A qualitative investigation on the awareness level and healthcare challenges of Dengue and Japanese B encephalitis in Assam

INTRODUCTION

Dengue and Japanese Encephalitis (JE) are major public health issues in many regions, especially in Asia, where they are endemic. The World Health Organization reports that there are about 390 million annual dengue infections, with 96 million presenting clinically, particularly in urban areas where Aedes mosquitoes are prevalent. The disease’s rise over recent decades underscores the importance of vector control and community involvement in managing outbreaks. Dengue is caused by the dengue virus (DENV), which has four serotypes (DENV-1, DENV-2, DENV-3, DENV-4).^[1] DENV is mainly transmitted by Aedes mosquitoes, particularly Aedes aegypti and Aedes albopictus, common in tropical and subtropical areas.^[2,3] Transmission occurs when an infected mosquito bites a human, with factors such as mosquito and human density, and climate influencing transmission dynamics.^[4] Vertical transmission from infected female mosquitoes to offspring also plays a role in dengue persistence.^[5-7] In addition, mechanical transmission via contaminated mosquito mouthparts may contribute to dengue spread, especially in areas with high mosquito populations.^[8]

JE is a major cause of viral encephalitis in Asia, with around 70,000 cases and 14,000–20,000 deaths annually, primarily in children.^[9] It is transmitted by Culex mosquitoes, particularly Culex tritaeniorhynchus, which breed in rice fields and stagnant water, with pigs acting as amplifying hosts.^[10,11] Vaccination is a key preventive measure, reducing incidence in endemic regions.^[12] Humans are dead-end hosts, as the virus does not replicate efficiently in them.^[10]

Environmental factors such as rainfall, temperature, and the presence of breeding sites heavily influence mosquito populations and, consequently, the risk of JE transmission.^[10,11] The proximity of human populations to pigs in rural areas increases the risk of transmission. JE and dengue share overlapping epidemiology in endemic regions, complicating clinical diagnosis due to similar neurological symptoms.^[9,12]

In Assam, JE has been a persistent issue, especially in upper Assam, with recent studies showing its spread to lower districts. Between 2018 and 2020, JE cases and fatalities increased, accounting for about 25% of acute encephalitis syndrome (AES) cases in the region. Dengue, though historically less common, has risen significantly in urban areas such as Guwahati, with seasonal outbreaks linked to monsoon rains favoring Aedes mosquito breeding.^[13]

This study aims to explore the causes, community awareness, and healthcare challenges in managing Dengue and JE diseases in Karbi Anglong.

MATERIALS AND METHODS

For this study, both urban and rural areas were covered, given the differing prevalence of dengue and encephalitis in these settings. Specifically, urban areas such as Ward No. 3, Ward No. 9, Birla Market, and Diphu Town were selected, alongside rural villages such as Rongkhelan, Longnit, and Manjha, which reported a high number of cases of both diseases over the past 5 years. A purposive sampling method was used to select respondents who met specific criteria, enhancing the study’s credibility. Participants were required to have resided in the area for at least a year. For the focus group discussions (FGDs), homogenous groups were formed based on gender and age, including adult, middle-aged, and elderly groups within the community, as well as separate groups for adolescent boys and girls. This approach allowed for an assessment of awareness levels across different age groups, informing the design of age-based intervention strategies. In addition, specific FGDs were conducted with frontline workers, such as Accredited Social Health Activists (ASHAs), health workers, and Anganwadi workers, who are closely engaged with the community. The characteristics of the participants are presented in Tables 1 and 2. Separate questionnaires were designed for community members and health officials, reflecting their unique roles and expertise. This qualitative exploratory descriptive study was conducted by 9 project scientists (6 males and 3 females) under one Project Coordinator and one Coordinator from February to December 2024. A total of 135 participants took part in the interviews and discussions [Tables 1 and 2].

The particulars of patients included in the FGD study are presented in Table 2:

A semi-structured interview was conducted in a noise-free environment and was audio recorded with the consent of the participant. Interviews continued for 45–60 min, depending upon the responses, till they reached the saturation level. All the interviews were transcribed verbatim into a common language (English) for easy analysis. For analysis, two methods, i.e., content analysis and thematic analysis, were adopted as these two suited the study most. For FGDs, homogenous groups of different genders and age groups, such as adult age groups of boys and girls, middle-aged groups, and older age groups of the community, were formed. This ensured the awareness level in the community among different age groups, as well as helped design age-based intervention approaches. Specific FGDs were also conducted with ASHAs, health workers, Anganwadi workers, etc., who are mostly engaged with the community.

RESULTS

The recent status of Dengue and Encephalitis in Karbi Anglong: Dengue and Encephalitis have created havoc in certain areas of Karbi Anglong recently. The outbreak in 2022–2023 affected almost every household in some areas of Diphu town and Manjha. Among all, children and elderly people are the worst affected. As a precaution, educational institutions were closed temporarily as cases of dengue were reported in some students as well. The platelet count in the affected person has reduced to <1 lakh, and many deaths have been reported due to Dengue. Some major highlights of the discussion in in-depth interview (IDI), key informant interview(KII), and FGDs are presented in Tables 3 and 4.

“A recent dengue outbreak in the area has led to numerous hospitalizations, particularly among vulnerable populations such as children and the elderly.” (IDI participant)

“Several local schools were forced to close temporarily due to the health crisis.” (FGD participant)

Encephalitis cases were initially reported from rural areas only, but in the past few years, some cases, as well as mortality, were reported from urban areas too. The introduction of pig farming in certain urban areas has increased in recent times.

“Now a days, pig culture is practiced in urban areas too.” (KII participant)

DISCUSSION

The present study utilized a qualitative research approach to assess the situation of dengue and JE in Assam, with special reference to Karbi Anglong District, which recently witnessed the outbreak of dengue. Several aspects, such as awareness, causal factors, preventive measures, and healthcare challenges, were explored. The thematic analysis of the FGD provided a comprehensive understanding of the multifaceted challenges faced by people of Karbi Anglong. As qualitative research in this field is scarce, it is crucial to explore this area to identify key determinants of their control and prevention.

The findings highlight limited awareness in Karbi Anglong about diseases such as dengue and JE. While basic knowledge of common diseases exists, misconceptions about transmission and prevention, especially regarding the Aedes mosquito’s daytime biting for dengue, persist. The focus on dengue over JE further reveals gaps in understanding and prevention.

The study found that dengue spread in Karbi Anglong was mainly due to poor hygiene, waste management, stagnant water, and inadequate drainage. A similar study in Puducherry highlighted that inefficient waste collection and drainage systems lead to stagnant water, promoting mosquito breeding.^[14] Water shortages in Karbi Anglong cause residents to store water in uncovered containers, fostering mosquito breeding. A study in Delhi found that intermittent water supply leads to similar practices, further contributing to mosquito breeding sites.^[15] In addition, the railway station in Karbi Anglong, which borders Dimapur, was identified as a key source of disease spread, with many travelers facilitating the transmission of dengue. A study in Bangkok confirmed that public transport networks play a significant role in dengue transmission, with areas featuring dense transport connections experiencing higher rates of the disease.^[16] Furthermore, overcrowding, unplanned urbanization, and the presence of slum areas in Karbi Anglong create favorable environments for mosquito breeding. A similar study in Brazil and Latin America found that socio-economic factors, such as poverty and overcrowding, exacerbate these issues, as they limit access to proper sanitation and waste management services.^[17]

The community’s response to Dengue and Encephalitis showed preferences for traditional remedies, such as papaya leaf juice and tulsi, alongside modern methods such as mosquito nets and repellents. This reflects a cultural reliance on natural healing alongside modern techniques. The World Health Organization notes that many in developing countries turn to traditional medicine due to economic constraints and limited healthcare access.^[18] Studies in Costa Rica show that people in dengue-affected regions often use traditional remedies with over-the-counter medications such as paracetamol for relief.^[19] In Malaysia, many reported using both traditional medicine and modern care, highlighting their complementary relationship.^[20]

The study highlighted challenges in Karbi Anglong’s healthcare system, including under-equipped facilities, a shortage of trained professionals, and limited access to care, especially in rural areas. A similar study in Mongolia found that surges in patient numbers can overwhelm healthcare systems, emphasizing the need for effective workforce planning to address public health emergencies.^[21]

The strength of this study lies in its inclusion of diverse and homogenous representatives from the region, capturing a broad range of perspectives. The study provided an in-depth exploration of key areas, such as awareness, causal factors, preventive measures, and healthcare challenges, yielding rich qualitative data. However, the study primarily engaged various populations, from the general public to frontline healthcare workers. A more comprehensive approach could have involved FGDs with NGOs and other organizations working at the grassroots level to combat vector-borne diseases. Based on our findings, we recommend the implementation of urgent intervention programs, the strengthening of healthcare infrastructure, the promotion of public health campaigns, the encouragement of community involvement, the assurance of consistent government actions, the development of comprehensive.

CONCLUSION

This qualitative study offers a comprehensive perspective on the situation in Karbi Anglong concerning the preparedness and challenges encountered during vector-borne diseases such as dengue and JE. Future research could broaden the scope by including a larger and more diverse sample to gain a deeper understanding of the underlying causes, issues, and challenges. A mixed-method approach, combining qualitative insights with quantitative data, could provide a more complete view of the region. In addition, conducting a longitudinal study in the area would offer valuable insights into how the population adapts and copes over time.