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Why communities are key to dengue vaccine effectiveness

Dengue prevention update from the AIDF Asia Summit in Bangkok

A new vaccine against dengue was licensed for the first time in December of last year and is now in the market in five countries in the world, namely Mexico, Brazil, El Salvador, Costa Rica and The Philippines. Nevertheless, the shots against the virus will not be sufficient enough to beat the disease infecting about 390 million people around the world every year, according to experts.

“This vaccine is not a magic bullet. It has to be integrated with a holistic approach where community engagement its center alongside vector control”, Jean- Antoine Zinsou, Senior Director, Public Affairs and Advocacy at Sanofi- Pasteur, the vaccine manufacturer that developed the Dengvaxia.

Dengue is the fastest growing mosquito-borne disease in the world, mainly due to increasing urbanization in tropical and sub-tropical climates where the Aedes aegypti, the mosquito that carries the dengue virus, lives.

“Community engagement is the key to successful dengue prevention and to get rid of the mosquito breeding sites”

Due to the rapid spread of the virus, the World Health Organization accelerated its procedure for evaluating new vaccines and, last April, the Organization released a recommendation to adopt the vaccine and a definitive position paper is expected to be released on July 29.

The Aedes aegypti depends on stagnant water to lay its eggs and reproduce. Natural water containers, like puddles, or artificial recipients, such as flower pots, forgotten buckets or even coconut shells, make ideal breeding grounds. “Community engagement is the key to successful dengue prevention and to get rid of the mosquito breeding sites”, explains Zinsou.

dengue-vaccine-efective-communities

Southeast Asia, the region with the highest dengue incidence in the world, is well aware of the importance of communities in the fight against dengue and, six years ago, the Association of Southeast Asian Nations (ASEAN) launched the ASEAN Dengue Day. This information day is celebrated every June 15 to raise awareness about the risk of the disease.

“Dengue prevention and control is a shared responsibility which needs collective action from all stakeholders to work together and enhance cooperation as one community “, says the Bangkok Call for Action released on the occasion of the 6th ASEAN Dengue Day, held under the theme, ‘Community Empowerment: A Sustainable Success to Fight Dengue’.

For this approach to be effective, identifying the key actors in the communities is essential. “This is very context specific. Some may believe more in religious figures. For other, the village chief is more acceptable to them,” says Muhammad Shafique, Regional Behaviour Change Communication Specialist at the Malaria Consortium.

image of Aedes aegypti mosquito

One key ingredient that could improve dengue-vaccine effectiveness is community.

Nevertheless, research shows that the most trusted figures are community healthcare workers (CHW). In India, for instance, CHW help to strengthen the immunization programs and reduce the burden of vaccine-preventable diseases, according to a study from the University of Pittsburgh.

Experts also stress the indirect benefits that communities can get from vaccination since it reduces the odds of the mosquito biting an already infected person and transmitting the disease to a healthy individual. In the case of dengue, this indirect benefit is even more important because the vaccine is only approved for use in people nine to 45 years old.

The vital ingredients to a recipe for a successful of a dengue vaccination program

Implementing a vaccination program is usually not an easy task with many variables coming into play. According to a literature review carried out by researchers from Sanofi-Pasteur and Kingston University, the non-socio-demographic determinants to vaccination adoption can be organized into five main dimensions: access, or easiness to get the vaccine; affordability, or cost related to it; awareness of the existence of the vaccine and its benefits; acceptance of the vaccine; and activation or a motivation that brings people into the vaccination centers.

Find out more about the global cost of dengue

Even when governments adopt the vaccine into their Expanded Programs on Immunization, such as The Philippines which launched the first public dengue vaccination program last March, communities are still key in breaking some of these barriers. “If we understand that in order for the vaccine to be effective, you need all three shots (six months apart), it is critical that the persons who start their vaccine complete all three,” said Indeok Oak, Independent consultant on development.

Image of researcher on the dengue vaccine

“In order to facilitate this, the process of obtaining the vaccine shots must be readily accessible. Providing vaccine shots at schools, workplaces, or already existing facilitate where people go regularly would make it easier to get the shots rather than having to physically go to a designated clinic or hospitals.” These community places are also important in monitoring and implementing surveillance systems on the effectiveness of the vaccine in the communities where it has been administrated.

Sharing these community-based experiences is also essential to build knowledge on how to fight the rapid spread of dengue. For this reason, Break Dengue has organized the €10,000 Prize, a competition that aims to find the best initiatives and campaigns that help to combat dengue fever by integrating the new vaccine into the anti-dengue arsenal.

Join Dengue Track! Click the link below to report dengue near you.

Dengue Track

 

ASEAN countries consider new dengue vaccine

Image of an art piece demonstrating the increase in dengue cases across Southeast Asia the last 10 years

An art installation shows the evolution in the number of dengue cases in Southeast Asia over the last 10 years

After decades of research, the World Health Organization endorsed earlier this year the first vaccine against dengue, a virus that infects about 390 million people in the world every year and has no known treatment. Now the vaccine faces its next challenge: adoption.

In the heavily affected region of Southeast Asia, the Philippines was the first to launch a public dengue immunization program and several countries are looking with interest at the new vaccine, according to experts attending ASEAN Dengue Day in Bangkok on June 15.

“We have to be very careful with the approval process because there will be a lot of questions [being raised], on topics such as effectiveness”, says Amnuay Gajeena, director- general of the Department of Disease Control at the Thai Ministry of Public Health during the celebration of the Sixth ASEAN Dengue Day that this year was hosted by Thailand.

“[In Thailand] it is still in the process of being put in the agenda but we haven’t made any decision yet…”

In December last year, Mexico became the first country in the world to license Dengvaxia, the dengue vaccine developed by French-based Sanofi Pasteur. Three more countries, namely Brazil, El Salvador and The Philippines, have followed since.

Image: A group of students from Bangkok attend the opening of the Sixth ASEAN Dengue Day

Students of the Assumption College in Bangkok attend the opening of the Sixth ASEAN Dengue Day

“[In Thailand] it is still in the process of being put in the agenda but we haven’t made any decision yet,” says Dr. Gajeena. According to his department, it normally takes years to include any vaccine in the National Expanded Programme on Immunization (EPI) that today administers 10 vaccines to Thai children. The government could nevertheless approve the vaccine to be sold at private hospitals in the coming months.

During its development, a clinical trial was run in 10 countries – five in Asia and five in Latin America but the widespread vaccination campaign earlier this year. “It is a brand new vaccine. It has not yet been widely used except in a few countries, like in the Philippines’ public immunization drive. Therefore it is natural that some governments hesitate when it comes to adoption,” says Dr. Tikki Pang, visiting Professor of the Lee Kuan Yew School of Public Policy. Dr. Pang highlights effectiveness, but also cost and safety concerns as the main barriers for the administration of the vaccine. “Other governments, e.g. Singapore, have also invested heavily in other tools such as mosquito control and public education/awareness”, says the expert.

The approval of new dengue vaccines could also make the process of adoption into the National Immunization Plans lengthier. According to the World Health Organization, there are at least five additional dengue vaccine candidates in clinical development, with two of them (developed by Butantan and Takeda) expected to begin Phase III trials in early 2016. ”

In this scenario, each country will choose the vaccine that will work best in their own setting, based on the public health authorities’ assessment of public health needs, country capacities, and available cost-effectiveness, safety and efficacy data” says Dr. Pang.

Image: A student takes the Readiness Quiz on a tablet raising awareness with Dengue Mission Buzz Barometer.

A student takes the Readiness Quiz of the Dengue Mission Buzz Barometer.

Local communities, key in adopting the dengue vaccine

Governments may not be the only ones slow to embrace the vaccine. “Both government and populations will be difficult to convince but perhaps for different reasons. […] Individuals in the population will have to be convinced of its safety and ability to prevent disease”, says Dr. Tang.

“Education and communication are very important. You need to give them the right information and tell them that it is not 100% effective but there is efficacy there,” adds Usa Thisyakorn, chairman of the Asian Dengue Vaccination Advocacy (ADVA), a scientific working group dedicated to disseminating information and making recommendations on dengue vaccine introduction strategies in Asia.

Discover the public health value of dengue vaccination

The first public dengue immunization program launched last March in The Philippines, where about 1 million children will be vaccinated this year, will likely be a reference for its neighbors in Southeast Asia, one of the regions in the world most heavily affected by dengue fever. Last year, when large dengue outbreaks were reported worldwide, the Philippines registered more than 169,000 cases and Malaysia exceeded 111,000 suspected cases of dengue, representing a 59.5% and 16% increase, respectively, compared to the previous year, according to WHO.

Nevertheless, even though the vaccine is an important step forward in the fight against dengue, vector control remains one of the main strategies to eradicate the disease. And, as stressed by this year’s ASEAN Dengue Day theme, ‘Community Empowerment: A Sustainable Success to Fight Dengue’, communities are the key to containing the spread of the virus.

“This is a vector-borne disease. The vector, the Aedes aegypti, is a house mosquito, so the problem starts from the environment and it should be addressed by the residents of the communities,” says Dr. Amnuay Gajeena. Dr. Gajeena explains that the Thai government follows the ‘Triple K’ strategy for vector-borne control asking villagers to keep containers closed or empty of water; keep the house clean, and keep trash in its proper place.

Image of students from Assumption College exploring the Dengue Mission Buzz Barometer on tablets in Bangkok.

Visitors at Assumption College in Bangkok explore the Dengue Mission Buzz Barometer with the help of an assistant

Understanding the knowledge that local populations have related to the disease is also important to designing better strategies. With this aim, the Asian Dengue Vaccination Advocacy group has launched this year the Dengue Mission Buzz Barometer, a tool to measure engagement of communities throughout Southeast Asia in dengue prevention.

“They need to understand that vector is everywhere and if you don’t participate in vector control it is going to be a disaster,” says Dr. Usa Thisyakorn, who stresses that dengue is a global problem. “People now travel a lot so the disease can go everywhere in the world.”

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Learn more on the lasting affects dengue has on people’s  lives in our short documentary.

Watch, ‘The Lingering Effect of Dengue Fever’

 

Can a bus teach children in Thailand how to fight dengue?

dengue-busHow can a child be crucial in the fight against dengue? Sure they are one of the most dengue-affected groups, but kids are also valuable assets in spreading information about preventing the disease in their communities. This is because parents listen to them, especially in developing countries where they are often the first or second generation to receive an education.
This is why the Dengue Mission Buzz, an awareness raising initiative launched by Sanofi Pasteur, is visiting schools throughout Thailand and other Asian countries to explain how to avoid the dengue mosquito’s bite.
The first stop of this educational bus was Nakhon Pathom, a small city close to Bangkok in one of the provinces with the highest rates of dengue infections.
“We have no problems at the school because we know how to prevent it. But the parents of some students are farmers and they don’t know how to do it,” says Samart Rodsumran, the principal at the Nakhon Pathom Wittayalai school, the largest in the province.

“Children don’t normally think about prevention so we have to remind them often,” says Janngarm Chat,deputy director of the Provincial Health Office in Nakhon Pathom.
Dengue Mission Buzz in Thailand

Reminding children to be cautious
According to the Ministry’s statistics, the most affected group in Thailand are children between 9 and 14. This is why it’s important to remind them to be careful.
Because kids learn better by doing and playing, the bright orange Dengue Mission Buzz bus has a number of funny games that teach children how to fight the disease.
“To prevent dengue, we have to avoid bites and put fish in the water ponds so they eat the mosquito larvae,” says 16 year-old Athinan, one of the students who attended the event.
quote“We also have to use mosquito repellent if we play outside and avoid stagnant water at home,” says his classmate Piyaboot.
The prevention tips are given to them in a colorful leaflet in the shape of a mosquito, which, funnily enough, they can also wear on their heads.
The activities also include a speech on key aspects on prevention, a short concert, and a small contest with gifts for those who learned the most about dengue.
About the Dengue Mission Buzz

The bus started its journey last June in Laos, during ASEAN Dengue day. It will travel to Malaysia, Indonesia, Thailand, Vietnam, and Philippines, to improve public understanding of the disease and its prevention. The bus will travel over 4,000 kilometers to more than 30 communities, reaching a population of about 50 million, according to Sanofi Pasteur.

A small fish frees a village in Laos from dengue

FishBunmi Ngotleusay’s most valuable assets in her garden aren’t her car or the thick fruit trees, but the big jars containing hundreds of small fish. They are her main protection against the deadly dengue that used to ravage the village just a few years back.

"Before we didn’t know where the mosquitoes live and how they reproduce. We didn’t know how to combat them," remembers Bunmi, who since 2005 has been the Chief of Ban Tat Thong, a small village close to Vientiane.

In 2007, a big dengue outbreak led Bunmi to seek assistance from the Lao Ministry of Health, who found a big epidemic of the Aedes aegypti mosquito in the area.

After Bunmi’s request, a local doctor donated some guppy fish to the village’s pagoda. This small, popular fish specie has proven to be an effective way to eradicate mosquito populations as they eat the larvae floating in water.

The right fish for the fight

quote1A trial study conducted by the governments of Cambodia and the Lao People’s Democratic Republic (Lao PDR) between 2009 and 2011, with the support of the Asian Development Bank (ADB) and the World Health Organization (WHO), showed that the introduction of guppy fish in some communities have resulted in a sharp decline in mosquito larvae in water storage tanks and, consequently, in the number of mosquitoes in the area.

Ban Tat Thong has been one of the pilot programs in Laos to use these small aquatic animals to fight mosquitoes.

From the pagoda, the small fish spread around the village and, today, roughly 90% of the 300 households in Ban Tat Thong have their own anti-mosquito jars.

"We haven’t had any cases of dengue in the village in the last 3 or 4 years," shares Bunmi.


Watch the fish in action (video not from Ban Tat Thong)

quote3No more fear

Kam Sengsavang’s daughter was close to death in 2005 after a mosquito bit her at school. "On the third day we sent her to the hospital because she was in shock," recalls Kam.

She recovered after seven days at the hospital but the memories of high fever and muscle pain remain with her.

"We heard about the fish and wanted to have them to protect ourselves. And ever since we have the fish here, we are not afraid anymore," shares Kam.

Having guppies isn’t enough to ensure a dengue-free environment though. Avoiding any stagnant water where mosquito-larvae can grow is also crucial in guaranteeing the success of the program. And although vector management is important, it’s just one of the steps in eliminating dengue.

quote2"I try to always have everything clean and to empty any container where water can remain. We have to be very careful with [the leftovers of] the coconuts and make the shells face down," says Lee Vanh, a middle-aged mother of three who has a small shop in front of her house.

"With dengue, there is only losing, there is no winning. If villagers are sick, they lose time and money because they cannot work," says Bunmi. "So we work very hard to fight against it."

What are people in your community doing to fight dengue?