Communicable Diseases and Environmental Determinants of Health Department, PAHO, Washington, DC, USA.
Robert Stempel College of Public Health and Social Work, Florida International University, Miami, FL, USA.
Trop Med Int Health. 2019 Apr;24(4):442-453. doi: 10.1111/tmi.13200. Epub 2019 Jan 28.
OBJECTIVE: Since the 1980s, dengue incidence has increased 30-fold. However, in 2017, there was a noticeable reduction in reported dengue incidence cases within the Americas, including severe and fatal cases. Understanding the mechanism underlying dengue's incidence and decline in the Americas is vital for public health planning. We aimed to provide plausible explanations for the decline in 2017. METHODS: An expert panel of representatives from scientific and academic institutions, Ministry of Health officials from Latin America and PAHO/WHO staff met in October 2017 to propose hypotheses. The meeting employed six moderated plenary discussions in which participants reviewed epidemiological evidence, suggested explanatory hypotheses, offered their expert opinions on each and developed a consensus. RESULTS: The expert group established that in 2017, there was a generalised decreased incidence, severity and number of deaths due to dengue in the Americas, accompanied by a reduction in reported cases of both Zika and chikungunya virus infections, with no change in distribution among age groups affected. This decline was determined to be unlikely due to changes in epidemiological surveillance systems, as similar designs of surveillance systems exist across the region. Although sudden surveillance disruption is possible at a country or regional level, it is unlikely to occur in all countries simultaneously. Retrospective modelling with epidemiological, immunological and entomological information is needed. Host or immunological factors may have influenced the decline in dengue cases at the population level through immunity; however, herd protection requires additional evidence. Uncertainty remains regarding the effect on the outcome of sequential infections of different dengue virus (DENV) types and Zika virus (ZIKV), and vice versa. Future studies were recommended that examine the epidemiological effect of prior DENV infection on Zika incidence and severity, the epidemiological effect of prior Zika virus infection on dengue incidence and severity, immune correlates based on new-generation ELISA assays, and impact of prior DENV/other arbovirus infection on ZIKV immune response in relation to number of infections and the duration of antibodies in relation to interval of protection. Follow-up studies should also investigate whether increased vector control intensification activities contributed to the decline in transmission of one or more of these arboviruses. Additionally, proposed studies should focus on the potential role of vector competence when simultaneously exposed to various arboviruses, and on entomological surveillance and its impact on circulating vector species, with a goal of applying specific measures that mitigate seasonal occurrence or outbreaks. CONCLUSIONS: Multifactorial events may have accounted for the decline in dengue seen in 2017. Differing elements might explain the reduction in dengue including elements of immunity, increased vector control, and even vector and\or viruses changes or adaptations. Most of the results of this expert consensus group meeting are hypothetical and based on limited evidence. Further studies are needed.
目的:自 20 世纪 80 年代以来,登革热发病率增长了 30 倍。然而,2017 年美洲报告的登革热发病率病例,包括严重和致命病例,均出现显著下降。了解登革热在美洲发病率下降的机制对于公共卫生规划至关重要。我们旨在为 2017 年的下降提供合理的解释。
方法:来自科学和学术机构的专家小组代表、拉丁美洲卫生部官员和泛美卫生组织/世界卫生组织的工作人员于 2017 年 10 月举行会议,提出假设。会议采用了六次专题小组讨论,与会者审查了流行病学证据,提出了解释性假设,对每个假设发表了专家意见,并达成了共识。
结果:专家组确定,2017 年,美洲的登革热发病率、严重程度和死亡人数普遍下降,同时寨卡病毒和基孔肯雅热病毒感染的报告病例也有所减少,而受影响年龄组的分布没有变化。这种下降不太可能是由于流行病学监测系统的变化所致,因为该地区存在类似的监测系统设计。尽管在国家或区域一级突然中断监测是可能的,但不太可能同时发生在所有国家。需要使用流行病学、免疫学和昆虫学信息进行回顾性建模。宿主或免疫因素可能通过免疫在人群水平上影响登革热病例的下降;然而,群体保护还需要更多的证据。关于不同登革热病毒(DENV)类型和寨卡病毒(ZIKV)以及反之亦然的连续感染对结果的影响仍存在不确定性。建议进行未来的研究,以检验先前登革热感染对寨卡病毒发病率和严重程度的流行病学影响、先前寨卡病毒感染对登革热发病率和严重程度的流行病学影响、基于新一代 ELISA 检测的免疫相关性,以及先前 DENV/其他虫媒病毒感染对寨卡病毒免疫反应的影响,包括感染次数和抗体持续时间与保护间隔的关系。后续研究还应调查增加病媒控制强化活动是否有助于减少这些虫媒病毒中的一种或多种的传播。此外,拟议的研究应侧重于当同时接触多种虫媒病毒时媒介的易感性的潜在作用,以及昆虫学监测及其对传播媒介物种的影响,目的是采取具体措施减轻季节性发生或暴发的情况。
结论:多种因素可能导致 2017 年登革热的下降。不同的因素可能解释了登革热的减少,包括免疫因素、增加病媒控制,甚至媒介和/或病毒的变化或适应。专家组会议的大多数结果都是假设性的,并且基于有限的证据。还需要进一步的研究。
Trop Med Int Health. 2019-1-28
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