Dengue, zika and vector control

Dr Alex Cook, Associate Professor, SSHSPH

 How many people are infected with
dengue in a typical week in Singapore?
(A) 0
(B) 1 to 10
(C) 11 to 20
(D) 21 to 50
(E) 51 to 100
more than 100 actually

Photo by Ronggy
 Plasma leakage,
Fever, nausea,
severe bleeding,
vomiting, rash,
Death severe organ
aches , pains,
involvement
reduced white
(liver, CNS,
blood cells Dengue heart)
Hemorrhagic Fever

Dengue fever

Mild symptoms

Asymptomatic
If you get infected by dengue, can you get it again, like influenza?

Or just once in your life, like measles?

Bitten by
mosquito Symptoms

Infectious
immune to that virus

DENV2 DENV4 DENV1 DENV3

immune to all viruses

How is it
spread?
Average life US CSC
2 weeks ~1d

Life cycle
of Aedes
aegypti
~2d ~4d
Male: vegetarian
Female: bites during day (dawn and dusk) to get protein for her eggs
Where the mosquitoes are

Kraemer et al (2015) eLife 4:e08347

What about
the cases?
Where got dengue?

Bhatt et al (2013) Nature 496, 504507

How does Singapore compare to other countries?
 Global
DALY
losses
due to
dengue

Source: IHME GBD2013

Wats a DALY?? disability adjusted life years

Die if you were

Die here from car accident average Japanese

Death

You lose this many years of life due to

car accident this year
Die if you were
Suffer stroke average Japanese
You have reduced mobility
Chronic disability
the bar is less (loss of quality of life is less compared to car accident
You lose a fraction of this many years of life due to disability
due to stroke that happened this year
Die if you were
Infected by influenza average Japanese

Acute disability
You lose this many years of life due to short term
effects of influenza infection this year
Why is SG
an outlier?
 Vector control programme
Reduced the breeding index
to very low levels
like random spot checks at houses
JeCCo

Breeding index still very low levels

Dengue was a childhood disease Dengue is an adult disease

Most people had multiple Most young people have never had
infections before reaching majority dengue
Very high incidence
Very high herd immunity Very low herd immunity

cost of dengue is approx ~ 100m

1960s
Index
case
1980s
Index
case
2010s
Index
case
Where does
infection
occur?
 dengue is a geographical disease

people are the vector of dengue, mosquitoes cant travel far

But only
~33% of
cases are
linked to
a cluster!
What about
Zika?
Index
case
Take home
points
Take homes
Most dengue cases are mild and not diagnosed, but many need to be hospitalised and
some people die
Dengue is primarily an adult disease in Singapore
Burden of dengue is lower in Singapore than our neighbours
It has been reduced a lot due to public health interventions: eliminating mosquito
breeding from most homes and reactive source reduction around domestic clusters
Control is expensive
Because herd immunity is low, it is easy to spread, and incidence has risen to the highest
on record
The mosquitoes that spread dengue also spread Chikungunya, zika, and potentially
yellow fever
yellow fever very highly dangerous

Is vector control broken?

Most cases are not linked to a domestic cluster
We dont know where these infections occur
Officers chase breeding sites but their hit rate is low
More and more cases, more impact to the health system (hospitalisations)
What do the data look like?
ASEAN trial

Adapted from Capeding et al (2014) Lancet: 384:1358-1365

Lat Am trial

Both trials
in children
Adapted from Villar et al (2015) NEJM 372:113-123
Braddell
Nee Soon
Tampines