Challenges

Dengue is the most prevalent arbovirus in the Americas. The trend in numbers of cases of this disease in the Americas has been increasing, with epidemics occurring every three to five years, the most recent being in 2019 with more than 3.1 million reported cases, resulting in 1,773 deaths. In addition, other endemic arboviruses, such as chikungunya and Zika circulate simultaneously, posing a constant challenge to health services in terms of clinical diagnosis, proper management of cases and proper reporting for epidemiological surveillance.

The dengue case fatality rate for Andean countries in 2021 was 0.08 percent[1] Reducing deaths due to dengue to 0.05 percent or less (and reducing deaths due to other arboviral diseases) is one of the impact goals of the PAHO Strategic Plan 2020-2025.[2] This requires the strengthening of national technical capacities for clinical management of arboviral diseases and improvement of national epidemiological surveillance systems so that early warning of the occurrence of cases can generate the necessary actions to prevent and control transmission.

Toward a Solution

This initiative aims to reduce the case fatality rate due to dengue and other arboviral diseases in the Andean countries. In 2020, PAHO/WHO began a collaboration with the Andean Health Organization-Hipólito Unanue Agreement (ORAS-CONHU) to strengthen national technical capacities for the prevention and control of arboviral diseases in Bolivia, Colombia, Chile, Ecuador, Peru and Venezuela. This collaboration falls under the framework of the Integrated Management Strategy for the Prevention and Control of Arboviral Diseases, approved by PAHO/WHO Member States in September 2016 through Resolution CD55.R6. This project contributes to SDG 3 (Good Health and Well-being), specifically with targets 3.3 (communicable diseases) and 3.d (national and global health risks).

In collaboration with ORAS-CONHU, virtual cooperation spaces (VCS) have been created using informatics tools that allow for the automated generation of different epidemiological analyses, situation rooms and epidemiological bulletins, strengthening the epidemiological surveillance of dengue, chikungunya and Zika. Each country has its own VCS, and in addition a VCS was developed for the Andean subregion, which allows not only an integrated analysis of what happens in each country and in border areas, but also a more fluid communication between them to address the epidemiological situation of these three arboviruses at a subregional level.

Another aspect of technical cooperation between the group of Andean countries, promoted through ORAS-CONHU, is strengthening national capacities for clinical diagnosis and management of dengue, chikungunya and Zika cases. This is carried out through three key lines of work described below. 

1. The creation of national networks of clinical experts in arboviral diseases, under the direction of the Ministries of Health in each country, which are responsible for conducting clinical training at the local level.
2. A continuing education programme, for which there is a regional virtual classroom in the PAHO/WHO Virtual Campus of Public Health. In addition to discussing current and complex topics on dengue, chikungunya and zika, as part of this programme, users have access to didactic material that can be used during training processes carried out through national networks of clinical experts in arboviral diseases. The virtual classroom allows a fluent and direct communication between professionals and experts from different countries, for example to consult about clinical cases (atypical, severe or complicated cases). A total of 31 professionals from Bolivia, Colombia, Chile, Ecuador, Peru and Venezuela are registered in the virtual classroom.
3. An online self-learning course on clinical diagnosis and management of dengue, which is available free of charge on the PAHO/WHO Virtual Campus of Public Health. This course, as of mid-2022, had more than 67,000 registered health professionals (of whom 70 percent had already passed the course), out of which 31,265 are from Andean countries. 

These three lines of work in the clinical area, enjoy high political and technical commitment, fostering permanent exchanges between professionals, technical teams and managers at different levels within each country and between countries in the Andean subregion. This increases human resources and response capacities, based on best practices and experiences, and leads to greater calls for exchange and technical cooperation. Combined with systematic and joint follow-up by ORAS-CONHU and PAHO/WHO, this gives the project vitality and sustainability. The impact of these three lines of work is being measured through a decrease in the dengue case fatality rate, previously noted.

Technical and political sustainability of the work is also reflected in agreements established between ORAS-CONHU and PAHO/WHO and the incorporation of dengue and arboviruses in the political agenda and proposed five-year plan of Andean health ministers in 2022. The establishment of VCS facilitates that use epidemiological information simultaneously and in real time (including a situation room of arboviral diseases in Andean countries, which can be accessed by technical staff and managers from these countries) is of great value for decision-making. 

South-South cooperation principles have been adopted and are ensuring that thematic areas related to maternal, child and adolescent health communications, climate change and other transmissible diseases are being incorporated into a common work agenda.

Financial and technical sustainability is further strengthened through a cooperation agreement between PAHO/WHO and the United States Centers for Disease Control and Prevention for surveillance of arboviruses over the three years 2022 to 2024, through which countries of the Andean subregion are direct beneficiaries. This is improving surveillance systems and development of new tools for analysis and control response in real time.

Through South-South cooperation, and working together with the ORAS-CONHU, the below lessons have been learned:

• ORAS-CONHU represents one more channel, in addition to PAHO/WHO, to bring the issue of dengue to the forefront of political and health agendas in the countries.
• The creation and use of a common work scenarios maximizes efforts to achieve communal goals. This has allowed PAHO/WHO to maximize the use of resources to provide a strong response to prevent and control arboviral diseases.
• PAHO/WHO has served as a catalyst for technical cooperation, bringing experience and good practices from other regions to the Andean countries.
• In conjunction with ORAS-CONHU, a workspace has been created that facilitates the technical cooperation provided by PAHO/WHO and the exchange of experiences between Andean countries.

The close collaboration between the PAHO/WHO Subregional Program for South America (SAM) and the Communicable Diseases and Environmental Determinants of Health/ Neglected, Tropical and Vector Borne Diseases (CDE/VT) technical team for arboviral diseases has allowed adequate coordination with ORAS-CONHU to guarantee technical cooperation, and cooperation among Andean countries.

This initiative can be replicated effectively in regions in which subregional health organizations exist (for example COMISCA in Central America and MERCOSUR in South America) that can support and guarantee an additional method of making arboviral diseases part of the political and health agenda in the countries.