The epidemiology of Dengue fever in the English speaking Caribbean over the last two decades is reviewed. Dengue cases reported to the World Health Organization, Pan American Health Organization, Caribbean Epidemiology Centre and in recent published papers were collated and analysed to determine the incidence and geographical distribution among the various countries. Dengue fever was observed among most Caribbean countries with various intensities of transmission. During 2010 all four dengue serotypes were found co-circulating within the Caribbean islands with crude fatality rates of 6 in Barbados, 4 in Jamaica, 3 in the Bahamas and 2 in Dominica. Similar numbers of males and females from the 20-39 age group were found with DHF but the 10-19 age group shows a slight increase in disease levels. Overall more males were reported with DF/DHF than females. The results show significant (P<0.002) increases in the number of DF/DHF cases and in Ae. aegypti indices during the rainy season compared to the dry season. Little data is available on the density of the Aedes aegypti population in the Caribbean region, and most information comes from Jamaica and Trinidad and Tobago.

1. 17
Abstract
The epidemiology of Dengue fever in the English speaking
Caribbean over the last two decades is reviewed. Dengue cases
reported to the World Health Organization, Pan American
Health Organization, Caribbean Epidemiology Centre and in
recent published papers were collated and analysed to determine
the incidence and geographical distribution among the various
countries. Dengue fever was observed among most Caribbean
countries with various intensities of transmission. During 2010
all four dengue serotypes were found co-circulating within the
Caribbean islands with crude fatality rates of 6 in Barbados,
4 in Jamaica, 3 in the Bahamas and 2 in Dominica. Similar
numbers of males and females from the 20-39 age group were
found with DHF but the 10-19 age group shows a slight increase
in disease levels. Overall more males were reported with
DF/DHF than females. The results show significant (P<0.002)
increases in the number of DF/DHF cases and in Ae. aegypti
indices during the rainy season compared to the dry season.
Little data is available on the density of the Aedes aegypti
population in the Caribbean region, and most information comes
from Jamaica and Trinidad and Tobago.
So, it is not surprising that dengue transmission in the Caribbean
region is expanding because without mosquito index data it is
very difficult to do adequate planning and implement new
methodologies to reduce dengue transmission in the region.
Introduction
Within the Caribbean and Latin American region Aedes aegypti
(L.) is the primary vector of urban Yellow Fever and Dengue
Fever (DF), including Dengue Haemorrhagic Fever (DHF) and
Dengue Shock Syndrome (DSS) [1]. Over the last 36 years, Ae.
aegypti eradication and control programmes have been conducted
throughout the Caribbean region [2] but in spite of these efforts,
DHF has emerged as a serious public health problem [3, 4].
Dengue infection is caused by any of 4 different serotypes of
the arbovirus (DEN-1, DEN-2, DEN- 3 and DEN- 4). Following
an incubation period of 2-8 days after an infective bite by the
Ae. aegypti mosquito, the disease usually occurs with sudden
onset of fever and headache, typically accompanied by any of
the following: chills, retro-orbicular pain, photophobia, backache,
severe muscle ache and joint ache. High fever may be experienced
over 5-6 days. Other significant signs and symptoms include a
generalized maculopapular rash, lymph node enlargement, a
positive tourniquet test, petechiae and haemorrhagic
manifestations, such as epistaxis and gastrointestinal bleeding
[5].
In 2012, over 3 billion people lived in areas where dengue was
endemic which included most counties between latitude 45º N
and 35ºS [1, 6]. Each year an estimated 100 million cases of
DF and several thousand cases of DHF occur, depending on
epidemic activity in different geographic regions [7]. Currently,
DF causes more illness and death than any other arbovirus
disease in humans [5, 8] and DHF is the leading cause of
hospitalization and death among children in many Southeast
Asian countries [8].
The recent emergence and re-emergence of DF and its
haemorrhagic manifestations within the Caribbean can be
attributed to numerous climatic and anthropological factors
including demographic (urbanization) and societal changes [9],
post World War II increases in the air and sea transportation [9,
10] and failure of Ae. aegypti programmes due to poor
management and little or no political will [11, 12].
In addition, dengue pandemics within the Caribbean have been
attributed to numerous biological factors: the introduction of
different dengue strains or serotypes within the Caribbean region
[13]; the vector Ae. aegypti developed resistance to conventional
insecticides [14, 15]; the vector, especially dengue infected
mosquitoes, require long feeding times [16]; changes in the
physical size and geographical origin of mosquito strains enhance
their vector potential [17]; and higher temperatures can shorten
the duration of the life cycle [18]. Behavioural studies have
confirmed that Ae. aegypti biting times showed varying patterns
with feeding occurring during the day and early evening in both
Africa and theAmericas [19,20]. However, Chadee and Martinez
[12] reported the collection of biting Ae. aegypti during both
day and night in urban areas. Their results suggested this new
behaviour pattern increased transmission of DF and explained
the origin of clusters of DHF cases.
In the Caribbean region water drums are the primary breeding
sites of Ae. aegypti [21, 22, 23]. These containers are used to
store water for drinking, washing, bathing and other household
needs. Therefore in theory, control of this vector in water drums
should be attained by the provision of an adequate water supply,
eliminating two-thirds of the disease vector population and
possibly reducing the incidence of DF [22, 24, 25]. However,
in the Caribbean region especially in Barbados, Jamaica and
Trinidad large sections of the human population live in rapidly
expanding urban areas with inadequate water supplies due to
rapid population growth and poor urban planning [22, 23].
Although DF was first identified in the Caribbean in the 1950’s,
it was not until 1979, that the first review of dengue outbreaks
in the Caribbean region was reported [26]. The review of the
1977-1978 epidemic outbreak demonstrated the wide
geographical distribution of DF cases and outlined the
implications for future outbreaks. However, no identifiable or
Commentary
Dengue Fever Epidemiology and Control in the Caribbean:
A Status Report (2012)
D.D. Chadee 1
PhD, MPH, DSc, R. S. Mahabir 2
MSc and J. M. Sutherland 1
PhD
Caribbean Medical Journal
1Department of Life Sciences, University of the West Indies, St. Augustine, Trinidad, West Indies
2Department of Geography and Geoinformation Sciences, George Mason University, Fairfax, VA, USA

2. 18
meaningful program changes were implemented to prevent
future episodes of DF and its haemorrhagic manifestations [28].
In 1981 the first major DHF epidemic occurred in Cuba due to
an outbreak of DEN-2 following an outbreak of DEN-1 and
resulted in 400,000 cases of DF, over 10,000 cases of DHF and
158 reported deaths after which some action was taken to re-
introduce systematic vector control programs [2]. In 1995 a
similar epidemic of DHF occurred in Venezuela with almost
30,000 DF cases and 5,000 DHF cases [27] and in Brazil where
over 120,570 DF cases, 647 DHF cases with 48 deaths were
reported in 2008 [28]. These outbreaks suggest that vector
control strategies previously adopted in the hemisphere did not
effectively reduce vector populations to below transmission
levels.
In Trinidad Dengue serotypes DEN-1, DEN-2 and DEN-4 are
endemic but the importation of Dengue 3 (DEN-3) from
Southeast Asia to the Caribbean region 1999 significantly
increased the risk and DHF outbreaks [6] were reported from
many Caribbean islands.
At present much information is available on the vector Ae.
aegypti, DF epidemiology and control from Trinidad but little
is known from the rest of the Caribbean region. This study
provides some information on the epidemiology of DF in the
Caribbean region supplemented by data from Trinidad providing
an update on the epidemiology and control of DF in the English
speaking Caribbean region.
Methods
In order to determine the DF disease patterns in the Caribbean
region data were obtained from records of the World Health
Organization, Pan American Health Organization (PAHO) and
the Caribbean Epidemiology Centre (CAREC) an organization
with over 21 member countries (Fig.1) , as well as data from
published papers from the Caribbean region. Due to problems
in accessing demographic information including age and sex
and spatial patterns from the region, available data from Trinidad
and Tobago were used to fill this gap in knowledge. Only the
data from the English speaking Caribbean region were recovered
and reviewed from the period 2000 to 2011 (i.e. Anguilla,
Antigua and Barbuda, Bahamas, Barbados, Cayman Islands,
Dominica, Grenada, Guyana, Jamaica, Montserrat, St. Kitts, St.
Lucia, St. Vincent and the Grenadines, Turks and Caicos,
Trinidad and Tobago). To determine the seasonal distribution
and dengue control strategies used, available data from Trinidad
and Tobago were analyzed because most of the published data
from the region comes from Trinidad and Tobago [6, 29].
Results
Geographic distribution of Dengue Fever in the Caribbean
Over the period 2008 to 2010, 23,431 cases of DF and DHF
cases were reported from 15 Caribbean countries. In 2008, 7,210
DF cases were reported with the most significant (G=724.5 df.9
P>0.01) number of cases being reported from Trinidad and
Tobago (86%), followed by Jamaica (7.5%), Barbados (3.4%)
and St. Lucia (1.5%) (Figure 1). In 2009, 3992 cases were
reported with the most significant (G=256.7 df. 13; P>0.02)
outbreak occurring in Guyana (83%) followed by Jamaica (6%),
Trinidad (2%) and Grenada (2%). In contrast, during 2010
12,229 cases were reported, with the most significant (G=387.2
df 14, P>0.02) outbreak occurring in the Bahamas (57%),
followed by St. Vincent and the Grenadines (10.1%), Guyana
(8.9%), Montserrat (7.6%) and Barbados (6.0%). (Table 1).
Epidemiology patterns, Dengue Incidence and Serotypes
Table 1 shows the number of reported DF/DHF cases in
Caribbean region with the largest number of cases reported
from the Bahamas (7,000 cases), St. Vincent and the Grenadines
(1243), Guyana (1,093), Montserrat (939) and Barbados (745).
During 2010 all four dengue serotypes were found co-circulating
within the Caribbean islands with crude fatality rates of 6 in
Barbados, 4 in Jamaica, 3 in the Bahamas and 2 in Dominica
Table 2 compares the dengue epidemiology patterns found
among 14 Caribbean countries for 2009 and 2012. The results
show a major outbreak of dengue occurred in the Caribbean
region during 2012 (12, 229 cases), with an incidence of 93.1
per 100,000 population, 23 deaths and a crude fatality rate of
0.1 whereas in 2009 there were fewer cases (3,992), a lower
incidence rate and fewer deaths recorded but the crude fatality
rates were higher 4.6.
Caribbean Medical Journal
DENGUE FEVER EPIDEMIOLOGY AND CONTROL IN THE CARIBBEAN: A STATUS REPORT (2012)
Table 1: Table 1. Number of Clinical Dengue cases , incidence
rate (x 100,000 population), dengue serotypes identified
and crude fatality rates (CFR) reported in the Caribbean
region in 2010
Table 2. Epidemiological parameters of Dengue Fever
among 14 Caribbean islands
Table 3 Gender and age group of persons contracting
DHF in 1998 and 2002
Age Group DHF 1998 DHF 2002
Males % Females% Males % Females %
0-4 5 2 7 5
5-9 5 12 6 13
10-19 28 26 24 23
20-39 39 39 43 33
40-59 18 17 18 23
60+ 5 4 2 3
20-39 39 39 43 33
40-59 18 17 18 23
60+ 5 4 2 3
100 100 100 100
Country Clinical Incidence Serotype Death CFR
Rate
Anguilla 9 69.2 D 4 0
Antigua & Barbuda 7 7.8 D 4 0
Bahamas 7,000 2,049 D 1,3 3
Barbados 745 273.9 D 1,2,3,4 6
Cayman Is 2 5.0 D 2 0
Dominica 40 56.3 D 1,4 2
Grenada 87 92.5 D 1 5
Guyana 1,093 143.2 D 4 0
Jamaica 408 15.7 D 1,4 4
Montserrat 939 60.0 D 1 0
St Kitts & Nevis 47 123.7 DEN 1
St Lucia 585 358.9 DEN 1
St Vincent & Grenadines 1243 44.3 DEN 0
Trinidad & Tobago 24 91.5 D 1,2,3,4 1
12,229
2009 2012
No Cases 3,992 12,229
Incidence 50.4 93.1
Deaths 2 23
CFR 4.6 0.1

3. 19
Age and gender
Table 3 summarizes the gender and age groups contracting DHF
in Trinidad in 1998 and 2002, these years representing two
different epidemics (see Table 3). When the data from the two
outbreaks were compared with respect to age and gender no
significant differences were observed (Table 3) with the age
profiles of males and females indicating similar numbers of
males and females (39%) from the 20-39 age group in 1998
and 43% among males and 33% among females in the 20-39
age group in 2002. In each of the years 1998 and 2002 the
combined 10-19 and 20-39 age groups for both males and
females accounted for over 60% of the DHF cases, that is, 67%
for males and 56.6% for females. The results show the number
of pediatric and geriatric cases were extremely low with pediatric
cases accounting for 10% in males and 13% in females in 1998
and 13% among males and 18% among females in 2002. Geriatric
cases accounted for 5% in males and 4% in females respectively
in 1998 and 2% for males and 3% for females in 2002. Published
data [6] clearly demonstrated a seasonal pattern of dengue fever
transmission, coinciding with the rainy season (May to
December). The monthly rainfall patterns and monthly incidence
of reported DF cases show that significantly larger numbers of
DF cases occurred during the rainy season (G=147.64 d.f 5 ;
P<0.001) than that occurring during the dry season (December
to May)(See Figure 2 ). For example, during 2002 5,019 cases
Caribbean Medical Journal
DENGUE FEVER EPIDEMIOLOGY AND CONTROL IN THE CARIBBEAN: A STATUS REPORT (2012)
were recorded with a significantly higher incidence rate during
the months of June, July, August, September and October
(P<0.001) than in other months of the year. Figure 2 shows the
monthly incidence of DF cases, rainfall patterns and the Ae.
aegypti mosquito indices with significant (P<0.002) peaks in
mosquito density coinciding with the onset of dengue
transmission during the rainy season.
Control measures
The prevention of dengue fever transmission involves the
management of Aedes aegypti mosquito populations. Within
the Caribbean region each country has responsibility for their
respective vector control programs with input from the PAHO
regional office in Barbados and the Caribbean Epidemiology
Centre (CAREC). All countries conduct focal inspections and
treatment using temephos 1% (technical grade insecticide) in
potable water holding containers [4, 21]. The main Ae. aegypti
breeding sites were water drums in Trinidad [22] and Jamaica
[23]. In Jamaica, Barbados and Trinidad and Tobago the vector
control programs are planned using adulticing (intra-domiciliary
spraying, space spraying using ultra-low-volume (ULV) spraying
and dyna-fogging), larviciding (focal treatment of containers
with temephos) and source reduction measures with health
education and community participation components [4, 14, 30,
31]. Little entomological data is currently available from the
Caribbean region except from Trinidad and Tobago with an
annual Aedes index of 12 [32] and 19 from Jamaica [23]
Table 4 shows the Ae. aegypti indices collected during the wet
and dry seasons in Jamaica and Trinidad. In Portland, Jamaica
all indices showed that the Ae. aegypti population density was
higher in the dry season than during the wet season. In contrast
the patterns observed in St Patrick, Trinidad were different with
higher container, house, Breteau and pupae per person indices
in the wet season than the dry season. Data on mosquito indices
have not been published from the other islands or Guyana for
15 years.
Discussion
Despite the relatively small number of cases reported during this
study, it is quite clear that DF is endemic in the Caribbean region
with some countries still experiencing outbreaks due to one
serotypes (e.g.Antigua & Barbuda,Anguilla) while the countries
with DHF and deaths reporting two or more co-circulating
serotypes like Barbados and Trinidad and Tobago [6, 10, 33].
These results suggest that the current epidemiologic pattern is
different from that reported in the 1970s and 1980s when dengue
outbreaks were attributed to a single serotype and occurred every
8 to 10 years [10]. However, the outbreak in Cuba in 1981
changed this pattern with the infection of DEN 2 following an
Figure 1. Showing the geographic distribution of English
speaking Caribbean countries and the number of dengue
cases reported during 2008 (source WHO 2012)
Figure 2
Table 4: The Aedes aegypti indices observed during the wet
and dry seasons in Jamaica and in Trinidad, West Indies.
Aedes aegypti indices
Country Season Container House Breteau Pupae/ References
person
Trinidad Wet 16.1 32.2 66.2 1.35 Chadee
(St.Patrick) Dry 10.1 12.7 26.0 0.75 2009
Jamaica Wet 17.6 19.0 3.4 2.7 Chadee et
(Portland) Dry 20.4 25.0 5.7 3.0 al. 2009
(No. of positive
containers for
larvae per 100
premises)

4. Caribbean Medical Journal
20
outbreak of DEN-1 [2]. Similarly, the introduction of DEN-3
from Southeast Asia to the Caribbean region in 1994, after an
absence of 17 years brought with it the fourth serotype and this
has increased the frequency of epidemic outbreaks at 3 to 5 year
intervals especially in Trinidad and Tobago (Table 5).
If this change in epidemiologic pattern continues, it gives cause
for concern as DF/DHF in the Caribbean islands may emerge
as a major public health problem with an increase in the
DHF/DSS burden of disease and the associated impacts on
morbidity and mortality rates, DALYS and economic cost [29].
Results from the present study are already showing that within
the first decade of the 21st century countries such as the Bahamas,
Guyana, St. Vincent and the Grenadines and Barbados
experienced major epidemics with significant numbers of DF,
DHF cases and deaths reported [33] (Table 2). Coinciding with
this emerging trend is significant evolutionary changes occurring
among the dengue serotypes, such as changes occurring within
DEN-3 genotype III strains which have been associated with
increased virulence and severe disease epidemics [34, 35].
Within the Caribbean region the age group with the highest
prevalence of DHF was the 20-39 age group in 1998 and in
2002 (Table 3). This pattern is completely different to that
observed in Southeast Asia where DHF occur primarily among
young children [36]. It is noteworthy that during two DHF
outbreaks in Trinidad (1998 and 2002) the number of pediatric
and geriatric cases were quite low with pediatric cases accounting
for 10% in males and 13% in females in 1998 and 13% among
males and 18% among females a in 2002. Studies in Latin
America suggest a similar trend with higher DHF prevalence
rates among adults than among children [29, 37]. However,
during the 2008 DHF outbreak in Brazil an increase in the
number of severe and fatal cases occurred among children [37].
It is postulated that this shift in age profile may be attributed
to the sequential transmission of DEN-3 followed by DEN-2
serotypes. A similar trend has been observed among the 10-19
age groups in Trinidad but these changes are not statistically
significant but should be monitored in the future.
Within the Caribbean region peak DF transmission occurs during
the latter part of the year (May to December) that is, during the
rainy season [6] when slightly higher numbers of males (61%)
than females (54%) were infected [6, 38]. The observed pattern
in Latin America is different with slightly higher infection rates
among females in Brazil, Cuba and in Mexico [28]. These results
suggest that variations in occupational and residential exposure
to infected mosquitoes may account for the different disease
patterns currently being observed in Trinidad and the rest of
the Caribbean region. Aedes aegypti mosquitoes live in close
association with man occupying both natural and artificial
containers - namely tree holes, buckets, tyres, water drums,
flower pots and animal watering pans [1, 25]. The higher
infestation of Aedes indices during the dry season in Jamaica
is interesting (Table 4) and suggest that dengue transmission
can occur during both the wet and dry seasons. The higher
mosquito indices during the dry season may be due to the
unreliability of the potable water supply and therefore the need
to store water in many containers like water drums. Therefore,
mosquito control efforts should be targeting the most productive
breeding sites. This is imperative as vaccines are not currently
available against any of the four DF serotypes, so control and
prevention rely primarily on emergency vector control and the
clinical management of DF/DHF cases [2, 4].
Due to the fact that very little data is available on the mosquito
indices it is unclear whether vector control programs are
adequately managed, however where entomological data exists
the Aedes indices far exceed the transmission thresholds [4].
These results support the view that within the Caribbean region
vector control programs are generally poorly staffed, poorly
managed and poorly funded due to a lack of political will, with
staff lacking an understanding of new control modalities [11-
12]. Therefore it is not surprising that dengue transmission in
the Caribbean region is expanding. For example, within Barbados,
Jamaica and Trinidad large sections of the human population
live in rapidly expanding urban areas with inadequate water
supplies due to rapid population growth and poor urban planning
[22-23]. These factors directly contribute to poor environmental
sanitation, deterioration of the public health infrastructure and
poor delivery of health care which result in an increase in the
burden of disease [28]. It is clear that a concerted effort must
be made to introduce a suite of vector control strategies including
targeted vector control, sterile insect technique, molecular tools
and the re-introduction of old strategies such as intradomicillary
spraying as part of an integrated management strategy for
Dengue control and prevention.
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DENGUE FEVER EPIDEMIOLOGY AND CONTROL IN THE CARIBBEAN: A STATUS REPORT (2012)
Table 5. Summary of the number of Dengue Fever and Dengue Haemorrhagic Fever cases which occurred in
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