Napoleon Hill once said, “Most great people have attained their greatest success just one step beyond their greatest failure.”
It’s time for all of us to convert our biggest failure of controlling the mosquito menace into success.
We must all agree that collectively we have failed in controlling the mosquito menace and consequently, Delhi today is in the midst of an epidemic of Chikungunya with increasing numbers of dengue and malaria patients. This is a collective failure of Municipal Corporation, Delhi Government, Central Government, LG office, Medical Associations, CSR departments, Media, NGOs and Private sector.
As per the current picture, the mosquito container index (the percentage of water-holding containers infested with larvae or pupae) in Delhi is over 40% and any index above 5% requires a community integrated cluster approach to reduce mosquito density together with effective anti-larval measures.
But even today, 3 lakh mosquito repellent impregnated mosquito nets received by MCD as donations are not available to patients. Anti-larval measures, Temephos an organophosphate larvicide and/or mosquito fish or Gambusia, a freshwater fish are not available to a common man.
What is the answer then?
We need a paradigm shift in our thinking. We need to over report and act in time. There is no point acting when the cases have started. Often the civic bodies publically act in monsoon season. They may be planning ahead but public awareness and public involvement must start much ahead of time. Even the recent CAG report mentions that under reporting of dengue is disastrous to the society.
We need to act against all the mosquitos, Aedes, Culex and Anopheles. Action against only the Aedes mosquito will not work.
The campaign that Aedes mosquito is a day biter and only breeds in indoor fresh water will not work. Even if it is true, by killing Aedes you may end up in increasing the density of Culex and malaria causing Anopheles mosquitoes. Culex mosquito, which causes filarial and Japanese encephalitis is already rampant in the city.
Even Aedes mosquito, which causes Chikungunya, West Nile, Zika and Dengue can spread by the bite of infected female indoor Aedes aegypti or outdoor Aedes albopictus mosquito.
It is true that Aedes aegypti are more dangerous because they can fly up to 200 meters and only feed on human blood, whereas the Aedes albopictus that thrives outdoors can only fly as far as 80 meters and feed on animal blood other than human blood. The outdoor Aedes mosquito cannot be ignored. .
The entire campaign up till now has been focused on a day biter, wearing long sleeves shirt and pants during the day and using night mosquito nets. But precautions needs to be taken throughout the day as the mosquitoes only recognize the light and not whether it is day or night.
The fact that the mosquito only breeds in clear water also needs to be relearnt. The Aedes mosquito breeds in stagnant water anywhere inside or outside the house. Rain water is the most important source and can collect in any plastic container inside or outside the house. Even collected garbage in open areas can have left over plastic cups or tiny bottle caps with collected rain water collections providing an ideal atmosphere for mosquito breeding.
It is true that disease spreading mosquitos do not make noise but the ‘noise-producing’ nuisance mosquitos unless addressed will not create a public movement.
The law says that dengue or Chikungunya cases must be notified, but one can notify them within 7 days of diagnosis. Aedes mosquito takes up to three meals in a day and within 7 days will bite over 21 people in the vicinity. Municipal anti-mosquito and anti-larval actions must occur within hours of its detection. The very purpose of notification is lost if the disease is not notified within hours of even suspecting a diagnosis of Chikungunya. So, all suspected cases must be reported without waiting to confirm the diagnosis.
We have failed because the government has been insisting that only ELISA-confirmed cases be notified. An SMS should be sent to all doctors practicing in that PIN code areas with a case so that they can become a part of the public health action chain.
When the first case is suspected in a state, colony or house, all public health measure should start. An SMS should go to local councilor, MLA, MPs, all practicing doctors, local chemists, NGOs, RWAs, local IMA Branch, State IMA Branch, IMA Headquarters and other Specialty Organizations to join the public health chain efforts.
It has taken over a decade for us doctors to understand that dengue 1 and 3 strains are not dangerous and cause only platelet deficiency with thinning of blood, while dengue 2 and 4 strains are dangerous as they destroy platelets and thicken blood due to capillary leakage and rise in hematocrit. Also, that platelet transfusion is not required in absence of active bleeding and it is the timely fluid resuscitation that is more important and not platelet resuscitation. Dengue becomes serious when the fever is subsiding. Earlier, dengue patients with high fever were hospitalized and there was always an urgency to discharge them when fever was subsiding.
Now we know that the machine reading of platelet count can be defective. There can be an error of 20%. A platelet count of 10,000 by machine reading can mean it is actually 50,000.
Hospital beds should be reserved only for severe dengue and severe Chikungunya cases. Just because one can claim reimbursement in Mediclaim or PSU, should not be the factor to decide on hospital admission. If it was US, Medicare by now would have come out with admission guidelines.
The message has been going that fogging has no answer. But at this stage of container index of > 40, we need not only ground fogging but also aerial fogging.
When Zika threat came up in Brazil they deployed the army to join and make it a public movement.
All political parties reach every house during election process, then why can’t each one of them reach every house and make the anti-mosquito and anti-larval measures effective.
Breeding checkers are only with Municipal Corporations and they also have regulatory powers to impose fine. We need breeding checker in private sector. The Skill development Ministry should start courses so that anyone can hire a breeding checker on weekly basis to check their premises.
Community approach involves that 100% of the society talks about dengue. Every premise must write that their premises are mosquito-free. When you are invited to somebody’s place, you should ask “I hope your premises are mosquito-free” and when you invite somebody, write “Welcome to my house and it is mosquito-free”.’
Even today most hospitals do not provide mosquito nets to dengue or Chikungunya patients. While they may be having anti-larval mesh doors or mesh windows but for secondary prevention of dengue or Chikungunya, we need to ensure that medial establishments are certified mosquito-free.
Many of us live in flats and the mosquitoes may be breeding on the roof top belonging to one of the owners of the flats and if he/she is out of station for a holiday, the anti-larval measures may remain deficient. RWAs should use their powers to check all unoccupied or closed premises including hostels, hotels and construction places in that premises.
One of the five great vows of Jainism is Non-attachment/Non-possession or Aparigraha. It talks about not storing unwanted things. But in today’s era our roofs and verandahs are littered with left over tires, utensils, plastic utensils etc. We buy new car tires and keep the old ones on our roof top. We need to change this habit.
We have forgotten to plant Tulsi and Peepal in our premises and stopped the daily Yagna, all of which have anti-mosquito properties.
The new strategy has to focus on small collections of water such as bottle caps, finding mosquitoes lower in the room under the table or the bed, to look for them in all three parts of the house – roof tops, verandahs and inside the rooms including unused toilets accessories.
Also the slogan “Check your house once a week” needs a change. One should be alert every day. It should be a part of your routine. You do not clean your premises once a week. Make it a habit to look for the breeding places.
The new approach should be a war against indoor or outdoor mosquitoes; fresh stagnant or dirty water mosquitoes; small containers like bottle caps or large containers like overhead tankers; made of mud or plastic; throughout the day (early morning fogging when pupa hatch for Aedes, late night for malaria); scrubbing clean the utensils
Slogan: Ghar ke ander or ghar ke bahar; din me or rat me, deewaron ke niche or upar, chote pani or bade pani ke collection me, eggs larve or mosquito, teeno ko maro.
Authored By: Dr K K Aggarwal
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