H E A L T H

MA N A GE ME N T &
R E S E A R C H
I N S T I T U T E
HMRI MonographSeries: #1
Brief noteonDengue, DengueinAndhraPradeshand
Utilityof HMRI-IDSPLabSurveillanceDatafor epidemic
alert.
HMRI IDSP DATA
in Epidemic Alert
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Research&AnalysisDiv., HMRI
UTILITYOFHMRI-IDSPLABSURVEILLANCEDATAINDENGUEEPIDEMICALERT
Dr .Balaji Uttala
Dr. M. Pattabhi Ramayya&Dr. M. Sudhakar Babu
ABSTRACT:
Of late, theincidenceof vector bornecommunicablediseasesisontheriseandAndhraPradeshisnoexception
to this. Accurate Data on the incidenceof thevirus appears to be not adequate for the Health Personnel to
take-up timely interventions. HMRI is obtaining data on the incidence of different communicable diseases
throughLabsurveillanceunder itsIDSPproject. Anattempt ismadeinthispaper toanalysetheavailabledata
and to examine its usefulness in alerting the concerned Health Care Officials to take appropriate remedial
actionintimesoastoavoidepidemics.
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The Incidence of dengue fever is variable anddepends onthe geographical regionandthe
densityof mosquito-bornediseasesinaregion. Theworldwideincidenceisestimatedtobe
50to100millioncasesof denguefever (DF) andseveral hundredthousandcasesof dengue
hemorrhagic fever (DHF) per year. DHF is more serious and the fatality rate is about 5%.
Childrenyounger than15years comprise 90%of DHFsubjects intheworld. DHF canaffect
both adults and children. Poor surveillance systemin India makes it difficult to know the
exact incidenceof theepidemicinthecountry.
Inrecent years, Dengueis increasinglybeingreportedfromperi-urbanandrural areas, due
to expandingurbanizationand lifestyle changes. The most affectedareas are West Bengal,
Delhi, Kerala, Tamil Nadu, Gujarat, Karnataka, Maharashtra, Rajasthan, PunjabandHaryana.
The first outbreak of Dengue fever/DHF was reported fromKolkata in 1963. Gradually it
spread to other states including Andhra Pradesh. All the four serotypes of dengue are
prevalent inIndia.
Disease surveillance is an epidemiological practice by which the spread of disease is
monitored in order to establish patterns of progression. The main role of disease
surveillance is to predict, observe, and minimize the harmcaused by outbreak, epidemic,
and pandemic situations, as well as increase our knowledge as to what factors might
contributeto suchcircumstances. Akeypart of moderndiseasesurveillance is the practice
of diseasecasereporting.
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Infectious diseases reportingis a requirement placed upon health care providers by many
regional and national governments and upon national governments by the World Health
Organization. Regional and national governments typically monitor a larger set of
communicablediseasesthat canpotentiallythreatenthegeneral population.
DENGUE FEVER
Dengue fever is a viral disease, which is transmitted by the mosquitoes. People infected
with dengue virus are commonly asymptomatic or only have mild symptoms such as an
uncomplicatedfever. Others have muchmore severe illness, andinasmall proportionit is
life-threatening. Dengue hemorrhagic fever (DHF) is a more severe form of dengue
infection. It canbefatal if unrecognizedandnot properlytreatedinatimelymanner. DHFis
causedbyinfectionwiththesamevirusesthat causedenguefever.
(Myalgiasandarthralgiasseverepainthat givesit thenicknamebreak-bonefever or bone
crusher disease)
TRANSMISSION
Dengue is transmitted by Aedes mosquitoes, particularly A. aegypti and A. albopictus.
Dengue is transmitted to people by the bite of an Aedes mosquito that is infected with a
denguevirus.
The mosquito becomes infectedwithdengue virus whenit bites apersonwho has dengue
virus intheir blood. Thepersoncaneither havesymptoms of denguefever or DHF, or they
may have no symptoms. The incubation period (time between exposure and onset of
Aedesalbopictus Amosquitolarva Aedesaegypti
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symptoms) rangesfrom314days, but most oftenit is47days. Thismeansthat travelers
returningfromendemicareas areunlikelyto havedengueif fever or other symptoms start
more than 14days after arriving home. Children often experience symptoms similar to
those of the common cold and gastroenteritis (vomiting and diarrhea), but are more
susceptibletotheseverecomplications.
Dengue cannot be spreaddirectlyfrompersonto person. Dengue mayalso be transmitted
viainfectedbloodproducts(bloodtransfusions, plasma, andplatelets)
ALARMINGSIGNSINDENGUE
Minutespotsontheskinsuggestingbleedingwithintheskin
Nosebleedsandgumbleeds, hemetemesis
Abdominal painand/or passageof blacktarrystool
Refusal tofoodor drink
Abnormal behaviour or drowsiness
Difficultyinbreathingor coldhandsandfeet, reducedamount of urinebeingpassed
TREATMENT
There are no specific treatments for the dengue fever. Treatment depends on the
symptoms, and may vary fromadvice to drink plenty of fluids such as oral rehydration
solutionat homewithclosefollowup, toadmissiontohospital for carefullytitratedisotonic
intravenous fluids and/or blood transfusions. A decision for hospital admission is typically
basedonthepresenceor absenceof the"warningsigns" listedabove, andthepresenceof
pre-existinghealthconditions.
Therearecurrentlynoapprovedvaccinesfor thedenguevirus. Preventionthusdependson
control of andprotectionfromthebitesof themosquitothat transmitsit.
Misconception:
It isreportedthat, thefear of thediseasehadgrowntosuchanextent that denguepatients
were subjectingthemselves to the platelet count test without even consultingdoctors. In
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extreme cases, patients were buyingblood platelets themselves and askingthe doctors to
helpthemonlyintransfusion.
The experts say that - in most of the dengue cases there was no problemat all. The fever
would subside after six or seven days. But in a few cases it could lead to Dengue
HemorrhagicFever (DHF) or DengueShockSyndrome(DSS), twotypesof complication. Such
patients should be hospitalized and their condition closely monitored. Not all the patients
withDHFor DSScomplicationrequiredplatelet transfusion.
BURDENOFTHEDISEASE
The burden of disease from dengue is estimated to be similar to other childhood and
tropical diseases, such as tuberculosis, at 1600 disability-adjusted life years per million
populations. It is the most common viral disease transmitted by arthropods. As a tropical
diseaseit isdeemedonlysecondinimportancetomalaria. Whileonceexclusivelyatropical
diseaseit hasbecomeglobal, andisendemicinmorethan110countries. TheWorldHealth
Organizationcountsdengueasoneof sixteenneglectedtropical diseases.
Most people with dengue recover without any ongoing problems. The mortality is 15%
without treatment, and less than 1%with adequate treatment. Severe disease carries a
mortality of 26%. Dengue is believed to infect 50 to 100million people worldwide a year
with 1/2 million life-threatening infections requiring hospitalization, resulting in
approximately12,500-25,000deaths.
CONTROL
As there is no specific treatment for Dengue, the emphasis is on avoidance of mosquito
breedingconditionsinhomes, workplacesandminimizingtheman-mosquitocontact.
TheAedesmosquitoesbreedincleanwater inman-madecontainerssuchaswater coolers,
discardedtyres, disposablecups, flower vasesandother water storagecontainers.
The World Health Organization recommends an Integrated Vector Control program
consistingof fiveelements:
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(1) Advocacy, social mobilizationandlegislationtoensurethat publichealthbodiesand
communitiesarestrengthened,
(2) collaborationbetweenthehealthandother sectors(publicandprivate),
(3) anintegratedapproachtodiseasecontrol tomaximizeuseof resources,
(4) evidence-baseddecisionmakingtoensureanyinterventionsaretargetedappropriately
and
(5) capacity-buildingtoensureanadequateresponsetothelocal situation.
NATIONALVECTORBORNEDISEASECONTROLPROGRAMME[NVBDCP]
Accordingto the Report of the Joint MonitoringMission(2007), the National Vector-Borne
DiseaseControl Programme(NVBDCP) hasmadegoodprogressinachievingintegrationand
decentralizationof diseasecontrol programmesandinreducingtheburdenof vector-borne
diseases (VBDs). VBDS particularly malaria, lymphatic filariasis (LF), kala-azar, Japanese
Encephalitis (JE), dengue, and Chikungunya (CHIK) are of major public health concern in
India.
Key findings: The NVBDCP has developed a long-termaction plan and good guidelines on
casedetectionandmanagement of dengue, chikungunya(CHIK) andJE. Theprogrammehas
organizedworkshopstotraintrainers oncasemanagement andpreventionof dengueinall
endemicstates. However, it isobservedthat thereisnoclear strategyfor selectingasample
of clinicallysuspectedcasesfor laboratoryconfirmation.
Further, it is mentioned that there is little or no analysis, interpretation and use of the
surveillance data at the point of collection and at the district level. At the secondary and
tertiary care levels there are no protocols for triage and for handlinga sudden increase in
casesneedingcritical careintheevent of amajor epidemic.
TheNVBDCP activities mainlyservethe rural areas, withlittlecoverageof theurbanareas,
which carry a large burden of vector-borne viral diseases and which has an epidemic
potential. This is largely because the programme only has an advisory role and not a
mandatetoimplement measuresinthemunicipalitiesandcorporations.
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Routine entomological data are collected but there is no systematic analysis for decision
makingpurposes, nor isthereanyoversight of thereliabilityandaccuracyof data. Theskills
inmedical entomology, pesticidemanagement andapplicationmethods areinadequatefor
theneedsof amulti-diseaseprogramme.
DENGUEINANDHRAPRADESH
In Andhra Pradesh, the Dengue Incidence was almost Nil upto the year September, 2002.
Only sporadic cases were reported in Chittoor District which is neighbouring to Chennai
during the year, 2001 and 2002. The Dengue incidence is mostly Urban and Semi Urban
disease.
Dengue/DHF: Epidemiological data:
Cases Deaths
2006 197 17
2007 587 2
2008 313 2
[Source: NRHMAPStateReport 2005-2010]
HMRIsIDSPDATA
HMRI is capturing information on the spread of dengue through laboratory surveillance
under theIDSPinitiativesinceMarch, 2008. The objective of the laboratory surveillance is
to detect any unusual increase in the spread of dengue transmission. HMRI also
captures lab surveillance data on 14 communicable diseases viz.malaria, TB, Typhoid,
Hepatitis, Dengue, Leptospirosis, Measles, HIV, Chikengunya, Cholera, Poliomyletis,
Japanese encephalitis, Anthrox and Plague. About 2688 Clinical laboratories have been
registered fromboth private and public sectors. Data is captured fromthemon a regular
basisandanalysedat HMRI for anyunusual trends.
Asper theHMRI-IDSPdata, 12528theDenguepositivecaseswererecordedfromall the23
districts of AndhraPradesh. Out of these12528, 5422(43%) cases wereconfirmedthrough
RapidTest for Dengueand7106(57%) werethroughElisaTest for DengueIGM.
It isinterestingtonotethat only313denguecasesand2deathswerereportedduring2008
in AP as per the NRHM AP State Report (2005-2010). The HMRI-IDSP captured 764 cases
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fromApril 2008toDecember 2008. Eventhesecasesmaynot reflect theactual numbersas
theHMRI iscapturingonlythosecasesidentifiedpositiveinthe2700labsregistered.
DenguepositivecasesrecordedfromApr 2008toJan2011
Most of thedenguecases(5913 48%) recordedduringOctober 2008andJanuary2011have
beenreportedfromGHMC, Hyderabadfollowedby13%(1616) casesfromNelloredistrict
764
5720
5880
164
0
1000
2000
3000
4000
5000
6000
7000
fromApr -Dec08 Jan-Dec 09 Jan-Dec10 Jan-11
Total DenguePositiveCases
PositiveCasesrecordedfor Dengue_ District wise: 01-Oct-08to31-Jan-11
47.63
13.02
7.85
5.45
4.74
3.943.79
2.962.83
1.741.64
1.060.920.740.580.420.370.170.090.060.020.01
0.00
10.00
20.00
30.00
40.00
50.00
60.00
%of positivecases_ Districtswise
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and8%(974) casesfromKrishnadistrict. Theremaining31%(4025) arefromtheremaining19
districtswiththeexceptionof Medakdistrict fromwherenopositivecaseswerereported.
Denguepositivecases(Apr 2008toJan2011)- monthwise
Month-wise analysis of the HMRI-IDSP data revealed some interestingobservations in the
incidence of cases. During the period 2008-2010, in each year, there is a spurt in the
incidence of dengue positive cases during July-August and the peak is reached during
September October. The number of cases recorded in October 2009 is 60 while is 55 in
September 2010. This helps in alerting the Service providers for timely interference with
appropriateactiontocontrol thespreadof thevirus.
Thisisaclear indicationthat thedenguevirusisspreadingduringJuly October monthsof
theyear andshowingadeclinefromNovember (maybeduetomedical intervention).
The following stories from leading news papers provide evidence of the severity of the
epidemicduringSeptember November months. Bythisstage, thediseasehastransformed
to an epidemic with all its ill-effects includingloss of life. At this stage, there is not much
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Denguecasesper Day
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scopefor controllingthevirusinacommunity. Interventionscanbeeffectivelyinitiatedonly
whenthereisreliableinformationontriggeringof theepidemic.
The HMRI-IDSP dataprovides suchauthentic interms of volume, spreadandtime as it can
identify the triggering points more precisely and accurately even at district level or sub-
district level. This informationcanbe usedbythe HealthCareAdministrators inpreventing
andcontrollingtheepidemicat theinitial stages, therebycansavevaluablelives.
Somestoriesfromleadingnewspapers:
1. Timesof India, Sep1, 2010: Spurt in viral fever cases in Hyderabad
The downpour over the last one week has triggered a spurt in viral fever cases in
the twin cities. City hospitals are recording a steep rise in the number of cases in
viral fevers, pneumonia and asthma attacks, due to the dip in temperatures along
with malaria cases in considerable numbers, more so in the last 10 days.
Ref: http://timesofindia.indiatimes.com/c...#ixzz0yDe7spyi
2. DeccanChronicle, Sep10, 2010: Viral fevers claim 50 lives in one month
Viral fevers, malaria and dengue cases are unabated in different parts of Krishna
district during the past one month. At least 50 people lost their lives due to
seasonal diseases and thousands of people are suffering from seasonal diseases.
Ref: http://www.deccanchronicle.com/vijay...-one-month-415
3. Minister at Vijayawada, Sep 16,2010: 19 Dengue deaths in Andhra Pradesh
As many as 19 people have died of dengue and 24 people from other viral fevers
including malaria during the last two months in Krishna District, Animal
Husbandry Minister K Parthasarathi informed here today. Admitting at a press
conference here that viral fevers including dengue and malaria were rampant in
Krishna District and several people had died, he said 52 people were being
treated for dengue, 1977 for malaria and 1204 for diarrhoea in the district in
various hospitals. Contradicting the media reports that more than 100 people
have died of dengue in the city itself, the Minister said only 13 persons have died
in the city with dengue fever during the last two months.
Ref: http://www.newkerala.com/news2/fullnews-43816.html
4. DeccanChronicle, Sep22, 2010: Viral fever cases cross one lakh mark
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Viral fever cases crossed the one lakh mark in Krishna district this season. Due to
changes in climatic conditions, poor hygiene, consumption of contaminated water,
mosquito menace and other reasons, the seasonal diseases became rampant
across the district. Dengue cases reported in almost all mandals of the district.
Ref: http://www.deccanchronicle.com/vijay...-lakh-mark-168
5. TheHindu, Sep16, 2010: Diseases claim four lives in Prakasam
Four persons died due to vector and water-borne diseases, while 15 others were
taken ill in Prakasam district on Friday. While a woman died due to gastro-
intestinal disorder, two men died of dengue. The fourth person, who was
undergoing treatment for malaria, died before he was shifted to a hospital in
Guntur.
Ref: http://www.hindu.com/2010/10/16/stor...1653420600.htm
6. Times of India, Nov 22, 2010: 3 die of dengue in Bhadrachalam
Three persons died due to dengue outbreak in Bhadrachalam Agency in
Khammam district in the last 24 hours. While a five-year-old boy died in the
temple town on Sunday, two others died on Saturday evening.
Ref: http://timesofindia.indiatimes.com/c...#ixzz15xvWLZsk
7. TheHindu, Nov30, 2010: Spurt in fever cases in Vizianagaram
In the aftermath of rains that battered the district in the first two weeks of the
month, the number of malaria, typhoid and viral fevers increased in rural areas.
According to official figures, out of 3,17,711 blood smears tested, some 2,300
people have been confirmed malaria positive in the last one week. At district
headquarters hospital the number of fever cases has almost doubled from 1,000
between November 18 and till date.
Ref: http://www.hindu.com/2010/11/30/stor...3052820500.htm
CONCLUSION
Incidence of any disease, if monitored appropriately in time saves life. Because of
the lack of proper surveillance data, many epidemics could not be averted. Those
monitoring at the field level are able to identify isolated cases which may not
always reflect the severity or magnitude of the problem. On the other hand, the
media brings to light situation only after the epidemic at the peak. Hence, timely
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Research&AnalysisDiv., HMRI
and reliable large scale information on the incidence of dengue, if available, many
epidemics can be averted.
HMRI- IDSPlabsurveillancedataaptlyaddressesthisneedasdataisbeingcaptured
for 14 communicable diseases across the state and regularly analysed for making
alerts at appropriate times. HMRI intends to strengthen this IDSP lab surveillance
programmebyregisteringmorelaboratoriesfor enhancingthescopeof itsdatabase.