Suspected Dengue Heamorrhagic Fever in Nowshera.

A case of Dengue Hemorrhagic Fever in District Nowshera was reported in Daily “The News” International on 11/08/11. According to the press report a 52 years old man Namely Amir Hassan of Moti Bazaar, Nowshera Cantt, was confirmed as a case of Dengue Hemorrhagic fever. His condition was critical and shifted from Benazir Bhutto Hospital, Rawalpindi to Al-Shifa International, Islamabad.

The EDO Health Nowshera formed a health team in the leadership of Dr Abu Zar to investigate & respond to the case. The team comprised the following:-

1. Dr Abu Zar, Coordinator, DHIS, Nowshera

2. Dr Kamran Yousaf, Coordinator, Malaria Program, Nowshera

3. Dr Younas Muhammad Saeed, Surveillance Officer, WHO-PEI, Nowshera

4. Mr Khwaja Muhammad Khan, Lead CSP, PEI, Nowshera

5. Dr Umair Kamal, Public Health officer, WHO-EHA, Nowshera

6. Mr Safi Ullah Bangash, Environmental Health Engineer, WHO-EHA

The Health team traced the residence of the case on Club Road Nowshera. The team met Mr Amir Hussain, the son of the patient. According to him his father died on 12/08/11. The health team prayed for the departed soul of the deceased and expressed their sorrow and grief with his bereaved son & family. Medical documents of the deceased were left in Shifa International Hospital, Islamabad. They will be provided to EDO Health Office after Soyem of the patient. During investigation the following facts came to the surface:

Ø The patient had mild fever for which he went to a private clinic in Nowshera.

Ø In laboratory investigation his platelets count was found below the normal count.

Ø He received medicines without any improvement in his condition.

Ø He was admitted in Benazir Bhutto Hospital, Rawalpindi from where he was shifted to Shifa International hospital, Islamabad.

Ø He was tested for dengue in Excel Laboratory Islamabad, which turned to be negative.

Ø The test was done in NIH Islamabad, where it was found negative.

Ø The patient blood sample was tested in Shifa International Hospital, Islamabad for dengue as well, where the test was weakly positive.

Ø According to the son of the deceased, he had a severe brain hemorrhage.

History of the patient

The patient was an obese man of 52 years. He was already taking tablets Calan for controlling arrhythmias. The patient had a travel history to Peshawar & Rawalpindi one to two weeks before his illness. On active surveillance his contacts were normal and no suspected case of Dengue found in the area.

Symptoms of the Patient

1. He was running low grade fever.

2. Headache.

3. Severe Brain Hemorrhage.

4. No history of hemorrhage/bleeding from any part of the body.



Laboratory Investigations

The laboratory result is not available, but the son of the case states that the platelets count was sub-normal.

The Doctors at Shifa hospital told the attendants that he has intra-cranial bleeding CVA. The patients did not have any of the major clinical features of Dengue Hemorrhages except low grade fever and low platelets count. None of the relative or neighbors had any signs or symptoms of dengue; hence samples were not collected by the investigation & Response team.

According to WHO guidelines, DHF cases must fulfill all of the following four criteria:

1. Fever or history of acute fever lasting 2 to 7 days.

2. Hemorrhagic tendencies evidenced by at least one of the following: a positive tourniquet test, petechiae, purpura, ecchymoses, bleeding from mucosa, gastrointestinal tract, injection sites or other location; hematemesis; melaena.

3. Thrombocytopenia (100,000 platelets/µl or less)

4. Hemoconcentration (20% or more rise in the hematocrit (Hct) value relative to baseline average for the same age and sex) or evidence of plasma leakage (e.g. pleural effusion, ascites and/or hypoproteinaemia)



However the following preventive/precautionary measures were undertaken.

1. The whole of Moti Bazaar was fumigated with Permethrine insecticide because the patient had his office there and used to remain in his office from morning to evening.

2. The Residence and the neighborhood around Club Road were also fumigated with permethrine insecticide.

3. The staff of the cantonment General Hospital was sensitized and a session of awareness about the symptoms of Dengue Hemorrhagic fever was conducted. The staff was given case reporting forms to report any such case to EDO Health Nowshera on urgent basis.

4. Awareness of the people was enhanced through Health Education material and discussion in Moti Bazaar and club Road.

5. Contacts of the patient were examined for any sign and symptoms of Dengue Hemorrhagic fever, but none of them had any sign or symptoms of DHF.

6. The contacts of the patients were advised to immediately report to a hospital, if any signs/symptoms of DHF appear. They were given contact numbers for immediate information to EDO Health Office.

7. Insecticide treated nets were distributed in the area.



Conclusion

The case could not be termed as Dengue Hemorrhagic Fever in the absence of patient documents. On the basis of history given by son of the deceased person and absence of bleeding from any part of the body was observed. The result of Government of Pakistan Reference Laboratory i.e National Institute of Health Islamabad needs to be followed for declaring the reported case as DHF.



End Note: The final Report will be generated as soon as the Medical documents of the patient and result from NIH Islamabad is made available to the team.





Report Prepared by:- Dr Abu Zar Taizai Coordinator DHIS Nowshera

Good work Abuzar.
Dengue season is on, so one needs to be on close guard. Environmental hunt for aedes egyptii should be on. And areas should be regularly sprayed

Thank You Sir, for the encouragement.

Dr Mumtaz from NIH told us on telephone yesterday, that the case was positive in our NIH Lab too, thus it is the first confirmed case of Dengue heamorrhiagic fever in Nowshera, we put it on our line list.

Today is our emergency meeting for all incharge of health facilities working in NOWSHERA to conduct awareness session.

Dear Abu zar sb,

Great work.

I want to add something.

The fumigation should be repeated every 8 to 10 days for at least 2-3 months.

Entomological assessment also needed and as Mr.M.Kamal is your close freind contact him for confirming the Aedes Aegypti.

Important to mention larviciding activities as a control measures.



One thing more, as you Know it better than me that Calan tablet is a Ca++ Channel blocker and that also work in controling hypetension.



Anyway, great work and that is great you are once again active on forum.

Thanks for your inputs.

The patient BP was ok (120/75), he was using calan for arrythmias. All the activities you mentioned have already been completed today by Dr Kamran Yousaf malaria coordinator.

Dear Colleagues

The dengue transmitting vector (Aedes Aegypti) becomes very active during post monsoon season when there are plenty of fresh water bodies available for mosquito to breed in and produces many many million generations. Experience has proved that this (autumn) is also the time when people move indoor in rural areas and thus stop using their nets. They become more vulnerable to contract infected bites and the disease. Most importantly the dusk and dawn biting is more intense when people are still outside their rooms/nets.

Choice of Interventions to supplement LLINs/ITNs efficacy:

1. Thermal Fogging was once effectively used in Malaysia in densely populated urban areas where the local mosquitoes were mainly exophilic/exophagic (outdoor resting and outdoor biting). In our epidemiological context, because of its visibility, its political dimension is more heavier than its technical value.

2. IRS: Indoor Residual Spray is more effective in areas where the local mosquitoes are endophilic (indoor resting) with an effective pyrethroid group of insecticide. The available data suggests that District Nowshera is one of the district where local species are predominantly indoor resting ones.

A word of caution for public health specialists: There is now enough scientific evidence available that Organo-chlorine and Organo-phosphate groups of insecticides has lost its place in public health due to higher resistance to it among local mosquito species. Price wise they are much cheaper but carry very little or almost nil value for money.

The Good News:

Our organization (Merlin) has recently imported some good quality pyrethroids (Alphacypermethrin) to be very focally sprayed (Indoor) in a few UCs in Nowshera and Charsadda beside other districts in severely affected Punjab. The intervention will resume in a few days time and fellow students are most welcome to contribute to the supervisory aspects of the campaign.


All the best

Naeem Durrani
Program Manager (VBDC)
Merlin Pakistan

Naeem Thanks for your valuable updates!



I will be very much thankfull, if you could arrange IRSs in some, (High Risk UCs)of Nowshera, as we do not have any fund in this head.



Sincerely Yours

Dr Abu Zar

Deputy EDO Health/

Coordinator DHIS & Coordinator Public Health

District Nowshera

My teams are coming today to plan limited scale IRS and we have also initiated health promotion campaign through Merlin health promoters. I have some funds to support other vector borne disease control related activities and in first phase all health facilities in Nowshera have been given adequate quantity of medical supplies. We will continue to do that till end of the current transmission season.

Support from EDO office is highly appreciated.