JRA

HCP/HCT/VBD

Dengue: How are we doing?

Celebrating 100 Years of PAHO

Pan American Health Organization

1902–2002
Jorge R. Arias, Ph.D.
PAHO/WHO
2002
JRA
HCP/HCT/VBD

Aedes aegypti:
Distribution
throughout the world

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Reinfestation of Aedes aegypti

1930s 1970 2002

PAHO/WHO
2002
JRA

The first eradication campaigns

HCP/HCT/VBD

were successful
• Internal and external financing for personnel,
equipment, and materials.
• Emphasis on source reduction.
• Efficient residual insecticide.
• Centralized vertical programs, with military-style
organization, strict supervision, and a high level of
discipline.

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Reasons Why the Eradication Failed

•• Not
Not all
all countries
countries were
were willing
willing to eradicate Aedes
to eradicate Aedes aegypti.
aegypti.
•• The
The program
program lost
lost political
political importance
importance in
in the
the majority
majority of
of the
the
countries
countries that
that achieved
achieved eradication.
eradication.
•• Once
Once re-infestation
re-infestation was
was observed
observed reaction
reaction was
was too
too late.
late.
•• High
High cost
cost of
of materials,
materials, equipment,
equipment, salaries
salaries and
and social
social benefits.
benefits.
•• Aedes
Aedes aegypti
aegypti Resistance
Resistance to
to organochloride
organochloride insecticides.
insecticides.
•• Rapid
Rapid and
and uncontrolled
uncontrolled growth
growth of
of urban
urban centers.
centers.

PAHO/WHO
2002
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HCP/HCT/VBD

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.

PAHO/WHO
2002
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HCP/HCT/VBD

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.

PAHO/WHO
2002
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HCP/HCT/VBD

The Problem: Dengue

• It is a growing problem.
• The number of cases in the Americas
has gone from 66,011 in 1980, to
over 700,000 en 2000.
• The control activities that are being
carried out are not working.

PAHO/WHO
2002
 JRA

Incidence of Dengue* 2001

HCP/HCT/VBD

St. Lucia
Hawaii D.R..
St. Kitts & Nevis
P.R. Anguilla
Grenada
Antigua & Barbuda
Aruba Jamaica Barbados Grenada
Bahamas Trinidad & Tobago British Virgin Islands
Bermuda Monserrat
Cayman Islands
Curação
Guadaloupe
Turkas & Caicos Islands

>100 or more (14 countries) Dominica

10 to 99 (14 countries) St.Vincent & the Grenadines
1 to 9 (5 countries)
<1 (2 countries)
0 cases (9 countries)

* per 100,000
PAHO/WHO population
2002
JRA

Central America & Mexico HCP/HCT/VBD

DHF
1995–2001
1,600
1,400
1,200
1,000
800
600
400
200
0
1995 1996 1997 1998 1999 2000 2001

Dengue
120,000
100,000

80,000
60,000

40,000
20,000

PAHO/WHO 0
2002 1995 1996 1997 1998 1999 2000 2001
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Caribbean Islands DHF HCP/HCT/VBD

1995–2001 600
500
400
300
200
100

Dengue
0
1995 1996 1997 1998 1999 2000 2001

30,000
25,000
20,000
15,000
10,000

5,000
PAHO/WHO 0
2002 1995 1996 1997 1998 1999 2000 2001
 JRA

Andean Countries HCP/HCT/VBD

DHF 1995–2001
14,000
12,000
10,000
8,000
6,000
4,000 Dengue
2,000
0 180,000
1995 1996 1997 1998 1999 2000 2001 160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
PAHO/WHO 0
2002 1995 1996 1997 1998 1999 2000 2001
JRA
Southern Cone Countries HCP/HCT/VBD

1995–2001 DHF
4,000
3,500
3,000
2,500
2,000
1,500
1,000
500

Dengue 0
1995 1996 1997 1998 1999 2000 2001

600,000

500,000

400,000

300,000

200,000

100,000

PAHO/WHO 0
2002 1995 1996 1997 1998 1999 2000 2001
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HCP/HCT/VBD

Cases of Dengue, 1980–2001

800,000

700,000

600,000

500,000

400,000

300,000

200,000

100,000

0
9

7
0
1
2
3
4
5
6
7
8

0
1
2
3
4

8
9
0
1
19 8
19 8
19 8
19 8
19 8
19 8
19 8
19 8
19 8
19 8
19 9
19 9
19 9
19 9
19 9
19 9
19 9
19 9
19 9
19 9
20 0
200
PAHO/WHO
2002
 JRA

50,000
100,000
150,000
200,000
250,000

2002
19 8 0

PAHO/WHO
1981
19 8 2
19 8 3
19 8 4
19 8 5
19 8 6
19 8 7
19 8 8
19 8 9
19 9 0
19 9 1
19 9 2
19 9 3
1994
19 9 5
1996
19 9 7
without Brasil or Cuba

19 9 8
19 9 9
Cases of Dengue 1980–2001

20 0 0
20 0 1
HCP/HCT/VBD
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HCP/HCT/VBD

Dengue Epidemics in the Americas

Hawaii

2000 2001

9 countries 11 countries

PAHO/WHO
2002
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HCP/HCT/VBD

Dengue Epidemics 2000–2002

Hawaii

PAHO/WHO
2002
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Dengue Epidemics 2002

HCP/HCT/VBD

DEN-3


DEN-? 


2002  
 DEN-1 >250,000
DEN-1 DEN-3 cases

DEN-3
PAHO/WHO
2002
JRA
HCP/HCT/VBD

The Problem: DHF

• The tendency of DHF in the Americas
is increasing.
• The situation is going to get worse
before it improves.

PAHO/WHO
2002
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HCP/HCT/VBD

Dengue Hemorrhagic Fever (DHF)

1968–1980 1981–2001*
5 Countries: 60 Cases 28 Countries >93,000
Cases

* to
01/01/2002
PAHO/WHO
2002
JRA

Cases of DHF, <1980 to 2001

HCP/HCT/VBD

16,000
15,503
14,000
12,369
12,000 11,783

10,312
10,000

8,223
8,000

6,000 5,663
5,092 5,117
4,723
4,189
4,000 3,646
2,682
2,309
2,000 1,753

0 60 3 0 8 12 35 97 86
1 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
198 198 198 198 198 198 198 198 198 198 199 199 199 199 199 199 199 199 199 199 200 200
<

PAHO/WHO
2002
JRA

Number of Cases of DHF, 1981–2001 HCP/HCT/VBD

VEN

COL 22,781 45,799

CUB 10,586
NIC 4,607
MEX 3,852
BRA 1,599
HON 867
ELS 816
PR 640
DOR 537
TRT 306
PER 251
JAM 150
GUT 71
FRG 61
** 216

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

** all other countries

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Cases of DHF in Asia, 1955–1998

700,000
600,000
500,000
400,000
300,000
200,000
100,000
Cases

PAHO/WHO
2002
 JRA
HCP/HCT/VBD
700,000

Cases of DHF in
600,000

500,000

Asia and in the

400,000
Cases

300,000

200,000

100,000

0
Americas
16000
15503

14000

12369
12000 11783
10312
10000

8000 8223

6000 5663
5092 5117
4723
4000 4189
3646
2682 2309
2000 1753

0 60 3 0 8 12 35 97 86
PAHO/WHO 1 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1
2002 98 198 198 198 198 198 198 198 198 198 199 199 199 199 199 199 199 199 199 199 200 200
<1
JRA
HCP/HCT/VBD

If we take the
first 18 years that DHF was reported in Asia (1955–1973) and
the first 18 years that it occurred in the Americas (1984–2001)
after the Cuban epidemic of 1981, and we compare the data,
what we get is:

PAHO/WHO
2002
JRA
HCP/HCT/VBD

First 18 Years of DHF in Asia and in the Americas

(1955-1973) (1984-2001)
30,000

25,000

20,000

15,000

10,000

5,000

PAHO/WHO
First years DHF was reported
2002
 The Evolution of DHF
JRA
HCP/HCT/VBD

1984
1998
1981 1988
1978 1975
1995
1977 1968 1982
1987
1991
1995
1985
2000
1986
2001

PAHO/WHO
2002
 Case Fatality Rate (CFR) of DHF
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HCP/HCT/VBD

vs. Case Frequency

80
60
40
CFR

20
1 0
%
1 10 100 1000 10000
PAHO/WHO
2002 Cases
 Circulation of DEN-1
JRA
HCP/HCT/VBD

2001 1998 -1999 -2000

Antigua and
Barbuda
1977
Martinique Dominica
Martinique
Barbados
Puerto Rico
Santa Lucia
Trinidad & Tobago

2002

PAHO/WHO
2002
 Circulation of DEN-2
JRA
HCP/HCT/VBD

1998 - 1999 - 2000

Barbados British Vírgin Islands
Martinique Granada
1981 Puerto Rico St. Kits & Nevis
St. Vincent &
Grenadines
Trinidad & Tobago

2001

PAHO/WHO
2002
 Circulation of DEN-3
JRA
HCP/HCT/VBD

1998 - 1999 - 2000

Anguilla Martinique
Aruba
Barbados British Vírgin Islands
Puerto Rico Curação
Dominica
St. Kits & Nevis
1994 Guadeloupe
Martinique

2002

2001–2002

PAHO/WHO
2002
 Circulation of DEN-4
JRA
HCP/HCT/VBD

1998 - 1999- 2000

Bahamas Antigua & Barbuda

Barbados Trinidad & Tobago
1981 British Virgin Islands
Puerto Rico

DHF

PAHO/WHO
2002
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Countries at Risk of Yellow Fever HCP/HCT/VBD

and Outbreaks, 1985–2001

At Risk
Outbreaks reported

PAHO/WHO
2002
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Yellow Fever 1999
HCP/HCT/VBD

(YF)

2000

Municipalities with epizootics & YF cases

Municipalities with epizootics Municipalities with
Municipalities with YF cases Aedes aegypti

PAHO/WHO
2002
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HCP/HCT/VBD

PAHO/WHO
2002
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HCP/HCT/VBD

The majority of the obstacles for

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

PAHO/WHO
2002
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HCP/HCT/VBD

Obstacles for Dengue Control

Present-day
Present-day dengue
dengue programs
programs are
are not
not
progressing
progressing because:
because:
•• Community
Community participation
participation inin dengue
dengue prevention
prevention and
and
control
control isis limited
limited to
to official
official demands
demands and
and never
never
attains
attains community
community ownership;
ownership;

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Obstacles for Dengue Control

•• Local
Local health
health services,
services, now
now politically
politically and
and
administratively
administratively responsible
responsible for
for the
the
prevention
prevention and
and control
control programs
programs are
are not
not
sufficiently
sufficiently established;
established;

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Obstacles for Dengue Control

•• Individual
Individual and
and community
community behavioral
behavioral
change
change strategies
strategies are
are weak
weak and
and are
are
not
not incorporated
incorporated into
into the
the programs;
programs;

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Obstacles for Dengue Control

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

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Obstacles for Dengue Control

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

PAHO/WHO
2002
 JRA
HCP/HCT/VBD

Obstacles for Dengue Control

•• Little
Little capacity
capacity for
for intersectoral
intersectoral coordination
coordination

The dengue problem is not the

sole responsibility of the
Ministry of Health.

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Obstacles for Dengue Control

•• Operational
Operational research
research on
on individual
individual or
or
community-based
community-based strategies
strategies have
have
not
not been
been sufficient.
sufficient.

PAHO/WHO
2002
JRA
HCP/HCT/VBD

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.

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Opportunities for Dengue Control

Intersectoral
Intersectoral Actions
Actions
Community
Community Participation
Participation

PAHO/WHO
2002
 JRA
HCP/HCT/VBD

ns
l a ctio
o ra Fo
e ct rm
e rs Beh al
Int a vior ed
Healthy houses al c u
ca
h an
ge tion
Environment io n
ca t
du
h e Co
al t m
He pr
om
Ec
oc

ise
lu
sb

Healthy schools
PAHO/WHO
2002
JRA
HCP/HCT/VBD

Social Communication
Component

Dengue and DHF

Prevention and Control Program

Pan American Health Organization

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Where are we coming from?

The Hemispheric Plan (1997) establishes the role of
community participation and of
social communication as components of the national
programs.

It also refers to 10% of the budget for

this component.

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Where are we coming from? (2)

The Blueprint for Action for the Next Generation:

Dengue Prevention and Control (1999) reinforces
the Directive that was established for community
participation and
social communication as specified in the
Hemispheric Plan of Action.

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Where are we coming from? (3)

The Global Strategy for Dengue Fever and
DHF Control (2000)

Surveillance for planning

and response

Reduction of Behavioral
disease burden change
PAHO/WHO
2002
JRA

Where are we?

HCP/HCT/VBD

• Strengthening the implementation of the

social-communication component in the
national programs.

• Promote the behavioral change focus

so that it will be more than just
dissemination of information.

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Where are we? (2)

• Dissemination of the
behavioral change strategy.

• Social advocacy in favor of

intra- and intersectoral actions to
minimize environmental health problems
(water and solid waste management).

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Where are we? (3)

• PAHO Directing Council Resolution [CD43.R4] for
the prevention and control of dengue based on a
technical working document
 September 2001
• Technical assistance in the preparation of a
social-communication component based on
community participation
 Mexico
PAHO/WHO
2002
JRA
HCP/HCT/VBD

Where are we? (4)

• Supporting countries for the preparation of dengue
community-participation projects.
 Post-Mitch Meso-America Project

• Supporting countries for the inclusion of a social

communication component (based on behavioral
change) in dengue control programs.
 Andean Countries / Carta de Guayaquil (2001) and its
follow-up meeting (2002).

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Where are we going?

Integrated Strategy
for dengue prevention and control
in the countries of
the Americas
PAHO/WHO
2002
JRA
HCP/HCT/VBD

Integrated Strategy (Decalog)

I. Integrated epidemiological and entomological
surveillance.
II. Advocacy and implementation of intersectoral actions
between health, environment and education as well as
other sectors such as industry and commerce for new
materials, tourism, legislation and judiciary.

III. Effective community participation.

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Integrated Strategy (Decalog)

IV. Environmental management and addressing
basic services such as water supply,
disposal of used water, solid waste management and
disposal of used tires.

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

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

and deaths due to DHF, circulating serotypes).

PAHO/WHO
2002
JRA
HCP/HCT/VBD

Integrated Strategy (Decalog)

VII. Incorporation of the subject of dengue/health into
formal education.
VIII. Critical analysis of the use and function of
insecticides.
IX. Formal health training of professionals and
workers (both in the medical and social areas).
X. Emergency preparedness, establishing
mechanisms and plans to face outbreaks and
epidemics.

PAHO/WHO
2002
JRA

How are we going?

HCP/HCT/VBD

Strategies
• Policy
Manuals, guides, policy, protocols

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

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

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

• Consultation
Support the implementation of social communication and dissemination of
information
PAHO/WHO
2002
JRA
HCP/HCT/VBD

How do we know when we have arrived?

Strategies

• Monitoring
Surveys, reports, supervisory missions, etc.

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

• Epidemiological data
PAHO website: dengue case reporting)

PAHO/WHO
2002
JRA
HCP/HCT/VBD

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

• A person achieves behavioral changes in steps.

There is a need to go from one phase to another
sequentially.

PAHO/WHO
2002
JRA
HCP/HCT/VBD

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

PAHO/WHO
2002
JRA
HCP/HCT/VBD

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