Dengue causes a wide spectrum of disease. This can range from subclinical disease (people may not know they are even infected) to severe flu-like symptoms in those infected. Although less common, some people develop severe dengue, which can be any number of complications associated with severe bleeding, organ impairment and/or plasma leakage. Severe dengue has a higher risk of death when not managed appropriately.
In this blog Pritish Kumar, discuss Dengue distribution and outbreaks, its transmission procedure and treatment process.
Dengue is caused by a virus of the Flaviviridae family and there are four distinct, but closely related, serotypes of the virus that cause dengue (DENV-1, DENV-2, DENV-3 and DENV-4). Recovery from infection is believed to provide lifelong immunity against that serotype. However, cross-immunity to the other serotypes after recovery is only partial, and temporary.
Global burden
The number of dengue cases reported to WHO increased over 8-fold over the last two decades, from 505,430 cases in 2000, to over 2.4 million in 2010, and 5.2 million in 2019. Reported deaths between the year 2000 and 2015 increased from 960 to 4032, affecting mostly younger age group. The total number of cases seemingly decreased during years 2020 and 2021, as well as for reported deaths. However, the data is not yet complete and COVID-19 pandemic might have also hampered case reporting in several countries.
The overall alarming increase in case numbers over the last two decades is partly explained by a change in national practices to record and report dengue to the Ministries of Health, and to the WHO. But it also represents government recognition of the burden, and therefore the pertinence to report dengue disease burden.
Distribution and outbreaks
The largest number of dengue cases ever reported globally was in 2019. All regions were affected, and dengue transmission was recorded in Afghanistan for the first time. The American region alone reported 3.1 million cases, with more than 25,000 classified as severe. Despite this alarming number of cases, deaths associated with dengue were fewer than in the previous year.
High number of cases were reported in Bangladesh (101,000), Malaysia (131,000) Philippines (420,000), Vietnam (320,000) in Asia. In 2020, dengue affected several countries, with reports of increases in the numbers of cases in Bangladesh, Brazil, Cook Islands, Ecuador, India, Indonesia, Maldives, Mauritania, Mayotte (Fr), Nepal, Singapore, Sri Lanka, Sudan, Thailand, Timor-Leste and Yemen. Dengue continues to affect Brazil, India, Vietnam, the Philippines, Cook Islands, Colombia, Fiji, Kenya, Paraguay, Peru and, Reunion islands, in 2021.
Transmission
Transmission through mosquito bite
After feeding on an DENV-infected person, the virus replicates in the mosquito midgut, before it disseminates to secondary tissues, including the salivary glands. The time it takes from ingesting the virus to actual transmission to a new host is termed the extrinsic incubation period (EIP). The EIP takes about 8-12 days when the ambient temperature is between 25-28°C. Variations in the extrinsic incubation period are not only influenced by ambient temperature; a number of factors such as the magnitude of daily temperature fluctuations, virus genotype, and initial viral concentration can also alter the time it takes for a mosquito to transmit virus. Once infectious, the mosquito is capable of transmitting virus for the rest of its life.
Disease characteristics (signs and symptoms)
While majority of dengue cases are asymptomatic or show mild symptoms, it can manifest as a severe, flu-like illness that affects infants, young children and adults, but seldom causes death. Symptoms usually last for 2–7 days, after an incubation period of 4–10 days after the bite from an infected mosquito.
Dengue
Dengue should be suspected when a high fever (40°C/104°F) is accompanied by 2 of the following symptoms during the febrile phase (2-7 days):
1)severe headache
2)pain behind the eyes
3)muscle and joint pains
4)nausea
5)vomiting
6)swollen glands
7)rash.
Severe dengue
A patient enters what is called the critical phase normally about 3-7 days after illness onset. During the 24-48 hours of critical phase, a small portion of patients may manifest sudden deterioration of symptoms. It is at this time, when the fever is dropping (below 38°C/100°F) in the patient, that warning signs associated with severe dengue can manifest. Severe dengue is a potentially fatal complication, due to plasma leaking, fluid accumulation, respiratory distress, severe bleeding, or organ impairment.
Warning signs that doctors should look for include:
1)severe abdominal pain
2)persistent vomiting
3)rapid breathing
4)bleeding gums or nose
5)fatigue
6)restlessness
7)liver enlargement
8)blood in vomit or stool.
If patients manifest these symptoms during the critical phase, close observation for the next 24–48 hours are essential so that proper medical care can be provided, to avoid complications and risk of death. Close monitoring should also continue during the convalescent phase.
Diagnostics
Several methods can be used for diagnosis of DENV infection. Depending on the time of patient presentation, the application of different diagnostic methods may be more or less appropriate. Patient samples collected during the first week of illness should be tested by both methods mentioned below:
Virus isolation methods
The virus may be isolated from the blood during the first few days of infection. Various reverse transcriptase–polymerase chain reaction (RT–PCR) methods are available and are considered the gold standard. However, they require specialized equipment and training for staff to perform these tests.
The virus may also be detected by testing for a virus-produced protein, called NS1. There are commercially-produced rapid diagnostic tests available for this, and it takes only ~20 mins to determine the result, and the test does not require specialized laboratory techniques or equipment.
Serological methods
Serological methods, such as enzyme-linked immunosorbent assays (ELISA), may confirm the presence of a recent or past infection, with the detection of anti-dengue antibodies. IgM antibodies are detectable ~1 week after infection and remain detectable for about 3 months. The presence of IgM is indicative of a recent DENV infection. IgG antibody levels take longer to develop and remains in the body for years. The presence of IgG is indicative of a past infection.
Treatment
There is no specific treatment for dengue fever. Patients should rest, stay hydrated and seek medical advice. Depending on the clinical manifestations and other circumstances, patients may be sent home, be referred for in-hospital management, or require emergency treatment and urgent referral.
Supportive care such as fever reducers and pain killers can be taken to control the symptoms of muscle aches and pains, and fever.
1)The best options to treat these symptoms are acetaminophen or paracetamol.
2)NSAIDs (non-steroidal anti-inflammatory drugs), such as ibuprofen and aspirin should be avoided. These anti-inflammatory drugs act by thinning the blood, and in a disease with risk of hemorrhage, blood thinners may exacerbate the prognosis.
For severe dengue, medical care by physicians and nurses experienced with the effects and progression of the disease can save lives – decreasing mortality rates to less than 1% in majority of the countries.
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