Dengue outbreaks in Chiapas, Jalisco, Veracruz, Oaxaca, and Quintana Roo

Since the beginning of 2019, a regional epidemic cycle of dengue has broken out in Latin American and the Caribbean. According to the government, as of 2 September, Mexico has 11,593 confirmed cases of dengue, including 798 cases of severe dengue. However, the total number of probable cases is expected to be much higher by the end of 2019. 70% of the cases are primarily within five of Mexico’s provinces: Chiapas, Jalisco, Veracruz, Oaxaca, and Quintana Roo (GoM 02/09/2019) Veracruz de Ignacio de la Llave (Veracruz) a state with a population of over 8.1 million, has the highest total number of dengue (3,234) (GoM 02/09/2019 GoV 2017). As of 31 August, Veracruz has 3,234 confirmed cases of dengue, including 82 cases of severe dengue, and 2 confirmed deaths (GoM 02/09/2019). This number is already higher than the figure for the entirety of 2018 for Veracruz, which had 2,239 cases of dengue and 95 cases of severe dengue (GoM 12/2018). Given that the rainy season is expected to continue until October, this number could continue to increase.

Anticipated scope and scale

The Government of Mexico predicts there will be 74,200 probable cases of dengue by the end of 2019. In 2018 there were roughly 25,000. 16 states in Mexico have confirmed cases dengue so far, of which the state of Veracruz currently has the highest number. Vulnerable populations include those in poverty, who account for 58% of the state’s population. Children under 14 are also highly susceptible to the current outbreak; they account for almost a quarter of the population in Veracruz. The ongoing rainy season, which last year resulted in widespread flooding across 21 municipalities within Veracruz, could heighten the number of dengue cases.

Crisis impact

Dengue is found in Mexico – and Veracruz – every year (PAHO 2016). In 2018, the government determined there were 12,706 across Mexico (GoM 12/2018). The government of Mexico confirms that so far for 2019 there are 11,593 cases of dengue, but accounting for probable cases may place the number much higher. The Pan American Health Organisation (PAHO) states that the total number is 39,700; , it is not clear whether PAHO includes probable cases in their number, which would explain the larger figure (PAHO 09/08/2019). This suggests that there is a possibility that the 3,234 government confirmed cases in Veracruz is in fact higher, if including probable cases. HHowever, Government sources state there is nothing alarming about the current outbreak, as dengue outbreaks fluctuate in cycles over the years Contradictions to this exist, and claim that the number of cases so far is still too high to be average (Yucatan Times 04/09/2019). The population of children within the state is most at risk; in 2019 the highest cases of severe dengue, a potentially deadly strain of the disease, has been found in children between 5 and 9 years of age (GoM 02/09/2019).

Health:

There is no specific treatment for dengue fever. However in cases of severe dengue hospitalisation may be required to mitigate complications and the risk of death (WHO 2019). Government figures suggest that as of 9 September there were 103 cases of severe dengue in Veracruz (GoM 02/09/2019). According to the National Statistics office, Instituto Nacional de Estadística y Geografía (INEGI), as of 2015 nearly 80% of those living in Veracruz were affiliated with either public of private health care, while 20% were not (INEGI 2015). The gap in health care coverage may lead to difficulty in accessing necessary treatment for some of the population.

Mexico is based on both a public and private healthcare system. Overall, the capacity of health facilities in Veracruz to respond to the current outbreak is not clear. However, the Mexican government constantly engages in the training of health personnel in the identification the disease, which is essential to the provision of adequate and timely medical attention in cases of severe dengue (GoM 05/05/2019). It is not apparent where in Mexico these staff have been or are being trained. Further information is required to determine whether both the public and private systems institutions can respond effectively to the current dengue outbreak and an increased caseload of severe dengue. Humanitarian and operational constraints There are no access constraints directly related to the dengue fever outbreak. However, the ongoing rainy season, which lasts until October, could result in future flooding impeding access to certain areas of the state. In 2018, flooding that affected road access and destroyed homes occurred in 21 municipalities across Veracruz (SEGOB 09/28/2018 GoM 12/2018) The prevalence of gangs in the region may pose security risks. Veracruz’s strategic positioning on the Atlantic Ocean makes it an entry and exit point for drugs and other contraband. Gang violence is prevalent, and escalations have the potential to restrict movement of the population to access healthcare. On 28 August, a gang killed 26 civilians inside a nightclub in the city of Coatzacoalcos, Veracruz, over drug territory (Mexico News Daily 28/08/2019) Vulnerable groups affected The current regional outbreak has had the greatest impact on children under the age of 15 (PAHO 15/08/2019). In Mexico the highest number of severe dengue cases in 2019 has been in the age-range between 5 and 9 (see Figure 1). Their young age likely means they have had less exposure to the virus, and therefore lack immunity (PAHO 15/08/2019). There are approximately 2.1 million children under 14 currently living in Veracruz that could be exposed to the virus, including the most deadly serotype (DEN-2) which is currently present in the state (GoV 2017). The impact of dengue in Veracruz is determined by social, economic, and political factors (PAHO 2016). A dimension of these three elements is poverty. As of 2017, 58% of the population was categorized in poverty, and just over 17% in extreme poverty (World Bank 2017). The low income of households in Veracruz is attributed to precarious employment and low levels of pay (World Bank 2017). The poor population in the state is characterised by a lack of access to food, low levels of education, and low levels of access to social security (World Bank 2017). According to the latest census data, over 3.6 million people living in Veracruz do not have access to healthcare (INEGI 2010). It is not clear whether this is a direct function of poverty or not. However, low income and poverty could mean the population has less access to adequate dengue treatment, which is crucial in lowering the fatality rate (WHO 15/04/2019). At the end of 2018 Mexico was hosting over 165,500 people of concern, including around 58,650 refugees, and 23,800 asylum seekers (UNHCR 2019). The exact number that Veracruz is hosting is not clear, however UNHCR is active within the state (UNHCR 04/2019). People of concern may be more exposed to dengue, particularly if they are living in unhygienic and unsanitary conditions that encourage the breeding habitats of the mosquito. More information is required on the numbers that Veracruz is hosting, their living situations, and levels of access to adequate medical care. Furthermore, Migrants who are not legally registered within the country may avoid accessing medical treatment, so as not to be identified to the authorities.

Aggravating factors Climate The rainy season in Mexico lasts from approximately May until October. The climate of the majority of Veracruz is humid with abundant rains in the summer (GoV 2017). Heavy rains could deteriorate the dengue situation in two ways: 1) heavy rains can increase the presence of standing water, facilitating the breeding of mosquitoes, and 2) rainfall that results in flooding can create access issues. In October 2018, Veracruz faced heavy rainfall across 21 municipalities, which led to the flooding of businesses and homes (Mexico News 20/10/2018). Lack of Insecticides The lack of insecticides available within Veracruz has been cited as one of the reasons for the higher than average level of dengue cases so far in 2019. The government has received criticism as it apparently did not utilise allocated funds in order to purchase the necessary insecticides for the province (Yucatan Times 04/09/2019). However, official government sources claim this is untrue, attributing the high caseload to the climate and the immune response of those exposed (GoM 05/09/2019). Other Diseases Other viruses and diseases are currently present in Veracruz, which could impact the ability of healthcare facilities to focus on response to the dengue outbreak. The presence of other viruses and diseases may strain the health sector, diminishing the ability of facilities to respond timely and effectively to dengue cases.

Contextual information

Previous outbreaks Dengue fever is endemic to Mexico; the country experiences outbreaks every year (PAHO 2016). Veracruz also experiences yearly outbreaks. In 2018 there were over 2,700 government- confirmed cases in the state (GoM 12/2018). Cause and symptoms Dengue fever is a mosquito-borne viral infection caused by a virus of the Flaviviridae family. The disease can be transmitted to humans via females of the Aedes aegypti species (WHO 15/04/2019). The disease is usually transmitted during the day, more often in the morning and before dusk (WHO 03/01/2017). Malaria-like symptoms are the most common at the beginning of dengue fever (WHO 31/08/2016). There are four serotypes of dengue present in Latin America (DEN-1, DEN-2, DEN-3, and DEN-4), serotype-2 being the most deadly (PAHO 15/08/19). Symptoms can take about one week to show, and include a high fever of over 40 degrees Celsius, headache, pain behind the eyes (PAHO 15/08/19). More severe dengue symptoms include rapid breathing, severe abdominal pain, persistent vomiting/blood in the vomit, fatigue, irritability, and bleeding from mucous membranes (WHO 2019). Dengue becomes severe when it develops complications – such as organ impairment or severe bleeding – which can lead to death (WHO 15/04/19). Treatment Early detection and access to quality healthcare lowers the fatality rate of dengue (WHO 15/04/2019). Admission to the hospital in case of severe dengue symptoms is necessary in order to reduce the risk of death through adequate medical attention. Blood transfusion can also be used in cases of severe dengue (Mayo Clinic 20/04/2016).

Key characteristics Population: 130,759,000 country-level (UN Data 2018), 8,112,505 Veracruz (GoV 2017) Access to improved drinking water sources: 97.2 % of urban, 92.1% rural (UN Data 2018) Access to improved sanitation facilities: 88% urban, 74.5% rural (UN Data 2018) Urban population: 80.2% of total population (UN Data 2018) Physicians: 2.2/1000 population (UN Data 2018) Infant mortality rate: 18.8/1000 live births (UN Data 2018) Employment: Agriculture: 13%, Industry: 25.9%, Services: 61.2%, Unemployment: 3.6% (UN Data 2018) Response capacity Local and national response capacity The Ministry of Health (Ministerio de Salud) of Mexico is responding to the outbreak. Over the past four decades the country has developed permanent activities in epidemiological and entomological surveillance, health promotion, and training of personnel to minimise effects of dengue. To reduce further spread of the disease, the primary activities are focused on eliminating breeding grounds for the mosquitos, which eradicates the larvae (GoM 2019). Specialised sanitary brigades have been deployed across the country to eliminate breeding Mosquito breeding areas. Information from the Ministry of Health suggests that this year’s dengue programme has sprayed 500,000 homes for larvae control (GoM 05/05/2019). Community prevention and control activities are crucial for mitigating further outbreaks (PAHO 09/08/2019). Due to the frequency of dengue outbreaks in Mexico, the government trains health personnel every year, although it is not clear where these trainings have taken place. There appears to be no request for international assistance in responding to the disease. Information gaps and needs The impact of the dengue fever outbreak on hospitals’ capacity in Veracruz remains unclear. More information is needed on the state of hospitals ability to respond effectively to the caseload. Further information is required on the number and location of refugees/migrants in Veracruz and their levels of access to healthcare.

Source: reliefweb, acaps.org, https://www.acaps.org/sites/acaps/files/products/files/20190916_acaps_start_briefing_note_mexico_dengue_0.pdf

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