Health officials in Phnom Penh are setting off alarm bells in the hopes that city

residents will not get caught up in what experts on dengue fever predict will be

a major epidemic in the capital in less than three months.

The last of the major dengue epidemics, which are known to occur throughout the Southeast

Asian region every two or three years, hit Cambodia in 1990.

More than 7,241 cases were reported nationwide and more than 330 people died from

the mosquito-born viral disease. About 4,000 cases and 159 fatalities were reported

in Phnom Penh alone.

"We are very concerned about dengue fever," said Dr. Jean Paul Menu of

the World Health Organization (WHO). "Soon we will be entering the hot season

and an epidemic will come. If we don't do enough between now and May it will be too

late for some (prevention) activities."

Dr. Menu said that eliminating mosquito habitats is as important as identifying the

early signs of the disease and proper patient care in order to reduce the impact

of the expected dengue outbreak.

Children are particularly vulnerable to dengue, especially those between three and

10 years of age. About 90 percent of the fatalities in recent years have been among

this age group.

"Usually you don't die from normal dengue," said Dr. Menu, "but if

children are under certain conditions they can die from hemorrhagic fever."

Officially known as dengue hemorrhagic fever (DHF), the disease is carried by the

Aedes aegypti mosquito, which lives primarily in cities and bites during the daytime.

They breed in containers with water. The mosquito glues its eggs to the side of anything

with water in it where the larvae develop. A tin can, old tire, water jar or ant

trap make perfect homes for the mosquito to multiply comfortably. During the hot

season the incubation period for the virus to develop in the mosquito before it can

be transmitted to a human decreases. The mosquitos are also more active when it is

hot.

People infected with simple dengue fever develop a sudden fever (39.5 to 41.5 degrees

centigrade), have a severe headache with pain behind the eyeballs and maybe a rash

during the first day or two. Muscle and bone pain come soon after the fever, hence

the common nickname for dengue: "breakbone fever." Between the second and

sixth day nausea and vomiting may occur. The fever usually clears in five to seven

days after which there may be a raised rash. Recovery may be associated with prolonged

fatigue and depression.

With dengue hemorrhagic fever the patient starts out as above and then just as the

fever ends and they are about to "recover" the blood capillaries start

leaking. There are frequently scattered red spots on the forehead and extremities,

easy bruising and bleeding from the nose and gums. If the blood pressure drops and

the patient develops intestinal bleeding they could possibly go into shock and die.

Statistics from the National Centre for Hygiene and Epidemiology (CNHE) of the Ministry

of Health in Phnom Penh indicate that the number of seasonal cases since l980 have

increased steadily since then (see graph), with a two-to-three year cycle of epidemic

proportions.

"It is very complex for people to understand why (epidemics) come in cycles,"

Dr. Michael Macdonald of the United Nations High Commission for Refugees (UNHCR)

said.

While simple dengue fever has been around for a long time, its hemorrhagic and potentially

fatal form (DHF) was first discovered in Asia in Manila in l953. Bangkok experienced

a DHF epidemic in l958 with more than 2,700 cases recorded. Thailand logged approximately

171,000 DHF cases in 1987, a record high for the Land of Smiles. In 1990 the number

had dropped to 120,000.

However, in Thailand the mortality rate is much lower than that of Cambodia due to

more widespread awareness of the disease and better health facilities. "Always

children still die, but not 10 percent. Maybe we can save some hundreds of lives,"

said Dr. Menu referring to the possibility that a sustained public awareness campaign

might have on the number of fatalities.

Efforts to combat dengue fever are being coordinated through the "Committee

for the Control of Dengue Hemorrhagic Fever" established by the State of Cambodia's

Ministry of Health in cooperation with UNICEF, UNDP, the World Health Organization

and UNHCR. The Committee was established in 1992 to combat a dengue outbreak in Battambang

and is credited with reducing significantly dengue-related fatalities. Caseloads

were reduced through a public education campaign and deaths were cut through early

treatment. More than 900 cases were recorded in Battambang during 1992. Eighty people

died during the outbreak in the province. Kompong Cham and Kratie provinces were

also badly hit the same year.

The main objectives of public education efforts are to insure that citizens do what

they can to eliminate breeding areas and to make sure mothers recognize dengue fever

symptoms at an early stage so that proper treatment can be secured for children affected.

Residents are encouraged to clean water jars or containers on a weekly basis to destroy

mosquito larvae, and to put salt in ant traps which kill larvae. Areas around houses

should also be examined to remove other potential breeding sites.

However, health officials are cautious about the impact of such programs. "It's

extremely difficult to convince people to change their behavior, especially since

dengue is a relatively new disease here," said Dr. Macdonald. "Plus spraying

insecticide is not such a good idea. It's expensive and not that effective as many

mosquitos are inaccessible."

With minimal resources the CNHE is activating a dengue awareness campaign in Phnom

Penh. A more comprehensive two year plan has been designed which would include public

education, increased capacity to diagnose and treat cases and to insure sufficient

data collection, but the necessary U.S. $800,000 has not been secured.

"Nobody has money," said Dr. Menu. "We are very desperate to keep

the (current) program going. We need funds, that's why we are trying to mobilize

as many people as possible. It's a joint activity between Cambodia, UN agencies and

some NGOs."