Outbreak containment of Malaria, JE, Dengue and Chikungunya

Dr.Murugan.N, Asst. Professor, Dept. of Community Medicine, Pondicherry Institurte of Medical Sciences

Definitions

Epidemic: The occurrence of more cases of disease than normally expected in a given area or among a specific group of people over a particular period of time (An epidemic is a disease that affects many people at the same time) Pandemic: It is very extensive epidemic like plague, that is prevalent in country, continent or world

Definitions

Outbreak: The term outbreak describes sudden rise in the incidence of a disease Difference between these terms is often determined by the percentage of the deaths caused by the disease. Endemic: Where there is a constant incidence of cases over a period of many successive year.

Prevention or control of epidemics

Epidemics Causes Mortality Heavy loss of man-days and economic -loss of income -expenditure on treatment Therefore, better to prevent epidemics by -detecting them in time or -recognise the impending outbreaks -make all efforts to prevent the outbreaks

Seasonal variation v/s outbreak

Malaria shows very clear seasonal variation in any given year. The incidence increases during and following the monsoon rains. This variation would not be labeled as an outbreak

The incidence during any part of the year should be compared to the situation in the previous year/ years to demonstrate clear increase to be declared as an epidemic.

Detection of malaria epidemics

The PHC medical officer - analyze the malaria data in MF-9 (village wise register of the PHC) By doing so he can not miss any unusual change in malaria incidence in the community / villages Similarly, the number of fever cases from the same area reporting to PHC OPD.

 Other

sources of information are:

a) Rise in malaria positivity rate in the lab. examination, b) Rising fever incidence reported by i) FTD holder /MPW, ii) community leaders, iii) Press, iv) legislature and v) medical practitioners of the area.

Epidemic risk in different areas

Epidemic areas subject to a sudden increase in the number of exposed non immune individuals, caused by: y The arrival en block of non immune populations into a malarious areas. Hypo and meso-endemic areas subject to a sudden increase in vectorial capacity, caused by:

Epidemic risk in different areas

Abrupt rise in Anopheles density- due to unusual heavy rains Increased survival of mosquitoes due to prolonged hot and humid weather Acceleration of the parasite sporogonic cycle due to exceptionally long and warm summers

Epidemic risk in different areas

Invasion of more efficient vector into non endemic areas Deviation of Anophelines from animals to man due to IRS spraying of animal sheds Hypo or meso endemic areas subject to environment modifications, which may lead to increase in vector density and population movement, such as: -Irrigation projects, Agriculture development; -Rapid, uncontrolled growth of cities.

Epidemic risk in different areas

Resurgence of malaria transmission due to failure of control measures (Premature termination or unplanned interruption of anti malarial measures) Spread of parasite resistance to Chloroquine

Epidemic preparedness
In epidemic prone areas, it is essential that a close collaboration between the specialized anti-malarial services and the emergency preparedness teams. The specialized anti-malarial services could then assist in the: Identification of epidemic prone areas, the main risk factors and alarm signals Monitoring of risk factors Planning, implementation and evaluation of prevention or control measures

Signals for prediction of malaria epidemics

1. Climate factors:

Temperature and Relative Humidity (RH): Optimum temp. for parasite development: 25 0 C To 30 0 C, RH: 60 - 80%. This Temp & RH also increase the longevity of mosquitoes & thus aid malaria transmission.

Rainfall- Increased rainfall specially rainy days result in mosquitogenic conditions.

Signals for prediction of malaria epidemics

Pre-monsoon rains:- lead to increase vector density and longevity to initiate malaria transmission. Natural calamities- The natural calamities/ disasters like flood, drought and earthquake - cause increase in mosquitogenic conditions resulting in outbreak of malaria epidemic.

2. Vulnerability
Some of the important points of vulnerability of an area are:

In urban slums: Increase in mosquitogenic conditions due to increased houses, water storage, and poor drainage

Change in resting and feeding habits of vectors due to change in environment and response to insecticides Deforestation Increase in breeding and density of vector; and Increase in the degree of man- mosquito contact.

3. Parasite factors

Increasing trend of fever cases and SPR Increase in Pf proportion Increasing in proportion of gametocytes in the community Resistance in parasite to drug/s Increase in malaria mortality; and Increase in consumption of anti- malariaials

4. Operational factors
Inadequate basic health services may contribute heavily to outbreak of malaria epidemic

Staff vacancy Poor surveillance machinery; Lack of adequate transport facilities Lack of approach road to far flung areas Inadequacy in material and equipment; and Inadequate training and lack of motivation of work.

Detecting a malaria epidemic

Step I: The clue for proceeding in this direction may be taken from the following Increase in fever rate reaching to one third or more of new OPD cases in dispensaries, PHC or hospitals during the current months Increased fever incidence in the population (informed by the field staff, MPWs, DDC and FTD holders or Panchayat members, etc. Increase in the incidence of malaria in the current months as compared to those of preceding year (s); this may be seen from MF-4

Detecting a malaria epidemic

Step II:

Carry out rapid fever survey (RFS) in the area (collect and examine blood smears, find out SPR to understand the quantum of disease in the community Compare the SPR of RFS and current months, with that of the same months of the previous years (s) Collect the data and information on the signals related to climatic factors, vulnerability, receptivity, operational status. etc. and examine them to note specific points of abnormality / increase, etc.

Epidemic response - Actions suggested

Carry out fever survey in the affected areas specially those with surveillance blackout or poor surveillance (as would be seen from MF-9 register) by collecting blood slide and giving treatment, and delineate areas Strengthen the treatment facilities at health institutions by providing anti-malarials and supportive medicines Review of the laboratory functions Interrupt the transmission by undertaking IRS with suitable insecticide(s). If not, focal spraying may be carried out

Epidemic response - Actions suggested

Activate DDC & FTD specially where surveillance is weak. Ensure providing complete radical treatment to all positive cases with suitable drug ( s);. Intensify IEC to increase awareness about malaria & its control and motivate community to adopt preventive measures for vector control & protect themselves from mosquito bite

Epidemic response - Actions suggested

In case of water logging etc. the district administration may be approached to ensure drainage of the area immediately, taking help of concerned departments.

Close entomological monitoring may be done to assess the impact of intervention measures and vector bionomics (e.g density, resting, feeding, breeding etc.)

Rapid response to prevent epidemic

Rapid response: the district must develop two essential components District mobile malaria epidemic control team ( DMECT) : to be pressed into service during epidemics This team in each district may be constituted as follows, in addition to the personnel for routine anti- malaria activities: (i) Medial Officer - 1, ii) Lab. Technician - 2, iii) Spraymen - 5, iv) Insect Collector - 2 and v) Driver)

Rapid response to prevent epidemic

In the event of an epidemic, the zonal entomologist should be associated with the DMECT team -supervise entomological activity and collate entomological data with epidemiological data. The State Programme Officer may decide to provide additional input depending on the magnitude of the problem in addition to DMECT

Guiding points to control the epidemics

Establish a control cell (or room) at district for monitoring and sending information to state and national level DMECT Pressed in to action with the available material & equipment and manpower; (DMO & MO, PHC should also reach Check and update the logistics and manpower; if need supplement and put indent for additional;

Guiding points to control the epidemics

Delineate the affected areas roughly and also include additional and adjoining areas. (For this, rapid fever survey is to be done from the epicenter, till we get areas with normal malaria positivity rate Ensure that all age groups are covered with special attention to children, pregnant women & migrants; and All fever cases are given treatment

Guiding points to control the epidemics

Investigate death cases (to confirm whether death has take place due to malaria / otherwise) Establish a field laboratory simultaneously; Fever radical treatment (FRT) to be deployed specially in rural areas. Mass radical treatment (MRT) may be resorted to only in highly malarious villages with high mortality;

Guiding points to control the epidemics

Vector control measures to be started as soon as possible , after the areas are identified; Submit regular information on daily / weekly basis to all concerned in the state & at national level. The information may include epidemiological data, investigation reports of death due to malaria, vector Control Measures undertaken

Emergency Vector Control Measures in Rural areas

Space spray with pyrethrum extract to knock down infected mosquitoes till the IRS is taken up;

IRS with suitable insecticide (DDT, Malathion & Deltamethrin) Fogging (ULV) with malathion - when vector is exophilic Wherever feasible, anti larval measures may be supplemented to IRS.

Emergency Vector Control Measures in Rural areas

Alternative measures like use of ITMNs & taking environmental measures for vector control Entomological investigation on vector density & breeding and vector response to insecticide being used, to be carried out

Emergency Vector Control Measures in Urban areas

Pyrethrum space spray in about 50 houses in and around a malaria positive house Anti larval measures must be intensified IRS must be undertaken in periphery and slum areas.

Post epidemic action

Documentation and reporting of the epidemic along with the control measures undertaken is an important step. It is essential to determine: What deficiencies predicted the prediction of the epidemic or hindered the implementation of preventive measures; What problems, if any, affected early detection, confirmation of an epidemic or timely response; What indicators should be monitored in order to improve the detection of epidemic risk.

Japanese Encephalitis

Distribution: Agricultural areas Pathogen: Flavivirus (arbovirus) Reservoir: Pigs, cattle, Horses, Water birds Vectors: Culex vishnui group Symptoms: Encephalopathy Fever, Headache, Encephalitis (meningeal signs, disorientation, stupor, coma, tremors, paralysis, loss of Coordination) Treatment: No specific therapy (supportive therapymaintaining fluid & electrolyte balance)

Transmission cycle of Japanese Encephalitis

Vector control activities

Focal IRS Outdoor space spraying Preventing man-vector contact (ITMN, Repellents) Preventing animal reservoir-vector contact Health education

Outbreak control of JE Issues to remember

Main issues to remember about outbreak control are:

By the time JE cases are identified and reported, it is often too late to prevent further transmission of disease. Usually, the peak of the epidemic has already occurred. Environmental interventions (mosquito and pig control) not successful in preventing/controlling JE outbreaks The inactivated, mouse brain-derived JE vaccine is not useful for outbreak response because at least 2 doses of vaccine (4 weeks apart) must be administered to achieve an adequate immunological response.

Outbreak control of JE Issues to remember

Live, attenuated SA 14-14-2 JE vaccine : Successfully prevented an outbreak in selected districts in Nepal in 1999. (Because a single dose of vaccine provided rapid protection, and the vaccine was administered several weeks before the most intense period of virus transmission)

The best prevention of the next JE outbreak - through routine human immunization.

Dengue

Distribution: South east Asia, India, American tropics Pathogen: Flavivirus (DEN1, 2, 3, 4) Reservoir: Human (Anthroponotic) Vectors: Ae. aegypti, Ae. Albopictus Breeding: Container habitats Symptoms: High fever, Frontal headache, Muscle & joint pain, rashes on chest & upper limbs, mild bleeding of nose gums DHF: Bleeding of GI tract, Diffuse capillaries leakage of Plasma Treatment: No drug or vacine (vaccine under development) symptomatic treatment (oral fluids & electrolyte therapy)

Dengue / Chikungunya Transmission cycle

Dengue / Chikungunya Transmission cycle

Chikungunya

Distribution: Tropics (Asian countries including India) Pathogen: Alphavirus (Chik virus) Reservoir: Human (Anthroponotic) Vectors: Ae. aegypti, Ae. Albopictus Breeding: Container habitats Symptoms: High fever with headache & joint pain, Chills, vomitting, Nausea, rashes on limbs & trunks, redness in eyes Treatment: No drug or vaccine (cured by immune system) symptomatic treatment & rest

Control of Outbreaks of Dengue / Chikungunya

Source reduction Health education community participation Anti-larval measures Personal prophylactic measures (ITMN, Repellents etc) Focal IRS Outdoor space spraying & ULV spray- No use

Thank YOU