Based on my experience, I see the same pattern as 2007 emerging now

As Cambodia enters its dengue season, with outbreaks in four out of 24 provinces, the National Dengue Control Programme is warning that a repeat of the 2007 epidemic – when about 40,000 people were hospitalised, more than 10,000 in one week – may be imminent.

“Based on my experience, I see the same pattern as 2007 emerging now,” said To Setha, a vector control specialist at the NDCP, pointing to the higher number of cases than usual during the final months of last year and the first two months of this year.

Rekul Huy, chief of epidemiology at the NDCP, is also alarmed by the high number of cases during months when dengue is usually rare.

A change in the serotype of the virus, which has four, from DEN2 to DEN1 detected in the middle of last year also concerns him, as does the increase in the percentage of patients with dengue haemorrhagic fever in the first four months of this year: from about 50 percent last year to two-thirds this year. An increase in DHF patients signals the possible presence of a new serotype, he said.

In Cambodia, where dengue is endemic, the number of cases spikes in June and July – a period NDCP director Ngan Chantha refers to as the “nightmare season” – with major outbreaks occurring in three- to five-year intervals.

Ngan Chantha said the number of cases at the beginning of this year had reached the “alert” level, signalling a possible nationwide outbreak during the rainy season.

This year, however, his department faces severe financial constraints to implement the swift interventions necessary to contain local outbreaks before they spiral out of control as in 2007.

The Asian Development Bank, which contributes about three-fifths of the NDCP’s less than US$500,000 annual budget, has yet to disburse the funds, while the decentralisation of health services that began in 2008 has left the NDCP’s 12 staff unclear about what many of their provincial counterparts are doing.

Furthermore, there has been only one test so far this year to detect the prevalent serotype, according to Rekul Huy. Testing is not conducted at the hospitals where most dengue patients are treated, which are run by a Swiss foundation that offers free treatment for children and a high level of service but operates outside the state-run system.

National officials do not know where or when the larvicide Abate, their primary preventative tool, is being distributed because it is now held by provincial officials, Rekul Huy said.

Steven Bjorges, team leader of the malaria and vector-borne diseases department of the World Health Organisation in Cambodia, explained that the high turnover of officials at the provincial level meant that in some provinces they lacked experience in preventing or containing outbreaks. “Everyone likes decentralisation, but the adverse consequences can perversely result in less optimal public health outcomes,” he said.

He is, however, less alarmed than officials at the NDCP that a repeat of the 2007 epidemic is imminent because there have been fewer cases reported nationwide this year than last. “But that could change next week,” he added.

Bjorges agreed that the chronic lack of funding undermined the NDCP’s efforts to prevent or contain outbreaks. “We’re begging for funds year after year. If the dengue programme could get sustained, even limited funding, for a long period, it could accomplish so much more,” he said.

“Foreign funding of public health in Cambodia is often not directed at the primary health needs of Cambodians, and it sometimes distorts the delivery of services,” Ngan Chantha said. “What is more alarming than a dengue outbreak is the lack of funding to deal with it.”

The NDCP has been trying to expand its most successful project for preventing dengue for the past four years, using guppy fish to get rid of the larvae of the mosquito that transmits dengue from water storage containers. In the 16 villages where this project has been operating since 2004, there have been no outbreaks, To Setha said.

The small amount of funding to expand the project, which costs about $1 per person a year to maintain, has been restricted to either one- or one-and-a-half-year grants, which have been insufficient to allow for its sustainability in other villages, he said.

It takes about four years for a health centre and its surrounding villages to develop the physical and social infrastructure needed to sustain it, he said.