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Vol 21, No. 09, September 2017   |   Issue PDF view/purchase
Managing Dengue
APBN interviews Assoc Prof Daniel Goh on dengue management strategies for Singapore and in the region.

Associate Professor Daniel Goh

A/Prof Goh is the current Chair of the Paediatric Cluster (Paediatric Medicine, Neonatology and Paediatric Surgery) at the National University Health System (NUHS). He is the immediate past-Head of Paediatrics at the National University Hospital, Singapore and the National University of Singapore (from 2007 to 2017), and is also Senior Consultant at the Paediatric Pulmonary and Sleep Division at the same institution.

Assoc Prof Goh is also the current Chairperson of the Asia Pacific Paediatric Sleep Alliance (APPSA) and Executive Committee member of the Asian Strategic Alliance for the Prevention of Pneumococcal Diseases (ASAP) and Asian Dengue Vaccine Advocacy group (ADVA).

He is a Fellow of the Royal College of Paediatrics and Child Health (UK) and a Fellow of the American College of Chest Physicians (USA) as well as a Fellow of the Academy of Medicine, Singapore.

A/Prof Goh serves on many Institutional, National and Regional committees and workgroups in Paediatrics, Vaccinology as well as Sleep. He is also reviewer of many regional as well as international peer-reviewed journals.

His clinical interests include childhood respiratory conditions including childhood asthma and allergies, sleep habits and practices in children across different cultures, sleep-related breathing disorders in children as well as paediatric bronchology, fiberoptic bronchoscopy and vaccinology.

Assoc Prof Daniel Goh completed undergraduate medical studies in the National University of Singapore and trained in Paediatrics in Singapore. He underwent further subspecialty training in Paediatric Pulmonology and Sleep at the Johns Hopkins Children’s Centre, USA

1. As a paediatrician, how do you see the importance of dengue prevention in a society?

Disease prevention is always better than cure; as a paediatrician, I focus a lot on maintaining and enhancing health in the child, as much as (or even more so) than treating diseases. Disease prevention and vaccination are essential areas in my work, and the work of all paediatricians and doctors alike.

Dengue can often be a silent disease. It is well established that asymptomatic infections (cases where one is infected with dengue but does not display any symptoms) can be up to four times more common than symptomatic infections. It is therefore a disease that can be transmitted anywhere, any time and anyone can be infected with dengue regardless of age, gender, underlying health conditions, occupation or socioeconomic status.1

By taking measures to prevent dengue and reducing the incidence of dengue infection, we protect the population by reducing the rate of disease transmission in the community.

2. Are children more vulnerable in developing dengue fever compared to adults? Are dengue vaccinations more effective for children than adults?

In Singapore, the prevalence for previous dengue infection is higher in adults compared to children. The prevalence for previous dengue infection for adults is more than twice as high compared to that of children. The prevalence for children below the age of 18 years is 10 per cent whereas the prevalence for adults above the age of 18 to 40 years is as high as 20 to 40 per cent.

In Singapore, the vaccine has been approved by the Health Sciences Authority (HSA) for use in individuals aged 12 to 45 years.2 No comparative studies have been conducted to conclusively say that dengue vaccination is more effective in children than adults.

Two major clinical studies conducted in children in Latin America and Asia showed that dengue vaccination is effective in the target age group from 12 to 16 years old. Among children aged 12 to 16 years, the vaccine was effective in reducing dengue illnesses by 69 per cent and in reducing severe dengue illness by 95 per cent. However, it does not offer the same level of protection against all dengue serotypes and is most effective for DEN-3 (76 per cent) and DEN-4 (88 per cent) but less effective against DEN-1 (60 per cent) and DEN-2 (53 per cent). The vaccine provides better protection in those with previous dengue infection compared to those without previous exposure.

Extrapolation of findings from clinical studies in children, based on antibody levels in adults who have been given the dengue vaccine, have shown that protection in adults up to 45 years of age is likely to be similar or higher than in children.

3. How do you define a holistic dengue management programme?

As recommended by the World Health Organisation (WHO) in its dengue position paper last year, a holistic dengue management programme involves a carefully executed and sustained vector control programme, prompt and good clinical care for dengue patients, as well as consistent vigilance and dengue surveillance in the community.3

The WHO has also recommended dengue vaccination as a programme in countries with high burden of disease where the seroprevalence of dengue is 70 per cent or greater in target age group for maximum public health impact and cost-effectiveness.

In Singapore, Dengvaxia® is not recommended as part of the national vaccination programme. The WHO does not recommend that countries implement a national vaccination programme using Dengvaxia when the population vaccinated has a prevalence of previous dengue infection below 50 per cent. The Ministry of Health’s Expert Committee on Immunisation (ECI) recommends that individuals who wish to use Dengvaxia® should do so in consultation with their doctors.

4. What are some of Singapore’s efforts and stands in fighting dengue? How is it different from the implementations in other countries?

Singapore has always been a strong advocate in the fight against dengue. Eliminating mosquito breeding remains a key strategy of the National Environment Agency (NEA). NEA works with various agencies and stakeholders, including those from the Inter-Agency Dengue Task Force (IADTF) as well as community leaders and grassroots organisations, to ensure that mosquito control programmes are sustained in the respective areas under their care. NEA takes a systematic and holistic approach to arrest dengue transmission in Singapore.

Its strategies include:

  1. Killing adult mosquitoes to prevent transmission of the dengue virus. The most common measures are spraying of insecticide at outdoor and indoor areas. Since 2013, NEA has also been placing Gravitraps in dengue cluster areas to complement these conventional measures. Gravitraps are designed to attract and trap female Aedes mosquitoes that are looking for sites to lay their eggs.

  2. iRemoving mosquito breeding sources to prevent the emergence of adult mosquitoes to reduce disease transmission. This is achieved through intensive search-and-destroy operations, both indoors and outdoors, to remove mosquito breeding, and applying larvicides.

  3. Rallying the community to help sustain efforts for dengue prevention and control through publicity and community engagement efforts as part of the National Dengue Prevention Campaign.

5. Do you think people in Singapore are aware of the steps preventing dengue from impacting themselves?

Singapore’s dengue control programme is decades-old and is complemented by outreach and publicity efforts. The majority of Singaporeans are aware of the threat of dengue and the actions that they should take to prevent mosquito breeding in their homes and neighbourhoods. Dengue prevention messages to urge vigilance and action by members of the public are publicised via a broad range of platforms including TV, newspapers, radio, bus stops, trains, digital media, social media and community spaces. NEA also works closely with community leaders and grassroots organisations to conduct on-ground activities to reach out to Singaporeans and educate them on dengue prevention steps.

6. What are the ‘costs’ of dengue disease?

In Southeast Asia, the average annual cost of dengue including the associated loss of productivity was estimated at US$4.8 billion per year.4

More importantly (and significantly), the cost to the patient and the caregivers are even greater as dengue can be a very painful disease and can lead to the potentially lethal severe dengue requiring hospitalisation.5 Other facts that exemplify the ‘cost’ of the dengue include:

  • Quality of life is decreased by up to 67 per cent during the acute phase of dengue illness, impacting patient well-being and productivity.6

  • The average number of school or work days missed for someone suffering from dengue is about 6 days.7

  • Post-infectious symptoms such as fatigue have also been reported to last up to 6 months after the acute phase.8,9,10

  • Studies have shown that the disease can cause fear and anxiety across entire communities.11

Dengue is a significant economic burden not just to a country’s healthcare system but also its productivity. Dengue illness is estimated to cost Singapore US$51.8 million per year while the annual cost of dengue in Southeast Asia, including the associated loss of productivity, is estimated at US$950 million billion.12,13,14

7. How is dengue diagnosed? Current diagnosis method is only via blood testing?

Currently, dengue can only be diagnosed with a blood test.15 Those who suspect that they have dengue should consult a doctor immediately as dengue infection can present in its more serious form, Dengue Haemorrhagic Fever, which could result in complications including widespread bleeding and organ failure.16

8. After bitten by mosquitoes infected by dengue virus, what are the chances of getting infected? If diagnosed, how long would it take the patients to recover?

The risk of contracting dengue after getting bitten by an infected mosquito has never been quantified. After getting a bite from an infected mosquito, the incubation period of the virus is four to ten days and the symptoms usually lasts for two to seven days.

Depending on the severity of the dengue disease, the recovery period may differ on a case by case basis. On average, patients may spend six days away from work or school to recover.17 The recovery phase of dengue usually begins on the 7th day from the onset of symptoms where general wellbeing improves and appetite returns.18 However, patients may display post-infectious symptoms such as fatigue for up to 6 months following a case of severe dengue.19,20,21

This interview was conducted by Carmen Loh Jia Wen.


  1. Philippine Council for Health Research and Development. Dengue vaccine research and development. 2017; https://www.pchrd.dost.gov.ph/index.php/news/library-health-news/3787-dengue-vaccine-research-and-development. Accessed 7 April, 2017.

  2. Sanofi Pasteur . Dengvaxia Product Information. Registration number SIN 15096P.Singapore 2016.

  3. World Health Organization (WHO). Dengue vaccine: WHO position paper- July 2016. Wkly Epidemiol Rec. 2016;91(30):349-364.

  4. Shepard D. Undurraga E. Halasa Y. Stanaway J. The global economic burden of dengue: a systematic analysis. The Lancet 2016

  5. World Health Organization. Dengue and severe dengue. Factsheet No 117, updated April 2017. Available at: https://www.who.int/mediacentre/factsheets/fs117/en/

  6. Armien B, et al. Clinical characteristics and national economic cost of the 2005 dengue epidemic in Panama. Am J Trop Med Hyg. 2008;79:364-71.

  7. Suaya, Jose et al. Cost of Dengue Cases in Eight Countries in the Americas and Asia: A Prospective Study. Am. J. Trop. Med. Hyg., 80(5), 2009, pp. 846–855

  8. Seet RC, Quek AM, Lim EC. Post-infectious fatigue syndrome in dengue infection. J Clin Virol. 2007;38(1):1-6.

  9. García G, González N, Pérez AB, et al. Long-term persistence of clinical symptoms In dengue-infected persons and its association with immunological disorders. Int J Infect Dis. 2011;15(1):e38-43.

  10. Tiga DC, Undurraga EA, Ramos-Castañeda J, Martínez-Vega RA, Tschampl CA, Shepard DS. Persistent Symptoms of Dengue: Estimates of the Incremental Disease and Economic Burden in Mexico. Am J Trop Med Hyg. 2016 May 4;94(5):1085-1089.

  11. Douglas DL et al. Will dengue vaccines be used in the public sector and ifo, how? Findings from an 8-country survey of policymakers and opinion leaders. PLoS Negl Trop Dis 2013. 7(3): e2127.

  12. Shepard DS, Undurraga EA, Halasa YA. Economic and disease burden of dengue in Southeast Asia. PLoS neglected tropical diseases. 2013;7(2):e2055.

  13. Shepard DS, Undurraga EA, Halasa YA et al. The global economic burden of dengue: a systematic analysis. Lancet Infect Dis. 2016;16(Suppl):1-59.

  14. Shepard DS, Undurraga EA, Halasa YA et al. The global economic burden of dengue: a systematic analysis. Lancet Infect Dis. 2016;16(8):935-941.

  15. SingHealth. Dengue Fever. https://www.singhealth.com.sg/PatientCare/ConditionsAndTreatments/Pages/Dengue-Fever-Child.aspx. Accessed 28 June, 2017.

  16. SingHealth. Dengue Fever. https://www.singhealth.com.sg/PatientCare/ConditionsAndTreatments/Pages/Dengue-Fever-Child.aspx. Accessed 28 June, 2017.

  17. Suaya, Jose et al. Cost of Dengue Cases in Eight Countries in the Americas and Asia: A Prospective Study. Am. J. Trop. Med. Hyg., 80(5), 2009, pp. 846–855

  18. World Health Organisation. Dengue Guidelines for diagnosis, treatment, prevention and control 2009

  19. Seet RC, Quek AM, Lim EC. Post-infectious fatigue syndrome in dengue infection. J Clin Virol. 2007;38(1):1-6.

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