Culprit known, reasons known, yet New Delhi reels under dengue and chikungunya again

The Municipal Corporations of Delhi accepted the findings and the then health minister instructed municipal health officers that the DBCs should continue breeding surveys throughout the year rather than the eight months. However, on the ground, little was done and the finding of the research gathered dust. This year, 771 cases of dengue and 560 of chikungunya have been officially reported in the capital so far.

So why did the NIMR recommend conducting the breeding survey throughout the year? For this one needs to understand the behaviour of the Aedes mosquito. The fight against dengue and chikungunya is about controlling the spread of Aedes mosquitoes.

There is consensus among experts that eliminating these infections as a public health burden can only achieved by integrating “vector control” with vaccines. Hence it is essential to focus on larval source reduction. The population of Aedes fluctuates with rainfall and humidity and under optimal conditions, it takes just seven days to emerge as an adult mosquito. And at low temperatures, it may take several weeks for an adult to emerge. Hence, the period from June to November, when the conditions are optimum, the transmission is high and usually the period from December to May is considered as non-transmission period.

Since the period from December to May is the non-transmission period, questions arise on the what civic agencies do during this period. The NIMR study answers this crucial question. The NIMR carried out its study in 20 high dengue case reporting localities of west zone in Delhi during July 2012 to May 2014. During the study, about 7,000 houses covering approximately 35,000 population across 20 localities were surveyed in collaboration with the MCD. Before the surveys, meetings were organised with councillors, resident welfare associations, schools requesting them to permit NIMR and MCD teams to visit their premises to check their water storage containers on a regular basis. During the study, source reduction was carried out by the community and MCD.

A total of 1,408 unused containers containing water were emptied and were scrubbed to kill the attached eggs and about 185 overhead tanks having broken lids were covered with cloth. Additionally, 1 mg/l temephos granules was introduced in 1,213 containers, in accordance with WHO recommendations, for drinking water. Overhead tanks and water storage containers were identified as “key containers” of the study areas because they support breeding in both transmission (June-November) and non-transmission (December-May) seasons.

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What analysis revealed

During the transmission season, vector breeding spread from key containers to secondary containers such as cemented tanks, coolers, solid waste and mud pots, and the maximum breeding took place in solid waste. More importantly, the analysis also revealed that breeding takes place throughout the year.

But what was revelatory was that while there was not much change in the incidence of dengue cases in other localities of west zone, no case was reported from the study area due to intervention during the non-transmission season. This revealed that proper intervention in non-transmission season reduces Aedes breeding containers and subsequently breeding and dengue cases in transmission season.

Apart from the MCD accepting the findings of the study, the Indian Council of Medical Research also “appreciated” it and decided to “circulate the findings” to the National Vector Borne Disease Control Programme and other ICMR institutes working on dengue and chikungunya.

“Preventing the vector has to be the main priority. Civic reconstruction and solid waste disposal has to be ensured so that there is no clean water accumulation. If the civic authorities fail at this stage, then we have to go for fumigation. However, one has to remember that this process is not related to dengue season. The strategy is to spot the vector during the non-transmission period and eliminate it before the vector starts to spread during the peak period,” Dr Tarun Seem, Director General Health Services, Delhi government, told The Indian Express.

In this direction, for the first time, sources said the Delhi government held its coordination committee meeting with the MCDs as early February this year. It was followed by four more meetings till June. “For the first time, a coordination meeting was held in February. It was an early wake-up call for the MCDs. If the spread has to be controlled, it has to happen early in the year during the non-transmission period,” said a source.

As far as augmenting the capacity of beds and laboratory diagnostic services in the capital, review meetings began in March. A total of seven such meeting were conducted. Sources said it was decided to increase the bed strength in the capital. “An assessment was done to check the hospitals that were underutilised. It was found that three hospitals — Rajiv Gandhi super speciality hospital, Janakapuri Super speciality hospital, and Deep Chand Bandhu hospitals — were underutilised. A decision was taken to add 1,000 beds in these hospitals,” the sources added.

While the Delhi government has established 1,000 new beds in hospitals and more than 400 dedicated fever clinics in the capital, it has continued to lag behind in the Advocacy, Communication and Social Mobilisation (ACSM) programme for dengue and chikungunya control.

Take for instance the death of Nazish (38), the sister-in-law of AAP legislator Amanatullah Khan. She succumbed to dengue in the second week of August. This was the second dengue death of the season. The government summoned the medical files related to her case to ascertain the reason for her death. Sources said it came to fore that Nazish underwent an inappropriate treatment as prescribed by an AYUSH doctor and this led to complications. It was after this incident that at least 270 AYUSH doctors were giving training by the Delhi government towards the end of August at Ayurvedic and Unani Tibbia college in Karol Bagh. “All the AYUSH doctors were informed about prompt diagnosis of cases of fever and appropriate clinical management,” said Dr S M Raheja, Additional Director General of Health services.

While the Delhi High Court has now said that plans of the government authorities “have not reached the public at large”, the Delhi government is yet to begin is door-to-door awareness campaign. Sources said there had been a delay on this front, but the campaign would begin by September 10.

How three countries saw success in fight against the diseases

Indonesia
In Purwokerto, Central Java, a partnership between the local government, the family welfare empowerment organization, and municipal health services, with technical support from the National Health Research Department, enabled the development of an effective community-based integrated vector control project.
Within each neighbourhood, houses were grouped into sets of 10, known as dasawisma. Each dasawisma had a leader, trained in dengue fever prevention and control, known as the “source reduction cadre”. Each dasawisma got a source reduction kit containing a flashlight for checking for the presence of larva in containers stored in dark areas, simple record forms, and a booklet for health education. The dasawisma arranged schedules, where one house inspected the other nine houses. Known as Piket Bersama (Picket Together), these house-to-house inspections were conducted on a weekly basis. The dasawisma leader collected the weekly record forms and reported the results to the next administrative level. The success of this project was measured by the reduction in the House Index from 20 per cent before the activities started to 2 per cent once the activities were running well.

Malaysia
In Johor state, an integrated social mobilisation and communication campaign motivated householders in Johor Bahru District to destroy any larval breeding sites found around their premises, and to organise voluntary teams to inspect and control larval breeding sites in public spaces such as community halls, parks and vacant lots. Dengue Volunteer Inspection Teams (DeVIT) were formed in 48 localities. Some 615 volunteers came forward to join DeVIT. During the three-month campaign period, the teams advised 1,00,956 people, distributed 1,01,534 flyers, and inspected 1,440 vacant lots. The campaign resulted in a dramatic drop in the occurrence of dengue in the district. Three months after the campaign, tracking surveys revealed that 70 per cent householders were still checking their premises.

Colombia
In Bucaramanga, high school students were trained in “Ae. aegypti biology and control” and assisted as community-based health educators. Results over 11 years (1992-2001) showed a steady decrease (with occasional increases) in the number of houses with Ae. aegypti larvae present.