A retrospective analysis of dengue fever case management and frequency of co-morbidities associated with deaths

Malaria and Dengue Co-infection: A Comprehensive Study in Peshawar, Pakistan

BACKGROUND

Malaria and dengue are significant mosquito-borne diseases prevalent in tropical and subtropical climates, with increasing reports of co-infections. This study aimed to determine the frequency, patterns, and risk factors of these co-infections in Peshawar.

METHODS

A cross-sectional study was conducted from June to December 2023 in three tertiary care hospitals in Peshawar. We evaluated 322 febrile patients (temperature >38 °C) using dengue serological tests (NS1, IgM, IgG), malarial parasite microscopy (thick and thin films with double-reading quality control), and immunochromatography. Clinical and demographic data were collected using structured questionnaires. Statistical analysis was performed using SPSS Version 26 (IBM Corp., Armonk, NY).

RESULTS

 Of 322 patients (mean age 35.7 ± 14.2 years; 187 male, 58.1%), 72 (22.4%) had malaria-dengue co-infection. Co-infected patients showed NS1 positivity in 30/72 (41.7%), with higher rates in urban areas (60/231 [26.0%] vs. 12/91 [13.2%]; odds ratio [OR] = 2.31, 95% confidence interval [CI]: 1.18-4.52, P < 0.01). Age (r = 0.15, P = 0.007) and education (OR = 1.84, 95% CI: 1.09-3.12, P = 0.02) were significant risk factors. Co-infected patients had longer hospital stays (5.8 ± 2.3 vs. 3.9 ± 1.8 days, P < 0.001) and higher mortality (2.8% vs. 1.2%, P = 0.04).

CONCLUSIONS

Co-infection of malaria and dengue is common in Peshawar, particularly in urban areas and during monsoon seasons. Age and educational status are significant risk factors. These findings necessitate routine screening for both diseases in febrile patients from endemic areas, especially during peak seasons. Targeted surveillance and vector control strategies in urban areas are recommended.

E-dengue System Insights: Exploring the Factors Influencing Dengue-related Deaths in an Urbanized State in a Low-Middle Income Country (LMIC)

BACKGROUND

Dengue has emerged as a rapidly escalating health issue in low- and middle-income countries, with its burden and geographic spread increasing over the years. Malaysia, in particular, has witnessed a significant rise in dengue cases, accompanied by a spike in mortality rates. Several studies have identified various factors, primarily focusing on the 27 clinical aspects of severe dengue infection and the development of dengue-related fatalities. Expanding on this focus, this study aims to identify the demographic, clinical, and environmental factors contributing to dengue mortality, providing a more comprehensive understanding of the variables influencing dengue-related fatalities.

METHODS

This study utilized a 1:2 case-control design, analyzing data from the E-dengue system database and medical records from January 2015 to December 2022, involving 219 participants (73 dengue fatalities as cases and 146 recovered patients as controls). Dengue deaths were confirmed by the Penang State Mortality Review Committee, and controls were randomly selected from laboratory-confirmed dengue cases. Statistical analyses were performed using SPSS software, including descriptive statistics, chi-square tests, and multivariable logistic regression to identify predictors of dengue mortality, with variables included in the multivariable model if p < 0.05.

RESULTS

Several significant predictors of dengue-related mortality, including clinical and environmental factors were identified. Key predictors were a platelet count below 50,000/µL (OR 15.70; 95% CI: 5.65-43.53), presence of one comorbid condition (OR 2.90; 95% CI: 1.22-6.90), more than two comorbid conditions (OR 10.15; 95% CI: 3.53-29.23), bronchial asthma (OR 12.00; 95% CI: 1.08-132.13), and outbreak locality status (OR 2.3; 95% CI: 1.11-4.79). An interaction was also found between locality status and platelet levels.

CONCLUSION

The study emphasizes the need for developing risk profiles for dengue patients by integrating factors such as platelet levels, comorbidities, and locality status to improve clinical care. Nuanced protocols are needed to address the specific challenges of single-case and outbreak areas. In single-case localities, patients with low platelet counts (below 100,000/µL) should be prioritized for rapid intervention to mitigate severe outcomes. In outbreak areas, healthcare systems should bolster resources and apply comprehensive triage approaches considering platelet levels and other risk factors. Implementing predictive models that account for geographical factors can enhance resource allocation and preparedness for dengue outbreaks. These recommendations aim to empower public health personnel, healthcare providers, and communities to collectively reduce dengue-related mortality rates.

Clinical profiles and predictors of survival in severe dengue cases

Introduction

Dengue is endemic in tropical countries. Severe dengue has a high risk of morbidity and mortality. We aimed to identify factors associated with dengue survival among our intensive care unit (ICU) patients.

Methods

A retrospective study was conducted among dengue cases admitted to the ICU of Hospital Sultan Abdul Halim, Kedah, Malaysia from 2016 to 2019.

Results

Out of 1,852 dengue cases admitted to the hospital, 7.2% of patients required ICU admission. Survival rate was 88.6% among severe dengue cases. The majority of severe dengue patients were obese, while other notable comorbidities included hypertension and diabetes mellitus. Also, 73% of patients presented in the critical phase, at a median of Day 4 of illness. All patients admitted to the ICU had a history of fever. The predominant warning signs were lethargy, fluid accumulation and haemoconcentration with rapid platelet reduction. Among nonsurvivors, 69.2% had fulminant hepatitis, 53.8% had massive bleeding or disseminated intravascular coagulation, 38.5% had haemophagocytic lymphohistiocytosis and 30.8% had myocarditis. The predominant serotypes were DENV-3 and DENV-1. The least number of cases was seen in 2017, when all serotypes were equally presented. Multiple logistic regression showed that Sequential Organ Failure Assessment (SOFA) score, peak international normalised ratio, peak partial thromboplastin time and aspartate aminotransferase on admission were independent risk factors for survival. This model had an area under the curve of 0.98, giving an overall 98.2% accuracy.

Conclusions

Specific warning signs and blood investigations in dengue patients may aid in early decision for ICU admission. Monitoring of SOFA scores plus coagulation and liver enzyme profiles could improve dengue survival rates.

Burden and distribution of dengue infection in Pakistan (2000-19): a review

The goal of this study is to review the overall prevalence, burden, and distribution of the dengue disease in Pakistan from 2000 to 2019. Literature was searched using different search engines like Google scholar, PubMed, etc. providing the keywords "Dengue disease/infection, Dengue virus, DENV, DF/DHF/ DSS Pakistan". All the published research papers/reports on the dengue virus over the period 2000 to 2019 were studied and selected data were summarized using MS Excel for windows such as total cases, age wise, gender, DENV serotype distribution, total DHF, and DSS patients. The literature providing insufficient data was excluded. The total number of cases reported during 2000-19 were 201,269. The maximum number of cases during the mentioned literature survey period was reported in Khyber Pakhtunkhwa (KP) (23.3%) followed by Punjab (3.8%) and Sindh (1.9%). The majority of dengue-infected cases were reported as Dengue fever (74.4%) followed by DHF (24.1%) and DSS (1.5%). Overall the deaths during the mentioned literature survey were 1082, of which the maximum mortalities were reported from KP (N=248) followed by Punjab (N=220). DENV remains a major public health problem in Pakistan and seems to remain endemic for a long time. The total prevalence of dengue infection is increased accordingly with time from 2000 to 2019. Moreover, all the four serotypes exist in Pakistan with increased mortalities.

High Glucose Induces in HK2 Kidney Cells an IFN–Dependent ZIKV Antiviral Status Fueled by Viperin

Zika virus (ZIKV) is an emerging mosquito-borne flavivirus that rapidly became a major medical concern worldwide. We have recently reported that a high glucose level decreases the rate of Zika virus (ZIKV) replication with an impact on human kidney HK-2 cell survival. However, the mechanisms by which cells cultured in a high glucose medium inhibit ZIKV growth remain unclear. Viperin belongs to interferon-stimulated genes (ISG) and its expression is highly up-regulated upon viral infection, leading to antiviral activity against a variety of viruses, including flaviviruses. As such, viperin has been shown to be a major actor involved in the innate immune response against Zika virus (ZIKV). Our present study aims to further characterize the involvement of viperin in ZIKV growth inhibition under high glucose concentration (HK-2^HGC). We show for the first time that endogenous viperin is over-expressed in HK-2 cells cultured under high glucose concentration (HK-2^HGC), which is associated with ZIKV growth inhibition. Viperin knockdown in HK-2^HGC rescues ZIKV growth. In addition, our results emphasize that up-regulated viperin in HK-2^HGC leads to ZIKV growth inhibition through the stimulation of IFN-β production. In summary, our work provides new insights into the ZIKV growth inhibition mechanism observed in HK-2 cells cultured in a high glucose environment.

Stochastic Model of the Adaptive Immune Response Predicts Disease Severity and Captures Enhanced Cross-Reactivity in Natural Dengue Infections

The dengue virus circulates as four distinct serotypes, where a single serotype infection is typically asymptomatic and leads to acquired immunity against that serotype. However, the developed immunity to one serotype is thought to underlie the severe manifestation of the disease observed in subsequent infections from a different serotype. We developed a stochastic model of the adaptive immune response to dengue infections. We first delineated the mechanisms initiating and sustaining adaptive immune responses during primary infections. We then contrasted these immune responses during secondary infections of either a homotypic or heterotypic serotype to understand the role of pre-existing and reactivated immune pathways on disease severity. Comparison of non-symptomatic and severe cases from heterotypic infections demonstrated that overproduction of specific antibodies during primary infection induces an enhanced population of cross-reactive antibodies during secondary infection, ultimately leading to severe disease manifestations. In addition, the level of disease severity was found to correlate with immune response kinetics, which was dependent on beginning lymphocyte levels. Our results detail the contribution of specific lymphocytes and antibodies to immunity and memory recall that lead to either protective or pathological outcomes, allowing for the understanding and determination of mechanisms of protective immunity.

Dengue Virus Infection and Associated Risk Factors in Africa: A Systematic Review and Meta-Analysis

Dengue contributes a significant burden on global public health and economies. In Africa, the burden of dengue virus (DENV) infection is not well described. This review was undertaken to determine the prevalence of dengue and associated risk factors. A literature search was done on PubMed/MEDLINE, Scopus, Embase, and Google Scholar databases to identify articles published between 1960 and 2020. Meta-analysis was performed using a random-effect model at a 95% confidence interval, followed by subgroup meta-analysis to determine the overall prevalence. Between 1960 and 2020, 45 outbreaks were identified, of which 17 and 16 occurred in East and West Africa, respectively. Dengue virus serotype 1 (DENV-1) and DENV-2 were the dominant serotypes contributing to 60% of the epidemics. Of 2211 cases reported between 2009 and 2020; 1954 (88.4%) were reported during outbreaks. Overall, the prevalence of dengue was 29% (95% CI: 20-39%) and 3% (95% CI: 1-5%) during the outbreak and non-outbreak periods, respectively. Old age (6/21 studies), lack of mosquito control (6/21), urban residence (4/21), climate change (3/21), and recent history of travel (3/21) were the leading risk factors. This review reports a high burden of dengue and increased risk of severe disease in Africa. Our findings provide useful information for clinical practice and health policy decisions to implement effective interventions.

Knowledge, attitude and practice towards dengue fever prevention and associated factors among public health sector health-care professionals: in Dire Dawa, eastern Ethiopia

Background: The Ethiopian national strategy for the prevention, control and elimination of malaria is one of the Health Development Programs (HDP IV). Dengue fever is one of the vector borne diseases that causes Acute Febrile Illness and death in tropical and sub-tropical countries. Knowledge, attitude and practice of health-care professionals towards dengue fever prevention and associated factors among health professionals is not yet well known across the country and concern is varied in context and place. Therefore, the aim of this research was to assess knowledge, attitude and practice towards dengue fever prevention and associated factors among public health sector health-care professionals in Dire Dawa administrative city, eastern Ethiopia.

Materials and methods: An Institution-based cross sectional study was conducted from September 9 to October 13, 2017. The study was conducted among a sample of 348 health-care professionals which were from the randomly selected nine clusters of public health facilities located in urban and rural areas of Dire Dawa. Data were collected by self-administered structured questionnaire. Bivariate and multinomial logistic regression analyses were made to check the associations among predictor variables and to control for confounding factors. A P-value <0.05 was used to declare statistical significance.

Results: Of the 348 sampled health-care professionals, 300 were included in the analysis giving a response rate of 86.2%. Nearly half (148/49.3%) of the participants demonstrated a moderate level of knowledge, 140 (46.7%) a neutral level of attitude and 156 (52%) a low level of practice towards dengue fever prevention. Multinomial logistic regression revealed that type of health profession, type of health facility and dengue fever prevention training status were significantly associated with the knowledge, attitude and practice of health-care professionals. The odds of physicians and public-health officers having a high level of knowledge or a low knowledge level were (AOR [95% CI] =38.793 [7.279, 206.734]) and (AOR[95% CI] =6.15[1.643, 23.026]) times higher than the odds for nurse professionals. The odds for professionals who worked in health centers and had a high knowledge level towards dengue fever prevention were (AOR [95% CI] =0.252 [0.086, 0.737]) times higher than those working in referral hospitals. The odds of health-care professionals who were public-health officers and those who worked in primary hospitals having a favorable attitude towards dengue fever prevention were (AOR [95% CI] =7.011 [1.867, 26.321]) and (AOR [95% CI] =3.683 [1.284, 10.563]) times higher than the odds for nurse professionals and those who worked in a referral hospital setting respectively. The odds of health-care professionals who took dengue fever prevention training were 10.23 times (AOR [95% CI] =10.23 [1.052, 99.478]) higher than the odds for health-care professionals who had not received the training.

Conclusion: Knowledge attitude and practice of health-care professionals were not satisfactory towards dengue fever. Additional training is required to plug this gap. Thus, the regional health bureau and stakeholders should follow up and provide support including provision of the World Health Organization’s standardized guidelines of dengue fever prevention. We recommend similar studies to be done specifically in Ethiopia and elsewhere to better understand the gaps.

Atypical lymphocyte count correlates with the severity of dengue infection

INTRODUCTION

The early identification of patients at risk of severe dengue infection (DI) is critical to guide clinical management. There is currently no validated laboratory test which can predict severe complications of DI. The Atypical lymphocyte count (ALC) is a research parameter generated at no extra cost when an automated Full Blood Count (FBC) is performed. The purpose of this study was to assess the association of ALC with the severity of DI.

METHODS

We prospectively collected data on patients admitted to Nawaloka Hospital Sri Lanka (NH) with DI between December 2016 and November 2017. DI was diagnosed based on a positive Non-structural antigen 1 (NS1) or dengue IgM antibody. ALC (absolute ALC and percentage) data were extracted from the Sysmex XS500i automated full blood count (FBC) analyzer (Sysmex Corporation Kobe, Japan). Clinical data was recorded from medical records and the computerized data base maintained by NH.

RESULTS

530 patients were enrolled. Patients with clinical manifestations of severe dengue have a significantly higher AL % compared to dengue without warning signs. Patients who presented with respiratory compromise had statistically significantly higher AL% compared to those without. (AL%; 8.65±12.09 vs 2.17±4.25 [p = 0.01]). Similarly, patients who developed hypotension had higher AL% compared to those who did not suffered from shock (AL%; 8.40±1.26 vs 2.18±4.25 [p = 0.001]). The AL% of dengue patients presenting with bleeding, at 4.07%, is also higher than those without bleeding complications, at 2.15%. There was a significant negative association between platelet count and AL% (p = 0.04).

CONCLUSIONS

Clinical manifestations of severe dengue have a significantly higher AL % compared to dengue without warning signs. AL % at presentation may be predictive of severe DI and future larger prospective longitudinal studies should be done to determine if AL % on admission is predictive of the complications of DI.

Spatiotemporal analysis of dengue outbreaks in Samanabad town, Lahore metropolitan area, using geospatial techniques

Dengue is endemic to Pakistan with its usual peak incidence in the post-monsoon period. In the last decade, dengue outbreaks have occurred in major urban areas particularly Karachi and Lahore, affecting large numbers of people. This study is an attempt to analyze the spatiotemporal variation of dengue fever (DF) in Samanabad town, Lahore metropolitan area. The study is based on secondary data, acquired from concerned government departments. Point level geo-coding is used to transform the relative location to the absolute location using Google Earth, and Global Position System (GPS) is used to validate the geo-coded location. Geographic information system (GIS) has been used to perform spatial analysis. It has been found that temporally DF prevalence varies from month to month and year to year. Major outbreak was observed in the year 2013 with more than 900 confirmed DF cases. Rainfall, temperature, and humidity have played a central role in outbreaks. The land cover pattern and population density further intensified the outbreak. Spatially, the number of DF incidence was high in those localities where the entire land is built-up and with little/no green space areas. Analysis reveals that DF is still a major threat to the area as socioeconomic and geographic conditions favor vector breeding and transfer of disease from one person/place to another. This study presents useful information regarding spatiotemporal patterns of dengue outbreak and may bring the attention of public health departments to formulate dengue-combating strategies. The methodology is general for spatiotemporal analysis and can be applied to other infectious diseases as well.

The Sensitivity, Specificity and Accuracy of Warning Signs in Predicting Severe Dengue, the Severe Dengue Prevalence and Its Associated Factors

Objectives: To study Malaysian dengue clinical practice guideline (CPG) warning signs (WS) in predicting severe dengue (SD) and its associated factors among confirmed cases presented to a teaching hospital in north-eastern Malaysia in 2014. Methods: A cross-sectional study was performed in February 2015 using secondary data acquired from the hospital records. There were 2607 confirmed dengue cases presented to Hospital Universiti Sains Malaysia (HUSM) in 2014. Seven hundred patients were selected after proportionate stratified random sampling conducted according to the number of cases in 12 different months in 2014. Data were collected and analysed using SPSS version 22.0. Results: Severe dengue outcomes represented 4.9% of cases. The prevalence of any of WS in SD was 91.2%. The most common WSs prior to SD were persistent vomiting (55.9%), and abdominal pain/tenderness (52.9%). The most sensitive warning sign in detecting SD was abdominal pain (59%). Specificity of individual WS were generally good, especially of clinical fluid accumulation (99%), hepatomegaly (98%) and mucosal bleeding (93%). Factors associated with SD were persistent vomiting (Adjusted odds ratio (aOR)): 2.41), mucosal bleeding (aOR: 4.73) and haematocrit rise with rapid platelet drop (aOR: 2.74). Conclusion: A focus on sensitivity, specificity, predictive values and association of a number of particular WS should be emphasized in order to better predict severe dengue outcomes.

Prevalence of chronic comorbidities in dengue fever and West Nile virus: A systematic review and meta-analysis

Background

Flavivirus diseases such as dengue fever (DENV), West Nile virus (WNV), Zika and yellow fever represent a substantial global public health concern. Preexisting chronic conditions such as cardiovascular diseases, diabetes, obesity, and asthma were thought to predict risk of progression to severe infections.

Objective

We aimed to quantify the frequency of chronic comorbidities in flavivirus diseases to provide an estimate for their prevalence in severe and non-severe infections and examine whether chronic diseases contribute to the increased risk of severe viral expression.

Methods

We conducted a comprehensive search in PubMed, Ovid MEDLINE(R), Embase and Embase Classic and grey literature databases to identify studies reporting prevalence estimates of comorbidities in flavivirus diseases. Study quality was assessed with the risk of bias tool. Age-adjusted odds ratios (ORs) were estimated for severe infection in the presence of chronic comorbidities.

Results

We identified 65 studies as eligible for inclusion for DENV (47 studies) and WNV (18 studies). Obesity and overweight (i.e., BMI> 25 kg/m², prevalence: 24.5%, 95% CI: 18.6–31.6%), hypertension (17.1%, 13.3–21.8%) and diabetes (13.3%, 9.3–18.8%) were the most prevalent comorbidities in DENV. However, hypertension (45.0%, 39.1–51.0%), diabetes (24.7%, 20.2–29.8%) and heart diseases (25.6%, 19.5–32.7%) were the most prevalent in WNV. ORs of severe flavivirus diseases were about 2 to 4 in infected patients with comorbidities such as diabetes, hypertension and heart diseases. The small number of studies in JEV, YFV and Zika did not permit estimating the prevalence of comorbidities in these infections.

Conclusion

Higher prevalence of chronic comorbidities was found in severe cases of flavivirus diseases compared to non-severe cases. Findings of the present study may guide public health practitioners and clinicians to evaluate infection severity based on the presence of comorbidity, a critical public health measure that may avert severe disease outcome given the current dearth of clear prevention practices for some flavivirus diseases.

Global dengue death before and after the new World Health Organization 2009 case classification: A systematic review and meta-regression analysis

BACKGROUND

Since the introduction of 2009 WHO dengue case classification, no literature was found regarding its effect on dengue death. This study was to evaluate the effect of 2009 WHO dengue case classification towards dengue case fatality rate.

METHODS

Various databases were used to search relevant articles since 1995. Studies included were cohort and cross-sectional studies, all patients with dengue infection and must report the number of death or case fatality rate. The Joanna Briggs Institute appraisal checklist was used to evaluate the risk of bias of the full-texts. The studies were grouped according to the classification adopted: WHO 1997 and WHO 2009. Meta-regression was employed using a logistic transformation (log-odds) of the case fatality rate. The result of the meta-regression was the adjusted case fatality rate and odds ratio on the explanatory variables.

RESULTS

A total of 77 studies were included in the meta-regression analysis. The case fatality rate for all studies combined was 1.14% with 95% confidence interval (CI) of 0.82-1.58%. The combined (unadjusted) case fatality rate for 69 studies which adopted WHO 1997 dengue case classification was 1.09% with 95% CI of 0.77-1.55%; and for eight studies with WHO 2009 was 1.62% with 95% CI of 0.64-4.02%. The unadjusted and adjusted odds ratio of case fatality using WHO 2009 dengue case classification was 1.49 (95% CI: 0.52, 4.24) and 0.83 (95% CI: 0.26, 2.63) respectively, compared to WHO 1997 dengue case classification. There was an apparent increase in trend of case fatality rate from the year 1992-2016. Neither was statistically significant.

CONCLUSIONS

The WHO 2009 dengue case classification might have no effect towards the case fatality rate although the adjusted results indicated a lower case fatality rate. Future studies are required for an update in the meta-regression analysis to confirm the findings.

Analysis of dengue virus burden and serotypes pattern in Faisalabad, 2016–2017

Dengue is the fastest growing mosquito-borne viral infection and has become a public epidemic in Pakistan. This cross-sectional study was carried out to explore the prevalence and characterization of dengue virus serotypes in Faisalabad, Pakistan during 2016–2017. Aim: To determine most prevalent dengue serotype in Faisalabad, Pakistan. Methodology: Cross-sectional study of stored serum specimens for dengue virus genotype by multiplex real time (RT)-PCR, antidengue IgM, IgG and NS1.Results: Viral RNA detection of 42 patients revealed positive results in 125 (34.4%) samples. DENV-3 (76%) was the predominant genotype followed by DENV-2 (17%) and 7% of DENV1. None of the samples were positive for DENV-4. Conclusion: DENV-3 is the most prevalent serotype of dengue virus observed in Faisalabad, Pakistan.

Reporting of ethics in peer-reviewed verbal autopsy studies: a systematic review

Introduction

Verbal autopsy (VA) is a method that determines the cause of death by interviewing a relative of the deceased about the events occurring before the death, in regions where medical certification of cause of death is incomplete. This paper aims to review the ethical standards reported in peer-reviewed VA studies.

Methods

A systematic review of Medline and Ovid was conducted by two independent researchers. Data were extracted and analysed for articles based on three key areas: Institutional Review Board (IRB) clearance and consenting process; data collection and management procedures, including: time between death and interview; training and education of interviewer, confidentiality of data and data security; and declarations of funding and conflict of interest.

Results

The review identified 802 articles, of which 288 were included. The review found that 48% all the studies reported having IRB clearance or obtaining consent of participants. The interviewer training and education levels were reported in 62% and 21% of the articles, respectively. Confidentiality of data was reported for 14% of all studies, 18% did not report the type of respondent interviewed and 51% reported time between death and the interview for the VA. Data security was reported in 8% of all studies. Funding was declared in 63% of all studies and conflict of interest in 42%. Reporting of all these variables increased over time.

Conclusions

The results of this systematic review show that although there has been an increase in ethical reporting for VA studies, there still remains a large gap in reporting.

[About 98 cases of dengue hospitalized in a private clinic of Ouagadougou: epidemiology, diagnostic and evolution]

Extremely widespread, the dengue is a reemerging infectious disease. In Burkina Faso, dengue is a reality that was little known. The aim of this study was to study epidemiology, diagnostic and outcomes of dengue patients in Ouagadougou. A retrospective study covered a period of two years, from 1 January 2013 to 31 December 2014 in a private clinic in Ouagadougou. Patients included in the study were hospitalized for fever and painful syndrome with a positive test to the dengue non-structural antigen 1 (NS1 Ag). Ninety-eight cases of dengue on 343 suspected cases were registered. The average age of patients was 35.9 years. The sex-ratio (M/F) was 1.18. According to the professional activity, there was a predominance of civil servants (35.7%). The pain syndrome was found in 93.9% of patients. Leukopenia (73.5%), neutropenia (56.1%) and severe thrombocytopenia (57.1%) were the predominant hematological disturbances. Of the patients, 18.4% had hemorrhagic dengue and 11.2%, a dengue shock syndrome. Four patients died. The use of non-steroidal antiinflammatory drugs was associated with the severity of the infection (p=0.04). Dengue fever occurs in our context and constitutes a risk of mortality. The diagnosis of dengue should be performed systematically in front of a painful and febrile syndrome. The vector control is the best way of prevention against dengue pending the development of a vaccine.

The reintroduction of DENV-2 in 2011 in Panama and subsequent outbreak characteristic

The circulation of the South-east Asian/American (AS/AM) dengue 2 virus (DENV-2) genotype in the Americas has been associated with a high rate of severe disease. From 1993, the year DENV was reintroduced in Panama, until 2011 there were 29 dengue-associated deaths, 17 of which occurred in 2011, the most severe outbreak with a case fatality rate (CFR) of 44% (17 deaths out of 38 severe dengue cases). During this outbreak DENV-2 was reintroduced into the country, whereas over the prior five years DENV-1 and -3 were predominant. Herein, we describe the 2011 Panama outbreak and genetically characterize the Panamanian DENV-2 strains, which were associated with severe dengue disease in Panama. Our results suggest that the DENV-2 isolates from this outbreak belonged to the AS/AM genotype sub-clade 2BI and were genetically close to viruses described in the outbreaks in Nicaragua, Honduras, Guatemala and Mexico from 2006-2011. Sub-clade 2BI has previously been associated with severe disease in Nicaragua during outbreaks from 2005-2007.

Adherence to Clinical Practice Guidelines (CPG) management of dengue infection in adults (revised 2nd edition)

The Malaysian Dengue Clinical Practice Guidelines (CPG) have been developed to provide evidence-based guidance in the management of dengue infections. The use of these guidelines is essential to ensure its recommendations are being practiced. However, the adherence to the guidelines for management of dengue (revised 2^nd edition) by healthcare providers still remains unknown. Therefore, the aim of this study was to evaluate the proportion among healthcare providers that adhere to this Dengue CPG. A retrospective cohort study of dengue cases registered from 1 January 2014 to 1 June 2015 was conducted in public hospitals and health clinics in Selangor, Putrajaya and Kuala Lumpur. Adherence to the CPG recommendations were recorded by reviewing patients’ case notes. Overall proportion of adherence in clinical components of the recommendation were (7.1 to 100.0% versus 7.7 to 73.8%) in history taking, (6.7 to 100.0% versus 12.3 to 60.0%) in physical examinations, (18.4 to 100.0% versus 23.1 to 83.2%) in assessment of warning signs, (0.6 to 100.0% versus 12.3 to 87.7%) in assessment of haemodynamic status, (60.0 to 100.0% versus 27.7 to 40.0%) in diagnosis, (46.6 to 80.0% versus 52.3%) in case notifications, (73.2 to 100.0% versus 89.2 to 96.9%) in performing specific laboratory investigations and (7.9 to 100.0% versus 21.5%) in monitoring, for outpatient versus inpatient, respectively. Adherence trends were demonstrated to be higher in hospital settings compared to outpatient settings. Adherence to this Dengue CPG varies widely with overall good clinical outcomes observed.

Asymptomatic dengue infection in adults of major cities of Pakistan

OBJECTIVE

To determine the asymptomatic dengue infection in adults of Pakistani population.

METHODS

This study was conducted in five major cities (Islamabad, Karachi, Lahore, Multan, and Peshawar) of Pakistan. A total of 5 230 adults aged 18 years and above without a history of dengue fever at any point in their life were enrolled from participating laboratories. Those who were confirmed for dengue previously were excluded. Of the total, 62.6% (n = 3 276) were male with an average age of 34.6 years. Participants were briefed about the objectives of the study, and written consent was obtained to perform dengue IgG test using enzyme linked immunosorbent assay. The brief information related to age, gender and area was also taken on proforma.

RESULTS

Overall 32.3% (n = 1 691) was having asymptomatic dengue infection which was 67.5% (n = 756) in Karachi followed by 39.1% (n = 391) in Islamabad, 29.9% (n = 316) in Lahore and 21% (n = 228) in Peshawar and none from Multan. More males were affected with asymptomatic dengue infection than females. The asymptomatic dengue infection was significantly higher in different cities; however, there was no significant difference with respect to age groups.

CONCLUSIONS

The asymptomatic dengue infection is higher in cities i.e. Karachi, Islamabad and Lahore which are at risk of developing secondary dengue infections. There is a need of awareness among the public about secondary dengue infection.

Dengue infection

Dengue is widespread throughout the tropics and local spatial variation in dengue virus transmission is strongly influenced by rainfall, temperature, urbanization and distribution of the principal mosquito vector Aedes aegypti. Currently, endemic dengue virus transmission is reported in the Eastern Mediterranean, American, South-East Asian, Western Pacific and African regions, whereas sporadic local transmission has been reported in Europe and the United States as the result of virus introduction to areas where Ae. aegypti and Aedes albopictus, a secondary vector, occur. The global burden of the disease is not well known, but its epidemiological patterns are alarming for both human health and the global economy. Dengue has been identified as a disease of the future owing to trends toward increased urbanization, scarce water supplies and, possibly, environmental change. According to the WHO, dengue control is technically feasible with coordinated international technical and financial support for national programmes. This Primer provides a general overview on dengue, covering epidemiology, control, disease mechanisms, diagnosis, treatment and research priorities.

Dengue Deaths: Associated Factors and Length of Hospital Stay

Background. Dengue continues to pose a public health problem globally. Objective. To review factors associated with patients who died from dengue in Trinidad. Methods. A retrospective case note review of hospitalized patients who died during 2001 to 2010. Results. A total of 23 cases were identified: 13 males, 10 females-12 East Indians, 9 Africans, and 2 unknown. More than half (n = 17) were over 40 years of age with 10 being over 60 years of age; three were children. A falling platelet count was observed in 16 while 18 patients had a low normal haematocrit. There was a significant association of ethnicity, hypertension, and diabetes with length of hospital stay. Conclusions. The study sample included 10 patients over 60 years of age. Patients with diabetes and hypertension and patients of East Indian origin appeared to have a shorter hospital stay prior to death.

Clinical Manifestations and Predictors of Thrombocytopenia in Hospitalized Adults with Dengue Fever

Background:

India is one of the seven identified Southeast Asian countries reporting frequent outbreaks of dengue fever (DF).

Aims:

This study was to analyze clinical and laboratory profile and predictive markers of thrombocytopenia and length of hospital stay in DF.

Materials and Methods:

This record-based retrospective study conducted in a coastal district of Karnataka, South India, included all dengue cases in adults aged >18 years, admitted during period of January 2011 to December 2014. Multivariate logistic regression analysis was carried out to compute odds ratio (OR) and 95% confidence interval (CI) to assess independent associations of variables with low platelet count and longer duration of hospital stay.

Results:

Among 207 dengue immunoglobulin M (IgM) antibody confirmed cases (mean age of 36.94 ± 14.61 years), 143 (69.1%) were males and 64 were females. The mean duration of illness and hospital stay were 4.94 ± 3.58 days and 5.98 ± 2.58 days, respectively. Abdominal symptoms included nausea and vomiting (53.6%), abdominal pain (25.1%), and diarrhea (13.5%). Bleeding manifestations were seen in 24 (11.6%) cases and fluid accumulation was revealed in 18 (8.7%) cases. The mean platelet count was 110,159.42 ± 68,397.32 (cells/mm³). Low platelet count on admission was associated with the presence of rash (OR = 0.43, 95% CI 0.23-0.81), high aspartate aminotransferase (AST) levels (OR = 3.14, 95% CI 1.58-6.23), high alanine aminotransferase (ALT) levels (OR = 2.91, 95% CI 1.55-5.47), and low albumin levels (OR = 4.48, 95% CI 1.02-19.75). The duration of hospital stay was associated with diarrhea (OR = 0.4, 95% CI 0.18-0.9), abdominal pain (OR = 0.52, 95% CI 0.27-1.00), ascites (OR = 0.26, 95% CI 0.09-0.69), and low hemoglobin (OR = 0.46, 95% CI 0.25-0.86) level on admission.

Conclusions:

Though thrombocytopenia on admission was associated with the presence of rash, high AST and ALT levels, and low albumin levels, it was not predictive of length of hospitalization. Duration of hospital stay was longer with the presence of diarrhea, abdominal pain, ascites, and low hemoglobin level on admission.

Relevance of Non-communicable Comorbidities for the Development of the Severe Forms of Dengue: A Systematic Literature Review

Patients with dengue fever and comorbidities seem to be at higher risk of developing complications and/or severe dengue compared to healthier individuals. This study systematically reviews the evidence related to comorbidities and dengue. A systematic literature review was performed in five databases (EMBASE, PUBMED, Global Health, SciELO, Cochrane) and grey literature for full-text articles since its inceptions until October 10, 2015. A total of 230 articles were retrieved. Sixteen studies were analysed after applying all inclusion and exclusion criteria. Seven case control studies and nine retrospective cohort studies showed that comorbidities may contribute to severe dengue, especially 1) cardiovascular disease, 2) stroke, 3) diabetes, 4) respiratory disease and 5) renal disease, as well as old age. However, due to heterogeneity in studies, the real estimate effect of comorbidities as modifiers of dengue severity could not be established. Further research in regions with high prevalence of dengue infection would contribute to a better understanding of the relevance of comorbidities in severe dengue, especially with a standardised protocol, for outcomes, specific comorbidities, study design—best using prospective designs—and sample sizes.

Dengue fever is a viral disease, transmitted by Aedes mosquitoes. Although for most cases of dengue fever the illness is self-limiting or asymptomatic, severe dengue can occur. Severe dengue is now classified by 1) plasma leakage, and/or 2) severe haemorrhage and/or 3) organ failure. Complications and deaths occur in this group of cases with severe dengue. Patients with dengue fever and comorbidities seem to be at higher risk of developing complications and/or severe dengue compared to healthier individuals. This study systematically reviews the evidence related to comorbidities and the severe forms of dengue fever. Sixteen studies were analysed after applying all inclusion and exclusion criteria. Seven case control studies and nine retrospective cohort studies assessed comorbidities and development of severe forms of dengue. The results showed that comorbidities are relevant to severe dengue, especially 1) cardiovascular disease, 2) stroke, 3) diabetes, 4) respiratory disease and 5) renal disease, as well as old age. The study of comorbidities in dengue fever is fundamental for improved patient outcome by differential case management of patients, reducing the burden of the disease. Further research in regions with high prevalence of dengue infection would contribute to a better understanding of the relevance of comorbidities with severe forms of dengue fever. An agreed protocol for such studies is urgently needed.

Dengue death with evidence of hemophagocytic syndrome and dengue virus infection in the bone marrow

INTRODUCTION

HPS is a potentially life-threatening histiocytic disorder that has been described in various viral infections including dengue. Its involvement in severe and fatal dengue is probably more common but is presently under recognized.

CASE DESCRIPTION

A 38-year-old female was admitted after 5 days of fever. She was deeply jaundiced, leukopenic and thrombocytopenic. Marked elevation of transaminases, hyperbilirubinemia and hypoalbuminemia were observed. She had deranged INR values and prolonged aPTT accompanied with hypofibrinogenemia. She also had splenomegaly. She was positive for dengue IgM. Five days later she became polyuric and CT brain image showed gross generalized cerebral edema. Her conditions deteriorated by day 9, became confused with GCS of 9/15. Her BMAT showed minimal histiocytes. Her serum ferritin level peaked at 13,670.00 µg/mL and her sCD163 and sCD25 values were markedly elevated at 4750.00 ng/mL and 4191.00 pg/mL, respectively. She succumbed to the disease on day 10 and examination of her tissues showed the presence of dengue virus genome in the bone marrow.

DISCUSSION AND EVALUATION

It is described here, a case of fatal dengue with clinical features of HPS. Though BMAT results did not show the presence of macrophage hemophagocytosis, other laboratory features were consistent with HPS especially marked elevation of ferritin, sCD163 and sCD25. Detection of dengue virus in the patient's bone marrow, fifteen days after the onset of fever was also consistent with the suggestion that the HPS is associated with dengue virus infection.

CONCLUSIONS

The findings highlight HPS as a possible complication leading to severe dengue and revealed persistent dengue virus infection of the bone marrow. Detection of HPS markers; ferritin, sCD163 and sCD25, therefore, should be considered for early recognition of HPS-associated dengue.

Dengue fever in Pakistan: a paradigm shift; changing epidemiology and clinical patterns

Dengue fever has huge public health implications and affects over 100 million people worldwide. This review pictures the current situation of Dengue in Pakistan and presents a review of published literature. Pakistan has seen recurrent epidemics of Dengue Fever recently. Unfortunately, these epidemics are becoming more severe in their clinical manifestation. Pakistan experienced large epidemics of dengue fever during 2008, 2010 and 2011 affecting thousands of people and claiming hundreds of deaths. A comparison of data during these epidemics indicates a shift from mild to a more severe disease, which could be interpreted as an epidemiologic transition pattern in the country. Expansion of Dengue in Pakistan seems to be multifactorial, including the climate change, frequent natural disasters, vector resistance to insecticides and lack of resources. This highlights the need for rigorous vector control. Continuing education of primary care physicians is crucial for early appropriate management to reduce mortality.

Retrospective Review of Platelet Transfusion Practices during 2013 Dengue Epidemic of Delhi, India

BACKGROUND

Dengue infection is a major public health problem. During explosive outbreaks, there is sudden surge in demands of platelet products. The present study was carried out in order to review platelet transfusion practices during the epidemic of dengue.

METHODS

We retrospectively reviewed the clinical details including the platelet counts and haemorrhagic tendencies of dengue patients as well as the transfusion requirements of diagnosed dengue cases admitted at our centre.

RESULTS

A total of 1,750 random donor platelet and 114 single donor platelet units were transfused to 531 patients. 23.2% platelet transfusions were found to be inappropriate Mean dosage of platelets transfused was 2 × 10(11) platelets per patient. A total of 347 (65.3%) patients had bleeding diathesis at the time of presentation. Skin and the oropharynx were the most common bleeding sites. Major bleeding was seen in 119 (34.3%) patients, whereas 228 (65.7%) patients had minor bleeding episodes.

CONCLUSION

The study emphasises the need for minimising unnecessary transfusions and for using this scarce resource judiciously, which can be achieved by strict adherence to evidence-based transfusion guidelines and regular review of the on-going transfusion practices.