History and particular features of dengue epidemiology in French Polynesia Van-Mai Cao-Lormeau, Claudine Roche, Elodie Descloux, Jérôme Viallon, Stéphane Lastère re, Axel Wiegandt Institut Louis Malardé Direction de la Santé de Polynésie Française
Introduction French Polynesia Geography 120 islands, 5 archipelagoes Inhabitants > 259 000 inhabitants (37,3% under 20 years) Population flows - 220 000 tourists/year - cyclic renewal of one part of the working population (civil servants, teachers, militaries, coming from France and staying in FP for 3-6 yrs) Climate Hot and rainy season (november to april) Cooler and dry season (may to october)
Introduction Dengue Mosquito-borne disease affecting most of the tropical and subtropical regions 2,5 billion people exposed, > 50 million cases/yr, > 500 000 hospitalizations/yr, >24 000 deaths (mostly children) Dengue virus belongs to the Flavirirus genus (family Flaviviridae) (West-Nile, Yellow Fever, Japanese Encephalitis) Four DV serotypes (DV1-4), each includes several genotypes (phylogenetic classification - Envelope gene) DV is transmitted by mosquitoes from the Aedes (Stegomyia) specie principally Ae aegypti endemic vectors (Ae polynesiensis in the polynesian triangle) Clinical spectrum of DV infection Dengue Fever (DF) Dengue Hemorrhagic Fever (DHF) Dengue Shock Syndrome (DSS)
Introduction Dengue in the South Pacific Earliest dengue epidemics: second part of the XIXth century (1882 FP/NC) DV emergence in the Pacific: after World War II 1943-44: DV1, first reported dengue pandemic in the South Pacific, including FP 1965: DV3 in FP Since the 70s, whole chains of dengue epidemics occurred in the South Pacific - DV2 in the early 70s (first reported DHF cases in the South Pacific, in FP in 1971) - DV1 in the late 70s (DHF cases in Tonga 1975) - DV4 in the 80s - DV1 and DV3 in the 90s - DV2 in the late 90s - DV1 in 2000-03 and 2006-08, currently circulating - DV4, since 2008 Nauru, Samoa, American Samoa, Kiribati, Fiji, Vanuatu, New Caledonia and French Polynesia (imported cases detected in Cook islands, Wallis & Futuna,)
I. Dynamic of dengue epidemics in French Polynesia History of dengue virus circulation in French Polynesia Epidemiological features Epidemic - emergence: a) new introduction (Americas, SE Asia, Pacific) b) re-ermergence of the endemic strain (molecular data) - season and climate (outbreaks can occur at any season) - epidemic duration (average: 8 mths) - epidemic pattern
I. Dynamic of dengue epidemics in French Polynesia
I. Dynamic of dengue epidemics in French Polynesia History of dengue virus circulation in French Polynesia Epidemiological features Epidemic Inter-epidemic period - post-epidemic emergence: a) period new introduction and endemic (Americas, transmission SE of Asia, DV Pacific) strains b) re-ermergence of the endemic strain (molecular data) - non-persistent co-circulation of serotypes - season and climate (outbreaks can occur at any season) - delay epidemic between duration epidemics (average: 8 mths) - epidemic epidemics pattern due to different serotypes: average 3 yrs epidemics due to same serotype (different genotypes): average 21 yrs re-ermergence of an endemic strain: average 5 yrs
II. Attack rates and affected population Attack rates per year of birth for 5 successive dengue epidemics Attack rates / 100 000 inhabitants 7-15 yrs mostly affected <14 yrs never exp. DV1 epidemic > 5 yrs exp. DV4 epid. 3000 2500 1988/89 DV1 >18 yrs infections 20-22 yrs peak? exp. DV4, DV1, DV2 epid. asymptomatic IIIary 2000 20/22 yrs 37-39 yrs peak (new residents?) 1500 1000 37/39 yrs 15 yrs 7 yrs 500 0 Year of birth 1944 1965 1969 1971 1975 1979 1985 1988 1990 1996 2001 2006
II. Attack rates and affected population Attack rates per year of birth for 5 successive dengue epidemics Attack rates / 100 000 inhabitants 3000 2500 2000 1996 DV2 5-17 yrs >8 yrs mostly affected exp. DV3, DV1 epid. asymptomatic IIIary never exp. DV2 epid. >12 yrs exp. DV3, DV1, DV4 epid. asymptomatic IIIary or IVary infections 32-40, 47-51 yrs peaks (new residents?) 1500 1000 47/51 yrs 37/40 yrs 32/34 yrs 17 yrs 5 yrs 500 0 Year of birth 1944 1965 1969 1971 1975 1979 1985 1988 1990 1996 2001 2006
II. Attack rates and affected population Attack rates per year of birth for 5 successive dengue epidemics Attack rates / 100 000 inhabitants 3-13 yrs >4 yrs mostly affected never exp. DV1 epid. exp. DV2 epid. 3000 1988/89 >13 yrs exp. DV2, DV3, DV1 epid. asymptomatic IIIary or IVary infections 2500 2001 DV1 2000 1500 1000 13 yrs 3 yrs 500 0 32/34 yrs Year of birth 1944 1965 1969 1971 1975 1979 1985 1988 1990 1996 2001 2006
II. Attack rates and affected population Attack rates per year of birth for 5 successive dengue epidemics Attack rates / 100 000 inhabitants 3000 2500 2000 2001 2006/07 DV1 3-17 yrs mostly affected >6 yrs exp. DV1 epid. >10 yrs exp. DV1, DV2 epid. >17 yrs exp. two DV1, DV2, DV3 epid. asymptomatic IIIary or IVary infections 27-37, 46, 53-57 yrs peaks (new residents?) 1500 1000 57 yrs 53 yrs 37 yrs 27 yrs 17 yrs 3 yrs 500 0 Year of birth 1944 1965 1969 1971 1975 1979 1985 1988 1990 1996 2001 2006
II. Attack rates and affected population Attack rates per year of birth for 5 successive dengue epidemics Epidemics that emerged just after the introduction of a new serotype most targeted population: 4-15 yrs (in majority children born after the previous epidemic of same serotype) previous exposure to 1 heterologous serotype: no impact the attack rates (no heterotypic immune protection) previous exposure to >1 heterologous serotype: under-estimate of the attack rates (occurrence of more asymptomatic infections) peaks in ranges of ages corresponding to the working population : due to the cyclic renewal of one part of this population The 2006-07 DV1 (genotype IV) re-emergence - mostly affected: 3-17 yrs old (a big part was born before the 2001 epidemic) - there was a broad increase in attack rates for several ranges of ages The 2006 re-emergence was based on the renewal of the susceptible population particularly due to new residents (families)
Conclusion Epidemiology in FP follows a recurrent model - introduction of a serotype that hasn t circulated for years - epidemic - endemic transmission - re-placement by a new introduced serotype or re-ermergence of the endemic strain (5-6 years after the 1st epidemic) How to explain - the re-emergence of an endemic strain? - the non-persistent co-circulation of serotypes? Why is this epidemiological situation of interest for dengue research? - studies on dengue infected patients (anti-dv memory immunity, human genetic factors and outcome of infection) - genetic evolution of dengue viruses What about the situation in the South Pacific region? - long term predominance of a specific serotype/genotype
Conclusion References Chungue E, Boutin JP, Roux J (1991). European Journal of Epidemiology 7(6), 616-20 Chungue E, Deubel V, Cassar O, Laille M, Martin PM (1993). Journal of General Virology 74(12), 2765-70 Chungue E, Cassar O, Drouet MT, Guzman MG, Laille M, Rosen L, Deubel V (1995). Journal of General Virology 76(7), 1877-84 Chungue E, Deparis X, Murgue B (1998). Public Health and Dialog, 5, 154-62 Hubert B (2002). www.spc.org.nc/phs/rossp/epidemies/rapports/dengue2001-polynesiefrancaise.pdf Laille M & Roche C (2004). The American Journal of Tropical Medicine and Hygiene 71(4), 478-84 Singh N., Kierdzynski T, Lepers C, Benyon EK (2005). Pacific Health Surveillance and Response 12(2), 111-19 Wiegant A, Lastere S, Hirshauer C, Loncke S (2006). Inform ACTION N 25 Wiegant A, Renou L, Louette R, Melix G, Hirshauer C, Lastere S, Roche C (2007). Inform ACTION N 27, Cao-Lormeau VM, Roche C, Teyssou R (2007). Bulletin d Informations Sanitaires et Epidémiologiques 6, 5-6 Lepers C (2008). Inform ACTION N 29 Acknowledgments Direction de la Santé de Polynésie Française (Bureau de Veille Sanitaire - Dr HP Mallet)
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