Clinical Characteristics and Outcomes Among Travelers With Severe Dengue : A GeoSentinel Analysis

Epidemiology of travel-associated dengue from 2007 to 2022: A GeoSentinel analysis

BACKGROUND

Dengue is a leading cause of febrile illness among international travellers. We aimed to describe the epidemiology and clinical characteristics of imported dengue in returning travellers evaluated at GeoSentinel sites from 2007 to 2022.

METHODS

We retrieved GeoSentinel records of dengue among travellers residing in non-endemic countries. We considered dengue confirmed when diagnosed by a positive dengue virus (DENV)-specific reverse-transcriptase polymerase chain reaction, positive NS-1 antigen and/or anti-DENV IgG seroconversion, and probable when diagnosed by single anti-DENV IgM or high-titre anti-DENV IgG detection. Severe dengue was defined as evidence of clinically significant plasma leakage or bleeding, organ failure, or shock, according to the 2009 World Health Organization guidance. Complicated dengue was defined as either severe dengue or dengue with presence of any warning sign. Analyses were descriptive.

RESULTS

This analysis included 5958 travellers with confirmed (n = 4859; 81.6%) or probable (n = 1099; 18.4%) dengue. The median age was 33 years (range: <1-91); 3007 (50.5%) travellers were female. The median travel duration was 21 days (interquartile range [IQR]: 15-32). The median time between illness onset and GeoSentinel site visit was 7 days (IQR: 4-15). The most frequent reasons for travel were tourism (67.3%), visiting friends or relatives (12.2%) and business (11.0%). The most frequent regions of acquisition were South East Asia (50.4%), South Central Asia (14.9%), the Caribbean (10.9%) and South America (9.2%). Ninety-five (1.6%) travellers had complicated dengue, of whom 27 (0.5%) had severe dengue and one died. Of 2710 travellers with data available, 724 (26.7%) were hospitalized. The largest number of cases (n = 835) was reported in 2019.

CONCLUSIONS

A broad range of international travellers should be aware of the risk of acquiring dengue and receive appropriate pre-travel counselling regarding preventive measures. Prospective cohort studies are needed to further elucidate dengue risk by destination and over time, as well as severe outcomes and prolonged morbidity (long dengue) due to travel-related dengue.

Vaccination against dengue fever for travellers

Dengue fever, endemic to most tropical and subtropical countries, is a major cause of illness in travellers, but severe dengue, hospitalisation and death are considered rare in this population. Two vaccines against dengue fever, Dengvaxia® and Qdenga®, are available. While there is no recommendation for the use of Dengvaxia® in travellers, Qdenga® has been licensed for travellers in many European countries since December 2022, most recently (29 July 2024) in Switzerland by Swissmedic. The Swiss Expert Committee for Travel Medicine (ECTM), having assessed available data on the Qdenga® vaccine, issues the following recommendations: (1) Vaccination against dengue fever virus with Qdenga® is not recommended for persons with no previous dengue fever infection. (2) Vaccination with Qdenga® may be recommended for travellers aged 6 years and older who have evidence of previous dengue infection, defined as (a) a laboratory-confirmed dengue infection (PCR, antigen or seroconversion) or (b) a compatible history of dengue infection with a positive IgG serological test AND expected exposure to a region with significant dengue transmission. Travel medicine advisors should provide clear information in accessible language on the complexity of dengue vaccines and the risk/benefit evaluation for their use in travellers.

The Impact of Climate on Human Dengue Infections in the Caribbean

Climate change is no longer a hypothetical problem in the Caribbean but a new reality to which regional public health systems must adapt. One of its significant impacts is the increased transmission of infectious diseases, such as dengue fever, which is endemic in the region, and the presence of the Aedes aegypti mosquito vector responsible for transmitting the disease. (1) Methods: To assess the association between climatic factors and human dengue virus infections in the Caribbean, we conducted a systematic review of published studies on MEDLINE and Web of Science databases according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. (2) Results: In total, 153 papers were identified, with 27 studies selected that met the inclusion criteria ranging from the northern and southern Caribbean. Rainfall/precipitation and vapor pressure had a strong positive association with dengue incidence, whereas the evidence for the impact of temperatures was mixed. (3) Conclusions: The interaction between climate and human dengue disease in the Caribbean is complex and influenced by multiple factors, including waste management, infrastructure risks, land use changes, and challenged public health systems. Thus, more detailed research is necessary to understand the complexity of dengue within the wider Caribbean and achieve better dengue disease management.

Novel chikungunya and dengue vaccines: travel medicine applications

Recent epidemics of dengue and chikungunya have highlighted the urgent need for vaccines to reduce the risk of infection in travellers. Given challenges with tracking chikungunya outbreaks in real-time and the widespread resurgence of dengue, broader indications for the use of the new chikungunya and dengue vaccines should be considered.

Mechanistic insights into bone remodelling dysregulation by human viral pathogens

Bone-related diseases (osteopathologies) associated with human virus infections have increased around the globe. Recent findings have highlighted the intricate interplay between viral infection, the host immune system and the bone remodelling process. Viral infections can disrupt bone homeostasis, contributing to conditions such as arthritis and soft tissue calcifications. Osteopathologies can occur after arbovirus infections such as chikungunya virus, dengue virus and Zika virus, as well as respiratory viruses, such as severe acute respiratory syndrome coronavirus 2 and enteroviruses such as Coxsackievirus B. Here we explore how human viruses dysregulate bone homeostasis, detailing viral factors, molecular mechanisms, host immune response changes and bone remodelling that ultimately result in osteopathologies. We highlight model systems and technologies to advance mechanistic understanding of viral-mediated bone alterations. Finally, we propose potential prophylactic and therapeutic strategies, introduce 'osteovirology' as a research field highlighting the underestimated roles of viruses in bone-related diseases, and discuss research avenues for further investigation.

Comparison of clinical and laboratory parameters of primary vs secondary dengue fever in travellers

BACKGROUND

Dengue fever (DF), caused by the dengue virus (DENV), is the most common arboviral disease in travellers worldwide. It is hypothesized that compared with primary DF, secondary DF may result in antibody-dependent enhancement of the immune response, resulting in more severe disease. We aimed to compare clinical and laboratory parameters in travellers with primary and secondary DF to determine whether secondary DF is associated with markers of severe disease.

METHODS

We conducted a retrospective cohort study, which included all patients diagnosed with DF at the Central Virology Laboratory of the Israeli Ministry of Health during 2008-19. Clinical, laboratory and virological data were extracted from laboratory and patient records. A diagnosis of DENV infection was based on a positive nonstructural protein 1 (NS1) test, polymerase chain reaction or serology testing for immunoglobulin M (IgM) and immunoglobulin G (IgG). Primary and secondary infections were classified based on travel history, NS1 result and IgM/IgG ratio. Severe DF was defined according to WHO classification.

RESULTS

We identified 245 DF cases: 210 (86%) primary and 35 (14%) secondary. Whilst fever duration was significantly longer in secondary compared with primary infections (6.4 vs 5.3 days, P = 0.027), mean Aspartate aminotransferase levels were significantly higher in primary compared with secondary cases (146 vs 65 U/L, P < 0.001), and no other clinical or laboratory parameter differed significantly between the groups. Of note, only four patients had severe DF, all had primary infections and none died.

CONCLUSIONS

In a cohort of returning travellers with DF, secondary infection, compared with primary infection, was not associated with a consistent trend towards greater severity of the clinical and laboratory markers examined in this study.