Deadly Toxic Jellyfish Health Problem
Community Medicine Department, Chiang Mai Medicine Faculty, Chiang Mai University

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Among all the species of toxic jellyfish in the world, box jellyfish is the most venomous. Box jellyfish killed over 100 people worldwide over the last century. Thailand reported at least eight deaths during 1999 and 2016. The number of deaths was underestimated due to reasons such as lack of knowledge, absence of toxic jellyfish surveillance system, not all patients contacting health services, and misdiagnosis. In 2008, when we started to solve the toxic jellyfish health problem in Thailand, the situation was difficult and complicated because of the following obstacles: (1) experts denied the existence of box jellyfish envenomation (deadly toxic jellyfish); (2) health personnel perceived that foreigners died due to allergic reactions, not toxins; (3) misdiagnosis led to inappropriate treatments, which caused complications; (4) death of foreigners was a politically and diplomatically sensitive issue; (5) fatal cases drew media attention, and the international media perceived that Thailand ignored and concealed the problem; (6) the existence of box jellyfish envenomation was a controversial issue among experts due to unavailability of prior education in the academic sector; (7) no laboratory can identify box jellyfish toxins and species; (8) no laboratory can confirm box jellyfish cases; (9) no anti-venom is available; (10) the first aid for toxic jellyfish that is usually practiced by health personnel and population can lead to death; and (11) lack of effective first aid. The toxic jellyfish health problem affects large groups of the population, including local communities, fishery, tourism, public health, marine biology, academic, politic, police, and forensic. The population initially did not participate due lack of evidence, conflict of interest, misperception, and lack of knowledge. Thus, we had to patiently work hard to gain acceptability and participation from all sectors. The initial obstacles of the different levels were as follows: (1) Local community level: stakeholders were afraid that existence of box jellyfish and intervention would affect their business and tourism-related occupations; (2) National level: the government officers denied the existence of box jellyfish. For those who acknowledged the problem, they hesitated to involve themselves because they were afraid that the discovery would affect tourism and the image; and (3) International level: other countries perceived that Thailand ignored and concealed the problem. The toxic jellyfish problem can be divided into three periods: (1) First period (2008–2011): Communities, stakeholders, and partnerships were in denial that jellyfish-related deaths occurred in Thailand. There was lack of knowledge, no surveillance system for toxic jellyfish related health problems, and no intervention. (2) Second period (2012–2014): There was limited knowledge as regards effective prevention and control measures, limited educational materials for risk communication, and limited financial and human resources. (3) Third period (2015–2016): There is a need to ensure that the implementation of intervention is such that it is sustainable. Thus, an innovative solution is required.

B. Strategic Approach

 2. What was the solution?
The initiative solution has five components, which are knowledge sharing, early warning and rapid response, effective intervention, ensuring sustainability, and evidence-based management. Strategy plans are executed through a non-traditional holistic approach that is based on the context of communities, stakeholders, and partnerships. The initiative solution lead to engagement of communities, stakeholders, and partnerships.

 3. How did the initiative solve the problem and improve people’s lives?
The solution has five components, which are as follows: 1) Knowledge sharing Knowledge sharing is necessary throughout the solution. Proving that deadly toxic jellyfish exist in Thailand was an important first step to convince communities and stakeholders. Identifying affected populations and determining the magnitude of the problems were important for prevention and control measures. Appropriate and effective intervention required knowledge about capabilities and contexts of communities, stakeholders, and partnerships. Innovative creations were made by sharing and integrating knowledge. These lead to acceptability, involvement, engagement, and contribution. We conducted many types of research: basic science, action research, research and development, and community-based research studies without specific research funding. Fiscal budget for the toxic jellyfish health problem from the Epidemiology Bureau (BOE) of the Ministry of Public Health (MOPH) was the main financial resource. Throughout the strategy’s roadmap, evidence-based management was used for convincing, making decisions, and executing plans. The data were analyzed, interpreted, and disseminated to communities, stakeholders, and partnerships via appropriate routes for each target population. 2) Early warning and rapid response Because there was no existing surveillance for deadly jellyfish, ad-hoc surveillance for toxic jellyfish was initially established to detect cases. We conducted case investigation to gain knowledge and to prove that toxic jellyfish could kill people, particularly box jellyfish. The toxic jellyfish surveillance was evaluated and improved over time. It is currently part of the national surveillance operated by the BOE. The toxic jellyfish surveillance is a combination of event-based and indicator-based surveillance. Not only health personnel but also non-health personnel, communities, stakeholders, and international partnerships participate in this surveillance. It differs from the traditional surveillance system that is more indicator-based. Thus, it increases sensitivity, early detection, and early warning, which is necessary for deadly toxic jellyfish health threats. The reports of injured and fatal cases increased after the surveillance was established: this was due to better detection. The surveillance and outbreak investigation provided new knowledge regarding the toxic jellyfish, which led to development of educational materials, training courses, and appropriate intervention. 3) Effective intervention methods The factors that made the intervention effective were knowledge sharing, innovation, community context, and availability of resources in the community. These factors contributed to community engagement, practical innovation, and sustainability. Many severe cases reported by toxic jellyfish networks received appropriate first aid at the scene in recent years. These cases had fewer symptoms and signs. In 2016, no fatal case was reported. 4) Ensuring sustainability The deadly toxic jellyfish problem requires partnership involvement. Thus, policy commitment is necessary. The second memorandum of understanding (MOU) between the MOPH and the Marine and Coastal Resources Department of Natural Resources and Environment Ministry was signed following good outcomes and impacts in the assessment of the first MOU. This MOU covered issues of treatment, surveillance, prevention and control measures, knowledge building, research, innovation, laboratory settings, laboratory test, training, education, and risk communication. Training for the trainer courses was provided to distribute knowledge, maintain good practice, build up knowledge, and improve surveillance in the long run. The trainers supervised and provided training for target populations. 5) Evidence-based management The strategy plans were executed through a non-traditional holistic approach that was based on the context of communities, stakeholders, and partnerships. The data were collected, analyzed, interpreted, translated, and disseminated to the target audiences. The target audiences were mainly divided into three groups: policy maker/partnership, community/stakeholder, and general population. This solution contributed toward enhancing the well-being of the general public and the vulnerable population, including fishermen, fishery workers (legal and illegal immigrants), boat divers, jet-ski employees, resort/hotel staffs, lifeguards, beachboys, tourists, health personnel, marine personnel, students, and academic professional.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The toxic jellyfish health problem was complicated and difficult to solve because in the beginning there was lack of data, knowledge, resources, and laboratories. Furthermore, it was a diplomatically sensitive issue, and professionals and policy makers denied the existence of deadly jellyfish in Thailand. In typical traditional approach, the government had the upper hand in determining what should be done. The toxic jellyfish problem is different because the community, stakeholder, and partnership play important roles. The initiative solution is a combination of five components (knowledge sharing, early warning and rapid response, effective intervention, ensuring sustainability, and evidence-based management). The newly acquired data and knowledge contribute to adjustment of the strategy plans. Strategy plans are executed by a holistic approach based on the context of communities, stakeholders, and partnerships. The characteristics of this initiative solution: (1) social engagement scholarship (using the capabilities of experts from universities to cooperate with the community’s knowledge); (2) sharing financial and human resources; (3) information and evidences for managing the plans, such as convincing, making decisions, building cooperation, and building engagement; (4) executing operation plans through networks; (5) multidisciplinary organizations, 6) using unofficial approach dominantly; (7) risk communication for each target group; and (8) mutual benefit.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
In the first period (2008–2011), the major missions were to investigate whether deadly toxic jellyfish existed in Thailand and, if they existed, the magnitude of the problem. Medical epidemiologists (Dr. Lakkana Thaikruea) from the Community Medicine Department of Chiang Mai Medicine Faculty, Ministry of Education (nominee) and from the Epidemiology Bureau (BOE) of Ministry of Public Health (MOPH) (Dr. Potjaman Siriarayaporn) proved that deaths caused by box jellyfish stings really occurred in Thailand. They educated and disseminated pieces of evidence to non-health personnel for further cooperation and partnership. They established ad hoc toxic jellyfish surveillance. After that, they invited Phuket Marine Biology Center to join the working group in order to study about toxic jellyfish in Thailand. They created three toxic jellyfish networks, namely working, expert, and community networks. They linked the three toxic jellyfish networks, based on activities and contexts. The working group network included the nominee, BOE, Marine and Coastal Resources Department of Natural Resources and Environment Ministry (MNRE), Surveillance and Rapid Response Teams, Regional Offices of Disease Prevention and Control, and Provincial Health Offices. The expert network included the nominee, BOE, Marine and Coastal Resources Research and Development Centers, government and private health services along the coasts of Thailand, an expert from Australia, a journalist from aboard, and the Divers Alert Network (http://www.diversalertnetwork.org). The community network included hotel and resort owners, province/city/town/sub-district/municipality administrative organizations, tourism organizations, the Thailand Hotel Association, the Tourist Association, the Tourist Guide Association, the Long-tail Boat Association, the Emergency/Rescue Association/Unit, fishermen, journalists, the Naval Medical Department, and teachers. Medical epidemiologists from the nominee and BOE developed knowledge and educational materials, implemented intervention in some communities that were willing to participate, and conducted risk communication to other risk areas and target populations along both the coasts of Thailand (23 provinces). Other missions included conducting research studies about toxic jellyfish envenomation, providing seminars/training courses that cover all issues, creating and producing a variety of educational materials appropriate for each target audience, expanding the toxic jellyfish network of the communities, and developing a memorandum of understanding (MOU) between the Disease Control Department of the MOPH and the Marine and Coastal Resources Department of MNRE in order to establish prevention models in the selected provinces. All three toxic jellyfish networks (working team, expert, and community and stakeholder) cooperated in implementing the intervention. In the second period (2012–2014), medical epidemiologists from the nominee and BOE expanded the networks and improved the toxic jellyfish surveillance to be part of the national surveillance system. They proved that not only foreigners (misperception of allergy) but also Thai people could suffer severe clinical manifestation or death when stung by box jellyfish. They improved the educational materials and the reference book. By knowledge sharing, they supported the communities in innovating on the vinegar first aid pole and sting net by using the available resources in the communities. Dr. Lakkana Thaikriea from the nominee helped the officers of the MOPH and the MNRE to develop the vision and the missions of the second MOU between them. The members of the toxic jellyfish networks expanded the intervention to other risk areas and risk populations. The mission of the third period (2015–2016) was to make implementation sustainable. The medical epidemiologists from the nominee and BOE provided training for the trainers. They cooperated with personnel from MNRE, communities, and stakeholders to improve the sting nets. The toxic jellyfish networks installed vinegar first aid poles and educational warning signs and posters along both the coasts of Thailand. They collaborated with universities to study new species of box jellyfish and toxicology. The government supported the policy. Up to date, the main organizations responsible for knowledge management, surveillance, and jellyfish situation are the nominee, BOE, and MNRE, subsequently. The medical epidemiologists from the nominee created cheap simple practical techniques to collect and transfer specimen (tentacles of the jellyfish) and identify nematocysts. Neither specific instruments nor chemical agents were required. The local personnel can send data to the working team and the expert networks to allow early warning and rapid response. The populations that directly benefited include people residing along both the coasts of Thailand (23 provinces accounted for about 20 million people; the Thai population was 65,729,098 million in December 2015), fishermen, tourists from the provinces in Thailand and abroad, resort/hotel owners, people who work in tourism industries, jet-ski and long-tail boat drivers, guides, emergency medical service teams, lifeguards, and healthcare providers. Because there was lack of knowledge about toxic jellyfish in Thailand when we started the initiative, there were other populations that benefited indirectly: health personnel, marine personnel, forensic personnel, policemen, academic personnel, students, teachers, and researchers.
 6. How was the strategy implemented and what resources were mobilized?
The initiative’s solution implementation has been gradual and continuous. Strategic plans were designed based on the context and the situation, and executed via a non-traditional holistic approach. Evidence-based management included data collection, analysis, interpretation, and dissemination to the target audiences, which were the policy maker/partnership, community/stakeholder, and general population. Partnership, engagement, knowledge sharing, and mutual benefit were used to reduce the conflicts of interest and implement intervention. The strategies comprise three periods: 1) 2008–2011: To prove the existence of deadly toxic jellyfish and determine the magnitude of the problem, case investigations and research studies were conducted. An ad hoc surveillance system and two toxic jellyfish networks (working teams and experts) were established. These networks were linked by two medical epidemiologists, from the nominee and BOE (leaders). The operational plans of the research studies were executed to gain knowledge about clinical manifestation, first aid, treatment, and prevention and control measures. 2) 2012–2014: The mission was to improve the toxic jellyfish surveillance system, expand the toxic jellyfish networks, gain and disseminate knowledge, and implement intervention. The leaders evaluated the toxic jellyfish surveillance and improved the definition, reporting, and case investigation. The BOE integrated the ad hoc surveillance system into the national surveillance system. The members of each of the toxic jellyfish networks recruited more members from risk areas and related organizations. The activities included training, consultation, early warning, rapid response, information dissemination, and knowledge sharing. The leaders of the working groups linked all the networks together. They identified sensitive issues, and provided important information, consultancy, and recommendation. They improved educational materials based on field experiences and research findings. Through knowledge sharing, they supported communities to innovate on vinegar first aid poles and sting nets using available resources. Experts, partnerships, communities, and stakeholders were involved in developing content of educational warning signs installed with vinegar first aid poles. The book had four versions. The latest reference book was published in 2014. The second MOU between the MOPH and the MNRE was signed. 3) 2015–2016: The mission was to make the implementation sustainable. Human resources and knowledge related to toxic jellyfish were necessary to accomplish the mission. The leaders created training courses for the trainers. The government supported the trainers in conducting training courses, providing technical support, and performing surveillance tasks. The sting net models were examined and improved. The first one was made for a small area and the big one for a large area. The sting nets were examined and improved every year. The educational materials were improved. More vinegar first aid poles and educational warning signs and posters were installed along both the coasts of Thailand. Studies about new species of box jellyfish, toxicology, and laboratory techniques were conducted in 2016. For finance, the BOE used the fiscal budget to run surveillance and related plans and activities. The toxic jellyfish networks mainly used the Internet and social media without financial support. The government, private sector, communities, stakeholders, and partners contributed the implementation budget. As for human resources, the leaders and staffs from the BOE performed the surveillance tasks. The leaders trained the personnel, who later joined the working team. As for technical resources, experts from Australia and the Diving Alert Network supported training and consultancy for the leaders initially. Marine personnel collected data regarding toxic jellyfish in Thailand and provided technical support later on. In 2016, the leaders developed training courses for the trainers from health and non-health personnel for distributing knowledge, conducting surveillance, and consultancy. Updates and important information were disseminated via social media, electronic mail, websites, YouTube, and blogs (www.oknation.net/blog/peeguay — general population and www.oknation.net/blog/lakthai — professionals).

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
For the initiative design, the Community Medicine Department (nominee) of Chiang Mai Medicine Faculty supported Dr. Lakkana Thaikruea to collaborate with Dr. Potjaman Siriarayaporn, the chief of the Investigation and Public Health Emergency Response Unit, Epidemiology Bureau of Ministry of Public Health (BOE-MOPH), in order to design and implement the initiative solution. Dr. Potjaman Siriarayaporn and Dr. Lakkana Thaikruea were the leaders in the initiative solution. Other sectors involved in the different phases of the implementation are as follows: (1) Knowledge sharing: Business groups and fishermen cooperated with experts from the government to devise innovative creations (vinegar first aid pole and sting net). The Natural Resources and Environment Ministry (MNRE) contributed to the knowledge on toxic jellyfish by producing educational materials and providing workshops and seminars. Communities, business groups (Thais and foreigners), and local governments held activities and events about health that are related to toxic jellyfish. (2) Early warning and rapid response: MNRE personnel, communities, fishermen, people who had tourism-related occupations, business persons, the Driving Alert Network, members of toxic jellyfish networks, and international partnerships participated in the surveillance. (3) Effective intervention: The same group of “early warning and rapid response” provided the resources (human, finance, and techniques) for the installation of vinegar first aid poles and sting nets. They and the Ministry of Tourism and Sport contributed to public education and risk communication. (4) Ensuring sustainability: For political commitment, the nominee supported Dr. Lakkana Thaikruea to recommend development of strategy. The second memorandum of understanding between the MOPH and the MNRE was signed for at least a four-year period. In the implementation, human resources and financial contribution in the form of vinegar poles, sting nets, trainers, surveillance, lifeguards, educational warning signs, etc. was done by governments, communities, and stakeholders.

 8. What were the most successful outputs and why was the initiative effective?
The initiative solution differs from the traditional approach of government domination and top-down command. This initiative is effective because it strengthens the capabilities of early warning, rapid response, innovation, and risk communication. It makes the communities and stakeholders engage in and contribute to problem-solving via knowledge sharing and mutual benefit. Furthermore, it constitutes multidisciplinary involvement with political commitment for sustainable implementation. Evidence-based management is used throughout the process. The following are at least five of the most successful outputs: 1. New knowledge: (1) Proving the existence of deadly toxic jellyfish and determining the magnitude of the problem, (2) identifying the dangerous box jellyfish species (Chironex spp.) existing in Thailand, (3) documenting case definitions of box jellyfish and Portuguese-man-of war, (4) documenting and implementing new appropriate first aid that is different from what is practiced (increased probability of dying), and (5) creating and disseminating educational materials about appropriate treatment (caused by the toxin) different from the existing one (caused by anaphylactic shock) and prevention and control measures (reduced probability of dying). 2. Policy commitment: the Community Medicine Department (nominee) of Chiang Mai Medicine Faculty supported Dr. Lakkana Thaikruea in developing the strategy and direction for solving the health problem. The first memorandum of understanding between the Ministry of Public Health (MOPH) and the Ministry of Natural Resources and Environment (MNRE) was signed. The outcomes and impacts were good; consequently, the second MOU was signed (period 2014–2018). 3. Toxic jellyfish surveillance and network: In complicated health problems with a conflict of interest, partnerships and networks play important roles. A toxic jellyfish surveillance system was, thus, established. Three toxic jellyfish networks were established: working, expert, and community networks. They worked together to detect early and rapid response using non-traditional approach and available affordable technology. 4. Innovation- effective intervention methods: Knowledge sharing leads to effective intervention which reduces severity and fatality. Innovative creations, including vinegar first aid poles, vinegar signs, sting nets, and educational warning materials, were distributed to the target population and the risk areas. A new technique, “vacuum sticky tape,” was created for collecting and transferring the tentacles of toxic jellyfish and identifying the nematocyst of toxic jellyfish. A pilot study tested its feasibility. 5. National and international technical support: Dr. Lakkana Thaikruea from the nominee and Dr. Potjaman Siriarayaporn from the Epidemiology Bureau of the MOPH provided technical support for the diagnosis, first aid, treatment, and prevention and control measures.

 9. What were the main obstacles encountered and how were they overcome?
The main obstacles were the following: (1) lack of knowledge and information, (2) denial of existence of box jellyfish envenomation, (3) conflicts of interest among communities and stakeholders, (4) inappropriate treatment leading to death, (5) the politically and diplomatically sensitive nature of the issue, (6) perception of international media that Thailand ignored and concealed the problem, (7) absence of experts, (8) lack of laboratories for confirming box jellyfish cases, and (9) lack of laboratories for identifying toxins and box jellyfish species. In order to overcome these obstacles, the leaders (Dr. Lakkana Thaikruea from the nominee and Dr. Potjaman Siriariyaporn) needed to have relevant knowledge (epidemiology, evidence-based management, human resource development, etc.), relevant skills (risk communication, plan execution, partnership building, and implementation of measures), and strategic thinking for excellence management. For obstacles (1) and (2), they conducted case investigation, research studies, surveillance, and consultation of experts from Australia. For obstacle (3), we used the lessons learned, case studies, knowledge sharing, and risk communication for each target population gradually and continuously over time. For obstacle (4), they provided training to target populations and created educational materials that are appropriate for each target group. We expanded the toxic jellyfish networks to become more distributed and pushed the policy makers to implement intervention. For obstacles (5) and (6), they cooperated with embassies and international journalists and organizations regarding the situation in Thailand. Once they understood the situation, they participated in the toxic jellyfish networks for detection, warning, providing information, and dissemination of correct and creative news. To overcome obstacles (7) to (9), they collaborated with Australian experts and conducted literature reviews for building knowledge. Dr. Lakkana Thaikruea developed simple techniques and tests for field specimen collection and initial diagnosis. By the end of 2016, DNA and toxicological studies were being conducted.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
The government normally provides health service via the heath system under the Ministry of Public Health (MOPH). The initiative made a difference in the delivery. Non-health personnel can help health personnel in educating the public and conducting first aid. Communities, stakeholders, and partnerships participate in the implementation. Communities and stakeholders play important roles in providing first aid because ambulances of emergency service teams hardly ever reach the beaches within two minutes of deadly jellyfish attack; also, the beaches do not always have lifeguards. There were impacts on knowledge development case detection, early warning, rapid response, and prevention and control measures. There were two reported deaths of box jellyfish stings in 2015 but none in 2016. Reported cases have increased lately because the toxic jellyfish networks detect more cases; also, jellyfish blooming has occurred in many countries. The safe tourism policy has adopted deadly toxic jellyfish sting into the program. New knowledge includes knowledge regarding the existence of deadly multiple-tentacle box jellyfish species (Chironex spp.) in Thailand, case definitions for toxic jellyfish surveillance, appropriate vinegar application in first aid increasing the probability of survival, wrong first aid increasing the severity of wounds and causing fatality, wrong treatment leading to wound complications, and new techniques for specimen collection and transferring and nematocyst identification. As for policy commitment, it is the first time that the MOPH and the Ministry of Natural Resources and Environment have signed a memorandum of understanding (MOU). The second MOU was signed (2014–2018) after the first MOU was assessed as having good outcomes and impacts. Toxic jellyfish surveillance and networks contribute to new knowledge and lead to case detections, early warnings, rapid responses, interventions, and new knowledge. Based on our recommendation during the box jellyfish sting season, the swimming competition was cancelled from the 2016 triathlon held in Samui Island. Effective intervention for complicated problems with conflicts of interest needs participation and involvement of stakeholders and communities. The vinegar first aid pole was created using available resources. Its knowledge was transferred to other risk areas. Fishermen and long-tail boat drivers have vinegar available in their boats; near-fatal box jellyfish sting cases received vinegar being poured as first aid. For sustenance and transferring, training courses for the trainers were provided for health and non-health personnel in 2016. Obstacles for these trainers while consulting experts included difficult-to-perform, expensive, and time-consuming laboratory techniques. Dr. Lakkana Thaikruea from the nominee created and tested a new technique, “vacuum sticky tape.” It can be used in three processes of toxic jellyfish specimen collection and transferring, and nematocyst identification. It is a potential public health breakthrough because it is cheap, simple, durable, and practical. Based on the context and situation of Thailand, the ultimate goal of this innovation is rapid consultation and preliminary diagnosis, which would lead to proper notification and response. Furthermore, it contributes to knowledge development about nematocyst identification, toxicity, species, clinical manifestation, and treatment. It will be tested for feasibility of generalization in 2017.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Not applicable.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Not applicable.

Contact Information

Institution Name:   Community Medicine Department, Chiang Mai Medicine Faculty, Chiang Mai University
Institution Type:   Academia  
Contact Person:   Lakkana Thaikruea
Title:   Associate Professor Doctor  
Telephone/ Fax:   Mobile 66-88-9204243 / office 66-53-935471/66-53-9
Institution's / Project's Website:  
E-mail:   lakkana.t@cmu.ac.th  
Address:   Community Medicine Department, Chiang Mai Medicine Faculty, Chiang Mai University
Postal Code:   50200
City:   Muang
State/Province:   Chiang Mai
Country:  

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