Fresh ap­proach needed to tackle dengue

The Sun (Malaysia) - - SPEAK UP -

OUT of the RM25 bil­lion ex­tra health al­lo­ca­tion in the 2017 bud­get, RM80 mil­lion was ear­marked to ex­pand the Na­tional Com­mu­nity Health Em­pow­er­ment pro­gramme to pre­vent and con­trol mos­quito-borne dis­eases.

This comes on the back of a wors­en­ing dengue prob­lem, with an in­creas­ing num­ber of cases recorded yearly since 1980. There were 120,836 cases in 2015, up from 43,346 cases in 2013 – an in­crease of 179%. From Jan­uary to Au­gust this year, 71,590 cases were de­tected – 193 Malaysians have lost their lives.

How­ever, is di­rect­ing RM80 mil­lion to mos­quito con­trol the most ef­fec­tive use of these funds?

Most of the money will prob­a­bly be spent on com­mu­nity ed­u­ca­tion and fog­ging.

Fog­ging is highly vis­i­ble and sends re­as­sur­ing sig­nals to the af­fected com­mu­nity. Un­for­tu­nately, stud­ies look­ing at the ef­fec­tive­ness of fog­ging in­di­cate that the method achieves lit­tle. To be ef­fec­tive, fog­ging must rapidly re­duce the mos­quito pop­u­la­tion by around 97% and be re­peated reg­u­larly.

Many in­fec­tive mos­qui­toes es­cape un­harmed as they are of­ten found in­doors in homes, of­fices and en­closed spa­ces when the fog­ging teams pass by.

A lot de­pends on the dili­gence of the op­er­a­tor: ma­chines can be poorly main­tained; in­sec­ti­cide dosages can be in­cor­rect, un­der­min­ing ef­fec­tive­ness. Fog­ging can also give res­i­dents a false sense of se­cu­rity, lead­ing to a com­pla­cent at­ti­tude to­wards en­sur­ing that drains are cov­ered and con­tain­ers are emp­tied of stag­nant wa­ter.

Mos­quito con­trol ef­forts, mainly based around fog­ging, are ex­tremely ex­pen­sive at RM6,700 per re­ported dengue case. Malaysia spends around RM310 mil­lion every year on these ac­tiv­i­ties. This amount is the equiv­a­lent to the bud­get cuts ex­pe­ri­enced by the Min­istry of Health in 2015 and 2016. About the same amount was al­lo­cated for the 1Malaysia Sup­ple­men­tary Food Pro­gramme for pri­mary school pupils un­der the 2017 Bud­get.

There are a num­ber of strate­gies avail­able to re­duce the breed­ing op­por­tu­ni­ties for mos­qui­tos. Wa­ter-col­lect­ing lit­ter, clogged drains and dis­carded tyres are par­tic­u­larly favoured by these in­sects.

Health author­i­ties can­not hope to elim­i­nate all breed­ing places in parks, empty land, build­ings, build­ing sites, blocked drains and sep­tic tanks.

Health Min­is­ter Datuk Seri Dr S. Subra­ma­niam said in 2014 that pub­lic ap­a­thy un­der­mines ef­fec­tive dengue con­trol ef­forts. Few peo­ple seem will­ing to give up 10 min­utes each day to get rid of breed­ing sites around their homes and workspaces.

The­o­ret­i­cally, mos­quito num­bers could be re­duced by in­fect­ing the males with a fer­til­ity-re­duc­ing bac­te­ria (Wol­bachia). Tri­als are tak­ing place in Sin­ga­pore, with plans for Malaysian field tests next year. A few years ago, “ge­net­i­cally ster­ile” male Aedes ae­gypti mos­qui­toes were re­leased as part of vi­a­bil­ity tests to de­crease the pop­u­la­tion of this in­sect. New mos­quito traps are be­ing de­vel­oped. But the ar­rival on the scene of a new vac­cine against dengue fever, calls into ques­tion the wis­dom of pump­ing more money into mos­quito con­trol. This vac­cine, Deng­vaxia (CYD-TDV) was first li­censed in Mexico in De­cem­ber 2015, which has now in­cluded it in their na­tional im­mu­ni­sa­tion pro­gramme.

Deng­vaxia demon­strated sig­nif­i­cant lev­els of pro­tec­tion (57%) against dengue in­fec­tion dur­ing clin­i­cal tri­als, which in­volved over 10,000 chil­dren in five Asian coun­tries, in­clud­ing Malaysia.

The vac­cine has since been li­censed by nine other en­demic coun­tries in­clud­ing Sin­ga­pore, In­done­sia, Thai­land and the Philip­pines. WHO has rec­om­mended coun­tries to adopt the vac­cine in na­tional im­mu­ni­sa­tion pro­grammes, par­tic­u­larly for chil­dren aged be­tween nine and 16 years.

Deputy Health Min­is­ter Datuk Seri Dr Hilmi Yahya stated ear­lier that the gov­ern­ment is “still doubt­ful of the vac­cine’s ef­fec­tive­ness, as such there is no need to reg­is­ter the vac­cine in the coun­try for the time be­ing”.

What is clear is that ap­proaches to mos­quito con­trol are both in­ef­fec­tive and costly. In light of tighter bud­get lines and the avail­abil­ity of more cost ef­fec­tive meth­ods, per­haps it is time for the Min­istry of Health to take on a fresh ap­proach to fight­ing dengue.

Philip Stevens Se­nior Fel­low In­sti­tute for Democ­racy and Eco­nomic Af­fairs

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