Dengue, Jakarta, and Southeast Asia
Dengue fever is a vector-borne disease, meaning that it transmits via contact with an infected organism—in this case, an infected mosquito. The spread of an infectious disease is traditionally addressed with direct intervention. Efforts include synthesizing a vaccine, quarantining infected individuals, educating the public, organizing communities, and eliminating the mosquito’s habitat. Despite these effective and necessary efforts, officials can slow the spread of a disease by allocating resources to intervene on social issues, such as climate change, pollution, deforestation, and environmental justice. Addressing these environmental issues, I argue, will lead to a significant reduction of mosquito breeding and biting behavior, especially regarding the spread of dengue fever in Jakarta, Indonesia.
Jakarta serves as an excellent case study. The city has faced numerous outbreaks of dengue fever over the past few years, particularly since 2004.i The city is a valuable illustrative case for other tropical cities, because Jakarta faces several environmental issues characteristic of tropical climates that contribute to the spread of dengue fever. The effects of climate change, deforestation, pollution, and class-based environmental injustice have indirectly caused more cases of dengue fever in the region.
Indonesia has rapidly urbanized in recent years. The country’s urban population has grown from 12.4% in 1950 to 22.1% in 1980 to 53.2% in 2010.iiIn urban environments, dengue fever has potent effects, a fact which exacerbates the need to address social justice issues in rapidly urbanizing regions. Jakarta illustrates the susceptibility of cities to incur dengue fever. However, dengue fever can be mitigated by addressing various environmental issues that affect Jakarta, Indonesia. I hope to offer solutions that can be applied to different infectious diseases and growing cities across the world.
Dengue Fever: Characteristics, History, and Prevalence
Dengue fever transmits by the bite of an infected female mosquito, typically Aedes aegypti, into a susceptible human host. The virus incubates for 4-10 days within the mosquito before the vector spreads the infection to healthy individuals.iiiThe disease cannot spread from person-to-person, save for rare cases of via blood transfusion or mother-to-child infections. Another type of mosquito, Aedes albopictus, can also cause infections of dengue fever.iv When considering the disease in an urban context, proximity of people is not a direct factor in contributing to the propagation of infection. However, dengue fever is found primarily in urban areas, suggesting that other characteristics of urban areas provide a suitable habitat for these mosquitos.
The disease was formally studied starting in the 1900s and became epidemic following World War II. The Center for Disease Control claims that accidental transportation of the Aedes mosquitos on cargo ships during the war spread dengue fever beyond its previous geographical boundaries.v
Dengue is mostly prevalent in the tropics and sub-tropics across the world, although there are some cases in colder climates.vi The type of mosquito that spreads dengue fever thrives in latitudes between 35°N and 35°S.vii Figure 1 shows dengue fever most prominently in the countries highlighted in orange. The area covers Southeast Asia, parts of Australia, India, Pakistan, Central Africa, Central America, and most of South America.
The climate must support the vector so that it can survive and transmit the virus. This brings up an issue: how climate change affects viable mosquito habitats. Climates currently supporting dengue fever may become even hotter and more humid, possibly resulting in larger mosquito populations. Further, high-elevation regions previously inhospitable to large mosquito populations could begin to see more infections as local climates warm.
Figure 1: Current Spread of Countries at risk for Dengue Feverviii
While dengue fever is severely infectious, it is unlikely to cause death in adults. As a public health problem, it is a leading cause of hospitalization and death of children in some Asian and Latin American countries.ix The symptoms of dengue fever are flu-like in nature. According to the World Health Organization,
Dengue should be suspected when a high fever (40°C/104°F) is accompanied by 2 of the following symptoms: severe headache, pain behind the eyes, muscle and joint pains, nausea, vomiting, swollen glands or rash. Symptoms usually last for 2–7 days, after an incubation period of 4–10 days after the bite from an infected mosquito.x
When patients have recovered from infection, they have immunity for life from that specific strand of the dengue virus. However, the patient is still susceptible to infection from the other three strands.xi All four versions of the disease can be contracted simultaneously. The different versions of the virus are DEN-1, DEN-2, DEN-3, and DEN-4. If a person experiences multiple serotypes of the virus at once, there is a tendency to develop more severe forms of dengue fever known as dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS) that each have more severe symptoms than dengue fever alone. In a major 2004 outbreak of dengue in Jakarta, 82.5% of those infected with DHF suffered from a secondary infection from a second serotype.xii
Increased awareness and better healthcare for the virus has decreased the case fatality rate, the number of deaths per confirmed cases of dengue. Dealing with the virus is a matter of access to adequate health care, early detection, and maintaining the patient’s fluid levels to combat the flu-like symptoms.xiii Figure 2 illustrates case-fatality rates in DHF patients from 1968 to 2005, and the rapid decrease in case fatality rate for DHF in Indonesia because of modern clinical techniques. If the host seeks medical attention for the fever’s symptoms, the survival rate is relatively high. However, children and people without access to health facilities are at a greater risk of not combating the symptoms. Without proper management, case fatality for DHF can be as high as 30%.xiv
Figure 2: Historic Case Fatality of Dengue Hemorrhagic Fever in Indonesiaxv
In early 2016, the first vaccine for dengue was registered for some countries that are endemic for dengue. However, a majority of Indonesia’s population practices Islam. A significant cultural concern in Indonesia reflects the need for the materials of vaccines not to conflict with the religious strictures of Islam. Islam maintains that any live vaccine synthesized through dogs and other animals is unclean, according to Islamic law, and must therefore be avoided.xvi Implementing a live vaccine synthesized from other animals may not be an option for public health officials. Luckily, it is possible to create a vaccine using another virus as a template.
The World Health Organization estimates that 3.9 billion people around the world are at risk for contracting dengue fever, and that there are 390 million global infections per year. As the tropical and sub-tropical cities in the global South grow at rapid rates, this urban disease will only become deadlier.
Surveillance in Southeast Asia
Two ways exist to monitor a disease: mortality and morbidity. Mortality rates reflect the lethality of a disease, and morbidity rates analyze how prevalent a disease is within a population. Morbidity is measured by prevalence (the number of current cases in a population) and incidence (the number of new cases in a susceptible population). By examining incidence, public health officials can determine yearly when new infections occur or how many occur per outbreak.
To survey dengue fever, the disease is now reportable. Whenever a doctor diagnoses a patient with dengue fever, the doctor must report the diagnosis to the local public health department. Public health departments can then effectively monitor diffusion of the disease while sparing their resources. To observe the incidence and prevalence of dengue fever in a region, health authorities wait for phone calls from physicians through “passive surveillance”. Though, some public health experts criticize Southeast Asian countries because many do not enforce reportable disease laws that require doctors to report instances of dengue to local health departments.xvii
Since dengue is a growing issue for Southeast Asia, some call for the use of “active surveillance,” which employs health department resources to increase awareness and precautionary measures for dengue fever. Active surveillance surveys homes for mosquito larva, sprays breeding grounds, educates the public, and encourages community participation. Active surveillance can be costly, but its effects noticeable. Singapore, another Southeast Asian city, became concerned with dengue fever in the 1960s. They implemented active surveillance through entomological and epidemiological surveys to reduce larval habitats and educate the public. This resulted in a 15-year period of low incidence of dengue until the active surveillance was slowed and the virus was reintroduced due to immigration from the surrounding region.xviii
In Indonesia, prevention efforts for dengue fever are a combination of passive surveillance and vector surveillance. Vector surveillance is done through community participation programs. One such program is called “Together Picket (Piket Bersama)” where the Family Welfare Empowerment Organization (PKK), Rotary club members, and DHF working groups educate the populace about the spread of dengue fever and reduction of the vector habitats.xix Another method of community prevention is called Bulan Geraken, which has three components:
- Health education using mass media, women’s groups, and schoolchildren
- Door-to-door visits by PKK (Women Empowerment Welfare Group) to cover, clean, and bury discarded water containers
- Source reduction using community participation and intersectoral coordinationxx
In addition to this community participation for vector surveillance, Indonesian health officials conduct larval surveys every three months using a metric called the Larvae-Free Index, which measures the percentage of houses without any Aedes mosquito larvae. However, an academic study determined that this is not ideal because the Larval-Free Index “fails to identify key containers for vector breeding sites and is not useful to evaluate vector control activities”.xxi Some places in Indonesia have also trained Village Health Volunteers (VHVs) who can conduct surveys to determine the amount of Aedes larva in an area.xxii
Active surveillance produces tangible decreases in disease incidence, but not all cities in Southeast Asia have the resources to prioritize disease prevention. It is important to establish how to fix environmental issues to also slow the propagation of dengue fever. By fixing these environmental issues and indirectly slowing dengue, one can kill two mosquitos with one stone.
Geography and Governance of Jakarta: Key Issues
Jakarta is a Southeast Asian city with a population of 10.323 million people,xxiii 23.91% of which consists of children aged 14 years or younger,xxiv who are the most susceptible to being killed by the dengue virus. As the capital of Indonesia, Jakarta is a central economic and political force for the island nation. The providence of Jakarta covers about 661km2,xxv about 60km2 larger than the city of Chicago. It is part of a larger island called Java, one of the major islands in Indonesia. Jakarta is also one of the largest cities in Southeast Asia regularly affected by the dengue virus. The population of 10.323 million people incurs an incidence rate of approximately 17.3/1,000 people per year in a 2008 study,xxvi meaning that each year about 17.3 in 1,000 people contract dengue fever in West Java, where Jakarta is located.
Along with dengue fever, Indonesia ranks eighth in the world for HIV/AIDS related deaths, and has a presence of malaria and bacterial diarrhea.xxvii Indonesian health departments are already burdened with these diseases. Indonesia ranks 180th in the world for health expenditure, which equates to 2.8% of their GDP.xxviii This means that health departments are a severely underfunded department of governance in Indonesia. Linking Jakarta’s environmental issues to disease prevention issues is key for environmental and health departments operating under low funding.
Notable geographical features of Jakarta include its direct contact with the Java Sea, which serves as an economic hub for shipping by ocean, and other short rivers dominate the area. Indonesia ranks 7th in the world for waterwaysxxix with 1,400km of manmade waterways.xxx The proximity to so many bodies of water creates an economic advantage, but also danger. Floods are an extremely present natural disaster in Jakarta. With an elevation of a mere 14 meters,xxxi the city is severely low in elevation and 40% of it is below sea level.xxxii Moreover, Jakarta has massive quantities of annual rainfall. Floods, while being costly to the city, also make the environment ideal for mosquito breeding. Still water and damp conditions make for excellent breeding grounds. Particularly, the urban poor settled in informal settlements called “kampung” neighborhoods are at great risk. These kampung neighborhoods are typically found along Jakarta’s waterways, which make them flood-prone and adjacent to mosquito breeding grounds.
Environmental Justice, Pollution, and the Citizens of Jakarta
Environmental injustice describes the discrepancies in environmental conditions between wealthy and poor communities. Jakarta’s kampung communities are urban villages throughout the city and its outskirts. Approximately 60% of the citizens in Jakarta live in kampung villages, which have 600 persons per 10,000m2.xxxiii Typically, those near the urban core have a higher density than those on the outskirts of the city.xxxiv These communities’ high population density creates a noticeably greater risk of contracting dengue fever in these settlements. Since an Aedes mosquito infects a victim with the dengue virus, the virus can be transmitted to other mosquitos that bite the host. This makes urban density important to the vicious cycle of growing infection, putting the members of kampungs at a greater risk of contracting the virus. Figure 3 illustrates land use of Jakarta’s kampungs highlighted in red.
Figure 3: Kampung Neighborhoods Land Use in Jakartaxxxv
Other issues involve access to clean drinking water and adequate sanitation. About half of Jakarta’s dwellings do not have toilet facilities or piped water.xxxvi Lack of plumbing can lead to dangerous situations created by water containers near homes. Since mosquitos tend to breed in containers full of water, this also leaves the urban poor at greater risk, which is a clear example of environmental injustice.
In many situations across the world, poverty is accompanied by poorer health care, thus leaving the poor more susceptible to infectious disease. Poverty is also associated with unpotable water, unsafe shelter, and lesser-quality education regarding disease prevention. When considering the impact of unresolved environmental justice issues, reduction in local poverty could alleviate the situation:
According to WHO, almost 137 million people in urban populations have no access to safe drinking water, and more than 600 million urban dwellers do not have adequate sanitation.xxxvii
Though many of the worst urban diseases spread through person-to-person contact or via sewage systems, mosquito-borne diseases like dengue fever tend to affect the urban poor more than others. Disparity in health care between the rich and the poor is one problem, but in terms of dengue prevention, the main factors to consider are the breeding sites of the Aedes mosquito and people’s protection from those mosquitos.
While advances in medicine are attributable as the main cause of dramatic declines in disease spread and fatality over the course of human history, sanitation has played a more prominent role in disease management. Purifying unsanitary water systems has done wonders for public health. Advances in areas from food safety to personal hygiene have diminished the negative effects of many diseases that used to plague populations. Likewise, though dengue fever cannot spread through water, food, or person-to-person contact, the propagation of the disease would be severely reduced through effective sanitation in Jakarta. Every day, the city of Jakarta produces 23,400m3 of trash, while the City Sanitation Office only cleans up 14,700m3 of this trash,xxxviii which equals a net gain of 8,700m3 of trash each day. To put that number into perspective, Jakarta produces about one and a half Goodyear blimps worth of uncleaned-up trash every single day.xxxix
This much trash around the city will directly cause more infections of dengue fever because artificial containers serve as breeding grounds for the Aedes mosquito. Common breeding grounds for this type of mosquito are still water containers, dark and humid areas inside homes, and plastic containers.xl Epidemiologists conducted a study in villages on Java to determine what sorts of containers the Aedes mosquito preferred when breeding. The general finding was that artificial containers were more likely to serve as a breeding ground than natural containers,xli which puts tropical urban civilizations at a disadvantage since those regions generally use artificial containers more than rural areas.
Among the vessels tested, discarded tires were found to have the highest proportion of infested breeding ground for the dengue-carrying Aedes mosquito. Other popular infestation containers include bathtubs, buckets, aquariums, flowerpots, plastic bottles, cans, water storage containers, and water dispensers.xlii Since many in Jakarta do not have access to clean water, many water dispensers and water storage containers serving as favorable breeding sites for the Aedes mosquito could cause big issues in this tropical city. Reducing excess trash also reduces the artificial container breeding grounds of the Aedes mosquito, therefore curtailing the spread of dengue fever across the greater Jakarta region.
Since Jakarta produces so much trash, it must all go somewhere. Figure 4 and Figure 5 are pictures of some of Jakarta’s kampung neighborhoods. The pictures show homes surrounded by many of the risk factors for mosquito breeding grounds: water sources, high population density, and numerous artificial containers floating in water.
Figure 4: Picture of Jakarta’s Kampung Neighborhoodxliii
Figure 5: Picture of Jakarta’s Kampung Neighborhoodxliv
In addition to the conditions of the dwellings, only 40% of the water in Jakarta is piped.xlv Those without access to piped water are poor urbanites residing in kampung housing. Since the study in Wijayanti’s article marked containers of still water as a potential breeding ground to be sprayed, poor urbanites without access to tap water who use containers to collect potable drinking water are in trouble. If they leave a container of water lying outside, dengue-infected Aedes mosquitos could breed near their homes. Outdoor faucets have this same issue as well. This inequality in drinking water access is environmentally unjust and leaves the kampung residents susceptible to more infections of dengue fever than those of cleaner, richer neighborhoods.
Indonesian culture has shaped the urban environment of Jakarta. As the familiar battle between economic development and social welfare wages on, the country and its capital have made many advances to celebrate, but there is still much room for improvement. Economic development and environmental welfare allow the country to combat and reduce the prevalence of infectious diseases. Although it makes sense for the Indonesian government to intervene to reduce dengue fever, acquisition of the economic means to fund public health expenditures is also necessary.
There are clear reductions in the spread of dengue fever that would stem from local governments and international NGOs cleaning-up these kampung neighborhoods. Environmental justice for the kampung neighborhoods and reduction of pollution has drastic impacts on how many Aedes mosquitos can breed and spread dengue fever. Investing in treating environmental issues could save Jakarta money in the fight against dengue and the health care costs incurred by dengue infections.
Climate Change, Biting, and Breeding
Along with pollution and environmental injustice in the Jakarta kampung of Jakarta, global climate change is an indirect cause of a growing prevalence of dengue fever. Multiple studies and correlations suggest that weather alterations associated with climate change, such as higher temperatures and rising sea-levels, increase the biting and breeding behaviors of various mosquitos.
Jakarta has a tropical climate with annual temperatures ranging from 24°C to 30°Cxlvi or about 75.2°F to 86°F. The rainy season runs from December to March, and a dry season from June to September. The rainy season peaks in January, with 19 rainy days, and the dry season peaks in August, with only about five rainy days.xlvii The highest monthly incidences of dengue fever occur in January, which correlates with the changing of the dry season into the rainy season.xlviii
The distinction in rainy and dry seasons in Jakarta allow us to determine which weather conditions lead to the most biting activity of the Aedes mosquito. Over a ten-year study, the incidences of DHF in the region were mapped in Figure 6.
Figure 6: Incidence of DHF in Jakarta from 2000–2010xlix
To draw attention to the rainy seasons, I have highlighted the graph during each rainy season from 2004 to 2010. There is a strong positive correlation between new cases of DHF and increased rainfall in Jakarta. The substantial spike in 2004 is likely related to the 2004 outbreak of DHF.
This positive correlation between tropical weather conditions and mosquito biting behavior is also reflected in a laboratory study that occurred in Bangkok, Thailand, attempting to understand the biting patterns of mosquitos related to temperature and humidity. The following graphs in Figure 7 demonstrate these findings.
Figure 7: Mosquito Biting Patterns Under Cool, Hot, and Rainy Conditions over the Course of a Dayl
During the peak biting times of the cool season, about 14 mosquitos were attracted to the human bait. The cool season rarely had more than 10 mosquitos attracted to the bait at any given time. Compare this to the peak of both the hot season and the rainy season, where each has a peak of about 20, and well over 10 at most hours of the day. Clearly, higher temperatures and rainier weather correlate with mosquitos’ increased attraction to the human bait. Although this study was conducted in Bangkok, its results give important insight into how local weather conditions in Jakarta can dramatically change the behavior of dengue-carrying mosquitos. This study also shows that the mosquito’s biting behavior tends to die down after sunset.
In these tropical climates of Southeast Asian cities, high rainfall and warm temperature dominate the weather. These weather conditions will only increase as global warming heats the earth and polar ice caps melt. According to Changing Epidemiology of Dengue Hemorrhagic Fever in Indonesia, the dengue incidence is directly related to a hotter, more humid climate. Likewise, the authors cite that higher temperatures are associated with larger mosquito populations and increased biting. They even attribute an outbreak in Palembang, Indonesia in 1997 to “a marked increase in rainfall and sustained higher temperatures compared to earlier years”li and note that the peak of annual dengue infections typically coincides with the rainy season.lii
The currently most-favored approach for fighting dengue in the area is through a combination of eliminating mosquito breeding grounds by spray, community participation, and education. Although this method combats the spread of the disease, global efforts to reduce greenhouse emissions and stop the cataclysmic effects of global warming would significantly slow the rising temperatures and humidity in tropical cities. That reduction in growth of temperature and humidity would impede the breeding and biting behaviors of the Aedes aegypti mosquito. Hence, this would reduce the number of dengue fever infections without directing any additional money directly toward the fight against dengue fever.
Deforestation and Dengue
Although some species of the Aedes mosquito live and breed in the woods (Reiter 3), a strong argument could be made that putting government resources into preventing deforestation will lower the spread of dengue fever.
The city of Jakarta has lost tremendous amounts of green space over the years. In 1984, the region was composed of 28.8% green space. That number dwindled to a mere 6.2% in 2007 with losses in forests, fields, and gardens.liii Governing forces in Jakarta have essentially accepted this deforestation with the Draft City Plan from 2002–2010.liv Floods occur regularly in the city of Jakarta due to its low elevation, abundant bodies of water, and heavy yearly rainfall. Excellent defenses against urban flooding are green spaces, as soil has great rainfall absorbency. Losses in forests and green space entails eroded natural flood barriers. Flooding can create many still water pools, which serve as breeding sites for the mosquito. Since floods produce large pools of still water, flood patterns must also be accounted for when planning how to prevent formation of Aedes mosquito habitats. By protecting natural flood barriers, the city can reduce the incidence of dengue fever while making the city a healthier, more appealing place to live.
Conclusions and Recommendations
An anonymous politician interviewed regarding dengue fever in Indonesia once said, “Community participation is almost impossible, since we’re asking poor people to think about a disease and they’re concerned with what they are going to eat today”.lv Tropical cities like Jakarta can have numerous social, environmental and economic issues that need to be addressed. What makes dengue fever so important? The more severe version of the disease, DHF, has a high case fatality rate and hospitalization rate among children.
I have identified Jakarta’s various environmental issues and the significant impact of each on the reduction of dengue fever’s spread. Global climate change makes tropical weather conditions grimmer, since it has shown to increase biting behavior of the Aedes mosquito. Pollution and solid trash buildup increase the mosquito’s available breeding grounds. Deforestation can increase regional flooding, which destroys urban landscape and leaves pools of still water in which the Aedes can breed. Environmental injustice leaves Jakarta’s kampung residents more exposed to dengue fever than others, whether by inaccessibility to potable water or by proximity to trash serving as a mosquito breeding sites.
More dengue infections beget more dengue-carrying mosquitos, which means that these environmental issues presented here must be addressed immediately. The fight against dengue fever in Jakarta does not need to be thought of exclusively in terms of vaccination, vector surveillance, or spraying breeding sites for the Aedes mosquito with insecticide. Addressing Jakarta’s outstanding environmental problems would directly lower the incidence of dengue fever in the region while helping the millions who live there.
There is some merit to claiming Indonesians may not care about dengue fever because they are hungry. However, there is significant evidence that there are several environmental issues that people do care about—flooding, pollution, and climate change—which will also slow the spread of dengue fever, if addressed more comprehensively. Fixing global climate change will take more than the Indonesian government alone, but world leaders should be informed that this is yet another reason to address global warming: to save countries some of the cost of infectious diseases that spread through the Aedes mosquito.
Policymakers in Indonesia should continue to encourage the use of cheaper measurements against dengue, such as Village Health Volunteers and spraying potential breeding sites. They should be aware, however, that the numerous studies have proved that investment in slowing global climate change, reducing trash build-up, building more open green spaces, taking steps to clean the kampung neighborhoods, and enforcing passive surveillance laws will drastically reduce the spread of dengue fever. Other countries should take interest in these Indonesian efforts as well, since the range of dengue could expand countries where dengue is not endemic as more climates become hospitable to the Aedes mosquito.
Investment in environmental and social justice efforts can drastically reduce the spread of mosquito-borne disease. The methods discussed for fighting dengue can apply to tropical cities with characteristics like those of Jakarta, but can also apply to any disease that spreads like dengue fever. Malaria, yellow fever, and other deadlier mosquito-borne diseases can be fought by addressing climate change, pollution, deforestation, and environmental justice. A more substantial focus on these environmental prevention methods will result in tangible reduction of infectious diseases.
Endnotes
i Monika S. Sitepu, et al, “Temporal patterns and a disease forecasting model of dengue hemorrhagic fever in Jakarta based on 10 years of surveillance data”, Southeast Asian Journal of Tropical Medicine and Public Health 44, no. 2 (2013): 210.
ii Peter James Rimmer, and H. W. Dick, The City in Southeast Asia: Patterns, Processes, and Policy (Singapore: NUS Press, 2009), 8
iii “Dengue and severe dengue”, World Health Organization, last updated April 2017, http://www.who.int/mediacentre/factsheets/fs117/en/.
iv “Dengue: Epidemiology”, Centers for Disease Control and Prevention, last modified June 09, 2014, https://www.cdc.gov/dengue/epidemiology/index.html.
v “Dengue and severe dengue”, WHO.
vi “Dengue: Epidemiology”, CDC.
vii “Epidemiology, burden of disease and transmission”, in Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control: New Edition, (Geneva: World Health Organization, 2009).
viii “Dengue and severe dengue”, WHO.
ix Ibid.
x Ibid.
xi Denise DeRoeck,Jacqueline Deen, and John D. Clemens, “Policymakers’ views on dengue fever/dengue haemorrhagic fever and the need for dengue vaccines in four southeast Asian countries”, Vaccine 22, no. 1 (2003): 121.
xii Sari Fadli Sungkars and A. Sukmaningsih, “Trend of dengue hemorrhagic fever in North Jakarta”, Journal of the Indonesian Medical Association 61, no. 10 (2011): 855.
xiii “Dengue and severe dengue”, WHO.
xiv Eng-Eong Ooi, & Duane J. Gubler, “Dengue in Southeast Asia: epidemiological characteristics and strategic challenges in disease prevention”, Cadernos de Saúde Pública, 25, supl. 1 (2009): 115.
xv Tatty E. Setiati, et al, “Changing Epidemiology of Dengue Haemorrhagic Fever in Indonesia”, Dengue Bulletin 30 (2006): 11.
xvi DeRoeck, 126.
xvii Ooi & Gubler, 4.
xviii Ibid., 6.
xix Aishah H. Azil, Ming Li, and Craig R. Williams, “Dengue Vector Surveillance Programs: A Review of Methodological Diversity in Some Endemic and Epidemic Countries”, Asia -Pacific Journal of Public Health, 23, no. 6 (2011): 7.
xx Rita Kusriastuti, and Sumengen Sutomo, “Evolution of dengue prevention and control programme in Indonesia”, Dengue Bulletin 29 (2005): 3.
xxi Azil, 7.
xxii Siwi P. M. Wijayanti, et al, “Dengue in Java, Indonesia: Relevance of Mosquito Indices as Risk Predictors”, PLOS Neglected Tropical Diseases 10, no. 4 (2016): 10.
xxiii “Indonesia”, CIA World Factbook, last modified November 14, 2017, https://www.cia.gov/library/publications/the-world-factbook/geos/id.html.
xxiv Statsmonkey, Total Population Statistics of DKI Jakarta by Gender, Age | Indonesia Stats, data visualization, https://www.statsmonkey.com/sunburst/22619-total-population-statistics-o....
xxv Roman Cybriwsky, and Larry R. Ford, “City profile: Jakarta”, Cities, 18, no. 3 (2001): 199.
xxvi Herman Kosasih, et al, “The epidemiology, virology and clinical findings of dengue virus infections in a cohort of Indonesian adults in Western Java”, PLOS Neglected Tropical Diseases 10, no. 2 (2016): 1.
xxvii “Indonesia”, CIA
xxviii Ibid.
xxix Ibid.
xxx Judy L. Baker, ed, Climate change, disaster risk, and the urban poor: cities building resilience for a changing world (Washington DC: World Bank Publications, 2012), 204.
xxxi Elevationmap.net, interactive online map, http://elevationmap.net/jakarta#menu2.
xxxii Baker, 204.
xxxiii Florian Steinberg, “Jakarta: Environmental problems and sustainability”, Habitat International 31, no. 3-4 (2007): 356.
xxxiv Cybriwsky, 202.
xxxv Pablo Ruiz, and Juliette Stoehr, “The water equation in Jakarta”, StoryBuilder, https://storybuilder.jumpstart.ge/en/the-water-equation-in-jakarta.
xxxvi Cybriwsky, 207.
xxxvii Emilie Alirol, et al, “Urbanisation and infectious diseases in a globalised world”, The Lancet infectious diseases, 11, no. 2 (2011): 132/
xxxviii Steinberg, 359.
xxxix Randall Marsh, “Goodyear replacing its current blimp fleet with zeppelins”, New Atlas, July 21, 2013.
xl Wijayanti, 5.
xli Ibid, 8.
xlii Ibid.
xliii Chris Bentley, “Trying to confront a massive flood risk, Jakarta faces ‘problem on top of problem’”, PRI, September 15, 2016, https://www.pri.org/stories/2016-09-15/trying-confront-massive-flood-ris....
xliv Ruiz & Stoehr.
xlv Steinberg, 358.
xlvi “Average monthly Rainfall, Sunshine, Temperatures, Humidity, Wind Speed”, World Weather & Climate Information, last modified 2016, https://weather-and-climate.com/average-monthly-Rainfall-Temperature-Sun....
xlvii Ibid.
xlviii Sitepu, 210.
xlix Ibid.
l M. Yasuno, and Robert J. Tonn, “A study of biting habits of Aedes aegypti in Bangkok, Thailand”, Bulletin of the World Health Organization 43 no. 2 (1970): 320.
li Setiati, 12.
lii Ibid.
liii Tommy Firman, “The continuity and change in mega-urbanization in Indonesia: A survey of Jakarta–Bandung Region (JBR) development”, Habitat International 33, no. 4 (2009): 332.
liv Steinberg, 356.
lv DeRoeck, 125.