Tuesday, 27 September 2016

Mosquito Menace: How to win over our collective failure

Mosquito Menace: How to win over our collective failure

Dr KK Aggarwal
National President Elect & Honorary Secretary General IMA
& President Heart Care Foundation of India

 Napoleon Hill once said that "Most great people have attained their greatest success just one step beyond their greatest failure."

It’s time for all of us to convert our biggest failure, to control mosquitos menace into success.

We all must agree that collectively we have failed in controlling the mosquitos menace and Delhi today is having an epidemic of chikungunya with rising cases of dengue and malaria.
It’s a collective failure of Municipal Corporation, Delhi Government, Central Government, LG office, Medical Associations, CSR departments, Media, NGOs and Private sector.

As per the current picture the mosquito container index in Delhi is over 40% and any index above 5% require community integrated cluster approach for mosquito density reduction together with effective anti-larval measures.

But even today the three lac mosquito repellent impregnated mosquito nets received my MCDs as donations are not available to patients.

Anti-larval measures, temephos an organophosphate larvicideteme and mosquitofish or Gambusia a freshwater fish is not available to a common man.

Then what is the answer. We need a paradigm shift in our thinking.

We need to over report and act in time. There is no point acting when the cases have started. Often the civic bodies publically act in monsoon season. They may be planning ahead but public awareness and public involvement must start much ahead of time. Even the recent CAG report mentions that under reporting of dengue is disastrous to the society.

We need to act on all the mosquitos, aedes, culex and anopheles; just acting on aedes will not work.

That campaign that aedes is a day biter and only breeds in indoor fresh water will not work. Even if it is true by killing aedes you may end up in increasing the density of Culex and malaria causing Anopheles mosquito. Culex mosquito which causes filarial and Japanese encephalitis is already rampant in the city. 

Even aedes which causes chikungunya, West Nile, Zika and Dengue can spread by the bite of infected female indoor Aedes aegypti or outdoor albipecto mosquito. 

It is true that Aedes aegypti are more dangerous because they can fly up to 200 metres and only feed on human blood whereas the Aedes albopictus that thrives outdoors can only fly as far as 80 metres and feed on animal blood other than human blood, but the outdoor aedes cannot be ignored. .

Whole campaign uptil, now has been focussed on a day biter, wear long sleeves shirt and pants during the day and no need to use night mosquito nets. But precautions needs to be taken throughout the day, the mosquito only recognise the light and not the day or night.

That the mosquito only breeds in clear water also needs to be relearnt. Aedes breed in stagnant water anywhere inside or outside the house. Rainy water is the most important source and can collect in any plastic container inside or outside the house. Even collected garbage in open areas can have left over plastic cups or tiny bottle caps with collected rainy water collections providing ideal atmosphere for mosquito breeding.

It is true that disease spreading mosquitos do not make noise but noise producing nuisance mosquitos unless addressed to will not create a public movement.

The law says that one must notify dengue or chikungunya but one can notify within seven days of diagnosis. Aedes mosquito takes upto three meals in a day and by seven days will bite over 21 people in the vicinity. Municipal anti mosquito and anti-larval actions must occur within hours of its detection. The very purpose of notification is lost if the disease is not notified within hours of even suspected cases.

One must report all the suspected cases and not wait for confirmation of the diagnosis. We have failed because the government has been insisting to notify only ELIESA confirmed cases. An SMS should be sent to all doctors practising in that PIN code areas with a case so that they can become a part of the public health action chain.

When the first case is suspected in a state, colony or house all public health measure should start. An SMS should go to local councillor, MLA, MPs, all practising doctors, local chemists, NGOs, RWAs, local IMA Branch, State IMA Branch, IMA Head-quarters and other Speciality Organisations to join the public health chain efforts.

It has taken over a decade for we doctors to understand that dengue 1 and 3 strains are not dangerous and causes only platelet deficiency with thinning of blood and dengue 2 and 4 strains are dangerous as they leads to platelet destruction along with thickening of blood due to capillary leakage and rise in haematocrit. That platelet transfusion is not required in absence of active bleeding. And that timely fluid resuscitation is more important and not platelet resuscitation.

That dengue becomes serious when the fever is subsiding. We used to admit dengue cases with high fever and always I urgency to discharge them when fever was subsidising.

Now we know that the machine reading of platelet count cab be defective. There can be an error of 20%. A platelet count of 10,000 by machine reading can mean it is actually 50,000.

Hospital beds should be reserved only for sever dengue and severe chikungunya cases. Just because one has a reimbursement in mediclaim or PSU one should not be admitted. If it was US, the Medicare by now would have come out with admitting guidelines.

The message has been going that fogging has no answer. But at this stage of container index of > 40 we need not only ground fogging but also aerial fogging.

When Zika threat came in Brazil they deployed army to join and make it a public movement. All political parties reach every house during election process then why can’t each one of them reach every house and make the anti-mosquito and anti-larval measures effective.

Breeding checkers are only with Municipal Corporation and they also have regulatory powers to put fine. We need breeding checker in private sector. The Skill development Ministry should start courses so that anyone can hire a breeding checker on weekly basis to check their premises.

Community approach involves that 100% of the society talks about dengue. Every premises must write that their premises are mosquito free. When you are invited to someone you should ask “I hope your premises are mosquito free” and when you invite write: welcome to my house and it is mosquito free’

Even today most hospitals do not provide mosquito nets to dengue or CHIKV patients. It is true they may be having anti- larval mesh doors or mesh windows but for secondary prevention of dengue or CHIKV we need to ensure that medial establishments are certified mosquito free.

In a flat oriented house the mosquito may be breeding in the roof top belonging to one of the owner and if he is out of station for a holiday, the anti-larval measures may remain deficient. The RWAs may use their powers to check all unoccupied or closed premises including hostels, hotels and construction places in that premises.
One of the five great vows of Jainism is Non-attachment/Non-possession or Aparigraha. It talks about not storing unwanted things. But in today’s era our roof and varandas are full of left over tyres, utensils, plastic utensils etc. We buy a new car tyre and keep the old one on our roof top. We need to change this habit.

We have forgotten to plant Tulsi and Pepaal in our premises and stopped the daily Yagna all which have anti mosquito properties.

The new strategy has to focus on small collection of water like in bottle caps, finding mosquitos lower in the room under the table or the bed, to look for them in all three parts of the house roof tops, varandas and inside the rooms including unused toilets accessories.

Also the slogan check your house once a week needs a change. One needs to be alert every day. It should be a part of your routine. You do not clean your premises once a week. Make it a habit to look for the breeding places.

The new approach should be a war against indoor or outdoor mosquitos; fresh stagnant or dirty water mosquitos; present in small containers like bottle caps or large container like overhead tankers;  made of mud or plastic; through out the day (early morning fogging when pupa hatch for aedes, late night for malaria); rub cleaning the utensils

Slogan: Ghar ke ander or ghar ke bahar; din me or rat me, devaro ki niche or upper, chote panui or bade pani ke collection me, eggs larve or mosquito, teno ko maro.

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