Eighty-five-year old Shashikala Devi*, who in September became the first person in Jaipur to test positive for Zika, laughed at all the fuss being made over her. After her diagnosis, Devi and her seven-member family were visited at their home by several teams of doctors, including one from the National Institute of Virology in Pune and another from the National Centre for Disease Control in Delhi. Every member of the family, including a 27-year-old pregnant woman, was tested for Zika. Barring Devi, all others were negative.

Devi’s samples were first tested randomly for Zika at the Sawai Mansingh Medical College. She had been admitted to the hospital for treatment of epileptic fits that she had become prone to over the past year. Once Zika showed up in Devi’s blood samples, the hospital sent them to the National Institute of Virology, where the results were confirmed.

Devi’s family was initially worried. But they said they feel more at ease since they have all tested negative for Zika and Devi herself has recovered from the infection – her latest tests were negative.

With more than 140 people in Jaipur testing positive for Zika, most of whom are in the Shastri Nagar area where Devi lives, the city authorities have finally swung into action on mosquito control.

Zika is transmitted through the bite of the Aedes mosquito, which can also spread dengue and chikungunya. Rajasthan reported 5,605 cases of dengue in 2017 and 4,506 cases this year so far, said state health minister Kalicharan Saraf at a press conference last week. The state should have had strong mosquito control measures in place.

But the residents of Shastri Nagar claim municipal workers never paid much attention to controlling disease vectors like mosquitos or to sanitation in their neighbourhood. “I am seeing fogging done for the first time in 30 years,” claimed Devi’s son, referring to the mosquito control technique of spraying pesticide through a blower.

The Amanisha nullah runs through the area and many migrant families live along the large sewage drain. In the Bhatta Basti slum, open drains run right next to the houses. The residents of Bhatta Basti said that municipal workers normally clean the area once in four or five days.

A health official said on condition of anonymity that vector control in the area was “sub-optimal” even after 15 days after the Zika outbreak came to light. “The vector indices [number of mosquitoes] in this area was extremely high – unimaginably high, many folds above normal,” the official said. “If you don’t control mosquitoes, this is likely to spread.”

A municipal van that carries a screen running public service announcements about mosquito control. (Photo: Menaka Rao)

The official added that in this crowded locality, people had not been told about mosquito control measures like using larvicide tablets in drinking water and throwing out stagnant and possibly larvae-infested water. Last week, the Union Health Ministry said that health teams going from house to house found 74,483 larvae breeding sites in the locality.

Dr Narottam Sharma, Jaipur’s district medical health officer, said that earlier health workers would only spray pesticide along the main roads. “This time [after the outbreak] the municipal authorities have gone in the inner lanes of the Shastri Nagar colony,” he said.

Lack of coordination

Since the outbreak began, the Rajasthan government established a control room in a large hall of a temple complex in Shastri Nagar where health workers assemble to coordinate surveillance and disease control activities. They collate data on home visits, people tested, insecticide spraying and fogging activities.

The surveillance activities have spread to 14 wards of the city, which the Integrated Disease Surveillance Programme has defined as the “containment area” of the current outbreak. This includes the Sindhi Camp area, where 24 students and staffers from Rajput Hostel tested positive for Zika. The area is a few meters away from the state bus stop where buses head to different parts of Rajasthan and to other states.

State health authorities said they had created 330 teams of doctors, health workers and municipal insecticide officers. These teams fanned out every day in the 14 wards. The health workers are also providing education on how to prevent Zika infection.

Jaipur civic authorities, unlike many other urban civic authorities, only provide sanitation services related to health but do not provide health services. There is a lack of coordination between the state authorities and the civic authorities. Ideally, the health authorities should identify clusters where patient loads are higher to help sanitation officials to prioritise their activities.

“Micro-planning of cleaning activities or vector control becomes difficult because of the lack of convergence between the National Health Mission [implemented by state health authorities] and civic authorities who carry out sanitation and vector control activities,” said Poonam Kulshrestha who handles the sanitation project of the non-profit organisation Centre for Advocacy and Research in Jaipur. She said that earlier this year, the civic authority did not respond to requests for fogging. It began door-to-door mosquito control only after the Zika outbreak.

By the fourth week of October though, health authorities and civic authorities had left their mark on the city. Writing in chalk on the walls outside homes in Shastri Nagar, municipal officers and doctors displayed how they have visited each house in the area at least two times. Dr Rajendra Kumar Garg, the chief health officer of the Jaipur Nagar Nigam, said that the authorities have been working hard to educate the people about vector-borne diseases and has even fined 300 people for “causing nuisance”.

Houses in Bhatta Basti have been marked by health and sanitation workers to indicate number of times they have visited. (Photo: Menaka Rao)

Sixteen-year-old Hafeez Khan, a resident of Bhatta Basti, said government authorities had come to his house three times in the past month. “They checked every single water container in our house,” said Khan. “They told us about the places where mosquitoes breed. They also checked if any person in the house has fever.”

Khan claimed that the authorities spent at least 10 minutes each time they came to his house. Kulshrestha said that it would have been better if the authorities had taken preventive measures before the outbreak.

Parveen Bano, who lives in the same area, felt grateful when the authorities took her eight-year old daughter Farhana’s blood sample for testing about 10 days ago. The doctors told her that Farhana did not have any infection.“This is the first time any government authority asked about our health,” she said. “It feels good.”

Shashikala Devi, who tested positive for Zika, did not entirely understand the “illness” everyone said she had. But she is glad it had a positive impact. “I do not even have fever,” she said, chuckling. “But, at least the area got cleaned as a result.”

*Name changed to protect anonymity.

This is the second story in a two-part series about the Zika outbreak in Rajasthan. Read the first part here.