Dengue, a Flavivirus and chikungunya, an Alphavirus, transmitted by Aedes mosquitoes, are a cause of great concern to public health in India. Every year, thousands of individuals are affected and contribute to the burden of health care. Dengue outbreaks have continued since the 1950s but severity of disease has increased in the last two decades. Chikungunya outbreaks started in the 1960s and dwindled to sporadic cases until a resurgence in 2006. Based on the data of National Vector Borne Disease Control Programme (NVBDCP), the number of cases reported in 2013 was about 74 454 for dengue with 167 deaths and 18 639 for chikungunya. The number of cases reported is increasing, probably because of the availability of IgM detection kits produced and distributed by National Institute of Virology through NVBDCP and better reporting. In the absence of well-structured epidemiological studies, this review attempts to summarize reports on dengue and chikungunya outbreaks from various regions of India. For dengue, young adults are the major group affected; the severity of disease in India is still lower than that reported elsewhere in South-East Asia; and paediatric cases of dengue haemorrhagic fever have a high mortality. For chikungunya, all age groups are affected but severe manifestations are more often seen in children. Persisting arthralgia, neurological syndromes and non-neurological manifestations are recorded. Changes in the genotype and mutations in the genome have been detected for both dengue and chikungunya viruses. The review ends with a short summary of the most recent vector-control studies.

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Ticks are distributed worldwide and can harbourand transmit a range of pathogenic microorganisms that affect livestock and humans. Most tick-borne diseases are caused by tick-borne viruses. Two major tick-borne virus zoonotic diseases, Kyasanur forest disease (KFD) and Crimean-Congo haemorrhagic fever (CCHF), are notifiable in India and are associated with highmortality rates. KFD virus was first identified in 1957 in Karnataka state; the tick Haemaphysalis spinigera is the main vector. During 2012–2013, cases were reported from previouslyunaffected areas in Karnataka, and newer areas of Kerala and Tamil Nadu states. These reports may be the result of improved active surveillance or may reflect altered virus transmission because of environmental change. CCHF is distributed in Asia, Africa and some part of Europe; Hyalomma spp. ticks are the main vectors. The existence of CCHF in India was first confirmed in 2011 in Gujaratstate. In 2013, a non-nosocomial CCHF outbreak in Amreli district, as well as positive tick, animal and human samples in various areas of Gujarat state, suggested that the virus is widespread in Gujarat state, India. The emergence of KFDand CCHF in various Indian states emphasizes the need for nationwide surveillance among animals and humans. There is a need for improved diagnostic facilities, more containment laboratories, better public awareness, and implementation ofthorough tick control in affected areas during epidemics.

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Fifty years after narrowly missing the opportunity to eliminate malaria from Sri Lanka in the 1960s, the country has now interrupted malaria transmission and sustained this interruption for more than 12 months – no indigenous malaria cases have been reported since October 2012. This was achieved through a period overlapping with a 30-year separatist war in areas that were endemic for malaria. The challenge now, of sustaining a malaria-free country and preventing the reintroduction of malaria to Sri Lanka, is examined here in the context of rapid postwar developments in the country. Increased travel to and from the country to expand development projects, businesses and a booming tourist industry, and the influx of labour and refugees from neighbouring malarious countries combine with the continued presence of malaria vectors in formerly endemic areas, to make the country both receptive and vulnerable to the reintroduction of malaria. The absence of indigenous malaria has led to a loss of awareness among the medical profession, resulting in delayed diagnosis of malaria despite the availability of an extensive malaria diagnosis service. Highly prevalent vector-borne diseases such as dengue are competing for health-service resources. Interventions that are necessary at this critical time include sustaining a state-of-the-art surveillance and response system for malaria, and advocacy to maintain awareness among the medical profession and at high levels of government, sustained funding for the Anti-Malaria Campaign and for implementation research and technical guidance on elimination. The malaria-elimination effort should be supported by rigorous analyses to demonstrate the clear economic and health benefits of eliminating malaria, which exceed the cost of a surveillance and response system. An annual World Health Organization review of the programme may also be required.

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Background: Vector-borne diseases (VBDs) caused by parasites and viruses are a major cause of morbidity and mortality in Madhya Pradesh (MP), central India. These diseases are malaria, lymphatic filariasis, dengue and chikungunya. Epidemiological information is lacking on different VBDs that are commonly prevalent in rural-tribal areas of MP, except on malaria. Methods: The studies were carried out at the request of Government of Madhya Pradesh, in three locations where many VBDs are endemic. Data on malaria/filaria prevalence were collected by repeatedly undertaking cross-sectional parasitological surveys in the same areas for 3 years. For dengue and chikungunya, suspected cases were referred to the research centre. Results: Monitoring of results revealed that all the diseases are commonly prevalent in the region, and show year-to-year variation. Malaria slide positivity (the number of malaria parasitaemic cases, divided by the total number of blood smears made) was 18.7% (190/1018), 16.4% (372/2266) and 20.4% (104/509) respectively in the years 2011, 2012 and 2013. There was a strong age pattern in both Plasmodium vivax and P. falciparum. The slide vivax rate was highest among infants, at 5% (odds ratio [OR] = 3.8; 95% confidence interval [CI] – 1.5 to 9.4; P<0.05) and the highest slide falciparum rate was 20% in children aged 1–4 years (OR = 2.0; 95%CI 1.5 to 2.7; p<0.0001). This age-related pattern was not seen in other VBDs. The microfilaria rate was 7.5%, 7.6% and 7.8% in the years 2010, 2012 and 2013, respectively. Overall, microfilaria rates were higher in males (8.7%) as compared to females 6.4% (OR = 1.5; 95% CI = 1.1 to 2.0; P < 0.01). The prevalence of dengue was 48% (dengue viruses 1 and 4 – DENV-1 and DENV-4), 59% (DENV-1) and 34% (DENV-3) respectively, in the years 2011, 2012 and 2013 among referred samples, while for chikungunya very few samples were found to be positive. Conclusion: Despite recent advances in potential vaccines and new therapeutic schemes, the control of VBDs remains difficult. Therefore, interruption of transmission still relies on vector-control measures. A coordinated, consistent, integrated vector-management approach is needed to control malaria, filaria, dengue and chikungunya.

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About 95%of India’s population resides in malaria-endemic areas and, according to government sources, 80%of malaria reported in the country is confined to populations residing in tribal, hilly, difficult and inaccessible areas. Using a nationally representative sample, this study has estimated the economic burden of malaria in India by applying the cost-of-illness approach, using the information on cost of treatment, days lost and earnings foregone, from the National Sample Survey data. A sensitivity analysis was carried out, by presenting two alternative scenarios of deaths. The results indicate that the total economic burden from malaria in India could be around US$ 1940 million. The major burden comes from lost earnings (75%), while 24%comes from treatment costs. Since mortality is low, this is not a major source of economic burden of malaria. An analysis of the trend and patterns in public expenditure by the National Vector Borne Disease Control Programme shows a declining focus of the central government on vector-borne diseases.Also, allocation of financial resources among states does not reflect the burden of malaria, the major vector-borne disease in the country.

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Background:During September 2012, an increased number of fever cases was reported from Ramnagar-II block, Purba Medinipur district. This study investigated the outbreak, with the following objectives: to describe the distribution of fever cases, to determine the risk factors and to recommend preventive measures. Materials and Methods:The clinical features, date of onset and outcome of all cases of fever were listed. Blood specimens were collected from affected patients and sent for serological examination. An epidemic curve was plotted and environmental and entomological surveys were carried out. Results:There was a total of 100 cases, of which 56% (56/100) were men.Among the four villages studied, the highest number of cases was from Gopalpur 37% (37/100), followed by Badalpur 26% (26/100); 19% (19/100) of cases had a history of migration from dengue-endemic areas. The majority of cases were in age group 15–45 years – 52% (52/100), followed by the age group >45 years – 28% (28/100). All the cases had history of fever (100%), followed by myalgia – 82%, headache – 78%, and retro-orbital pain – 73%. The outbreak started on 7 September 2012, peaked on 18 September, then gradually declined and no further cases were noted after 28 September 2012. Seventy-nine percent (79/100) of cases were NS1 test positive (non-structural antigen-1) and 72% (13/18) cases were positive on a dengue monoclonal antibody (IgM) capture enzyme-linked immunosorbent assay (MAC-ELISA) test. All recovered except one (case-fatality ratio: 1%). The values for Household Index, Container lndex and Breteau Index of the four villages were: Badalpur, 3%, 10% and 5%; Gopalpur, 13%, 23% and 18%; Ramchandrapur, 9%, 11%, and 13%; and Tajpur, 2%, 2% and 2%. Conclusion:The outbreak was probably due to dengue fever. The study led to a recommendation to destroy water containers and use mosquito nets. The outbreak was controlled.

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Background:Dengue is endemic in Maldives. The largest epidemic to date was in 2011. This study evaluates the surveillance system for dengue during 2011, identifies gaps and suggests ways to improve. Methods:This evaluation of the national surveillance system for dengue was done in September to October 2012, using an evaluation tool based on United States Centers for Disease Control and Prevention (US CDC) guidelines, staff involved in surveillance of different levels, and doctors expected to notify, were interviewed, and surveillance data from the Health Protection Agency (HPA) were compared by use of an independent database of the country’s national referral hospital in Malé, Indira Gandhi Memorial Hospital (IGMH), to assess sensitivity and timeliness. Results:National surveillance is conducted by HPA, which collects information daily from a network of health facilities. Standard case definitions were published, butthey were not easily accessible to clinicians. The quality of data was acceptable. Information is disseminated as annual communicable disease reports to health facilities and uploaded onto the official website. The timeliness of reporting was good (median 2 days). However, the usefulness for early warning of outbreaks was limited, owing to central and peripheral resource limitations. Data were useful for planning. Sensitivity was 0.54. Acceptability by clinicians was poor, owing to the lack of feedback reaching them. The reporting rate was high from the paediatric ward in IGMH (85%), where the responsibility of notifying was also assigned to ward in-charge and support staff, but it was extremely low from the medical ward (1.7%), where only doctors were given the responsibility. Conclusion:This evaluation shows the performance of the dengue surveillance system was good overall. However, clinicians need more regular feedback. The performance could be improved significantly by written protocols, legislature and assigning the responsibility of surveillance in hospitals to ward managers in addition to doctors.

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In 1998, the resurgence of Plasmodium vivax malaria in the Democratic People’s Republic of Korea quickly increased to an epidemic, with 601 013 cases reported I during 1999–2001. The introduction of mass primaquine preventive treatment (MPPT) in 2002 was followed by a rapid reduction of malaria disease burden. The intervention has been well accepted by the community. Doctors were part of a strong functional health system with the ability to deliver interventions at the household J level. MPPT was considered for control of malaria after a study conducted in two J neighbouring endemic villages (ris) involving 320 healthy adults demonstrated that presence of parasitaemia was significantly lower among those receiving MPPT than those who did not. Similarly, in a mass blood survey conducted in the study sites during May, 2002 involving 5138 persons in study and 4215 in comparison areas, the total positive results were 7–10 times rarer in the treatment group both before and after the malaria transmission season. In addition, the number of malaria cases in the MPPT treatment ris was strikingly lower than control ris in every month during the malaria transmission season of 2002. The prevalence of G6PDD deficiency in DPR Korea is low, haemolytic events are rare and deaths due to MPPT have not been reported. MPPT in itself is a powerful intervention and the decision to deploy it depends on the epidemiology of malaria, urgency of malaria control and resources available in the country.

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Artemisinin resistance is a major threat to global malaria control and elimination efforts. Myanmar detected the first indication of the resistance in 2009 in the eastern part of the country, bordering Thailand. Since 2010, WHO has played a vital role in ensuring that a comprehensive programme on the containment of the resistance is in place. This paper documents achievement made in terms of output, outcomes and early impact on malaria from July 2011 to December 2013. It also identifies enabling factors to success and, most importantly, challenges awaiting the national programme and its partners.

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Background:Dengue and chikungunya present with very similar signs and symptoms in the initial stage of illness and so it is difficult to distinguish them clinically. Both are transmitted by Aedes aegypti and Aedes albopictus mosquitoes. This study was conducted with the aim to explore the co-circulation of dengue and chikungunya viruses in central India. Materials and methods:Samples from suspected dengue cases were subjected to dengue immunoglobulin M (lgM) enzyme-linked immunosorbent assay (ELISA) and dengue-negative samples were tested with chikungunya-specific IgM ELISA. The samples collected in acute phase of illness were tested by nested reverse transcription polymerase chain reaction (nRT-PCR). Chikungunya virus (CHIKV) sequences were analysed to determine their genotype. Results:Of 138 samples screened for dengue, 21 (15.2%) were positive, and of 119samples screened for chikungunya, 13 (10.9%) were positive. Dengue viruses 1 and 4 were found co-circulating with chikungunya virus in Jabalpur, central India. The chikungunya virus detected belonged to the East Central South African genotype. Conclusion:Accurate and timely diagnosis would help in patient management and use of resources. It is advocated to simultaneously test samples for these two diseases in endemic areas. This will also aid in understanding the epidemiology of chikungunya.

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A comprehensive and integrated assessment of health-system functioning requires measurement of universal health coverage (UHC) for disease-specific interventions. This paper aims to contribute to measurement of UHC by utilizing locally available data related to malaria in Nepal. This paper utilizes the elements of UHC as outlined by the World Health Organization (WHO). The concept of UHC represents both improvements in health outcomes and protection of people from poverty induced by health-care costs. Measuring UHC focusing on a tropical disease highlights the progress made towards elimination of the disease and exhibits health-system bottlenecks in achieving elimination of the disease. Several bottlenecks are found in the Nepalese health system that strongly suggest the need to focus on health-system strengthening to shift the health production function of malaria intervention. The disaggregated data clearly show the inequality of service coverage among subgroups of the population. Analysis of effective coverage of malaria interventions indicates the insufficient quality of current interventions. None of households faced catastrophic impact due to payment for malaria care in Nepal. However, the costs of hospital-based care of malaria were not captured in this analysis. The paper provides the current status of UHC for malaria interventions and reveals system bottlenecks on which policy-makers and stakeholders should focus to improve Nepal's malaria control strategy. It concludes that financial coverage of the malaria intervention is at an acceptable level; however, service coverage needs to be improved.

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Understanding and improving the durability of long-lasting insecticidal nets (LLINs) in the field is critical for the success of malaria prevention using mosquito nets, as well as contributing to procurement decisions based on the number of years of protection, rather than the current practice of unit cost. Using the recently published guidelines from the World Health Organization (WHO) some progress has been made in the monitoring and assessment of performance of nets in the field. This paper describes the protocol of an ongoing retrospective study of the attrition rate, physical integrity and bioefficacy of three polyester LLIN products that were distributed during 2010 to 2013 in Nepal. It is hoped that robust and auditable data on net survival (physical integrity and bioefficacy) of these three brands in different environments will assist the Nepal National Malaria Control Programme in planning future LLIN-replacement strategies, including behaviour-change communication about LLIN care and maintenance. The advantages and disadvantages of prospective and retrospective cross-sectional approaches are discussed, including appropriate strategies to validate the timing for mass distribution of nets. Similar studies should be done in other countries to (i) track LLIN durability to support management of resupply, and (ii) inform procurement decisions at the global level. New, more predictive, textile laboratory testing is also urgently needed.

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Background and Methods India is one of the countries in the World Health Organization South-East Asia Region that regularly reports outbreaks of dengue fever (DF)/dengue hemorrhagic fever (DHF). As effective control and preventive programmes depend upon improved surveillance data, this study was carried out to report the seroprevalence of dengue virus infection in an area around Jamnagar city, Western India. ^[1] Methods The laboratory records of clinically suspected dengue patients from July 2008 to June 2011 were analysed retrospectively for the results of immunoglobulin M (IgM) anti-dengue antibodies, tested by dengue monoclonal antibody (IgM) capture enzyme-linked immunosorbent assay (MAC ELISA). Variations in disease incidence by sex, age group and season were assessed. Results A total of 903 serum samples were tested, of which 253 were positive. The majority were males (72%) and in the age group of 16–30 years. The incidence of dengue peaked in October and slowly tapered by December. Conclusion Dengue cases were higher during September to December, in the post-monsoon season. This observation is useful for planning special preventive strategies. The study draws attention to the susceptibility of the male, young adult age group.

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Background:Dengue is rapidly becoming established in north-east India and spreading, on account of rapid urbanization and population movement, with reported morbidity and attributable death cases. This study aims to determine the seasonal abundance of Aedes (Stegomyia) albopictus and Aedes (Stegomyia) aegypti in Guwahati metropolis and suburban settlements; to characterize the breeding resources for these mosquitoes; and to ascertain the status of their susceptibility to adulticides and larvicides. Methods:Mosquito larval surveys were carried out in different localities in both Guwahati city and adjoining suburbs from January to December 2013, to determine the seasonal abundance of disease vectors and their breeding preferences. The insecticide susceptibility status of mosquito adults and larval populations of both Aedes aegypti and Aedes albopictus was ascertained, using World Health Organization standard diagnostic concentrations and test procedures. Results:The study revealed that both Aedes aegypti and Aedes albopictus are widely abundant in Guwahati city and suburbs, and breeding in a wide variety of resources. Aedes albopictus, however, was the predominant mosquito species in suburbs, breeding preferentially in flower vases, cut-bamboo stumps and leaf axils. Aedes aegypti was the most common in the city, breeding predominantly in discarded tyres, cement tanks and used battery boxes. Both Aedes aegypti and Aedes albopictus were resistant to dichlorodiphenyltrichloroethane (DDT; 4%), but susceptible to malathion (5%), and exhibited a varied response to pyrethroids. However, larval populations of both these mosquito species were susceptible to larvicides, including malathion (1.0 mg/L), temephos (0.02 mg/L) and fenthion (0.05 mg/L), at much lower dosages than diagnostic concentrations. Conclusion:Given the seasonal abundance and case incidence in city areas, it is highly probable that Aedes aegypti is the predominant mosquito vector transmitting dengue virus. The study results have direct relevance for the state dengue-control programme, for targeting interventions and averting outbreaks and spread of disease.

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Background: Malaria is an important health problem in Timor-Leste. Although funding has been provided to reduce the burden of this disease, few studies have investigated whether this has improved malaria-related knowledge, management of symptoms, and treatment in rural communities. The aim of this study was to explore the perceptions and practices undertaken in relation to all aspects of malaria control by members of two rural communities in Timor-Leste. Methods:A qualitative study was undertaken in two rural hamlets in Timor-Leste. Research methods included transect walks, focus groups and semi-structured interviews. Content analysis was used to identify themes. Results:The location of the hamlets near rice fields, leaking taps, inadequate water supplies and dumping of waste from the local hospital provided opportunities for mosquitoes to breed. Most participants were aware of the link between mosquitoes and malaria, but a lack of control over their environment was a major barrierto preventing malaria. The distribution ofbed nets had occurred once, and was the only intervention undertaken bythe National Malaria Control Programme. However, limiting the distribution of bed nets to pregnant women and children aged under 5 years had resulted in some focus group respondents believing that only those in these groups could be affected by malaria. Self-diagnosis and home treatmentwere common. Treatment for unresolved infections depended on access to transport funds, and belief in the power of traditional healers. Conclusion:Improvements in infrastructure, empowerment of rural communities, and better access to treatment are recommended if the incidence of malaria is to be reduced throughout the country.

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The National Academy of Vector Borne Diseases (NAVBD) was founded at Bhubaneswar in 1994, by Dr AP Dash, along with 15 like-minded scientists from all over India. NAVBD is a non-profit academic organization in India, dedicated to advancing and promoting knowledge on vectors and vector-borne diseases, and encouraging scientists and members of the academy to conduct research on vectors and vector-borne diseases. NAVBD convenes national and international seminars, symposia and workshops to exchange knowledge on recent advances in the field of vectors and vector-borne diseases and raise public awareness. Plans are under way to expand the Academy’s activities to the rest of the South-East Asia Region.

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Leishmaniasis is a major public health problem in various part of world; it has also emerged in new geographic areas and host populations. Visceral infection can remain subclinical or become symptomatic, with an acute, subacute or chronic course. Kala-azar, or visceral leishmaniasis (VL), presents as fever, pancytopenia and hypergammaglobulinaemia. The presence of splenomegaly is characteristic of VL. It may be absent in immunocompromised patients, who may present atypically. Absence of splenomegaly is rare in immunocompetent patients, though it may occur in the early stages. Atypical presentations can be challenging to the clinician. This paper presents an atypical presentation of kala-azar, with multi-organ failure in the absence of splenomegaly or fever.

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