In Africa, fever is the most common symptom leading patients to seek health care [1
]. Fever of unknown origin has long served as an entry point for the treatment of malaria [3
]. With encouraging gains in malaria control in Sub-Saharan African countries, the incidence of this disease is in decline, leading to a decreasing proportion of febrile illness attributable to malaria. Between 2000 and 2013, malaria mortality rates decreased by 47% globally, and by 54% in sub-Saharan Africa—the region most affected by the disease—whereas the proportion of patients presenting with non-malaria febrile illness (NMFI) increased, respectively [4
]. Acute febrile episodes are caused by various bacterial and viral pathogens, and infections with these agents result in patients presenting with malaria-like symptoms [5
]. Although resulting in a higher mortality than malaria, NMFIs are not being reliably diagnosed due to the lack of accurate, rapid and affordable diagnostic tests, and also due to poor access to diagnostics facilities in many resource-poor endemic settings [1
]. The objective of this study was to determine potential arboviral etiologies of NMFI in children in a low resource setting, using mobile recombinase polymerase amplification (RPA)—a real-time isothermal amplification technique [8
]. For this purpose, we conducted a prospective arbovirus investigation in children seeking healthcare, at a health centre in the Dakar suburb of Medina Gounass, during a period of six months—from September 2015 to March 2016. The mobile suitcase laboratory has also been successfully used for Ebola virus detection [9
The objective of this study was to assess the use of a mobile suitcase laboratory for the routine testing of arboviral etiologies of NMFI in an outpatient clinic of a suburb of Dakar, Senegal. During the six month survey of arboviral infections in febrile non malaria patients, three cases of dengue infection were detected in 104 enrolled children under 10 years old.
None of the targeted arboviruses (CHIKV, RVFV, YFV, ZIKV) except for DENV were detected during this study. The prevalence of DENV was 2.8%.
In a previous study on the etiology of acute febrile illness in Abidjan, an inter epidemic DENV prevalence of 0.4% was reported in the 812 patients tested [25
]. Similarly, our work highlights an inter epidemic circulation of DENV in poor urban settings of Dakar. The difference in prevalence between the two studies may be attributable to the fact that the study conducted in Abidjan was not limited to children ≤10 years of age, as well as the smaller number of enrolled patients in our study (104 patients).
The border between interepidemic and epidemic prevalence in sub-Saharan Africa is difficult to assess, as noted by a study on febrile patients in Ibadan, Nigeria [26
], which determined a prevalence of 35% of dengue infection through NS1 antigen detection. The infected patients secrete large quantities of soluble NS1 (sNS1) into the bloodstream, with concentrations of up to 50 µg/mL [27
]. Soluble NS1 (sNS1) can remain in the blood for 9 days, and persist for up to 18 days in some patients [28
], exceeding viremia which lasts up to 6 days. This makes NS1 a good biomarker of acute illness as it provides a wide window for DENV detection. It has been suggested that combining NS1 detection with IgM detection can outperform PCR [29
]; however, the use of NS1 detection in the routine screening in dengue epidemics, as a prerequisite for hospitalization, has been questioned [30
]. Additionally, fieldable ELISA systems which would allow for a comparison between the ratios of DENV NS1-Ag and DENV-RNA, are not currently available.
Phylogenetic analysis of the obtained DENV C-prM gene sequences yielded 100% identity with the isolates collected in Guangzhou, China, in 2014. A calculated phylogenetic tree clustered the determined DENV-1 sequences with Asian strains, supported by high bootstrap values (Figure 4
). This finding suggests an importation of the virus to Senegal from Asia, via acutely viremic cases or by infected mosquitoes or their eggs. Indeed, in recent years, international travel and trade activity between the Asian and African continents has increased considerably [31
]—between 1994 and 2009, the annual volume of trade between Senegal and China grew from 23 million U.S. dollars to 441 million U.S. dollars, representing a twenty-fold increase in 15 years [32
]. The potential to extend the distribution area of individual arboviruses was recently supported by the detection of Japanese encephalitis virus (JEV), during a yellow fever outbreak in Lunda (Angola), in 2016 [33
]. This virus is endemic in Asia and the western pacific, but local circulation had never been documented before in Africa [34
]. Another example is the first case of RVFV infection, detected in China from a patient returning from Angola in 2017—while this virus was previously restricted to sub-Saharan Africa, it has been spreading in the Arabic peninsula since 2000 [35
In Africa, dengue is likely to be underreported and under-recognized. This is due to the low awareness of health care providers, and the circulation of other prevalent NMFI [5
]. The absence of surveillance in many African countries and the lack of effective diagnostic tools also contribute to the underestimation of the real incidence of dengue fever in Africa [31
]. Since other studies report the expansion of dengue fever among NMFI [36
], our study and the cited studies in Abidjan and Ibadan stress the need to implement laboratory capacity to assess the real burden of DENV in rural and urban areas of West Africa, during inter epidemic periods.
The RPA positive samples were confirmed by serological assay, viral isolation as well as real-time RT-PCR. The laboratory-based real-time RT-PCR and mobile RT-RPA results were concordant, but mobile RT-RPA yielded results in approximately 20 min, including the extraction step (Table 1
). Additionally, the RPA was performed at the point of need in a suitcase laboratory. In conclusion, although virus isolation remains the “gold standard” in diagnostics [37
], rapid molecular testing at the point of care can provide reliable results (short time-length process, sensitivity and specificity).