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Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 175-176

Morbidity and mortality in dengue fever: Does it too change periodically?

DepartmentofPediatricIntensiveCare,MediclinicAirportRoadHospital, Abu Dhabi, UAE

Date of Submission15-Jun-2021
Date of Acceptance19-Jun-2021
Date of Web Publication10-Jul-2021

Correspondence Address:
Dr. Satheesh Ponnarmeni
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcc.jpcc_49_21

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How to cite this article:
Ponnarmeni S, Benakatti G. Morbidity and mortality in dengue fever: Does it too change periodically?. J Pediatr Crit Care 2021;8:175-6

How to cite this URL:
Ponnarmeni S, Benakatti G. Morbidity and mortality in dengue fever: Does it too change periodically?. J Pediatr Crit Care [serial online] 2021 [cited 2021 Sep 19];8:175-6. Available from: http://www.jpcc.org.in/text.asp?2021/8/4/175/321106

Dengue, a vector borne viral hemorrhagic fever transmitted via female mosquitoes (Aedes aegypti and to a lesser extent, Ae. Albopictus) is a disease of grave concern to global health. Dengue occurs all over the world. However, Asia accounts for 70% of the global burden.[1] The incidence of dengue has increased alarmingly - 8 fold in past two decades and so are the reported deaths.[2] In India, it's endemic (transmission occurring year-round) all-over and hyperendmic in certain regions with seasonal variation in incidence — peaks during rainy season, humid weather, etc. India had the highest number of outbreaks amongst WHO regions since 2000 and 13 million estimated number of infections annually.[3] In 2017, highest seroprevalence was seen in southern regions (76.9%), followed by western (62.3%), and northern (60.3%) regions and higher in urban (70.9% vs 42.3%) areas.[3] Dengue is known to cause wide spectrum of disease, mostly subclinical or mild illness to severe/lethal disease, i.e., dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). Overall mortality is 0.5 - 2.0%.[4] which may reach 20% in DSS (in-ICU/in-hospital mortality). It's known that patient age distributions, DHF or severe disease rates, secondary infections and mortality rates often differs between outbreaks.[4] In intensive care requiring patients, variations are seen between outbreaks in terms of organ dysfunction profile, hyperinflammation, immuno-pathology, life threatening hemorrhages, etc. And so, the mortality and its immediate cause/s. The serotype distribution has shown to vary with time and across geography.[4] All four serotypes with district epidemiological patterns circulate in India causing outbreaks. It is not known whether these epidemiological shifts and clinical variations correlate with serotype (atleast dominant serotype) causing the outbreak. However, the longitudinal trend since 2000 shows co-infection with all four serotypes dominated the outbreaks in India with predominant serotype being serotype 3 followed by serotype 2 and least common being serotype 4.[4] In contrast, of the global outbreaks between 1990-2015, serotype 2 was the predominant before 2000, serotype 3 between 2000 - 2009 and serotype 1 after 2010. Coinfection with more than one serotype was reported in nearly half of the outbreaks.[4] This study also showed decreased rates of DHF, secondary infection and mortality in outbreaks occurring after 2010 suggesting somewhat decreased severity in global dengue. This is unlike in India in terms of serotypes as well as disease severity. Moreover, it's possible that certain serotype/s and co-infection are associated with varied disease severity, laboratory abnormalities, outcomes, etc., A study from Tamil Nadu, India, during 2017 outbreak, found association of serotype 4 with elevated liver enzymes.[5] During 2019 outbreak, a study from Karnataka, India, found higher number of patients with HLH syndrome had serotype 3 infection (8 out of 9 cases).[6] Similarly, thrombocytopenia, haemorrhagic manifestations and atypical presentations were found most commonly in serotype 3 infected patients and co-infections were associated with a more serious clinical profile.[7]

In the current issue of Journal of Pediatric Critical care, the study by Sugunan S, et al.[8] describes the changing epidemiology of the disease severity and causes of mortality between 2013 to 2017. This is in accordance with the varied reports on cause of death and severity of disease across geography and between outbreaks, suggesting dynamic epidemics. However, refractory hypotension,[9] multi-organ failure,[10] massive haemorrhage[11] and encephalitis are commonly reported causes of deaths in dengue. Bleeding or massive haemorrhage as primary cause of death were reported less common all over. Efforts have been made with several clinical and laboratory markers to correlate with mortality and poor outcome, recent being elevated liver enzymes and hyperleveated ferritin. However these lack uniformity and cut off levels, which need to be defined and validated.

In our opinion, more sample sized, longitudinal, serotype studies across Indian geography may help to answer whether particular serotype/s and co-infection patterns are associated with varied spectrum of the disease in terms of clinical manifestations, severity, laboratory abnormalities, and mortality rate. This may in-turn aid in improved identification, prediction and prognostication.

  References Top

Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature 2013;496:504-7.  Back to cited text no. 1
Dengue and severe dengue - WHO | World Health Organisation. Published on 19 May 2021. Available on: https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue. [Last Accessed on 2021 Jun 10].  Back to cited text no. 2
Murhekar MV, Kamaraj P, Kumar MS, Khan SA, Allam RR, Barde P, et al. Burden of dengue infection in India, 2017: a cross-sectional population based serosurvey. Lancet Glob Health 2019;7:e1065-e1073.  Back to cited text no. 3
Guo C, Zhou Z, Wen Z, Liu Y, Zeng C, Xiao D, et al. Global Epidemiology of Dengue Outbreaks in 1990-2015: A Systematic Review and Meta-Analysis. Front Cell Infect Microbiol 2017;7:317.  Back to cited text no. 4
Rajesh NT, Alagarasu K, Patil JA, Bharathi E, More A, Kakade MB, et al. Serotype-specific differences in the laboratory parameters among hospitalized children with dengue and genetic diversity of dengue viruses circulating in Tamil Nadu, India during 2017. J Med Virol 2020;92:1013-1022.  Back to cited text no. 5
Rao P, Basavaprabhu A, Shenoy S, Dsouza NV, Sridevi Hanaganahalli B, Kulkarni V. Correlation of Clinical Severity and Laboratory Parameters with Various Serotypes in Dengue Virus: A Hospital-Based Study. Int J Microbiol 2020;2020:6658445.  Back to cited text no. 6
Mehta TK, Shah PD. Identification of prevalent dengue serotypes by reverse transcriptase polymerase chain reaction and correlation with severity of dengue as per the recent World Health Organization classification (2009). Indian J Med Microbiol 2018;36:273-278.  Back to cited text no. 7
[PUBMED]  [Full text]  
Sugunan S, Santhosh Kumar A, Krishnan RR, Manayankath R. A clinico epidemiological analysis of dengue deaths in children during outbreaks in year 2013 and 2017: A retrospective observational study from a tertiary care teaching hospital in south India. J ped crit care.2021;8:186-91.  Back to cited text no. 8
Karyanti MR, Uiterwaal CSPM, Hadinegoro SR, Jansen MAC, Heesterbeek JAPH, Hoes AW, Bruijning-Verhagen P. Clinical Course and Management of Dengue in Children Admitted to Hospital: A 5 Years Prospective Cohort Study in Jakarta, Indonesia. Pediatr Infect Dis J 2019;38:e314-e319.  Back to cited text no. 9
Padyana M, Karanth S, Vaidya S, Gopaldas JA. Clinical Profile and Outcome of Dengue Fever in Multidisciplinary Intensive Care Unit of a Tertiary Level Hospital in India. Indian J Crit Care Med 2019;23:270-3.  Back to cited text no. 10
Lam PK, Tam DT, Diet TV, Tam CT, Tien NT, Kieu NT, et al. Clinical characteristics of Dengue shock syndrome in Vietnamese children: a 10-year prospective study in a single hospital. Clin Infect Dis 2013;57:1577-86  Back to cited text no. 11


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