The legend says that Sisyphus, being a cunning mortal, came to annoy the Greek gods in such a way that they decided to punish him. The punishment was to push a monumental rock up a mountain so that, when trying to reach the top, it would fall again, and the punishment would start over and over again. This is how the situation in Paraguay could be described regarding dengue, which is now considered endemic in the country by health authorities, but with cyclical outbreaks every so often.
A lot has been said about dengue lately, and adding more can seem exhausting, but in view of the emergence of more and more cases, it seems that there is never enough said about this issue. As long as our own Sisyphean punishment remains a public health problem, it is up to all citizens to continue to be informed.
Dengue is the paradigm of tropical disease, as well as being the most common one in the world according to figures from the World Health Organization (WHO). In the last 50 years its incidence has grown thirtyfold with the increasing geographic expansion toward new countries and from urban to rural areas. Some 50 million dengue infections are detected annually, and some 2.5 billion people live in countries with endemic dengue. According to statements by Dr. Antonio Arbo, recipient of the 2010 National Science Prize, the first major outbreak of dengue in Paraguay was recorded in 1989. As of 2000, sprouts have reappeared every 3 or 4 years.
The Health Ministry has launched contingency programs, and in 2007 found the serotype 3, with some cases fatal cases, attributed to dengue. Later they would appear in 2013, 2016, and, finally, this year, in all these seasons with fatal victims (1).
In view of the continued failures of the Health Ministry to prevent new outbreaks or minimize their impact, one thing is certain: if it is not the state, the responsibility of public health falls upon citizens. So it is hard to overstate the importance of obtaining and applying the right information to minimize new infections or, in case of having contracted the disease, to obtain a quick and prompt recovery.
What Is Dengue?
Dengue is a disease caused by a virus of the family Flaviviridae, genus Flavivirus and of which there are 4 serotypes. For example, this year’s epidemic (2018) is due to serotype 1, the most benign. The virus is transmitted through the mosquitoes Aedes aegypti and Aedes albopictus, so the elimination of mosquito breeding is fundamental in preventing the spread of the virus.
An interesting detail is that the overall increase in temperatures has made the incubation period of these mosquitoes shorter, so they tend to proliferate more quickly. Perhaps that is one of the causes of the increase in new cases (2).
How Does the Mosquito Acquire the Virus?
When the female mosquito sucks blood from a patient already sick with dengue who is in the febrile phase of the disease. It is during this phase that the virus circulates in the blood.
Subsequently, the virus incubates in the mosquito for 4 to 10 days, then it becomes a transmitter for up to two months. Once the patient is inoculated with the virus through the mosquito vector bite, it takes from 7 to 10 days for the disease to manifest again (3).
How is the disease diagnosed? The diagnosis is based predominantly by the clinical presentation: fever of recent onset along with generalized muscular and bony pain in addition to a laboratory test, which is done from the patient’s serum, or a blood sample. The most popular is the NS1 Antigen screening test, which is quite specific and can already be positive within a few hours of the onset of the symptoms.
The onset of the disease is characterized by high fever (up to 40° C) and muscular and osteoarticular pain, and the typical retro-ocular headache, hence the name of «bone-breaking fever». This constitutes the febrile phase of the disease, which can last from 3 to 5 days. The presentation itself can be baffling, as the physician may know very well when the disease starts, but not how long it will last or when or how it will end.
Later the critical phase begins, in which paradoxically the fever and the aches cease, so it is common to think that one is already cured. The name of this phase is because it coincides chronologically with the damage caused by the virus to the capillary endothelium (cells that upholster the inside of the blood vessels) and to the bone marrow, with the consequent capillary leakage (that is, displacement of the plasma to a compartment outside the vascular compartment) and a decrease in white blood cells (cells of the immune system) and platelets (responsible for blood clotting).
These two effects (capillary leakage and platelet reduction) will end up determining the alarm signs, which in turn serve to classify the disease and its management. It is during the critical phase when the blood count controls become more frequent, depending on the patient’s condition. If the patient is stable, the controls may be laxer, up to 48 hours, if severe, at least every 12 hours.
Typically, the signs of alarm are: nausea and vomiting (more than three times in less than one hour), inability to ingest fluids, lethargy, severe abdominal pain, skin or mucosal bleeding, platelet count lower than 100,000/mm3 and a significant increase in liver enzymes. The appearance of these signs constitutes an indication for the patient’s hospitalization (fever is not a sign of alarm). This phase lasts from 3 to 5 days and is the period in which the disease can resolve or worsen. Lastly, a recovery phase of 48 to 72 hours is characterized by clinical improvement and increase of the platelet count (4).
The treatment of dengue is hydration adequate to the weight and age of the patient so as to attenuate the effects of capillary leakage, and a symptomatic treatment of the discomfort caused by fever. A specific treatment for fever is not prescribed if it does not present discomfort and it is unrealistic to pretend not to have fever precisely in the febrile phase.
Medication
Currently only two drugs are approved for the treatment of these symptoms, namely, paracetamol and dipyrone, always considering their recommended maximum doses. There is no proven treatment to increase the number of platelets or other signs of alarm. Serious investigations are being conducted with the extract of the leaves of papaya, but the evidence is inconclusive (5, 6). Dengue vaccine is recommended for patients who have already suffered the disease at least once and have no contraindications.
The recommendations of the government agencies remain in force. In the presence of the symptoms and signs mentioned, it is recommended to seek a doctor. The physician then will classify the case into three types: 1) dengue with signs of alarm; 2) dengue without signs of alarm or 3) severe dengue. According to this classification, the physician will initiate outpatient treatment, he will keep the patient in observation for a few hours or admit the patient to the hospital.
The citizens are advised to report the disease and the treatment received, and especially to work on preventing it by eliminating the vector, because without the mosquito there is no disease. Any treatment that offers prompt remission or a sudden increase in platelets does not currently have scientific backing and should be dismissed.
Sisyphus could not get rid of his punishment, but today we have education and science that, if applied in an integral way, can help us move this great rock with much more ease, and maybe even get rid of this scourge completely.
References
- ABC Color. Arbo acusa de negligente al sistema de salud por el dengue – Edición Impresa – ABC Color. [citado 7 de marzo de 2018]. Disponible en: http://www.abc.com.py/edicion-impresa/politica/arbo-acusa-de-negligente-al-sistema-de-salud-por-el-dengue-1680141.html
- Dengue: guías para el diagnóstico, tratamiento, prevención y control. [citado 7 de marzo de 2018]. Disponible en: https://www.mspbs.gov.py/dependencias/imt/adjunto/e347a4-dengueCONTROL.pdf
- OMS | Dengue y dengue grave. WHO. [citado 8 de marzo de 2018]. Disponible en: http://www.who.int/mediacentre/factsheets/fs117/es/
- Dengue: abordaje inicial y tratamiento. [citado 8 de marzo de 2018]. Disponible en: https://www.mspbs.gov.py/dependencias/imt/adjunto/b5a976-Dengue2.pdf
- Ahmad N, Fazal H, Ayaz M, Abbasi BH, Mohammad I, Fazal L. Dengue fever treatment with Carica papaya leaves extracts. Asian Pac J Trop Biomed. 2011;1(4):330-333. https://doi.org/10.1016/S2221-1691(11)60055-5
- Hettige S. Guidelines in using carica papaya leaf extract for Dengue fever patients. BMJ 2015;351. https://doi.org/10.1136/bmj.h4661
Translation of the original article published by Ciencia del Sur. Translators: Julio Torales, Israel González, and staff of Revista Medicina Clínica y Social.
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Osvaldo Meza es médico especializado en Medicina Interna por la Universidad Católica de Asunción (UCA) y editor de Ciencias Médicas en Ciencia del Sur. Forma parte de la Asociación Paraguaya Racionalista, y entre sus aficiones se encuentran la física, astronomía, la divulgación científica y el pensamiento crítico.
