Combating The Chikungunya Outbreak

At a time when the city is once again experiencing a surge of mosquitoes, residents are concerned about a resurgence of the diseases they carry. The mosquitoes biting us at all hours of day and night though are largely of the Culex variety, which while bothersome, does not bear disease. Aedes however causes dengue and worryingly, chikungunya, which crippled many in the city for some time last year.

Last year, Dhaka's residents suffered from raging fever along with severe joint pain (arthralgia) and swelling which restricted them to their beds, unable to get up or even move. Some were hospitalised in droves but many more suffered and recuperated at home, creating a public health crisis across the city. The city corporations and government agencies responded, but how effective were the measures taken in combating the outbreak?

Little to be done

Santi Begum, a 45-year-old mother of six, living in Moghbazar was struck by the disease last June. A domestic worker, she was debilitated from the fever and joint pain and unable to go to work for two weeks. One of her employers subsequently gave her the DSCC hotline number which she called for the services then provided by the DSCC—free doctor and physiotherapy consultation and home visits on request.

She received a visit from a physiotherapist who taught her how to gently exercise and stretch her joints."I tried to carry on with it but it didn't help much," she says. All she could do was wait, suffer from the pain in her hands and feet, and take paracetamol to help ease the pain."I still have pain in my left foot, so much so that I can't move it for some time," she says. She was not the only one in her family—her 17-year-old daughter was similarly affected by chikungunya.

Saddam Hossain, a physiotherapist at the National Institute of Traumatology and Orthopaedic Rehabilitation (known locally as Pangu Hospital), saysthis was not uncommon. Dr Hossain was in charge of providing physiotherapy support for areas under Zone 5 of DSCC, including Jatrabari, Sayedabad, and Gendaria, which saw the most requests for help by patients. In the course of his work, he along with physiotherapists working under him encountered up to seven members of a household down with the virus. "In one madrasa in Dholaipar, we treated 16 young boys," he recounts.

"No ward in DSCC was unaffected by the virus. Particularly worse was the situation in Jatrabari, Demra and Kamrangirchar. Mirpur and the Ramna area were also bad off," adds Dollilur Rahman, chief coordinator of the initiative and president of the Bangladesh Physiotherapy Association (BPA).

There is no preventive vaccine or drug treatment for chikungunya—treatment can only relieve the symptoms. Other than mild exercise, rest, a proper diet and pain relief medications such as paracetamol are the only course of treatment. "Last year when chikungunya patients presented symptoms such as joint pain and debilitated movement, a lot of senior doctors [themselves affected] started coming to us for treatment and advised us that physiotherapy can play a big role in the recovery of so many affected," says Dr Rahman.

In July last year, BPA started 15 support centers around the city where they provided consultation free of cost and physiotherapy sessions at minimal cost. "We treated around 950 patients that month," says Dr Rahman. They then collaborated with the DSCC—285 physiotherapists worked under Dr Rahman, consulting with patients over phone or making a home visit on request. The month-long programme reached around 3000 patients. "We gave advice on how to manage their pain and what activities they can do so as to return to regular life as soon as possible," he says.

At last count, a total of 13,814 patients sought treatment in Dhaka's hospitals for chikungunya and post-chikungunya arthralgia (between May 12 to September 28, 2017), according to IEDCR. However, only 1,003 cases were clinically confirmed as chikungunya.

But these numbers are likely to be way off the mark since many like Santi Begum did not go to the hospital to get diagnosed. The test for the chikungunya virus was only available at the Institute of Epidemiology, Disease Control and Research (IEDCR) and testing was also discouraged by health authorities struggling to manage the outbreak, since it did not affect treatment.

People at particular risk were the elderly and those with additional medical conditions, with joint pain likely to persist for months, and even, years. 60-year-old Mohd. Ali Belal, a retired doctor of internal medicine, came down with chikungunya in the last days of Ramadan last year. He couldn't get up from bed or eat, let alone pray or fast. Joint pain still lingers, a year later, rendering him unable to pray standing up as before.

Dr Belal blames the general unclean state of the drains and waterbodies in the city. "If our surroundings are not clean, if the drains and lakes are not cleaned regularly, mosquitoes will continue to breed," he says. "Fogging is useless, an eyewash. All it does is drive mosquitoes indoors."

Mosquitoes breeding everywhere

The city corporations were primarily blamed for the outbreak, with residents complaining of unclean roads, waterbodies and drains and limited mosquito-control methods such as insecticide fogging and larvicide. With mosquitoes now flourishing, the DSCC is currently conducting a crash programme to thoroughly target places where mosquitoes breed. "This means that we are concentrating all our resources [fogging machines and handheld sprays] and spraying larvicide in waterbodies in the mornings and adulticide in the evenings one zone at a time," says Brigadier General Sheikh Salahuddin, Chief Health Officer of DSCC.

Contrary to the dominant complaint by Dhaka's residents, he states, "We conduct fogging routinely, every 3-4 days in all areas. Spraying everyday is not possible, as it would be detrimental to health." However, insecticide is not the only remedy. Fogging is mainly used to control Culex mosquitoes, which which bite but don't infect, but not Aedes, he says.

The onus of the problem, he says, cannot be addressed by the city corporations as Aedes mosquitoes breed in clean and stagnant water in spaces in and around homes and buildings, such as pots on rooftops and water tanks. A survey conducted by the Communicable Disease Control of the DGHS found 27 percent of households in the DNCC and 14 percent in the DSCC to have stagnant water with mosquito larvae or pupae. Upscale neighbourhoods and cramped areas alike were breeding grounds for Aedes.

This, in addition to properties which fall under the jurisdiction of WASA and other organisations, means that the city corporations cannot reach all areas. "It is the responsibility of citizens to ensure that their homes and the surrounding environment are kept clean." These include measures such as regularly emptying containers carrying water in and around our houses, he advises.

Earlier this month, director general of the Directorate General of Health Services (DGHS), Professor Abul Kalam Azad, declared, "There is no possibility of a chikungunya outbreak this year." While the effectiveness of theme asures being taken since the outbreak will tell in time, "We are preparing regardless [for an outbreak]," says Salahuddin. For a city where healthcare is largely privatised and fragmented, chikungunya and similar diseases due to unchecked mosquitoes could prove a substantial public health burden without long-term preventative measures in place.