FACTORS ASSOCIATEDWITH THE PATTERN OF

DENGUE HAEMORRHAGIC FEVER (DHF) INCIDENCE IN

INDONESIA

ERMI NDOEN1), TITIK RESPATI 1),

PUSPARINI2), ANA M LIMBONG2), BAYU AJI2)

Indonesian Dengue in the Media

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

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

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.

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.

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).

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).

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

ObjectivesTo 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.

Areas of Study

Deli SerdangDeli Serdang

JakartaJakarta

Indonesia at a Glance• Area: 1,919.4 sq km• Population (2003): 235 million; • 100 Distinct ethnic groups.

Data collection

1. The monthly data of DHF cases from each sub district collected from DHF surveillance data.

2. The monthly meteorological data (temperature, rainfall, rain day and humidity) obtained from weather monitoring station.

3. The population density, land use and dwellings type data data obtained from The Indonesian Statistics Bureau (BPS).

4. Type of water containers obtained from DHF survey in in selected areas.

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

ClimateTemperature, Humidity,

Rainfall, Rain day, Precipitation and Extreme weather

events

EcologyVegetation, Soil

moisture, and Land use

Transmission BiologyVector reproduction/

movement

Social FactorsVector control,

Travel/migration, Behavior, Population,

Basic sanitation

Disease OutcomeRate of transmission,

Incidence Rate

THEORITICAL FRAMEWORK

Research Framework

Weather condition: Land Use

– Rainfall– Temperature – Humidity

DHF Cumulative

Incidence

Demographic condition:

- Population density

- Migration

Control Activity

Number of DHF Cases and Infected Areas in Indonesia (1968 –2003)

IR p

er 1

00,0

00

No

of C

ity/D

istr

icts

Inf

ecte

d

Incidence Rate (IR)No of Infected Areas

Dengue (DHF) Outbreak in Indonesia (2004)

Outbreak areas

Potential Outbreak areas

The Spatial Distribution DHF

Incidences in West Jakarta

The Spatial Distribution of DHF Incidence in Central Jakarta

1

84

7

2

9

6 203

40

15

5

16

13

23

41

33

18

37

14

43

10

24

27

1231 29

39

17

32

28

2126

19

38

11

22

35

30

3634

25

4244

1

84

7

2

9

6 203

40

15

5

16

13

23

41

33

18

37

14

43

10

24

27

1231 29

39

17

32

28

2126

19

38

11

22

35

30

3634

25

4244

1

84

7

2

9

6 203

40

15

5

16

13

23

41

33

18

37

14

43

10

24

27

1231 29

39

17

32

28

2126

19

38

11

22

35

30

3634

25

4244

1

84

7

2

9

6 203

40

15

5

16

13

23

41

33

18

37

14

43

10

24

27

1231 29

39

17

32

28

2126

19

38

11

22

35

30

3634

25

4244

119979 7 1998

1999 2000

1

84

7

2

9

6 203

40

15

5

16

13

23

41

33

18

37

14

43

10

24

27

12

31 2939

17

32

28

2126

19

38

11

22

35

30

3634

25

42

44

1

84

7

2

9

6 203

40

15

5

16

13

23

41

33

18

37

14

43

10

24

27

12

31 2939

17

32

28

2126

19

38

11

22

35

30

3634

25

42

44

1

84

7

2

9

6 203

40

15

5

16

13

23

41

33

18

37

14

43

10

24

27

1231 29

39

17

32

28

2126

19

38

11

22

35

30

3634

25

4244

220011 220022

2003

Category: Low Middle High Very High

1998

1999 2000

2003

Climate Factors and DHF Incidence (West Jakarta)

Climate Factors Spearman R Square P ValueCoefficient correlation

Average Temperature -0.075 0.0056 0.573Relative Humidity 0.468** 0.219 0.000

Number of rainy days 0.436** 0.1901 0.001Average Daily Rainfall 0.469** 0.2200 0.000

.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60

0

5

10

15

20

25

30

DHF Incidence Temperature Relative Humidity No. of Rainy Day Daily Rainfall

Rainfall, rainy days & humidity had positive relationship with DHF incidence

Temperature had no significance relationship with DHF incidence

Population Density and DHF Incidence (West Jakarta)

  (< 13568 people/km2)

(-48.32 – 27.66) 96.672. Low

0.585-10.329(> 13568 people/km2)

  86.341. High

Mean Diffe-rence

Mean

P value (95% CI)

DHF Cum IncCategory of Population

Density Area

Land Use and DHF (West Jakarta)

(-25.69 – 14.71) 66.35 - Low (< 0.095%)0.588-5.4960.86 - High (> 0.095%)

   3. Free & Agriculture

(-34.62 – 5.08) 70.99 - Low (< 11.17%)

0.142-14.7756.22 - High (> 11.17%)

   2. Office & Industry

(-5.83 – 33.95) 56.57 - Low (< 72.32%)0.16214.0670.63 - High (> 72.32%)

   1. Residential

Mean Diffe-rence

MeanLand Use AreaP value

(95% CI)

DHF Cum IncidenceCategory of

Dwellings Type and DHF (West Jakarta)

(-39.53 – -0.52) 73.61 - Low (< 9.25%)

0.071-20.0253.59 - High (> 9.25%)

   3. Temporary

(-13.64 – 26.71) 60.34 - Low (< 24.87%)

0.5196.5366.87 - High (> 24.87%)

   2. Semi Permanent

(-13.75 – 26.60) 60.39 - Low (< 65.52%)

0.5266.4366.81 - High (> 65.52%)

   1. Permanent

Mean Difference

MeanDwelling TypeP value (95% CI)

DHF Cum IncidenceCategory of

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

Gelora

GambirCideng

Menteng

Pasar Baru

Senen

Kenari

Kebon Sirih

Cikini

Sumur Batu

Johar Baru

Pegangsaan

Paseban

Kramat

Duri Pulo

KaretTengsin

Serdang

Bendungan Hilir

Cempaka Baru

Kebon Melati

Gn.Sahari Utara

Cemp. Putih Timur

Rawa Sari

Kebon Kelapa

Kampung Bali

Petojo Utara

Kartini

Petamburan

Cemp. Putih Barat

Gondangdia

Mangga 2 Selatan

Gn.Sahari Selatan

Kwitang

Petojo Selatan

Karang Anyar

Kebon Kosong

Tanah Tinggi

Bungur

Galur

Kebon Kacang

Utan Panjang

Harapan Mulia

Kemayoran

Kampung Rawa

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Cumulative Incidence 30 - 6768 - 9293 - 123124 - 174175 - 256

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

0

5

10

15

20

25

30

35

40

45

50

Jan-

99

Mar

-99

May

-99

Jul-9

9

Sep

-99

Nov

-99

Jan-

00

Mar

-00

May

-00

Jul-0

0

Sep

-00

Nov

-00

Jan-

01

Mar

-01

May

-01

Jul-0

1

Sep

-01

Nov

-01

Jan-

02

Mar

-02

May

-02

Jul-0

2

Sep

-02

Nov

-02

Jan-

03

Mar

-03

May

-03

Jul-0

3

Sep

-03

Nov

-03

Month

DH

F C

I

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… ”

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

Typical water containers in Indonesia that can be potential breeding place for

dengue mosquitoes

Typical Water Containers in Rural Area

MBSEP of Respondents in two areas in Deli Serdang District

39%

17%

61%

83%

Urban Rural

Participated Not participated

(2 = 12.6; df = 1; p = 0.00; = 0.1) = Significant

MBSEP = Mosquito Breeding Site Eradication Program

Education No Variable High Low

P Value

OR (CI)

Comment

High 105

(80 %) 44

(63 %)

Low 25 (20 %)

26 (27 %)

1.

Knowledge

Total 130 (100 %)

70 (100 %)

0. 006 2.482 (1.764 - 4.764)

Significant

Good 85

(65 %) 40

(57 %)

Poor 45 (35 %)

30 (42 %)

2. Attitude

Total 130 (100 %)

70 (100 %)

0.251 1.417 (0.781 – 2.570)

Not Significant

Participated 43 (33 %)

14 (20 %)

Not Participated

87 (67 %)

56 (80 %)

3. Practice

Total 130 (100 %)

70 (100 %)

0.051 1.977 (0.991 – 3.943)

Significant

Education No Variable High Low

P Value

OR (CI)

Comment

High 105

(80 %) 44

(63 %)

Low 25 (20 %)

26 (27 %)

1.

Knowledge

Total 130 (100 %)

70 (100 %)

0. 006 2.482 (1.764 - 4.764)

Significant

Good 85

(65 %) 40

(57 %)

Poor 45 (35 %)

30 (42 %)

2. Attitude

Total 130 (100 %)

70 (100 %)

0.251 1.417 (0.781 – 2.570)

Not Significant

Participated 43 (33 %)

14 (20 %)

Not Participated

87 (67 %)

56 (80 %)

3. Practice

Total 130 (100 %)

70 (100 %)

0.051 1.977 (0.991 – 3.943)

Significant

The Relationship between Respondents’ Level of Education with Knowledge, Attitude and Practice in

Mosquito Breeding Site Eradication Programs (MBSEP)

Occupation No Variable Employed Unemployed

P Value

OR (CI)

Comment

High 57 (77 %)

92 (73 %)

Low 17 (23 %)

34 (27 %)

1.

Knowledge

Total 74 (100 %)

126 (100 %)

0. 530

1.239

(0.634 – 2.420)

Not Significant

Good 56 (75 %)

69 (55 %)

Poor 18 (25 %)

57 (45 %)

2. Attitude

Total 74 (100 %)

126 (100 %)

0.003

2.570

(1.360 – 4.857)

Significant

Participated 23 (31 %)

34 (27 %)

Not Participated

51 (69 %)

92 (73 %)

3. Practice

Total 74 (100 %)

126 (100 %)

0.535

1.220

(0.650 – 2.292)

Not Significant

Occupation No Variable Employed Unemployed

P Value

OR (CI)

Comment

High 57 (77 %)

92 (73 %)

Low 17 (23 %)

34 (27 %)

1.

Knowledge

Total 74 (100 %)

126 (100 %)

0. 530

1.239

(0.634 – 2.420)

Not Significant

Good 56 (75 %)

69 (55 %)

Poor 18 (25 %)

57 (45 %)

2. Attitude

Total 74 (100 %)

126 (100 %)

0.003

2.570

(1.360 – 4.857)

Significant

Participated 23 (31 %)

34 (27 %)

Not Participated

51 (69 %)

92 (73 %)

3. Practice

Total 74 (100 %)

126 (100 %)

0.535

1.220

(0.650 – 2.292)

Not Significant

Relation between Occupation and KAP

Economic No Variable High Low

P Value

OR (CI)

Comment

High 111 (76 %)

38 (70 %)

Low 35 (24 %)

16 (30 %)

1.

Knowledge

Total 146 (100 %)

54 (100 %)

0. 415

1.335 (0.665 – 2.680)

Not Significant

Good 93 (63 %)

32 (59 %)

Poor 53 (37 %)

22 (41 %)

2. Attitude

Total 146 (100 %)

54 (100 %)

0.565

1.206 (0.637 – 2.286)

Not Significant

Participated 45

(30 %) 12

(22 %) Not Participated

101 (70 %)

42 (78 %)

3. Practice

Total 146

(100 %) 54

(100 %)

0.232

1.559 (0.750 – 3.241)

Not Significant

Relation Between Economic Status and KAP

Health Promotion

No

Variable Had ever

heard

Never heard

P

Value

OR (CI)

Comment

High 44 (83 %)

105 (71 %)

Low 9 (17 %)

42 (29 %)

1.

Knowledge

Total 53 (100 %)

147 (100)

0. 097

1.956

(0.877 – 4.358)

Significant

Good 38 (71 %)

87 (59 %)

Poor 15 (29 %)

60 (41 %)

2. Attitude

Total 53 (100 %)

147 (100)

0.107

1.747

(0.883 – 4.456)

Not Significant

Participated 16

(30 %) 41

(27 %) Not Participated

37 (70 %)

106 (73 %)

3. Practice

Total 53 (100 %)

147 (100)

0.751

1.118

(0.562 – 2.225)

Not Significant

Relationships Between Health Promotion and KAP

TV

TV

RadioRadio

Health Worker

Health Worker

News paper

News paper

0%

10%

20%

30%

40%

50%

60%

70%

80%

Kenangan Tembung

The Preferences of Health Promotion Media for DHF in Deli Serdang District, North

Sumatera - Indonesia

(Urban area) (rural area)

Conclusions1. Dengue Haemorrhagic Fever (DHF) is one of the most important

communicable diseases occurs in urban areas such as Jakarta.

2. DHF incidence is associated with relative humidity, number of

rainy days and average daily rainfall.

3. Analysis of population density and DHF incidence at sub-district

level indicates that DHF incidence was high in low population

density areas.

4. 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.

• 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

5. In areas of permanent and semi-permanent dwellings,

DHF incidence was higher than in the temporary

dwellings areas.

6. Water containers inside and around the houses are

important factors in DHF transmission due to the

abundance of vectors.

7. Education and Socio-economic Factors in Relation

to The Mosquito Breeding Site Eradication Program

• Health promotion campaigns have a relationship with the level of knowledge in the MBSEP.

• Respondents with low education level prefer greater consultation with health workers.

• 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 .

Knowledge, Attitude, Practice (KAP) in the MBSEP

Health Promotion in Mosquito Breeding Site

Eradication Program

Media in health promotion in Mosquito

Breeding Site Eradication Program

Recommendations1. The information of seasonal patterns of DHF

incidence can be useful in preparing of DHF control programs to prevent an outbreak.

2. 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)

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.

THANK YOU