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Re-emergence of locally acquired Dengue Fever in Palm Beach County, Florida Robert Parkes, MD; Sandra Warren, MPH, JoEllen Alvarez, RN, MPH, Barbara Johnson, RN, BSN, Epidemiology Unit, Palm Beach County Health Department; John Pellosie, JR.,D.O., MPH., FAOCOPM, Chair, Department of Preventive Medicine, Nova Southeastern University Alina Alonso, MD, Director, Palm Beach County Health Department Dengue Virus • Single-stranded RNA flavivirus • Arbovirus (Arthropod-Born) Vector = mosquitoes • Same virus family that causes West Nile fever, St. Louis encephalitis, yellow fever • Causes dengue and dengue hemorrhagic fever Dengue Virus • Four virus serotypes (DENV-1, 2, 3, 4) • Provides specific life-time immunity for that serotype only • Presence of a serotype may cause infection with a different serotype to be worse Common Dengue Vectors Aedes aegypti and Aedes albopictus Incubation / Viremic Periods Source: CDC Dengue Fever • Often mild, non-specific • Sudden onset of high fever • Severe headache • Pain behind the eyes • Body aches and joint pains • Nausea or vomiting • Rash Dengue Hemorrhagic Fever • Severe abdominal pain • Bleeding from the nose, mouth, and gums • Frequent vomiting with or without blood • Black stools • Excessive thirst • Pale, cold skin • Restlessness or sleepiness Dengue Epidemiology • Re-emerging infectious diseases in the world • 50 to 100 million cases annually • 500,000 hospitalizations • 22,000 deaths (mostly children) • Occurs in explosive epidemics Dengue World Distribution in 2008 Dengue in the Americas 1980 – 2009 Dengue in USA • During 1946--1980, no cases of dengue acquired in the continental United States were reported. • Since 1980, a few locally acquired U.S. cases have been confirmed along the Texas-Mexico border • Temporally associated with large outbreaks in neighboring Mexican cities Dengue in Florida • Dengue previously endemic • Increase in imported cases • Warm climate, regular rainfall • Abundant vectors Imported Dengue in Florida IMPORTED DENGUE FEVER 160 140 120 100 80 60 40 20 0 1997 - 2011 1986 – 2008: Puerto Rico (41); Dominican Republic (21); Haiti (13) 2011: Bahamas (9); Puerto Rico (7); Haiti (3), Colombia (3), Trinidad (3) Vector Presence in Florida Dengue Fever in Key West, 2009 • September 1 - Monroe County Health Department notified of a New York resident diagnosed with dengue after travel to Key West • Issued a press release to the public and notified area physicians of potential for local transmission of dengue • Florida Keys Mosquito Control District implemented enhanced trapping and spraying of Aedes aegypti Number of locally acquired dengue cases (N = 28), by week of illness onset and method of identification --- Key West, Florida, 2009--2010 Locally acquired Dengue in Florida Cumulative 2011 Data as of 3 am, Dec 14, 2011 Palm Beach County Dengue Cases 2005-2011 Acquired in FL Acquired in US, not FL Acquired outside of US 2005 0 0 3 2006 0 0 3 2007 0 0 5 2008 0 0 4 2009 0 0 1 2010 0 0 7 2011 2 0 9 Purpose • To present two cases of locally acquired dengue fever in Palm Beach County, Florida in 2011 • To highlight the need for continued surveillance Methods • Case interviews and medical records review • Confirmatory testing using enzyme-linked immunosorbent (ELISA) and real time polymerase chain reaction (PCR)/reverse transcriptase PCR (RT-PCR) Methods • Transmission from recent imported cases and travel companions was assessed. • Environmental evaluation • Classified using the Dengue Fever case definitions for reportable diseases in Florida (1) Case Classification Confirmed: a clinically compatible case that is laboratory confirmed Test Days post onset Explanation Interpretation Real time PCR ≤ 5days Patient viremic while febrile Confirmatory ≤ 5days for acute >5 days for convalescent Negative IgM in acute followed by a positive IgM in convalescent specimen Confirmatory ≤ 5days for acute >5 days for convalescent Must be a 4 fold increase in titer between acute and convalescent Confirmatory IgM antibodies demonstrated in cerebrospinal fluid Confirmatory IgM (paired specimens, acute and convalescent) IgG (paired specimens,acute and convalescent) IgM antibody in CSF Case Classification Probable: a clinically compatible case with supportive serologic findings • A positive IgM antibody test on a single acute (late)- or convalescent-phase serum specimen to one or more dengue virus Case Classification Suspect: a clinically compatible case with both epidemiologic linkage criteria • Travel to a dengue endemic country, OR • Presence at a location with an ongoing outbreak within previous two weeks of dengue-like illness, OR • Association in time and place with a confirmed or probable dengue case Results • CASE 1: • On 9/30/2011, PBCHD received a positive lab for Dengue IgG • 49 yr female, fever, sweating, fatigue • DENV-1 positive by PCR/RT-PCR in acute serum • IgG antibodies positive in acute and convalescent serum Results • CASE 2: • On 10/3/2011, PBCHD received a positive lab for Dengue IgG • 23 yr male, fever, chills, headache, fatigue and meningeal signs • IgM and IgG antibodies positive in acute and convalescent serum • Serological findings consistent with previous infection of dengue fever (3) Results • Case 1 traveled to Haiti one month before onset of illness, outside incubation period (2) • None of case 1 travel companions were sick • Case 2 had no travel history outside Florida or the U.S. • Secondary transmission ruled out from recently imported cases Results • Environmental investigation – Aedes albopictus for both cases. Conclusion • Case 1- confirmed dengue fever • Case 2- probable dengue fever • Both acquired locally in Palm Beach County, Florida • Both cases recovered Control efforts implemented • County-wide mosquito advisory/alert were enacted • Information and updates were provided • Enhanced surveillance continued • No new cases have occurred Conclusion • It is essential to continue surveillance for Dengue Fever in Florida. References • 1. Florida Department of Health Bureau of Epidemiology. Surveillance case definitions for Select reportable diseases in Florida. Retrieved February 15, 2012, from http://www.doh.state.fl.us/disease_ctrl/epi/surv/CaseDefJan2010.pdf • 2. Heymann,D.L., (Ed.). (2008). Control of communicable diseases manual. Washington: American Public Health Association. • 3. Centers for Disease Control and Prevention. Dengue laboratory guidance and diagnostic testing. Retrieved February 15, 2012, from http://www.cdc.gov/dengue/clinicalLab/laboratory.html