With people in Saudi Arabia increasingly living in urban and semi-urban areas, the country may face a bigger threat of sudden outspread of mosquito vectors of dengue and Zika virus.1 A total of 2926 confirmed cases of dengue fever were documented in 2016 in Saudi Arabia alone,2 and dengue infection remains a major public health concern in the Western and South-western areas of Saudi Arabia and Yemen. Most cases are related to predominant dengue virus serotypes (DENV 1, 2, 3, and 4), climate change/extreme weather and urbanization drivers facilitate the proliferation of the incriminated disease vector (Aedes mosquito species).

Saudi Arabia recorded 6000 cases of dengue fever in 2015, and six infected patients died.2 Aedes aegypti and Ae. albopictus female mosquito species may bite both day and night and feed indoors and outdoors, which increases transmission in Saudi Arabia.1–3 Dengue is closely related to other mosquito-borne flaviviruses within the Flaviviridae family such as Zika, yellow fever, West Nile, and Japanese encephalitis.1,3–5 In 2006, a total of 10 000 infected dengue cases were recorded compared to a significant upsurge of more than 2.5 million at risk in 2016 in more than 130 countries. Zika virus causal factor infection is associated with congenital malformations (microcephaly) and neurological complications (Guillain-Barré syndrome) in children and maternal health issues and remains a serious concern in neighboring Aedes-prone countries.1,4–6

The current integrated vector management (IVM) drawbacks and operational challenges to rid A. aegypti and Ae. albopictus female mosquitoes breeding sites and case management costs have been highlighted by the persistent and changing pattern of Aedes sp.1,3,4,5,6 Understanding the drivers of mosquito abundance and competence, dengue and other arboviral infection threshold and seroconversion requires further research to elucidate viral host reservoirs and transmission routes (e.g., blood products transfusion, breastfeeding, transplacental, and sexual intercourse). Surveillance and monitoring of performance metrics are the keys to control and eliminate these viruses in Gulf Cooperation Council (GCC) Aedes-prone countries.1,2,5,6

Elucidating dengue and other emerging arboviral asymptomatic carriers, antigenic diversity and phylogenetic of DENV 1–4 and other arboviral diseases in Saudi Arabia, Yemen, and other Middle Eastern countries is crucial for timely prevention and case management strategies in Saudi citizens, Muslim pilgrims, and expatriate workers.7–10

Although the Health Committee of the GCC announced that all Gulf countries are free from Zika virus, innovative preventive and control methods are encouraged.11 A regional ‘One Health’ policy should comprise of innovative and sustainable vector prevention, environmental management, IVM, and care delivery solutions including enhanced community engagement and education, integration of new biocontrol approaches to law enforcement/regulations, regular laboratory screening of mosquito/blood-borne arboviral diseases, quality standards integration, and preparedness and capacity building strategies. Such strategies are crucial to reduce adult and larval mosquito populations. Investment in research and development is required to guide novel, affordable, and effective strategies and tools for timely preparedness and emergency response/containment, point of care diagnostics, and safe and effective vaccines and drugs.

This review seeks to highlight the urgent need to implement effective and contextual integrated ecofriendly behavioral communication change (BCC) and biocontrol approaches against persisting Aedes mosquitoes and other disease vectors including ticks, fleas, mites, and sandflies, which pose a significant public health threat in Saudi Arabia.

Improving community behavioral communication change approaches

Fostering practical approaches for sustainable development in human/community awareness and improving BCC impact are important in reducing and eliminating the persistent public health threat of dengue and emerging arboviral diseases and their vectors. In achieving this goal, leveraging on the community-based ‘One Health’ approach is paramount in elucidating the relationship between animal-human and environment interactions. Also, there is a need to increase vulnerable populations awareness and for health education promotion in schools/universities, culture/faith-based, stands/tribunes, and community/mass gatherings to improve people’s knowledge of vector-borne and zoonotic diseases, incriminated vectors breeding habitats, biological behavior, disease transmission dynamics, and complications to develop robust and sustainable community-based sanitation and hygiene practices to combat arboviral/zoonotic disease temporal/spatial spread.9,11 Additionally, social media and traditional media options can be used to accelerate community awareness and health education outreach, and acceptance and participation with biocontrol reductionist methods.

Such an approach is vital to support policy-making and emergency response management teams, adequate resource allocation, sufficient and sustained supervision, and evaluation of integrated programs incorporating Muslim religious and cultural (tradition and custom) concepts and experiences to satisfy residents healthcare needs.9–12 Community-based programs associated with governmental ministries, municipalities, social agencies, and interested stakeholders (health, education, environment, agriculture, irrigation, customs affairs, information, communication, and media) are needed to enhance community social mobilization and communication in Saudi Arabia, Oman, Yemen, UAE, Qatar, and Kuwait regarding the threat of dengue, Zika, and other arboviral diseases [Figure 1].1,2,10,13

Consolidating innovative and integrated biological control solutions implementation

Increasing funding and financial allocations are crucial for the development and deployment of innovative biological control solutions, which includes scaling-up community-based programs for awareness and empowerment as an effective
eco-friendly weapon against disease vectors.

Eco-friendly biological control measures, such as genetically modified mosquitoes artificially infected with Wolbachia — a bacterium that stops dengue — placed in large water-storage reservoirs/tanks and rain fall streams were deployed successfully in Aedes vector control in China, Brazil, Singapore, and parts of America. Another biological control measure is the use of fish/copepod predators, which can prey upon, parasitize, and compete with the wild vector and reduce the target vector populations.2,14–16 Deployment of genetically engineered mosquitoes, sugar toxic baits, and biologically new larvicide or adulticide agents’ complements are crucial tools in improving biocontrol approaches and strategies and should be used in parallel with insecticide resistance monitoring and development of appropriate countermeasures.17–19 Strengthening local-tailored and proven effective communities’ preventive and resilience methods coupled with educative approaches are needed in delivering vulnerable populations coverage against re/emerging public health threats (particularly maternal-child healthcare).13,14 Furthermore, adoption and adaptation of the CDC Pregnancy Risk Assessment Monitoring System to improve tracking and monitoring of Zika-related fetal development and birth defects, Guillain-Barré syndrome, and related motherhood and childhood complications in all endemic countries are highly recommended among the local population and expatriate workers. There is also need to establish green space to mitigate climate change as well as to develop a biodiversity conservation culture, which incorporates improved sanitation and drainage systems and mosquito repellants plants and waste management to develop a healthier environment. When introducing Wolbachia into urban or rural communities, it is important to understand mosquito host fitness and coexistence, the influence of biological competition outcomes, and the impact of vector competence as well as the ecological and bacterial profile in control and elimination.

Expanding sero-surveillance and response approaches implementation among the asymptomatic population at risk of arboviral diseases

Expansion of field and laboratory sero-surveillance and research among asymptomatic populations at risk (including pilgrims, school children, and expatriate workers) is crucial in documenting and generating data on arboviral diseases prevalence and potential risk factors. This is vital to establish robust evidence-based and sustainable early warning indices, policy planning and prediction, response approaches, and action plans. Moreover, it is imperative to enhance quality data and data sharing for evidence community-based risk reduction tactics and management. Promoting community participation and education programs remain key prevention and elimination tactics particularly during annual Hajj and seasonal Umrah pilgrimage, which may need quarantine measures in place to protect tourists from tropical and subtropical endemic high-risk areas in the GCC, Central/South America, Latin America, Asia-pacific, and Africa.10,13,14

It is worth noting that the use of window and door screens, air-conditioning, approved insect repellents (DEET and permethrin, which are safe and effective for pregnant women when used in accordance with the product label), and wearing long-sleeved shirts and long pants as protection against mosquito bites are the best prevention.2,4

Strengthening early warning system and risk communication to promote evidence-based preparedness and decision making

The use of pilot surveillance stations for early warning detection of disease outbreak accompanied by efficient data analysis and the implementation of remote sensing technologies and geographical information system analysis to predict communities at risk and forecasting the spatial/temporal landscape occurrence of the disease incriminated vectors could be used to sustain control and eliminate the threat of arboviral diseases. The use of such a modeling approach is of vital importance to enhance community/government preparedness and resilience tactics, pathogenic vector mapping, and implementing behavior change.

Integrating a contextual national ‘One Health’ approach is core in providing an integrated and improved understanding of human, animal, and environment interaction in tackling arboviral emerging threats and outbreaks. While concerted efforts in adapting the Sendai Framework Disaster Risk Reduction of United Nations is essential in reducing public health hazards, behavioral and environmental risks and implementing performance-based projects/programs that offer new opportunities for shared Aedes mosquitoes risk/burden reduction engagement in the GCC. Essentially, strengthening laboratory and epidemiological surveillance as well as insecticide resistance and monitoring Aedes mosquito behavior changes is needed to elucidate vector exposure versus immune profile diversity and phylogeography. The approach relies on generating comprehensive data to formulate reliable, effective, and sustainable decision-making policies, which can be used to inform projects and interventions in different vulnerable settings. This includes updates to travel information to protect pilgrims of Hajj and Umrah, and prevention and control packages on Zika, Chikungunya, and dengue co-infections. It has been noted that improving proven conventional entomological indices surveillance and monitoring analysis (i.e., house index; percentage of households with larvae or pupae and container index; percentage of water-holding containers with larvae or pupae/containers and Breteau index; number of positive containers with larvae or pupae per 100 households inspected) is crucial. In addition, fine risk mapping and early warning systems implementation should be done for timely case detection and monitoring, enhanced risk communication and rapid actions against emerging local and global circulating Aedes-linked dengue and arboviral diseases
threats and pandemics in Saudi Arabia, the GCC, and worldwide.

Strengthening governmental/private research and development renewed commitment and investments

Although laudable financial support has been devoted to fighting dengue, the threat of dengue and other arboviral diseases epidemic potential remains a public health concern locally and in the region. Promoting public-private stakeholders partnership (e.g., health and environment providers, pharmaceutical companies, non-government organizations, and other sectors), renewed leadership commitment and investment in collaborative and participative research in regional biosecurity including ample funding of research and development is essential for more sensitive diagnostics and tailored cost-effective community-based programs. Importantly, safe and effective dengue and Zika drugs and vaccines discovery for pilgrims/traveler immunization programs should remain a priority in curbing the global health security and other emerging pandemics.2,5,10,14,15,17,19

Conclusion

The threat of Aedes-linked vector-borne arboviral diseases epidemics represents a continuous and increasing public health concern in GCC countries. Strengthening robust, integrated preventive, and resilient multidisciplinary local and cross borders collaboration in resource mobilization and allocation is needed to scale-up integrated and sustainable Aedes vector control. Enhanced field epidemiological and laboratory importance surveillance is imperative to generate quality data and database sharing for evidence-based decision-making, biological control, and BCC approaches and targeted programs and interventions.

Establishing joint local and international experts, committee technical assistance to oversee, evaluate and monitor programs performance and impact on local dengue or potential pandemics threats situation and sustaining building capacity to improve alert warning alerts and best practices implementation is core.

Strategic inter-regional collaboration and contextual early detection and monitoring programs, including remote sensing/satellite and fine risk mapping analysis and safety practices monitoring, is crucial. Moreover, sustained community behavioral change, awareness, and resilience in emerging vector-borne diseases threat and epidemics innovations in control and eventual elimination in Saudi Arabia and its neighbor countries. Likewise, increasing monitoring and evaluation of single and multiple vector control projects in defining effective indicators and metrics of effectiveness and quality outcomes is crucial in promoting scale citizenry engagement and resilience in access to and uptake of sustained Aedes-related arboviral diseases preventive and control interventions.19

Disclosure

The authors declared no conflicts of interest. No funding was received for this study.

Acknowledgements

The authors would like to thank the Golden Eyes Ets. for the enabling environment and support.

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