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. Author manuscript; available in PMC: 2012 Aug 1.
Published in final edited form as: Lancet. 2011 May 3;377(9778):1673–1680. doi: 10.1016/S0140-6736(11)60246-8

Dengue vector control strategies in an urban setting: an economic modelling assessment

Paula Mendes Luz 1, Tazio Vanni 1, Jan Medlock 1, A David Paltiel 1, Alison P Galvani 1
PMCID: PMC3409589  NIHMSID: NIHMS297192  PMID: 21546076

Summary

Background

An estimated 2·5 billion people are at risk of dengue. Incidence of dengue is especially high in resource-constrained countries, where control relies mainly on insecticides targeted at larval or adult mosquitoes. We did epidemiological and economic assessments of different vector control strategies.

Methods

We developed a dynamic model of dengue transmission that assesses the evolution of insecticide resistance and immunity in the human population, thus allowing for long-term evolutionary and immunological effects of decreased dengue transmission. We measured the dengue health burden in terms of disability-adjusted life-years (DALYs) lost. We did a cost-effectiveness analysis of 43 insecticide-based vector control strategies, including strategies targeted at adult and larval stages, at varying efficacies (high-efficacy [90% mortality], medium-efficacy [60% mortality], and low-efficacy [30% mortality]) and yearly application frequencies (one to six applications). To assess the effect of parameter uncertainty on the results, we did a probabilistic sensitivity analysis and a threshold analysis.

Findings

All interventions caused the emergence of insecticide resistance, which, with the loss of herd immunity, will increase the magnitude of future dengue epidemics. In our model, one or more applications of high-efficacy larval control reduced dengue burden for up to 2 years, whereas three or more applications of adult vector control reduced dengue burden for up to 4 years. The incremental cost-effectiveness ratios of the strategies for two high-efficacy adult vector control applications per year was US$615 per DALY saved and for six high-efficacy adult vector control applications per year was $1267 per DALY saved. Sensitivity analysis showed that if the cost of adult control was more than 8·2 times the cost of larval control then all strategies based on adult control became dominated.

Interpretation

Six high-efficacy adult vector control applications per year has a cost-effectiveness ratio that will probably meet WHO's standard for a cost-effective or very cost-effective intervention. Year-round larval control can be counterproductive, exacerbating epidemics in later years because of evolution of insecticide resistance and loss of herd immunity. We suggest the reassessment of vector control policies that are based on larval control only.

Funding

The Fulbright Programme, CAPES (Brazilian federal agency for post-graduate education), the Miriam Burnett trust, and the Notsew Orm Sands Foundation.

Introduction

About 50 million dengue infections occur every year worldwide.1 The incidence of dengue is increasing, especially in metropolitan areas, mainly because of growing vector and human population densities. Dengue incidence is high in resource-constrained countries where restricted health budgets are divided between control and treatment. Dengue control relies mainly on insecticides targeted at larval or adult mosquitoes.2,3 However, the evolution of insecticide resistance can lead to the failure of dengue control programmes.4,5

To estimate the effect of insecticide-based vector control on health and health economic outcomes, we developed a dengue transmission model that extends previous analyses of vector control6–8 by considering the evolution of insecticide resistance in mosquito populations together with human population immunity, and by integration of a dynamic model with an economic assessment. We use the city of Rio de Janeiro in Brazil as a case study because it is an example of a resource-constrained urban setting with endemic dengue, and because adequate data are available for setting the parameters of the model. We used the model to calculate the health burden in terms of disability-adjusted life years (DALYs) lost to dengue and the cost-effectiveness of various interventions.

Methods

Mathematical model

To describe the transmission cycle of dengue in a metropolitan area, we extended a previous mosquito model9 to include human population dynamics and dengue transmission (webappendix p 4). The mosquito model incorporates seasonality and population genetics of insecticide-resistance evolution. The model parameters were set with ecological and biological data specific to Aedes aegypti, retrieved through searches of PubMed, Web of Science, SciELO, reports from the Brazilian government, and WHO publications (webappendix p 5).9 To simulate dengue transmission, adult mosquitoes were divided into two groups: uninfected old adult (older than 5 days; O), and dengue-virus infected adult mosquitoes (OI). Uninfected old adults acquire infection (entering the compartment OI) at a rate that depends on the force of infection (λM) and the duration of the extrinsic incubation period (τ). We defined the force of infection as a function of biting rate of mosquitoes (c); proportion of people with infection (either primary or secondary infections; I), and their respective probabilities of infecting a mosquito, (β1I1 + β2I2)/H, where H is the total number of human beings; and mosquitoes’ susceptibility to infection (□M). Thus, λM = (c□M(β1I1 + β2I2))/H.

We incorporated the demographic dynamics of the human population from Rio de Janeiro into the model (webappendix p 5). Newborn babies (Rm) have maternally acquired immunity that wanes at rate α. Susceptible individuals (S1) acquire primary infection at the force of infection rate (λ1), which depends on the biting rate of mosquitoes; the proportion of infected mosquitoes and their infectivity, βmOI / OT, where OT is the total number of adult mosquitoes; the density of mosquitoes to people, OT / H; and the susceptibility of people to primary infection, □1. Thus, λ1 = (c□1(βmOI))/H.

The mortality rate for individuals with dengue haemorrhagic fever is given by □1. Most human beings with primary infection (I1) recover at rate (γ) into a cross-immunity compartment (immunity to all four dengue serotypes; R1). Cross-immunity wanes at a rate δ, resulting in susceptibility to secondary infection (S2). Secondary infection (I2) occurs at a rate λ2. This force of secondary infection depends on the biting rate of mosquitoes; the proportion of infected mosquitoes and their infectivity; the density of mosquitoes to human beings; and the susceptibility of people to secondary infection (□2). Thus, λ2 = (c□2(βmOI))/H. Most individuals with secondary infection, recover at rate γ into a resistant compartment (R2). Those presenting with dengue haemorrhagic fever die with probability □2 (which is greater than □1 because secondary infections are more severe).1 Thus, as with previous analyses,10 we modelled primary and secondary infections, but did not specify the dengue serotype causing the infection. Despite this simplification, we incorporated the force of infection for all four serotypes by defining full susceptibility to primary infection and 75% susceptibility to secondary infection resulting from immunity to the primary serotype.

Insecticide-based vector control

We assessed the effect of vector control for a 5-year period. Two forms of vector control were analysed—larval and adult control. Larval control has an environmental persistence of 2 months,11,12 during which the effectiveness of the insecticide wanes (webappendix p 3). Adult control with ultra-low-volume insecticide applications has an immediate effect on the mosquito population that lasts for 1 day (webappendix p 3).13,14 Larval and adult control interventions consisted of one to six applications every year. Because field-based estimates of vector control efficacy vary substantially as a function of many factors,15,16 we explored a full range of efficacies. For both forms of control, we assessed the effect of high-efficacy (90% mortality), medium-efficacy (60% mortality), and low-efficacy (30% mortality) interventions. We also assessed six combined strategies: one application of high-efficacy larval control with either three, four, or five applications of low-efficacy adult control, and two applications of high-efficacy larval control with either three, four, or five applications of low-efficacy adult control. Thus, including no vector control, 43 vector control strategies were considered.

Health outcomes and costs

DALYs were used to measure health outcomes because they incorporate both death and disability.17 Details of DALY calculations, including parameter values, are shown in the webappendix (p 7). We considered the costs of larval and adult control in a large metropolitan area (webappendix p 6). In conformity with international standards for economic assessments,18 we did the analysis from a societal perspective, assessing direct medical and non-medical costs and indirect costs from workdays lost because of dengue (webappendix p 6).19,20 Costs were expressed in 2009 US dollars (US$). Costs and DALYs were discounted at a yearly rate of 3%, as per WHO recommendations.21

Cost-effectiveness analysis of vector control

We calculated the incremental cost-effectiveness of all 43 vector control strategies. Comparative value was measured in $ per DALY saved during the 5-year vector control assessment period. We defined Brazil-specific thresholds of $24660 per DALY saved for a cost-effective intervention, and of $8220 per DALY saved for a very cost-effective intervention, on the basis of the criteria of the WHO Commission on Macroeconomics and Health.21,22

Sensitivity analysis

We did probabilistic sensitivity analyses and threshold analyses to examine the effect of parameter uncertainty on the results (webappendix p 9). In the probabilistic sensitivity analysis we assessed the effect of uncertainty in both the DALY and cost parameters. Gamma distributions were assigned to cost parameters, and beta distributions were assigned to probabilities. By sampling from these distributions, 10000 estimates for the costs and effects of each strategy were calculated. Cost-effectiveness acceptability curves were used to depict the level of uncertainty surrounding our cost-effectiveness estimates at different values of society's willingness to pay for an additional DALY saved.23 In view of the uncertainty of available cost estimates for insecticide-based vector control, we did a specific threshold analysis of cost parameters. In the threshold analysis, we established the cost of adult mosquito control beyond which any strategy involving such control would become dominated (a strategy is said to be dominated if it costs more and delivers fewer DALYs than another strategy [strong dominance] or a combination of other strategies [weak dominance]) according to WHO's standard for a cost-effective intervention for Brazil.21,22 Statistical analyses were done with MatLab Version 7.5, Microsoft Office Excel 2003, and PopTools Version 3.2.3.

Role of the funding sources

The sponsors of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

Results

Without any vector control intervention, large epidemics of mostly primary infections are predicted to occur over 5 years, with interepidemic periods of lower dengue incidence (figure 1). After this initial period, stable equilibrium is reached because of the deterministic nature of the model, and dengue becomes endemic. Over 20 years, the average yearly incidence of dengue fever is 100 cases per 10000 population, which is consistent with epidemiological data from Brazil and Latin America.24–27 Our baseline period of analysis was a 5-year period after dengue established itself endemically (figure 1). For this period, the average annual dengue burden was 227 DALYs lost per million population, which accords with estimates based on empirical data.20,28–32 For the entire 5-year period, the expected dengue burden was 1133 DALYs lost per million populations (table).

Figure 1. Model of predicted incidence of dengue with no vector control.

Figure 1

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The area between the dashed lines shows the 5-year vector control assessment window.

Table.

Mean number of disability-adjusted life years lost per million population with and without vector control

Year 1 Year 2 Year 3 Year 4 Year 5 Total
No vector control 205 256 208 236 228 1133
High-efficacy larval control
    One application 82 170 286 145 224 908
    Two applications 45 38 296 327 136 841
    Three applications 14 5 251 537 23 829
    Four applications 5 2 282 552 15 854
    Five applications 2 1 356 493 20 872
    Six applications 1 2 501 326 100 930
Intermediate-efficacy larval control
    One application 138 234 210 181 209 973
    Two applications 103 178 264 152 214 913
    Three applications 62 117 323 152 232 886
    Four applications 37 62 361 204 234 897
    Five applications 23 31 366 292 174 886
    Six applications 16 18 383 350 120 887
Low-efficacy larval control
    One application 172 243 192 200 201 1009
    Two applications 154 231 206 187 206 985
    Three applications 130 227 219 175 211 962
    Four applications 110 220 235 163 216 943
    Five applications 95 211 252 151 222 931
    Six applications 85 200 269 142 229 925
High-efficacy adult control
    One application 36 105 348 108 216 812
    Two applications 9 6 92 480 64 652
    Three applications 4 0 2 147 578 730
    Four applications 3 0 0 3 571 577
    Five applications 2 0 0 0 365 368
    Six applications 2 0 0 0 246 248
Intermediate-efficacy adult control
    One application 99 255 214 184 188 940
    Two applications 38 110 353 123 211 836
    Three applications 18 26 256 293 116 709
    Four applications 8 3 29 472 152 664
    Five applications 6 0 3 172 527 708
    Six applications 4 0 0 21 632 658
Low-efficacy adult control
    One application 154 253 195 195 213 1009
    Two applications 111 237 225 170 213 956
    Three applications 73 228 249 155 203 907
    Four applications 51 149 323 115 208 846
    Five applications 36 86 341 150 198 810
    Six applications 25 43 318 193 161 740
High-efficacy larval control (LC) combined with low-efficacy adult control (AC)
    One application of LC and three applications of AC 29 35 289 276 169 798
    One application of LC and four applications of AC 21 18 233 380 101 753
    One application of LC and five applications of AC 15 8 142 470 98 733
    Two applications of LC and three applications of AC 17 4 72 628 43 763
    Two applications of LC and four applications of AC 13 2 38 646 58 756
    Two applications of LC and five applications of AC 10 1 16 635 104 767
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High-efficacy larval control reduced the dengue health burden during the first 2 years (table; figure 2)—three or more applications of high-efficacy larval control reduced the expected annual dengue burden to below 14 DALYs lost per million population. For all high-efficacy larval control interventions, use of three applications led to the smallest loss of DALYs in the third year, use of one application led to the smallest loss of DALYs in the fourth year, and use of four applications led to the smallest loss of DALYs in the fifth year (table; figure 2). Medium-efficacy larval control resulted in 18 or fewer DALYs lost per million population annually during the first 2 years when six applications of larval control were applied (table; figure 2). However, this same strategy led to the loss of most DALYs (among all intermediate-efficacy larval control interventions) in years 3 and 4. Low-efficacy larval control had little effect on dengue health burden (table; figure 2). For the entire 5-year period, three applications of high-efficacy larval control every year reduced the dengue burden the most (table).

Figure 2.

Figure 2

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Effect of larval control on dengue burden

Four or more applications of high-efficacy adult control decreased the number of DALYs lost in the first 4 years (table; figure 3). In the fifth year, the most effective high-efficacy intervention strategy was two applications of high-efficacy adult vector control. Although use of six applications of medium-efficacy adult control was the most effective medium-efficacy strategy in the first 4 years, it was the least effective strategy in the fifth year (table; figure 3). Low-efficacy adult vector control offered sustained reduction of the dengue health burden in the first 2 years when used at a frequency of six applications (table; figure 3). For the entire 5-year period, six applications of high-efficacy adult vector control reduced the dengue burden to the greatest extent, resulting in 248 DALYs lost per million individuals.

Figure 3.

Figure 3

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Effect of adult vector control on dengue burden

Of the combined intervention strategies, those with two applications of high-efficacy larval control substantially reduced dengue burden in the first 3 years. However, a severe epidemic occurred in year 4 (table; figure 4). If only one high-efficacy larval control application was used in combination with low-efficacy adult control, epidemics were predicted to occur in the third and fourth years, but the magnitude of these epidemics was lower than that of the epidemic expected in the fourth year with use of two high-efficacy larval control applications. During the 5-year period, one high-efficacy larval control application and five low-efficacy adult control applications reduced the dengue burden to the greatest extent (table). Of all vector control strategies, the strategy that most substantially reduced the number of DALYs lost per million population during the 5-year period was six applications of high-efficacy adult vector control (table).

Figure 4. Effect of combined vector control on dengue burden.

Figure 4

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LC=larval control. AC=adult control. Adjacent numbers refer to numbers of applications.

Figure 5 shows all 43 interventions in the cost-effectiveness plane, which depicts the difference in costs and effectiveness between the strategies. Cost-effectiveness analysis showed that three strategies were non-dominated: no control, use of two applications of high-efficacy adult control, and use of six applications of high-efficacy adult control (figure 5). One and five applications of high-efficacy adult control were weakly dominated strategies. All other strategies were dominated.33 The incremental cost-effectiveness ratio for two high-efficacy adult control applications was $615 per DALY saved and for six high-efficacy adult control applications was $1267 per DALY saved.

Figure 5. Cost-effectiveness of different control strategies.

Figure 5

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LC=larval control. AC=adult control. HE=high efficacy. IE=intermediate efficacy. LE=low efficacy. The slopes of the black lines represent the incremental cost-effectiveness ratios of the non-dominated strategies.

The probabilistic sensitivity analysis (figure 6) showed that use of six applications of adult control would meet WHO's standard for cost effective with probabil ity 99% and the standard for very cost effective with probability 89%. Threshold analysis showed that if the cost of adult control was more than 8·2 times the cost of larval control then all strategies involving adult control became dominated.

Figure 6. Acceptability curves for control strategies for which the probability of being cost effective is greater than zero.

Figure 6

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Acceptability curves show the probability that a given intervention meets the WHO definition of cost-effective.

Discussion

In our model, one or more applications of high-efficacy larval control reduced dengue burden for up to 2 years, whereas three or more applications of high-efficacy adult vector control reduced dengue burden for up to 4 years. The WHO Commission on Macroeconomics and Health suggests that interventions be deemed cost effective in a given country if their cost-effectiveness ratio is less than three times the national per head gross domestic product. With use of this standard, we showed that the intervention consisting of six high-efficacy adult control applications is cost effective over a wide range of epidemiologically realistic parameter values.

Year-round larval control is used in many settings where dengue transmission occurs.34,35 However, our analyses indicate that strategies based on continuous larval control could be counterproductive. Initially, such strategies reduce the mosquito population and suppress dengue transmission. Indeed, our results show that only a few DALYs are lost per million population during the first 2 years. However, as insecticide resistance evolves and, consequently, the effect of vector control decreases, the mosquito population recovers. Additionally, the suppressed dengue transmission during the initial years of control results in a loss of herd immunity in the human population. Growth of the insecticide-resistant mosquito populations coupled with the loss of herd immunity increases the magnitude of the eventual epidemic when the DALYs lost per million population offsets the predicted dengue burden.

Our model extends previous analyses6–8 by considering the evolution of insecticide resistance together with the loss of herd immunity, thus accounting for the long-term effects of reductions in dengue transmission. Our predictions of a rapid evolution of insecticide resistance in the mosquito population accord with data from other studies.36 In Rio de Janeiro, for example, a substantial rise in the prevalence of resistance was recorded in a 2-year period.4 Furthermore, we linked the dynamic model with a health burden analysis and a cost-effectiveness analysis. The probabilistic sensitivity analysis allowed us to assess the probability of a strategy being cost effective with parameter uncertainty and willingness-to-pay uncertainty. Using a threshold analysis, we were able to show the extent to which the cost of adult vector control would have to offset the cost of larval control for adult vector control strategies to become dominated.

The results of our uncertainty analysis are presented with use of multiway cost-effectiveness acceptability curves as suggested by a broad consensus of experts.37,38 Concern has been raised that cost-effectiveness acceptability curves can violate the economic assumption of independence of irrelevant alternatives and that pairwise comparisons might be more appropriate.39 This discrepancy can arise if one or more of the strategies under consideration is politically or administratively infeasible, or if the analysis is directed at different decision makers, not all of whom agree on the set of viable choices. In either situation, inclusion of irrelevant strategies in such a comparison would negatively affect the assessment of other, more viable options. In our analysis, however, none of the options were politically or administratively infeasible, nor was our analysis aimed at decision makers with differing opinions on the set of viable choices. Pairwise comparisons would not account for the interaction between all strategic choices avail able to decision makers and would therefore be uninterpretable.

A limitation of our economic assessment is that it was done in the context of an urban area with endemic dengue. Thus, our results are generalisable to settings with endemic dengue, where epidemics of fairly constant size are expected. In settings where dengue transmission dynamics are erratic, with introduction, elimination, and reintroduction of serotypes, our results could be less applicable because epidemic size can vary by year.

Ideally, our analysis would have used local cost estimates. However, vector control spending data for Brazil were not available. Instead, we obtained cost parameter estimates from data from other countries (webappendix p 6). In recognition of the uncertainty surrounding these parameters, we did extensive probabilistic sensitivity analysis and threshold analysis. Although our cost-effectiveness results were robust to uncertainty in the cost parameters, our findings should be interpreted with caution. We recommend studies of vector control resource use as an important area for further investigation that will better inform future cost-effectiveness analyses.

In the present study, costs and effectiveness were assessed for a 5-year period. Guidelines on cost-effectiveness analysis recommend the use of a period appropriate for the assessments of all disease-specific costs, and of costs and effectiveness of the interventions being assessed.40 The effect of vector control could extend beyond our 5-year period. However, interactive factors related to the human population (demography and immunity), vectors (fitness and insecticide resistance), vector and human population dynamics (relative population sizes and patterns of urbanisation), and the possible development of other technologies for disease treatment and prevention (such as a vaccine) introduce substantial uncertainty when modelling for longer periods, suggesting that the 5-year period used in this study is justified as an initial assessment.

More studies of insecticide delivery, efficacy, and effect are urgently needed. Most studies that assessed field-based efficacy of adult and larval control were done more than two decades ago.15,16 The theoretical efficacy of insecticides measured under laboratory conditions is quite different from what is achieved when applied in real conditions. Such studies would be important for the guidance of future economic analyses of vector control.

Although our analysis was based mainly on data from metropolitan areas of Brazil, the results are likely to be applicable to other urban settings with endemic dengue. Our model incorporates location-specific data for climate (temperature and rainfall), human population size and demographics, and, whenever possible, locally estimated biological model parameters for the mosquito population. These parameters could be adjusted to represent other locations. Moreover, the model could be extended to incorporate other available interventions such as breeding site elimination41 or other vector control interventions such as insecticide-treated curtains or water container covers,42 in addition to potential new interventions, such as vaccines43 and release of genetically modified mosquitoes.44,45 Indeed, if included in the model, these factors could affect our findings. We encourage similar economic assessments for settings with endemic dengue to better understand the best practices of dengue control and how they vary according to location-specific factors. The optimum use of the model developed in this study would use up-to-date data from mosquito and dengue case surveillance systems, which would allow for adaptable strategies to be constructed as dengue dynamics unfold in a given place and time.

Dengue control is a challenging endeavour, especially because A aegypti evolves in response to control interventions (ie, development of insecticide resistance), because herd immunity is affected by reduced transmission associated with control, and because viral reintroduction can occur from other locations, making dengue elimination unlikely. Our model shows that when the effect of insecticide-based interventions wane because of the evolution of insecticide resistance, pronounced epidemics will occur, the severity of which depends on the specific intervention used. These findings draw attention to the importance of considering insecticide resistance and dengue transmission dynamics when implementing insecticide-based dengue vector control programmes in a specific setting.

Supplementary Material

Panel: Research in context.

Systematic review

PubMed, Web of Science, and SciELO with the search terms “dengue”, “model”, “aedes aegypti”, and “vector” for dengue modelling studies, giving priority to studies from Brazil, then studies done in other parts of the Americas, then studies from other settings. We also searched reports from the Brazilian Government and WHO publications.

Interpretation

Previous modelling studies have shown that insecticide-based larval and adult vector control strategies can reduce dengue incidence. Whereas previopus models take into account transmission dynamics and the effects of seasonality, ours is the first study to assess the effect of vector control in the presence of evolution of insecticide resistance in mosquito populations. Furthermore, we integrate a dynamic model with an economic assessment. Our study draws attention to the importance of the acknowledgment of both the evolution of insecticide resistance in mosquito populations and of herd immunity in the human population when considering insecticide-based vector control strategies for dengue.

Acknowledgments

PML was funded by The Fulbright Programme, CAPES (Brazilian federal agency for post-graduate education), and the Miriam Burnett trust. APG was funded by Notsew Orm Sands Foundation and the Miriam Burnett trust. JM was supported by the National Science Foundation (grant SBE-0624117) and the Notsew Orm Sands Foundation. We gratefully acknowledge support from NIH MIDAS (grant UO1 GM087719-01).

Footnotes

See Online for webappendix

Contributors

PML had the idea for the study and drafted the paper. PML and TV did the cost-effectiveness analysis and the sensitivity analysis, interpreted the results, and discussed the findings. PML and JM developed the mathematical model. ADP and APG assisted in the design of the study, interpretation of results, and discussion of the findings. All authors revised the paper for important intellectual content. All authors have approved the final version of the paper.

Conflicts of interest

We declare that we have no conflicts of interest.

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