Eli Schwartz MD,DTMH

Transcription

1 DENGUE FEVER in INTERNATIONL TRAVELERS Eli Schwartz MD,DTMH The Center of Geographic Medicine & Tropical Diseases Sheba Medical Center, Tel-Hashomer Sackler Faculty of Medicine, Tel-Aviv univ. ISRAEL

2 World Distribution of Dengue Areas infested with Aedes aegypti Dengue in 1960 Areas with Aedes aegypti and recent epidemic dengue CENTERS FOR DISEASE CONTROL ANN PREVENTION

3 DENGUE -PUBLICATIONS general travelers reported cases

4 Travel & Dengue fever * Affects International travelers * Contributing factor in spread of dengue worldwide.

5 Why GeoSentinel? To augment existing public health systems by providing rapid and comprehensive global surveillance for a spectrum of diseases and syndromes amongst increasingly mobile populations days millions Days to circle the globe International arrivals

6 Dengue Fever: Epidemiology in Travelers The Problems: Lack of true numerator Lack of denominator

7 MORBIDITY AND MORTALITY IN TRAVELERS TO DEVELOPING CONTRIES: RATES / MONTH OF STAY Travelers Diarrhea Malaria Acute febrile respiratory tract infections Hepatitis A Gonorrhea Hepatitis B Typhoid (India; N, NW-Africa) HIV-infection Legionellosis Typhoid (other areas) Poliomyelitis, asymptomatic 100% 100,000 10% 10,000 1% 1, % % % 1 Cholera % Paralytic poliomyelitis 0,00007% Any health problem: used medication or felt ill Felt subjectively ill Consulted doctor abroad or home Stayed in bed Incapacity of work after return Hospitalized abroad Air evacuation Died abroad (PVC) Died abroad (any traveler) Steffen in Manson s, 1999, p 407

8 Diagnosis of DF in returning travelers hospitalized with febrile illness Country Ref. Number of Travelers Dengue % Years of study Canada MacLean U.K Doherty et al Germany Jelinek et al Australia O'Brien et al Israel Schwartz et al

9 Attack Rate of Dengue Fever among Israeli Travelers to Thailand,1998 Cohort No. Travelers Dengue cases Attack Rate SHARIV /1000 All Visitors /1000 Schwartz E. et al: Eur. J. Clin Microbiol Infect Dis. 2000: 784-6

10 Dengue Seroconversion among Israeli Travelers to Tropical Countries Number 104 travelers Year of study-1998 Age (mean) years Trip (average)- 6 (3-16) mo. Destination- S.E. Asia- 70 % S. America- 24 % Africa- 4% Combined-2% Potasman I, Srugo I, Schwartz E. : E.I.D; 1999,824-6

11 Dengue Seroconversion; Results: 7/104= 6.7 % (95% CI= %) 3/7- were asymptomatic Potasman I, Srugo I, Schwartz E. : E.I.D; 1999,824-6

12 Dengue Seroconversion /month of Exposure S.E Asia- 5/451= 1.1% (95% CI= %) S. America-1/159=0.6% (95% CI= %) Africa-1/25= 4% (95% CI= %) Potasman I, Srugo I, Schwartz E. : E.I.D; 1999,824-6

13 Dengue Seroconversion among Dutch Travelers to Asia 447 travelers to Asia Short-term (1 month) Study period during Cobelens FG et al; Trop Med Int Health 2002;7:331-8.

14 Dengue Seroconversion /month of Exposure Seroconversion rate of 2.9% The incidence was 30 per 1000 personmonths of travel (pmt). and 6.9 per 1000pmt for clinical infection. Cobelens FG et al; Trop Med Int Health 2002;7:331-8.

15 MORBIDITY AND MORTALITY IN TRAVELERS TO DEVELOPING CONTRIES: RATES / MONTH OF STAY Travelers Diarrhea Malaria Dengue Acute febrile respiratory tract infections Hepatitis A Gonorrhea Hepatitis B Typhoid (India; N, NW-Africa) HIV-infection Legionellosis Typhoid (other areas) Poliomyelitis, asymptomatic 100% 100,000 10% 10,000 1% 1, % % % 1 Cholera % Paralytic poliomyelitis 0,00007% Any health problem: used medication or felt ill Felt subjectively ill Consulted doctor abroad or home Stayed in bed Incapacity of work after return Hospitalized abroad Air evacuation Died abroad (PVC) Died abroad (any traveler) Steffen in Manson s, 1999, p 407

16 Year Dengue Fever - Israel Total-156 No. of Cases

17 Year Dengue Fever - Thailand Total=87 No. of Cases

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19 Distribution of dengue cases according to seasons Rainy season 80% 48% 32 % Dry season 20% 52% 68 % Schwartz E. WHO, Dengue Bull. Dec.2002

20 GEOSENTINEL SURVEILLANCE SITES GeoSentinel The Global Surveillance Network of the ISTM and CDC A worldwide communications and data collections network of travel/tropical medicine clinics

21 Dengue Cases, Percent of Morbidity per Month 8 6 Percent of Morbidity % 9/97 1/98 5/98 9/98 1/99 5/99 9/99 1/00

22 Dengue Fever: Clinical Aspects *Asymptomatic infection *Classical Dengue fever *Complicated DF (DHF/DSS)

23 Dengue- Asymptomatic Infection In the endemic countries most infections are asymptomatic. Among travelers?

24 Asymptomatic Infection Israeli Study; 104 travelers Dutch study; 447 travelers 3/7- asymptomatic 8/13 asymptomatic Ratio- 1:0.75 Ratio- 1:3.3

25 Dengue Fever-Classical

26 D.F- Symptoms Europe Sweden USA Israel TropNet C.I.D 2002 E.I.D 2003 MMWR; Am.J. Med 1996 Fever 86 % 100 % 95 % 100 % Headache 60 % 75 % 62 % 83 % Fatigue 43 % N.R N.R 100 % Myalgia 42 % 73 % 50 % 26 % Rash 29 % 62 % 53 % 44 % Hospitalization 25 % 66 % Average days 5 days 3 days

27 DHF/DSS

28 DHF/DSS in Travelers GeoSentinel Inern l Net EuropeTrop Net (C.I.D 2002) CDC MMWR Number of Travelers DHF/DSS 2% 2% 1.8% Death cases =0.7% or=0.2%

29 Global Dengue Disease Burden Reported (1998) Estimates No. Dengue cases/year 1.2 million 51 million No. DHF/DSS cases/year No data 400,000 No. deaths/year 3,500 15,000 WHO/CDS

30 WHO/CDS Global Dengue Disease Burden Reported (1998) Estimates No. Dengue cases/year 1.2 million 51 million No. DHF/DSS cases/year No data 400,000 [=0.8%] No. deaths/year 3,500 [=0.3%] 15,000 [=0.03%]

31 Dengue infection-outcome Significant morbidity * Interruption of the trip * Dengue hemorrhagic fever (DHF) Dengue shock syndrome (DSS) * Death

32 Estimate rate of dengue infection and outcome in travelers to endemic area (S.E. Asia)/month 3-5-Death DHF/DSS hospitalization/ evacuation 700 symptomatic DF 3000-Dengue infection 100,000 travelers to endemic area

33 Diagnosis of DF in Travelers

34 Cross-reaction of Dengue Ab. Among Vaccinees with J.E & Y.F % IgG Positive Control 11 J.E short J.E long 44 Y.F short 42 Y.F long J.E+Y.F N=100 vaccinees Schwartz E. et al: J. Clin Virol. 2000,

35 IgM seroconversion during Acute DF Patient First day of IgM Schwartz E. et al: J. Clin Virol. 2000,

36 Dengue cross reactivity with West-Nile Fever patients IgM+ IgG+ 8/37= 22% 15/30= 50% Bin et al., National Ctr.for Arboviruses, CVL, MOH, Sheba Medical Ctr., Israel

37 Conclusions: D.F is a significant disease among travelers Travelers can be sentinels for changing epidemiology of the disease. The attack rate is similar to Hepatitis A (without vaccine), or to Malaria in Africa without prophylaxis. There is a need to improve diagnosis (rapid test of Ag. Detection). There is an urgent need for vaccine.

38 Dengue cross-reactivity (X-R) with West Nile fever patients Complete X-R Partial X-R No X-R IgM 5/37 (13.5%) 3/37 (8.1%) 29/37 (78.4%) IgG 10/30 (33.3%) 5/30 (16.7%) 15/30 (50%) Bin et al., National Ctr.for Arboviruses, CVL, MOH, Sheba Medical Ctr., Israel

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40 Dengue Seroconversion among Israeli Travelers to Tropical Countries Number 104 travelers Age (mean) years Trip (average)- 6 (3-16) mo. Destination- S.E. Asia- 70 % S. America- 24 % Africa- 4% Combined-2% Potasman I, Srugo I, Schwartz E. : E.I.D; 1999,824-6

41 Dengue Seroconversion; Results: 7/104= 6.7 % (95% CI= %) 4/104= 3.8 % ; IgM + 3/104= 2.8% ; IgG+ 3/7- were asymptomatic Potasman I, Srugo I, Schwartz E. : E.I.D; 1999,824-6

42 Distribution of dengue cases according to seasons Rainy season 80% 48% 32 % Dry season 20% 52% 68 %

43 GeoSentinel Database CDC & ISTM List of most frequent diagnosis All Travelers N=26408 Dengue diagnosis# 22 Percent of morbidity- 0.9% ISRAEL N=1046 Dengue diagnosis# 6 Percent of morbidity- 5% Date: June,2002

44 Dengue Fever Break- bone fever Dandy fever Denguero fever Geraffe fever Polka fever 5-7 days fever Donkey fever

45 Israeli data 27 hospitalized 69 days ~ 3 days (2.6)

46 Thanks to the Central Virology Lab. staff At Sheba Medical Ctr. Dr. Ella Mendelson Dr. Hanna Bin Dr. Zehava Grossman Mr.Fernando Mileguir

47 Diagnosis of DF in returning travelers hospitalized with febrile illness Country Ref Total number of febrile pts. Number of DF cases/ % Year of study Canada MacLean (see below) % UK Doherty (see below) % Germany Australia Jelinek(ref 27) Obrien (ref 40) % ? Please check I do not have the paper % Israel Abst. (see below) %

48 symptoms Europe (jelinek) Sweden (Lindback) US MMW R No. travelers Fever % 100 Headache 60% 78% 62% 83 Fatigue 43% Not reported Not reporte d Rash 29% 62% 53% 44 Israel Am.J.Med Myalgia/arthralgi a 42% 73% 50% 28 Vomiting/nausea 8% 16% 25% 38 Hemorrhagic manifestation 28% 13% 22 DHF/DSS 2% 3+ (2 death) cases Death cases 0 0 Hospitalization 25% Not reported 66%

49 World Distribution of Dengue Areas infested with Aedes aegypti Dengue in 1960 Areas with Aedes aegypti and recent epidemic dengue CENTERS FOR DISEASE CONTROL ANN PREVENTION

50 GeoSentinel: The Global Surveillance Network of the ISTM and CDC A worldwide communications and data collection network of travel/tropical medicine clinics

51 Malaria Cases, Percent of Morbidity per Month 20 Percent of Morbidity % 5 9/97 1/98 5/98 9/98 1/99 5/99 9/99 1/00 Month of Office Visit, N=303 cases