DENGUE OUTBREAK -IS THE PANIC JUSTIFIED ?

Abstract

In this era of startling developments in the medical field there remains a serious worry about the  hazardous  potential  of  various  by  products  which  if  not  properly  addressed  can  lead  to consequences of immense public concern. Hospitals and other health care facilities generate waste products which are evidently hazardous to all those exposed to its potentially harmful effects. Need for effective legislation ensuring its safe disposal is supposed to be an integral part of any country's health related policy. This issue is of special importance in developing countries like Pakistan which in spite of framing various regulations for safeguarding public health, seem to overlook its actual implementation. The result unfortunately  is the price wehave to pay not only in terms of rampant spread of crippling infections but a significant spending of health budget on combating epidemics which could easily have been avoided through effective waste disposal measures in the first place. Waste classified under the heading  'bio-hazardous' includes any infectious or potentially infectious  material  which  can  be  injurious  or  harmful  to  humans  and  other  living  organisms. Amongst the many potential sources are the hospitals or other health  delivery centres which are ironically  supposed to be the centres of infection control and treatment. Whilst working in these setups, health care workers such as doctors, nurses, paramedical staff and sanitation workers are actually the ones most exposed and vulnerable to these challenges.  Biomedical waste may broadly be classified into Infectious and toxic waste. Infectious waste includes sharps, blood, body fluids and tissues etcwhile substances such as radioactive material and by-products of certain drugs qualify  as toxic waste. Furthermore health institutions also have to cater for general municipal waste such as carton boxes, paper and plastics. The World Health Organisation  has  its  own  general  classification  of  hospital  waste    divided  into  almost  eight categories of which almost  15% (10% infectious and 5% toxic) is estimated to be of a hazardous nature while the remaining 85% is general non hazardous content.1A recent study from Faisalabad, Pakistan has estimated hospital waste generation around 1 to 1.5 kg / bed /day for public sector hospitals in the region,2while figures quoted from neighbouring India are approximately 0.5 to 2 KG / hospital  bed  /day.3   Elsewhere in the  world variable  daily  hospital waste production  has been observed ranging from as low as 0.14 to 0.49 kg /day in Korea4 and 0.26 to 0.89 kg/day in Greece5to as high as 2.1 to 3.83 kg/day in Turkey6 and 0.84 to 5.8 kg/day in Tanzania.7Ill effects of improper management of hospital waste can manifest as nosocomial infections or occupational hazards such as needle stick injuries. Pathogens or spores can be borne either through the oro-faecal or respiratory routes in  addition  to direct inoculation  through contact with infected  needles  or  sharps.  Environmental  pollution  can  result  from  improper  burning  of  toxic material leading to emission of dioxins, particulate matter or furans into the air. The habitat can also be affected by illegal dumping and landfills or washing up of medical waste released into the sea or river. Potential organisms implicated in diseases secondary to mismanagement of hospital waste disposal include salmonella, cholera, shigella, helminths, strep pneumonia, measles, tuberculosis, herpesvirus, anthrax,  meningitis, HIV,  hepatitis  and candida etc. These infections can cause a considerable strain on the overall health and finances of the community or individuals affected. The basic principal of Public health  management i.e  'prevention  is better than  cure' cannot be more stressed in this scenario as compared to any other health challenge.  Health facilities must have a clear policy on hazardous waste management. To ensure a safe environment hospitals need to adopt  and  implement  international and  local  systems  of  waste  disposal.    Hospital  waste management  plan  entails  policy  and  procedures  addressing  waste  generation,  accumulation, handling, transportation, storage, treatment and disposal.  Waste needs to be collected in marked containers usually  colour coded and  leak  proof. Segregation at source is of vital importance. The standard practice in many countries is the Basic Three Bin System ie to segregate the waste into RED bags/ boxes for sharps, YELLOW bags for biological waste and BLUE or BLACK ones for general/ municipal waste. All hospital staff needs to be trained in the concept of putting the right waste in relevant containers/ bags. They need to know that  more than  anything  else  this  practice  is  vital  for  their  own  safety.  The  message can  be reinforced through appropriate labelling on the bins and having posters with simple delineations to avoid mixing of different waste types. Sharps essentially should be kept in rigid, leak and puncture-resistant containers which are tightly lidded and labelled. Regular training sessions for nurses and cleaning staff can be organised as they are the personnel who are more likely to deal with waste disposition at the level of their respective departments. Next of course is transportation of waste products to the storage or disposal.  Sanitary staff and janitors must be aware of the basic concepts of waste handling  and should wear protective clothing, masks and gloves etc, besides ensuring regular practice of disinfection and sterilization techniques.8Special trolleys or vehicles exclusively designed and reserved for biomedical waste and operated by trained individuals should be used for transportation to the dumping or treatment site. Biomedical waste treatment whether on site or off site is a specialised entity involving use of chemicals and equipment intended for curtailing the hazardous potential of the material at hand. Thermal treatment via  incinerators, not only results in combustion of organic substances but the final  product in the form of non-toxicash is only  10  to 15% of the original  solid mass of waste material  fed  to the  machine.   Dedicated autoclaves  and  microwaves can also be  used for  the purpose of disinfection. Chemicals such as bleach, sodium hydroxides, chlorine dioxide and sodiumhypochlorite are also effective disinfectants having specialised indications.  Countries  around  the  world  have  their  own regulations  for waste management.  United Kingdom practices strict observance of Environmental  protection act 1990, Waste managementlicensing  regulations  1994  and  Hazardous  waste regulations  2005  making  it  one  of  thesafest countries in terms of hazardous waste disposal. Similar regulations specific for each state have been  adopted  in  United  States  following  passage  of  the  Medical  Waste tracking  act 1988.  In Pakistan,  every  hospital  must comply with  the  Waste Management  Rules  2005  (Environment Protection Act  1997),  though  actual compliance is far from satisfactory. It  is high  time that  the government and responsible community organisations shape up to seriously tackle the issue of bio hazardous waste management through enforcement of effective policies and standard operating procedures for safeguarding  the health  and lives  of the public in  general and  health  workers in particular.

Outbreaks,  defined  as  excess  cases  of  a  particular  disease  or  illness  which  outweighs  the  response capabilities, have the capacity to overwhelm health care facilities and need timely response and attention to details in order to avoid potentially disastrous sequelae . In this day and age when improvement in public health practices have significantly curtailed outbreak of various diseases, certain viral illnesses continue to make headlines. One of the notable vector borne infectious disease affecting significant portions of south east Asia in the early part of twenty first century is 'Dengue fever'. Dreaded as it is by those suffering from the illness, a lot of the hysteria created is secondary to a lack of education and understanding of the nature of the disease and at times a result of disinformation campaign for vested interests by certain political and media sections.'Dengue' in fact is a Spanish word, assumed to have originated from the Swahili phrase -ka dinga peppo -which  describes  the  disease  as  being  caused  by  evil  spirit. 1 Over  the  course  of  time  it  has  been  called 'breakbone fever', 'bilious vomiting fever', 'break heart fever', 'dandy fever', 'la dengue' and 'Phillipine, Thai and Singapore hemorrhagic fever' Whilst the first reported case referring to dengue fever as a water poison spread  by  flying  insects,  exists  in  the  Chinese  medical  encyclopedia  from  Jin  Dynasty  (265-420  AD),  the disease is believed to have disseminated from Africa with the spread of the primary vector, aedes egypti, in the 15th to 19th century as a result of globalisation of slave trade 45In  80%  of  the  patients  affected  by  this  condition  the  presentation  is  rather insidious  and  at  best characterized by mild fever. The classical 'Dengue fever' present in about 5% of the cases is characterized by high temperature, body aches, vomiting and at times a skin rash. The disease may regresses in two to seven days. However inrare instances (<5%) it may develop into more serious conditions such as Dengue hemorrhagic fever whereby the platelet count is significantly reduced leading to bleeding tendencies and may even culminate in a more life threatening presentation i.e Dengue shock syndrome.6To understand the actual dynamics of Dengue epidemic it is important to understand the mode of its spread in affected areas. Aedes mosquito (significantly Aedes Egypti) acts a vector for this disease. Early morning and evening times7 are favoured by these mosquitos to feed on their prey. There is some evidence that the disease  may  be  transmitted  via  blood  products  and  organ  donation. 8 Moreover  vertical  transmission (mother to child) has also been reported 9Diagnostic investigations include blood antigen detection through NS-I or nucleic acid detection via PCR. IO Cell cultures and specific serology may also be used for confirming the underlying disease. Whilst sporadic and  endemic  cases  are  part  of  routine  medical  practice  and  may  not  raise  any  alarm  bells,  outbreaks certainly need mobilization of appropriate resources for effective control. Needless to say 'prevention is better  than  cure'  and  should  be  the  primary  target  of  the  health  authorities  in  devising  strategies  for disease control.The  WHO  recommended  'Integrated  Vector  control  programme',  lays  stress  on  social  mobilisation  and strengthening of public health bodies, coherent response of health and related departments and effective capacity building of relevant personnel and organisations as well as the community at risk. For Aedes Egypti the  primary  control  revolves  around  eliminating  its  habitats  such  as  open  sources  of  water.  In  a  local perspective  in  our  city  Peshawar,  venue  of  the  recent  dengue  epidemic,  it  may  be  seen  in  the  form  of incidental reservoirs such as receptacles and tyres dumped in open areas  such as roof tops with rain water accumulating in them and provtdjng excellent breeding habitats, Larvicidal and insecticides may be added to more permanent sources   such   as   watertanks   and   farm   lands.   There   is   not   much   of   a   role   for   spraying   with organophosphorous agents which is at times resorted to for public consumption. Public education is the key to any effective strategy which must highlight the need for wearing clothing that fully covers the skin, avoiding  unnecessary  early  morning  and  evening  exposure  to  vector  agents,  application  of  insect repellents  and  use  of  mosquito  nets.  It  is  also  important  not  to  panic  if  affliction  with  the  disease  is suspected as in a vast majority of instances it is a self limiting illness without any long term harmful effects and needs simple conservative management like antipyretics and analgesics.An  important  consideration  for  responsible  authorities  in  a  dengue  epidemic  is  to  ensure  that maximum management facilities for simple cases are provided at the community level through   primary and  secondary  health  care  facilities  and  that  the  tertiary  care  hospitals  are  not inundated with all sort of patients demanding consultation. These later facilities should be reserved for those patients who end up with any complications or more severe manifestation of the disease.Research  is  underway  to  develop  an  ideal  vaccine  for  Dengue  fever.  In  2016,  a  vaccine  by  the  name 'Dengvaxia' was marketed in Phillipines and Indonesia. However with development of new serotypes of the virus, its efficacy has been somewhat compromised.As for treatment , there are no specific antiviral drugs. Management is symptomatic revolving mainly around oral and intravenous hydration. Paracetamol (Acetaminophen) is used for fever as compared to NSAIDS such as Ibuprophen infusion as well as blood and platelet transfusion.Data to date shows that slightly more than twenty three thousand people have been diagnosed with dengue over the past three months ie August to October there is a lower risk of bleeding with the former. Those with more severe form of the disease may need Dextran 2017, in Peshawar, Pakistan with around fourteen thousand  needing  admission  and  about  sixty  nine  recorded  deaths.  The  mortality  is  well  within  the acceptable international standards of less than 1%  for the disease. In the backdrop of all the debate surrounding  the  current  epidemic,  one  can  infer  that  such  outbreaks  are  best  addressed  with  effective planningwell ahead of the time before the disease threatens to spiral out of control. Simple measures such as covering water storage facilities, using larvicidals where practical, use of insect repellents, mosquito nets and  avoiding  unnecessary  exposure  can  offerthe  best  protection.  Public  health  messages  via  print  and electronic media can help educate people in affected areas and allay any anxiety building up from a fear of developing life threatening complications. Health department must mobilise all its resources to ensure local management of diagnosed patients with simple dengue fever and facilitate hospital admission only for those suffering from more severe form of the disease. Moreover the media hype into such situations needs to be addressed  through  constant  updates  and  discouraging  any  negative  politicking  on  the  issue.  To  sum  up Dengue  fever  is  not  really  an  affliction  to  be  dreaded  provided  it  is  viewed  and  managed  in  the  right perspective.