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Dengue: How are we doing?. Celebrating 100 Years of PAHO. Pan American Health Organization 1902–2002. Jorge R. Arias, Ph.D. Aedes aegypti: Distribution throughout the world. 2002. 1930s. 1970. Reinfestation of Aedes aegypti. The first eradication campaigns were successful.

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Dengue:How are we doing?

Celebrating 100 Years of PAHO

Pan American Health Organization

1902–2002

Jorge R. Arias, Ph.D.


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Aedes aegypti: Distribution throughout the world


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2002

1930s

1970

Reinfestation of Aedes aegypti


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The first eradication campaigns 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.


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Reasons Why the Eradication Failed

  • Not all countries were willing to eradicate Aedes aegypti.

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

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

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

  • Aedes aegypti Resistance to organochloride insecticides.

  • Rapid and uncontrolled growth of urban centers.


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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.


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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.


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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.


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Hawaii

D.R..

Grenada

Antigua & Barbuda

Grenada

British Virgin Islands

Monserrat

Incidence of Dengue* 2001

St. Lucia

St. Kitts & Nevis

Anguilla

P.R.

Aruba

Bahamas

Bermuda

Cayman Islands

Curação

Guadaloupe

Turkas & Caicos Islands

Barbados

Jamaica

Trinidad & Tobago

Dominica

St.Vincent & the Grenadines

>100 or more (14 countries)

10 to 99 (14 countries)

1 to 9 (5 countries)

<1 (2 countries)

0 cases (9 countries)

* per 100,000 population



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Caribbean Islands

1995–2001


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Andean Countries

1995–2001




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Cases of Dengue 1980–2001without Brasil or Cuba


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Dengue Epidemics in the Americas

Hawaii

2001

2000

9 countries

11 countries



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Dengue Epidemics 2002

2002

DEN-3

DEN-?

DEN-1

>250,000 cases

DEN-3

DEN-1

DEN-3


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The Problem: DHF

  • The tendency of DHF in the Americas is increasing.

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


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1981–2001*28 Countries >93,000 Cases

1968–19805 Countries: 60 Cases

* to 01/01/2002

Dengue Hemorrhagic Fever (DHF)



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Number of Cases of DHF, 1981–2001

** all other countries



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Cases of DHF in Asia and in the Americas


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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:


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First 18 Years of DHF in Asia and in the Americas

(1984-2001)

(1955-1973)

First years DHF wasreported


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1984

1998

1981

1988

1978

1975

1995

1977

1968

1987

1982

1991

1995

1985

1986

2000

2001

The Evolution of DHF


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1%

Case Fatality Rate (CFR) of DHFvs. Case Frequency

CFR

Cases


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-2000

-1999

1998

2001

Antigua and Barbuda

Dominica

Martinique

Puerto Rico

Santa Lucia

Trinidad & Tobago

1977

Martinique

Barbados

2002

Circulation of DEN-1


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- 1999

Circulation of DEN-2

- 2000

1998

British Vírgin Islands

Granada

St. Kits & Nevis

Barbados

Martinique

Puerto Rico

St. Vincent & Grenadines

Trinidad & Tobago

1981

2001


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1998

Anguilla

Aruba

Barbados

Puerto Rico

St. Kits & Nevis

Martinique

1994

2002

2001–2002

Circulation of DEN-3

- 2000

- 1999

British Vírgin Islands

Curação

Dominica

Guadeloupe

Martinique


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- 2000

- 1999

1998

DHF

Circulation of DEN-4

Bahamas

Barbados

British Virgin Islands

Puerto Rico

Antigua & Barbuda

Trinidad & Tobago

1981


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Countries at Risk of Yellow Fever and Outbreaks, 1985–2001

At Risk

Outbreaks reported


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Yellow Fever

(YF)

1999

2000

Municipalities with epizootics & YF cases

Municipalities with epizootics

Municipalities with YF cases

Municipalities with Aedes aegypti



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Obstacles for Dengue Control be the same as they were in the past.

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;


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Obstacles for Dengue Control be the same as they were in the past.

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


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Obstacles for Dengue Control be the same as they were in the past.

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


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Obstacles for Dengue Control be the same as they were in the past.

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


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Obstacles for Dengue Control be the same as they were in the past.

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


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Obstacles for Dengue Control be the same as they were in the past.

  • Little capacity for intersectoral coordination

The dengue problem is not the sole responsibility of the Ministry of Health.


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Obstacles for Dengue Control be the same as they were in the past.

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


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A Dengue Vaccine? be the same as they were in the past.

  • 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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Opportunities for Dengue Control be the same as they were in the past.

Intersectoral Actions

Community Participation


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Intersectoral actions be the same as they were in the past.

Health education

Compromise

Formal education

Behavioral change

Healthy houses

Environment

Ecoclubs

Healthy schools


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Social Communication Component be the same as they were in the past.

Dengue and DHF Prevention and Control Program

Pan American Health Organization


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Where are we coming from? be the same as they were in the past.

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.


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Where are we coming from? be the same as they were in the past.(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.


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Surveillance for planning be the same as they were in the past.

and response

Behavioral

change

Reduction of

disease burden

Where are we coming from?(3)

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


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Where are we? be the same as they were in the past.

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

  • Promote the behavioral change focus so that it will be more than just dissemination of information.


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Where are we? be the same as they were in the past.(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).


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Where are we? be the same as they were in the past.(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


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Where are we? be the same as they were in the past.(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).


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Where are we going? be the same as they were in the past.

Integrated Strategy for dengue prevention and control in the countries of the Americas


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Integrated Strategy (Decalog) be the same as they were in the past.

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.


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Integrated Strategy (Decalog) be the same as they were in the past.

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).


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Integrated Strategy (Decalog) be the same as they were in the past.

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.


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How are we going? be the same as they were in the past.

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


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How do we know when we have arrived? be the same as they were in the past.

Strategies

  • Monitoring

    Surveys, reports, supervisory missions, etc.

  • Evaluation

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

  • Epidemiological data

    PAHO website: dengue case reporting)


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Social-Communication Component be the same as they were in the past.

  • 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.


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Social-Communication Component be the same as they were in the past.

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


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http://www.paho.org/Project.asp?SEL=TP&LNG=ENG&CD=DENGU be the same as they were in the past.


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