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The Maldives Health Protection Agency (HPA) has issued a dengue fever alert, following the death of a foreign migrant worker and the hospitalisation of two children for hemorrhagic dengue fever in Male’, with the HPA and World Health Organisation (WHO) emphasising that construction workers are particularly at risk.

Dengue is transmitted by the bite of an Aedes mosquito infected with any one of the four dengue viruses. It occurs in tropical and sub-tropical areas of the world, including the Maldives, which only has two strains of the virus. Though the Maldives holds South-East Asia’s record for being malaria-free, since 2004 the country has been battling a growing epidemic of dengue fever annually with nearly a 1000 reported cases and three deaths annually.

The year 2011 saw quite a severe outbreak of dengue in Maldives – though far below the 2788 cases recorded in 2006, the worst year ever for dengue in Maldives, according to the WHO. Fatalities reached 10 in 2006 and 12 in 2011 – a record high in the country’s history. While in 2012 there were a total of 1083 dengue cases in the Maldives.

Between January 1 and July 13 of this year, a total of 256 cases of dengue have been reported, with 90 in Male’ and 166 in the atolls, while dengue hemorrhagic fever accounts for 16 of those cases, the Health Ministry’s HPA has noted.

“The HPA issued a general alert – the first one for 2013 – regarding dengue fever to raise the level of public awareness a bit,” HPA Epidemiologist Dr Aishath Aroona Abdulla told Minivan News today (July 15). “Since it’s Ramazan it’s very difficult to conduct normal activities, so we wanted to alert people early.”

“We are beginning to see a rise in reported cases, but starting in May [the beginning of the south west monsoon season] this is to be expected,” said Dr Aroona. “Generally dengue peak season is June to early July, so this year its coming a little later, which could be because of changing rainfall patterns.”

She explained that while one of the dengue virus strains found in the Maldives is not fatal, the hemorrhagic strain is life threatening.

“The hemorrhagic variety is usually found in the Atolls, however people are getting sick from that strain of the virus in Male’,” explained Dr Aroona.

“Unfortunately one person, a foreign construction site worker, already died from the hemorrhagic strain [of dengue],” she continued. “He was in the country for about 15 days, according to the report we received.”

“Construction workers and people living near construction sites are at very high risk [for contracting dengue],” she noted.

Dr Aroona explained that when the sites are abandoned or the owner is not there, no one takes responsibility to ensure standing water or items that could collect water are removed.

“It’s important for the owners – the government or private businesses – to get rid of the [standing] water at the sites,” she said. “If removing all the water is not possible, large areas can be filled with sand as an alternative.”

“[However,] the Male’ City Council (MCC) or Local Government Authority (LGA) can be contacted to help control mosquitoes in these areas,” she added.

Foreign workers at risk

“While any reports of dengue are not good, comparatively, dengue cases in 2013 are not something to think of as an outbreak,” WHO Representative Dr Akjemal Magtymova told Minivan News today.

“However, there has been an unfortunate case of death and a few individuals in critical condition,” she noted.

While the children have subsequently been released from the hospital, the death of one foreign migrant worker has highlighted the risk foreign construction workers face due to their lack of social safety net support.

With an abundance of active construction sites in Male’ and the lack of inspection and control of these sites to prevent and control mosquito breeding places, it is expected that vector borne diseases will continue to persist in the capital, the WHO has noted.

“This [HPA alert] relates to foreign migrant workers. The individual who died was only here for about two weeks and must not have had a social safety net support,” said Dr Magtymova.

“While Maldivians are generally aware of dengue fever, migrant workers need more information and support because they may not know about dengue or have a support network if they fall ill,” she added.

“There should be more forceful promotion of awareness materials,” emphasised Dr Magtymova. “Everyone needs to be vigilant and aware, we don’t want people in critical condition.”

The WHO is working with the Health Ministry to leverage resources and extend dengue awareness. Additionally, the WHO in the Maldives has been an active partner in all aspects of dengue prevention, control and management – including training of doctors and nurses in clinical management of dengue, technical support in surveillance and situational analysis, provision of supplies and support in health promotion activities both at national and local levels.

Prevention

The Aedes mosquito breeds in small clean water collections in and around the home, places where people live (e.g. rainwater collections, pots, wells, tanks, tires, gutters, etc.). This is why controlling mosquitoes is everyone’s responsibility, noted the HPA.

“The dengue carrying mosquito bites in the early morning and in the evening close to sunset,” said HPA’s Dr Aroona.

There are two primary ways to prevent the spread of dengue, the most effective being to remove breeding areas and also to protect against bites.

“In addition to standing water at construction sites, garbage areas are also prime breeding grounds, especially since only a small amount of water is needed for mosquitoes to lay their eggs,” Dr Aroona said.

“It is very important for people to keep their gardens and homes clean, by collecting cups, cans, and other items that collect water,” she explained. “It takes seven days for mosquitoes to hatch after the eggs have been laid, so cleaning at least once a week is essential.”

The HPA has highlighted additional preventative measures individuals can take to protect themselves and their families from contracting the disease:

• Keeping windows and doors shut in the early morning, as well as covering air vents.
• Not littering, including throwing trash into air vents – which is particularly problematic in Male’.
• Covering any open tanks or wells and putting fish that eat larvae into them.
• Adding a little soap or salt to water to prevent eggs from being laid in planters, or they can be covered with cotton wool.
• Wearing clothes that cover the arms and legs.
• Using mosquito nets and screens.
• Using sand to fill areas that collect standing water.

Seek medical attention

“Although individuals can develop a lifelong immunity after recovering from dengue, they are only immune to that particular strain and are still at risk of infection,” explained Dr Aroona.

Dengue symptoms appear three to 14 days after the infective bite.

The fever is typically high grade, above 38oC (101oF) and continuous. The fever may not disappear even after taking paracetamol, although paracetamol may reduce the fever to some extent, noted the HPA.

Other accompanying symptoms are headache, body aches, backache and joint pains, and sometimes a transient rash or reddening of skin.

Symptoms of simple viral fever generally last less than 3 days. Dengue fever, a more severe form of viral fever caused by the dengue virus may last slightly longer, between three to five days, and may be accompanied by more severe symptoms like vomiting and fatigue, particularly when the fever begins to subside, the HPA has highlighted.

If an individual has a fever, the HPA recommends rest, drinking coconut water, oral rehydration solution, fruit juices, milk or any home-based drinks, and only taking paracetamol – not other medication which can lead to bleeding.

“Fever is an important part of your immune reaction to the virus in your body, and helps to kill the virus. So you need not be alarmed, so long as you do not have any of the warning signs or danger signs,” stated the HPA.

The HPA has urged people to seek immediate medical attention if the fever lasts more than three days, or any warning signs of hemorrhagic dengue are present, which include:

• Continuous vomiting and an inability to take fluids by mouth
• Severe pain in the abdomen
• Difficulty breathing
• Not passing urine for more than six hours
• Cold hands and feet
• Bleeding from the nose or gums, vomiting blood, or black, tarry faeces
• Changes in behaviour, such as lethargy or drowsiness, often with inability to stand, sit up or get up from the bed; Restlessness or irritability (excessive crying in children, adults may have behavioural changes and use foul language)

The Epidemiology and Surveillance Unit of the Health Protection Agency is conducting weekly monitoring of dengue nationwide and is issuing weekly reports.

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