How to eradicate Dengue virus from

Sri Lanka

By a special correspondent-April 3, 2017,

Sri Lanka is in the grip of a severe epidemic of Dengue fever and
Dengue haemorrhagic fever. The epidemic did not happen over a
short period. Dengue has been in Sri Lanka since 1962. However,
it was not a major public health problem. The disease was
progressing at a very slow rate. Since about 2004, the numbers of
cases have started going uprated dramatically since about 2008.
There have been great efforts to stop the spread of dengue in the
country for several decades with singular lack of success, with the
ever increasing spread of the decease as seen in the graph below.
It is therefore evident that the approach to the problem and the
means adopted are questionable, including the highly
questionable proposals of large scale use of chemicals recently
advocated and adopted.
See Graph 1
In recent years, there has been a National Dengue Control
programme involving most government departments, the police
and even the armed forces, coordinated at the highest level.
However, all these efforts have been directed towards the
elimination of the mosquitoes and not finding the means of
controlling and eliminating the root cause, which is the Dengue
Virus.
See Graph 2
BI = No of positive containers/No of premises inspected x 100

As the blue line in Graph 2 shows, their efforts have not been in
vain, when reviewed only by the success in reducing the
mosquitoes. The Breteau Index (BI) which is an index of the
presence of mosquito breeding sites, has continued to fall until
2012. But during the same period the dengue cases have
continued to rise (red line).

However, the same strategy to control dengue is continued to be

followed today because;

=there appears to be no viable alternative and

*it is the recommended strategy; namely to reduce and eradicate

aedes mosquito breeding sites.
See Graph 3

Should we continue with this strategy?

As Graph 3 shows, every year, since 2012,

the annual cases have been going up.
Although there have been periods of
high and low incidence of cases, the
pattern has been the same every year.
In addition to the ongoing routine
programme of dengue control, special 3, 5
or 7 day eradication programmes
are also instituted periodically. We can use
the pattern of dengue incidence
during the past five years to test whether
the special eradication programmes
have any effect.

See Graph 4

Graph 4 shows in blue the pattern of

average dengue cases during the years
2002 2015. The red line indicates
what happened in 2016. The dates on the
horizontal axis (29th Mar., 15th Jun.
etc.) are for 2016 and special programmes
for eradication of breeding sites started
thereon. The reader can seeif the special
programmes have been successful
or not, in 2016, from the way the red line
has moved with the blue line in spite of
the special programmes.
It is therefore time to institute an alternative method of control or
even eradicating dengue from Sri Lanka. Before such a strategy is
even considered, a certain mindset has to be eliminated as
regards the public and bureaucrats. They seem to think the only
way dengue can be controlled is to prevent the breeding of aedes
mosquitoes".

If one analyses the dengue cases since 2004, some features were
observed.

See Graph 5 and 6

See Graph 7

*The more densely populated a district is, the more intensely will
the epidemic spread in that district

*The more populated a district is the faster the disease will spread
in that district

*The more cases there are in a month the more cases there will
be in the next month

These are the features of an infectious disease

Knowing that dengue in Sri Lanka behaves as an infectious

disease we can adopt the measures that are traditionally used to
control an infectious disease; when there is neither an effective
treatment nor an effective vaccine. That measure or strategy is
isolation.

Isolation works by preventing the transfer of the disease-causing

organism from a sick individual to a healthy individual by
whatever means. The transfer may be by touch, sneezing and
coughing or by an insect

In epidemiology, there is a concept named Effective Reproductive

Rate. (R) What this means is that in infectious disease epidemics,
the behaviour or progress of the epidemic depends on, among
other things, how many healthy persons a sick individual will pass
on the disease to. If the sick person infects only one other person
(R=1), the disease will continue to affect the community but will
not become an epidemic. If the sick person (on average) passes
on the disease to no one (R<1 but="" disappear.="" disease=""
hand="" healthy="" if="" infects="" more="" on="" one=""
other="" person="" sick="" slowly="" surely="" than="" the=""
will="">1), there will be an epidemic.

This, in effect, means that in order to stop the epidemic (of

dengue or any other disease), we do not have to isolate every
case. Graph 6 shows (in theory), what would happen if we
reduced the average number of healthy people thaHow to
eradicate Dengue virus from Sri Lankat a dengue patien

t infects. As the graph shows, how soon we eradicate dengue will

depend on how effective we are in isolating dengue patients.
(50% isolation will eliminate dengue in 6 generations or 4
months).

See Graph 8
This naturally raises the question; how do we isolate dengue
patients? We do not actually "isolate" a dengue patient in the
traditional sense. We isolate the dengue patient from mosquito
bites.

One would notice that what is suggested is quite a radical

departure from the accepted dogma. If we are to adopt the
strategy proposed, two things are essential.

=There must be very strong commitment at the highest level to

the new strategy.

=There is a need to mount an intensive health education

campaign.

Some basic misconceptions have to be corrected. For example,

that dengue is acquired from mosquitoes. Dengue is actually
acquired from a dengue patient; the mosquito only "transports"
the virus. All campaign literature must display the image of a
dengue virus and not a mosquito.

Undoubtedly, there will be many who will object to the proposed

solution. Some will say that what is proposed is not practicable. I
should like to ask them what the aim of the present strategy is. It
is aimed at preventing mosquito breeding? The final aim of the
present strategy is also to prevent mosquitoes biting dengue
patients. There is no harm done if aedes mosquitoes bite healthy
people, unless of course the mosquitoes has bitten a dengue
patient previously.
Only a little reflection is necessary to realise what a roundabout
and wasteful method we employ to control dengue. Take the
Colombo District as an example. There are 2,000,000 people
there. Every month about 800 cases are reported from Colombo.
When one infected mosquito bites a person (2,000,000 800)
some 1,999,200 could be bitten by non-infected mosquitoes.
What this means is that in order to prevent one mosquito biting a
dengue patient we have to prevent the birth of (2,000,000/800)
2,500 mosquitoes.

Another argument that might be advanced is that the cooperation

of the public cannot be expected. Once again if we take the
Colombo District as an example, there are approximately 500,000
households there. What the authorities are now asking the public
to do is keep these 500,000 premises free of mosquitoes
breeding. What I am asking is to look after 800 patients. Which is
easier? A further difficulty is that people find it difficult to
eliminate all breeding sites from houses and gardens because
some breeding sites are either inaccessible or hidden e. g. on the
roof, in tree hollows and underground. Dengue -patients on the
other hand are easily identified because of fever.

Finally, if evidence is required to prove that it is not mosquitoes

that cause dengue epidemics, rather than individual dengue
cases, the next graph from Singapore is sufficient:

Dengue and Dengue Haemorrhagic Fever Singapore 1966 - 2005

(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)
Premises index = premises with breeding sites/total premises
inspected x 100

When there were plenty of mosquito breeding ( premises index of

50 in 1966) there were fewer than 50 cases of dengue per
100,000. However, when the premises index was brought down to
about 2 by 2005, there were 300 dengue cases per 100,000
population.

Even in Singapore, the authorities have now realised that control

of mosquito breeding alone is not sufficient to eradicate dengue.
From 2016 there is an additional bit of advice to people.

"You should apply insect repellent in the following situations:

*You are a confirmed or suspected dengue patient, having a fever.

Fever in dengue patients coincide with the presence of dengue
virus in their blood, which could be inadvertently transmitted to
family members and neighbours via Aedes mosquitoes.

*A family member or neighbour has contracted dengue.

*Your neighbourhood has been declared a dengue cluster.

Click here for the list of active clusters. Use of repellent can
minimise chances of being bitten by an infective mosquito.

*You are visiting a place that is a declared cluster or has high

mosquito population".
(http://www.dengue.gov.sg/subject.asp?id=160)

A Thought Experiment

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 will 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
(This is an abridged version of a larger document. The original
document containing the development of the suggested strategy
together with the sources of data, references etc. can be found in
http://eradicatedengue.blogspot.com) Please email any comments
to eradicatedengue@gmail.com

This report has been compiled by a MBBS Qualified Doctor with

over 50 years service experience in public health in Sri Lanka and
the UK. The data used for the compilation of the detailed report is
from publicly available documents.

Posted by Thavam