Opening the Door to Public Health Work: Dengue Fever in Costa Rica

Victoria Egedus Associated Colleges of the Midwest, San Pedro, San Jose, Costa Rica

Lake Forest College, Lake Forest, IL

ACM Symposium 2014 April 11th

Most prevalent and deadly arthropod-borne human illness worldwide

4 viral serotypes DENV1-DENV4 11kb and 10 genes

Tang, Y et al. Genomic sequence of 10 dengue serotype 1 viruses associated with different genotypes, epidemics, and disease severity isolated in thailand over 22 years. Am J Trop Med Hyg. 2012; 83(5):1156-1165 www.rcsb.org/pdb/101/motm.do?momID=103 news.thomasnet.com

Transmitted by Aedes, which live exclusively with humans

What is dengue fever?

Dengue Can Kill

Young child in Dominican Republic with Severe Dengue-suffering extravasation

Child in Tarcoles, CR with a rash break out

What is Dengue?

•Number of incidence is 30X > it was 50 years ago •Estimated 390 million dengue infections annually (Bhatt et al., 2013)

WHO, 2009

•2.5 billion people live in areas of risk > 40% of world’s population

Pan-American Health Organization

Integrative Management Strategy

www.nanduti.com.py

Goal: Remove Breeding Sites

Study Site: Quebrada Ganado, Garabito, Puntarenas, Costa Rica

Population: 1,916

Prior to my arrival: 2-3 new cases a

week

Objectives for this Study in Quebrada Ganado

Evaluate Community Knowledge and Opinions about Dengue and its Prevention

Relate Findings from Property Inspections with the Knowledge or

Opinions of Property Owners

Gather Opinions on How to Effectively Educate the Community and Solicit

Involvement

Interviews in Houses Methodology

Learning through training… Property Inspections…

I learned to identify problems...

and find solutions

Often solutions are not easy

Results: Demographics of Study Sample

320 total households interviewed

61%

39%

0% 10% 20% 30% 40% 50% 60% 70%

Previous Infection

No Previous Infection

Percentage of Participants

Infe

ctio

n St

atus

of H

ouse

hold

Previous Dengue Infection within the Household for Participants Interviewed in

Quebrada Ganado, Costa Rica, March-April, 2013

Source: Interviews conducted in Quebrada Ganado, 2013

Average of 2 people/household

Education Level of Participants Interviewed in Quebrada Ganado,

Costa Rica, March-April, 2013

Source: Interviews conducted in Quebrada Ganado, 2013

7%

52%

32%

9%

0% 10% 20% 30% 40% 50% 60%

No Education

Primary Eductation

Secondary Education

University

Percentage of Participants

Educ

atio

n Le

vel

89%

11%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Know Dengue Symptoms

Do Not Know Dengue Symptoms

Percentage of Respondents

Know

ledg

e of

Den

gue

Sym

ptom

s

Knowledge of Dengue Symptoms for Participants Interviewed in Quebrada

Ganado, Costa Rica, March-April, 2013

Source: Interviews conducted in Quebrada Ganado, 2013

98% of Participants Knew…

…Dengue is Transmitted by a Mosquito …The Dengue Mosquito Reproduces in Stagnant Water

But there was a Misunderstanding of the Type of Water Aedes aegypti Prefers

blog.smu.edu/studentadventures/2012/raamis-in-india/dont-let-them-see-you-grimace/

abc.com.py/nacionales/salu-publica-y-comuna-asuncena-unen-fuerzas-440885.html

Source: Interviews conducted in Quebrada Ganado, 2013

Participant Responses for Type of Water Preferred by Dengue Mosquito in Quebrada

Ganado, Costa Rica, March-April, 2013

Status of Inspection at Time of Interview TOTAL

Number who Reported Aedes Prefers Clean Water N %

No Previous Inspection 238 84 35 Previous Inspection 5 Weeks Prior 45 29 64 Question not Realized 37 TOTAL 320

Education by Ministry of Health Workers was retained 5 weeks later

Most Frequent Participant Responses on “Who has the Responsibility of Protecting the Community from Dengue?" in Quebrada Ganado, Costa Rica, March-

April, 2013

Who is Responsible? Total %

Us; The Community 167 52

Community + Ministry of HealthTogether 54 17

Ministry of Health 43 13

Everyone 26 8

Other --- ---

Source: Interviews conducted in Quebrada Ganado, 2013

20% reported no responsibility is held by the community

Most Frequent Participant Responses on "How Can the Community be Educated about Dengue and its

Prevention?" in Quebrada Ganado, Costa Rica, March-April, 2013

How Can the Community be Educated about Dengue and Its Prevention? TOTAL % Talks/Lectures 119 37 Work and Inspections by the Ministry of Health 43 13 Educating Children 43 13 Do Not Know 39 12 Campaigns 29 9 Education is Already Sufficient 20 6 Giving Examples and Training 19 6

Other --- ---

Source: Interviews conducted in Quebrada Ganado, 2013

A breadth of different ideas…

How Can the Community be Convinced to Eliminate Stagnant Water? TOTAL %

Do Not Know 72 23

Campaigns 47 15

Information on the Risks and Dangers 36 11

Talks/Lectures 35 11

House Visits and Inspections by Ministry of Health 32 10

Contracting Dengue is the Only Way 30 9

Other --- ---

Most Frequent Participant Reponses on "How Can the Community Members be Convinced to

Eliminate Stagnant Water in their Properties?" in Quebrada Ganado, March-April 2013

Source: Interviews conducted in Quebrada Ganado, 2013

Through education and raising awareness

Results from Inspections by Ministry of Health

•264 houses inspected. 100% with possible breeding sites

•Mode=5, median=7, range from 2-51 possible breeding sites

•9% of houses inspected had at least 1 breeding site positive for Aedes aegypti

Citizens display a hazy understanding of the dengue vector versus other mosquitoes (Culex and Chironomidae) More education is needed to differentiate the vector’s habits

Conclusions

biologie.uni-regensburg.de/Zoologie/Boeckh/Bosch/

Target audiences for dengue education include:

Households with: more frequent infections, lower education level, lower perception on the importance of dengue prevention actions, and lower perceived danger of dengue

teamtarget.org/home.asp

Majority of community believe prevention is their responsibility, and perceive that the Ministry of Health plays an important role in educating and convincing the community to eliminate breeding sites

-Allowed me publish as a first author in the Tropical Biology Journal

(September 2014)

What has this program done for me?

-Created a passion for the country, their culture, and their way of

life.

-Set the foundation for the work I will do during my gap year- return to Costa

Rica and do public health work

-Opened the door to many new connections and lifetime friendships in Costa Rica

Acknowledgements

Chris Vaughan, PhD

Mike McCoy, MS

Mario Morera, PhD

ACM

Area of Jacó, Health Ministry of Costa Rica José Morales Ortega, MD

Vector Control workers:

Jaime Rodriguez Arguedas

José Valerín Cordero

Maynor Peraza Solas

Zulema Conejo Mora

Community members of Quebrada Ganado Lynn Westley, PhD

Anabelle Alfaro, MD, Advisor

Thank you. Questions?

References Bhatt, S., Gething, P. W., Brady, O. J., Messina, J. P., Farlow, A. W., Moyes, C. L., Drake, J. M., Brownstein, J. S., Hoen, A. G., Sankoh, O.,

Myers, M. F., George, D. B., Jaenisch, T., Wint, G. R. W., Simmons, C. P., Scott, T. W., Farrar, J. J., Hay, S. I. The global distribution and burden of dengue. Nature, 2013, 0:1-5.

de María Cáceres-Manrique, F., Vesga-Gómez, C., Perea-Florez, X., Ruitort, M., & Talbot, Y. (2009). Conocimientos, actitudes y prácticas sobre dengue en dos barrios de Bucaramanga, Colombia. Revista de Salud Pública, 11(1), 27-38.

Espinoza F, Hernandez CM, Coll R. Educational campaign versus malathion spraying for the control of Aedes aegypti in Colima, Mexico. J Epidemiol Community Health, 2002; 56(2): 148-52.

Farrar, J., Focks, D., Gubler, D., Barrera, R., Guzman, M. G., Simmons, C., Kalayanarooj, S., Lum, L., McCall, P.J., Lloyd, L., Horstick, O., Dayal-Drager, R., Nathan, M.B., & Kroeger, A. (2007). Editorial: Towards a global dengue research agenda. Trop Med & Int Health, 12(6), 695-699.

Freire, P. (1973). Education for critical consciousness. New York, NY: Seabury press. p 40. Gubler DJ. Dengue and dengue hemorrhagic fever. Clin Microbiol Rev. 1998; 11: 480–96. Guzman M, Kouri G. Dengue: an update. Lancet Infect Dis.2002; 2: 33-40. INEC, Instituto Nacional de Estadística y Censos. Estadística Censo 2011. Available from: Área de Servicios de Información y Divulgación. San

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dengue by community programs using mesocyclops(copepod) against Aedes aegypti in central Vietnam. Am J Trop Med Hyg. 2005; 72(1): 67-73.

Panagos, A., Lacy, E. R., Gubler, D. J., & Macpherson, C. N. (2005). Dengue in Grenada. Revista panamericana de salud pública, 17(4), 225-229.

Parks W, Lloyd L. Planning social mobilization and communication for dengue fever prevention and control: a step-by-step guide. Geneva: WHO; 2004.

Perez, CL, Zielinski E, Vargas D, Clark GG. Community beliefs and practices about dengue in Puerto Rico. Rev Panam Salud Publica. 2009; 25: 218-26.

References Pérez-Guerra, C. L., Seda, H., García-Rivera, E. J., & Clark, G. G. (2005). Knowledge and attitudes in Puerto Rico concerning dengue

prevention. Rev Panam Salud Pública, 17(4), 243-253. Rosenbaum J, Natahan MB, Ragoonanansingh R, et al. Community participation in dengue prevention and control: a survey of

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Study Site: Quebrada Ganado, Garabito, Puntarenas, Costa Rica

Population: 1,916

Prior to my arrival: 2-3 new cases a

week

76%

24%

Females

Males

Sex of Participants Interviewed in Quebrada Ganado, Costa Rica,

March-April, 2013

Source: Interviews conducted in Quebrada Ganado, 2013

320 total interviews