Fever pitch

The heavy rains and dug-up roads have contributed to the rapid spread of dengue in Delhi this year.

in New Delhi

THE heavy rains in the National Capital Region of Delhi this year came with a side effect: its biggest ever outbreak of dengue fever, a mosquito-borne viral disease. In earlier years, insignificant rains and lesser construction activities prevented the disease from assuming epidemic proportions. On September 14, the official number of dengue fever cases in Delhi had gone past 2,000, and four people had already died. There are fears that the official figures are understated.

According to the Delhi government, the outbreak is nowhere close to an epidemic though the number of cases is the highest this year. However, the official figures were arrived at only on the basis of the cases registered at government hospitals; the hundreds of other patients who get treated privately are not taken into account. Just four of the major hospitals in Delhi Max, Batra, Holy Family, and Apollo together recorded nearly 3,000 cases until the first week of September. The numbers are constantly increasing.

But officials of the Municipal Corporation of Delhi (MCD), the body in charge of controlling the spread of dengue, say that it can only account for people who undergo government-authorised tests. Private laboratories and hospitals claim that the tests conducted by them are duly authorised and 100 per cent correct. D. Navin Dang of Dr Dangs Lab Pvt Ltd, a leading pathological laboratory, said: We get 50 positive reports of dengue every day and our tests are 100 per cent accurate. Without any doubt, this is the worst year as far as dengue spread is concerned.

Dengue is a mosquito-borne seasonal viral infection caused by four closely related viruses called DENV. The virus is transmitted by the bite of a female mosquito of the genus Aedes Aegypti. These domestic mosquitoes bite typically in daylight and are easily recognisable with their dotted-white legs. The outbreak of the disease usually occurs in the post-monsoon season, when the mosquito population peaks.

These mosquitoes breed in stagnant, clean water; so, dengue is predominantly reported in urban and semi-urban areas. A more severe infection, known as dengue haemorrhagic fever (DHF), caused by the same virus can be fatal as it drastically reduces the number of platelets in the victim's body.

The first instances of dengue were reported in Delhi in 1996. The numbers increased every year, though the health authorities claimed they were taking adequate measures to prevent the spread of the disease. Explaining the situation this year, V.K. Monga, chairman of the MCD's health committee, told Frontline: We conducted domestic breeding checks and held awareness meetings with NGOs [non-governmental organisations] and residents welfare associations from April, instead of July, which is when it started in earlier years. However, people have to keep a check on mosquitoes breeding in their homes.

Aggravating factors

He added that there were three main reasons for the high number of cases in 2010. The first was the heavy rainfall. The dengue outbreak, the worst since 2006, was exacerbated by the heaviest monsoon rains in 15 years, Monga said. Secondly, there were pools of stagnant water everywhere because the city had been dug up extensively for the construction work for the Commonwealth Games. These, Monga said, had turned into breeding grounds for mosquitoes. Thirdly, increased breeding was also part of the natural process, he said.

The MCD initially complained that government funds for tackling the spread of the disease were extremely delayed. Once the funds were available, preventive work became satisfactory though it was interrupted by rain from time to time. Awareness campaigns, anti-larval measures and anti-adult mosquito measures were the three components of the MCD's preventive programme, Monga said.

He said that South Delhi, Central Delhi and areas under the New Delhi Municipal Council (NDMC), another municipal body controlling 3 per cent of the total area of Delhi, were the worst affected. These places have pockets where the richer sections of the population live. In Delhi, dengue is a disease that spreads best in the kind of neighbourhoods where the upper middle class and the rich live, said Sandeep Budhiraja, a doctor at the Max Institute of Medicine. I treated at least five CEOs this week alone.

Most houses in affluent neighbourhoods have private gardens and a large number of flower pots and vases that become breeding grounds for mosquitoes. However, areas like Jamia Nagar, Okhla, Zakir Nagar and Abul Fazl Enclave (also in South Delhi), dominated by slums and lower middle class colonies, have seen the largest number of dengue cases. The hospitals in this areas have reported a platelet crisis because of the growing number of cases; they were also forced to increase the number of beds.

The preventive action took a jolt when almost half of the 3,200 domestic breeding checkers went on a strike in early September demanding regularisation of jobs and hastening of their payments. The workers have been demanding regularisation since 2008 and the MCD has been maintaining that it is impossible to do so because of shortage of funds and inadequate infrastructure. The strike was called off after Lieutenant-Governor Tejendra Khanna promised to look into their demands.

With the Commonwealth Games just round the corner, both the Union Ministry of Health and the Delhi government's Health Ministry have shown some concern. Kiran Walia, Delhi's Health Minister, said she had issued notices to the Delhi Development Authority (DDA), the MCD and all the authorities concerned to take special care of the Games village, which is very close to the Yamuna. She also said the innumerable potholes and dug-up roads in the city were a cause of concern because heavy rainfall was expected through September.

Union Health Minister Ghulam Nabi Azad blamed the unfinished Commonwealth Games venues for the dengue outbreak.

If the Commonwealth Games has had a role to play in the spread of dengue this year, it has also spurred government agencies into addressing the problem. Earlier, it was only the MCD that was responsible for dealing with dengue. However, because of the Commonwealth Games, every department is now supporting us to control the menace and we are happy for that, Monga said.

Dr Chusak Prasttisur, the Southeast Asia Coordinator of Communicable Diseases for the World Health Organisation (WHO), has expressed concern that the dengue season may peak in early October, when the Games will be held. India expects 8,000 athletes and team officials from 71 countries to attend the Games. Many Commonwealth countries, especially South-East Asian countries, are also sending inspection teams to check out the dengue situation and ensure their players' safety. The National Disaster Management Authority has been alerted to initiate mosquito vector control programmes. The Army has been asked to sanitise the areas around the Games village.

The global scenario

According to the WHO, dengue is prevalent in more than 100 countries and is the most widespread tropical disease after malaria. Its website says that dengue-related complications cause about 500,000 hospitalisations a year, mostly of children. About 3 per cent of the cases are fatal, according to the Centres for Disease Control and Prevention in Atlanta. The WHO says some 2.5 billion people, two-fifths of the world's population, are affected by dengue and estimates that there may be 50 million cases of dengue infection worldwide every year.

The WHO website says: In 2007 alone, there were more than 890,000 reported cases of dengue in the Americas, of which 26,000 cases were dengue haemorrhagic fever. The disease is now endemic in more than 100 countries in Africa, the Americas, the Eastern Mediterranean, South-East Asia and the Western Pacific. South-East Asia and the Western Pacific are the most seriously affected. Before 1970 only nine countries had experienced DHF epidemics, a number that had increased more than fourfold by 1995. Not only is the number of cases increasing as the disease is spreading to new areas, but explosive outbreaks are occurring. In 2007, Venezuela reported over 80,000 cases, including more than 6,000 cases of DHF.

Given the seriousness of the situation, the Indian response to dengue has been inadequate and the country still lacks a broad policy initiative. Inefficient government bodies only make things worse. Every year, despite the government's claims of success, the number of dengue cases has increased, pointing to a governance failure in the health department.

The Cuban Experience

Among tropical countries, Cuba stands out in tackling the dengue menace. The Innovation for Development and South-South Cooperation (IDEASS), a Cuban government agency, has developed two bio-larvicides Bactivec and Griselesf that are highly effective in controlling mosquito breeding. Bio-larvicides kill mosquito larva, thus eliminating vectors of mosquito-borne diseases. Bactivec, especially, is highly efficient in tackling the Aedes Aegypti mosquito responsible for the spread of dengue. We have been using it from the 1980s. We introduced the Griselesf in 1990 to prevent other mosquito-borne diseases like malaria, too. Both the bio-larvicides stop the mosquito breeding cycle. If you look at the dengue figures every year in Cuba and the surrounding Carribean countries, the numbers in Cuba are almost negligible. These larvicides control not only dengue but any mosquito-borne disease, said the Cuban Ambassador in India Miguel Angel Ramirez Ramos.

We have 2.4 million tourists every year and our economy is agriculture-driven. The spread of dengue needed to be controlled to protect these two sectors. Fortunately, we have had no epidemic in the last two decades, he added. Ramos said that the dengue virus was introduced in Cuba in the 1980s by the Central Intelligence Agency (CIA). The Cubans had to develop a long-term solution for it (interview with Fidel Castro in Frontline, November 22, 2002).

IDEASS claims that Bactivec and Griselesf are highly effective in controlling larvae of different mosquito species in urban, rural, industrial and tourism development areas in all climactic conditions. It also claims that the bio-larvicides developed in Cuba do not harm other animal and plant species and are environment-friendly because of their biodegradable nature. (In India, the most encouraged experiment in dealing with mosquitoes used dichlorodiphenyltrichloroethane (DDT), an insecticide. It has gone sour, and DDT, found to be highly harmful to the environment, has been banned. Also, mosquitoes were able to develop immunity to it.)

Ramos said that Cuba was willing to share its registered technology with India and that he was trying to talk to Indian health officials. He pointed out that Sri Lanka had just signed a memorandum of understanding with Cuba to import the technology; it would be the first South Asian country to use Cuban technology. Cuba has been working closely in tackling the dengue fever problem with South American and Central American countries. Ramos said Brazil and countries around the Amazon river, where dengue was widespread, were working closely with Cuba.

Singapore has also shown interest in buying Cuba's technology. Ramos said such a solution was possible only through a dedicated research team working with a healthy infrastructure provided by the government. Such technology complemented with a universal health care system and people's participation in checking mosquito-breeding helped us bring down dengue cases in Cuba, he said. (Cuba's doctor to people ratio is 1:167, the highest in the world.)

While universal health care is a distant dream in India, the Indian government could learn from the Cuban experience and seek whatever help it could get in preventing another epidemic of dengue in future.