**2. Dengue fever status in Indonesia**

Indonesia is reported as the second largest with dengue fever cases among 30 endemic countries. The number of cases of dengue fever is most prevalent in the provinces of East Java, West Java, and Central Java. However, there are a number of provinces that are vulnerable with its high incidence rate of dengue fever. In 1968, the first 58 dengue cases were reported in Indonesia from the city of Jakarta (DKI Jakarta) and Surabaya (East Java) [16–19]. Since then, the sharp increasing numbers of cases and spreading to many other geographical locations have been reported [16, 17, 20–25]. The epidemiology of dengue fever in Indonesia has been described mostly in the form of case series, reporting on single outbreaks, or clinical and virological studies in confined geographical locations and selected years [26].

A study in 2014 reported that the annual dengue fever incidence increased from 0.05/100,000 in 1968 to ~35–40/100,000 in 2013. The highest epidemic occurred in 2010 with the incidence of 85.7/100,000 population. The data revealed declining of case fatality rate (CFR) from 41% in 1968 to 0.73% in 2013. Dengue cases increased among ages during the observation period up to 1998 with the highest incidence of aged 5–14 years. From 1999 onward, the trend of dengue incidence increased among those aged 15 years or over. This study indicates incidence of dengue fever increased rapidly over the past 45 years in Indonesia with peak incidence shifting from young children to older age groups [27].

The threat of dengue fever among children was emphasized clearly on a recently published study among 3194 children aged 1 through 18 years who lived in 30 different urban neighborhoods. Children blood samples were drawn for antibodies to dengue, an indication that someone has been infected with the virus in the past, and found that 69.4% of all children tested positive for dengue antibodies. Among the age groups, positive antibodies found 33.8% at the group of 1–4 year olds, 65.4% at the group of 5–9 year olds, 83.1% at the group of 10–14 year olds, and 89% at the group of 15–18 year olds. The first time to become infected with dengue was at the age of 4.8 years as the median, and in addition, 13.1% of children on average get their first dengue infection each year. It was also found that the more people in a household who had been diagnosed with dengue since a child's birth, the more likely the child were to test positive for dengue antibodies [28].

The incidence rate (IR) for every 100,000 population in seven provinces were found over 100 or are prone to dengue cases. The seven provinces are Bali (484), East Kalimantan (306), DKI Jakarta (198.7), DI Yogyakarta (167.9), North Kalimantan (158.3), Southeast Sulawesi (123.3), and South Kalimantan (101.1). The lowest IR is achieved by Papua province (11.8) and West Kalimantan (12.1) (**Figure 1**). The whole of Indonesia is high (IR is 78.0). In general, the increasing number of dengue fever cases is more likely followed by the spread of the cities

of

Dengue infection is the most rapidly spreading mosquito-borne viral disease in the world. Infections are most commonly acquired in the urban environment. In recent decades, the expansion of villages, towns, and cities in the areas in which it is common and the increased mobility of people have increased the number of epidemics and circulating viruses. Dengue fever, which was once confined to Southeast Asia, has now spread to Southern China, countries in the Pacific Ocean and America, and might pose a threat to Europe. In the last 50 years, dengue virus infections had expanded to many other countries with significant increasing cases [1] up to 2.5 billion people living in endemic countries where about 1.8 billion (more than 70%) in Southeast Asia and the Western Pacific Region [1–4]. About 50 million dengue infections occur every year [2, 3], and approximately 500,000 patients are hospitalized of whom dominated by children [2–7]. The increasing incidence and geographical spread of dengue virus were more likely driven by demographic and societal changes such as population growth, urbanization, and modern transportation [8]. The traveler movement also contributed to the risk of contracting dengue disease from nonendemic countries to endemic dengue areas to nonendemic regions where competent mosquito vectors are currently found [9–12]. Indonesia, with 257.5 million inhabitants and 17,500 islands spread across the equator, poses as the largest archipelago country in the world [13], comprising 3.1 million km<sup>2</sup>

ocean (62% of the total area) with a coastline of 81,000 km and approximately 2 million km<sup>2</sup> of land (38% of the total area). Its tropical climate and subsequent relative high humidity makes Indonesia favorable conditions for vector-borne disease transmission. The increasing trend of dengue infections over the current decades putting Indonesia as one of endemic area for dengue fever and tread both the people as well as travelers visiting the archipelago [14]. Its burden is a result of a constant ground of established infections in the past period, combined with epidemics of emerging infectious diseases (EID) [15]. This chapter describes the dengue fever status or situation in Indonesia, its vulnerability among population, the

Indonesia is reported as the second largest with dengue fever cases among 30 endemic countries. The number of cases of dengue fever is most prevalent in the provinces of East Java, West Java, and Central Java. However, there are a number of provinces that are vulnerable with its high incidence rate of dengue fever. In 1968, the first 58 dengue cases were reported in Indonesia from the city of Jakarta (DKI Jakarta) and Surabaya (East Java) [16–19]. Since then, the sharp increasing numbers of cases and spreading to many other geographical locations have been reported [16, 17, 20–25]. The epidemiology of dengue fever in Indonesia has been described mostly in the form of case series, reporting on single outbreaks, or clinical and

A study in 2014 reported that the annual dengue fever incidence increased from 0.05/100,000 in 1968 to ~35–40/100,000 in 2013. The highest epidemic occurred in 2010 with the incidence of 85.7/100,000 population. The data revealed declining of case fatality rate (CFR) from 41% in 1968 to 0.73% in 2013. Dengue cases increased among ages during the observation period up to 1998 with the highest incidence of aged 5–14 years. From 1999 onward, the trend of dengue incidence increased among those aged 15 years or over. This study indicates incidence of

virological studies in confined geographical locations and selected years [26].

future challenges, and the disease prevention and control.

**2. Dengue fever status in Indonesia**

82 Current Topics in Tropical Emerging Diseases and Travel Medicine

**Figure 1.** Incidence rate (IR) of dengue fever per 100,000 population by province in Indonesia 2016 (source: DG of CDC MOH 2017).

Jakarta, East Java, Bali, and Central Kalimantan which were selected based on the availability of monitoring station of the Indonesian Agency for Meteorology, Climatology, and Geophysics (BMKG). The dengue disease vulnerability components were generated based on bionomic mosquito and habitat, pathology dengue disease, and factors related to dengue disease occurrence. The exposure variables include land use (settlement, offices, business, schools, etc.) and population density. The sensitivity variables include breeding places and resting areas of *Aedes* mosquitoes, pupa and adult density, incidence of dengue fever, and population mobility. The adaptive capacity variables include availability of health services (number of hospitals, clinics, and public health centers), treatment management and skilled providers, implementation of dengue fever intervention program, community participation and involvement on dengue fever prevention program, and personal protection behavior. The Intergovernmental Panel Convention for Climate Change (IPCC) vulnerability analysis was implemented to gain the coping range index of DF for each city/district [31]. The coping range index (CRI) = 1 (blue) indicates the people vulnerability of having dengue fever is very low and located at quadrant between low exposure and sensitivity index and high adaptive capacity index; CRI = 2 (green) indicates the people vulnerability of having dengue fever is low and located at quadrant between high exposure and sensitivity index and high adaptive capacity index; CRI = 3 (yellow) indicates the people vulnerability of having dengue fever is medium and located at quadrant between medium exposure and sensitivity index and medium adaptive capacity index; CRI = 4 (brown) indicates the people vulnerability of having dengue fever is high and located at quadrant between low exposure and sensitivity index and low adaptive capacity index; and CRI = 5 (red) indicates the people vulnerability of having DF is very high and located at quadrant between high exposure and sensitivity index and low adaptive capacity index (**Figure 3**) [30]. A study of Research Center for Climate Change—Universitas Indonesia 2013–2014 reported that in almost all districts/municipalities under study (in 17 out of 20 regencies/cities) indicated a very serious vulnerability condition of very high coping range index (CRI) (red = 5) since 2005.

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**Figure 3.** The coping range index (CRI) of dengue disease vulnerability.

**Figure 2.** Incidence rate (IR) of dengue disease per 100,000 population and number of cities/districts infected in Indonesia 1968–2016.

and districts infected in all of 34 provinces in Indonesia (**Figure 2**). From the total of 497 cities and districts in Indonesia, about 80% have reported the dengue fever cases in 2017.

In the context of dengue fever mortality, as many as 1229 people died in 2015 from the disease caused by this dengue virus. Throughout the history of dengue fever in Indonesia, the highest death rate occurred when first time the disease was discovered in 1968 in Surabaya. Of the 58 people infected, 24 lives were lost. In 2016, the highest percentage of CFR was obtained in Maluku Province (6.0%), Gorontalo (6.1%), and West Papua (4.6%). Provinces with the lowest CFR were achieved by Papua (0%), DKI Jakarta (0.1%), and NTT (0.2%). In some provinces, dengue disease was an outbreak in 1998 and 2004 that caused 79,480 people and 800 more deaths. In subsequent years, there has been reported a decrease in the case of death but note that the number of cases continues to increase. In 2008, there were 137,469 cases and 1187 deaths. In 2009, there were 154,855 cases and 1384 deaths [29].

#### **3. Dengue fever vulnerability**

Studies on Indonesian vulnerability to climate change were mostly focused on mitigation aspects, such as water scarcity, reduction emission from deforestation and degradation (REDD), the forest conservations, disasters, land drought, floods, and others. Meanwhile, the vulnerability study on adaptation is still rare, especially to human health. In 2013, Research Center for Climate Change—University of Indonesia (RCCC-UI) initiated a study on vulnerability of dengue disease to climate change/variability in collaboration with the Directorate of Environmental Health of the Ministry of Health and supported by Indonesia Climate Change Trust Fund (ICCTF). The study involved 20 districts/cities in 5 provinces namely West Sumatra, Jakarta, East Java, Bali, and Central Kalimantan which were selected based on the availability of monitoring station of the Indonesian Agency for Meteorology, Climatology, and Geophysics (BMKG). The dengue disease vulnerability components were generated based on bionomic mosquito and habitat, pathology dengue disease, and factors related to dengue disease occurrence. The exposure variables include land use (settlement, offices, business, schools, etc.) and population density. The sensitivity variables include breeding places and resting areas of *Aedes* mosquitoes, pupa and adult density, incidence of dengue fever, and population mobility. The adaptive capacity variables include availability of health services (number of hospitals, clinics, and public health centers), treatment management and skilled providers, implementation of dengue fever intervention program, community participation and involvement on dengue fever prevention program, and personal protection behavior. The Intergovernmental Panel Convention for Climate Change (IPCC) vulnerability analysis was implemented to gain the coping range index of DF for each city/district [31]. The coping range index (CRI) = 1 (blue) indicates the people vulnerability of having dengue fever is very low and located at quadrant between low exposure and sensitivity index and high adaptive capacity index; CRI = 2 (green) indicates the people vulnerability of having dengue fever is low and located at quadrant between high exposure and sensitivity index and high adaptive capacity index; CRI = 3 (yellow) indicates the people vulnerability of having dengue fever is medium and located at quadrant between medium exposure and sensitivity index and medium adaptive capacity index; CRI = 4 (brown) indicates the people vulnerability of having dengue fever is high and located at quadrant between low exposure and sensitivity index and low adaptive capacity index; and CRI = 5 (red) indicates the people vulnerability of having DF is very high and located at quadrant between high exposure and sensitivity index and low adaptive capacity index (**Figure 3**) [30].

A study of Research Center for Climate Change—Universitas Indonesia 2013–2014 reported that in almost all districts/municipalities under study (in 17 out of 20 regencies/cities) indicated a very serious vulnerability condition of very high coping range index (CRI) (red = 5) since 2005.

**Figure 3.** The coping range index (CRI) of dengue disease vulnerability.

**Figure 2.** Incidence rate (IR) of dengue disease per 100,000 population and number of cities/districts infected in Indonesia

and districts infected in all of 34 provinces in Indonesia (**Figure 2**). From the total of 497 cities

In the context of dengue fever mortality, as many as 1229 people died in 2015 from the disease caused by this dengue virus. Throughout the history of dengue fever in Indonesia, the highest death rate occurred when first time the disease was discovered in 1968 in Surabaya. Of the 58 people infected, 24 lives were lost. In 2016, the highest percentage of CFR was obtained in Maluku Province (6.0%), Gorontalo (6.1%), and West Papua (4.6%). Provinces with the lowest CFR were achieved by Papua (0%), DKI Jakarta (0.1%), and NTT (0.2%). In some provinces, dengue disease was an outbreak in 1998 and 2004 that caused 79,480 people and 800 more deaths. In subsequent years, there has been reported a decrease in the case of death but note that the number of cases continues to increase. In 2008, there were 137,469 cases and 1187

Studies on Indonesian vulnerability to climate change were mostly focused on mitigation aspects, such as water scarcity, reduction emission from deforestation and degradation (REDD), the forest conservations, disasters, land drought, floods, and others. Meanwhile, the vulnerability study on adaptation is still rare, especially to human health. In 2013, Research Center for Climate Change—University of Indonesia (RCCC-UI) initiated a study on vulnerability of dengue disease to climate change/variability in collaboration with the Directorate of Environmental Health of the Ministry of Health and supported by Indonesia Climate Change Trust Fund (ICCTF). The study involved 20 districts/cities in 5 provinces namely West Sumatra,

and districts in Indonesia, about 80% have reported the dengue fever cases in 2017.

deaths. In 2009, there were 154,855 cases and 1384 deaths [29].

**3. Dengue fever vulnerability**

84 Current Topics in Tropical Emerging Diseases and Travel Medicine

1968–2016.

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.

**4. Dengue fever challenges**

centers, and the availability of drugs and vaccines.

affect the high number of dengue fever incidence.

breeding of *Aedes aegypti* mosquitoes.

just reacted [33].

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

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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

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

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

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

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

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