Dengue Shock Syndrome

What is Dengue Shock Syndrome?

Dengue Shock Syndrome is a collection of symptoms resulting from a dengue infection. Its symptoms – including hemorrhaging – resemble those you’d see after an accident, when someone is ‘in shock’. Typically, older children or adults suffer 2–7 days of high fever and show two or more of the following symptoms:

  • severe headache,
  • retro-orbital eye pain,
  • myalgias,
  • arthralgias,
  • a diffuse erythematous maculo-papular rash, and
  • mild hemorrhagic manifestation.
  • Subtle, minor epithelial hemorrhage, in the form of petechiae, are often found on the lower extremities (but may occur on buccal mucosa, hard and soft palates and or subconjunctivae as well), easy bruising on the skin, or the patient may have a positive tourniquet test.
  • Other forms of hemorrhage such as epistaxis, gingival bleeding, gastrointestinal bleeding, or urogenital bleeding can also occur, but are rare.
  • Leukopenia is frequently found and may be accompanied by varying degrees of thrombocytopenia.
  • Children may also present with nausea and vomiting.
  • Patients with DF do not develop substantial plasma leak (hallmark of DHF and DSS, see below) or extensive clinical hemorrhage.
Dengue virus image
Dengue virus: Dengue Shock Syndrome

Serological testing for anti-dengue IgM antibodies or molecular testing for dengue viral RNA or viral isolation can confirm the diagnosis, but these tests often provide only retrospective confirmation, as lab results are typically not available until well after the patient has recovered.

Clinical presentation of DF and the early phase of DHF are similar, and therefore it can be difficult to differentiate between the two forms early in the course of illness. With close monitoring of key indicators, the development of DHF can be detected at the time of defervescence so that early and appropriate therapy can be initiated.

The key to successfully managing patients with dengue infection and lowering the probability of medical complications or death due to DHF or DSS is early recognition and anticipatory treatment(For more detailed guidance on management for DF please see the recommended treatment courses for DHF in the links listed below.)

Dengue Hemorrhagic Fever (DHF) or Dengue Shock Syndrome (DSS): The third clinical presentation results in the development of DHF, which in some patients progresses to DSS. Vigilant is critical for identifying warning signs of progressing illness and early symptoms of DHF which are very similar to those of DF. Case Definitions Page

There are three phases of DHF:

  1. the Febrile Phase;
  2. the Critical (Plasma Leak) Phase; and
  3. the Convalescent (Reabsorption) Phase.

The Febrile Phase: Early in the course of illness, patients with DHF can present much like DF, but they may also have hepatomegaly without jaundice (later in the Febrile Phase). The hemorrhagic manifestations that occur in the early course of DHF most frequently consist of mild hemorrhagic manifestations as in DF. Less commonly, epistaxis, bleeding of the gums, or frank gastrointestinal bleeding occur while the patient is still febrile (gastrointestinal bleeding may commence at this point, but commonly does not become apparent until a melenic stool is passed much later in the course). Dengue viremia is typically highest in the first three to four days after onset of fever but then falls quickly to undetectable levels over the next few days. The level of viremia and fever usually follow each other closely, and anti-dengue IgM anti-bodies increase as fever abates.

The Critical (Plasma Leak) Phase: About the time when the fever abates, the patient enters a period of highest risk for developing the severe manifestations of plasma leak and hemorrhage. At this time, it is vital to watch for evidence of hemorrhage and plasma leak into the pleural and abdominal cavities and to implement appropriate therapies replacing intravascular losses and stabilizing effective volume. If left untreated, this can lead to intravascular volume depletion and cardiovascular compromise. Evidence of plasma leak includes sudden increase in hematocrit (≥20% increase from baseline), presence of ascites, a new pleural effusion on lateral decubitus chest x-ray, or low serum albumin or protein for age and sex. Patients with plasma leak should be monitored for early changes in hemodynamic parameters consistent with compensated shock such as increased heart rate (tachycardia) for age especially in the absence of fever, weak and thready pulse, cool extremities, narrowing pulse pressure (systolic blood pressure minus diastolic blood pressure <20 mmHg), delayed capillary refill (>2 seconds), and decrease in urination (i.e., oliguria). Patients exhibiting signs of increasing intravascular depletion, impending or frank shock, or severe hemorrhage should be admitted to an appropriate level intensive care unit for monitoring and intravascular volume replacement. Once a

patient experiences frank shock he or she will be categorized as having DSS. Prolonged shock is the main factor associated with complications that can lead to death including massive gastrointestinal hemorrhage. Interestingly, many patients with DHF/DSS remain alert and lucid throughout the course of the illness, even at the tipping point of profound shock. CDC:

Doctors: See case definition for DHF and DSS. Adobe PDF fileExternal Web Site IconThere are no good videos about dengue shock syndrome, but this text video might help:

Dengue Bribery in Philippines?

Was there Dengue bribery in Philippines? Questions hover over Asia’s first dengue vaccination program in Philippines.

Dengue Mosquito
Dengue Mosquito: Asian Tiger

The Aedes aegypti mosquito carries the dengue virus, Zika virus, and other mosquito-borne illnesses as it travels from person to person.

Asia’s first dengue vaccine has been distributed in a mass school-based immunization program in the Philippines. So far, the program appears to be running without difficulties, but some health professionals are concerned that the vaccine was released before researchers could ensure its long-term safety.

From the beginning, the vaccine’s French manufacturer Sanofi Pasteur has been concerned about a potential problem with the vaccine — that while it could help prevent dengue initially, it could later increase the severity of the disease, according to Dr. Antonio Dans, a professor at the University of the Philippines College of Medicine.

“The real dengue we are afraid of is severe dengue, not the mild ones,” Dans said in a statement. “If a vaccine prevents mild disease but causes severe dengue, we shouldn’t be using it at all.”

This possibility is being monitored by the vaccine’s developer, Dans said in a news release; and since the phenomenon may happen a full three years after immunization occurs, it will take some time to study the vaccine’s long term effects.

However, as the virus infects as many as 400 million people annually, the vaccine for dengue has been awaited with increasing impatience. In an effort to stem the spread of the virus in regions heavily burdened by the disease, the WHO recommended that the drug be introduced in dengue-endemic sites while awaiting prequalification.

According to the organization, the WHO is now waiting on an application from the vaccine’s manufacturer.

The vaccine, Dengvaxia, has also been registered in Mexico, Brazil and El Salvador. Now, the Philippines — which in 2015 saw an almost 60 percent increase in dengue cases from the year prior — has become the first to make the vaccine commercially available.

“This initiative sends a strong message to the rest of the … world that dengue vaccination is a critical addition to integrated disease prevention efforts,” according to a statement from the vaccine’s developer Sanofi Pasteur.

The official launch of the school-based immunization program on April 4 sidestepped a prequalification procedure by the WHO, as is standard buy viagra online canada for new vaccines to ensure safety and effectiveness. This raised additional concern from some medical professionals, according to Philippine media network GMA, who say the immunization program should not have skipped the prequalification process, especially considering such limited knowledge of the vaccine’s long-term side effects.

Still, the company said the Dengvaxia vaccine, which took 20 years and $1.8 billion to develop, should prevent 80 percent of dengue-related hospitalizations and up to 93 percent of cases of severe hemorrhagic dengue fever. The vaccine is designed for people ages 9 to 45, and is administered in three separate doses over a six-month period.

Since the start of the immunization program last month, Dengvaxia has been administered to more than 200,000 grade-school students in the capital city of Manila. Of 17,000 people who were injected with the vaccine in the Philippines in February as part of the clinical study, just 27 developed side effects, Health Undersecretary Vicente Belizario told reporters.

According to Health Minister Janette Garin, the $103 million program aims to administer the first dose of the vaccine to 1 million children by June.

The history of developing a vaccine for dengue has been wrought with challenges. An effective vaccine must protect against four closely related viruses that can cause the disease, and researchers have had limited understanding of how the virus affects the immune system. Among other barriers making vaccine development more difficult, there are no easily measurable sign (such as antibodies) that a person is immune to the disease.

The WHO estimates that dengue fever, the world’s most common mosquito-borne virus, infects an estimated 390 million people around the world each year. So far this year, more than 33,000 dengue cases have been recorded in the Philippines alone. Read more…


Dengue Pandemic

Are we looking at a Dengue Pandemic soon?

Will Climate Change Bring a Dengue Pandemic?

Dengue Pandemic Vector
Dengue Pandemic Vector

Dr Shahera Banu, and colleagues from QUT’s Faculty of Health, investigated the impact of climate change on transmission of the mosquito-borne disease and found there would be “devastating” consequences. Dr Banu analysed high-risk areas for dengue fever transmission in the Asia-Pacific region, with particular focus on Dhaka, the capital of Bangladesh and a megacity of 11.8 million people.

Using modelling from the Intergovernmental Panel on Climate Change (IPCC) which predicts an annual average temperature rise for the South Asia region of 3.3 degrees by 2100, the research found there would be a swell of dengue cases. The research has been published in the journals PLOS One and Environment International.

“Without any changes in the socio-economic situation, by the end of this century there will be a projected annual increase of 16,030 cases in Dhaka,” Dr Banu said.”The consequence of this will be devastating.”

The warmer temperatures and humidity would provide optimal conditions for mosquitos to thrive, Dr Banu said. The research collected the monthly number of dengue cases in Dhaka from January 2000 to December 2010 and estimated 377 cases attributable to temperature variation in 2010.

“Assuming a 1 degree temperature increase in 2100, we project an increase of 583 cases, for 2 degrees it would be 2,782 but it is at 3.3 degrees, a rise the IPCC has projected, that will have an overwhelming impact,” Dr Banu said.”Our results show that the monthly temperature and humidity were significantly associated with the monthly dengue incidence in Dhaka.

“These results are consistent with findings of other studies and may assist to forecast dengue outbreaks in different regions.”

Dengue Epidemic Viral Diagnosis
Dengue Epidemic Viral Diagnosis

Dr Banu said places with similar weather conditions to Dhaka would also likely be at risk from a climate change-driven increase in dengue cases.”We’re hopeful this research will be helpful for improving surveillance of dengue fever and control through effective management and community education programs in Bangladesh and other countries in a similar situation,” she said.

Here’s a report about Singapore’s recent, unexpected dengue outbreak: Epidemic resurgence of dengue fever in Singapore in 2013-2014: A virological and entomological perspective. Long story short: The culmination of the latest epidemic is likely to be due to a number of demographic, social, virological, entomological, immunological, climatic and ecological factors that contribute to DENV transmission. A multi-pronged approach backed by the epidemiological, virological and entomological understanding paved way to moderate the case burden through an integrated vector management approach.

Artemisia for Dengue

Artemisia for dengue?

Can artemisia for dengue be as effective as it is for malaria? There’s a chance – admittedly slim – that artemisia might be effective in treating dengue fever. Last year, researcher Pierre Lutgen  wrote : In the 1970s, there were only about nine countries where dengue fever existed but now the number is closer to 60. As of 2010 dengue fever is believed to infect 50 to 100 million people worldwide per year with 1/2 million life-threatening infections There is no cure and no real treatment.

Dengue Transmission Artemisia
Dengue Transmission Artemisia

A major dengue fever outbreak took place in Vanuatu in 2014, with several hundred cases. A female person living in Vanuata was infected by this virus. The infection was classified as dengue by clinical analysis in the hospital where she spent a week. She claims to have recovered after drinking Artemisia annua infusion (origin of the herb : Luxembourg). Subsequently several of her relatives suffered from the same symptoms and were all cured in a few days after tea A annua consumption. The Health Authorities confirm that these people were infected by the dengue virus. This is the first in vivo report on the efficiency of Artemisia annua against dengue. It needs of course to be confirmed by clinical trials in accordance with the WHO protocol.

So some clever scientists decided to try artemisia for dengue in the lab. Here’s what they found:

Malaria and dengue are the two most important vector-borne human diseases caused by mosquito vectors Anopheles stephensi and Aedes aegypti, respectively. Of the various strategies adopted for eliminating these diseases, controlling of vectors through herbs has been reckoned as one of the important measures for preventing their resurgence. Artemisia annua leaf chloroform extract when tried against larvae of A. stephensi and A. aegypti has shown a strong larvicidal activity against both of these vectors, their respective LC50 and LC90 values being 0.84 and 4.91 ppm for A. stephensi and 0.67 and 5.84 ppm for A. aegypti. The crude extract when separated through column chromatography using petroleum ether-ethyl acetate gradient (0–100 %) yielded 76 fractions which were pooled into three different active fractions A, B and C on the basis of same or nearly similar R f values. The aforesaid pooled fractions when assayed against the larvae of A. stephensi too reported a strong larvicidal activity. The respective marker compound purified from the individual fractions A, B and C, were Artemisinin, Arteannuin B and Artemisinic acid, as confirmed and characterized through FT-IR and NMR. This is our first report of strong mortality of A. annua leaf chloroform extract against vectors of two deadly diseases. This technology can be scaled up for commercial exploitation.

Author(s): Gaurav Sharma , Himanshi Kapoor , Madhu Chopra , Kaushal Kumar & Veena Agrawa
Reference: Parasitology Research, January 2014, Volume 113, Issue 1, pp 197-209
Access: Click here to go to the Journal
Contact email:

So the news so far is good on artemisia and dengue!

For more on artemesia and its modern history, check out this article in Forbes. And watch this video to see where in the dengue virus lifecycle artemisia might be useful:

Dengue in the USA

Dengue in the USA

Dengue in the USA is here to stay. With the Department of Health of Hawaii confirming two locally-acquired dengue fever cases in the state, two video bloggers have decided to share their own struggles dealing with the tropical disease to help raise public awareness.

Hawaii State health officials are investigating a dengue fever cluster. Thirty-three people on Hawaii’s Big Island have become sick with dengue since September – the first locally transmitted outbreak of the viral illness on the Big Island and the first outbreak in the state since five people were infected on Oahu in 2011. Twenty-five of those infected in this current outbreak are residents of the Big Island, while eight are visitors. Four children are among those who have become ill. All patients have recovered or are recovering.

Allie Wesenberg and Charles Trippy feature prominently on an ongoing web series known as “Internet Killed Television” on the YouTube channel CTFxC.

For the past seven years, the channel, which caters to more than 1.5 million subscribers, has been

uploading adventure clips of the duo taken in different parts of the world.

On one of their recent trips dated on Oct.13, Wesenberg and Trippy visited several popular spots in Hawaii, including South Kona’s Honaunau, the Volcanoes National Park and South Point.

However, by the time they got back from their Big Island trip, Wesenberg suddenly fell ill and was taken to the hospital on Oct. 22. Yep, dengue in the USA is a reality. Now watch the video:

Dengue Diagnostic Tests

Dengue Diagnostic tests are urgently needed. Health workers need to know immediately if your symptoms indicate dengue or a simple fever. For obvious reasons, dengue diagnostic tests are most urgently needed for pediatric (child) dengue cases, where the youngster cannot answer questions. The Medford-based manufacturer of point-of-care tests for HIV and syphilis said the dengue partnership was concluded Monday, the same day that Chembio announced a partnership with Integrated BioTherapeutics Inc. of Maryland…Read more on Newsday

Natural Dengue Controls

Many states are using natural dengue controls to fight dengue, as this article explains:

Guangzhou Turns to Mosquito-Eating Fish to Help Control Dengue Outbreak

The southern Chinese city of Guangzhou has introduced a fish that eats mosquito larvae, in an effort to control its worst-ever dengue fever outbreak, state news media have reported.

Mosquito fish, seen here in an aquarium in Virginia, are being deployed in the southern Chinese city of Guangzhou to help fight dengue fever.
Mosquito fish, seen here in an aquarium in Virginia, are being deployed in the southern Chinese city of Guangzhou to help fight dengue fever.Credit Associated PressSome scientists have warned that use of the nonnative mosquito fish could have unexpected consequences, while others say that mosquito fish are already found in Guangdong waters and the environmental impact might not be significant, but that the effectiveness of the fish may also be limited.

Some scientists have warned that use of the nonnative mosquito fish could have unexpected consequences, while others say that mosquito fish are already found in Guangdong waters and the environmental impact might not be significant, but that the effectiveness of the fish may also be limited. As of Monday, the number of dengue cases in Guangdong Province this year had reached 41,155, the local health authorities reported, with six deaths. The province has seen 200 to 300 new cases a day in recent days. That is lower than the more than 400 per day last week and the more than 1,000 per day the week before that, offering some hope that the outbreak is beginning to ease…. Read more.


Natural Dengue Strategies

Here are some natural tricks that discourage aedes aegypti mosquitoes:

  • Eat raw garlic, cook with onion and bell pepper, and take vitamin B. All these foods help produce a body odor that mosquitoes find unattractive.
  • Grow mint, roses, tuberose (Polianthes tuberosa), orchid tree (Aglaia odorata var. microphylla), and marigold. All repel mosquitoes to some degree.
  • Burn the leaves of the lemon-scented gum eucalyptus (Eucalyptus citriodora Hook) for household protection.
  • Use outdoor LED lights on your porch and around your house. They don’t attract pests like other lights.
  • Burn citronella candles outside.

Natural (Mostly) Insecticides & Repellents

If natural options are not available to everyone mosquito sprays can be a good alternative. Some of the least toxic sprays:

  • Oil of Lemon Eucalyptus has been used for many years in China as a mosquito repellent.
  • Essential Oils – Some essential oils used in repellents include Cedarwood, Soybean Oil (, and Geraniol (MosquitoGuard-, Bite Stop-, Bugband-
  • Picaridin – a synthetic dervived from pepper. The CDC says its protection is comparable to DEET at similar concentrations (Cutter Advanced).
  • Citronella – The active ingredient in those candles. It’s in some natural spray blends like Insect Shield (Bug Off) Synergy: an undiluted, therapeutic grade blend of the essential oils of Citronella, Eucalyptus, Cedarwood, Lemongrass, Lavender, Litsea, Tea Tree, Patchouli & Catnip.
  • Vanillin – Adding vanillin 5% to plant-based repellents and to DEET repellents increased their protection by about 2 hours. [Read this]

Some Commercial Products

All these repellents have different durations of effectiveness so be sure to reapply them following the directions on the label to repel mosquitoes most effectively.

Product Name & Link: Cutter Lemon Eucalyptus Insect Repellent Pump Spray, 4-Ounce.

Sales Pitch: Cutter lemon eucalyptus pump spray is an effective, naturally plant to based repellent that repels mosquitoes for up to 6 hours. Contains oil of lemon eucalyptus to the only plant to based ingredient recommended by the centers for disease control and prevention (CDC). Average Score: 4.2/5

Product Name & Link: Bite Blocker Organic Insect Repellent Spray, 6 Oz.

Sales Pitch: Bite Blocker’s proven effective Insect Repellent now in a highly effective waterproof formulation though enough for extreme environments and safe for the entire family. This Xtreme botanical formula provides protection form bites for up to 8 hours against mosquitoes, blackflies and more than 2 hours for ticks. Average Score: 4.1/5.0

Dengue in Asia

Dengue Fever Outbreaks Strike in Asia:

The number of dengue fever cases in Taiwan in the past four months has jumped to more than 4,000, recording the worst summer outbreak in the country since it started keeping systematic track of the disease in 2003, the Centers for Disease Control (CDC) said Thursday. As of Wednesday, the total number of dengue cases reported around the country since May 1 had reached 4,343, compared with 3,704 in the same period of last year, the CDC said. “The situation might ease up after September if we could effectively get things under control,” said CDC Deputy director-general Chuang Jen-hsiang. More

Southern China, Japan, Taiwan Battle Potentially Deadly Disease

Though much of the world is focused on the Ebola virus, pockets of Asia are struggling with record outbreaks of a mosquito-borne infectious disease called dengue fever, which has no specific drug treatment. Read more…

Dengue deaths nearly triple in Malaysia

KUALA LUMPUR – Prime Minister Najib Razak on Tuesday urged people to take precautions against dengue fever, which has caused 44 deaths in the first five weeks of the year in Malaysia. “Dengue is now a growing concern in several areas around Malaysia,” he said. “I hope you will take precautions as well and immediately seek medical help if you experience symptoms of dengue.” Najib said the government was intensifying its efforts to deal with the mosquito-borne disease, including sanitation awareness campaigns and taking actions against contractors who neglect to clean up their work sites. Health Ministry director general Noor Hisham bin Abdullah said 44 people died from dengue from Jan 1 to Feb 7, compared with 17 deaths during the same period last year. A total of 15,039 cases of dengue fever were reported nationwide during the first five weeks of 2015, compared with the 9,453 last year. More

Dengue and the W.H.O.

Dengue and the WHO are clashing!

MANILA, Philippines – With almost half of the world’s population now at risk of dengue, the World Health Organization (WHO) is pushing for “cross-border” collaboration to stop the spread of the mosquito-borne disease.

The WHO said collaboration to build regional capacity is the key to avert the impact of the dengue outbreak that has affected more than 100 countries worldwide. “Through such cross-border collaboration and sharing of dengue information, timely sensing of the dengue situation can improve preparedness within each country in the event of an outbreak,” the WHO said. The agency said the incidence of dengue has been increasing dramatically in the last few decades, with an estimated 50-100 million dengue infections occurring worldwide each year.

Before 1970, only nine countries had experienced severe dengue epidemics, but today the disease is endemic in more than 100 countries. “Not only is the number of cases increasing as the disease spreads to new areas, but frequent explosive outbreaks are occurring,” the WHO said.

It said the Western Pacific, home to a quarter of the world’s population, bears the heavy socio-economic burden due to dengue. In 2013, member-states of the Western Pacific region reported 428,635 cases and 964 deaths from the disease. The Philippines recorded over 204,906 cases and 660 deaths last year. The WHO recently held the 10-day Fourth Asia-Pacific Dengue Workshop to discuss measures to lessen the dengue epidemic.

It said there is currently no available vaccine or effective medication against dengue, thus preventing mosquitoes from breeding and propagating and protecting people from Aedes mosquito vectors are the best defense against the disease. Early detection of suspected cases, access to proper medical care and disease management, especially during outbreaks, can help in reducing the number of fatal cases, the WHO noted.

The WHO supports countries through its collaborating network of centers and laboratories, and provides technical and financial support and guidance for the effective management of dengue. WHO regional director for Western Pacific Shin Young-soo said dealing with a deadly disease such as dengue requires strong and consistent collaboration from everyone.

“Dengue hinders progress, which prevents our people from enjoying quality life. It is therefore imperative that we pool our considerable resources together to rid our region of dengue,” he said. He then urged governments, communities, stakeholders and donor agencies to strengthen efforts and programs for the routine control of vector-borne diseases and to ensure that systems are in place to detect, prepare for and respond to dengue outbreaks.

Read more about dengue in the Philippine Star

Dengue in Australia

Dengue in Australia is not new, but Dengue mosquitoes have been found in Darwin.

The exotic breed of mozzies, capable of carrying the virus, was found at Darwin’s East Arm Wharf. The mosquitoes were discovered in traps set up around the port by Department of Agriculture staff.

Medical entomologist William Petit said where the blood suckers came from was being investigated.

“It is likely they have emerged from water holding cargo that has arrived from a country where this variety of mosquito is prevalent,” he said.

“Two female Aedes aegypti mosquitoes were detected on Monday from a trap set last week.”

He said people couldn’t catch dengue in the Territory thanks to strict monitoring.

“We jump straight into ­action to ensure we eliminate them quickly, to maintain the Northern Territory’s dengue mosquito-free status,” he said.

“We work collaboratively … to carry out a surveillance and control operation which includes fogging with a safe household-strength insecticide and inspecting the area to ensure we’ve stopped the incursion. With a busy international port this variety of mosquito appears from time to time, but thanks to our surveillance and control measures they are picked up and dealt with ­swiftly.”

Dengue fever is a viral ­disease that is spread when mosquitoes bite an infected person and then pass the ­infection on to others.

It is a problem in many tropical and subtropical parts of the world, including north Queensland. It is estimated about 100 million cases occur worldwide each year. Read more in The Northern Territory News.


Cairns’ dengue fever outbreak spreads to Trinity Beach


Dengue fever has spread from Cairns’ southern suburbs to the northern beaches.

The outbreak had been contained to Edmonton since it began two weeks ago but a person has fallen ill with the mosquito-borne virus in Trinity Beach.

It brings the total number of cases so far this season to eight.

Tropical Public Health Services’ Dr Richard Gair said it appeared the latest case was linked to the Edmonton outbreak.

“They hadn’t really been anywhere else during the incubation period and because their house is quite close to somebody else we know acquired dengue in Edmonton it’s fairly sure and the Edmonton outbreak is a dengue type one,” he said.

He said it appeared the patient fell ill after someone with dengue fever from Edmonton visited the area.

“The mosquitoes actually never move very far. They usually stay in an area about 100-200 metres across,” he said.

“So the mosquitoes more or less stay where they are, it’s people that move around and spread dengue because they get it in one area and they move to another area and infect the mosquitoes there.” More on Dengue in Australia…