Dengue:

Dropping platelet count no cause for alarm- Government Paediatric Consultant

By Manjula FERNANDO

Somasiri arrived at a private clinic in Gampaha to get his handicapped daughter some medicine for her illness - a persistent cough. He was worried and wished that the bill would be a lesser burden on his already sapped wallet.

Although the nine-year-old is an 'acutely disabled' who is way beyond any hope of restore, it was pretty obvious that the child was the apple of his eye.

But it was not the girl who caught the attention of the sharp-eyed Doctor in charge at the clinic. She had a case of an ordinary viral flu. It was the father who appeared a lot more sick than the child.

Upon inquiries he told the Doctor that he had been having fever for the past few days. The Doctor asked him to get a full blood count and get himself admitted to a hospital. Somasiri who regarded looking after the daughter was more important was very reluctant on the prospect.

The Doctor then called one of his juniors and saw to it that he was admitted to Gampaha hospital.

The blood test revealed that Somasiri's platelet count was an alarming 8,000 - a sure sign that he was having Dengue Fever (DF) or may be the fatal Dengue Haemorrhagic Fever known as DHF.

The doctors at Gampaha hospital were using a novel treatment method based on a technique successfully applied in Thailand to manage the Dengue Fever during its critical phase. Thai practice proved to have brought down the fatalities related to Dengue Haemorrhagic fever significantly in Thailand, where prevalence of Dengue is nine times higher than Sri Lanka.

It was consultant Paediatrician Dr. Lak Kumar Fernando who had returned after undergoing training in Thailand along with eight other consultants learning the novel treatment techniques, who identified the critical signs in Somasiri.

"Hadn't he brought that child to the clinic the father would have most probably died of Dengue," Dr. Fernando told the Sunday Observer. He was destined to live and love his daughter.

The doctors at Ward 11 of Gamapaha Hospital closely monitored Somasiri. Despite his low platelet count he was never given platelet transfusions. Instead they restricted his fluids and monitored the counts. He gradually improved. He is still in the medical ward of Gampaha Hospital. The doctors found that his wife had also been having dengue. She was also treated.

"Platelet transfusions are very rarely needed in the treatment of DHF," Dr. Mihira Manamperi, the Paediatric Registrar of the Gampaha hospital said. He is among the team of doctors who make use of the Thai treatment technique that has been developed after 40 years of research. It has seen a vast improvement in recoveries with regard to worst case scenarios of DHF.

"Platelet counts are a very good indication to determine the phase of the DHF patient - whether he is heading towards the 'critical phase'.

With the reading of the platelet count we can identify if the patient is deteriorating or not, It's the nature's way of sending an SOS."

"We must reassure the public that Dengue is not a disease of platelets. Platelet transfusion is not a treatment method for Dengue."

The Kandy Hospital doctor who died of Dengue recently had recorded a platelet count of 50,000 at the time of her death but in contrary patients with lower counts have survived the disease.

In the case of Dengue there are two varieties, Dengue fever DF and DHF. All patients with just Dengue fever will undergo a 'Feverish Phase' and the 'Recovery Phase'. About half of DF patients record platelet counts below 100,000.

In DHF there is a feverish phase, critical phase and a recovery phase.

The number of patients who suffer DHF is about 100 from 10,000 dengue patients. All DHF patients get their platelets dropping below 100,000.

The critical phase of DHF has to be managed with extreme caution. This is the phase the patients could die due to shock if inadequate fluid is given. But if too much fluid is given during this period, they might go into fluid overload later. During the critical phase that can develop within the 3rd to 7th day of the onset of fever the patients start plasma (the fluid in the blood) leakage through the tiny blood vessels. This phase lasts for about 48-hours. During the height of the leakage (after first 24 hours) the patients could completely leak one bottle of ordinary saline into his abdominal or the chest cavities within 1-2 hours. As a result he would develop breathing difficulties due to fluid in the lungs.

Clinical administrating of fluid is needed to retain the lost fluid in a DHF patient who develop plasma leakage, in order to prevent them going into 'shock'. Shock is one of the two reasons for death in dengue. But during the 48 hour critical phase the IV administration should be done with extreme care and strict supervision of a skilled medical practitioner.

The health Ministry has brought down a special drug Dextran 40 to treat patients in this critical phase. The drug which is also an Intravenous fluid like Saline does not seep through as easily as Saline. Therefore the drug can minimize fatalities caused by fluid overload - the second cause of death in Dengue.

Dengue deaths can be minimised if the patient and the condition is properly managed during the critical stage of the disease, Dr.Manamperi said.

Tests - when and what

* After second day of fever - Check Full Blood Count

* If the test results indicate a drop in white blood cells and platelet count (eg.4000 WBC / 150,000 PLT) see doctor and repeat FBC

* If the platelet count is below 100,000 - see doctor immediately - patient need hospital admission

* The special dengue test in hospitals cannot be deemed accurate since if the patient has had a mild dengue attack recently he may carry antibodies in the blood stream so the test will show a 'positive' reading. Since antibody development will take time, sometimes dengue antibody tests specially the rapid tests will be negative.

Indications

Headache or

severe headache

Lost apetite

Pain behind the eye ball

Red colour rash on skin

Slight nasal or

gum Bleeding

Red colour stools

and urine

* Some of these are

synonymous with

viral flue conditions

as well

Tips for mothers

A lots (reasonable amount) of fluids (electrolyte solutions) like fruit juices, king coconut, and Jeevani should be given. Water alone is not sufficient. Rest during the first few days of illness is a critical factor.

A child or any person with suspected Dengue Fever should be allowed to rest at home. Patients should not be given too much fluid after day 2 of illness because excessive fluids (even oral) can lead to fluid overload in dengue haemorrhagic fever. Transition of dengue from a person to person occurs when the patient has fever. So the patient should be under a mosquito net when he is having fever.

Physical exertion was closely associated with the reported 64 deaths in Gampaha district.(On an analysis of 64 patients who died in 2009, a majority has had excessive physical exertion within the first two three days of illness.) Dengue patients should be kept under a mosquito net to prevent infection to others.

Breeding ground: In most cases dengue breeding ground is in your home itself. If not, it could be your next door neighbour. The doctors say so because the Dengue mosquito cannot fly long distances. So if your child is affected by Dengue there is a breeding ground within your house or property. Start cleaning up!

Papaw juice remedy

No hard evidence has been found to prove that papaw juice boosts your Platelet count. It is not a chance you can afford to take when dealing with a fatal disease like Dengue.

If papaw juice is increasing platelet count alone, without doing any good to other problems of the disease there is a theoretical possibility that this could even harm the patient because dropping of platelet count below hundred thousand is the most useful indicator we have to identify a patient entering the most dangerous critical phase (critical 48 hours) of the illness. If the juice give a falsely high platelet count it may delay or prevent us from detecting the patient entering the critical phase.

Health Snippet:

Why hair turns grey

It is reported that experts are close to discovering what makes your hair turn gray. Although graying hair is the easiest stage of ageing to solve (with hair dyeing) it is often inconvenient because you have to colour your hair so frequently to keep the gray roots from constantly showing up. However, coloring your hair is easy, easier and cheaper than let's say Botox or plastic surgery.

The gray hairs that develop with age really are signs of stress, at least of the cellular kind, say scientists.

Genotoxic stress, namely anything that damages the genetic code of life DNA, causes a malfunction of the cells ultimately responsible for hair colour.

The stress sets off a chain of reactions involving specialised cells called melanocyte stem cells, their work on mice in Cell journal reveals. Similar mechanisms appear to be at work in humans too, they say. The findings could help explain why people with Ataxia telangiectasia, a rare, neurodegenerative syndrome caused by a mutation in a gene called ATM, go grey prematurely. In their study, Dr Emi Nishimura and colleagues found the ATM "caretaker" gene serves as a checks and measures system to stop melanocyte stem cells going awry.

It is the job of these cells within the hair follicles to make the mature pigment-producing melanocytes that give hair its youthful colour.

Damaged DNA

Researchers have already traced graying to the gradual dying off of the stem cells.

But this is not the only way the stem cells are depleted. They also progressively make errors, turning or differentiating into fully committed pigment cells in the wrong place within the hair follicle, where they are useless for colouring hair. And the latest work on mice shows irreparable DNA damage, as caused by ultraviolet light and ionising radiation is responsible.

Dr Nishimura of Kanazawa University said: "Once stem cells are damaged irreversibly, the damaged stem cells need to be eliminated to maintain the quality of the stem cell pool. "We found that excessive genotoxic stress triggers differentiation of melanocyte stem cells." But others believe going gray is caused by a massive build up of hydrogen peroxide due to wear and tear of our hair follicles. The hydrogen peroxide ends up blocking the normal production of melanin, an team of European scientists recently reported in the FASEB scientific journal, published by the Federation of the American Societies for Experimental Biology.

Finding the cure to gray hair would be a miracle come true for most people.

- BBC Health

 'Discipline is the key to curb the dengue problem' - Director of Health Services WP

by Nilma DOLE

Dr. Amal Harsha de Silva

Dengue is Sri Lanka's buzzing topic and as a last resort to prevent a serious epidemic, the health authorities and ministry of health officials have decided to put the nail in the coffin by strengthening the new Public Nuisance Ordinance. "We are in the final stages of implementing strategic measures in getting the public to clean the environment to not only wipe away mosquito breeding sites but to clean the environment," said the Director of Health Services Western Province, Dr. Amal Harsha de Silva. He said drastic steps had to be taken to clean up the city of mosquito breeding sites by issuing a severe fine of Rs. 50,000 if people were found to be dumping garbage. "Often people dump garbage at their neighbour's gate or drive to a different location and dump at other sites. Such people should be fined on the spot for being a public nuisance and not disposing their garbage in a good manner."

Mosquitoes breed in cesspits and even a teaspoon or two of water is a thriving environment for them to breed.

Colombo's population is estimated to be about 6 million and as many as 500,000 to 700,000 mosquito repelent coils are burned everyday in households to keep mosquitoes at bay. Dr. de Silva said, "This is a massive social cost on part of the general public and it is a kind of economic burden when it comes to spending on mosquito prevention measures." In addition to this, burning coils are some sort of air pollution as well which is likely to cause side effects, so people should be aware of the harmless effects coils have.

Speaking about the variety of mosquitoes, Dr. de Silva said, "There are 145 species of mosquitoes where the five major disease-causing ones are the mosquitoes that breed dengue, malaria, filaria, Japanese encephalitis and chikungunya." While there are vaccinations for some of these diseases, the only way to completely wipe out the disease is to clean the environment.

"The Presidential Task Force for eradication of dengue was set up in a bid to totally wipe out the mosquito but there are other matters pertaining to it which is linked to controlling the problem," said Dr.De Silva. He added, "I thank the health officials and public health inspectors for working tirelessly, day and night and even on weekends to ensure that households all across the Western Province have been cleared of mosquito breeding sites."

The Colombo Municipal Council together with public health inspectors (PHIs) have done their duty in serving the public. "Officials such as G.H. Buddhadasa of the Kaduwela Pradeshiya Sabha, Omar Kamil of CMC, Upali Kodikara of the Maharagama Pradeshiya Sabha have been instrumental in helping the public beat the mosquito menace while areas such as Dehiwala, Moratuwa, Wattala need to have stringent measures in place."

Speaking to the Sunday Observer about various scandals and public eye-wash campaigns that have taken place to curb the dengue problem, Dr. De Silva said, "There are plenty of officials who need to be taken to task for not serving the public in wiping out the mosquitoes. Also, just by 'fogging', it isn't sufficient to eradicate the mosquitoes." Grass roots measures need to be in place to control mosquitoes so that there isn't any ability for them to reproduce. "The BTI bacteria isn't enough to eradicate the mosquito problem because it feeds on the mosquito larva and eggs and stops there without propagating. There have been medical experts who have said that they have formulated a local bacteria and we openly invite them if they have a solution that will multiply in a nature-friendly manner without harming the environment and kill mosquitoes," said the doctor.

With about 70,000 people dying of dengue so far, the Ministry of Health has taken strict steps to ensure that every health officials from the lowest to the highest level have been educated and trained on the topic. "At the municipal council level, we have various officials like the divisional secretariat, the respective Mayors, Chairmen of the Pradeshaya Sabhas, Grama Niladhari, the PHIs, MoHs and other health and government agents to help in giving the public sound advice and facilities to stop the mosquito problem."

Dr. Amal Harsha de Silva is optimistic that in six months that the mosquito menace can be brought under control. "We have had a massive response from the public and are happy that they are vigilant in detecting mosquito breeding sites as they play an immense role in beating the dengue fever." He said that it will be a matter of time when the country will be cleaner and a safer place for visitors to see a cleaner and greener Sri Lanka.

"Once we have the new Public Nuisance Ordinance implemented, our country will be better than Singapore and tourists will flock here instead of being discouraged when it comes to sensationalised reporting of dengue. So far, we have managed to keep dengue at bay and we are training our medical professionals in dealing with dengue patients," said Dr. de Silva. Like we have eradicated the war, we are sure to eradicate the mosquito menace too!