Epidemiologic Notes and Reports Dengue Fever in U.S. Military Personnel -- Republic of the Philippines

Between June and September 1984, an outbreak of dengue fever occurred at Clark Air Base, a large U.S. military installation located about 70 kilometers north of Manila on Luzon Island, Republic of the Philippines. The base has an active-duty population of approximately 10,000 persons. Dengue fever was first suspected when seven servicemen presented at the Clark Air Base Regional Medical Center between June 26 and June 29 with similar illnesses characterized by high fever, body aches and pains, rash, leukopenia, and thrombocytopenia. Subsequently, a disease surveillance system was initiated at all primary health-care clinics in the hospital to detect patients with similar clinical presentations.

The most frequent clinical findings were fever (97%), headache (80%), and myalgia/arthralgia (80%). Other common signs and symptoms were malaise, chills, anorexia, nausea, vomiting, diarrhea, and maculopapular eruption. An aberrant taste sensation, dizziness, and desquamation/pruritus in the palms were occasionally reported. Hemorrhagic manifestations consisted of petechial rash in 13 patients, gastrointestinal bleeding in four patients, and gum bleeding in one patient. One patient initially admitted to the intensive-care unit was in shock (blood pressure 60/40) with upper gastrointestinal bleeding.

Common laboratory findings for the 29 hospitalized patients were white blood cell count below 4 x 10((9))/L (90%), relative lymphocytosis (71%), and a platelet count below 0.10 x 10((12))/L (72%). The partial thromboplastin time was increased in six of the 12 patients tested, and the fibrinogen/fibrin degradation products were elevated for six of the seven patients tested.

Twenty-nine of the patients were hospitalized, including 25 active-duty personnel. This latter group lost a total of 212 duty days as a result of this illness. No patients died.

A total of 119 patients were referred for study, and 42 cases of dengue fever were confirmed by hemagglutination-inhibition (HI) antibody seroconversion or by virus isolation. An additional nine cases were considered probable dengue based on the presence of HI antibody in an acute serum only. All four dengue serotypes were isolated (12 cases of dengue 1, four of dengue 2, five of dengue 3, and one of dengue 4).

Patients' ages ranged from 2 years to 43 years, and the male:female ratio was 3.2:1. Thirty-five of the patients were active-duty service members, most of whom were males between the ages of 20 years and 40 years. The remaining 16 patients were their wives and children. Over 90% of the cases were clustered in several off-base residential areas in Angeles City. The first seven patients recognized during the last week of June resided in the same neighborhood, and three of these servicemen shared the same house. Multiple cases occurring in the same household also were recorded among members of five different families.

Mosquito surveys revealed the presence of both Aedes aegypti and

1. albopictus in most off-base residential areas. An extensive education program and malathion spraying resulted in the marked reduction of vector populations in these communities by the end of September. Reported by CG Hayes, PhD, T O'Rourke, MD, G Schultz, PhD, US Naval Medical Research Unit No. 2, V Fogelman, DVM, G Crow, MPH, M Albersmeyer, DVM, Environmental Health, DD Leavengood, MD, Clark Air Base Regional Medical Center; Dengue Br, Div of Vector-Borne Viral Diseases, Center for Infectious Diseases, CDC.

   Editorial Note

Editorial Note: Epidemic dengue is not uncommon among U.S. military personnel stationed in endemic areas of the tropics. Outbreaks similar to the one described here have been reported earlier in Thailand and, more recently, at the Subic Bay Naval Base in the Philippines. These outbreaks underscore the need for effective instruction on methods of prevention that can reduce the chance of infection among U.S. military personnel living off-base in endemic areas.

The severity of the disease observed in this outbreak is of interest. While the majority of patients presented with classical dengue fever, some with minor hemorrhagic manifestations, several patients had upper gastrointestinal bleeding, a severe clinical presentation similar to that recently described in Indonesia (1). While none of the patients in the current outbreak died, deaths have been reported in other outbreaks, indicating the continuing need for training military physicians in diagnosing and treating dengue and dengue hemorrhagic fever.

Reference

1. Sumarmo, Wulur H, Jahja E, Gubler DJ, Suharyono W, Sorensen K. Clinical observations on virologically-confirmed fatal dengue infections in Jakarta, Indonesia. Bull WHO 1983;61:693-701.

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