HEALTH EDUCATION LESSON

COMMUNICABLE DISEASES

TASK: A JOURNAL ON COMMUNICABLE DISEASES

DENGUE
Communicable Disease: DENGUE
Reference: Centers for Disease Control and Prevention
Updated 2005 Aug 22
LINK: https://archive.cdc.gov/www_cdc_gov/csels/dsepd/ss1978/lesson1/section10.html
Article No. 1

DENGUE FACT SHEET

WHAT IS DENGUE?
Dengue is an acute infectious disease that comes in two forms: dengue and dengue hemorrhagic fever. The
principal symptoms of dengue are high fever, severe headache, backache, joint pains, nausea and vomiting,
eye pain, and rash. Generally, younger children have a milder illness than older children and adults.

Dengue hemorrhagic fever is a more severe form of dengue. It is characterized by a fever that lasts from 2 to
7 days, with general signs and symptoms that could occur with many other illnesses (e.g., nausea, vomiting,
abdominal pain, and headache). This stage is followed by hemorrhagic manifestations, tendency to bruise
easily or other types of skin hemorrhages, bleeding nose or gums, and possibly internal bleeding. The smallest
blood vessels (capillaries) become excessively permeable (“leaky”), allowing the fluid component to escape
from the blood vessels. This may lead to failure of the circulatory system and shock, followed by death, if
circulatory failure is not corrected. Although the average case-fatality rate is about 5%, with good medical
management, mortality can be less than 1%.

WHAT CAUSES DENGUE?

Dengue and dengue hemorrhagic fever are caused by any one of four closely related flaviviruses, designated
DEN-1, DEN–2, DEN-3, or DEN-4.

HOW IS DENGUE DIAGNOSED?

Diagnosis of dengue infection requires laboratory confirmation, either by isolating the virus from serum within
5 days after onset of symptoms, or by detecting convalescent-phase specific antibodies obtained at least 6
days after onset of symptoms.

WHAT IS THE TREATMENT FOR DENGUE OR DENGUE HEMORRHAGIC FEVER?

There is no specific medication for treatment of a dengue infection. Persons who think they have dengue should
use analgesics (pain relievers) with acetaminophen and avoid those containing aspirin. They should also rest,
drink plenty of fluids, and consult a physician. Persons with dengue hemorrhagic fever can be effectively
treated by fluid replacement therapy if an early clinical diagnosis is made, but hospitalization is often required.
HOW COMMON IS DENGUE AND WHERE IS IT FOUND?
Dengue is endemic in many tropical countries in Asia and Latin America, most countries in Africa, and much of
the Caribbean, including Puerto Rico. Cases have occurred sporadically in Texas. Epidemics occur periodically.
Globally, an estimated 50 to 100 million cases of dengue and several hundred thousand cases of dengue
hemorrhagic fever occur each year, depending on epidemic activity. Between 100 and 200 suspected cases
are introduced into the United States each year by travelers.

HOW IS DENGUE TRANSMITTED?

Dengue is transmitted to people by the bite of an Aedes mosquito that is infected with a dengue virus. The
mosquito becomes infected with dengue virus when it bites a person who has dengue or DHF and after about
a week can transmit the virus while biting a healthy person. Monkeys may serve as a reservoir in some parts
of Asia and Africa. Dengue cannot be spread directly from person to person.

WHO HAS AN INCREASED RISK OF BEING EXPOSED TO DENGUE?

Susceptibility to dengue is universal. Residents of or visitors to tropical urban areas and other areas where
dengue is endemic are at highest risk of becoming infected. While a person who survives a bout of dengue
caused by one serotype develops lifelong immunity to that serotype, there is no cross-protection against the
three other serotypes.

WHAT CAN BE DONE TO REDUCE THE RISK OF ACQUIRING DENGUE?

There is no vaccine for preventing dengue. The best preventive measure for residents living in areas infested
with Aedes aegypti is to eliminate the places where the mosquito lays her eggs, primarily artificial containers
that hold water.
Items that collect rainwater or are used to store water (for example, plastic containers, 55-gallon drums,
buckets, or used automobile tires) should be covered or properly discarded. Pet and animal watering containers
and vases with fresh flowers should be emptied and scoured at least once a week. This will eliminate the
mosquito eggs and larvae and reduce the number of mosquitoes present in these areas.
For travelers to areas with dengue, as well as people living in areas with dengue, the risk of being bitten by
mosquitoes indoors is reduced by utilization of air conditioning or windows and doors that are screened. Proper
application of mosquito repellents containing 20% to 30% DEET as the active ingredient on exposed skin and
clothing decreases the risk of being bitten by mosquitoes. The risk of dengue infection for international travelers
appears to be small, unless an epidemic is in progress.

CAN EPIDEMICS OF DENGUE HEMORRHAGIC FEVER BE PREVENTED?

The emphasis for dengue prevention is on sustainable, community-based, integrated mosquito control, with
limited reliance on insecticides (chemical larvicides and adulticides). Preventing epidemic disease requires a
coordinated community effort to increase awareness about dengue/DHF, how to recognize it, and how to
control the mosquito that transmits it. Residents are responsible for keeping their yards and patios free of sites
where mosquitoes can be produced.
Communicable Disease: DENGUE
Reference: National Library of Medicine
Published online 2021 Dec 15
LINK: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8694986/
Article No. 2

ABSTRACT

Dengue remains one of the most serious and widespread mosquito-borne viral infections in human beings, with
serious health problems or even death. About 50 to 100 million people are newly infected annually, with
almost 2.5 billion people living at risk and resulting in 20,000 deaths. Dengue virus infection is especially
transmitted through bites of Aedes mosquitos, hugely spread in tropical and subtropical environments, mostly
found in urban and semiurban areas. Unfortunately, there is no therapeutic approach, but prevention, adequate
consciousness, detection at earlier stage of viral infection, and appropriate medical care can lower the fatality
rates. This review offers a comprehensive view of production, transmission, pathogenesis, and control measures
of the dengue virus and its vectors.

1. INTRODUCTION

Dengue regards one of the utmost serious arboviral infections around the world. Dengue Virus (DENV) is
transmitted through bites of female Aedes mosquitos especially Aedes (Stegomyia) aegypti, Ae. alpopictus, Ae.
niveus, and Ae. polynesiensis. DENV infection is almost like flu-like infection and sometimes develops into possibly
lethal difficulties or severe illness including dengue shock syndrome and dengue hemorrhagic fever. World
Health Organization (WHO) reports that DENV infection has been shown to 30-fold increase around the globe
over the past five decades, and approximately 100 million newly infected people are estimated in over 100
endemic countries with 20,000 deaths annually.

DENV and its vectors are primarily noticed in tropical and subtropical environments globally, frequently in
urban and semiurban areas. In Bangladesh, DENV has been detected as a severe health hazard. Between
2000 and 2008, 50,148 people were hospitalized for dengue in Bangladesh. But in August 2019, nearly
60,000 dengue patients have been hospitalized, and approximately 100 deaths have been reported. Severe
DENV infection is a leading cause of tenacious sickness and deaths of people of all ages in Asian and Latin
American countries. Unfortunately, we have no treatment strategy for dengue infection. It may be because
historically our pharmaceutical section did not come up with much attention to this vector-borne viral disease.

This review is aimed at sketching a current scenario on DENV, dengue infection, and dengue vectors along with
the production, transmission, pathogenesis, and ways of control of DENV, and its vectors offers a comprehensive
view of production, transmission, pathogenesis, and control measures of DENV and its vectors.

2. DENGUE VIRUS (DENV)

DENV, a pathogenic arthropod-borne flavivirus (arbovirus), is a single-stranded and positive-sense RNA

molecule belonging to the family Flaviviridae.

The Flaviviridae family includes viruses transmitted by arthropods that cause serious illness in humans. The family
includes a single genus-Flavivirus, with several types. Recently, another subdivision of the family into three
genera has been proposed as follows: genus Flavivirus includes arboviruses (yellow fever virus, dengue fever
virus); genus Pestivirus-viruses involved in animal pathology; and genus Hepacavirus-the proposed name for
different variants of hepatitis C virus.

To date, 47 strains of DENV have been identified. The total number of four closely linked serotypes (from
DENV -1 to -4) of DENV has been identified to date, but they are lightly antigenically distinct, and those can
be subdivided into several genotypes according to their gene sequences. These serotypes are generally
progressed from a mutual ancestor, and all are considered as the causative agent of approximately similar
disease spectrum in humans due to DENV selecting different receptors based on cell types and virus strains.
Developed viral particles have a spherical shape with 11 kb in length and 40-50 nm in diameter, containing
single-stranded and positive-sense RNA molecule, which has a 5-methyl cap with a single open reading frame.
Dengue virus and its common four serotypes have shown in Figure 1.

Figure 1
Diagram with dengue virus and its four serotypes.

2.1. DENV VECTORS

Dengue virus infection usually spreads through bites of infected female mosquitos of genus Aedes, especially
by the Aedes aegypti and Ae. Albopictus. However, the other two vectors such as Ae. polynesiensis and Ae.
niveus have been identified as the secondary vectors in some regions throughout the world (Figure 2).
Figure 2
Aedes mosquitoes (dengue virus vectors).

Adult Ae. aegypti has a white scale that forms a lyre or violin shape at the dorsal side of the thorax, while the
adult Ae. albopictus forms a white stripe at the middle point of the top of the thorax region. The white bands
of every tarsal segment of the hind legs of these mosquitos are known as the white stripe. The abdomen is
generally found to be black or dark brown, but sometimes, it also bears white scales. Females are usually
larger than males; on the other way, through finding small palps tipped with silver or white scales, they can be
discriminated against properly. Males are specially identified by the plumose type of antennae. On the other
hand, females are seen to bear short hair. Under a microscope, the mouthparts of the male are watched as a
structural modification for nectar feeding, and female mouthparts are viewed as a modified structure for
feeding on blood. The darkly coloured proboscis is found to be present in both sexes. In addition, two clusters
of white scales presented on the segment above the proboscis are known as clypeus. The tip of the abdomen
is pointed out as a distinctive feature of all Aedes species.

2.2. GEOGRAPHICAL DISTRIBUTION

DENV mainly originated from monkeys, then jumped to humans in Southeast Asia or Africa between 100 and
800 years ago. Geographically DENV has been restricted till the 1950s, but after the Second World War
caused a rapid distribution throughout the world. Firstly, DENV infection was recognized in the Thailand and
Philippines in the 1850s, and after the 1980s towards Latin America and the Caribbean. Presently, DENV is
prevalent throughout the different countries (at least 100 countries) including in Asia, the Pacific, the Americas,
Africa, and the Caribbean. DENV epidemics occurred in 26 states. Scientific reports demonstrate that DENV-2
and 3 serotypes were mostly outbroken before 2000 and between 2000 and 2009, respectively. DENV-1
serotype started to dominate worldwide dengue outbreaks and after 2010, the DENV-4.
The geographical distribution of DENV worldwide has been shown in Figure 3.

Figure 3
Geographical distribution of dengue worldwide.

Ae. Aegypti is scattered in tropical areas geographically, and it breeds artificially in containers (such as tyres,
drums, flower vases including plastic food containers, tin cans, and old motor parts) that are filled with water.

Ae. aegypti is an insect of holometabolous type, which is fully developed after completing metamorphosis (i.g.,
four growing phases from egg to adult period). The duration of the life span of an adult may be 2 to 4 weeks;
however, it depends on the environmental conditions, at least 4-5 times a female mosquito lays eggs throughout
her whole life span and the average 10 to 100 eggs in a single spawn. Three diverse polytypic forms are
found in Ae. aegypti such as sylvan, domestic, and peridomestic.

A sylvan type is generally a rural form which breeds in tree holes, normally in forests; the domestic type
commonly breeds in municipal surroundings, frequently inside or around houses; and the peridomestic type
usually survives in biologically modified regions as groves and coconut farms. Ae. aegypti can survive above
4°C; on the other hand, about 15-37°C temperature is required for a complete life cycle.

The extent of DENV epidemics not only depends on the presence of DENV and mosquito genotypes but also
depends on how they interrelate with local temperature. Nevertheless, a current study demonstrated that DENV
infection can alter gene expression in the Ae. aegypti mosquito's head that causes a loss of their olfactory
preferences, thereby modifying oviposition site choice. Now, the question is how safe is the host nervous system's
homeostasis during Dengue infection?
2.3. LIFE CYCLE

Primarily, the DENV was transmitted via sylvatic cycles in Asia and Africa by Aedes mosquito and the nonhuman
primates, with occasional appearances of human populations. However, nowadays, the global spread of DENV
follows its emergence of all types of transmissions (e.g., sylvatic cycles and vertical: mosquito to mosquito). Thus,
its primary life cycle entirely involves the transmission between Aedes mosquitoes and humans. One report
suggests that dogs or other animals may act as incidental hosts and may serve as reservoirs of DENV infection.
Life cycles of mosquitoes have been shown in Figure 4.

Figure 4
Mosquito life cycle.

2.4. IMMUNE DEFENSIVE PATHWAYS

The Toll pathway is one of the well-known potential immune defensive pathways against the DENV and its
serotypes bearing Ae. aegypti. In a study, after ten days postinfection of DENV, the antioxidant enzymes were
found to suppress, while upregulated the expressions of Toll, JAK-STAT, and pathogen recognition receptor
(PRR). It has also been analyzed that the JAK-STAT pathway is another important DENV defensive pathway in
invertebrates. The mosquitoes of genus Aedes should be more vulnerable to DENV infection if the receptor JAK
homolog HOP or Dome is inhibited by RNA inference (RNAi, e.g., ds RNA and prM RNA).
In a study, miR-375 was found to enhance DENV2 replication capacity. In another study, in the period of DENV
infection, miRNAs were identified in different forms (about sixty-six) in Ae. albopictus, where upregulated miR-
34-5p targets the Toll pathway signalling protein (REL-1). Conversely, downregulated peptidoglycan
recognition protein LE, and AMP defensin D. miR87 targets the Toll pathway.

Differential expression of miRNAs in DENV has been also reported by Yen et al. In this study, the authors
highlighted the possibility of using artificial antiviral miRNAs to reduce the transmission of two major arboviruses
in transgenic Ae. Aegypti. The miRNA-based approach resulted in a dual resistance phenotype for Dengue
serotype 3 viruses (DENV-3).

The piRNAs also plays essential roles in the innate antiviral response in DENV. Moreover, nonretroviral
integrated RNA viruses (NIRVS) were recognized in Ae. aegypti and Ae. albopictus in a larger number.

The expression of cecropin-like AMPs was expressively upregulated by the infection of DENV. In Ae. aegypti,
the immune deficiency (IMD) pathway shows a significant role to resist DENV susceptibility, while the increase
in viral replication. The ubiquitin variant (Ub3881) residues may inhibit the DENV envelope protein, thereby
and decrease the production rate of DENV in Aedes vectors.

The DENV-containing blood meal first appears in the midgut of the vectors, which has the first line of defense
systems, such as the infection barrier and the escape barriers. It is evident that, after a successful entry of
DENV, something has happened inside the midgut cells such as uncoating, replication, and new virus particle
assembly. The innate immune signalling pathways have been seen to be effective during the infection of DENV
in Ae. aegypti. Exogenous siRNA pathways also play a substantial role against DENV infections in
the Aedes midgut. DENV infection causes the production of NO in the hemolymph, where the virus is released
into the hemocoel from the midgut. The hemocytes allow replication other than the distribution of DENV.
Interestingly, DENV replication in hemocytes is extensively inhibited by NO. It has been reported that about
40 differentially bacterial types have been isolated from the gut of Ae. aegypti through a gut microbiome
study. In another study, colonization of Csp_P in the midgut of the Ae. aegypti also inhibited DENV infection.
The Talaromyces (Tsp) secretome shows a considerable modulating effect on the midgut
transcriptome. Tsp secretome may display a significant role in the advancement of DENV infection in the midgut
through downregulating trypsin encoding genes involved in the digestion of blood and through reducing the
enzymatic activity of trypsin. It is cited that the presence of gram-negative endosymbiotic
bacteria Wolbachia spp. in Aedes mosquitoes effectively suppressed the DENV infection. Wolbachia activates
antimicrobial peptides defensin and cecropin Toll pathway through producing reactive oxygen species (ROS)
after inducing a reduction-oxidation (Redox) reaction in the mosquitos. Wolbachia also upsurges vago1
expression in Ae. aegypti by acting as a ligand of the JAK-STAT pathway.

Ae. aegypti macroglobulin complement related factor (AaMCR) recognizes DENV particles. An anti-DENV effect
on Aedes mosquitoes has been found to link with the upregulation of AMP expression in the hemocytes. The
salivary glands also contain the infection barrier and the escape barriers. Moreover, incomplete apoptosis of
DENV occurs here, which is required for the virus to release via saliva. A study revealed that multiple immune
defensive pathways (e.g., Toll and IMD) can be found here, and this can rise putative antibacterial
proteins/peptides (e.g., attacin, cecropins, defensins,and gambicin). In the brain of Ae. aegypti, a homolog
of Hikaru Genki (AaHig) has been found to express ubiquitously.

Lipid droplets (LDs) containing a few exclusive structural proteins (Perilipin 1, 2, and 3) and a fatty acid
monolayer are exclusively found to present in a variety of organisms including DENV. These have been found
to provide immunological defense of Aedes mosquitoes.
3. DENV INFECTION

3.1. Transmission

After initial midgut infection, DENV distributes systemically through the body cavity (commonly known as
hoemocel) of Aedes vectors, after that way disseminates in secondary tissues. The time taken between initial
midgut infection and successive transmission of DENV by its vector (e.g., Ae. aegypti) is termed as extrinsic
incubation period (7 to 14 days at 25-30°C). DENV stays in the midgut of the vectors which it may be due to
the viral genome being stable here.

The ubiquitin-proteasome, an important pathway, acts significant activity in the regulation of infectious DENV
production in vectors. Finally, an infection of the salivary glands and the release of virions into the host's saliva
occur throughout the DENV transmission to the host. Blood cells and plasma are important media for the four
serotypes of DENV spreading into the host. A relation of domain III from the envelope glycoprotein of DENV-
II with human plasma proteins has been identified by Huerta et al. DENV infection inductees after the
attachment of the dengue virus to the target cell through interfaces between the various cell surface receptors
and viral envelope (E) protein. In mammalian cells, all categorized serotypes interact with mannose, heparan
sulfate, nLc4Cer, and DC-SIGN/L-SIGN receptors.

Additionally, the DENV-2 serotype is found to intensity of binding with GRP78, CD14-associated protein,
HSP70/HSP90, and two other unidentified receptor proteins. Conversely, serotypes DENV 1-3 bind with the
laminin receptor while serotypes DENV 2-4 attach with an unknown protein receptor.

DENV after receptor-mediated endocytosis, virion fuses with acidic lysosomes, and its genomic RNA is released
into the cytoplasm and translated into a polyprotein of ~3400 amino acids (genome is about 11000 bases of
positive-sense, a single-stranded RNA (ssRNA)) that are further cleaved by viral and host proteases into three
structural (capsid: C, membrane: M, and envelope: E) and seven nonstructural (NS1, NS2A, NS2B, NS3, NS4A,
NS4B and NS5) proteins.

C protein is a foremost structural component of DENV that is localized in the cytoplasm and nuclei. The nuclear
localization of this protein is thought to be crucial for its well-organized replication.

The lipid bilayer of virions is formed by lipid (approximately 17% by weight) between the nucleocapsid core
and E/M outer shell. During the replication of DENV, a membrane-bound replication complex formation helps
to incorporate host factors, viral proteins, and genomic RNA. In this case, positive-strand (+) DENV genomic
RNA acts as a template to synthesize complementary negative-strand (-) RNA, which is sequentially used for
multiple (+) RNA genomes production that is obtainable for translation and regulation of replication cycles or
packaging into virions. However, in a study, Raquin and Lambrechts showed the presence of DENV genomic
RNA in the salivary galnds of Ae. aegypti, indicating an active replication of DENV in its vector prior to
transmission. DENV itself encodes RNA-dependent RNA polymerases, and the infection cycle of this virus is
catalyzed by other cellular factors.

DENV infections can alter many important proteins in the subcellular locales, including the Alix apoptosis-linked
gene-2-interacting protein X; therefore, blocking this step may be one of the innovative beneficial approaches
to reduce DENV replication in the host. Instead, several genes have been identified that reduce infection of
DENV when silenced by at least 60% in its most important vector Ae. aegypti. Among them, a putative cysteine-
rich venom protein SeqID AAEL000379 (CRVP379) silencing has been found to reduce DENV infection
significantly in the cells of midgut tissues of Ae. aegypti.

Loqs2, a gene has been found only in Aedes mosquitoes, which is essential for the appropriate effectiveness of
RNA interference in this type of mosquito. However, without Loqs2, the viruses can multiply and consequently
infect their salivary glands.
An interaction between DENV nonstructural protein 4A (NS4A) and host cellular vimentin has been
demonstrated in localizing and concentrating the viral replication complex at the perinuclear site, in
consequence assisting well-organized replication of viral RNA.

Figure 5 shows a general DENV transmission mode in its vector to hosts.

Figure 5
DENV transmission mode between the vector and hosts.

3.2. PATHOGENESIS

DENV is usually greater in tropical and subtropical environments throughout the world, frequently in urban and
semiurban zones. People, exposed to infected mosquitoes of all ages are susceptible to DENV infection. DENV
infection causes dandy fever, breakbone fever, and dengue hemorrhagic fever; and in severe cases, dengue
shock syndrome has occurred. The rainy season is the most favorable climate for DENV infection outbreaks in
tropical countries in Asia and South America. Generally, the infected female Aedes mosquitoes transmit DENV
in humans. Although humans are not capable of transmitting DENV, it can be transmitted during the blood
transfusion between an infected person to a noninfected (healthy) person.

3.3. PHYSIOLOGICAL DATA

After the incubation period (3 to 14 days) of DENV, the person may experience one or more early symptoms
such as nausea, headache, rash, fever, musculoskeletal pain, and joint pain. In classic dengue fever, body
temperature ranges from 39 to 40°F (5-7 days). In the meantime, the DENV may enter systematically into the
bloodstream at the peripheral zones and sequentially damage lymph nodes and blood vessels resulting in
dengue hemorrhagic fever. Symptoms of the latter case include bleeding under the skin and from the gums
and nose. On the other hand, difficulty in breathing appears in patients having dengue hemorrhagic fever,
and severe progress of it can lead to dengue shock syndrome, if left untreated, can result in death.

3.4. MICRONUTRIENT IMBALANCE

The morphogenesis and translation and/or replication of DENV occur in the endoplasmic reticulum (ER), where
Ca2+ plays a significant activity in cell signaling. The immune response of T-cell has been drawn in DENV
infection. At the time of secondary infection (i.e., infection after 1-2 days of fever onset), high concentration of
interferon-alpha (IFN-α) is found, while high levels of soluble interferon γ (IFN-γ), interleukin 2 receptor (IL-2R),
and soluble CD4 and CD8 were reported throughout the outset of vascular permeability. Dengue antigen is
evident to increase the influx of Ca2+ into T-cells, thus reducing blood Ca2+ levels.

A multifunctional intermediate messenger protein calmodulin is well known as a primary sensor of intracellular
Ca2+ in the eukaryotic cells, which plays imperative utility for proper decoding of Ca2+ signalling. DDX3X is
a DEAD-box RNA helicase, which binds with the TRPV4 cation channel that regulates its functions. DDX3X is
released by the TRPV4-mediated Ca2+ influx; at the same time, DDX3X nuclear translocation is derived through
a process involving calmodulin and its kinase II-dependent pathway.

Therefore, pharmacological inhibition or genetic depletion of TRPV4 can diminish DDX3X-dependent functions,
including translation and nuclear viral export. Thus, targeting TRPV4 may reduce the infectivity of some viruses,
including dengue, Zika viruses, and hepatitis C. In a study, the effect of W-7, a calmodulin antagonist in DENV
infection in Huh-7 cells, was seen, where W7 was inhibited viral yield, NS1 secretion and viral RNA, and protein
synthesis, possibly through direct inhibition of NS2B-NS3 activity and/or inhibition of the interaction between
NS2A with Ca2+-calmodulin complex. Calcium depletion can modulate cardiac functions, immunopathogenesis,
and platelet functions in dengue infection. Another study on 36 h postinfection of Huh7 cells has been
demonstrated that calcium modulating cyclophilin-binding ligand influences the apoptosis process by changing
the activation of caspase-3 and the potentiation of mitochondrial membrane.

3.5. CLINICAL ASPECTS

In most cases, asymptomatic or mildly symptomatic pathways are promising ways for transiting DENV infection.

The most common signs and symptoms include pain of bone, joint, muscle, and retro-orbital; headache; fever
(40°C); maculopapular or macular rash; and minor hemorrhagic manifestations including purpura, malaise,
ecchymosis, petechiae, epistaxis, hematuria, bleeding gums, aches or pain, or a positive tourniquet test result.
Dengue fever lasts from 3 to 7 days. Before appearing the warning signs of severe DENV infection, a slight
portion of the infected patients goes to life-threatening conditions.
Severe DENV infection can cause organ impairment, bleeding, and plasma leakage. The warning signs during
dengue infection include vomiting, abdominal pain, respiratory distress, clinical/fluid accumulation, lethargic
condition, mucosal bleeding, liver enlargement (>2 cm), restlessness, lethargic condition, and rapid decrease in
platelet count. An intensive care should be taken for the patients having infancy, pregnancy, chronic hemolytic
diseases, renal failure, diabetes, obesity, and old age. Chronic infections of DENV may preserve in the central
nervous system and can be considered in progressive dementia patients.

In a recent study by Suppiah et al., the link between clinical manifestation characteristic of Dengue fever and
genotypes, respectively, and DENV-specific phenotypes, was highlighted. Thus, it was found that the clinical
symptoms are more severe in patients infected with DENV 2 serotype, compared to patients infected with
DENV1 serotype. Musculoskeletal manifestations are characteristic of DENV serotype 3 infection. Also,
nonstructural proteins (e.g., NS1, NS3, and NS5) can be targeted to develop a novel vaccine strategy.

3.6. DIAGNOSIS

Unfortunately, still, the signs and symptoms are the foremost tools for the DENV infection diagnosis. Fever or
flu-like fever is the initial tool of DENV infection.

To date, the well-known tests for detecting the presence of DENV include identification of the responsible viral
genomic sequences, DENV serotype, viral antigen(s) (e.g., NS1 by MAC-ELISA assays) and/or antibodies in
response to it (e.g., IgG, IgM), and platelet counts.

Other important diagnosis includes viral RNA detection (by nucleic acid amplification tests (NAAT) or RT-PCR),
detection of dengue specific monoclonal antibodies, IgM captured ELISA, alive and/or viral isolation from
mosquito cell lines. Immune-fluorescence tests, capture ELISA, and hemagglutination assays are the commonly
used laboratory methods. Other test includes +ve tourniquet test, leukopenia, HCT concurrent with a rapid
decrease in platelet count, AST or ALT ≥ 1000 IU/L, and impaired consciousness. Some important diagnostic
approaches and methodology have been shown in Table 1.

TABLE 1
Laboratory diagnostic approaches for DENV infection detection.
Clinical sample Diagnostic approach Methodology

Virus isolation Mosquito or mosquito cell culture inoculation

Acute serum (1-5 days of DF) and Nucleic acid detection RT-PCR, real-time PCR
necropsy tissue
NS1 Ag rapid test, NS1 Ag capture ELISA,
Antigen detection
immunohistochemistry

ELISA
Paired sera
IgG or IgM seroconversion (S1
S1: acute serul from 1 to 5 days HI
to S2)
S2: convalescent serum 15-21 days
Plaque reduction neutralization test

Serum after day 5 of DF IgM detection MAC-ELISA, IgM rapid tests (lateral flow)
 Clinical sample Diagnostic approach Methodology

IgG detection IgG ELISA, HI, IgG rapid tests (lateral flow)

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Abbreviations: Ag: antigen; DF: dengue fever; ELISA: enzyme-linked immunosorbent assay; HI:
hemagglutination inhibition assay; IgG: immunoglobulin G; IgM: immunoglobulin M; MAC: immunoglobulin M
antibody capture; NS1: non-structural protein 1; RT-PCR: reverse-transcription polymerase chain reaction.

4. CONTROL OF DENV AND ITS VECTORS

Public awareness counts as one of the major consequences of the management of DENV, which essentially helps
to avoid or inhibit the contacts of the infected Aedes mosquitoes or other animals and their derivatives [103].
In this way, Ae. aegypti was properly eradicated during the 1960s from different areas of the USA. For this,
a well-educated society needs the strongest collaborative activities with skilful and well-trained mosquito
control staff.

It is possible to control DENV infection by using different interesting methods.

4.1. PREVENTIVE MEASURES

Preventive measures should be the first and best choice in this case, such as the prevention of direct contact of
blood or blood-derived products from the infected patients and infected vectors from the infected host [105].
Daytime is the most suitable time for biting Aedes mosquitoes; consequently, its contact can be diminished or
avoided using the following techniques:

i. By using nets (e.g., insecticide-treated nets) and mosquito repellents (e.g., coils, solids (sticks), aerosols,
liquids, pump sprays, and nonsticky creams)
ii. By wearing gloves and other defensive clothing
iii. Through well-planed management of wastes and stored water
iv. By destroying the mature Aedes mosquitoes or larvae through applying some protective chemicals (e.g.,
N,N-Diethyl-3-Methylbenzamide, diethyl carbonate, metofluthrin, oil of lemon-eucalyptus, diethyl
phthalate, ethyl hexanediol, and picaridin).

CYD-TDV (brand name Dengvaxia), an one and only FDA approved live-attenuated dengue vaccine prepared
by applying rDNA technology through substituting the premembrane (PrM) and envelope (E) structural proteins
of the 17D strain of attenuated yellow fever vaccine with those from the dengue serotypes excepting DENV-
5 serotype, is manufactured by Sanofi Pasteur. Other vaccines under development are DENVax/TAK-003
(recombinant chimeric vaccine with DENV-1, -3, and -4 components on the DENV-2 backbone, developed at
Mahidol University in Bangkok), TetraVax-DV (tetravalent admixture of monovalent vaccines, being tested in
Brazil and Thailand in phase II trial), TDEN PIV (inactivated tetravalent vaccine, being experimented by the
Walter Reed Army Institute of Research and GSK in phase I clinical trials), V180 (recombinant subunit vaccines
expressed in Drosophila cells, undergoing phase I trial by Merck, and DNA vaccines (the Naval Medical
Research Center attempted to develop a monovalent DNA plasmid vaccine).
4.2. THE ROLE OF NATURAL PRODUCTS AND THEIR BIOACTIVE CONSTITUENTS IN CONTROLLING DENV
INFECTION

Natural products are the potential sources of many important modern medicines. Plants and/or their extracts
having antidengue activities are also distributed worldwide. To date, a number of medicinal plants have been
reported to act against DENV and/or their vectors, for example, Alternanthera philoxeroides (Fam:
Amaranthaceae), Azidarachta indica (Fam: Meliaceae), Boesenbergia rotunda (Fam: Zingiberaceae), Carica
papaya (Fam: Caricaceae), Cladosiphon okamuranus (Fam: Chordariaceae), Cryptonemia crenulata (Fam:
Halymeniaceae) and Gymnogongrus griffithsiae (Fam: Phyllophoraceae), Cymbopogon citratus (Fam:
Poaceae), Andrographis paniculata (Fam: Acanthaceae), Momordica charantia (Fam: Cucurbitaceae), Ocimum
sanctum (Fam: Labiatae), Piper retrofractum (Fam: Piperaceae), Flagellaria indica (Fam:
Flagellariaceae), Cladogynos orientalis (Fam: Euphorbiaceae), Rhizophora apiculata (Fam: Rhizophoraceae)
and Houttuynia cordata (Fam: Saururaceae), Gymnogongrus torulosus (Fam: Phyllophoraceae), Lippia
alba and L. citriodora (Fam: Verbenaceae), Meristiella gelidium (Fam: Solieriaceae), Mimosa scabrella (Fam:
Fabaceae), Psidium guajava (Fam: Myrtaceae) and Euphorbia hirta (Fam: Euphorbiaceae) (Abd), Quercus
lusitanica (Fam: Fagaceae), Tephrosia crassifolia, Tephrosia madrensis, Leucaena leucocephala, and Tephrosia
viridiflora (Fam: Fabaceae), Uncaria tomentosa (Fam: Rubiaceae), Zostera marina (Fam: Zosteraceae), Myristica
fatua, Cymbopogon citratus and Acorus calamus, Doratoxylum apetalum, Psiloxylon mauritianum, Acorus
calamus (Fam: Acoraceae), Cinnamosma fragrans, Pedalium murex, Aesculus hippocastanum, Norantea
brasiliensis, Azadirachta indica, Spondias mombin, Angelica sinensis, Phyllanthus spp., Solanum
xanthocarpum, Mesocyclops thermocyclopoides (Mahesh), Delonix elata (Fam: Fabaceae), Acalypha
alnifolia (Fam: Euphorbiaceae), Combretum collinum, and Solanum villosum.

The aqueous extract of Houttuynia cordata (10-100 mg/mL) against DENV-2 with human hepatocarcinoma cell
lineage (HepG2) cells showed that extract significantly decreased intracellular DENV-2 RNA production with
the reduction in the expression of dengue protein. It also showed a potential role in the release of the virion
from infected LLC-MK2 cells at 10-40 mg/mL concentrations. 9 N-methylamine and Harmol may selectively
inhibit DENV-2 multiplication without virucidal effect in cell cultures.

The ethyl acetate fraction of H. cordata and quercetin showed in vitro activity against mouse hepatitis virus
(MHV) and DENV-2 with IC50 0.98 and 125 μg/mL for MHV while 7.50 and 176.76 μg/mL for DENV-2.
Delphinidin and epigallocatechin gallate showed a direct effect on against West Nile virus (WNV) and also
reduced the infectivity of ZIKV and DENV. The effect of delphinidin and, particularly of epigallocatechin
gallate, was found higher for the African strain (MR766) than for the American strain.

In another study, it was found an absence of anti-DENV activity in chemical constituents like acetyl-L-carnitine,
melatonin, α-tocopherol, and folic acid while resveratrol exhibited some limited anti-DENV activity.
Organosulfur compounds in garlic were tested against DENV-2 NGC (New Guinea C) virus U937 human
macrophage-like cells and Huh-7 human liver cells. The organosulfur compounds reduced the levels of
proinflammatory cytokines (TNF-α, IL-8 and IL-10) and affect the oxidative stress response.

The methanol extract of Rumex dentatus showed the highest antiviral efficacy by inhibiting DENV-2 replication,
with IC50 of 0.154 and 0.234 μg/mL, while gallic acid showed with IC50 of 0.191 μg/mL and 0.522 μg/mL at
45 and 90 PFU of DENV-2 infection, respectively.

Naringenin (citrus flavanone) was evaluated against dengue viruses (serotypes 1–4) in Huh7.5 cells which
impaired virus replication in human cells with IC50 = 35.81, 17.97, 117.1, and 177.5 μM, respectively. Annona
muricata aqueous leave extract was evaluated against dengue virus type 2. Selectivity index of the extract
was found more than 10 against DENV-2 which showed potential as a nature-based antiviral drug. Three
spirotetronate compounds (2EPS-A, -B, -C) isolated from Actinomadura strain showed strong DENV-2 NS2B-
NS3 protease inhibition with IC50 values of 1.94 ± 0.18, 1.47 ± 0.15, and 2.51 ± 0.21 μg/mL, respectively.
In vitro activity of essential oils of β-caryophyllene was evaluated against DENV-2. β-caryophyllene acts on
the initial steps of the viral replication cycle and showed inhibition with IC50 = 22.5 ± 5.6 μM against DENV-
2. The ethanol extract of polyherbal formulation Nilavembu kudineer showed antiviral activity against DENV-2
virus infection in Vero and human macrophage cell line (THP-1 cells) from 0.78% till 0.01% of the human dose.

The aqueous leave extract of Orthosiphon stamineus was evaluated against DENV-2. The extract exhibited the
ability to reduce DENV-2 replication in the pretreated cell while ineffective in inhibiting cell death in the
posttreated cell. Antiviral activity of natural alkaloid anisomycin was evaluated against DENV and ZIKV viruses.
The compound prevented DENV and ZIKV multiplication in human cell lines, inhibited viral protein expression,
and also impaired viral replication in the posttreated cell. In a lower dose, it also showed a significant decrease
in viremia levels in ZIKV infected AG129 mice. A natural antimicrobial agent (latarcin peptide) was evaluated
against DENV replication in infected cells. The peptide exhibited a significant inhibitory effect (IC50 = 12.68
± 3.2 μM) against the dengue protease NS2B-NS3pro at room temperature and also reduced the viral RNA
in a dose-dependent manner.

The crude extract of Rhodiola imbricata showed an antiviral immune response against the dengue virus. It
induced interferon (IFN) b and other cytokines and also upregulated MIF-2a, PKR, and NF-κB phosphorylation
in infected cells. The antiviral effect of C. longa extract showed low cytotoxicity and effective inhibitor (IC50 =
17.91 μg/mL) against DENV-2 infected Huh7it-1 cells. The hydroalcoholic extracts of leaves and bark
of Uncaria guinanensis DENV-2-infected Huh-7 cells reduced intracellular viral antigen and inhibited the
secretion of viral nonstructural protein. The chemical compound 5-hydroxy-7-methoxy-6-methylflavanone
inhibited DENV2 infectivity in LLC/MK2 (EC50 = 15.99 ± 5.38) as well as Vero cell lines (EC50 = 12.31 ±
1.64 μM) and DENV4 (EC50 = 11.70 ± 6.04 μM). Phospholipase A2, a chemical constituent of Crotalus durissus
terrificus venom, was inhibited dengue virus and yellow fever virus infection in Vero cells, inducing a partial
exposure of genomic RNA through glycerophospholipids cleavage. Tomatidine has inhibited dengue virus
mainly at late stages of infection towards all dengue virus serotypes and controlled the activating transcription
factor 4 (ATF4) expression. It showed inhibition of DENV2 (EC50 = 0.82 μM) infection mainly independent of
ATF4.

In silico analysis showed that Nimbin is found to be effective and reducing the morbidity and mortality against
the envelope protein of DENV 1-4 infection. Quinic acid derivatives were found effective against DENV1-4
and exhibited impaired dengue virus replication in infected Huh7.5 cell lines. The antiviral activity of isobutyl
gallate was evaluated against DENV. Isobutyl gallate exhibited no cytotoxic activity against Huh 7 and
possessed strong activity (IC50 = 4.45 μg/mL against DENV. Gallic acid, fisetin, quercetin, and catechin
inhibited infectious viral particles production against DENV-2 infected Vero cells. Gedunin was evaluated
against the DENV infected BHK-15 cells. Gedunin showed a significant reduction (EC50 = 10 μM). In addition,
the molecular docking study showed the strong interaction of the compound with the ATP/ADP binding site of
the host protein (Hsp90).

The study of thrombocytopenia (≤30,000/μl) in adult dengue infections, leaves of Carica papaya extract, was
enhanced platelet counts, TNFα, and IFNγ levels while it reduced IL-6 levels in patients. In another pilot study
was done in Srilanka, two doses of leaves extract at 8 h of intervals were found an increase in total WBC and
platelet count within 24 h of treatment. The 25 mL leave juice of C. papaya (two times a day for 5 days) was
found an increase in total WBC and platelet count after 2 days of drug administration in Pakistani patients.

The aqueous leave extract of C. papaya was tested against DENV-infected THP-1 cells and its role on platelet
augmentation. The leave extract was facilitated in platelet augmentation and showed antidengue activity by
a significant reduction in the envelope expression, erythrocyte damage, nonstructural (NS1) proteins, lipid
peroxidation, and intracellular viral load. In addition, thrombocytopenic rats administered with aqueous extract
exhibited increased IL-6 and thrombopoietin levels. In Indonesia, hydroalcoholic leave extract of C.
papaya was given in capsule form to the patient having a thrombocyte count of <150,000/μL along with 20%
hematocrit. The recovery of patients was found faster via speedy increase platelets levels.
The leave extract of Hippophae rhamnoides was tested in DENV-2 infected BHK-21 cells. The extract was found
potential antidengue activity by sustaining the cell viability in infected cells, decreasing TNF-α and increasing
IFN-γ levels. Aqueous extract of the Scutellaria baicalensis roots was tested against DENV 1-4 serotype-
infected Vero cells. The extract exhibited strong virus replication property (IC 50 = 74.33 to 95.83 μg/mL for
DENV 1-4 serotypes). The aqueous extract of Solanum villosum green berries showed the highest mortality
against Stegomyia aegypti. The silver nanoparticles (AgNPs) were synthesized from Holarrhena antidysenterica
bark extract which showed strong larvicidal activity (LC50 = 9.3 ppm) as compared with other organic solvents
and aqueous extract alone. The synthesized AgNPs from Gmelina asiatica leave extracts showed potent
larvicidal activity (LC50 = 22.44 μg/mL) against Anopheles stephensi larvae.

4.3. CHEMICOBIOLOGICAL DATA

Isolated compounds of medicinal plants and/or their derivatives may be one of the potential tools for the
treatment of DENV and act against the vectors, such as essential oils, polyphenols, flavonoids, alkaloids,
glycosides, and tannins.

The antiviral mechanism of natural compounds inhibiting viral entry and replication is shown in Figure 6.

Figure 6
Potential antiviral mechanism and molecular targets of the bioactive compounds inhibiting viral entry and
replication of dengue virus.
INFECTION OF VIRUS INVOLVES VARIOUS STAGES:

i. In the initial steps, DENV binds to cell receptors including mannose-binding receptor (MR) and DC-SIGN
(dendritic cell-specific ICAM3 grabbing nonintegrin) receptor present at the surface of the cell, followed
by fusion and entry
ii. Clathrin-mediated endocytosis and transport of DENV take place along with pH-dependent fusion with
endocytosis
iii. The genomic ssRNA (positive-sense) is translated hooked on a polyprotein, which is smitten into all
proteins
iv. Transcription and ribonucleic acid (RNA) replication occurs at the endoplasmic reticulum (ER) surface
v. A synthesized dsRNA genomic virus is taking place at ER. At the ER, virions bud and are passaged to
the Golgi, where DENV prM (membrane) protein is cleaved, and virion maturation takes place and is
released by exocytosis

Natural compounds inhibit several proteins involved in the transcription as well as translation machinery
essential in the DENV life cycle.

Furthermore, natural compounds block the virus replication by modulating the inflammatory redox-sensitive
pathways and host cell signaling. Details of plant-derived natural compounds and their antidengue activities
are stipulated in Table 2, and their chemical structures have been displayed in Figure 7.

Figure 7
Chemical structures of natural compounds acting against dengue.
TABLE 2
Antidengue activities of natural compounds.
Botanical name Plant’s part Isolated compounds Model Results References

DENV infection in ↓ virus replication, ↓ TNF-

Garcinia human peripheral
Fruits α-Mangostin α, ↓ IFN-γ, ↓ IL-6, ↓ MIP- [196, 197]
mangostana blood mononuclear
cells (PBMC) in vitro 1β, ↓ IP-10

DENV NS5 RNA-

Anacolosa Octadeca-9,11,13-triynoic dependent RNA
Leaves IC50 = 3 μM [198]
pervilleana acid polymerase (RdRp)
assay in vitro

DENV2-infected
Streptomyces IC50 = 1 μM ↓ viral
Fermentation Narasin hepatocytes Huh-7 [199]
aureofaciens protein synthesis
cells in vitro

DENV serotypes1-3 EC50 = 450, 174.2,

Glycyrrhizin [200]
in vitro 632.7 μg/mL
Glycyrrhiza glabra Root
DENV2 infected
Glycyrrhizic acid IC50 = 8.1 μM [201]
Vero E6 cells in vitro

Human endothelial ↓ viral infection IC50 =

Squalus acanthias Liver Squalamine [202]
cells HMEC-1 in vitro 100 μg/mL

Zastera marina. Marine DENV serotypes (1– IC50 = 24, 46, 14,
Zoasteric acid [137]
Rees eelgrass 4) in vitro 47 μmol/L
Botanical name Plant’s part Isolated compounds Model Results References

↓ DENV-2 NS2B/3
DENV-2 infected protease IC50 =
Quercus lusitanica Galls Methyl gallate [203]
C6/36 cells in vitro 0.3 mg/mL
↓NS1 protein

DENV
Flacourtia
Stem bark Flacourtosides A, E NS5 polymerase IC50 = 9.3 − 9.5 μmol/L [204]
ramontchi
RdRp in vitro

DENV-2, DENV-4
Gymnochrinus Stalked fossil
Gymnochrome B infected PS cells in ED50 = 0.029 nmol/mL [205]
richeri crinoïd
vitro

Gymnochrinus Living fossil Gymnochrome D, DENV-1 infected PS Reduction of foci was

[206]
richeri crinoid isogymnochrome D cells in vitro smaller than 1 μg/mL

Verbascoside,
Arrabidaea DENV-2 infected EC50 = 3.2, 2.8,
Leaves caffeoylcalleryanin, ursolic [207]
pulchra Vero cells in vitro 3.4 μg/mL
acid

DENV
Trigonostemon Bark and Trigocherrin A, IC50 = 12.7, 3.1,
NS5 polymerase [208]
cherrieri wood trigocherriolides A and B 16.0 μmol/L
RdRp in vitro

Micromonospora DENV-2 infected

Whole part Geneticin EC50 = 2 μg/mL [209]
rhodorangea BHK cells in vitro

DENV-2 infection of
Huh-7 and BHK-21 IC50 = 1 μM ↓ mortality
Castanospermum cells 105 PFU of in a mouse model
Seeds Castanospermine [210]
australe mouse-adapted Dose = 10, 50, and
DENV-2 in vitro/in 250 mg/kg
vivo

Coptis chinensis DENV-2 infected

Rhizomes Palmatine EC50 = 26.4 μmol/L [211]
Franch Vero cells in vitro

DENV-2 infected
Psychotria
Roots Emetine hydrochloride Huh-7, BHK-21 in IC50 = 0.5 μM [212]
Ipecacuanha
vitro

DENV-2 infected
Distictella elongate Leaves and Petcolinarin and acacetin- EC50 =
Vero, LLCMK2 cells [213, 214]
(Vahl) Urb fruits 7-O-Rutinoside 86.4 and 11.1 μg/mL
in vitro

Scutellaria DENV-2 infected

Roots Baicalein IC50 = 6.46 μg/mL [180, 215]
baicalensis Vero cells in vitro

Dengue virus
Cryptocarya
Barks Chartaceones C-F NS5 RdRp inhibition IC50 = 1.8 to 4.2 μM [216, 217]
chartacea
in vitro

Boesenbergia Panduratin A 4- DENV-2 NS2B/NS3 Ki (inhibitory constants) =

Rhizomes [123]
rotunda (L.) hydroxypanduratin B protease in vitro 21, 25 μmol/L

Glabranine 7-O-methyl- DENV-2 serotype in 70% inhibition IC50 =

Tephrosia s.p. Aerial parts [134]
glabranine vitro 25 mM
Botanical name Plant’s part Isolated compounds Model Results References

↓ virus titer IC50 =

Mimosa scabrella Mannose/galactose (1 : 1) [114, 131]
347 mg/L
DENV-1 (Hawaii
Seeds
strain) virus in vitro
Leucaena ↓ virus titer IC50 =
Mannose/galactose (1 : 4) [114, 131]
leucocephala 37 mg/L

Gymnogongrus
DL-galactan hybrids IC50 = 0.19 − 1.7 μg/mL [128]
torulosus
DENV-2 serotype
Red
infected Vero cells in
G. griffithsiae and seaweed
Sulfated G3d and C2S- vitro
Cryptonemia IC50 = 1 μg/mL [125]
3 polysaccharides
crenulata

Cladosiphon Brown DENV-2 infected

Fucoidan IC50 = 4.7 μg/mL [78, 218]
okamuranus seaweeds BHK-21 cells in vitro

DENV-2 E domain III

Nephelium
Whole plant Geraniin (rE-DIII) protein in IC50 = 1.75 μM [219, 220]
lappaceum L.
vitro

DENV-2 (NGC
Scutellaria IC50 = 13.5 ±
Radices Baicalin strain) infected Vero [221, 222]
baicalensis 0.08 μg/mL
cells in vitro

Dengue virus
(serotypes 1–4) EC50 = 14.8, 18, 11.2,
Camellia sinensis Dried leaves Epigallocatechin gallate [223]
infected Vero cells in and 13.6 μM
vitro

DENV-2
Animal
Zoanthus spp. Zoanthone A NS5 polymerase in EC50 = 19.61 ± 2.46 μM [224]
materials
vitro

Mammea Coumarin A EC50 =

Seeds [225]
americana Coumarin B 9.6 and 2.6 μg/mL
DENV-2/NG strain
in vitro
Tabernaemontana Lupeol acetate EC50 =
Seeds [225]
cymosa Voacangine 37.5 and 10.1 μg/mL

IC50 = 54.6 ± 0.9 nM

(DENV-2)
DENV serotypes (1–
Angelica keiskei Roots Brefeldin A IC50 = 61.32 ± 13.5, [226]
4) in vitro
57.9 ± 0.1, and 65.7 ±
6.3 nM (DENV − 1, 3, 4)

Uncaria DENV-1 infected

Leaves Hirsutine EC50 = 1.97 μM [227]
rhynchophylla A549 cells in vitro

DENV infected HEK-

Viola yedoensis
Aerial parts Luteolin 293 T, A549, and EC50 = 4.36 to 39.16 mM [228]
Makino
BHK-21 cells in vitro

(2 R,4 R)-1,2,4-
DENV serotypes (1– EC50 = 14.61, 10.98,
Persea americana Fruits Trihydroxyheptadec-16- [229]
4) in vitro 12.87, and 14.61 μM
yne
 Botanical name Plant’s part Isolated compounds Model Results References

DENV-2 RNA
Nephelium
Rind Geraniin synthesis in Vero cells IC50 = 1.78 μM [195]
lappaceum
in vitro

Formosan IC50 = 4.50 ±

Palythoa mutuki Peridinin [230]
zoanthid 0.46 μg/mL
DENV NS2B/NS3
protease in vitro
Ganoderma Fruiting
Ganodermanotriol IC50 = 50, 25 μM [231]
lucidum bodies

5-Hydroxy-4′-methoxy-
flavanone-7-O-ß-D- DENV-2 in HepG2 ↓ viral replication
Faramea bahiensis Leaves [232]
apiofuranosyl-(1 → 6)-β-D- cells in vitro ↓ infected cell number
glucopyranoside

↓ DENV envelope protein

Rhodiola rosea Roots Salidroside [233]
↑ RNA helicases
DENV serotype-2
infection in vitro
Swietenia
Seeds Swielimonoid B EC50 = 7.2 ± 1.33 μM [234]
macrophylla

Open in a separate window

Monocyte macrophages are thought to be the principal target cells for the DENV, the cause of dengue fever
and hemorrhagic fever. Besides Ca2+, depletion of Mg2+ is also evident during binding of DENV to monocyte
macrophages and cells of T cell and B cell lineages in in vitro studies. It has been seen that the monocyte-
derived macrophages discriminated in the presence of vitamin D3 restrict DENV infection and moderate the
classical inflammatory cytokine (e.g., TNF-α and IL-1β, -4, and -10) response, where a reduced surface
expression of C-type lectins, including the mannose receptor.

In another report, 1,25(OH)2D3 is evident to suppress the levels of IL-4 and IL-17A and modulate the levels
of IL-12p70 and IL-10 in DENV infected U937-DC-SIGN cells and THP-1 macrophages, suggesting an
immunomodulatory power that can ameliorate inflammation during dengue infections. These findings have also
complied with an earlier report. In a clinical study, patients (n = 64), received a single dose of 200,000 IU
vitamin D, was found to decrease the risk of dengue fever. A challenge test done with 10 healthy individuals
supplemented with 1000 or 4000 international units (IU)/day of vitamin D for 10 days suggested that
4000 IU/day of vitamin D represents an adequate dose to control DENV progression and replication.

5. CONCLUSIONS AND PERSPECTIVES

To date, it is not possible to recognize intricate details and the complexity of the target of DENV of the other
suitable vectors/secondary or hosts for its entrance, production, transmission, and pathogenesis. Several
preventive measures have been taken; however, still, there is a deficiency of operative treatment modalities
of DENV infections in human and pet animals. DENV-mediated imbalance of micronutrients may be one of the
effective significances of numerous pathophysiological situations, such as Ca+2 depletion for muscle pain,
irregular heartbeats, muscle weakness, fatigue, painful signs and symptoms, and deficiency of vitamin D in case
of inflammatory conditions. The deficiency of vitamin D leads to oxidative stress and the inflammatory process,
which may contribute to lowering the standard levels of platelet in patients with DENV. The internal bleeding
and fatigue of the infected patients perform the leading functions for platelet deficiency.

Taken together, the biochemical markers and immunological parameters can be considered as important
diagnostic tools in DENV infection. Besides preventive measures, the medicinal plants and their derivatives might
be alternative tools in the treatment of DENV infection. Calcium along with vitamin D supplements can be used
in DENV infection. More research are necessary regarding to the successful diagnosis, prevention, and control
of dengue worldwide.
Communicable Disease: DENGUE
Reference: World Health Organization
March 17, 2023
LINK: https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue
Article No. 3

DENGUE AND SEVERE DENGUE

KEY FACTS

Dengue is a viral infection caused by the dengue virus (DENV), transmitted to humans through the bite of
infected mosquitoes.

About half of the world's population is now at risk of dengue with an estimated 100–400 million infections
occurring each year.

Dengue is found in tropical and sub-tropical climates worldwide, mostly in urban and semi-urban areas.

While many DENV infections are asymptomatic or produce only mild illness, DENV can occasionally cause more
severe cases, and even death.

Prevention and control of dengue depend on vector control. There is no specific treatment for dengue/severe
dengue, and early detection and access to proper medical care greatly lower fatality rates of severe dengue.

Overview

Dengue (break-bone fever) is a viral infection that spreads from mosquitoes to people. It is more common in
tropical and subtropical climates. Most people who get dengue won’t have symptoms. But for those that do,
the most common symptoms are high fever, headache, body aches, nausea, and rash. Most will also get better
in 1–2 weeks. Some people develop severe dengue and need care in a hospital.

In severe cases, dengue can be fatal. You can lower your risk of dengue by avoiding mosquito bites especially
during the day. Dengue is treated with pain medicine as there is no specific treatment currently.

SYMPTOMS

Most people with dengue have mild or no symptoms and will get better in 1–2 weeks. Rarely, dengue can be
severe and lead to death. If symptoms occur, they usually begin 4–10 days after infection and last for 2–7
days. Symptoms may include:

• high fever (40°C/104°F)

• severe headache
• pain behind the eyes
• muscle and joint pains
• nausea
• vomiting
• swollen glands
• rash.
Individuals who are infected for the second time are at greater risk of severe dengue. Severe dengue symptoms
often come after the fever has gone away:

• severe abdominal pain

• persistent vomiting
• rapid breathing
• bleeding gums or nose
• fatigue
• restlessness
• blood in vomit or stool
• being very thirsty
• pale and cold skin
• feeling weak

People with these severe symptoms should get care right away. After recovery, people who have had dengue
may feel tired for several weeks.

DIAGNOSTICS AND TREATMENT

Most cases of dengue fever can be treated at home with pain medicine. Preventing mosquito bites is the best
way to avoid getting dengue. There is no specific treatment for dengue. The focus is on treating pain symptoms.

Acetaminophen (paracetamol) is often used to control pain. Non-steroidal anti-inflammatory drugs like
ibuprofen and aspirin are avoided as they can increase the risk of bleeding. There is a vaccine called
Dengvaxia for people who have had dengue at least once and live in places where the disease is common.
For people with severe dengue, hospitalization is often needed.

GLOBAL BURDEN

The incidence of dengue has grown dramatically around the world in recent decades, with cases reported to
WHO increased from 505 430 cases in 2000 to 5.2 million in 2019. A vast majority of cases are asymptomatic
or mild and self-managed, and hence the actual numbers of dengue cases are under-reported. Many cases
are also misdiagnosed as other febrile illnesses.

One modelling estimate indicates 390 million dengue virus infections per year of which 96 million manifest
clinically (2). Another study on the prevalence of dengue estimates that 3.9 billion people are at risk of infection
with dengue viruses.

The disease is now endemic in more than 100 countries in the WHO Regions of Africa, the Americas, the Eastern
Mediterranean, South-East Asia and the Western Pacific. The Americas, South-East Asia and Western Pacific
regions are the most seriously affected, with Asia representing around 70% of the global disease burden.

Dengue is spreading to new areas including Europe, and explosive outbreaks are occurring. Local transmission
was reported for the first time in France and Croatia in 2010 and imported cases were detected in 3 other
European countries.

The largest number of dengue cases ever reported globally was in 2019. All regions were affected, and
dengue transmission was recorded in Afghanistan for the first time. The American Region reported 3.1 million
cases, with more than 25 000 classifieds as severe. A high number of cases were reported in Bangladesh (101
000), Malaysia (131 000) Philippines (420 000), Vietnam (320 000) in Asia.

Dengue continues to affect Brazil, Colombia, the Cook Islands, Fiji, India, Kenya, Paraguay, Peru, the
Philippines, the Reunion Islands and Vietnam as of 2021.

TRANSMISSION

Transmission through the mosquito bite. The virus is transmitted to humans through the bites of infected female
mosquitoes, primarily the Aedes aegypti mosquito. Other species within the Aedes genus can also act as vectors,
but their contribution is secondary to Aedes aegypti.

After feeding on a DENV-infected person, the virus replicates in the mosquito midgut before disseminating to
secondary tissues, including the salivary glands. The time it takes from ingesting the virus to actual transmission
to a new host is termed the extrinsic incubation period (EIP). The EIP takes about 8–12 days when the ambient
temperature is between 25–28°C. Variations in the extrinsic incubation period are not only influenced by
ambient temperature; several factors such as the magnitude of daily temperature fluctuations, virus genotype,
and initial viral concentration can also alter the time it takes for a mosquito to transmit the virus. Once infectious,
the mosquito can transmit the virus for the rest of its life.

Human-to-mosquito transmission

Mosquitoes can become infected by people who are viremic with DENV. This can be someone who has a
symptomatic dengue infection, someone who is yet to have a symptomatic infection (they are pre-symptomatic),
but also people who show no signs of illness as well (they are asymptomatic). Human-to-mosquito transmission
can occur up to 2 days before someone shows symptoms of the illness, and up to 2 days after the fever has
resolved.

The risk of mosquito infection is positively associated with high viremia and high fever in the patient; conversely,
high levels of DENV-specific antibodies are associated with a decreased risk of mosquito infection. Most people
are viremic for about 4–5 days, but viremia can last as long as 12 days.

Maternal transmission

The primary mode of transmission of DENV between humans involves mosquito vectors. There is evidence
however, of the possibility of maternal transmission (from a pregnant mother to her baby). At the same time,
vertical transmission rates appear low, with the risk of vertical transmission seemingly linked to the timing of
the dengue infection during the pregnancy. When a mother does have a DENV infection when she is pregnant,
babies may suffer from pre-term birth, low birthweight, and fetal distress.

Other transmission modes

Rare cases of transmission via blood products, organ donation and transfusions have been recorded. Similarly,
transovarial transmission of the virus within mosquitoes have also been recorded.

Risk factors

Previous infection with DENV increases the risk of the individual developing severe dengue.

Urbanization (especially unplanned), is associated with dengue transmission through multiple social and
environmental factors: population density, human mobility, access to reliable water source, water storage
practice etc.
Community’s risks to dengue also depend on population’s knowledge, attitude and practice towards dengue,
as well as the implementation of routine sustainable vector control activities in the community.

Consequently, disease risks may change and shift with climate change in tropical and subtropical areas, and
vectors might adapt to new environment and climate.

Prevention and control

The mosquitoes that spread dengue are active during the day.

• Lower the risk of getting dengue by protecting yourself from mosquito bites by using:
• clothes that cover as much of your body as possible
• mosquito nets if sleeping during the day, ideally nets sprayed with insect repellent
• window screens
• mosquito repellents (containing DEET, Picaridin or IR3535)
• coils and vaporizers

If you get dengue, it’s important to:

• rest
• drink plenty of liquids
• use acetaminophen (paracetamol) for pain
• avoid non-steroidal anti-inflammatory drugs, like ibuprofen and aspirin
• watch for severe symptoms and contact your doctor as soon as possible if you notice any

So far one vaccine (Dengvaxia) has been approved and licensed in some countries. However, only persons
with evidence of past dengue infection can be protected by this vaccine. Several additional dengue vaccine
candidates are under evaluation.

WHO response

WHO responds to dengue in the following ways:

• supports countries in the confirmation of outbreaks through its collaborating network of laboratories;
• provides technical support and guidance to countries for the effective management of dengue
outbreaks;
• supports countries in improving their reporting systems and capture the true burden of the disease;
• provides training on clinical management, diagnosis and vector control at the country and regional level
with some of its collaborating centres;
• formulates evidence-based strategies and policies;
• support countries in the development of dengue prevention and control strategies and adopting the
Global Vector Control Response (2017–2030)
• reviews and recommend the development of new tools, including insecticide products and application
technologies;
• gathers official records of dengue and severe dengue from over 100 Member States; and
• publishes guidelines and handbooks for surveillance, case management, diagnosis, dengue prevention
and control for Member States.
References:

1. Bhatt, S., et al., The global distribution and burden of dengue. Nature, 2013. 496(7446): p. 504–507.

2. Brady, O.J., et al., Refining the global spatial limits of dengue virus transmission by evidence-based
consensus. PLOS Neglected Tropical Diseases, 2012. 6(8): p. e1760.
Communicable Disease: DENGUE

Reference: Department of Education

LINK: https://doh.gov.ph/list-of-diseases/dengue/

Article No. 4

DENGUE

About Dengue

Dengue fever is a mosquito-borne viral infection that is endemic to the Philippines. It affects people of all ages.
Its severe form, dengue hemorrhagic fever, involves heavy bleeding and can be fatal.

Dengue has four strains, which means a person can be infected as many as four times in a lifetime. Each
succeeding infection increases the chance of developing hemorrhagic fever.

Causes

Transmitted by the mosquitoes Aedes aegypti and Aedes albopictus, which commonly bite during the day, but
may also bite at night. These mosquitoes lay eggs in clear and stagnant water (e.g., water in flower vases,
clean rainwater collected in barrels, cans, or old rubber tires). Adult mosquitoes rest in dark places of the house.
Mosquitoes can also become infected with the virus when they bite a person who has already been infected
and can thus spread the infection to other people.

Signs and Symptoms

• Sudden onset of high fever which may last from 2 to 7 days;

• Joint and muscle pain, pain behind the eyes, and/or headache;
• Feeling weak;
• Skin rashes;
• Nausea and vomiting, decreased appetite;
• Bleeding during hemorrhagic fever, which can manifest as nosebleeding, gum bleeding, vomiting of coffee-
colored matter, dark-colored stools, or even just abdominal pain (as a sign of internal bleeding).

Management (Diagnostic, Treatment, Other Care)

• Anyone with a fever lasting 2 or more days, especially fever that resolves momentarily but keeps returning,
with or without any of the symptoms mentioned, should be brought to the nearest hospital.

• Adequate bed rest and fluid intake is required, but a patient should be assessed by a doctor first to determine
the proper ways of rehydration.

• Paracetamol to control fever is advised.

WHAT YOU CAN DO (PREVENTION AND CONTROL)

Follow the 4-S against Dengue:

1. Search and Destroy Mosquito Habitats

• Cover water drums and pails to prevent water from accumulating in them.

• Replace water in flower vases at least once a week.

• Clean gutters from leaves and debris to prevent water from becoming stagnant.

• Collect and dispose all unusable tin cans, jars, bottles, and other items that can collect and hold water.

2. Self-Protect

• Wear long pants and long-sleeved tops.

• Use mosquito repellant regularly.

3. Seek Early Consultation

• Consult a physician immediately if fever persists or keeps recurring after 2 days, and/or any of the other
symptoms appear.

4. Say Yes to Fogging

• Only when there is an impending outbreak or a hotspot.

“Stay safe and stay healthy.”