dengue in the philippines essay

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• Published: 15 March 2024

Knowledge, attitudes, and practices related to dengue among public school teachers in a Central Luzon Province in the Philippines: an analytic cross-sectional study

• Ernesto R. Gregorio   ORCID: orcid.org/0000-0003-1931-0458 1 , 10 , 2 ,
• Rie Takeuchi 10 , 11 , 3 ,
• Paul Michael R. Hernandez 4 ,
• John Robert Medina 5 ,
• Shin-ya Kawamura 6 ,
• Mikaela B. Salanguit 1 ,
• Marian Danille C. Santillan 1 ,
• Kimberly Mae S. Ramos 7 ,
• Gideon John Tuliao 1 ,
• Lyndon Morales 8 ,
• Maylin Palatino 9 ,
• Fumiko Shibuya 10 , 11 &
• Jun Kobayashi 1 , 10 , 11  

Tropical Medicine and Health volume  52 , Article number:  25 ( 2024 ) Cite this article

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Dengue has become a major health issue in tropical regions as the numbers of reported cases and estimated infections continuously increase. In the Philippines, many challenges remain in preventing and controlling the disease amidst all the mitigation efforts of the government. This study sought to measure the health literacy of Filipino teachers and determine the associations among teachers’ knowledge, attitudes, and selected practices (KAP) against dengue.

Elementary and secondary school teachers from the consistently declared dengue hotspots in the City of San Fernando, Pampanga, Philippines, from the years 2017 to 2019 were selected as target participants in this cross-sectional study. A self-administered online survey tool was used in this study for both screening of participants and the KAP survey proper. STATA, descriptive statistics, and multiple logistic regression were used for the data analysis. Odds Ratios (ORs) and 95% confidence intervals (CIs) were reported.

The study comprised 604 participants whose mean age was 38.4 years. Television was determined as the top media source of information, and various health staff were the most trusted and common source of information. Good knowledge on dengue treatment (OR = 1.81; 95% CI 1.18–2.78) and dengue prevention (OR = 1.85; 95% CI 1.26–2.71) were positively associated with having good practices on protection against mosquito bites. Good knowledge on dengue signs and symptoms (OR = 1.56; 95% CI 1.02–2.37) and dengue prevention (OR = 2.38; 95% CI 1.59–3.58) were positively associated with having good practices on preventing breeding sites. Those with positive perceived susceptibility to dengue had lower odds of having good practices on protection against mosquito bites (OR = 0.64; 95% CI 0.41–0.99) and of having good practices on preventing breeding sites (OR = 0.46; 95% CI 0.26–0.81).

Even with the existing dengue policies, programs, and strategies, and the high disease literacy rate of Filipinos, dengue remains a struggle with an increasing case rate. Therefore, specific concepts should be emphasized, and interventions should be fine-tuned to better reach and influence the target population to attain a dengue-free Philippines.

Introduction

The majority of low- and middle-income countries are in the tropics where the spread of neglected tropical diseases has become a major public health crisis. Dengue, in particular, has become a global threat due to the increasing number of infected people and endemic areas, which is strongly influenced by global warming. According to the Philippines’ Department of Health, dengue is the fastest-spreading vector-borne disease in the world, being endemic in 100 countries [ 1 ]. In Southeast Asia, the number of reported dengue fever outbreaks has increased dramatically [ 2 ]. About 100 million cases of dengue occur each year along with an estimated 400 million infections. Forty percent of the world’s population, or about 3 million people, live in areas with risk of the disease [ 2 , 3 , 4 ].

Due to the limited resources in low- and middle-income countries, correct diagnosis of dengue has become even more important. Early detection of the disease leads to administration of timely and appropriate medical interventions. This has lowered the fatality rate of severe dengue from 20% to below 1% [ 2 ]. However, the diagnosis of dengue has proved to be challenging due to its nonspecific presentation, especially during its early stages [ 5 ]. With the limited resources available, low accessibility to healthcare, and hesitancy to go to hospitals, compounded by the challenges brought about by the COVID-19 pandemic, differential diagnosis of febrile diseases is expected to be very difficult [ 6 ]. For example, during the early phase of the COVID-19 pandemic, dengue and COVID-19 were incorrectly diagnosed as both patients presented with lymphopenia, leukopenia, thrombocytopenia, and elevated transaminases in laboratory tests. In addition, false information that COVID-19 is transmitted by mosquitoes has become a problem in low- and middle-income tropical countries where mosquito-borne diseases such as dengue are widespread. While this could be protective to a certain extent, the said misinformation still poses a challenge in terms of the diagnosis and treatment of dengue. Therefore, risk communication to convey appropriate information is important in febrile disease control.

Challenges remain in controlling the spread of dengue despite the presence of Philippine government’s prevention policies and an established case reporting system. Contributing to the Philippines’ situation of increased dengue cases is the 2017 dengue vaccine controversy involving Dengvaxia. Yu et al. discovered that after the controversy, there is widespread mistrust and fear in various communities towards the state and health authorities [ 7 ]. The researchers also added that the media played a role in the public's vaccine hesitancy, as well as the altered perceptions towards the government and healthcare. Therefore, it is essential to efficiently implement prevention programs through vector control strategies, appropriate health behavior change, and early diagnosis and appropriate treatment.

Although dengue fever affects all age groups, it is still most common among older children, adolescents and adults [ 8 ]. In a Knowledge, Attitude, and Practice (KAP) study conducted on primary school children in Thailand, it was discovered that the main sources of information on dengue were primary school teachers and guardians and that most of the study participants possessed poor dengue-related knowledge [ 9 ]. The health literacy of school teachers related to dengue must be assessed to see how well they respond to cues important for school-based vector surveillance. Health literacy may then be further enhanced to improve their surveillance responses through appropriate school health education, with a focus on febrile diseases important in the public health context.

In 2022, the Philippine government began to lift the COVID-19 pandemic restrictions, and dengue was expected to become even more widespread. As the number of cases continues to increase, it is important to understand these implications and take appropriate measures. With the resumption of face-to-face classes in the Philippines, health literacy in schools can be an important area for intervention in the Philippines where underreporting of dengue fever cases exists [ 10 ]. Misinformation such as “COVID-19 is transmitted by mosquitoes” should be corrected. To further amplify the current surveillance, prevention, and control measures of dengue cases in the Philippines, knowledge of the factors that affect the rise of dengue cases is vital in implementing appropriate measures.

A study conducted in Lao People’s Democratic Republic found that knowledge about climate change and dengue was significantly associated with one’s level of education and socioeconomic status [ 11 ]. In addition, attitudes toward climate change and dengue were associated with internet use and level of education whereas practices related to dengue were associated with internet use, level of education, socioeconomic status, and previous dengue experience. From this study, it can be seen that one’s knowledge, attitudes, and practices toward dengue are highly dependent on their level of education. In the Philippine context, Labrague and Yboa conducted a study among rural residents in Samar, Philippines [ 12 ]. Despite access to correct information on dengue, the disease remains as a challenge. They found that there are high levels of knowledge and preventive practices regarding dengue. However, higher levels of knowledge do not necessarily lead to better practices of prevention. With this information, it is also important to determine the associations among knowledge, attitudes, and practices to determine which aspects may be the focus of health communication program that can lead to better health outcomes.

This study thus targeted the health literacy of Filipino teachers who serve as one of the sources of health information about dengue. The study aimed to determine the association between the knowledge, attitudes, and selected practices of teachers on dengue and specifically to (1) determine the respondents’ knowledge on the modes of transmission, signs and symptoms, diagnosis, treatment, and methods of preventing dengue; (2) assess the respondents’ attitudes towards dengue prevention and control measures; (3) determine the proportion of respondents who practice health-seeking behaviors and prevention and control measures against dengue; (4) determine the association between the respondents’ prevention and control practices, and their knowledge and attitudes towards dengue and COVID-19; and (5) determine the primary sources of information of the respondents on dengue.

Research design

An analytical cross-sectional design was used to assess the knowledge, attitudes, and practices of public elementary and junior high school teachers regarding dengue. The data were collected from September 2022 to November 2022.

The City of San Fernando, Pampanga, in the Philippines was chosen purposively as the study site. The researchers obtained data on the dengue cases from 2017 to 2019 in the City of San Fernando, Pampanga from their City Health Office  in coordination with their Department of Education Schools Division Office (SDO) to identify the villages (barangays) that had consistently been dengue hotspots, that is, areas with confirmed clustered cases that had increased in number during the past four weeks [ 13 ]. Based on this information, nine public elementary schools and 10 junior high schools in the identified villages were selected.

Study population

The target participants of the study were public elementary and junior high school teachers of the villages that have consistently been dengue hotspots in the City of San Fernando, Pampanga. This study included all eligible teachers in the selected schools. The inclusion criteria were (a) currently employed or on active duty for the school year 2021–2022; (b) teaching staff; and (c) age 18 to 64 years old. A questionnaire that included consent to participation and data inclusion in the study was used for the initial screening. Participants were excluded from the study if they did not provide consent.

Research instrument

The KAP survey instrument was developed based on existing literature and survey tools including a similar study on Zika Virus, which referenced an instrument provided by the World Health Organization (WHO)-Pan American Health Organization [ 14 ].

The self-administered tool consisted of six domains. The first domain contained eight questions that collected the participants’ sociodemographic characteristics. The second domain had four questions relating to any history of exposure to dengue. The third domain had 20 questions about the participant’s knowledge on the dengue virus, which was further categorized into mode of transmission, signs and symptoms, diagnosis, treatment, and prevention. Mode of transmission refers to the participants’ knowledge on how dengue virus is spread from one susceptible host to another, which was measured using seven questions. Signs and symptoms refer to the participants' knowledge of the clinical signs and symptoms of dengue and was measured using two questions. Diagnosis refers to the participants’ knowledge of the correct method of dengue diagnosis, which was measured using five questions. Treatment refers to the participants' knowledge of appropriate treatment for dengue and was measured using four questions. Lastly, prevention refers to the participants' knowledge on how dengue can be prevented. This was measured using two questions. The transmission, diagnosis, and treatment categories in the knowledge domain were measured using true or false statements, with the option to choose “I don’t know.” Meanwhile, the signs and symptoms and prevention categories used multiple-answer questions.

The fourth domain had 15 items that measured the attitudes of the participants towards dengue control, prevention, and treatment. For this, the study utilized the constructs of the health belief model, specifically, perceived benefit, perceived barriers, perceived susceptibility, perceived severity, and external cues to action. All constructs were measured using three questions that were answered through a modified Likert Scale. Perceived benefit refers to the participants' belief in the effectiveness of proper actions to reduce the risks related to dengue. Perceived barriers refer to the participants' belief that tangible and intangible barriers such as costs and safety concerns can prevent the enactment of the advised action. Perceived susceptibility refers to the belief of the participants about their chances of contracting dengue. Perceived severity refers to the belief of the participants about the serious clinical effects of dengue. External cues to action refer to the people or personalities that may possibly influence the participant’s decision to enact the advised action.

The fifth domain contained five questions, four of which could have multiple answers regarding the sources of information and health literacy. The sixth domain measured the participants' practices on dengue prevention and health-seeking behaviors through an item that can have multiple answers. Five questions answered with a four-point Likert scale on their perceptions on the COVID-19 pandemic’s effect on the government’s response in fighting dengue and an open-ended question on the most appropriate strategy for teaching dengue prevention were included in this domain.

To test the reliability of the survey tool, Kuder–Richardson 20 and Cronbach’s Alpha were used with result interpretation considered to be highly reliable.

Data collection, management, and analysis

A letter of request to conduct the study was sent to the SDO Superintendent and to the school heads. Once permission was obtained, assistance from the School Governance and Operations Division was sought to enable the research team to gain access to the teachers. The link to the study questionnaire was sent through an email to the school head of each of the selected schools and was then distributed to the teachers through their group chats. A printed QR code for the questionnaire was also distributed to help facilitate the dissemination of the survey to the teachers. The settings of the online tool used for the study questionnaire ensured that all fields and questions were answered before submission. If the submitted answer was not applicable to the question, the cell was then left blank and was not included in the logistic regression analysis. All individual questionnaire responses were double-checked and verified for completeness and consistency before processing.

The data collected were encoded through Microsoft Excel (Microsoft Corporation, Redmond, WA, USA). Correct answers in the knowledge domain items were coded as 1, 0 otherwise. The percentages of correct answers of the participants for each knowledge domain were computed. A score of more than 75% was considered as having good knowledge, coded as 1, poor knowledge otherwise, coded as 0. For the attitude domain, the responses of 4 and 3 to the Likert scale were coded as being answers with favorable (positive) attitudes towards dengue prevention and control, whereas 2 and 1 were answers indicating less favorable (negative) attitudes towards dengue prevention and control.

STATA 16.1 (STATA Corp., College Station, TX, USA) and descriptive statistics were used for data analysis of the survey, including the sociodemographic profile and knowledge, attitudes, and practices of the participants. For continuous variables such as age of the participants, means and standard deviations were calculated while frequencies and percentages were computed for categorical variables.

Two binary prevention and protection practice outcome variables were defined, namely, (1) practices on protection from mosquito bites; and (2) practices on preventing breeding sites, which included four and five items, respectively. For each outcome, good practice was defined as doing at least 75% of the included items. Binary logistic regression modeling was employed to determine the factors in the knowledge and attitude domains that were associated with the outcome variables, while controlling for confounding of age, sex, educational attainment and subject taught.

Sociodemographic profile

Of the 987 teachers, 618 answered the questionnaire, giving a response rate of 62.6%. Of the 606 teachers who agreed to participate, 604 were eligible for the study and analysis, the two participants who were not part of the teaching staff were excluded from the study. Thus, 604 respondents participated in the study. Their average age was 38.4 (S.D. 10.2; range: 20–62) years. The majority were females (81.6%), had a master’s level or were a master’s graduate (58.8%), and had a family income between PHP 25,200 and PHP 95,299 monthly. About a quarter reported teaching Science or Music, Arts, Physical Education, and Health (Table  1 ).

More than half (65.1%) of the respondents were married individuals. Three-quarters (75.8%) declared themselves to be in the middle-income bracket.

Almost half (48.7%) of the participants were currently taking up their master’s degree, while 34.4% were college graduates. Almost a quarter (24.3%) of the participants taught Science and Music, Arts, Physical Education, and Health.

Sources of information on dengue

The respondents’ commonly used media platforms on obtaining dengue information were television (85.3%), Facebook (79.6%), and Youtube (52.3%), whereas the social media app Viber (3%) and comics (2.7%) were the least preferred.

The respondents’ top three primary sources of data on dengue were Department of Health (DOH) officials (83%), Rural Health Unit staff (64.4%), and members of the Barangay Health Emergency Response Team (56.1%). Other sources (4.1%) and the Department of Education officials (29.8%) were ranked the lowest.

DOH officials (89.1%), Rural Health Unit staff (63.6%), and WHO officials (58.4%) were the top three most trusted sources of information about dengue. The most trusted source of information among non-health officials/employees was family members (34.6%).

Knowledge on dengue

Table 2 shows that the majority of the respondents  knew that skin-to-skin contact (95.5%) and sexual intercourse (90.7%) cannot transmit the disease. Only over half of the respondents (53.5%) knew that dengue can be transmitted through blood transfusion, which is low compared to the other items.

More than half of the participants claimed that abdominal pain, bleeding, diarrhea, headache, and muscle pain are signs and symptoms of dengue, with fever (96.7%) and rashes (89.1%) as the most recognized symptoms linked to dengue (Table  2 ).

Respondents were assessed on their knowledge of preventive measures against dengue, which were divided into (1) prevention and control of the disease; and (2) diagnosis and treatment options. Table 2 shows that the majority of the respondents (> 80%) were able to correctly identify prevention and control methods for dengue, which are the following: removal of standing water at home and school, use of window screens and bed nets to prevent mosquito bites, covering water containers, using mosquito repellent as a self-protection measure, fogging/spraying during a dengue outbreak, with child vaccination identified by the lowest number of participants (56.1%).

Respondents agreed that the diagnosis of dengue is based on blood samples (95.5%), and only a physician can give the final diagnosis of dengue (93.4%), whereas more than half of them (75.3%) either disagreed on the diagnosis of dengue through a PCR test or did not know the answer (Table  2 ).

Attitudes on dengue

Respondents were assessed on their perceptions of dengue, and the responses were categorized into (1) perceived benefits; (2) perceived barriers; (3) perceived severity; (4) perceived susceptibility; and (5) cues to action. Table 3 shows that respondents viewed the use of mosquito coils (62.7%) and application of mosquito repellants (78.5%) as beneficial in the prevention and protection against dengue.

More than half of the respondents in Table  3 agreed that even if the materials that can be used to protect oneself against dengue are expensive (65.1%), health facilities are not accessible (56.1%), and information regarding dengue prevention is not made available (81.8%), they are still willing to avail of these options.

Almost all (98.3%) of the respondents in Table  3 either agreed or strongly agreed that dengue can lead to more severe dengue hemorrhagic fever, and more than half agreed that there is no currently available medicine (54.5%) or effective and safe vaccines (61.3%) against dengue.

Over half (67.1%) of the participants agreed that they feel they are at risk of contracting dengue in the next three months, whereas 69.0% and 97.5% feel that they are more susceptible when the people around them have dengue fever and if there are mosquito breeding sites in their area, respectively (Table  3 ).

Almost all (98.7%) of the respondents feel the need to seek medical attention when they experience flu-like symptoms. They will also protect themselves against the disease when family members or relatives (89.4%) or their doctors (89.6%) recommend it (Table  3 ).

Practices related to dengue prevention

As shown in Table  4 , the most commonly practiced preventive option for dengue done by the respondents in the past three months was the disposal of garbage or trash (88.1%). Although the use of mosquito coils was ranked the lowest, it is still being practiced by more than half of the respondents (57.8%).

Factors associated with dengue-related practices

For this part of the study, a total of 602 participants with complete data were included in the analyses.

Correlates of good practices on protection from mosquito bites

Controlling for age, sex, educational attainment, subject taught, and the other variables, those with good knowledge on the treatment of dengue had 1.81 times the odds of having good practices on protection from mosquito bites compared to those who had poor knowledge (aOR = 1.81; 95% CI 1.18, 2.78). Those with good knowledge on the prevention of dengue had 1.85 times the odds of having good practices on protection from mosquito bites compared to those who had poor knowledge (aOR = 1.85; 95% CI 1.26, 2.71). Those with positive perceived susceptibility to dengue had 36% lower odds of having good practices on preventing mosquito bites than those with negative perceived susceptibility (aOR = 0.64; 95% CI 0.41, 0.99) (Table  5 ).

Correlates of good practices on preventing breeding sites

Controlling for age, sex, educational attainment, subject taught, and the other variables, those with good knowledge on signs and symptoms of dengue and on prevention of dengue had 1.56 (95% CI 1.02, 2.37) and 2.38 (95% CI 1.59, 3.58) times the odds of having good practices on preventing breeding sites, respectively, compared to those with poor knowledge. Those with positive perceived barriers of using personal protective/preventive measures against dengue had 1.58 times the odds of having good practices on preventing breeding sites compared to those with negative attitudes (aOR = 1.58; 95% CI 1.03, 2.44). Finally, those with positive perceived susceptibility to dengue had 54% lower odds of having good practices on preventing breeding sites than those with negative perceived susceptibility (aOR = 0.46; 95% CI 0.26, 0.81) (Table  5 ).

This study evaluated the knowledge, attitudes, and preventive practices regarding dengue among public elementary and secondary school teachers in the City of San Fernando, Pampanga, Philippines. The participants showed good overall knowledge on the modes of dengue transmission, signs and symptoms, prevention and control, and diagnosis and treatment as more than half of the respondents were able to correctly answer most of the items. This could be attributed to the programs and strategies implemented by the Department of Health and the Local Government Unit of Pampanga to achieve its vision of a dengue-free Philippines [ 1 ]. This study result is also consistent with previous investigations reflecting high dengue knowledge levels in Filipino populations [ 12 , 15 ]. However, even with the reported number of individuals knowledgeable about dengue, this study still shows that a certain proportion of the respondents either hold incorrect concepts or are unfamiliar with some facts about the disease.

Only about half of the participants could correctly identify that dengue can be transmitted through blood transfusion. Available information about transfusion-transmitted dengue is limited and could be the reason why this type of transmission is not a common knowledge among the respondents. Relatively, vaccination against dengue scored the lowest among the correct prevention and control measures, which could be attributed to the apprehensions toward vaccines as a result of the former Dengvaxia controversy. Official statistics conveyed the significant increase in vaccine hesitancy supported by individual reports on how immunization coverage rates dropped in the aftermath of the controversy [ 7 ]. On the contrary, the majority of the participants mistakenly believe that getting vaccinated against COVID-19 could lead to protection against dengue. Whether this identifies what the public considers as an alternative to obtaining protection against dengue by mode of vaccination merits further investigation. However, this also points to a significant concern about health communication to the public. In addition, only a low number of the participants correctly believe that a dengue diagnosis can be confirmed through PCR, that there is currently no medicine to cure dengue, and that having a fever for one to seven days without any other symptoms cannot confirm the presence of dengue. To bridge these gaps, emphasis on points regarding modes of dengue transmission, prevention, control, diagnosis, and treatment should be added to the different dengue awareness programs in the province. Specifically, the dengue awareness programs should focus on correcting the misconceptions surrounding vaccination to address vaccine hesitancy.

This study also reports an overall positive attitude towards dengue prevention and control measures, which is consistent on what was found in other Asian countries, although intervention studies have been suggested as points for improvement [ 16 , 17 , 18 ]. This shows that the majority of the respondents have positive perceptions of benefits and barriers to using personal dengue protection and are willing to undertake additional efforts for health safety. In addition, perceived severity and susceptibility show the participants’ awareness of the trends and risks of the disease. Internal and external cues to action against dengue was also found among the majority of the respondents. All of these perceptions could possibly be among the effects of various news reports and articles regarding the continuous and alarming increase of dengue cases from the start of the first half of the year 2022 until the start of the second half in the Philippines [ 19 , 20 ].

A high proportion of respondents also claimed to have practiced, within the past three months, every health-seeking behavior, prevention, and control measures against dengue listed in this study. This could be attributed to the desire to remain vigilant against the disease despite the decrease in reported cases in Central Luzon, Philippines for the first four months of 2022 compared with the records reported for the same period in 2021 [ 21 ]. A similar practice result was seen in KAP investigations regarding dengue among Malaysian populations [ 22 , 23 ]. In contrast, preventive practices against the disease in Singapore for the same year 2022 were reported to be low and could be attributed to the seemingly ineffective prevention regimens imposed on residents, thereby resulting in a reluctance to engage with dengue volunteers and national health officers [ 18 ].

This study likewise found that good knowledge on the treatment and prevention of dengue was associated with good practice of mosquito bite prevention. Moreover, good knowledge on the signs, symptoms, and prevention of dengue were associated with an increased odds of good practice of preventing breeding sites. These findings, however, were not consistent with the results reported from a study in Cebu City and Metro Manila Philippines where the knowledge of participants about dengue fever did not correlate with their practices against the disease [ 15 , 24 ]. Differences in the ways of living between Pampanga, Metro Manila, and Cebu City could be a reason for this discrepancy, with a high dependency on paid workers doing the cleaning and other utility jobs in the latter two areas than the former area.

Finally, a positive association was observed between the respondents’ attitudes and practices on preventing breeding sites, such that a positive perception of barriers increases the likelihood of engaging in good practices. However, participants with a favorable attitude towards the perceived susceptibility to dengue, such as those who feel that they are at risk of contracting dengue, were less likely to practice prevention of dengue breeding sites compared to those with less favorable attitudes. This is in contrast with studies from Central Nepal and Indonesia where strong associations between a good attitude and good preventive practices were reported [ 16 , 25 ]. A possible explanation for this is that while the perceived susceptibility has affected the participants’ intentions, but they did not have the opportunity to implement these practices. Therefore, appropriate programs should be developed to further translate attitudes into practice, such as through consistent garbage collection schedules and regular clean-up drives.

DOH officials, Rural Health Unit staff, barangay health emergency response teams, family members, and WHO officials are the top five primary and most trusted sources of dengue information for the study respondents. From this list, only family members are included among the non-health officials or employees. Empowering these specific people could serve great advantage in increasing good practices, given the reported high associations of good knowledge and preventive actions. In terms of media coverage, television and Facebook are the top sources of dengue information and could be used as means to better reach this particular segment of the population.

While significant statistical associations were observed in some variables, cause and effect relationship was not established as this is one of the limitations of the cross-sectional nature of this study. Moreover, the study results may not be generalized to the study population since a nonrandom sampling method was utilized in the selection of schools.

Second, the online means of survey distribution eliminated interviewer bias that could possibly occur when conducted using face-to-face interviews. However, the use of the digital platform might have introduced information bias as validation of each input from the respondents was difficult. Recall bias could have also occurred as one section of the survey involved remembering the practices done in the past three months and identifying any disease history for self, family, friends, and colleagues, with the latter event as a possible influence on knowledge about dengue. However, a previous study reported no association between having a family member with a history of dengue and obtaining increased knowledge on the disease [ 25 ].

Finally, this study assured the participants of the study’s confidentiality and that their identity will be protected in the survey. This might have reduced the information bias because they knew that their responses will not be traced back to them. This study’s internal validity was strengthened by controlling the effects of the confounding variables during the data analysis. As for the external validity, although the strict inclusion criteria could have limited the generalizability of the findings, a good participation and representation was achieved through a reminder from the SDO superintendents and school heads to ensure a timely and complete response from all of the eligible participants.

Dengue is among the seasonal struggles in a tropical country like the Philippines. Even with its decades-worth of efforts and the high degree of dengue literacy of its citizens, the Philippines still struggles in combating the disease, especially with the emergence of additional challenges influencing the knowledge, attitude, and practices of Filipinos. The findings of this study can serve as baseline health literacy of teachers in the province on dengue, and can be used as a guide in the review and redesign of school-based dengue prevention programs and strategies to fit the status and needs of the teachers who can influence the learners and, to a certain extent, the general population. The in-service training programs for Filipino teachers can include topics on dengue with emphasis on the findings where teachers have low level of knowledge. Based on the findings from this study, learning modules for teachers as well as students can be developed to improve their dengue literacy. Moreover, the significant factors associated with dengue prevention and control derived from this investigation could be used in developing health communication materials with messages that can influence the target population in the province and thereby contributing to the attainment of the vision of a dengue-free Philippines.

Availability of data materials

The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Adjusted odds ratio

Confidence interval

Coronavirus disease-19

Department of Health

Knowledge, attitude, and practice

Polymerase chain reaction

School Division Office

World Health Organization

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Dengue cases up 106% from Jan 1–July 16. Philippine News Agency. https://www.pna.gov.ph/articles/1180415 . Accessed 19 Feb 2024.

Dengue cases in Central Luzon down by 64%. Philippine News Agency. https://www.pna.gov.ph/articles/1175639 . Accessed 19 Feb 2024.

Hairi F, Ong CH, Suhaimi A, Tsung TW, Bin Anis Ahmad MA, Sundaraj C, et al. A knowledge, attitude and practices (KAP) study on dengue among selected rural communities in the Kuala Kangsar district. Asia Pac J Public Health. 2003;15:37–43.

Firdous J, Mohamed A, Amin M, Ihsan M, Hakim M, Afiq M, et al. Knowledge, attitude and practice regarding dengue infection among Ipoh Community, Malaysia. J Appl Pharm Sci. 2017;7(8):099–103. https://doi.org/10.7324/japs.2017.70814 .

Herbuela VRDM, de Guzman FS, Sobrepeña GD, Claudio ABF, Tomas ACV, Arriola-Delos Reyes CM, et al. Knowledge, attitude, and practices regarding dengue fever among pediatric and adult in-patients in Metro Manila, Philippines. Int J Environ Res Public Health. 2019;18:96.

Harapan H, Rajamoorthy Y, Anwar S, Bustamam A, Radiansyah A, Angraini P, et al. Knowledge, attitude, and practice regarding dengue virus infection among inhabitants of Aceh, Indonesia: a cross-sectional study. BMC Infect Dis. 2018;18:96.

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Acknowledgements

The authors of this research study would like to thank the schools’ division office and the principals who assisted in study implementation as well as the teachers who participated in this study. We also would like to express our thanks to the technical and ethics reviewers of this research project. The authors are also grateful to the University of the Ryukyus, Okinawa, Japan, for the support they provided to this study.

This work was supported by JSPS KAKENHI Grant Numbers JP20KK0223 and JP21HP2006.

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Department of Health Promotion and Education, College of Public Health, University of the Philippines Manila, 625 Pedro Gil St, Ermita, 1000, Manila, Metro Manila, Philippines

Ernesto R. Gregorio, Mikaela B. Salanguit, Marian Danille C. Santillan, Gideon John Tuliao & Jun Kobayashi

SEAMEO-TROPMED Regional Center for Public Health, Hospital Administration, and Environmental and Occupational Health, Manila, Philippines

Ernesto R. Gregorio

Graduate School of Public Health, International University of Health and Welfare, 4‑3 Kodunomori, Narita, Chiba, 286‑8686, Japan

Rie Takeuchi

Department of Environmental and Occupational Health, College of Public Health, University of the Philippines Manila, Manila, Philippines

Paul Michael R. Hernandez

National Institutes of Health, University of the Philippines Manila, Manila, Philippines

John Robert Medina

Chubu Institute for Advanced Studies, 1200 Matsumoto‑Cho, Kasugai, Aichi, 487‑8501, Japan

Shin-ya Kawamura

College of Medicine, University of the Philippines Manila, Manila, Philippines

Kimberly Mae S. Ramos

Department of Education, Schools Division Office, City of San Fernando, Pampanga, Philippines

Lyndon Morales

School of Medicine, University of Maryland Baltimore, Baltimore, MD, USA

Maylin Palatino

Department of Global Health, Graduate School of Health Sciences, University of the Ryukyus, Nishihara, Japan

Ernesto R. Gregorio, Rie Takeuchi, Fumiko Shibuya & Jun Kobayashi

Japanese Consortium for Global School Health Research, University of the Ryukyus, Nishihara, Japan

Rie Takeuchi, Fumiko Shibuya & Jun Kobayashi

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ERGJ, RT, and JK conceived and developed the study design. ERGJ, MBS, MDCS, and LM conducted the data collection. ERGJ, RT, MCP, and PMRH conducted the data analysis. ERGJ, MDCS, KMSR, GJT, and JK developed the manuscript. ERGJ, PMRH, JRM, SK, FS, and JK reviewed and edited the manuscript. All authors read and approved the final manuscript.

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Correspondence to Ernesto R. Gregorio .

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This study received ethics approval from the Far Eastern University—Dr. Nicanor Reyes Medical Foundation (FEU–NRMF) (Approval code: 2021–0131). Study participants provided consent to participate before study measurements were taken.

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Permission was sought and received from the study respondents to conduct and publish the results of this study.

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Gregorio, E.R., Takeuchi, R., Hernandez, P.M.R. et al. Knowledge, attitudes, and practices related to dengue among public school teachers in a Central Luzon Province in the Philippines: an analytic cross-sectional study. Trop Med Health 52 , 25 (2024). https://doi.org/10.1186/s41182-024-00591-7

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DOI : https://doi.org/10.1186/s41182-024-00591-7

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Different domains of dengue research in the Philippines: A systematic review and meta-analysis of questionnaire-based studies

Affiliations.

• 1 Faculty of Pharmacy, Department of Pharmaceutical Life Sciences, Universiti Malaya, Kuala Lumpur, Malaysia.
• 2 Faculty of Medicine and Health Science, Department of Biomedical Science and Therapeutics, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia.
• 3 Department of Community and Global Health, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
• 4 College of Pharmacy, University of the Philippines, Manila, Philippines.
• 5 School of Health, Medical & Applied Sciences, Central Queensland University, Brisbane, QLD, Australia.
• 6 College of Health & Human Sciences, Charles Darwin University, Casuarina, NT, Australia.
• 7 College of Health Sciences, Vin University, Gia Lam District, Hanoi, Vietnam.
• 8 Centre for Virus and Vaccine Research, School of Medical and Life Sciences, Sunway University, Selangor, Malaysia.
• 9 Department of Biological Sciences, School of Medical and Life Sciences, Sunway University, Selangor, Malaysia.
• 10 Faculty of Medicine & Health Sciences, UCSI University, Port Dickson, Negeri Sembilan, Malaysia.
• 11 Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
• 12 Asia-Europe Institute, Universiti Malaya, Kuala Lumpur, Malaysia.
• 13 Department of Pathology and Microbiology, Faculty of Medicine and Health Science, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia.
• PMID: 34929011
• PMCID: PMC8687574
• DOI: 10.1371/journal.pone.0261412

Background: Dengue is the most rapidly spreading mosquito-borne viral disease of humans worldwide, including southeast Asia region. This review provides a comprehensive overview of questionnaire-related dengue studies conducted in the Philippines and evaluates their reliability and validity in these surveys.

Methods: A review protocol constructed by a panel of experienced academic reviewers was used to formulate the methodology, research design, search strategy and selection criteria. An extensive literature search was conducted between March-June 2020 in various major electronic biomedical databases including PubMed, EMBASE, MEDLINE and ScienceDirect. A systematic review and meta-analysis (PRISMA) were selected as the preferred item reporting method.

Results: Out of a total of 34 peer-reviewed dengue-related KAP studies that were identified, 15 published from 2000 to April 2020 met the inclusion criteria. Based on the meta-analysis, a poor mean score was obtained for each of knowledge (68.89), attitude (49.86) and preventive practice (64.69). Most respondents were equipped with a good knowledge of the major clinical signs of dengue. Worryingly, 95% of respondents showed several negative attitudes towards dengue prevention, claiming that this was not possible and that enacting preventive practices was not their responsibility. Interestingly, television or radio was claimed as the main source of gaining dengue information (range 50-95%). Lastly, only five articles (33.3%) piloted or pretested their questionnaire before surveying, of which three reported Cronbach's alpha coefficient (range 0.70 to 0.90).

Conclusion: This review indicates that to combat the growing public health threat of dengue to the Philippines, we need the active participation of resident communities, full engagement of healthcare personnel, promotion of awareness campaigns, and access to safe complementary and alternative medicines. Importantly, the psychometric properties of each questionnaire should be assessed rigorously.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Fig 1. PRISMA flowchart of the literature…

Fig 1. PRISMA flowchart of the literature search.

Fig 2. Meta-analysis of dengue knowledge scores…

Fig 2. Meta-analysis of dengue knowledge scores in the Philippines.

Fig 3. Meta-analysis of proportion of people…

Fig 3. Meta-analysis of proportion of people with good dengue knowledge in the Philippines.

Fig 4. Meta-analysis of attitude scores among…

Fig 4. Meta-analysis of attitude scores among Philippines communities.

Fig 5. Meta-analysis of dengue practice score…

Fig 5. Meta-analysis of dengue practice score in the Philippines.

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Dengue: Philippines declares national epidemic as cases surge across South East Asia

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The government of the Philippines has declared a national epidemic of dengue fever for the first time this century, as the number of infections surged to twice last year’s toll, killing 622 people, many of them young children.

The country recorded 146 062 dengue cases from January to 20 July this year, 98% more than in the same period in 2018.

The health secretary, Francisco Duque, told a press conference on 7 August that his ministry was now recording more than 5000 new cases a week. “This is really staggering,” he said. “This is going to be a record number.”

Two years ago the Philippines banned Sanofi Pasteur’s Dengvaxia, 1 the …

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Philippines: Worst dengue outbreak in years kills over a thousand

Outbreak reported across Southeast Asia but the Philippines has the highest number of cases and confirmed deaths.

Manila, Philippines – Emie Angeles and her husband, Rico Reyes, have not had a decent night’s sleep for days.

Two weeks ago, the couple rushed two of their children, two-year-old Katelyn and seven-year-old KD, to hospital with a fever of over 39C (102.2 Fahrenheit) that would not subside.

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Katelyn had contracted dengue last year and the couple did not want to take any chances.

Her blood test was positive for dengue while KD’s showed no infection but indicated a low platelet level, so the parents decided to have both children admitted.

Two days later, Katelyn no longer had a fever.  “She was already singing her favourite song about balloons … We were getting ready to go home,” Reyes said.

Then Katelyn’s fever came back.

“It all happened so fast. She vomited blood, her nose began bleeding and she began to convulse. The doctors tried to revive her but …” said Katelyn’s mother, still dazed.

Katelyn was pronounced dead on September 8.

Dengue outbreak

Over the past months, the Philippines has been grappling to stem its worst dengue outbreak since 2012.

According to the Department of Health, a total of 271,480 dengue cases were reported from January to August 31 of this year, prompting the declaration of a national dengue epidemic .

In 2012,  187,031 cases of dengue were recorded.

As of August 31 this year, an estimated 1,107 people have died of dengue in the Philippines, almost half were children between five and nine years of age.

At Manila’s Tondo Medical Center, where Katelyn was treated, 21 dengue patients were crowded into one room in the paediatric ward.

Two to three patients have to share a bed, with additional beds set up in the corridors to deal with the overflow.

“Children are particularly susceptible to dengue because they have weaker immune systems compared to adults,” said Amado Parawan, health and nutrition officer at Save the Children Philippines.

The Philippines is grappling to stem its worst dengue outbreak since 2012. There have been 271,480 #dengue cases from the start of this year until end of Aug. Almost half of the estimated 1,107 deaths are among children. Two-year old Katelyn Reyes is one of the victims. pic.twitter.com/hZYjVpe43K — Ana P. Santos (@iamAnaSantos) September 17, 2019

An attempt in 2016 to run a dengue vaccination programme – using the Dengvaxia vaccine  – ended abruptly when the efficacy and safety of the vaccine were called into question.

Tens of thousands of dengue cases have been reported in neighbouring Southeast Asian countries but the Philippines appears to be the worst-hit in terms of the number of cases and fatalities, according to a  report  by the World Health Organization (WHO).

According to the WHO report, 124,751 cases of dengue were recorded in Vietnam, 85,270 in Malaysia and 10,206 in Singapore as of the end of August – as much as a three-fold increase compared with the previous year.

Trying to contain the disease

A patient infected with dengue  exhibits  flu-like symptoms and a fever that runs for two to seven days.

The fever may go down temporarily after three days, making many patients think it is over. However, this is a critical phase that must be monitored as it may  progress  to severe dengue, according to Leila Jane Narag, the doctor overseeing the paediatric ward at the Tondo medical facility.

In reaction to the outbreak, the health department has intensified its dengue prevention campaign, destroying mosquito breeding sites and ensuring adequate blood supply in hospitals.

Dengue is transmitted by the Aedes aegypti mosquito, common in all parts of the Philippines.

The rainy season, typically June to February, is the peak period for dengue as water collects in blocked gutters and street drains, turning them into breeding grounds for mosquitoes.

According to Narag, reducing mosquito populations by cleaning water sources like wells and water storage containers is essential to preventing further spikes in dengue cases.

“A dengue outbreak is not exactly a new phenomenon. We have seen this happen every four to five years and it is often linked to changing weather patterns,” said Rabindra Abeyasinghe, Philippines representative for the WHO.

But higher temperatures and longer rainy seasons contribute to the scale of the outbreak, as can a change in the type of dengue virus, he added. 

Among the four types of dengue, the “Asian” genotypes of DEN-2 and DEN-3 are frequently associated with severe diseases like pneumonia, accompanying secondary dengue infections.

An estimated 64 percent of profiled dengue cases in the Philippines are DEN-3, a ccording to the health department.

Dengvaxia controversy

In 2016, large dengue outbreaks were reported worldwide.

More than 375,000 suspected cases of dengue were reported in the Western Pacific region, a lmost half were in the Philippines.

The same year, the Philippines rolled out a large-scale school-based dengue immunisation campaign using Dengvaxia, touted at the time as the world’s first dengue vaccine.

However, the programme was  suspended in 2017  after Sanofi Pasteur, which manufactured the vaccine, issued new clinical findings saying that taking it may not be effective in some cases and may lead to more severe symptoms of dengue among those who have not been previously infected.

Consequently, the Philippines’ Food and Drug Administration permanently revoked the use of Dengvaxia, although several investigations had concluded that no deaths could be directly linked to it.

Officials of President Rodrigo Duterte’s administration were criticised for their “knee-jerk” reaction to the vaccine controversy, given that the programme was introduced during the previous government.

As dengue cases escalated in August, Duterte said he would consider the resumption of the use of the vaccine upon the recommendation of the health department.

But Health Secretary Francisco Duque was adamant that Dengvaxia would not be appropriate for an outbreak response.

Currently, the vaccine is licensed for use in some countries in Europe, the United States and Latin America.

Doctors for Truth and Public Welfare, a group of medics and scientists led by former Health Secretary Esperanza Cabral, is appealing to the government to allow Dengvaxia back onto the market.

“It is not a perfect vaccine, but we think that it should be made available to those who need it and can benefit from it,” Cabral said.

“This (outbreak) is not normal. We cannot accept the 1,000 deaths related to dengue. With proper treatment, you do not die from dengue.”

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Dengue vaccine controversy in the philippines.

Michaeleen Doucleff

A dengue vaccine put thousands of kids at risk for a deadly disorder. Some scientists says the manufacturer did too little to warn parents in the Philippines.

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Dengue cases up, DOH warns public

MANILA, Philippines —  Dengue cases have increased and strategies must be implemented to combat the virus, according to the Department of Health.

Latest DOH data showed a 10 percent increase.

“From 5,547 cases reported from May 5 to 18, (cases went up) to 6,082 from May 19 to June 1. While there have only been 4,689 cases reported from June 2 to 15, the DOH cautions that this number may still change due to incoming late reports,” the agency said in a statement.

From Jan. 1 to June 15, 77,867 dengue cases have been reported, with 205 deaths.

“The number of cases this year is 15 percent higher than the previous year’s tally of 67,576 for the same period,” the DOH noted.

Only five regions did not record an increase from May 5 to June 1: National Capital Region, Calabarzon, Central Visayas, Eastern Visayas and Caraga.

Filipinos are advised to practice the “4S” strategy to combat dengue: search and destroy mosquito breeding grounds by eliminating stagnant water and their containers, self-protection measures like insect repellent and wearing long-sleeved shirts and long pants, seek early consultation for any symptoms and support fogging or spraying in local hotspots or outbreak areas where a case increase is registered.

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Dengue at the time of COVID-19 in the Philippines

Cases of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease 2019 (COVID-19), have been increasing since the virus emerged in Wuhan, China, in December 2019. As of 13 March 2021, confirmed COVID-19 cases have exceeded 119 million infected individuals across 188 countries, with more than 2.6 million recorded deaths. ( 1 ) National health systems have attempted to contain the pandemic through control measures such as community quarantine and isolation. In the Philippines, an enhanced community quarantine (ECQ) took effect on 15 March 2020 in an effort to flatten the epidemic curve. ( 2 ) ECQ involves placing stringent limitations on people’s mobility and strict regulations on various industry operations, all of which are enforced by uniformed personnel. ( 3 ) In spite of the ECQ, active infections have been steadily increasing in the country, at 611 618 total cases and 12 694 deaths as of 13 March 2021. ( 1 )

In 2020, the Philippines recorded a substantial decrease in the number of dengue cases, with a reduction in notified cases of about 70–90% during the rainy season ( 4 ) specifically from epidemiological weeks 28 to 40. ( 5 ) Apart from existing control and prevention measures implemented in the country – such as the establishment of dengue centres of excellence in tertiary hospitals and the creation of dengue fast lanes – the decrease in the number of cases during the COVID-19 pandemic may be largely due to the reduced mobility of the population. Several studies noted that reduction of localized household movement could lead to a reduction in transmission. ( 6 ) On a larger geographical scale, movement control measures reportedly slow or even prevent the spread of a dengue epidemic from locations with high transmission intensity to suburbs or remote areas. ( 7 ) Conversely, the decrease may have also been a result of reporting hesitancy due to the fear of contracting COVID-19 while visiting a health facility. In Caribbean and Latin American countries, an initial sharp decrease in dengue cases coincided with the start of reporting of COVID-19 cases. ( 8 ) The reduction in dengue trend may be due, in part, to the impact of the pandemic on health-seeking behaviour of the population, driven by fear of being infected. A similar reduction in health facility visits was also purported to be the reason behind the decrease in both infectious diseases and non-infectious diseases during the pandemic. ( 9 ) The Philippines has experienced several clusters of infection in hospitals. COVID-19 hospital transmissions have been widely documented in hospitals in various countries. ( 3 ) The existence of these hospital clusters has decreased medical-seeking behaviour due to the fear of contracting the disease, to the extent that it has impacted the reporting of other diseases and illnesses.

Several other countries in the World Health Organization (WHO) Western Pacific Region also noted a decrease in dengue cases in 2020. ( 5 ) However, this was not the case in Singapore, which has seen a substantial increase in cases, possibly associated with the country’s physical distancing measures implemented in response to COVID-19. ( 10 ) For example, the work-from-home measure implemented may have contributed to the increase in dengue cases, compared with the usual workplace setting. Compared with workplaces, residences have a higher propensity for causing dengue infection, owing to the thriving conditions for mosquito breeding. The rise in dengue cases in Singapore and the reduction in the Philippines and other countries in the region show how different control measures (e.g. mobility restrictions) can vary in their effects on levels of dengue. These variations may be due to the extent and degree of control measures, coupled with prevention and control measures directed to either dengue or COVID-19, and inherent country-specific sociodemographic factors; thus, further investigation of these factors is warranted, subject to the availability of data.

The Philippines and other countries in the WHO Western Pacific Region did not see a similar increase in dengue cases in 2020. However, caution should be exercised, because a trend of increasing dengue cases could still develop in current conditions. The renewed rise of COVID-19 cases and the roll-out of COVID-19 vaccinations may have an impact on dengue cases in the latter part of 2021. The increase in COVID-19 cases may lead to more stringent control measures, but the strength of these measures will depend on the progress of vaccination coverage. According to the Philippines’ current COVID-19 vaccination timeline, the general population will probably start receiving vaccinations in July 2021, after completion of the full master list of people to be vaccinated, which is expected by 30 June 2021. ( 1 ) The dengue season starts a month later, at the end of July.

In summary, although the Philippines has seen a decrease in dengue cases in 2020, a scenario in which cases increase is possible, as has happened in Singapore. Further investigation of countries in the region is needed to ascertain which factors have affected the varying impact on notified dengue cases from COVID-19-related measures, compounded by innate sociodemographic characteristics. Nevertheless, health managers can plan ahead and appraise the current conditions, including the rise in COVID-19 cases and vaccination progress, and consider how these may affect the number of dengue cases in the latter part of 2021.

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Philippines

Nearly half of all dengue deaths in the Philippines are children under nine years old

• Save the Children

Manila, August 16 – At least 300 children aged 5-9 have died in the recent Dengue outbreak in the Philippines, Save the Children said today, amid fears the epidemic could claim many more lives before it’s brought under control. In the first seven months of 2019, some 170,000 people were infected with the disease, killing 720 people – 42 percent were children between 5 and 9 years old. Compared to the same period in 2018, this year’s dengue caseload is 97 per cent higher. The virus is disproportionately affecting children and young people with a staggering 73 per cent of recorded cases under the age of 19.

Albert Muyot, ceo of Save the Children in the Philippines, said: “Hundreds of children have sadly already died, we expect the numbers to rise. The rainy season started late and will continue this month, creating the perfect breeding ground for dengue mosquitoes.

“Children are particularly a vulnerable to the disease because their immune systems are weaker than adults and they tend to play outside where there’s less protection against the mosquitos. Schools in particular are a hotbed of dengue because many have open windows and lack mosquito repellents.

“It is extremely important that health authorities step up their information campaigns in schools, communities and other places where people come together, so people know what to do if they suspect dengue. Also, the government must step up their fumigation campaign to kill adult dengue mosquitoes in densely populated areas.

“In the Philippines, we are working with schools and communities to improve awareness on how to prevent infection. To save lives, children need extra protection. Wearing long sleeves and trousers is one of the simple measures to protect against being bitten. Early diagnosis is critical and we are raising awareness of those symptoms, like fever and body pain, and encouraging all parents to take their children to hospital immediately if they have concerns.

“Save the Children is referring child dengue cases to health centers in vulnerable communities in Navotas, Caloocan and Malabon as well as in conflict-affected provinces in Bangsamoro Automous Region in Muslim Mindanao (BARMM).”

Notes to editors :

Dengue causes flu-like illness, including a sudden high fever coming in separate waves, pain behind the eyes, muscle, joint and bone pain, severe headache, and a skin rash with red spots. People with symptoms get ill between 4 to 7 days after a bite from an infected Aedes mosquito.

The illness can become the fatal Severe Dengue, characterised by severe abdominal pain, vomiting, diarrhoea, convulsions, bruising, uncontrolled bleeding, and high fever which can last from 2 to 7 days.

Complications can lead to circulatory system failure, shock, and death.

There were 167,607 dengue cases between January-July 2019, up from 85,011 in the same period in 2018.

Of the 167,607 recorded cases of dengue between January and July 2019, 121,942 were under the age of 19.

On August 6th, the government declared a national dengue epidemic.

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