, Volume 2, Issue 4, pp 273–290 | Cite as

Barriers and Bridges to Prevention and Control of Dengue: The Need for a Social–Ecological Approach

  • Jerry Spiegel
  • Shannon Bennett
  • Libby Hattersley
  • Mary H. Hayden
  • Pattamaporn Kittayapong
  • Sustriayu Nalim
  • Daniel Nan Chee Wang
  • Emily Zielinski-Gutiérrez
  • Duane Gubler
Original Contributions


This article critically examines how programs for the prevention and control of dengue fever have been conducted in the absence of an integrated approach, and considers the social and ecological factors influencing their effectiveness. Despite recognition of dengue fever as the most important arboviral disease affecting humans, and in spite of a greater emphasis on community-based control approaches, the burden placed on the communities, countries, and regions affected by this disease continues to rise. In considering historical experience in the Americas and the Asia-Pacific region, as well as the global forces that are exerting new pressures, the important elements of successful control programs are identified as community ownership, partnership with government, leadership, scalability, and control of immature mosquitoes. The key barriers to the exchange of knowledge and the transdisciplinary cooperation necessary for sustainable dengue control are rooted in differences in values among policy-makers, citizens, and scientists and are repeatedly expressed in technical, economic, cultural, geographic, and political dimensions. Through consideration of case studies in Cuba, Guatemala, Singapore, Thailand, Indonesia, and Vietnam, the limitations of control approaches that fail to take into account the complexities of ecological and social systems are presented. Bridges to effective control are identified as the basis for adaptability, both of control programs to the mosquito vector’s changing behavior and of education programs to public, regional and local particularities, as well as transdisciplinarity, community empowerment, the ability to scale local experiences up to the macro-level, and the capacity to learn from experience to achieve sustainability.


dengue fever Aedes aegypti mosquitoes social and ecological systems driving forces community-based partnership 



Ideas for this article were developed during a working meeting on social–ecological systems and emerging infectious diseases, hosted by the Asia-Pacific Institute of Tropical Medicine & Infectious Diseases and the East-West Center in Honolulu, Hawaii (March 9–11, 2005). This meeting was supported by a grant to promote methodological innovation in interdisciplinary health research from the National Institutes of Health (R13 TW007300) and funded by the Fogarty International Center and Office of Behavioral and Social Sciences under the NIH Roadmap initiative “Research Teams of the Future.” We acknowledge the efforts of the meeting organizers, and especially other colleagues who played a full role in these discussions that produced the core ideas for the article, including Martin Meltzer, Eileen Shea, and Rainer Sauerborn. Special thanks to Mayee Wong for her valuable contributions to the working group discussions.


  1. Dietz V, Gubler DJ, Ortiz S, Kuno G, Casta-Velez A, Sather GE, et al. (1996) The 1986 dengue and dengue hemorrhagic fever epidemic in Puerto Rico: epidemiology and clinical observations. Puerto Rico Health Sciences Journal 15:201–210Google Scholar
  2. Focks DA (2003) A review of entomological sampling methods and indicators for dengue vectors. Geneva, Switzerland: World Health Organization, p 11. Available: [accessed August 16, 2005]
  3. Gubler DJ (1989) Aedes aegypti and Aedes aegypti-borne disease control in the 1990s: top down or bottom up. American Journal of Tropical Medicine and Hygiene 40:571–578Google Scholar
  4. Gubler DJ, Casta-Valez A (1992) A programme for prevention and control of epidemic dengue and dengue haemorrhagic fever in Puerto Rico and the U.S. Virgin Islands. Bulletin of the Pan American Health Organization 113:2Google Scholar
  5. Gubler DJ, Trent DW (1993) Emergence of epidemic dengue/dengue hemorrhagic fever as a public health problem in the Americas. Infectious Agents and Disease 2:383–393Google Scholar
  6. Gubler DJ, Clark GG (1994) Community-based integrated control of Aedes aegypti: a brief overview of current programs. American Journal of Tropical Medicine and Hygiene 50(Suppl):50–60Google Scholar
  7. Gubler DJ, Clark GG (1996) Community involvement in the control of Aedes aegypti. Acta Tropica 61:169-179CrossRefGoogle Scholar
  8. Gubler D, (1997) Dengue and dengue hemorrhagic fever: its history and resurgence as a global public health problem. In: Gubler D, Kuno G (editors), Dengue and Dengue Hemorrhagic Fever, Wallingford, UK: CAB International, pp 1-21Google Scholar
  9. Gubler D (1998a) Dengue and dengue hemorrhagic fever. Clinical Microbiology Reviews 11:480–496Google Scholar
  10. Gubler DJ (1998b) Resurgent vector-borne diseases as a global health problem. Emerging Infectious Diseases 4:442–450CrossRefGoogle Scholar
  11. Gubler DJ, Meltzer MI (1999) The impact of dengue/dengue hemorrhagic fever on the developing world. Advances in Virus Research 53:35–70CrossRefGoogle Scholar
  12. Gubler DJ (2002) Epidemic dengue/dengue haemorrhagic fever as a public health, social and economic problem in the 21st century. Trends in Microbiology 10:100–103CrossRefGoogle Scholar
  13. Gubler DJ (2004) Cities spawn epidemic dengue viruses. Nature Medicine 10:129–130CrossRefGoogle Scholar
  14. Gubler DJ (2005) The emergence of epidemic dengue fever/dengue hemorrhagic fever in the Americas: a case of failed public health policy. Pan American Journal of Public Health 17:221– 224Google Scholar
  15. Guha-Sapir D, Schimmer B (2005) Dengue fever: new paradigms for a changing epidemiology. Emerging Themes in Epidemiology 2:1-10; DOI:10.1186/1742-7622-2-1 [accessed May 2, 2005]Google Scholar
  16. Gunderson LH (2002) Adaptive dancing: interactions between social resilience and ecological crises. In: Berkes F, Colding J, Folke C (editors), Navigating Social-ecological Systems: Building Resilience for Complexity and Change, Cambridge, UK: Cambridge University Press, pp 33–52Google Scholar
  17. Gunderson LH, Holling CS, Light SS (editors) (1995) Barriers and Bridges to the Renewal of Ecosystems and Institutions, New York: Columbia University Press, pp 3–35Google Scholar
  18. Gunderson LH, Holling CS (2002) Panarchy: Understanding Transformations in Human and Natural Systems, Washington DC: Island Press Google Scholar
  19. Guzman MG, Alvarez M, Rodriquez R, Rosario D, Vazquez S, Vald L, et al. (1999) Fatal dengue hemorrhagic fever in Cuba, 1997. International Journal of Infectious Diseases 3:130–135 CrossRefGoogle Scholar
  20. Guzman MG, Kouri G (2002) Dengue: an update. Lancet Infectious Diseases 2:33–42Google Scholar
  21. Guzman MG, Kouri G (2003) Dengue and dengue hemorrhagic fever in the Americas: lessons and challenges. Journal of Clinical Virology 27:1–13CrossRefGoogle Scholar
  22. Halstead SB (2000) Communicable diseases: successes and failures in dengue controlglobal experience. Dengue Bulletin 24. World Health Organization, Regional Office for South-East Asia. Available: [accessed April 20, 2005]
  23. Holling C (1995) What barriers? What bridges? In: Gunderson LH, Holling CS, Light SS (editors), Barriers and Bridges to the Renewal of Ecosystems and Institutions, New York: Columbia University Press, pp 3–35Google Scholar
  24. Holling C (2001) Understanding the complexity of economic, ecological and social systems. Ecosystems 4:390–405CrossRefGoogle Scholar
  25. Kouri G, Guzman MG, Bravo J (1986) Hemorrhagic dengue in Cuba: history of an epidemic. Bulletin of the Pan American Health Organization 20:24–30Google Scholar
  26. Levin SA (1999) Fragile Dominion: Complexity and the Commons, Reading, MA: Perseus Books Group Google Scholar
  27. Lewis ND (2005) Is the social-ecological framework useful in understanding infectious diseases? The case of HIV/AIDS. EcoHealth 2 (DOI: 10.1007/s10393-005-8477-x, this issue) Google Scholar
  28. Meltzer MI, Rigau-Perez JG, Clark GG, Gubler DJ (1998) Using DALYs to assess the economic impact of dengue in Puerto Rico: 1984–1994. American Journal of Tropical Medicine and Hygiene 59:265–271Google Scholar
  29. Nalim S, Hartono B, Suskamdani dan SW (2002) Community partnership in vector control for dengue. Journal Ekologi Kesehatan 2:19–24Google Scholar
  30. Nam VS, Yen NT, Holynska M, Reid JW, Kay BH (2000) National progress in dengue vector control in Vietnam: survey for Mesocyclops (Copepoda), Micronecta (Corixidae), and fish as biological control agents. American Journal of Tropical Medicine and Hygiene 62:5–10Google Scholar
  31. Nam VS, Kay B, Yen NT, Ryan P, Bektas A (2004) Community mobilization, behaviour change and biological control in the prevention and control of dengue fever in Viet Nam. Dengue Bulletin 28(Suppl):57–61Google Scholar
  32. Nam VS, Yen NT, Phong TV, Ninh TU, Mai LQ, et al. (2005) Elimination of dengue by community programs using Mesocyclops (Copepoda) against Aeges Aegypti in central Vietnam. American Journal of Tropical Medicine and Hygiene 72:67–73Google Scholar
  33. Newton EA, Reiter P (1992) A model of the transmission of dengue fever with an evaluation of the impact of ultra-low volume (ULV) insecticide applications on dengue epidemics. American Journal of Tropical Medicine and Hygiene 47:709–720Google Scholar
  34. Ooi EE, Goh KT, Gubler DJ (2005) Singapore’s 35 year experience with dengue prevention: is vector control effective? Emerging Infectious Diseases (in press) Google Scholar
  35. PAHO (1994) Dengue and Dengue Haemorrhagic Fever in the Americas: Guidelines for Prevention and Control, Scientific Publication No. 548, Washington, DC: World Health Organization/Pan American Health Organization 548Google Scholar
  36. Parks WJ, Lloyd LS (2004) Planning Social Mobilization and Communication for Dengue Fever Prevention and Control: a Step-by-Step Guide, Geneva: World Health OrganizationGoogle Scholar
  37. Parks WJ, Lloyd LS, Nathan MB, Hosein E, Odugleh A, Clark GG, et al. (2004) International experiences in social mobilization and communication for dengue prevention and control. Dengue Bulletin 28(Suppl):1–7Google Scholar
  38. Pinheiro FP, Corber SJ (1997) Global situation of dengue and dengue hemorrhagic fever, and its emergence in the Americas. World Health Statistics Quarterly 50:161Google Scholar
  39. Reiter P, Lathrop S, Bunning M, Biggerstaff B, Singer D, Tiwari T, et al. (2003) Texas lifestyle limits transmission of dengue virus. Emerging Infectious Diseases 9:86–89Google Scholar
  40. Renganathan E, Parks W, Lloyd L, Nathan MB, Hosein E, Odugleh A, et al. (2003) Towards sustaining behavioural impact in dengue prevention and control. Dengue Bulletin 27:6–12Google Scholar
  41. Rifkin SB (1996) Paradigms lost: towards a new understanding of community participation in health programs. Acta Tropica 61:79–92CrossRefGoogle Scholar
  42. Rigau-Pérez JG, Clark GG, Gubler DJ, Reiter P, Sanders EJ, Vorndam AV (1998) Dengue and dengue hemorragic fever. Lancet 352:971–977Google Scholar
  43. Sanchez L, Perez D, Pérez T, Sosa T, Cruz G, Kouri G, et al. (2005) Intersectoral coordination in Aedes aegypti. A pilot project in Havana City, Cuba. Tropical Medicine and International Health 10:82–91CrossRefGoogle Scholar
  44. Schliessman DJ, Calheiros LB (1974) A review of the status of yellow fever and Aedes aegypti eradication programs in the Americas. Mosquito News 34:1–9Google Scholar
  45. Shepard DS, Suaya JA, Halstead SB, Nathan MB, Gubler DJ, Mahoney RT, et al. (2004) Cost-effectiveness of a pediatric dengue vaccine. Vaccine 22:1275–1280CrossRefGoogle Scholar
  46. Soper FS, Wilson DB, Servulo L, Waldemar SA (1943) The Organization of Permanent Nationwide anti-Aedes aegypti Measures in Brazil, New York: The Rockerfeller FoundationGoogle Scholar
  47. Spiegel JM, Yassi A, Tate R (2002) Dengue in Cuba: mobilization against Aedes aegypti. Lancet Infectious Diseases 2:207–208Google Scholar
  48. Speigel JM, Bonet M, Tate GM, Ibarra AM, Tate B, Yassi A (2004) Building capacity in central Havana to sustainably manage environmental health risk in an urban ecosystem. EcoHealth 1(Suppl 2):120–130Google Scholar
  49. WHO (1997) Dengue Haemorrhagic Fever: Diagnosis, Treatment, Prevention and Control, 2nd ed., Geneva: World Health OrganizationGoogle Scholar
  50. WHO (1999) Prevention and Control of Dengue and Dengue Haemorrhagic Fever – Comprehensive Guidelines. WHO Regional Publication, SEARO No. 29. New Delhi: WHO Regional Office for South-East AsiaGoogle Scholar
  51. WHO (2001) Report of the Consultation on Key Issues in Dengue Vector Control, toward the Operationalization of a Global Strategy, Geneva: World Health OrganizationGoogle Scholar
  52. Wilcox BA, Colwell RR (2005) Emerging and re-emerging infectious diseases: biocomplexity as an interdisciplinary paradigm. EcoHealth 2 (DOI: 10.1007/s10393-005-8961-3, this issue) Google Scholar
  53. Wilcox BA, Gubler DJ (2005) Disease ecology and the global emergence of zoonotic pathogens. Environmental Health and Preventive Medicine 10:263–272CrossRefGoogle Scholar
  54. Zielinski-Gutierrez E (2002) Evaluating the Sustainability of a Community-based Prevention Intervention in Escuintla, Guatemala: Tulane UniversityGoogle Scholar

Copyright information

© EcoHealth Journal Consortium 2005

Authors and Affiliations

  • Jerry Spiegel
    • 1
  • Shannon Bennett
    • 2
  • Libby Hattersley
    • 3
  • Mary H. Hayden
    • 4
  • Pattamaporn Kittayapong
    • 5
  • Sustriayu Nalim
    • 6
  • Daniel Nan Chee Wang
    • 7
  • Emily Zielinski-Gutiérrez
    • 8
  • Duane Gubler
    • 2
  1. 1.Liu Institute for Global IssuesUniversity of British ColumbiaVancouverCanadaV6T 1Z2
  2. 2.Asia-Pacific Institute of Tropical Medicine and Infectious DiseasesUniversity of HawaiiHonolulu
  3. 3.Global Health Research ProgramUniversity of British ColumbiaVancouverCanada
  4. 4.CU Trauma Center, NISSCUniversity of ColoradoColorado Springs
  5. 5.Center for Vectors and Vector-Borne Diseases and Department of Biology, Faculty of ScienceMahidol UniversityBangkokThailand
  6. 6.Vector and Reservoir Control Research UnitNational Institute of Health Research and DevelopmentCentral JavaIndonesia
  7. 7.National Environment AgencySingaporeSingapore
  8. 8.Division of Vector-Borne Infectious DiseasesCenters for Disease Control and PreventionAtlanta

Personalised recommendations