vector borne diseases and NVBDCP

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

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

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.
.

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.

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.

• 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)

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

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

12
STRATEGIES OF NVBDCP:
• - Early case detection and complete
treatment,
• - strengthening of referral services,
• -epidemic preparedness and rapid
response.
1.DISEASE
MANAGEMENT
2.INTEGRATED
VECTOR
MANAGEMENT(IVM)
• -Behavioural change communication(BCC)
• -Intersectoral convergence
• -public private partnership
• -Operational research
• -Monitoring and evaluation
3.SUPPORTIVE
INTERVENTIONS:
 Entomological surveillance
 Anti-larval measures
 Anti adult nmeasures

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.

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.

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

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.

PRODROMAL STAGE(1-
6DAYS):
-fever
-lethargy
-malaise
-headache
ENCEPHALITIC STAGE:
-Fever(38-40 c)
-Nuchal rigidity
-Focal CNS signs
-Convulsion
-increased ICT
-Dystonia
hemiplegia,quadriplegia
-Extrapyramidal sympotms
-Coma
LATE STAGE &
SEQUELE:
-Active iflamm. Ends
I.e ESR and temp.
normal
-Neurological signs
stationary or tends
to improve
-Residual
neurological defect
may present
 CASE FATALITY RATE VARIES BETWEEN 20-40% MAY INCREASE UPTO 58%
 AVERAGE PERIOD BETWEEN THE ONSET OF ILLNESS AND DEATH IS ABOUT 9 DAYS.

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.

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)

VACCINATION
Mouse brain derived
-inactivated
-Nakayama or Beijing
strain of JE
Cell cultured derived
-inactivated
Based on Beijing p-3 strain
Cell cultured derived
-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 .

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)

CASE
CLASSIFICATION:
2.Probable cases:
suspected cases in close relation to
confirmed cases
1.Laboratory-
confirmed cases:
-IgM in serum/CSF
-4 fold increase in IgG in paired
sera
-Virus isolation in brain tissue
Nucleic acid ditection by PCR
4.AES due to unknown
agent
3.AES due to other
agents

• 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.

CHIKUNGUNYA
Clinically Supected Chikungunya Fever Cases Since 2008
Sl.
No.
Affected States/UTs 2008 2009 2010 2011 2012 2013* 2014**
1 Andhra Pradesh 5 591 116 99 2827 4827 895
2 Assam 0 0 0 0 0 742 0
3 Bihar 0 0 0 91 34 0 0
4 Goa 52 1839 1429 664 571 1049 306
5 Gujarat 303 1740 1709 1042 1317 2890 200
6 Haryana 35 2 26 215 9 1 1
7 Jharkhand 0 0 0 816 86 61 0
8 Karnataka 46510 41230 8740 1941 2382 5295 1584
9 Kerala 24685 13349 1708 183 66 219 18
10 Madhya Pd. 0 30 113 280 20 139 71
11 Meghalaya 0 0 16 168 0 0 0
12 Maharashtra 853 1594 7431 5113 1544 1432 879
13 Orissa 4676 2306 544 236 129 35 0
14 Punjab 0 0 1 0 1 0 1
15 Rajasthan 3 256 1326 608 172 76 0
16 Tamil Nadu 46 5063 4319 4194 5018 859 181
17 Uttar Pradesh 11 0 5 3 13 0 0
18 Uttarakhand 0 0 0 18 0 0 0
19 West Bengal 17898 5270 20503 4482 1381 646 190
20 A& N Island 0 0 59 96 256 202 64
21 Chandigarh 0 0 0 1 0 0 0
22 D&N Haveli 0 0 0 0 100 2 0
23 Delhi 14 18 120 110 6 18 1
24 Lakshadweep 0 0 0 0 0 0 0
25 Puduchery 0 0 11 42 45 146 183
Total 95091 73288 48176 20402 15977 18639 4574
* Provisional till 31st December | ** Provisional till 30th June | NR=Not Received

EPIDEMIOLOGICAL TRIAD FOR CHIKUNGUNYA:
AGENT
HOST ENVIRONMENT
VECTOR
Chikungunya virus(family
Togaviridae, genus Alphavirus)
Aedes mosquito(Aedes aegypti.)
(PEAK 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)

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

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

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.

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.
Prevention of mosquito bites by personal prophylactic measures.

DENGUE :
Emerging Public Health Problem

Magnitude of Problem:
• The 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.

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.

 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.

Dengue Cases and Deaths in the Country since 2008
Sl.
No.
Affected
States/UTs
2008 2009 2010 2011 2012 2013* 2014**
C D C D C D C D C D C D C D
1
Andhra
Pradesh
313 2 1190 11 776 3 1209 6 2299 2 910 1 74 0
2
Arunachal
Pradesh
0 0 0 0 0 0 0 0 346 0 0 0 0 0
3 Assam 0 0 0 0 237 2 0 0 1058 5 4526 2 12 0
4 Bihar 1 0 1 0 510 0 21 0 872 3 1246 4 0
5 Chattisgarh 0 0 26 7 4 0 313 11 45 0 52 1 0 0
6 Goa 43 0 277 5 242 0 26 0 39 0 198 2 55 0
7 Gujarat 1065 2 2461 2 2568 1 1693 9 3067 6 6170 15 220 0
8 Haryana 1137 9 125 1 866 20 267 3 768 2 1784 5 3 0
9
Himachal
Pd.
0 0 0 0 3 0 0 0 73 0 86 2 0 0
10 J & K 0 0 2 0 0 0 3 0 17 1 1837 3 0 0
11 Jharkhand 0 0 0 0 27 0 36 0 42 0 161 0
12 Karnataka 339 3 1764 8 2285 7 405 5 3924 21 6408 12 528 0
13 Kerala 733 3 1425 6 2597 17 1304 10 4172 15 7911 25 651 2
14 Madhya Pd. 3 0 1467 5 175 1 50 0 239 6 1255 9 174 0
15 Meghalaya 0 0 0 0 1 0 0 0 27 2 46 0 0 0
16 Maharashtra 743 22 2255 20 1489 5 1138 25 2931 59 5432 48 963 0
17 Manipur 0 0 0 0 7 0 220 0 6 0 9 0 0 0
18 Mizoram 0 0 0 0 0 0 0 0 6 0 7 0 0 0
19 Nagaland 0 0 25 0 0 0 3 0 0 0 0 0 0
20 Orissa 0 0 0 0 29 5 1816 33 2255 6 7132 6 21 0
21 Punjab 4349 21 245 1 4012 15 3921 33 770 9 4114 11 32 0
22 Rajasthan 682 4 1389 18 1823 9 1072 4 1295 10 4413 4 89
23 Sikkim 0 0 0 0 0 0 2 0 2 0 38 0 0 0
24 Tamil Nadu 530 3 1072 7 2051 8 2501 9 12826 66 6122 0 677 0
25 Tripura 0 0 0 0 0 0 0 0 9 0 0 0 0 0
26
Uttar
Pradesh
51 2 168 2 960 8 155 5 342 4 1409 5 2 0
27 Uttrakhand 20 0 0 0 178 0 454 5 110 2 54 0 0
28 West Bengal 1038 7 399 0 805 1 510 0 6456 11 5920 6 59 0
29 A& N Island 0 0 0 0 25 0 6 0 24 0 67 0 34 0
30 Chandigarh 167 0 25 0 221 0 73 0 351 2 107 0 0 0
31 Delhi 1312 2 1153 3 6259 8 1131 8 2093 4 5574 6 12 0
32 D&N Haveli 0 0 0 0 46 0 68 0 156 1 190 0 7 0
33
Daman &
Diu
0 0 0 0 0 0 0 0 96 0 61 0 0 0
34 Puduchery 35 0 66 0 96 0 463 3 3506 5 2215 0 150 0
Total 12561 80 15535 96 28292 110 18860 169 50222 242 75454 167 3763 2

DENGUE/ DENGUE HAEMORRHAGIC FEVER
MAGNITUDE OF THE PROBLEM

As per endemicity SEAR divided into 3
categories:
• CATEGORY-A:(HYPERENDEMIC)(india,
Bangladesh,Srilanka,Myanmar,Maldives, Thailand and Timor-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.

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 5th 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.
Infection 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.

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

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

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

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.

• 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

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
58

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

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

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

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

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

• 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

• Function of Sentinel Surveillance Hospital:
• Blood sample collection
• Maintain line listing of Dengue positive case
• Capacity building of PHC/CHC
65

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

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

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

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

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

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
71

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

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

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

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.

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.

 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:

Proactive
surveillance
.
• Proactive system is Serological surveillance designed to monitor dengue
virus transmission, especially during inter-epidemic periods and to
continually provide information on where transmission is occurring, what
virus serotype or serotypes are involved and what type of illness is
associated with the dengue infection. If this type of information is available
without delay, one would be able to detect the introduction of virus into
new area/s. In case of a IgM NS1 positive Dengue case detected during non-
transmission period, the case should be investigated properly. It may be an
index case or may an old case with low IgM titre.
Proactive
surveillance
• The disease surveillance will include clinical diagnosis,
monitoring of fever trends and sero surveillance. The
medical OPDs of the hospitals will be the sites for
monitoring the clinical cases as per the definitions and
fever cases for an increase/ clustering and send samples of
suspected or probable cases for the sero –surveillance
Disease
Surveillance
SURVEILLANCE

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

.
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 Pupae X100
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

CASE MANAGEMENT
• GoI recommends use of ELISA based antigen detection test (NS1)
for diagnosing the cases from 1st day onwards and antibody
detection test IgM Capture ELISA (MAC ELISA) for diagnosing the
cases after 5th day of onset of disease for confirmation of
Dengue infection.
Laboratory
Diagnosis
• Clinical management of Dengue Fever(DF)/ Dengue
Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS)
had been developed in 2007 in a brain storming session at All
India Institute of Medical Sciences (AIIMS), New Delhi involving
subject experts from National and International fame. The
treating physician should consider the condition of the patient
in totality and decide about management of an individual
patient.
Clinical
management

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

CHEMICAL CONTROL:
ADULTICIDE
Pyrethrum spray:It may be used in indoor
situations as space spray at a
concentration of 0.1% - 0.2% @ 30-60
ml/1000 cu. ft.the ratio of one part of 2%
pyrethrum extract with 19 parts of
kerosene (volume/volume).
Malathion fogging or Ultra Low Volume (ULV)
spray:by using 95% or pure
technical malathion.(insecticide is broken down
into small droplets of 40-80 microns that remain
suspended in air for an appreciable time and
driven under the
influence of wind.
LARVICIDE
Temephos :The recommended dose
for application of Temephos (50 EC)
is 1ppm (1 mg per litre of water).

.
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.

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.

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:

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.

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

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

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.

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

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.

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

• 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

• Increased population management –
• Significant increase in plantations –
• Increased demand for rubber
• Rubber plantation increased

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

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)

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

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

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.

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

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

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

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

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
Filariasis and the target for global elimination is by 2020.
• In 2003 -04 it was merged with NVBDCP.

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.

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.

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 5th june).

• 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.

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:

• 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

Trend of Average Microfilaria rates (%) in the State since 2004
Sl.
No.
States/UTs 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
1
Andhra
Pradesh
1.36 0.74 0.69 0.26 0.38 0.45 0.35 0.21 0.20 0.22
2 Assam ND 0.04 0.19 1.46 0.88 0.81 1.06 0.17 0.19 0.15
3 Bihar 1.50 2.15 1.38 0.68 ND 1.07 0.94 ND 1.15 ND
4 Chhattisgarh ND 1.96 ND 0.61 0.45 0.54 0.40 0.10 0.10 0.08
5 Goa 0.11 0.04 0.02 0.08 0.01 0.00 0.01 0.00
MDA
stopped
MDA
stopped
6 Gujarat 0.22 0.84 0.84 0.42 0.83 0.92 0.46 0.52 0.24 0.31
7 Jharkhand ND 0.84 1.40 1.34 1.10 1.11 0.82 0.63 NR ND
8 Karnataka 1.87 0.84 0.69 1.15 1.07 0.93 0.89 0.83 0.65 ND
9 Kerala 0.68 0.50 0.67 0.65 0.29 0.39 0.17 0.14 0.21 0.15
10
Madhya
Pradesh
0.83 0.40 0.38 0.70 0.36 0.40 0.19 0.23 0.09 ND
11 Maharashtra 1.13 1.45 1.13 0.83 0.35 0.46 0.53 0.51 0.43 0.46
12 Orissa 2.60 2.37 1.11 0.99 0.74 0.69 0.40 0.43 0.34 0.34
13 Tamil Nadu 0.04 0.38 0.39 0.29 0.15 0.12 0.07 0.09 0.17 ND
14 Uttar Pradesh 1.77 1.01 0.81 0.32 0.41 ND 0.28 0.24 0.38 0.10
15 West Bengal 4.74 4.10 2.72 2.83 0.89 0.48 0.44 0.55 0.70 ND
16 A&N Islands 1.4 0.09 0.15 0.34 0.19 0.46 0.10 0.12 0.17 0.14
17
D & N
Haveli
1.96 2.01 2.91 3.47 1.82 1.23 0.95 1.79 0.71 0.54
18
Daman &
Diu
0.47 0.14 0.27 0.09 0.07 0.07 0.06 0.07
MDA
stopped
MDA
stopped
19 Lakshadweep 1.19 0.09 0.07 0.02 0.27 0.00 0.00 ND ND ND
20 Pondicherry 0.42 0.50 0.15 0.06 0.03 0.00 0.00 0.00
MDA
stopped
MDA
stopped
National
Average
1.24 1.02 0.98 0.64 0.53 0.65 0.41 0.37 0.41 0.27

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.

• 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

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)

KALA-AZAR
Kala-azar Cases and Deaths in the Country since 2008
Sl.
No.
Affected
States/UTs
2008 2009 2010 2011 2012
2013(P)
2014(P)
C D C D C D C D C D C D C D
1 Assam 98 0 26 0 12 0 5 0 6 0 4 0 0 0
2 Bihar 28489 142 20519 80 23084 95 25222 76 16036 27 10730 17 3529 3
3 Delhi* 34 0 12 0 92 0 19 0 11 0 6 0 0 0
4 Gujarat* 0 0 0 0 0 0 0 0 0 0
5
Himachal
Pradesh
0 0 0 0 6 1 1 0 0 0 0 0
6 Jharkhand 3690 5 2875 12 4305 5 5960 3 3535 1 2515 0 578 0
7 Madhya Pradesh 1 0 0 0 0 0 0 0 0 0 0 0
8 Punjab* 0 0 0 0 1 0 0 0 0 0
9 Sikkim 4 1 5 0 3 0 7 0 5 0 8 0 3 0
10 Uttrakhand 0 0 2 0 1 0 0 0 7 1 2 0
11 Uttar Pradesh 26 0 17 1 14 0 11 1 5 0 11 1 7 0
12 West Bengal 1256 3 756 0 1482 4 1962 0 995 0 595 2 238 0
Total 33598 151 24212 93 29000 105 33187 80 20600 29 13827 20 4357 3
As per the reports received from state till May 2014

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

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

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

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)

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.

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:

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

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

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

• 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.

ANOPHELES AEDES CULEX SAND FLY
Sophisicated Mosquito Tiger Mosquito Nuisance Mosquito
DISEASE
SPREAD
Malaria 1. Dengue
2. Yellow Fever
3. Chikungunya
1. Japanese Encephalitis
2. 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

LARVAE(5-7
days)
-Floats horizontally in water
-No siphon tube
-Suspended in water with head downwards
-Siphon tube situated on the 8th 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.

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