Leptospirosis which started as anisolated public health problem ofsome of the waterlogged areas ofAlappuzha and Kottayam districts inthe 1990 has become a public healthproblem of all districts of Keraladuring the last decade. Thiscommunicable disease is causingthe highest number of deathsconsistently for the last few years inthe state. Although it showed a littledecline during the last year,leptospirosis caused more than 100deaths every year during the past fewyears. The young male adultsespecially of the labour class gettingaffected is an area of serious concern

A broader analysis of the availablestatistics shows that the diseasem a i n l y r e p o r t e d d u r i n g t h emonsoon season is now being

reported throughout the year. Yet, the morbidity andmortality levels are high in the monsoon seasonextending from June to September.

The links of the disease with certain occupationalgroups especially of those who work in the paddy fields,pineapple farms and engage in pond and canalcleaning were observed in Kerala. During the recentyears, unused ponds utilized as dumping area of varioushousehold/public wastes were extensively cleaned aspart of the NREG scheme. There were occasions ofoutbreaks following such cleaning drives in some areas.

The presence of a wide range of rodent and non-rodentreservoir hosts along with a favorable environmentmakes most parts of Kerala vulnerable to leptospirosis.In India leptospirosis is predominant in South India. Theecological and environmental factors including heavymonsoon seasons, intermittent rains, and waterlogging create a favourable environment for the spread

Favourable ecological and environmental

scenario of Kerala

Leptospirosis:

A public health problem

Dr .C.K.JagadeesanAssistant. DHS (PH), Directorate of Health Services

which deservesspecial attention

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of leptospirosis in Kerala The waterlogged areas force the rodentpopulation to abandon theirburrows and contaminate thestagnant water by their urine.Although rats are mainly noted as thecarrier host, worldwide, other non-rodent reservoir hosts includingcattles, rabbits and other variousdomestic animals are reported as thec a r r i e r s o f t h e o r g a n i s m .Epidemiological research studies foridentifying the major carrier hostsand common mode of spread iswarranted in Kerala settings. This willenable us to design relevant andappropriate control and preventivestrategies more effectively

The preliminary analysis of theleptospirosis death cases shows thatdelay in definitive diagnosis andeffective treatment (including theadministration of Doxycycline/Crystalline Penicillin) is a cause forhigh case fatality. We hope that thesystematic training programmes ondiagnostic criteria and clinicalmanagement of leptospirosis whichalready initiated for the doctors andother staff at the state and districtlevel will help in early diagnosis andeffective case management in thecoming years. We are in the processof printing and distribution of"treatment protocol chart and thetreatment guideline based on theNCDC (NICD- Delhi)" to the districtsfor further improvement of casemanagement and reduction ofmortality.

Need for strengthening early

diagnosis and definitive

treatment

For strengthening the early diagnosis 'rapid test kit' isgetting purchased and will be made available to alldistrict/ taluk hospitals this year itself. It is proposed tomake available this kit to the major community healthcenters(CHC) in the coming years. This would facilitatethe early diagnosis of leptospirosis at the CHC level.

As a part of the IEC activities, we strengthened thegeneral awareness generation programmes on modeof spread and the control measures at the communitylevel. The strategy of special focuse to IEC andawareness campaigns among the high riskoccupational groups are yielding some good results inrecent years.

Doxycycline prophylaxis programme which started afew years back among the NREG workers, and thosewho engaged in the canal / pond cleaning andagricultural works in the affected areas is also helpingin reducing the morbidity and mortality of leptospirosis.

In the absence of a special National programme, districtpilot projects of Zoonosis division of NCDCimplemented in Kottayam and Alappuzha districts,through the infectious diseases department of Medicalcollege Kottyam. There is a scope for furtherstrengthening the implementation of this programmein these districts and expansion of the programme toother districts.

It is expected that the epidemiological study which isbeing conducted by the department through theCommunity medicine department of medical collegeTrivandrum in coordination with the Animal Husbandrydepartment would provide some insight for theeffective implementation of the control measures.

Hopefully, with the effective community levelpreventive activities and special focused prophylacticintervention along with early diagnosis and effectivecase management, it would be possible for us to reducethe morbidity and mortality due to leptospirosis in thecoming years.

Community level awareness programmes

focusing the special occupational groups

NCDC pilot project on leptospirosis

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The Pandemic Alert about H1N1was received in the State in April2009, soon after the press and Netreports about the new/ emerginginfection labeled Swine Flu,attracted Global attention. Govt.of India then alerted the states,through the Ministry of Health andFamily Welfare. A special Divisionof the MoHFW- The EMR Division(Emergency Medical Relief) wasalso activated to oversee allactivities related to the new threat.A 24 x 7 State Control Room wasset up at the Directorate of HealthServices, using space, equipmentand mobility support provided byNRHM -Surveillance, analysis, andreporting upwards, laterally, andd o w n w a r d s , l i a i s o n w i t hs u p p o r t i n g o f f i c e s , a n dcoordination between State anddistricts, as well as State and GoI,were the main functions of this

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unit headed by the State Nodal Officer-H1N1. Newreporting formats were created , for DailyConsolidated report, Death report, Media Report,Daily EMR Report, and SARI & School Surveillance

As a first step, Airport screening and surveillance wasestablished at the three international airports ofKerala, as the disease had to come through theseportals if it had to enter the state. Comprehensivestaffs including doctors, HIs/JHIs were posted on 24hr duty at these centres, equipped with PersonalProtection Equipment, and Flash Thermometers tomeasure temperature instantaneously. Thearrangements were supervised by the Directorate ofHealth Services, The District Medical Officers, DSOs,The Regional Directorate of Health Services, of theGoI. Airport Authority of India, once advised of theirgravity of the situation, offered full cooperation.Travellers found to have Influenza like illness, and atemperature of more than 1000F, were picked up, forquarantine.

District level testing, treatment, and quarantinefacilities were established immediately in thedistricts of Trivandrum, Ernakulam, Kozhikode, and

The H1N1 Pandemic in Kerala,2009-2011Control and Management-

An Interim Review

Dr. Amar. S. FettleState Nodal Officer-H1N1(Consultant Pediatrician, General Hospital, Trivandrum, and DSO, IDSP-TVM)

51

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Malappuram, at the respectiveD H / G H . T e r t i a r y c a r earrangements were established inthe Medical Colleges, both Govt.and private sector. Pr ivatecorporate hospitals also wereroped in for this venture.

Once suspect, probable andconfirmed cases started to beidentified, and managed in theState, the issue of managingcommunity spread acquired anew dimension. This ranged fromtracing, testing and treatment ofcontacts of the confirmedinternational travelers, to massives c h o o l a n d c o m m u n i t yprevention activities all associatew i t h s i g n i f i c a n t p u b l i capprehension and panic. Goodresults in this area were achievedthrough on site health education,DMO meetings with AEOs, DEOs,etc. School guidelines of MoHFWwere widely distributed to allschools, and compliance of schoolan authorities as well as guardiansensured by tight monitoring ofthe situation, and even dictates bythe respective District Collectorswhen indicated.

Initial sample testing of the throatswabs collected was done atNCDC, Delhi- Samples packed incold chain and transported toDelhi by flights from Tvm, Kochiand Kozhikkode. Cooperation ofIndian Airlines, and KingfisherAirlines, and also the AAI wasobtained after a great deal ofeffort.

Later, the lab at Centre forMolecular Diagnostics at RGCBwas made functional, under the

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initiative, leadership, and spirit of Public Service, of itsDirector, and the lab scientists The training of staffwas done at NCDC Delhi, and inspection of labconducted by a Central team, prior to certification.

Discussion was held with authorities of KMCManipal, and with the cooperation of the GoI, thiscentre too was recognized as a Virology lab fortesting Kerala's samples.

In the meantime large stocks of Oseltamivir, testingmedium (VTM), and PPE kits were airlifted to the statefrom Delhi, by the EMR Division. Suppliesmanagement of these was undertaken on a warfooting by the GMS at State Level, and the DistrictMedical Stores personnel at district level. RoHFWand NRHM too chipped in with additionalsupplements of locally procured equipment.

The Mass Media Wing of the Directorate of HealthServices took up the massive task of pushing forwardAdvocacy and IEC, release of information brochures,posters, advertisements, District specific mastercopies in order to equip all categories of health staff,as well as the general public, with the informationback-up needed to fight the pandemic.

The threat posed to the health of the state, as well asto the crores of interstate pilgrims arriving for thetwo successive Sabarimala Pilgrimage seasons, wasdealt with by a set of special initiatives- the coldseason, high influx of pilgrims coming from affectedstates, all under stressful conditions, poor attentionto personal needs like proper food, rest, etc, crowdedtravel methods, were the special issues . A massivemanagement strategy in collaboration with NRHMwas undertaken- this included facility andinfrastructure enhancement, scores of mobileequipped helpdesks, 6-language inter-state andlocal IEC and Communication strategy, dedicatedhelplines by the health dept, and also the IT Missioncall centre, and a fleet of emergency Advanced LifeSupport type ambulances on 24x7 duty.

A single spokesman approach was decided on, andscrupulously followed. This had a very positivefallout, in the form of extreme transparency,promptness, and accuracy in data dissemination to l

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the mass media. The excellentreciprocation by the electronicand print media of the state, aswell as national networks was inthe form of the very professional,calm, educative, supportive, andpro-people coverage of thepandemic in the State.

All DMO/DSO were informedabout anticipated increase inimmediate post monsoon period.The link with general ARI/ VF peakswas stressed and surge capacityreadiness was ensured. DMOswere urged not to be in false sense

Special Activity for Pandemic

Control

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of security due to fall in Jan-April period 2010.

Vaccination of health workers phase I and phase IIcampaigns were a big success in the State, achieving100% utilisation of the GoI provided 79600 doses. Ameticulous State action plan, trainings, and intensesensitization of all stakeholders resulted in thissuccess.

Special training/ sensitization of Obstetricians andalso Paediatricians through the channels of the Addl.DHS-FW, FOGSI, QPMPA, KGMOA and IAP and IMA,contributed to controlling the rise of dealt inpregnancy associated H1N1 influenza. .

Video conferencing with districts, by Health Minister,Secretary to Health, Director of Health Services, Addl.Director of Health Services (PH) on several occasionswas found to be a very effective tool. IT mission, andKeltron provided studio and technical support.

Sl Item No.

1 Passengers screened at the 3 Airports 1568432

2 Passengers reporting for advice at airport helpdesk 2658

1. 1.10 to 10.03.11 90/ (24 preg)

Monsoon Season 1. 5. 10 to 10.03.11 84/ (24 preg)

*see page no 30 & 31 for H1N1- Month Wise and District Wise data

H1 N1 Control Room Statistics As on 10.03.2011

3 Patients screened at hospitals 79593+

4 Patients quarantined in hospitals 4563+

5 Patients treated in ICUs 262+

6 Patients treated in home quarantine 35981+

7 Swabs taken for testing 10225

from Aug 09 to 10.03.11 3122

from 1.1.10 to 10.03.11 1544

8 Positives

from 1.5.10 to 10.03.11 1504

9 Deaths

1. 5. 09 to 10.03.11 121/(32preg)

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The distribution of Oseltamivir ona wide unprecedented scale rightdown to PHC level, and alsoselected private hospitals was themeasure which turned the tide,and stopped the spiking increaseof cases in the monsoon

A Central team of specialists wasinvited to Kerala by Secretary(Health). The team extensivelytoured the most affected areas,had interviews, took samples, andfinally complimented the StateHealth Department on the

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excellent and professional way in which thesituation was being managed.

State Nodal Officer-H1N1 was invited to shareKerala's experience of controlling H1N1, and itsvaccination campaign success, with representativesfrom Maharashtra Govt. as panelists in an H1N1Seminar at Nairs Hospital, Mumbai on 1/08/10.

A telephonic survey was started in Thrissur,Kozhikode and Pathanmthitta districts to assessinformation level of Medical Officers working invarious hospitals about H1N1 under the directleadership of Dr. Rakhi Vijayan, of the Control Room,and Dr. Rani.K.R of NRHM .

54

Swab testing Rate Jan-Dec (2010)

55

Acknowledgement.

No Review of H1N1 Control in Kerala State will becomplete, without placing on record in goldenletters, the acknowledgement due to variouspeople, who worked smilingly and untiringly tosupport me and enable the Health ServicesDepartment to help and save the people ofKerala.

In the H1N1 State Control Room, the 24 Hr.untiring work of my Medical Officers Dr.RakhiVijavan, Dr.Arun Sasi, Dr.Nibin Krishna, and Sri.Manoj Kumar and Sri. Amarnath (JHIs) kept theplace humming like a turbine all these months.Their cheerful exuberance in times of immensestress, and selfless dedication has been mysustaining force all these months.

We were supported from above by our ever sofriendly and boldly encouraging Hon'ble HealthMinister P K Srimathi Teacher, Secretaries SriManoj Joshi,IAS, Dr Usha Titus, IAS, Sri K.S.Srinivas,IAS, the State Mission Directors Dr Dinesh Arora,IAS, Dr. Ratan Kelkar, IAS, and Sri Saurabh Jain, IAS,Directors of Health Services, Dr K. Shylaja, DrM.K.Jeevan, and Dr K.T. Remani, Addl.Directors ofHealth Services (PH) Dr Anil Kumar KS, Dr D.Radhakrishnan, Dr PP Aravindan and Dr UmaMaheshwari Thankachi,and Addl.Director ofHealth Services( FW) Dr P.K.,Jameela, and alsoAddl Secy , Health Department, Sri Suresh Kumar.

Dr. Ravindran, Head, EMR Division, MoHFW, Delhi,Dr Shashi Khare, of NCDC, Dr Swasthi Charan,CMO, EMR Division, and Dr.Das have beenimmensely helpful and positive in guiding theefforts of the state, and providing all manner oflogistics support all the time. The RoHFW, Tvmteam has stood by us similarly, all the time.

Dr. C. K.Jadeeshan, Asst.Director of HealthServices (PH) deserves a very specialacknowledgement for being my friend,philosopher and guide, in addition to constantlyeducating me on the finer nuances ofa d m i n i s t r a t i o n a n d p r o g r a m m eimplementation.

The support of Dr.A.S.Pradeep Kumar, Dy.Director of Health Services (NVBDCP), Dr SatyajithThyagu, Dr Bipin Gopal, and Dr Shoba and Prof.Umarul Farook of the SSU-IDSP are sincerelyacknowledged. Their supporting staff, Sri K.V.SasiKumar, Sri Sanjayan Sri Asokan and Sri Rajesh, SriJ a y a n u n d e r t o o k a l o t o f a d d i t i o n a lresponsibilities at the time.

The lab support of Dr.Arun Kumar, Head VirologyDivision, MCVR Manipal, Dr Radhakrishna Pillai,Director, and the Scientists especially Dr. Sanjai,of RGCBT, Trivandrum, Dr Sunija, Head of PH Lab

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Tvm, (whose team at PH Lab Tvm developed and produced VTM forthe whole state Indigenously) was instrumental in keeping our self-competence at high levels.

The 14 District Administrations, headed by the Collectors, and thevital teams of the DMO, DSO, DPM, and the district Nodal MedicalOfficer, the doctors, nurses, the lab technicians, pharmacists,nursing assistants, and supporting hospital staff of every singleScreening centre, Testing and treatment centre, and health unitsright up to PHC level, are sincerely acknowledged as theimplementing arms of the massive efforts we initiated. Thisacknowledgement is extended whole heartedly to the entiremanagement and staff of numerous private sector Hospitals andMedical Colleges, who stood by the Health Services Department,hand in hand, to combat the H1N1 threat.

The entire team of IDSP Tvm, where this management effort for thewhole State started in April 2009- Especially Dr.N.Sridhar DistrictMedical Officer(H), Dr Meyma, District Medical Officer(H), Dr. AnilKumar, former DSO, Sri Abhayan, TA Gr- I, Sri.Abdul Kahar-DataManager, Sri Binoy-Data Entry Operator, Smt.Annie-Accountant, SriPadmarajan, Sri. Adarsh, Sri. Jayashankar, Sri. Juju and SriSubramaniam, (JHIs) put in a creditably brilliant launching effort, andthen sustained the momentum gained.

.The invaluable services of the Staff of the Mass Media Wing of theDHS-especially Sri.C.Gopakumar, Sri.T.Rajkumar, Sri.R.Austin, Sri.HariKumar.V, Smt. Shoba Ganesh, Smt. Kaladevi., Sri.S.Pushparajan andSri.Dalayi in the offices of the Director of Health Services (PH), andthe Public Health Section, The GMS, the District IDSPs, the NRHMHQ, are all acknowledged with gratitude.

The Stores Department personnel of the GMS, and especially SmtBaby S (Technical assistant to the store officer, GMS) whomaintained the constant laison with the State Control Room, are tobe commended for the vital managerial role they played in themanagement of the large stocks of Oseltamivir and logisticsthroughout the state.

The Divisional Railway Manager Sri Titus Koshy IRS, Senior DivisionalCommercial Manager, Station Managers, senior officials, andguards of the Southern Railways, and Konkan Railway, AirportManagers, Airport Medical Officers, Airline Staff of Indian andKingfisher and supporting staff provided vital help throughout thecampaign.

Though every single person in the Health Services, and MedicalColleges did their duties in H1N1 control with commitment, theState Control Room team would never have achieved “control” ofthe situation , if not for the very special role during the uncertaintension ridden early days, played by immensely supportivecolleagues / friends like Dr Sudhakaran, DMOH Ekm, Dr Sribiju andDr Sakeena,(MPLM), Dr Michael ( Kozhikkod) , Dr Abhilash, (KNR), DrAlosius, (TCR), Dr Jayakumar (KTM), Dr Laila Divakar (PTA) Dr Ajayan(WYD) Dr Gopinath, (KSR) Dr Sivasuthan (KLM) Dr Aswini Kumar, DrSibi, Dr Selvaraj, Dr Indu PS, Dr Nirmala and Dr Asok Kumar GM, of MCTvm, Dr Anoop (KIMS Hospital), and Dr Thomas Mathew(SDCMC)…

My family, as well as my colleagues in DH Peroorkada and later,General Hospital Tvm, who bore with my absence from their midstfor prolonged periods of time with the minimum of grumbling ( ! ),merit my deep indebtedness and gratitude…

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A properly collected

Properly labeled

Properly Stored and

Properly transported clinicalspecimen, which is properlyprocessed and tested

Blood and separated serum are themost common specimens taken toi n v e s t i g a t e o u t b r e a k s o fcommunicable diseases.

Venous Blood can be used forisolation and identification ofPathogen in culture.

Separated serum can be used fordetection of specific antibodies,antigens (by ELISA) and geneticmaterial (by PCR)

When specific antibodies areassayed, paired samples will bebeneficial. (Acute phase as well asconvalescent phase samples)

Finger prick sample -Slides formicroscopy and absorption to Filterpaperdices.

Follow the general biosafetymeasures (Disposable Gloves, Lab

Blood Specimen

Blood Collection

Dr. S. Sunija MD(State Public Health and Clinical Laboratory Thiruvananthapuram)

COLLECTION, STORAGE &TRANSPORTATION

OF CLINICAL SPECIMENS(for the diagnosis of communicable diseases)

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coats, masks, gown, protective eye shield etc,whenever applicable)

Disinfect the venepuncture site with 70% isopropylalchohol/10% povidone iodine. (swabbingconcentrically from centre of venepuncture site tooutwards. Do not repalpate the vein)

Collect the required quantity (2-5 ml) of blood andtransfer to the sterile collection bottles/vials.

Label the tubes with patient ID and Date of collectionusing a permanent marker pen. The same ID numbershould be noted on the Lab request form.

Keep the blood sample bottles upright andundisturbed at room temperature for 30-45 minutesto avoid haemolysis.

Blood sample can be stored at 4-80C up to 48 hrs.

Separated Serum can be stored in Screw caped vials at4-80C for 7-10 days.

If serum has to stored for weeks store at -200 freezers &for months in -700C.

Do not freeze whole blood, to avoid haemolysis.

The sample should be taken in a properly labeledscrew capped vial. Plastic tape/ sealant should beapplied around the cap to avoid leakage of specimen.

Ideally it should be transported with tripple layerpacking & cold chain maintenance.

Storage of Blood Samples

Transportation of blood sample

A proper Laboratory Diagnosis

is based on

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Lab request form with all therelevant data should be enclosed.

L a b e l t h e b o x / c o n t a i n e r( t h e r m o c o l b o x , v a c c i n ec a r r i e r / s u i t a b l e c o n t a i n e r )'Pathological sample handle withcare'

Inform the referral lab in advanceand keep a rapport with the labincharge

Stool samples are most useful formicrobiological diagnosis i fcollected soon after the onset ofdiarrhoea.

Rectal swabs may also be used incase of infants, debilitated patientsetc.

In general rectal swabs are notrecommended for isolation of virus.

As far as possible do not collectstool sample from a bed pan

Collect the voided sample in aster i le disposable containertransport to the lab with in 2-3 hrs.

In case of delay transport media likeV-R media/ Cary Blair medium,Alkaline peptone water should beused. (1-2 gm of stool specimen in10 ml of medium)

If cholera is suspected, keep thesample at room temperature till it istransported.

From infants and children rectalswabs are taken and send to the labin transport medium

Store at room temperature, ifcholera is suspected.

Collection of sample

Sample collection and

transportation

Stool sample

Keep it at 4 C if Salmonella/ Shigella is suspected.0

Respiratory tract specimen

Materials Required

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Upper respiratory-Throat & Nasopharyngeal

Lower respiratory-Usually Sputum

Transport media-bacterial and viral.

Throat swabs (Dacron and cotton swabs).

Tongue depress

Nasal speculum

20-50 ml syringe

Sterile screw-cap test tubes and wide-mouthed cleansterile containers (minimum volume 25 ml.)

Hold the tongue down with the tongue depressor.

Use a strong light source to locate areas ofinflammation and exudate. (Posterior pharynx and thetonsillar region of the throat behind the uvula) .

Rub the area back and forth with a sterile dacron swab.

Sample the posterior pharyngeal wall at the end toavoid gagging by the patient.

Collect psudo membrane if present

Withdraw the swab without touching cheeks, teeth orgums and insert into a sterile screw-cap test tubecontaining appropriate transport medium required.

Seat the patient comfortably, tilt the head back andinsert the nasal speculum.

Insert a flexible cotton swab through the speculumparallel to the floor of nose.

Alternately, bend the wire and insert it into the throatand move the swab upwards into the nasopharyngealspace.

Rotate the swab on the nasopharyngeal membrane afew times, remove it carefully and insert it into a screw-cap tube containing transport medium.

Break off the top part of the stick without touching thetube and tighten the screw cap firmly.

swab

Method of collecting throat swab

Method of collecting Nasal swab

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Label the specimen tube.

Transport the sample as quickly aspossible to reduce over growth bynormal flora.

All respiratory specimens exceptsputum are transported in viraltransport media for diagnosis ofviral infection.

For transit period upto 24 hourstransport specimen for bacterialisolation at ambient temperature atviruses at 4-8 C

Should be col lected by anexperienced Physician.

CSF is used for the diagnosis of Viral,Bacterial and fungal infections.

About 1-2 ml of CSF is collected in 3t u b e s 1 f o r c u l t u r e , 1 f o rbiochemical analysis and 1 forcytology.

H a e m o r r h a g i c C S F i s n o trecommended for Serological test.

In general send the specimen tothe laboratory and process as soonas possible.

Transport CSF specimen forB a c t e r i o l o g y a t a m b i e n ttemperature (Many of the bacteriad o n o t s u r v i v e u n d e r l o wtemperature).

CSF for virology do not needtransport media. (transport at 4-8oC

Need to be collected duringoutbreak situations when causativeagent is not known.

Handling and transportation

o

Handling and Transportation

CSF Specimen

Post mortem Specimen

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Collect the specimen preferably within 24 hours. (Viraltitre decline and bacteria over grow)

Use a separate sterile instrument for each tissuespecimen from affected sites

Place different tissues in separate sterile containerscontaining relevant medium. Fixat ive forHistopathology, Steri le Sal ine for Immunofluorescence, Transport media for Bacterial/Viral)

Blood may be collected from heart cavities.

If cerebral malaria is suspected take several smearsfrom the cerebral cortex

Fixed specimen can be stored and transported atambient temperature.

Transport tissue specimen for isolation of ViralPathogen in VTM or Sterile Saline at 4 - 8 C for 24 - 48hours. For longer periods freeze and store -70 C.

For isolation of Bacterial Pathogen transport atambient temperature in Transport media

Handling and Transportation

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59

Ever since the mosquitoes wereincriminated as the vectors of somehuman diseases, they have beenstudied in detail across the world.These studies have generatedimmense literature dealing withbiology, ecology, taxonomy etc. ofmosquitoes which constitute theintegral part of the epidemiologyand control of vector borne diseases.

Malaria and filariasis were the twomajor vector- borne diseasesprevalent in Kerala in the past. Malariawas rampant in the hills and foothillswhile filariasis was endemic in thecoastal belt and a few inland pockets.In Kerala, several investigators havecarried out tremendous studies onthe epidemiology of these diseases.Milton and Horne carried out someprel iminary invest igat ions inWayanad in1914. But, detailedscientific studies on malaria andfilariasis were done by M.O.T.Iyengarin the erstwhile Travancore in1930s.Subsequently, Covell andHarbhagvan carried out in-depthinvestigations on malaria in Wayanadin 1939.As a result of these studies the

vectors of malaria and lymphatic filariasis in Kerala couldbe incriminated. The studies done by Centre forResearch in Medical Entomology (CRME), Madurai,Tamil Nadu and Vector Control Research Centre (VCRC),Pondicherry led to the incrimination of vectors ofJapanese encephalitis, dengue fever and chikungunyain Kerala. The entomological surveys carried out by theentomology wing of the Heath Services Departmentrevealed the presence of different mosquito vectors indifferent geographical areas in the state. The surveysalso revealed the presence of some vectors which werenot reported in the past.

It is considered as the principal vector in Kerala. It ismainly prevalent in the hills and foot hills where slowmoving streams are the major breeding source. It is ahighly anthropophilic (prefering human blood)mosquito. It has caused massive epidemics of malaria inseveral areas in the past. The recent entomologicalsurvey done in Wayanad exposed the presence of thisvector.

This species was first reported from Kochi in1 9 9 2 . S u b s e q u e n t l y , i t w a s r e p o r t e d f r o m

A brief narrative of the mosquito vectors of Kerala

Anopheles fluviatilis

Anopheles stephensi

1. Malaria Vectors

Dr. T. Dilip KumarAssistant .Director (Entomology) Directorate of Health Services

Mosquito Vectorsof Keralaof Kerala

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Thiruvananthapuram,Kollam,Thrissur,Valancherry(Malappuram),Kasaragod and Thodupuzha(Idukki).Thisvector has been implicated in therecent malaria out breaks in differentareas in the state. It was found tobreed in wells, over head tanks,ground level cement tanks, roofg u t t e r , a n d s e e p a g e w a t e rcollections etc. Cattle sheds andhuman dwellings were found to bethe resting places of this species. Theman-hour density (MHD) in differentareas varied from 0.4 to 3.

It is a major vector in rural areas. It is a

Anopheles culicifacies

An.fluviatilis An.stephensi An. culicifacies An.varuna

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Apical paleband

equal to Pre-

apical dark band

Tarsomeres

without bands.

Inner costa

completely dark

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Apical & Sub-apical

pale bands equal

Foreleg tarsomeres

without broad

bands

Legs & Palpi with

speckling

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Apical pale band

equal to pre-epical

dark band

Tarsomeres

without bands.

Inner costa

interrupted

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Apical and sub apical

pale bands equal

Inner costa

completely dark

Tarsomeres without

bands

zoophilic mosquito and was mostlycollected from cattle sheds. Paddyfields, ponds, pits etc. are the favoredbreeding sites. Its MHD variedbetween 1.5 to 7.

It is a proven malaria vector in southKerala. It was collected from severaloutbreak areas along with other

Anopheles varuna

vectors. Wells, tanks, pools etc were found to supportthe breeding of this species. The adults are rarelycollected. The density of this vector was found to bevery low wherever it was collected.

Culex quinquefasciatus

It is the principal vector of bancroftian filariasis whichconstitutes more than 95% of the filarial problem inKerala. It is also one of the most predominantmosquitoes and breeds in a large number of habitats.Polluted water collections such as drains, cesspools, pitsetc are the major breeding sites. It prefers human bloodand mainly rest indoors. The density of this species,which is expressed as 10 man-hour-density, in someareas in some seasons goes beyond 200 and in such

2. Vectors of Lymphatic Filariasis

situations it causes severe biting nuisance especiallyduring night time..

These are the vectors of brugian filariasis which ispredominant in Cherthala Alappuzha region.Thesemosquitoes breed in association with certain aquaticplants such as pistia, salvinia, eichhornia etc.Of these,Mansonia annulifera is the primary vector. It prefers

Mansonia uniformis, Mansonia indiana and

Mansonia annulifera

of Kerala

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3. Vectors of Japanese

encephalitisCulex tritaeniorhynchusIt is the principal vector of Japaneseencephalitis in Kerala.It is prevalent in theentire state. The major breeding places arepaddy fields, pools, canals, pits etc. The recentsurveys have shown that this species hasadapted to breed in wells, tins and barrels inurban areas. It is predominantly a cattle biterand prefers resting outdoors among

Cx.quiquefasciatus Ma.annulifera

Proboscis with a pale ring

Hind femur pale with a narrow dark ring distally

Accessory pale patches on the ventral surface of the proboscis.

Cx. tritaeniorhynchus :

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Main Identification Characters

vegetation. The outdoor density in someareas during favorable seasons will cross 300per man-hour. From the epidemiologicalpoint of view 'Dusk Index' (DI) of the species istaken as a vital entomological parameter.

These mosquitoes have been incriminated as'bridge vector' of JE in Kuttanadu area wherethese mosquitoes are abundant.

Mansonia annulifera, Mansonia

uniformis and Mansonia indiana

human blood and is mostly collected fromhuman dwellings. The other two species arecollected mainly from cattle sheds andoutdoor vegetation.The 10 man- hour-density of Mansonia annulifera variesbetween 20and 150 inhuman dwellings.

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4. Dengue

5. Chikungunya

Dengue was reported for the firsttime in Kerala in1997.Subsequently, itspread far and wide and now it hasbecome endemic in certain areasespecially in Thruvananthapuramdistrict. Aedes aegypti and Aedesalbopictus are the vectors of dengue.The former is considered globally asthe epidemic vector while the latter isrecognized as the secondaryvector.The presence of Aedesaegypti has been noticed in a fewd i s t r i c t s n a m e l yThiruvananthapuram, Ernakulam,Kozhikode and Kannur. But, Aedesalbopictus is widely distributed in thestate.

Chikungunya appeared in Kerala in2006 and it ravaged the entire state inthe following years causing very highmorbidity among affected people.

Though Aedes aegypti is considered as the majorvector of chikungunya, in Kerala Aedes albopictus wasincriminated as the primary vector. Aedes albopictus isone of the most predominant species in Kerala and thiswas the reason why chikungunya assumed epidemicproportions within a short period of time and spreadlike a wave in the state. These species breed in a varietyof habitats ranging from a spoon-full of water in the leafaxils to large water bodies such as wells and huge tanks.Aedes aegypti shows preference to artificial watercollections such as cement tanks, bottles, fountains,tins, cans, discarded utensils, drip trays of the fridge etc.Aedes albopictus indiscriminately breeds in artificial aswell as natural sources.

The entomological indices of Aedes such as HouseIndex (HI), Breteau Index (BI) and pupal index (PI)showed marked fluctuations in different areasindifferent seasons. The indices were high duringmonsoon season and were low in summer. The resultsof a longitudinal study carried out by the entomologywing of the Health Services Department in Keraladuring pre-monsoon season in 2008 are summarizedbelow

District HI % (Range) BI (Range) PI (Range)

TVM 7.69 - 83.33 11.48 - 145.83 21.43 - 87.5

KLM 5 - 24 5 - 39 2.7 - 41.7

PTA 15 - 55 20 - 91.3 15 - 155

ALP 21.95 - 44.83 31.82 - 82.76 33.33 - 109.09

KTM 30 - 56.25 40 - 90.63 16.1 - 118.2

IDK 0 - 50 0 - 73.08 21.6 - 107.7

EKM 30.95 - 59.46 50 - 248.15 17.07 - 109.52

TSR 5.56 - 58.06 10.87 - 147.83 28.95 - 143.48

PKD 31.25 - 88.8 31.25 - 131.8 9.7 - 29.7

MPM 9 - 50 10 - 115.25 11.6 - 24.5

KKD 5.56 - 60 11.11 - 104.55 20.59 - 89.47

WYD 5 - 20 5 - 22 13.3 - 16.7

KNR 0 - 13 0 - 28 16 - 26.5

KSGD 6.67 - 47.37 10 - 142.86 25 - 121.74

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Outbreak investigation and timelyreporting is one of the importantactivities carried out by the IDSP inthe state. State Surveillance Unit oft h e I D S P r e c e i v e s D i s e a s ealerts/outbreak reports from 14districts on weekly basis. Even nilweekly reporting is mandated and

Table showing number of disease alerts/outbreaks reported in 2010

Disease No of Outbreaks % among total outbreaks

Malaria 5 6

Dengue 9 12

Chikungunya 1 1

ADD 6 8

Typhoid 4 5

Hep-A 18 23

Chickenpox 8 10

Dysentry 1 1

Measles 2 3

Rubella 1 1

Lepto 2 3

Hep-B 1 1

Hooch Tragedy 1 1

Food Poison 18 23

Prof. Umarul Farook MState Entomologist, SSU, IDSP.

Outbreak Investigation

response&the compilation of disease outbreaks/alerts is beingdone in the SSU on weekly basis for sharing with theCentral Surveillance Unit (CSU) Delhi and otherstakeholders and programme officers coming underthe Directorate of Health Services.

During the year 2010 a total of 77 outbreaks have beendetected by the District Surveillance Units and reportedto the SSU/CSU as shown in the table below.

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From the table it is seen that a total of77 outbreaks consisting foodpoisoning (23%), Hepatitis A (23%),Dengue (12%), Chickenpox (10%),ADD (8%), Malaria (6%), Typhoid (5%),Lepto (3%), Measles (3%), CG (1%) etcwere detected by 14 DSUs during2010. It is also seen that out of thetotal outbreaks reported, vectorborne diseases constitute 19 Percent,w h i l e w a t e r b o r n e d i s e a s e scontribute 37 per cent.

There is an approved format forreporting the disease alert/outbreakto the higher levels in IDSP. Wheneach outbreak is reported many vitalinformation about the outbreak areto be provided by the reporting unitin the reporting format. One of theinformation is about the outbreakaffected area, such as Name ofaffected area, PHC, Block, Sub center,Village & Panchayath. Date of start ofoutbreak and date of reporting toSSU/CSU is also important. Anothermost important information to bep r o v i d e d i s a b o u t t h eepidemiological observations andnecessary investigations about theo u t b r e a k . R e g a r d i n g t h einvestigation and epidemiologicalobservation usually the informationprovided by the reporting units areseen incomplete or blank.

Each and every outbreak should beinvestigated to ascertain its etiologyand understand why they occurredas well as to identify high risk areasand groups.

Reporting an outbreak

Outbreak Investigation

The purpose of an investigation is

To verify the outbreak

To recognize the magnitude and spread of theoutbreak.

To identify the etiological agent, the source and rootof transmission as well as the people at risk.

To recommend measures so that the outbreak canbe controlled as well as prevented in the future.

At the PHC and CHC level the Medical Officer in Chargewill be the nodal officer who will be responsible torespond to an outbreak. At the district level District RRTwill have the primary responsibility to investigate

The RRT is a multi faceted team that looks in to thevarious aspects of an outbreak. It should have minimumcomposition of three members namely, anEpidemiologist, a Clinician and a Microbiologist. Themain role of the RRT will be to investigate and confirmoutbreak. It is to be noted that the RRT is not apermanent team waiting for an outbreak. They areindividuals who are normally performing their usualroles, but in the event of an outbreak they cometogether to undertake a special function. They shouldwork in close coordination with the local health staff inthe event of an outbreak. While they will help andsupport the local staff in the management and controlof the outbreak the prime responsibility forimplementing the control measures rest with the localhealth staff.

Spot Maps are the integral part of an outbreakinvestigation. Preparing a spot map will help theinvestigator to locate exactly the cases and also tounderstand the geographical distribution of the cases.A spot map prepared in connection with theindigenous Malaria outbreak at Thriuvananthapuramdistrict during 2010 is shown below.

suspected/ impending/ actual outbreaks.

Rapid Response Team (RRT)

Spot Maps

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Indigenous Malaria Cases at Valiyathura & Poovar 2010SPOT MAP of

Role of RRT Members

Epidemiologist:

Clinician:

The epidemiologist

plays a crucial role in the epidemicinvestigation She/he will carry out ad e t a i l e d e p i d e m i o l o g i c a linvestigation that will look in to theepidemiological and environmentalaspects of the outbreak. The basica i m o f t h e e p i d e m i o l o g i c a linvestigation is to identify the sourceof the problems and the routes oftransmission. For this epidemiologistmay ask for further tests like wateranalysis/entomological survey etc.

Clinician is expected to do

medical investigation. Clinician may

be a physician/pediatrician and will clinically examinethe available cases (in the hospital or the community)and make a clinical diagnosis. Clinician will identify thepossible source, route of transmission and contacts andalso will review the case management.

He is expected to do the laboratory

investigation. Laboratory help should be utilized inestablishing the diagnosis of early cases only. Once thecause of the outbreak is confirmed, laboratory supportshould not be wasted for each and every case. Themicrobiologist will advice on what samples arerequired, mode of collection and method oftransportation and also to which lab samples are also tobe sent.

In the case of vector borne disease

Microbiologist:

Entomologist:

It is not necessary to collect specimens from all

cases, just enough to confirm the diagnosis.

Spot Map Prepared by: District Malaria Officer, tvpm.

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Report preparation

Preliminary report:

Daily Situation updates:

The Medical

Officer in charge of PHC/CHC whofirst reports the outbreak shouldsubmit a preliminary report to theDSO as early as possible. The reportshould cover briefly about how theoutbreak came to his attention,verification of the outbreak, totalnumber of affected cases/deaths,t ime, person, place, analysis ,management of the patients, likelysuspected source, immediatecontrol measures implemented etc.

During the

period of the outbreak the nodal MOshould continue to give dailysituation updates of the outbreak tothe DSO. The DSO should transmitthe information to the SSO. Thisshould continue even when the RRT

has started its investigation and should include the linelist of new cases, lab results received, any new findings,any containment measures taken etc. This daily reportshould continue till the end of the outbreak (i.e nosuspected cases during a period which is double theincubation period of the identified disease)

The RRT will submit an interim

report within one week of starting their investigation.The report should cover the verification of the outbreak,total number of affected cases/deaths with line lists,

Interim report by RRT:

Aracanut Soaking pot Aracanut leaf Rock pool Bamboo stump Dish Antenna

o u t b r e a k s , e n t o m o l o g i c a li n v e s t i g a t i o n i s m a n d a t o r y .Entomological investigation is carriedout to incriminate the vector species,to identify the breeding places andalso to assess the vector density at thetime of outbreak. Some of thebreeding sites identified in Thrissurand Palakkad districts in connectionwith the dengue outbreak in 2010 isgiven below.

time, person, place analysis, management of thepatients, likely suspected source, immediate controlmeasures implemented etc. Along with these thereport of the physicians, microbiologist andentomologist (where applicable), the lab resultsreceived during the period should be attachedEnvironmental factors responsible for the outbreakshould also be mentioned in the report.

Within ten days after the outbreak has

ceased, a final outbreak investigation report must besubmitted by the local health authorities. This reportmust be comprehensive and give a complete picture ofthe multifactorial causes of the outbreak, theprecipitating factors, the evolution of the epidemic,descriptions of the persons affected, time trends, areasaffected and directions of the spread of the epidemics.It should have complete details of the lab resultsincluding regional lab. Feedback: It is important thatfeedback from the report is shared with all the relevantstake holders.

Final report:

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An outbreak of Crimean CongoHemorrhagic Fever (CCHF) occurred ina private hospital in Gujarat on the firstday of January 2011. It is a major hospitalin that region and caters to patients allover the world. Approximately 30malayalies work in this hospital asnurses.

One female patient was admitted withfever, vomiting, stomach ache and jointpains on 30 Dec 2010 in the aboveh o s p i t a l . S h e l a t e r d e v e l o p e dhemorrhagic symptoms. She wastreated in the MICU. Dialysis was alsodone. She died on 3 Jan 2011. Thedoctor who treated the above patientgot sick with the same symptoms later.He was initially treated in anotherhospital in Ahmedabad.Later he was transferred tohis own hospital just beforedeath. He died on 13 Jan2011. ( The doctor hadintubated the first patient)One nurse who was involvedin the care of the first patientdeveloped fever on 10 Jan2011 and was admitted tothe same hospital on 13 Jan2 0 1 1 . H e r c o n d i t i o nworsened on 15 Jan 2011.Doctors informed the family

th

rd

th

th

th

th

Crimean Congo Haemorrhagic Fever (CCHF):

An inter-stateemergencyDr. Iype JosephAssistant Surgeon, CHC Pathanapuram

DistrictRisk Level

TotalLow High

of the unknown nature of the sickness and asked them toinform other relatives. Samples were sent to NationalInstitute of Virology (NIV), Pune for investigation. On 18 Jan2011, the nurse died with hemorrhagic symptoms.Diagnosis was known only on the day of death. Few nursesfrom Kerala were directly involved in the care of the firstpatient but many nurses from Kerala were directly involvedin the care of the last patient.

So the last possible point of transmission of CCHF was 18Jan 2011 (early morning).

In the ensuing panic, a number of nurses returned to Keralaby train. Dr. Paresh Dave, Additional Director of HealthServices, Gujarat after enquiry with the management of theprivate hospital made available a list of nurses who stoppedreporting to duty after the outbreak. Efforts were madethrough the surveillance system under the AdditionalDirector of Health Services (Public Health) to track thenurses who have already returned and who were in the

th

th

Note: Risk level High: was involved in the direct clinical care of any of the three patients.

Risk level Low: Never saw the patients but shared the hostels and train with the high risk persons.

Ernakulam 3 3 6

Kottayam 4 3 7

Idukki 2 1 3

Palakkad 1 0 1

Pathanamthitta 1 0 1

Returned to Gujarat 4 4

Removed from tracking as incubation period is over 1 1

Total 23

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different trains to Kerala. Many were trackedwith the help of other returnees. Out of 23persons, all have been tracked, 4 of whom havereturned to Gujarat. One person was outsidethe incubation period and was not followed-up.

On 24 Jan 2011, 4 persons complained ofmild influenza like features. The symptomsdecreased in the following days and mosthave almost become asymptomatic by 27Jan 2011. No-body had been started onRibavarin. Adequate drugs were stocked inthe godown of the manufacturer.

Blood for investigation at NIV, Pune wascollected on 27.1.11. It was collected withfull protection for the staff and packed in 3layers. Mr. Anoop, Microbiologist (IDSPEranakulam) transported the blood samplesto NIV, Pune. Many of the persons underfollow-up had tested their blood in differentlabs on their own and as per doctors' advice.Even after repeated requests and officialcommunication to DMOs, this practice wascontinued. So, in case if any one of thesepeople was positive, then, the concernedlabs had to be taken up for surveillance.Results of the blood investigations showedthat all persons were negative. It wasinstructed that all high risk persons to stay athome till 20 days are over as an addedprecaution.

Thus the threat of CCHF ended for the timebeing.

This experience helped us to learn someimportant things . They were , theimportance of “universal precautions” inhealth care settings, the benefit ofinvestigating unusual cases to the greatestpossible extent, the need for interstatecooperation for interstate problems, thepossible rapid importation of diseases fromfar and wide and the need for reducingunnecessary investigations.

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