Lessons from the dengue outbreak in Hawaii

Hawaii_1There are millions of cases of mosquito-borne disease world wide every year so why should we care about a few dozen dengue cases in Hawaii?

Hawaii is no stranger to dengue. There have been outbreaks first dating back to the 1840s. Travellers, including returning residents, are diagnosed with dengue routinely. However, this is the first outbreak of locally-acquired infection since 2011.

As of 17 November 2015, Hawaii Department of Health reports there have been approximately 65 locally acquired cases on Hawaii Island (aka Big Island) including both residents and visitors. Why has this happened and what lessons can be learned from the outbreak?

[update: As of 29 January 2016, there have beenĀ 242 confirmed cases of locally acquired dengue.]

Hawaii provides a fascinating example of the implications (as well as study of spread) of exotic mosquito invasions. With no endemic mosquito species, the pest species found in the Hawaiian islands have all been introduced from elsewhere.

The first mosquito to make it to Hawaii was Culex quinquefasciatus. It is thought to have arrived on a boat from Mexico in the mid 1820s. Interestingly, with no native mosquitoes in Hawaii, there was no word to describe them so they were initially referred to as “singing flies”.

In recent years, it has been the role of Culex quinquefasciatus in the spread of avian malaria that’s been grabbing the headlines. However, in the last few weeks, it has been Aedes aegypti and Aedes albopictus playing a role in the local spread of dengue virus in the spotlight. These two container-inhabiting mosquitoes are the key vectors of dengue viruses (as well as chikungunya, yellow fever and zika viruses) internationally. They’re driving the outbreak now as they have in the past.

There was an outbreak of dengue in 2001 with a total of 122 locally acquired cases. Cases were reported from Maui, Oahu and Kauai with the outbreak thought to have been triggered by travellers from French Polynesia where there was a major outbreak underway at the time. Between 1944 and 2001, the only cases of dengue reported in Hawaii were imported with travelers. Firstly, this highlights how important it is to understand the pathways of infected people, this can help guide assessments of risk.

This was also done from the potential introduction of West Nile virus into Hawaii. Analysing the movement of travelers from regions of endemic mosquito-borne disease has also been used to assess the risk of chikungunya virus introduction to North America.

It was believed that Aedes albopictus played an important role in this 2001 outbreak. This mosquito was not a significant presence in Hawaii until the 1940s. More importantly, Aedes albopictus is not exclusively found in water-holding containers in urban area. Unlike the other vector of dengue viruses, Aedes aegypti, Aedes albopictus is also found in bushland habitats. This makes mosquito control just a little more difficult when authorities need to look beyond the backyard.

Previous dengue outbreaks in Hawaii were thought to have been driven by Aedes aegypti. These outbreaks were significant with an estimated 30,000 cases in the early 1900s followed by approximately 1,500 cases around Honolulu in the period 1943-1944. While not necessarily easy to manage, outbreaks of dengue driven primarily by Aedes aegypti can be strategically targeted by residual insecticide treatments and community education. That education focuses on raising awareness of the public health risks associated with mosquitoes and the need to remove opportunities for mosquitoes to be breeding around dwellings. This model is essentially what is in place to address occasional outbreaks of dengue in Far North Queensland, Australia.

The current outbreak has raised concern in the community. Shelves of stores have been emptied of insecticides and repellents. Community meetings have been held by local authorities to provide information on dengue and address concerns on the Big Island. You can watch some of the meetings here. You can see some of the health promotion (aka “Fight the Bite”) flyers here.

Community engagement is important. An indirect impact of this engagement though is that the total number of confirmed cases of dengue on the Big Island is likely to rise over coming weeks. Not necessarily due to new cases but a greater likelihood that older cases will now be diagnosed through blood tests. Even those who may be suffering a mild illness are likely to be tested for infection and may end up in official statistics.

This dengue outbreak is a reminder to authorities across the world that where suitable mosquitoes are present, a risk of mosquito-borne disease outbreak is possible. The mosquitoes provide the tinder and it only takes the spark of an infected traveler to ignite an outbreak. We saw this in 2014 with the first outbreak of dengue in Japan for 70 years. We’ve seen it this year with local transmission of chikungunya virus in Spain and other outbreaks across Europe.

For Australian authorities, ensuring there are strategic responses in place to address the risk of exotic mosquito introduction, as well as outbreaks of disease, is critical. What this outbreak in Hawaii reminds us is that if Aedes albopictus becomes established in our major cities, it is only a matter of time before we see local outbreaks of dengue, chikungunya or Zika viruses.

What is it like if a loved one comes down with dengue? Check out the channel of YouTube stars Charles Trippy and Allie Wesenberg as they document their brush with mosquito-borne disease during this outbreak.

[Update: Implications for potential Zika virus spread] The recent spread of Zika virus in the Americas has raise concerns by health authorities. In particular, the spread of the virus to North America. What about Hawaii? There has already been one case of microcephaly in Hawaii with a baby born on Oahu to a mother who had been residing in Brazil. The pregnant women was infected in South America, not Hawaii. However, authorities should be on alert as travellers from the Americas, or the Pacific, have the potential to introduce the virus and the mosquitoes currently present in Hawaii spreading dengue viruses are the same that spread Zika virus.








Perfume won’t protect you from mosquito bites

VictorissecretThe headlines have been awash with claims that a popular perfume may repel as many mosquitoes as those regularly recommended by health authorities. Could it be true?

In short, no. There is little surprise that the results of this recently published study in the Journal of Insect Science has attracted so much attention. Everyone loves the idea that some unexpected substance could be used as a mosquito repellent. Even better if it performs as well, or even better, than those such as DEET or picaridin that are widely recommended by health authorities.

The scientists tested a range of commercial insect repellents. Three formulations of DEET based repellent, an oil of lemon eucalyptus (aka PMD) based repellent, three botanical-based repellents, a mosquito repellent patch (Vitamin B), a product not specifically designed as a repellent but often quoted as being effective (Avon skin so soft) and the perfume. Why include the perfume at all?

The logic behind including the perfume was a good one. It is often said that floral perfumes and other cosmetics attract mosquitoes. I’ve never thought this is actually the case. I mean, there is stronger evidence that mosquitoes re attracted to smelly foot bacteria than pleasant smelling cosmetics! I always suspected that the idea comes from the fact the mosquitoes (mostly the non-biting males) will feed on plant sugars. However, it was worth including in this study. Always good to gather some quantitative evidence on the response of blood-seeking mosquitoes. It could be a good opportunity to bust (or perhaps confirm) some urban myths.

I’ve written before about how you can test mosquito repellents. While the “arm-in-cage” methodology typically provides the best indication of how a mosquito repellent will perform, there are other methods commonly employed. In this case, the researchers used a “Y-tube” setup. This system basically allows mosquitoes to make a choice as to whether they preferentially fly towards one or the other ends of the tube. If you insert a hand treated with a substance into one end and another untreated hand as a control into the other, it is possible to measure the overall repellent effect by tracking the movement of mosquitoes.

Firstly, it is interested to note that the researchers found that some mosquitoes were attracted to the hand treated with DEET. If I was conducting an “arm in cage” test. I would be very surprised if I had any mosquitoes biting a DEET-treated arm within 2h of application. In one study, I found an approximately 7% DEET-based repellent stopped bites for a little under 2h. It makes me wonder how many mosquitoes may fly up to tube towards the treated hand but, given the chance, would actually bite the hand?

Fewer mosquitoes were attracted to hands treated with oil of lemon eucalyptus, not surprising either given this product is regularly recommended as an effective repellent by health authorities.

The testing of the perfume provided the headline grabbing results! For the first couple of hours, there wasn’t much difference in the proportion of mosquitoes repelled by the perfume compared to the other repellents. Why? It may be related to the strength of the odour overpowering the sensory organs of the mosquito. I think this is how some strongly smelling essential oils can provide some protection. It masks the normal chemical cocktails of smells on our skin that attracts mosquitoes.

We all know how overpowering the smell of some cosmetics can be. In this case of this experiment, a relatively high dose of the products as used. The authors make note of this too when they state “It must be noted that the concentration of perfume we used in this test was rather high and that lower concentrations of the same fragrance might have different effects.”

Could this perfume be used as a repellent?

Studies like this provide some fun headlines but they can be misleading to the public. What “works” for a relatively short period in a small laboratory based study does not necessarily stand up the practicalities of real life.

Notwithstanding the expense (the perfume is about AUS$80 for 100ml compared to less than AUS$10 for about the same amount of DEET-based repellent) I must admit that for some of these products, the smell can be so overpowering that applying them to large areas of skin would probably be more unpleasant than the bites of mosquitoes!

When trying to help the public choose and use mosquito repellents more effectively, it is critical that health authorities stick to products that are currently registered for use as a mosquito repellent and that have been demonstrated to provide suitable protection from biting mosquitoes over extended periods of time.

Perhaps the most important finding of the paper is not that the perfume repelled some mosquitoes but that patches infused with Vitamin B provide absolutely no protection from mosquitoes. This is one urban myth that never really seems to go away!

We also know that Victoria’s Secret perfume doesn’t stop bed bugs invading lingerie stores!

[The image used at the top of this piece is taken from here.]