More than 1,000 people a day are seeking dengue fever tests in Swat District in Pakistan’s Khyber-Pakhtunkhwa Province (KP). At least 22 have died and holiday leave has been cancelled for district medical staff.
The outbreak began in Swat in mid-August and has spread to neighbouring districts. Health officials say nearly 8,000 people have tested positive for the virus and that the death toll could be much higher than 22, as most people appear not to be seeking medical treatment.
The number of infections is on a par with an outbreak of dengue fever in 2011 in Lahore in which more than 17,000 people were infected and over 300 died in four months.
Shifa Medical Complex in Swat's biggest city, Mingora, is full of dengue patients waiting for, or receiving, treatment. One of the doctors, Abdul Wasih, says most of the over 100 patients a day coming to his private clinic there are seeking treatment for dengue.
A number of top officials, including the KP chief minister and governor, have visited Mingora to see the epidemic first hand. KP has released more than Rs. 65 million (US$612,000) in emergency aid to deal with the outbreak.
A few blocks away at the Saidu Teaching Hospital, medical doctor Wasil Ahmad, recalls the latest death: a 22-year-old man from the village of Bishbanr Khwar, some 20 km away.
“He came too late,” said Ahmad, who is in charge of the dengue cell at the hospital. “First he went to a private clinic; they did not test him properly and prescribed garbage [drugs], [thinking] it was malaria or typhoid.”
When the man's fever did not subside after five days, he came to the Saidu Teaching Hospital, but by then he had suffered haemorrhaging and gone into shock, the final stage of dengue fever.
Ahmad said his hospital saw 28 cases of dengue last year, and 58 in 2011, but never any deaths. “Right now, for this area, this is the most important problem - more dangerous than polio or malaria, or any other diseases,” he told IRIN.
Most of the dengue patients at the hospital are aged 20-30, and there are twice as many males as females, something Ahmad attributed to men coming to the area to find work and tending to work outside, while local women stayed indoors.
The teaching hospital is Swat district’s principal facility for treating dengue patients. Testing for the virus - which can cost thousands of rupees at private clinics - is provided free of charge, along with basic fever-reducing drugs for those who test positive.
Ahmad said more than 1,200 people show up daily to be tested. The hospital has a capacity of 560 beds; more than half have been assigned to dengue patients, but only patients in a serious condition are admitted.
“Everyone's vacations have been cancelled, and doctors and nurses are even coming in from [KP capital] Peshawar,” said Muhammad Elyaz, a nursing student volunteering to help with the outbreak.
Najma, 19, was vomiting and suffering from body aches for several days, so her father decided to bring her to the hospital. Three days later, her mother also contracted dengue. Now they are together in the women's ward.
“Everyone, everyone is sick with this,” said Najma's father. One adjacent home has two kids with dengue, and the father in the other is also sick. But like many Swat residents, they decided to treat themselves at home.
Ahmad says it is likely that 90 percent of dengue patients fail to seek treatment.
“In every house, it seems there are three or four people sick,” said Anaitullah, who owns a shop selling handicrafts in Nishat Chowk, near the city centre.
His brother and three of his children were sick with dengue, but after hearing about the crowds at the Saidu Teaching Hospital, they went to private clinics where they have to pay.
“Dengue is a serious problem.” said Anaitullah. “[The government] should show [it] some importance like the Punjab government did.”
The 2011 outbreak in Lahore was contained by the Punjab government thanks to an aggressive awareness campaign, targeted pesticide use, and stringent efforts to clear standing water. In Swat, officials are in regular contact with dengue experts in Punjab, but the KP government has not adopted all of the same methods.
Applying Punjab’s lessons
“Punjab officials came and taught us their mistakes and shortcomings,” said Haider Ali, who is in charge of the dengue control effort. “Books and seminars teach a lot, but you can't learn until you have to deal with something yourself.”
Ali lists a range of initiatives the government has taken to raise awareness and collect data on the dengue outbreak.
Ali says they are compiling the locations of each reported patient, but unlike in Punjab, this is not being used in real time: the most detailed information is contained in stacks of papers Ali showed IRIN and which have yet to be entered into any database.
The documents are reports from teams of Lady Health Workers, more than 1,300 trained women volunteers who visit homes in Mingora to check on standing water and advise women on how to avoid being infected with dengue.
They often tag along with polio vaccination workers, and are provided with security by a pair of Frontier Corps paramilitaries. Ideally, the home of each dengue patient should be visited.
Ali says the plan was to spray pesticide in neighbourhoods where there are known to be patients, but many say this has yet to happen.
Swat is still under emergency rule, giving the authorities wide-ranging powers, which they have used to ban the outdoor storage of tyres (known to be breeding grounds for mosquitos). Farrukh Attique, deputy commissioner of Swat, said more than 30 criminal cases have been lodged against people storing used tyres outside.
To raise awareness, students have been assigned “homework” - to survey their homes for sources of mosquito larvae. The government has purchased airtime on local channels and published warnings in local newspapers about the outbreak; signs warning people about dengue symptoms have been posted around town.
While in August, 200-300 cases of dengue fever were being reported each day, that number is now down to around 100 a day, something Attique attributes to the current awareness drive. “The downtrend is due to our work, not due to the weather changing.”
As for the cause, Ahmad says an outbreak of Hepatitis A late last year may have prompted a change in water storage behaviour in homes.
“The water supply here is contaminated,” he said. “The sewage lines mix with the drinking water, and the water [supply] is sometimes unreliable... so the locals store water.” One tank is usually on the roof and covered, but another is kept inside the home and left uncovered - the perfect breeding ground for mosquitoes.
The rate of infections is expected to decline by late October, as temperatures fall below 16 degrees Centigrade, making it too cold for the dengue-carrying mosquitos to survive.
Health officials fear next year’s dengue death toll could be worse: There are four serotypes of dengue viruses that can cause the infection, and someone who is infected with just one can usually fight it off. However, each subsequent infection by another dengue serotype dramatically increases the chances of developing dengue shock syndrome and dying.
Punjab has seen repeated outbreaks of dengue, so the mortality rate there was higher in 2011 than this year's outbreak in Swat, which has been spared an epidemic until now.
“Next season, before suitable conditions for the mosquitos to grow [emerge],” said Ali, “we will go and eliminate larvae sites we identified this year. This is our biggest goal.”