SEPTEMBER 8-12, 2014 INOGATE PIPELINE QRA SEMINAR PIPELINE QRA SEMINAR 1.
Dengue Seminar September 2011
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Transcript of Dengue Seminar September 2011
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Epidemiology of Dengue in Sri Lanka: past, present and future
Hasitha Tissera MBBS, MSc, MDConsultant Epidemiologist
Ministry of Health Epidemiology Unit
Ministry of Health Sri Lanka
Dengue SeminarSeptember, 2011
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Outline
• Background
• Pre-endemic period
• Endemic period
• How we could change the epidemiology
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Dengue
• Most important mosquito borne viral infection in the world
• Very common infection in tropics • Large epidemics occur • Nearly 90% of infections in children• Wide spectrum of infection outcomes Asymptomatic infection → Death • High morbidity, relatively low mortality disease
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Transmission Modulating FactorsTransmission Modulating Factors
Vector Host (human) Virus
Dispersion
Density
Deposited eggs
Vector’s competency
Individual immnunity
Herd immnunity
Sequential Infections
Individual factors
Magnitude of the Epidemics (DF/DHF)
Serotypes
(Previous Circulation)
Genetic differences
Virulence
Probability of Transmission
Source: Prof. Maria Gloria Teixeira, London May 2008
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Dengue: Global burden Dengue ploriferates from 20th to 21st century with increasing burden, despite a lot of hard work on control and prevention
1960 2004
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Why Epidemiology ?
• To aid in setting health priorities
• To aid in setting research priorities
• To identify prospective health interventions
• To provide a comparable measure of output for interventions
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Pre-endemic History• Clinical dengue-like illness from beginning of 20th century
• Serologically confirmed in 1962
• First outbreak in 1965
• D1-D4 circulating since at least 1966
• 1965-68 had 51 cases and 15 deaths
• 1969 – 88’ multiple outbreaks of DF with occasional DHF
• Mostly from Western Province• School cohort study 1980-85’ (pre DHF): Dengue sero- prevalence 50% (7000, 5-7 year olds in Colombo MC)
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Endemic Period – 1989 onwards
• DHF became endemic in 1989*• 1989 – 203 hospitalized with 20 deaths (CFR 9.8%)• 1990 – sharp increase to 1300 cases and 54 deaths
(CFR 4%)• 1991- 95’ – multiple outbreaks • 1996 – became nationally notifable disease
*Source: Vitarana T, Jayakuru WS and Withane N, Ministry of Science Technology and Human Resources, 1993
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Temporal and Spatial Spread, 1996 - 2009
1996 2004 2005 2006 2009
N=1294 N=15463 N=5994 N=11980 N=35007
Reported Cases to National Epidemiological UnitReported Cases to National Epidemiological Unit
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Dengue Trends in Sri Lanka
2009 CFR – 0.99%2010 CFR – 0.71%2011 CFR - 0.71%
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2004 : 7 districts >100 2009 : 13 districts >100
Geographic Expansion 2004 - 2010
Incidence 80/100,000 Incidence 170/100,000
2010 : 21 districts >100
Incidence 170/100,000
2004 2009 2010
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6
197
318
181
73104 92
36 38 28 15 6 526
< 1 year 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 >60
Age group
0
100
200
300
400
Nu
mb
er
Dengue cases by age groups Sri Lanka - 1996 and 2006
38
209
352
261
339
513
366
257
189141
10958 38
64
< 1 year 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 >60
Age group
0
100
200
300
400
500
600
Num
ber
No. of cases analysed N= 2934
38
327
493
395
532
904
808
510425
318260
198127
218
< 1 year 1-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 >60
Age group
0
200
400
600
800
1000
Num
ber
No. of cases analysed N= 5553
Data as 22/01/2008
1996
No. of cases analysed N= 1125
Source: Epidemiology Unit Sri Lanka
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Overall Sero-prevalence among children < 12 – 52% study supported by PDVI
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Seasonality
• South-western monsoon peak: May – July • North-eastern monsoon peak: Oct - Jan
South-west monsoon North-east monsoon
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What we did to control & prevent
• Vector control through awareness – until 2004 • With epidemic shift in 2004:
- Active social mobilization- Aggressive vector control- Attempt improvement in clinical management
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Where are we today
• In general to date , the targeted health interventions largely not sustainable, less effective than expected. Why?
• A few model countries on effective surveillance (Brazil), Vector control (Singapore, Cuba) and effective clinical management (Thailand, Vietnam) exist, but are exceptions.
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WHY IS DENGUE SUCH A BIG PROBLEM TODAY?
• Global population growth
• Rural to urban migration
• Growth of cities• Deterioration of
cities
• Jet travel• Health services
poorly organized/ underfunded
• Lack of vector control professionals
Slide courtesy of Dr. Scott Halstead
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Which Perspective Do We Take?
SOCIETY
PATIENT
FAMILY
GOVERNMENT
ALL OTHER STAKE HOLDERS
SCIENCE
Slide courtesy of Dr. Ananda Amarasinghe
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National Plan: Outputs
1. Improved Case Management2. Strengthened Surveillance – disease,
laboratory, entomological3. Capacity building – at all levels infrastructure,
staff, equipment, 4. Strengthened control activities at National,
Provincial, District, & Divisional levels5. Enhanced intersectoral & community
participation for sustainable programme
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Dengue Epidemiology
• Primary Prevention:(A)Reduce disease transmission (interruption) –
solidifying evidence based vector control approach;
- improved entomological assistance - adult vector control
(B) Vaccine – preparation for vaccine introduction when become available (earliest 2015) – need to plan now
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Dengue Epidemiology…
• Secondary Prevention: (A)Early case detection – Iry care & pvt. sector
through improved diagnostics:- Full Blood Count - NS1 (cost implications)
(B) Improving Clinical Management - reducing disease severity- reducing case fatality
National Guidelines 2010
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1%
49%
37%
13%DF
DHF I & II
DHF III
DHF IV
Statistics LRH Ward 04 - 2009Statistics LRH Ward 04 - 2009
Source: Infection Control Unit LRH + Ward 04 records Slide courtesy of Dr. Padmakanthi Wijesuriya, Consultant Paediatrician LRH
DF
DHF I & II
DHF III
DHFIV
Total Dengue Patients : 333(Jan-Aug 2009)
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5,565
12,422
Source: Epidemiology Unit Data
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Dengue Situation by Month201120102009
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To bring down mortality…
Scott B. Halstead, M.D.
Providing Micro-haematocrit Machines to Hospitals
Setting up of National ‘Hotline’
Standardized teaching and training curricula at all levels
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Advocacy - Highest Level
• Health
•Local Govt.
• Environment
• Defense
• Education
• Media
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High - risk areas June - July 2011
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Major Breeding Habitats Urban Breeding Sites Rural Breeding Sites
Discarded containers – plastic cups, tins, cans, bottles.…
Discarded containers – coconut shells, clay pots, bottles ….
Water Storage –tanks, barrels, buckets Water storage – tanks, barrels, buckets
Used Tyres - domestic, workshops, depots
Used Tyres – domestic, workshops, depots
Roof Gutters - domestic, offices, high-rising building tops Roof Gutters – domestic, sun shades
Other – ornamental items, blocked drains, construction sites, natural breeding -ornamental plants, underprivileged communities, bare lands
Other – spare part yards, natural breeding sites -bamboo shoots, tree axills/holes, fallen tree leaves, plantations
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www.epid.gov.lk
Regular update on dengue situation
Thank You!