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Contents lists available at ScienceDirect

Journal of Infection and Public Health

journal homepage: http://www.elsevier.com/locate/jiph

Risk factors for dengue outbreaks in Odisha, India: A case-control

study
Subhashisa Swain a,c,∗ , Minakshi Bhatt a , Debasish Biswal b , Sanghamitra Pati d ,
Ricardo J. Soares Magalhaes e,f
a
Indian Institute of Public Health-Bhubaneswar, Public Health Foundation of India, Odisha, India
b
Department of Biotechnology, Ravenshaw University, Cuttack, Odisha, India
c
School of Medicine, University of Nottingham, Nottingham, United Kingdom
d
Regional Medical Research Center, Indian Council of Medical Research, Odisha, India
e
UQ Spatial Epidemiology Laboratory, School of Veterinary Science, The University of Queensland, Gatton 4343 QLD, Australia
f
UQ Child Health Research Centre, Children’s Health and Environment Program, The University of Queensland, South Brisbane 4101 QLD, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Environmental and climatic risk factors of dengue outbreak has been studied in detail. How-
Received 21 May 2019 ever, the socio–epidemiological association with the disease is least explored. The study aims to identify
Received in revised form 13 August 2019 the social and ecological factors associated with emerging dengue in Odisha, India.
Accepted 25 August 2019
Methods: A population-based case-control study (age and sex matched at the ratio of 1:1) was conducted
in six districts of the state in 2017. A structured validated questionnaire was used to collect information
Keywords:
for each consenting participant. An ecological household survey was done using a checklist during the
Dengue
month of July–September. Along with the descriptive statistics, conditional logistic regression model was
Outbreak
Epidemiology
used to calculate the adjusted odds ratio using STATA.
Odisha Results: Of 380 cases, nearly 55% were male and the median age was 33 years. The adjusted odds of having
India dengue was nearly three times higher among the people having occupation which demands long travel,
presence of breeding sites (1.7; 95% CI 1.2–2.6), presence of swampy area near home (1.5; 95% CI 1.1–2.1)
and having travel history close to the index date (1.6; 95% CI 1.1–2.4). People staying in thatched houses
had three times higher risk of the disease, however, households keeping the swampy areas clean had
50% less risk for the disease (0.5; 95% CI 0.31–0.67). Nearly 22.2% of cases had a travel history during the
index date. Of them, 36% had diagnosis before the travel, whereas, 64% developed the disease after the
returning from the travel.
Conclusion: Household factors such as occupation and ecological condition of households play important
roles in dengue outbreaks in Odisha. However, our study suggests travel/commuting are also essential
factors to be considered during disease prevention planning.
© 2019 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University
for Health Sciences. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction
Dengue, a neglected tropical vector born disease has become
challenge to the public health system in the world. The estimated
annual dengue burden in the globe is nearly 390 million cases from
∗ Corresponding author at: School of Medicine, University of Nottingham, United
Kingdom.
E-mail addresses: Subhashisa.Swain@nottingham.ac.uk (S. Swain),
bminakshi563@gmail.com (M. Bhatt), debasishbiswal1492@gmail.com (D. Biswal),
drsanghamitra12@gmail.com (S. Pati), r.magalhaes@uq.edu.au
(R.J. Soares Magalhaes).
120 countries [1]. However, these estimates can be higher due
to large number of under-reporting and non-symptomatic cases.
Most of the notified cases are concentrated in the South East Asia
(SEA) and Western Pacific Regions of the World Health Organiza-
tion (WHO) [2,3]. In the SEA, countries like Thailand, Indonesia,
India contribute in large extent to the burden [4].
Since the mid-1990s, dengue epidemic episodes in India have
grown rapidly and have become more frequent [5]. Currently India
is endemic for both dengue fever (DF) and dengue hemorrhagic
fever (DHF). Initially the infection was geographically limited to
a few states, which later expanded to most of the states in the
country [6]. Odisha, an Eastern state of the country historically
did not have any reported cases of the dengue till 2009, but now

https://doi.org/10.1016/j.jiph.2019.08.015
1876-0341/© 2019 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Swain S, et al. Risk factors for dengue outbreaks in Odisha, India: A case-control study. J Infect Public
Health (2019), https://doi.org/10.1016/j.jiph.2019.08.015
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Table 1
Sociodemographic description [Univariate analysis].

Variables Category Control Case Total Crude OR

N = 380% [95% CI] N = 387% [95% CI] N = 767% [95% CI] [95% CI]

Sex Men 54.5 [49.4–59.4] 52.2 [47.2–57.1] 53.3 [49.8–56.8] Matched

Women 45.5 [40.6–50.6] 47.8 [42.9–52.8] 46.7 [43.2–50.2]

Age group <= 15 years 12.6 [9.6–16.4] 12.7 [9.7–16.4] 12.6 [10.5–15.2] Matched
16–25 years 20.0 [16.3–24.3] 23.3 [19.3–27.7] 21.6 [18.9–24.7]
26–35 years 23.9 [19.9–28.5] 22.2 [18.3–26.7] 23.1 [20.2–26.2]
36–45 years 21.3 [17.5–25.7] 18.6 [15.0–22.8] 19.9 [17.3–22.9]
>= 46 years 22.1 [18.2–26.6] 23.3 [19.3–27.7] 22.7 [19.9–25.8]

Education No schooling 19.5 [15.8–23.8] 14.7 [11.5–18.6] 17.1 [14.6–19.9] Reference

Primary 20.0 [16.3–24.3] 19.1 [15.5–23.4] 19.6 [16.9–22.5] 1.2 [0.7–1.9]
Secondary 47.6 [42.6–52.7] 42.4 [37.5–47.4] 45 [41.5–48.5] 1.2 [0.8–1.8]
High School and above 12.9 [9.9–16.7] 23.8 [19.8–28.3] 18.4 [15.8–21.3] 2.5 [1.5–4.2]*

Ethnicity Non SC/ST 22.6 [18.7–27.1] 15.5 [12.2–19.5] 19.1 [16.4–22.0] Reference
SC/ST 77.4 [72.9–81.3] 84.5 [80.5–87.8] 81.0 [78.0–83.6] 1.6 [1.1–2.3]*

Occupation Unemployed 22.4 [18.4–26.8] 9.8 [7.2–13.2] 16.1 [13.6–18.8] Reference

Agriculture/Daily worker 15.3 [11.9–19.2] 19.4 [15.7–23.6] 17.3 [14.8–20.2] 3.9 [2.1–7.5]*
Business 7.6 [5.3–10.8] 8.8 [6.3–12.1] 8.2 [6.5–10.4] 3.5 [1.7–7.4]*
Home maker/student 36.6 [31.9–41.6] 46.5[41.6–51.5] 41.6 [38.1–45.1] 4.6 [2.6–8.1]*
Industry/Office 19.1 [14.6–22.4] 15.5 [12.2–19.5] 16.8 [14.3–19.6] 2.7 [1.4–5.2]*

Housing type Asbestos roof 32.4 [27.8–37.2] 19.9 [16.2–24.2] 26.0 [23.1–29.3] Reference
Concrete roof 30.3 [25.8–35.1] 34.6 [30.1–39.5] 32.5 [29.2–35.9] 1.9 [1.3–2.9]*
Mixed roof 18.4 [14.8–22.6] 17.8 [14.3–21.9] 18.1 [15.5–21.0] 1.6 [1.1–2.6]*
Thatched roof 18.9 [15.3–23.2] 27.6 [23.4–32.3] 23.3 [20.5–26.5] 2.6 [1.7–4.1]*

SC- Schedule caste, ST- Schedule Tribe; OR- Odds Ratio; CI- Confidence Interval.
*
P value < 0.05.

there is wide reporting from all the districts. According to the
surveillance data, the state now contributes nearly 10–15% total
dengue cases of the country [7]. These cases are scattered in distri-
bution and uneven with circulation of four serotypes of the virus
[8].
The transmission of dengue is dependent on various macro and
micro level factors such as temperature, humidity, rainfall, the pop-
ulation density, movement, immunity and virus load, urbanization,
environmental factors and socio-demographic and economic fac-
tors [4,9,10]. These influence the spread of the disease through
increased Aedes aegypti mosquito population, transmission of the
vector, spreading of the disease and practices of protection mech-
anism. Vector dynamics [11], population movement [12] and their
association with the dengue outbreak is well searched. Climatic
and environmental factors create the most favorable conditions
for dengue transmission and mostly studied. But investigating the
socio-demographic and other individual factors is equally impor-
tant for identifying the people at risk.
Especially, with current shift in the disease pattern it has become
essential to study the mentioned factors in detail. Studies say,
dengue is no more a disease of women, children and urban prob-
lem [13–15]. Community and individual practices can prevent or
increase the chances of the disease depending on the nature of
practices. Potential socio–demographic and ecological factors can
spread dengue to other regions due to increasing frequency of
transportation and travel [16]. Even though environmental factors
are crucial for the disease epidemic, a comprehensive prevention
mechanism would require information at individual level. Espe-
cially, in country like India, where diversity and differences are
predominant, studying these factors is essential.
The recent spike of cases in the state Odisha supports the
hypothesis of availability of favorable conditions for the disease
spread [17]. Moreover, recurring dengue epidemics also cre-
ates hyperendemic areas, typically large, densely populated areas
where several or all four serotypes dengue virus circulate in a sus-
tained fashion. In the state, increased numbers of cases are reported
among children and adults [8,18,19]. The available literature is lim-
ited to the epidemiological profile of the clinical cases, disease
burden and studying the serotypes [20,21]. Till date, there is scant
of evidence on social epidemiology of the disease in the state of
Odisha. We aimed to identify the socio–demographic and ecologi-
cal factors associated with dengue outbreaks in the state of Odisha,
India through population-based case-control study design.
Methods
Sample size calculation
For estimating sample size and testing of the study tool, a pilot
study was conducted among 30 subjects (10 cases and 20 controls)
from non-study area. Findings from the pilot study was used for
sample size calculation in the absence of relevant literature on risk
of travel for dengue. To detect minimum 10% difference of travel
exposure to endemic area among case (25%) and control (15%) of 1:1
ratio, with a power of 90% at a significant level of 0.05, the required
sample size was calculated as 354 in each group. Considering 10%
non-response rate, total required sample in each group was 393.
Proportionate sampling method was used to recruit patients from
five districts, based on the disease burden in the year 2016. Within
each district, patients were selected randomly from the available
list of cases obtained from the health department. The study was
conducted during the rainy seasons from July to September 2017
with additional purpose of inspecting the environmental condi-
tions (Table 4).
Study setting
The eastern state of India, Odisha covers about 155,707 sq km of
the total area of the country and has nearly 48,903 km2 of forests
spread over 31.41% of the state’s total area. The average rain-
fall in Odisha is measured as 1482 mm, of which 78% is received
between the months of June and September of a year. The summer
season in Odisha spans from March to June during which the max-
imum temperature at most of the places goes well above 40 ◦ C.
The state projects distinct yet homogeneous features of topogra-
phy and divided into five morphological units such as mountainous

Please cite this article in press as: Swain S, et al. Risk factors for dengue outbreaks in Odisha, India: A case-control study. J Infect Public
Health (2019), https://doi.org/10.1016/j.jiph.2019.08.015
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Fig. 1. Mapping of case and control samples.
Red dots represent cases and green dot represents controls. These are only spot maps, does not represent the numbers exactly.
and highlands region, coastal plains, western rolling uplands, cen-
tral plateaus and flood plains. According to the 2011 census of India,
the total population of Odisha was 41,947,358, of which 21,201,678
(50.54%) are male and 20,745,680 (49.46%) are female with popu-
lation density of 269 per km2 .
The study was carried out in 5 of the 9 high dengue burden
districts of the state, which contributes to more than 85% of the
total cases. Details of the distribution of dengue has been provided
elsewhere [17]. These districts represent nearly, 40% of the total
population. Within each district, high burden blocks were selected,
based on reported number of cases. This purposive selection was
done after consulting with the state nodal officers.
Study participants
The list of confirmed dengue patients within last one year (2016)
recorded at public & private hospitals of Odisha was used for selec-
tion of cases. The place of residence at the time of getting disease
was chosen as the study areas. This information was obtained
from National Vector Borne Disease Control Program (NVBDCP)
cell, Odisha, India. We excluded cases, who had disease history
of more than one year to avoid the recall bias. For the participant
aged less than 18 years, parents were interviewed, preferably those
who spend more time with them (for e.g. mother for single parent
working and grandparents or elder siblings in case of both parents
working).
Cases were confirmed dengue fever patients tested through IgM
method and hospitalized to any public or private health facilities
of the state. Controls were from same living area of cases matched
with sex and age (±2 years) with no history of dengue, chikungunya
or acute febrile illness in last one year. People having any history
of dengue in last one year but were not living in the study area in
during that period were excluded from the study. The index date
of the matched control was same that of (diagnosis date) cases. All
the questions referred to the index date only. The distribution of
the cases and controls are given in Fig. 1.
Data collection procedures
For the data collection, cases and controls were interviewed
with the help of a questionnaire designed for the study in vernacu-
lar language (Odia). The tool was tested for validity and reliability
and reported Cronbach’s alpha (0.76) for all the items. Based
on the responses from pilot study, necessary modification was
done. The survey questionnaire comprised four sections namely;
Please cite this article in press as: Swain S, et al. Risk factors for dengue outbreaks in Odisha, India: A case-control study. J Infect Public
Health (2019), https://doi.org/10.1016/j.jiph.2019.08.015
3
sociodemographic, travel history and exposure, environmental
condition and cleanliness practice, disease status of the family.
Socio–demographic and household profile section had questions on
age, sex, ethnicity (defined as ‘schedule caste/tribe’ or not according
to government classification), education (based on the schooling
completed), occupation (current and during the disease) and hous-
ing conditions. The housing type was categorized according to the
type of roof, like asbestos, concrete, thatched or mixed. Travel his-
tory section asked questions on travel history during the disease
period, duration of travel, place of travel, onset of disease in relation
to travel time and purpose of travel. Environmental and sanita-
tion section constituted questions on the presence of mosquito
breeding sites, current and past cleaning practices (during the dis-
ease period). Reported environmental conditions were validated
with the visit made by investigators with a check list. Participant’s
houses and gardens, including those of the neighbors (living within
10 ms radius of the house of the study participants) were inspected
to check the sources for the stagnant water, one of the favorable
breeding sites. The potential dengue breeding sites such as, water
storage containers or tanks (whether the containers were tightly
covered or not), gutters (collect rainwater), empty receptacles (bot-
tles, cans, tires, plastic containers, coconut shells etc.), presence of
any cattle shed was noted by the investigators. The heads of fami-
lies (cases, controls and the respective neighbors) who were asked
to participate in the study permitted inspection of their houses,
courtyards and gardens and voluntarily gave all information
requested.
Final approved tool was created in epi collect+ software and
installed in two tablets which was used during data collection.
We used digital data collection methods to obtain accurate geo-
coordinates of the houses, easy data management and real time
monitoring. Ten percent of the randomly picked data from total
was cross checked by the principal investigator. Members of the
research team had access to collected data through unique pass-
word.
Ethical considerations
The study was approved by state research and ethics committee,
Department of Health and Family Welfare, Government of Odisha,
India (letter number 141/SHRMU). Participants were explained
about the nature and the purpose of the study. Anonymity and
confidentiality of information provided were guaranteed. Before
the commencement of the interview, their right to refuse or with-
draw from the interview at any time during the process was clearly
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Table 2
Environmental practices [univariate analysis].

Environmental condition Control Case Total Crude OR

during the index date N = 380% [95% CI] N = 387% [95% CI] N = 767% [95% CI] [95% CI]

Presence of swampy area 71.0 [66.3–75.4] 78.6 [74.2–82.4] 74.8 [71.6–77.8] 1.5 [1.1–2.0]*
surrounding home
Participants clean the 51.1 [46–56.1] 43.7 [38.8–48.7] 47.3 [43.8–50.9] 0.7 [0.5–0.9]
swampy Area
Presence of breeding sites 44.5 [39.5–49.5] 55.5 [50.5–60.4] 50.1 [46.5–53.6] 1.6 [1.2–2.1]*
surrounding home
Presence of container 18.4 [14.8–22.7] 29.5 [25.1–34.2] 24.0 [21.1–27.1] 1.8 [1.3–2.6]*
breeding surrounding
home
Participants clean the 20.0 [16.3–24.3] 22.7 [18.8–27.2] 21.4 [18.6–24.4] 1.2 [0.8–1.8]
breeding sites
Presence of the 18.4 [14.8–22.7] 21.4 [17.6–25.8] 19.9 [17.3–22.9] 1.2 [0.8–1.7]
construction sites

Reference group for all the variables was ‘No’; OR- Odds Ratio; CI- Confidence Interval.
*
P value < 0.05.

Table 3
Travel history during the index date.

Variables Categories Control Case Total Crude OR

N = 380 n[95% CI] N = 387 N = 767 [95% CI]
n[95% CI] n[95% CI]

Travelled during the Yes 16.3 [12.9–20.4] 22.2 [18.3–26.7] 19.3 [16.7–22.3] 1.5 [1.1–2.1]*
index datea
Purposes of the travel Never 83.7 [79.6–87.1] 77.8 [73.3–81.7] 80.7 [77.7–83.3] Reference
Business 4.5 [2.8–7.1] 2.1 [1.0–4.1] 3.3 [2.2–4.8] 0.5 [0.2–1.2]
Work 4.7 [3–7.4] 12.4 [9.5–16.1] 8.6 [6.8–10.8] 3.3 [1.8–6.1]*
Other 7.1 [4.9–10.2] 7.8 [5.5–10.9] 7.4 [5.8–9.5] 1.2 [0.7–2.1]

Place visited during the Did not travel 83.7 [79.6–87.1] 77.8 [73.3–81.7] 80.7 [77.7–83.3] Reference
travel
Nearby town 7.4 [5.1–10.5] 11.4 [8.6–14.9] 9.4 [7.5–11.7] 1.7 [1.1–2.7]*
Cities within the state 4.7 [3.0–7.4] 2.1 [1.0–4.1] 3.4 [2.3–4.9] 0.5 [0.2–1.1]
Out of the state 4.2 [2.6–6.8] 8.8 [6.3–12.1] 6.5 [5.0–8.5] 2.4 [1.3–4.7]*

Period of travel with Did not travel 83.7 [79.6–87.1] 77.8 [73.3–81.7] 80.7 [77.7–83.3] Reference
reference to index date
Within 7 days of 8.7 [6.2–12] 14.2 [11.1–18.1] 11.5 [9.4–13.9] 1.8 [1.1–2.8]*
getting the disease
7-30 days 1.3 [0.5–3.1] 3.1 [1.8–5.4] 2.2 [1.4–3.5] 3.2 [1.02–10.1]*
1month to 6 months 2.9 [1.6–5.2] 1.8 [0.9–3.8] 2.3 [1.5–3.7] 0.80 [0.29–2.1]
More than one year 3.4 [2.0–5.8] 3.1 [1.8–5.4] 3.3 [2.2–4.8] 1.1 [0.41–2.4]

OR- Odds Ratio; CI- Confidence Interval.

*
P value < 0.05.
a
Reference group —‘did not travel’.

explained. Written consent was obtained from each adult partic-
ipants and parental consent was obtained for study participants
aged less than 18 years before the interview.
Results
Dataset for analysis
In total, 767 individuals (387 cases and 380 controls) from 5 dis-
tricts participated in the study. Of 387 cases, 380 had age (±2 years)
and sex matched controls. Proportion of males (53.3%) were higher
than females but not statistically significant. Participants age var-
ied from 3 to 91 year (median age 33 year, IQR 8). The response
rate during the study was 97.54% (780 subjects were contacted but
only 767 responded positively). Other sociodemographic charac-
teristics is described in Table 1. Significant association was seen
with occupation, education and type of housing.
Compared to controls, cases (78.6%) had more swampy areas
(including gutter) surrounding their home. Nearly, 51% of the con-
trol population clean their environment compared to 43.7% cases.
Whereas, equal proportion of people in both the groups, were
involved in cleaning of wastes surrounding their home. Case house-
hold had more mosquito breeding sites (55.5%) and container
breeding empty receptacles (29.5%), which was statistically signif-
icant (Table 2).
Travel history collected during the survey is provided in Table 3.
Nearly 22.2% of cases had travel history during the index date. Of
them, 36% had diagnosis before the travelling, whereas, 64% were
diagnosed with dengue after returning from the travel. Describ-
ing the purposes of travel, 12.4% of the cases travelled for work,
whereas, 7.8% travelled for other purposes (including visit to rela-
tive home). Of the cases, who travelled, 80% travelled within one
month of the disease and 53% travelled to the nearby town (Fig. 2).
Risk factors for dengue outbreaks in Odisha
Univariate regression models show ethnicity, occupation,
higher education, housing types, environmental factors like pres-
ence of swampy area around home, travel history, travelling from
outside of the state and having disease before the travelling had
statistically significant unadjusted odds ratio (OR) at p value 0.05.
Multivariate conditional logistic regression model explains the
association with occupation (OR ranged from 3–5), housing (OR
ranged from 2–3), travelling during the disease [1.6, 95% CI: 1.1–2.4]

Please cite this article in press as: Swain S, et al. Risk factors for dengue outbreaks in Odisha, India: A case-control study. J Infect Public
Health (2019), https://doi.org/10.1016/j.jiph.2019.08.015
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Fig. 2. Distribution of the travel details among cases. Percentage in each cell has been calculated with respect to the total people travelled during the disease (86).
and presence of the breeding sites [1.7, 95% CI: 1.2–2.6] were sta-
tistically significant after adjusting for other variables.
Discussion
Researchers have studied the risk factors of dengue transmis-
sion, especially the environmental and climatic associations. More
advanced researches use the population dynamics of both human
and vector to understand the outbreak. However, most of these
population-based studies are based on simulative mathematical
models [11]. Few in India have researched the epidemiological
determinants for dengue. This is the first ever study done to identify
the risk factors in the Eastern India. We found the leading associ-
ated factors are (i) occupation demanding travel has nearly three
times higher risk; (ii) presence of breeding sites increases the risk
by nearly two times and (iii) travel during the disease increases the
risk by two times as well. The case-control study is matched for
age, gender and small extent of area of living; thus, the identified
individual and housing level factors making the estimates real and
comparable.
We found significant association of dengue with occupation and
housing type. Which demonstrates a clear difference in the occupa-
tion and housing characteristics of cases compared to controls. The
positive association with businesspersons and agriculture/daily
worker indicates the jobs demanding travel to other places or
nearby towns predisposes them more at risk towards the disease.
There is inconsistent evidence on dengue association with occu-
pation [16,22,23]. The reported age group of cases in our study
is quite same as reported in other studies from the country [6].
However, the four times high association with students and home-
makers needs further investigation. Also, the reporting of the cases
within same families need to be studied in detail for better expla-
nation. As there is no difference across the groups observed, our
findings indicate the possible source of the disease could be the
workplace.
Please cite this article in press as: Swain S, et al. Risk factors for dengue outbreaks in Odisha, India: A case-control study. J Infect Public
Health (2019), https://doi.org/10.1016/j.jiph.2019.08.015
5
Housing structure is proved to be linked with dengue outbreak.
Studies reported that, staying in sheds/old flats creates higher
chances of dengue [16]. Especially, densely and nearly located
houses increase the dengue spread chances because of the crowd-
ing and environmental conditions [24]. I Peri–urban areas of India
are crowded, and the houses are closely located. Thus, the outbreak
is thought to have affected all the houses irrespective of the struc-
ture. But gradient association with the housing structure provides
a proxy indication towards the socio–economic condition of the
people. People living with thatched houses, may represent lower
socio–economic strata compared to others. So, increased dengue
from these houses could be because of the low protective mea-
sures in practice. Also, the housing characteristics such as windows,
curtains, gardens and its relationship with dengue breeding sites
cannot be ruled out. This specific aspect needs further investigation
in an Indian context.
Environmental factors as the risk factor of dengue is well estab-
lished in different countries [16,25–27]. Interestingly, we found
the presence of swampy area and breeding sites increases the
dengue outbreak by two times but, the presence of container was
not significant. Similar findings were reported other studies [28].
The non-association of the container breeding sites could have
two possible explanations. One, there could be lack of knowl-
edge in understanding the ‘container breeding’ sites. Even though
the researchers explained the participants with examples, still the
under-reporting could have been because of the knowledge gap
[29,30]. Another factor could be unorganized and unstructured
urbanization as most of the participants were from the peri-urban
area, the environmental sanitation conditions are often neglected.
Thus, the presence of container breeding sites in surrounding areas
instead of the house of the participants which could have been over-
looked and under reported. We did find similar responses among
school children in our previous study [31]. Presence of breeding
sites and their association necessitates a comprehensive preven-
tion strategy for stopping the dengue spread, which is supported
by the findings from our study. Dengue is being new to the state,
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JIPH-1176; No. of Pages 7 ARTICLE IN PRESS
6 S. Swain et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx

Table 4 questionnaire and limited the recall period to 12 weeks. Interviews

Conditional logistic regression for association of dengue.
were always performed by the same investigators to minimize the
Variable Categories Adjusted OR [95% inter-observer bias. We reduced the non-response bias by active
CI] case recruitment through the health workers. These health work-
Ethnicity SC/ST Reference ers live in the study areas and have most of the information about
Non SC/ST 1.4 [0.9–2.1] the patient. Because of financial constraints and logistic reasons, it
Education Illiterate Reference was not possible to perform laboratory test for the control group.
Primary 0.8 [0.47–1.5] Some controls accidentally may have been asymptomatic cases,
Secondary 0.9 [0.54–1.5] and misclassification bias cannot be excluded. We reduced this bias
High School and 1.4 [0.76–2.8]
by excluding rigorously subjects from the control group who pre-
above
sented with fever or any of the symptoms associated with dengue
Occupation Unemployed Reference fever. For the control group, who was not sure about the questions,
Agriculture/Daily 3.8 [1.8–7.9]*
help of other family members were taken. Our findings are based
worker
Business 4.6 [1.9–10.6]* on cases reported in 2016 only. Further, expanding the analysis,
Home 4.4 [2.3–8.4]* we found nearly 2/3 of cases developed the dengue after returning
maker/student from the travel. However, we did not have enough sample size to
Industry/Office 3.0 [1.4–6.5]* run any further regression model to estimate the risk. Thus, gener-
Housing Asbestos Reference alization of the risk factor needs caution because of the change in
Concrete 1.9 [1.2–3.1]* dengue virus circulation in the state.
Mixed 2.0 [1.1–3.5]*
Thatched 2.9 [1.7–5.1]*
Conclusions
Presence of swampy area No Reference
surrounding home
Yes 1.5 [1.1–2.1]* Our study is the first in the Eastern India to explore the risk
factors at individual and environmental level. Our findings corrob-
Participants clean the swampy No Reference
area
orate the available evidence on dengue transmission and suggest
Yes 0.5 [0.31–0.67] a dynamic pathway. It can hypothesize that, the initial infection
of the cases happened at other places than home. The travel his-
Presence of container breeding No Reference
surrounding the home tory might help the infected person to carry the virus to home and
Yes 1.5 [0.95–2.3] the favorable environmental conditions and mosquitos could have
spread the disease. At present, we do not have enough evidence to
Presence of any breeding site No Reference
Yes 1.7 [1.2–2.6]* support our hypothesis, but the future research should explore this
aspect.
Travelled during the index date No Reference
Yes 1.6 [1.1–2.4]*
Authors’ contributions
Variables with significant association in univariate analysis were included in mul-
tivariate analysis; OR- Odds Ratio; CI- Confidence Interval; SC- Schedule Caste; ST-
Schedule Tribe. SS and RSM conceptualised the study. MB and DB did data col-
*P value < 0.05. lection. SS and MB did data analysis. SS and SP drafted the full paper.
RSM and SP revised edited the manuscript. All authors contributed
to final development of the article.
the lower knowledge about the disease and risk factors cannot be
excluded.
Funding
The travel history among cases during the index date was asso-
ciated with more risk. This explains the link between the travel
This study was financially supported by the PHRI-Research
and dengue infection, which to some extent gives information on
Grant awarded by Public Health Foundation of India with the
the source of the infection. There is a clear evidence on the travel
financial support from Department of Science and Technology, Gov-
history and dengue infections both nationally and internationally
ernment of India (No. IN-DL220960833674480).
[32]. Studies from other cities of India also reported similar findings
[11]. We found majority of the people got the disease within 7 days
Competing interests
of the travel and of them nearly 70% travelled to the nearby cities.
Even though we did not enquire about the reason of the travel, the
None declared.
association of occupation and dengue it is an attempt for it. The
purposes of the travel could be for business, occupation and visit to
other places/houses. A study mapped the epidemic dynamics of the Ethical considerations
vector borne diseases in villages and city with commuter network
found positive association with travel to the cities and acquiring the The study was approved by state research and ethics committee,
infection [33]. Studying the age structure in detail we find, nearly Department of Health and Family Welfare, Government of Odisha,
30% of the people are below 25 years and 45% of the cases were India with letter number 141/SHRMU.
women. So, the higher chances of the travel could be to the schools,
workplace or to relative’s houses. Stoddard et al. reported the posi- Consent for publication
tive association with house–house movement [34]. Similar findings
are reported in Brazil [35]. Verma et al. too mentioned the travel Not applicable.
history as an essential criterion for suspicion of dengue in India
[36]. A mathematical model used similar concept to estimate the Availability of data and materials
outbreak in the western India [37].
Our study has some inherent limitations of case-control study The data that support the findings of this study are avail-
design. To minimize recall bias, we used a pre-tested standardized able from National Vector Borne Disease Control Cell, Department

Please cite this article in press as: Swain S, et al. Risk factors for dengue outbreaks in Odisha, India: A case-control study. J Infect Public
Health (2019), https://doi.org/10.1016/j.jiph.2019.08.015
G Model
JIPH-1176; No. of Pages 7 ARTICLE IN PRESS
S. Swain et al. / Journal of Infection and Public Health xxx (2019) xxx–xxx
of Health and Family Welfare, Government of Odisha, India but
restrictions apply to the availability of these data, which were used
under license for the current study, and so are not publicly avail-
able. Data are however available from the authors upon reasonable
request and with permission of Department of Health and Family
Welfare, Government of Odisha, India.
CRediT authorship contribution statement
Subhashisa Swain: Conceptualization, Formal analysis, Funding
acquisition, Investigation, Methodology, Project administration,
Resources, Software, Writing - original draft, Writing - review &
editing. Minakshi Bhatt: Data curation, Formal analysis, Software.
Debasish Biswal: Data curation. Sanghamitra Pati: Investigation,
Methodology, Resources, Validation, Writing - review & editing.
Ricardo J. Soares Magalhaes: Conceptualization, Methodology,
Supervision, Writing - review & editing.
Acknowledgments
We are thankful to Dr Madan Mohan Pradhan, Joint Director of
National Vector Borne Disease Control Cell, Odisha, India for his
kind support. The authors acknowledge the support provided by
the Directorate of Health Services and National Vector Borne Dis-
ease Control Cell, Government of Odisha for providing the data. We
thank to all the health workers, medical officers, field investigators
and participants for their valuable support.
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