Epidemiology and challenges of dengue surveillance in the WHO South-East Asia Region

Serosurveillance of dengue infection and correlation with mosquito pools for dengue virus positivity during the COVID-19 pandemic in Tamil Nadu, India - A state-wide cross-sectional cluster randomized community-based study

Background

Dengue is a vector-borne viral disease impacting millions across the globe. Nevertheless, akin to many other diseases, reports indicated a decline in dengue incidence and seroprevalence during the COVID-19 pandemic (2020-22). This presumably could be attributed to reduced treatment-seeking rates, under-reporting, misdiagnosis, disrupted health services and reduced exposure to vectors due to lockdowns. Scientific evidence on dengue virus (DENV) disease during the COVID-19 pandemic is limited globally.

Methods

A cross-sectional, randomized cluster sampling community-based survey was carried out to assess anti-dengue IgM and IgG and SARS-CoV-2 IgG seroprevalence across all 38 districts of Tamil Nadu, India. The prevalence of DENV in the Aedes mosquito pools during 2021 was analyzed and compared with previous and following years of vector surveillance for DENV by real-time PCR.

Findings

Results implicate that both DENV-IgM and IgG seroprevalence and mosquito viral positivity were reduced across all the districts. A total of 13464 mosquito pools and 5577 human serum samples from 186 clusters were collected. Of these, 3·76% of mosquito pools were positive for DENV. In the human sera, 4·12% were positive for DENV IgM and 6·4% were positive for DENV IgG. The anti-SARS-CoV-2 antibody titres correlated with dengue seropositivity with a significant association whereas vaccination status significantly correlated with dengue IgM levels.

Interpretation

Continuous monitoring of DENV seroprevalence, especially with the evolving variants of the SARS-CoV-2 virus and surge in COVID-19 cases will shed light on the transmission and therapeutic attributes of dengue infection.

Evolving Spectrum of Dengue: A Two-Year Experience From a Tertiary Care Hospital in Pakistan

OBJECTIVE

This study focused on examining the clinical manifestations, disease severity, and outcomes among cases of dengue fever (DF) confirmed through serological testing. The study specifically targeted individuals admitted to a tertiary care hospital in Islamabad, Pakistan.

METHODOLOGY

This prospective observational study at the Pakistan Institute of Medical Sciences, Islamabad, Pakistan, tracked 1,003 patients from admission to discharge or death between August 2022 and November 2023. Patients were monitored, and admission criteria were established based on the identification of warning signs. The data collection process encompassed gathering demographic information, documenting clinical symptoms, and utilizing a severity classification system for the disease. Outcome measures comprised the duration of critical illness, length of hospital stay, overall outcomes (discharge or mortality), and the assessment of complications. The collected data were analyzed using IBM Statistical Package for the Social Sciences (SPSS) software version 22.0 (IBM Corp., Armonk, NY).

RESULTS

Baseline characteristics revealed a male predominance (67.8%), with an average age of 35.77 years, and common comorbidities such as hypertension (9.3%) and diabetes mellitus (7.3%). Dengue fever was most prevalent among patients whose blood group was B+ (15.0%). Nonstructural protein 1 (NS1) was positive in 73.4% of the cases. Fever was the predominant complaint in 98.0% of instances. Common bleeding manifestations included epistaxis, gum bleeding, and hematemesis. About 52.20% of cases were observed to have severe thrombocytopenia at admission. Hospital-related aspects demonstrated a mean stay of 3.35 days, a critical phase lasting 1.68 days, and rare complications like expanded dengue syndrome (2.2%). Encouragingly, 98.9% of patients were discharged, 0.4% were shifted, and 0.7% succumbed to the disease.

CONCLUSION

This study comprehensively analyzes the demographic and clinical aspects of DF, emphasizing a male predominance and the fact that fever was the most common presenting complaint. The duration of hospitalization revealed a brief mean stay, a short critical phase, and low complication rates, with a high discharge rate suggesting positive outcomes.

The detection of Japanese encephalitis virus in municipal wastewater during an acute disease outbreak

AIM

To demonstrate the capability of wastewater-based surveillance (WBS) as a tool for detecting potential cases of Japanese Encephalitis Virus (JEV) infection in the community.

METHODS AND RESULTS

In this study, we explore the potential of WBS to detect cases of JEV infection by leveraging from an established SARS-CoV-2 wastewater surveillance program. We describe the use of two reverse transcriptase quantitative polymerase chain reaction (RTqPCR) assays targeting JEV to screen archived samples from two wastewater treatment plants (WWTPs). JEV was detected in wastewater samples collected during a timeframe coinciding with a cluster of acute human encephalitis cases, alongside concurrent evidence of JEV detection in mosquito surveillance and the sentinel chicken programs within South Australia's Riverland and Murraylands regions.

CONCLUSIONS

Current surveillance measures for JEV encounter multiple constraints, which may miss the early stages of JEV circulation or fail to capture the full extent of transmission. The detection of JEV in wastewater during a disease outbreak highlights the potential WBS has as a complementary layer to existing monitoring efforts forming part of the One Health approach required for optimal disease response and control.

Recent Dengue Infection in Bangladesh: A Seasonal Endemic Progressing to Year-long Serious Health Concern

Dengue represents one of the most dangerous mosquito-borne viral diseases. Although the disease has been prevalent around the globe over the centuries, recent outbreaks of dengue have devasted the healthcare delivery system of many countries. Being a global infection, dengue virus (DENV) is endemically present mainly in Latin America and Caribbean countries as well as countries in South Asia. The recent outbreak of DENV infection has indicated an exceptional outbreak of DENV in some countries in South Asia. There has been a serious endemic of DENV during 2019. After a heterogeneous pause, another severe outbreak of DENV was reported in some Asian countries in 2023. Among the Asian countries, Bangladesh has reported an acute upsurge of DENV infection in 2023 with record numbers of fatalities. However, this pattern of DENV has not been detected in neighbors of Bangladesh, such as India or other countries in Southeast Asia. This provides an emergent task of dissecting the present DENV infection in Bangladesh from different angles to get insights for future containment of the DENV infection, not only in Bangladesh but also in other DENV endemic areas or DENV-native areas.

How to cite this article

Akbar SMF, Khan S, Mahtab M, et al. Recent Dengue Infection in Bangladesh: A Seasonal Endemic Progressing to Year-long Serious Health Concern. Euroasian J Hepato-Gastroenterol 2023;13(2):145-151.

Efficacy of household Aedes larval control practices in a peri-urban township, Yangon, Myanmar: Implication for entomological surveillance

Dengue is a major public health concern in Myanmar. We carried out a cross-sectional study to investigate the efficacy of larval control practices in household water containers, such as the use of the larvicide, temephos, covering the containers with lids and weekly cleaning. We surveyed 300 households in Kaw Hmu Township, a peri-urban community in the Yangon region. We inspected 1,892 water storage containers and 342 non-water storage/household waste containers during the rainy season and 1,866 water storage containers and 287 non-water storage/household waste containers during the dry season. The presence of Aedes larvae and larval control measures were recorded for each container. Results revealed that larval indices were higher than World Health Organization standard indices, and infestations in water storage containers were more common in the rainy season (6.6%) than in the dry season (5.7%). Infestations were also more likely in containers of non-potable water (9.1%-9.9%) than in containers of potable water (0.1%-0.7%). Two thirds of water storage containers were treated with temephos. Containers most likely to contain Aedes larvae were cement basins and barrels. Temephos was effective in controlling infestations in cement basins, while weekly cleaning was effective in controlling infestations in barrels. Combinations of control methods were more effective at larval control than the use of a single method. Larval infestations were high (18.4% in the rainy season) in unused containers and in containers which were household waste. Overall, we found a complex interaction between household water use, container characteristics, and larval control practices. Larval control strategies in Myanmar will require ongoing entomological surveillance and the identification of key breeding sources and optimal control methods.

Comparative phylogenetic analysis and transcriptomic profiling of Dengue (DENV-3 genotype I) outbreak in 2021 in Bangladesh

Background

The next-generation sequencing (NGS) technology facilitates in-depth study of host-pathogen metatranscriptome. We, therefore, implicated phylodynamic and transcriptomic approaches through NGS technology to know/understand the dengue virus (DENV) origin and host response with dengue fever.

Methods

In this study, blood serum RNA was extracted from 21 dengue patients and 3 healthy individuals. Total transcriptomic data were analyzed for phylogenetic, phylodynamic, differential express gene (DEG), and gene ontology (GO) using respective bioinformatics tools.

Results

The viral genome sequence revealed dengue viral genome size ranges 10647 to 10707 nucleotide. Phylogenetic and phylodynamic analysis showed that the 2021 epidemic isolates were DENV-3 genotype-I and maintained as a new clade in compared to 2019 epidemic. Transcriptome analysis showed a total of 2686 genes were DEG in dengue patients compared to control with a q-value < 0.05. DESeq2 plot counts function of the top 24 genes with the smallest q-values of differential gene expression of RNA-seq data showed that 11 genes were upregulated, whereas 13 genes were downregulated. GO analysis showed a significant upregulation (p = < 0.001) in a process of multicellular organismal, nervous system, sensory perception of chemical stimulus, and G protein-coupled receptor signaling pathways in the dengue patients. However, there were a significant downregulation (p = < 0.001) of intracellular component, cellular anatomical entity, and protein-containing complex in dengue patients. Most importantly, there was a significant increase of a class of immunoregulatory proteins in dengue patients in compared to the controls, with increased GO of immune system process. In addition, upregulation of toll receptor (TLR) signaling pathways were found in dengue patients. These TLR pathways were particularly involved for the activation of innate system coupled with adaptive immune system that probably involved the rapid elimination of dengue virus infected cells. These differentially expressed genes could be further investigated for target based prophylactic interventions for dengue.

Conclusion

This is a first report describing DENV complete genomic features and differentially expressed genes in patients in Bangladesh. These genes may have diagnostic and therapeutic values for dengue infection. Continual genomic surveillance is required to further investigate the shift in dominant genotypes in relation to viral pathogenesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12985-023-02030-1.

Dengue as a Disease Threatening Global Health: A Narrative Review Focusing on Latin America and Brazil

Arboviruses constitute the largest known group of viruses. These viruses are the etiological agents of pathologies known as arboviruses, with dengue being one of the most prevalent. Dengue has resulted in important socioeconomic burdens placed on different countries around the world, including those in Latin America, especially Brazil. Thus, this work intends to carry out a narrative-based review of the literature, conducted using a study of the secondary data developed through a survey of scientific literature databases, and to present the situation of dengue, particularly its distribution in these localities. Our findings from the literature demonstrate the difficulties that managers face in controlling the spread of and planning a response against dengue, pointing to the high cost of the disease for public coffers, rendering the resources that are already limited even scarcer. This can be associated with the different factors that affect the spread of the disease, including ecological, environmental, and social factors. Thus, in order to combat the disease, it is expected that targeted and properly coordinated public policies need to be adopted not only in specific localities, but also globally.

Species-specific MARCO-alphavirus interactions dictate chikungunya virus viremia

Arboviruses are public health threats that cause explosive outbreaks. Major determinants of arbovirus transmission, geographic spread, and pathogenesis are the magnitude and duration of viremia in vertebrate hosts. Previously, we determined that multiple alphaviruses are cleared efficiently from murine circulation by the scavenger receptor MARCO (Macrophage receptor with collagenous structure). Here, we define biochemical features on chikungunya (CHIKV), o'nyong 'nyong (ONNV), and Ross River (RRV) viruses required for MARCO-dependent clearance in vivo. In vitro, MARCO expression promotes binding and internalization of CHIKV, ONNV, and RRV via the scavenger receptor cysteine-rich (SRCR) domain. Furthermore, we observe species-specific effects of the MARCO SRCR domain on CHIKV internalization, where those from known amplification hosts fail to promote CHIKV internalization. Consistent with this observation, CHIKV is inefficiently cleared from the circulation of rhesus macaques in contrast with mice. These findings suggest a role for MARCO in determining whether a vertebrate serves as an amplification or dead-end host following CHIKV infection.

Dengue amid COVID-19 pandemic

The increasing in dengue cases nowadays is a global threat concern. Fifty per cent of the world's population is vulnerable to dengue infection with Asia contributing over two-thirds of the global burden. The double trouble of Coronavirus disease 2019 (COVID-19) arising from novel severe respiratory syndrome coronavirus (SARS-CoV-2) and dengue virus is a major challenge, particularly in developing countries due to overburdened public health systems and economic constraints including the ability to diagnose. The objective of this study was to analyze the prevalence of dengue in Thailand during the outbreak of COVID-19. We studied data on dengue cases reported at epidemiological information centers, the Bureau of Epidemiology, and the Ministry of Public Health, Thailand during 2019 to 2021. Patients can be observed across all age groups, particularly adolescents and adults. Dengue was seen year-round, with highest incidence in the rainy seasons between June and September. Total number of cases was markedly declined by nearly 93 percentage from 2019 to 2011. Taken together, Thailand is still at risk of spreading of dengue in the midst of COVID-19 pandemic. Continuous status updates on dengue patients in Thailand should be incorporated into global health advisory on preventive measures before travelling.

Development and application of survey-based artificial intelligence for clinical decision support in managing infectious diseases: A pilot study on a hospital in central Vietnam

Introduction

In this study, we developed a simplified artificial intelligence to support the clinical decision-making of medical personnel in a resource-limited setting.

Methods

We selected seven infectious disease categories that impose a heavy disease burden in the central Vietnam region: mosquito-borne disease, acute gastroenteritis, respiratory tract infection, pulmonary tuberculosis, sepsis, primary nervous system infection, and viral hepatitis. We developed a set of questionnaires to collect information on the current symptoms and history of patients suspected to have infectious diseases. We used data collected from 1,129 patients to develop and test a diagnostic model. We used XGBoost, LightGBM, and CatBoost algorithms to create artificial intelligence for clinical decision support. We used a 4-fold cross-validation method to validate the artificial intelligence model. After 4-fold cross-validation, we tested artificial intelligence models on a separate test dataset and estimated diagnostic accuracy for each model.

Results

We recruited 1,129 patients for final analyses. Artificial intelligence developed by the CatBoost algorithm showed the best performance, with 87.61% accuracy and an F1-score of 87.71. The F1-score of the CatBoost model by disease entity ranged from 0.80 to 0.97. Diagnostic accuracy was the lowest for sepsis and the highest for central nervous system infection.

Conclusion

Simplified artificial intelligence could be helpful in clinical decision support in settings with limited resources.

Impact of extreme weather on dengue fever infection in four Asian countries: A modelling analysis

The rapid spread of dengue fever (DF) infection has posed severe threats to global health. Environmental factors, such as weather conditions, are believed to regulate DF spread. While previous research reported inconsistent change of DF risk with varying weather conditions, few of them evaluated the impact of extreme weather conditions on DF infection risk. This study aims to examine the short-term associations between extreme temperatures, extreme rainfall, and DF infection risk in South and Southeast Asia. A total of 35 locations in Singapore, Malaysia, Sri Lanka, and Thailand were included, and weekly DF data, as well as the daily meteorological data from 2012 to 2020 were collected. A two-stage meta-analysis was used to estimate the overall effect of extreme weather conditions on the DF infection risk. Location-specific associations were obtained by the distributed lag nonlinear models. The DF infection risk appeared to increase within 1-3 weeks after extremely high temperature (e.g. lag week 2: RR = 1.074, 95 % CI: 1.022-1.129, p = 0.005). Compared with no rainfall, extreme rainfall was associated with a declined DF risk (RR = 0.748, 95 % CI: 0.620-0.903, p = 0.003), and most of the impact was across 0-3 weeks lag. In addition, the DF risk was found to be associated with more intensive extreme weathers (e.g. seven extreme rainfall days per week: RR = 0.338, 95 % CI: 0.120-0.947, p = 0.039). This study provides more evidence in support of the impact of extreme weather conditions on DF infection and suggests better preparation of DF control measures according to climate change.

Monitoring human arboviral diseases through wastewater surveillance: Challenges, progress and future opportunities

Arboviral diseases are caused by a group of viruses spread by the bite of infected arthropods. Amongst these, dengue, Zika, west nile fever and yellow fever cause the greatest economic and social impact. Arboviral epidemics have increased in frequency, magnitude and geographical extent over the past decades and are expected to continue increasing with climate change and expanding urbanisation. Arboviral prevalence is largely underestimated, as most infections are asymptomatic, nevertheless existing surveillance systems are based on passive reporting of loosely defined clinical syndromes with infrequent laboratory confirmation. Wastewater-based surveillance (WBS), which has been demonstrated to be useful for monitoring diseases with significant asymptomatic populations including COVID19 and polio, could be a useful complement to arboviral surveillance. We review the current state of knowledge and identify key factors that affect the feasibility of monitoring arboviral diseases by WBS to include viral shedding loads by infected persons, the persistence of shed arboviruses and the efficiency of their recovery from sewage. We provide a simple model on the volume of wastewater that needs to be processed for detection of arboviruses, in face of lower arboviral shedding rates. In all, this review serves to reflect on the key challenges that need to be addressed and overcome for successful implementation of arboviral WBS.

Dengue Fever in Italy: The "Eternal Return" of an Emerging Arboviral Disease

Enhanced surveillance for dengue virus (DENV) infections in Italy has been implemented since 2012, with annual reports from the National Health Institute. In this study, we summarize available evidence on the epidemiology of officially notified DENV infections from 2010–2021. In total, 1043 DENV infection cases were diagnosed, and most of them occurred in travelers, with only 11 autochthonous cases. The annual incidence rates of DENV infections peaked during 2019 with 0.277 cases per 100,000 (95% confidence interval [95% CI] 0.187–0.267), (age-adjusted incidence rate: 0.328, 95% CI 0.314–0.314). Cases of DENV were clustered during the summer months of July (11.4%), August (19.3%), and September (12.7%). The areas characterized by higher notification rates were north-western (29.0%), and mostly north-eastern Italy (41.3%). The risk for DENV infection in travelers increased in the time period 2015–2019 (risk ratio [RR] 1.808, 95% CI 1.594–2.051) and even during 2020–2021 (RR 1.771, 95% CI 1.238–2.543). Higher risk for DENV was additionally reported in male subjects compared with females subjects, and aged 25 to 44 years, and in individuals from northern and central Italy compared to southern regions and islands. In a multivariable Poisson regression model, the increased number of travelers per 100 inhabitants (incidence rate ratio [IRR] 1.065, 95% CI 1.036–1.096), the incidence in other countries (IRR 1.323, 95% CI 1.165–1.481), the share of individuals aged 25 to 44 years (IRR 1.622, 95% CI 1.338–1.968), and foreign-born residents (IRR 2.717, 95% CI 1.555–3.881), were identified as effectors of annual incidence. In summary, although the circulation of DENV remains clustered among travelers, enhanced surveillance is vital for the early detection of human cases and the prompt implementation of response measures.

Dengue surveillance using gravid oviposition sticky (GOS) trap and dengue non-structural 1 (NS1) antigen test in Malaysia: randomized controlled trial

Dengue remains a major public threat and existing dengue control/surveillance programs lack sensitivity and proactivity. More efficient methods are needed. A cluster randomized controlled trial was conducted for 18 months to determine the efficacy of using a combination of gravid oviposition sticky (GOS) traps and dengue non-structural 1 (NS1) antigen for early surveillance of dengue among Aedes mosquito. Eight residential apartments were randomly assigned into intervention and control groups. GOS traps were placed at the intervention apartments weekly to trap Aedes mosquitoes and these tested for dengue NS1 antigen. When dengue-positive pool was detected, the community were notified and advised to execute protective measures. Fewer dengue cases were recorded in the intervention group than the control. Detection of NS1-positive mosquitoes was significantly associated with GOS Aedes index (r_s = 0.68, P < 0.01) and occurrence of dengue cases (r_s = 0.31, P < 0.01). Participants' knowledge, attitude, and practice (KAP) toward dengue control indicated significant improvement for knowledge (P < 0.01), practice (P < 0.01) and total scores (P < 0.01). Most respondents thought this surveillance method is good (81.2%) and supported its use nationwide. Thus, GOS trap and dengue NS1 antigen test can supplement the current dengue surveillance/control, in alignment with the advocated integrated vector management for reducing Aedes-borne diseases.

Potential Development of Digital Environmental Surveillance System in Dengue Control: A Qualitative Study

Background: The development of digital environmental technology can be conducted to implement reports, surveillance, and manage dengue control. Therefore, this study aims to determine the barriers to the use of paper-based and the potential development of digital environmental technology in dengue control.   Methods In-depth qualitative interviews were conducted using 14 key informants and four focus group discussions (FGD) from May-August 2021 in Denpasar City, Bali. The interviews were consistent with the flow of the epidemiological and entomological surveillance system, the obstacles to the dengue control program, the potential for the application of digital technology, and the challenges in the application of digital surveillance technology. Furthermore, open-ended questions and content analysis by qualitative study procedures were adopted. The results were transcribed verbatim and triangulation of sources was conducted for data validation.   Results The reporting system that used paper-based was not optimally implemented due to repetition of reporting, speed of information, data bias, performance measurement as well as case surveillance and reporting system constraints. An integrated digital environmental surveillance system (SILIRA) was also developed for dengue control. In the current Covid-19 pandemic, the need for digital applications is high due to the policy of not accepting guests and keeping a distance. Epidemiological surveillance for case data collection, entomological surveillance for larva density, case reporting, and educational videos are the required data in the application.   Conclusion The development of an integrated application for an environmental monitoring system can be created for the continuous reporting of case information and larval density for dengue hemorrhagic fever control. Keywords: digital, surveillance, environment, dengue  

Weather, climate, and climate change research to protect human health in sub-Saharan Africa and South Asia

Weather, climate, and climate change are affecting human health, with scientific evidence increasing substantially over the past two decades, but with very limited research from low- and middle-income countries. The health effects of climate change occur mainly because of the consequences of rising temperatures, rising sea levels, and an increase in extreme weather events. These exposures interact with demographic, socio-economic, and environmental factors, as well as access to and the quality of health care, to affect the magnitude and pattern of risks. Health risks are unevenly distributed around the world, and within countries and across population groups. Existing health challenges and inequalities are likely to be exacerbated by climate change. This narrative review provides an overview of the health impacts of weather, climate, and climate change, particularly on vulnerable regions and populations in sub-Saharan Africa and South Asia, and discusses the importance of protecting human health in a changing climate; such measures are critical to reducing poverty and inequality at all scales. Three case summaries from the INDEPTH Health and Demographic Surveillance Systems highlight examples of research that quantified associations between weather and health outcomes. These and comparable surveillance systems can provide critical knowledge to increase resilience and decrease inequalities in an increasingly warming world.

Clinical predictors of severe dengue: a systematic review and meta-analysis

Background

Severe dengue is a life-threatening complication; rapid identification of these cases, followed by adequate management is crucial to improve the clinical prognosis. Therefore, this study aimed to identify risk factors and predictors of severe dengue.

Methods

A literature search for studies reporting risk factors of severe dengue among individuals with dengue virus infection was conducted in PubMed, Scopus and Web of Science database from inception to December 31, 2020. Pooled odds ratios (ORs) for patients’ demographic characteristics, co-morbidities, and warning signs were estimated using an inverse variance heterogeneity model.

Results

We included 143 articles in the meta-analysis from a total of 13 090 articles retrieved from the literature search. The risk factors of severe dengue were: being a child [OR = 1.96; 95% confidence interval (CI): 1.22–3.13], secondary infection (OR = 3.23; 95% CI: 2.28–4.57), and patients with pre-existing diabetes (OR = 2.88; 95% CI: 1.72–4.81) and renal disease (OR = 4.54; 95% CI: 1.55–13.31). Warning signs strongly associated with severe disease were increased haematocrit with a concurrent decrease in platelet count (OR = 5.13; 95% CI: 1.61–16.34), abdominal pain (OR = 2.00; 95% CI: 1.49–2.68), lethargy (OR = 2.73; 95% CI: 1.05–7.10), vomiting (OR = 1.80; 95% CI: 1.43–2.26), hepatomegaly (OR = 5.92; 95% CI: 3.29–10.66), ascites (OR = 6.30; 95% CI: 3.75–10.60), pleural effusion (OR = 5.72; 95% CI: 3.24–10.10) and melena (OR = 4.05; 95% CI: 1.64–10.00).

Conclusions

Our meta-analysis identified children, secondary infection, diabetes and renal disease(s) as important predictors of severe dengue. Our finding also supports the predictive ability of the WHO warning signs to identify severe dengue. These findings are useful for clinicians to identify severe dengue for management and timely interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-021-00908-2.

Medical practitioner's knowledge on dengue management and clinical practices in Bhutan

Background

Dengue has emerged as a major public health problem in Bhutan, with increasing incidence and widening geographic spread over recent years. This study aimed to investigate the knowledge and clinical management of dengue among medical practitioners in Bhutan.

Methods

We administered a survey questionnaire to all practitioners currently registered under the Bhutan Medical and Health Council. The questionnaire contained items on four domains including transmission, clinical course and presentation, diagnosis and management, and surveillance and prevention of dengue. Participants were able to respond using an online Qualtrics survey, with the invitation and link distributed via email.

Results

A total of 97 respondents were included in the study (response rate: 12.7%), of which 61.86% were Health Assistants/Clinical Officers (HAs/COs) and 38.14% were medical doctors. The afternoon feeding behaviour of Aedes mosquito was correctly identified by only 24.7% of the respondents, and ~66.0% of them failed to identify lethargy as a warning sign for severe dengue. Knowledge on diagnosis using NS1 antigen and the clinical significance of elevated haematocrit for initial fluid replacement was strikingly low at 47.4% and 27.8% respectively. Despite dengue being a nationally notifiable disease, ~60% of respondents were not knowledgeable on the timing and type of cases to be reported. Respondent’s median score was higher for the surveillance and reporting domain, followed by their knowledge on transmission of dengue. Statistically significant factors associated with higher knowledge included respondents being a medical doctor, working in a hospital and experience of having diagnosed dengue.

Conclusion

The study revealed major gaps on knowledge and clinical management practices related to dengue in Bhutan. Physicians and health workers working in Basic Health Units need training and regular supervision to improve their knowledge on the care of dengue patients.

Nationwide Distribution of Dengue Virus Type 3 (DENV-3) Genotype I and Emergence of DENV-3 Genotype III during the 2019 Outbreak in Bangladesh

Bangladesh is an endemic region of dengue fever and experienced an unprecedented large outbreak with more than 100,000 confirmed cases in 2019. To understand the prevalence of dengue antibody in patients and molecular epidemiological characteristics of dengue virus (DENV) in this outbreak, a total of 179 blood samples were collected from patients in 10 districts (seven divisions) covering nearly the whole country from August to December 2019. DENV NS-1 was detected in 162 samples, among which DENV-specific IgM was positive in 119 samples (73.5%), including 60.5% samples also positive for DENV-specific IgG. Sequencing of the partial C-prM gene and its phylogenetic analysis revealed predominance of DENV type 3 genotype I, accounting for 93% of samples examined. DENV-3 genotype III was identified in two samples from separate districts, and only one DENV-2 cosmopolitan genotype was found in the capital city, Dhaka. These findings suggest the predominance of DENV-3 genotype I and occurrence of DENV-3 genotype III, associated with increased incidence of recent secondary infection in Bangladesh in 2019.