Ernesto Gozzer

Cost of dengue outbreaks: literature review and country case studies

BackgroundDengue disease surveillance and vector surveillance are presumed to detect dengue outbreaks at an early stage and to save – through early response activities – resources, and reduce the social and economic impact of outbreaks on individuals, health systems and economies. The aim of this study is to unveil evidence on the cost of dengue outbreaks.MethodsEconomic evidence on dengue outbreaks was gathered by conducting a literature review and collecting information on the costs of recent dengue outbreaks in 4 countries: Peru, Dominican Republic, Vietnam, and Indonesia. The literature review distinguished between costs of dengue illness including cost of dengue outbreaks, cost of interventions and cost-effectiveness of interventions.ResultsSeventeen publications on cost of dengue showed a large range of costs from 0.2 Million US

Sharing experiences: towards an evidence based model of dengue surveillance and outbreak response in Latin America and Asia

in Venezuela to 135.2 Million US

A crucial time for public health preparedness: Zika virus and the 2016 Olympics, Umrah, and Hajj

in Brazil. However, these figures were not standardized to make them comparable. Furthermore, dengue outbreak costs are calculated differently across the publications, and cost of dengue illness is used interchangeably with cost of dengue outbreaks. Only one paper from Australia analysed the resources saved through active dengue surveillance. Costs of vector control interventions have been reported in 4 studies, indicating that the costs of such interventions are lower than those of actual outbreaks. Nine papers focussed on the cost-effectiveness of dengue vaccines or dengue vector control; they do not provide any direct information on cost of dengue outbreaks, but their modelling methodologies could guide future research on cost-effectiveness of national surveillance systems.The country case studies – conducted in very different geographic and health system settings - unveiled rough estimates for 2011 outbreak costs of: 12 million US

Yellow fever outbreaks, vaccine shortages and the Hajj and Olympics: call for global vigilance

in Vietnam, 6.75 million US

Improved tools and strategies for the prevention and control of arboviral diseases: A research-to-policy forum

in Indonesia, 4.5 million US

Mass gatherings: A one-stop opportunity to complement global disease surveillance

in Peru and 2.8 million US

¿Quién es la víctima y quién el agresor en la violencia física entre parejas?: estudio epidemiológico en siete ciudades del Perú

in Dominican Republic (all in 2012 US

It's time for your life: How should we remind patients to take medicines using short text messages?

). The proportions of the different cost components (vector control; surveillance; information, education and communication; direct medical and indirect costs), as percentage of total costs, differed across the respective countries. Resources used for dengue disease control and treatment were country specific.ConclusionsThe evidence so far collected further confirms the methodological challenges in this field: 1) to define technically dengue outbreaks (what do we measure?) and 2) to measure accurately the costs in prospective field studies (how do we measure?). Currently, consensus on the technical definition of an outbreak is sought through the International Research Consortium on Dengue Risk Assessment, Management and Surveillance (IDAMS). Best practice guidelines should be further developed, also to improve the quality and comparability of cost study findings. Modelling the costs of dengue outbreaks and validating these models through field studies should guide further research.

It's time for your life

BackgroundThe increasing frequency and intensity of dengue outbreaks in endemic and non-endemic countries requires a rational, evidence based response. To this end, we aimed to collate the experiences of a number of affected countries, identify strengths and limitations in dengue surveillance, outbreak preparedness, detection and response and contribute towards the development of a model contingency plan adaptable to country needs.MethodsThe study was undertaken in five Latin American (Brazil, Colombia, Dominican Republic, Mexico, Peru) and five in Asian countries (Indonesia, Malaysia, Maldives, Sri Lanka, Vietnam). A mixed-methods approach was used which included document analysis, key informant interviews, focus-group discussions, secondary data analysis and consensus building by an international dengue expert meeting organised by the World Health Organization, Special Program for Research and Training in Tropical Diseases (WHO-TDR).ResultsCountry information on dengue is based on compulsory notification and reporting (“passive surveillance”), with laboratory confirmation (in all participating Latin American countries and some Asian countries) or by using a clinical syndromic definition. Seven countries additionally had sentinel sites with active dengue reporting, some also had virological surveillance. Six had agreed a formal definition of a dengue outbreak separate to seasonal variation in case numbers. Countries collected data on a range of warning signs that may identify outbreaks early, but none had developed a systematic approach to identifying and responding to the early stages of an outbreak. Outbreak response plans varied in quality, particularly regarding the early response. The surge capacity of hospitals with recent dengue outbreaks varied; those that could mobilise additional staff, beds, laboratory support and resources coped best in comparison to those improvising a coping strategy during the outbreak. Hospital outbreak management plans were present in 9/22 participating hospitals in Latin-America and 8/20 participating hospitals in Asia.ConclusionsConsiderable variation between countries was observed with regard to surveillance, outbreak detection, and response. Through discussion at the expert meeting, suggestions were made for the development of a more standardised approach in the form of a model contingency plan, with agreed outbreak definitions and country-specific risk assessment schemes to initiate early response activities according to the outbreak phase. This would also allow greater cross-country sharing of ideas.

Uso y percepciones hacia las tecnologías de información y comunicación en pacientes con diabetes, en un hospital público del Perú

The 138th session of WHO’s Executive Board on Jan 25, 2016, noted both the end of the 2014 Ebola crisis and the beginning of a global public health threat, the outbreak of Zika virus infection in the Americas. On Jan 15, 2016, the US Centers for Disease Control and Prevention advised pregnant women to refrain from travelling to countries affected by Zika, given a possible association between Zika virus infection with microcephaly and other neurological disorders. On Feb 1, 2016, WHO’s International Health Regulations Emergency Committee declared the possible association between Zika virus infection and clusters of microcephaly and other neurological disorders as a Public Health Emergency of International Concern. With the spread of the arbovirus to more than 25 countries, Zika virus could be following the geographical spread of dengue and chikungunya, all of which are transmitted by the Aedes aegypti mosquito. The potential role of scheduled international mass gatherings in 2016 could exacerbate the spread of Zika virus beyond the Americas. In Brazil, the Rio Carnival on Feb 5–10 attracts more than 500 000 visitors, and on Aug 5–21 more than 1 million visitors are expected to go to the summer Olympics followed by Paralympic Games on Sep 7–18. Meanwhile, Saudi Arabia expects to host more than 7 million pilgrims from over 180 countries for the Umrah, between June and September, and the Hajj pilgrimage on Sept 8–13. Saudi Arabia receives about 7000 pilgrims from Latin America annually. Since the Rio Carnival participants are largely domestic, and the spread of Zika virus is already extensive, it will be challenging to assess if there was excess transmission related to the Carnival. Although winter temperatures mean that mosquito density is expected to be low in Brazil at the time of the Olympics, given the summer time mosquito density in the northern hemisphere, including in Saudi Arabia, the introduction of a few infections to the mosquito population might be sufficient to cause outbreaks of Zika virus in other countries. In Brazil, cases of dengue are more frequent from February to May. In the regions of Saudi Arabia frequented by pilgrims (Jeddah, Mecca, Medina), Aedes aegypti larvae are present throughout the year, nearly two thirds in indoor habitats. Larvae density is, however, variable and decreases in the months before October. In these regions, where rainfall is rare and unpredictable, reports have suggested all year risk for dengue fever, with dengue seroprevalence ranging from 32% to 57% among general patients seeking medical consultations. Although the Olympics and the Hajj are very different events, each of them might favour transmission of Zika virus. The Olympics attracts mostly young healthy adults from middle and upper-middle income groups who live in developed countries. Such visitors are less likely to have been exposed to arbovirus infections and less familiar with mosquito bite prevention than Hajj pilgrims. Sexual transmission of Zika virus from commercial sex workers with asymptomatic infection might also be a possibility for those who attend the Olympics. By contrast, the Hajj and Umrah participants are more likely to be older adults, many of whom have pre-existing health problems, and about two thirds of them originate from low-income countries and the tropics where personal habits of mosquito bite prevention can be suboptimum. Also, Umrah and Hajj pilgrims’ immersion in religious rituals could reduce personal uptake of mosquito avoidance measures. For Saudi Arabian authorities, it is now a standard procedure to convene international public health consul tations each year before the pilgrimage season to develop disease-specific recommendations. Brazilian authorities in collaboration with the Organizing Committee for the Olympic and Paralympic Games have already outlined vector control measures in the Olympics vicinity. Although both countries may have robust vector control efforts, no single approach is adequate to prevent mosquito bites and non-vector modes of Zika virus transmission; a combination of measures is needed at personal, community, and policy levels. With the emergence of chikungunya and dengue, Hajj authorities have been proactive in vector control measures. Given that pilgrim flow to Saudi Arabia is continuous, these efforts will help minimise current transmission of Zika virus as well. CD C/ Sc ie nc e Ph ot o Li br ar y