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

Incidence and co-infection with COVID-19 of dengue during the COVID-19 pandemic

The co-infection of dengue and COVID-19 has been regarded as a public health issue for dengue-endemic countries during the COVID-19 pandemic. Travel restrictions might decrease the chance of mosquitoes biting and, thus, reduce the risk of dengue transmission. However, the spread of dengue was reported to increase with the policies of lockdowns and social distancing in specific areas due to delayed interventions in dengue transmission. Of cases experiencing dengue and COVID-19 co-infection, most recovered after receiving supportive care and/or steroid therapy. However, some episodes of severe or fatal diseases in specific individuals, such as pregnant women, have been reported, and the clinical course of this co-infection is unrecognized or unpredictable. Accordingly, it is crucial to promptly identify predictors of developing severe viral diseases among co-infection patients.

Clinical Epidemiology of Dengue and COVID-19 Co-infection Among the Residents in Dhaka, Bangladesh, 2021-2023: A Cross-sectional Study

Background

Co-infection of dengue and COVID-19 has increased the health burden worldwide. We found a significant knowledge gap in epidemiology and risk factors of co-infection in Bangladesh.

Methods

This study included 2458 participants from Dhaka city from 1 December 2021 to November 30 2023. We performed the Kruskal-Wallis test and χ2 test. Multivariable logistic regression was also performed.

Results

Co-infection of dengue and COVID-19 was found among 31% of the participants. Coprevalence of dengue and COVID-19 was found in higher frequency in Jatrabari (14%) and Motijhil (11%). Severe (65%, P = .001) and very severe (78%, P = .005) symptoms were prevalent among the participants aged >50 years. Long-term illness was prevalent among the participants with co-infection (35%; 95% confidence interval [CI], 33-36) and COVID-19 (28%; 95% CI, 26-30). Co-infected participants had a higher frequency of heart damage (31.6%, P = .005), brain fog (22%, P = .03), and kidney damage (49.3%, P = .001). Fever (100%) was the most prevalent symptom followed by weakness (89.6%), chills (82.4%), fatigue (81.4%), headache (80.6%), feeling thirsty (76.3%), myalgia (75%), pressure in the chest (69.1%), and shortness of breath (68.3%), respectively. Area of residence (odds ratio [OR], 2.26; 95% CI, 1.96-2.49, P = .01), number of family members (OR, 1.45; 95% CI ,1.08-1.87; P <.001), and population density (OR, 2.43; 95% CI, 2.15-3.01; P = .001) were associated with higher odds of co-infection. We found that coinfected participants had a 4 times higher risk of developing severe health conditions (OR, 4.22; 95% CI, 4.11-4.67; P = .02).

Conclusions

This is one of the early epidemiologic studies of co-infection of dengue and COVID-19 in Bangladesh.

Comparison of clinical and virological features in pediatric and adult dengue cases at Insein General Hospital during Myanmar's 2022 dengue season

BACKGROUND

Myanmar is one of the countries in Southeast Asia where serious dengue outbreaks occur and Yangon is among the regions with the highest number of cases in the country. Many infections including dengue are common in Yangon during the rainy season, and co-infections may also occur. Adults are more likely than children to experience co-infections of dengue and other diseases. Although pediatric dengue has been studied in Yangon for decades, research on adult dengue is scant. Therefore, this study compared the clinical and virological characteristics of pediatric and adult dengue cases in Yangon.

METHODS

This cross-sectional study was conducted at Insein General Hospital in Yangon, Myanmar, from June to September 2022. We recruited 221 suspected dengue patients (134 children and 87 adults), with or without other diseases, and tested their dengue serological markers using a serological method and their dengue virus (DENV) serotypes using conventional RT-PCR. Chi-squared and Fisher's exact tests were conducted to assess significance.

RESULTS

The dengue non-structural protein-1 antigen (NS1Ag) positivity was 37% in children and 32% in adults. DENV serotypes were identified in 80% of NS1Ag-positive patients. Among NS1Ag-positive cases, the DENV-1 serotype predominated (67%), followed by DENV-2 (17%), DENV-3 (9%), DENV-4 (5%), and mixed DENV-1 and DENV-2 (2%) serotypes. Shock was observed in 14% of children and 3% of adults. Anti-dengue IgG antibody positivity was positively correlated with dengue shock. Three pediatric dengue cases (6%) also had other infections including bronchiolitis, ear infection, and diarrhea. Seven adult dengue cases (25%) also had other diseases including advanced HIV infection, severe pneumonia, tonsillitis, thyroid disease, cholecystitis, drug poisoning, and thalassemia.

CONCLUSION

The serotype distribution and clinical presentations of pediatric and adult dengue cases were not significantly different, but adults were more likely to have dengue together with other diseases than children. This study provides information for the better management of febrile children and adults in hospital settings and provides a foundation for nationwide epidemiological studies on dengue serotypes and modifications of the national guidelines for dengue management in Myanmar.

Dengue virus: Etiology, epidemiology, pathobiology, and developments in diagnosis and control - A comprehensive review

Dengue flavivirus (DENV) is the virus that causes dengue, one of the most dangerous and common viral diseases in humans that are carried by mosquitoes and can lead to fatalities. Every year, there are over 400 million cases of dengue fever worldwide, and 22,000 fatalities. It has been documented in tropical and subtropical climates in over 100 nations. Unfortunately, there is no specific treatment approach, but prevention, adequate awareness, diagnosis in the early stages of viral infection and proper medical care can reduce the mortality rate. The first licensed vaccine for dengue virus (CYD Denvaxia) was quadrivalent, but it is not approved in all countries. The primary barriers to vaccine development include inadequate animal models, inadequate etiology mechanistic studies, and adverse drug events. This study provides current knowledge and a comprehensive view of the biology, production and reproduction, transmission, pathogenesis and diagnosis, epidemiology and control measures of dengue virus.

Dengue and SARS-CoV-2 co-circulation and overlapping infections in hospitalized patients

Since its emergence in 2019, coronavirus disease (COVID-19) has spread worldwide and consumed public health resources. However, the world still has to address the burdens of other infectious diseases that continue to thrive. Countries in the tropics and neotropics, including Brazil, are affected by annual, cyclic dengue epidemics. Little is known about the impact of subsequent infections between DENV and SARS-CoV-2. Our study was performed on 400 serum samples collected from laboratory-confirmed COVID-19 patients between January and June 2021, months historically known for DENV outbreaks in Brazil. The samples were tested by serology and molecular assays for the presence of DENV and other arboviruses. While no DENV PCR results were detected, 6% were DENV IgM-positive, and 0.25% were DENV NS1-positive according to ELISA. IgM antibodies were isolated by chromatography, and 62.5% of the samples were positive for neutralizing antibodies (FRNT80) against DENV IgM, suggesting a recent infection. We also observed increased IL-10, TNF-α, and IL-1β levels in patients with overlapping SARS-CoV-2/DENV infections. Intriguingly, diabetes was the only relevant comorbidity (p=0.046). High rates of hospitalization (94.9%) and mortality (50%) were found, with a significant increase in invasive mechanical ventilatory support (86.96%) in SARS-CoV-2/DENV- infected patients, suggesting an impact on patient clinical outcomes. When analyzing previous exposure to DENV, secondary dengue patients infected with SARS-CoV-2 more frequently presented with dyspnea and respiratory distress, longer hospital and intensive care unit (ICU) stays (4 and 20.29 days, respectively) and a higher mortality rate (60%). However, a greater proportion of patients with primary DENV infection had fever and cough than patients with secondary dengue (87.50% vs. 33.33%, p=0.027 for fever). Our data demonstrate that differentiating between the two diseases is a great concern for tropical countries and should be explored to improve patient management.

Severe dengue in the intensive care unit

Dengue fever is considered the most prolific vector-borne disease in the world, with its transmission rate increasing more than eight times in the last two decades. While most cases present mild to moderate symptoms, 5% of patients can develop severe disease. Although the mechanisms are yet not fully comprehended, immune-mediated activation leading to excessive cytokine expression is suggested as a cause of the two main findings in critical patients: increased vascular permeability that may shock and thrombocytopenia, and coagulopathy that can induce hemorrhage. The risk factors of severe disease include previous infection by a different serotype, specific genotypes associated with more efficient replication, certain genetic polymorphisms, and comorbidities such as diabetes, obesity, and cardiovascular disease. The World Health Organization recommends careful monitoring and prompt hospitalization of patients with warning signs or propensity for severe disease to reduce mortality. This review aims to update the diagnosis and management of patients with severe dengue in the intensive care unit.

Effective Preventative Measures are Essential to Lower Disease Burden From Dengue and COVID-19 Co-infection in Bangladesh

Bangladesh is widely recognized as one of the dengue prone nations, and empirical evidence has consistently demonstrated an upward trend in the severity of the disease over time. With the persistent occurrence of dengue in Bangladesh and the ongoing presence of COVID-19, which has not been fully eradicated and may persist for an uncertain period of time, there is a high probability of co-infection between these 2 illnesses. Given the circumstances, the concurrent occurrence of the COVID-19 and dengue epidemics, along with the potential co-infection, may pose an overwhelming burden on healthcare systems that are already grappling with challenges in meeting the existing demand. Due to a lack of awareness, an inadequate health infrastructure, and ineffective disease prevention initiatives, the country is now more susceptible to the threat posed by a co-infection that has been found to be associated with more severe outcomes, marked by significant morbidity and mortality. The objective of this opinion piece is to explore the gravity of co-infection in Bangladesh, as well as the potential challenges to overcome and the preventative measures that need to be implemented to address the severity. This opinion piece proposes a set of modern preventative strategies that, when integrated with conventional methods, have the potential to mitigate disease severity, avert the occurrence of co-infection between COVID-19 and dengue, and halt the co-epidemics of COVID-19 and dengue.

Management of Dengue: An Updated Review

Dengue is an important public health problem with a wide clinical spectrum. The World Health Organization classifies dengue into probable dengue, dengue with warning signs, and severe dengue. Severe dengue, characterized by plasma leakage, severe bleeding, or organ impairment, entails significant morbidity and mortality if not treated timely. There are no definitive curative medications for dengue; management is supportive. Judicious fluid resuscitation during the critical phase of dengue is the cornerstone of management. Crystalloids are the initial fluid of choice. Prophylactic platelet transfusion is not recommended. Organ involvement in severe dengue should be carefully looked for and managed. Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication of dengue that needs to be recognized, as specific management with steroids or intravenous immunoglobulin may improve outcomes. Several compounds with anti-dengue potential are being studied; no anti-dengue drug is available so far.

COVID-19 and monkeypox co-infection: A rapid systematic review

In this paper we aimed to study the characteristics, laboratory data and outcomes of monkeypox virus (MPV) and COVID-19 co-infection. On 2nd October 2022, we used the search term "("monkeypox virus" OR "MPV" OR "monkey pox" OR "monkeypox") AND ("COVID-19" OR "COVID 19" OR "novel coronavirus" OR "SARS-CoV-2")" in five databases to collect the relevant articles. We found three male patients, who had sex with men prior to the infection, had multiple comorbid conditions, were diagnosed with PCR, and were admitted to the hospital. The length of hospital stay was 4, 6, and 9 days. On admission, two cases had multiple vesicular lesions on various sites of the body associated with tonsillar inflammation, while the third case had genital ulcers and inguinal lymph node enlargement. All cases were managed in the hospital and recovered well. It might still be too early to establish solid evidence about the exact cause-effect association between SARS-CoV-2 and MPV co-infection and patient's outcomes because of the current low sample size. Accordingly, future relevant investigations, estimating the risk ratio of this association are needed to formulate definite evidence.

COVID-19 and dengue coinfection in Latin America: A systematic review

Introduction

Coronavirus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has spread globally, becoming a long-lasting pandemic. Dengue is the most common arboviral disease in tropical and subtropical regions worldwide. COVID-19 and dengue coinfections have been reported, associated with worse outcomes with significant morbidity and mortality. Therefore, this study aims to determine the epidemiological situation of COVID-19 and dengue coinfection in Latin America.

Methods

A systematic literature review was performed using PubMed, Scopus, Embase, Web of Science, LILACS, and BVS databases from January 1, 2020, to September 4, 2021. The key search terms used were "dengue" and "COVID-19".

Results

Nineteen published articles were included. The studies were case reports with a detailed description of the coinfection's clinical, laboratory, diagnostic, and treatment features.

Conclusion

Coinfection with SARS-CoV-2 and dengue virus is associated with worse outcomes with significant morbidity and mortality. The similar clinical and laboratory features of each infection are a challenge in accurately diagnosing and treating cases. Establishing an early diagnosis could be the answer to reducing the estimated significant burden of these conditions.

Antibodies against the SARS-CoV-2 S1-RBD cross-react with dengue virus and hinder dengue pathogenesis

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread globally since December 2019. Several studies reported that SARS-CoV-2 infections may produce false-positive reactions in dengue virus (DENV) serology tests and vice versa. However, it remains unclear whether SARS-CoV-2 and DENV cross-reactive antibodies provide cross-protection against each disease or promote disease severity. In this study, we confirmed that antibodies against the SARS-CoV-2 spike protein and its receptor-binding domain (S1-RBD) were significantly increased in dengue patients compared to normal controls. In addition, anti-S1-RBD IgG purified from S1-RBD hyperimmune rabbit sera could cross-react with both DENV envelope protein (E) and nonstructural protein 1 (NS1). The potential epitopes of DENV E and NS1 recognized by these antibodies were identified by a phage-displayed random peptide library. In addition, DENV infection and DENV NS1-induced endothelial hyperpermeability in vitro were inhibited in the presence of anti-S1-RBD IgG. Passive transfer anti-S1-RBD IgG into mice also reduced prolonged bleeding time and decreased NS1 seral level in DENV-infected mice. Lastly, COVID-19 patients’ sera showed neutralizing ability against dengue infection in vitro. Thus, our results suggest that the antigenic cross-reactivity between the SARS-CoV-2 S1-RBD and DENV can induce the production of anti-SARS-CoV-2 S1-RBD antibodies that cross-react with DENV which may hinder dengue pathogenesis.

False Positivity of Anti-SARS-CoV-2 Antibodies in Patients with Acute Tropical Diseases in Thailand

Serology remains a useful indirect method of diagnosing tropical diseases, especially in dengue infection. However, the current literature regarding cross-reactivity between SARS-CoV-2 and dengue serology is limited and revealed conflicting results. As a means to uncover relevant serological insight involving antibody classes against SARS-CoV-2 and cross-reactivity, anti-SARS-CoV-2 IgA, IgM, and IgG ELISA, based on spike and nucleocapsid proteins, were selected for a fever-presenting tropical disease patient investigation. The study was conducted at the Faculty of Tropical Medicine during March to December 2021. The study data source comprised (i) 170 non-COVID-19 sera from 140 adults and children presenting with acute undifferentiated febrile illness and 30 healthy volunteers, and (ii) 31 COVID-19 sera from 17 RT-PCR-confirmed COVID-19 patients. Among 170 non-COVID-19 samples, 27 were false positives (15.9%), of which IgA, IgM, and IgG cross-reactive antibody classes were detected in 18 (10.6%), 9 (5.3%), and 3 (1.8%) cases, respectively. Interestingly, one case exhibited both IgA and IgM false positivity, while two cases exhibited both IgA and IgG false positivity. The false positivity rate in anti-SARS-CoV-2 IgA and IgM was reported in adults with dengue infection (11.3% and 5%) and adults with other tropical diseases (16.7% and 13.3%). The urea dissociation method applied to mitigate false positivity resulted in significantly decreased ELISA-based false and true positives. In conclusion, the analysis of antibody against SARS-CoV-2 in sera of patients with different tropical diseases showed that high IgA and IgM false positivity thus potentially limits serological assay utility in fever-presenting patients in tropical areas.