HCP/HCT/VBD PAHO/WHO 2002 JRA Dengue: How are we doing? Pan American Health Organization 1902–2002...
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Transcript of 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
JRA
Reinfestation of Aedes aegypti 1930s 1970 2002
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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.
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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.
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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.
HCP/HCT/VBD
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.
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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..
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
Dengue Epidemics in the Americas
9 countries
2000 2001
Hawaii
11 countries
HCP/HCT/VBD
PAHO/WHO 2002
JRA
Dengue Epidemics 2000–2002
Hawaii
HCP/HCT/VBD
PAHO/WHO 2002
JRA
Dengue Epidemics 2002
2002
DEN-3
DEN-1
DEN-3
DEN-?
DEN-1 >250,000 casesDEN-3
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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.
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
Case
sCases of DHF in Asia, 1955–1998
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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:
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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)
HCP/HCT/VBD
PAHO/WHO 2002
JRA
19681975
19771978
1981
1984
1982
1985
1986
1987
1988
The Evolution of DHF
2001
19911995
1995
1998
2000
HCP/HCT/VBD
PAHO/WHO 2002
JRA
0
20
40
60
80
1 10 100 1000 10000
Cases
CFR
Case Fatality Rate (CFR) of DHFvs. Case Frequency
1%
HCP/HCT/VBD
PAHO/WHO 2002
JRA
Circulation of DEN-1-2000
Barbados
-1999
Martinique
1998
Antigua and BarbudaDominicaMartiniquePuerto RicoSanta LuciaTrinidad & Tobago
1977
2002
2001
HCP/HCT/VBD
PAHO/WHO 2002
JRA
Circulation of DEN-2
British Vírgin IslandsGranadaSt. Kits & Nevis
- 2000Barbados
MartiniquePuerto RicoSt. Vincent & GrenadinesTrinidad & Tobago
1998
1981
2001
- 1999
HCP/HCT/VBD
PAHO/WHO 2002
JRA
Circulation of DEN-3
AnguillaArubaBarbadosPuerto RicoSt. Kits & Nevis
1998
Martinique
- 1999
1994
British Vírgin IslandsCuraçãoDominicaGuadeloupeMartinique
- 2000
2002
2001–2002
HCP/HCT/VBD
PAHO/WHO 2002
JRA
Circulation of DEN-4
BahamasBarbadosBritish Virgin IslandsPuerto Rico
1981
DHF
Antigua & BarbudaTrinidad & Tobago
1998- 1999
- 2000
HCP/HCT/VBD
PAHO/WHO 2002
JRACountries at Risk of Yellow Fever and Outbreaks, 1985–2001
At Risk
Outbreaks reported
HCP/HCT/VBD
PAHO/WHO 2002
JRA 1999
Municipalities with epizootics & YF casesMunicipalities with epizooticsMunicipalities with YF cases
Municipalities with Aedes
aegypti
Yellow Fever(YF)
2000
HCP/HCT/VBD
PAHO/WHO 2002
JRA
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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.
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
• 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;
Obstacles for Dengue Control
HCP/HCT/VBD
PAHO/WHO 2002
JRA
• 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;
Obstacles for Dengue Control
HCP/HCT/VBD
PAHO/WHO 2002
JRA
• Water supply and solid waste management are limited in high-risk areas;
• Water supply and solid waste management are limited in high-risk areas;
Obstacles for Dengue Control
HCP/HCT/VBD
PAHO/WHO 2002
JRA
• 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;
Obstacles for Dengue Control
HCP/HCT/VBD
PAHO/WHO 2002
JRA
• Little capacity for intersectoral coordination
• Little capacity for intersectoral coordination
Obstacles for Dengue Control
The dengue problem is not the sole responsibility of the
Ministry of Health.
HCP/HCT/VBD
PAHO/WHO 2002
JRA
• Operational research on individual or community-based strategies have
not been sufficient.
• Operational research on individual or community-based strategies have
not been sufficient.
Obstacles for Dengue Control
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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.
HCP/HCT/VBD
PAHO/WHO 2002
JRA
Community ParticipationCommunity Participation
Opportunities for Dengue Control
Intersectoral ActionsIntersectoral Actions
HCP/HCT/VBD
PAHO/WHO 2002
JRA
Intersectoral actions
Formal education
Health educatio
n
Behavioral change
Comprom
ise
Healthy houses
Healthy schools
Environment
Ecoclubs
HCP/HCT/VBD
PAHO/WHO 2002
JRA
Dengue and DHF Prevention and Control Program
Social Communication Component
Pan American Health Organization
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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.
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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.
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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)
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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.
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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).
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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).
HCP/HCT/VBD
PAHO/WHO 2002
JRA
Where are we going?Where are we going?
Integrated Strategy for dengue prevention and control
in the countries of the Americas
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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)
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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).
Integrated Strategy (Decalog)
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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.
Integrated Strategy (Decalog)
HCP/HCT/VBD
PAHO/WHO 2002
JRA
• 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?
HCP/HCT/VBD
PAHO/WHO 2002
JRA
• 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?
HCP/HCT/VBD
PAHO/WHO 2002
JRA
• 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
HCP/HCT/VBD
PAHO/WHO 2002
JRA
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..
HCP/HCT/VBD
PAHO/WHO 2002
JRA
http://w
ww.paho.org/Project.asp?SEL=TP&LNG=ENG&CD=DENGU