**4. Dengue fever challenges**

**Figure 4.** Map of CRI of dengue fever vulnerability in Jakarta/Banten and West Sumatra in 2012.

Very high CRI was found in 75% of regencies/cities in West Sumatra province (City of Padang in 2005, 2007, 2008, 2009, and 2012; Padang Pariaman Regency in 2008, 2011, and 2012; and City of Padang Panjang in 2007 and 2008), all of regencies/cities in Bali province (City of Denpasar in 2006, 2009, and 2010; Jembrana Regency in 2007; City of Badung in 2007, 2009, and 2010), 80% of regencies/cities in East Java province (City of Surabaya in 2007, 2008, 2009, 2011, and 2012; Malang Regency in 2007, 2008, 2009, 2011, and 2012; City of Pasuruan in 2007, 2008, 2009, 2010, and 2011; Sumenep Regency in 2007, 2008, 2009, 2011, and 2012), all of cities in Jakarta province (City of Central Jakarta in 2005, 2006, 2007, 2008, 2009, and 2012; City of North Jakarta in the year 2006–2012), half of cities in Banten province (City of Tangerang in 2007–2012), all of regencies/cities in Central Kalimantan province (City of Palangkaraya in 2006, 2008, and 2012; Kotawaringin Barat Regency in 2005–2008 and in 2012; Kotawaringin Timur Regency in 2008, 2010, and 2011; Barito Utara Regency in 2008). High CRI (brown = 4) was also happened more often before and following the years of the very high CRIs occurrences in the regencies/cities [30]. Thus, this concluded that dengue fever is in the level of seriously vulnerable to people living in the regencies/cities under study in Indonesia. **Figures 4** and **5** show the dengue fever vulnerability among cities/districts in 2012 in the provinces of Jakarta/Banten, Bali, Central Kalimantan, and East Java.

86 Current Topics in Tropical Emerging Diseases and Travel Medicine

**Figure 5.** Map of CRI of dengue fever vulnerability in Bali, Central Kalimantan, and East Java in 2012.

Dengue emerged as a public health burden and has become increasingly important, with progressively longer and more cyclical epidemics of dengue including cases of dengue with alarm signs and severe dengue. In Indonesia, although some programs and control efforts have been performed, both the incidence and case fatality rate are still high and not showing significant changes. There are still some challenges that need to be handled, such as surveillance system, availability adequate laboratory, community knowledge, awareness, and involvement against dengue, many new cases reported from new city or district, high mobility of dengue fever's carrier, density of community in the city/district central, access to health centers, and the availability of drugs and vaccines.

Surveillance for this vector-borne viral disease remains largely passive and based on the hospital report which is the estimation of real cases still underreported. It was also reported that many health centers and clinics were without adequate laboratory support. This will lead increasing of referral activities to hospitals with the consequences of time spent and transportation challenges in rural areas. Some studies found about one-third adult population with sufficient knowledge about dengue fever and its fast spreading to other people. However, only about 17% of them aware and clearly know the way for prevention [31, 32]. In addition, the high number of dengue fever incidence can also be caused by increasing *Aedes aegypti* mosquito breeding places, mosquito habitat, more effective mode of transmission, more frequent dengue fever course, shorten dengue fever symptoms, access for dengue fever treatment. Home conditions such as governance and the layout of goods at home can also affect the high number of dengue fever incidence.

Indonesia is a country with a vast region, varied geographic and biodiversity, populated density, and characteristics of various populations. In the last decade, several new administration districts developed with the newly reporting and recording management systems. This will lead underreporting of dengue fever both from the passive surveillance and the number of real cases estimation. The increasing number of people and the area of dengue fever spread in Indonesia is due to the high population mobility, the development of urban areas, climate change, increasing population density, and changes in population distribution. Climate change causes changes in rainfall, temperature, humidity, and air direction thus affecting the breeding of *Aedes aegypti* mosquitoes.

The last and most important thing of the challenges is community participation. The participation of the community to participate consistently to keep the environment from dengue is still difficult. Various breakthroughs by government such as 3 M plus (draining, covering, burying or utilizing/recycling and all forms of prevention, such as to apply powder of larvae-killers in water tanks, to use mosquito repellents, to keep fish predators to consume mosquito larvae, etc.) movement, Jumantik (volunteer or student who periodically monitor *Aedes* larvae on water storages at home) and so have long been circulated. But people who forget and bored easily become a problem. For example, after some time, there was no extraordinary incident, the community considered it safe and careless, consequently when the case exploded, people just reacted [33].

Among other challenges, passive surveillance systems tend to underestimate the burden of communicable diseases such as dengue. By utilizing the data from the Indonesian surveillance

is currently implementing WHO Global Strategy 2012–2020 that promotes coordination and collaboration among multisectoral partners, an integrated vector management approach and sustained control measures at all levels. Dengue is an ecological disease, therefore coordination and collaboration by all sectors within the government, communities, civil societies, private sectors, and media need to be strengthened. All sectors should harmonize the prevention, surveillance (entomological and epidemiological), and case management with the existing health systems, in order to make the program sustainable, cost-effective, and

Indonesia Dengue Fever: Status, Vulnerability, and Challenges

http://dx.doi.org/10.5772/intechopen.82290

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It has long been believed that preventing and reducing dengue virus transmission was very depended upon vectors control (*Aedes sp*.) or interrupt the human-vector contact. Activities to control transmission should target *Ae. aegypti* (the main vector) in the habitats of its adult stages as well as the immature. The high death toll from dengue fever demands people to stay alert to possible outbreaks of this disease in their neighborhoods [35]. Therefore, it is important for the community to collectively jointly create a healthy environment free of larvae to suppress the incidence of dengue disease. The prevention and control programs need to be undertaken with specific commitments from stakeholders from the top to the bottom levels. Currently, the Ministry of Health has launched a program of Nest Mosquito Eradication

Given the wide area in the tropical temperature, high population density in urban area, and various geographic and biodiversity, putting Indonesia as a natural potential for the habitat of dengue viruses. The number of dengue fever cases reported dramatically increases since it was firstly found in 1968 and spread out almost in 80% cities and districts in Indonesia in 2016. Many of those cities and districts were very vulnerable and putting million people at risk to the disease in 2012. Some challenges are still heading in the front of the prevention and control implementation actions. However, keeping spirit for struggling to combat dengue fever in Indonesia along with full commitment and involvement of community are urgently needed as well as to revitalize dengue disease eradication programs at every stage with close

In addition, technical guidance and increased skills of health officers are indispensable. Socialization of a hands-on program activities in particular and increased capacity and active participation of community on the action could be a joint action in preventing the increase in

ecologically sound.

**6. Conclusion**

monitoring implementation.

**Conflict of interest**

dengue disease associated to climate change.

The author declares no competing financial interests.

Program (PSN) through 3 M plus way.

**Figure 6.** Estimated annual number of dengue cases and hospitalizations in Indonesia following adjustment of surveillance reports with EFs, and their 95% confidence intervals (CIs), 2006–2015.

system and associated health system parameters, a study to estimate the proportion of dengue was conducted by Delphi panel in 2017. The iterative estimation was generated by calculating the expansion factors (EF), the ratio of total and reported cases during the presentation of medical and epidemiological data and subsequent discussions. The data revealed that from all of symptomatic Indonesian dengue episodes, 57.8% enter healthcare facilities to seek treatment but only 39.3% of them are diagnosed as dengue. Furthermore, only 20.3% of them are subsequently reported in the surveillance system. Public sector found dominating occurrence of hospitalizations and followed by private sector for ambulatory episodes (∼55%). Therefore, estimations gave an overall EF of 5.00; hospitalized EF of 1.66; and ambulatory EF of 34.01 which, when combined with passive surveillance data, equates to an annual average (2006–2015) of 612,005 dengue cases, and 183,297 hospitalizations (**Figure 6**.). The findings are lower than those similar estimations published elsewhere, perhaps due to case definitions, local clinical perceptions, and treatment-seeking behavior [34].

## **5. Dengue fever prevention and control**

The goal of WHO Global Strategy is to reduce the burden of dengue. Its specific objectives are: (1) to reduce dengue mortality by at least 50% by 2020, (2) to reduce dengue morbidity by at least 25% by 2020, and (3) to estimate true burden of the disease by 2015 (the year 2010 is used as the baseline). The implementing strategy is expected to pave the way for reducing dengue morbidity and mortality nationwide through strengthening local and national capabilities, as well as regional coordination. National Dengue Control Program in Indonesia is currently implementing WHO Global Strategy 2012–2020 that promotes coordination and collaboration among multisectoral partners, an integrated vector management approach and sustained control measures at all levels. Dengue is an ecological disease, therefore coordination and collaboration by all sectors within the government, communities, civil societies, private sectors, and media need to be strengthened. All sectors should harmonize the prevention, surveillance (entomological and epidemiological), and case management with the existing health systems, in order to make the program sustainable, cost-effective, and ecologically sound.

It has long been believed that preventing and reducing dengue virus transmission was very depended upon vectors control (*Aedes sp*.) or interrupt the human-vector contact. Activities to control transmission should target *Ae. aegypti* (the main vector) in the habitats of its adult stages as well as the immature. The high death toll from dengue fever demands people to stay alert to possible outbreaks of this disease in their neighborhoods [35]. Therefore, it is important for the community to collectively jointly create a healthy environment free of larvae to suppress the incidence of dengue disease. The prevention and control programs need to be undertaken with specific commitments from stakeholders from the top to the bottom levels. Currently, the Ministry of Health has launched a program of Nest Mosquito Eradication Program (PSN) through 3 M plus way.
