Dengue can be controlled

Dr H I Karunadasa

The aim of this article is to draw the Health Ministry’s attention to consider even at this late stage to go for a National Community Based long term Action Plan to wipe out dengue from this country. Participatory Representative Action Planning methods are used in many developing countries in South Asia and Western Pacific Region Countries

Dengue cases and deaths are on the increase in spite of some intensive clean up campaigns. In 2007, we repeated the same preventive measures that are functioning today and did not observe much appreciable control.

Cases continued at the same intensity in 2008 and 2009 although we applied same measures much more vigorously and failed again to see some effective results although cases ceased in all occasions along with the monsoon rains coming to an end.

There is an impact of these massive clean-up campaigns in preventing dengue spreading in major epidemic proportions. Although this impact is quite obvious during the spreading months of dengue in previous years, it reveals that something more is needed indicating that short term measures are blessed with short term impacts.

By resorting to the same process of short term prevention we are unable to control dengue to the manageable level.

If we evaluate the same preventive measures as reported in printed and electronic media, there is something deficient in our approaches. The preventive measures particularly, clean up campaigns were prominent during the months of May, June and July and to some extent the first half of August.

Cases started declining in August and along with it people’s interest also declined as if dengue will not raise its head again. It is a pity to note that the incidence of dengue continued unabated in 2007, 2008, 2009 and up to the end of July, 2010.

Absence of long term plan

We have no knowledge of any scientific evaluation done to determine as to what has gone wrong, and what remedial measures should be adopted to curb this national threat.

The answer is simple.

We did not have a family and community based long term Action Plan.

It is heartening to note that our political sector with other interested groups and national media are making mighty efforts by organizing and implementing clean up campaigns.

This is a vital necessity to arrest the present increasing trend of the incidence of dengue. But, after these clean up campaigns how could we manage to maintain this clean level. Is it for how long? Will it be possible to launch such campaigns right through the year?

It is very pathetic to note that this national responsibility is cleanly forgotten and the nation is suffering heavy losses. If we fail to organize a community and family based self sustaining long term action plan and, launch it with the active participation of the Presidential Task Force working at Grama Niladhari Divisional level, we are heading for a bigger threat with serious consequences.

Creating awareness is a healthy sign but, one should remember that there is a gap between knowledge and behaviour. What we should strive is to direct educational interventions to bring about a behavioural change so that people develop right attitude and change their own behaviour for some positive benefits.

In spite of all educational efforts there are some incorrigible in any community. They are few in number. We have legal measures against them.

Dengue menace can be controlled by developing a strategy on the basis of Participatory Representative Techniques (PRT) and go into self sustaining family and community based long term action planning.

Most members in the public health and health education sector are not proficient in participatory planning.

Following is that long term action plan that I proposed for the eradication of dengue in the Kelaniya MoH area.

Strategy

The action oriented small group based process of Participatory Representative Technique (PRT) at community level is envisaged for the active involvement of the community. Small groups of families consisting of 10 to 15 will be identified on the basis of a set of criteria and action oriented units are formed.

Presidential Task Force Committee working at Grama Niladhari level is given leadership and the committee member responsible for the families is expected to work with the public health staff. Each unit will select their own two representative activists using simple socio-metric technique.

Objectives

Objectives not included in this. Variables include strengthening of group behaviour, elimination of mosquito breeding places, quick and efficient case referrals and measures for sustenance and coordination with all interested agencies.

Setting the target population

On the basis of the following criteria the entire MOH area is divided into three units. They are the morbidity incidence of dengue in previous years and the case distribution, entomological evidence as regards mosquito density (Particularly aedes agyptae and albopictus), present outbreak and its distribution and environmental vulnerability.

The three units are high risk area, medium risk area and the minimum risk area.

A map indicating these three areas are prepared by the staff and families are identified. High priority was given to high risk area and about 1,500 families were selected from four PHI areas. All other activities planned for the area are being carried out in addition to this program.

Coordination and support

All the field officers of Kelaniya area attached to different departments that have a linkage to the environment are scheduled for an orientation of this participatory methodology. Some are already orientated.

Task Force Committee working at Grama Niladhari level is given direct responsibility to work with the family level activists. Some of the members have already been orientated.

This methodology provides them opportunities to coordinate and work with their own community. Some Kelaniya PS members have already been briefed for their support.

While educating the entire school population on the preventive measures of dengue, students above Grade Eight from the high risk area will be given a separate task of planning to assist family unit level representatives. They will be orientated as to how to perform this task.

Methodology

Methodologies are available under Participatory Representative Techniques (PRT). Taking the urgency into consideration the PRT process is designed to support the Ministry’s ongoing clean up campaigns and other interventions and to create a family based self sustaining community infrastructure to implement a long term community based action program.

This will facilitate to undertake follow up work to sustain the cleaner and mosquito breeding free environment now we are achieving through massive clean-up campaigns. The PRT process involves the following steps.

•  Taking into consideration the status of socio-economic, geographic and housing density the families in high risk area and breaking them into 10 to 15 workable units.
   
• The application of simple sociometric tests to select two representative activists from each unit. They are not selected by the Public Health staff, but the community.

The members of the Kelaniya health staff have been fully trained by me as how to conduct this test and full freedom is given to the community to come out with their nominees. If there are 15 units in a selected area, there will be about 30 Family Representative Activists (FRA).

•  Orientation training of FRAs through group sessions. This is conducted by the Members of the health staff to apprise them about dengue and the role of the community in this program. This will also facilitate planning with the community.
   
• As mentioned, all the schools in the Kelaniya and the neighbourhood will be taken up for dengue health education and other preventive activities. Secondly, schoolchildren from the High Risk Area will be involved for a separate action plan to coordinate with community and family level representatives. They will be given guidelines as to how to develop this plan and implement in the high risk area.

Community action planning

To pave the way for long term community action planning, the members of the public health staff working in a particular area need to organize meetings with FRAs. It is necessary to organize these meetings in consultations with them at suitable time convenient to them.

Community action planning is the most vital stage of this program and the sacrifice they make at the beginning will pay good dividends not only for dengue eradication work but also for other preventive health work in the area in future.

Implementation

All the FRAs in all the units with family members and high schoolchildren of the area are responsible for the implementation of the community action plan as planned according to time frame.

Assistance of the health staff and the coordinating members particularly members of the Task Force working at Grama Niladhari level is planned to be made available and is expected to perform their role as planned.

Monitoring and evaluation

Monitoring should be planned by the health staff so as to comprehensively cover the effective implementation of the total process. Remedial measures should be brought in without delay.

Indicators for the purpose of evaluation should be identified during the planning stage and used at any point of the process to check the progress and bring in corrective measures.