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Dengue: How are we doing?

Pan American Health Organization19022002

Jorge R. Arias, Ph.D.

Celebrating 100 Years of PAHO

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Aedes aegypti:

Distributionthroughout the world

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Reinfestation ofAedes aegypti1930s 1970 2002

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The first eradication campaigns

were successful Internal and external financing for personnel,Internal and external financing for personnel,

equipment, and materials.equipment, and materials.

Emphasis on source reduction.Emphasis on source reduction.

Efficient residual insecticide.Efficient residual insecticide.

Centralized vertical programs, with militaryCentralized vertical programs, with military--stylestyle

organization, strict supervision, and a high level oforganization, strict supervision, and a high level ofdiscipline.discipline.

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Complicating Factors

Intrinsic factors of the vectorAedes aegypti

Reproductive capacity

Domestic breeding sites Disorganized urbanization of urban centers.

Industrialization of disposable packaging.

Persistence of tires and plastics. Deterioration or lack of basic services.

Intrinsic factors of the vectorAedes aegypti

Reproductive capacity

Domestic breeding sites Disorganized urbanization of urban centers.

Industrialization of disposable packaging.

Persistence of tires and plastics. Deterioration or lack of basic services.

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The Problem: Dengue It is aIt is a growinggrowingproblem.problem.

The number of cases in the AmericasThe number of cases in the Americashas gone fromhas gone from 66,011 in 198066,011 in 1980, to, tooverover 700,000 en 2000700,000 en 2000..

The control activities that are beingThe control activities that are being

carried out arecarried out arenot workingnot working..

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Incidence of Dengue* 2001

0 cases (9 countries)

ArubaBahamasBermudaCayman Islands

CuraoGuadaloupeTurkas & Caicos Islands

1 to 9 (5 countries)

DominicaSt.Vincent & the Grenadines

Jamaica

100 or more (14 countries)

Barbados

P.R.

St. Kitts & NevisAnguilla

St. Lucia

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Central America & Mexico

19952001

0

20,000

40,000

60,000

80,000

100,000

120,000

1995 1996 1997 1998 1999 2000 2001

Dengue

020 0

40 0

60 0

80 0

1,000

1,200

1,400

1,600

1 99 5 19 96 1 99 7 1 99 8 19 99 2 00 0 20 01

DHF

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Caribbean Islands

19952001

0

5,000

10,000

15,000

20,000

25,000

30,000

1995 1996 1997 1998 1999 2000 2001

Deng e0

100

200

300

400

500

600

1995 1996 1997 1998 1999 2000 2001

DHF

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Andean Countries

19952001

Andean Countries

19952001

0

20,000

40,000

60,000

80,000100,000

120,000

140,000

160,000

180,000

1995 1996 1997 1998 1999 2000 2001

Dengue

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

1995 1996 1997 1998 1999 2000 2001

DHF

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0

100,000

200,000

300,000

400,000

500,000

600,000

1995 1996 1997 1998 1999 2000 2001

Dengue

Southern Cone Countries

19952001

0500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

1995 1996 1997 1998 1999 2000 2001

DHF

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Cases of Dengue 19802001

without Brasil or Cuba

0

50,000

100,000

150,000

200,000

250,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

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Dengue Epidemics in theAmericas

9 countries

2000 2001

Hawaii

11 countries

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Dengue Epidemics 20002002

Hawaii

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Dengue Epidemics 2002

2002

DEN-3

DEN-1

DEN-3

DEN-?

DEN-1 >250,000cases

DEN-3

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The Problem: DHF The tendency ofDHF in the AmericasThe tendency ofDHF in the Americas

is increasing.is increasing. The situation is going to get worseThe situation is going to get worse

before it improves.before it improves.

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Cases ofDHF,

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216

61

71

150

251

306

537

640816

867

1,599

3,852

4,607

10,586

22,781 45,799

0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 40,000

**

FRG

GUT

JAM

PER

TRT

DOR

PR

ELS

HON

BRA

MEX

NIC

CUB

COL

VEN

Number of Cases ofDHF, 19812001

** all other countries

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0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

1955

1960

1965

1970

1975

1980

1985

1990

1995

Cases

Cases ofDHF in Asia, 19551998

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60

10312

3 0 8 12 35 97 86

2682

3646

23091753

41894723

8223

5092

1178312369

51175663

15503

0

2000

4000

6000

8000

10000

12000

14000

16000

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0

5,000

10,000

15,000

20,000

25,000

30,000

1 3 5 7 9 11 13 15 17

First 18 Years ofDHF inAsia and in theAmericas

First yearsDHF was reported

(1955-1973) (1984-2001)

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19681975

19771978

1981

1984

1982

1985

1986

1987

1988

The Evolution ofDHF

2001

19911995

1995

1998

2000

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0

20

40

60

80

1 10 100 1000 10000

Cases

Case FatalityRate (CFR) ofDHF

vs. Case Frequency

1%

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Circulation ofDEN-1

-2000

Barbados

-1999

Martinique

1998

Antigua andBarbudaDominicaMartiniquePuerto RicoSanta Lucia

Trinidad & Tobago

1977

2002

2001

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Circulation ofDEN-2

British Vrgin IslandsGranadaSt. Kits & Nevis

- 2000BarbadosMartiniquePuerto RicoSt. Vincent &GrenadinesTrinidad & Tobago

1998

1981

2001

- 1999

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Circulation ofDEN-3

AnguillaArubaBarbadosPuerto RicoSt. Kits & Nevis

1998

Martinique

- 1999

1994

British Vrgin IslandsCuraoDominicaG

adeloupeMartinique

- 2000

2002

20012002

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Circulation ofDEN-4

BahamasBarbadosBritish Virgin IslandsPuerto Rico

DHF

Antigua & BarbudaTrinidad & Tobago

1998- 1999- 2000

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and Outbreaks, 19852001

AtRisk

Outbreaks reported

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Municipalities with epizootics & YF cases

Municipalities with epizooticsMunicipalities with YF cases

Municipalities withAedes aegypti

Yellow Fever

(YF)

2000

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The majority of the obstacles for

dengue control continue to be thesame as they were in the past.

The majority of the obstacles for

dengue control continue to be thesame as they were in the past.

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Present-day dengue programs are not

progressing because:

Community participation in dengue prevention and

control is limited to official demands and never

attains community ownership;

Present-day dengue programs are not

progressing because:

Community participation in dengue prevention and

control is limited to official demands and never

attains community ownership;

Obstacles for DengueControl

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Localhealth services, nowpoliticallyand

administrativelyresponsible forthe

preventionandcontrol programsare not

sufficiently established;

Localhealth services, nowpoliticallyand

administrativelyresponsible forthe

preventionandcontrol programsare not

sufficiently established;

Obstacles forDengue Control

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Watersupplyandsolidwastemanagement

arelimitedinhigh-riskareas;

Watersupplyandsolidwastemanagement

arelimitedinhigh-riskareas;


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Sustainabilityandcontinuityofcontrolactionsare

constantlycompromised byotherhealthdemands

andpoliciesthatcompetewiththem;

Sustainabilityandcontinuityofcontrolactionsare

constantlycompromised byotherhealthdemands

andpoliciesthatcompetewiththem;


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Littlecapacity forintersectoralcoordination Littlecapacity forintersectoralcoordination


Thedengue problem is notthesoleresponsibilityofthe

Ministryof Health.

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Operationalresearchonindividualor

community-based strategieshave

notbeen sufficient.

Operationalresearchonindividualor

community-based strategieshave

notbeen sufficient.


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A Dengue Vaccine?

There is no licensed vaccine at present.

An efficient vaccine has to be tetravalent.

Several vaccines are in the pipeline.

An effective, safe, low-cost vaccine will

not be available in the near future.

There is no licensed vaccine at present.

An efficient vaccine has to be tetravalent.

Several vaccines are in the pipeline.

An effective, safe, low-cost vaccine will

not be available in the near future.

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Community ParticipationCommunity Participation

Opportunities forDengueControl

Intersectoral ActionsIntersectoral Actions

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Healthy houses

Healthyschools

Environment

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Dengue and DHFPrevention and Control Program

Social CommunicationComponent

Pan American Health Organization

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Where are we coming from?Where are we coming from?TheTheHemispheric PlanHemispheric Plan(1997) establishes the role of(1997) establishes the role of

community participationcommunity participationand ofand of

social communicationsocial communicationas components of theas components of thenational programsnational programs..

It also refers toIt also refers to 10%10%of the budget forof the budget for

this component.this component.

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Where are we coming from? (2)Where are we coming from? (2)

The Blueprint for Action for the Next Generation:The Blueprint for Action for the Next Generation:

D

engue Prevention and Control (1999)D

engue Prevention and Control (1999)reinforcestheDirectivethat was established forreinforcestheDirectivethat was established for

community participation andcommunity participation and

social communicationsocial communicationasspecified intheasspecified intheHemispheric Plan ofAction.Hemispheric Plan ofAction.

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Where are we coming from? (3)Where are we coming from? (3)

Surveillance for planningand response

Reduction ofdisease burden

Behavioralchange

TheGlobalStrategy for Dengue Fever andTheGlobalStrategy for Dengue Fever and

DHF Control (2000)DHF Control (2000)

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Where are we?Where are we?

Strengthening the implementation of theStrengthening the implementation of thesocialsocial--communicationcomponentcommunicationcomponentin thein the

national programs.national programs.

Promote thePromote thebehavioral changebehavioral changefocusfocusso that it will be more than justso that it will be more than just

dissemination of information.dissemination of information.

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Where are we? (2)Where are we? (2) Dissemination of theDissemination of the

behavioralchangestrategy.behavioralchangestrategy.

Social advocacy in favor ofSocial advocacy in favor of

intraintra--and intersectoral actionsand intersectoral actions toto

minimize environmental health problemsminimize environmental health problems

(water and solid waste management).(water and solid waste management).

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Where are we? (3)Where are we? (3) PAHO Directing Council Resolution [CD43.R4] forPAHO Directing Council Resolution [CD43.R4] for

the prevention and control of dengue based on athe prevention and control of dengue based on atechnical working documenttechnical working document

September 2001September 2001

Technical assistance in the preparation of aTechnical assistance in the preparation of asocialsocial--communication component based oncommunication component based on

community participationcommunity participation

MexicoMexico

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Where are we? (4)Where are we? (4) Supporting countries for the preparation ofSupporting countries for the preparation of

dengue communitydengue community--participation projects.participation projects.

PostPost--Mitch MesoMitch Meso--America ProjectAmerica Project

Supporting countries for the inclusion of a socialSupporting countries for the inclusion of a socialcommunication component (based on behavioralcommunication component (based on behavioralchange) in dengue control programs.change) in dengue control programs.

Andean Countries / Carta deG ayaquil (2001) and itsAndean Countries / Carta deG ayaquil (2001) and itsfollowfollow--up meeting (2002).up meeting (2002).

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Where are we going?Where are we going?

Integrated Strategyfordengue prevention and control

in the countries of

the Americas

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IV.IV. EnvironmentalmanagementEnvironmentalmanagement and addressingand addressing

basic servicess ch as waters pply,basic servicess ch as waters pply,

disposalofused water, solid wastemanagementanddisposalofused water, solid wastemanagementand

disposalofused tires.disposalofused tires.

V.V. PatientcarePatientcarewithinand o tsideofthe health system.withinand o tsideofthe health system.

VI.VI. CasereportingCasereporting(clinicalcases, confirmed cases,D

HF(clinicalcases, confirmed cases,D

HFand deaths duetoDHF, circulatingserotypes).and deaths duetoDHF, circulatingserotypes).

Integrated Strategy (Decalog)

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VII.VII. IncorporationIncorporationofthes bjectofofthes bjectof dengue/healthdengue/healthintointo formaled cationformaled cation..

VIII.VIII. CriticalanalysisCriticalanalysisofthe useandf nctionofofthe useandf nctionof

insecticidesinsecticides..IX.IX. Formalhealth trainingofprofessionalsandFormalhealth trainingofprofessionalsand

workersworkers (both inthemedicalandsocial(both inthemedicalandsocialareas).areas).

X.X. Emergency preparednessEmergency preparedness, establishing, establishingmechanismsandplanstofaceo tbreaksandmechanismsandplanstofaceo tbreaksandepidemics.epidemics.

Integrated Strategy (Decalog)

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PolicyPolicyManuals, guides, policy, protocolsManuals, guides, policy, protocols

Trai iTrai iManagers, socialworker, communicators, educators, promoters, etc.Managers, socialworker, communicators, educators, promoters, etc.

Operative alliancesOperative alliancesEcocl bs, i dustry, commerce, schools, enviro mentEcocl bs, i dustry, commerce, schools, enviro ment

Technical assistanceTechnical assistanceDesi and implementatio of regular and/or emergencyplansDesi and implementatio of regular and/or emergencyplans

C o s l tatioC o s l tatioSupport theimplementatio ofsocialcommunicatio and dissemi atio ofSupport theimplementatio ofsocialcommunicatio and dissemi atio of

i formatioi formatio

Strategies

How are we going?

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MonitoringMonitoring

Surveys, reports, s pervisory missions, etc.Surveys, reports, s pervisory missions, etc.

Eval ationEval ationTechnicalvisits, reports, workshops, task forces, etc.Technicalvisits, reports, workshops, task forces, etc.

EpidemiologicaldataEpidemiologicaldataPAHOPAHO websitewebsite: dengue casereporting): dengue casereporting)

Strategies

How do we know when we have arrived?

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Itis notasilver bulletItis notasilver bullet that can stopthethat can stopthe

increasingtrend ofdenguefeverandincreasingtrend ofdenguefeverand

dengue hemorrha ic fever.dengue hemorrha ic fever.

A personachievesA personachievesbehavioral changesin stepsbehavioral changesin steps..

There is a need to go from onephase to anotherThere is a need to go from onephase to another

sequentiallysequentially..

Social-Communication Component

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Social-Communication ComponentSocial-Communication Component

Formal health trainingFormal health training

ofhealth workers/providers is theofhealth workers/providers is thecentral pointcentral point

(managers, communicators, social workers,(managers, communicators, social workers,

educators, promoters, etc.) to theeducators, promoters, etc.) to the

NewNew--Generation Dengue Prevention and ControlGeneration Dengue Prevention and Control

ProgramProgram..

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dens it

Documents