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’:

 

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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.

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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.

 

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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.

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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.

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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 .

 

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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’:

 

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Global Flu Activity Update

 

# 4737

 

 

Since it is summer, as one might expect, influenza activity remains low in North America and most of Europe.  South of the equator and in tropical regions, however, flu-like illnesses are far more prevalent.

 

A couple of reports on the global flu trends this morning.  One from the World Health Organization and the other from PAHO.

 

While pandemic H1N1 continues to circulate - currently nowhere are we seeing alarming levels of influenza activity – although a number of countries are reporting rates of illness typical for this time of year.

 

The latest WHO update (week 26 – ending July 3rd) highlights the mixtures of laboratory typed flu strains from several reporting countries.  

 

As you can see, reports of seasonal H3N2’s demise last fall were premature. It continues to circulate in Mexico, Brazil, Argentina, South Africa, Australia, and parts of South East Asia.

 

(click to enlarge)

 

 

PAHO (Pan American Health Organization) meanwhile has their latest report on influenza activity in the Americas.

 

Regional Update, Pandemic (H1N1) 2009. (Published on July 19, 2010)

The information contained within this update is obtained from data provided by Ministries of Health of Member States and National Influenza Centers through reports sent to Pan American Health Organization (PAHO) or updates on their web pages.

To download the full report in PDF click here .

Weekly Update

• In South America, Colombia and Peru reported an increasing trend of acute respiratory disease.
• In Central America, El Salvador reported an increasing trend in acute respiratory disease.
• In the Caribbean, Dominica reported an increasing trend in acute respiratory disease.
• In North America, acute respiratory disease activity remained low.
• The respiratory viruses circulating in Central America and Caribbean are diverse, with different predominance of influenza viruses (H1N1 pandemic, seasonal influenza A H3N3 and influenza B) in each country.
• 2 new confirmed deaths in 2 countries were reported; in total there have been 8,525 cumulative confirmed deaths in 28 countries of the Region.

 

 

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PAHO Flu Report – Week 23

 

 

 

# 4666

 

With the arrival of summer north of the equator - and flu activity at or below normal levels for this time of year in most of Europe, Canada, and the United States - we increasingly direct our gaze southward to  monitor the progress of influenza.

 

PAHO (Pan American Health Organization) – which also serves as a regional office for the WHO – receives, collates, and distributes influenza surveillance data from member nations.  

 

Along with reports out of Australia, New Zealand, and South Africa we can get a pretty good idea of how the flu season is going south of the equator.

 

The WEEK 23 Regional Update from PAHO shows considerable variability in the level – and strains – of influenza circulating among member nations.

 

The highlights from this week’s report, plus a look at some of the maps and graphics.

 

Weekly Summary

• In North America, acute respiratory disease activity remained low.

•  The Caribbean countries reported decreasing or unchanged trends in acute respiratory disease.

• In Central America, Panama reported an unchanged trend in acute respiratory disease. 

•  In South America, Bolivia, Colombia, and Venezuela reported increasing trends of acute respiratory disease.

•  From EW 1 to 23, 2010,  El Salvador reported a predominance of influenza type B, while Cuba,
Jamaica, Mexico, and Panama reported predominately influenza type A.  Paraguay reported a predominance of respiratory syncytial virus.

• 23 new confirmed deaths in 3 countries were reported; in total there have been 8,450  cumulative confirmed deaths in 28 countries of the Region.

 

This first graphic shows the trends of respiratory infections (all types), with DARK BLUE indicating increasing reports.

 

 

While there are 47 members nations in PAHO, not all of them report every week.  Below (click to enlarge) you’ll find statistics from 8 nations showing a wide variance in flu-like illnesses detected.

 

 

In Paraguay RSV and Parainfluenza viruses dominate, in El Salvador Influenza B is the primary culprit, while in Mexico and Jamaica it is Influenza A that comes up most in laboratory testing.

 

Among Influenza A sampling, pandemic H1N1 remains the most common strain, although Jamaica and Panama both report fairly high rates of seasonal H1/H3  strains. 

 

Unfortunately the mix of H1 and H3 isn’t provided, nor is it completely clear whether non-subtyped A viruses are included in those numbers. 

 

Thus far, respiratory illnesses from reporting members of PAHO are having only a low to moderate impact on health care services.

 

 

Over the next few months we’ll keep an eye on these weekly reports, along with information from Australia and New Zealand, to track the southern hemisphere's flu
season.

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