, kala-azar and lymphatic filariasis have emerged as serious public health problems in India. Many of these, particularly dengue and chikungunya fever, Japanese encephalitis and malaria, occur in epidemic forms, causing considerable morbidity and mortality. Dengue is spreading rapidly to newer areas, with outbreaks occurring more frequently and explosively. Over the past five decades, the incidence of dengue has increased 30-fold globally, resulting in 20 000 deaths annually.[6] Chikungunya has re-emerged in Address for correspondence: Dr Neena Valecha, National Institute of Malaria Research, Sector 8 Dwarka, New Delhi 110077, India. E-mail:
[email protected],
[email protected] India after a gap of more than three decades, affecting many states of India, such as Andhra Pradesh, Andaman and Nicobar Islands, Delhi, Gujarat, Karnataka, Kerala, Madhya Pradesh, Maharashtra, Tamil Nadu and Odisha .[7] Currently, around 3.4 billion people live at risk of malaria globally; during 2012 at least 207 million people were affected and, of these, 627 000 died as a result of malaria,[8] while India reported more than one million cases of malaria in 2012 and more than 40% of the global burden of lymphatic filariasis.[9] The National Academy of Vector Borne Diseases Considering the importance of these diseases, the National Academy of Vector Borne Diseases (NAVBD) was founded at Bhubaneswar in 1994, by Dr AP Dash, along with 15 likeminded scientists from all over India; this site was chosen in view of its strategic location in the country in relation to vectorborne diseases, as it is highly endemic for malaria, lymphatic filarisis, dengue and chikungunya. NAVBD is a non-profit academic organization in India, dedicated to: • advance and promote knowledge on vectors and VBDs; WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 113 Symposia The First International Symposium on Vectors and Vector Borne Diseases was held in November 1994 at the Regional Medical Research Centre. The academy was registered under the Society of Registration Act. The membership of the Academy has now increased to more than 300. Patiala and Udaipur. The academy has so far organized 12 international symposia. Director. Dr VP Sharma and Professor AP Dash were the founder president and secretary-general. SCB Medical College. and the medallion. are borne by Vestergaard Frandsen. and is given to a scientist who has working experience in India and has made an outstanding contribution in any field of vector-borne diseases. Director. Jabalpur. Bhubaneswar. Director. sponsored by Vestergaard Frandsen Ltd since 2008. Dr C Silvera. attended as the guest of honour. or foreign scientists. Dr Chetan Chitnis and Dr Deepak Gaur. The award includes a cash prize of INR 100 000. then Union Minister of Health and Family Welfare.: The National Academy of Vectors and Vector Borne Diseases in India • encourage scientists and members of the academy doing research on vectors and vector-borne diseases. Indian nationals working abroad. including Goa. Since 2008. Director. Gwalior. which consists of a president. vice. 114 In addition.Valecha et al. New Delhi respectively. provided their work has made a significant contribution to the understanding and control of vector-borne disease in India. All India Institute of Medical Sciences. Madurai. and the medallion. These symposia provided excellent opportunities to reflect on the recent advances made in research on vector-borne diseases. Dr Shovna Sharma. Gwalior. National Institute of Virology. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . respectively. vector bionomics and control. So far. both Directors of the National Institute of Malaria Research. and Dr MM Parida. Regional Adviser.presidents. New Delhi. the recipients of these awards include Dr VS Chauhan. for excellence in research on personal protection from mosquitoes. the academy has made steady progress and further symposia were organized in different cities in India. Tata Institute of Fundamental Research. Secretary for Health Research and Director-General of ICMR. Dr P Jambulingam. • Godrej Sara Lee Award: Godrej Sara Lee Ltd declared this award for 2009. since 2008 and is to be given to a scientist who has working experience in India and has made outstanding contributions in the field of biological control of vectors. The academy is governed by an elected executive committee. the last one being in Udaipur. at each symposium. preferably in the aspect of vector/disease management. Jabalpur. The World Health Organization (WHO) Regional Office for South-East Asia has supported the NAVBD symposia since 2008. Vector Control Research Centre. Pune. At least 150 scientists of repute from India and abroad participated and engaged in discussion on all aspects of the prevalent vector-borne diseases. The cost of travel and other expenses of the recipient. In exceptional cases. Government of India (1880). scientists of the International Centre for Genetic Engineering and Biotechnology. Cuttack. Dr Neeru Singh. senior scientist. • Bayer Environmental Science Award: this cash award for INR 100 000 has been sponsored by Bayer India Ltd since 2008. may also be considered for the award. WHO South-East Asia Regional Office. Mumbai. Professor of Medicine. Defence Research and Development Establishment. the academy has instituted various awards for outstanding contributions on: environmental management of vectorborne diseases. the academy has also encouraged young scientists by giving six Best Poster Presentation Awards. which was to be presented during the tenth annual international/national symposium organized by the academy. inaugurated the symposium. The symposium was organized with support from ICMR and the WHO regional office. Dr YD Sharma. Dr BK Das. secretarygeneral and other members. Dr Sarla K Subbarao and Dr NeenaValecha. Professor and Head of Biotechnology. and is given to active researchers who are nationals of any member country of the South Asian Association for Regional Cooperation and have contributed significantly in the fields of understanding the mechanism of insecticide resistance. and clinical aspects of vector-borne diseases. Rajasthan. Pondicherry. which was inaugurated by Dr VM Katoch. Since then. and create awareness of vectors and vector-borne diseases among the general public. Government of India. Regional Medical Research Centre for Tribals. Two scientists from Sri Lanka have also been honoured. molecular biological aspects of vector-borne diseases. Awards and recognition To encourage scientists working on vector-borne diseases. Dr DT Mourya. while Dr Leonard I Ortega. the academy makes the following awards. New Delhi. on a competitive basis: • Vestergaard Frandsen Award for Vector Control: this is a cash award of INR (Indian rupees) 200 000 . and assist them whenever possible. The recommendations of the symposium were forwarded to the Government of India and Indian Council of Medical Research (ICMR). • hold national and international seminars/symposia/ workshops to exchange knowledge on recent advances in the field of vectors and vector-borne diseases. They also helped in scaling-up of elimination/prevention of vector-borne diseases to alleviate suffering and bring about social growth and development. are borne by Bayer Environmental Science. with further support from industries as a part of public– private partnership. • Biotech International Award: this cash award of INR 100 000 is sponsored by Biotech International Ltd. The cost of travel and other expenses of the recipient. the children feel greatly concerned and angry. StansfieldSk. 2014. Zerhouni E. Publications The abstracts of the papers presented at all international and national symposia have been published. pii: S0001-706X(13)00328-8. Science. safely store containers and sleep under a mosquito net. made a cartoon educational film for children. Calcutta School of Tropical Medicine. Kafatos FC. and will soon be dubbed in Hindi and various regional Indian languages. The Asiatic Society. who is friendly with the children. 2005 Mar. Bhatia R. 6.4(10):e847. Other activities Besides international and national conferences. children sing a song to conclude the film. http://www. Kalra NL. This animated film highlights how mosquitoes cause serious diseases. doctors. In addition. The Asiatic Society. mosquito-proof overhead tanks.accessed 6 March 2014. It is currently available in English. Pro-Vice Chancellor. and consider future courses of action. ecology and biodiversity of the Himalayan region. On the advice of a doctor. The academy so far has published eight volumes of News Letters. Medical Secretary. Geneva. They then take a pledge to destroy mosquitoes with the help of friends and parents.int/campaigns/world-health-day/2014/ vector-borne-diseases/en/ . Acta Trop. the academy has published two proceedings of the International Symposia on Vectors And Vector-Borne Diseases held in 1995 and 1997.3(3):262-8. where they are able to listen to mosquitoes talking to each other and come to know about their nefarious designs. 36:1– 13. 5. Kolkata was the chief guest. At least 110 scientists. Bheecarry A. former Director of 3. doctors and postgraduate students attended and presented papers. 2010 Oct 26.: The National Academy of Vectors and Vector Borne Diseases in India Awareness campaign In the field of raising awareness. Vice Chancellor of the Patiala University inaugurated the conference. Varmus H. which is available on YouTube. and an integrated model of vermin biotechnology and Spirulina biotechnology as an effective tool for environmental conservation. Bossin HC. Dash AP. President of the Asiatic Society. At least 150 scientists. Collins FH. a day-long national seminar on “Challenges of mosquito borne diseases in Indian perspectives” was organized by NAVBD at Asutosh College (University of Calcutta). WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 115 . Grand challenges in global health.302(5644):398-9. Hearing this. bio-ecology of malaria vectors in India. in collaboration with the Punjabi University Environment Society. as well as other important persons working/interested in the field of vectors and vector-borne diseases. 2013 Nov 16. researchers and academicians attended and discussed topics such as health issues related to genetically modified food and non-food crops. research scholars. and postgraduate students attended and presented papers. delivered the keynote address. References 1. Professor Biswanath Banerjee. Kolkata. Kolkata. inaugurated the seminar. which have been circulated to all life members. Klausner R. Professor Dhrubojyoti Chattopadhyay. Future plans It is planned to expand the academy to a broader sphere in the South-East Asia Region in the near future. Dr Jaspal Singh. Neglected funding for vector-borne diseases: a near miss this time. Kolkata. Acharva T. 2012. On 6 February 2010. Lees RS. delivered the keynote address. at the Asiatic Society. After conquering the mosquitoes. and then spread the knowledge by involving their friends in tackling them. it is proposed to organize a global meeting on vector-borne diseases in 2015. “Bholu” the monkey. a member of NAVBD’s executive committee. for students and young faculty members of universities and postgraduate colleges. in collaboration with the Foundation of Academic Excellence and Access (FAEA). Information about Vector Borne Diseases. Professor AK Hati. Children hear mosquitoes and malaria parasites boasting about their powers in bringing about sickness and destruction of many human civilizations in the past. 4. Around 120 postgraduate students. the academy organizes seminars and conferences in different academic institutions. a day-long national seminar on “Climate change and vector borne diseases” was organized by NAVBD. LaBeaud AD. Dr Ashwani Kumar. called Mosquito control: I can do it. bestows upon them magical powers to enter the world of mosquitoes. Knols B. Dengue in South-East Asia: an appraisal of case management and vector control. in collaboration with Professor D Deobagkar. Bellini R. in collaboration with The Asiatic Society. World Health Organization. a national conference on “Environment degradation and its impact on mankind” was organized by NAVBD at Punjabi University. the President of the academy. They mosquito-proof their homes by screening windows and doors. on 13 February 2009. Public health. Daar AS. Patiala. Arthropod-borne diseases: vector control in the genomics era. Hill CA. research scholars. and the havoc they continue to create even today in the world. both a girl and her mother take upon themselves to first acquire knowledge about mosquitoes and the diseases transmitted by them. Bearing in mind the World Health Day 2014 theme of vector-borne diseases. 2. which will address recent advances in vector-borne diseases research and control. et al. The film lasts 20 minutes and is ideal to show in the classroom. University of Calcutta and Biological Science Secretary. Professor Subir Kumar Dutta. introduce fish in wells and ponds. Singer PA. a possible disaster the next time. Nat Rev Microbiol. As a part of this activity.Valecha et al. and the children start taking various actions to eliminate mosquito breeding. Patiala. PLoS Negl Trop Dis.who. Dengue Bulletin. Benedict MQ. On 19 and 20 November 2010. Review: Improving our knowledge of male mosquito biology in relation to genetic control programmes. Aksoy S. 2003 Oct 17. National Vector Borne Disease Control Programme (NVBDCP). World malaria report 2013. World Health Organization.nvbdcp.who. Regional Office for South-East Asia.gov.R.: The National Academy of Vectors and Vector Borne Diseases in India 7. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) .accessed 6 March 2014.in/ accessed 6 March 2014. Source of Support: Nil.Valecha et al. www. Magnitude of disease: malaria & filariasis. WHO South-East Asia J Public Health 2014. Geneva: WHO. 8.int/entity/emerging_diseases . Conflict of Interest: None declared. New Delhi. searo. The National Academy of Vectors and Vector Borne Diseases in India: two decades of progress. 9. 2014. Surveillance and outbreak alert: Chikugunya. 3(1): 113–116. 116 World Health Organization. 2014. How to cite this article: Neena Valecha N & Ranjit M. www. WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 117 . The original paper is reproduced by permission of the British Medical Journal. In this Special Issue on Vector-borne Diseases we reproduce the article by Sir Ronald Ross published in 1897: “On some peculiar pigmented cells found in two mosquitos fed on malarial blood” (Br Med J 1897.115828 Quick Response Code: This section looks at some ground-breaking contributions to public health and reproduces them in their original form.2:1786).searo.int/ publications/journals/seajph DOI: 10.4103/2224-3151.Public health classic Access this article online Website: www.who. Ross: On some peculiar pigmented cells found in two mosquitos fed on malarial blood 118 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . Ross: On some peculiar pigmented cells found in two mosquitos fed on malarial blood WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) 119 . Ross: On some peculiar pigmented cells found in two mosquitos fed on malarial blood 120 WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . there are pockets within countries that continue to be challenging. Operational research and generating evidence on effectiveness of interventions is needed for better policy guidance. dengue has become the fastest growing with a 30-fold increase in disease incidence over the past 50 years.int/publications/journals/seajph 121 .Recent WHO Publications Recent WHO Publications Aide-mémoires – Dengue. More research and better data are needed to understand the trends in endemic areas.searo.int/entity/world_health_day/2014/en/ Vector-borne diseases account for 17% of the estimated global burden of all infectious diseases. New Delhi ISBN: 9789381559017 Available from: http://www. Access this article online Quick Response Code: WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) Website: www.int/entity/world_health_day/2014/en/ This series of ‘aide-mémoires’ on aims to provide a quick overview and checklist for policy-makers and programme managers on specific vector-borne diseases. 2009–2013 World Health Organization Regional Office for South-East Asia. Kala-azar.who. Malaria World Health Organization Regional Office for South-East Asia.searo. lymphatic filariasis and kala-azar is decreasing.int/publications/journals/seajph Bibliography on Vector-borne Diseases from the South-East Asia Region. Although at a global. New Delhi ISBN: 9789290224525 Available from: http://www.searo. New tools and interventions need to be field tested and compared to overcome the challenges and to progress towards disease elimination. The prevalence of malaria.searo. the WHO South-East Asia Regional Office has compiled this published literature on vector-borne diseases in the Region from the past five years. While malaria is still the deadliest vector-borne disease. but we are being challenged by emerging trends of dengue and chikungunya. To help Member States in better understanding the available research evidence and data on vector-borne diseases in order to take informed decisions.who. regional and national level we are making good progress in controlling most of the vector-borne diseases.who. Lymphatic filariasis. Access this article online Quick Response Code: Website: www.who. information about circulating DENV strains and all other related aspects.who. in collaboration with the Western Pacific Region. All manuscripts received for publication are subjected to in-house review by professional experts and are peer-reviewed by international experts in the respective disciplines.int/entity/world_health_day/2014/DengueBulletin-2013pdf The WHO Regional Office for South-East Asia. changing epidemiological patterns. short notes. has been jointly publishing the annual Dengue Bulletin. 2013 World Health Organization Regional Office for South-East Asia.Recent WHO Publications Dengue Bulletin.searo. Volume 37. The objective of the Bulletin is to disseminate updated information on the current status of DF/DHF infection.searo. clinical management.who. book reviews and letters to the editor on DF/DHF-related subjects.int/publications/journals/seajph WHO South-East Asia Journal of Public Health | January-March 2014 | 3 (1) . The Bulletin also accepts review articles. 122 Access this article online Quick Response Code: Website: www. Proceedings of national/international meetings for information of research workers and programme managers are also published. new attempted control strategies. New Delhi IssN: 02508362 Available from: http://www.