Research Article: The Impact of the Demographic Transition on Dengue in Thailand: Insights from a Statistical Analysis and Mathematical Modeling

Date Published: September 1, 2009

Publisher: Public Library of Science

Author(s): Derek A. T. Cummings, Sopon Iamsirithaworn, Justin T. Lessler, Aidan McDermott, Rungnapa Prasanthong, Ananda Nisalak, Richard G. Jarman, Donald S. Burke, Robert V. Gibbons, Jeremy Farrar

Abstract: Analyzing data from Thailand’s 72 provinces, Derek Cummings and colleagues find that decreases in birth and death rates can explain the shift in age distribution of dengue hemorrhagic fever.

Partial Text: In Thailand, dengue fever (DF) and dengue hemorrhagic fever (DHF) have traditionally been diseases of childhood, causing substantial morbidity and mortality among children <15 y of age. Recently, an increasing number of DHF cases among older individuals has been observed in Thailand [1],[2]. In several Southeast Asian countries the age distribution of dengue cases detected by passive surveillance has shifted towards older age groups [3]–[5]. This shift has implications for clinical diagnosis and management, and may present new challenges to dengue control. Identifying the mechanism responsible for this age shift would enable us to forecast whether this trend is likely to continue, understand its impact on public health, and identify policies that may reduce morbidity and mortality from dengue. Standardized age-specific incidence rates (see Text S1, Age Standardization) show a substantial increase in the average age of dengue cases (Figure 1C). Increases in average age have been observed for DHF, DF, and DSS (Figure 1D), with DHF cases having a slightly higher average age than DF and DSS cases. Recent changes in the average age of DHF in Southeast Asia have been attributed to control measures [6], development [31], and changes in the distribution of serotypes or genotypes [5]. Here we present evidence of another mechanism, a change in the demographic structure of the population. We find that, in Thailand, median age is consistently associated with the (1) estimated change in the force of infection (1985–2005), (2), mean forces of infection (1985–2005) and (3) changes in the multiannual periodicity of DHF incidence. Our simulations indicate that changes in birth and death rates similar to those experienced in Thailand create changes in the age distribution of cases and the periodicity of incidence consistent with observations. Changing age structure has been suggested by other authors as a driver of reductions in childhood infectious disease mortality due to other infectious diseases in western countries in the 19th and 20th centuries [32], and as driving changes of the average age of measles infection [12]. Mechanistically, reduction in all cause mortality increases the longevity of immune individuals. These immune individuals decrease the risk of dengue infection of susceptible individuals around them by providing alternative feeding sources for infectious mosquitoes. Reduced birth rates decrease the relative abundance of susceptible individuals to immune individuals, thus further reducing the risk of infection. Serological testing could determine whether patterns of age-specific immunity are consistent with our findings using age-specific incidence data. Studies with greater geographic resolution could elucidate more specific mechanisms for changes in the force of infection. Many demographic changes accompany shifts in birth rates, death rates, and age structure, and analysis at the individual or household level is needed to understand the effect of each component of demographic change. However, our simulations indicate that only changes in birth and death rates are necessary to explain the observed changes in dengue dynamics in Thailand. Source: