Text by Henrylito D. Tacio
Photos by Dr. Richard Mata and Wikipedia
(First of Two Parts)
After two days of rain, one night, six-year-old Jenny came down with a fever. Her mother, Esther, noted that Jenny had lost her appetite and that her skin was flushed but wasn’t particularly concerned. She gave her paracetamol, which she believed would help the temperature to subside. The fever vanished the following day but returned the next.
Seven days after the symptoms first appeared, Jenny became drowsy, breathing rapidly and with a racing pulse. Then she began to vomit blood. Esther rushed her daughter to the hospital, where a doctor administered blood transfusions, but it was too late. The little girl died soon afterwards.
Jenny died of what is considered the most widespread mosquito-viral disease in the world. “After a dengue patient has gone into shock,” the doctor who tried to save Lenny explained, “it is just a matter of time before multi-organ failure occurs and death becomes inevitable.”
Dengue has been known for over 200 years, with the first reported cases arising in 1779 and 1780 from a simultaneous outbreak in Jakarta, Indonesia; Philadelphia, United States, and Cairo, Egypt. It has been in the Philippines since the 1950s, but until now, it has not been able to eradicate the disease.
One study on the prevalence of dengue estimates that 3.9 billion people are at risk of infection with the dengue virus. Despite a risk of infection existing in 128 countries, the World Health Organization (WHO) reports that 70% of the actual burden is shouldered by Asia.
“The problem is increasing, the epidemics are dramatic and dengue is now one of the leading three causes of death in Asia,” says Dr. Allan Schapira, an epidemiologist working at the regional office of the World Health Organization (WHO) in Manila.
There are two kinds of diseases caused by the dengue virus – classical dengue fever has been known for more than 200 years and is now resurging. The other new entity, dengue hemorrhagic fever (DHF) – also called Philippine, Thai, or Southeast Asian hemorrhagic fever or dengue shock syndrome – emerged in 1953 in Manila and in 1958 in Bangkok.
Today, DHF is now all over in tropical areas but is most common in Southeast Asia, China, and Cuba.
In Asia, the number of recorded dengue cases per year is about 200,00 to 400,000 – “but this is just the tip of the iceberg,” Dr. Schapira points out. “The real number of infections is probably about 10 times as high, but many people get infected without falling sick.”
Every year, about 3,000 deaths are recorded, but it is likely that several times as many are not reported.
The WHO regional office says that the peak incidence for dengue cases in most Asian countries, including the Philippines, is during the rainy season from June to November each year. During these months, high cases of dengue are recorded in all endemic areas.
More than 90% of the recorded deaths are in children under 15. “Dengue is a big problem among children because it is a major cause of illness and deaths,” says Dr. Lulu C. Bravo of the College of Medicine at the University of the Philippines.
Approximately 5% of all DHF cases are fatal. Without proper treatment, DHF fatality rates reach 15% more. “Although dengue is rarely lethal, its contribution to disease and ill health, especially among young children, should make dengue control a primary public health concern,” says Dr. Dominic Garcia, an infectious disease specialist.
The symptoms of dengue fever are now familiar to most people situated in areas where the disease is most widespread. Dengue fever usually starts suddenly with a high fever with chills or chilly sensations. Headaches, pain in moving the eyes, backache, and muscle and joint pains are also common.
“Extreme aching in the legs and joints occurs during the first hours of illness,” says The Merck Manual of Medical Information. “The temperature rises rapidly to as high as 40 degrees Centigrade, with relative bradycardia (heart beating less than 60 beats a minute) and hypotension (abnormal condition in which the blood pressure is too low for normal functioning). Fever and other symptoms of dengue persist for 48 to 96 hours, followed by rapid dropping of fever with profuse sweating.”
A rash usually appears 3 to 4 days after the start of the fever. The illness can last up to 10 days, but complete recovery can take as long as a month. Older children and adults are usually sicker than young children.
DHF is a potentially deadly complication that is characterized by high continuous fever (40-41 degrees Celsius) lasting 2-7 days that may be accompanied by loss of appetite, nausea, vomiting, abdominal pain, and subsequent evidence of bleeding like persistent red spots on the skin, nose or gum bleeding, coffee-ground vomit, and dark stools. The patient can go into shock (referred to as dengue shock syndrome).
In moderate DHF cases, all signs and symptoms abate after the fever subsides. In the worst cases, parents are advised to watch for these danger signs: restlessness, cold, clammy skin, sudden abdominal pain, having difficulty in breathing, and behavioral change.
Most people equate DHF with influenza and similar flu-like diseases. “There is usually a rash in dengue while there is none in flu,” Dr. Schapira explains. “Fever caused by dengue tends to last almost a week, while that of flu disappears after 3-5 days.”
Sarah Estrera thought her 8-year-old son, Justin, had the flu since he manifested symptoms like fever, chills, headache, runny and stuffy nose, sore throat, and weakness. A day later, her son complained of muscle and joint pains. The fever was gone one day and returned the following day. By this time, there were rashes all over his arms, and blood was oozing from his nose.
“There’s something wrong with our son,” Sarah frantically told her husband, Gerry. The couple immediately brought their son to the nearest hospital. The doctor conducted a blood test and confirmed Sarah’s observation. “Justin is suffering from dengue fever,” he said. “He is in need of type-B blood as his platelets have dropped to a critical level.”
Since Gerry had the same blood type as his son, the doctor conducted a blood transfusion. Three days after he was admitted, Justin was back to his former self. His parents were relieved. “We thought we would lose him,” Sarah said. “We had a neighbor whose daughter also experienced the same thing. Left untreated, she died.”
Most people, particularly parents, are terrified of dengue because when the blood platelets decrease, it causes severe bleeding and may ultimately result in death. This thinking, said Dr. Richard T. Mata, is very wrong.
“That’s a misconception,” stressed Dr. Mata, who is a consultant for dengue through WHO at the health department. In an interview, he talked of another disease called ITP, which stands for idiopathic thrombocytopenia purpura. “It is not dengue, but it also has low platelets as less than five, but I noticed patients are just playing around far from dying.
“So, that proves the point: the low platelet is not the main cause of dengue deaths,” he said. “What really kills dengue patients is dehydration.”
According to Dr. Mata, “when the mosquito bites you, the dengue virus will enter your blood vessels, and it will cause plasma leakage, or what I call as butas ang mga ugat. It’s like you have thousands of pinpoint holes in your blood vessels that cause it to leak with water that will cause dehydration.
“Para kang supot na may tubig na may butas,” he continued. “It’s like a secret diarrhea. And that’s why it’s dangerous because you cannot see the fluids that come out of the vessels unlike in loose bowel movement where it’s obvious. So, it’s easier to estimate the needed amount of hydration in diarrhea than that of dengue. All the worst if you don’t even know it’s dehydration.”
Dr. Mata said dehydration causes shock: “Dahil naubos na ang tubig, wala ng pressure. Kaya nga tinawag na dengue shock.”
Dehydration also causes intestinal ulcers that cause bleeding. “And because the platelets are low, the bleeding becomes severe. But if there was no dehydration, there will be no ulcer and thus no bleeding – even if the platelets are low just like in ITP. So, it still boils down to dehydration.”
Dehydration likewise causes kidney failure, which results from a decrease in urine output. “This causes the water to be retained in the lungs thereby creating congestion that can kill the patients,” Dr. Mata said.
Right now, there is no specific treatment for dengue. Fevers and pain killers can be taken to control the symptoms of muscle aches and pains and fever. For severe dengue, medical care by physicians and nurses experienced with the effects and progression of the disease can save lives. (To be concluded)