Dengue and

Malaria Education

Prepared by Katie Strong

References

- National Dengue Control Program of

Ministry of Health

- Cambodian National Malaria Center -III

- ---

- --

NATIONAL DENGUE CONTROL PROGRAM, CAMBODIA 2013

Monthly Report of Hospitalized Dengue Cases and Deaths by Province, as at 20 Aug., 2013

Apr Oct Nov IncidenceJan Feb Mar May J" J,' A,g Sep Dec Total II::PopulationPROVINCES per 100,000

o PoPes~mated Ie 10 Ie 10 Ie 10 Ie 10 Ie 10 Ie 10 Ie 10 Ie 10 Ie 10 Ie 10 Ie 10 Ie 10 Ie 10 I IL

B.Meanchey 756,808 44 a 32

Battambang I 1,144,5491 21 a 9

KampongChaml1'875~~L 44- a 12 Kg~hnan~527,3421 8 a 9

Kampongspet800.428

KampongThom

Kampal

KandaT--- ­

---------r-­Koh K~--+_

Kratie I

MondulKiri

Phnom Penh

704,933-- -t-----+----+----+-654,089 7

1,412,614 ~'"

131,181

356,388

1,482,208

PreahVihear

PreyVeng

~7 a 0.0~-+rl1 5 0.2 :

68 a 0.0

~ -

.0

106 a 0.0

27 a 0.0 55.9

34 2 0.~+-209.2 7 n n n "'75

--~

Total 010 o

= Non-report from PHD C: Case, 0: Death, CFR: Case Fatality Rate NB ! .. I

EPL_NOCP/CNM-MoH-CAM 02-09-13 email:rekolh@cnm.gov.kh

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Transmission

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The Dengue virus is spread by mosquitoes. It is transmitted from one human to another by a female Aedes aegypti mosquito, a household mosquito

. that feeds on human blood. This mosquito

is also called the Tiger mosquito because it is striped.

The mosquito becomes infected when it bites an infected human. It passes the virus on when it bites another human. Only the female can spread the virus because the male does not feed on blood. The female needs the blood to incubate hereggs.

The Tiger mosquito feeds during the days, with peak biting times after dawn and in the late afternoon till sunset.

Dengue Fever mainly affects children and young adults, but adults can get sick too.

The virus attacks the white blood cells. The body reacts by developing antibodies to fight the infection but there are 4 types of the Dengue virus. The antibodies to one type of the virus can cause infection by a second type to lead to a more severe

illness.

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Not everyone who gets infected by the Dengue virus gets sick, In most cases the infected person experiences no illness or a minor fever that goes away after several days, This is called asymptomatic.

In cases like this, however, the infected person can pass on the virus. If he or she is bitten by a mosquito and tbat mosquito goes on to bite other people the virus can be transmitted.

Those who get sick from Dengue usually get a high fever as well as headache, muscular and joint pain, and a rash that is easy to confuse with measles. These symptoms appear suddenly, within 2 to 7 days of infection. Most of these cases, though extremely debilitating, are not life threatening.

However, Dengue Fever cases can develop into Dengue Hemorrhagic Fever (DHF). In these cases the white blood cells leak plasma. This can lead to shock.

Without immediate and proper treatment Dengue Shock Syndrome can kill.

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How to prevent or contain Dengue

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There are two strategies to prevent

Dengue Fever, and they work best when

done in tandem:

1. Eliminate Tiger mosquitoes and their

breeding sites.

2. Prevent mosquito bites.

Eliminating Tiger mosquitoes and their breeding sites

Health workers can encourage people to

eliminate possible Tiger mosquito

breeding sites in, under and around their

homes. They should also encourage them

to inform and assist their neighbors to do the same. This will reduce the number of

mosquitoes and the risk of being infected

with Dengue. ----~--------------

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Since Tiger mosquitoes breed in containers, eliminating unused containers and controlling necessary ones will prevent more mosquitoes from being born. If a household container is unnecessary then it should be removed, destroyed or buried. If the container is essential then it is necessary to prevent Tiger mosquitoes from breeding inside it.

In Cambodia water storage containers are the Number One breeding site for Tiger mosquitoes, so preventing the mosquitoes from getting inside the containers and cleaning them weekly to kill larvae are key to eradicating the mosquitoes and reducing the risk of Dengue.

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Water storage containers

Households that collect rainwater or store well water need containers. There are about 12 million water-storage containers in Cambodia. Consequently, people need .to be told how to prevent Tiger mosquitoes from breeding inside the storage containers. Although there are numerous kinds of water storage containers, including clay jars, drums, tanks, barrels,and concrete basins, Tiger mosquitoes can be prevented from breeding in all

.. of them.

,With the Dengue outbreak at its peak it is crucial that all households scrub and clean the edges and insides of their water containers once a week to remove possible Aedes eggs and larvae. This will prevent new mosquitoes from emerging.

It is also advisable to . • Cover water jars with either a screen cover or tightly fitting lid • . Cover containers used to collect rainwater with screen netting or cloth

• Put a fewguppies (sevenco,loured fish) in water containers. They eat mosquitoeggs and larvae . . . ..' . . ..

• .Pour boiling water down the sides of water storage containers to kill larvae and eggs when water levels ,are/ow ' . .' . , .'.

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Larvae-eating fish

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Putting guppy fish in water storage containers is a safe way of preventing Tiger mosquitoes from

breeding in them.

Larvae-eating fish can also be used as a larvicide. Fish that feed on larvae and feed at the surface of the water can be used in potted decorative water plants, ponds, and other water sources that are open and are more permanent. Only fish species that are found locally should be used.

A recently completed study in Trapeang Kong commune, Kampong Speu province, found that adding a few guppy fish to water storage containers resulted in an 80 per cent reduction in Aedes aegypti _ in the commune. . '-"'-"---~-The results of the pilot program, implemented by the World Health Organisation and the Ministry of Health, suggests that it could succeed as an intervention strategy on a national level.

" •

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Although water storage containers are the main breeding site for Tiger mosquitoes in Cambodia, there are several other sites that are cause for grave concern.

Rubbish should be cleaned up from around the house and buried. This includes tin cans, plastic bags, bottles, and coconut shells. Any piece of rubbish that can hold water should be disposed of.

Unused tyres should be kept away from households and stacked so that they will not collect rain. If possible, the tyres should be shredded or cut into strips and discarded away from communities.

Household and garden utensils (bowls, buckets, cups, jars, cans, etc.) should be turned upside down to prevent rainwater from collecting inside of them.

Small fishing boats should also be turned upside down when not being used. Water should be emptied from the boat if it has accumulated inside of it.

Roof gutters should be repaired and cleared of debris regularly.

" •

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Tree holes around the house that can collect rainwater should be filled with sand or concrete.

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~K~.. : . -.,." ., ... "

During a Dengue outbreak people must

prevent mosquito bites. Health workers

can advise people how to protect

themselves and their children, and

encourage them to pass this knowledge on

to their neighbors. Children should be

encouraged to tell their friends how to

protect themselves. ______1

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near possible

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and late afternoon.

sites.

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.form of prevention for Dengue as well as malaria.

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\l1iIi'iiwUWiJd61.IiBWDU BiJd61.liBmm Dengue and malaria transmitting mosquitoes

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The mosquito that transmits Dengue is not the same as the mosquito that transmits Malaria, and because its environment and behavior differ many of the steps used to protect against Malariawill not protect against Dengue.

mn~MUlf~'lMtdAnim~tJPuunu ~ Difference between Dengue and Malaria transmitting mosquitoes 'MtdAnim~mstrl,!

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n~mBm']j Malaria'

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fJflJf!1 Tiger mosquito

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"" ,.... Qmmtu< tUa 13mttlmm.,., ., Day time (from sunrise to sunset)

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mftiimt3lii9tit13mmBtEn Bltlritl BltltttilH ytEnt1iL]~8 Containers found in, under or around the home

~n:~OH. tm ~OOH. Short distances: 50 to 500 meters

Malaria Endemic Area in Cambodia:

Battambang - Stung Treng

Mondul Kiri - Banteay Mean Chey

Ratanah Kiri - Pailin

Kratie - Kampong Cham

Kampong Some - Oddor Mean Chey

Kep - Preah Vihea

Kampot - Kampong Tom

Kampong Speu - Siem Reap

Koh Kong - Kampong Chhnang

Takeo - Pursat

Mild Malaria Symptoms:

1.) Chills

2.) High Temperature (39 - 40 degrees C)

3.) Sweat

Signs that may accompany main symptoms:

Headache - Jaundice

Muscle ache - Stunting

Joint Pain - Enlarged Liver

Pallor (pale coloring)

. Severe/Cerebral Malaria:

Includes same symptom of mild malaria with addition ofthe following:

Problems with consciousness: coma, delirium, nervousness, sleepiness

Hypoglycemia (low blood sugar, tired ,weak, increased heart rate, poor circulation)

Convulsions

High Temperature ( > 38 degrees Celsius)

Pale Skin Color

Vomiting

Dehydration

Oliguria - concentrated urine (little urine with dark color)

Hyperparasitaemia - high number of parasites invading red blood cells

- Clinical

Blood tested under microscope can find disease of Malaria, can be determined only by blood

test.

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Prevent

Malaria can be prevented

We can protect by giving attention to the female Anopheles mosquito

We ought to do something to stop mosquito bit, there are more than one way to

prevent the female Anopheles mosquito from attacking at night

A. In early night before sleep, wear long protective clothes especially outside the house

(children, pregnant women and migrant workers are at a higher risk)

B. Sleep in a Mosquito net every night

C. Use a mosquito net properly, mosquito can bite from the outside of net if body is

against net

D. Every night forest workers must sleep in a mosquito net with their hammock

Treatment

If person experiences the symptoms discussed previously (above), go to the health center!

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" •

Malaria Overview By: Health Messenger

Malaria is a disease caused by a parasite called Plasmodium tltat invades tlte red blood cells.

The parasites are so small that they can only be seen under a microscope. Once inside the cells, the parasite multiples, ruptures the cell and then invades new red blood cells.

In time, the parasites may cause a fever or more serious conditions such as anaemia and even a coma.

How is malaria transmitted? Malaria is transmitted by the bite ofa female

Anopheles mosquito that is infected with the malaria parasite. If the person has malaria, some ofthe parasites in their blood will be taken into the mosquito while she is feeding.

The malaria parasites multiply and develop in the mosquito. After 10 to 14 days they are mature and ready to be passed on to another person. When the mosquito now bites a healthy person, the malaria parasites will then enter the bodY'ofthe healthy person who will become ill.

This cycle is what happens during an epidemic in a community. Mosquitoes bite people with malaria and then pass it on to many other people in the community.

The mosquito, which carries the malaria parasites and bites a human, is called the vector. The human being infected by the parasites is called the host.

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• Plasmodium vivax causes a milder type ofmalaria but can remain dormant in the liver cells resulting in relapses ofinfection if not treated; .

• Plasmodium ovale and Plasmodium Malariae are much less common.

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" •

Malaria Situation in Cambodia By: Dr. Chea Nguon, National Malaria Centre

Malaria is a serious disease affecting the lives ofKhmer men, women and children who live or work in the rural mountainous andforested areas ofCambodia.

Where does malaria mainly occur? .. ....-...._~.'_.",_._..-"-...,..

Malaria occurs where the mosquito that transmits the disease is found. The Anopheles mosquito likes rural heavily forested and mountainous areas, including coastal mangroves.

In Cambodia, these areas are found in the north-eastern part ofthe country as well as in the northern and western regions located close to the Cambodian-Thai borders. A high prevalence ofmalaria occurs over 65% ofthe country area.

Malaria vector

There are two types of Anopheles mosquitoes that transmit malaria in Cambodia. Anopheles minimus and Anopheles dirus. These mosquito types prefer to bite their hosts during the night time between dusk to dawn.

Transmission of malaria occurs all year long in Cambodia with the peak of transmission occurring during the rainy season between June and November.

~lariaspecies in Cambo~~ Percentage of malaria species fo'~nd in ! Cambodia is as follows: I • Plasmodiumfalciparum causes 90% of ~I

the malaria cases in Cambodia. This type causes most ofthe malaria deaths, I and also develops resistance to anti-malaria drugs.

• Plasmodium vivax causes about 7-10% of the malaria cases.

I• Plasmodium malariae, causes only 1-2% of all malaria cases.

What populations are most at risk?

Approximately only 5% (600,000) of the Cambodian people are living permanently in areas with high prevalence of malaria. Population density in this area remains low Those who permanently inhabit this area such as labourers, military and tribal persons have developed immunity.

However, children under 10 years of age and pregnant women are still at risk because of their low immune status (see Malaria in Pregnancy page 25).

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In Cambodia, there is another group of people who are at risk of acquiring malaria. They are migrant forest workers who are moving from non-endemic areas of the country to epidemic areas for economic reasons. Because they were not exposed when they were children, their immune status is low, making them 'even more susceptible to malaria and the severe complications of malaria (see Forest Workers at Risk page 45).

Prevention of malaria

The main form of malaria control in Cambodia is primary prevention from being bitten by the Anopheles mosquito. In Cambodia, personal protection is emphasised.

The main strategy is to encourage the use of insecticide treated bed-nets.

The National Malaria Centre (CNM) has been persistently distributing bed-nets to whole communities in endemic areas with the aid of local and international NGO's. In addition, a new impregnated hammock net was developed and is being marketed to migrant forest workers.

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Health Education is the second tool that is being used by the CNM in order to encourage personal protection against the mosquito. Health workers educate the communities about malaria transmission, disease and prevention during bed-net distributions and also while seeing patients at the Health Centres.

The CNM promotes rapid diagnosis and treatment for malaria in order to prevent any of the serious complications due to malaria and even death.

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Diagnosing and Treating Malaria By: Dr. Sio Lean Sin, Sdav Health Centre

Correct diagnosis and early treatment by Healtlt Centre workers can prevent malaria patients from developing severe malaria.

The clinical features of malaria vary from mild to severe. There are several factors, which influence the severity of the disease, such as the patient's immunity level and the number of parasites present.

For example, in areas where malaria is very common, adults with the disease might have just a slight increase in body temperature. However, pregnant women and young children often have severe illness with many signs and symptoms.

We should suspect malaria in all patients who live in malaria zones or who have trav- . elled through malaria zones during the night time in the past 10 - 15 days and who have the following signs: - Fever or a history of fever within the last

2-3 days. The fever may be continuous or intermittent at the start of the illness. Each febrile attack may last several hours beginning with chills and shivering (body shaking), and ending with profuse sweating.

- The other signs that may accompany the fever are headache, malaise, nausea, vomiting, diarrhoea, muscular pains,joint pains, pallor, jaundice, and/or enlarged spleen or liver.

Examining a stained blood slide under a microscope is the only way to determine if there are malaria parasites in the blood (parasitaemia). Dipsticks can also be used for diagnosis (see Dipstick page 20).

Ifa microscope or dipstick is not available at your Health Centre, send the blood slide to another Health Centre that has a microscope for examination, Prescribe the anti-malaria drugs to the patient while you are waiting for the results.

. At the immediate onset of malaria symptoms, the patient needs to go to the nearest Health Centre as soon as possible. Treatment of malaria at this stage is very effective and uses less medicine. i~"~'''~'----~-~~-'~''~_.~. '~"'~~"'--~~~"-~l

I Health centre staff should educate the ~

! patients and the conununity about: f r'I- how to recognise the signs and symptoms I

ofmaJaria. f! Il- the im portance ofseeking treatment very f

It quickly! I _~."_"' ~ ~__ '_' ...~__ •• •._.1.

Complications and severe malaria may develop if the patient does not receive any treatment, inappropriate treatment, or late treatment thus placing the patient's life in danger.

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If the result of the slide is negative, begin to consider other illnesses similar to malaria such as influenza, typhoid fever, meningitis, septicaemia, pneumonia, dengue fever, measles, tonsillitis, ear infection and tuberculosis.

If symptoms persist though, a new blood' slide should be examined,

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Malaria patients need to seek treatme1lt as soon as symptoms begin.

A patient may have malaria but have a smear that is negative due to: .

• Lab error ( Lab made a mistake) • Low parasitaemia (Too little parasites in

the blood) • Partial pre-treatment with anti-malaria

drugs

Before sending the patient home, make sure the patient and the family are able to recognise the signs of severe malaria. Encourage them to bring the patient back to the Health Centre as soon as signs of severe malaria occur. Early treatment of severe and cerebral malaria decreases the risk of death for the patient.

Treatment for uncomplicated malaria'-_._----_._-------_.• In Cambodia, drug resistance is very high;

one of the highest in the world. As a result, the National Malaria Centre has developed

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Forest Workers at Risk B.Y': Dr. Sio Leall Sill. Sdav Health Centre

For business purposes, people go i1lto theJorests where malaria transmission is high. Tlteir lack ojimmunity and knowledge

about malaria prevention puts them at high riskJor the disease.

In the last twenty years, the number of malaria cases has been changing because of population movements into the forest and mountains where very high malaria transmission occurs.

These malaria regions are covered with thick forests and are rich with natural resources such as precious stone mines, bamboo, vines, rattans and fertilised land for farming. All these natural resources are important things that attract a large portion of the population to earn their living in this area. This region, however, is home to the main source of severe malaria, Plasmodium falciparum.

Because migrant forest workers are moving from a non-endemic area, they have not yet developed immunity to the disease. The forest workers are then at risk ofnot only getting malaria, but also ofcomplications and even death.

eNM

Migrant H'orkers sleep in the forest without a mosquito net.

The accessibility to these mountainous and forest locations by normal means of transportation is very difficult, especially during the rainy season. As a result, the health services provided are limited or do not exist

in some of these areas, thus limiting care and treatment to malaria patients.

Even more dangerous is the fact that many of the migrant forest workers do not know

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that malaria is transmitted by mosquitoes. Instead, they think that malaria is caused by environmental change or guardian forest spirits.

Without the proper knowledge about malaria transmission or prevention, they neglect to protect themselves from mosquito bites. During the night time, they are not use to sleeping inside mosquito nets. They usually stay-up very late drinking, eating, and talking. They go to defecate in the forest. .All these activities create a favourable occasion for a mosquito to bite them.

In order to protect these migrant forest workers, the National Malaria Centre (CNM) is now marketing insecticide treated hammock nets. These hammock nets help prevent mosquitoes from biting them while they are sleeping in the forests. The CNM is using mass media and advertisements to promote this new health product.

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Health workers can play an important role in preventing malaria among this high-risk group. The Health Centre staff can provide health education to the population living in the malaria zones. They need to help them understand more about how to prevent malaria. In addition, they can add to the CNM's mass media campaign by encouraging malaria patients and communities to use the insecticide treated hammocks. With time and education, these migrant forest workers will change their risky behaviours and apply the safer ones.

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to go to the Health Centre immediately should any of the symptoms occur. Early treatment can prevent serious malaria complications or death.

·1 mBmmg8g1 y.tt\Jo~ty1U '1

How to prevent malaria in forest workers

Health workers can: 1. Educate forest workers about malaria transmission and disease. This can be

done at the Health Centre while they are being treated and also in the community.

2. Encourage forest workers to wear protective thick clothing such as long-sleeves, pants, gloves, socks and mask and/or insect repellent when going into the forest during mosquito feeding times: from sunset to sunrise.

3. Encourage forest workers to sleep under insecticide treated bed-nets at home or to use an insecticide treated hammock net if they are sleeping in the forest.

'-'''''' ­

I11III 4. Teach forest workers how to recognise the symptoms of malaria. Remind them

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Some key messages about insecticide treated bed-nets: I

I,1. The bed-net should be hung over the bed and used EVERY night.

2. When hanging the mosquito net over

the bed, make sure that it is low enough so that some of the net can be tucked in underneath the mattress and high enough so that the family will not be touching the edges ofthe bed-net.

3. When sleeping under the bed-net:

• Tuck the net under the mattress

to prevent mosquitoes from entering under the bed-net.

• Keep arms, legs and body away

from the edges of the bed-net because mosquitoes are able to bite from the outside.

4. Washing the bed-nets too often will decrease the effectiveness ofthe ins€cticide. Therefore, keep the bed-nets in a safe place in order to avoid getting the bed-nets dirty. During the daytime, when the bed-nets are not in use, they should be tied up so they will not be damaged.

5. When the bed-nets do become dirty, they can be washed with water. Do not wash with soap or detergent. The bed-nets should be dried in a shaded area, not in the direct sun light. Detergent and sun light decrease the effectiveness of the insecticide on the bed-nets.

6. The insecticide on the bed-nets is effective for 6 to 9 months. After this time, the bed-nets need to be re-treated either by the Provincial Department ofHealth, Operational Districts (OD), or Health Centre staff.

-- I7. Ifthere are any tears in the bed-nets, the bed-nets need to be repaired immediately.

Tears can be fixed by simply sewing together the openings in t4e bed-net.

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