Dengue drama unfolds
| • | Map: World distribution of dengue fever |
| • | Special: Dengue fever: health crisis in the making |
By Timothy Hurley
Advertiser Maui County Bureau
NAHIKU, Maui — Dengue fever plagues far-off places, such as Borneo, Guyana and Tanzania.
Timothy Hurley • The Honolulu Advertiser
It's exotic. It's Third World. But it's not Hawai'i. At least not for more than half a century.
Patti Delaria sprays insect repellent on husband, Don, in preparation for their journey to Hana, Maui. The Raleigh, N.C., couple were given the repellent at an information center in Ha'iku.
So it was with a healthy dose of skepticism that two Maui public health officials drove out to rural East Maui on Sept. 13, the day after a doctor from Hana reported a possible cluster of dengue fever victims with no recent travel history.
While Hawai'i health officials periodically respond to cases of dengue fever, the mosquito-borne virus has always been acquired in foreign countries. Once a case of dengue fever is identified, the state Health Department's response is swift: Vector control personnel are sent to spray insecticide around the home of the victim. That always took care of it, having worked 22 times this year alone.
But this time was different. The number of confirmed cases on Maui has ballooned to 26 and about 100 more are suspected on the other islands.
Health department officials said yesterday that another nine people in Hawai'i — five on Maui and four on O'ahu —Êare suffering from undiagnosed fevers, bringing the total number of people who will be screened for dengue fever to more than 120.
It has become one of the most serious health threats of its kind, a phenomenon that hasn't been seen in Hawai'i since 1943.
As epidemiologist Chris Mills and Maui District Health Office Administrator Lorrin Pang drove the winding Hana Highway, they had no idea they would be helping to write a new chapter in Hawai'i's health history.
The victims in Nahiku, a rural community carved into the lush jungle on Maui's northeast coast, were three family members — one who was just getting sick, another who was just getting over it and one who had recovered a couple weeks earlier.
"As soon as I got there I was thinking dengue,'' said Pang, who has firsthand experience with the disease as a physician who treated some 400 cases during stints in Brazil and Thailand.
He immediately saw what he described as one of the classic dengue symptoms: a rash on the palms of the hands.
But the medical detective work was just beginning as he and Mills had to eliminate any number of other possible maladies through questioning and observation. They also drew blood for testing.
What clinched it for Pang was that a neighbor showed up with classic dengue symptoms: headache, muscle ache and rash.
The neighbor hadn't socialized recently with the family, and the doctors found other residents with similar symptoms who were sick at different times.
Brazil epidemics
Timothy Hurley • The Honolulu Advertiser
Pang began to see what he saw in the urban epidemics of Brazil: a wave of dengue that spread from house to house, one street at a time.
An information center in Ha'iku is sporting a new sign.
Based on these observations, Pang called the Vector Control Branch for spraying the next day.
Pang also wanted to send the blood samples for testing to the Centers for Disease Control and Prevention laboratory in Puerto Rico, but flights were grounded because of the East Coast terrorist attacks. As a quick alternative, he ordered some field diagnostic test kits, which also had to be shipped.
"Classically, this kind of thing happens in big cities,'' Pang said of a dengue outbreak. "A lot of people were questioning what I was seeing.''
When vector control personnel appeared the next day, Sept. 14, they were met with resistance by residents afraid of the toxic side effects of any insecticide. Only a couple of households granted permission to spray.
Pang called a town meeting Sept. 15, telling residents he was sure dengue fever had struck the community and that spraying was vital to ridding the area of infected mosquitoes. He explained that they would be using Permanone, a permethrin-based insecticide that evaporates quickly. More agreed to have their yards sprayed, but not everyone.
By Sept. 17, the initial blood samples were sent to the CDC, after officials were sure they wouldn't be spoiled by a delayed flight.
Based only on Pang's expert opinion, state officials in Honolulu dispatched three employees on Sept. 18 to scour the community for cases, drawing blood and taking histories.
Among other things, they discovered the first case had occurred in mid-June. Apparently, people didn't bother to see a doctor, in part, because it's too much of a hassle to drive into Hana. In addition, some believed they had "the Tahitian flu'' and chose to fight it with their own herbal remedies.
Health officials have not pinpointed how the dengue virus was brought to Hawai'i, but they have speculated that several members of a Hana hula halau who visited Tahiti may have come home sick with the virus.
Weird rash
Timothy Hurley • The Honolulu Advertiser
Nineteen-year-old Mahina Stoner came down with the disease in late August, spending an agonizing week in bed with a high fever, severe headaches, joint and muscle pain and a weird rash under her skin. It took her another week to recover.
Public health officials have closed the road to Nahiku, the remote East Maui community where dengue fever was first discovered.
"It's such a terrible thing,'' said Stoner, whose mother, father and brother also contracted the disease. "It sucks. You can't even get out of bed.''
By Sept. 19, the diagnostic kits arrived, and all of the initial blood samples tested positive. The next day, another town meeting was held and, armed with the preliminary results, Pang won over even more converts to insecticide spraying.
On Sept. 20, the CDC confirmed the field tests, and the health department issued a news release announcing that in addition to the four confirmed cases, more than 20 other cases were suspected in the Nahiku area alone.
The East Maui dengue fever outbreak has since become a statewide problem, with cases reported on all four of Hawai'i's most populous islands.
As it turns out, Hawai'i may be just the latest domino in an epidemic marching across the Pacific. Thousands have already come down with the virus in places such as American Samoa, French Polynesia and the Philippines over the past 18 months.
According to the CDC, a major reason for the global emergence of dengue fever is increased air travel between population centers in the tropics, allowing for the exchange of the virus and other pathogens.
"We've been lucky. We could have gotten dengue a lot sooner,'' said Chad Meyer, a Hana teacher and physician who has practiced tropical medicine in Africa and Asia.
In French Polynesia, there have been 30,000 suspected cases of dengue fever and eight deaths of children in the past eight months. More than 1,000 children have been hospitalized, according to Dr. Bruno Hubert, who heads the communicable diseases office for the government of French Polynesia.
Officials there believe the epidemic started in Palau in the Western Pacific, then spread to French Polynesia, Samoa, New Caledonia and the Cook Islands, and now, perhaps, to Hawai'i.
Hubert said the epidemic in French Polynesia is starting to wane, and he expects it to clear in another two months. In fact, some islands, including Bora Bora where it started locally, are now dengue-free.
Efforts to contain the disease, he said, consist mainly of public education and a cleanup campaign to eliminate mosquito breeding sites. There was some limited spraying of insecticide in the capital of Papeete, but that was largely ineffective, Hubert said.
Of most concern in the current epidemic in French Polynesia is the severe impact it is having on children, he said.
Health officials discovered that most of the youngsters who have fallen ill are between the ages of 4 and 15, and that children under the age of 4, who were born after 1997 when the last dengue epidemic hit, are least affected.
Four types of dengue
There are four types of dengue fever. Once you suffer from one type, you are immune to that strain. However, the first occurrence makes you more vulnerable to severe illness if later infected with a different type of dengue virus.
The 1997 epidemic involved dengue Type 2, but the current epidemic is dengue Type 1, so those children who experienced the first epidemic are suffering the worst.
Many adults are not being affected by the current outbreak because of an epidemic of dengue Type 1 in the late 1980s, Hubert said.
Despite the dire consequences of dengue fever, Hubert said the disease hasn't changed life for most French Polynesians.
"People here are used to mosquitoes," he said. "We have a tropical climate and it's very humid, and we're used to mosquitoes.''
But one problem in containing the epidemic is sustaining mosquito control programs. Hubert said that in the first couple months of the outbreak, people were conscientious about cleaning up to eliminate breeding areas. But then they became lax, allowing the epidemic to drag on for eight months, which is a very long time for such an outbreak, he said.
In American Samoa, there have been more than 800 suspected cases of dengue fever since summer, with more expected, according to Dr. Joseph Tufa, director of the territory's Department of Health.
There have been three deaths over the past three months, the last a 6-year-old girl who died in September.
Tufa said dengue fever is a relatively new public health problem in American Samoa. The first outbreak occurred in 1976, followed by a second in 1987 and a third in 1996.
Health officials there don't spray insecticides because of environmental and health concerns, he said. Instead, they rely on a public education campaign aimed at eliminating breeding sites.
The situation is exacerbated because many Samoan homes are substandard and lack screens.
"Once the social and economic conditions are improved, it will disappear,'' he said of dengue fever.
As it is, most people in American Samoa aren't too worried about it, he said. "It's just like the flu. It's becoming an everyday thing so it's not something unusual,'' Tufa said.
Will dengue become an everyday thing in Hawai'i?
State officials have promised to throw everything they have at the problem.
Hubert predicts the Hawai'i outbreak will not be widespread, considering it hasn't happened here in more than 50 years. However, if a different strain strikes the Islands in a few years, Hawai'i could mirror the struggles of French Polynesia.
On the other hand, this outbreak could very well fizzle out on its own accord, said Paul Reiter, a CDC specialist on dengue fever.
Reiter said Hawai'i's Asian tiger mosquito, or Aedes albopictus, isn't the most efficient carrier for dengue fever. It is the Aedes aegypti, believed to have been largely eradicated in Hawai'i in 1943, that has been the scourge of most tropical areas battling dengue, he said.
"It's amazing to have dengue in Hawai'i, considering you have only albopictus,'' Reiter said.
Reiter traveled here from Puerto Rico because he wants to see for himself if the Aedes aegypti is really driving Hawai'i's outbreak. He will be overseeing efforts to capture mosquitoes in East Maui.
Neighbor Island Editor Christie Wilson contributed to this report.
