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Dengue Transmission and Risk Factors in Dhaka, Bangladesh

Parnali Dhar Chowdhury1, C. Emdad Haque1, Robbin Lindsay2, Abdullah Brooks3,4, Michael A Drebot2
1Natural

Resources Institute, University of Manitoba
Microbiology Laboratory, Public Health Agency Canada
3John Hopkins University, USA, and 4 icddr,b Bangladesh

2 National

GRF Davos One Health Summit 2013
17-20 November, 2013; Davos, Switzerland
Areas of risk for dengue disease
Dengue viruses 1- 4 can cause DF / DHF
Person  Aedes mosquito  Person
A. aegypti
Estimated population at risk of dengue fever under
“standard” climate change scenario: 1990, 2085

1990

2085

Decreased mosquito abatement
Increased urbanization, etc.

.

Source. Hales S et al. Lancet (online) 6 August 2002. http://image.thelancet.com/extras/01art11175web.pdf
•

Dhaka, the capital of Bangladesh, 16th
Largest city (15.4 million population in
2012) of the world

• Estimated to grow to about 20 million
(2020), making it the world’s third
largest city
• Population growth =~7%

 Insert map of Bangladesh and
Location of Dhaka

• Attracts some 300-400 thousand new
migrants/year

Source:http://www.google.com/imgres
Dengue Trends in Dhaka:
Facts from Reality

Dhaka : Total number of reported dengue cases by year
(n = 22,705).

 Asymptomatic nature of dengue
(known as Dhaka fever) since 1964

 First major outbreak in 2000 with
5,551 hospitalized cases (93 deaths)

 Short term (2000-2008) trend reveals
short cyclical pattern – reasons
are unknown

Dhaka: Total number of reported dengue cases, by month,
2000-2008 (n = 22,705)

 Limited knowledge of dengue
vector distribution and density,
disease risk perception, and
circulating serotypes


nearly all viruses isolated were DENV-3
(Rahman et al. 2002; Wagatsuma et al. 2004; Podder
et al. 2006; Islam et al. 2006)



co-circulation of DENV3 with DENV 2 & 4
(Aziz et al. 2002)

Source: (Karim et al. 2012)
First Outbreak in 2000
Panic situation
• People
• Professional
• Media
• Posters –Blood
Test… labs.
• Blaming!!

BANGALI A, Mannan Dr.
Questions and Objectives about Dengue in Dhaka

Ecological / Entomological / Virological / Socialogical-Economic Factors for Dengue
What are the distribution of
Aedes mosquitoes and
whether Aedes density vary
with different socio-economic
statuses (SES)?
What are the seroprevalence
of DENV and how it is
correlated with Aedes
abundance?
How human Knowledge,
Attitudes, and Practices (KAP)
at the individual and
household levels are involved
in enhancing or reducing
vector habitat?

Objectives:



To delineate vector distribution by
examining Aedes larva and pupa
breeding spaces in houses



To conduct household level
serosurvey in the same household



To map risk perception and analyze
KAP regarding dengue disease
Methodology
• Multi-stage, multi-level study
design for entomological
survey of dengue vector
distribution
• Focus group discussions
(FGDs) and key informant
interviews (KIIs) for risk
perception analysis
• Guiding Principles:

2

1. Representative samples of
the City of Dhaka
2. Socio-economic variability
among the wards considered
3. Gender perspectives
considered in FGDs and KIIs
Differences among Socio-economic Statuses: Some Selected Images
An Outline of Findings and Analysis

Vector ecology and distribution during 2011 and 2012
Container analysis (mosquito breeding and larval
development) and water-use pattern at household level

Serosurvey result of pre- and post-monsoon 2012
Risk perception of dengue disease and its vector
Overview of Entomological Survey
MONSOON 2011

MONSOON 2012

TOTAL LARVAE
COLLECTED

2587

3644

Ae. aegypti

2128 (84%)

Ae. albopictus

344 (13%)

2811
(77.1%)
634(17.4%)

Other Sp.

3%

61 (1.7%)

TOTAL PUPAE
COLLECETED

339

1129

Survey
Time

House
Index

Container Breteau
Index
Index

PUPAE/100
HOUSES

MONSOON
2011

27.74%

32.84%

52.39%

36.02

MONSOON
2012

24.17%

31%

44.17%

169.9

Total Household Visited
(target=1200) :

842 (2011)
834 (2012)

Overwhelming majority
of households have been
found to be infested with
Aedes aegypti

Calculation of Stegomyia
Indices are quite high for
vector surveillance in both
years
Most Frequent Container Types, Monsoon 2012

 8 major types of positive containers
seemed to be dominant

 These 8 containers types account for
72% of all positive containers

CONTAINER CODE:
A1=Water tank
A3=Clay pot
A4=Ceramic pot
A13=Metal bucket
A14=Plastic bucket
A19=Plastic drum (sealable)
A21=Flower tub & tray
A27=Tires
A34= Broken sports/toy parts
A38=Plastic sheets
A39=Broken plastic pots
Images of most frequent container types, Monsoon 2012
Dengue Lab Diagnostics Overview

HI

IgG ELISA

Neutralization

RT- PCR
10k

1k

100

10

1

1000

100

1

0.1

10

1

0.1

400 bp


Rn
Rn
10,000

10k

+

1k

100

10

1

0.1

0.1

Cycle
Ct
Serosurvey Results
Pre monsoon 2012

Post monsoon 2012

 1129 samples were collected

 1130 samples were collected

 906 (80.2%) were IgG
Positive
(3.6%) were IgM positive

Children had lower ~ 30%
seroprevalence rates

(630 paired sera and 500
replacement sera)

 924 (81.8 %) samples were
IgG positive

 Were there higher IgM
positives and children
seroconversions post
monsoon ?
Confirmatory Serology

+

Neutralization Assays : 1. Plaque Reduction Neutralization Test
2. Microneutralization Assay

Subset of “dengue IgG” positive patient sera tested by more specific
neutralization assays indicated that a minority of Dhaka residents
may have been exposed to Japanese Encephalitis and West Nile virus
Water Supply & Storing at the
Household Level
Based on entomological
survey questionnaire

Based on FGDs and KII
 I cover those water holding

 In the city of Dhaka, 94%
(n=842)households have piped
water supply with 4.6% has
reliance on deep tube-well.

 40.8% (n=842) households
(mainly from HSES & LSES) store
water for multiple reasons.

 38.4% household members
empty/clean containers on weekly
basis, whereas 59.6% empty
water more than weekly basis and
no idea of cleaning the water
holding containers.

containers which I use only for
cooking but not for other purposes
(Female respondent from MSES)

 We have no choice but to store water
everyday as we don’t have 24 hours
supply of electricity(Respondent from
LSES)

 We don’t store water in our house.
However, I have no idea whether our
housemaids are storing water or not
as they are not allowed to use our
toilets(Respondent from HSES)
HSES=High Socio-economic Status; MSES=Medium
Socio-economic Status; LSES=Low Socioeconomic Status
Knowledge about Dengue Vector Breeding Sites
 Respondents (n=15) do not
fully recognize breeding sites
of the dengue vector.

 Respondents associated

other “dirty” sites (i.e.,sewage
drains, waste sites) where
they found lots of larvae and
adult mosquitoes.

 There is a marked hierarchy

of people’s perceptions of
dengue vector breeding sites.
Sites outside the home were
ranked as highly probable
breeding sites, while
containers in the houses were
ranked as less likely breeding
sites.

 Dengue mosquitoes breed
everywhere.

 Dengue mosquitoes grow in
stagnant water but I never
knew about that water has to
be clean not dirty.

 I know mosquitoes those
bite, mostly breed from
outside containers and they
don’t lay eggs inside houses.

 All biting mosquitoes come
from outside to the inside of
our houses to bite us.
Relation of demograph,
KAP and Vector
Risk Perceptions of Dengue Disease and Vector
 Perception of dengue vector: its dilution with other mosquitoes
I know that dengue disease is caused by striped mosquitoes. Though
this disease is fatal, they come once a year or every two years. It is less severe when
we think of how often we are annoyed by other mosquitoes, which come daily, all the
time and everywhere
Dengue is not a problem in Dhaka, why should I worry about dengue mosquito then?
(HSES respondent)



Perception of dengue as a disease:Partial knowledge with misconception
I know dengue is caused by dengue mosquito bites but I don’t have any idea about
dengue fever or DHF
Dengue is like a mild fever, it never became severe to people in our country
Conclusions and Implications
 Vector and sero survey related: significant overlap ;high degree of exposure
(high degree of dengue seroprevalence, risk for 2nd exposure – >DHF)

 Differential water storage and water use patterns are profoundly
influenced by varied utility supplies and constraint in services (e.g. piped
water, electricity) to different socio-economic categories of city dwellers

 A sense of complacency about dengue disease exists across socioeconomic categories but their reasons are rooted in varied macro level
contexts

 The degree of misconception about dengue transmission is quite high,
and risk communication on dengue disease needs to be strengthened
among the community stakeholders

 Single disciplinary approach is not adequate to encompass complexities in
dengue transmission, and application of an Ecohealth approach would be
appropriate
Acknowledgement
Thesis Committee Personnel:
C. Emdad Haque (UM)
Michael Drebot (PHAC)
Robbin Lindsay (PHAC)
Stephane McLachlan (UM)
Institutions:
International Centre for Diarrh Disease, Bangladesh
(icddr,b)
North South University (NSU), Dhaka, Bangladesh
Population Services and Training Centre (PSTC),
Bangladesh
Public Health Agency Canada (PHAC)
Government:
Ministry of Health & Family Welfare, Govt. of Bangladesh

Funding Agencies:
IDRC-CRDI, Canada
IDRC Doctoral Research Award
Manitoba Health Research Council (MHRC)
Graduate Fellowship
University of Manitoba (UM)
Parnali and Robbin Lindsay

Parnali

???
Questions ?

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Dengue Transmission and Risk Factors in Dhaka, Bangladesh

  • 1. Dengue Transmission and Risk Factors in Dhaka, Bangladesh Parnali Dhar Chowdhury1, C. Emdad Haque1, Robbin Lindsay2, Abdullah Brooks3,4, Michael A Drebot2 1Natural Resources Institute, University of Manitoba Microbiology Laboratory, Public Health Agency Canada 3John Hopkins University, USA, and 4 icddr,b Bangladesh 2 National GRF Davos One Health Summit 2013 17-20 November, 2013; Davos, Switzerland
  • 2. Areas of risk for dengue disease Dengue viruses 1- 4 can cause DF / DHF Person  Aedes mosquito  Person A. aegypti
  • 3. Estimated population at risk of dengue fever under “standard” climate change scenario: 1990, 2085 1990 2085 Decreased mosquito abatement Increased urbanization, etc. . Source. Hales S et al. Lancet (online) 6 August 2002. http://image.thelancet.com/extras/01art11175web.pdf
  • 4. • Dhaka, the capital of Bangladesh, 16th Largest city (15.4 million population in 2012) of the world • Estimated to grow to about 20 million (2020), making it the world’s third largest city • Population growth =~7%  Insert map of Bangladesh and Location of Dhaka • Attracts some 300-400 thousand new migrants/year Source:http://www.google.com/imgres
  • 5. Dengue Trends in Dhaka: Facts from Reality Dhaka : Total number of reported dengue cases by year (n = 22,705).  Asymptomatic nature of dengue (known as Dhaka fever) since 1964  First major outbreak in 2000 with 5,551 hospitalized cases (93 deaths)  Short term (2000-2008) trend reveals short cyclical pattern – reasons are unknown Dhaka: Total number of reported dengue cases, by month, 2000-2008 (n = 22,705)  Limited knowledge of dengue vector distribution and density, disease risk perception, and circulating serotypes  nearly all viruses isolated were DENV-3 (Rahman et al. 2002; Wagatsuma et al. 2004; Podder et al. 2006; Islam et al. 2006)  co-circulation of DENV3 with DENV 2 & 4 (Aziz et al. 2002) Source: (Karim et al. 2012)
  • 6. First Outbreak in 2000 Panic situation • People • Professional • Media • Posters –Blood Test… labs. • Blaming!! BANGALI A, Mannan Dr.
  • 7. Questions and Objectives about Dengue in Dhaka Ecological / Entomological / Virological / Socialogical-Economic Factors for Dengue What are the distribution of Aedes mosquitoes and whether Aedes density vary with different socio-economic statuses (SES)? What are the seroprevalence of DENV and how it is correlated with Aedes abundance? How human Knowledge, Attitudes, and Practices (KAP) at the individual and household levels are involved in enhancing or reducing vector habitat? Objectives:  To delineate vector distribution by examining Aedes larva and pupa breeding spaces in houses  To conduct household level serosurvey in the same household  To map risk perception and analyze KAP regarding dengue disease
  • 8. Methodology • Multi-stage, multi-level study design for entomological survey of dengue vector distribution • Focus group discussions (FGDs) and key informant interviews (KIIs) for risk perception analysis • Guiding Principles: 2 1. Representative samples of the City of Dhaka 2. Socio-economic variability among the wards considered 3. Gender perspectives considered in FGDs and KIIs
  • 9. Differences among Socio-economic Statuses: Some Selected Images
  • 10. An Outline of Findings and Analysis Vector ecology and distribution during 2011 and 2012 Container analysis (mosquito breeding and larval development) and water-use pattern at household level Serosurvey result of pre- and post-monsoon 2012 Risk perception of dengue disease and its vector
  • 11. Overview of Entomological Survey MONSOON 2011 MONSOON 2012 TOTAL LARVAE COLLECTED 2587 3644 Ae. aegypti 2128 (84%) Ae. albopictus 344 (13%) 2811 (77.1%) 634(17.4%) Other Sp. 3% 61 (1.7%) TOTAL PUPAE COLLECETED 339 1129 Survey Time House Index Container Breteau Index Index PUPAE/100 HOUSES MONSOON 2011 27.74% 32.84% 52.39% 36.02 MONSOON 2012 24.17% 31% 44.17% 169.9 Total Household Visited (target=1200) : 842 (2011) 834 (2012) Overwhelming majority of households have been found to be infested with Aedes aegypti Calculation of Stegomyia Indices are quite high for vector surveillance in both years
  • 12. Most Frequent Container Types, Monsoon 2012  8 major types of positive containers seemed to be dominant  These 8 containers types account for 72% of all positive containers CONTAINER CODE: A1=Water tank A3=Clay pot A4=Ceramic pot A13=Metal bucket A14=Plastic bucket A19=Plastic drum (sealable) A21=Flower tub & tray A27=Tires A34= Broken sports/toy parts A38=Plastic sheets A39=Broken plastic pots
  • 13. Images of most frequent container types, Monsoon 2012
  • 14. Dengue Lab Diagnostics Overview HI IgG ELISA Neutralization RT- PCR 10k 1k 100 10 1 1000 100 1 0.1 10 1 0.1 400 bp  Rn Rn 10,000 10k + 1k 100 10 1 0.1 0.1 Cycle Ct
  • 15. Serosurvey Results Pre monsoon 2012 Post monsoon 2012  1129 samples were collected  1130 samples were collected  906 (80.2%) were IgG Positive (3.6%) were IgM positive Children had lower ~ 30% seroprevalence rates (630 paired sera and 500 replacement sera)  924 (81.8 %) samples were IgG positive  Were there higher IgM positives and children seroconversions post monsoon ?
  • 16. Confirmatory Serology + Neutralization Assays : 1. Plaque Reduction Neutralization Test 2. Microneutralization Assay Subset of “dengue IgG” positive patient sera tested by more specific neutralization assays indicated that a minority of Dhaka residents may have been exposed to Japanese Encephalitis and West Nile virus
  • 17. Water Supply & Storing at the Household Level Based on entomological survey questionnaire Based on FGDs and KII  I cover those water holding  In the city of Dhaka, 94% (n=842)households have piped water supply with 4.6% has reliance on deep tube-well.  40.8% (n=842) households (mainly from HSES & LSES) store water for multiple reasons.  38.4% household members empty/clean containers on weekly basis, whereas 59.6% empty water more than weekly basis and no idea of cleaning the water holding containers. containers which I use only for cooking but not for other purposes (Female respondent from MSES)  We have no choice but to store water everyday as we don’t have 24 hours supply of electricity(Respondent from LSES)  We don’t store water in our house. However, I have no idea whether our housemaids are storing water or not as they are not allowed to use our toilets(Respondent from HSES) HSES=High Socio-economic Status; MSES=Medium Socio-economic Status; LSES=Low Socioeconomic Status
  • 18. Knowledge about Dengue Vector Breeding Sites  Respondents (n=15) do not fully recognize breeding sites of the dengue vector.  Respondents associated other “dirty” sites (i.e.,sewage drains, waste sites) where they found lots of larvae and adult mosquitoes.  There is a marked hierarchy of people’s perceptions of dengue vector breeding sites. Sites outside the home were ranked as highly probable breeding sites, while containers in the houses were ranked as less likely breeding sites.  Dengue mosquitoes breed everywhere.  Dengue mosquitoes grow in stagnant water but I never knew about that water has to be clean not dirty.  I know mosquitoes those bite, mostly breed from outside containers and they don’t lay eggs inside houses.  All biting mosquitoes come from outside to the inside of our houses to bite us.
  • 20. Risk Perceptions of Dengue Disease and Vector  Perception of dengue vector: its dilution with other mosquitoes I know that dengue disease is caused by striped mosquitoes. Though this disease is fatal, they come once a year or every two years. It is less severe when we think of how often we are annoyed by other mosquitoes, which come daily, all the time and everywhere Dengue is not a problem in Dhaka, why should I worry about dengue mosquito then? (HSES respondent)  Perception of dengue as a disease:Partial knowledge with misconception I know dengue is caused by dengue mosquito bites but I don’t have any idea about dengue fever or DHF Dengue is like a mild fever, it never became severe to people in our country
  • 21. Conclusions and Implications  Vector and sero survey related: significant overlap ;high degree of exposure (high degree of dengue seroprevalence, risk for 2nd exposure – >DHF)  Differential water storage and water use patterns are profoundly influenced by varied utility supplies and constraint in services (e.g. piped water, electricity) to different socio-economic categories of city dwellers  A sense of complacency about dengue disease exists across socioeconomic categories but their reasons are rooted in varied macro level contexts  The degree of misconception about dengue transmission is quite high, and risk communication on dengue disease needs to be strengthened among the community stakeholders  Single disciplinary approach is not adequate to encompass complexities in dengue transmission, and application of an Ecohealth approach would be appropriate
  • 22. Acknowledgement Thesis Committee Personnel: C. Emdad Haque (UM) Michael Drebot (PHAC) Robbin Lindsay (PHAC) Stephane McLachlan (UM) Institutions: International Centre for Diarrh Disease, Bangladesh (icddr,b) North South University (NSU), Dhaka, Bangladesh Population Services and Training Centre (PSTC), Bangladesh Public Health Agency Canada (PHAC) Government: Ministry of Health & Family Welfare, Govt. of Bangladesh Funding Agencies: IDRC-CRDI, Canada IDRC Doctoral Research Award Manitoba Health Research Council (MHRC) Graduate Fellowship University of Manitoba (UM)
  • 23. Parnali and Robbin Lindsay Parnali ???