title: What caused the 2012 dengue outbreak in Pucallpa, Peru? A socio-ecological autopsy.
abstract: Dengue is highly endemic in Peru, with increases in transmission particularly since vector re-infestation of the country in the 1980s. Pucallpa, the second largest city in the Peruvian Amazon, experienced a large outbreak in 2012 that caused more than 10,000 cases and 13 deaths. To date, there has been limited research on dengue in the Peruvian Amazon outside of Iquitos, and no published review or critical analysis of the 2012 Pucallpa dengue outbreak. This study describes the incidence, surveillance, and control of dengue in Ucayali to understand the factors that contributed to the 2012 Pucallpa outbreak. We employed a socio-ecological autopsy approach to consider distal and proximal contributing factors, drawing on existing literature and interviews with key personnel involved in dengue control, surveillance and treatment in Ucayali. Spatio-temporal analysis showed that relative risk of dengue was higher in the northern districts of Calleria (RR = 2.18), Manantay (RR = 1.49) and Yarinacocha (RR = 1.25) compared to all other districts between 2004 and 2014. The seasonal occurrence of the 2012 outbreak is consistent with typical seasonal patterns for dengue incidence in the region. Our assessment suggests that the outbreak was proximally triggered by the introduction of a new virus serotype (DENV-2 Asian/America) to the region. Increased travel, rapid urbanization, and inadequate water management facilitated the potential for virus spread and transmission, both within Pucallpa and regionally. These triggers occurred within the context of failures in surveillance and control programming, including underfunded and ad hoc vector control. These findings have implications for future prevention and control of dengue in Ucayali as new diseases such as chikungunya and Zika threaten the region.
authors.affiliation: Department of Geography, McGill University, Burnside Hall Building, Room 705, 805 Sherbrooke Street West, Montreal, Quebec, H3A OB9, Canada. Electronic address: margot.charette@mail.mcgill.ca.
authors.forename: Margot
authors.initials: M
authors.lastname: Charette
authors.affiliation: Department of Geography, McGill University, Burnside Hall Building, Room 705, 805 Sherbrooke Street West, Montreal, Quebec, H3A OB9, Canada.
authors.forename: Lea
authors.initials: L
authors.lastname: Berrang-Ford
authors.affiliation: School of Public Health and Administration, Universidad Peruana Cayetano Heredia, 31 Av.Honorio Delgado 430, Lima, Peru.
authors.forename: Elmer Alejandro
authors.initials: EA
authors.lastname: Llanos-Cuentas
authors.affiliation: School of Public Health and Administration, Universidad Peruana Cayetano Heredia, 31 Av.Honorio Delgado 430, Lima, Peru.
authors.forename: César
authors.initials: C
authors.lastname: Cárcamo
authors.affiliation: School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, 600 Peter Morand Cres., 301D, Ottawa, Ontario, K1G 5Z3, Canada.
authors.forename: Manisha
authors.initials: M
authors.lastname: Kulkarni
mesh_terms: D003715:Dengue / Q000175:diagnosis / Q000453:epidemiology* / Q000635:transmission; D003716:Dengue Virus / Q000472:pathogenicity; D004196:Disease Outbreaks; D006801:Humans; D015994:Incidence; D010568:Peru / Q000453:epidemiology; D011159:Population Surveillance / Q000379:methods; D018570:Risk Assessment / Q000379:methods; D012621:Seasons; D062211:Spatio-Temporal Analysis
keywords: Dengue; Environmental health; Infectious disease outbreak; Peru