title: Evidence based community mobilization for dengue prevention in Nicaragua and Mexico (Camino Verde, the Green Way): cluster randomized controlled trial.
abstract: OBJECTIVE
  To test whether community mobilization adds effectiveness to conventional dengue control.
  
  
  METHODS
  Pragmatic open label parallel group cluster randomized controlled trial. Those assessing the outcomes and analyzing the data were blinded to group assignment. Centralized computerized randomization after the baseline study allocated half the sites to intervention, stratified by country, evidence of recent dengue virus infection in children aged 3-9, and vector indices.
  
  
  METHODS
  Random sample of communities in Managua, capital of Nicaragua, and three coastal regions in Guerrero State in the south of Mexico.
  
  
  METHODS
  Residents in a random sample of census enumeration areas across both countries: 75 intervention and 75 control clusters (about 140 households each) were randomized and analyzed (60 clusters in Nicaragua and 90 in Mexico), including 85,182 residents in 18,838 households.
  
  
  METHODS
  A community mobilization protocol began with community discussion of baseline results. Each intervention cluster adapted the basic intervention-chemical-free prevention of mosquito reproduction-to its own circumstances. All clusters continued the government run dengue control program.
  
  
  METHODS
  Primary outcomes per protocol were self reported cases of dengue, serological evidence of recent dengue virus infection, and conventional entomological indices (house index: households with larvae or pupae/households examined; container index: containers with larvae or pupae/containers examined; Breteau index: containers with larvae or pupae/households examined; and pupae per person: pupae found/number of residents). Per protocol secondary analysis examined the effect of Camino Verde in the context of temephos use.
  
  
  RESULTS
  With cluster as the unit of analysis, serological evidence from intervention sites showed a lower risk of infection with dengue virus in children (relative risk reduction 29.5%, 95% confidence interval 3.8% to 55.3%), fewer reports of dengue illness (24.7%, 1.8% to 51.2%), fewer houses with larvae or pupae among houses visited (house index) (44.1%, 13.6% to 74.7%), fewer containers with larvae or pupae among containers examined (container index) (36.7%, 24.5% to 44.8%), fewer containers with larvae or pupae among houses visited (Breteau index) (35.1%, 16.7% to 55.5%), and fewer pupae per person (51.7%, 36.2% to 76.1%). The numbers needed to treat were 30 (95% confidence interval 20 to 59) for a lower risk of infection in children, 71 (48 to 143) for fewer reports of dengue illness, 17 (14 to 20) for the house index, 37 (35 to 67) for the container index, 10 (6 to 29) for the Breteau index, and 12 (7 to 31) for fewer pupae per person. Secondary per protocol analysis showed no serological evidence of a protective effect of temephos.
  
  
  CONCLUSIONS
  Evidence based community mobilization can add effectiveness to dengue vector control. Each site implementing the intervention in its own way has the advantage of local customization and strong community engagement.
  
  
  BACKGROUND
  ISRCTN27581154.
authors.affiliation: Centro de Investigación de Enfermedades Tropicales (CIET), Universidad Autónoma de Guerrero, Acapulco, Mexico Department of Family Medicine, McGill University, 5858 Côte-des-Neiges, Montreal, Canada andersson@ciet.org.
authors.forename: Neil
authors.initials: N
authors.lastname: Andersson
authors.affiliation: Centro de Investigación de Enfermedades Tropicales (CIET), Universidad Autónoma de Guerrero, Acapulco, Mexico.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Nava-Aguilera
authors.affiliation: CIET, Managua, Nicaragua.
authors.forename: Jorge
authors.initials: J
authors.lastname: Arosteguí
authors.affiliation: Centro de Investigación de Enfermedades Tropicales (CIET), Universidad Autónoma de Guerrero, Acapulco, Mexico.
authors.forename: Arcadio
authors.initials: A
authors.lastname: Morales-Perez
authors.affiliation: CIET, Managua, Nicaragua.
authors.forename: Harold
authors.initials: H
authors.lastname: Suazo-Laguna
authors.affiliation: Centro de Investigación de Enfermedades Tropicales (CIET), Universidad Autónoma de Guerrero, Acapulco, Mexico.
authors.forename: José
authors.initials: J
authors.lastname: Legorreta-Soberanis
authors.affiliation: CIET, Managua, Nicaragua.
authors.forename: Carlos
authors.initials: C
authors.lastname: Hernandez-Alvarez
authors.affiliation: Facultad de Ciencias Biológicas, Universidad Autónoma de Nuevo León, Monterrey, Mexico.
authors.forename: Ildefonso
authors.initials: I
authors.lastname: Fernandez-Salas
authors.affiliation: Centro de Investigación de Enfermedades Tropicales (CIET), Universidad Autónoma de Guerrero, Acapulco, Mexico.
authors.forename: Sergio
authors.initials: S
authors.lastname: Paredes-Solís
authors.affiliation: Laboratorio Nacional de Virología, Centro Nacional de Diagnóstico y Referencia, Ministerio de Salud, Managua, Nicaragua.
authors.forename: Angel
authors.initials: A
authors.lastname: Balmaseda
authors.affiliation: Departamento de Prevención y Control de Enfermedades Transmisibles por Vector, Servicios Estatales de Salud Guerrero, Av Rufo Figueroa 6, Colonia Burócratas, Chilpancingo, Mexico.
authors.forename: Antonio Juan
authors.initials: AJ
authors.lastname: Cortés-Guzmán
authors.affiliation: Centro de Investigación de Enfermedades Tropicales (CIET), Universidad Autónoma de Guerrero, Acapulco, Mexico.
authors.forename: René
authors.initials: R
authors.lastname: Serrano de Los Santos
authors.affiliation: Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA.
authors.forename: Josefina
authors.initials: J
authors.lastname: Coloma
authors.affiliation: CIET International, New York, NY, USA.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Ledogar
authors.affiliation: Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, Berkeley, CA, USA.
authors.forename: Eva
authors.initials: E
authors.lastname: Harris
mesh_terms: D000330:Aedes; D000818:Animals; D002648:Child; D002675:Child, Preschool; D003153:Community Health Services / Q000458:organization & administration*; D003715:Dengue / Q000453:epidemiology / Q000517:prevention & control*; D003716:Dengue Virus / Q000254:growth & development*; D004197:Disease Reservoirs / Q000469:parasitology*; D019317:Evidence-Based Medicine; D015438:Health Behavior; D007722:Health Knowledge, Attitudes, Practice; D006798:Housing / Q000592:standards*; D006801:Humans; D007306:Insecticides; D008800:Mexico / Q000453:epidemiology; D009032:Mosquito Control / Q000379:methods / Q000458:organization & administration*; D009527:Nicaragua / Q000453:epidemiology; D010342:Patient Acceptance of Health Care; D012621:Seasons; D014881:Water Supply / Q000592:standards
chemical_list: D007306:Insecticides