Unprecedented dengue in Nepal: Myths & Misunderstandings

Since August this year, over 9,000 people from 65 of Nepal’s 77 districts have been diagnosed with dengue, including six patients who have died, in an unprecedented outbreak of the disease. High altitudes are thought to have precluded the Aedes mosquito from becoming established in Nepal and surrounding regions, but some believe that climate change may be to blame for changes in environment which enabled a recent dengue outbreak.

Dr. Sher Bahadur Pun is a senior infectious disease clinician at Sukraraj Tropical and Infectious Disease Hospital in Kathmandu, Nepal. He is responsible for diagnosing and treating the many people who have come into the hospital with suspected dengue during the current unprecedented outbreak in Kathmandu. Visiting him is Anna Durrance-Bagale, a research assistant and tutor at the London School of Hygiene and Tropical Medicine in the UK, working on applied communicable disease control, with a focus on zoonotic disease. In this Infectious Thoughts interview, Anna Durrance-Bagale asks Dr. Pun about the burden of dengue in Nepal, public perceptions about this infection and urgent community engagement efforts needed to improve the understanding and prevention of dengue given recent outbreaks in Nepal.

What is the dengue situation in Kathmandu like now?

Dr. Sher Bahadur Pun (SBP): Dengue started sometime in late May 2019, in Dharan [eastern lowland Nepal], and people thought that dengue would be restricted only to Dharan, but at the same time I was thinking that it is likely to spread to other parts of the country because in Kathmandu I’d seen a lot of mosquito larvae in water containers. So I began to write articles, trying to convince policymakers that something needed to be done. But nobody listened at that time. But then dengue spread to Hetauda, much closer to Kathmandu. So I tried again to share my concern about dengue: if it spread to Kathmandu the situation would be different to that in other places. Kathmandu is over-populated and rapidly urbanising, and the current construction boom is making it even more congested.

This is the first time that we faced such a situation, of dengue spreading into Kathmandu, so we did not have an idea about how to control the spread – this is a big problem for the Kathmandu valley. People residing in the valley don’t know anything about dengue – this was a BIG surprise for me. Even after infection with dengue people would ask: ‘can I eat with them, can I sit with them?’ and I have a lot of examples of couples, husbands and wives, sleeping in separate rooms. The husband has been infected with dengue and, with a smile on their face, he says ‘you know doctor, now we are spending time in different rooms in the same house and the baby is in another room’. They thought it would easily spread person-to-person.

That was a big surprise so I began to explain to policymakers that Kathmanduites really don’t know about dengue. The first report of dengue in Kathmandu was published in 2004, but even before that people were suspicious about dengue, because the virus was present in India so it wouldn’t have been a big thing for it to spread to neighbouring Nepal.

One thing I wanted to know, and you’ve already partly answered, is that when people come to you do they know much about dengue?

SBP: No they don’t – many people have never even heard of dengue. This is surprising because over the last year dengue has been occurring in the southern parts of the country and every year for the last few years the government has run some activities to promote awareness about dengue. In Kathmandu many people are educated, so my understanding was that, as they watch television and listen to the radio they would know, but in fact I was wrong.

What has the government been doing to raise awareness of dengue?

SBP: Soon after the government realised that dengue was spreading in Kathmandu there was something on television about the fact that mosquitoes breed in standing water but there was no aggressive campaign. They are still informing people but not much has been done so far. Whenever the media asks politicians why they didn’t do this or that, they point at each other. The federal government points at the provincial government, the provincial government points at the local government: ‘we already gave the money so they have to do!’ and ‘we don’t have the manpower, the skilled people, so what to do’.

Dengue is present in many places now so let’s see this as an opportunity, find out what we lack. If there is a lack of co-ordination let’s try to minimise that gap. There are opportunities as well as challenges. Maybe next year this will happen again. Somebody with dengue, even today, was saying to me ‘doctor, this outbreak is so big this year, but next year the same thing will happen again, what can we do, we are scared now’. But how can we sensitise the government? I think we have to do these things otherwise in the next couple of years we might have an outbreak of severe dengue. Most people have only been infected once, so next time if they get infected with another serotype, it can become a severe form.