World Mosquito Day 2016 is here! Read why we're optimistic

World Mosquito Day 2016: 5 ways to beat the bugs

World Mosquito Day 2016!

If you keep up with the news, you might be tempted to believe that the bugs are winning. The Zika virus regularly steals recent headlines. Meanwhile, dengue fever affects over 390 million people every year; malaria kills 600 million+ annually, and other mosquito-borne diseases continue to cause devastation worldwide – including Japanese encephalitis, West Nile virus, chikungunya, and yellow fever. But, we remain optimistic.

World Mosquito Day 2016 unofficial logo designed by Oluwaseun Esho

Read our Top 5 reasons for hope on World Mosquito Day 2016

Designer mosquitoes: The idea that releasing more mosquitoes into the community might help to curb disease may feel counterintuitive but field trials in Brazil have shown it can be done. Genetically-modified mosquitoes, bred in a lab, have reduced mosquito populations by up to 90%. The offspring of the GM-mosquitoes do not reach maturity, meaning the number of bugs falls dramatically.

Diagnostics: Tests to diagnose dengue and other vector-borne diseases can be tricky. Differentiating between dengue and Zika, for example, can only be done in high-end laboratories – which can be slow and expensive. But innovative new diagnostics that will make diagnosis faster, more precise and more mobile. Knowing which disease you have improves that chances of swift and effective treatment. Expect to see more action in this field in the year to come.

Vaccines: The world’s first dengue vaccine is here. It has already been embraced by countries in Asia and Latin America and recommended by the WHO in areas where the disease is endemic. More countries are expected to follow later this year as the public health value becomes clear. Meanwhile, a malaria vaccine is closer than ever, and the search for a Zika vaccine is hotting up.

Awareness: Dengue has long been a neglected disease but there are signs that it has crept up the public health agenda. ASEAN Dengue Day has never been bigger and non-governmental organizations, including the Malaria Consortium, have dengue in their sights.

Disease surveillance: The WHO says recording the number and location of dengue fever is essential to its control. After all, decisions about how to allocate resources – and conclusions about whether interventions have worked – are informed by strong monitoring systems. Break Dengue is helping to build the ultimate disease tracking tool that adds crowd-sourced data to traditional sources of disease surveillance. You can help by becoming a Dengue Tracker

Yes, there are plenty of challenges on the horizon but given the progress seen in recent years there is cause for optimism. Maybe one day we’ll celebrate World Mosquito Day by remembering all the misery they used to cause – before we won the war.

image with a quote from Ronald Ross reading "he belief is growing on me that the disease is communicated by the bite of the mosquito. … She always injects a small quantity of fluid with her bite—what if the parasites get into the system in this manner." on World Mosquito Day.

Image via NIAID

What is World Mosquito Day?

In 1897, a British doctor named Sir Ronald Ross made a discovery which ultimately led to smarter ways to prevent dengue fever – even if that wasn’t his primary intention at the time.

It was Ross who found that female mosquitoes (of the Anopheles genus) were to blame for transmitting the malarial parasite. And he won the Nobel Prize in Physiology or Medicine in 1902. Since then, his discovery is celebrated August 20, every year on World Mosquito Day.

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Now you can help map the dengue virus, from your phone. Click the link below:

Dengue Track

Launch of crowdsourced dengue fever tracker

Innovative Dengue Track initiative turns big data into actionable information

People from all over the world now have the chance to report cases of the disease in their area and get tailored advice on how to avoid infection.

Brought to you by our team here at Break Dengue, Dengue Track is a novel approach to disease mapping which could also be used to tracking Zika virus or Malaria.

Through a user-friendly online chat system, the tool will build a crowdsourced map of dengue outbreak. Users – known as Dengue Trackers – can access free toolkits to help them reduce their risk of dengue fever while providing details of outbreaks.

Try it now

Dengue fever is a potentially-fatal disease that infects 390 million people per year at an annual global cost of US$8.89 billion. The World Health Organisation estimates that about 40% of the global population lives in high-risk areas.

Improved disease surveillance is essential to tackling dengue, according to the WHO Global Strategy for Dengue Prevention and Control 2012-2020, but gathering accurate data from traditional sources has been challenging. Dengue Track is helping to fill this gap.

The 4Vs of big dengue data

Dengue Track is unique. It collects an unprecedented volume of data by adding crowd surveillance and data from social media and search engines to existing official data. This variety of sources offers a 360˚ view of the disease.

“Not only that, but it does it fast,” says Nicholas Brooke, Director at Break Dengue. “The velocity of data collection and processing allows for modeling and targeted alert systems in close to real time. And, perhaps most importantly, this multi-layered approach delivers veracity. The model is more accurate because the volume and variety of data sources helps to correct errors that may arise in any individual source.”

What can you do?

First, users can visit the site and use the system for themselves. Then they can sign up to become a dengue tracker, and share. “We need to mobilize an army of dengue trackers if we are to meet our shared goal of reducing the burden of dengue fever,” says Nicholas Brooke.

Users are also invited to embed Dengue Track on their websites. Contact the Break Dengue team to learn more.

What’s new?

This self-learning digital surveillance program is highly innovative.

Dengue Track:

Provides actionable push-pull surveillance, combining close to real-time data with the ability to push it to the right audience at the right time
Taps into multiple sources to deliver an overall correlation higher than the sum of the individual data sources
Integrates all stakeholders and allows them to take an active role, proving authorities and NGOs with a valuable resource
Offers value to the audience by providing actionable surveillance data which citizens can use
Is a scalable model which can be extended to all digital channels and expanded to other diseases such as Zika and malaria
Applies self-learning techniques by providing the audience with an opportunity to endorse or correct the model

Online game helping Brazil beat dengue

Game-changer: play and share new interactive dengue fever game

Play now! Help win the race against dengue.

As the Olympic Games kick off in Rio, a new online game is raising awareness of dengue fever

The game carries a serious message. Dengue fever is endemic in Brazil with more than 750,000 cases reported this year in the nine states experiencing an epidemic.

By reducing breeding opportunities for the mosquitoes that spread the disease and using insect repellents, everyone can play their part in preventing its spread.

Brought to you by our team here at Break Dengue, the game is part of the All Against Dengue campaign designed to help people in Brazil protect themselves from the disease – and have a little fun along the way.

Participants must race against dengue fever, learning about its prevalence, transmission, and prevention, then challenge their friends to beat their score.

Play the game and share what you learn with your community.

Play now

Serious fun

Brazil’s dengue problem has been in the headlines lately as Paraná state launched the country’s first dengue vaccination program.

The problem is so severe that Brazil has also been a key testing ground for researchers testing genetically-modified mosquitoes, designed to reduce the dengue infection rate.

The modified bugs may also help curb the risk from another dreaded mosquito-borne virus: Zika. The disease has cast a long shadow over the Olympics with some sports stars opting out of the Games amid fears of infection.

The major concern with Zika is its link with microcephaly in babies whose mothers are infected during pregnancy. However, researchers at the London School for Hygiene and Tropical Medicine say dengue is a real pregnancy risk. According to a major review of top-quality studies on birth defects, contracting dengue fever during pregnancy increases the risk of stillbirth, prematurity, and low birth weight.

That’s why it’s everybody’s responsibility to reduce the risk of dengue infection and report cases in their local area.

The launch of the new game follows the unveiling of Dengue Track which allows the public to report cases of dengue fever in real time.

Play the game

Help track dengue

WHO backs dengue vaccine use in areas of high burden

Another week, another milestone. Momentum is building for the widespread use of the first-ever dengue vaccine.

Last week saw the launch of a dengue vaccine program in Paraná State in Brazil, while private clinics in El Salvador began offing vaccination to clients.

This week public health officials are poring over the World Health Organisation’s first ever position paper on a dengue vaccine.

With a vaccination program well under way the Philippines, several Asia countries considering adding the vaccine to their schedules and Mexico inching towards rolling out a dengue program, the second half of 2016 is shaping up to be a momentous chapter in the fight against the disease.

3.2 million severe cases

The paper supports the recommendation by the WHO’s immunization expert group (SAGE) published in April and sets out clear recommendations for governments around the world.

The WHO says dengue is responsible for around 3.2 million cases of severe illness and 9,000 deaths, mostly in lower-middle income countries. This translates into a loss of 1.1 million disability adjusted life years.

The need for action is plain.

“Countries should consider the introduction of the dengue vaccine only in geographic settings (national or subnational) where epidemiological data indicate a high burden of disease,” the paper states.

The vaccine should be introduced along with a strong communication campaign and as part of an integrated approach to dengue control that includes vector control and disease surveillance.

“Dengue vaccine introduction should be a part of a comprehensive dengue control strategy, including well-executed and sustained vector control, evidence-based best practices for clinical care for all patients with dengue illness, and strong dengue surveillance,” according to the WHO.

Choosing target age groups

It sets out advice on how to select which age groups to target with vaccination, taking into account a combination of seroprevalence, disease surveillance data, and local factors.

“Some countries may experience the highest incidence of dengue illness among adults and may consider vaccinating populations up to 45 years of age in routine programs,” the WHO says.

This broadly chimes with the strategy adopted by Paraná where people aged 15 to 27 will be targeted in 28 municipalities, while the target group ranges from 9 to 44 years in two additional areas with the highest incidence.

“The selection of the municipalities was based on the disease epidemiology in Paraná,” Michele Caputo Neto, Paraná Health Secretary, told Break Dengue. “The municipalities that suffered three epidemics or more in the last five periods, between 2010 and 2015 were taken into consideration.” Hospitalization for serious dengue was also a factor, according to health officials in the Brazilian state.

Clearing logistical hurdles

The WHO position paper answers a range of practical questions health officials may have had regarding how to run an immunization program.

For example, it states that should a vaccine dose be delayed for any reason, the vaccine course should be resumed rather than restarted, maintaining a six-month interval between subsequent doses.

The challenge of fitting the new vaccine into existing vaccine schedules is also tackled with a particular emphasis on the practicalities of giving the dengue vaccine at the same time as other immunizations.

“Because the risk of immunological interference due to co-administration of live with non-live vaccines is considered small, co-administration is permissible with these and other non-live attenuated vaccines,” according to the WHO paper. “Co-administration may be desirable to reduce programmatic costs associated with school-based vaccination programs.”

In short, the dengue jab can be incorporated into existing vaccine programs without any major problem. Indeed, where school-based vaccination systems are already in place, it may save money to add the dengue vaccine to the schedule.

Now, what?

The WHO position paper is a major landmark in the dengue vaccine story. With health officials in Asia and Latin America currently exploring when and how to introduce the vaccine, this may be the tipping point for improving public health and the dengue vaccine’s widespread adoption.

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Click below to improve public health, become a Dengue Tracker.

Dengue Track

Brazil launches dengue vaccination program

Paraná State’s dengue vaccine program targets 500,000 people

Brazil’s dengue vaccination program in Paraná marks the first of its kind in Latin America. The populous region has more than 10 million residents, 85% of whom live in densely-populated urban centers. Dengue incidence has tripled from 2013 to 2015, prompting Paraná health officials to lead the way in embracing the first dengue vaccine.

Map showing the location of the dengue vaccination program launch in Brazil.

Brazil’s Paraná State launches the first public dengue immunization program in the Americas

The southern Brazilian state of Paraná rolls out public vaccination campaign against dengue fever

Officials there say they initial campaign will target 500,000 people in urban areas where the human and economic burden of dengue fever is highest. People around Brazil can also access the dengue vaccine program at private healthcare clinics.

During the period from 2015 to 2016, Paraná has recorded more than 55,000 cases of dengue, 843 cases of severe dengue, and 61 deaths, at a cost of around €90 million.

Learn more about the global cost of dengue

The introduction of the immunization initiative makes Paraná the first state in the Americas to avail of the vaccine.

Disease surveillance and community engagement

The new vaccine fits into a broader dengue control strategy which includes robust disease monitoring and engagement with local communities, according to officials in Paraná.

“The world finally has a clinical prevention tool against dengue that has been shown to be efficacious in the Brazilian population, as well as endorsed by the WHO,” says, Michele Caputo Neto, Minister of Health for Paraná State.

“With our strong disease surveillance and community mobilization infrastructure in Paraná State, we are well-positioned to introduce the first public dengue immunization program in the Americas to significantly reduce our disease burden.”

Dengue continues to represent a growing public health threat for Brazilians with disruptive outbreaks that often paralyze local healthcare systems. As the country prepares for visitors attending the Olympic opening ceremony in Rio next week, its health service will be in the spotlight will be hoping to avoid major epidemics.

Is low-cost travel spurring dengue outbreaks?

In 2015, over 1.6 million Brazilians reported being ill with dengue. The real figure may be much higher. Almost 60% of the reported dengue cases in the country occur in individuals 10 to 39 years of age³, which falls within the approved age range (9 to 45 years) for the Dengvaxia® vaccine in Brazil.

This pre-adolescent to adult population represents a highly mobile and social segment of the community who contribute significantly to spread the infection. In 28 of Paraná’s municipalities, people between 15 and 27 years will be vaccinated. In the municipalities of Paranaguá and Assaí the vaccine will target the complete age range – between 9 and 44 years.

This approach has been taken because the younger population, between 15 and 27 years of age, account for about 30% of the dengue cases in Paraná. The full vaccine age range will be targeted in municipalities with a disease incidence greater than 8,000 cases per 100,000 inhabitants.

See why it’s time we all care about dengue

Public health trendsetter?

Paraná’s new dengue vaccination program is not the world’s first – that honor was claimed by the Philippines earlier this year – but it does make the Brazilian state a trendsetter in the region.

The vaccine is also registered in Mexico, El Salvador and Costa Rica. Regulatory review processes for the dengue vaccine are continuing in other countries where dengue is a public health priority.

Discover the public health value of dengue vaccination

More good news may not be far away: Mexico’s national advisory council on immunization has also agreed on recommendations for the use of the dengue vaccine, prompting speculation that it could become the next country to launch a public program.

Will Paraná’s public program put pressure on its peers?

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New wearable protection against mosquito bites

Watch out! Mosquito bites from the Aedes aegypti spread dengue fever, chikungunya, Zika, yellow fever, and other diseases

Mosquito bites can be deadly, but new clothing and wristbands impregnated with repellents and insecticides could help keep mosquitoes at bay. These new ‘wearables’ may do more than simply offer protection against mosquito bites; they could also reduce mosquito numbers near to their wearers.

Aedes aegypti mosquitoes, which transmit dengue fever and Zika, most commonly feed at dawn and dusk. The mosquito bites, both indoors or out, particularly in shady areas, or when the weather is cloudy. Researchers say effective ‘wearable’ protection offers a convenient way to stop mosquitoes from biting.

Image of Dr. Logan courtesy of ARCTEC

“What’s really needed is some form of protection while you’re on the move,” says Dr. James Logan, director of arctec at the London School of Hygiene and Tropical Medicine (LSHTM). “After all, you don’t just need protection from Aedes aegypti in your home and your garden; you need it at school or when working outside, for instance.”

Developing novel personal protection products

Rebranded as “ARCTEC” in 2010, the arthropod control material testing laboratory has been operating at LSHTM for more than 20 years. Dr. Logan and his team are currently exploiting new technologies and collaborations to develop new wearable protection solutions. By using these to change the vector’s behavior, they hope to protect the wearer from Aedes aegypti bites and, in doing so, help reduce the spread of dengue.

But finding acceptable forms of wearable personal protection can be challenging. Despite being advised to wear long-sleeved clothing and long trousers when outdoors during the day and evening to avoid mosquito bites, many people living in dengue-endemic regions may be actually more likely to wear shorts and short sleeves a lot of the time – which is not surprising considering that the weather is hot and humid.

Impregnated clothing reduces mosquito numbers

ARCTEC was recently involved in the DengueTools research project, taking a key role in identifying strategies for reducing dengue transmission in children when they’re in school. This project included a blind study aimed at investigating whether school uniforms impregnated with permethrin, a synthetic insecticide, offered a viable approach to protecting children.

“ARCTEC led the development of the clothing impregnation technology,” reveals Dr. Logan. “We worked with a number of companies to investigate how well their solutions worked.”

Unfortunately, the insecticide – permethrin – washed out of the school uniforms earlier than anticipated. Nevertheless, the research project allowed the team to answer another very important question: how well does permethrin prevent bites?

“We already knew that clothing impregnated with permethrin can kill mosquitoes, but we didn’t know how well it would stop the mosquitoes from biting,” explains Dr. Logan. “The mosquitoes might still land and bite before they die, for instance.”

The study found that, before the permethrin had washed out, the impregnated clothing did provide very good protection against mosquito bites. More than that, it found the clothing also significantly reduced mosquito numbers in and around the school.

“We might also be able to use the clothing, not just to protect people, but also to influence local populations of mosquitoes around a school, home, workplace or anywhere else,” adds Dr. Logan.

Counting mosquito bites

The team is now continuing their studies back at ARCTEC’s London laboratory where they are releasing mosquitoes into their free-flight rooms. These rooms allow the team to evaluate products in a natural setting. Volunteers sit in these rooms with their trousers rolled up and their arms bared waiting for mosquitoes to bite – or not.

Is low-cost travel spurring dengue outbreaks?

In this instance, the team is using these rooms to carry out unique research into the level of protection provided against mosquito bites by impregnated clothing when the wearer doesn’t have long sleeves and long trousers. “We measure how many mosquitoes land on a person and how many mosquito bites they get,” reveals Dr. Logan. “We compare people wearing long sleeves and long trousers with people wearing short sleeves and short trousers.”

Evaluating insect repellent products. Image courtesy of ARCTEC

The clothing is showing great potential. It offers someone wearing a t-shirt and shorts greater than 50 percent protection against bites from Aedes aegypti – which is very significant.

Testing out in the field

The team is currently developing a wide range of wearable protection technologies, from wristbands to different types of clothing. For the next phase, ARCTEC will work with companies that have developed unique ways of keeping the permethrin in the clothing. Their aim? They are looking to develop protection that might, in some cases, last up to four to five months.

“We’re making good progress in keeping actives in the wearable technology for longer,” comments Dr. Logan. “We’re also working with companies who are adding other active ingredients that have a better repellency than permethrin.”

Learn how

The next stage will see Dr. Logan and his team go back to into the field to trial their enhanced clothing. They will need to evaluate how it well works in the real world: what effect UV lights, washing, tumble drying, and ironing have, amongst other things. All these factors need to be fully understood before an end product can be developed.

Maximizing uptake

Focus group studies, in Columbia as a starting point, will give the team some insight into which types of wearable technology might be acceptable for different populations of people: pregnant women, school children with different types of uniforms and outdoor workers, for example.

Learn more about combating growing insecticide resistance

Dr. Logan explains why this is so important: “We want to get a feel for what those technologies should look like, so we can maximize uptake.”

The output from the studies will be fed into the eventual design to help with initial prototypes. A user acceptability study will then confirm how many people will use the product and reveal how it could be improved. This research will ensure the final product is accepted and likely to be used.

ARCTEC’s wearable protection technologies will offer dengue-endemic communities a welcome additional tool to help them combat the disease. Combining them with improved surveillance, enhanced vector control, vaccination, community participation, cross-industry collaboration and more, will help in the fight against dengue fever.

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How communities in Asia can help beat dengue

Behavior change communication (BCC) can help to mobilize individuals, families, and communities to reduce the risk of mosquito bites and embrace the dengue vaccine

The anti-dengue arsenal is growing. New insecticides and diagnostics, GM mosquitoes, better surveillance systems and the first dengue vaccine, along with smart mosquito control practices, have the potential to dramatically reduce the burden of the disease. But these tools are only useful if they are used.

Modern behavior Change Communication (BCC) techniques could help to turn the tide against dengue fever in Asia, according to Muhammad Shafique, Malaria Consortium Regional Behaviour Change & Communications Specialist.

In an interview with Break Dengue (see full transcript below), Muhammad questions the effectiveness of some information, education and communication materials designed to improve community health. Instead, he calls for more evidence-based strategies that mobilize communities to play an active role in adopting healthy behaviors.

“We should discourage the ad hoc allocation of money for the development of information, education and communication (IEC) materials and some volunteer training which is then labeled as BCC,” he says. “This practice has limited effectiveness and always brings into question the BCC approach. When there are setbacks, it further erodes the trust of donors on the approach.”

Outmoded information and communication materials should be swapped for up-to-date strategies that try not only to inform but to change behavior, he says.

“There is a huge knowledge-practice gap regarding malaria and dengue in these communities,” says Muhammad. “Many surveys have revealed that most people know the causes of dengue but they do not practice the required behaviors to prevent mosquito breeding. That means something is missing in our existing BCC strategies, which focus more on knowledge than actual practices.”

Establishing village health committees, training local volunteers and highlighting local examples of healthy behaviors are among the approaches that the Malaria Consortium has found to be effective in the past. The organization is already turning its attention to how this way of thinking can be applied to dengue fever, building on its experience and a growing body of research in the field of BCC.

BCC is gaining momentum and will be one of many topics tackled at this week’s Aid and International Development Forum (AIDF) Asia Summit in Bangkok (21 & 22 June).

Interview: Muhammad Shafique, Malaria Consortium Regional Behaviour Change & Communications Specialist

What can behavioral change communication bring to the fight against dengue?

Behaviour change communication (BCC) can play a very important role in fighting dengue. Firstly, it helps us get a grasp on a community’s existing knowledge, beliefs, perceptions and behaviors with respect to dengue prevention and control. This, in turn helps us to develop tailored and culturally appropriate BCC strategies to improve their health.

Do you think this field has gained momentum recently? Have books like ‘Nudge’ and ‘Thinking, fast and slow’ helped governments and funding agencies to take it more seriously?

I believe BCC is gaining momentum. National programs and donors have started to understand the importance of BCC in health programs. However, these initiatives still need to be well planned and incorporated into projects at the proposal/design stage, with clearly chalked out BCC activities and processes. BCC activities should include all the usual steps, including formative assessments to ensure the development of context-specific strategies and tools. We should discourage the ad hoc allocation of money for the development of information, education and communication (IEC) materials and some volunteer training which is then labeled as BCC. This practice has limited effectiveness and always brings into question the BCC approach. When there are setbacks, it further erodes the trust of donors on the approach.

Do some campaigns still rely too heavily on the ‘deficit model’ of communication: giving people information and presuming – or hoping – they will take action instead of taking a closer look at motivations and barriers to action?

Unfortunately, most campaigns are expert-driven and focused on developing messages and IEC materials. In many cases, BCC strategies are developed without any formative assessment which means they lack a basic understanding of context, perceptions, social, cultural and economic barriers and behaviors of the community members. As a result, the desired objectives are difficult to achieve. Another main reason for failure is the lack of community participation and engagement in the change process. The communities are considered to be passive recipients and are not involved in the planning or implementation process, which further alienates them from the interventions.

Get started improving public health using Dengue Track

The communities – volunteers and community-based organizations – should be given a key role in project implementation so that they own the project. When they are actively involved, they are partners rather than recipients and feel accountable for the success or failure of the project, which ensures their ownership and fosters sustainability. To succeed, the strategies and campaigns should be context-specific, well-informed and based on the actual needs of the communities. They should be supported by the appropriate theoretical models in order to influence sustained behavioral changes in the target communities.

Are there any examples of campaigns that led to behavioral shifts that have had an impact on dengue fever?

I am not aware of any examples yet. This is an area of innovation for Malaria Consortium.

Despite knowing how to reduce the risk of dengue, many people do not practice good household mosquito control. What do you think are the barriers to overcoming inertia in this area?

There is a huge knowledge-practice gap regarding malaria and dengue in these communities. Many surveys have revealed that most people know the causes of dengue but they do not practice the required behaviors to prevent mosquito breeding. That means something is missing in our existing BCC strategies, which focus more on knowledge than actual practices. Another issue is the use and repetition of similar knowledge-related messages and materials, which were developed long ago and do not correspond to the actual needs and ‘stages of change’ of the communities. Therefore, we need to review and revise our BCC messages/materials and strategies on a regular basis and develop motivational messages to further encourage communities to take action.

Communities also need some support mechanisms at the household (family) and community levels, and access to diagnosis and treatment health facilities in order to perform or continue the recommended behaviors. Community volunteers and community-based organizations/structures, if revitalized and mobilized, can also play a positive role in encouraging community members to modify their behaviors to prevent dengue more effectively. If the community is provided with health education through culturally appropriate channels and receives proper support from other local or national institutions/sectors, there is a better chance that they will follow positive dengue control behaviors to stop mosquito breeding in their communities.

What is positive deviance and can you give an example?

Positive deviance (PD) is an innovative, asset-based behavior change approach that looks at and builds on the assets or strengths of the community, on what is already working in the community. A one-week interactive process with communities helps us understand the context and existing behaviours around the health issue (a component which is missing in most BCC approaches) and identifies ‘positive deviant’ individuals who, despite living in the same environment and sharing similar risks, occupations, and socio-economic resources as others in the community, manage to have better health outcomes than their neighbours and peers.

The PD approach focuses on existing behaviors or practices and shares these simple, local and easily replicable behaviors with other community members via the actual PD role models or volunteers. The PD role models serve as evidence of the effectiveness of the behaviors, which encourages their peers to more readily accept their easy-to-adopt local behaviors. In contrast to other deficit-based BCC approaches, which find faults and problems in a community and aims to fix them, positive deviance puts emphasis on existing positive behaviors of communities and encourages others to follow.

image of Dr Muhammad Shafique explaining the needed behavioural change needed to reduce dengue cases.

Images courtesy of Malaria Consortium

A new vaccine is available for dengue fever. What are the barriers to increasing vaccine uptake?

First of all, we need to create demand for the vaccine through focused BCC campaigns using culturally appropriate channels of communication. The major barriers to vaccine uptake will be a lack of knowledge, accessibility, affordability and availability. Therefore, we need to improve community knowledge about the vaccine – its effectiveness, importance, benefits, affordability and availability.

In the ASEAN region, do you think vaccine hesitancy (or even anti-vaccine sentiment) is a problem? Or it is more to do with access, affordability and so on?

As far as I know, there is no hesitancy towards vaccines in these communities. The important thing is that we need to create demand for the vaccines and ensure a regular supply is maintained and that the community has access. The community will only pay for a vaccine when they understand that its benefits will outweigh the costs – for example, if they can work extra days to earn more money, instead of being sick with dengue. Overall, a strong public-private partnership is required for the social marketing of vaccines at affordable prices in these communities.

Muhammad Shafique, presenting at joint international tropical medicine meeting in Bangkok

This week’s Aid and International Development Forum (AIDF) Asia Summit in Bangkok (21 & 22 June) includes sessions that address community health, mobilizing communities for development projects and vaccine adoption.

Example of a positive deviant from the Malaria Consortium PD dengue project:

Ma Su Lei Yee is a 25-year-old farmer who lives in Sein Pan Kone village, Hinthada, in southwest Myanmar. She and her family have never had dengue despite living in a community that has a high risk of transmission. She understands that dengue is caused by mosquitoes that bite during the day.

To prevent mosquito bites, she always wears long-sleeved clothes and sleeps under mosquito nets during the day time as well. She always covers the big water containers, changes water in small containers every 2-3 days and changes her Buddha flower vase regularly to prevent mosquito larvae from forming. She cleans the household surroundings and fills in the ditches with sand, especially in the rainy season, to avoid larvae breeding. She removes empty cans, coconut shells and turns extra containers upside down to avoid larvae growth. She recognizes the signs and symptoms of dengue and goes for early diagnosis if she has a fever. “If a patient does not get an early diagnosis from a health facility, he or she can die with dengue fever,” she said.

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Is low-cost travel spurring dengue outbreaks?

The boom in low-cost airlines in the ASEAN region is helping people and mosquitoes spread dengue virus

Cheap flights have become the norm between the 10 members of the Association of Southeast Asian Nations (ASEAN) thanks to the arrival of low-cost carriers.

The introduction of the ASEAN Open Sky Policy – which allows airlines to fly freely within the region has made travel even more attractive and accessible.

Research shows a surge in demand across the region, with low oil prices fueling rapid growth.

Low-cost airlines and increased global travel make spreading dengue easier than ever before.

But there may be a downside. As experts gather in Bangkok for ASEAN Dengue Day (June 15), a leading expert is warning that planes are facilitating the spread of dengue fever and other vector-borne illnesses.

“The increase in the number of budget airlines in the region has been dramatic in the last 10 to 15 years,” says Prof Tikki Pang of the National University of Singapore. “This is obviously heeling dengue to move around the region.”

He says the low-cost travel phenomenon is not a direct threat to the Asian tourism industry – after all, the disease is endemic in every ASEAN country – but is making it difficult to get a grip on outbreaks.

“There is more movement of infected people. Flight distances in this part of the world are fairly short so people can get on a plane for an hour or two even if they have dengue fever. Then they could be bitten by a mosquito at their destination, and that mosquito may subsequently infect someone else,” Professor Pang explains.

It is also possible that infected mosquitoes are boarding aircraft when they are being loaded. Mosquitoes may enter the cabin or, perhaps more frequently, hitch a ride in the cargo hold. Upon arrival, the mosquitoes can find their next dengue victim with ease.

“In some parts of the world they routinely spray aircraft prior to landing but it is not standard practice here,” says Professor Pang. “I have seen cabin crew go along the aisle with bug spray but it’s unclear whether that is effective.”

In addition to the costs of spraying insecticide through aircraft, passengers may object to being doused with bug spray. Yet some form of action may be required.

There is little that can be done in terms of controlling the huge volume of travel but individuals can take measures to protect themselves from dengue.

“As individuals, we can reduce the risk of bites by using repellents and avoid staying outside,” says Professor Pang but the arrival of the first dengue vaccine is a game-changer.

“My big crusade at the moment is highlighting the importance of vaccination,” he says. To me, personal protection is the logical way of approaching this.”

While he doesn’t see the dengue vaccine as a travel vaccine per se, it may ease individuals’ concerns about the growth in travel.

“If someone takes it upon themselves to get the vaccine they would worry less about travel, particularly if visiting an area where there is an ongoing outbreak. But for most of us in the ASEAN region, dengue is an everyday risk whether you travel or not.”

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The value of vaccination to public health.

Image of a young woman getting a vaccine to discover the true value of vaccination

Vaccination at the National Institute of Pediatrics. Image via Sanofi Pasteur.

Experts are calling for a broader view of how to measure the value of vaccination to public health. Contrary to popular belief, vaccines do not need to be 100% effective to significantly reduce the public health burden of major diseases.

In the 20th century, vaccines against common and highly infectious diseases such as measles were developed – saving millions of lives every year.

However, while the research that led to those vaccines was undoubtedly complex and ground-breaking, diseases such as measles were low-hanging fruit compared to dengue, malaria, and other vector-borne illness.

Impossible task?

Indeed, the challenge was so great that some considered it technically impossible to invent vaccines against them, prompting public health authorities to focus on mosquito control measures.

But they were wrong. Science has risen to the challenge and developed vaccines that protect against these devastating diseases.

The trouble is that while measles and hepatitis A vaccines protect almost everyone who receives their shots, many other vaccines do not achieve such high efficacy.

We accept success rates for cancer medication, for example, that are well below 50% but past experience has raised our expectations of vaccination.

With the arrival of the first dengue vaccine – and as scientists work on malaria and Zika vaccines – some epidemiologists and economists want a rethink of how vaccine impact is evaluated.

If a disease causes tens of millions of deaths, isn’t a modestly effective vaccine going to have a huge impact on the contribution of disease to reduced public health?

To borrow an extreme analogy, would you rather have 10% of Bill Gates’ fortune or 100% of your own?

Measuring impact

Vaccine efficacy (VE): the percentage reduction of disease in a vaccinated group of people compared to an unvaccinated group

Vaccine-preventable disease incidence (VPDI): the reduction in disease rates that can be achieved by vaccine in a given context; higher is better.

Number needed to vaccinate (NNV): the number of people that need to be vaccinated to avoid a case of disease; lower is better.

The public health value of the dengue vaccine – beyond efficacy

Ask a public health expert or a Health Minister in a low or middle-income country what they expect from a new vaccine and the answer is clear: they want to reduce the burden of disease in their country.

The number of cases of disease – ranging from mild to severe – and the number that can be prevented by vaccination are relevant pieces of information. But what decision-makers with limited budgets really want to know is how many severe or debilitating cases will be avoided and how this will benefit the health system as a whole.

Vaccine efficacy is an important factor but so too are the numbers of deaths, severe clinical cases, hospitalization and outpatient visits, and lost working or school days.

Health ministers are looking at the bottom line but this, says Dr. Bradford Gessner of the French non-profit Agence de Médecine Préventive (AMP), is not the kind of information that clinical trials present. These studies are designed to get through regulatory approval and are focused on demonstrating vaccine efficacy and safety only.

Disease burden

In a new research paper co-authored with Annelies Wilder-Smith of Lee Kong Chian School of Medicine in Singapore, Dr. Gessner proposes a broader view of assessing the value of new vaccines.

“Finding the true value of a vaccine is complicated,” Dr. Gessner told Break Dengue. “If dengue fever were in the US at the levels seen in, for example, Brazil the vaccine would immediately be widely used. Dengue, malaria, and typhoid are in lower and middle-income countries where decisions must be made based on impact and so burden of disease matters a great deal.”

Dr Gessner and Dr Wilder-Smith propose a more nuanced way of measuring this impact that goes beyond vaccine efficacy. Vaccine-preventable disease incidence (VPDI) is a way to measure the reduction in disease rates (or incidence) achievable by vaccine (higher is better), while calculating the number needed to vaccinate (NNV) to prevent a single case of disease (lower is better) is another way to show the potential for vaccines to reduce the burden of disease.

“VPDI takes efficacy and applies it to the background incidence of disease as measured when a vaccine is not used. It can help decision-makers look at the burden reduction that a vaccine can deliver,” says Dr. Gessner. His latest study shows that the dengue vaccine has favorable VPDI and NNV compared to vaccines currently used in national publicly funded immunization programs in Latin America and Asia.
For example, all national immunization programs now include Hib vaccine, in large part to prevent Hib pneumonia. In Asia, the VPDI for Hib vaccine against pneumonia is similar to that for dengue vaccine against severe hospitalized dengue while in Latin America it is similar to the VPDI for all hospitalized dengue cases.

Another example: “The pneumococcal conjugate vaccine reduces all-cause severe pneumonia by 10-15%. But pneumonia is very common and the impact of severe diseases is immense so reducing it by this amount is a great investment.”

Dr. Gessner and Prof Wilder-Smith argue a similar case for dengue fever. The first dengue vaccine, Dengvaxia (CYD-TDV) by Sanofi Pasteur, has been registered for use in individuals 9-45 years of age living in endemic areas.

The vaccine works around 65% of the time against a very common illness, and is even more effective against severe forms of the disease, and for this reason has high public health value in dengue endemic populations. “The vaccine has a higher impact in populations with a high dengue disease burden,” adds Prof Wilder-Smith who is Director of Global Health and Vaccinology at her university.

Big picture

Preventing cases of disease is a great outcome for an immunization program but this doesn’t do justice to the true impact of public health measures.

“There are all sorts of ways to measure public health value beyond just preventing a case of illness in an individual,” explains Dr. Gessner. “You should also factor in the decrease in disease transmission and a reduction in unpredictable impacts on the health system.”

Diseases such as pneumonia or malaria are present at a high but fairly steady – rate in countries where they are endemic. While these diseases have a devastating effect on those infected, the health system is relatively well-equipped to deal it.

“Systems adapt,” Dr. Gessner says. “People are put in place and the capacity is there to deal with the high but constant rate of disease. But diseases that cause unpredictable outbreaks or epidemics can be very disruptive.”

He points to the Ebola epidemic where the shock to the health system had immeasurable knock-on effects on people not directly affected by the outbreak.

“The West African Ebola outbreak undoubtedly caused many deaths by disrupting the health system. Its biggest impact may well have been not indirectly killing people infected by the virus but by disrupting care and thus increasing deaths from vaccine preventable diseases through the reduction in immunization coverage, maternal deaths during childbirth through reductions in antenatal care, malaria deaths by disrupting malaria prevention programs, and so on.”

That is why Gessner describes measles vaccines as “probably the greatest investment” available to developing countries: it is a dangerous disease, measles outbreaks disrupt health systems and prevention is inexpensive. “While dengue has a less dramatic impact on mortality, dengue and measles otherwise share many of the same characteristics of epidemic-prone diseases,” he says.

Better data

Dr. Gessner says that future vaccine clinical trials will need to be conducted – and their results presented – in ways that are meaningful to public health decision-makers. “Clinical trials were not designed to show Ministers of Health how to maximize public health,” he says.

He would like to see trials that look at the indirect effects of vaccination. For example, immunization programs for Hib, rotavirus and measles have all been linked to less disease even in unvaccinated people by reducing the circulation of the infecting agent.

Individually randomized trials – the gold standard in clinical research – may not be up to the task. Dr. Gessner would like to see more ‘cluster randomized trials’ where entire villages or neighborhoods are vaccinated en masse and compared to similar villages or neighborhoods that do not receive the vaccine. That way, he says, scientists could look at the direct and indirect impact of mass immunization.

Some of these issues were already creeping up the public health agenda at WHO level in response to the Ebola outbreak and are now being applied to handling the Zika outbreak. The approval of the dengue vaccine in several countries adds further momentum.

A new era awaits

With dengue fever continuing to impose an enormous burden on countries around the world the arrival of a new vaccine against the disease is accelerating a shift in how epidemiologists, economists, and policymakers think.

The relatively blunt ways used to value measles and pertussis vaccines decades ago are being replaced by a more sophisticated approach that puts the various dimensions of public health burden firmly in the spotlight.

Interview: Documentary filmmaker on the History Channel’s ‘Programmed to Kill: Dengue’

Image of a patient getting treatment for dengue infection from the film Programmed to Kill

Image from the film Programmed to Kill: Dengue shared via historyasia.com

Q&A with the documentary filmmaker targeting dengue

Programmed to Kill: Dengue, the new documentary from Malaysian filmmaker Gerard Benedict is set to air on the History Channel across Asia this week. The film takes an in-depth look at dengue fever, a disease unknown to many, that affects almost 1/2 of the globe. In just over 30 years, dengue has gone from having a presence in only 9 countries to becoming the world’s most rapidly spreading mosquito-born viral disease. In his documentary, Benedict examines many of the reasons why the dengue virus can be difficult to manage. But how did this film come about?

The former TV presenter, and producer based in Kuala Lumpur, Gerard Benedict met dengue expert Professor Lam Sai Kit of the University of Malaya with the intention to make a film about Nipah virus. But instead, found himself making a film on an entirely different topic. “He encouraged me to do a documentary on dengue instead because a potential dengue vaccine was in the coming,” Gerard told Break Dengue.

Image, A team of doctors discuss dengue trzeatment for patients in need.

A team of doctors discuss treatments for dengue patients in need. Image from the documentary film, Programmed to Kill: Dengue shared via historyasia.com

“He encouraged me to do a documentary on dengue instead because a potential dengue vaccine was in the coming…”

We caught up with Gerard for a quick-fire interview about the making of his powerful public health documentary to uncover more about the making of this epic tale. Read our exclusive interview with Gerard Benedict on Programmed to Kill: Dengue, and find out how his production of the neglected disease was realized.

What motivated you to make this film about dengue?

It immediately struck me that there were many things about the disease that I had not known and that meant that most people would not know either. All we knew was dengue gave you terrible fever, horrible joint pain and you bled and that you had to take a lot of fluids. But there were so many other facts about dengue that we didn’t know.

What key pieces of information were you missing?

For a start, I didn’t know about the dengue vaccine. I didn’t know that there were four serotypes and that you could get dengue multiple times. I found out why you bleed and why you go into shock and that secondary infections are the ones that can lead to severe dengue.

So it was these new facts and more, which I learned from the experts I met later, that made me want to do a documentary. And fortunately up to that point no one had ever done a full-documentary on dengue.

How did this film come to life?

I discussed with my co-producer Harjit and Chris Humphrey, the Executive Producer at the History Channel and both they realized that there were a lot of people who didn’t really know “the inside story” of dengue. That’s how it started.

But from the outset, we wanted to make a film that had international appeal, at least for southeast Asia. We wanted an international cast and a show that even looked and felt international. So we have Prof. Duane Gubler, Prof. Annelies Wilder-Smith and of course Dr. Alain Bouckenooghe of Sanofi plus others from Malaysia and Singapore on the show. And we even engaged a former BBC TV presenter – Ms. Juliet Morris – to narrate.

Have you made films about public health issues before?

No. This is the first so it was a lot harder because for one thing we needed to put all the facts together in a 45-minute show. And for another, the documentary was targeting audiences who already know the disease well in endemic countries.

What is the focus of the film?

The target audience is anyone above 14. So the film is really a story of many aspects of the disease but delivered in simple language that the layman can understand. It is a history of the disease and its vector…it’s about the virus, it’s about the vector, it’s about the symptoms, it’s about our current challenges and methods employed to control dengue, and it ends with a brief explanation on the making of the vaccine and its release. We are blessed that the timing of our show and the release of the vaccine have coincided.

Image from the film Programmed to Kill: Dengue shared a doctor tests blood for dengue

Image from the film Programmed to Kill: Dengue shared via historyasia.com

What is your goal in making this film ?

I hope that people who watch it will have better knowledge of the disease and so be more prepared and able to get around it with the least number of problems. For example, if a person comes away with very mild fever and is told they have dengue, they may be more careful if they get it the next time. Or people may, after the documentary, really look out for the warning signs or be aware of what they need to do if they do display a few of the warning signs. They can even get a few tips on how to combat the vector.

Do you have any direct experience of dengue fever?

I have not had a personal experience of the disease but know of friends who have and one who died.

When and where will Programmed to Kill: Dengue, air?

Titled Programmed to kill: dengue, and it premieres on the History Channel in Asia on 29 May 2016. The documentary will be available to millions of people in Malaysia, Singapore, Thailand, Indonesia, Philippines. Laos, Cambodia, Vietnam, Brunei, PNG, Hong Kong, and Taiwan.

Why is the History Channel interested in this story?

Because it’s a universal subject matter that is very appealing to all of the Channel’s markets in southeast Asia since dengue is endemic in the region. A tropical disease is one of the few subjects that can go across borders in this diverse region. And the story does have elements of history from the virus to the disease, to the vector, even to vaccine research itself.

What do you hope will come of this film?

Definitely greater dengue awareness and also that people will get some new value added information on topics such as ‘herd immunity”, change of serotype, some unknown facts about Aedes, and of minor importance – dengue’s notorious cousins including the new kid in town – Zika.

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Watch the official trailer for the documentary film below. Programmed to Kill: Dengue airs Sunday, May 29 across southeast Asia on the History channel. ‘Like’ the film’s official Facebook page to find out when the documentary will be released in your area.