Special Report on Malaria in the Dominican Republic – 9 December 2004

On 9 December 2004, local health authorities in the Dominican Republic issued the following update in the Dominican Republic: "Following the completion of the data collection corresponding to the epidemiologic week number 48 (November 28 to December 4), and according to the data from the Nation Centre for Control of Tropical Diseases (CENCET - Spanish acronym), the endemic curve [of malaria] is within the secure zone. In epidemiological terms, the secure zone signifies that the endemic disease is under control. In the 49th week (from December 5 to date) no/no cases have been reported in the Province of La Altagracia. Doctors have been placed at the major construction sites in the area, to guarantee the periodical evaluation of the workers entering and leaving the sites, allowing for the sustained control of malaria in the zone. The National Coordinator for the Malaria Program and those responsible for Entomological and Vector Control are regularly performing observations. Furthermore, vector control teams are taking entomological supervisory actions, searching for and controlling the breading places of the Anopheles albimanus and controlling the adult mosquitoes through thermic fogging using "Malathion" and cold fogging using "permetrinas" during the nights." The authorities of Public Health and Tourism, as well as the Pan American Health Organization (PHO) confirmed on Thursday, 9 December that the recent outbreak of malaria in the DR is under control. The Pan American Health Organization's official, Gerardo Alfaro, reassured that what was happening was an ordinary situation being treated in an extraordinary manner. Doctors Rafael Schiffino of the Public Health Ministry, Jose Manuel Puello of the Center for Tropical Diseases, Gerardo Alfaro of the PHO, and Luis Simo of the international chapter of the Ministry of Tourism spoke at a press conference on Thursday, 8 December, where they said they believed as many 11 deaths this year could be attributed to malarial infection in the DR, but that no cases at all had been reported since 5 December. Tourists that have visits planned to the Dominican Republic have expressed concern after the Center for Disease Control of the United States issued an alert recommending malaria prophylaxis for travelers to the resort areas of eastern La Altagracia (Punta Cana-Bavaro area). Over 1.3 million tourists visited Punta Cana last year of around three million visitors to the DR. The CDC reported that there had been two cases of malaria in November 2004 affecting US travelers to Punta Cana-Bavaro and the city of San Francisco de Macoris (Duarte province in the northeast). The CDC reported that in the first week of December eight cases were reported in European travelers who had visited Punta Cana, and another four cases of Canadians. No cases have been reported in other tourist areas of the country. The CDC is recommending chloroquine prophylaxis for travelers to La Altagracia province and to Duarte province. As far as the caution issued by CDC is concerned, it would be a level 2 alert, Outbreak Notice, out of 4 levels used by the CDC. The Pan American Health Organization and World Health Organization have yet to issue alerts regarding the DR. The Dominican Republic is generally considered a low risk transmission country in the Americas, with only prophylaxis recommendations for travelers to rural areas, especially near the border with Haiti. Because of the low incidence, prophylaxis such as that recommended by CDC is not undertaken by Dominican and foreign residents in the DR regardless of where they travel in the country. This is with the exception of the medical operations that are required of Haitian resident construction workers in areas considered of risk. As of 1 December, there have been 2,021 cases of malaria detected in the Dominican Republic of 270,000 people examined. This compares to an average of 60 cases in Florida, USA each year. In Latin America, this compares to 349,873 registered cases in Brazil (2002) and 195,719 registered cases in Colombia (2002), and 4,289 cases for Mexico (2002), all countries for which CDC posts permanent prophylaxis recommendations, for instance. In 2002, in the Dominican Republic there were 1,296 registered cases. While the 2,021 cases only suggests a 0.75% incidence, the Ministry of Public Health, in coordination with representatives from the Pan American Health Organization (PHO), is working to eliminate the vectors that carry the disease from the area, and have been successful as of 5 December with the control of the outbreak. Public Health officials, including Jose Manuel Puello, director of the National Center of Tropical Diseases (CENCET), Under-Secretary Hector Otero Cruz, and head of the Epidemic Department of SESPAS indicated that the highest incidence of malaria is concentrated in three southwestern provinces (Bahoruco, Barahona and Azua). These provinces are either located on the frontier with Haiti, or have large sugar cane plantations or other heavy irrigation-based agriculture. Among the programs studied and approved for use are biological agents to control mosquito larvae, nighttime spraying of chemical agents and the treatment of the patients according to the severity of each case. In the Dominican Republic in September 1998, following the passing of Hurricane Hortense through the La Altagracia province the first cases were reported in that area. At the time, of 1,289,741 cases of malaria that occurred in the Americas in 1998, 2,006 occurred in the Dominican Republic, including 14 in the La Altagracia area. The 1998 outbreak is attributed to the hurricane flooding of wet forest areas that occurred at a time of intense hotel construction in the area and the import of large numbers of Haitian workers that were hired for the constructions. The situation was quickly controlled by the Ministry of Public Health and private sector efforts by implementing mosquito surveillance, case management and control activities in the area. The outbreak of September-November 2004 also coincided with the passing of Hurricane Jeane in the area and another boom in hotel construction. The Center for Tropical Diseases of the Ministry of Health has recommended that persons that come from countries where malaria is not endemic and that will be taking excursions into rural areas consider prophylaxis and should use of an insect repellent with DEET. According to Dr. Guillermo Gonzalvez, Dominican tropical disease expert, what is important is that any person developing a high fever upon returning from the Dominican Republic should visit their medical service, explain they were in an area where there have been malaria cases and get checked. Other symptoms are profuse sweating and headache. Only one drop of blood is needed for the test and results can be had in ten minutes. The cost of treating the sickness is around US$1.00. If diagnosed on time, malaria does not leave any short, medium or long term effects. The treatment is three tablets of chloroquine every day together at the same time for three days. The illness is sometimes confused with hepatitis, salmonella and typhoid fever. Gonzalvez has explained that malaria has such a bad name because it has been part of the history of humanity and at times has wiped out entire populations due to the lack of treatment. He explains that malaria is a social sickness that primarily affects persons of low income given their living conditions. Following the reports of cases in the La Altagracia province, special fumigation with machines, insecticides and others have been taking place some daily, others on a weekly basis. To read more about malaria, see http://dr1.com/forums/showthread.php?t=36395 http://www.astdhpphe.org/infect/Malaria.html http://www.cdc.gov/travel/other/malaria_dr_2004.htm http://www.cdc.gov/travel/outbreaks.htm http://www.who.int/ith/chapter07_01.html http://www.who.int/ith/countrylist04.html#60 http://www.wrongdiagnosis.com/m/malaria/stats.htm http://www.phac-aspc.gc.ca/tmp-pmv/info/pal_mal_e.html http://www.drgreene.com/21_38.html http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5319a2.htm