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Dengue outbreak investigation
Source: H. Gelderblom, RKI
Dengue
Matthias Niedrig, Robert Koch Institut, Berlin
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Dengue/dengue haemorrhagic feverEbola / RestonLassaYellow feverInfluenza
Crimean Congo haemorrhagic feverJapanese EncephalitisViral MeningitisRift Valley feverHanta
Viral Threats Worldwide
Sources: WHO (outbreak list/EPR), ProMed
2005
Polio
Chikungunya
Polio
Acute HF
Marburg virus
Hepatitis E
Measles
Nipah
/ 2006
Hepatitis A
/ 2007
Machupo virus
Measles
/ 2008
West-Nilevirus
New Arena
Hendra
/ 2009
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ENIVD 03 / 10
Background: causes
travellers / infectious pathogens [Dengue, Malaria, ...]
Goods / vectors [rodents, mosquitoes, ...]
Animal
migrations
climate factors
International transport
livingconditions
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Megacities of the world 1992-2010
Increase of population in mega-cities
1992 2010Source: DIE ZEIT
numbers in millions
11.9
13.9
Los AngelesNew York
Lagos
Mexico City
Rio de JaneiroSão Paulo
Buenos Aires
18
15.3
25
19.2
13.7
11.8
17.2
16.2
13.3
11.3
13.4
921.1
8.7
11.9
7
24.4
13.3
17.6
7.4
15.6
8
28.9
25.8
18
11.4
10
17.2
Teheran
Bombay
DelhiDhaka
Beijing
Jakarta
TokyoCairo
© ENIVD 2010
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Epidemiology: population increase in urban areas of Africa
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World Population 1850-2050
Increase of world population from 1850 to 2050
1850 1900 1950 1998 2050
392
172
504
809167
729628
547
221
7491766
1402
3585 5268
13 4630
305
numbers in millions
© ENIVD 2010
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ROBERT KOCH INSTITUT Low hygiene conditions in hospital settings
Delhi local hospital, department for treatment of Dengue patients
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Dengue Dengue InfectionInfection
AssymtomaticAssymtomatic symtomaticsymtomatic
No schock No schock DengueDengue schockschock (DSS)(DSS)
FeverFever DengueDengue Fever Fever DengueDengue Hemorragic FeverHemorragic Fever
50 – 100.000.000diseased persons
22.000 death
500.000 severcourse of disease
Dengue Dengue InfectionInfection: a : a diaseasediasease withwithdifferent different clinicalclinical picturespictures
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ROBERT KOCH INSTITUT Dengue in European Dengue in European travellerstravellersclinicalclinical presentationpresentation::
Wichman O., et al. JID 2007, vol 195 (1089-1096)
Statement on dengue CCDR RMTC 2009, vol 35 (1-12)
UNUSUAL MANIFESTATIONS:
Severe hepatitis Encephalitis Visual loss
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ROBERT KOCH INSTITUT Dengue Dengue casescases importedimported to Europe: to Europe: Travellers Travellers areare good good indicatorsindicators
DENV1 DENV1
DENV2
DENV1 DENV2 DENV3 DENV4
DENV1 DENV2 DENV3
DENV1 DENV2
DENV2 DENV3 DENV1
DENV3
DENV2 DENV4
DENV3 DENV2
ENIVD-TropNet Dengue Working Group; unpublished results
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Global distribution of Flaviviruses
Yellow Fever Virus
Japan EncephalitisVirus
Tick Borne Encephalitis Virus
Dengue Virus
West Nile Virus
Dengue Virus
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AFRICAN SYLVATIC
CYCLE
URBAN CYCLE
Ae. africanusAe. luteocephalusAe. furcifer-taylori
Ae. dalzieli
Ae. aegyptiAe. albopictus
Primates e.g. forest
redtailmonkey
Livecycle CHIKV
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Aedes aegypti
Aedes albopictus
Dengue transmission cycle
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SKIN of UNINFECTED VERTEBRATE
Non-Viremic Transmission
Infected mosquito Uninfected mosquito
McGee et al., (2007) Nonviremictransmission of West Nile virus: evaluation of the effects of space, time and mosquito species. Am. J. Trop. Med. Hyg. 76: 424-30.
Time: 45 min.
Distance: ≥ 40 mm
Source: S. Higgs, UTMB, USA
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ROBERT KOCH INSTITUT ImportedImported Dengue Dengue casescases intointo Europe: Europe: ReturningReturning travelerstravelers givegive usefuluseful informationinformation
DENV1 DENV1
DENV2
DENV1 DENV2 DENV3 DENV4
DENV1 DENV2 DENV3
DENV1 DENV2
DENV2 DENV3 DENV1
DENV3
DENV2 DENV4
DENV3 DENV2
ENIVD-TropNet Dengue Working Group; unpublished results
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ENIVD-TropNet Dengue Working Group; unpublished results
ImportedImported Dengue Dengue casescases intointo Europe: Europe: ReturningReturning travelerstravelers givegive usefuluseful informationinformation
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ROBERT KOCH INSTITUT Dengue in European Dengue in European travelerstravelers: : EpidemiologicalEpidemiological presentationpresentation
Source:TropNet Europ Sentinel SurveillanceReport, November 2008
1.6%Foreign visitors
3.2%Eurpean expatriates
8.1%Immigrant/refugees
87.1%Europeans living in EU
2008PATIENT CHARACTERISTICS
1.6%Foreign visitors
3.2%Eurpean expatriates
8.1%Immigrant/refugees
87.1%Europeans living in EU
2008PATIENT CHARACTERISTICS
Popularity of these countries as touristic destination
Activity and possible variations in the virulence of dengue viruses
Vector activity in endemic countries
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ROBERT KOCH INSTITUT Importe Dengue Importe Dengue casescases intointo Europe: Europe: Travelers as Travelers as „„vectorsvectors““
June-Sept 2006
0
5
10
15
20
25
30
35
40
45
AUG02
OCT02
DEC02
FEB03
APR03
JUN03
AUG03
OCT03
DEC03
FEB04
APR04
JUN04
AUG04
OCT04
DEC04
FEB05
APR05
JUN05
AUG05
OCT05
DEC05
FEB06
APR06
JUN06
AUG06
OCT06
DENGUE IMPORTED INFECTIONS (SPAIN)ACUTE DENGUE CASES NEGATIVE DENGE CASES
June-Sept 2007outbreaks
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ImortedImorted Dengue Dengue casescases intointo Europe: Europe: Travellers Travellers areare good good indicatorsindicators
NEW LINEAGE DESCRIPTION
Domingo C., et al. J. Clin. Microbiol., 2006; vol. 44: 1519-1529
DENGUE SEROTYPE 1 GENOTYPE AMÉRICA-ÁFRICA
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ROBERT KOCH INSTITUT DengueNet registeredDengue cases
854,452
2002-2006
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African countrieswhereDengue (DEN2, -3) have beenidentified in 2008 / 2009
ROBERT KOCH INSTITUT
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ROBERT KOCH INSTITUT Reinvasion of Aedes aegyptiinto the Amerika
1970 20011930
12
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ROBERT KOCH INSTITUT Dengue Dengue hemorragischichemorragischic FeverFever: : A A newnew form of form of diseasedisease
DHF reported cases
60
10312
3 0 8 12 35 97 96
26823646
2319 1753
4189 4723
8228
5092
11783 12369
5216 5667
1555714374
109949815
14557
9962
02000400060008000
1000012000140001600018000
< 19
8119
8119
8219
83198
419
8519
8619
8719
8819
8919
9019
9119
9219
9319
9419
9519
9619
9719
9819
9920
0020
0120
02200
320
0420
0520
06
Year
NON ENDEMIC
HYPERENDEMIC
Source: PAHO
DHF reported cases in Central, South America and the Caribbean
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DENGUE UPDATE 2011
Source: PAHO
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DENGUE watch 2011
Source: PAHO
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DENGUE UPDATE 2011
Source: WHO
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DENGUE UPDATE 2011
Source: WHO
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DENGUE UPDATE 2011
Source: WHO
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DENGUE UPDATE 2011
Source: WHO
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DENGUE UPDATE 2011
Source: WHO
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DENGUE UPDATE 2011
Source: WHO
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DENGUE UPDATE 2011
Source: WHO
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DENGUE UPDATE 2011
Source: WHO
Action Against Dengue: Dengue Day Campaigns Across AsiaDengue continues to pose a threat to public health in our region. This threat has been recognizedby countries throughout the region, which have taken action to protect their populations. National
leaders also have acknowledged that they must act regionally in order to protect people withintheir own borders.
The Association of Southeast Asian Nations (ASEAN) and the World Health Organization haveformed an effective alliance to achieve a shared goal: a healthy and secure population.
One clear sign of this cooperation was seen on 15 June 2011. ASEAN Health Ministers declaredthat day—and each subsequent 15 June—to be ASEAN Dengue Day. This important annual eventallows ASEAN members, in coordination with WHO, to consolidate dengue prevention and control
measures.
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Increase of world tourism
Source: WTO
1990459
1996592
2000702
20101018
20201600
(after 2009 forecast)
number of personstravellingabroadin millions
18
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Imported Dengue cases into Germany
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Age distribution of Dengue fever patients 2005 - 2010
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Destination of returning travelers with Dengue fever 2005 - 2010
Quelle: Institute of Medical Virology, Frankfurt / Main
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DENGUE UPDATE 2011
Source: ECDC, Surveillance report 2010
Notification rates of dengue fever cases in EU and EEA/EFTA countries, by age and
gender, 2008 (n = 429 confirmed) from 530
20
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DENGUE UPDATE 2011
Source: ECDC, Surveillance report 2011
Rates of reported confirmed dengue fevercases in EU and EEA/EFTA countries, by age
and gender, 2009
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DENGUE UPDATE 2011
Source: ECDC, Surveillancereport 2011
Number and rate of dengue fevercasesreported in EU and EEA/EFTA countries, 2008–09
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DENGUE UPDATE 2011
Source: ECDC, Surveillance report 2011
Seasonal distribution of reported confirmeddengue cases in the EU and EEA/EFTA
countries, 2009
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DENGUE UPDATE 2011
Source: ECDC, Surveillancereport 2011
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ROBERT KOCH INSTITUT East and West distribution of Aedesalbopictus in the mediterranean area
Source: Development of Aedesalbopictus risk maps, ECDC, Stockholm, 03, 2008
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Distribution of Aedes albopictusin Europe, January 2010
surveys and studies on mosquitoes wereconducted during thelast five years (2003–2007) and no specimenof Aedes albopictus was reported
Aedes albopictuswas reported
No information
Source: Development of Aedesalbopictus risk maps, ECDC, Stockholm, March, 2008
Straetemans M. Eurosurveillance 2008, vol 13 (1-3)
AedesAedes aegyptiaegyptiPresencePresence in Europein Europe
authochtoneDengue cases
in 2010
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Distribution of Viruses and disease vectors within Europe
Tick borneencephalitisvirus
Hanta virus
CrimeanCongohemorraghicfever virus
West Nilevirus
Sandfly fevervirussource:
Snow & Ramsdale, Biologist (2002) 49 (2)
Aedesalbopictus
Ochlerotatusatropalpus
Ochlerotatusjaponicus
WN
WN WNWN
WN
ChikungunyaVirus
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Distribution of CHIK since 2005
Reunion
KeyniaSeychelles
ComoresMauritius
CanadaUSA
2006
2005
20072008
2007
20092009
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ROBERT KOCH INSTITUT Chikungunya outbreak in Italy in June 2007
source:
Distribution of Chikungunya Fever.Source: CDC, USA, 2007
15th June – 21st Sep. 292 suspected cases of Chikungunya Fever 125 cases were confirmed by laboratory diagnosis Increase of Aedes albopictus in the region in recent years
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Important requirements for a good diagnosis
Good physician
Consider-ing allcircum-stances
Kind of disease, travel history, vaccinations,
etc….?
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Cross reactivity between different Flaviviruses in different diagnostic
assays (IFA, EIA)
Tick Borne Enzephalitis TBEV
vaccine available
Japanese Enzephalitis JEV
vaccine available
Yellow FeverYFV
vaccine available
Dengue Fever 1-4DEN V
West Nile FeverWNV
Koraka et al., 2002
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What comes next?
CHIKVDengue
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Quelle: Van der Werf, Pasteur Institut
previous Hotel Metropol in Hong Kong
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Acknowledgements
Cristina Domingo
Thomas Jelinek
Stephen Higgs
Klaus Stark
Christina Frank