Tapachula Day 9: Tuesday, June 5, 2018

After starting our morning off with medialunas from the local panaderia and coffee with our German counterparts at our favorite café, we headed over to ECOSUR to get to work. One of the most impressive aspects of the project that we’re supporting is the community engagement component. Transgenic mosquitoes have the potential to make a huge impact in decreasing the spread of Dengue, Chikungunya, and Zika, but not without local residents taking their own measures to decrease the mosquito population (ie. ensuring that there are no open sources of fresh water).

They’ve thought to incorporate community support on all levels—from hiring local community members to work in the biofábricas to partnering with local schools for youth education, the project facilitators recognized the importance of community support and successfully wove it into the program. And that’s where we come in!

Dr. Ariane Dor of ECOSUR and her team have created a puppet show that teaches children about Técnica del Insecto Estéril and how they can support the efforts. It just so happens that they need puppeteers! After reviewing the script and assigning roles (I still can’t believe that Peter passed on the opportunity to play Doña Zancudo—it’s the role of a lifetime) we got down to business. With only 4 days to prepare before our soft opening, it’s high stakes. But not shying away from these types of high-pressure situations is probably what got us into medical school in the first place.

We’ve been looking forward to seeing the clinical side of the project, so when the opportunity arose to meet Dra. Romero’s boss, Dr. Adrian, we were happy to head over to Hospital General de Tapachula. He was enthusiastic about our participation in the project and eagerly shared the most recent data about the current Dengue outbreak. And the information is pretty bleak: Tapachula (along with the surrounding municipalities within Chiapas) is currently facing an unexpected increase in aggressive cases of Dengue. It’s clear that further efforts to control the spread of disease can’t come soon enough. And although we haven’t been cleared for clinical work  yet (fingers crossed for later this week!), we can absolutely support these efforts from a public health perspective.

With that in mind, we’re even more determined to help this project succeed. Let’s get this (puppet) show on the road!

Rehearsal time!

This is Doña Zancudo– you can tell because of her smoother antennae (and blood meal).

The magic begins.

The lab where TIE happens.

Just a few of the amazing characters.

Tapachula Weekend 1: Friday, June 1- Sunday June 3, 2018

We made it through our first week—and lets be real, it wasn’t easy. So we’re heading to Finca Argovia resort. Treat yo self! Chiapas is known for its exceptional coffee and we’d be crazy not enjoy as much of it as we can, so we’re visiting a coffee plantation to see how they make the magic happen. It just happens to be located in a rain forest, no big deal.

The drive from Tapachula is long and winding. As we snaked our way up the mountain, tightly hugging the narrow cliff side, we passed by countless waterfalls, increasingly jungle-ish flora, and vibrant Ejidos.

The long drive is worth it, y’all. Situated deep in the rainforest of Sierra Madre de Chiapas mountain range, the views are stunning. The daily thunder storms definitely pay off!

Now for a weekend of relaxation (and delicious food) before we jump into a week full of amazing clinical learning opportunities!

The walk from the lobby to our room almost captures hows beautiful the land is.

Más tamales de chipilin!

We’re basically coffee experts now.

Just kidding, but we did learn about the different roasting processes!

The view from our room was spectacular.

Tapachula Day 5: June 1, 2018

At 8 am, we were picked up by Dr. Ariane Dor to go to ECOSUR, another research center in Tapachula that’s heavily involved with the TIE project. There we met Ana Laura, a social anthropologist, and Cesar, an entomologist. The three of them gave part of yesterday’s seminar on TIE and it’s clear after working with them today that their team is more focused on the aspect of community engagement. For instance, they shared with us an adorable script for a puppet theater play they’re going to use for teaching primary school kids about the Aedes mosquito as well as sterile insect technique. In the story, a male and female mosquito (zancudos) get introduced along with a crazy but good-natured scientist. They demonstrate that the zancudo has many more fine hairs on his antennae while the zancuda does not, and the zancuda is the only one interested in drinking human blood. The zancudo on the other hand feeds only on nectar, and as he spots the zancuda in every scene he’s always trying to court her with flowers. The scientist later explains to the audience that the zancudo is sterile and was created in his special laboratory so that dengue, chikungunya, and zika viruses will stop spreading. It ends with the two zancudos falling in love and a special reminder that all his work will be for nothing if the audience doesn’t help with keeping their yards clean and water tanks covered to keep the zancudos away.

In the afternoon, we went to Hospital General de Tapachula to meet with Dr. Daenna Romero, who is both a medical doctor and epidemiologist. She explained that virtually all of the mosquito-borne cases they receive are dengue fever. There are actually different classifications of dengue fever, based on WHO 2009 guidelines: non-serious dengue fever without warning signs, non-serious dengue fever with warning signs, and serious dengue fever. There are a list of signs and symptoms shared among the different groups but is upgraded in severity if something like tachycardia, pleural effusion, or ascites is observed. There is also a sequelae that is usually observed from day to day, leading to what’s known as the febrile, critical, and recovery/convalescent phases. However, Dr. Romero noticed that more recently patients have been showing a more rapid onset of sequelae and other severe signs such as tachycardia on as early as the first day.

Tapachula Day 4: Thursday, May 31

We attended a seminar today on Técnica del Insecto Estéril (TIE) at the center. TIE, which translates to Sterile Insect Technique, is one of the most significant components here at INSP-CRISP in the effort to reduce the Aedes mosquito population, which is the vector for dengue, chikungunya, and zika viruses. The presentation consisted of two parts: background and methodology of TIE in the morning, and past/present/future efforts in community education and participation in the afternoon.

The morning portion was given by Dr. José Liedo Pablo Hernández, an entomologist at ECOSUR which also collaborates in this project. He talked briefly about the use of TIE to successfully eradicate the screw-worm fly (Cochliomyia hominivorax) from the Americas, an effort that started in the U.S. in the 1950s and continued on through Central and South America in the ’80s and ’90s. The idea of completely eradicating mosquitoes is too impractical, however, so the aim is to suppress their population in specific areas instead. TIE is already being tested in two rural communities near Tapachula: Rio Florido and Ejido Hidalgo. So, how many sterile mosquitoes need to be released in order to effectively reduce the population? Dr. Liedo demonstrated this with Curaçao, a simulation software based on Knipling’s model of sterile insect release, and showed us that there needs to be at least a 5:1 sterile-to-fertile ratio in order to effectively reduce the population over x generations (e.g. at 4:1, the population doesn’t decrease at all).

The afternoon portion was more focused on what’s been implemented so far, including community aspects of mosquito control. For example, surveys were conducted to assess the knowledge and prevention of mosquitoes in the community. Some of these questions included: 1) do you know about zika, dengue, and chikungunya? 2) how are these diseases transmitted? 3) what do you do to protect your house? Community members are encouraged to clean their windows and yards and to not leave any standing pools of water around their homes, where mosquitoes can breed. Novaluron is a larvicide that they can use. Ariane, an entomologist, and others also showed us puppets that they made, one male and female, to teach young children about mosquitoes in schools.

Everyone at the seminar was very enthusiastic about the TIE project and the level of community engagement so far. Most of the people in attendance were actually the bioengineering team that helped make the sterile mosquitoes for this project, so it was probably amazing for them to see the other aspects of this project. We ended with a small exercise in which we all wrote and explained what TIE is, in our own words.

Tapachula Day 3: Wednesday, May 30, 2018

It’s been a whirlwind since day one, really. We arrived, we met a series of gifted and driven doctors that work at CRISP, and we got to work on the project available. And there’s so much to learn! Culturally (What’s expected of us?Are we ever going to eat lunch? Do I have to keep using the Usted form?), from a scientific perspective (How do you estimate mosquito counts?), even logistically. Like the fact that there is significant overlap between concurrent projects at CRISP. Which made today a day of realizations

1. We’re on our own in Tapachula. As supportive as Dr. Velasco is, he’s not here and it’s up to us to ensure things move forward smoothly.
2. CRISP operates a variety of different projects, many of which focus on Chikungunya, Dengue, and Zika.
3. We aren’t assisting with the project that we intended to work on. Oops.

By virtue of its tropical location, CRISP is the perfect site for multiple studies focusing on mosquito-borne diseases and with Drs. Rogelio Danis and Iliana Malo out of the office, Dr. Clemente kindly stepped in to guide our efforts. However, as we discovered while comparing protocols today, Dr. Clemente works on a similar, but distinct project. So while we have been helping to continue efforts toward Chikungunya research, it’s not the project we came to support. Good to know.

While this does change the foundation of our research a bit (yikes), we’re up for the challenge! Can’t be too upset when there’s horchata (and the biggest burrito I’ve ever seen), right?

When live gives you lemons, go buy horchata.

This is just ONE burrito! They had to cut it to fit it into the container. It goes without saying that it was delicious.

Tapachula Day 2: Tuesday, May 29, 2018

We survived! (It was questionable at one point.)

After a morning spent working on our survey at CRISP, we set out to track down patients with a history of Chikungunya. This phase of the project was fairly simple conceptually: ascertain whether patients have continued sequelae and assess their living space for possible “criaderos” where mosquito eggs hatch. We had been told it was difficult to locate many of them, due to the lack of consistent addresses, but we like a challenge! We grabbed our coats and doctoring bags, joined our colleagues in a 12 seater van, and headed out into Tapachula. Barely 20 minutes from the city center the setting was drastically different: instead of a grid of streets, we were in the mountains– as we drove down an unpaved hill, surrounded by jungles, winding creeks, and small houses, I was struck by the raw beauty of the surroundings. Until we got stuck.

After advancing down an unpaved road, we realized we wouldn’t be able to make it up the impending hill, so our fearless driver tackled a three point turn. On the edge of a cliff. With the vantage point of the back row of seats that provided a full view of the cliff we were teetering on, trust me when I say we came close. Close enough that one of our German counterparts had the door open ready to jump (no joke!). But as you may have guessed by virtue of reading this now, we made it!

After deciding it was better to continue on foot, our first patient greeted us outside of her home and invited us in. We spoke with her for a while about the chronic arthralgias, the limited treatments (NSAIDs, for the most part), and the methods of transmission. She was familiar with all the information we shared and happily invited us to search her property for criaderos, of which we found 3. This really highlights the challenge that prevention presents in a location as tropical as Tapachula. With near-daily thunderstorms, rainwater will collect in almost any receptacle, and Aedes aegypti take full advantage. After collecting samples of larvae and providing further education of prevention, we continued on our way.

Despite attempting to visit 5 other patients throughout different neighborhoods within Tapachula, we were unsuccessful. The lack of addresses, changed phone numbers, and hesitant participants make this a challenging effort. Beyond the logistic challenges, in speaking with patients and colleagues we’ve gathered that there is some degree of mistrust of these public health efforts– repeated blood tests for different mosquito-borne diseases (sometimes without follow-up regarding results) has left people wary of participating. But today’s educational efforts (and even our presence as medical students) are helping to slowly reinforce the good intentions of INSP-CRISP and other local public health organizations.

And to cap it all off, we experienced our first tropical thunderstorm today. Let’s just say the weather here does not play and I now understand the humidity.

Sampling the criadero found in the dog’s water bowl.

Larva from a criadero.

After we decided to continue on foot.

The road where we almost died.

Tapachula Day 1: Monday, May 28, 2018

We’re learning that Tapachula is all about flexibility.

We arrived at Central Regional del Instituto en Salud Publica (CRISP) at 9 am to meet with Dra. Iliana Malo, as CRISP director, Dr. Rogelio Danis, was out of the office. Instead, Dr. Clemente met us at 10:30 and gave us a brief tour of the facilities at CRISP. The mosquito cages are pretty neat!

After introducing us to several of the incredible scientists that are contributing to various projects that CRISP is hosting, Dr. Clemente gave us a more in-depth look at the obstacles that the projects face. Community engagement seems to be the common hurdle across all projects. Despite the scientific research that has identified modes of transmission and methods of prevention, obtaining support from the community to implement best practices still proves to be challenging. The exact issue varies by project, from a general mistrust of the objectives of the government to different levels of social consciousness, but its clear that the current efforts to establish meaningful engagement within the community will change the impact of studies throughout the area.

After a morning spent acquainting ourselves with CRISP, one of the center’s fearless drivers, Zavala, met us and offered to take us around to find a new place to stay. Woohoo! We jumped in a pickup and started exploring the city. Zavala helped us to navigate the different areas and locate a jungle-esque apartment that immediately caught our interest. Wi-Fi, AC, and hot water?! Sold!

With our housing situation finally settled, we returned to CRISP and began the real work. When our German counterparts learned that we were interested in conducting a survey, we decided to team up to assess the knowledge of local communities regarding disease transmission and prevention. So the fun begins!

Have you ever devised a survey? It’s as thrilling as it sounds.

Inside the CRISP grounds

CRISP!

The view from our apartments.

Tapachula Day 0: Sunday, May 27, 2018

We made it to Tapachula!

After falling in love with Mexico City, we arrived at Tapachula airport in the early afternoon. As we landed, I was struck by the vibrant green of the city below. At the airport we were met by the endlessly kind and welcoming Dr. Clemente Mosso.

Dr. Clemente took us into town and to the rooms that had been reserved for us. Unfortunately, there had been miscommunication with the rooms rented (this happens frequently– people will rent rooms that have already been reserved or change the price; both happened to us). Dr. Clemente was amazingly kind and helped us as we worked through different possibilities. Be prepared that some of the options are less well appointed. Dr. Velasco was able to speak with the woman who rented the rooms and helped us renegotiate the pricing, but they were ultimately unable to provide rooms for both of us.

Not to worry, Dr. Clemente assured us that we would be able to find more options tomorrow (not many people work on Sundays). We found a nearby hotel (with clima!) and set about exploring the city.

I don’t do humidity well, but I quickly forgot about the weather as we made our way through the small city center. Even on a hot, slow Sunday, the city’s vibrant energy was obvious—parks were filled with families and people streamed through the streets. We sampled the local specialties (tamales de chipilin—yum) and headed back to get ready for our first day.

Bring on the Chikungunya!

Parque Central Miguel Hidalgo

Our view as we landed at Tapachula airport.

Tamal de chipilin! Que rica!