Dengue fever: a worldwide crisis Used with permission from Microsoft Good day, my name is Abigail Jeffers and today I will be giving a presentation about the negative impacts of Dengue Fever in the world but most specifically in countries plagued by low socioeconomic status . I am honored to have the opportunity to share this information with you and upon completion, I hope that you will have a clear understanding of the detrimental effects of dengue fever in an endeavor to implement measures to control this problem. It impacts our every day life. Abigail Jeffers MPH Student Walden University PUBH 6165-4 Environmental Health Dr. Robert P. Marino Winter Quarter 2010

agenda Expected learning outcome Understand cost to society Recognize impact on health Develop effective control Describe infection routes Audience WHO CDC Government General population Purpose of presentation I will first start by giving a brief synopsis of what the expected learning outcomes are, the target audience, and the purpose of this presentation. Upon completion of my presentation, I expect you to have a better understanding of the impact of dengue fever on a population, understand the routes of infection, recognize its economic strain on society and develop effective control methods needed to remedy this problem. This presentation is being delivered to appeal to audience that can effect positive change for underdeveloped countries that are combating the dengue fever disease for years. Audience include the World Health Organization (WHO), Center for Disease Control and Prevention, Government officials of affected countries and the general population worldwide. The purpose of this presentation is to raise awareness about the ongoing problem of dengue fever in order to design more effective control techniques that would eliminate the vectors and thus eradicate this disease. Used with permission from Microsoft

What is it? Mosquito-borne viral disease DENV-1 DENV-2 DENV-3 DENV-4 Endemic to Tropical regions No cure DHF Used with permission from Microsoft Now, we always hear about dengue fever outbreaks around the world but do we really understand what it is? Dengue fever, which is also referred to as break bone fever has been around for the past 50 years but was first referred to in 1779. It is the most important viral disease known today that does not have a cure or vaccine. It is endemic mostly to tropical regions such and South America and the Caribbean islands due to the abundance of rainfall and perfect weather that is conducive to mosquito breeding, development and feeding. There are four virus serotypes that cause infection. Usually, an infection with one serotype gives lifelong immunity to that particular serotype but only short-term immunity to the others. The four serotypes are DENV-1, DENV-2, DENV-3 and DENV-4. These four serotypes originated in monkeys and made their way to humans by way of mosquitoes. A fatal form of dengue fever is known as dengue hemorrhagic fever (DHF), which is responsible for reported deaths mostly in children (CDC, 2010). Center for Disease Control and Prevention. (2010). Epidemiology. Retrieved from http://www.cdc.gov/dengue/epidemiology/index.html

Cause of dengue fever Bite from infected Aedes aegypti mosquito Stagnant water Poor surveillance Poor Control Poorly constructed homes Solid waste disposal In order to understand what dengue fever is, its etiology has to be known and understood. Dengue fever is caused by the dengue virus which is transmitted through the bite from an infected Aedes aegypti mosquito and rarely Aedes albopictus mosquito. Factors that encourage the prevalence of this disease and its vectors are the presence of stagnant water, which may have collected in trash receptacles from heavy rainfall, improper use or lack of control measures such as mosquito nets and bug repellent sprays, and lack of a proper surveillance system. Poorly constructed houses also create easy access of mosquitoes into homes. Inadequate solid waste disposal services also increases the problem (WHO, 2009). Used with permission from CDC World Health Organization. (2009). Dengue and dengue hemorrhagic fever. Retrieved from http://www.who.int/mediacentre/factsheets/fs117/en/

Lifecycle of aedes aegypti Shown above, is a diagram of the lifecycle of the Aedes aegypti mosquito. Climatic variables such as temperature and precipitation influence the way the mosquito develops and whether or not it survives. An adult female Aedes Aegypti only requires one mating to fertilize a successful lifetime laying of eggs. Blood is their main food source that is required for proper egg development. Another pertinent factor to their development is an adequate water supply because most of their life cycle takes place in water, hence why the Tropical regions are ideal (Ugonabo & Valdovinos, 2008) . Used with permission from Hopp & Foley, 2001

Endemic regions According to the map, one can see that dengue fever is most endemic to South American territories such as Brazil and Venezuela. These territories account for the most recorded infection rates and mortality. Almost all of South America has been taken over by dengue. Although this disease may not be endemic to certain regions, especially the United States, it is a serious public health problem that affects populations worldwide through aspects of migration and international travelling. Used with permission from World Health Organization. (2009). Dengue and dengue hemorrhagic fever. Retrieved from http://www.who.int/mediacentre/factsheets/fs117/en/

Symptoms treatment Fever 105ºF Rash Headache Backache Petechiae Ecchymoses Supported care Acetaminophen Rehydration Blood pressure control Transfusions Infections from dengue fever varies depending on the individual. Infections can range from asymptomatic to life threatening. Time between exposure to onset of disease usually ranges from 4-10 days. Symptoms of dengue fever include a high fever up to 105ºF, a rash over most of the body, severe headaches and backaches, ecchymoses and petechiae. DHF usually causes hemorrhage in the body which may appear as tiny spots on the skin (petechiae) or large patches of pooled blood under the skin (ecchymoses). Since Dengue fever has no cure or vaccine, methods to control the symptoms are used to prevent death of the patient. Treatment options, in the form of supported care, include fever reducers such as acetaminophen, rehydration via intravenous fluids or oral rehydration, and control of blood pressure. For patients who experience petechiae and ecchymoses, transfusion of blood and fresh frozen plasma is an effective method to replenish volume (Gurugama, 2010). Used with permission from Microsoft Used with permission from Microsoft Gurugama, P., Garg, P., Perera, J., Wijewickrama, A. & Seneviratne, S.L. (2010). Dengue Viral Infections. Indian J Dermatol, 55(1):68-78. DOI: 10.4103/0019-5154.60357

prevalence 100 million cases per year Prevalence of dengue fever is high. There are 100 million cases per year (CDC, 2010). The disease is endemic in populations of tropical climate such as Africa, the Americas, the Eastern Mediterranean, South-east Asia and the Western Pacific; however, this disease has made its way around the world via international travelers and immigrants. Each year, the number of reported cases of dengue fever are increasing and the virus is spreading to new areas causing outbreaks. The prevalence of this disease will keep growing until proper measures are implemented to eradicate the vectors (CDC, 2009). Used with permission from Microsoft Center for Disease Control and Prevention. (2009). Dengue Fact Sheet. Retrieved from http://www.cdc.gov/dengue/faqFacts/fact.html

incidence 2.5 billion people 2/5 of the world's population 500,000 DHF cases 120 million travellers Incidence is variable and depends on geographical region; however, incidence of dengue has grown dramatically around the world. 2.5 billion people, two fifths of the world's population, are now at risk from dengue. Incidence measures the rate of occurrence of new cases of a disease or condition. New cases of dengue fever are seen everyday. Today, everyone is at risk of contracting dengue fever because the viruses are spreading to new regions everyday. 120 million people travel to endemic areas for business and pleasure and each year over 500,000 dengue hemorrhagic fever cases are seen (WHO, 2011). Used with permission from Microsoft World Health Organization. (2011). Dengue/dengue hemorrhagic fever. Retrieved from http://www.who.int/csr/disease/dengue/en/

morbidity Children Elderly The morbidity rate of dengue fever increase from year to year because of travelers going to and from endemic areas and transporting the viruses to various regions. Children younger than 15 years old comprise 90% of dengue fever cases. The elderly are the second most vulnerable. Children are most vulnerable because of their underdeveloped immune systems. Morbidity rates are also highest in months ranging from May to October, which is the rainy season when the climate is favorable for mosquito breeding which is also the time that most tourists travel (Schwartz et al., 2008). Used with permission from Microsoft Schwartz, E., Weld, L.H., Wilder-Smith, A., von Sonnenburg, F., Keystone, J.S., Kain, K.C., Torresi, J. & Freedman, D.O. (2008). Seasonality, annual trends, and characteristics of dengue in ill returned travelers, 1997–2006. Emerging Infectious Diseases, 14(7):1081-1088. DOI: 10.3201/eid1407.071412

mortality 2.5% of children >20% w/o proper treatment 22,000 deaths per year Without proper supportive care, dengue fever can be a fatal disease especially for children. Greater than 20% of the population dies from dengue fever due to lack of proper treatment. Approximately 2.5% of children infected with dengue fever dies. Without proper treatment, fatality rates can exceed 22,000 deaths per year globally.(CDC, 2010). Image shows the gut of a mosquito filled with blood during feeding. Used with permission from CDC Center for Disease Control and Prevention. (2010). Epidemiology. Retrieved from http://www.cdc.gov/dengue/epidemiology/index.html

Used with permission from Google images outbreaks 2007 Venezuela 2007 Puerto Rico 2008 Brazil 2009 Cape Verde 2010 The Americas Used with permission from Google images Numerous individuals are usually infected with dengue fever during the same period of time. There are many documented dengue fever outbreaks around the world. For example, in 2009, there were 21000 reported cases and 6 deaths in Cape Verde. In 2007, Venezuela reported 80,000 cases and Puerto Rico reported greater than 10,000 cases in that same year. In 2008, Brazil experienced a dengue fever epidemic where 35,902 persons were infected and 48 died. In 2010, there was a total of 1,432,410 dengue cases out of which 30,820 cases were reported as severe dengue hemorrhagic fever in the Americas. These cases were compiled from Brazil, Colombia, Costa Rica, Dominican Republic, El Salvador, French Guiana, Guadeloupe, Guatemala, Honduras, Martinique, Mexico, Nicaragua, Puerto Rico, and Venezuela (Ribeiro, 2009). Ribeiro, P. (2009). 2008 Dengue fever outbreak in Rio de Janeiro . Retrieved from http://gobrazil.about.com/od/denguefeverinbrazil/a/denguerio.htm

Cost to society Funds availability Decreases GDP Economic strain $1.8 billion annually Loss of income Used with permission from Microsoft Dengue fever and dengue hemorrhagic fever has a great economic impact of the same magnitude as malaria and other infectious diseases (Gubler, 2006). It decreases GDP since many societies do not have available funds or enough funds to fight the disease. Funds need to be channeled more into eradicating the vectors which may be less expensive than paying for treatment options. “Dengue imposes substantial costs on both the health sector and the overall economy”. In 2005, the Americas spent over $1.8 billion is spent annually to treat this disease. (Suaya et al., 2009). Likewise, in the past ten years, Puerto Rico has estimated spending $250 million to fight and treat dengue fever (CDC, 2009). Income is also lost as a result of family members missing work days to stay home to take care of sick loved ones. Center for Disease Control and Prevention. (2009). Dengue Fact Sheet. Retrieved from http://www.cdc.gov/dengue/faqFacts/fact.html Gubler, D.J. (2006). Dengue/dengue hemorrhagic fever: history and current status. U.S. National Library of Medicine, 277:3-16. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17319151 Suaya, J.A., Shepard, D.S., Siqueira, J.B., Martelli, C.T., Lum, L.C., Tan, L.H., Kongsin ,S., Jiamton, S,. Garrido, F., Montoya ,R., Armien, B., Huy, R., Castillo, L., Caram, M., Sah, B.K., Sughayyar ,R., Tyo, KR. & Halstead, S.B. (2009). Cost of dengue cases in eight countries in the Americas and Asia: a prospective study. American Journal of Tropical Medicine Hygiene, 80(5):846-855. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19407136

Prevention and control Eradicating the mosquitoes Eliminating stagnant water Use of mosquito pesticide Testing of blood products For many years, research has been done to try to develop a vaccine for dengue fever; however, due to increased population growth and urbanization, it is difficult. There is no cure for dengue fever. Proper prevention and control methods need to be implemented in order to reduce and ultimately eliminate dengue fever problems. In order to interrupt the transmission cycle, vector control is important. It has also been noticed that the dengue virus can be transmitted via blood donations. Biomedical organizations such as the American Red Cross ensures the testing of all blood products for dengue virus. Eliminating or significantly reducing the Aedes aegypti mosquito would be one of the main methods of controlling and ultimately eradicating this disease (Gurugama, 2010). Used with permission from Microsoft Gurugama, P., Garg, P., Perera, J., Wijewickrama, A. & Seneviratne, S.L. (2010). Dengue Viral Infections. Indian J Dermatol, 55(1):68-78. DOI: 10.4103/0019-5154.60357

challenges Community involvement Physicians knowledge Increased air travel Urbanization There are many challenges that are encountered on the path to eradicating dengue fever. Some of these challenges include increase incidence around the world due to increased urbanization and more frequent air travel. The disease is poorly understood by physicians and the community is not fully involved in prevention and control programs. Improved surveillance programs need to be developed globally as well as more effective community-based prevention programs (CDC, 2009). Government officials, public health officials and the community all need to work together to implement effective methods that would eliminate dengue virus and save millions of lives. Used with permission from Microsoft Center for Disease Control and Prevention. (2009). Dengue Fact Sheet. Retrieved from http://www.cdc.gov/dengue/faqFacts/fact.html

references Center for Disease Control and Prevention. (2009). Dengue Fact Sheet. Retrieved from http://www.cdc.gov/dengue/faqFacts/fact.html Center for Disease Control and Prevention. (2010). Epidemiology. Retrieved from http://www.cdc.gov/dengue/epidemiology/index.html Gubler, D.J. (2006). Dengue/dengue hemorrhagic fever: history and current status. U.S. National Library of Medicine, 277:3-16. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17319151 Gurugama, P., Garg, P., Perera, J., Wijewickrama, A. & Seneviratne, S.L. (2010). Dengue Viral Infections. Indian J Dermatol, 55(1):68-78. DOI: 10.4103/0019-5154.60357 Ribeiro, P. (2009). 2008 Dengue fever outbreak in Rio de Janeiro . Retrieved from http://gobrazil.about.com/od/denguefeverinbrazil/a/denguerio.htm Suaya, J.A., Shepard, D.S., Siqueira, J.B., Martelli, C.T., Lum, L.C., Tan, L.H., Kongsin ,S., Jiamton, S,. Garrido, F., Montoya ,R., Armien, B., Huy, R., Castillo, L., Caram, M., Sah, B.K., Sughayyar ,R., Tyo, KR. & Halstead, S.B. (2009). Cost of dengue cases in eight countries in the Americas and Asia: a prospective study. American Journal of Tropical Medicine Hygiene, 80(5):846-855. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19407136

References Schwartz, E., Weld, L.H., Wilder-Smith, A., von Sonnenburg, F., Keystone, J.S., Kain, K.C., Torresi, J. & Freedman, D.O.(2008). Seasonality, annual trends, and characteristics of dengue in ill returned travelers, 1997–2006. Emerging Infectious Diseases, 14(7):1081-1088. DOI: 10.3201/eid1407.071412 Ugonabo, N., & Valdovinos, C. (2008). Assessing the impact of treatment of septic tanks with expanded polystyrene beads on Aedes aegypti larval and adult mosquito emergence. Retrieved from http://www.stanford.edu/group/parasites/ParaSites2008/Nkem_Cr istina%20Valdoinos/ugonabon_valdovinosc_dengueproposal.htm World Health Organization. (2009). Dengue and dengue hemorrhagic fever. Retrieved from http://www.who.int/mediacentre/factsheets/fs117/en/ World Health Organization. (2011). Dengue/dengue hemorrhagic fever. Retrieved from http://www.who.int/csr/disease/dengue/en/

supplemental reading Ballenger-Browning, K.K. & Elder, J.P. (2009). Multi-modal Aedes aegypti mosquito reduction interventions and dengue fever prevention. Tropical Medicine and International Health, 14(12):1542-1551. doi:10.1111/j.1365-3156.2009.02396.x. Use the Walden Library Academic Search Premier database, and search using the article’s Accession Number: 2010496140 National Institute of Allergy and Infectious Diseases. (2009). Dengue Fever. http://www.niaid.nih.gov/TOPICS/DENGUEFEVER/RESEARCH/ Pages/Default.aspx

I sincerely appreciate the time that you have devoted to my presentation. If you have any questions, I will be happy to answer them. Thank you!!! Used with permission from Microsoft