Clinical spectrum and predictors of severity of dengue among children in 2019 outbreak: a multicenter hospital-based study in Bangladesh

Clinical Manifestations of Dengue in Children and Adults in a Hyperendemic Region of Colombia

Dengue is the most common arboviral disease in the world. Traditionally, it has affected more adults, but the incidence in children has increased in recent years. Colombia is no stranger to this change; therefore, we aimed to find the differences in signs, symptoms, and clinical, hematological, and hemogram characteristics between children under 12 years old and individuals aged 12 years and older in an endemic region of Colombia in 2020-2022. The analyses were conducted with baseline data, corresponding to a cross-sectional design. Multiple correspondence analysis was used for general, dermatological, and clinical symptom profiles. Discriminant analysis was used for laboratory profiles. Multiple correspondence analysis was applied to nominal categorical data, employing Euclidean distances to analyze age groups. Discriminant analysis was applied to a training sample and validated on a test sample. The overall agreement of the model's discrimination, sensitivity, specificity, and fit indicators was calculated. The results indicated that individuals under 12 years exhibited distinct dermatological and clinical features, including rash, pruritus, hypotension, lymphocyte count, and platelet count, compared with those aged 12 years and older. In contrast, those 12 years and older were profiled for general and clinical symptoms such as pain (back pain, retro-orbital pain, headache), dizziness, chills, hematuria, tachypnea, and elevated/high hematocrit, hemoglobin, and basophil values. These findings are crucial to understanding the high incidence in children; they also facilitate rapid understanding of the disease in clinical care settings and differentiate it from other febrile outbreaks. This will affect disease control, particularly in severe cases, and reduce mortality.

Risk factors associated with severe dengue in Latin America: A systematic review and meta-analysis

OBJECTIVE

Severe dengue is a significant health problem in Latin America, with children being the most affected. Understanding risk factors for severe dengue is crucial for enhancing patient care. Therefore, this study aims to systematically review the literature to identify the risk factors associated with severe dengue in Latin America through systematic review and meta-analysis.

METHODS

PubMed, SciELO, LILACS and EMBASE databases were used to search for eligible scientific articles for the review. The outcomes considered were symptoms of severe dengue, hospitalisation and death. The Joanna Briggs Institute Critical Appraisal Checklist was used to assess the quality of the studies. Data analysis was performed using STATA v 13.0 software. The degree of heterogeneity between studies was quantified using the I2 measure, and statistically significant results were defined as those with p values <0.05.

RESULTS

Of the 1876 articles screened, 47 articles were included in the systematic review and 45 articles were analysed through meta-analysis. Identified risk factors associated with severe dengue included secondary dengue infection, female sex, white or Caucasian ethnicity and specific signs and symptoms such as headache, myalgia and/or arthralgia, vomiting/nausea, abdominal pain or tenderness, diarrhoea, prostration, lethargy, fatigue or similar. For the death outcome, respiratory symptoms and age <18 years were identified as risk factors. On the other hand, in women, the diagnosis of positive tourniquet test, platelet count <100,000 per μL and symptoms of capillary fragility were associated with a lower probability of death. These data highlight the importance of early screening of patients, to identify possible haemorrhagic signs and reduce deaths from dengue. This study has limitations, including possible publication bias, heterogeneity of results and study design biases.

CONCLUSION

These findings are significant for shaping strategies, management approaches and identifying high-risk groups, which will help establish future guidelines.

Association of cardiovascular disease with severe dengue: A systematic review and meta-analysis

BACKGROUND

Cardiovascular disease (CVD) and dengue are both significant global health concerns, and their intersection presents a growing clinical challenge. Emerging evidence suggests that individuals with pre-existing CVD may face an elevated risk of severe dengue outcomes. The present study aims to perform a systematic review to assess the relationship between CVD and the severity of dengue.

METHODS

We conducted a literature search across multiple databases from inception to November 25, 2023. Primary studies reporting the number of dengue patients with CVD in severe dengue and non-severe dengue groups were included. Quality assessment was performed using the Newcastle-Ottawa Scale, and a meta-analysis was conducted using R software version 4.2 to determine the pooled Relative Risk (RR). The study protocol has been registered in PROSPERO.

RESULTS

Based on data from 5 studies involving 274,576 dengue patients, our meta-analysis revealed a significant association between CVD and an increased risk of severe dengue, with a calculated RR of 2.71 (95  % CI: 1.03 to 7.10). However, substantial heterogeneity was observed among the included studies (I2 = 79  %).

CONCLUSION

The current evidence suggests an association between CVD and severe dengue, emphasizing the importance of closely monitoring individuals with pre-existing cardiovascular disease and providing them with targeted interventions upon dengue diagnosis to mitigate the risk of severe outcomes.

The Effect of Age on Dengue Presentation and the Diagnostic Accuracy of the 2015 Pan American Health Organization Case Criteria in a Puerto Rican Cohort

Background

We evaluated dengue presentation by age, the performance of the 2015 Pan American Health Organization (PAHO) case criteria in identifying dengue cases, and variables to improve specificity.

Methods

Patients with fever ≤7 days (N = 10 408) were recruited from 2 emergency departments from May 2012 through December 2015. Serum samples were tested for dengue, chikungunya, and nasopharyngeal swabs for respiratory viruses. Smoothing splines assessed differences in the frequencies of signs/symptoms by age. Least absolute shrinkage and selection operator regressions identified the variables that best predicted dengue.

Results

Among 985 dengue cases, children aged <5 years were least likely to have leukopenia, but most likely to have rash and petechiae. Adults had the highest odds of aches/pains and headaches/retro-orbital pain. The 2015 PAHO criteria had sensitivity of 93% and specificity of 25%. Specificity could be improved by requiring at least 2 of the following criteria: vomiting/nausea, petechiae, rash, or leukopenia (specificity 68%, sensitivity 71%) or by using 2015 PAHO criteria plus either (1) aspartate aminotransferase >50 IU/L or platelet count <100 000 platelets/μL (specificity 81%, sensitivity 56%) or (2) itchy skin or absence of rhinorrhea or cough (specificity 51%, sensitivity 82%).

Conclusions

The 2015 PAHO dengue case criteria had excellent sensitivity but poor specificity. This can be improved by adding signs/symptoms associated with dengue diagnosis.

Twenty-two years of dengue outbreaks in Bangladesh: epidemiology, clinical spectrum, serotypes, and future disease risks

Dengue is the most rapidly spreading mosquito-borne disease and has become a major public health threat, particularly for tropical and subtropical countries including Bangladesh. This comprehensive review aims to summarize the overall scenario of dengue, including disease burden, clinical spectrum, seroprevalence, circulating serotypes/genotypes, and spatial distribution since the first recorded outbreak in Bangladesh. Since the first recorded outbreak in 2000, dengue epidemiology has shown the typical epidemic pattern with more frequent and bigger outbreaks and gradual geographic expansion to non-endemic regions in Bangladesh. For instance, highly confined Rohingya refugee camps that provide shelters to nearly 1.2 million forcibly displaced vulnerable Myanmar nationals in Cox's Bazar district confronted a massive outbreak in 2022. Recent major outbreaks are found to be associated with the emergence of serotype DENV-3, which was undetected for a long time. Consequently, changes in serotypes might be attributed to increased severity in clinical manifestation in recent years. The existing weak surveillance and risk management systems are inadequate to deal with impending dengue risks. The healthcare system, particularly at the district level, is not prepared to manage impending large-scale dengue outbreaks in Bangladesh. Our findings would contribute to the development of strategies for dengue control and management in Bangladesh as well as other similar settings elsewhere in the world.

Epidemiological Investigation of the 2019 Dengue Outbreak in Dhaka, Bangladesh

Introduction. Bangladesh experienced its largest dengue epidemic in 2019. Our objective was to investigate the epidemiological, clinical, and laboratory characteristics of the hospital-admitted dengue patients during this epidemic. Methods. This cross-sectional study was conducted among 369 adult dengue patients admitted to two tertiary care hospitals in Dhaka, Bangladesh, from June to September 2019. The disease severity was determined according to the WHO’s 2009 classification. Results. The average age of the patients was 33.3 (SD 14) years with a predominance of men. Almost 10% developed severe dengue (plasma leakage 67%, clinical bleeding 25%, and organ involvement 25%). Fever, headache, retro-orbital pain, diarrhea, and warning signs such as abdominal pain, clinical fluid accumulation, and persistent vomiting were the most common clinical presentations. Thrombocytopenia, leukopenia, elevated HCT levels, and ALT/AST were common laboratory findings. Conclusions. Severe dengue was mostly attributable to plasma leakage with warning signs, especially abdominal pain, clinical fluid accumulation, persistent vomiting, and altered hematological parameters which might assist in the early prediction of severe dengue.

Demographic characteristics, clinical symptoms, biochemical markers and probability of occurrence of severe dengue: A multicenter hospital-based study in Bangladesh

Establishing reliable early warning models for severe dengue cases is a high priority to facilitate triage in dengue-endemic areas and optimal use of limited resources. However, few studies have identified the complex interactive relationship between potential risk factors and severe dengue. This research aimed to assess the potential risk factors and detect their high-order combinative effects on severe dengue. A structured questionnaire was used to collect detailed dengue outbreak data from eight representative hospitals in Dhaka, Bangladesh, in 2019. Logistic regression and machine learning models were used to examine the complex effects of demographic characteristics, clinical symptoms, and biochemical markers on severe dengue. A total of 1,090 dengue cases (158 severe and 932 non-severe) were included in this study. Dyspnoea (Odds Ratio [OR] = 2.87, 95% Confidence Interval [CI]: 1.72 to 4.77), plasma leakage (OR = 3.61, 95% CI: 2.12 to 6.15), and hemorrhage (OR = 2.33, 95% CI: 1.46 to 3.73) were positively and significantly associated with the occurrence of severe dengue. Classification and regression tree models showed that the probability of occurrence of severe dengue cases ranged from 7% (age >12.5 years without plasma leakage) to 92.9% (age ≤12.5 years with dyspnoea and plasma leakage). The random forest model indicated that age was the most important factor in predicting severe dengue, followed by education, plasma leakage, platelet, and dyspnoea. The research provides new evidence to identify key risk factors contributing to severe dengue cases, which could be beneficial to clinical doctors to identify and predict the severity of dengue early.

Does dengue and COVID-19 co-infection have worse outcomes? A systematic review of current evidence

In dengue-endemic regions, the co-infection with SARS-CoV-2 and dengue is a significant health concern. Therefore, we performed a literature search for relevant papers in seven databases on 26 Spetember 2021. Out of 24 articles, the mortality rate and intensive care unit (ICU) admission were 19.1% and 7.8%, respectively. The mean hospital stay was 11.4 days. In addition, we identified two pregnancies with dengue and COVID-19 co-infection; one ended with premature rupture of membrane and intrauterine growth restriction fetus, while the other one ended with maternal mortality and intrauterine fetal death. COVID-19 and dengue co-infection had worse outcomes regarding mortality rates, ICU admission, and prolonged hospital stay. Thus, wise-decision management approaches should be adequately offered to these patients to enhance their outcomes. Establishing an early diagnosis might be the answer to reducing the estimated significant burden of these conditions.

Majority of pediatric dengue virus infections in Kenya do not meet 2009 WHO criteria for dengue diagnosis

From 1975-2009, the WHO guidelines classified symptomatic dengue virus infections as dengue fever, dengue hemorrhagic fever, and dengue shock syndrome. In 2009 the case definition was changed to a clinical classification after concern the original criteria was challenging to apply in resource-limited settings and not inclusive of a substantial proportion of severe dengue cases. Our goal was to examine how well the current WHO definition identified new dengue cases at our febrile surveillance sites in Kenya. Between 2014 and 2019 as part of a child cohort study of febrile illness in our four clinical study sites (Ukunda, Kisumu, Msambweni, Chulaimbo) we identified 369 dengue PCR positive symptomatic cases and characterized whether they met the 2009 revised WHO diagnostic criteria for dengue with and without warning signs and severe dengue. We found 62% of our PCR-confirmed dengue cases did not meet criteria per the guidelines. Our findings also correlate with our experience that dengue disease in children in Kenya is less severe as reported in other parts of the world. Although the 2009 clinical classification has recently been criticized for being overly inclusive and non-specific, our findings suggest the 2009 WHO dengue case definition may miss more than 50% of symptomatic infections in Kenya and may require further modification to include the African experience.