CONTENTS. 1 Executive Summary 2 2 Goals of the Dengue Component of the Mesoamerican Health Initiative 3. 5 Integration Theory of Change 3

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1 CONTENTS 1 Executive Summary 2 2 Goals of the Dengue Component of the Mesoamerican Health Initiative 3 3 Theory of Change Problem Target Population Vision Levers Outcomes 6 4 Literature-Based Evidence for Effective Practices Summary of Relevant Effective Practices (EP) Drawn from Literature Outcomes, Impacts, and Cost Effectiveness of Relevant Effective Practices (EP) Drawn from Literature Outcomes and Impacts Possible Solutions/ Effective Practices for Regional Implementation Packages of Effective Practices Implementation Process Sustainability 45 5 Integration Integration within Focus Area Integration within the Focus Areas Maternal, Child and Reproductive Health Group Vaccines Group Human and Systems Capacity Building Staff and Infrastructure Skills & Competencies Tools 46 6 Feasibility 46 7 Emerging Issues 47 8 Policy 47 9 Indicators for Monitoring and Evaluation 49 ANNEX 1. Theory of Change: Decreased Dengue Transmission in Mesoamerica 53 1

2 1. Executive Summary Dengue is a widespread health problem across the Mesoamerican region that is now extending into rural areas. Dengue control programs confront such problems as serious delays in disease detection and a lack of entomological data that anticipate the risk of transmission. Controlling dengue demands strengthened laboratory infrastructure and surveillance systems to prompt control interventions as soon as dengue infection is diagnosed. Human, technical and financial resources are insufficient to cope with the growing number of affected urban areas, vast numbers of breeding sites; high vector and human Current population densities; human movements and opportunities for transport. Control strategies must therefore focus on high risk areas. This proposal is built on evidence that dengue transmission responds to certain rules that make infection more likely in certain areas. Environmental parameters such as altitude, latitude, mean annual temperature and precipitation patterns, and population variables such as density, dispersal, socioeconomics and household characteristics all influence the likelihood of transmission. The proposal assumes that financial resources to control dengue fever will always be insufficient given the geographical expansion of the problem, the dispersion of breeding sites, vector densities in urban areas and cost for the diagnosis and control. The effective control depends on defining appropriate interventions for the different stages of the vector and establishing responsibility for implementation (individual, neighborhood, locality and municipal levels). These interventions must be organized by delivery complexity, and applied in a sequential manner: 1) elimination and control of productive breeding sites with community participation, 2) chemical control of productive breeding sites; and, 3) chemical control of adult stages by treatment with insecticides according to the resources are insufficient to cope with the growing number of affected areas, breeding sites and vector densities. transmission period. Intensified activities are carried out in the early transmission period so as to achieve the greatest impact. For implementation to be effective, several actions need to be taken to ensure adequate quality and delivery. These actions include: Stratification of target areas according to their epidemiological risks: identification of risks areas will be performed according to the history of dengue, concentration of cases, presence of severe dengue cases and population density. Definition of entomological risks: entomological indexes will be used to select high risk areas in major urban centers where stable and high vector densities have been identified. Entomological data should guide identification of the most productive breeding sites as the main targets for control. Breeding site productivity is determined by local conditions therefore appropriate control measures must be determined for each breeding site. Laboratory based surveillance: early detection of dengue cases is an essential component of the control strategy. Rapid diagnostic test should be available on a national and regional laboratory network to ensure opportune identification of transmission and launch control measures in the early stages of the epidemic. Early clustering of cases in high risk areas should be tackled intensively to decrease local transmission and dispersal into neighboring areas. Management of severe cases: the most appropriate intervention to prevent premature mortality from dengue infection is by strengthening clinical capabilities of health personnel to identify and treat severe dengue cases. Scaling-up interventions to achieve appropriate coverage: control strategies must be designed and 2

3 implemented on a local basis to guarantee the best coverage of risk areas. Scaling up control measures should be deployed in an logical and orderly manner: o Domestic hygiene promotion: physical control measures o Community participation interventions: environmental control o Elimination of disposable breeding sites (cleanup campaigns) o Control of breeding sites: application of chemical or biological agents o Insecticides spraying: focalized in areas where cases have been confirmed. o Emergency control: aerial spraying of insecticides in outbreak situations 2. Goals of the Dengue Component of the Mesoamerican Health Initiative Global Goal Based on regional, coordinated dengue surveillance and control we expect to effectively reduce dengue transmission and to prevent mortality in Mesoamerica. Achieving this goal will require increased capacity of national and regional systems for epidemiological and entomological surveillance, and implementation of effective dengue control programs in southern Mexico and Central America. Main Goals of the Dengue Component are: Capacity building for accurate and opportune labbased diagnosis and surveillance, and development of a regional network of laboratories for dengue. Epidemiological stratification and selective attack of high-risk zones within a regional plan of coordinated actions. Implementation of evidence-based programs with proven strategies to diminish the incidence of dengue by 50% in a five-year period. Opportune attention to outbreaks. Decrease the lethality of dengue hemorrhagic fever <1% through the effective clinical management of the hospitalized cases. Advocate for intersectoral dengue control programs (including Ministries of Health of Mesoamerica, and regional/local stakeholders) with an integrated control approach, emphasizing management of eco-bio-social determinants of vector abundance and disease transmission. 3. Theory of Change The theory of change to reduce dengue transmission is based on addressing the following questions: a) if we address these issues, barriers and problems, b) with these activities, c) our actions will result in these changes, d) which have the potential to impact these health indicators (Annex 1). 3.1 Problem Dengue is an urban health problem (expanding to rural areas) associated with poor infrastructure of public services (access to potable water, solid waste management, trash collection systems, an absence of recyclable and a consumer lifestyle). The inevitable urbanization of Mesoamerica and lack of urban planning, particularly in medium-sized cities in the next decade, will place dengue as a major health problem in the region. The trend of dengue fever in the region, and severe forms of infection Dengue Hemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS), is increasing. Biannual epidemics are associated with simultaneous circulation of all 4 DEN-virus serotypes and high density of the vector Aedes aegypti in urban areas. Past vector control interventions have not proven effective for several reasons: 3

4 o they are usually implemented late in the transmission period; o have low coverage of at-risk urban areas with a diverse array of breeding sites; o are not implemented as an integrated strategy o are based on insecticide spraying in emergency situations. The capacity for laboratory-based diagnosis is very limited and impedes early detection of cases. Management of severe cases is not standardized and emergency plans for control are not implemented when required. Poor integration of actions dilutes the effect of interventions. 3.2 Target Population The target populations are inhabitants of all urban localities where dengue transmission is concentrated-- localities with a history of dengue and severe dengue. Although human and disease dispersion may encompass a wide range of localities including rural communities, this plan will focus and will be intensified on populations at highest risk. High-risk localities are those that have had cases in the past 5 years, have concentrated >50 % of the cases, historic reports of hemorrhagic dengue cases and demographically important as social, commercial, tourist or industrial axes in the region. Within these urban areas surveillance and control activities will be emphasized in neighborhoods with limited urban infrastructure and conditions conducive to high vector densities and disease. A key element of stratification is the identification of persistent localities whose important networks make them high-risk nodes. In addition, there are other receptive localities where transmission is contingent on the intensity of transmission in those areas of greatest risk. This network of high-risk localities goes beyond political borders and is concentrated in the urban poles of high industrial, agricultural, commercial and tourist development. The strategy envisages focusing on areas with active transmission and houses where cases occur in order to limit mosquito densities by affecting the breeding, emergence, survivorship of infected females and prevent vector-human contact. 3.3 Vision If we strengthen epidemiological surveillance systems, laboratory networks and vector control programs we will be able to detect dengue in high-risk areas in a timely manner and thereby improve control results. If we early detect high vector densities and emergent cases, we will be able to act promptly to control transmission and prevent the occurrence of severe cases of infection. If we detect cases early, opportune integrated and intensive actions focused on areas of transmission will avoid dispersal of infection. If we early detect cases we will be able to improve the medical care and reduce the risk of potential complications and mortality. This proposal in the medium term involves a progressive and sustained decrease in transmission through the timely detection of cases, particularly at the low transmission season, together with the intensive, integrated (targeted) measures that diminish transmission at high-risk localities, accompanied by less intensive interventions in towns of moderate to low risk. This plan incorporates training in appropriate management of hospitalized cases to prevent deaths from severe dengue. At the conclusion of activities it is expected to control transmission at high-risk areas reducing spillover to localities of moderate/low risk and contributing to regional control. The strengthening of local and national health services to improve their capabilities of epidemiological surveillance, diagnosis and severe case management and for timely, integrated deployment of anti-vectoral activities is essential for the development of this strategy. Vector control must sustain effective mobilization, organization and coordination of communities. Health services should be coordinated from the central level, but within each of 4

5 the departments and jurisdictions we must guarantee the provision of effective instruments for the collection, processing and analysis of epidemiological and entomological information supported by a network of diagnostic laboratories allowing the timely identification of transmission. The strategy relies on good management for monitoring the health problem, the vector control program and the adequate management of severe cases. 3.4 Levers Health Policies. The commitment for joint and coordinated actions to control of dengue fever in Mesoamerica has already been expressed by the Ministries of Health of the countries of the region. There are also substantive efforts by all countries in the region to review and adapt a strategy supported by the Pan-American of Health Organization (PAHO) for an Integrated Management Strategy (EGI) for the control of dengue fever in Mexico, Central America and the Dominican Republic. Program Models. While the current control strategy in most countries traditionally follows an operational dengue stratification in response to outbreaks (in areas of highest transmission), a conversion into preventive and focalized programs based on epidemiological, entomological and socio-demographic risk levels is critical to organize the scarce resources available and direct them to areas of higher risk. The strategy recovers issues identified by EGI-PAHO and incorporates the epidemiological stratification as the driving axis for actions. The criteria for stratification and identification of high-risk localities are: urban centers over 350,000 inhabitants, localities with repeated dengue cases in the last 5 years; 50 % cases in the period, a history of dengue hemorrhagic fever and the circulation of 2 DEN-virus serotypes. Moderate and low-risk areas are defined by the size of the locality, 100,000 to 350,000 and < 100,000 inhabitants, respectively. Organizational Leaders. The project requires the conjunction of a group of national experts with the technical and managerial capacity for the coordination of the operations of the plan. This technical group must have recognition and operational high-level support by the ministries of health to establish and coordinate activities with other parts of the Government and other institutions involved in the management of the initiative of control of dengue fever in Mesoamerica. The program also requires leaders in the different levels operating with technical and managerial capabilities. An international advisory group to coordinate activities and accompany the process of implementation and evaluation of the project will also exist. Community Leadership. Organization of communities emerges as a central issue for the control of dengue vectors since most of the actions are deployed at home and the available tools for effective vector control require their participation to ensure its efficacy, impact and success. It is also vital to identify civil organizations (ONG s) who are working within communities and that can support the program (environmentalists, recycling, education and health promoters, etc). A fundamental ingredient is to involve municipalities and partnerships with companies related to the program objectives. Technology. The plan must have a technological development program whose design and deployment should be accompanied by training and organizational development of the national health services and their local counterparts. Areas of technological development include: Modern and appropriate epidemiological and entomological surveillance tools, with the corresponding capacity for processing and analysis at all levels and online data capture systems. The introduction of modern and appropriate rapid tests to support local diagnostic laboratories with quality control schemes, timely processing of samples for decision-making and to provide feedback to the operational areas. 5

6 Strengthening of anti-vectorial capabilities, particularly for the introduction of new and effective strategies/tools for chemical (including new insecticides and equipment) and non-chemical control Incorporate new and sustainable eco-bio-social approaches to modify/manage determinants of vector abundance and disease transmission. i.e. recycling and social participation in the vector control strategies. Financial Resources. The availability of financial resources to effectively attack dengue fever in Mesoamerica will always be insufficient given the geographical expansion of the problem, the wide-range of breeding sites, the lack of adequate human resources (quantitatively and qualitatively) to control vector densities and the actual cost of diagnosis and control. National and local programs have historically made efforts to overcome the problem by non-lineal increases on the program s budget, always with financial constraints. The aggregated value of the strategy is that the epidemiological stratification proposes a more rational employment of available resources, and thereby programs are expected to be in a better position to operate. Nevertheless, it requires additional funding to strengthen epidemiological and entomological surveillance, laboratories and vector control equipment, human resources with technical, professional and managerial training and for the promotion and educational communication strategies. In addition, it is of paramount importance to establish the current economic contribution of local governments and the commitment to keep it, or even to increase it. These resources are essential to continue the maintenance (and sustainability) of activities at the conclusion of the activities financed by the plan. Regional Initiatives Integrated Management Strategy-PAHO (EGI-OPS) Mesoamerican Epidemiologic Surveillance System Conduct modification and Behavior Intervention (COMBI-OPS) Box 1. Active Dengue Control Early diagnosis of dengue transmission Targeting interventions to the high risk urban centers Integrate evidence-based effective interventions Opportune vector control interventions Achieve appropriate coverage of high risk areas and the most productive breeding sites Ensure delivery of high quality clinical care for severe cases Implementing monitoring and evaluation Strengthen human capabilities 3.5 Outcomes Principal Regional Goal: Accomplish a 50% decrease in the number of dengue cases and to maintain/decrease lethality <1% in the region. Midterm Results for 2015 National and regional surveillance systems within a laboratory network for early and accurate diagnosis for dengue infection. Control programs with effective strategies/tools based on the stratification of populations at risk according to epidemiological/entomological/socioeconomic parameters. Increased community participation schemes with better informed and committed populations addressing dengue control interventions. Better trained health personnel for diagnosis and treatment of severe cases. Health systems better prepared with emergency plans combined with effective and anticipatory control programs. 6

7 4. Literature-Based Evidence for Effective Practices A literature review was performed by the Mesoamerican group in order to identify and select the most appropriate interventions available to achieve the goal of effectively decreasing dengue transmission in the region. The evidence was collected from worldwide experiences (emphasizing on Latin-American experiences) and was organized in three main strategies or effective practices (Table 1): Improved surveillance and early detection of cases Efficacy of particular and/or integrated vector control interventions Management of severe dengue cases 4.1 Summary of Relevant Effective Practices (EP) Drawn from Literature Improved Surveillance and Early Detection of Cases Dengue control faces biological, social, and health s clinical picture ranges from an ample proportion of asymptomatic and febrile cases that are not reported nor identify. Dengue cases are usually misdiagnosed for other viral entities and underreported cases are also common. Risk perception of cases by the population is usually very low, the illness is mild or moderately severe that precludes them form demanding health care and sufferers usually turn to the automedication. If the disease deserves demanding health care, the provider has to confirm the clinical diagnosis with serology in order to report it as dengue. This situation has promoted the under report of dengue cases and therefore precise information of the magnitude of the burden of disease is difficult to collect. More importantly, passive surveillance leads to dengue detection when the outbreak is already out of reach of the control interventions. The objective is to detect dengue transmission in its early stages and diminish its intensity and disbursal to neighboring areas. In order to cope with these problems and adjust the surveillance schemes that most dengue control programs in the region work with, this proposal is based on the early detection of dengue cases supported by the active search and prompt laboratory diagnosis of infection. The search for cases must be performed in the pre and low transmission period (dry season) in order to tackle the first cases with intensive and integrated vector control actions. The main objective of this strategy is to detect transmission in the early stages in order to diminish its intensity of local dissemination and its force of dispersal to neighboring areas. Ative surveillance demands a tight coordination within the health services in order to identify febrile cases in primary health units that are supported by an efficient laboratory network for prompt diagnosis and speedy notification to vector control areas. The period of identification, clinical suspicion, laboratory diagnosis and notification to operational areas (surveillance and control) should be minimal since potential for transmission (dispersal) is at its peak during the febrile stage (1 to 5 days). Effective surveillance should lead to effective control of transmission in the peri-domestic setting of cases detected since focalized interventions must be installed in order to limit local transmission. Scarce resources compels interventions to concentrate the surveillance and control activities in the high risk areas where more population is at risk of infection, the burden of infection can be highest and where more intensive local social dynamics promotes its fast dispersal and dissemination to other areas. Regional evidence demonstrates that dengue cases historically concentrate in certain areas (urban areas) that can be identified as recurring sites where transmission occur. Dissemination to other areas depends on the intensity of local transmission in these high risk areas, therefore, the concentration of control ac- 7

8 tivities in these areas is expected to have a spillover effect over smaller urban areas (dependent localities) if control actions in those areas are also implemented with opportunity. Table A1. Entomological Surveillance Tools: Usefulness, Limitations and Impact Guidance Indexes Levels of Risk Detection Usefulness Problems Impact Measurement House Container Breteau Low No. Houses + No. Container + No. + Container per 100 houses Types of containers Risk of transmission is not related so as no information on productivity of breeding sites No information regarding type of control measures required to control or eliminate breeding sites Provides guidance of how interventions are working in terms of the prevalence of positive containers Ovitramps Medium Identifies gravid female mosquitoes Practical Requires less time to implement and measure No information on productivity Rapid assessment of adult female mosquito populations Pupal High Provides data on productivity of breeding sites and risk of transmission Low coverage Requires technical skills to identify pupae Good measure of impact of interventions House condition Medium high Provides data on general prevalence of breeding sites, simple to collect No data on productivity nor measures require to control or eliminate the most important breeding sites Good measure for long term risk of breeding Entomological Surveillance: Traditional tools for measuring vector densities have been used since the eradication campaign of yellow fever on the continent. Serious restrictions for their appropriateness for control have been put forward, especially regarding their suitability for measuring productivity of breeding sites and providing a good proxy for risk of transmission. New tools and indexes are now in place but either offer limited information on productivity or are labor intensive and require technical personnel to collect them. The proposal includes the integration of every entomological tool to describe the entomological risk situation in specific areas. Management of Severe Cases Entomological surveillance must identify risk areas in the urban centers where vector densities have been traditionally high or more difficult to control and where intensive interventions should be implemented 8

9 must be supported by good entomological information that guides early warning epidemiological and entomological interventions. While classical dengue is considered a benign disease, it is very incapacitating and requires symptomatic treatment of fever and general malaise; dengue infection can rapidly evolve into a life threatening disease that demands specialized medical care, strict clinical supervision, prompt fluid management that could vary according to the hemodynamic picture of each patient. Death is a common outcome in circumstances where good medical care is not accessible. Severe dengue cases must be detected on time in order to be hospitalized, monitored, treated orrectly and discharged once it is no longer life threatening. Since WHO case definitions of severe dengue have been poorly adopted in endemic countries there is a wide need to adopt the new classification proposed by WHO in search of simplification and efficacy in diagnosis and treatment. Medical personnel in emergency units, hospitals and health care centers must be trained for proper diagnosis and management of severe cases. Population should also be informed and advised of the warning signs that may trigger severe dengue in order to immediately search for medical care. Experience from Southeast Asia has demonstrated that good clinical training of health personnel and health promotion of the population can make the difference in preventing premature mortality. Efficacy of Particular and/or Integrated Vector Control Interventions Figures 1 and 2 summarize interventions based on environmental management and bio-rational control in Latin American countries. (For a more detailed description, see Table 1.) Environmental management searches for temporal or permanent modifications of the mosquito habitat to prevent or minimize vector propagation and human-vector-pathogen contact. Briefly, it includes: i) Environmental modification (long-lasting) i.e. reliable piped water supply; ii) Environmental manipulation (temporary) i.e. recycling, management of containers and iii) Changes to human habitation or behavior to reduce human vector contact i.e. installation of mosquito screening on doors and windows. Bio-rational control of Aedes aegypti includes i) biological control and ii) the employment of chemical substances with selective effect on mosquito larvae such as temephos, Bacillus thuringiensis israelensis, fishes, copepods and insect growth regulators. The most effective interventions (>80% change in the control vs. intervention group) based on environmental management were characterized by a) wide coverage with intersectorial participation (Sánchez et al., 2005; Tun-Lin et al., 2009) and/or b) targeted to the most productive breeding-sites (those producing more pupae and eventually more adults) with community participation (Romero-Vivas et al., 2002; Tun- Lin et al., 2009). Bio-rational control has reported a good efficacy, but the production and deployment of control agents such as Bacillus thuringiensis, fishes and copepods still have restricted progress in the region, but definitively further development is desired and should be encouraged. Temephos is widely used to treat Ae. aegypti larval habitats in containers that cannot be otherwise eliminated or managed, and in emergencies. Adulticides are either applied as residual surface treatments or as space treatments. Methods of chemical control that target adult vectors are intended to impact on mosquito densities and other transmission parameters, notably longevity. 9

10 Figure 1. Efficacy Based on Environmental Management Figure 1. Efficacy of interventions (on different entomological indices) based on environmental management in Latin-American countries. Efficacy = % change in the control group - % change in the intervention group; % Change = [(entomological indicator post-treatment pre-treatment)/entomological indicator pre-treatment] x 100. BI= Breteau index, CI= Container index, HI= House index, PPI= Pupae per person index, PUHI= Pupae House index. 10

11 Figure 2. Efficacy Based on Bio-Rational Control Figure 2. Efficacy of interventions (on different entomological indices) based on bio-rational control in Latin-American countries. Efficacy = % change in the control group - % change in the intervention group; % Change = [(entomological indicator post-treatment pre-treatment)/entomological indicator pre-treatment] x 100. CI= Container index, HI= House index. 11

12 Figure 3. Chemical Control with Larvicides and Adulticides 12

13 Figure 3 summarizes chemical control experiences with larvacides and adulticides and their reported efficacy in Latin American countries. Temephos is widely used to treat Ae. aegypti larval habitats in containers that cannot be otherwise eliminated or managed, and in emergencies. Adulticides are either applied as residual surface treatments or as space treatments. Methods of chemical control that target adult vectors are intended to impact on mosquito densities and other transmission parameters, notably longevity. Temephos-based interventions usually reach 100% of immediate efficacy after their application and last generally up to a month; however their residual effect decreases notably with time (<2 months) and it is associated with the renewal of water of the containers (Soares y Tadei, 2002; Palomino et al., 2006). Ultra low volume (ULV) spraying has reported inconsistent results, reaching ( 100%) in bioassays (Echevers et al. 1975; Uribe et al. 1984; CDC 1987; Perich et al. 2003; Arredondo-Jiménez y Rivero 2006; Arredondo- Jiménez y Arvizu 2007). However, their efficacy clearly decreases with field-based entomological indicators such as ovitrapping and adult female collections (CDC 1987; Perich et al. 1990; Manrique-Saide et al. 2007). Insecticide-treated materials (ITMs) represent a novel option for the delivery of adulticides (deployed as bed nets or curtains/mosquito nets on windows and doors), with recent evidence of reductions of dengue vector densities to levels that could potentially reduce dengue transmission risk. Research on the efficacy of ITMs in controlling Ae. aegypti and dengue should be encouraged. Integrated vector control (MIV) should be the strategic approach to dengue vector control to support human-environmental health (WHO, 2004). Defined as a rational decision-making process for the optimal use of resources for vector control, IVM considers five key elements in the management process: (i) advocacy, social mobilization and legislation; (ii) collaboration within the healt sector and with other sectors; (iii) integrated approach to disease control; (iv) evidencebased decision-making; and (v) capacity building. In selecting the most appropriate vector control method, or combination of methods, consideration should be given to the particular biology/ecology of the vector, resources available affecting the feasibility of application of interventions in a timely manner and the adequacy of coverage and the cultural context. Environmental management should be the foundation of dengue vector control. Nevertheless, chemical control of larvae and adults still are indispensable elements for dengue control programs that are impossible to discontinue until new strategies/tools become available, particularly for emergencies. Nevertheless, investing disproportionately in chemical control methods should be avoided when affordable, more sustainable environmental management solutions are available. 13

14 Table 1: Summary of relevant effective practices (EP) early diagnosis of cases, risk stratification and management of severe cases (Epidemiological surveillance) drawn from literature Name of EP or Package of EPs Description (Briefly describe the implementation process) Geographical Context urban/ rural, etc.) Target Population(s) indigenous, poor, other vulnerable) Scale of Implementation community, national, regional) Country(ies) where Implemented Selected Sources Case Detection Describe the presentation of clinical disease by age and points out the risk of under-registration in younger populations and children. The difficulties in meeting the criteria for DHF classified by WHO and the technical difficulties and need for resources for diagnosis in the clinical areas impacting on the sub-registry of hemorrhagic dengue in the region Describe the monitoring system with clinical epidemiological and entomological components and environmental indicators and output of thematic maps that allowed risk stratification, Describe the problem of dengue sub recording. Urban Urban Sub- Urban General Population General Population General Population Regional International Regional Americas Community Cuba Joseph R. Egger* and Paul G. Coleman, Age and Clinical Dengue Illness, Emerging Infectious Diseases 13, 6 José Rigau Pérez Definiciones de casos clínicos de dengue, dengue hemorrágico y síndrome de shock de dengue en Mejores prácticas para la prevención y el control del Dengue en las Américas, Febrero 2003, Environmental Health Project USAID,58-65 Álvarez Valdés A.; Díaz Pantoja C.; García Melian C., Piquero Valera M, 2007Sistema integrado de vigilancia para la prevención de dengue, Rev Cubana Med Trop. 5:9.3 Urban General Population Community Granada Panagos A, Lacy ER, Gubler DJ, Macpherson CNL. Dengue in Grenada. Rev Panam Salud Publica. 2005;17:

15 Reproductive, Dengue Master Maternal Plan and Neonatal Health Master Plan Name of EP or Package of EPs Diagnostics Clinical Management Description (Briefly describe the implementation process) Describe the diagnostic capacity of an ELISA 96% sensitivity and 95 specificity for IgG Describe the evidence for serotype dengue rapid d den 1 through nonstructural protein NS1. This protein was detectable from 1 to 18, with peaks of 6 to 10 days, sensitivity 82% and specificity of 99%. Present a management plan that integrates the monitoring dengue vector control and health promotion. The emphasis on early detection of cases of the formation of a rapid response team for intradomiciliar sprayed with pyrethroids. Concludes that the strategy to contain outbreaks affected areas in terms of duration of the epidemic and the number of cases. The selective spraying is the most appropriate intradomicilliary The implementation of primary health care concepts in the management of certain diseases improved the lethality (prioritization of diseases, the adaptation of treatment modalities, community financing, training workshops were conducted for health services in hospitals and operates the education of family patients, they were promoted hospitalization and cost effective therapies. There is 40% of reduction in overall mortality. In dengue decreased by 64%. Geographical Context urban/ rural, etc.) Target Population(s) indigenous, poor, other vulnerable) Scale of Implementation community, national, regional) Country(ies) where Implemented Laboratory General Population Community International Urban Probable cases of dengue Community China Urban General Population National Australia Urban Infants Hospital Vietnam Selected Sources P. H. Tio and P. Malasit, Antidengue IgG detection by an indirect ELISA, 1995 Southeast Asian J Trop Med Public Health.26: H. Xu, B. Di, Y. X. Pan, L. W. Qiu, Y. D. Wang, W. Hao, L. J. He, K. Y. Yuen and X. Y. Che, Serotype 1-specific monoclonal antibody-based antigen capture immunoassay for detection of circulating nonstructural protein NS1: Implications for early diagnosis and serotyping of dengue virus infections, J Clin Microbiol. 44: J. N. H. Scott A Ritchie, Susan L Hills, John P Piispanen, and A. P. W John H McBride, Ross L Spark, Dengue Control in North Queensland, Australia- Case Recognition and Selective Indoor Residual Spraying, Dengue Bulletin, WHO,26,: 7 T. N. Nguyen and T. T. Tran; Vietnam: appropriate management of a pediatric hospital in the context of limited resources, Med Trop (Mars)55: N. N. Anh and T. T. Tram; 1995 Integration of primary health care concepts in a children s hospital with limited resources, Lancet. 346:

16 Name of EP or Package of EPs Epidemiological Stratification Description (Briefly describe the implementation process) Present a management plan that integrates the monitoring dengue vector control and health promotion. The emphasis on early detection of cases of the formation of a rapid response team for intradomiciliar sprayed with pyrethroids. Concludes that the strategy to contain outbreaks affected areas in terms of duration of the epidemic and the number of cases. The selective spraying is the most appropriate intradomicilliary The great environmental heterogeneity of housing and neighborhoods in cities where Aedes aegypti breeding, combined with shortages of resources and personnel trained in mosquito control are challenges to control dengue hemorrhagic fever (DHF). Adequate epidemiological surveillance can serve as a basis to begin to stratify urban and identify critical areas where efforts should be focused control. In this study we stratified a city with hyperendemic dengue hemorrhagic fever (Maracay, Venezuela) with the help of a geographic information system (GIS) and analysis of the persistence, incidence and prevalence of dengue by clinical diagnoses reported from 1993 to The incidence of DHF was related to the incidence of dengue, the number of inhabitants and population density. The spatial pattern of dengue incidence was stable over the years studied and found positive and significant in the incidence of dengue by neighborhood between pairs of years. The persistence of dengue was related directly to monthly incidence by quarter. These spatial patterns facilitated the stratification of the city into three strata: 68 neighborhoods without apparent dengue, 226 neighborhoods with low persistence and prevalence, and 55 neighborhoods with high persistence and prevalence. We recommend giving high priority to control these 55 neighborhoods that occupy 35% of the urban area had 70% of all cases of dengue. Geographical Context urban/ rural, etc.) Urban Urban Target Population(s) indigenous, poor, other vulnerable) General Population General Population Scale of Implementation community, national, regional) Country(ies) where Implemented National Australia City Maracay Venezuela Selected Sources J. N. H. Scott A Ritchie, Susan L Hills, John P Piispanen, and A. P. W John H McBride, Ross L Spark, Dengue Control in North Queensland, Australia- Case Recognition and Selective Indoor Residual Spraying, Dengue Bulletin, WHO,26,: 7 Roberto Barrera, Nereida Delgado,Matilde Jiménez,Iris Villalobos e Ivonne Romero, Estratificación de una ciudad hiperendémica en dengue hemorrágico, Rev Panam Salud Publica/Pan Am J Public Health. 8 :4, 16

17 Name of EP or Package of EPs Epidemiological Stratification Description (Briefly describe the implementation process) Describe the seroprevalence of dengue in 120 locations in Mexico stratified by size of locality, annual temperature average altitude and socioeconomic status. The results indicate that infection is higher in low areas, with TMA> 25 degrees, in large cities and in poorer neighborhoods. Describes the concentration of dengue cases in Recurrent localities (cities, large, with roads, services, not excluded). In 6% of total localities with 70% of cases of dengue We describe a methodological approach for stratify according to population density, vector populations, herd immunity, environmental and geographical conditions such as temperature, altitude, rainfall. Geographical Context urban/ rural, etc.) Urban and rural Urban/ rural Urban rural Target Population(s) indigenous, poor, other vulnerable) General Population. General Population General Population. Scale of Implementation community, national, regional) Country(ies) where Implemented National México Regional Veracruz, México National México Selected Sources Koopman J.S., Prevots, D.R., Vaca M. M.A., Gómez-Dantés H Determinants and Predictors of Dengue Infection in México, Am. J. Epidemiol ; 133: Escobar J., Gómez-Dantés H, Determinantes de la Transmisión del dengue en Veracruz: Un abordaje ecológico para su control, Salud Publica Mex. 45:43-53 Gómez-Dantés H., Ramos B.B., Tapia C.R., El riesgo de transmisión del dengue: un espacio para la estratificación, Salud Publica de Méx ; 37 supl:

18 Name of EP or Package of EPs Epidemiological Stratification Description (Briefly describe the implementation process) The work has identified the hot within the urban area being studied, ie the northwest of the city. The exchange of people who characterize the hot pockets are located precisely in areas of the city where the vector has already been registered. This determines a high probability of viral transmission and movement to other areas or places where the mosquito is present. The sum of Very High Risk Areas and High Risk form an urban space that is normal in passive displacement vector to meet their day-cutting activities to obtain blood. A union of the indispensable factors for the occurrence of Dengue Vector, viruses and susceptible population in this study adds high-density areas. The use of GIS allows a rapid analysis to determine in advance the most appropriate interventions to prevent or reduce the development of epidemics. the study to appreciate the areas of greatest risk of transmission of dengue virus. From the standpoint of prevention strategies and vector control, easy to prioritize those areas of the city where dengue negative impact may be greater in the health of the population. The consolidation in the use of GIS in this type of work will allow us to relate the presence of the vector, the notification of patients, the population density by districts, with a result that will address prevention and control measures in those areas that are verified as the highest risk. Very High Risk (MAR) = Assistant Center Area with an estimated population density greater than 500 inhabitants per hectare and the presence of the vector High Risk (HR) = Area with schools and / or public institutions, a population density greater than 300 per hectares and vector presence Risk (R) = Residential Area Neighborhoods with high reluctance important vehicle fleet, with higher population density 100 people per hectare and the presence of the vector is noted that of 595 apples or hectares under study, we stratified indicates that falls under the category: Geographical Context urban/ rural, etc.) Urban Target Population(s) indigenous, poor, other vulnerable) Population Density Scale of Implementation community, national, regional) Country(ies) where Implemented City Argentina Selected Sources Bottinelli O. R.,Marder G., - Ulón S. N., Ramírez, L., Sario, H. R., Estratificación de áreas de Riesgo-Dengue en la ciudad de Corrientes mediante el uso de los (SIG) Sistemas de Información Geográfico 18

19 Name of EP or Package of EPs Climate, Concentration of Cases Description (Briefly describe the implementation process) To understand the disease behavior of dengue by analyzing studies on dengue and geoprocessing, as well as socioeconomic and environmental indicators. Twenty-two studies from Latin America (19 from Brazil) were evaluated. Six were serologic surveys and 16 employed secondary data. Geographic information systems were employed in one survey, and 11 used secondary data analyses. Spatial clustering was similar in both types of studies. Poverty was not a major risk factor for the disease. Spatial heterogeneity of living conditions and incidence was reported by 15 of 16 studies with secondary data. Since the complexity of dengue is closely tied to the ecological characteristics of the environment, studies based on spatial clusters plus local environmental determinants provide a more comprehensive view of the disease. These studies also allow for the identification of spatial heterogeneity, shown to be a key to under-standing how dengue epidemics develop. Geographical Context urban/ rural, etc.) Urban Target Population(s) indigenous, poor, other vulnerable) General Population Scale of Implementation community, national, regional) SIG Country(ies) where Implemented Latin-American countries Selected Sources Flauzino RF, Souza-Santos R, Oliveira RM Dengue, geoprocessamento e indicadores socioeconômicos e ambientais: um estudo de revisão. Rev Panam Salud Publica.25:

20 Name of EP or Package of EPs Climate, Concentration of Cases Description (Briefly describe the implementation process) The impact of weather variables and climatic indicators associated with the incidence of dengue in two municipalities of the state of Veracruz, Mexico, from 1995 to A retrospective ecological study was conducted, using time-series analysis in which we compiled the weekly reported cases of dengue and the weather and climatic parameters: temperature, rainfall and sea-surface temperature (SST), the latter as an El Nino Southern Oscillation indicator. Each degree Centigrade increase in SST was followed by an increase in the number of dengue cases: 46% in San Andre s Tuxtla (P = 0.001) 16 weeks later and 42% in Veracruz 20 weeks later (P = 0.002). Increases in weekly minimum temperature and rainfall were also significant factors in the increase in the reported cases of dengue. The Amazonian state of Roraima has one of the highest incidence rates of dengue in the country. determine whether significant temporal relationships exist between the number of reported dengue cases and short-term climate measures for the city of Boa Vista, the capital of Roraima. If such relationships exist,it may be possible to predict dengue case numbers based on antecedent climate, thus helping develop a climate- based dengue earlywarning system for Boa Vista. The strength of the individual averaged correlations varied from weak to moderate. The correlations differed according to the period of the year, the particular climatic variable, and the lag period between the climate indicator and the number of dengue cases. The seasonal correlations showed far stronger relationships than had daily, full-year measures reported in previous studies. Relationships between climate and dengue are best analyzed for short, relevant time periods. Climate-based multivariate temporal stochastic analyses have the potential to identify periods of elevated dengue incidence, and they should be integrated into local control programs for vector-transmitted diseases. Geographical Context urban/ rural, etc.) Urban Urban Target Population(s) indigenous, poor, other vulnerable) General Population Climate and population Scale of Implementation community, national, regional) Municipal Municipal Country(ies) where Implemented Veracruz, México Amazonia, Brazil Selected Sources M. Hurtado-Dıaz, H. Riojas- Rodrıguez, S. J. Rothenberg, H. Gomez-Dantés and E. Cifuentes ; Impact of climate variability on the incidence of dengue in Mexico, Tropical Medicine and International Health.12:1 11. Rosa-Freitas MG, Schreiber KV, Tsouris P, Weimann ETDS, Luitgards-Moura JF Associations between dengue and combinations of weather factors in a city in the Brazilian Amazon. Rev Panam Salud Publica.;20:

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