The Need for a "Culturally-connected" Public Health Infrastructure at the Local Level

Ronald D. Warner, D.V.M., M.P.V.M., Ph.D., Associate Professor, Department of Family and Community Medicine, School of Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas

Many epidemiologists and other health care workers fear that dengue fever may become the next major plague of the Western Hemisphere. Dengue fever is often misdiagnosed as "flu" or "viral syndrome." There is no vaccine to protect against it and infection by more than one of the virus's four serotypes often leads to very lethal consequences: dengue hemorrhagic fever (DHF)/dengue shock syndrome (DSS). The only "defense" is avoiding exposure to the two mosquito species that vector the virus to humans. This includes education of the human population and denying local breeding and larval habitats to the vectors. Community experience with "anti-dengue" education and sanitary interventions in the Brownsville, Texas area are subjects of an article in this issue of the Texas Journal of Rural Health (Winn, Dennis, Paine, Warner, & Hayes, 2002). Dengue is the most common and widespread arthropod-borne viral infection in the world. Before 1970, only nine countries had experienced DHF; that number has increased more than four-fold and continues to rise. The pandemic in 1998, in which 1.2 million cases of dengue fever and DHF were reported from 56 countries (in the Americas, Western Pacific, Southeast Asia, and Eastern Mediterranean), was unprecedented (World Health Organization, 2002).

In mid-January 2002, Cuba began an emergency campaign to contain the worst outbreak of dengue fever since 1981, when 158 Cubans died of the illness. In 1997, an outbreak in one municipality (Santiago de Cuba) resulted in 3012 confirmed cases, 205 of which were DHF/DSS and 12 fatalities were officially reported. President Fidel Castro presided over a ceremony on January 11, 2002 and declared "war" on the insect vector, launching fumigation brigades. "I have been hearing about more and more hemorrhaging cases," a Havana hospital employee said. "If Fidel is getting involved, you know the situation is serious" (ProMED Digest, 2002a). On February 2, 2002 Castro was reported to have said, "By November 28, 2001, 1601 cases had been reported in Havana. After that, the situation became worse. Unfortunately two people have died, but no children" (ProMED Digest, 2002b). Cases had been reported from 95 of Cuba's 165 municipalities as of January 1, 2002. This current epidemic in Cuba is due to dengue type-3 virus, which is the type also responsible for a burgeoning epidemic in Brazil.

Public health officials in Rio de Janeiro have been alerting the public as cases of dengue fever steadily increase in 2002. As of February 5, 2002, six deaths from DHF have been reported in Rio. Of nearly 5,880 infected in Rio, 108 had been diagnosed with the hemorrhagic form within the metropolitan area and doctors were investigating more "suspicious" deaths; health authorities had confirmed approximately 12,975 cases of dengue statewide (ProMED Digest, 2002c). In the entire country of Brazil, the number of cases rose from 240,00 in 2000 to 391,000 in 2001, with heorrhagic cases increasing from 51 to 675 and attributable deaths rising from 3 to 28. Venezuelan health authorities released a report, as of January 19, indicating that 4,733 people had contracted dengue fever in the first days of 2002, 10% being DHF, with no deaths reported. The "under-15" age group was most affected, comprising 54% of the cases (ProMED Digest, 2002d). This is an extension of an epidemic that began in 2001.

Dengue fever is not considered a priority agent for bioterrorism, but if local health authorities were better equipped to routinely deal with outbreaks of this disease and other naturally occurring problems, they would be better able to deal with intentionally-propagated disease outbreaks and disasters. \line There is little doubt that additional United States federal monies will flow to state health departments, especially after September 11, 2001, for building and enhancing the public health infrastructure. Dr. Jeffrey P. Koplan, Director of the Centers for Disease Control and Prevention (CDC), recently addressed state health officials to share his views on being prepared for public health threats and emergencies. Dr. Koplan outlined seven priority areas for "capacity-building (Koplan, 2001)." I will not discuss all seven in this brief space, but I will highlight the ones I feel are most important at the local (city and/or county) level:

1. A well-trained, well-staffed, local public health workforce, which is the basis of any adequate public health system.
2. The workforce needs to be equipped to conduct reliable "grass roots" surveillance and field epidemiology. The ability to rapidly detect health threats is essential.
3. The local public health workforce must also be provided with equipment that facilitates secure, two-way, swift communication in order to provide accurate, timely information to citizens; advice about local public health emergencies to policymakers; and routine preventive medicine messages to their community.
4. Each community needs adequate preparedness and response capabilities to minimize morbidity and mortality until outside assistance, if needed, arrives.

I trust that as increased federal dollars are funneled to the local level, there is not excessive program skimming or subject-matter layering at the state level. Local health departments must have the ability to build and sustain the four areas highlighted above. The state's primary role should be the provision of adequate regional laboratory capabilities, accessible and secure information systems, and the evaluation tools necessary to ensure that the local community can make the most adequate "first response" that is possible.

Local health department administrators should not assume that all the funds they need will come from state, CDC, or other federal sources. Dr. Koplan provided examples and indicated that "leveraging" is very important in building, sustaining, and enhancing public health programs. In communities such as those Winn et al. studied, local health departments might be able to work with recycling companies, for example, to provide facilities and incentives for citizens to routinely remove plastic, glass, and old tires from their neighborhoods, thus denying breeding/larval habitats for mosquito vectors.

The World Health Organization (WHO) has summarized the conditions most likely related to the resurgence of dengue fever. During the past 50 years, the world's population has more than doubled, most rapidly in the tropics and subtropics. Rapid and continuing rural-to-urban migration has resulted in more unreliable potable water supplies (residents collect and store water) and poor storm water drainage on urban "fringes," and there has been a huge increase in solid waste (plastic, glass, and tire casings) from new consumer "habits." Some of these conditions are also problems in rural areas. When such conditions combine, they favor the transmission of not just the dengue virus, but also St. Louis encephalitis virus and West Nile Virus, which some project will reach Texas in 2002. The magnitude of public health problems will increase unless there are adequate and more-effective local public health measures in-place. The WHO (1999) has highlighted two areas that correspond directly with Dr. Koplan's comments:

• Epidemiology/surveillance, especially entomological surveillance and monitoring human behaviors (inappropriate disposal of discarded household items such as plastic, glass, furniture, and appliances);
• Communication, a culturally appropriate package of guidelines, "tools," and approaches for the control of vectors and prevention of exposure to their bites at the individual, household, and political (community) level.

It is my fervent hope that both legislative representatives and public health policymakers see the need for, and ensure the adequate funding of, appropriate "culturally-connected" public health infrastructure elements at the local level. Only through such means will we all be empowered to protect ourselves as early, quickly, and thoroughly as possible.

References

Koplan, J. P. (2001). Building infrastructure to protect the public's health. [On-line]. Available: http://www.phppo.cdc.gov/documents/KoplanASTHO.pdf .

ProMED Digest (2002a). Cuba: Biggest dengue fever outbreak since 1981. [On-line]. Available: http://www.reutershealth.com/frame2/eline.html (archive # 20020115.3265).

ProMED Digest (2002b). Cuba: Hundreds sick in dengue outbreak. [On-line]. Available: http://www.promedmail.org (archive # 20020209.3520).

ProMED Digest (2002c). Rio de Janeiro: Dengue fever outbreak update as of Tue 5 Feb 2002. [On-line]. Available: http://www.promedmail.org (archive # 20020209.3520).

ProMED Digest (2002d). Venezuela: Dengue/DHF, epidemic activity update. [On-line]. Available: http://www.promedmail.org (archive # 20020115.3265).

Winn, B. F., Dennis, P. A., Paine, R. R., Warner, R. D., & Hayes J. (2002). Dengue fever in the Lower Rio Grande Valley of Texas: Medical anthropology and public health. Texas Journal of Rural Health, 20(1), 20-33.

World Health Organization (1999). Report of consultation on strengthening implementation of the global strategy for prevention and control of dengue fever. Geneva, Switzerland: Author.

World Health Organization (2002). Dengue prevention and control. Weekly Epidemiological Record, 6(8), 41-44.