Sri Lanka

Dengue has become a major public health problem in Sri Lanka with a considerable economic burden. As a response, in June, 2014, the Ministry of Health initiated a proactive vector control programme; but in partnership with military and police forces, known as the Civil-Military Cooperation (CIMIC) programme; that was target at high-risk Medical Officer of Health (MOH) divisions in the country.

Evaluating the effectiveness and cost-effectiveness of population-level interventions is essential; to guide public health planning and resource allocation decisions, particularly in resource-limited health-care settings. Using an interrupted time series design with a non-linear extension, they evaluated the impact of vector control interventions; from June 22, 2014, to Dec 29, 2016, in Panadura, a high-risk MOH division in Western Province, Sri Lanka.

They used dengue notification and larval survey data to estimate the reduction in Breteau index and dengue; incidence before and after the intervention using two separate models; adjusting for time-varying confounding variables (ie, rainfall, temperature, and the Oceanic Niño Index).

Different levels of hospitalization of dengue cases

They also assessed the cost and cost-effectiveness of the CIMIC programme from the perspective of the National Dengue Control Unit; under the scenarios of different levels of hospitalization of dengue cases (low [25%], medium [50%]; and high [75%]) in terms of cost per disability-adjusted life-year averted (DALY).

Vector control interventions had a significant impact on combined Breteau index (relative risk reduction 0·43, 95% CI 0·26 to 0·70); but on dengue incidence (0·43, 0·28 to 0·67), the latter becoming prominent 2 months after the intervention onset. The mean number of averted dengue cases was estimated at 2192 (95% CI 1741 to 2643); and the total cost of the CIMIC programme at 2016 US$271 615. Personnel costs accounted for about 89% of the total cost.

Cost-effectiveness thresholds

In the base-case scenario of moderate level of hospitalisation, the CIMIC programme was cost-saving with a probability of 70% under both the lowest ($453) and highest ($1686) cost-effectiveness thresholds, resulting in a net saving of $20 247 (95% CI -57 266 to 97 790) and averting 176 DALYs (133 to 226), leading to a cost of -$98 (-497 to 395) per DALY averted. This was also the case for the scenario with high hospitalization levels; (cost per DALY averted -$512, 95% CI -872 to -115) but with a higher probability of 99%.

In the scenario with low hospitalization levels (cost per DALY averted $690, 143 to 1379), although the CIMIC programme was cost-ineffective at the lowest threshold with a probability of 77%, it was cost-effective at the highest threshold with a probability of 99%.

This study suggests that communities affected by dengue can benefit from investments in vector control if interventions are implemented rigorously and coordinated well across sectors. By doing so, it is possible to reduce the disease and economic burden of dengue in endemic settings.