National Meeting on Strengthening Dengue Prevention and Control

4 March 2014, Male, Maldives

Inaugural Address by Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia

It is my pleasure to speak to you on this crucial and timely event, on a subject that is very important to the Maldives, to WHO South-East Asia Region and beyond. As you all are aware, this year’s World Health Day theme is on vector-borne diseases, giving us an opportunity to create a global platform to highlight their health, economic and social impact and strengthen our efforts in controlling them. While malaria is still the deadliest of all vector-borne diseases, dengue has been the fastest growing, with a 30-fold increase in incidence over the last 50 years.

First recognized in the 1950s in Thailand and the Philippines, dengue fever has now become endemic in more than 100 countries. Over 2.5 billion people, making more than 40% of the world's population, are currently at risk from dengue. In the South-East Asia Region, it has spread to 10 of the 11 countries, putting about 52% of the regional population at risk. Dengue outbreaks are occurring in small island communities like the Maldives, large continental countries like India and high altitude mountainous countries like Bhutan and Nepal. It is seen in urban and rural areas, infecting young and old, putting tremendous pressure on the health systems.

Despite many efforts to control, dengue continues to be endemic in the Region. Though four countries, including Maldives, showed a decreasing trend of dengue in 2012, the overall regional figure shows an increasing trend compared to 2011. With Indonesia contributing to the second highest number of cases in the world, five countries in this Region are among the 30 most highly endemic countries in the world.

However, the good news is that despite the large number of cases reported, by strengthening country capacity and improving case management, the Region has been able to maintain a very low case fatality rate from dengue. Nonetheless, the high morbidity and associated social and economic burden is of concern.

In 2007, the WHO South-East Asia and Western Pacific regions jointly developed a biregional strategic plan on dengue control and prevention, which was adopted by the regional committees of both regions. In 2011, the WHO Regional Office for South-East Asia published a revised and expanded edition of the Comprehensive Guidelines for Prevention and Control of Dengue and Dengue Haemorrhagic Fever, which is a very useful and popular publication on dengue management. In 2012, WHO headquarters developed a global strategy for dengue prevention and control for the period 2012–2020. We believe these are extremely useful guidelines from which we can build and develop national strategies and action plans specific to individual countries. I am happy to note that Maldives is moving ahead in this direction and embarking on the development of a national strategic plan, which I am confident, will be an important guiding document for all stakeholders, converging individual efforts towards a national objective.

Dengue is a complex disease, with four established serotypes of causative viruses, and an extremely versatile and efficient vector. Dengue vector dynamics are strongly influenced by environmental factors, population dynamics and climate change. Despite these challenges, dengue is a preventable disease. The solution lies in a united and sustained effort from all of us. Ministries of health alone cannot control dengue. A lot of factors that create favourable conditions for the spread of dengue and emergence of outbreaks lies beyond the scope and mandate of the health sector. Therefore, dengue control and prevention require a truly committed multisectoral engagement, with strong political support, where every partner takes full ownership and responsibility for their domain of work.

Vector control is the backbone of dengue prevention. Good environmental management, effective solid waste management and better management of water and water resources are key elements of vector control. No single approach could work on mosquitoes; and hence, an integrated vector management approach needs to be practised. Educating and empowering communities to take ownership of the mosquito control in their individual houses and communities is the cornerstone of a sustainable mosquito control programme.

As of now, there is no vaccine available to prevent dengue. However, there is optimism on vaccine development, with several candidate vaccines in various advanced stages of clinical trial. In the meantime, we must focus on strengthening dengue prevention and control efforts, more specifically, vector control. We must continue to sustain the gains made on reducing case fatality and continue educating and re-educating the doctors, nurses and health workers on clinical management of dengue cases. We need to strengthen the referral systems, ensuring timely referral of patients to appropriate levels of health care to ensure that no child dies of dengue.

Much needs to be learnt to improve our understanding of dengue epidemiology and its control. More research needs to be done to bridge the knowledge and data gap. We must strengthen the research capacity in Member States and generate more interest on research, including operational research. We must strive to find innovative and more effective tools and approaches for vector control.

Since it was first reported in 1979, Maldives has experienced sporadic outbreaks of dengue, till the disease became endemic in 2004 with a high incidence rate. Since then, every year, a large number of cases have been reported from every atoll of the country. Maldives has also made serious efforts to strengthen its disease surveillance, response and case-management capacity. Despite the many challenges, including the high turnover rate of doctors in the islands, and difficulty in retaining experience and expertise, Maldives has maintained a low case fatality-rate. However, much needs to be done, and I am confident that Maldives will build on the gains made so far. This is a country whose collective efforts and strong determination have successfully eliminated malaria, and have been sustaining that remarkable achievement – the only country in this Region having achieved this goal. We suggest your reflecting on that experience and using that expertise to eliminate yet another major public health issue in this country.

I understand this meeting will discuss most of these issues and bring the stakeholders and partners together. WHO will continue supporting this process, helping the country strengthen its capacity and be better prepared in the fight against dengue.