Dengue fever 4-year plan ---prevention and control program

Dengue fever 4-year plan ---prevention and control program The southern part of Taiwan, the area most affected by Dengue Fever, is where Aedes aegypti is found. Aedes aegypti is a non-indigenous species on Taiwan island; if we completely eliminate breeding sources of the mosquitoes, keep natural and environments clean, and properly use pesticides, we shall reach the target of eliminating Aedes aegypti and reducing the proliferation of Aedes albopictus ( that scattered in plains and mountains under the altitude of 1500 meters on the island) Elimination of breeding places is the first strategy for Dengue Fever prevention (i.e. first class prevention). The second strategy is to create an effective monitoring system; in the case of discovery of any cases of dengue fever, proper measures should be adopted to guard against the epidemic (i.e. second class prevention). The third strategy is to strengthen medical care and to reduce the death rate in patients with dengue hemorrhagic fever (i.e. third class prevention). {1}. Primary prevention (i.e. elimination of breeding sources and control of vector mosquitoes) [1] Since no vaccine can prevent the infection of Dengue Fever, once patients are infected, there is no medicine to cure them and kill the viruses living within their bodies. However, through an intensive health education via different channels, people become well aware of Dengue Fever prevention; in addition, through cultivating in daily life the habits of not creating mosquito breeding grounds and eliminating existing breeding places, infection can be prevented. The keys of health education are as follows: (1) Knowledge on epidemic characteristics and Dengue Fever prevention (e.g., a brief introduction to the pubic regarding Dengue Fever/Dengue Hemorrhagic Fever, channels of infection, clinical symptoms, etc.). (2) Recognition of breeding sources and cultivation of habits of not creating mosquito breeding places and eliminating existing breeding grounds (3) Cultivation of the awareness and daily habits to prevent infection (e.g. when visiting domestic or foreign areas affected by the disease, one should wear long sleeve clothing and apply mosquito repellents to uncovered body parts, etc.) (4) Install in the public the concept that only complete elimination of breeding sources is the permanent cure, while spraying medicine is just a temporary, superficial measure for coping with emergency. (5) Some of the Dengue Fever symptoms are not evident; in the case of a 1

suspected infection, one should receive a physical examination (especially tourists from a foreign country) (6) Knowledge of physical indications preceding the onset of hemorrhage, shock and other serious illness triggered by dengue fever, and understanding when to seek urgent medical care.. (7) Strengthening health education for employers who hire foreign laborers. [2]. Mobilization of community organizations, overall elimination of breeding sources and maintenance of clean homesteads. (1) Collecting information on all sorts of community organizations which can be mobilized (including schools, governmental units, companies, religious and private groups, markets, women s and senior citizens clubs, and volunteer groups) (2) Building a mechanism for the mobilization of community organizations 1. Integrating community-building works initiated by various ministries, councils and bureaus of the central government (for example, health, environmental protection, culture, etc.). Each city or county government is responsible for supervising mobilization work by the country, town, district and city) offices under its jurisdiction. Each neighborhood or village constitutes a unit of mobilization. The head of a neighborhood, village or basic community is responsible for coordinating and inspecting inhabitants and concerning groups in the community in improving environmental and household hygiene, and in eliminating larva breeding grounds. (cross-inspection if necessary). 2. The city and county governments and administration units of villages, towns, cities, and districts should direct the groups and companies under their jurisdiction to cooperate. (3) Tasks of organizational mobilization 1. To list the main areas of breeding sources such as unused land, houses or a public facilities (i.e. community centers, markets, basements, factories, etc.) 2. To participate in sanitation education and to expand training of seed personnel 3. To remove the breeding sources, both indoor and outdoor, thoroughly: Indoor breeding sources: any school, family, working place Outdoor breeding sources: any unoccupied land, park, public place; 4. To check, at least monthly, on the result of removal of breeding 2

sources and the index of vector mosquitoes through the collaboration between local environmental protection and public health offices, and report to the Centers for Disease Control, Department of Health, Executive Yuan. (3) Implementation procedures 1. Each city or county government has to direct the village, town, city, and district offices under its jurisdiction to collectively choose a day of the week as the " Cleaning Day" (i.e. taking into consideration the daily cycle of people's live and the prolific cycle of the vector mosquitoes from laying eggs to maturing into insects). Continue with the removal of breeding sources and maintain environmental cleanness. 2. The public health clinic of each of country, town, city or district is responsible for the overall all training of volunteers and heads of neighborhoods, villages or basic communities, who will direct community citizens in eliminating the breeding sources. 3. The instructors should visit families, offices, groups and companies in the neighborhood or basic community to illustrate how to recognize breeding sources and the methods of removal, with on site demonstrations; and lead the participants to check breeding sources both indoor and outdoor. 4. If necessary, follow the recommendation of using insecticide from the Centers for Disease Control, Department of Health, Executive Yuan, to spray the insecticide throughout an area or at certain spots to reduce the density of grown mosquitoes or destroy them. 5. The central and local governments should enact the laws and regulations concerning rewards and punishments, and should check the performance of each country, town, city and district regularly in order to make sure that the mentioned procedures have been properly implemented. implementation [3] To enact and amend the related laws/regulations and put in place an autonomic act (1)To enact an autonomic act on management of unused land and houses: To instruct each county or city government to enact an autonomic act on management of unused land and houses, to order each county or city to assemble an inspection team with members from different 3

bureaus and departments such as city development, traffic, construction management, usage management, park, environmental protection, police and land administration. If the inspection team finds out that the owner of an unused land or house has not managed the property properly and no improvement is made after the notice period, the bureau/department should fine the owner. The enforced act should be executed by the expert teams of unused land and houses in the city after re-notice and non-observance. (2) Review of current construction laws/regulations and the matching norms of public sanitation. The current laws and regulations consider the problems of public health in a fire lane, a ditch, a basement, a water reserve for fire fighting, a roof balcony, and so on, places that easily accumulate water. The Department of Health shall consult with the concerning ministries and councils for the need to evaluate the concerning laws and regulations of guarding against an epidemic in Taiwan, and to reconsider the necessity of setting up water reserves for fire fighting and similar public facilities. Strengthen management of building sites and for buildings that fall behind schedule or are not complete within the deadline, the government shall intervene for the sake of ensuring and maintaining public health, and make sure that the sites would not become breeding places for contagious mosquitoes due to lack of management personnel or poor maintenance. [4] To enforce the implementation of laws and regulations (1) Regular classification, inspection and reporting All administration units of each county, city, village or town shall collaborate in the monthly inspection of unoccupied households, unoccupied lands, parks, markets, fire lanes, flower shops, deserted building sites, basements filled with water, resources recycle sites and other larva breeding places. The responsible units shall make a list of the sites and manage them accordingly, and shall inform the head of a neighborhood or a basic community unit that he or she needs to regularly check on the progress in eliminating breeding sources on the listed sites. The local public health and environmental protection units shall also inspect the listed larva breeding areas regularly to find out about the progress in elimination. (2) Effective implementation of mechanisms for inspection, reporting and emergency response 4

Upon receiving reports of confirmed larva breeding grounds, such as in deserted tires, furniture, houses, basements filled with water, etc., environmental protection authorities and other relevant administration units shall step up their efforts in dealing with such cases and give the owners a deadline for cleanup. The cases need to be cataloged and followed up. (3) Set up a joint investigation team Large public buildings, lands and facilities owned by the central and local governments shall be inspected regularly. Furthermore, in order to avoid undue influence from local politics, the central Environmental Protection Administration, the Department of Health, the local environmental protection unit and the local public health unit shall each send one person to form the inspection team to assess the effectiveness of breeding source elimination at a specific location. Cross-county/ cross-city inspection is another option. [5] To strengthen education and training of personnel of public health and environmental protection (1) Understandings of dengue fever and contagious mosquitoes, and trainings on the mechanism for managing breeding sources: Trainings to improve volunteers understandings of dengue fever and the vector mosquitoes, teaching people to change their behaviors that lead to the creation of breeding sources (2) Training on density investigation of vector mosquitoes of dengue fever Strengthening knowledge of laws and regulations and trainings on how to enforce the laws (3) Trainings on insecticide spraying 1. Trainings of workers for medicine spraying: local branches of the Centers for Disease Control and local bureaus of Public Health should recommend personnel and volunteers to take courses on relevant laws and practical operation, in order to enhance their ability on medicine spraying to kill the mosquitoes. 2. Trainings for leaders of medicine spraying: The leaders are responsible for leading and supervising workers in carrying out insecticide spraying. The Centers for Disease Control is responsible for recruiting personnel, and the Environmental Protection Administration should assist in the provision of trainings - including courses on laws and regulations, trainings on practical 5

operation and examinations to enable the personnel to carry out the responsibilities of field supervision for medicine spraying, filling out documents for the purpose of reporting back, etc. [6] To create a monitoring mechanism of the breeding sources, the larva and the contagious mosquitoes (1) The monitoring of the breeding sources and the larva When a survey shows that the density of contagious mosquitoes has reached the third degree or above in a country town or a neighborhood, the local authorities are excepted to mobilize for the purpose of eliminating the breeding sources; the local bureau of Public Health needs to hold a double check, and places warning flags. At first or second degree density, the concerning units should mobilize to eliminate the resources, and the local bureau of Public Health should hold a double check. If the Breteau index is zero degree, the responsible unit should use a special machine to seduce the mosquitoes to lay eggs in order to monitor. (2) The plan for monitoring viruses inside vector mosquitoes of dengue fever Regular visits to the area of focus or places with a large flow of people to collect the grown mosquitoes for RT-PCR and detaching inspection on the viruses. (3) The monitoring of mosquitoes resistance to the medicine and tests on the effect of medicine. [7] Preventative insecticide spraying (1) Spraying insecticide When Aedes aegypti with viruses is collected from a spot, spray insecticide within a radius of 50 meters around the spot and following a 7-day interval, spray the second time and the third time. When spraying on a large-scale or when a change in the type of insecticide is required, we shall carry out insecticide evaluation on the scene. (2) Buying the medicine Before the epidemic season each year, the Centers for Disease Control will release data on the mosquitoes' resistance to the medicine and based on that and the list of medicine items approved by Department of Health, local governments will buy the proper medicines to be used. {2} Secondary prevention (i.e. to construct a system for monitoring the number of infections and a mechanism for responding tothe epidemic promptly; 6

and to stop indigenous cases of dengue fever.) [I] to construct a mechanism for monitoring the number of infections When doctors and medical personnel in this country discover suspected cases, they should report within 24 hours. Furthermore, in order to control non-dominance infection and unidentified fever which have failed to be reported, the Centers for Disease Control, via the following monitoring system, would take the approach of allowing no one to slip through the net to strengthen the monitoring and reporting of Dengue fever. We endeavor to control the suspected cases promptly to prevent dengue fever viruses from spreading further via the vector mosquitoes, and we strive to strengthen our ability in monitoring the epidemic and assessing the epidemic information.. 1. Doctors monitoring reports from fix spots: Due to the difficulty in the diagnosis of non-dominance infection and atypical cases of dengue fever, the blood test for patients of unidentified fever syndrome should be incorporated into the doctor monitoring mechanism; (weekly in ordinary time, and more frequently during the epidemic season from March to October.)2. Epidemic monitoring and reporting in school: the unidentified fever shall be included in epidemic monitoring and reporting in school. If suspected cases are discovered and pupils are absent due to unidentified fever, it should be reported to the public health unit that then proceeds to investigate and collect samples on a large-scale. 3. Monitoring and reporting of new infection cases: intensify monitoring efforts in the epidemic season. We have an acute hemorrhagic report system and shall add dengue fever viruses into the list of general inspection items. 4. Self reporting by patients: anyone who suspects of being infected with the fever shall visit the local public health bureau for a blood test. 5." Communicable Diseases Survey Form": residents returning from a business trip or vocation abroad shall fill out the Communicable Diseases Survey Form", and the public health unit shall follow up on suspected patients. 6. Take body temperature in the airport: inbound travelers shall take body temperature in the airport, and those with a fever case shall take a blood test. 7

[2] The mechanism for prompt management of epidemic (1) The epidemic investigation Both central and local health authorities should establish epidemic field investigation teams. If there is a suspected case, the local health authorities proceed to epidemic investigation; if there is a need for specialists or special research skills, or when the supply of investigation tools is insufficient, the central health authorities will coordinate and help. 1. To create a list of the members in the central and local investigation groups. 2. To provide members of the investigation groups professional trainings on the characteristics of dengue fever 3. To provide members of the investigation groups professional trainings on visiting and interviewing dengue fever patients 4. To provide members of the investigation groups professional trainings on epidemic field investigation and analytical skills to determine the source of dengue fever 5. To provide practical trainings and drills for members of the investigation groups on field investigation and analysis. (2) Medicine spraying According to data on the sensitivity of each medicine, the authorities set forth the medicine items and machines to be used, the scope of medicine spraying, pictures, work journals and records of the household, to formulate a complete plan. 1 The timing of medicine spraying and effectiveness: where there is a case of suspected dengue fever, the authorities shall spray the medicine within a radius of 50 meters, and following a 7-day interval, spray the second time and the third time (stop spraying if the area tests negative after three sprays). If there are many confirmed cases at a specific location, it is necessary to expand medicine spraying to the whole of the country town/neighborhood. If medicine spraying on a large scale or a change in the type of medicine is needed, it is necessary to evaluate the medicine on the site. 2. Manpower structure for medicine spraying: -each municipal city or county/city shall at least reserve 40 medicine spraying workers and 20 medicine spraying leaders according to the size of the area and the number of its population; each location needs to be 8

equipped with at least 10 medicine spraying machines. Besides, the Centers of Disease Control shall organize and train a medicine spraying group of 30 professionals, who are equipped with two units of car-carried, low-volume sprayers and foggers each. The group will be responsible for assisting in emergencies, monitoring and managing an epidemic, and conducting large-scale medicine spraying. 3. Implement monitoring: Before medicine spraying, the authorities shall negotiate with the chief of a village, a neighborhood or a basic community, to increase cooperation from citizens. Arranging for urgent medicine spraying, and in addition to controlling the timing, whether the job is thoroughly carried out constitutes the key to successful prevention. Once medicine spraying begins, it needs to be enforced by fining uncooperative citizens and by opening locks to unoccupied houses. Complete elimination of the mosquitoes can prevent the epidemic from spreading. Besides, to enhance the effectiveness of the spraying, the entomologists shall collaborate with the local research institutions in carrying out supervision and training. (3) Investigating the epidemic: After receiving report of a suspected case, the authorities shall investigate the areas surrounding the household and other possible epidemic areas, and carry out investigation on the density of larva and grown mosquitoes. (4) Intensify the efforts to eliminate breeding sources immediately : until the case is confirmed, the head of a neighborhood or a basic community shall mobilize volunteers of the community to eradicate breading sources within a 50-meter radius of the patient, s residence and at locations visited by the patient prior to the onset of the disease. The responsibility of cleaning these areas should be divided among the volunteers. [3] To upgrade the effectiveness of laboratory diagnosis : (1)To install dengue fever laboratory diagnosis centers in the south of the island. (2) To increase automatic laboratory diagnosis facilities. (3) To upgrade the ability of laboratory testing in identifying dengue 9

hemorrhagic through international cooperation (4) To send personnel to top international laboratories to study new ways of laboratory diagnosis. (5) To hold dengue fever laboratory diagnosis seminars and proceed to exchanges in the field of research to raise the standards (6) To develop and improve reagents to improve their specificity and sensitivity. {3} Tertiary prevention (to prevent advanced cases that cause death) The target is to reduce the death rate of dengue hemorrhagic fever to less than 5% [1] To set medical treatment procedures of dengue hemorrhagic fever [2] To carry out compulsory education on dengue hemorrhagic fever for medical personnel on a continuous basis [3] To hold international seminars on the medical treatment of dengue fever/ dengue hemorrhagic fever [4] To set selection criteria for sending medical treatment personnel of dengue hemorrhagic fever abroad for training [5] To train medical treatment personnel of dengue hemorrhagic fever [6] To amend standards for designated hospitals in treating fatal dengue hemorrhagic fever in an emergency [7] To select hospitals for treating dengue hemorrhagic fever in an emergency [8] To create a mechanism for allocating hospital beds in an emergency {4} Organizational Operation According to the Communicable Disease Control Act, the local unit responsible for the prevention of dengue fever is the government of a municipal city or a county/city, and its subsidiaries, including public health, environmental protection and other relevant bureaus/departments/offices shall be under the command of the head of the government. Any related ministry, department or administration shall focus on its area of responsibility in monitoring and instructing the local bureaus, departments/ or offices. Besides, if the infection spreads across counties or cities, the Department of Health will report to the Executive Yuan to initiate a mechanism of disease prevention, which is the "National disasters Prevention and Protection Commission, R. O. C. ", to coordinate the mobilization of all concerning units in the government. 10

{5} International cooperation Strengthening the exchange of experiences in dengue fever prevention with partners worldwide, especially in the Asia-Pacific region, and improving information sharing in order to obtain information of current pandemics globally, prevent inbound cases of the fever and improve our ability in the prevention and treatment of dengue fever. This project of international cooperation has three directions: [1] To share and exchange information on dengue fever prevention in the Asia pacific area (1) To cooperate with the US in the provision of training courses on bacteria laboratory diagnosis of dengue fever (2) To create an online information network for the Asia-pacific area via APEC channels (including studies on epidemic diseases and information from laboratories) (3) To hold an APEC research camp on managing an epidemic area of dengue fever through regional cooperation. (4) Mutual exchange and visits of personnel of dengue fever prevention [2]. To cooperate with the US disease control bureau and Belgium AW tropical medical research center in the planning dengue fever prevention [3].To promote bilateral or multilateral cooperation in the planning of dengue fever prevention To cooperate with high-risk areas such as Panama in Central America and Malaysia/Vietnam in Asia for bilateral cooperation on dengue fever [4] Actively participating in international seminars at least twice per year to enhance the professional knowledge. [5] To invite domestic and foreign specialists and scholars to visit the epidemic area to assess the management of vector mosquitoes. [6] To arrange a summit on dengue fever prevention strategies To invite health ministers in the Asia-Pacific area to hold a summit on dengue fever prevention strategies and consult with one another on prevention strategies and cooperation projects of dengue fever prevention in the Asia Pacific area. 11