Kanal Pengetahuan | Seminar Nasional : “Tantangan baru pengendalian penyakit arbovirus di Indonesia: Dengue, Chikungunya atau Zika”

Epidemiology of Arboviruses
Challenge to Control

Citra Indriani
Departemen Biosta;s;k, Epidemiologi dan Kesehatan Populasi
Fakultas Kedokteran, UGM

Slide adopsi dari Riris Andono Ahmad

Outline
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Arbovirus
Arbovirus of Public Health Importance
Main transmission cycle
Brief on Dengue, Zika, Chikungunya
Global Distribu;on of Arbovirus

–  Dengue, Zika and Chikungunya

•  Challenge in Control

Arbovirus
"ARthropod Borne Virus".
•  Not taxonomic indicator – describe need of vector on
their transmission
•  Viruses that are transmi(ed between arthropod and
vertebrates (people and mammals)
•  Arthropod
–  mosquitoes, ;cks, sandflies, midges, bugs, etc.
–  the infected one don’t show detectable sign of sickness an
–  virus may remain for life


Arbovirus
"ARthropod Borne Virus".

1985

20XX

14 families
535 species

?

•  Not all are pathogen
•  Highly adapted virus
•  Immense resource for emergence new pathogen in future
Karabatsos N. Interna;onal catalogue of arthropod-borne viruses. 3rd ed. San Antonio: American Society for Tropical Medicine and
Hygiene, 1985.
Liang, G., Gao, X., & Gould, E. A. (2015). Factors responsible for the emergence of arboviruses; strategies, challenges and limita;ons for
their control. Emerging Microbes & Infec1ons, 4(3), e18–. h`p://doi.org/10.1038/emi.2015.18

Arbovirus
•  100 species
•  4 main families

Pathogen to Human

– 
– 
– 
– 

Flaviviridae
Togaviridae
Bunyaviridae
Reoviridae

•  wide range
–  sub clinic – fatal
haemorrhagic/encephali;s

Disease in Human

•  oden resolve spontaneously
•  no specific treatment,

–  symptoma;c treatment, fluid
therapy

Most Arbovirus of
Public Health Importance
Transmi(ed by

Flaviviridae
Flavivirus genus

Mosquitoes

• 
• 
• 
• 
• 


Ticks

• 
• 

Dengue
Zika
Yellow Fever
Japanese E
West Nile

Tick-borne Encephali;s
Kyasanur Forest Disease
(KFD)
•  Alkhurma Disease
•  Omsk Hemorrhagic
Disease

Togaviridae
Alphavirus genus
• 

• 
• 
• 
• 
• 

Bunyaviridae
Bunyavirus genus

Chikungunya
Mayaro
O nyong nyong
Eastern equine encephali;s
Western equine encephali;s
Venezuela equine encephali;s
• 

Crimean-Congo
Hemorrhagic
Fever (CCHV)

US CDC, Na;onal Center for Emerging and Zoono;c Infec;ous Diseases (NCEZID) Division of High-Consequence Pathogens and
Pathology (DHCPP) Viral Special Pathogens Branch (VSPB), April 2014
Dash AP1, Bha;a R, Sunyoto T, Mourya DT (2013). Emerging and Re-emerging Arboviruses in South East Asia. J Vector Borne
Disease 50. June 2013.

Examples of Arthropod Vectors

Source: CDC

Aedes Aegyti

Assorted Ticks

Source: University of Florida, Dept Entomology

Culex Mosquito

Phlebotmine Sandfly

Transmission Cycle
Man - arthropod - man Animal - arthropod vector – man (zoonosa)
Dengue**
Zika**
Chikungunya**
Urban Yellow Fever*

Example

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• 
• 
• 

Reservoir

•  Man
•  Arthropod vector

Other

• 
• 
• 
• 

Japanese encephaliYs (JE)**
Eastern equine encephali;s (EEE)
Western equine encephali;s (WEE)
Jungle Yellow fever*

•  Animal

•  virus is maintained in nature in a transmission
cycle involving the arthropod vector and
•  Arthropod transovarial
transmission may take
animal
•  Man becomes infected incidentally.
place

* Both cycle may be seen with some arbovirus such as yellow fever
** iden;fy in Indonesia

Brief on Dengue, Zika, Chikungunya
Dengue

Chikungunya

Zika

•  Clinical descrip;on 992
China
•  Batavia- joint fever
•  1990: Viral e;ology
(Ashburn and Craig)
•  Fever, myalgia, arthralgia,
headache, rash, nausea
and vomit

•  1953 in Tanzania
•  Severe artralgiapersist
•  Local name
Makande-bends
up
•  Similar to dengue
and zika

•  1947 Uganda Forest
•  Zika forest
•  Iden;fied in
Macaque monkey
•  Fever, rash, non
purulent
conjunc;vi;s

Fatal/
•  Fatal
Disability

•  Rare fatal
•  Chronic joint pain

•  Rare fatal excl. GBS
•  Pregnancy outcome

Asympto
ma;c

•  yes


•  yes

History

•  yes
•  50%

•  First well documented
outbreak 1779 -1780
Outbreak
•  1956 in Manila : DEN 3 &
4

•  2004 large
outbreak Africa
and Southeast
Asia
•  2015 rapidly
progress western


•  Africa, South East
Asia un;l 2007 –
Micronesia (73% of
island was infected
during outbreak)
•  December 2015 –
Brazil suspected 1.3

Global Distribu;on Arboviruses
Dengue, Zika, Chikungunya

Geography distribu;on of Dengue

Blue dot: Geographic extension of dengue 2000-2007
Blue shaded areas: Risk of dengue transmission
Lines: Lines demarcate the area where the vector for dengue exists

Global geographic distribu;on of DENV
(1940 – 2013)

Suitability for Dengue Transmission

Suitability for Dengue
Transmission
High suitability

Low suitability
Unsuitable or nonendemic

Dengue Es;mated annual economic
burden in SE Asia (in million USD 2010)

Zika virus

•  63 countries ac;ve transmission, 20 countries report
microcephaly and other neurological abnormali;es
•  2 cases in Jambi
•  115 locally acquired cases in Singapore as of today
•  Previously found in Klaten among hospitalized
pa;ents in late 70’s

Global Chikungunya DistribuYon

Countries and territories where chikungunya cases have been reported* (as of April
22, 2016)
Chikungunya was first iden;fied in Tanzania in the early 1952 and has caused periodic outbreaks in Asia and Africa since the 1960s.

Countries Areas at Risk

Historical overview of Chikungunya Outbreak

EsYmated Global DistribuYon of
Dengue, Zika, and Chikungunya, 2016

Pa`erson, J., Sammon, M., & Garg, M. (2016). Dengue, Zika and Chikungunya: Emerging Arboviruses in the New World. Western Journal of Emergency
Medicine, 17(6), 671–679. h`p://doi.org/10.5811/westjem.2016.9.30904

Range DistribuYon of Ae.aegypY and Ae. Albopictus
in US

Ae. aegyp;

Ae. albopictus

Pa`erson, J., Sammon, M., & Garg, M. (2016). Dengue, Zika and Chikungunya: Emerging Arboviruses in the New World. Western Journal of Emergency
Medicine, 17(6), 671–679. h`p://doi.org/10.5811/westjem.2016.9.30904

Disease Spread Globally
Dengue, Zika, Chikungunya

Global Air Travel

•  59,036 routes (2012),
•  37.4 million flights (2014),
•  3.6 billion passengers (2016)

Challenge in Control Strategy
Dengue, Zika, Chikungunya

Opportunity to control - Challenge
natural history

Epi triangle
Agen

Time

Infected
SuscepYble
host

Clinical
horizon

Death

Cure
Non infected

IncubaYon period
Latent
Exposure

- 
- 
- 

InfecYous

Non-infecYous

Host

Onset

Environmental
Host

Agen


: vector control
: decrease suscep;bility
: decrease infec;on period

Enviro

Global Strategy
TREATMENT, PREVENTION AND CONTROL

GOAL:
TO REDUCE THE BURDEN OF DENGUE

OBJECTIVES:
2O12–2O2O

GLOBAL STRATEGY
FOR DENGUE PREVENTION AND CONTROL

UÊ /œÊÀi`ÕViÊ`i˜}ÕiʓœÀÌ>ˆÌÞÊLÞÊ>Ìʏi>ÃÌÊxä¯ÊLÞÊÓäÓäI
UÊ /œÊÀi`ÕViÊ`i˜}ÕiʓœÀLˆ`ˆÌÞÊLÞÊ>Ìʏi>ÃÌÊÓx¯ÊLÞÊÓäÓäI
UÊ /œÊiÃ̈“>ÌiÊ̅iÊÌÀÕiÊLÕÀ`i˜ÊœvÊ̅iÊ`ˆÃi>ÃiÊLÞÊÓä£x
IÊ/…iÊÞi>ÀÊÓä£äʈÃÊÕÃi`Ê>ÃÊ̅iÊL>Ãiˆ˜i°

Technical element 1:

Technical element 2:

Technical element 3:

Technical element 4:

Technical element 5:

Diagnosis and case
management

Integrated surveillance
and outbreak
preparedness

Sustainable vector
control

Future vaccine
implementation

Basic operational
and implementation
research

ENABLING FACTORS FOR EFFECTIVE IMPLEMENTATION OF THE GLOBAL STRATEGY:
UÊ
UÊ
UÊ
UÊ
UÊ

>`ۜV>VÞÊ>˜`ÊÀiÜÕÀViʓœLˆˆâ>̈œ˜Ê
«>À̘iÀň«]ÊVœœÀ`ˆ˜>̈œ˜Ê>˜`ÊVœ>LœÀ>̈œ˜Ê
Vœ““Õ˜ˆV>̈œ˜Ê̜Ê>V…ˆiÛiÊLi…>ۈœÕÀ>ÊœÕÌVœ“iÃ
V>«>VˆÌއLՈ`ˆ˜}Ê
“œ˜ˆÌœÀˆ˜}Ê>˜`ÊiÛ>Õ>̈œ˜

Case management - Dengue
•  Improve case management and diagnosis to prevent deaths
from dengue
–  Improve early clinical case detec;on for dengue with
warning signs and severe dengue;
–  Improve management of severe cases.

•  Improve capaci;es to facilitate a reduc;on in the burden of
the disease
–  Improve access health care services;
–  Reorganiza;on of health service for be`er managing
outbreak situa;ons;
–  Establish QA in both the private and the public sector;

Surveillance and outbreak preparedness
•  Improve surveillance to enhance repor;ng,
preven;on and control
–  Surveillance indicators – for clinical reasons, a minimum
set of indicators should be reported;
–  Risk indicators:
•  Mosquito breeding sites (i.e. household water storage containers, poor
urban water drainage)
•  Environmental control measures (i.e. ;ghtly fiung water storage lids,
presence of fish or other biological control measures, and regular cleaning
containers)

–  sen;nel sites for age- stra;fied seroprevalence and burden
of disease (including economic costs).
–  Serotype changes should be monitored con;nuously.

Sustainable vector control
•  Combina;on of:
–  Environmental management
–  Biological control
–  Chemical control

Future Strategy and Research
•  Develop therapeu;c drug
•  Develop vaccines
•  Develop vector controlled – not threat to wildlife
survival but locally reduce the incidence
•  Surveillance strengthening – capacity to detect
(include lab – feasible)
•  Link academia and public health prac;ce-
research program: pathogenicity, evolu;on,
emergence, dispersal
•  Strengthening public educa;on

Strengthening Public Educa;on
Tingkat Bahaya DBD
35

32
29.53

30
25.62
25
20
%
15
9.05

10
5
0

0.21

0.41

0.31

0.41

0.62

0

1

2

3

4

5

1.85

0
Skala 0 - 10

6

7

8

9

10

Tingkat Bahaya DBD di Lingkungan Tempat Tinggal
18
16.36
15.33

16
14
12

11.63

11.21
9.36

10

8.74

%

7.61

8

6.28

6.07
6
4.12
4

3.29

2
0
0

1

2

3

4

5
Skala 0 - 10

6

7

8

9

10

Cara Pencegahan DBD

Lo;on an; nyamuk

6.20

Lainnya, sebutkan

7.05

Fogging/pengasapan

13.56

Mengendalikan jumlah

38.07

Menjaga kebersihan rumah

84.44

0.00

10.00

20.00

30.00

40.00

50.00
%

60.00

70.00

80.00

90.00

End

Natural history