High Fever

Shanty towns and poor neighborhoods were more
affected by the dengue outbreak. But in Rio the fever
hit even the wealthy and celebrities. Some of them
have been sharing their "feverish" experience
with the public in a special section called
"I Have Dengue" in Rio's O Globo newspaper.

Carolina Berard

Aedes aegypti is not a soap opera character, but it has become the newest villain on the Brazilian public health stage. Although this mosquito that carries dengue was believed to be eradicated from the country years ago, the current outbreak shows that the battle against dengue fever is far from over.

The state of Rio de Janeiro has been the most badly hit—137, 712 cases were reported by April 4^th, 49 resulted in death. Other states also demonstrate a high number of cases, and the total amount of cities struck by the dengue fever mosquito is believed to be about 3,600. The current outbreak is considered to be one of the worst ever, and in Rio, it is the worst since 1991.

Dengue is an old problem in Brazil. It was believed to be eliminated in the 1950s and the 1970s, but, in 1998, the country had its worst outbreak: 530,000 cases registered. In 1999 and 2000, the numbers were much lower (210,000 and 240,000 cases, respectively) but the first quarter of 2002 seemed to indicate that dengue was stronger than ever.

A special episode of this soap opera took place when federal, state and local authorities and institutions tried to avoid responsibility for the outbreak. The population and the media astonishingly watched what could be called "a political show," in which actors downplayed their role in leading to such a chaotic situation. Besides dealing with such political conflicts, politicians tripped over themselves taking measures to restrain the potentially fatal disease.

The battle against Aedes aegypti has been very much hampered both by the lack of organized actions on the part of government and institutions and by the aforementioned political game, since it involves two pre-candidates in next October's presidential elections: José Serra, who ran the Ministry of Health until he stepped down on February 20^th (so that he can run in this year's elections), and Anthony Garotinho, ex- governor of the state of Rio de Janeiro who also just stepped down. Mr. Serra left the Ministry at the very moment when concern about dengue fever peaked. Criticisms, questions and public opinion polls were inevitable. Serra's enemies even called him "candidate for the Presidengue."

"It is only natural that society's eyes are turned to problems. However, there cannot be electoral exploitation as a result," Serra responded in an interview with Veja magazine in February. A recent Institute MCI poll showed that the population did not consider Mr. Serra responsible for the outbreak.

Despite what the apparent buck-passing might suggest, the federal government has invested in this area, claims Mauro Costa, president of FUNASA (Fundação Nacional de Saúde—National Health Foundation). According to FUNASA data, the government has increasingly invested in the battle against the mosquito. Since 1996, 2.9 billion reais (about US$ 1.26 billion) were allocated to actions to control dengue and authorities now expect to invest an additional 607 billion reais (US$ 264.88 billion) until the end of 2002. Of course, these figures were ignored as presidential candidates traded barbs.

Mr. Costa also criticized the exploitation of the outbreak for political purposes, explaining "by saying the State [of Rio de Janeiro] is not responsible for the dengue fever outbreak, Mr. Garotinho transformed the issue in a political question. But dengue fever is not a political question, it is a technical one and it involves many elements: education, sanitation, etc."

In fact, these other elements contributed to the spread of dengue throughout the country. The disease is especially likely to occur in houses, mainly in poor neighborhoods where stagnant pools of water allow Aedes aegypti to breed. Shanty towns and poor neighborhoods were certainly more affected because of the poor sanitation system. But in Rio the fever hit even the wealthy and celebrities—some of them appear and share their "feverish" experience with the public in a special column called "I Have Dengue" in Rio's O Globo newspaper.

The combination of causes of dengue—hot weather, a rainy season, poor sanitation, lack of continuous policies against mosquitoes throughout the year and of participation of the population—made many cities, especially Rio, a breeding ground for a possible epidemic. This is why it is widely agreed that there is no acceptable excuse for the failure of the government and the population to act decisively. Researcher Luiz Hildebrando Pereira da Silva, however, sees a positive point amid the problem: "maybe this will show how important it is to develop preventative measures to avoid mosquitoes-carrying diseases in the future."

Until a better future arrives, FUNASA, the media and local governments have been promoting campaigns to encourage citizens to participate in the eradication of the mosquito's breeding places. Fortunately, they have been reasonably successful and figures show a reduction in the number of cases. In Rio de Janeiro, for example, according to the city's department of public health, the number of cases registered in March was 20,370, whereas there were 25,550 and 23,078 in February and January respectively.

The number of cases is expected to continue to decline both because of the measures being taken and the end of the rainy season. This, by the way, has been a sticking point between authorities and researchers. "When authorities claim that dengue fever epidemic is about to finish by April, they are deceiving population. The epidemic will break out again once the temperature gets higher, because there is no systematic control of mosquitoes and the living conditions are bad. Dengue fever is not likely to be won," says infectologist Celso Ferreira Ramos Filho.

FUNASA, however, does not even consider the outbreak an "epidemic." "Brazil is not having an epidemic," says FUNASA. "The high number of cases is mostly concentrated in the state of Rio de Janeiro. If we see statistics that do not include Rio, we will see that Brazil had a 7 percent reduction in the number of cases in January comparing to the same period in 2001. In other states, such as Amazônia and Acre, the effort put into this battle was so successful that dengue fever was practically won over."

There are many projects and plans that are being implemented throughout the country that help to explain the reduction shown by figures. In Rio, volunteers trained by FUNASA have been promoting "the D Day," both in shantytowns and good neighborhoods, by cleaning about 500 houses, streets and abandoned areas. In the state of Pernambuco, where the number of cases increased this year, there were also efforts to inform the population about the disease, clean neighborhoods and fumigate mosquitoes-infested areas. The same has been done in São Sebastião —located on the outskirts of Brasilia — the most badly hit city of the Federal District, and in many other places of the country. In Ceilândia, another city of the Federal District, there are programs in public schools to inform children and teenagers through lectures, videos and other activities.

Besides these preventative measures, FUNASA has also been spraying insecticides against the mosquito and its larvae. According to Mr. Costa, they have been using two types: 1) a larvicide, which is environmentally-friendly and effective for 60 days; 2) fumigation with a mixture of soy oil and insecticide, which is only used where there are many adult mosquitoes. The larvicides are applied to perforated screens, water reservoirs or in places where stagnant water cannot be eliminated. Fumigation, used to kill adult Aedes aegypti mosquitoes, is considered an extreme measure that should only be taken when the preventative actions have failed or have not existed. Mr. Ramos criticizes this practice saying "it is not effective in the long run, because it does not kill the larvae. Also, it is not environmentally-friendly, since it applies insecticide inside houses and in the environment itself."

Reduction of the number of cases registered, however, will never mean a definite solution, since it is impossible to completely eradicate Aedes aegypti, according to some researchers, as long as there are areas with poor sanitation system and little permanent (not limited to periods of outbreak) participation of society. Mr. da Silva says that there are many mosquitoes in Florida, for example, but epidemics are prevented by having an effective sanitation system. The disease is also hard to eliminate completely because there is no vaccine against it. "There are four types of dengue fever, and a vaccine against one of them would not be effective to the others," explains Anthony Érico Guimarães, a doctor in Parasitology.

Since there is no vaccine, Brazil — as well as other places which have problems fighting dengue fever, such as Hawaii, Vietnam, Thailand, India, the Philippines, Colombia, Peru, Mexico, and Pakistan — has to develop a very organized plan and follow it strictly. According to researchers, this plan has to include: a) permanent action to fight the mosquito and its breeding places (which has not yet happened); b) permanent campaign to inform citizens how they change some of their habits, such as by not leaving stagnant water in flower pots, discarded bottles or abandoned tires. According to Mr. Costa, changing (bad) habits would be highly effective; c) investment in infrastructure to treat the ill, since proper treatment could have avoided many of the deaths of those who contracted Dengue Hemorrhagic Fever, the most dangerous form of the disease. It is fatal, but, according to Mr. Costa and researchers in general, death can be avoided through proper treatment. (see below for further information about DHF); d) investment in sanitation in poor neighborhoods since they can be breeding grounds in which the female Aedes aegypti mosquitoes lays their eggs; e) the training of medical and support staff to diagnose and treat dengue related problems; f) better control of the use of the funds destined to the subject.

Such measures will only be the first step towards controlling the disease. The future of dengue fever in Brazil is still to be determined by how governments, institutions, and society face it. The end of this soap opera is still unwritten, but Brazilians, as with any other national soap opera, eagerly await the next episodes.

Dengue and the Economy

The good side…

Every cloud has a silver lining. Following the Brazilian tradition of seeing problems with a sense of optimism, some merchants have not been that angry with Aedes aegypti. Although concerned about the national health situation, they might even be satisfied — in a very discrete way, obviously —with the profit the mosquito has provided them.

Repellents, insecticides and screens have had a boom in sales. Merchants from Rio say that the number of requests for such products have been so high that inflation in the sector was inevitable. When it comes to fighting Aedes aegypti, however, consumers do not seem concerned about the prices.

In Rio, andiroba candles are in greater demand than any girl from Ipanema. Unlike its rivals, that are made of chemical elements, the andiroba candles do not cause side-effects on personal health and the environment. As a result, sales multiplied greatly. People also buy citronella candles, but it has many disadvantages, according to andirobla candles producers. "Citronella's use is limited, since it has been observed that the sweet aroma attracts bees who sting worse than mosquitoes and cause fatal allergies. Its mosquito-repellent efficiency is only 30 percent, against the 100 percent efficiency of andiroba candles. Citronella works better against flies. Andiroba acts against all bloodsucking mosquitoes," they provocatively advertise in their website http://www.andiroba.com.br/bio.htm 

It does not matter what problem the country faces. The war among merchants and the basic logic of supply and demand will always be present.

…and the bad one

It was not only the government and institutions that incurred losses and expenses with the epidemic. The population—especially some merchants—have also been bitten by the mosquito induced loss.

"Almost half of my employees had dengue and could not come to work for at least one week," says Alexandre Lobo, who owns a candle store (yes, the same who has more clients due to dengue).

According to an article published in www.no.com.br, merchants fear that the high number of sick people will result in fewer people buying products in general, which would affect other sectors of economy. "Also, I believe that about 20 percent of our employees will contract dengue fever in the near future," he fears. Data from the Shopping Centers' Association, in Rio, show that at least 30 percent of the total number of employees were hit by the disease and had to stay home.
 

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MORE ABOUT DENGUE

The Disease

Dengue fever is an acute viral infection spread through the bite of female Aedes aegypti mosquitoes infected with the dengue fever virus. The virus belongs to the genus Flavivirus and has four serotypes: DEN-1, DEN-2, DEN-3 and DEN-4. Until recently, only the three first were known to exist in Brazil, but Anthony Érico Guimarães, a doctor in Parasitology, affirmed in an interview: "a fourth serotype has been registered in Brazil, but only in Amazônia." The serotypes are closely related and cause the same symptoms, but they are antigenically distinct.

Dengue Hemorrhagic Fever (DHF) is the most serious form of the disease and it may cause blood clotting problems, resulting in bleeding and extremely low blood pressure. Due to the danger it represents—in Brazil many deaths were caused by DHF—Martinho Gonçalves da Costa, director of a hospital in Brasília, the capital of Brazil, considered Naldina Rodrigues, one of the ill patients the hospital assisted, a very lucky person. Ms. Rodrigues had the first symptoms of dengue fever and, thinking it was just a cold, took some aspirin, which is forbidden in these cases because it impairs blood clotting. After the intense treatment, she survived the DHF and was told by the director of the hospital: "You won the lottery! You had Dengue Hemorrhagic Fever and survived!"

Symptoms

The symptoms of dengue include high fever that may last from 5 to 7 days, intense headache, joint and muscle pain, nausea, vomiting and a rash. The symptoms usually occur within 5 to 6 days after the person has been bitten by the mosquito. Dengue Hemorrhagic Fever, besides these symptoms, is characterized by bleeding.

Treatment

It is very important to provide the population with a high level structure to assist the ill, since if there are no complications with the patient, recovery is likely to occur within 1 to 2 weeks. As for Dengue Haemorrhagic Fever, the treatment is more complex and includes hospital care with intravenous fluids. This is why a permanent preparedness of the health system, especially the public one, is a paramount measure to be taken in Brazil.

Vaccine

Since the four serotypes of the dengue fever virus are distinct, vaccine development is difficult because protection against one of these serotypes would not be effective against the others, and, even worse, it might actually increase the risk of more serious disease, according to researchers.

Tips for Travellers

Dengue fever usually occurs in tropical regions, so, if you are planning to visit Brazil or any other tropical country in the near future, make sure you include in your baggage some useful things other than a swimming suit, cameras and suntan lotion. There are some important measures you might want to take in order to avoid the so-feared Aedes aegypti.

Use mosquito repellents;
Use aerosol insecticides indoors;
If possible, wear long-sleeved shirts and long pants;
Do not leave water in flower pots, discarded bottles or abandoned tires. Mosquitoes thrive in urban areas and lay their eggs in clean water.
If you suspect you contracted dengue fever, DO NOT take aspirin, because it can impair blood clotting.
After getting back to your country, tell your doctor what countries you have visited. This will help him or her diagnose dengue fever, since it is often mistaken with typhoid, malaria, influenza, measles or scarlet fever.
 

The Light Side Brazilians are often known for their sense of humor. If you have ever been to Brazil, you probably know Brazilians joke about even the most serious subject or problem the country (or other countries) is going through. It is no different with dengue. A popular text circulated in the Internet as being a manual from the Health Ministry to answer the most common questions about the disease. Stupid Answers to Common (or sometimes equally stupid) Questions About Dengue Fever Does every Aedes aegypti mosquito carry dengue? There is no reason to panic. Not all Aedes aegypti mosquitoes are infected with the virus. Only those who bite you. When taking a bath, my belly button gets full of water. Since the mosquitoes lay their eggs in clean water, is my belly button a potential larval breeding place? Yes. The best you can do is stopping washing your belly button, so that the water in it is always dirty. No matter what I do, there are always mosquitoes in my house. What should I do to sleep safely? Put some of your blood into a bowl. Thus, instead of biting you, Aedes aegypti will feed on the blood in the bowl, saving time and work. A spider ate one Aedes aegypti mosquito in my bedroom. Is the spider infected now? Yes. Call the authorities so that they can kill the spider, since it is likely to attack you. Do not try to kill it yourself, because the dengue-carrying spider becomes more dangerous and may dominate you, by putting you and your whole family in its web. The battle against dengue fever seems inefficient. Should I blame the government? No. You should blame yourself, since you chose the current government. Good luck in the next elections, in case you survive this epidemic...

Carolina Berard is a translator in Brazil. She worked as a translator and journalist for the portal MultARTE Brazilian Culture  www.multarte.com.br) and has translated texts on various subjects ranging from economic integration to popular culture in Brazil. She is currently doing freelance translations and articles for several publications. Her email: carolinaberard@hotmail.com or kerolmb@ig.com.br

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