Brazil port chief struck down by dengue in Paranaguá

Image of the Brazil port chief who contracted dengue fever

Happy new year? Not for Rodrigo Buffarah Coelho, a 38-year old port terminal manager from Paranaguá in the Brazilian state of Paraná. His encounter with a mosquito at a New Year’s Eve party made him another high-profile victim of dengue in Paranaguá, a city hitting back hard against repeated outbreaks.

New Year’s Eve was supposed to be a regular party for Rodrigo Buffarah Coelho. But, unfortunately for him, an evening of celebration turned into a nightmare after an encounter with Aedes aegypti. “I’m pretty sure the mosquito bit me during New Year’s Eve. We were at a party at a house which neighbors a wasteland.”

He emphasizes his concern about the state of dengue in Paranaguá: even before that episode: “At my house, we’ve always taken care with trash, avoided standing water and taken all the other routine precautions against dengue fever,” he says. “That’s why I suspect that I wasn’t bitten at home.”

Rodrigo remembers exactly the day he started feeling unwell. “It was January 5th, 2016. My suffering started then. That afternoon I started to feel weak and unwell. When I got home, everything began getting even worse – very fast. I had a terrible headache and the weird ‘back of the eye pain’, which the media were talking about. That’s when I started to suspect it could be dengue.” As he didn’t get any better the next day, he sought medical help, but things weren’t easy in his town.

Image showing dengue fever incidence in Brazil

image via PAHO

“Paranaguá was witnessing an epidemic at that time, so the hospitals were all crowded. I wasn’t admitted to any hospital, and as it was confirmed I got the dengue fever, the doctors asked me for a lot of exams. They verified that my platelet levels were decreasing, and that was worrisome.” Rodrigo was told by the doctors to rest, take acetaminophen and take plenty of fluids, including yam juice. “I was dehydrated, but it was very hard to ingest anything during the first five days, so I had to go to the hospital twice to take saline serum.”

He only recovered and was able to go back to work two weeks later. Rodrigo became an important character in the fight against dengue fever in Paranaguá. “Because I hold a leadership position at the port company, and being a young and healthy person, people around me were really struck by the fact that I became so very ill,” he recalls. “Sometimes people think diseases like dengue are only present in socially-disadvantaged communities. When people saw someone like me could catch dengue, it caught everyone’s attention.”

After the episode, Rodrigo decided to stand up and fight against the repeated dengue outbreaks in his city. From August 2015 to July 2016, Paranaguá registered a total of 15,779 cases. From August 2016 to July 2017, the city registered only 35 cases. From August 2017 to November 2017, no cases were reported.

“This drastic drop was no accident. The work of the public authorities along with private companies and the population was something I’ve never seen before. The campaigns promoted by Paraná’s Health Department were massively obeyed by people,” says Rodrigo.

Read why storms and earthquakes boost mosquito populations and risks of dengue 

In the port authority where he works, staff spent an entire day cleaning everything and taking action to reduce the opportunity for mosquitoes to breed. “We also had the visit of the health authorities to give shots to our employees at the three stages of the vaccine”.

He says about 90% of the 330 employees got the vaccine, and they also helped to raise the awareness of their family and friends about the importance of avoiding dengue.

“I’m pretty sure after this epidemic, and all the efforts that everyone made to almost eliminate dengue in Paranaguá, people will develop a new culture of taking the appropriate care to keep this numbers down and avoid a new wave of epidemics,” says Rodrigo, a committed anti-dengue ambassador.

Dengue vaccination campaign: thousands reached in second drive

Image: Man get immunized in dengue vaccination campaign in Parana, Brazil.

Image via Disclosure/SESA

During the first half of 2017, the Brazilian state offered 30 cities the second of three doses against dengue. Those who missed out on the first dose were given a second chance to begin the vaccination program.

After launching the dengue vaccination program in 2016, Paraná State is now reflecting on the second phase of the dengue vaccination campaign – and gearing up for the third. It lasted from March to April and, in addition to the 154,000-second doses administered, 99,000 people who had not benefited from the first round of vaccination were given their first doses.

“People understood the importance of vaccination and the effort made by the state in buying and distributing the vaccine to the municipalities,” according to Dr. Júlia Cordellini, Superintendent of Health Surveillance of Paraná State.

One of the 30 cities involved in the dengue vaccination campaign has reached 100% of its target population, after vaccinating only 33% during the first round: it was Bela Vista do Paraíso, in the north of the state.

Seventeen out of these 30 cities have vaccinated between 80% and 99% of the target audience. One of them was Munhoz de Mello, also in the north of Paraná, that reached 83%, after vaccinating 87% during the first stage) Mauro Sérgio de Araújo, Health Secretary of Munhoz de Mello, says the small town of 3,900 inhabitants, has a vaccination team of 60 people.

“Almost everyone knows each other, so communication between our population was important, and we were able to handle all the demand,” he says. “Another thing was that we’ve seen a high number of dengue cases, so the population was alarmed and joined our cause.”

The city has adjusted details of the dengue vaccination campaign every week in order to maximize its impact. “We realized many people couldn’t attend the opening hours of the Health Unit, so we extended some of our working hours, or sent teams to companies to vaccinate the employees. We even sent professionals to do door-to-door vaccination and to convince the population of the importance of taking the vaccine.”

Population approves State’s actions

Jefferson Meneguite, 23, an electrical engineering student and poultry farmer, lives in Munhoz de Mello and agrees with the Health Secretary that the public came on board. “After the outbreaks here in town, we became apprehensive. There were 78 confirmed cases and when the campaign was launched, the population embraced it in order to avoid the spread of the disease,” he says. “Even those who didn’t go to the Health Units got vaccinated at their workplaces or homes. The campaign was everywhere”. From August 2016 to July 2017 there were no cases reported.

The results from Munhoz de Mello are seen as an example for the last 12 cities that received the vaccines: 11 of them vaccinated between 60% and 79% of the target population, while one city (Mandaguari, curiously also in the north of the state), reached only 59% of the target vaccinated.

“Paraná is the only state in the Americas to vaccinate its population for free, so people appreciate the magnitude of this great opportunity and they’re spreading the word about it,” says Dr. Cordellini.

Image of Dr. Júlia Cordellini talking about the dengue vaccination campaign in Parana, Brazil.

Image of Dr. Júlia Cordellini

She highlights the difficulties some cities faced in reaching its targets. “All vaccines that cover teenagers and young adults are harder to handle [than infant immunizations],” she says. “This age group is a serious issue for us. That’s why we’re working so hard on these campaigns. Also, the fact that the vaccine is something ‘new’ on the medical market leads some people to hesitate, even though we are always reinforcing that the vaccine is safe and effective.”

The fact that the immunization is only complete after the third dose is another barrier: “It’s already hard to attract people to take one dose, so you can imagine how hard it is to get them to come to the health units three times to take all the doses and be totally immunized,” says Dr Cordellini.

She points to another factor that may discourage some younger people from having the vaccination: complacency “Young people nowadays haven’t experienced the major epidemics that older people did,” she says. “Cholera, typhoid fever, meningitis, congenital rubella syndrome, poliomyelitis and measles no longer circulate on the continent. Nowadays these diseases are under control and people have a higher quality of life thanks to vaccination campaigns.”

Vaccine confidence is key to beating dengue: Read More

Soon after the second round of dengue vaccination has finished, the Paraná Health Department began preparing for the third stage of the dengue vaccination campaign. Dr. Cordellini reveals some of the strategies that will be used to make the third stage even stronger than the previous ones.

“We are rethinking local strategies. We have to make every town act according to its reality,” she says. “We will bring immunization to schools, universities, and companies.”

While Health Units remain a crucial entry point for accessing care, authorities are keen to go where the population is to engage with the public about vaccination and highlight its positive impact on quality of life.

“We will also continue to use social media and ‘young’ language to attract our target audience,” Cordellini says.

Image of a woman getting vaccinated against dengue in Parana, Brazil.

Image by Venilton Küchler

The third stage of the dengue vaccination campaign is expected to happen next September.

Fighting Aedes aegypti: more than vaccination

Vaccination is only one of the actions taken by the Paraná Health Department to decrease the numbers of dengue cases in the state.

Dr. Cordellini says the positive story of Paraná’s anti-dengue drive does not mean that people can neglect other aspects of mosquito control. “Vaccination is a great and efficient tool, but we cannot forget about environmental control measures, especially taking extremely good care with our garbage”.

Since all the actions by the State and the population began, the total numbers look encouraging: the last epidemiological period has ended with 870 confirmed cases but no deaths from August 2016 to July 2017. This has meant 98% fewer cases compared with the previous period (from August 2015 to July 2016), which finished with 56,351 cases and 63 deaths.

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Paraná dengue battle: Brazilian state is pioneer in vaccination

The Paraná dengue battle is not new, but high rates of dengue fever in the region have prompted the government to take serious, and innovative actions to tackle the disease.

Paraná is a big and important state located in southern Brazil. Its economy is the fourth strongest of the country and its population is more than 11 million people.

But lately, the state is in the spotlight due to the high numbers of people infected with dengue fever. Just from August 2015 to July 2016, the State’s Health Department has recorded over 56,000 confirmed cases, which caused a total of 61 deaths. Besides that, it is estimated that this epidemic cost R$ 330 million (about €91 million) in healthcare expenses.

Parana dengue battle continues. Image of the Aedes mosquito, with a caution.

Image via

Thinking about the future of the disease and the effect on the population, the Paraná Government launched a daring and pioneering program of dengue immunization.

It was the first state in all of the Americas to introduce a public and free vaccination program to fight dengue. The state has bought 500,000 doses of Dengvaxia, a dengue vaccine developed by Sanofi Pasteur, a French pharmaceutical company. The vaccine has been approved in 11 countries and endorsed by the World Health Organization.

The vaccines were distributed in the 30 most highly-epidemic municipalities. These cities concentrate 84% of the cases and 91% of the total deaths in the state. Most cities (28) are vaccinating young people between 15 to 27 years of age, while the two cities with the top dengue burden in the state (Paranaguá and Assaí) vaccinated individuals from 9 to 44 years of age. These two cities had more than 8,000 cases for every 100,000 inhabitants.

The goal was to vaccinate 80% of this population – at least 400,000 people. During the first stage of the dengue vaccine program, from August 13th to September 24th, 50% of this goal was reached: more than 200,000 Paranaenses were vaccinated. There will be two more rounds of vaccination as three doses are required.

Governor Beto Richa and other authorities announcing the innovative approach to controlling dengue in the region.

Governor Beto Richa and other authorities announce the innovative approach to controlling dengue in the region. Photo by Pedro Ribas

“It was a very satisfactory experience. At first, as it was an innovative action, we had difficulty attracting the public to come and have the vaccine. It is a range of people that don’t usually deliberately attend Health Centers, especially teenagers because they are young and ‘strong’. They think this kind of disease won’t reach them, even if someone of their family already has been infected,” said João Luís Crivellaro, State Coordinator of Immunization.

According to the Coordinator, another factor making it difficult to convince people to come forward was that the program was rolled out during the winter, a non-epidemic period when the disease cases are very low. This may make people think they dengue is not a risk for them.

The Strategies behind the Paraná dengue battle

Because of these obstacles, the State Health Department had to take different and innovative actions to pursue and convince people to go and get the vaccine: “We had to go offer the vaccine to the community. If people won’t go to the Health Center, the Health Center has to come to them. We put vaccination spots in universities, schools, gyms, theaters, supermarkets. We didn’t just have health professionals vaccinating- we had experts talking, discussing and guiding people about the importance of the vaccine,” said Crivellaro.

He also highlighted the communication strategies to increase the numbers of following the campaign: “We had to innovate and speak the public’s language. We used our Facebook page and other social media, including text messages through Whatsapp, to communicate with the young public. The communication material distributed had to have a different approach as well. Besides that, we registered everyone who took the first dose and we will remember them when it’s time to take the second and third doses,” he said.

Another strategy used by the Health Department of Paraná was to ask for famous artists, TV presenters, influencers, and athletes born in the state to take the vaccine and reinforce the importance of it. One of them was Ágatha Rippel, beach volley silver medalist at the Rio 2016 Olympic Games and born in the city of Paranaguá.

Like Ágatha, 27-year-old physics teacher Rafael Coutinho also lives in Paranaguá, one of the two cities most affected by dengue in the state. He already had dengue fever earlier this year and knows how important it is to be vaccinated. As a teacher, he approved of the government’s actions and tried to spread the importance of vaccination to his students: “Dengue really puts your body down, and I realized that a lot of people here think the mosquito won’t get them, so they just don’t take the preventive actions, even though they know everything about the disease,” he said.

“The campaign was very positive here in Paranaguá,” said Coutinho. “I saw a lot of actions not only in the school but also in the streets and the neighborhoods of the city. A good point to highlight is that the professionals were vaccinating students during class periods, which student cooperation.”

Image of Governor Beto Richa witnessing an individual receiving the dengue vaccine.

Governor Beto Richa witnessing an individual receiving the dengue vaccine. Photo: Pedro Ribas

Now the first phase is finished, Paraná Health Department wishes to see a significant decrease in dengue numbers, once more people are immunized and the viral circulation is lower. In addition to the vaccination program, the Paraná Government is still investing in preventive actions and environmental vigilance to avoid new epidemics.