DAVE D.CHADEE, INSECT VECTOR CONTROL DIVISION, MINISTRY OF HEALTH, TRINIDAD, WEST INDIES

1. IMPACT OF CLIMATE VARIABILITY ON AEDES AEGYPTI INDICES AND DENGUE CASES IN THE CARIBBEAN REGION: A PROSPECTIVE STUDY DAVE D.CHADEE, INSECT VECTOR CONTROL DIVISION, MINISTRY OF HEALTH, TRINIDAD, WEST INDIES

2. Dengue situation Globally and in the Caribbean RegionBackground • Over 2.5 billion people live in areas where dengue is endemic (latitude 45oN-35oS) • Dengue causes more illness and death than any other arbovirus disease in humans • Each year over 100 million cases of dengue and several thousands cases of DHF occur • DHF is the leading cause of hospitalization and death among children in South East Asia

3. Dengue transmission within the Caribbean Region • Dengue is caused by any of 4 different serotypes of the arbovirus (Den 1,2,3,& 4) • An incubation period of 2-8 days after an infective bite by the Aedes aegypti mosquito. • The disease usually begins with onset of fever, headaches followed by chills, retro-orbicular pain, photophobia, backache, severe muscle ache and joint pain • Maculopapular rash, lymph node enlargement, petechiae and haemorrhagic manifestations like epistaxis and gastrointestinal bleeding (WHO 1997)

4. Emergence of dengue and DHF in the Caribbean Region Attributed to: • anthropological factors including demographic (urbanization) and societal changes • post World War II increases in land and sea transportation • failure of Aedes aegypti programs due to a lack of political will (Breteau index of 5)

5. Emergence of dengue and DHF in the Caribbean Region • biological factors • insecticide resistance • infected vectors require longer feeding time • change in size and vector potential • introduction of new and different strains or serotypes

6. Emergence of dengue and DHF in the Caribbean Region 5. Climatic factors a. smaller size mosquitoes (temperature) b. quicker development time of life cycle c. faster virus replication time (temp.) d. increased risk of dengue transmission (temperature and humidity)

7. INTRODUCTION Two of the most significant aspects of climate change relates to mosquitoes: • Monitoring changes in vector abundance and disease transmission • Indicating where and when intervention for control is appropriate

8. OBJECTIVESRetrospective and Prospective study • To determine by a retrospective study whether there is any relationship between climate change, mosquito production and dengue transmission. • Conduct a prospective study throughout the Caribbean region to examine changes in mosquito densities, climate and dengue transmission.

9. Map of Caribbean Region

10. Dengue prevalence and Aedes aegypti Breteau indices in Trinidad and Tobago (1981-2001)

11. Study sites • We have started work in 5 countries • Jamaica • Barbados • Trinidad and Tobago • St. Kitts/Nevis • St. Vincent and the Grenadines

12. Dengue Data from the Caribbean region (2)

14. Epidemiological triad Man • Climate Dengue virus • Environment • Mosquito

15. What is a prospective study • It measures the burden of disease in a population • It shows the distribution of exposure to the disease- dengue

16. Prospective study • is distinguished by the fact that it starts with a group of subjects who lack a positive history of the outcome of interest yet are still at risk for it • There are two observational points 1. to determine exposure status and eligibility 2. to determine the number of incident cases that develop during the follow-up.

17. Type of Prospective study • Population based representing a heterogeneous sample in terms of exposure (cohort) • Unit of observation and unit of analysis in a cross-sectional study is the individual

18. Research strategy • A prospective study is characterized by determining exposure levels at baseline (the present) and follow-up for occurrence of disease in two or more years • DESIGN PAST PRESENT FUTURE Prospective E D Retrospective E D Historical Prosp. E E D E=Exposure D=Disease

19. Data Collection (March 2003-February 2004) • Mosquito densities using the Breteau index (no.of positive containers in 100 houses) • Dengue data to be collected from the Ministry of Health in each country • Climate Data to be collected from our network of meteorologist or from weather stations nearby

20. Statistical analysis of Data • Assessment of risk- 1. Relative risk- a measure of the extent to which those exposed to a risk factor are likely to get a disease compared with the non-diseased general population. 2. Absolute risk- the incidence rate for a group exposed to a risk factor

21. Data analysis • 3. Attributable risk- the difference in the incidence of a disease between the exposed (diseased) and non exposed (non-diseased) groups. . 4. Analysis of Variance (Anova) the association between climate, mosquito densities, dengue cases, seasonal changes etc. 5. Regression analysis to determine changes in time and space etc.

22. Evaluating Epidemiologic Association • could the association have been observed by chance? • could the association be due to bias? • could other confounding variables have accounted for observed relationship? • to whom does this association apply? • Does the association represents a cause and effect relationship?

23. Can we prove causation? • Is there a logical time relationship • Is there a large relative risk • Can we demonstrate a dose-response relationship • Is it reversible • Is it consistently found to be present in different study sites • Is it consistent for various study designs • Is it biologically plausible

24. Collaborators • Dr S.C. Rawlins, Caribbean Epidemiology Centre, Trinidad • Dr A. Chen, University of the West Indies, Mona, Jamaica