dengue is the most important vector - borne viral infection worldwide with 2.5 billion people at risk , according to the world health organisation ( who ) . the number of cases and number of countries affected has doubled from the period 19901994 to 20002004 [ 13 ] . larger epidemics are becoming more common , with countries in asia witnessing an increase in severe dengue and a higher mortality in the earlier stages . nepal reported its first case of dengue in 2004 and the first indigenous case in 2006 . only sporadic cases were then seen until the outbreak in 2010 , with 917 cases reported nationally ( unpublished data ) , seen almost solely in 3 administrative districts in the terai region on the indian border : chitwan , nawalparasi , and rupandehi . the aim of this paper is to describe the public health surveillance and outbreak response to dengue in nepal in 2010 and to draw lessons from the experience of a fragile state . the who world health assembly urged member states to improve surveillance , prevention , control , and management of dengue . guidelines highlight the need to incorporate lessons learnt from country experiences into outbreak response plans . country responses to dengue have been documented from all around the world ; however , little published literature is available in countries which have seen a recent introduction of dengue viruses , such as nepal . the  early warning reporting system  ( ewars ) in nepal was set up in 1997 with eight hospital sentinel sites rising to 39 hospital sentinel sites by 2011 . there are six targeted diseases / syndromes : malaria , kala - azar , dengue fever , acute gastroenteritis , cholera , and severe acute respiratory infection . nepal is a postconflict fragile state , a term used  for countries facing particularly severe development challenges : weak institutional capacity , poor governance and political instability  . nepal faces many challenges in healthcare provision including weak , poorly structured healthcare services with financial and human resource limitations [ 10 , 11 ] . looking through the lens of dengue helps identify the key strengths and weaknesses in the public health system in the context of a fragile state . this paper focuses on dengue case notification , surveillance , laboratory facilities , intersectoral collaboration , and how government services and the community responded to the dengue outbreak . the study aims to describe the good practices and limiting factors of the surveillance  recognition  system and the intersectoral  response  to dengue . participants were sampled purposively , with deliberate selection regarding their experience , to help ensure involvement of the key stakeholders in the dengue surveillance and outbreak response , including government policy - makers , officials from three key districts , healthcare workers and community leaders . this range of perspectives ensures fair dealing , improving the quality of the data . a list of all government and district officials and healthcare providers involved with the dengue surveillance and outbreak response was compiled with help from epidemiology and disease control division ( edcd ) and public health and infectious disease research centre in nepal  this became the sampling frame . all central officials involved with dengue were included plus district officials from the 3 districts most affected , chitwan , nawalparasi , and rupandehi . doctors from the central level and all three districts that had managed dengue cases were included . other districts with few cases were excluded ( < 4% of total dengue cases ) . community leaders available for focus groups discussions ( fgds ) were identified with district officials . the sample size took into account the saturation principle ; data collection was deemed sufficient when new data did not provide new information or ideas on the topics being questioned . in - depth interviews and focus group discussions were used for data collection . twenty in - depth interviews explored the experiences , successes , and failures of the recognition of dengue cases and response to the outbreak . this was elaborated on , allowing flexible questioning and exploration of issues raised.recognition of the dengue caseswhich disease surveillance techniques are used and how data surveillance is analysed?how is dengue classified?how are dengue cases reported?the laboratory confirmation available.collecting data for virological surveillance and its use.vector surveillance how is this done and by whom?community participation  to what extent is the community involved and how?preparing for a dengue outbreak  is there a plan?recent experience with a dengue outbreak.which sectors and organisations were involved with outbreak response , including training and measures used?budget . recognition of the dengue cases which disease surveillance techniques are used and how data surveillance is analysed?how is dengue classified?how are dengue cases reported?the laboratory confirmation available.collecting data for virological surveillance and its use.vector surveillance  what surveys are done ? response to the dengue outbreak vector control  how is this done and by whom?community participation to what extent is the community involved and how?preparing for a dengue outbreak  is there a plan?recent experience with a dengue outbreak.which sectors and organisations were involved with outbreak response , including training and measures used?budget . community participation  to what extent is the community involved and how ? preparing for a dengue outbreak  is there a plan ? which sectors and organisations were involved with outbreak response , including training and measures used ? qualitative data collected through in - depth interviews and fgds were transcribed , coded , and analysed using nvivo software . each participant provided informed consent for data collection and recordings . the research received ethical approval from the liverpool school of tropical medicine and the nepal health research council ( reference no . tables 2 and 3 summarise the main activities and limitations regarding dengue outbreak detection and response described by participants , alongside potential recommendations suggested .   guidelines on the dengue surveillance system and dengue clinical management were available but there were no other public health guidelines . with one exception , all respondents recognised that dengue reporting was mandatory . ten respondents noted that active surveillance was undertaken ; however it became clear from the interviews that this only occurred during an outbreak.we have active data collection , only in case of outbreak nine participants noted that there was focal surveillance ( active case detection around reported cases ) . however this only happened in two of the districts during the outbreak , not routinely . one respondent reported that  we are only touching the tip of the iceberg  as many fever cases will not present to hospital , and there may be  hundreds of thousands of dengue cases  in the community ( doctor in district hospital , identifier 16 ) . furthermore , quality control of disease surveillance was insufficient.we do not say if the data is accurate or not . we just analyse which hospitals , which sentinel sites send the data and how many cases are there  ( government official , identifier 9 ) . we just analyse which hospitals , which sentinel sites send the data and how many cases are there  ( government official , identifier 9 ) .   the late recognition of dengue cases by the government was noted to be the primary limitation . most people go to [ the ] private sector  but they do not record or report properly . and less people go to visit the government clinics but there is a good system of recording.district official , identifier 22  most people go to [ the ] private sector  but they do not record or report properly . and less people go to visit the government clinics but there is a good system of recording .  district official , identifier 22 the main method of classifying dengue cases was the df / dhf / dss  system ( according to 14 participants who knew about classification ) . however , the majority of these participants ( 10 out of these 14 ) were aware of the revised who dengue case classification . a national case definition of dengue is available , but clinicians did not consistently apply this , with a variety of answers provided when asked to state this definition . a government official said:so many samples were collected here , [ we ] can not identify the types of virus involved . so many samples were collected here , [ we ] can not identify the types of virus involved . interviews with healthcare workers and the laboratory technician highlighted that the main diagnostic tools were haematological and clinical findings alongside serological diagnosis ( rapid diagnosis test ( rdt ) or mac elisa ( igm antibody capture enzyme - linked immunosorbent assay kit ) ) . only one participant had access to polymerase chain reaction ( pcr ) privately , which was not otherwise available . the lack of facilities within nepal was identified as a key limitation by both government and clinical staff as elisa tests were not available countrywide . on analysis of secondary government data , at least 803 out of the 917 dengue cases nationwide were confirmed by igg / igm tests ( either rdt or elisa , not specified ) . there was a variation in the proportion of cases confirmed by the laboratory , with participants noting that between 10 and 50% of dengue cases were confirmed . regional healthcare centres relied on less specific and sensitive rdts which were in short supply.during the last season the government provided around 100 [ rdt ] kits in our hospital , and 100 kits will finish in one day . we see more than 200 people in one day!(clinician , district level , identifier 20 ) .  during the last season the government provided around 100 [ rdt ] kits in our hospital , and 100 kits will finish in one day . we see more than 200 people in one day !  ( clinician , district level , identifier 20 ) . according to a senior health official , the overall budget for all dengue activities was $ 70'000 ( us dollars ) in 2010 . these funds were used for the provision of rdt kits , orientation ( one day training given to staff ) , and case management training . hence an  insufficient budget  at the district level was identified as the  main problem  ( district official , identifier 10 ) . one entomologist ( identifier 4 ) admitted that there were methodological weaknesses with  no sampling method . the latest survey from 2010 was small and only examined 122 houses in one municipality . all vector control measures were done exclusively as an emergency response once the outbreak had started.no experience among our health workers and local people [ meant that ] it took some time to realise this was not a disease but a disaster type of disease . it took two months to realise [ that it was an outbreak of dengue ] no experience among our health workers and local people [ meant that ] it took some time to realise this was not a disease but a disaster type of disease . it took two months to realise [ that it was an outbreak of dengue ] key emergency vector control activities included community education and awareness campaigns , clean - up campaigns , environmental habitat destruction (  search and destroy  campaigns ) , and insecticide space spraying ( fogging ) .   according to participants ( figure 1 ) , the most successful response measures were the door - to - door awareness campaigns and the search and destroy campaign , which were run simultaneously by female community health volunteers ( fchvs ) . this included demonstrating the destruction of vector habitats and the use of water container covers . furthermore , one respondent identified these fchvs as the strongest partners in the outbreak response as  community people believe them more than others no respondent noted water treatment by insecticides or that insecticide - treated nets were in use . there was no process employed to improve water protection or cleaning . despite recognising that fogging ( district official , identifier 10 ) , it was still employed by district officials due to public demand .   the emergency response was a good example of good intersectoral collaboration with many sectors being involved:  hospitals as well as civil society , administrations , security forces , all sector people helped , even housewives , schoolchildren , market people , business people hospitals as well as civil society , administrations , security forces , all sector people helped , even housewives , schoolchildren , market people , business people   ( government official , identifier 9 ) . nine respondents thought that the district public health offices were in charge , six thought that the central level staff and one person thought the vector borne disease research and training centre were in charge . the need for better coordination was recognised and plans to  conduct an annual meeting of municipalities the media played a strong role in the outbreak ; 16 respondents first heard about the outbreak through television or newspaper . the study findings demonstrate the extensive limitations existing in a fragile state that need to be addressed before and during a dengue outbreak in order to provide reliable dengue surveillance data and an adequate response in accordance with international dengue guidelines . overall the response to dengue was lacking in numerous areas , such as disease surveillance , but was strong with respect to community participation and the media . good case notification relies on three key components : an accurate case definition , reliable diagnostic facilities , and quality control to assess the data . case definition needs to be specific and applied consistently to prevent under-/overreporting of the epidemic and misdiagnosis . the majority of reported cases in nepal were confirmed by igg / igm tests demonstrating that the outbreak data is valid . however , some respondents thought that up to 90% of potential dengue cases were not confirmed by a laboratory test . there may be a large number of potential cases undetected in the community , demonstrating the underrepresentation of true epidemic figures . dengue guidelines state that as a minimum , laboratories should be able to perform igm antibody - capture elisa . relying on clinical and haematological features for a diagnosis can lead to a delay in laboratory diagnosis and response time . this weakness of diagnostics only available at central level has been documented in other countries such as brazil . although , it is important to consider the context , improving access to reliable rdt kits across the country may be a practical alternative to providing more expensive facilities . active case detection , to complement passive surveillance , was only undertaken in two districts . surveillance should be continuous to collect information on the origin and distribution of dengue cases ; helping to estimate incidence and allowing services to prepare . sentinel surveillance can help determine transmission dynamics of infectious diseases ; however as the sites only represent a specific cohort and not the general population , they can not be used alone to ascertain national trends . thirty - nine sites in nepal were apparently too few in such a diverse country with distinct terrains to detect the outbreak in a timely manner . private hospitals not being properly integrated in the surveillance system were a key cause of notification delay , generally a problem in nepal . many dengue patients in the high risk areas utilised private healthcare services  for example , 324 out of 592 dengue patients recorded in chitwan / nawalparasi were seen in just one private hospital . studies from south east asia have highlighted the underreported burden of dengue from hospital case reporting , with the average underrecognition of total dengue cases 8.7-fold in thailand and 9.1-fold in cambodia . hence , primary healthcare centres should be included in the surveillance system , as recommended previously in 2004 . fchvs are an effective part of the district healthcare system and should be better incorporated into the reporting system . any changes in the surveillance system must recognise the cost and resource limitations . including dengue surveillance as part of an integrated system for other vector - borne diseases may reduce costs and staffing . although active surveillance increases the sensitivity of a surveillance system , it places huge demands on resources . there is little information on cost effectiveness of surveillance programmes and this needs to be addressed . there is a huge research gap on vectors in nepal , particularly with up - to - date dengue vector surveillance and control . nepal can not combat dengue without information on the vectors present , their spatial distribution , and environmental risk factors . nepal has numerous other vector - borne and infectious diseases to contend with , for example , updating 40-year - old data on malaria prevalence . however , dengue should be a priority as new research could help prepare integrated response measures to mitigate the impact of future outbreaks . regional collaboration with neighbouring countries endemic for dengue , such as india , may facilitate this vector research through cost and expertise efficiencies , helping to implement a cross - border disease and virological surveillance programme and to provide comprehensive training . as another arboviral disease , a cross - border virological surveillance programme that includes japanese encephalitis may prove beneficial for disease monitoring and research purposes . the success of the awareness programmes and search and destroy campaigns can be attributed to excellent community mobilisation . conflict may have had positive effects on health services in nepal , notably helping to acknowledge community groups and civil society in health programmes . this is in contrast to other literature which notes that mobilisation may not be suitable for communities in conflict . however , evidence shows how conflict encouraged the development of community support programmes and fchv involvement . evidence suggests that community participation is vital in an outbreak response , both with dengue for vector control and reducing larval indices and with other vector - borne diseases [ 8 , 20 , 21 ] . however , a comprehensive review calls for better documentation of the successes of community participation , with weak evidence that the strategies have an effect on dengue transmission . future research needs to look at statistical evidence . both awareness and search and destroy programmes need to be routine , utilising community mobilisation and incorporating dengue in current job titles within the local district public health offices . improvements in community participation should incorporate all areas vulnerable to dengue , not just selecting few districts . sustainability of the programmes needs to be guaranteed and the community should be involved with decision - making . a more formal community coordination group needs to be created between different sectors such as water and sanitation . community working groups  as seen in cuba were in charge of all aspects , from designing plans , voicing community concerns , and evaluating results . this highlights how communities can become self - sufficient  yet they will need some initial direction to build capacity . this capacity building may come from the private sector or the government if the context allows . multisectoral dengue action committee  should meet regularly , collaborating with sanitation services and government heads of environment to improve water supply . officials should liaise with nongovernmental organisations ( ngos ) working in vector - borne diseases , such as malaria , to incorporate dengue into their programmes . the media played an important part in the outbreak response . using the media for health communication has many benefits ; it can be participatory and driven by the local context and culture allowing community members to be seen as equal . for example , the reach of a mass media family planning campaign increased to 75% when indirect effects ( spread of information through the community ) were considered . mass media messages can have extensive impact in nepal and should be built upon further . one limitation of the sampling methodology was not including more community leaders and members and fchvs involved with the response . however , the sample included key stakeholders and policy makers in the government and the district . it was not possible to accurately determine the number of doctors involved in the dengue response ; however the doctors from four hospitals that dealt with 81% of recorded cases were included ( edcd unpublished data 2010 ) . the respondents may have been less willing to criticise themselves or their institutions in order to show themselves in the best light , according to social acceptability norms . several times participants did not wish to comment about the ministry of health activities , reducing reliability of results . the role of the participant was not deemed to have induced any additional bias to results . this research is not transferable to all other settings where dengue outbreaks are seen , such as wealthier countries or those with high dengue endemicity . however , this research provides a good insight into challenges dealing with emerging infectious diseases within a fragile political context . it is difficult to run a disease surveillance system in a postconflict environment with reduced access to care and no consistent use of national case classification , particularly in a country like nepal , where dengue has recently emerged . the political context can affect the financial and trained human resources available to combat dengue . future studies for the implementation of dengue surveillance and control programmes need to take into account the political context as well as the level of endemicity . country - specific packages for dengue outbreak response are needed which recognise realistic solutions that are achievable in the short term ( figure 2 ) . two key solutions involve the following : using regional assistance to improve research into the vectors and spatial distribution of serotypes as well as to provide training for healthcare and public health professionals ; regional efforts are advocated by many countries for improved vector control , including those with a strong political infrastructure , such as singapore ; building upon good community mobilisation and improving awareness ; potential strategies include fchv help with primary care case notification , wider participation in vector control activities , and the quick mobilisation of community response teams .   using regional assistance to improve research into the vectors and spatial distribution of serotypes as well as to provide training for healthcare and public health professionals ; regional efforts are advocated by many countries for improved vector control , including those with a strong political infrastructure , such as singapore ; building upon good community mobilisation and improving awareness ; potential strategies include fchv help with primary care case notification , wider participation in vector control activities , and the quick mobilisation of community response teams .   alongside this , the need for the integration of a case reporting system in the private sector must be addressed as a priority . with good intersectoral and regional collaboration , community empowerment , and access to reliable diagnostic facilities , major dengue outbreaks can be prevented .
objectives . the number of countries reporting dengue cases is increasing worldwide . 
 nepal saw its first dengue outbreak in 2010 , with 96% of cases reported in three districts . 
 there are numerous policy challenges to providing an effective public health response system in a fragile state . 
 this paper evaluates the dengue case notification , surveillance , laboratory facilities , intersectoral collaboration , and how government and community services responded to the outbreak . methods . 
 qualitative data were collected through 20 in - depth interviews , with key stakeholders , and two focus - group discussions , with seven participants . results . limitations of case recognition included weak diagnostic facilities and private hospitals not incorporated into the case reporting system . 
 research on vectors was weak , with no virological surveillance . 
 limitations of outbreak response included poor coordination and an inadequate budget . 
 there was good community mobilization and emergency response but no routine vector control . 
 conclusions . 
 a weak state has limited response capabilities . 
 disease surveillance and response plans need to be country - specific and consider state response capacity and the level of endemicity . 
 two feasible solutions for nepal are ( 1 ) go upwards to regional collaboration for disease and vector surveillance , laboratory assistance , and staff training ; ( 2 ) go downwards to expand upon community mobilisation , ensuring that vector control is anticipatory to outbreaks .