Comayagua, Honduras —
For several weeks now, Honduras has been going through one of the worst crises in the region due to insufficient water. This scarcity forces the population to gather this vital resource whenever possible and store it for consumption. Without water, there is no life and poor management can lead to the development and rapid spread of dengue fever via the Aedes aegypti vector.
Aedes aegypti, or the yellow fever mosquito, use natural locations and artificial containers with water to reproduce. According to the Center for Disease Control and Prevention, this vector is extremely common in tropical and subtropical regions, where piped water systems are lacking and the population depends on water storage. It thrives on proximity to places where humans live to lay its eggs because people provide an ideal larval habitat and female mosquitoes feed on blood to produce eggs.
On July 23, 2019, The Honduran Ministry of Health declared a national emergency due to a dengue outbreak, with 16 confirmed deaths, 1,839 hemorrhagic-dengue patients, and more than 12,000 cases of common dengue reported throughout the country.
“The urban conditions in Honduras, Central America and the Caribbean are favorable for this mosquito. People need to understand that dengue kills and that it’s preventable by destroying breeding grounds for mosquitoes,” said Jarbas Barbosa Da Silva, deputy director of the Pan-American Health Organization in Honduras during a conference with Honduran authorities early August.
With the entire country placed in a state of alert due to the high mortality rates, especially among populations ages 15 and below, public health practices are on the frontlines facing the viral disease, much like a combat unit would when an enemy attacks in the battlefield.
In Epidemiological-Week 32, there were 300 new cases reported, 143 from Comayagua alone. The situation was so critical that emergency rooms in regional hospitals were beyond capacity with patients; local authorities forced to improvise dengue wards in other smaller clinics and facilities.
“Epidemiologically, the year is divided in weeks to make it easier to track disease processes and map statistics. Indexes are tracked to know if certain diseases based on vectors or viruses are within the range of tolerance. In epidemiological week 23, thedengue virus exceeded that index and began to quickly climb,” said U.S. Army Maj. Jorge Chavez, Joint Task Force Bravo, Combat Support Hospital public health. “We meet with the Honduran Ministry of Health regional health office, as a professional exchange and partnership development on a weekly basis to track statistics, with their cooperation.”
JTFB public health personnel also conduct weekly missions into the community to assist in multiple areas such as providing dental services in local schools, exchanging knowledge in local care facilities and assisting in orthopedic missions; providing an opportunity for U.S. military personnel to participate in the disease surveillance process to create an epidemiological survey.
“That data that is being generated becomes a platform for us on the public health side to then define a course of action. What we identified as the biggest challenge that the MOH had was the lack of mechanical platforms by which to fight the virus. They were in need of devices known as vector fogs – handheld fumigators,” said Chavez. “If you want to break the chain what you have to attack is the vector, so we are bringing the ‘guns to the fight’ and this is a real life testament of our commitment to our long lasting partnership in the region.”
As neighbors to Comayagua and longstanding partners to Honduras, JTFB provided the ammunition to fight back this disease by donating seven fumigation pumps, spare parts and chemical supplies valued at $ 15,000 to support local efforts to fight the dengue epidemic in Comayagua on August 27, epidemiological week 34.
Comayagua is immediately adjacent to Soto Cano Air Base, the only forward deployed military installation in the U.S. Southern Command’s area of operations.
“This is a significant and strategic region; so from a force protection standpoint, this or any other virus, could pose a serious health hazard to military and civilian personnel. It’s important not only that we take care of the people outside the fence line but that we also protect the force and take care of our folks inside,” said Chavez. “A good percentage of the population of the folks that work and do business with the military population of Soto Cano reside in either the city of Comayagua or the city of La Paz. So, the public health of Comayagua is essentially the community health of Soto Cano. They are integrally related, we share an interest and we share a strategic benefit in ensuring that both populations stay as healthy as possible.”
After discussions and assessments with the Regional Health director in Comayagua, JTFB found that the department did have machinery in their inventory, but only one machine was operational, making it impossible for them to fight back the disease. This led to initiating a mitigation strategy through the office of public health to incorporate Humanitarian Assistance Projects, known as HAPS, through the US Embassy in Honduras and in conjunction with USAID, making this urgent donation possible.
Other challenges faced by local health authorities are changing the culture and educating the population to prevent this disease, providing adequate maintenance to the machinery, and the ability to repair those that were broken. JTFB also stepped up to assist in these matters by providing training so the MOH in Comayagua could become self-sustaining.
“Our strategy was: let us acquire the tools that we need to start to fight back, to facilitate the purchase of maintenance items to try to get as many of those devices functional, and to sustain the new acquired machinery through prolonged use and training for the technicians. This way we ensure that they are fully capable of operating them and perform preventative maintenance of the items,” Chavez explained.
Other ways in which JTFB has been contributing to mitigate this disease is through preventive health classes during Medical Readiness Training Exercises throughout the country. The plan is to educate the local population in basic sanitation guidelines and disease prevention, a step that can make all the difference in containing this virus. The unit has also donated multiple cases of acetaminophen for children and adults at the Jose Maria Ochoa clinic in Comayagua to treat dengue symptoms. The clinic has been receiving a large number of dengue patients due to the regional hospital exceeding capacity.
“We are pleased and motivated by the great help JTFB has given us to be able to fight the national dengue emergency in the department of Comayagua,” said Dr. Dolores Ortega, Comayagua Regional Health director. “We thank you for responding to our request and we hope to always count on the valuable alliance with our region, to continue providing assistance to the most vulnerable populations.”
With emerging science on prevention techniques, such as educational programs and vaccines, JTFB public health representatives continue to search for potential interventional strategies like providing educational material that is consistent with the Pan-American and World Health Organizations, medical exchanges in local clinics and vector studies.
“The U.S. Army has a very proud history of medicine in the field. Yellow Fever, smallpox, and varicella - these are all diseases that the Army made significant contributions to in the public health and epidemiological contexts,” said Chavez. “Public health in Central America and the SOUTHCOM area of operations is hemispheric community health. It is in our best interest as an organization to build relationships for a stable and healthier region, and quite frankly for a much better place to live in and more productive part of the world.”
According to Chavez, the Honduran Ministry of Health seeks partnerships that are action oriented and they see JTFB as a partner that can step up to the plate when necessary. “This tells you something about which partner you want to have in your corner,” said Chavez. “One of the ways in which we define our value is when we are able to take decisive, positive and substantive actions, and that’s what we’ve been able to do with this outbreak.”
For U.S. military medical personnel, tropical arboviruses such as dengue, zika and chikungunya are rare pathologies by American clinical standards, and their knowledge on them is relatively academic. With increased mobility and climatic changes, deployments to areas like Soto Cano are of extreme importance because they provide soldiers with the perfect environment for training to develop their clinical proficiency and overall medical readiness.
While engaging in exchanges with Honduran counterparts, JTFB battles the diseaseby developing a clinician service to train Combat Support Hospital providers on what dengue does, how the disease develops, and how to manage a patient through the disease process..
“Our Honduran hosts are more than able, willing, and ready to share their expertise in these diseases with American military medical personnel. Their knowledge base is excellent and we speak the same language when it comes to public health,” said Chavez. “It’s not an ‘us and them’; it’s a collective effort where shared information has optimal outcomes and is precisely the kind of relationship that we should be developing.”
According to recent information shared by the Comayagua Regional Health authorities, incidences in the region have started to decline, proving that the mitigation efforts have been successful after the donation. However, Honduran health authorities must maintain a strong-preventative posture and state of alert toward this epidemic as the rainy season is set to begin.
The Honduran Ministry of Health has confirmed 117 deaths from dengue in 2019 with 50 cases pending confirmation; approximately 70 percent of these deaths are among children ages 15 and under. So far this year, more than 66,000 people have contracted dengue in the country, making it the worst dengue epidemic in the history of Honduras with the highest incidences concentrating in the departments of Cortes, Santa Barbara and Comayagua.
“We have to ask ourselves ‘Are we conducting ourselves as a strategic partner? Are we conducting ourselves as a responsible ally when faced with a common enemy and common threat?’ When we step in with resources and expertise, we are having a significant positive impact in people’s lives, not just in a statistical kind of way, but in a very tangible human way,” said Chavez. “That is the kind of return on investment that people do not forget. Not all enemies carry a rifle; this is a different two-fold enemy – there is a vector and there is a virus. You can’t see it and you can’t attack it in the conventional sense. So, our number one weapons are the four pillars of public health and the strategic application of science."