Chapter 1

The Problem and Its Scope

Introduction

Dengue is a rampant and perilous vector - borne infection

paradoxically transmitted through a single bite from a tiny mosquito which

deviously can ensure impending benign and detrimental results. In the last

50 years, the virus has dramatically expanded its geographical range and

shortened its endemic cycle in numerous places. There is no treatment

beyond fluid control, there is no therapeutic, and there is no vaccine.

Moreover, it’s spread by one of nature’s toughest and most versatile

mosquito. Due to these realities, it has emerged as a serious international

public health threat that could only be prevented or reduced through

dengue virus transmissions control strategies.

Dengue, also known as Dengue fever or “breakbone fever”, is a fast-

emerging pandemic - prone viral disease. It is an arthropod – borne

infection that causes severe flu – like illness which can sometimes lead to a

potentially lethal complication called severe dengue. The virus flourishes in

urban poor areas, suburbs and the countryside but also affects more

affluent vicinities in tropical and subtropical countries. It is transmitted by

1
the bite of an infected female Aedes mosquito and is caused by the four

distinct stereotypes of the dengue flavivirus (DEN 1, DEN 2, DEN 3 and

DEN 4). This febrile illness is not conveyed directly from person - to –

person and is one disease entity with different clinical presentations and

often results to unpredictable clinical evolution and outcome. Thus, this

infection produces a broad spectrum of symptoms, many of which are non-

specific. Symptoms range from mild fever, to incapacitating high fever, with

severe headache, pain behind eyes, muscle and joint pain, and rash.

Severe dengue, also known as dengue haemorrhagic fever, is

characterized by fever, abdominal pain, persistent vomiting, bleeding and

breathing difficulty. As it is a virus, the vaccine or any specific medicine to

treat the disease remains elusive. The victims who have dengue fever are

advised to rest, drink fluids and reduce the fever using paracetamol or see

a doctor but these can only substantially lower the risk of medical

complications and death (World Health Organization, [Link]).

During the past five decades, Dengue has emerged as a worldwide

problem as the virus continues to be a leading cause of illness and death in

numerous regions with no definite treatment. Today 125 countries harbour

the risk of the disease putting more than half the world’s population at risk

resulting in an estimated 400 million infections each year, and of the total

2
number of cases, 96 million require medical treatment. The true numbers

are probably far worse, since severe underreporting and misclassification

of dengue cases have been documented (Centers for Disease Control and

Prevention, [Link]

Dengue imposes a major health, economic, and social burden on the

population of endemic areas. As this threat becomes greater and greater

globally, prevention is the most important key to reduce and control the risk

of dengue infection. This would involve developing and implementing

preparedness plans. These include early warning systems,

epidemiological, entomological and environmental surveillance, laboratory

support, clinical case management, vector control, environmental controls,

risk communication and social mobilization (World Health Organization

[WHO], 2009, p. 111).

Due to the alarming global threat the dengue virus possess, everyone

is needed to collaborate in order to lessen the impact of this evolving

disease through effective and efficient control methods. This can be

improved by determining the major risk factors that cause dengue.

In this research paper, the specific setting that the researchers paid

attention in order to gather the needed data was the city health department

of Cagayan de Oro, Philippines.

3
 Philippines is one of the endemic countries that continue to be

tormented by dengue. It is still an ongoing health concern in several areas

as it has become a significant cause of hospitalisation and death among

Filipinos. According to the World Health Organization, the Philippines

experienced the seventh highest number of dengue fever cases in the

world between 2004 and 2010 though outbreaks continue to occur through

passing years (InterHealth Worldwide,

[Link]

Presently, dengue cases in Northern Mindanao have noticeably risen

this year despite the massive awareness campaigns done. Among the

cities in the region, the Department of Health registered Cagayan de Oro

as the city that had the highest number of cases. In the municipality, the

city health department holds all dengue patient records in every hospital

found in the area (Orias, 2016, p. 1).

Dengue has no mercy on all ages. Through research studies, it has

been found out that the possibility of a person to be afflicted by dengue

differ by age. If this could be confirmed, dengue virus transmission control

strategies could be improved as definite risk factors are to be examined in

order to create effective and efficient methods that prevent and reduce the

dengue threat.

4
Background of the Study

Dengue is a serious ongoing health concern in numerous areas

including Cagayan de Oro. It is a painful, debilitating and mosquito – borne

diseases that has no definite treatment. Because of these points, the

awareness and prevention of this threat have been heavily implied to the

community. Research about possible risk factors in order to help the

reduction of dengue virus transmissions have also been done to improve

prevention and control strategies. Some evidences suggest that risk for

dengue, with both dengue fever and hemorrhagic fever, varies by age.

The researchers are dismayed to witness the severity of dengue in

many aspects of the country. The researchers are motivated to study about

the relationship between age groups and the relative risk of becoming ill

with dengue based on dengue patient – records in Cagayan de Oro City as

the foundation. This study will confirm the relationship of both factors in

order to help determine if age is a definite risk factor of dengue and

comprehend which age group is afflicted by the infection the most. The

researchers have chosen ages 0 to 90. Additional findings would include

the other factors that boost the risk of dengue or prevent it. This will raise

awareness to stress the control strategies to the appropriate age group as

well as disclose effective prevention methods. With this, the research paper

5
could give recommendations to residents in Cagayan de Oro City, doctors,

hospitals, and other communities.

Objectives

The study aims:

1. To determine if there is a relationship between specific age groups

and the risk of dengue;

2. To identify the other risk factors influencing the patients that led them

to become ill with dengue;

3. To analyse specific environmental and lifestyle conditions that

influenced the patients to become ill with dengue.

Statement of the Problem

This research aims to illustrate the correlation between specific age

groups and the risk of dengue. It specifically brings light to the following

areas:

1. Does the risk of the dengue vary by age?

2. What other factors are influencing individuals to be afflicted with

dengue?

3. Do specific environmental and lifestyle conditions increase or

decrease the risk of dengue?

The researchers are guided on the following assumptions:

1. There is a relationship between specific ages (0 – 90) and dengue

risk;

2. There are other risk factors that increase the risk of dengue;

3. Different specific environmental and lifestyle conditions of dengue

patients increase or decrease the risk of dengue.

Significance of the Study

The study gives further understanding about the widespread of a

deadly virus called dengue. This research is important because it can

improve many vector control strategies that prevent more individuals to fall

as victims of dengue. Furthermore, it helps specific age group who have

the highest risk of dengue as well as others to be conscious of the

surroundings or environment as well as the lifestyle conditions they live in

to prevent this virus infection. This will benefit to the following:

For the community, the research discloses additional information

about the relationship between specific age groups and the risk of dengue

and the risk factors of the infection. It will empower community to be aware

of this ongoing threat and to improve control strategies that prevent the

7
disease. Furthermore, it stresses the importance of cleanliness in the

environment and healthy lifestyle conditions because these lessen the risk

of dengue in the area, stop the rapid spread of the dengue virus, and avoid

costly hospital bills.

For the doctors, the research would pave way to fresh ideas on new

prevention and control strategies to lessen the spread of dengue, and

improve patient consultations with regards to age groups.

For the patients, the research would inform the patients of what

lifestyle and environmental conditions they committed to increase the risk

of dengue in order to prevent the rise of the dengue virus in the future.

For the students, the research would serve as reference for future

researches concerning the topic. It will also raise awareness of the dangers

of dengue and to avoid its risk factors. Since mostly the viruses’ work is to

continue spreading and evolve over time, the research would broaden the

future researchers’ knowledge about the dengue virus by continuing this

research and discover new impelling factors that causes this virus.

8
Conceptual Framework

The study identified the relationship between different age groups

and the risk of dengue. The research identified which ages would be at risk

of being infected by dengue the most through dengue patient - records in

the city health department of Cagayan de Oro. The different age groups

pertain to the certain age group of patients in every hospital in the area due

to dengue. The chosen ages involved are from 0 to 90. Ultimately, the

study answers the question if dengue risk could vary by age. Dengue risk

has factors that is greatly dependent on environmental and lifestyle

conditions. Environmental conditions pertain to environmental degradation,

improper management and disposal, rapid urbanization, and lack of reliable

water supply. On the other hand, lifestyle conditions pertain to exposure,

immunity levels, and nutritional state.

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Delimitation of the Study

The researchers will only include the following:

1. The dengue patient – records in the City Health Department of

Cagayan de Oro, Philippines;

2. The doctors of dengue in Madonna & Child Hospital and Northern

Mindanao Medical Centre Hospital, Cagayan de Oro City, Philippines,

were interviewed and researched.

Definition of Terms

The following terms are defined operationally:

● Aedes - a genus of mosquitoes originally found in tropical and

subtropical zones, but now found on all continents except Antarctica;

known vectors for numerous viral infections.

● Age group - number of people classed together as being of similar

age.

● Arthropod - borne disease - are the arthropods that usually act as

vectors for various pathogens (disease - causing microorganisms),

● Dengue – an acute mosquito – borne viral illness.

● Dengue Virus Transmission Control Strategies – prevention and

reduction methods that effectively regulate the transmission of

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 dengue.

● Disease - an illness that affects a person, animal, or plant; a condition

that prevents the body or mind from working normally.

● Endemic - (of a disease or condition) regularly found among

particular people or in a certain area.

● Environmental Conditions - the state of the environment.

● Flavivirus - any of a group RNA viruses, mostly having arthropod

vectors, which causes a number of serious human diseases.

● Immune System - the body’s defence mechanism that protects the

body against infectious organisms, diseases, infections and other

invaders.

● Lifestyle Conditions – the way in which a person or group lives

● Mosquito - borne - diseases caused by bacterial, viruses or parasites

transmitted by mosquitoes.

● Prevention – effectual hindrance.

● Risk of Dengue – the possibility to be inflicted by the dengue virus

● Risk Factors of Dengue - attribute, characteristic or exposure of an

individual that increases the likelihood of developing dengue.

● Severe Dengue – (haemorrhagic fever) a severe and sometimes a

more fatal form of the dengue disease.

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● Symptoms - a physical or mental feature that is regarded as

indicating a condition of disease, particularly such a feature that is

apparent to the patient.

● Treatment - medical care given to a patient for an illness or injury.

● Vaccine - a substance used to stimulate the production of antibodies

and provide immunity against one or several diseases, prepared from

the causative agent of a disease.

● Virus – the causative agent of an infectious disease.

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 Chapter 2

Review of Related Literature

The following are different studies related to the present research:

International Studies:

Age-Specificity of Clinical Dengue during Primary and

Secondary Infections

The first study that is being reviewed here is by Khoa T.D. Thai, et.

al., entitled, “Age-Specificity of Clinical Dengue during Primary and

Secondary Infections,” which was conducted in Binh Thuan, Vietnam, last

June 21, 2011.

The purpose of this study was to estimate the age – specific risks of

clinical dengue attack (i.e., the risk of symptomatic dengue among the total

number of dengue virus (DENV) infections) during primary and secondary

infections. The researchers analyzed two epidemiological information in the

province of Binh Thuan focusing on age-specific seroprevalence and a

community-wide longitudinal study of clinical dengue attack. A simple

modelling approach was employed to estimate the age – specific risks of

clinical dengue attack during primary and secondary infection (Thai et. al.,

13
2011, p.1).

The study used the seroprevalence data and it was found out that

there were 382 confirmed dengue patients, and only 76 patients were

primary infected while 306 patients were found out to be secondary

infected. Patients who have dengue fever during primary and secondary

infections were examined and it was found out that 12 was the median age

between the specific-age group of 9 to 20; while 20 was the median age

from 14 to 31. At the age of 20 years old, 8-11% percentage rate of total

individuals were infected by the DENV for both primary and secondary

infections while less than 7% individuals for those aged younger than 10

years old. However, secondary infections occur more as age grows older,

and the risk of symptomatic dengue during secondary infection was higher

than primary infection for all specific-age groups. Fortunately, only a few

symptomatic patients resulted to severe diseases. It was also assumed in

the study that the force of infection was time and age independent, thus the

transmitted serotypes were all identical. In the overall of the study, the

adolescents and young adults (teenagers) are more likely to develop

symptomatic dengue than younger individuals. Age as an important

modulator of clinical dengue explains the sudden increase of the DENV

among Southeast Asian countries. Thus, the rise of DENV is more likely

14
caused by various factors including time - dependent variations in

epidemiological, ecological and demographic dynamics (Thai et. al., 2011,

p.2).

In the current research, the researchers are determining the

relationship of age and the possibility to be inflicted by dengue. Through

the study that was reviewed, it is confirmed that there is a correlation

between age and dengue virus (DENV) infection and disease severity

though the contributions of age to disease development have yet to be

quantified in detail. Additionally, it has been assessed that other factors

greatly affect the risk of dengue such as time - dependent variations

in epidemiological, ecological and demographic dynamics.

15
 Relationship between Age and Risk for Classic Dengue Fever

Another study that is being reviewed here was written by the

corresponding authors, Joseph R. Egger and Paul G. Coleman from

London School of Hygiene and Tropical Medicine, entitled, “Age and

Clinical Dengue Illness,” which was operated in London, United Kingdom

on June 13, 2007.

The main purpose of this study was to quantify the relationship

between age and risk for classic dengue fever. The researchers used data

from clinical patients to show that the relative risk of having classical

disease after primary dengue virus infection increases with age. This

relationship has implications for strategies aimed at controlling dengue

fever.

The findings of the study were consistent with results of earlier

studies which suggest that adults are more likely than young children to

have clinical dengue. There were several factors that were considered

when the results were interpreted. First, because dengue virus serotypes I

and 2 were circulating in the population during the study period, some

people may have been infected with both serotypes during the 1-year

period and, therefore; clinical signs may have resulted from a secondary

16
infection. This proportion is probably small. Second, several factor other

than age is thought to influence severity of classic dengue illness, including

viral serotype and strain. Data from a dengue epidemic (dengue virus type

3) in Puerto Rico showed the attack rate to be independent of age.

Although the proportion of these cases that were due to primary infection

was uncertain, the different infecting serotype may be partly responsible for

the conflicting findings between that study and ours. Further research

should be conducted to determine whether the relationship between age

and classic dengue fever is similar in epidemics involving all 4 dengue virus

serotypes. Finally, whether all age groups in the study population had equal

access to participating health facilities is not known. However, if a reporting

bias were introduced, it would likely be in adults (because of child-rearing

duties and difficulty taking time off work). Therefore, since adults represent

a higher proportion of total patients with clinical cases in this study,

underreporting in this age group would suggest that our relative-risk

estimates in the adult age classes are conservative. (Egger & Coleman,

2007, p.2).

Egger and Coleman (2007) deduced that despite the complexities of

dengue epidemiology, these findings provide strong empirical evidence that

17
age is an important factor in determining risk for disease severity after

primary dengue virus infection. As such, these findings have significant

implications for initiatives at controlling dengue. Interventions focused on

reducing the number of Aedes mosquitos are the mainstay of dengue

worldwide. At best, vector control may result in a partial reduction in the

rate at which dengue virus is transmitted, which consequently increases the

average age of the population susceptible to dengue infection. If age is a

risk factor for clinical dengue fever, as results suggest, then while partial

control will decrease the rate of dengue infection, it may have the adverse

effect of increasing clinical incidence.” (p.2). Nevertheless, the researchers

deduced that age is an important risk factor of dengue.

18
 Gender Differences of Dengue Fever Cases in Six Asian Countries

The last study that is being reviewed here was written by Martha

Anker and Yuzo Arima on behalf of Emerging Diseases Surveillance and

Response, Division of Health and Security Emergencies, and World Health

Organization Regional Office for the Western Pacific. The study was done

in six Asian countries, specifically Laos, the Philippines, Singapore, Sri

Langka, Cambodia, and Malaysia, in 2011.

The purpose of this study was to analyse the incidents of the DENV

in relation with age and sex among the people in a certain six Asian

countries. According to the World Health Organization (WHO), dengue is

endemic in over 100 countries and two-fifths of the world’s population is at

risk for dengue fever (DF) and 50 million infections were recorded annually.

The top countries that were obtained from DengueNet were the Philippines,

Singapore, and Sri Lanka; there were four specified age groups from 1 year

old and below, 1 to 4 years old, 5 to 14 years old until 15 years old that

were conducted between male and female. Since most studies about the

DENV were not analyzed in accordance to age and sex, the researchers’

then proposed this type of study. It was also to determine whether there

was a different approach of DENV between different genders. Aside from

19
the four countries that were obtained from the DengueNet, Cambodia and

Malaysia were also being studied in this research; however, there was

slight difference in age groups compared to four countries. The specified

age groups of Cambodia and Malaysia were from 4 years old and below, 5

to 9 years old, 10 to 14 years old, until 15 years old. (Anker & Arima, 2011,

p.1).

The study found out that males were more likely to get infected by the

DENV than females. The data showed was that over a period of 6 to 10

years, among the studied specified age groups, there was a consistent

excess of male cases over a 12 year period. To sum up this research, the

researchers’ conclude that there may be gender-related difference in

dengue incidence due to exposure differences among older adolescents

and adults. A consistent pattern of male predominance was found in the

reported number of dengue cases among persons 15 years or older in

several Asian countries. Since collapsing the data over all ages would have

masked some of the observed differences, the findings showed that it is

important to report sex- and age - stratified data for dengue surveillance.

The assessment of the differences of dengue between males and females

by age is important because biological and gender-related factors can

change over the life cycle, and gender - related factors can differ across

20
countries. Further research is required on the sex - specific differences to

identify the causes and to take targeted preventive measures to reduce the

dengue burden in each region. (Anker & Arima, 2011, p.5).

With this study, the researchers’ further assembled more knowledge

about the relationship between age and the risk of dengue. Age indicates

the different exposure capacities as well as life cycle factors concerning the

dengue virus. Additionally, many aspects about the study were covered

such as influencing triggers that increase and

decrease the likeliness of acquiring the dengue virus.

21
 Local Studies:

Epidemiology of Dengue Disease in the Philippines (2000–2011)

The study that is being reviewed here is by Lulu Bravo, et. al.,

entitled, “Epidemiology of Dengue Disease in the Philippines (2000 - 2011):

A Systematic Literature Review,” which was conducted within the

Philippines, by the year of 2000 to 2011.

The purpose of the study was to conduct a literature analysis and

review to assess the epidemiology of the DENV since the major health

concerning issues in the Philippines is dengue. It also further proved the

factors of the sudden increase of the DENV, in relation to growing

population, increasing urbanization, improvements in surveillance, and the

limited success of vector control measures. The overall findings showed

how DENV continued to rise in the Philippines within the year of 2000 to

2011 with the use of comprehensive data, which shows the relation of

DENV to the person’s age, the serotype, and seroprevalence on both

national and regional levels. Additionally, the study improved both

preparedness and response activities relating to DENV outbreaks.

The study found out many factors about the dengue virus. The

sudden increase of DENV can be explained by several factors. There are 4

Linnaeus mosquito, primarily transmits the DENV to humans, and it

continues to grow population as it breeds in an open water container, and

can survive in a year with either tropical or subtropical climates. The DENV

continues to propagate due to rapid urbanization, environmental

degradation, the lack of reliable water supply, and improper management

and disposal. In the year of 2005, Department of Health (DOH) classified

the 3 different symptomatic of DENV which now we know as dengue fever

(DF), dengue hemorrhagic fever (DHF), or dengue shock syndrome (DSS).

As the years continued to pass by, the most outnumbered region affected

by DENV was NCR. Though in 2010, there was a large increase of the

DENV cases which was recorded to be 131, 976 and 173, 033 from the 56,

545 and 57, 819 cases in 2009; as well as out of 131, 976 - 173, 033

cases, from the 788 - 793 fatal cases reported as compared in 2009 which

was only 548 cases. Therefore, DENV can be rampant in urban areas such

as NCR. Thus, the highest risk of being infected by DENV was the children

whose age from 5 to 14 years old in the year 2000 - 2009. However in 2010

- 2011 children who were aged between 1 to 10 years old were reported to

be more likely capable of getting the DENV. The study concluded that as

the years continues to pass by; the DENV also grows its population. Infants

23
in the recent years are being infected by DENV followed by children then

teenagers or young adults due to various factors, including environmental

degradation, improper management and disposal, rapid urbanization, and

lack of reliable water supply. (Bravo, Roque, Brett, Dizon & L’Azou, 2011,

p.1).

It has been deduced that younger age groups are mostly likely to

have a higher possibility to be inflicted by the dengue virus due to various

factors including environmental degradation, improper management and

disposal, rapid urbanization, and lack of reliable water supply. However,

environmental factors play a significant role in determining this risk. With

this study, the researchers perceived that the relationship between age and

the risk of dengue have a strong

correspondence as lifestyles are enumerated by phase.

24
 Dengue in the Philippines

The study that is being reviewed here is written by Maria Rosario

Capeding, MD, entitled, “Issue 7 – Dengue in the Philippines,” which was

conducted in the Philippines, from January to September 2011.

The purpose of this study was to raise awareness to the public since

dengue has been the leading cause of childhood hospitalizations in 2011.

The issue focused on epidemiology of dengue in children, current

surveillance systems, and efforts to stop mosquitoes from spreading

nationwide.

By September of 2011, DENV was the leading cause of childhood

hospitalizations and the researchers analyzed that DENV has already

resulted to 285 deaths from ages between 1 and 9, nearly 60% of dengue-

based deaths in 2011 (Capeding, 2011, para. 1).

The average age of DENV infection is at age 12, but children aged 1

– 9 are affected by DENV at 36% of annual DENV infections. Dengue

cases of young children and adolescents from January to September 2011

reached 65,000, approximately 74% of all nationwide cases. Epidemics of

dengue or dengue hemorrhagic fever in the Philippines occur every 3 – 4

years and with other illnesses, it is a level of difficulty for the national

25
healthcare system. (Capeding, 2011, para. 4 & 5).

Dengue surveillance systems like the National Epidemiological

Center’s (NEC) surveillance system was implemented in 2007, named the

Philippine Integrated Disease Surveillance System and Response

(PIDSSR). Possible dengue outbreaks in a region are then notified by the

PIDSSR so that preventions can be made. “Kill the mosquito, Knock out

Dengue” or “4 o’clock habit” was a government-based initiative that

requested residents to change their lifestyle in their homes to prevent

mosquitoes from spreading, residents were to clean their surroundings and

always drain water containers that contain stagnant water and could be a

factor of mosquitos spreading. This was to be done at 4 o’clock in the

afternoon every day. (Capeding, 2011, para. 7 & 8).

In this study, adolescent years are mostly burdened by the risk of

dengue. Though the varying of seasons influenced the total number of

dengue patients, the incidences were closely related to exposure. Through

this, the researchers realized that the link between certain age groups and

dengue has various other factors that

affect the relationship but the relation is still present.

26
 Laboratory – Confirmed Dengue in Children in Three Regional

Hospitals in the Philippines

The final study that is being reviewed here is by Maria Rosario Z.

Capeding et. al., entitled, “Laboratory – confirmed Dengue in Children in

Three Regional Hospitals in the Philippines in 2009 – 2010,” which was

conducted within Jose B. Lingad Memorial Regional Hospital, Southern

Philippines Medical Center, and the Western Visayas Medical Center, in

between November 2009 and November 2010.

The first purpose of the study was to conduct a prospective

epidemiological study to estimate the proportion of laboratory – confirmed

dengue cases among the clinically suspected dengue cases hospitalized in

the paediatric wards of 3 regional hospitals in the Philippines. The second

purpose of the study was to describe the clinical and laboratory features of

suspected and laboratory – confirmed dengue; to describe the age

distribution, case fatality rates and stereotype distribution of laboratory

confirmed dengue and to assess the feasibility of case detection and

laboratory confirmation.

The study confirmed 1809 (86.1%) cases of dengue infection in 2013

and suspected cases between November 2009 and November 2010. The

27
6- to 10-year-old age group had the highest proportion of cases overall

(36.7%) and to decrease in older age groups. These results are consistent

with data from the Philippine Department of Health showing that the highest

proportions of DF and DHF cases were in the 5- to14-year-old age group in

2000–2009. Although the study was unable to compute the age group

incidence rates for these areas and did not investigate adult transmission

rates, these results suggest that dengue susceptibility in the Philippines

peaks between 6 and 10 years of age and then decreases. These findings

are consistent with the hyperendemicity and the high burden of dengue

disease in the Philippines, where dengue immunity increases with age.

Fever, anorexia, myalgia, abdominal pain and headache were the most

common symptoms at admission. Hemorrhagic manifestations, signs of

plasma leakage, thrombocytopenia and leucopenia were all significantly

more common in confirmed than in non - confirmed cases. Most cases

(76.5%) developed dengue hemorrhagic fever or dengue shock syndrome,

and the overall case fatality rate was 0.94%. Distributions of all 4 virus

serotypes varied at each hospital.

With this study, the researchers gathered the appropriate data that

relate the link between age and the risk of dengue. Age affect many factors

that relate to health such as immunity levels which further influence

28
diseases. Furthermore, dengue cases were mostly seen in children than

other older years due to the health concerns corresponding to the age

(Capeding et. al., 2010, para. 3).

29
 Chapter 3

Research Methodology

Overview of the Study

This study was conducted in order to determine the relationship

between specific ages (0 – 90) and dengue risk based on patient – records

in the City Health Department of Cagayan de Oro City, Philippines. To be

able to gather the necessary data, the researchers utilized statistical

mathematical methods using the quantitative approach. Moreover,

interviews with paediatricians were conducted to identify other risk factors

influencing the patients that led them to become ill with dengue. The results

with the appropriate respondents were used further to analyse

environmental and lifestyle conditions that influenced the patients to

become ill with dengue. Relevant literatures were also used to support the

gathered findings.

Data was initially gathered through obtaining an official information in

the patient’s records inside the administration office of the city health

department of Cagayan de Oro. The information gathered were then used

to create a questionnaire that was used to interview the doctors. Each

30
particular question in the interview was specifically and carefully prepared

by the group, and respondents responded in accordance with the questions

asked. The study was done from October 2016 to February 2017.

Setting of the Study

The researchers chose the City Health Department of Cagayan de

Oro, Philippines as the location for data gathering in the study.

To be able to have easier access for more valid data, the study was

based on the City Health Department records and interviews were

conducted in Madonna & Child Hospital and Northern Mindanao Medical

Center as most of the researchers have connections within the setting.

Among the other hospital institutions in the city, Northern Mindanao

Medical Center also has the highest admissions of dengue patients.

However, the researchers gathered data from all hospitals in Cagayan de

Oro through the City Health Department for the study to be more efficient,

accurate, and appropriate in data gathering and analysis as the preeminent

means are utilized for the excellent study outcomes.

31
Respondents of the Study

The study involved the conduct of interview with a number of selected

pediatricians. The researchers have chosen the ages from 0 to 90. All of

these participants were selected randomly.

Since the study involved only one respondents - the doctors; one set

of questions were prepared beforehand. This set was presented to the

doctors through interview about other risk factors, influencing triggers, and

diverse conditions of dengue risk considering that they have broad

knowledge regarding the subject matter. With the knowledge, the doctors

ultimately helped us determine if the dengue risk varies by specific age

groups.

Statistical Tools

The primary instrument of the research was the statistical technique

called correlation using gathered data in the past records of dengue

patients in Cagayan de Oro City within the year 2016. The secondary

instrument was a set of tentative questions. The questionnaire served to

interview specific professional doctors about the relationship between

specific age groups and dengue risk as well as the evaluation of other risk

32
factors. The Data was gathered through simple tallying from the patient

records of different age groups and through interviews of different doctors

in Madonna & Child Hospital and Northern Mindanao Medical Centre

Hospital.

Data was gathered by the researchers through the traditional means

and actual recording of the interviews. The correlation technique

determined how much variation in patients’ ages is related to dengue risk.

The statistical module called the Pearson Product Moment and Pearson

Product Moment Correlation Coefficient r were utilized to evaluate the

relationship as correlations provided the appropriate general indications.

The Pearson product-moment correlation coefficient, often shortened

to Pearson correlation or Pearson's correlation, is a measure of the

strength and direction of association that exists between two continuous

variables. The Pearson correlation generates a coefficient called the

Pearson correlation coefficient, denoted as r. A Pearson's correlation

attempts to draw a line of best fit through the data of two variables, and the

Pearson correlation coefficient, r, indicates how far away all these data

points are to this line of best fit (i.e., how well the data points fit this new

model/line of best fit). Its value can range from -1 for a perfect negative

linear relationship to +1 for a perfect positive linear relationship. A value of

Correlation is an effect size and so we can verbally describe the

strength of the correlation using the guide that Evans (1996) suggests for

the absolute value of r:

● .00-.19 “very weak”

● .20-.39 “weak”

● .40-.59 “moderate”

● .60-.79 “strong”

● .80-1.0 “very strong”

The researchers categorises the type of correlation by considering as

one variable increases what happens to the other variable:

Positive correlation – the other variable has a tendency to also increase;

Negative correlation – the other variable has a tendency to decrease;

No correlation – the other variable does not tend to either increase or

decrease.

The starting point of the analysis was the construction and

subsequent examination of a scatterplot based on the acquired data.

34
 Chapter 4

Presentation, Analysis, and Interpretation of Data

This chapter would discuss the presentations, analysis, and the

interpretation of data gathered from the City Health Department of Cagayan

de Oro, Philippines as well as interviews from selected pediatricians in

Madonna & Child Hospital and Northern Mindanao Medical Centre

Hospital.

Presentations are in table and graph form. Graphs presented involve

the correlation between specific ages (0 – 90) and dengue risk (Year 2016)

and the Dengue Cases by Age Group and Sex (Cagayan de Oro City,

December 31, 2016). On the other hand, tables presented involve the

Dengue Update (January 1 to December 31, 2016) and Top 15 Barangay.

January to December 31, 2016 vs 2015 (Cagayan de Oro City).

The researchers interviewed Dr. Rene Gaid, Dr. Patricia V. Gaid, and

Dr. Jose Segundo N. Imperio with questions pertaining to the relationship

between specific age groups and dengue risk, other risk factors of the

dengue virus, environmental and lifestyle conditions influencing patients to

become ill with dengue, as well as recommendations to lessen and hinder

the dengue virus.

35
 From the analyzed statistics, figures, and data, the relationship

between specific age groups and dengue risk is determined to have a

strong negative correlation. The researchers have also identified other risk

factors as well as specific environmental and lifestyle conditions that

influence patients to become ill with dengue to gain further comprehension

about the subject matter, the dengue virus.

Data gathered from the City Health Department of Cagayan de Oro

City, Philippines of the Dengue Cases within the year 2016 in the

municipality:

Dengue Dengue
Age Age Dengue Cases Age
Cases Cases
0 111 - - - -
1 127 31 12 61 2
2 133 32 11 62 2
3 182 33 15 63 5
4 201 34 12 64 4
5 193 35 14 65 3
6 184 36 10 66 4
7 193 37 19 67 0
8 152 38 8 68 3
9 140 39 8 69 3
10 119 40 7 70 1
11 126 41 6 71 1
12 127 42 7 72 4
13 101 43 7 73 0
14 93 44 5 74 1
15 95 45 11 75 1
16 76 46 10 76 1
17 74 47 8 77 2
18 66 48 5 78 2

36
19 71 49 5 79 1
20 50 50 6 80 1
21 46 51 4 81 0
22 33 52 4 82 0
23 27 53 3 83 0
24 35 54 10 84 1
25 17 55 7 85 1
26 30 56 7 86 0
27 22 57 3 87 0
28 23 58 3 88 0
29 18 59 6 89 0
30 17 60 2 90 1

37
 The Correlation between Age (0 – 90) and Dengue Risk

The researchers used the Pearson product moment correlation

coefficient, r, a dimensionless index that ranges from -1.0 to 1.0 inclusive

and reflects the extent of a linear relationship between two data sets.

The Pearson function syntax of the graph above has the following

arguments: Array1 (x) - Age (0 - 90) A set of independent values; Array2 (y)

- Dengue Risk (Cases) A set of dependent values. The researchers only

used the dengue cases within the year 2016 (January 1, 2016 - December

31, 2016) in the municipality as received from the City Health Department

of Cagayan de Oro City, Philippines.

The formula for the Pearson product moment correlation coefficient, r,

38
used was:

r = - 0.7763006

The coefficient value reflected a negative correlation or an inverse

correlation. The researchers used the r < 0 to test as the variables are

negatively correlated, where observations of one variable tend to increase

as observations in the other variable decrease. Additionally, when a

relationship is random or non-existent, then the correlation coefficients are

nearly zero. The closer the value is to 1 or –1, the stronger the linear

correlation. Hence, the graph constructed between the two data sets does

not create a clear and distinct linear relationship but reflects a strong

negative linear correlation.

Although the correlation coefficient is a measure that determines the

degree to which two variables' movements are associated, there is a

common tendency to think that correlation between variables means that

one causes or influences the change in the other one. However, correlation

does not imply causation. There may be an unknown factor that influences

both variables similarly. Thus, the researchers have identified other factors

that affect the relationship of both data sets. Basically, other risk factors

also influence the correlation between Age (0 - 90) and Dengue Risk.

39
 Dengue Cases by Age Group and Sex
Cagayan de Oro City December 31,2016

The graph shows the number of dengue cases by age group and sex.

The blue side shows the number of female cases and the green side shows

the number of male cases. The age group with the most dengue cases are

ages 5 to 9, as shown in the graph, while the group over 60 years old have

the least dengue cases, both for the male and female.

Gender and age influences both patterns of exposure to the Aedes

mosquito. Examples of common gender and age differences that influence

exposure patterns include: time spent at home and away from home,

responsibility for caring for livestock, responsibility for cleaning homes as

40
well as surrounding environments and scientific knowledge about the virus.

Exposure to the dengue virus is related to activities that dictate where

people are throughout the day, and with the Aedes mosquito habitat they

come into contact. Males and females frequently have different activity

patterns related to gender driven differences in occupation and in family

roles. Depending on the activity and the disease, these gender and age

differences may increase the risk of exposure either for males or females in

varied ages.

The reason why children ages 5 to 9 have the most number of

dengue cases is because they often are more exposed to the vector due to

their activities outside. In this age interval, males have more cases then

females. DOH attributed the males’ vulnerability to dengue infection as they

tend to be outside their homes more often than females. The immune

system in those ages are still developing which make them more

vulnerable to the DENV. However, the way in which differences in

exposure influence infectious disease patterns is complex and may have

unexpected results. Those ages greater than 60 have the least amount of

the DENV cases, because they are usually indoors and protected from the

areas where dengue mosquito usually thrive or incubate like the drainage

or damp areas.

41
 Those ages less than 1 year have very small number of cases

because they are usually being constantly watched over by their parents

and doctors. There are also more female dengue cases than male in most

age intervals due to how they dress or their type of clothing as women tend

to expose their bodies more so than men which increase the risk of

infliction to open areas.

42
 DENGUE UPDATE
As of December 31, 2016

The table shows the dengue cases and deaths per month in terms of

years from January 2013 to December 2016. The year 2014 had the most

cases for dengue with 3647 cases followed by the year 2016 with 3161

cases, the year 2015 with 1934 cases, and the year 2013 with 1355 cases.

Dengue cases were reported from different Disease Reporting Unit in

Cagayan de Oro City from January 1, 2013 to December 31, 2016. Ages of

cases ranged from <1 to 90 years of age (median = 9).

The progression of dengue cases is at peak during July to November

then proceeds to decrease until May which have the lowest afflicted cases.

In the Philippines, the month of May is usually the start of the rainy season.

Although dengue has become a year-round threat in the Philippines, with a

peak in cases from July to November each year, one to two months after
43
the start of the rainy season.

The year 2014 has the most number of cases due to Typhoon Haiyan

striking the Philippines at the end of the former year, stagnant waters and

heavy rain have been on constant watch due to mosquitoes breeding and

causing epidemics around the area. Later, Typhoon Glenda hit landfall in

the month of July which brought about more heavy rain and stagnant

waters. The year 2016 came in second due to typhoons and heavy rain

seasons having an earlier landfall during the month of May to June which

led to more infected patients on the month of August, September, and

October.

Based on the graph above, the dengue cases have a cyclical

increase every 2 to 3 years. However, some experts say that climate

change is a disruptive force on the environment with ripple effects on

everything. For that reason, it has made the environment go wild which

affects the weather as it becomes more and more unpredictable yet

becomes more beneficial to the Aedes mosquitos, transmitter of the

dengue virus.

44
 Top 15 Barangay. January to December 31, 2016 vs 2015
Cagayan de Oro City

NO. OF CASES
BARANGAY Percent Change (%)
2016 2015
1. Carmen 452 228 98.24
2. Balulang 215 146 47.25
3. Kauswagan 188 133 41.35
4. Bulua 161 104 54.80
5. Lapasan 150 95 57.89
6. Lumbia 146 60 143.33
7. Tablon 146 44 231.81
8. Macasandig 139 62 124.19
9. Bogo 138 89 55.05
10. Patag 126 57 121.05
11. Canitoan 124 70 77.14
12. Iponan 121 113 7.07
13. Gusa 110 65 69.23
14. Camaman-an 103 54 90.74
15. Cugman 83 52 59.61

This table shows the top 15 barangays who had the most number of

dengue cases in the city and their cases on the year 2015 as well as the

percent change that occurred. Among the Barangays of Cagayan de Oro

City, Carmen has the highest number of cases (14.3%) followed by

Balulang (6.8%), Barangay Kauswagan (5.9%), Barangay Bulua (5.1%),

and Barangay Lapasan (4.7%). Among the top 15 barangays, barangay

Tablon has the highest percentage change with 231.81% increase.

Barangay Carmen had the most number of cases due to unsanitary

environments within the large area. Another problem however is the

45
community behavior when it comes to cleaning the surroundings. An

increase in percentage changes were mostly in disaster or flood prone

barangays such as Balulang, Bulua, Camaman-an, Carmen, Gusa, Iponan,

Kauswagan, Lapasan, Lumbia, Macasandig, Patag, and Tablon. After

floods, many areas would have stagnant waters which would not be quickly

addressed as well as poor management to surrounding water bodies.

46
 Interview

1. Is there a relationship between specific age groups and dengue risk?

Answer: There is no relationship between specific age

groups and dengue risk. Basically, dengue is a virus spread by purely

through the probability of mosquito exposure.

2. What is the specific age range of patients who commonly get infected by

the Dengue Virus?

Answer: Age doesn’t matter, however children between 5 to 10 are

most commonly infected by the dengue virus. Dengue Severity, on the

other hand, is dependent to immunity levels. Children (ages 5 below) have

developing immune systems which make them unprepared and vulnerable

for the sudden intrusion of the virus. Older people (ages 60 and above)

have weaker immune systems that makes it easier for the virus to

overpower their antibodies.

3. What causes this certain age group to be more prone to the virus?

Answer: Children ages 5 to 10 are most likely to get infected by

the DENV because of exposure time with the Aedes mosquito as they tend

to play outside in areas that have stagnant water.

47
4. What risk factors influenced the patients to become ill with dengue?

Answer: Areas that have poor drainage systems are usually at

high risk of dengue infection. Also, areas recently affected by disasters are

at high risk. Time exposure to the Aedes mosquito.

5. What specific environmental conditions influenced the patients to

become ill with dengue?

Answer: Specific environmental conditions include poor drainage

systems, stagnant water residue in plants, canals, and others areas with

numerous Aedes mosquitos, rainy seasons, and climate change. Aedes

mosquitos only reproduce in clean water. When those waters are stagnant

in areas such as drainage and canals due to clogging or in banana plants

or plant plots, an increase of mosquito numbers will lead to more infections.

Rainy seasons lead to more stagnant watery areas; however, climate

changes lead to more rampant infection all throughout the years.

6. Which areas are more prone to the dengue virus? Why?

Answer: Areas with unclean environments especially in stagnant

waters such as in squatter areas which have a more rampant spread of the

virus due to their close proximity. Urban areas due to rapid increase in

larval habitats.
48
7. What specific lifestyle conditions influenced the patients to become ill

with dengue?

Answer: Specific lifestyle conditions include active and outgoing

character, time exposure and working conditions in an environment where

the Aedes mosquito and their habitats prevail as well as not wearing

appropriate clothing in said areas. On the other hand, dengue severity is

relative to the immune system levels and nutritional state of the inflicted

patient.

8. What other external conditions aside from mentioned above are great

influencing mechanisms of dengue virus infection probability rates?

Answer: External conditions include natural disasters especially

certain hydrometeorological or tropical storms which lead to flooding which

increase mosquito reproduction in numerous areas and result to more

infections.

9. What causes the dengue virus to worsen over the years?

Answer: The dengue mosquitos are constantly adapting to new

and old methods of prevention. There is also a cyclical increase of dengue

every 2 to 3 years. Additionally, it has spread as a result of rapid

49
urbanization, especially where a lack of clean water and sanitation are a

problem. Also, disease transmission rates increase when people live in

close proximity to each other. Some say that climate change is also

contributing to the rapid spread of dengue virus which plays with rainy

seasons. Small pools of water are common, especially after it has rained,

which have enabled the mosquito to incubate quickly and in great numbers.

Increased international travel also means that travelers can carry the virus

to other countries.

10. What recommendations can you provide to lessen or hinder dengue

infections?

a. Environmental Conditions

Answer: As dengue is a virus, it has no valid vaccine, treatment,

and medication, prevention methods would be more effective by eliminating

vector signs. Be wary of stagnant waters in prone areas such as banana

plants, plant pots, pools, drainage systems, and canals. If you have those

areas near you, clean regularly everyday to prevent clogging and dirty

areas or space-spray application of insecticides which eliminate

opportunities for the mosquito to reproduce and incubate (breeding sites).

Other prevention methods include disposing of solid waste properly and

50
removing artificial man-made habitats; covering, emptying and cleaning of

domestic water storage containers on a weekly basis; applying appropriate

insecticides to water storage outdoor containers; using of personal

household protection such as window screens, long-sleeved clothes,

insecticide treated materials, coils and vaporizers; and active monitoring

and surveillance of vectors should be carried out to determine effectiveness

of control interventions. To help with dengue severity, vaccinations and

treatments by prescribed doctors would be best. Effective ‘bottom-up’

community participation due to awareness increasingly is recognized as an

important component of environmentally-sustainable control programs –

which make use of recent knowledge and more environmentally ‘friendly’

biological and chemical tools.

b. Lifestyle Conditions

Answer: A healthy lifestyle would be best to prevent an increase in

dengue severity. Focus on adequate Nutritional levels for greater results.

Avoid areas where dengue outbreaks have continued to occur and possible

breeding sites of the mosquito. Wear protective clothing. Use mosquito

repellant. Destroy mosquito habitat or possible breeding sites.

51
Interviewees:

Dr. Rene Gaid and Dr. Patricia V. Gaid (Paediatricians in Northern

Mindanao Medical Center Hospital)

Dr. Jose Segundo N. Imperio M.D. (Paediatrician in Madonna & Child

Hospital)

52
 Chapter 5

Conclusion and Recommendation

Conclusions:

The findings in this study would lead the researchers to conclude

that:

Based on the gathered data through the Pearson product-moment

correlation, the researchers conclude that age (0 - 90) and dengue risk

have a strong negative or inverse correlation relationship. Therefore, as

one variable increases, the other decreases. In details, as ages increase

from 0 to 90, dengue risk cases decreases. However, although there is a

strong negative correlation as the result of pearson r coefficient was -

0.7763006, correlation does not imply causation. There may be unknown

factors that influence both variables similarly if a perfect relationship was

not shown. Thus, the researchers have identified other risk factors that

influence dengue risk and age. Other risk factors identified were gender

differences, exposure to the mosquito transmitter, areas where breeding

sites thrive such as flood prone areas and stagnant waters especially in

tropical or subtropical regions, rainfall seasons, aftermath of natural

disasters, and daily activities regarding work conditions, school conditions,

nutritional state, etc. All of these can be categorized under environmental

53
and lifestyle conditions as these influences the increase the risk of dengue.

Environmental conditions include areas with unsanitary

environments, stagnant waters, squatter thresholds, flood prone areas and

poorly managed drainage systems or bodies of water. It also includes

incubation areas after rainy seasons or heavy rainfall, dynamic happenings

due to climate change, natural disasters that make landfall. Ultimately,

factors include environmental degradation, improper management and

disposal, rapid urbanization, and lack of reliable water supply. On the other

hand, lifestyle conditions include daily activities that increase time exposure

with the Aedes mosquito and their breeding sites in work, school, church,

etc. Also, clothing choices that give open areas for infliction, being wary of

the dangers of dengue, and avoiding areas that have possible thriving

breeding sites. Ultimately, the rise of DENV is more likely caused by

various lifestyle factors including time - dependent variations in

epidemiological, ecological, demographic dynamic of an individual. For

dengue severity, have a healthy lifestyle as the nutritional state would

greatly affect the immune system. The researchers analyzed that these

conditions include prime contact with the dengue virus transmitter, the

Aedes aegypti mosquito.

Regardless, interviewed pediatricians have seen that specific ages (0

54
- 90) and dengue risk have no relationship. Basically, dengue is a virus

spread by purely through the probability of mosquito exposure, however,

age is a risk factor. Risk factors put a greater risk of developing dengue

fever or a more severe form of the disease.

To prevent the rapid spread of Dengue from worsening, these details

should be used for recommendations to achieve a dengue - free

environment. People made numerous prevention methods and solutions

into treating dengue as the dengue mosquitoes have been constantly

adapting to new and old methods of prevention, thus making them immune

to it as well as passing this immunity to further generations. There is also a

cyclical increase of dengue every 2 to 3 years. In order to decrease these

problems, environmental and lifestyle factors that increase dengue risk

should be modified.

Recommendations:

The researcher’s would like to recommend that:

1. The government should provide more budgets to establish better

canal and drainage system in the city. Given the fact that the

breeding grounds for mosquitoes are stagnant water, constructing

good qualities of such would destroy the root factor and greatly

55
 decline the rapid growth of the dengue mosquitoes.

2. Dengue has no valid vaccine, treatment, or medication. However,

prevention methods would be more effective and this would be

completed through eliminating vector signs. Individuals should be

wary of stagnant waters in prone areas such as banana plants, plant

pots, pools, drainage systems, and canals and such. If those areas

are present, cleaning regularly every day is advised to prevent

clogging and dirty areas. Such unhygienic conditions should be care

of.

Additionally, individuals should turn over empty pails and

buckets, so that this does not collect excess water. If the

container that contains water cannot be emptied, remember to

cover it well when not in use. Also remember to clean out

empty flower pots and not to over water potted plants (Pavita

Sampath, 2016, para. 1).

3. It is advised to employ space-spray application of insecticides for

vector and public health control which eliminate opportunities for the

mosquito to reproduce and incubate (breeding sites).

4. To help with dengue severity, vaccinations and treatments by

56
 prescribed doctors would be best. Effective ‘bottom-up’ community

participation due to awareness increasingly is recognized as an

important component of environmentally-sustainable control

programs – which make use of recent knowledge and more

environmentally ‘friendly’ biological and chemical tools.

5. A healthy lifestyle would be best to prevent an increase in dengue

severity. Individuals should focus on adequate Nutritional levels for

greater results. An individual with an unhealthy and weak immune

system is more likely to get affected by the virus and can acquire

greater damage due to the low immune system. Thus, eating right

and choosing a healthy meal can reduce the risk of acquiring the

virus.

6. Another way to prevent getting bitten is by wearing protective clothing

and the use of mosquito repellant.

Clothing can offer protection from biting insects when it is

of a thickness and texture through which insects cannot easily

bite. Lighter colours generally attract fewer insects than darker

colours. Boots can protect the ankles from biting insects. Thick

socks in combination with long trousers offer protection when

57
 the bottoms of the trousers are tucked into the socks. Some

protection is also offered by long sleeve shirts, head nets,

collars and hats. However, some insects can bite through socks

or other clothes; the treatment of clothing with an insecticide or

repellent can deter this. The small biting midges, sandflies and

blackflies are unable to bite through clothes, even if these are

made of thin material. People active during daytime can best

protect themselves by wearing thin clothing over as much of the

body as possible and applying repellents to the parts of the

body left exposed. Repellents are only partially effective against

swarms of biting midges. Head nets or hooded wide-mesh

jackets impregnated with a repellent offer good protection

(“Control Measures”, 2017, p. 59).

7. Possible dengue outbreaks in a region should be notified to the

government immediately so that preventions can be made.

Government-based initiatives are programs that request residents to

change their lifestyle in their homes to prevent mosquitoes from

spreading, residents were to clean surroundings and always drain

water that contain stagnant water and could be a factor of mosquito

spreading.

58
8. The researchers noticed that the government can be of great help to

destroying dengue threats. The government should have a budget to

implement traps for dengue mosquitoes such as ovitraps.

To Aedes aegypti, ovitraps appear to be ideal locations to

lay their eggs. The female lays its eggs on the paddles. The

eggs then fall beneath the mesh, where the mosquitoes

develop through the immature larval and pupal stages. When

the adult mosquitoes emerge, however, they are trapped

beneath the mesh and are unable to escape from the ovitrap.

Some ovitraps have been adapted to include sticky surfaces

that entrap adult mosquitoes, and others include the use of a

pesticide on the device (“Controlling Dengue Outbreak”, para.

6).

9. As dengue has various components, it is recommended to the future

researchers that they would include other components such as

dengue severity in relation to the four types of dengue that they would

widen the scope making the study more versatile and useful for

generations to come.

59