Dengue Reduction through Vector Control

Abstract

Dengue fever is a disease transmitted by the mosquito aegypti. There is a secondary vector: Aedes albopictus with some epidemiological importance in the transmission of dengue. Pharmacological treatment for dengue is a palliative treatment for the disease and there is an absence of a universally accepted vaccine for the different clinical infections. In these circumstances, the interruption of the infection cycle is possible basically through the reduction of the Aedes aegypti, reducing its breeding sites or physically reducing its population through chemical or biological means. Traditional approaches to vector control are becoming less effective as a result of the combination of resistance to insecticides and the logistic complexity of covering increasingly large urban centers with the same number of health workers as in past decades. Experiences in different countries reflect the need to involve more actively families and communities in the reduction of breeding sites. Several innovations have been introduced using biological methods, physical control of sources, and involvement of families and schools in vector control. The possibility to scale up successful experiences requires a joint effort of governments and communities to tackle mosquito source reduction and add a multipurpose concept of domestic hygiene.

1. Introduction

Dengue fever is a viral infection transmitted by a mosquito. Different studies calculate that 3900 million people are living at risk of contracting a dengue infection. According to model-based estimations every year, there are 390 million infections caused by the dengue virus, and from those 96 million present clinical manifestations ranging from very mild to extremely severe and life threatening [1].

Dengue fever is endemic of tropical and subtropical regions where weather conditions favor the presence of its vector A. aegypti mosquitoes and its alternative vector Aedes albopictus with more prevalence in Asia but is now also present in the Americas. In these regions, the contrasting conditions of rainfall and severe lack of accessible water supply enable the presence of breeding sites in artificial containers filled by the rainfall during the rainy season and water reservoirs kept by the population to assure its access during the severe dry season (tropical summer) [2, 3]. Interestingly enough, natural conditions and human behaviors induced by the need to have access to reliable water supply are the catalyzers to the presence of high densities of A. aegypti mosquitoes and as a consequence the transmission of dengue fever [4], which is explained in its clinical characteristic elsewhere in this book.

Dengue is caused by a family of viruses (flavivirus) that are carried by the A. aegypti females from infected human hosts to healthy but susceptible human hosts (ready to be infected) that establish a cycle of human-mosquito-human that repeats constantly keeping the viral activity and its transmission in the population [2, 3].

The transmission cycle cannot be interrupted by curative drugs (to reduce the number of cases of dengue infection), prevention through vaccines has been tried but after unsuccessful attempts to introduce effective vaccines, the pharmaceutical industry continues to work in safe vaccines without definite results [5].

The only alternative currently, as was the case a century ago, is to interrupt the transmission by reducing the population of A. aegypti through the elimination of the adults and immature forms (eggs, larvae, and pupae) or by making an effort to reduce the breeding sites through improving sanitation measures in human dwellings and peridomestic areas. In the 1920s, there was an extraordinary effort to eliminate the vector A. aegypti completely based on the destruction of breeding sites, the results were impressive in the areas it occurs under the leadership of Dr. Fred Sopper, but it was not complete and now, the objective is the reduction of Aedes populations rather than complete eradication [6].

In the Public Health field, there is a current tendency to integrate the different programs in more comprehensive approaches where local health actions are useful to get more objectives completed in large thematic areas such as environmental health improving the access to water, optimizing the refuse systems, and the beautification of peridomestic areas in the different neighborhoods.

Vector control in the twenty-first century requires not only a clear government commitment to this activity but a convinced and active population participating in the different required tasks.

This chapter then discusses strategies for population reduction through vector control.

2. Type of A. aegypti breeding sites

A. aegypti is the primary vector for dengue fever as well as responsible for the transmission of other diseases such as yellow fever, zika, and chikungunya that have produced epidemics throughout recent history. And most of this chapter will discuss about its control [1, 7].

The A. aegypti mosquito in its life cycle goes through immature stages to mature or adult stages (Figure 1).

Figure 1.

Life stages of Aedes aegypti and Aedes albopictus from US CDC. https://www.cdc.gov/mosquitoes/about/life-cycles/aedes.html.

The female mosquito is responsible for the transmission of dengue since in her need to obtain human protein to form eggs bites human hosts and feeds in their blood and at the same time inoculates the dengue virus. Once the female is fed is ready to complete the egg formation and lay in deposits with water where it can remain viable for days to months, once the egg hatches it becomes larvae for 4–5 days before evolving into pupae, and this stage is previous to the adult one that is reached in two days.

The immature stages then include eggs, larvae (instar I through 4), and pupae that are aquatics. The immature stages require deposits with water where these stages can be complete—those deposits are called breeding sites.

Historically, breeding sites for A. aegypti have been classified as: discardable and water storage containers. The discardable are usually those that are kept or thrown in peridomestic areas of the household and usually do not have an economic or utilitarian value and are the product of deficiencies in the refuse systems and/or behaviors to retain articles assuming a future use.

Discardable containers become more important during the rainy season because of their abundance in the patio; the propensity to fill with small volumes of rain and the possibility to collect water during consecutive days of rainfall. Their role as breeding sites is completed during periods of rain remissions when the female mosquitoes can lay eggs and those already in the deposits can hatch and produce the larvae forms [8, 9].

The water storage containers exist in the patios as a result of deficiencies in the regular supply of water to the households and the resulting behavior of the families to keep water collected from rain, water stream, or the water supply service when there is a chance to obtain it [9, 10]. It is worthy to mention that some discardable containers are kept in the patios with the expectation to assign a function in the future. Used tires are an example of containers with potential subjective use [11].

A third category of containers is the natural reservoirs like the leaves of some ornamental plants (bromeliads), or tree holes in the patios [8].

3. Control methods

Traditional control has been based on two strategies: reducing discardable containers and using larvicides in those water storage containers. These approaches target the vector in its immature and/or adults’ stages. These methods have to do with the use of chemical products: larvicides when directed to larvae or adulticides when the mature stages are targeted.

In the last twenty years, formulations with chlorine by itself or in combination with detergents have been used in different countries in America [12, 13]. In Honduras, there were assays with sodium chlorine (kitchen salt) and limestone to modify the environment of containers like tires to make unlikely the hatching of viable eggs into larvae [14].

4. Adulticides and Larvicides

According to the World Health Organization (WHO) there are several types of vector control insecticides, divided into the following classes: organochlorines, organophosphates, carbamates, pyrethroids, bacterial larvicides, insect growth regulators and newly developed types such as neonicotinoids, spinosyns, and pyrroles [15].

Vector control programs directed to A. aegypti act to neutralize the adult populations using adulticides based on chemical products with an organophosphate or pyrethroid or carbamates and in the past, it was more popular to use organochlorine like DDT that has been gradually withdrawn in many countries based on environmental considerations being in use in areas of Africa and Southeast Asia with adequate results.

In the different regions, there has been an standardization of the methods to apply insecticides: residual spraying, space spraying, ITNs, treatment of nets (ITN-kits), and larviciding. Residual spraying a popular and commonly used method can be conducted indoors or outdoors. Indoor residual spraying consists of the application of residual insecticide products on indoor surfaces (e.g. walls) to kill vectors landing or resting on those surfaces; it is commonly used against indoor-resting mosquitoes [15].

Outdoor residual spraying commonly referred to as “perifocal treatment,” consists of spraying the surfaces of breeding containers, with or without standing water, to obtain larvicidal and adulticidal effects on dengue vectors [15].

Space spraying, or fogging, produces insecticide-containing droplets that are small enough to remain airborne for some time [16] and are intended to cause a quick knock-down effect on flying or resting mosquito vectors upon direct contact. As low doses of chemical insecticides are used for space spraying, it does not leave a meaningful deposit that could have a residual effect [17]. Space spraying has been commonly used for the control of dengue outbreaks because of its efficacy against vector species, despite the lack of evidence of its effectiveness [15].

The use of adulticides has increased according to one of the most recent reports released by WHO for the period 2010–2019 from 434 tons in 2010 to 1680 tons in 2019 [15].

The stage of immature forms is also targeted with insecticide products generically called larvicides. The most common larvicide has been temephos, an organophosphate, but formulations with biological principles are becoming more frequent.

An interesting experience has been the use of limestone and salt in old tires laying on the patios. Tires are breeding sites that can persist positives for larvae and pupae all year long. In northern Honduras, the effect of these two products of domestic use was tested for the control of A. aegypti populations and the findings were highly promising, obtaining with salt a total of 112 days free of larvae and pupae, and after that time (without new treatments), a small number of larvae were produced per day (3 larvae per day compared to 15 larvae per day in control tires), which implies that with regular treatments of salt every 3 months an adequate control can be reached in these breeding sites.

When limestone (in powder) was used, the tires were kept free of larvae and pupae for 185–217 days in treated tires, and past that time without the new introduction of limestone, the production of the larval population remained minimum, which means applications of limestone can be used every 6 months to keep tires free of larvae [14].

Larvicide use of formulations based on organophosphate or pyrethroids is currently challenged by reports of resistance, and the use of salt and limestone has been mentioned as causing concerns about environmental contamination.

It is becoming more frequent to have reports of resistance to larvicides and adulticides, which represents an additional obstacle to adequate vector control [18, 19].

5. Ovicides

In a variation of the chemical control and the context of hygiene improvement, there has been a promotion of the method called little dab (la untadita) using a mixture of chlorine and detergent for the weekly cleaning of water deposits (cement tanks, cisterns, drums). This method improves the quality of deposit hygiene and has an ovicide effect on the eggs laid on the deposit walls. Days after the application of la untadita, this mixture remains with some repellent effect on the females getting to the deposits to lay eggs.

This technique was developed in 1994 based on traditional methods of cleaning water deposits but adding steps to direct the scrubbing of the walls to all surfaces covering them with a thin layer of detergent. It requires access to water to do it at least once a week and rinse it [13, 20]. See Figure 2.

Figure 2.

Sample of a sticker for advertising the use of la Untadita. Honduras Ministry of Health.

6. Biological control

One of the prevalent ideas during several decades has been to use natural predators to destroy immature populations of A. aegypti. Predators such as larvivorous fishes (The biocontrol efficacy of six larvivorous fish species, namely, Poecilia reticulata, Rasbora daniconius, Aplocheilus dayi, Oriochromis mossambicus, Oreochromis niloticus, Puntius bimaculatus) and other similar species were tested in experimental conditions [21], another predator: Larvae of Toxorrhynchites sp. was also identified as effective at reducing larvae of A. aegypti. More recently Bacillus turingiensis var israelensis [22] and Bacillus sphericus (microbial agents and their spores) [23] have been also studied and found effective in experimental conditions acting as toxins for the larvae of the mosquito.

Copepods, small crustaceans, have been identified as effective predators in different studies in the Americas and Southeast Asian countries [24].

In Honduras during the first two decades of the current century, baby turtles of the species Trachemys scripta elegans [25, 26] have also been used for biological control of the A. aegypti larvae in small-scale field research sites.

Wolbachia is endosymbiotic bacteria capable of infecting some insect species including mosquitoes causing a reproductive phenotype called cytoplasmic incompatibility having as consequence the generation of inviable offspring when uninfected females mate infected males. If the female is infected this inviability does not occur, the Wolbachia infection can continue spreading in the population. The purpose of the Wolbachia infection from a control perspective is to interfere with the transmission of the dengue virus (DENV) to A. aegypti [27, 28, 29].

7. Other types of control

In an experimental process, there have been experiences modifying genetically the A. aegypti to produce offspring which die in the first days of life, and also the release of sterile males that, mating the females, do not produce any offspring [29].

Most of the new methods are used on a small scale and are undergoing the experimental stage and require to be implemented at the national level once they are authorized for extended use.

8. Social and legal control

Some countries have opted for severe fines for households keeping uncontrolled breeding sites or obstructing the work of vector control personnel. Such is the case of Singapore and Cuba [30, 31, 32].

In both countries, transmission of dengue has been relatively low during the last decades in comparison with their neighboring countries that suffer periodical epidemics. There is value in reaching a high level of vector control but the capacity to enforce strict regulation seems more viable in a small city-state like Singapore or countries with authoritarian regimes (both examples).

However, it is important that countries have a set of regulations and enforcement measures known by the population in order to prevent the transmission and reduce the number of trespassers that require legal actions.

The vector control programs require better support from the legal system when conflicts with the population limit their function.

9. Measuring the vector control measures

For close to a century, the control measures have been assessed using traditional entomological indexes such as: Container index, House index, and Breteau indexes corresponding to the measurement of the proportion of positive deposits in a visited section of a neighborhood, a city or town or any other concentration of houses, the number of positive houses or premises in an area, and the relationship of positive deposits and supervised houses [33, 34].

Since the times of Fred Soper, there was an effort to reach indexes below 5% of positives as indicators of success, but even in highly controlled areas of Singapore with very low indexes, outbreaks of dengue have occurred [30, 31].

The limitation of the indexes is that they reflect the situation of a geographic area that is visited optimistically several times a year and in a more somber scenario once a year. They reflect the concentration of larvae in a container, which is not an accurate measurement of the potential of the breeding site to produce a healthy adult mosquito population. Different levels of mortality may depend on the container and its capacity to sustain larvae and pupae. Several studies prefer to calculate the presence of pupae because that stage does not need to feed in the container giving more predictability of the adult population to emerge from the breeding site, and they are 24 to 48 hours away from the emergences of adults that are at the active stage for the viral transmission (36). Traditional A. aegypti larval indices do not differentiate between containers in which all the immature stages are present and those which hold only first- and second-instar larvae. This means measuring pupae population represents an advantage [35].

A different way to measure both the activity of A. aegypti and the success of the vector control efforts is the installation of Ovitraps in sentinel sites to assess the oviposition activity of existing female A. aegypti in an area of study. The ovitrap itself and in combination with larvicides can be used as a control method [36].

There is an issue with measuring the success of vector control actions through traditional vectorial indexes stemming from the differences in the performance of anti-vectorial personnel, the capacity to cover broad areas of houses and identify correctly breeding sites sometimes with high levels of difficulty to be accessed.

In contrast to old-style vector control operations currently, we are facing increasingly large and explosive urbanizations in areas with poor infrastructure, deficient access to water, sanitation (and refuse systems) [11].

The advent of more complex methods of measurement based on statistical modeling requires to assess the relationship between entomological indexes and densities of adult mosquitoes in an area and the risk of transmission and to use the newly acquired computer technology in producing consolidates in real time to feed urgent decision making in vector control and identify areas of failure or success in real time.

10. Community involvement

Mosquito control has been in most countries a responsibility of the governments and the level of engagement from families and communities has been relatively low but recent studies demonstrate that there is great potential for population participation and collaboration in anti-vectorial control with the advantages of overcoming the logistic difficulty of visiting households to perform an effective control.

It is fundamental to the understanding of vector control that it has been traditionally managed in a vertical way taking as a model the Malaria and Yellow fever Campaigns of the beginning of twentieth century with a quasi-military hierarchical structure where all initiatives and directions followed a top-down format [6, 37].

During several decades, this vertical structure was functional without many challenges from the population and the members of the vector control structures but in the twenty-first century, there is a tendency to democratize the society and its organizations and to decentralize the decision process [38, 39].

One of the main challenges during the last quarter of the twentieth century and the first decades of the current one is the lack of cooperation with the procedures of source reduction that involve entering the patios, applying larvicides to water deposits, removing useless breeding sites (from the official perspective) that could have potential use for the household members.

How to deal with decreasing cooperation in the communities? There is a need to involve those same communities in the control of their own homes and communities [38]. The perception of vector control needs to be less of fulfilling an imposed and confused sanitary obligation and more of a clear routine to protect health and life of the family members.

The work of vector control now requires knowing more than just the dengue vector and more about the community dynamic, practices, and culture to design more effective and socially acceptable control.

Recent experiences in Latin America and South/South-East Asia for community-based control have demonstrated that there are possibilities to apply innovation in vector control. Most of them have occurred because of a reassessment of the relationship between communities and their vector control [38].

Ethnographic studies have provided light on how perceptions of discardable, conservancy deposit management relate to cleanliness and hygiene aspirations in the family and their relation to disease, the need for health care/hospitalization, and risk of death [11].

As part of the knowledge required to improve vector control by the family is what are the social roles of the members in a family nucleus. The domains or responsibilities of mother and father need to be understood to be effective in tailoring effective messages to community members.

Depending on the culture, there are gender-based roles in the maintenance and elimination of potential breeding sites and this knowledge will provide a more clear effort to target the individuals in charge of keeping the containers free of mosquito sources [14].

The concept of hygiene and cleanliness needs to be linked in the communication to the preservation of health and the prevention of a spectrum of diseases and health disorders, and in this way, the removal or neutralization of breeding sites becomes relevant to the community as it is now to the vector control worker and the Ministry of Health.

Once vector control ceases to be important only for the vector control worker and the government institutions to some degree, it is important to operationalize a transference of responsibility to the individual, the family, and the community.

There are actions to be taken to transform the vector control of a routine in charge of the vector worker into a global effort that includes periodical cleaning-up campaigns helping neighbors to get rid of potential breeding sites (plastic objects, old metal pots, tires, cans, and similar) being careful not to stimulate the turn-over of old containers to brand new ones. As a personal testimony, many people observe that after a cleaning campaign, there is a tendency to replace those articles taken as refuse with new ones, and new breeding sites will be placed in the patios and backyards.

The second change in the vector control is to modify the profile of the vector control personnel into a more polyvalent profile, providing them a more comprehensive training to become more of an environmental care officer.

11. Community involvement: Schools, neighbor associations, and local governments

In the past, many public health programs were disease-specific and the members of the households were required to participate in programs that cause temporary or low motivation to them. In the case of dengue, the benefit for the household and the community seems to be scarce. Are they only acting for dengue control or does their participation lead to real family and community improvement?

Unless we are facing a dengue epidemic the main concern of the population is the nuisance of mosquitoes biting the house dwellers but they have more urgent needs to solve such as the perennial crisis with water supply, the accumulation of garbage, and the irregular refuse system or the total absence of one. Curiously, these felt needs are related to mosquitoes and dengue. There is a need to get a trade-off with community members to act on mosquito control as part of a more comprehensive package of community improvement measures.

Some communities facing the difficulty of getting rid of trash and other solid waste have organized themselves to pay individuals to mobilize their refuse in their own vehicles when the local governments are not able to do it. There is a real concern for the elimination of trash reinforced with the knowledge of dengue and similar mosquito-borne disease and the presence of their breeding sites in their homes.

Neighbor associations have demonstrated that if they identify a problem such as disease/s caused by mosquitoes, they are highly receptive to orientations leading them to take action, raise awareness in their own neighborhoods about control of trash and adequate control of water deposits, and even advocate for projects to provide better and more frequent water supply and wastewater systems.

In countries such as Honduras and Puerto Rico, there have been joint partnerships of the private and public sectors involved in the control of breeding sites and the School nucleus of teachers, parents, and students, which has been expressed in the production of educational material including textbooks and workbooks.

The development of school modules has followed a long process since the genesis of the idea as a research project in Latin American countries with a component of formative research, with rigorous measurement and the partnership of schools. Initially, the idea was to emphasize the dengue control component but later it was identified the need to incorporate environmental components based on the adequate water supply and the care required by the deposits containing water indoors and outdoors, and the component of adequate disposal of domestic waste. Finally, the last modules center on water deposits and solid waste more relevant to dengue control. More details were provided in the dengue module about concrete actions needed from parents and school-age children. The learning objectives were reached and the next step was the application of skills in the practical tasks of developing the actions of control in the family and with community members [40, 41, 42].

The Environmental School Program (PEA, for its Spanish acronym) is a dengue control initiative focused on primary schools that took place during 2005–2010 in several cities in Honduras. The environmental health program was designed to increase knowledge and develop skills in the identification and control of A. aegypti breeding sites, as well as in water and solid waste management [41] as mentioned before.

Incorporating through the school, young school children, their parents, and teachers can provide sustainability to a renewed vector control program targeting the action on dengue transmission but improving the environmental conditions at home and in peri-domestic spaces. Internalizing some values on domestic hygiene seems to be the route to long-term control.

Communities are also mobilized in the development of the activity called D-days when every household assumes the responsibility to clean their water deposit and eliminate discardable containers, and the government institutions provide support for an effective refuse system.

It is important to mention that experiences are crossing borders, and in many countries, the school system and the local government adjust experiences to their local circumstances. Scientific community has a role in supporting the development of innovative methods, diffusing them through scientific literature and institutional communications, and doing an appropriate and intense advocacy for the adoption of new techniques. Only an active scientific community can lead to changes in the routines of control and the assignment of more responsibilities to local authorities (decentralization) and empowerment to the population to take part in the reduction of the A. aegypti populations.

12. Last comments: where do we go?

Policy makers need to know that dengue is a recurrent problem for most countries, and the possibility to obtain an acceptable vaccine is still uncertain and the only known and used control method is vector control, which is potentially suitable as part of broader environmental health measures.

Paradoxically, we have as a result of a long tradition of vector control the emergence of a multiplicity of control methods that remain as collection of effective laboratory and field tests waiting to be taken to a national level, upscaling them in a careful but decided adoption.

It is not possible just to use one single method for vector control, but a combination of them according to needs, availability, and access of expertise by the personnel.

From experimental pilot, experiences are important to rescue the opening of different channels of communication with the communities through the vector-control workers, teachers, students, local governments and including the private sectors and grassroots organizations that have a real interest in all processes improving the life of citizens.

The vulnerability to dengue transmission comes in many places especially in poor neighborhoods because of the chronic lack of water supply, which presses the community dwellers to keep their water deposits that are necessary for their daily routines of cleaning/hygiene, laundry and more important for drinking and preparing their food. It is a common experience for vector control workers to witness the despair and anger of neighbors pressed to use larvicides in water deposits that change the appearance and odor of the water, or when forced to empty some positive deposits depriving them of water that is needed for them.

There is a need to link mosquito (A. aegypti) control to the development of programs to provide reliable water supply that will turn clean-up campaigns, temephos applications, or containers emptying from real nuisance to acceptable ways to protect family health.

In recent years, several epidemics of dengue and other A. aegypti-borne infections have affected the Americas, and South and South-East Asia, with outbreaks as well in the Pacific Islands and Africa. It is time that the national authorities are convinced that vector-control measures need to be redirected to be a tool for multi-disease control beyond only dengue and severe dengue. This would lead to alliances with other actors to combine control strategies and develop synergic actions that will have less opposition in the population and more strategic allies.

An area that is essential to the success of vector control is communication, and in an increasingly democratic world, the effectiveness of health programs is based on effective communication between institutions (Vector Control/Ministries of Health) and the population. Once many countries are passing from authoritarian regimes to more democratic institutions, the type of health communication needs to change from unidirectional to bilateral and multidirectional providing an opportunity to gather new ideas and needs from the population to optimize the implementation of new ideas for vector-control and community improvement.

Health policies related to dengue reduction and vector controls need to be shared with the national audiences in a clearer way, and to be open to observations, contributions, and dissent if that happens. As we have mentioned in this vector-control overview, there are many community issues that only solved will provide opportunities for a fully successful control.

There is an increasing level of understanding in the World Health Organization of the role of vector control in reducing dengue transmissions, and once a safe vaccine for all is reached, there must be an effort to use both approaches in a synergic approach. Previous discussions about abandoning the efforts of vector control once the vaccine was reached are practically over especially considering that vector control can have a synergic effect with the vaccine.

With the advent of other pandemic diseases like COVID-19 with more media attention, it is a priority to adopt new control strategies, and identify and integrate allies in the expanded approaches to reduce Aedes populations while a higher purpose: improvement of peridomestic spaces with less trash and wiser use of water containers is achieved.

13. Conclusions

Dengue is a viral infection with the main mode of transmission as vector-borne infection. Its clinical range goes from an asymptomatic infection to a severe lethal disease. We are relying on the prevention of dengue in effective control of the A. aegypti mosquito. There is a broad range of options for vector control but the most widely used are based on insecticides that are the cause of debate because of their potential environmental toxicity but also by their increasing report of resistance. Recent WHO reports state their use in the different world regions with variable levels of the result.

Most of the effort to control A. aegypti population concentrate on the reduction of breeding sites and the population of immature stages, while the use of adulticides is used when there are evidences of active transmission of infection and high densities of the mature adult mosquitoes (outbreaks of disease).

Currently, there are many studies on alternative methods that show high effectivity and efficacy when treating breeding sites, there is an urgency to implement the new methods outside of its research context adopting a more operational process.

Technology resources need to be applied to the challenges produced by unorganized urban growth, limited personnel, passive resistance to authoritarian styles to perform breeding sites assessment and control.

Modern times require new approaches including the adoption of new techniques for control, reviewing the profile of the vector-control worker and the organization in its entire structure, and a necessary process of relearning how to be more effective in interacting with the communities and the civic organizations.

Populations need to know better what is done in vector control in their own homes to turn a passive and sometimes hostile attitude into a more cooperative one, incentivizing their participation in the control through neighbors and civic organizations and as it is proposed through their school systems: learning and participating in their own domestic hygiene, which includes the vector’s breeding site control.

There is a need to develop a more integrated approach with other disease-control programs and privileging a more decentralized process to perform disease control.

Acknowledgments

Special thanks to my colleagues at Brock University who provided me an opportunity to grow and look for some answers to the questions posed by this topic.

Thanks to my colleagues at the Americas Dengue Control Board who were actively asking and responding with their perspectives about some questions for dengue prevention and control.

Thanks to Neiby, Milan, and Ivan Fernandez who give me the chance to think about this topic with more realism.

Conflict of interest

The authors declare no conflict of interest.