Anatomy of a Public Health Crisis: Dengue in Peten
Last November,2009 many of GUAMAP's supporters helped us in a great hour of need for acupuncturists and health promoters in Peten, Guatemala. Our efforts are reported on below. The epicenter of the Dengue outbreak was in Poptun. The rising levels of classical Dengue and hemorrhagic Dengue was of grave concern given several public health functions had failed to address the crisis.It should be noted, that the epidemic levels of dengue were under reported and this is part of the inherent weakness of the the Guatemalan infectious disease surveillance system and the CDC's system in Guatemala as well. For example the CDC does not monitor for dengue or malaria in the lowland semi-tropical area of the Northern and Northeastern Guatemala, but rather in Guatemala city, which is a temperate zone, and in San Marcos, which is mostly highlands with a coastal strip, sharing a border with Mexican state of Chiapas. We interviewed CDC personnel in Guatemala City, and they took our comments and said they would share them with their Ministry of Health contacts.
Several extenuating circumstances exacerbated the outbreak. If you look at reports for the rise of Dengue in the Americas in 2009, higher levels for several countries last year were reported compared to previous years, however Guatemala was not one of them, and according to a CDC Malaria specialist in Puerto Rico, that is due to chronic under reporting of mosquito born diseases from Guatemala. During the previous months leading up to last November, 2009, a drought occurred in Eastern Guatemala. GUAMAP works in Peten, in the Northern region. The prolonged drought caused crop failures and the population quickly lost the fragile food security it had previously maintained. The national government asked for and received international aid form the UN World Food Program and the US Dept. of State. The newspaper reports stated that 40% of Guatemala Children were malnourished due to the crisis. The food crisis was the only crisis the government would address at the time.
The Ministry of Health, during the last months of 2009 had its public health budgets cut, thereby passing on cuts to regional offices which made some unfortunate choices in Peten. Fumigation workers went out on strike in a pay dispute, and the critical fumigation of public areas was not carried out as needed, this effected Poptun, where GUAMAP trains, the worst place in the Peten during the outbreak. The longer that mosquitoes are allowed to breed the higher the risk for dengue to become hemorrhagic as multiple serotypes infect people, a necessary condition for classical dengue infected persons to be infected by hemorrhagic dengue.
The communities began to see advanced symptoms and suspected that hemorrhagic dengue was evident in patients seen by health promoters. The only way to discern the symptoms ultimately is though testing. Poptun hospital started transferring all its cases to the Regional hospital in San Benito because it is a higher level hospital and it was not in Poptun which was inundated with cases.
A third problem was the delay in receiving test results sent to Guatemala City since the regional hospital cannot test for hemorrhagic dengue. The hospital however soon ran out of test kits. they could not receive a fresh supply because the government, in an effort to increase transparency in bidding to supply government ministries, held a new bidding process on an official website. However, the bidding process was new, and companies failed to submit bids on line, and as a result, no kits were ordered due to a dysfunctional attempt to improve government purchasing. This of course was embarrassing to the Director of the Regional Hospital in San Benito. The hospital itself had several day clinics to absorb the inflow of patients with dengue symptoms.
The actions taken by GUAMAP and briefly described below cannot be fully understood unless the fuller report is read in the project section. Highlights only are mentioned in this section.
GUAMAP administered aid funds according to the best use of the resources from our analysis during the crisis. We looked into providing testing kits, but it was impractical due to low capacity in communities to use a cold chain for samples. We settled on two ares to fund. Given that the Poptun Training center used by GUAMAP did not have screens on all the windows and doors, and that it is the place for health promoters to consult and receive services from, we decided to give a portion of funds to fumigating the center, and having screens installed on all the windows and doors of the large classrooms and dormitories at the training center to make it less vulnerable to mosquitoes.
The remaining portion was spent on ASECSA training workshops for the health promoters in other communities.The local office of the Ministry of health, and the Health Promotion Program of Poptun and ASECSA, the later two are GUAMAP's partners, held training workshops in Poptun to help health promoters distinguish the symptoms of classical dengue and hemorrhagic dengue, and when to refer patients to hospitals. They were instructed in prevention measures, and the groups carried out neighborhood inspections to desroy or burn receptacles that rain can stand in which create mosquito breeding grounds. The Health Promotion Program of Poptun also paid for testing of patients that needed it at private, non-governmental labs. ASECSA-Peten did even more training for 14 male health Promoters and six female health promoters from 17 communities. Like their counter points in Poptun, workshop participants were instructed in distinguishing symptoms of dengue, when to refer patients to hospitals, and they engaged in neighborhood action to remove containers that allow mosquito breeding during the rainy season.