Who-2011 Dengue

Comprehensive Guidelines for
Prevention and Control of Dengue and

Dengue Haemorrhagic Fever
Revised and expanded edition
WHO Librar Cataloguing!in!Publication data
World Health Organi"ation# Regional Office for $outh!%ast &sia'
Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever'
Revised and expanded edition'
($%&RO )echnical Publication $eries *o' +,-
.' Dengue / epidemiolog ! prevention and control ! statistics and numerical data' 0' Dengue
Hemorrhagic Fever / epidemiolog ! prevention and control / statistics and numerical data'
1' Laborator )echni2ues and Procedures / methods' 3' 4lood $pecimen Collection / methods'
5' 6nsect Repellents' +' Guidelines'
6$4* 789!70!7,00!198!, (*L: classification; WC 509-
< World Health Organi"ation 0,..
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Printed in 6ndia
Contents
Preface ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' vii
&cBno=ledgements ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''ix
&bbreviations and &cronms ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''xi
.' 6ntroduction '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .
0' Disease 4urden of Dengue Fever and Dengue Haemorrhagic Fever ''''''''''''''''''''''''' 1
0'.
0'0
Global '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 1
)he WHO $outh!%ast &sia Region ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 5
1' %pidemiolog of Dengue Fever and Dengue Haemorrhagic Fever '''''''''''''''''''''''''''' 7
1'.
1'0
1'1
1'3
1'5
1'+
1'8
1'9
)he virus '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 7
Cectors of dengue ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 7
Host ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .0
)ransmission of dengue virus '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .0
Climate change and its impact on dengue disease burden '''''''''''''''''''''''''' .3
Other factors for increased risB of vector breeding '''''''''''''''''''''''''''''''''''''' .3
Geographical spread of dengue vectors '''''''''''''''''''''''''''''''''''''''''''''''''''''' .5
Future proDections of dengue estimated through empirical models '''''''''''''' .5
3' Clinical :anifestations and Diagnosis '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .8
3'.
3'0
3'1
3'3
3'5
3'+
3'8
Clinical manifestations '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .8
Clinical features '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .9
Pathogenesis and pathophsiolog ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 00
Clinical laborator findings of DHF ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 01
Criteria for clinical diagnosis of DHFED$$'''''''''''''''''''''''''''''''''''''''''''''''''''' 03
Grading the severit of DHF ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 05
Differential diagnosis of DHF '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 05
Comprehensive Guidelines for Prevention and Control of Dengue and Dengue Haemorrhagic Fever
iii
3'9
3'7
Complications ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 0+
%xpanded dengue sndrome (unusual or atpical manifestations- '''''''''''''''' 08
3'., High!risB patients ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 08
3'.. Clinical manifestations of DFEDHF in adults ''''''''''''''''''''''''''''''''''''''''''''''' 09
5' Laborator Diagnosis ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 1.
5'.
5'0
5'1
5'3
5'5
5'+
5'8
5'9
5'7
Diagnostic tests and phases of disease''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 1.
$pecimens; Collection# storage and shipment '''''''''''''''''''''''''''''''''''''''''''' 10
Diagnostic methods for detection of dengue infection ''''''''''''''''''''''''''''''' 13
6mmunological response and serological tests ''''''''''''''''''''''''''''''''''''''''''''' 18
Rapid diagnostic test (RD)- '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 17
Haematological tests ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 3,
4iosafet practices and =aste disposal '''''''''''''''''''''''''''''''''''''''''''''''''''''''' 3,
Fualit assurance ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 3,
*et=orB of laboratories '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 3,
+' Clinical :anagement of DengueE Dengue Haemorrhagic Fever ''''''''''''''''''''''''''''' 3.
+'.
+'0
)riage of suspected dengue patients at OPD ''''''''''''''''''''''''''''''''''''''''''''''' 30
:anagement of DFEDHF cases in hospital observation =ardsEon
admission ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 35
8' Disease $urveillance; %pidemiological and %ntomological '''''''''''''''''''''''''''''''''''''' 58
8'.
8'0
8'1
8'3
8'5
8'+
%pidemiological surveillance ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 58
6nternational Health Regulations (0,,5- '''''''''''''''''''''''''''''''''''''''''''''''''''''' 57
Cector surveillance ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' +,
$ampling approaches ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' +5
:onitoring insecticide resistance ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' ++
&dditional information for entomological surveillance ''''''''''''''''''''''''''''''''' ++
9' Dengue Cectors ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' +7
9'. 4iolog of &edes aegpti and &edes albopictus ''''''''''''''''''''''''''''''''''''''''''' +7
7' Cector :anagement and Control ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 85
7'. %nvironmental management ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 85
iv
7'0
7'1
7'3
4iological control'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 9,
Chemical control '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 90
Geographical information sstem for planning# implementation
and evaluation'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 99
.,' 6ntegrated Cector :anagement (6C:- '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 71
.,'. Genesis and Be elements '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 71
.,'0 &pproach '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' 75
.,'1 6C: implementation '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .,1
.,'3 6C: monitoring and evaluation '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .,1
.,'5 4udgeting ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .,1
..' Communication for 4ehavioural 6mpact (CO:46- ''''''''''''''''''''''''''''''''''''''''''''''' .,5
..'. Planning social mobili"ation and communication; & step!b!step
guide '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .,9
..'0 %nsuring health!care infrastructureEserviceEgoods provision ''''''''''''''''''''''' .01
..'1 &pplication of CO:46 ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .03
.0' )he Primar Health Care &pproach to Dengue Prevention and Control ''''''''''''''' .08
.0'. Principle of primar health care '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .08
.0'0 Primar health care and dengue prevention and control ''''''''''''''''''''''''''' .09
.1' Case 6nvestigation# %mergenc Preparedness and OutbreaB Response'''''''''''''''''' .17
.1'. 4acBground and rationale ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .17
.1'0 $teps for case investigation and outbreaB response ''''''''''''''''''''''''''''''''''' .17
.3' :onitoring and %valuation of DFED HF Prevention and Control Programmes ''''''' .35
.3'. )pes of evaluation ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .35
.3'0 %valuation plans ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .3+
.3'1 Cost!effective evaluation '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .38
.5' $trategic Plan for the Prevention and Control of Dengue in the &sia!Pacific
Region; & 4i!regional &pproach (0,,9/0,.5- '''''''''''''''''''''''''''''''''''''''''''''''''''''' .5.
.5'. *eed for a biregional approach and development of a $trategic Plan for the
Prevention and Control of Dengue in the &sia!Pacific Region ''''''''''''''''''' .5.
.5'0 Guiding principles '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .5.
v
.5'1 Goal# vision and mission ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .50
.5'3 ObDectives '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .50
.5'5 Components of the $trateg'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .55
.5'+ $upportive strategies ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .55
.5'8 Duration '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .58
.5'9 :onitoring and evaluation ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .58
.5'7 6mplementation of the $trategic Plan ''''''''''''''''''''''''''''''''''''''''''''''''''''''' .59
.5'., %ndorsement of the &sia!Pacific $rategic Plan (0,,9/0,.5-''''''''''''''''''''''' .59
.+' References '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .57
&nnexes
.' &rbovirus laborator re2uest form'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .+7
0' 6nternational Health Regulations (6HR# 0,,5- ''''''''''''''''''''''''''''''''''''''''''''''''''''''' .8,
1' 6HR Decision 6nstrument for assessment and notification of events''''''''''''''''''''''' .80
3' $ample si"e in &edes larval surves'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .81
5' Pictorial Be to &edes ($tegomia- mos2uitoes in domestic containers in
$outh!%ast &sia '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .85
+' Designs for overhead tanB =ith cover masonr chamber and soaB pit '''''''''''''''''' .89
8' Procedure for treating mos2uito nets and curtains ''''''''''''''''''''''''''''''''''''''''''''''' .87
9' Fuantities of .G temephos (abate- sand granules re2uired to treat
different!si"ed =ater containers to Bill mos2uito larvae '''''''''''''''''''''''''''''''''''''''' .93
7' Procedure# timing and fre2uenc of thermal fogging and HLC space
spra operations '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .95
.,' $afet measures for insecticide use '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .97
..' Functions of %mergenc &ction Committee (%&C- and Rapid &ction
)eam (R&)- '''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .73
.0' Case 6nvestigation Form (prototpe- ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' .75
vi
Preface
Dengue fever is the fastest emerging arboviral infection spread
b &edes mos2uitoes =ith maDor public health conse2uences in
over .,, tropical and sub!tropical countries in $outh!%ast &sia#
the Western Pacific and $outh and Central &merica' Hp to 0'5
billion people globall live under the threat of dengue fever and its
severe formsIdengue haemorrhagic fever (DHF- or dengue shocB
sndrome (D$$-' :ore than 85G of these people# or approximatel
.'9 billion# live in the &sia!Pacific Region' &s the disease spreads to
ne= geographical areas# the fre2uenc of the outbreaBs is increasing
along =ith a changing disease epidemiolog' 6t is estimated that 5,
million cases of dengue fever occur =orld=ide annuall and half a
million people suffering from DHF re2uire hospitali"ation each ear#
a ver large proportion of =hom (approximatel 7,G- are children
less than five ears old' &bout 0'5G of those affected =ith dengue
die of the disease'
OutbreaBs of dengue fever in the .75,s and .7+,s in man countries of the &sia!Pacific Region
led to the organi"ation of a biregional seminar in .7+3 in 4angBoB# )hailand# and a biregional meeting
in .783 in :anila# Philippines' Follo=ing these meetings# guidelines for the diagnosis# treatment
and control of dengue fever =ere developed b the World Health Organi"ation (WHO- in .785'
WHO has since then provided relentless support to its :ember $tates b =a of technical assistance#
=orBshops and meetings# and issuing several publications' )hese include a set of revised guidelines in
.79,# .79+ and .775 follo=ing the research findings on pathophsiolog and clinical and laborator
diagnosis' )he salient features of the resolution of the Fort!sixth World Health &ssembl (WH&- in
.771 urging the strengthening of national and local programmes for the prevention and control of
dengue fever# DHF and D$$ =ere also incorporated in these revised guidelines'
& global strateg on dengue fever and DHF =as developed in .775 and its implementation
=as bolstered in .777' $ubse2uentl# the a=areness of variable responses to the infection presenting
a complex epidemiolog and demanding specific solutions necessitated the publication of the
Comprehensive Guidelines for the Prevention and Control of DengueEDHF =ith specific focus on
the WHO $outh!%ast &sia Region in .777' )his document has served as a roadmap for :ember
$tates of the Region and else=here b providing guidance on the various challenges posed b dengue
fever# DHF and D$$'
)he 0,,0 World Health &ssembl Resolution urged greater commitment to dengue from
:ember $tates and WHO' )he 6nternational Health Regulations (0,,5- re2uired :ember $tates to
detect and respond to an disease (including dengue- that demonstrates the abilit to cause serious
public health impact and spread rapidl globall' &n &sia!Pacific Dengue Partnership =as established
vii
in 0,,8 to increase public and political commitment# to more effectivel mobili"e resources# and
implement measures of prevention and control in accordance =ith the Global $trateg'
6n 0,,9# a biregional (for the WHO $outh!%ast &sia and Western Pacific Regions- &sia!Pacific
Dengue $trategic Plan (0,,9/0,.5- =as developed to reverse the rising trend of dengue in the
:ember $tates of these regions' & voluminous 2uantit of research and studies conducted b WHO
and other experts have additionall brought to light ne= developments and strategies in relation to
case diagnosis and management of vector control# and emphasi"ed regular sensiti"ation and capacit!
building' )he publications underscored as =ell as reinforced the need for multisectoral partnerships
in tandem =ith the revitali"ation of primar health care and transferring the responsibilit# capabilit#
and motivation for dengue control and prevention to the communit# bacBed up b effective
communication and social mobili"ation initiatives# for responsive behaviour en route to a sustainable
solution of the dengueEDHF menace' )his is important because dengue is primaril a man!made
health problem attributed to globali"ation# rapid unplanned and unregulated development# deficient
=ater suppl and solid =aste management =ith conse2uent =ater storage# and sanitar conditions
that are fre2uentl unsatisfactor leading to increasing breeding habitats of vector mos2uitoes' &ll
this# needless to sa# necessitates a multidisciplinar approach'
6n this edition of the Comprehensive Guidelines for the Prevention and Control of Dengue
and Dengue Haemorrhagic Fever# the contents have been extensivel revised and expanded =ith the
focus on ne=Eadditional topics of current relevance to :ember $tates of the $outh!%ast &sia Region'
$everal case studies have been incorporated to illustrate best practices and innovations related to
dengue prevention and control from various regions that should encourage replication subse2uent
to locale! and context!specific customi"ation' 6n all# the Guidelines have .3 chapters that cover
ne= insights into case diagnosis and management and details of surveillance (epidemiological and
entomological-# health regulations# vector bioecolog# integrated vector management# the primar
health care approach# communication for behavioural impact (CO:46-# the &sia!Pacific Dengue
$trategic Plan# case investigation# and emergenc preparedness and outbreaB response that has been
previousl published else=here b WHO and others'
)his revised and expanded edition of the Guidelines is intended to provide guidance to national
and local!level programme managers and public health officials as =ell as other staBeholders /
including health practitioners# laborator personnel and multisectoral partners / on strategic planning#
implementation# and monitoring and evaluation to=ards strengthening the response to dengue
prevention and control in :ember $tates' )he scientists and researchers involved in vaccine and
antiviral drug development =ill also find crucial baseline information in this document'
6t is envisioned that the =ealth of information presented in this edition of the Guidelines =ill
prove useful to effectivel combat dengue fever# DHF and D$$ in the WHO $outh!%ast &sia Region
and else=here? and ultimatel reduce the risB and burden of the disease'
Dr $amlee Plianbangchang
Regional Director
WHO $outh!%ast &sia Region
viii
&cBno=ledgements
)his revised and expanded edition of the Comprehensive Guidelines on Prevention and Control of
Dengue and Dengue Haemorrhagic Fever =as initiall drafted b :r *and L' Jalra# independent
expert on dengue prevention and control' &n in!house appraisal of the draft document =as done b
Dr &'4' Koshi# Dr &'P Dash# :r &lex Hilderbrand# Dr 4usaba $a=guanprasitt# Dr ChusaB PrasittisuB#'
Dr Ferdinand Laihad# Dr Kai P *arain# Dr :adhu Ghimire# Dr *alini Ramamurth# Dr *ihal'
&besinghe# Dr Ong!arD Ciputsiri# Dr Oratai RauaDin# Dr $udhansh :alhotra# Dr $uvaDee Good#
Dr $u"anne Westman# and others'
$ubse2uentl# the draft document =as criticall revie=ed at a peer revie= =orBshop held
in 4angBoB# )hailand# chaired b Dr $atish &pppoo# Director# %nvironmental Health# *ational
%nvironment &genc# $ingapore' )he peer revie=ers# including Dr $uchitra *immanita# Dr $iripen
JalaanarooD# Dr &non $riBiatBhachorn and Dr $u=it )hamapalo of )hailand? Dr Luc Chai $ee Lum
of :alasia? Dr J'*' )e=ari# Dr $'L' Hoti# Dr Jalpana 4aruah# :r *'L' Jalra and Dr $hampa *ag of
6ndia? :r )' Cha=alit from the WHO Countr Office in )hailand? Dr Raman Celaudhan (WHO HFE
*)D-# Dr Olaf HorsticB (WHO HFE)DR-? Dr Chang :oh $eng from the WHO Regional Office for the
Western Pacific? Dr ChusaB PrasittisuB# Dr RaDesh 4hatia# Dr $uvaDee Good# Dr $halini Pooransingh
and Dr 4usaba $ang=anprasitt from the WHO Regional Office for $outh!%ast &sia? and Dr D' K' Gubler
(H$&E$ingapore- provided valuable inputs to and suggestions for the draft document'
Revision and incorporation of comments of peer revie=ers =as performed b :r *and Lal Jalra
and Dr $hampa *ag' )echnical scrutin of the final draft =as undertaBen b Dr &non $riBiatBhachorn#
Dr 4usaba $ang=anprasitt# Dr ChusaB PrasittisuB# :r *and Lal Jalra# Dr $hampa *ag# Prof' $iripen
JalaanarooD and Prof' $uchitra *immanita'
)he chapters on LClinical :anifestations and DiagnosisM and LClinical :anagement of DengueE
Dengue Haemorrhagic FeverM included in the Comprehensive Guidelines =ere revie=ed et again
during a consultative meeting on dengue case classification and case management held in 4angBoB#
)hailand# in October 0,.,' )he revie=ers included Prof' %mran 4in Nunnus from 4angladesh?
Dr Duch :oniboth from Cambodia? Dr Ku"i Deliana and Dr DDatniBa $etiabudi from 6ndonesia?
Dr Jhampe Phongsavarh from the Lao PeopleAs Democratic Republic? Prof' Luc Lum Chai $ee
from :alasia? Dr )alitha Lea C' Lacuesta and Dr %dna &' :iranda from the Phillippines? Dr LaB
Jumar Fernando from $ri LanBa? and Prof' $uchitra *immanita# Dr Wichai $atimai# Prof' $iripen
JalanarooD# Prof' $aomporn $irinavin# Prof' JulBana ChoBpaibulBit# Prof' $aitorn LiBitnuBool#
Prof' :uBda Candveeravong# Dr &non $iriBiatBhachorn# Dr $uchart Hongsiri=an and Dr CalaiBana
Plasai from )hailand'
)he final editing =as done b Dr ChusaB PrasittisuB# Dr *'L' Jalra and Dr &'P Dash' )he'
contributions of all revie=ers are gratefull acBno=ledged'
ix
&bbreviations and &cronms
&4C$
&D4
&e'
&6D$
&L)
&n'
&PDP
&PD$P
&P$%D
&$)
4CC
46
4:&
4P
4s
4$L0
4t'H!.3
4H*
C4C
CDC
CF
CFR
C6
C*$
CPG
CPJ
C$F
C) (or C&)-
Cx
acidosis# bleeding# calcium# (blood- sugar
&sian Development 4anB
&edes
ac2uired immunodeficienc sndrome
alanine amino transferase
&nopheles
&sia!Pacific Dengue Partnership
&sia!Pacific Dengue $trategic Plan
&sia!Pacific $trateg for %merging Diseases
aspartate aminotransferase
behaviour change communication
4reateau 6ndex
4angBoB :unicipal &dministration
blood pressure
4acillus sphaericus
4iosafet Level!0
4acillus thuringiensis serotpe H!.3
blood urea nitrogen
complete blood count
Center for Disease Control# &tlanta# H$&
complement fixation
case!fatalit rate
Container 6ndex
central nervous sstem
clinical practice guidelines
creatine!phosphoBinase
cerebrospinal fluid
computed axial tomograph
Culex
xi
CO:46
CPG
C$R
C$F
CCP
D&LN
DD)
D%%)
D%*CO
DeC6)
D%*C
DF
DHF
D6C
D*&
DE*$$
DLR
D$$
%&C
%CG
%6P
%L6$&
%*C6D
%$R
G!+PD
G6$
GP$
HC)
H%
HF&
HH)
H6
H6
H6&
H6CD&R:
H6C
6CP
6%C
6F*!g
communication for behavioural impact
Clinical Practice Guidelines
corporate social responsibilit
cerebrospinal fluid
central venous pressure
disabilit!adDusted lifeear
dichlorodiphenltrichloroethane
*# *!Diethl!m!)oluamide
Dengue and Control stud (multicountr stud-
Dengue Colunteer 6nspection )eam
dengue virus
dengue fever
dengue haemorrhagic fever
disseminated intravascular coagulation
deoxribonucleic acid
dextrose in isotonic normal saline solution
dextrose in lactated RingerOs solution
dengue shocB sndrome
%mergenc &ction Committee
electrocardiograph
extrinsic incubation period
en"me!linBed immunosorbent assa
%uropean *et=orB for Diagnostics of L6mportedM Ciral Diseases
erthrocte sedimentation rate
glucose!+!phosphatase dehdrogenase
Geographical 6nformation $stem
Global Positioning $stem
haematocrit
health education
Health For &ll
hand!held terminal
haemagglutination!inhibition
House 6ndex
Health 6mpact &ssessment
hear# inform# convince# decision# action# reconfirmation# maintain
human immunodeficienc virus
intracranial pressure
information# education and communication
interferon gamma
xii
6gG
6g:
6GR
6HR (0,,5-
66F)
6P:
6)*
6R$
6$R%
6C
6C:
J&P
J&4P
L&:P
LL6*
:&C!%L6$&
:DGs
:P%
:oH
mph
:R6
:!R6P
:$'CR%F$
*&$4&
*GO
*$
*$&6D
*J
*$.
*)
OPD
OR$
P&HO
PCR
pH
PH%6C
PHC
P6
immunoglobulin G
immunoglobulin :
insect gro=th regulator
6nternational Health Regulations (0,,5-
insecticide impregnated fabric trap
integrated pest management
insecticide!treated mos2uito net
insecticide residual spraing
intensive source reduction exercise
intravenous
integrated vector management
Bno=ledge# attitude# practice(s-
Bno=ledge# attitude# belief# practice(s-
loop!mediated amplification
long!lasting insecticidal net
6g: antibod!capture en"me!linBed immunosorbent assa
:illennium Development Goals
monitoring and evaluation
:inistr of Health
miles per hour
magnetic resonance imaging
massive# repetitive# intense# persistent
message# source# channel# receiver# effect# feedbacB# setting
nucleic acid se2uence!based amplification
nongovernmental organi"ation
nonstructural protein
non!steroidal anti!inflammator drugs
natural Biller cells
nonstructural protein .
neutrali"ation test
outpatient department
oral rehadration solution
Pan &merican Health Organi"ation
polmerase chain reaction
potential hdrogenEpresence of active hdrogen (hdrogen strength in a
given substance to measure its acidit or alBalinit-
public health emergenc of international concern
primar health care
Pupal 6ndex
xiii
ppm
PR*)
P)
P))
RPD
RC
RD)
R*&
R*&i
RR
R$
R)!PCR
$%&
$%&RO
$:&R)
)DR
)*F!a
))
HLC
H*
H*%P
H*6C%F
H$&6D
CHW
CPC
W4C
WH&
WHO
WPRO
parts per million
pla2ue reduction neutrali"ation test
prothrombin time
partial thromboplastin time
research and development
Regional Committee (of WHO $%& Region-
rapid diagnostic test
ribonucleic acid
R*& interference
relative risB
remote sensing
reverse transcriptase polmerase chain reaction
$outh!%ast &sia
$outh!%ast &sia Regional Office (of WHO-
specific# measurable# appropriate# realistic# time!bound
tropical diseases research
tumor necrosis factor!a
thrombin timeEtourni2uet test
ultra!lo= volume
Hnited *ations
Hnited *ations %nvironment Programme
Hnited *ations ChildrenAs Fund
Hnited $tates &genc for 6nternational Development
voluntar health =orBer
ventricular premature contraction
=hite blood cell
World Health &ssembl
World Health Organi"ation
Regional Office for the Western Pacific (of WHO-
xiv
.' 6ntroduction
Dengue fever (DF- and its severe formsIdengue haemorrhagic fever (DHF- and dengue shocB
sndrome (D$$-Ihave become maDor international public health concerns' Over the past three
decades# there has been a dramatic global increase in the fre2uenc of dengue fever (DF-# DHF and
D$$ and their epidemics# =ith a concomitant increase in disease incidence (4ox .-' Dengue is found
in tropical and subtropical regions around the =orld# predominantl in urban and semi!urban areas'
)he disease is caused b a virus belonging to famil Flaviviradae that is spread b &edes ($tegomia-
mos2uitoes' )here is no specific treatment for dengue# but appropriate medical care fre2uentl saves
the lives of patients =ith the more serious dengue haemorrhagic fever' )he most effective =a to
prevent dengue virus transmission is to combat the disease!carring mos2uitoes'
&ccording to the World Health Report .77+#. the Lre!emergence of infectious diseases is
a =arning that progress achieved so far to=ards global securit in health and prosperit ma be
=astedM' )he report further indicated that; Linfectious diseases range from those occurring in tropical
areas (such as malaria and DHF# =hich are most common in developing countries- to diseases found
=orld=ide (such as hepatitis and sexuall transmitted diseases# including H6CE&6D$- and foodborne
illnesses that affect large numbers of people in both the richer and poorer nations'M
4ox .; Dengue and dengue haemorrhagic fever; Je facts
Q $ome 0'5 billion people / t=o fifths of the =orldOs population in tropical and subtropical
countries / are at risB'
Q &n estimated 5, million dengue infections occur =orld=ide annuall'
Q &n estimated 5,, ,,, people =ith DHF re2uire hospitali"ation each ear' & ver large
proportion (approximatel 7,G- of them are children aged less than five ears# and about
0'5G of those affected die'
Q Dengue and DHF is endemic in more than .,, countries in the WHO regions of &frica# the
&mericas# the %astern :editerranean# $outh!%ast &sia and the Western Pacific' )he $outh!%ast
&sia and Western Pacific regions are the most seriousl affected'
Q %pidemics of dengue are increasing in fre2uenc' During epidemics# infection rates among
those =ho have not been previousl exposed to the virus are often 3,G to 5,G but can also
reach 9,G to 7,G'
Q $easonal variation is observed'
Q &edes ($tegomia- aegpti is the primar epidemic vector'
Q Primaril an urban disease# dengue and DHF are no= spreading to rural areas =orld=ide'
Q 6mported cases are common'
Q Co!circulation of multiple serotpesEgenotpes is evident'
)he first confirmed epidemic of DHF =as recorded in the Philippines in .751/.753 and in
)hailand in .759' $ince then# :ember countries of the WHO $outh!%ast &sia ($%&- and Western
Pacific (WP- regions have reported maDor dengue outbreaBs at regular fre2uencies' 6n 6ndia# the
.
first confirmed DHF outbreaB occurred in .7+1' Other countries of the Region# namel 6ndonesia#
:aldives# :anmar and $ri LanBa# have also reported maDor DHF outbreaBs' )hese outbreaBs
prompted a biregional ($%& and WP regions- meeting on dengue in .783 in :anila# the Philippines#
=here technical guidelines for the diagnosis# treatment# and prevention and control of dengue and
DHF =ere developed' )his document =as later revised at a summit meeting in 4angBoB in .79,'
6n :a .771# the Fort!sixth World Health &ssembl (3+th WH&# .771- adopted a resolution on
dengue prevention and control# =hich urged that the strengthening of national and local programmes
for the prevention and control of dengue fever (DF-# DHF and D$$ should be among the foremost
health priorities of those WHO :ember $tates =here the disease is endemic' )he resolution also
urged :ember $tates to; (.- develop strategies to contain the spread and increasing incidence of
dengue in a manner sustainable? (0- improve communit health education? (1- encourage health
promotion? (3- bolster research? (5- expand dengue surveillance? (+- provide guidance on vector
control? and (8- prioriti"e the mobili"ation of external resources for disease prevention' 6n response
to the World Health &ssembl resolution# a global strateg for the operationali"ation of vector control
=as developed' 6t comprised five maDor components# as outlined in 4ox 0'
4ox 0; $alient Features of Global $trateg for Control of DFEDHF Cectors
Q
Q
Q
Q
Q
$elective integrated mos2uito control =ith communit and intersectoral participation'
&ctive disease surveillance based on strong health information sstems'
%mergenc preparedness'
Capacit!building and training'
6ntensive research on vector control'
&ccordingl# several publications =ere issued b three regional offices of the World Health
Organi"ationI$outh!%ast &sia ($%&RO- R:onograph on dengueEdengue haemorrhagic fever in .771#
a regional strateg for the control of DFEDHF in .775# and Guidelines on :anagement of Dengue
%pidemics in .77+S? Western Pacific (WPRO- RGuidelines for Dengue $urveillance and :os2uito
Control in .775S? and the &mericas (&:RO P&HO- RDengue and Dengue Haemorrhagic Fever in
the &mericas; Guidelines for Prevention and Control in .773S'
& 0,,0 World Health &ssembl resolution (WH& 55'.8- urged greater commitment to dengue from
:ember $tates and WHO' 6n 0,,5# the 6nternational Health Regulations (6HR- =ere formulated' )hese
regulations stipulated that :ember $tates detect and respond to an disease (for example# dengue- that
has demonstrated the abilit to cause serious public health impact and spread rapidl internationall'0
:ore recentl# a biregional ($%& and WP regions- &sia!Pacific Dengue $trategic Plan (0,,9/
0,.5- =as developed to reverse the rising trend of dengue in the :ember countries of these Regions'
)his has been endorsed b the Regional Committees of both the $outh!%ast &sia Region Rresolution
$%&ERC+.ER5 (0,,9-S and the Western Pacific Region Rresolution WPRERC57ER+ (0,,9-S'
Due to the high disease burden# dengue has become a priorit area for several global
organi"ations other than WHO# including the Hnited *ations ChildrenAs Fund (H*6C%F-# Hnited
*ations %nvironment Programme (H*%P-# the World 4anB# and the WHO $pecial Programme for
Research and )raining in )ropical Diseases ()DR-# among others'
6n this bacBdrop# the .777 Guidelines for Prevention and Control of DengueEDHF (WHO
Regional Publication# $%&RO *o' 07- have been revised# updated and rechristened as the
LComprehensive Guidelines for Prevention and Control of Dengue and Dengue Haemmorhagic
Fever; Revised and %xpandedM' )hese Guidelines incorporate ne= developments and strategies in
dengue prevention and control'
0
0' Disease 4urden of Dengue Fever
and Dengue Haemorrhagic Fever
0'. Global
Dengue epidemics are Bno=n to have occurred regularl over the last three centuries in tropical#
subtropical and temperate areas around the =orld' )he first epidemic of dengue =as recorded in
.+151 in the French West 6ndies# although a disease outbreaB compatible =ith dengue had been
reported in China as earl as 770 &D'3 During the .9th# .7th and earl 0,th centuries# epidemics of
dengue!liBe diseases =ere reported and recorded globall# both in tropical as =ell as some temperate
regions' Rush5 =as probabl describing dengue =hen he =rote of LbreaB!bone feverM occurring in
Philadelphia in .89,' :ost of the cases during the epidemics of that time mimicBed clinical DF#
although some displaed characteristics of the haemorrhagic form of the disease'
6n most Central and $outh &merican countries# effective disease prevention =as achieved b
eliminating the principal epidemic mos2uito vector# &edes aegpti# during the .75,s and .7+,s' 6n
&sia# ho=ever# effective mos2uito control =as never achieved' & severe form of haemorrhagic fever#
most liBel aBin to DHF# emerged in some &sian countries follo=ing World War 66' From the .75,s
through .78,s# this form of dengue =as reported as epidemics periodicall in a fe= &sian countries
such as 6ndia# Philippines and )hailand'
During the .79,s# incidence increased marBedl and distribution of the virus expanded to
the Pacific islands and tropical &merica'+ 6n the latter region# the species re!infested most tropical
countries in the .79,s on account of disbanding of the &e' aegpti eradication programme in the
earl .78,s' 6ncreased disease transmission and fre2uenc of epidemics =ere also the result of
circulation of multiple serotpes in &sia' )his brought about the emergence of DHF in the Pacific
6slands# the Caribbean# and Central and $outh &merica' )hus# in less than 0, ears b .779# the
&merican tropics and the Pacific 6slands =ent from being free of dengue to having a serious dengueE
DHF problem'+
%ver ., ears# the average annual number of cases of DFEDHF cases reported to WHO
continues to gro= exponentiall' From 0,,, to 0,,9# the average annual number of cases =as
. +5+ 98,# or nearl three!and!a!half times the figure for .77,/.777# =hich =as 387 939 cases
(Figure .-' 6n 0,,9# a record +7 countries from the WHO regions of $outh!%ast &sia# Western Pacific
and the &mericas reported dengue activit'
1
Geographical extension of the areas =ith dengue transmission or resurgent dengue activit has
been documented in 4hutan# *epal# )imor!Leste# Ha=aii (H$&-# the Galapagos 6slands (%cuador-#
%aster 6sland (Chile-# and the Hong Jong $pecial &dministrative Region and :acao $pecial
&dministrative Region of China bet=een 0,,. and 0,,3 (Figure 0-' *ine outbreaBs of dengue
occurred in north Fueensland# &ustralia# in four ears from 0,,5 to 0,,9'8
Figure .; &verage annual number of cases of DFEDHF reported to WHO
. 9,, ,,,
. +,, ,,,
. 3,, ,,,
*umber of cases
*umber of countries
. +5+ 98,
8,
+,
5,
3,
1,
. 0,, ,,,
. ,, ,,,
9,, ,,,
+,, ,,,
3,, ,,,
0,, ,,,
,
7,9
.5 378
.00 .83
075 553
387 939
0,
.,
.755/.757 .7+,/.7+7 .78,/.787 .79,/.797 .77,/.777
$ource; ==='=ho'int'
Figure 0; Countries and areas at risB of dengue transmission# 0,,9
$ource; Dengue *et# WHO# 0,,9' ==='abc'net'auErnEbacBgroundbriefingEdocumentsE0,.,,00.Tmap'pdf
3
0,,,/0,,9
,
*umber of
countries
*umber of
cases
&ll four dengue viruses are circulating in &sia# &frica and the &mericas' Due to earl detection
and better case management# reported case!fatalit rates have been lo=er in recent ears than in the
decades before 0,,,'9 CountriesEareas at risB of dengue transmission in 0,,9 are sho=n in Figure
0 and the maDor risB factors associated =ith DFEDHF are outlined in 4ox 1'
4ox 1; RisB factors associated =ith DFEDHF
Q Demographic and societal changes; Demographic and societal changes leading to unplanned
and uncontrolled urbani"ation has put severe constraints on civic amenities# particularl
=ater suppl and solid =aste disposal# thereb increasing the breeding potential of the
vector species'
Q Water suppl; 6nsufficient and inade2uate =ater distribution'
Q $olid =aste management; 6nsufficient =aste collection and management'
Q :os2uito control infrastructure; LacB of mos2uito control infrastructure'
Q Consumerism; Consumerism and introduction of non!biodegradable plastic products# paper
cups# used tres# etc' that facilitate increased breeding and passive spread of the disease
to ne= areas (such as via the movement of incubating eggs because of the trade in used
tres-'
Q 6ncreased air travel and globali"ation of trade; 6ncreased air travel and globali"ation of
trade has significantl contributed to the introduction of all the D%*C serotpes to most
population centres of the =orld'
Q :icroevolution of viruses;7 )he use of the most po=erful molecular tools has revealed
that each serotpe has developed man genotpes as a result of microevolution' )here
is increasing evidence that virulent strains are replacing the existing non!virulent strains'
6ntroduction of &sian D%*C!0 into Cuba in .79.# =hich coincided =ith the appearance
of DHF# is a classic example'
)he burden of illness caused b dengue is measured b a set of epidemiological indicators
such as the number of clinical cases classified b severit (DF# DHF# D$$-# duration of illness episode#
2ualit of life during the illness episode# case!fatalit rate and absolute number of deaths during a
given period of time' &ll these epidemiological indicators are combined into a single health indicator#
such as disabilit!adDusted life ears (D&LNs-'a
0'0 )he WHO $outh!%ast &sia Region
Of the 0'5 billion people around the =orld living in dengue endemic countries and at risB of
contracting DFEDHF# .'1 billion live in ., countries of the WHO $outh!%ast &sia ($%&- Region =hich
are dengue endemic areas' )ill 0,,1# onl eight countries in the Region had reported dengue cases'
4 0,,7# all :ember countries except the Democratic PeopleAs Republic (DPR- of Jorea reported
dengue outbreaBs' )imor!Leste reported an outbreaB in 0,,3 for the first time' 4hutan also reported
its first dengue outbreaB in 0,,3'., $imilarl# *epal too reported its first indigenous case of dengue
in *ovember 0,,3'..
)he reported dengue cases and deaths bet=een .795 and 0,,7 in ., countries of the WHO
$%& Region (all :ember $tates except DPR Jorea- ()able . and )able 0- underscore the public health
importance of this disease in the Region'
)he number of dengue cases has increased over the last three to five ears# =ith recurring
epidemics' :oreover# there has been an increase in the proportion of dengue cases =ith their
severit# particularl in )hailand# 6ndonesia and :anmar' )he trends in reported cases and case!
fatalit rates are sho=n in Figure 1'
a Details =ith example are presented in chapter .3'
5
+
)able .;
Dengue
cases
reported
from
countries of
the $%&
Region#
.795/0,,7
.77,
, ,
+ 07.
00 9,8
,
5 030
,
. 15,
70 ,,0
31 5..
3. .05
+8 ,.8
5. +99
+, 11,
18 707
.,. +97
.07 753 03 90+
.9 +.8
.17 108
..3 9,,
+0 8+8
. ,39
+5+
85,
590
33,
. 079
79,
. 085
. +99
1 131
3 1,3
9 71.
3 837
,
,
,
,
,
,
,
,
,
,
,
,
,
,
.5 3+119 1+8
313
.0. 3,.
89 830
+1 8+7
79 597
7, .73
.,+ .7+
.,0 039 .17 ,87
0.9 90. 53 9..
+1 +80
0.. ,17
.99 0.0
.3, +15
+ 880
. +95
0 087
.. +38
0 388
. 953
3 5,,
.1 ,,0
5 909
. 993
.5 +75
.+ ,38
8 7,8
8 1+7
,
,
,
,
,
,
1
. 85,
..9
.9,
81
08
19
830
. .0+
.8 353
,
5 773
35 971
. .09
.50 5,1 .87 7.9
0. .0,
.8 +0,
.8 3.9
.9 891
15 .,0
33 +5,
1, 81,
80 .11
0. .13
11 331
35 7,3
3, 188
5. 713
87 3+0
75 087
0 +91
.. .05
8 373
8 938
.+ 5.8
. .88
8,8
733
+5,
1 1,+
. 70+
.0 853
3 .51
.. 795
.0 1.8
.,+ 305
0 8+9
.. 191
05
.. 79,30 35+
.+0
.97 91,
,
,
,
,
,
,
,
,
,
,
,
,
,
0 587
..
..+
.0,
5 ,01
.58 330
. +9,
.5 095
1
8 1.3
+0 737
008
05, 5,7
,
,
,
,
,
,
,
,
081
5 555
0 31,
+ .,3
39+
1 713
. ,39
0 .79
3++
.77.
.770
.771
.773
.775
.77+
.778
U.779
U.777
0,,,
0,,.
0,,0
0,,1
0,,3
0,,5
0,,+
0,,8
0,,9. .9.
18
.. 38+
0,,7383 15.
.5 515
.55 +,8 .5+ ,50
. 38+
.3 39,
+
+ 555
97 +0+
.,9
883
03 098
1,
15 ,.,05 .73
.85
09, 550 010 51,
Countr
.795
.79+
.798
.799
.797
4angladesh
,
,
,
,
,
4hutan
,
,
,
,
,
6ndia
*&
*&
*&
*
6ndonesia
.1 599
.+ 507
01 9+3
33 581
., 1+0
:aldives
,
,
,
0 ,53
,
:anmar
0 +++
0 ,70
8 01.
. .89
. .7+
*epal
,
,
,
,
,
$ri LanBa
.,
0,1
)hailand
9, ,8+
08 918
.83 095
0+ 70+
83 17.
)imor!Leste $%& Region
7+ 11,
3+ 359
0,5 19,
83 83.
9+ .50
$ource; WHO!
$%&RO# 0,,7'
)able 0;
Dengue
deaths and
case!fatalit
rates (CFR-
reported
from
countries of
the $%&
Region#
.795/0,,7
.77,
, ,
*& 90.
,
.87
,
53
3.3
.18
.1+
000
.3,
.91
1.
.5
8
8
..
,
,
,
,
,
,
53
..+
090
18
+8
3+.
51
.9
,
,
,
,
,
,
,
90
,
.8
051
589
5,7
3.9
38.
995
. .70
+9.
1
.0
1+
3
.,
535
1+
.9
. 3.3
,
0..
, 9
303
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
,
3 ,
.8
300
.
99
,
.3 5+
.77.
.770
.771
.773
.775
.77+
.778
.779
.777
0,,,
71
, 8
380
.
.3
,
18 10
0,,.
33
,
51
378
,
0,3
,
53
035
0,,0
59
,
11
511
.
.8,
,
+3
.8+
0,,1
.,
,
0.5 873
,
89
,
10 81
0,,3
.1
,
35
758
1
87
,
99 39
0
. 3+9
.'0.
.'1.
.'..
,'8+
. ,1.
8,7
85,
. ,91
.'0,
.30 .',9
. 705
.'99
. ,+7
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,
,
,
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,
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6ndia
*&
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. .1+
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0 117
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91+
Case!fatalitrate
.'.9
0',+
.'.3
0'19
,'78
$ource; WHO!
$%&RO# 0,,7'
Figure 1; )rends in reported number of dengue cases and case!fatalit rates (CFR- reported from
countries of the $%& Region# .795/0,,7
1,, 1
*umber of
cases in
thousands
05, 0'5
0,, 0
.5, .'5
.,, .
5, ,'5
.795 .79+ .798 .799 .797 .77, .77. .770 .771 .773 .775 .77+ .778 .779 .777 0,,, 0,,. 0,,0 0,,1 0,,3 0,,5 0,,+ 0,,8 0,,9
Nears
*umber of cases Case!fatalit rate (CFR-
$ource; Countr reports
)he above figure sho=s that in countries of the $%& Region the trend of dengue cases is sho=ing
an increase over the ears' )he case!fatalit rate (CFR-# ho=ever# has registered a declining trend
since .795 and this could be attributed to better case management'
Cariable endemicit for DFEDHF in countries of the $%& Region
DFEDHF is endemic in most countries of the $%& Region and detection of all four serotpes has
no= rendered these countries hperendemic' Ho=ever# the endemicit in 4hutan and *epal is
uncertain (4ox 3-'
4ox 3; Cariable endemicit of DFEDHF in countries of the $%& Region
Categor & (4angladesh# 6ndia# 6ndonesia# :aldives# :anmar# $ri LanBa# )hailand and
)imor!Leste-
Q
Q
Q
Q
:aDor public health problem'
Leading cause of hospitali"ation and death among children'
Hperendemicit =ith all four serotpes circulating in urban areas'
$preading to rural areas'
Categor 4 (4hutan# *epal-
Q
Q
Q
%ndemicit uncertain'
4hutan; First outbreaB reported in 0,,3'
*epal; Reported first indigenous dengue case in 0,,3..'
Categor C (DPR Jorea-
Q *o evidence of endemicit'
0,,7
, ,
Case!fatalit
rate G
8
1' %pidemiolog of Dengue Fever and
Dengue Haemorrhagic Fever
)he transmission of dengue virus depends upon biotic and abiotic factors' 4iotic factors include the
virus# the vector and the host' &biotic factors include temperature# humidit and rainfall'
1'. )he virus
)he dengue viruses are members of the genus Flavivirus and famil Flaviviridae' )hese small (5,
nm- viruses contain single!strand R*& as genome' )he virion consists of a nucleocapsid =ith cubic
smmetr enclosed in a lipoprotein envelope' )he dengue virus genome is .. +33 nucleotides
in length# and is composed of three structural protein genes encoding the nucleocaprid or core
protein (C-# a membrane!associated protein (:-# an envelope protein (%-# and seven non!structural
protein (*$- genes' &mong non!structural proteins# envelope glcoprotein# *$.# is of diagnostic
and pathological importance' 6t is 35 BDa in si"e and associated =ith viral haemagglutination and
neutrali"ation activit'
)he dengue viruses form a distinct complex =ithin the genus Flavivirus based on antigenic and
biological characteristics' )here are four virus serotpes# =hich are designated as D%*C!.# D%*C!0#
D%*C!1 and D%*C!3' 6nfection =ith an one serotpe confers lifelong immunit to that virus serotpe'
&lthough all four serotpes are antigenicall similar# the are different enough to elicit cross!protection
for onl a fe= months after infection b an one of them' $econdar infection =ith another serotpe
or multiple infections =ith different serotpes leads to severe form of dengue (DHFED$$-'
)here exists considerable genetic variation =ithin each serotpe in the form of phlogeneticall
distinct Lsub!tpesM or LgenotpesM' Currentl# three sub!tpes can be identified for D%*C!.# six for
D%*C!0 (one of =hich is found in non!human primates-# four for D%*C!1 and four for D%*C!3#
=ith another D%*C!3 being exclusive to non!human primates'.0
Dengue viruses of all four serotpes have been associated =ith epidemics of dengue fever
(=ith or =ithout DHF- =ith a varing degree of severit'
1'0 Cectors of dengue
&edes ($tegomia- aegpti (&e' aegpti- and &edes ($tegomia- albopictus (&e' albopictus- are the
t=o most important vectors of dengue'b
b
Further details on vectors are presented in Chapter 7'
7
&edes ($tegomia- aegpti
)he &edes ($tegomia- aegpti (&e' aegpti-c mos2uito originates in &frica# =here it exists as a feral
species breeding in forests independent of humans' &t a later stage# the species adapted to the
peridomestic environment b breeding in =ater storage containers in the &frican region' $lave trade
and commerce =ith the rest of the =orld in the .8th to .7th centuries provided a mechanism for
the species to be introduced to the L*e= WorldM and $outh!%ast &sia'3 4 .9,,# the species had
entrenched itself in man large tropical coastal cities around the =orld'
World War 66 provided et another opportunit to the species for penetration into inland areas
through the increased navigation into the hinterland b countr boats on river sstems' 6ncreased
transport# human contact# urbani"ation and the proliferation of drinBing =ater suppl schemes in
rural areas ultimatel led to the species getting entrenched in both urban and rural areas of most
parts of the =orld' On account of the speciesA high degree of domestication and strong affinit for
human blood# it achieved high vectorial capacit for transmission of DFEDHF in all the areas =here
it prevailed' &s per the distribution related records# &e' aegpti no= persists in most of the countries#
and even in those from =here it had been eradicated' )oda# &e' aegpti is a cosmotropical species.1
bet=een latitudes 35V* and 15V$'
&edes ($tegomia- albopictus
&edes ($tegomia- albopictusd belongs to the scutellaris group of subgenus $tegomia' 6t is an &sian
species indigenous to $outh!%ast &sia and islands of the Western Pacific and the 6ndian Ocean'
Ho=ever# during the last fe= decades the species has spread to &frica# West &sia# %urope and the
&mericas (*orth and $outh- after extending its range east=ard to the Pacific islands during the earl
0,th centur'
)he maDorit of the introductions are passive due to transportation of dormant eggs through
international shipments of used tres' 6n ne=l infested countries and those threatened =ith
introduction# there has been considerable concern that &e' albopictus =ould cause serious outbreaBs
of arboviral diseases since &e' albopictus is a competent vector of at least 00 arboviruses# notabl
dengue (all four serotpes-# =hich is more commonl transmitted b &e' aegpti'.3
Figures 3a and 3b sho= the global distribution of &e' aegpti and &e' albopictus'.5
c
d
)he subgenus $tegomia has been upgraded to genus level# Bno=n as $tegomia aegpti' Ho=ever# for simplicit of reference# the name
has been retained as &e' aegpti RReinert K'F' et al' Phlogen and Classification of &edine (Diptera; Culicidae-# based on morphological
characters of all life stages' Woo' Kr' Linnean $ociet# 0,,3? Polas"eB' &' )=o =ords colliding; Resistance to changes in the scientific names
of animalsI&edes versus $tegomia' )rends Parasital# 0,,+# 00 (.-; 9!7? Kr':ed' %ntom' Polic on *ames of &edine :os2uito Genre and
$ubgenreS'
)he sub!genus# $tegomia has been upgraded to genus level# called as $tegomia albopictus' Ho=ever for simplicit of reference#
the name has been retained as &e' albopictus (Reinert K'F' et al' Phlogen and classification of &edine (Diptera; Culicidae-# based on
morphological characters of all life stages' Woo' Kr' Linnean $ociet# 0,,3? Polas"eB' &' )=o =ords colliding; resistance to changes in the
scientific names of animals!!&edes versus $tegomia' )rends Parasital# 0,,+# 00 (.-; 9!7? Kr':ed' %ntom' Polic on *ames of &edine
:os2uito Genre and $ub!genre-'
.,
Figure 3a; Global distribution of &e' aegpti
$ource; Rogers D'K'# Wilson# &'K'# Ha# $'L' )he global distribution of ello= fever and dengue' &dv' Parasitol' 0,,+' +0;.9./00,'.5
Figure 3b; Global distribution of &e' albopictus
$ource; Rogers D'K'# Wilson# &'K'# Ha# $'L' )he global distribution of ello= fever and dengue' &dv' Parasitol' 0,,+' +0;.9./00,'.5
Cectorial competenc and vectorial capacit
)he terminolog of vectorial competenc and vectorial capacit has been used interchangeabl in
literature' Recentl# ho=ever# these have been defined'
Cectorial competenc
Cectorial competenc denotes;
Q
Q
Q
High susceptibilit to infecting virus'
&bilit to replicate the virus'
&bilit to transmit the virus to another host'
4oth &e' aegpti and &e' albopictus carr high vectorial competenc for dengue viruses'
..
Cectorial capacit
Cectorial capacit is governed b the environmental and biological characteristics of the species#
and thus these t=o species differ in their vectorial capacit'
&e' aegpti is a highl domesticated# strongl anthropophilic# nervous feeder (i'e' it bites
more than one host to complete one blood meal- and is a discordant species (i'e' it needs more
than one feed for the completion of the gonotropic ccle-' )hese habits epidemiologicall result in
the generation of multiple cases and the clustering of dengue cases in cities' On the contrar# &e'
albopictus still maintains feral moorings and partl invades peripheral areas of urban cities# and thus
feeds on both humans and animals' 6t is an aggressive feeder and a concordant species# i'e' the
species can complete its blood meal in one go on one person and also does not re2uire a second
blood meal for the completion of the gonotropic ccle' Hence# &e' albopictus carries poor vectorial
capacit in an urban epidemic ccle'
1'1 Host
Dengue viruses# having evolved from mos2uitoes# adapted to non!human primates and later to
humans in an evolutionar process' )he viraemia among humans builds up high titres t=o das
before the onset of the fever (non!febrile- and lasts 5/8 das after the onset of the fever (febrile-' 6t is
onl during these t=o periods that the vector species gets infected' )hereafter# the humans become
dead!ends for transmission' )he spread of infection occurs through the movement of the host (man-
as the vectorsA movements are ver restricted'
)he susceptibilit of the human depends upon the immune status and genetic predisposition'.+#.8#.9
4oth monBes and humans are amplifing hosts and the virus is maintained b mos2uitoes
transovariall via eggs'
1'3
(.-
)ransmission of dengue virus
%n"ootic ccle; & primitive slvatic ccle maintained b monBe!&edes!monBe ccle as
reported from $outh &sia and &frica' Ciruses are not pathogenic to monBes and viraemia
lasts 0/1 das'.7 &ll the four dengue serotpes (D%*C!. to !3- have been isolated from
monBes'
%pi"ootic ccle; )he dengue virus crosses over to non!human primates from adDoining
human epidemic ccles b bridge vectors' 6n $ri LanBa# the epi"ootic ccle =as observed
among tou2e maca2ues (:acaca sinica- during .79+/.798 in a stud area on a serological
basis' Within the stud area (three Bilometres-# 73G maca2ues =ere found affected'0,
%pidemic ccle; )he epidemic ccle is maintained b human!&edes aegpti!human
ccle =ith periodicEcclical epidemics' Generall# all serotpes circulate and give rise to
hperendemicit' &e' aegpti has generall lo= susceptibilit to oral infection but its strong
anthrophil =ith multiple feeding behaviour and highl domesticated habitats maBes it an
efficient vector' )he persistence of dengue virus# therefore# depends on the development
of high viral titres in the human host to ensure transmission in mos2uitoes'0.
)ransmission of dengue viruses occur in three ccles;
(0-
(1-
)ransmission of DFEDHF
For transmission to occur the female &e' aegpti must bite an infected human during the viraemic
phase of the illness that manifests t=o das before the onset of fever and lasts 3/5 das after onset
of fever' &fter ingestion of the infected blood meal the virus replicates in the epithelial cell lining of
.0
the midgut and escapes into haemocoele to infect the salivar glands and finall enters the saliva
causing infection during probing' )he genital tracB is also infected and the virus ma enter the full
developed eggs at the time of oviposition' )he extrinsic incubation period (%6P- lasts from 9 to .0
das and the mos2uito remains infected for the rest of its life' )he intrinsic incubation period covers
five to seven das'00
$easonalit and intensit of transmission
Dengue transmission usuall occurs during the rain season =hen the temperature and humidit
are conducive for build!up of the vector population breeding in secondar habitats as =ell as for
longer mos2uito survival'
6n arid "ones =here rainfall is scant during the dr season# high vector population builds up
in man!made storage containers'
&mbient temperature# besides hastening the life!ccle of &e' aegpti and resulting in the
production of small!si"e mos2uitoes# also reduces the extrinsic incubation period of the virus as
=ell' $mall!si"e females are forced to taBe more blood meals to obtain the protein needed for egg
production' )his has the effect of increasing the number of infected individuals and hastening the
build!up of the epidemic00 during the dr season'
& number of factors that contribute to initiation and maintenance of an epidemic include; (i- the
strain of the virus# =hich ma influence the magnitude and duration of the viraemia in humans? (ii-
the densit# behaviour and vectorial capacit of the vector population? (iii- the susceptibilit of the
human population (both genetic factors and pre!existing immune profile-? and (iv- the introduction
of the virus into a receptive communit'0.
Features of dengue viral infection in the communit
DFEDHF sndrome
DFEDHF is characteri"ed b the LicebergM or pramid phenomenon' &t the base of the pramid# most
of the cases are smptomless# follo=ed b DF# DHF and D$$' Clusters of cases have been reported
in particular households or neighbourhoods due to the feeding behaviour of the vector'01
&ffected population
)he population affected varies from one outbreaB to another' &ctual estimates can be made
b obtaining clinicalEsubclinical ratios during epidemics' 6n a =ell!defined epidemic stud in
*orth Fueensland# &ustralia# =ith primar infection# 0,G to 5,G of the population =as found
affected'03
$everit of the disease
)he serotpe that produces the secondar infection and# in particular# the serotpe se2uence are
important to ascertain the severit of the disease' &ll the four serotpes are able to produce DHF cases'
Ho=ever# during se2uential infections# onl 0G to 3G of individuals develop severe disease'05
$tudies in )hailand have revealed that the D%*C!.ED%*C!0 se2uence of infection =as associated
=ith a 5,,!fold risB of DHF compared =ith primar infection' For the D%*C!1ED%*C!0 se2uence
the risB =as .5,!fold# and a D%*C!3ED%*C!0 se2uence had a 5,!fold risB of DHF'0+
.1
)here is no time!limit to sensiti"ation after a primar infection' )he .778 $antiago de Cuba
epidemic clearl demonstrated that =ith the introduction of D%*C!0# DHF had occurred .+/0,
ears after the primar infection =ith D%*C!.'08
)ransmission sites
Due to the limited flight range of &e' aegpti#.1 DFEDHF spread is caused b human movement'
Receptivit (high!breeding potential for &e' aegpti- and vulnerabilit (high potential for importation
of virus- need to be mapped' &n congregation at receptive areas =ill result in either transmission
from infected mos2uito to human or from viraemic human to the uninfected mos2uito' Hospitals#
schools# religious institutions and entertainment centres =here people congregate become the foci of
transmission on account of high receptivit and vulnerabilit for DFEDHF' Further human movement
spreads the infection to larger parts of the cit'09
1'5 Climate change and its impact on dengue disease burden
Global climate change refers to large!scale changes in climate patterns over the ears# including
fluctuations in both rainfall! and temperature!related greenhouse effects (including the emission of
carbon dioxide from burning fossil fuel and methane from padd fields and livestocB-# =hereb solar
radiation gets trapped beneath the atmosphere' Global =arming is predicted to lead to a 0', VC/3'5 VC
rise in average global temperatures b the ear 0.,,#07 and this could have a perceptible impact
on vector!borne diseases'1,
)he maximum impact of climate change on transmission is liBel to be observed at the extreme
end of the temperature range at =hich the transmission occurs' )he temperature range for dengue
fever lies bet=een .3 VC and .9 VC at the lo=er end and 15 VC and 3, VC at the upper end' &lthough
the vector species# being a domestic breeder# is endophagic and endophilic# it largel remains
insulated b fitting into human ecological re2uirements' Ho=ever# =ith a 0 VC increase in temperature
the extrinsic incubation period of D%*C =ill be shortened and more infected mos2uitoes =ill be
available for a longer period of time'1. 4esides that# mos2uitoes =ill bite more fre2uentl because
of dehdration and thus further increase man!mos2uito contact'
1'+ Other factors for increased risB of vector breeding
Other factors that facilitate increased transmission are briefl outlined belo=;
Hrbani"ation
&s per Hnited *ations reports# 3,G of the population in developing countries no= lives in urban
areas# =hich is proDected to rise to 5+G b 0,1,e largel due to rural/urban migration' $uch migration
from rural to urban areas is due to both LpushM (seeBing better earning avenues- and LpullM (seeBing
better amenities such as education# health care# etc'- factors' )he failure of urban local governments to
provide matching civic amenities and infrastructure to accommodate the influx generates unplanned
settlements =ith inade2uate potable =ater# poor sanitation including solid =aste disposal# and poor
public health infrastructure' &ll this raises the potential for &e' aegpti breeding to a high level and
maBes the environment for transmission conducive'
e
H* Population Division' World Hrbani"ation Prospects; )he 0,,. revision' 0,,0' *e= NorB# H*' p'.90' http;EEinfo'B3health'orgEprEm.+E
m.+chap.T.'shtml
.3
6ncreased global travel
With expanding travel and an exponential increase in tourism and trade# there exists a high possibilit
of introduction of ne= D%*C serotpesEgenotpes through health viraemic persons# thus helping
in the build!up of a high transmission potential'
1'8 Geographical spread of dengue vectors
&e' albopictus has spread farther north compared =ith &e' aegpti (Figures 3a and 3b-' 6ts eggs are
some=hat resistant to sub!free"ing temperatures'10 )his raises the possibilit that &e' albopictus
could mediate a re!emergence of dengue in the Hnited $tates of &merica or in %urope' )his species
survived the extreme =inters in 6tal11 and =as recentl implicated in an outbreaB of chiBunguna
in 6tal'13
1'9 Future proDections of dengue estimated through
empirical models
:athematical models proDect a substantial increase in the transmission of vector!borne diseases
in various climate change situations' Ho=ever# these models have been critici"ed on the grounds
that the do not ade2uatel account for rainfall# interaction bet=een climate variables or relevant
socioeconomic factors' )he dengue vector &e' aegpti is highl domesticated and breeds in safe
clean =aters devoid of an parasite# pathogen or predators' $imilarl# adults feed on humans inside
houses and rest in se2uestered# darB places to complete the gonotropic ccles' 6n vie= of these
ecological features# &e' aegpti is least affected b climatic changes and instead maintains a high
transmission potential throughout'
6n an empirical model15 vapour pressure / =hich is a measure of humidit / =as incorporated
to estimate the global distribution of dengue fever' 6t =as concluded that the current geographical
limits of dengue fever transmission can be modelled =ith 97G accurac on the basis of long!term
average vapour pressure' 6n .77,# almost 1,G of the =orld population# i'e' .'5 billion people# lived
in regions =here the estimated risB of dengue transmission =as greater than 5,G'
4 0,95# given the population and climatic change proDections# it is estimated that 5/+ billion
people (5,G/+,G of the proDected global population- =ould be at risB of dengue transmission
compared =ith 1'5 billion people or 15G of the proDected population if climate change =ould not
set in' Ho=ever# further research on this is needed'
.5
3' Clinical :anifestations and
Diagnosisf
3'. Clinical manifestations
Dengue virus infection ma be asmptomatic or ma cause undifferentiated febrile illness (viral
sndrome-# dengue fever (DF-# or dengue haemorrhagic fever (DHF- including dengue shocB sndrome
(D$$-' 6nfection =ith one dengue serotpe gives lifelong immunit to that particular serotpe# but
there is onl short!term cross!protection for the other serotpes' )he clinical manifestation depends
on the virus strain and host factors such as age# immune status# etc' (4ox 5-'
4ox 5; :anifestations of dengue virus infection
Dengue virus infection
&smptomatic $smptomatic
Hndifferentiated
Fever
(viral sndrome-
Dengue fever (DF- Dengue haemorrheagic
fever (DHF-
(=ith plasma leaBage-
%xpanded dengue $ndromeE
6solated organopath
(unusual manifestation-
Without
haemorrhage
With unusual
haemorrhage
DHF
non!shocB
DHF =ith shocB
Dengue shocB
sndrome (D$$-
)he details of dengue virus infection are presented belo='
Hndifferentiated fever
6nfants# children and adults =ho have been infected =ith dengue virus# especiall for the first
time (i'e' primar dengue infection-# ma develop a simple fever indistinguishable from other viral
f )his chapter =as revie=ed at the Consultative :eeting on Dengue Case Classification and Case :anagement held in 4angBoB#
)hailand# on 8!9 October 0,.,' )he participants included experts from $%&RO and WPRO :ember $tates and one observer each
from the Hniversit of :assachusetts :edical $chool# H$&# and &rmed Forces Research 6nstitute of :edical $ciences# )hailand# and
the secretariat comprised members of the WHO Collaborating Centre for Case :anagement of DengueEDHFED$$# F$*6CH (4angBoB#
)hailand-'
.8
infections' :aculopapular rashes ma accompan the fever or ma appear during defervescence'
Hpper respirator and gastrointestinal smptoms are common'
Dengue fever
Dengue fever (DF- is most common in older children# adolescents and adults' 6t is generall an acute
febrile illness# and sometimes biphasic fever =ith severe headache# malgias# arthralgias# rashes#
leucopenia and thromboctopenia ma also be observed' &lthough DF ma be benign# it could
be an incapacitating disease =ith severe headache# muscle and Doint and bone pains (breaB!bone
fever-# particularl in adults' Occasionall unusual haemorrhage such as gastrointestinal bleeding#
hpermenorrhea and massive epistaxis occur' 6n dengue endemic areas# outbreaBs of DF seldom
occur among local people'
Dengue haemorrhagic fever
Dengue haemorrhagic fever (DHF- is more common in children less than .5 ears of age in
hperendemic areas# in association =ith repeated dengue infections' Ho=ever# the incidence of
DHF in adults is increasing' DHF is characteri"ed b the acute onset of high fever and is associated
=ith signs and smptoms similar to DF in the earl febrile phase' )here are common haemorrhagic
diatheses such as positive tourni2uet test ())-# petechiae# eas bruising andEor G6 haemorrhage in
severe cases' 4 the end of the febrile phase# there is a tendenc to develop hpovolemic shocB
(dengue shocB sndrome- due to plasma leaBage'
)he presence of preceding =arning signs such as persistent vomiting# abdominal pain# letharg
or restlessness# or irritabilit and oliguria are important for intervention to prevent shocB' &bnormal
haemostasis and plasma leaBage are the main pathophsiological hallmarBs of DHF' )hromboctopenia
and rising haematocritEhaemoconcentration are constant findings before the subsidence of feverE
onset of shocB' DHF occurs most commonl in children =ith secondar dengue infection' 6t has also
been documented in primar infections =ith D%*C!. and D%*C!1 as =ell as in infants'
%xpanded dengue sndrome
Hnusual manifestations of patients =ith severe organ involvement such as liver# Bidnes# brain or heart
associated =ith dengue infection have been increasingl reported in DHF and also in dengue patients
=ho do not have evidence of plasma leaBage' )hese unusual manifestations ma be associated =ith
coinfections# comorbidities or complications of prolonged shocB' %xhaustive investigations should
be done in these cases'
:ost DHF patients =ho have unusual manifestations are the result of prolonged shocB =ith
organ failure or patients =ith comorbidities or coinfections'
3'0 Clinical features
Dengue fever
&fter an average intrinsic incubation period of 3/+ das (range 1/.3 das-# various non!specific#
constitutional smptoms and headache# bacBache and general malaise ma develop' )picall# the
onset of DF is sudden =ith a sharp rise in temperature and is fre2uentl associated =ith a flushed
face1+ and headache' Occasionall# chills accompan the sudden rise in temperature' )hereafter#
there ma be retro!orbital pain on ee movement or ee pressure# photophobia# bacBache# and
pain in the muscles and DointsEbones' )he other common smptoms include anorexia and altered
.9
taste sensation# constipation# colicB pain and abdominal tenderness# dragging pains in the inguinal
region# sore throat and general depression' )hese smptoms usuall persist from several das to a
fe= =eeBs' 6t is note=orth that these smptoms and signs of DF var marBedl in fre2uenc and
severit'
Fever; )he bod temperature is usuall bet=een 17 VC and 3, VC# and the fever ma be
biphasic# lasting 5/8 das in the maDorit of cases'
Rash; Diffuse flushing or fleeting eruptions ma be observed on the face# necB and chest during
the first t=o to three das# and a conspicuous rash that ma be maculopapular or rubelliform appears
on approximatel the third or fourth da' )o=ards the end of the febrile period or immediatel after
defervescence# the generali"ed rash fades and locali"ed clusters of petechiae ma appear over the
dorsum of the feet# on the legs# and on the hands and arms' )his convalescent rash is characteri"ed
b confluent petechiae surrounding scattered pale# round areas of normal sBin' $Bin itching ma
be observed'
Haemorrhagic manifestations; $Bin haemorrhage ma be present as a positive tourni2uet test
andEor petechiae' Other bleeding such as massive epistaxis# hpermenorrhea and gastrointestinal
bleeding rarel occur in DF# complicated =ith thromboctopenia'
Course; )he relative duration and severit of DF illness varies bet=een individuals in a given
epidemic# as =ell as from one epidemic to another' Convalescence ma be short and uneventful but
ma also often be prolonged' 6n adults# it sometimes lasts for several =eeBs and ma be accompanied
b pronounced asthenia and depression' 4radcardia is common during convalescene' Haemorrhagic
complications# such as epistaxis# gingival bleeding# gastrointestinal bleeding# haematuria and
hpermenorrhoea# are unusual in DF' &lthough rare# such severe bleeding (DF =ith unusual
haemorrhage- are an important cause of death in DF'
fever'
Dengue fever =ith haemorrhagic manifestations must be differentiated from dengue haemorrhagic
Clinical laborator findings
6n dengue endemic areas# positive tourni2uet test and leuBopenia (W4C X5,,, cellsEmm1- help in
maBing earl diagnosis of dengue infection =ith a positive predictive value of 8,G/9,G'18#19
)he laborator findings during an acute DF episode of illness are as follo=s;
Q
Q
)otal W4C is usuall normal at the onset of fever? then leucopenia develops =ith decreasing
neutrophils and lasts throughout the febrile period'
Platelet counts are usuall normal# as are other components of the blood clotting mechanism'
:ild thromboctopenia (.,, ,,, to .5, ,,, cellsEmm1- is common and about half of all
DF patients have platelet count belo= .,, ,,, cellsEmm1? but severe thromboctopenia
(Y5, ,,, cellsEmm1- is rare'17
:ild haematocrit rise (Z.,G- ma be found as a conse2uence of dehdration associated
=ith high fever# vomiting# anorexia and poor oral intaBe'
$erum biochemistr is usuall normal but liver en"mes and aspartate amino transferase
(&$)- levels ma be elevated'
6t should be noted that the use of medications such as analgesics# antipretics# anti!emetics
and antibiotics can interfere =ith liver function and blood clotting'
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.7
Differential diagnosis
)he differential diagnoses of DF include a =ide variet of diseases prevalent in the localit (4ox +-'
4ox +; Differential diagnoses of dengue3,
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&rboviruses; ChiBunguna virus (this has often been mistaBen for dengue in $outh!%ast &sia-'
Other viral diseases; :easles? rubella and other viral exanthems? %pstein!4arr Cirus (%4C-?
enteroviruses? influen"a? hepatitis &? Hantavirus'
4acterial diseases; :eningococcaemia# leptospirosis# tphoid# melioidosis# ricBettsial diseases#
scarlet fever'
Parasitic diseases; :alaria'
Dengue haemorrhagic fever and dengue shocB sndrome
)pical cases of DHF are characteri"ed b high fever# haemorrhagic phenomena# hepatomegal# and
often circulator disturbance and shocB1+#3.' :oderate to marBed thromboctopenia =ith concurrent
haemoconcentrationErising haematocrit are constant and distinctive laborator findings are seen'
)he maDor pathophsiological changes that determine the severit of DHF and differentiate it from
DF and other viral haemorrhagic fevers are abnormal haemostasis and leaBage of plasma selectivel
in pleural and abdominal cavities'
)he clinical course of DHF begins =ith a sudden rise in temperature accompanied b facial flush
and other smptoms resembling dengue fever# such as anorexia# vomiting# headache# and muscle or
Doint pains ()able 1-3.' $ome DHF patients complain of sore throat and an inDected pharnx ma be
found on examination' %pigastric discomfort# tenderness at the right sub!costal margin# and generali"ed
abdominal pain are common' )he temperature is tpicall high and in most cases continues as such
for 0/8 das before falling to a normal or subnormal level' Occasionall the temperature ma be as
high as 3, VC# and febrile convulsions ma occur' & bi!phasic fever pattern ma be observed'
)able 1; *on!specific constitutional smptoms observed in haemorrhagic
fever patients =ith dengue and chiBunguna virus infection
$mptom
6nDected pharnx
Comiting
Constipation
&bdominal pain
Headache
Generali"ed lmphadenopath
ConDunctival inDection
Cough
Restlessness
Rhinitis
:aculopapular rash
:algiaEarthralgia
%nanthema
&bnormal reflex
Diarrhoea
Palpable spleen (in infants of Y+ months-
Coma
DHF (G-
79'7
58'7
51'1
5,',
33'+
3,'5
10'9a
0.'5
0.'5
.0'9
.0'.a
.0',a
9'1
+'8
+'3
+'1
1',
3.
ChiBunguna fever (G-
7,'1
57'3
3,',
1.'+
+9'3
1,'9
55'+a
01'1
11'1
+'5
57'+a
3,',a
..'.
,',
.5'+
1'.
,',
$ource; *immannita $'# et al'# &merican Kournal of )ropical :edicine and Hgiene# .7+7# .9;753!78.'
a$tatisticall significant difference'
0,
& positive tourni2uet test ([., spotsEs2uare inch-# the most common haemorrhagic
phenomenon# could be observed in the earl febrile phase' %as bruising and bleeding at venipuncture
sites are present in most cases' Fine petechiae scattered on the extremities# axillae# and face and
soft palate ma be seen during the earl febrile phase' & confluent petechial rash =ith small# round
areas of normal sBin is seen in convalescence# as in dengue fever' & maculopapular or rubelliform
rash ma be observed earl or late in the disease' %pistaxis and gum bleeding are less common' :ild
gastrointestinal haemorrhage is occasionall observed# ho=ever# this could be severe in pre!existing
peptic ulcer disease' Haematuria is rare'
)he liver is usuall palpable earl in the febrile phase# varing from Dust palpable to 0/3 cm
belo= the right costal margin' Liver si"e is not correlated =ith disease severit# but hepatomegal is
more fre2uent in shocB cases' )he liver is tender# but Daundice is not usuall observed' 6t should be
noted that the incidence of hepatomegal is observer dependent' $plenomegal has been observed
in infants under t=elve months and b radiolog examination' & lateral decubitus chest \!ra
demonstrating pleural effusion# mostl on the right side# is a constant finding' )he extent of pleural
effusion is positivel correlated =ith disease severit' Hltrasound could be used to detect pleural
effusion and ascites' Gall bladder oedema has been found to precede plasma leaBage'
)he critical phase of DHF# i'e' the period of plasma leaBage# begins around the transition
from the febrile to the afebrile phase' %vidence of plasma leaBage# pleural effusion and ascites ma#
ho=ever# not be detectable b phsical examination in the earl phase of plasma leaBage or mild
cases of DHF' & rising haematocrit# e'g' .,G to .5G above baseline# is the earliest evidence'
$ignificant loss of plasma leads to hpovolemic shocB' %ven in these shocB cases# prior to
intravenous fluid therap# pleural effusion and ascites ma not be detected clinicall' Plasma leaBage
=ill be detected as the disease progresses or after fluid therap' Radiographic and ultrasound evidence
of plasma leaBage precedes clinical detection' & right lateral decubitus chest radiograph increases
the sensitivit to detect pleural effusion' Gall bladder =all oedema is associated =ith plasma leaBage
and ma precede the clinical detection' & significantl decreased serum albumin ],'5 gmEdl from
baseline or Y1'5 gmG is indirect evidence of plasma leaBage'17
6n mild cases of DHF# all signs and smptoms abate after the fever subsides' Fever lsis ma be
accompanied b s=eating and mild changes in pulse rate and blood pressure' )hese changes reflect
mild and transient circulator disturbances as a result of mild degrees of plasma leaBage' Patients
usuall recover either spontaneousl or after fluid and electrolte therap'
6n moderate to severe cases# the patientAs condition deteriorates a fe= das after the onset of
fever' )here are =arning signs such as persistent vomiting# abdominal pain# refusal of oral intaBe#
letharg or restlessness or irritabilit# postural hpotension and oliguria'
*ear the end of the febrile phase# b the time or shortl after the temperature drops or bet=een
1/8 das after the fever onset# there are signs of circulator failure; the sBin becomes cool# blotch
and congested# circum!oral canosis is fre2uentl observed# and the pulse becomes =eaB and rapid'
&lthough some patients ma appear lethargic# usuall the become restless and then rapidl go into
a critical stage of shocB' &cute abdominal pain is a fre2uent complaint before the onset of shocB'
)he shocB is characteri"ed b a rapid and =eaB pulse =ith narro=ing of the pulse pressure X0,
mmHg =ith an increased diastolic pressure# e'g' .,,E7, mmHg# or hpotension' $igns of reduced
tissue perfusion are; delaed capillar refill (]1 seconds-# cold clamm sBin and restlessness' Patients
in shocB are in danger of ding if no prompt and appropriate treatment is given' Patients ma pass
into a stage of profound shocB =ith blood pressure andEor pulse becoming imperceptible (Grade
3 DHF-' 6t is note=orth that most patients remain conscious almost to the terminal stage' $hocB is
reversible and of short duration if timel and ade2uate treatment =ith volume!replacement is given'
0.
Without treatment# the patient ma die =ithin .0 to 03 hours' Patients =ith prolonged or uncorrected
shocB ma give rise to a more complicated course =ith metabolic acidosis and electrolte imbalance#
multiorgan failure and severe bleeding from various organs' Hepatic and renal failure are commonl
observed in prolonged shocB' %ncephalopath ma occur in association =ith multiorgan failure#
metabolic and electrolte disturbances' 6ntracranial haemorrhage is rare and ma be a late event'
Patients =ith prolonged or uncorrected shocB have a poor prognosis and high mortalit'
Convalescence in DHF
Diuresis and the return of appetite are signs of recover and are indications to stop volume
replacement' Common findings in convalescence include sinus bradcardia or arrhthmia and the
characteristic dengue confluent petechial rash as described for dengue fever' Convalescence in
patients =ith or =ithout shocB is usuall short and uneventful' %ven in cases =ith profound shocB#
once the shocB is overcome =ith proper treatment the surviving patients recover =ithin 0 / 1 das'
Ho=ever# those =ho have prolonged shocB and multiorgan failure =ill re2uire specific treatment
and experience a longer convalescence' 6t should be noted that the mortalit in this group =ould
be high even =ith specific treatment'
3'1 Pathogenesis and pathophsiolog
DHF occurs in a small proportion of dengue patients' &lthough DHF ma occur in patients
experiencing dengue virus infection for the first time# most DHF cases occur in patients =ith a
secondar infection'30#31 )he association bet=een occurrence of DHFED$$ and secondar dengue
infections implicates the immune sstem in the pathogenesis of DHF' 4oth the innate immunit such
as the complement sstem and *J cells as =ell as the adaptive immunit including humoral and cell!
mediated immunit are involved in this process'33#35 %nhancement of immune activation# particularl
during a secondar infection# leads to exaggerated ctoBine response resulting in changes in vascular
permeabilit' 6n addition# viral products such as *$. ma pla a role in regulating complement
activation and vascular permeabilit'3+#38#39
)he hallmarB of DHF is the increased vascular permeabilit resulting in plasma leaBage#
contracted intravascular volume# and shocB in severe cases' )he leaBage is uni2ue in that there is
selective leaBage of plasma in the pleural and peritoneal cavities and the period of leaBage is short
(03/39 hours-' Rapid recover of shocB =ithout se2uelae and the absence of inflammation in the
pleura and peritoneum indicate functional changes in vascular integrit rather than structural damage
of the endothelium as the underling mechanism'
Carious ctoBines =ith permeabilit enhancing effect have been implicated in the pathogenesis
of DHF'37!51 Ho=ever# the relative importance of these ctoBines in DHF is still unBno=n' $tudies
have sho=n that the pattern of ctoBine response ma be related to the pattern of cross!recognition
of dengue!specific )!cells' Cross!reactive )!cells appear to be functionall deficit in their ctoltic
activit but express enhanced ctoBine production including )*F!a# 6F*!g and chemoBines'53#55#5+
Of note# )*F!a has been implicated in some severe manifestations including haemorrhage in some
animal models'58#59 6ncrease in vascular permeabilit can also be mediated b the activation of the
complement sstem' %levated levels of complement fragments have been documented in DHF'57
$ome complement fragments such as C1a and C5a are Bno=n to have permeabilit enhancing
effects' 6n recent studies# the *$. antigen of dengue virus has been sho=n to regulate complement
activation and ma pla a role in the pathogenesis of DHF'3+#38#39
Higher levels of viral load in DHF patients in comparison =ith DF patients have been
demonstrated in man studies'+,#+. )he levels of viral protein# *$.# =ere also higher in DHF patients'+0
)he degrees of viral load correlate =ith measurements of disease severit such as the amount of
00
pleural effusions and thromboctopenia# suggesting that viral burden ma be a Be determinant of
disease severit'
3'3
Q
Clinical laborator findings of DHF
)he =hite blood cell (W4C- count ma be normal or =ith predominant neutrophils in
the earl febrile phase' )hereafter# there is a drop in the total number of =hite blood
cells and neutrophils# reaching a nadir to=ards the end of the febrile phase' )he change
in total =hite cell count (X5,,, cellsEmm1-+1 and ratio of neutrophils to lmphocte
(neutrophilsYlmphoctes- is useful to predict the critical period of plasma leaBage' )his
finding precedes thromboctopenia or rising haematocrit' & relative lmphoctosis =ith
increased atpical lmphoctes is commonl observed b the end of the febrile phase and
into convalescence' )hese changes are also seen in DF'
)he platelet counts are normal during the earl febrile phase' & mild decrease could be
observed thereafter' & sudden drop in platelet count to belo= .,, ,,, occurs b the end
of the febrile phase before the onset of shocB or subsidence of fever' )he level of platelet
count is correlated =ith severit of DHF' 6n addition there is impairment of platelet function'
)hese changes are of short duration and return to normal during convalescence'
)he haematocrit is normal in the earl febrile phase' & slight increase ma be due to high
fever# anorexia and vomiting' & sudden rise in haematocrit is observed simultaneousl
or shortl after the drop in platelet count' Haemoconcentration or rising haematocrit b
0,G from the baseline# e'g' from haematocrit of 15G to [30G is obDective evidence of
leaBage of plasma'
)hromboctopenia and haemoconcentration are constant findings in DHF' & drop in
platelet count to belo= .,, ,,, cellsEmm1 is usuall found bet=een the 1rd and .,th
das of illness' & rise in haematocrit occurs in all DHF cases# particularl in shocB cases'
Haemoconcentration =ith haematocrit increases b 0,G or more is obDective evidence of
plasma leaBage' 6t should be noted that the level of haematocrit ma be affected b earl
volume replacement and b bleeding'
Other common findings are hpoproteinemiaEalbuminaemia (as a conse2uence of plasma
leaBage-# hponatremia# and mildl elevated serum aspartate aminotransferase levels (X0,,
HEL- =ith the ratio of &$);&L)]0'
& transient mild albuminuria is sometimes observed'
Occult blood is often found in the stool'
6n most cases# assas of coagulation and fibrinoltic factors sho= reductions in fibrinogen#
prothrombin# factor C666# factor \66# and antithrombin 666' & reduction in antiplasmin (plasmin
inhibitor- has been noted in some cases' 6n severe cases =ith marBed liver dsfunction#
reduction is observed in the vitamin J!dependent prothrombin co!factors# such as factors
C# C66# 6\ and \'
Partial thromboplastin time and prothrombin time are prolonged in about half and one
third of DHF cases respectivel' )hrombin time is also prolonged in severe cases'
Hponatremia is fre2uentl observed in DHF and is more severe in shocB'
Hpocalcemia (corrected for hpoalbuminemia- has been observed in all cases of DHF#
the level is lo=er in Grade 1 and 3'
:etabolic acidosis is fre2uentl found in cases =ith prolonged shocB' 4lood urea nitrogen
is elevated in prolonged shocB'
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01
3'5
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Criteria for clinical diagnosis of DHFED$$
Fever; acute onset# high and continuous# lasting t=o to seven das in most cases'
&n of the follo=ing haemorrhagic manifestations including a positive tourni2uet testg (the
most common-# petechiae# purpura (at venepuncture sites-# ecchmosis# epistaxis# gum
bleeding# and haematemesis andEor melena'
%nlargement of the liver (hepatomegal- is observed at some stage of the illness in 7,G/79G
of children' )he fre2uenc varies =ith time andEor the observer'
$hocB# manifested b tachcardia# poor tissue perfusion =ith =eaB pulse and narro=ed
pulse pressure (0, mmHg or less- or hpotension =ith the presence of cold# clamm sBin
andEor restlessness'
Clinical manifestations
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Laborator findings
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)hromboctopenia (.,, ,,, cells per mm1 or less-h'
Haemoconcentration? haematocrit increase of [0,Gi from the baseline of patient or
population of the same age'
)he first t=o clinical criteria# plus thromboctopenia and haemoconcentration or a rising
haematocrit# are sufficient to establish a clinical diagnosis of DHF' )he presence of liver enlargement in
addition to the first t=o clinical criteria is suggestive of DHF before the onset of plasma leaBage'
)he presence of pleural effusion (chest \!ra or ultrasound- is the most obDective evidence of
plasma leaBage =hile hpoalbuminaemia provides supporting evidence' )his is particularl useful
for diagnosis of DHF in the follo=ing patients;
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anaemia'
severe haemorrhage'
=here there is no baseline haematocrit'
rise in haematocrit to Y0,G because of earl intravenous therap'
6n cases =ith shocB# a high haematocrit and marBed thromboctopenia support the
diagnosis of D$$' & lo= %$R (Y., mmEfirst hour- during shocB differentiates D$$ from septic
shocB'
)he clinical and laborator findings associated =ith the various grades of severit of DHF are
sho=n in 4ox 8'
g
h
i
)he tourni2uet test is performed b inflating a blood pressure cuff to a point mid=a bet=een the sstolic and diastolic pressures for five
minutes' )he test is considered positive =hen ., or more petechiae per s2' inch are observed' 6n DHF the test usuall gives a definite
positive result =ith 0, petechiae or more' )he test ma be negative or onl mildl positive in obese patients and during the phase of
profound shocB' 6t usuall becomes positive# sometimes strongl positive after recover from shocB'
)his level is usuall observed shortl before subsidence of fever andEor onset of shocB' )herefore# serial platelet estimation is essential
for diagnosis' & fe= cases ma have platelet count above .,, ,,, mm1 at this period'
Direct count using a phase!contrast microscope (normal 0,, ,,,!5,, ,,,Emm1-' 6n practice# for outpatients# an approximate count from
a peripheral blood smear is acceptable' 6n normal persons# 5/., platelets per oil!immersion field (the average observed from ., fields
is recommended- indicate an ade2uate platelet count' &n average of 0/1 platelets per oil!immersion field or less is considered lo= (less
than .,, ,,,Emm1-'
03
4ox 8; :aDor manifestationsEpathophsiological change of DHFD
3'+ Grading the severit of DHF
)he severit of DHF is classified into four grades1+#3.()able 3-' )he presence of thromboctopenia =ith
concurrent haemoconcentration differentiates Grade 6 and Grade 66 DHF from dengue fever' Grading
the severit of the disease has been found clinicall and epidemiologicall useful in DHF epidemics
in children in the $outh!%ast &sia# Western Pacific and &merica Regions of WHO' %xperiences in
Cuba# Puerto Rico and Cene"uela suggest that this classification is also useful for adults'
3'8 Differential diagnosis of DHF
%arl in the febrile phase# the differential diagnoses include a =ide spectrum of viral# bacterial and
proto"oal infections similar to that of DF' Haemorrhagic manifestations# e'g' positive tourni2uet test
and leucopenia (X5,,, cellsEmm1-+1 suggest dengue illness' )he presence of thromboctopenia =ith
concurrent haemoconcentration differentiates DHFED$$ from other diseases' 6n patients =ith no
significant rise in haematocrit as a result of severe bleeding andEor earl intravenous fluid therap#
demonstration of pleural effusionEascites indicates plasma leaBage' HpoproteinaemiaEalbuminaemia
supports the presence of plasma leaBage' & normal erthrocte sedimentation rate (%$R- helps
differentiate dengue from bacterial infection and septic shocB' 6t should be noted that during the
period of shocB# the %$R is Y., mmEhour'+3
D Refer to section 3'+ for description of DHF severit grades'
05
)able 3; WHO classification of dengue infections and grading of severit of DHF
DFE DHF
DF
Grade
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DHF 6
$igns and $mptoms
Fever =ith t=o of the follo=ing;
Headache'
Retro!orbital pain'
:algia'
&rthtralgiaEbone pain'
Rash'
Haemorrhagic
manifestations'
*o evidence of plasma
leaBage'
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Q
Laborator
Leucopenia (=bc X5,,,
cellsEmm1-'
)hromboctopenia (Platelet
count
Y.5, ,,, cellsEmm1-'
Rising haematocrit
(5G / .,G -'
*o evidence of plasma loss'
Fever and haemorrhagic manifestation )hromboctopenia Y.,, ,,, cellsE
(positive tourni2uet test- andmm1? HC) rise [0,G
evidence of plasma leaBage
&s in Grade 6 plus spontaneous
bleeding'
&s in Grade 6 or 66 plus circulator
failure
(=eaB pulse# narro= pulse pressure
(X0, mmHg-# hpotension#
restlessness-'
&s in Grade 666 plus profound shocB
=ith undetectable 4P and pulse
)hromboctopenia
Y.,, ,,, cellsEmm1? HC) rise [0,G'
)hromboctopenia
Y.,, ,,, cellsEmm1? HC) rise [0,G'
DHF
DHF^
66
666
DHF^ 6C )hromboctopenia
Y .,, ,,, cellsEmm1? HC) rise [0,G'
$ource; http;EE==='=ho'intEcsrEresourcesEpublicationsEdengueEDenguepublicationEenE
^; DHF 666 and 6C are D$$
3'9 Complications
DF complications
DF =ith haemorrhage can occur in association =ith underling disease such as peptic ulcers# severe
thromboctopenia and trauma'
DHF is not a continuum of DF'
DHF complications
)hese occur usuall in association =ith profoundEprolonged shocB leading to metabolic acidosis and
severe bleeding as a result of D6C and multiorgan failure such as hepatic and renal dsfunction' :ore
important# excessive fluid replacement during the plasma leaBage period leads to massive effusions
causing respirator compromise# acute pulmonar congestion andEor heart failure' Continued fluid
therap after the period of plasma leaBage =ill cause acute pulmonar oedema or heart failure#
especiall =hen there is reabsorption of extravasated fluid' 6n addition# profoundEprolonged shocB
and inappropriate fluid therap can cause metabolicEelectrolte disturbance' :etabolic abnormalities
are fre2uentl found as hpoglcemia# hponatremia# hpocalcemia and occasionall# hperglcemia'
)hese disturbances ma lead to various unusual manifestations# e'g' encephalopath'
0+
3'7 %xpanded dengue sndrome (unusual or atpical
manifestations-
Hnusual manifestations are uncommon' 6n recent ears =ith the geographical spread of dengue
illness and =ith more involvement of adults# there have been increasing reports of DF and DHF
=ith unusual manifestations' )hese include; neurological# hepatic# renal and other isolated organ
involvement' )hese could be explained as complications of severe profound shocB or associated
=ith underling host conditionsEdiseases or coinfections'
Central nervous sstem (C*$- manifestations including convulsions# spasticit# changes in
consciousness and transient paresis have been observed' )he underling causes depend on the
timing of these manifestations in relation to the viremia# plasma leaBage or convalescence'
%ncephalopath in fatal cases has been reported in 6ndonesia# :alasia# :anmar# 6ndia and
Puerto Rico' Ho=ever# in most cases there have been no autopsies to rule out bleeding or occlusion
of the blood vessels' &lthough limited# there is some evidence that on rare occasions dengue viruses
ma cross the blood!brain barrier and cause encephalitis' 6t should be noted that exclusion of
concurrent infections has not been exhaustive' )able 5 details the unusualEatpical manifestations
of dengue'
)he above!mentioned unusual manifestations ma be underreported or unrecogni"ed or not
related to dengue' Ho=ever# it is essential that proper clinical assessment is carried out for appropriate
management# and causal studies should be done'
3'., High!risB patients
)he follo=ing host factors contribute to more severe disease and its complications;
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infants and the elderl#
obesit#
pregnant =omen#
peptic ulcer disease#
=omen =ho have menstruation or abnormal vaginal bleeding#
haemoltic diseases such as glucose!+!phosphatase dehdrogenase (G!+PD- deficienc#
thalassemia and other haemoglobinopathies#
congenital heart disease#
chronic diseases such as diabetes mellitus# hpertension# asthma# ischaemic heart disease#
chronic renal failure# liver cirrhosis#
patients on steroid or *$&6D treatment# and
others'
08
)able 5; %xpanded dengue sndrome (Hnusual or atpical manifestations of dengue-
$stem
*eurological
Hnusual or atpical manifestations
Febrile sei"ures in oung children'
%ncephalopath'
%ncephalitisEaseptic meningitis'
6ntracranial haemorrhagesEthrombosis'
$ubdural effusions'
:ononeuropathiesEpolneuropathiesEGuillane!4arre $ndrome'
)ransverse melitis'
GastrointestinalEhepatic HepatitisEfulminant hepatic failure'
&calculous cholecstitis'
&cute pancreatitis'
Hperplasia of PeerAs patches'
&cute parotitis'
Renal
Cardiac
&cute renal failure'
Hemoltic uremic sndrome'
Conduction abnormalities'
:ocarditis'
Pericarditis'
Respirator
:usculosBeletal
LmphoreticularEbone marro=
&cute respirator distress sndrome'
Pulmonar haemorrhage'
:ositis =ith raised creatine phosphoBinase (CPJ-'
Rhabdomolsis'
6nfection associated haemophagoctic sndrome'
6&H$ or Haemophagoctic lmphohistioctosis (HLH-# idiopathic
thromboctopenic purura (6)P-'
$pontaneous splenic rupture'
Lmph node infarction'
%e :acular haemorrhage'
6mpaired visual acuit'
Optic neuritis'
Others Post!infectious fatigue sndrome# depression# hallucinations# pschosis#
alopecia'
$ource; Gulati $'# :ahesh=ari &' &tpical manifestations of dengue' )rop :ed 6nt Health' 0,,8 $ep'? .0(7-;.,98 / 75'+5
3'.. Clinical manifestations of DFEDHF in adults
Compared =ith children# adults =ith DF have more severe manifestations such as incapacitating
headache and muscle# Doint and bone pain' Depression# insomnia and post!infectious fatigue
ma cause prolonged recover' $inus bradcardia and arrhthmias during convalescence are more
common in adults than in children'
09
Generall# the percentage of DHF in adults is lo=er than in children' &dults =ith DHF have a course
similar to that in children' Ho=ever# some studies have mentioned less severe plasma leaBage in adult
patients' Net there are some countries =here most deaths are seen in adults# =hich could be explained b
the late recognition of DHFEshocB and the higher incidence of bleeding =ith delaed blood transfusion'
&dult patients =ith shocB have been reported to be able to =orB until the stage of profound shocB'
6n addition# patients self!medicate =ith analgesics such as paracetamol# *$&6Ds# anti!emetic and
other drugs that =orsen liver and platelet functions' $ometimes fever ma not be detected b adult patients
themselves' )he are more liBel to have the risB factors for severe disease such as peptic ulcer disease
and others as stated above' & summar of diagnosis of DF and DHF is presented in 4ox 9a!9c'17
4ox 9a; Diagnosis of dengue fever and dengue haemorrhagic feverB
Dengue fever
Probable diagnosis;
&cute febrile illness =ith t=o or more of the follo=ingl;
Q
Q
Q
Q
Q
Q
Q
Q
Q
headache#
retro!orbital pain#
malgia#
arthralgiaEbone pain#
rash#
haemorrhagic manifestations#
leucopenia (=bc X5,,, cellsEmm1-#
thromboctopenia (platelet count Y.5, ,,, cellsEmm1-#
rising haematocrit (5 / .,G-?
and at least one of follo=ing;
Q supportive serolog on single serum sample; titre [.09, =ith haemagglutination inhibition
test# comparable 6gG titre =ith en"me!linBed immunosorbent assa# or tasting positive in 6g:
antibod test# and
occurrence at the same location and time as confirmed cases of dengue fever' Q
Confirmed diagnosis;
Probable case =ith at least one of the follo=ing;
Q
Q
Q
Q
isolation of dengue virus from serum# C$F or autops samples'
fourfold or greater increase in serum 6gG (b haemagglutination inhibition test- or increase in 6g:
antibod specific to dengue virus'
detection of dengue virus or antigen in tissue# serum or cerebrospinal fluid b immunohistochemistr#
immunofluorescence or en"me!linBed immunosorbent assa'
detection of dengue virus genomic se2uences b reverse transcription!polmerase chain
reaction'
B
l
4ased on discussions and recommendations of the Consultative :eeting on Dengue Case Classication and Case :anagement held
in 4angBoB# )hailand# on 8!9 October 0,.,' ')he participants included experts from $%&RO and WPRO countries and one observer
each from Hniversit of :assachusetts :edical $chool# H$& and &rmed Forces Research 6nstitute of :edical $ciences# )hailand#
and secretariat from the WHO Collaborating Centre for Case :anagement of DengueEDHFED$$# F$*6CH (4angBoB# )hailand-'
$tudies have sho=n that in endemic areas acute febrile illness =ith a positive )) and leucopenia (W4CX5,,, cellsEmm1- has a good
positive predictive value of 8,G to 9,G' 6n situations =here serolog is not available# these are useful for earl detection of dengue
cases'18#19
07
4ox 9b; Dengue haemorrhagic fever
&ll of follo=ingm;
Q
Q
acute onset of fever of t=o to seven das duration'
haemorrhagic manifestations# sho=n b an of the follo=ing; positive tourni2uet test# petechiae#
ecchmoses or purpura# or bleeding from mucosa# gastrointestinal tract# inDection sites# or other
locations'
platelet count X.,, ,,, cellsEmm1
obDective evidence of plasma leaBagen due to increased vascular permeabilit sho=n b an of
the follo=ing;
/ Rising haematocritEhaemoconcentration [0,G from baseline or decrease in convalescence#
or evidence of plasma leaBage such as pleural effusion# ascites or hpoproteinaemiaE
albuminaemia'17
Q
Q
4ox 9c; Dengue shocB sndrome
Criteria for dengue haemorrhagic fever as above =ith signs of shocB including;
Q
Q
Q
tachcardia# cool extremities# delaed capillar refill# =eaB pulse# letharg or restlessness# =hich
ma be a sign of reduced brain perfusion'
pulse pressure X0, mmHg =ith increased diastolic pressure# e'g' .,,E9, mmHg'
hpotension b age# defined as sstolic pressure Y9, mmHg for those aged Y5 ears or 9, to
7, mmHg for older children and adults'
m 6f all the four criteria are met# the sensitivit and specificit is +0G and 70G respectivel' &non $' et al' Dengue Hemorrhagic Fever;
)he $ensitivit and $pecificit of the World Health Organi"ation Definition for 6dentification of $evere Cases of Dengue in )hailand#
.773/0,,5# Clin' 6nf' Dis' 0,.,? 5, (9-;..15!31'
n 6f fever and significant plasma leaBage are documented# a clinical diagnosis of DHF is most liBel even if there is no bleeding or
thromboctopenia'
1,
5' Laborator Diagnosis
Rapid and accurate dengue diagnosis is of paramount importance for; (i- epidemiological surveillance?
(ii- clinical management? (iii- research? and (iv- vaccine trials' %pidemiological surveillance re2uires
earl determination of dengue virus infection during the outbreaB for urgent public health action
to=ards control as =ell as at sentinel sites for detection of circulating serotpesEgenotpes during
the inter!epidemic periods for use in forecasting possible outbreaBs' Clinical management re2uires
earl diagnosis of cases# confirmation of clinical diagnosis and for differential diagnosis from other
flavivirusesEinfection agents'
)he follo=ing laborator tests are available to diagnose dengue fever and DHF;
Q
Q
Q
Q
Q
Cirus isolation
/ serotpicEgenotpic characteri"ation
Ciral nucleic acid detection
Ciral antigen detection
6mmunological response based tests
/ 6g: and 6gG antibod assas
&nalsis for haematological parameters
5'. Diagnostic tests and phases of disease
Dengue viraemia in a patient is short# tpicall occurs 0/1 das prior to the onset of fever and lasts
for four to seven das of illness' During this period the dengue virus# its nucleic acid and circulating
viral antigen can be detected (Figure 5-'
&ntibod response to infection comprises the appearance of different tpes of immunoglobulins?
and 6g: and 6gG immunoglobulin isotpes are of diagnostic value in dengue' 6g: antibodies are
detectable b das 1/5 after the onset of illness# rise 2uicBl b about t=o =eeBs and decline to
undetectable levels after 0/1 months' 6gG antibodies are detectable at lo= level b the end of the
first =eeB# increase subse2uentl and remain for a longer period (for man ears-' 4ecause of the
late appearance of 6g: antibod# i'e' after five das of onset of fever# serological tests based on this
antibod done during the first five das of clinical illness are usuall negative'
During the secondar dengue infection (=hen the host has previousl been infected b dengue
virus-# antibod titres rise rapidl' 6gG antibodies are detectable at high levels# even in the initial
phase# and persist from several months to a lifelong period' 6g: antibod levels are significantl lo=er
in secondar infection cases' Hence# a ratio of 6g:E6gG is commonl used to differentiate bet=een
primar and secondar dengue infections' )hromboctopenia is usuall observed bet=een the third
and eighth da of illness follo=ed b other haematocrit changes'
1.
Figure 5 sho=s the timeline of primar and secondar dengue virus infections and the diagnostic
methods that can be used to detect infection at a particular time of illness'
Figure 5; &pproximate timeline of primar and secondar dengue virus infections and the
diagnostic methods that can be used to detect infection
*$. detection
Cirus isolation
R*& detection
Ciraemia
O'D
6g: primar
6g: secondar
H6&
[05
O'D
6gG secondar
+,
6gG secondar infection
9,
,
!0 !. , . 0 1 3 5 + 8
Onset of smptoms
9 7 ., .. .0 .1 .3 .5 .+!0, 0.!3, 3.!+, +.!9, 7, ]7, Das
$ource; WHO' Dengue Guidelines for Diagnosis# )reatment# Prevention and Control# *e= edition# 0,,7' WHO Geneva'++
5'0 $pecimens; Collection# storage and shipment
&n essential aspect of laborator diagnosis of dengue is proper collection# processing# storage and
shipment of clinical specimens' )he tpe of specimens and their storage and shipment re2uirements
are sho=n in )able +'
)able +; Collection# storage and shipment re2uirements of specimens
$pecimen tpe
&cute phase blood ($.-
Recover (convalescent-
phase blood ($0>$1-
)issue
)ime of collection
,/5 das after onset
.3/0. das after
onset
&s soon as possible
after death
Clot retraction
0/+ hours#
3 VC
0/03 hours#
ambient
$torage
$erum /8, VC
$erum /0, VC
8, VC or in
formalin
$hipment
Dr ice
Fro"en or
ambient
Dr ice or
ambient
$ource; Gubler D'K'# $ather G'%'' Laborator diagnosis of dengue and dengue haemorrhagic fever' Proceedings of the 6nternational
$mposium on Nello= Fever and Dengue? .799? Rio de Kaneiro# 4ra"il'+8
$erological diagnosis using certain methods is arrived at based on the identification of changes
in specific antibod levels in paired specimens' Hence serial (paired- specimens are re2uired to
confirm or refute a diagnosis of acute flavivirus or dengue infection'
Collection of specimens is done at different time intervals as mentioned belo=;
10
Q
Q
Q
Collect a specimen as soon as possible after the onset of illness# hospital admission or
attendance at a clinic (this is called the acute phase specimen# $.-'
Collect a specimen shortl before discharge from the hospital or# in the event of a fatalit#
at the time of death (convalescent phase specimen# $0-'
Collect a third specimen# in the event hospital discharge occurs =ithin ./0 das of the
subsidence of fever# 8/0. das after the acute serum =as dra=n (late convalescent phase
specimen# $1-'
)he optimal interval bet=een paired sera# i'e' the acute ($.- and the convalescent ($0 or $1-
blood specimen# is .,/.3 das'
Q $amples of re2uest and reporting forms for dengue laborator examination are provided
in &nnex .' 4lood is preferabl collected in tubes or vials# but filter paper ma be used if
this is the onl option' Filter paper samples are not suitable for virus isolation'
4lood collection in tubes or vials
)he follo=ing are the steps for blood collection in tubes or vials;
Q
Q
Collect 0 ml/., ml of venous blood =ith aseptic precautions'
Hse adhesive tape marBed =ith pencil# indelible inB# or a tpe=rittenEprinted self!adhesive
label to identif the container' )he name of the patient# identification number and date
of collection must be indicated on the label'
Hse vacuum tubes or sterile vials =ith scre= caps and gasBet# if possible# for collection'
$ecure the cap =ith adhesive tape# =ax or other sealing material to prevent leaBage during
transport'
6n case of an anticipated dela of more than 03 hours before specimens can be submitted
to the laborator# separate the serum from the red blood cells and store fro"en' Do not
free"e =hole blood as haemolsis ma interfere =ith serolog test results'
$hip specimens to the laborator on =et ice (blood- or dr ice (serum- as soon as
possible'
)he shipment should adhere to nationalEinternational guidelines on shipment of infectious
material'
Q
Q
Q
Q
4lood collection on filter paper
)he follo=ing are the steps for blood collection on filter paper;
Q
Q
With a pencil# =rite the patientAs initials or number on t=o or three filter!paper discs or
strips of standardi"ed absorbent papero'
Collect sufficient fingertip blood (or venous blood using a sringe- on the filter paper to
full saturate it through to the reverse side' :ost standard filter paper discs or strips =ill
absorb ,'. ml of serum'
&llo= the discs or strips to dr in a place that is protected from direct sunlight and insects'
Preferabl# the blood!soaBed papers should be placed in a stand =hich allo=s aeration of
both sides' For unusuall thicB papers# a dring chamber ma be useful# e'g' desiccator
Dar# air!conditioned room or =arm!air incubator'
Q
o
Whatman *o' 1 filter paper discs .0'8 mm (_ inch- in diameter are suitable for this purpose# or *obuto tpe!. blood!sampling paper
made b )oo Roshi Jaisha Ltd# )oBo# Kapan'
11
Q Place the dried strips in plastic bags along =ith a silica bead sachet if possible# and staple
them to the LLaborator %xamination Re2uestM form' $tore =ithout refrigeration' Dried
filter paper discs ma be sent through postal mail'
$erum elution in the laborator; One of the recommended methods for eluting the blood
from filter paper discs is mentioned belo=;
Q
Q
Q
Q
%lute the disc at room temperature for +, minutes# or at 3 VC overnight# in . ml of Baolin
in borate saline (.05 gElitre-# pH 7',# in a test!tube'
&fter elution# Beep the tube at room temperature for 0, minutes# shaBing it periodicall'
Centrifuge for 1, minutes at +,, g'
For haemagglutination inhibition (H6- test using goose erthroctes# =ithout removing the
Baolin add ,',5 ml of 5,G suspension of goose cells to the tube# shaBe =ithout disturbing
the pellet# and incubate at 18 VC for 1, minutes'
For 6gG and 6g: assas# elute discsEstrips in phosphate buffered saline (P4$- containing
,'5G )=een 0, and 5G non!fat dried milB for t=o hours at room temperature'
Centrifuge at +,, g for ., minutes and decant the supernatant'
)he supernatant is e2uivalent to a .;1, serum dilution'
Q
Q
Q
%ach laborator must standardi"e the filter paper techni2ue prior to using it in diagnostic
services# using a panel of =ell characteri"ed sera samples'
5'1 Diagnostic methods for detection of dengue infection
During the earl stages of the disease (up to six das of onset of illness-# virus isolation# viral nucleic
acid or antigen detection can be used to diagnose infection' &t the end of the acute phase of infection#
immunological tests are the methods of choice for diagnosis'
6solation of virus
6solation of dengue virus from clinical specimens is possible provided the sample is taBen during the
first six das of illness and processed =ithout dela' $pecimens that are suitable for virus isolation
include; acute phase serum# plasma or =ashed buff coat from the patient# autops tissues from
fatal cases (especiall liver# spleen# lmph nodes and thmus-# and mos2uitoes collected from the
affected areas'
For short periods of storage (up to 39 hours-# specimens to be used for virus isolation can be
Bept at >3 VC to >9 VC' For longer storage the serum should be separated and fro"en at /8, VC
and maintained at such a temperature that tha=ing does not occur' 6f isolation from leucoctes is
to be attempted# heparini"ed blood samples should be delivered to the laborator =ithin a fe=
hours' Whenever possible# original material (viraemic serum or infected mos2uito pools- as =ell as
laborator!passaged materials should be preserved for future stud'
)issues and pooled mos2uitoes are triturated or sonicated prior to inoculation' Different methods
of inoculation and methods of confirming the presence of dengue virus are sho=n in )able 8'5, )he
choice of methods for isolation and identification of dengue virus =ill depend on local availabilit of
mos2uitoes# cell culture and laborator capabilit' 6noculation of serum or plasma into mos2uitoes
is the most sensitive method of virus isolation# but mos2uito cell culture is the most cost!effective
method for routine virological surveillance' 6t is essential for health =orBers interested in maBing
a diagnosis b means of virus isolation to contact the appropriate virolog laborator prior to the
collection of specimens' )he ac2uisition# storage and shipment of the samples can then be organi"ed
to have the best chances of successful isolation'
13
)able 8; Dengue virus isolation methods
Recommended methods
Q 6noculation of mos2uitoes (&edes aegpti#
&e' albopictus# )oxorhnchites amboinensis
and )oxorhnchites splendens-'
Q
Confirmation of dengue virus infection
Dengue virus generall replicates to high
titres (.,+ to .,8 :6D in an hour to five
das-'p
Presence of antigens in head s2uashes
demonstrated b immunofluorescence (6F&-
RRimanAs test is the gold standardS'
Presence of antigens in cells demonstrated b
immunofluorescence (6F&-' Ciral titre is done
b R)!PCR'
Ctopathic effect and pla2ue formation in
mammalian cells / less efficient'
Q
Q
Q
6noculation of insect cell cultures# namel
C+E1+# a clone of &e' albopictus cells'
6noculation of mammalian cultures# namel
vero cells# LLC:J0 and 4HJ0.'
Q
Q
$ource; Corndam C'# Juno G'' Laborator diagnosis of dengue virus infection' 6n; Gubler D'K'# Juno G'# %ditors' Dengue and dengue
haemorrhagic fever' Wallingford# Oxon; C&4 6nternational? .778' p' 1.1!13'+9
6n order to identif different dengue virus serotpes# mos2uito head s2uashes and slides
of infected cell cultures are examined b indirect immunoflourescence using serotpe!specific
monoclonal antibodies'
Currentl# cell culture is the most =idel used method for dengue virus isolation' )he mos2uito
cell line C+E1+ or &P+. are the host cells of choice for isolation of dengue viruses' 6noculation of
sucBling mice or mos2uitoes can be attempted =hen no other method is available'
)he isolation and confirmation of the identit of the virus re2uires substantial sBills# competenc
and an infrastructure =ith 4$L0E4$L1 facilities'
Ciral nucleic acid detection
Dengue viral genome# =hich consists of ribonucleic acid (R*&-# can be detected b reverse
transcripatse polmerase chain reaction (R)!PCR- assa' R*& is heat!labile and# therefore# specimens
for nucleic acid detection must be handled and stored according to procedures described for virus
isolation'
Reverse transcriptase!polmerase chain reaction (R)!PCR-
6n recent ears# a number of R)!PCR assas have been reported for detecting dengue virus' )he offer
better specificit and sensitivit compared =ith virus isolation =ith a much more rapid turnaround
time' & 4$L0 laborator =ith e2uipment for molecular biolog and sBilled professionals are needed
to carr out this test'
&ll nucleic acid detection assas involve three basic steps; (i- nucleic acid extraction and
purification? (ii- amplification of the nucleic acid? and (iii- detection of the amplified product' False
positive results can occur# and this can be prevented b proper isolation of different steps of the
assa and observing strict decontamination procedures'
p Disadvantages include hard =orB# need for insectaries to produce a large number of mos2uitoes and the isolation precautions to
avoid release of infected mos2uitoes' Ho=ever# )oxorhnchitis larvae can be used for inoculation to avoid accidental release of
infected mos2uitoes'
15
*ested R)!PCR
*ested R)!PCR assa involves using universal dengue primers targeting the CEpr: region of the
viral genome for an initial reverse transcription and amplification step# follo=ed b a nested PCR
amplification that is serotpe!specific'
One!step multiplex R)!PCR
)his test is an alternative to nested R)!PCR' & combination of the four serotpe!specific oligonucleotide
primers is used in a single reaction step in order to identif the serotpe' )he products of these
reactions are separated b electrophoresis on an agarose gel# and the amplification products are
visuali"ed as bands of different molecular =eights after staining the gel using ethidium bromide
de# and compared =ith standard molecular =eight marBers' 6n this assa# dengue serotpes are
identified b the si"e of their bands'
Real!time R)!PCR
)he real!time R)!PCR assa is also a one!step assa sstem using primer pairs and probes that are
specific to each dengue serotpe' )he use of a fluorescent probe enables the detection of the reaction
products in real time# in a speciali"ed PCR machine# =ithout the need for electrophoresis' Real!time
R)!PCR assas are either LsingleplexM (detecting onl one serotpe at a time- or LmultiplexM (able
to identif all four serotpes from a single sample-' )hese tests offer high!throughput and hence are
ver useful for large!scale surveillance'
6sothermal amplification method
)he *&$4& (nucleic acid se2uence!based amplification- assa is an isothermal R*&!specific
amplification assa that does not re2uire thermal ccling instrumentation' )he initial stage is a
reverse transcription in =hich the single!stranded R*& target is copied into a double!stranded
D*& molecule that serves as template for R*& transcription' &mplified R*& is detected either b
electrochemiluminescence or in real time =ith fluorescent!labelled molecular beacon probes'
Compared =ith virus isolation# the sensitivit of the R)!PCR methods varies from 9,G to
.,,G and depends upon the region of the genome targeted b the primers# the approach used to
amplif or detect PCR products and the methods emploed for subtping' )he advantages of this
technolog include high sensitivit and specificit# ease of identifing serotpes and earl detection
of the infection' 6t is# ho=ever# an expensive technolog that re2uires sophisticated instrumentation
and sBilled manpo=er'
Recentl# Loop :ediated &mplification (L&:P- PCR method has been developed# =hich promises
an eas!to!do and less expensive instrumentation alternative for R)!PCR and real!time PCR assas'
Ho=ever# its performance needs to be compared =ith that of latter nucleic acid methods'+7
Ciral antigen detection
)he *$. gene product is a glcoprotein produced b all flaviviruses and is essential for replication
and viabilit of the virus' )he protein is secreted b mammalian cells but not b insect cells' *$.
antigen appears as earl as Da . after the onset of the fever and declines to undetectable levels b
5/+ das' Hence# tests based on this antigen can be used for earl diagnosis'
%L6$& and dot blot assas directed against the envelopEmembrane (%:- antigens and nonstructural
protein . (*$.- demonstrated that this antigen is present in high concentrations in the sera of the dengue
virus!infected patients during the earl clinical phase of the disease (Figure 5- and can be detected
in both patients =ith primar and secondar dengue infections for up to six das after the onset of
1+
the illness' Commercial Bits for the detection of *$. antigens are no= available? ho=ever# these Bits
do not differentiate bet=een the serotpes' 4esides providing an earl diagnostic marBer for clinical
management# it ma also facilitate the improvement of epidemiological surves of dengue infection'
5'3 6mmunological response and serological tests
Five basic serological tests are used for the diagnosis of dengue infection'+8#8, )hese are;
haemagglutination!inhibition (H6-# complement fixation (CF-# neutrali"ation test (*)-# 6g: capture
en"me!linBed immunosorbent assa (:&C!%L6$&-# and indirect 6gG %L6$&' For tests other than
those that detect 6g:# une2uivocal serological confirmation depends upon a significant (four!fold or
greater- rise in specific antibodies bet=een acute!phase and convalescent!phase serum samples' )he
antigen batter for most of these serological tests should include all four dengue serotpes# another
flavivirus# such as Kapanese encephalitis# a non!flavivirus such as chiBunguna# and an uninfected
tissue as control antigen# =hen possible'
6g:!capture en"me!linBed immunosorbent assa (:&C!%L6$&-
:&C!%L6$& has become =idel used in the past fe= ears' 6t is a simple and rapid test that re2uires
ver little sophisticated e2uipment' :&C!%L6$& is based on detecting the dengue!specific 6g:
antibodies in the test serum b capturing them out of solution using anti!human 6g: that =as
previousl bound to the solid phase'30 6f the patientAs serum has antidengue 6g: antibod# it =ill
bind the dengue antigen that is added in the next step and can be detected b subse2uent addition
of an en"me!labelled anti!dengue antibod# =hich ma be human or monoclonal antibod' &n
en"me!substrate is added to produce a colour reaction'
)he anti!dengue 6g: antibod develops a little earlier than 6gG# and is usuall detectable b Da
5 of the illness# i'e' the antibod is not usuall detectable during the first five das of illness' Ho=ever#
the time of appearance of 6g: antibod varies considerabl among patients' 6g: antibod titers in
primar infections are significantl higher than in secondar infections# although it is not uncommon
to obtain 6g: titers of 10, in the latter cases' 6n some primar infections# detectable 6g: ma persist
for more than 7, das# but in most patients it =anes to an undetectable level b +, das (Figure +-'
Figure +; Principle of :&C!%L6$& test
$pectrophotometer
*on!coloured
substrate
Coloured
substrate
&nti!dengue
&b coDugated
=ith en"me
D%* antigen
*on!dengue!specific
6g:
PatientAs 6g:
&nti! chain
:icroplate
$ource; Dengue Guidelines for Diagnosis# )reatment# Prevention and Control# *e= edition# 0,,7# WHO Geneva'++
18
:&C!%L6$& is slightl less sensitive than the H6 test for diagnosing dengue infection' 6t has the
advantage# ho=ever# of fre2uentl re2uiring onl a single# properl timed blood sample' Considering
the difficult in obtaining second blood samples and the long dela in obtaining conclusive results
from the H6 test# this lo= error rate =ould be acceptable in most surveillance sstems' 6t must be
emphasi"ed# ho=ever# that because of the persistence of 6g: antibod# :&C!%L6$& positive results
on single serum samples are onl provisional and do not necessaril mean that the dengue infection
is current' 6t is reasonabl certain# ho=ever# that the person had had a dengue infection sometime
in the previous t=o to three months'
:&C!%L6$& has become an invaluable tool for surveillance of DF# DHF and D$$' 6n areas
=here dengue is not endemic# it can be used in clinical surveillance for viral illness or for random#
population!based serosurves# =ith the certaint that an positives detected are recent infections'+8
6t is especiall useful for hospitali"ed patients =ho are generall admitted at a late stage of illness
after detectable 6g: is alread present in the blood'
6gG!%L6$&
&n indirect 6gG!%L6$& has been developed and compares =ell =ith the H6 test'8, )his test can also
be used to differentiate primar and secondar dengue infections' )he test is simple and eas to
perform# and is thus useful for high!volume testing' )he 6gG!%L6$& is ver non!specific and exhibits
the same broad cross!reactivit among flaviviruses as the H6 test? it cannot be used to identif the
infecting dengue serotpe' )hese tests can be used independentl or in combination# depending upon
the tpe of the sample and test available in order to confirm the diagnosis as sho=n in )able 9'
)able 9; 6nterpretation of dengue diagnostic test
Highl suggestive
One of the follo=ing;
(.-
(0-
6g:>ve in a single serum sample' (.-
Confirmed
One of the follo=ing;
R)!PCR>ve'
Cirus culture>ve'
6g: seroconversion in paired sera'
6gG seroconversion in paired sera or four!
fold 6gG titre increase in paired sera'
6gG>ve in a single serum sample =ith a H6 (0-
titre of .09, or greater'
(1-
(3-
$ource; Kaenisch )'# Wills 4' (0,,9- Results from the D%*CO stud' )DREWHO %xpert :eeting on Dengue Classification and Case
:anagement' 6mplications of the D%*CO stud' WHO# Geneva# $ept' 1,/Oct' . 0,,9'8.
6g:E6gG ratio
)he 6g:E6gG ratio is used to distinguish primar infection from secondar dengue infection ' & dengue
virus infection is defined as primar if the capture 6g:E6gG ratio is greater than .'0# or as secondar
if the ratio is less than .'0' )his ratio testing sstem has been adopted b select commercial vendors'
Ho=ever# it has been recentl demonstrated that the ratios var depending on =hether the patient
has a serological non!classical or a classical dengue infection# and the ratios have been redefined
taBing into consideration the four subgroups of classical infection =ith dengue'80 )he adDusted ratios
of greater than 0'+ and less than 0'+# established b these authors# correctl classified .,,G of
serologicall classical dengue infections and 7,G of serologicall non!classical infections'
19
Haemagglutination inhibition test
Of the above tests# haemagglutination inhibition or H6 test has been most fre2uentl used in the past
for routine serological diagnosis of dengue infections' 6t is sensitive and eas to perform# re2uires
onl minimal e2uipment# and is ver reliable if properl done' 4ecause H6 antibodies persist for long
periods (up to 5, ears or longer-# the test is ideal for sero!epidemiologic studies'
)he maDor disadvantage of the H6 test is lacB of specificit# =hich maBes it unreliable for
identifing the infecting virus serotpe' Ho=ever# some primar infections ma sho= a relativel
monotpic H6 response that generall corelates =ith the virus isolated'+8 6n recent times not man
laboratories are performing this test'
Complement fixation test
)he complement fixation or CF test is not =idel used for routine dengue diagnostic serolog' 6t is
more difficult to perform and re2uires highl trained personnel' )he CF test is based on the principle
that the complement is consumed during antigen!antibod reactions' )=o reactions are involved#
a test sstem and an indicator sstem' &ntigens for the CF test are prepared in the same manner as
those for the H6 test' )he CF test is useful for patients =ith current infections# but is of limited value
for seroepidemiological studies =here detection of persistent antibodies is important' Onl a fe=
laboratories conduct this assa'
*eutrali"ation test
)he neutrali"ation test or *) is the most specific and sensitive serological test for dengue viruses used
for determining the immune protection' )he common protocol used in most dengue laboratories
is the serum dilution pla2ue reduction neutrali"ation test (PR*)-' )he maDor disadvantages of this
techni2ue are the expense and time re2uired to perform the test# and the technical difficult involved
since it re2uires cell culture facilit' 6t is# therefore# not routinel used in most laboratories' Ho=ever#
it is of great use in the development of vaccines and their efficac trials'
5'5 Rapid diagnostic test (RD)-
& number of commercial rapid format serological test!Bits for anti!dengue 6g: and 6gG antibodies
have become available in the past fe= ears# some of these producing results =ithin .5 minutes'8,
Hnfortunatel# the accurac of most of these tests is uncertain since the have not et been properl
validated' Rapid tests can ield false positive results due to cross!reaction =ith other flaviviruses#
malaria parasite# leptospires and immune disorders such as rheumatoid and lupus' 6t is anticipated
that these test Bits can be reformulated to maBe them more specific# thus maBing global laborator!
based surveillance for DFEDHF an attainable goal in the near future' 6t is important to note that these
Bits should not be used in the clinical setting to guide the management of DFEDHF cases because
man serum samples taBen in the first five das after the onset of illness =ill not have detectable 6g:
antibodies' )he tests =ould thus give a false negative result' Reliance on such tests to guide clinical
management could# therefore# result in an increase in case!fatalit rates'2
6n an outbreaB situation# if more than 5,G of specimens test positive =hen rapid tests are used#
dengue virus is then highl suggestive of being the cause of febrile outbreaB'
2 For further details# refer to; Hpdate on the Principles and Hse of Rapid )ests in Dengue# Prepared b the :alaria# Other Cector!
borne and Parasitic Diseases Hnit of the Western Pacific Region of WHO for dengue programme managers and health practitioners
(0,,7-'
17
5'+ Haematological tests
$tandard haematological parameters such as platelet count and haematocrit are important and are
part of the biological diagnosis of dengue infection' )herefore# the should be closel monitored'
)hromboctopenia# a drop in platelet count belo= .,, ,,, per `l# ma be occasionall observed
in dengue fever but is a constant feature in DHF' )hromboctopenia is usuall found bet=een the
third and eighth da of illness often before or simultaneousl =ith changes in haematocrit'
Haemoconcentration =ith an increase in the haematocrit of 0,G or more (for the same patient
or for a patient of the same age and sex- is considered to be a definitive evidence of increased
vascular permeabilit and plasma leaBage'
5'8 4iosafet practices and =aste disposal
Handling of blood and tissues exposes health!care =orBers to the risB of contracting serious
communicable diseases' 6mproper disposal of clinical and laborator materials containing pathogens
is a health risB to individuals as =ell as the communit' )o minimi"e these risBs# health!care =orBers
need to be trained and provided =ith appropriate infrastructure# especiall personal protective
material and e2uipment'81
5'9 Fualit assurance
Laboratories undertaBing dengue diagnosis =orB need to establish a functional 2ualit sstem so that
the results generated are reliable' $trengthening internal 2ualit control and checBing the 2ualit
of diagnostics using a panel of =ell!characteri"ed samples at regular intervals =ill ensure accurate
diagnosis'
Laboratories emploing in!house diagnostics need to standardi"e the assa against =ell!
characteri"ed samples in order to ascertain sensitivit and specificit' Participating in an external
2ualit assessment scheme can enhance the credibilit of the laborator and support the selection
of appropriate public health action'
5'7 *et=orB of laboratories
%ver countr should endeavour to establish a net=orB of dengue diagnostic laboratories =ith
a specific mandate for each level of the health laborator' While the peripheral laboratories can
undertaBe RD) and have the competence to collect# store and ship the material to the next higher
level of laboratories# the national laboratories should perform genetic characteri"ation of the virus#
organi"e external 2ualit assessment schemes# impart training and develop national guidelines' )he
national laboratories are also encouraged to Doin international net=orBs such as the %uropean *et=orB
for Diagnostics of L6mportedM Ciral Diseases (%*6CD- to dra= support from the global communit'
3,
+' Clinical :anagement of DengueE
Dengue Haemorrhagic Feverr
)he clinical spectrum of dengue infection includes asmptomatic infection# DF and DHF# =hich is
characteri"ed b plasma leaBage and haemorrhagic manifestations' &t the end of the incubation
period# the illness starts abruptl and is follo=ed b three phases# the febrile# critical and recover
phase#83 as depicted in the schematic representation belo= (Figure 8-;
Figure 8; Course of dengue illness
$ource; *immannita $'' Clinical manifestations and management of dengueEdengue haemorrhagic fever' 6n; )hongcharoen# P %d''
:onograph on dengueEdengue haemorrhagic fever' WHO $%&RO .771# p 39/53# 55/+.'83
r
)his chapter =as revie=ed at the Consultative :eeting on Dengue Case Classification and Case :anagement held in 4angBoB# )hailand#
on 8/9 October 0,.,' )he participants included experts from :ember $tates of the WHO $%& and WP Regions and observers from the
Hniversit of :assachusetts :edical $chool# H$& and the &rmed Forces Research 6nstitute of :edical $ciences# )hailand' )he $ecretariat
comprised staff from the WHO Collaborating Centre for Case :anagement of DengueEDHFED$$# F$*6CH# 4angBoB# )hailand'
3.
+'. )riage of suspected dengue patients at OPD
During epidemics all hospitals# including those at the tertiar level# find a heav influx of patients'
)herefore# hospital authorities should organi"e a frontline LDengue DesBM to screen and triage
suspected dengue patients' $uggested triage path=as are indicated belo= in 4ox 7 and 4ox .,'
4ox 7; $teps for OPD screening during dengue outbreaB
4ox .,; $uggested triage path=a
30
Primar triage
)riage has to be performed b a trained and competent person'
Q
Q
6f the patient arrives in hospital in a severeEcritical condition# then send this patient directl
to a trained nurseEmedical assistant (refer to number 1 belo=-'
For other patients# proceed as follo=ing;
(.- Histor of the duration (number of das- of fever and =arning signs (4ox ..- of high!risB
patients to be assessed b a trained nurse or staff# not necessaril medical'
(0- )ourni2uet test to be conducted b trained personnel (if there is not enough staff# Dust
inflate the pressure to 9, mmHg for ].0 ears of age and +, mmHg for children aged
5 to .0 ears for five minutes-'
(1- Cital signs# including temperature# blood pressure# pulse rate# respirator rate and
peripheral perfusion# to be checBed b trained nurse or medical assistant'
Peripheral perfusion is assessed b palpation of pulse volume# temperature and colour
of extremities# and capillar refill time' )his is mandator for all patients# particularl so
=hen digital blood!pressure monitors and other machines are used' Particular attention
is to be given to those patients =ho are afebrile and have tachcardia' )hese patients
and those =ith reduced peripheral perfusion should be referred for immediate medical
attention# C4C and blood sugar!level tests at the earliest possible'
(3- Recommendations for C4C;
/
/
/
/
all febrile patients at the first visit to get the baseline HC)# W4C and PL)'
all patients =ith =arning signs'
all patients =ith fever ]1 das'
all patients =ith circulator disturbanceEshocB (these patients should undergo a
glucose checB-'
Results of C4C; 6f leucopenia andEor thromboctopenia is present# those =ith =arning
signs should be sent for immediate medical consultation'
(5- :edical consultation; 6mmediate medical consultation is recommended for the
follo=ing;
/
/
/
/
shocB'
patients =ith =arning signs# especiall those =hose illness lasts for ]3 das'
$hocB; Resuscitation and admission'
Hpoglcemic patients =ithout leucopenia andEor thromboctopenia should
receive emergenc glucose infusion and intravenous glucose containing fluids'
Laborator investigations should be done to determine the liBel cause of illness'
)hese patients should be observed for a period of 9/03 hours' %nsure clinical
improvement before sending them home# and the should be monitored dail'
)hose =ith =arning signs'
High!risB patients =ith leucopenia and thromboctopenia'
(+- Decision for observation and treatment;
/
/
(8- Patient and famil advice should be carefull delivered before sending himEher home
(4ox .0-' )his can be done in a group of 5 to 0, patients b a trained person =ho ma
not be a nurseEdoctor' &dvice should include bed rest# intaBe of oral fluids or a soft diet#
and reduction of fever b tepid sponging in addition to paracetamol' Warning signs should
be emphasi"ed# and it should be made clear that should these occur patients must seeB
immediate medical attention even if the have a scheduled appointment pending'
31
(9- Follo=!up visits; Patients should be a=are that the critical period is during the
afebrile phase and that follo=!up =ith C4C is essential to detect earl danger signs
such as leucopenia# thromboctopenia# andEor haematocrit rise' Dail follo=!up is
recommended for all patients except those =ho have resumed normal activities or are
normal =hen the temperature subsides'
4ox ..; Warning signs
Q
Q
Q
Q
Q
Q
Q
Q
4ox .0;
&'
*o clinical improvement or =orsening of the situation Dust before or during the
transition to afebrile phase or as the disease progresses'
Persistent vomiting# not drinBing'
$evere abdominal pain'
Letharg andEor restlessness# sudden behavioural changes'
4leeding; %pistaxis# blacB stool# haematemesis# excessive menstrual bleeding# darB!
coloured urine (haemoglobinuria- or haematuria'
Giddiness'
Pale# cold and clamm hands and feet'
LessEno urine output for 3/+ hours'
Handout for home care of dengue patients (information to be given to patients
andEor their famil member(s- at the outpatient department-
Home care advice (famil education- for patients;
Q
Q
Patient needs to taBe ade2uate bed rest'
&de2uate intaBe of fluids (no plain =ater- such as milB# fruit Duice# isotonic electrolte
solution# oral rehdration solution (OR$- and barleErice =ater' 4e=are of over!
hdration in infants and oung children'
Q Jeep bod temperature belo= 17 VC' 6f the temperature goes beond 17 VC# give the
patient paracetamol' Paracetamol is available in 105 mg or 5,, mg doses in tablet
form or in a concentration of .0, mg per 5 ml of srup' )he recommended dose is
., mgEBgEdose and should be administered in fre2uencies of not less than six hours'
)he maximum dose for adults is 3 gmEda' &void using too much paracetamol# and
aspirin or *$&6D is not recommended'
Q )epid sponging of forehead# armpits and extremities' & luBe=arm sho=er or bath is
recommended for adults'
Watch out for the =arning signs (as in 4ox ..-;
Q
Q
Q
Q
Q
Q
Q
Q
*o clinical improvement or =orsening of the situation Dust before or during the transition
to afebrile phase or as the disease progresses'
Persistent vomiting# lacB of =ater intaBe'
$evere abdominal pain'
Letharg andEor restlessness# sudden behavioural changes'
4leeding; %pistaxis# blacB coloured stools# haematemesis# excessive menstrual bleeding#
darB!coloured urine (haemoglobinuria- or haematuria'
Giddiness'
Pale# cold and clamm hands and feet'
LessEno urine output for 3/+ hours'
4'
33
+'0 :anagement of DFEDHF cases in hospital observation =ardsE
on admission
)he details of management of DFEDHF cases in hospital observation =ards or upon admission
are presented belo=;85#8+#88
:onitoring of dengueEDHF patients during the critical period (thromboctopenia
around .,, ,,, cellsEmm1-
)he critical period of DHF refers to the period of plasma leaBage =hich starts around the time
of defervescence or the transition from febrile to afebrile phase' )hromboctopenia is a sensitive
indicator of plasma leaBage but ma also be observed in patients =ith DF' & rising haematocrit of
.,G above baseline is an earl obDective indicator of plasma leaBage' 6ntravenous fluid therap
should be started in patients =ith poor oral intaBe or further increase in haematocrit and those =ith
=arning signs'
)he follo=ing parameters should be monitored;
Q
Q
Q
Q
General condition# appetite# vomiting# bleeding and other signs and smptoms'
Peripheral perfusion can be performed as fre2uentl as is indicated because it is an earl
indicator of shocB and is eas and fast to perform'
Cital signs such as temperature# pulse rate# respirator rate and blood pressure should be
checBed at least ever 0/3 hours in non!shocB patients and ./0 hours in shocB patients'
$erial haematocrit should be performed at least ever four to six hours in stable cases and
should be more fre2uent in unstable patients or those =ith suspected bleeding' 6t should
be noted that haematocrit should be done before fluid resuscitation' 6f this is not possible#
then it should be done after the fluid bolus but not during the infusion of the bolus'
Hrine output (amount of urine- should be recorded at least ever 9 to .0 hours in
uncomplicated cases and on an hourl basis in patients =ith profoundEprolonged shocB or
those =ith fluid overload' During this period the amount of urine output should be about
,'5 mlEBgEh (this should be based on the ideal bod =eight-'
Q
&dditional laborator tests
&dult patients and those =ith obesit or suffering from diabetes mellitus should have a blood
glucose test conducted' Patients =ith prolongedEprofound shocB andEor those =ith complications
should undergo the laborator investigations as sho=n in 4ox .1'
Correction of the abnormal laborator results should be done; hpoglcemia# hpocalcemia
and metabolic acidosis that do not respond to fluid resuscitation' 6ntravenous (6C- vitamin J. ma be
administered during prolonged prothrombin time' 6t should be noted that in places =here laborator
facilities are not available# calcium gluconate and vitamin J. should be given in addition to intravenous
therap' 6n cases =ith profound shocB and those not responding to 6C fluid resuscitation# acidosis
should be corrected =ith *aHCO1 if pH is Y8'15 and serum bicarbonate is Y.5 m%2EL'
35
4ox .1; &dditional laborator investigations
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Complete blood count (C4C-'
4lood glucose'
4lood gas analsis# lactate# if available'
$erum electroltes and 4H*# creatinine'
$erum calcium'
Liver function tests'
Coagulation profile# if available'
Right lateral decubitus chest radiograph (optional-'
Group and match for fresh =hole blood or fresh pacBed red cells'
Cardiac en"mes or %CG if indicated# especiall in adults'
$erum amlase and ultrasound if abdominal pain does not resolve =ith fluid
therap'
&n other test# if indicated'
6ntravenous fluid therap in DHF during the critical period
6ndications for 6C fluid;
Q
Q
Q
Q
Q
=hen the patient cannot have ade2uate oral fluid intaBe or is vomiting'
=hen HC) continues to rise .,G/0,G despite oral rehdration'
impending shocBEshocB'
6sotonic crstalloid solutions should be used throughout the critical period except in
the ver oung infants Y+ months of age in =hom ,'35G sodium chloride ma be used'
Hper!oncotic colloid solutions (osmolarit of ]1,, mOsmEl- such as dextran 3, or starch
solutions ma be used in patients =ith massive plasma leaBage# and those not responding to
the minimum volume of crstalloid (as recommended belo=-' 6so!oncotic colloid solutions
such as plasma and hemaccel ma not be as effective'
& volume of about maintenance >5G dehdration should be given to maintain a LDust
ade2uateM intravascular volume and circulation'
)he duration of intravenous fluid therap should not exceed 03 to 39 hours for those =ith
shocB' Ho=ever# for those patients =ho do not have shocB# the duration of intravenous
fluid therap ma have to be longer but not more than +, to 80 hours' )his is because the
latter group of patients has Dust entered the plasma leaBage period =hile shocB patients have
experienced a longer duration of plasma leaBage before intravenous therap is begun'
6n obese patients# the ideal bod =eight should be used as a guide to calculate the fluid
volume ()able 7-'
)he general principles of fluid therap in DHF include the follo=ing;
Q
Q
Q
3+
)able 7; Re2uirement of fluid based on ideal bod =eight
6deal bod
=eight (Jgs-
5
.,
.5
0,
05
1,
:aintenance
(ml-
5,,
. ,,,
. 05,
. 5,,
. +,,
. 8,,
: >5G
deficit (ml-
85,
. 5,,
0 ,,,
0 5,,
0 95,
1 0,,
6deal bod
=eight (Bgs-
15
3,
35
5,
55
+,
:aintenance
(ml-
. 9,,
. 7,,
0 ,,,
0 .,,
0 0,,
0 1,,
: >5G deficit
(ml-
1 55,
1 7,,
3 05,
3 +,,
3 75,
5 1,,
$ource; Holida :'&'# $egar W'%'' :aintenance need for =ater in parenteral fluid therap' Pediatrics .758?.7; 901'89
Q Rate of intravenous fluids should be adDusted to the clinical situation' )he rate of 6C fluid
differs in adults and children' )able ., sho=s the comparableEe2uivalent rates of 6C infusion
in children and adults =ith respect to the maintenance'
)able .,; Rate of 6C fluid in adults and children
*ote
Half the maintenance :E0
:aintenance (:-
: > 5G deficit
: > 8G deficit
: > .,G deficit
Children rate (mlEBgEhour-
.'5
1
5
8
.,
&dult rate (mlEhour-
3,/5,
9,/.,,
.,,/.0,
.0,/.5,
1,,/5,,
$ource; Holida :'&'# $egar W'%'' :aintenance need for =ater in parenteral fluid therap' Pediatrics .758? .7;901'89
Q Platelet transfusion is not recommended for thromboctopenia (no prophlaxis platelet
transfusion-' 6t ma be considered in adults =ith underling hpertension and ver severe
thromboctopenia (less than ., ,,, cellEmm1-'
:anagement of patients =ith =arning signs
6t is important to verif if the =arning signs are due to dengue shocB sndrome or other causes such
as acute gastroenteritis# vasovagal reflex# hpoglcemia# etc' )he presence of thromboctopenia
=ith evidence of plasma leaBage such as rising haemotocrit and pleural effusion differentiates DHFE
D$$ from other causes' 4lood glucose level and other laborator tests ma be indicated to find the
causes' :anagement of DHFED$$ is detailed belo=' For other causes# 6C fluids and supportive and
smptomatic treatment should be given =hile these patients are under observation in hospital' )he
can be sent home =ithin 9 to 03 hours if the sho= rapid recover and are not in the critical period
(i'e' =hen their platelet count is ].,, ,,, cellsEmm1-'
:anagement of DHF grade 6# 66 (non!shocB cases-
6n general# the fluid allo=ance (oral > 6C- is about maintenance (for one da- > 5G deficit (oral
and 6C fluid together-# to be administered over 39 hours' For example# in a child =eighing 0, Bg#
the deficit of 5G is 5, mlEBg x 0, a .,,, ml' )he maintenance is .5,, ml for one da' Hence#
the total of : > 5G is 05,, ml (Figure 9-' )his volume is to be administered over 39 hours in non!
shocB patients' )he rate of infusion of this 05,, ml ma be as sho=n in Figure 9 belo= Rplease
38
note that the rate of plasma leaBage is *O) evenS' )he rate of 6C replacement should be adDusted
according to the rate of plasma loss# guided b the clinical condition# vital signs# urine output and
haematocrit levels'
Figure 9; Rate of infusion in non!shocB cases
$ource; JalaanarooD $' and *immannita $' 6n; Guidelines for Dengue and Dengue Haemorrhagic Fever :anagement' 4angBoB
:edical Publisher# 4angBoB 0,,1'87
:anagement of shocB; DHF Grade 1
D$$ is hpovolemic shocB caused b plasma leaBage and characteri"ed b increased sstemic vascular
resistance# manifested b narro=ed pulse pressure (sstolic pressure is maintained =ith increased
diastolic pressure# e'g' .,,E7, mmHg-' When hpotension is present# one should suspect that
severe bleeding# and often concealed gastrointestinal bleeding# ma have occurred in addition
to the plasma leaBage'
6t should be noted that the fluid resuscitation of D$$ is different from other tpes of shocB such
as septic shocB' :ost cases of D$$ =ill respond to ., mlEBg in children or 1,,/5,, ml in adults over
one hour or b bolus# if necessar' Further# fluid administration should follo= the graph as in Figure
7' Ho=ever# before reducing the rate of 6C replacement# the clinical condition# vital signs# urine
output and haematocrit levels should be checBed to ensure clinical improvement'
39
Figure 7; Rate of infusion in D$$ case
$ource; JalaanarooD $' and *immannita $' 6n; Guidelines for Dengue and Dengue Haemorrhagic Fever :anagement' 4angBoB
:edical Publisher# 4angBoB 0,,1'87
Laborator investigations (&4C$- should be carried out in both shocB and non!shocB cases
=hen no improvement is registered in spite of ade2uate volume replacement (4ox .3-'
4ox .3; Laborator investigations (&4C$- for patients =ho present =ith profound shocB or
have complications# and in cases =ith no clinical improvement in spite of ade2uate volume
replacement
&bbreviation
&I&cidosis
Laborator investigations *ote
4lood gas (capillar or 6ndicate prolonged shocB' Organ involvement
venous-should also be looBed into? liver function and
4H*# creatinine'
Haematocrit 6f dropped in comparison =ith the previous
value or not rising# cross!match for rapid blood
transfusion'
Hpocalcemia is found in almost all cases of DHF
but asmptomatic' Ca supplement in more severeE
complicated cases is indicated' )he dosage is
. mlEBg# dilute t=o times# 6C push slo=l (and ma
be repeated ever six hours# if needed-# maximum
dose ., ml of Ca gluconate'
:ost severe DHF cases have poor appetite
together =ith vomiting' )hose =ith impaired liver
function ma have hpoglcemia' $ome cases ma
have hperglcemia'
4I4leeding
CICalcium %lectrolte# Ca>>
$I4lood sugar 4lood sugar (dextrostix-
37
6t is essential that the rate of 6C fluid be reduced as peripheral perfusion improves? but it must be
continued for a minimum duration of 03 hours and discontinued b 1+ to 39 hours' %xcessive fluids
=ill cause massive effusions due to the increased capillar permeabilit' )he volume replacement
flo= for patients =ith D$$ is illustrated belo= (4ox .5-'
4ox .5; Colume replacement flo= chart for patients =ith D$$s
:anagement of prolongedEprofound shocB; DHF Grade 3
)he initial fluid resuscitation in Grade 3 DHF is more vigorous in order to 2uicBl restore the blood
pressure and laborator investigations should be done as soon as possible for &4C$ as =ell as organ
involvement' %ven mild hpotension should be treated aggressivel' )en mlEBg of bolus fluid should
be given as fast as possible# ideall =ithin ., to .5 minutes' When the blood pressure is restored#
further intravenous fluid ma be given as in Grade 1' 6f shocB is not reversible after the first ., mlE
Bg# a repeat bolus of ., mlEBg and laborator results should be pursued and corrected as soon
as possible' Hrgent blood transfusion should be considered as the next step (after revie=ing the pre!
resuscitation HC)- and follo=ed up b closer monitoring# e'g' continuous bladder catheteri"ation#
central venous catheteri"ation or arterial lines'
6t should be noted that restoring the blood pressure is critical for survival and if this cannot be
achieved 2uicBl then the prognosis is extremel grave' 6notropes ma be used to support the blood
pressure# if volume replacement has been considered to be ade2uate such as in high central venous
pressure (CCP-# or cardiomegal# or in documented poor cardiac contractilit'
s :odified from *immannita# $' 6n; Comprehensive Guidelines for Dengue and Dengue Haemorrahgic Fever# WHO $%&R
Publication .777'
5,
6f blood pressure is restored after fluid resuscitation =ith or =ithout blood transfusion# and
organ impairment is present# the patient has to be managed appropriatel =ith special supportive
treatment' %xamples of organ support are peritoneal dialsis# continuous renal replacement therap
and mechanical ventilation'
6f intravenous access cannot be obtained urgentl# tr oral electrolte solution if the patient
is conscious or the intraosseous route if other=ise' )he intraosseous access is life!saving and
should be attempted after 0/5 minutes or after t=o failed attempts at peripheral venous access
or after the oral route fails'
:anagement of severe haemorrhage
Q 6f the source of bleeding is identified# attempts should be made to stop the bleeding if
possible' $evere epistaxis# for example# ma be controlled b nasal pacBing' Hrgent blood
transfusion is life!saving and should not be delaed till the HC) drops to lo= levels' 6f blood
loss can be 2uantified# this should be replaced' Ho=ever# if this cannot be 2uantified#
ali2uots of ., mlEBg of fresh =hole blood or 5 mlEBg of freshl pacBed red cells should be
transfused and response evaluated' )he patient ma re2uire one or more ali2uot'
6n gastrointestinal bleeding# H!0 antagonists and proton pump inhibitors have been used#
but there has been no proper stud to sho= its efficac'
)here is no evidence to support the use of blood components such as platelet concentrates#
fresh fro"en plasma or croprecipitate' 6ts use could contribute to fluid overload'
Recombinant Factor 8 might be helpful in some patients =ithout organ failure# but it is
ver expensive and generall not available'
Q
Q
Q
:anagement of high!risB patients
Q Obese patients have less respirator reserves and care should be taBen to avoid excessive
intravenous fluid infusions' )he ideal bod =eight should be used to calculate fluid
resuscitation and replacement and colloids should be considered in the earl stages of fluid
therap' Once stabili"ed# furosemide ma be given to induce diuresis'
6nfants also have less respirator reserves and are more susceptible to liver impairment
and electrolte imbalance' )he ma have a shorter duration of plasma leaBage and
usuall respond 2uicBl to fluid resuscitation' 6nfants should# therefore# be evaluated more
fre2uentl for oral fluid intaBe and urine output'
6ntravenous insulin is usuall re2uired to control the blood sugar levels in dengue patients
=ith diabetes mellitus' *on!glucose containing crstalloids should be used'
Pregnant =omen =ith dengue should be admitted earl to intensel monitor disease
progress' Koint care among obstetrics# medicine and paediatrics specialities is essential'
Families ma have to be counselled in some severe situations' &mount and rate of 6C fluid
for pregnant =omen should be similar to those for non!pregnant =oman using pre!pregnant
=eight for calculation'
Patients =ith hpertension ma be on anti!hpertensive therap that masBs the cardiovascular
response in shocB' )he patientAs o=n baseline blood pressure should be considered' &
blood pressure that is perceived to be normal ma in fact be lo= for these patients'
&nti!coagulant therap ma have to be stopped temporaril during the critical period'
Haemoltic diseases and haemoglobinopathies; )hese patients are at risB of haemolsis and
=ill re2uire blood transfusion' Caution should accompan hperhdration and alBalini"ation
therap# =hich can cause fluid overload and hpocalcemia'
Q
Q
Q
Q
Q
Q
5.
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Congenital and ischaemic heart diseases; Fluid therap should be more cautious as the
ma have less cardiac reserves'
For patients on steroid therap# continued steroid treatment is recommended but the route
ma be changed'
:anagement of convalescence
Q
Q
Q
Q
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Convalescence can be recogni"ed b the improvement in clinical parameters# appetite
and general =ell!being'
Haemodnamic state such as good peripheral perfusion and stable vital signs should be
observed'
Decrease of HC) to baseline or belo= and dieresis are usuall observed'
6ntravenous fluid should be discontinued'
6n those patients =ith massive effusion and ascites# hpervolemia ma occur and diuretic
therap ma be necessar to prevent pulmonar oedema'
HpoBalemia ma be present due to stress and diuresis and should be corrected =ith
potassium!rich fruits or supplements'
4radcardia is commonl found and re2uires intense monitoring for possible rare
complications such as heart blocB or ventricular premature contraction (CPC-'
Convalescence rash is found in 0,G/1,G of patients'
$igns of recover
Q
Q
Q
Q
Q
Q
Q
Q
$table pulse# blood pressure and breathing rate'
*ormal temperature'
*o evidence of external or internal bleeding'
Return of appetite'
*o vomiting# no abdominal pain'
Good urinar output'
$table haematocrit at baseline level'
Convalescent confluent petechiae rash or itching# especiall on the extremities'
Criteria for discharging patients
Q
Q
Q
Q
Q
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Q
&bsence of fever for at least 03 hours =ithout the use of anti!fever therap'
Return of appetite'
Cisible clinical improvement'
$atisfactor urine output'
& minimum of 0/1 das have elapsed after recover from shocB'
*o respirator distress from pleural effusion and no ascites'
Platelet count of more than 5, ,,,Emm1' 6f not# patients can be recommended to avoid
traumatic activities for at least ./0 =eeBs for platelet count to become normal' 6n most
uncomplicated cases# platelet rises to normal =ithin 1/5 das'
:anagement of complications
)he most common complication is fluid overload'
50
Detection of fluid overload in patients
Q
Q
%arl signs and smptoms include puff eelids# distended abdomen (ascites-# tachpnoea#
mild dspnoea'
Late signs and smptoms include all of the above# along =ith moderate to severe respirator
distress# shortness of breath and =hee"ing (not due to asthma- =hich are also an earl sign
of interstitial pulmonar oedema and crepitations' RestlessnessEagitation and confusion are
signs of hpoxia and impending respirator failure'
:anagement of fluid overload
Revie= the total intravenous fluid therap and clinical course# and checB and correct for &4C$
(4ox .3-' &ll hpotonic solutions should be stopped'
6n the earl stage of fluid overload# s=itch from crstalloid to colloid solutions as bolus fluids'
Dextran 3, is effective as ., mlEBg bolus infusions# but the dose is restricted to 1, mlEBgEda because
of its renal effects' Dextran 3, is excreted in the urine and =ill affect urine osmolarit' Patients ma
experience LsticBM urine because of the hperoncotic nature of Dextran 3, molecules (osmolarit
about t=ice that of plasma-' Coluven ma be effective (osmolarit a 1,9 mosmole- and the upper limit
is 5,mlEBgEda' Ho=ever# no studies have been done to prove its effectiveness in cases of DHFED$$'
6n the late stage of fluid overload or those =ith franB pulmonar oedema# furosemide ma be
administered if the patient has stable vital signs' 6f the are in shocB# together =ith fluid overload .,
mlEBgEh of colloid (dextran- should be given' When the blood pressure is stable# usuall =ithin ., to
1, minutes of infusion# administer 6C . mgEBgEdose of furosemide and continue =ith dextran infusion
until completion' 6ntravenous fluid should be reduced to as lo= as . mlEBgEh until discontinuation
=hen haematocrit decreases to baseline or belo= (=ith clinical improvement-' )he follo=ing points
should be noted;
Q
Q
)hese patients should have a urinar bladder catheter to monitor hourl urine output'
Furosemide should be administered during dextran infusion because the hperoncotic
nature of dextran =ill maintain the intravascular volume =hile furosemide depletes in the
intravascular compartment'
&fter administration of furosemide# the vital signs should be monitored ever .5
minutes for one hour to note its effects'
6f there is no urine output in response to furosemide# checB the intravascular volume status
(CCP or lactate-' 6f this is ade2uate# pre!renal failure is excluded# impling that the patient
is in an acute renal failure state' )hese patients ma re2uire ventilator support soon' 6f
the intravascular volume is inade2uate or the blood pressure is unstable# checB the &4C$
(4ox .3- and other electrolte imbalances'
6n cases =ith no response to furosemide (no urine obtained-# repeated doses of furosemide
and doubling of the dose are recommended' 6f oliguric renal failure is established# renal
replacement therap is to be done as soon as possible' )hese cases have poor prognosis'
Pleural andEor abdominal tapping ma be indicated and can be life!saving in cases =ith
severe respirator distress and failure of the above management' )his has to be done =ith
extreme caution because traumatic bleeding is the most serious complication and leads
to death' Discussions and explanations about the complications and the prognosis =ith
families are mandator before performing this procedure'
Q
Q
Q
Q
:anagement of encephalopath
$ome DFEDHF patients present unusual manifestations =ith signs and smptoms of central nervous
sstem (C*$- involvement# such as convulsion andEor coma' )his has generall been sho=n to be
51
encephalopath# not encephalitis# =hich ma be a result of intracranial haemorrhage or occlusion
associated =ith D6C or hponatremia' 6n recent ears# there has been an increasing number of
reported cases =ith C*$ infections documented b virus isolations from the cerebrospinal fluid
(C$F- or brain'
:ost of the patients =ith encephalopath report hepatic encephalopath' )he principal
treatment of hepatic encephalopath is to prevent the increase of intracranial pressure (6CP-'
Radiological imaging of the brain (C) scan or :R6- is recommended if available to rule out intracranial
haemorrhage' )he follo=ing are recommendations for supportive therap for this condition;
Q :aintain ade2uate air=a oxgenation =ith oxgen therap' PreventEreduce 6CP b the
follo=ing measures;
/
/
/
/
/
/
Q
give minimal 6C fluid to maintain ade2uate intravascular volume? ideall the total 6C
fluid should not be ]9,G fluid maintenance'
s=itch to colloidal solution earlier if haematocrit continues to rise and a large volume
of 6C is needed in cases =ith severe plasma leaBage'
administer a diuretic if indicated in cases =ith signs and smptoms of fluid overload'
positioning of the patient must be =ith the head up b 1, degrees'
earl intubation to avoid hpercarbia and to protect the air=a'
ma consider steroid to reduce 6CP Dexametha"one ,'.5 mgEBgEdose 6C to be'
administered ever +/9 hours'
give lactulose 5/., ml ever six hours for induction of osmotic diarrhoea'
local antibiotic gets rid of bo=el flora? it is not necessar if sstemic antibiotics are
given'
Decrease ammonia production b the follo=ing measures;
/
/
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Q
:aintain blood sugar level at 9,/.,, mgEdl per cent' Recommend glucose infusion rate
is an=here bet=een 3/+ mgEBgEhour'
Correct acid!base and electrolte imbalance# e'g' correct hpoEhpernatremia# hpoE
hperBalemia# hpocalcemia and acidosis'
Citamin J. 6C administration? 1 mg for Y.!ear!old# 5 mg for Y5!ear!old and ., mg
for]5!ear!old and adult patients'
&nticonvulsants should be given for control of sei"ures; phenobarbital# dilantin and
dia"epam 6C as indicated'
)ransfuse blood# preferabl freshl pacBed red cells# as indicated' Other blood components
such as as platelets and fresh fro"en plasma ma not be given because the fluid overload
ma cause increased 6CP'
%mpiric antibiotic therap ma be indicated if there are suspected superimposed bacterial
infections'
H0!blocBers or proton pump inhibitor ma be given to alleviate gastrointestinal
bleeding'
&void unnecessar drugs because most drugs have to be metaboli"ed b the liver'
Consider plasmapheresis or haemodialsis or renal replacement therap in cases =ith
clinical deterioration'
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Referral and transportation
:ore severeEcomplicated cases should be managed in hospitals =here almost all laborator investigations#
e2uipment# medicines and blood banB facilities are available' )he medical and nursing personnel ma be
53
more experienced in the care of these criticall ill dengue patients' )he follo=ing patients should be referred
for closer monitoring and probabl accorded special treatment at a higher tier of hospital care;
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
infants Y. ear old'
obese patients'
pregnant =omen'
profoundEprolonged shocB'
significant bleeding'
repeated shocB 0/1 times during treatment'
patients =ho seem not to respond to conventional fluid therap'
patients =ho continue to have rising haematocrit and no colloidal solution is available'
patients =ith Bno=n underling diseases such as Diabetes mellitus (D:- # hpertension#
heart disease or haemoltic disease'
patients =ith signs and smptoms of fluid overload'
patient =ith isolatedEmultiple organ involvement'
patients =ith neurological manifestations such as change of consciousness# semi!coma#
coma# convulsion# etc'
Discussions and counselling sessions =ith families'
Prior contact =ith the referral hospital? communicating =ith doctors and nurses responsible'
$tabili"ing patients before transfer'
%nsuring that the referral letter must contain information about clinical conditions#
monitoring parameters (haematocrit# vital signs# intaBeEoutput-# and progression of disease
including all important laborator findings'
)aBing care during transportation' Rate of 6C fluid is important during this time' 6t is preferable
to be given at a slo=er rate of about 5 mlEBgEh to prevent fluid overload' &t least a nurse
should accompan the patient'
Revie= of referred patients b a specialist as soon as the arrive at the referral hospital'
Referral procedure
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OutbreaB preparedness for clinical management
)here has been increasing incidence of dengue outbreaBs in man countries globall' )he follo=ing
elements are recommended for the preparedness of dengue clinical management;
Q Organi"ation of a rapid response team coordinated b the national programme;
/
/
/
/
/
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/
/
/
/
frontline health!care centre'
emergenc department'
medical team'
laborator team'
epidemiolog team'
doctors'
nurses'
health!care =orBers'
bacB!office personnel'
Personnel (to be recruited# trained and assigned appropriate duties-;
55
Q
Q
Clinical Practice Guidelines (CPG- (the above!named personnel should undergo a brief
training on the use of CPG-'
:edicines and solutions;
/
/
/
paracetamol'
oral rehdration solution'
6C fluid'
b crstalloid; ,'7G and 5G Dextrose in isotonic normal saline solution (DE*$$-# 5G
Dextrose &ectated RingerAs (D&R-# 5G Dextrose Lactated RingerAs (DLR-'
b colloid!hperoncotic (plasma expander-; .,G dextran/3, in *$$'
/
/
/
/
/
0,G or 5,G glucose'
vitamin J.'
calcium gluconate'
potassium Chloride (JCl- solution'
sodium bicarbonate'
6C fluids and vascular access# including scalp vein# medicut# cotton# gau"e and 8,G
alcohol'
oxgen and deliver sstems'
sphgmomanometer =ith three different cuff si"es'
automate C4C machine (Coulter counter-'
micro!centrifuge (for haematocrit determination-'
microscope (for platelet count estimation-'
glucometer (for blood!sugar level-'
lactatemeter'
4asic;
b Complete blood count (C4C-; haematocrit# =hite blood cell (W4C- count# platelet
count and differential count'
/ :ore complicated cases;
b blood sugar'
b liver function test'
b renal function test (4H*# creatinine-'
b electrolte# calcium'
b blood gas analsis'
b coagulogram; partial thromboplastin time (P))-# prothrombin time (P)-# thrombin
time ())-'
b chest \!ra'
b ultrasonograph'
Q %2uipment and supplies;
/
/
/
/
/
/
/
/
Q Laborator support;
/
Q 4lood banB;
/ fresh =hole blood# pacBed red cell (platelet concentrate-'
5+
8' Disease $urveillance;
%pidemiological and %ntomological
8'. %pidemiological surveillance
%pidemiological surveillance is an ongoing sstematic collection# recording# analsis# interpretation and
dissemination of data for initiating suitable public health interventions for prevention and control'
ObDectives of surveillance
)he obDectives of public health surveillance applicable to dengue are to;
Q
Q
Q
Q
Q
Q
detect epidemics earl for timel intervention?
measure the disease burden?
monitor trends in the distribution and spread of dengue over time?
assess the social and economic impact of dengue on the affected communit?
evaluate the effectiveness of prevention and control programmes? and
facilitate planning and resource allocation based on the lessons learnt from programme
evaluation'
Components of a surveillance sstem
)he surveillance sstem comprises passive surveillance# active surveillance and event!based
surveillance'
&ll three surveillance components re2uire a good public health laborator to provide diagnostic
support in virolog# bacteriolog and parasitolog' )he laborator need not be able to test for all
agents but should Bno= =here to refer specimens for testing# for example# select samples for the
WHO collaborating centres for reference and research'
6ndividuall# the three components are not sensitive enough to provide effective earl =arning'
4ut =hen used collectivel the can often accuratel predict epidemic activit'
Passive surveillance
%ver dengue endemic countr should have a surveillance sstem and it should be mandated b la=
in most countries that DFEDHF is treated as a reportable disease' )he sstem should be based on
standardi"ed case definitions (4ox 9 on pages 07/1,- and formali"ed mandated reporting' &lthough
passive sstems are not sensitive and have lo= specificit since cases are not laborator confirmed#
the are most useful in monitoring long!term trends in dengue transmission'
)he clinical spectrum of illnesses associated =ith dengue infection ranges from non!specific
viral sndrome to severe haemorrhagic disease or fatal shocB' 6t ma sometimes be difficult to
58
differentiate the associated illnesses from those caused b other viruses# bacteria and parasites'
)herefore# surveillance should be supported b laborator diagnosis' Ho=ever# the reporting of
dengue disease generall has to rel on clinical diagnosis combined =ith simple clinical laborator
tests and available epidemiological information'
Passive surveillance should re2uire case reports from ever clinic# private phsician and health
centre or hospital that provides medical attention to the population at risB' Ho=ever# even =hen
mandated b la=# passive surveillance is insensitive because not all clinical cases are correctl
diagnosed during periods of lo= transmission =hen the level of suspicion among medical professionals
is lo=' :oreover# man patients =ith mild# non!specific viral sndrome self medicate at home and
do not seeB formal treatment' 4 the time dengue cases are detected and reported b phsicians
under a passive surveillance sstem# substantial transmission has alread occurred and it ma even
have peaBed' 6n such cases# it is often too late to control the epidemic'
Ho=ever# passive surveillance for DFEDHF has t=o problems' First# there is no consistenc in
reporting standards' $ome countries report onl DHF =hile others report both DF and DHF' $econdl#
the WHO case definitions are also not strictl adhered to =hile reporting the cases' )hese problems
lead to both underreporting and overreporting that actuall =eaBens the surveillance sstems'
&ctive surveillance
)he goals of an active surveillance sstem allo= health authorities to monitor dengue transmission in
a communit and tell# at an point in time# =here transmission is occurring# =hich virus serotpes
are circulating# and =hat Bind of illness is associated =ith the dengue infection'3 )o accomplish this#
the sstem must be active and have good diagnostic laborator support' %ffectivel managed# such a
surveillance sstem should be able to provide an earl =arning or predictive capabilit for epidemic
transmission' )he rationale is that if epidemics can be predicted# the can be prevented' )his tpe
of proactive surveillance sstem must have at least three components that place emphasis on the
inter! or pre!epidemic period' )hese are a sentinel clinicEphsician net=orB# a fever alert sstem
that uses communit health =orBers# and a sentinel hospital sstem (4ox .+-'
4ox .+; Components of laborator!based# proactive surveillance for DFEDHF during inter!
epidemic periodst
)pe of surveillance
$entinel clinicEphsician
$amplesu &pproach
4lood from representative casesRepresentative samples taBen
of viral sndrome# taBen 5 to .5round the ear and processed
das after the onset of smptoms' timel for virus isolation and for
6g: antibodies'
4lood samples from
representative cases of febrile
illness'
4lood and tissue samples taBen
during hospitali"ation andEor at
the time of death'
6ncreased febrile illness in the
communit is investigated
immediatel'
&ll haemorrhagic disease and
all viral sndromes =ith fatal
outcome are investigated
immediatel'
Fever alert
$entinel hospital
t
u
During an epidemic# after the virus serotpe(s- is Bno=n# the case definition should be more specific and surveillance focused on
severe disease'
&ll samples are processed =eeBl for virus isolation andEor for dengue!specific 6g: antibodies'
59
)he sentinel clinicEphsician and fever alert components are designed to monitor non!specific
viral sndromes in the communit' )his is especiall important for dengue viruses because the
are fre2uentl maintained in tropical urban centres in a silent transmission ccle# often presenting
as non!specific viral sndromes' )he sentinel clinicEphsician and fever alert sstems are also ver
useful for monitoring other common infectious diseases such as influen"a# measles# malaria# tphoid#
leptospirosis and others that present in the acute phase as non!specific febrile illnesses'
6n contrast to the sentinel clinicEphsician component# =hich re2uires sentinel sites to monitor
routine viral sndromes# the fever alert sstem relies on communit health and sanitation and the
alertness of other =orBers to an increase in febrile activit in their communit# and to report this to
the health departmentAs central epidemiolog unit' 6nvestigations b the latter should be immediate
but flexible' 6t ma involve telephonic follo=!up or active investigation b an epidemiologist =ho
visits the area to taBe samples'
)he sentinel hospital component should be designed to monitor severe disease' Hospitals
used as sentinel sites should include all facilities that admit patients for severe infectious diseases in
the communit' )his net=orB should also include the phsicians for infectious disease =ho usuall
consult patients =ith such cases' )he sstem can target an tpe of severe disease# but for dengue
it should include all patients =ith an haemorrhagic manifestation? an admission diagnosis of viral
encephalitis# aseptic meningitis and meningococcal shocB? andEor a fatal outcome follo=ing a viral
prodrome'.7
&n active surveillance sstem is designed to monitor disease activit during the inter!epidemic
period prior to increased transmission' 4ox .+ outlines the active surveillance sstem for DFEDHF#
giving the tpes of specimens and approaches re2uired' 6t must be emphasi"ed that once epidemic
transmission has begun# the active surveillance sstem must be refocused on severe disease
rather than on viral sndromes' $urveillance sstems should be designed and adapted to the
areas =here the =ill be initiated'
%vent!based surveillance
%vent!based surveillance is aimed at investigating an unusual health event# namel fevers of
unBno=n aetiolog and clustering of cases' HnliBe the classical surveillance sstem# event!based
surveillance is not based on routine collection of data but should be an investigation conducted
b an epidemiological unit / supported b a microbiologist# an entomologist and other personnel
relevant to the particular event / to initiate interventions to control and prevent further spread of
the infection'
8'0 6nternational Health Regulations (0,,5-
)he 6nternational Health Regulations (6HR- =ere formulated in 0,,5 (World Health &ssembl
resolution WH&59'1- and came into force in 0,,8' )he purpose and scope of these Regulations are
to prevent# protect against# control and provide a public health response to the international spread
of disease in =as that are commensurate =ith and restricted to public health risBs# and =hich avoid
unnecessar interference =ith international traffic and trade'0
)he 6HR (0,,5- encompass dengue as a disease of concern to the international communit
because of its high potential for build!up of epidemics of DF and DHF' )he 6HR enDoin :ember
$tates to develop capabilities for detection# reporting and responding to global health threats b
establishing effective surveillance sstems' Core obligations for :ember $tates and for WHO are
outlined in the Decision 6nstrument for the assessment and notification of events that ma constitute
a public health emergenc of international concern (PH%6C-' )hese are also mentioned in &nnex 0
57
and 1 respectivel' )hailand is the first countr in the $outh!%ast &sia Region to have developed an
6HR &ction Plan for 0,,9/0,.0 (4ox .8-'
4ox .8; )hailand develops 6HR &ction Plan for 0,,9/0,.09,
)he :inistr of Public Health# Roal Government of )hailand# has formulated national action
plans to develop public health infrastructure and human resources to meet the core capacit
re2uirements as envisaged under the 6nternational Health Regulations (0,,5-' )he Plan for
0,,9/0,.0 =as approved b the Cabinet in December 0,,8' )he obDectives of the Plan focus
on capacit!building of all institutions involved in surveillance and public health emergencies#
including laboratories and hospitals# and the .9 points of entr# and also on building capacit
to coordinate# among various related governmental and private institutions and the communit#
the implementation of 6HR (0,,5- in an integrated manner'
8'1 Cector surveillance
$urveillance of &e' aegpti is important in determining the distribution# population densit# maDor
larval habitats# and spatial and temporal risB factors related to dengue transmission# and levels of
insecticide susceptibilit or resistance#9. in order to prioriti"e areas and seasons for vector control'
)hese data =ill enable the selection and use of the most appropriate vector control tools# and can
be used to monitor their effectiveness' )here are several methods available for the detection and
monitoring of larval and adult populations' )he selection of appropriate methods depends on
surveillance obDectives# levels of infestation# and availabilit of resources'
Larval surves
For practical reasons# the most common surve methodologies emplo larval sampling procedures
rather than egg or adult collections' )he basic sampling unit is the house or premise# =hich is
sstematicall searched for =ater!storage containers'
Containers are examined for the presence of mos2uito larvae and pupae' Depending on the
obDectives of the surve# the search ma be terminated as soon as &edes larvae are found# or it ma
be continued until all containers have been examined' )he collection of specimens for laborator
examination is necessar to confirm the species present' )hree commonl used indices for monitoring
&e' aegpti infestation levels9.#90 are presented in 4ox .9'
+,
4ox .9; 6ndices used to assess the levels of &e' aegpti infestations
House 6ndex (H6-; Percentage of houses infested =ith larvae andEor pupae'
H6 a *umber of houses infested
*umber of houses inspected
\ .,,
Container 6ndex (C6-; Percentage of =ater!holding containers infested =ith larvae or pupae'
C6 a *umber of positive containers \ .,,
*umber of containers inspected
4reateau 6ndex (46-; *umber of positive containers per .,, houses inspected'
46 a *umber of positive containers
\ .,,
)he House 6ndex has been most =idel used for monitoring infestation levels# but it neither taBes
into account the number of positive containers nor the productivit of those containers' $imilarl#
the container index onl provides information on the proportion of =ater!holding containers that
are positive'
)he 4reateau 6ndex establishes a relationship bet=een positive containers and houses# and
is considered to be the most informative# but again there is no reflection of container productivit'
*evertheless# in the course of gathering basic information for calculating the 4reateau 6ndex# it
is possible and desirable to obtain a profile of the larval habitat characteristics b simultaneousl
recording the relative abundance of the various container tpes# either as potential or actual sites
of mos2uito production (e'g' number of positive drums per .,, houses# number of positive tres
per .,, houses# etc'-' )hese data are particularl relevant to focus efforts for the management or
elimination of the most common habitats and for the orientation of educational messages in aid of
communit!based initiatives'
PupalEdemographic surves
)he rate of contribution of ne=l emerged adults to the adult mos2uito population from different
container tpes can var =idel' )he estimates of relative adult production ma be based on pupal
counts9. (i'e' counting all pupae found in each container-' )he corresponding index is the Pupal
6ndex (4ox .7-'
4ox .7; Pupal 6ndex; *umber of pupae per house
Pupal 6ndex (P6- a *umber of pupae
\ .,,
6n order to compare the relative importance of larval habitats# the Pupal 6ndex can be
disaggregated b LusefulM# Lnon!essentialM and LnaturalM containers# or b specific habitat tpes such
as tres# flo=er vases# drums# cla pots# etc' Given the practical difficulties faced and labour!intensive
efforts entailed in obtaining pupal counts# especiall from large containers# this method ma not be
used for routine monitoring or in ever surve of &e' aegpti populations# but ma be reserved for
+.
special studies or used in each localit once during the =et season and once during the dr season
to determine the most productive container tpes' )he Pupal 6ndex has been most fre2uentl used
for operational research purposes'
6n an communit# if the classes of containers =ith the highest rates of adult emergence are
Bno=n# their selective targeting for source reduction or other vector control interventions can be the
basis for the optimi"ed use of limited resources'91#93 )he pupalEdemographic surve is a method for
identifing these epidemiologicall most important container classes' HnliBe the traditional indices
described above# pupalEdemographic surves measure the total number of pupae in different classes
of containers in a given communit'
6n practice# conducting a pupalEdemographic surve involves visiting a sampling of houses' )he
number of persons living in the house is recorded' &t each location# and =ith the permission of the
householder# the field =orBers sstematicall search for and strain the contents of each =ater!filled
container through a sieve# and re!suspend the sieved contents in a small amount of clean =ater
in a =hite enamel or plastic pan' &ll the pupae are pipetted into a labelled vial' Large containers
are a significant problem in pupalEdemographic surves because of the difficult of determining
the absolute number of pupae' 6n such circumstances s=eep!net methods have been developed
=ith calibration factors to estimate the total number of pupae in specific container tpes' 6f there
is container!inhabiting species in the area other than &e' aegpti# on return to the laborator the
contents of each vial are transferred to small cups and covered =ith mos2uito netting secured =ith
a rubber band' )he are held until adult emergence occurs and taxonomic identification and counts
can be made'
)he collection of demographic data maBes it possible to calculate the ratio bet=een the numbers
of pupae (a prox for adult mos2uitoes- and persons in the communit' )here is gro=ing evidence
to suggest that together =ith other epidemiological parameters# notabl dengue serotpe!specific
seroconversion rates and temperature# it is possible to determine the degree of vector control needed
in a specific location to inhibit virus transmission' )his remains an important area for research and
a=aits validation'
&dult surves
&dult vector sampling procedures can provide valuable data for specific studies such as seasonal
population trends# transmission dnamics# transmission risB# and evaluation of adulticide interventions'
Ho=ever# the results ma be less reproducible than those obtained from the sampling of immature
stages' )he collection methods also tend to be labour!intensive and heavil dependent on the
proficienc and sBill of the collector'
Landing collections
Landing collections on humans are a sensitive means of detecting lo=!level infestations# but are ver
labour!intensive' 4oth male and female &e' &egpti are attracted to humans' $ince adult males have
lo= dispersal rates# their presence can be a reliable indicator of proximit to hidden larval habitats'
)he rates of capture# tpicall using hand nets or aspirators as mos2uitoes approach or land on the
collector# are usuall expressed in terms of Llanding counts per man hourM' &s there is no prophlaxis
for dengue or other viruses transmitted b &edes mos2uitoes# the method raises safet and ethical
concerns in endemic areas'
Resting collections
During periods of inactivit# adult mos2uitoes tpicall rest indoors# especiall in bedrooms# and mostl
in darB places such as clothes closets and other sheltered sites' Resting collections re2uire sstematic
+0
searching of these sites for adult mos2uitoes =ith the aid of a flashlight' & labour!intensive method
is to capture the adults using mouth or batter!po=ered aspirators and hand!held nets =ith the aid
of flashlights' Recentl# a much more productive# standardi"ed and less labour!intensive method
using batter!operated bacBpacB aspirators has been developed'95 Follo=ing a standardi"ed# timed
collection routine in select rooms of each house# densities are recorded as the number of adults
collected per house (females# males or both- or the number of adults collected for ever human!hour
of effort' When the mos2uito population densit is lo=# the percentage of houses found positive for
adults is sometimes used'
&nother means of collecting adult mos2utoes is through the use of the insecticide impregnated
fabric trap9+#98 (66F)-# =herein the mos2uitoes resting on the fabric hung inside the trap get Billed
upon contact =ith the insecticide and are collected in the bottom tra of the trap' )hese can then
be sorted according to species and checBed for the presence of &edes' )hese traps# ho=ever# need
to be evaluated for their efficac in different field settings'
Oviposition traps
LOvitrapsM are devices used to detect the presence of &e' aegpti and &e' albopictus =here the
population densit is lo= and larval surves are largel unproductive (e'g' =hen the 4reateau 6ndex
is less than 5-# as =ell as under normal conditions' )he are particularl useful for the earl detection
of ne= infestations in areas from =hich the mos2uitoes have been previousl eliminated' For this
reason# the are used for surveillance at international ports of entr# particularl airports# =hich
compl =ith the 6nternational Health Regulations (0,,5- and =hich should be maintained free of
vector breeding'
&n ovitrap enhanced =ith ha infusion has been sho=n to be a ver reproducible and efficient
method for &e' aegpti surveillance in urban areas and has also been found to be useful to evaluate
control programmes such as adulticidal space spraing on adult female populations'99
)he standard ovitrap is a =ide!mouthed# pint!si"ed glass Dar# painted blacB on the outside'
6t is e2uipped =ith a hardboard or =ooden paddle clipped verticall to the inside =ith its rough
side facing in=ards' )he Dar is partiall filled =ith =ater and is placed appropriatel in a suspected
habitat# generall in or around homes' )he Lenhanced CDC ovitrapM has ielded eight times more
&e' aegpti eggs than the original version' 6n this method# double ovitraps are placed' One Dar contains
an olfactor attractant made from a Lstandardi"edM seven da!old infusion =hile the other contains
a .,G dilution of the same infusion' Ovitraps are usuall serviced on a =eeBl basis# but in the case
of enhanced ovitraps are serviced ever 03 hours' )he paddles are examined under a dissecting
microscope for the presence of &e' aegpti eggs# =hich are then counted and stored'
Where both &e' aegpti and &e' albopictus occur# eggs should be hatched and then the larvae
or adults identified# since the eggs of those species cannot be reliabl distinguished from each other'
)he percentage of positive ovitraps provides a simple index of infestation levels' &gain# if the eggs are
counted it can provide an estimate of the adult female population' Figure ., illustrates assembled
and non!assembled ovitraps'
+1
Figure .,; Ovitrap
Female
mos2uito
Plastic collar
:os2uito eggs
Plastic ring
float
Hardboard
paddles
Wire mesh
&ssembled *on!assembled
$ource; *ational %nvironment &genc# :inistr of %nvironment and Water Resource# $ingapore# 0,,9'97
)re section larvitraps
)re section larvitraps of various designs have also been used for monitoring oviposition activit' )he
simplest among these is a =ater!filled radial section of an automobile tre' & prere2uisite for an
design is that it must either facilitate visual inspection of the =ater in situ or allo= the read transfer
of the contents to another container for examination' )re larvitraps differ from ovitraps in that =ater
level fluctuations brought about b rainfall induce the hatching of eggs? hence the presence of larvae
is noted instead of the paddles on =hich eggs have been deposited'v
%pidemiological interpretation of vector surveillance
&dult surveillance
)he epidemiolog of dengue infection ma be complicated because &e' aegpti ma probe repeatedl
on one or more persons during a single blood meal' )he correlation of different entomological
indices in terms of actual disease transmission is difficult' )he interpretation of the epidemiolog of
dengue transmission must taBe into account inter!urban population movement# focalit of &edes
populations =ithin the urban area# and fluctuations in adult population densities# all of =hich
influence transmission intensit' :ore attention should be given to understanding the relationships
among adult vector densities# densities of the human population in different parts of the cit# and
the transmission of dengue viruses'
v )he placement and use of this method is discussed in detail b *athan :'4'' et al'93
+3
Larval surveillance
)he commonl!used larval indices (house# container and 4reateau- are useful for determining general
distribution# seasonal changes and principal larval habitats# as =ell as for evaluating environmental
sanitation programmes' )he have direct relevance to the dnamics of disease transmission' Ho=ever#
the threshold levels of vector infestation that constitute a trigger for dengue transmission are influenced
b man factors# including mos2uito longevit and immunological status of the human population'
)here are instances (e'g' in $ingapore-# =here dengue transmission occurred even =hen the House
6ndex =as less than 0G'7,
)herefore# the limitations of these indices must be recogni"ed and studied more carefull to
determine ho= the correlate =ith adult female population densities# and ho= all indices correlate
=ith the disease!transmission risB' )he development of alternative# practical and more sensitive
entomological surveillance methodologies is an urgent need' )he level and tpe of vector surveillance
selected b each countr or control programme should be determined b operational research
activities conducted at the local level'
8'3 $ampling approaches
)he sample si"e for routine larval surves should be calculated using statistical methods based on the
expected level of infestation and the desired level of confidence in the results' &nnex 3 gives tables
and examples on ho= to determine the number of houses to be inspected' $everal approaches as
in 4ox 0, can be used'
4ox 0,; $ampling approaches
$stematic sampling;
%ver nth house is examined throughout the communit or along linear transects through the
communit' For example# if a sample of 5G of the houses is to be inspected# ever 0,th house
=ould be inspected' )his is a practical option for rapid assessment of vector population levels#
especiall in areas =here there is no house numbering sstem'
$imple random sampling;
)he houses to be examined are obtained from a table of random numbers (obtained from
statistical textbooBs or from a calculator or computer!generated list-' )his is a more laborious
process# as detailed house maps or lists of street addresses are a prere2uisite for identifing the
selected houses'
$tratified random sampling;
)his approach minimi"es the problem of under! and over!representation b subdividing the
localities into sectors or LstrataM' $trata are usuall based on identified risB factors# such as areas
=ithout piped =ater suppl# areas not served b sanitation services# and densel!populated areas'
& simple random sample is taBen from each stratum# =ith the number of houses inspected being
in proportion to the number of houses in that sector'
Fre2uenc of sampling
)he sampling fre2uenc =ould depend on the obDective of the control programme' 6t should be
decided on a case!b!case basis taBing into consideration the life!ccle of the mos2uito'
+5
Control programmes using integrated strategies do not re2uire sampling at fre2uent intervals
to assess the impact of the applied control measures' )his is especiall true =here the effect of the
alternative strategies outlasts residual insecticides (example# larvivorous fish in large potable =ater!
storage containers# source reduction or mos2uito!proofing of containers- or =hen larval indices are
high (H6 greater than .,G-'
On the other hand# feedbacB at least on a monthl basis ma be desirable to monitor and
guide communit activities and to identif the issues that need more scrutin# especiall =hen the
H6 is .,G or lo=er' For specific research studies# it ma be necessar to sample on a =eeBl# dail
or even hourl basis (e'g' to determine the diurnal pattern of biting activit-'
8'5 :onitoring insecticide resistance
6nformation on the susceptibilit of &e' aegpti to insecticides is of fundamental importance for
the planning and evaluation of control' )he status of resistance in a population must be carefull
monitored in a number of representative sentinel sites depending on the histor of insecticide usage
and eco!geographical situations# to ensure that timel and appropriate decisions are made on issues
such as use of alternative insecticides or change of control strategies'
During the past 3, ears# chemicals have been =idel used to control mos2uitoes and other
insects from spreading diseases of public health importance' &s a result# &e' aegpti and other
dengue vectors in several countries7. have developed resistance to commonl!used insecticides#
including DD)# temephos# malathion# fenthion# permethrin# propoxur and fenitrothion' Ho=ever#
the operational impact of resistance on dengue control has not been full assessed'=
6n countries =here DD) resistance has been =idespread# precipitated resistance to currentl!
used prethroid compounds that are being increasingl used for space spra is a challenge as =ell'
$ince both groups of insecticide have the same mode of action =hich acts on the same target site# the
voltage!gated sodium channel and mutations in the Bdr gene have been associated =ith resistance
to DD) and prethroid insecticides in &e' aegpti'
6t is# therefore# advisable to obtain baseline data on insecticide susceptibilit before insecticidal
control operations are started# and to continue periodicall monitoring susceptibilit levels of larval
or adult mos2uitoes' WHO Bitsx for testing the susceptibilit of adults and larval mos2uitoes remain
the standard methods for determining the susceptibilit of &edes populations'70
4iochemical and immunological techni2ues for testing individual mos2uitoes have also been
developed and are et available for routine field use'
8'+ &dditional information for entomological surveillance
6n addition to the evaluation of aspects such as vector densit and distribution# communit!oriented#
integrated pest management strategies re2uire that other parameters be periodicall monitored'
)hese include the distribution and densit of the human population# settlement characteristics# and
conditions of land tenure# housing stles and education'
)he monitoring of these parameters is relevant and of importance to planning purposes and
for assessing the dengue risB' Jno=ledge of changes over time in the distribution of =ater suppl
=
x
Ranson H# 4urhani K# LumDuan *# 4lacB WC' 6nsecticide resistance in dengue vectors# 0,.,' )rop6J&'net Kournal? .(.-' http;EEDournal'
tropiBa'netEscielo'phpcscriptasciTarttextPpida$0,89!9+,+0,.,,,,.,,,,1PlngaenPnrmaisoPtlngaen
6nstructions for testing and purchase of Bits# test papers and solutions are available at http;EE==='=ho'intEentitE=hopesEresistanceE
enEWHOTCD$TCP%TPCCT0,,.'0'pdf
++
services# their 2ualit and reliabilit# as =ell as in domestic =ater!storage and solid =aste disposal
practices is also particularl relevant' :eteorological data are important as =ell' $uch information
aids in planning targeted source reduction and management activities# as =ell as in organi"ing
epidemic interventions measures'
$ome of these data sets are generated b the health sector# but other sources of data ma be
necessar' 6n most cases# annual or even less fre2uent updates =ill suffice for programme management
purposes' 6n the case of meteorological data# especiall rainfall patterns# humidit and temperature#
a more fre2uent analsis is =arranted if it is to be of predictive value in determining seasonal trends
in vector populations and their short!term fluctuations'
+8
9' Dengue Cectors
9'. 4iolog of &edes aegpti and &edes albopictus
6n the $outh!%ast &sia Region of WHO# &edes aegpti (or &e' aegpti# and also Bno=n as
$tegomia aegpti-71 is the principal epidemic vector of dengue viruses' &edes albopictus (&e'
albopictus- has been recogni"ed as a secondar vector that is also important in the maintenance of
the viruses'
&edes aegpti
)axonomic status
&e' aegpti exhibits a continuous spectrum of scale patterns across its range of distribution from a
ver pale form to a darB form# =ith associated behavioural differences'73 6t is essential to understand
the bionomics of the local mos2uito population as a basis for its control (Figure ..-'
Figure ..; &e' aegpti (female-
$ource; D'$' Jettle# :edical and Ceterinar %ntomolog' 0nd %dition' C&4
6nternational' .775' p' ..,'75
+7
Geographical distribution in $outh!%ast &sia
Distribution
&e' aegpti is =idespread in tropical and subtropical areas of $outh!%ast &sia' 6ts distribution appears
to be related to the 0, VC isotherm# =hich roughl correlates =ith the tropical "one bet=een latitude
3,V* and 3,V$' 6t is most common in urban areas' )he rural spread of &e' aegpti is a relativel recent
occurrence associated =ith developmental and infrastructural gro=th initiatives such as expansion
of rural =ater suppl schemes and improved transport sstems (see Figure 3a-'
6n semi!arid areas as in parts of 6ndia# &e' aegpti is an urban vector and populations tpicall
fluctuate =ith rainfall and =ater storage habits'7+ 6n other countries of $outh!%ast &sia =here the annual
rainfall is generall greater than 0,, cm# &e' aegpti populations
Figure .0; Life!ccle of
are more stable and established in urban# semi!urban and rural
&e' aegpti
areas' 4ecause of traditional =ater storage practices in 6ndonesia#
:anmar and )hailand# their densities are higher in semi!urban
areas than in urban areas'
Hrbani"ation tends to increase the number of habitats
suitable for &e' aegpti' 6n some cities =here vegetation is
abundant# both &e' aegpti and &e' albopictus occur together'
4ut &e' aegpti is generall the dominant species# depending
on the availabilit and tpe of larval habitat and the extent of
urbani"ation' )he premise index for &e' aegpti =as the highest in
slum houses# shop houses and multistoreed flats' &e' albopictus#
on the other hand# did not seem to relate to the prevailing housing
tpe in its distribution but tended to occur more commonl in
areas =ith open spaces and vegetation'
&ltitude
&ltitude is an important factor in limiting the distribution of &e'
aegpti' 6n 6ndia# &e' aegpti ranges from sea level to heights of
approximatel .0,, metres above sea level' Lo=er elevations (less
than 5,, metres- have moderate to heav mos2uito populations
=hile mountainous areas (higher than 5,, metres- have lo=
populations'78 6n countries of $outh!%ast &sia# an altitude of .,,,
to .5,, metres appears to be the limit for &e' aegpti distribution'
6n other regions of the =orld# it is found at even higher altitudes#
for example# up to 00,, metres79 in Columbia'
Life!ccle
)he mos2uito has four distinct stages in its life!ccle; egg# larva#
pupa and adult (Figure .0-'
%ggs
)he female &e' aegpti las about 5, to .0, eggs in small
containers such as flo=er vases# =ater!storage Dars and other
indoor =ater recepticles# as =ell as in rain=ater collected in small
containers such as cups# tres# etc' outdoors' %ggs are deposited
$ource; 4ruce!Ch=att L'K'' %ssential
:alariolog' .795# Kohn Wile and $ons
*e= NorB'
http;EE==='ifrc'orgEdocsEpubsEhealthE
chapter5a'pdf
8,
singl on damp surfaces Dust above the =aterline' :ost female &e' aegpti la eggs in several
oviposition sites during a single gonotrophic ccle' %mbronic development is usuall completed in
39 hours in a =arm and humid environment' Once the embronic development is complete# the
eggs can =ithstand long periods of desiccation (for more than a ear-' %ggs hatch once the containers
are flooded# but not all eggs hatch at the same time' )he capacit of eggs to =ithstand desiccation
facilitates the survival of the species in adverse climatic conditions'
Larvae and pupae
)he larvae pass through four developmental stages' )he duration of the larval development depends
on temperature# availabilit of food and larval densit in the receptacle' Hnder optimal conditions#
the time taBen from hatching to the emergence of the adult can be approximate ., das and as
short as seven das# including t=o das in the pupal stage' &t lo= temperatures# ho=ever# it ma
taBe several =eeBs for adults to emerge'
)hroughout most of $outh!%ast &sia# &e' aegpti oviposits almost entirel in domestic and
man!made =ater receptacles' )hese include a multitude of receptacles found in and around urban
environments (households# construction sites and factories- such as =ater!storage Dars# saucers on
=hich flo=erpots rest# flo=er vases# cement baths# foot baths# =ooden and metal barrels# metal
cisterns# discarded tres# bottles# tin cans# polstrene containers# plastic cups# discarded =et!cell
batteries# glass containers associated =ith Lspirit housesM (shrines-# drainpipes and ant!traps in =hich
the legs of cupboards and tables are often rested'
*atural larval habitats are rare# but include tree holes# leaf axils and coconut shells' 6n hot
and dr regions# overhead tanBs and ground=ater!storage tanBs ma be primar habitats' 6n areas
=here =ater supplies are irregular# inhabitants store =ater for household use# thereb increasing the
number of available larval habitats'
While such man!made =ater receptacles ma be removed to den the &e' aegpti a breeding
habitat# one must also be prepared to eliminate other unconventional breeding habitats that the
mos2uito =ould be forced to find'
&dults
$oon after emergence# the adult mos2uitoes mate and the inseminated female ma taBe a blood meal
=ithin 03/1+ hours' 4lood is the source of protein essential for the maturation of eggs' &e' aegpti#
being a discordant species# taBes more than one blood meal to complete one gonotropic ccle' )his
behaviour increases man/mos2uito contact and is of great epidemiological importance'
Feeding behaviour
&e' aegpti is highl anthropophilic# although it ma feed on other available =arm!blooded animals'
4eing a diurnal species# females have t=o periods of biting activit; one in the morning for several
hours after dabreaB and the other in the afternoon for several hours before darB'77#.,,#.,. )he actual
peaBs of biting activit ma var =ith location and season'
&e' aegpti# being a nervous feeder# ma feed on more than one person' )his behaviour greatl
increases its epidemic transmission efficienc' )hus# it is not uncommon to see several members of
the same household =ith an onset of illness occurring =ithin 03 hours# suggesting that the =ere
infected b the same infective mos2uito'.7 &e' aegpti generall does not bite at night# but it =ill
feed at night in lighted rooms'.,,
Cisual representations of potential breeding habitats are available at http;EE==='dengue'gov'sgE subDect'aspcida.55
8.
Resting behaviour
:ore than 7,G of the &e' aegpti population rests on non!spraable surfaces# namel darB# humid#
secluded places inside houses or buildings# including bedrooms# closets# bathrooms and Bitchens'
Less often is it found outdoors in vegetation or other protected sites' )he preferred indoor resting
surfaces are the undersides of furniture# hanging obDects such as clothes and curtains# and =alls'
Hence# indoor residual spra is not an option for its control as =ith malaria vectors'
Flight range
)he dispersal of adult female &e' aegpti is influenced b a number of factors including the availabilit
of oviposition sites and blood meals# but appears to be often limited to =ithin 1,/5, metres of the
site of emergence' Ho=ever# recent studies in Puerto Rico (H$&- indicate that the ma disperse
more than 3,, metres primaril in search of oviposition sites'.,0 Passive transportation can occur via
desiccated eggs and larvae in containers'
Longevit
)he adult &e' aegpti has a lifespan of about 1/3 =eeBs' During the rain season# =hen survival is
longer# the risB of virus transmission is greater' :ore research is re2uired on the natural survival of
&e' aegpti under various environmental conditions'
Cirus transmission
& vector mos2uito ma become infected =hen it feeds on a viraemic human host' 6n the case of DFE
DHF# viraemia in the human host ma occur ./0 das before the onset of fever and lasts for about
five das after the onset of fever'.,1 &fter an intrinsic incubation period of .,/.0 das# the virus
gro=s through the midgut to infect other tissues in the mos2uito# including the salivar glands' 6f it
bites other susceptible persons after the salivar glands become infected# it transmits dengue virus
to those persons b inDecting the salivar fluid'
&edes albopictus
&e' albopictus (Figure .1- belongs to the same subgenus ($tegomia- as &e' aegpti' )his species is
=idel distributed in &sia in both tropical and temperate countries' During the past t=o decades#
the species has extended its range (Figure 3b- to *orth and $outh &merica including the Caribbean#
&frica# $outhern %urope and some Pacific islands'.,3 6t is estimated that the northern limit for over!
=intering &e' albopictus is the , ,C isotherm# and in summer its north=ard expansion is /5 ,C
isotherm# much further north than &e' aegpti can coloni"e'75
Figure .1; &edes albopictus
$ource; http;EE==='invasive'orgEbro=seEdetail'cfmcimgnuma.1++,05
80
&e' albopictus is primaril a forest species that has adapted to rural# suburban and urban
human environments' 6t oviposits and develops in tree holes# bamboo stumps and leaf axils in forest
habitats? and in artificial containers in urban settings' 6t is an indiscriminate blood feeder and more
"oophagic than &e' aegpti' 6ts flight range ma be up to 5,, metres'
HnliBe &e' aegpti# some strains in northern &sia and &merica are adapted to the cold# =ith eggs
that can spend the =inter in diapause' 6n some areas of &sia and the $echelles# &e' albopictus has
been occasionall incriminated as the vector of epidemic DFEDHF though it is much less important
than &e' aegpti' 6n the laborator# both species can transmit dengue virus verticall from a female
through the eggs to her progen# although &e' albopictus does so more readil'.,5
)axonomic status
&e' alobopictus can be easil recogni"ed from other stegomia species b the follo=ing combination
of characters; palpi =ith =hite scales# scutum =ith a long# medium longitudinal =hite stripe extending
from the interior margin to about the level of =ing root (Figure .1-'
Geographical distribution in $outh!%ast &sia
&e' alobopictus is =idespread in all countries of $outh!%ast &sia' 6t is believed that the species
originated from this region of the =orld'.,+
&ltitude
4asicall &e' albopictus is a feral species most commonl found in fringe areas of forests' )he presence
of this species deep inside the forest is 2uestionable' 6n )hailand# &e' albopictus has been collected
in three forested habitats in elevations ranging from 31, metres to .9,, metres'.,8
Life!ccle
)he species has four distinct stages in its life!ccle; egg# larva# pupa and adult'.,+
%ggs
)he female mos2uito las about .,, eggs that can =ithstand desiccation for long periods' %ggs
hatch on flooding'
Larve and pupae
Hnder laborator conditions# the larval stages at 05 VC and =ith optional food taBe 5 to ., das to
transform to the pupal stage# =hich taBes t=o more das to emerge as an adult' &t lo= temperatures#
the development period get prolonged' Development# ho=ever# ceases at temperatures of .. VC and
belo=' 4eing feral species the mos2uito breeds in tree holes# bamboo stumps and coconut shells at
forest fringes# although it invades peripheral areas of urban cities through man!made containers filled
=ith rain=ater' 6n parBs and gardens in cities# the species breeds on flo=er beds and various other
naturalEman!made containers' While such man!made =ater receptacles ma be removed to den the
&e' aegpti a breeding habitat# one must be prepared to =atch out for other more unconventional
breeding habitats that the mos2uito =ould be forced to find'
&dults
&fter emergence# mating occurs bet=een adult mos2uitoes and the inseminated females ma taBe
a blood meal =ithin 03/1+ hours' &e' albopictus is an aggressive feeder and taBes the full blood
meal in one go to complete genesis# as it is a concordant species' )his behaviour as =ell as feeding
81
on other mammalsEbirds reduces its vectorial capacit' HnliBe &e' aegpti# some strains are adapted
to the cold of northern &sia =ith their eggs spending the =inter in diapause'
&e' albopictus is an efficient bridge vector bet=een en"ootic and human ccles among the
human population living near the forest fringes' 6t is also more efficient then &e' aegpti in maintaining
the virus transovariall (verticall- as a reservoir'
Resting behaviour
&e' albopictus generall rests outdoors near the ground and in an part of a forest'
$urvival
Results of laborator research =ith &e' albopictus at 05 VC and relative humidit of 1,G brought
out that; i- females live longer than males? and ii- females usuall live from four to eight =eeBs in
the laborator but ma survive up to three to six months'
Cector identification
Pictorial Bes to &edes ($tegomia- mos2uitoes breeding in domestic containers are given in &nnex
5' )he Bes include Culex 2uin2uefasciatus# =hich ma be found in the same habitats'.,9
83
7' Cector :anagement and Control
Dengue feverEDHF control is primaril dependent on the control of &e' aegpti# since no vaccine is
et available for the prevention of dengue infection and there are no specific drugs for its treatment'
Dengue vector control programmes in the $outh!%ast &sia Region have# in general# recorded modest
success' %arlier attempts relied almost exclusivel on space spraing of insecticides for adult mos2uito
control' Ho=ever# space spraing re2uired specific operations that =ere often not adhered to#
and most countries found its costs prohibitive as =ell' $ubse2uentl# source reduction b clean!up
campaigns andEor larviciding =ith insecticides has been promoted =idel' Ho=ever# their success
has been limited on account of the variable degrees of compliance b communities and the non!
acceptabilit of larvicidal treatment either due to the bad odour of the larvicide used or inherent
misgivings about it that are prevalent in some communities'
)o achieve sustainabilit of a successful DFEDHF vector control programme it is essential to
focus on the larval source reduction =hile closel cooperating =ith non!health sectorsIsuch as
nongovernmental organi"ations# civic organi"ations and communit groupsIto ensure communit
understanding and involvement in implementation' )here is# therefore# a need to adopt an integrated
approach to mos2uito control b including all appropriate methods (environmental# biological and
chemical- that are safe# cost!effective and environmentall acceptable' & successful and sustainable
&e' aegpti control programme must involve partnerships bet=een government agencies and the
communit' )he approaches described belo= are considered necessar to achieve long!term and
sustainable control of &e' aegpti'
7'. %nvironmental management
%nvironmental management involves planning# organi"ation# execution and monitoring of activities for
the modification andEor manipulation of environmental factors or their interpla =ith human beings
=ith a vie= to prevent or minimi"e vector breeding and reduce human!vector!virus contact' )he
control of &e' aegpti in Cuba and Panama in the earl part of the 0,th centur =as based mainl
on environmental management'.5#.,7 $uch measures remain applicable =herever dengue is endemic'
6n .790 the World Health Organi"ation.., defined three Binds of environmental management (see
4ox 0.-'
%nvironmental methods to control &e' aegpti and &e' albopictus and reduce man!vector
contact include source reduction# solid =aste management# modification of man!made breeding sites#
and improved house design' )he maDor environmental management methods used for controlling
immature stages of vectors are summari"ed in 4ox 00'
85
4ox 0.; %nvironmental management methods
Q %nvironmental modification; )his includes an long!lasting phsical transformation of
land# =ater and vegetation aimed at reducing vector habitats =ithout causing undul
adverse effects on the 2ualit of the human environment'
%nvironmental manipulation; )his incorporates planned recurrent activities aimed
at producing temporar changes in vector habitats that involve the management of
LessentialM and Lnon!essentialM containers# and the management or removal of LnaturalM
breeding sites'
Changes to human habitation or behaviour; )hese feature the efforts made to reduce
man!vector!virus contact'
Q
Q
4ox 00; %nvironmental measures for control of some &e' aegpti production sites
Production site
%mpt# clean#
scrubbed
=eeBl
:os2uito!
proof cover
$tore
under
roof
:odif
design
Fill
(sandE
soil-
Collect#
reccleE
dispose
Puncture or
drain
%ssential
Water evaporation
cooler
Water storage tanBE
cistern
Drum (3,/55 gallons-
Flo=er vase =ith
=ater
Potted plants =ith
saucers
Ornamental poolE
fountain
Roof gutterEsun
shades
&nimal =ater
container
&nt!trap
*on!essential
Hsed tres
Discarded large
appliances
Discarded bucBets
Discarded food and
drinB containers
*atural
)ree holes
RocB holes
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8+
%nvironmental modification
6mproved =ater suppl
Whenever piped =ater suppl is inade2uate and available onl at restricted hours or at lo= pressure#
the storage of =ater in varied tpes of containers becomes a necessar practice that leads to increased
&edes breeding' )he maDorit of such containers are often large and heav (e'g' storage Dars- and can
neither be easil disposed of nor cleaned' 6n rural areas# unpolluted# disused =ells become breeding
grounds for &e' aegpti' 6t is essential that potable =ater supplies be delivered in sufficient 2uantit#
2ualit and consistenc to reduce the necessit and use of =ater!storage containers that serve as
the most productive larval habitats'
:os2uito!proofing of overhead tanBsEcisterns or underground reservoirs
Where &e' aegpti larval habitats include overhead tanBsEcisterns and masonr chambers of piped
=aterlines# these structures should be mos2uito!proofed'... & suggested design is illustrated in &nnex
+a' $imilarl# mos2uito!proofing of domestic =ells and underground =ater!storage tanBs should be
ensured'
Filling# land levelling and transformation of impoundment margins
)hese are usuall of permanent nature? ho=ever# correct operation and ade2uate maintenance are
essential for their effective functioning'
%nvironmental manipulation
Draining =ater suppl installations
Water collectionEleaBages in masonr chambers# distribution pipes# valves# sluice valves# surface
boxes for fire hdrants# =ater meters# etc' that serve as important &e' aegpti larval habitats in the
absence of preventive maintenance should be provided =ith soaB pits (&nnex +b-'
Covering domestic =ater!storage containers
)he maDor sources of &e' aegpti breeding in most urban areas of $outh!%ast &sia are containers
storing =ater for household use# including cla# ceramic and cement =ater Dars# metal drums# and
smaller containers storing fresh =ater or rain=ater' Water storage containers should be covered
=ith tightl fitting lids or screens and care should be taBen to replace them after =ater is used' &n
example of the efficac of this approach has recentl been demonstrated in )hailand'..0
Cleaning flo=erpotsEvases and ant!traps
Flo=erpots# flo=er vases and ant!traps are common sources of &e' aegpti breeding' Water that
collects on the saucers that are placed belo= flo=erpots should be removed ever =eeB' Water
in flo=er vases should be removed and discarded =eeBl and vases scrubbed and cleaned before
reuse' &lternativel# live flo=ers can be placed in a mixture of sand and =ater' 4rass flo=erpots#
=hich maBe poor larval habitats# can be used in cemeteries in place of traditional glass containers'
&nt!traps to protect food!storage cabinets should be cleaned on a =eeBl basis and treated =ith
common salt or oil'
88
Cleaning incidental =ater collections
Desert (evaporation- =ater!coolers# condensation collection pans under refrigerators# and air!
conditioners should be regularl inspected# drained and cleaned' Desert =ater!coolers generall
emploed in aridEsemi!arid regions..1 of $outh!%ast &sia to cool houses during summer contain t=o
manufacturing defects' )hese are as follo=s;
Q )he exit pipe at the bottom of the =ater!holding tra is generall fixed a fe= centimetres
above the bottom' )his exit pipe should be fitted at such a level that =hile empting the
tra# all the =ater should get drained off =ithout an retention at the bottom'
Desert coolers are normall fitted to =indo=s =ith the exit pipe located on the exterior
portion of the tra' )hese sites are usuall difficult to access# and therefore# there is a need
to change the design so that both the filling and empting of the =ater!holding tras can
be manipulated from the room# thus eliminating the need for climbing to approach the
exit pipe from the exterior of the building'
Q
%ach countr should develop regulator mechanisms to ensure the application of the design
specifications as outlined above for manufacturing desert coolers'
:anaging construction sites and building exteriors
Water!storage facilities at construction sites should be mos2uito!proof' HouseBeeping should also
be stepped up to prevent occurrence of =ater stagnation' )he design of buildings is important to
prevent &edes breeding' Drainage pipes of rooftops# sunshadesEporticos often get blocBed and
become breeding sites for &edes mos2uitoes' Roof gutters of industrialEhousing sheds also get similarl
blocBed' Where possible# the design of such features should minimi"e the tendenc for mos2uito
breeding' )here is a need for periodic inspection of such structures during the rain season to locate
potential breeding sites'
:anaging mandator =ater storage for fire!fighting
Fire prevention regulations ma re2uire mandator =ater storage in some countries'..3 $uch storage
tanBs need to be Bept mos2uito!proof' )hese drums should be Bept covered =ith tight lids? failing
=hich larvivorous fish or temephos sand granules (one part per million- can be used'
:anaging discarded receptacles
Discarded receptacles / namel tins# bottles# bucBets or an other consumable pacBaged items
such as plastic cupsEtras and =aste material# etc' scattered around houses / should be removed
and buried in landfills' $crap material in factories and =arehouses should be stored appropriatel
until disposal' Household and garden utensils (bucBets# bo=ls and =atering devices- should be Bept
upside do=n to prevent accumulation of rain =ater' $imilarl# in coastal areas canoes and small
boats should be emptied of =ater and turned upside do=n =hen not in use' Plant =aste (coconut
shells# cocoa husBs# etc'- should be disposed of properl'
:anaging glass bottles and cans
Glass bottles# cans and other small containers should be reused# reccled or buried in landfills'
)re management
Hsed automobile tres are of significant importance as breeding sites for urban &edes# and are
therefore a public health problem' 6mported used tres are believed to be responsible for the
introduction of &e' albopictus into the Hnited $tates of &merica# %urope and &frica'..5 )res in
depots should al=as be Bept under cover to prevent collection of rain=ater' *e= technologies for
89
tre reccling and disposal are continuall coming into use# but most of them have proved to be of
limited application or cost!intensive'
6t is recommended that each communit should looB at =as to reccleEreuse used tres so
that the do not become breeding habitats' $ome examples of ho= used tres can be reused are
mentioned belo=;
Q
Q
Q
Q
&s soil erosion barriers# e'g' creation of artificial reefs in order to reduce beach erosion b
=ave action'
&s planters or trafficEcrash barriers# after filling =ith earth or concrete'
&s sandals# floor mats# industrial =ashers# gasBets# bucBets# garbage pails and carpet bacBing#
etc' (after reccling-'
&s durable# lo=!cost refuse containers b using larger tres such as trucB tres'
Filling up of cavities of fences
Fences and fence!posts made from hollo= trees such as bamboo should be cut do=n to the node#
and concrete blocBs should be filled =ith pacBed sand or cement to eliminate potential &edes larval
habitats'
:anaging public places
:unicipalities should have in place a programme to inspect and maintain structures in public
places such as street lamp posts# parB benches and litter bins that ma collect =ater if not regularl
checBed' Discarded receptacles that ma hold =ater such as plastic cups# broBen bottles and metal
cans should be regularl removed from public areas'
Personal protection
Protective clothing
Clothing reduces the risB of mos2uito bite if the cloth material is sufficientl thicB or loosel fitting'
Long sleeves and trousers =ith stocBings ma protect the arms and legs# =hich are the preferred sites
for mos2uito bites' $choolchildren should adhere to these practices =henever possible'
:ats# coils and aerosols
Household insecticidal products# namel mos2uito coils and aerosols# are used extensivel for
personal protection against mos2uitoes' %lectric vapori"er mats and li2uid vapori"ers are more recent
additions# and are marBeted in practicall all urban areas'
Repellents
Repellents are common means of personal protection against mos2uitoes and other biting insects'
)hese are broadl classified into t=o categories# natural repellents and chemical repellents'
%ssential oils from plant extracts are the main natural repellent ingredients# such as citronella
oil# lemon grass oil and neem oil'
Chemical repellents such as D%%) (*# *!Diethl!m!)oluamide- can provide protection against
&e' aegpti# &e' albopictus and anopheline species for several hours' & ne= compound# picaridin
R0!(0!hdroxethl-!.!piperidinecarboxlic acid .!methlpropl esterS is ver effective against
mos2uitoes' 6t has lo= toxicit and efficac levels comparable =ith that of D%%)'..+ Permethrin is an
effective repellant =hen impregnated in cloth' )able .. presents the names of the principal insect
repellents and the duration of protection'
87
)able ..; 6nsect repellents and length of duration
:ain ingredient
D%%)" Y.,G
D%%) .,G/1,G
D%%) 0,G/11G# extended duration
Citronella oil 5G/.5G
Lemon eucalptus oil .,G/1,G
Picaridin 8G
Picaridin .5G
Permethrinaa ,'5G>
Duration
./1 h
3/+ h
+/.0 h
0,/1, min
0/5 h
1/3 h
+/9 h
$everal =ashings
Formulation
Pump spra# aerosol# gel# lotion'
Pump spra# aerosol# lotion# sticB'
Lotion# aerosol'
Pump spra# lotion# oil# to=elette'
Lotion'
Pump spra'
&erosol'
&erosol# pump spra'
$ource; Jat" )':'# :iller K'H'# Hebert &'&'' 6nsect repellents; Historical perspectives and ne= developments' K &m &cad Dermatol'
0,,9 :a? 59(5-; 9+5/8.'..+
6nsecticide!treated materials; :os2uito nets and curtains
6nsecticide!treated mos2uito nets (6)*s-..8#..9 have limited utilit in dengue control programmes since
the vector species bites during the da' Ho=ever# treated nets can be effectivel utili"ed to protect
infants and night =orBers =ho sleep b da' )he can also be effective for people =ho generall
have an afternoon nap' Details of insecticide treatment of mos2uito nets and curtains are explained
in &nnex 8'
)he long!lasting insecticidal net (LL6*- is a factor!treated mos2uito net =ith insecticide
(snthetic prethroids- either incorporated into or coated around the fibre' 6t is expected to retain
its biological activit for a minimum number of WHO =ashes and a minimum period of time
under field conditions' Currentl# an LL6* is expected to retain its biological activit for at least 0,
standard WHO =ashes under laborator conditions and three ears of recommended use under
field conditions'..7
7'0 4iological control
4iological control is based on the introduction of organisms that pre upon# parasiti"e# compete
=ith or other=ise reduce populations of the target species'++ )he application of biological control
agents# =hich are directed against the larval stages of dengue vectors# in $outh!%ast &sia has been
some=hat restricted to specific container habitats in small!scale field operations' While biological
control avoids chemical contamination of the environment# there ma be operational limitations
such as the expense and tasB of rearing the organisms on a large scale# difficult in appling them
and their limited utilit in a2uatic sites =here temperature# pH and organic pollution ma exceed the
narro= re2uirements of the organism' 6mportantl# the biological control organisms are not resistant
to desiccation# hence their utilit is mainl restricted to container habitats that are seldom emptied
or cleaned# such as large =ater!storage containers or =ells' Ho=ever# the =illingness of communities
to accept the introduction of organisms into =ater containers is essential' Communit involvement
is also desirable in distributing the agents# and monitoring and restocBing containers# as necessar'
" D%%)# *#*!diethl!1!methlben"amide'
aa Permethrin is not formulated for direct application to the sBin'
9,
Fish
Larvivorus fish (Gambusia affinis and Poecilia reticulata- have been extensivel used for the control
of &n' stephensi andEor &e' aegpti in large =aterbodies or large =ater containers in man countries
in $outh!%ast &sia (for example# the communit!based use of larvivorous fish Poecilia reticulata to
control the dengue vector &e' aegpti in domestic =ater!storage containers in rural Cambodia-'.0,
)he applicabilit and efficienc of this control measure depends on the tpe of containers used'
4acteria
)=o species of endotoxin!producing bacteria# 4acillus thuringiensis serotpe H!.3 (4t'H!.3- and
4acillus sphaericus (4s-# are effective mos2uito control agents' )he do not affect non!target organisms
associated =ith mos2uito larvae' 4t'H!.3 has an extremel lo=!level mammalian toxicit and has been
accepted for the control of mos2uitoes in containers storing =ater for household use'.0. 4t'H!.3 has
been found to be most effective against &n' stephensi and &e' aegpti# =hile 4s is the most effective
against Culex 2uin2uefasciatus =hich breeds in polluted =ater'
)here is a =hole range of formulated 4ti products produced b several maDor companies for
the control of vector mos2uitoes' $uch products include =ettable po=ders and various slo=!release
formulations including bri2uettes# tablets and pellets' Further developments are expected in slo=!
release formulations' 4t'H!.3 has an extremel lo=!level mammalian toxicit and has been accepted
for the control of mos2uitoes in containers storing =ater for household use'
Cclopods
)he predator role of copepod crustaceansab =as documented bet=een .71, and .75,' Ho=ever#
scientific evaluation =as carried out onl in .79, in )ahiti# French Polnesia# =here it =as found that
:esocclops aspericornis could effect a 77'1G mortalit rate among &edes ($tegomia- larvae and
7'8G and .'7G# respectivel among Cx' 2uin2uefasciatus and )oxorhnchities amboinensis larvae'.00
)rials in crab burro=s against &e' polnesiensis and in =ater tanBs# drums and covered =ells met
=ith mixed results'
6n Fueensland# &ustralia# of seven species evaluated in the laborator all but :' notius =ere
found to be effective predators of both &e' aegpti and &n' farauti but not against Cx' 2uin2uifasciatus'
Field releases in both northern and southern Fueensland# ho=ever# sho=ed mixed results' 6n )hailand
too# the results =ere mixed? but in Cietnam the results =ere more successful# contributing to the
eradication of &e' aegpti from one village'.01
&lthough the lacB of nutrients and fre2uent cleaning of some containers can prevent the
sustainabilit of copepods# the could be suitable for large containers that cannot be cleaned
regularl (=ells# concrete tanBs and tres-'.01 )he can also be used in conDunction =ith 4t'H!.3'
Copepods have a role in dengue vector control# but more research is re2uired on the feasibilit of
operational use'
&utocidal ovitraps
&utocidal ovitraps =ere successfull used in $ingapore as a control device in the eradication of
&e' aegpti from the Paa Lebar 6nternational &irport'.03 6n )hailand# the autocidal trap =as further
modified as an auto!larval trap using plastic material available locall' Hnfortunatel# under local
conditions of =ater!storage practices in )hailand# the techni2ue =as not ver efficient in reducing
ab Copepods should not be used in countries =here Gnathostomiasis are endemic as the ma act as intermediate hosts
for these parasites'
9.
natural populations of &e' aegpti' 4etter results can be expected if the number of existing potential
larval habitats is reduced# or more autocidal traps are placed in the area under control# or both
activities are carried out simultaneousl' 6t is believed that under certain conditions this techni2ue
could be an economical and rapid means of reducing the natural densit of adult females as =ell
as serve as a device for monitoring infestations in areas =here some reduction in the population
densit of the vector has alread taBen place' Ho=ever# successful application of autocidal ovitrapsE
larval traps depends on the number placed# the location of placement# and their attractiveness as
&e' aegpti female oviposition sites'.05
7'1 Chemical control
Chemicals have been used to control &e' aegpti since the beginning of the 0,th centur' 6n the first
campaigns against the ello= fever vector in Cuba and Panama# along =ith =idespread clean!up
campaigns# &edes larval habitats =ere treated =ith oil and homes =ere fumigated =ith prethrins'
When the insecticidal properties of DD) =ere discovered in the .73,s# this compound became
a principal method of &e' aegpti eradication programmes in the &mericas' When resistance to
DD) emerged in the earl .7+,s# organophosphate insecticides# including fenthion# malathion and
fenitrothion# =ere used for &e' aegpti adult control and temephos as a larvicide' Current methods
of appling insecticides include larvicide application and space spraing'.05
Chemical larviciding
Larviciding or LfocalM control of &e' aegpti is usuall limited to domestic!use containers that cannot
be destroed# eliminated or other=ise managed' 6t is difficult and expensive to appl chemical
larvicides on a long!term basis' )herefore# chemical larvicides are best used in situations =here the
disease and vector surveillance indicate the existence of certain periods of high risB and in localities
=here outbreaBs might occur'
%stablishing the precise timing and location are essential to ensure maximum effectiveness'
Control personnel distributing the larvicide should al=as encourage house occupants to control
larvae b environmental sanitation# i'e source reduction' )here are three insecticides that can be used
for treating containers that hold drinBing =ater'ac )he WHO guidelines on drinBing =ater 2ualit.0+
provide guidance on the use of pesticides in drinBing =ater'
)emephos .G sand granules
One per cent temephos sand granules are applied to containers using a calibrated plastic spoon to
administer a dosage of . ppm' )his dosage has been found to be effective for 9/.0 =eeBs# especiall
in porous earthen Dars under normal =ater use patterns' )he 2uantit of sand granules re2uired
to treat various si"es of =ater containers is presented in &nnex 9' )he susceptibilit level of &edes
mos2uitoes should be monitored regularl in order to ensure effective use of the insecticide'
6nsect gro=th regulators (6GR-Epriproxfen
6nsect gro=th regulators (6GRs- interfere =ith the development of the immature stages of the mos2uito
b interference of chitin snthesis during the moulting process in larvae or b disruption of the pupal
and adult transformation processes'
Priproxfen is an insect!Duvenile hormone analogue that has been found extremel effective
against &e' aegpti at concentrations as lo= as . ppb or less# =hile high concentration does not
inhibit oviposition'.08 Cer lo= doses of priproxfen can also sub!lethall affect adults b decreasing
ac http;EE==='=ho'intE=aterTsanitationThealthEd=2Egd=21revEenE
90
fecundit or fertilit and the contaminated adult female can transfer effective doses to an breeding
sites subse2uentl visited b the female'.09 *e= formulations of priproxfen.07 can retain efficac
for six months' Ho=ever# the disadvantages include non!visibilit since the mode of action prevents
eclosion and larvae and pupae remain visibl active after treatment' &s a result# suspicion among
communities about the 6GRAs effectiveness regarding treatment of domestic =ater is et another
impediment'
4acillus thuringiensis H!.3 (4t'H!.3-
4t'H!.3# =hich is commerciall available under a number of trade names# is a proven and
environmentall non!intrusive mos2uito larvicide' 6t is entirel safe for humans =hen the larvicide
is used in drinBing =ater in normal dosages'.0. $lo=!release formulations of 4t'H!.3 have been
developed' 4ri2uette formulations that appear to have greater residual activit are commerciall
available and can be used =ith confidence in drinBing =ater'
)he use of 4t'H!.3 is described in the section on biological control' )he large parabasal bod
that forms in this agent contains a toxin that degranulates solel in the alBaline environment of the
mos2uito midgut' )he advantage of 4t'H!.3 is that an application destros larval mos2uitoes but
spares an entomophagus predators and other non!target species that ma be present' 4t'H!.3
formulations tend to rapidl settle at the bottom of =ater containers# and fre2uent applications are
therefore re2uired' )he toxin is also photolabile and is destroed b sunlight'
$pace spras
$pace spraing involves the application of small droplets of insecticide into the air in an attempt to
Bill adult mos2uitoes' 6t has been the principal method of DFEDHF control used b most countries
in the $outh!%ast &sia Region for 05 ears' Hnfortunatel# it has not been effective# as illustrated b
the dramatic increase in DHF incidence in these countries during the same period'
Recent studies have demonstrated that the method has little effect on the mos2uito population#
and thus on dengue transmission'.1,#.1.#.10 :oreover# =hen space spraing is conducted in a
communit# it creates a false sense of securit among residents# =hich has a detrimental effect on
communit!based source reduction programmes' From a political vie=point# ho=ever# it is a desirable
approach because it is highl visible and conves the message that the government is taBing action'
)his# ho=ever# is a poor Dustification for using space spras'
$pace spraing of insecticides (fogging- should not be used except in an epidemic situation'
Ho=ever# the operations should be carried out at the right time# at the right place# and according to
the prescribed instructions =ith maximum coverage? so that the fog penetration effect is complete
enough to achieve the desired results'
When space spras are emploed# it is important to follo= the instructions on both the
application e2uipment and the insecticide label and to maBe sure that the application e2uipment is
=ell maintained and properl calibrated' Droplets that are too small tend to drift beond the target
area =hile large droplets fall out rapidl' *o""les for ultra!lo= volume ground e2uipment should
be capable of producing droplets in the 5/08 micron range and the mass median diameter should
not exceed the droplet si"e recommended b the manufacturer'
Desirable spra characteristics include a sufficient period of suspension in the air =ith suitable
drift and penetration into target areas =ith the ultimate aim of impacting adult mos2uitoes' Generall#
there are t=o forms of space spra that have been used for &e' aegpti control# namel Lthermal
fogsM and Lcold fogsM' 4oth can be dispensed b vehicle!mounted or hand!operated machines'
91
)hermal fogs
)hermal fogs containing insecticides are normall produced =hen a suitable formulation condenses
after being vapori"ed at a high temperature' Generall# a thermal fogging machine emplos the
resonant pulse principle to generate hot gas (over 0,, VC- at high velocit' )hese gases atomi"e the
insecticide formulation instantl so that it is vapori"ed and condensed rapidl =ith onl negligible
formulation breaBdo=n' )hermal fogging formulations can be oil!based or =ater!based' )he oil!
based (diesel or Berosene- formulations produce dense clouds of =hite smoBe# =hereas =ater!based
formulations produce a colourless fine mist' )he droplet (particle- si"e of a thermal fog is usuall less
than .5 microns in diameter' )he exact droplet si"e depends on the tpe of machine and operational
conditions' Ho=ever# uniform droplet si"e is difficult to achieve in normal fogging operations'
Hltra!lo= volume (HLC-# aerosols (cold fogs- and mists
Hltra!lo= volume (HLC- involves the application of a small 2uantit of concentrated li2uid
insecticides' )he use of less than 3'+ litresEha of an insecticide concentrate is usuall considered as
an HLC application' HLC is directl related to the application volume and not to the droplet si"e'
*evertheless# droplet si"e is important and the e2uipment used should be capable of producing
droplets in the .,/.5 micron range# although the effectiveness changes little =hen the droplet si"e
range is extended to 5/05 microns' )he droplet si"e should be monitored b exposure on )eflon or
silicone!coated slides and examined under a microscope' &erosols# mists and fogs ma be applied
b portable machines# vehicle!mounted generators or aircraft e2uipment'
Q House!to!house application using portable e2uipment; Portable spra units can be
used =hen the area to be treated is not ver large or in areas =here vehicle!mounted
e2uipment cannot be used effectivel' )his e2uipment is meant for restricted outdoor
use and for enclosed spaces (buildings- of not less than .3 m1' Portable application can
be made in congested lo=!income housing areas# multi!storeed buildings# =arehouses#
covered drains# se=age tanBs and residential or commercial premises' Operators can treat
an average of 9, houses per da# but the =eight of the machine and the vibrations caused
b the engine maBe it necessar to allo= the operators to rest ade2uatel and hence t=o
or three operators are re2uired per machine'
Cehicle!mounted fogging; Cehicle!mounted aerosol generators can be used in urban or
suburban areas =ith a good road sstem' One machine can cover up to .5,,/0,,, houses
(or approximatel 9, ha- per da' 6t is necessar to calibrate the e2uipment# vehicle speed
and s=ath =idth (+,/7, m- to determine the coverage obtained b a single pass' & good
map of the area sho=ing all roads is of great help in undertaBing the application'
&dvocac and communication efforts ma be re2uired to persuade residents to cooperate
b opening their doors and =indo=s' )he speed of the vehicle and the time of da of
application are important factors to consider =hen insecticides are applied b ground
vehicles' )he vehicle should not travel faster than .+ Bilometres per hour (Bph- R., miles
per hour (mph-S' )he insecticide should not be applied =hen the =ind speed is greater
than .+ Bph or =hen the ambient air temperature is greater than 09 VC (90 VF-'.11#.13 )he
best time for application is in the earl morning (approximatel ,+,,/,91, hours- or late
afternoon (.8,,/.71, hours-' Details of procedures# timing# fre2uenc of thermal fogging
and HLC space operation are given in &nnex 7'
Performance of fogging machines
%stimates have been made of the average coverage per da =ith certain aerosol and thermal fog
procedures (4ox 01-'
Q
93
4ox 01; &verage coverage per da =ith space spraing procedures
%2uipment
.' Cehicle!mounted cold fogger
0' Cehicle!mounted thermal fogger
1' 4acB!pacB HLC mist blo=er
3' Hand!carried thermal fogger s=ing fog
5' Hand!carried HLC aerosol generators
6nsecticide formulations for space spras
Organophosphate insecticides such as malathion# fenitrothion and pirimiphos methl have been
used for the control of adult &edes vectors' Hndiluted technical grade malathion (active ingredient
75G>- or one part technical grade diluted =ith 03 parts of diesel have been used for HLC spraing
and thermal fogging respectivel' For undiluted technical grade HLC malathion applications from
vehicles# the dosage on an area basis is ,'5 litres per hectare'
&part from the above!mentioned formulations# a number of companies produce prethroid
formulations containing either permethrin# deltamethrin# lambda!chalothrin or other compounds
=hich can be used for space spra applications' 6t is important not to under!dose during operational
conditions' Lo= dosages of prethroid insecticides are usuall more effective indoors than outdoors'
&lso# lo= dosages are usuall more effective =hen applied =ith portable e2uipment (close to or
inside houses- than =ith vehicle!mounted e2uipment# even if =ind and climatic conditions are
favourable for outdoor applications'
Outdoor permethrin applications =ithout a snergist should be applied at concentrations ranging
from ,'5G to .',G# particularl in countries =ith limited resources and a paucit of staff experienced
in routine spraing operations' Regardless of the tpe of e2uipment and spra formulations and
concentrations used# an evaluation should be made from time to time to checB if effective vector
control is being achieved'
6nsecticides suitable as cold aerosols and for thermal fogging for mos2uito control are described
in )able .0'
Possible dail coverage
005 ha
.5, ha
1, ha
5 ha
5 ha or 05, houses
$afet precautions for chemical control
&ll pesticides are toxic to some degree' $afet precautions should therefore be follo=ed' )hese
include care in handling of pesticides# safe =orB practices for those =ho appl them# and their
appropriate use in and around occupied housing' & safet measure for insecticide application is
described in &nnex .,'
95
)able .0; $ome insecticides suitable for cold aerosol or
thermal fog applications against mos2uitoes
Dosage of a'iad (gEha-
6nsecticide
Fenitrothion
:alathion
Pirimiphos!methl
4ioresmethrin
Cfluthrin
Cpermethrin
Cphenothrin
d#d!trans!
Cphenothrin
Deltamethrin
D!Phenothrin
%tofenprox
d!Chalothrin
Permethrin
Resmethrin
Chemical
Organophosphate
Organophosphate
Organophosphate
Prethroid
Prethroid
Prethroid
Prethroid
Prethroid
Prethroid
Prethroid
Prethroid
Prethroid
Prethroid
Prethroid
Cold
aerosols
05,/1,,
..0/+,,
01,/11,
5
./0
./1
0/5
./0
,'5/.',
5/0,
.,/0,
.',
5
0/3
)hermal
fogsae
05,/1,,
5,,/+,,
.9,/0,,
.,
./0
/
5/.,
0'5/5
,'5/.',
/
.,/0,
.',
.,
3
66
666
666
H
66
66
66
*&
66
H
H
66
66
666
WHO ha"ard
classification
of &i
$ource; WHO 0,,+E0' Pesticides and their application for the control of vectors and pests of public health importance' WHOECD$E
WHOP%$EGCDPPE0,,+'.' http;EE=h2libdoc'=ho'intEh2E0,,+EWHOTCD$T*)DTWHOP%$TGCDPPT0,,+'.Teng'pdf
:onitoring and evaluation of space spra
:onitoring and evaluation of space spra is extremel important' &n example of :P% of space spra
and secondar transmission of DFEDHF in an urban area in )hailand is presented in 4ox 03'
6ntegrated control approach
Human societ is divided along socioeconomic# cultural and religious lines and different tpes
of domestic =ater storage practices are evident' :an such practices promote the breeding
of &e' aegpti and &e' albopictus' )his diversit is further multiplied at =orBplaces# i'e' offices#
commercial housesEmarBets# industrial houses# =ater!based manufacturing units# etc' 6n vie= of this
diversit# the intervention tools described earlier should be evidence!based and all control measures
should be suitabl integrated =ith each specific and particular situation or case'
ad a'iI&ctive ingredient? Class 66# moderatel ha"ardous? class 666# slightl ha"ardous? class H# unliBel to pose an acute ha"ard in
normal use? *&; not available' Label instructions must al=as be follo=ed =hen using insecticides'
ae )he strength of the finished formulation =hen applied depends on the performance of the spraing e2uipment used'
9+
4ox 03; %xample of monitoring and evaluation of space spra and secondar transmission
of DFEDHFaf
%valuation of timeliness# coverage and effectiveness of space spra for DFEDHF control =ere
evaluated using the geographical information sstem (G6$- and an attempt =as made to describe
the spatial!time patterns of DFEDHF secondar case' & longitudinal monitoring of DFEDHF cases
and spra activities in $ongBhla municipalit in )hailand =as conducted' &fter a case =as detected#
subse2uent cases occurring =ithin a radius of .,, metres from the venue of the case up to a period
of bet=een .+ and 15 das =ere considered potential secondar cases' Poisson regression =as
used to identif risB factors for the secondar attacB during the period :a 0,,+/&pril 0,,8'
6n the stud period# .3, cases residing in $ongBhla municipalit =ere detected' Of these# 05
=ere potential secondar cases contracted from 0, index cases' Where combine secondar
cases occurred# the mean secondar attacB rate =as 0'8 per .,,, population' Houses in the
neighbourhood of all the index cases =ere spraed# but onl once' )he median lag time of spra
=as .8'1 hours' &verage percentage of the total area spraed =as 5'+G' 6t =as concluded that
space spra in the stud area =as inade2uate and often failed to prevent secondar cases of DFE
DHF' Further investigation =ith a larger sample =as# ho=ever# underscored'
For effective space spra for DFEDHF outbreaB control# increasing the spra area to cover a radius
of .,, metres from the patientAs house and doubling the time of spra at an interval of ever seven
to ten das in addition to a control programme focusing on the houses of the poorer sections of
the communit =as suggested'
)he use of insecticides for the prevention and control of dengue vectors should be integrated
into environmental methods =herever possible' During periods of little or no dengue virus activit# the
routine source reduction measures described earlier can be integrated into the larvicide application
processes in containers that cannot be eliminated# covered# filled or other=ise managed'
For emergenc control to suppress a dengue virus epidemic or to prevent an imminent
outbreaB# a programme of rapid and massive destruction of the &e' aegpti population should be
undertaBen involving both insecticides and source reduction and using the techni2ues described in
these guidelines in an integrated manner'
Preparedness for minimi"ing magnitude of transmission
during seasonal peaBs
)here is an opportunit for targeted dengue control since endemic countries are a=are of their
seasonal peaB dengue transmission periods' %fforts should be made to taBe pre!emptive action to
minimi"e the magnitude of dengue transmission during this period' )hese pre!emptive actions#
focusing on source reduction# should begin as earl as up to four months ahead of the seasonal peaB
to first cover areas demonstrating lo=er to higher risB of dengue transmission' )he areas at higher
risB of dengue transmission should be covered at least a month before the seasonal peaB'ag
&n example of such a preparedness programme in $ingapore is presented in 4ox 05'ah
af $u=ich )' et al'; $pace $pra and $econdar )ransmission of DFEDHF in an Hrban &rea# $outhern )hailand' (:anusript-
ag For additional information refer to section on MOutbreaB ResponseM in the &sia!Pacific Dengue $trategic Plan (0,,9/0,.5- and
Chapter .1 of this document'
ah $ource; *ational %nvironment &genc# $ingapore# 0,,7'
98
4ox 05; Preparedness programme in $ingapore
)o reduce dengue transmission $ingapore has adopted an integrated evidence!based approach'
)his comprises vector surveillance and control# intersectoral collaboration# public education and
communit outreach# la= enforcement and research' )he approach is revie=ed periodicall to
ensure its relevance and effectiveness in addressing ne= challenges =hich arise from a number
of factors including changing dengue serotpes# &edes mos2uito adaptation# transboundar
transmission# lo= herd immunit# increasing population densit and rapid urbani"ation'
4efore to the beginning of each ear# areas at potential risB for dengue outbreaBs are identified
for intensive source reduction exercises (6$R%- to be conducted t=o months before the traditional
dengue season# =hich falls bet=een :a and October' 4ased on this risB assessment# resources
for vector control operations are deploed in a targeted manner to achieve maximum impact'
6n addition to the 6$R%# through intersectoral collaboration the various land agencies =ill also be
alerted to conduct intensive source reduction exercises on their properties' )he public is also
regularl reminded about the need for preparedness against dengue through outreach initiatives
on different local media and through communit events at the grassroots level' )his helps to Beep
the subDect of dengue fresh and the public on alert'
4 taBing a proactive stance =ith a preparedness programme# this integrated evidence!based
approach has been successful in curbing the spread of dengue in $ingapore' )he dengue situations
in 0,,9 and 0,,7 have sho=n do=n=ard trends; from 8,1. cases in 0,,9 to 3378 in 0,,7' )his
is in sharp contrast =ith a high of .3 0,7 cases reported during $ingaporeAs =orst ever dengue
outbreaB in 0,,5' )his is the first time in three decades that such a do=n=ard trend has been
observed in $ingapore not=ithstanding the global surge in dengue cases'
7'3 Geographical information sstem for planning#
implementation and evaluation
)he geographical information sstem (G6$- is an automated computer!based sstem =ith the abilit
to capture# retrieve# manage# displa and analse large 2uantities of spatial and temporal data in
a geographical context' )he sstem comprises hard=are (computer and printer-# soft=are (G6$
soft=are-# digiti"ed base maps# information and a =hole set of procedures such as data collection#
management and updating'
$pecific diseases and public health resources can be mapped in relation to their surrounding
environment and existing health and social infrastructures' $uch information =hen mapped together
creates a po=erful tool for monitoring and management of disease' G6$ provides a graphical analsis
of epidemiological indicators over time# captures spatial distribution and severit of the disease#
identifies trends and patterns# and indicates if and =here there is a need to target extra resources'
Carious potential usages and constraints of G6$ for dengue control =ere described b a $cientific
WorBing Group on Dengue in 0,,+'.15
Potential usages of G6$ technolog in dengue control programme
G6$ technolog could be used to improve dengue control programmes in the follo=ing =as;
Q G6$ technolog improves the abilit of programme staff# planners# decision!maBers and
researchers to organi"e and linB datasets (e'g' b using geocoded addresses# geographical
boundaries or location coordinates- from different sources'
99
Q G6$# global positioning sstem (GP$- and remote sensing (R$- technologies provide dengue
programme staff =ith additional tpes of data such as latitude!longitude coordinates for
locations of breeding sites# and cases and transmission sources according to house lot#
blocB and neighbourhood' Digital imager from satellites and aerial photographs provide
additional details to the map and improve the accurac of the information'
G6$ technolog encourages the formation of data partnerships and data sharing at the
communit level'
$patial analsis capabilit of G6$ (distance# proximit# containment measures- can be used
to improve entomologicalEvector control activities and interventions such as focal treatment#
and to search for and destro transmission sources'
G6$ technolog enables =orB on multiple scales in space and other dimensions (time#
individual and aggregated data-'
G6$ capabilities for spatial and spatial/temporal statistical analsis can improve the
information sstem b providing better support to planning# monitoring# evaluation and
decision!maBing in the dengue control programme'
G6$ capabilit allo=s for snthesi"ing and visuali"ing information in maps'
Q
Q
Q
Q
Q
Constraints of G6$ technolog in the context of dengue control
$ome of the constraints of G6$ technolog from the dengue control programme perspective are
mentioned belo=;
Q
Q
G6$ technolog is not et a common tool in vector control programmes' 6n fact# fe= G6$
applications can be found for the control of dengue and other vector!borne diseases'
&ccurate# lo=!cost street maps and other cartographic databases such as of neighbourhood#
blocB and house lot boundaries are essential for dengue control programmes' $ome of
these maps can be accessed through the 6nternet'
Professionals# planners# technicians and especiall stateEdepartmentalEprovincial and local
dengue control programme staff need training and user support in G6$ technolog# data and
epidemiological methods in order to use the technolog appropriatel and effectivel'
)he cost of commercial G6$ soft=are is a barrier to extending the use and development of
G6$ applications in public health and# particularl# in dengue control programmes' Ho=ever#
in recent times# more G6$ soft=are# =hich could be accessed at no cost# is becoming
increasingl available through the 6nternet'
Q
Q
Field applications of G6$ for dengue control; Case studies
Hse of G6$ for dengue control in $ingapore
Q Ovitraps are used extensivel in $ingapore.1+ as a tool to monitor# detect and control &edes
populations' )he give an approximate measure of the adult population in an area and
act as an earl =arning signal to pre!empt an impending dengue outbreaBs' & G6$ =as
established in .779 to develop a real!time &edes mos2uito control and monitoring sstem
for spatial epidemiological stud'
)he G6$ monitors the net=orB of 0,,, ovitraps placed island!=ide to better understand
vector trends and disease patterns' &nalsis is done on the ovitrap breeding data collected
=eeBl to identif hotspots and risB areas =here there is a danger of high &e' aegpti
infestation' )hree ovitrap models have been developed to analse the ovitrap breeding
data' )he analsis results are used to plan vector surveillance and control operations'
$ubse2uentl# an improved approach of G6$ =as applied that included spatial identification
97
of Lhot spotsM b using hand!held terminals (HH)- for collection of field surveillance data
in the field itself#.18 unliBe the previous approach of collecting information on paper forms
in the field and then feeding the same into the computer for analsis'
Q Currentl# $ingapore uses G6$ in its dengue surveillance and control programme to process#
map and analse huge amounts of epidemiological# entomological and environmental
data'.19 & full automated dengue model is run dail using G6$ to conduct spatial and
temporal analsis of the dengue cases (Figure .3-' With this information# s=ift vector control
action can be taBen to prevent further dengue transmission =ithin the affected area'
Figure .3; Densit mapping of dengue cases in $ingapore
$ource; *ational %nvironment &genc# $ingapore# 0,,7'.17
)hrough the use of G6$# the distribution of &edes mos2uitoes breeding# dengue cases# dengue
serotpes and environmental factors such as construction sites# vacant premises and congregation
areas could be monitored and analsed' RisB assessment is conducted to develop areas of potential
risB for dengue outbreaBs based on the principles of dengue epidemiolog and &edes ecolog and
behaviour'
)aBing into consideration the predominant serotpe and the populationAs past exposures to
that serotpe# the areas identified as having relativel higher epidemic potential are marBed out as
Lfocus areasM (Figure .5-' :ore resources and intensive vector control =ill be carried out in these
Lfocus areasM# and this information assists the programme managers in their deploment of scarce
resources in accordance =ith the risBs and operational needs'
7,
Figure .5; Focus areas identified using G6$ to prioriti"e resource allocation
for dengue surveillance
Coupled =ith the timel availabilit of information# G6$ has been found useful for planning
vector control operations# and managing and deploing resources for dengue control (Figure .+-'
Figure .+; Planning# managing and deploing resources for vector control operations using G6$
7.
&lert sstem for informing environmental risB of dengue infections
)he LOvitrap 6ndexM has been in use in man countries' )his is a measurement of mos2uito eggs in
specified geographical locations# =hich in turn reflects the distribution of &edine mos2uitoes# the
vector for dengue' Hsing G6$ application# an alert sstem =as created from a snthesis of geospatial
data on ovitrap indices in Hong Jong' )he inter!relationship bet=een ovitrap indices and temperature
=as established' )his forms the rationale behind the generation of =eighted overlas to define risB
levels' )he =eighting could be controlled to set the sensitivit of the alert sstem'
)his sstem can be operated at t=o levels; one for the general public to assist the evaluation of
dengue risB in the communit and the other for professionals and academia in support of technical
analsis' )he alert sstem offers one obDective means to define the risB of dengue in a societ# =hich
=ould not be affected b the incidence of the infection itself'ai
Dengue spatial and temporal patterns# French Guiana# 0,,.
)o stud a 0,,. dengue fever outbreaB in 6racoubo# French Guiana# the locations of all patientsA
homes =ere recorded along =ith the dates =hen smptoms =ere first observed' & G6$ =as used to
integrate the patient!related information' )he Jnox test# a classic space!time analsis techni2ue# =as
used to detect spatiotemporal clustering' &nalsis of the relative!risB (RR- variations =hen space and
time distances differed highlighted the maximum space and time extent of a dengue transmission
focus'
)he results sho=ed that heterogeneit in the RR variations in space and time corresponds to
Bno=n entomological and epidemiological factors such as the mos2uito feeding ccle and host!
seeBing behaviour' )his finding demonstrates the relevance and potential of the use of G6$ and
spatial statistics in elaborating a dengue fever surveillance strateg'.3,
ai $"e W'*'# Nan L'C'# J=an L':'# $han L'$'# Hui L'' &n alert sstem for informing environmental risB of dengue infections'
http;EE==='iseis'cuhB'edu'hBEengEresearchEcompletedEalertTsstem'pdf
70
.,' 6ntegrated Cector :anagement
(6C:-
.,'. Genesis and Be elements
:aDor mos2uito!borne diseases in the WHO $outh!%ast &sia Region include malaria# dengue#
lmphatic filariasis# Kapanese encephalitis and Bala a"ar' %ach :ember countr in the past decades
had a national control programme for each disease' $ubse2uentl it =as reali"ed that due to various
technical and operational issues these did not turn out to be cost!effective and that these lacBed
the coordination and focus re2uired to achieve the expected outcomes' Countries then s=itched
over to the national vector borne disease programmes# since this =as not onl more cost!effective
and efficient but also gave the freedom to programme managers to utili"e allocated funds as per
the re2uirements to control a particular disease' Resurgence of malaria# dengue and other vector!
borne infections highlighted the need for planning control activities at the micro level on the basis
of ecoepidemiological tpes# =hich inter alia re2uired the use of old and ne= proven technologies
in tandem'
6n 0,,3# WHO published the Global $trategic Frame=orB for 6ntegrated Cector :anagement'.3.
6ntegrated Cector :anagement (6C:- entails the use of a range of vector control interventions of
proven efficacies through collaborations =ithin the health sector and =ith other sectors# namel the
environment# education# public =orBs department# agriculture and others' $uch intersectoral and
interprogrammatic approaches improve the efficac# cost!effectiveness# ecological soundness and
sustainabilit of disease!vector control'
)he application of more than one evidence!based or selective intervention in an integrated
manner# competent public health legislation# and a sound pesticide management polic are integral
to 6C:' )hrough evidence!based decision!maBing# 6C: rationali"es the use of human and financial
resources and organi"ational structures for the control of vector borne disease and emphasi"es the
engagement of communities to ensure sustainabilit'
)he characteristic features of 6C: include;
Q
Q
Q
Q
Q
methods based on Bno=ledge of local vector biolog# disease transmission and
morbidit?
use of a range of interventions# often in combination and snergisticall?
collaboration =ithin the health sector and =ith other public and private sectors that
impact vector breeding?
engagement =ith local communities and other staBeholders? and
a public health regulator and legislative frame=orB'
)he Be elements of 6C: are described in 4ox 0+'
71
4ox 0+; )he Be elements of 6C:
.' &dvocac# a=areness generation# social mobili"ation and legislation;
Q
Q
Promotion and embedding of 6C: principles in the development policies of all relevant
agencies# organi"ations and civil societ'
%stablishment of or bolstering regulator and legislative controls for public health
to ensure access to necessar services and health information and communication
materials'
%mpo=erment of communities and their active participation for advocating local polic
changes# resolution of demand!side issues and challenges and inculcating appropriate
practices for long!term prevention and control'
Consideration of all options for collaboration =ithin and bet=een public and private
sectors# =hich should be optimal and necessar in times of high alert'
&pplication of the principles of subsidiarit in planning and decision!maBing'
*ecessar capacit!building of partners to address health e2uit# surveillance# control
and prevention of vector!borne diseases'
$trengthening channels of communication among polic!maBers# managers of vector!
borne disease control programmes and other 6C: partners'
:obili"ation of additional resources# especiall at the local levels'
%nsuring the rational use of available resources through the application of a
multidisease!control approach'
6ntegration of non!chemical and chemical vector!control methods'
6ntegration =ith other disease!control measures'
%stablishment of specific integrated bodiesEmechanisms to ensure rapid responseE
action to tacBle an outbreaB or epidemic'aD
&dapting strategies and interventions to local vector ecolog# epidemiolog and
resources'
Guidance b operational research and routine monitoring and evaluation'
6nformation management and research evidence to introduce and advocate for polic
change' Local authorities# polic!maBers and planning officers should be involved in
information management to build o=nerships and sustainable response'
Developing essential phsical infrastructure'
Financial resources and ade2uate human resources at the national and local level to
manage 6C: programmes based on situation analsisEneeds assessments'
Q
0' Collaboration =ithin the health sector and =ith other sectors;
Q
Q
Q
Q
Q
1' 6ntegrated approach;
Q
Q
Q
Q
3' %vidence!based decision!maBing;
Q
Q
Q
5' Capacit!building
Q
Q
aD & LDisease Control )asB Force led b communitEarea!based CDCM? a LHealth promotion and preventive medicine unit in the
Primar Health Care HnitM? a LCommunit )asB ForceM led b full participation of people =ho are empo=ered =ith technical
support from the health sectors? a Lcommunit surveillance mechanismM =hich can be used in other health alert sstems as an
integral part of vector!borne disease control'
73
)he $%& Regional 6C: $trateg recommended 6C: approval for malaria# dengue and Bala
a"ar control'.30 )his =as prompted b promising results achieved in malaria control in $ri LanBa b
empo=ering communities through the involvement of LFarmersA Field $choolsM'.31
.,'0 &pproach
)he urban and peri!urban eco!epidemiological paradigm is home to vectors of dengue and
chiBunguna# =here the proliferate in diverse tpes of =ater!storage containers both indoors and
outdoors (see Chapter 9-'
)he 6C: approach for dengue control is a classic example of multiple disease control# thus
maBing control of three infections (namel' dengue# chiBunguna and urban malaria- possible in a
most cost!effective manner'aB For example# in the 6ndian subcontinent# urban malaria transmitted
b &nopheles stephensi is also endemic' &n' stephensi# also being a container habitat species# shares
breeding sites =ith &e' aegpti'
Ho=ever# the urban disease control programme suffers from lacB of; (i- social mobili"ation of
communities? (ii- intersectoral coordination? (iii- public health infrastructure (especiall experts in
vector ecolog for mapping of breeding sites and for selection of appropriate mix of interventions-?
(iv- capacit!building? (v- administrative# financial and logistic support? and (vi- monitoring and
evaluation'
Over the last fe= decades# efforts to promote communit!oriented activities for dengue control
in an 6C: mode have increased' & comprehensive revie= of communit!based programmes for
dengue control.33 =as carried out' )he revie= found a tangible need to strengthen such programmes'
)he essential steps to improve the outcome and sustainabilit of control activities on a long!term
basis are described belo='
Communit participation
Communit participation has been defined Las a process =hereb individuals# families and
communities are involved in the planning and conduct of local vector control activities so as to ensure
that the programme meets the local needs and priorities of the people =ho live in the communit#
and promotes the communitAs self!reliance in respect to developmentM'.35 6n short# communit
participation entails the creation of opportunities that enable all members of the communit and
extended societ to activel contribute to it# influence its development# and share e2uitabl the
fruits of accrued benefits' )he obDectives of communit participation in dengue prevention and
control are to;
Q
Q
Q
Q
Q
%xtend the coverage of the programme to the =hole communit b creating communit
a=areness' )his# ho=ever# often re2uires intensive inputs'
:aBe the programme more efficient and cost!effective# =ith greater coordination of
resources# activities and efforts pooled b the communit'
:aBe the programme more effective through Doint communit efforts to set goals# obDectives
and strategies for action'
Promote e2uit through the sharing of responsibilit# and through solidarit in serving those
in greatest need and at greatest risB'
Promote self reliance and self!care among communit members and increase their sense
of control over their o=n health and destin'
aB :ore details can be seen in the Report of the WHO Consultation on 6ntegrated Cector :anagement# Geneva# ./3 :a 0,,8'.3+0
75
Communit participation approaches
Q 4 sho=ing concern; Communit and government organi"ers should reflect true concern
for human suffering# i'e' in this case morbidit and mortalit due to dengue in the countr#
economic loss to families and the nation on account of it# and ho= the benefits of the
dengue prevention and control programme fit into the peopleAs needs and expectations'
6nitiating dialogue; Communit organi"ers and opinion leaders or other Be personnel
in the po=er structure of the communit# namel =omenAs groups# outh groups and
civic organi"ations# should be identified' Dialogue should be carried out through
personal contacts# group discussions and filmEaudiovisual sho=s# etc' 6nteraction should
generate mutual understanding# trust and confidence# enthusiasm and motivation' )he
interaction should not be a one!time affair but should be a continuing dialogue to achieve
sustainabilit'
Creating communit o=nership; Organi"ers should use communit ideas and participation
to initiate the programme# communit leaders to assist the programme# and communit
resources to fund the programme' )he partnership of the communit =ith mos2uito
control and abatement agencies should be strong and the latter should provide technical
guidance and expertise'
Health education (H%-; Health education should not be based on telling people the doAs
and donAts through a vertical# top!do=n communication process' 6nstead# health education
should be based on formative research to identif =hat is important to the communit
and should be implemented at three levels# i'e' the communit level# the sstems level
and the political level'
Communit level; People should not onl be provided =ith Bno=ledge and sBills on vector
control# but relevant educational material should empo=er them =ith the Bno=ledge that
allo=s them to maBe positive health choices and gives them the abilit to act individuall
and collectivel' & participator approach in communit health communication is
imperative'
$stems level; )o enable people to mobili"e local action and social forces beond a single
communit# i'e' health# development and social services'
Political level; :echanisms must be made available to allo= people to articulate their
health priorities to political authorities' )his =ill facilitate placing vector control high on
the priorit agenda and effectivel lobb for suitable policies and actions'
Defining communit actions; )he follo=ing communit actions are essential to sustain
DFEDHF prevention and control programmes;
/ &t the individual level# encourage each household to adopt routine health measures
that =ill help in the control of DFEDHF# including source reduction and implementation
of proper personal protection measures'
&t the communit level# organi"e Lclean!upM campaigns t=o or more times a ear to
control the larval habitats of the vectors in public and private areas of the communit'
$ome Be factors for the success of such campaigns include; extensive publicit via
media!mix including audiovisuals# posters# pamphlets# etc'? and proper planning# pre!
campaign evaluation of foci# execution in the communit as promised# and follo=!up
evaluations' Participation b municipalEpublic sector sanitation services and agencies
should be ensured'
Where communit!=ide participation is difficult to arrange for geographical# occupational
or demographic reasons# arrange communit participation through nongovernmentalE
voluntarEcommunit!basedEfaith!based associations and organi"ations' )he people
in these organi"ations ma interact dail at =orB or institutional settings# or come
Q
Q
Q
Q
Q
Q
Q
/
/
7+
together for special purposes# i'e' religious activities# civic clubs# =omenAs groups and
schools# etc'
/
/
%mphasi"e school!based programmes targeting children and parents to eliminate vector
breeding at home and at school'
Challenge and encourage the private sector to participate in the beautification and
sanitar improvement of the communit as sponsors# emphasi"ing source reduction
of dengue vectors'
Combine communit participation in DFEDHF prevention and control =ith other
priorities of communit development' Where services such as refuse collection# =aste
=ater disposal# provision of potable =ater# etc' are either lacBing or inade2uate# the
communit and its partners can be mobili"ed to improve such services and at the
same time reduce the larval habitats of &edes vectors as part of an overall effort at
communit development'
Combine dengue vector control =ith the control of all species of disease!bearing
and nuisance mos2uitoes as =ell as other vermin# to ensure greater benefits for the
communit# and conse2uentl greater participation in neighbourhood campaigns'
&rrange novel incentives andEor service recognition programmes for those =ho
participate in communit programmes for dengue control' For example# a nation=ide
competition can be promoted to identif the cleanest communities or those =ith the
lo=est larval indices =ithin an urban area'
/
/
/
Over the ears# communit participation in controlling dengue vector is being increasingl
applied in man countries' 4ox 08 illustrates an example of ho= dengue prevention and control
in 6ndonesia has evolved from a vertical# government!controlled programme to a more hori"ontal#
communit!based approach'
:odel development
Development of a model for dengue control through the communit participation approach should
be initiated in order to define potential prime!movers in the communities and to stud =as to
persuade them to participate in vector control activities' $ocial# economic and cultural factors that
promote or discourage the participation of these groups should be intensivel studied to enhance
participation from the communit' :apping of communit resources and infrastructure phsicall and
sociall =ould help shape up the model development for dengue control' :apping =ill also identif
Be change agents that mobili"e communities to change their behaviour to=ards and compliance
of vector!borne disease control'
Different models in different settings should be applied;
Q
Q
6n rural areas# =here an acute sense of communit exists# communit participation is needed
and has to be encouraged in addition to training and capacit!building'
6n urban and semi!urban areas# civil societ groups# nongovernmental organi"ations and
municipalities can act as prime movers for change and need to be mobili"ed to involve
the communit'
:odel development focusing on schoolchildren has been studied in several countries (4ox 09-
and this strateg should be modified and introduced in each countr'
78
4ox 08; e)ogether PicBetA; Communit activities in dengue source reduction in Pur=oBerto
cit# Central Kava# 6ndonesia.3+
6n Pur=oBerto# Central Kava# 6ndonesia# a partnership has been established bet=een the local
government# the Rotar Club# the Famil Welfare %mpo=erment Organi"ation (PJJ-# and
municipal health services' Leadership and commitment from these partners# =ith strong technical
support from the *ational Health Research Department# has enabled the development of an
effective communit!based integrated vector control proDect in Pur=oBerto# =hich has a population
of 00, ,,,'
)his proDect operates at the level of neighbourhood associations' %ach neighbourhood
consists of bet=een 05 and 5, households' Within each neighbourhood# houses are grouped into
sets of .,# called Ldasa=ismaM' %ach dasa=isma has a leader# usuall a =oman cadre from the
PJJ# trained in DFEDHF prevention and control' )he leader is Bno=n as the Lsource reduction
cadreM' Hsuall# being besto=ed this title itself is an honour to be proud of' %ach dasa=isma gets a
Lsource reduction BitM containing a flashlight (for checBing for the presence of larva in containers
stored in darB areas-# simple record forms# and a health education booBlet' )he dasa=isma arrange
schedules =ithin =hich one house inspects the other nine houses' Jno=n as LPiBet 4ersamaM
(LPicBet )ogetherM-# these house!to!house inspections are conducted on a =eeBl basis so that
each household taBes its turn ever ., =eeBs'
)he dasa=isma leader collects the =eeBl record forms and reports the results to the next
administrative level' )he success of this proDect can be measured b the reduction in the House
6ndex from 0,G before activities began to 0G once the activities =ere on a roll' )his proDect has
no= been expanded to .3 cities in 6ndonesia through grants from the Rotar 6nternational and
CDC# Colorado'
4ox 09; Health education in elementar school.38
& child!focused approach to dengue prevention and control has been an important component
of a broader public health programme in Puerto Rico since .795' )he highlights include health
education in elementar schools =ith collaboration bet=een the departments of Health and
%ducation# among other initiatives'
6n elementar schools# an activit booBlet =as developed that contained 09 activities about
dengue and its prevention and =as accompanied b a guide to aid teachers in the presentation of
the various activities' &fter several ears of use and follo=ing suggestions from teachers and external
programme revie=ers# the booBlet and teacherAs guides =ere revised' %ach ear# an estimated
5, ,,, fourth!grade students use the booBlet in their social studies classes and it has no= been
incorporated into the public school curriculum' &n important aspect of this programme has been
the provision of training programmes for teachers# school nurses and school nurse supervisors b
staff of the Center for Disease Control and Prevention# Puerto Rico'
$ocial mobili"ation
&dvocac meetings should be conducted for polic!maBers for garnering political commitment
to mass clean!up campaigns and environmental sanitation' 6ntersectoral coordination meetings
should be conducted to explore possible donorsEpartners for mass antilarval control campaigns and
79
measures and to help finance the programme' Reorientation training of health =orBers should be
conducted to improve their technical capabilit# and their abilit to supervise prevention and control
activities' & LDFEDHF monthM should be identified t=ice a ear# during the pre!transmission and
peaB transmission period'
Health education
Health education is ver important in achieving communit participation' 6t is a long!term process
to achieve human behavioural change# and thus should be carried out on a continuous basis'al
)hough countries ma have limited resources# health education should be given priorit in endemic
areas and in areas at high risB for DFEDHF' Health education is conducted through the channels of
interpersonal communication# group educational activities# mid!media activities such as =all =riting#
and mass media broadcasts'
Health education can be implemented b =omenAs groups# school teachers# formal and informal
communit leaders# and health =orBersEvolunteer net=orBs' Health education efforts should be
intensified before the period of dengue transmission as one of the components of social mobili"ation'
)he main target groups are school children# =omen and other LinfluencersM at the communit level
in addition to the communit in general'
6ntersectoral coordination
Developing economies in the $outh!%ast &sia Region have identified man social# economic and
environmental problems that promote mos2uito breeding' )he dengue control issue thus exceeds the
capabilities of the ministries of health' )he prevention and control of dengue re2uires collaboration
and partnerships bet=een the health and non!health sectors (both government and private-#
nongovernmental organi"ations (*GOs- and local communities'
During epidemics such cooperation becomes even more critical since it re2uires the pooling
of resources from all groups to checB the spread of the disease' 6ntersectoral cooperation involves
at least t=o components;
Q
Q
Resource sharing'
Polic adDustments and activities among various ministries and nongovernment sectors'
Resource sharing;
Resource sharing should be sought =herever the dengue control coordinator can maBe use of
underutili"ed human resources# e'g' for local manufacture of re2uired tools# seasonal government
labourers for =ater suppl improvement activities# or communit and outh groups to clean up
discarded tres and containers in neighbourhoods'
)he dengue control programme should seeB the accommodation or adDustment of existing
policies and practices of other ministries# sectors and municipal governments to incorporate public
health as a central focus of their goals' For instance# the public =orBs sector could be encouraged
to accord first priorit to =ater suppl improvements for communities at the highest risB of dengue'
6n return# the :inistr of Health could consider authori"ation of the use of some of its field staff
to assist the ministr responsible for public =orBs to repair =ater suppl and se=erage sstems# as
appropriate'
al Refer to Chapter .0 for additional details (Communication for 4ehavioural 6mpact- on responsive behaviour =ithin an enabling
environment'
77
&ctivities b government ministriesEdepartments and *GOs
)he role of the ministr(ies-Edepartment(s-Emunicipalities responsible for
public =orBsEroads and the buildings sector;
)he Be roles to be performed b these sectors pertaining to dengue prevention and control include;
reduction at source (storage containers- b providing a safe and dependable =ater suppl# ade2uate
sanitation# and effective solid =aste management' 6n addition# through the adoption and enforcement
of housing and building codes a municipalit ma mandate the provision of utilities such as individual
household piped =ater supplies or se=erage connections and rain=ater (storm =ater- run!off control
for ne= housing developments# or forbid open surface =ells as =ell as formulate or update public
health b!la=s' During the construction of roads and buildings# efforts need to be made to merge
pits b breaBing bunds# maBing excavations in line =ith the natural slope or gradient and maBing
arrangements for the =ater to flo= into natural depressions# ponds or rivers' Follo=!up action after
each excavation is also critical'
)he role of the ministrEdepartment responsible for =ater suppl;
)he Be roles for this ministrEdepartment pertaining to dengue prevention and control include;
repair of leaBages to prevent pooling of =ater# restoration of taps# diversion of =aste =ater to pondsE
pits# staggering of =ater suppl# mos2uito!proofing of =ater harvesting devices and repair of sluice
valves'
Role of the ministrEdepartment responsible for urban development;
)he Be roles for this ministrEdepartment pertaining to dengue prevention and control include;
implementation of building b!la=s# improved designs to avoid undue =aterlogging# securing correct
building use permission after clearance b the health department'
Role of the ministrE department responsible for education;
)he :inistr of Health should =orB closel =ith the :inistr of %ducation to develop a health
education (health communication- component targeted at schoolchildren that =ill design and
communicate appropriate health messages' Health education models can be Dointl developed#
tested# implemented and evaluated for various age groups'
Research programmes in universities and colleges can be encouraged to include components
that produce information of direct importance (e'g' vector biolog and control# case management- or
indirect importance (e'g' improved =ater suppl# educational interventions to promote communit
sanitation# =aste characteri"ation studies- to dengue control programmes'
Role of the ministrEdepartment responsible for environmentEforests;
)he :inistr of %nvironment can help the :inistr of Health collect data and information on
ecosstems and habitats in or around cities at high risB of dengue' Data and information on local
geolog and climate# land usage# forest cover# surface =ater and human populations are useful in
planning control measures for specific ecosstems and habitats'
)he :inistr of %nvironment ma also be helpful in determining the beneficial and adverse
impacts of various &e' aegpti control tactics (chemical# environmental and biological-' )hese ma
include appropriate environment management policies and pesticide management policies' Other
roles could be the reclamation of s=amp areas and social forestr'
.,,
Role of the ministrEdepartment responsible for information# communication
and mass media;
6nformation directed at the communit at large is best achieved through the mediaEchannel!mix#
including such mass media as television# radio and ne=spapers' )herefore# the ministr responsible
for information# communication and the mass media should be approached to coordinate the release
of messages on the prevention and control of dengue developed b public health specialists'
Role of the ministrEdepartment responsible for =ater resources;
)he Be roles for this ministrEdepartment pertaining to dengue prevention and control include
development and maintenance of a canal sstem# intermittent irrigation# design modifications and
lining of canals# =eeding for proper flo=# creating small checB!dams a=a from human settlements
and health impact assessment (H6&-'
Role of the ministrEdepartment responsible for industrEmining;
improving drainageEse=erage sstems# safe disposal of solid =asteEused containers# mos2uito!
proofing of d=ellings# safe =ater storageEdisposal and use of 6)*E LL6*' Other roles ma include;
RPD in relation to the development of ne=# safer and more effective insecticidesEformulations# and
promoting safe use of public health pesticides'
Role of the ministrEdepartment responsible for agriculture;
)he Be roles for this ministrEdepartment pertaining to dengue prevention and control include the
utili"ation of FarmersA Field $chools to implement 6C:# populari"ing the concept of dr!=et irrigation
through extension education# and pesticide management'
Role of the ministrEdepartment responsible for fisheries;
institutional helpEtraining in mass production of larvivorous fish# and the promotion of composite
fish farming schemes at the communit level'
Role of the ministrEdepartment responsible for rail=as;
)he Be roles for this ministrEdepartment pertaining to dengue prevention and control include proper
excavations# maintenance of ards and dumps and anti!larval activities =ithin their Durisdiction# and
H6& for health safeguards'
Role of the ministrEdepartment responsible for remote sensingEG6$;
)he Be roles =ith regard to remote sensing and G6$ pertaining to dengue prevention and control
include technical support and training in mapping environmental changes and disease risBs using
G6$'
Role of the ministrEdepartment responsible for planning;
the active involvement of health authorities at the planning stage for H6& and the incorporation of
appropriate mitigating actions in development proDects'
.,.
Role of nongovernmental organi"ations (*GOs-;
*GOs can pla an important role in promoting communit organi"ation and mobili"ation for
implementing environmental management for dengue vector control and to improve health!seeBing
behaviour' )his =ill most often involve health education# source reduction and improvement of
housing related to vector control' Communit *GOs ma be informal neighbourhood groups or
formal private voluntar organi"ations# service clubs# churches or other religious groups# as =ell as
environmental and social action groups'
&fter ade2uate training on source reduction methods is provided b the :inistr of Health staff#
*GOs can contribute activel b collecting discarded containers (tres# bottles# tins# etc'-# cleaning
drains and culverts# filling depressions# removing abandoned cars and roadside DunB# and distributing
sand or cement to fill tree holes' *GOs ma pla a Be role in developing a regimen of reccling
activit to remove discarded containers from ards and streets' $uch activities must be coordinated
=ith the environmental sanitation service'
*GOs ma also be able to pla a specific# but as et not full explored# role in environmental
management during epidemic control' With guidance from the :inistr of Health# *GOs could
concentrate on the phsical control of locall identified# Be breeding sites such as =ater drums#
accumulated =aste tres and cemeter flo=er vases' )he *GOs can be involved in village!level
training# distribution of 4CCE6%C materials# and 6)* promotion and distribution'
Clubs such as Rotar 6nternational have supported DFEDHF prevention and control programmes
in the &merican Region for over .5 ears' 6n &sia and the Pacific# programmes have been initiated
b them in $ri LanBa# Philippines# 6ndonesia and &ustralia to provide economic and political support
for successful communit!based campaigns' & ne= grant from the Rotar Foundation has been made
to stud the possibilit of upscaling this proDect to a global programme'
WomenAs clubs and associations in man countries have contributed to &e' aegpti control
b conducting household inspections for foci and carring out source reduction' )here are man
opportunities# mostl untapped# for environmental organi"ations and religious groups to pla similar
roles in &e' aegpti!infested communities'
Legislative support
Legislative support is essential for the success of dengue control programmes' :an countries in the
$%& Region have formulated and enacted legislation to address the control of epidemic diseases
=hich authori"e health officers to taBe necessar action =ithin the communit for the control of
epidemics' $ome municipalitiesElocal governments have also adopted legislative provisions related
to dengue control'
&ll :ember countries of the $%& Region are signatories to the 6nternational Health Regulations
(6HR- 0,,5' )hese Regulations have a specific provision for the control of &e' aegpti and other
disease vectors at seaEairEland entr points'
)he formulation of legislation on dengueE&e' aegpti control should taBe into consideration
the follo=ing points;
Q
Q
Legislation should be a necessar component of all dengueE&e' aegpti prevention and
control programmes' Dengue should be made a notifiable disease'
Legislation should cover all aspects of environmental sanitation in order to effectivel
contribute to the prevention of all transmissible diseases and should aim at developing
human resources =ithin the institutional frame=orB' 6n countries =here sanitar regulations
are primaril the responsibilit of agencies other than the :inistr of Health# there should
be coordinated plan of action =ith all the ministries and agencies concerned'
.,0
Q Legislation should contemplate intersectoral coordination among the ministries involved in
national development in order to prevent isolated implementation of individual programmes
and the triggering of harmful environmental changes that could create potentiall ha"ardous
public health conditions' :inistries should be advised on the best =as to encourage
disease prevention'
.,'1 6C: implementation
6C: implementation should thus begin =ith situational analsis (epidemiological# entomological#
insecticide resistance status# pesticide management# polic frame=orBs- and vector control needs
assessment (related to health public polic# and technical# financial and operational needs-' )he
next maDor steps are setting goals and obDectives# selecting priorit diseases for integrated action#
appropriate decision!maBing regarding the application of 6C: and choosing appropriate interventions#
stratification of targeted area(s- RmacroEmicro!stratification b paradigms# terrainEaccessibilit#
epidemiological# entomological# ecological and socio!anthropological factors# development activities
and drug!resistance areasS'
Further implementation steps should include advocac and intersectoral collaboration =ithin
health and other sectors? communication and social mobili"ation using the CO:46 approach?am
capacit!building and training that improves vector control Bno=ledge and sBills? and building
institutional capacit as =ell as facilitating capacit!building of other sectors'.39
.,'3 6C: monitoring and evaluation
:onitoring and evaluation are essential components of 6C:' :onitoring measures the implementation
of its range of activities (the process-# =hile evaluation measures the extent to =hich direct outcomes
have been achieved' 6mpact assessment determines the effects or the impact attributable to the
programme' )he inputs and processes re2uired to deliver each activit or intervention# and their
relative contribution to the overall impact# must be assessed for effectiveness# cost!effectiveness
and sustainabilit in a given situation' Regular supportive supervision =ith a standardi"ed checBlist
should be an important element'
& sound monitoring and evaluation sstem involving suitable input# process# output# outcome#
impact indicators and targets should be set as per local re2uirements# especiall in the case of
communit empo=erment and multisectoral action' )he involvement of partners and communit
representatives in participator evaluation is important because it increases programme o=nership
and has the potential to generate data on behavioural# social and political changes that =ould be
difficult to obtain through intervie=s'
Operational research should also be a priorit' & number of issues =ill need scientific
examination to develop feasible# cost!effective# sociall acceptable and thus sustainable interventions
for each local eco!epidemiological settingEstratum' :onitoring and evaluation can be considered
a part of operational research in the context of 6C: since the outcomes =ill enable improvement
of inputs and implementation processes' )he operational research issues =ill be identified for each
district' $ome of the Be areas ma include J&4P surves to determine communit acceptance of
interventions# evaluation of effectiveness of 6C: programme# insecticide resistance monitoring# and
evaluation of ne= vector control intervention methods# etc'.39
.,'5 4udgeting
LiBe an other plan# the 6C: implementation plan also =ill re2uire an estimation of the resources
re2uired and then a budget covering all possible anticipated activities and Beeping the time frame
in mind'.39
am Refer to Chapter .0 for additional infomation'
.,1
..' Communication for 4ehavioural
6mpact (CO:46-
6n the absence of vaccines and drugs# the strategies for the prevention and control of dengue include
prompt diagnosis of fever cases# providing appropriate clinical management# and reducing human!
vector contact through vector control and personal protection methods' For effective reduction of
human!vector contact# particular emphasis has to be placed on the management or elimination of
larval habitats in and around homes# =orB settings# schools# and in other less obvious places such
as informal dump!sites and plagrounds'an Communit a=areness generation and communit and
intersectoral participation in addition to disease and vector surveillance# emergenc preparedness#
capacit!building and training# and research are essential ingredients of prevention and control
efforts'
)hough carefull researched and meticulousl planned advocac# mobili"ation and
communication initiatives =ith high levels of communit engagement are recogni"ed as fundamental
to the promotion of health behaviour and social change# et till date fe= national DFEDHF
programmes and international funding agencies have invested soundl in such initiatives'.37#ao
&de2uate prevention and control methods exist# but man national programmes are unable to
deliver them effectivel'.5,#ap :an programmes struggle to achieve and sustain behavioural impact
at the household# =orBplace# urban planning# and polic levels'.1,#.5./.58#a2 Further# translation of
Bno=ledge to practice often varies'.58/.+3 )his is on account of reasons as diverse as lacB of resources#
irregular application and ineffectiveness of methodsEinterventions for vector control that have been
promoted (example# methods promoted for cleaning =ater containers-'.+5#.++ %ven =ith good levels
of Bno=ledge# people ma resist household or personal practices to control the vector and vie=
such actions to be the responsibilit of the government'.+8#.+9
6n addition# people do not change their behaviour all of a sudden and sta the LchangedM =a
from that moment' 6nstead# peopleAs behaviour graduall moves through subtle stages of change;
from becoming a=are to becoming informed# then becoming convinced# follo=ed b the decision
to taBe action# then the actual taBing of relevant action the first time# then repeating the same# and
finall maintaining that action (4ox 07- continuousl'
an WHO' Report of the Consultation on; Be issues in dengue vector control# to=ard the operationali"ation of a global strateg# C)DE
F6L(D%*-E6CE7+'.# 0,,.' http;EE==='=ho'intEemc!documentsEdengueEdocsE=hocdsdenic0,,,.'pdf
ao Cited from; ParBs# et al' 6nternational %xperiences in $ocial :obili"ation and Communication for Dengue Prevention and Control'
Dengue 4ulletin / Col 09# 0,,3 ($uppl'-; .!8'
ap ibid'
a2 ibid'
.,5
4ox 07; H6CD&R: and 4ehaviour &doptionar
First# =e
)hen# =e become
&nd later
6n time#
We maBe the
&nd later =e taBe
We next a=ait
and if all is =ell# =e
H ear about the ne= behaviour'
6 nformed about it'
C onvinced that it is =orth=hile'
D ecision to do something about our conviction'
& ction on the ne= behaviour'
R e!confirmation that our action =as good'
: aintain the behaviourf
:ost programmes usuall manage to increase a=areness and inform# educate and convince
individuals about =hat needs to be done (the H6C phase-' Prompting people to taBe the necessar
steps to=ards adopting and maintaining an effective and feasible ne= behaviour (the D&R: phase-
remains a challenge'
Human recall is ver short; communities ma activel respond to a Lcrisis situationM but once
that phase is over the tend to retire into the restive phase' Hence# the success and sustainabilit
of the programmes depend upon continued motivation and mobili"ation of communities# till the
threat of disease (for example# DFEDHF- exists'
Constraints in various communit!based prevention programmes in general have been
documented'.+7 :aDor constraints identified to come in the =a of achieving modest success in
communit!based programmes include the follo=ing;
Q
Q
Q
Q
Designs have a strong educational component but =ithout the motivational elements that
set off communit participation and inculcate a sense of o=nership'
6nsufficient and intermittent efforts and inade2uate resources'
6nade2uate intersectoral convergence in terms of time and resource sharing'
6ndifferent attitude of the upper strata of societ =herein there is the inherent belief that
dengue control is the responsibilit of the government# and that the urban poor# =ho are
mostl illiterate and too bus securing the minimum dail earnings# can perhaps live =ith
the presence of mos2uitoes'
$ecurit concerns and inconvenience caused often prevent the entr of health =orBers
into households'
Prevailing superstitions# beliefs and faiths Rfor example# children suffering from &6D$#
malaria and other diseases are prime targets of =itchcraft accusations# in &ngola'.8, Once
accused of practising =itchcraft# a child is punished# beaten# starved and sometimes Billed
to LcleanseM her or him of supposed magical po=ersS'
Q
Q
Jle and Harris1, summed up the performance of communit!based programmes saing that
the Be to promote such programmes is to close the motivational gap bet=een the communitAs
Bno=ledge and sustainable practices (namel reducing mos2uito breeding sites-'
)he rationale for communit!based health promotion is the notion that individuals cannot
be considered separatel from their social milieu and context and that programmes incorporating
multiple interventions extending beond the individual level have the potential to be more successful
in the context of changing behaviours'.8.#.80
ar <Hosein# %' (cited from; ParBs W'# Llod L'' Planning $ocial :obili"ation and Communication for Dengue Fever Prevention and
Control; & step!b!step guide' WHO# Geneva 0,,3 (WHOECD$EW:CE0,,3'0 and )DRE$)RE$%4ED%*E,3'.-'
.,+
6t is onl during the last decade that emphasis on a communit!based integrated approach
(Lbottom upM rather than Ltop do=nM- started gaining attention#.1, moving a=a from the biomedical
approach# although change is often resisted'as )he supportive activities included an understanding
of prevalent Bno=ledge# attitudes and practices (J&P- and the development and dissemination of
material related to information# education and communication (6%C- focusing mostl on prevention!
oriented messages to=ards actions taBen to be taBen b the communities'
$ince then# there is a gro=ing bod of evidence to prove that social mobili"ation and
communication are critical to sustainable dengue prevention and control' & revie= of the use of
communit participation for controlling &e' aegpti via larval source reduction and of the effectiveness
and sustainabilit of programmes in four countries concluded that a combination of verticall
structured centrali"ed and communit!based approaches should provide short!term success as
=ell as long!term sustainabilit'.81 Considerable importance is placed on negotiating behaviour and
social change as opposed to education for Bno=ledge change? resources and decision!maBing are
decentrali"ed? targeted government and private sector advocac is deploed to increase political
and financial commitment? extensive partnerships and support net=orBs are developed through
intensive mobili"ation? and greater focus is given to environmental improvements such as through
better urban planning and services# including refuse disposal and =ater suppl management# =ith
the active involvement of communities'.83
&part from individualEfamilEcommunit behaviour change# an LenablingM environment# i'e'
one that supports# for example# ne= appropriate behaviours / perhaps b providing improved
services# better housingEinfrastructure construction techni2ues or superior policies and more effective
legislation / is also imperative'.85
Communication for behavioural impact (CO:46-# espoused b WHO# is an innovative
approach that refers to Lgthe tasB of mobili"ing all societal and personal influences on an individual
and famil to (ensure- prompt individual and famil action'Mat CO:46 focuses on and is informed
b behavioural outcomes that are made explicit# =hile health education and promotion ma be
dedicated to behavioural outcomes stated implicitl'au
CO:46As premise is that =hile Bno=ledge of effective tools and technologies# availabilit of
services# etc' needs to be introduced or reinforced# that alone is not enough# since Bno=ing =hat to
do is in realit different from doing or adopting appropriate activities =ithout the necessar motivation
and an enabling environment' 6n other =ords# an informed and educated individual is not necessaril
a behaviourall responsive one' CO:46As process blends strategicall a variet of communication
interventions intended to engage individuals and families in considering recommended health
behaviours and to encourage the adoption and maintenance of those behaviours'av
CO:46 thus entails purposive and tailor!made strategic communication solutions intended to
engage a specific target audience to translate information into responsive action and integrate it =ith
advocac and social mobili"ation initiatives to create an enabling environment' $uch an environment
=ill result in desired behavioural outcomes and impact'
Developed and tested over several ears# CO:46 incorporates the lessons learnt from five
decades of public health communication and dra=s substantiall from the experience of private
sector consumer communication'.8+ 6n effect# CO:46 represents a neat coalescence of a variet
of marBeting# communication# education# promotion# advocac and mobili"ation approaches that
as Changes that are fre2uentl resisted have been described in chapter .0'
at World Health Organi"ation# :obili"ing for &ction; Communication!for!4ehavioural!6mpact (CO:46-' 0,,3' WHO'
http;EE==='B3health'orgEsitesEdefaultEfilesECO:46'pdf
au http;EE==='comminit'comEpdfECombi3!pagerT*ovT.3'pdf
av ibid'
.,8
generall aim to do the same thing; have an impact on behaviour and foster programme/communit
partnerships b integrating principles and techni2ues of health education and promotion'
Furthermore# Lit is almost an article of faith that locating programmes in the communit and
involving communit members in planning# implementation and evaluation can be an effective
strateg for improving population healthM'.88 Hsing participator methods to include people in the
designing# implementation and evaluation can be a productive =a to start understanding the
motivational gaps and barriersa= and ensuring sustainabilit# =hich are integral to CO:46 planning
and implementation as =ell' *e= evidence!based methodologies focus on furnishing communit
members =ith Be concepts and evidence!based training so that the gather their o=n data# evaluate
the control programme and generate and implement their o=n improved interventions based on
the successes and challenges encountered in their settings'
..'. Planning social mobili"ation and communication;
& step!b!step guide
)he step!b!step guide on planning social mobili"ation and communication for dengue fever
prevention and control using the CO:46 approach b the World Health Organi"ation (0,,3-
provides clear guidance on designing national communication and social mobili"ation plans and its
implementation and monitoring and evaluation'.89 CO:46 planning comprises .5 steps (4ox 1,-;
4ox 1,; Fifteen steps of CO:46 planning
(.-
(0-
(1-
(3-
(5-
(+-
(8-
(9-
(7-
&ssemble a multidisciplinar planning team'
$tate preliminar behavioural obDectives'
Plan and conduct formative research'
6nvite feedbacB on formative research'
&nalse# prioriti"e# and finali"e behavioural obDectives'
$egment target groups'
Develop strateg'
Pre!test behaviours# messages and materials'
%stablish a monitoring sstem'
(.,- $trengthen staff sBills'
(..- $et up a sstem to manage and share information'
(.0- $tructure the programme'
(.1- Write a $trategic 6mplementation Plan'
(.3- Determine budget'
(.5- Conduct a pilot test and revise the $trategic 6mplementation Plan'
a= & classification derived b a literature revie= b :efalopulos (0,,1- includes (.- passive participation# =hen staBeholders attend
meetings to be informed? (0- participation b consultation# =hen staBeholders are consulted but the decision!maBing rests in the
hands of the experts? (1- functional participation# =hen staBeholders are allo=ed to have some input# although not necessaril from
the beginning of the process and not in e2ual partnership? and (3- empo=ered participation# =hen relevant staBeholders taBe part
throughout the =hole ccle of the development initiative and have an e2ual influence on the decision!maBing process' Cited from;
:efalopulos# P Development Communication $ource 4ooB; 4roadening the boundaries of communication' 0,,9' World 4anB'''
http;EEsiteresources'=orldbanB'orgE%\)D%CCO::%*GEResourcesEDevelopmentComm$ourcebooB'pdf
.,9
%ach organi"ationAs planningEprocesses include different names for the steps but there are
common elements' :ost Be steps should engage the participation of members of the intended
audience and other Be staBeholders'ax
Follo=ing the .5 steps of CO:46 planning# starting =ith establishing clear behavioural
obDectives (and not Dust Bno=ledge change-# the strategic roles of a variet of social mobili"ation and
communication actions (4ox 1.- and their integrated application as suitable is determined'a
4ox 1.; CO:46As integrated actions
(.- Public relationsEadvocacEadministrative mobili"ation; to place the particular health
behaviour on the agenda of the business sector and administrativeEprogramme management
via the mass media (ne=s coverage# talB sho=s# soap operas# celebrit spoBespersons and
discussion programmes-? meetingsEdiscussions =ith various categories of government and
communit leadership# service providers# administrators and business managers? official
memoranda? and partnership meetings'
Communit mobili"ation; including the use of participator research# group meetings#
partnership sessions# school activities# traditional media# music# song and dance# road
sho=s# communit drama# leaflets# posters# pamphlets# videos and home visits'
$ustained appropriate advertising; in :!R6P (massive# repetitive# intense and persistent-
mode via the radio# television# ne=spapers and other locall available media# to engage
people in revie=ing the merits of the recommended behaviour vis!h!vis the LcostM of
carring it out'
Personal sellingEinterpersonal communicationEcounselling; involving volunteers#
schoolchildren# social development =orBers and other field staff at the communit level# in
homes and particularl at service points# =ith appropriate information and literature and
additional incentives# and allo=ing for careful listening to peopleAs concerns and addressing
them'
Point!of!service promotion; emphasi"ing easil accessible and readil available vector
control measures and fever treatment and diagnosis'
(0-
(1-
(3-
(5-
Fifteen steps of CO:46 planning
$tep .; &ssemble a multidisciplinar planning team
Dengue fever epidemiolog is complex and re2uires a mixture of expertise in different disciplines to
define the set of technicall sound solutions' )eam members might include phsicians# epidemiologists#
entomologists# social scientists# health communication specialists# communit development =orBers#
urban planners# =aterEcivil engineers and advertisingEmedia experts' $ocial scientistsEcommunication
specialists are the Be persons to understand the demands of control of dengue vectors (example#
ax Kohns HopBins 4loomberg $chool of Public Health' Center for Communication Programs' Jno=ledge for Health ProDect# )he )ools
for 4ehaviour Change Communication' Kanuar 0,,9 Q 6ssue *o' .+' http;EEinfo'B3health'orgEinforeportsE4CCtoolsE4CC)ools'pdf
a For additional information# refer to the ParBs W'# Llod L'' Planning social mobili"ation and communication for dengue fever
prevention and control; & step!b!step guide' WHO# Geneva 0,,3 (WHOECD$EW:CE0,,3'0 and )DRE$)RE$%4ED%*E,3'.-'
&dditional literature include; .- $%P& ($ociali"ing %vidence for Participator &ction- programme based on C6%) methods (http;EE
==='ciet'orgEenE-? 0- ParBs W' et al'# 6nternational %xperiences in $ocial :obili"ation and Communication for Dengue Prevention
and Control' Dengue 4ulletin 0,,3? 09 ($upplement-; ./8? 1- :efalopulos# P Development communication source booB;''
4roadening the boundaries of communication' 0,,9' World 4anB' http;EEsiteresources'=orldbanB'orgE%\)D%CCO::%*GEResourcesE
DevelopmentComm$ourcebooB'pdf? 3- Carbanero!Cerso"a# C'' $trategic communication for development proDects; & toolBit for tasB
team leaders' 0,,1' World 4anB' http;EEsiteresources'=orldbanB'orgE%\)D%CCO::%*GEResourcesEtoolBit=ebDan0,,3'pdf
.,7
through 6C:- on the one hand and the diversit of cultures# literac and degree of povert of urban
and rural populations on the other hand to evolve suitable strategies'
)he terms of reference should include the follo=ing;
Q
Q
Q
Q
Q
Q
Q
Q
Q
Determining preliminar behavioural obDectives (see $tep 0-'
Recruiting principal investigators and field =orBers (as re2uired- to design and conduct
formative research (see $tep 1-'
Organi"ing feedbacB on the formative research findings (see $tep 3-'
Finali"ing behavioural obDectives (see $tep 5- on the basis of research findings'
Designing the strateg (see $teps + and 8-'
Overseeing pre!testing of messages# materials and behaviours (see $tep 9-'
%nsuring that monitoring and evaluation activities are conducted and relevant reports
=ritten (see $teps 7 and ..-'
$upervisingEparticipating in relevant training activities (see $tep .,-'
Writing a $trategic 6mplementation Plan that details the social mobili"ation and
communication strategies re2uired to achieve the stated behavioural obDectives (see $tep
.1-'
$eeBing financial and other support in Bind for the proposed proDectEactivit (see $tep .3-'
6dentifing the location of a pilot proDect and discussing subse2uent design and
implementation =ith the relevant communit and civic authorities (see $tep .5-'
Presenting the programme progress to communit groups# relevant national committees#
donor agencies and the national media# as re2uired'
Presenting programme results at relevant forums (meetings# smposiums# etc'-'
Q
Q
Q
Q
$tep 0; $tate preliminar behavioural obDectives
&chievement of specific behavioural results vis!h!vis behavioural obDects is the essence of CO:46
planning' Hence# at the ver start enunciation of preliminar behavioural obDectives is absolutel
imperative'
6n developing the preliminar obDectives# the planning team must discuss the follo=ing
2uestions;a"
Q
Q
Q
Q
Q
Whose behaviour should be changed to bring about the desired outcomesc Who is the
target audiencec
What is re2uired to be donec 6s it feasiblec 6s it effectivec
Wh are the not doing it no=c What are the barriers and motivatorsc
What activities can address the factors most influential to change behaviourc
&re materialsEproductsEservices needed to support those activitiesc 6f es# are those easil
availablec 6f not# =hat should be donec
a" Dra=n from; ParBs# W' and Llod L'' Planning social mobili"ation and communication for dengue fever prevention and control; &
step!b!step guide' WHO' 0,,3'.89
..,
$tep 1; Plan and conduct formative research
Formative research (also Bno=n as marBet or intervention or communication research- is conducted
primaril at the start of the programme and includes all research that helps to inform the development
of a ne=# or refinement of an existing# social mobili"ation and communication strateg'
)he Be focus areas of research are described in 4ox 10'
4ox 10; Formative research
Formative research;
Q 6dentifies Be socioeconomic issues# gaps in Bno=ledge and health education# and
Be resource! and non!resource!related constraints that impede existing prevention or
control programmes'
Provides in!depth information about attitudes# beliefs and practices about health and
the factors affecting health behaviours among the target audience and ascertains the
degree of access to information# services and other resources'
Highlights the felt needs in the communit that could be shared b programme
priorities'
Jeeps those developing the strategies informed about =hat local populations are doing#
thinBing# and saing about focal issues# behaviours# technologies and service staff'
Discovers Be cultural analogies that can be used for effective health education messages
and materials'
6dentifies behaviours that# after modification# could become more effective in removing
or reducing health risBs? and examines =hat obstacles ma come in the =a of adopting
ne= behaviours and ho= to resolve them'
6nvestigates barriers# motivations and opportunities for change and identifies the stage
people are at in the behaviour change process'
Points out the degree of access to information# services and other resources# and basic
media habits'
%xamines recent and current programmes and policies# assesses structures# scope and
capabilities of programme planners and implementers# and provides details on ho= best
to implement the strateg (=ho# =hen# =here# ho=-'
Records the availabilit of communication channels and their strengths and =eaBnesses
in terms of reaching the target audience'
Pre!tests behaviours# messages# and materials =ith representative samples of intended
target groups'
&ssesses health =orBersA andEor polic!maBersA perceptions and practices'
Lists the staBeholders and partners for planning# implementation and monitoring of
CO:46 programmes and the motivations# sBills and resources re2uired to ensure their
active involvement to maBe dengue prevention and control everoneAs business'
:onitors communit response to interventions over time# enabling mid!course
correction'
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
& specific bod of research in addition to a series of practices to induce change through specific
methods and media is essential in development communication' While there is vast literature about
planning# production and strategic use of media in development# there is significantl less material
...
about the LdialogicM communication to investigate issues at the beginning of development proDects
and programmes'
6t is =ell recogni"ed that communication is a hori"ontal process aimed# first of all# at building
trust# then assessing risBs# exploring opportunities# and finall facilitating the sharing of Bno=ledge#
experiences and perceptions among staBeholders' )he aim of this process is to probe each situation
through communication in order to reduce or eliminate risBs and misunderstandings that could
negativel affect proDect design and success' Onl after this explorator and participator research has
been carried out does communication regain its =ell!Bno=n role of communication of information
to specific groups and tring to influence voluntar change among staBeholders'ba
For carring out research# research design and protocol must be developed at the outset'
%mphasis should be on 2ualitative research =hile 2uantitative information should also be gathered'
6n!depth intervie=s# focused group discussions# and observations# etc' should be considered'
6nstitutional capabilities must be assessed to carr out research and identif =ho =ill conduct it'
$election and contracting should be executed as necessar' FuestionnaireEintervie=er guides
must be developed# pre!tested and revised and a field plan for the research (responsibilities# schedules#
etc'- should be prepared' Research staff (from the contracted organi"ation- must be trained and
conducted to facilitateEsupport research' 6nformation should be carefull collated and analsed and
a final formative research report =ith findings and implications for programme activities prepared'
)he Be steps are presented in 4ox 11'
4ox 11; Je steps for conducting a formative research
)he follo=ing steps provide an idea of =hat to schedule for' )ime estimates given are for a full
stud investigating all issues rather than for a speciali"ed stud;
(.-
(0-
(1-
(3-
(5-
(+-
planning the research (3 =eeBs-'
training (1 =eeBs-'
field =orB (+ =eeBs-'
analsis and =riting summar report of findings (+ =eeBs-'
final report =riting (1 =eeBs-'
dissemination'
)he cost of the research =ill var depending mainl on ho= man communities need to be
visited (sampled- and the cost incurred on personnel and transport' )he larger the geographical
area and the more diverse the population# the greater the number of das re2uired in the field and
more expensive the research'
%ngagement of target audienceEcommunitEgroupEindividual; $ensiti"e and discuss the obDectives
and purpose =ith the target' $elect participants =ho =orB =ith or represent those most affected
b the health issue and ensure fair representation of vulnerable segments such as =omen and
marginali"ed groups' %ncourage response regarding their felt needs and involve them and other Be
staBeholders in analsis of concerns' Carious participator methods should be emploed' )hese ma
include preference ranBing# scoring of various problems and solutions (for example# programme
interventions for vector control- in addition to mapping the availabilit of various programmes and
prioriti"ing the best modeEplace for implementation'
ba :efalopulos# P Development communication source booB; 4roadening the boundaries of communication' 0,,9' World 4anB'''
..0
$tep 3; 6nvite feedbacB on formative research
On the basis of formative research# the planners and decision!maBers should maBe suitable
recommendations for action b different segments of the programme'
$tep 5; &nalse# prioriti"e and finali"e behavioural obDectives
Q
Q
Q
Q
%xamine criticall'
&lterations of the obDectives originall set should respond to the outcome of formative
research'
)arget a fe= behaviour items'
Choose not more than three behavioural obDectives at a time'
CO:46 obDectives are different from the obDectives to =hich one is used to because it
includes;
Q
Q
the clear identification of the target audience (e'g' Lhouse=ives =ho store =aterM rather
than LhouseholdsM-'
a detailed description of the behaviour being promoted and the fre2uenc of the behaviour
(e'g' Lscrub the interior =alls of =ater!storage drums t=ice a =eeB =ith a rigid bristle brush
and laundr detergentM rather than Lscrub =ater!storage containers to prevent mos2uito
productionM-'
the measurable impact that is desired over a specific time period (e'g' L+,G of =omen
=ho store =ater =ill scrub the interior =alls of g after the first ear of the programmeM
rather than Lall =omen =ill scrub =ater!storage drumsM-'
Q
6n other =ords the obDectives should be e$:&R)A (specific# measurable# appropriate# realistic#
time!bound-'
Q
Q
Q
Q
Q
$pecific; =ho or =hat is the focus? =hat change(s- are intended'
:easurable; specified 2uantum (e'g' G change intended-'
&ppropriate; based on target needs and aimed at specific health!related benefits'
Realistic; can be reasonabl achieved'
)ime!bound; specific time period to reali"e the obDectives'
$tep +; $egment target groups
6n vie= of the diversit of the thinBing processes of the communit# perceptions about a particular
message ma differ' 6n contrast# if the messages are segment!specific# it is then seen as concerning
that segment alone'
)here are t=o main advantages to segmentation;
Q
Q
:eeting the needs of the smaller segments is better than targeting everone'
$ince operation is often attempted =ith ver limited resources# one can become more
efficient and effective if it is determined as to =hich segments demand more resources
than others and strategies are tailored accordingl'
$tep 8; Develop strateg
& LstrategM is the broad approach that the programme taBes to achieve its behavioural obDectives'
$trategies are made up of specific social mobili"ation and communication activities that on their
..1
o=n or in combination lead to the achievement of the obDectives' 4ox 13 gives an example of ho=
obDectives# strategies and activities ma be linBed'
4ox 13; ObDectives# strategies# activities
ObDective
)o prompt .,,, householders in RlocationS to prevent an tre that is not in use for a car from
accumulating =ater during the next .0 months'
$trateg
(one of several# each aimed at different target groups-'
)o drill holes in discarded tres to stop them from collecting =ater' )he strateg =ill be delivered
in t=o =as;
Q
Q
& field team of 1, volunteers and five vector control programme staff =ill visit households
and drill holes into tres =ith hand!held batter!driven drills'
)re replacement centres and gas stations and the liBe =ill provide an ongoing drilling
service =hen old tres are exchanged for ne= ones but are still =anted b householders#
and before storing un=anted tres at a public dump site'
)raining =orBshop for field team on communication sBills and the drilling of old tres'
Field team to visit .,,, households and drill holes in old tres as =ell as disseminate
information on vector control'
6nterpersonal communication (6PC- =ith householders supported b information
dissemination pamphlets'
Pamphlets handed out to drivers b sales staff and cashiers at tre replacement centres
and gas stations'
Radio and )C spots to raise a=areness about the mos2uito breeding problem in usedE
dumped tres and drilling those for channelling out =ater'
Letters and follo=!up telephone calls and visits to tre replacement centres and gas
stations'
&ctivities
Q
Q
Q
Q
Q
Q
$trateg development re2uires creativit' Fre2uentl# it is not the lacB of funds# Bno=ledge#
technolog# sBilled emploees# or motivated communities that is the principal impediment? =hat
programmes lacB most is a suppl of ne= ideas' *o effective dengue control programme can exist
=ithout an innovative approach to social mobili"ation and communication because everthing must
change on a regular basis' &n example of creativit at =orB is illustrated in 4ox 15'
..3
4ox 15; Dengue 4iccle!Riders in Kohor 4ahru# :alasia.89
&s part of a carefull integrated social mobili"ation and communication campaign in Kohor 4ahru
in :alasia# biccle!riding teams (DAR6D%R$- =ere formed to undertaBe tours of the district ever
$unda during the three!month campaign' )hese riders =ere local ouths =ho volunteered for
this activit' %ach team consisted of 0, riders'
%ver $unda morning# the team toured selected areas on biccles accompanied b a van
e2uipped =ith a public announcement sstem to promote the campaign' )he rode on mountain!
terrain biBes clad in special )!shirts =ith the t=o behavioural obDectives of the campaign printed
on the bacB (L%ver famil should carr out a house inspection once a =eeB for 1, minutesM and
L&none =ith fever should seeB immediate treatment in a clinicM-'
&t each location# the team =as greeted b local communit leaders and residents and the
atmosphere =as Lcarnival!liBeM' )here =ere speeches delivered# along =ith distribution of health
education materials# refuse!collection activities# traditional dances and singing# and occasionall
some competitions' Refreshments =ere also served'
Designing strategies depends on the obDectives to be achieved and the resources available'
& number of resources are necessar to ensure four important design features of good strategies;
consideration given to more than Dust the LmessageM? the careful blending of communication actions?
gender sensitivit? and the timing of interventions to coincide =ith local events and calendars'
%ffective communication is central to achieving behavioural outcomes and impact'
Communication is the process in =hich a :essage from a $ource is sent via a Channel to a Receiver
=ith a certain %ffect intended =ith opportunities for FeedbacB# all taBing place in a particular $etting
(:$'CR%F$-bb R)able .1S'
)able .1; :$'CR%F$ components
Components
:essage
6mportant considerations
%nsure that the language is clear and easil understandable' )hat it is not too
technical' Giving too man messages confuses the audience' 4e clear about =hat is
the main central message'
Hse a credible person to deliver the message' For example# people ma not pa
attention if a local shopBeeper =as giving advice about dengue# but it =ould be
more credible if a =ell!Bno=n doctor =as delivering the same' 6n other cases# a
oung teenager =ould be more liBel to persuade other teenagers to taBe action
rather than a figure seen as authoritarian' Remember# appearances maBe a difference
in ho= the source is perceived'
6dentifing the most appropriate channel is important# either using the mass media
through radio# television and ne=spaper andEor interpersonal channels such as
door!to!door visits# traditional theatre# group meetings# etc' )he right channel must
be used for the right target audience and generall the most effective is a selective mix
of channels' *ote the importance of non!verbal channels such as gesticulation# facial
expressions and posture'
$ource
Channel
bb <%verold Hosein
..5
Components
Receiver
6mportant considerations
)he receiver filters and interprets the =orld through the cultural lens =ith =hich the vie=
the =orld' &n understanding of this =orld is crucial to effective communication' )herefore#
ho= ou =ould explain the need to correctl protect =ater containers to a rural farmer
ma be different from ho= one =ould deal =ith urban schoolchildren and house=ives'
)his is the end result of communication' )he effect is the behavioural focus through
improving Bno=ledge# sBills and providing promptsEtriggers that could have an
impact on ultimate behavioural outcomes' )his is the point of departure for CO:46
planning' One must be clear about the communication effect(s- desired that =ould
lead to behavioural results'
6t is important to ensure that communication interventions are appropriate# effective
and engage the receiver to provide feedbacB' FeedbacB allo=s for such assurance'
With it one can fine!tune communication actions'
)his can facilitate or hinder communication' 6f there is too much noise# or the timing is
=rong# or the setting is inappropriate to the subDect being discussed# or there are too
man distractions# or it is too hot# or too cold# all these factors affect ho= messages
are heard and interpreted' Locations such as religious venues# health centres# cafes#
marBetplaces and schools provide their uni2ue features that can affect the dnamics of
communication and must be considered in the planning of communication actions'
%ffect
FeedbacB
$etting
$ource; ParBs W'# Llod L'' Planning social mobili"ation and communication for dengue fever prevention and control; & step!b!step
guide' WHO# Geneva 0,,3 (WHOECD$EW:CE0,,3'0 and )DRE$)RE$%4ED%*E,3'.-.89
%ngagement of the target audienceEcommunitEgroupEindividual; 6nvolve targets# staBeholders
andEor facilitate their involvement in strateg design consultations or =orBshops that should include
deliberations on :$'CR%F$ ' $uch events should be held at locations preferred b the communit and
at times that are convenient for them' )he =orBshops should arrive at a consensus regarding strategic
planning' )he staBeholders should Lbu inM b agreeing to taBe on responsibilities as appropriate'
$tep 9; Pre!test behaviours# messages and materials
Pre!testing is the hallmarB of a =ell!designed social mobili"ation and communication strateg' )he
stud should be designed and carried out b social scientists' )he subDect matter for pre!testing
includes; (i- product testing# (ii- behavioural trials# and (iii- message and material testing'
(i- Product testing helps avoid =hat could be called the Lproduct mindsetM' 6n this mindset# it is
presumed that if an &edes breeding control measure (example# e'g' larvicide# =ater container
cover- is offered to the communit it =ill be acceptedEfollo=edEused' Ho=ever# in the absence of
visibilit# i'e' if dengue is not perceived to be a problem or if dengue cases occur despite vector
control or if people continue to be bitten b mos2uitoes despite &edes control or if mos2uito
breeding is thought to be in areas such as s=amps and drains (not in cleaner household =ater
containers-# or use of certain measures is thought to contaminate =ater supplies# &edes control
measures often have no clear advantage for the communities# in general' $o# decision!maBers
have to generate evidence for the acceptance of the product'
4ehavioural trial is a small!scale test of a ne= behaviour =ith a representative sample of
the target group to determine its abilities to effectivel adopt a different practice (sometimes#
behavioural trials and product tests are combined-' & behavioural trial can help to;
Q
Q
Q
Q
..+
(ii-
analse those parts of the desired behaviour that are# and are not# readil adopted?
identif material or behavioural barriers to the adoption of the ne= behaviour?
identif =hat =orBs best to reinforce learning of the ne= behaviour? and
refine communication to reinforce the desired behaviour'
(iii- Pre!testing messages and materials including brochures# booBlets# flipbooBs# information
cards# scripts for plasEsBitsEstor boards as relevant for entertainment educationEinfotainment
(information through entertainment-# print# radio or )C advertisements# audiotapes or
videotapes# pacBaging of technical products# etc' )hese help to;
Q
Q
Q
Q
assess =hether messages are clear and compelling?
identif unintended messages?
detect totall unpredictable audience responses and other aspects of materials that ma
re2uire modification?
select from among a range of potential messages and materials and provide some insight
into =hether these messages and materials =ill generate the desired behavioural impact'
%ffective messages should be clearl stated and specific to the desired action(s-Ebehaviour(s-#
technicall correct# consistentl repeated# eas to understand# command attention? and should
appeal to both the heart and the head# build trust and call for action'
%ngagement of the target audienceEcommunitEgroupEindividual; Form a group of Be staBeholders
close to or representing the audience' &dvisor groups can provide useful advice about developing
appropriate messages and materials and can help =ith suggesting revisions after pre!testing' 6nvite
members of the audience to suggest messages and materials'
$tep 7; %stablish a monitoring sstem
:onitoring of an programme is continuous and enables the desired modification of the strateg to
achieve the desired goals' %valuation is either periodic or a terminal activit' :onitoring and evaluation
(:P%- demonstrate if a particular interventionEmedium has reachedEserved its goalEpurpose or not'
:P% also helps obtain guidance for programme decisions and determine if improvements in health
outcomes are causall linBed to a given intervention or a given behavioural change'bc
)here are t=o =as to monitor strateg progress;
(i-
(ii-
(i-
4ehavioural impact monitoring (or surveillance-# and
Process evaluation'
4ehavioural impact monitoring;
6ndividual behaviour change =ill be reflected b an increase or decrease in (i- production of adults of
&e' aegpti mos2uitoes? (ii- the risB of other members of the famil being bitten b &edes mos2uitoes?
and (iii- the risB of ac2uiring dengue virus infection'
(ii- Process evaluation;
Q
Q
Q
:aBing decisions about refining the strategAs obDectives# activities# behaviours# products#
services and so on'
Documenting and Dustifing ho= resources have been spent'
:aBing a compelling case for continued or additional funding (especiall if combined =ith
behavioural impact data-'
Process evaluation =ill help in utili"ation of the data in three =as;
bc For additional information# refer to; )ools for 4ehaviour Change Communication' 6*FO proDect' Center for Communication
Programs' Kohns HopBins 4loomberg $chool of Public Health' 0,,9' 6ssue *o' 9' http;EEinfo'B3health'orgEinforeportsE4CCtoolsE
4CC)ools'pdf
..8
Process evaluation ma be carried out b =a of tracBing planned activities# field supervision
and monitoring b using the standardi"ed supervision checBlist' Regular supervision ensures that an
gap or problem =ith Bno=ledge# sBills or attitude is readil recogni"ed and corrected'
:id!term and end!term evaluations# as appropriate# should be planned and conducted' )hese
should be a component of the overall programme evaluations or ma be conducted independentl#
as necessar and appropriate' )he information generated through formative research should serve
as the baseline' 4oth 2uantitative and 2ualitative methods should be applied'
%ngagement of the target audienceEcommunitEgroupEindividual; Comparison of outputs#
outcomes =ith shared vision and original obDectives is important' For purposes of continued
motivation and re=ard# it is important that most of the communitEstaBeholders participate in the
:P% process so that lessons learnt about =hat =orBed and =h are shared and the =a for=ard
discussed' 6nclude the target audience and other staBeholders (as part of steering committees# etc'-
to tracB the progress of implementation# maBe recommendations and ensure action to improve
activities' 6nvolve the target audience in evaluating the programme(s- against the parameters the
set themselves (participator evaluation-' Discuss their involvement in conducting the evaluation#
and ho= the results =ill be used' %ncourage the sharing of evaluation findings =ithin the communit
and =ith others# as =ell as advocate further activities'
6n 0,,5# an evaluation of .. WHO!supported dengue communication and mobili"ation
programmes using the CO:46 planning tool =as conducted in six $outh &sian and Latin &merican
and Caribbean countries'.87 Certain Be issues from the conclusions derived from this evaluation#
as =ell as from the revie= of recent programmes#bd are presented in 4ox 1+'
4ox 1+; Je 6ssues from CO:46 evaluation from $outh &sian and
Latin &merican and Caribbean countries
Je issues;
Q
Q
Programme leadership and planning for sustainable communit participation and
involvement'
)ransfer of technical Bno=ledge and sBills in planning participator behavioural
interventions to health =orBers# communit volunteers and other partners at the local
level'
Creation and maintenance of monitoring and feedbacB sstems at the local and national
levels# including the development of behavioural indicators'
Kudicious mix of communication channels (interpersonal# mass media# publicit# etc'-
to support programme behavioural goals over time# based not Dust on available funding
but also on effectiveness in the local context'
Q
Q
$tep .,; $trengthen staff sBills
Long!term sustainabilit of social mobili"ation and communication =ill be difficult unless the
organi"ation and orientation of government!run services emphasi"es the development of communit!
based programmes =ith genuine decision!maBing at the local level' Where programmes have
undergone decentrali"ation or are currentl being decentrali"ed# capacit at provincial# district and
bd &chieving 4ehaviour Change For Dengue Control; :ethods# $caling Hp and $ustainabilit WorBing Paper for the $cientific WorBing
Group# Report on Dengue# ./5 October 0,,+# Geneva# $=it"erland# World Health Organi"ation on behalf of the $pecial Programme
for Research and )raining in )ropical Diseases# 0,,8' http;EE==='=ho'intEtdrEpublicationsEpublicationsEs=gTdengueT0'htm
..9
sub!district levels to plan# manage and implement social mobili"ation and communication strategies
is often far from sufficient' 6t is# therefore# essential to provide opportunities for service personnelE
volunteers involved in the programme to learn ho= to plan and implement appropriate social
mobili"ation and communication strategies# ho= to listen and =orB =ith communit members# and
ho= to linB their plans and activities =ith local perceptions# conditions and resources'
)raining programmes should have feedbacB# and pre! and post!test sessions in addition to
brainstorming on the maDor challenges in planning and implementing social mobili"ation and
communication programmes for malaria' Further# group =orB should be organi"ed on various
prevention and control components =ith the exercises focusing on related current behaviours#
desired behaviours# target audience# communication# obDectives# Be benefits# Be barriers# draft
messages# interventions# monitoring and evaluation# etc'# thereb ensuring that sBills are developed
or refreshed' )hese should dra= from the experiences of traineesEtrainers'
$tep ..; $et up sstems to manage and share information
Programmes can no longer rel on their former practices to sustain dengue prevention and control'
)he abilit to change re2uires an abilit to learn' Dengue programmes need to become Llearning
organi"ationsM# =ith information management sstems that enable rapid understanding of trends and
developments affecting the behaviour of target groups' $uch sstems =ould include carefull filed or
electronicall stored data on target groups and programme partners# dra=ing from formative research
(see $tep 1- as =ell as from pre!testing (see $tep 9-# monitoring (see $tep 7-# and negotiations =ith
programme partners (see $tep .0-' )his information sstem ma be called LCommunit ProfilesM
or LConsumer 6nformation $stemM or the LFormative Research DatabanBM' 6n essence# a CO:46
database is needed as e2uivalent to a health information sstem or entomological surveillance
sstem'
$uch database and archived research findings and lessons learned should be used in future
programmes andEor for revisingEredesigning communication# behaviour change obDectives# channels#
messages# tools# materials# indicators# etc' and for restarting the strategic designingEplanning# till the
desired behavioural obDectives are achieved'
)he programmes should plan and prepare information products for dissemination among Be
staBeholders# partners# ne=s media# funding agencies and the liBe'
$tep .0; $tructure of the programme
$ocial mobili"ation and communication are usuall accorded lo= priorit in most programmes and
are often developed and implemented at the lo=est levels (b Dunior staff or staff =ith no relevant
bacBgroundEexperience-' )he obvious implication of this structural location is that senior management
doesnAt consider it to be ver important' Organi"ational or structural change is often re2uired'
$trategies for organi"ational change ma include;
Q
Q
Q
forming multidisciplinar teams and intersectoral committees to help managers =orB
through the tasBs re2uired?
training# mobili"ing and supervising a field =orBforce?
establishing management procedures# benchmarBs (indicators that sho= =hether the
programme is moving to=ards a particular goal-# and feedbacB or tracBing mechanisms
(e'g' monthl reports or ne=sletters shared at all levels and regular meetings-? and
designing a modified organi"ational structure b identifing and delineating ne=
responsibilities# creating ne= positions (=hen necessar-# modifing =orBing hours# and
covering the expenses that increased field =orB generates'
Q
..7
Four basic organi"ational structures (not mutuall exclusive- can be used to enable programmes
to practise social mobili"ation and communication' )he are;
Q
Q
Q
Functional organi"ation (namel involving a number of staff and consultants# and the
creation of =orBing groups-'
Programme!centred organi"ation (namel an identified staff given the responsibilit of
coordinating all functions-'
Communit!centred organi"ation (namel structuring the programme in accordance =ith
ho= the interventions are perceived b communit groups# i'e' on the basis of ho= the
use them and =hat the thinB about them# and not on ho= the programme promotes
them-'
Organi"ing strategic alliances (namel involving partner organi"ations such as *GOs# other
ministries# advertising agencies# etc'-'
Q
$tep .1; Write a strategic implementation plan
)he purpose of strategic planning for social mobili"ation and communication is to devise a plan
that is appropriate to the health problem and target audience# taBes into account the resources
available# and has the best chance of bringing about sustainable behavioural impact' 6t should
be locale! and context!specific and ensure implementation in a socioculturall and economicall
appropriate =a'
Plansbe can be short!term and long!term' While eshort!termA normall refers to a period of one
ear or less# Llong!termM plans usuall extend to three to five ears'
)he plan should focus on enhancing a=areness among the targeted at!risB and affected groups
about source and transmission risB reduction# treatment and availabilit of services' 6t should also
address and promote attitudinal and value changes among target groups that =ould lead to informed
decision!maBing and modified behaviour (such as the adoption of timel and appropriate practices
at the individual# famil and communit levels-# and stimulate an increased and sustained demand
for 2ualit prevention and care services and optimal utili"ation of available services' )he plan should
be discussed and debated b the multidisciplinar planning team and b other staBeholders' 6deall#
there should be three basic sections# as enunciated in 4ox 18'
4ox 18; 4asic sections of a strategic implementation plan.89
.' 6*)RODHC)6O*
.'. Principal findings from formative research; Prepare a summar of existing data and results
of the formative research on the behavioural and programme environments# including a list
of issues re2uiring further formative research'
.'0 4ehavioural analsis; Write do=n a detailed description of the behaviours selected for
attention through the analsis process (for example# problem analsis# risB factor analsis#
force!field analsis# 4%H&C% frame=orB analsis# priorit analsis# $:&R) obDective
analsis-' $tate the behavioural obDective(s- Rensure that the obDectives are $:&R); specific#
measurable# appropriate# realistic and time!boundS' %xplain the significance of the
obDectiveEs'
.'1 )arget group segmentation; Describe target groups (classified b behavioural segments
and primar and secondar audiences-'
be &lso referred to as e&ctionA or eOperational PlanA
.0,
0' )H% $)R&)%G6C &PPRO&CH (explaining the L=hatM# L=hM and Lho=M-
0'. Overall goal; Define the overall goal# for example; Lto contribute to the reduction in
morbidit and mortalit from dengue feverEdengue haemorrhagic fever in RlocationS b the
ear RdateS'
0'0 4ehavioural obDective(s-; Define the behavioural obDective(s-' Re!state the specific
obDectiveEs as presented in .'0' For example; LWithin one ear from the start of the
programme# to increase the percentage# from 1,G to +,G# of =omen in Rplace nameS =ho
vigorousl scrub the interior =alls of =ater!storage drums t=ice a =eeB using a rigid bristle
brush and laundr detergent'M
0'1 $trateg(ies-; & general overvie= of the social mobili"ation and communication strateg
stating the Be messages# their se2uencing (if an-# the overall tone of the strateg# the
blend of communication actions (administrative mobili"ation# communit mobili"ation#
advertising# personal selling# point!of!service-# and the relationships bet=een different
communication actions and an overvie= of ho= the plan =ill be managed' )he strateg
should focus on delivering the Lright messagesM to the Lright audienceM at the Lright timeM
through the Lright channel mixM'
1' )H% 6:PL%:%*)&)6O* PL&* (explaining the L=hatM# L=henM# L=hereM# L=hoM# Lho=
muchM-
1'. Communication actions; Detail specifications of communication actions outlined in the
L$trategM section# including descriptions and plans for production# procurement# pricing
and distribution of an technological products# services# incentives (such as bags# caps#
)!shirts# pri"es- and other materials# as =ell as identifing =hat training and supervision
activities are re2uired for staff andEor partner agencies (for =hom# =hat# =hen# =here#
=h# and facilitated b =hom-' Dra=ing from the formative research# a locale! and
context!specific media mix should be considered' Reach# credibilit and costs should be
discussed'
1'0 :onitoring and evaluation; Determine the details of the behavioural monitoring and
process evaluation to be used# outline the methods for data collection and analsis# prepare
a description of the sstem for managing and sharing monitoring information (communit
feedbacB# programme reports# etc'-# and read an explanation of ho= the plan =ill be
modified as a result of monitoring' &lso included here =ould be a description of an mid!
term or final evaluations of behavioural impact (alongside other areas of interest such as
entomological impact# social and organi"ational impact# impact on morbidit and mortalit#
environmental impact# cost/benefit analses# and other unintended impacts-'
1'1 :anagement; Describe the management team (e'g' the multidisciplinar planning team-#
including specific staff or collaborating agencies (e'g' local advertising firms and research
institutions-# designated to coordinate communication actions and other activities (such as
monitoring-' &lso consider including an technical advisor group or government bod from
=hich the management team is to receive technical support or to =hich it =ill report'
.0.
1'3 WorBplan; Develop a detailed =orBplan =ith time schedules for the preparation and
implementation of activities re2uired to execute each communication action as described
in $ection 1'.' )he =orBplan could taBe the form of a table =ith column headings such as
e&ctivitiesA# eCompletion dateA# eResponsibilitA (staff member# partner agenc# and so on-#
etc'' & tabular flo=chart (or Gantt Chart- =ith column headings for =eeBs# months# 2uarters
or ears along the top and specific activities being listed as ro= headings do=n the left!
hand side is also useful' Cells =ithin the table can be shaded to indicate the =eeB or month
during =hich a particular activit is scheduled'
$uch a diagram allo=s instant comprehension of =hen different activities begin and end#
=hether preparator activities have been given enough time# =hether communication
actions that need to be integrated have indeed been integrated# and highlights periods of
peaB activit'
1'5 4udget; WorB out a detailed list of costs for the various activities (see $tep .3-'
%ngagement of target audienceEcommunitEgroupEindividual; %nsure that discussions are held
=ith the target audience prior to finali"ation of the plan and encourage them to understand various
roles and responsibilities in programme implementation and share their vie=s on participation and
self!monitoring'
$tep .3; Determine the budget
Dengue is basicall a problem of domestic and =orBplace =ater management and sanitation# and
the behaviours re2uired to improve this management are considerabl cheaper than largescale
application of insecticide' 4ut it =ould be a mistaBe to believe that the problem can be addressed
=ith little or no investment of funds and commitment of other resources (e'g' staff and time-' 6t is a
huge challenge to find =as of transferring to the communit the desired degree of responsibilit#
capabilit and sense of motivation for the prevention and control of dengue' &n appropriate budget
should be allocated for these important activities'
$tep .5; Conduct a pilot test and revise the strategic implementation plan
While a lot of attention needs to be devoted to the obDectives# strategies# activities and monitoring
procedures of the strategic implementation plan# and the resources needed for its implementation#
the LprocessM of social mobili"ation and communication implementation is often overlooBed' Pilot!
testing represents an important first step in implementing a social mobili"ation and communication
plan' During piloting# formative research is again used to obtain feedbacB from participants involved
in the planAs implementation as =ell as from the staff on the 2ualit of the activities covering all
dimensions from educational materials to the competence of the personnel chosen to deliver the
activities'
Pilot!testing serves at least three basic functions;
Q
Q
Q
%nsuring that the chosen strategies have no obvious maDor deficiencies'
Fine!tuning possible approaches so that the speaB to target audiences in the most effective
=as'
Convincing staff and partners'
*o matter ho= the behavioural results from the pilot test are captured# stored or analsed#
the next important tasB is to determine =hether the strateg can proceed to full implementation or
=hether modifications are needed' Here# the communit!centred vie= of planning must dominate'
.00
6n other =ords# the focus of learning should be on =hat primar and secondar audience members
said# =hat the did# =hat additional information and resources the =anted and in =hat form# and
so on' & pilot!test ma reveal the need for re!setting the behavioual obDectives# as =ell as redesigning
strateg and approaches and also the plan of implementation itself'
%ngagement of target audienceEcommunitEgroupEindividual; :obili"e the target audience and
other staBeholders in the pilot!test =hile including a control groupEcommunit among =hom nothing
beond routine activities have been conducted'
)he above!mentioned .5 steps of CO:46 planning =ill accomplish three essential managerial
tasBs;
Q
Q
First# to establish clear behavioural obDectives'
$econd# to determine the strategic roles of a variet of social mobili"ation and communication
disciplines? for example# public relations# advocac# administrative mobili"ation# communit
mobili"ation# advertising# interpersonal communication# and point!of!service promotion# in
achieving and sustaining these obDectives'
&nd third# to combine these disciplines into a comprehensive plan that provides clarit#
consistenc and maximum behavioural impact to the social mobili"ation and communication
efforts'
Q
)he overall process or ccle of development communication# as in CO:46# too illustrates
four main phases; research# is the first phase communication!based assessment (C4&- for obtaining
inputs for strateg design# maBes up the second phase' )he next phase concerns the production of
the materials and implementation of the planned activities' Finall# the fourth phase is concerned
=ith evaluation' Proper evaluation of the impact of the communication intervention re2uires the
definition of monitoring and evaluation indicators during the initial research phase'bf
6t is =ell acBno=ledged that social mobili"ation and communication is an ongoing process#
=hich is mostl non!linear and cclical' %xamples of non!linear models have been developed and
applied across the =orld'bg $ustainable behaviour change re2uires time and repeated effort' )he
results and lessons from evaluation are utili"ed for refinement of the strateg ($tep 8-' )he other
steps# namel# developing and pre!testing messages and materials# the strategic implementation plan#
:P%# etc' continue till the desired behavioural obDectiveEs isEare achieved'
..'0 %nsuring health!care infrastructureEserviceEgoods provision
:an a time behaviour change at the individualEcommunit level ma be limited to a short duration
in time unless other measuresEprogrammes are undertaBen to ensure that the changes are self!
sustaining' $ince most behaviour change interventions are delivered through the existing structure
of dengue programmes# for the most part# after a certain period the programme reverts to its
original focus and programming; that is# entomological surveing and source reduction conducted
b vector control staff' )his is not onl the case for behavioural interventions# but laborator and
case management also tend to function independentl even though the need to integrate the five
essential components (epidemiolog# entomologEvector control# communit participation# laborator
and case management- has been highlighted over the past ears'.9,#.9.#.90
bf :efalopulos# P Development Communication $ourcebooB; 4roadening the boundaries of communication' 0,,9' World 4anB''
bg P!Process b the Kohns HopBins 4loomberg $chool of Public HealthECenter for Communication Programs (http;EE==='hcpartnership'
orgEPublicationsEP!Process'pdf-? Planning and 6mplementing a Communication Program b the World 4anB (http;EEsiteresources'
=orldbanB'orgE%\)D%CCO::%*GEResourcesEtoolBit=ebDan0,,3'pdf-
.01
..'1 &pplication of CO:46
:an countries have applied CO:46 for dengue prevention and control' & fe= examples are
presented in 4ox 19 and 4ox 17'bh
4ox 19; &pplication of CO:46 in Colombia.93
& dengue prevention initiative =as applied in the cit of 4ucaramanga in northeastern Colombia'
Hse of 2ualitative and 2uantitative research# including formative research# and data analsis based
on the L$tages of ChangeM model =as the basis for planning an integrated social mobili"ation and
communication approach' )he model classifies individuals according to =here the fall in the
behaviour change process;
(i-
(ii-
pre!contemplation; the person is not thinBing of changing his or her behaviour (0.G
of house=ives =ere found to be in this stage-?
contemplation; the person begins to thinB about the action (5,G =ere found to be in
this stage-?
action; the person implements the plan to change the behaviour (07G =ere found to
be in this stage-? and
maintenance; the person continues to practise the ne= behaviour'
(iii- preparation; the person plans to change the behaviour?
(iv-
(v-
)he initiative focused on one da a =eeB (i'e' )hursda- =hen residents =ere to seeB
and destro the sites =here the &edes aegpti mos2uito might occur and breed' On this da#
communication and educational actions =ere used to mobili"e and motivate people' Follo=ing
this approach# innovative printed communication materials =ere designed and disseminated' )his
resulted in a massive mobili"ation of students# houseBeepers and other members of the public'
:aterials and a methodolog of interpersonal communication =ere additionall produced that
generated partnerships =ith the private sector and communit groups' &nother innovative feature
included a mobile dengue exhibit =ith interactive educational games'
)he evaluation found that 73G of the teachers and 7+G of the students Bne= about the
calendar and 99G of the teachers and 88G of the students used it' )he impact on households
of message broadcast on radio in 0,,0/0,,1 recorded a score of 08G associating )hursda as
LDengue Prevention DaM and the same percentage practising specific actions to looB for and
control &e' &egpti breeding sites on that da of the =eeB' )he number of houses and schools =ith
immature &e' aegpti =as found to be fe=er during the post!intervention evaluation compared
=ith the pre!intervention surve' )o monitor behavioural impact among house=ives and the rest
of the population# the House 6ndex =as measured ever three months' )he results sho=ed the
index had decreased from .9G in .779 to 5G in 0,,1'
)he three most important lessons learnt from this exercise included;
(i-
(ii-
(iii-
ObDectives should be based on results from research that combine appropriate 2ualitative
and 2uantitative methods'
6t is necessar to generate a critical mass of committed persons acting in different roles
to prevent dengue'
6n order to develop a behaviour change proDect# it is necessar to have at least three
ears of continuous =orB done before an significant changes are observed'
bh For additional examples# refer to Dengue 4ulletin 0,,3# Col' 09 ($upplement-'
.03
4ox 17; &pplication of CO:46 in $ri LanBa.91
$ri LanBa initiated CO:46 for dengue prevention and control in 0,,7 in .0 high!risB districts on
a campaign mode'
)he overall goal has been to reduce the incidence of DFEDHF in the high!risB districts b
5,G b the end of 0,,+ (i'e' from 0,,, to 0,,5-' )he behaviour obDectives for the period of .+
=eeBs from :arch and .0 =eeBs from $eptember in select high!risB areas =ere to; .- prompt
house=ives in 9,G/7,G of homes to remove breeding sites in their houses and surroundings
ever $unda for 1, minutes? 0- motivate 9,G/7,G of tre traders to Beep their premises free
of breeding sites? and 1- prompt school principals and teachers of 9,G/7,G of schools to Beep
their school premises free of dengue breeding sites through inspections conducted ever Frida
for 1, minutes'
&ppropriate messages =ere disseminated through the channel mix of administrative
mobili"ationEpublic relationsEadvocac? communit mobili"ation? advertising? personal selling and
interpersonal communication? and point!of!service promotion' )he :P% plan included monitoring
during the planning and preparator phase and during the implementation phase as =ell as pre!
and post!intervention surves' %valuation of the CO:46 plan =as carried out in 0,,7 through
Be informant intervie=s (=ith supervisors of the implementers of the CO:46 plan-# focus group
discussions (=ith the target audience-# entomological surves# and b testing the consistenc of
the messages' Ho=ever# certain constraints such as lacB of commitment# and paucit of human
resources and funds# ho=ever# needed resolution for sustaining CO:46 activities'
.05
.0' )he Primar Health Care &pproach
to Dengue Prevention and Control
.0'. Principle of primar health care
Primar health care# or PHC# is a broad and comprehensive concept# and is defined as Lgessential
health care based on practical# scientificall sound and sociall acceptable methods and technolog
made universall accessible to individuals and families in the communit through their full participation
and at a cost that the communit and countr can afford to maintain at ever stage of their development
in the spirit of self!reliance and self!determination' 6t forms an integral part of both the countrAs health
sstem# of =hich it is the central function and main focus# and of the overall social and economic
development of the communit'bi
PHC# thus# is a multidisciplinar approach that encompasses a continuum of 2ualit and
comprehensive care / health promotion# disease prevention# treatment# and rehabilitation / b
addressing a range of social# cultural# economic and environmental factors that cause ill health as
=ell as those that sustain and maintain health' 6t is the first level of contact of individuals and the
famil and communit =ith the national health sstem through a referral sstem# bringing health care
as close as possible to =here people live and =orB# and constitutes the first element of a continuing
health!care process in a cost!effective and e2uitablebD manner'.95 6t is applied as a public health tool
that re2uires and promotes maximum communit and individual self!reliance# self!determination
and participation in the planning# organi"ing# operation and control of primar health care# maBing
fullest use of local# national and other available resources'bB 6t also serves as the foundation of health
sstems strengthening'
PHC and Health For &ll (HF&- are part of the &lma!&ta (no= called &lmat- Declaration of
.789 that marBed the commitment of :ember $tates of the Hnited *ations to=ards achieving
a more e2uitable health status across the =orld# particularl in developing countries' :ore than
three decades after the Declaration# there is gro=ing reali"ation that the concepts and approaches
of PHC continue to remain valid' & Regional Conference on Revitali"ing Primar Health Care =as
recentl organi"ed b the World Health Organi"ationAs $outh!%ast &sia Region in KaBarta# 6ndonesia#
in 0,,9'bm
bl
Declaration of &lma!&ta' 6nternational Conference on Primar Health Care# &lma!&ta# (then- H$$R# +/.0 $eptember .789' (http;EE
==='=ho'intE*PHEdocsEdeclarationTalmaata'pdf-
bD WHOAs definition of Le2uit in healthM encompasses t=o different aspects; .- %2uit in health (health status- means attainment b all
citi"ens of the highest possible level of phsical# pschological and social =ell!being? and 0- %2uit in health care means that health
care is provided in response to the legitimate expectations of the people? health services are received according to need regardless
of the prevailing social attributes# and pament for health services is made according to the abilit to pa' (WHO $%&RO' %2uit in
access to public health' Report and documentation of the )echnical Discussions held in conDunction =ith the 18th :eeting of the
CCPD:' *e= Delhi# 1. &ugust 0,,,' *e= Delhi# WHO# 0,,, (Document *o' $%&!H$D!03,-'
bB Declaration of &lma!&ta' 6nternational Conference on Primar Health Care# &lma!&ta# (then- H$$R# +/.0 $eptember .789 (http;EE
==='=ho'intE*PHEdocsEdeclarationTalmaata'pdf-'
bl & result of a Doint WHO!H*6C%F 6nternational Conference on Primar Health Care held at &lma!&ta (no= called &lmat-# +/.0
$eptember .789'
bm WHO' World Health Report 0,,9' Primar health care; *o= more than ever' Geneva# WHO# 0,,9' http;EE==='=ho'intE=hrE0,,9E
bi
.08
)he :illennium Development Goals that =ere adopted b H* :ember $tates in 0,,,bn
provided continuit to the values of social Dustice and fairness articulated at &lma!&ta in .789 and
further affirmed the central and pivotal position of health on the development agenda as a Be
driver of social and economic productivit and a route to povert alleviation' One can consider
the health!related :DGs as the principal mission or primar obDectives of HF& till the target ear of
0,.5' )he also simultaneousl serve as prox indicators for HF&'
.0'0 Primar health care and dengue prevention and control
)he ultimate goal of controlling an epidemic disease including dengue is to prevent its transmission
and contain the spread of the disease as soon as possible' )he success of the efforts for prevention
and control of dengue relies on the effectiveness of the initiatives to control the breeding sites of the
vector b improving public and household environmental sanitation and =ater suppl# and through
sustained modification of human behaviour'.9+
)his re2uires the entire gamut of public health activities# namel# health promotion# =hich
is the process of enabling people across all socioeconomic groups to increase control over# and to
improve# their health?.98 and disease prevention and treatment =ith appropriate technolog along
=ith rehabilitation' Ho=ever# efforts to prevent and control dengue in the past have been constrained
due to inade2uate communit participation.33 as =ell as lacB of the necessar degree of intersectoral
cooperation and service coverage# =hich are the core elements of PHC'
6t has time and again been underscored that the PHC approach if applied effectivel contributes
to the achievement of desired health goals and obDectives# especiall =hen the success of a disease
control programme relies heavil on communit participation and intersectoral cooperation =ith
non!health sectors in the prevention of disease# including vector control# and the treatment of the
sicB' PHC is# therefore# indubitabl the right tool to ensure the effectiveness of strategies and related
actions'
)o secure and sustain communit participation and intersectoral cooperation# the follo=ing
activities should be carried out;
Communit participation involves Lgactive voluntar engagement of individuals and groups to
change problematic conditions and influence policies and programmes that affect the 2ualit of
their lives or the lives of othersM'.99#bo Communit participation can lead to initiatives on the part of
the communit and allo= members to assume Lo=nershipM of the development process'.97
Regarding DFEDHF control# communit participation is extremel important as can be gauged
from the fact that even those households =hich do follo= the recommended actions for prevention
ma still harbour &e' aegpti or other mos2uitoes in their homesteads and# =orse still# ma suffer
dengue infections if their neighbours do not participate in controlling domestic breeding sites'
:embers of such households ma also get infected outside their homes or at their place of =orB or
stud' )herefore# the issue regarding vector control is not about =hether source reduction is effective
but =hether and ho= communit participation can be a part of that source reduction effort'.81#.7,
=hr,9Ten'pdf
bn Hnited *ations General &ssembl' Resolution 55'0' Hnited *ations :illennium Declaration' 0,,,' http;EE==='un'orgEmillenniumE
declarationEares550e'pdf
bo Refer to Chapter .. on 6C: for definition and additional details on communit participation'
.09
6n rural areas# frontline public health =orBers =orBing in peripheral health units pla a significant
role# =ith technical and material support from district and provincial authorities# in securing the
participation from the communit in dengue control'
6n urban areas communit lifestle is 2uite different' )ogether =ith primar health!care services
offered through organi"ations responsible for urban health such as health centres and health units in
municipalities# the basic principles of health promotion such as health!promoting schools# health
communities and cities# and health =orBplaces should be applied'
)his is because# unliBe in rural areas# most urban people are engaged in the formal sector or
institutions such as schools# factories# offices and =orBplaces# marBetplaces and the liBe' Furthermore#
man of them migrate from rural areas to =orB in cities and live in slums =here the environment
and sanitar conditions are often poor or decrepit' Cector proliferation in urban areas in particular
is often associated =ith human activities that aggravate the rate of deterioration of environmental
sanitation' & change in human behaviour and lifestle is# therefore# a pressing and felt need'
)his can be achieved if individuals# families and communities are made a=are of the detrimental
effect that careless and irresponsible behaviour has on their health and are then empo=ered =ith
the necessar sBills' $ecuring communit participation in urban areas is important for the success
of the programme and re2uires a similar# et different# approach from that adopted for rural areas'
&dopting a more structured approach at various levels from the polic to the individual =ould be
more appropriate for urban areas'
Once initiated# communit participation re2uires continuous government and organi"ational
support# failing =hich it =ill not last long' )he governmentAs responsibilit to=ards developing
health!care services and facilities is# therefore# not diminished' Communit participation needs
both guidance and active interest from the government and can be sustained onl through the
constant motivation that is derived from the successes of their Doint efforts andEor =ith support from
relevant organi"ations and agencies' )he political =ill of the government is of vital importance in this
connection' 6t is extremel important that the government should adopt communit participation
as integral to the national polic for promoting health development'
Communit organi"ation and social mobili"ation
Despite constraints#bp organi"ing and mobili"ing the communit and other communit!level
staBeholders is a critical element in an effective and sustainable dengue control programme' )his
entails several tasBs;
Q Raising communit a=areness; b2 Hse different communication channels and an
appropriate media!mix such as local radio# communit theatres# posters# leaflets# group
sessionsEcivic forums# etc' to inform the communit about the morbidit and mortalit due
to dengue in a particular area and else=here and the related economic and opportunit
losses incurred b both the famil as =ell as the communitEcountr' Ho= the benefits of
the programme can be dovetailed =ith the needs and expectations of the people must
also be explained to the communit'
6nitiating communit dialogue; )he Be steps should include; recogni"ing the dengue
prevention and control issue(s-Eproblem(s-? initiating a discussion among communit
members? clarifing perceptions to reach a common understanding? expressing individual
and shared needs? and sharing a vision for the future that includes an ideal picture of ho=
the communit =ants to see itself in the context of the dengue problem'
Q
bp For additional details# refer to Chapter ..'
b2 For additional details# see section on eHealth Promotion and Prevention &ctivitiesA belo='
.07
Q 6dentifing and involving communit health volunteersE=orBers; 6dentif and select
communit health volunteersE=orBers =ho =ill be instrumental to the success of the
programme# and =ho =ill in particular galvani"e the communit into action' )he =ill
serve as health educators# communicators# problem!detectors and problem!solvers#
communit organi"ers# and leaders for health to enhance individual and famil self!care
and responsibilit as integral components of everda life'.95 )he =ill also serve as the
linB bet=een the communit and the health =orBers at the peripheral health units of the
health!care deliver sstem'
Dengue control should evolve as a natural component of the overall mixture of health
services that a communit chooses for itself' )his should not involve the Ladding onM of
ne= tasBs for the communit health volunteersE=orBers# =hich leave them exhausted
and fosters programme inefficienc' )he issue of overburdening the communit health
volunteersE=orBers =ill not arise if the communit is trul involved in the planning of and
taBing responsibilit for their o=n health and environment'
Q 6dentifing Be staBeholders for local planning and actions; With communit health
volunteersE=orBers taBing the lead# local leaders / both formal and informal / should
taBe part in the planning process so that their Bno=ledge of the local culture and their
experiences in mobili"ing communit action can be used to their advantage' )he planning
exercise ma begin b motivating Be staBeholders such as local administrative authorities#
communit and opinion leaders (village elders# religious leaders# teachers# =omenAs group
leaders# outh groups and civic organi"ations# traditional healers# etc'- and forming a local
groupEcommittee for planning and action follo=ing needs assessment'
%nsure real communit representatives are identified as leaders since the =ill serve as
good role models and as change agents for the communit in dengue prevention and
control' Dialogue =ith local leaders to galvani"e them to participate in dengue control
should be undertaBen through personal contact# group discussions and use of audiovisual
materials' 6nteraction should generate mutual understanding# trust and confidence# as =ell
as enthusiasm and motivation' )he interaction should not be a one!time affair and should
continue to achieve sustainabilit'
)he local committees should describe the importance of the uptaBe of interventionsEservices
offered to the communit and assist in building their capacit to identif their problems'
)he seriousness of the identified problems should be explained and that should include
siteEfield visits for exposure' & sense of o=nership among the local committees should be
promoted and local resources mobili"ed as much as possible' %fforts should be made to
grant recognition to the successes and best practices of local staBeholder committees b
designating them as Lmodel committeesM'
Q %mpo=ering staBeholders b building capacit; )o facilitate the contribution of
staBeholders to the programme# the should be empo=ered to possess necessar Bno=ledge
and sBills# at least in the follo=ing;
/
/
$imple methods of planning and evaluation of dengue control# namel surve of larvae
and different methods of larvicides# CO:46'br
With regard to leadership# man communities leave leadership in vector control entirel
to professionals' )his does not mean that the communit lacBs leadership from =ithin
itself' 6n fact# for primar health care to succeed# the existing and potential leadership
pool must be enhanced' Local leadership ma emerge from man sources# such as
traditional healers and birth attendants# elders and religious leaders as =ell as from
serving officials of the local communit' Leadership development re2uires that the
br For additional details refer to Chapter .0'
.1,
health professional indentif and collaborate =ith local leaders' )he communit health
=orBer is an important linB in this process' Communit!level management sstems
for ac2uiring# monitoring and distributing vector control supplies and e2uipment#
appropriate action as =ell as timel case detection and proper treatment!seeBing can
gro= from the development of local primar health!care leadership'
4aseline data collection
&n assessment of current status tells the communit =here the stand in relation to the problem
toda'
$imple tools should be developed b the members of the planning committee =ith the help of
health =orBers and supported b technical experts to collect baseline data on the nature and extent
of vector problems# breeding sites# location of human habitats# disease outbreaBs# the number of
dengue cases =hich turned severe and complicated =ithin a certain period# and sociobehavioural data
related to disease transmission# treatment!seeBing# etc' 4oth 2uantitative and 2ualitative assessments
are necessar to get a comprehensive picture' &nalsis of such data should be simplified to suit the
group' Discussions on the results of the surve should be held among members'
Programme planning
4aseline data should be used in planning dengue control programme activities' )he Be strategies
are;
Q $et feasible obDectives; )hese must be specific# measurable# achievable# realistic and time!
bound# and should create a high level of individualEcommunit motivation that is re2uired
for taBing appropriate action to resolve problem(s-'
Determine appropriate strategies and tools including those for communit education and
mobili"ation# maBing use of staBeholder Bno=ledge and experiences about the social#
cultural and behavioural aspects of the communit'
Develop an implementation plan =ith clearl defined actions'
Design a basic monitoring# evaluation and surveillance sstem'
%stablish indicators to measure progress and outputs vis!h!vis the obDectives'
6dentif resource needs (materials# financial# e2uipment# supplies# expertise# etc'- and
indicate those that can be procured locall as against those that have to be procured
externall'
Clarif roles and responsibilities of staBeholders including local committee members'
$eeB collaborative support and involvement from relevant agencies and voluntar
organi"ations at the district and communit levels'
Q
Q
Q
Q
Q
Q
Q
For planning# it is critical to engage the communit and staBeholders in various activities# as
appropriate'
6mplementationEcommunit actions;
& specific =orBplanEtimetable for each activit should be discussed among the communit or
staBeholders to achieve consensus# understand timelines and to determine =ho does =hat# =hen
and ho= and =ith =hat Bind of support from local health personnel' )he more the communit
participates in such discussions and vie=s the proposed actions as their o=n the more liBel are
the to taBe tangible and successful action' &n programme directed to=ards the communit =ill
not =orB =ithout the essential elements of communit a=areness and communit involvement at
its planning and implementation stage'.7.#.70
.1.
&chieving a consensus on action can at times lead to conflict bet=een interest groups or reveal
a degree of lacB of commitment on the part of some groups' )he leadership needs to explore options
and evaluate them from the standpoint of conflict and its resolution'
)he plan should cover the =hole range of activities from health promotion and disease
prevention / =hich include changing health behaviours and ensuring household and surrounding
environmental sanitation / to monitoring the outbreaB of disease# referring patients to the nearest
primar care unit# and :P% of the programme using simple indicators such as household index#
container index# number of cases# etc' &ctivities should be tailored to fit the communit lifestle
and the prevailing social# cultural and economic conditions'
& Be element that communit actions need to Beep in mind is the involvement of individuals
=ho are the most vulnerable or most disadvantaged in the communit' *ot everone =ill experience
the problem(s- =ith the same degree of severit' For example# economicall affluent families =ith
means of personal protection and ade2uate access to 2ualit heath care ma not have to cope =ith
health problems regularl and# therefore# perceive such problems to be individual issues' 6f an
conflict arises# the leaders are to resolve it first before progressing =ith the problem' )o resolve an
conflict# more clarification ma be needed or ne= leadersEstaBeholders ma have to get involved
so that the maDorit can convince a reluctant minorit to go along =ith them'
(a- Promotion and prevention activities;
From a health promotion perspective# gaining the trust of the entire communit is often difficult# and
=ithout trust it is hard to convince people to adopt healthier lifestles'.71 )he desired changes in a
communit as =ell as in the supportive structures necessar for communit!based health promotion
are often slo=' )here are a number of changes that are fre2uentl resisted and these are;.73
Q
Q
Q
Q
Q
changes that are not clearl understood?
changes that the communit or their representatives have no part in bringing about?
changes that threaten vested interests and securit?
changes advocated b those =hom the communit do not liBe or trust? and#
changes that do not fit into the cultural values of the communit'
Communit capacit should be developed and fostered =ith different components of the
communit =orBing together as =ell as through capacit!building and the involvement of health
promotion =orBers as mentioned above'
Health education and empo=erment;bs
Health education should raise a=areness about the magnitude# severit# transmission and control
of the disease# and initiateEsustain appropriate behavioural changebt at both the communit and
individual levels' )he behaviour change needed for vector control / =hich often involves changing
old and familiar habits or methods =ith regard to =ater storage# solid =aste disposal (DunB# etc'-#
proper personal protection measures and action to be taBen =hen having fever / should be aimed
at' )he broad categories of factors that ma influence individual and communit health behaviours
must be taBen into account =hen planning for health education activities' )hese include Bno=ledge#
beliefs# values# attitudes# sBills# finance# materials and time# and the influence of famil members#
friends# co!=orBers# opinion leaders as =ell as the health =orBers themselves'
bs For details# refer to chapter on communication on behavioural impact'
bt For details# refer to chapter on communication on behavioural impact'
.10
Health education should use locale! and context!specific communication channels (such as
mass media including local radio stations# cable )C net=orBs# ne=spapers? communit outreach
programmes such as communitEgroup sessions b communit health volunteersE=orBers# theatreE
folB media# public announcements? interpersonal communication? and posters# leaflets# activit
booBlets =ith guides# etc'- in a snergistic manner'
Different methods of education and sBill development such as group discussions# slide
presentations# demonstrations# role pla# role models# participator learning and problem solving
should be used to address factors influencing individual and communit health behaviours' 6n
other =ords# an understanding of the local sociocultural and economic characteristics# together
=ith consultation =ith staBeholders should maBe it possible to select suitable methods for health
education'
6n addition to improving Bno=ledge and a=areness# the necessar sBills in dengue prevention
and control / such as elimination of breeding sites# methods of larvicide use# and actions to be taBen
during fever / should be inculcated among the target groups' &t the communit level# the tasB to
increase peopleAs a=areness and develop necessar sBills for the desired environmental and sanitation
changes can be effectivel shifted to the =omenAs groups# self!help groups# *GOs including faith!
based organi"ations# formal and informal communit leaders# communit health volunteers# school
studentsEteachers# and the liBe' )argeting children and their families to eliminate vector breeding at
home and at school together =ith the rest of the communit should be emphasi"ed'
Health education can be implemented in a campaign mode andEor as part of a routine
programme' )he campaignsEroutine programmes could be implemented in an integrated manner
=ith other necessar communit development programmes# especiall those =ith health implications'
)he activities should be intensified before and during the period of dengue transmission =hile
continuing on a regular basis to reinforce message dissemination for sustaining appropriate actions'
)his is 2uite a challenging endeavour'
Campaigns; Organi"e Lclean!upM campaigns t=o or more times a ear to control the larval
habitats of the vectors in public and private areas of the communit' One such campaign should
be timed prior to the transmission season' )hese could be coincided =ith significant national or
communit events such as the observance of the L*ational DaM# e%arth DaA# other religious das
and so on' )hese campaigns should be supported b appropriate communication activities for the
dissemination of messages designed to change individual behaviour or promote collective action'
6ntegrated programmes; Communit programmes for dengue prevention and control could
be integrated =ith other priorities of communit development' Where municipal services related
to refuse collection# =aste =ater disposal# provision of potable =ater# etc' are either lacBing or
inade2uate# the communit and partners could be mobili"ed to improve such services' &t the same
time larval habitats of vectors can be reduced# thereb contributing to the overall effort'
$ome Be factors for the success of such programmes include the use of the LChampionM#
=ho is considered to be the LcatalstM or Lchange agentM or LBe influencerM' Communit
involvement in planning and implementation =ith the support of health personnel and related
sectors# extensive publicit via various communication channels and follo=!up evaluations are also
of crucial importance' Children should be encouraged to participate from the planning stage till
the end' Participation b municipal authorities in cities and appropriate local bodies in rural areas
should be promoted' *ovel incentives and re=ard schemes for those =ho participate in communit
programmes for dengue control should be designed to recognise their services and motivate them
into continual engagement'
.11
(b-
$urveillance (vector and disease- and treatment
&bout once a =eeB trained communit health volunteersE=orBers andEor communit leaders andE
or schoolchildren and teachers should visit households# schools# etc' in their respective catchment
areas to checB mos2uito breeding sites and appl control interventions as locall appropriate'
Other preventive behaviours such as using bednets or screens on doors and =indo=s and mos2uito
repellants# and adoption of suitable =ater!storage and household and environmental sanitation
measures should also be discussed =ith the householders'
During the period of dengue transmission# the communit health volunteersE=orBers andEor
communit leaders should visit households to maBe sure that an fever case# particularl children
or at!risB# are properl taBen care of and referred on time to the primar health care centre or other
referral health facilities for proper treatment' Communication and transportation for referring patients
must be ensured' Positive cases must immediatel be reported to the agenc concerned and action
taBen to control the disease'
(c- Containment of disease
6n an outbreaB of dengue# health staff at the peripheral health unit together =ith communit health
volunteers =ill be notified to Doin the $urveillance and Rapid Response )eam as members to carr
out disease investigation and control measures' Health education must also be imparted along =ith
case investigation and insecticide spraing'
(d- :onitoring and evaluation
People are =illing to continue their activities if the see the results of their efforts' )herefore#
evaluation of the prevention and control programme is an important element in maBing the
programme sustainable' & monitoring sstem should be designed to collect and analse necessar
data (entomological and epidemiological- as =ell as revie= ongoing programme activities through
supportive supervision' Feasible indicators should be set to measure progress in outputs and outcomes'
Participation b the communit in monitoring and evaluation should be ensured' )he results are
also to be shared =ith the communit'
6n urban areas# efforts should be made to set up a databanB =ith all the information obtained
from surves and the studies carried out in areas that either have foci of infestation or are capable
of generating them' )he databanB should also contain information on the underling causes of such
foci# vector densit per residential unit# blocB or hectare# seasonal fluctuations and oscillations# and
the relationship bet=een indicators and the incidence of diseases associated =ith or transmitted or
borne b such vectors'
(e- $ocial support and social net=orB
6n order to maBe the programme sustainable# social support from communit health volunteersE
=orBers should be provided to the communit on a regular basis' $ocial net=orBs should be
encouraged about Doint activities to both sustain and expand the dengue control programme'
6ntersectoral collaboration
)he dengue control programme cannot be successfull implemented or accomplished b the health
sector alone' Contributions from other sectors (non!health departments of the governments such as
education# public =orBs# information and mass media# environment# urban and rural development
and the liBe# and nongovernment organi"ations# the private sector# and local self!government
institutions such as the municipalities- are also re2uired to participate andEor contribute to maBe
the programme effective and sustainable'
.13
6ntersectoral collaboration is another Be element of primar health care in addition to communit
participation' Hence# an programme should ensure that the health sector interacts =ith sectors
involved =ith national development or that impact the health and =ell!being of the people# in both
urban and rural areas' )he :inistr of Health must have a focal point responsible for coordinating and
convincing other related sectors to taBe health aspects into consideration during their polic formulation'
6ntersectoral tasB forces or committees that meet periodicall for strategic planning# implementation
and oversight should be formed as =ell' High!level intersectoral meetings that are held at least once a
ear are useful in establishing the principle of sustainable intersectoral cooperation'
6ntersectoral collaboration is and should be an important feature of vector control programmes'bu
6t is =ell Bno=n that the activities of other sectors and the communit contribute to the breeding
and spread of vectors and that is =h such collaboration can help limit and control vectors in both
rural and urban areas' 6mproved intersectoral collaboration re2uires that vector control be better
integrated in the developmental plans of other sectors# or in other =ords# incorporated into health
public polic' RHealth public polic aims at creating a supportive environment to enable people
to lead health lives' 6n the pursuit of health public polic# government sectors concerned =ith
trade# agriculture# education# industr# and communications# etc' need to taBe into account health
as an essential factor =hen formulating polic' )hese sectors should be accountable for the health
conse2uences of their polic decisions; $econd 6nternational Conference on Health Promotion#
&delaide# $outh &ustralia# 5!7 &pril .799S' Health development must not compete =ith the social
and economic goals associated =ith rural# industrial and urban development? it must evolve as an
essential re2uirement on its o=n'
One starting point for intersectoral collaboration is the exchange of information bet=een sectors
to determine priorities' $ince vector propagation is linBed =ith planned activities such as road!
building# the opening up of ne= land for agriculture and urban development and the liBe# it is possible
to evolve an information sstem that graphicall depicts and forecasts important developments'
Cector control in urban areas should also include urban planning' )he planning of urban
settlements and planned urbani"ation can help enhance the 2ualit of life on the =hole as =ell as
the health and general =ell!being of urban populations and that of migrants to the cities' Planning
should be undertaBen b a multidisciplinar group that can provide the necessar guidance as =ell
as establish guidelines for consistent and ade2uate polic decisions'
)hree distinct situations associated =ith vector proliferation need to be considered in the
planning process; (i- the construction of a ne= cit? (ii- the expansion of a neighbourhood or an existing
part of a cit? and (iii- the gro=th of small pocBets in different parts of the cit' 6t is easier to plan for
a completel ne= cit and it is moderatel difficult to forecast the needs of a ne= neighbourhood
or sector of a cit# but it is extremel difficult to foresee =hat preventive or coercive measures =ill
be needed for small areas' )he multidisciplinar group in charge of urban planning or of studies to
serve as the input for urban planning activities must include phsicians# public health personnel#
vector control specialists# sanitar engineers and architects speciali"ed in urban planning'
)he ministries of health and urban development as =ell as the municipalities should organi"e
regular meetings =ith architects# buildersA sssociations and institutions such as RW&s (residentsA
=elfare associations-? and enact and implement building b!la=sEact# civic b!la=s for preventing
mos2uito breeding conditions' Public health engineers must be involved to design mos2uito!proof
=ater!coolers# lids for =ater tanBs and such utilities as =ell as initiate technolog exchanges for
effective and =ide implementation' Health impact assessment of all development proDects must also
be undertaBen b the authorities concerned'bv
bu &lso refer to Chapter .,'
bv For additional detals refer to Chapter .,'
.15
6n communit settings in urban and rural areas# the organi"ations responsible for providing
health!care services / such as the ministr of health or the municipalit / must ensure that 2ualit primar
health!care services are accessible and available to the communit and effective referral sstems from
the communit to the health!care unit are in place' )he ministr responsible for public =orBs and their
municipal counterparts in urban areas and the ministr of rural development and allied entities# including
nongovernmental organi"ations# in rural areas should be involved in preparing appropriate development
programmes that preclude mos2uito breeding' )he can contribute to source reduction b providing a
safe and dependable =ater suppl# ade2uate sanitation and effective solid =aste management' 6n addition#
through the adoption and enforcement of housing and building codes# a municipalit ma mandate
the provision of utilities such as individual household piped =ater suppl or se=erage connections and
rain=ater run!off control for ne= housing developments# or forbid open surface =ells'
6n communities# health personnel should carr out a surve and map out the area to familiari"e
themselves =ith it and identif Be staBeholders and *GOs =orBing in the communit there and
secure their cooperation for the dengue control programme' *GOs can pla an important role in
promoting communit organi"ation and participation and implementing environmental management
for dengue control' )his =ill most often involve health education# breeding source reduction and
housing sanitation improvement'
Communit *GOs ma even be informal neighbourhood groups or formal private voluntar
organi"ations# service clubs such as Rotar or =omenAs clubs# churches or other religious groups# or
environmental and social action groups' 6f needed# the should be trained b staff of the :inistr
of Health in breeding source reduction methods# recogni"ing signs and smptoms of dengue fever#
undertaBing appropriate action thereof# and other related issues' )he can help in mobili"ing and
=orBing =ith the communit to collect discarded containers# clean drains and culverts# fill depressions#
remove abandoned cars and roadside DunB# and distribute sand or cement to fill tree holes' )he ma
also pla a Be role in the formulating reccling activities and removing discarded containers from
ards and streets' $uch activities must be coordinated =ith the environmental sanitation services'
6n schools# a health education component targeted at schoolchildren should be developed and
appropriate health messages devised and communicated' 6t must be Bept in mind that the school is
an excellent medium to reach out to the main target groups# children and families (4ox 09-'
Health education models can be Dointl developed# tested# implemented and evaluated for
various age groups b the :inistr of %ducation and :inistr of Health' $uch cooperation bet=een
the t=o ministries =ill facilitate health personnel to =orB =ith schools in dengue control through
the principles of primar health care and health promotion in schools' $everal activities should be
encouraged# such as monthl cleanliness drives in different neighbourhoods supported b give!a=a
4CC materials (leaflets# hand outs# etc'-# and proDects# debates and competitions'
)he ministr of education should consider the inclusion of topics and practical =orB related
to dengue prevention and control in the curriculum and the printing of appropriate messages in
textbooBs# as appropriate' )o maBe the programme sustainable# teachers must be e2uipped =ith the
necessar Bno=ledge and sBills in dengue control through training and b =orBing closel =ith health
personnel so that the =ill be able to independentl continue the programme in the future'
)he concept of volunteers and peer support can be applied =ith schoolchildren to encourage
them to activel participate in the programme' )hese oung volunteers should be provided =ith
leadership and dengue control training so that the can be efficient as change agents for others in
their schools and communities' &s part of leadership training and enhancement of self!efficac# these
children should be involved in planning# implementing and evaluating the programme'
.1+
&t the =orBplaceEfactorEindustr# health personnel of the area should =orB =ith the
managementEunions of organi"ations to put dengue control through the concept of health =orBplace'
Raising the Bno=ledge and a=areness levels about the importance of dengue control could be done
through the LChampionsM =ho are easil recogni"ed b the communit and command respect
for their capacit to inform# convince# reinforce and advocate on the basis of evidence' Ho=ever#
convincing the management is the most challenging tasB because the programme ma eat into the
=orBing hours of emploees and improvement of =aste management and sanitation can cost both
time and mone' Hence# government policies# la=s and regulations concerning environmental
sanitation and saniti"ing =orBplaces and industries =ill be needed'
Once agreed b the management of the =orBplace# primar health care and health =orBplace
can be effectivel applied' 6n a large organi"ation# there is at least one occupational health personnel
=ho is responsible for the health and safet of emploees' Government health personnel should
=orB closel =ith the =orBplace authorit# occupational health personnel# and leaders of emploees
in matters of planning# implementing and evaluating dengue control programmes' For sustainabilit
of the programme# these staBeholders should be empo=ered =ith the necessar Bno=ledge and
sBills# including leadership sBills# to enable them to completel taBe over the programme in the future
=hile retaining technical support from government health personnel'
%xamples of successful communit participation and intersectoral involvement Ithe core
elements of PHC approach for dengue control I are illustrated belo= (4ox 3,-'
4ox 3,; Dengue control through communitEintersectoral involvement in )hailand# :alasia
and Cuba
6n )hailand#.91 PHC =as initiated in .79, and currentl there are has 7,, ,,, village health
volunteers (CHCs- =ith one CHC for ever ., households' )he CHC is selected b communit and
health staff and trained for t=o =eeBs' &fter that self!learning =ith the help of booBs and other
media is encouraged' )he Be roles and responsibilities of CHCs for dengue control include; 6%C b
means of interpersonal communication# village!level broadcasts# etc' supported b larval surves and
subse2uent control =ith temephos# Lcleaning daM campaigns# as =ell as dengue fever control b
advising patients to taBe essential drugs and refer to hospitals if there is no improvement' Warning
the communit about disease outbreaBs as informed and screening case(s- in respective catchment
areas? coordinating =ith school or house=ivesA groups to taBe care of children? producing herb!
based repellents (for example# citronella-? and conducting monthl meetings =ith health staff to
exchange information on situations and ne= 6%C materials are other responsibilities'
&ccording recognition to CHCs to sustain their commitment is a critical aspect of the programme'
6n )hailand# health volunteers are identified in the =orBplace# schools# and other places' )he local
administrative organi"ations that have the financial resources and regulations to support dengue
control encourage CHC activities' )he 4angBoB :unicipal &dministration (4:&- has also taBen
a lead role to control dengue in the national capital' Generating public a=areness# Beeping the
environment clean and eliminating breeding places as =ell as space!spraing in outbreaB situations
are the maDor responsibilities'
.18
6n :alasia.89 (Kohore $tate-# a campaign motivated householders to seeB prompt diagnosis for
an fever# destro an larval breeding site found around their premises# and organi"e voluntar
teams to inspect and control larval breeding sites in public spaces such as communit halls# parBs
and vacant lots' Dengue volunteer inspection teams (DeC6)- =ere formed in 39 localities =ith +.5
volunteers' During the three!month campaign# DeC6) teams proferred advice to .,, 75+ people#
distributed .,. 513 handouts# and inspected .33, vacant lots'
)he campaign resulted in a dramatic drop in the occurrence of dengue in the district? three
months after the campaign tracBing surves revealed that 8,G householders =ere still inspecting
their household premises regularl' )oda# 75G of DeC6) volunteers continue =ith their =orB' )he
government of the state of Kohore has decreed that the campaign be implemented throughout
the state' )he experience sho=ed that a group of committed and dedicated people can plan and
execute a proDect? and that communities and households =ill readil get involved if the behavioural
targets set are reasonable and achievable' Ho=ever# sustaining the interest of the volunteers is
fundamental'
6n Cuba.75achieving sustainabilit is one of the maDor challenges currentl in disease control
programmes' 6n 0,,./0,,0# a communit!based dengue control intervention =as developed
in three health "ones of $antiago de Cuba' *e= structures (heterogeneous communit =orBing
groups and provincialEmunicipal coordination groups inserted in the vertical programme- =ere
formed# and constituted a Be element to achieve social mobili"ation' 6n three control "ones#
routine programme activities =ere intensified' $ustainabilit of the intervention strateg over a
period of t=o ears follo=ing the =ithdra=al of external support =as evaluated'
)he interventions / evaluated through larval indices and behavioural change indicators / =ere
found to have been maintained during the t=o ears of follo=!up' 6n the intervention area#
98'5G of the =ater!storage containers remained =ell covered in 0,,3 and 7,'5G of the families
continued to use a larvicide correctl as against 0.'5G and +1'5G respectivel in the control area'
)he house indices declined from ,'15G in 0,,0 to ,'.8G in 0,,3 in the intervention area# =hile
in the control area the increased from ,'50G to 0'05G'
6nstitutionali"ation of the intervention =as reaching a saturation point b the end of the stud'
Je elements of the intervention had lost their separate identit and become part of the control
programmeOs regular activities' )he host organi"ation adapted its structures and procedures
accordingl' Continuous capacit!building in the communit led to participator planning#
implementation and evaluation of the &edes control activities' 6t =as concluded that in contrast
=ith intensified routine control activities a communit!based intervention approach promises to
be sustainable'
$trengthening of health!care services
:edical and public health services provided b the government (the health sector- and the private
sector should be assessed and strengthened since improved communit participation and intersectoral
collaboration expect robust suppl!side sstems'
.19
.1' Case 6nvestigation# %mergenc
Preparedness and OutbreaB
Response
.1'. 4acBground and rationale
Dengue outbreaBs evolve 2uicBl# re2uiring emergenc actions to immediatel control infected
mos2uitoes in order to interrupt or reduce transmission and reduce or eliminate the breeding sites
of the vector mos2uito# &e' aegpti' 6n order to meet such emergencies# it is essential that persons
at all levels# including individuals# the famil# the communit and the government# contribute to
preventing the spread of the epidemic'
)=o maDor components of the response to a dengue outbreaB are;
(.-
(0-
%mergenc vector control to curtail transmission of the dengue virus as rapidl as
possible'
%arl diagnosis and appropriate clinical case management of dengue to minimi"e the
number of dengue!associated deaths'
)hese t=o components should be implemented concurrentl' )he response =ill also differ
depending on the endemicit in countries'
For endemic countries# the overall aim is to reduce the risB of dengue outbreaBs and strengthen
control measures for an future outbreaB in order to minimi"e the clinical# social and economic
impact of the disease'
Receptive countries (i'e' dengue vectors present =ithout circulating virus-# should focus on
strategies for risB reduction' )hese should include rapid investigation of sporadic cases (clinicall
suspected or laborator confirmed- to determine =hether the are imported or locall!ac2uired#
monitoring of vectors and their abundance (particularl in regions =ith recorded or suspected
cases-# social mobili"ation# and environmental management efforts' Once a locall ac2uired case is
confirmed# the response ma be escalated to epidemic response to prevent further spread andEor
ensure interruption of transmission'
.1'0 $teps for case investigation and outbreaB response
)he follo=ing are the essential steps for case investigation and response;
$tep One; Designation of an investigation team (see &nnex ..-
Prior to conducting an outbreaB investigation# it is important that a multidisciplinar team including
epidemiologists# entomologists# microbiologists and social scientists# is designated' )he team should
taBe up the follo=ing tasBs;
.17
Q )echnical; )his involves the process of planning for laborator materials# specimen
collection# and storage and transportation techni2ues' & sample case investigation form
ma be prepared'
Logistics; &dministrative procedures including travel plans and other arrangements should
be =orBed out' 6nvestigators should establish and build partnerships =henever possible'
)he team should plan for further necessar steps to deal =ith media and other communities
in the localit'
Coordination; 4efore starting the investigation all team members should agree on the plan
and their roles stipulated and responsibilities'
Q
Q
$tep )=o; Cerification of the outbreaB
)he investigation team should visit the area as earl as possible to collect information on cases# their
clinical signsEsmptoms# histor of exposures and other relevant epidemiologicalEentomological and
laborator information (=here possible- to substantiate the outbreaB'
$tep )hree; Case definitions and additional case!finding
Case definition as mentioned in 4ox 9 should be applied to all suspect cases to decide ho= the
should be classified' %fforts should be made to find additional cases from health institutions and
communit!based investigation and to determine =hether clustering exists'
$tep Four; $tandard case investigation and methods of control
$tandard investigation includes completion of standard investigation forms (&nnex .0- and analsis
of dengue laborator reports'
Q Facilit!based (hospitalEmedical institutionEclinics# etc'- investigation;b=
/ Contact the medical provider =ho diagnosed or ordered the testing of the case and
obtain the follo=ing information' )his includes copies of hospitalEclinic records# etc'
*ote; 6f the phsician submitted samples to an appropriate laborator facilit# the case
investigation form ma alread be completed or started' )r to obtain a cop'
/ 6dentif if the patient =as ill =ith smptoms of dengue fever'
b Refer to 4ox 9'
b Record onset date of first smptom'
/ %xamine the laborator testing that =as done? if not et reported'
b Record date of serum specimen(s- andEor tissue (specif- collection'
b Record or obtain copies of serolog results and virus isolation and PCR tests# if
done'
/ Collect demographic data and contact information of case Rfull name# date of birth#
countr# sex# raceEethnicit# home address# occupation and =orB address# relevant
phone number(s-S'
Record hospitali"ation details; location# admission and discharge dates'
Record outcomes; recover or date of death? an mental status changes'
/
/
b= &dapted from; Dengue Fever# Dengue Haemorrhagic Fever# Dengue $hocB $ndrome 6nvestigation Guidelines' Cersion ,.E 0,.,'
Jansas# H$&'
.3,
Q Communit!based investigation;bx
/
/
6ntervie= the case or prox to determine source and risB factors? focus on incubation
period of t=o =eeBs prior to illness onset'
)ravel histor;b
b )ravel outside to=nEcit; list the places visited and dates'
b )ravel outside countr; list countr# date of departure and return (to the countr
of origin-'
b &n exposure to mos2uitoes (include dates and places-'
b Collect information from case for the contact investigation (see belo=-'
/ 6nvestigate epidemiolog linBs among cases (clusters# household# co!=orBers# etc'-
Contacts are those =ho have exposure' %xposure is defined as;
b travel to a dengue endemic countr or presence at a location =ith ongoing outbreaB
=ithin previous t=o =eeBs of dengue!liBe illness? or
b association in time and place =ith a confirmed or probable dengue case'
/
/
6dentif other individuals =ho ma have had contact =ith the source in the t=o =eeBs
prior to the case becoming ill to find unreported or undiagnosed cases'
6f travel b the case occurred as part of a commercial travel group# investigate travel
companions'
Follo= blood and bod fluid precautions as prescribed b phsician'
Prevent access of mos2uitoes to the case until fever subsides through the use of screened
sicBrooms# spraing =ith insecticides# and bednets'
%ducate all contacts on the smptoms of dengue fever'
6nvestigate smptomatic contacts =ith dengue!liBe illness as suspect cases# collect
acute and convalescent specimens and coordinate testing at the appropriate laborator
facilit'
$mptomatic contacts should be instructed to rest# drinB plent of fluids# and consult a
phsician' 6f the feel =orse (example# develop vomiting and severe abdominal pain-
03 hours after the fever declines# the should immediatel seeB medical evaluation
=ith their phsician or hospitalEclinic'
Q Contact investigation;b"
/
Q 6solation# =orB and da care restrictions;
/
/
Q Contact management;
/
/
/
$tep Five; Laborator and environmental information
Laborator confirmation is essential for establishing the aetiolog of the disease causing the
outbreaB'ca
bx &dapted from; Dengue Fever# Dengue Haemorrhagic Fever# Dengue $hocB $ndrome 6nvestigation Guidelines' Cersion ,.E0,.,'
Jansas# H$&'
b )ravel to an active dengue fever area is a crucial element'
b" &dapted from; Hemann# D' L' (%d'-; Control of Communicable Diseases :anual' .9th edition' 0,,3' &merican Public Health
&ssociation' Washington DC# H$&'
ca 6t is important to have an idea about =hat specimens =ill be collected# stored and shipped to the appropriate laborator' Refer to
Chapter 5'
.3.
6t is not necessar to confirm the diagnosis of all cases detected during an outbreaB' 6t is sufficient
to confirm diagnosis in a sample of cases at the beginning# the interim period and the resolution of
the outbreaB' Containment measures should not be delaed b lacB of laborator diagnosis'
&e' aegpti is the primar vector# =hich is a container habitat species and =ell entrenched in
urban areas' %ntomological indices of container index (C6-# house or premise index (H6- and 4reateau
6ndex (46- should be determined for the affected areas' $imilarl# tpes of containers# both indoors
and outdoors# should be mapped for control of vector breeding'
$tep $ix; Communication =ith authorities concerned and recommendation of
control measures
Findings should be communicated to appropriate decision!maBers and control measures
recommended' )he follo=ing action is to be carried out b local health authorities'
Q &n %mergenc &ction Committee (%&C- (see &nnex ..- ma be constituted to coordinate
activities aimed at emergenc vector control measures and management of serious cases'
)he committee ma comprise administrators# epidemiologists# entomologists# clinicians
and laborator specialists# social scientists# school health officers# health educators and
representatives of other related sectors including civil societ' )he functions of the %&C
=ill be to;
/ taBe all administrative actions and coordinate activities aimed at the management
of serious cases in all medical care centres and undertaBe emergenc vector control
measures?
dra= urgent plans of action and resource mobili"ation in respect of medicines#
intravenous fluids# blood products# insecticides# e2uipment and vehicles?
form a rapid action team comprising epidemiologists# entomologists and laborator
specialists to undertaBe urgent epidemiological investigations and provide on!the!spot
technical guidance re2uired and logistic support?
liaise =ith inter!sectoral committees to mobili"e resources from non!health sectors#
namel Hrban Development# :inistr of %ducation# :inistr of 6nformation#
Legal Department# Water $uppl Department# Waste Disposal Department and
share and disseminate information for the elimination of the breeding potential of
&e' aegpti? and
interact =ith the media and *GOs for health education and communit
participation'
/
/
/
/
$tep *ine; 6mplementation of control measures
Control measures should be initiated as soon as the outbreaB is verified even before an epidemiological
investigation is started or completed' )he usuall direct against one or more segments in the chain
of transmission (agent# source# mode of transmission# portal of entr or host- that are susceptible to
intervention'
For control of epidemics# vector control is considered to be one of the important strategies
to interrupt or reduce transmission' &dult mos2uitoes can be controlled b the use of chemical
insecticides' 6t should be emphasi"ed# ho=ever# that rapid and effective source reduction for
elimination of breeding sites of vector mos2uitoes =ill achieve the same results' :oreover# larval
control is more economical and provides sustainable control b eliminating the source of ne=l!
emergent adult mos2uitoes' Chemical space spras are not effective in most of the conditions and it is
rare that an epidemic =ill be controlled b using these methods' 4ecause of their visibilit# ho=ever#
.30
people thinB that the government is active in disease control =hen space spras are carried out'
)his often creates a false sense of securit and preventsEslo=s do=n communit as =ell as individual
efforts for vector control' Hence# communities need to be engaged appropriatel' 6ndoor space
spra =ith prethrum 0G extract (,'0G read to spra solution =ith Berosene oil- is applied =here
the case(s- isEare detected and in surrounding houses'
Public education must continue to reinforce ho= important it is for people to seeB medical
attention if the have dengue smptoms# reduce larval habitats and use options for personal
protection'
During an epidemic the aim of risB communication# generall through the media# is to build
public trust' 6t is done b announcing the epidemic earl# communicating openl and honestl =ith
the public (transparenc-# and particularl b providing accurate and specific information about
=hat people can do to maBe themselves and their communit safer'
)his gives people a sense of control over their o=n health and safet# =hich in turn allo=s
them to react to the risB =ith more reasoned responses'15 6n endemic countries# involving the media
before the occurrence of the seasonal increase in dengue enhances the opportunit to increase
public a=areness about the disease and the personal and communit actions that can be taBen to
mitigate the risB'
$tep )en; Follo=!up of implementation of control measures
6t is important to follo= up and ensure consistenc of implementation control measures and assess
the effectiveness of control measures' &n absence of ne= cases for at least t=o incubation periods
of the disease under investigation could suggest that the outbreaB is subsiding' )he local health
authorities in consultation =ith staBeholders can decide =hen to declare the outbreaB to be over'
.31
.33
.3' :onitoring and %valuation of
DFED HF Prevention and Control
Programmes
6t is essential to monitor and evaluate the progress of DFEDHF prevention and control programmes'
)he enable the programme manager to assess the effectiveness of control initiatives and must be
continuous operational processes'
)he specific obDectives of programme evaluation are to;
Q
Q
Q
Q
Q
Q
measure overuse progress and specific programme achievements?
detect and solve problems as the emerge?
assess programme effectiveness and efficienc?
guide the allocation of programme resources?
collect information needed for revising polic and replanning interventions? and
assess the sustainabilit of the programme'
.3'. )pes of evaluation
)here are t=o tpes of evaluation;
Q
Q
:onitoring'
Formal evaluation'
:onitoring
:onitoring or concurrent evaluation involves the continuous collection of information during
programme implementation' 6t allo=s immediate assessment and identification of deficiencies
that can be rectified =ithout delaing the programmeAs progress' :onitoring provides the tpe of
feedbacB that is important to programme managers' :ost monitoring sstems follo= the 2uantum
and timing of various programme elements such as activities undertaBen# staff movements# service
utili"ation# supplies and e2uipment# and budgeting'
Focus should also be given to the process of implementation of the dengue control strateg
in time and space and the 2ualit of implementation# seeBing reasons for successes and failures'
:onitoring should be undertaBen b persons involved in the programme at various levels' )his
exercise b programme managers =ill give a better and deeper understanding of the programmeAs
progress# strengths and =eaBnesses' )he information collected should help programme managers
strengthen the =eaBer linBs and optimi"e output'
.35
Formal evaluation
6n addition to regular monitoring# =hich is generall built!in# there is also a need for more formal
evaluation at different intervals to obtain a precise picture of the progress of the programme' )his tpe
of evaluation is even more essential =hen the programme is failing to achieve its targets or goals or
=hen it has become static' )his tpe of special evaluation should be done sstematicall and should
taBe into account all programme elements' )he main idea of such a stud is to determine =hether
the programme is moving on course to=ards its targets and goals# to identif ne= needs / particularl
for increased inputs (e'g' / additional manpo=er# mone# materials# 6%C activities# capacit!building-
and to identif operational research areas for maximum operationali"ation' Formal evaluation#
therefore# should sstematicall assess the elements outlined belo=' Ho=ever# the evaluation can
cover one or more other processes depending on the obDectives of the evaluation'
Q
Q
Q
%valuation of need# i'e' evaluation of the relative need for the programme'
%valuation of plans and design# i'e' evaluation of the feasibilit and ade2uac of programme
plans or proposals'
%valuation of implementation# i'e' evaluation of the conformit of the programme to its
design' Does the programme provide the goods and services laid do=n in the plan in terms
of both 2ualit and 2uantitc
%valuation of outcomes# i'e' evaluation of the more immediate and direct effects of the
programme on relevant Bno=ledge# attitudes and behaviour' For training activities# for
example# outcomes ma relate to the achievement of learning obDectives and changes in
staff performance'
%valuation of impact# i'e' evaluation of the programmeAs direct and indirect effects on the
health and socioeconomic status of individuals and the demograph of the communit'
Q
Q
.3'0 %valuation plans
&n evaluation plan should have realistic and measurable targets' With this proviso# the development
of an evaluation plan consists of the follo=ing steps;
Q
Q
Q
Q
Clarification of the obDectives of the evaluation; these must be agreed upon b all
concerned'
6dentification of the resources available; there must be sufficient resources to collect the
data on the scale envisaged and turn that into useful information'
$election of the tpe of evaluation; once the purpose of the evaluation is clear# it is necessar
to decide the tpe of evaluation and the depth of information re2uired'
$election of indicators; a good indicator is directl related to programme activities and
anticipated outcomes' )herefore# indicators chosen should be limited in number# readil and
uniforml interpretable# and operationall useful' For comparison purposes# use of standard
indicators =ill introduce consistenc into programme revie=s and allo= comparison over
time and among countries' &lthough there are man =as of classifing indicators# one
useful =a is according to the programme structure outlined in 4ox 3.' )hus# there can
be input# process# outcome and impact indicators'
Formulation of the detailed evaluation plan; the detailed plan should include the obDectives#
methods# sampling procedures# source of data and methods of data analsis to be used
as =ell as budgeting and administrative arrangements' 6t should also give details of staff
responsibilities for each activit# the reporting mechanism# and the strategies to ensure that
results are used for programme replanning and implementation'
Q
.3+
Q
Q
Q
Collection of data; the obDective of this step is to ensure that procedures are follo=ed in
such a =a that data are collected in a reliable and timel manner'
6nterpretation and analsis of data; the decisions about the main approaches to data analsis
=ill have been made =hen the indicators are selected and the detailed plan formulated'
Re!planning; at this step the results of the evaluation are fed bacB into the managerial
process' Hnfortunatel# it is often this re!planning step that is done the least correctl'
Carious aspects of programme that can be monitored and evaluated are presented in
4ox 3.'
4ox 3.; &spects of programme that can be evaluated
6n 4ox 30# a scheme is suggested to identif expected results pertaining to an dengue prevention
and control programme component (example# 6C:.3+- and decide $:&R)cb indicators for monitoring
and evaluation of targets# =hich in turn# =ill re2uire the development or use of available methodsE
tools'
4ox 30; :P% frame=orB
%xpected
results
.'
&ctivit
ObDectivel verifiable
indicators
.' Process indicators
0' Outcome indicators
1' 6mpact indicators
:eans of
verification
)argets
Near . Near 0
&ssump!
tionsErisBs
Resources
re2uired
.3'1 Cost!effective evaluation
6n most countries of the Region# it is difficult to estimate ho= much mone dengue prevention andE
or control programmes use up annuall' Often# dengue or &edes control programmes function as
branches of malaria control programmes andEor operate sporadicall in response to real or perceived
emergencies' $upplies# e2uipment and personnel are not continuousl available' 6n emergencies# or
under public pressure# expenditures from national funds or donations can be ver high# especiall
for insecticides# =hile little mone is available for routine operations at other times'
&s a result# substantial funds are spent on unstructured activities# the results of =hich are
difficult or impossible to evaluate' 6t is# therefore# important that economic factors be considered
during the reorgani"ation or strengthening of dengue control programmes' 6nformation of this nature
is essential for; planning# evaluating cost!effectiveness of individual control measures# comparing
cb specific# measurable# achievable# relevant# time!bound'
.38
different control measures# and evaluating ne= methods' %xamples of tpes of cost estimates that
should be obtained are described belo='
(a- Cector control costs
Operational costs; 6t is not enough to merel estimate the 2uantities of insecticide re2uired' Costing
should begin =ith the si"e of the population to be protected# the number of premises or extent of
the area to be treated# as =ell as the personnel re2uirements (at all levels- based on the fre2uenc
of application' Personnel costs include expenditure on training# safet e2uipment# and per diem or
overtime =here applicable'
6nitial capital costs for e2uipment and on depreciation# andEor shared usage =ith other
programmes must also be considered' Operational costs# especiall for HLC space spraing# should
include machiner and vehicle maintenance# regular calibration of pumps# as =ell as the costs of
monitoring vector populationsA penetration of droplets# and the level of compliance b the local
population# depending on the control measures emploed' )he compilation and analsis of data
also involves costs'
%nvironmental management; $ource reduction programmes are often considered less
expensive alternatives to chemical control measures' Ho=ever# this ma onl be true for short!term
Lclean!upM campaigns' Long!term success in environmental management re2uires health education#
public health communication# and development of communit cooperation' %ducational materials#
promotion through the media# introduction of sanitar concepts into school curricula# training of
teachers# etc' ma involve considerable costs' $ome of these costs can be covered b other sectors
such as education (municipal or private- and such collaboration should be encouraged'
%nvironmental management campaigns# especiall clean!up campaigns# ma fail due to lacB
of transport support and inade2uate facilities for solid =aste disposal' Communities# especiall in
cities# need either to invest in such e2uipment or maBe arrangements to rent or borro= them from
other sources' &s =ith chemical control# environmental management programmes must be evaluated
and the vector and disease data organi"ed and analsed' &ll of these activities involve costs'
(b- Laborator surveillance
:ost national laboratories that perform serolog or virus isolation for other agents (measles# polio#
etc'- can also include dengue' )he cost of the dengue component must be ade2uatel assessed
based on an analsis of the number of samples processed# the cost of reagents# and the e2uipment
re2uired' Long!term investment must be made and accounted for in the training of professionals
and technicians' Refresher training sessions need to be routinel scheduled'
(c- Coordination =ith hospitals and medical supplies
6n addition to coordination among its component parts# the programme re2uires coordination
bet=een curative and preventive services and these expenses should be recogni"ed' &n information
exchange net=orB is also re2uired' 6n order to meet the potential for epidemic situations# hospital
supplies and e2uipment must be readil available and be replaced andEor updated regularl' %ach
countr should estimate the costs associated =ith individual case management' )hrough cooperation
=ith and information from neighbouring countries and international organi"ations# countries must
estimate its re2uirements on an annual or biennial basis'
.39
(d- $urveillance
Guidelines for entomological and epidemiological surveillance methods are given in the chapter
on surveillance' )hese can be used as a frame=orB to estimate the si"e of the re2uired surveillance
sstem in a given cit# state# province or countr# as =ell as the cost of the surveillance that# in addition
to laborator costs and information exchange# includes expenditure for collecting and processing
samples in the field'
(e- Communit participation# health education and communication costs
6n addition to the costs that have alread been mentioned# liaison must be established =ith
communit groups' )his is in order to provide technical assistance =here re2uired and to determine
ho= the health authorities can assist these groups =ith their individual and collective efforts' Health
education and communication activities =ill pla a significant role in communit participation
efforts' Conse2uentl# it is extremel important to estimate their cost' )he calculation of the actual
costs of health education# communication and communit participation should also be made on
an annual basis'
(f- $ocial and economic impactcc
)he social and economic burden of DFEDHF is another element to be considered =hen determining
the cost!effectiveness of DHF control' 6n a .775 stud carried out b the Facult of )ropical :edicine
of :ahidol Hniversit in )hailand#.7+ in collaboration =ith the Facult of %conomics of ChulalongBorn
Hniversit ()hailand-# several parameters Rtreatment!seeBing behaviour# direct impact# i'e' cost of the
illness of patients (average 8'7 das- and time!cost spent b parentsEcaretaBers (average 7'5 das-# and
indirect impact due to disruption of famil life resulting in increased expensesS =ere identified' From
the provider side# expenditures for the hospitali"ation of DHF patients included drug# laborator and
nursing costs and the cost of prevention and control' 6n a recent stud in )hailand# =eighted average
of direct patient cost (including travel# food# lodging and opportunit- =as estimated at H$i +. per
case excluding the cost of the government component of services in hospital'.78
&nother approach is to measure the disabilit!adDusted life ears (D&LNs- associated =ith dengue
infection' & stud in Puerto Rico sho=ed a constant increase in the D&LNs associated =ith dengue
infection from .793 to .773'.79 $urprisingl# the D&LNs associated =ith dengue infection in Puerto
Rico =ere of the same order of magnitude as the D&LNs relating to a number of other infectious
diseases in Latin &merica# including malaria# tuberculosis# sexuall transmitted diseases (excluding
H6CE&6D$-# hepatitis# the childhood cluster and the tropical cluster'
& more recent.77 stud on the economic impact of DFEDHF at the famil and population levels#
accounting for the direct cost of hospitali"ation# indirect costs due to loss of productivit# and the
average number of persons infected per famil# observed a financial loss of approximatel H$i +.
per famil# =hich =as more than the average monthl famil income in )hailand at that time' )he
D&LNs =ere calculated using select results from a famil!level surve# and resulted in an estimated
308 D&LNsEmillion population in 0,,.' )his figure =as of the same order of magnitude as that of
impact of several diseases that =ere given priorit in $outh!%ast &sia# such as malaria# meningitis#
hepatitis and the tropical cluster (trpanosomiasis# Chagas disease# schistosomiasis# leishmaniasis#
lmphatic filariasis and onchocerciasis-'
cc For further reading; Finsterbusch# J' and WicBlin 666# W'&'C' (.797-' 4eneficiar participation in development proDects; empirical
tests of popular theories# %conomic Development and Cultural Change# Chicago; the Hniversit of Chicago'
.37
(g- Other costs
%ach national programme =ill have additional cost elements depending on the government structure
and the re2uirements of their accounting sstems' )hese ma include depreciating capital investments
(vehicles# pumps# etc'-# shared use of facilities (=arehouses# administrative services# etc'-# and in!
countr purchase and deliver of supplies (insecticides-'
Once the costs of the components of individual dengue control proDects have been determined#
it =ill not onl be possible to estimate total costs but also to identif =here savings ma be achieved
through collaboration =ith other government agencies and the private sector' )he cost data collected#
along =ith the epidemiological and entomological data# provide an initial frame=orB for conducting
cost!effectiveness studies of the different interventions used in the national programme'
*e= methods and improvements in existing methods can be more effectivel evaluated for
operational use =hen their economic benefits or limitations are full understood' )he benefits of such
methods to dengue control programmes should be considered in the light of social and economic
considerations as =ell as the impact of epidemics on health'
.5,
.5' $trategic Plan for the Prevention
and Control of Dengue in the
&sia!Pacific Region; & 4i!regional
&pproach (0,,9/0,.5-
.5'. *eed for a biregional approach and development of a
$trategic Plan for the Prevention and Control of Dengue in
the &sia!Pacific Region
Dengue is emerging rapidl as one of the maDor public health problems in countries of the &sia!Pacific
Region# =here nearl .'9 billion people are estimated to be at risB against a global total of 0'5 billion'
%pidemics of dengue are being reported more fre2uentl and in an explosive manner' )he disease
continues to spread to ne= areas# including rural settings# in affected countries' Rapid spread of
dengue in the &sia!Pacific Region is attributed to globali"ation# rapid unplanned and unregulated
urban development# poor =ater storage and unsatisfactor sanitar conditions' 6ncreased travel has
contributed to the spread of viraemia'
6n a region =here ecological and epidemiological conditions are similar# effective control of
dengue is not possible if the efforts are limited to one countr or a fe= countries' $ince dengue
does not respect international boundaries# control efforts have to be coordinated regionall' 6n this
direction# WHO tooB an initiative to develop a L$trategic Plan for the Prevention and Control of
Dengue in the &sia!Pacific RegionM' Development of such a strategic plan is also important in meeting
the re2uirements of the 6nternational Health Regulations (6HR- 0,,5'
$alient components of the &sia!Pacific Dengue $trategic Plan (0,,9/0,.5-0,, are outlined
belo='
.5'0 Guiding principles
)he Dengue $trategic Plan underlines several guiding principles intended for formulation#
implementation and evaluation of activities in the prevention and control of dengue' )he $trategic
Plan;
Q
Q
supports collaboration# cooperation and biregional solidarit for effective and sustained
prevention and control of dengue in countries of the &sia!Pacific Region'
uses existing polic frame=orBs and infrastructure as integral parts of dengue prevention
and control programmes# and integrates disease surveillance =ithin the umbrella of basic
health services'
uses national# multicountr# biregional and global partnerships to support countr activities'
)he $trategic Plan =ill be harmoni"ed =ithin the &sia!Pacific Dengue Partnership
(&PDP-'
Q
.5.
Q
Q
Q
uses evidence!based interventions and best practices in developing and implementing
dengue prevention and control programmes'
uses net=orBing to optimi"e available resources'
supports intersectoral and interprogrammatic collaboration to maximi"e the provision
of integrated services? e'g' developing linBs =ith the &sia!Pacific $trateg for %merging
Diseases (&P$%D- to strengthen health sstems for surveillance and thereb contribute to
6HR (0,,5-'
promotes the adoption of evidence!based interventions =hile at the same time recogni"ing
the need for vaccine development# improved diagnostics and drugs and other innovations
and intensifing related efforts'
Q
.5'1 Goal# vision and mission
)he goal of the $trategic Plan is to reduce the disease burden due to maDor parasitic and vector!borne
diseases to such an extent that the are no longer maDor public health problems'
)he vision of the $trategic Plan is to minimi"e the health# economic and social impact of the
disease b reversing the rising trend of dengue'
)he mission of the $trategic Plan is to enhance the capacit in countries of the &sia!Pacific
Region through partnerships so that evidence!based interventions can be applied in a sustainable
manner through better planning# prediction and earl detection# characteri"ation and prompt control
and containment of outbreaBs and epidemics'
.5'3 ObDectives
)he obDectives are to enable :ember countries to achieve the regional goal and reali"e the mission
and vision of dengue prevention and control' Different countries =ill achieve these obDectives and
expected results in the context of their current capacities and policies'
General obDective
Q )o reduce incidence rates of dengue fever and dengue haemorrhagic fever'
$pecific obDectives
Q
Q
Q
Q
Q
Q
)o increase the capacit of :ember countries to monitor trends and reduce dengue
transmission'
)o strengthen capacit to implement effective integrated vector management'
)o increase the health =orBersA capacit to diagnose and treat patients and improve health!
seeBing behaviour of communities'
)o promote collaboration among affected communities# national health agencies and maDor
staBeholders to implement dengue programmes for behavioural change'
)o increase capacit to predict# detect earl and respond to dengue outbreaBs'
)o address programmatic issues and gaps that re2uire ne= or improved tools for effective
dengue prevention and control'
%xpected results
)he summar of expected results vis!h!vis obDectives is given in )able .3'
.50
)able .3; $ummar of expected results related to obDectives
$' *o'
.
ObDectives
)o increase the capacit
of :ember $tates
to monitor trends
and reduce dengue
transmission'
%xpected results
.' %xisting standard dengue case definition adopted'
0' Laborator surveillance strengthened'
1' Regional dengue information sstem developed'
3' :echanisms for sharing timel and accurate data
strengthened'
5' RegionalEintercountr response to timel advisor and
resource (personnel# financial# stocBpiling- mobili"ation
improved'
+' 6ncorporate dengue surveillance (case# vector and
seroprevalence- into an integrated and strengthened
disease surveillance sstem'
8' :onitoring :ember $tatesA surveillance sstems'
0 )o strengthen capacit
to implement effective
integrated vector
management'
.' Cectors full described and vector indicators regularl
monitored'
0' Regional 6C: $trateg developed'
1' %vidence!based strategies to control vector populations
adopted according to 6C: principles'
3' :ember $tate!level 6C: strateg and guidelines
developed'
5' Consistent =ith regional strateg'
+' Capacit to implement 6C:# including training and
recruitment of entomologists# strengthened'
8' :echanisms to facilitate communit involvement for
vector control established'
9' Rational use of insecticides for vector control promoted'
7' Cector resistance monitoring strengthened'
1 )o increase health
=orBersA capacit
to diagnose and
treat patients and
improve health!
seeBing behaviour of
communities'
.' Public a=areness increased on the =arning signs and
actions to be taBen for dengue'
0' $trengthen capacit of health!care providers to
diagnose# treat or refer cases'
1' Laborator support for case management improved'
3' Referral net=orB sstem in public and private sectors
established'
.51
$' *o'
3
ObDectives
)o promote
collaboration among
affected communities#
national health agencies
and maDor staBeholders
to implement dengue
programmes for
behavioural change'
%xpected results
.' CO:46 resource group for CO:46 implementation
established'
0' &ssessment# including situation analsis of current
strategies (social mobili"ationEhealth education- and
extent and success of CO:46 if implemented (=ith
respect to dengue and other vector!borne diseases-'
1' CO:46 training implemented'
3' CO:46 approach disseminated and promoted'
5' Development and implementation of CO:46 plan
supported'
+' Partnerships set up =ith private sectorEand other multi!
staBeholders'
5 )o increase capacit
to predict# detect earl
and respond to dengue
outbreaBs'
.' %arl =arning sstemEdengue surveillance sstem
developed and scaled up'
0' Dengue outbreaB standard operating sstem developed'
1' Coordination mechanisms =ithin :oH and =ith other
programmes and sectors established'
3' 6ntercountr coordination mechanisms in place'
5' & mechanism to incorporate rumour surveillance
developed and implemented'
+' Regional outbreaB response guidelines developed'
8' )he abilit of health =orBers to respond to the dengue
outbreaB strengthened'
9' RisB communication plan developed'
+ )o address
programmatic issues
and gaps that re2uire
ne= or improved tools
for effective dengue
prevention and control'
.' Operational research capacit in dengue of existing
academicEscientific institutions in :ember $tates
enhanced'
0' Disease burden estimated (epidemiological impact#
social costs and cost of illness-'
1' *e= Bno=ledge gained# ne= tools developed# existing
tools improved and ne= strategies created'
3' %valuation of tools and strategies for dengue control and
case management'
5' )ranslation of ne= improved tools into programmatic
activities'
$ource; World Health Organi"ation' &sia!Pacific Dengue $trategic Plan (0,,9 / 0,.5-' 0,,9' $%&ERC+.E.. 6nf' Doc' $%&ROEWHO'0,,
.53
.5'5 Components of the $trateg
)he follo=ing are the components of the strateg;
(.-
(0-
(1-
(3-
(5-
(+-
Dengue surveillance'
6ntegrated vector management'
Case management'
$ocial mobili"ation'
OutbreaB response communication'
Research'
.5'+ $upportive strategies
Dengue outbreaBsEepidemics are a reflection of the failure of the public health sstem in a countr to
prevent and control dengue' Dengue is a neglected disease that becomes visible during an epidemic'
6nterest as =ell as commitment levels decline after the epidemic is controlled' :an of the affected
countries do not even have a national programme for dengue' 6ts control re2uires a high level of
sustained government and public interest and commitment# tangible strengthening of the public health
infrastructure# intersectoral and intercountr collaboration# and communit participation' & number of
supportive strategies are needed for effective implementation of the &sia!Pacific $trategic Plan'
$upportive polic environment
& national polic should be prepared b the :inistr of Health in collaboration =ith other ministries
and departments concerned' )he polic should be the legal and regulator frame=orB =hich needs
to ensure the health impact assessment of development proDects related to industr and housing
infrastructure and also appropriate designing of utilities such as evaporation (desert- coolers# =ater
storage tanBs# refrigerators and air!conditioners'
6n addition# dengue should be made a notifiable disease# if not alread# as mandated under
the 6HR (0,,5-' )he polic document should be endorsed b different staBeholders including
the legislators' & health public policcd includes the provision of health impact assessment of
medium and large developmental proDects that have the potential of encouraging breeding
of the vector' )he health public polic should contribute to effective vector control and reduce
vector breeding'
:obili"ation of resources
Despite the gro=ing threat from dengue# resources for the control of dengue have not increased'
*ational and international support continues to fall far short of the needs# even though there are
untapped resources at the national# regional and global levels' )o mobili"e additional resources#
snchroni"ed action is needed =ith support from partners and different staBeholders' Harmoni"ation
of the strateg =ith the &sia!Pacific Dengue Partnership (&PDP- is also re2uired to mobili"e the
additional resources needed' Countries need to prepare operational plans that identif funding gaps'
6n addition# an advocac plan should be prepared and implemented for mobili"ing the resources
on a sustained basis'
cd Health public policies improve the conditions under =hich people live; secure# safe# ade2uate# and sustainable livelihoods# lifestles#
and environments# including housing# education# nutrition# information exchange# child care# transportation# and necessar communit
and personal social and health services' Polic ade2uac ma be measured b its impact on population health' http;EE==='searo'=ho'
intELinBFilesE)oolsTPTGuidelinesT$%&!:&L!055TT4ooBfold'pdf' Health public polic is characteri"ed b an explicit concern for health
and e2uit in all areas of polic and b accountabilit for health impact' http;EE==='=ho'intEhealthpromotionEconferencesEpreviousE
adelaideEenEindex.'html
.55
*ational dengue control programmes in :ember countries should be implemented as part
of national polic' )hese programmes have to find a niche and visibilit =ithin the existing disease
surveillance programmes and the vector!borne disease control programme' 6t has to be a part of the
basic health services and be able to find a place =ithin the polic of decentrali"ation in the national
programme' LinBage to the 6HR (0,,5- should also be encouraged'
Dengue prevention and control efforts =ill be successful onl if it becomes everoneAs concern and
responsibilit' $ustained action is re2uired at the individual# famil and communit levels' 6t has to
be supported b the local self!government and the national government through the involvement
of the health and other relevant sectors'ce
&t the level of the individual and the famil# self!reliant actions are needed for effective vector
control and personal protection' )his includes regular cleaning of containers in =hich =ater is
stored# safe disposal of solid =aste and prevention of vector breeding' Other responsibilities include
monitoring vector activit =ithin households and observing a =eeBl dr da' Cector breeding sites
in the communit include public places such as schools# places of =orship# cinema halls# hospitals
and communit centres'
4esides supporting individuals and families# communit actions can assist in monitoring and
reducing vector breeding' Communit groups can also =orB =ith industr that can help in dealing
=ith the problem of used tres# curing of plastic and cement =ater storage tanBs and reducing the
risB of vector breeding in refrigerators and =ater coolers' 6n addition# specific measures such as
larviciding# insecticide spraing and biological control activities can be supported# subse2uent to
training and capacit!building'
For initiating and sustaining communit participation# a strategic communication plan should
be developed' &doption of a CO:46 strateg has demonstrated success in man countries' 4est
practices are recommended for documentation and adoption'cf
Partnerships
)he &sia!Pacific Dengue Partnership (&PDP- for Dengue Prevention and Control =as formed in
:arch 0,,+'cg &t a meeting of the Core Group organi"ed b the Regional Offices for the $outh!%ast
&sia and Western Pacific Regions and the Government of $ingapore held during Februar 0,,8 in
$ingapore# the $trategic Frame=orB for the &PDP =as finali"ed' & biregional plan and a road map
for the establishment of an executive board# secretaries and =orBing groups =ere also agreed upon#
in addition to all other relevant administrative matters'
)he &sia!Pacific $trategic Plan for Dengue Prevention and Control recogni"es that partnerships
are re2uired to strengthen collaboration bet=een countries# establish net=orBs =ithin the countr
and across borders# enhance cooperation in access to innovations# and contribute to the discover
of improved tools' 6n addition# partnerships are crucial for mobili"ing additional resources and
sho=casing the cause of dengue prevention and control through advocac and sharing of 2ualit
Bno=ledge on dengue =idel'
ce For additional details# refer to Chapter ..'
cf For additional information# refer to Chapter .1'
cg WHO' :eeting of Partners on Dengue Prevention and Control in &sia!Pacific# Chiang :ai# )hailand# 01/03 :arch 0,,+
($%&!C4C!7.-'
.5+
Programme planning and management
%ffective programme management necessitates the preparation of an operational plan that identifies
the resources committed and resource gaps' )he capacit of staff at different levels / national# sub!
national and district / in programme planning and management needs to be increased' Human
resource development is a Be component of capacit development' )he development of capacit
for the prevention and control of dengue is not an isolated effort but an integral part of strengthening
the health sstem for improving the control of vector!borne diseases# disease surveillance and
provision of basic health services'
Capacit development is to be undertaBen based on training needs# the institutional environment
and national polic' $ince different countries in the &sia!Pacific Region have different health sstems
and policies# the dengue prevention and control programmes have to be consistent =ith the national
situation' )he &sia!Pacific $trategic Plan should be used b countries to developEstrengthen operational
plans# including finding the best options'
%ven =ithin a decentrali"ed or an integrated frame=orB# it is necessar to identif the specific
needs of dengue prevention and control so that control measures have ade2uate visibilit' )hese
include increased laborator capacit# standard case management of dengue# and vector surveillance'
Programme planning and management also includes developing a sstem for procurement# logistics
and effective suppl management' )he health management information sstem and revamped
surveillance are crucial in the context of dengue control since the disease often striBes in the form
of outbreaBs and epidemics'
.5'8 Duration
)he $trategic Plan is prepared to cover the period 0,,9/0,.5'
.5'9 :onitoring and evaluation
& monitoring and evaluation frame=orB is necessar to tracB the progress of implementation of
the operational p6an' :P% should be result!based and the frame=orB should include outcome
and output indicators that are easil measurable and verifiable' $ome of the indicators that can be
considered include the follo=ing;
Q
Q
Q
Q
Q
Q
Q
Q
*umber of countries that have a legal and regulator frame=orB for the prevention and
control of dengue'
*umber of countries that allocate resources for the prevention and control of dengue'
*umber of national laboratories that are able to identif and characteri"e the virus'
Reported dengue cases based on a three!ear moving average'
Proportion of outbreaBs investigated =ithin t=o =eeBs of first reporting'
Case!fatalit rates due to DHFED$$'
*umber of countries that have developed and implemented 6C: strateg'
*umber of countries that have CO:46 plan developed and implemented'
.58
.5'7 6mplementation of the $trategic Plan
%lements of the $trategic Plan overlap =ith those of the &sia!Pacific Partnership for Prevention
and Control of Dengue in several areas' )o implement the Plan# it =ould be necessar to harness
the expertise available in the countries through collaboration and net=orBing' Coordination =ill
be achieved through the mechanism of the Regional )echnical &dvisor Groups and b forming a
secretariat for the partnership' )echnical guidance =ill also be the provided b the advisor group'
6t is proposed to develop a roadmap for the implementation of the strateg besides developing a
log frame'
)he first step after establishing a coordination mechanism =ill be to assist the countries
in preparing operational plans =ith a budget# and identifing resource gaps and ne=er funding
opportunities' Political# technical and managerial expertise in counties =ould need to be mobili"ed
for increasing the capacit to implement the operational plans' Regular revie=sch of the programme
should be encouraged and efforts made to promote research and innovations in the development of
diagnostics# drugs and a vaccine for the prevention and control of dengue in the &sia!Pacific Region
in addition to various operational aspects to improve the programme'
.5'., %ndorsement of the &sia!Pacific $rategic Plan (0,,9/0,.5-
)he &sia!Pacific Dengue Programme :anagerAs :eeting# =hich =as held in $ingapore in :a 0,,9ci
=as attended b .8 :ember countries from the WHO Western Pacific Region (WPR- and 5 from
the $outh!%ast &sia Region' 6n addition# the meeting =as attended b partner agencies and observers
from &D4# H*%P H$&6D and representatives from the health ministries of Kapan and the Republic#
of Jorea' )he meeting facilitated the establishment andEor implementation of national plans'
While endorsing the Draft &sia!Pacific $trategic Plan 0,,9/0,.5# all 00 participating :ember
$tates =orBed on their respective national dengue control plans for the ear 0,,7/0,.,' )he
also incorporated the re2uirements stipulated b the 6HR 0,,5' Furthermore# countries =ithout
national programmes for dengue control =ere encouraged to involve the relevant ministries and
other agencies for allocation of funds and ensure implementation of necessar activities' )o start
=ith# the programme managers planned for a t=o!ear budget period and specified the funds to
be provided b funding agencies'
ch For additional information# refer to the Guidelines for Conducting a Revie= of a *ational Dengue Prevention and Control Programme
(WHOECD$ECP%EPCCE0,,5'.1-'
ci &sia!Pacific Dengue Programme :anagers :eeting in $ingapore# :a 5!7# 0,,9' Field Research Report' &sia!Pacific Dengue
Programme :anagers :eeting in $ingapore# :a 5!7# 0,,9' Prepared b :inaBo Ken NoshiBa=a# . Joto Hniversit' http;EE==='
cseas'Boto!u'ac'DpEstaffEnishibuchiE0,,9EdocEfieldTResarch,9,5,5Ten'pdf
.59
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(0-
(1-
(3-
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(0.-
(00-
(01-
(03-
(05-
(0+-
(08-
(09-
(07-
(1,-
(1.-
(10-
(11-
(13-
(15-
(1+-
(18-
(19-
(17-
(3,-
.+,
(3.- *immannita $# Halstead $4# Gohen $*# :argotta :R' Dengue and chiBunguna virus infection in
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(30-
(31-
(33-
(35-
(3+-
(38-
(39-
(37-
(5,-
(5.-
(50-
(51-
(53-
(55-
(5+-
(58-
(59-
(57-
(+,-
(+.-
.+.
(+0- Librat DH# Noung PR# PicBering D' et al' High circulating levels of the dengue virus nonstructural
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(+1-
(+3-
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(80-
(81-
(83-
(85-
(8+-
(88-
(89-
(87-
(9,-
(9.-
(90-
.+0
(91- FocBs D&# &lexander *' :ulticountr stud of &edes aegpti pupal productivit surve methodolog
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(93-
(95-
(9+-
(98-
(99-
(97-
(7,-
(7.-
(70-
(71-
(73-
(75-
(7+-
(78-
(79-
(77-
(.,,- Lumsden WHR' )he activit ccle of domestic &e aegpti in $outhern Provinces )anganiBa' 4ull
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(.09- Dell Chism 4# &pperson C$' Hori"ontal transfer of the insect gro=th regulator priproxfen to larval
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Delhi ; WHO!$%&RO# 0,,9'
(.37- Renganathan %' et al' )o=ards sustaining behavioural impact in dengue prevention and control' Dengue
4ulletin' 0,,1? 08; +/.0'
.+5
(.5,- Lines K# Harpham )# LeaBe C# $chofield C' )rends# priorities and polic directions in the control of
vector!borne diseases in urban environments' Health Polic and Planning' .773? 7(0-; ..1/.07'
(.5.- Dunn FL' Human behavioural factors in mos2uito vector control' $outheast &sian K )rop :ed Pub
Health' .791? .3 (.-; 9+/73'
(.50- Gillett KD' )he behaviour of homo sapiens; )he forgotten factor in the transmission of tropical disease'
)ransactions of the Ro $oc of )rop :ed and Hg' .795? 87; .0/0,'
(.51- Gordon &K# RoDas W# )id=ell :' Cultural factors in &edes aegpti and dengue control in Latin &merica;
& case stud from the Dominican Republic' 6nternational Fuarterl of Communit Health %ducation'
.77,? 1; .71/0..'
(.53- Winch PK# Llod L$# HoemeBe L# Leontsini %' Cector control at the household level; an analsis of its
impact on =omen' &cta )ropica' .773? 5+(3-; 108/117'
(.55- Fernmnde" %&# Leontsini %# $herman C# Chan &$# Rees C%# Lo"ano RC# Fuentes 4&# *ichter :# Winch
PK' )rial of a communit!based intervention to decrease infestation of &edes aegpti mos2uitoes in
cement =ashbasins in %l Progreso# Honduras' &cta )ropica' .779? 8,(0-; .8./.91'
(.5+- :acoris :L# :a"ine C&# &ndrighetti :)# Nasumaro $# $ilva :%# *elson :K# Winch PK' Factors favouring
houseplant container infestation =ith &edes aegpti larvae in :arnlia# $oo Paulo# 4ra"il' Revie= of
Panamerica $alud Publica' .778? .(3-; 09,/09+'
(.58- Winch PK' $ocial and cultural responses to emerging vector!borne diseases' Kournal of Cector %colog'
.779? 01(.-; 38/51'
(.59- Llod L# Winch P Ortega!Canto K# Jendall C' Results of a communit!based &edes aegpti control#
program in :erida# Nucatan# :exico' &merican Kournal of )ropical :edicine and Hgiene' .770? 3+;
+15/+30'
(.57- $=addi=udhipong W# LerdluBanavonge P JlumBlam P Joonchote $# *guntra P et al' & surve of###
Bno=ledge# attitudes and practice of the prevention and control of dengue haemorrhagic fever in an
urban communit in )hailand' $outheast &sian Kournal of )ropical :edicine and Public Health' .770?
01(0-; 0,8/0..'
(.+,- Rosenbaum K# *athan :# Ragoonanansingh R# Ra=lins $# Gale C' Communit participation in dengue
prevention and control; a surve of Bno=ledge# attitudes and practices in )rinidad and )obago'
&merican Kouranl of )ropical :edicine and Hgiene' .775? 51 (0-; .../..8'
(.+.- Gupta P Jumar P &ggar=al OP Jno=ledge# attitude and practice related to dengue in rural and slum##'
areas of Delhi after the dengue epidemic of .77+' Kournal of Communicable Diseases' .779? 1,;
.,8/..0'
(.+0- Lefevre F# Lefevre &:C# $candar $&$# Nassumaro $' $ocial representations of the relationships bet=een
plant vases and the dengue vector' Revista De $aude Publica' 0,,3? 19 (1-; 3,5/3.3'
(.+1- )ram )# &nh *# Hung *# Lan *LC# Cam Le )hi# Chuong *P )ri L# FonsmarB L# Poulsen &# Heegaard#
%D' )he impact of health education on motherAs Bno=ledge# attitude and practice (J&P- of dengue
haemorrhagic fever' Dengue 4ulletin' 0,,1? 08; .83/.9,'
(.+3- Pai HH# Lu NL# Hong NK# Hsu %L' )he differences of dengue vectors and human behaviour bet=een
families =ith and =ithout members having dengue feverEdengue hemorrhagic fever' 6nternational
Kournal of %nvironmental Health Research' 0,,5? .5 (3-; 0+1/0+7'
(.+5- Leontsini %# Gril %# Jendall C# ClarB GG' %ffect of a communit!based &edes aegpti control program
on mos2uito larval production sites in %l Progreso# Honduras' )ransactions of the Roal $ociet of
)ropical :edicine and Hgiene' .771? 98; 0+8/08.'
(.++- Jhun $# :anderson L' Communit and $chool!4ased Health %ducation for Dengue Control in Rural
Cambodia; & Process %valuation' PLo$ *egl )rop Dis' 0,,8 Dec 5? .(1-; e.31'
(.+8- Whiteford L:' Local identit# globali"ation and health in Cuba and the Dominican Republic' 6n;
Whiteford L:# :anderson L' %ds' Global health polic# local realities; )he fallac of a level!plaing
field' 4oulder# CO; Lnne Rienner Publishers# 0,,,' p' 58/89'
(.+9- Pere"!Guerra CL# $eda H# Garcia!Rivera %K# ClarB GG' Jno=ledge and attitudes in Puerto Rico
concerning dengue prevention' Pan!&merican Kournal of Public Health' 0,,5? .8(3-; 031/051'
.++
(.+7- :er"el C# DA&fflitti K' Reconsidering communit!based health promotion; promise# performance# and
potential' &m K Pub Health' 0,,1? 71(3-; 558/583'
(.8,- H*HCR' Witchcraft allegations# refugee protection and human rights; & revie= of the evidence' Geneva;
0,,7'
(.8.- $chooler C# Far2uhar KW# Flora K&' $nthesis of findings and issues from communit prevention trials'
&nn %pidemiol' .778? 8(suppl 8-; $53/$+9'
(.80- %lder KP $chmid )L# Do=er P Hedlund $' Communit heart health programmes; Components##'#
rationale# and strategies for effective interventions' K Public Health Polic' .771? .3; 3+1/387'
(.81- Gubler DK# ClarB GG' Communit involvement in the control of &edes aegpti' &cta )ropica' .77+?
+.(0-; .+7/.87'
(.83- ParBs WK# Llod L$# *athan :4# Hosein %# Odugleh &# ClarB GG# Gubler DK# PrasittisuB C# Palmer J#
$an :artin KL# $iversen $R# Da=Bins W# Renganathan %' 6nternational experiences in social mobili"ation
and communication for dengue prevention and control' Dengue 4ulletin' 0,,3? 09 ($uppl-; ./8'
(.85- Halstead $' $uccesses and failures in dengue controlIglobal experience' Dengue 4ulletin' 0,,,? 03;
+,/8,
(.8+- World Health Organi"ation' 6ntegrated marBeting communication for behavioural results in health and
social development / summar of concepts' Geneva; *e= NorB HniversitEWHO 6ntegrated :arBeting
CommunicationECO:46/:alasia# 0,,.'
(.88- Cheadle &# 4eer W# Wagner %# Fa=cett $# Green L# :oss D# Plough &# Wandersman &# Woods 6'
Conference report; communit!based health promotionIstate of the art and recommendations for
the future' &m K Prev :ed' .778? .1; 03,/031'
(.89- ParBs W# Llod L' Planning social mobili"ation and communication for dengue fever prevention and
control; & step!b!step guide' Geneva; WHO# 0,,3' Document *o' WHOECD$EW:CE0,,3'0 and
)DRE$)RE$%4ED%*E,3'.'
(.87- %lder KP %valuation of communication for behavioural impact (eCO:46A- efforts to control &edes aegpti'
breeding sites in six countries' )unis; WHO :editerranean Centre for Culnerabilit Reduction# 0,,5'
(.9,- World Health Organi"ation# Regional Office for the Pan &merica' Dengue and dengue hemorrhagic
fever in the &mericas; guidelines for prevention and control' Washington DC; WHO!P&HO# .773'
($cientific Publication *o' 539-'
(.9.- World Health Organi"ation# Regional Office for the &mericas' )he blueprint for action for the next
generation; dengue prevention and control' Washington DC; WHO!P&HO# .777'
(.90- World Health Organi"ation' $trengthening implementation of the global strateg for Dengue FeverE
Dengue Haemorrhagic Fever Prevention and Control; Report of the informal consultation# .9/0,'
October .777' Geneva; WHO# 0,,,' Document *o' WHOECD$(D%*-E6CE0,,,'.'
(.91- World Health Organi"ation# Regional Office for $outh!%ast &sia' Report of the Regional :eeting on
Dengue and ChiBunguna Fever# Chiang Rai# )hailand' *e= Delhi; WHO!$%&RO# 0,.,' (6n press-'
(.93- Luna K%# Chain 6# Hernande" K# ClarB GG# 4ueno &# %scalante R# &ngarita $# :artine" &' $ocial mobili"ation
using strategies of education and communication to prevent dengue fever in 4ucaramanga# Colombia'
Dengue 4ulletin' 0,,3? 09 ($uppl-; .8/0.'
(.95- World Health Organi"ation' & global revie= of primar health care; %merging messages' Geneva;
WHO# 0,,1'
(.9+- Llod L$' 4est practices for dengue prevention and control in the &mericas' Washington DC;
%nvironmental Health ProDect# 0,,1'
(.98- World Health Organi"ation' Health promotion glossar' Geneva; WHO# .779'
(.99- Gamble D*# Weil :O' Citi"en participation' 6n; %d=ards RL' %d' %ncclopaedia of social =orB' .7th
edn# vol' .' Washington# DC; *ational &ssociation of $ocial WorBersE*&$W Press# .775' p' 391/373'
(.97- Finsterbusch J' WicBlin 666 W&C' 4eneficiar participation in development proDects; %mpirical tests of
popular theories' Chicago; %conomic Development and Cultural Change# .797'
.+8
(.7,- Llod L$# Winch P Ortega!Canto K# Jendall C' Results of a communit!based &edes aegpti control#
program in :erida# Nucatan# :exico' &merican Kournal of )ropical :edicine and Hgiene' .770# 3+;
+15!+30'
(.7.- Galve"!)an K' Participator $trategies in Communit Health' 6n; Council for primar health care series'
:anila; Council for Primar Health Care# .795'
(.70- Fuesada :L' Primar health care as a social development strateg; a focus on peopleAs participationA in
PHC reader series' :anila; Council for Primar Health Care# .795'
(.71- Cox %' 4uilding social capital' Health Promotion :atters' .778? 3; ./3'
(.73- 4racht *# Jingsbur L' Communit organi"ation principles in health promotion' 6n; 4racht *' %d'
Health promotion at the communit level' *e=bur ParB; $age Publications# .77,' p' ++!99'
(.75- )oledo Romani :%# Canlerberghe C# Pere" D# Lefevre P Ceballos %# 4andera D# 4al Gil &# Can der#
$tuft P'&chieving sustainabilit of communit!based dengue control in $antiago de Cuba' $ocial
$cience P :edicine' 0,,8' +3 (3-; 78+/799'
(.7+- $antasiri $ornmani# Jamolnetr OBamuraB# Jaemthong 6ndaratna' $ocial and economic impact of
dengue haemorrhagic fever; $tud report' 4angBoB; Facult of )ropical :edicine# :ahidol Hniversit
and Facult of %conomics# ChulalongBorn Hniversit# .775'
(.78- $hepard D$# $uaa K&# Halstead $4# *athan :4# Gubler DK# :ahone R)# Wang D*# :elt"er :6' Cost!
effectiveness of a pediatric dengue vaccine' Caccine' 0,,3? 00; .085/.09,'
(.79- :elt"er :6# Rigau!Pere" KG# Reiter P Gubler DK' Hsing disabilit!adDusted life ears to access the#
economic impact of dengue in Puerto Rico; .793/.773' &m K )rop :ed Hg' .779? 57; 0+5/8.'
(.77- Danielle C ClarB# :ammen P :ammen Kr# &nanda *isalaB# Cirat Puthimethee# )imoth P %nd''
%conomic impact of dengue feverEdengue haemorrhagic fever in )hailand at the famil and population
levels' &m K )rop :ed Hg' 80(+-? 0,,5; 89+/87.'
(0,,- World Health Organi"ation# Regional Office for $outh!%ast &sia' &sia!Pacific Dengue $trategic Plan
(0,,9/0,.5-' *e= Delhi; WHO!$%&RO# 0,,9' Document *o' $%&E RC+.E .. 6nf' Doc'
.+9
.8' &nnexes
.' &rbovirus laborator re2uest form
*ame of patient TTTTTTTTTTTTTTTTTTTTTTTTT Hospital *o' TTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
&ddress TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT Hospital TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
&ge TTTTTTTTTTTTTTTT$ex TTTTTTTTTTTTTTT Phsician TTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT
Date of admission TTTTTTTTTTTTTTTTTTTTTTT &dmission complaintTTTTTTTTTTTTTTTTTTTTTTTT
Date of onset TTTTTTTTTTTTTTTTTTTTTTTTTTT
Clinical findings;
.'
0'
1'
3'
Fever TTTTTTTTTTTTT VC or VF (max-' Duration TTTTTT das
)ourni2uet test TTTTTTTTTT Petechiae TTTTTTTTTTT %pistaxis TTTTTTTTTTTT
HaematemesisEmelaena TTTTTTTTT Other bleeding (describe- TTTTTTTTTTTTTTTTTTTTT
Hepatomegal TTTTTTTTTTTTT (cm at right costal margin-' )enderness TTTTTTTTTTTTT
$hocB TTTTTTTT 4lood pressure TTTTTTTT (mmHg- Pulse TTTTTTT (per min'-
RestlessnessELetharg TTTTTTTTTTT Coldness of extremitiesEbod TTTTTTTTTTTTTT
Clinical laborator findings;
Platelets (\.,1 - TTTTTTTTTTTTTTTTTTTTTEmm1 (on TTTTTTTTTTTTTTTTTTTTT da of illness-
Haematocrit (G- TTTTTTTTTTTTTTTTTTTTTTT (max- TTTTTTTTTTTTTTTTTTTTTTTTTTTTT (min-
4lood specimens
(&cute-
Hospital admission
DateTTTTTTTTTTT
Hospital discharge
DateTTTTTTTTTT
Convalescent
DateTTTTTTTTTT
6nstructions; Fill the form completel =ith all clinical findings in duplicate' $aturate the filter!paper discs completel so
that the reverse side is saturated and clip them to the form' Obtain admission and discharge specimens from all patients'
6f the patient does not return for a convalescent sample# mail promptl'
$ource; Dengue Haemorrhagic Fever; Diagnosis# treatment# prevention and control# $econd edition# WHO# Geneva# .775'
.+7
0' 6nternational Health Regulations
(6HR# 0,,5-
Core obligations for :ember $tates
Q
Q
Designate a *ational 6HR Focal Point as the operational linB for urgent communications
concerning the implementation of the Regulations'
Develop# strengthen and maintain the surveillance and response capacit to detect# assess#
notif# report and respond to public health events# in accordance =ith the core capacit
re2uirements under the 6HR (0,,5-'
*otif WHO of all events that ma constitute a public health emergenc of international
concern (PH%6C- =ithin 03 hours of assessment b using the decision instrument Ran
algorithmS'
Respond to re2uests for verification of information regarding public health risBs'
Provide WHO =ith all relevant public health information# if a $tate Part has evidence of
an unexpected or unusual public health event =ithin it territor# =hich ma constitute a
PH%6C'
Control urgent national public health risBs that threaten to transmit diseases to other
:ember $tates'
Provide routine inspection and control activities at international airports# ports and some
ground crossings to prevent international disease transmission'
:aBe ever effort to full implement WHO!recommended temporar and standing
measures and provide scientific Dustification for an additional measures'
Collaborate =ith other $tates Parties and =ith WHO in implementing the 6HR (0,,5-#
particularl in the area of assessment# provision of technical and logistical support# and
mobili"ation of financial resources'
Q
Q
Q
Q
Q
Q
Q
Core obligations for WHO
Q
Q
Q
Q
Q
Q
Designate WHO 6HR contact points as operational linBs for urgent communications
concerning the implementation of the 6HR (0,,5-'
$upport :ember $tatesA efforts to develop# strengthen and maintain the core capacities
for surveillance and response in accordance =ith the 6HR (0,,5-'
Cerif information and reports from sources other than official notifications or consultations#
such as media reports and rumors# =hen necessar'
&ssess events notified b :ember $tates (including on!site assessment# =hen necessar-
and determine if the constitute a public health emergenc of international concern'
Provide technical assistance to $tates in their response to public health emergencies of
international concern'
Provide guidance to $tates to strengthen existing surveillance and response capacities to
contain and control public health risBs and emergencies'
.8,
Q
Q
Q
Q
Q
Provide all :ember $tates =ith public health information to enable :ember $tates to
respond to a public health risB'
6ssue temporar and standing recommendations on control measures in accordance =ith
the criteria and the procedures set out under the Regulations'
Respond to the needs of :ember $tates regarding the interpretation and implementation
of the 6HR (0,,5-'
Collaborate and coordinate its activities =ith other competent intergovernmental
organi"ations or international bodies in the implementation of the 6HR (0,,5-'
Hpdate the Regulations and supporting guides as necessar to maintain scientific and
regulator validit'
$ource; http;EE==='=ho'intEihrEaboutEenE and http;EE==='=ho'intEihrEaboutEF&F0,,7'pdf
.8.
1' 6HR Decision 6nstrument for
assessment and notification of
events
$ource; http;EE==='=ho'intEihrEenE
.80
3' $ample si"e in &edes larval surves
For &edes larval surves# the number of houses to be inspected in each localit depends on the level
of precision re2uired# level of infestation# and available resources' &lthough increasing the number
of houses inspected leads to greater precision# it is usuall impractical to inspect a large percentage
of houses because of limited human resources'
)able & sho=s the number of houses that should be inspected to detect the presence or absence
of infestation' For example# in a localit =ith 5,,, houses# in order to detect an infestation of ].G#
it is necessar to inspect at least 07, houses' )here is still a 5G chance of not finding an positive
houses =hen the true House 6ndex a .G'
)able &; *umber of houses that should be inspected to detect &edes larval infestation
*umber of houses
in the localit
.,,
0,,
1,,
3,,
5,,
.,,,
0,,,
5,,,
., ,,,
6nfinite
)rue House 6ndex
].G
75
.55
.97
0..
005
059
088
07,
073
077
]0G
89
.,5
..8
.03
.07
.19
.31
.38
.39
.37
]5G
35
5.
53
55
5+
58
59
57
57
57
)able 4 sho=s the number of houses that should be inspected in a large (]5,,, houses- positive
localit# as determined b the expected House 6ndex and the degree of precision desired' For example#
if the preliminar sampling has indicated that the expected House 6ndex is approximatel .,G# and
a 75G confidence interval of 9G/.0G is desired# then .,,, houses should be inspected' 6f there
are onl sufficient resources to inspect 0,, houses# the 75G confidence limits =ill be +G/.3G' 6n
other =ords# there is a 5G chance that the true House 6ndex is less than +G or greater than .3G'
6n small localities# the same precision ma be obtained b inspecting fe=er houses' For example#
if the expected House 6ndex is 5,G and a 75G confidence interval of 33G/5+G is acceptable# then
in a large localit it =ould be necessar to inspect 1,, houses ()able 4-' Ho=ever# as seen in )able
C# if the localit consists of onl .,,, houses# the same precision =ill be obtained b inspecting
01. houses'
.81
)able 4; Precision of the &edes House 6ndex in large localities (]5,,, houses-
House 6ndex (G-
.,,
0
5
.,
0,
5,
8,
,'0/8',
0/..
5/.9
.1/07
3,/+,
+,/87
75G confidence interval of the House 6ndex
0,,
,'5/5',
0/7
+/.3
.+/0+
31/58
+0/8+
1,,
,'8/3'1
1/9
8/.3
.+/05
33/5+
+3/85
.,,,
.'0/1'.
3/8
9/.0
.9/01
38/51
+8/81
)able C; *umber of houses to inspect in small localities
)otal number of houses
in the localit
5,
.,,
0,,
1,,
3,,
5,,
.,,,
5,,,
., ,,,
0, ,,,
1, ,,,
3, ,,,
.,, ,,,
*umber of houses to be inspected for desired precision if this =ere a
small localit (from )able 4-
.,,
11
5,
+8
88
9,
91
7.
.,,
.,,
.,,
.,,
.,,
0,,
3,
++
.,,
.00
.13
.30
.++
0,,
0,,
0,,
0,,
0,,
0,,
1,,
5,
85
.0,
.5,
.8.
.97
01.
095
1,,
1,,
1,,
1,,
1,,
.,,,
5,
.,,
.8,
01,
07,
11,
5,,
91,
7.,
75,
.,,,
.,,,
.,,,
$ource; Pan &merican Health Organi"ation' Dengue and dengue haemorrhagic fever in the &mericas; Guidelines for prevention and
control' Washington; WHOEP&HO? .773' ($cientific publication? no' 539-'
.83
5' Pictorial Be to &edes ($tegomia-
mos2uitoes in domestic containers
in $outh!%ast &sia
$ource; &dapted from; Niau!:in Huang' )he mos2uitoes of Polnesia =ith a pictorial Be to some species associated =ith filariasis
andEor dengue fever' :os2uito $stematics# .788# 7(1-; 097!100'
.85
&nnex 5 (contd-
.8+
&nnex 5 (contd-
(.- Central brush =ith 5 pairs of setae (.- Central brush =ith 3 pairs of setae
(0- Comb scale =ith ver strong
denticles at base of apical spine
$addle complete $addle incomplete
&edes aegpti (Linnaeus- Polnesian feral &edes spp'
$eta 3a# b!\ single $eta 3a# b!\ branched
&edes albopictus Polnesian feral &edes species
.88
+' Designs for overhead tanB =ith
cover# masonr chamber and soaB
pit
(a- $tandard design for overhead tanB =ith cover design for
mos2uito proofing of overhead tanBs and cisterns
(b- Design for masonr chamber and soaB pit for sluice valve and =ater meter
$ource; $harma R'$'# $harma G'J'# Dhillon GP$# %pidemiolog and control of malaria in 6ndia' .77+' Dte' of *:%P 00 $hamnath#
:arg# Delhi .., ,53# 6ndia'
.89
8' Procedure for treating mos2uito
nets and curtains
)he steps described belo= mainl refer to treatment of mos2uito nets =ith permethrin' )he net
treatment techni2ue can be easil used for curtains'
(a- Calculate the area to be treated
:easure the height# length and =idth of the net' &ssuming a rectangular mos2uito net is .5,
cm high# 0,, cm long and .,8 cm =ide# the calculations are as follo=s;
&rea of one end a .,8 x .5, a .+ ,5, cm0
&rea of one side a 0,, x .5, a 1, ,,, cm0
&rea of top a .,8 x 0,, a 0. 3,, cm0
)he sides and ends need to be multiplied b 0;
0 (.+ ,5, > 1, ,,,- a 70 .,, > 0. 3,, a ..1 5,, cm0
(end- (side- (top-
6f ., ,,, cm0 a . m0 then
..1 5,,E., ,,, a ..'15 m0 area of net
(b- Determine ho= much insecticide is needed
&ssume that a permethrin emulsifiable concentrate =ill be used# and the dosage desired is ,'5
grams per s2uare metre'
)o determine the total grams re2uired# multipl the net si"e b the dosage;
..'15 x ,'5 a 5'+8 grams of insecticide needed'
(c- Determine the amount of li2uid re2uired to saturate a net
6n order to determine the percentage solution to be used for dipping# it is first necessar to determine
the approximate amount of =ater retained b a net' &nother term for dipping is soaBing'
Pour five litres of =ater# but preferabl a dilute solution of the insecticide to be used# into a
plastic pan or other suitable container' For cotton# a ,'1G solution can be tried? for polethlene
or other snthetic fibre# a .'5G solution can be tried' &dd the net to the solution till it is thoroughl
=et and then remove it' &llo= the drips to fall into a bucBet for .5 to 1, seconds' $et the net aside'
Repeat the process =ith t=o other nets' Cotton nets can be lightl s2uee"ed but not the snthetic
ones' :easure the =ater or solution remaining in the drippingEsoaBing container and in the bucBet
to calculate the amount of li2uid used per net'
.87
&ssuming that one polethlene net retained 09, ml of solution# the percentage concentration
re2uired for dipping is calculated as follo=s;
grams re2uired per net
ml solution retained per net
(d-
a
5'+8
09,
a 0G
Preparation of dipping solutions to treat bulB 2uantities of mos2uito nets or curtains
)he general formula is;
\ a (&E4- / .
in =hich#
\ a parts of =ater to be added to one part of emulsifiable concentrate'
& a concentration of the emulsifiable concentrate (G-'
4 a re2uired concentration of the final solution (G-'
%xample; & 0',G solution of permethrin for dipping nlon mos2uito nets or curtains is to be prepared
from a 05G concentrate'
\ a (05E0',- / . a .0'5 / . a ..'5
)herefore ..'5 parts of =ater to one part of concentrate are re2uired# or one litre of concentrate
to ..'5 litres of =ater'
%xample; & 0',G solution of permethrin for dipping nlon mos2uito nets or curtains is to be prepared
from a 5,G concentrate'
\ a (5,E0',- / . a 03
)herefore# 03 parts of =ater to one part of concentrate are re2uired# or one litre of concentrate
to 03 litres of =ater'
%xample; & ,'1G solution of permethrin for dipping cotton mos2uito nets or curtains is to be prepared
from a 05G concentrate'
\ a (05E,'1- / . a 91'1 / . a 90'1 or rounded to 90'
)herefore# 90 parts of =ater to one part concentrate are re2uired# or one litre of concentrate
to 90 litres of =ater# or half a litre of concentrate to 3. litres of =ater to accommodate a smaller
container'
%xample; & ,'1G solution of permethrin for dipping cotton mos2uito nets or curtains is to be prepared
from a 5,G concentrate'
\ a (5,E,'1- / . a .++'+ / . a .+5'+ or rounded to .++'
.9,
)herefore# .++ parts of =ater to one part of concentrate are re2uired# or one litre of concentrate
to .++ litres of =ater# or half a litre of concentrate to 91 litres of =ater to accommodate a smaller
container'
(e- Preparation of a 0G dipping solution using a one litre bottle of 05G or 5,G permethrin
emulsifiable concentrate for soaBing polethlene or other snthetic fibre nets or curtains' )his
operational approach minimi"es detailed measurements in the field'
For 05G concentrate;
&dd ..'5 litres =ater to a container (=ith premeasured marBs to indicate volume-'
&dd . litre (. bottle- concentrate to the container'
)otal volume; .0'5 litres
Grams permethrin; 05,
G concentration; 0G
For 5,G concentrate;
&dd 03 litres =ater to a container'
&dd one litre (one bottle- concentrate to the container'
)otal volume; 05 litres
Grams permethrin; 5,,
G concentration; 0G
(f- Preparation of a ,'1G dipping solution using a one litre bottle of 05G or 5,G permethrin
emulsifiable concentrate for soaBing cotton nets or curtains
For 05G concentrate;
&dd 90 litres of =ater to a container'
)otal volume; 91 litres
Grams permethrin; 05,
G concentration; ,'1G
For 5,G concentrate;
&dd .++ litres of =ater to a container'
)otal volume; .+8 litres
Grams permethrin; 5,,
G concentration; ,'1G
.9.
(g- Dring of nets
Polethlene and snthetic nets are dried in a hori"ontal position' Do not hang to dr' Dring the
nets on mats removed from houses has proved to be convenient and acceptable' )he nets should
be turned over about once ever hour for up to three or four hours' 6f the =eather is good# the nets
can be dried outside in the sun but for not more than several hours' Hnder rain conditions# the
can be placed in sheltered areas or inside and left overnight to dr' When dripping stops# the can
be hung for completion of dring' )reated cotton nets =hich are not oversaturated and do not drip
can be hung up to dr soon after the soaBing procedure'
(h- )reatment of one net in a plastic bag (soaBing-
&s sho=n in (a- above# if it is assumed that the net si"e is ..'15 m0# 5'+8 grams of permethrin are
needed to achieve a target dosage of ,'5 grams per s2uare metre# and a net of this si"e absorbs 09,
ml of solution'
)he amount of 05G permethrin emulsifiable concentrate to use is determined as follo=s;
grams re2uired x .,, a 5'+8 x .,, a 00'+9 ml (rounded to 01 ml-
G concentrated used; 05
)herefore# 01 ml of 05G permethrin is mixed =ith 09, ml of =ater' )he net is placed inside
the bag and the solution added' )he net and solution are mixed together# shaBen and Bneaded in
the bag' )he net is removed and dried on top of the bag or a mat as described in (g- above' )he
amount of =ater can be reduced b 01 ml if there is excess run!off after the net is removed from
the bag'
(i- $ummar of treatment procedures
)he important points in the treatment are summari"ed as follo=s;
(.- Dipping is the preferred method of net treatment' & 0G solution is usuall sufficient to
achieve a target dosage of ,'5 grams per s2uare metre of permethrin on polethlene#
polester# nlon or other tpe of snthetic fibre net or curtain' )he residual effect lasts
for six months or more' & 0G solution can be prepared simpl b pouring the contents
of a one litre bottle of 05G permethrin emulsion concentrate into a container =ith ..'5
litres of =ater' With a 5,G concentrate# one litre is poured into 03 litres of =ater' )he
container used can be marBed to sho= one or both of these volume levels' & ,'1G solution
is normall re2uired for cotton material# =hich absorbs more li2uid' $taff need to checB
on the dosage applied and refine the operation accordingl' With bamboo curtains or
mats used over doors or =indo=s# a higher dosage (.', gram per s2uare metre- can be
used'
Dipping the nets in a permethrin solution is a fast and simple method for treating nets
and curtains in urban or rural housing conditions' Communit members can easil learn
the techni2ue re2uired for follo=!up treatment' & dish!pan tpe of plastic or aluminum
container =hich holds .5 to 05 litres of solution has been found to be 2uite suitable'
*ormall# about one litre of solution can treat four to five double (.,m0-!si"ed polethlene
or polester nets' When the nets are removed from the solution# the should be held to
drip in a bucBet for no more than one minute before being laid out to dr in a hori"ontal
position' $tra= mats removed from houses are 2uite suitable for dring the nets outside
in the open air' With one dipping station# about .5, nets or curtains can be treated in
t=o hours or less'
(0-
.90
(1- &bout .,, treated double!si"ed nets or an e2uivalent area of curtain material can protect
05, persons' 6t is not reasonable to expect ever person in a cro=ded household to
sleep under a net' 6t is important that ever house in a communit or village has one or
t=o treated nets to Bill mos2uitoes so as to reduce the vector densit' When used in this
manner# protection is provided to those =ho do not even sleep under the nets' 6nfants
and small children can sleep under the nets during the da'
.91
9' Fuantities of .G temephos (abate-
sand granules re2uired to treat
different!si"ed =ater containers to
Bill mos2uito larvae
)able D; Fuantities of .G temephos (abate- sand granules re2uired to treat
different!si"ed =ater containers
$i"e of =ater Dar# drum or
other container (in litres-
Less than 05
5,
.,,
0,,
05,
5,,
.,,,
Grams of .G granules*umber of teaspoons re2uired#
re2uiredassuming one teaspoon holds 5 grams
Less than 5
5
.,
0,
05
5,
.,,
Pinch; small amount held bet=een
thumb and finger
.
0
3
5
.,
0,
:ethoprene (altosid- bri2uettes can also be used in large =ater drums or overhead storage tanBs'
One bri2uette is suitable to treat 093 litres of =ater' 4ri2uettes of 4acillus thuringiensis H!.3 can
also be used in large cistern tanBs'
$ource; WHOEWestern Pacific Region 4acBground Document *o' .+# .775'
.93
7' Procedure# timing and fre2uenc of
thermal fogging and
HLC space spra operations
4asic steps
)he steps listed belo= are to be follo=ed in carring out the space spraing of a designated area;
Q
Q
Q
Q
Q
)he street maps of the area to be spraed must be studied carefull before the spraing
operation begins'
)he area covered should be at least 1,, metres =ithin the radius of the house =here the
dengue case =as located'
Residents should be =arned before the operation so that food is covered# fires extinguished
and pets are moved out together =ith the occupants'
%nsure proper traffic control =hen conducting outdoor thermal fogging since it can pose
a traffic ha"ard to motorists and pedestrians'
)he most essential information about the operational area is the =ind direction' $praing
should al=as be done from do=n=ind to up=ind# i'e' going against the direction of the
=ind'
Cehicle!mounted spraing
Q
Q
Q
Doors and =indo=s of houses and buildings in the area to be spraed should be
opened'
)he vehicle is driven at a stead speed of +/9 BmEh (1'5/3'5 milesEh- along the streets'
$pra production should be turned off =hen the vehicle is stationar'
When possible# spraing should be carried out along streets that are at right angles to the
=ind direction' $praing should commence on the do=n=ind side of the target area and
progressivel move up=ind'
6n areas =here streets run parallel as =ell as perpendicular to the =ind direction# spraing
is onl done =hen the vehicle travels up=ind on the road parallel to the =ind direction'
6n areas =ith =ide streets =ith houses and buildings far a=a from the roadside# the spra
head should point at an angle to the left side of the vehicle (in countries =here driving is
on the left side of the road-' )he vehicle should be driven close to the edge of the road'
6n areas =here the roads are narro=# and houses are close to the roadside# the spra head
should be pointed directl to=ards the bacB of the vehicle'
6n dead!end roads# the spraing is done onl =hen the vehicle is coming out of the dead!
end# not =hile going in'
)he spra head should be pointed at a 35V angle to the hori"ontal to achieve maximum
effect =ith droplets'
Cector mortalit increases do=n=ind as more streets are spraed up=ind in relation to
the target area'
Q
Q
Q
Q
Q
Q
.95
Portable thermal fogging
Q
Q
Q
)hermal fogging =ith portable thermal foggers is done from house to house# al=as fogging
from do=n=ind to up=ind'
&ll =indo=s and doors should be shut for half an hour after the fogging to ensure good
penetration of the fog and maximum destruction of the target mos2uitoes'
6n single!storeed houses# fogging can be done from the front door or through an open
=indo= =ithout having to enter ever room of the house' &ll bedroom doors should be
left open to allo= dispersal of the fog throughout the house'
6n multistoreed buildings# fogging is carried out from upper floors to the ground floor and
from the bacB of the building to the front' )his ensures that the operator has good visibilit
along his spraing path'
When fogging outdoors# it is important to direct the fog at all possible mos2uito resting
sites# including hedges# covered drains# bushes# and tree!shaded areas'
)he most effective tpe of thermal fog for mos2uito control is a mediumEdr fog# i'e' it
should Dust moisten the hand =hen the hand is passed 2uicBl through the fog at a distance
of about 0'5/1', metres in front of the fog tube' &dDust the fog setting so that oil deposits
on the floor and furniture are reduced'
Q
Q
Q
4acBpacB aerosol spraing =ith HLC attachments
Q
Q
Q
Q
Q
%ach spra s2uad consists of four spramen and one supervisor'
%ach spraman spras for .5/1, minutes and is then relieved b the next spraman' For
reasons of safet# he must not spra =hen tired'
)he supervisor must Beep each spraman in his sight during actual spraing in case he falls
or needs help for an reason'
Do not directl spra humans# birds or animals that are in front of spra no""les and less
than five metres a=a'
$pra at full throttle' For example# a HLC Fontan no""le tip ,'3 can deliver 05 ml of
malathion per minute# and a ,'5 tip# +5 ml' )he smaller tip is usuall preferred unless
spramen move 2uicBl from house to house' $ome machines can run for about one hour
on a full tanB of petrol'
House!spraing techni2ue
Q
Q
Do not enter the house' House spraing means spraing in the vicinit of the house'
$tand 1/5 metres in front of the house and spra for ., to .5 seconds directing the no""le
to=ards all open doors# =indo=s and eaves' 6f appropriate# turn a=a from the house and#
standing in the same place# spra the surrounding vegetation for ., to .5 seconds'
6f it is not possible to stand three metres from the house due to the closeness of houses
and lacB of space# the spra no""le should be directed to=ards house openings# narro=
spaces and up=ards'
While =alBing from house to house# hold the no""le up=ards so that particles can drift
through the area' Do not point the no""le to=ards the ground'
$pra particles drift through the area and into houses to Bill mos2uitoes =hich become
irritated and fl into the particles' )he settled deposits can be residual for several das to
Bill mos2uitoes resting inside houses and on vegetation not exposed to the rain'
Q
Q
Q
.9+
Q )his techni2ue permits treatment of a house =ith an insecticide ranging from . gram to 05
grams in one minute' )he dosage depends on the discharge rate# concentration of insecticide
applied# and the time it taBes to spra the house' For comparison# an indoor residual house
spra ma re2uire 1, minutes of spraing to deposit 1,, grams of insecticide' )his assumes
a dosage of t=o grams per s2uare metre to .5, s2uare metres of spraable surface'
6nformation to be given to inhabitants
Q
Q
Q
Q
Q
)ime of spraing# for example# ,+1, to .,,, hours'
&ll doors and =indo=s should be open'
Dishes# food# fish tanBs and bird cages should be covered'
$ta a=a from open doors and =indo=s during spraing# or temporaril leave the house
andEor the spraed area until the spraing is completed'
Children or adults should not follo= the spra s2uad from house to house'
)iming of application
$praing is carried out onl =hen the right =eather conditions are present and usuall onl at the
prescribed time' )hese conditions are summari"ed belo=;
For optimum spraing conditions ()able %-# please note the follo=ing;
Q 6n the earl morning and late evening hours# the temperature is usuall cool' Cool =eather
is more comfortable for =orBers =earing protective clothing' &lso# adult &edes mos2uitoes
are most active at these hours'
6n the middle of the da# =hen the temperature is high# convection currents from the ground
=ill prevent concentration of the spra close to the ground =here adult mos2uitoes are
fling or resting# thus rendering the spra ineffective'
&n optimum =ind speed of bet=een 1 BmEh and .1 BmEh enables the spra to move slo=l
and steadil over the ground# allo=ing for maximum exposure of mos2uitoes to the spra'
&ir movements of less than 1 BmEh ma result in vertical mixing =hile =inds greater than
.1 BmEh disperse the spra too 2uicBl'
6n heav rain# the spra generated loses its consistenc and effectiveness' When the rain
is heav# spraing should stop and the spra head of the HLC machine should be turned
do=n to prevent =ater from entering the blo=er'
$praing is permissible during light sho=ers' &lso# mos2uito activit increases =hen the
relative humidit reaches 7,# especiall during light sho=ers'
Q
Q
Q
Q
.98
)able %; Conditions for spraing
:ost favourable
conditions
)ime %arl morning
(,+1,/,91, hrs- or
late evening
$tead# bet=een
1/.1 BmEh
*o rain
Cool
&verage conditions
%arl to mid!morning
or late afternoon#
earl evening
,/1 BmEh
Light sho=ers
:ild
Hnfavourable
conditions
:id!morning to mid!
afternoon
:edium to strong#
over .1 BmEh
Heav rain
Hot
Wind
Rain
)emperature
Fre2uenc of application
)he commencement and fre2uenc of spraing generall recommended is as follo=s;
Q
Q
$praing is started in an area (residential houses# offices# factories# schools- as soon as
possible after a DFEDHF case from that area is suspected'
&t least one treatment should be carried out =ithin each breeding ccle of the mos2uitoes
(seven to ten das for &edes-' )herefore# a repeat spraing is carried out =ithin seven to
ten das after the first spraing' &lso# the extrinsic incubation period of dengue virus in
the mos2uito is 9 to ., das'
%valuation of epidemic spraing
Within t=o das after spraing during outbreaBs# a parous rate of .,G of female mos2uito have
alread laided eggs or less# compared =ith a much higher rate before spraing# indicates that most
of the mos2uito population is ne=l emerged and incapable of transmitting the disease' )his also
indicates the spra =as effective and had greatl reduced transmission b Billing the older infected
mos2uito population'
Ho=ever# a lo= parous rate after spraing can occur in the absence of a marBed reduction in
vector densit' )his can be attributed to the emergence of a ne= population of mos2uitoes =hich
escaped the spra# a relativel lo= adult densit before spraing and adult sampling methods =hich
sho= considerable variations in densit in the absence of control' &n effective spra programme
should also be accompanied b a reduction in hospitali"ed cases after the incubation period of the
disease in humans (about 5/8 das- has elapsed' )he spraing should be repeated at seven!da
intervals to eliminate the possibilit of infected mos2uitoes'
$ource; WHO Western Pacific Region 4acBground Document *o'.+# .775'
.99
.,' $afet measures for insecticide use
$afet measures for insecticide use are adopted to protect the health and lives of those appling
insecticides' )hese measures seeB to minimi"e the degree of poisoning b insecticides and exposure
to insecticides# prevent accidental poisoning# monitor sub!acute poisoning# and provide ade2uate
treatment for acute poisoning' )hese measures can be broBen do=n into the four broad categories
listed belo='
Four issues for safet measures;
Q
Q
Q
Q
the choice of insecticides to be used?
the safe use of insecticides?
the monitoring of sub!acute insecticide poisoning? and
the treatment of insecticide poisoning'
)he human population exposed to insecticide treatment is of prime importance' 6t must be ensured
that the are not exposed to health ha"ards'
.'
Q
Q
Q
Choice of insecticides to be used
toxicit and its safet to humans and the environment?
effectiveness against the vector? and
cost of the insecticide'
)he choice of an insecticide for vector control is determined b the follo=ing factors;
6n =eighing the relative importance of the three factors above# the follo=ing are important
aspects from a safet standpoint;
Q
Q
Q
Q
&n effective andEor cheap insecticide should not be used if the chemical is highl toxic to
humans and other non!target organisms'
Prethroids# generall# have ver lo= mammalian toxicit =hen compared =ith other groups
of insecticides such as carbamates'
)he li2uid formulation of an insecticide is usuall more dangerous than a solid formulation
of the same strength' Certain solvents in li2uid formulation facilitate sBin penetration'
With regard to occupational exposure# dermal exposure is more important than
gastrointestinal or respirator exposure' )hus# an insecticide =ith lo= dermal toxicit is
preferred'
)he latest information on the safet aspect of insecticides being considered must be available
before a =ise choice can be made'
Q
.97
0' )he safe use of insecticides
)he Be to the safe use of insecticides is to control and minimi"e the level of routine or accidental
exposure of an individual to a given insecticide' )he level of exposure is in turn dependent on man
factors# as outlined in the box belo='
Level of exposure depends on;
Q
Q
Q
Q
Q
Q
Q
Q
6nsecticide storage conditions'
Personal hgiene and attitude of =orBers'
Jno=ledge and understanding of =orBers concerning insecticides'
%2uipment used'
:ethod and rate of application'
%nvironmental conditions such as prevailing =inds# temperature and humidit'
Duration of the =orB'
Protective clothing and masB used'
6n order to minimi"e the routine and accidental exposure of staff to insecticides# safet
precautions must be observed at all stages of insecticide use'
$afet precautions during storage
Q
Q
Q
Q
$tore insecticides in containers =ith the original label' Labels should identif the contents#
nature of the material# preparation methods and precautions to be emploed'
Do not transfer insecticides to other containers# or to containers used for food or
beverages'
&ll insecticide containers must be sealed'
Jeep insecticides in a properl!designated place# a=a from direct sunlight# food# medicine#
clothing# children and animals and protected from rain and flooding# preferabl in a
locBed room =ith =arning signs such as LDangerous; 6nsecticides? Jeep &=aM posted
prominentl'
)o avoid unnecessar and prolonged storage of insecticides# order onl sufficient amounts
needed for a given operation# or order on a regular basis (e'g' ever three months depending
on routine needs-# or order onl =hen stocBs get lo='
$tocBs received first must be used first' )his avoids prolonged storage of an batch of
insecticide'
Q
Q
$teps before insecticide use
Q Read the label carefull and understand the directions for preparing and appling the
insecticides as =ell as the precautions listed# then follo= the precise directions and
precautions'
Jno= the first!aid measures relevant and antidotes for the insecticides being used' Q
Q
Q
During mixing and spraingEfogging =ith insecticides
Do not drinB# eat or smoBe =hile =orBing' )his prevents accidental inhalation or ingestion
of insecticides'
:ix insecticides in a =ell ventilated area# preferabl outdoors'
.7,
Q
Q
Q
Q
Q
Q
Q
Q
Q
:ix onl as much insecticide as is needed for each application' )his =ill reduce the problem
of storing and disposing of excess insecticide'
Do not smell or inhale insecticides'
*ever mix insecticides directl =ith bare hands'
$tand =ith the =ind blo=ing from behind =hen mixing insecticides'
Do not clear blocBed spra no""les b blo=ing =ith the mouth'
:aBe sure that the spra e2uipment does not leaB? checB all Doints regularl'
Jeep all persons not involved a=a from =here the insecticides are being mixed'
%xposure to spraing normall should not exceed five hours a da'
When spraing is undertaBen# the hottest and most humid period of the da should be
avoided if possible' 6t is best to appl insecticides earl in the morning or late in the evening'
)his minimi"es excessive s=eating and encourages the use of protective clothing' &lso#
high temperatures increase the absorption of insecticides'
)hose appling insecticides should al=as =ear long!sleeved shirts and trousers'
Wear protective clothing and headgear# =here necessar# to protect the main parts of the
bod as =ell as the head and necB# lo=er legs# hands# mouth# nose and ees' Depending
on the insecticide and tpe of application# boots# gloves# goggles and respirators ma be
re2uired'
:ixers and baggers should =ear rubber boots# gloves# aprons and masBs# since the come
in contact =ith technical material and concentrated formulations'
)hose engaged in thermal fogging and HLC spraing should be provided =ith overalls#
goggles# hats and masBs'
)hose engaged in larviciding (e'g' =ith temephos- need no special protective clothing
because the risB of toxicit is lo='
)o protect ourself and our famil# never =orB =ith insecticides in our street clothes'
Do not =ear un=ashed protective clothing' :aBe sure our gloves and boots have been
=ashed inside and outside before ou put them on'
)aBe heed of the =ind direction to avoid drift'
Q
Q
Q
Q
Q
Q
Q
Q
Q
Q
$teps after spraingEfogging of insecticides
Wash all spra e2uipment thoroughl and return to the storeroom' 6t is important to maintain
e2uipment in good =orBing order after usage'
%mpt insecticide containers should not be used in the household to store food or drinBing
=ater' )he should be buried or burned' Larger metal containers should be punctured so
that the cannot be reused'
Hsed containers can be rinsed t=o or three times =ith =ater# scrubbing the sides thoroughl'
6f a drum has contained an organophosphorus compound# an additional rinse should be
carried out =ith =ashing soda# 5, gEl (5G-# and the solution should be allo=ed to remain
in the container overnight' & soaBage pit should be provided for rinsing'
&ll =orBers must =ash thoroughl =ith soap and =ater' )his removes deposits of insecticides
on the sBin'
&ll protective clothing should be =ashed after each use'
&ll use of insecticides must be recorded'
%at onl after thoroughl =ashing hands =ith soap and =ater'
Q
Q
Q
Q
Q
.7.
1' :onitoring sub!acute insecticide poisoning
Regular medical surveillance of all spraing personnel ma be re2uired if space spra operations are
done on a routine# long!term basis'
Q
Q
Q
:ixers# baggers and spramen should be instructed to detect and report an earl signs
and smptoms of mild intoxication'
&n undue prevalence of illness not associated =ith =ell recogni"ed signs and smptoms
of poisoning b a particular insecticide should be noted and reported'
& regular medical examination# including the determination of blood cholinesterase
for those appling organophosphorus compounds# should be conducted' 6f the level of
cholinesterase activit decreases significantl (5,G of a =ell!established pre!exposure
value-# the affected operator must be =ithdra=n from exposure until he recovers' )est Bits
for monitoring cholinesterase activit are available'
$mptoms of insecticide poisoning
Field =orBers should be taught to recogni"e the follo=ing smptoms;
DD) and other organochlorines
$mptoms include apprehension# excitement# di""iness# hperexcitabilit# disorientation# headache#
muscular =eaBness and convulsions ' )hese compounds are normall not used for DHF vector
control'
:alathion# fenitrothion and other organophosphates
%arl smptoms include nausea# headache# excessive s=eating# blurred vision# lacrimation (tears
from ees-# giddiness# hpersalivation# muscular =eaBness# excessive bronchial secretion# vomiting#
stomach pains# slurred speech and muscular t=itching' Later# advanced smptoms ma include
diarrhoea# convulsions# coma# loss of reflexes# and loss of sphincter control'
(*ote; )emephos has a ver lo= toxicit rating and can safel be used in drinBing =ater to Bill
mos2uito larvae-'
Carbamates
$mptoms include headache# nausea# vomiting# bradcardia# diarrhoea# tremors# convulsive sei"ures
of muscles# increased secretion of bronchial# lacrimal# salivar and s=eat glands '
Prethroids (e'g' permethrin and $!bioallethrin-
)hese insecticides have ver lo= mammalian toxicit# and it is deduced that onl single doses above
.5 gm could be a serious ha"ard to an adult' 6n general# the effective dosages of prethroids for vector
control are much lo=er =hen compared =ith other maDor groups of snthetic insecticides' &lthough
prethroids ma be absorbed b ingestion# significant sBin penetration is unliBel' $mptoms# if the
develop# reflect stimulation of the central nervous sstem' *o cases of accidental poisoning from
prethroids have been reported in humans' $ome prethroids such as deltamethrin# cpermethrin
and lambdachalothrin# can cause ee and sBin irritation if ade2uate precautions are not taBen'
4acterial insecticide bacillus thuringiensis H!.3 and insect gro=th regulators (methoprene-
)hese control agents have exceedingl lo= mammalian toxicit and cause no side!effects' )he can
be safel used in drinBing =ater'
.70
3'
Q
Q
Q
Q
)reatment of acute insecticide poisoning
Jno= the smptoms of poisoning due to different insecticides'
Call a phsician'
4egin emergenc treatment in the field' )his treatment is continued during transport and
ends in a medical centre'
Provide supportive treatment for the patient' )his ma include;
/
/
/
Q
&rtificial respiration if spontaneous respiration is inade2uate'
& free air=a must be maintained' %xcess vomitus and secretions should be
removed'
Oxgen therap for canosis (a blue or purplish discolouration of the sBin due to
insufficient oxgen-'
Removal of contaminated clothing'
)horough =ashing of the sBin and hair =ith soap and =ater'
Flushing contaminated ees =ith =ater or saline solution for ., minutes'
%vacuation to fresh air'
Decontaminate the patient as soon as possible' )his ma involve;
/
/
/
/
Q %liminate the poison' Determine =hether the insecticide is in =ater emulsion or petroleum
solution# if possible'
/ 6f the insecticide is dissolved in a =ater emulsion# induce vomiting b putting a finger
or spoon do=n the throat' 6f this fails# give one tablespoon of salt in a glass of =arm
=ater until vomitus is clear'
6f the insecticide is dissolved in a petroleum product# have the doctor or nurse perform
gastric lavage# sucBing the insecticide out of the stomach =ith a tube to prevent the
possibilit of the petroleum product entering the lungs and causing pneumonia'
&dminister a laxative such as %psom salts or milB of magnesia in =ater to eliminate the
insecticide from the alimentar tract' &void oil laxatives such as castor oil# =hich ma
increase the absorption of insecticide'
)he insecticide container must be made available to the phsician =herever possible'
)his =ill help in determining the group of insecticides involved in the poisoning' )he
label =ill indicate if it is a chlorinated hdrocarbon# an organophosphate# a carbamate#
a prethroid or a bacterial insecticide'
6f the insecticide is an organophosphate# either airopine sulphate or a 0!P&: chloride
(pralidoxime chloride- can be used as an antidote' &n inDection of 0 mg to 3 mg
atropine sulfate is given intravenousl' :ore atropine ma be re2uired depending on
the severit of the poisoning' )he dose of 0!P&: chloride is . gram for an adult and
,'05 gram for an infant'
6f the insecticide is a carbamate# atropine sulphate is used as an antidote? 0!P&: and
other oximes are not to be used'
/
/
Q &dminister an antidote =here possible' )his involves the follo=ing steps;
/
/
/
$ource; WHO Western Pacific Region' 4acBground Document *o'.+# .775
.71
..' Functions of %mergenc &ction
Committee (%&C- and Rapid &ction
)eam (R&)-
(&- %mergenc &ction Committee (%&C-
Constitution
)he %&C =ill comprise administrators# epidemiologists# entomologists# clinicians and laborator
specialists# school health officers# health educators and representatives of other related sectors'
Functions
(.- )o taBe all administrative actions and coordinate activities aimed at the management
of serious cases in all medical care centres and undertaBe emergenc vector control
intervention measures'
)o dra= urgent plans of action and resource mobili"ation in respect of medicines#
intravenous fluids# blood products# insecticides# e2uipment and vehicles'
)o liaise =ith intersectoral committees in order to mobili"e resources from non!health
sectors# namel the ministrEdepartment of ! urban development# education# information#
la=# =ater suppl# =aste disposal for the elimination of the breeding potential of &edes
aegpti'
)o interact =ith the ne=s media and *GOs for dissemination of information related to
health education and communit participation'
(0-
(1-
(3-
(4- Rapid &ction )eam (R&)-
Constitution
)he R&) at the state or provincial levels =ill comprise epidemiologists# entomologists and a laborator
specialist (at state and local levels-'
Local levels
:edical officer# public health officer# non!health staff# local government staff'
Functions
Q
Q
Q
Q
Q
Q
HndertaBe urgent epidemiological and entomological investigations'
Provide re2uired emergenc logistical support# e'g' deliver of medical and laborator
supplies to health facilities'
Provide on!the!spot training in case management for local health staff'
$upervise the elimination of breeding places and application of vector control measures'
Carr out health education activities'
$ample the collection of serum specimens'
$ource; :anagement of Dengue %pidemic# Report of a WHO )echnical :eeting# *e= Delhi# 09/1, *ovember .77+# WHO Regional
Office for $outh!%ast &sia# *e= Delhi ($%&ED%*E.# $%&EC4CE55# :a .778# 19 pp-'
.73
.0' Case 6nvestigation Form
(prototpe-
6D no';
*ame of hospitalEinstitutionEclinic;
LocalitEto=nEcit;
Date;
Case investigation;
*ame;
≥
$ex;
FatherAsEmotherAs name;
&ddress;
Whether visited an other area during last t=o =eeBs;
$igns and smptoms;
Date of onset of fever;
Date of admission;
Course of fever; continuousEintermittentEremittent
Presenting smptoms;
Haemorrhagic manifestations; NesEno
Petechiae# parpura# ecchmosis# epistaxis# gum bleeding# haematemesis# malena
%nlarged lever; NesEno
)orni2uet test; PositiveEnegativeEnot done
Rash; NesEno
$hocB; NesEno
Condition of patient; stableEcritical
&n platelet or blood transfusion given;
Laborator findings;
.75
Haematocrit (percentage-
Platelet count
Differential leucocte count
$eroogical input; *$.# 6g:# 6gG
&cute sera collected on date;
Convalescent sera collected on date;
Outcome of the patient;
$erial readings
0
$erial readings
0
$erial readings
0
.
.
.
$ent on date;
$ent on date;
RecoveredEexpiredEdischarged on;
$ignature
(:edical OfficerE Designated authorit-
$ource; &dapted from Dengue Fever# Dengue Haemorrhagic Fever# Dengue $hocB $ndrome 6nvestigation Guidelines' Cersion
,.E0,.,' Jansas# H$&
.7+

Who-2011 Dengue

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Who-2011 Dengue

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Comprehensive Guidelines for

Prevention and Control of Dengue and

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