Dengue Risk in TT

“Like flies to wanton boys are we to the gods, they kill us for their sport.” –William Shakespeare

A hot country thick with humidity can close around you: grass is wide at the bottom and angled like so many swords. The foliage, dense and matted, looms threateningly. Flowers are large, blood-coloured, orange, yellow, without fragrance, appear plastic. All around are signs of decay. Guavas riddled with worms are crushed underfoot into pulp. Papaws rot on a kitchen counter. In a forgotten vase, stems rot into water leaving a stench.

Sounds of the earth are harsh and persistent: shots of bamboo, barking dogs, creaking frogs, a mad man shouting obscenities, randomly, to no one in particular. A mosquito wheels about mockingly, escaping the swatter easily, swooping down, swaying menacingly, then flying out of reach. Nervously you scratch at a small red welter on your index finger.

Somewhere a restless, feverish woman clutches her sweaty palms and patches of blood appear under her skin. She goes into shock and dies. There is a funeral. Then another. Wards fill up with fevered men and women. There is loose talk of an epidemic, and in my local grocery there are no more mosquito coils to be found.

Innocent images of a half drunk glass of water, left overnight under the bed, an itch on your arm, are now, ridiculously, intimations of death. In this land where the lines between folklore, heresy, myth, truth and prejudice are blended into a blurred hysteria it is difficult enough simply to establish facts. Between conjecture and media reports, this is what I managed to establish:

Two women have died from Dengue Haemorrhagic Fever (DHF). There are 30 confirmed cases of DHF. At the San Fernando hospital more than 220 patients with dengue-like symptoms have been admitted for observation. Overcrowding was severe and at one point up to five patients were occupying one bed. It was reported that patients who might have gone into shock and begun to bleed from DHF on a weekend ran the risk of bleeding to death since the hospital did not have adequate supplies of life saving platelets - blood cells which help clotting.

It was too little to go on. I could no longer look at a glass of water standing still on a table for five minutes without thinking of DHF. So I did what all hypochondriacs do. Called the doctors: the closest we hypochondriacs will ever get to divinity because we trust them with our neuroses. But they are wary of journalists, of our capacity to alarm or twist their replies into sensationalism. I was lucky to be put on to Dr James Hospedales at Carec, by a helpful doctor at PAHO. I also used the Net. My questions to doctors and the “search” on the Net reflected paranoia, hysteria, megalomania. The questions tumbled out. Was it true that that there was an epidemic, that Dengue Haemorrhagic Fever was fatal, that it came about because we were not spraying for mosquitoes? Was it preventable?

Here are the facts as I now understand them, gleaned from these various reliable sources. Firstly there is a dengue outbreak, but no epidemic in Trinidad and Tobago. Dengue fever is transmitted through the bite of an infected female Aedes aegypti mosquito. It affects as many as 50 million people worldwide each year. There has been a recent outbreak in Cuba and dengue remains a major health risk in Africa, South and Central America and southern areas of the United States. The dengue virus, most prevalent in Third World tropical regions but also found in subtropical developed countries, causes dengue fever, a severe, flu-like illness. The dengue virus has circulated in the tropical world for generations. Symptoms include pain to the joints and muscles, headaches, sore throat, fever, runny eyes, and an irritating rash. There is no cure, but recovery usually occurs within several days.

Dengue fever is part of a vicious cycle: the Aedes aegypti mosquito is infected when it bites a person who has dengue. Then the mosquito, now a carrier of dengue in turn infects people. If you are bitten by an infected mosquito, you have an incubation period of a week to ten days before you get ill with symptoms. On the day before you fall ill and for four days afterwards you have the virus in your blood stream. In order to break the cycle and prevent the spread of the virus it is vital to prevent the person who has dengue fever from being bitten during the incubation period. This can be done by spraying the patient’s walls with insecticide. (A vital and underrated aspect of prevention.) The dengue infection, however, cannot be passed on through direct contact with a person who has the virus.

Dengue Haemorrhagic Fever (DHF) is a severe, frequently fatal infection caused by one of several dengue viruses (there are four “types”) and is also spread by the bite of female Aedes aegypti mosquitoes. Anybody getting a dengue infection is at risk of getting DHF, but it’s very low if it’s the first time you are getting infected by dengue or a long time since your last infection. DHF generally occurs when several types of virus are present at the same time or when the patient has contracted a second or third dengue virus after previous infections by another type. The overall risk of DHF has increased in Trinidad and Tobago due to the heavy outbreak of dengue fever of the type 1 virus last year. Those who contract dengue for the second and third time before they have become immune to the virus are the most susceptible to the Dengue Haemorrhagic Fever. Their blood vessels become leakier and leak plasma, there is hemorrhaging, the liver swells, and the patient suffers from sudden and severe abdominal pains. “A one two combination punch in quick succession,” as Dr Hospedales put it. No one type of dengue is intrinsically bad. It the sequential fever that sets us up DHF.

It is believed that the various types of dengue virus are brought back to Trinidad by people who travel to countries where they exist. Infections of any one type of dengue dominate a population for a few years until people become immune to it. Then another type against which there is no immunity is introduced to a population, causing infection. The early symptoms of Dengue Haemorrhagic Fever (DHF) are similar to those of dengue fever but after several days the patient becomes irritable, restless and sweaty followed by a shock-like state. Bleeding may appear as pinpoint spots of blood on the skin and larger patches of blood under the skin. Bleeding may occur from minor injuries. Death generally occurs from shock. If the patient survives, recovery begins after a one-day crisis period. DHF deaths are preventable if symptoms are recognised and treated early enough. The treatment largely consists of replacing lost fluids. For those under observation it can take anything from three days to three weeks to get a confirmed diagnosis, depending on how far the disease has progressed.

Hundreds of people have dengue to various degrees but Dr Hospedales says it is neither necessary nor practical to admit all of them to hospital. Doctors need to make a judgment call. People with dengue-like symptoms need to be told to watch for the danger signs. If they bleed easily or profusely, start coughing blood, are restless, sweaty, or suffer from abdominal pain then they need to go to the hospital immediately. Basic dengue lasts for between five and seven days and recovery is complete. Even patients recovering from DHF have long term complications. However, patients may suffer from post viral fatigue which can last up to four weeks.

There are no commercially available dengue vaccines available although vaccine research has been going on for some time. Many people with dengue fever have mild symptoms or no symptoms at all. This is where the general campaign to eliminate the breeding Aedes aegypti is so important. The mosquito breeds in clear water, and it doesn’t need a lot. It especially thrives in a human domestic atmosphere, and lives under beds, on walls. Water lying in a child’s plastic boat in a bath could do it, or rainwater in a brick, or water in a vase. These are all breeding grounds, anything that will collect water.

The big producers are the big uncovered drums and tanks with water. You get rid of the mosquitoes by spraying with insecticide inside and outside the house. It is impossible to get rid of mosquitoes in one home because they come in from the outside so entire communities need to band together both to prevent breeding and to eradicate them by spraying.

The surprise in my investigation was the conclusion that the effectiveness of spraying was limited, like spinning top in mud. Apparently (although I was not able to confirm this) the Ministry has been spraying but the experts say that even if spraying was done both inside and outside homes and was 100 percent effective (a very costly and labour intensive exercise) the pesky eggs hatch the moment your back is turned, the next day.

The way out is to interrupt the breeding by creating a zero tolerance of mosquitoes which can only be done if all of us (some won’t do) in every home interrupt the breeding. We do this through eternal vigilance: cleaning our drains, covering our water, emptying every vessel, every tin pan, drum, vase and pot of standing water. And every single home needs to do it. If you do it, and I don’t, the damn things will still breed and get into your house and vice versa.

Whether we like it or not we are all in this together. United we stand, divided we fall like flies. And I found that the clear water must be left standing for at least a week before the female Aedes aegypti mosquito will breed in it. I didn’t have to drain every drop from the glass before I went to sleep.

A woman in sun-glasses sits in an outdoor restaurant, overlooking the beach, swatting mosquitoes from a lukewarm, over-sweet fruit cocktail. Welcome to life in the tropics.