Recommendations
p. 195-200
Texte intégral
Preamble
1The state-of-the-art survey reveals deficiencies in the availability and use of data and in the knowledge required to improve dengue control in the FDAs.
2The knowledge gap concerns basic knowledge of epidemiology and dengue control in general on the one hand, and more applied knowledge on the other. In this case, there is a lack of local investigations and of adaptation to the FDAs of knowledge acquired elsewhere.
3Improving knowledge and obtaining data in the FDAs is a main focus of the recommendations below for optimizing dengue control. The theme recurs in recommendations under all the headings below: entomology and vector control, epidemiological monitoring, clinical aspects, organizing the information and organisational systems, community participation.
4The last two groups of recommendations deal specifically with improving knowledge in spheres where more applied research is needed, and the training investment required to continually increase the knowledge store of all involved in dengue control.
5No specific recommendations on estimating the economic impact of dengue is made. An interview with a recognized expert revealed that, with the planet-wide spread of dengue and its clinical diversification in the FDAs and the Caribbean, the specific or relative cost of dengue is poorly understood and probably underestimated. It would therefore be useful to know more about it, although it is hard to assess exhaustively.
6Lastly, the experts wish to draw the attention of the blood products surveillance services to the risk of transmission of the dengue virus via blood transfusions, though they are aware that given the brevity of the viremia, the intensity of the fever and the treatment of transfused blood, this risk probably only concerns exceptional emergency situations.
Entomology and vector control
7To date, vector control operations are the major part of dengue control in the FDAs. Considerable resources are mobilized, but they have not made it possible to predict or halt the epidemics of recent years. Strengthening current operations will mean (a) greater involvement by stakeholders (b) standardization of the main entomological tools available and (c) rational insecticide use. Whence the following recommendations:
1. Promote general mosquito control, i.e. control of all mosquito species that bite humans and not only the dengue vector Aedes aegypti.
2. Standardize data entry of entomological records and preferably use the Yébakima index (weighted Breteau index) to monitor fluctuations in Ae. aegypti density.
3. Promote monitoring of insecticide efficiency and mosquito resistance, and resistance management methods, aiming for a rehabilitation of the use of temephos used alternately with other suitable insecticides.
4. Support EDEN's request to the EU to exempt extreme outlying territories from the European insecticides ban with regard to those that are indispensable for vector control and general mosquito control.
Epidemiological monitoring
8With the emergence of hemorrhagic dengue in recent years, there have been many meetings between actors in the field to discuss epidemiological monitoring in the FDAs. However, it seems to be necessary to improve biological diagnosis, monitoring of serotypes and circulation of information. This leads to the following recommendations:
5. Reinforce the international and interdepartmental role of the National Reference Center for the arbovirus and virus influenzae (CNR) in the Antilles-Guyane region, especially in its following mandates:
stimulating a laboratory network participating in the biological diagnosis of infection by dengue virus in the FDA's,
ensuring quality control in those laboratories,
collaborating with epidemiological and entomological surveillance networks, and microbiology networks, at the national, regional and international levels,
building up a reference collection of virus strains isolated in the region.
6. Secure permanently the availability of the serological and virological diagnosis of dengue, as well as the follow-up of the circulating serotypes, at least in one laboratory in each of the départements, Set up a systematic genotyping in particular cases such as the incept of epidemics, the emergence of a new serotype or cases of severe dengue.
7. Improve the characteristics of the dengue epidemiological surveillance system, in terms of sensitiveness, data quality, simplicity and acceptability, especially through the integration of the follow-up of indicators (dengue-like syndromes, biologically confirmed cases, circulating serotypes, hospitalised cases, severe dengue cases ...), in the information system of the S2E.Dengue project. Legitimate the notification of dengue cases through a legal procedure of “obligatory declaration” of biologically confirmed dengue cases, hospitalisations for dengue, deaths from dengue, for the implementation of individual and collective prevention measures (Art. R11-3 of décret 99-362 and Art. D11-2 of décret 99-363, both of 6th May 1999).
Clinical aspects
9As dengue extends its range on all continents, it presents a wider variety of clinical pictures. For the clinician, updating the clinical definition of dengue has become a necessity. We therefore recommend the following:
8. Review clinical definitions of dengue in the FDAs and make sure local clinicians' knowledge is updated.
Organisational factors, information systems and the new information technologies
10A large number of people are involved in local dengue control work, working in the private sector or for various administrative entities that function in different ways, with different sectoral intervention fields and information needs. Harmonization would be a step towards more comprehensive dengue control.
11There are numerous actors handling very large amounts of heterogeneous data from diverse sources: epidemiological data (nominative or not) from monitoring, entomological data, environmental data, socio-economic data, etc.
12We can therefore adopt as a general principle the pooling of knowledge and data analyses, and joint organisation of activities. In practice, this can be expressed in a number of recommendations that apply either at département level or at regional level, through existing links between département monitoring structures and those that cover the whole of the Caribbean and the Guyanas.
9. Organise the various dengue control actors in a formalized network including all the competencies needed for a comprehensive approach to dengue control, based on a collectively pre-established charter and possessing a permanent, long-term Internet platform responsible for data analysis and management and for circulating information and feedback.
10. Create a single database with data duly validated and standardized at the far upstream end, manage this database according to strict principles of automated data capture, interactivity, accessibility (for local communities and health workers) and guaranteed confidentiality.
11. Create a collegial decision body to supervise the network, with a membership chosen so as to fulfil two functions: policy and administration (defining the network's policy, setting objectives, planning resources) and technical-scientific (monitoring indicators, preparing operations, functioning as a crisis management unit during epidemic alerts).
12. At the regional level, strengthen and officialize the co-ordination and information exchange functions of CIRE, between the three départements' monitoring networks and with other Caribbean and South American networks, those of the PAHO and CAREC in particular; permanently maintain a French technical assistance epidemiologist's post within CAREC; generally promote French expertise on dengue fever in the Caribbean and the Americas.
Community participation
13Any attempt to change individual behavioural habits that affect dengue control and transmission must take into account the diversity, dynamics and changeability of social situations, with their historical, ethnic, economic, professional, and educational components etc. Such initiatives must be based on a sufficiently detailed social inventory to take account of local diversity and changes in the social fabric. The following recommendations are intended for the three départements:
13. Promote the gathering of scattered social data, utilize the data supplied by earlier initiatives, develop analysis tools to make available to decision-makers the information they need for decision-making on community mobilization and awareness campaigns.
14. Identify categories of individuals, communities and partner networks either as direct actors in community mobilization, as target groups, or as relays or transmitters of awareness messages; support collective initiatives towards mechanical elimination of mosquito breeding sites.
15. Fully integrate social communication into dengue control activities: mobilize the best existing expertise in health education and media techniques to design, produce and disseminate messages at least as effective as those people habitually receive in their daily lives.
Enhancing knowledge
14The gaps in current knowledge about dengue in the FDAs concern all three protagonists in the transmission process: man, vector and virus. To varying degrees in the three départements, the inadequacy of existing data concerns the biology and ecology of Ae. aegypti, its vector competence and capacity, viral infection in man and mosquito, clinical expression, epidemiology and the economic impact of the disease. The organisation and circulation of information is also deficient, both as regards surveillance between epidemics and operations during epidemics. These shortcomings hamper the capacity to forecast, prevent and manage epidemics. They should be addressed by targeted applied research. The following recommendations are aimed at this.
16. In the appropriate structures of the FDAs, promote the development and local adaptation of early, non-specific biological indicators, rapid diagnosis methods and differential diagnostic tools.
17. Conduct retrospective studies of genotype and IgM profile data in order to describe in greater detail the circulation of the viruses and how they emerge at the start of an epidemic.
18. Take part in the S2E.Dengue project and assess its potential for modelling, integrated analysis of all types of data, and detecting early signs of a coming epidemic.
19. Introduce into vector control a permanent operational research component:
enhance knowledge of the genetics and bio-ecology of Ae. aegypti in the different ecological and epidemiological contexts of the FDAs;
experiment locally insecticides new to the FDAs;
develop, assess and validate intervention strategies for both epidemic and inter-epidemic situations;
20. Develop a geographical information system (SIG-Dengue) capable of spatializing and integrating data of all kinds gathered or processed by the network.
Training
15The question of training can be glimpsed in the background throughout the experts' reports. Whether in the technical, scientific or social spheres, optimizing dengue control depends on improving knowledge and know-how. In the absence of any spectacular progress in developing anti-dengue drugs or vaccines, which is unlikely in the short term, what counts is to ensure that at every stage of surveillance and intervention, the methods and technologies used have proven their efficacy in the FDAs and are used in a timely and appropriate fashion. Whence the following recommendation, our last:
21. Introduce continuous training, retraining and skill updating programmes and quality control programmes tailored to the various categories of actors involved in dengue control. This especially applies to the mosquito control teams: they are the people closest to the ground facts, in contact with residents and mosquitoes, and so involved not only in day to day vector control but also in daily information exchange with the residents whose homes they visit.
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