Recent Epidemiological Trends, the Global

Strategy and Public Health Advances in Dengue

M.B. Nathan1 and R. Dayal-Drager2

1 Department of Control of Neglected Tropical Diseases, Communicable Diseases Cluster, World Health
Organization, Geneva, Switzerland. 2 Department of Epidemic and Pandemic Alert and Response, Communicable
Diseases Cluster, World Health Organization, Geneva, Switzerland

Epidemiological highlights

We conservatively estimate that, since the last meeting of the Scientific Working Group (SWG) on
Dengue in 2000 [9], there has been an increase of 110 million in the number of persons living in urban
areas of the world with a high burden of dengue [10]. Approximately 975 million people now live in
these urban areas, that is, almost half the global population estimated to be at risk of dengue
infection.

By decade, the annual average number of cases of dengue fever or severe dengue reported to the
World Health Organization (WHO) continues to grow exponentially. For the first 5 years of the current
decade, the annual average number of cases was 925 896, almost double the figure for 1990–1999
(479 848 cases) (Figure 1). In 2001, a record 69 countries from the WHO Regions of South-East Asia,
Western Pacific, and the Americas reported dengue activity (Figure 1). In 2002, the WHO Region of the
Americas reported more than 1 million cases for the first time. Although there is poor surveillance and
no official reporting of dengue to WHO from countries in the WHO African Region and the Eastern
Mediterranean Region, recent outbreaks of suspected dengue have been recorded in Madagascar,
Pakistan, Saudi Arabia, Sudan and Yemen, 2005–2006. For reviews of dengue history in these regions,
see the paper by Rosemary Sang, in the present report, and EMRO [4].

Geographical extension of areas with dengue transmission or resurgent dengue activity have been
documented in Bhutan, Hawaii (USA), the Galapagos Islands (Ecuador), Easter Island (Chile), Hong
Kong Special Administrative Region and Macao Special Administrative Region (China) between 2001
and 2004 (Figure 2). All four dengue viruses are circulating in Asia, Africa and the Americas. Perhaps
the only comforting news is that reported case-fatality rates have been lower in recent years than in
the decades before 2000.

Chikungunya virus, Alphavirus (Togaviridae), has received considerable attention recently, because of
severe outbreaks in areas of known endemicity, notably India and Indonesia, and in islands of the
Indian Ocean, where it has seldom or never been reported before. Mention is made of these outbreaks
because chikungunya and dengue share common vectors in Aedes aegypti and Ae. albopictus
mosquitoes.

The Global and Regional Strategies

The Global Strategy for Dengue Fever/Dengue Haemorrhagic Fever Prevention and Control is more
than ten years old [18] but remains essentially unchanged. It comprises five major elements: selective
integrated vector control, with community and intersectoral participation; active disease surveillance
based on a strong health-information system; emergency preparedness, capacity building and
training; and vector-control research. Efforts have since focused on three fundamental aspects:
surveillance for planning and response; reducing the disease burden; and changing behaviours. The
Fifty-fifth World Health Assembly in 2002 [17] urged greater commitment among Member States and
WHO to implement the strategy.

Of particular significance is the resolution [14]. Revision of the International Health Regulations, made
by the Fifty-eighth World Health Assembly in 2005 [15], which includes mention of dengue fever (and
yellow fever) as an example of a health ‘event that may constitute a public health emergency of
international concern’, and of which, under such circumstances, WHO should be notified under the
International Health Regulations.

Advances Since The Last Swg

Since the last SWG, several new, improved or validated tools and strategies have been developed and
are available to public health practitioners and clinicians. They include:

 Rapid commercial diagnostic tests in use in endemic countries.

 Pocket book of hospital care for children. Guidelines for the management of common illnesses
with limited resources (inclusion of dengue in the management of fever) [13].
 An audiovisual guide and transcript for health-care workers responding to outbreaks [12].
 Guidelines for planning social mobilization and communication.
 Global strategic framework for integrated vector management [16].
 Dengue CD-ROM, Wellcome Trust, Topics in International Health series [11].
 Entomological survey technique to identify the most productive container habitats of the
vector(s).
 Seven insecticide products evaluated by WHO for mosquito larviciding (five insect growth
regulators, two bacterial larvicides), four of which are approved for use in drinking-water
(methoprene EC, pyriproxyfen GR, Vectobac DT and GR); three insecticide products evaluated
by WHO for space spray applications to control mosquitoes (all pyrethroids).
 The sequence of the Ae. aegypti genome.
 Advances in the development and operational deployment of DengueNet [2] for global dengue
surveillance.
 International Health Regulations 2005: voluntary compliance in effect.

New initiatives contributing to the development of new tools and strategies include:

 Paediatric Dengue Vaccine Initiative [7] (Bill & Melinda Gates Foundation).
 The Innovative Vector Control Consortium [6] (Bill & Melinda Gates Foundation).
 Asia-Pacific Dengue Partnership.
 DENFRAME [3] and DENCO (European Union).
 Novartis Institute for Tropical Diseases [8] (Novartis and the Singapore Economic Development
Board).
 Regional Development Banks (Asian Development Bank, Inter-American Development Bank).

Streams of dengue research and training that have been supported by the UNICEF-UNDP-World Bank-
WHO Special Programme for Research and Training in Tropical Diseases (TDR) [9] and by the Initiative
for Vaccine Research, or which will soon be the subject of investigation, are summarized in figure 3
[5]. They involve the development and efficacy testing of tools for vector control, case management
and primary prevention (vaccine development).

Cattand et al. [1] perceive a growing consensus that community-based approaches to transmission
control are desirable and necessary (see table 1), and that they improve prospects for the
sustainability of vector-control programmes, although few such interventions have expanded beyond
the pilot stage. However, Cattand et al. suggest that decentralization of budgets and programme
operations offer opportunities for strengthening and expanding this integrated vector management
approach for transmission control.

The biggest challenge today appears to be how to maximize the cost-effective deployment of tools and
interventions that are already available. For this, we need clearly-directed operational research. For
tomorrow, we must pursue the development of new tools and strategies, including better diagnostics,
treatments and the elusive public-health vaccine.

Figure 1. Average annual number of cases of dengue or severe dengue reported to WHO, and average annual
number of countries reporting dengue
 Figure 2. Countries and areas at risk of dengue transmission, 2006

Isoth.: Isotherm; the 10°C January and July isotherms represent the approximate northern and southern
geographic limits, respectively, at which Aedes aegypti can survive the coolest months of the year. It has been
found at higher latitudes (45 degrees N) but has not been able to survive the winter.
IMPLEMENTATION RESEARCH: IMPROVING DENGUE PREVENTION & CONTROL
TOOL DEVELOPMENT & EFFICACY TESTING IMPLEMENTATION RESEARCH

Ecosystem management &

Social mobilization *

IMPROVED
Targeted vector control*
VECTOR
CONTROL
Transgenic mosquitoes

New vector control tools

& strategies*

REDUCTION
High quality diagnostics* COST -EFFECTIVE OF
IMPROVED TRANSMISSION
CASE IMPLEMENTATION
MANAGEMENT STRATEGY* &
Improved case classification
& case management* CASE
FATALITY

Improved knowledge
of pathogenesis*

IMPROVED
Effective
Support of vaccine PRIMARY
development & vaccine PREVENTION
evaluation

TDR supported * Multi -country studies in place or forthcoming

IVR supported

Figure 3. Dengue research and training supported and encouraged by the UNICEF-UNDP-World Bank-WHO
Special Programme for Research and Training in Tropical Diseases or the Initiative for Vaccine Research

*Topics that are currently under investigation, or will soon be under investigation, in multicountry studies.
IVR = Initiative for Vaccine Research
TDR = UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases
Modified from Kroeger et al. (2006) Annals of Tropical Medicine and Parasitology, 100(Suppl. 1):S98, with the
permission of the Liverpool School of Tropical Medicine.
Main control strategy Major problems and challenges Major research needs

Reduction/interruption of Lifestyles that provide abundant Vector-control targets/thresholds

transmission through vector
control
larval habitats
Water infrastructure and solid
waste management
Sustainability of vector control
to reduce/interrupt transmission
Behavioural changes conducive
to the prevention and control of
dengue

Patient management and Early diagnosis and treatment Patient management and
supportive treatment supportive treatment

Vaccine and drug development Pathogenesis and disease

prognosis
Vaccine and drug development

Table 1. Control strategy, major challenges and research needs for the prevention and control of dengue

Modified from Cattand et al. (2006), reproduced with permission from the World Bank.

References

1. Cattand P, et al. Tropical diseases lacking adequate control measures: dengue, leishmaniasis and
African trypanosomiasis. Chapter 6. In: Jamison Dean T, ed. Disease control priorities in
developing countries, 2nd ed. New York. World Bank and Washington, Oxford University Press. p.
451–66.

2. DengueNet: http://www.who.int/csr/disease/dengue/denguenet/en/index.html

3. DENFRAME: http://www.denframe.org/

4. EMRO. Division of Communicable Disease Control, Regional Office for the Mediteranean,
Newsletter, Issue No. 6, pp. 7–8 (http://www.emro.who.int/pdf/dcdnewsletter6.pdf).

5. Kroeger A, et al. Dengue research and training supported through the World Health Organization.
Ann Trop Med and Parasitol. 100; (Suppl.1): S97–S101.

6. Innovative Vector Control Consortium: http://www.ivcc.com/

7. Paediatric Dengue Vaccine Initiative: http://www.pdvi.org/

8. Novartis Institute for Tropical Diseases: http://www.nitd.novartis.com/

9. TDR. Scientific Working Group, 3–4 April 2000, Geneva, Switzerland: recommendations. Geneva,
UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical
Diseases/World Health Organization (TDR/DEN/SWG/00.1).
http://dosei.who.int/uhtbin/cgisirsi/iIub4vjK8c/241550010/18/X710/XAUTHOR/UNDP%5e2FWorld+
Bank%5e2FWHO+Special+Programme+for+Research+and+Training+in+Tropical+Diseases.

10. United Nations (2002). World urbanization prospects. The 2001 revision. New York, United Nations,
Department of Economic and Social Affairs (ESA/P/WP.173).

11. Wellcome Trust/UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in
Tropical Diseases (2006). Dengue [CD-ROM]. Wellcome Trust (Topics in International Health
series) (http://www.who.int/tdr/media/multimedia/dengue.htm).

12. WHO (2006a). An audiovisual guide and transcript for health care workers responding to
outbreaks. Geneva, World Health Organization (WHO/CDS/EPR/2006.4 and 4a).

13. WHO (2006b). Pocket book of hospital care for children. Guidelines for the management of
common illnesses with limited resources. Geneva, Department of Child and Adolescent Health,
World Health Organization.

14. WHO (2006c). World Health Assembly resolution WHA59.2. Application of the International Health
Regulations (http://www.who.int/gb/ebwha/pdf_files/WHA59/WHA59_2-en.pdf).

15. WHO (2005). World Health Assembly resolution WHA58.3. Revision of the International Health
Regulations (http://www.who.int/csr/ihr/IHRWHA58_3-en.pdf).

16. WHO (2004). Global strategic framework for integrated vector management. Geneva, World Health
Organization (WHO/CDS/CPE/PVC/2004.10;
http://whqlibdoc.who.int/hq/2004/WHO_CDS_CPE_PVC_2004_10.pdf).

17. WHO (2002). World Health Assembly resolution WHA55/19. Dengue prevention and control.
(http://www.who.int/gb/ebwha/pdf_files/WHA55/ea5519.pdf).

18. WHO (1996) Report of the Consultation on Key Issues in Dengue Vector Control: toward the
operationalization of a global strategy, 6–10 June 1995, Geneva. Geneva, World Health
Organization (CTD/FIL(DEN)/IC/96.1).