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Press Briefing Transcript

CDC/NIH/PAHO Media Availability during the Dengue Research Conference

Thursday, February 17, 2011 – 12:00pm ET

Operator: Good morning, everyone. Thank you all for standing by. Welcome to today's conference call. At this time your lines have been placed on listen only for today's conference. During the question and answer portion of our call you will be prompted to press star 1 on your touch tone phone. Please be sure to record your name and affiliation in order to ask your question. Conference is also being recorded and if you have any objections you may disconnect at this time. I will now turn the conference over to Ann Mosher. Ma'am, you may proceed.

Ann Mosher: Thank you. Good afternoon, everyone. Today we're offering you three experts in dengue research and epidemiology. Dr. Anthony Fauci is director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health; Dr. Harold Margolis is chief of the Centers for Disease Control and Prevention and Prevention's Dengue Branch; and Dr. Jose Luis San Martin is the regional adviser for dengue at the Pan American Health Organization. They'll discuss epidemiology of dengue in the Americas and the latest developments in dengue research as we are concluding a three-day scientific meeting in Puerto Rico. I'll now turn it over to Dr. Fauci.

Tony Fauci: Thank you very much, Ann. It's a pleasure to be here with you today to just give you a very brief outline of the rationale and the approach that we've taken to this meeting, which took place in San Juan on February 16th to the 18th called the dengue research conference, which was co-hosted by the national institute of allergy and infectious diseases, the Centers for Disease Control and Prevention and prevention, and the pan American health organization. I gave the introductory remarks at the meeting, at the opening session, on the morning of the 16th. And I'm just going to really very briefly outline for you some of the points that were made and some of the rationale for the meeting.

In the first place, when one thinks of the issue of global health, which is really a truly important component of the health approach that many nations throughout the world are taking, thinking in the terms of the globality of diseases, particularly infectious diseases, they are one of the leading causes of death and morbidity throughout the world. They have unfortunately falsely been misinterpreted as being under excellent control, mostly because this occurs in the developed world, where there are ongoing problems of established diseases and what we call emerging and re-emerging infectious diseases throughout the world. We have had the ability and the implementation of controlling many of them. But some of them continue to emerge and re-emerge even as we develop modalities to control them.

There are two major ways of approaching this. One is by basic research to develop tools. And the other is the implementation of tools. Dengue is an important emerging and re-emerging disease. It's an ancient disease. It's been in the Americas for several centuries. Right now it continues, although most people don't appreciate that, to play a major role in disease, particularly in areas like Latin America and the Americas, to some extent in other developing, middle, and low income countries in Africa and Asia. But dengue alone infects more than 1.5 million people in Latin America alone last year. In have been a number of attempts to control this. And we need research tools and collaboration to make this goal possible. I spoke about the commitment of the United States government as well as PAHO and other agencies in trying to control dengue. The motivating forces for this is that there's an enormous public health need and there are important scientific opportunities. I spoke about the research agenda to Hal dengue that range from fundamental basic research, understanding what we call the pathogenesis of the disease, the relationship between the host and the virus, and the vector, the mosquito, particularly aedes aegypti, which is the major transmitting agent for this disease. Also the ability to develop animal models, understand the vector, the mosquito, to do what we call translational research to develop things like vaccines, therapeutics, and diagnostics. There are some promising leads in all of those three areas to provide what we call tools, resources, and services that investigators throughout the world can utilize such as some of the genomic sequences of the virus, the various serotypes of the virus, data bases, core immunological facilities as well as a variety of other services.

And finally, importantly, we spoke about international collaboration that's go on throughout the world, particularly in the Americas, where this meeting was held. Rather than go into many of the details of this particular approach to our agenda, we'd like to leave some sufficient time, the majority of the time, to discuss questions and comments that the press might have about what the direction of where we're going is. But to underscore and to conclude these brief remarks, the purpose of the meeting was to engender collaborations, scientific interactions, and to help develop a robust research collaboration agenda for dengue that we may in partnership, we being the parties involved, the CDC, PAHO, the NIAID, and others, to work synergistically together. An important part of that has been the epidemiology. During the question period Dr. Harold Margolis, who's the chief of the dengue branch at the Centers for Disease Control and Prevention and Prevention in the United States is one of the world's, if not the world's, expert on this. And he is available for the question period to answer any questions that you might have about that. But we also have a representative from PAHO who will be introduced now by Ann Mosher, who is running the call, and that is Jose Luis San Martin. So why don't I hand it back to you, Ann, have Dr. San Martin make some comments, and then we'll open it up for questions that any of the three of us can answer.

Ann Mosher: Terrific. And Dr. San Martin will be using a translator today.

Jose Luis San Martin: Thank you very much. My name is Jose Luis San Martin. I am the regional adviser for dengue. We're happy to be here in this meeting. We are very involved in the issues of dengue. And along with not just us but all of the other nations in the region. Dengue is one of the principal public health issues that we are facing. And there's not a single country in the region that is not working toward controlling this disease. This has been a difficult problem, and this is for all of the countries that have been involved, and this is something that can be seen in trying to develop a vaccine, which is a quite complicated function and situation. And we hope that part of the results of this meeting will result in tools that will allow us to impact – or allow us to control the impact of this disease in the region.

Ann Mosher: Thank you, Dr. San Martin. I think at this point we're ready to open it up to questions.

Operator: Thank you. At this time if you would like to ask a question, please press star 1 on your touch-tone phone. Please record your name and affiliation to ask your question at this time. Once again, it is star 1. And please record your name and affiliation. Please stand by for questions. Our first question comes from Michael Smith with MedPage Today. Sir, your line is open.

Michael Smith: Yeah. Hi, everybody. Just I'm trying to get a sense of what's actually needed to control dengue fever, where the state of play is in terms of I guess treatment and prevention, and then what did you learn at this meeting that's new? What's the big surprise out of the meeting? I don't know, Dr. Margolis or Dr. Fauci.

Tony Fauci: Well, let me start off, and then I'll hand it over to Dr. Margolis. What is needed to control dengue is really a combination of things. It's the implementation of tools that we already have. Some of them are really rather low-tech. In the sense that it really requires some common sense things that relate to not allowing the mosquitoes to be able to essentially overwhelm us in areas by creating conditions that are very favorable to mosquitoes such as water that is resting and lying there where larvae can hatch and mosquitoes can then proliferate greatly. Others have to do with being able to diagnose it by point of care diagnoses early on. That requires both the development of tools and the implementation of these tools. We have some very exciting leads on different types of vaccines that are in various stages of clinical trials that hopefully can be implemented within a reasonable period of time. And we need—we definitely do—better therapeutics. And we heard the pipeline, which is growing robustly, regarding areas such as therapeutics. And also, and I'll pass this on to the others, is that the understanding of the relationship between the virus, the dengue virus, and the vector, namely, the mosquito, particularly the aedes aegypti mosquito, to understand the interaction with those two parties, namely, the virus and the vertical, to better understand how you might be able to control not only the spread of infected mosquitoes but how to get mosquitoes out of the play, I mean, you can eliminate them but you can also do a variety of other things. So it was a whole bunch of things. What we try to get out of it is to foster collaborations and to help get input from the people who are on the ground, who understand this, who've been doing it for years, to help us put together a more appropriate research agenda. We are already putting a lot of resources in relatively speaking. But we want to make sure we're spending the money in a way that Hales the problem that exists in the region where it is most applicable. And that's really one of the reasons why we had the meeting in San Juan. So I will ask Hal or professor san martin to also chime in on that.

Hal Margolis: Yes. I think just to reiterate what we need, dengue's been around for ages. This year is one of the worst years. And remember, we have dengue in the United States, here in Puerto Rico, had a horrific epidemic. And the tools that we have, which are primarily vector control, haven't worked. So what do we need? Well, we need better ways to do it. And there are some really innovative things we're hearing about at this meeting which I think – you asked what's new. Well, one of the more important things that's used, we're bringing different disciplines together to begin to say, well, how do we use these and how do we best evaluate them to see how well they work? Some of the newest things we heard this morning were some of the progress in vaccines. I think everybody agrees that we need another primary prevention tool besides vector control. These mosquitoes have tricked man for a long time, and they live in places that aren't highly amenable, you know, to the same control that's been used for malaria and West Nile and some of the other diseases. So it's going to take a combination of things. I think the vaccine data we're hearing, which are coming from many sources, there isn't an efficacy trial that's finished yet, but there are a number of vaccines that are now in human clinical trials, and there's some very exciting new information there. You also asked about the clinical side. And I think that's the other part, which actually this last year the world health organization put out new guidelines for clinical management of dengue. And here in Puerto Rico, for instance, we have been training physicians on these new guidelines to really reduce the morbidity and the mortality from this disease.

Jose Luis San Martin: I just want to add that even though the difficulty is that this is one virus, it really is like four different viruses. You have serotypes 1, 2, 3, and 4. And this does bring a certain complexity in trying to develop an effective vaccine. The other issue is that the vector has been very well adapted to an urban setting. So it's established in a niche that is – filling in a niche that is quite well adapted and is difficult to Hal. And human behavior is also an important factor that plays a role in the control of dengue. Environmental factors are also important if they are not haled in trying to control the mosquito. To summarize, to – the best way to Hal this is going to take a multidisciplinary action, and something such as this meeting where we have asked people to come together to add such disciplines that are not normally Haled but such as the clinical and environmental. The response is more than just a public health response. It has to be broader than that and should include the government and communities that would have to work together to Hal this problem. This meeting has presented all types of disciplines from basic research to research that is further along but is trying to also identify gaps of where there is a lack of knowledge and research.

Operator: we have our next question comes from Bob Roos with CIRDAP News. I would just like to remind participants to please press star 1 and record your name and affiliation if you would like to ask a question. Mr. Roos, your line is open.

Bob Roos: Thank you. Yes. I'm wondering if the speakers can comment on how soon – or predict how soon we might actually have a dengue vaccine that's effective. And also I wonder if you could comment on what you think will happen in the United States as far as the spread of dengue. Is that something that's going to continue and worsen or will it be controlled? Thank you.

Tony Fauci: This is Dr. Tony Fauci. Let me just take a really quick shot at the vaccine. Hal is the expert on your second question, and I'll certainly give that to him. There are a number of vaccines at different stages. It is really folly to predict when you're going to have a vaccine because not only does it have to go through the trial, determine if it's effective, there are regulatory issues that come about about whether or not you're going to actually have it ready on the shelf. I'll give you an example of one vaccine. As you all know, vaccines start off as a concept. You do it in an animal model. You do a phase 1 for safety and some dosing of – in humans. Then you do a phase 2 to get a little more data on safety. And then you get phase 3, which actually asks the question is it effective. And one vaccine, and this is not the only one, there were several that were mentioned just a moment ago by the others at varying stages of development from concept to clinical to preclinical. One, for example, is the chimeric dengue vaccine with a yellow fever virus vaccine backbone where you take an already existing attenuated vaccine and you insert in it the genes of the four serotypes that Dr. San Martin mentioned and then you wind up having what's called a chimeric vaccine. That is in phase 1 – excuse me. Phase 3. Phase 3 clinical trials. Which is really essentially an efficacy trial that's run by Sanofi. The NIAID supported that in its early development. So if that turns out to be successful, then you're advanced, you're just a few years away. If it doesn't, then you really can't predict. When you talk about the vaccines that are in different stages, from concept to preclinical to phase 1, it is virtually unpredictable when we're going to get it. But if the ones that are advanced in phase 3 are in fact successful, you're talk a few years, three, four, five years away, maybe even earlier, depending on the results. There are a number of other vaccines that are in phase 1 trials, some that went into phase 1 trials last year, some that went into phase 1 trial last summer and last fall. Again, difficult to predict. But we are in some candidates a very advanced stage. And I know that's not a specific answer to your question. But I would be misleading you if I gave you a specific date when I thought we would have one. But there are some really promising leads in these vaccine candidates that I've spoken about. So all of us, I believe, are reasonably optimistic that we're heading in the right direction and should not be too far away. So let me hand it over now to Hal for any – and professor san martin for any further comments about vaccine but also about the question that you asked concerning dengue in the United States. Hal?

Hal Margolis: Thanks. I fully agree with the comments that Dr. Fauci made in terms of vaccine. Myself, I have actually been working on this issue for the last five years, and I think there's been tremendous progress in the last five years, but now we have to – as we both said, there are a number of vaccines in clinical trials. So we're finally getting into that home stretch. But the home stretch can take a while. In terms of the spread of dengue in the United States, which was your other question, look, we have dengue that is called endemic. It's always here in Puerto Rico and the Virgin Islands. And some of our smaller pacific islands have dengue all the time. So it is in the United States. The continental United States, well, there had been essentially incursions along the U.S.-Mexico border at various times with small outbreaks. You all know about Key West, where dengue's circulating there now for two years. There were 69 cases of clinical dengue that were recognized just this year – during 2010. So whether that virus is here to stay in the Key West area, we honestly don't know. But there are investigations, doing very aggressive vector control. The other aspect of dengue in the United States is when we have millions of travelers who go to places in the world where there is dengue, we don't know how many of them get infected but we do know right now we get reports of about 500 a year. We think that's a very significant underestimate of people who bring dengue back. Are they likely to spread it? Well, it will only happen in a place where the vectors, these aedes mosquitoes live. And we do have them in the U.S., mainly the southeastern part of the United States. So areas that tend to be more subtropical. So will dengue spread in the U.S.? The fact is dengue used to be all the way as far north as Philadelphia back in the late 1700s. So dengue is actually constricted in its locations in the U.S. What's only going to happen now is how good our surveillance is to pick up this disease and interdict it. So I think right now we know where it is, and now we need to be creative with these new tools that are being developed and with this research to try to make sure it doesn't go any further.

Bob Roos: Thank you.

Ann Mosher: Operator, do we have any more questions?

Operator: We have no more questions at this time. I would just like to remind parties to please press star 1 and record your name and affiliation if you would like to ask a question. We do have a follow-up from Michael Smith. Sir, your line is reopened.

Michael Smith: Yeah. Hi. Just – thank you. I just wanted to get a sense. Dr. Fauci, you said earlier on there were financial commitments to various aspects of this from my guess the region. Can you give me a sense of how much is being spent I guess by your agency?

Tony Fauci: Sure. I can tell you exactly. And not only tell you how much but also to give you a perspective of the commitment that we have toward dengue and to global health because the commitment has been increasing over the past several years despite a relatively flat budget at NIH in general and certainly at NIAID. So in 2010, fiscal 2010, we don't have the file numbers for fiscal 2011 because we're still in that fiscal year. But the numbers for fiscal 2010 was $44.4 million. About $45 million on dengue research funding from NIAID. This is up from 30 million in 2005 and up from 5 million in 2000. So it has gone from 5 million to30 million to now $45 million over a period of approximately ten years. And even though in the big picture that's not an awful lot of money, it is a reflection of a commitment toward trying to capitalize on the exciting scientific opportunities, many of which that we heard about at this meeting.

Michael Smith: How much of that is aimed at therapeutic or vaccines? Does it break down that way?

Tony Fauci: I'll tell you. Basic research is 62%; vaccines is 24%; therapeutics is 12%; and diagnostics is 2%.

Hal Margolis: Let me – this is Dr. Margolis. Let me just give you another source for the global picture on this. And if you – I can't give you the whole website. But look for g, g as in go, g-finder. It's an international report that puts out – and so the last one was for 2009. The expenditures. Both governmental and non-governmental on these tropical diseases. And dengue's in there. So rather than me trying to recall the total number, you can look it up. And it's been very well done. It's being used by a number of organizations to track this now.

Michael Smith: Thank you.

Operator: I would just like to remind parties to please press star 1 and record your name and affiliation to ask a question. We have a question from Ginger Correa with radio university of Puerto Rico. Ma'am, your line is open. Miss Correa, are you on mute?

Ginger Correa: Yes. Thank you to everyone. And I would like to know how advanced is the research of dengue in Puerto Rico right now. I also would like to know how is the collaboration between the Puerto Rican government and your organizations?

Tony Fauci: The collaboration has been for a long period of time excellent. When you talk about collaborations between government, I think it's more important to talk about collaborations from scientist to scientist and scientific and health organizations back and forth. So if you're talking about universities and organizations like PAHO and the minister of health, for example, at – in Puerto Rico was at our meeting. Dr. – the honorable Lorenzo Gonzales Feliciano, who is the secretary of the Puerto Rican Health Department, was there greeting us and expressing his support for the continued collaboration that has been going on between Puerto Rico, PAHO, the Centers for Disease Control and Prevention and prevention, and the national institutes of health. So I would say that the collaboration has been excellent. Hal Margolis is actually much more of an on the ground person there in Puerto Rico and has been interacting. So Hal, you might want to make comments about your own experience in that.

Hal Margolis: Yes. The Centers for Disease Control and Prevention has had a laboratory and a group here working on dengue for 30 years. So we're located in San Juan. We work on both epidemiology, diagnostics, and vector ecology and control issues. We work very closely with the Puerto Rico department of health. We're there all the time working together on both the surveillance and helping the health department in terms of their dengue control and prevention activities. As you're aware this very large recent effort to educate physicians here on the island in the care and management of dengue, something that – some aspects of that were discussed at this meeting. It was a joint effort with the health department. And as you know, that's been quite newsworthy and been a tremendous amount of effort. So no, I think it's a very strong collaboration. There are investigators at UPR who are funded through the NIH on dengue research who presented here at this meeting. I think it's been very strong, both historically and ongoing.

Ann Mosher: Thank you. Operator, are there any more questions?

Operator: We have no further questions at this time.

Ann Mosher: All right. Thank you very much, everyone.

Tony Fauci: Thank you, Ann. And thank you, Hal and professor San Martin. We appreciate not only the collaboration and congeniality but the fact that we I believe had a very successful meeting. And we look forward to the fruits of that meeting as we all in a collaborative way develop our respective agendas. So thank you all very much. We appreciate it.

Ann Mosher: Thank you, everyone. The news conference is now over.

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