How to Eradicate Dengue from Sri

Lanka
Dengue has not always been with us. It was only in 1962 that dengue was
scientifically recognised as being present in Sri Lanka. 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
What do we do to
control dengue?
 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:

Less larvae less adult mosquitoes less

dengue patients.
Have we succeeded?
We can use the BI (Breteau Index) data to test whether we have managed to persuade
the public to reduce breeding sites in their premises. Graph below shows how the
average BI has steadily gone down. The average was between 6 and 10 till 2009. It has
gone down to 4 by 2012. This shows that the efforts at controlling breeding sites has
been very successful.

( BI = No of positive Containers/no of premises examinedx100)

The Graph below 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%
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 show that we have reduced mosquito breeding in and around houses.
We have reduced mosquito
breeding.

What about dengue patients?

We can test whether mosquito breeding causes the dengue cases to go up. We will plot
the data from 2004 to 2012 for the three districts Coplombo, Gampaha and Kalutara
combined. If mosquito breeding causes dengue cases to increase, the dotted line should
run upwards from the left bottom to top right. As can be seen what has happened is the
opposite. In other words mosquito breeding has no effect on the increase in dengue
cases
Each dot is the number of cases in a quarter in a district. There are 9x4x3 =108 dots for
the 9 years and 3 districts
The graph below clearly shows that the mosquito breeding sites as shown by BI (breteau
index) in blue columns, have gradually come down from around 8 in 2004 to around 4 in
2012.(please note in the graph BI is x 10) But during the same period, 2004 to 2012,
dengue cases in a quarter have actually gone up from less than 1000 to over 2500. This
graph once again proves that reducing breeding sites of mosquitoes does not prevent
dengue.
The graph below has been drawn using survey data of mosquito breeding sites during
2014 and 2015. During these two years premises were surveyed in all districts. The
percentages of the houses that were positive for mosquito breeding was calculated. The
bottom axis shows the percentages positive. The vertical axis shows the number of
dengue cases in each month and district for the two years . Each dot represents the 25x
17= 425 readings. Once again the line is running right across rather than upwards from
left to right if mosquito breeding causes dengue to increase
The chart below shows the yearly pattern of dengue cases for the last five
years. Although the pattern has remained the same, the total cases have
steadily gone up.
The blue line in the chart below is the average of the annual dengue cases for 2012 -
2015 shown in the previous slide. The red line is the pattern of dengue cases for 2016.
The dates with arrows pointing upwards are the starting dates of the special mosquito
eradication programmes that were implemented in 2016. We do not know whether the
mosquito eradication was successful or not. But, as can be seen the curve of the red line
has very closely followed the blue line indicating that the special eradication programmes
have had no effect on the dengue cases.
If the breeding of mosquitoes is not
the cause of the dengue epidemic,
what is ?
The chart below shows the yearly averages of the 25 districts during 2008-2015. The
red line is the average for the whole country. It can be seen that the number of cases
vary a lot. Districts with larger populations will naturally have more cases. Colombo and
Gampaha have had the most number of cases. If Colombo and Gampaha were left out,
the average would be much less than 1000 shown in the graph.
As stated before, it is natural that more cases will be found in districts with a larger
population than in those with a smaller population. We can control for this by calculating
a rate of infection. The blue columns in this chart are the rates per 100,000 population.
The red line is the rate for the whole country which averages to about 150/100,000
population for the years 2008 -2015. As can be seen not only the number of cases as in
the previous slide, but also rates too vary a lot. The districts with larger populations
have higher rates. Unlike with dengue cases, there is no natural reason why the rates
should be higher in more populated districts, unless dengue spreads more in districts
with higher population density..
We can see the effect of population density in the graph below. The blue dots
are the 25 districts. The horizontal axis shows the population density of the
district and the vertical axis the average cases for the district. The blue line has
been drawn by the excel programme and R^2 of 0.9327 shows a nearly perfect
match between population density and cases.
It might be argued that why there are more cases in more densely populated
districts is because there are more mosquitoes in more densely populated
districts. We can test this theory by plotting the Breteau Index (BI) against
population density of divisions (MOH areas). As the blue line shows there is no
association of BI ( or mosquito breeding) with population density.

*(Divisions in western province for which data was

available)
We have seen that the more populated districts have higher rates of dengue cases. The
graph below shows that not only are the rates of infection higher in densely populated
districts, the infection also progresses at a higher rate in those districts. The blue
trace/line for Colombo and red trace/line for Gampaha are moving upwards at a steeper
incline than the grey line/trace for all other districts combined. This shows that the
infection spreads quicker in more densely populated districts.
When the cases of dengue in districts and months are analysed, it is
seen that the number of cases in a district and month is related
directly to the number of cases in the district in the previous month.
This is shown by a graph below.
Dengue is an infectious disease
Three features in the previous slides point to the fact that dengue in Sri Lanka
behaves as any other infectious disease. There are more cases in crowded
districts, cases go up faster in crowded districts and more cases in one month
give rise to more cases next month and vice versa. The formula below applies to
diseases like chicken pox. But we could use it to demonstrate what happens
with dengue in Sri Lanka. X or susceptible people means a bigger population, Y
or infectious people means cases and degree of contact would in this case
means more mosquitoes.
In epidemiology, there is the concept of an Effective Reproductive Rate or R. R is equal
to the number of new cases that one sick individual will give rise to. If R=1, then
although the disease will continue to affect the community there will not be large
numbers of cases or an epidemic. If R>1 then there will be an epidemic. In the same
manner, if R<1 the disease will in time disappear from the community or country. How
soon the disease is eliminated from the country will depend how well we protect sick
people from passing on the infection.
In the case of dengue in Sri Lanka, we can see what would happen (in theory) if
we reduced R by different amounts. 20% is the same as R=0.8, 25% is the
same as R=0.75, 50% is R=0.5. Present policy is R>= 1 A generation of
dengue lasts from the first infectious day (to the mosquito) of the first patient to
the first infectious day of the next patient, or 20 days.
Have we been fighting the wrong
enemy?
During 1992 there were 656 cases of dengue in Sri Lanka. In 2016 there were
54,364 cases. How did this happen? All these cases were caused by the
dengue virus. If we say that each dengue patient had in his or her body one
billion virus particles. Then there has been an enormous increase in the number
of virus particles in Sri Lanka by 2016. Did these extra viruses come from
outside the country. No we grew them ourselves. While this was going on we
kept fighting the mosquitoes. From 1992 to 2016 there has been an 83 times
increase of dengue cases. Has there been a similar increase of mosquitoes to
account for the extra cases? If anything the number of mosquitoes in the
country has gone down.
If the following are true:

We live in an island
Dengue is caused by a virus
The virus cannot lead an independent life outside man or mosquito
Dengue is transmitted only by the bite of a mosquito.

Then the following should happen:

If mosquitoes stop biting everybody no new dengue cases will

appear after one week
If mosquitoes stop biting all dengue patients no new dengue cases
will appear after 5 weeks
If mosquitoes stop biting half the dengue patients no new cases will
appear after 16 weeks