Prevention of Dengue Fever: An Exploratory School-Community Intervention Involving Students Empowered as Change Agents

RE S E A R C H AR T I C L E

Prevention of Dengue Fever: An ExploratorySchool-Community Intervention InvolvingStudents Empowered as Change Agents∗WASANTHA P. JAYAWARDENE, MDa DAVID K. LOHRMANN, PhD, CHESb AHMED H. YOUSSEFAGHA, PhDc DAYANI C. NILWALA, MBBSd

ABSTRACTBACKGROUND: Dengue fever and dengue hemorrhagic fever (DF/DHF) are epidemic and endemic in tropical and subtropicalcountries including Sri Lanka. Numerous structural and community interventions have been shown to be effective in interruptingthe life cycle of mosquitoes that transmit DF/DHF; however, these interventions are not always implemented intensely and/orconsistently enough to control the mosquito populations and suppress the disease. Following a planned and systematic trainingand mobilizing program, in conjunction with a public information campaign, seventh-, eighth-, and ninth-grade students in 2schools performed multiple mosquito control and education interventions in their communities once a week for 8 weeks.

METHODS: Five actions identified in previous literature and executed by students were tracked and secondary entomologydata were obtained from public health surveillance systems. The Z-test for determining differences between proportions wasutilized to determine significant changes between pre- and post-entomological survey findings in 2 intervention areas, 1 ruraland 1 urban. Pre- and post-incidence rates from the intervention areas and comparable control areas were compared.

RESULTS: In intervention areas, all proportions of larval indexes were found to be significantly lower following the intervention.Surveillance data showed a 73% reduction in case load for the urban area and a 61% reduction in the rural area during the yearfollowing intervention.

CONCLUSION: If properly involved and guided, school children can be an asset to mosquito-borne disease control; theeducation sector could be an important partner in DF/DHF control.

Keywords: dengue; mosquito; school; community.

Citation: Jayawardene WP, Lohrmann DK, YoussefAgha AH, Nilwala DC. Prevention of dengue fever: an exploratoryschool-community intervention involving students empowered as change agents. J Sch Health. 2011; 81: 566-573.

Received on June 12, 2010Accepted on November 3, 2010

Dengue is considered an emerging threat thatremained as a relatively minor, geographically

restricted disease until first reported in epidemicproportions in the Philippines and Thailand during1950s.1 Dengue fever and dengue hemorrhagic fever(DF/DHF) are now leading causes of illness anddeath in the tropics—almost 100 million people areinfected annually, including 500,000 cases with 22,000deaths, mostly among children.1 Dengue is transmitted

aGraduate Student, ([email protected]), Department of Applied Health Science, School of Health, Physical Education and Recreation, Indiana University Bloomington, Room116, 1025 E Seventh Street, Bloomington IN 47405.bProfessor, ([email protected]), Department of Applied Health Science, School of Health, Physical Education and Recreation, Indiana University Bloomington, Room116, 1025E Seventh Street, Bloomington IN 47405.cAssistant Professor, ([email protected]), Department of Applied Health Science, School of Health, Physical Education and Recreation, Indiana University Bloomington, Room116, 1025 E Seventh Street, Bloomington IN 47405.dMedical Doctor, ([email protected]), Base Hospital Homagama, Homagama, Colombo, Sri Lanka.

Address correspondence to: Wasantha P. Jayawardene, Graduate Student, ([email protected]), Department of Applied Health Science, School of Health, Physical Educationand Recreation, Indiana University Bloomington, Room116, 1025 E Seventh Street, Bloomington IN 47405.

*Indicates CHES and Nursing continuing education hours are available. Also available at: http://www.ashaweb.org/continuing_education.html

between people by the mosquitoes Aedes aegypti andAedes albopictus, which are found throughout the worldand are endemic in more than 100 countries in Africa,Asia, Pacific region, South America, and the Caribbeanregion along with Texas and Puerto Rico. Endemicdisease, by definition, occurs annually, usually duringthe rainy season when Aedes mosquito populationsare high, resulting in greater risk of frequent dengueepidemics.

566 • Journal of School Health • September 2011, Vol. 81, No. 9 • © 2011, American School Health Association

Dengue fever is caused by any of the 4 serotypes(DENV1, DENV2, DENV3, and DENV4) of denguevirus. The occurrence of DF/DHF epidemics requires acoexistence of a large number of Aedes mosquitoes(vectors), a large number of nonimmune people(hosts) in relation to any of the 4 dengue virusserotypes, and an increased probability for contactbetween vectors and hosts. Therefore, like any othervector-borne disease, the basic principles of diseasecontrol are based on reducing the mosquito breed-ing places, reducing the survival rate of the mosquito,reducing or preventing man-vector contact, and iden-tifying and managing cases early.1

Sri Lanka is a 25,000-square-mile island located33 km south of India. For a tropical country like SriLanka, mosquito-borne diseases, such as malaria, filar-iasis, dengue, and chikungunya, commonly occur andare endemic. Therefore, complete elimination of thebreeding of mosquito vectors or complete eradicationof the disease is not possible. Nevertheless, these dis-eases realistically could be controlled and kept at levelsthat do not result in epidemic threats to public health.

In Sri Lanka, epidemics of dengue often occurfrom May to September during the southwesternmonsoons. A total of 15,408 cases with 88 deaths(case fatality rate [CFR] = 0.57 and range 0.4-1.1%)was reported in 2004.2 The 2004 outbreak was serious,although the CFR was lower than in the past, dueto early diagnosis and better treatment. In 2005,incidence decreased significantly but in 2006 thereported DF/DHF cases and deaths increased 2-fold ascompared to 2005. These outbreaks were assumed tobe of national importance.2 Over the past 25 years, theworst outbreak occurred in 2009, with 32,000 reportedcases and 290 deaths, of which the majority werechildren. Unlike previous outbreaks that lasted lessthan 6 months, the 2009 outbreak has been continuinguntil the present time, resisting all the preventivemeasures.2

For any vector-borne disease control program tobe successful, it should be well managed, acceptedby the community, and sustainable, continuing withfull citizen participation.3 The community should begiven scientifically accurate information about the dis-ease, behavior patterns of mosquitoes, risk factorsinvolved, control measures envisaged, and specificrecommendations regarding how community mem-bers can cooperate and participate in the program soas to make it a part of their daily life habits.4 The pro-gram must persist over long periods of time even in theabsence of epidemics.5 In addition, people should beconvinced that they have a control over their health inrelation to dengue rather than depending on externalsupport such as the health care system.6

Schools are key community institutions that cantake a substantial role in prevention and control ofmosquito-borne illness. Nevertheless, at the present

time participation of Sri Lankan schools in the denguecontrol program has not been encouraging. Manystudents still do not understand simple concepts relatedto the behavior of dengue-carrying mosquitoes, theirbreeding places, or the proven strategies communitiescan implement to eliminate the breeding and restingplaces of mosquito populations.7 To learn how to bet-ter involve schools, the current pilot intervention wasintended to:

1. Investigate the feasibility of a program to systemat-ically involve students in DF/DHF control.

2. Determine whether the incidence of DF/DHF in aselected semi-urban setting and its adjoining villagein Ampara district of Sri Lanka declined in the yearfollowing implementation of an 8-week student-ledcontrol program.

METHODS

ParticipantsSchool children of grades 7 through 9 and inhab-

itants of 2 selected communities, representing urbanand rural areas, respectively, in the Ampara districtof Sri Lanka, were subjects in this exploratory inter-vention. Two communities were chosen as sites forthe intervention based on relatively higher incidenceof DF/DHF as recorded at surrounding hospitals over3 years. The selected urban area reported an annualincidence rate of 68, 51, and 68 per 100,000 in 2004,2005, and 2006, respectively, while the rural areareported annual incidence rates of 45, 45, and 90 per100,000 for these years.8 These rates are based onnotification data from the current surveillance systemand most likely are a gross underreporting of casesseen by private medical practitioners and governmen-tal hospitals.8 In addition, many cases are likely tohave been misdiagnosed or undiagnosed due to clinicaldifficulties in the differential diagnosis of the DF/DHF.

The situation in Ampara district, located in the east-ern province of the island with a 2008 populationof approximately 300,000, varies somewhat. Amparadistrict, with both urban and village communities issituated in the dry zone of Sri Lanka, with a meantemperature 25 to 27◦C and a mean rainfall of 1500to 2000 mm.8 Most rainfall occurs from November toFebruary with lesser amounts occurring from May toAugust. Ampara has a relatively lower incidence ofDF/DHF (26 compared to 34 per 100,000 per year forthe country), although the cases occur in the Novem-ber to February period in addition to the more typicalMay to September period due to the prominence ofnortheastern monsoon.8

For this study, 1 school was selected from eachof the 2 selected areas within Ampara district. Theurban school had 1152 children in 1st to 12th grades,while the rural school had 737 children in 1st to

Journal of School Health • September 2011, Vol. 81, No. 9 • © 2011, American School Health Association • 567

10th grades. In 2007, grade 7, 8, and 9 studentsfrom both schools were selected to participate (313urban and 233 rural).8 Students in these grades wereselected because of the relatively lesser intensity oftheir academic programs, absence of critical examina-tions, and their developmental ability to function aschange agents within their families and communities.

Altogether, 1395 families and 5900 inhabitants livein the semi-urban settlements (area of 3 square miles)and 860 families and 4430 inhabitants live in the ruralsettlement (area of 4 square miles). Almost 80% of thepopulation was categorized as living in poverty as theyearn less than Rs. 3000 ($30) per month and receivegovernment assistance.8

Data SourcesRoutine entomological surveillance system for

Aedes vector and current epidemiological surveil-lance system for DF/DHF cases were used as studyinstruments for data collection. This surveillance haspassive, active, and sentinel components.8 In the pas-sive component, physicians report all patients treatedfor DF/DHF to the public health department. Once acase is reported, a public health officer visits the hometo actively determine whether other family membersand neighbors are also infected. Weekly, an infectioncontrol nurse visits every department in a hospital toidentify any patients with detected DF/DHF infectionwho have not been previously reported to the publichealth department.

These data were retrieved from databases andrecords of 2 surveillance systems in the Epidemiolog-ical Unit of Sri Lanka and the Regional EpidemiologyUnit of Ampara district. Epidemiological data includ-ing multiyear trends in case rates were available forthe district in which these 2 communities were locatedas well as for the adjoining districts of Monaragala,Badulla, and Polonnaruwa, which served as de factocomparison communities for this study.2 Monaragalaand Polonnaruwa districts have rainfall and temper-ature patterns as well as socioeconomic status and ademographic makeup among the population almostidentical to Ampara.2,8 Badulla district has somewhatgreater rainfall and a larger minority population withsubstantial employment in tea plantations.2

Four process indicators were created with theseinstruments for evaluation of the intervention: 3 ofthem are entomological and 1 (the last) is epidemio-logical.

1. Container index (CI) = Percentage of containers,where the larvae are found.

2. House index (HI) = Percentage of houses, wherethe larvae are found.

3. Breteau index (BI) = Number of infested containersper 100 houses inspected.

4. Number of DF/DHF cases reported from allareas under routine epidemiological surveillancesystem.

ProceduresOn the basis of previous research, 20 intervention

activities were identified and categorized based onwhether they could be expected to have an immediatedisruptive effect on the life cycle of dengue-carryingmosquitoes (Figure 1) or were essential for long-termsustainability of mosquito population control efforts.Feasibility and importance of achieving outcomes andprogram priorities were the main criteria for selectingspecific activities (Table 1).

Following discussions with educational authorities,permission was obtained to involve school childrenin the study. Two advocacy programs were con-ducted to negotiate with and obtain support frommultiple community stakeholders including politi-cal, religious, community organization, and businessleaders as well as high-level government officials.The advocacy campaigns comprised of speeches anddemonstrations designed to generate understandingand support among targeted stakeholders.8

In addition, 2 awareness programs were conductedfor teachers and 2 for parents. This activity wasdesigned to heighten awareness of DF/DHF magni-tude in the community, explain the community’srole and responsibility in infection control, describethe intended role of students in the planned controlprogram, and elicit support for student involvement.Active consent was obtained from parents or guardiansat informational meetings or by letters sent home withstudents and 257 of the 313 (82%) urban school stu-dents and 205 of the 233 (88%) rural students wereallowed to participate. Concerns about security, extraclasses, and chronic health conditions were the pri-mary reasons for parent refusal. By gender, 115 of the257 (45%) urban participants and 87 of the 205 (42%)

Figure 1. Aedes Mosquito Life Cycle

Several Weeks (depending onenvironmental conditions andavailability of resting places)

2-5 Days (30-50 eggs,which can resistdehydration up to 1 yr)

2-3 Days5-10 Days

2 Days

Water

Air

Adult

EggsMosquito Life CycleAdultEmerges

Pupa

Larva


Table 1. Interventions Implemented During Each of the Intervention, Guiding Principles, and Short-Term/Long-Term OutcomeIndicators

Week Intervention Resources Principle of Intervention Outcome Indicator

1 Identification of most productivecontainer types for Aedes mosquitobreeding both inside and outsidehouses

249 students in urban area, 188students in rural area, 10 members ofentomology teamwith 2 vehicles

Careful local assessment of the ecologyof Aedes larvae and pupae usingsurveys of pupal productivity toidentify the categories of containersfromwhich the majority of adultmosquitoes emerge

CI for different types of containers∗

2 Eliminate most productive containertypes identified by larval survey inthe first week

242 students in urban area, 181students in rural area guided by 2PHIs and 2 PHMs

Targeted environmental managementand other control measures towardthe categories of breeding sites,which were identified as havinghighest pupal productivity

Number of containers destroyed orbreeding controlled∗

3 Eliminating other types of breedingsites outside houses and shops withless pupal productivity

237 students in urban area, 177students in rural area guided by 2PHIs and 2 PHMs, leaflets, posters,larvivarous fish

Aedes mosquito breeding ischangeable if outdoor environmentis modified. Mosquito can adopt newbreeding places if preferred placesare eliminated. Therefore, all outsidebreeding sites should be targeted

CI for various types of outdoorcontainers∗

4 Eliminate other types of breeding sitesinside houses and shops with lesspupal productivity

240 students in urban area, 181students in rural area guided by 2PHIs and 2 PHMs, leaflets and posters

Aedes mosquito breeding ischangeable if indoor environment ismodified. Mosquito can adopt newbreeding places if its preferred placesare eliminated. Therefore, all indoorbreeding sites should be targeted

CI for various types of indoorcontainers∗

5 Continuation of activities of second,third, and fourth weeks to ensurecompleteness

224 students in urban area, 173students in rural area guided by 2PHIs and 2 PHMs, larvivarous fish

Essential that environment be almostfree of Aedes mosquito breedingsites although complete eliminationof breeding places is impossible in atropical country

CI, HI, and BI∗

6 Minimize indoor and outdoor restingplaces of adult Aedes mosquito byestablishing good rapport withhousehold members

239 students in urban area, 183students in rural area guided by 2PHIs and 2 PHMs, leaflets and posters

Adult Aedes mosquito usually rests indark places after a blood meal.Eliminating such places also reducesmosquito survival and mosquitobites. In addition, activity used tobuild good rapport with people forsustainability of outcomes

Not measured∗

7 Educating household members on allaspects of dengue fever with simpledemonstrations of preventionactivities

229 students in urban area, 172students in rural area guided by2 PHIs and 2 PHMs, leaflets, posters,larvivarous fish

Provide people with basic knowledgeand skills on importance of diseaseburden, minimizing mosquitodensity, preventing mosquito bites,identifying a case and communityrole in prevention is critical in longterm

Not measured†

8 Continuation of activities of fifth andsixth weeks, also include householdmembers fromrespective localitiesas preplanned in week 7(approximately 1 member per family)

229 students in urban area, 172students in rural area guided by 2PHIs and 2 PHMs, 1200 people inurban, and 800 in rural areasapproximately, leaflets, posters,larvivarous fish

Knowledge and skills alone are notsufficient to achieve desiredoutcome as active motivation isrequired to put knowledge and skillsinto practice. Working with studentsmakes adults more responsible andhelps adults develop self-efficacy fora sustainable behavioral change

Not measured†

BI, Breteau index; CI, container index; HI, house index; PHIs, public health inspectors; PHMs, public health midwives.∗Short-term indicators.†Long-term indicators.

rural participants were girls. Girls comprised 50% ofeligible students in both schools.8

Six health care workers, including 2 doctors, 2public health inspectors (PHIs), and 2 public healthmidwives, conducted 3 training sessions, 1 week apart,

in each school during September 2007. One sessionper school included 3 subsessions in order to addresseach grade. This approach was adopted to addressstudents in more age-appropriate ways and havemanageable numbers in each group. Sessions lasted


1 hour including multimedia presentations, case sce-narios and discussion. Attendance at each session wasover 80%. The first training session increased aware-ness and alertness in relation to dengue.7 The secondsession explained how the intervention should be car-ried out, with demonstrations and case scenarios basedon the experience of resource persons. The third, mostimportant session, gave students field experience byhaving them face actual problems, but under guidanceof resource persons.

Active participation of students, especially duringthe second and third sessions was prominent.

With this phase of training, each group of studentswas shown the geographical demarcations of the area(about 1/10th square mile) where they would carryout the intervention. Every student was given theoption to select the area where he or she lives or anadjacent area.

The program occurred weekly for 8 weeks inOctober and November 2007 before year-end schoolexaminations. A communication campaign designedto seek assistance and the corporation of the com-munity preceded the intervention. It consisted of apublic announcement over the official health sectorannouncing system and distribution of health edu-cation leaflets by participating children. Intervention

activities were carried out every Friday for 2 hours(2-4 PM), after school under the concept ‘‘Every weekhas a dry day.’’ In groups of 6, 2 from each grade witha ninth-grade leader, students carried out activitiesfrom lists (Table 1). After 8 weeks, the interventionwas transferred to the regular public health system,in collaboration with existing community committees,with the goal of periodically motivating citizens untilsustainable behavioral change was attained.1

Data AnalysisSecondary data related to entomology were

obtained from the Epidemiology Unit of the AmparaDistrict (Table 2) and tabulated according to pretest/posttest design to demonstrate any changes thatoccurred post-intervention. Entomology surveillancewas conducted by PHIs and District entomologists1 month before the intervention and, again, 2 monthsfollowing the intervention. Entomology surveillanceis routinely and periodically conducted in the controldistricts; however, it was not specifically conducted inconjunction with this study. The Z-test for determin-ing differences between proportions was utilized todetermine significant changes between pre- and post-entomological survey findings in the 2 areas where thestudent intervention was conducted.

Table 2. CI, HI, and BI Before and After Intervention by Breeding Places

Urban Area Rural AreaType of Containerfor Entomology Measurement Before Intervention After Intervention Before Intervention After Intervention

Cement water storage tanks No. inspected 139 139 116 116CI 36% 4%∗ 61% 3%∗

Plastic water storage tanks No. inspected 110 110 144 144CI 35% 3%∗ 57% 4%∗

Small inside household jars No. inspected 139 139 118 118CI 67% 4%∗ 34% 5%∗

Small outside household jars No. inspected 224 217 164 166CI 31% 5%∗ 66% 4%∗

Large outside household jars No. inspected 167 167 156 159CI 29% 2%∗ 59% 3%∗

Toilet water storage No. inspected 192 192 174 170CI 33% 3%∗ 29% 2%∗

Ant traps for food cupboards No. inspected 128 112 132 130CI 71% 4%∗ 23% 3%∗

Flower vase No. inspected 193 193 178 173CI 31% 3%∗ 28% 4%∗

Flower pot plate No. inspected 176 174 166 168CI 29% 2%∗ 67% 4%∗

Used tires No. inspected 186 124 159 110CI 78% 4%∗ 71% 3%∗

Coconut shelves No. inspected 154 49 177 68CI 29% 3%∗ 71% 4%∗

Other discarded containers No. inspected 214 69 201 54CI 34% 3%∗ 64% 5%∗

Other indices HI 64% 12%∗ 38% 7%∗BI 655/100 houses 43/100∗ houses 343/100 houses 28/100∗ houses

BI, Breteau index; CI, container index; HI, house index.∗Difference between this proportion and pre-intervention proportion is statistically significant according to Z-test for difference between proportions.


RESULTS

Container index and BI were decreased by morethan 90% and HI by more than 80% (Table 2).8 Allpre-intervention larval indices in the urban area weresignificantly different from pre-intervention larvalindices in the rural area except for 3 containerindices: toilet water storage, flower vase, and usedtires. Conversely, all post-intervention larval indicesin the urban area were not significantly different frompost-intervention indices in the rural area. In both theurban and rural areas, all proportions of larval indiceswere found to be significantly lower following theintervention compared to pre-intervention indices.8

Program outcomes were revealed by routinesurveillance data related to particular areas, whichshowed a 73% reduction of case load in urban area and61% reduction in rural area for 2008 compared to theaverage per year for the period 2004-2006 (Figure 2).8

The intervention was more effective in the urban area.The majority of 2008 cases were probably contractedfrom other areas during traveling.8 (Note that the 2009incidence rates when the student control program wasnot formally conducted sharply increased, doubling inthe intervention area as compared to 2008 but alsotripling in the control areas. These dramatic increaseswere due to a severe DF/DHF epidemic throughoutSri Lanka in 2009.) Active participation of schoolchildren, highly valued by community members, as

well as unexpectedly encouraging support from thecommunity, were prominent compared to communityparticipation in regular activities conducted by healthcare staff or other organizations prior to and after 2008.

DISCUSSION

This study was conducted in 2 selected areas, withinthe Ampara District of Sri Lanka where the pre-intervention incidence rate of DF/DHF, as compared toadjacent locales, was continuously higher (Figure 2).Viewed another way, the calculated incidence rate wassubstantially higher than that of other areas, as thesecommunities had only 10,330 residents.

Following the intervention, the incidence rate wasreduced by 75%, and, for the first time, was lowerthan that of comparable within-district areas.8

Second, the calculated average incidence rate forother Ampara areas increased by 93% from 2006 to2008, clearly representing the natural disease trendexperienced in the district. Trends in adjoining districts,(Monaragala, Badulla, and Polonnaruwa.) also show<30% variation (increase or decrease) from 2006 to2008.2 As noted earlier, average incidence rates inthese districts were used for comparison purposes toverify the impact of the intervention (Figure 2).

While the increase in incidence rate from 2008 to2009 for the intervention area was lower as comparedto the control area in the same province, trajectories in

Figure 2. Trend of Dengue Fever and Dengue Hemorrhagic Fever Annual Incidence Rates (Per Population 100,000) of InterventionArea and Adjoining Areas, 2004-2009

Sources: Epidemiology Unit, Ministry of Health Care and Nutrition, Sri Lanka and Regional Epidemiology Unit,Ampara District, Sri Lanka.


both these areas plus other control provinces were con-sistent with the severity of the 2009 DF/DHF epidemic.In addition, the 2009 incidence rate in the interventionareas was still only half of what it had been in 2006,also an epidemic year. Regardless, the 2009 incidencerate increase should not be considered as a reasonto discount the effects of 2008 student interventionfor 2 reasons: (1) the infectivity of the dengue virusincreases during a severe epidemic and (2) movementof mosquito vectors and infected individuals into inter-vention areas from adjoining areas is not restricted.

Dengue fever and dengue hemorrhagic feverrestricts national development and constitutes a sub-stantial economic burden due to the cost of treat-ment and control as well as its debilitating effecton communities, families, and individuals. While sev-eral affordable interventions exist, technical solutionsalone rarely guarantee effective control and preven-tion. Strategies to mobilize all levels of society, frompoliticians to families, are essential.3 This particularintervention supports, through empirical evidence, theposition that empowering school children as com-munity change agents is a realistic and productiveapproach for obtaining social participation in DF/DHFcontrol.

LimitationsA study limitation could be that the 2008 biennial

national DF/DHF caseload also decreased. However,this artifact does not affect the study for 2 reasons. First,surveillance data from the previous 10 years confirmthat almost 90% of annual cases occurred in wetzone districts where climate, population density, andhuman activities facilitate vector breeding and diseasetransmission. Therefore, cases from the dry zone,such as Ampara and neighboring districts, have littleinfluence on national trends; the historic variation ofincidence rates in the dry zone is appreciably differentfrom the variation in average national incidencerates.

In addition, improvement of knowledge on DF/DHFprevention among community members as well astheir behavioral and attitudinal changes was notmeasured directly by a method of qualitative datacollection, due to limitation of required humanresources. Knowledge, behaviors, attitudes, and skillsof community members should be added as indicatorsfor direct measurement in future interventions.

ConclusionParticipation of older students in DF/DHF control

activities is encouraging because properly trainedschoolchildren were shown to be capable of executinga range of simple, low-cost, and effective interventionstrategies in places where mosquitoes typically breed.Students were able to participate in activities that

disrupted mosquitoes’ life cycles and teach others todo so. If properly involved and guided, school childrencan be an asset to mosquito-borne disease control.Therefore, the education sector could be an importantpartner in DF/DHF control.

Future research should critically assess thisapproach to determine its generalizability.

The main restrictions are ethical and public con-cerns about utilizing school children for activities nottraditionally viewed as educationally beneficial. Futureresearch should analyze the possibilities of negativeconsequences, such as interference with curriculum-related learning, environmental health hazards, insectbites, injuries, resistance from waste disposal compa-nies, and negative social reactions, because the absenceof such negative consequences in the current interven-tion does not guarantee absence in the future. Furtherresearch may test more effective ways of conductingthe intervention, including community preparation,advocacy, training, multisectoral involvement, pro-gram evaluation, and combining the intervention withtechnical preventive measures and with other forms ofbehavioral change communication. Research may alsotest methods of ensuring sustainability of outcomes.Finally, a cost-benefit analysis should be performed,by weighing all negative outcomes, against all pos-itive outcomes, including behavioral change withincommunities.

IMPLICATIONS FOR SCHOOL HEALTH

This study describes a novel school and publichealth collaboration conducted in urban and rural SriLankan communities that engaged seventh-, eighth-,and ninth-grade students in a successful mosquitocontrol program to reduce DF/DHF. This approach con-stitutes a prime example of ‘‘real-world’’ applicationof concepts from both science and health educationand affords students with a deeper understanding ofwhat, how, and why they learn.9 In addition, thisapproach is consistent with concepts of ‘‘service learn-ing’’ employed in developed countries that involvessecondary school students in community volunteerexperiences. Such experiences provide learning oppor-tunities not afforded through the school curriculumand, most importantly, help students comprehendthe importance of citizen participation that promotesthe common good.9,10 In doing so, they can fosterresponsible citizenship, generate support for publichealth, and, potentially, spark interest in public healthcareers.9

Communicable diseases such as DF/DHF affectschool children in numerous ways including devel-opmental delays, reduced attendance, and lethargy,all of which negatively affect achievement. Therefore,it is in school leaders’ best interest to engage pub-lic health officials responsible for controlling endemic


disease in the adoption of policies and practices thatincorporate participation of secondary school childrenin these efforts where risk is low. Given the success ofthe student-led DF/DHF control program, it should beconsidered for annual implementation with possiblecountry-wide dissemination.

Human Subjects Approval StatementEthical approval to use human subjects was

obtained from Human Subjects Office of Indiana Uni-versity Bloomington.

REFERENCES

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3. Parks WJ, Lloyd LS, Nathan MB, Hosein E, Odugleh A,Clark GG. International experiences in social mobilizing andcommunication for dengue prevention and control. DengueBull. 2005;28:1-7.

4. Kay BH, Nam VS, Tien TV, et al. Control of Aedes vectors ofdengue in three provinces of Vietnam by use of mesocyclops(copepoda) and community-based methods validated byentomologic, linical, and serological surveillance. Am J TropMed Hyg. 2002;66(1):40-48.

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6. Toledo ME, Vanlerberghe V, Baly A, Ceballos E, Valdes L,Searret M. Towards active community participation in denguevector control: results from action research in Santiago deCuba, Cuba. Trans R Soc Trop Med Hyg. 2007;101(1):56-63.

7. Koenraadt CJ, Tuiten W, Sithiprasasna R, Kijchalao U, JonesJW, Scott TW. Dengue knowledge and practices and theirimpact on Aedes aegypti populations in Kamphaeng Phet,Thailand. Am J Trop Med Hyg. 2006;74(4):692-700.

8. Regional Epidemiology Unit RDoHSO, Ampara, Sri Lanka.Dengue Fever and Dengue Hemorrhagic Fever: Surveillanceand Control. Regional Epidemiological Surveillance Data andInterventions. Ampara, Sri Lanka: Regional Director of HealthServices Office, Ampara, Sri Lanka; 2007.

9. Smith J. Education and Public Health Natural Partners in Learningfor Life. Alexandria, VA: Association for Supervision andCurriculum Development; 2003.

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Gold Endowment PartnersArtsTech, A Center for Youth Enterprise, 1522 Holmes Street, Kansas City, Missouri; http://www.artstech-kc.org/ Cerner Corportation, 2800 Rockcreek Parkway, Kansas City, Missouri 64117; www.cerner.com; www.firsthandfoundation.orgKansas Association of Health, Physical Education, Recreation and Dance, PO Box 11, Holcomb, Kansas 67851; http://www.kahperd.org/Kansas State Dept. of Education, Safe and Drug Free Schools, 120 SE 10th Avenue, Topeka, Kansas 66612; www.ksde.orgMarshMedia, 8025 Ward Parkway Plaza, Kansas City, Missouri 64114; www.marshmedia.comMissouri Coordinated School Health Coalition, PO Box 309, Columbia, Missouri 65205 http://www.healthykidsmo.org/Missouri Dept. of Elementary and Secondary Education, PO Box 408, Jefferson City, Missouri 65102; www.dese.mo.govThe SPARK Programs, 438 Camino Del Rio South, San Diego, CA 92108; http://www.sparkpe.org/Wiley-Blackwell, 350 Main Street, Malden, MA 02148; http://www.wiley.com/WileyCDA/

Silver Endowment PartnersDepartment of Applied Health Science, Indiana University, 1025 E. 7th Street, HPER 116, Bloomington, Indiana 47405;http://www.indiana.edu/~aphealth/Kansas Coordinated School Health, 120 SE 10th Avenue, Topeka, Kansas 66612; www.kshealthykids.org/KCSH_Menus/KCSH_Home.htm Kansas State Dept. of Education, Special Education Services, 120 SE 10th Avenue, Topeka, Kansas 66612; www.ksde.org

Sustaining PartnersAmerican Cancer Society, School Health Project National Home Office, 143 Elizabeth Street, Saugatuck, Michigan 49453; www.cancer.org Center for American Indian Community Health, University of Kansas Medical Center, Office of Preventive Medicine, Kansas City,Kansas 66160; ww2.kumc.edu/hr/diversity/diversity.html University of Florida, Department Health Education & Behavior, Gainesville, Florida 32611 http://www.hhp.ufl.edu/heb.php/ Missouri Association of School Nurses, 2308 Ridgemont, Columbia, Missouri 65203-1542; http://www.missourischoolnurses.org/home/homepage.htm

Century PartnersASCD, 1703 N. Beauregard St, Alexandria Virginia 22311; www.ascd.org/ Center for Health and Learning, 28 Vernon Street , Ste. 319, Brattleboro, Vermont 05301; www.healthandlearning.org GOJO Industries, P.O. Box 991, Akron, Ohio 44309; www.gojo.com/united-states/HealthTeacher, 5200 Maryland Way, Ste. 200, Brentwood, Tennessee 37027 www.healthteacher.com Kansas School Nurse Organization, 13174 X Road, Meriden, Kansas 66512; www.ksno.org

Missouri Association for Health, Physical Education, Recreation, and Dance, 1220 W. Crestview Drive, Marysville, Missouri 64468;http://www.moahperd.org/National Association of State School Nurse Consultants, 4705 Circle Drive, Columbia, South Carolina 29206; www.nassnc.org


Documents

Prevention of Dengue Fever: An Exploratory School-Community Intervention Involving Students Empowered as Change Agents