hcp/hct/vbd paho/who 2002 jra dengue: how are we doing? pan american health organization 1902–2002...

HCP/HCT/VBD

PAHO/WHO 2002

JRA

Dengue: How are we doing?

Pan American Health Organization1902–2002

Jorge R. Arias, Ph.D.

Celebrating 100 Years of PAHO

HCP/HCT/VBD

PAHO/WHO 2002

JRA

Aedes aegypti: Distribution

throughout the world

HCP/HCT/VBD

PAHO/WHO 2002

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Reinfestation of Aedes aegypti 1930s 1970 2002

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PAHO/WHO 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 military-Centralized vertical programs, with military-

style organization, strict supervision, and a style organization, strict supervision, and a

high level of discipline.high level of discipline.

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PAHO/WHO 2002

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Reasons Why the Eradication Failed

• Not all countries were willing to eradicate Not all countries were willing to eradicate Aedes aegypti.Aedes aegypti.

• The program lost political importance in the majority of the The program lost political importance in the majority of the countries that achieved eradication.countries that achieved eradication.

• Once re-infestation was observed reaction was too late.Once re-infestation was observed reaction was too late.

• High cost of materials, equipment, salaries and social benefits.High cost of materials, equipment, salaries and social benefits.

• Aedes aegyptiAedes aegypti Resistance to organochloride insecticides. Resistance to organochloride insecticides.

• Rapid and uncontrolled growth of urban centers.Rapid and uncontrolled growth of urban centers.

• Not all countries were willing to eradicate Not all countries were willing to eradicate Aedes aegypti.Aedes aegypti.

• The program lost political importance in the majority of the The program lost political importance in the majority of the countries that achieved eradication.countries that achieved eradication.

• Once re-infestation was observed reaction was too late.Once re-infestation was observed reaction was too late.

• High cost of materials, equipment, salaries and social benefits.High cost of materials, equipment, salaries and social benefits.

• Aedes aegyptiAedes aegypti Resistance to organochloride insecticides. Resistance to organochloride insecticides.

• Rapid and uncontrolled growth of urban centers.Rapid and uncontrolled growth of urban centers.

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PAHO/WHO 2002

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Hemispheric erradication of Aedes aegypti is no longer realistic.

• The problem is larger than it was prior to the previous campaigns.

• Lack of resources.• Resistance to vertical programs and the use

of insecticides.• Lack of effective insecticides.• Low priority and lack of sustainability.

• The problem is larger than it was prior to the previous campaigns.

• Lack of resources.• Resistance to vertical programs and the use

of insecticides.• Lack of effective insecticides.• Low priority and lack of sustainability.

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PAHO/WHO 2002

JRA

Complicating Factors

• Intrinsic factors of the vector Aedes 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 vector Aedes 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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PAHO/WHO 2002

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The Problem: Dengue

• It is a It is a growinggrowing problem. problem.

• The number of cases in the The number of cases in the Americas has gone from Americas has gone from 66,011 in 66,011 in 19801980, to over , to over 700,000 en 2000700,000 en 2000..

• The control activities that are The control activities that are being carried out are being carried out are not workingnot working..

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Incidence of Dengue* 2001

0 cases (9 countries)

ArubaBahamasBermudaCayman IslandsCuraçãoGuadaloupeTurkas & Caicos Islands

1 to 9 (5 countries)

Dominica St.Vincent & the Grenadines

Jamaica

<1 (2 countries)

* per 100,000

population

10 to 99 (14 countries)

Grenada

D.R..

Antigua & BarbudaGrenadaBritish Virgin IslandsMonserrat

Hawaii

Trinidad & Tobago

>100 or more (14 countries)

Barbados

P.R.St. Kitts & NevisAnguilla

St. Lucia

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Central America & Mexico1995–2001

0

20,000

40,000

60,000

80,000

100,000

120,000

1995 1996 1997 1998 1999 2000 2001

Dengue

0

200

400

600

800

1,000

1,200

1,400

1,600

1995 1996 1997 1998 1999 2000 2001

DHF

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Caribbean Islands1995–2001

0

5,000

10,000

15,000

20,000

25,000

30,000

1995 1996 1997 1998 1999 2000 2001

Dengue 0

100

200

300

400

500

600

1995 1996 1997 1998 1999 2000 2001

DHF

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Andean Countries1995–2001

Andean Countries1995–2001

020,00040,00060,00080,000

100,000120,000140,000160,000180,000

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 Countries1995–2001

0

500

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, 1980–2001

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

800,000

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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Cases of Dengue 1980–2001without 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 the Americas

9 countries

2000 2001

Hawaii

11 countries

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Dengue Epidemics 2000–2002

Hawaii

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Dengue Epidemics 2002

2002

DEN-3

DEN-1

DEN-3

DEN-?

DEN-1 >250,000 casesDEN-3

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The Problem: DHF• The tendency of DHF in the The tendency of DHF in the

Americas is increasing.Americas is increasing.

• The situation is going to get The situation is going to get worse before it improves.worse before it improves.

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1968–19805 Countries: 60

Cases

1968–19805 Countries: 60

Cases

Dengue Hemorrhagic Fever (DHF)Dengue Hemorrhagic Fever (DHF)

1981–2001*28 Countries >93,000

Cases

1981–2001*28 Countries >93,000

Cases

* to 01/01/200

2

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Cases of DHF, <1980 to 2001Cases of DHF, <1980 to 2001

60

10,312

3 0 8 12 35 97 86

2,6823,646

2,3091,753

4,1894,723

8,223

5,092

11,78312,369

5,1175,663

15,503

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

<1981

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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216

61

71

150

251

306

537

640

816

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 of DHF, 1981–2001

** all other countries

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PAHO/WHO 2002

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0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

Case

sCases of DHF in Asia, 1955–1998

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60

10312

3 0 8 12 35 97 86

26823646

23091753

41894723

8223

5092

1178312369

51175663

15503

0

2000

4000

6000

8000

10000

12000

14000

16000

<1981

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

0

100,000

200,000

300,000

400,000

500,000

600,000

700,000

Cases

Cases of DHF in Asia and in the

Americas

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PAHO/WHO 2002

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If we take the If we take the first 18 years that DHF was reported in Asiafirst 18 years that DHF was reported in Asia (1955– (1955–

1973) and 1973) and the first 18 years that it occurred in the Americasthe first 18 years that it occurred in the Americas

(1984–2001) after the Cuban epidemic of 1981, and (1984–2001) after the Cuban epidemic of 1981, and we we compare the datacompare the data, ,

what we get is:what we get is:

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PAHO/WHO 2002

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0

5,000

10,000

15,000

20,000

25,000

30,000

First 18 Years of DHF in Asia and in the Americas

First years DHF was reported

(1955-1973)

(1984-2001)

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19681975

19771978

1981

1984

1982

1985

1986

1987

1988

The Evolution of DHF

2001

19911995

1995

1998

2000

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0

20

40

60

80

1 10 100 1000 10000

Cases

CFR

Case Fatality Rate (CFR) of DHFvs. Case Frequency

1%

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Circulation of DEN-1-2000

Barbados

-1999

Martinique

1998

Antigua and BarbudaDominicaMartiniquePuerto RicoSanta LuciaTrinidad & Tobago

1977

2002

2001

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Circulation of DEN-2

British Vírgin IslandsGranadaSt. Kits & Nevis

- 2000Barbados

MartiniquePuerto RicoSt. Vincent & GrenadinesTrinidad & Tobago

1998

1981

2001

- 1999

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AnguillaArubaBarbadosPuerto RicoSt. Kits & Nevis

1998

Martinique

- 1999

1994

British Vírgin IslandsCuraçãoDominicaGuadeloupeMartinique

- 2000

2002

2001–2002

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BahamasBarbadosBritish Virgin IslandsPuerto Rico

1981

DHF

Antigua & BarbudaTrinidad & Tobago

1998- 1999

- 2000

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At Risk

Outbreaks reported

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Municipalities with epizootics & YF casesMunicipalities with epizooticsMunicipalities with YF cases

Municipalities with Aedes

aegypti

Yellow Fever(YF)

2000

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The majority of the obstacles for dengue control continue to be the same as they were in

the past.

The majority of the obstacles for dengue control continue to be the same as they were in

the past.

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PAHO/WHO 2002

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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 Dengue Control

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• Local health services, now politically

and administratively responsible for the

prevention and control programs are

not sufficiently established;

• Local health services, now politically

and administratively responsible for the

prevention and control programs are

not sufficiently established;


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• Individual and community

behavioral change strategies are

weak and are not incorporated

into the programs;

• Individual and community

behavioral change strategies are

weak and are not incorporated

into the programs;


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• Water supply and solid waste management are limited in high-risk areas;

• Water supply and solid waste management are limited in high-risk areas;


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• Sustainability and continuity of control actions are constantly compromised by other health demands and policies that compete with them;

• Sustainability and continuity of control actions are constantly compromised by other health demands and policies that compete with them;


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• Little capacity for intersectoral coordination

• Little capacity for intersectoral coordination


The dengue problem is not the sole responsibility of the

Ministry of Health.

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• Operational research on individual or community-based strategies have

not been sufficient.

• Operational research on individual or community-based strategies have

not been 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 for Dengue Control

Intersectoral ActionsIntersectoral Actions

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Intersectoral actions

Formal education

Health educatio

n

Behavioral change

Comprom

ise

Healthy houses

Healthy schools

Environment

Ecoclubs

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Dengue and DHF Prevention and Control Program

Social Communication Component

Pan American Health Organization

HCP/HCT/VBD

PAHO/WHO 2002

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Where are we coming from?Where are we coming from?

The The Hemispheric PlanHemispheric Plan (1997) establishes the (1997) establishes the role of role of community participationcommunity participation and of and of

social communicationsocial communication as components of the as components of the national programsnational programs..

It also refers to It also refers to 10%10% of the budget for of 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 The Blueprint for Action for the Next

Generation:Generation: Dengue Prevention and Control Dengue Prevention and Control

(1999) reinforces the Directive that was (1999) reinforces the Directive that was

established for established for community participation and community participation and

social communicationsocial communication as specified in the as specified in the

Hemispheric Plan of Action.Hemispheric Plan of Action.

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

Surveillance for planning and response

Reduction ofdisease burden

Behavioral change

The Global Strategy for Dengue Fever and The Global Strategy for Dengue Fever and

DHF Control (2000) DHF Control (2000)

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Where are we?Where are we?

• Strengthening the implementation of Strengthening the implementation of thethesocial-communication componentsocial-communication component in in the national programs. the national programs.

• Promote the Promote the behavioral changebehavioral change focus focus so that it will be more than just so 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 the Dissemination of the behavioral change strategy.behavioral change strategy.

• Social advocacy in favor of Social advocacy in favor of intra- and intersectoral actionsintra- and intersectoral actions to to minimize environmental health minimize environmental health problems 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] PAHO Directing Council Resolution [CD43.R4] for the prevention and control of dengue for the prevention and control of dengue based on a based on a technical working documenttechnical working document September 2001September 2001

• Technical assistance in the preparation of a Technical assistance in the preparation of a social-communication component based on social-communication component based on community participationcommunity participation MexicoMexico

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

dengue community-participation projects.dengue community-participation projects.

Post-Mitch Meso-America ProjectPost-Mitch Meso-America Project

• Supporting countries for the inclusion of a social Supporting countries for the inclusion of a social communication component (based on behavioral communication component (based on behavioral change) in dengue control programs.change) in dengue control programs.

Andean Countries / Carta de Guayaquil (2001) and its Andean Countries / Carta de Guayaquil (2001) and its follow-up meeting (2002).follow-up meeting (2002).

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Where are we going?Where are we going?

Integrated Strategy for dengue prevention and control

in the countries of the Americas

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I.I. Integrated Integrated epidemiological and entomological epidemiological and entomological surveillancesurveillance..

II.II. Advocacy and implementation of Advocacy and implementation of intersectoral intersectoral actionsactions between health, environment and between health, environment and education as well as other sectors such as education as well as other sectors such as industry and commerce for new materials, industry and commerce for new materials, tourism, legislation and judiciary.tourism, legislation and judiciary.

III.III. Effective Effective community participationcommunity participation..

Integrated Strategy (Decalog)

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IV.IV. Environmental managementEnvironmental management and addressing and addressing

basic services such as water supply, basic services such as water supply,

disposal of used water, solid waste management and disposal of used water, solid waste management and

disposal of used tires. disposal of used tires.

V.V. Patient carePatient care within and outside of the health system. within and outside of the health system.

VI.VI. Case reportingCase reporting (clinical cases, confirmed cases, DHF (clinical cases, confirmed cases, DHF

and deaths due to DHF, circulating serotypes).and deaths due to DHF, circulating serotypes).


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VII.VII. Incorporation Incorporation of the subject ofof the subject of dengue/health dengue/health intointo formal education formal education. .

VIII.VIII. Critical analysis Critical analysis of the use and function ofof the use and function of insecticidesinsecticides. .

IX.IX. Formal health training of professionals and Formal health training of professionals and workersworkers (both in the medical and social (both in the medical and social areas).areas).

X.X. Emergency preparednessEmergency preparedness, establishing , establishing mechanisms and plans to face outbreaks and mechanisms and plans to face outbreaks and epidemics.epidemics.


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

• TrainingTrainingManagers, social worker, communicators, educators, promoters, etc.Managers, social worker, communicators, educators, promoters, etc.

• Operative alliancesOperative alliances Ecoclubs, industry, commerce, schools, environmentEcoclubs, industry, commerce, schools, environment

• Technical assistanceTechnical assistance Design and implementation of regular and/or emergency plansDesign and implementation of regular and/or emergency plans

• ConsultationConsultation Support the implementation of social communication and Support the implementation of social communication and

dissemination of informationdissemination of information

StrategiesHow are we going?

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• MonitoringMonitoring Surveys, reports, supervisory missions, etc.Surveys, reports, supervisory missions, etc.

• EvaluationEvaluation Technical visits, reports, workshops, task forces, etc.Technical visits, reports, workshops, task forces, etc.

• Epidemiological dataEpidemiological dataPAHO PAHO websitewebsite: dengue case reporting): dengue case reporting)

Strategies

How do we know when we have arrived?

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• It is not a “silver bullet”It is not a “silver bullet” that can stop the that can stop the increasing trend of dengue fever and increasing trend of dengue fever and dengue hemorrhagic fever.dengue hemorrhagic fever.

• A person achieves A person achieves behavioral changes in behavioral changes in stepssteps. . There is a need to go from one phase There is a need to go from one phase to another to another sequentiallysequentially..

Social-Communication Component

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Social-Communication ComponentSocial-Communication Component

• Formal health trainingFormal health training of health workers/providers is the of health workers/providers is the central central pointpoint (managers, communicators, social (managers, communicators, social workers, educators, promoters, etc.) to the workers, educators, promoters, etc.) to the New-Generation Dengue Prevention and New-Generation Dengue Prevention and Control ProgramControl Program..

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hcp/hct/vbd paho/who 2002 jra dengue: how are we doing? pan american health organization 1902–2002...

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