Challenges of infectious diseases

in Urban Area

Dr. VIKAS K. DESAI

Public Health and Nutrition Consultant

Urban health

Double burden of diseases

New and resurgent infections

Migration of infections

Source of data

Hospital statistics/ UHC statistics/ IDSP/ Surveillance / Community/ Media

Hub of Medical care for the region

Urban planning, sanitation, water supply , solid waste disposal, food safety departments

GIS MIS operationalisation

Environmental pollution and climate change

Academic and technical support at the door steps

Constraints

New arena Lack of Urban Health Policy Skewed Priority at all levels Absence or Weak Health Infrastructure in ULBs Absence or Weak Health Management Capacity No dedicated Resources

No or weak health surveillance system Lack of Integrated Approach

Age group wise contribution to

total deaths

7 15 1

6

2

4

5

9

8

10

10

8

12

9 13

12 8

7

34 20

2008 1989

<1 yrs. 1-4 yrs. 5-14yrs. 14-24yrs.

25-34yrs. 35-44yrs. 45-54yrs. 55-64

65-69yrs. >70yrs.

Changes in last decade

6 times increase in the contribution of

deaths due to HT, CVD, Malignancy

5 times increase in the contribution of

Diabetes

>2 times increase in contribution of

deaths due to Accidents/ homicides/

suicides Asthma, Malaria, Rabies and TB.

No change in contribution of deaths

due to GE

Rise in contribution of PUO and some

rise in contribution of Asthma and

Malaria during flood year (2006 )

compared to non flood year (2008).

Contribution of Under five and school age

mortality is lowered by 15%

Contribution of young adults (14-34 yrs) is

lowered by 6%.

Anopheles Mosquitoes

0.29

0.52

1.08

1.42 1.39 1.55

1.15 1.07

0.75 0.62

0.52 0.53 0.49 0.56

0.36 0.45

0.34 0.4 0.38 0.47

89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08

Densi

ty p

er

man

ho

ur

colle

ctio

n

Trend of Anopheles Mosquito Density

88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08

SPR 21.56 33.00 31.81 23.06 17.94 15.23 9.40 5.09 4.05 1.66 1.53 2.07 1.85 2.23 1.56 1.22 1.32 1.37 1.71 1.27 1.12

% p

osi

tive s

lid

es

ou

t o

f to

tal

exam

ined

Slide Positivity Rate Active surveillance

Emphasis on Environment management

Epidemiological situation of Malaria in

Surat city, Gujarat

0.00

5.00

10.00

15.00

20.00

25.00

30.00

35.00

40.00

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

4500000

5000000

Population API ABER

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

SPR 31.8 23.1 17.9 15.2 9.4 5.09 4.05 1.66 1.53 2.07 1.85 2.23 1.56 1.22 1.32 1.37 1.71 1.27 1.12 1.16 1.22

SFR 19.7 13.2 10.1 7.06 4.52 2.06 1.77 0.6 0.61 0.8 0.78 0.94 0.55 0.48 0.45 0.44 0.66 0.57 0.51 0.36 0.38

No. of P.F. Cases 3335 2491 2577 1551 1034 4949 6921 3548 3272 4412 3582 4781 2926 2739 2793 2669 4895 4387 4649 3609 4278

0

5000

10000

15000

20000

25000

30000

35000

40000

0

5

10

15

20

25

30

35

Vector Borne Diseases Control DepartmentSPR SFR No. of P.F. Cases

Malaria and climate

Climate Anophele

se Density

Malaria cases

Maximum

temperature

Inverse

trend

Inverse trend in

Summer

Positive trend in

post monsoon

Minimum

temperature

Inverse

trend

SPR peak follows

minimum

temperature peak

Difference between

Maximum and

Minimum

temperature

Inverse Positive

Humidity Positive Positive

SPR Peak follows

peak of Humidity

Seasonal trend of maximum temperature and Anopheles

density

0

0.2

0.4

0.6

0.8

1

1.2

Jan '06Feb.

Mar.Apr.

MayJun.

jul.Aug.

Sep.Oct.

Nov.Dec.

Jan.'07Feb.

Mar.Apr.

MayJun.

jul.Aug.

Sep.Oct.

Nov.Dec.

Jan.'08Feb.

Mar.Apr.

MayJun.

jul.Aug.

Sep.Oct.

Nov.Dec.

Dens

ity /p

mh

25.0

27.0

29.0

31.0

33.0

35.0

37.0

39.0

Tem

pera

ture

(C)

Density Max.Temp

Seasonal trend of Humidity and Anopheles density

0

0.2

0.4

0.6

0.8

1

1.2

Jan

'06Feb

.M

ar.Apr

.M

ayJu

n. jul.

Aug.Sep

.O

ct.Nov

.

Dec

.

Jan.

'07Feb

.M

ar.Apr

.M

ayJu

n. jul.

Aug.Sep

.O

ct.Nov

.

Dec

.

Jan.

'08Feb

.M

ar.Apr

.M

ayJu

n. jul.

Aug.Sep

.O

ct.Nov

.

Dec

.D

ensi

ty/p

mh

40.0

45.0

50.0

55.0

60.0

65.0

70.0

75.0

80.0

85.0

90.0

Hu

mid

ity

Density Humidity

Seasonal trend of minimum temperature and Anopheles

density

0

0.2

0.4

0.6

0.8

1

1.2

Jan '06Feb.

Mar.Apr.

MayJun.

jul.Aug.

Sep.Oct.

Nov.Dec.

Jan.'07Feb.

Mar.Apr.

MayJun.

jul.Aug.

Sep.Oct.

Nov.Dec.

Jan.'08Feb.

Mar.Apr.

MayJun.

jul.Aug.

Sep.Oct.

Nov.Dec.

Dens

ity/p

mh

10.0

12.0

14.0

16.0

18.0

20.0

22.0

24.0

26.0

28.0

30.0

Tem

pera

ture

(C)

Density Min.Temp

Seasonal trend of difference of maximum and Minimum

temperature and Anopheles density

0

0.2

0.4

0.6

0.8

1

1.2

Jan '06Feb.

Mar.

Apr.M

ayJun.

jul.

Aug.Sep.

Oct.

Nov.Dec.

Jan.'07Feb.

Mar.

Apr.M

ayJun.

jul.

Aug.Sep.

Oct.

Nov.Dec.

Jan.'08Feb.

Mar.

Apr.M

ayJun.

jul.

Aug.Sep.

Oct.

Nov.Dec.

Ano

phel

es d

ensi

ty/p

mh

0

5

10

15

20

tem

pera

ture

(C)

Density Diff. of temp.

Trend and location of Malaria

Trend of Rainfall and Anopheles Density

20

30

40

50

60

70

80

90

Rain

fall(

Inches)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Anophele

s d

ensity/p

mh

Rain fall 29 42 33 85 52 83 54 45 41 56 38 31 47 45 68 77 75 56 76 58

Anopheles density 0.3 0.5 1.1 1.4 1.4 1.6 1.2 1.1 0.8 0.6 0.5 0.5 0.5 0.6 0.4 0.5 0.3 0.4 0.4 0.5

89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08

Trend of Rainfall and SPR

25

35

45

55

65

75

85

Rain

fall

(In

ch

es)

0

5

10

15

20

25

30

35

SP

R(%

)

Rain fall 29 42 33 85 52 83 54 45 41 56 38 31 47 45 68 77 75 56 76 58

SPR 33 32 23 18 15 9.4 5.1 4.1 1.7 1.5 2.1 1.8 2.2 1.6 1.2 1.3 1.4 1.7 1.3 1.1

89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08

Dengue in Surat city

48%

8% 1% 15%

5% 2%

21%

Breeding sites of Aedes mosquito

TYRES BARELS

PLASTIC DRUM EARTHEN POT

0.8

6

0.4

4

0.5

2 0.7

4

0.3

5 0.5

8

0.2

3

0.9

6

0.4

4

0.5

7 0.7

8

0.3

9 0.5

9

0.2

4 0.4

5

0.2

7

0.2

3

0.1

8

0.2

4 0.4

4

0.1

3

0

0.5

1

1.5

Central South South-West East

%

Entomological indices of Aedes

mosquitoes

House index Breteau index Container index

Culex mosquito infection rate

(Filaria monitoring)

0

5

10

15

20

25

56 57 58 59

Mosquito Infection rate

(Pre ’60) Under

Ground

drainage

0.00

0.05

0.10

0.15

0.20

0.00

0.10

0.20

0.30

0.40

0.50

0.60

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

Infe

ctio

n r

ate

Infection rate and Infectivity rate

in 1988 to 2009 - Surat city

Infection rate Infectivity rate

Migrants Influence

150

117

6

354

11

103

945

14 41 , 7

Distribution of Filaria Infection cases -

nativeplacewise

Surat city Gujarat Rajasthan UP

MP Bihar Orrissa AP

Maharashtra Others

Surat city health system development

1970 Filaria control unit expanded as VBDC unit

1987-1992 Very high contribution to state malaria and

PF

1994 flood – overall revamping of system including

health

1996-2000 DFID supported “ Urban malaria project ”

capacity building of SMC, Medical and Engineering

college, Center for social studies and facilitated PPP

2009 “Climate & Health” ACCRN project & TARU

support

Preparedness- SMC (post 1994)

System reform

Health and sanitation and Infrastructure

Health department Human resource

Standard Operation procedures

Disaster preparedness

Inter and Intra sectoral convergence

Participation of Academic institutions

Public private partnership, Corporate and NGO partnership

Leadership and political will

Resources

National urban health Mission, Five years plan

Philanthropic culture of citizens

Vector borne Disease Control Strategy

(1) Early detection & Prompt treatment (EDPT)

Active Surveillance (460) & passive surveillance (39 + 250)

(2) Vector Control Measures

Anti Larval Measures, Intra domestic, Peri domestic, Construction site

(3) Anti Adult Measures.

Space Spray (Fogging with natural pyrethrum extract), Intra Residual Spray

(synthetic Pyrethroid)

(4) Implementation of Bye Laws

Notices, Prosecution , Collection of Admin. Charges

(5) Information, Education and Communication

posters, Banners, hand bills. Advertisement ,Puppet shows, street plays.

Demonstrations , Schools , Streets, and public functions

(6) Monitoring

Weekly, Monthly, Quarterly, Yearly

(7) GIS based MIS system

Surat Urban Health Services

16 16 16 17

26 26 11 11 12 12

11 11

2005 2006 2007 2008 2009 2010

N

o

.

o

f

U

H

C

s

UHCs MH

SPR and SFR trend 2005 to 2007 (Flood)

2006 Flood year SPR was higher from June than previous year, SPR continued to remain high Up to may 2007

than previous year. The duration of seasonal epidemic was July-Jan in 2005 Was July to march in 2006 flood year.

0.00

0.50

1.00

1.50

2.00

2.50

Longitudinal studies of flea fauna indices prevalence

in Surat city

0.00

0.20

0.40

0.60

0.80

1.00

1.20

19951996

19971998

19992000

20012002

20032004

20052006

20072008

General Flea Index (%) Cheopis Index (%) Astia Index (%)

37%

14%

7.3%

16%

15%

2.9%

Leptospirosis zones

6.5%

Convergence

H

E

A

L

T

H

W

A

T

E

R

Skill Building Urban Public health Specialty to Grass root to community

Human Resource Governance, Supervisors, Implementers,

Primary Health workers, Link workers

Disease

Surveill

ance

--------- Active/Pa

ssive

CD/NCD

Routine/

Disaster

------------

Climate &

Health

Health

Medical

care

--------- Protocol

SOPs

------------

Primary

to

Tertiary

------------

Public &

Private

Urban

Planning

&

Infrastruc

ture

----------- Water

supply

Sanitation

Garbage

--------------

Maintana

nce

Academic

Institutio

ns

------------

Technical

&

research

support

------------

Learning

by doing

for

future

specialists

Urban HealthResilience development

Financial Resource