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Dengue: An emerging arboviral disease

Dengue: An emerging arboviral disease. Gary G. Clark, Ph.D. Mosquito and Fly Research Unit CMAVE, ARS, USDA Gainesville, Florida. My “emergence” at Balboa Naval Hospital. San Diego, California. First interaction with a Navy physician. Discussion topics. Epidemiology of dengue and DHF

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Dengue: An emerging arboviral disease

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  1. Dengue:An emerging arboviral disease Gary G. Clark, Ph.D. Mosquito and Fly Research Unit CMAVE, ARS, USDA Gainesville, Florida

  2. My “emergence” at Balboa Naval Hospital San Diego, California First interaction with a Navy physician

  3. Discussion topics • Epidemiology of dengue and DHF • Emergence of dengue in the Americas • Aedes aegypti and its development • Adult control methods for Ae. aegypti • Evaluation of emergency control studies (CDC and the military) • Dengue and the US military

  4. Dengue virus • An arbovirus; transmitted by mosquitoes • Four virus serotypes (DEN-1, 2, 3, 4); single-stranded RNA • Family Flaviviridae (WNV, SLE, YF, JE) • Causes dengue (headache, fever, joint/retrorbital pain, rash, bleeding) and dengue hemorrhagic fever (DHF)

  5. Dengue viruses • Each serotype provides specific lifetime immunity and short-term cross-immunity • All serotypes can cause severe and fatal disease • Genetic variation within serotypes; some appear to be more virulent or have greater epidemic potential • Can produce outbreaks/epidemics in urban areas

  6. Extrinsic incubation period Illness Illness Transmission of dengue virusby Aedes aegypti Mosquito refeeds / Mosquito feeds / transmits virus acquires virus Intrinsic incubation period Viremia Viremia 0 5 8 12 16 20 24 28 Days Human #1 Human #2

  7. Dengue: A global perspective* • Most important arboviral disease of humans; 2.5- 3 billion people (40% of the world) at risk of infection • 10’s of millions of cases of dengue and 100’s of thousands of DHF cases annually • A leading cause of hospitalization and death among children in Asia • DHF mortality rate averages about 5% * Source: WHO, 1996

  8. World distribution of dengue 2006 Areas infested with Aedes aegypti Areas with Ae. aegypti and recent dengue epidemics

  9. Dengue/DHF cases reported to the World Health Organization1955-2005* Ave. annual no. cases * Source: WHO, Sep. 2006

  10. Dengue in the Americas 1980 – 2006* Year * Source: PAHO (Jan. 19, 2007)

  11. Dengue hemorrhagic fever in the Americas1980 – 2006* Cases * Year * Source: PAHO (Jan. 19, 2007)

  12. Why has dengue emergedin the Americas? • Presence of competent mosquito vector • Large, susceptible human population • Conditions supporting abundant mosquito population • Frequent introduction of dengue viruses • Ineffective vector control programs

  13. 1830 1930 2000 Emergence of dengue Socio-economic factors Population increase Billion • Unprecedented population increase • Uncontrolled and unplanned urbanization • Inadequate environmental conditions 6 5 4 3 2 1

  14. Reinfestation of the Americas by Aedes aegypti* 1930s 1970 2006 * Source: CDC/PAHO

  15. Emergence of dengueUncontrolled urbanization* • In 1954, 42% of the population of Latin America lived in urban areas, increasing to 75% in 1999. • “Informal” communities proliferated as a result of poverty. • Scarcity of basic services: running water, sewage and collection of garbage. * High population density Sources: Gubler, 1998. PAHO, 1997.

  16. Insufficient collection of disposable containers Non-biodegradable containers Discarded tires Insufficient and inadequate water service Increased number of “pilas” and water storage containers Inadequate water and sewer conditions Emergence of dengue Inadequate environmental conditions* * Increase in production sites

  17. Production sites for Aedes aegypti Buckets and pails

  18. Production sites for Aedes aegypti Water storage tanks

  19. Production sites for Aedes aegypti Discarded tires

  20. Migrations International Tourism More than 750 millon people cross frontiers annually Increase of migration from rural areas to cities 1.4 billion international passengers in 1999 697 million international tourist arrivals in 2000. 715 million in 2002, an increase of 3.1% Emergence of dengue Population movement* * Traffic of microorganisms Source: WTO

  21. Why has dengue emergedin Latin America? • Reinfestation by Aedes aegypti • Ineffective mosquito control programs • Deteriorated public health infrastructure • Uncontrolled population growth and unplanned urbanization • Increased air travel by humans

  22. Aedes aegypti

  23. Aedes aegypti • Lives in and around human habitations in urban areas • Lays eggs and produces larvae preferentially in artificial containers • Strong preference for human blood; primarily a daytime feeder and bites several times in her life • Most important vector of dengue viruses in the world

  24. Life cycle of Aedes aegypti 4. Adult 3. Pupae 1. Eggs 2. Larvae

  25. Personal protection against mosquitoes • Apply repellent (20-30% DEET) to exposed skin- avoid eyes, mouth, and children’s hands • Spray clothing with repellents with DEET or permethrin • Use treated mosquito netting over bed • Spray insecticide in room before going to bed, follow label instructions • Wear long-sleeved shirts and long pants

  26. Dengue vaccine? • No licensed vaccine at present • Effective vaccine must be tetravalent • Field testing of an attenuated tetravalent vaccine currently underway • Effective, safe and affordable vaccine will not be available in the immediate future Vector control continues to be key to dengue prevention

  27. Vector control methods:Biological and environmental control • Biological control • Largely experimental • Option: place fish in containers to eat larvae • Environmental control • Elimination of larval habitats • Method most likely to be effective in the long term

  28. Spraying to control adult Aedes aegypti • Thermal fog • Aerosols – Cold fog and ultra low volume (ULV) • Inside of residences with portable equipment • From the ground with vehicle-mounted equipment • Aerial application

  29. CDC evaluations: Emergency control in Puerto Rico* • Ground ULV applications versus Aedes aegypti • C-130 (Hercules transporter) with USAF Reserve Unit from Columbus, OH • US Navy (DVECC) with PAU-9 from JAX • Mosquitoes susceptible to naled (Dibrom 14) and insecticide reached the ground but did not penetrate houses • Limited, transitory impact on wild population * Other projects with US Army in Honduras and the Dominican Republic

  30. Ground ULV application

  31. Ground ULV application

  32. Aerial application in San Juan with C-130

  33. Aerial application in San Juan with PAU-9

  34. US Navy’s PAU-9 unit

  35. Indoor application with thermal fog unit

  36. Indoor application with portable ULV unit

  37. Operation Restore Hope Somalia- 1992-1993 • 30,000 troops deployed; 530 were studied - 289 hospitalized with fever- 129 with “unspecified illness”- 41 with DEN virus and 18 with anti-dengue ABs= 59/129 (46%) with DEN infections. • Study of unit in Baardera: 9% (44) of 494 with dengue infections • 70% used DEET < 1 time/day, 22% never treated uniforms, 61% did not use bed nets and only 25% kept sleeves rolled down at all times • Poor compliance with PPMs vs. insects

  38. Operation Uphold DemocracyHaiti- 1995 • 249 with fever- 79 (32%) with DEN infection - 44/79 participated in survey - 73% with mosquito bites daily - 50% used repellents < 1/week or never - 48% did not use a bed net • 10/14 (71%) of Army units did not have deployed, functional field sanitation teams • 31% of soldiers indicated PPMs emphasized “some but not enough or not at all” • Low unit readiness to perform VC activities • Command enforcement of PM doctrine is essential for dengue prevention

  39. DHF in Venezuela 1989-1990 • PAHO-Venezuela requested that CDC-San Juan test specimens from suspected fatal case (12 year-old girl) of DHF from Venezuela • Dengue etiology was confirmed; epidemic was spreading from Maracay to Caracas • Minister of Health sought epidemic response recommendation. Discussed results of USAF and Navy trials. “Aerial control… limited impact, dangerous, could not recommend aerial control as the solution.” • Minister “… must take action and intended to spray using helicopters with booms attached” • With Minister’s decision, I changed hats and recommended that he seek “professional assistance such as from the US Navy” No aerial spray experience in Venezuela. • Venezuelan Air Force transported DVECC personnel and equipment to Venezuela.

  40. Preparing to spray with Venezuelan helicopter MMART* Preventive Medicine Assists Venezuela LCDR Mark T. Wooster, MSC, USN Navy Medicine (Mar-Apr 1991) * Mobile Medical Augmentation Readiness Team

  41. DHF in Venezuela 1989-1990 • DVECC’s “equipo deexpertos rociadores aereos” • LCDR Mark Wooster • LT Joseph Conlon • LT Stanton Cope • LT David Claborn • LT Rafael del Vecchio • U.S. Navy personnel performed 60 aerial spray missions (malathion @ 3 oz/acre) during 135 flight hours over Maracay and Caracas.

  42. Aterriza de emergencia helicóptero de fumigación (Newspaper report) MARACAY (Especial) –Uno de los helicópteros de la Fuerza Aérea, queparticipa en las operaciones de fumigación contra el dengue, aterrizó de emergencia en el estacionamiento del centro comercial “El Castaño”, de esta ciudad, resultando gravemente herido el piloto de la unidad, que no fue identificado por las autoridades. En la aeronave viajaban dos oficiales [LT Joseph Conlon and LT Stanton Cope] de la Marina de los Estados Unidos, quienes habrian sufrido lesiones. Tambien iban dos oficiales de la Fuerza Aérea Venezolana, y tres guardias nacionales. La aeronave arrancó una linea de alta tensión y dejo al sector “El Castaño” sin electricidad.

  43. After mission! Venezuelan helicopter

  44. Fortunately, the injuries to the crew and US Navy personnel were minor. And, some of our “expertos” developed a new feeling for helicopters on the ground.

  45. “I love my choppers!” “Private parking space” for AFPMB RLO Silver Spring, Maryland

  46. u b s CAPT Stanton E. Cope- “Dengue fighter”

  47. Take home messages • Importance of command emphasis for personal protection measures • Critical that you lead by example and use repellents • Be prepared to respond to requests for help in dealing with dengue and other VBD in support of US military or in humanitarian missions • There is no “magic bullet” to solve the emerging problem of dengue/DHF • You are part of unique national/international vector control resources; challenges and danger may accompany your work • USDA is anxious to support US military in protecting deployed personnel and in responding to humanitarian missions

  48. Walter Reed Army Medical Center PSA Washington, D.C. My last interaction with an Army physician

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