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%
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