CHAPTER II
REVIEW OF LITERATURE
INTRODUCTION
The chikungunya epidemic involves both individual and community aspects because the patients are suffering from the pain and impairs to do even small activities and the total community has to pay a lot to both in treatment and in losing of man hours. This chapter of the study is trying to overview the problems of public health and chikungunya with the previous studies, expert reports and the comments of significant individuals.
This chapter supports the study by covering information on health, public health, hygiene, Public health and the difference between prevention and promotion, problems of public health system, communicable diseases, public health promotion, present threat to the Indian public health, kerala responses, severity of chikungunya and health literacy as an outcome of health promotion.
HEALTH
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO). The World Health Report 2007 - A safer future: global public health security in the 21st century marks a turning point in the history of public health, and signals what could be one of the biggest advances in health security in half a century. It shows how the world is at increasing risk of disease outbreaks, epidemics, industrial accidents, natural disasters and other health emergencies which can rapidly become threats to global public health security.
Health behaviours are strongly determined by the different social, economic and environmental circumstances of individuals and populations. Improvement of health literacy can help individuals to tackle the determinants of health better as it builds up the personal, cognitive and social skills which determine the ability of individuals to gain access to, understand and use of information to promote and maintain good health.
PUBLIC HEALTH
Public health is defined generically as the field of knowledge and institutionally organized practices aimed at promoting the health of populations (Sabroza, 1994). Public health is the study and practice of managing threats to the health of a community. The field pays special attention to the social context of disease and health, and focuses on improving health through society-wide measures like vaccination, the fluoridation of drinking water, or through policies like seatbelt and non-smoking laws.
The mission of public health is to "fulfill society's interest in assuring conditions in which people can be healthy." (Institute of Medicine 1988). The goal of public health is to improve lives through the prevention or treatment of disease. In 1920, C.E.A. Winslow defined public health as "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals". The public-health approach can be applied to a population of just a handful of people or to the whole human population. According to World Health Report, International Health regulations are needed because no single country, regardless of capability or wealth, can protect itself from outbreaks and other hazards without the cooperation of others. The report says the prospect of a safer future is within reach - and that this is both a collective aspiration and a mutual responsibility. Public health is typically divided into epidemiology biostatistics, and health services. Environmental, social, behavioural, and occupational health is also important subfields.
The focus of a public health intervention is to prevent rather than treat a disease through surveillance of cases and the promotion of healthy behaviors. In addition to these activities, in many cases treating a disease can be vital to preventing its spread to others, such as during an outbreak of communicable diseases or contamination of food or water supplies. Vaccination programme is an example of public health measures. Many diseases are preventable through simple, non-medical methods. For example, research has shown that the simple act of hand washing can prevent many contagious diseases. Therefore personal and community hygiene is very important in the disease prevention.
HYGIENE
Hygiene refers to practices associated with ensuring good health and cleanliness. The scientific term "hygiene" refers to the maintenance of health and healthy living. The term appears in phrases such as personal hygiene, domestic hygiene, dental hygiene and occupational hygiene and is frequently used in connection with public health. The term "hygiene" is derived from “Hygieia” the Greek goddess of health, cleanliness and sanitation. Hygiene is also a science that deals with the promotion and preservation of health. It is important to give focus on the prevention of diseases and promote the public health through awareness programmes and behaviour modification programmes to ensure the healthy existence of the community.
A study to assess the effect of ‘Integrated Health Promotion Initiative’ on Awareness among Opinion Leaders Regarding Hypertension found that the preventive mechanisms at the primary level is more effective than the health care activities in the district/ or state level through the hospitals(AR Dongre, PR Deshmukh and BS Garg 2008). It is clear from this study that the prevention is better than cure, but it not only focuses on vaccination programmes but also the community level awareness and behaviour modification towards a positive health.
PUBLIC HEALTH AND THE DIFFERENCE BETWEEN PREVENTION AND PROMOTION
To prevent means, "To forestall or thwart by previous or precautionary measures; provide beforehand against the occurrence of (something); make impracticable or impossible by anticipatory action; stop from happening". (New Shorter Oxford English Dictionary 1997).
Prevention in health, according to the classic work by Leavell & Clarck (1976:17), "Calls for action in advance, based on knowledge of natural history in order to make it improbable that the disease will progress subsequently".
Preventive actions are defined as interventions directed to averting the emergence of specific diseases, reducing their incidence and prevalence in populations. The discourse of prevention is based on modern epidemiological knowledge. It aims to control the transmission of infectious diseases and reduce the risk of degenerative diseases or other specific ailments. Health prevention and education projects are structured by circulation of scientific knowledge and normative recommendations to change habits.
To promote means "to further the development, progress, or establishment of (a thing); encourage, help forward, or support actively (a cause, process, etc.)" (New Shorter Oxford English Dictionary 1997). Traditionally, health promotion is defined more broadly than prevention, since it relates to measures that are not directed to a given disease or disorder, but serve to increase overall health and well-being (Leavell & Clarck, 1976: 19). Promotion strategies emphasize changing the conditions of people's lives and work, which form the structure underlying health problems, calling for an inter-sectoral approach (Terris, 1990).
PROBLEMS OF PUBLIC HEALTH SYSTEM
The major threats to the public health system are mainly the diseases, disasters, polluted land and water and drinking water and sanitation problems. Except the natural calamities, all other health problems can be reduced with the effective and timely intervention and awareness creation.
A disease is a condition that impairs the proper function of the body or of one of its part. Every living thing both plants and animals can succumb to diseases. There are hundreds of diseases exists with its own signs and symptoms. A symptom is something a patient can detect and the sign is something a doctor can detect. Every disease has some causes although the causes of some remain to be discovered. Every disease also displays a cycle of outbreak or beginning, course or time span of affliction. The diseases may either epidemic or endemic. An epidemic disease is one that strikes many people in a community. When it strikes the same region year after year it is an endemic disease.
COMMUNICABLE DISEASE
Communicable disease are those that can be passed between person such as by means of air born droplets from cough or sneeze, tiny organisms such as bacteria, virus, fungi and worms at a particular period of time at a particular population. It can be defined as an illness due to a specific infectious agent or its toxic products capable of being directly or indirectly transmitted from man to man, animal to animal or from the environment to man or animal. (CIOMS 1973)
Diseases which are caused by malfunctions of the body is called non communicable diseases. This includes organs or tissues degeneration, erotic cell growth, and faulty blood function and flaw. (Manorama year book 2008). Communicable diseases severely affect the population and public health. The control of communicable diseases depends on a healthy environment (clean water, adequate sanitation, vector control, and shelter), immunization, and health workers trained in early diagnosis and treatment.
The concept of disease control describes operations aimed at reducing:
1 the incidence of the disease
2 the duration of diseases, and consequently the risk of transmission
3 the effects of infection, including both the physical and psychological complications and
4 the financial burden to the community..
Control activity may focus on primary prevention or secondary prevention. Most of the control programmes combine the two (Park, 2005)
PUBLIC HEALTH PROMOTION
The preservation of public health is the responsibility of individuals, community and the Government. No community or government measures cannot give health otherwise each individual get oriented about the self care. Through the self care each one can protect themselves from the epidemics. But when talk in the community level, the concept is changed from “Health care for the people” to “health care by the people”. Participatory health care system evolved in India through the “Village Health Guide” Scheme in 1977. But the responsibility of state does not end with the individual and community health care. The constitution of India part IV declare as the health is one of the fundamental Right of the citizen and. Then it is the duty of the government to protect the public health and made adequate facilities to preserve it. (Justice R.K. Abichandani)
India is a signatory member of Alma-Ata Declaration 1978 and clearly indicated her commitment to the goal of “Health for All” through the National Health Policy in the year 1983. And also government established different mechanisms to maintain the public health from time to time. But still there is epidemic and endemic outbreaks strikes different part of the country. It shows the presence of some loopholes in the health care system of the country. According to Dr. K.Raghava Prasad the president of Indian Association of Preventive and Social Medicines there is a feeling that public health infrastructure in our country is deteriorating and there is diffidence on the part of the health system to face the threats posed by the new and old health problems. There is lack of standardized and effective public health interventions to tackle either disease outbreaks or natural disasters. The authorities usually respond to various health problems with a `crisis approach' instead of a `planned approach' for prevention and control. Further, the ad-hoc vertical programmes launched from time to time are adversely affecting the implementation and monitoring of the existing health programmes and services especially at the level of primary health care.
Some of the underlying causes for the public health crisis are low priority for public health specialty; dominance of generalities in policy making and programme planning; inadequate training of public health personnel, both basic and in-service; lack of focused public health research and lack of effective disease surveillance system. He suggests giving focus on specific problems or areas, identifying the problems accurately and building up research expertise in the chosen area, instead of conducting operational research, which is Problem solving research. (Dr. K.Raghava Prasad 2001).
PRESENT THREAT TO THE INDIAN PUBLIC HEALTH- CHIKUNGUNYA
In India a major epidemic of Chikungunya fever was reported during the last millennium viz.; 1963 (Kolkata), 1965 (Pondicherry and Chennai in Tamil Nadu, Rajahmundry, Vishakapatnam and Kakinada in Andhra Pradesh; Sagar in Madhya Pradesh; and Nagpur in Maharashtra) and 1973, (Barsi in Maharashtra). Thereafter, a small outbreak of CHIK was reported from Sholapur district, Maharashtra in 1973. After quiescence of about three decades, CHIKV re-emerged in India in the states of Andhra Pradesh, Karnataka, Maharashtra, Madhya Pradesh and Tamil Nadu since December, 2005. Cases have also been reported from Rajasthan, Gujarat and Kerala.
These continuing scenario of outbreaks questions the effectiveness of the public health mechanism, because the severity of the epidemic was too high than it happened ever before. The statistics (WHO India 2007) shows the severity of the present outbreak of chikungunya in Indian states. A total number of 1958 confirmed cases of Chikungunya have been reported from 13 States in India during 2006-07 (up to 17.01.2007), with no death directly attributable to Chikungunya. The outbreak in India is continuing but presently is at low levels because of the non-monsoon period – i.e. inter-epidemic period. The state wise details are given below.
13 states were affected with chikungunya and the total suspected cases were 1391992. 15477 samples tested and 1958 cases confirmed with the chikungunya. In the state of Andra Pradesh, 23 districts affected with the disease. Total suspected cases were 77535, 1224 samples tested and 248 cases confirmed. In Karnataka 27 districts affected, 762026 suspected, 5000 samples tested and 298 cases identified. In Maharashtra, 34 districts affected, 268333 cases suspected, 5421 samples tested and 786 cases confirmed. 35 districts of Tamilnadu affected with chikungunya 64802 suspected cases reported 116 cases confirmed when 648 samples tested. In Madhya Pradesh, 60132 suspected cases reported from 21 districts. 106 cases confirmed from the 892 samples. 225 chikungunya cases confirmed in the state of Gujarat from 25 districts when 1155 samples tested from 76012 suspected cases. In Kerala all the districts were affected with the disease, 70731 cases suspected and 43 cases confirmed when 235 samples tested. In Delhi, 67 cases confirmed with the disease out of 560 samples tested from 12 districts. In Rajasthan and Pondichery one district each affected the disease and confirmed cases were 24 and 9 respectively. In Goa, 2 cases confirmed and in Orissa 34 from 6461 suspected cases. (WHO India 2007).
KERALA RESPONSES
The state-Kerala, which sets an example for the rest of India and third world countries in providing primary health care, now gropes in the dark and is fast losing the edge. The great achievements in the fields of mortality and fertility have reached a plateau, the near universal immunization coverage achieved in the nineties has fallen in most districts.
The state is regularly visited by emerging outbreaks of leptospirosis, dengue fever and other insect borne viral fevers; the latest entrant is chickungunya. Natural ecology has been tampered with and the once-famous backwaters of the state are polluted and weed infested. Waste disposal in the municipalities and corporations still remains a formidable challenge. Conventional methods like land fill evoke furious protests from local inhabitants. Critics have re-christened 'God's Own Country' as 'God's own junkyard'. (C.R. Soman, 2007)
The chikungunya epidemic severely affects in the plantation areas especially the rubber and pineapple plantations. Dr. Jagvir Singh, the joint director of National Institute of Communicable Diseases said in his presentation on Epidemiology of chikungunya and Kerala experience in the National Workshop on Chikungunya conducted at Kochi on 28th December, 2008, that Aedes breeding is high in domestic and peri domestic situations and in the rubber plantations . The latex collecting cups are one of the favorite breeding source of aedes mosquitoes; and pineapple leaf axils are also favorite breeding points of aedes.(Dr. B.K.Thyagi 2007).The following table shows the district wise chikungunya confirmed cases. (Dr. B.K. Thyagi Dec. 2007)
NO Districts Confirmed Cases
1 Thiruvananthapuram 1204
2 Kollam 918
3 Pathanamthitta 3455
4 Alappuzha 1768
5 Kottayam 10661
6 Idukki 538
7 Eranakulam 1882
8 Thrissur 328
9 Malappuram 1775
10 Palakkad 240
11 Kozhikkode 806
12 wayanadu 57
13 Kannur 77
14 Kasargode 75
The number of cases is increased in the districts Kottayam, Pathanamthitta and Malappuram which are having rubber and pineapple plantations.
SEVERITY OF CHIKUNGUNYA
Chikungunya disease itself may not causes death, but co morbidity of many other diseases associated with chikungunya is proved in many studies. These finding indicate the necessity of the serious preventive approaches against the disease. Some studies are presenting here to show the severity of the chikungunya disease.
A study on Chikungunya infection in pregnancy was conducted by Randrianaivo H (2005).The results showed that three of nine miscarriages before 22 weeks of gestation could be attributed to the virus. 3,829 births took place during this time. Among the 151 infected women, 118 were viremia negative at delivery, and none of the newborns showed any damage. Among the 33 with positive viremia at delivery, 16 newborns (48.5%) presented neonatal Chikungunya. Though fetal contamination risks appear to be rare before 22 weeks of gestation, they are potentially dangerous. After 22 weeks gestation, newborns infection occurs if the mother is viremia positive at delivery. Trans placental transmission is suspected, but the pathogenic mechanism remains unknown.
Bernillon, P. and Brouard C (2007) studied on 'Estimated risk of Chikungunya viremic blood donation during an epidemic on Reunion Island in the Indian Ocean, 2005 to 2007'. The study revealed that, between 2005 and 2007, Chikungunya virus (CHIKV) caused a massive epidemic on Reunion Island with a major peak in the number of cases in February 2006. Blood donation was interrupted on the island in January 2006. Over the course of the outbreak, the mean risk was estimated at 132 per 100,000 donations. The risk peaked at 1,500 per 100,000 donations at the height of the outbreak in February 2006. In total, 47 blood donations would have been potentially viremic if blood collection had not been interrupted. During this period, an estimated 312,500 of 757,000 inhabitants had been infected by mosquito-borne transmission. The study concluded that; during this large outbreak, the estimated risk of viremic blood donation was high, but low compared to the risk of mosquito-borne CHIKV transmission.
A study conducted by Nicolas X (2006) revealed that, skin involvement was observed in 50% of patients. It consisted of patches of healthy skin mainly on the trunk and limbs that sometimes displayed diffuse, congestive and even edematous features. Itching was reported in some cases (19.3%) and was sometimes isolated. Peeling of the skin was observed in a few cases but remained uncommon in adults. Outcome was rapidly favorable in most cases sometimes with scaling or persistence of patches. These findings suggest that chikungunya should be suspected in subjects presenting a febrile rash while in an endemic area or after returning from a tropical zone.
Another study on early clinical and laboratory features of chikungunya was conducted bu Lory M in 2006.The results were; laboratory-confirmed acute chikungunya was documented in 157 patients. Sixty percent of patients had at least one co morbidity. Ninety-seven patients (61.8%) were hospitalized, and 60 (38.2%) were treated as outpatients. Five fatalities were reported. One hundred fifty-one patients (96.1%) experienced polyarthralgia, and 129 (89%) experienced fever. Gastrointestinal symptoms were reported by 74 patients (47.1%), and skin rash was reported by 63 (40.1%). Hemorrhagic signs were rare.
Neurological complications are also associated with Chikungunya fever. This was proved in a study conducted by Sharda M., Rampal, & Meena H in 2006.This prospective study has been conducted in hospitalized patients admitted in government and private hospitals of Kota city, Rajasthan from August 2006 to October 2006. Patients showing neurological involvement with typical clinical picture of chikungunya infection were studied in detail and followed up for improvement and any permanent damage or death. Results showed that chikungunya infection have observed a spectrum of neurological abnormalities in terms of altered mental functions, seizures and focal neurological deficit. Permanent neurological sequelae and even death has occurred.
The findings of a study by Ali Mohamed A. in 2006 were; at the early stage of the disease (within 10 days of the disease onset), fever was present in 45 of 47 patients. A rash was present in the first week in 25 cases. All patients suffered with arthritis. The most frequently affected joints were fingers, wrists, toes, and ankles. Eight patients were hospitalized during the acute stage, including 2 severe life-threatening cases. A total of 38 patients remained symptomatic after the tenth day with chronic peripheral rheumatism, characterized by severe joint pain, with a dramatically limited ability to ambulate and carry out activities in daily life. Three patients were hospitalized at this stage for severe persistent handicap. Follow-up demonstrated slow improvement in joint pain and stiffness despite symptomatic treatment, mainly anti inflammatory and analgesic drugs.
A study was conducted by Mittl A., Mittal S. and others(2007) on Optic neuritis associated with chikungunya virus infection in South India to define optic neuritis associated with chikungunya virus (CHIKV) infection in a clinical setting. Relevant clinical findings of optic neuritis associated with seropositive CHIKV infection were recorded. Nineteen eyes (in 14 patients) had optic nerve involvement. 42% had papillitis, 21%had retrobulbar neuritis, 21% had retrochiasmal (optic tract) neuritis, and 16% had neuroretinitis. The study found that acute-onset visual loss due to optic neuritis may be associated with CHIKV infection.
Observations made during a recent outbreak in south India about Cutaneous manifestations of chikungunya fever, by Inamdar A.C. and Palit A.(2008), found that all age groups were affected with chikungunya , including newborns. Some of the cutaneous features were observed during the acute stage of the illness, and others during convalescence or thereafter. Pigmentary changes were found to be the most common cutaneous finding (42%), followed by maculopapular eruption (33%) and ulcers (21.37%). Lesions with significant morbidity were generalized vesiculobullous eruptions (2.75%), found only in infants, lymphedema, and intertriginous aphthous-like ulcers. All patients responded well to symptomatic, conservative treatment.
There are many other studies explaining the co morbidity and severity of the chikungunya. All these want the immediate and adequate intervention on the issues related to chikungunya and public health.
HEALTH LITERACY AS AN OUTCOME OF HEALTH PROMOTION
Education has been an essential component of action to promote health and prevent disease throughout this century. Campaigns to promote maternal and child health, to prevent communicable disease, and to promote immunization and other preventive health services have a long history. In developing countries, health education directed towards these goals remains a fundamental tool in the promotion of health and prevention of disease.
In the recent past, considerable attention has been given to analyzing the determinants of health, and to the definition of outcomes associated with health promotion activity. This has led to the development hierarchies of ‘outcomes’ from health interventions, which illustrate and explain the linkages between health promotion actions, the determinants of health, and subsequent health outcomes. (Nutbeam, 1996).
As a tool for disease prevention, health education was considerably strengthened by the development of a new generation of more sophisticated, theory-informed interventions during the 1980s. These programs focused on the social context of behavioural decisions, and focused on helping people to develop personal and social skills required to make positive health behaviour choices. This type of program was pioneered through school-based health education programs directed towards preventing teenage substance misuse, and subsequently has been applied in other settings (Glanz., 1997).
Behaviour Change Communication activities are crucial for community sensitization and participation so as to prevent and control Chikungunya fever. People need to be educated about the disease, mode of transmission, availability of treatment facilities and adoption of control measures. Community ownership has to be encouraged for sustaining low larval and adult densities of mosquitoes in the long term and continued practice of personal protection measures and/or indoor space spraying operations. They should be reassured that this is a preventable disease only if action at household and community levels is taken.
Behaviour Change Communication (BCC) is a process of learning that empowers people to take rational and informed decisions through appropriate knowledge; inculcates necessary skills and optimism; facilitates and stimulates pertinent action through changed mindsets, modified behaviour. It is more evidence-based; cost-benefit oriented and aims towards pre-identified actions, outputs and outcomes amongst the target audience. Salient components of BCC campaign include: Advocacy, Inter-sectoral convergence, Programme communication (IEC) and Monitoring & Evaluation.
Correct reporting, sustaining positive messages and countering negative stories by the media are also ensured. Inter-sectoral convergence is crucial in bringing together all partners (NGOs, Faith Based Organizations, Community-Based Organizations including Residents’ Welfare Organizations, Self-Help Groups and professional associations like Medical Associations, corporate sector, etc) to comprehend felt needs, disseminate information and cross reporting, and facilitate delivery of services in a collaborative manner.
Communication through media-mix (mass media, inter-personal communication, etc) is required for strengthening: knowledge, beliefs, values, attitudes, confidence; enabling environment; and reinforcement of knowledge, action. Appropriate BCC materials, messages should be developed. ‘Influencers’ like school children/teachers, opinion leaders, informal health care service providers, elected representatives can initiate mass clean-up campaigns, source reduction and environmental sanitation and adoption of personal protection measures. This study clearly establishes the need of such awareness and behaviour modification campaigns.
