Imported dengue virus serotype 3, Yemen to Italy, 2010

Dengue fever among febrile patients in Taiz City, Yemen during the 2016 war: Clinical manifestations, risk factors, and patients knowledge, attitudes, and practices toward the disease

The current war in Yemen has displaced millions of people from their homes into living in cramped shelters where the healthcare is limited. The breakdown of Yemen's healthcare and sanitation systems has facilitated the spread of infectious diseases including mosquito-borne diseases. The present study aimed to describe the prevalence of dengue virus (DENV) infection among the febrile patients of the Taiz governorate, Yemen as well as their knowledge, attitude and preventive practices (KAPs) regarding dengue fever (DF), and to investigate the factors associated with dengue preventive practices during the war. A total of 384 clinically dengue-suspected patients who sought health care in Taiz, Yemen during the period from July 2016 until October 2016 were recruited for the study. Serum samples were obtained and screened for the presence of DENV RNA and anti-DENV antibodies by reverse transcription-recombinase polymerase amplification (RT-RPA) and dengue IgM/IgG-capture ELISA, respectively. KAP questionnaires were obtained from all participants too. In the study, dengue was laboratory confirmed in approximately 49.3% (189/384) of the clinically suspected dengue patients. In general, 67.1% of the patients had low knowledge scores regarding DF. Low scores for knowledge about DF was significantly associated with those in the age groups of ≤20 years and 21-30 years, illiterates and patients with non-skilled jobs or jobless. The most common preventive practices reported by participants were covering stored water (78.6%) and putting a screen on the house's windows (65.3%). A low proportion of participants (6.7%) had 51-100% of good DF preventive practices. Low scores of positive attitudes toward DF was identified as a risk factor. The study participants showed poor knowledge about DF and their ways of dealing with the various aspects of DF prevention was quite limited, hence, preventive measures against the disease were less likely to be undertaken. Findings from the study highlight the peril of dengue in Taiz, Yemen, which is now comparable to that of endemic regions. The ongoing civil war with disruption in regular health services compounded by the low knowledge about DF as well as the limited DF preventive practices could result in entrenchment of dengue in Yemen.

Dengue Virus Type 2 Infection in a Traveler Returning from Saudi Arabia to Japan

In July 2018, a Japanese traveler returning from Saudi Arabia was diagnosed with dengue. The dengue virus type 2 gene was detected from a whole blood sample. Phylogenetic analysis revealed that the strain was clustered with isolates from Singapore and India. Travelers to Saudi Arabia should be cautious about mosquito bites.

Autochthonous spread of DENV-3 genotype III in Malaysia mitigated by pre-existing homotypic and heterotypic immunity

Dengue virus type 3 genotype III (DENV-3/III) is widely distributed in most dengue-endemic regions. It emerged in Malaysia in 2008 and autochthonously spread in the midst of endemic DENV-3/I circulation. The spread, however, was limited and the virus did not cause any major outbreak. Spatiotemporal distribution study of DENV-3 over the period between 2005 and 2011 revealed that dengue cases involving DENV-3/III occurred mostly in areas without pre-existing circulating DENV-3. Neutralisation assays performed using sera of patients with the respective infection showed that the DENV-3/III viruses can be effectively neutralised by sera of patients with DENV-3 infection (50% foci reduction neutralisation titres (FRNT50) > 1300). Sera of patients with DENV-1 infection (FRNT50 ⩾ 190), but not sera of patients with DENV-2 infection (FRNT50 ⩽ 50), were also able to neutralise the virus. These findings highlight the possibility that the pre-existing homotypic DENV-3 and the cross-reacting heterotypic DENV-1 antibody responses could play a role in mitigating a major outbreak involving DENV-3/III in the Klang Valley, Malaysia.

Viral hemorrhagic fevers in the Tihamah region of the western Arabian Peninsula

Viral hemorrhagic fever (VHF) refers to a group of diseases characterized by an acute febrile syndrome with hemorrhagic manifestations and high mortality rates caused by several families of viruses that affect humans and animals.

These diseases are typically endemic in certain geographical regions and sometimes cause major outbreaks. The history of hemorrhagic fever in the Arabian Peninsula refers to the 19th century and most outbreaks were reported in the Tihamah region—the Red Sea coastal plain of the Arabian Peninsula in the west and southwest of Saudi Arabia and Yemen.

Herein, we describe the agents that cause VHFs and their epidemiology in Tihamah, the history of the diseases, transmission, species affected, and clinical signs. Finally, we address challenges in the diagnosis and control of VHFs in this region.

A household-based survey of knowledge, attitudes and practices towards dengue fever among local urban communities in Taiz Governorate, Yemen

BACKGROUND

Yemen has witnessed several dengue fever outbreaks coincident with the social unrest and war in the country. The aim of the present study was to describe the knowledge, attitudes and practices (KAPs) of at-risk urban populations residing in Taiz, southwest of Yemen. In addition, factors possibly associated with poor preventive practices were investigated.

METHODS

A household-based, cross-sectional survey was conducted in three urban districts encompassing 383 households. Data on the socio-demographic characteristics and KAPs of the participating household heads were collected using a pre-designed, structured questionnaire. The association of socio-demographic characteristics, knowledge and attitudes of the population with poor preventive practices against dengue fever was then analyzed using logistic regression.

RESULTS

More than 90.0 % of respondent household heads had correct knowledge about fever, headache and joint pain as common signs and symptoms of dengue fever. Moreover, muscular pain and bleeding were perceived by more than 80.0 % of the respondents as being associated with dengue fever; however, only 65.0 % of the respondents reported skin rash as a sign of dengue fever. More than 95.0 % of respondents agreed about the seriousness and possible transmission of dengue fever; however, negative attitudes regarding the facts of being at risk of the disease and that the infection is preventable were expressed by 15.0 % of respondents. Despite the good level of knowledge and attitudes of the respondent population, poor preventive practices were common. Bivariate analysis identified poor knowledge of dengue signs and symptoms (OR = 2.1, 95 % CI = 1.24-3.68; P = 0.005) and its vector (OR = 2.1, 95 % CI = 1.14-3.84; P = 0.016) as factors significantly associated with poor preventive practices. However, multivariable analysis showed that poor knowledge of the vector is an independent predictor of poor preventive practices of the population (adjusted OR = 2.1, 95 % CI = 1.14-3.84; P = 0.018).

CONCLUSION

The majority of people in urban communities of Taiz have a clear understanding of most signs/symptoms of dengue fever as well as positive attitudes towards the seriousness and possible transmissibility of dengue fever. However, negative attitudes regarding their perception of the risk and possible prevention of the infection are prevailing among a small proportion of the population and need to be targeted by educational campaigns. It appears that the good level of the population knowledge of the signs/symptoms of dengue fever and the factors contributing to the spread and control of its vectors did not translate into good practices.

Co-circulation of Dengue and Chikungunya Viruses, Al Hudaydah, Yemen, 2012

We investigated 400 cases of dengue-like illness in persons hospitalized during an outbreak in Al Hudaydah, Yemen, in 2012. Overall, 116 dengue and 49 chikungunya cases were diagnosed. Dengue virus type 2 was the predominant serotype. The co-circulation of these viruses indicates that mosquitoborne infections represent a public health threat in Yemen.

Phylogeny of Dengue and Chikungunya viruses in Al Hudayda governorate, Yemen

Yemen, which is located in the southwestern end of the Arabian Peninsula, is one of countries most affected by recurrent epidemics caused by emerging vector-borne viruses. Dengue virus (DENV) outbreaks have been reported with increasing frequency in several governorates since the year 2000, and the Chikungunya virus (CHIKV) has been also responsible of large outbreaks and it is now a major public health problem in Yemen. We report the results of the phylogenetic analysis of DENV-2 and CHIKV isolates (NS1 and E1 genes, respectively) detected in an outbreak occurred in Al-Hudayda in 2012. Estimates of the introduction date of CHIKV and DENV-2, and the phylogeographic analysis of DENV-2 are also presented. Phylogenetic analysis showed that the Yemen isolates of DENV belonged to the lineage 2 Cosmopolitan subtype, whereas CHIKV isolates from Yemen belonged to the ECSA genotype. All the CHIKV isolates from Yemen were statistically supported and dated back to the year 2010 (95% HPD: 2009-2011); these sequences showed an alanine in the aminoacid position 226 of the E1 protein. Phylogeographic analysis of DENV-2 virus showed that cluster 1, which included Yemen isolates, dated back to 2003 Burkina Faso strains (95% HPD 1999-2007). The Yemen, cluster dated back to 2011 (95% HPD 2009-2012). Our study sheds light on the global spatiotemporal dynamics of DENV-2 and CHIKV in Yemen. This study reinforces both the need to monitor the spread of CHIKV and DENV, and to apply significant measures for vector control.

Outbreak of viral hemorrhagic fever caused by dengue virus type 3 in Al-Mukalla, Yemen

Background

Investigations were conducted by the authors to explore an outbreak of viral hemorrhagic fever (VHF) reported in 2010 from Al-Mukalla city, the capital of Hadramout in Yemen.

Methods

From 15–17 June 2010, the outbreak investigation period, specimens were obtained within 7 days after onset of illness of 18 acutely ill patients hospitalized with VHF and 15 household asymptomatic contacts of 6 acute cases. Additionally, 189 stored sera taken from acutely ill patients with suspected VHF hospitalized in the preceding 12 months were obtained from the Ministry of Health of Yemen. Thus, a total of 222 human specimens were collected; 207 specimens from acute cases and 15 specimens from contacts. All samples were tested with RT-PCR for dengue (DENV), Alkhumra (ALKV), Rift Valley Fever (RVFV), Yellow Fever (YFV), and Chikungunya (CHIKV) viruses. Samples were also tested for DENV IgM, IgG, and NS1-antigen. Medical records of patients were reviewed and demographic, clinical, and laboratory data was collected.

Results

Of 207 patients tested, 181 (87.4%) patients were confirmed to have acute dengue with positive dengue NS1-antigen (97 patients, 46.9%) and/or IgM (163 patients, 78.7%). Of the 181 patients with confirmed dengue, 100 (55.2%) patients were IgG-positive. DENV RNA was detected in 2 (1%) patients with acute symptoms; both samples were molecularly typed as DENV type 3. No other VHF viruses were detected. For the 15 contacts tested, RT-PCR tests for the five viruses were negative, one contact was dengue IgM positive, and another one was dengue IgG positive. Of the 181 confirmed dengue patients, 120 (66.3%) patients were males and the median age was 24 years. The most common manifestations included fever (100%), headache (94.5%), backache (93.4%), malaise (88.4%), arthralgia (85.1%), myalgia (82.3%), bone pain (77.9%), and leukopenia (76.2%). Two (1.1%) patients died.

Conclusions

DENV-3 was confirmed to be the cause of an outbreak of VHF in Al-Mukalla. It is important to use both IgM and NS1-antigen tests to confirm acute dengue particularly under the adverse field conditions, where proper storage and transportation of specimens are missing, which substantially reduce the sensitivity of the RT-PCR for detecting DENV RNA.

Infectious diseases in the Arabian Peninsula and Egypt

Infectious diseases are important causes of morbidity and mortality globally. Epidemiologically, differences in the patterns of infectious diseases and antimicrobial resistance exist across diverse geographical regions. In this review on infectious diseases in the Arabian Peninsula and Egypt, the epidemiology of tuberculosis, malaria and human immunodeficiency virus (HIV) infections will be addressed. The challenges of the hepatitis C epidemic in Egypt and the epidemiology of this infection across the region will be reviewed. In recent years, we have seen dengue endemicity become established, with major outbreaks in parts of the region. Emerging data also indicate that, across the region, there is an increasing burden of antibiotic resistance, with endemicity in healthcare settings and dissemination into the community. New challenges include the emergence of the Alkhurma haemorrhagic fever virus in Saudi Arabia. The annual Hajj pilgrimage in Saudi Arabia serves as a model for the control of infectious disease in mass gatherings. As most of these countries constantly experience a uniquely dynamic population influx in the form of expatriate workers, tourists, or pilgrims, concerted regional and international collaboration to address these public health concerns in a region that lies at the crossroads for the global spread of infectious pathogens is imperative.

Spatial and temporal patterns of dengue transmission along a Red Sea coastline: a longitudinal entomological and serological survey in Port Sudan city

Background

Dengue is an emerging health problem in several coastlines along the Red Sea. The objective of the present work is to elucidate spatial and temporal patterns of dengue transmission in Port Sudan.

Methods/Findings

A longitudinal study with three cross-sectional surveys was carried out in upper, middle and lower class neighborhoods, from November 2008 to October 2009. Monthly, entomological surveys were followed by serological surveys in dengue vector-positive houses. Meteorological records were obtained from two weather stations in the city during the same time. Overall, 2825 houses were inspected. Aedes aegypti represented 65% (35,714/54,944) and 68% (2526/3715) of the collected larvae and pupae, respectively. Out of 4640 drinking water containers, 2297 were positive for Ae. aegypti. Clay-pots “Zeirr” followed by plastic barrels were key productive containers for pupae of dengue vector, 63% (n = 3959) and 26% (n = 1651), respectively. A total of 791 blood samples were tested using PanBio Capture/Indirect IgM ELISA. Overall, the sero-prevalence rate of dengue ranged between 3%–8% (41/791), compared to an incidence of 29–40 new cases per 10,000 (193/54886) in the same examined population. Lower and middle class neighborhoods had higher entomological indices compared with upper class ones (p<0.001). Although, dengue incidence rate was significantly lower in the middle and lower class neighborhoods (F = 73.97, d.f. = 2, p<0.001), no difference in IgM prevalence was shown. The city is subject to two transmission peaks in the winter (i.e. November–January), and summer (i.e. June–August). The serological peaks of dengue are preceded by entomological peaks that occur before the onset of winter (November) and summer (March) respectively.

Conclusion

Dengue incidence is heterogeneously distributed across the neighborhoods of Port Sudan and exhibits a bi-cyclic intra-annual pattern. Hence, it should be feasible to carry out timely vector control measures to prevent or reduce dengue transmission.

Dengue is a tropical infectious disease that is of emerging global importance. As a dengue vaccine is still a distant prospect, descriptive epidemiological studies are a vital tool for developing a surveillance system capable of preventing dengue outbreaks. In the current work, the investigators describe epidemiology of dengue in Port Sudan on the Red Sea. There, the disease has distinctive spatial and temporal patterns. Households use water storage containers to supplement Port Sudan’s poor public water supply. These containers provide breeding sites for dengue mosquitoes. Differences in water consumption patterns across neighborhoods result in differences in disease incidence. Our results suggest that Lower class neighborhoods may suffer dengue more than upper class ones. In addition, two transmission peaks are observed during the winter and summer seasons. These spatial and temporal patterns of dengue may describe dengue epidemiology along similarly affected coastlines of the Red Sea.

Dengue outbreak in Hadramout, Yemen, 2010: an epidemiological perspective

We analyzed surveillance data of a dengue outbreak (2010) reported to the Hadramout Health Office (Yemen) and retrospectively analyzed dengue-related epidemiological and entomological events reported in Hadramout from 2005 to 2009. A total of 630 immunoglobulin M (IgM) -confirmed dengue cases of 982 febrile cases was reported during the period from February to June of 2010; 12 cases died, giving case fatality a rate of 1.9%. Among febrile cases, the highest proportion of dengue cases (37.3%) was reported in the 15- to 24-year-old age group. The overall attack rate was 0.89/1,000. The average number of cases reported by month over the preceding 5-year period compared with the 2010 data is consistent with endemicity of dengue in the region and supports epidemic designation for the dengue activity in 2010. Recognition of endemic dengue transmission and potential for substantial dengue epidemics highlight the need for consistent laboratory-based surveillance that can support prevention and control activities accordingly.