Specialists are predicting this year’s outbreak of the deadly fever could have life-threatening consequences for people across the region
Dr Pipat is a worried man. As head of the paediatric department and deputy director of Mae Sot Hospital, he fears that 2015 is going to be a bad year for dengue cases.
“I am concerned. We know that this year is going to be more serious than last year. Our stats show that in January we had six confirmed dengue patients, 34 cases in April, and in June it has risen to 74.”
He says hospitals nationwide have to be prepared, while at Mae Sot they are already collecting and storing blood in preparation for any urgent need for transfusions. Dr Pipat’s statistics on what is happening in his community reflect a growing threat across the country.
According to the Ministry of Public Health’s National Disease Surveillance report, from Jan 1 to June 29 there were 24,742 dengue cases in 77 provinces in Thailand.
A closer look at the statistics reveal there were 14,591 cases of dengue fever with one death, 9,824 cases of the potentially dangerous dengue haemorrhagic fever, resulting in five deaths, and of the 327 patients who had DHF shock syndrome, 11 died.
Inside the Mae Sot Hospital’s busy Child Outpatient Department, mothers fail to comfort infants, panicked and crying when examined by medical staff. Inside a small room facing the patient waiting area, Dr Pipat removes sheets of paper from a hospital file. He scribbles on a writing pad as he deciphers the meaning of the tables, graphs and explains his concerns.
“From these stats we can estimate that more than 1,000 local people are infected with dengue fever already. During their fever period if an infected person is bitten by the Aedes mosquito it then spreads the disease when biting a different person.”
Dr Pipat says if they suspect a patient has dengue haemorrhagic fever that person is immediately admitted to hospital and kept under close observation for 24 hours in case they go into shock. He added that “if a child is under one year, has a high fever and cannot eat we will admit them — our goal is no one dies from dengue”.
He says fighting dengue is a community effort.
“People need to clean out places in their homes and yards where mosquitoes can lay eggs and breed.
“Get rid of old tyres, coconut husks and bottles — even discarded eggs shells. Village heads need to check to make sure their villages are free of larvae — if we can accomplish this by working together we can reduce the risk.”
Dr Pipat says that in the 15 years he has worked in Mae Sot he has “seen too many children die from dengue haemorrhagic fever”.
Through the large glass window of the “Dengue Zone” at Mae Sot Hospital’s paediatric ward, young children struggle with pain while anxious relatives ease their own worry by fussing over beds, touching or whispering soft words.
WE THOUGHT SHE WOULD DIE
A small boy, still in street clothes, lies on a bed in the busy Child Inpatient Department at the Mae Tao Clinic in the Thai border town of Mae Sot. He wavers between an uneasy wakefulness and unconsciousness, too weak to acknowledge the anxious hand strokes his mother gives his thin body.
The boy, Ko Sue, was admitted to the Mae Tao Clinic with suspected severe dengue. His mother, Ah Nage Ma, a migrant, was working in a restaurant when she had a call from her sister, who takes care of her two children across the border in Myawaddy. “My sister told me that my son, Ko Sue, had been sick with fever for four days and she had taken him to Myawaddy Hospital.”
Ah Nage Ma says that when Ko Sue, six, started to show signs he may have severe dengue — bleeding from the nose, a rash, sore throat and high fever — the hospital insisted he seek medical care in Mae Sot.
Ah Nage Ma says when she got her sister’s phone call she burst into tears.
“When I heard he had blood coming out of is nose, I worried. My boss wouldn’t let me go to him — we fought and I left without telling him.”
Ah Nage Ma earns about 3,000 baht a month selling food, and says: “My family needs my money, but my child is more important than my job.”
Nan May Soe, a senior medic and support manager at the Mae Tao Clinic, brushes the boy’s damp hair and reads from his chart: “When Ko Sue was admitted his temperature was 38.9C — that’s dangerous. It has now dropped to 36.2C.”
Now that Ko Sue’s condition has stabilised, his mother has time to worry about her job.
“My family relies on my wages. I don’t think I’ll be able to get my job back.”
Nan May Soe turns and studies the chart of the small girl lying in the bed next to Ko Sue, and says: “Her temperature was dangerously high when she was admitted, but has now dropped from 39.3C to 36.3C — this is a good sign.”
Despite Nan May Soe’s confidence young Aye Aye is recovering, the family are still concerned about her welfare.
“We are relieved, but we still worry … we won’t leave until she is better.”
The eyes of her father, Myint Aung, betray his feelings. He wipes them with his forearm as he attempts to stem the tears while he continues to stroke his daughter’s thin arm.
“We thought she would die, she was vomiting, couldn’t open her eyes and didn’t want food. Yesterday was bad, today she has come good and has asked to eat.”
Nan May Soe says the number of dengue cases the clinic is seeing is increasing daily and had now reached 71. “Yesterday we had five patients — before we were seeing at least two or three every day.”
The Tha Sai Luat Health Promotion Hospital is about one kilometre from the Thai Myanmar border and about five kilometres from Mae Sot Hospital. The hospital is wedged between a large temple and the four-lane Asia Highway 1 that runs through Mae Sot to Myanmar. Staff describe their work as providing a front-line service in controlling infectious disease.
Jiranan, a health promotion specialist, says there are about 6,000 Thais, 14,000 registered migrant workers and a lot of unregistered people living in the area, but “disease and mosquitoes don’t recognise borders”.
She says that 2015 is shaping up to being a bad year for dengue infections.
“We are expecting a pandemic. We have more cases presenting … the larvae count is up. The early rain, then hot weather, then more rain, this supports the breeding of mosquitoes. We have officially been on alert since January — I have been on alert the whole year.
“In 2013 we had a 12-year-old boy who died from dengue haemorrhagic fever. It was distressing for all of us.”
Jiranan says education plays an important role in stopping the spread of dengue. Part of their front-line strategy in battling infectious diseases is to train villagers as community health volunteers.
“We need to make everyone aware. People have to learn to clean their environment — remove waste water where mosquitoes can breed.
“We train the volunteers to carry out house checks — on the number of people living there, on drinking and other water containers, lotus ponds, household and garden rubbish, old tyres, spirit house flower vases and plates — anywhere where mosquitoes can lay eggs.”
Outside the Tha Sai Luat Public Health Hospital, Jiranan leads her team of volunteers and the deputy village head to check a small cluster of homes on the other side of the highway.
“During the wet season we visit every house, every month for a thorough assessment. We have 127 volunteer health workers covering the whole area. For the eight clusters we will visit today, we have 12. They look after a population of 500 Thais and as many migrant workers.”
Jiranan introduces volunteer team leader Thipmanee, who is dressed in an official-looking grey jacket, Wellington boots and a bamboo hat to protect against the harsh sun. She carries a serious black, metal torch.
“I’ve been doing this work for more than 15 years. I’m happy to do it — our people want health education, all are familiar with the pain of dengue.”
Traffic noise from the Asia Highway drops to a distant drone as the volunteers weave among a cluster of wooden, bamboo and concrete houses nestling under the shade of huge trees.
Thipmanee becomes excited when the contents of a 44-gallon metal drum reveal hundreds of mosquito larvae wriggling beneath the surface of rain water dumped there by an earlier storm.
Jiranan explains what they do when they suspect there is a dengue case. “We clean and fumigate 200 metres around the house. We assess within the hour … within 24 hours we begin fumigation, after one week we repeat the fumigation to make sure we kill the mosquito eggs and larvae — we do it twice to break the breeding cycle.”
Jiranan warns that June, July and August could be the most difficult months for the Tha Sai Luat health team.
“That’s if we have good controls in place, if we cannot control the mosquitoes, we will still be busy with dengue well beyond October.”
WAITING FOR VACCINE
Professor Usa Thisyakorn, from the dengue project named Bangpong-Photharam, agrees with the health workers that “at present, effective control of the vector [mosquito] is the only means for prevention and control of dengue, but it needs a high level of community participation … the community has to be willing. They need to make a very high commitment.”
Ms Usa has been working on dengue for more than 40 years and has received numerous awards for her research and paediatric work — Woman of the Year from the Foundation for Thai Society, scientific awards from the Elizabeth Glaser Paediatric Aids Foundation and an Outstanding Asian Paediatrician Award.
Despite the accolades, Ms Usa is realistic about the chances of controlling the Aedes mosquito and the subsequent spread of dengue.
“I have worked on dengue since 1971 — that’s 44 years and I have seen it increase. We now have better ways to treat the patient, but that doesn’t mean that we stop trying to prevent dengue.”
Ms Usa hopes a dengue vaccine may soon be available.
“At the moment there is no vaccine on the market, there are some still being researched and one of them is close for consideration. This is good news as we will have another preventive measure.”
But she is dismayed it has taken decades for it to become a reality.
“Dengue is a neglected tropical disease — the will to develop a dengue vaccine has not been there because it is happening in poor countries. I am sorry to say so, but it is true. It has been nearly 50 years — 50 years too long … too long for one vaccine to be developed.”
Ms Usa says until a vaccine is available, “people do not have a choice but to try to control the vector, and that needs to be effective and sustainable vector control”.
She admits that getting people to completely rid their environments of mosquitoes is a big ask.
“It is almost an impossible task to get everyone to clean all their water containers every seven days in and outside the house — there are so many places the mosquito can breed.”
Ms Usa cautions that it is very difficult for people to know if they have dengue. “We are now seeing more adults with dengue. If they are not aware they have dengue, this is dangerous.”
She says there are other complicating factors. “If dengue patients need intravenous fluid but have a heart condition, they have to be very careful.
“Anti-pyretics can complicate the disease since some of them may cause gastrointestinal bleeding and some may be harmful to the liver.”
Ms Usa highlights a number of factors being “responsible for the increase of vector-borne diseases — climate changes, land use, water storage and irrigation and invasive vectors. The transitory nature of work and environmental climate change has also added to the increase in mosquitoes.”
She warns that “so-called rich nations” cannot rely on being protected from dengue by it being contained in “poorer countries”.
The World Health Organisation Fact Sheet 117, which was updated in May, adds a chilling edge to Ms Usa’s warning.
“Before 1970, only nine countries had experienced severe dengue epidemics. The disease is now endemic in more than 100 countries.”
The WHO lists France, Croatia, Maderia Islands, Florida and China as places where dengue has recently been detected. Japan reported a dengue outbreak, “after a lapse of 70-years”.
Ms Usa cites WHO statistics which show globally that 3.9 billion people are at risk from dengue and, of those, 70% are in Asia and 25% in Latin America.
PUTTING THE BRAKES ON
Aya Tabata, the Stop Dengue 2015 campaign coordinator, urged governments at the national and local levels, communities and health professionals to take action to eliminate the places where mosquitoes can lay their eggs.
“Governments need to support targeted public health campaigns, both with money and human resources,” she said.
“Local districts need to monitor and continue fumigation programmes and pesticide needs to be made available to stop the mosquito larvae from breeding.”
The Stop Dengue campaign asks people to do five basic things — “get rid of rubbish around the house, use pesticide, use a mosquito repellent, sleep under a mosquito net (both night and day), and wash out water containers every week and cover them”.
Ms Tabata, a health professional who has worked on the Thai-Myanmar border for three years, says it is difficult to get people to comply on a weekly basis.
“It’s hard for people to do. Some people forget to change the water in their flower vases or the plates the vase rests on, but it is really important that we keep repeating the message — stop dengue, get rid of waste water, otherwise the number of dengue cases will continue to rise.”
Ms Tabata says there is a critical need for health education campaigns to target schools.
“The research clearly confirms that almost 48% of dengue cases are school students. Health messages have to focus and educate school teachers and their pupils about dengue.”
Ms Tabata says even in Thailand the deadliness of dengue is not fully comprehended.
“I was talking to a worker, in a health related job, who says they were shocked to hear that dengue killed, as ‘it was just dengue’.
“We need to change this attitude — dengue is not just another everyday illness. It is deadly.”
*This article first appeared on Bangkok Post on 5 July 2015.