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
 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
 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)
 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
Transmission of dengue virus
by Aedes aegypti

Mosquito feeds / Mosquito refeeds /

acquires virus transmits virus

Extrinsic
incubation Intrinsic
period incubation
Viremia period Viremia
0 5 8 12 16 20 24 28

Illness Days Illness

Human #1 Human #2
 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

World distribution of dengue 2006

Areas infested with Aedes aegypti

Areas with Ae. aegypti and recent dengue epidemics
 Dengue/DHF cases reported to the
World Health Organization
1955-2005*
1000000

800000

Ave. 600000
annual
no.
cases400000

200000

0
1955- 1960- 1970- 1980- 1990- 2000-
1959 1969 1979 1989 1999 2005
* Source: WHO, Sep. 2006
 Dengue in the Americas
1980 – 2006*
1,000,000

800,000

600,000
Cases

400,000

200,000

0
1980 1985 1990 1995 2000 2005

Year

* Source: PAHO (Jan. 19, 2007)

 Dengue hemorrhagic fever
in the Americas
1980 – 2006*
20,000
18,000
16,000
C 14,000
a 12,000
s 10,000
e 8,000
s 6,000
4,000
2,000
0
*
1980 1985 1990 1995 2000 2005

Year
* Source: PAHO (Jan. 19, 2007)
 Why has dengue emerged
in 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
 Emergence of dengue
Socio-economic factors
Billion Population increase
 Unprecedented
6
population
increase 5

4
 Uncontrolled and 3
unplanned
2
urbanization
1

 Inadequate
1830 1930 2000
environmental
conditions
 Reinfestation of the
Americas by Aedes aegypti*
1930s 1970 2006

* Source: CDC/PAHO
 Emergence of dengue
Uncontrolled 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.

Urban and rural populations
in Latin America
 Emergence of dengue
Inadequate environmental conditions*
 Insufficient  Insufficient and
collection of inadequate water
disposable service
containers  Increased number of
 Non-biodegradable “pilas” and water
containers storage containers
 Discarded tires  Inadequate water and
sewer conditions

* Increase in production sites

Production sites for Aedes aegypti

Buckets and pails

Production sites for Aedes aegypti

Water storage tanks

Production sites for Aedes aegypti

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

Years
 Why has dengue emerged
in 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
Aedes aegypti
 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
 Life cycle of Aedes aegypti

4. Adult

3. Pupae 1. Eggs

2. Larvae
 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
 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
 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
 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
 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
Ground ULV application
Ground ULV application
Aerial application in San Juan with C-130
Aerial application in San Juan with PAU-9
US Navy’s PAU-9 unit
Indoor application with thermal fog unit
Indoor application with portable ULV unit
 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
 Operation Uphold Democracy
Haiti- 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
 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.
 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
 DHF in Venezuela 1989-1990
 DVECC’s “equipo de expertos 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.
 de fumigación (Newspaper report)
MARACAY (Especial) – Uno de los
helicópteros
de la Fuerza Aérea, que participa en las operaciones
fumigación contra el dengue, aterrizó de emergencia
en el
estacionamiento del centro comercial “El Castaño”,
esta ciudad, resultando gravemente herido el piloto
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.
 After mission!

Venezuelan helicopter
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.
 “I love my choppers!”

“Private parking space” for AFPMB RLO

Silver Spring, Maryland
 u
b
s

CAPT Stanton E. Cope- “Dengue fighter”

 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
PSA
Walter Reed Army Medical Center

Washington, D.C.

My last interaction with an Army physician