And Now, Something New To Worry About: Dengue Fever

By Pamela Ferdinand
Special to The Washington Post
Sunday, May 6, 2007

One week I was lounging in paradise, snorkeling past giant clams and midnight blue starfish and eating freshly picked passion fruit and mangoes on a South Pacific beach with my fiance.

The next week I lay in torment at my home in Cambridge, Mass., alternately suffering chills and sweats with excruciating joint pain, bleeding under the skin and severe dehydration that landed me in the hospital for nearly a week.

Mark and I had chosen New Zealand over Thailand or Kenya for a month-long winter getaway, largely for its spectacular outdoors, where we could hike, kayak and scuba dive in remote and pristine wilderness. We also made the booking, after a year of family illnesses, because it promised a vacation free of political turmoil (no coups) and disease (no malaria shots).

The joke was on us.

When Air New Zealand offered a $100-per-person stopover at one of several island chains, including the Cook Islands, it seemed like a no-brainer: the perfect way to end our trip and an opportunity to see a place we might not otherwise visit. We opted to spend one night on Rarotonga and five on Aitutaki, the latter surrounded by an idyllic turquoise lagoon featured last year on the television reality show "Survivor."

Little did we know that our romantic detour had led us straight into a major disease outbreak striking hundreds of Cook Islanders and thousands of other people around the world. And, despite extensive trip homework and previous travels, we knew even less about the disease: dengue fever, a mosquito-borne virus also known as "break-bone fever."

When a fellow tourist came down with dengue, we figured: What are the odds of getting that?

As it turns out, pretty high.

* * *

Dengue fever (pronounced DENG-ee) is a common cause of illness in travelers returning to the United States from tropical areas, according to the Centers for Disease Control and Prevention. There is no vaccine, although clinical trials are underway, nor (unlike malaria) any preventive medication. Treatment involves close monitoring of vital signs, bed rest, fluids, and pain and fever relievers that do not encourage bleeding. Hospitalization can be required, especially for dengue hemorrhagic fever (DHF), a more severe and sometimes fatal form of the disease, but the good news is that dengue fever does not recur spontaneously, as does malaria.

The first reported dengue epidemics occurred in the late 18th century, and only nine countries experienced DHF epidemics before 1970. But scientists say the frequency and severity of outbreaks have increased in the past two decades -- particularly in the developing world -- due to climate change, increased air travel, uncontrolled urbanization with concurrent population growth, and failed or abandoned mosquito control efforts.

Now the disease is endemic in more than 100 countries in Africa, the Americas, Southeast Asia and the western Pacific, according to the World Health Organization. With one-third of the world's population at risk, there are an estimated 50 million to 100 million cases of dengue infection and 500,000 cases of DHF worldwide every year.

Travelers may find themselves at risk because they are less likely to be aware of dengue than malaria, an even more common and life-threatening illness, said Anton Peleg, an infectious disease research fellow at Beth Israel Deaconess Medical Center in Boston. Peleg, one of the doctors who treated me, trained for a year in Brisbane, Australia, where he saw people returning with dengue fever from the Pacific Islands, Indonesia and New Guinea, among other places.

"Certain regions have intermittent outbreaks of dengue, as seen in the Cook Islands, and it is these regions [where] tourists are often at great risk, as the outbreaks are difficult to predict and preventative measures may not be utilized," Peleg said. He added, "With the current trends in global warming, dengue will no doubt continue to be a major public health problem and risk for the traveler."

So far this year, Brazil has reported more than 135,000 dengue cases and 17 deaths, according to the Pan American Health Organization. Paraguay declared a state of emergency with upward of 25,000 cases -- more than six times last year's total -- and 11 deaths. The Jakarta Post reports that 45 people have died from the disease in the Indonesian capital already this year, with more than 13,000 infected, triggering citywide fumigations of dengue-prone areas. And in the Cook Islands, health officials predict that the current cyclical outbreak, which began last June and is now winding down, will exceed 1,000 reported cases (out of a total population of about 18,000).

The Cook Islands Tourism Corp. was told by health authorities in February that about 10 tourists had contracted dengue there in the previous five months, and health officials in Auckland, New Zealand, received 29 notifications of dengue cases among returning travelers this year, with 19 from the Cook Islands and a small number from other Pacific Islands. However, the exact number of tourist infections in any particular country is generally difficult to determine because many people have mild symptoms and do not see a health-care provider. In addition, mandatory reporting of dengue does not exist in most countries, and laboratory confirmation is often lacking.

Other countries with recent or current outbreaks include Cuba (albeit officially unconfirmed), Pakistan, Mexico, Bolivia, the Dominican Republic and India, said Hamish Mohammed, an epidemiologist with the CDC Dengue Branch in San Juan, Puerto Rico. Nor is the United States immune. Dengue fever has appeared along the U.S.-Mexico border, with cases reported in South Texas in 1999 and 2005. Health officials estimate that 30 cases are confirmed each year among returning U.S. travelers.

Travelers like me.

* * *

Mark and I returned home to Cambridge on Monday, Jan. 22, rested and healthy, looking forward to the new year. Five days later, I woke up with a strange feeling. I didn't have a stomachache or temperature, but my joints ached intensely, as if I were having an all-body arthritis attack.

I spent the weekend clutching a blanket and taking painkillers as my body grew chilled, then feverish. My walk was stilted, my skin sensitive to the touch. Mark assumed it was severe flu or fatigue after our long journey. My primary care doctor, Gary Trey, whose father once had dengue, considered the disease a possibility and urged me to head to the hospital if my fever spiked above 102 degrees.

On Monday, things got worse and I became dangerously dehydrated. I went to Beth Israel, where emergency room attendants hooked me up with intravenous fluids and ordered a CT scan, antibiotics, a pelvic ultrasound, a chest X-ray and blood tests. Given our travels, dengue quickly became a prime suspect that only a serology test sent to the CDC could confirm. (It did, two months later.)

In the Cook Islands, we'd slathered on sunscreen by day and insect repellent by night, not realizing that the dengue-infected female Aedes mosquito bites at its peak in the morning and late afternoon. Four dengue strains exist, and contracting one type does not confer immunity to the rest. In fact, subsequent infections are likely to be more serious.

Generally more severe in children and young adults, dengue fever incubates for three to 14 days, which is why many travelers do not get sick until they are home. (Malaria, another mosquito-borne disease, takes more than 10 days to appear.) More than half of dengue cases are asymptomatic. But symptoms can include a high fever for up to a week, intense headache, eye pain, muscle or joint pain, and body rash. Classic dengue often involves a rash that may include pinpoint-size bleeding spots on the skin, called petechiae, while DHF features capillary leaks and can lead to shock.

I had a constellation of symptoms that put me on the severe end of classical dengue, said Howard Gold, a member of Beth Israel's Division of Infectious Diseases and one of the physicians who treated me. Rashes spread over my torso and arms and down my legs, turning them the color of ripe raspberries. My platelet count plummeted to 48,000 (the normal range is 150,000 to 440,000), and my white cell count dropped to 2.4 (vs. a healthy 4 to 11). I also had liver abnormalities, with enzymes elevated to about 10 times the top end of the normal range.

My room became a medical theater, with a constant flow of fascinated interns, residents, fellows and attending physicians, few of whom had seen dengue in the flesh. One asked if he could photograph my legs, and not for their sex appeal.

"I can't recall another case, certainly not one as spectacular as yours," Gold told me later. "People were impressed and, knowing it can be quite serious and sometimes fatal, you were a case we were all following with tremendous interest and concern."

The aches and fever got worse before they got better. But by the following Saturday morning, I was ready to go home, seven pounds lighter and exhausted for weeks still to come.

Meanwhile, back in the Cook Islands, the owners of our Aitutaki hotel both came down with dengue after we left, and authorities launched a controversial chemical insecticide-spraying program.

"Everyone speaks of it as a disease you do not want to get," said John Woods, editor of the Cook Islands News, whose wife is recovering from dengue. "It's wrong to pretend that it's not here, and that it's not a threat. It definitely is."

I know.

Pamela Ferdinand is a freelance journalist based in Cambridge, Mass.

When a fellow tourist came down with dengue fever, a writer figured: What are the odds of getting that? As it turns out, pretty high.

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