Brunilda Lugo, PhD studentBrunilda Lugo, PhD student

Walden UniversityWalden University

PUBH-8165-10 PUBH-8165-10

Instructor: Dr. Robert MarinoInstructor: Dr. Robert Marino

Spring term, 2010Spring term, 2010

Table of ContentTable of Content ContentContent SlidesSlides Learning objectivesLearning objectives Learning outcomesLearning outcomes Dengue and causative agentDengue and causative agent Transmission and vectorsTransmission and vectors Geographic distributionGeographic distribution Breeding sites & life cycle of Breeding sites & life cycle of

AedesAedes Signs and symptoms of DengueSigns and symptoms of Dengue Diagnostic, treatment, Diagnostic, treatment,

preventionprevention EpidemiologyEpidemiology Dengue and Public HealthDengue and Public Health Final wordsFinal words ReferencesReferences CreditsCredits

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Learning ObjectivesLearning Objectives The learning objectives of this presentation are The learning objectives of this presentation are

to:to:

• Understand what is Dengue Fever, Dengue Understand what is Dengue Fever, Dengue Hemorrhagic fever and Dengue Shock SyndromeHemorrhagic fever and Dengue Shock Syndrome

• Understand the modes of transmission and how Understand the modes of transmission and how to prevent exposureto prevent exposure

• Understand the geographic importance of the Understand the geographic importance of the diseasedisease

• Understand the importance of dengue from a Understand the importance of dengue from a public health point of viewpublic health point of view

Learning OutcomesLearning Outcomes By the end of the presentation the audience will By the end of the presentation the audience will

be able to:be able to:Define dengue fever Define dengue fever Describe vectors, breeding sites and life cyclesDescribe vectors, breeding sites and life cyclesRecognized the signs and symptoms of the Recognized the signs and symptoms of the

clinical manifestation of dengueclinical manifestation of dengueDescribe diagnostics, treatment and preventive Describe diagnostics, treatment and preventive

measures of denguemeasures of dengueDemonstrate knowledge about the epidemiology Demonstrate knowledge about the epidemiology

of dengueof dengueDiscuss what public health is doing about this Discuss what public health is doing about this

diseasedisease

What is Dengue?What is Dengue?

Is an acute fever producing infectious diseaseIs an acute fever producing infectious disease Mostly found in the tropicsMostly found in the tropicsPronounce DEN-gheePronounce DEN-gheeComplications can be fatalComplications can be fatalIt is also known as Dengue fever , breakbone fever orIt is also known as Dengue fever , breakbone fever or

Dengue hemorrhagic fever Dengue hemorrhagic fever

Bauman, R., (2006). Microbiology disease by systems. San Francisco ,

CA: Pearson Benjamin Cumming Publishers

Causative agent of Causative agent of DengueDengue

Dengue is cause by a RNA virusDengue is cause by a RNA virus This virus is a member of the viral family This virus is a member of the viral family

Flaviviridae. Flaviviridae.

Dengue virusDengue virus

Bauman, R., (2006). Microbiology disease by systems. San Francisco , CA: Pearson Benjamin Cumming Publishers

Transmission of DengueTransmission of DengueA mosquito is the biological vector A mosquito is the biological vector This mosquito is the obligate intermediate host This mosquito is the obligate intermediate host

for some virusesfor some virusesAedes albopictus/aegypti Aedes albopictus/aegypti are generally are generally

associated with the spread of dengue feverassociated with the spread of dengue feverBiting around the ankles and knees close to the Biting around the ankles and knees close to the

ground in the daytime.ground in the daytime.Only female mosquitoes will bite; mostly in the Only female mosquitoes will bite; mostly in the

daytimedaytimeAkram, W., (n.d.). Aedes as a vector of Dengue: a possible threat to our lives. Khwarzimig

Science Society. University of Agriculture, Faisalabad. Retrieved April 19, 2010 from http://www.khwarzimic.org/takveen/dengue_kss.pdf

Aedes albopictusAedes albopictusThe Asian tiger mosquito was found in Florida at The Asian tiger mosquito was found in Florida at

a tire dump site near Jacksonvillea tire dump site near JacksonvilleThe species has spread rapidly throughout the The species has spread rapidly throughout the

eastern states, including all Florida’s 67 countieseastern states, including all Florida’s 67 countiesAedes albopictus Aedes albopictus is a vector for many viruses is a vector for many viruses

including dengue fever and Eastern equine including dengue fever and Eastern equine encephalitis virusencephalitis virus

Currently this mosquito is established in 866 Currently this mosquito is established in 866 counties in 26 statescounties in 26 states

Rios, L., Maruniak, J.E. (2008). Asian tiger mosquito. University of Florida Institute of Food and Agricultural Sciences . Retrieved April 19, 2010 from http://www.entemdept.ufl.edu/creatures/aqutic/asian_tiger.htm

Aedes albopictus

Aedes aegyptiAedes aegyptiCurrently is limited to the southeastern quadrant of the Currently is limited to the southeastern quadrant of the

U.S., and small areas in New York and ArizonaU.S., and small areas in New York and ArizonaThe most competent vector of dengue virus and yellow The most competent vector of dengue virus and yellow

feverfeverAs As A. albopictusA. albopictus, this mosquito depend greatly on stored , this mosquito depend greatly on stored

water for breeding sites.water for breeding sites.Male and Females adults feed on nectar of plantsMale and Females adults feed on nectar of plantsFemales bloodfeed primarily on humans in order to Females bloodfeed primarily on humans in order to

produce eggsproduce eggsA. aegypti bites during the day, indoor as well as A. aegypti bites during the day, indoor as well as

outdoorsoutdoors Zettel, C., Kaufman, P. (2008). Yellow fever mosquito. University of Florida Institute of Food and

Agricultural Sciences. Retrieved April 19, 2010 from http://entnemdept.ufl.edu/creatures/aqutic/aedes_aegypti.htm

Aedes aegypti

Geographic distribution Geographic distribution of Dengueof Dengue• Dengue disease occurs in tropical and Dengue disease occurs in tropical and

subtropical areassubtropical areas• Endemic in over 100 countries in the Endemic in over 100 countries in the

Caribbean, South, Central and North America, Caribbean, South, Central and North America, Africa, the Pacific Islands, Hawaii, Asia, Eastern Africa, the Pacific Islands, Hawaii, Asia, Eastern Mediterranean and AustraliaMediterranean and Australia

• Before 1970 only nine countries had experience Before 1970 only nine countries had experience dengue hemorrhagic fever epidemics, a number dengue hemorrhagic fever epidemics, a number that had increased more than four-fold by 1995that had increased more than four-fold by 1995

• World Health Organization, (2009). Dengue and Dengue haemorrhagic fever. Retrieved April 19, 2010 from http://www.who.int/mediacentre/factsheets/fs117/en/

Geography distribution Geography distribution of Dengueof Dengue

BBB

Blue dot: Geographic extension of dengue 2000-2007Blue shaded areas: Risk of dengue transmissionLines: Lines demarcate the area where the vector for dengue exists

Dengue in the United Dengue in the United StatesStatesDengue reported in the U.S. were acquired Dengue reported in the U.S. were acquired

elsewhere by travelers or immigrantselsewhere by travelers or immigrantsThe majority of dengue cases in U.S. citizens occur in The majority of dengue cases in U.S. citizens occur in

Puerto Rico, the U.S. Virgin Island, Samoa and GuamPuerto Rico, the U.S. Virgin Island, Samoa and GuamIn Puerto Rico, and most of the Caribbean Basin, the In Puerto Rico, and most of the Caribbean Basin, the

dengue vector is dengue vector is Aedes aegyptiAedes aegypti, this vector is , this vector is abundant year-roundabundant year-round

Dengue transmission in Puerto Rico follows a Dengue transmission in Puerto Rico follows a seasonal pattern, high transmission begins in August seasonal pattern, high transmission begins in August until Novemberuntil November

Center for Disease Control and Prevention, (2009)Dengue epidemiology. Retrieved Center for Disease Control and Prevention, (2009)Dengue epidemiology. Retrieved April 22, 2010 from http://www.cdc.gov/Dengue/epidemiology/index.htmlApril 22, 2010 from http://www.cdc.gov/Dengue/epidemiology/index.html

Common breeding sitesCommon breeding sitesDengue cases usually increase during the rainy Dengue cases usually increase during the rainy

seasonseasonThe spread of the mosquito is attributed to poor The spread of the mosquito is attributed to poor

environmental sanitationenvironmental sanitationWhen it rains the water gets stored in any place When it rains the water gets stored in any place

such as discarded tires, broken bottles, and even such as discarded tires, broken bottles, and even shoesshoes

Other examples are soda cans, birdbaths, rain Other examples are soda cans, birdbaths, rain gutters, toys, pool covers, tree stumps, and gutters, toys, pool covers, tree stumps, and garbage cans. garbage cans.

Illinois Environmental Protection Agency, (2007). Mosquito-Borne illnesses prevention techniques. Retrieved April 22, 2010 from http://www.epa.st.il.us /land/tires/mosquito-borne-illness.html

Aedes aegypti Aedes aegypti life cyclelife cycle

2-7 days

>4 days 2 days

Signs and Symptoms of Signs and Symptoms of Dengue FeverDengue Fever High fever, up to 105 F (40.6 C)High fever, up to 105 F (40.6 C) A rash over most of your body, can subside after a couple of A rash over most of your body, can subside after a couple of

days and then reappeardays and then reappear Sever headache, backache or bothSever headache, backache or both Pain behind your eyesPain behind your eyes Severe joint and muscle pain (breakbone fever)Severe joint and muscle pain (breakbone fever) Nausea and vomitingNausea and vomiting Signs and symptoms usually begin about four to seven days Signs and symptoms usually begin about four to seven days

after being bitten by after being bitten by A. aegyptiA. aegypti. . Mild dengue fever rarely causes death, it is usually self-limitingMild dengue fever rarely causes death, it is usually self-limiting

Mayo clinic, (2010). Dengue fever symptoms. Retrieved April 19, 2010 from http://www.mayoclinic.com/health/dengue_fever/DS01028/DSECTION=symptoms

Signs and Symptoms of Signs and Symptoms of Dengue Hemorrhagic fever Dengue Hemorrhagic fever (DHF)(DHF)A more severe form of dengue that begins the same A more severe form of dengue that begins the same

way as dengue fever but become worse after several way as dengue fever but become worse after several daysdays

Significant damage to your blood and lymph vesselsSignificant damage to your blood and lymph vesselsA decrease in the number of blood cells that help your A decrease in the number of blood cells that help your

blood clot (platelets)blood clot (platelets)Bleeding from nose and mouthBleeding from nose and mouthBleeding under the skin, which gives the appearance Bleeding under the skin, which gives the appearance

of bruisingof bruisingDeathDeath Mayo clinic, (2010). Dengue fever symptoms. Retrieved April 19, 2010 from

http://www.mayoclinic.com/health/dengue_fever/DS01028/DSECTION=symptoms

Signs and Symptoms of Signs and Symptoms of Dengue Shock Syndrome Dengue Shock Syndrome (DSS)(DSS)The most severe form of the diseaseThe most severe form of the diseaseIt may start with the signs and symptoms of mild It may start with the signs and symptoms of mild

dengue plusdengue plusSevere abdominal painSevere abdominal painFrequent vomitingFrequent vomitingDisorientationDisorientationFluid (plasma) leakage from blood vesselsFluid (plasma) leakage from blood vesselsHeavy bleedingHeavy bleedingA sudden drop in blood pressure (shock)A sudden drop in blood pressure (shock)

DeathDeath Mayo clinic, (2010). Dengue fever symptoms. Retrieved April 19, 2010 from

http://www.mayoclinic.com/health/dengue_fever/DS01028/DSECTION=symptoms

Why does different clinical Why does different clinical manifestations of Dengue manifestations of Dengue exists?exists?There are four different types (serotypes) of the There are four different types (serotypes) of the

dengue virusdengue virusThese are DEN-1, DEN-2, DEN-3 and DEN-4These are DEN-1, DEN-2, DEN-3 and DEN-4Recovery from infection by one provides lifelong Recovery from infection by one provides lifelong

immunity against that virus, confers only partial and immunity against that virus, confers only partial and transient protection against subsequent infection by transient protection against subsequent infection by the other three virusesthe other three viruses

There is evidence that sequential infection increases There is evidence that sequential infection increases the risk of developing dengue hemorrhagic feverthe risk of developing dengue hemorrhagic fever

World Health Organization, (2009). Dengue and dengue haemorrhagic fever. Retrieved April 19,2010 from http://www.who.int/mediacentre/factsheet/fs117/en/

Diagnosis for DengueDiagnosis for DengueTravel history and symptom profileTravel history and symptom profileDetection of antibodies against the virusDetection of antibodies against the virusComplete blood countComplete blood countChemistry panelChemistry panelLiver function testLiver function testOccult blood in stoolOccult blood in stoolDIC panelDIC panel

Price, D.D., Wilson, S.R., (2009). Dengue fever: differential diagnoses and workout. Medscape. Retrieved April 19, 2010 from http://emedicine.medscape.com/article/781961-diagnosis

Treatment for DengueTreatment for DengueNo specific therapeutic agents exist for dengue No specific therapeutic agents exist for dengue

infectionsinfectionsBed rest and hydration therapyBed rest and hydration therapyFever control with acetaminophen. Narcotics Fever control with acetaminophen. Narcotics

may be necessary if headaches are very severemay be necessary if headaches are very severeAspirin should be avoid because of Aspirin should be avoid because of

anticoagulant properties, children should avoid anticoagulant properties, children should avoid aspirin when a viral infection is suspectedaspirin when a viral infection is suspected

Monitoring of signs and symptoms for warning Monitoring of signs and symptoms for warning signs of DHF or DSSsigns of DHF or DSS

Price, D.D., Wilson, S.R., (2009). Dengue fever: differential diagnoses and workout. Medscape. Retrieved April 19, 2010 from http://emedicine.medscape.com/article/781961-diagnosis

Preventive Measure for Preventive Measure for TravelersTravelers No vaccine or drugs are available for the prevention of dengueNo vaccine or drugs are available for the prevention of dengue Preventive measure should be taken to avoid the bite of the Preventive measure should be taken to avoid the bite of the

mosquito mosquito Well screen accommodations or air conditioningWell screen accommodations or air conditioning Use of insecticide indoorsUse of insecticide indoors Apply insect repellent to skin and clothing. The most Apply insect repellent to skin and clothing. The most

effective are the ones with DEETeffective are the ones with DEET Empty , clean or cover any standing water that can be a Empty , clean or cover any standing water that can be a

mosquito-breeding site mosquito-breeding site

Center for Disease Control and Prevention, (2009). Other infectious disease related to Center for Disease Control and Prevention, (2009). Other infectious disease related to travel, dengue fever (DF) and dengue hemorrhagic fever (DHF). Retrieved April 19, travel, dengue fever (DF) and dengue hemorrhagic fever (DHF). Retrieved April 19, 2010 from http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/dengue-fever-2010 from http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/dengue-fever-dengue-hemorrhagic-fever.aspxdengue-hemorrhagic-fever.aspx

Incidence of Dengue Incidence of Dengue FeverFeverGlobal incidence of dengue has grown dramaticallyGlobal incidence of dengue has grown dramatically2500 million people- two fifths of the world’s 2500 million people- two fifths of the world’s

population- are now at risk from denguepopulation- are now at risk from dengueWHO estimates 50 million to 100 million cases of WHO estimates 50 million to 100 million cases of

dengue infection worldwide every yeardengue infection worldwide every yearIn 1998,there were 616,000 cases of dengue in the In 1998,there were 616,000 cases of dengue in the

Americas of which 11,000 cases were DHFAmericas of which 11,000 cases were DHFIn 2007, there were more than 890,000 reported cases In 2007, there were more than 890,000 reported cases

of dengue in the Americas, of which 26000 were DHFof dengue in the Americas, of which 26000 were DHF

World Health Organization, (2009) Dengue and dengue haemorrhagic fever. Retrieved April 19, 2010 from http://www.who.int/mediacentre/factsheets/fs117/en/

More StatisticsMore Statistics

An estimated 500,000 people with DHF An estimated 500,000 people with DHF require hospitalization each year, a large require hospitalization each year, a large proportion are children, about 2.5% of these proportion are children, about 2.5% of these diedie

DHF fatality rates can exceed 20% without DHF fatality rates can exceed 20% without proper treatmentproper treatment

World Health Organization, (2009) Dengue and dengue haemorrhagic

fever. Retrieved April 19, 2010 from http://www.who.int/mediacentre/factsheets/fs117/en/

Dengue and Public Dengue and Public HealthHealthDengue fever is a major public health problemDengue fever is a major public health problemThe reasons for the emergence of this disease The reasons for the emergence of this disease

are complex are complex Effective mosquito control is virtually nonexistent Effective mosquito control is virtually nonexistent

in most dengue-endemic countriesin most dengue-endemic countriesMajor global demographic changes have occurredMajor global demographic changes have occurred

Uncontrolled urbanizationUncontrolled urbanization Concurrent population growthConcurrent population growth Substandard housing, inadequate water, sewer, and Substandard housing, inadequate water, sewer, and

waste management systemswaste management systemsGubler, D.J., Clark, G.G., (1995)Dengue/dengue hemorrhagic fever: The emergence

of a global health problem. Retrieved April 19, 2010 from ftp://ftp.cdc.gov/pub/EID/vol1no2/adobe/gubler.vol1no2.pdf

Dengue Branch in Puerto Dengue Branch in Puerto RicoRicoProvides global leadership in dengue risk, Provides global leadership in dengue risk,

assessment, research and effective public assessment, research and effective public health practiceshealth practices

The branch has collected, analyzed and The branch has collected, analyzed and reported dengue cases from Puerto Rico, U.S. reported dengue cases from Puerto Rico, U.S. Virgin Island and the continental U.S.Virgin Island and the continental U.S.

Serves as the primary reference laboratory for Serves as the primary reference laboratory for state health departments and the World state health departments and the World Health OrganizationHealth Organization

Center for Disease Control and Prevention, (2009). About CDC’s dengue Center for Disease Control and Prevention, (2009). About CDC’s dengue branch. Retrieved April24, 2010 from branch. Retrieved April24, 2010 from http://www.cdc.gov/Dengue/about/index.htmlhttp://www.cdc.gov/Dengue/about/index.html

Public Health Prevention Public Health Prevention and Control of Dengueand Control of DengueThe importance of the activities of the Dengue The importance of the activities of the Dengue

Branch can translate to:Branch can translate to:New technologies into real-timeNew technologies into real-timeRapid diagnosis to treat patient earlier and Rapid diagnosis to treat patient earlier and

effectivelyeffectivelyImproving surveillance that will allow an effective Improving surveillance that will allow an effective

and targeted public response to dengue and targeted public response to dengue outbreaksoutbreaks

Clearer picture of the burden of dengue in Puerto Clearer picture of the burden of dengue in Puerto Rico, the continental U.S. and internationallyRico, the continental U.S. and internationally

Center for Disease Control and Prevention, (2009). About CDC’s dengue branch. Center for Disease Control and Prevention, (2009). About CDC’s dengue branch. Retrieved April24, 2010 from http://www.cdc.gov/Dengue/about/index.htmlRetrieved April24, 2010 from http://www.cdc.gov/Dengue/about/index.html

Prevention and Control Prevention and Control cont.cont.• Providing training to the medical community to Providing training to the medical community to

improve their knowledge of the diseaseimprove their knowledge of the disease• Conducting mosquito control interventions that Conducting mosquito control interventions that

allow the CDC to make recommendations to allow the CDC to make recommendations to vector control programvector control program

• Improving quality of surveillance dataImproving quality of surveillance data• Analyzing all the clinical manifestation of the Analyzing all the clinical manifestation of the

disease to conduct studies to improve the disease to conduct studies to improve the knowledge of the dengue virusknowledge of the dengue virus

Center for Disease Control and Prevention, (2009). About CDC’s dengue Center for Disease Control and Prevention, (2009). About CDC’s dengue branch. Retrieved April24, 2010 from branch. Retrieved April24, 2010 from http://www.cdc.gov/Dengue/about/index.htmlhttp://www.cdc.gov/Dengue/about/index.html

Final word of advice for Final word of advice for travelerstravelersThe times of higher risk of being bitten by the The times of higher risk of being bitten by the

female mosquito is 2 to 3 hours after daybreak female mosquito is 2 to 3 hours after daybreak and 3 to 4 hours before nightfalland 3 to 4 hours before nightfall

The mosquito can feed indoors as well as The mosquito can feed indoors as well as outdoorsoutdoors

Precautions as mention before should be taken Precautions as mention before should be taken especially at peak biting activity timeespecially at peak biting activity time

The risk of exposure may be lower in modern, The risk of exposure may be lower in modern, air-conditioned hotels with well-kept grounds air-conditioned hotels with well-kept grounds

Gubler, D., (1998). Dengue and dengue hemorrhagic fever . Clinical Microbiology Reviews, July 1998, p.480-496. Retrieved April 24, 2010 from http:/www.cmr.asm.org/cgi/repreint/11/3/480

Thank you for your timeThank you for your time I hope that this presentation was informative I hope that this presentation was informative

and useful especially when traveling to and useful especially when traveling to countries where dengue is endemiccountries where dengue is endemic

References:References: Akram, W., (n.d.). Aedes as a vector of Dengue: a possible threat to our lives.

Khwarzimig Science Society. University of Agriculture, Faisalabad. Retrieved April 19, 2010 from http://www.khwarzimic.org/takveen/dengue_kss.pdf

Bauman, R., (2006). Microbiology disease by systems. San Francisco , CA: Pearson Benjamin Cumming Publisher

Center for Disease Control and Prevention, (2009)Dengue epidemiology. Retrieved April 22, 2010 from http://www.cdc.gov/Dengue/epidemiology/index.htm

Center for Disease Control and Prevention, (2009). Other infectious disease related to travel, dengue fever (DF) and dengue hemorrhagic fever (DHF). Retrieved April 19, 2010 from http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/dengue-fever-dengue-hemorrhagic-fever.aspx

Center for Disease Control and Prevention, (2009). About CDC’s dengue branch. Retrieved April24, 2010 from http://www.cdc.gov/Dengue/about/index.html

Gubler, D.J., Clark, G.G., (1995)Dengue/dengue hemorrhagic fever: The emergence of a global health problem. Retrieved April 19, 2010 from ftp://ftp.cdc.gov/pub/EID/vol1no2/adobe/gubler.vol1no2.pdf

Gubler, D., (1998). Dengue and dengue hemorrhagic fever . Clinical Microbiology Reviews, July 1998, p.480-496. Retrieved April 24, 2010 from http:/www.cmr.asm.org/cgi/repreint/11/3/480

Reference:Reference: Mayo clinic, (2010). Dengue fever symptoms. Retrieved April 19, 2010 from

http://www.mayoclinic.com/health/dengue_fever/DS01028/DSECTION=symptoms Price, D.D., Wilson, S.R., (2009). Dengue fever: differential diagnoses and workout.

Medscape. Retrieved April 19, 2010 from http://emedicine.medscape.com/article/781961-diagnosis

Rios, L., Maruniak, J.E. (2008). Asian tiger mosquito. University of Florida Institute of Food and Agricultural Sciences . Retrieved April 19, 2010 from http://www.entemdept.ufl.edu/creatures/aqutic/asian_tiger.htm

World Health Organization, (2009). Dengue and Dengue haemorrhagic fever. Retrieved April 19, 2010 from http://www.who.int/mediacentre/factsheets/fs117/en/

Zettel, C., Kaufman, P. (2008). Yellow fever mosquito. University of Florida Institute of Food and Agricultural Sciences. Retrieved April 19, 2010 from http://entnemdept.ufl.edu/creatures/aqutic/aedes_aegypti.htm

List of recommended sources:List of recommended sources:

Dengue Fever , disease information: Dengue Fever , disease information: http://www.cdc.gov/ncidod/Diseases/submenuhttp://www.cdc.gov/ncidod/Diseases/submenus/sub_dengue.htms/sub_dengue.htm

CDC-Dengue: CDC-Dengue: http://www.cdc.gov/ncidod/dvbid/dengue/http://www.cdc.gov/ncidod/dvbid/dengue/

WHO/Dengue/dengue haemorrhagic fever: WHO/Dengue/dengue haemorrhagic fever: http://www.who.int/csr/disease/dengue/en/http://www.who.int/csr/disease/dengue/en/

CreditsCredits Slide 7: Google images dengue virusSlide 7: Google images dengue virus Slide 10: Google images-cdc-gathaway-Slide 10: Google images-cdc-gathaway-aedes-albopictusaedes-albopictus Slide 12: Google images- Slide 12: Google images- Aedes aegyptiAedes aegypti Slide 14: Google images Figure 1: Dengue TransmissionSlide 14: Google images Figure 1: Dengue Transmission Slide 17: Google images a mosquito breeding site, mosquito Slide 17: Google images a mosquito breeding site, mosquito

breeding breeding areas areas Slide 18: Google images – Slide 18: Google images – Aedes aegypti Aedes aegypti life cyclelife cycle Slide 19: Google images- mosquito breeding groundSlide 19: Google images- mosquito breeding ground Slide 34: Google images- beach photo Slide 34: Google images- beach photo