JOINT PLAN OF ACTION SCALING UP DENGUE PREVENTION AND CONTROL FOR THE CYCLONE NARGIS-AFFECTED POPULATIONS June-September 2008
1. SITUATION ANALYSIS
In Myanmar dengue fever (DF)/dengue haemorrhagic fever (DHF) is one of the leading causes of morbidity and mortality among children under the age of 10 years, with approximately 85% of cases occurring in this age group. Some adult cases have been reported, especially from rural areas.
An annual average of 7,000-10,000 cases of DF/DHF are reported nationwide. However, in recent epidemic years (2001, 2002 and 2007), the number has risen to over 15,000 cases. National figures indicate that the largest number of cases are from Yangon Division. In 2007, Yangon (31%), Ayeyarwaddy Division (16%) and Mon State (15%) accounted for 62% of all reported cases. Reliable forecasting of epidemics is not possible.
Distribution of Dengue Cases by State/Division in Myanmar, 2007
Number of dengue cases 2007
0 1- 100 101 - 500 501 - 1,000 1,001 - 2,000 > 2,000
1 Most cases of DF/DHF occur between May and October, during the rainy season, with a peak in July.
Monthly distribution of Dengue Cases in Myanmar 2007 and 5-year average (2003 - 2007)
5000 4500 4000 3500 3000 2500 2000 1500 1000 Num ber of Dengue Cases 500 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Months
2007 5-year average
The DHF case fatality rate (CFR) varies from 0.2% to 6.25% but is consistently lower in Yangon than in other Divisions and States. The reasons for these differences are unclear, but high to moderate CFRs could be due to (a) admission of a high proportion of DHF/dengue shock syndrome (DSS) cases compared to DF; (2) lack of experienced doctors and nurses; and (c) inadequate equipment for essential clinical laboratory tests, e.g. PCV, platelet counts, WBC. Nevertheless, early detection and effective clinical management are critical for keeping CFRs low.
The main mosquito vector of dengue in the country is Aedes aegypti , a highly domesticated species that is found mainly in urban / peri-urban areas in all townships in Yangon and throughout most of the country. In breeds almost exclusively in man-made water-filled receptacles. Aedes albopictus , is also widespread in Myanmar, particularly in more rural settings and may have a secondary role in transmission. Breeding sites are found indoors as well as outdoors. The profile of container habits supporting larval populations of the vector vary between localities. However, in a recent study by Department of Medical Research (Lower Myanmar) supported by TDR on the larval ecology of Aedes aegypti in a sample of Yangon townships, 65% of all adult mosquito production derived from only 4 container habitats: 22% of adult mosquitoes originated from water storage drums, a further 22% from spirit worship flower bowls, 12% from spirit house flower vases and 7% from concrete water storage tanks.
The risk of dengue transmission in the cyclone affected areas may be increased among people living in temporary shelters and/or overcrowded conditions, particularly where fresh water is stored in unprotected water containers and rainfall collects in other artificial containers, allowing mosquitoes vectors to proliferate. Damaged and un-repaired roofs in urban areas may also contribute to increased vector populations wherever water accumulates indoors on flooded floors or in basements. Similarly, rainwater collecting in the hollowed-out cavities of felled trees will provide additional new breeding sites. Moreover, rural populations displaced from rural to urban areas are likely to have lower herd immunity to dengue viruses and may therefore facilitate virus transmission in urban areas. 2
As of 10 June 2008, 781 cases of dengue / DHF were reported form Yangon Division, and as of 31 May 2008, 471 case were reported in Ayeyawaddy Division. In the later, over 50% of cases are from rural areas.
2. KEY STRATEGIES
2.1 Disease surveillance
National epidemiological surveillance and reporting systems are in place for DF/DHF. Laboratory support for confirmation of DF/DHF is unlikely to be available in some of the severely affected areas. Surveillance is based mainly on the reporting of clinical cases, using WHO case definitions. Additionally, dengue is included in the Early Warning and Reporting System (EWARS) put in place for the cyclone affected areas in Yangon and Ayeyawaddy Divisions. Where available, commercial rapid diagnostic kits for use in the field may also aid outbreak investigation especially in rural areas, but their sensitivity and specificity are limited.
2.2 Clinical management
Early recognition and effective clinical management of DHF patients is essential for minimizing case fatality rates and physicians and nurses in areas endemic should be well-trained. Clinical laboratory support for severe cases in referral hospitals is important for monitoring haematocrit and platelet counts and for fluid therapy during critical stages. Hospitals and temporary health facilities should be prepared to respond in the event of outbreaks.
2.3 Vector control
Aedes aegypti is the main target of dengue prevention and control measures. It breeds almost entirely in man-made container habitats inside the houses and close to human habitation, particularly items such as rain-filled discarded food and beverage containers, plastic packaging, used tyres, domestic water storage containers, flower vases and any other confined, water-filled containers.
2.3.1 Environmental management
Environmental management is the main strategy for reducing dengue vector populations. For all collections of water in receptacles in and around houses and other habitation, the objective is to either eliminate the receptacles or to manage them in ways that do not allow mosquitoes to proliferate. Depending on the type of container and its use, there may be different options, e.g., the collection and removal of discarded items in which rainwater can settle; overturning, crushing or puncturing such items so they do not accumulate water; storing them under shelter. Containers used for storing water at the household should be covered with tight fitting lids to prevent mosquito access or emptied, scrubbed and refilled no less than once per week. Flower vases for spirit houses can be managed in a similar manner to avoid mosquito production. Tree holes can be filled with sand or soil.
2.3.2 Chemical control: insecticides and their application 2.3.2.1 Larvicides
Where water is stored in large containers (large tanks, cisterns, etc) which cannot be tightly covered or regularly emptied, insecticides are used to control the larvae. The larvicide temephos, formulated as 1% sand granules, is recommended by WHO for application and it is safe use in drinking water. It has a residual effect and can provide control for 6-8 weeks at the recommended dosage of 1 ppm (10g/100 litres). 3
2.3.2.2 Adulticides
Space spraying to kill adult mosquitoes (thermal or cold fogging) is an epidemic contingency measure and should only be carried out in support of other measures that provide longer term control of the mosquitoes in their man-made larval habitats. Where fogging is warranted, e.g., in crowded campsites for displaced persons, or adjacent urban settlements where (a) mosquito biting is occurring during daylight hours (indicating the presence of one or other of the main dengue vectors, Aedes aegypti and Aedes albopictus ) or (b) suspected or probable cases of DF and/or DHF are reported, the entire campsite or settlement will be systematically fogged, preferably in the early morning between dawn and 09:00 hrs, when the adult mosquitoes are active and meteorological conditions are usually most favourable (or if necessary, in the late afternoon between 16:30 hrs and dusk). This allows the insecticide fog to drift slowly through the area. Fogging has only a transient effect, killing flying mosquitoes which come into direct contact with the insecticide droplets. As soon as the insecticide cloud has drifted away the effect is gone. Fogging should not be carried out during periods of rainfall. Machine operating procedures and insecticide label instructions must be followed. The procedure should repeated twice per week for at least two weeks or until no further cases are reported.
All machine operators and insecticide handlers must be trained prior to the operations and provided with the necessary protective equipment.
Resource documents:
Space spray application of insecticides for vector and public health pest control. A practitioner's guide. http://whqlibdoc.who.int/hq/2003/WHO_CDS_WHOPES_GCDPP_2003.5.pdf Safe use of pesticides. In Pesticides and their application for the control of vectors and pests of public health importance. Chapter 2 pp 11-20. http://whqlibdoc.who.int/hq/2006/WHO_CDS_NTD_WHOPES_GCDPP_2006.1_eng.pdf
2.4 Social mobilization
Effective control of Aedes aegypti requires a multi-disciplinary approach, with involvement of the at-risk communities in environmental management. Key groups within those communities are mobilized to undertake measures to reduce the number of containers that are producing mosquitoes, e.g., housewives, schoolchildren, monks, shopkeepers. Clear behavioural messages and channels of communication to reach the target groups must be identified.
Other resource documents
Prevention and control of dengue and dengue haemorrhagic fever. Comprehensive Guidelines (WHO SEARO No. 29) 1999 http://searo.who.int/EN/Section10/Section332/Section554.htm
4 3. OPERATIONAL PLAN
3.1 Objectives o To reduce the risk and/or intensity of transmission during the current transmission season o To suppress or contain localized outbreaks o To minimize DHF case fatality rates o To strengthen national capacity for the prevention and control of DF/DHF
3.2 Target Areas
3.2.1 Yangon townships with highest DF/DHF case reporting rates – 1st priority The first priority is the 11 townships in Yangon Division (Table 1) with highest average annual number of DF/DHF cases (2005-2007). Although least affected by the cyclone, Hlegu township is included since currently more cases are coming from this township.
Table 1. Priority townships for dengue prevention in Yangon Division townships
Average annual number of Estimated Estimated Yangon reported DF/DHF target number of Townships cases and population target houses deaths (2005- 2007) Hlaingthayar 238 (3) 194,419 38,900
Insein 218 (2) 278,722 55,700
Dagon (S) 202 (2) 106,458 21,300
Thakayta 188 (2) 294,716 58,900
South Okkalapa 177 (2) 259,086 51,800
North Okkalapa 164 (3) 305,055 61,000
Manyangone 157 (1) 213,748 42,700
Dagon (N) 155 (1) 97,986 19,600
Thingangyun 150 (0) 287,921 57,600
Tamwe 145 (1) 176,058 35,200
Hlegu 98(1) 317,305 63,500
Total 2,531,474 506,200
3.2.2 Ayeyawaddy, township urban areas; 2nd priority The second priority is the 7 townships in Ayeyawaddy Division severely affected by the cyclone, plus the townships of Pathien, Myaummya, Maubin and Hinthada where high numbers of dengue cases were detected in the past three years (Table 2). Information from VDBC, DOH, indicates that over 50% of cases this year and 1/3 of cases last year are from rural areas. Thus, rural population (20% of total population in the whole township) is included in this plan.
5 Table 2. Priority townships and estimated target populations for dengue prevention in Ayeyawaddy Division
Average Estimated Estimated Estimated Cyclone- annual Estimated number of target number of affected number of target target houses population in target Ayeyarwady reported population in in urban rural areas houses in Townships DF/DHF cases urban areas* areas** (20% of total rural and deaths population) areas** Ngaputaw 32 (1) 101,407 20,300 67,604 13,500 Phyapon 140 (1) 75,584 15,100 50,389 10,100 Mawgyum 11 (0) 100,638 20,100 67,092 13,400 Laputta 52 (0) 107,461 21,500 71,641 14,300 Kyeiklat 22 (1) 65,714 13,100 43,809 8,800 Bogalay 21 (0) 132,561 26,500 88,374 17,600 Dedaye 35 (0) 74,947 15,000 49,966 10,000 Pathein ** 266(9) 113,125 14,100 75,416 15,100 Myaummya ** 86(0) 121,690 24,300 81,127 16,200 Maubin ** 143(2) 113,668 22,700 75,779 15,200 Hinthada** 109(1) 140,282 28,000 93,521 18,700 Total 1,147,077 220,700 764,718 152,900 * Estimation based on 2006 population and urban-rural ratio of 30:70 **Estimation based on 1 house per 5 persons ***Not directly affected by cyclone but with high number of cases
3.2.3 All other townships in Yangon - 3rd priority The third priority is all the other townships in Yangon Division (Table 3).
Table 3. All other townships in Yangon Division
All other Yangon Total Estimated number of Townships Population houses (2006)
32 townships 3,985,062 797,000
3.3 Vector control measures
The Vector Borne Diseases Control (VBDC), Department of Health, MOH, will provide technical guidance to the local health authorities, NGOs and INGOs in the implementation of vector control measures. They will coordinate with the Yangon City Development Committee in Yangon City and with the respective Township Peace and Development Committees in other target townships. They will be supported by the Central Health Education Bureau, Ministry of Health, for social mobilization.
3.3.1 Environmental management
all Coverage: townships in Ayeyawaddy Division and Yangon Divisions 6 In collaboration with the local authorities and under the technical guidance and direction of the Township Medical Officer and VBDC Team Leader, the implementing partners (e.g., national and international NGOs) will mobilize the communities to implement environmental management measures, specifically to: o Collect discarded items in which rainwater can settle, e.g., food and drink containers, plastic bags and sheeting, used tyres, etc. Such items will be removed from the immediate vicinity, or buried, or stored in such a way that they do not collect water.
o Tightly cover water storage containers to prevent mosquito access. Alternatively they will be completely emptied and scrubbed at least once every 7 days to prevent development and emergence of adult dengue mosquitoes. The same procedure can be followed for religious flower vases and spirit house flower bowls.
These measures will be systematically carried out in all the target townships. Particular attention will be given to (a) temporary settlements; (b) households; (c) schools; (d) hospitals / health centres, and (e) monasteries.
3.3.2 Larviciding
st nd Coverage: 1 and 2 priority townships
Larviciding will be carried out in the 1st and 2 nd priority townships. The larvicide will only be applied to those water containers in which the environmental management measures cannot be readily implemented. The larvicide temephos 1%SG will be applied at 1ppm of active ingredient, based on container capacity. VBDC and WHO will develop a simple guide for this activity.
Larviciding will be done for two rounds – the first round will be in June and the second round will be 6 – 8 weeks after the first round. It is estimated that on average 50g of temephos 1% SG will be needed for each house per round. Thus, 44 tons will be needed to cover 880,000 target houses during the first round. A similar quantity will be needed during the second round; however, the estimate will be will be adjusted based on the actual usage during the first round.
As of 12 June 2008, only 1.5 tons of temephos 1% SG are available in the country. Another 5 tons will be available at the latest on 18 June 2008. Thus, 37.5 tons should be mobilized for the for the first round alone, and around 44 tons for the second round. The estimated budget required for application of larvicide is US$48,000 for each round (US$96,000 for 2 rounds).
The plan calls for mobilization of around 1,760 volunteers or members of national NGOs (e.g., MRCS, MMCWA, MWAF) to do larviciding in the target townships. They will be oriented and supervised by around 211 VBDC, Divisional and Township Health Staff. International NGOs with local staff are also encouraged to participate in larviciding.
3.4 Strengthening clinical management
Paediatricians have already been deployed to cyclone-affected townships. Essential supplies were provided, and will be augmented as necessary.
Training of station hospital medical officers and assistant surgeons in Ayeyarwady and Yangon on clinical diagnosis and management of dengue fever / DHF will be done in September. Paediatricians from the Children’s Hospital and other referral hospitals will serve as resource persons. The duration of training will be 3 days.
7 To facilitate the training, 50 CD-ROMs on "Dengue Haemorrhagic Fever: early recognition, diagnosis and hospital management - an audiovisual guide for health care workers responding to outbreaks" have been provided by WHO. A Burmese language voice over is also being prepared.
3.5 Disease surveillance and outbreak response
Coverage Surveillance – in all target townships
Outbreak response – as needed
Surveillance of dengue fever / dengue hemorrhagic fever is already part of the Early Warning System and the national diseases surveillance. If the epidemiological surveillance system indicates a clustering of dengue cases in a neighbourhood, environmental management measures will be intensified under the direction of the Township Medical Officer and VBDC Team Leader. As a complementary outbreak measure only, fogging will be undertaken throughout the affected area and extending, for at least 200 metres beyond the case cluster (most adult Aedes aegypti do not fly more than 100m). Fogging operations will be carried out according to the criteria and procedures described in section 2.3.2.2.
Small quantities of malathion for fogging have been used in the past and field staff of the national programme are therefore most familiar with the handling and use of this insecticide.
No insecticide resistance in the target mosquito species has been reported in Myanmar. Any additional purchases of malathion should be in accordance with WHO specifications. All insecticides must be applied in accordance with label instructions.
Resource documents:
Guidelines for treatment of dengue fever/dengue haemorrhagic fever in small hospitals (WHO SEARO 1999) http://searo.who.int/LinkFiles/Dengue_Guideline-dengue.pdf
Dengue Haemorrhagic Fever: early recognition, diagnosis and hospital management - an audiovisual guide for health care workers responding to outbreaks (WHO/EPR 2006). [50 copies have been made available to Ministry of Health]
3.6 Training in dengue vector control
Training and retraining on dengue vector control, including the management of fogging operations and machine operation, maintenance and repair, is one of the needs identified by VBDC. Because of the urgency of the current situation and scheduling of field operations, the training will be carried out in two phases, the first in early August and the second in late September. In the interim any urgently needed on-the-job training will be provided by VBDC personnel.
(a) National level training/retraining on dengue vectors and their control for 3 entomologists and approx.30 assistant entomologists of the VBDC. Training will be carried out in Yangon and Nay Pyi Taw. The course will include: mosquito biology and behaviour, identification, control methods, safe handling of insecticides (larvicides and adulticides), use and maintenance of insecticide application equipment (portable fogging machines).
Duration: one week Date: early September Trainers: to be identified.
8 (b) Divisional and township level training for Yangon and Ayeyarwady VBDC and basic health staff with emphasis on field operations, as above.
Duration: 3 days Date: late September Trainers: selected from trained national and divisional levels VBDC staff
3.7 Roles of partners
3.7.1 National NGOs
The activities that national NGOs may carry out are: larviciding, health education and environmental management.
Selected members of national NGOs (e.g., MMCWA, MWAF, MRCS) will be trained by VBDC staff and supported to do larviciding in the priority townships. The VBDC staff and Basic Health Staff will supervise them to carry out this activity.
The national NGOs with grass roots activities in the two cyclone-affected divisions will be given orientation briefings by VBDC on pr omotion of the above-mentioned behaviours(please see 3.3.1) and provided with educational pamphlets a nd laminated cards, illustrated with those behaviours as 'talking points' to aid face-to-face communication with householders.
The Myanmar Maternal and Child Welfare Association (MMCWA) is already actively engaged in dengue prevention. It will intensify its efforts during the main transmission season - until the end of September - using its very large volunteer network of human resources and skills. The volunteers will receive re-orientation training for face-to-face communications on dengue prevention and treatment seeking (the first re-orientation, involving 10 volunteers from 10 Yangon townships will take place in the week of 9 June). The MMCWA will take a lead role in promoting the desired behaviours among householders. Other community service organizations will also be engaged in this effort, notably the Myanmar Red Cross Society (MRCS) and the Myanmar Women's Affairs Federation (MWAF). The initial focus of these efforts will be the urban areas and townships of Ayeyarwady and Yangon Divisions. These organizations will extend these intensified activities to other townships in Yangon Division.
Each MMCWA volunteer has the responsibility of providing advice and guidance to mothers in 10 neighbouring houses. The volunteers have IEC materials prepared by the MoH (pamphlets and posters) to share with mothers and housewives. These contain several key behavioural messages on mosquito control. They also encourage owners of child day care centres to place children under mosquito nets when they rest during the daytime, and to provide donated nets to some of the centres. Each volunteer will visit their respective cluster of 10 households once per week until the end of September for face-to-face communication and they will also actively assist the housewives in preventing mosquito production on their premises. 'Outreach volunteers' will be used to stimulate and encourage the work of these volunteers, giving priority to (a) the displaced population settlements and their immediate neighbourhoods in urban areas, (b) the schools, child day care centres and monasteries.
The MRCS had trained 300 volunteers from cyclone-affected areas of Ayeyarwady and Yangon Divisions (training continues to 10 June) on a range of public health measures, including on dengue and dengue mosquito control, and will be able to impart the same behavioural messages to target groups. Batches of trainees are already, and will continue to be deployed to Ayeyarwady on an ongoing basis. The local authorities will be encouraged to mobilize other community-based organizations to actively participate in dengue prevention and control.
9 3.7.2 School teachers and school children
Teachers Hygiene Kits were developed by MoH in 2007 with specific information on dengue (mosquito control, clinical danger signs in children, treatment seeking and personal protection measures). With the aid of UNICEF, some thousands were distributed to schools in Yangon as part of an ' Aedes-free schools' initiative. Additional copies, with a revision that includes signs and symptoms of DF and DHF, will be prepared and further distributed for use in schools. Ministry of Education will be encouraged to use these educational materials to actively involve schoolchildren in eliminating breeding sites around the schools and at their homes.
3.7.3 International agencies and non-governmental organizations
The international agencies and INGOs will be encouraged to support this plan. Depending on their comparative advantages, the support can be, for example, provision of logistics, technical assistance, development and dissemination of IEC materials, environmental management, etc.
3.8 IEC using electronic and print media
The state television and radio, and print media, will be used to re-enforce the specific behavioural messages related to the measures on environmental management outlined in section 3.3.1. The Central Health Education Bureau produces and has programmes and 'spots' on dengue. Additional video clips and radio messages on the specific behaviours will be developed. These will be broadcast on Myanmar Radio & Television and Myawady TV.
The short messages will be broadcast several times per day for 2 weeks, to be followed by a break of 2 weeks. Broadcasts will be at peak viewing/listening times. This monthly cycle will begin in mid- June and be repeated through September. Additionally, the behavioural messages should be topics for discussion on other health-related media programmes.
In the print media, the same behaviours will be re-enforced by inserting health promotion messages in the following newspapers and journals for circulation at the same times as the radio and TV schedules: New Light of Myanmar (daily newspaper) and Mirror (daily newspaper).
The video clips will also be distributed through the Myanmar Video Association to the video parlours in Yangon and Ayeyarwady, for regular showing, again on the same calendar days as the radio and TV schedules.
4. Monitoring and evaluation Systematic monitoring and evaluation will be carried out by each partner agency that will carry out the activity. Some of the key indicators are:
Output indicators (to be measured by implementing agency / NGO) o Number of houses treated with larvicide in each cycle of larviciding o Population protected o Number of volunteers mobilized for dengue prevention and control Outcome / Impact indicators (to be measured by VBDC) o House Index o Breteau Index o Container Index o Cases reported o DHF case fatality rate
5. Supplies and equipment Please see annex.
10 6. Estimated budget
Key Activities Cost (in USD) 1. Provision of insecticide and materials to be used for its 260,000 application
880,000 houses @ 50g per round x 2 rounds = 84 metric tons of temephos, 1% SG @ $2.88/kg (US$253,440) Delivery of temephos , 1% SG to township (average of $200/township x 22 = $4,400 Materials for application (teaspoon, containers for larvicides = US$2,00)
2. Larviciding (labor cost, supervision, travel costs for 111,000 community mobilization and supervision) (1,760 volunteers @$2/day x 10 days per round x 2 rounds = $70,400) (211 supervisors@US$5/day x 12 days /round x 2 rounds = $25,320); Travel costs = $15,000 2. Clinical management of severe hospitalized cases, including consumables and laboratory support, estimated 5,000 cases in Ayeyarwady & Yangon @US$ 50 per case 250,000
3. Social mobilization: (a) mass media and video materials development and 10,000 dissemination (b) IEC materials for use of the volunteers, teachers, etc 30,000
4. Technical supervision, monitoring and evaluation of 50,000 interventions
5. Training on vector control and clinical management 50,000
6. Personal protective equipment for insecticide handlers 5,000 and fogging machine operators
Total (US$) 766,000
11 Timeline for the implementation of dengue prevention and control in cyclone affected urban townships
Timeline - week beginning 9- 16- 23- 30- 14- 21- 28- 4- 11- 18- 25- 1- 8- 15- 22- 29- Planned activities Jun Jun Jun Jun 7-Jul Jul Jul Jul Aug Aug Aug Aug Sep Sep Sep Sep Sep Development, printing and dissemination of IEC materials Broadcasting of messages daily for 2 weeks per month Procurement of additional supplies Mobilization and training of national NGO volunteers for larviciding
Larviciding-round 1
Larviciding-round 2
Environmental management by NGO volunteers (& others) Training VBDC national level staff-vector control
Training VBDC division and township level staff Yangon, Ayeyarwaddy- vector control Clinical management training Disease surveillance Monitoring and evaluation
12 ANNEX
List of essential supplies prevention and control of dengue fever
Patient management — intravenous fluids physiological saline Ringer’s lactate 0.167 mol/litre sodium bicarbonate — colloidal fluids (one or more of the following) plasma, fresh frozen or dried plasma protein fraction, human 5% dextran-40 other plasma substitutes blood products whole blood platelet concentrate — oral rehydration solution — paracetamol — chloral hydrate — furosemide Laboratory — blood-drawing equipment — specimen containers or filter paper — haematocrit centrifuge — platelet counting equipment — serum or plasma storage facilities —20°C freezer for serological specimens —70°C freezer (or liquid nitrogen) for virus isolation specimens — specimen shipping equipment (consult local or regional virology laboratory)
Control — Temephos sand granules, 1% — teaching and information materials (posters, pamphlets, video tapes, articles for newspapers, radio and television, etc)
13