Dengue

Almost 80% of dengue patients recorded so far this year have required hospitalisation. According to the health authorities, 151 (78.6 percent) of 192 dengue cases in Ghaziabad have been hospitalised. At the moment, 45 such patients are being treated in hospitals, 42 of which are in private facilities.

Although no fatalities have been officially recorded, the hospitalisation rate is concerning, and many severe to critical patients with dengue symptoms have been observed at private hospitals.

Health officials said they are keeping tabs on the situation. “Most of the patients are being admitted as a precautionary measure and being discharged after three-four days. This is also evident from the daily reports as the number of patients in hospitals remains around 35-40 daily,” Ghaziabad chief medical officer (CMO) Dr Bhavtosh Shankhdhar said.

“It is a good thing that patients are coming to hospitals on time and getting treatment. Hospitals have also been asked to keep them in observation if there are indications of their health worsening,” the CMO added.

According to medical professionals, the most common reason for hospitalisation is a low platelet count. Several patients with dengue complications, such as serositis (a disease in which tissues in the belly, heart, and lungs swell with fluid), have also been hospitalised.

Dr Nishesh Jain, senior consultant (internal medicine) at Max Hospital, Vaishali, said: “Every patient who is diagnosed with dengue doesn’t require admission. There are set guidelines for admission. Either they have fluid overload symptoms, low platelet count or some other complications, like cardiac ailments or uncontrolled diabetes.” Jain said out of 35-40 dengue patients he has seen till now, 15 have been hospitalised.

At Yashoda Hospital in Nehru Nagar, 20 dengue patients have been admitted and 20% were found to be suffering from haemorrhage.

“We are a tertiary care hospital, so we generally get patients in a serious condition. But we have not seen any patient with severe bleeding or dengue shock,” Dr Saurabh Gupta, senior consultant of internal medicine at the hospital, said.

A retrospective research on Dengue serotypes done by the National Institute of Virology, Pune, and recently published in the International Journal of Infectious Diseases, has shed light on the prevalent dengue strains in Telangana.

The DENV-2 strain is the most common in the state, and it is known to induce serious symptoms such as thrombocytopenia, low platelet count, and cutaneous bleeding more frequently than other strains.

According to the study, around 34% of Telangana samples obtained in 2018 were infected with DENV-2, with another 10% infected with several serotypes.

Nearly 4,963 samples were examined across the country. The study discovered that the DENV-2 strain is prevalent not only in Telangana but throughout India, and that among the four strains, it is the most likely to decrease platelet count and induce stomach discomfort.

However, there is no reason to fear, according to public health experts, because the approach to dealing with this strain was comparable to others.

“From what we know, DENV-2 does not significantly change the transmission rate, morbidity or change the clinical management as done in treating other strains,” said Dr Rangareddy Burri, president, Infection Control Academy and Honorary Professor, UoH. The Centre has stated the strain as one of the likely causes for the current outbreak in UP.

The existence of two strains of the dengue virus — Type I and Type II — was verified by serotyping of samples tested positive for dengue in Delhi. The first produces dengue fever, whereas the second causes hemorrhagic fever and shock.
The other two categories are III, which causes a fever without shock, and IV, which causes a fever with shock or deep shock.
The Type II strain’s existence has sparked considerable alarm. Officials with the Union Health Ministry’s National Vector Borne Disease Control Program (NVBDCP) stated there was no need to be concerned.

“Type I, which causes milder symptoms, is predominant. Only a few samples have been found to be positive for Type II strain,” said an official.

Dengue has been a major public health concern in the city with recurrent outbreaks, prompting a rush to hospitals particularly in the post-monsoon period when mosquito breeding is at its peak.

An NVBDCP official said the serotyping results were preliminary in nature due to the small sample size. “We plan to have more tests to identify the trend so that clinicians are notified in advance about the strains in circulation,” she added. Uttar Pradesh, where febrile illness has claimed the lives of several children over the past few weeks, has also been found to have Type I and II strains of the dengue virus.

Dr Neeraj Nischal, additional professor of medicine, AIIMS, said the type of strain of dengue virus that is in circulation is important to prepare for a potential crisis. However, he added, it was more important to focus on preventing the spread of the disease itself by checking mosquito-breeding.

Nischal said people needed to ensure there was no stagnation of water in such places. The authorities need to make fighting dengue a social movement through public awareness, timely identification of high-risk zones and use of anti-larval spraying, among others, he added.

The latest data collated and shared by the municipal corporations on mosquito-borne diseases in the capital show 158 confirmed cases of dengue on September 11. This is higher than the number of cases of the viral illness reported in the same period last year. At least 68 cases of malaria and 40 of chikungunya — two other mosquito-borne diseases — have also been confirmed.

Said Nischal, “This is a worrying trend and urgent action is needed to prevent a full-blown crisis. We are in the middle of a pandemic caused by the novel coronavirus and another disease outbreak at this time may increase the load of the already stressed health services.

Dr Vinay Aggarwal, chairman, Pushpanjali Medical Centre, east Delhi, said there seemed to be more cases of dengue than of Covid at the moment. At Lok Nayak Hospital too, medical director Dr Suresh Kumar reported a significant surge in cases of dengue. “New admissions due to Covid have gone down. But there is a big increase in cases of febrile illness that are testing positive for dengue. Some patients have required admission,” Kumar said.

The government of Uttar Pradesh has sent a group of 15 doctors to Firozabad to investigate why Dengue and Viral Fever have increased since mid-August and claimed 60 lives.

Although no deaths have been noted over the last few days, there has been no decline in the flow of patients into public medical schools and community health centres.

The team, comprising 10 doctors and five specialists, took charge on Thursday, on the instructions of Chief Minister Yogi Adityanath, Additional Director (Medical and Health), Agra Division, Dr A K Singh, said.

Led by Dr G S Vajpayee, a specialist in communicable diseases, the team will investigate the causes behind patients not getting proper treatment before they reach the government medical college and other primary health centres in the district, he said.

It will also investigate the reasons behind the increasing cases, despite efforts to stem them since last month, Singh said, adding that the team will suggest measures to control the spread of dengue and viral fever. Singh also said that a section of the media is reporting an inflated death toll, and maintained that fatalities stood at 60.

Deaths due to other diseases are also being attributed to dengue and viral fever, he said. In another development, a team of women doctors has arrived here and it is monitoring the treatment of patients in at the government medical college.

They are trying to work out ways for better treatment of patients and are continuously visiting wards, principal of the medical college Dr Sangeeta Aneja said. The team includes Dr Jaimini and Dr Ayushi from Saifai and Dr Pragati from Kanpur, she said.

Countering complaints of shortage of beds, Aneja said that all patients arriving at the hospital are first given primary treatment at the Trauma Centre and then shifted to different wards after proper testing. This is being interpreted as shortage of beds, she said.

As Uttar Pradesh managed to control Covid-19 cases, the state is now experiencing rising number of Dengue cases and the biggest concern of this is Firozabad, where 57 people, mostly children have died of the disease. According to a recent statement by the ICMR, the D2 strain is causing high number of cases and deaths in the state, which might also cause haemorrhaging that could be fatal.

To discuss the reason behind this fatality, Medically Speaking talked to a panel of experts that included: Dr Rommel Tickoo, Director of Internal Medicine from Max Hospital; Dr Ashutosh Biswas, Professor of Medicine from AIIMS; Dr Ajay Agarwal, Head of Department, Internal Medicine from Fortis Hospital and Dr Suranjit Chatterjee, Senior Consultant, Internal Medicine form Indraprastha Apollo Hospital.

Cases of Dengue are witnessed each year. Why are we talking about it particularly this year?

Dr Rommel Tickoo: We are currently in the midst of a pandemic, and we must contend with another virus, dengue fever, which can be fatal in certain individuals. There are a lot of patients in Firozabad, Uttar Pradesh, where a lot of people have died. Dengue fever is a mosquito-borne bone illness that is spread through mosquito bites. There are four strains, which means you may be infected four times in your lifetime, and each strain offers you lifetime immunity once you are infected. However, if you are infected with the second strain, you may get a serious illness.

The second issue is that all of these variants are quite deadly, with strains two and four being particularly harmful, and we are currently dealing with strain 2 (dengue virus strain 2), which is causing so many deaths in Firozabad. The majority of Dengue patients (75%) are asymptomatic or have a mild form of the disease. Only a few people get severe dengue, which can result in a plasma leak, multi-organ failure, or haemorrhage. It affects individuals who do not have access to medical treatment, and today, if it occurs in tiny towns or villages where sanitisation is a problem, it can result in such terrible consequences.

That is what occurred in Firozabad, and the issue is that we do not have a specific dengue treatment. So drink plenty of water, avoid painkillers, take paracetamol, and keep in touch with your doctor. So, if you catch it early on and have access to medical help, you won’t have any issues. If severe disease progression is diagnosed in time, then you won’t get into trouble.

Why is D2 strain causing brain haemorrhage and when does risk for the fatality?

Dr Ashutosh Biswas: yes, this is very important area to understand that there are three phases of dengue. First is the febrile phase, next three days are the critical phase and another three days recovery phase. 75% of the infected people don’t need to come to the hospital, they don’t need any treatment or any medications. But the rest of them really need hospitalisation, care or may be 5-10% of these people undergo severe manifestation. if we talk about 5% of the total infected people, symptomatic cases are very less. It is not necessary that only the second strain is virulent, other strains can also be dangerous if the person if infected second time.

What are the treatment for dengue?

Dr Suranjit Chatterjee: The platelet count is something we always think about, even if it isn’t as important.

It’s crucial to keep an eye on your blood’s thickness. Anyone who is in shock or has a low blood pressure should be taken seriously. As a result, the platelet count is low.

Firozabad residents, particularly young people, are suffering from haemoconcentration, shock, and liver failure. These are asymptomatic and not treatable. We’ve been treating Dengue fever for a long time, and only a small percentage of patients end up in the ICU. At least three of my patients have gone to the ICU in the previous five days, one of them was 15 years old, another was 21 years old, and the third was over 45 years old.

Why is dengue is affecting children more?

Dr Rommel Tickoo: Children don’t have that much great immunity against infections like these, specially viral infections. And the fact that children are mostly outdoors playing, they don’t have enough protection against mosquito bites.

Why are we all more focused on the platelet count? What are the other factors one should monitor if one gets dengue?

Dr Ashutosh Biswas: The platelet count isn’t important until it falls below 20,000 or even 10,000, at which point it must be transferred. Other variables that cause bleeding include coagulation factor. The second factor is a patient going into shock as a result of capillary leakage, which increases disease severity. The vessels get engaged in this stage, which is known as vasculopathy, and the bodily fluids leak out into the extra-vascular region of the body. The third crucial element to examine is organ involvement, with the liver and kidney being the most frequent organs affected.

Would you recommend that once someone recovers, they should continue monitoring their condition for a few days?

Dr Ajay Agarwal: We are seeing a lot of liver involvement with dengue fever. After most of the patients recover, they may have capillary leaks still, may have high blood pressure, hypertension and the fluids accumulate in the lungs and abdomen. It is important that once the patient is discharged, he stays at home and gets adequate hydration, and must report back to the hospital if symptoms like breathlessness, giddiness or hypertension are experienced. If patient is undergoing domestic care, they should be well educated about the disease. Only getting the platelets count done will not help, other factors like organ involvement must be checked.

How do you see planning the spike in cases in the coming few days?

Dr Suranjit Chatterjee: Very few cases of Dengue last year but this year, the numbers have increased again due to the heavy rains and waterlogging in the city. Therefore, we again have a potential of Dengue epidemic which have wreaked havoc in the previous years. Hence, we must be very careful as citizens and the government because though the cases are at an all-time low this time, but there is a possibility that Covid might come back to Delhi since the other parts of the country are experiencing spike in cases and many countries in the world are now suffering from the third wave. Covid along with Dengue will prove to be very dangerous for the healthcare infrastructure of our country.

Speaking about dengue in relation to covid, is it possible that people are misunderstanding the symptoms of dengue with covid? What will you suggest in that?

Dr Rommel Tickoo: It is quite difficult to identify the problem by Symptoms in early 4-5 days as all of them are quite similar and people are coming with symptoms like fever cold cough which is common in Flu, Covid and Dengue. Until and unless they have running nose and heavy breathing, you probably think that it is Covid but talking about current situation where many Covid and Dengue cases are coming at the same time, what I will suggest is to get tested for Covid and dangue both at the same time if you have those symptoms. But in Delhi there is no Covid that much there is flu, which is a self-limiting disease and gets better in 6-7 days which doesn’t need hospitalization. Our focus should be more on Dengue right now.

There is no vaccine for Dengue, does that make the conversation more pertinent and requires people to be even more vigilant?

Dr Ashutosh Biswas: Around 10 to 15 countries have vaccines for Dengue but they are not much effective due to which the Indian government is not much confident about using them in the country. Therefore we need to be more careful about Dengue because we do have vaccines for Covid. We have been witnessing Dengue for years now and it is very difficult to fight against mosquitoes. If someone experiences warning signs of Dengue like abdomen pain, vomiting, low urination and confusion, they must be cautious.

What are the precautions of the disease?

Dr Ajay Agarwal: Prevent water logging around the house, water bodies should be sprinkled over by Kerosene so that mosquito breeding is stopped. Wear full sleeves when going out and keep the house mosquito free through mosquito repellents.

Patients have a fear of catching Covid if they visit hospital for Dengue. What is your suggestion to them?

Dr Suranjit Chatterjee: If there is a need to come to the hospital, they must come because many cases of strokes and heart diseases were seen last year where patients feared coming to the hospital and ended up losing their lives to it. Dengue patients do not necessarily require hospitalization but if the symptoms are severe, they must visit because Covid may not kill you but Dengue might if you are in shock or there is multi-organ failure. It is all need based.

Biomarkers are used to identify the state or risk of a disease in patients. Examples of biomarkers can include naturally occurring molecules or genes in the vascular, inflammatory or other biological pathways. The new findings could aid the development of biomarker panels for clinical use and help improve triage and risk prediction in patients with dengue.

Dengue is the most common mosquito-borne viral disease to affect humans globally. In 2019, the World Health Organization identified dengue as one of the top 10 threats to global health, with transmission occurring in 129 countries and an estimated 3.9 billion people being at risk.

“While most symptomatic dengue infections are self-limiting, a small number of patients develop complications that usually occur at around four to six days from symptom onset,” explains first author Vuong Nguyen Lam, Researcher and PHD Student at Oxford University Clinical Research Unit (OUCRU), Ho Chi Minh City, Vietnam. “Large numbers of patients therefore need regular assessments to identify these complications. The accurate and early identification of such patients, particularly within the first three days of illness, should allow for the appropriate care to be provided.”

The role of blood biomarkers in predicting severe outcomes has been investigated in other studies, but mostly later in the disease progression or at hospital admission. Many of these biomarkers either peak too late in the disease course or have too short a half-life to be clinically useful.

To address this, Vuong and colleagues selected 10 candidate biomarkers from vascular, immunological and inflammatory pathways that are associated with dengue disease pathogenesis. These biomarkers were: VCAM-1, SDC-1, Ang-2, IL-8, IP-10, IL-1RA, sCD163, sTREM-1, ferritin, and CRP. They were chosen based on their likelihood to be increased during the early stages of disease.

The team then conducted a study using samples and clinical information from a large multi-country observational study called ‘Clinical evaluation of dengue and identification of risk factors for severe disease’ (IDAMS study). Of the 2,694 laboratory-confirmed dengue cases included in the IDAMS study, 38 and 266 cases were classified as severe and moderate dengue, respectively.

For the current study, the researchers selected 281 cases in four countries — Vietnam, Cambodia, Malaysia and El Salvador — as the blood samples from these participants were stored at the OUCRU laboratory. For comparison, the team also selected 556 patients with uncomplicated dengue who shared similar geographies and demographic characteristics.

They measured the participants’ blood biomarkers at two different time points — one during the first three days of illness, and the second following recovery (10-31 days after symptom onset). They found that, during the first three days of illness, higher levels of any of the 10 biomarkers increased a patient’s risk of developing moderate to severe dengue.

They also identified a combination of six biomarkers that was best associated with severe disease in children, and a combination of seven biomarkers that was best associated with severe disease in adults. “This highlights how relationships between biomarkers and clinical outcome can differ between age groups,” Vuong says.

“Together, our findings should assist the development of biomarker panels to help improve future triage and early assessment of dengue patients,” concludes senior author Sophie Yacoub, Dengue Research Group Head at OUCRU. “This would help improve individual patient management and healthcare allocation, which would be of major public health benefit especially in outbreak settings.”

Source: eLife