Dengue fever: How does Sri Lanka’s health system cope with the threat?

Author: Nikita Misella Hansen

This summer I participated in a three-week field course on cross-disciplinary health research in Anuradhapura, Sri Lanka. The University of Copenhagen has a collaboration with Rajarata University’s medical department, which makes it possible for students to explore Sri Lanka in a scientific setting by conducting field research within a subject of interest. In this case my research team and I wanted to focus on the field of infectious diseases, more precisely: dengue fever.

Infectious diseases continue to be a major threat to the health of people living in low and middle-income countries. Dengue fever is a mosquito-borne viral infection, known to exist in four different serotypes. If a person is bitten by a dengue mosquito, they can become ill after a couple of days with high fevers and joint pains. There is still no cure for dengue; only supportive treatment is possible. New dengue fever cases are reported every day in Sri Lanka, with the most recent massive outbreak in 2017. In a country with a population of approximately 21 million there were 80,732 dengue cases reported between January and July; 215 of these resulted in death. WHO estimates a total of 670,000 symptomatic cases in Sri Lanka annually. In 2012, dengue fever was ranked as the most important mosquito-borne viral disease in the world; outbreaks exert a major burden on populations, health systems and economies.

Sri Lanka is a tropical country with high humidity and warm temperatures throughout the year. There are two rainfall seasons in Sri Lanka: May to August brings plenty of rain to the western and southern regions, while from November to February rain comes to the dry north and eastern regions of Sri Lanka. Mosquitoes breeds in stagnant water, so monsoon rains are typically followed by two dengue fever peak periods; the main one in June/July and a second at the end of the year.

During our time in Sri Lanka, my research group and I wanted to explore the Sri Lankan health care system’s approach to dengue control, with the main focus on identifying ways the surveillance system could be improved. In order to collect data, we chose to focus mainly on Anuradhapura, where the field course was taking place. We undertook interviews with the medical officer of health, the public health inspector, nurses and doctors both at the medical ward within the hospital and in private practice, as well as the regional epidemiologist and malarial health officer. Besides interviews, we also had the opportunity to observe their daily work and their role in reporting new dengue cases to the authorities.

Our main findings were that Sri Lanka has a unique surveillance system that is very well- established. However, we did identify gaps that led us to suggest possible areas for improvement. When notified, the system responds to outbreaks by sending staff to find and eliminate potential mosquito breeding sites. Thus, staff could benefit a lot from having more structure when it comes to engaging with civil society. We found that some citizens in Anuradhapura received frequent household visits from the public health officer searching for potential mosquito breeding sites. Meanwhile, others in the same geographical area had only experienced such controls in their home once every seventh year. Another potential area for improvement is that the majority of the dengue surveillance system is paper-based, while some larger hospitals use an electronic system and are therefore more able to keep a more robust record of outbreaks and potential risk factors.

WHO describes dengue fever as a major global health problem. The surveillance system for dengue in Sri Lanka is part of the National Health information system, and therefore relies on inputs from a range of health care professionals across the country. These data are vital for the health of Sri Lankan people, and our project found that a more robust internet infrastructure is needed to keep track of potential new epidemic in different parts of Sri Lanka. This is not an impossible goal; infrastructure in Sri Lanka is growing, exemplified by the increasing number of citizens using the internet in their daily lives.

Sri Lanka is special in many ways, one being that it is an island; a benefit in terms of controlling mosquito-borne disease. Having successfully eliminated malaria in 2016, Sri Lanka has a good opportunity to address the gaps in its health care system and aim to also win the fight against dengue.

 

Acknowledgements
A warm thank you to my research team- Isabella Pepe Razzolini, Tobias Mussgnug, Samantha Gross and Monika Vaerst- for our collaboration in Sri Lanka.

Furthermore, thank you to medical student Sanura Hapuarachchi, who was a great help during the entire process. Finally, I would like to express my deep gratitude to our supervisor Dr. Janith Warnasekara, for teaching us so much about how to conduct field work in Sri Lanka, and for facilitating contact with several key stake-holders relevant to our project.