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OUTBREAK REPORT: ESCALATING DENGUE FEVER IN PERU INTENSIFIES WITH EL NIÑO RAINFALL

Gabriel Helupka, Jennifer Radlinsky, Jayde Dorland, Dan Flanagan, Emergency Management, Health, and Hazards (EMH2) Team

Jennifer Loy, Chief Editor

Week June 12, 2023


Dengue-Carrying Aedes Species Mosquito[1]


In response to a record number of cases, Peruvian health officials warned citizens and travelers to take precautions to prevent dengue fever.[2] A record-breaking 150,000 cases and at least 186 deaths with a daily average hospitalization rate of 1,146 have been reported this year and continue to increase.[3] Health officials and climate experts raised concerns that an El Niño year will result in higher rainfall amounts, multiplying the dengue fever-carrying mosquito population.[4] El Niño weather patterns occur every two to seven, characterized by above-average surface temperatures in the Pacific Ocean near the equator, resulting in droughts and heavy rain and exacerbating conditions already experienced in some locations.[5] Biologists confirmed three of the four serotypes of dengue fever are circulating in Peru, complicating mitigation planning and straining overburdened healthcare facilities.[6] Inadequately supplied hospitals, especially in northern Peru, will face challenges in treating patients, potentially contributing to death increases.[7]


Description of Pathogen

Dengue is a virus composed of four serotypes primarily transmitted to humans through the bite of infected female mosquitoes of the Aedes species. Dengue virus (DENV) replicates in the female mosquito midgut and spreads to secondary tissues, such as the salivary glands, after feeding on DENV-infected humans. Once infected with DENV, mosquitoes can transmit the virus for the remainder of their lifespan. While cases are low, DENV is also transmissible through blood transfusions, organ donations, and maternally, from pregnant mother to baby.[8] DENV is not a seasonal virus, but increased outbreaks of DENV are stimulated by seasonal weather changes. Temperatures between 78.8 and 84.2 degrees Fahrenheit,[9] precipitation, and humidity provide an optimal breeding and transmission environment for the Aedes mosquitos, heightening the number of DENV cases.[10]


Around one in four DENV-infected humans get sick and display symptoms. Common symptoms of DENV include fever, rash, nausea, and aches and pains in the eye area, muscles, joints, or bones.[11] Mostly, humans infected with DENV recover within one to two weeks.[12] Primary infection with one of the four dengue serotypes is hypothesized to protect humans from re-infection of the same serotype for decades but cannot protect against secondary infection from one of the other three serotypes. Secondary infection of the remaining serotypes can increase the development of DENV into severe dengue.[13] Symptoms of severe dengue include abdominal tenderness or pain, increased rates of vomiting, traces of blood in vomit or stool, fatigue, and bleeding from the nose or gums. Symptoms of severe dengue usually occur 24-48 hours after the initial fever has subsided. Individuals displaying signs of severe dengue should seek immediate medical care as it can result in internal bleeding and, in some cases, death.[14] A study sponsored by the EU documented extremely rare cases where 247 dengue patients, primarily children in Vietnam, experienced persistent long-term symptoms of hair loss and vision problems.[15]


Currently, there is no treatment for DENV. Infected individuals are usually treated for their pain and prescribed acetaminophen. Anti-inflammatory drugs, such as ibuprofen and aspirin, can increase the risk of internal bleeding and are avoided when treating patients.[16] 2015 saw the creation of Dengvaxia, a vaccination to decrease the risk of re-infection among previously DENV-infected individuals.[17] Dengvaxia is available for individuals between nine and 45, except for the US (ages nine through 16), to mitigate their chances of secondary infection. Dengvaxia is licensed in 20 countries and exclusively accessible to individuals with prior DENV infection, per the World Health Organization (WHO) recommendation for previously infected individuals residing in endemic regions. The vaccine manufacturer, Sanofi Pasteur, warns that those who receive the vaccine without prior infection may face a risk of severe dengue if they contract the virus afterward.[18] In December 2022, a second vaccine, Qdenga, was authorized for use against DENV regardless of individuals’ previous exposure to the virus. The vaccinations clinical testing found Qdenga to reduce DENV-related symptoms in 80 percent of confirmed cases and reduce hospitalization in 90 percent of cases. Qdenga is currently only available in the EU for individuals over four years of age[19] and in Indonesia for individuals aged between six and 45.[20]


Location

Dengue Fever Cases in Peru, June 17, 2023[21]


On February 23, Peru declared a “health emergency” in 13 departments, focused in the north, center, and southeast regarding a dengue outbreak.[22] Peruvian health officials confirmed 193 deaths and 150,000 cases as of June 18.[23] Most dengue cases have originated in the northern Piura Region, which currently accounts for over 44,000 of the national total.[24] In response to the outbreak, Piura Regional Directorate of Education suspended in-person classes for another week, intending to resume them on Monday, June 19.[25] The North has recorded more deaths than other regions, where hospitals have surpassed their capacity.[26] As of June 16, 2023, Lambayeque, the second most affected province, has recorded over 16,000 cases with 58 deaths. The Lima metropolitan area and the Ica department are experiencing a significant increase in cases,[27] with nearly 20,000 and 13,000 reported respectively.[28]


Peru is known for its high, rugged mountains in the Andes. Western Peru has coastal plains, while the east features lowland jungles that lead into the Amazon River basin. The country’s highest point is Nevado Huscaran, a mountain standing at 22,205 feet (6,768 meters) and spans 496,222 square miles (1,285,216 square kilometers).[29] Peru has three central climatic regions; the Coast, the Andean Highlands, and the Eastern lowlands and Amazon rainforest. The Coast is a subtropical desert climate that experiences an annual rainfall of approximately 6 inches (150 millimeters). Temperatures vary from 55˚F (13˚C) to 79˚F (26˚C) along the southern and central coast, with colder months in May and October. The northern coast is a semi-tropical environment with an average 75˚F (24˚C) temperature. The climate in the Andean Highlands varies with elevation. The rainy season typically spans from September to March, while the dry and cold season extends from May to August. Temperatures average between 52˚F (11˚C) and 64˚F (18˚C), with an annual rainfall ranging from 2 inches to 39 inches (50 to 1000 millimeters). The southwest is drier, while the eastern regions receive more precipitation. Frosts in the northern Andes are common, whereas the southern Andes are prone to drought. The Eastern lowlands and Amazon rainforest exhibit a tropical climate characterized by high temperatures and consistent rainfall throughout the year. In the eastern Andes, average temperatures range from 72˚F (22˚C), while in the Amazon, temperatures reach 88˚F (31˚C). Annual rainfall amounts vary between 39 and 118 inches (1000 and 3000 millimeters).[30]


Response Challenges

Medical centers in Peru are becoming overwhelmed, lacking the capacity to address a rising number of daily cases and lacking testing and medicine shortages.[31] The Peruvian government will almost certainly prioritize mobilizing additional personnel and resources to shore up overwhelmed medical centers, likely requiring assistance from the WHO and NGOs to maintain sustainable response efforts. El Niño-related heavy rainfall and flooding will likely negatively impact healthcare infrastructure and exacerbate capacity shortages. The absence of reliable access to DENV vaccines, available treatment, and sufficient qualified medical professionals will likely further exacerbate the challenges of overwhelmed medical centers, hampering the effective management of the outbreak.


El Niño, a climate phenomenon characterized by unusually warm ocean temperatures in the Pacific,[32] leads to higher temperatures and torrential rains that result in increased flooding. As of June 15, 2023, over 765,781 people were affected by torrential rains and flooding of El Niño in Peru, with over 41,670 homes destroyed or uninhabitable.[33] Peru experienced a record-breaking dengue epidemic during the last El Niño event in 2017, causing 141,973 cases and 232 deaths.[34] The current El Niño has outpaced those numbers, as Peru now contends with over 147,000 reported cases, an average of 1,331 hospitalizations per day, and 188 confirmed deaths.[35] El Niño heightens moisture levels, creating an ideal breeding habitat for mosquitoes due to the increased water accumulation in densely populated urban areas. The warmer temperatures in these regions expedite the growth and reproduction rates of Aedes mosquitoes, the primary carriers of dengue fever,[36] and cause adult mosquitoes to bite more frequently.[37] As a result, these mosquitoes become more active, and their breeding cycles shorten, leading to a higher population of infected mosquitoes in populated areas. As infected mosquitoes transmit the virus to more individuals, uninfected mosquitoes can acquire DENV from humans, contributing to its further spread.[38] Warmer temperatures extend the active season for mosquitos, prolonging the period of DENV transmission. As more areas have prolonged periods of warmer climates, mosquitoes survive into winter months, lengthening transmission periods and increasing the chances of DENV-infected mosquitoes migrating to current-dengue-free areas.[39]


In El Niño-affected regions, heavy periods of rainfall often follow the onset of drought conditions. In response to water scarcity, individuals commonly store water in containers or tanks, inadvertently creating additional breeding sites for Aedes mosquitoes. When these containers are inadequately covered or left untreated, they become optimal breeding grounds for mosquito larvae, heightening the risk of dengue transmission.[40] El Niño's impact on increased floods and storms can lead to population displacement,[41] with people likely seeking temporary shelter in crowded areas or makeshift housing outdoors. Overcrowding and inadequate sanitation in these temporary settlements will very likely facilitate the spread of dengue fever, likely increasing the chances of mosquitoes coming into contact with infected individuals who may lack sufficient protection against mosquito bites. Individuals displaced by climate-changing events can relocate to areas unaffected by increased dengue cases.[42] Displaced persons infected with DENV will very likely increase its spread to other areas or populations, having a roughly even chance of further outbreaks occurring. Aedes mosquitoes are also carriers of the Zika virus,[43] with a likely increase in Aedes mosquito populations, a local epidemic of Zika will likely happen; this will very likely further complicate already strained medical centers, likely resulting in further overwhelming of the medical industry.


Peru's healthcare system follows a decentralized model consisting of five entities, four public and one private. The Ministry of Health administers the Seguro Integral de Salud, providing insurance coverage for approximately 60 percent of the population. While the Ministry of Labor's social security program, EsSalud, covers around 25 percent of the population. The private sector, national police, or armed forces cover the remaining 10 percent of the population. According to the World Bank (WBG), Peru spends approximately 5.5 percent of its annual GDP on healthcare,[44] amounting to an average of $388 per capita annually.[45] Individuals living in impoverished conditions face limited access to healthcare as they cannot afford it or do not receive sustainable healthcare funding.[46] According to a June 15 International Rescue Committee (IRC) survey, only 30 percent of Peruvian respondents reported having access to health insurance.[47] Peru's poverty rates have surged since the COVID-19 pandemic, reversing decades of progress in poverty reduction. By the end of 2021, the country's poverty rate reached 25.9 percent, attributed to declining labor incomes and reduced per capita household expenditures. WBG estimates the number of impoverished Peruvians rising from one in four in 2021 to seven in ten in 2023, facing the risk of falling into poverty. WBG's April 2023 geographic analysis underscores regional disparities, with poverty rates standing at 42 percent in the northern Andes, 32 percent in the central Andes, 17 percent in the central and south coast, and 25 percent in Lima.[48] Limited access to healthcare for impoverished Peruvian citizens will likely result in poorer health outcomes, likely contributing to higher fatality rates and unreliably undocumented cases.


The COVID-19 pandemic expedited the collapse of Peru’s healthcare system, particularly impacting the system's ability to address healthcare demands. Before COVID-19, 45 percent of the population sought care outside of health centers. By 2021, this number increased to 55 percent due to healthcare systems becoming overwhelmed by COVID-19, with a significant portion of the population relying on pharmacies instead of recognized healthcare providers to fulfill healthcare needs.[49] As medical centers struggle to handle increasing cases of dengue, this trend will very likely persist, likely leading to a higher number of Peruvian citizens seeking alternative healthcare options due to limited resources and a lack of trust in health institutions’ ability to adequately address healthcare needs.


Peru faces a shortage of qualified medical professionals, partly due to doctors migrating to other countries to search for better opportunities.[50] According to the Peruvian Medical Federation, public hospitals need 18,000 more doctors, including 15,000 medical specialists, to meet patient demands.[51] The scarcity of quality doctors directly impacts the overall quality of healthcare services; Peru scores 17 on the WHO's quality in health services index, falling below the recommended threshold of 23 percent.[52] The scarcity of sustainable medical professionals almost certainly contributes to the strain experienced by medical centers and related fatalities, likely leading to higher numbers of DENV infections compared to other countries facing dengue outbreaks.


Parts of Peru, such as the Andes and Amazon regions, are widely remote that they have complicated the distribution efforts for the COVID-19 vaccine;[53] this will very likely create a similar scenario with providing medical supplies, mosquito control equipment, or DENV vaccines to eligible individuals living in these regions. Only 39 percent of households have access to safe water, with only a further 36 percent of schools having access to safe water and drainage;[54] this very likely increases the risk of mosquitoes finding favorable breeding areas around unsafe water sources to lay their eggs, likely increasing DENV infections and challenges in controlling mosquito populations.


Ineffective government responses to the dengue outbreak will likely encourage protests to resume, likely centered in indigenous regions still loyal to former President Pedro Castillo. In December 2022, Castillo was arrested after announcing his intentions to dissolve Congress before his impeachment trial. Castillo’s arrest prompted protests mainly by indigenous and peasant communities from the country's south, who are poor and often ignored by the government. Castillo remained well-liked among the communities. The post-Castillo government used heavy-handed tactics to suppress protesters, shooting indiscriminately into crowds and killing several people.[55] Peru’s population is 33 million, of which the indigenous population accounts for 25 percent. The indigenous population hindered vaccination efforts during the COVID-19 pandemic. Quechua-language radio stations spread misinformation that echoed Q-anon conspiracies regarding the vaccine. The population's hesitancy to take the vaccine also comes from government mistrust under former President Alberto Fujimori; between 1990-2000, doctors and nurses sterilized around 273,000 indigenous women under the Fujimori government’s instruction.[56] At the end of 2016, Peru approved the use of Dengvaxia.[57] Indigenous communities will almost certainly be skeptical of vaccination efforts.


Travel Warnings

Most travelers likely lack a reliably approved vaccine. The best advice is to avoid mosquito bites. Travelers should always use insect repellent, wear long-sleeved shirts and pants outdoors, choose air-conditioned rooms for sleeping, and ensure the presence of window screens in the room.[58] If air-conditioned rooms or window screens are unavailable, travelers should purchase mosquito nets to sleep under at a local outdoor store or before departure.[59] There are no restrictions on food as dengue is primarily transmitted through mosquito bites. mosquitoes are known to lay eggs in stagnant bodies of water, such as buckets, vases, or flower pots.[60] Travelers should ensure that they use clean water at all times.


The Peruvian government will very likely rely on other countries to communicate dengue risks, likely leaving some travelers unaware of the risks and requiring travelers to plan ahead, including checking health guidance from respective embassies, following local public health recommendations, and monitoring reliable local news sources while traveling through infected regions. Travel to high-risk areas like Piura and Lambayeque Provinces should be avoided or limited; Piura alone contributes to over one-third of national cases, while Lambayeque has reported over 12,000 cases. Travelers should exercise caution or restrict travel within the Lima metropolitan area, which is witnessing a surge in cases, by taking extra measures to prevent mosquito bites.[61] Travelers should regularly check the Peruvian Health Ministry's dengue dashboard, which offers daily updates on the number of cases, yearly and weekly case trends, emerging hotspots, and cases categorized by province and district. The dashboard indicates current cases are increasing within the Piura, Loreto, Ucayali, Ica, San Martin, and Lambayeque departments.[62] Travelers should avoid using open-air forms of transportation, like bikes. If open-air transportation is unavoidable, travelers should cover their bodies with clothing or use mosquito repellant on exposed areas.


Political Effects/Effects on Terrorism

While political instability is unlikely to occur immediately, the potential for volatility very likely increases the longer the outbreak goes on. Members of the indigenous, farming, and peasant communities in hard-hit northern Peruvian regions of Piura and Lambayeque have started expressing sentiments that the government is not helping them when their families get infected with dengue and believe they have been forgotten on top of torrential rains making their homes uninhabitable.[63] These sentiments will likely continue to grow, likely resulting in anti-government protests. Past anti-government protests from indigenous and peasant communities this year have resulted in clashes, with the Inter-American Commission on Human Rights in May 2023 concluding that the Peruvian military and police forces used excessive force to quell violent anti-government protests.[64]


Shining Path launched its first campaign against the Peruvian government in 1980. A 20-year armed struggle followed, where 69,000 were killed or went missing. Remnants of Shining Path are still operational. In February 2023, seven police officers died in an ambush, the deadliest attack on law enforcement in over a decade. Officers were killed in the Andean and jungle region called the VRAEM, where Shining Path and drug traffickers allied to produce cocaine.[65] In March, the Peruvian military attempted to capture Victor Quispe Palomino, known as Comrade Jose, the leader of Shining Path’s remnant forces. The operation resulted in the deaths of five soldiers and one member of Shining Path. The Peruvian military estimates 200-350 members of Shining Path are active in the VRAEM.[66] Peruvian military and law enforcement are likely to reduce operations against drug traffickers and Shining Path to divert resources to aid in containing the dengue outbreak. Drug traffickers are very likely to seize this chance to increase cocaine production and distribution, while Shining Path is very likely to increase recruitment.


Shining Path Founder Abimael Guzmán[67]


Recommendations for AOCs

Agencies, organizations, and companies (AOCs) associated with healthcare, the hospitality industry, non-governmental organizations (NGOs), emergency management, government health agencies, and other similar industries should enforce stringent hygiene and safety protocols to guard against mosquito bites, including strongly urging or mandating employees to wear long-sleeved shirts and pants. AOCs should educate residents in affected areas about the risks of contracting dengue and how to prevent mosquito bites by launching public awareness campaigns. AOCs should reinforce their preparedness for potential outbreaks and prioritize mosquito population control. AOCs should proactively implement preventive measures to safeguard water supplies from mosquito egg contamination. Weekly maintenance should involve emptying, scrubbing, covering indoor and outdoor water sources, or disposing of water-containing items. Trash cans, tires, buckets, planters, toys, flowerpots, pools, and birdbaths are common items to address.[68]


AOCs should also utilize air conditioning or screens on windows and doors, and ensure the repair of holes in screens promptly to keep mosquitoes out. AOCs should offer mosquito nets treated with Permethrin, an insecticide lethal to mosquitoes and other insects, to residents and employees who sleep outdoors or cannot access rooms with screens in outbreak areas. Nets should be spacious enough to be tucked under a mattress, white colored, compact, rectangular, and possess 156 holes per square inch. AOCs should monitor weather forecasts to implement effective mitigation measures. Increased rainfall and temperatures, particularly during rainy seasons, significantly impact mosquitos’ lifespans. This knowledge is crucial in identifying potential mosquito population growth and the associated increased risk of dengue.[69] AOCs should also attempt to experiment further with potential vaccinations for individuals who have not previously experienced a DENV infection. Having an administrable vaccination for travelers to Peru who have not had the infection before will very likely reduce potential outbreaks and lessen the overburdening of emergency management.


Medical workers and laboratory technicians very likely face an increased risk of infection when handling infected mosquitoes due to exposed skin, equipment contamination, and potential splash risk from shaking incubators if they do not practice proper precautions.[70] Widely distributing Personal Protective Equipment (PPE) to medical workers in affected areas, including safety glasses, laboratory coats, and disposable gloves, is crucial to prevent infection. Laboratories handling the outbreak should operate using Biosafety Level 2 practices, including access restrictions, appropriate PPE usage, and alternative decontamination methods.[71]


Local, state, and federal Peruvian agencies should engage mosquito control professionals to conduct ultra-low volume (ULV) spraying or fumigation operations using synthetic insecticides such as permethrin, sumithrin, and deltamethrin to reduce mosquito populations in outbreak areas.[72] As an alternative approach, government agencies should explore solutions from countries facing comparable dengue outbreaks, such as Argentina's utilization of atomic radiation to genetically modify mosquitoes through sterilization in April 2023.[73] Other emerging technologies include the release of Wolbachia-infected mosquitoes, an infection that mitigates mosquitos’ ability to transmit human viruses, in DENV-affected areas.[74] Government agencies should consider administering such practices as releasing genetically modified mosquitoes into the environment has a roughly even chance of dominating over DENV-spreading species, lessening the chances of future outbreaks. Effective coordination among local, national, and international partners is essential for the swift delivery of medical personnel, equipment, personal protective equipment (PPE), and information resources to keep up with the increasing number of cases.


Overwhelmed local healthcare institutions will almost certainly require international support from organizations like the WHO, Médecins Sans Frontières (MSF), and the American Red Cross. As most highly qualified health personnel are located in the coastal regions, Peruvian health organizations should increase investments and incentives to recruit qualified medical personnel throughout the country to close the gap on its lagging number of doctors and nurses per capita, as recommended by the WHO.[75] Medical organizations and the Peruvian Health Ministry should follow WHO guidance on surveillance, case management, diagnosis, dengue prevention, control, and methods to improve case reporting systems to ensure accurate data on the outbreak.[76]

 

[2] El Nino rains intensify record dengue outbreak in Peru, Reuters, June 2023, https://www.reuters.com/world/americas/el-nino-rains-intensify-record-dengue-outbreak-peru-2023-06-08/

[3] SALA SITUACIONAL DIARIA DE DENGUE, Peru Ministerio de Salud, June 2023, https://www.dge.gob.pe/sala-situacional-dengue/diaria/ (Translated by Gabriel Helupka)

[4] El Nino rains intensify record dengue outbreak in Peru, Reuters, June 2023, https://www.reuters.com/world/americas/el-nino-rains-intensify-record-dengue-outbreak-peru-2023-06-08/

[5] NOAA declares the arrival of El Nino, National Weather Service and National Oceanic and Atmospheric Administration, June 2023, https://www.weather.gov/news/230706-ElNino

[6] Peru: Officials warn that three dengue serotypes currently circulate nationwide, Outbreak News Today, June 2023, https://outbreaknewstoday.com/peru-officials-warn-that-three-dengue-serotypes-currently-circulate-nationwide-17500/

[7] El Nino rains intensify record dengue outbreak in Peru, Reuters, June 2023, https://www.reuters.com/world/americas/el-nino-rains-intensify-record-dengue-outbreak-peru-2023-06-08/

[8] Dengue and Severe Dengue, World Health Organization, March 2023, https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue

[9] “Detecting the impact of temperature on transmission of Zika, dengue, and chikungunya using mechanistic models,” Public Library of Science Neglected Tropical Diseases, 2017, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5423694/

[10] Dengue and Sever Dengue Overview, World Health Organization, 2023, https://www.who.int/health-topics/dengue-and-severe-dengue#tab=tab_1

[11] Dengue Symptoms and Treatment, Centers for Disease Control and Prevention, September 2021, https://www.cdc.gov/dengue/symptoms/index.html

[12] Dengue and Severe Dengue, World Health Organization, March 2023, https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue

[14] Dengue Symptoms and Treatment, Centers for Disease Control and Prevention, September 2021, https://www.cdc.gov/dengue/symptoms/index.html

[15] Burden of Postinfectious Symptoms after Acute Dengue, Vietnam, Centers for Disease Control and Prevention, January 2023, https://wwwnc.cdc.gov/eid/article/29/1/22-0838_article#:~:text=In%20addition%20to%20previously%20observed,long%2Dterm%20symptoms%20after%20dengue.

[16] Dengue and Severe Dengue, World Health Organization, March 2023, https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue

[17] Vaccines and immunization: Dengue, World Health Organization, April 2018, https://www.who.int/news-room/questions-and-answers/item/dengue-vaccines

[18] GRADE Analysis: Dengvaxia® Dengue Vaccine, Centers for Disease Control and Prevention, January 2022, https://www.cdc.gov/vaccines/acip/recs/grade/CYD-TDV-dengue-vaccine.html

[19] “Qdenga (dengue tetravalent vaccine [live, attenuated]),” European Medicines Agency, December 2022, https://www.ema.europa.eu/en/documents/overview/qdenga-epar-medicine-overview_en.pdf

[20] Takeda’s QDENGA®▼ (Dengue Tetravalent Vaccine [Live, Attenuated]) Approved for Use in European Union, Takeda, December 2022, https://www.takeda.com/newsroom/newsreleases/2022/takedas-qdenga-dengue-tetravalent-vaccine-live-attenuated-approved-for-use-in-european-union/

[22] Peru declares health emergency over dengue outbreak, Medical Xpress, February 2023, https://medicalxpress.com/news/2023-02-peru-declares-health-emergency-dengue.html

[23] SALA SITUACIONAL DIARIA DE DENGUE, Peru Ministerio de Salud, June 2023, https://www.dge.gob.pe/sala-situa (Translated by Gabriel Helupka)

[24] Ibid

[25] Piura: amplían clases virtuales una semana ante contagios de dengue | VIDEO, El Comercio, June 2023, https://elcomercio.pe/peru/piura/piura-amplian-clases-virtuales-una-semana-ante-contagios-de-dengue-video-minedu-ultimas-noticia/ (Translated by Dan Flanagan)

[27] Peru - Dengue outbreak (DG ECHO, UN OCHA, media) (ECHO Daily Flash of 13 June 2023), ReliefWeb, June 2023, https://reliefweb.int/report/peru/peru-dengue-outbreak-dg-echo-un-ocha-media-echo-daily-flash-13-june-2023#:~:text=Piura%20

[28] SALA SITUACIONAL DIARIA DE DENGUE, Peru Ministerio de Salud, June 2023, https://www.dge.gob.pe/sala-situa (Translated by Gabriel Helupka)

[30] Climate Change Knowledge Portal for Development Practitioners and Policy Makers, The World Bank, 2021, https://climateknowledgeportal.worldbank.org/country/peru/climate-data-historical

[31] Peru - Dengue outbreak (DG ECHO, UN OCHA, media) (ECHO Daily Flash of 13 June 2023), ReliefWeb, June 2023, https://reliefweb.int/report/peru/peru-dengue-outbreak-dg-echo-un-ocha-media-echo-daily-flash-13-june-2023#:~:text=Piura%20

[32] What are El Niño and La Niña?, US National Ocean Service, https://oceanservice.noaa.gov/facts/ninonina.html

[33] Peru: Flood Emergency - Situation Report No. 07 (as of June 13, 2023), ReliefWeb, June 2023, https://reliefweb.int/report/peru/peru-emergencia-por-inundaciones-informe-de-situacion-no-07-al-13-de-junio-de-2023

[34] Ibid

[35] SALA SITUACIONAL DIARIA DE DENGUE, Peru Ministerio de Salud, June 2023, https://www.dge.gob.pe/sala-situacional-dengue/diaria/ (Translated by Gabriel Helupka)

[36] Peru is enduring its worst dengue outbreak ever. Is El Niño making it worse?, CBC, June 2023, https://www.cbc.ca/news/health/peru-dengue-el-nino-1.6875012

[37] The Increasing Burden of Dengue Fever in a Changing Climate, The Rockefeller Foundation, November, 2022, https://www.rockefellerfoundation.org/blog/the-increasing-burden-of-dengue-fever-in-a-changing-climate/

[38] Peru is enduring its worst dengue outbreak ever. Is El Niño making it worse?, CBC, June 2023, https://www.cbc.ca/news/health/peru-dengue-el-nino-1.6875012

[39] The Increasing Burden of Dengue Fever in a Changing Climate, The Rockefeller Foundation, November, 2022, https://www.rockefellerfoundation.org/blog/the-increasing-burden-of-dengue-fever-in-a-changing-climate/

[41] El Niño, US National Aeronautics and Space Administration, February 2017, https://earthobservatory.nasa.gov/features/ElNino

[42] The Increasing Burden of Dengue Fever in a Changing Climate, The Rockefeller Foundation, November, 2022, https://www.rockefellerfoundation.org/blog/the-increasing-burden-of-dengue-fever-in-a-changing-climate/

[44] Healthcare Technologies Resource Guide, US International Trade Administration, https://www.trade.gov/healthcare-resource-guide-peru

[45] Current health expenditure per capita (current US$) - Peru, The World Bank, April 2023, https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD?locations=PE

[46] Rising Strong: Peru Poverty and Equity Assessment, The World Bank, April 2023, https://documents1.worldbank.org/curated/en/099042523145533834/pdf/P17673806236d70120a8920886c1651ceea.pdf

[47] Peru: Medical attention, food and water, main needs of Venezuelans and Peruvians affected by heavy rains, reports IRC, ReliefWeb, June 2023, https://reliefweb.int/report/peru/peru-atencion-medica-alimentos-y-agua-principales-necesidades-de-personas-venezolanas-y-peruanas-afectadas-por-fuertes-lluvias-reporta-irc

[48] Rising Strong: Peru Poverty and Equity Assessment, The World Bank, April 2023, https://documents1.worldbank.org/curated/en/099042523145533834/pdf/P17673806236d70120a8920886c1651ceea.pdf

[49] Ibid

[50] “Encuesta Nacional de Satisfacción de Usuarios del Aseguramiento Universal en Salud 2014,” Instituto Nacional de Estadística e Informática,​ December 2014, https://www.inei.gob.pe/media/MenuRecursivo/publicaciones_digitales/Est/Lib1192/libro.pdf (Translated by Gabriel Helupka)

[51] Healthcare Technologies Resource Guide, US International Trade Administration, https://www.trade.gov/healthcare-resource-guide-peru

[52] Rising Strong: Peru Poverty and Equity Assessment, The World Bank, April 2023, https://documents1.worldbank.org/curated/en/099042523145533834/pdf/P17673806236d70120a8920886c1651ceea.pdf

[53] In Peru, rumors feed vaccine reluctance among Indigenous, AP, November 2021, https://apnews.com/article/coronavirus-pandemic-health-peru-lake-titicaca-9b45371f40b5bbaf24ac7c7998bfbfc4

[54] Rising Strong: Peru Poverty and Equity Assessment, The World Bank, April 2023, https://documents1.worldbank.org/curated/en/099042523145533834/pdf/P17673806236d70120a8920886c1651ceea.pdf

[55] Rights panel: Peru used excessive force to quell protests, AP, May 2023, https://apnews.com/article/peru-protests-human-rights-iachr-58cd564147552f48ed8a0b8330954f53

[56] In Peru, rumors feed vaccine reluctance among Indigenous, AP, November 2021, https://apnews.com/article/coronavirus-pandemic-health-peru-lake-titicaca-9b45371f40b5bbaf24ac7c7998bfbfc4

[57] Sanofi's dengue vaccine approved in 11 countries, Reuters, December 2016, https://www.reuters.com/article/us-sanofi-vacccine-idUSKCN1240C5

[58] Dengue in the Americas, Centers for Disease Control and Prevention, August 2019, https://wwwnc.cdc.gov/travel/notices/level1/dengue-americas

[59] Mosquito Bite Prevention, Centers for Disease Control and Prevention, https://www.cdc.gov/mosquitoes/pdfs/MosquitoBitePreventionTravelers_508.pdf

[60] Transmission, Centers for Disease Control and Prevention, September 2019, https://www.cdc.gov/dengue/transmission/index.html

[61] Peru - Dengue outbreak (DG ECHO, UN OCHA, media) (ECHO Daily Flash of 13 June 2023), ReliefWeb, June 2023, https://reliefweb.int/report/peru/peru-dengue-outbreak-dg-echo-un-ocha-media-echo-daily-flash-13-june-2023#:~:text=Piura%20

[62] SALA SITUACIONAL DIARIA DE DENGUE, Peru Ministerio de Salud, June 2023, https://www.dge.gob.pe/sala-situa (Translated by Gabriel Helupka)

[63] ‘We have been forgotten’: People in northern Peru grapple with dengue outbreak, France24, June 2023, https://www.france24.com/en/video/20230616-we-have-been-forgotten-people-in-northern-peru-grapple-with-dengue-outbreak

[64] Rights panel: Peru used excessive force to quell protests, AP, May 2023, https://apnews.com/article/peru-protests-human-rights-iachr-58cd564147552f48ed8a0b8330954f53

[65] Peru's Boluarte vows to crush 'narcoterrorism' after deadly police ambush, Reuters, February 2023, https://www.reuters.com/world/americas/perus-boluarte-vows-crush-narcoterrorism-after-deadly-police-ambush-2023-02-13/

[66] At Least 6 Die in Peru Clash With Shining Path, Voice of America, March 2023, https://www.voanews.com/a/at-least-6-die-in-peru-clash-with-shining-path/7011720.html

[69] Dengue—an Epidemic Within a Pandemic in Peru, ReliefWeb, January 2021, https://reliefweb.int/report/peru/dengue-epidemic-within-pandemic-peru

[71] Recognizing the Biosafety Levels, Centers for Disease Control and Prevention, https://www.cdc.gov/training/quicklearns/biosafety/

[73] Argentina battles major dengue outbreak with atomic radiation, Reuters, April 2023, https://www.reuters.com/world/americas/argentina-battles-major-dengue-outbreak-with-atomic-radiation-2023-04-17/

[75] Rising Strong: Peru Poverty and Equity Assessment, The World Bank, April 2023, https://documents1.worldbank.org/curated/en/099042523145533834/pdf/P17673806236d70120a8920886c1651ceea.pdf

[76] Dengue and severe dengue, World Health Organization, March 2023, https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue

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