National team enters
fray to stop
dengue outbreak

The disease center officials
will aid local doctors in controlling
the spread of the virus

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By Helen Altonn
haltonn@starbulletin.com

A national team with expertise in dengue fever is joining state health officials in their battle to control an outbreak of the viral disease on four islands.

The head of the dengue branch in the Centers for Disease Control and Prevention's epidemiology center was expected to arrive late today with three Epidemic Intelligence Services officers, said Dr. Paul Effler, chief of the state Health Department's Epidemiology Branch.

Two CDC officials already have arrived -- a senior entomologist who specializes in mosquitoes and an Epidemic Intelligence Services officer who is working with the entomologist and the health office on Maui.

Effler, a former EIS officer with the CDC, noted that he was once sent to Hawaii on a disease outbreak. They want to help Hawaii and "they work really long hours," he said.

Since some clinics weren't open yesterday, the numbers of cases remain about the same. On Friday the Health Department listed 26 CDC-confirmed dengue fever cases, all on Maui, and 115 suspected cases scattered on Maui, Oahu, Kauai and the Big Island. Of those, nine tested positive in preliminary screening.

Effler said doctors have reported nine other potential cases, five on Maui and four on Oahu, but most don't meet the clinical definition of dengue.

Opinions of federal experts differ on the seriousness of the outbreak, he said, explaining it's difficult to make predictions.

There may be continued imported cases with infected travelers arriving from Pacific and Southeast Asia areas with dengue epidemics, he said, noting one of the latest patients recently was in Sumatra.

Also there can be a gap in people showing up with the illness because not all of them get sick, he said.

Nonetheless, a mosquito that bites an infected person, even without symptoms, can pass it on, he said.

The outbreak developed in East Maui but there was no evidence of it until one of the infected residents went to a doctor in September, Effler said. The Sept. 11 terrorist attacks delayed shipment of a blood sample to the CDC dengue lab in Puerto Rico. It was confirmed Sept. 21.

In investigations of that case, health officials learned of about 20 other people in East Maui who began having dengue fever symptoms in June but never went to a doctor. As a result, they weren't reported, Effler said.

"It's not that we knew about it in June and didn't do anything about it until September. We started working on it but there was no evidence until Sept. 21."

In backtracking, he said the DOH has to rely on the accuracy of people in describing when they were sick, what the illness was like and results of their blood tests.

He said it would be interesting to go back further "but at this point, we're in a control mode."

Very few Hawaii patients are children, Effler said, explaining it's a misconception that dengue is a disease of children. He said 85 percent of children infected have no symptoms. However, children more often have negative reactions to a second infection in places with dengue epidemics.

The state has urged all residents to eliminate any potential mosquito breeding sites and city refuse crews will help. Starting tomorrow, they'll pick up tires, rubbish, containers and objects that hold water. Residents can call 523-CITY (2489) for assistance.

Effler said he has sent blood samples to the Tropical Retrovirus Research Laboratory at Leahi Hospital to try to isolate the virus.

The lab once was a world-famous research facility for dengue fever. Now it works primarily on HIV.

Dr. Rick Yanagihara, the laboratory director, said it isn't adequately equipped to isolate dengue, which requires inoculating live mosquitoes. "We went ahead and resurrected some cell cultures that support growth of dengue, but no cell cultures are as good as live mosquitoes."

Effler said he hopes to reestablish the laboratory's dengue research capabilities. "Any time you are shipping (blood samples) all the way across the hemisphere to another lab, you've got delays that could be avoided if you have local capacity. With our geographic proximity to the rest of the Pacific, it is important to work on diseases in the Pacific."

The Hawaii outbreak is of particular interest because it's the first known here in 50 years. "We know people have come in and had it in the past, yet we haven't had a spread, so there is something about Hawaii probably favoring control," Effler said. "We just have to exploit that."

Yanagihara also said there are many questions about the island cases, "not the least is, 'why now, as opposed to before?'" Since none of the cases has been very severe, he added, "One wonders if maybe it is just a matter of viruses adapting more readily to albopictus."

The Asian tiger mosquito, Aedes albopictus, is the dengue carrier here while the major fly spreading it in other regions is Aedes aegypti.