Updates on the Epidemiology of Dengue Fever in Chiapas, MX

Well, March 11, 2020 was the date the World Health Organization declared COVID-19 a global pandemic. I recall the director of W.H.O. struggling with the decision for a day or two prior, with the understanding that such a proclamation from W.H.O. carries extreme significance .Last such pandemic was 2009-2010 H1N1 swine flu pandemic, which is already dwarfed by the current pandemic.

That being said, just because a novel virus causes a global pandemic doesn't render the rest of the public health threats obsolete. As a follow up, we are now in week 15 of 2020 and Mexico's Secretaría de Salud has continued to post weekly updates tracking the epidemiology of Dengue Fever throughout the country of Mexico. Thankfully we are currently off-season for Dengue. Here are the last three years of case counts for 2020 (partial), 2019 and 2018:

The seasonal curve for 2018-2019 was significantly higher than the previous year, and I worry that the curve may continue to elevate this year. Of note, the distribution of cases in 2018-2019 was not localized to the state of Chiapas as it was in 2017-2018. It's still too early to tell what will be this year's distribution.

2018-2019 (concentration in Jalisco)

2017-2018 (concentration in Chiapas)

Taking a step back, Macías et al. (2019) observed the hospital burden of Dengue Fever throughout Mexico over 2009-2014 and consolidated this information into a similar graphic, showing a significant and expected distribution of disease burden throughout the southern half of the country.

The troubling aspect of public health is that the most vulnerable populations among us tend to carry the disproportionate weight of disease burdens, and Dengue Fever is no different. As the ecology of the Aedes egypti vector continues to evolve through an ever-changing world, I expect that the COVID-19 crisis will have little influence on the trajectory of Dengue Fever. However, human activity may be significantly altered by the COVID-19 crisis, and that may have myriad possible effects on the ecology of the Aedes egypti mosquitos. As always, only time will tell for sure.


References
1. https://www.gob.mx/cms/uploads/attachment/file/546854/Pano_dengue_15_2020.pdf
2. https://www.gob.mx/cms/uploads/attachment/file/524262/Pano_dengue_52_2019.pdf
3. https://www.gob.mx/cms/uploads/attachment/file/478592/Pano_dengue_sem_52_2018.pdf
4. https://www.medigraphic.com/pdfs/revinvcli/nn-2019/nn193b.pdf

My day today + Running

My Day Today

My friend Félix recently wrote, “If you don’t want to write, you write. That’s how writing works. When every part of your body resists writing, that is precisely when you must write the most. Ancient memories are locked within you, and you must tease them out. If there must be one tyrant in your life, may it be writing.”

Well, I’m lagging in documenting my experiences through this blog. So I figure, to break this dry spell, I will simply tell you about my day today. First of all, today is Monday. I have the day off. Tomorrow there will be plenty of work in the community, collecting epidemiological data by going house-to-house in Rio Florido with Dra. Roberta (a preventative medicine doctor visiting from Spain), Ana Laura (the ethnography specialist on our team) and César (the master’s student who taught me how to ride the colectivo on my first day here). But today, I had the day off.

Today technically started last night while I was watching Annihiliation, a new movie produced by Paramount that had its international rights sold to Netflix, meaning that is only available on Netflix if you are outside of the United States / Canada / China. So, lucky me! Movie was dope. It was kinda scary and surreal and made me think a lot, which is fun. The downside of watching movies past midnight is that, I don’t really know how clearly I was perceiving everything. But that may be an intended side-effect of this film.

This morning, after musing around / wasting away on social media for an hour, I went for a run. I’m actually supposed to be training for my first ever marathon, taking place in San Francisco this Sunday morning. Yikes!!!! So I went on a 7-mile run from my apartment to la Zona Arqueológica de Izapa, which hosts impressive remnants of an ancient mayan civilization.

I want to pause for a moment to talk about running abroad. This is a topic that I have discovered through necessity. There are good rules of thumb to follow, especially when running in an area that’s unfamiliar. I am going to compose a list so that this blog post has a chance of going viral, since everyone loves tiny lists of what to do.

How to run abroad

1. Check the climate of where you are going. For example, if you are going to Tapachula, MX figure out in advance that it is incredibly hot and humid here, and be sure to bring your sweat-ready running gear with you. If you’re like me, and you have a ton of running shirts but forgot to pack any with you, do not mess around with any off-brand merchandise. You need to invest in an authentic dry fit shirt, otherwise you will drown.

2. Snot rockets are obligatory. It’s important for all runners to enjoy launching snot rockets while running, especially after recovering from a cold or illness. This allows you to focus on the most important point…

3. Focus on your breathing. From a physiological standpoint, I have personally decided (i.e. this is not medical advice or even well researched) that focusing on the exhalation is the most important part of the breathing cycle for runners. This has to do with the purpose of exhalation: refilling for your next breath, but even more so, getting rid of excess carbon dioxide. Exhalation literally removes acid from your blood and muscles. So make sure to have strong and extended exhalations at a sustainable rate, each followed by a rapid, full inhalation (which is a lot easier to do without thinking about). Full disclosure, I was first told to focus on exhalation by a lifeguard when I was in elementary school, and it stuck with me. It’s easier to automatically breathe in, so it makes sense to focus on breathing out. However, more recently a neurosurgeon was teaching me about ventilators in the hospital. And by reflecting on this review of respiratory physiology (while running), I figured out that it really makes sense to be sure to blow all the CO2/acid out and keep my muscles working.

4. A good rule of thumb is to run against the flow of traffic. So in México and the United States, that means running on the left side of the road. However, this is still just a rule of thumb. Exceptions include always running on the side walk, if available. And if there is a sharp turn on a narrow road, it is better to be on the outside of the curve, so that the cars are turning away from you rather than toward you. I made these up myself (out of necessity) and they are also not medical advice.

The view from today's run on route 200 east. For example, running forward along the highway (not ideal as there are no sidewalks, but thankfully the shoulder is wide). It might be better to cross the street and run on right side, outside of the upcoming turn, so that the cars are turning left away from me, but I didn't bother since there was no way to cross safely.

Sorry for the bad lighting. This is from a run up to the big cross in Tuxtla Gutierrez. I'm running on the left side of the street, but will cross (when it's safe) to be on the right side for the upcoming turn.

5. Blue gatorade is the best. This thought was implanted into my mind after seeing this video of Steph Curry drinking blue gatorade. Literal mind control, there is no free will (jk). But all this is to share one of two stories of kindness in México, which is in great abundance from my experience. In Tuxtla Gutierrez, I ran a round-trip 10 miles to the top of a mountain where there was a huge cross on the top. I carried $50 pesos in my pocket so I could buy a drink or something. I underestimated how intense the run would be and I was THIRSTY in all caps. At the top of the mountain there was a store. This was the first time I saw blue gatorade during my entire time in México, and I was stoked. I took it to the cash register and asked how much it costs. $10 pesos. “We are in business” I thought to myself as I put my hand in my pocket to find that the bill had gone missing. “Uh oh… I lost my money” I reported to the merchants. “Welp, guess I’m SOL” I thought to myself, as I put the gatorade back in the fridge and made my way to the big cross, which was an awesome site of the big city of Tuxtla Gutierrez. As I was zoning out overlooking the city, I thought to myself, “I wonder if they would give me the gatorade and let me pay them back tomorrow.” It was worth a shot. On my way back, I stopped in the store and asked, and to my surprise, the guy, “sure no problem!” And that was literally the best gatorade I’ve ever tasted in my life. I did the run again the next morning and there was a woman working who had no idea what had happened, but I paid for two gatorades and drank only 1 and knew I had paid my debts, which felt good (in addition to running and getting some hills, like the only hills in the past 6 weeks, oh  the SF marathon is gonna be fun).

Made it to the top!

View of Tuxtla

The best hydration I've ever felt absorbing into my interstitium ever in my life

I initially thought there was no "running culture" here in Chiapas... mostly because there are literally holes in the ground that are hazardous to running gringos like me (i.e. one could easily run into a 5- or 10-foot drop if not constantly observing below one's feet). But then on a Sunday morning at around 7:30am, in front of the Palacio de Gobierno in Tuxtla -- where 5,000 farmers from the highlands of Chiapas once held a huge protest in June of 1994 -- as I was walking out of my hostel, I came across the finish line of a race that takes place every Sunday morning! So it turns out I was completely wrong, there is a thriving running culture here, and next time I should actively try to participate more in that part of life here!

Back to my day today

Well that was a bit of a tangent, but so it goes. Today, I arrived at Izapa around 12:30pm. But when I got there, it was closed!!! I was so disappointed. The man working there told me it’s only open Wednesday - Sunday. I asked, “so there’s no way for me to go in?” He responded, “No.” I asked, “well, can I walk around outside the gate and take some photos?” He said, “Yes, but it’s still closed.” So I snapped some pics...

And as I was about to leave, admitting a mild defeat, a small group drove up in a pick up truck. This changed everything. Here I met Didi Galvez, who is a college student in Tapachula and hosting her friends from way up north along the Texas/México border. She is serving as an informal tour guide and she knows how to get us in. It just costs $50 pesos (roughly $2.50 USD), and we can go in and enjoy Izapa all to ourselves. So thankful that Didi and her friends let me join them. I got to hear her historical account of what went down like 4000 years ago in Mayan society, which was technologically advance enough to have aqueducts for communal water access, common spaces for rituals and prayers, and definitely art carved into stone. Back then, they enjoyed products of the cacao tree, which fit perfectly with the warm and wet climate of this region of Soconusco. To that end, this site requires extensive maintenance to keep the plants from overgrowing the ruins. Only a small fraction of the site is currently available for viewing, as the rest has been overgrown and is not maintained because there is not adequate staff. Here are some photos from the visit:

Serpent head 

Water is life

Waves of water at the bottom

Toward the end of our informal tour, Didi and I were talking and exchanging our brief stories. It turns out, her husband works closely with Réne, the husband of my boss at Ecosur (Dra. Ariane). Small world!!! Afterwards, Didi and friends were so very kind to allow me to ride back to Tapachula with them in the back of their pickup truck. They invited me to join them to go swim in the river, but I declined, I felt that it was important for me to “get something done” today, even though it is a day off.

I went home. Ate an ice-cream cone on the way home, amazing relief. It is so hot and so humid here, all the time. Showered. Ate some lunch. Read a couple more chapters of East of Eden, which I’ve been reading with great reverence, especially after having worked and lived in Salinas during the past year. I went to my favorite coffee shop. I called my representatives in congress to support the new formation of a Medicare For All Caucus in the House of Representatives. I checked in with mimentor.org where I’ve had an account for several years, and reconnected with some people I hadn’t talked to in a while. I made like zero progress on my massive email inbox that I’ll eventually have to take care of. Sorry if I owe you a reply! I opened some more tabs of articles to read. And I wrote this blog.

Better to write, I think. It feels good to have this written in a secure format (i.e. personally backed up on my computer, rather than just here in blogger), so it cannot be erased like the last blog post (or my journal which was stolen about a year ago). There is vulnerability in writing, but also great privilege. If you’ve actually read this far down the page, I am grateful for your time and energy, and I hope we can keep in touch.

A final plug. This report on the Chut Pyin Massacre against the Rohingya in Myanmar, Bangladesh is immediately next on my reading list. Though I still haven’t finished reading this report on the human rights violations and injustices committed in Chiapas during the 1994 Zapatista uprising, I am learning how to navigate such human rights reports, which are documents that I haven't encountered before. "Learning how to learn" from these documents is my goal. It just doesn't seem very intuitive to me so far, so I'm going to try and really dive in during the remaining free time I have, and hopefully connect some dots. So I will read the Chut Pyin Massacre report report before posting my next blog post, hopefully by this Wednesday, the 25th of July, 2018 years after the common era / christ…

-Matt

Making a tiny impact from Tapachula

La Biofabrica

After taking a slightly tangential detour in Jaltenango de la Paz, I’ve resumed my work in El Equipo de Sueño — El Equipo de Zancudo Estéril con Dra. Ariane, Ana Laura y César y mucho más. After our last reunión in Rio Florido, we had a gathering in the Biofabrica yesterday, which went well. And we have a meeting with the women of Ejido Hidalgo tomorrow. It’s an action-packed week!

The Biofabrica is a special place where the sterile mosquitos will be grown. They are currently refining the techniques of rearing males of the Aedes egyptii vector species. Males are selected based on the size of their pupa using water chromatography. The reason we want males is that they do not bite, so they cannot be a vector. By releasing sufficient quantities of sterile males into the environment, the females should be "occupied" in exchanges that result in no offspring to an extent  that the population goes down, and the incidence of diseases like Dengue go down.

Separation by size... water sprayed at the top
Female pupa are the largest
Male pupas are in the middle
Larvae are the smallest

Me in the Biofabrica

Mosquito Life Cycle

As you may recall from my past post Community Meeting at Rio Florido, two areas I focused on for improving were (1) the question over when should someone with suspected Dengue go to the hospital, and (2) how to generate more dialogue among the group during these meetings. Later, during discussions with Dr. Ariane and Ana Laura, we noticed that more men were speaking up (among those who did speak up) than women. And I offered an idea: what if we had a meeting just for women? And now that’s happening, and I’m in charge of an activity. Oh god, what have I done?

The activity I’m leading tomorrow consists of splitting up the women from Ejido Hidalgo into small groups of 4-5 people and discussing things they like, dislike, don’t understand, or would like to see implemented in order to improve our project. I will start with an icebreaker of talking about our favorite color. I’m excited, scared, and ready to give it my all!

Also, with help, I prepared a handout guide for when to go to the hospital, in response to the lengthy Q&A session we had on this topic at our last meeting. It can be scary or confusing when a member of the family is sick. By collaborating with Dra. Romero and the rest of our equipo, we were able to come up with this table that hopefully clears things up a bit:

Draft of handout I made on when to go to the hospital if you have symptoms of Dengue Fever

That's all for now. Today I thought I finished my blog post summarizing my trip to Jaltenango but it got deleted, so I'll have to rewrite that from scratch. But in the meantime, there's a lot going on in Tapachula, and I'm grateful to be able to play a small role in this public health project.

Salud para la gente!

Tree in the middle of the road near my house in Tapachula

clarifying incidence of Dengue in Chiapas

I've been meaning to write this for over a week. Can't keep ignoring this blog! Thankful that Touro has decided I can use this blog to satisfy some of my requirements for this field study.

Last week, I thought was hearing mixed messages about how bad Dengue is this year. Clearly, it's bad -- many more cases are falling into the serious categories of Dengue Grave ("Serious Dengue" - likely lethal) or Dengue con Signos de Alarmo ("Dengue with alarm signs" - when abdominal pain and vomiting appear with transaminitis from liver inflammation, low platelets - responsible for the potential hemorrhagic/bleeding component of the disease, high hematocrit, third-spacing with fluid in the abdomen or lungs, in addition to the regular awfulness of the least serious classification Dengue no Grave or "non-serious Dengue").

So in my work in the community and hospitals, I've heard the number of cases is much higher this year than last year. Yet, last week when I did the literature search and compiled some information from the Secretaria de Salud's Panorama Epidmiologia de Dengue, I thought it showed the opposite:

As you can see, at the time I compiled this table, it was week 25 of 2018 for tracking the Epidemiology of Dengue in Mexico, which the Mexican government takes very seriously. This is why there are doctors like Dra. Romero at Hospital General de Tapachula whose focus is to track the cases of Dengue and other infectious diseases (e.g. Tuberculosis). But, I was perplexed to see the incidence of Dengue appearing far, far lower this year, even in Chiapas... However, it was my mistake. The 778 should have also been in the far right column under 2018, and that would have shown me that there is nearly double the incidence of confirmed cases of Dengue in Chiapas so far.

I caught this error while checking up on week 26 this morning, which now shows a clear increase in the incidence of Dengue within Chiapas this year:

From week 25 to week 26, the % increase in annual incidence up to that week between 2017 and 2018 has increased from 92% to 93%. The Dengue season has started earlier this year, the cases are more severe, and the children are affected most. Below, the graph to the right shows a much higher prevalence of more serious cases of Dengue among children aged 5-9 years old:

Panorama Epidemiológico de Dengue 2018, Publicación Actual (05 julio 2018), Semana Epidemiológica 26

This unfortunate view of the problem helps to highlight the serious nature of this disease for the people of Chiapas. It provides motivation to me to do what I can to contribute to the success of the project to use Sterile Insect Technique to reduce the population of mosquito vectors in this area. I hope to further clarify the situation using local/regional data soon.

Community Meeting at Rio Florido

español: Comentario sobre la reunión comunitaria con Rio Florido el 30 de junio de 2018

La reunión se llevó a cabo en un "centro comunitario" en un formato que parecía normal. Había 28 personas presentes, como cuentan en la asistencia principio. El presidente de Río Florido dio palabras de introducción y luego Dr. Ariane y Ana Laura anunció el plan para la reunión.

La presentación fue sin problemas. Las hijas de Dr. Ariane y Ana Laura eran jóvenes y enérgicas, lo cual es saludable, y esto no interrumpió la presentación, que se centró en las actualizaciones del Proyecto Zancudo Estéril.

Hacia el final, tal vez 20 minutos después, hubo tiempo para preguntas, comentarios y preocupaciones de la comunidad. Esta parte de la reunión fue interesante porque escuchamos cómo se siente la comunidad, lo cual es importante porque la gente de la comunidad son esencialmente nuestros jefes, ya que nuestro equipo trabaja para la gente de Río Florido y Ejido Hidalgo (además del público en general, que tiene un interés en controlar estos mosquitos vectores).

Una preocupación recibió más atención de lo que esperaba: ¿cuándo es apropiado enviar a alguien con sospecha de fiebre de dengue al hospital? Creo que este es un área lista para una "intervención," como la creación de un folleto promocional para regalar a las personas que deja en claro cuándo llevar a alguien al hospital. tal vez esto ya se haya hecho. Si no, quizás es algo en lo que puedo trabajar para crear.

En general, la reunión fue exitosa y eficiente en la comunicación de información importante. Si pudiera cambiar una cosa, agregaría algún tipo de componente interactivo durante la mitad de la reunión, para probar la comprensión y obtener ideas de la comunidad sobre cómo hacer que el proyecto sea aún mejor.

íngles: Commentary on the Community Meeting with Río Florido on June 30, 2018

The meeting took place in a "community center" in a regular format (it seemed like they held similar meetings frequently). There were 28 people present, as counted at the beginning attendance. The president of Río Florido gave introductory remarks and then Dr. Ariane and Ana Laura announced the plan for the meeting.

The presentation went smoothly The daughters of Dr. Ariane and Ana Laura were young and healthy, which is healthy, and this did not interrupt the presentation, which was focused on the updates of the Sterile Mosquito Project.

Toward the end, maybe 20 minutes later, there was time for questions, comments & concerns from community. This part of the meeting was interesting because we listened to how the community feels, which is important because the people of the community are essentially our bosses, since our team works for the people of Río Florido and Ejido Hidalgo (as well as the general public, who have an interest in controlling these vector mosquitos).

One concern received more attention than I had anticipated: When is it appropriate to sent someone with suspected Dengue Fever to the hospital? I think this is an area that is ripe for intervention, such as creating a promotional brochure to give to people that makes it clear when to take someone to the hospital. Maybe this has already been done. If not, maybe it's something I can work on to create.

In general, the meeting was successful and efficient in the communication of important information. If I could change one thing, I would add some kind of interactive component during the middle of the meeting, to test for understanding and get ideas from the community about how to make the project even better.

a public health challenge

Today I woke up having slept perfectly for about 7 hours. This is no cupcake given the constantly humid 80-degree air (in fahrenheit... equal to 26.7 celsius). Although I lucked out by arriving in Tapachula a little bit late -- late for the hottest weather of the year in April/May -- I unfortunately also arrived late for a golden opportunity in community engagement at the schools of Rio Florido and Ejida Hidalgo. Kat & Peter were lucky enough to participate in the Puppet Show Patas Rayadas Enamorados and explain through puppet-acting to the children in these communities how mosquito lifecycles work and how they (right now... as kids of the community) can help reduce the incidence of mosquito-born illnesses like Dengue Fever, Chikungunya, and Zika Virus. That said, I take solace in having slept soundly through the night without being drenched in sweat. This is in part thanks to the heavy rain of yesterday afternoon, captured below:

~4:30pm on 27 Jun 2018 at Hospital General de Tapachula 

But I am left with a predicament. ECOSUR's Equipo de Zancudo Transgénica (Dra. Ariane Dor, Ana Laura Pacheco y César) have concluded their Puppet Shows, because the schools are no longer in session due to summer break. There are a couple of community meetings planned, but I am here to work "full time" as a public health professional; this means I must find ways to gain experiences in Public Health outside of the pre-arranged means. Thanksfully, I am connected with Dr. Rogelio Danis at INSP/CRISP. This opens the door for other opportunities in public health experiences.

Every afternoon I can work with Dra. Daenna Romero in Hospital General de Tapachula. As an epidemiologist in México, Dra. Romero is both a physician and a public health professional. Each day we collect information on patients' progress, particularly those with Dengue Fever (which is currently experiencing a large outbreak in this region). Although the incidence of dengue in México may appear unimpressive at first glance, and it's true that the incidence has gone down considerably since 2015, this year it is highly concentrated in the state of Chiapas:

From Panorama Epidemiológico de Dengue 2018 - Semana Epidemiológica 25

And that is why making information accessible to the people in the affected communities is so crucial, and I'm so sad that I don't get to make a fool of myself puppet-acting in Spanish at the schools in Chiapas. But maybe there will be other opportunities for health promotion activities soon. Right now we're waiting for the election (this Saturday) before doing more outreach. In the meantime, enjoy this PSA:

Campaña de Prevención del #Zika, #Chikungunya y #Dengue 2017

Beginning words

Writing from my apartment in Tapachula, a bustling city near the very southwest tip of Chiapas, the southernmost state of Mexico. I have spent the past week here, and it is with much excitement that I still have another 5 weeks of living and working here, as part of my Public Health Field Study.

There are a number of established sites around the world where public health students at my school may go, but I have wanted to come to Chiapas ever since reading my step-grandmother June Nash's essay in Cultural Anthropology. So I am the first student from TU to complete an MPH Field Study in Chiapas. That said, about a year ago, Martha Benitez (an OG) did a Global Health rotation here as part of the College of Osteopathic Medicine (COM). The difference between that and what I'm doing is the intended nature of the work. For a medical rotation, the goal is to see healthcare in action internationally, to gain clinical experiences. In a public health field study, the work is generally anything but clinical. For me, I'm helping build a community engagement project to use the Sterile Insect Technique and help reduce the population of Aedes egypti mosquitos, the vector for Dengue Fever, Chikungunya, and Zika Virus.

This is actually my second time in Chiapas. After planning this trip, my partner Diana and I visited this past January for a few days in San Cristóbal and an excursion to Hospital San Carlos in Altamirano. I would say it is half coincidence, half intention. It's nice to be back and It's a lot easier having some experience of the way things move here.

On my arrival this time, there were two other students here from Touro already: Peter & Kat. They started an awesome blog for the COM Global Health program during their month here. Below is a multidisciplinary team photo after breakfast with some folks at ECOSUR, some folks at INSP/CRISP, and us medical students from TU.

Upper Left: Peter & Kat. Upper Right: Erica and myself

Bottom Left: César and Ariane. Bottom Right: Ana Laura and Iliana.

So this morning: I woke up, cleaned up, created this blog... all before 8:45am !!! And now it's time to start the day.... more on what that entails to come!