The document outlines India's long term and mid term plans for the prevention and control of dengue. The long term plan from 2007-2010 focused on early case reporting and management, integrated vector management, and supporting interventions like capacity building and behavior change communication. The mid term plan from 2011-2013 revisited these strategies and emphasized disease and vector surveillance, case management, laboratory diagnosis, and vector control. It also discussed dengue vaccination research and challenges, and reasons for the reemergence of dengue like urbanization, inadequate environmental management, and climate change.

1. Dengue : Emerging Public Health
Problem
PRESENTER : Dr Kaushik K N
GUIDE : Dr Jayanth Kumar
Date : 19-2-2014
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2. DENGUE : AN EMERGING
HEALTH PROBLEM
PART
2
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3. Previous presentation
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Introduction
Dengue epidemiology
Problem statement - World
Problem statement - India
Dengue case classification
Burden of disease
Transmission
Clinical management, laboratory diagnosis and delivery of
clinical services
• Case management
3

4. Contents Of Today’s
Presentation
• Long term action plan for Prevention and control
of Dengue (2007-2010)
• Mid Term Plan for Prevention & Control of
Dengue (2011-2013)
• Dengue emergency outbreak response /
containment of dengue epidemic
• Dengue vaccine
• Reasons/underlying causes for the worsening
Dengue situation
• References
4

5. PURPOSE OF THE LONG TERM
ACTION PLAN
• Vellore (1956) - Dengue first reported
• 1963-1964 - initial epidemic of dengue fever - Eastern Coast
of India
• Spread northwards to reach Delhi in 1967 and Kanpur in 1968.
• Simultaneously - southern part of the country and gradually
the whole country involved
• 1991- 2006 – 31 out of 35 states dengue cases reported
5

6. PURPOSE OF THE LONG
TERM ACTION PLAN
• Dengue transmission has shown substantial
increase over years
• Government of India has Developed a Long
Term Action Plan for Prevention and Control
of Dengue in the country and sent to the
State(s) on January 2007 for implementation.
6

7. LONG TERM ACTION PLAN FOR
PREVENTION AND CONTROL OF
DENGUE
• Dengue Fever & Dengue hemorrhagic fever – ever
increasing endemicity in India.
• Both Dengue and Chikungunya are Vector Borne
disease and are caused by viruses carried by same
Mosquito [Aedes aegypti].
• Dengue/ DHF is being managed as a part of National
Vector Disease Control Programme (NVBCDP).
• Chikungunya fever has occurred in epidemic form in
the year of 2006 after about 30 years.
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8. LONG TERM ACTION PLAN FOR
PREVENTION AND CONTROL OF
DENGUE
• Chikungunya was not a part of the National Vector
Borne Disease Control but the strategies for its
prevention and control is similar to that of Dengue
prevention and control strategies as both the disease
are caused by the same Vector (Mosquito) i.e. Aedes
aegypti.
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9. LONG TERM ACTION PLAN FOR
PREVENTION AND CONTROL OF
DENGUE
• The long term strategies for prevention and
control of DF/DHF/DSS and Chikungunya in
India is three-pronged : (2007-2010)
1.Early case reporting & management
2.Integrated Vector Management
3.Supporting Interventions
9

10. EARLY CASE REPORTING &
MANAGEMENT
• Early case reporting –
– fever alert surveillance
– Sentinel surveillance sites with laboratory support
– Strengthening of referral services
– Involvement of Private Sector in sentinel
surveillance
• Case management –
• Case management
• Epidemic preparedness & Rapid response
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11. INTEGRATED VECTOR
MANAGEMENT
• Entomological surveillance including larval surveys
• Anti - larval measures
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Source reduction
Chemical larvicide
Larvivorous fish
Environmental management
• Anti – adult measures
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Indoor space spraying
Fogging
Personal protection measures
Protective clothing
ITBN & repellents
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12. SUPPORTING INTERVENTIONS
• Human resource development through
capacity building
• Behavioral change communication
• Inter – sectoral collaboration
• Supervision & monitoring
• Coordination committees
• Legislative support
12

13. FEVER ALERT SURVEILLANCE
– Early capture of suspected Dengue outbreak
– ASHA, Anganwadi worker (AWW) & Fever
treatment depot (FTD) trained – indentifying &
reporting
– Fever syndrome reported to District Vector Borne
Disease Control Officer (respective PHC/CHC)
– Information on disease shared
• District Health Mission
• Rogi Kalyan Samiti
• Village Health & Sanitation Committee
13

14. ESTABLISHMENT OF SENTINEL
SURVEILLANCE
– Epidemics at peak transmission before recognition
& confirmation of Dengue – Dengue surveillance
needs to be Proactive
– Programme employs proactive surveillance to
predict Dengue outbreak
– Serological/ virological surveillance important –
monitor transmission during inter – epidemic
periods
14

15. ESTABLISHMENT OF SENTINEL
SURVEILLANCE
• Network of sentinel surveillance hospital
– Regional & District levels
– One sentinel surveillance site – each district in
India
– 110 sentinel sites in the country
– 50,000 contingency grant
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16. ESTABLISHMENT OF SENTINEL
SURVEILLANCE
• Function of Sentinel Surveillance Hospital
– Blood sample collection
– Maintain line listing of Dengue positive case
– Capacity building of PHC/CHC
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17. DENGUE CASE CONFIRMED
& THEN WHAT?
• Dengue confirmed by serological test – IgM
MAC Elisa kits (NIV Pune)
• District Vector Borne Disease Control Officer
intimated
• He/she initiate remedial measure – 24 hours
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18. INVOLVEMENT OF PRIVATE SECTOR
IN SENTINEL SURVEILLANCE
• Private health centers – clinics, nursing homes
in endemic district – sentinel surveillance site
• Avail existing lab facility from public sector
• Line listing
• Physician / MO – training programme
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19. STRENGTHENING OF REFERRAL
SERVICES
• PCR, Virus isolation – 13 apex referral lab
• Capacity building
• Have advanced diagnostic facilities
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20. APEX LABS
National Institute of Virology, Pune.
National Institute of Communicable Diseases, Delhi.
(National Institute of Mental Health & Neuro-Sciences, Bangalore.
Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow.
Post- Graduate Institute of Medical Sciences, Chandigarh.
All India Institute of Medical Sciences, Delhi.
ICMR Virus Unit, Kolkata
Regional Medical Research Centre (ICMR), Dibrugarh, Assam.
King’s Institute of Preventive Medicine, Chennai.
Institute of Preventive Medicine, Hyderabad.
B J Medical College, Ahmedabad.
State Virology Institute, Allappuzha, Kerala
DRDE, Gwalior, Madhya Pradesh
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21. INTEGRATED VECTOR
MANAGEMENT
• Prevention and reduction in disease burden –
control of mosquito vectors
• Activities to control transmission – target
vector in the habitats of its immature 7 adult
stages in households and immediate vicinity
• Integrated vector management – strategic
approach to control vector - promoted by
WHO
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22. INTEGRATED VECTOR
CONTROL
• Key elements –
1.
Advocacy, social mobilization & legislation
2.
Collaboration within the health sector and
with other sectors
3.
Integrated approach to disease control
4.
Evidence based decision making
5.
Capacity building
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23. METHODS OF VECTOR
CONTROL
• Environmental management –
1. Environmental modification-piped water supply
2. Environmental manipulation-street cleansing,
recycling, planning of construction
• Chemical control : larvicides
1. Target area
2. Insecticides
3. Application procedure
4. Treatment cycle
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24. METHODS OF VECTOR CONTROL
• Chemical control : Adulticides
1.Residual treatment – space sprays and their
application
2.Target area
3.Insecticides
4.Application procedure
5.Treatment cycle
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25. METHODS OF VECTOR CONTROL
• Monitoring of insecticide susceptibility –
1.Insecticide resistant Aedes aegypticus –
organophosphates, pyrethroids, carbamates
2.Routine monitoring of insecticide
susceptibility
3.WHO kits for testing the susceptibility of adult
and larval mosquitoes – standard method
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26. METHODS OF VECTOR CONTROL
• Biological control –
1.Fish
2.Predatory copepods – mesocyclops – vietnam
• Improved tools for vector control –
1.Insecticide treated materials
2.Lethal ovitraps
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27. 27

28. DENGUE SURVEILLANCE
• Disease surveillance
• Entomological surveillance
• Monitoring environmental risk
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29. DENGUE SURVEILLANCE
• 3 components of dengue surveillance
– Disease surveillance –
• Critical component
• Provide information necessary for risk assessment,
epidemic response & program evaluation
• Utilize both passive & active data collection processes
• Event based surveillance
• Case based surveillance
• Active and passive surveillance
• Sentinel surveillance
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30. DENGUE SURVEILLANCE
– Entomological surveillance
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Larval & pupal surveillance
Pupal/demographic surveys
Passive collection of larvae/pupae
Adult mosquito population survey
Landing collections
Resting collections
Trap collections
Frequency of sampling
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31. DENGUE SURVEILLANCE
– Monitoring environmental & social risks
• Various factors have been determined to influence a
community’s vulnerability to dengue epidemics
• Distribution and density of population
• Settlement characteristics
• Conditions of land tenure
• Housing styles
• Education
• Socio economic status
• Water supply services
• Knowledge of domestic water storage practices
• Solid waste disposal services
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32. SUPPORTING INTERVENTIONS
• Human resource development through
capacity building
• Behaviour change communication
• Inter sectoral collaboration
• Operational reasearch
• Supervision, monitoring & evaluation
• Geographical information system
• Legislation support
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33. 33

34. MID TERM PLAN FOR PREVENTION &
CONTROL OF DENGUE
• Purpose of this document– Intensity of dengue transmission shows substantial
increase over the years in spite Of Long Term
Action Plan
– To revisit the current strategies of Long Term
Action Plan
– Develop a programmatic & comprehensive Mid
Term Plan for prevention and control of Dengue in
India
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35. MID TERM PLAN FOR PREVENTION
& CONTROL OF DENGUE
• Objectives
– To reduce the incidence of dengue to bring down
the disease burden
– To reduce the case fatality rate due to dengue
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36. MID TERM PLAN FOR PREVENTION
& CONTROL OF DENGUE
• Elements
– Disease & vector surveillance
– Case management
– Laboratory diagnosis
– Vector management
– Outbreak response
– Capacity building
– Behavior change communication
– Inter sectoral co ordination
– Monitoring & supervision
36

37. MID TERM PLAN FOR PREVENTION
& CONTROL OF DENGUE
• Implementation period – 2011 to 2013
• Surveillance concept –
– Monitor trends in distribution & spread of disease
– Early case detection for timely intervention
– Measure disease burden
– Assess social & economic impact
– Evaluate effectiveness of prevention & control
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38. MID TERM PLAN FOR PREVENTION &
CONTROL OF DENGUE - LARVAL
SURVEILLANCE
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39. MID TERM PLAN FOR PREVENTION
& CONTROL OF DENGUE –
ENVIRONMENTAL MANAGEMENT
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40. DENGUE VACCINE
OVERVIEW
• Significant progress made.
• Researchers, funding agencies, policy makers
and vaccine manufacturers – attracted by
unchecked spread of dengue worldwide
• Public private partnerships facilitated the
process of product development
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41. DENGUE VACCINE
PRODUCT & ITS DEVELOPMENT
• Primary immunological mechanism – virus
neutralization through circulating anti bodies
• Vaccine – needs to protect against all 4
serotypes of virus strain
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42. DENGUE VACCINE
• 4 types of vaccines under development –
– Live attenuated vaccine
– Chimeric live attenuated vaccine
– Inactivated or sub unit vaccine
– Nucleic acid based vaccine
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43. LIVE ATTENUATED - DENGUE
VACCINE
• Induce durable humoral & cellular immune
response
• Pr M & E (structural genes) of each of 4
dengue virus inserted into yellow fever 17D
vaccine
• 2 doses required for high rates of tetravalent
neutralizing antibodies
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44. CHALLENGES FOR LIVE
ATTENUATED VACCINE
• Major problem - Need to develop not one but
four immunogen
• Interefence between 4 vaccine virus must be
avoided
• Lack of validated correlate of protection –
mechanism of protective immunity not fully
understood
• Antibody dependant immune enhancement DHF
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45. VACCINE UTILIZATION
• Cost effectiveness, outcome of financial &
operational analysis
• Infants – need to carry out vaccination on a
schedule compatible with others
• Research to be continued
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46. INDIA UPDATE ON DENGUE
VACCINE
• Indian scientists have achieved an important
breakthrough in their efforts to develop a vaccine to
prevent the deadly dengue. Supported by the
Department of Biotechnology under the Ministry of
Science & Technology, scientists at International
Centre for Genetic Engineering and Biotechnology
(ICGEB) in New Delhi have developed a noninfectious dengue vaccine from yeast.
India today, New Delhi, September 20, 2013
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47. INDIA UPDATE ON DENGUE
VACCINE
• "Search for a dengue vaccine has been going on
across the world for past several decades. We, at our
centre, started experiments seven years ago. The new
technology we have used, i.e. recombinant DNA
technology, to develop the dengue vaccine is a
breakthrough," said Dr Navin Khanna, group leader
of Recombinant Gene Products Group, ICGEB.
– PUBLISHED: 00:01 GMT, 20 September 2013 | UPDATED: 00:01
GMT, 20 September 2013
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48. REASONS FOR RE EMERGENCE
OF DENGUE FEVER
• Demographic & Societal Changes –
– Unplanned & uncontrolled urbanization
– Population growth
– Restraints on civic amenities – water supply, solid
waste disposal
– Increase in breeding potential of vector species
– Improved communication facilities- rapid
transporatation – establish in rural area
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49. REASONS FOR RE EMERGENCE
OF DENGUE FEVER
• Effective mosquito control based on source
reduction – non existent in endemic areas
• Solid waste management –
– Increase in use of plastics, paper cups, tyres
– Facilitate breeding
– Insufficient solid waste collection & management
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50. REASONS FOR RE EMERGENCE
OF DENGUE FEVER
• Increased population management –
• Significant increase in plantations –
– Increased demand for rubber
– Rubber plantation increased
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51. REASONS FOR RE EMERGENCE
OF DENGUE FEVER
• Uncontrolled urbanization
• Inadequate environment management
• Population movements
• Growth in global air traffic
• Increase in maritime passenger and cargo traffic
• Climate change
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52. REASONS FOR RE EMERGENCE
• Unrestrained
production and use of
non biodegradable food
and drink packaging
like plastic, tetra packs
• Unmonitored use and
abandoning of
containers, drums
(construction site)
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53. RE EMERGENCE OF DENGUE: INADEQUATE
ENVIRONMENTAL MANAGEMENT
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Inefficient waste collection and management
Non biodegradable containers
Improper tyre disposal
Insufficient and inadequate water distribution
Inadequate management of water storage &
disposal
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54. RE EMERGENCE OF DENGUE:
POPULATION MOVEMENTS
• Migration : > 750 million people annually
cross international borders
• Increase in rural migration to urban areas
• Ever increasing international travelers across
the globe
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55. GROWTH IN GLOBAL AIR TRAFFIC
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56. INCREASE IN MARITIME
PASSENGER & CARGO TRAFFIC
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57. CLIMATE CHANGE
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58. CLIMATE CHANGE
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Viral incubation in mosquito quickens
Shorten mosquito breeding cycle
Increase mosquito feeding frequency
More efficient transmission of
dengue/chikungunya virus from mosquito to
man
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59. OBSTACLE IN AEDES CONTROL
• Community participation in dengue prevention
& control is limited.
• Local health services are politically driven
now and are not sufficiently established
• Water supply and solid waste management are
limited in high risk areas
• Lack of inter sectoral co ordination
• Insufficient operational research on individual
and community based strategies
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60. A FEW SUGGESTIONS –
MAINTENANCE OF WATER
SUPPLY SYSTEMS
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61. A FEW SUGGESTIONS –
ESTABLISHING PROPER
DRAINAGE SYSTEM
BBMP and BWSSB should formulate an integrated approach programme for
water supply, sewerage, drainage and waste management so as to keep the
environment free from the risks of vector breeding/growth
Storm water drains should be invariably be covered and be maintained by the way of
Regular cleaning, de-silting etc to prevent stagnation of water
Large storm water drains should be suitably channeled and cleaned regularly to
facilitate adequate velocity for flow of waste water
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62. A FEW SUGGESTIONS –
CONSTRUCTION SITE
Water stagnation in construction areas should be cleared
Clearance of garbage in vacant sites at proper intervals
of time to avoid breeding of Aedes mosquito
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63. A FEW SUGGESTIONS – MODEL
CIVIC BYELAWS
Standard design for lids for over head tanks and cisterns
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64. CONCLUSION
• Dengue virus has become a fatal disease
• Small creatures (mosquito) is posing a big
threat of late
• Re emergence and spread of dengue is a
serious issue
• Role of vaccine is still a question though many
advancements in vaccine manufacture is
promising
64

65. REFERENCES
• Dengue guidelines for diagnosis, treatment, prevention and control,
a joint publication of the world health organization (WHO) and the
special programme for research and training in tropical diseases
(TDR)
• Long Term Action Plan for prevention & control of Dengue &
Chikungunya. Directorate of NVBDCP : Delhi; 2007.
• Mid Term Plan for Prevention & Control of Dengue &
Chikungunya. Directorate of NVBDCP : Delhi; 2011.
• Global strategy for Dengue prevention & control 2012-2020. World
Health Organization. Publication Data: Geneva ; 2012
• Guidelines for clinical management of Dengue fever, Dengue
hemorrhagic fever & Dengue shock syndrome. Directorate of
NVBDCP : Delhi; 2008
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66. THANK YOU
66

67. APEX REFERRAL
LABORATORIES
1. National Institute of Virology, Pune.
2. National Center for Disease Control (former NICD), Delhi.
3. National Institute of Mental Health & Neuro-Sciences, Bangalore.
4. Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow.
5. Post- Graduate Institute of Medical Sciences, Chandigarh.
6. All India Institute of Medical Sciences, Delhi.
7. ICMR Virus Unit, National Institute of Cholera & Enteric Diseases,
Kolkata.
8. Regional Medical Research Centre (ICMR), Dibrugarh, Assam.
9. King’s Institute of Preventive Medicine, Chennai.
10. Institute of Preventive Medicine, Hyderabad.
11. B J Medical College, Ahmedabad.
12. State Public Health Laboratory, Thiruvananthapuram, Kerala
13. Defence Research Development and Establishment, Gwalior
14. Regional Medical Research Centre for Tribals, (ICMR) Jabalpur,
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68. Stagnant water sources (heavy rainfall) – vector breedingincreased incidence of dengue - indicate that preventive
measures against dengue infection should probably come
into full-swing during the post-monsoon months.
Presence of some dengue IgM positive cases even during
dry months - reflective of the year-round activity of the
mosquito vector.
Minimal collections of water sources (like stagnating
water within indoor plants) – favour breeding of the
vector thereby helping in the maintenance of the vector
population throughout the year.
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69. • Curtailment of outdoor playing activities
(especially during the post-monsoon months)
by children could be done.
• As the mosquito vector exhibits activity during
the dusk, this could reduce probably to a great
extent the chances of children getting exposed
to the vector.
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70. Govt.of Karnataka guidelines –
original document
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71. Govt of Karnataka guidelinesoriginal document
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72. Dengue vaccine
• the pathogenesis of DHF is not fully known
• Animal model – absent
• a tetravalent vaccine that prevents infection with all
four DV serotypes - needed.
• Natural
• DV infection induces long-lasting protective immunitysame serotype.
• A tetravalent formulation that retains the
immunogenicity of all four serotypes has proven
difficult, requiring the use of more complicated,
multiple dose immunization regimens.
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73. Epidemics Of Dengue-like Illness In India
Year
Places
1780
1824–1925
1844–1949
1852–1956
1870–1973
1897–1999
1901–2007
1907–1913
1920–1926
1927–1928
1930–1933
1934–1936
1940–1945
Madras
Rangoon to Madras
Kanpur, Calcutta
Wide spread
Bombay, Calcutta, Madras
Bombay
Madras
Calcutta, Pune, Meerut
Lucknow, Bombay, Calcutta
Coimbatore
Madras
Madras
Calcutta
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75. 75

76. • Rapid Action Team should be constituted with
the aim to undertake urgent epidemiological
investigations and provide on the spot
technical guidance required and logistic
support
76