Viral fever, dengue, diarrhoea speading, warns health protection agency

Viral fever, dengue, common cold, and diarrhoea is spreading across the Maldives at an alarming rate, the health protection agency (HPA) has warned.

In a health alert issued yesterday (September 12), the agency revealed that 2,000 cases of common cold, 500 cases of diarrhoea, 800 cases of viral fever, and 500 cases of dengue fever were reported across the country during the past week.

The HPA cautioned that common cold and viral fever were highly contagious diseases and advised those affected to drink lots of liquids.

The agency also advised taking precautionary measures to prevent breeding of mosquitos during rainy weather.


HPA warns of viral fever and common cold epidemic

The Health Protection Agency (HPA) has warned of a viral fever and common cold epidemic in the Maldives.

According to the agency, approximately 1600 cases of viral fever 2000 cases of common cold and diarrhea are being reported every week.

A health alert issued on Thursday also expressed concern over rising dengue fever cases. Approximately 20 cases of dengue fever are being reported every week in the past two weeks.

“There have been 20 cases of dengue fever, reported on average, every week in the past two weeks. This agency also notes the common cold cases being reported at the moment are stronger than usual.”

Noting that viral fever and common cold are highly contagious, the agency has called on individuals with symptoms such as fever, cough or cold to avoid public places.

The HPA has also instructed those infected to cover their mouths and noses when coughing and to increase fluid intake.

Increase in dengue is linked to increased mosquito breeding with the southwest monsoon in full swing, the agency said and has urged the public to eradicate mosquito breeding grounds and take steps such as applying mosquito repellant to decrease the risk of infection.

HPA also called on the public to pay attention to cleanliness, such as washing hands before preparing food and refrigerating food, to decrease risk of infection.


Government warns of dengue and scrub typhus risk on World Health Day

Minister of Health and Gender Dr Mariyam Shakeela has noted an increase in the incidence of mosquito-borne dengue and mite-borne scrub typhus in the Maldives.

In a televised address to mark World Health Day, Shakeela said increased travel, trade, migration and climate change is leading to an increase in insect-borne diseases worldwide.

Dengue fever has become endemic in the Maldives since 2004, she said.

“I am deeply saddened to note that individual level action to control diseases spread by small insects is not being taken. The result is the increase in dangerous diseases such as dengue and scrub typhus and deaths,” said the minister.

There were 680 reported cases of dengue in the Maldives in 2013, a decline from 2006 peak of 2,788 cases, the Health Protection Agency (HPA) said.

The year 2011 also saw a relatively severe outbreak of dengue in the Maldives, with fatalities reaching a dozen – a record high in the country’s history. In 2012 there were a total of 1,083 dengue cases in the Maldives. Construction workers face an increased risk, the HPA has said.

Deaths have also been reported from scrub typhus due to failure to seek healthcare and improper diagnosis, epidemiologist at the HPA Dr Aishath Aroona told Minivan News.

The Health Ministry runs a yearly campaign called ‘Madhiri Rulhi Rulhi’ (‘Unfriendly to Mosquitoes’) to limit mosquito breeding during the rainy season.

Waste management and cleanliness are the most effective methods of controlling mosquito breeding grounds, Aroona said.

The Maldives eradicated malaria in 1984, making it the only country in the region to have done so. The last case of mosquito-borne filariasis was recorded in 2003, and the Health Ministry will complete a screening and surveillance project by October to determine the eradication of the filariasis vector, the ministry has said.

According to the World Health Organisation (WHO), mosquito-borne dengue has spread from nine to over a hundred countries, making it the most rapidly spreading vector-borne disease. Over 40 percent of the global population is at risk from dengue, the organisation said.

The WHO’s World Health Day campaign this year – ‘Small Bite, Big Threat’ – focuses on the risks of diseases spread by mosquitoes, flies, ticks, and freshwater snails.

The International Federation of Red Crescent and Red Cross Societies (IFRC) has called on governments for a shift in approach, from responding to isolated dengue outbreaks to investing in long-term programmes for behavioral change.

“This can be done by empowering communities with essential knowledge concerning hygiene and environmental sanitation, training and engaging community health volunteers to identify and refer suspected dengue cases and improving community-based disease surveillance,” the IFRC said in a recent report


Health Protection Agency warns of viral fever in Male’

In light of what it claims is a rapid spread of viral fever in Male’, the Maldives Health Protection Agency (HPA) issued a warning Sunday (June 16) urging the public to take precautionary measures.

Local media quoted HPA Epidemiologist Dr Aishath Aroona as saying that those who contract fever were advised to avoid crowded places, cover their mouth when coughing or sneezing, and consult a doctor if the fever persists for more than three days.

“Increasing viral fever is a sign of spread of dengue. Hence the best way to counteract dengue is to guard against breeding grounds for mosquitoes,” Aroona told Haveeru.

Amidst concerns about recent growth in the number of cases of viral fever and increase in patients at both ADK and Indira Gandhi Memorial Hospital (IGMH), the HPA has refused to label the current situation as an epidemic, according to local media.

“Such spread of fever is always common in June and July. Now only we’re starting to see it. So everyone must take precautionary measures,” said Aroona.


‘Mosquito Lady’ and local community combine to deter unwanted guests on Kuda Huraa

Pest control consultant Trudy Rilling-Collins, better known as the ‘Mosquito Lady’ has been working closely with Four Seasons Kuda Huraa resort and the local community of neighbouring Boda Huraa to introduce sustainable and environmentally friendly mosquito control procedures.

As the South-West monsoon season reaches the Maldives, wetter weather will bring rain to replenish the water tanks that provide safe drinking water for the people of the islands. But it is not just the human population who will be glad to see the clouds rolling overhead.

The increased rainfall is also particularly appealing to the country’s mosquito population, which will take full advantage of any available water in which they can lay their eggs. Any stagnant body of water will be most appreciated by Aedes aegypti and her cousin Aedes albopictus, the mosquito species that carry the dengue virus which has been afflicting Maldivians in increasing numbers in recent years.

Aedes aegypti will utilise any water available in which to lay her eggs. She will live for only one month, but in that time her larvae will take full advantage of any accommodating bucket, well, puddle, blocked drain or water tank.

She will sustain herself during this period by feeding exclusively on human blood, unlike her cousin who will happily feed off any red-blooded creature.

Aedes aegypti is a particular fan of mid-market tourism, preferring to find accommodation in close proximity to the local community. Eager to ingratiate herself with her human food supply, she can visit up to five people per blood meal, potentially passing the dengue virus to all she acquaints herself with.

She will be able to lay four lots of eggs in her lifetime which is more than long enough to see her young grow into fully grown biting adults, a process that takes only one week.

Fully booked

One place where Aedes aegypti and her kin will not receive a hospitable welcome this year, however, is on the resort island of Kuda Huraa in North Male’ Atoll and the inhabited island of Bodu Huraa next door.

The resort has this year enlisted the help of Trudy Rilling-Collins, otherwise known as ‘Mosquito Lady’, to ensure that its hospitality extends only to the human guests.

Trudy runs her own consultancy, specialising in environmentally responsible pest control, and has been working closely with Four Seasons Kuda Huraa and the Bodu Huraa community to ensure that there are no vacancies for dengue spreading visitors.

The resort on Kuda Huraa and the local community share a symbiotic relationship. The resort provides around 13 percent of the registered population in Bodu Huraa with jobs and has provided vital infrastructure to the local population.

The town’s sewerage system was provided by Four Seasons and the company has even assisted in providing fresh water to Bodu Huraa during the current dry season.

This close relationship is not lost on the mosquitos, who can easily travel the short distance between the islands, to feed happily from tourists and locals alike.

Trudy studied the biological control of insects and became disillusioned with the extensive use of harmful pesticides in what she sees as often futile attempts to control pests.

The use of pesticides in a diesel fuel carrier, referred to as fogging, is widely practised in the Maldives and throughout the tropical regions, although Four Seasons Kuda Huraa, which also pays for mosquito control in the two islands, has not fogged since Trudy’s arrival in April.

“The neurotoxins present in pesticides used for fogging on the islands have the same effects on humans that they have on the insects, it just takes far higher doses to affect humans,” said Trudy.

“Fogging kills only a small percentage of adults, five to ten percent if you’re lucky, and over time results in increased resistance,” she added.

Trudy believes that the key to mosquito control lies in making the area inhospitable to the pests: “80-90 percent of the problem can be sorted by eliminating standing water where mosquitoes breed.”

The effects of these chemicals are also harmful to the local environment, a particular concern for SEAMARC, a Maldivian an environmental consultancy that works closely with Four Seasons.

Alban Viaud, a marine biologist on Kuda Huraa, explained that the fogging chemicals which are quickly washed into the ocean are harmful to marine health: “Only a few parts per million can kill fish.”

Trudy has been working closely with the resort, the local council, schools and the community to implement a sustainable, effective and environmentally friendly way to keep mosquito numbers down.

Strength in numbers

After having visited the islands, there is a strong understanding emerging that, rather than chemicals, it is the community that is the strongest weapon in making Aedes aegypti feel unwelcome.

Measures have been taken to clear breeding grounds during Trudy’s time on Bodu Huraa. She has worked with the islanders to identify and eliminate as many breeding grounds as possible.

Of particular concern were the islands old septic tanks, long since replaced by the sewerage system supplied by the resort, but still capable of retaining water through gaps in the paving slabs. After water collects in such areas, Aedes aegypti is sure to follow.

Covering these gaps with concrete eliminates the tanks as another potential holiday home for the mosquitoes.

A similar, and innovative, method to prevent mosquitoes checking in to household water tanks was in full swing when Minivan News visited Boda Huraa.

Ringed hoses, filled with sand were being constructed in order to secure a fine mesh over the top of the water tanks, allowing access to rainwater but not to mosquitoes.

In the shade of the local council building, three resort employees could be found steadily working on the project. With around 250 tanks on the island, the team had a long way to go but seemed enthusiastic.

One of the men working on the rings was resort employee Rafeeq, who has been assigned the vital task of checking, sampling and clearing potential breeding areas. The job will require four hours of Rafeeq’s time every day, for six days every week.

The town’s households have been surveyed and divided into eight zones, meaning that each house should be checked three times in each one month cycle.

Around the corner, another simple and sustainable method was being used for removing larvae from water supplies. Fish are a far more welcome guest in the ground wells. No room service is required as they feed largely off any larvae they can find in water, which the townsfolk no longer use for drinking. One type of fish often found in the wells can eat up to 40 mosquitoes in three minutes.

Community action

“Energy and action are key components  the success of this project. I try to push for simple sustainable solutions,” said Trudy.

“But it takes someone on the ground to create action,” she added.

A vital part of her mission in Bodu Huraa has been to raise awareness and create enthusiasm for the eradication scheme. This has involved numerous presentations given to all sections of the community, from the employees at the resort to the children in the local school.

Shafyga Arif, the island’s Community Health Officer noted that there had been a big reduction in the mosquito population since the scheme had begun.

She also noted that the community would be important in keeping numbers low, with leaders appointed within each of the project’s eight zones. “They have to do it themselves. Each person should take responsibility. People had some previous awareness but didn’t care before,” said Shafyga, who has herself pledged nine hours of her working week to the project.

Back at the council building, the Island’s Council President Abdel Rahman Saleh explained that a local task force comprising fifty members of the local community had been formed to work on the scheme.

The task force members are working on a volunteer basis as there is no space in the council’s current budget for the scheme. Saleh said that he had requested more funds for such projects for next year.

“The task force will work. The government requested that we continue the project for twelve weeks, but we intend to continue it forever,” he added.

The appreciation of the health and environmental benefits of these sustainable methods appeared to be widespread as Trudy neared the end of her time on the islands.

Of equal importance was the realisation that the fight against the mosquitoes will only be as strong as its weakest link, and that the resort, the local government and the community must continue to patrol and eradicate potential breeding sites.

With the entire community working together and remaining vigilant, it is hoped that Kuda Huraa and Bodu Huraa will be receiving poor reviews from Aedes aegypti for the foreseeable future.


Maldives Red Crescent and CCHDC begin dengue awareness raising campaigns

The Maldivian Red Crescent yesterday began a door-to-door awareness raising campaign in the greater Male’ area.

The campaign coincides with the government’s annual awareness campaign during the summer months, organised by the Centre for Community Health Disease Control (CCHDC). The Red Crescent campaign will also cover Fuvahmulah.

The Red Crescent’s campaign will involve representatives going door to door handing out informative leaflets in order to avoid a repeat of the outbreak last year which claimed a record twelve lives in the country, according to the CCHDC’s figures.

2012 has already seen one recorded dengue-related fatality after a six-year old girl died as a result of Dengue-shock syndrome on April 10.

The campaign started by the CCDHC is called “Madhiri, rulhi, rulhi” (“Mosquito, unfriendly, unfriendly).


Six-year old girl dies of dengue shock syndrome

A six year-old girl died at Male’s ADK hospital on Tuesday shortly after being admitted with dengue fever complicated by respiratory difficulties.

Referred to as ‘Dengue Shock Syndrome’, ‘Dengue Haemorhaggic Fever’, or ‘severe dengue’, this type of complication greatly increases the risk of death in cases as blood pressure drops to dangerous levels.

“The girl was brought in at 4:00pm, gasping, blue, in a critical condition and was taken to the intensive care unit where she died,” said the hospital’s Managing Director, Ahmed Afaal.

Afaal was not yet able to confirm the girl’s home island, but confirmed that there would be a thorough investigation into the case as it involved dengue.

Her death is the first dengue-related death to have been recorded this year. A record 12 deaths last year were mostly children suffering from similar complications. Instances of the disease have been rising steadily both within the Maldives and globally.

Health Minister Dr Ahmed Jamsheed he was unable to comment on the issue, as he said he was engaged in SAARC meetings. He did, however, say that a communicable diseases paper would be discussed at the meeting.

The Centre for Community Health and Disease Control (CCHDC) issued its first warning of the year on March 20, blaming the large amount of construction work in the capital and pools of stagnant water, which serve as breeding grounds for dengue-carrying mosquitoes.

According to the World Health Organisation (WHO) the specific type of insect that carries dengue, the Aedes Aegypti Mosquito, is unusual in that it bites during the daytime. Once infected, humans are the most prominent carriers of the dengue illness, passing the strain on to other mosquitoes when bitten.

The organisation estimates that between 50 and 100 million people a year are infected, with 40 percent of the world’s population at risk. It advises that dengue should be suspected whenever a high fever is accompanied by any of the two following symptoms: severe headaches, pain behind the eyes, muscle and joint pains, nausea, vomiting, swollen glands, a rash.

It can be difficult to distinguish from the milder Chikungunya disease that can last for up to five days. Even healthy adults can be left immobile by dengue for several weeks while the disease runs its course.

Prevention rather than cure

The government has attempted to raise awareness of the disease in order to prevent the spread of what remains an illness without a specific cure.

After last summer’s outbreak was labelled an epidemic by the government, the Maldives National Defence Force (MNDF) was drafted in to assist with spraying breeding sites, although it did encounter difficulties in accessing some sites.

Such instances led to calls from the now Health Minister Ahmed Jamsheed, head of the CCHDC at the time, for the introduction of a Health Protection Bill that would provide “sufficient resources to ongoing efforts on community education, awareness and health promotion, access to premises with mosquito breeding and legal action against those who do not comply with the law or regulations.”

At the time of last month’s warning Public Health Programme Coordinator for the CCHDC, Dr Fathmath Nazla Rafeeq shared her concerns over the lack of public attention to the Centre’s alerts.

“Since December [2010] we had warned about the increase in dengue cases. But most of the people don’t even remember. They assume that mosquitoes should be controlled if there is a dengue outbreak and everything will be okay when authorities spray fog,” Nazla observed. “Therefore, on most islands, its [mosquito control] is highly neglected. Once dengue starts to spread, people panic”.

She also added that another epidemic would be inevitable if the authorities did not consistently eradicate breeding areas.


Construction sites blamed as dengue cases surge

The Centre for Community Health and Disease Control (CCHDC) on Tuesday issued the first warning this year on a possible outbreak of dengue fever, and urged the public to to take preventive measures to fight the mosquito-borne disease that has become one of the worst public health threats in the Maldives.

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, except in 2006 and 2011 where the reported cases doubled, and fatalities reached 10 and 12 respectively – a record high in the country’s history.

According to the CCHDC statement, 163 cases have been reported so far this year, 100 cases from Male’ and Hulhumale’ and the other cases from across the islands.

Although Maldives usually experience two peaks of dengue following the rainy seasons; one between January to March and the other during June to August, the center observed that dengue cases continues to be reported from Male’ and Hulhumale’ outside the peak periods.

“This is due to the non-stop construction work going on Male’ and Hulhumale”, noted the center.

Health experts have also echoed similar concerns and pinpointed Male’s mosquito-breeding to pools of stagnant water in building sites across the city – which is often poorly monitored.

The center meanwhile called for public support to in the fight against dengue by taking preventive measures including the clearance of mosquito breeding grounds inside homes, schools and other public areas and increased use of mosquito repellant sprays and lotions.


However, health experts worry that public will ignore the warnings until the death toll increases.

In 2011, dengue did not come to the center of attention until June when four children died of dengue in 48 hours, making headlines on almost all local media outlets. The government the next day set up a task force to combat the outbreak.

At the time, speaking to this author, Public Health Programme Coordinator for the Center for Community Health and Disease Control (CCHDC) Dr Fathmath Nazla Rafeeq shared her concerns over the lack of public attention to the center’s alerts.

“Since December [2010] we had warned about the increase in dengue cases. But most of the people don’t even remember. They assume that mosquitoes should be controlled if there is a dengue outbreak and everything will be okay when authorities spray fog,” Nazla observed. “Therefore, on most islands, its [mosquito control] is highly neglected. Once dengue starts to spread, people panic,” she added.

According to her, a dengue outbreak is inevitable, unless public collaborate with the authorities to eliminate mosquito breeding sites regularly.

Health Minister and former Director of CCHDC Dr Ahmed Jamsheed meanwhile wrote on his blog on June 2011: “Multiple reminders in the form of health warnings and press releases issued by CCHDC following heavy rain and prior to an expected outbreak are either ignored or not acted upon sufficiently”.

Furthermore, he noted “there are several fundamental problems in how mosquito control work is being carried out; with improper approaches and wrong techniques resulting not only in a failure to control mosquito, but also mosquitoes getting resistant to chemicals due to irrational and improper use of chemicals, which is an extremely worrying problem.”

While advice and reminders fail, Jamsheed suggests that punitive measures need to be taken to continue the fight against dengue – including the introduction of Health Protection Bill.

When passed, the bill will provide “sufficient resources to ongoing efforts on community education, awareness and health promotion, access to premises with mosquito breeding and legal action against those who do not comply with the law or regulations,” according to Dr Jamsheed.

“With neither a cure nor a specific treatment, prevention becomes the only strategy we have,” Jamsheed concluded.


New bug kills young to stop dengue

An experiment by British biotechnology company Oxitec Limited has yielded mosquitoes genetically engineered to prevent the spread of dengue fever by killing their own offspring.

The mosquitoes, formally termed aedes aegypti RIDL strain, transmit a lethal gene to their offspring which kills them before they reach maturity. Only male mosquitoes carry the gene.

The engineered mosquitoes were first released in the Cayman Islands in 2009 in a 25-acre area. A report published yesterday (October 30) revealed signs of success.

According to the traps, genetically engineered male mosquitoes accounted for 16 percent of the total male population in the test area, while 10 percent of the larvae contained the lethal gene. Scientists concluded that although genetically engineered males were half as successful at mating as normal mosquitoes, their activities would still suppress the population in dengue-endemic areas.

A larger trial on Grand Cayman island in 2010 reduced the targeted mosquito population by 80 percent for three months, Oxitec has reported.

“The results, and other work elsewhere, could herald an age in which genetically modified insects will be used to help control agricultural pests and insect-borne diseases like dengue fever and malaria,” the US’ New York Times reported today.

The insects have also been released in Brazil and nearby Malaysia.

Dengue is reported in between 50 and 100 million cases each year, and accounts for an estimated 25,000 deaths. According to Oxitec, dengue threatens 50 percent of the world’s population and costs the global economy US$4 billion annually.

The new bug could prove useful to the Maldives. Though it ranks number one on South-East Asia’s list of malaria-free zones, the Maldives continues to combat dengue fever annually.

This year, hospitals documented the highest number of fatalities when Ahmed Shinah of Vaadhoo in Gaaf Dhaal Atoll succumbed to the disease in July. An Oxitec report shows a steady increase in cases weekly since 2009.

Director General of Health Services Dr. Ibrahim Yasir said health officials are aware of Oxitec’s experiment but are awaiting confirmation that the mosquitoes are a valid solution.

“We have heard about it, but we are not discussing the experiment at a policy level right now,” Yasir said. “We are waiting to see how it works in other countries first.”

Yasir was unable to say if the Maldives would be able to genetically modify its own mosquitoes, but noted that the environmental parallels between Malaysia and the Maldives gave officials confidence in Malaysia’s results.

“We will not pilot the experiment here, but I think the way they are exploring it in Malaysia will help us decide if it safe for the Maldives. It could certainly be a cutting edge solution to dengue,” Yasir said.

The Maldives is particularly vulnerable to the impact of dengue. Using Maldives as an example, Oxitec reported that dengue cases had occurred more frequently this year than in the two years previous in tourism-dependent countries. Travel warnings were issued by various government and international health organisations for these areas.

The economic impact of even a warning can be significant for tourism-dependent countries such as the Maldives, Oxitec claims. A paper by Mavalankar et al. found that French Réunion lost 40 percent of its tourism traffic in the year following the 2005-2006 chikungunya oubreak. The paper estimated that a country such as Thailand could lose US$363 million annually for every four percent drop in tourism traffic.

Deputy Director General of Tourism Hassan Zameel said dengue had never been reported on resorts in the Maldives, and was not expected to become a concern.

“Of course dengue is a problem if it becomes widespread and cannot be controlled, but the government has given this lots of thought and emergency mechanisms are in place,” he said, adding that emergency procedures were carried out effectively for the outbreak in July and August.

“Cases are mostly reported on local islands. Resorts have their own methods involving sprays and smoke to counter the spread of mosquitoes. They’re doing very well at controlling it. But I don’t think it will be an issue moving forward,” Zameel added.

Oxitec lately opened a new facility to serve further experiments in Brazil and Malaysia. However, the program is also being criticised for possible health and environmental risks.

Unlike an antibiotic, mosquitoes cannot be recalled once they have been released. Some scientists interviewed by the Times said the insects could develop a resilience to the gene and survive. Todd Shelly of Hawaii’s Agricultural Department said 3.5 percent of the insects in a lab test survived the gene and matured into adulthood.

The mosquitoes are also sorted by hand according to gender, leaving room for error which could be signficant when thousands are released over an area.

One possible solution is modifying female mosquitoes, which do not carry the lethal gene, to stay grounded.

Chief Scientist at Oxitec Dr. Luke Alphey deemed the new approach safe because it releases only males, while only females bite people and spread the disease. He said it should have little environmental impact, reports the Times.

Meanwhile, authorities in Florida, United States hope to conduct an experimental release of the bugs in December.