Communicable Diseases and Disease Surveillance

Dengue Report 2003

Proceedings of the meetings on Vector Borne Disease Surveillance with special focus on DengueNet at Delhi and Bangalore organized by NICD in collaboration with WR India, CSR/ Hq. SEARO under USAID/WHO/Hq. grant 2003

      Background

      The Objectives of the meeting

      Methodology

      Proceedings of the meetings & salient observations

      Summary recommendations of both the meetings

      Annexure-1

     Annexure-2

      Annexure-3

      Annexure-4

Background

      The geographical spread of Dengue Fever (DF) is increasing across the world and the more fierce form of Dengue Hemorrhagic Fever (DHF) is also spreading to newer areas. Before 1970 only 9 countries experienced DHF epidemics. Globally some 2.5 billion people now live in areas having active dengue transmission. It is estimated that some 50 million DF cases occur every year accompanied by 500,000 DHF and 24000 deaths. In India Dengue infection is known to exist for over a century now. The virus which has four subtypes was first isolated in India in 1945 in Kolkata, West Bengal. All the four serotypes are in circulation in India in different parts of the country. The first major outbreak with haemorrhagic manifestations was in Kolkata in 1963. Since then, there has been a dramatic rise in the incidence of DHF cases and increased number of outbreaks are being reported from different states. In the year 2003 the country reported 12023 cases and 209 deaths from dengue/DHF. The measures for control of dengue vary according to country situation and priorities. But, effective surveillance is the first step in such a control programme. The disease transmission being global the surveillance need also be global. For example, the recent epidemic in Indonesia put Thailand on alert and helped avert a wider disaster. Such a surveillance system should monitor dengue virus to show at any given point in time, where dengue transmission is occurring; what serotypes are involved; what type of illness is associated with those serotypes. But, the reporting of DF/DHF is not standardized. Often the epidemiological and laboratory data are collected by different institutions and reported in different formats, resulting in delay and comparability problems at regional and international levels.

      With this background, the 55^th World Health Assembly in May 2002 asked member states – “to build and strengthen the capacity of health systems for surveillance, prevention, control and management of dengue and DHF”. The model that was adopted for DengueNet was based on the time tested experience of Pan American Health Organization for epidemiological and laboratory surveillance of dengue/DHF in the Americas. The DengueNet was floated by WHO to collect and analyse standardized epidemiological and virological data in a timely manner, and to present epidemiological trends, as soon as new data are entered; Display in real-time important indicators such as incidence data, case fatality rates (CFR) for DHF, frequency distribution of dengue and DHF cases, number of deaths, and distribution of circulating dengue virus serotypes; and Provide both historical and real-time data.

      The main features of this web based surveillance tool are password protected capability for remote data entry by all DengueNet partners worldwide, with data updated on a real-time basis; Inclusion of the state/province subdivisions of the countries for which data will be entered and indicators (such as incidence) calculated; Dynamic query facility with analysis and presentation of data in graphic, tabular, map and free-text formats; Use of GIS tools to provide a real-time map of the epidemiological situation; Links to the dengue web pages of WHO offices, countries, collaborating centers, and research and medical institutions working worldwide on dengue/DHF prevention and control; An up-to-date directory of national and international partners in the DengueNet network; Dengue news, information and document center.

      The first Inter-country meeting of DengueNet was held at Kualalumpur in Malayasia in December 2003 with the purpose was to develop a framework for implementation of DengueNet in the Asia-Pacific regions. The meeting was attended by 23 countries from WPRO and SEARO.  Following the Kualalumpur meeting, a proposal was placed by the National Institute of Communicable Diseases (NICD), Delhi to the WHO for a meeting on Vector borne disease surveillance with special reference to Dengue. The need for some sort of real-time database like DengueNet was a felt need for India given the rising outbreaks of dengue/DHF in different parts of the country.

The Objectives of the meeting:

     General:

      To strengthen disease surveillance and response to vector borne diseases using the DengueNet as an entry point.

     Specific:

      To assess current surveillance practices, including laboratory facilities and tests for DHF.

      Identify and strengthen regional collaborative laboratories.

      Establish a framework for participating in DengueNet.

Methodology

      A bottom up strategic approach was adopted for the meetings. Two separate meetings were organized with the northern and the southern states and WHO collaborating institutions. The Delhi meeting was held on 11-12 March, 2004. The Bangalore meeting was held on 16-17 March, 2004. The lists of participants are in Annex 1 and 3, respectively. The programmes of the meetings are marked Annex 2 and 4, respectively. 

      To make the meeting successful the WHO and the USAID came forward and provided technical and financial assistance. A fund of Rs. 1244000 was made available to meet the expenditure for the two meetings. All the states that were reporting the disease were contacted and asked to nominate their participants for the meeting. The states, which are not reporting dengue/DHF cases, were also asked to send representatives. In addition to the NICD, the National Institute of Virology was roped in for contribution to the meeting. The Ministry of Health and Family Welfare, Govt. of India; the Directorate of Health Services, Govt. of India; The International Health Division of DGHS; The National Tuberculosis Institute, Bangalore and the WHO, SEARO and WR India came together with key resource persons to make the meeting successful. 

Proceedings of the meetings & salient observations

      The workshop did an in depth review of the current communicable diseases surveillance and control strategies in India. This included Early Warning System (EWS), laboratory networking for effective surveillance and entomological surveillance strategies. The review revealed that there are states, which have some sort of surveillance in place, and there are others, which have none specific for dengue/DHF.

      There was very wide differences on the criteria for labeling a case as dengue or otherwise. The WHO definition for DF/DHF/DSS also generated some debate. There were further debates on the advisability of reporting a case as dengue without confirmatory diagnosis. Also came up the constraints of building up and maintaining an infrastructure to facilitate timely diagnosis for adequate number of samples on the one hand and credibility and quality of laboratories operating in the private sector. Generally the WHO definitions were accepted and the need for laboratory strengthening emphasized to make DengueNet feasible.

      There were general consensus for an integrated rather than piece-meal approach for all vector borne diseases. Some participants were keen to include entomological indices into DengueNet. There was general consensus on private public partnership. All the participants emphasized the need for training at all levels of operations. 

     Delhi Meeting

      The Delhi meeting was held at the India Habitat Centre at Lodhi Road on 11^th and 12^th March, 2004. This was the first DengueNet meeting following Kualalumpur meeting of December 2003. The list of participants and programe of the meeting is attached Annex 1 & 3. The states representing the Delhi meeting were –Punjab; Haryana; Chandigarh; Jammu & Kashmir; Rajasthan; Uttar Pradesh; Delhi; Bihar and West Bengal.

      The meeting was inaugurated by the Additional DG & Director of NICD, Delhi, Dr. Shiv Lal. After the inauguration the purpose of the meeting was presented before the participants by Dr. Renu Dayal from WHO Geneva. Following this speakers/ experts presented an overview on dengue/DHF and then the states presented their dengue situation and answered queries from the audience.

     This was followed by group work wherein the participants were divided into 3 groups –

      Epidemiology group

      Dengue Net group

      Laboratory group

      Each of these groups were given terms of reference and the group work was assisted by the faculties of NICD, resource persons and experts from the WHO, SEARO and WR India office. The groups deliberated and came up with recommendations and suggested future course of action.

     Bangalore Meeting

      The Bangalore meeting was held at Bangalore at the National Tuberculosis Institute campus on 16^th and 17^th March, 2004. The meeting was formally inaugurated by the Principal Secretary health, Govt. of Karnataka and the chief guest was the NTI Director. The states represented at Bangalore meeting were – Karnataka; Kerala; Tamil Nadu; Chattishgarh; Jharkhand; Maharashtra; Gujarat; Goa and Pondicherry.

      The meeting completed general deliberations on epidemiology, DengueNet, laboratory techniques and laboratory surveillance. The states presented their respective situations vis-à-vis dengue/DHF. The group work was built up on the recommendations of the Delhi meeting. The participants were divided into 2 groups –

      Epidemiology and DengueNet group

      Laboratory and DengueNet group

      The groups came up with specific recommendations and identified the areas for strengthening so that the DengueNet can be implemented. The list of participants of the Bangalore meeting and the programme is given at annexe 2 & 4.

Summary recommendations of both the meetings

      As envisaged in the Integrated Disease Surveillance Programme of the Govt. of India, special efforts are required to improve capacity for vector borne disease surveillance and response (with special focus on Dengue) at state and district levels through training of concerned officials.

      The existing monthly reporting system for PHC may be suitably modified to suit the needs of DengueNet. Dengue and DHF should be reported separately. 

      The data submitted for DengueNet by the District programme managers may be validated and authorized by the state focal person dealing with vector borne disease. As a pilot project initially the information for DengueNet may be initiated from some of the selected states.

      There is need to strengthen laboratory networking and quality assurance through provision of guidelines and tools for the same.

      Suggested to adapt case definitions to suit the knowledge and skill of the primary information generation point.

      Designate NICD and NIV for reference laboratory for dengue/DHF in northern and southern regions of the country.

      Suggested to integrate DengueNet implementation through IDSP programme.

      The scope of DengueNet should be expanded to encompass other vector borne diseases.

      It was suggested to arrange the stake holder meetings dealing with surveillance and vector borne diseases for finalizing the action plan and accordingly feed back may be given to the Ministry of Health.

Annexure-1

Government of India

National Institute of Communicable Diseases

(Directorate General of Health Services)

NICD-WHO Meeting on “Vector Borne Disease Surveillance and Control with special reference To DengueNet

India Habitat Centre, Light House Room, Lodhi Road, New Delhi

11^th & 12^th Mar, 2004

List of participants

Annexure-2

Government of India

National Institute of Communicable Diseases

(Directorate General of Health Services)

NICD-WHO Meeting on “Vector Borne Disease Surveillance and Control with special reference To DengueNet

India Habitat Centre, Light House Room, Lodhi Road, New Delhi

11^th & 12^th Mar, 2004

Annexure-3

Government of India

National Institute of Communicable Diseases

(Directorate General of Health Services)

NICD-WHO Meeting on “Vector Borne Disease Surveillance and Control with special reference To DengueNet on 16^th & 17^th March 2004

Venue- NTI auditorium, 8, Bellary Road, Bangalore

List of participants Meeting