PAHO/WHO: Epidemiological Alert On Chikungunya & Dengue In the Americas

 

 

# 9020

 

While Ebola garners the bulk of the headlines, other serious disease threats like Chikungunya and Dengue continue their inexorable spread across the globe, infecting hundreds of times more people than does Ebola, albeit with a far lower morality rate.   

 

For 2013, PAHO provides the following assessment for Dengue in the Americas:

 

In 2013, dengue behaved like a classic epidemic for the Americas region, with the largest historical cases reported. In total, countries in the Americas reported more than 2.3 million cases of dengue, with 37,692 cases of severe dengue and 1,280 deaths, for a mortality rate of about 0.05%.

 

This year, for the first time, the Americas are also dealing with Chikungunya – which arrived late last fall in the Caribbean, and has spread rapidly since then.  PAHO’s most recent report (Week 34) indicates just over 650,000 CHKV infections in the Americas, and 37 deaths.

 

The arrival of Chikungunya to the Americas has been anticipated for some time, and the CDC & PAHO produced a 161 page guide on preparing for its arrival 3 years ago (see Preparedness and Response for Chikungunya Virus Introduction in the Americas).

 

Last May, in Florida Prepares For Chikungunya we looked at local preparations for its arrival.  Given its climate, its position as the gateway to the Caribbean, and that it receives millions of tourists every year -  Florida was considered a likely first US battleground against any CHKV invasion.  

 

And indeed, the first first locally acquired case in Florida was reported in July.

 

For now, the major concern is in the Caribbean, Central & South America where both Dengue and CHKV co-circulate, and where the burden of these diseases is infinitely higher than it is in the United States. As the height of the Dengue season generally occurs in the second half the year, the next few months are considered a critical time for mosquito control programs.

 

Yesterday PAHO and the World Health Organization released an 8-page PDF Epidemiological Alert for the Americas on these co-circulating mosquito-borne diseases.  Follow the link to read the entire document:

 

Epidemiological Alert

Chikungunya & Dengue Fever In the Americas

29 August 2014

Situation summary

The first evidence of autochthonous chikungunya transmission in the Americas was recorded in December 2013, since then, autochthonous transmission has been detected in 33 countries and territories of the Americas (27 countries and territories in the Caribbean, 3 countries in Central America, 1 country and 1 territory in South America and 1 country in North America).1,2 As of epidemiological week (EW) 35 of 2014, the Pan American Health Organization / World Health Organization (PAHO/WHO) has been informed of a total of 659,367 cases, including 37 deaths, in the Americas.

Usually during the second semester of the year, Central America, Mexico and the Caribbean experience a seasonal increase in dengue fever transmission. Currently, the Dominican Republic, El Salvador, Guatemala, and Honduras, are recording increases in cases coinciding with this period of greater transmission.

The threats posed by the seasonal increase of dengue transmission and the introduction, or risks of introduction of the chikungunya virus in the Region require an integrated approach of prevention and vector control activities of both diseases. With the rapid spread of the chikungunya virus observed in some countries of the Americas, simultaneous dengue and chikungunya outbreaks may occur, which would result in increased health care demand. Accordingly, health care services must be prepared to meet expected increased demand without compromising quality of care; preparations should be guided by the PAHO/WHO recommendations for clinical management of patients with dengue or chikungunya.
 

(Continue . . . . .)

 

 

With the rapid expansion of both Dengue and Chikungunya around the globe, Europe and the United States are seeing signifcant increases in the number of imported cases every year – each with at least the potential to seed local mosquito populations with the virus. So far locally acquired infections in both regions remain relatively rare.

 

The lack of an abundant non-human animal reservoir for the virus is likely partly responsible. But in 2003, a CDC EID study also found that economics and lifestyle may have a lot to do to with our lack of locally transmitted Dengue (see Texas Lifestyle Limits Transmission of Dengue Virus).

 

But given the availability of two competent mosquito vectors (Aedes Aegypti & Aedes Albopictus), and repeated introductions of the virus from travelers coming from regions where the virus is endemic, our luck in this matter may not last forever.

 

The good news is that these mosquito-borne illnesses (and others, including WNV, SLEV, EEE, etc.) are largely preventable.

 

Florida’s Health department reminds people to always follow the `5 D’s’:

PAHO Chikungunya Update & Videos

Aedes Albopictus – Asian Tiger Mosquito

 

 

# 8792

 

Up until about a decade ago, Chikungunya was a rarely seen mosquito-borne virus pretty much limited to central and eastern Africa.  All of that changed in 2005 when it jumped to Reunion Island in the Indian Ocean, where it reportedly infected about 1/3rd of that island’s population (266,000 case out of  pop.770,000) in a matter of a few months.

 

From there, apparently aided and abetted by a recent mutation that allowed it to be carried by the Aedes Albopictus `Asian tiger’ mosquito (see A Single Mutation in Chikungunya Virus Affects Vector Specificity and Epidemic Potential), it quickly cut a swath across the Indian ocean and into the Pacific. 

 

That is, until about six months ago, when one (or more) infected travelers apparently arrived on the French Part of St. Martins, introducing the virus into the local mosquito population.  On December 10th there were 2 confirmed, 4 probable and 20 suspected cases of chikungunya on the island. 

 

A short six months later, and the virus has spread across nearly the entire Caribbean basin, and has infected at least 260,000 people. 

Further expansion into North, South, and Central America seems but a matter of time.

 

A textbook example of what happens when a emerging infectious disease enters an immunologically naive population under favorable environmental conditions.  And the reason why we talk so much about the global spread of disease in this age of globalization and increased international travel  (see The Global Reach Of Infectious Disease).

Yesterday’s update from PAHO has already made headlines, as it shows an increase of roughly 93,000 cases over the previous week (a 40% increase), although not all of those cases emerged over the past 7 days. 

 

As you’ll see by the chart below, some countries are still several weeks behind in their reporting, and surveillance and reporting in some regions is `sub-optimal’, so these numbers are still likely a significant undercount.

 

 

This week the WHO/PAHO Youtube Channel released several short videos showing the effects of the illness. The first one is more of a slide show, but shows the symptoms of the disease.  The second video on Clinical Management is in Spanish, but has English sub-titles. 

 

 

There are currently at total of five videos in their CHIKUNGUNYA Playlist.

 

For more on how the State of Florida and the CDC are working to meet the challenges of chikungunya, you may wish to revisit:

 

Florida Prepares For Chikungunya 

Chikungunya Update & CDC Webinar Online

CDC HAN Advisory On Recognizing & Treating Chikungunya Infection

 

 

PAHO Chikungunya Surveillance Update – June 13th

 

 

# 8742

 

The Chikungunya virus – which was only first reported in this hemisphere last December on the French Part of St. Martins - continues to spread across the Caribbean and make incursions into Central and South America at an impressive rate. 

 

Two weeks ago (see PAHO Chikungunya Epidemiological Update – May 30th) the estimated number of cases had grown to just over 100,000 – today that number exceeds 165,0000.

 

As impressive as these growth numbers are, it should be noted that surveillance in some of the reporting nations is sub-optimal, and in some cases, reporting to PAHO lags behind by several weeks.  Meaning the number of reported cases today is likely to be an undercount.  

 

First a look at the latest numbers, then I’ll be back with more:

 

The hardest hit areas are islands in the `Latin Caribbean’, which have reported more than 90% of all of the cases in this outbreak to date.  Particularly hard hit are Martinique and the Dominican Republic, although anecdotal reports suggest the situation in Haiti is badly underreported.

 

While lagging well behind, the Non-Latin Caribbean nations have reported a roughly 30% increase in cases over the past two weeks.

And lastly, a look at nations that have reported imported Chikungunya cases – but as of yet, no local transmission of the virus. 

 

While this virus has spread quite efficiently through just the normal tourist trade and international travel, this week the month-long FIFA World Cup begins in Brazil, which is expected to draw more than 500,000 visitors.  And among them will be some who either reside in, or have recently visited, areas where this virus is currently spreading (see  The ECDC Risk Assessment On Brazil’s FIFA World Cup).

 

With an incubation period of between 3 and 7 days, and the enormous amount of international travel to, and from, the Caribbean, the concern is that this virus will soon migrate to other areas that also have a favorable climate and the right kind of mosquitoes.

 

In April, in Study: Chikungunya’s Growing Threat To The Americas, we looked at models showing how the spread of CHKV could be aided and abetted by the spike in travelers to the World Cup this summer. 

 

Until about a decade ago, the Chikungunya virus was fairly localized in Central Africa, and only believed transmitted by the Aedes Aegypti mosquito.  In 2005  the virus took off on the wings of the Aedes Albopictus mosquito, and quickly conquered the Indian Ocean and parts of Asia, and moved into the Pacific.

 

Between the two, these mosquito vectors cover a lot of territory, including much of the Eastern United States and Southern Europe.

 

 

While no one knows how well the virus will spread, once it gets a foot hold in the United States or Europe, public health agencies are trying to be as proactive as they can in anticipation of its arrival. The state of Florida is concerned enough that it has issued warnings to the public, and is actively Preparing For Chikungunya. 

 

In March the CDC held a Chikungunya Webinar, in December they released a CDC HAN Advisory On Recognizing & Treating Chikungunya Infection, and just last week the MMWR published a report on  Chikungunya In the Caribbean & South America.

 

Chikungunya – while rarely fatal, can cause prolonged fever and severe polyarthralgias (joint pain), which in some cases can last weeks, months, or even longer.  

 

While the kind of widespread epidemic we are seeing in the Caribbean seems highly unlikely in the United States or Europe (based primarily on differences in lifestyle, better mosquito control, and other socio-economic factors), no one really knows what will happen when this emerging arbovirus, aided and abetted by a pair of competent and ubiquitous vectors, is introduced to a highly susceptible and immunologically naive population.

 

But considering Chikungunya’s remarkable run over the past 10 years, it seems likely that this virus will continue to spread to new territories, bringing with it serious public health challenges.

PAHO: Chikungunya Numbers Jump Nearly 30K In Past Week

 

 

# 8717

 

With the caveat that an exact count of cases is impossible, and the numbers we have are likely an undercount, yesterday PAHO (Pan American Health Organization) released their weekly update on Chikungunya, which shows a jump of nearly 30,000 cases across the Caribbean during the past week. 

 

Last week (see PAHO Chikungunya Epidemiological Update – May 30th) the number of suspected and confirmed cases sat at just over 103,000.

 

This latest update (June 6th) sits at nearly 131,0000, with the vast majority of cases being reported on the Latin Caribbean islands, with Haiti and the Dominican Republic showing the fastest rise in cases.

 

 

 

Previously, Chikungunya has shown the ability to spread explosively among an immunologically naive population when the competent vectors (Aedes mosquitoes) and favorable environmental and societal conditions converge.

 

The 2005 outbreak on Reunion Island in the Indian Ocean reportedly resulted in the infection of roughly 1/3rd of that island’s population (266,000 case out of  pop.770,000) in a matter of a few months.

 

In the past couple of days Crof has carried a number of reports from Haiti and the Dominican Republic (see Dr. Halverson on Haiti's chikungunya numbers) that give us some idea on how pervasive this virus has become in 6 short months in parts of the Caribbean.

 

While rarely fatal, Chikungunya can produce a severe fever and excruciating joint pain usually lasting for at least a week.  Some studies (cite) indicate significant arthritis-like sequelae can persist for months or even years post-infection.

 

With an incubation period of between 3 and 7 days, and the enormous amount of international travel to, and from, the Caribbean, the concern is that this virus will soon migrate to other areas that also have a favorable climate and the right kind of mosquitoes. 

 

Brazil is particularly at risk this summer with the FIFA World Cup, something we discussed yesterday.

 

But then, so is the United States, and even parts of Europe (Italy saw a mini-epidemic in 2007 when just one infected traveler started a chain of infection that eventually touched 300 people).  

 

The good news, at least in most of the United States, is that most of us live and work in air-conditioned spaces, and live in regions that maintain pretty good mosquito control programs, and so we aren’t as apt to be continually exposed to (and bitten by) mosquitoes as people living in the Caribbean.

 

But as a native Floridian, I can assure you that it is pretty much impossible to totally avoid feeding our unofficial `state bird’.

 

The state of Florida is concerned enough that it has issued warnings to the public, and is actively Preparing For Chikungunya.  In March the CDC held a Chikungunya Webinar and last December they released a CDC HAN Advisory On Recognizing & Treating Chikungunya Infection. 

No one knows if Chikungunya will spread rapidly in the United States, like West Nile Virus has over the past 15 years, or produce infrequent and highly sporadic outbreaks, as has Dengue.  

 

But given its rapid global expansion over the past nine years, no one in public health is taking the threat lightly.

PAHO Chikungunya Epidemiological Update – May 30th

# 8695

 

 

Although it only first appeared in the Americas last November, we’ve gone from a handful of cases on the French Part of St. Martins to more than 100,000 cases spread across much the the Caribbean, in just six months.  A demonstration of just what an emerging  virus, aided and abetted by a competent and ubiquitous vector, can do to a highly susceptible and immunologically naive population.

 

In recent weeks we’ve looked at how Florida Prepares For Chikungunya , a Study on Chikungunya’s Growing Threat To The Americas, and several CDC presentations, including a Chikungunya Update & CDC Webinar Online.

 

 

Today, a brief update from PAHO on the most recent reporting week (22) for Chikungunya across the Caribbean.

 

Chikungunya

PAHO / WHO received on December 6, 2013 the confirmation of the first cases of autochthonous transmission of Chikungunya virus in the Americas. Existing cases are registered and weekly updated in the following table:

• Number of Reported Cases of Chikungunya Fever in the Americas.

 

:: Technical guidelines and recommendations

PAHO / WHO recommends that countries with a presence of the transmitting mosquito establish and maintain their capacity to detect and confirm cases; manage patients; and implement an effective communication strategy to reduce the presence of the mosquito. It is also recommended to strengthen laboratory capacity to identify and confirm the virus in a timely manner.

ECDC: Epidemiological Update On Cholera In Mexico

Cholera In The Americas 10/12 – 10/13 - Credit PAHO 

 

# 7848

 

 

According to a recent epidemiological alert, issued on October 1st, PAHO (the Pan American Health Organization) lists four nations in the Americas reporting cholera over the past 12 months. Of these, three have been battling this disease for some time; Cuba, Haiti, The Dominican Republic. While the fourth – Mexico – has only recently begun reporting locally acquired  cases. 

They write:

 

In  Mexico, the International Health Regulations (IHR) National Focal Point of Mexico reported 36 new confirmed cases of autochthonous infection with Vibrio cholerae O:1 Ogawa toxigenic in the state of Hidalgo. With the additional confirmed cholera cases, the national total is now 46, including one death; with two of the cases in the Federal District and 44 in the
state of Hidalgo. 

The cases are 24 women and 22 men with ages ranging from 2 to 82 years old. 

The Mexico health authorities continue to: strengthen epidemiological activities at the national level; ensure the availability of inputs and quality of care in medical units; implement actions to ensure access to drinking water and basic sanitation at the community level; and monitor and check the chlorine levels.

 

On October 5th, the CDC’s Traveler’s Health website posted a low-level advisory regarding the situation in Mexico (See Cholera in Mexico : Watch - Level 1, Practice Usual Precautions).

 

Today, the ECDC has posted an epidemiological update on the situation.

 

 

Epidemiological update: Cholera in Mexico

10 Oct 2013

​On 1 October, 46 confirmed cases of cholera, including one death, were reported by the Pan American Health Organization (PAHO) in Mexico. Of those, two were identified in the Federal District and 44 in the state of Hidalgo. However, media reports mention up to 81 confirmed cases: 77 in the state of Hidalgo, two in the state of Mexico and two in the Federal District, which is the most populated area of Mexico.

 

Of the cases where information was available, 44% are male and 56% are female, age ranging from two to 82 years old; 30% have been hospitalized.

 

This is the first sustained autochthonous transmission of cholera recorded since the 1991-2001 endemic period. These infections are caused by Vibrio cholerae O:1 Ogawa toxigenic. The strain is different from the one that circulated in Mexico during the 1991-2001. Genetic testing suggests this strain to be similar to the strain currently circulating in Haiti, Dominican Republic and Cuba.

 

Travellers to Mexico should be aware of preventive hygiene measures and seek advice from travel medicine clinics prior to their departure, to assess their personal risk. In addition, physicians in the European Union should consider the diagnosis of cholera in returning travellers from Mexico presenting with compatible symptoms. Upon diagnosis, notification to the relevant public health authorities is essential.

 

In Cuba, according to the same update, 678 confirmed cholera cases, including 3 deaths, have been reported from July 2012 through August 2013. The affected provinces are Camaguey, Granma, Guantanamo, Havana, and Santiago de Cuba. Twelve of the confirmed cases had travelled to Cuba from other countries (two from Chile, two from Germany, three from Italy, one from the Netherlands, two from Spain, and two from Venezuela). The overall risk for travellers is still considered low.

 

ECDC Rapid Risk Assessment: Outbreak of cholera in Cuba, potential risk for European travellers; 12 July 2012

Updated ECDC Risk assessment: Outbreak of cholera in Cuba, potential risk for European travelers, 17 January 2013

PAHO Epidemiological alert on 1 October 2013

 

PAHO: Dr Keiji Fukuda Briefs Delegates On H7N9 & MERS-CoV

 

Dr Keiji Fukuda – Credit WHO

 

# 7838

 

The 53rd Directing Council of the Pan American Health Organization (PAHO) and 66th Session of the WHO Regional Committee for the Americas gathered in Washington D.C. between September 29th and October 3rd. Among the many presentations was a briefing by World Health Organization Assistant Director-General for Health Security and the Environment - Dr Keiji Fukuda – who briefed delegates on both the emerging MERS Coronavirus and the newest avian flu threat; H7N9.

 

While both viruses have only produced limited regional outbreaks (in China and the Middle East) to date, Dr Fukuda urged member countries to be alert and to prepare their public health agencies to deal with the possible spread of either virus.

 

The following excerpts come from the 53rd Directing Council blog, posted 10/1/13. Follow the link to read it in its entirety.

 

Fukuda briefs Directing Council delegates on MERS-CoV and A(H7N9)

Keiji Fukuda, WHO Assistant Director-General for Health Security and Environment, briefed delegates to the 52nd Directing Council on the status of outbreaks of Middle East respiratory syndrome coronavirus (MERS-CoV) and the influenza virus A(H7N9), which are being closely monitored for their potential impact on international health security.

Fukuda noted that there are both similarities and difference between the two viruses. Both are from animal reservoirs, both are “unusually pathogenic,” and both are capable of human-to-human transmission. Although neither has shown sustained transmission in the community, both remain major underlying public health risks.

A(H7N9) is an avian influenza virus that so far has caused outbreaks only in China, the largest outbreak so far during March and April of 2013, when 130 cases were reported during one four-week period. The source of human infection is contact with infected poultry, said Fukuda, mostly in live markets. As with all influenza viruses, A(H7N9) appears to be more active in cold weather, both in birds and in humans.

In contrast to A(H7N9)’s appearance only in China, MERS-CoV has been reported in nine countries, most in the Middle East, but also in Tunisia and in patients with histories of travel to the Middle East returning to France, Italy and the United Kingdom. Fukuda noted that less is known about coronaviruses in general than about influenza viruses, for example, it is not known if coronaviruses are seasonal.

(Continue . . . )

 

Honduras Declares Dengue Emergency

 

 

# 7528

 

Although historical records suggest that Dengue fever has been endemic in South and Central America and the Caribbean for centuries, it was all but eliminated by an intensive Yellow Fever eradication campaign organized by PAHO in the late 1940s.

 

According to the 2002 paper  Dengue in the Americas by Mary E Wilson and Lin H Chen:

 

Records show no evidence of epidemic dengue in the Americas from 1946 through 1963, presumably reflecting in part the benefits from the eradication programme. In areas where Aedes aegypti was eliminated, transmission of dengue virus was interrupted.

 

Support for programmes waned and vector control activities declined allowing the mosquito to reinfest areas where it had been eliminated and to spread to areas where it had never previously been recorded.

 

Aedes aegypti was repeatedly introduced from areas where the vector was not controlled.

 

Dengue re-emerged in the 1960s and 1970s, initially affecting Jamaica, then Puerto Rico, other Caribbean islands,and Venezuela. Subsequently, dengue was reported from at least 43 countries in the region.

 

Over the past half century the disease has literally exploded in the Americas – often infecting millions of people each year.  The growth of Dengue around the world is well illustrated by the following graph from the World Health Organization.  

 

 

Since the 1950s a rare, but far more serious form of the disease – DHF or (Dengue Hemorrhagic Fever) –  has also emerged. The WHO now estimates there may be as many as 50 million dengue infections each year (Dengue and dengue haemorrhagic fever fact sheet).

 

In 2009, Honduras saw their worst dengue season in more than a decade, resulting in 12 deaths. The following year, 83 people died. While Dengue outbreaks tend to be cyclical, once again Honduras is facing a dengue epidemic, and yesterday declared a state of emergency.

 

 

Honduras declares state of emergency due to dengue fever

English.news.cn   2013-07-31 10:56:13

TEGUCIGALPA, July 30 (Xinhua) -- The Honduran government declared a state of emergency Tuesday due to the spread of dengue fever, which has killed 16 people this year and infected more than 12,000, local media reported.

 

Dengue has affected more than half of all the municipalities in Honduras. Out of the 12,135 reported cases, 1,839 are suspected to be of the fatal hemorrhagic variety, which can lead to shock and internal bleeding.

 

Minister of Health Salvador Pineda said five cities, including the capital of Tegucigalpa and its surrounding central district, had the largest number of Dengue cases.

 

Pineda declared a national priority to control mosquitoes and prevent them from transmitting dengue.

 

He said more than 4 million U.S. dollars were needed to control the nationwide epidemic effectively and that his ministry would seek coordinated efforts from other government institutions.

 

Honduras is no stranger to dengue outbreaks. In 2009, a dozen of people were killed by hemorrhagic dengue, with more than 66,700 people infected. In 2010, the disease killed 83 people.

 

 

In late June, PAHO issued the following epidemiological alert for the Americas on Dengue:

 

Epidemiological Alert:

Dengue

June 21, 2013

The Pan American Health Organization / World Health Organization (PAHO / WHO) ecommended to Member States that entered the rainy season where there greater transmission of dengue, such as Mexico and those in Central and Caribbean continue their preparedness and response efforts, based on the lessons learned and using the approach of Integrated Management Strategy (IMS) for the prevention and control, with emphasis on reducing deaths from this disease.

 

Current Situation

 

During the year 2013 and to epidemiological week (EW) 21, in the region of the Americas were 868 653 cases of dengue, 8,406 cases of severe dengue and 346 deaths (case fatality 1 0.04%). With the circulation of the 4 serotypes in the region, increases the risk of severe forms of dengue. The breakdown of the number of cases, cases serious, deaths and circulating serotypes are available on our website.

 

In the first half of 2013, outbreaks of dengue in Brazil, Costa Rica, Colombia, Paraguay and the Dominican Republic. In places like Peru, cases recorded in areas where there had been no indigenous cases of dengue before.

 

Given the usual behavior of dengue in the region, is expected to in the coming months to register an increase in cases in Central America, Mexico and the Caribbean, which coincides with the rainy season in these countries.

 

The purpose of this alert is to reiterate to member states that they will enter the period increased transmission of dengue, to continue their coordination efforts with other sectors 3, Based on the activities identified in the national and EGI-dengue in comprehensive plans outbreak response. They also recommended that the services fit health for a greater flow of patients as well as to strengthen and provide one upgrade to detect warning signs and clinical management of dengue cases health personnel.

 

The most recent numbers from PAHO on Dengue in the Americas for 2013 show well over 1.3 million cases in the first half of the year.

 

 

The World Health Organization’s Dengue and Severe Dengue Fact Sheet highlights the following points about the disease.

Key facts

• Dengue is a mosquito-borne viral infection.
• The infection causes flu-like illness, and occasionally develops into a potentially lethal complication called severe dengue.
• The global incidence of dengue has grown dramatically in recent decades.
• About half of the world's population is now at risk.
• Dengue is found in tropical and sub-tropical climates worldwide, mostly in urban and semi-urban areas.
• Severe dengue is a leading cause of serious illness and death among children in some Asian and Latin American countries.
• There is no specific treatment for dengue/ severe dengue, but early detection and access to proper medical care lowers fatality rates below 1%.
• Dengue prevention and control solely depends on effective vector control measures.

 

For an extensive list of my blogs on Dengue and Mosquito Borne Diseases you can select the DENGUE Quick Search here,  on my sidebar.

Dengue Update: Puerto Rico, Florida & The Americas

 

# 6702

 

While not reaching the levels we saw during their 2010 Dengue epidemic, Puerto Rico is once again seeing epidemic levels of the mosquito-borne virus, as evidenced by this latest chart from the CDC.  

 

As indicated by the red line, the number of cases over the past couple of weeks has been climbing like a homesick angel. 

 

Health Secretary Lorenzo Gonzalez of the Puerto Rico Health Department declared a Dengue epidemic on the island (PDF Link – in Spanish) in early October after six people died or the disease, two of them children.

 

This week, Florida also reported its third locally acquired Dengue case (see Another Central Florida dengue case confirmed) of 2012. This latest case was identified in Osceola County, and a fourth suspected case is being investigated.

 

While once a serious problem in Florida, through aggressive mosquito control efforts during the 1940s Dengue and Malaria were both eliminated from the Sunshine State – and remained so for nearly a half century.

 

In 2009 – for the first time in more than 50 years – we started to see a small number of locally acquired Dengue cases showing up in Key West (see MMWR: Dengue Fever In Key West), and in 2010 they totaled 65 cases in Key West and 1 each in Broward and Miami-Dade County.

 

The number of cases dropped in 2011, and have been low once again in 2012.

 

The concern is - with millions of visitors arriving each year, many from regions where these diseases are endemic – there are plenty of opportunities to re-introduce the virus.

 

The CDC’s MMWR in a report in May of 2010 on Locally Acquired Dengue in Key West, had this to say:

 

Cases of dengue in returning U.S. travelers have increased steadily during the past 20 years (8). Dengue is now the leading cause of acute febrile illness in U.S. travelers returning from the Caribbean, South America, and Asia (9).

 

Many of these travelers are still viremic upon return to the United States and potentially capable of introducing dengue virus into a community with competent mosquito vectors.

 

In truth, it may take many such introductions of Dengue or Malaria to an area before the right combination of weather, insect vectors, and ongoing transmission occur to enable it to get a foothold in a community.

 

But Florida’s latest Arbovirus Surveillance report lists more than 90 cases of Imported Dengue this year:

 

Ninety-four cases of dengue with onset in 2012 have been reported in individuals with travel history to a dengue endemic country in the two weeks prior to onset. Countries of origin were Brazil, Colombia, Cuba (21), Dominican Republic (9), Ecuador (4), El Salvador (2), Ghana, Guyana (2), Haiti (14), Honduras, India, Jamaica (17), Mexico (2), Nicaragua, Panama, Philippines, Puerto Rico (6), South Africa, Sri Lanka, St. Vincent, Suriname, Trinidad (4), and Turks & Caicos.

Counties reporting cases were Brevard (3), Broward (17), Collier, Duval (2), Hillsborough (4), Lee (2), Marion, Miami-Dade (36), Orange (12), Palm Beach (6), Pinellas (2), Polk, Sarasota (2), Seminole (3), and Volusia (2). Nine of the cases were reported in non-Florida residents.

 

The state has also reported more than 50 cases of Imported Malaria, although no locally acquired cases have been reported.

 

Fifty-three imported cases of malaria with onset in 2012 have been reported.  Countries of origin were: Afghanistan (2), Cameroon, Central African Republic, Colombia, Costa Rica, Ethiopia, Ghana (5), Guyana (2), Haiti (9), Honduras (3), India, Ivory Coast (3), Kenya, Liberia (2), Nigeria (8), Pakistan, Peru, Sierra Leone (2), South Africa, Sub Saharan Africa, Sudan, Togo, Uganda, Zambia, and multiple African countries (2).

Counties reporting cases were: Alachua, Brevard, Broward (8), Charlotte, Duval (6), Hillsborough (6), Lake (2), Leon, Manatee, Marion, Martin, Miami-Dade (7), Orange (5), Osceola (2), Palm Beach (4), Pinellas (3), Polk, Seminole, and Volusia. Five of the cases were reported in non-Florida residents.

 

A broader perspective comes from PAHO, who's Oct 31st update shows nearly 1 million cases of Dengue in the Americas this year.

 

An interactive map view of Dengue activity in the Americas, and around the world, can be seen via the CDC-Healthmap collaborative DengueMap.

 

 

Although the overall risk of contracting a mosquito-borne illness in Florida or Puerto Rico remains very small, reports of Dengue (along with West Nile, EEE, SLEV, and other rare arboviral threats) are reason enough that health departments continue to urge people to remember to follow the `5 D’s’:

 

Preparing For An Unwanted Arrival

 

 

 

# 6177

 

 

PAHO, the Pan American Health Organization, in partnership with the CDC, have put together a 161-page guide for preparing for the arrival of Chikungunya to the Americas.

 

Chikungunya is a mosquito borne alphavirus (similar to Australia’s Ross River Virus, and EEE), of East African origin, that typically produces a fever, severe muscle and joint pain, and headaches.

 

They symptoms usually go away after a few weeks, but some patients can retain permanent disability.

 

First described in the early 1950s in Tanganyika, it was only sporadically seen over the years in eastern and central Africa. That is, until 2005, when Chikungunya made a jump to the Indian Ocean island of Réunion.

 

In the seven years since that time, Chik has migrated to India, Indonesia, and much of south-east Asia.   It has even been imported into Italy.

 

I told the story several years ago in It's A Smaller World After All, but the short version is that a traveler, returning from India, brought the virus to Italy in 2007 which led to more than 290 cases reported in the province of Ravenna, which is in northeast Italy.

 

 

Many infectious disease specialists have expressed concerns that Florida – which has recently seen a return of Dengue fever after more than 5 decades – could one day face the establishment of chikungunya as well.

 

The two primary mosquito vectors of Chikungunya are the Aedes aegypti and Aedes albopictus, both of which can be found across many regions of the Americas.

 

Aedes albopictus (Asian Tiger) Mosquito

Dark blue: Native range
Dark green: introduced (as of December 2007)

 

 

Credit – PAHO

 

For more on all of this, excerpts from the press release from PAHO, and a link to the PDF.

 

PAHO, CDC publish guide on preparing for chikungunya virus Introduction in the Americas

 

The Pan American Health Organization/World Health Organization (PAHO/WHO), in collaboration with the U.S. Centers for Disease Control and Prevention (CDC), has published new guidelines on chikungunya, a mosquito-transmitted virus transmitted that causes fever and severe joint pain.  The Guidelines for Preparedness and Response for Chikungunya Virus Introduction in the Americas aims to help countries throughout the Americas improve their ability to detect the virus and be prepared to monitor, prevent, and control the disease, should it appear.

 

Hundreds of people who have traveled from the Americas to Asia and Africa in the past five years have become infected with the chikungunya virus. While the virus has not spread locally in the Western Hemisphere, experts say there is a clear risk of its introduction into local mosquito populations. Local transmission could occur if mosquito populations in the United States or elsewhere in the Americas became infected with the virus and began spreading it to people in that area.

(Continue . . . )

 

To download the guide, Preparedness and Response for Chikungunya Virus Introduction in the Americas select this link.

Dengue Roundup: Puerto Rico, Florida, Bahamas

 

 

# 5712

 

Aedes aegypti

 

This time last year Dengue fever was a big story in Puerto Rico, and to a lesser extent, also in South Florida and the Bahamas. 

 

• The worst epidemic in more than a decade had swept across the island of Puerto Rico, and at one point as many as  900 new cases were being reported each week (see Puerto Rico Dengue Week 31: Cases Back On The Ascendant).
• Florida, for the second year in a row, was reporting relatively small numbers of Dengue infections - (2010: a total of 63 locally-acquired cases in Key West, one in Broward County, and one in Miami-Dade County) – after more than six decades without a locally acquired case.
• And last September the Bahamas issued a public health advisory after a rise in Dengue cases and at least one death (see Dengue Reports From The Bahamas).

 

 

Outbreaks of Dengue fever are often cyclical, and thus far in 2011 - for Florida, Puerto Rico, and the Bahamas - reports of Dengue fever have been far lower than we saw last year.

 

The epidemic in Puerto Rico, which claimed 31 lives, finally burned itself out over the winter.  The chart below shows what a difference a year can make.

 

 

 

While fewer than 100 cases are being reported each week right now, it should be noted that the rainy season still lies ahead.  Precautions against mosquitoes are still important.

 

In Florida, only one locally acquired case of Dengue has been reported in 2011, likely due to the extended drought the state has been experiencing. That situation could change, of course, with the arrival of one good tropical storm.

 

For now, mosquito activity remains relatively low for this time of year (see report  Florida Arbovirus Surveillance :Week 28: July 10 – July 16, 2011) with only one county (Seminole) under a mosquito-borne illness advisory.

 

 

 

According to a recent report in The Bahamas Weekly, the Bahamas are once again seeing a rise in Dengue activity, with two laboratory confirmed cases in New Providence, and another eleven cases awaiting test results. 

 

DEHS ‘steps up’ source reduction in response to 2 cases of dengue

Jul 21, 2011 - 5:27:13 PM

 

 

Across the rest of South America, Central America, and the Caribbean dengue activity varies considerably, with more than 700,000 cases and 400 deaths reported in 2011.

 

The chart below is gleaned from the latest PAHO Dengue surveillance report.

 

 

 

 

The explosive growth of Dengue around the world is well illustrated by the following graph from the World Health Organization. . 

 

Since the 1950s a rare, but far more serious form of the disease – DHF or (Dengue Hemorrhagic Fever) –  has emerged.  

 

The WHO now estimates there may be as many as 50 million dengue infections each year (Dengue and dengue haemorrhagic fever fact sheet).

 

 

For an extensive list of my blogs on Dengue and Mosquito Borne Diseases you can select the DENGUE Quick Search here,  on my sidebar.

 

Despite the lower numbers of dengue cases this year, the threat of mosquito borne illnesses (which may include Dengue, EEE, St. Louis Encephalitis, West Nile Virus, and others) remains.

 

So if you live in mosquito territory, it pays to be mindful of the 5 D’s.

 

The `Other Reason’ For Traveler’s Vaccinations

 

 

# 5292

 

 

Most travelers think of vaccinations as being important protection for the recipient, particularly when visiting regions where rare, or exotic diseases (like Yellow Fever or Meningococcal Meningitis) might be encountered.

 

But as a statement by PAHO reminds us, routine vaccinations against common communicable diseases (ie. polio, rubella, measles, pertussis) are needed to protect the people who live in the countries where western travelers visit.

 

And today, nowhere is that more important than on the fragile earthquake and cholera ravaged island of Haiti, where the last thing they need is another imported disease threat to deal with.

 

 

 

PAHO/WHO Urges Travelers to Get Vaccinated Before Entering Haiti

 

Immunization is needed to ensure that infectious diseases are not imported into Haiti

Washington, DC, February 4, 2011 (PAHO/WHO) – The Pan American Health Organization/World Health Organization (PAHO/WHO) is urging all international travelers to Haiti to get up-to-date on their vaccines, to ensure they do not unknowingly import infectious diseases into Haiti.

 

The recommendation follows recent epidemiological investigations of two disease outbreaks in Haiti, one involving suspected polio and the other, suspected measles. The investigations were carried out by Haiti’s Ministry of Health with support from PAHO/WHO and the U.S. Centers for Disease Control and Prevention (CDC).

 

The first investigation concerned four cases of paralysis in cholera patients in the coastal city of Port-de-Paix. Laboratory tests have ruled out polio as the cause of the illnesses. However, as a precaution, polio vaccine is now being included in vaccination campaigns against diphtheria and measles in the area. No cases of indigenous wild polio have been reported in Haiti since polio was declared eradicated from throughout the Americas in 1994.

 

The second investigation involved a case of measles in the 8-month-old child of a U.S. volunteer who traveled from her home in Pennsylvania to Haiti in late December. The baby developed measles after returning to the United States on Jan. 7, followed by two siblings who also developed the disease. Four of the family’s six children were unvaccinated.

 

<SNIP>

Infectious diseases including measles and polio can be carried and transmitted even by individuals who do not have symptoms themselves. Because of the risk of importing disease, PAHO strongly recommends that all individuals planning to go to Haiti make sure they have been vaccinated against measles, rubella, polio and other vaccine-preventable.

Update: Dengue In Puerto Rico

 

 

 

# 5138

 

 

Since I featured Vincent Racaniello’s TWiV podcast on Florida’s dengue control efforts earlier this morning, it seems an opportune time for an update on Puerto Rico’s ongoing dengue epidemic, now in its 10th month.

 

The (very) good news is, that for the 10th week in a row, the number of new cases of dengue being reported by the CDC has dropped dramatically, although the rate remains somewhat above the epidemic threshold.

 

 

 

PAHO has also released new numbers on dengue in the Americas for 2010, in this pdf file, dated December 10th.    So far, more than 1.5 million cases have been reported (many more are likely undiagnosed).

 

 

None of this should dissuade you from making that long anticipated trip to Florida or the Caribbean, of course. The odds of acquiring a mosquito-borne disease while visiting these locales remain quite small, and diminish even further over the winter.

 

 

Particularly if you follow the advice of health departments who continue to urge people to follow the `5 D’s’:

 

 

 

 

For an extensive list of my blogs on Dengue and Mosquito Borne Diseases you can select the DENGUE Quick Search here,  on my sidebar.

PAHO Press Conference Today On Haiti

 

 

 

# 5007

 

 

A head’s up for later today.  PAHO - the Pan American Health Organization – will hold a press conference this afternoon at 2pm (EDT) today in Washington to talk about the Cholera outbreak in Haiti.

This press conference will be offered in English & Spanish, and will be aired online.

 

The details from the PAHO website follow:

Cholera Outbreak in Haiti: PAHO Press Briefing Monday, October 25, at 2:00 p.m.

WHAT: Briefing on cholera outbreak in Haiti by Dr. Jon K. Andrus, Pan American Health Organization (PAHO).

WHEN: Monday, October 25, 2010 at 2:00 p.m. (14:00 HS Washington, DC Time).

WHERE: Room B, PAHO HQ, 525 23rd St. NW, Washington, DC (Corner 23rd St. & Virginia Ave)

WHO: Dr. Jon K. Andrus, Deputy Director of PAHO.

HOW: Briefing will be in person, webcast, livestream, phone-in, and Elluminate, and you can send your questions by email.

WEBCAST: www.paho.org/webcast (you can choose English or Spanish)

LIVESTREAM: http://www.livestream.com/paho

TELEPHONE: + 1 202 974 3075
Code for English: 2222
Code for Spanish: 1111

ELLUMINATE: Room in English: http://new.paho.org/pressconference
                    Room in Spanish:  http://new.paho.org/ruedadeprensa

QUESTIONS BY EMAIL: During this press conference, questions can be sent to Sonia Mey-SchmidtThis e-mail address is being protected from spam bots, you need JavaScript enabled to view it .

 

Dengue: Puerto Rico & Beyond - Week 33

 

 

# 4892

 

 

The latest report from the CDC indicates a slight leveling off – at least in the last reporting week – of the number of new cases of suspected Dengue on the island of Puerto Rico, albeit at a level far exceeding the epidemic threshold.

 

The number of confirmed fatalities has reached 20, exceeding the 19 known deaths from the last big Dengue epidemic on the island in 1998.

 

Another 14 deaths are being investigated.

 

According to local media reports, Chief Epidemiologist Carmen de la Seda has blamed “unprecedented rains” over the past few months for the rise in Dengue cases, but rejected the idea that the epidemic is out of control.

 

Better surveillance, and analysis from the CDC, she suggested, may be turning up cases that in past years might have been missed.

 

The Health Department has acquired 10 new mosquito fogging machines which they are lending out to municipalities unable to afford their own.

 

Meanwhile an extensive educational campaign is underway to get the residents to destroy mosquito breeding habitats and to take measures to protect themselves against mosquito bites.

 

 

The problem isn’t restricted to Puerto Rico, of course.

 

Many regions of South and Central America, and the Caribbean are dealing with dengue outbreaks that are often more severe than what is currently being reported in Puerto Rico.

 

PAHO issued an Epidemiological Alert: Update on Dengue Outbreaks in the Americas (8 September 2010), stating:

During the first semester of 2010, the epidemiological situation of dengue in the Region has displayed unstable behavior, with intense outbreaks of dengue in various countries of the Region. The climatological conditions have remained favorable for the proliferation of the Aedes aegypti mosquito – its transmitting agent – while certain unusual alterations have been observed in its seasonality, where, since the beginning of the year, Central American countries and Caribbean islands have been affected during periods that are considered unusual.

 

 

 

 

 

In June of this year, a CDC report (see MMWR: Travel Associated Dengue Surveillance 2006-2008) stated:

 

`Clinically recognized cases of travel-associated dengue likely underestimate the risk for importation because many dengue infections are asymptomatic or mildly symptomatic’.

 

Dengue’s spread has increased dramatically over the past 50 years, and since the 1950s a rare, but far more serious form of the disease – DHF or (Dengue Hemorrhagic Fever) –  has emerged.

 

 

 

None of this should dissuade you from making that long anticipated trip to South America, Florida or the Caribbean, of course. The odds of acquiring a mosquito-borne disease while visiting these locales are actually quite small.

 

But when millions of people make that trek, invariably some small number of tourists may become infected.

 

And if they return home to a region where the Aedes aegypti or the Aedes Albopictus mosquito (both Dengue vectors) are found, they have at least the potential to introduce the virus to a new area.

 

Which is probably how Dengue ended up returning to south Florida after an absence of more than 60 years (see Update On The Florida Dengue Cases).

 

Those who travel to or live in areas where mosquitoes are present are reminded that to protect yourself from mosquitoes, follow the `5 D’s’: