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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 specifically with the Punjab province and so we have trained here about 25,000 doctors and nurses in last 8 years. Also, we run a training session province-wide every month and run a refresher course for doctors at every level starting from junior doctors up to consultant level, general practitioners and including the paramedical staff. We train, evaluate and then certify and what we’ve seen is that, over the years since 2011, we have reported a much improved disease management protocol being followed in all the hospitals, not only in the public sector but also the private sector. This has been reflected in the fact that the mortality has gone down considerably: the mortality rate we currently have is less than 1 percent, and keeping the mortality rate to less than 1 percent is our goal.

KR: What do you think is triggering the outbreak? For example, is it a vector control issue, is it climate change, etc. ?

Pr. Muhammad Ali Khan (MAK): Well, firstly we are in an endemic region for dengue and plenty of mosquito eggs are available in the environment. When the environmental conditions are conducive, these mosquito eggs will hatch into larvae and every year we are seeing larger epidemics - so the tropical weather cycle here in Asia certainly plays a part. We’ve seen that the bulk of cases seem to happen between temperatures of 18 and 40 degrees; once it's below 18 degrees, the case numbers drop. Here in Lahore, as an example, we have a temperature range over the year from below zero degrees to above 40 degrees, so dengue is only really happening in that part of the year when temperatures are between 18 and 40 degrees.

SI: As you know, there is a current global surge in dengue, and especially so in the Asian region. We're wondering, maybe there is a serotype switch whereby a small mutation in the virus is causing this. More studies need to happen to explore this, but we are certainly seeing an increase in Dengue Hemorrhagic Fever patients this year compared to previous years.

MAK: What we have seen is that in the 2011 Lahore outbreak we only had the serotype DENV2 whilst at present we have all four serotypes, which means that there is no natural immunity which in turn means that no one is safe from infection and everybody is at risk. Given the high chances of a seropositive population in this region, the next infection with another serotype increases the chances of patients going into Dengue Hemorrhagic Fever and this is exactly what we are seeing. Dengue is here to stay with us here, as well as in the wider Asian region. We are talking about millions of eggs in the soil in these regions .

KR: Given these circumstances as well the fact that there is no vaccine available in Pakistan, where do you think the pendulum is going to swing to, i.e. who do you need to engage with to combat dengue?

SI: We have been holding seminars for the general public to build up community awareness. In parallel, we have also been developing the communication and training skills of the healthcare providers so that they can further share education on dengue in schools and colleges. In fact, we are planning next year’s government-backed dengue control programme and in that we have put forward a segment on media, communication and awareness campaigns.

This would fall under the Director General for Health Services as this is very much both a medical but also a social problem and so together we are designing this public campaign. We feel that it's at a household level that this should be addressed, and we want to include community engagement, awareness around preventative measures, helping communities to recognise which mosquitoes are responsible for dengue, breeding sites and ultimately what they as the public have to do. The government has set up a helpline which allows the public to register a dengue complaint and also get information from this helpline. We’ve set up a team of doctors which is then disseminating correct information to the public, including about dengue symptoms, where they need to go and what do they have to do in case of suspected infection, which test is available, warnings signs also importantly address and debunk the myths around dengue (papaya leaf extract, as an example, is not an effective cure).

Importantly, we have developed an animation-based communication around these issues on our website, which is available at this link:

Finally, we wanted to mention that we hold awareness symposia for private and public hospitals, schools and colleges to engage the younger generation. We feel that they are a very important asset in terms of driving momentum in this fight.

KR: From a structural perspective does the DEAG have vector control specialists?

MAK: We are rooted in clinical management, however we have many collaborations with entomologists, vector control specialists and epidemiologists who are co-opted members of the DEAG. We have them as trusted advisors and we have repeatedly advised the government that in order to beat dengue we need to use prevention approaches not by clinical management alone.

The first step is public awareness: we have to educate the people about how communities are going to live with dengue as it is here to stay. I’ve personally been to Sri Lanka, Malaysia, Thailand and Singapore where I've found the public to be much more aware. So we have to work to bring our communities to the same level of awareness.

A major factor to us is the reduction of water sources to remove any possible mosquito breeding sites. That is only possible when the public is aware, involved and takes responsibility.

KR: In the above discussion, you are describing a paradigm of empowerment, involvement and sustainability– we’ve covered the first 2 points in terms of empowering and involving the community - in terms of sustainability, what kind of ideas are you working on?

SI –For us here, sustainability has to involve behaviour change which has to be inculcated over time. Over the years, the population has been given a lot of information around the disease - with so many people affected in the 2011 outbreak, we had a situation whereby each hospital in Lahore was seeing 5,000 patients a day at one point which really induced a sense of panic. Our information and awareness programmes really helped to abate this panic and fear.

MAK: Education and involvement will not be possible without the engagement of the people themselves; the government working alone cannot do anything. There seems to be 2 ways to induce community engagement and behaviour change, these are: motivation and fear. In 2011, I’d say that the fear amongst the public was palatable and became the biggest driver which translated in the people adopting source reduction approaches. As we have become more accustomed to living with dengue, the fear factor has gradually dropped and so now we are trying to motivating the public so that they continue with their good habits in terms of prevention. Source reduction costs nothing to the public, and so people have to learn how to deal with these issues by inculcating good habits.

KR: How can we make this approach less prescriptive? Is there a role for technology to drive the sustainability element, perhaps something like an app?

SI - That is exactly the approach which we have taken for the purpose of dengue surveillance and reporting. We have developed with the Punjab Information Technology Board an app and also an entire dashboard attached to this app. All of the dengue surveillance is done through this app. Some further information is contained in the figure below.

KR: What are your thoughts about our World Dengue Day petition and effort?

SI: I had already started this campaign on social media in 2013 - if there is a world day for TB, malaria and other infectious diseases, why not for dengue? A World Dengue Day will really help to strengthen the message and bring in an international community feel! We do already celebrate our Dengue Days and Dengue Weeks throughout the epidemic season but we feel that this can be amplified to a World Day and is an important initiative. We are 100 percent behind this – we can use this to not only focus the technical effort but to also include the wider public.


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