Haitian Child

Haitian Child

Saturday, December 31, 2011

Book Review - Unfinished Revolution by Kenneth Morris

Unfinished Revolution - Daniel Ortega and Nicaragua’s Struggle for Liberation. 
Kenneth E. Morris. 2010. Lawrence Hill Books. Chicago.


The points below include the ideas and information from this book that I considered interesting. These are points that Morris makes and I do not have sufficient experience to confirm or refute the information. 


According to Morris, in Nicaragua, the words "to succeed" are interpreted as "to conquer." Nicaragua has been conquered on so many occasions (initially by Spain and then by the US) that success and conquer are interchangeable words.


United States hegemony over Nicaragua
My generation likely only relates to the Iran Contra - Oliver North debacle, but the US has an almost two century record of intervention. The Monroe Doctrine, a US policy introduced in 1823, "legalized" US hegemony over all of Latin America. In 1856, William Walker, a US soldier of fortune, invaded Nicaragua and proclaimed himself President. American troops have since occupied Nicaragua in 1865 to 1877, 1894, 1896, 1898, 1899, 1907, 1910, and 1912 to 1932. The Contra War in the '80's is only the most recent armed intervention by the US. Any paranoia in Nicaragua about American intervention is therefore well justified.


Daniel Ortega, the current President, is 66 years old, and he joined the Sandinista Youth at age 15 years.  He killed his first National Guardsman at age 22 years.  He served 7 years in prison and was tortured by the Somoza jailers.


The Sandanista revolution was successful but resulted in 45,000 deaths. The Contra War that followed resulted in an additional 40,000 deaths. Nicaraguans of my generation have mostly known war in their youth and middle age, and almost all have had a family member killed, injured, or who fled the country.


After the first elections in 1984, the Sandinista government made freedom of religion a right, abolished the death penalty, and extended formal rights to women.


Ortega lost in the 1990 election, in part because of fear of American invasion if he was re-elected. According to Morris, the US invasion of Panama was not only designed to oust Noriega, but also to threaten Nicaragua to shape up or to suffer a similar fate.


Presidents Chamorro (1990), Aleman (1996) and Bolanos (2001) did not improve the welfare of the average Nicaraguan. They were either corrupt or inept.


Ortega, who was re-elected in 2006 and again in 2011, is viewed as authoritarian and corrupt, but according to Morris, his corruptness is directed to achieve the power to help the people rather than to achieve personal gain, and in this sense his actions are considered by some to be altruistic.


Nicaraguan citizens expect corruption. In a 2001 poll, 73% of those polled desired an authoritarian president and 57% considered bribery of a public official as acceptable conduct.


After his re-election in 2006, Ortega eliminated fees in public schools, worked out an energy deal with Venezuela that eliminated the habitual power blackouts in the capital, provided subsidies to lower the price of food staples, and provided free access to medical care. He initiated Zero Usury, a small business incentive loan program, and Zero Hunger, a program to provide each mother (women are the head of the household) with a chicken and cow to provide eggs and milk for the family.


Nicaragua is still the second poorest country in the Western Hemisphere. 
This morning at 5:45 AM, this Crab-eating Raccoon & I crossed paths.
    He looked real surprised to see me in the forest. 
The light was very poor but iPhoto allowed a pretty good image.



Friday, December 30, 2011

Planning Pays Off

The first week has gone very well.

For this trip I arranged an interpreter and Sheyla was terrific. She quickly learned the routines and she improved each day. For a person without any medical training whatsoever, she did fabulous. Thank you Sheyla.


I decided that I wanted to bring the medications that I would likely need so that I had my drug of choice for treatment and also so that I would not need to deplete the clinic pharmacy. I have only accessed the clinic pharmacy on one occasion, which is amazing.

I prepared Spanish teaching handouts on sixteen common problems and this week I used 11 of them, many of them multiple times. Not every Mother can read, but the family will have access to someone who can. I consider this a solid success.  

None of the children today were real sick. Most had colds or diarrhea. A baby had an infected insect bite, likely a spider. One girl had high fever, delirium, diarrhea, vomiting and abdominal pain. She looked great but her fever was down because Mom gave her both acetaminophen and ibuprofen, which was the right intervention for high fever and delirium. I treated her for Typhoid Fever. I remember that our Med School Infectious Disease Prof, Dr. Ken Buchan, told us that delirium is common with Typhoid. Ken Buchan was an absolutely fabulous teacher. His teaching decades ago, made a difference today!  


Rainbow at Dawn 


Surf Spray Rainbow

Thursday, December 29, 2011

I think all the children have worms and parasites.

When I arrived at the clinic this morning there was a five year-old girl with abdominal pain and vomiting in the exam room and Dr. Flores was talking to her Mom. For three days she had experienced episodes of acute central abdominal pain. The episodes lasted up to an hour, sometimes she cried, she was doubled over with the pain, and occasionally she vomited during the episodes. She had up to seven episodes a day. Between the episodes she wasn’t eating as well but she otherwise felt fine. Her last poop was three days ago and described as stickly black. Her exam was normal. 


The pattern of the pain and the vomiting was suspicious for intestinal obstruction. I could feel a lump on the right lower side of her abdomen. I obtained a poop specimen. The clinic can test for parasite cysts, worm eggs, and blood. She had all three. The child developed an episode of abdominal pain while she was at the clinic and I examined her again. She was not distressed and the lump as no longer palpable. I treated her for parasites and for worms. I did a quick Google Scholar search of worms and intestinal obstruction and learned that this is possible. I’m not sure she had obstruction due to worms, but that is how I treated her. The 3 day mebendazole treatment will get rid of the worms and Mom knows she must come back if the pain and vomiting continue.

The two week-old baby came in with the results of the ultrasound. Amazing! Mom obtained an ultrasound in Rivas for $20 and the films with the report were available to me in 48 hours. Wow! Outpatient results that fast would be difficult to obtain in most Canadian centers. The Mom and Dr. Flores made this happen and this shows that the system can function.

I checked poop for parasites and worms twice today and both tests came back positive for both. Both families used well water. I'm sure most of the children are "colonized" or infected with worms and parasites. I reviewed how to disinfect water with the SODIS system and the need to wash hands and fresh produce to minimize ingestion of worm eggs. My Spanish teaching handouts on these preventative measures came in real handy.

A Dad brought in a three year-old boy with typical nephrotic syndrome. These children develop generalized edema (swelling) after common colds. An abnormality in the immune system is the likely cause.  The Dad was told (or he understood) that the edema was due to infection and that antibiotics were the treatment for nephrotic syndrome. I had a hard time clearing up this misconception, but the distinction is important. Nephrotic syndrome requires treatment with a steroid medication and the problem is usually recurrent. I was not convinced that the Dad really understood but Sheyla felt confident that he did.  













Wednesday, December 28, 2011

The Interpreter is Making a Difference

Another kidney clinic day. When Dr. Flores found out that I was a paediatric kidney specialist he asked if I would see the chronic kidney patients in the community.

"Of course," I replied. I asked that he designate kidney patient days and general paediatric patient days. My reasoning was that chronic kidney patients would take more time than general paediatric patients. I asked to spend an hour with a kidney patient and to see 6 children a day, and to spend half an hour with a general paediatric patient and to see 12 children a day.

Yesterday and today I saw only kidney patients and all but one had recurrent urinary tract infection, which is a very common problem, but when I asked Dr. Flores if there were other kidney problem patients, such as nephrotic syndrome, nephritis, kidney failure, high blood pressure, etc, he replied, "No, all urinary tract infection." This sounded strange to me. 

The solitary patient that did not have recurrent urinary tract infection had hemolytic anemia with dark urine during infectious events. The mother was told the dark urine was infection but the dark colour is really due to the chemicals in urine from broken down red blood cells.

I have learned this is a common situation. On prior visits I realized that "dark urine" was interpreted as urinary tract infection. Dark urine can mean dehydration, kidney stone, nephritis, hemolysis, and other problems, but is not usually a sign of urinary tract infection, except it appears, in Nicaragua. In Nicaragua, dark urine or blood in the urine is interpreted to mean urinary tract infection and the child is treated with antibiotics. My sense is that every kidney problem is urinary tract infection. Gosh, I wish it were that simple.


Sheyla, the interpreter, is getting better at explaining the ins and outs of how to prevent urinary tract infection and I can see that mothers are happy with her explanations, so I presume the patient teaching is happening. How can I know for sure?  I can't. Only time and experience with Sheyla, and follow up visits with the same child, will clarify if we are connecting properly. I really need to learn Spanish.


Today I learned that Dr. Flores and Marta, the clinic nurse, were informed that I only wanted to see kidney patients. This is not true. There is a communication problem with the Director of the Clinic. I definitely asked to see both kidney and general paediatric patients. Sadly, this sort of communication problem is routine. The Executive Director of the clinic speaks English, is originally from Rivas, now lives in the US, and he helps manage and raise money for the clinic, and he means well, but communication problems like this are the rule. Today I asked Marta to cancel some kidney patient days and to arrange general paediatric patient days. 


Communication. Communication. Communication.

Whimbrel with Crab, Dawn, Surfside. 
      




  

Tuesday, December 27, 2011

Great First Clinic Day!!!

What a great day!


Sheyla, the Nicaraguan interpreter, met me at the clinic and we saw five moderately complicated nephrology patients. By the end of the day Sheyla and I were coming together as a team. She will be with me for four days this week and next week a new interpreter will take over. Sheyla is a pre-school teacher. She did a great job. Thank you Sheyla.


In addition to treating the presenting problem, I gave each mother a vitamin supply for two months and some acetaminophen to have at home to use as necessary. The vitamins were courtesy of Health Partners International Canada. Thank you HPI Canada. 


The Spanish teaching handouts on common problems worked great. Most of the children had a non-urinary problem as well. Constipation is just as common in Nicaragua as in Calgary. One child came in because of urine infection but had an ear infection and pneumonia. This child also had intestinal worms and as losing weight. 


This boy had recurrent foreskin infections, epilepsy, and he smelled like he lived beside a campfire. Many of the children live in poorly ventilated homes with an open fire for cooking. Mom reports he has asthma but his lungs were clear today. 

The sickest child was a 15 day-old baby boy. On the third day of life, the day he went home from hospital, he developed fever, fresh blood in the urine, and he cried every time he peed. The blood and fever continued for two days and then stopped but he continued to cry with voiding. Mom reported that he "really" cried with voiding and the voiding took a long time. Mom noted some orange powder in the diaper, likely uric acid, and this lasted two days. Then when he continued to cry she took him to Rivas and he was treated with IV Gentamycin for five days. He improved. His urine was clearer. He was crying less with voiding but still crying. The Rivas doctors sent him home on Clavulin but while in hospital they did not do a blood test or ultrasound. I’ve heard this story before. The standard intervention is to treat the acute issue (infection) and not look for the cause. This was the way things were done in Canada before I graduated in the ‘70’s. Mom also reported that he was tired with feeding and breathing a bit fast. I asked Mom whether she had seen him pee and if so, whether his stream was weak or strong. “Slow and weak,” she reported. He did not look septic but he was breathing a bit fast. His abdomen was softly distended. I put a urine bag on at just the right time (my luck has definitely turned) and he peed within two minutes. I dipped the urine and there was no infection.

This is a classic story of posterior urethral valves, which is a congenital blockage in the urethra, the tube that carries the urine from the bladder through the penis. Male infant, infection in the neonatal period, blood in the urine, discomfort voiding, and a weak urinary stream. We don’t see children present like this anymore in Canada. Prenatal ultrasounds pick this congenital problem up and intervention is planned after delivery. Infection is prevented from birth.  

In Canada, if this child presented without any prenatal care, the child would have been referred to a Pediatric Urologist when admitted to hospital, blood work, an ultrasound, and either a catheter x-ray study or a cystoscopy would have been performed as soon as the infection was under control and the valves (blockage) would have been removed to relieve the obstruction.

I asked Dr. Flores how to arrange a good ultrasound and blood work on short notice so that I can review the results during my stay. Getting things done fast is sometimes a concern in Canada so I wasn’t optimistic.  However, this might happen. The next challenge was who would pay. The state does not pay for ultrasound. This is only offered by private facilities. The cost is about $25.00. Marta, the clinic nurse, and Sheyla looked at me as if to say, “Will you pay.” I did not offer. If I offer to pay for this ultrasound, I will need to pay for all the ultrasounds. There are limits to how much I can afford. Twenty-five dollars does not seem like much, but in a country where the average wage is $100 a month, where over half the families make less than $500 a year, and where public health clinic doctors make $500 a month, this is a lot of money.  The clinic is working hard to raise money to purchase an ultrasound.  

So the first day went well, and I am now sitting in a covered area, enjoying the sunset and a cold Tona, the local beer. Time for a Tona.
Brown Pelican Flying South





Midnight Motorcycle Madness

Planes, Automobiles, and Motorcycles.


There is a great John Candy and Steve Martin movie 
with a similar name, 
and I am starting to feel like Steve Martin.


Last night I left the restaurant after a great dinner. 
I'm about half way back to the casa
and I smell gas.  
Then I realize that I can feel gas 
spraying on my left leg. 
So I pull over. 
The bike stops, 
the lights go out.
I put my hand down by the left side of the engine
and there is gas spurting out.
My leg, shoe, and hand are covered in gas. 
Didn't think it was a good thing 
to try and restart the bike.


Pitch dark. 
Of course I am exactly 
in the darkest portion of a dirt country road,
not a casa or light in sight.  
The moon was only a sliver. 
The stars however were magnificent. 
No flashlight, 
but my cell phone allowed me 
to illuminate the bike a bit
and I found and toggled off the gas supply. 
The gas stopped spurting, 
which by now had covered a lot of my lower body. 
If this were a classic Roadrunner Coyote story, 
that would be the time when someone 
would strike a match.  Boom!

I moved the bike as close to curb as I dare,
without the bike toppling into the ditch
and walked back to the casa.
The cell phone was sufficient with the stars
and the walk back was pleasant.


Too bad.
I was just getting my motorcycle legs back.


I WILL get to the clinic today. 





Monday, December 26, 2011

Arrived






Little Blue Heron Surfside

This morning I did manage to confirm that the rental car was not available. I actually spoke to a Hertz employee who turned up at the hotel. No car for me.
So, I took a taxi, a 2.5 hour taxi, to Limon, and around noon, I arrived. Whew. Seemed like longer but really only 3 days compared to the usual 1.5.   



The next problem is how to get back and forth to the clinic. Well, Matt, an especially helpful person who manages the casa where I stay, has offered to lend me his motorcycle. Ok by me. I enjoyed my motorcycle days as a young man. I even raced motorcycles for a season. So, the motorcycle works for me. 

Matt's Honda

I unpacked and placed all the medications and supplies in one bag. I had mixed them all up with my clothes and equipment because there was a last minute snafu with the permit for customs. This time the meds were co-mingled and I chose the correct time to put the bags on the conveyer belt that takes the bags through the scanner. I was watching the scanner operator and he was periodically pre-occupied with a young woman. I put the bags on during one of his pre-occupied moments. Hey no problema! So, now the meds are ready to take the clinic.  


All in all, the sky is clear, the sun is shining, the bags and medications all arrived intact, and tomorrow is another day.  















Sunday, December 25, 2011

Peace, Goodwill, and Complicated Travel

A trip to Nicaragua would not seem right unless something went wrong with the outgoing travel. Major glitches in the past include luggage that did not arrive, and officious customs officials who confiscated supplies.


The problem started on the 23rd when my flight from Calgary to Houston didn't happen. The pilot advised that the repair crews swapped out multiple computers and the plane was repeatedly powered up and down,
but all to no avail. The fuel tank, definitely full of fuel, did not say full. Safety is important and rules are meant to be followed in the interest of public safety. So, after several hours on the tarmac, without any hope of making my connecting flight to Managua, I re-booked for the next day. Sounds simple, but that was not my karma.


Christmas travel is generally complicated. Everybody is traveling. Seats are in short supply. Patience is thin. Even so, I did manage a flight to Houston on the 24th, but there was simply no possibility of a connection to Managua the same day. So, last night I enjoyed the Houston Marriott. Nice hotel with a revolving restaurant at the top.


The good news is that I am now in Nicaragua, with my luggage, and the supplies were not confiscated.


The bad news is that I arrived two days late, and I am still in Managua.


The 4 Wheel Drive Toyota Land Cruiser that I rented with Hertz was not waiting for me. I had phoned to make sure they would hold my car, and I had offered and was happy to pay for the two missed-use days before I arrived. I arranged a very early morning flight from Houston so that I could pick up the vehicle and drive the same day to Limon, the nearest community to the clinic. Not only was the car not waiting for me, but the Hertz booth at the airport was not even open. A confirmation number is worthless when there is no one to discuss this with. All the other car rental agencies were open. Of course none had vehicles.


So, I took a taxi to the Hotel Intercontinental. I had been scheduled to stay there on the 23rd, and ended up paying for the room because by the time the airplane computer thing ended, I had passed the cancel-before deadline. Not that I hoped that the hotel would offer me a free room. That doesn't happen. But, I did want to check the Hertz counter at the Hotel and I hoped to enlist the concierge in my quest for a car.


The Hertz counter at the hotel was also closed, of course.


I checked in. The Hotel Intercontinental is definitely the best hotel in Managua. I'm lucky there was accommodation. In fact, the availability of the room lifted my spirits and I thought, surely fortune is now smiling on me.


I enlisted the help of the concierge and thanked him with a large monetary encouragement. He phoned the person who was on local-Hertz-Christmas-duty, and this person apparently agreed to contact the Manager, or more likely, to try and contact the Manager on Christmas Day. They are to call back. Hmm.


The rainy season ended in Nicaragua a month ago, but you could have fooled me. The palm trees are swaying very briskly, the sky is grey, and there is rain falling. But, I am on the Hotel veranda, which is very dry, and somehow I know that tomorrow will be sunny.
"Into every life, some rain must fall."


That's Longfellow quoted by a Shortfellow.

Tuesday, December 20, 2011

"Wake Up"

The lyrics of the song, "Wake Up," 
by Arcade Fire, 
certainly my favorite group from the last decade, 
should be read by my generation.  
Win Butler, the lead singer songwriter, 
alternates between sadness and screaming, 
in this anthem for his generation.


Somethin' filled up
my heart with nothin'
someone told me not to cry.

But now that I'm older
my heart's colder,
and I can see that it's a lie.

Children wake up,
hold your mistake up,
before they turn the summer into dust.

If the children don't grow up,
our bodies get bigger but our hearts get torn up.
We're just a million little god's causin' rain storms 
turnin' every thing to rust. 

I guess we'll just have to adjust.

With my lightin' bolds a glowin'
I can see where I am goin' to be
when the reaper he reaches and touches my hand.

With my lightnin' bolts a glowin'
I can see where I am goin'
With my lightnin' bolts a glowin'
I can see where I am goin'

You better look out below.


The song is not merely about children waking up, 
but also about the need for their parents 
and their grandparents (my generation) to wake up.


Change waits on nothing, 
and change now happens on a logarithmic scale.
This song helped me realize 
that my eyes have not stayed wide open 
to the changes in the world around me.


The Internet is woven into the lives of 
the youth in Nicaragua, 
and they must be restless.


Daniel Ortega, 
a young revolutionary of my generation, 
started a successful revolution 
in a relative communication vacuum.


Arab Spring 
proves what is possible 
with restless revolutionaries
in the digital age.


I do not know whether Ortega 
has the pulse of the Nica youth. 
Are his eyes wide open? If not, 
the poverty and the discrepancy 
between what Nica youth live at home 
and what they see on the Internet, 
might herald spring in Nicaragua.  












Monday, December 19, 2011

Worms in Nicaragua

Intestinal worms are common in Nicaragua. 


Children Without Worms (CWW), an organization dedicated to the worldwide control of worm disease, performed a survey in five Nicaragua communities in 2005, and documented a prevalence rate for worms of 49%!


Worms are soil-transmitted helminths (STH). Eggs are ingested by individuals through food that is not carefully washed or on dirty hands. Larvae penetrate the skin directly. The eggs or larvae develop into adult worms, which produce eggs. Infected individuals contaminate the soil with their feces. Eggs develop in the soil. The cycle continues. 


Once infected the child can develop abdominal pain and distension, intestinal obstruction, iron-deficiency anemia, malnutrition and poor growth, allergic reactions, and lung disease.


CWW in partnership with Johnson & Johnson and local government, targets school-aged children to receive a 500 mg dose of mebendazole and the families to be educated on hygiene.  In Nicaragua the drug is administered by the Ministry of Immunization. 


CWW advocates four key components to break the cycle of worm disease.


1. Water - access to potable water for handwashing and cleaning of foodstuffs. 
2. Sanitation - latrines to keep infected feces away from individuals.
3. Hygiene Education - personal and environmental hygiene (handwashing).
4. Deworming. 


I emailed Ms. Kim Koporc, Director of Children Without Worms. to inquire if there is a way for me to help in the clinic where I will work.  


At the very least, I will prepare my own handout on how to disinfect water and on the need to wash all fruits and vegetables prior to food preparation, and the importance of regular hand washing.  


While in Nicaragua, I will find out if the Ministry of Immunization campaign in 2010 included the clinic region where I work and how often the dosing is administered. Without intervention to prevent re-infestation, the worms will return. I will bring enough 500 mg tablets of mebendazole for every child I see and handouts in Spanish on hygiene and how to prevent re-infestation.   


I've traveled extensively in my life and I only developed a gastrointestinal problem once. While on a family vacation to snorkel in the Cayman Islands, I developed shellfish toxin poisoning after eating at a fancy restaurant, which could just as easily have happened in Calgary. I've never been ill, touch wood, with any of my trips into rougher country. I've visited Haiti once and Nicaragua three times in the last twenty months and stool tests performed on my return from each trip have been negative. I set high standards and my compulsive nature helps. I was very strict about hand washing and all the fruits and vegetables were carefully washed in a dilute bleach solution before use.  

Saturday, December 17, 2011

Malaria in Nicaragua


Malaria is present in Nicaragua. The Center for Disease Control reports malaria is present in only 6 of the 17 Departments (sort of provinces). The six reported Departments are located on both the Pacific and Atlantic coasts and in the interior. The absence of reports in the other 9 departments must be a reporting anomaly. Mosquitos do not acknowledge borders.

Malaria in Nicaragua is due to Plasmodium vivax in 95% of cases and P. falciparum in the remaining 5%. This is good news because P. vivax is still chloroquine sensitive and has a good prognosis for full recovery, compared to P. falciparum, which is a much more serious infection. 

The anopheles mosquito transmits malaria. The bite transfers asexual parasite forms into the bloodstream and these parasites undergo a liver and then a red blood cell stage. About a week or two after entering the red blood cells, the blood cells burst and release thousands of parasites and inflammatory chemicals into the blood. The inflammatory chemicals include pyrogens, which cause the fever. The fever in P vivax develops every 48 hours days, which is referred to as tertian malaria. The red blood cell destruction results in anemia.

Children suffer the most severe disease; especially children aged 6 months to 5 years. In parts of the world where malaria is endemic, malaria might cause as many as 10% of all deaths in children. Survivors develop partial immunity.

Older children might present with the classic periodic fever with chills and shivering. However, this is uncommon in young children. After the mosquito bite, younger children are asymptomatic for one or two weeks. The fever is usually continuous and might be very high (40°C) from the first day. The symptoms are non-specific. Children become restless, drowsy, apathetic, and anorexic. Older children might report generalized ache, headache, and nausea. Many children have only flu-like respiratory symptoms, with mild cough and cold. Vomiting is very common. Mild diarrhea is also common, with dark green mucoid stools. Seizures might occur at the onset of the disease. Differentiating a febrile seizure from cerebral malaria is often difficult. The liver might be slightly tender. Splenomegaly takes many days, especially in the first attack in nonimmune children. Children with partial immunity might develop only a low-grade fever, anemia, poor appetite, and malaise. The diagnosis is established when parasites are noted on a thick blood smear, but only 50% of children with malaria have a positive smear, even on repeated examination. P vivax malaria might relapse for up to 3 years.

Since the symptoms are often non-specific, high fever in a susceptible young child requires a high index of suspicion, and in the absence of a recognized cause for the fever, empirical treatment might be necessary.

The treatment of P vivax is a 3-day course of chloroquine, followed by a 14-day course of primaquine. The primaquine is necessary to eliminate the dormant stage of the parasite in the liver. 

An Ounce of Prevention is Worth a Pound of Cure

I believe in immunizations.


There are serious infectious illnesses that were common when I started medical school but are no longer a concern in Canada. Polio was still around when I started my training, and this scourge has been "officially" eradicated worldwide. One of the first children I resuscitated as a medical student in the ER died later that day of measles. I saw literally hundreds of children with invasive H flu infections. I know how deadly infections can be and I know that immunizations work.  

I've travelled a lot and I've always made sure to keep my immunizations up to date. In preparation to travel around the world in 1974 I was inoculated for smallpox, typhoid (3 shots), cholera (2 shots), typhus, yellow fever, and the plague. These immunizations are either no longer offered or are administered as different and improved vaccines. The latest preventative therapy for cholera is Dukoral, a liquid ingested weekly for two weeks prior to travel and which offers protection for about six months.  

Like almost every Canadian of my generation I have a smallpox scar on my upper left arm. The scar implies immunity. However, on a trip to Kenya in 1979, my immunization permit did not include a record of immunization with Smallpox. They refused to let me into the country unless I submitted to an immunization at the airport in Nairobi. My scar on the arm was not proof enough. Since then I have traveled with documentation, although these records no longer seems to be checked.  


For my trip to Haiti in 2010 I updated my status for diphtheria, pertussis, tetanus, typhoid, measles, mumps, rubella, H1N1, and cholera.  All I need for this trip is more Dukoral for cholera. Cholera is not currently a concern in Nicaragua, but, I believe in immunizations, and an ounce of prevention is worth a pound of cure.


Friday, December 16, 2011

Doomed to Develop Dengue?

As part of my preparation to return to Nicaragua I recently spent several hours reading about Dengue Fever. I'm glad I did. 


Dengue fever is common in Nicaragua. Fortunately up to 50% of infections are not symptomatic. However, for those who do develop Dengue Fever, the symptoms are severe. The infection is sometimes called Breakbone Fever because of the severe bone pain with the infections. The bone pain is thought to be due to destruction of white blood cells and platelet precursors in the bone marrow.  

The infection is caused by one of four serotypes of the Dengue virus and individuals who live in endemic regions will be infected by multiple strains over their lifetime.  

The mosquito that transmits the virus bites by day so mosquito nets are of limited use. Only takes one bite. I have been bitten by lots of mosquitos in dengue endemic areas of the world, so the chances are good that I have had an asymptomatic infection.  

The really bad news about dengue is that a small percent develop Dengue Hemorrhagic Fever and Shock Syndrome. This happens when an individual is infected with a new strain. The risk of Dengue Hemorrhagic Fever increases as the duration of time between infections increases. So, if I experienced an asymptomatic infection in the past, perhaps in Asia, Africa, South America, or the Middle East, and I am infected with a different strain on a trip to Nicaragua, I could be in trouble.  

An immunization has not been developed. There is no anti-viral medication available. The only treatment is supportive care with hydration, blood pressure support with pressors, platelets and plasma for bleeding, and so on. All modern (read not available in Nicaragua) ICU therapies.

So, prevention is important. I will be much more careful with DEET application with this trip.  

For the medical professionals who would like to learn more, I made notes on Dengue Fever from my reading, and the notes follow below.  

The WHO ranks Dengue Fever as the most common mosquito-borne viral disease in the world. In the last 50 years, the incidence of dengue has increased 30-fold.  In 2007, the Pan American Health Organization (PAHO) reported the highest number of dengue fever and dengue hemorrhagic fever cases (918,495) in the Americas since 1985.  Each year Dengue results in an estimated 22,000 deaths, mainly in children.

Dengue is caused by infection with 1 of 4 serotypes of dengue virus. Genetic studies suggest that the serotypes evolved from a common ancestor in primate populations approximately 1000 years ago and emerged into a human urban transmission cycle 500 years ago in either Asia or Africa.

Infection with one dengue serotype confers lifelong immunity only to that serotype. Antibody prevalence increases with age, and most adults are immune.

Dengue is transmitted by mosquitoes of the genus Aedes, which breed around dwellings in small amounts of stagnant water such as those found in old tires or other small containers.

In the Americas, dengue epidemics were rare post World War II because mosquitoes were eradicated with coordinated vector-control efforts. Systematic spraying was halted in the early 1970s because of environmental concerns. By the 1990s, A aegypti mosquitoes repopulated Central and South America.

Female Aedes mosquitoes are daytime feeders. Humans are their preferred hosts, with ankles and the back of the neck being the preferred sites. The mosquito inflicts an innocuous bite and is easily disturbed during a blood meal, causing them to move on to finish a meal on another individual, making them efficient vectors. Not uncommonly, entire families develop infection within a 24- to 36-hour period, presumably from the bites of a single infected mosquito.

Mosquitoes acquire the virus when they feed on a carrier of the virus. Persons with dengue viruses in their blood can transmit the viruses to the mosquito 1 day before the onset of the febrile period. The patient can remain infectious for the next 6-7 days. The mosquito can transmit dengue if it immediately bites another host. In addition, transmission occurs after 8-12 days of viral replication in the mosquito's salivary glands (extrinsic incubation period).  The mosquito remains infected for the remainder of its life. The life span of A aegypti is usually 21 days but ranges from 15
to 65 days. The virus does not adversely affect the mosquito.

Once inoculated into a human host, dengue has an incubation period of 3-14 days (average 4-7 days) during which viral replication takes place in target dendritic cells of the reticuloendothelial system, such as dendritic cells, hepatocytes, and endothelial cells, and the process results in the production of immune mediators.

Infection with the virus is asymptomatic in 50 to 90% of individuals.
Data from the 1997 Cuban epidemic suggest that for every clinically apparent case of dengue fever, 13.9 cases of dengue infection went unrecognized because of absent or minimal symptoms of a non-specific febrile illness.

Classic dengue fever is defined by the Pan American Health Organization (PAHO) as an acute febrile illness of 2-7 days duration associated with 2 or more of the following - severe headache, pain behind the eyes, severe muscle pain, joint pain, characteristic rash, hemorrhagic manifestations, low white blood cell count.

Many patients experience a prodrome of chills, red mottling of the skin, and facial flushing (a sensitive and specific indicator of dengue fever). The prodrome might last for 2-3 days. The illness presents with the rapid onset of high fever. The fever lasts 2-7 days and might reach 41°C. In addition to the symptoms and signs above, the patient might have weakness, vomiting, sore throat, or altered taste sensation. The severity of the pain led to the term breakbone fever. The rash is a centrifugal, maculopapular or macular confluent rash over the face, thorax, and flexor surfaces, with islands of skin sparing. The rash typically begins on day 3 and persists 2-3 days. Fever typically resolves with the cessation of viremia.

Leukopenia and thrombocytopenia are common findings in dengue fever and might be caused by direct destructive actions of the virus on bone marrow precursor cells. The resulting active viral replication and cellular destruction in the bone marrow might be the cause the severe bone pain. Approximately one third of patients with dengue fever have mild hemorrhagic symptoms, including petechiae, gingival bleeding, and a positive tourniquet test.

Dengue fever is typically a self-limiting disease with a mortality rate of less then 1%. Supportive care with analgesics, fluid replacement, and bed rest is usually sufficient. Acetaminophen can be used to treat fever and relieve other symptoms. Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids should not be used.

A small percentage of persons who were previously infected by a dengue serotype develop bleeding and endothelial leakage after infection with another serotype. The severity of secondary dengue infections appears to intensify with longer intervals between infections. When an individual is infected with another serotype, non-neutralizing antibodies recognize the dengue virus but do not neutralize or inhibit virus replication. Instead, the virus and antibody form an antigen-antibody complex. This complex is recognized by receptors on macrophages, which then internalize the immune complex and allow the virus to replicate unchecked. This phenomenon is called antibody-dependent enhancement. The affected macrophages release vasoactive mediators that increase vascular permeability.

Patients with dengue fever are at risk for development of dengue hemorrhagic fever or dengue shock syndrome at approximately the time of defervescence. Abdominal pain in conjunction with restlessness, change in mental status, hypothermia, and a drop in the platelet count presages the development of dengue hemorrhagic fever. Of patients with dengue hemorrhagic fever, 90% are younger than 15 years. In persons with dengue hemorrhagic fever, the fever reappears, as a biphasic or "saddleback" fever curve. Along with this biphasic fever, patients with dengue hemorrhagic fever have more obvious hemorrhagic manifestations and plasma leakage.  The critical feature of dengue hemorrhagic fever is plasma leakage. Plasma leakage is caused by increased capillary permeability. Bleeding is caused by capillary fragility and thrombocytopenia. Dengue shock syndrome is essentially dengue hemorrhagic fever with progression into circulatory failure, with ensuing hypotension, and, ultimately, shock and death. Death can occur within 8-24 hours after onset of signs of circulatory failure. The most common clinical findings with impending shock include hypothermia, abdominal pain, vomiting, and restlessness. Dengue hemorrhagic fever has a mortality rate of 2-5% when treated and up to 50% when not treated. Worldwide, children younger than 15 years constitute 90% of dengue hemorrhagic patients

No specific antiviral medication is available to treat dengue infections. Single-dose methylprednisolone showed no mortality benefit in the treatment of dengue shock syndrome in a prospective, randomized, double-blind, placebo-controlled trial.

The only way to prevent dengue virus acquisition is to avoid being bitten
by a mosquito.  Susceptible individuals should wear N,N-diethyl-3-methylbenzamide (DEET)–containing mosquito repellant and protective clothing, preferably impregnated with permethrin insecticide.  They should choose well-screened or air-conditioned places.  Mosquito netting is of limited benefit, since the mosquitos bite by day.  Larval habitats (stagnant water) should be eliminated or treated with larvacides.  Indoor sprays should be considered to eliminate mosquitos. Community-based vector control programs include vectoricidal agents and biological control agents.