Short Report: Serological Evidence of Under-Reported Dengue Circulation in Sierra Leone

The global incidence and trends of three common flavivirus infections (Dengue, yellow fever, and Zika) from 2011 to 2021

Background

Flavivirus pose a continued threat to global health, yet their worldwide burden and trends remain poorly quantified. We aimed to evaluate the global, regional, and national incidence of three common flavivirus infections (Dengue, yellow fever, and Zika) from 2011 to 2021.

Methods

Data on the number and rate of incidence for the three common flavivirus infection in 204 countries and territories were retrieved from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021. The estimated annual percent change (EAPC) was calculated to quantify the temporal trend during 2011-2016, 2016-2019, and 2019-2021, respectively.

Results

In 2021, an estimated 59,220,428 individuals were infected globally, comprising 58,964,185 cases of dengue, 86,509 cases of yellow fever, and 169,734 cases of Zika virus infection. The age-standardized incidence rate (ASIR) of the three common flavivirus infections increased by an annual average of 5.08% (95% CI 4.12 to 6.05) globally from 2011 to 2016, whereas decreased by an annual average of -8.37% (95% CI -12.46 to -4.08) per year between 2016 to 2019. The ASIR remained stable during 2019-2021, with an average change of 0.69% (95% CI -0.96 to 2.37) per year globally for the three common flavivirus infections. Regionally, the burden of the three common flavivirus infections was primarily concentrated in those regions with middle income, such as South Asia, Southeast Asia, and Tropical Latin America. Additionally, at the country level, there was an inverted "U" relationship between the SDI level and the ASI. Notably, an increase in the average age of infected cases has been observed worldwide, particularly in higher-income regions.

Conclusion

Flavivirus infections are an expanding public health concern worldwide, with considerable regional and demographic variation in the incidence. Policymakers and healthcare providers must stay vigilant regarding the impact of COVID-19 and other environmental factors on the risk of flavivirus infection and be prepared for potential future outbreaks.

A Serological Multiplexed Immunoassay (MIA) Detects Antibody Reactivity to SARS-CoV-2 and Other Viral Pathogens in Liberia and Is Configurable as a Multiplexed Inhibition Test (MINT)

The SARS-CoV-2 pandemic ignited global efforts to rapidly develop testing, therapeutics, and vaccines. However, the rewards of these efforts were slow to reach many low- to middle-income countries (LMIC) across the African continent and globally. Therefore, two bead-based multiplexed serological assays were developed to determine SARS-CoV-2 exposure across four counties in Liberia. This study was conducted during the summer of 2021 on 189 samples collected throughout Grand Bassa, Bong, Margibi, and Montserrado counties. Our multiplexed immunoassay (MIA) detected elevated exposure to SARS-CoV-2 and multiple variant antigens. Additionally, we detected evidence of exposure to Dengue virus serotype 2, Chikungunya virus, and the seasonal coronavirus NL63. Our multiplexed inhibition test (MINT) was developed from the MIA to observe antibody-mediated inhibition of SARS-CoV-2 spike protein binding to its cognate cellular receptor ACE-2. We detected inhibitory antibodies in the tested Liberian samples, which were collectively consistent with a convalescent serological profile. These complementary assays serve to supplement existing serological testing needs and may enhance the technical capacity of scientifically underrepresented regions globally.

Analysis of dengue fever disease in West Africa

Dengue fever disease (DFD) which is caused by four antigenically distinct dengue viruses (DENV) presents a global health threat, with tropical and subtropical regions at a greater risk. The paucity of epidemiological data on dengue in West African subregion endangers efforts geared toward disease control and prevention. A systematic search of DFD prevalence, incidence, and DENV-infected Aedes in West Africa was conducted in PubMed, Scopus, African Index Medicus, and Google Scholar in line with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines. A total of 58 human prevalence studies involving 35,748 people from 8 countries were identified. Two incidence and six DENV-infected studies were also reviewed. Nigeria and Burkina Faso contributed the majority of the prevalence studies which spanned between 1968 and 2018, with a considerable variation in coverage among the countries reviewed in this study. An average prevalence of 20.97% was observed across both general prevalence and acute DENV infection study categories, ranging between 0.02% and 93%. The majority of these studies were conducted in acute febrile patients with a prevalence range of 0.02-93% while 19% (n = 11) of all studies were general population-based studies and reported a prevalence range of 17.2-75.8%. DENV-infected Aedes aegypti were reported in four out of the five countries with published reports; with DENV-2 found circulating in Cape Verde, Senegal, and Burkina Faso while DENV-3 and DENV-4 were also reported in Senegal and Cape Verde, respectively. High prevalence of DFD in human populations and the occurrence of DENV-infected A. aegypti have been reported in West Africa, even though weaknesses in study design were identified. Epidemiological data from most countries and population in the subregion were scarce or non-existent. This study highlights the epidemic risk of DFD in West Africa, and the need for research and surveillance to be prioritized to fill the data gap required to enact effective control measures.

Recurrent Episodes of Some Mosquito-Borne Viral Diseases in Nigeria: A Systematic Review and Meta-Analysis

Different ecological zones favor the breeding of Aedes species. The molecular epidemiology of dengue virus (DENV), yellow fever virus (YFV), and Chikungunya virus (CHIKV) was determined from outbreaks and surveillance activities in Nigeria. Twenty-eight DENV, twenty-five YFV, and two CHIKV sequences from Nigeria were retrieved from GenBank. Genotyping was performed with a genome detective typing tool. The evolutionary comparison was performed by the Maximum Likelihood method on MEGA. Chi-square was used to compare the association between the proportions of viral infections at different times. Six DENV-1 were detected in 1964, 1965, 1978, 2007, and 2018. Nineteen DENV-2 strains were reported, four belonging to sylvatic VI, one belonging to cosmopolitan II, and twelve to Asian I genotype V. DENV-2 genotype VI was detected in 1966, and genotypes II and V in 2019. All three DENV-3 were detected in 2018, while only one DENV-4 was identified in 2019. YFV was reported in 1946 and then in the 60s, 70s, 80s, 90s, 2018, and 2019 with reports to date. CHIKV is still circulating following its identification in 1964 and 1965. Recurrent episodes of dengue, Chikungunya, and yellow fever continue unabated. Vector control initiatives and immunization should be greatly sustained.

A systematic review and meta-analysis of the aetiological agents of non-malarial febrile illnesses in Africa

Background

The awareness of non-malarial febrile illnesses (NMFIs) has been on the rise over the last decades. Therefore, we undertook a systematic literature review and meta-analysis of causative agents of non-malarial fevers on the African continent.

Methodology

We searched for literature in African Journals Online, EMBASE, PubMed, Scopus, and Web of Science databases to identify aetiologic agents that had been reported and to determine summary estimates of the proportional morbidity rates (PMr) associated with these pathogens among fever patients.

Findings

A total of 133 studies comprising 391,835 patients from 25 of the 54 African countries were eligible. A wide array of aetiologic agents were described with considerable regional differences among the leading agents. Overall, bacterial pathogens tested from blood samples accounted for the largest proportion. The summary estimates from the meta-analysis were low for most of the agents. This may have resulted from a true low prevalence of the agents, the failure to test for many agents or the low sensitivity of the diagnostic methods applied. Our meta-regression analysis of study and population variables showed that diagnostic methods determined the PMr estimates of typhoidal Salmonella and Dengue virus. An increase in the PMr of Klebsiella spp. infections was observed over time. Furthermore, the status of patients as either inpatient or outpatient predicted the PMr of Haemophilus spp. infections.

Conclusion

The small number of epidemiological studies and the variety of NMFI agents on the African continent emphasizes the need for harmonized studies with larger sample sizes. In particular, diagnostic procedures for NMFIs should be standardized to facilitate comparability of study results and to improve future meta-analyses. Reliable NMFI burden estimates will inform regional public health strategies.

Previous systematic reviews have highlighted the research priorities of causative agents for non-malarial febrile illnesses by counting the number of publications attributed to an agent. However, proportional morbidity rates are calculated by dividing the number of cases with a specific disease (numerator) by the total number of diagnosed fever cases (denominator) and are better indicators of the relative importance of aetiological agents in a population. Therefore, we present the leading causes of non-malarial febrile illnesses in African patients in both healthcare and community settings. Preference is given to HIV-negative patients when data could be found. We also determined summary estimates of Brucella spp., Chikungunya virus, Dengue virus, Haemophilus spp., Klebsiella spp., Leptospira spp., non-typhoidal Salmonella spp., typhoidal Salmonella spp., Staphylococcus spp., and Streptococcus spp.

The wide array of aetiological agents causing febrile illnesses on the African continent does not only complicate malaria control programs but may also hamper response to epidemic and pandemic illnesses such as Ebola and COVID-19. The harmonisation of diagnostics and study designs will reduce between-study differences, which may result in better estimates of disease burden on the continent and in the different African regions. This information is important for Pan-African surveillance and control efforts.

Epidemiology and Laboratory Diagnostics of Dengue, Yellow Fever, Zika, and Chikungunya Virus Infections in Africa

Arbovirus infections are widespread, and their disease burden has increased in the past decade. In Africa, arbovirus infections and fever with unknown etiology are common. Due to the lack of well-established epidemiologic surveillance systems and accurate differential diagnosis in most African countries, little is known about the prevalence of human arbovirus infections in Africa. The aim of this review is to summarize the available epidemiological data and diagnostic laboratory tools of infections with dengue, yellow fever, Zika, and chikungunya viruses, all transmitted by Aedes mosquitoes. Studies indicate that these arboviral infections are endemic in most of Africa. Surveillance of the incidence and prevalence of the infections would enable medical doctors to improve the diagnostic accuracy in patients with typical symptoms. If possible, arboviral diagnostic tests should be added to the routine healthcare systems. Healthcare providers should be informed about the prevalent arboviral diseases to identify possible cases.

Mosquito-Associated Viruses and Their Related Mosquitoes in West Africa

Mosquito-associated viruses (MAVs), including mosquito-specific viruses (MSVs) and mosquito-borne (arbo)viruses (MBVs), are an increasing public, veterinary, and global health concern, and West Africa is projected to be the next front for arboviral diseases. As in-depth knowledge of the ecologies of both western African MAVs and related mosquitoes is still limited, we review available and comprehensive data on their diversity, abundance, and distribution. Data on MAVs’ occurrence and related mosquitoes were extracted from peer-reviewed publications. Data on MSVs, and mosquito and vertebrate host ranges are sparse. However, more data are available on MBVs (i.e., dengue, yellow fever, chikungunya, Zika, and Rift Valley fever viruses), detected in wild and domestic animals, and humans, with infections more concentrated in urban areas and areas affected by strong anthropogenic changes. Aedes aegypti, Culex quinquefasciatus, and Aedes albopictus are incriminated as key arbovirus vectors. These findings outline MAV, related mosquitoes, key knowledge gaps, and future research areas. Additionally, these data highlight the need to increase our understanding of MAVs and their impact on host mosquito ecology, to improve our knowledge of arbovirus transmission, and to develop specific strategies and capacities for arboviral disease surveillance, diagnostic, prevention, control, and outbreak responses in West Africa.

Aedes-borne disease outbreaks in West Africa: A call for enhanced surveillance

Arboviruses transmitted by Aedes mosquitoes are a growing global concern; however, there remain large gaps in surveillance of both arboviruses and their vectors in West Africa. We reviewed over 50 years of data including outbreak reports, peer-reviewed literature, and prior data compilations describing Zika, dengue, and chikungunya, and their vectors in West Africa. Large outbreaks of dengue, Zika, and chikungunya have recently occurred in the region with over 27,000 cases of Aedes-borne disease documented since 2007. Recent arboviral outbreaks have become more concentrated in urban areas, and Aedes albopictus, recently documented in the region, has emerged as an important vector in several areas. Seroprevalence surveys suggest reported cases are a gross underestimate of the underlying arboviral disease burden. These findings indicate a shifting epidemiology of arboviral disease in West Africa and highlight a need for increased research and implementation of vector and disease control. Rapid urbanization and climate change may further alter disease patterns, underscoring the need for improved diagnostic capacity, and vector and disease surveillance to address this evolving health challenge.

Dengue Virus Serotype 1 Exported to Japan from Côte d'Ivoire, 2019

Dengue fever outbreaks have been repeatedly reported in Côte d'Ivoire. During the 2019 outbreak, DENV-1 was the predominant strain and phylogenetic analysis of the DENV-1 genome obtained from the present patient who returned to Japan in January 2019 revealed a high homology with the 2013-2014 Southeast Asian strains. In a previous outbreak in 2017, DENV-1 accounted for 5% of the DENV serotypes. The endemic DENV-1 strain in Abidjan in 2019 could be a strain that was imported from Southeast Asia. Dengue virus can spread globally, and imported dengue fever cases could serve as an alert for outbreaks in the exporting country.

Clinical and epidemiologic characteristics associated with dengue during and outside the 2016 outbreak identified in health facility-based surveillance in Ouagadougou, Burkina Faso

Background

In Africa, the magnitude of dengue virus (DENV) transmission is largely unknown. In Burkina Faso, several outbreaks have been reported and data are often based on findings from outbreak investigations.

Methods

To better understand dengue epidemiology and clinical characteristics in Burkina Faso, a fever surveillance study was conducted among patients aged 1–55 years, who presented with non-malarial febrile illness at five primary healthcare facilities in Ouagadougou, Burkina Faso from December 2014 to February 2017, encompassing a 3-month dengue outbreak in September-November 2016. Acute and convalescent blood samples were collected within an interval of 10–21 days between visits. Acute samples were tested with dengue rapid diagnostic tests (RDT) and a selected subset with RT-PCR, and all acute/convalescent samples with IgM/IgG ELISA.

Results

Among 2929 non-malarial febrile patients, 740 (25%) were dengue–positive based on RT-PCR and/or IgM/IgG ELISA; 428 out of 777 patients (55%) and 312 out of 2152 (14%) were dengue-positive during outbreak and non-outbreak periods, respectively. There were 11% (316/2929) and 4% (129/2929) patients showing positive for NS1 and IgM, on the RDT, respectively. DENV 2 predominated during the outbreak, whereas DENV 3 predominated before the outbreak. Only 25% of dengue-positive cases were clinically diagnosed with suspected dengue. The odds of requiring observation for ≤3 days (versus routine outpatient care) were 11 times higher among dengue-positive cases than non-dengue cases. In adjusted analyses, dengue-positivity was associated with rash and retro-orbital pain (OR = 2.6 and 7.4, respectively) during the outbreak and with rash and nausea/vomiting (OR = 1.5 and 1.4, respectively) during the non-outbreak period.

Conclusion

Dengue virus is an important pathogen in Burkina Faso, accounting for a substantial proportion of non-malarial fevers both during and outside outbreak, but is only infrequently suspected by clinicians. Additional longitudinal data would help to further define characteristics of dengue for improved case detection and surveillance.

There is not much evidence on dengue in Africa, relative to the Asia-Pacific and Latin American regions. To estimate the proportion of dengue among patients with fever, and to identify clinical features of dengue during outbreak and non-outbreak periods, we studied 2929 patients with non-malarial fever, aged 1–55 years, who attended five primary healthcare centers in Ouagadougou, Burkina Faso. Patients were tested with a rapid test for dengue, and further tests were carried out on paired blood samples taken 10–21 days apart. Overall, a quarter of non-malarial febrile episodes identified between December 2014 and February 2017 were dengue-positive. Dengue-positive cases were 11 times more likely than non-dengue cases to require observation for ≤3 days. During the study period in 2016, there was a dengue outbreak where more than half of non-malarial febrile patients were identified to be dengue-positive. DENV 2 was the main serotype in circulation during the outbreak, whereas DENV 3 was the main serotype before the outbreak. Rash and retro-orbital pain were more frequently found among dengue-positive cases, compared to non-dengue cases, during the outbreak. During the non-outbreak period, rash and nausea/vomiting were more likely in dengue-positive versus non-dengue cases. There was a low level of clinical suspicion of dengue even during the 2016 outbreak. Therefore, a broader use of rapid diagnostic tests and more epidemiologic data would help to improve dengue case detection and surveillance in Burkina Faso.

Elimination of Falciparum Malaria and Emergence of Severe Dengue: An Independent or Interdependent Phenomenon?

The global malaria burden, including falciparum malaria, has been reduced by 50% since 2000, though less so in Sub-Saharan Africa. Regional malaria elimination campaigns beginning in the 1940s, up-scaled in the 1950s, succeeded in the 1970s in eliminating malaria from Europe, North America, the Caribbean (except Haiti), and parts of Asia and South- and Central America. Dengue has grown dramatically throughout the pantropical regions since the 1950s, first in Southeast Asia in the form of large-scale epidemics including severe dengue, though mostly sparing Sub-Saharan Africa. Globally, the WHO estimates 50 million dengue infections every year, while others estimate almost 400 million infections, including 100 million clinical cases. Curiously, despite wide geographic overlap between malaria and dengue-endemic areas, published reports of co-infections have been scarce until recently. Superimposed acute dengue infection might be expected to result in more severe combined disease because both pathogens can induce shock and hemorrhage. However, a recent review found no reports on more severe morbidity or higher mortality associated with co-infections. Cases of severe dual infections have almost exclusively been reported from South America, and predominantly in persons infected by Plasmodium vivax. We hypothesize that malaria infection may partially protect against dengue – in particular falciparum malaria against severe dengue – and that this inter-species cross-protection may explain the near absence of severe dengue from the Sub-Saharan region and parts of South Asia until recently. We speculate that malaria infection elicits cross-reactive antibodies or other immune responses that infer cross-protection, or at least partial cross-protection, against symptomatic and severe dengue. Plasmodia have been shown to give rise to polyclonal B-cell activation and to heterophilic antibodies, while some anti-dengue IgM tests have high degree of cross-reactivity with sera from malaria patients. In the following, the historical evolution of falciparum malaria and dengue is briefly reviewed, and we explore early evidence of subclinical dengue in high-transmission malaria areas as well as conflicting reports on severity of co-morbidity. We also discuss examples of other interspecies interactions.

Surveillance of Vector-Borne Infections (Chikungunya, Dengue, and Malaria) in Bo, Sierra Leone, 2012-2013

Malaria remains a significant cause of morbidity and mortality in West Africa, but the contribution of other vector-borne infections (VBIs) to the burden of disease has been understudied. We used rapid diagnostic tests (RDTs) for three VBIs to test blood samples from 1,795 febrile residents of Bo City, Sierra Leone, over a 1-year period in 2012-2013. In total, 24% of the tests were positive for malaria, fewer than 5% were positive for markers of dengue virus infection, and 39% were positive for IgM directed against chikungunya virus (CHIKV) or a related alphavirus. In total, more than half (55%) of these febrile individuals tested positive for at least one of the three VBIs, which highlights the very high burden of vector-borne diseases in this population. The prevalence of positives on the Chikungunya IgM and dengue tests did not vary significantly with age (P > 0.36), but higher rates of malaria were observed in children < 15 years of age (P < 0.001). Positive results on the Chikungunya IgM RDTs were moderately correlated with rainfall (r² = 0.599). Based on the high prevalence of positive results on the Chikungunya IgM RDTs from individuals Bo and its environs, there is a need to examine whether an ecological shift toward a greater burden from CHIKV or related alphaviruses is occurring in other parts of Sierra Leone or the West African region.

Identification of dengue type 2 virus in febrile travellers returning from Burkina Faso to France, related to an ongoing outbreak, October to November 2016

Dengue fever is rarely reported in travellers returning from Africa. We report two cases of dengue fever in travellers returning from Burkina Faso to France. One of them presented a severe dengue fever with ALT > 1,000 IU/L and pericarditis. Serotype 2 was identified. The cases reflect a large ongoing outbreak with over 1,000 reported cases between August and November in the capital city. Clinicians should consider dengue fever in malaria-negative febrile travellers returning from Africa.