Dengue/DHF

Situation of Dengue/Dengue Haemorrhagic Fever in the South-East Asia Region

Introduction

Dengue fever is an acute febrile viral disease characterized by sudden onset, fever of 3-5 days, intense headache,
myalgia, anthralgic retro-orbital pain, anorexia, GI disturbances and rash. Dengue viruses are flaviviruses and
include four serotypes 1, 2, 3 and 4 (Dengue – 1, -2, -3 and - 4). These viruses are also responsible for Dengue
Haemorrhagic Fever (DHF). The viruses are transmitted to man by the bite of infective mosquitoes, mainly
Aedesaegypti. The incubation period is 4-7 days (range 3-14 days). This disease is now endemic in most tropical
countries. DHF caused by the same viruses, is characterized by increased vascular permeability, hypovolaemia
and abnormal blood clotting mechanisms.
Dengue fever (DF) with its severe manifestations such as Dengue Haemorrhagic Fever (DHF) and Dengue Shock
Syndrome (DSS) has emerged as a major public health problem of international concern. The geographical
distribution has greatly expanded over the last 30 years, because of increased potential for breeding of
Aedesaegypti, the vector species. This has been prompted by demographic explosion, rapid growth of urban
centres with a strain on public services, such as potable water. This has been augmented by rainwater harvesting
in diverse types of containers resulting in multiple storage practices.

As per current estimates, availability of at least 100 countries are endemic for DHF and about 40% of the world
population (2.5 billion people) are at risk in tropics and sub-tropics. As per estimates, over 50 million infections
with about 400,000 cases of DHF are reported annually which is a leading cause of childhood mortality in several
Asian countries.

Countries in SEA Region reporting Dengue in Countries in SEA Region reporting Dengue in 2007
2003

In 2003 only 8 countries in South East Asia Region reported dengue cases. As of 2006, ten out of the eleven
countries in the Region (Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand
and Timor-Leste) reported dengue cases. Bhutan reported the first dengue outbreak in 2004. An outbreak,
with a high case fatality rate (3.55%) was first reported in Timor -Leste in 2005. Nepal reported dengue cases
for the first time in November 2006. The Democratic Peoples’ Republic of Korea is the only country in this
Region of WHO that has no report of indigenous transmission of DF/DHF.

Of the total world population of 6.2 billion, countries of the South-East Asia Region (SEAR) account for 1.5 billion
(24%). On that scale, of the 2.5 billion people (living in the tropics and sub-tropics) at risk of DF/DHF, 52%, i.e.
1.3 billion population, live in SEAR. (Figure 1).
Figure 1: Population at risk of DF/DHF in the South-East Asia Region
Variable endemicity for DF/DHF in countries of SEA Region

Although Dengue/Dengue Haemorrhagic Fever is endemic in most countries of the region, all four serotypes have
been detected in all the countries . The transmission potential, however , is different both at the macro- and micro
levels.

The current situation of DF/DHF in countries of the South East Asia Region can be stratified
as follows:

Category A (Indonesia, Thailand, Sri Lanka and Timor- Leste)

Major public health problem
Leading cause of hospitalization and death among children
Cyclical epidemics in urban centers
Spreading to rural areas
Multiple virus serotypes circulating
Category B (Bangladesh, India, Maldives)
Cyclical epidemics are becoming more frequent
Multiple virus serotypes circulating
Expanding geographically within countries

Category C ( Bhutan and Nepal )

Endemicity uncertain
Bhutan: First outbreak reported in 2004
Nepal: Reported dengue cases for the first time in November 2006.
Category D ( DPR Korea )
No evidence of endemicity.

While the ecological and climatic factors influence the seasonal prevalence of the species, factors related to human
ecology determine the extent and intensity of breeding. On the basis of climatic factors, the countries oft the
Region can be divided into four distinct climatic zones with different DF/DHF transmission potential. These are as
follows:
Tropical Monsoon and Equatorial Climatic Zone
Deciduous Dry and wet Climatic Zone
Sub-Himalayan foothill Region
Temterate Climate Region

Tropical Monsoon and Equatorial Climatic Zone

This zone includes four countries, viz. Indonesia, Myanmar, Thailand and Timor-Leste. The annualrainfall in this
zone is >150 cm. Aedes aegypti is widespread in both urban and rural areas. Transmission is extended and DHF
epidemics occur in 3-5 years cycles, associated with high morbidity in children.
Development of National Dengue Prevention and Control Programme
In response to the resolution accepted by the World Health Assembly in 1993, WHO/ SEARO developed a
regional strategy for control of DF/DHF in 1995 and revised it in July 2001 with the following major
components:
Establish an effective disease and vector surveillance system based on reliable laboratory and health
information systems.
Ensure early recognition and effective case management of DHF/DSS to prevent case mortality.
Undertake disease prevention and control through integrated vector management with community and
intersectoral participation.
Undertake activities to achieve sustainable behavioural changes and partnerships.
Establish emergency response capacity to control outbreaks with appropriate medical services, vector
control, communications and logistics.
Strengthen regional and national capacities to undertake prevention and control of dengue and research
related to epidemiology, disease and vector management and behavioural changes.
 Different countries formulated control programmes as per their priorities, availability of infrastructure, and
resources, etc. Consequently, Thailand, Indonesia and Myanmar established National Dengue Prevention and
Control Programmes followed by Sri Lanka which has established a National Task Force for control of DF/DHF.
India, Bangladesh and Maldives do not have National Dengue Control Programmes but undertake vector-borne
disease control/malaria control activities for emergency control of epidemics.

Major activities under Dengue/DHF Control Programme

Disease Surveillance

A strong surveillance system is crucial for priority setting, policy decision to reduce disease burden,
prediction and early detection of epidemics. All the countries in the Region have passive surveillance
systems, which do not help in predicting epidemics.

Emergency Response

Practically most of the dengue-endemic countries do not have the necessary infrastructure to respond early
and effectively to control epidemics. Emphasis is always on fogging and larvicide application. There has been
an attempt to mobilize communities to undertake source reduction methods to prevent transmission. In
most of the cases, the community will rely almost exclusively on government services to address the
problem.

Clinical Diagnosis and Management

Prompt diagnosis and standardized treatment is a key to case management and for reducing the case
fatality rate. In the South-East Asia Region clinicians and physicians in Thailand have provided the
leadership in this direction. Seminal studies on the pathogenesis and pathophysiological changes in DHF
patients were carried out in 1960 at the Queen Sirikit Institute of Child Health, the WHO Collaborating
Centre for Clinical Management of DF/DHF, which resulted in development of guidelines for clinical diagnosis
and management of severe cases to bring down the CFR below 0.5%. These guidelines were adopted by
WHO in 1975 and have also been incorporated into the IMCI protocols of Indonesia, Vietnam and Philippines.

Vector Surveillance

Larval Surveys: Specialized ecologies of Aedes mosquitoes, limited dispersal and container breeding
habitat and preference for human blood, enable the species to stay within human settlements. Vector
surveillance is largely based upon sampling larval population for estimation of appropriate indices for
planning, monitoring and evaluation of control programmes.

Vector Control

The Regional dengue control strategy envisages a "selected, sustainable and integrated control approach
with community and intersectoral participation".

The countries of the Region have developed various models of community-based control programmes based
source reduction and have met with varying degrees of success.