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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