How to Eradicate Dengue Virus

from Sri Lanka

by a Special Correspondent

Foreword

Aedes aegypti, the principal mosquito vector of dengue viruses is an insect closely associated
with humans and their dwellings. People not only provide the mosquitoes with blood meals but
also water-holding containers in and around the home needed to complete their development.
The mosquito lays her eggs on the sides of containers with water and eggs hatch into larvae after
a rain or flooding. A larva changes into a pupa in about a week and into a mosquito in two days.
See Aedes main aquatic habitats ; from tree cavities to toilets and learn about the mosquitoes life
cycle . People also furnish shelter as Ae. aegypti preferentially rests in darker cool areas, such as
closets leading to their ability to bite indoors.

It is very difficult to control or eliminate Ae. aegypti mosquitoes because they have adaptations to
the environment that make them highly resilient, or with the ability to rapidly bounce back to initial
numbers after disturbances resulting from natural phenomena (e.g., droughts) or human
interventions (e.g., control measures). One such adaptation is the ability of the eggs to withstand
desiccation (drying) and to survive without water for several months on the inner walls of
containers. For example, if we were to eliminate all larvae, pupae, and adult Ae. aegypti at once
from a site, its population could recover two weeks later as a result of egg hatching following
rainfall or the addition of water to containers harboring eggs.

It is likely that Ae.aegypti is continually responding or adapting to environmental change. For

example, it was recently found that Ae. aegypti is able to undergo immature development in
broken or open septic tanks[PDF - 1 page] in Puerto Rico, resulting in the production of hundreds
or thousands ofAe.aegypti adults per day. In general, it is expected that control interventions will
change the spatial and temporal dispersal of Ae. aegypti and perhaps the pattern of habitat
utilization. For these reasons, entomological studies should be included to give support before
and throughout vector control operations.

1
http://www.cdc.gov/dengue/entomologyEcology/index.h
tml

(accessed 22/07/2016)

Introduction
There is little doubt that dengue fever is the one condition that people
most dread when someone, specially a young person, falls ill in Sri Lanka
today. It is also most likely the commonest cause of hospitalisation of
young people in Sri Lanka. In spite of strenuous efforts, not only by the
health department but also by numerous other agencies including the
Police and Armed Services, no sign of controlling the disease is in sight.
On the contrary dengue is on the rise. (1) The purpose of this book is to
demonstrate that the present strategy is not working and outline other
measures we could be utilising to control and in the end, eliminate this
epidemic from Sri Lanka.
The book is also very unusual because the readership it is aimed at are
three very different groups. The three groups are: the educated public,
the political leadership and finally the professionals who are engaged in
the efforts at controlling dengue in Sri Lanka. Because of the nature of
the subject it is difficult to avoid technical terms and concepts. However
great efforts have been taken to use simple language and avoid jargon as
far as possible. In an attempt to make the book more readable, text is
kept to a minimum and charts and graphs have been used wherever
possible.
Perhaps a word is needed here to explain why such efforts are necessary
to address such a wide audience. It may be felt that as this is essentially
a technical matter of interest only to the professionals tasked with
formulating policy, what is needed therefore is a technical memorandum
addressed to only those who matter. Unfortunately, (or fortunately
depending on how you look at it) it is not so. There are several good
reasons for adopting the approach taken. There seems to be an
assumption that there is only one way of controlling the dengue epidemic;
namely the control of breeding sites of aedes mosquitoes. The
newspapers frequently carry correspondence from readers on the subject
of dengue eradication but no one ever criticizes the strategy itself,
although readers may be critical of some aspects such as infrequent visits
by inspectors, not cleaning drains or clearing garbage. (2) In order to
break this mindset, it is necessary to address the public. A change in
strategy would require a political decision. Therefore, Politicians need to
be addressed. Politicians are likely to take notice if the general public
clamour for a change in strategy. It would also be difficult for the

2
professionals to claim superior knowledge in the face of a well-informed
public. Finally, the most important reason for addressing the public
directly is because in the end, the success or failure of any strategy would
depend on the cooperation of the community, which is more likely if the
people believe in the control measures adopted.
As stated earlier, this book is about finding an alternative to the present
unsuccessful strategy to control and eradicate dengue from Sri Lanka.
However, partly for the reasons mentioned earlier, i.e., the unquestioning
belief in the effectiveness of elimination of breeding sites, it is necessary
to deal with this issue at length. Hence the first part of the book is
devoted to the effectiveness of the present strategy.
It is also worth mentioning that the information and data, on which the
arguments advanced here, are all available in the public domain. All data
on the breeding site surveys and the weekly, monthly and quarterly
incidence of dengue cases are from two sites: www.epid.gov.lk and
www.dengue.health.gov.lk , the Epidemiological Unit and Dengue Control
Units respectively. It should also be mentioned that since the data are
freely available, the conclusions reached here can be tested by anyone
with the required skill.

The Story So Far

Dengue has not always been with us. It was only in 1962 that dengue
was scientifically recognised as being present in Sri Lanka (3). Even then
the illness was not present as an epidemic as it is now. It was only as late
as 2000 that the disease started being a major problem.

Yearly Dengue Cases

1992 - 2016 Sri Lanka
60000
50000
40000
30000
cases for year 20000
10000
0
92

94

96

98

00

02

04

06

08

10

12

14

16
19
19

19

19

20

20

20

20

20

20

20

20

20

year

Graph 1

3
As the graph below shows the number of cases tends to go up twice a
year, although large numbers of cases are reported throughout the year.

Four Weekly Average Dengue Cases

Sri Lanka
900
800
700
600
500
total cases averaged over last 4 weeks 400
300
200
100
0
2

year

Graph 2

Four weekly average dengue cases

Colombo District 2012 - 2016
2012 2013 2014 2015 2016

1500

1000

avegae cases over previous 4 weeks

500

0
1
8
15
22
29
36
43
50

week no.

Graph 3

4
There is little doubt that dengue has been steadily going up from about
2004 (see Graph 1). We therefore need to question whether, the means
we are employing at present to control the disease are working.

What is the present strategy?

Remembering that the aim of this book is to suggest an alternative
strategy to control the spread of dengue, it is important to outline what
the present strategy is. As far as the public in Sri Lanka are aware the
present strategy is primarily aimed at eliminating mosquito breeding sites
from the home environment. All activities such as awareness education,
garden cleaning campaigns, inspections by officials and even prosecution
of householders and managers of public institutions are aimed at this one
strategy. All the same, it is important to know what the official position is.
The National Dengue Control Unit is the agency that coordinates all
dengue control activities in the country. Their website (
http://www.dengue.health.gov.lk/), lists the dengue control activities under
the following headings:
Disease Surveillance
Integrated Vector Management
Case Management
Social Mobilisation
Disease Surveillance
There are only two items under this heading.
Establishment of a web-based system to enhance disease
surveillance in collaboration with the Epidemiology Unit in 50
Sentinel Hospitals, and
Training of relevant staff.
Integrated Vector Management
Integrated Vector Management is described under two subheadings,
namely:
Vector Surveillance
Vector Control

5
Vector Surveillance is defined as systematic monitoring of the seasonality
and abundance of vector population. Vector is defined here as larva,
pupae and adult (presumed of mosquitoes). The main purpose of vector
surveillance is to obtain information regarding vector density to predict
outbreaks/epidemics, which in turn enables initiation of early measures to
prevent/control outbreaks.
For further details please visit www.dengue.health.gov.lk

Is the Strategy Working?

Looking at the graphs above (Graphs 1-3) it does not appear that the
present strategy is working. In fact, the situation has worsened since the
beginning of 2009. How can one prove or disprove that the strategy is
working? It could be said that since the cases are continuously going up
year after year, it is quite obvious that the strategy is definitely not
working. However, there is an argument that the situation would be even
worse if the present measures were not adopted. It is impossible to prove
the latter reasoning is not true.
However, it must be admitted that those who have been given the task of
reducing breeding sites have done a remarkable job. In 2004 the average
BI (index of mosquito larvae) was 9. By 2012 it had come down to <4. In
2004 the percentage of BI less than 5 was 5% while in 2012 it was >60%.
Whether this achievement had any effect or not on the incidence of
dengue, there is no doubt the environment around households are cleaner
as a result.
There is also the premise that there is no alternative to dengue control,
other than reducing breeding sites of mosquitoes. The last argument is
not strictly tenable as we have shown that malaria and now filariasis can
be successfully eradicated from Sri Lanka even though there is no vaccine
against either disease.
In addition, there is no strong evidence worldwide to indicate that there is
a relationship between larval indices like Breteau index (or other larval
index) and dengue transmission. (4,5,6,7)

6
Data on Vector Surveillance
As part of Integrated Vector Control there is Vector Surveillance which
means the systematic measurement of the presence of the vector
(mosquito larvae) over time and in different locations.
These surveillance data are publicly available and we can analyse the
data to determine if they show any effect on the appearance of dengue in
different times and locations. These measurements are available for two
periods namely: 2004 to 2012 in respect of the districts of Colombo,
Gampaha and Kalutara. And for 2014 and 2015 for all districts of the
country . No data are published for 2013 and after 2015. Whether it is
because the surveys were not routinely carried out in 2013 and are no
longer being done, or for some other reason is not known.
The following is an example of larval data that is publicly available for the
period 2004 to 2012.
Breteau Index
= No. of Positive containers x 100
No. of premises inspected (300 in every division)

7
(A)= Aedes aegypti
(B)= Aedes albopictus
The table below summarises the data. Under each district are shown the number of
surveys carried out during the year.

Number of Surveys Carried out By Year and District 2004 to 2012

Year Colombo Gampaha Kalutara Total

2004 30 18 48
2005 54 36 90
2006 108 67 14 189
2007 64 66 3 133
2008 61 58 12 131
2009 61 93 11 165
2010 51 64 2 117
2011 58 77 4 139
2012 58 67 4 129
TOTAL 545 546 50 1141
Table 1
In addition to the above, larval survey data are available for inspections
carried out during 2014 and 2015. These surveys were different from the

8
above as they were done throughout the country. The reporting of the
results is also different. Instead of reporting Breteau Index, the number of
households inspected and the percentage of households with positive
larvae are reported by district. The table below shows the data for the
entire country. Anyone interested can view the detailed data at
http://www.dengue.health.gov.lk/.for further details
Number of Inspections Carried out by month and Year All
Districts
Year 2014 2014 2015 2015
Inspected Positive % Inspected Positive %
January 26379 13.54
February 21136 5.7
March 26047 9.02
April 31393 6.90
May 62885 5.4 22192 7.79
June 32900 7.46 23472 9.14
July 20315 6.34 26103 8.03
August 26131 5 25785 5.81
September 29256 5.72 17650 6.15
October 27624 6.73 22229 7.22
November 33084 11.31 23973 10.1
December 29620 13.66
Table 2

In addition to the data on vector surveillance, (presence of mosquito

larve), information on the number of dengue cases reported are
published by each district and by each quarter since 2004 and by each
week since 2010. This information is available on www.epid.gov.lk

Causes of the Dengue Epidemic.

We know that dengue fever is caused by a virus spread by the aedes
mosquito. However, we do not know what factors cause dengue
epidemics. The present strategy to control the dengue epidemic is based
on the assumption that increased presence of aedes mosquitoes is
associated with increase of dengue cases. In fact, the strategy is based on
the presence of dengue larvae and not adult mosquitoes. The reasoning
is:

more larvae more adult mosquitoes more

dengue patients.

9
We can test this hypothesis by using the data on breeding sites and
dengue cases. We will plot the data from 2004 to 2012 for the three
districts Coplombo, Gampaha and Kalutara combined. Each dot represents
a quarter and district combination.
[As correlation or association are very important concepts used in this
analysis a detailed description of correlation is given in APPENDIX I]

Dengue Cases and Breteau Index (BI) (all aedes)

Colombo, Gampaha and Kalutara Districts 2004 - 2012
4100
3600
3100
2600

Quarterly Cases 2100

1600
1100 R = 0.26

600
100
0 2 4 6 8 10 12 14 16

Quarterly BI (aeg+alb) #

Graph 4
# aeg = aegpti , alb = albopictus

Dengue Cases and BI (ae. aegypti)

Colombo, Gampaha and Kalutara Districts 2004 - 2012
4000
3500
3000
2500
Quarterly Cases 2000
1500
1000 R = 0.1
500
0
0 2 4 6 8 10 12

Quarterly BI (aeg)

Graph 5

10
 Dengue Cases and BI (ae. albopictus)
Colombo, Gampaha and Kalutara Districts 2004 -2012
4100
3600
3100
2600

Quarterly Cases 2100

1600
R = 0.29
1100
600
100
2 4 6 8 10 12 14 16 18 20 22

Quartely a BI (alb.)

Graph 6

It will be seen that there is no association between the presence of

mosquito larvae (represented by Breteau Index or BI) and dengue cases.
The R^2 figures are: 0.2981, 0.1388 and 0.3147 for all aedes, aegypti
and albopictus respectively. Curiously if anything the dengue cases seem
to go down with increasing BI! The explanation of this apparent anomaly is
possibly because, the number of dengue cases have steadily gone up over
the period of study, while during the same period (2004 to 2012), because
of intense health education and other measures undertaken by the
authorities, the number of areas with high breeding sites and therefore
high BI, have gone down. (This is clearly seen in Graph 7 on Page 11)
Please see APPENDIX II for further analysis of BI and cases.

Quarterly Cases and BI

Colombo District

BI Cases

Quarters 2004 to 2012

4000 140
3500 120
3000 100
2500
80
2000
BIx10 60 Quarterly cases
1500
40
1000
500 20
0 0
1

9
13

17

21

25

29

33

11
Graph 7
Graph 7 above shows that from 2004 to 2012 the Quarterly BI has steadily
declined but over the same period the dengue cases have steadily gone
up, proving once again that there is no rational correlation between BI
(presence of larvae in a district) and the number of dengue cases in a
district.

This lack of correlation between larval indices and dengue cases is not
confined to Sri Lanka as the chart from Singapore shows. (8)

12
Figure 1. Annual incidence dengue fever (DF) and dengue hemorrhagic fever (DHF)
and the premises index, Singapore, 19662005. DHF was made a notifiable disease
in 1966, while DF became a notifiable disease in 1977. The annual incidences of DF
and DHF reported in this figure were calculated from the number of reported cases
each year from 1966 to 2004. The annual premises index is expressed as a
percentage of the premises in which Aedes aegypti or A. albopictus larvae were
found divided by the number of premises visited by environmental health officers.

Surveys in Other Districts.

So far, we have analysed the results of breeding site surveys of the
Colombo, Gampaha and Kalutara districts only. Data is also available of
mosquito breeding site surveys carried out in all districts of the country in
2014 and 2015. During these surveys the index of study was the

13
percentage of premises inspected that was positive for breeding sites of
mosquitoes as follows:
District No premises No. premises Percentage
Inspected positive positive

Now we have two tables with 17 columns for the months June 2014 to Oct
2015 and 25 rows for the 25 districts.

Table 4 Shows the way data is available for % +ves for

the 25 districts and
from June 2014 to Oct 2015
Month Ju Au Se Oc No De Ja Fe Ma Ap Ma Ju Ju Au Se O T
/ Jun l g p t v c n b r r y n l g p c 0
Distric 14 1 14 14 14 14 14 15 15 15 15 15 15 1 15 15 1 T
t 4 5 5 A
L
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Total Tot
al
Table 4

14
 Table 5 Shows the way Data is available for Dengue
Cases for the
25 districts and from June 2014 to Oct
2015

Mont Jun Ju Au Se Oc No De Ja Fe Ma Ap Ma Ju Ju Au Se O T
h/ 14 l g p t v c n b r r y n l g p c 0
Distri 1 14 14 14 14 14 15 15 15 15 15 15 1 15 15 1 T
ct 4 5 5
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Tot Tot
al
Table 5

To examine correlation if any between the two sets of data, we can

virtually place one table on top of the other. First let us plot the

15
 horizontal totals for % +ve (table 4) against the horizontal totals of the
dengue cases (table 5). Average of % +ve vs average of cases for each
month, Result are shown in Graph 8

Average Percent Positive Premises and Average Monthly Cases. June 2014 - Oct.2015l
300

250

200

Av Monthly Cases 150 R = 0.02

100

50

0
4 6 8 10 12 14 16

Av Percent Positive

Graph 8

Next, we can plot the averages for all the months taken together for each
district (vertical totals in blue)
(Average % +ve vs average cases for each district) Shown in Graph 9
below.

Average Percentage Positive of District and Average District Cases

All Districts June 2014 - Oct. 2015
1200

1000

800

Average District Cases 600

400

200
R = 0.03
0
2 4 6 8 10 12 14 16 18

Av Percent Positive

16
Graph 9

We can also plot all pairs of readings, one pair of readings of +ves and
cases each, for district and month (25x17=425 represented by one dot),
as shown in Graph 10 below.

Percent Positive Premises and Dengue Cases

All Districts June 2014 - Oct 2015
10000

1000

100 R = 0.01
Monthly Cases

10

1
0 5 10 15 20 25 30 35 40 45 50

% Positive

Graph 10

Once again there is no association of dengue cases in each district and

month and the percentage of positives for larvae in that district and
month. This is true when we take the district and month individually as in
Graph 10 similar to what we found when we plotted the district and
monthly averages in Graphs 8 and 9 above.. The R2 readings are 0.0204,
0.0277 and 0.0078 respectively.

As was done before with BI in APPENDIX II, we can also plot the three
districts Colombo, Gampaha and Kalutara separately, the results are in
APPEMNDIX III

17
Have we Succeeded in Controlling Breeding Sites?
We can use the BI data to test whether we have managed to persuade the
public to reduce breeding sites in their premises. The graph 11 below
shows how the average BI has steadily gone down. The average was
between 6 and 10 till 2009. Then it has gone down to 4 by 2012. This
shows that the efforts at controlling breeding sites has been very
successful.

Average Yearly BI (all aedes)

Colombo, Gampaha and Kalutara Districts
12

10

Average BI 6

0
2004 2005 2006 2007 2008 2009 2010 2011 2012

Graph 11

Percentage of BI Under 5 (all aedes)

Colombo, Gampaha and Kalutara Districts 2004 - 2012
70

60

50

40
% of BI under 5
30

20

10

0
2004 2005 2006 2007 2008 2009 2010 2011 2012

Graph 12

18
Graph 12 above shows the success in controlling breeding sites in a different
manner. In 2004 the percentage of BI readings under 5 was below 10 while by
2012 it had risen to over 60.

Percentage of BI under 2 (all aedes)

Colombo, Gampaha and Kalutara Districts 2004 -2012
0.25

0.2

0.15

% of BI under 2
0.1

0.05

0
2004 2005 2006 2007 2008 2009 2010 2011 2012

Graph 13

Graph 13 shows the same thing, this time counting BIs that was below 2.
There were no readings below 2 until 2009. It should be remembered that
BI or Breteau Index is a measure of breeding sites in household premises.
A low BI means less breeding. So, all three graphs above 11,12 and 13
show that there has been a steady improvement in keeping household
premises free of breeding sites, at least in the Colombo, Gampaha and
Kalutara districts.

Period between 2014 and 2015

It will be remembered that during 2014 and 2015, surveys were carried
out in all districts to estimate larval frequency. The findings were reported
as percentage positives. The summary data is sown in table 2 on page 8.

19
 Percent Positive Premises All Districts
June 2014 - Oct. 2015
16
14
12
10
8
Percent Positive 6
4
2
0

6
1

8
79

85

91

97

03

09

15

21

27
42
41

41

41

41

42

42

42

42
Graph 14
When the country as a whole is considered in Graph 14, immediately it is
apparent that there has been no marked change in the pattern of
positivity over the period for which we have data. In the short series, we
have i.e. for years 2014 and 2015, there is the appearance of two peaks,
one at the end of the year and the other at the middle of the year but no
reduction over the whole period, June 2014 to Oct 2015 in the
percentages of premises found to be positive.

Percent of Households Positive and Total dengue cases June 2014 - Oct 2015

Percent +ve Cases

16 8000
14 7000
12 6000
10 5000
8 4000
percent +ve total cases
6 3000
4 2000
2 1000
0 0
1

15
11

13

17

Graph 15

When the total dengue cases for each of the 17 months are plotted
against the average positives figure for that month, the pattern is as
shown in Graph 15. It can be seen that once again there is no relationship

20
between the percentage of households positive for a month and the
dengue cases for that month.

Reasons for Failure to Control Dengue by Preventing

Mosquito Breeding.
What the present strategy aims to do is to reduce the visible mosquito
breeding sites in and around households and public buildings. The
assumption seems to be that if there are no easily available sites for the
female aedes mosquito to lay its eggs, it will not lay any eggs at all. Is this
assumption reasonable? In addition to the visible breeding sites there are
invisible or less easily accessible breeding sites such as gutters, tree
holes, leaf axils and septic tanks etc. and even wells. (8) Will not the
female aedes mosquito who has had a recent blood meal have an urgent
instinct to find a site to lay its eggs even with difficulty?
We saw that the efforts to reduce the number of visible sites in and
around households (Breteau Index , BI) has been successful. However,
this success in reducing BI was not accompanied by a reduction in cases.
If we had succeeded in reducing adult aedes mosquitoes, then we
might with some justification expect the dengue cases to come down.(9)
But our strategy so far has not been to reduce mosquitoes or even to
eliminate all mosquito breeding sites but only to reduce visible
breeding sites.
In any case, is there evidence to suggest that reducing breeding sites (let
alone reducing the number of adult mosquitoes ) have any influence on
the outcome of dengue epidemics? (10,11)
The following is an extract from an excellent publication of the Sri Lanka
Medical Research Institute in 2011: Practical Manual and Guidelines for
Dengue Vector Surveillance

21
V)Threshold mosquito density for dengue transmission.
The minimum mosquito density below which arbovirus disease
transmission ceases has been debated for many years without a clear
resolution. House index for 1% has been selected as the objective for
yellow fever control in Senegal but it was not based on scientific studies
(WHO 1972). In Singapore were vector density has been held extremely
low through a vigorous control programme dengue haemorrhagic
fever/dengue shock syndrome (DHF/DSS) outbreaks still occurred even
when the house index dropped to 1% (WHO 1992a)
It was also observed from many studies that large number of mosquitoes
per residence are not always associated with epidemic transmission. In a
localised school outbreak in Malasia, only three Ae. Aegypti females were
collected in one hostel where 20 students were infected. (Smith 1956a)

Is Preventing of Mosquito Breeding an Efficient Way of

Preventing Dengue?

Take an example of 2000 larvae in Colombo District

22
 The 2000 larvae will produce:

1000 Female mosquitoes and

1000 Male mosquitoes

The district of Colombo has a population of

2,000,000
Every month on average there are 800 dengue cases
in Colombo

A ratio of 2500 : 1

Therefore:

One female mosquito will bite a dengue patient 999 female mosquitoes will
bite a healthy person

To prevent one mosquito biting a dengue patient and

thus perpetuating
the epidemic, it is necessary to prevent the
breeding of 2000
23
 mosquitoes

Special Eradication Programmes

Periodically (sometimes in anticipation of the rainy season) special eradication
programmes are mounted. The graphs below will attempt to evaluate the
success of these programmes.

Four weekly average dengue cases

Colombo District 2012 - 2016
2012 2013 2014 2015 2016

1500

1000

avegae cases over previous 4 weeks

500

0
1
8
15
22
29
36
43
50

week no.

24
Graph 16
Graph 16 shows the pattern of the notification of dengue cases during the last 5
years. To smooth out the curves, 4 weekly averages are plotted rather than
weekly cases. (each point on the graph is an average of the previous 4 weeks
cases).

Four weekly average dengue cases

mean over the 4 years 2012-2015 Colombo District
300
250
200
150
4 weekly average (mean over 4 years)
100
50
0
1
8
15
22

50
29
36
43
week no.

Graph 17
Graph 17 shows the pattern of spread over the year, averaged over the period
2012 2015 taken together.

Four weekly mean dengue cases

Colombo 2012 - 2015 & 2016
Mean yrs.12-15 Yr. 2016

700
600
500
400
mean cases previous 4 weeeks 300
200
100
0
1

8
15

22

29

36

43

50

wk no.

Graph 18

25
 Four weekly mean dengue cases
Colombo 2012 - 2015 & 2016
Mean yrs.12-15 Yr. 2016

1000

100

mean cases previous 4 weeeks

10

8
15

22

29

36

43

50
wk no.

Graph 19
Graph 18 shows the pattern of notification of cases in 2016 along with the line
showing the pattern for the previous 4 years. (the same line as in graph 17).
Graph 19 shows the exact same thing but the cases are plotted in logarithmic
scale to show the relationship between the two lines better.

The dates 29th March, 15th June, 30th July and 27th September are the
starting dates of three special breeding site eradication programmes of 2016.
Readers can judge from the shapes of the curves whether the eradication
campaigns have had any effect on the pattern of occurrence of dengue cases.

What Factors Are Really Associated with

Dengue Incidence?
Rainfall
It is reasonable to expect rainfall to have an influence on the number of
dengue cases that appear in a geographical area like a town or district.
Rainfall is not expected to have an immediate effect as the average
person might think. People would imagine that rainfall causes water to
collect, mosquitoes to breed and then spread dengue. Therefore people
may expect the cases to go up after even a good shower of rain. However,
there has to be a lapse of time for the mosquitoes to lay eggs in the
water collections, the eggs to hatch and develop into adult mosquitoes.
Even then the mosquitoes have to bite a dengue patient and wait for 10
days before the mosquito becomes infectious. Even after that there is an
incubation period of a few days before the new patient becomes ill and is
counted as a case. All this should take about 20 to 30 days as shown
below.

26
Development of Mosquito
Google Image

Number of days to reach adult: Egg to larva 2-3 days; Larva to

pupa 4-5 days;
Pupa to adult 1-2 days.
Total: 7-10 day

Transmission of Infection

27
Google Image

Number of days for transmission of infection

Incubation Period inside mosquito 8-10 days
Incubation period in patient 4-13
Total: 12-23 days

Total number of days for complete cycle of transmission = 19-33 days.

We can now test whether rainfall has had an influence on numbers of

dengue cases in Sri Lanka. Rainfall data were obtained from the
Meteorological Department for the main measuring stations of the
following 8 districts for 2015.
Colombo, Gampaha, Kalutara, Kandy, Anuradhapura, Galle, Kurunegala
and Ratnapura

28
The monthly rainfall data of the 8 districts were plotted against the
dengue case data for the same districts and months. The results are
shown in the Graphs ( 20 to 22 ).

Rainfall and dengue cases in 8 districts 2015

RF and cases in same month
2000

1500

Dengue cases same month 1000

500

0 R = 0
0 200 400 600 800 1000

Month's RF in mm

Graph 20

Rainfall and dengue cases in 8 districts 2015

RF in one month and cases next month
12
10
8

Dengue cases one month later 6

4
2
0
0 R
10 =
200 30 40 50 60 70 80 90

Month's RF in mm

Graph 21

29
 Rinfall and dengue case in 8 districts 2015
RF in one month and case 2 months later
1400
1200
1000
800
Dengue cases 2 months later 600
400
200 R = 0.05
0
0 100200 300400 500600 700

Month's RF in mm

Graph 22

As the R^2 figures show rainfall has no influence on cases in the same
month when these 8 districts are analysed. Rainfall has a modest
influence on cases in the following month, R^2 of 0.219. When cases are
considered 2 months after the rainfall the modest association disappears.
This is different from what has been described in other countries where an
association has been found with cases after a lag of 2 months. (12)
We need not dwell too long on this aspect for two reasons. One, we have
only considered 8 districts. Two, even in those districts the rainfall and
cases are analysed for the whole district while the rainfall is in reality
counted in one place in the district. We may get a different result if we
analysed the rainfall against the cases in the divisions (MOH areas).
Unfortunately, dengue case data are not publicly available at that level.
In any case, we have no power to change the rainfall pattern, although we
may be more vigilant following rains. This has been taken into
consideration by the authorities in their dengue control efforts but with
little or no benefit as will be shown earlier. (see Graph 18 and 19 on page
25 ).

30
Population

Yearly Average Cases

All Districts 2008 - 2015
Dist. Average Nat. Av

9000
8000
7000
6000
5000
4000
Aerage cases per year 3000
2000
1000
0

m
le

le
bo

a
iy

al
al

la
m

n
G

g
ta
vu
lo

Ke
t
Co

Va

Pu

Graph 23

Average Rate per 100,000 population

All Districts 2008 to 2015
Dist. Rate Nat. Rate

400
350
300
250
200
150
Average rate/100000 pop 100
50
0
m
le

le
bo

a
iy

al
al

la
m

n
G

g
ta
vu
lo

Ke
t
Co

Va

Pu

Graph 24
Graph 24 above shows that there is a difference between districts in the
way that dengue has appeared in the district. The red line in Graph 24
shows the average rate in the country which is approximately 150 per
100,000 population. However, some districts have either higher than the
average rate or lower than the average rate. One would expect all districts

31
to have the same attack rate as the size of the population has been taken
into consideration by calculation a rate.

We can also calculate the number of cases that a district should have in a
year by multiplying the population of the district by the national rate:

Expected cases in district = population of district x national rate

(National rate = total cases in the whole country during year/ total
population of country)

Observed and Expected Cases

All Districts 2016
Obs Exp.

18000
16000
14000
12000
10000
8000
6000
total cases 4000
2000
0
e

ee

le
bo

a
iy

w
al

ar

al
m

al

ru
n
at

at

g
vu

m
lo

Ke
na
M

M
Co

co
Va

n
in

lo
Tr

Po

Graph 25
Graph 25 shows the observed cases in a district in blue and the expected
cases in red for the different districts. We can see that the difference
between observed and expected number of cases is different in different
districts. As Graph 26 below shows the more densely populated districts
have a bigger difference between observed and expected cases.

32
 Population Density and Obs-Exp Cases
All Districts 2016
12000
10000
8000 R = 0.81
6000
observed - expected cases 4000
2000
0
0 1000 2000 3000 4000
-2000
-4000

Pop. Density

Graph 26
Clearly the population of a district has an influence on the number of
cases in a district in addition to the size of the population.

Next let us see what association population DENSITY has with district
cases

Population Density and District Cases

All Districts 2008-2015
80000
70000
60000 R = 0.93
50000
total cases 2008-2015 40000
30000
20000
10000
0
0 1000 2000 3000 4000

pop. density

Graph27
There is a strong association between Pop. DENSITY and Cases even when
we exclude Colombo district as Graph 28 below shows.

33
 Population Density and Obs-Exp Cases
Districts less Colombo 2016
2500
2000 R = 0.56
1500
1000
Obs. - Exp. cases
500
0
0 500 1000 1500 2000
-500
-1000
-1500

Pop. Density

Graph 28

Population Density and Breteau Index

Is there a relationship between population density and the presence of

breeding sites? This seems a reasonable assumption. We can soon test
this possibility.

34
 BI and Pop Density of Districts
Colombo, Gampaha and Kalutara 2008 - 2012
12
10
8

BI 6
4
2
0
500 1000
R =0 1500 2000 2500 3000 3500 4000

Population Density

Graph 29
Graph 29 shows the situation when the three districts Colombo, Gampaha and
Kalutara are plotted.

We can also test the possibility that population density is related to mosquito
breeding by considering the smaller divisional areas for which data is available.

Pop Pop
Division Density BI Division2 Density3 BI4
9.7916 7.2251
Bandaragama Kelaniya
1951 67 6867 9
6.5023 14.858
Biyagama Kolonnawa
3162 81 6846 33
Sri
Colombo 4.4338 Jayawardanapura 6.7083
17959 46 Kotte 4497 33
6.1552 7.9257
Dehiwala Mahara
6843 08 2210 15
8.4385 6.8827
Dompe Maharagama
875 42 11554 42
15.959
Gampaha Minuwangoda
2059 72 1393 6.7275
Homagama 1966 6.98 Mirigama 899 6.0455
Horana 1040 5.25 Moratuwa 2629 5.3315
8.2595 5.8016
Ja-Ela Negombo
3359 59 2843 67
8.8399 9.3966
Kaduwela Panadura
2864 54 4143 67
5.9468
Kalutara Kesbewa
2314 7.15 3832 75
7.4410 5.4521
Katana Wattala
2028 53 3250 01

35
Table 6

Population Density of Divisions and BI

Divisions 2006-2012
20

15

Average BI in division 10
R = 0.02
5

0
0 5000 10000 15000 20000

Pop. density of division

Graph 30

As Graph 30 shows there is no such association even when we consider

the larger number of divisions.

District Population and Progress of the

Epidemic

36
 Quarterly Cases 2008 -2015
Colombo Linear (Colombo)
Gampaha Linear (Gampaha)
Av. Rest Linear (Av. Rest)

5000
4000

3000

Average cases per quarter 2000

1000

0
20 8
20 0
13
0
1
20

Graph 31
As can be seen from Graph 31 there seem to be different rates of progress
of the epidemic between the different districts. Clearly the progress of the
epidemic from 2008 to 2015 in Colombo and Gampaha appear to be much
more aggressive than in the other districts taken as a whole. It would be
too tedious to plot graphs for all 25 districts. Fortunately the computer can
work out what the slope of such graphs would be if we were to plot the
graphs separately. That fuction is called LINEST (presumably meaning
line estimated).
Excel describes the function as follows:
The LINEST function calculates the statistics for a line by using the "least
squares" method to calculate a straight line that best fits your data, and then
returns an array that describes the line.

The equation for the line is:

y = mx + b

When the exercise is carried out the results are as follows:

37
 LINES
District T
91.71
Colombo 004
Gampah 35.41
a 092
10.74
Kalutara 707
-
0.296
Kandy 37
-
4.382
Matale 51
1.036
N Eliya 107
7.136
Galle 364
-
Hambant 0.718
ota 84
-
0.397
Matara 36
10.67
Jaffna 705
Kilinochc 0.873
hi 9
0.744
Mannar 685
-
3.342
Vavuniya 74
1.126
Mulativu 466
Batticalo 5.433
a 284
-
0.715
Ampara 18
Trincoma 0.493
lee 218
Kuruneg 7.589
ala 993
3.629
Puttalam 582
0.185
Apura 667
Polonnar 2.408
uwa 358
3.436
Badulla 4

38
 -
Monerag 0.801
ala 69
Ratnapur 5.914
a 956
-
4.023
Kegalle 64

The range is very wide from over 91.7 to -4. When it is negative, the
cases have actually gone down over the period 2008 to 2015.
What is the explanation for such a wide variation? What district features
give rise to this difference in the progress of the epidemic? As before let
us test the population of the district against LINEST.

Population and LINEST

All Districts
100

80

60

40
R = 0.54

20

0
0 500000 1000000 1500000 2000000 2500000
-20

Graph 32
As Graph 32 shows, there is a very strong association between the
population of the district and the progress of the epidemic in that district.
(as represented by LINEST)

39
Now let us try population density and LINEST.

Pop Density and LINEST of cases 2008 to 2015

All Districts
100

80
R = 0.91
60

LINEST cases 2008=2015 40

20

0
0 1000 2000 3000 4000
-20

Pop. density of district

Graph 33
Now the correlation is even stronger with a R^2 of 0.91.

Association with Cases in Previous Month

Do cases during a month in an area have an influence on the number of
cases in the area during the following month? If we are dealing with an
infectious disease like measles, chicken pox etc., we would expect it to be
the case. We would expect an area such as a district with high cases in a
month to produce high cases in the next month and low cases to produce
low cases next month. As dengue is spread by a mosquito, does dengue
behave differently? Graph 44 below seems to suggest otherwise. Dengue
behaves like any other infectious disease. Districts with high cases in
January produces high cases in February while districts with fewer cases
will produce fewer cases the following month.

40
 Monthly Cases in January & Februay
All Districts 2010
2000

1500

February Cases 1000 R = 0.7

500

0
0 200 400 600 800 10001200140016001800

January Cases

Graph 34
This is true if we plotted data for 2010 in Graph 34 and for 2015 in Graph
35.

Monthly Cases in January & in February

All Districts 2015
1400
R = 0.77
1200
1000
800
Cases in February 600
400
200
0
0 500 1000 1500 2000

Cases in January

Graph 35
Or if we took all years together as in Graph 36

41
 Monthly Cases in Jauary and in February
All Districts 2010-2015
2500

2000
R = 0.74
1500
cases in February
itle 1000

500

0
0 500 1000 1500 2000 2500

Cases in January

Graph 36

What would be the situation if we plotted January cases with cases in

March. The association, though still present is weaker as shown in Graph
37

Monthly cases in January and in March

All Districts 2010-2015
2500

2000

1500 R = 0.51
Cases in March
1000

500

0
0 500 1000 1500 2000 2500

Cases in January

Graph 37

And weaker still with April. Graph 38

42
 Monthly Cases in January and April
All Districts 2010 - 2015
2500

2000

1500
R = 0.39
cases in April
1000

500

0
0 500 1000 1500 2000 2500

cases in January

Graph 38

However, If we plotted April against March, the correlation is again very

strong with an R^2 of 0.75

Monthly Cases March and in April

All Districts 2010 - 2015
2500

2000
R = 0.75
1500
cases in April
1000

500

0
0 500 1000 1500 2000 2500

Cases in March

Graph 39

Dengue as an Infectious Disease

43
 healthy sick

Fig 1 Island with Infectious Disease

Let us imagine an island in which an infectious disease is present (Fig 1).

Let us also imagine that during a particular period, say one year no one
leaves the island or enters the island. In such a situation, the new cases
that arise in the year, in the island, are dependent on three factors; the
number of infectious persons (cases) at the beginning of the year, the
total number of people living in the island and the degree of mixing of
infectious and healthy persons.

i = XY ..
. Equation 1

Where i = new cases

X = susceptible people
Y = infectious people
= degree of mixing
(Oxford Textbook of Public Health 3rd Edition pp 697-700)

Although it is expressed as a mathematical equation, the scenario

described is really common sense.

Isnt it common sense to say that new cases would be greater if there are
more healthy people to catch the disease than less healthy people?

44
Similarly, the more infectious people (cases) there are, the more
opportunity there is for the infection to be passed on and therefore, more
new cases will arise. Also, more mixing produces more cases.
What has been described above is applicable to diseases that spread by
direct contact such as measles, chicken pox etc. In addition, describes
not only the amount of mixing but also other factors such as how
infectious the disease is and other factors that may influence the ease of
spread such as for example the climate and weather.
Although dengue is spread via a mosquito we can check if dengue has
followed the laws that apply to infectious diseases which spread by direct
contact.

healthy sick

Fig 2 Island with a large number of healthy people

The greater the number of healthy people there are, the

more cases that will arise (an increase of X resulting in an increase of i) Fig
2 . We have shown this to be true with dengue in Sri Lank as seen by the
Graph 26.

45
 healty sick

Fig 3 Island with large number of sick people

The more, Sick People (cases) there are the more

cases that will arise (an increase in Y resulting in an increase of i) as in Fig
3. Again, in Sri Lanka this is true for dengue. Please see graphs 34 to 39

healthy sick

Fig 4 Island where people mix more

Fig 4 represents a situation where there is greater mixing, resulting in

greater spread and more cases. An increase in resulting in an increase
of i. The higher the population density, the greater the opportunity for
mixing. This is shown to be true for Sri Lanka as seen by the R^2 value of
0.9327, when population density is plotted against cases in Graph 26.

46
Basic Reproductive Rate of Infection R0
R0 measures the average number of secondary cases generated by one
primary case introduced into a completely susceptible population.
(13,14,15)

R0 = XD ..
equation 2

X = susceptible people
D = duration of infectiousness
= degree of mixing
(Oxford Textbook of Public Health 3rd Edition Pp 700-702)

The expression above describes the situation when an infection is

introduced for the first time to a healthy population. As dengue is already
present in the country R0 does not apply to Sri Lanka. However there is
another concept called:

Effective Reproductive Rate R

R describes the generation of secondary cases in a population that has

both cases and susceptible people, as in Sri Lanka.

When R = 1 each infectious case gives rise to one new case

When R > 1 each infectious case gives rise to more than one new case
When R < 1 each infectious case gives rise to less than one new case.

Clearly to reduce the number of new cases we must strive to achieve a

situation where

R<1

47
It will be noted that to reduce R0 (or R) we must reduce either X, D or .
(equation 2 above)

As X represents the number of susceptible people the only way we can

reduce X is by immunisation. However, as there is no vaccine against
dengue we cannot reduce X.

As D is duration of infectiousness the way to reduce D is by treatment of

cases so that they are no longer infectious. We cannot do that either
because there is no treatment for dengue. (incidentally one of the more
effective measures we took to eradicate malaria from Sri Lanka was by
identifying and treating cases)

We are therefore left with the only option of reducing .

How do we reduce which represents mixing of cases and healthy

people? It is by isolation. It is the time-honoured method of fighting
contagious or infectious disease from plague to ebola, when there is
neither vaccination or treatment available.

48
Isolation
We do not seem to treat dengue as other infectious disease such as
chicken pox or influenza, because it is spread by a mosquito. People
imagine that dengue is caught from a mosquito. It is not. It is caught from
another dengue case. It is true that the infection is carried from the case
to the healthy person by the mosquito. This is no different from the
situation where the nasal droplets carry the influenza virus from a sick
person to a healthy person. So if we isolated dengue cases we can control
the epidemic, as much as we can eradicate Ebola by isolating Ebola
patients.

The way to isolate dengue cases is by preventing mosquitoes

biting dengue patients.

Please do not panic! We do not have to isolate EVERY dengue patient.

Remember our aim is to achieve a situation where:

R<1

In other words, we have to achieve a situation where every dengue

patient gives rise to less than one new dengue patient.
It would be easier to understand what needs to be done if we represented
R as 100%. Then what needs to be done is to make R = 80%, 75%. 50%
etc. What is happening at present in Sri Lanka is that R is at least 100 %
or more. The greater the reduction of R the sooner the disease will be
controlled.

Before analysing the effect of reducing R on the progress of the dengue

epidemic in Sri Lanka, it is necessary to explain what a generation of
dengue infection is in the next page.

49
What is a Dengue Generation?

Notes: Viremia = the dengue virus is present in the blood of the patient.
Extrinsic incubation period = the number of days required by the
mosquito after
acquiring the virus before it can
spread the infection
Intrinsic Incubation period = The number of days that must pass
by the patient after
being bitten by an infected
mosquito before becoming

50
 ill

We can start the clock from the first day of viremia of the first human case
to the first day of viremia in the second human case. This would give rise
to a generation time of 20 days.

How many Generations do we need to control dengue?

If we took Colombo district as an example, in 2015 on average there were

about 800 dengue cases reported from the district per month. The chart
below shown in theory the effect of reducing R.

Effect of Reducing R by the Percentage Shown

A Worked Example Only
20% 75% 60%
50% Present Policy

1000
800
600
dengue cases per generation 400
200
0
1

9
11

13

15

17

generations ((a generation = 20 days)

Graph 50

It will be seen that the greater the reduction of R the sooner the dengue
cases come down. A 20% reduction in R will bring down dengue cases to 0

51
in 15 generations while a 50 % reduction of R will result in elimination of
dengue in only 6 generations i.e 6 x20 days or 4 months.

How do we reduce R?
How do we in practice reduce R? We reduce R by preventing dengue
patients from spreading the virus to other people. In other words, by not
allowing mosquitoes to bite dengue patients.
It is at this stage that the nay-sayers would rise up and protest that in
practice we cannot do it. What must be remembered is, to achieve
elimination of dengue in 4 months we need to stop mosquitoes
biting only half the patients.

Dengue Patients in Colombo South Hospital (Courtesy The Island)

The steps needed to stop dengue patients being bitten are:

1 By the state. All hospital wards admitting fever patients should be
mosquito proofed. (16,17)
No statistics are publicly available on the proportion of all dengue patients
who are treated in hospitals and those treated at home. This information
could not be obtained from the Epidemiological unit either. But there is no
doubt that it is quite high. During one study out of 3127 patients 2817 or
90.1 percent of cases were from hospitals. (18) Therefore, by mosquito
proofing hospital wards a large part of the reduction of R can be achieved.
Not all wards in a hospital need to be mosquito proofed. However, once a
few wards are screened, any patient reporting to the hospital with a
history of fever, whatever the initial diagnosis, must be admitted only to
one of the screened wards.
2. By the public. Anyone living at home with fever must rest and sleep
under a mosquito net. Once again it does not matter what illness caused

52
the fever, anyone with a temperature must be put in bed under a net. It
also helps if in addition anyone with fever living at home is also protected
against mosquito bites by applying insect repellents such as citronella oil,
Siddhalepa or commercially available mosquito repellents.
Screening hospital wards only requires political will and some resources.
However, it will be nave to expect the public to change their behaviour
that easily. Two steps are necessary to get public cooperation. They must
be helped to get mosquito nets (or even a thermometer) and they must
be motivated by intense and appropriate health education regarding the
true nature of dengue transmission.
The above two steps are the most important and likely to achieve a
reduction of R. However, there are other steps that can be taken to reduce
transmission of dengue. The energy that is now being taken to reduce
breeding of mosquitoes should be redirected towards preventing the
harbouring adult mosquitoes indoors. In addition to houses, it is very
important to reduce the mosquito population in public buildings such as
schools and offices. Places where large numbers of people gather are
especially important because an infectious mosquito biting in a confined
place with many people, can infect a large number. It is also the case that
when a large number of people are present there is a higher possibility
that at least one person may be harbouring dengue and an uninfected
mosquito biting in such a situation can acquire the virus from that person.
One other high risk situation for dengue transmission is transport. Trains
and buses provide not only multiple bite sites for mosquitoes they also
provide geographical access. There is little doubt that dengue spread
around the country via buses and trains. Not only did they carry dengue
infected people, they may also have carried dengue infected mosquitoes.
It would therefore make sense to control adult mosquito populations in (at
least long distance) buses and trains by spraying.

53
Asymptomatic Infections

DENV-1 to DENV-4 means Dengue virus 1 to Dengue virus 4

54
It seems appropriate to comment on one possible criticism of what has
been proposed. It is to do with asymptomatic dengue patients. In other
words, people who are harbouring dengue virus and therefore capable of
transmitting the disease to others but are not showing any symptoms,
particularly fever. It can be argued that they would escape from being
screened from mosquitoes either in hospital or at home.
There are two groups of people who are asymptomatic but harbour virus.
The first group are those who will develop symptoms such as fever in a
day or two and then will be protected from then on (by screening or insect
repellent)
The other group are those who develop a mild illness and recover without
any symptoms such as fever. The exact proportion of the dengue
patients who are symptomatic is not exactly known. However one study
in Sri Lanka reported that the ratio of inapparent to apparent infections
was 1.48. In other words there were approximately 3 patients with
symptoms to 2 patients without symptoms. (19)
The infectiousness of dengue patients depends on the strain of dengue
and the severity of viremia (the amount of virus in the blood). DENV1 &
DENV2 are more infectious than DENV & DENV4. People with a high
viremia are more likely to be both symptomatic as well as infectious.
Conversely those who are asymptomatic are likely to have a low viremia
and be less infectious. (20,21)
There is no doubt that those in the first group, i.e. those who will
eventually develop symptoms are a source of infection and not protected
for 1-2 days. The second group i.e. those who remain asymptomatic
throughout are unlikely to be a source of infection. Although the virus has
been detected in contacts of cases that did not proceed to illness, the
extent or severity of the viremia has not been tested. Nor has it been
proved that those with no symptoms are capable of transmitting the
infection.
In any case the success of eradication of dengue does not depend on
complete or 100% quarantine of all sources of infection. It is worth
remembering that even in the successful control of the recent Ebola
outbreak in West Africa, some people with mild or no symptoms were
missed and not quarantined. (22,23)

55
Health Education
What has been proposed requires 100% cooperation from the public. Such
cooperation cannot be expected unless the people have complete
confidence in the viability of the project. The potential for success of
public awareness and cooperation has been proven by the results of the
current strategy to reduce breeding sites as seen by the progressive
reduction of BI over the years.
The same level of cooperation can be expected for the new strategy of
protection of sick people from mosquito bites as it is far easier than
preventing the breeding of mosquitoes.Towards this end, health education
should be aimed at ensuring that people understand all the elements of
the dynamic of dengue transmission. In other words, all that has been said
so far. The topics that need to be covered are:
Dengue is caused by a virus and not a mosquito
The mosquito only transfers infection from a sick person to a healthy one
In order to eliminate dengue from the country we need to eliminate the
virus and not the mosquito
We have always had mosquitoes in the country, but not dengue virus
We can eliminate dengue without eliminating mosquitoes

56
We have eliminated malaria without eliminating anopheles mosquitoes
(24)
We have eliminated filariasis without eliminating culex mosquitoes
The virus can live only in a human or mosquito
It cannot live outside a human or mosquito
The virus increases in large numbers only when living in a human body
It lives in a human for only about a week
After that it needs to find another human or die
The mosquito only helps the virus to find another human
If we prevent the last step i.e. transfer of the virus from one human to
another human, the virus will die out
If by some magic we stopped ALL mosquito bites, dengue will disappear in
one week
We cannot easily stop mosquitoes biting everybody because there are so
many humans.
But we can stop mosquitoes biting sick people because they are so much
fewer in number
We need not even stop mosquitoes biting ALL sick people
If we reduce the number of sick people being bitten from month to month
consistently, we can in time eliminate dengue altogether.
How soon we eliminate dengue depends on how efficient we are in
protecting sick people

57
References
1 Anonymous How dengue will lose its sting Editorial Sunday
Times 02.04.2016
2 Vitarana Tissa, Jayakuru W.S., Withane Nalini. Historical account
of dengue haemorrhagic fever in Sri Lanka. Dengue Bulletin Vol
21 1997 pp 117-118
3 Kara K. Ballenger-Browning and John P. Elder Multi-modal Aedes
aegypti mosquito reduction interventions and dengue fever
prevention. Tropical Medicine and International Health volume 14
no 12 pp 1542-1551 December 2009
4 Duane J. Gubler Prevention and Control of Aedes aegypti-borne
Diseases: Lessons Learned from Past Successes and Failures.
AtPac J. Mol.Biol.Biotechnol. 2011 Vol 19(3): 111-114
5 Eng-Eong Ooi, Kee-Tai Goh, and Duane J. GublerDengue
Prevention and 35 Years of Vector Control in Singapore. Emerging
Infectious Diseases www.cdc.gov/eid Vol. 12, No. 6, June 2006
6
7 The Island newspaper Dengue mosquitoes found in Wells
09.12.2011
8 Bowman LR, Donegan S, McCall PJ (2016) Is Dengue Vector Control
Deficient in Effectiveness or Evidence?: Systematic Review and Meta-
analysis. PLOS Neglected Tropical Diseases 10(3): e0004551. doi:
10.1371/journal.pntd.0004551

58
9 Aishah H. Azil et al The Development of predictive tools for pre-
emptive dengue vector control: a study of Aedes aegypti
abundance and meteorological variables in North Queensland,
Australia. Tropical Medicine and International Health Vol 15(10)
pp 1190-1197
10 DANA A. FOCKS, RICHARD J. BRENNER, JACK HAYES, AND ERIC DANIELS
TRANSMISSION THRESHOLDS FOR DENGUE IN TERMS OF AEDES
AEGYPTI PUPAE PER PERSON WITH DISCUSSION OF THEIR UTILITY IN
SOURCE REDUCTION EFFORTS Am. J. Trop. Med. Hyg., 62(1), 2000,
pp. 1118
11 Leigh R. Bowman, Silvia Runge-Ranzinger, P.J. McCall Assessing
the relationship between vector indices and dengue
transmission: A systemic review of the evidence. Plos Neglected
Tropical Diseases DOI: 10.1371/journal.pntd.0002848 Aug 25,
2014
12 Ivonne Morales, et al Seasonal Distribution and Climate
Correlates of Dengue Disease in Dhaka, Bangladesh. Am. J. Trop.
Med. Hyg. 94(6). 2016 pp. 1359-1361.
13 Lorenzo Pellis, Frank Ball, Pieter Trapman Reproduction numbers
for epidemic models with households and other social structures.
I. Definition and Calculation of R0
14 Adnan Khan, Muhammad Hassan and Mudassar Imran Estmating
the basic reproduction number for single-strain dengue fever
epidemics. Infectious Diseases of Poverty 2014, 3:12
http://www.idpjournal.com/content/3/1/12
15 G. Chowell et al Estimation of the reproduction number of dengue
fever from spatial epidemic data. Mathematical Biosciences 208
(2007) 571-589
16 The Island Newspaper Kbowila hospital treats over 4000
dengue patients. Its own employee dies of the disease. 19
December 2016
17 The Island Newspaper Kandy Teaching Hospital hit by dengue
02.06.2016
18 Hasitha Tissera, et al Laboratory-Enhanced dengue sentinel
surveillance in Colombo District, Sri Lanka: 2012-2014 PLoS Negl
Trop Dis 2016 Feb; 10(2); e0004477
19 David W. Vaughn et al Dengue viraemia titre, antibody response
pattern and virus serotype correlate with disease severity.
http://jid.oxfordjournals.org/
Downloaded on 19/06/2015.
20 Hasitha Tissera, et al. Burden of Dengue Infection and Disease in
a Pediatrict Cohort in Urban Sri Lanka. Am J Trop Med
Hyg 2014 vol. 91 no. 1 132-137
21 Lauren B. Carrington and Cameron P. Simmonds. Human to
mosquito transmission of dengue virus. FrntiersinImmunology|
MicrobilImmunology June 2014|volume5|Article290|2

59
 22 Richardson ET et al. Minimally symptomatic cases show Ebola
outbreak may have been larger. PLoS Negl Trop Dis.
2016;doi:10.137/journal.pntd.0005087. Accessed 13/01/2017
23 Sissoko D. et al First Ebola-related death from breast milk
transmission reported in Guinea. Helio Infectious disease News.
Clin.Infect.Dis. 2016;doi:10.1093/cid/ciw79. Accessed 13.01.2017
24 Catherine Cheney. Inside Development Focus on Global Health
Sri Lanka became a malaria-free country by eliminating the
malaria parasite, not the vector Dr Risintha Premaratne
Ministry of Health Sri Lanka.
Accessed 15.12.2016

APPENDIX I

Association and Correlation

In order to tease out what factors contribute to the cause of an outbreak of a
disease, it is necessary to test the association between the presence of the
disease and the presence of a possible cause. This is best explained by means of
an example using imaginary data. Suppose the following data was available for
an imaginary country called Sri Lanka with district names exactly the same as
ours!

Diarrho
Annual ea Colds
District Rainfall Cases Cases

60
Colombo 700 120 417
Gampaha 750 150 417
Kalutara 600 40 389
Kandy 630 10 400
Matale 660 100 389
N'Eliya 500 200 363
Galle 510 140 362
H'Tota 520 220 366
Matara 540 210 365
Jaffna 550 50 400
K'nochchi 570 130 380
Mannar 580 190 390
Vavuniya 590 180 365
Mulativu 400 230 305
Batticoloa 410 170 302
Ampara 430 110 299
T'malee 420 240 310
Kurunegal 450
a 20 304
Puttalam 480 30 302
A'pura 310 60 260
Polonnaru 360
wa 90 252
Badulla 320 80 270
Moneraga 350
la 250 230
Ratnapur 370
a 160 260
Kagalle 200 70 222

Table 1

Let us suppose that the data shown in Table 3 above, are what happened in the
country in a particular year. Looking at the table, one is not able to say whether
there is an association between rainfall and either diarrhoea or colds. The
relation between the two factors i.e. rainfall and diarrhoea or rainfall and colds
can be best seen if they are shown graphically as shown below. Each District is
represented by a dot.

61
 Rainfall and Colds
(Imaginary Data)
450
R = 0.89
400

350

No of Rported Colds in District 300

250

200

150
100 200 300 400 500 600 700 800

Annual Rainfall in District mm

Graph 1

Rainfall and Diarrhoea

(Imaginary Data)
300

250

200

Reported cases of Diarrhoea in District 150

100 R = 0

50

0
100 200 300 400 500 600 700 800

Annual Rainfall in District mm

Graph2

Immediately one can see that the graphs look different in the two instances.
Each dot on the graph shows a pair of data. For example, Colombo had 700 mm
of rain, 120 cases of diarrhoea and 417 reported cases of colds. In the graph
showing relation between rainfall and colds the dot for Colombo district is at
the point showing 700 for rainfall and 417 for colds
In the graph showing the relation between rainfall and diarrhoea the dot for
Colombo is at point showing 700 for rainfall and 120 for diarrhoea.

62
The same applies to all other districts.
In the graph for colds all the points fall more or less on a straight line. But in the
case of the diarrhoea graph, the points are much more scattered. The dotted line
running through the points has been drawn by the computer and not by the
author! (although it is possible to calculate the line manually). The figure of R^2
(termed the coefficient of determination), is very important and shows the
degree of association. If the association is very strong, an increase of one factor
is always associated by an increase of the other factor by a fixed amount.
Similarly, a decrease of one factor is always associated by a fall in the other
factor by a fixed amount.
On the other hand, if there is absolutely no association of one factor with the
other, one factor can go up and down while the other factor can remain the same
or change by varying amounts.

We can show this by drawing two other imaginary graphs (using imaginary data
not shown here) one for a perfect association and other for a completely random
and therefore with absolutely no association.

Rainfall in Districts and Reported Colds

(Imaginary Data)
300
250 R = 1

200

Colds 150
100
50
0
450 500 550 600 650 700 750

Rainfall

Graph 3

63
 Rainfall in Districts and Diarrhoea Cases
(Imaginary Data)
250

200

150
Diarrhoea
100 R = 0

50

0
450 500 550 600 650 700 750

Rainfall

Graph 4

It will be seen once again a dotted line has been drawn by the computer. In one
case when there is complete association the figure for R^2 is 1. In the case when
there is absolutely no association the figure for R^2 is 0.

In real life (and even in our imagined data shown in graphs 4 and 5 the figure is
never 1 or 0). If the association is very strong it will be nearer 1 and with no
association at all, it will be nearer 0.

It must be remembered that association or correlation is not the same as

causation. In our example rainfall and colds are strongly associated as shown by
an R^2 of 0.84. This does not mean that rainfall caused the colds. However, (in
our example) if people wanted to avoid colds they should either live in areas with
little or no rainfall or at least not get wet! Because one of the causes of getting a
cold maybe (only maybe) that one gets a cold by getting wet. This is a
reasonable assumption because (in our example), colds are strongly associated
with rainfall. At the same time, there is no reason to believe that diarrhoea can
be avoided by living in a dry area or not getting wet (once again in our imaginary
example), because diarrhoea is not associated with rainfall.

64
APPENDIX II

The three graphs below show the results when dengue cases in a district
are plotted against the BI for that district separately, namely Colombo,
Gampaha and Kalutara .

Dengue Cases and BI (all aedes)

Colombo District 2004 - 2012
4100
3600
3100
2600

Quarterly Cases 2100 R = 0.42

1600
1100
600
100
2 4 6 8 10 12 14

Quarterly BI (ae+alb)

Graph 1

65
 Dengue Cases and BI (all aedes)
Gampaha District 2004 - 2012
2600

2100

1600
Quarterly Cases R = 0.36
1100

600

100
0 2 4 6 8 10 12 14 16

Quarterly BI (aeg+alb)

Graph 2

Dengue Cases and BI (all aedes)

Kalutara District 2014 - 2012
700
600
500
400
Quarterly Cases 300

200 R = 0.08
100
0
2 4 6 8 10 12 14

Quarterly BI (aeg+alb)

Graph 3

Once gain there is no association between cases and BI. The R^2
numbers are 0.4233, 0.3662 and 0.1973) For Colombo and Gampaha,
R^2 figures are quite high but in the wrong direction! i.e. in quarters
when the BI was low the cases were high and conversely in quarters with
high BI there were fewer cases.

66
APPENDIX III

Districts Taken Separately

Graphs 1,2 and 3 below show the lack of coherent correlation between the
monthly percentage of positive premises and the number of monthly
cases for the Districts of Colombo, Gampaha and Kalutara, the three
districts with the largest number of dengue cases.

Percent Positive and Dengue Cases

Colombo District 2014 & 2015
2500

2000

1500
Monthly Cases R = 0.2
1000

500

0
4 6 8 10 12 14 16

monthly % Positive

Graph 1

67
 Percent Positive and Dengue Cases
Gampaha District 2014 & 2015
1200
1000
800

Monthly cases 600

R = 0
400
200
0
0 5 10 15 20 25

monthly % Positive

Graph 2

Percent Positive and Dengue Cases

Kalutara District 2014 & 2015
300
250
200 R = 0.46

Monthly cases 150

100
50
0
5 6 7 8 9 10 11 12

monthly % Positive

Graph 3

68