Objectives. The number of countries reporting dengue cases is increasing worldwide. Nepal saw its first dengue outbreak in 2010, with 96% of cases reported in three districts. There are numerous policy challenges to providing an effective public health response system in a fragile state. This paper evaluates the dengue case notification, surveillance, laboratory facilities, intersectoral collaboration, and how government and community services responded to the outbreak. Methods. Qualitative data were collected through 20 in-depth interviews, with key stakeholders, and two focus-group discussions, with seven participants. Results. Limitations of case recognition included weak diagnostic facilities and private hospitals not incorporated into the case reporting system. Research on vectors was weak, with no virological surveillance. Limitations of outbreak response included poor coordination and an inadequate budget. There was good community mobilization and emergency response but no routine vector control. Conclusions. A weak state has limited response capabilities. Disease surveillance and response plans need to be country-specific and consider state response capacity and the level of endemicity. Two feasible solutions for Nepal are (1) go upwards to regional collaboration for disease and vector surveillance, laboratory assistance, and staff training; (2) go downwards to expand upon community mobilisation, ensuring that vector control is anticipatory to outbreaks. 1. Introduction Dengue is the most important vector-borne viral infection worldwide with 2.5 billion people at risk, according to the World Health Organisation (WHO) [1]. The number of cases and number of countries affected has doubled from the period 1990–1994 to 2000–2004 [1–3]. Larger epidemics are becoming more common [4], with countries in Asia witnessing an increase in severe dengue and a higher mortality in the earlier stages [5]. Nepal reported its first case of dengue in 2004 and the first indigenous case in 2006 [6]. Only sporadic cases were then seen until the outbreak in 2010, with 917 cases reported nationally (unpublished data), seen almost solely in 3 administrative districts in the Terai region on the Indian border: Chitwan, Nawalparasi, and Rupandehi. The aim of this paper is to describe the public health surveillance and outbreak response to dengue in Nepal in 2010 and to draw lessons from the experience of a fragile state. The WHO World Health Assembly urged member states to improve surveillance, prevention, control, and management of dengue [7]. Guidelines highlight the need
References
[1]
WHO and TDR, Dengue Guidelines for Diagnosis, Treatment, Prevention and Control, WHO, Geneva, Switzerland, 2009.
[2]
J. D. Clemens, “Evaluating diagnostics: dengue,” Nature Reviews Microbiology, vol. 8, supplement 12, p. S1, 2010.
[3]
M. G. Guzman, S. B. Halstead, H. Artsob, et al., “Dengue: a continuing global threat,” Nature Reviews Microbiology, vol. 8, supplement 12, pp. S7–S16, 2010.
[4]
E. E. Ooi and D. J. Gubler, “Global spread of epidemic dengue: the influence of environmental change,” Future Virology, vol. 4, no. 6, pp. 571–580, 2009.
[5]
B. Kay and V. S. Nam, “New strategy against Aedes aegypti in Vietnam,” The Lancet, vol. 365, no. 9459, pp. 613–617, 2005.
[6]
B. D. Pandey, K. Morita, S. R. Khanal et al., “Dengue virus, Nepal,” Emerging Infectious Diseases, vol. 14, no. 3, pp. 514–515, 2008.
[7]
WHO, “Dengue fever and dengue haemorrhagic fever prevention and control,” in Proceedings of the 55th World Health Assembly WHA55.17, Agenda item 13.14, May 2002.
[8]
O. Horstick, S. Runge-Ranzinger, M. B. Nathan, and A. Kroeger, “Dengue vector-control services: how do they work? A systematic literature review and country case studies,” Transactions of the Royal Society of Tropical Medicine and Hygiene, vol. 104, no. 6, pp. 379–386, 2010.
[9]
The World Bank, “Definitions of Fragility and Conflict, 2009,” 2011, http://go.worldbank.org/NEK8GNPSO0.
[10]
P. R. Shankar, “Attracting and retaining doctors in rural Nepal,” Rural and Remote Health, vol. 10, no. 3, p. 1420, 2010.
[11]
B. Devkota, “Effectiveness of essential health care services delivery in Nepal,” Journal of Nepal Health Research Council, vol. 6, no. 13, pp. 74–83, 2008.
[12]
M. E. Beatty, A. Stone, D. W. Fitzsimons et al., “Best practices in dengue surveillance: a report from the asia-pacific and americas dengue prevention boards,” PLoS Neglected Tropical Diseases, vol. 4, no. 11, p. e890, 2010.
[13]
S. Vong, V. Khieu, O. Glass et al., “Dengue incidence in urban and rural cambodia: results from population-based active fever surveillance, 2006–2008,” PLoS Neglected Tropical Diseases, vol. 4, no. 11, p. e903, 2010.
[14]
O. Wichmann, I. K. Yoon, S. Vong et al., “Dengue in Thailand and Cambodia: an assessment of the degree of underrecognized disease burden based on reported cases,” PLoS Neglected Tropical Diseases, vol. 5, no. 3, p. e996, 2011.
[15]
D. F. Pyle, L. M. Nath, B. L. Shrestha, A. Sharma, and S. Koirala, “Assessment of early warning and reporting systems (EWARS) in NEPAL,” Activitiy Report 126, 2004.
[16]
S. Runge-Ranzinger, O. Horstick, M. Marx, and A. Kroeger, “What does dengue disease surveillance contribute to predicting and detecting outbreaks and describing trends?” Tropical Medicine and International Health, vol. 13, no. 8, pp. 1022–1041, 2008.
[17]
B. Devkota and E. Van Teijlingen, “Understanding effects of armed conflict on health outcomes: the case of Nepal,” Conflict and Health, vol. 4, no. 1, p. 20, 2010.
[18]
J. Spiegel, S. Bennett, L. Hattersley et al., “Barriers and bridges to prevention and control of dengue: the need for a social-ecological approach,” EcoHealth, vol. 2, no. 4, pp. 273–290, 2005.
[19]
C. Glenton, I. B. Scheel, S. Pradhan, S. Lewin, S. Hodgins, and V. Shrestha, “The female community health volunteer programme in Nepal: decision makers' perceptions of volunteerism, payment and other incentives,” Social Science and Medicine, vol. 70, no. 12, pp. 1920–1927, 2010.
[20]
C. Heintze, M. V. Garrido, and A. Kroeger, “What do community-based dengue control programmes achieve? A systematic review of published evaluations,” Transactions of the Royal Society of Tropical Medicine and Hygiene, vol. 101, no. 4, pp. 317–325, 2007.
[21]
V. S. Nam, N. T. Yen, T. V. Phong et al., “Elimination of dengue by community programs using Mesocyclops (copepoda) against Aedes aegypti in central Vietnam,” American Journal of Tropical Medicine and Hygiene, vol. 72, no. 1, pp. 67–73, 2005.
[22]
M. E. Toledo Romani, V. Vanlerberghe, D. Perez et al., “Achieving sustainability of community-based dengue control in Santiago de Cuba,” Social Science and Medicine, vol. 64, no. 4, pp. 976–988, 2007.
[23]
M. Gibbon, R. Labonte, and G. Laverack, “Evaluating community capacity,” Health and Social Care in the Community, vol. 10, no. 6, pp. 485–491, 2002.
[24]
M. J. Dutta and I. Basnyat, “The radio communication project in Nepal: a culture-centered approach to participation,” Health Education and Behavior, vol. 35, no. 4, pp. 442–454, 2008.
[25]
M. Boulay, J. D. Storey, and S. Sood, “Indirect exposure to a family planning mass media campaign in Nepal,” Journal of health communication, vol. 7, no. 5, pp. 379–399, 2002.
[26]
E. E. Ooi, K. T. Goh, and D. J. Gubler, “Dengue prevention and 35 years of vector control in Singapore,” Emerging Infectious Diseases, vol. 12, no. 6, pp. 887–893, 2006.
