DENGUE PREVENTION IN

TRINIDAD AND TOBAGO

Oumatee Nyoka Arjoon-Singh MPH student

Walden UniversityPUBH 6165-6

Instructor: Professor Dr. Eve CluteTerm 4, Year 1.

Aedes aegypti: Distribution throughout the Word

Figure 1 Source: PAHO. (2007). TRINIDAD AND TOBAGO. HEALTH IN THE AMERICAS , 2, 662-664.

DEFINITION

Classic Dengue Fever• Acute Febrile Illness:5-7 days, mild disease• Dengue triad: fever, rash headache• Nil mortality

Dengue hemorrhagic fever• Syndrome•Shock• Abnormal blood clotting mechanism

Wyngaarden, J. B., & Smith, L. H. (1982). Cecil Textbook of Medicine. Philadelphia, PA, United States of America: W. B. Saunders Company ,1671-1691.

Doug-Deen, R., & Hull, B. (1999). Public Health Surveillance. (C. Hospidales, Ed.) Port of Spain, Trinidad and Tobago: Caribbean Epidemiology Centre.

Figure 2 Source: Rainbow Childrens Hospital U.S.A. (2011) URL: http://www.rainbowhospitals.in/images/dengue-illness.gif

LEARNING OUTCOMES

• What is dengue?• Importance: Trinidad and Tobago; The World• Demographics of Nariva/Mayaro• The Vector: Aedes aegypti• Epidemiology • The Public Health Laws: Trinidad and Tobago• Contribution: Mayaro/RioClaro Regional Corporation

(M.R.C.R.C.)• Emphasis: (M.R.C.R.C.)• Dengue Prevention: Genetically Modified Mosquitoes

TRINIDAD AND TOBAGO PRESENT STATUS

• Globally: 1,000,000 • Twin island state• Population: 1.3 million• Life expectancy: 70 Years• Childhood immunization:

90%• Urban population: 14%• Antenatal care coverage:

96%• Population using improved

drinking water: 67-90%• Dengue 2011: 1639 cases• Most common-DEN V2Unicef. (2003). At a glance Trinidad and Tobago. Retrieved July 1st, 2012, from Unicef: http://www.unicef.org/infobycountry/trinidad_tobago_statistics.html

Figure 3 Source (Unicef, 2003)

Demographics of nariva/ mayaro•Citizens: 48,000•The land area: 853 km2•Population density: 0-50 persons per square km•Persons per household: 3.7•Number of homes: 8,000•Ethnic groups: 80% Indo and Afro Trinidadian•“Together we are aspire, together we achieve”

CARICOMSecretariat. (2009). cso.gov. Retrieved July10, 2012, from http://www.cso.gov.tt: http://www.cso.gov.tt/statistics/Statistics/chapter%203.pdf Figure 4 Source

(CARICOMSecretariat, 2009).

AEDES AEGYPTI MOSQUITO• The Aedes aegypti mosquito breeds in clean water• Remains in close proximity to feeding site.• Flight: less than 100 meters from its breading site.• Human assistance: Larva frequently transported in vases• Human assistance: Adults are transported in vehicles• Dengue Virus: females mosquitoes bites.• Blood meal: for development of eggs.• Daylight hours: Optimum time for dengue transmission• Improved artificial lighting: manifestation of night feeding.

Shultis, E. B. (2009). Bromeliads as a Breeding Site for the Dengue Vector Aedes aegypti. Brown University, Natural and Cultural Ecology, Cairns.Nielsen, C. (2008). Best Management Practices for Mosquito Control on California State Properties. California Department of Public Health.

REPRODUCTION OF THE MOSQUITO

• First dengue virus: 1953• Adult mosquito: develops from pupal stage.• Lifetime infection: female mosquito • Blood meal: propagation of dengue virus• 1 dengue infected mosquito: several persons

in 1 mealShultis, E. B. (2009). Bromeliads as a Breeding Site for the Dengue Vector Aedes aegypti. Brown University, Natural and Cultural Ecology, CairnsTheStateofQueensland. (2009). Dengue Fever.

AEDES AEGYPTI PROPAGATION• Eggs-:varying amount of eggs at one sitting • Places: sides of containers, vases, barrels, drums and uncovered tanks.• Cluster Eggs: are cemented for survival • Appearance: The eggs are pale in colour initially.• Next stage, eggs becomes larva in two to four days.• Survival time: Eggs remain viable for a period of twelve months• It develops into a pupa in about seven days

Shultis, E. B. (2009). Bromeliads as a Breeding Site for the Dengue Vector Aedes aegypti. Brown University, Natural and Cultural Ecology, Cairns.Nielsen, C. (2008). Best Management Practices for Mosquito Control on California State Properties. California Department of Public HealthChadee, D. D., Williams, F. S., & Kitron, U. D. (2005). Impact of vector control on a dengue fever outbreak in Trinidad, West Indies, in 1998. Tropical Medicine & International Health , 10 (8), 748-754.

AEDES AEGYPTI PUPAL STAGE

• Sensitive: to light, vibrations and other water disturbances.• Feeding: on microscopic substances and microscopic

organisms.• Pupal stage: develops all the characteristics of the adult.• The pupal stage last for about 2 days• Flotation: by the surface tension in the water.• Breathing: through 2 cylindrical breathing apparatus.• There is no gill type arrangement and utilizes oxygen

directly from the air.• Color changes: with maturity it gets darker in colourShultis, E. B. (2009). Bromeliads as a Breeding Site for the Dengue Vector Aedes aegypti. Brown University, Natural and Cultural Ecology, Cairns.Nielsen, C. (2008). Best Management Practices for Mosquito Control on California State Properties. California Department of Public Health.

EPIDEMIOLOGY-Incidence

• 2001-250 cases• 2010-600 cases-3 deaths• Increase in the number of

peak periods• Multiple peak periods May to

October as noted in this figure

• The Americas-most cases to WHO (68% 2000-2006)

Figure 5 (Mc-Knight, Ramkissoon, Seepersad-Bachan, George, & Baker, 2011)

Mc-Knight, C. B., Ramkissoon, H., Seepersad-Bachan, C., George, E., & Baker, D. (2011). First Report of the Joint Select Committee on Ministries, Statutory Authorities and State Enterprises. PARLIAMENT OF THE REPUBLIC OF TRINIDAD AND TOBAGO. Port-of-Spain: PARLIAMENT OF THE REPUBLIC OF TRINIDAD AND TOBAGO.San Martin, J. L., Brathwaite, O., Zambrano, B., Solorzana, J. O., Bouckenooghe, A., Dayan, G. H., et al. (2010). The Epidemiology of Dengue in the Americas Over the Last Three Decades: A Worrisome Review. Am. J. Trop. Med. Hyg , 128-135.

EPIDEMIOLOGY-Mortality/Hospitalization

• Classic dengue: 2000, 2001, 2003-2000 cases• Classic dengue: 2002-6000 cases• Classic dengue:2004, 2005-400 and 519 cases

respectfully• DHF:2002- 218 cases• Classic dengue:2008-3500 cases• Classic dengue fever:2010-4700cases• DHF:2010-3 cases/deaths

PAHO. (2007). TRINIDAD AND TOBAGO. HEALTH IN THE AMERICAS , 2, 662-664.Mc-Knight, C. B., Ramkissoon, H., Seepersad-Bachan, C., George, E., & Baker, D. (2011). First Report of the Joint Select Committee on Ministries, Statutory Authorities and State Enterprises. PARLIAMENT OF THE REPUBLIC OF TRINIDAD AND TOBAGO. Port-of-Spain: PARLIAMENT OF THE REPUBLIC OF TRINIDAD AND TOBAGO.

MODE OF TRANSMISSION

• Virus transmitted to human in mosquito saliva.• Virus replicates in target organs.• Virus infects white blood cells and lymphatic

tissues.• Virus released and circulates in blood.• Second mosquito ingest virus with blood. • Virus replicates: in mosquito midgut, salivary gland

and other organs.Nielsen, C. (2008). Best Management Practices for Mosquito Control on California State Properties. California Department of Public Health.Gubler, D. J. (1998). Dengue and Dengue Hemorrhagic Fever. Clinical Microbiology Reviews , 11 (3), 480-496.

PUBLIC HEALTH LAW TRINIDAD AND TOBAGO

• The Public Health Ordinance Chapter 2 No 4 was enacted on January 1st 1917

• Maintenance: markets, abattoirs, cemeteries and ports.

• Services: insect vector; bat, rodent and canine control.

• Scavenging: Rubbish, refuse and waste matter• Penalty: a fine of four hundred and eighty dollars or

imprisonment for six months on breaking the law.(CaribbeanMedicalJournal, 2003)(TheGovernmentOfTrinidadAndTobago, 2009)

LOCAL GOVERNMENT CONTRIBUTION

.

Environmental Case

Municipal Corporation

Insect Vector Control Division

Health Centers Surveillance

Nurse

Case notification

Public Health Inspectorate

Dengue Case

Doctors

Environmental Case Control Management System for Dengue Fever in Trinidad and Tobago

.•breeding sites in the community,•chemical control•vector surveillance•water storage monitoring•Community Plastic Water Tanks

METHODS OF ERADICATION

• Thermal Fogging• Genetically modified

mosquitoes (GMMs): Switzerland 2009

WorldHealthOrganizaon. (2011). Dengue Bulletin. New Dehli: World Health Organization.Bholasingh, M. (2012, July 12th). Dengue Fever Control 2012. (O. N. Arjoon-Singh, Interviewer)

Rio Claro, Nariva/Mayaro, Trinidad and Tobago.

Figure 7: Source (M.R.C.R.C., 2012)

Dengue trends Nariva/Mayaro 1997-2012

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

50

100

150

200

250

57

164

70

17

93

76

52

5 110

61

163

49

120

210

40

Figure 8: Dengue Trends Nariva Mayaro 1997-2012

Amou

nt

Bholasingh, M. (2012, July 12th). Dengue Fever Control 2012. (O. N. Arjoon-Singh, Interviewer) Rio Claro, Nariva/Mayaro, Trinidad and Tobago.

RENEWED EMPHASIS- M.R.C.R.C.

• Elimination: intensification of the national programs of larviciding and source reduction.

• Maintenance: vector control programs.• Source Reduction: ports, beaches, ponds,

schools, government buildings, farms and periphery of the forests .

• Water storage: Elimination of barrels and other uncovered sources with replacement by water tanks with proper covers Nielsen, C. (2008). Best Management Practices for Mosquito Control on California State Properties. California Department of Public Health

. Padmanabha, H., Soto, E., Mosquera, M., Lord, C. C., & Lounibos, L. P. (2010). Ecological Links Between Water Storage Behaviours and Aedes aegypti Production: Implications for Dengue Vector Control in Variable Climates. Eco Health , 7, 78-90.

SUMMARY

• Understanding Dengue• Deaths from dengue• Dengue trends in Nariva/Mayaro• Mosquito eradication in Nariva/Mayaro• New methods of the M.R.C.R.C.• Health care burden• Public Health Laws: Implementation• Each Household: One Water Tank• Pipe Borne Water: Every Community• Dengue vaccine (Guy, Almond, & Lang, 2011)

THANK YOU

Questions please, as we walk on the shores of Mayaro Beach, Trinidad and Tobago

Figure 9 Brighouse, R. (2008). Economic diversification: the role of the tourism secotor. (Port-of-Spain, Ed., & G. o. Tobago, Trans.) Port of Spain, Economic diversification: the role of the tourism sector: 174.-175.

REFERENCES • Arias, J. R. (2002). Dengue: How are we doing? Celebrating 200 years of

PAHO . Washington D.C., United States of America: PAHO.• Berkow, R. (1992). The Merck Manual. (A. J. Fletcher, Ed.) Rahway, New

Jersey, United Systes of America: Merck & Co.,Inc.• Bholasingh, M. (2012, July 12th). Dengue Fever Control 2012. (O. N.

Arjoon-Singh, Interviewer) Rio Claro, Nariva/Mayaro, Trinidad and Tobago.

• Brighouse, R. (2008). Economic diversification: the role of the tourism secotor. (Port-of-Spain, Ed., & G. o. Tobago, Trans.) Port of Spain, Economic diversification: the role of the tourism secotor: 174.

• Brown, T. U., Babb, K., Nimrod, M., Carrington, C., & Salas, R. (2004). A Retrospective Study of the 1996 DEN-1 Epidemic in Trinidad: Demographic and Clinical Features. Geneva: World Health Organisation.

REFERENCES• Chadee, D. D., Williams, F. S., & Kitron, U. D. (2005). Impact of vector

control on a dengue fever outbreak in Trinidad, West Indies, in 1998. Tropical Medicine & International Health , 10 (8), 748-754.

• Campione-Piccardo, J., Ruben, M., Vaughan, H., & Morris-Glasgow, V. (2003). Dengue viruses in the Caribbean. Twenty years of dengue virus isolates from the Caribbean Epidemiology Centre. West Indian Medical Journal , 52 (3), 191-198.

• CaribbeanMedicalJournal. (2003). Public Ordinance 1917 Chapter 12: No 4. Caribbean Medical Journal , 65 (1).

• Doug-Deen, R., & Hull, B. (1999). Public Health Surveillance. (C. Hospidales, Ed.) Port of Spain, Trinidad and Tobago: Caribbean Epidemiology Centre.

• Gubler, D. J. (1998). Dengue and Dengue Hemorrhagic Fever. Clinical Microbiology Reviews , 11 (3), 480-496.

REFERENCES• Guy, B., Almond, J., & Lang, J. (2011). Dengue vaccine prospects: a

step forward. The Lancet , 377 (9763), 381-382.• Mc-Knight, C. B., Ramkissoon, H., Seepersad-Bachan, C., George, E., &

Baker, D. (2011). First Report of the Joint Select Committee on Ministries, Statutory Authorities and State Enterprises. PARLIAMENT OF THE REPUBLIC OF TRINIDAD AND TOBAGO. Port-of-Spain: PARLIAMENT OF THE REPUBLIC OF TRINIDAD AND TOBAGO.

• Neaves, J. (2011, August 12). Ministry has enough medication to deal with dengue. Ministry has enough medication to deal with dengue . Port of Spain, Trinidad: Trinidad Express Newspapers.

• Nielsen, C. (2008). Best Management Practices for Mosquito Control on California State Properties. California Department of Public Health.

REFERENCES• Padmanabha, H., Soto, E., Mosquera, M., Lord, C. C., & Lounibos, L. P. (2010).

Ecological Links Between Water Storage Behaviours and Aedes aegypti Production: Implications for Dengue Vector Control in Variable Climates. Eco Health , 7, 78-90.

• PAHO. (2007). TRINIDAD AND TOBAGO. HEALTH IN THE AMERICAS , 2, 662-664.• ParlimentofTrinidadndTobago. (2011). The Ministry of Health and its

Management of Vector borne diseases. Port of Spain: Government of Trinidad And Tobago.

• San Martin, J. L., Brathwaite, O., Zambrano, B., Solorzana, J. O., Bouckenooghe, A., Dayan, G. H., et al. (2010). The Epidemiology of Dengue in the Americas Over the Last Three Decades: A Worrisome Review. Am. J. Trop. Med. Hyg , 128-135.

• Shultis, E. B. (2009). Bromeliads as a Breeding Site for the Dengue Vector Aedes aegypti. Brown University, Natural and Cultural Ecology, Cairns.

REFERENCES• TheGovernmentOfTrinidadAndTobago. (2009, December 31). Laws

ofTrinidadAnd Tobago. Municipal Corporations Act . Port Of Spain, Trinidad And Tobago: The Parliment of Trinidad and Tobago.

• TheStateofQueensland. (2009). Dengue Fever. • Unicef. (2003). At a glance Trinidad and Tobago. Retrieved July 1st,

2012, from Unicef: http://www.unicef.org/infobycountry/trinidad_tobago_statistics.html

• WorldHealthOrganization(2011). Dengue Bulletin. New Dehli: World Health Organization.

• Wyngaarden, J. B., & Smith, L. H. (1982). Cecil Textbook of Medicine. Philadelphia, PA, United States of America: W. B. Saunders Company, 1671-1691.

FURTHER READING• Angel, B., & Joshi, V. (2008). Distribution and sedengue viruses in Aedes

mosquito in arid and semi-arid areas of Rajasthan, Indiaasonality of vertically transmitted. J. Vector Bourne Dis , 45, 56-59.

• Halstead, S. B. (2008). Dengue Tropical Medicine: Science and Practice — Vol. 5. (G. Pasvol, & S. L. Hoffman, Eds.) London, United Kingdom: Imperial College Press.

• Harris, E., Perez, L., Phares, C. R., Perez, M. A., Idiaquez, W., Rocha, J., et al. (2003). Fluid Intake and Decreased Risk for Hospitalization for Dengue Fever, Nicaragua. Emerging Infectious Disease , 9 (8), 1003-1006.

• Hopp, M. J., & Foley, J. A. (2003). Worldwide fluctuations in dengue fever cases related to climate variability. Climate Research , 85-94.

• Kouri, G., & Guzman, M. G. (2003). Dengue and dengue hemorrhagic fever in the Americas lessons and challenges. Journal of Clinical Virology , 1-13.

FURTHER READING• Lambrechts, L., Scott, T. W., & Gubler, D. J. (2010). Consequences of the expanding

global distribution of Aedes albopictus for dengue virus tranamission. PloS Negl Trop Dis , 4 (5), e646.

• Liebman, K. A., Stoddard, S. T., Morrison, A. C., Rocha, C., Minnick, S., Sihuinsha, M., et al. (2012). Spatial Dimensions of Dengue Virus Transmission across Interepidemic and Epidemic Periods in Iquitos, Peru (1999–2003). PLos Neglected Tropical Diseases , 6 (2), e1472.

• PanAmericanHealthOrganisation. (1994). Dengue and Dengue Hemorrhagic Fever in the Americas:Guidelines for the Prevention and Control. Washington, DC, United States of America: PAHO Scientific Publication.

• Shepard, D. S., Coudeville, L., Halasa, Y. A., Zambrano, B., & Dayan, G. H. (2011). Economic Impact of Dengue Illness in the Americas. The American Journal of Tropical Medicine and Hygiene , 84 (2), 200-207.

• Strobel, M., Muller, P., Lamaury, I., & Rouet, F. (2001). Dengue fever: A Harmful Disease in Patients with Thrombocytopenia. Clinical Infectious Diseases , 33 (4), 580-581.