Outcomes among children and adults at risk of severe dengue in Sri Lanka: Opportunity for outpatient case management in countries with high disease burden

Global prevalence and risk factors of fatigue and post-infectious fatigue among patients with dengue: a systematic review and meta-analysis

Background

Fatigue during the acute phase of dengue infection can persist as post-infectious fatigue (PIF), potentially impacting quality of life. We aimed to determine the prevalence and risk factors of fatigue and PIF among dengue patients.

Methods

This systematic review and meta-analysis was registered in the PROSPERO (CRD42024543058). We searched PubMed, Ovid MEDLINE, Web of Science, Embase, and CINAHL from their inception to June 22, 2024. Observational studies reporting the prevalence of fatigue or PIF among dengue patients were included. We excluded case studies, review articles, conference abstracts, protocols, duplicate publications, and studies without full text. Quality assessment was performed using Hoy's risk of bias tool. Data were analyzed using R software version 4.3.3. A random-effects model pooled prevalence with 95% confidence intervals (CIs). Risk factors were identified using odd ratios (ORs) and 95% CIs or p values. Heterogeneity, moderator analysis, sensitivity analysis, and publication bias were also assessed.

Findings

From 715 identified studies, 40 were included for review. Of these, 37 studies were included in the meta-analysis for fatigue prevalence and nine studies for PIF prevalence, respectively involving 37,790 and 5045 dengue patients. The pooled prevalence of fatigue was 59.0% (95% CI 0.47-0.70), and that of PIF was 20.0% (95% CI 0.10-0.36), with significant heterogeneity but no significant moderators. Sensitivity analysis confirmed the robustness of this meta-analysis. Female sex (pooled OR = 1.65, 95% CI 1.27-2.14), dengue hemorrhagic fever (pooled OR = 1.80, 95% CI 1.02-3.16), and preexisting comorbidities (pooled OR = 2.14, 95% CI 1.36-3.38) were significant risk factors for PIF.

Interpretation

This meta-analysis highlights the high prevalence of fatigue and PIF among dengue patients, with several risk factors identified. Although the study has its limitations, these results can inform future studies to more standardized study designs, improved definitions, and systematic assessment methods for fatigue, PIF, and potential moderators. These are essential to better understand the mechanisms of fatigue in dengue patients and explore potential interventions.

Funding

None.

Estimating per-infection cost and burden for dengue and Zika as a function of antibody-dependent enhancement

The complex immune interactions produced by the tetravalent dengue vaccine Dengvaxia have foregrounded the important role of antibody-dependent enhancement (ADE) in dengue infection. Some evidence exists that ADE may extend beyond the four dengue serotypes to Zika, a closely related flavivirus transmitted by the same mosquito species as dengue, and may also account for the increased severity of some cases. Estimates of the public health impact of dengue vaccination may then need to include its effects on the transmission of Zika in addition to dengue. This study gathers primary references to build estimates of per-case economic cost and disease burden for dengue and Zika infection with and without ADE in the ten countries where clinical trials were held for Dengvaxia, under the hypothesis that severe outcomes are associated with ADE of disease. From these estimates, per-infection weighted averages are developed (without assumptions on transmission dynamics or case totals) which will facilitate population-level estimates of the potential impact of dengue vaccination on a dual outbreak using mathematical modeling. Results estimate that ADE amplifies the per-case toll of dengue by a factor of 2-16 but increases that of a Zika case by more than two orders of magnitude due to the greater risk of severe consequences. As expected, dengue vaccination affects per-infection dengue toll much more when high prior dengue seropositivity involves a different serotype than the one(s) circulating, but that same high dengue seropositivity makes vaccination exacerbate Zika toll less.

Clinical and Laboratory Features and Treatment Outcomes of Dengue Fever in Pediatric Cases

Background Globally, dengue fever (DF) is the leading cause of arthropod-borne viral illness, which considerably contributes to an atrocious death rate. The disease is now endemic in some parts of the world, including Bangladesh. The disorder exhibits a wide range of clinical and laboratory features in children. Judicial fluid resuscitation during the critical phase and prompt referral to the appropriate health facility can be lifesaving. Objectives This research appraised clinical and laboratory features and treatment outcomes of DF in pediatric cases. Methods This prospective investigative work was conducted at Islami Bank Hospital, Dhaka, India, from July to October 2023. The study included 135 admitted pediatric cases of DF, either dengue nonstructural protein 1 (NS1) or anti-dengue antibody IgM or IgG positive. Results Among the selected cases, boys were more predominant than girls, and most patients were in the age group of 5 to 10 years (n=46, 34%), most of them belonging to lower-middle-class families (n=56, 41.5%). All of the study participants had raised body temperatures, and most had abdominal pain (n=82, 60.7%), vomiting (n=77, 57%), cough (n=43, 31.9%), headache (n=38, 28.2%), body aches (n=32, 23.7%), and diarrhea (n=23, 17%). Dengue NS1 was positive in 91.1% (n=123) of cases. Raised hematocrit was found in 36.3% (n=49) of cases, leukopenia in 47% (n=63), and thrombocytopenia in 69.6% (n=94) of cases. Most of our patients were categorized as having DF (68.1%, n=92), followed by dengue with warning signs (16.3%, n=22), and severe dengue was present in 15.6% (n=21) of patients. Most were treated with crystalloid, and some with crystalloid and colloid solution. Fortunately, most of them recovered with no death. Conclusion DF may manifest with varied clinical and laboratory features in children. Appropriate treatment of critical phases, depending on clinical and laboratory features, is crucial to reducing dengue-induced miseries and fatal clinical outcomes among the pediatric population.

Severe Organ Impairment Was Common in Elderly Individuals with Dengue in Guangdong, China

Guangdong, China, has experienced several dengue epidemics involving thousands of confirmed cases in recent decades, and elderly individuals suffered severe dengue (SD) most seriously. However, the clinical characteristics and risk factors for SD among elderly patients in Guangdong have not been investigated. Patients older than 65 years were recruited and divided into a dengue fever (DF) group and an SD group according to the 2009 Dengue Guidelines of the WHO. We analyzed the clinical manifestations of the elderly patients with dengue and then assessed the risk factors for SD. Of a total of 1,027 patients, 868 patients were diagnosed as having DF and 159 as having SD. Of the 159 elderly patients with SD, 129 (81%) had comorbidities, with hypertension being the most common. Severe organ impairment (SOI) (115, 54%) was the most common presentation in SD patients, followed by severe plasma leakage (52, 24.4%) and severe hemorrhage (46, 21.6%). The most common symptom of SOI was kidney injury, followed by heart injury and central nervous system injury. Furthermore, multivariate regression revealed that the presence of chronic obstructive pulmonary disease (COPD), a lower red blood cell (RBC) count (≤3.5 × 1012/L; odds ratio [OR], 0.35; 95% CI, 0.17-0.55; P <0.001), lower serum albumin (ALB) (≤35 U/L; OR, 0.18; 95% CI, 0.09-0.32; P <0.001), and hyperpyrexia (body temperature ≥39°C; OR, 1.8; 95% CI, 1.2-2.6, P <0.001) were risk factors for SD. Severe organ impairment was the predominant manifestation in elderly individuals with SD characterized by kidney injury. The potential risk factors of SD such as presence of COPD and hyperpyrexia and lower RBC and ALB levels might help clinicians identify patients with SD early.

Incidence of acute liver failure and its associated mortality in patients with dengue infection: A systematic review and meta-analysis

Acute liver failure (ALF) is a devastating consequence of dengue infection. This systematic review and meta-analysis assessed the incidence of ALF in dengue infection and its associated mortality. We systematically searched the EMBASE and MEDLINE databases from inception to December 2023 for observational studies reporting ALF incidence and mortality in dengue patients. Twenty-one studies encompassing 26,839 dengue-infected patients were included. Meta-analysis revealed a pooled incidence of ALF in cases of general dengue infection of 2.0 % (95 % CI, 1.2-3.0 %), with 1.2 % (95 % CI, 0.6-2.1 %) in adults and 5.0 % (95 % CI, 1.5-10.2 %) in children. ALF incidence was 17.3 % (95 % CI, 6.5 %-31.5 %) in severe dengue and 7.4 % (95 % CI, 0.8-18.5 %) in dengue shock syndrome. The pooled mortality rate of dengue-associated ALF was 47.0 % (95 % CI, 32.9-61.2 %). These findings underscore the detrimental impact of dengue infection on the development of the relatively uncommon, albeit life-threatening, condition of ALF.

Trends in emerging vector-borne viral infections and their outcome in children over two decades

This review utilizes quatitative methods and bibliometric data to analyse the trends of emerging and re-emerging vector-borne diseases, with a focus on their impact on pediatric population. To conduct this analysis, a systematic search of PubMed articles from the past two decades was performed, specifically looking at 26 different vector-borne viruses listed in WHO and CDC list of vector-borne viruses. The review found that diseases like Dengue, Zika, West Nile, and Chikungunya were frequently discussed in the literature. On the other hand, diseases such as Tick-borne encephalitis, Rift Valley fever, Venezuelan equine encephalitis, Sindbis fever, Venezuelan equine encephalitis, Ross River virus, and Eastern equine encephalitis showed an upward trend in publications, indicating potential resurgence. In addition to discussing trends and patterns, the review delves into the clinical manifestations and long-term effects of the top 10 viruses in children. It highlights various factors including deforestation, urbanization, global travel, and immunosuppression that contribute to disease emergence and resurgence. To effectively combat these vector-borne diseases, continuous surveillance is crucial. The review also emphasizes the importance of increased vaccination efforts and targeted research to address the health challenges they pose. IMPACT: This review employs quantitative analysis of publications to elucidate trends in emerging pediatric vector-borne viral diseases over two decades. Dengue, the most prevalent of these diseases, has spread to new regions. New strains of Japanese Encephalitis have caused outbreaks. Resurgence of Tick-borne Encephalitis, West Nile, and Yellow Fever due to vaccine hesitancy has also transpired. Continuous global surveillance, increased vaccination, and research into novel therapeutics are imperative to combat the substantial morbidity and mortality burden these diseases pose for children worldwide.

DENV-2 NS1 promotes AMPK-LKB1 interaction to activate AMPK/ERK/mTOR signaling pathway to induce autophagy

The global incidence of dengue fever has gradually increased in recent years, posing a serious threat to human health. In the absence of specific anti-dengue drugs, understanding the interaction of Dengue virus (DENV) with the host is essential for the development of effective therapeutic measures. Autophagy is often activated during DENV infection to promote viral replication, but the mechanism of how DENV's own proteins induce autophagy has not been clarified. In this study, we first preliminarily identified DENV-2 NS1 as the most likely viral protein for DENV-2-induced autophagy with the help of molecular docking techniques. Further experimental results confirmed that DENV-2 NS1 regulates DENV-2 infection of HUVEC-induced autophagy through the AMPK/ERK/mTOR signaling pathway. Mechanistically, DENV-2 NS1 mainly interacted with AMPK by means of its Wing structural domain, and NS1 bound to all three structural domains on the AMPKα subunit. Finally, the experimental results showed that DENV-2 NS1 promoted the interaction between LKB1 and AMPKα1 and thus activated AMPK by both increasing the expression of LKB1 and binding LKB1. In conclusion, the results of this study revealed that DENV-2 NS1 protein served as a platform for the interaction between AMPK and LKB1 after DENV-2 infection with HUVEC, and pulled AMPK and LKB1 together to form a complex. LKB1 to form a complex, promoting LKB1 action on the kinase structural domain of AMPKα1, which in turn promotes phosphorylation of the Thr172 site on the AMPK kinase structural domain and activates AMPK, thereby positively regulating the AMPK/ERK/mTOR signaling pathway and inducing autophagy. The present discovery improves our understanding of DENV-2-induced host autophagy and contributes to the development of anti-dengue drugs.