Introduction
Dengue Epidemic is caused by Dengue Virus through mosquito specie namely “Aedes Aegypti”. Presently there is no vaccine or proper medical treatment against this disease. It is a self-terminating disease and its complications are controlled through health care facilities. Dengue is the most rapidly spreading mosquito-borne viral disease in the world. In the last 50 years, incidence has increased 30-fold with increasing geographic expansion to new countries and, in the present decade, from urban to rural settings. An estimated 50 million dengue infections occur annually and approximately 2.5 billion people live in dengue endemic countries.
The proper and effective remedy against this epidemic is the eradication of breeding sources of dengue vector hence there is key role of environmental health managers and the local administration. No single department can overcome this epidemic; the entire community has to take charge. The effective integrated and coordinated efforts are required to control the epidemic through the body fabric of the entire civil society.
WHY DEPCAM
Dengue took us by surprise in the summer of 2011 when Lahore in a matter of few weeks became the epicenter of one of the worst Dengue epedemics known in recent history. Neither the health facilities nor the health mangers were adept in the intricacies of this relatively new disease. Initial visits of Sri Lankan and Indonesian teams in the midst of the epidemic provided basic knowledge and expertise in effectively dealing with dengue. The kind of urgent and effective response demonstrated by the Punjab Government will go in the annals of epidemic history as an exemplary response which mitigated a far bigger disaster and effectively contained damages to bare minimum.
It is in this backdrop that the Chief Minister Punjab decided to emergently upgrade the capacity and expertise of important players against Dengue from various segments of the government and society. An extensive exercise to put in place an appropriate training programme was conducted at the highest level of the Punjab Government and the outcome was what came to be known as DEPCAM: “Dengue Epidemic Prevention, Control and Management program”. This program had its setting in Thailand and Sri Lanka and was organized and conducted by the Asian Institute of Technology (AIT). AIT is a research university chartered as an intergovernmental organization with Pakistan as a charter member since 1959. AIT extension works actively with public and private sector organizations to build capacity and expertise in a wide range of areas relevant to strategic development needs of its partners.
DEPCAM training Programme took place from 04 to 25 December 2011 in Sri Lanka and Thailand. The program was aimed to enhance capacity of the concerned departments and sectors of the Punjab in Dengue management and to benefit from practical experience of these two regional states with considerable experience in facing Dengue epidemics.
Training Modules and Cohorts
The DEPCAM program was divided into three basic training modules. The first week focused on core areas comprising of critical information common to all segments of the training group, mostly in a class Hall setting. The medium was lectures, critical analysis and interactive sessions. Written material was provided to each participant.
During the second week participants were broken in several sub-groups and taken to field visits in geographical areas relevant to their field of expertise for experiential learning and on the job training. Theoretical knowledge was augmented with practical experiences and demonstrations during these field trips.
Finally, in the third week the sub-groups again regrouped at central location for integration and consolidation of this richly varied experience. A synthesis was the outcome with integration of experience and knowledge sought. Key learning points and experience sharing was put to test as each cohort group made presentations before a panel of experts. The DEPCAM participants were also invited to comment on the presentation of cohort groups.
Composition of the Training Batch
The total number of persons who received training and were certified by AIT was 115. This included 21 participants from policy level group who did a special Programme of one week only whereas the remaining 94 participants from operation level cohorts completed three weeks. Mr. Sajjad Saleem Hotiana, Secretary Environment Protection Department, Government of Punjab was appointed Chef de Mission for this DEPCAM batch for the entire duration of the training.
The policy level group was consisted of 02 MPAs, 01 MNA, 07 civil servants, 02 prof doctors, 02 consultants, 01 representative of NGO, 01 religious scholar, 03 local government officers and 02 media representatives. Likewise, the operational level cohort group comprised of 17 doctors from government health care centres, 12 doctors from private health care units, 14 nurses, 01 blood- lab technician, 02 environmentalist, 12 vector control managers, 06 lady health supervisors, 06 officers of local government, 04 health managers, 10 professional entomologists, 03 officers of DGHS, 01 horticulturist (PHA), 04 entomologists of agriculture universities, 01 officer of fisheries, 01 health education officer.
The DEPCAM participants were at another level further divided into four cohorts groups including Policy Level Group comprising of 21 members, Research and Surveillance Group comprising on 17 members, Behavioral Change and Response Group consisting on 25 members, and Clinical Case Management Group comprising of 51 members.
Sub-group leaders were appointed for each cohort. Dr. Waseem Akram was the group coordinator for policy level group. Dr. Nisar Cheema EDO health was leading the research and surveillance group. Behavioural change and response group’s leader was Mr. Mehmood Masood Tamana EDO MS Lahore. Finally, the largest of all clinical case management groups was led by Prof. Dr. Muhammad Ali from SIMS.
The clinical case management group visited Hospitals and municipality offices in Colombo while the behavioural change and response systems groups visited different public services offices besides visiting several residences at Saraburi and Lopburi, Thailand. Similarly, the research and surveillance group visited the health care facilities, epidemiology office at Chiangmai, Thailand. The policy level group visited municipality offices and health care units at Bangkok. Each participant of the policy level group presented a three minutes brief before the jury regarding their findings and recommendations. The policy level group returned to Pakistan in the end of the second week.
Mr. Sajjad Saleem Hotiana- Chef de Mission conducted meetings with Defence Minister, Director Police Environment Protection Division Colombo Sri Lanka, Commissioner & Local Administration Kandy Sri Lanka along with several physical inspections of potential breeding sources.
The Chef de Mission also conducted inspections at old tyre works, plan nurseries and junk/ scrap yards at Saraburi & Lopburi Thailand.
As the AIT University was under repair due to flood damage hence the venues of lectures were arranged at Windsor Suits Hotel and Chulalongkorn University, Bangkok. The field visits were arranged according to relevancy of the cohort groups.
Chapter # 2
Detail of Activities
The 92 members of DEPCAM program under the supervision of Chef de Mission Sajjad Saleem Hotiana left for Bangkok airport on December 5, 2011. They were seen off at the airport by Secretary Health Mr. Jehazab Khan, Member Provincial Assembly of the Punjab Mr Salman Rafique among other.
The opening ceremony of DEPCAM program was held in Bangkok in which all the ATI Extension trainees, program directors and DEPCAM program participants participated. Prof. Dr. Willi Zimmermann, Dr. Sup Chai Ruekngam, Senior Medical Expert of Department of Disease Control MoPH, and Dr. Sujittra Nimmanittaya were the guest of honor on this occasion. Chef de Mission Sajjad Saleem Hotiana gave an address of thanks to the sponsors and organizers of the training and gave shields to the guests on the behalf of Punjab Government.
First Week
In first week training module, the AIT Extension healthcare resource group, comprising of faculty of the top medical institutions from the public sector and academia, briefed the DEPCAM participants regarding the core concepts regarding Dengue. The AIT trainees delivered lectures and provided the written material to the DEPCAM participants. The AIT trainees in their lectures covered the current concepts on the basic epidemiology of dengue, its pathogenesis and clinical management within the public health management context, and with particular emphasis on characteristics that responds to preventative measures.
Participants were also given written reading material and group assignments at the end of every session. During the first week training, very comprehensive lectures on “epidemics in the public health perspective” and “active control measures including mapping of disease partners”, “epidemiological risk assessments” were delivered by Dr. Apinya Niramitsantipong, dengue pathogenesis, Dr. Sujittra Nimmanittya, Dr. Tarawit Oupapong, and internationally renowned figure from Mahidol University, Dr. Sutee Yoksan.
The DEPCAM participants took keen interest during these sessions which were very interactive. The communication experts Mr. Smith Boonchutima and Mr. Anand Prachansri played a vital role in getting the participants involved in these lectures. After the completion of first module, the participants were ranked and awarded recognitions based upon their participation by speakers during the lectures and training session.
Second Week
In the 2nd week, the DEPCAM participants were trained in applied work and attended field programs. The first 44 members group comprising of doctors, nurses and health workers visited the Queen Siritkit Institute where they were briefed by Dr. Siripeng. Meanwhile, the second group went to Bureau of Epidemiology and was led by Dr. Tarawit Oupapong with a total 33 of 12 epidemiologists and officers of DGHS. Similarly, the third group comprising of 15 entomologists and Health managers visited the Department of Medical Sciences, Ministry of Health and the group was briefed by Siriporn Yongchaitrakul and Evanshainia Syiem.
Third Week
The 3rd week was meant for synthesis of learning and consisted of orientation-level Training of Trainers (ToT), syndicate discussions and presentations which included review of field visits experience coupled with group discussion and relating it to back home situation. Dr WillieZimmermann conducted most of tese sessions along with other eminent penalists. Detailed Q&A and review was done by Dr. Faiz Shah, Executive Director Extension AIT. A separate session was chaired by Mr. Sajjad Saleem Hotiana Chef de Mission which focused on relating acquired knowledge to Pakistan in which all the groups and sub-groups leaders participated.
Chapter 3
The Placement and Activities of Groups
Placement A: Clinical Case Management Group, Colombo, Sri Lanka
The largest sub group of 52 Participants comprising doctors, clinicians, family physicians, nurses etc. attended training at Colombo Sri Lanka and visited various medical facilities and underwent rigorous training in relevant fields under the Group Coordinator Prof. Dr. Muhammad Ali.
Ms. Lekha Ratnayake was the AIT Coordinator at Colombo. The participants covered the following areas during the Colombo’s training including DF/ DHF, Clinical Approach to Dengue, Fluid Management in DHF, Management of difficult Dengue cases, Documentation/Monitoring/Referral etc. Practical demonstrations by Dr.Paba, Dr. Tissera, Dr. Sunethra, Dr. Fernando and Dr. Weeraman were witnessed by Doctors. Chef de Mission Sajjad Saleem, who accompanied the
delegation and stayed for three days in Colombo, also held meetings with high officials of the Ministry of Health, Ministry of Defense, Ministry of Environment, and with High Commissioner of Pakistan in Sri Lanka. The Director, Environment Protection Division (EPD) Mr. Quintas Fernando gave comprehensive presentation to the Chef on the functions & administrative set up of the “Environmental Police” peculiar only to this country in SARC. He also conducted meetings with Commissioner and field officers of Kandy District and studied environmental control measures in urban and sub-urban settings.
Jehanzab khan Secretary Health Punjab, who joined the group in the middle of the week, reviewed the program with Chef de Mission and minor remedial measures were discussed to get optimal results from DEPCAM. He participated in closing ceremony attended by highest level of Health officials and reported widely in Sri Lankan National press. Sri Lankan segment of the visit was adjudged by participants as most robust primarily because of the extra ordinary efforts of Dr. Paba and her team, and the great interest shown by HE the HC of Pakistan in Sri Lanka and the visit of Secretary Health Mr. Jehanzab Khan.
Placement B: Research and Surveillance System Group, Saraburi & Lopburi, Thailand
The 2nd group of 12 participants comprising vector control managers and entomologists visited Basic Health units at Saraburi & Lopburi Thailand. At the Regional Office of Disease Prevention Control, Dr.. Preecha Prempree assisted the group in scheduling useful visits. The group was paid surprise visit by Chef de Mission on December 16, 2011 and the training activities and attendance etc. found in perfect order.
Placement C: Behavioural Change and Response Group
Chiang Mai, Thailand
The third Group of 23 participants comprising of TMOs, Heath Managers and other officials got their training & field visits at Chiang Mai under Group Coordinator Dr. Nisar Cheema. The group visited all the major towns of Chiang Mai situated besides the border of Burma. The group participants took keen interest during the practical visits and they did extremely well in terms of getting valuable exposure and learning.
Policy Makers Group, Bangkok, Thailand
A special group of Policy makers comprising of 19 participants including members of National and Provincial assembly, Senior public servants, Media representatives and civil society members had a special week long program tailored for them at Bangkok, Thailand. This included intensive field visits and panel discussions etc. Chef de Mission also attended the entire final session with the group.
Chapter 4
Critical Observations by DEPCAM Participants:
Chapter 5
Concluding Ceremony
The closing ceremony of DEPCAMP training was held on December 23, 2011 at the Chulalongkornn University, Bangkok, Thailand.
The closing ceremony was attended by Dr. Faiz Shah, Dr. Willy Zimmermann, Dr. Paba, Dr. Hasitha Tissera, Dr.Jonathan Shaw, Chef da Mission Sajjad Saleem Hotiana, AIT Extension trainers and by the DEPCAM participants.
At the ceremony, Dr. Faiz Shah delivered summary speech for the closing ceremony and congratulated to the participants for successful completion of the training.
Then the certificates have been presented to all DEPCAM programme participants by Sajjad Saleem Hotiana and Dr. Jonathan Shaw.
Following the certificate awarding ceremony, there were guest speeches. They congratulated to the organizers for organizing the training successfully and the participants for successful completion of their training.
Talking to the ceremony participants, Chef Da Mission Sajjad Saleem said that the training had not only been an enriching and educational experience, but a cultural one as well. He observed that the participants had learnt a lot from the team of AIT trainers and from one another, and he urged them to pass on the knowledge acquired to their colleagues back home.
The group in spite of its sheer huge size and diversity has been working harmoniously and dedicatedly far beyond any body’s expectations, he added. Sajjad Saleem said that AIT showed considerable commitment in running this programme he is thankful to DEPCAM Programme Director and his team for their dedication and keen interest in the said programme and providing all the necessary support to make it successful. He said that it is his belief that all of this would not have been possible without the kind of hard planning gone into this programme at the highest level of the provincial government and the merit based selection of this group by various Departments.
Prof Dr. Muhammad Ali Khan, in his thank you speech on behalf of the participants, expressed gratitude to AIT trainers for organising the DEPCAM programme. He remarked that the workshop had been an “exceptional experience and unique learning opportunity” for all of them, and encouraged fellow participants to “make a difference in their home country”.
Critical Observations by DEPCAM Participants:
1) People of Thailand have learned to live with Dengue and they have no fear of Dengue Epidemic / Vector.
2) In a village near Sara Buri / Log Buri Thailand Dengue Vector Larvae was observed approximately in each house.
3) In Chiang Mai Thailand the local volunteers place red flag at those houses having Dengue Vector Breeding Site and Green Flag at Larvae / Dengue Vector Breeding Site free houses.
4) In Thailand herbal vector repellents are being used. Larvicide, bacteria and guppifish are used in water vessels / reservoirs.
5) There are several water reservoirs and plan vessels in Thailand wherein Guppifish have been found to control Dengue Vector Larvae.
6) The Health Care Facilities and Administrative Hierarchy are found excellent in Thailand & Sri Lanka.
7) The Nursing Staff was found well trained and having control over Dengue Case Management.
8) The Hospitals were not overloaded as compared to Pakistan.
9) Documentation of Servillance was found good having Electronically Record Keeping.
10) The passive implementation has been seen in both countries while in our Country the implementation is active & effective.
11) Public awareness & community mobilization is effecive.
12) The Tyres at road sides have been seen in both countries but have holes for drainage of water.
13) No remedial measures were taken at junk / scrap yards and old tyre godowns / works.
14) In Sri Lanka the natural breeding sources in various types of trees have been observed. The anthropogenic sources are less than the natural breeding sources in Sri Lanka.
15) In Sri Lanka there is Environmental Police called Environment Protection Division working under Ministry of Defence. This Police not only take action under the provisions of PPC but also facilitate the Environment Protection Agency and Municipalities for action on Environmental Violations along with Dengue issues.
16) Both Countries have Evidance based actions / sprays collected through survillance.
17) The solid waste management is better than our country. Public of both countries don’t through waste / recepticles in streets or in the open sun.
18) The priority is given to kill the Dengue Vector at its larval phase. Some experts at Saraburi Thailand Questioned the effectivness of periferal thermal fogging.
19) The Media Awareness Campaigns is effective especially during Dengue Epidemic Season.
20) The temperature in both coutries remain approximately uniform (20 - 38oC) during the whole year while in our country extreme cold & hot conditions prevail, hence there is off seasons of Dengue Epidemic in our Country in the extreme weather conditions.
Recommendations
After practical experience of the DEPCAM participants following recommendation have been suggested;
A. DEPCAM training related:
The three weeks training program is too long, it may be adjusted within two weeks with same training contents and field visits.
AIT is willing to arrange training course at Services Institute of Medical Sciences (SIMS), Lahore, Pakistan. It will not only save foreign exchange but neighbouring countries e.g. Afghanistan, Iran, India etc. can also avail this
In the composition of DEPCAM participants, the ratio of vector control managers, environmentalists and health managers should be increased as the control of epidemic is in their hands whereas the number of participants from health care units in the DEPCAM program should be decreased.
The gender ratio in the DEPCAM program should be kept balanced.
Pakistani/ Indian meals should be served as the buffet in Thailand hotels is only wastage of money as almost all participants disliked Thai food buffet.
The nurses and some other officers were unable to understand presentations in English accent of Thai presenters/ speakers hence a local resource person/ translator is recommended.
B. Epidemic control:
Asia Pacific Strategic Plan (2008- 2015) for Dengue should have greater involvement and ownership of Pakistan.
The best control of epidemic is in the control of vector at its larval stage hence the infrastructure of health managers, vector control managers and environmentalists should be improved. Priority target should be larva and pupa, not the adult.
Integrated vector Control Management is needed through effective Environmental (predominantly breeding source reduction), Managerial(Effective administrative Hierarchy), Chemical(fogging / larvicide- Temephos, Permethrine & Delta Metherine), Biological (Bti Bacilus thuringiensis israeliensis bacteria and B. sphaericus bacteria.& larvivorous fish/Guppi fish) and self-protection( Repellants etc) Management. Availability of Bti in Thailand is in Tablet form, Dust form, Water dispersible granules and Suspension.
The health care units in Pakistan are working under different umbrellas (Federal, provincial, local, departmental, trust, autonomous, private level) hence data collection analysis and preparation of consolidated reports at National or Provincial level is difficult. The Health care units should work under the umbrella of single administration or they should be bound to report to a single authority. Data be utilized for evidence based action. Needed to strengthen referral system and to establish Standardized formats -on line.
Thermal Fogging in open spaces not only causes damage to the environment and public health but also does not ensure killing of dengue vector hence instead of thermal fogging, the removal of breeding sources and larvacidal sprays may be prioritized.
Negligence of a doctor can kill single patient but negligence of vector control/ health manager can kill large number community members and increase the size of epidemic.
The community mobilization against removal of dengue larvae breeding sources is necessary through seminars, electronic and print media and political backing.
Self-protection through use of replants and local bio products.
Dengue week should be notified in a year so that everyone will ensure the removal of potential breeding sources.
Diagnostic facilities be provided at basic health unit level to lessen the pressure on the secondary and tertiary healthcare units. Case Management & reporting system in hospitals be improved and computerized.
Survey of houses through local volunteers for identification of breeding/ potential breeding sources as observed in Chiangmai, Thailand is recommended in which the houses having no larvae or breeding points are flagged as green while the others are flagged as red. Village Health Volunteers be organized.
The epidemic is spreading in tropical regions due to Trans-boundary movement of used tyres, junk/ scrap items carrying dengue vector eggs hence strict checking of such materials is required.
Guppi fish which eats larvae may be put in water ponds or in the vassals of aquatic plants.
Mosquito replant herbs (Niazbow etc.) may be grown in plants pots and in flower beds.
Effective enforcement of relevant laws regarding epidemic control should be ensured. The relevant laws need revision & updating.
Inventory of patients may be compiled for evidence based surveillance and analysis.
Dengue secretariat be established and all stakeholder departments should report there. Job description of relevant departments for dengue control be notified along with reporting hierarchy. Online data entry is required along with Integrated Service Delivery
A Chapter regarding potential breeding sites of dengue larvae and dengue epidemic control measures should be added in the syllabus at primary and secondary level.
Formulation of Short & Long Term Plans are needed including capacity building / training programmes
Insect Museum should be established for the public & researchers.
School/ College Health Programs be launched through the Dengue resource Persons trained by the Government.
Standard case definitions are required for proper data analysis & reporting. It will also ensure effective triage system.
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