Dengue and Vectorborne Diseases in Sik

DENGUE FEVER
There are 2 common species of Aedes mosquito which is A. albopictus and A. aegypti. A. aegypt is more commonly found outdoors and associated with Dengue fever while the other species is more common indoors and is often associated with Chikungunya . The life cycle of an Aedes mosquito from the eff to an adult mosquito only takes a gesticulation period of 7 days( egg-->larva --> pupae -->adult mosquito).
Incidence of Dengue Fever in Sik ***accurate statistics were not fully disclosed as it was confidential***
2006 --> 200+ cases
2007 -->200+ cases
2008 -->200-300+ cases
2009 --> <100 cases

The cases were more common in months of January, May, September and October.
Strategies
Notified from the hospital -->prepare the Investigation Form --> go to hospital or field --> interview patient --> Classify case as local/ imported case.
If local --> register case -->notify state Vector Unit (JKN) --> prepare investigation report -->further action
If imported -->notify state Vector Unit (JKN)
For routine action, an aedes survey is carried out everyday. It is done to see if there are potential breeding spots for the Aedes mosquitos and preventive fogging will be done if the results at the end of the survey indicates potential for mosquito breeding.
During the Aedes survey, the results are based on specific indexes.
>Aedes Index:
The percentage of houses in a specific location that has a positive breeding ground for Aedes. (In percentage
= Num. of houses positive for Aedes x 100%/
Num. of houses investigated in the specific location
If > 1%, sensitive for Outbreak of Dengue

Breteau Index
The number of containers that is positive for Aedes mosquito breeding in 100 houses. ( in numbers)
Num. of containers positive for Aedes x 100/
Num. of houses investigated in a specific location
If > /= 5 , sensitive for Outbreak of Dengue

Container Index
The percentage of containers in a specific location that is positive for Aedes mosquito breeding. ( In percentage)
= Num. of containers positive for Aedes x 100%/
Number of containers investigated in a specific location
If >/= 5, sensitive for Outbreak of Dengue

During the Aedes survey, the number of containers is noted and the number of it which contains larva. Abate 1.1G will be put into the containers that contain larva. A sample of the water which contains larvae will be sent to the Entomologist in Alor Star. If its confirmed that the larvae is an Aedes, a compound will be imposed at RM100 for housing area, RM150 for government sectors ,and RM500 for factories. The payment is to be made at the District Health Office. If failed to do so, a warning will be given and if persistent failure to pay, a court order will be sent out. If the container does not contain any larva, advise to remove that container will be given to the residents. A warning notice of 5 days will be given and if still present after 5 days, compound will be imposed.
For an outbreak of Dengue fever, an Aedes survey is to be done as above and then fogging is done.
Fogging
Before fogging is done, the families will be informed beforehand and asked to cover all food as well as leave the door open. Those who rear birds and chickens are asked to keep them out of the sight and smell of the fog.
It is usually done for a radius of 200 metres and usually done in the morning or evening around 6 pm-7 something when the mosquitos are known to be out. If there is an outbreak of Dengue fever,fogging will be done 4 times consecutively with an interval of 7-10 days between each fogging. If there is a confirmed case of Dengue Fever but no outbreak, fogging will be done 3 times consecutively with an interval 7-10 days between each fogging. For routine fogging, it is only 2 times consecutively with an interval of 7-10 days between each fogging. The reason for the interval of days is due to the life cycle of the Aedes mosquito.
The normal equipment used for fogging is the Thermofog and the Ultra Low Volume(ULV)machines. A mixture ofpoison and diesel is needed to make it appear as fog. The common poisons used are
• Malathion
• Resigen
• Aqua resigen – to be put into ULV
• Abate 1% - distributed to the public( 1 time )
• Abate 500 Emulsion- only for larvaciding ( 1ml Abate mixed with 1000 ml of water) *not poisonous to humans nor animals*

MALARIA
It is transmitted by a female Anopheles mosquito. It is a mosquito common from streams, jungle area, seaside, paddy fields. There are no specific seasons for Malaria and no specific areas.
Most of the cases in Sik are all imported cases.
Incidence Of Malaria in Sik * accurate statistics were not fully disclosed as it was confidential*
2006 --> ~3 cases
2007 --> ~ 6 cases
2008 --> ~ 7 cases
2009 --> ~ 1 case
Strategies
a. Routine hunt for foreign workers from Myanmar, Thailand, Bangladesh, India, Indonesia. It is done everyday and targeted 80% of foreign workers. Blood smears will be taken from every single foreign worker and slides are sent to Alor Star Hospital. There are around 4400 slides in one year. This was implemented since year 2000.
b. Fogging will be done only if there is a confirmed case of Malaria. The time done for fogging is usually done from 9-12pm 3 nights in a row. Other than the normal types of fogging as for dengue, there is another specific type of fogging for Malaria and that is the Focal Spray where the fog containing the poison is sprayed onto the walls. This is so that when the mosquito rests on a wall, the poison absorbs through its legs into its body killing it slowly.The type of poison is K- Othrine and is available in 2 forms ; the powder form and the liquid form. The liquid form is the one most commonly used in the Focal Spray.
c. Night trapping is also done but mostly in Alor Star.
d. Medicated Mosquito Nets is given to the residents with incidence of Malaria. These nets are soaked with K-Othrine and then dried up.

e. Flyers, brochures and posters on Malaria are also given out to schools, housing areas periodically. Talks and advice will be given at the Malaria-prone areas to educate the residents on Malaria and the prevention methods. This is done in conjunction with the Health Promotion Department

FILARIASIS

There is one case of filariasis in Sik this year and it is an imported case from India. There are no endemic cases of filariasis in Sik. It is transmitted by the Mansonia mosquito from the infected individual. The strategies for controlling Filariasis are the same as for Malaria except that the fogging done for Filariasis is usually done at 5 something in the evening. The blood smears for Filariasis can only be taken from 9pm- 12 pm as the antigen only appears in the bloodstream during that time.

Kubang Pasu District (Day 3)

Kubang Pasu District

First session

Date:7th July 2009
Time:9.00am
Location:Kampung Guar Batu Hitam
Topic: Vector control activity(Aedes survey)
Person in charge: Penolong Pegawai Kesihatan Persekitaraan Hj.Salleh b Md Isa

-In the morning we were divided into 2 groups in Kampung Guar Hitam randomly. Each of the groups was guided by a health inspector where we were initially briefed about how to perform an aedes survey. We were shown different forms that was needed in this particular survey such as the Aedes survey form, sample collection form and the compound form. We were also given copies of the form by the health inspector.
Next, we then follow the health inspector to do the survey in which they explain to us the steps involved in doing the survey. On top of that the health inspector briefed us about dengue disease and the particular breeding spots of the mosquito that is responsible as the vector of dengue disease.

-We were then instructed on how to examine this susceptible spots such as tyres ,bath tub and water containers for the presence of mosquito larvae. Next we were tought on how to obtain samples from these susceptible spots and to store it in special vial tubes. Subsequently, we were tought on how to label these vial tubes.
Finally we advised the local residents on the importance of ensuring that these susceptible breeding spots are always kept clean to prevent the futher development of the larvae to adult mosquito.

Second session

Date:7th July 2009
Time 2:00pm
Location:Vector unit District Health Office Kubang Pasu, Jitra
Topic:Vector Control Activity(Larvae analysis)
Person incharge: Penolong Pegawai Kesihatan Persekitaraan Hj.Salleh b Md Isa

-In the afternoon we were directed to the vector unit of this district health office. We were once again briefed about the protocol involved in Aedes survey. On top of that we were also tought about the origin of dengue disease. The health inspector also explained to us about the compound imposed on those local residents whose premises was found to be harbouring Aedes mosquito. Next we were taken to an analysis lab in which we were tought on how to differentiate between Aedes Aegypti which causes Dengue Heamorrhagic Fever and Aedes Albopictus which causes Classical Dengue Fever by microscopic examination.


Evening session(Fogging session)

-In the evening we were separated into three groups and each of the groups were sent to different region guided by a team of health inspectors each. Those regions are Kampung Padang Tui, Kampung Tok Ubin and Kodiang.Upon arrival at these destination we were explained about the importance of explaining the local residents about fogging and the precaution steps taken before fogging is done. We were also shown the equipment that is required for this fogging process which is the Thermal fogging machine and Ultra Low Volume. Finally we were shown on how the fogging process done .

Kuala Muda District - Vector Unit

Kuala Muda DHO Posting
Third Day (7th July 2009)

First Session
Venue : Vector Unit (PPKP Office)
Time : 8.00 am
Topic : Briefing on Vector Unit
Person in charge : PPKP Burke Patrick Lummuria

Organizational chart of Vector Unit Kuala Muda:

The Vector Unit of Kuala Muda is headed by PPKP(K) Nordin Omar under which there are 3 PPKP and 1 AKS (Insect Analyst). The 3 PPKPs are:
- PPKP Burke
- PPKP Zamani
- PPKP Rosli
and the only AKS in Kuala Muda (covering for Southern Kedah area) is Puan Mas.

The vector unit is equipped with 11 PKAs, 18 PRAs and 4 drivers. The unit also possesses 1 van, 2 pajeros, 2 land rovers and 2 pick-up trucks to assists in operations.

The programmes handled by vector unit include:
- Active case detection (ACD)
o House visits, take blood sample
- Passive case detection (PCD)
o Data, notifications and samples are obtained from other medical and health facilities
- Case investigations/Case follow-up
o To identify sources of infection, contact tracing
- Spraying operations
o Malaria control spraying (regular, special, focal)
o Thermal fogging, ULV
o Fumigations
- Anti-larval operations
o Abate 500 E
- Health education
o Demonstrations, exhibitions
- Records and documentations

Additional highlights:

In the DHO setting, an outbreak is defined as 2 or more cases reported in a certain locality within 14 days. This incident mobilizes multiple task force and an organized plan as well as actions are carried out. When an outbreak occurs, the medical officer from the public health department is notified and he or she decides the course of action need to be taken for containment and prevention measures. If an outbreak is declared, the PPKP officers fill the outbreak survey form with tedious details of the cases that are reported daily. This will continue daily till the outbreak ends. Meanwhile, a set of team is organized for the outbreak control. Mr. Burke Patrick, PPKP involved in the dengue prevention unit explained the task of the ‘morning team’ and the ‘evening team’. The morning team involves aedes surveillance where a thorough house to house check is carried out to identify potential aedes breeding spots within the area. Enforcement takes place when officers face problems with difficult residents who refuse to cooperate. Notices and compounds are sent out. For the evening team, the officers are mainly responsible for fogging of a designated area.

Second Session (Outdoor activity)
Venue : Taman Seri Utama (Gurun)/ Taman Kempas (Sungai Petani)
Time : 10.00 am
Topic : Aedes Survey
Person in charge : PPKP Burke Patrick Lummuria

The aedes surveillance activity was conducted from house to house. There were 10 officers from the vector unit sent to Taman Seri Utama to conduct the survey. They are separated in 5 groups (Each group consists of 1 Pegawai Kesihatan Am; PKA and 1 Pegawai Rendah Am; PRA). The teams were distributed to cover different areas of the residential neighbourhood (Each house has to be visited without exception). In regard to the visit to the houses, certain rules and regulations apply:
- Officers have to introduce themselves fully and briefly explain the purpose of the visit
- Consent has to be given verbally by the resident before entering house
- If the only resident left at home is younger than 18 years old, consent is invalid
- If the house is not occupied, officers may enter the outside compound of the house if the gate is not locked (if the gate is locked, entering is prohibited)

Upon receiving consent, officer proceeded with acquiring data as follows:
- The address of the house
- The name of the owner of the house
- The number of residents living permanently in the house
- Is there anyone living in the house suffers from fever?
- When was the house last inspected by officers from district health office?

All these data were recorded in a survey form. Upon entering the house, officers went directly to the washroom and inspected the ‘kolah’ and also the ‘flush pot’ of the toilet for any presence of mosquito larvae. Inspection was done by using a special ultra-bright flashlight. Regardless of the result of the inspection, these places are medicated with abate 1.1. Inspection was also done inside the house, looking at other possible places where mosquito larvae may breed. The next place that was inspected was the back of the house, followed the outside compound around the house. In the event of positive findings of mosquito larvae, sample are taken with pipette and kept in a small sealed container. The container is properly labelled with the date of the inspection, the address of the house, the name of the inspector and also the area where the samples are taken (i.e within the house, outside the compound of the house). Depending on the circumstances, the officers will either issue a ‘cleaning notice’ or a ‘compound notice’. If a cleaning notice is given, the resident has 7 to 14 days to properly clean the area of his/her house and make sure that there is no more breeding site found when the next visit is done. If compound is given, the resident has to pay the fine accordingly:
- residential houses : RM 100
- shop houses : RM 150
- school : RM 300
- factory : RM 500

Appeal can be made in the office of vector control units, as the main idea for the fine is not monetary but instead, to make the public realize the important of vector control. Usually, the appeal will bring about 50-70% discount from the maximum value of fine.

Health education is also another important part of the aedes survey. After the house was inspected, the resident was given pamphlets regarding the dengue fever and ways for the public to help the local health authority fight the ‘battle’.

Additional highlights:

There are priorities given for aedes surveillance to certain areas with high chances of dengue outbreak and they are graded according to their number of cases usually found. For example 16 prioritized locations 1 are areas with high number of cases in Kuala Muda district:

- Taman Sri Tanjung, SP
- Taman Keladi, SP
- Taman Permai, SP
- Taman Orkid, SP
- Taman Ria Jaya, SP
- Taman Arked, SP
- Bandar Baru Sg. Lalang, SP
- Flat Paya Nahu, SP
- Taman Murni, Gurun
- Taman Sri Utama, Gurun
- Taman Gurun Jaya, Gurun
- Taman Sri Impian, Tikam Batu
- Taman Melati, SP
- Taman Sejati Indah, SP
- Taman Ria, SP
- Pekan Bedong, SP

Prioritized locations grade 2 comprises locations with sporadic cases while grade 3 describes crowded areas such as factories, school hostels etc.

Third Session
Venue : Vector Unit (PPKP Office)
Time : 2.30 am
Topic : Briefing on Fogging
Person in charge : PPKP Burke Patrick Lummuria

All the poisons used for fogging are environmental friendly (the poison will not kill other animals or insects other than mosquitoes, therefore will not adversely affect the food chain). The types of poison used in fogging are as follows:
- aqua-resigen
o water-based
o class IV
- resigen
o water-based & oil-based
o class III
- malathion
o oil-based
o class II
- sumithion (not used in Kedah)

In fogging, officers will prefer to use the lowest class poison first. This is because, apart from the fewer side effects that it might cause, it will also allow for ‘backup’ poison if the one used does not work. Proper technique of fogging is also an issue. This is very important because ineffective fogging will cause the vector to develop resistant towards the poison.

Other poisons used by the vector unit include:
- Abate 500 Emulsion
o Used for larvaciding only

Two types of fogging used by Kuala Muda Vector Unit are Thermal Fogging and Ultra-Low Volume Fogging (ULV). For the thermal fogging, the machines used are the Agrofog 35 model with two available variants (electric starter and spark plug mechanism). Kuala Muda Vector Unit currently owns 14 of these machines with each one costing around RM 5000+. All advance maintanence of the machines is done by specialist technician sent by federal engineering unit from Kuala Lumpur. For the ULV, the main machine is mounted at a back of a 4-wheel drive vehicle. The vehicle will travel at a speed of 5-8 kilometres per hour with the nozzle of the fog machine pointed at an angle of more than 45 degrees. The poison of choice for ULV is either aqua-resigen or pure malathion. A ULV operation with 22 liters capacity (20 litres of water + 2 litres of aqua-resigen) can cover up to 400 to 500 houses.

Fogging is done 48 hours after notification of cases and the area of operation should cover about 200 meters radius from the patient’s residence & usually, vector unit will send out 4 thermal fogging to operate first before topping up with ULV after that for a wider coverage. ‘Contraindications’ for fogging operation includes:
- Funeral services
- ‘Kenduri’ or ‘majlis keramaian’

Fourth Session (Outdoor activity)
Venue : Taman Ria Jaya
Time : 5.30 am
Topic : Thermal Fogging Session
Person in charge : PPKP Burke Patrick Lummuria

The fogging session was done at Taman Ria Jaya, Sungai Petani and the coverage was targeted around a house in which a dengue case has been notified beforehand. The fogging team from the Kuala Muda Vector Unit that afternoon consists of 1 PPKP, 2 drivers and 4 PRAs. The first step was to notify all the residents of the areas concerned about the commencement of the operation. The residents were advised:
- To come out from their house and stay outside temporarily for 5 minutes while the inside of their residences were fogged.
- To cover all the consumable products within the house

Then, the agrofog machines and all the personnel involved in handling the machines were prepped. The personnel were equipped with PPE (personal protective equipments) as a protective gear. These include:
- filtered mask (nose & mouth piece with carbon-activated filter placed within retainers)
- eye goggle
- safety gloves
- whole-body protective suit
- safety boots

The fogging was done simultaneously from different directions and they also moved in parallel to each other to ensure no place was missed. The fogging operation took a little over 2 hours to be completed.

Padang Terap District

DAY 3
Date: 7th July 2009
Venue: Dewan Terap, Pusat Kesihatan Daerah Padang Terap
Topic: Vector Control Unit
Person Incharge: Encik Mohd. Zin (Penolong Pegawai Kesihatan Daerah Kanan)

Control of Vector Borne Diseases
1. We were taken by the Penolong Pegawai Kesihatan Persekitaran (PPKP), Encik Mohd. Zin.
2. He explained about the organization chart of the Vector Control Unit and its role in controlling vector borne diseases.



3. We mainly discussed dengue and the recent outbreak of chikungunya.
4. For 2009(till week 26), there were 31 reported cases of dengue and 844 cases of chikungunya.


Control of Dengue/ Chikungunya
1. Cases of dengue have to be notified within 24 hours.
2. After notification, investigation and control is done by the VCU within 3 days of onset.
3. Control is achieved by investigation on every house to determine Aedes Index and Breteau Index.
a. AI= number of houses with positive breeding place x 100
Number of houses surveyed

- Target should be less than 1%

b. BI= number of positive breeding sites x 100
Number of houses surveyed

- Target should be less than 2.5
- For touldhese values to be valid, the sample size should be at least 50 houses.
4. Then Larva survey is done. Here, operation search and destroy is carried out to identify potential breeding sites and destroy them.
5. ‘Larvaciding’ is mainly done by using chemicals which is targeted at Aedes Larvae.
6. There are two forms of larvacides: one is liquid which is ABATE 500E and the other is in powder form which is ABATE 1.1G.
7. The last step in controlling dengue is by fogging. There are mainly two types of fogging, one is Thermofog and another is ULV(ultra low volume).
8. The fogging covers a total radius of 200m. If there is an outbreak, this radius is increased to 400m.
9. Fogging is usually done either in the early morning or in the late evening, during the mosquitos’ active hours.
10. Fogging has to be postponed if the conditions are unfavorable such as strong winds or rain.

Precaution Steps and Safety Measures
1. During fogging, no residents are allowed to remain in the house.
2. All pets should be evacuated.
3. All food should be covered.
4. All windows should be closed with all doors open.
5. The foggers should also take safety precautions, by wearing personal protective equipments (PPE), such as the earplugs and facemask, overall and boots.
6. They should make sure that all body parts are covered.
7. The foggers cannot eat, smoke or drink before, during and after fogging.
8. After fogging, they should wash themselves before entering their respective houses.
9. Serum level of poison is checked routinely in foggers. If it is found to be high, they are then moved to a different unit for 2 to 3 months until the level returns back to normal range.

Offences (Destruction of Disease Bearing Insect Act 1975)
1. For the first offence
a. Fine not exceeding RM1000 or imprisonment of not more than 3 months.
2. For second offence or subsequent offences
a. Fine not more than RM2000 or imprisonment of not more than 1year or both.
3. Offender can also be fined not more than RM50 a day till breeding place is destroyed.
4. An offender can be immediately compounded not more than RM100 without warning.