By Tyler M. Sharp, PhD
Before we left off in Part 1 I had just gotten on a boat to visit a small atoll in the Marshall Islands affected by the dengue outbreak…
A few days earlier we had identified a small cluster of cases on Arno, a small atoll about 30 miles from Majuro. I traveled by boat to Arno where I was able to provide clinical education, help the health assistants set up surveillance, and teach them how to use the dengue rapid diagnostic test. The hours on the boat gave me plenty of time to relax, think, and plan my next move: something that I probably would not have done if I had stayed in Majuro. Luckily, my WHO colleague had much more experience in emergency management than I, and he had done an excellent job of getting things under control back at the hospital.
First, the hospital exercise room had been transformed into a dengue ward. This was an area where dengue patients could be given dedicated attention and not mixed in with other patients, allowing nurses to keep a close eye on any cases that might need immediate attention. In short order, the maintenance staff got the exercise equipment moved out and moved in cots, IV stands, and even to got the bed nets we’d brought strung up over the patients’ cots. This was to prevent mosquitoes from feeding on dengue patients and then later infecting others in the hospital.
Meanwhile, the mosquito guys from CDC had been surveying the local community for mosquito breeding sites. In short, they were finding mosquitoes that transmit dengue everywhere they looked. The local Environmental Protection Authority was therefore working with the Navy and Army teams to eradicate mosquitoes from the community and remove any remaining water containers where the bloodsuckers could breed. They sprayed in schools, churches, the hospital, and other areas of the community where people gather. After finding a few large piles of tires, which are a favorite breeding site for the mosquitoes that transmit dengue, Japan assisted in fixing the tire shredder at the local dump to destroy the tires. The Australian Aid Agency also provided funds to assist in the eradication effort. Thus, from both the community and hospital sides, a relatively smoothly operating, dengue-fighting machine was beginning to form in Majuro.
Our next concern was Ebeye, a small island immediately next to Kwajalein Army Base and about 45 minutes by plane from Majuro. Ebeye has a total area of 0.12 square miles and about 11,000 residents, equating to a population density greater than Manhattan. Because population density is one factor that contributes to dengue outbreaks, if the virus were introduced into Ebeye and the hospital and community wasn’t prepared, there could be thousands more cases.
When I arrived at the hospital in Ebeye, I was pleasantly surprised. They had already formed a Dengue Task Force to prepare for the outbreak, including contingency plans for various scenarios of when and how cases might arrive and where they would put them in the hospital. They had also initiated public health awareness messaging and island-wide clean-up campaigns to eliminate water containers where mosquitoes were breeding. I gave the dengue clinical case management course and threw in a couple suggestions during the response planning, but by and large the team in Ebeye had the situation well under control.
Day 29. Case Count: 751
After more than two weeks, things were finally beginning to look better in Majuro. There were half as many cases presenting per day as there had been a week ago, surveillance was in place on the various islands, and the physicians were showing up smiling and well-groomed, suggesting that they’d finally had a chance to get more than a few hours of sleep. Even better, the Taiwanese Embassy had arranged for some basic medical supplies and mosquito repellent to be sent to assist in the response efforts. But then, on the day that I was planning on leaving, word came that there were new cases
on Ebeye and Utrik, an atoll some 500 miles north of Majuro. The team was ready to deal with this, but it was a test of their days-old surveillance system. For safety’s sake, hours before my plane was scheduled to depart, the Secretary asked me to stay a few more days.
The team reacted exactly as planned: they sent teams to investigate the cases and initiate vector control on Ebeye and Utrik, and made sure that there was adequate surveillance in the other regions of the Marshall Islands. By this time, they were standing on their own feet and were more than capable of continuing the efforts on their own. Late the next night, I stepped back on the plane to begin my long journey back to San Juan.
Day 62. Case Count: 1,295
In my short career at CDC, this was my first time going overseas for a response. I expected to learn about field epidemiology, outbreak response, leadership and organization during an emergency, and I did. But I learned about something much more important during this response: Unity. The Marshallese have a sense of community that I’ve not experienced anywhere else in the world. This was an integral component in the early interventions that probably limited the size and duration of the outbreak. Moreover, dengue is an illness that can’t be combatted solely by physicians, or epidemiologists, or vector control teams, or politicians. To succeed in their efforts, they all have to contribute their skills and abilities and coordinate a response together. In this outbreak, individuals from all of these disciplines made a concerted effort as one entity, and the effects were palpable. Finally, the compassion I witnessed in the doctors, nurses, and hospital staff in Majuro and Ebeye was beyond words. They are educated individuals from across the world, living in very austere conditions, often working 12 or 14 hour shifts, 7 days a week, 365 days a year. And why do they do it? Not because they have to, and certainly not for the money, but simply because they are a part of their community and care about saving lives.
In the end, this outbreak wasn’t Contagion; it didn’t sweep the globe and kill millions of people. But it did have one important thing in common with the movie: many people from across the globe coming together for a common goal of keeping people safe and healthy. Because of this response, and especially due to the efforts of the local community, despite nearly 1,300 cases, there were no deaths. And that is something for which this cast of characters certainly deserves a round of applause.
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