Reducing mortality and mobbility of dengue fever in Malaysia

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Nursing is a profession to promote health, healing, growth and development which enable people to understand and cope with their disease or disability. Nurses therefore serve as an educator to educate public and other disciplines in early recognition and effective case management especially for those who suffer from dengue fever.

Dengue fever (DF) is one of the most common mosquito-borne viral disease of humans and mostly occurs in the tropical and sub-tropical areas of the world. WORLD HEALTH ORGANIZATION (WHO) has estimates that more than 2.5 billion people are at risk of dengue infections, with 50 million cases occurring annually with 22,000 deaths. Of an estimated 500,000 cases of Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS) requiring hospitalization each years, roughly 5% die according to WHO statistics.

The reason for dramatic emergence of DF and DHF are not clear and complex, however many factors combine to produce epidemiological condition. Kumarasamy (2006) illustrates that favor viral transmission by the main mosquito vector Aedes aegyptii such as population growth, rapid urbanization, rural urban migration inadequacies in urban infrastructure, including solid water disposal, rise in domestics and international travel are some of the contributing factors.

Similarly in Malaysia, the number of reported DF and DHF cases shows an


increasing trend. Base on the Clinical Practice Guideline (CPG) (2010) the incidence rate in 1999 is 44.3 cases/100,000 population has been increased to 181 cases/100,000 population in 2007 which means that the national target (less than 50 cases/100,000 population)has been exceed. From my view and experience as a nurse in medical ward, the rainy season seems to be one of the risk factors for epidemics of dengue. This was supported by Hay et al (2002) who had done a study on relationship between temperatures, rainfall and vector borne disease concluded factors related to history of heird immunity, introduction of new serotypes or demographic transitions influence transmission. A comprehensive service in the diagnosis and treatment for Dengue Fever are disputable as this involves appropriate training of the health care provider and a proactive laboratory based surveillance.

As Dengue Fever is the contemporary issue in Malaysia at present, this has provoke me to further exploring on it and as a registered nurse in my practice setting, my responsibilities is early notification of suspected dengue cases, educate public and providing holistic quality care through teamwork and caring service. In this paper, I will critically discuss the contemporary issue on its contributing factors, delay in seeking treatment, key components of Dengue Control Strategy, Implication, hence give suggestion to reduce the epidemiology in my working area.

Gubler (1998) described that DF and DHF are caused by one of four closely related but antigenically distinct virus serotypes that is DEN-1,DEN-2 DEN-3 AND DEN-4, of the genus Flavivirus. Dengue viruses are transmitted to


humans(host) through the bites of the female striped Aedes aegypti mosquito (vector).

The person living in a dengue-endemic area can suffer up to four dengue infections during their lifetime, this is because infection with one of these serotypes does not cross-protect. At present, combating the vector mosquitoes is the only method to prevent dengue. Currently there is no any vaccines or special treatment to prevent infection with dengue virus (DENV). According to WHO in the initiative for vaccine research (2010), To be an effective vaccine, it must be able to immunize against all four types of the dengue virus. However, the limitation of understanding behavior of the disease and the interaction of the virus towards the immune system has become the barrier of the development of the vaccine. Despite of these challenge, WHO has provides the technical advice and guidance to support vaccine research and evaluation. Therefore ,the most effective protective measures for the time being is to avoid mosquito bites. When infected, early recognition and prompt supportive treatment can substantially lower the risk of developing severe disease as suggested by Disease Control Division ( 2008)

Dengue is the fastest growing vector-borne infectious disease in the world. Estimate from the WHO shows an incidence of 50 million dengue infections a year. This translates into 67 deaths per 100,000 people, higher than H1N1 at 64 deaths per 100,000 people. In Malaysia alone, there were more than 3149 dengue cases in May 2010, 3585 in June 2010 and 2112 in July 2010 (the latest statistics were given by the MOH until July 10, 2010). Statistics


show that 200 people will die from dengue this year.

Although it is quite difficult to estimate the economic impact of dengue fever, Deborati and Barbara (2005) tells us that dengue virus has became endemic in half of the world’s population, this resulting to the consequence of loss of workdays for wage labour especially for in the community and if severe it can brings to mortality. This is supported by Suaya et al (2009) who had performed a study on the patients diagnosed as DF in America and Asia, the mean costs for patients with ambulatory care was I$514 and hospitalized cases was I$1,394.This indicates that dengue has brings to a burden for economic cost in the society and global health system. It is necessary to improve surveillance and reporting effort and reduction in underreporting cases.

Wallace et al (1980) illustrated that all suspected dengue cases must be notified to the nearest health office from April 1971. The incidence rate is higher in the age group of 15 years and above and majority of them are working and school-going age group as stated in CPG (2008), those were people were active outdoors causing the Aedes breeding in the house is low.

Majority of the state in Malaysia were affected, Selangor has shown the highest incidence rate (14,121 cases with 40 deaths) compare to Perlis which is the lowest rate as 160 cases and no death cases been reported according to the Ministry of Health in Oct 2010. Most of the dengue cases reported were from urban areas that is 70-80%, this is due to high density of population, the exodus of susceptible in the endemic areas, rapid


urbanization, disturbance in human ecology and living conditions that perpetuated vector breeding. In Perlis, the population is smaller and less crowded if compare to Selangor.

Based on WHO in 2000, dengue cases that been reported as higher fatality rates in Malaysia (0.63%) that is about cases compared to other Western Pacific Region countries such as Vietnam (0.2%) and Singapore(0.3%). Gubler (1998) says even though Malaysia has a good laboratory base surveillance system but the notification of the dengue cases only been carried out after the laboratory confirmation and this had lead to the delaying in the control measure taken and eventually end up with outbreaks.

Dengue may be asymptomatic or sometimes the clinical presentation can be confused with influenza, rubella, malaria, chikungunya, leptospirosis or typhoid. It can leads to a range of clinical presentation, if severe eventually death.

There are three types of dengue fever, namely classical dengue fever(DF),which is characterized by the sudden onset of fever and a variety of nonspecific signs and symptoms, leukopenia and mild thrombocytopenia and hemorrhagic manifestation are quite common. DHF is defined as acute febrile illness plasma leakage, thrombocytopenia, hypoalbuminemia as well as minor or major bleeding and DSS is the condition when a positive tourniquet, collection of exudates at pleural and abdominal cavities, a progressively decreasing platelet count and a rising hematocrit means the fatality rate may be as high as 12-44%. In Malaysia, the case of fatality rate


remain well below 0.3% since 2002 as stated in CPG( 2008). This is probably due to the public’s awareness and action taken towards the disease has slow down the fatality rate.

According to Malaysia Department of Public Health (2008), the contributing factor for dengue mortality include delaying in seeking treatment (47.3%), delay in diagnosis or assessment in severity such as low index of suspicion as (36.4%), Inadequate monitoring or treatment such as inadequate fluid resuscitation 21.8% and co-morbid conditions included obesity (14.5%), hypertension, diabetes, fits , hepatitis (18.2%).

In the article ( New Straits Times, 2010) reported Current Malaysia Director-General of Health appealed the public must aware of self-medication and the symptom persists, they need to seek for professional treatment. Some may not realize the seriousness of the complication of dengue fever as they believe their symptom are best treated with local remedies and this resulting in delaying in seeking treatment. Thus, educating public about the disease may encourage them to seek medical care promptly.

Kumarasamy ( 2006) illustrated that low index of suspicion by the junior doctors also causing dengue mortality, early recognition of the warning signs of dengue haemorrhagic fever and early treatment are prime importance in reducing the mortality rate. In my practice setting, most of the doctors are junior so they need more sessions designated as educational, with protected time to attend these. In Malaysia, most of the patients in the health centre


are managed by medical assistant who are only diploma level and they are not capable enough in managing the case compared to doctor that are more educated and knowledgeable . However, they are facing with the problem shortage of trained doctor who understand and can develop effective prevention and control programs for vector borne disease.

An active laboratory-based surveillance, emergency response, training and education of the medical community in vector borne disease, community-based integrated mosquito control are effective preventive and control measures taken by majority affected area in Southeast Asia Region as suggested by WHO (2006). The main approaches for dengue prevention such as environment management and vector control using insecticides are recommended by WHO (2010).

Kumarasamy (2006) said that dengue fever has become important public health problem since it was first reported in 1902 and dengue haemorrhagic fever in 1962 in Malaysia. Ang et al (2010) mentioned that Malaysia Government has set up a very comprehensive National Dengue Control Programme including vector control, law enforcement, public education and case management to fight against this vector-borne disease. As for case management, control measures are taken within 24 hours of notification reported to health authorities and usually it is too late because the average day of illness during notification was roughly 5 days after the onset of illness.

A study was done by Ang et al ( 2010) found that 83.9% patients in Selangor, the highly urbanized states will seek treatment at primary care


clinics rather going to hospital, 96-98% reported that they are not given advice on preventive measure and 51.9% of them had high possibility of suspected dengue fever. This shows that the primary care facilities are the first points of contact and they are present a good opportunity to institute early measures to stop the transmission of dengue fever. Since those patients are highly suspected group, they should be given advice on the control and preventive measures for dengue fever so that they can understand and practice them regularly.

Data from DCD (2009) tells us that 50% of the dengue mortality cases were admitted on day 4 or 5 after onset of illness and 47% of dengue mortality cases comes in already ill. All suspected dengue patients are advised to seek for early treatment as they may think it is just normal fever and try to self-medicate at home. This is partly due to the fact that self-medication can be dangerous when patients use inappropriate medicine or wrong dosages thus delay in seeking treatment. They are also advised try to avoid being bitten by mosquito by using mosquito net.

Nurses who are the front liner and deal with patient, through the way they interacted with patient is extremely important for the well being, mentally and physically. Whitehead (2000) described that nurses have the responsibility to incorporate health promotion and health education activities into their professional roles in order to reduce the mortality and morbidity of DF.

As for nursing, collaboration among hospital staff and health centers are extremely important to take early preventive measures to break the chain of


dengue transmission. In my practice setting, nurses needs to notify to nearest health center once the blood sample are sent for dengue serology test. Patient’s weight and height are recorded as baseline intervention for fluid management especially for those obese patients. Close monitoring such as hemodynamic status, early bleeding sign and during defervescence ( a decrease in a fever), a critical phase of dengue begins and lasting for 24-48 hours is particularly important.

In my experience, community based nurses play an important role in the promotion, protection of health and the prevention of the disease. Moreover they also understand communities directly relates to the determinants of health such as housing, sanitation, education and safety. Russell (1997) found that community-based nurses often comment that lack of training and support, workload and resources are the contributing factor of ineffective health promotion activities. Lee (1997) commented despite of the dilemmas, majority of them agreed that health educational and promotion activities are an imperative component of their professional role. Therefore in order for nurses to perform the role effectively, supportive measures such as proper supervision and training for health promotion and education are extremely important as a guideline. Bagnall (1998) supported that community-based nurses should feel encouraged by the increasing emphasis on health promotion.

As suggestion, a comprehensive nursing programme on dengue management and vector control should be developed to prepare medical and


nursing staffs to apply knowledge, understand the rationale and skills to provide, maintain and complement the health of the public and communities effectively. Thus, they are able to detect early complication and to educate the community to seek medical attention promptly when dengue symptom appeared. Continuous professional development and continuous nursing education are mainly two learning sessions for nurses to improve their knowledge and skill to meet the public expectations and the demand of quality and greater accountability, nurses must be able to maintain their professional competence and deliver health education effectively. All doctors including private and government are encourage to improve the efficiency of medical care and the index of suspicion, early notification to treatment and able to reduce the mortality and morbidity.

Notification of infectious disease can be upgraded by using internet, e-notification web site where facilities are available at the Ministry of Health. More sophisticated data capture could accelerate action and the Ministry of Health investigation, and reduce the breeding of dengue fever.

Advances in computer technology, such as the use of online games has produced a variety of teaching and learning methods to improve public awareness about the epidemic of dengue fever which is very important. This is due to despite of the delivery of information and messages danger of dengue fever, Media Anti-Dengue Campaign which launched by the Ministry of Health, 185 television commercials are aired on all television stations. A total of 108 radio advertisement are published and13 insects advertisements


are published in the newspaper. it is still failing to increase public awareness of the outbreak of dengue fever. The Ministry of Health hopes the frequency of these media can increase awareness and encourage people to change behavior to take immediate action to prevent fever dengue.

Studies conducted by the MOH in 2006 showed the level of public knowledge about dengue fever is high, however, their participation in dengue prevention and control activities either at home or at the community level is still low.

Lennon (2005) suggested that Health behavior theory can be used as a tool in health education to evaluate the dengue fever prevention and control programme. Thus community participation in dengue prevention and control activities are needed. The public is also asked to maintain the cleanliness of their homes, particularly through collaborative activities to prevent the spread of dengue fever.

As conclusion, dengue disease is not a disease that can be easily identified with appropriate symptoms, especially in the early period of infection, this is particularly important the primary care practitioners to play their role if dengue can be diagnosed early, advice on preventive measures by primary care practitioners should proceed based on clinical suspicion. To strengthen the implementation of dengue prevention and control measure, campaigns such as mess media and health education are the important element to complement the awareness and encourage public to seek for early treatment. The transmission of dengue fever can be prevented through preventive measures and effective controls, however, it require the


participation from all parties. Ministry of Health’s monitoring shows that the majority of dengue infections occurred at home, especially with the breeding of aedes mosquitoes is high and a major contributing factor to the spread of dengue. A study done by Lee et al (2005) tells us that 2.35%-4.00% of mosquito larvae were found to be positive for dengue virus.

As a nurse, we should emphasize the cleanliness of the domestic environment to promote health education and health promotion. To achieve this, nurses require engaging in life long learning and involve in nursing research programme. By this knowledge, the nursing profession and the nursing role can be expanded and extended further leads to empowerment.