A. Situation analysis
Description of the disaster
A total of 19,296 dengue positive cases have been confirmed as of 2 October 2019 and more than 30 deaths were reported in September based on Federal Disease Surveillance and Response Unit from Field Epidemiology and Disease Surveillance Division – National Institute of Health (NIH), Islamabad.
Based on the case trend, daily 365 new cases are expected in Government Hospitals during next three months (refer to figures below). Approximately 9,403 cases have been reported in last fifteen days (1 to 16 September 2019) across the country, out of which 4,077 cases (51 per cent) were reported in Rawalpindi and Islamabad city. According to Ministry of Health statistics, around 2,777 positive cases of dengue has been reported in federal capital of Islamabad since the start of monsoon season. Print, electronic and social media are also actively reporting the presence of dengue in twin cities and prevailing condition of daily case reporting. According to a report by special Assistant to the Prime Minister on Health - Dr Zafar Mirza, reported confirmed 12,500 dengue cases across the country on 30 September 2019 and mainly half of them were reported from the Potohar region, which includes Islamabad and Rawalpindi. This region is a plateau in north-eastern Pakistan, forming the northern part of Punjab and borders the western parts of Azad Kashmir and the southern part of Khyber Pakhtunkhwa (KPK). Map of the affected areas can be accessed here.
The current outbreak is predominantly due to Dengue Fever Type 2 (DEN-2) in Rawalpindi and Islamabad, where as in KPK Province outbreak is due to Type 1 (DEN-1) and Type 2 (DEN-2) both. KPK province is the southern part of Potohar region and intra provincial transmission of Type 1 virus can be an additional threat of increased outbreak in twin cities. Viral transmission is highly probable due to frequent daily travel from capital to KPK cities and vice versa. The following slides were presented on 2 October 2019 during daily meeting at Department of Malaria Control (DoMC) about the exacerbating situation in twin cities.
In Pakistan Dengue fever and Dengue hemorrhagic fever are fastest emerging arboviral infections since 2005. During 1995 to 2004, only 699 dengue cases and 6 deaths were reported from three districts in the country while, these numbers have been dramatically increased to 127,500 and 709 deaths respectively effecting 105 out of 154 districts/ agencies/ territories during 2005 to 2018.
The disease epidemiology is complex in nature and patterns of disease transmission is influenced by many factors which include weather and environmental changes, vector species composition, behavior, geographic distribution, population dynamics, degree of immunity among local population and density, and time required for development of virus in vectors. The dengue outbreak trend in 2019 has increased 35 per cent from 2017 where similar increment can be seen in mortalities in 2019 with 37 death as of 2 October 2019 compared to five death in 2018. Epidemiological trend diagram above reflects a clear indication of disease outbreak in the year 2019 as compared to the last two years i.e. 2017 to 20191 .
Another reason of the outbreak is heavy rainfall during recent monsoon season which has been quite heavy this year as compare to last year across the country including Sindh and Punjab province, resulting in the emergence of dengue cases from most parts of the country in the 2nd half of September 2019. The worse hit areas are Rawalpindi and Islamabad. These cases continued to rise and by 20 September 2019 with a sudden surge was noticed where several patients admitted in the major Government hospitals of Islamabad.
This a precarious situation and need an immediate attention as far as its control is involved. Disease recurrence and potential to harm everyone in the city and adjacent areas. The safest corner of the capital city is not safe from dengue attack because of dangerously breeding capability of mosquito to lay eggs and reproduce in clean and neat available water reservoirs. The situation can be worsening as there is no suitable treatment available for the dengue fever caused by this virus or an effective vaccine. Clinicians mainly treat dengue fever patient’s symptoms and boosting the immunity, thus halting the progression of viral infection to its haemorrhagic state. As excessive bleeding internally as well as externally is considered quite dangerous as far as the health outcomes are concerned in severe stages of dengue fever. Nations across the world having winter temperature, not below ten degrees centigrade/55-degree Fahrenheit that constitute almost one-half of the world is at risk of dengue virus spread2 . Some are still safe, whereas, others like Pakistan have become a breeding ground for this mosquito posing a health risk to the entire nation. As such, country like other parts of the world, must live with this virus infection through prevention and control measures against mosquito the main culprit for dengue virus transmission from human to human3 .
Field Epidemiology and Disease Surveillance division of Ministry of Health (MoH) urge to step up dengue surveillance, case management and outbreak response in primary health facilities and hospitals, as well as through community and school-based health education campaigns, clean-up drives, surveillance activities, case investigations, vector control, and logistics support for dengue control (insecticides, rapid diagnostics tests, medicine, etc.). In view of the resource constraints from the Government side and rising trend of Dengue, PRCS has been requested by the Ministry of National health Services and Coordination to support the Government of Pakistan to deal this emergency in Pakistan with particular focus on Rawalpindi and Islamabad.
Department of Malaria Control Program contacted Pakistan Red Crescent Society (PRCS) to aid in raising awareness, provision of mosquito nets to isolate confirm and suspected patients to prevent further spread and to protect vulnerable population from mosquito bite during daytime. This population includes pregnant women (PW) and <5 children and elderly people. However, as per the DoMC guideline main focus will be on personal protection, cleanliness of environment and use of repellants as it not only provides protection for more than 8 hours but also easy to use at day time and create a zone of protection for more radius than bed nets4 . Printing materials and setting up mobile health teams in the urban slums of Rawalpindi-Islamabad area as preventive strategy for twin cities and subsequent reduce burden of disease. Role of Mobile Health Teams is provided below under activity section.