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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.

There are four serotypes of dengue, have you had people coming back with a second infection?

SBP: Unfortunately nobody here is doing serotyping. They do rapid diagnostic testing using a kit but I feel we need PCR testing, even just to find out which serotypes are circulating here. It’s important to find out as next year another serotype may be introduced in Kathmandu, and healthcare workers need to be alert to that. Unofficially I’ve heard that we have serotype 2 in Kathmandu, but this has not been officially announced. According to the literature this is more severe than the other types. I’m still sceptical because I need further information. But it’s certainly spreading very easily.

So it sounds as if people in local communities do not know about vector control and prevention of infection.

SBP: They don’t know about the disease so they certainly don’t know about prevention. That’s why whenever they come to me for treatment I ask them to take preventive measures as well. This is one of my objectives. I’ve been doing this since May. Before Dashain [major Nepal festival] there was a lot of media coverage about dengue but since then it’s been quieter. But when I ask the laboratory staff how many positive confirmed cases there are they say on average 50 or 60 every day. This is a big epidemic for Kathmandu, the first time.

And these are just the people who present to hospital – there are probably other people who are infected with dengue and stay at home and so don’t contribute to the data.

SBP: That’s true, and now we have the cough and cold season, so people come in with a cold but when we examine them they’re actually suffering from dengue. In 8 to 10 days most people recover – on the fifth or sixth day after symptom onset they begin to itch, they have a rash. And nowadays people are presenting with red eyes too – I didn’t observe this in the time before Dashain so I don’t know why this is happening now. Someone from the media called me yesterday about this and asked me if this could be Zika. I can’t say right now, but I also can’t exclude it.

That was one of the other questions I was going to ask you, as the same species of mosquito carries dengue and Zika, could there be Zika in Kathmandu?

SBP: That is possible but unless we get tested we cannot say. But since I read that in India Zika is present, there is probably a high risk that it will come to Nepal. The Aedes species carries both viruses but without research we don’t know if it is already here. In the Terai [lowland plains] area there are a lot of mosquitoes, so that is high risk. I am not involved in this research but I’m sure that someday soon someone will publish something about this.

Is the government doing enough to inform people? Are they giving you enough support? Are they asking for your advice?

SBP: They accept that they didn’t do enough at the beginning of the dengue outbreak. They didn’t do sufficient to try and control dengue. They even said this in the media, although they tried their best. As I said, the different levels of government pointed the finger at the others. They were confusing each other about who should act, where to send money and skilled people. We can do lots of things against dengue virus but we did not do these things. We need some kind of strategic plan for the next outbreak, and these three levels of government need to work together and make a plan, not only for dengue but also for other possible threats. They need to plan taking into account the culture and the infrastructure: India is different, Pakistan is different, Bangladesh is different.

We need to think about the culture. I’ve had people coming to me saying that their house is very clean but mosquitoes are coming from their neighbour’s well so what can they do? These are all practical problems that we need to consider. For a long time we’ve had a chronic water shortage in Kathmandu so people bring water from outside and then mosquitoes use that water to breed. People know that mosquitoes use the buckets to breed but what can they do. So we need intersectoral communication: water department, road construction etc. The Ministry of Health should co-ordinate with other sectors as well to plan a strategy.

What do you think about the ISNTD initiative to have a designated World Dengue Day, to help raise awareness everywhere, not just in South Asia?

SBP: This is very important. When I saw dengue for the first time in 2004 in Nepal, a single dengue case was detected at that time. In 2006 there were some pockets of infection. In 2010 for the first time there was a big outbreak. And then after that almost every year somewhere in Nepal there has been at least a small outbreak. Aedes mosquitoes are present in almost 60 to 70% of the country’s area. So that means that apart from the highest mountain areas the rest of Nepal, hilly and Terai areas, are at high risk. But probably one day the mosquitoes will reach into the high mountains too. There are many examples of tropical diseases that used to be present in the Terai area but are now in the mountains too. One good example is visceral leishmaniasis. Dengue is a very important disease now, and globally too I think. It spreads very rapidly, and one major cause I think is climate change. So this is one huge issue and so we must support this World Dengue Day.

Now of course it’s coming to the top of the agenda because it’s coming to the US and Europe, so it’s not just affecting people in LMIC anymore…

SBP: It’s very important. We must know about dengue and we must fight against it.

If you were the Prime Minister of Nepal what one policy or activity would you put in place?

SBP: Information or education. That is the most important thing. People think if they clean their room or they don’t collect water then they are safe from dengue. That is wrong. If you go 100 metres for shopping you might be bitten by a mosquito. We need to bring this awareness into primary schools as well, they can learn about dengue, start young. If they know this is dangerous they will be motivated.

Maybe we need an army of school children here in Nepal who can go home and educate their parents and their grandparents about dengue.

SBP: Yes, we need this kind of thing – this is a very good example. If we educate people about dengue then people won’t be so afraid. One guy waited at the hospital gate as his brother came in to find his test results. He was so scared of finding out that he had dengue. There are many stories of people being bitten and immediately assuming they have dengue and coming for admittance to the hospital.

There are two things: people don’t know anything about it, or they know the wrong thing about it, so they start panicking.

SBP: Yes, this is why we need lots of education and awareness.

Have any of your colleagues at the hospital contracted dengue?

SBP: Yes, some of the senior doctors have had it. Maybe half a dozen of the staff. Fortunately I haven’t. But I am now number 1 most wanted for the mosquitoes – there is probably a mosquito taskforce coming to get me because I am continually fighting against dengue. This outbreak has surprised me, it’s lasted such a long time. I thought maybe 4 or 6 weeks, or 2 months, but it’s been going since May. I have never seen it like this. Usually post-monsoon the number of cases reduces.

And finally, is the dengue outbreak taking resources away from other things that you should be working on? You’re having to spend so much of your time dealing with dengue cases.

SBP: Yes of course, almost all of my time I’m spending focused on dengue. People need to understand that they should not panic, that it will not kill them. There are so many myths and misunderstandings about dengue. The main thing is, they do not know what dengue is. Education is SO important for our country. Probably it will help people realise that we need to unite to do something against dengue. I will never tire of seeing people and writing things against these diseases, speaking to the media, I will keep trying my best.


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