María G. Guzmán, DrCs
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1 Considerations for introduction of dengue vaccines in Cuba María G. Guzmán, DrCs August 23, 2011 Centro Colaborador OPS/OMS para el Estudio del Dengue y su Vector
2 Epidemiological Cuban situation Does Cuban need a dengue vaccination? Opportunities for dengue vaccination Disadvantages/Barriers Possible vaccination strategies Research follow up
3 Mas y cols., 1983; Mas,, 1978 Cantelar y cols.,, 1979 Kouri y cols ; Kouri et al.,, 1998 Pelaez y cols., 2004 Guzman y cols., 2002; Guzman y cols.,, 2003
4 Period of Imported cases In this period some introductions All fully controlled & eliminated No endemicity
5 Current Epidemiological situation Different risk groups according to age & location After 1981 epidemic, all DHF cases in adults High % of children population at risk of primary infection
6 To maintain the country free of dengue transmission If local introduction, to rapidly eliminate transmission & avoid extension Strong Cuban eradication & prevention program
7 Need of dengue vaccination Vaccination is needed as Cuba is located in a hyperendemic region & maintain a very high human exchange with endemic countries with an increased dengue trend In 2010, medical collaborators in 77 countries mostly in LA Still the vector presents in some municipalities
8 Opportunities for dengue vaccination Cuban health system organization with a strong primary health care system Strong Vaccination program Regulatory body Aedes aegypti eradication program Integral surveillance with lab support
9 Asamblea Nacional Consejo de Estado Consejo de Ministros Asamblea Provincial del Poder Popular Asamblea Municipal del Poder Popular Grupo Básico de Trabajo National Health System Dirección Provincial de Salud Area de Salud Dirección Municipal de Salud Ministerio de Salud Pública Autoridad Central Area de Salud Grupo Básico de Trabajo Cuban Health System A political priority Surveillance Risk Stratification Consultorio del Médico de Familia Universal Free Consultorio del Médico de Familia Consultorio del Médico de Familia Consultorio del Médico de Familia Action Plan Municipality Priorities Accessible Primary health care Family doctors
10 Integration to primary health level Active community participation Totally free High coverage Adverse effects system surveillance
11 Diseases eliminated: - Poliomielitis in Difteria in Measles in Tosferina in Rubella in 1995 ELIMINATION OF SEVERE FORMS OF ILLNESS: - Tétanos Neonatal in Meningitis tuberculosa <1 year old in 1997 ELIMINATION OF SEVERE COMPLICATIONS: - Síndrome de Rubéola Congénita en Meningoencefalitis Post Mumps in 1989
12 DISEASES THAT ARE NOT A HEALTH PROBLEM: < 0.1 X 100,000 INHABITANTS. - Tétanos since H. Influenzae tipo b since Fiebre Tifoidea since 2005 DISEASES WITH REDUCED MORBIDITY / MORTALITY BY 98%: - Enfermedad Meningocócica since Hepatitis B since Mumps since 2009
13 Cuban Vaccination schedule 2011 BCG HB DTP + HB + Hib AM-BC PRS DTP Hib DT AT(Vi) TT OPV (campaña) Al nacer Al nacer 2, 4 y 6 meses 3 y 5 meses 1 y 6 años 18 meses 18 meses 6 años 10, 13 y 16 años 14 años cada 10 años <1, 1, 2 y 9 años
14 Cuban Dengue & A. aegypti eradication program Dengue Prevention P. Vector Eradication P Epidemiological Surveillance & Lab Support Febrile Suspected MR cases I. Travelers Risk facilities Preparatory Attack Consolidation Surveillance Phases >25,000 HR Larvitraps S. R.Stratification Training A. IPK
15 Entomology Clínic Environmental Laboratory Epidemiology Participation of all levels of the health system
16 Passive Active Paired sera (HI) VI: mice C. mosquitoes 1997-Today Serol., virol. & mol. Monosera 5-6 days UMELISA-Dengue IgM ELISA IgM/IgG VI: shell vial Molecular methods Network of labs Daily interaction at the different levels of the health system
17 Case definition Acute fever with Dengue suspicious (Fever & two more clinical manifestations) Serum sample collection 6 days Clinical and epidemiological information CPHE SUMA/Dengue Laboratories 30 labs around the country Quality Control 10% negatives UMELISA dengue IgM IgM (-) IgM (+) Clinical and epidemiological analysis 100% positives samples to IPK IPK
18 Barriers/challenges Safety at short & long term Cost of the vaccination Vaccine availability
19
20 Depending on availability & cost: Where? a) Country vaccination b) Provinces at risk of transmission (high vector indexes) Who? a) All population (all adults & possibly children) b) Risk groups (travelers) How? a) Inclusion in the national immunization program b) Associated with other vaccines (number of doses, interaction) Potential Vaccination strategies
21 Follow up Strong surveillance system with lab support for monitoring & evaluation Experience with sero-surveys Research studies to determine impact of immunization in different immune individuals. Cost of immunization + vector program
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