Dengue Outbreak

Sheryl · July 9, 2013

This thread replaces multiple separate threads that were started in various regional forums and is designed to provide a single source for information, questions, comments related to dengue.

Sheryl · July 9, 2013

Some general information:

Dengue is always endemic here but every 2-3 years there is an epidemic and this is one of those years. It is carried by the aedes egypti mosquito which usually bites in daytime. The guilty mosquito has a very limited flight path so you will almost always be bitten close to where it breeds. Water jars are a major source but any stagnant water will do. Since it doesn't fly very far, you can greatly reduce your risks by clearing out any stagnant water areas and being sure any water jars are securely covered (I use mosquito netting over it PLUS a lid). That will help prevent getting it at home,. Still need to take care when you go out. the fresh markets are especially bad as lots of water standing about. Put plenty of repellent on before you go places like that.

Simple dengue (the most common form) is managed symptomatically and indeed must run its course. Paracetemol is given for fever and pain, and sometimes stronger pain killers (e.g. codeine, tramadol) are necessary. Some people also require IVs to maintain hydration. There is a very wide clinical spectrum of "simple" dengue, from what feels like a mild flu to what has the person flat on their back unable to move for up to 2 weeks and everything in between.The convalescent period is prolonged and depression during it is common.

While very unpleasant, "simple" dengue carries no long term risks. However for reasons still not totally clear, but possibly related to an auto-immune response (and most commonly found in people who had prior dengue infections as a child), a minority of people develop a complicated hemorrhagic form of the disease (Dengue Hemorrhagic Fever AKA Dengue Shock Syndrome) and this is very serious. The deaths you see reported are from this, not from simple dengue.

Properly managed -- and the Thai hospitals have extensive experience with it -- the mortality rate for Dengue Hemorrhagic Fever is only about 1%. But it does require immediate hospitalization and close management. Fluid replacement and sometimes blood products, among other things, are often necessary. There is no "cure" for the hemorrhagic form either but like simple dengue it will run its course in about 10-14 days so it is a matter of preventing/treating shock until it has had a chance to do so. In more than 2 decades here I have known hundreds of cases of dengue in farang, only recall one where the hemorrhagic form occurred. Locals seem to be at higher risk of that, perhaps due to sensitization as a child. Not saying it can't happen, but the risk is small. Risk of having an unpleasant few weeks of pain and fever though is quite real. (I've had it 3 times myself so speak from experience).

Of course back in Europe or the US, you'd face periodic flu outbreaks with equal or higher mortality stats. Just to put it in perspective.

TallGuyJohninBKK · July 9, 2013

Sheryl...I've seen sporadic and limited reports of numbers of cases here and there...usually with very little context.

But is there any legitimate government reporting that would give all of us any sense of where the most outbreaks are occurring?

Sheryl · July 9, 2013

The department of Disease Control at the Ministry of Public Health tracks this but I am not aware of a website showing the data I do know that an increased number of cases has been reported from every province in the country and that currently they are projecting over 120,000 known cases for 2013.

Periodically news releases go out expressing concern about the number of cases in this location or that location (to date: Chiang Mai, Issan, Bangkok) but there isn't much rhyme or reason to what gets in the press. The highest number seems to be in the north and northeast but sometimes that is also a function of better reporting. The epidemic is definitely nationwide and also in neighboring countries and extending as far as Singapore and the Philippines. As has happened in the past as well.

We don't have permission to print links to the Bangkok Post but if you look up their July 8th addition you'll find an overview from the MOPH on the situation.

Sheryl · July 9, 2013

This advisory from the Canadiuan Public Health authorities:

http://www.phac-aspc.gc.ca/tmp-pmv/notices-avis/notices-avis-eng.php?id=44

Seems there are also outbreaks in some parts of Africa at this time. Raised global temperatures may be a factor.

TallGuyJohninBKK · July 9, 2013

Here's a news report from MCOT about the same time as the BKK Post one you mention above that seems to contain parallel info.

BANGKOK, July 7 – The Public Health Ministry has launched a campaign against the dengue fever outbreak as the number of patients may surpass 100,000 this year.

Public Health Minister Dr Pradit Sintavanarong said about the measures to contain the dengue fever outbreak that from July 10-17 the ministry will hold a major campaign nationwide to have more than one million volunteers eradicate mosquitoes in residential areas, houses, schools and temples while educating people about the disease.

In the past week, the country recorded 5,276 new infections with six deaths. The disease is spreading in the northern part of Thailand.

Deputy Director General of the Department of Disease Control, Dr Opas Karnkavinpong, said the dengue fever situation in the second half of this year is worrisome and the number of patients may be as high as 120,000.

The department is working to contain the outbreak and keep the number of infections below 100,000.

In July and August, the rainy season is at its peak for the outbreak. Patients with two days of flu-like symptoms including high fever are advised to seek medical treatment, he said.

So far this year, there have been 59,318 dengue fever patients and 68 fatalities. The infection rate is 92.57: 100,000 population with the death rate is 0.11: 100,000 population. (MCOT online news)

http://www.mcot.net/site/content?id=51d924bf150ba0f4050001e0#.UdwVdqya2Sp

TallGuyJohninBKK · July 9, 2013

Sheryl...I searched around and came up with this document from last month from the Ministry of Public Health's Bureau of Epidemiology...

I don't read Thai, but I gather it contains breakdowns on the spread of the disease by province.... Maybe someone here with better language skills can help decipher it. I believe it includes data on a # of reported cases per 100,000 population basis.

http://www.boe.moph.go.th/files/report/20130619_6071090.pdf

And it seems to have a color coded map showing the heaviest outbreak areas in red, as the case reporting progressed thru periods last month.

Sheryl · July 9, 2013

Indeed it does, thanks

My written Thai is pretty basic. Any volunteers to help translate this?

The map presumably follows the standrad green, yellow red meaning. Note though that green will not mean no dengue, just that the number of cases aren't unusually high for this time of year. Even in non-epidemic years there are always many dengue cases in the rainy season.

connda · July 9, 2013

Some general information:

Dengue is always endemic here but every 2-3 years there is an epidemic and this is one of those years. It is carried by the aedes egypti mosquito which usually bites in daytime. The guilty mosquito has a very limited flight path so you will almost always be bitten close to where it breeds. Water jars are a major source but any stagnant water will do. Since it doesn't fly very far, you can greatly reduce your risks by clearing out any stagnant water areas and being sure any water jars are securely covered (I use mosquito netting over it PLUS a lid). That will help prevent getting it at home,. Still need to take care when you go out. the fresh markets are especially bad as lots of water standing about. Put plenty of repellent on before you go places like that.

Simple dengue (the most common form) is managed symptomatically and indeed must run its course. Paracetemol is given for fever and pain, and sometimes stronger pain killers (e.g. codeine, tramadol) are necessary. Some people also require IVs to maintain hydration. There is a very wide clinical spectrum of "simple" dengue, from what feels like a mild flu to what has the person flat on their back unable to move for up to 2 weeks and everything in between.The convalescent period is prolonged and depression during it is common.

While very unpleasant, "simple" dengue carries no long term risks. However for reasons still not totally clear, but possibly related to an auto-immune response (and most commonly found in people who had prior dengue infections as a child), a minority of people develop a complicated hemorrhagic form of the disease (Dengue Hemorrhagic Fever AKA Dengue Shock Syndrome) and this is very serious. The deaths you see reported are from this, not from simple dengue.

Properly managed -- and the Thai hospitals have extensive experience with it -- the mortality rate for Dengue Hemorrhagic Fever is only about 1%. But it does require immediate hospitalization and close management. Fluid replacement and sometimes blood products, among other things, are often necessary. There is no "cure" for the hemorrhagic form either but like simple dengue it will run its course in about 10-14 days so it is a matter of preventing/treating shock until it has had a chance to do so. In more than 2 decades here I have known hundreds of cases of dengue in farang, only recall one where the hemorrhagic form occurred. Locals seem to be at higher risk of that, perhaps due to sensitization as a child. Not saying it can't happen, but the risk is small. Risk of having an unpleasant few weeks of pain and fever though is quite real. (I've had it 3 times myself so speak from experience).

Of course back in Europe or the US, you'd face periodic flu outbreaks with equal or higher mortality stats. Just to put it in perspective.

I had Dengue Hemorrhagic fever in Korat in October 2010. I know exactly when and where I contracted it: I was in a local hospital that has a fountain in the lobby (great breading ground). The lobby was always infested with though small, aggressive, day-dwellers. I had visited the hospital for a test. While there my wife killed a mosquito on my neck who had enjoy and nice meal. One week later I had a 102 degree fever; back to the hospital for two weeks. I had blood seeping from the pores in my legs. The doctor refused to give me codeine (the pr*ck) so a friend hooked me up with over-the-counter tramadol. It didn't do much for the pain, but it did make me feel better.

Post dengue pretty well changed my life. Over the next year I lost over 26 lbs of body weight. I was fatigued all the time and basically felt beaten down. I finally had to quit work. I just no longer had the energy, and I wasn't doing my students any service by sticking around. I then moved back to Chiang Mai. I made numerous visits to Maharah hospital and our local clinic. I thought I was dying for sure, but the hospital assured me that I had no potentially fatal diseases -- only Post Dengue Fatigue Syndrome. It's real and it's nasty. I was told to hang in there, take care of myself, and wait it out. I waited about 14 month before I started feeling better. Then I got back into working out at the gym, walking, biking, and basically exercising again regularly. And slowly, the weight started building back up.

Dengue is NOT something you ever what to get. It ain't fun. And if you ever go to a local hospital in Korat with a fountain in the lobby, you might want to liberally apply mosquito repellent before you go. And if you live anywhere with active, aggressive, daytime mosquitoes I'd suggest applying liberal amounts of DEET on a daily basis to any bare skin.

connda · July 9, 2013

Sheryl...I searched around and came up with this document from last month from the Ministry of Public Health's Bureau of Epidemiology...

I don't read Thai, but I gather it contains breakdowns on the spread of the disease by province.... Maybe someone here with better language skills can help decipher it. I believe it includes data on a # of reported cases per 100,000 population basis.

http://www.boe.moph.go.th/files/report/20130619_6071090.pdf

And it seems to have a color coded map showing the heaviest outbreak areas in red, as the case reporting progressed thru periods last month.

Dengue-2013 06.jpg

I think it is showing the spread from the 5th, 11th, to the 14th of June respectively from left to right. But my reading glasses suck so I might be wrong

TallGuyJohninBKK · July 9, 2013

Re the Dengue map by province that I posted above, Google Translate works to a certain extent on PDF documents, unfortunately very roughly in Thai.

My Thai wife translated the three map images I posted above as each represting a week in June, starting at the beginning of the month and then moving thru the month in stages.

Edited July 9, 2013 by TallGuyJohninBKK

TallGuyJohninBKK · July 9, 2013

This document from the Thai Bureau of Epidemiology also provides dengue case statistics, in ENGLISH, including the case rates per 100,000 population and deaths rates, by area, province I believe, from Jan 1 thru May 28, 2013.

So it's not as recent as the color coded maps posted above that reflect June. But this data is much more detailed in its breakdown.

The English detail charts on dengue through May 28 are on pages 12-13 of the document.

http://203.157.15.4/wesr/file/y56/H56212013-05-192013-05-25.pdf

Here's what the beginning of the dengue chart looks like in the PDF document, including the detail for BKK:

As an added bonus, the charts on the prior couple pages show similar breakdowns by area for a range of other reportable diseases.

This series of documents are coming from this MOPH website:

http://boe-wesr.net/index.php

And the files that make up the reports series over time are found in this directory:

http://203.157.15.4/wesr/file/y56/

And here's another document from MoPH on dengue, unfortunately in Thai, that appears to be dated for the current month of July.

http://www.boe.moph.go.th/boedb/surdata/506wk/y56/d26_2756.pdf

It certainly appears to show a recent surge of cases in the Northeast area, far more than in other areas.

Edited July 9, 2013 by TallGuyJohninBKK

jrtmedic · July 9, 2013

Advice from the American CDC

Here

http://www.cdc.gov/dengue/symptoms/

wilcopops · July 9, 2013

Not one species - Dengue is transmitted by SEVERAL speciesof mosquito of the genus Aedes.

there is evidence that the disease goes through waves (cycles) normally 7 years but there has been a steady increase in occurrence and range over the last few years and this is quite probably due to climate change and increased air travel to tropical destinations.

Flu virus, unlike Dengue has a vaccine program that can reduce the impact even though high percentages of vaccination have yet to be achieved.

whereas flu comes in distinct waves, dengue is endemic to places like Thailand.

"simple" dengue can be asymptomatic and the patient may not be aware that he/she even has the fever. However in many cases ity lives up to its old name of "break bone fever"

Fountain? _the Mozzie larvae like standing water.

A point ot note about the behaviour of the Aedes mozzie - you may see many flying about in front of you......these are most likely the males waiting for the females who are far more sneaky as it is they and only they who require your blood. THis behaviour of the males has the added advantage that it distracts the victim rom noticing the females landing on them.

One bite is all it takes - but considering that this has to be a successful bite from a female with the virus already developed in her salivary glands, and the exchange of fluids is minute, in reality you could be bitten several times before an infection takes place.

Edited July 9, 2013 by wilcopops

TallGuyJohninBKK · July 9, 2013

By province, the largest dengue case numbers and fatalities in the report thru May 28 appear to be as follows:

But note, these are raw case numbers and fatalities, not per capita case numbers.

Bangkok Metropolis -- 3577 -- 1

Songkhla -- 2595 -- 6

Nakhon Si Tham. -- 1566 -- 3

Chiang Mai -- 1335 -- 2

Nakhon Ratchasima -- 1195 -- 2

The highest per capita case reports (per 100,000 population) appear to be:

Krabi -- 208.20

Songkhla -- 189.83

Phuket -- 185.96

Phangnga -- 159.26

Loei -- 134.26

Trat -- 104.50

Nakhon Si Tham -- 102.62

Of course, to have meaning, the per capita stats have to be based on realistic, accurate population data. And I have no idea how realistic are the end of 2011 population figures they use in the report.

Soi Sauce · July 9, 2013

Wiil the gov do anything about this?

No chance.

Hi-speed trains that no-one will use and cheap cars are much more imp. than healthcare and hospitals.

TallGuyJohninBKK · July 9, 2013

And here's another document from MoPH on dengue, unfortunately in Thai, that appears to be dated for the current month of July.

http://www.boe.moph.go.th/boedb/surdata/506wk/y56/d26_2756.pdf

It certainly appears to show a recent surge of cases in the Northeast area, far more than in other areas.

PS0862.jpg

Just to clarify on this document above, the Bureau of Epidemiology appears to have several different versions of this report....

This one is labeled "Dengue Fever":

http://www.boe.moph.go.th/boedb/surdata/506wk/y56/d66_2756.pdf

This one is labeled "DHF," which may stand for dengue hemorrhagic fever:

http://www.boe.moph.go.th/boedb/surdata/506wk/y56/d26_2756.pdf

This above is the one for which I previously posted a link and graphic above.

This one is labeled "DHF Shock Syndrome":

http://www.boe.moph.go.th/boedb/surdata/506wk/y56/d27_2756.pdf

And this one is labeled as "DHF+DSS+DF"

http://www.boe.moph.go.th/boedb/surdata/506wk/y56/d262766_2756.pdf

Here's the graphic from that final, combined types report that shows cases by region:

Edited July 9, 2013 by TallGuyJohninBKK

RickBradford · July 9, 2013

The graph from the Bureau of Epidemiology, Ministry of Public Health is titled "Situation of types of hemorrhagic diseases (hemorrhagic fever, hemorrhagic shock fever and dengue) across the whole of Thailand".

The left (vertical) axis shows the actual number of cases; the horizontal axis is the week number of the year, running from 1 to 52. The blue line represents last year, the red line is this year, and the magenta line is the median (somewhat like an average) of the past 5 years.

It looks like an 'outbreak' (that is, a significant increase over the median) began last year in about week 43, i.e. the end of October 2012.

The document comments: "[Occurrences] have been unusually high since the beginning of the year as there has been a continuing spread since late last year, which was a year which saw a spread of the disease in the second half.

Regarding the dotted portion of the red line, the document says: "It is expected that the outbreak of the group of hemorrhagic diseases will begin to slow down in the month of June (weeks 23 - 24), but there will still be a high number of cases each week (from 4,000 to 4,500) and it is expected to stay at this level (a flat curve) for the next 1 to 3 months), similar to previous years when this portion of the year shows the outbreak at its peak."

So the red dotted line is very misleading; it looks like it is a prediction of the end of the outbreak, but it isn't. It may just be unfinished figures of people reporting in sick.

RickBradford · July 10, 2013

The final graph posted by @TallGuyJohninBKK has some interesting details:

* The whole country average is 101.76 cases per 100,000

* 51.6% of the sufferers are school-children

* Phuket has the highest rate at 370/100k, central Thailand the lowest at 68.39/100k

* The Isaan region has an especially high number of 7-9 year-olds affected

* There have been a total of 67,889 cases with 71 deaths.

Once again, the bottom graph makes it look as though there is a crash in the outbreak; this is not so.

TallGuyJohninBKK · July 10, 2013

Rick, I posted above a series of documents/reports from the Bureau of Epidemiology's website on dengue...

But in your two posts above, I'm not sure where/which documents you're drawing those references from, and the numbers you're citing don't seem to be the same as the ones in the documents I linked to, and posted the statistics on above (the dengue data by province thru May 28).

For clarity's sake, perhaps you would repost your two posts above and add into them the specific links for the particular documents you're pulling those numbers from. PS - I don't read Thai, so perhaps you're seeing info there that I can't follow.

For example, in most of the graphics I saw in and used from those documents, the different colors used (red, blue, magenta and green) were keyed to data from the four different regions of the country -- not this year, last year and median references that you mention in your post above.

Edited July 10, 2013 by TallGuyJohninBKK

MrWorldwide · July 10, 2013

Awesome - I was about to post asking what vaccinations I should get before returning to Asia when I remembered that you cant get vaccinations for several of the nastiest mosquito-borne diseases - happy to hear otherwise. Some of the advice given by health officials is gold - 'avoid stagnant water or other mosquito habitat'. Right - pretty much rules out the entire Mekong and large slabs of Bangkok. I can get a shot for Japanese encephalitis, but I know that I wont remember to wear mosquito-repellant every single day, particularly in an urban area. I've lived in a variety of tropical and subtropical regions in Oz without incident, and haven't had a problem in Asia (to date), but I suspect that is more good luck than good management.

Interested to know if others burn incense or whatever to keep mossies at bay, and any shots you may be getting prior to getting on the plane. Mosquito coils stink to high heaven, but it it takes coils and nets, so be it. Anything known as 'breakbone fever' has to be worth the effort ....

jrtmedic · July 10, 2013

Seems that Queensland,Australia has a Dengue problem !

http://www.health.qld.gov.au/dengue/outbreaks/current.asp

wilcopops · July 10, 2013

Awesome - I was about to post asking what vaccinations I should get before returning to Asia when I remembered that you cant get vaccinations for several of the nastiest mosquito-borne diseases - happy to hear otherwise. Some of the advice given by health officials is gold - 'avoid stagnant water or other mosquito habitat'. Right - pretty much rules out the entire Mekong and large slabs of Bangkok. I can get a shot for Japanese encephalitis, but I know that I wont remember to wear mosquito-repellant every single day, particularly in an urban area. I've lived in a variety of tropical and subtropical regions in Oz without incident, and haven't had a problem in Asia (to date), but I suspect that is more good luck than good management.

Interested to know if others burn incense or whatever to keep mossies at bay, and any shots you may be getting prior to getting on the plane. Mosquito coils stink to high heaven, but it it takes coils and nets, so be it. Anything known as 'breakbone fever' has to be worth the effort ....

"happy to hear otherwise" - ????

Whilst there is research into a dengue vaccine I don't believe one is available yet.....I would love to be wrong on this. Anyone??

TallGuyJohninBKK · July 10, 2013

The graph from the Bureau of Epidemiology, Ministry of Public Health is titled "Situation of types of hemorrhagic diseases (hemorrhagic fever, hemorrhagic shock fever and dengue) across the whole of Thailand".

The left (vertical) axis shows the actual number of cases; the horizontal axis is the week number of the year, running from 1 to 52. The blue line represents last year, the red line is this year, and the magenta line is the median (somewhat like an average) of the past 5 years.

It looks like an 'outbreak' (that is, a significant increase over the median) began last year in about week 43, i.e. the end of October 2012.

The document comments: "[Occurrences] have been unusually high since the beginning of the year as there has been a continuing spread since late last year, which was a year which saw a spread of the disease in the second half.

Regarding the dotted portion of the red line, the document says: "It is expected that the outbreak of the group of hemorrhagic diseases will begin to slow down in the month of June (weeks 23 - 24), but there will still be a high number of cases each week (from 4,000 to 4,500) and it is expected to stay at this level (a flat curve) for the next 1 to 3 months), similar to previous years when this portion of the year shows the outbreak at its peak."

So the red dotted line is very misleading; it looks like it is a prediction of the end of the outbreak, but it isn't. It may just be unfinished figures of people reporting in sick.

OK...now I see that your post above here appears to be referring to the very first document I posed above, an 8-page one from the MOPH, Bureau of Epidemiology, that's entirely in Thai language, including its number references. I'm assuming this is the graph you refer to in your quoted post above:

Here's the link, again, to the full document, which appears to be dated June 19:

http://www.boe.moph.go.th/files/report/20130619_6071090.pdf

This document on pages 6-8 also includes a breakdown of cases province by province, probably later than the May 28 data I cited above. But again, all of those province names and corresponding cases numbers are in Thai lettering and numerals, meaning I and many others here can't decipher them.

And the original color-coded graphic I posted from that document showing the levels of cases by province during the month of June, week by week.

Edited July 10, 2013 by TallGuyJohninBKK

wilcopops · July 10, 2013

I feel that Fighting dengue in Thailand can be hindered by Government information........

Government figures with explanation of cause don't really have much use. - Also one has to consider by who and how the figures are collected and then interpreted.

The govt does engage in fogging asa precaution however I must say that those who carry out these operations seem to be little more than "cowboys" so how effective this is - even if it actually takes place - has to be questioned.

reporting of the disease is dodgy too - Doctors are prone to diagnosing any fever as Dengue without supporting evidence (as I understand it blood tests ae the only convincing way to diagnose) - on the other hand many people go through Dengue without reporting to a hospital. Foreigners may actually be out of the country by the time they get the disease.

My Thai colleagues although aware of Dengue, do not seem to be aware of how it is transmitted or how to increase personal protection against it. They are mostly of the opinion that if they see some "fog" then everything is OK. Small quantities of standing water never seem to come into consideration and there is a prevailing attitude that the disease is a JUNGLE problem - which couldn't be further from the truth. Very few consider the proliferation of domestic water tanks, used to counteract the erratic supply of mains water to some areas (inc Bangkok) as a problem.

Although a vaccine would be great the introduction of GM mosquitoes may present a more immediate and quite effective weapon against the disease.

Edited July 10, 2013 by wilcopops

TallGuyJohninBKK · July 10, 2013

There certainly are limitations and issues with any kind of national statistical reporting...

However, a lot of members here over the past weeks have been, understandably, asking for some information indicating what parts of the country are having the greatest levels of dengue cases.

The various data points listed above begin to give all of us some sense of where the hotspots have been occurring.

Kudzu · July 10, 2013

Phuket. Just recovering after horrible week of my illness. Keep you place safe and dry!

impulse · July 10, 2013

From the CDC website:

Treatment

There is no specific medication for treatment of a dengue infection. Persons who think they have dengue should use analgesics (pain relievers) with acetaminophen and avoid those containing ibuprofen, Naproxen, aspirin or aspirin containing drugs. They should also rest, drink plenty of fluids to prevent dehydration, avoid mosquito bites while febrile and consult a physician.

Source: http://www.cdc.gov/dengue/symptoms/

Can anyone clue me in on why aspirin, Naproxen and ibuprofen are not recommended?

Sheryl · July 10, 2013

Because these decrease blood clotting, and in dengue there is always the risk of developing hemorraghic complications.

People taking these drugs who need elective surgery are advised to discontinue them a few weeks before for the same reason.

MrWorldwide · July 10, 2013

Queenslanders are at risk from a host of mosquito-borne diseases. I worked with a guy who had Ross River fever and it basically stuffed him up for the best part of an entire year - IMO, he was never the same after contacting the disease.

http://www.health.qld.gov.au/mozziediseases/consumers/snapshotqld.asp

This is the mossie-borne disease that currently has authorities in northern Australia packing their daks:

http://en.wikipedia.org/wiki/Chikungunya

Thus far, they seem to have detected it in the bilge of ships from SE Asia - particularly Thailand - but they seem fatalistic about the chance of keeping it at bay forever. The pain associated with the onset of the disease is reportedly even worse than dengue - easy for me to say, but that's the claim.

http://www.chikungunya.in/chikungunya-joint-pain.shtml

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