FACTORS ASSOCIATED WITH THE PATTERN OF DENGUE HAEMORRHAGIC FEVER (DHF) INCIDENCE IN INDONESIA

1. ERMI NDOEN1), TITIK RESPATI 1), PUSPARINI2), ANA M LIMBONG2), BAYU AJI2) FACTORS ASSOCIATEDWITH THE PATTERN OF DENGUE HAEMORRHAGIC FEVER (DHF) INCIDENCE IN INDONESIA

2. Indonesian Dengue in the Media Home>>World Last updated at: (Beijing Time) Friday, February 27, 2004 Death toll of dengue fever in Indonesia rises to 267 Death toll of the dengue fever across Indonesia has risen to 267 people and the sufferers increased to 15,316 people, an official of the Health Ministry said Thursday. 175 die from mosquito-borne virus JAKARTA An outbreak of dengue fever has killed at least 175 people as of Thursday, and a health official warned that floods beginning to inundate Jakarta and other cities would worsen the situation. .The mosquito-borne outbreak has spread to four more provinces and infected 8,735 people in a total of 12 provinces since Jan. 1, said Dr. Mariani Reksoprojo of the Health Ministry, who called the outbreak "extraordinary Travellers warned about Dengue By Zhao Huanxin (China Daily) Updated: 2004-08-20 01:56 Quarantine authorities are urging travellers to take precautions against the mosquito-borne disease dengue fever after some Southeast Asian countries have reported cases. Bangladesh, Bhutan, Indonesia and Sri Lanka have recently reported outbreaks of the disease, according to the World Health Organization (WHO).

3. Aim To examine the associations between DHF Incidence pattern with demographic, environmental factors (climate, land use), and DHF control activities in selected areas in Indonesia

4. Objectives • To describe the fluctuation and spatial distribution of DHF incidence • To examine the association between climatic conditions and DHF incidence • To examine the association between population density, migration, land use with DHF cumulative incidence • To explore the influence of DHF control activities on the DHF incidence In selected areas.

5. Indonesia at a Glance • Area: 1,919.4 sq km • Population (2003): 235 million; • 100 Distinct ethnic groups. Areas of Study Deli Serdang Jakarta

6. Data collection • The monthly data of DHF cases from each sub district collected from DHF surveillance data. • The monthly meteorological data (temperature, rainfall, rain day and humidity) obtained from weather monitoring station. • The population density, land use and dwellings type data data obtained from The Indonesian Statistics Bureau (BPS). • Type of water containers obtained from DHF survey in in selected areas.

7. Data Analysis Statistical analysis included: • Descriptive analysis : Time series graphs, Frequency distributions Test of normality • The independent t-test • Chi Square analysis • A correlations analysis Spatial Analysis  To show the spatial distribution and the variation of DHF incidence at study areas

8. THEORITICAL FRAMEWORK Climate Temperature, Humidity, Rainfall, Rain day, Precipitation and Extreme weather events Ecology Vegetation, Soil moisture, and Land use Social Factors Vector control, Travel/migration, Behavior, Population, Basic sanitation Transmission Biology Vector reproduction/ movement Disease Outcome Rate of transmission, Incidence Rate

9. Research Framework Weather condition: Land Use • Rainfall • Temperature • Humidity DHF Cumulative Incidence Demographic condition: - Population density - Migration Control Activity

10. Number of DHF Cases and Infected Areas in Indonesia (1968 –2003) IR per 100,000 No of City/Districts Infected

12. Dengue (DHF) Outbreak in Indonesia (2004)

13. The Spatial Distribution DHF Incidences in West Jakarta

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15. Climate Factors and DHF Incidence (West Jakarta)

16. Rainfall, rainy days & humidity had positive relationship with DHF incidence • Temperature had no significance relationship with DHF incidence

17. Population Density and DHF Incidence (West Jakarta) Category of Population Density Area P value (95% CI) DHF Cum Inc Mean Mean Diffe- rence 1. High 86.34 (> 13568 people/km2) 0.585 -10.329 (-48.32 – 27.66) 2. Low 96.67 (< 13568 people/km2)

18. Land Use and DHF (West Jakarta) Category of DHF Cum Incidence P value (95% CI) Mean Diffe- rence Land Use Area Mean 1. Residential - High (> 72.32%) 70.63 14.06 0.162 - Low (< 72.32%) (-5.83 – 33.95) 56.57 2. Office & Industry 0.142 - High (> 11.17%) 56.22 -14.77 (-34.62 – 5.08) - Low (< 11.17%) 70.99 3. Free & Agriculture 60.86 -5.49 0.588 - High (> 0.095%) - Low (< 0.095%) (-25.69 – 14.71) 66.35

19. Dwellings Type and DHF (West Jakarta) Category of P value (95% CI) DHF Cum Incidence Mean Difference Dwelling Type Mean 1. Permanent 66.81 6.43 0.526 - High (> 65.52%) - Low (< 65.52%) (-13.75 – 26.60) 60.39 2. Semi Permanent - High (> 24.87%) 66.87 6.53 0.519 (-13.64 – 26.71) - Low (< 24.87%) 60.34 3. Temporary - High (> 9.25%) 53.59 -20.02 0.071 (-39.53 – -0.52) - Low (< 9.25%) 73.61

20. Most DHF cases occurred in unplanned housing areas (Central Jakarta)

21. In Central Jakarta Control Activity (Fogging) was found to be ineffective in preventing DHF outbreak

22. Another Control Strategy for Combating DHF is Mosquito Breeding Site Eradication Program (MBSEP) “…to encourage communities in the eradication of dengue, especially in removing mosquito larvae, so the infection by the disease can be prevented… ”

23. The Way of Executing Mosquito Breeding Site Eradication Program • Cleaning water containers • Covering water containers • Burying discarded containers • Other activities such as changing water regularly in flower pots and bird feeding cups, etc

24. Typical water containers in Indonesia that can be potential breeding place for dengue mosquitoes

25. Typical Water Containers in Rural Area

27. (2 = 12.6; df = 1; p = 0.00; = 0.1) = Significant MBSEP = Mosquito Breeding Site Eradication Program

28. The Relationship between Respondents’ Level of Education with Knowledge, Attitude and Practice in Mosquito Breeding Site Eradication Programs (MBSEP)

29. Relation between Occupation and KAP

30. Relation Between Economic Status and KAP

31. Relationships Between Health Promotion and KAP

32. The Preferences of Health Promotion Media for DHF in Deli Serdang District, North Sumatera - Indonesia (Urban area) (rural area)

33. Conclusions • Dengue Haemorrhagic Fever (DHF) is one of the most important communicable diseases occurs in urban areas such as Jakarta. • DHF incidence is associated with relative humidity, number of rainy days and average daily rainfall. • Analysis of population density and DHF incidence at sub-district level indicates that DHF incidence was high in low population density areas. • DHF incidence tended to be higher where residential buildings occupied a high percentage of land, whereas areas with high proportion of ‘office and industrial’ and ‘free space and agriculture’ land use had lower incidence of DHF.

34. In areas of permanent and semi-permanent dwellings, DHF incidence was higher than in the temporary dwellings areas. Water containers inside and around the houses are important factors in DHF transmission due to the abundance of vectors. Education and Socio-economic Factors in Relation to The Mosquito Breeding Site Eradication Program • Respondents with higher education level tend to be more involved in MBSEP. • The economic status of respondents had no relationship with their participation in the MBSEP. • Occupation was found to have no correlation with the participation level of the MBSEP

35. Knowledge, Attitude, Practice (KAP) in the MBSEP • Knowledge of the MBSEP has no relationship with respondent participation in the program. • Respondents attitudes have no relationship towards their participation in the MBSEP. • More respondents in urban area participated more than in the rural area for MBSEP . • Health promotion campaigns have a relationship with the level of knowledge in the MBSEP. • Health Promotion in Mosquito Breeding Site Eradication Program • Media in health promotion in Mosquito Breeding Site Eradication Program • Respondents with low education level prefer greater consultation with health workers.

36. Recommendations • The information of seasonal patterns of DHF incidence can be useful in preparing of DHF control programs to prevent an outbreak. • It is necessary to strengthen socio-environmental intervention through several efforts as follows: • Healthy housing condition with sufficient water supplies and solid waste disposal. • Use biological control • Intensive health promotion program that emphasises and encourages people to participate in preventive programs such as the “3M Plus” reduction of mosquito breeding sites program (PSN)

37. Recommendations • Collaboration is needed between health sectors, other institutions and the community targeted by the MBSEP activities • Further studies: more comprehensive study designs taking into account the location of water containers inside or around the house and the abundance of dengue vectors in the wet and dry seasons. Other climate factors such wind, heat and lighting (sun) should be considered in future research.

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