vector borne diseases and NVBDCP

Different vector borne diseases under NVBDCP and related programmes.

1. VECTOR BORNE DISEASES AND NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME(NVBDCP) DR SANJAYA KUMAR SAHOO AIIH&PH,KOLKATA

2. World Health Day theme 2014: “vector borne diseases” “SMALL BITE – BIG THREAT”  

3. INTRODUCTION: With this World Health Day, WHO is drawing attention to a group of diseases that are spread by insects and other vectors, the heavy health and economic burdens they impose, and what needs to be done to reduce these burdens . Vector-borne diseases cause more than one million deaths each year and Over half the world's population is at risk from vector-borne diseases such as malaria and dengue. Vectors like mosquitoes, ticks, and fleas transmit parasites, viruses, or bacteria between people or between animals and people . But death counts, though alarming, vastly underestimate the human misery and hardship caused by these diseases, as many people who survive infections are left permanently debilitated, disfigured or blind. .

4. Vector-borne diseases: Key facts Marking the World Health Day, WHO has released some key facts and figures based on this year's theme: Vector-borne diseases are commonly found in tropical and sub-tropical regions and places with problems surrounding safe drinking-water and sanitation systems. Vector-transmitted diseases account for 17% of the estimated global burden of all infectious diseases. Malaria is the most deadly vector-borne disease. It caused an estimated 660,000 deaths in 2010 and 627,000 deaths in 2012, most of whom were African children. Dengue is the world's fastest growing vector-borne disease with a 30-fold increase in disease incidence over the last 50 years. Nearly 40% of the world's population is at risk from dengue . An estimated 1.3 million new cases of leishmaniasis , caused by sandflies , occur annually. Globalisation of trade and travel, climate change and urbanisation are all having an impact on the global spread of vector-borne diseases.

5. What Is it? Vector: It is defined as an arthropod or any living carrier that transport an infectious agent to a susceptible individuals. The transmission by a vector may be mechanical or biological. So , vectors themselves are not an infectious agents. E.g. - mosquito, fly, rodents, tick Vector borne disease: A disease that is transmitted to humans or other animals by an insect such as a mosquito or another arthropod is called a vector-borne disease .

6. Launched in 2003-04 by convergence of three ongoing programmes on malaria,filaria & Kala Azar and inclusion of Japanese Encephalitis and Dengue/ DHF.In 2007 chikungunya fever added to this programme due to re-emergence of the diseases in 2006. This program is now runs under the umbrella of NRHM. NATIONAL VECTOR BORNE DISEASES CONTROL PROGRAMME(NVBDCP)

7. DISEASES INCLUDED UNDER NVBDCP: 1 . Malaria 2. Dengue 3. Chikungunya 4. Japanese Encephalitis 5. Kala- Azar 6. Filaria  (Lymphatic Filariasis )

8. VISION: A Well informed and self-sustained, healthy india free from vector borne diseases with equitable access to quality health care . MISSION : An integrated and accelerated action towards reducing mortality on account of malaria, dengue and JE BY HALF Elimination of kala-azar by 2010 Elimination of lymphatic filariasis by 2015

9. 12 STRATEGIES OF NVBDCP : Entomological surveillance Anti-larval measures Anti adult nmeasures

10. Japanese encephalitis(JE)

11. History 1870s: Japan “Summer encephalitis” epidemics 1924: Great epidemic in Japan 6,125 human cases; 3,797 deaths 1935: Virus first isolated From a fatal human encephalitis case 1938: Isolated from Culex tritaeniorhynchus 1952: First evidence of J E 1955:First case in India 1958:First viral isolation in India 1973:First outbreak in Bankura / Burdwan 1978:widespread occurance /monitoring NMEP Initiation of immunisation –in 2006 JE vaccine included in UIP in 11 endemic district of four states. In October 2013 India launched it’s indigenous vaccine named “ janvac ” developed by NIV,ICMR AND BIOTECH Ltd.

12. BURDEN OF JE: Japanese Encephalitis is becoming a health problem in a number of States especially in AP, TN, Kerala, Karnataka , WB, Assam, Bihar, & Haryana and has been reported from 26 states and UTs since 1978. There was no national programme for this disease and the affected states were managing the problem with the technical Assistance from the centre . This disease was included under the NVBDCP in 2003-04.

13. EPIDEMIOLOGICAL TRIAD FOR JE: AGENT HOST ENVIRONMENT VECTOR Group-B arbovirus ( flavivirus ) NEUROTROPIC VIRUS c. Tritaenicorhynchus c.Vishuni & Culex pseudovishnui JE virus is primarily zoonotic in its natural cycle and man is an accidental host. Natural hosts of JE virus include water birds of Ardeidae family (mainly pond herons and cattle egrets). Pigs play an important role as an amplifier host since they allow manifold virus multiplication without suffering from disease and maintain prolonged viraemia . 85% cases occur among children <15yrs. Rural agricultural field where flooding irrigation is practised common breeding places for the mosquito is irrigated rice fields,shallow ditches and pools

14. Clinical Signs and symptoms: Incubation period: 5 to 15 days Mostly asymptomatic or mild signs. Children < 15 years and Elderly at highest risk for severe disease. For every case there are 200-1000 undetected/asymptomatic cases Clinically it is difficult to differentiate between JE and other viral encephalitis. Convalescent phase is prolonged and vary from a few weeks to several months . Amongst patients who survive, some lead to full recovery through steady improvement and some suffer with stabilization of neurological deficit.

15. CASE FATALITY RATE VARIES BETWEEN 20-40% MAY INCREASE UPTO 58% AVERAGE PERIOD BETWEEN THE ONSET OF ILLNESS AND DEATH IS ABOUT 9 DAYS .

16. DIAGNOSIS AND TREATMENT: IgM captured ELISA detects Ab. Within 7 days of onset of illness. Ab. Assay of paired sera. Dot-blot IgM assay. No specific treatment Symptomatic treatment and Supportive care. For prophylaxis : Travellers (>1yr) visiting rural areas of endemic countries for atleast 2 weeks. vaccination: 3 doses—on days 0,7 &28 or 2 doses 4 weeks apart.

17. PREVENTION: Vector control Eliminate mosquito breeding areas Adult and larvae control( chemical larvicides , larvivorous fish) Environmental management Vaccination Equine and swine Humans Personal protective measures Avoid prime mosquito hours Use of repellants / ITN/curtains Space spray -Fogging with pyrethrum/malathion(Spraying should cover the vegetation around the houses,breeding sites and animal shelter.unaffected villages falling within 2-3 kms radius of the infected village should also receive spraying as a preventive measures)

18. VACCINATION Mouse brain derived -inactivated -Nakayama or Beijing strain of JE Cell cultured derived -inactivated Based on Beijing p-3 strain Cell cultured d erived -Live attenuated Based on SA-14-14-2 strain In India SA 14-14-2 Live attenuated vaccine used for immunization in 83 endemic districts in UP,ASSAM,WEST BENGAL AND KARNATAKA IN AGE GROUP 1-15 under UIP. Shedule : At 16-24 months 0.5ml,S.C Single dose BOOSTER AFTER 1 YEAR .

19. NVBDCP developed surveillance guidelines for endemic states and advised that all the JE cases be reported under Acute Encephalitis syndrome(AES) Case definition of suspected cases: -Acute onset of fever not more than 5-7 days duration. -Change in mental status with or without -New onset of seizure(Excluding febrile seizure) -Other early clinical findings –may include irritability,somnolence or abnormal behavior greater than that seen with usual febrile illness. GUIDELINES FOR MANAGEMENT OF AES INCLUDING JE IN INDIA(-2009)

20. CHIKUNGUNYA

21. In India major epidemic of chikungunya fever was reported during 60s & 70s; 1963—Kolkata 1965---TN,MP,AP& Maharastra 1973--- Maharastra The disease re-emerged in the country after a gap of three decades .During 2006 a total of 1.39 million clinically suspected chikungunya cases reported in the country involving 16 states.The outbreak first noticed in AP then subsequently spread to TN and other states. There were no reported deaths attributed to chikungunya.

22. EPIDEMIOLOGICAL TRIAD FOR CHIKUNGUNYA: AGENT HOST ENVIRONMENT VECTOR Chikungunya virus( family Togaviridae , genus Alphavirus ) Aedes mosquito ( Aedes aegypti .) ( P EAK BITING TIME FEW HOURS AFTER DAWN AND LATE AFTERNOON ) Artificial accumulations of water in and around human dwellings such as discarded tins,broken bottles,flower pots,coconut shells,earthen pots etc Humans are thought to be the major source, or reservoir, of chikungunya virus for Mosquitoes)

23. In cubation period : 4-7 days( Ranges from 2-12 days) Symptoms : Sudden onset of Fever with chills , A petechial or maculopapular rash usually involving the limbs and trunk , Arthralgia or arthritis affecting multiple joints like metacarpophalangeal jt ., wrist,elbow,shoulderwhich can be debilitating. The name Chikungunya is derived from the Makonde word meaning "that which bends up" in reference to the stooped posture developed as a result of the arthritic symptoms of the disease headache,anorexia Conjunctival congestion and slight photophobia. Disease is self limiting . No death have been attributed to chikungunya fever . Dr.G.C.Sahu /ROH&FW/ GoI /Ahmedabad

24. DIAGNOSIS : Chikungunya is diagnosed by blood tests. Since the clinical appearance of both chikungunya and dengue are similar, laboratory confirmation is important, especially in areas where dengue is present. Key Diagnostic Tests: Detection of antigens or antibody to the agent in the blood (serology) If ELISA is available An IgM capture ELISA is necessary to distinguish the disease from dengue fever

25. TREATMENT: 􀁺􀁺 There is no specific treatment for CHIK V . -Symptomatic treatment only. -No vaccine or preventive pill is available . The illness is usually self-limiting . No relapses occur – no second attacks. The acute phase of the chikungunya fever lasts for 3-10 days but the convalescent phase can usually last from weeks to months with accompanying joint pain, swelling and tenderness. Sometimes it can last for even a year or more . Infected persons should be isolated from mosquitoes as much as possible in order to avoid transmission of infection to other people . Drugs like aspirin and steroids should be avoided .

26. PREVENTION: There is no separate programme for chikungunya fever as control stratergies for dengue and chikungunya are same. Eliminating mosquito breeding sites in and around the house. Use of larvicides such as abate and biological control by larvivorous fish like gambusia . Anti adult measures like aerosol spray of malathion/ sumithion . P revention of mosquito bites by personal prophylactic measures.

27. DENGUE : Emerging Public Health Problem

28. Magnitude of Problem: T he world's fastest growing vector-borne disease is dengue, with a 30-fold increase in disease incidence over the last 50 years. Dengue in particular is emerging as a serious public health concern. In 2012, it ranked as the most important mosquito-borne viral disease with epidemic potential in the world . Dengue and DHF is now endemic in more than 100 countries. Around 2.5 billion people i.e two fifth of the world’s population in tropical and subtropical countries are at risk of the diseases. An estimated 50 million dengue infection occur worldwide annually and about 50000 people wiyh DHF require hospitalization each year. Approximately 90% of them are children aged less than five years and about 2.5% of those affected die.

29. INDIAN SCENARIO: The first evidence of occurrence of DF in the country was reported during 1956 from Vellore district in Tamil Nadu . The first DHF outbreak occurred in Calcutta (West Bengal) in 1963 with 30%of cases showing haemorrhagic manifestations. During 1996, one of the most severe outbreaks of DF/DHF occurred in Delhi where,10,252 cases and 423 deaths occurred. In 2006, the country witnessed another outbreak of DF/DHF, total 12,317 cases and 184 deaths were reported in 21 states/UTs.

30. The number of dengue cases has been steadily rising since 2008 — when the count was 12,561 —witnessing a dip only in 2011. The number of deaths due to the disease has increased from 80 in 2008 to 242 in 2012 and 167 in 2013.  The dengue morbidity trend, or the proportion of deaths in comparison to the number of cases, has been coming down. The dengue fatality rate was 3.3% in 1996 when the number of cases reported was 16,517. This has dropped to 0.5% in 2012 and 0.2% in 2013 .   Among the NE States Manipur has reported Dengue outbreak for the first time in 2007. Every year during the period of July-Nov there is an upsurge in the cases of Dengue/DHF . All the four serotypes i.e. Dengue 1,2,3 and 4 have been isolated in India.

31. DENGUE/ DENGUE HAEMORRHAGIC FEVER   MAGNITUDE OF THE PROBLEM

32. As per endemicity SEAR divided into 3 categories: CATEGORY-A:(HYPERENDEMIC )( india , Bangladesh,Srilanka,Myanmar,Maldives , T hailand and T imor-leste ) a.Major public health problem b.Leading cause of hospitalisation and death among children c.Hyperendemicity with all 4 serotypes circulating in urban areas d.Spreading to rural areas. CATEGORY-B :( Bhutan, Nepal) a.Endemicity uncertain. b.Bhutan and Nepal reported their first outbreak in 2004. CATEGORY-C :( DPR Korea) No evidence of endemicity .

33. EPIDEMIOLOGICAL TRIAD FOR DENGUE AGENT HOST ENVIRONMENT VECTOR flavivirus (4 SEROTYPES DEN-1,2,3 &4) Aedes aegypti and aedes albopictus (becomes infective by feeding on a patient from the day before onset to the 5 th of illness.) Artificial accumulations of water in and around human dwellings such as discarded tins,broken bottles,flower pots,coconut shells,earthen pots etc Humans are thought to be the major source, or reservoir, of Dengue virus for Mosquitoes.Under-5 children are more vulnerable. I nfection with any one serotype confers lifelong immunity to that virus serotype).secondary infection with another serotype/multiple inf. With diff. serotype leads to severe form of dengue.

34. Clinical Presentation Of Dengue Dengue Virus Infection Asymptomatic Symptomatic Undifferentiated fever (viral syndrome) Dengue fever syndrome Without hemorrhage With unusual hemorrhage Dengue hemorrhagic fever (plasma leakage) No shock Dengue shock syndrome Dengue fever Dengue hemorrhagic Fever WHO 95629

35. Dengue Clinical Syndromes Undifferentiated fever Classical dengue fever Dengue hemorrhagic fever(DHF) Dengue shock syndrome(DSS)

36. LAB. DIAGNOSIS: 1.VIRUS ISOLATION( specimen :acute phase serum,washed buffy coat,autopsy tissue from fatal cases and mosquito collected from affected area) 2.VIRAL NUCLEIC ACID DETECTION 3.SEROLOGICAL TESTS : Haemagglutination -Inhibition (HI), Complement Fixation (CF), Neutralization test (NT), IgMcapture enzyme-linked immunosorbent assay (MAC-ELISA), an Indirect IgG ELISA 4.VIRAL ANTIGEN DITECTION : Nonstructrual protein 1 (NS 1) and Envelope/ membrance (EM) antigen 5.RAPID DIAGNOSTIC TEST(RDT) ditects IgM and IgG antibody 6.ANALYSIS OF HAEMATOLOGICAL PARAMETERS: NVBDCP IS CURRENTLY FOLLOWING IgM ANTIBODY CAPTURED ELISA (MAC ELISA) FOR DIAGNOSIS OF DENGUE INFECTION IN THE NETWORK OF SENTINEL SURVEILLANCE LAB. IT HAS ESTABLISHED/IDENTIFIED ACROSS THE COUNTRY.

37. MANAGEMENT: DENGUE FEVER(DF): Management of Dengue fever is symptomatic and supportive i . Bed rest is advisable during the acute phase. ii . Use cold sponging to keep temperature below 39 C . iii . Antipyretics may be used to lower the body temperature . Aspirin/NSAID like Ibuprofen etc should be avoided since it may cause gastritis, vomiting, acidosis and platelet disfunction . iv . Oral fluid and electrolyte therapy are recommended for patients with excessive sweating or vomiting. v . Patients should be monitored in DHF endemic area until they become afebrile for one day without the use of antipyretics and after platelet and haematocrit determinations are stable, platelet count is >50,000/ cumm .

38. INDICATIONS OF RED CELL TRANSFUSION : Loss of blood(overt blood) -10%ormore of total blood volume . Preferably whole blood/ component to be used Refractory shock despite adequate fluid administration and declining haematocrit Replacement volume should be 10ml/kg body wt at a time and coagulogram should be done If fluid overload is present PCV is to be given INDICATIONS OF PLATELET TRANSFUSION: In general there is no need to give prophylactic platelets even at < 20,000/ cumm Prophylactic platelet transfusion may be given at level of < 10,000/ cumm in absence of bleeding manifestations. Prolonged shock; with coagulopathy and abnormal coagulogram In case of Systemic massive bleeding, platelet transfusion may be needed in addition to red cell transfusion. Use of fresh frozen plasma/ cryoprecipitate in coagulopathy with bleeding as per advise of Physician and patients condition. These are only broad guidelines. The treating physician should consider the condition of the patient in totality and decide

39. 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) Early case reporting & management Integrated Vector Management Supporting Interventions 58

40. 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 59

41. INTEGRATED VECTOR MANAGEMENT(IVM) Entomological surveillance including larval surveys Anti - larval measures Source reduction Chemical larvicide Larvivorous fish Environmental management Anti – adult measures Indoor space spraying Fogging during outbreaks Personal protection measures Protective clothing ITBN & repellents 60

42. SUPPORTING INTERVENTIONS Human resource development through capacity building Behavioral change communication Inter – sectoral collaboration Supervision & monitoring Coordination committees Legislative support 61

43. 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 62

44. 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 63

45. 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 64

46. ESTABLISHMENT OF SENTINEL SURVEILLANCE Function of Sentinel Surveillance Hospital: Blood sample collection Maintain line listing of Dengue positive case Capacity building of PHC/CHC 65

47. 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 66

48. 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 67

49. STRENGTHENING OF REFERRAL SERVICES PCR, Virus isolation – 13 apex referral lab Capacity building Have advanced diagnostic facilities 68

50. 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 69

51. INTEGRATED VECTOR MANAGEMENT (IVM): Prevention and reduction in disease burden – control of mosquito vectors Activities to control transmission – target vector in the habitats of its immature & adult stages in households and immediate vicinity Integrated vector management – strategic approach to control vector - promoted by WHO 70

52. INTEGRATED VECTOR CONTROL: Key elements – Advocacy, social mobilization & legislation Collaboration within the health sector and with other sectors Integrated approach to disease control Evidence based decision making Capacity building 71

53. 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

54. MID TERM PLAN FOR PREVENTION & CONTROL OF DENGUE : Implementation period – 2011 to 2013 Objectives : To reduce the incidence of dengue to bring down the disease burden. To reduce the case fatality rate due to dengue. 73

55. MID TERM PLAN FOR PREVENTION & CONTROL OF DENGUE: Key eight elements of Mid Term Plan called as the ‘ OCTALOGUE 1 . Surveillance : a.Disease Surveillance b . Entomological Surveillance 2. Case management : a . Laboratory diagnosis b.Clinical management 3 . Vector management: a . Environmental management for Source Reduction b. Chemical control c . Personal protection d . Legislation 4. Outbreak response : a . Epidemic preparedness b . Media management 5. Capacity building : a . Training b . Infrastructure development c . Operational research 6 . Behaviour Change Communication: - a . Social mobilization b . IEC 7 . Inter- sectoral coordination: Health & non health sector 8 . Monitoring & Supervision: Review, field visit , feedback

56. Epidemiological surveillance will be carried out as under : : For effective epidemiological surveillance, uniform data collection would be carried out in prescribed formats. All suspected cases should be recorded. All components of surveillance i.e. collection, compilation, analysis and interpretation of data, follow-up action and feedback should be carried out in a systematic and organized manner. During transmission period (monsoon and post Monsoon reporting will be on daily basis by email or by fax. In non or low transmission period reporting will be on weekly basis. Report of the previous week (Monday to Saturday) should be compiled by the States and send to NVBDCP by every Monday.

57. Strengthening of reporting system by provision of e-reporting mechanism. Software would be developed for this purpose. The state programme officers would arrange epidemiological, entomological, clinical and laboratory investigations, whenever necessary . Supervision and monitoring at all levels would be strengthened for ensuring effective surveillance.

58. surveillance Monitor trends in the distribution and spread of disease over time; Detect the cases early for timely intervention; Measure the disease burden; Assess the social and economic impact of dengue on the affected community; Evaluate the effectiveness of prevention and control programme OBJECTIVES OF SURVEILLANCE:

59. Proactive surveillance . SURVEILLANCE

60. ENTOMOLOGICAL SURVEILLANCE Larval Surveillance Adult Surveillance Oviposition traps Tyre section larvitraps visual inspection of the water-filled radial section of an automobile tyre. “ Ovitraps : are devices used to detect the presence of Ae. aegypti and Ae. albopictus where the population density is low and larval surveys are largely unproductive Surveillance for dengue vector mosquito is important in determining the factors related to dengue transmission in order to prioritize areas and seasons for vector control

61. . LARVAL /PUPAE SURVEILLANCE Number of houses infested X100 Number of houses inspected Number of positive containers X100 Number of containers inspected Number of positive containers X100 Number of houses inspected Number of Pupae X100 Number of houses inspected House Index (HI): Container Index (CI): Breteau Index (BI): Pupal Index (PI): Depending upon potential for outbreak areas are divided into 4 categories CATEGORY-I Death due to dengue confirmed CATEGORY-II HI>5 AND BI>20 CATEGORY-III HI<5 AND BI<20 CATEGORY-IV Despite active search no breeding site found positive

62. Mosquito Control Measures 82 Anti larval measures Anti adult measures Protection against mosquito bites Legislative control Environmental control Chemical control 3. Biological control Space sprays Residual sprays 3. Genetic control 1. Mosquito nets 2. Screening 3. Repellents Civic laws Integrated vector control approach for mosquito

63. ENVIRONMENTAL MANAGEMENT 83

64. . BIOLOGICAL CONTROL Larvivorous fish Eg . Gambusia affinis & Lebister reticulatus are recommended for control of Ae. aegypti in large water bodies or large water containers Endotoxin-producing bacteria, Bacillus thuringiensis serotype H-14 ( Bt H-14) has been found an effective mosquito control agent.

65. PERSONAL PROTECTION AGAINST BITES MOSQUITO NETS Protects against bites SCREENING Door and window screening With nets gives excellent protection REPELLENTS Mosquito repellent creams, Lotions are good as short term personal protective measures Wearing Full Sleeve Clothes and covering most of the body parts against mosquito and fly bites.

66. OUT BREAK RESPONSE Epidemic preparedness: Verification of the outbreak and Communication with authorities concerned and recommendation of control measures Early diagnosis and appropriate clinical case management of dengue to minimize the number of dengue-associated deaths. Emergency vector control to curtail transmission of the dengue/chikungunya virus as rapidly as possible.; Constitution of a Rapid Response Team (RRT) : Dy.cmoh -II, Epidemiologists, vbd consultant, entomologists, microbiologists/pathologist and IEC Officer/Consultant /Media officer in each district HQ including Municipalities. Media Management Print and electronic media shall be informed on day to day activities for control of dengue involving the media before the occurrence of the seasonal increase in dengue enhances the opportunity to increase public awareness about the disease and the personal and community actions that can be taken to mitigate the risk.. Two major components of the outbreak response are :

67. CAPACITY BUILDING Training 1.Clinical and laboratory-based surveillance, diagnosis and case management 2. Vector Surveillance 3. Emergency control (Rapid Response) Infrastructure development The entomological setup is very poor in almost majority of the states/ districtrs /municipalities. The vacant posts of entomologists and Insect collectors at each district and zonal level should be filled up. Operational research It is desirable to prioritize research areas and develop new strategy by undertaking operational research with a view to improving its effectiveness and efficiency of the existing tools for giving greater scientific credibility to dengue control in India.

68. BEHAVIOR CHANGE COMMUNICATION(BCC) Process of bringing together all feasible and practical inter- sectoral social allies to raise people’s awareness of and demand for dengue prevention and control, to assist in the delivery of resources and services, and to strengthen community participation for sustainability and self-reliance. Social Mobilization IEC & BCC Increase the visibility of the problem Increase levels of political commitment Enhance mobilization of resources Community Mobilization Sustainability

69. INTER-SECTORAL COORDINATION Resource sharing Policy adjustment Role of non-health sectors in dengue control Ministry of Urban Development / Construction Agencies (CPWD). , Local Governments/ Corporations/ Municipality, Ministry of Rural Development, Ministry of Panchayati Raj, Ministry of Science and Technology , Ministry of Surface Transport , Ministry of Earth Science (Meteorological Department), Ministry of HRD, Ministry of Irrigation, Ministry of Agriculture, Ministry of Railways, Ministry of Defence , Ministry of Commerce

70. MONITORING & EVALUATION (M & E) Flow of information Supervision Monitoring : is a process tool used to keep a watch on goal setting , analysis and planning activities aimed to achieve the set goals. Evaluation: is an outcome tool. Assessment of input, process and output indicators are carried out to know the outcome. Depending on the outcome, the course of the programme is evaluated. Information flow may start from the periphery to the centre or vice versa. While the information regarding output indicators and process indicators flow from periphery to the centre, input indicator and outcome indicator information flows from centre to the periphery. Impact indicators have to be communicated to the periphery as a feedback from the centre to periphery. They would help in timely and complete reporting. A set back of the current Dengue and Chikungunya has been perceived due to poor or nil supervision of the programme implementation at peripheral level.

71. DENGUE VACCINE : 4 types of vaccines under development – Live attenuated vaccine Chimeric live attenuated vaccine Inactivated or sub unit vaccine Nucleic acid based vaccine

72. 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.

73. 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

74. 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

75. REASONS FOR RE EMERGENCE OF DENGUE FEVER Increased population management – Significant increase in plantations – Increased demand for rubber Rubber plantation increased

76. 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

77. 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)

78. RE EMERGENCE OF DENGUE: INADEQUATE ENVIRONMENTAL MANAGEMENT : Inefficient waste collection and management Non biodegradable containers Improper tyre disposal Insufficient and inadequate water distribution Inadequate management of water storage & disposal

79. 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

80. FILARIA

81. Magnitude of the problem: It is a global problem (mainly Africa, Asia, West pacific & Americas ) affecting over 83 countries. More than 1.3 billion people live in areas where there is risk of infection,of whom 120 million are infected and in need of treatment, including 40 million people with overt disease i.e 15 million with lymphoedema and 25 million men with urogenital swelling mainly scrotal swelling.   About 95% of cases of lymphatic filariasis are caused by infection with W . bancrofti ; other parasites include Brugia malayi and B. timori .  An estimated 600 million people are at risk of lymphatic filariasis infection in 250 endemic districts in 20 states/UT in India .   Bancroftian   filariasis  is widely  distributed while Brugian filariasis caused by Brugia Malayi is restricted to  6 statesUP,Bihar ,  AndhraPradesh,Orissa ,  Tamilnadu , Kerala, and Gujarat.

82. 103 HUMAN FILARIAL INFECTIONS: ORGANISM VECTORS DISEASE PRODUCED Wuchereia bancrofti Culex Mosquitoes Lymphatic filariasis Brugia malayi Mansonia Mosquitoes Lymphatic filariasis Brugia timori Anopheles Mosquitoes Mansonia Mosquitoes Lymphatic filariasis Onchocera volvulus Simultum flies Subcutaneous nodules; River blindness Loa loa Chrysops flies Recurrent, transient subcutaneous swellings T. Perstans Culicoides Probably rarely any clinical illness T. Streptocerca Culicoides Probably rarely any clinical illness Mansonella ozzardi Culicoides Probably rarely any clinical illness

83. EPIDEMIOLOGICAL TRIAD FOR FILARIASIS: AGENT HOST ENVIRONMENT VECTOR Wucereria bancrofti , Brugia malayi and B. timori . Culex & Mansonia Mosquitoes 1.CLIMATE: Favourable  temperature for  Culex  is  between22   –38 deg C with relative humid  environment 2.BAD DRAINAGE: - Inadequate   sewage disposal and lack of townplanning have aggravated the problem in India . - The common breeding place are cesspools, soakagepits , ill maintained drains, septic tanks, open ditches,burrow pits,     -All ages are susceptible but usually Infection rates rises with age upto 20-30 years and then level off. -Higher prevalence in males . -Urbanization , Industrialization, Illiteracy, Poverty and Poor sanitation

84. CLINICAL MANIFESTATION: Incubation period: 8-16 months Manifestation divided into Two types: - Lymphatic filariasis - occult filariasis LYPMHATIC FILARIASIS: ( i )Asymptomatic amicrofilaraemia :- - No symptom & no microfilariae .(But they have the same degree of exposure to infective larvae as those who are infected) ( ii)Asymptomatic  microfilaraemia :- - No symptom but mf present in the blood .(Important source of infection in the community) ( iii)Stage of Acute manifestation :- - Filarial fever, lymphangitis , lymphadenitis and lymphoedema and epididyo-orchitis in male. ( iv)Stage of Chronic Obstructive Lesions:- - Develop 10-15 years after first acute attack and is due to fibrosis and obstruction of lymphatic vessels. - Hydrocele, Elephantiasis and  chyluria OCCULT FILARIASIS: - classical clinical filarial manifestation are not present and micofilariae not found in blood. -Due to hypersensitivity reaction to filarial antigen derived from microfilariae.e.g tropical pulmonary eosinophilia

85. CLINICAL FEATURES: 1.Asymptomatic Parasite Carrier State 2.Acute Disease: -- Adenolymphangitis : Acute dermato-adeno-lymphangitis (ADLA) Acute filarial lymphangitis (AFL ) -- Acute epididymo-orchitis and funiculitis : 3.Chronic Disease: Involvement of Limbs Lymphoedema of the extremities is a common chronic manifestation of LF, which on progression leads on to elephantiasis . Lymphoedema of the limbs is graded as follows: - Grade I lymphoedema : Mostly pitting oedema; spontaneously reversible on elevation - Grade II lymphoedema : Mostly non-pitting oedema; not spontaneously reversible on elevation - Grade III lymphoedema (elephantiasis): Gross increase in volume in a grade II lymphoedema with dermatosclerosis and papillomatous lesions. In the advanced stages of lymphoedema , the skin is thickened and thrown into folds, often with hypertrichosis , black pigmentation, nodules, warty growth, and Intertrigo in the webs of toes or chronic non-healing ulcers. Genito -urinary Involvement: --Hydrocele -- Chylocele -- Lymphoedema of the scrotum and penis --Lymph scrotum

86. NATIONAL FILARIA CONTROL PROGRAM This program was started in 1955. In 1962 the stratergy revised due to non- cooperarion of people because of side effect of DEC and development of resistance to insecticides by the vectors. In 1978 the operational component was merged with Urban Malaria Scheme for maximum utilization of available resources. In 1997 India became a signatory to WHO for global elimination of Lymphatic F ilariasis and the target for global elimination is by 2020 . In 2003 -04 it was merged with NVBDCP.

87. Revised Filaria Control Strategy The National Health Policy 2002 aims at Elimination of Lymphatic Filariasis by 2015. Elimination of Lymphatic filariasis is defined as “Lymphatic Filariasis ceases to be a public health problem when the no. of microfilaria carriers is less than 1% and children born after initiation of elimination of Lympmatic filariasis are free from circulating antigenaemia ( i.e presence of adult filarial worm in human body)” OBJECTIVES: - To reduce and eliminate transmission of lymphatic filariasis by MDA Of DEC in endemic areas. - To reduce and prevent morbidity in affected areas. - To strengthen the existing health care services.

88. STRATEGY: Single day Annual Mass Drug Administration  with single dose of Diethyl carbamazine (DEC) @ 6mg/kg body wt for consecutive 5-7 years(life span of adult worm) to interrupt transmission of disease. IEC for individual/community based preventive and protective measures for filarial control.IEC also directed at self care of affected parts and early seeking of care. Vector control measures. Coadministration of DEC +Albendazole had been upscaled to cover the population at risk since 2007.

89. MDA(Mass drug administration): The concept of MDA is to approach every individual in the target community and administer annual single dose of anti-filarial drugs (DEC or DEC+Albendazole ) except pregnant women, children below two years of age and persons who are very sick from other illness . This annual dose is to be repeated every year for a period of 5 years or more aiming at minimum 85 % actual drug compliance. --DEC tablets should be taken once in a year on the identified day of MDA (National Filaria Day 5 th june ).

90. The recommended approach based on the past experience is “ supervised drug administration by door to door visit supplemented with drug administration at booths and groups” preferably on a single day with two-day mopping upoperations , instead of mere distribution of drugs. Mopping-up: •Daily visits to the area for two days following MDA to cover the absentees • If any case with side effects , provide them with symptomatic treatment. • If any case requires hospital admission, report to the VHN/rapid response team •Record on the number of people covered daily.

91. CLINICAL PARAMETERS PARASITOLOGICAL PARAMETERS ENTOMOLOGICAL PARAMETERS Filarial Endemicity Rate Microfilarial Density Microfilaria Rate Average Infestation Rate Vector density per 10 man – hours catch % of mosquitoes positive for all stages of development % of mosquitoes positive for infective larvae types of breeding places Incidence of acute and chronic manifestation ASSESSMENT OF FILARIA CONTROL PROGRAMME:

92. 1. Microfilaria Rate: % of persons showing Mf in their peripheral blood in a sampled population . 2. Filarial Endemicity Rate : % of persons examined showing microfilariae in blood, or disease manifestation or both . 3. Microfilarial Density: No. of Mf per unit volume of blood in samples from individual persons. 4. Average Infestation Rate: Average number of Mf per positive slide. 1 . Vector density per 10 man – hours catch 2. % of mosquitoes positive for all stages of development 3. % of mosquitoes positive for infective larvae 4. types of breeding places. Parasitological indices Entomological indices

93. KALA -AZAR

94. KALA-AZAR( Lesmaniasis, black fever, sandfly disease, Dum-Dum fever and espundia ) Kala- azar is a slow progressing disease caused by a protozoan parasite of genus Leishmania . In India Leishmania Donavan is the only parasite causing this disease The parasite primarily infects reticuloendothelial system and may be found in abundance in bone marrow, spleen and liver. Post Kala- azar Dermal Leishmaniasis (PKDL) is a condition when Leishmania donovani invades skin cells, resides and develops there and manifests as dermal leisions .

95. MAGNITUDE OF PROBLEM: Currently , leishmaniasis occurs in 4 continents and is considered to be endemic in 88 countries, 72 of which are developing countries: 90% of all VL : Bangladesh, Brazil, India , Nepal and Sudan 90% of all MCL : Bolivia, Brazil and Peru 90% of all CL : Afghanistan, Brazil, Iran, Peru, Saudi Arabia and Syria, India(Central & Western India) Annual incidence: 1- 1.5 million cases of CL : 500,000 cases of VL Prevalence: 12 million people Population at risk: 350 million

96. SITUATION IN INDIA Surveillance being done by NVBDCP INDIA: 13827 cases and 20deaths by VL ( 2013) Endemic states in Eastern India: Bihar(52 districts), Jharkhand(31), West Bengal(11), Uttar Pradesh(6) Estimated 165.4 million population at risk in 4 states ( NVBDCP)

97. EPIDEMIOLOGICAL TRIAD FOR KALA-AZAR: AGENT HOST ENVIRONMENT VECTOR Leismania donovani Phlebotomous argentipes (sand fly) - Overcrowding, ill ventilation and accumulation of organic  matter facilitate transmission - Cracks and crevices in walls,holes in trees,dark rooms --Damp dark places in the vicinity of cattle sheds and poultry.   -All age groups are susceptible peak age is -5-9 years of age . -M:F ratio is 2:1 -More common in the poor. -Farming , forestry, fishing, mining people are at greater risk

98. Signs & Symptoms of Kala- Azar : incubation period: 1-4 months (10 days – 2yrs) Recurrent fever intermittent or remittent with often double rise loss of appetite, pallor and weight loss with progressive emaciation Splenomegaly - spleen enlarges rapidly to massive enlargement, usually soft and non tender Liver - enlargement not to the extent of spleen, soft, smooth surface, sharp edge Skin - dry, thin and scaly and hair may be lost. Light colored persons show grayish discoloration of the skin of hands, feet, abdomen and face which gives the Indian name Kala- azar meaning "Black fever" Anemia - develops rapidly

99. Post Kala Azar Dermal Leishmaniasis Non ulcerative cutaneous lesion prevalent in endemic areas of kala azar in India. In 10 % treated cases of Kala azar, Normally develops <2 years after recovery(When Visceral infection disappears but skin infection persists). Clinical feature: Depigmented macules: earliest lesion, trunk, extremities and face Erythematous patches: Nose, cheeks and chin Yellowish pink nodules: Nodules mostly on face & are soft, painless granulomatous growth of varying sizes (Absences of ulceration is a noticeable feature) Do not heal spontaneously. Recrudescence Restricted to skin Extensive nodular lesion, resembling lepromatous leprosy. A very resistant case cured after long continued treatment

100. Diagnosis Clinical: A case of fever of more than 2 weeks duration not responding to antimalarials and antibiotics. Clinical laboratory findings may include anemia, progressive leucopenia thrombocytopenia hypergammaglobulinemia Laboratory diagnosis: 1.Demonstration of the parasite ‘LD’ bodies in the aspiration of the spleen,liver,L.N is the only way to confirm VL or CL. 2. Aldehyde test: positive after 2-3 month after onset of disease and reverts to negative 6 months after cure. This test is useful for surveillance but not for diagnosis. 3. Serological test: DAT(direct agglutination test) rK 39 dipstick test ELISA ifat (Indirect fluorescent antibody test)

101. Treatment of Kala – Azar : Kala- azar Drugs available in India Sodium Stibogluconate Pentamidine Isethionate : Amphotericin B : Liposomal Amphotericin B: Drug Policy under Kala- azar Elimination Programme as per recommendations of Expert Committee ( 2000): Dosages : After enrollment oral miltefosine treatment will be administered as per following dosage schedule: i . Adults (>12 years) weighing more than 25kg : 100mg miltefosine daily as one capsule (50 mg) in the morning and one capsule in the evening, after meals for 28 days. ii. Adults (>12 years) weighing (less than 25kg ): 50mg,miltefosine daily as one capsule (50 mg) in the morning, after meals for 28 days. iii. Children (2-11 years ): miltefosine will be given at 2.5 mg/kg daily after meals for 28 days, i.e., 50mg once daily. iv. The drug is not to be used in the case of children below 2years of age.

102. Drug Policy under Kala- azar Elimination Programme as per recommendations of Expert Committee (2000) Short Term: Long Term: Areas with SSG sensitivity >90% Areas with SSG sensitivity <90% Areas with high level of SSG resistance (>20%) Areas with SSG sensitivity >80% SSG IM/IV 20mg/kg/day X 30 days Amphotericin B 1mg/kg b.w . IV infusion daily or alternate day for 15-20 infusions. Dose can be increased in patients with incomplete response with 30 injections Miltefosine 100 mg daily x 4 weeks » SSG IM/IV 20mg/kg/day X 30 days » Miltefosine 100 mg daily x 4 weeks First Line Drugs:

103. Second Line Drugs SSG Failures SSG and Miltefosine Failures Amphotericin B 1mg/kg b.w . IV infusion daily or alternate day for 15-20 infusions. Dose can be increased in patients with incomplete response with 30 injections » Liposomal Amphotericin B (when final results are available with proven efficacy and safety) Treatment of PKDL » SSG in usual dosages for KA could be given up to 120 days » Repeated 3-4 courses of Amphotericin B can be given in patients failing SSG trea

104. KALA AZAR CONTROL PROGRAMME: An organized centrally sponsored Control Programme launched in endemic areas in 1990-91 Government of India provided kala-azar medicines, insecticides and technical support and the State governments implemented the programme through primary health care system and district/zonal and State malaria control organizations and provided other costs involved in strategy implementation. GOAL OF NATIONAL HEALTH POLICY (INDIA) 2002: ELIMINATION OF KALA AZAR 2010 Elimination Programme is 100 per cent Centrally Supported (except regular staff of State governments & infrastructure) In addition to kala-azar medicines and insecticides, cash assistance is being provided to endemic state s since December 2003 to facilitate effective strategy implementation by state GOI also signed a tripartite memorandum of understanding with Nepal and Bangladesh in May 2004 for elimination of Kala- azar from South-east Asian region by2015

105. STRATEGY FOR KALA-AZAR ELIMINATION: Programme strategy included: - enhanced case detection and complete treatment including introduction of rK39 rapid diagnostic kits and oral drug miltefosine for treatment of kala-azar . - Vector control through insecticidal residual spray (IRS ) with DDT up to 6 feet height from the ground twice annually - Early Diagnosis and Complete treatment -  Information Education Communication - Capacity Building - Monitering ,supervision and evaluation -Operational research

106. Active case search by “ KALA-AZAR FORTNIGHT PROGRAMME ” During this programme HW and volunteers are engaged to make door to door search and refer cases confirming the case definition of kala-azar and PKDL to the treatment centres for definitive diagnosis and treatment. -Conducted four times in a year Incentives of Rs100/ provided to HW and ASHA for referring a suspected case and to ensure complete treatment . Kala- azar case Definition: Persons with fever of more than 15 days duration not responding to anti- malarials and antibiotics with splenomegaly is a suspected case of Kala- azar . PKDL: Persons with depigmented patches on the body with sensation and with a history of kala-azar in the past is a suspected case of PKDL.

107.   ANOPHELES AEDES CULEX SAND FLY   Sophisicated Mosquito Tiger Mosquito Nuisance Mosquito   DISEASE SPREAD Malaria Dengue Yellow Fever Chikungunya Japanese Encephalitis Filariasis   Kala-Azar SPECIES Foot-Hill Region: -Anopheles Fluviatilis -Anopheles Minimus     Coastal Region: -Anopheles Sundaicus -Anopheles Stephensi   Plains: -Anopheles Culicifaciens -Anopheles Philippinesis       Aedes aegypti   Others: Aedes vittatus Aedes albopictus Culex fatigans :Filariasis   Culex tritaniorhynichus : JE Phlebotomus argentipes EGG(48hrs) -Laid singly -Boat shaped -Posses lateral flots -Laid singly -Don’t have lateral floats - CIGAR SHAPED - Laid in clusters -Don’t have lateral floats -laid singly -Large, torpedo shaped with longitudinal wavy lines on the outer side

108. LARVAE(5-7 days) -Floats horizontally in water -No siphon tube -Suspended in water with head downwards -Siphon tube situated on the 8 th abdominal segment -Hairy maggots with distinct head,thorax and abdominal segment -Last abd. Segment carries two pairs of long,stout hairs one pair is remarkably long PUPA(1-2 days) -Siphon tube is broad and short -Siphon tube long and narrow Lasts 1 weeks ADULT(2 weeks) --Wings spotted --when at rest inclined at an angle to surface --It has white stripes on a black body and striped or banded character of their legs, called tiger mosquito.     BREEDING PLACE Clean water --An. Stephensi : overhead Tanks,wells , Fountains --An. Fluviatilis : moving Water --An. Sundaicus:Brackish water Artificial accumulations of water in and around human dwellings such as discarded tins,broken bottles,flower pots,coconut shells,earthen pots etc In dirty water collection e.g:stagnant drains,cesspools,septic tanks,burrow pits etc can breed all type of water collection. -- Cracks and crevices in walls,holes in trees,dark rooms --Damp dark places in the vicinity of cattle sheds and poultry. BITING HABBIT Mostly nocturnal ( between dusk and dawn.) Mostly during the day Enters the house at dusk and reaches max. density by midnight. Peak biting time is about midnight -Bite usually at night . -Bite is irritating and painful RANGE OF FLY 3-5 KM 100 METRES 11 KM Incapable of flying,merely hop about from one place to other.so confined within 50 yards of their breeding place.

109. 135 Thank You