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lunes, 29 de julio de 2013

ABCD del Dengue 2011. English version. D d-junking

This is the last  post in a 4 part series, about Dengue, which originally appeared at blogtorchey.blogspot.com in Spanish on June 2011.

D, Prevention: “de-junking”, water deposits, insecticides and barriers.
We have already addressed of its origins, how it arrives, how it presents itself and which are the dangers. We are missing the most important issue (hence why the title I suggested in the last installment changed): prevention.
As there is no vaccine against dengue virus, prevention focuses in attacking and eradicating the vector (carrier): the aedes mosquito. Attacking it is done in three manners: preventing bites, attacking the mosquito and breeding.
As for barriers we refer to the ways we can stop the mosquito from biting. Although a valuable prevention tool, it might be the less important as if the previous ones are correctly done, the mosquito would not appear. It has to do with avoiding the mosquito from reaching our skin (whether to inoculate the virus or extract it from an already sick person) and we can achieve it mainly in to forms: repellents and mosquito screens or nets. Use of repellents is well known; any presentation is valid and depending on every person’s preference, I will only mention that their use muse be increased during mosquitoes’ feeding schedules: dawn and dusk. Mosquito screens and nets keep the mosquito outside and may be used over beds (nets) or on windows and doors.
The second prevention aspect, concerns killing the mosquito. While the Health Department watches over and sprays over areas where cases have appeared, we should not expect that all mosquitoes will be killed and the problem eradicated. A large number of mosquitoes live inside homes and other locations where the spray cannot reach, therefore it is important that we take care of our own area and use commercial insecticides at home. Frequency thereof may also be determined by observing or not mosquito, however during this season doing it twice a week cannot hurt. We should not forget that certain spots are great hiding places for mosquitoes during the day such as behind furniture, inside closets and under the beds; in general, dark places.
The third and most important aspect refers to clearing areas from objects that become potential breeding grounds. Remember that the mosquito requires a small amount of water to place eggs and reproduce; if it finds such spaces in our own yards or homes, no matter how many times we fumigate every so often we will see the mosquito back again. Basically any junk could be used by them, from a lid of a jar or a bottle-cap to a bin o bucket, flower cases, open water tanks, a basin and we have even found then in potato chip bags. It only takes 24 hours of stagnant water to make hatching possible; without question the most important issue. First because is a mosquito does not breed, we stop 15 or more from hatching; second, because no matter how many times we fumigate, the mosquito may find a space to hide and reproduce again.
For large stagnant bodies of water such as puddles, ponds, water tanks, storm drains, wells and sewers we have two options. The first is to use temphos or abate, a substance that prevents mosquitoes from depositing the eggs and larvae settling in. Without going into further details, there are several types and mainly act breaking water’s surface tension, thus are the main option for bodies of water that cannot be covered and do not endanger the environment. The second option is to cover water deposits, starting with water tanks and wells placing sturdy and sealed covers; and, when this is not possible or an inflow/outflow watercourse, a screen cover could be used, depending on the case. For large bodies of water, health authorities must be contacted as they have the cost-free temphos or abate distribution and may carry out a better analysis to find the best solution.
This is it so far with the ABCD of Dengue; I hope the information is useful

jueves, 2 de mayo de 2013

ABCD of Dengue. 2011 ENGLISH VERSION. C. Cases and Clinic

This is the third post in a 4 part series, about Dengue, which originally appeared at blogtorchey.blogspot.com in Spanish on June 2011.

We have already seen how the Aedes reproduces and transports the dengue virus. In this installment we focus on its effects on us. I will start by differentiating the two general variants of the disease: the classic dengue and the hemorrhagic dengue. Even though considered two different entities, they clinically show a linear evolution: we all start with the symptoms of the classic dengue and, in some cases evolving to hemorrhagic dengue. I will not go into deep medical details, but it is important to mention that the presence of the virus in the blood produces an initial inflammatory response which produces in the body symptoms of classic dengue. In light of certain factors, the body may trigger a second inflammatory response by producing an accelerated use of platelets and dehydration which typify the symptoms of a hemorrhagic dengue.

The classic dengue has a variety of symptoms, hence often mistaken. An important example came about in 2009 with the presence of influenza, when a patient’s symptoms could be considered suspect of dengue and flue, assuming an important epidemiological challenge. At present dengue’s cardinal symptoms, those that determine a suspicious case are fever, headache, myalgia and arthralgia (bone and muscle pain); there is practically no case where these symptoms are not presents. Sometimes an allergic rash is present and may be preceded by a manifestation similar to a cold or simply sore throat and cough. With lower frequency we will find diarrhea, nausea or abdominal pain. Classic dengue symptoms last 3 to 4 days and, though we will not talk therapeutics in detail, the most important part of the treatment focuses on being well hydrated (4 to 5 liters of water or saline solution every day) and controlling the fever; use of antibiotics is usually a preventive measure (viruses are not attacked with antibiotics) and there are no antiviral medications or other drugs at present that may revert or reduce the duration of the symptoms.

Hemorrhagic dengue often manifests on the fourth or fifth day after the fever began. It’s a paradoxical and critical period as it comes about at the right moment the patient starts to feel better and the fever drops (which cause the symptoms to be underestimated). The essential symptoms are those that, after the classic dengue manifestation, they present abnormal bleeding: bleeding of the gums, nose bleeding, extended menstrual period, faces with blood or too dark. As well, presence of red punctiform spots on the skin usually on shins and forearms is a bottom-line manifestation of hemorrhagic dengue. At this point medical and lab evaluation are of utmost importance, as most cases require intravenous hydration, supervision of platelet levels, supervision and control of hemorrhages; very few are those cases that can be treated as out-patients (outside the hospital.)

Finally, I want to address some questions on the matter. First: this is a serious disease and has a large complication potential. I find that many patients feel that “nothing is being done” to them while at the hospital and want to be discharged. The reality is that although they do not require expensive or specialized medication, the sole administration of intravenous saline solution prevents many complications and, in case of hemorrhage, it can be controlled and patient’s complications be avoided. The second one is recovery. When patients are released, they want to return to their regular daily routines; it must be understood that hemorrhagic dengue (even the classic one) is a disease which, like pneumonias or kidney infections, significantly deplete the body reserves. Third and last, it is important to always seek medical advice when the main symptoms are present, in addition to the evaluation and proper treatment, the respective authorities must be notified of the case.

I hope this information is helpful. Wait for the next installment: D. Diagnosis and Epidemiology. Cheers.

ABCD DENGUE. 2011 ENGLISH VERSION. B: garBage, trash and water containers

This is the second post in a 4 part series, about Dengue, which originally appeared at blogtorchey.blogspot.com on Spanish on June 2011, by that time, little was known about Dengue and misleading information was a current language on the streets. In an effort to avoid our past experiences, the post hasn’t been edited. Whenever necessary or possible, 2013 remarks and comments will be properly pointed out.

B – Garbage, trash and water containers

First I wish to clarify about a question from the previous publication. An infected person has millions of viral particles in through its bloodstream (viraemia); when a mosquito bites and infected person and absorbs its blood, within the blood DV viral particles are included; thus, when a virus-free Aedes female (reminding you that from this species, only the female bites), she becomes the carrier and a virus transmission vector.

Now, addressing section B, we come into one of the definite issues in this disease’s prevention: water containers. As mentioned before, the virus needs the mosquito in order to spread and, in turn, the mosquito needs the water in order to reproduce. There is an anecdote presented in a course of Dengue where I participated. It explains the importance of this occurrence. In the '50s there was no dengue in the country or in a large portion of Central America. It is said that a cargo ship arriving from Brazilian coasts (where dengue did exist), carried a shipment of used tires and on route called ports in Central America; I don’t know if it ever called Mexico.
It turned out that the tires had wastewater containing mosquito eggs and larvae carrying DV which, when reaching port, infected Central America inhabitants and from there extending to the north, arriving to Mexico, thus reintroducing dengue.

So close is the relationship between the water and mosquito’s life cycle (and hence dengue) that dengue season begins with the rainy season. Why talk of trash and garbage? The mosquito does not need a large water stagnation to lay eggs, just a small accumulation in a bucket, a can turned upside down or any waste product able to collect water. It is here, in this close relationship where we must begin prevention: without water containers, dengue can be prevented.

The Ministry of Health’s campaign "Patio limpio" (clean patio) promotes the removal of cans, buckets, junk and any garbage container to prevent the potential of stagnant water. For this individual work, we only need to go outside, walk around checking and identifying where water accumulates on the house roof. We must get rid of waste, protect or keep buckets and canisters turned over; cisterns, water tanks or other fastened deposits should be covered and/or sealed. In waterloggings, ponds and other deposits which given their nature cannot be covered, temephos or abate (a substance that breaks the surface tension of water and prevents mosquitoes from standing on the surface to deposit its egg) must be used.

No matter how much we try to eradicate potential mosquito "nests" with the abovementioned measures, mosquitoes always appear. I do not have the official figures, but consider the 10 kms (6.2 miles) the mosquito may travel; and probably a few more depending on the wind speed. Hence, if there are no mosquitoes or dengue around us, the source could be a colony or a distant bog. In that case we must take precautions against the mosquito. Some of these measures are spraying (fumigation) our homes and surroundings (further below we will discuss spraying as a health campaign), use repellents even more at dawn and dusk (females’ feeding hours), place window screens and bed or hammock (pavilions) nets.
That's it for the B; wait for the next installment of C: Cases and dengue clinic.

viernes, 19 de abril de 2013

ABCDs of Dengue. English version of 2011 with 2013 remarks.

La temporada de Dengue ha empezado, para nuestros lectores de habla inglesa iré publicando las versiones en inglés del ABCD del dengue.  Para los de habla hispana los invito a checar los posts de 2011.  Si hay alguna razón de peso para que esta enfermedad regrese es nuestro descuido y amnesia.

Remembering, re-editing and reloading. It’s been two years since our last outbreak of dengue in Cozumel; exactly on april 2011 I remember having the first case of hemorraghic dengue at San Miguel Clinic and, after discussing it with some colleagues we concurred: that was a “dengue year”.
We tried to warn patients and authorities, the answer came three months later, once rain season started overtly, patients were filling hospitals and a very late attempt for prevention was just getting started.

I posted the following at blogtorchey.blogspot.com on its spanish version on june 2011, by that time, little had been made and misleading information was a current language on the streets. In an effort to avoid our past experience and after a very assertive sugestion and precious help from the Cozumel4you team, here it is: the ABCDs for dengue. I decided not to edit pieces of the article that tell how was our scenario at that moment, the reason for this is explained within the first paragraph: we forget and lower the guard quite fast. Whenever necessary or possible, I will add 2013 remarks and information which will be properly pointed out.

JUNE 2011
Though behind schedule, they arrived. After a very dry May in Cozumel, the rainy season came on mid June and a couple of heavy rains were enough for dengue season to formally begin; after five days, the reckoning was evident: five cases of dengue, four of them hemorrhagic. This is no alarm, however though it turns-up every year, we seem to forget about it; thus one of the reasons for writing about dengue. A second reason arises from remarks in hallways, in meetings and on the table, which, on the one hand suggest amnesia or ignorance about its monitoring and prevention or, otherwise, amongst colleagues, concern about its scope this season. In the following installments I will explain the ABCs and, if I may, the D of dengue.

A. Aedes aegypti. This is the main name of the mosquito that transmits dengue. You may soon find a picture in the blog where you may observe its white and black legs, one of its main features. While it transmits the dengue, it does not originate the disease. Dengue is a diseased produced by the dengue virus (DV), described as having four subtypes which cause, to our knowledge, the same type of disease. The only variable we have observed is that when a person who has previously had dengue caused by one of the viruses (say, DV type 1), when infected with a different type (for instance, DV type 4), that person is more susceptible to hemorrhagic dengue: We will speak of it later.
In general, viruses are microscopic organisms usually formed of primary chains of genetic material that do not have a cellular structure of their own. I do not intend to give a class on biology, but only want to emphasize these are microorganisms that depend on a host (in this case, the mosquito and the human being) in order to reproduce and fulfill their life cycle. On the particular case of DV, this is an ongoing cycle from man to mosquito and vice versa. Outside one of its hosts, the virus is very fragile.
We could summarize the virus’ life cycle as follows: from an infected man. The man has the virus circulating in the blood, the mosquito bites and draws the virus from the ingested blood. The virus reproduces and multiplies inside the mosquito; copies of the virus are placed in the “eggs” of future mosquito larvae. Thus, the mosquito lays the eggs (which contain genetic material of the virus) in a water container. The egg hatches and in just a few days, the larval stage begins within the water container. The larva settles on the surface of the water forming a cocoon, from where it emerges as a developed mosquito. We need to remember that this mosquito holds the genetic contents of the virus from the moment it was deposited in the form of an egg and once in the mosquito stage, the material rests in its “salivary” glands. When a human is bitten, this mosquito “saliva” slips anticoagulant and antihistamine into the skin, thus the infected mosquito transmits the virus.

APRIL 2013 remarks.
On a quick count with three colleagues, only in private practice, we have seen so far 4 hemorraghic dengue cases (DH), they have been notified to authorities and we have seen the fumigation team on the streets. Cases at public healthcare institutions must be, as they always use to, proportionally similar (somewhat a 1:4 ratio, but hard to really now).
We already mentioned that the virus has its own cylce, it has to be pointed out that a cycle of the disease itself has been described on different articles. This means that every 3 to 5 years a general elevation on dengue cases is observed with the consequent increase of complicated and hemorraghic cases. Although not completely understood a number of factors for this fenomena has been described: population immunity, viral enhanced infectivity, changes on natural and artificial water deposits and, of course, ceased or weak prevention strategies. In this intelligence, we may say that this year is not supposed to be one of the bad ones, nevertheless its very important to prevent any case.
See you on the next post: aBcd of Dengue.

This is All for the time being. I hope you find it helpful. Wait for the next installment: B – GarBage, trash and water containers

miércoles, 13 de marzo de 2013


  • Control de fiebre con baños cada toma de medicamento o cada vez que se observe temperatura de 38ºC o superior.
    • Baño por 20 minutos o más en agua tibia.
    • Aplicar paños de agua tibia a fría en abdomen, ingles y axilas.
    • Paracetamol se puede dar cada 4, 6 u 8 horas.
    • La fiebre regresa cuando el cuerpo agota el medicamento que se dio,  por lo que se debe de repetir la dosis.
  • Abundantes líquidos: el cuerpo gasta más líquido en moco y fiebre, se tiene que reponer para seguir protegiendo nariz y garganta con moco suficiente.
  • Frutas con abundante vitamina C: naranja, mandarina, limón, guayaba.
  • No use de antibióticos (ampicilina, penicilina, trimetoprim, etc…) SOLO debe ser indicado por médicos. NO SE AUTORRECETE.
    • La mayoría de las infecciones de garganta y gripa son por virus los cuales no se afectan por antibióticos y las molestias pueden durar 5 a 7 días a pesar de tratamiento
    • Después de una infección por virus puede atacar una por bacteria y entonces requerir antibiótico. La realización de gárgaras de isodine una o dos veces al día por 3 días puede ayudar a desarrollar la infección bacteriana pero no siempre se recomienda.
  • Datos de alarma (acudir a urgencias).
    • Dificultad para respirar
    • Pecho que sube y baja rápido, se hunde en costillas.
    • Nariz que aletea.
    • Respiración rápida y poco profunda.
  • Los ANTIGRIPALES solo disminuyen los síntomas y molestias, el cuadro seguirá aún si se ingieren. Solo se toman para poder desempeñar las actividades diarias; se sugiere que mejor se eviten si se puede reposar en casa.
    • CUIDADO ESPECIAL: Hay muchos antigripales que contienen cafeína y pueden dificultar el sueño, elevar la presión arterial en hipertensos o causar taquicardia si no se esta acostumbrado a la cafeína.
    • ANTIGRIPALES DE DIA:  sustancias como loratadina o cetirizina ayudan a la descongestión con poca somnolencia.
    • ANTIGRIPALES DE NOCHE: sustancias como clorfenamina o difenhidramina que tienen efecto sedante y por lo tanto inducen sueño y nos ayudan a tener una mejor noche.
  • Manejo de tos y jarabes: lo mejor es iniciar e intentar los remedios caseros y luego acudir al jarabe. Finalmente la tos es una defensa del cuerpo que nos permite expulsar flemas.
    • En caso de frío: dormir con sabana sobre nariz y boca, por la noche y madrugada tapar boca y nariz, tomar bebidas calientes y evitar las frías. Se puede usar cubrebocas.
    • El caldo de pollo (típico remedio de abuelita) ha demostrado tener propiedades antiinflamatorias y promover la inmunidad y recuperación en este tipo de enfermedades.
    • En general hay dos tipos de jarabes para la tos, los que quitan el reflejo de toser (benzonatato, dextrometorfano) y los que promueven la secreción y fluidificación del moco (ambroxol); en lo personal prefiero los segundos que permiten que se expulse la flema. Los que inhiben el reflejo de la tos los reservo para los casos en los cuales la tos lleva mas de 5 días o agota al paciente ya que  el uso temprano de estos productos no nos permite expulsar las flemas adecuadamente y éstas se pueden infectar.
  • El famoso Vick Vaporrub y otros eucaliptos ayudan a descongestionar, su uso se limita a la aplicación sobre el pecho, espalda y, si se tolera y no quema, por abajo de la nariz. No se debe usar para golpes, introducir en la nariz u otras prácticas inusuales e inadecuadas comúnmente observadas en ciertas regiones.