The current outbreak of dengue fever has started to cross provincial boundaries, gaining a strong foothold in Islamabad Capital Territory and the Khyber Pakhtunkhwa province after a deadly streak in the Punjab. Lahore, in particular, has been hit hard with dengue larvae found in more than 71,000 houses and nearly 100 cases being reported on a daily basis.

Dengue fever is a mosquito-borne disease, generally associated with a confluence of factors including urbanisation, poor water sector services and sanitation and environmental changes. A study by the Oxford University places Pakistan, along with Indonesia, Sri Lanka, Brazil and India, at high risk of dengue. The disease is spread when the female Aedes aegypti mosquito bites an infected person and becomes a carrier of the virus.

It is crucial to point out that the said mosquito is a daytime feeder and its peek biting times are early morning and the time before sunset. This mosquito prefers to bite indoors, and can bite people without being noticed because it approaches them from behind, generally biting the ankles and elbows.

The current dengue outbreak has once again laid bare the tall claims of any sort of effectiveness in governance. A notice has been issued by the Lahore High Court (LHC) to the chief secretary of the Punjab, the deputy commissioner of Lahore, and the Lahore Waste Management Company (LWMC), citing poor sanitation as a contributor to the spread of dengue virus. Just when the health departments had begun to take a sigh of relief following a slowdown in Covid-19 cases, a spanner has been thrown in the works in the form of another major public health challenge, albeit one that was successfully controlled in the previous regime.

Dengue fever control demands a multi-pronged response built upon engagement well beyond the health sector. Coordinated action among partners from public and private sectors, a robust approach for vector management and eradication and effective monitoring and evaluation are only the initial steps for controlling a public health challenge like dengue. The guiding principle, above all, according to the World Health Organisation (WHO), is prevention, complemented by epidemiological surveillance and sustained, long-term efforts. The cornerstone of this is a proactive approach that acknowledges the problem (dengue larvae following a record monsoon) and initiates action (fumigation and eradication) before the challenge snowballs into an epidemic.

As hospital beds continue to fill, the crumbling state of the curative healthcare system necessitates revisiting the existing strategy, which will be remembered as a spectacular failure of a once world-renowned dengue management system. An approach built upon effective case management, integrated disease surveillance and preparedness, and sustainable vector control, propped up by research can transform the way dengue will be handled in the years to come.

Dengue-related mortality can be reduced to near zero through effective clinical management of cases. An essential component of this is the presence of reliable laboratory testing facilities. Such a setup, in addition to dedicated dengue wards, needs to be well thought out. The mechanism for their establishment should be in motion well before the monsoon ends.

Besides, training of all medical and non-medical staff involved in treating the disease is essential for effective triage and management at primary and secondary care levels.

Insecticide spraying has emerged as the most effective solution for vector control in dengue. However, delivering spray indoors and in all households in a rapidly growing megalopolis like Lahore may not be practical

urveillance has been identified as a critical component of every successful dengue control programme in the world. Understanding the spatial and temporal distribution of dengue cases is crucial in order to allocate sufficient resources for its control and eradication. Surveillance activities include inspection of hotspots where the Aedes mosquitoes breed. This includes households and commercial establishments with poor sanitation, inspection of water containers including desert coolers and water tanks, plant nurseries, graveyards, and parks, to name a few.

The monsoon and post-monsoon period when puddles are abundant provide an ideal breeding habitat which can then exacerbate the prevalence of dengue in the following weeks and months. As such, surveillance must be complemented with regular fumigation or other corrective measures to fill up puddles and clean existing water storage sources regularly. Furthermore, surveillance systems must be integrated with provincial and national information systems for effective policy-making and action at local, provincial and regional levels.

A third crucial component that cannot be over-emphasised is sustainable vector control. It is evident that this year vector control measures were seriously taken up only after the onset of the epidemic, which is too late to achieve significant impact. Routine short-term interventions, which are neither sustained nor evaluated through real data are mere eyewash, ineffectively burdening resources and the provincial exchequer instead of creating a meaningful change. A successful vector control effort requires sound monitoring and evaluation.

Traditionally, vector control has been treated through source elimination: emptying water tanks, filling up puddles or ponds etc. However, this does not preclude the Aedes mosquito from laying eggs in unconventional sites, which is what happened in Puerto Rico and Singapore. Thus, insecticide spraying has emerged as the most effective solution for vector control in dengue. However, delivering spray indoors and covering all households in a rapidly growing megalopolis like Lahore may not be practical. Therefore, methods to deliver insecticide treatments rapidly and efficiently into large urban communities must be researched.

It is crucial to point out that insecticide sprays are not a one-stop solution: mosquitoes have shown resistance to certain chemicals and, thus, assessing the effectiveness of insecticides also needs to be taken up by the government.

Defining the relationship between mosquito breeding habits and prevalence, transmission risk, and epidemiological outcomes will help define a practical policy for the province. Furthermore, establishing various action thresholds according to the emerging epidemiological conditions, and utilising mechanisms such as the provincial disaster management setup can completely transform preparedness and outbreak response. Additionally, an effective public outreach strategy and behaviour change communication campaign prior or during the monsoon season can help people safeguard against the disease at the household level.

Sustainability and continuity of control measures are essential. Dengue prevention and control needs a more participatory approach at the local level, and key decision-makers and community leaders must be tapped for better communication and collaboration. There is a need to recognise and use the existing networks for responding to public health emergencies. In order to ensure implementation and sustainability of vector control at the provincial level, a national coordination body — similar to the NCOC — may be set up for public health emergencies to integrate surveillance and control measures across the board.

The aforementioned measures require multi-dimensional research including evaluating the impact of virus population structure, urbanisation and land-use changes, and the impact of climate parameters on dengue epidemiology, to name a few. Using this information, cost-effective strategies can be chalked out; local interventions can be scaled up; and protocols for surveillance, water resource management and sustainable vector control can be mainstreamed in the Punjab, and across Pakistan.

The writer is a development sector professional with nearly a decade of experience in communications and reporting. He has supported the implementation of The World Bank’s Disaster and Climate Resilience Improvement Project (DCRIP) and ADB’s Flood Emergency Reconstruction and Resilience Project (FERRP) in Pakistan