1. Dengue Outbreak in a Large Military Station: Have We Learnt Any Lesson?
Col Rajesh Kunwar, Col Rajat Prakash
Armed Forces Medical services, India

2. Introduction Dengue - a mosquito borne viral infection
Fast emerging in pandemic proportions
Incidence increased 30-fold over the last 50 years
Spread over 100 endemic countries
Annually
million cases reported
5,00,000 people require hospitalization
12,500 (about 2.5% of those affected) die.

3. Introduction In India from 2008 to 2013
Number of dengue cases increased by 6 – fold
Deaths due to dengue by 2-fold.
The outbreak of 2013 worst in last 6 years
States in Southern India affected the most
An outbreak reported from a large military station - more than 200 cases of dengue reported from Jun to Aug 2013

4. The objective
To share the challenges we faced in controlling the outbreak
To bring out the lessons learnt during our endeavour
To suggest strategy for controlling, if not preventing, a similar outbreak in future

5. Methodology Study design – Descriptive
The setting - The Military station located in contiguity with the civil areas on all sides
Altitude of 3092 ft from mean sea level
Mean atmospheric temp from 200C to 300C
Relative humidity from 60% to 80%.

6. Methodology - The Setting
The Military Station comprises of
6 Regimental Centres and many smaller units
Approx strength of serving personnel & families 25,000
Medical set up
Unit Regimental Medical Officers
Large tertiary care hospital
Station Health Organization (SHO)

7. Methodology - The Setting
Incidence of dengue
Year
No. of dengue fever cases
2010 13
2011 19
2012 36
2013
> 100

8. The Outbreak

9. Methodology - Data Collection
Data compiled from
Existing hospital records
Epidemiological case sheets
Inclusion criteria
All serologically confirmed cases
All admitted cases
Exclusion criteria
Dependents treated on outpatient basis
Dependents who did not report to service hospital

10. Control Measures Adopted
Health advisories issued well in advance.
Dengue Task Force (DTF) constituted at unit levels.
Capsule course for training of members of DTF conducted by the local SHO.
Dengue fever cases continued to be reported from almost all the units - 3 serving persons died due to severe dengue - indiscriminate fogging without much result.

11. The Challenges Vast training area with abundance of natural vegetation
Plenty of natural and artificial breeding places
Maintenance of ornamental ponds and potted plants perceived as essential
Laxity in garbage clearance

12. The Challenges
Indiscriminate and inappropriate use of hygiene and chemicals
Inadequate supervision of control activity
By unit/ sub-unit commanders
By health functionaries
Lack of awareness about dengue and its vector

13. The Action Senior Administrative Authorities visited the station.
Working uniform changed to full sleeve dress with immediate effect.
Administrative support and health resources augmented
Insecticides and repellants procured

14. The Action
Officer Commanding (OC) SHO stationed at unit which reported maximum number of cases
OC SHO with a health assistant visited all units and ensured elimination of breeding places in their presence.
Peri-domestic areas cleared of vegetation and all water bodies – small or large- were either drained out or larvicides were added to them.

15. The Action
Concerted indoor and outdoor fogging in the entire station on twice weekly basis.
Municipal authorities approached and daily clearance of garbage ensured
Early diagnosis, adequate treatment and prompt notification of dengue fever cases ensured

16. The Action
The epidemic curve started showing downward trend within a week
The outbreak controlled in about a months time

17. Age-wise Distribution of Cases
Age group
Serving pers (%)
Dependents (%)
Total (%)
<15 years -
23 (31.1)
23 (08.6)
16 – 20 years
36 (18.8)
12 (16.2)
48 (18.0)
21 – 25 years
60 (31.3)
07 (09.4)
67 (25.2)
26 – 30 years
19 (09.8)
03 (04.1)
22 (08.3)
31 – 35 years
27 (14.1)
04 (05.4)
31 (11.7)
36 – 40 years
24 (12.5)
28 (10.5)
41 – 45 years
20 (10.4)
> 45 years
06 (03.1)
18 (24.3)
24 (09.1)
Total
192 (100)
74 (100)
266 (100)

18. Distribution – Clinical Features

19. Trend of Dengue Fever Cases

20. Lessons Learnt - 1
Correct and timely perception of the threat is essential
Need to go beyond routine
Commander’s perception of threat matters
Commanders to be advised well in advance about
Likelihood of an outbreak
Perceived severity of the outbreak
Availability of resources to control
Administrative and technical support required

21. Lessons Learnt - 2 Behavioural change of individuals is desired
Protective behavior linked to risk perception
Change in human behaviour brought out by
Communicating risk perception to individuals
Emphasising that personal protection alone not adequate in outbreak situation
Health authorities imparting correct knowledge
Administrative authorities having the will to implement it.

22. Lessons Learnt - 3
Availability of adequate health functionaries is mandatory
Direct supervision by a Specialist in Community Medicine essential
Availability of adequate resources
Technical manpower for supervision
Administrative backup for ensuring availability of health functionaries at a short notice
Administrative will to support health functionaries and to implement their advice

23. Lessons Learnt - 4 Complete dataset helps correct perception
Threat perception based on availability of data helps early onslaught
Completeness of dataset can be achieved by
Having a mechanism to collect, compile and analyse the data and communicate the findings
Centralised registry system in the hospital
Cross verification of data from clinics and laboratories
Maintenance of data

24. Public Health Implications
Future strategy for control of dengue outbreak
Repeated survey for correct risk perception
Assessment of behavioural change among individuals
Operational research to assess the impact of ongoing public health campaign
Close interaction between communities and municipal vector control services
Newer research into development of vaccine for dengue

25. Conclusion
Gaps remain in knowledge, attitude and behaviour in the community with regard to dengue prevention.
Dengue surveillance and control policies
Should be reviewed regularly
Should focus on emergency preparedness and anticipated response planning

26. Conclusion
Two major components of the emergency response to a dengue outbreak are:
Emergency vector control to curtail transmission of the dengue virus as rapidly as possible
Early diagnosis and the appropriate clinical case management of severe dengue to minimize the number of dengue-associated deaths.
These responses should occur concurrently

27. Thank You !