Due to an alarming increase in cases of dengue fever in Honduras this year, MSF has launched an emergency intervention in Tegucigalpa, the capital of the Central American country, where the majority of cases have been reported. MSF is supporting local health services with a three-pronged approach focusing on medical care, vector control and community education. This sort of dengue intervention is relatively new for MSF.
Already, more than 80 children have been treated in an emergency paediatric ward set up by MSF. Mobile teams are also working with the local health authorities to identify and eliminate sources of infection in 4,000 households in the Tegucigalpa area.
Dengue, endemic in Central America, is a viral disease transmitted by mosquitoes of the genus Aedes. Symptoms are similar to flu, with headaches, fever, nausea, abdominal pain and rashes on the skin. The most severe form, haemorrhagic dengue, causes bleeding and can lead to irreversible shock and subsequent death.
In Honduras, cases of the common form of dengue have significantly increased in 2010 compared to the previous year, with more than 50,000 cases already reported. However, the most alarming feature of this outbreak is the prevalence of haemorrhagic dengue, with more than 1,500 cases reported and 160 deaths - a massive 1,850 percent increase on 2009. “I had come across the previous kind of dengue,” said Herminia Moncada, whose son was recently admitted to hospital with the disease. “But this is different. This dengue kills.”
The Ministry of Health has been responding to the high number of cases of dengue by making more hospital beds available and setting up specialised units in health centres in outlying areas. Despite this, the main referral hospital has been overwhelmed by the upsurge in patients. Until recently, children with dengue fever had been transferred to the referral hospital, as the decentralised units were only receiving adult patients. To ease the overcrowding, MSF set up an emergency ward at the San Felipe Hospital, on the outskirts of Tegucigalpa, where children under 15 with symptoms of the disease can be cared for. On its second day, the 23-bed ward was working to full capacity.
In hospital, treatment for children includes hydration and rest. “With dengue, we are unable to identify beforehand the patients who will improve rapidly. There is no vaccine or specific medicine for the virus, so all we can do is to control the symptoms and treat the consequences while waiting for the body to stabilise,” said Dr Elisabeth Bragança, in charge of the MSF emergency ward.
Even if the treatment sounds simple, oral hydration can be complex: serum needs to be administered carefully to avoid a fluid overdose, as dengue alters the permeability of blood vessels and there is a risk of fluids invading other parts of the body, causing complications such as pulmonary oedemas. “An ongoing balance in the amount of fluids given needs to be maintained,” said Dr Bragança.
Members of MSF’s health staff are also spending time teaching the children’s parents and carers how to administer the fluid regularly to their children. “the success of this medical intervention mostly relies on us collaborating with the parents,” said Dr Bragança. Frequently, parents stay in the ward overnight, giving their children serum at set intervals and writing down the amounts so that they can tell the health staff later. Often the parents have no one to stand in for them and may spend many days and nights without sleep. For this reason, emotional support for the parents is one element of the intervention.
For the MSF team, seeing the children start to recover can be a very rewarding experience. Just one day after being admitted to the ward, five-year-old Lucía Isammar Elvir was able to give her mother a big smile and say that she wanted to go home, saying, “I want to paint and draw”.
Education, ‘abate’ application and fumigation: core aspects in the fight against dengue
With dengue fever, medical treatment on its own is not enough, and must go hand in hand with educating people about how to prevent outbreaks from happening in the first place. “Education is an essential component of fighting dengue; it is a crucial aspect that will define the course of future epidemics,” said Luis Montiel, logistics coordinator for the project.
In addition to providing medical care, MSF is fighting the dengue outbreak with ‘vector control’. This means tackling the mosquitoes that spread the disease. Along with the Ministry of Health’s vector control body, MSF mobile teams are at work in the Manchen settlement, on the outskirts of Tegucigalpa, where the highest rates of affected people have been reported.
Mosquitoes carrying the dengue virus breed in stagnant water, so proper water management within households is vital. In the Manchen settlement, where the houses are on hillsides, families receive water only every fortnight, which they then store in tanks. In the narrow corridors of their houses, jerry cans and water containers provide a perfect environment for mosquitoes to breed, and are a potential source of infection. If rubbish and rubble are allowed to accumulate, they too can provide a breeding ground for mosquitoes. Among these mostly poor families, waste management is no easy task.
In addition to providing medical care, MSF is fighting the dengue outbreak with 'vector control': tackling the mosquitoes that spread the disease. Here, an MSF mobile team fumigates a house with the aim of breaking the mosquitoes cycle of reproduction'. Manchen settlement, near Tegucigalpa, Honduras. August 2010. Photo by Juan Carlos Tomasi/MSF.
This was highlighted by María Mercedes Suazo Bustillo, 89, who said that ever since one of the rooms in her house had collapsed, she had been unable to get rid of the rubble and useless furniture. “I am poor, and to throw this away costs money, this is why I cannot do it.”
In order to raise awareness and show people how to keep stored water free from mosquito larvae and to avoid rubbish accumulating, an MSF team is going from house to house through the neighbourhoods, looking for potential sources of infection. The challenge is to change people’s habits and social customs, and to involve them in the fight against dengue. “Bear in mind that the inspector does not come and stay with you,” says a member of the MSF team of educators through his loudspeaker.
The MSF teams going from house to house also apply ‘abate’: this process uses a chemical to treat any standing water and prevent mosquito larvae from hatching. Later on, once the team members have the trust of the families, they will return to fumigate the houses, with the aim of breaking the mosquitoes’ cycle of reproduction. So far, MSF has applied abate to 700 households and fumigated 400 houses, and plans to fumigate another 4,000 more.
Click here to read an interview with an MSF technical advisor about our work on dengue in Honduras