Dengue Fever - Post Olga

[DrChrisHE]

I'm not sure if there's another thread on this (pls move it if necessary.) We've seen a major increase in Dengue Fever in the South side of the island. Although I'm recovering from surgery (done Oct 31st kind of later-storm), I'm getting lots of pages and emergency calls on Dengue. I'm sure the official government stats will lag significantly. There have been a few confirmed (and more suspected) cases of Hemorrhagic Dengue Fever (the more rare and dangerous type) as well. Currently, there is no approved vaccine (although one is being tested), nor will antibiotics help (it is a viral infection spread by mosquitos--not person to person.)

For those who don't know: Dengue Fever is also known as Break Bone Fever (because you feel like your bones are broken); is characterized by high fever (39-40 c or 103-104 F) which usually is bimodal (spikes twice); terrible body aches; headache--particularly behind the eyes (orbital pain); dizziness/vertigo (due to dehydration & fever); extreme fatigue; possible rash; lack of appetite; and it usually lasts 10-14 days in otherwise healthy adults. Teenagers may recover in 7 days but infants, the elderly or otherwise infirmed persons may feel ill for over a month with lingering symptoms up to 6 months.

Dengue Fever in it's normal variety (there are 4 serotypes so you may get it more than once) is NOT dangerous IF dehydration is prevented, and fever is kept below convulsion level, it is not life threatening.
Practical Oral Rehdration Therapy for home or clinic:
The amount of rehydration that is needed depends on the size of the individual and the degree of dehydration. Rehydration is generally adequate when the person no longer feels thirsty and has a normal urine output. A rough guide to the amount of ORS solution needed in the first 4-6 hours of treatment for a mildly dehydrated person is:
1 liter pure water + 1/2 tsp salt + 8 tsp sugar (mix thoroughly and ideally add 1/2 cup orange juice or 1/2 mashed banana to increase potassium)
Quantities in 1st 4-6 hours of treatment (continued until fever comes down and person is eating normally):
Up to 5 kg (11 lb): 200 – 400 ml
5-10 kg (11-22 lb): 400 – 600 ml
10-15 kg (22-33 lb): 600 – 800 ml
15-20 kg (33–44 lb): 800 – 1000 ml
20-30 kg (44-66 lb: 1000 – 1500 ml
30-40 kg (66-88 lb): 1500 – 2000 ml
40 plus kg (88 lb): 2000-4000 ml
IF bottled water isn't available, water should be boiled for 12 min.

For fever management, for adults 800mg of ibuprofen (every 6-8 hours) is preferable to acetomenofen or paracetamol (neither of these two have strong anti-inflammatory action.)
* the above is for informational/self-education purposes and is not to be construed as medical advice; however, NOT being informed could have serious consequences and I believe in sharing information.

Note: The tests for Dengue often don't test positive right away and the type of test depends on how long someone has been ill. Therefore, there are many false negatives and misdiagnoses. In the DR, it is common for clinics to require you to come back 3-4 times. Other than obtaining a definitive diagnosis (to rule out something like Malaria and for statistical purposes), if you use the ORT, you don't need to be in a hospital where there are even more critters you might catch (IMHO).

[Frenki]

Please recommend me some mosquito repelent, can I buy something effective in Boca Chica or should I bring something from Europe ?

Thanks !!

[MommC]

Repellants are available here but do bring one from Europe until you locate where to buy here.......

[Hillbilly]

My only comments are:
1) Many thanks for the very lucid treatise on Dengue. Quite easy to read and understand.
2) I use the WHO "miracle" formula of 711: 7 tsp sugar; 1 tsp salt, 1 liter good water.
And I totally agree with addition of orange juice or mashed banana. I also use Alka-Seltzer® or Sal Andrews® for more minerals..

I have printed and saved that note....good work.

HB

[Chris]

You know, I think I'll make this a sticky for a while. Thanks DrChrisHE.

[CyaBye3015]

Trust me on this one, I live in Minnesota and if you sit outside at sunset without a shirt on for just a minute you’d have a minimum of a 100 skeeters on you. As someone said earlier DEET is the only sure way to keep them off.

[DrChrisHE]

Originally Posted by Frenki

Please recommend me some mosquito repelent, can I buy something effective in Boca Chica or should I bring something from Europe ?

Thanks !!

Depending on when you are coming, the mosquitos will abate as the rain decreases. It's definitely seasonal and the tourist season corresponds to the DRY-ER (Not DRY, DRY-ER) season. Let me know if you need more info.

The CDC recommends the following:
"Use insect repellent containing DEET or Picaridin on exposed skin. DEET concentrations of 30% to 50% are effective for several hours. Picaridin, available in 7% and 15% concentrations, must be applied more frequently. When using sunscreen, apply it before insect repellent.
DEET formulations as high as 50% are recommended for both adults and children over 2 months of age. Protect infants less than 2 months of age by using a carrier draped with mosquito netting with an elastic edge for a tight fit.
Wear loose, long pants and long-sleeved shirts when outdoors.
Indoors, spray insecticide where the Aedes mosquito likes to linger: closets, behind curtains, and under beds. If practical, empty or cover containers containing water.
Air conditioned, screened rooms furnished with mosquito nets provide further protection.
Empty or cover containers that can collect water (e.g., uncovered barrels, flower vases, or cisterns), because mosquitoes that transmit dengue breed in standing water.
Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Unlike malaria, dengue is often transmitted in urban as well as in rural areas."

Excerpted from:


Outbreak Notice
Update: Dengue, Tropical and Subtropical Regions
This information is current as of today, November 29, 2007 at 12:16

Updated: September 19, 2007

Dengue has become one of the most common viral diseases transmitted to humans by the bite of infected mosquitoes (usually Aedes aegypti); it is the most common cause of fever in travelers returned from the Caribbean, Central America, and South Central Asia.* Symptoms of dengue include fever, severe headache, retro-orbital eye pain (pain behind the eye), joint and muscle pain, and rash. Dengue can produce a range of illness from mild to severe, as well as fatal hemorrhagic fever. Travelers are at risk for dengue infection if they travel to or reside in areas where dengue virus is transmitted; the preventive measures outlined below can reduce their risk.

Dengue Risk Areas
The range of areas where dengue is located has rapidly expanded in recent years. Today it includes many tropical countries in Southeast Asia, the Indian Subcontinent, the South Pacific, the Caribbean, South and Central America, northeastern Australia, and Africa. See the Distribution of dengue maps for areas where it is present most of the time. Risk of infection is related to mosquito exposure, which can vary with the season. The mosquitoes that transmit dengue breed in man-made and natural containers, which are especially common in and around houses; therefore, dengue is common where many houses are clustered.

Currently, an outbreak of dengue is being reported in French Polynesia and Palau in the South Pacific. Singapore is also experiencing an increase in dengue cases this year. As of June 30, 2007, the outbreak of dengue in Paraguay was reported to be subsiding. Other areas in South and Central America and the Caribbean, such as Brazil, Guadeloupe, Martinique, Mexico, Nicaragua, and Puerto Rico, are experiencing an increase in dengue cases in 2007.

Prevention Measures for Travelers
No vaccine is available to prevent dengue, and there is no specific treatment other than therapeutic support. Travelers can reduce their risk by protecting themselves from mosquito bites:

Use insect repellent containing DEET or Picaridin on exposed skin. DEET concentrations of 30% to 50% are effective for several hours. Picaridin, available in 7% and 15% concentrations, must be applied more frequently. When using sunscreen, apply it before insect repellent.
DEET formulations as high as 50% are recommended for both adults and children over 2 months of age. Protect infants less than 2 months of age by using a carrier draped with mosquito netting with an elastic edge for a tight fit.
Wear loose, long pants and long-sleeved shirts when outdoors.
Indoors, spray insecticide where the Aedes mosquito likes to linger: closets, behind curtains, and under beds. If practical, empty or cover containers containing water.
Air conditioned, screened rooms furnished with mosquito nets provide further protection.
Empty or cover containers that can collect water (e.g., uncovered barrels, flower vases, or cisterns), because mosquitoes that transmit dengue breed in standing water.
Aedes mosquitoes, the principal mosquito vector, usually are active at dusk and dawn, but may feed at any time during the day, especially indoors, in shady areas, or when the weather is cloudy. Unlike malaria, dengue is often transmitted in urban as well as in rural areas.

Additional Information
Proper diagnosis of dengue is important; many other diseases may mimic dengue and health-care providers should consider dengue, malaria, and (in South Asia and countries bordering the Indian Ocean), chikungunya in the differential diagnosis of patients who have fever and a history of travel to tropical areas during the 2 weeks before symptom onset. See Dengue and Dengue Hemorrhagic Fever: Information for Health-Care Practitioners for information regarding reporting dengue cases and instructions for specimen shipping. Serum samples obtained for viral identification and serologic diagnosis can be sent through state or territorial health departments to CDC's Dengue Branch, Division of Vector-Borne Infectious Diseases, National Center for Zoonotic, Vector-Borne and Enteric Diseases, 1324 Calle Cañada, San Juan, Puerto Rico 00920-3860; telephone, 787-706-2399; fax, 787-706-2496.

For more information about dengue and protection measures, see the following links:

Dengue Fever in CDC Health Information for International Travel 2008
Insect and Arthropod Protection
Questions and Answers: Insect Repellent Use and Safety
Overview of dengue from CDC Division of Vector-Borne Infectious Diseases
For more information about dengue in travelers, see

Travel-Associated Dengue—United States, 2005 [MMWR 2006, 55 (25)].
Travel-Associated Dengue Infections—United States, 2001-2004 [MMWR 2005, 54 (22)]
For more information about recent dengue outbreaks, see

Pan American Health Organization http://www.paho.org/english/ad/dpc/cd/dengue.htm
South East Asia-Region/WHO (SEARO) Dengue/DHF - Situation of Dengue/DHF in SEA
* Freedman DO, Weld LH, Kozarsky PE, Fisk T, Robins R, von Sonnenburg F, et al.; for the GeoSentinel Surveillance Network. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med 2006;354:119-130

[DrChrisHE]

Originally Posted by Hillbilly

My only comments are:
1) Many thanks for the very lucid treatise on Dengue. Quite easy to read and understand.
2) I use the WHO "miracle" formula of 711: 7 tsp sugar; 1 tsp salt, 1 liter good water.
And I totally agree with addition of orange juice or mashed banana. I also use Alka-Seltzer® or Sal Andrews® for more minerals..

I have printed and saved that note....good work.

HB

Thanks HB...you might want to decrease the salt to HALF tsp as the most recent studies show the osmotic balance is better (reducing dehydration faster with less stress on the kidneys ESP if you use the AlkaSelter method too!) In lieu of AlkaSeltzer, a pinch of baking soda can be used too!

[DrChrisHE]

This probably should go under a separate heading but as Chris was kind enough to 'sticky' the thread and they both have to do with TS Noel, I'm putting it here. Feel free to move it.

Leptospirosis
Description
Leptospirosis is a bacterial zoonosis that is endemic worldwide, with a higher incidence in tropical climates (1). A variety of wild and domestic animals may act as reservoirs for leptospires, excreting the organism in their urine or fluids of parturition. Humans may be infected through direct contact with urine or fluids of parturition of infected animals, or through contact with contaminated water or soil. A variety of occupations have traditionally been associated with increased risk of leptospirosis, including farming, veterinary, and abattoir work.

Occurrence
Leptospira proliferate in fresh water, damp soil, and mud. The occurrence of flooding after heavy rainfall facilitates the spread of the organism because, as water saturates the environment, Leptospira present in the soil accumulate in surface waters (2). Leptospira can enter the body through cut or abraded skin, mucous membranes, and conjunctivae. Ingestion of contaminated water may lead to infection.

Risk for Travelers
Travelers participating in recreational water activities, such as whitewater rafting, adventure racing, or kayaking may be at increased risk for the disease, particularly following periods of heavy rainfall or flooding and even in areas not previously considered endemic (3). Recent outbreaks of leptospirosis in the US have occurred in Illinois and Florida (CDC, unpublished data), while leptospirosis is endemic to Hawaii (4,5). Outbreaks in which US residents acquired leptospirosis have also occurred recently in Malaysian Borneo and Costa Rica (2,6).

Clinical Presentation
The acute, generalized illness associated with infection can mimic other tropical diseases (e.g., dengue fever, malaria, and typhus), and common symptoms include fever, chills, myalgias, nausea, diarrhea, and conjunctival suffusion (1). Manifestations of severe disease can include jaundice, renal failure, hemorrhage, pneumonitis, and hemodynamic collapse. Confirmation of leptospirosis requires culture of the organism or demonstration of serologic conversion by the microagglutination test (MAT); however, culture is relatively insensitive and requires specialized media, and the MAT is difficult to perform. The availability of these techniques has been restricted to reference laboratories. Recently, several rapid, simple serologic tests have been developed that are reliable and commercially available (7).

Prevention
No vaccine is available in the United States to prevent leptospirosis. Travelers who might be at an increased risk for infection should be advised to consider preventive measures such as wearing protective clothing, covering cuts and abrasions with occlusive dressings, and minimizing contact with potentially contaminated water. Such travelers may also benefit from chemoprophylaxis (3). Until further data become available, CDC recommends that travelers who might be at increased risk for leptospirosis be advised to consider chemoprophylaxis with doxycycline (200 mg orally, weekly), begun 1-2 days before, and continuing through, the period of exposure. Travelers who may be at increased risk for leptospirosis and who are also in need of malaria chemoprophylaxis should consider using doxycycline for both indications. (See Table 4-10 for recommended doses.)

Treatment
Missed or delayed diagnosis of leptospirosis is common, due to its non-specific clinical presentation and a low index of suspicion among healthcare providers in non-endemic areas. Treatment with antimicrobial agents (e.g., penicillin, amoxicillin, or doxycycline) should be initiated early in the course of the disease if leptospirosis is suspected (1). Aggressive supportive care may be required for respiratory, renal, and hemodynamic compromise. An infectious diseases or tropical medicine specialist should be consulted.

References
Levett PN. Leptospirosis. Clin Microbiol Rev. 2001;14:296-326.
Sejvar J, Bancroft E, Winthrop K, Bettmyer J, Bajani M, Bragg S, et al. Leptospirosis in “Eco-Challenge” athletes, Malaysian Borneo. Emerg Infect Dis. 2003;6:702-7.
Haake DA, Dundoo M, Cader R, Kubak BM, Hartskeerl RA, Dejvar JJ, et al. Leptospirosis, water sports, and chemoprophylaxis. Clin Infect Dis. 2002;34:e40-3.
Morgan J, Bornstein SL, Karpati AM, et al. Outbreak of leptospirosis among triathlon participants and community residents in Springfield, Illinois, 1998. Clin Infect Dis. 2002;34:1593-9.
Park SY, Effler PV, Nakata M, et al. Leptospirosis after flooding of a university campus–Hawaii, 2004. MMWR Morbid Mortal Wkly Rep. 2004;55:125-127.
CDC. Outbreak of leptospirosis among white-water rafters–Costa Rica, 1996. MMWR Morbid Mortal Wkly Rep. 1997;46:577-579.
Bajani MD, Ashford DA, Bragg SL, Woods CW, Aye T, Spiegel RA, et al. Evaluation of four commercially available rapid serologic tests for diagnosis of leptospirosis. J Clin Microbiol. 2003;41:803-9.

[STEVE G.]

Leptospirosis finally under control.
Leptospirosis, which last week was on the verge of reaching epidemic status in the DR, is finally under control, according to health officials. Even so, officials are warning people to continue taking preventive measures. A total of 29 people have died, while 350 were infected. Health officials are still concerned about the spread of conjunctivitis and are advising private or public employers to send people home if they feel they might be infected, in order to prevent the spread of the disease.