Vector-Borne Diseases Potpourri.

The Intergovernmental Panel on Climate Change has reported that the prevalence of vector-borne diseases has increased in recent decades and that the prevalence of malaria, Lyme disease, dengue, and, in particular, West Nile virus infection are expected to increase further if control measures are not strengthened. (1)(2) This review article summarizes the epidemiology, various clinical manifestations, and management strategies of these vector-borne diseases with increasing prevalence both in the United States and worldwide.

[Considerations for the acute management of stroke during the dengue epidemic]. / Consideraciones para el manejo agudo del accidente cerebrovascular durante la epidemia de dengue.

Stroke is the leading cause of disability and the third leading cause of mortality in our country. Argentina and the Region of the Americas are going through the worst epidemic outbreak of dengue on record with significant demand on the health system. Dengue could increase the risk of stroke and given the time-dependent nature of the management of this disease to reduce morbidity and mortality and the potential considerations to be taken into account in patients with dengue, we present a focused review of the literature with points of uncertainty and aspects to be considered in the stroke code considering the clinical characteristics and high demand of the health system caused by the dengue fever. A call is also made to generate evidence on the management of stroke in patients with dengue.

El accidente cerebrovascular (ACV) es la principal causa de discapacidad y la tercera causa de mortalidad en nuestro país. Argentina y la región de las Américas se encuentran atravesando el peor brote epidémico de dengue del que se tenga registro, con una importante demanda en el sistema de salud. El dengue podría aumentar el riesgo de ACV y dada la naturaleza tiempo dependiente del manejo de esta enfermedad para reducir la morbilidad y mortalidad, y las potenciales consideraciones a tener en cuenta en los pacientes con dengue, se presenta una revisión breve de la literatura con puntos de incertidumbre y aspectos a considerar en el protocolo o código de ACV, considerando las características clínicas y alta demanda del sistema de salud provocada por el dengue. Se realiza también un llamado a generar evidencia sobre el manejo del ACV en pacientes con dengue.

Practice determinants for adherence to the Guide for the Comprehensive Clinical Care of Dengue Patients, Urabá (Colombia). A multifaceted approach to implementation research.

INTRODUCTION: Dengue is a significant public health issue in the Urabá region, accounting for 37.5% of morbidity and 41.7% of mortality resulting from dengue in the department of Antioquia (Colombia) in 2018. Clinical Practice Guidelines (CPGs) are tools based on Evidence-Based Medicine, intended for medical personnel to bridge the gap between proven intervention efficacy and clinical decision-making. This study aims to identify barriers and facilitators in the implementation of CPGs for dengue patient care by healthcare officials in the municipalities of the banana axis in the Urabá region. METHODOLOGY: From a multifaceted approach to implementation research, a mixed method study that combines qualitative and quantitative approaches, was conducted during the years 2020 and 2021, using combined instruments to identify determinants (Guide Indicative Factors, Individual factors of health professionals, Patient factors, Professional interactions, Incentives and resources, Capacity for organizational change, and lastly Social, political, and legal factors) affecting adherence to the Comprehensive Clinical Care Guide for Patients with Dengue (GACIPD). Semi-structured interviews and focus groups with healthcare workers were conducted to assess determinants based on clinical experience. Questionnaires on determinants of GACIPD adherence, using an adapted version of the Chronic Disease Implementation Checklist (TICD), were also employed. Qualitative analysis of the interviews and focus groups used a concept-based coding framework. The questionnaire responses were analyzed using Likert scaling and frequency counts of determinants within and across domains. Participants included general practitioners, other health professionals, researchers, academics, and administrators. RESULTS: There was a total of 103 participants in focus groups, 7 in semi-structured interviews, and 136 participants through questionnaires. Among the domains studied, the identification of barriers and facilitators emphasized institutional factors and individual factors. Organizational change capacity was identified as a major barrier, with only 3.6% of respondents indicating that their institution adjusted the prioritization of adequate care according to the guideline. The GACIPD domain received the highest facilitator rating, with 66.7% acceptance due to its practicality, simplicity, clarity, documentation, and ease of implementation, despite this, only 10% of professionals completely agree that their work is in accordance with the GACIPD. The determinant of patient factors was significant in the negative perception of adherence to GACIPD. CONCLUSIONS: Although barriers outweighed facilitators for GACIPD adherence, determinants for its use were generally positive, as most participants reported it as being a complete, documented, and easy-to-implement guide. The lack of knowledge of the guidelines impacting health professional's decision making was identified as a potentially modifiable barrier, and educational strategies could be implemented to overcome it. The region requires greater emphasis on the management of chronic health conditions, comorbidities, and coinfections of dengue with other endemic diseases.

What Is Dengue?

This JAMA Patient Page describes the viral infection dengue and its signs and symptoms, diagnosis, treatment, and prevention measures.

Dengue rhabdomyolysis successfully treated with hemoperfusion using CytoSorb® in combination with continuous renal replacement therapy: a case report.

BACKGROUND: Dengue fever is a mosquito-borne viral infection with a broad spectrum of clinical manifestations. Expanded dengue syndrome includes unusual manifestations that do not fall into the categories of dengue fever, dengue hemorrhagic fever, or dengue shock syndrome. Rhabdomyolysis causing acute renal failure in dengue is one such unusual manifestation, the pathophysiology of which is incompletely understood. CASE PRESENTATION: We describe a 21-year-old Sri Lankan man with dengue fever who developed severe rhabdomyolysis and acute kidney injury with extremely high creatinine phosphokinase levels (> 2 million U/L). Management of this patient was challenging as his creatinine phosphokinase kept rising with persistent anuria despite hydration, intermittent hemodialysis, and, later, continuous venovenous hemodiafiltration. Further therapeutic options were explored, and CytoSorb® adsorber was added as an adjunct to continuous venovenous hemodiafiltration, following which we observed a marked reduction in his creatinine phosphokinase and myoglobin levels over the next 12 hours and complete renal recovery over the next 5 weeks. CONCLUSION: We report a rare case of significant rhabdomyolysis secondary to dengue infection leading to acute kidney injury. Continuous venovenous hemodiafiltration performed with the hemofilter Pecopen 140 was ineffective, and the addition of CytoSorb® adsorber as an adjunct therapy to continuous venovenous hemodiafiltration may have a potential benefit in removing high-molecular-weight proteins such as myoglobin.

Uncovering the knowledge gap: A web-based survey of healthcare providers' understanding and management of dengue fever in East Azerbaijan, Iran.

BACKGROUND: Dengue fever (DF) is increasingly recognized as one of the world's major mosquito-borne diseases and causes significant morbidity and mortality in tropical and subtropical countries. Appropriate and timely diagnosis and risk stratification for severe disease are crucial in the appropriate management of this illness. Healthcare providers (HCPs) play a key role in dengue fever diagnosis, management and prevention. The present study was conducted to determine the knowledge, attitudes and practices (KAP) among HCPs in East Azerbaijan Province, Iran. METHODS: A cross-sectional survey among 948 HCPs, using a structured questionnaire, was conducted in East Azerbaijan Province from May to July 2022. Data analysis was undertaken using descriptive methods, the Chi-square test or Fisher's exact test, and logistic regression. A P-value <0.05 was considered for statistical significance. RESULTS: Out of the 948 (68.5% female) respondents, 227 were physicians and 721 were health professionals. The knowledge level of DF was found to be largely inadequate in the present study population (80.4%). The physician vs. health professional were a significant factor in differentiating attitude scores. The mean practice score regarding DF prevention and control measures among respondents was 8.40±1.97. CONCLUSION: The findings call for urgent continuous education and training courses to increase KAP levels and increased capacity and capability for DF prevention and control. This is of outmost importance for the first point of care of DF patients.

Intravenous fluid therapy in hospitalized adult dengue patients without shock: Impact on subsequent severe dengue and potential adverse effects.

There is a lack of evidence on the optimal administration of intravenous (IV) fluids in hospitalized adult dengue patients without compensated and hypotensive shock. This study utilized a well-established cohort of dengue patients to compare risks of progressing to severe dengue (SD) over time for patients who were administered IV fluid versus others who were not. We included adult patients (n = 4781) who were hospitalized for dengue infection from 2005 to 2008. Cases were patients who developed SD (n = 689) and controls were patients who did not up until discharge (n = 4092). We estimated the hazard ratios (HRs) and risk of SD over time between groups administered different volumes of IV fluids versus the no IV fluid comparison group using Cox models with time-dependent covariates. The doubly-robust estimation approach was used to control for the propensity of fluid administration given clinical characteristics of patients. Subgroup analyses by age, sex, and dengue warning signs before IV fluid administration were conducted. High (>2000 mL/day) IV fluids volume was associated with a higher risk of development of SD for those who had warning signs (HR: 1.77 [1.05-2.97], p: 0.0713) and for those below 55 years old (HR: 1.53 [1.04-2.25], p: 0.0713). Low (<1000 mL/day) IV fluids volume was protective against SD for patients without warning signs (HR: 0.757 [0.578-0.990], p: 0.0883), no lethargy (HR: 0.770 [0.600-0.998], p: 0.0847), and females (HR: 0.711 [0.516-0.980], p: 0.0804). Over the course of hospitalization, there were no significant differences in IV fluid administration and SD risk in most subgroups, except in those who experienced lethargy and were administered IV fluid volume or quantity. Administering high volumes of IV fluids may be associated with an increased risk of SD during hospitalization for adult dengue patients without shock. Judicious use of IV fluids as supportive therapy is warranted.

Dengue: A focused review for the emergency clinician.

Dengue is an arbovirus transmitted by the Aedes spp. mosquito. Approximately 390 million infections occur annually per World Health Organization estimates, with significant increases in infections throughout the last decade. The disease is endemic in warmer climates throughout the world, though cases may also be imported to non-endemic regions by returning travelers. Patients experience a wide variety of symptoms ranging from asymptomatic infection to severe disease requiring critical care. Emergency clinicians should consider the diagnosis of dengue in patients from endemic areas presenting with a flu-like illness, rash, and evidence of bleeding.

Reporte de caso de dengue clásico a predominio de sintomatología dermatológica en el marco de la epidemia en la provincia de Misiones 2023-2024 / Case of classic dengue with predominance of dermatologic symptoms in the 2023-2024 epidemic in the province of Misiones

Se presenta un caso femenino de dengue clásico (DC) en el marco de la epidemia 2023-2024 en la provincia de Misiones, con predominio de síntomas dermatológicos de exantemas máculo papulosos, habonosos y eritrodérmicos sobre los síntomas sindrómicos cardinales. Las lesiones presentan componente humoral y de extravasación, sin diátesis ni componentes purpúricos apreciables, presentando una rápida y efectiva evolución al eritema y la normalización con tratamiento antihistamínico y corticoide parenteral. De la misma manera se evalúan alteraciones analíticas hematológicas y hepáticas de gran magnitud, con escasa repercusión clínica, que se mensuran en función del riesgo relativo al dengue hemorrágico (DH) y el pronóstico de la paciente. (AU)

A female case of classic dengue (DC) is presented in the context of the 2023-2024 epidemic in the province of Misiones, with a predominance of dermatologic symptoms of maculopapular, hives, and erythrodermic rashes overlapping the cardinal syndromic symptoms. The lesions have a humoral and extravasation component, without any significant diathesis or purpuric components, showing rapid and effective progression to erythema and normalization with antihistamine and parenteral corticosteroid treatment. Similarly, hematologic and hepatic analytical alterations of great magnitude are evaluated, with little clinical impact, measured in terms of relative risk for hemorrhagic dengue (HD) and the prognosis of the patient. (AU)

Peptide-ligand conjugate based immunotherapeutic approach for targeted dismissal of non-structural protein 1 of dengue virus: A novel therapeutic solution for mild and severe dengue infections.

Dengue virus infection has significantly increased, with reported cases soaring from 505,430 in 2000 to 2,809,818 in 2022, emphasizing the need for effective treatments. Among the eleven structural and non-structural proteins of DENV, Non-structural protein 1 (NS1) has emerged as a promising target due to its diverse role in modulating the immune response, inducing vascular leakage, and facilitating viral replication and assembly. Monoclonal antibodies are the sole therapeutics to target NS1, but concerns about their cross-reactivity persist. Given these concerns, our study focuses on designing a novel Peptide Ligand Conjugate (PLC) as a potential alternative immunotherapeutic agent against NS1. This PLC aims to mediate the immune elimination of soluble NS1 and NS1-presenting DENV-infected host cells by pre-existing vaccine-induced immunity. By employing the High Throughput Virtual Screening (HTVS) method, QikProp analysis, and Molecular Dynamics studies, we identified three hits from Asinex Biodesigned Ligands out of 220,177 compounds that show strong binding affinity towards the monoclonal binding site of NS1 protein. After a rigorous analysis of physicochemical characteristics, antigenicity, allergenicity, and toxicity using various servers, we selected two peptides: the minimum epitopic region of the Diphtheria and Tetanus toxins as the peptide components of the PLCs. A non-cleavable, non-reactive oxime linker connected the ligand with the peptide through oxime and amide bonds. DPT vaccine is widely used in dengue-endemic countries, and it has been reported that antibodies titer against MER of Diphtheria toxin and Tetanus toxins persist lifelong in DPT-vaccinated people. Therefore, once the rationally designed PLCs bind to NS1 through the ligands, the peptide will induce an immune response against NS1 by triggering pre-existing DPT antibodies and activating memory cells. This orchestrated immune response will destroy soluble NS1 and NS1-expressing DENV-infected cells, thereby reducing the illness of severe dengue hemorrhagic fever and the DENV infection, respectively. Given the increasing demand for new therapeutics for DENV treatment, further investigation into this novel immune-therapeutic strategy may offer a new avenue for treating mild and severe dengue infections.

Dengue Fever Presenting As Acute Febrile Illness In Neonates: A Case Series From Pakistant.

Dengue fever is a mosquito-borne disease caused by flavivirus. It primarily infects people living in tropical and subtropical areas and can be transmitted vertically or horizontally to new-borns. We discuss the clinical spectrum, treatment, and outcomes of five neonates who presented with dengue fever at Aga Khan Hospital for Women in Karimabad, Karachi, Pakistan, during the 2021 post- monsoon season (October to December). Dengue infection was confirmed via positive NS1 antigen test. All new-borns had fever, flushing, and thrombocytopenia. Capillary leak syndrome and haemorrhagic complications occurred in one case. Two babies required oxygen support, with one mortality. Due to the severity of the disease in this population, we suggest that dengue fever should be evaluated as a differential diagnosis in neonates with sepsis and thrombocytopenia, especially in high-risk or endemic areas. Critical management strategies for neonatal dengue fever are the same as those for other paediatric patients and include judicious use of intravenous fluids and inotropes.

Economic Evaluation of Novel Models of Care for Patients With Acute Medical Problems.

Importance: During COVID-19, Singapore simultaneously experienced a dengue outbreak, and acute hospitals were under pressure to lower bed occupancy rates. This led to new models of care to treat patients with acute, low-severity medical conditions either at home, in a hospital-at-home (HaH) model, or in a clinic-style setting sited at the emergency department in an ambulatory care team (ACT) model, but a reliable cost analysis for these models is lacking. Objective: To compare personnel costs of HaH and ACT with inpatient care. Design, Setting, and Participants: In this economic evaluation study, time-driven activity-based costing was used to compare the personnel cost of inpatient care with treating dengue via HaH and treating chest pain via ACT. Participants were patients with nonsevere dengue and chest pain unrelated to a coronary event admitted via the emergency department to the internal medicine service of a tertiary hospital in Singapore. Exposures: HaH for dengue and ACT for chest pain. Main Outcomes and Measures: A process map was created for the patient journey for a typical patient with each condition. The amount of time personnel spent on delivering care was estimated and the cost per minute determined based on their wages in 2022. The total cost of care was calculated by multiplying the time spent by the per-minute cost of the personnel resource and summing all costs. Results: Compared with inpatient care, HaH used 50% less nursing time (418 minutes, 95% uncertainty interval [UI], 370 to 465 minutes) but 80% more medical time (303 minutes, 95% UI, 270 to 338 minutes) per case of dengue. If implemented nationally, HaH would save an estimated 56 828 SGD per year (95% UI, -169 497 to 281 412 SGD [US $41 856; 95% UI, -$124 839 to $207 268]). The probability that HaH is cost saving was 69.2%. Compared with inpatient care, ACT used 15% less nursing time (296 minutes, 95% UI, 257 to 335 minutes) and 50% less medical time (57 minutes, 95% UI, 46 to 69 minutes) per case of chest pain. If implemented nationally, ACT would save an estimated 1 561 185 SGD per year (95% UI, 1 040 666 to 2 086 518 SGD [US $1 149 862; 95% UI, $766 483 to $1 536 786]). The probability that ACT is cost saving was 100%. Conclusions and Relevance: This economic evaluation found that the HaH and ACT models decreased the overall personnel cost of care. Reorganizing hospital resources may help hospitals reap the benefits of reduced hospital-acquired infections, improved patient recovery, and reduced hospital bed occupancy rates.

Dengue overview: An updated systemic review.

Dengue is caused by the dengue virus (DENVs) infection and clinical manifestations include dengue fever (DF), dengue hemorrhagic fever (DHF), or dengue shock syndrome (DSS). Due to a lack of antiviral drugs and effective vaccines, several therapeutic and control strategies have been proposed. A systemic literature review was conducted according to PRISMA guidelines to select proper references to give an overview of DENV infection. Results indicate that understanding the virus characteristics and epidemiology are essential to gain the basic and clinical knowledge as well as dengue disseminated pattern and status. Different factors and mechanisms are thought to be involved in the presentation of DHF and DSS, including antibody-dependent enhancement, immune dysregulation, viral virulence, host genetic susceptibility, and preexisting dengue antibodies. This study suggests that dissecting pathogenesis and risk factors as well as developing different types of therapeutic and control strategies against DENV infection are urgently needed.

Dengue: updates for dermatologists on the world's fastest-growing vector-borne disease.

Dengue is the world's fastest-growing vector borne disease and has significant epidemic potential in suitable climates. Recent disease models incorporating climate change scenarios predict geographic expansion across the globe, including parts of the United States and Europe. It will be increasingly important in the next decade for dermatologists to become familiar with dengue, as it commonly manifests with rashes, which can be used to aid diagnosis. In this review, we discuss dengue for general dermatologists, specifically focusing on its cutaneous manifestations, epidemiology, diagnosis, treatment, and prevention. As dengue continues to spread in both endemic and new locations, dermatologists may have a larger role in the timely diagnosis and management of this disease.

Combined Therapeutic Plasma Exchange and Continuous Renal Replacement Therapy in Children With Dengue-Associated Acute Liver Failure and Shock Syndrome: Single-Center Cohort From Vietnam.

OBJECTIVES: Pediatric acute liver failure (PALF) is a fatal complication in patients with severe dengue. To date, clinical data on the combination of therapeutic plasma exchange (TPE) and continuous renal replacement therapy (CRRT) for managing dengue-associated PALF concomitant with shock syndrome are limited. DESIGN: Retrospective cohort study (January 2013 to June 2022). PATIENTS: Thirty-four children. SETTING: PICU of tertiary Children's Hospital No. 2 in Vietnam. INTERVENTIONS: We assessed a before-versus-after practice change at our center of using combined TPE and CRRT (2018 to 2022) versus CRRT alone (2013 to 2017) in managing children with dengue-associated acute liver failure and shock syndrome. Clinical and laboratory data were reviewed from PICU admission, before and 24 h after CRRT and TPE treatments. The main study outcomes were 28-day in-hospital mortality, hemodynamics, clinical hepatoencephalopathy, and liver function normalization. MEASUREMENTS AND MAIN RESULTS: A total of 34 children with a median age of 10 years (interquartile range: 7-11 yr) underwent standard-volume TPE and/or CRRT treatments. Combined TPE and CRRT ( n = 19), versus CRRT alone ( n = 15), was associated with lower proportion of mortality 7 of 19 (37%) versus 13 of 15 (87%), difference 50% (95% CI, 22-78; p < 0.01). Use of combined TPE and CRRT was associated with substantial advancements in clinical hepatoencephalopathy, liver transaminases, coagulation profiles, and blood lactate and ammonia levels (all p values < 0.001). CONCLUSIONS: In our experience of children with dengue-associated PALF and shock syndrome, combined use of TPE and CRRT, versus CRRT alone, is associated with better outcomes. Such combination intervention was associated with normalization of liver function, neurological status, and biochemistry. In our center we continue to use combined TPE and CRRT rather than CRRT alone.

Self-care practices and health-seeking behaviours in patients with dengue fever: A qualitative study from patients' and physicians' perspectives.

INTRODUCTION: Outpatient management for dengue fever is the mainstay of treatment for most dengue cases. However, severe dengue can develop rapidly while patients are at home. Understanding the self-care practices and healthcare-seeking behaviours among dengue patients managed as outpatients will help improve the delivery of care to these patients. OBJECTIVE: This study aimed to explore the self-care practices, health-seeking behaviour and outpatient management of dengue fever from the perspectives of patients and primary care physicians. METHODOLOGY: This qualitative study used in-depth interviews and focus group discussions to obtain information from laboratory-confirmed dengue patients who received outpatient care and primary care physicians who cared for them. Patients and physicians shared their experiences and perceptions of self-care practices, decisions to seek urgent care, and outpatient management procedures and visit frequency. Data were coded and analysed using thematic analysis. RESULTS: 13 patients and 11 physicians participated. We discovered that the use of traditional remedies was common with patients perceiving no harm from it, whereas physicians did not see a benefit. Dengue patients' knowledge of warning signs was inadequate despite the information being provided by physicians during clinical follow-up visits. Regarding the decision to seek urgent medical care, physicians assumed patients would seek help immediately once they experienced warning signs. However, for the patients, other factors influenced their health-seeking behaviour, such as their personal perceptions of symptom severity and often more importantly, their social circumstances (e.g., availability of childcare). Patients also described regular outpatient follow-up for dengue as inconvenient. There was variation in the prescribed outpatient follow-up interval recommended by participating physicians who complained about the lack of clear guidelines. CONCLUSION: Perceptions around self-care practices, health-seeking behaviour and outpatient management of dengue often differed between physicians and patients, especially on comprehension of dengue warning signs. Addressing these gaps between patient and physician perceptions and recognition of patient drivers of health-seeking behaviour are needed to improve the safety and delivery of outpatient care for dengue patients.