Dengue Fever Outbreak in Cebu

Susan Posadas-Gregorio, M.D.,* Vivian Lofranco, M.D.,* Colita Auza, R.N.,** Felilia White, R.N.,*** Jocelyn Merin, B.S.P.H.,**** Manuel M. Dayrit, M.D., M.Sc.***** and Mark White, M.D.******
(*FETP, Trainee; **RHO #7, Supervising Nurse; ***HIS, Nurse Epidemiologist; ****RITM, Research Assistant; *****FETP, Program Manager; ******FETP Consultant)

ABSTRACT
An outbreak of dengue fever occurred in Cebu City from August 1987 to January 1988. A total of 752 cases were hospitalized; 269 records were reviewed, 20 patients were interviewed, and 18 blood samples were collected. The majority of the cases were from urban areas. Seventy percent of the cases were aged 10 years and younger. Fifty-three percent were classical dengue fever; 22% Grade I; 21% Grade II; and 7% Grade III. There were three deaths; the case fatality ratio was 0.4%. Three of the 18 blood samples grew dengue virus serotype 1. Public health officials did active case finding in the affected cities while clinicians reported and treated dengue fever cases actively. Future dengue epidemics could be prevented by setting up a well-planned dengue control program (health education, environmental sanitation and mosquito spraying) as early as possible. Reports of insecticide resistance of mosquitoes should be further evaluated by more entomological studies. [Phil J Microbiol Infect Dis 1989; 16-20] Key Words: dengue fever, epidemic, outbreak, case-control study

INTRODUCTION Cebu City has the highest rate of reported dengue fever cases in the Philippines. In the last five years (1982-1986), the average incidence rate of Cebu City was 26/100,000 population, which was five times higher than the national rate.1 Early in November 1987, increasing dengue fever cases were noticed by local health officials of Cebu City. Immediately, an epidemiological team was formed to investigate the epidemic. On the first week of December 1987, the director of Regional Health Office No. 7, requested the FETP to assist the region in the epidemiologic al investigation of the outbreak in Cebu province, MATERIALS AND METHODS Case Finding To determine the extent of the outbreak, we did case finding in hospitals of Cebu City proper (urban) and randomly selected hospitals on the outside city (rural). A structured questionnaire was designed to elicit information on demographic characteristics, clinical signs and symptoms and laboratory results. Case Definition Dengue fever (DF) was defined as an acute febrile illness caused by dengue virus. It was characterized clinically by hemorrhagic phenomena and a tendency to develop a shock syndrome. The standard WHO criteria for the diagnosis of dengue was modified so that thrombocytopenia was used in place of a positive tourniquet test. The severity of Dengue Fever was classified as follows: I. Classical Dengue Fever: Fever and non-specific constitutional symptoms; a positive tourniquet test and/or low platelet count. (< 100,000

platelets/cu mm). II. Dengue Hemorrhagic Fever (DHF): 1. Grade I: Manifestations of classical dengue fever plus laboratory findings of thrombocytopenia and hemoconcentration. 2. Grade II: Grade I manifestations plus spontaneous bleeding in the skin and/or other sites. 3. Grade III: Circulatory failure manifested by rapid and weak pulse, narrowing of pulse pressure (20 mm Hg or less) or hypotension, cold clammy skin and restlessness. 4. Grade IV: Profound shock with undetectable blood pressure and pulse. Review of Records Dengue fever admissions for the year 1987 were analyzed. Particular attention was paid to the latter part of 1987 when the outbreak began. Records from four urban hospitals were reviewed: Southern islands Medical Center, Cebu Doctors Hospital, Cortes General Hospital and Velez General Hospital. Virology and Serology Twenty dengue fever patients confined in the hospitals were interviewed and 18 blood samples were extracted for virus isolation. Blood samples were centrifuged, stored in liquid nitrogen and transported to the Research Institute for Tropical Medicine (RITM) in Manila for virological analysis. Sera were inoculated in a C6-36 mosquito cell line tissue culture. After several days, cells were harvested and treated with immunoflourescent antisera against the four dengue serotypes for specific virus identif ication, RESULTS Epidemiology A total of 752 hospitalized cases of clinically-diagnosed dengue fever were reported to the health authorities for the period from January 1987 to January 1988. Records showed that for the Philippines the incidence rate for dengue fever was 3.8/100,000 population in 1985; in this same year Cebu City had a incidence rate of 19.9/100,000 population which is 5 times higher than the national rate. The incidence rate of Cebu City rose to 68.8/100,000 in December 1987 (Figure 1). 1 Most of the patients resided in the urban areas (Figure 2). The rest of the cases were sparsely distributed, in rural areas of Cebu province. Only three cases were found in the two rural districts of Danao and Argao. Figure 3 shows that both sexes were equally affected in all age groups. The mean age was 8.5 years and ranged from 1 to 50 years. Clinical Signs and Symptoms Of the 752 hospitalized cases, complete details for 269 cases were recorded by reviewing charts. There were three reported deaths due to dengue fever (charts were not available for review), resulting in a case fatality ratio of 0.4 percent. All identified cases were classified using the criteria issued by the World Health Organization Technical Advisory Committee on Dengue Hemorrhagic Fever for the South East Asian and Western Pacific Regions. Figure 4 shows that half of the reported cases were classical dengue fever.

Figure1. Epidemic Curve of Dengue fever Cases Region 7, Jan 87 Jan 88

Figure 2. Reported Dengue Fever Cases Region 7, Jan 87 Jan 88

Figure 3. Age and Sex Pattern Region 7, Jan 87 Jan 88

Figure 4. Classification of Dengue Fever Cases in Cebu, 1987 (N = 269)

Table 1 lists the clinical manifestations seen in these patients.

Table1. Clinical and Laboratory Manifestations of Patients admitted as Dengue Viral Infections in 269 cases Cebu Province October 1987-January1988 Manifestations Fever Low Platelets(<1500 per cu mm) Vomiting Positive Tourniquet Test Anorexia Abdominal Pain Headache Petechial Hemorrhage Joint Pains Hypotension Epistaxis Melena Bleeding Gums No. of Cases 269 162 133 103 87 82 79 64 62 57 38 12 9 % 100 60 49 38 32 30 29 24 23 21 14 4 3

Virologic Findings Of 20 dengue patients seen in the hospitals during the investigation, 18 consented to blood extraction. Dengue fever virus serotype 1 was isolated from 3 of the 18 blood specimens. DISCUSSION Dengue fever has been known in the Philippines since it was first described in 1954. It was called Philippine hemorrhagic fever prior to the isolation of dengue virus serotypes 3 and 4 in 1956.3 Several parts of the country are endemic for this disease but only dengue epidemics

occurring in Manila have been thoroughly investigated. 5 Where dengue is endemic, only a few individuals exhibit severe disease. But even mild dengue infection is important since studies suggest that sequential infection with different serotypes of dengue virus may increase the risk of Dengue Hemorrhagic Fever and Dengue Shock Syndrome.4 During this outbreak, reporting of dengue fever cases by clinicians was excellent due to their high index of' suspicion. Clinically the epidemic was similar to other outbreaks reported in Southeast Asia (Malaysia, Viet Nam, Indonesia and Thailand) with a high percentage of patients suffering from fever, anorexia, vomiting, headache, abdominal pain and joint pains.2,3,7,10 Virological studies suggested that dengue serotype 1 was the predominant virus for this outbreak. A larger number of isolates would have been required to determine if other dengue strains also were circulating. A study done in Thailand suggested that dengue serotype 1 infection may be associated with high rates of hemorrhagic fever and shock if followed by dengue serotype 2 re-infection. 7 Previous epidemics in Manila showed that the common dengue serotypes isolated were 2, 3 and 4. There was no pattern in the severity of the infection in relation to its isolated serotype.5,6 Other risk factors of DHF in children with either primary or secondary infection are still unknown. The bulk of cases occurred in the young population which is consistent with previous studies done in the Philippines.8 This could be explained by the fact that because of its endemicity, adults have developed some immunity against infection. The epidemic lasted over a five-month period and burned itself out naturally. Investigation of the epidemic and measures to control the outbreak were done late when they had little effect. Several public health measures can be implemented to prevent future dengue epidemics. Public health officials should undertake continuous active surveillance of dengue fever cases and mosquito breeding sites as a means of detecting dengue epidemics early so control measures may be instituted. Entomological studies have shown that Aedes aegypti indices are exceptionally high just before a Dengue fever outbreak. 10 The potential for mosquito-borne transmission is also enhanced by high population density. Aedes aegypti breeds near human dwellings, so environmental control by cl aning up old tires and changing water storage weekly is practical. e Mosquito spraying is an effective short-term emergency measure when dengue cases reach epidemic proportions. Further study of mosquito resistance to DDT and other insecticides is useful. Intensive health education and proper training of housewives in the elimination of mosquito harborage is important and allows for community-based participation in control activities. The future success of dengue control in Cebu City must be based on intensive surveillance of cases and mosquitoes, public cooperation in maintaining the environmental sanitation, and proper coordination of all dengue control activities. Health authorities in Cebu mounted a health education campaign against dengue in 1988. There was a marked decline in dengue cases (Figure 5), which suggests this program was successful. If the program continues in the next few years, we hope that dengue cases will continue to decrease. Acknowledgements
We wish to thank the following persons who have given us the invaluable support for making this outbreak investigation a successful one: The staff of the Regional Health Office #7 headed by Dr. F.F. Aniceto. The Director of RITM who made available to us Miss Jocelyn Merin for viral isolation studies. The Directors of the following hospitals who allowed access to their records: 1. Cebu Doctors Hospital 2. Cortes General Hospital 3. Chong Hua Hospital 4. Velez General Hospital 5. Southern Islands Medical Center 6. Lapu-Lapu District Hospital

7. Minglanilla District Hospital 8. Mactan Air Base Hospital 9. Miller Memorial Sanitarium 10. lsidro Kintanar District Hospital

Figure 5. Reported Dengue cases in Cebu City

REFERENCES
1. 2. Philippine Health Statistics, Health Intelligence Service, Department of Health, Republic of the Philippines, 1985. Technical Advisory Committee on Dengue Hemorrhagic Fever for the Southeast Asian and Western Pacific Regions, 1980. Guide for diagnosis, treatment and control of dengue hemorrhagic fever, 2nd ed., World Health Organization. 3. Halstead SB. Dengue hemorrhagic fever - A public health problem and a field for research. Bull WHO 1980; 58:1 -21. 4. Diaz BB, et al. Dengue fever/dengue hemorrhagic fever: Clinical experiences as verified by hemagglutination inhibition (HI) Antibody Titers. Phil J Pediatr 1986; 1:55-62. 5. Hayes CG, Manaloto CR. Dengue infections in the Philippines. AM J Trop Med Hyg 1987; 1-30. 6. Songco RS, Hayes CG, Leus CD, Manaloto CR. Dengue fever/ dengue hemorrhagic fever in Filipino children. Phil J Pediatr 1987; 18:284-290. 7. Sangkawibha N, et al. Risk factors in dengue shock syndrome: A prospective epidemiologic study in Rayong, Thailand. Am J Epidemiol 1984; 120:653-669. 8. Tupasi TE, Montalban CS. Virological and clinical studies in dengue Infection. Phil J Microbiol Infect Dis 1987; 16:14. 9. Venzon EL. The geater Manila dengue hemorrhagic fever epidemic of 1966. Phil J Sci 1972; 48:297-313. 10. Wallace HG, et al Dengue hemorrhagic fever in Malaysia: The 1973 epidemic. Southeast Asian J Trop Med Pub Hlth 1980; 2:113.