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Dengue in Suriname, Where Dengue Has Become Hyperendemic

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Dengue in Suriname, Where Dengue Has Become Hyperendemic Acknowledgements First and foremost, I want to extend my most sincere graduate to my dissertation advisor Maureen Lichtveld for the opportunity to pursue my PhD at Tulane and her guidance through the past five years. Her mentorship was paramount in providing me with a well-rounded understanding of public health and the tools to develop strong research methodology skills. Dr. Lichtveld encouraged me to work independently and often taught me the best lessons by placing me in a situation in which I had to make, and justify, my own decisions. Aside for the professional relationship, I would like to thank Dr. Lichtveld for her friendship. She always listened to my ‘coming-of-age’ problems and gave emotional support in times of challenge. I will always cherish the hot Surinamese evenings drinking fresh juice and eating spicy food while listening to calypso music with you. Dr. Oberhelman, you were also instrumental in my coming to Tulane. Dr. Oberhelman’s efforts in funding the Transdisciplinary doctoral scholars program created the unique opportunity of combining tropical medicine, environmental health, and community health in my education and research. His door was always open for me and he took the time to help me deal with research setbacks and to guide me through the dissertation process. Thank you for believing in me since the very first day. Dr. Shankar, thank you for being so patient with me. Dr. Shankar pushed me further into biostatistics than I thought I had the capabilities of managing and in the process she taught me that you can always do more. Every time I met with her I was greeted with a smile and a supportive attitude that I hope I can emulate 2 towards others. Within my own department, I had the fortune to work with Dr. Svendsen. Dr. Svendsen joined the faculty my second year of PhD and since he started he has always supported me and my peers in all aspects of our academic lives. Thank you for your guidance, friendliness and even opening up your house for our very culturally rich dinner. When I first signed up for the medical entomology course a student told me Dr. Wesson was the entomology guru. After taking her class, I am convinced she is! Dr. Wesson is the type of person that makes you wonder if you could ever teach her anything because she is always one step ahead of you yet she shares her knowledge in an unassuming and reassuring manner. Thank you for being so warm and kind to me and for always being excited about my research even when I failed to see the point. Every now and then you meet someone we wish would be a bigger part of our life. For me, that someone is Dr. Jessurun. He is everything a doctor should be and without his intellectual curiosity this research topic would never have come into fruition. The short time I spent with you was didactic and fun and I wish I had more opportunities to learn from you. In Suriname, I was privileged to work with two great women: Dr. Helene Hiwat and Astracia Warner. Their efforts and eagerness to advance science in Suriname made my research possible. Thank you for opening the doors of the Bureau of Public Health to me and welcoming me to Suriname. In the field, I counted with incredible backing of the environmental inspectors who not only helped me with my research but took care of me while showing me the warmth of the Surinamese people. Suriname would have been much harder to navigate 3 hadn’t it been for Dr. Hawkins’ advice and friendship. Thanksgiving and the Super Bowl would have been too boring without him and Kate! In New Orleans, the Department of Global Environmental Health Sciences made my 5 years at Tulane fly by. Dr. Wickliffe’s candor and research insight were always a breath of fresh air when I was stuck with a problem. Dr. McCaskill’s unique perspective always added dimension to every argument creating much more research awareness in me. Dr. Wilson, I’ve enjoyed watching you grow professionally and become a parent, thank you for teaching us how to power through! My past colleagues and friends, Ben and Amy, I am so lucky to have your friendship. Euridice, I miss our discussion about everything very much! My office mates, and partners in crime, Lekan and Kyle, what can I say… it’s been a wonderful journey and I am glad I got to share it with you. And Dev, thanks Bro. This dissertation is dedicated to my parents. They have always been and will always be my lifeline. My Papa and Mama have made me into the person I am today and given me all their support and love I need to achieve my best. Thank you for supporting me through the good, the bad and the ugly. Peter, my brother, you add color to my life. Thank you for sharing the good, getting me through the bad and covering up the ugly :P To my grandparents, I miss you very much. And to my husband, without whom my life would not be complete, I am grateful for every day I get to spend with you. Can’t wait to grow old together! Hartelijk dank, Diana. 4 Table of Contents Abbreviation List 6 1. Abstract 7 2. Background and Significance 8 Literature Review 11 Hypotheses and Research Questions 27 3. Materials and Methods 29 4. Spatial distribution of epidemiological cases of dengue fever in Suriname, 2001-2011 45 5. Characterization of Aedes aegypti breeding sites in Paramaribo, Suriname: a comparison between a high and a low rate cluster of cases of dengue66 6. A retrospective analysis of dengue cases in Suriname: implications for treatment and prevention in a LMIC 90 7. Main Results Summary 102 8. Discussion 123 9. Conclusion and Recommendations 136 10. Appendix 141 11. References 151 5 Abbreviation list ABS Algemeen Bureau voor de Statisiek (General Bureau for Statistics) AZP Academische Ziekenhuis Paramaribo (Academic Hospital Paramaribo) AZPL Academische Ziekenhuis Paramaribo Laboratorium (Academic Hospital Paramaribo Laboratory) BOG Bureau Openbare Gezondheidzorg (Bureau of Public Health) CAREC Caribbean Epidemiology Center CARICOM Caribbean Community CI Confidence Interval CPDB Cash Programma Dengue Bestrijding (Urgent Dengue Control Program) DENV Dengue Virus DF Dengue Fever DHF Dengue Hemorrhagic Fever DSS Dengue Shock Syndrome ENSO El Niṅo Southern Oscillation GIS Geographic Information Systems GPS Global Positioning System HRC High rate cluster Ig Immunoglobulin IRB Internal Review Board LDS Long dry season LRC Low rate cluster LRS Long rain season MDS Meteorologische Dienst Suriname (Meteorological Service Suriname) NS Non-structural protein OR Odds Ratio PAHO Pan American Health Organization RGD Regionale Gezondheidsdienst (Regional Health Service) RNA Ribonucleic acid RT-PCR Reverse Transcription Polymerase Chain Reaction SDS Short dry season SRS Short rain season SVZ Sint Vincentius Ziekenhuis (Saint Vincent Hospital) WHO World Health Organization 6 1. Abstract The dengue virus (DENV) is a flavivirus capable of causing severe disease in infected humans. DENV is most commonly transmitted by the Aedes aegypti (genus Aedes, subgenus Stegomyia) mosquito, which is uniquely domestic and thrives in urban settings. Upon infection with DENV, humans can develop mild disease, known as dengue fever (DF), or progress into the severe forms of the disease, known as dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS). High levels of urbanization and tropical climate conditions have facilitated the rapid emergence of dengue in Suriname, where dengue has become hyperendemic. The last confirmed dengue outbreak in 2012 exhausted national healthcare capabilities and prompted the Ministry of Health to open up an emergency hospital and implement citywide vector control measures in Paramaribo. These practices however were in general not preventive in nature. This research focuses on assessing the relative contribution and the relationship of environmental and demographic risk factors that potentially contribute to the development of DHF in Suriname in at risk populations. Epidemiological data were utilized to map historically high transmission areas of DF and DHF. Collection and integration of environmental entomological data allowed for determining how influential such factors are to transmission. The results obtained were used to inform best surveillance practices and shift the focus of dengue transmission from an ad hoc intervention to a more prevention-oriented approach. 7 2. Background and Significance Suriname is located in the Northeastern region of the South American continent. It shares a border with French Guyana to the East, Guyana to the West, Brazil to the South and the Atlantic Ocean to the North. In 1995, the country became a member of the Caribbean Community (CARICOM) and is classified as an upper- middle income country by the World Bank. Suriname has a tropical climate marked by two wet seasons: a long rainy season (LRS) from late April to August and a short rain season (SRS) from December to February. Approximately 80% of Suriname is covered by tropical rain forest, which is sparsely inhabited. Most of the population lives in the northern lower-coastal area concentrating in the country’s capital of Paramaribo. Currently, more than 70% of the total population of 529,000 lives in an urban area compared to 1975 when half of the population lived rurally. Following this continuous upward urbanization trend, it is estimated that by 2050 more than 80% of the population will be concentrated in an urban area (The World Bank, 2012; UNDESA, 2012). The increasing level of urbanization and the warm temperatures characteristic of the tropics has facilitated the fast emergence and persistence of some tropical diseases in Suriname, in particular dengue fever (DF). Over the last 50 years, the incidence of dengue fever worldwide has increased by 50-fold placing 2.5 billion people who live in dengue-endemic regions at risk of contracting the disease.
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