**5.1 Lethality in the context of Peru and Latin America**

In 2014, according to WHO and Pan American Health Organization (PAHO), the average fatality rate for the Americas is 0.04%, being among the countries with the highest rate, followed by Dominican Republic with 1.54%, Peru with 0.12%, compared to Guatemala and Colombia that have 0.07% [49]. In Colombia and Peru, the most frequent serotype 2 prevailed, and in the Dominican Republic serotype 4 prevailed [50].

Nationally, the Center for Epidemiology, Prevention and Control of Diseases of the Ministry of Health, reported in 2017, 76,093 cases of dengue in the country (3.03 times more cases in relation to 2016, and the largest number of cases reported in the last 5 years [9, 51] and 92 reports of deaths by dengue, the highest number reported in the last 10 years) (**Figure 6**).

About 43.6% came from Piura, 17.1% from Loreto, 9.9% from Madre de Dios, 8.8% from Ucayali, 4.2% from San Martín, and the remaining 16.4% from other regions; all the age groups were affected, but with a greater proportion in people over 65 (37%) and young adults (21.7%) [9].

In the Piura Healthcare Network, 30 deaths associated with dengue virus were confirmed by laboratory, and occurred between epidemiological weeks Nos. 08 and 35, over 8 months; a similar panorama reported by the Lambayeque Healthcare Network, which reported the death of six dengue-associated patients, until epidemiological week No. 20 [13, 52]; although this information could be underestimated, because in many cases it is attributed to pneumonia, and actually the cases of dengue are not properly diagnosed, causing figures not approximate to reality [53].

#### **Figure 6.**

*Death toll and dengue lethality in Peru, 2008–2017. Source: Metaxenic disease surveillance system of the Center for Epidemiology, Disease Prevention and Control of the Ministry of Health (CDC-Perú).*

In the departments of the north coast of Peru, such as Piura and Lambayeque, there are several conditions that favor the presence of epidemics, rainfall, and flooding due to the occurrence of the Coastal El Niño phenomenon, population growth at risk (young People, Urban Marginal Neighborhoods, etc) that is associated with the non-existence of basic infrastructure, insufficient water supply that leads to temporary water storage, constant circulation of *Aedes aegypti*, high temperatures and humidity, and poor community empowerment in the integrated control of vector control. Also in the Peruvian jungle, such as Loreto, Madre de Dios, Ucayali, and San Martin, they have a high incidence of death and lethality due to their diverse climatic and sanitary conditions, in addition to their population growth [13].

In the Healthcare Network of Piura, 22,562 cases of dengue were notified, 88 of which were severe dengue and 30 died, with 1.3% of lethality in general and 34.1% of lethality of severe cases; in Lambayeque there were 1384 cases; 13 being cases of severe dengue and nine deaths due to dengue, which makes 9.4% lethality in general and 43.3% lethality of severe cases, showing differences with national figures [37] (**Table 3**).

Although serotypes 2 and 3 were isolated in 94% of the positive cases; in Piura and Lambayeque, it was serotype 3 that was isolated in 90% of the cases and in almost all the deceased cases.

#### **5.2 Delays in the process of health care as a method to identify the causes of mortality**


The "delays" proposed by Thaddeus et al. in 1993, considered as the time between the appearance of a complication and its appropriate treatment and

#### **Table 3.**

*General lethality and severe cases lethality of dengue reported by Social Security of Piura and Lambayeque compared to countries of South America, 2017.*

**45**

*Situation of Dengue after the Phenomenon of the Coastal El Niño*

resolution, initiating these concepts in the framework of care for severe maternal mortality and morbidity evaluating them as autonomy factors for the search for medical care, distance, and health services [36]. The use of this approach is considered, since it would allow to identify and classify the barriers and situations related to the search for medical care in patients affected by dengue, which are part of a chain of delays or delays that would hinder risk prevention, limit the access to quality health services, and would result in the lack of timely attention to the complica-

Poor recognition of a clinical disorder is one of the factors that cause the delay in seeking attention. It includes deficiencies in health education for communities and families, which makes it difficult to recognize warning signs (signs and symptoms)

This delay is usually caused by limitations in the understanding of what medical care implies and could lead to a large number of patients arriving at health facilities in poor conditions, including factors such as information on dengue and institutional recognition, social and environmental situation, onset of symptoms, self-medication, gender and initial care, and motivations to make

It involves the difficulty of arriving at a health facility, either because of the difficult access to services or because it takes too long to reach the place of care, which can discourage the patient from seeking care, even when he has decided to seek care opportunely. It is generally the result of the lack of access to health services and economic, organizational, and sociocultural barriers which control the use of services. It is also possible to mention travel time, transport system used, and the

The cumulative effect of the first and second delays helps increase the risk of arrival at the health facility in serious conditions. Some never arrive at the hospital, and even if they do, it is possible that the treatment given to them is not adequate and poor surveillance or administrative procedures hinder the care. Other studies have shown more causes for inadequate treatment: chronic lack of trained personnel and essential supplies. Other factors mentioned are: failures in the operation of the public network, which determines waiting, reconsultation, and family movements between institutions; poor staff training and high emergency saturation [36, 55]. In relation to the first delay, aspects such as the delay in recognizing the health problem, absence of preventive-promotional talks, and lack of recognition of risk situations are described as the main ones, similar to studies that describe the population ignorance about the possibility of disease severity [56]. This last point reflects the poor knowledge by the population of less frequent dengue symptoms that in turn are associated with severity [57]. In the second delay, there are cases that went to non-health personnel and even self-medicating that are associated with delay as

*DOI: http://dx.doi.org/10.5772/intechopen.92095*

tion and, consequently, in death [54].

*5.2.2 Delay in deciding to get attention*

*5.2.3 Delay in arriving at health services*

socioeconomic impact of the delay [36, 55].

*5.2.4 Delay in receiving the appropriate treatment*

an explanation of serious or fatal cases [55, 58, 59] (**Figure 7**).

decisions [36, 55].

*5.2.1 Delay in the recognition of the health problem*

in conditions that can be life-threatening [36].

#### *Situation of Dengue after the Phenomenon of the Coastal El Niño DOI: http://dx.doi.org/10.5772/intechopen.92095*

*Dengue Fever in a One Health Perspective*

growth [13].

(**Table 3**).

**mortality**

South America

almost all the deceased cases.

**Country Serotype N° dengue** 

In the departments of the north coast of Peru, such as Piura and Lambayeque, there are several conditions that favor the presence of epidemics, rainfall, and flooding due to the occurrence of the Coastal El Niño phenomenon, population growth at risk (young People, Urban Marginal Neighborhoods, etc) that is associated with the non-existence of basic infrastructure, insufficient water supply that leads to temporary water storage, constant circulation of *Aedes aegypti*, high temperatures and humidity, and poor community empowerment in the integrated control of vector control. Also in the Peruvian jungle, such as Loreto, Madre de Dios, Ucayali, and San Martin, they have a high incidence of death and lethality due to their diverse climatic and sanitary conditions, in addition to their population

In the Healthcare Network of Piura, 22,562 cases of dengue were notified, 88 of which were severe dengue and 30 died, with 1.3% of lethality in general and 34.1% of lethality of severe cases; in Lambayeque there were 1384 cases; 13 being cases of severe dengue and nine deaths due to dengue, which makes 9.4% lethality in general and 43.3% lethality of severe cases, showing differences with national figures [37]

Although serotypes 2 and 3 were isolated in 94% of the positive cases; in Piura and Lambayeque, it was serotype 3 that was isolated in 90% of the cases and in

**5.2 Delays in the process of health care as a method to identify the causes of** 

The "delays" proposed by Thaddeus et al. in 1993, considered as the time between the appearance of a complication and its appropriate treatment and

> **N° severe cases**

DEN 2,3 1384 30 13 9.4 43.3%

Argentina DEN 1,3 557 0 0 0.0 0.0% Bolivia DEN 1,4 10,842 66 15 1.4 22.7% Colombia DEN 1,2,3 26,279 286 15 0.6 5.2% Chile DEN 1,3 10 0 0 0.0 0.0% Ecuador — 11,387 18 4 0.4 22.2% Brazil DEN 1,2,3,4 252,054 378 133 0.5 35.2% Venezuela DEN 1 8615 359 16 1.9 4.5% Paraguay DEN 1,2 1832 0 0 0.0 0.0% Uruguay — 0 0 0 0.0 0.0% Peru DEN 2,3 74,648 251 92 1.2 36.7% Essalud Piura\* DEN 2,3 22,562 88 30 1.3 34.1%

*General lethality and severe cases lethality of dengue reported by Social Security of Piura and Lambayeque* 

**Deceased General** 

387,669 1476 318 0.8 21.5%

**lethality (×1000)**

**Severe cases lethality (×100)**

**cases**

**44**

**Table 3.**

Essalud Lambayeque\*

*Taken and adapted: Díaz-Vélez et al. [37, 50].*

*compared to countries of South America, 2017.*

resolution, initiating these concepts in the framework of care for severe maternal mortality and morbidity evaluating them as autonomy factors for the search for medical care, distance, and health services [36]. The use of this approach is considered, since it would allow to identify and classify the barriers and situations related to the search for medical care in patients affected by dengue, which are part of a chain of delays or delays that would hinder risk prevention, limit the access to quality health services, and would result in the lack of timely attention to the complication and, consequently, in death [54].

### *5.2.1 Delay in the recognition of the health problem*

Poor recognition of a clinical disorder is one of the factors that cause the delay in seeking attention. It includes deficiencies in health education for communities and families, which makes it difficult to recognize warning signs (signs and symptoms) in conditions that can be life-threatening [36].

### *5.2.2 Delay in deciding to get attention*

This delay is usually caused by limitations in the understanding of what medical care implies and could lead to a large number of patients arriving at health facilities in poor conditions, including factors such as information on dengue and institutional recognition, social and environmental situation, onset of symptoms, self-medication, gender and initial care, and motivations to make decisions [36, 55].

### *5.2.3 Delay in arriving at health services*

It involves the difficulty of arriving at a health facility, either because of the difficult access to services or because it takes too long to reach the place of care, which can discourage the patient from seeking care, even when he has decided to seek care opportunely. It is generally the result of the lack of access to health services and economic, organizational, and sociocultural barriers which control the use of services. It is also possible to mention travel time, transport system used, and the socioeconomic impact of the delay [36, 55].

### *5.2.4 Delay in receiving the appropriate treatment*

The cumulative effect of the first and second delays helps increase the risk of arrival at the health facility in serious conditions. Some never arrive at the hospital, and even if they do, it is possible that the treatment given to them is not adequate and poor surveillance or administrative procedures hinder the care. Other studies have shown more causes for inadequate treatment: chronic lack of trained personnel and essential supplies. Other factors mentioned are: failures in the operation of the public network, which determines waiting, reconsultation, and family movements between institutions; poor staff training and high emergency saturation [36, 55].

In relation to the first delay, aspects such as the delay in recognizing the health problem, absence of preventive-promotional talks, and lack of recognition of risk situations are described as the main ones, similar to studies that describe the population ignorance about the possibility of disease severity [56]. This last point reflects the poor knowledge by the population of less frequent dengue symptoms that in turn are associated with severity [57]. In the second delay, there are cases that went to non-health personnel and even self-medicating that are associated with delay as an explanation of serious or fatal cases [55, 58, 59] (**Figure 7**).

#### **Figure 7.**

*Timeline of delays in the process of care of lethal cases care of dengue in two hospitals of EsSalud, in the Departments of Piura and Lambayeque, during 2017. Taken from: Burga-Cueva et al. Analysis of Lethality by Dengue in two Essalud Hospitals, in the Departments of Piura and Lambayeque. 2017. [64].*

In the third delay, limitations for access to health services are evidenced, and some are given references, but lack of economic resources or available transportation is evidenced, thus also describing the distance of health facilities (to go to the nearest one) [60]. Finally, the fourth delay involves aspects such as the time of transfer to establishments of greater resolving capacity and the waiting time of cases upon arrival in emergencies, as mentioned by Ardila et al. [55], who describe the feeling of discomfort generated by a new interrogation and the waiting time that involves admission to a health facility of greater complexity (**Figure 7**).

#### **6. Preventive measures against dengue**

A study conducted in a population with a recent dengue outbreak showed that the level of knowledge was low in 76.2% of the population, 45% did not recognize the bite of the vector as the form of disease transmission, and 34% did not recognize the etiologic agent; of the most recognized clinical manifestations were fever, followed by headache, and musculoskeletal pain. Overall, 74.9% have a low level of knowledge about warning signs and about 93% were intermediate/low in prevention, and 43% of them are unaware of the reproduction of the vector, and 71% are unaware of the role of abate; results that show that the population despite having been exposed still does not know the prevention measures [61].

PAHO has planned to cooperate with member countries to stimulate the search for concrete solutions through a communication methodology to impact behavior (COMBI) [62, 63]. It should be noted that, since the introduction of dengue in America, attempts have been made to propose some integrated programs, with a community approach to the control of *Aedes aegypti*. This approach has been to educate the community about dengue disease and how to prevent transmission by controlling the *Aedes aegypti* vector in the domestic and

**47**

*Situation of Dengue after the Phenomenon of the Coastal El Niño*

community environments; in this context, it has been documented that many of these programs were successful in educating the community about dengue and

Nevertheless, this improvement of the cognitive level related to the disease has not resulted in the action of preventing the disease. In this sense, even though people in a region with dengue endemicity are very well versed in the disease, they do not implement these measures that they know control vector proliferation and therefore the transmission of dengue; therefore, it is essential to reorient educational programs focused on the behavioral change of the population [66].

Likewise, historically in the region, efforts to control dengue vectors resulted in the elimination of populations of *Aedes aegypti* in many of the tropical and subtropical countries by the 1970s. However, vector populations were reintroduced through the emergence of new serotypes [67]. Therefore, currently, the main purpose of most programs is to reduce the densities of vector populations as much as possible and keep them at low levels. When feasible, efforts should also be made to reduce the longevity of adult female mosquitoes through the use of insecticidal methods in order to reduce

It should be noted that keeping infestation with *A. aegypti* low carries significant economic costs to society; however, when an outbreak of dengue occurs, the cost increases considerably in vector control and patient care; so, from this perspective, effectiveness and profitability could be maximized by intervening in the vector habitat (potential hatcheries) through promotion and prevention actions [68–70]. Although the concept of vector control is reasonable, control should be early in an outbreak or applied strategically during periods between epidemics to avoid escalation

Another preventive measure to control the rapid spread of an outbreak is to manage the infected human host and prevent it from infecting *Aedes* mosquitoes, this in turn would reduce the amount of new infections to humans, breaking the epidemiological chain of dengue transmission [72]. So, meanwhile, there is no vaccine with proven efficacy for dengue prevention in all population groups, and the main strategy to prevent transmission and disease is vector control through the elimination of larval habitats (elimination of potential hatcheries) and prevention of mosquito-human contact [73]. Some well-documented successes indicate that rigorously applied vector control can reduce the transmission of DENV and the

In that sense, success in reducing the burden of dengue on public health will require an integrated multiple approach; although the concept of integrated intervention for dengue prevention is gaining increasing acceptance, to date, no consensus has been reached regarding the details of how and what combination of approaches can be implemented most effectively to control the disease [75]. Integrated vector management, the strategic method promoted by WHO, is defined as, "a rational decision-making process for the optimal use of resources for vector control," which includes lobbying, social mobilization, and legislation; planning and delegated decision-making at the lowest possible administrative level; guaranteeing the rational use of available resources; adaptation of strategies and interventions based on vector habitat, epidemiology, and local resources; and development of an essential infrastructure for integrated vector management based

However, the discipline of vector control has been strongly influenced by the theory developed by Ronald Ross and George Macdonald (i.e., the Ross-Macdonald model), which states that the potential for transmission of mosquito-borne pathogens depends largely on the abundance of adult vector mosquitoes, survival through

the incubation period of the pathogen, and the rate of human infection [76].

*DOI: http://dx.doi.org/10.5772/intechopen.92095*

the risk of virus transmission [65].

in transmission [71].

disease [74].

on the situation analysis [67].

its prevention [65].

#### *Situation of Dengue after the Phenomenon of the Coastal El Niño DOI: http://dx.doi.org/10.5772/intechopen.92095*

*Dengue Fever in a One Health Perspective*

In the third delay, limitations for access to health services are evidenced, and some are given references, but lack of economic resources or available transportation is evidenced, thus also describing the distance of health facilities (to go to the nearest one) [60]. Finally, the fourth delay involves aspects such as the time of transfer to establishments of greater resolving capacity and the waiting time of cases upon arrival in emergencies, as mentioned by Ardila et al. [55], who describe the feeling of discomfort generated by a new interrogation and the waiting time that involves admission to a health facility of greater complexity (**Figure 7**).

*Timeline of delays in the process of care of lethal cases care of dengue in two hospitals of EsSalud, in the Departments of Piura and Lambayeque, during 2017. Taken from: Burga-Cueva et al. Analysis of Lethality by* 

*Dengue in two Essalud Hospitals, in the Departments of Piura and Lambayeque. 2017. [64].*

A study conducted in a population with a recent dengue outbreak showed that the level of knowledge was low in 76.2% of the population, 45% did not recognize the bite of the vector as the form of disease transmission, and 34% did not recognize the etiologic agent; of the most recognized clinical manifestations were fever, followed by headache, and musculoskeletal pain. Overall, 74.9% have a low level of knowledge about warning signs and about 93% were intermediate/low in prevention, and 43% of them are unaware of the reproduction of the vector, and 71% are unaware of the role of abate; results that show that the population despite having

PAHO has planned to cooperate with member countries to stimulate the search for concrete solutions through a communication methodology to impact behavior (COMBI) [62, 63]. It should be noted that, since the introduction of dengue in America, attempts have been made to propose some integrated programs, with a community approach to the control of *Aedes aegypti*. This approach has been to educate the community about dengue disease and how to prevent transmission by controlling the *Aedes aegypti* vector in the domestic and

**6. Preventive measures against dengue**

been exposed still does not know the prevention measures [61].

**46**

**Figure 7.**

community environments; in this context, it has been documented that many of these programs were successful in educating the community about dengue and its prevention [65].

Nevertheless, this improvement of the cognitive level related to the disease has not resulted in the action of preventing the disease. In this sense, even though people in a region with dengue endemicity are very well versed in the disease, they do not implement these measures that they know control vector proliferation and therefore the transmission of dengue; therefore, it is essential to reorient educational programs focused on the behavioral change of the population [66].

Likewise, historically in the region, efforts to control dengue vectors resulted in the elimination of populations of *Aedes aegypti* in many of the tropical and subtropical countries by the 1970s. However, vector populations were reintroduced through the emergence of new serotypes [67]. Therefore, currently, the main purpose of most programs is to reduce the densities of vector populations as much as possible and keep them at low levels. When feasible, efforts should also be made to reduce the longevity of adult female mosquitoes through the use of insecticidal methods in order to reduce the risk of virus transmission [65].

It should be noted that keeping infestation with *A. aegypti* low carries significant economic costs to society; however, when an outbreak of dengue occurs, the cost increases considerably in vector control and patient care; so, from this perspective, effectiveness and profitability could be maximized by intervening in the vector habitat (potential hatcheries) through promotion and prevention actions [68–70]. Although the concept of vector control is reasonable, control should be early in an outbreak or applied strategically during periods between epidemics to avoid escalation in transmission [71].

Another preventive measure to control the rapid spread of an outbreak is to manage the infected human host and prevent it from infecting *Aedes* mosquitoes, this in turn would reduce the amount of new infections to humans, breaking the epidemiological chain of dengue transmission [72]. So, meanwhile, there is no vaccine with proven efficacy for dengue prevention in all population groups, and the main strategy to prevent transmission and disease is vector control through the elimination of larval habitats (elimination of potential hatcheries) and prevention of mosquito-human contact [73]. Some well-documented successes indicate that rigorously applied vector control can reduce the transmission of DENV and the disease [74].

In that sense, success in reducing the burden of dengue on public health will require an integrated multiple approach; although the concept of integrated intervention for dengue prevention is gaining increasing acceptance, to date, no consensus has been reached regarding the details of how and what combination of approaches can be implemented most effectively to control the disease [75].

Integrated vector management, the strategic method promoted by WHO, is defined as, "a rational decision-making process for the optimal use of resources for vector control," which includes lobbying, social mobilization, and legislation; planning and delegated decision-making at the lowest possible administrative level; guaranteeing the rational use of available resources; adaptation of strategies and interventions based on vector habitat, epidemiology, and local resources; and development of an essential infrastructure for integrated vector management based on the situation analysis [67].

However, the discipline of vector control has been strongly influenced by the theory developed by Ronald Ross and George Macdonald (i.e., the Ross-Macdonald model), which states that the potential for transmission of mosquito-borne pathogens depends largely on the abundance of adult vector mosquitoes, survival through the incubation period of the pathogen, and the rate of human infection [76].

Therefore, with this approach, interventions that reduce the population density of adult mosquitoes, the daily probability of survival, and the contact of the mosquito with humans are expected to have the greatest impact on decreasing virus transmission. It should be noted, however, that the Ross-Macdonald model was not formulated to specifically explore larval mosquito control. Recent quantitative assessments indicate that, under certain circumstances, control of the larvae may lead to greater than expected reductions in the transmission of pathogens [77]. In the context of larval control of *Aedes aegypti*, there should be the large-scale elimination of potential hatcheries.

In this context, taking into account that there is limited efficacy and intensity of the interventions used for dengue vector control, other alternatives to combat dengue endemic persistence are explored. Sustainable community participation and school-based health education interventions have finally evolved as an effective tool in reducing the larval source over other interventions [78], since children have inherent curiosity and enthusiasm to learn new things. Therefore, they can serve as an effective change agent to achieve a change in behavior in the family and community.

Methods for vector control include elimination or management of larval habitats, eliminating larvae with insecticides, the use of biological agents, and the application of adulticides; being for our conviction the elimination and management of larval habitats. Habitats are eliminated by preventing the access of mosquitoes to these containers or by emptying and cleaning them frequently, eliminating the evolutionary stages with the use of insecticides or biological control agents, eliminating adult mosquitoes with insecticides, or by combining these methods [79].

Habitat management seeks to change the environment in order to prevent or minimize the propagation of vectors and human contact with the vector pathogen, destroying, altering (proper conservation of disused material), and eliminating or recycling nonessential containers that serve as larval habitats. Efforts to reduce solid waste should be directed against disposable or nonessential containers [78].

However, the main method of *Aedes* control (and, generally, the only one) used in many countries, remains the spatial application of ultralow volume insecticides (ULVs) for the control of adult mosquitoes [63]. This strategy has to be repeated constantly, its cost is high, and its effectiveness is limited. *Aedes aegypti* prefers to stay inside the houses, therefore, the insecticide aerial application or from trucks simply does not reach the mosquitoes that stay in hidden places, such as wardrobes. There have been several cases of homeowners in various countries who have not allowed the entry of home spraying equipment or have closed windows and doors well to prevent outside fog produced by the insecticide from entering their homes, reducing in this way the effectiveness of the intervention [65] (**Table 4**).

Due to inadequate dengue surveillance systems, spraying does not arrive in time to prevent epidemic transmission, and adult mosquito populations return quickly after spraying. Public confidence and complacency regarding such an ineffective approach have only made the challenge of explaining the need for community participation in hatchery control greater [79].

Therefore, our approach, which is the most cost-effective measure to control the transmission of dengue, would be based on the design and execution of activities aimed at eradicating vector proliferation through the elimination of favorable habitats (potential hatcheries: tires, bottles, and buckets) for oviposition and allowing the development of the aquatic stages of the vector; with a participatory methodology based on the sociocultural characteristics of the population under study, with the local schools as main actors; for which, at first, the level of knowledge, attitude, and practice of dengue prevention measures of the population must be determined and from which it will design and carry out promotional, prevention interventions, with emphasis on behavioral changes.

**49**

*Situation of Dengue after the Phenomenon of the Coastal El Niño*

*Aedes* **mosquito breeding** 

• Water storage practices • Home plant care • Animal care • Garbage disposal • Storage of daytime materials in the yard

• Communication with behavioral impact • Community cleaning • Promotion or organization of essential services: water, garbage collection • Promotion of the recycling of tires, cans, bottles, etc.

Finally, the need for a good understanding and emphasis on behaviors related to the management of *Aedes aegypti* hatcheries, the main dengue vector; it should be the promotion and prevention approach at the community level, divided into individual and collective activities for the prevention of *Aedes aegypti* reproduction,

*Comprehensive behavioral monitoring of mobilization and social communication for dengue prevention and* 

**Prevention of exposure to** *Aedes* **mosquito bites**

• Use of insecticides and spray repellents • Placing wire mesh on windows and doors • Sleep protected by a mosquito net during

• Housing improvement • Facilitation of

naps

**Search for medical attention**

patient transport to health facilities

• Disease recognition • Home treatment • Search for medical attention

Taken from: Parks W, Lloyd L. COMBI. Planning social mobilization and com-

prevention of exposure to *Aedes* mosquitoes, and seeking medical attention.

munication for the prevention and control of dengue. Ginebra; 2004 [65].

*DOI: http://dx.doi.org/10.5772/intechopen.92095*

Individuals and households

Communities, community groups, schools, NGOs

**Table 4.**

*control.*

**prevention**

*Situation of Dengue after the Phenomenon of the Coastal El Niño DOI: http://dx.doi.org/10.5772/intechopen.92095*


#### **Table 4.**

*Dengue Fever in a One Health Perspective*

of potential hatcheries.

Therefore, with this approach, interventions that reduce the population density of adult mosquitoes, the daily probability of survival, and the contact of the mosquito with humans are expected to have the greatest impact on decreasing virus transmission. It should be noted, however, that the Ross-Macdonald model was not formulated to specifically explore larval mosquito control. Recent quantitative assessments indicate that, under certain circumstances, control of the larvae may lead to greater than expected reductions in the transmission of pathogens [77]. In the context of larval control of *Aedes aegypti*, there should be the large-scale elimination

In this context, taking into account that there is limited efficacy and intensity of the interventions used for dengue vector control, other alternatives to combat dengue endemic persistence are explored. Sustainable community participation and school-based health education interventions have finally evolved as an effective tool in reducing the larval source over other interventions [78], since children have inherent curiosity and enthusiasm to learn new things. Therefore, they can serve as an effective

Methods for vector control include elimination or management of larval habitats, eliminating larvae with insecticides, the use of biological agents, and the application of adulticides; being for our conviction the elimination and management of larval habitats. Habitats are eliminated by preventing the access of mosquitoes to these containers or by emptying and cleaning them frequently, eliminating the evolutionary stages with the use of insecticides or biological control agents, eliminating

Habitat management seeks to change the environment in order to prevent or minimize the propagation of vectors and human contact with the vector pathogen, destroying, altering (proper conservation of disused material), and eliminating or recycling nonessential containers that serve as larval habitats. Efforts to reduce solid waste should be directed against disposable or nonessential containers [78]. However, the main method of *Aedes* control (and, generally, the only one) used in many countries, remains the spatial application of ultralow volume insecticides (ULVs) for the control of adult mosquitoes [63]. This strategy has to be repeated constantly, its cost is high, and its effectiveness is limited. *Aedes aegypti* prefers to stay inside the houses, therefore, the insecticide aerial application or from trucks simply does not reach the mosquitoes that stay in hidden places, such as wardrobes. There have been several cases of homeowners in various countries who have not allowed the entry of home spraying equipment or have closed windows and doors well to prevent outside fog produced by the insecticide from entering their homes,

change agent to achieve a change in behavior in the family and community.

adult mosquitoes with insecticides, or by combining these methods [79].

reducing in this way the effectiveness of the intervention [65] (**Table 4**).

participation in hatchery control greater [79].

emphasis on behavioral changes.

Due to inadequate dengue surveillance systems, spraying does not arrive in time to prevent epidemic transmission, and adult mosquito populations return quickly after spraying. Public confidence and complacency regarding such an ineffective approach have only made the challenge of explaining the need for community

Therefore, our approach, which is the most cost-effective measure to control the transmission of dengue, would be based on the design and execution of activities aimed at eradicating vector proliferation through the elimination of favorable habitats (potential hatcheries: tires, bottles, and buckets) for oviposition and allowing the development of the aquatic stages of the vector; with a participatory methodology based on the sociocultural characteristics of the population under study, with the local schools as main actors; for which, at first, the level of knowledge, attitude, and practice of dengue prevention measures of the population must be determined and from which it will design and carry out promotional, prevention interventions, with

**48**

*Comprehensive behavioral monitoring of mobilization and social communication for dengue prevention and control.*

Finally, the need for a good understanding and emphasis on behaviors related to the management of *Aedes aegypti* hatcheries, the main dengue vector; it should be the promotion and prevention approach at the community level, divided into individual and collective activities for the prevention of *Aedes aegypti* reproduction, prevention of exposure to *Aedes* mosquitoes, and seeking medical attention.

Taken from: Parks W, Lloyd L. COMBI. Planning social mobilization and communication for the prevention and control of dengue. Ginebra; 2004 [65].
