The Difficulty of Controlling and Preventing Dengue Outbreaks in

Latin America and the Caribbean:

A Multiple Perspective Analysis

Kimberly Boekhoudt
Global Health & Inequality
International Development Studies
University of Amsterdam
Contents

Introduction 3
The role of the climate changes in dengue outbreaks 4
Other factors contributing to dengue outbreaks 6
Recommendations for prevention 8
Conclusion 10
Reference List 12

2
Introduction

Dengue is one of the many neglected diseases in this world. Despite it causing a major burden
on the lives of those living in Africa, Asia and Latin America for decades, not much attention
has been paid to this disease and its prevention neither on a global level nor on a local level.
Since the last years more attention has been paid to the climate changes and the role it is
playing in the outbreaks of diseases such as dengue.
In this paper I will discuss the disease of dengue primarily in the region of Latin
America and the Caribbean. The main question I will try to answer is: What are the reasons
behind the difficulties of controlling and preventing dengue outbreaks in Latin America and
the Caribbean?
I think that it’s relevant to look at a disease such as dengue from a multiple perspective
in order to understand it and to come up with solutions in order to prevent future outbreaks.
Being from this region myself and experiencing dengue up close and the effects it can have on
a person, makes it even more of an important issue to tackle.
In the next chapters following the introduction I will try to answer the main question
asked above. This will be done by breaking down the main question into three sub-questions:
first, what is the role of the climate changes in the dengue outbreaks; second, besides the
climate changes, what other factors are contributing to an outbreak; and third, how can a
future outbreak be prevented?
In the first chapter I will discuss dengue and the role that the climate changes are
playing in its outbreaks. In the second chapter I will take a look at dengue from a more
political, economic and social-cultural perspective. In the third chapter I will discuss the
different ways in which a future dengue outbreak could and should be prevented. And last but
not least, in the conclusion I will conclude this paper and give an answer to the main question
asked above.

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The role of the climate changes in dengue outbreaks

Dengue is one of the many neglected diseases that are causing a major burden on the people
living in the region of Latin America and the Caribbean. The tropical environment and
temperatures encountered in Latin America and the Caribbean are ideal for diseases such as
dengue. Despite the primary vector of dengue, the Aedes aegypti mosquito, being eradicated
in the period of 1950s to approximately 1970s, dengue outbreaks have been reemerging in this
region since late 1960s. Most recent data state that in the year 2008 an estimate of 908.926
cases of dengue have been clinically reported in this region with a total of 25.696 cases of
DHF and 306 deaths (PAHO).
The reemergence of dengue outbreaks has been due several factors. In this chapter the
role of the climate changes will be discussed, but first we will take a look at what exactly is
dengue and what effects it can have on a person.
Dengue is an infectious tropical disease that is produced by the dengue virus (DENV).
This virus consists of 4 serotypes: DENV-1, DENV-2, DENV-3 and DENV-4. These
serotypes have all spread across the Latin American continent and the Caribbean throughout
the years.
The infectious disease of dengue is transmitted through mosquitoes, mainly two types:
Aedes aegypti and Aedes albopictus. The Aedes aegypti is the principal vector of dengue.
There are two ways in which a person can get infected. First, a mosquito bites someone who
is infected with the dengue virus and takes in his/her blood. This blood will be stored in a
mosquito for a total of 8 to 12 days. After this the mosquito begins to transmit the dengue
virus through biting other people. A second way of transmitting the dengue virus is when a
mosquito interrupts his alimentation on an infected person and goes directly to another
person, vulnerable host, to feed himself.
An infected person can experience symptoms of the dengue virus within 5 to 7 days.
The workings of the dengue virus can be spread out in 3 stages, first a fever stage, then a
critical stage and last rehabilitating stage. The fever stage lasts 2 to 7 days and it can come
together with physical pain. During this time dehydration is a major threat. If a person gets
better after the fever drops, then it is considered a case of dengue with no alarming signs. The
critical stage is when the fever descends to 37.5 Celsius degrees or less and it stays at this
level in the first 3 to 7 days. This can increase the vessel permeability simultaneously with the
levels of blood. During this time serious problems can occur such as bleeding and it can turn

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into a serious case of dengue. The critical stage lasts up to 48 to 72 hours. If a person doesn’t
get better when the fever drops and alarming signs present themselves, then it is considered a
case of dengue with alarming signs. The rehabilitation stage starts when a person survives the
critical stage and starts feeling better.
Next to the four serotypes of the dengue virus, we can also find a more serious variant
the dengue hemorrhagic fever (DHF) that can cause a more serious case of dengue. It has
effects like difficulty breathing, major blood loss, abdominal pain, severe vomiting and severe
effects on organs. In this case a medical intervention is necessary immediately. Without
medical intervention a person can die within 24 hours. This variant of dengue has become a
major concern due to the rapid increase of cases of DHF encountered in the last years.
As we’ve seen the dengue virus is transmitted through mosquitoes. Mosquitoes are
primarily found in great numbers during raining seasons in the second semester of the year in
the area of Latin America and the Caribbean. But in the year 2010 there were also an increase
in cases of dengue registered in the dry season in Honduras, Salvador and Guatemala
(PAHO). The climate phenomenon El Niño/La Niña in the region of Latin America and the
Caribbean has contributed greatly to these climate changes and its effects. Extreme weather
events due to El Niño/La Niña, such as hurricane, floods and tsunami’s, have also contributed
to the spreading of the dengue disease.
Global climate changes, such as increased precipitation, increased sea levels and the
warming of the ocean waters are playing a major role in the reproduction capacity of these
mosquitoes due to their sensitiveness to temperature changes. An increase in raining season
also means an increase in plants and their migration to other areas. Mosquitoes are found in
areas with lots of plants and water where they breed themselves, thus the migration of plants
leads to a migration of the mosquitoes to other parts that were not affected before.
Climate changes have thus played a major role in the spreading and adaptation of the
dengue virus. As mentioned in the article ‘The growing burden of dengue in Latin America’,
climate change has contributed to the development of an even more suitable environment for
the vector survival and disease transmission (Tapia-Conyer et al, 2009, S5). People living in
poverty are the ones more affected and the ones who experience more severe health effects
from these climate changes.

5
Other factors contributing to dengue outbreaks

As we’ve seen in the previous chapter, climate changes have played an important role in
dengue outbreaks in the last decades. In this chapter we will take look at other important
factors that are also contributing to dengue outbreaks. Factors such as economic, political and
socio-cultural conditions in Latin America and the Caribbean play an important role.
Poverty is one of the major factors behind the spreading of the dengue disease in this
region. The majority of the population in Latin America is poor and live in great poverty. One
of the key words when discussing poverty in Latin America is urbanization. Compared to the
rapid growth in urbanization in the Asian and African countries, their current percentage of
percentage of people living in urban areas is still half of that for Latin America (Cerrutti and
Bertoncello, 2003: 2). An estimated three quarters of the population in Latin America live in
urban areas. In Argentina, for an example, in the 1950s 63 percent of the population lived in
urban areas, while in the 2000s 90% of the population lived in urban areas (ECLAC). The
problem of urbanization also exists in the Caribbean in islands such as the Dominican
Republic. Here a great deal of the population is concentrated along the ports and the cities
living in houses crowded with people (Whiteford, 1997: 209).
The process of urbanization started early on in the history of Latin America. Between
the 1930s and 1970s, during the Import Substitution Industrialization (ISI) period, the
majority of the population in Latin American countries migrated to the cities. With the
migration of people, diseases also migrated to the cities. The concentration of the population
living and the population growth in the urban areas increased drastically. This development
and the failed attempt to change the economic situation during the ISI period, the ‘lost
decade’ of the 1980s and the consequences of neo-liberalism since the 1990s have taken its
toll on the majority of the population living in urban areas. The migration to the urban areas in
the cities has not offered the majority of the population a solution to their economic situation.
Instead the majority of the population ended up living in shanty towns near the cities. Poverty
and income inequality have become a major burden on the lives of those living in these areas.
Overcrowding, the accumulation of trash and poor sanitation in the urban areas have lead to
unsanitary, poor living conditions for humans and the perfect environment for diseases such
as dengue to reemerge and spread themselves. Human adaptations to these urban
environments have enhanced the spread of disease (Kendall et al, 1991: 258). Most of the
population doesn’t have access to fresh clean water at their homes and instead store water in

6
big containers that are not always covered. This makes it a perfect breeding place for
mosquitoes.
The vector of dengue transmission, compared to the vector for malaria transmission, is
concentrated primarily in periurban domestic settings (Whiteford, 1997: 203). In the urban
areas the Aedes aegypti mosquito has adapted itself to the conditions encountered there and
can pretty much breed itself in different places and things containing relatively clean water,
such as manufactured receptacles, water storage containers, bottles, tires or flowerpots
(Kendall et al, 1991: 260). This makes it difficult to control the spread of the disease’s
primary vector mosquito. In the next chapter we’ll discuss the different alternatives for
controlling and eliminating the Aedes aegypti mosquito.
In Latin America and the Caribbean the economic situation of a country and politics
play an important role in not improving the situations in the urban areas. One of the main
reasons could be lack of money to do so, but in most of the cases it’s a lack of political will to
address the current situation and try to improve it. In some countries a very small piece of the
country’s GDP is spent on improving water and sanitation situation or on health services.
Inadequate financial resources make it difficult to control diseases in general and dengue is no
exception. While in other countries there’s no money to be spend on improving the situation.
With no money it is difficult to introduce prevention programs or surveillance systems to keep
an eye on the expansion of the disease through collecting data and monitoring its evolution,
because equipment and personnel is needed. Another issue is the lack of health centers in
areas in which they are needed. Many of the cases of dengue pass by without ever being
detected and are underreported. In the period of 2000-2007 5.6 million cases were
underreported (Shepard et al, 2011: 202). As mentioned in the previous chapter, the primary
dengue vector has already been eradicated once, but with the reemergence of it little has been
done to address it as soon as possible in order to prevent it from spreading.
Another major factor that indirectly plays an important role in the spread of the dengue
disease is the lack of knowledge that the population has concerning dengue. Not everyone
knows what dengue is and can recognize its symptoms when someone gets sick because of its
similarity with other illnesses. For example, when someone gets a fever, bleeding or
dehydration it is not automatically assumed that it can be a case of dengue. The variety of
diseases and the increase in new diseases in the urban areas makes it difficult to detect. People
can confuse these similarities and think that perhaps it’s another illness; some maybe don’t
even know what dengue is; or think that it’s a simple fever without knowing really that there’s
more behind it.

7
Recommendations for prevention

In this chapter we will take a look at possible solutions or methods that can help to control
and combat dengue outbreaks now and in the future. As illustrated in the report ‘Hemispheric
plan to expand and intensify efforts to combat Aedes aegypti ’, the specific activities of the
health services and control programs are being hindered, to one degree or another, by
economic, political, social and administrative factors (6). Dengue prevention and control are
not the priority, there’s a lack of sustainability to control the vector, lack of
institutionalization, lack of intra- and intersectoral integration and community participation.
The most important issue that needs to be addressed first is making dengue prevention
and control a priority, both on a local level and a global level, so that prevention programs can
be implemented and can have a chance at being successful.
Secondly, there’s an important need to change the unsanitary, poor living conditions in
the urban areas so that the population living there can have a better life and foremost prevent
the spreading of diseases and the emergence of new ones. Better water and sanitation facilities
are required, but also better trash/solid waste disposal facilities; so that we can optimize the
environment for the people living in the urban areas and at the same time minimize the
‘perfect’ environment for the vector to breed. Manufactured receptacles, water storage
containers, bottles and tires were the vector breeds need to be removed.
The use of insecticides can also help to eliminate the breeding sites of the vector. The
application of Lavicides to water deposits, for example, can help disturb or eliminate the
breeding of the vector. In cases of emergencies, there’s also Adulticides that is used primarily
during epidemic outbreaks. But the use of insecticides must be done very careful, keeping in
mind that it can also maybe have an effect on humans and the environment. So insecticides
with low toxicity and little or no environmental pollution are preferred. One negative point in
the use of insecticides is that the vector can in some cases become resistant to insecticides. In
this case continuing research, surveillance and development of new insecticides are required
in order to keep up with the evolution of the vector.
Another way of preventing dengue outbreaks could be the introduction of dengue
vaccines that can block the infection. There is a general consensus that vaccination can be one
of the most cost effective ways to prevent dengue and DHF (Henderson, 1997: 262). Since the
past decades researches have been researching the makings of a possible vaccine for dengue
and DHF. We are now in the year 2011 and still there’s no sign of an introduction and

8
development of dengue vaccines. The most important question to ask is: when will they be
developed? When will a vaccine be developed is not the only issue. When developing a
vaccine, other issues arise like vaccine supply, quality and further support for research
(Henderson, 1997: 243-244). There’s a need for adequate quantity production of quality
vaccines, but also affordable prices so that it can be accessible for everyone not only a small
number of people. The quality of the vaccines must be within international standards. And
furthermore there will always be a need to support further research.
Next to improving living conditions and introducing dengue vaccines, education and
social participation is also needed. The population needs to be educated on what is dengue,
how can it be prevented, and, in case of an introduction of a dengue vaccine, the importance
of vaccination. Education is needed so that people can recognize certain symptoms and search
for treatment. Next to educating the population, human resources of health centers also needs
to be educated and trained so that they can diagnose dengue more effectively and know what
the next steps are that need to be taken in order to handle a case. Social participation, both at
community level and individual level, is also needed so that the population can help to
eliminate the breeding sites of the mosquito vector and prevent the spreading of dengue.
And last but not least there’s a need for collaboration between different actors that can
play a role in improving the situation. The public and private sectors and NGOs should work
together in order to be successful at preventing and eradicating dengue outbreaks. But most
importantly there’s a great need for political will to help change the situation. Without
investing money in education programs, improving water and sanitation facilities and
investing in research, little can be done to improve the situation within the countries and
eliminate future dengue outbreaks. Neglected diseases such as dengue should be given a
higher priority. There should also be more financial resources available for the building of
more health centers in areas where they are needed, so that they could be more accessible for
more people. Thus politicians need to be willing to spend more on healthcare and cover
additional costs in order control and prevent diseases such as dengue and to improve the
quality of living for everyone in the countries.
As cited in the article ‘The growing burden of dengue in Latin America’, “A healthy
population is fundamental to prosperity, security and stability, a cornerstone of economic
growth and social development. In contrast, poor health is a threat to the economic and
political interests of all countries” (Tapia-Conyer et al, 2009: S6).

9
Conclusion

As stated in the introduction, dengue is one of the many neglected diseases that have caused a
major burden on the lives of those living in the region of Latin America and the Caribbean.
The main question of this paper is: What are the reasons behind the difficulties of controlling
and preventing dengue outbreaks in Latin America and the Caribbean? This question has been
answered by looking at the dengue disease from multiple perspectives, such as climate
changes, politics, economics and socio-cultural perspectives.
The climate changes have played an important role in the reemergence and spreading
of the dengue disease. We found that increased precipitation, increased sea levels and the
warming of the ocean waters have contributed to an increase in the reproduction rate of the
mosquito vector. The climate phenomenon El Niño/La Niña and extreme weather events have
also played a major role in spreading the dengue disease in the last decades.
Next to the effects of the climate changes, political, economic and socio-cultural
factors have also contributed to the spreading of the dengue disease. The combination of
urbanization and poverty contributed to unsanitary, poor living conditions for the majority of
the population. Overcrowding, accumulation of trash and poor sanitation have lead to the
reemergence of the dengue disease and the emergence of new diseases. The dengue vector is
mostly found in the periurban areas in places filled with water, such as water storage
containers, tires and flowerpots. The lack of political will and financial resources to invest in
healthcare centers and programs and improve the water and sanitation situation makes it
difficult also contributed. Moreover, a lack of knowledge also makes it more difficult. Not
everyone knows what dengue is in order to understand it, recognize the symptoms and look
for treatment.
Last but not least possible solutions or methods of prevention were introduced for the
control and prevention of future dengue outbreaks. First of all, dengue control and prevention
has to become a priority both on a global level and local level. Secondly, living conditions
need to be improved in the urban areas. The use of pesticides and a future dengue vaccine will
help to improve the situation. Education and social participation need to be promoted to get
the population involved in the process of control and prevention. More importantly, there’s a
need for more political will and financial resources in order change the situation and prevent
future dengue outbreaks.

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 In the end I can conclude that there are various reasons making it difficult to control
and prevent dengue outbreaks in the region of Latin America and the Caribbean. But,
personally, I think that the lack of political will to invest in healthcare, water and sanitation,
and in control and prevention programs is the major reason why it’s difficult to improve the
current and future dengue outbreaks in the countries of Latin America and the Caribbean.

11
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America’
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http://www.eclac.cl/celade/depualc/
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desarrollo en América Latina y el Caribe (2010)
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