Dengue: A Real Buzz Kill

By Dr. Sarah Park
Interviewed by Rasa Fournier
Wednesday - April 20, 2011
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Dr. Sarah Park
Epidemiologist with the state Department of health

What is your background with infectious disease?

My clinical specialty is pediatric infectious diseases. I did my residency at Stanford and fellowship at University of California at San Francisco. Then I was accepted to the Centers for Disease Control and Prevention Epidemic Intelligence Service. As to how I got here, I had worked with CDC’s hospital infection group, and they needed a supervising officer for a field project with the Department of Health, assessing the prevalence of community associated methicillin-resistant Staphylococcus aureus in Hawaii. I came for a few weeks, got recruited by my predecessor, Dr. Paul Effler, and eventually ended up here.

I’ve been here almost seven years, and am now the state epidemiologist and the chief of the Disease Outbreak Control Division with the Department of Health.

Considering the latest outbreak, why is dengue so scary?

It’s scary to people who understand what dengue is. If you’ve ever traveled to Southeast Asian countries or Africa or South America or even the Pacific Islands, you invariably hear about this mosquito-borne disease called dengue. People in those countries are very aware of the possible serious complications and even death. “Lucky we live Hawaii” fortunately is true with dengue. We’re not endemic, meaning we don’t have the disease here all the time. We detect cases, but traditionally travelers bring it back from an endemic area. Then we try to make sure they stay indoors, that they’re not being exposed to mosquitos here, and our vector folks go and assess their property for mosquitos and perform abatement including getting rid of breeding sites.

Except for a couple of small pockets on the Big Island, we don’t have the primary mosquito that perpetuates the disease; Aedes aegypti, but we have albopictus, which can transmit dengue but doesn’t sustain it well as long as we implement the appropriate control measures, which means keeping the populations down. And doing our part to prevent being bitten. When we’re inside our houses, have screen windows and screen doors in good repair. When we’re outside in an area with mosquitos, wear DEET.

Dr. sarah park (second from right) with members of her staff: (from left) Leslie Au, rebecca kanenaka, Jed sasaki and Myra Ching-Lee

Even if we’re not in the area of outbreak?

The problem with dengue is, although it doesn’t go person to person, if you have someone who’s infected and they go somewhere else and get bitten by mosquitos there, those mosquitos become infected. I worry that people will think “I’m safe, I don’t live in Pearl City” and they don’t take the appropriate precautions. If they get bitten, then we have another focus for infection.

How do you get a feel for how big the outbreak is?

I sent out a medical alert to all Oahu clinicians to keep an eye out for anyone with consistent symptoms. We’ve also gone to where we first identified cases, approached the entire neighborhood, and asked questions about travel, about whether anyone has been ill, and if they’re willing to have their blood drawn; to look for dengue antibodies.

Why are antibodies important?

We try to determine whether you’ve had past or current infection with the dengue virus. If we do find such folks, then we ask where they’ve been. That may direct us to another part of the island to focus our efforts.

With dengue there’s a spectrum of disease severity. There’s a severe form called dengue hemorrhagic fever. A lot of people are more on the mild side or asymptomatic, meaning no symptoms. Kids tend to have mild or no symptoms. Older people tend to have more obvious symptoms. Some people will only have dengue fever and not dengue hemorrhagic fever. The two are different phases of the infection. Some people stop right after the end of the first phase. A few will go on to hemorrhagic fever. That’s more likely to happen if you’re having a second or third dengue infection.

So repeat infection is the biggie?

There are four types of dengue viruses. Say you get infected with dengue 1; you’re immune to dengue 1 from then on. But if you later get infected with dengue 2, 3, or 4, your immune response is increased. You have a huge inflammatory response, and that’s when you have hemorrhagic fever, which can be deadly.

What are the symptoms?

If you do have symptoms, you have a high fever, which itself is unusual for adults. You’ll start to feel achy; muscle aches, bone aches, headache. Usually there is no cough. Some will have a nonspecific red rash that develops two or three days after the fever starts. And then that phase cools down anywhere from day five to day seven. For most people, that’s it. When that high fever starts to come down, that’s the point when you need to be aware of potential signs of the second phase. If you have intractable vomiting, nausea, abdominal pain, signs of hemorrhaging; bleeding, blood dots (petechiae), an easily bloody nose, or hematoma (swellings of blood), or other indications that you’re bleeding, or you’re really lightheaded or pass out (may be an indication your blood pressure is dropping), you need to see your doctor.

With the last outbreak in 2001, the epi (epidemiology) team conducted surveillance for months and were still picking up cases for as long as eight months. Most cases were mild because people generally hadn’t been exposed to dengue before. So now along with CDC, we’re wondering, what’s this type? Do we only have one type to worry about? Regardless of the previous type and what this type is, there are people living in Hawaii who are from endemic areas and people who are travelers. And a lot of people may not know whether they’ve had dengue or not.

How treatable is dengue?

There is no direct treatment. It’s not like a bacteria where there’s an antibiotic. It’s supportive therapy; fluids, medications to maintain blood pressure, etc. It’s a matter of recognizing when to go to the doctor or at least checking with your doctor if you’re not sure.

There are reasonable measures everyone can take to protect themselves and their families. We just need to deprive mosquitos of their blood meals (us) and prevent them from having viable breeding sites by getting rid of standing water around the house. Dengue is not endemic in Hawaii, and to keep it that way we can and should do something about it.

We can’t get rid of all of the mosquitos but we can control it.


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