IMA Campaign: Katwayega to nahi

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Ask before visiting a place “Is your place free of mosquitoes?”

Cases of dengue and Chikungunya have started to appear in the capital of India. Unfortunately, no alert has been issued and in sporadic cases, no surgical strikes have been attempted openly in selected breeding places.

Napoleon Hill once said, “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 last year’s failure of controlling the mosquito menace into a success.

We must all agree that collectively we failed last year in controlling the mosquito menace and consequently Delhi again is showing cases. This is again a collective failure of Municipal Corporation, Delhi Government, Central Government, LG office, Medical Associations, CSR departments, Media, NGOs and Private sector.

The mosquito container index (the percentage of water-holding containers infested with larvae or pupae) now in Delhi is over 5% and had crossed 40% last year. Any index above 5% requires a community-integrated cluster approach to reduce mosquito density together with effective anti-larval measures.

Last year, 3 lakh mosquito repellent impregnated mosquito nets were distributed by MCD but what about this year. Last year, these nets were not available to actual patients. Even this year anti-larval measures, Temephos, an organophosphate larvicide and/or mosquito fish or Gambusia, a freshwater fish are not available to a common man.

Last year I wrote that we needed 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. But even this year, cases have started without alerts and involvement of private sector.

Are we again waiting to act in monsoon season?

Public awareness and public involvement must start if not started today.

We need to act against all the mosquitos, Aedes, Culex and Anopheles. Action against only the Aedes mosquito will not work.

The campaign that Aedes mosquito is a day biter and only breeds in indoor fresh water will not work. Even if it is true, killing Aedes would increase the density of Culex and malaria causing Anopheles mosquitoes. Culex mosquito, which causes filarial and Japanese encephalitis is already rampant in the city. Even Aedes mosquito, which causes Chikungunya, West Nile, Zika and Dengue can spread by the bite of infected female indoor Aedes aegypti or outdoor Aedes albopictus mosquito.

It is true that Aedes aegypti are more dangerous because they can fly up to 200 meters and only feed on human blood, whereas the Aedes albopictus that thrives outdoors can only fly as far as 80 meters and feed on animal blood other than human blood.

The outdoor Aedes mosquito cannot be ignored. The entire campaign up till now has been focused on Aedes as a day biter, wearing long sleeves shirt and pants during the day and using night mosquito nets. But precautions need to be taken throughout the day as the mosquitoes only recognize ‘light’ and not whether it is day or night. The fact that the mosquito only breeds in clear water also needs to be relearnt. The Aedes mosquito breeds in stagnant water anywhere inside or outside the house.

Rain 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 rain water collections providing an ideal atmosphere for mosquito breeding.

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

The law says that dengue or Chikungunya cases must be notified, but one can notify them within
7 days of diagnosis.

Aedes mosquito takes up to three meals in a day and within 7 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 suspecting a diagnosis of Chikungunya. So, all suspected cases must be reported without waiting to confirm the diagnosis. We have failed because the government has been insisting that only ELISA-confirmed cases be notified.

An SMS should be sent to all doctors practicing in that PIN code area with a case so that they can become a part of the public health action chain.

All public health measure should have started, right when the first case was suspected in Delhi.

An SMS should go to local councilor, MLA, MPs, all practicing doctors, local chemists, NGOs, RWAs, local IMA Branch, State IMA Branch, IMA Headquarters and other Specialty Organizations to join the public health chain efforts.

It has taken over a decade for us doctors to understand that dengue 1 and 3 strains are not dangerous and cause only platelet deficiency with thinning of blood, while dengue 2 and 4 strains are dangerous as they destroy platelets and thicken blood due to capillary leakage and rise in hematocrit. Also, that platelet transfusion is not required in absence of active bleeding and it is the timely fluid resuscitation that is more important and not platelet resuscitation.

Dengue becomes serious when the fever is subsiding. Earlier, dengue patients with high fever were hospitalized and there was always an urgency to discharge them when fever was subsiding. Now we know that the machine reading of platelet count can 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 severe dengue and severe Chikungunya cases. Being able to claim reimbursement in Mediclaim or PSU, should not be the factor to decide on hospital admission. If it was US, Medicare by now would have come out with admission guidelines.

The message that is being transmitted is that fogging has no answer. But when the container index is high, aerial fogging is also required and not just ground fogging.

When Zika threat came up in Brazil they deployed the 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 Corporations and they also have regulatory powers to impose fine. We need breeding checkers in the 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 premise must write that their premises are mosquito-free. When you are invited to somebody’s place, you should ask “I hope your premises are mosquito-free” and when you invite somebody, write “Welcome to my house and it is mosquito-free”.’

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

Many of us live in flats and the mosquitoes may be breeding on the roof top belonging to one of the owners of the flats and if he/she is out of station for a holiday, the anti-larval measures may remain deficient. RWAs should 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 roofs and verandahs are littered with left over tires, utensils, plastic utensils etc. We buy new car tires and keep the old ones on our roof top. We need to change this habit.

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

The new strategy has to focus on small collections of water such as bottle caps, finding mosquitoes lower in the room under the table or the bed, to look for them in all three parts of the house – roof tops, verandahs and inside the rooms including unused toilets accessories.

The slogan “Check your house once a week” needs a change. One should 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.

IMA approach is mosquito war against indoor or outdoor mosquitoes; fresh stagnant or dirty water mosquitoes; small containers like bottle caps or large containers like overhead tankers; made of mud or plastic; throughout the day (early morning fogging when pupa hatch for Aedes, late night for malaria); scrubbing clean the utensils

Slogan

Ghar ke andar maro and ghar ke bahar maro …
Din me maro, sham me maro and raat me maro …
Deewaron ke niche maro or upar maro …
Chote or bade pani ke collection me maro …
Eggs ko maro, larvae ko maro, pupae ko maro aur mosquitoes ko maro …
Chaat me maro, kamre me maro, veranda me maro …
Pani ke niche maro, pani ke upar maro …
Aedes ko maro, Culex ko maro aur Anopheles ko maro …