WEEKLY EPIDEMIOLOGICAL REPORT A publication of the Epidemiology Unit Ministry of Health, Nutrition & Indigenous Medicine 231, de Saram Place, 01000, Tele: + 94 11 2695112, Fax: +94 11 2696583, E mail: [email protected] Epidemiologist: +94 11 2681548, E mail: [email protected] Web: http://www.epid.gov.lk

Vol. 45 No. 05 27th – 02th February 2018 Dengue Epidemic 2017: Evidence and Lessons Learnt — Part 3 This article, discussed here as the third deaths in 2016. of 5 parts, continues to describe the out- August 2017, saw a decline in the number break and the preventive and mitigation of cases in most of the districts, to nearly a activities carried out during the 2017 half of the numbers in July. Nevertheless, outbreak. most of dry zonal districts like , (Continued from Previous WER) , , , Trin- comalee, , and Moneragala still In June 2017, a sharp increase in the total continued to report high number of cases, cases was seen from all districts, recording an increase of 4-5 times, while more than double the caseload in most of and had more than 6 times the them. Districts like , , Battica- patients during this month. loa, , , Puttalam, Anura- dhapura, and Kalmunai recorded about 4 The downward trend continued in Septem- times the previously reported average ber where there was less than 10,000 cas- caseload. Moneragala was showing a 10 es and only 5 deaths were reported for the fold increase, although no specific areas whole month. Most of the districts had their were identified as potential outbreak areas. case reporting declining but places like Hambantota, Batticaloa, , Mon- July 2017 saw the highest case reporting eragala, and continued to have 3-4 (averaging 10,000 cases per week) during times the cases than expected with only the peak of the outbreak and totaling more Moneragala district reporting more than a 5 than 41,000 cases for the whole month. -fold increase in sporadic cases, even This was more than 300% increase than though not in any notable outbreak setting. the expected for the month. Almost all the districts recorded more than 2-3 times the The post-outbreak case reporting decline number of cases than expected with Gam- reached the lowest for the year in October paha, Matara and Kegalle and many dis- 2017. Many districts reported this de- tricts in the dry zone, reporting nearly 5 crease, but Kandy and Kegalle along with times the cases. The severe drought which few other areas in the dry zone like Ham- prevailed during this period where people bantota, , Batticaloa, Trincomalee, tend to store water in various containers Kalmunai, and Moneragala continued to inside their houses resulted in Puttalam, have high case numbers being reported. Kalmunai, and Moneragala, Badulla in- The onset of sporadic rains in November creasingly reporting dengue patients at and December 2017, due to the North- more than 7 times the average for the last 5 Eastern Monsoonal rains, showed a gradu- years. Inevitably, the highest number of al increase in cases from areas like Ham- deaths for a month was also recorded dur- bantota, Vavuniya, Batticaloa, Puttalam, ing July which was more than the total Anuradhapura, and Moneragala districts.

Contents Page 1. Leading Article – Dengue Epidemic 2017 : Evidence and Lessons Learnt — Part 3 1 2. Summary of selected notifiable diseases reported (20th – 26th January 2018) 3 3. Surveillance of vaccine preventable diseases & AFP (20th – 26th January 2018) 4

WER Sri Lanka - Vol. 45 No. 05 27th– 02th February 2018

By the end of the year, the cases in 2017 had almost As mentioned above, despite the routine and special reached the last 5-years baseline values, signifying the preventive activities carried out from the beginning, end the unprecedented outbreak. health officials had to resort to extraordinary measures to bring the situation under control. The following de- As mentioned previously, Sri Lanka experiences annual scription of these control measures taken by different cyclical changes in dengue incidence due to the mon- units of the Health Ministry, are detailed into four broad soonal rain patterns experienced in different parts of the categories; island. It is noted that there appears to be an endemic level in the country which is changing every few years  Enhancing Clinical Management, apart. The annual incidence of dengue cases up to 1999  Vector Control Activities, appeared to be less than 10 cases per 100,000 popula-  Inter-Sectoral Collaborations tion for each year. The annual incidence increased to an  Communication to Community Empowerment average of 33 cases per 100,000 from the year 2000 to Clinical management aspects will be discussed initially 2003 with the endemic level being reset at a higher lev- and the public health activities will be elaborated in detail el. Next five years from 2004 to 2008 showed an aver- afterwards; age annual incidence of 48 cases per 100,000 cases. From 2009 to 2013 the endemicity was reset at a higher Enhancing Clinical Management of Dengue level at around 170 cases per 100,000 cases per year. It has always been shown that prompt and early diagno- This average incidence was again reset from 2014 to sis with meticulous monitoring and management of the 2016 to a higher level, 211 cases per 100,000 popula- critical phase was very important in bringing down mor- tion. As depicted in the above figures, it is apparent that tality and to keep morbidity at lower levels. in 2017, a new very high incidence (867 cases per 100,000 population) was reached.  Improving the clinical management with updating knowledge and skills of clinicians and para-medical By hindsight, this may not be a resetting of the endemic staff by continuous training sessions carried out in level, if 2017 was, in fact, a significant epidemic. Never- almost all provinces of the country. theless, in keeping with the virology trends and disease patterns in the other Dengue endemic countries in the  The high caseload which led to increased hospital region like Thailand and Malaysia, this pattern may con- admissions was a severe burden felt on the hospital tinue for a few more years. But, there are few postula- care system already laden with logistical and man- tions for the sudden increase in the caseload leading to power issues. This was very much in evidence in the unprecedented outbreak in 2017. places like Kinniya and Kalmunai where coping with a large number of admissions was difficult due to lack  Surge in fever patients due to the change in the circu- of space and staff. Temporary establishment of a lating dengue virus type from less virulent DENV1 dedicated unit (HDU with trained staff from DGH Ne- strain to DENV2 serotype which is relatively more gombo and other hospitals) was the turning point in virulent. controlling the Kinniya outbreak. Extra staff and staff  More asymptomatic but viraemic persons leading to a were also made available at DGH Trincomalee to relatively more virus load in the community curb the situation.  Increased migration of susceptible population (i.e.  Need for additional bed strength in major hospitals Dengue naïve) from low endemic areas to high en- was an urgent issue to be tackled. Incorporating demic areas with more primary exposure to the virus. (relatively) non-essential wards to be used for dengue  More indoor mosquito breeding sites due to the abun- patients as a temporary measure was one of the suc- dance of open water containers with the prevailing cessful options carried out in many hospitals. severe drought conditions in most dry-zone parts in  Where there was a need for an early solution, the Sri the country. Lanka Army was helpful in setting up semi-permanent  Increased exposure to mosquito bites due to the field hospital buildings within a very short time dura- weather changes and a possible change in mosquito tion as done at NIID (National Institute for Infectious biting habits and shifting breeding places from house- Diseases formerly known as IDH), CSTH Kalubowila holds to open places like schools, construction sites. and CNTH Ragama etc.  The response pattern towards the outbreak situation is more of a reactive nature than the more effective (to be continued…) Compiled by Dr. M. B. Azhar Ghouse, proactive nature. Registrar in Community Medicine, Epidemiology Unit

Page 2 to be continued… WER Sri Lanka - Vol. 45 No. 05 27th– 02th February 2018

Table 1: Selected notifiable diseases reported by Medical Officers of Health 20th – 26th Jan 2018 (04thWeek)

95 44 93 65 98 95

100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100

C**

69 54 75 57 63 19 34 65 59 38 31 30 69 46 61 46 35 68 71 41 68 47 50 42 66 42 54

WRCD T*

2 1 0 0 2 0 1 0 0 0 0 0 0 0 1 0 1 4 0 0

84 30 14 17 21 57

235

B

1 0 0 0 1 0 0 9 6 0 0 0 0 0 0 0 0 4 0 6 5 1 1 0 0

11

45

Leishmania- sis A

2 6 1 2 2 0 1 0 3 0 1 1 0 4 0 0 9 3 0 2 8 1 2 1

11 15

75

B

1 0 0 6 1 1 0 0 0 3 0 0 0 0 2 0 0 1 0 0 0 1 1 3 1 0

21

Meningitis A

4 4 1 8 3 0 4

47 69 44 21 28 21 23 27 13 26 41 10 25 12 24 13 23 25 14

530

Completeness

-

B

C**

1 6 8 0 6 9 1 1 2 0 2 4 4 8 2 3 2 5 7 6

14 35 17 13 10 15

181

Chickenpox A

0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0

2

B

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0

Human Human Rabies A

1 0 2 0 1 1 0 0 0 0 0 0 0 0 1 2 0 1 0 0 1 2 1 1 4 1

19

B

0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 1

5

Viral Viral Hepatitis A

1 1 0 0 9 3 7 1 2 0 4 1 0 0 5 3 2 6 0 5 3 5 0

10 98 10

176

B

1 1 0 0 1 5 0 4 1 0 0 2 0 0 0 2 0 1 1 0 2 3 1 3 0

22

Fever

50

Typhus A

1 7 2 7 2 0 1 6 2 4 7 6 1

17 13 27 21 19 11 19 21 27 16 56 32 13

338

B

0 3 3 6 1 0 4 1 2 1 0 0 3 0 3 0 2 5 1 1 3 6 5 4 0

16

70

Leptospirosis A

1 1 5 8 0 2 1 0 6 0 0 5 0 0 0 0 1 1 0 6 1 2 1 3

12 15

71

B

1 0 0 8 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1 2 1

19

Food Food Poisoning A

0 6 4 0 0 2 0 0 1 7 5 1 5 0 0 0 1 2 0 1 0 2 1 4 0 0

42

B

0 2 1 0 0 1 0 0 0 1 2 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0

8

January , Total2018 number reporting of units349 Number reporting of unitsdata providedforthe current week: 328

th th

Enteric Fever Enteric A

. .

0 1 1 1 1 0 0 0 0 0 0 0 0 0 1 0 0 2 1 0 1 0 1 7 2 0

19

B

0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 1 2 2 0

9

Encephaliti s A

1 3 6 7 5 2 3 1 3 5 6 0 0 4 7 4 7 2 4 3

15 20 13 15 16 23

175

B

0 1 0 2 3 2 2 0 1 3 2 1 0 0 3 1 2 3 1 0 0 3 7 5 0 1

= Cumulative= cases for year the

43

B B

Dysentery A

.

refersreturnsto received on before or 26

23 76 38 12 71 10 24 93 45 76

139 711 431 481 126 136 637 598 505 537 107 185 178 188 573

1159

7159

B

Timeliness

T=

*

5 1 8 1

33 20 26 36 13 10 20 91 26 11 10 34 31 43

278 147 102 113 120 145 143 114

1581

Dengue Fever Fever Dengue A

= reportedCases duringthe current week

Division

Kegalle RDHS RDHS Colombo Kandy Matale NuwaraEliya Hambantota Matara Jaffna Kilinochchi Mannar Vavuniya Mullaitivu Batticaloa Ampara Trincomalee Kurunegala Puttalam Anuradhapura Badulla Monaragala Kalmune SRILANKA

Source: Source: Weekly ofReturns Communicable Diseases(WRCD). A Page 3

WER Sri Lanka - Vol. 45 No. 05 27th– 02th February 2018 Table 2: Vaccine-Preventable Diseases & AFP 20th – 26th Jan 2018 (04th Week) Number of Number of Total num- Difference cases cases Total num- No. of Cases by Province ber of between the during during ber of cases cases to number of Disease current same to date in date in cases to date in week in week in 2017 2018 2018 & 2017 W C S N E NW NC U Sab 2018 2017

AFP* 01 00 00 00 00 00 00 00 00 01 01 04 06 - 33.3 %

Diphtheria 00 00 00 00 00 00 00 00 00 00 00 00 00 0 %

Mumps 02 00 00 01 01 00 01 00 01 06 04 29 22 31.8 %

Measles 02 01 01 00 01 00 01 00 00 06 04 29 31 - 6.4%

Rubella 00 00 00 00 00 00 00 00 00 00 00 00 00 0 %

CRS** 00 00 00 00 00 00 00 00 00 00 00 00 00 0 %

Tetanus 00 00 00 00 00 00 00 00 00 00 00 00 00 0 %

Neonatal Tetanus 00 00 00 00 00 00 00 00 00 00 00 00 00 0 %

Japanese En- 00 00 01 00 00 00 01 00 00 02 00 06 04 50 % cephalitis

Whooping Cough 00 00 00 00 00 00 00 00 00 00 00 01 01 0 %

Tuberculosis 85 05 11 11 05 00 11 18 23 169 193 631 653 -3.3 %

Key to Table 1 & 2 Provinces: W: Western, C: Central, S: Southern, N: North, E: East, NC: North Central, NW: North Western, U: Uva, Sab: Sabaragamuwa. RDHS Divisions: CB: Colombo, GM: Gampaha, KL: Kalutara, KD: Kandy, ML: Matale, NE: , GL: Galle, HB: Hambantota, MT: Matara, JF: Jaffna, KN: Killinochchi, MN: Mannar, VA: Vavuniya, MU: Mullaitivu, BT: Batticaloa, AM: Ampara, TR: Trincomalee, KM: Kalmunai, KR: Kurunegala, PU: Puttalam, AP: Anuradhapura, PO: Polonnaruwa, BD: Badulla, MO: Moneragala, RP: Ratnapura, KG: Kegalle. Data Sources: Weekly Return of Communicable Diseases: Diphtheria, Measles, Tetanus, Neonatal Tetanus, Whooping Cough, Chickenpox, Meningitis, Mumps., Rubella, CRS, Special Surveillance: AFP* (Acute Flaccid Paralysis ), Japanese Encephalitis CRS** =Congenital Rubella Syndrome NA = Not Available

Number of Malaria Cases Up to End of January 2018, 01 All are Imported!!!

PRINTING OF THIS PUBLICATION IS FUNDED BY THE WORLD HEALTH ORGANIZATION (WHO).

Comments and contributions for publication in the WER Sri Lanka are welcome. However, the editor reserves the right to accept or reject items for publication. All correspondence should be mailed to The Editor, WER Sri Lanka, Epidemiological Unit, P.O. Box 1567, Colombo or sent by E-mail to [email protected]. Prior approval should be obtained from the Epidemiology Unit before pub- lishing data in this publication

ON STATE SERVICE

Dr. S.A.R. Dissanayake CHIEF EPIDEMIOLOGIST EPIDEMIOLOGY UNIT 231, DE SARAM PLACE COLOMBO 10