HEALTH: If bites could kill

(Second of Three Parts)

In 2015, the dengue mortality in the Philippines reached 600 – that’s 0.35% case fatality rate (CFR). “(The figure) is basically very high because in comparison to other countries, the incidence would have supposed to be lesser if we use their CFR,” says Dr. Richard T. Mata, who serves as the official consultant on dengue prevention and control at the Department of Health.

“If we use Singapore’s CFR which is only .035%, the deaths could have only been 70 and not 600 for the Philippines,” he contends. “By using Thailand’s CFR of .09%, the dengue mortality rate in our country would go down to 180 instead of 600. Malaysia even has a lesser CFR of 0.28%, which means there could be 560 deaths than our 600.”

“Dengue fever is a dreaded disease but the majority of deaths are actually preventable,” says Dr. Mata, a pediatrician who has a clinic in Panabo City. “Caring for dengue patients have become almost an everyday task,” he admits.

Even before he was tapped by the health department, Dr. Mata is already known for his anti-dengue advocacy. In fact, he makes his own website – www.solving-dengue-fever.com, which he updates regularly – to educate thousands of people around the world on the truth about dengue fever.

Hydration

“There is a big information gap between the public and the medical professionals,” he points out. “The public believes that the main cause of dengue deaths is the decrease of the platelets while medical professionals know that the deaths are due to the complications of the plasma leakage that causes severe dehydration that results to multi-organ failure.”

This simply means that dengue fever is all about: the dengue-carrying mosquitoes live in the water and the solution to the problem is also water. “It’s about hydration,” says Dr. Mata with conviction.

What actually he is point out is the process of providing an adequate amount of water to body tissues of a dengue patient. “In dengue, our blood vessels will appear to have some holes through it and so the fluid, which we call as plasma, leaks out and causes dehydration among patients,” he explains.

But it’s not only water, which plasma contains, that comes out but platelet as well. “This is the reason why the platelet decreases because it comes out of the holes of the blood vessels,” he says.

Dr. Mata says that just like an ordinary wound, the blood vessel holes heal within six days. “That’s why in dengue, the platelet is observed to have decrease until the sixth day of fever and from there, the platelet starts to increase again as the holes begin to close,” he says.

What really kills a person with dengue is not due to low platelet counts but dehydration. It occurs when a person loses more fluid and his body doesn’t have enough water and other fluids to carry out its normal functions. “Dehydration is the killer,” he declares, “low platelet is only secondary.”

Dr. Mata explains that even if the platelet continuous to decrease each day for as long as the patient is fully hydrated with dextrose and oral fluids, the patient is safe. “The best indication the patient is fully hydrated is that he keeps on urinating with an interval of one to three hours,” he says. “If the patient does not urinate for more than 5 hours and looks very weak and sleepy, he can be in a brink of either hypotension (low blood pressure) or kidney failure.”

Low platelet

To further explain the dengue problem, he talks of another disease called idiopathic thrombocytopenic purpura (ITP).

“This is a disease where in the child has a low platelet from weeks to years in duration,” he explains. “I have some patients who have this disease. Some will have platelets as low as 10 or lesser, but once you see them you can’t believe that their platelets are that low. They are still playing and active despite the fact their blood platelet status is low.”

The ITP patients may have low platelet count “but they are not suffering from dehydration, which is not part of ITP but it is present in dengue cases.” According to him, “if an ITP patient will develop severe diarrhea and will not be brought to the hospital, he or she will develop severe bleeding just like dengue.”

In simpler terms, it’s the fluids that matter. “The low platelet will only cause harm if the patient is dehydrated,” Dr. Mata says.

Here is his brief explanation on the matter: “The truth is that even if the platelet of a dengue patient is low, but as long as the patient is properly hydrated, the patient will not give us any problem. Therefore, we need to bark at the right tree, the right tree is the fluids and not the platelets.”

In his experience, Dr. Mata discovered that dengue comes in various types. Not all dengue cases are created equal. “Some are very mild and some are very strong,” he says. “To understand it, we need to still look at it in the degree of fluid dehydration. The ones that are mild are those not so dehydrated and those that are toxic are those severely dehydrated.”

Now, going back to his “theory” about those holes in the blood vessels of dengue patients, thus causing the fluids and platelet to sip out. He classifies dengue into mild, moderate, severe and very severe. “What made these dengue types different from each other are simply the sizes and the amount of the holes it gives the blood vessels of the patient,” he explains.

To illustrate, he used a plastic bag filled with water. “If I will use a needle and put a few tiny holes through it, will the water inside drain immediately?” he asks. “Certainly not. This is therefore the mild one.”

Drinking water

According to him, drinking lots of fluids can easily compensate the minute loss. “That’s why you can hear dengue patients who survived without even being admitted in the hospital, they fortunately have small holes,” he says. “But what if I will use a nail and place holes in the plastic bag? Of course, the leaking will be faster and sooner than you expect. If only all dengue patients come in with tiny leaks in their blood vessels then everything will be easy and not messy.”

It is in those having big holes that water replacement is a necessity – and immediately. “It will just be a matter of time the patient will dehydrate that can cause the kidney be damaged and result to other organ failures,” Dr. Mata says.

This is the reason why dengue is very different from diarrhea, which is also a disease of dehydration. “In diarrhea, you can easily estimate the amount of fluids that goes out with stool and thus estimate the amount that is needed back to compensate the loss,” he says. “In dengue, you cannot see the fluid coming out literally because the plasma leakage only brings the fluids outside the blood vessels but still inside the body.”

This is what Dr. Mata believes: “The majority of dengue deaths are caused by lack of fluids that come in compared to the amount of fluids that come out of the blood vessels.”

There are those who believe that other dengue deaths are due to too much fluid that caused congestion in the lungs. His answer: “Congestion in dengue is caused by lack fluids in the first days of illness causing kidney failure which resulted to inability of the body to urinate. The outcome: congestion. Thus, it is still dehydration to begin with. Solving this balance will solve dengue.”

There are also those who think some dengue patients die because of low platelet which causes gastro-intestinal bleeding. “Those deaths were not really due to low platelet but due to dehydration that cause low blood supply to the intestines. This causes ulcer formation that resulted to bleeding and plus the fact that there’s a low platelet the bleeding won’t stop. But if there was no dehydration – even if the platelet is less than 10 – the patient will still not develop intestinal bleeding. I have proven that so many times in my practice,” Dr. Mata assures.

Although there is now a vaccine for dengue, there is still no specific treatment for the disease.

But Dr. Mata recommends aggressive fluid replacement. “Dextrose plus oral fluids is the key,” Dr. Mata suggests. “If the patient is already admitted, he needs to continue taking oral fluids like Oresol and water to push him to urinate at one- to 3-hour interval.” – (To be concluded)

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