Donald Brooks (Burkina Faso & USA): dengue & misdiagnosis
Donald Brooks is CEO and founder of Initiative:Eau an NGO dedicated to increasing the safety and quality of drinking water services in developing areas. In September 2017, he contracted dengue fever whilst on deployment in Burkina Faso, but was repeatedly misdiagnosed as infected with malaria and treated accordingly. Donald Brooks' illness highlights the current gaps in dengue diagnostics and surveillance, as well as the urgent need for both a low-cost dengue diagnostic tool and increasing the laboratory capacity in resource-poor regions. Here is Donald Brooks' story.
Several months after arriving for a 2-year deployment with Initiative: Eau at our West Africa regional office in Fada N’gourma, Burkina Faso, I contracted dengue fever.
A morning in early September 2017, I awoke sluggishly and was slow to begin the day. I had just returned from a trip to the capital, Ouagadougou, for several meetings. I remarked a generalized soreness, and hints of a headache and eye pain. I checked my temperature, and noticed a slight fever. Thinking it could be malaria, I went to the clinic and got tested for the gamut of typical tropical diseases: malaria, typhoid, and intestinal parasites. I returned to the clinic later that afternoon to retrieve my results, and was unsurprised to see a slightly positive result for malaria trophozoites. The doctor prescribed a curative treatment and I returned home to recover.
That evening, my symptoms worsened. My headache became unbearable, and it spread down my spinal cord into my lower back. The pain in my eyes prohibited me from moving them, and my fever went higher. I continued to take the prescribed malaria treatment, hoping that the next morning I would already feel some relief. To my dismay, this was not the case. The body aches and pain were debilitating. My local friends assured me that this was normal sometimes with malaria, though it had never been the case for me.
I remained in bed the next 4 days, with more or less the same symptoms, though by day 4 my fever had abated. On day 5, I returned to the clinic and described my persisting symptoms, namely eye, head, and body pain and fatigue. Given that I knew eye pain to be a common symptom of dengue, I wondered if the malaria parasite was secondary to this other virus in causing my symptoms. The doctor opted to prescribe a second round of curative malaria treatment with a different pharmaceutical. Afterwards, when I returned home and laid down to rest, I noticed that my legs were red and covered with small white patches. Recognizing this as an additional indicator of a dengue infection, it became more obvious to me that it was unlikely to be malaria continuing to cause my symptoms.
The next day I felt better, the pain and fatigue were still present but were beginning to subside, and within the next three I was back to normal. After a month and a half of persistent fatigue and joint pain, I consulted another doctor to seek additional counsel for my continued poor health. He ordered a dengue test, which returned positive for IgG antibodies, indicating a previous infection. Just prior, the Burkina Faso Ministry of Health declared a dengue epidemic on 28 September 2017 in the central region of the country including the capital, after they noticed a sharp increase in the number of reported cases since mid-August[1].
The dengue test I had done cost 10 000 XOF, about 18 USD. Compared to my medical bills for even routine lab work in the United States, 18 USD, to me, seemed like a deal. However, in the country ranked 183 out of 189 countries according to Human Development Index (HDI) and where 43% of the population lives on less than 1.90 USD per day, 10 000 XOF represents an enormous expense for the diagnosis of a disease currently with no curative treatment[2],[3]. Additionally, diagnostic laboratory capacity remains limited with regards to dengue as in Fada N’gourma, capital of the East region, only two private clinics were able to conduct the test.
From my experience with dengue, we can make a number of observations that may indicate trends across Burkina Faso with regards to dengue diagnosis. First, due to the similarity of dengue’s early symptoms with other febrile diseases, namely malaria, and its often concurrent geographic spread with other febrile diseases, namely malaria, it can be surmised that dengue can be misdiagnosed as other febrile illnesses, namely as malaria. Taking my case as an example, I was not counted as a positive instance of dengue as I was told I had malaria. This begs the question: how many cases of dengue remain unaccounted for because mild cases are misdiagnosed?
Compounding this, we must consider the impacts of limited diagnostic laboratory capacity. In a regional capital, the fact that no structure part of the public governmental health apparatus possessed the capacity to conduct a diagnostic test for dengue is alarming.
If this capacity is lacking in a regional capital, one can only imagine the non-existent capacity that must exist in more rural areas across the country and the underreporting and non-treatment of cases it causes. High test costs can be inferred to have a similar effect on reporting and treatment of dengue cases. Prohibitively high prices for tests likely leave many families simply opting against testing. High tests costs and lack of curative treatment may also prevent doctors from ordering the test, given the limited use of resultant information.
These three observations that I made during my experience with dengue hint at significant problems hindering the accurate reporting and diagnosis of dengue fever in Burkina Faso. Based on these observations, it becomes clear that development of affordable and easy-to-use diagnostics is essential. Such diagnostics enable more accurate, timely, and cost-efficient diagnosis of dengue cases, in a way that is affordable to families and that makes possible a better understanding of dengue prevalence in the country.
[1] https://reliefweb.int/disaster/ep-2017-000162-bfa
[2] http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/BFA.pdf
[3] http://povertydata.worldbank.org/poverty/country/BFA
