Special Issue "Epidemiology of Dengue: Past, Present and Future"

A special issue of Tropical Medicine and Infectious Disease (ISSN 2414-6366).

Deadline for manuscript submissions: closed (31 December 2018)

Special Issue Editor

Guest Editor
Prof. Dr. John McBride

Infectious Diseases Physician and Clinical Microbiologist, College of Medicine and Dentistry, James Cook University, Cairns Clinical School, Cairns Hospital, PO Box 902, Cairns, Queensland, Australia
Website | E-Mail
Interests: dengue; Rickettsia; Leptospirosis; HIV; Papua New Guinea

Special Issue Information

Dear Colleagues,

Dengue is widespread through tropical regions of the world and its distribution is affected by climate, human behaviour (including urbanisation), and the competence and distribution of its mosquito vector. The disease is endemic in many countries and episodically epidemic in still more. Worldwide, the disease is increasing in incidence with more than 300 million cases per year, and more than half the world's population is at risk.

This Special Issue of the journal seeks contributions from authors who can advance our understanding of how dengue has emerged, the current extent and clinical impact of the epidemic, and how it may behave in the future. We are especially interested in papers that describe the epidemic in the Pacific and Southeast Asian regions.

There are now several exciting tools to limit the spread of infection, including vaccines at various stages of development and deployment, the use of modified mosquito vectors and new insights in the deployment of traditional mosquito control measures. We would like to hear from authors in affected countries as to how these measures have impacted on their epidemics.

We welcome any other contributions relating to dengue including but not restricted to: Clinical manifestations of dengue fever; management of the complications of dengue fever (and the use of new clinical criteria); therapeutics; vector biology; blood safety; diagnostics and public health interventions.

We understand that many countries are grappling with concurrent epidemics of Dengue, Chikungunya and Zika virus and recognise that there is significant overlap of these infections both in the geographical distribution and the epidemiological/clinical pattern. There are lessons to be learned from the experiences of describing and dealing with any of these infections. We would welcome any discussion of concurrent epidemics or indeed papers that relate to either of the latter two infections, exclusively.

Prof. John McBride
Guest Editor

Manuscript Submission Information

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Tropical Medicine and Infectious Disease is an international peer-reviewed open access quarterly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 350 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • epidemiology
  • dengue
  • history
  • vaccine
  • entomology
  • Zika
  • Chikungunya

Published Papers (12 papers)

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Research

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Open AccessArticle
Ultrastructural Features of Human Liver Specimens from Patients Who Died of Dengue Hemorrhagic Fever
Trop. Med. Infect. Dis. 2019, 4(2), 63; https://doi.org/10.3390/tropicalmed4020063
Received: 22 February 2019 / Revised: 28 March 2019 / Accepted: 9 April 2019 / Published: 12 April 2019
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Abstract
Recent advances in electron microscopy and tomography have revealed distinct virus-induced endoplasmic reticulum (ER) structures unique for dengue virus (DV) and other flaviviruses in cell culture models, including hepatocytes. These altered ultrastructures serve as sites for viral replication. In this study, we used [...] Read more.
Recent advances in electron microscopy and tomography have revealed distinct virus-induced endoplasmic reticulum (ER) structures unique for dengue virus (DV) and other flaviviruses in cell culture models, including hepatocytes. These altered ultrastructures serve as sites for viral replication. In this study, we used transmission electron microscopy to investigate whether such structures were present in the liver of fatal dengue hemorrhagic fever (DHF) autopsy cases. In parallel, electron microscopic examination of suckling mouse brains experimentally infected with DV was performed as an in vivo model of acute DV infection. Typical features of ER changes containing abundance of replicative virions were observed in neurons and microglia of DV-infected suckling mouse brains (SMB). This indicated that the in vivo DV infection could induce similar viral replication structures as previously described in the in vitro DV-infected cell model. Nevertheless, liver tissues from autopsy of patients who died of DHF showed scant changes of ER membrane structures and rare particles of virions in hepatocytes, despite overwhelming evidence for the presence of viral antigens and RNA–indicating active virus replication. Instead hepatocytes contained an abundance of steatotic vesicles and structural damages. This lack of structural changes indicative of virus replication in human hepatocytes is discussed. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
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Open AccessCommunication
The First Outbreak of Dengue Fever in Greater Darfur, Western Sudan
Trop. Med. Infect. Dis. 2019, 4(1), 43; https://doi.org/10.3390/tropicalmed4010043
Received: 31 December 2018 / Revised: 15 February 2019 / Accepted: 27 February 2019 / Published: 1 March 2019
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Abstract
Dengue virus (DENV) is an arthropod-borne virus (arbovirus) transmitted by the Aedes mosquitoes, mainly Aedes aegypti. Dengue fever is a rapidly growing disease with expanding geographical distribution worldwide. We investigated a high number of non-malaria febrile cases reported to health clinics in [...] Read more.
Dengue virus (DENV) is an arthropod-borne virus (arbovirus) transmitted by the Aedes mosquitoes, mainly Aedes aegypti. Dengue fever is a rapidly growing disease with expanding geographical distribution worldwide. We investigated a high number of non-malaria febrile cases reported to health clinics in refugee camps in the five states of Darfur between August 2015 and March 2016. The clinical presentation of cases and case definition criteria suggested involvement of one or more arboviral hemorrhagic fevers. Out of 560 suspected cases, we collected and analyzed 204 blood samples and serologically positive samples were confirmed by PCR. We identified 32 (15.7%) dengue viral infections, six West Nile virus infections, and three Crimean–Congo viral infections. Dengue infections were found in four out of the five Darfur states. We reported the first dengue fever outbreak in the Darfur region. Our results highlight the need for public health education and further molecular, phylogenetic, and entomological investigations for a better understanding of the disease transmission and the associated risk factors in the region. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
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Open AccessArticle
Comparison of Knowledge, Attitude, and Practice among Communities Living in Hotspot and Non-Hotspot Areas of Dengue in Selangor, Malaysia
Trop. Med. Infect. Dis. 2019, 4(1), 37; https://doi.org/10.3390/tropicalmed4010037
Received: 21 December 2018 / Revised: 9 February 2019 / Accepted: 12 February 2019 / Published: 15 February 2019
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Abstract
Background: Dengue has affected more than one-third of the world population and Malaysia has recorded an increase in the number of dengue cases since 2012. Selangor state recorded the highest number of dengue cases in Malaysia. Most of the dengue infections occur among [...] Read more.
Background: Dengue has affected more than one-third of the world population and Malaysia has recorded an increase in the number of dengue cases since 2012. Selangor state recorded the highest number of dengue cases in Malaysia. Most of the dengue infections occur among people living in hotspot areas of dengue. This study aims to compare Knowledge, Attitude, and Practice among communities living in hotspot and non-hotspot dengue areas. Method: Communities living in 20 hotspot and 20 non-hotspot areas in Selangor were chosen in this study where 406 participants were randomly selected to answer questionnaires distributed at their housing areas. Total marks of each categories were compared using t-test. Result: Results show that there were significant mean differences in marks in Knowledge (p value: 0.003; 15.41 vs. 14.55) and Attitude (p value: < 0.001; 11.41 vs. 10.33), but not Practice (p value 0.101; 10.83 vs. 10.47) categories between communities of non-hotspot and hotspot areas. After considering two confounding variables which are education level and household income, different mean marks are found to be significant in Knowledge when education level acts as a covariate and Attitude when both act as covariates. Conclusion: Overall results show that people living in non-hotspot areas had better knowledge and attitude than people living in hotspot areas, but no difference was found in practice. This suggests that public health education should be done more frequently with people with a low education background and low household income, especially in hotspot areas to fight dengue outbreak and make dengue cases decrease effectively. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
Open AccessArticle
Using Google Trends to Examine the Spatio-Temporal Incidence and Behavioral Patterns of Dengue Disease: A Case Study in Metropolitan Manila, Philippines
Trop. Med. Infect. Dis. 2018, 3(4), 118; https://doi.org/10.3390/tropicalmed3040118
Received: 22 September 2018 / Revised: 31 October 2018 / Accepted: 5 November 2018 / Published: 11 November 2018
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Abstract
Dengue is a major public health concern and an economic burden in the Philippines. Despite the country’s improved dengue surveillance, it still suffers from various setbacks and needs to be complemented with alternative approaches. Previous studies have demonstrated the potential of Internet-based surveillance [...] Read more.
Dengue is a major public health concern and an economic burden in the Philippines. Despite the country’s improved dengue surveillance, it still suffers from various setbacks and needs to be complemented with alternative approaches. Previous studies have demonstrated the potential of Internet-based surveillance such as Google Dengue Trends (GDT) in supplementing current epidemiological methods for predicting future dengue outbreaks and patterns. With this, our study has two objectives: (1) assess the temporal relationship of weekly GDT and dengue incidence in Metropolitan Manila from 2009–2014; and (2) examine the health-seeking behavior based on dengue-related search queries of the population. The study collated the population statistics and reported dengue cases in Metropolitan Manila from respective government agencies to calculate the dengue incidence (DI) on a weekly basis for the entire region and annually per city. Data processing of GDT and dengue incidence was performed by conducting an ‘adjustment’ and scaling procedures, respectively, and further analyzed for correlation and cross-correlation analyses using Pearson’s correlation. The relative search volume of the term ‘dengue’ and top dengue-related search queries in Metropolitan Manila were obtained and organized from the Google Trends platform. Afterwards, a thematic analysis was employed, and word clouds were generated to examine the health behavior of the population. Results showed that weekly temporal GDT pattern are closely similar to the weekly DI pattern in Metropolitan Manila. Further analysis showed that GDT has a moderate and positive association with DI when adjusted or scaled, respectively. Cross-correlation analysis revealed a delayed effect where GDT leads DI by 1–2 weeks. Thematic analysis of dengue-related search queries indicated 5 categories namely; (a) dengue, (b) sign and symptoms of dengue, (c) treatment and prevention, (d) mosquito, and (e) other diseases. The majority of the search queries were classified in ‘signs and symptoms’ which indicate the health-seeking behavior of the population towards the disease. Therefore, GDT can be utilized to complement traditional disease surveillance methods combined with other factors that could potentially identify dengue hotspots and help in public health decisions. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
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Open AccessArticle
On the Home Front: Specialised Reference Testing for Dengue in the Australasian Region
Trop. Med. Infect. Dis. 2018, 3(3), 75; https://doi.org/10.3390/tropicalmed3030075
Received: 29 May 2018 / Revised: 29 June 2018 / Accepted: 10 July 2018 / Published: 15 July 2018
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Abstract
Reference laboratories are vital for disease control and interpreting the complexities and impact of emerging pathogens. The role of these centralized facilities extends beyond routine screening capabilities to provide rapid, specific, and accurate diagnoses, advanced data analysis, consultation services, and sophisticated disease surveillance [...] Read more.
Reference laboratories are vital for disease control and interpreting the complexities and impact of emerging pathogens. The role of these centralized facilities extends beyond routine screening capabilities to provide rapid, specific, and accurate diagnoses, advanced data analysis, consultation services, and sophisticated disease surveillance and monitoring. Within the Australasian region, the Public Health Virology Laboratory (PHV), Forensic and Scientific Services, Department of Health, Queensland Government, Australia, and the Institute of Environmental Science and Research Limited (ESR), New Zealand (NZ) perform specialised reference testing and surveillance for dengue viruses (DENVs) and other emerging arthropod-borne viruses (arboviruses), including chikungunya virus (CHIKV) and Zika virus (ZIKV). With a focus on DENV, we review the reference testing performed by PHV (2005 to 2017) and ESR (2008 to 2017). We also describe how the evolution and expansion of reference-based methodologies and the adoption of new technologies have provided the critical elements of preparedness and early detection that complement frontline public health control efforts and limit the spread of arboviruses within Australasia. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
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Open AccessArticle
The Importance of Water Typologies in Lay Entomologies of Aedes aegypti Habitat, Breeding and Dengue Risk: A Study from Northern Australia
Trop. Med. Infect. Dis. 2018, 3(2), 67; https://doi.org/10.3390/tropicalmed3020067
Received: 23 April 2018 / Revised: 5 June 2018 / Accepted: 5 June 2018 / Published: 18 June 2018
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Abstract
Dengue fever is making a significant comeback globally and its control still depends largely on residents’ actions. Community awareness and education are central to its management; however, programmes have had limited impact, because they are often based on short-term research and limited awareness [...] Read more.
Dengue fever is making a significant comeback globally and its control still depends largely on residents’ actions. Community awareness and education are central to its management; however, programmes have had limited impact, because they are often based on short-term research and limited awareness of the socio-ecological contexts wherein local knowledge of dengue and its vectors (lay entomology) is produced and enacted in and through place. Long-term studies of lay knowledge of dengue vectors are very rare, even though they are essential to the development of effective, targeted community education campaigns and mobilisation. In this paper, we examine the popular belief that dengue vector, Aedes aegypti, is ubiquitous in the north Australian landscape and demonstrate how local typologies of water are central to the reasoning underwriting this assumption. We show how these logics are fortified by people’s lived experiences of mosquitoes and the watery abodes they are thought to reside in, as well as through key messages from health education. We posit that long term, context-sensitive research approaches are better able to identify, understand and later address and challenge assumptions and may be more effective at informing, empowering and mobilizing the public to combat dengue fever. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
Open AccessArticle
The Rise of Imported Dengue Infections in Victoria, Australia, 2010–2016
Trop. Med. Infect. Dis. 2018, 3(1), 9; https://doi.org/10.3390/tropicalmed3010009
Received: 14 November 2017 / Revised: 19 December 2017 / Accepted: 3 January 2018 / Published: 21 January 2018
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Abstract
Dengue notifications have increased dramatically over the past seven years in Victoria, Australia—a trend which has been seen nationally and reflects increased cases internationally. We reviewed the epidemiology of dengue among Victorian travellers, changes in diagnostic methods and describe the burden placed on [...] Read more.
Dengue notifications have increased dramatically over the past seven years in Victoria, Australia—a trend which has been seen nationally and reflects increased cases internationally. We reviewed the epidemiology of dengue among Victorian travellers, changes in diagnostic methods and describe the burden placed on local health systems resulting from this disease of public health importance. Cases of dengue notified to the Department of Health and Human Services in Victoria, Australia, between 1 January 2010 and 31 December 2016 were included in this review. Demographic, clinical, diagnostic methods, and risk factor data were examined using descriptive epidemiological analyses. Cases of dengue increased on average by 22% per year, with a total of 2187 cases (5.5 cases/100,000 population) notified over the 7-year reporting period. The most frequently reported country of acquisition was Indonesia (45%) followed by Thailand (14%). The use of multiple diagnostic methods, including the non-structural protein 1 antigen (NS1Ag) detection test, increased over time. The median time between onset of illness and diagnosis diminished from 9 days (IQR: 2–15) in 2010 to 4 days (IQR: 2–7) in 2016. Proportionally more cases were discharged directly from emergency departments in recent years (10% in 2010 to 28% in 2016, p < 0.001).The increasing incidence of dengue in Australia is reflective of its growing prominence as a travel medicine problem in western countries. For travellers with non-severe dengue, the improved timeliness of dengue diagnostics allows for consideration of best practice ambulatory management approaches as used in endemic areas. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
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Open AccessArticle
Clinical Features and Laboratory Findings of Travelers Returning to South Australia with Dengue Virus Infection
Trop. Med. Infect. Dis. 2018, 3(1), 6; https://doi.org/10.3390/tropicalmed3010006
Received: 11 December 2017 / Revised: 3 January 2018 / Accepted: 3 January 2018 / Published: 7 January 2018
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Abstract
Reported cases of dengue are rising in South Australia (SA) in travellers returning from dengue-endemic regions. We have undertaken a retrospective analysis to identify the clinical and laboratory characteristics of patients returning to SA with suspected dengue virus (DENV) infection. From 488 requests, [...] Read more.
Reported cases of dengue are rising in South Australia (SA) in travellers returning from dengue-endemic regions. We have undertaken a retrospective analysis to identify the clinical and laboratory characteristics of patients returning to SA with suspected dengue virus (DENV) infection. From 488 requests, 49 (10%) were defined by serology as acute dengue, with the majority of patients (75%) testing as non-structural protein 1 (NS1) and/or IgM positive. Dengue was most commonly acquired in Indonesia (42.9%) with clinical features of fever (95%), headache (41%) and myalgia/arthralgia (56%). The presence of rash (36%) and laboratory findings of neutropenia, leukopenia, thrombocytopenia, but not elevated C-reactive protein, were distinct from findings in DENV-seronegative patients. Available dengue seropositive samples were analysed by RT-PCR, with 14/32 (43.8%) positive by a serotype non-specific DENV assay, but 28/32 positive (87.5%) when also assessed by serotype-specific RT-PCR. Serotype analysis revealed the predominance of DENV-1 and DENV-2 and the presence of DENV-3, but not DENV-4 or Zika virus (ZIKV). Thus, dengue in returned travellers in SA presents in a manner consistent with World Health Organization (WHO) definitions, with symptoms, travel history and laboratory results useful in prioritising the likelihood of dengue. This definition will assist the future management in DENV-non-endemic regions, such as SA. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
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Open AccessArticle
Application of Artificial Neural Networks for Dengue Fever Outbreak Predictions in the Northwest Coast of Yucatan, Mexico and San Juan, Puerto Rico
Trop. Med. Infect. Dis. 2018, 3(1), 5; https://doi.org/10.3390/tropicalmed3010005
Received: 31 October 2017 / Revised: 18 December 2017 / Accepted: 2 January 2018 / Published: 5 January 2018
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Abstract
Modelling dengue fever in endemic areas is important to mitigate and improve vector-borne disease control to reduce outbreaks. This study applied artificial neural networks (ANNs) to predict dengue fever outbreak occurrences in San Juan, Puerto Rico (USA), and in several coastal municipalities of [...] Read more.
Modelling dengue fever in endemic areas is important to mitigate and improve vector-borne disease control to reduce outbreaks. This study applied artificial neural networks (ANNs) to predict dengue fever outbreak occurrences in San Juan, Puerto Rico (USA), and in several coastal municipalities of the state of Yucatan, Mexico, based on specific thresholds. The models were trained with 19 years of dengue fever data for Puerto Rico and six years for Mexico. Environmental and demographic data included in the predictive models were sea surface temperature (SST), precipitation, air temperature (i.e., minimum, maximum, and average), humidity, previous dengue cases, and population size. Two models were applied for each study area. One predicted dengue incidence rates based on population at risk (i.e., numbers of people younger than 24 years), and the other on the size of the vulnerable population (i.e., number of people younger than five years and older than 65 years). The predictive power was above 70% for all four model runs. The ANNs were able to successfully model dengue fever outbreak occurrences in both study areas. The variables with the most influence on predicting dengue fever outbreak occurrences for San Juan, Puerto Rico, included population size, previous dengue cases, maximum air temperature, and date. In Yucatan, Mexico, the most important variables were population size, previous dengue cases, minimum air temperature, and date. These models have predictive skills and should help dengue fever mitigation and management to aid specific population segments in the Caribbean region and around the Gulf of Mexico. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
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Review

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Open AccessReview
New Immuno-Epidemiological Biomarker of Human Exposure to Aedes Vector Bites: From Concept to Applications
Trop. Med. Infect. Dis. 2018, 3(3), 80; https://doi.org/10.3390/tropicalmed3030080
Received: 2 July 2018 / Revised: 23 July 2018 / Accepted: 30 July 2018 / Published: 1 August 2018
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Abstract
Arthropod-borne viruses (arboviruses) such as dengue virus (DENV), chikungunya virus (CHIKV), Zika virus (ZIKV), and yellow fever virus (YFV) are the most important ‘emerging pathogens’ because of their geographic spread and their increasing impact on vulnerable human populations. To fight against these arboviruses, [...] Read more.
Arthropod-borne viruses (arboviruses) such as dengue virus (DENV), chikungunya virus (CHIKV), Zika virus (ZIKV), and yellow fever virus (YFV) are the most important ‘emerging pathogens’ because of their geographic spread and their increasing impact on vulnerable human populations. To fight against these arboviruses, vector control strategies (VCS) remain one of the most valuable means. However, their implementation and monitoring are labour intensive and difficult to sustain on large scales, especially when transmission and Aedes mosquito densities are low. To increase the efficacy of VCS, current entomological methods should be improved by new complementary tools which measure the risk of arthropod-borne diseases’ transmission. The study of human–Aedes immunological relationships can provide new promising serological tools, namely antibody-based biomarkers, allowing to accurately estimate the human–Aedes contact and consequently, the risk of transmission of arboviruses and the effectiveness of VCS. This review focuses on studies highlighting the concept, techniques, and methods used to develop and validate specific candidate biomarkers of human exposure to Aedes bites. Potential applications of such antibody-based biomarkers of exposure to Aedes vector bites in the field of operational research are also discussed. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
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Open AccessReview
From Incriminating Stegomyia fasciata to Releasing Wolbachia pipientis: Australian Research on the Dengue Virus Vector, Aedes aegypti, and Development of Novel Strategies for Its Surveillance and Control
Trop. Med. Infect. Dis. 2018, 3(3), 71; https://doi.org/10.3390/tropicalmed3030071
Received: 31 May 2018 / Revised: 18 June 2018 / Accepted: 19 June 2018 / Published: 22 June 2018
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Abstract
Globally, the dengue viruses (DENVs) infect approximately 300 million people annually. Australia has a history of epidemic dengue, with outbreaks in the early decades of the twentieth century responsible for tens of thousands of cases. Seminal experiments conducted by Australian scientists during these [...] Read more.
Globally, the dengue viruses (DENVs) infect approximately 300 million people annually. Australia has a history of epidemic dengue, with outbreaks in the early decades of the twentieth century responsible for tens of thousands of cases. Seminal experiments conducted by Australian scientists during these outbreaks were the first to incriminate Aedes aegypti as a major vector of dengue viruses. One hundred years later, Australian scientists are playing a lead role in the development of surveillance and suppression strategies that target this mosquito species. Surveillance of Ae. aegypti populations and their associated dengue risk was greatly improved by understanding the contribution of key premises, key containers, and cryptic larval habitats to mosquito productivity, and, more recently, the development of novel adult traps. In terms of mosquito control, targeted indoor residual pyrethroid spraying and community-based biological control utilizing predatory copepods can significantly reduce Ae. aegypti populations. The release of Ae. aegypti transinfected with the virus-blocking bacterium, Wolbachia, provides a promising strategy for limiting DENV transmission. These diverse strategies developed by Australian scientists have the potential to alleviate the burden of dengue in the future, whether it is at the local level or as part of a country-wide program. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
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Other

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Open AccessCase Report
Dengue Virus and Influenza A Virus Co-Infection in Pregnancy: A Case Report
Trop. Med. Infect. Dis. 2019, 4(2), 84; https://doi.org/10.3390/tropicalmed4020084
Received: 8 April 2019 / Revised: 25 April 2019 / Accepted: 26 April 2019 / Published: 21 May 2019
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Abstract
Dengue is still an important cause of disease and mortality in tropical countries, as is influenza A virus, which is also a cause of epidemics all over the globe. In this article, we present the case of a 31-year-old woman who was in [...] Read more.
Dengue is still an important cause of disease and mortality in tropical countries, as is influenza A virus, which is also a cause of epidemics all over the globe. In this article, we present the case of a 31-year-old woman who was in her second trimester of pregnancy and presented with severe dengue with hematological and neurological complications, and premature labor. She was misdiagnosed with bacterial infection and received antibiotic treatment with no improvement of the clinical manifestations and previous to death, she was diagnosed with dengue infection. She died from cardiorespiratory arrest. In the postmortem evaluation, influenza A co-infection was confirmed and characterization of the tissue damage and immune response in lung, liver, kidney, heart, spleen, and brain was determined, finding a severe inflammatory response in lung with T cells and macrophages infiltrating the tissue. This case report highlights the risks of accepting a single diagnosis, especially in endemic countries to multiple tropical diseases, which can lead to delay in appropriate treatment that could reduce morbidity and mortality. Full article
(This article belongs to the Special Issue Epidemiology of Dengue: Past, Present and Future)
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