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A Dengue Epidemic in Puerto Rico, 2010

A Dengue Epidemic in Puerto Rico, 2010. LT Tyler M. Sharp, Ph.D. USPHS Scientific and Training Symposium June 21, 2011. National Center for Emerging and Zoonotic Infectious Diseases. Division of Vector-Borne Diseases — Dengue Branch. Dengue.

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A Dengue Epidemic in Puerto Rico, 2010

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  1. A Dengue Epidemic in Puerto Rico, 2010 LT Tyler M. Sharp, Ph.D. USPHS Scientific and Training Symposium June 21, 2011 National Center for Emerging and Zoonotic Infectious Diseases Division of Vector-Borne Diseases — Dengue Branch

  2. Dengue • Most important vector-borne viral disease worldwide • ~100 million infections/year • ~500,000 hospitalizations/year • ~25,000 deaths/year • Four dengue viruses (DENV1–4) cause an acute febrile illness • Common symptoms: fever, headache, myalgia, retro-orbital and joint pain, rash • Severe symptoms: hemorrhage, shock, death Photos credits: “Train-the-Trainer” course material, CDC 2010

  3. Asymptomatic 75% Symptomatic 25% Severe dengue 1-5% Dengue Fever 95-99% Survive 95-99.5% Death 0.5 - 5% Dengue Virus Infections Infection Incidence ~ 5% / year Adapted from Vaccine 2002; 3043-3046

  4. The Vicious Cycle of DENV Infections Mosquito acquires virus during feeding, virus replicates in mosquito Mosquito bites susceptible human, transfers DENV Mosquito bites susceptible human, transfers DENV Mosquito acquires virus during feeding, virus replicates in mosquito

  5. Prevention and Control of Dengue • Surveillance • Disease • Vector • Primary prevention • Vector control • Vaccination • Secondary prevention • Clinical care • Anti-viral drugs Image: http://www.lafayettela.gov/eos/dpt122mosquitocontrol.asp

  6. Puerto Rico and Dengue • 3.7 million individuals • Endemic • Seasonal • 7,000 – 24,000 cases/year • Passive surveillance Puerto Rico Image: http://www.caribbeanplanning.com/caribbean-map.htm

  7. Recent Dengue Epidemics in Puerto Rico Mean

  8. Recent Dengue Epidemics in Puerto Rico 1994 Mean

  9. Recent Dengue Epidemics in Puerto Rico 1998 1994 Mean

  10. Recent Dengue Epidemics in Puerto Rico 2007 1998 1994 Mean

  11. Recent Dengue Epidemics in Puerto Rico 2010 2007 1998 1994 Mean

  12. Recent Dengue Epidemics in Puerto Rico 2010 Mean

  13. Diagnostics RT-PCR IgM ELISA • Positive: RT-PCR or IgM ELISA positive • Negative: RT-PCR and IgM ELISA negative • Indeterminate: negative RT-PCR, no convalescent specimen Acute Convalescent Virus IgG IgM 0 5 10 90 Day Post-Onset of Symptoms

  14. Diagnostic Results, 2010 Suspected Cases (n = 23,622) Positive Cases (n = 10,947) Indeterminate 42.2%

  15. Viral Serotypes, 2010

  16. Rates of Lab Positive Cases by Municipality, 2010 Lab positive cases per 1,000 persons 0.1-1.6 1.7-2.7 2.8-4.3 4.4-16.1 Overall incidence: 2.9 lab positive cases per 1,000 persons

  17. Age Distribution of Lab Positive Cases, 2010 47% of cases were in adults Cases per 1,000 Individuals

  18. Age distribution of serotypes, 2010

  19. Age distribution of serotypes, 2010 Percent Serotype

  20. Lab Positive Cases and Lab Positive Deaths by Month, 2010 Suspected deaths: 123 Lab positive deaths: 38 Deaths

  21. Age Distribution of Lab Positive Deaths, 2010 89% of deaths were in adults

  22. Deaths by Serotype*, 2010 (n = 17) (n = 10) (n = 5) *32 of 38 deaths have a confirmed serotype.

  23. First documented outbreak in Philadelphia in 1780 Dengue disappeared in the US following vector elimination due to concerns of yellow fever Travel-associated dengue has re-introduced the virus into the US History of Dengue in the United States

  24. Dengue more common than malaria in some travelers Mosquito vector exists in US Imported outbreaks in TX, FL, HI In 2010, 702 cases reported from 38 states 18X under-reporting Re-emergence of Dengue in the United States Distribution of Aedes mosquitoes Mosquito surveillance data courtesy of Chester G. Moore, Colorado State University

  25. Travel-associated Dengue in US, 2010 702 cases reported from 38 states 0 1-2 3-10 11-30 >30 Source: ArboNET

  26. Travel-associated Dengue in US, 2010 • Puerto Rico, Dominican Republic, Haiti and other Caribbean Islands made up nearly half of all cases Cases Week of Report Source: ArboNET

  27. Travel-associated Dengue in US, 2010 • Puerto Rico, Dominican Republic, Haiti and other Caribbean Islands made up nearly half of all cases Puerto Rico Cases Week of Report Source: ArboNET

  28. Conclusions • Dengue is re-emerging • Large epidemic in PR in 2010 • 2.9 lab positive cases/1,000 individuals • Most lab positive deaths ever (n = 38) • 3.5 lab positive deaths/1,000 lab positive cases • 10–19 year olds most affected • 6.5 lab positive cases per 1,000 persons • Most deaths in adults • Median age: 44 years • Epidemics in PR overflow into the continental U.S.

  29. Future Steps • Examine dengue deaths for: • Risk factors • Under-reporting and -recognition • Emphasize personal protection • Avoid mosquito bites • Educate physicians in clinical case management • 8,300 physicians and 2,500 nurses trained • Evaluation of clinical case management

  30. Acknowledgements Aidsa Rivera, M.S. –Fatal case findings and PDSS oversight Rosa Rodriguez, Ph.D. – EDSS oversight Jorge L. Muñoz-Jordan, Ph.D. – Lab Chief, Molecular diagnostics and research Elizabeth Hunsperger, Ph.D. – Lab Chief, Serology diagnostics and research Luis Santiago, MPH – Statistical analysis and data processing LCDR FermínArgüello, M.D., MPH – Study design and analysis Hal Margolis, M.D. – Dengue Branch Chief CAPT Kay Tomashek, M.D., MPH – Epidemiology Chief National Center for Emerging and Zoonotic Infectious Diseases Division of Vector-Borne Diseases — Dengue Branch

  31. Deaths per Population, 2010 Overall : 0.9 lab positive deaths per 100,000 individuals Deaths per 100,000 Individuals

  32. Consecutive Infections, 2010

  33. Distribution of Aedes aegypti, 2007 Source: Chester G. Moore, Dept. of Microbiology, Immunology & Pathology, Colorado State University

  34. Distribution of Aedes albopictus, 2007 Source: Chester G. Moore, Dept. of Microbiology, Immunology & Pathology, Colorado State University

  35. Rates of Lab Positive Cases by Municipality, 2010 Fatalities 1 2 3

  36. Under-reporting of Dengue in Puerto Rico • Lack of reporting • 10-27 symptomatic cases for every reported case in 1990’s • Failure of patients to present • Lack of clinical supicion • Failure of clinicians to report • Alternative methods of reporting • Category-1 form • Specimens sent off island for diagnostics (3 major companies) • Company A: ~2,000 from June-December, 2010 • Asymptomatic cases • ≤ 90% of all infections • In total, we estimate that 5-10% of Puerto Ricans were infected in 2010 • ~350,000 individuals

  37. Accuracy of Enhanced Fatal Dengue Surveillance, 2010 Cases

  38. DHF Cases by Serotype, 2010 (n = 57) (n = 70) (n = 17)

  39. DHF Cases by Serotype, 2010 (n = 92) (n = 52)

  40. DHF Cases per Population Overall : 6.7 lab positive DHF cases per 100,000 individuals DHF Cases per 1,000 Individuals

  41. DHF Cases per DF Cases Overall : 21.4 lab positive DHF cases per 1,000 lab positive cases DHF Cases per 1,000 DF Cases

  42. Suspected and Confirmed Cases by Week, 2010 Outbreak declared Feb. 27, 2010

  43. Clinical Course of Dengue Infection 1 to 3 days; usually <48 hrs Critical Phase Mosquito bite Range: 2 to 7 days; usually 3 to 5 days Usually 3 to 5 days Range: 3 to 14 d; usually 4 to 7 days Convalescent Phase Acute Febrile Phase Incubation Viremia -2 0 2 4 6 8 10 12 Day of Illness * Typically uncomplicated DHF/DSS lasts for 10 to 12 days

  44. WHO Dengue Case Definitions (1997) Dengue fever (DF) Fever plus 2 of: headache, retro-orbital pain, myalgia, joint pain, bone pain, rash, bleeding, low WBC count Dengue hemorrhagic fever (DHF): Fever, hemorrhagic manifestation(s), thrombocytopenia (≤100,000 cells per mm³), plasma leakage Dengue shock syndrome (DSS): DHF plus rapid, weak pulse and narrow pulse pressure, OR DHF plus hypotension and cold, clammy skin and restlessness

  45. Characteristics of the 2010 Epidemic * denominator varies due to data availability

  46. Age Distribution of Hospitalized Cases, 2010 Percent Serotype

  47. Infecting Serotypes in Non-Hospitalized and Hospitalized Individuals, 2010

  48. Hospitalization something or other, 2010

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