Sharp decline in death rate:

Dengue menace begins at home

By Ananda KANNANGARA

Dr.Paba Palihawadena

Unlike other diseases, dengue has become a `household' word in the country, due to the increase in number of patients from various parts of the country.

There is no particular age group of those who contract Dengue Haemorrhagic Fever (DHF), which has become an epidemic today. According to reports the epidemic had originated in the urban sector and later crept into rural and remote sectors in the country.

Although people tend to blame the Health Department for not taking precautionary measures, it is not so as research studies indicate that dengue cannot be controlled unless the country is rid of heaps of garbage and dengue breeding grounds.

The Head of the Health Ministry's Epidemiology Unit, Dr. Paba Palihawadana told the Sunday Observer that like several other diseases, no proper medicine or vaccines have so far been found to treat dengue patients.

She said destroying mosquitoes is the best way to be free of the disease.

"It's not a hard job to destroy mosquitoes which are a common sight in our environment.

If people clear thickets, heaps of garbage and culverts, destroy discarded tyres, coconut shells and plastic bottles which litter their home gardens, it will become an easy task to eliminate mosquito breeding grounds.

Referring to the `Dengue Control Week' (DCW) program that was launched by the Health Department Dr. Palihawadana said several programs were also launched in the past by the Department to educate the health authorities and the public, especially school children on the importance of eliminating mosquito breeding places.

There are similar programs such as the `National Dengue Eradication Program' and the `Dengue Prevention Drive'. she said.

The Health Department's main intention is to educate people from the grassroot-level as to how to combat the dengue menace.

"During this period we have conducted a large number of school awareness programs in Colombo. The suburbs, urban areas and in the rural sector with participation of children, parents and teachers,".

She said even in the city of Colombo mosquito breeding places were found in home gardens and compounds of popular school, following raids carried out by health officials recently.

Asked what action had been taken by the Health Ministry against local Government institutions such as Divisional Secretariats. Pradeshiya Sabhas and Provincial Councils for not taking proper steps to clear garbage dumping grounds and also clear shrubs in their areas, Dr. Palihawadana said a `National Steering Committee', (NSC) was appointed by the Health Ministry to look into the outbreak of dengue in the country.

She said senior officials, such as commissioners and directors attached to varous departments and local government institutions are the stakeholders in the NSC and it is their responsibility to keep their areas clean.

She said 26 regional epidemiologists have also been appointed to MOH offices countrywide including the most vulnerable areas such as Galle, Kandy, Matara, Jaffna, Vavuniya, Kegalle, Matale, Kilinochchi and Ratnapura to carry out dengue prevention campaigns.

According to statistics, 12,997 dengue patients were reported from various parts of the country and 72 patients have died during the first three months of this year.

She said due to the remarkable progress of the programs only three deaths were reported in April.

At a glance

                Patients       Deaths 
January         4,672		44

February  	4,542		13

March		2,522 		15

Dr. Palihawadana also said that 15 deaths were reported in the Jaffna District during the first four months, 15 from Colombo and nine from Batticaloa.

Asked about the Government's allocations to keep the countrywide dengue eradication program alive, she said Rs. 500 million has already been allocated and this will be utilised to purchase equipment and on other related programs. She said the doctors are also following dengue eradication training programs in Singapore and Thailand. Currently five doctors are receiving training in Thailand. Dr. Palihawadana also said that fever, headache, aches and pains and bleeding under the skin are the main symptoms of dengue.

If such symptoms continue for about 3-5 days, patients must seek treatments from a Government hospital since all state-owned hospitals are fully equipped to treat dengue patients.

The Health Ministry has also strengthened the activities of the Dengue Task Force (DTF) to eradicate the spread of the epidemic during the coming rainy season this month and in June.

The DTF was initiated by the Health Ministry in February this year to destroy dengue mosquito breeding grounds and the main task of the program is to co-ordinate with relevant officials from grassroots level and take precautionary measures to check the spread of the disease.

The DTF is Cabinet approved and has the authority to impose fines on those who are found guilty of violating the Mosquito Breeding Control (MBC) Act of 2009.

The DTF has also identified the countrywide dengue high risk zones in the districts of Colombo, Kandy, Gampaha, Kegalle, Kurunegala, Matale, Ratnapura, Puttalam, Hambantota, Kalutara, Trincomalee, Batticaloa and Vavuniya.

Health Ministry Senior Epidemiologist Dr. Sudath Peiris said that it is the sole duty of the public to engage in dengue eradication activities from time to time in their home gardens and areas.

He said if every citizen in the country considers that eradicating the mosquito menace is a national duty, the Government's Dengue Eradication Program or even any other epidemic could be controlled successfully.

He emphasised the importance of people from every state of society cleaning the environemnt and also carrying out a proper garbage disposal systems in their home gardens.

Dr. Peiris said that people could also use either mosquito repellents that containing DEET or picaridin (KBR3020) or mosquito nets to get rid of mosquitos.

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[ Fact File]

Dengue is an acute flu-like fever caused by a virus. It can cause disease in two forms:

(a) Dengue Fever (DF) - marked by an onset of sudden high fever, severe headache, pain behind the eyes, and pain in muscles and joints. Some may also have a rash.

(b) Dengue Haemorrhagic Fever (DHF) - is a more severe form, seen only in a small proportion of those infected. Typically DHF is characterised by high continuous fever for less than 7 days; bleeding from various parts of the body (including nose, mouth and gums or skin bruising) ; severe continuous abdominal pain mainly due to enlarged liver, and shock in severe cases. This can lead to death.

DHF is more serious in children.

Transmission

Dengue Fever spreads via bite of an infected dengue mosquito. It can spread fast in urban areas when the mosquitoes increase during rainy season.

Clinical features:

We may all confuse dengue fever with flu or a cold. Clinical features of dengue fever vary according to the age of the patient. Infants and young children may have nonspecific febrile illness with rash. Older children/adults may have a mild febrile illness or classical incapacitating disease with abrupt onset and high fever, severe headache, pain behind the eyes, muscle and joint pains, and rash.

1. Dengue Fever is a self limiting disease. For those who develop DHF hospital treatment is required.

2. Patient may feel ill and fever may last up to a week. They could feel weak and in low spirits for up to two weeks or so.

What you should really watch-out for are features of DHF.

Treatment:

There is no specific treatment for dengue fever. Treatment is symptomatic - keep the person home and allow to rest, this will help recover more quickly give plenty of fluids to drink allow to eat what they can, Paracetamol may relieve symptoms of fever and joint pain. Aspirin and other NSAIDs must be avoided.However, careful early clinical management frequently saves lives of DHF patients.

It would be advisable to see a qualified doctor if you/your child has high fever without any underlying reason for more than few days. However, even if dengue fever is suspected, you may not be expected to admit to a hospital.

Prevention and Control

DF is transmitted through a mosquito. Therefore, the best way to avoid dengue infection is to prevent mosquito bites. Still there is no vaccine or preventive drug. Hence, following tips are useful: Avoid mosquito bites during day time by wearing protective clothing.

Use mosquito nets when sleeping (both day and night) Get rid of mosquito breeding sites regularly in and around your household.These usually are discarded tyres, plastic containers, coconut shells, leaf axils, blocked roof gutters, bird baths flower vases, or any other place where rain water collect.

If you/your child develop dengue fever try to be protected from exposure to mosquito bites in order to avoid further spreading of the infection. Especially children should stay at home during the illness, ideally under a mosquito net when resting.

Courtesy:

Epidemiological Unit

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Preventing diabetes and cardiovascular problems:

Healthy lifestyle, a must

by Dr. Yanushi Dullewe WIJEYERATNE BMBS (UK), BMedSci Hons (UK)

Diabetes and Cardiovascular problems are increasing worldwide at an epidemic rate. Pre-diabetes (also referred to as impaired fasting glucose or impaired glucose tolerance) may begin several years before the clinical diagnosis of diabetes. Despite this, many people are unaware of this condition and therefore, do little to slow its progression at a reversible, early stage.

Impaired glucose tolerance is a transitional state from normoglycaemia to frank diabetes. Prior to the onset of type 2 diabetes, people almost invariably have pre-diabetes. In this condition, the blood glucose levels are higher than normal, but not yet high enough to be diagnosed as diabetes. Unlike in diabetes, where fasting blood glucose levels are greater than 7 mmol/L / 126mg/dL, people with pre-diabetes have fasting plasma glucose levels from 6.1 to 6.9 mmol/L (110-125 mg/dL). The progression from pre-diabetes to diabetes can be up to 50% over 10 years.

In the UK alone, there are 2.6 million people with diabetes, with an estimated 7 million people having pre-diabetes.

The predisposing factors for developing impaired glucose tolerance are similar to the risk factors for developing type 2 diabetes.

These comprise non-modifiable, constitutional risk factors such as advanced age and a strong family history of diabetes, but also readily modifiable risk factors including obesity, sedentary lifestyle and a high-fat / high-carbohydrate diet. The progression to type 2 diabetes is also influenced by these factors.

Similarly the pathogenesis of type 2 diabetes, the development of pre-diabetes is initiated by resistance of target organs to insulin, thereby reducing its action on the liver, muscles and adipocytes (fat cells). As a result, a relative insulin deficiency develops. The pancreas in turn attempts to increase insulin production, resulting in an initial compensatory hyperinsulinaemia (excess levels of circulating insulin in the blood). As diabetes progresses, insulin secretion from the pancreas becomes defective, which further impacts on the glycaemic control.

There is substantial heterogeneity in the regulation of glucose metabolism in individuals with impaired glucose tolerance. As a result, the absolute risk of progression and subsequent development of diabetes is difficult to predict for any single individual. It is however, known that impaired glucose tolerance is indeed a major risk factor for the development of type 2 diabetes.

In addition to the considerably increased risk of developing diabetes, people with impaired glucose tolerance are at an increased risk of developing cardiovascular disease. Research has shown that some long-term damage to the circulatory system, including the cerebral and coronary blood vessels, begin to occur during pre-diabetes.

The biochemical changes of cardiovascular disease in diabetes involve abnormalities in endothelial, vascular smooth muscle and platelet function. The metabolic abnormalities that characterise diabetes, particularly high blood glucose levels and insulin resistance provoke processes that alter the structure and function of blood vessels. Hyperglycaemia predisposes to increased oxidative stress and disturbances of intracellular signally mechanisms. Consequently, there is narrowing of blood vessels and increased production of pro-thrombotic factors. This predisposes to atherosclerosis and plaque development in blood vessels leading to occlusion of blood flow.

In addition to the above, levels of circulating free fatty acids are elevated in diabetes.

This is because of the increased liberation of free fatty acids from adipose tissue and reduced uptake by skeletal muscles as a result of the reduced response to insulin. Free fatty acids disturb endothelial function of blood vessels through several mechanisms, particularly by worsening the oxidative stress on the cells and also through exacerbation of lipid levels in the bloodstream.

Moreover, platelet function is altered in diabetes, favouring platelet aggregation and a propensity for thrombosis. Meanwhile, endogenous anticoagulants, which ensure that blood doesn't clot inappropriately in blood vessels, are decreased. The combination of these factors increases the risk of ischaemic heart disease, myocardial infarction and stroke.

There is evidence that the above changes begin to take place during the pre-diabetes stage. This is exacerbated by the fact that people with pre-diabetes also tend to have other risk factors for cardiovascular disease such as hypertension and high cholesterol levels.

Smoking and excess alcohol consumption further increases this risk. Many people with type 2 diabetes tend to be overweight, and obesity is associated with insulin resistance. The pattern of fat distribution in the body also has important implications.

People with a greater proportion of abdominal fat have an increased incidence of metabolic abnormalities than those with a more generalised fat distribution. Developing greater awareness of these modifiable risk factors and making early lifestyle changes are essential to delay the onset of pre-diabetes, reduce its progression to diabetes and minimise the risk to cardiovascular disease.

The benefits of sustained, regular exercise in reducing the risk of pre-diabetes, its progression to diabetes and improving cardiovascular risk are substantial.

It is important to aim for a regular pattern of moderate aerobic exercise of at least one hour, three or more times a week, and to sustain this level of activity as part of one's regular lifestyle. Resorting to excess exercise at irregular intervals without developing a regular habit that agrees with one's lifestyle, is far less likely to result in sustainable improvements to overall health.

Several studies have demonstrated that long-term moderate exercise improves carbohydrate metabolism, insulin sensitivity, blood pressure and lipid metabolism. These effects independently and cumulatively reduce overall risk of coronary heart disease, cerebrovascular disease renovascular problems and peripheral vascular disease.

The secret to healthy eating is to have a varied and well balanced diet that is rich in nutrients. Strict diets with little flexibility are rarely effective in terms of health benefits.

People who engage in such diets tend to divulge to former unhealthy dietary habits after attaining for example, a short-term weight loss goal.

Long-term dietary changes with smaller portions of starchy and lipid-rich food, together with larger portions and a varied intake of fruit and vegetables are an effective means of satisfying one's appetite and developing healthy dietary habits.

When contemplating dietary changes, it is imperative to always consider that it is the quality that matters, not the quantity.

Energy metabolism in the body is a balance between energy input and output. A good diet with a sedentary lifestyle, or plentiful physical activity with an unhealthy diet, is unlikely to have a positive impact on glycaemic control, body weight or cardiovascular risk. An overall healthy lifestyle is paramount.

Prevention is always better than cure. Developing awareness of pre-diabetes and early lifestyle modifications are the most effective means of delaying the onset of diabetes and associated cardiovascular complications.

(The writer is a medical doctor at United Lincolnshire Hospitals NHS Trust in United Kingdom and has authored several articles published in international scientific journals.)