Tackling dengue in Pakistan: an Infectious Thoughts interview

Dengue infections are soaring to record highs this month in Pakistan, a country used to frequent and severe dengue outbreaks, as numbers reach nearly 50,000 recorded cases and 80 deaths so far. In this Infectious Thoughts interview, Kamran Rafiq from the ISNTD speaks with Dr. Somia Iqtadar, Chairperson of the Dengue Expert Advisory Group, and Pr. Muhammad Ali Khan, Secretary of the Dengue Expert Advisory Group (DEAG), about the dengue burden in Pakistan, and the partnerships between the government, healthcare providers and the public to ensure the prioritisation of dengue awareness and prevention in this endemic country. As well as working in the field of dengue with their roles within the DEAG, Dr. Iqtadar is Associate Professor of Medicine at the King Edward Medical University, in Lahore, Pakistan, and part of many medical advisory boards as well as designated as Master Trainer of Dengue Infection for WHO and the Government of Punjab. Pr. Muhammad Ali Khan is ex-Head of Department of Pediatrics at SIMS/Services Hospital Lahore, Pakistan.

Kamran Rafiq (KR): You are currently steering the Dengue Expert Advisory Group, could you give a brief overview of this DEAG?

Dr. Somia Iqtadar (SI): The Dengue Expert Advisory Group (DEAG) is primarily concerned with the clinical management of dengue. It is comprised of a group of clinicians who work to develop treatment protocols and guidelines for healthcare professionals (HCPs), as well as give strategic advice to the provincial government of Punjab, Pakistan, on how to improve the dengue control programme.

In terms of structure, DEAG office bearers include a Chairperson, Secretary and an Assistant Secretary. Members are senior clinicians designated as Dengue Focal Persons from the teaching hospitals of Punjab, which are mainly centred in the capital of Punjab, Lahore, and eleven divisional DEAG setups. Co-opted members are representatives from Specialized Health Departments, Addl. Director General EP&C, the Chairman of the Punjab Healthcare Commission, Entomologists to the Government, and the Dean of the Institute of Public Health.

KR: Given the exposure to dengue that Pakistan has had - I’m referring to the massive outbreak in 2011 and moving forward to the situation now - what are some of the recommendations that you are putting forward?

SI : Some of the recommendations we have made are to assess the updates that are happening on a global basis and then to put forward how we can incorporate these into our Pakistani set up. We also advise on the prevention mechanisms, the patient load (ie. where is the area that patient cases originate from so that we can trace back to the disease hotspot), and also the disease trends and its demographic profile.

These recommendations are discussed in our DEAG meetings and carried forward to cabinet meetings. These cabinet meetings between the DEAG and stakeholders from the government are actually held weekly and headed up by the Minister of Health. In the dengue season (monsoon period), this is done weekly. The peak dengue months in Pakistan are August to October, in which we see a maximum number of dengue cases. In other months, the numbers of cases are sporadic and these meetings are held fortnightly or monthly.

KR: May I ask you - in your opinion how successful has this approach been?

SI: In my opinion, it's been very successful. If you recall, in 2011, we had the largest dengue outbreak reported in the world: there were 600,000 suspected cases and 22,000 lab confirmed cases and unfortunately we lost 375 people to dengue. This was a huge number of patients and we were not prepared for this 2011 outbreak - this was basically the first experience for our doctors regarding dengue and how to treat this kind of epidemic.

I am glad to say that we have learned from this experience and have had many collaborations and help from international experts. As an example, we've had support from Sri Lanka, Malaysia and Thailand to evolve and refine our guidelines.

Our first set of guidelines came out in 2012 in the name of good clinical practice and then as a result, in the subsequent years, we had very low mortality rates as our treatment algorithm was further disseminated throughout the Punjab province. We deal s