Prof Farakh A Khan
According to WHO (1999) 2.5 billion people are at risk of dengue virus infection in 200 countries. Before 1970 only nine countries had dengue fever. The mortality is about 5%, which can be reduced to 1% with proper treatment in the hospital. Dengue viral infection has become the leading public health problem.
According to Centres for Disease Control and Prevention USA dengue infection places more than 1/3rd population of the world at risk. Every year 100 million people get infected.
The first case of dengue virus in Pakistan was reported in 1996 and incidence started to rise in 2003-2004 (Shahid, Jamal. Govt blames lifestyle for dengue spread. Dawn. September 22, 2011). The dengue viral attack reached epidemic proportions in Lahore during the summer of 2011. The number of people down with dengue viral infection in Lahore can only be a vague conjecture since we have no system to collect reliable statistics. Our rough estimate is that more than 100,000 people in Lahore have so far been infected if the recorded deaths are to be relied upon. There have been 98 reported deaths allegedly due to dengue haemorrhagic fever in Lahore (Nine more die of dengue in Lahore. OC. The News. September 24, 2011).
First let us analyse what the Pakistani papers have been feeding us in this regard.
It is being claimed that the man in charge of anti dengue fight in Punjab is a retired IG police! The company, which allegedly imported defective fumigation insecticide, was again given contract for more imports. The Sri Lankan team claims that no one dies of dengue and there is no reason to give platelet drips as recommended by doctors here. The Siri Lankan team also told us that fumigation is effective in control of mosquitoes by 15% only. The rest of mosquito control has to be done by the people by eliminating breeding sites. It was embarrassing to know that A aegypti was found breeding in flowerpots in a government hospital. Hospitals in Lahore are most dangerous places to catch the virus (Dengue mosquitoes, eggs found in hospital. Our Staff Reporter. Dawn Metro & Central. September 17, 2011). It is obvious that our doctors don’t read or surf the Internet. One thing is obvious that Health Department like other government departments had disintegrated many years ago. The Sindh floods have again shown total breakdown of the government. We are experts at converting natural disasters into man made disasters.
The response from the government health department has been illogical and at times verges on absurd. A total of 110 labs in Lahore have been closed by the police for ‘over charging’ for complete blood test (CBC). The Punjab chief minister had fixed the rate at Rs90 per test for suspected dengue patients whereas it costs more than Rs150 to the lab (Closure of labs adds to patients’ misery. Our Staff Reporter. Dawn Metro & Central. September 20, 2011). Most labs shall now conduct ‘sink test’ or close down.
To deal with dengue panic the District Coordination Officer Rawalpindi has imposed Section 144 in the district besides other punitive measures (Yasin, Aamir. Section 144 imposed to deal with dengue. Dawn. September 20, 2011). I wish this Section was applicable for the mosquitoes as well. Again Section 144 was applied to car service stations since they used water. After a week this absurd curb was lifted (Rizvi, Jawwad. Service stations allowed to work. The News City News. September 24, 2011). The Punjab government came into action when dengue fever spread far and wide in Lahore (Shahbaz pays surprise visit to hospitals. HO. The News. September 20, 2011).
Ten days holidays were enforce in Lahore schools and Faysal Bank T20 Cup 2011 cricket tournament were shifted from Lahore to Karachi. Lahore has also clamped Section 144, which prevents collection of more than four people but is not applicable to the mosquitoes. This is decision making Pakistani style. Swimming pools have been closed. Some claimed that chlorine and other chemicals added to the pool water would not allow the mosquito to breed. This is not true (Ban on swimming pools in Sindh. APP. Dawn. September 22, 2011). One so called Islamic scholar from Faisalabad speaking (September 14) on GEO TV as usual claimed that the flood in Sindh and dengue in Punjab is the result of our immoral behaviour and sent by God. All we need to do is to ask God for forgiveness of our sins. President also asked for divine intervention. Various schools of alternative medicine have jumped on dengue bandwagon. The homeopaths have come out with a medicine, which if taken daily allegedly prevents dengue virus attack. Papaya leaves and now branches have devastated papaya trees in Lahore. These are being used as curative medicine for dengue patients. Another favourite is fresh apple juice with touch of lime to improve patient’s symptoms. Dengue virus patients are advised to drink a spoonful of ‘haldi’ in milk. Diagnostic equipment sellers also cashed into the epidemic. Anti mosquito devices and repellents became scarce in the market and were selling at high prices. Large numbers of banners were put up on Lahore roads regarding Dengue prevention.
In desperation Pakistan has to import insecticide from India our greatest enemy (PM directs PIA to airlift insecticide from India. OC. The News. September 21, 2011).
In Jang Economic Session on dengue problem in Pakistan none of the participants were remotely connected with dengue expertise. It was claimed that fatalities from dengue virus was only 0.04%. Needless to say that our statistics are always far off the mark and calculation of the number of cases and death rate due to dengue virus is mere conjecture (‘Death rate of dengue victims in Pakistan just 0.04 percent’. OC. The News City News. September 22, 2011).
We had many reports in the news media, which are badly reported, and often misleading. I had to do my own research to get some solid information regarding the outbreak. I felt that I should share this information.
Aedes aegypti mosquito lives for 2 to 4 weeks but the eggs survive under dry conditions for one year and larvae emerge when wet weather sets in. Eggs are laid in clean stagnant water and carry mother’s virus. In adults female the dengue virus is of four serotypes (DENV 1,2,3,4) carried in the salivary glands. Unlike other mosquitoes Aedes flight is soundless. It is a fast flying mosquito and cannot be killed by hand. The virus is coveyed from humans to the mosquitoes and back to humans. There are no other intermediary host The Aedes lives in a radius of about 100 meters to ensure supply of human blood. This female mosquito’s peak feeding hours are early morning and late evening but are active in the afternoon as well. Dengue Haemorrhagic fever, though uncommon, is dangerous and needs hospital admission. Its relative Aedes albopictus is the carrier of Yellow fever virus and also Dengue virus (Mortimer, Roland. Aedes aegypti and Dengue fever. Onview.net Ltd, microscopy-UK. 2010).
According to Centres for Disease Control and Prevention USA symptoms start after 4-7 days of the mosquito bite and lasts for 3-10 days. Symptoms vary from none to classical fever, aches, and pains. For 24-48 hours there is plasma leak followed by reabsorption (convalescent) phase lasting 2-4 days. The plasma leak phase where blood fluid leaks into the abdomen and chest is dangerous times for the patient. In few patients the disease advances to haemorrhagic and shock phases, which need hospitalisation and deaths occur in some. The mosquito viral infection from humans begins before the patient becomes symptomatic and lasts for five days when the patients’ blood virus load is high. The virus requires 8-10 days incubation in the mosquito before it can be transmitted to another human. The infected female mosquito can transmit the virus as long as it lives which is up to one month. The mosquito attack is highest during early morning and late evenings but they are also active in the afternoon. In the homes the mosquito attacks take place day and night.
There are number of serology tests (Luminex (Mia), Elisa (IgG and IgM), Viral isolation and PCR) to have a sure diagnosis. These are costly tests and require high value equipment and specially trained personal. Complete Blood Count (CBC) is a crude test but useful for patients developing dengue fever complications.
According to Punjab CM Dengue Eradication Force shall be established and Institute of Public Health made ‘vibrant and proactive’ (SL team guidance has helped save many lives: Shahbaz. OC. The News City News. September 23, 2011).
The solution to dengue fever outbreak is to attack the breeding grounds of the mosquitoes with mass awareness movement of the people. Personal precautions are needed. Pakistan desperately needs centres for mosquito research (malaria and now dengue). Lahore had a state of the art centre for malaria mosquito research run and funded by the Americans. The Americans wound its work in 1980 and the centre was abandoned. Since then we have no mosquito research facility in the country though there is a Vector-Borne Diseases, Public Health Laboratories Division in NIH, Islamabad (Ahmed, Shahzada Irfan. Epidemic concerns. The News Special Report. September 25, 2011). We have also lost people who were experts in this field. To set up a centre and train high calibre dedicated research workers in multidisciplinary (entomology, virology, community medicine, serology etc) field would take up to 10 years to develop. Funds have to be allocated for this centre, which would be substantial.
We should not use the epidemic for political point scoring. The Punjab Government should stop daily meetings and flag waving. Most of all the government functionaries should not visit hospitals, with strict security arrangements, for photo ops when the doctors are inundated with heavy patient load. Let the hospitals work.