PREVALENCE OF DENGUE VIRAL INFECTIONS AMONG FEBRILE PATIENTS

IN MOMBASA COUNTY, KENYA

OMUYUNDO K. MULATI (B.SC MLS)

A Thesis Submitted in Partial Fulfillment of the Requirements for the Award of Master
of Science Degree in Infectious Diseases in the School of Medicine of
Kenyatta University

June, 2014
 i

DECLARATION
This thesis is my original work and has not been presented for a degree or other awards in any
other University.

Signature: _______________________________________ Date: ________________________

Omuyundo K. Mulati

P150/20960/2010

This thesis has been submitted for review with our approval as the University supervisors.

Signature : __________________________________ Date: _____________________________

Dr. Gicheru. M. M

Department of Zoological Sciences, Kenyatta University

Signature : ________________________________ Date: _______________________________

Dr. Marion Burugu

Department of Biochemistry and Biotechnology, Kenyatta University

Signature: ___________________________________ Date: ____________________________

Prof. Matilu Mwau

Department of Medical Microbiology, Jomo Kenyatta University of Agriculture and

Technology
 ii

DEDICATION

I dedicate this thesis to my parents, Mr. Sibabi Nyukuri and Mrs. Dinnah Nekesa. The person I

am today is a direct result of my parent’s unconditional love. Their support and advice have

always been part of my decision process and I am a better man for it. With all of my heartfelt

sentiment, I wish them many years of happiness.

 iii

ACKNOWLEDGEMENTS

My sincerest thanks go to Prof. Matilu Mwau for offering me the opportunity to pursue my

Master’s degree research at the Kenya Medical Research Institute (KEMRI).

I would like to acknowledge my supervisors Dr. Gicheru MM, Dr. Burugu M and Prof. Mwau M

for guiding me in my thesis writing, and Mr. Muuo NS the co-referee for the discussions and

suggestions that improved this thesis.

My deepest thanks go to Dr. Shingo Inoue for overseeing my daily activities at KEMRI

production department (PD) and for his mentoring, support and encouragement throughout my

research work, and his commitment to improve my science.

I would like to extent my gratitude to dynamic colleagues at KEMRI PD namely Missiani O,

Kwallah A, and Salame A for their guidance and support at various junctures of my work.

I would also like to record my gratitude to Dr. Kimotho JH and Mr. Kaiguri P for accepting me

as a post graduate student at KEMRI PD Laboratories.

Finally and most importantly, I thank my father Mr. Sibabi Nyukuri and other family members

for continued support that greatly assisted in the completion of this thesis.

God bless you.

 iv

TABLE OF CONTENTS
Page
DECLARATION............................................................................................................................ i
DEDICATION............................................................................................................................... ii
TABLE OF CONTENTS ............................................................................................................ iv
LIST OF TABLES…………………………………………………………………………………………………………………………….vii
LIST OF FIGURES ................................................................................................................... viii
ABBREVIATIONS AND ACRONYMS ..................................................................................... x
ABSTRACT .................................................................................................................................. xi
CHAPTER ONE: INTRODUCTION ......................................................................................... 1
1.1 Background ............................................................................................................................... 1
1.2 Problem Statement .................................................................................................................... 2
1.3 Justification of the Study .......................................................................................................... 3
1.4 Significance of Study ................................................................................................................ 4
1.5 Research Questions ................................................................................................................... 4
1.6 Null Hypothesis ........................................................................................................................ 5
1.7 General Objective ..................................................................................................................... 5
1.8 Specific Objectives ................................................................................................................... 5
CHAPTER TWO: LITERATURE REVIEW ............................................................................ 6
2.1 Dengue Viral Infection ............................................................................................................. 6
2.2 Clinical Manifestations ............................................................................................................. 6
2.2.1 Dengue Fever ..................................................................................................................... 7
2.2.2 Dengue Hemorrhagic Fever ............................................................................................... 8
2.2.3 Dengue Shock Syndrome ................................................................................................. 10
2.3 Dengue Case Classification .................................................................................................... 10
2.3.1 Dengue Case Classification .............................................................................................. 10
2.3.2 Revised Dengue Case Classification ................................................................................ 12
2.4 Transmission of Dengue Virus Infection ................................................................................ 14
2.4.1 Mosquito Vectors ............................................................................................................. 14
2.4.2 Dengue Virus Transmission Cycles ................................................................................. 16
2.5 Factors Influencing DENV Transmission ............................................................................... 17
2.6 Global Geographical Distribution ........................................................................................... 18
2.7 Impact of Dengue Virus infections ......................................................................................... 21
 v

2.7.1 Public Health Impact ........................................................................................................ 21

2.7.2 Social Impact .................................................................................................................... 21
2.7.3 Economic Impact.............................................................................................................. 21
2.8 Dengue Virus .......................................................................................................................... 22
2.9 Pathogenesis Mechanisms of DENV ...................................................................................... 24
2.10 Laboratory diagnosis of Dengue Virus infection .................................................................. 30
2.12 Dengue Vaccine and Drug Development ............................................................................. 36
2.13 Methods of Vector Control ................................................................................................... 39
2.13.1 Environmental Management .......................................................................................... 39
2.13.2 Chemical Control ........................................................................................................... 39
2.13.3 Personal Protection ......................................................................................................... 40
2.13.4 Biological Control .......................................................................................................... 40
2.13.5 Integrated Control .......................................................................................................... 40
CHAPTER THREE: MATERIALS AND METHODS .......................................................... 41
3.1 Study Site ................................................................................................................................ 41
3.2 Study Design ........................................................................................................................... 42
3.3 Variables ................................................................................................................................. 42
3.4 Study Population ..................................................................................................................... 42
3.5 Sample Size............................................................................................................................. 43
3.6 Study Procedure ...................................................................................................................... 44
3.6.1 Recruitment of Patients .................................................................................................... 44
3.6.2 Clinical and Demographic Data Collection ..................................................................... 44
3.6.3 Blood Sample Collection Procedure ................................................................................ 44
3.6.4 Sample Handling, Transport and Storage ........................................................................ 44
3.7 Laboratory Procedures ............................................................................................................ 45
3.7.1 Cell Lines and Virus Strains ............................................................................................ 45
3.7.2 Antigen Production .......................................................................................................... 45
3.7.2.1 Propagation and Harvesting of the Virus .................................................................. 45
3.7.2.2 Virus Concentration Using Jumbosep™ Centrifugal Devices .................................. 46
3.7.3 Sandwich ELISA to Assay Dengue Antigen Titer ........................................................... 47
3.7.4 Preparation of Dengue Tetravalent Antigen..................................................................... 48
 vi

3.7.5 Dengue IgM-capture ELISA ............................................................................................ 48

3.7.6 Flavivirus Indirect IgG ELISA ......................................................................................... 49
3.9 Serological Definitions of DENV Infection ........................................................................... 49
3.10 Data Storage and Analysis .................................................................................................... 50
3.11 Ethical Consideration ............................................................................................................ 50
CHAPTER FOUR: RESULTS .................................................................................................. 51
4.1 Prevalence of Dengue Infection Cases among Febrile Patients.............................................. 51
4.2 Distribution of Dengue Positive Cases by Age....................................................................... 51
4.3 Proportion of Primary verses Secondary Dengue Cases …………………………………….53
4.4 Correlation of IgM with IgG Titer among Dengue Positive Patients ..................................... 53
4.5 Distribution of Dengue Positive Cases by Gender ................................................................. 57
CHAPTER FIVE: DISCUSSION.............................................................................................. 62
5.1 Prevalence of Dengue Viral Infection …………………………………………….…………62
5.2 Distribution of Dengue Viral Infections by Age..................................................................... 62
5.3 Distribution of Dengue Viral Infections by Gender ............................................................... 65
5.4 Distribution of Dengue Viral Infections by Month................................................................. 66
5.5 Limitations of the Study.......................................................................................................... 67
CHAPTER SIX: SUMMARY, CONCLUSION AND RECOMMENDATION ................... 68
6.1 Summary ................................................................................................................................. 68
6.2 Conclusion .............................................................................................................................. 68
6.3 Recommendations ................................................................................................................... 69
6.4 Further Research ..................................................................................................................... 69
REFERENCES ............................................................................................................................ 70
APPENDICES ............................................................................................................................. 80
Appendix A: Informed Consent Form ...................................................................................... 80
Appendix B: Clinical Investigation Questionnaire of Febrile Illnesses .................................... 82
Appendix C: KEMRI Ethical Review Clearance ...................................................................... 83

LIST OF TABLES

Page
 vii

Table 2.1: Countries in Africa with evidence of DENV transmission ………………….......... 20

Table 2.2: Existing hypotheses to explain DENV pathogenesis ………………..……………. 26

Table 4.1: Prevalence of Dengue Virus Infection among Febrile Patients…………………… 52

Table 4.2: Geometric mean titer (GMT) of anti-flavivirus IgG among febrile patients …… 55

Table 4.3: Distribution of primary dengue cases by age group and gender ………...…........... 59

Table 4.4: Distribution of secondary dengue cases by age and gender ………………............ 60
 viii

LIST OF FIGURES

Page

Figure 2.1: Clinical Manifestations of DENV infection …………………………………..…. 7

Figure 2.2: Phases of infection resulting in dengue haemmorhagic fever …………………… 9

Figure 2.3: Grades of DHF ……………………………………………………………........... 11

Figure 2.4: Criteria for dengue and severe dengue …………………………………….......... 13

Figure 2.5: Mosquito vectors for dengue virus transmission …………………………......... 14

Figure 2.6: Life cycle of Aedes mosquito ………………………………………………......... 15

Figure 2.7: Transmission cycle of DENV ……………………………………………………. 16

Figure 2.8: Countries or areas with active dengue transmission and principal vector
Ae. Aegypti …………………………………………………………………….... 19

Figure 2.9: Dengue virus ……………………………………………………………………... 23

Figure 2.10: Gene organisation in the dengue virus RNA genome and membrane topology
and proteolytic cleavage sites of the transcribed polyprotein …………………… 24

Figure 2.11: Host responses to cutaneous dengue virus injection ………………………….. 25

Figure 2.12: Model for antibody-dependent enhancement (ADE) of dengue virus

replication …………………………………………………………………........ 27

Figure 2.13: Model of T cell mediated immunopathogenesis in DHF leading to plasma

leakage …………………………………………………………………………. 29

Figure 2.14: Diagnostic markers of primary infection in a patient serum ………………….. 31

Figure 2.15: Haemagglutination inhibition test ……………………………………………… 33

Figure 2.16: IgM-capture ELISA ……………………………………………………….......... 34

Figure 2.17: Indirect IgG-ELISA ……………………………………………………….......... 35

Figure 2.12: Schematic of the different dengue vaccines currently developed ……………… 38

Figure 3.1: Jumbosep device components …………………………………………………… 46

 ix

Figure 4.1: Primary verses secondary DENV infection ……………………………….......... 53

Figure 4.2: Correlation of the anti-DENV IgM and anti-flavi IgG levels
among dengue cases ……………………………..…………………………… 54

Figure 4.3 (A): Distribution of anti-flavi IgG ELISA titers among 390 febrile patients ……. 56

Figure 4.3(B): Distribution of anti-flavi IgG ELISA titers among 54 dengue

infection cases ………………………………………………………………... 57

Figure 4.4: Distribution of DENV infections by age and gender ………………………........ 58

Figure 4.5:Correlation between monthly DENV infection and environmental

Conditions ……………………………………………………………………….. 61
 x

ABBREVIATIONS AND ACRONYMS

CPGH Coast Provincial General Hospital

DENV Dengue Virus

DF Dengue Fever

DHF Dengue Hemorrhagic Fever

DSS Dengue Shock Syndrome

ELISA Enzyme Linked Immunosorbent Assay

Flavi Flavivirus

GMT Geometric Mean Titer

ICTV International Committee on Taxonomy of Viruses

IgG Immunoglobulin G

IgM Immunoglobulin M

JEV Japanese Encephalitis Virus

KEMRI PD Kenya Medical Research Institute Production Department

rpm revolutions per minute

UTR Untranslated Regions

WHO World Health Orgarnization

 xi

ABSTRACT
Dengue virus infection is one of the major global public health problems. It is caused by one of
the four dengue virus (DENV) serotypes that are transmitted by Aedes mosquitoes. Following
infection, an individual remains vulnerable to re-infection with a different serotype of the
DENV. The infection usually occurs with clinical manifestations ranging from an asymptomatic
or mild febrile illness as classical dengue fever to the potentially life-threatening illness, dengue
hemorrhagic fever and dengue shock syndrome. Despite the public health relevance, prevalence
of DENV infections among febrile patients in Mombasa County is unknown. This study was
conducted from February 2012 to July 2012 among patients visiting Coast Province General
Hospital with high fever. The study was aimed at determining the prevalence of DENV infection
among febrile patients and describe the month-wise trend of the disease. A total of 390 blood
serum samples were collected and DENV specific IgM and flavivirus IgG antibodies were
determined by in-house enzyme linked immunosorbent assay (ELISA). Out of 390 febrile cases,
54 (13.9%) were found to be positive for anti-DENV IgM. Among the 54 dengue positive cases,
37 (68.5 %) were primary DENV infection and 17 (31.5%) were secondary DENV infection.
The most affected age group was 36-45 years (20.4%) and least affected group being 6-15years
(8.3%). Prevalence in difference age groups was statistically significant (p = 0.021). Primary
DENV infection was common among the age group between 36-45 years while secondary
dengue affected mostly the age group 26-35 years. In terms of primary DENV infection against
secondary DENV infection, it was observed that infants (<1 year) were the most affected but this
was not statistically significant (p = 0.057). The relationship between gender and DENV
infections was not statistically significant (p = 0.936). Although, females aged between 26-35
years (p = 0.010) and males aged above 46 years (p = 0.012) were the most affected with DENV
infection. Month-wise distribution of DENV infection was observed in February (20.0%) with
least occurrence in July (4.7%). The association between the month and occurrence of disease
was not statistically significant (p = 0.325). The present study has reported 13.9% prevalence of
Dengue virus infections as the cause of acute undifferentiated fever among febrile patients in
Mombasa County. Thus, calls for government attention to develop resources at hospital
laboratories for early dengue diagnosis and management of patients, coupled with general
awareness among the public and constant vigilance by the health care officials could help in
combating dengue.
 1

CHAPTER ONE: INTRODUCTION

1.1 Background

Dengue virus (DENV) infection is one of the mosquito-borne viral diseases with a major

impact on public health, globally (Guzman et al., 2010). World Health Organization (WHO)

data suggest that at least 100 countries are endemic of Dengue virus transmission. About 3.5

billion people, 55% of the world’s population living in tropical and subtropical regions are at

risk, with about 50 million DENV infections occurring annually and approximately 500,000

requiring hospitalization annually (WHO, 2009). The average case fatality rate is around 5%,

and mainly among children and young adults (Beatty et al., 2007).

Dengue virus is a positive-sense, single-stranded RNA enveloped virus that comprises of four

serotypes (DENV 1, 2, 3 and 4) that belong to family Flaviviridae and genus Flavivirus

(ICTVdB, 2006). All four serotypes of DENV are serologically related, but antigenically

distinct (Zanotto et al., 1996). They produce a spectrum of clinical illnesses ranging from a

classical dengue fever (DF) to severe and potentially fatal complications known as dengue

hemorrhagic fever (DHF) and dengue shock syndrome (DSS) (WHO, 2009). Dengue fever is

marked by a sudden onset of high fever, severe headache and retro-ocular pain and myalgia.

The symptoms and signs may be very similar to other viral infections. The distinctive

characteristics of DHF and DSS consist of hemorrhagic manifestations, plasma leakage, and

profound shock. Antibody dependent enhancement (ADE) of viral replication is considered

as a major reason for severity of DHF and DSS (Halstead, 2002). However, other factors also

might be associated with DHF, such as DENV genotype polymorphisms in human leukocyte

antigen (HLA) and other host genes (i.e. transporter associated with antigen processing

(TAP) and human platelet antigen (HPA) (Vaughn et al., 2000; Soundravally and Hoti, 2007;

Stephens, 2010).
 2

Peak DENV infection occurs after period of increased rainfall due to increased multiplication

of the mosquito vector, Aedes aegypti (Ae. aegypti) (El-Badry and Al-Ali, 2010). Aedes

mosquitoes shelter indoors and bite during the daytime. They are adapted to breed around

human dwellings, in water containers, vases, cans, tires, and other discarded objects (El-

Badry and Al-Ali, 2010). Ae. albopictus is also the vector for DENV which contributes

significantly to transmission in Asia and whose presence is spreading in Latin American

countries (Roiz et al., 2008). Dengue outbreaks have also been attributed to Ae. polynesiensis

and Ae. scutellaris, but to a lesser extent (Rodhain and Rosen, 1997). Early diagnosis of

DENV infection is important for proper treatment of DHF and DSS to avoid fatal outcome.

Currently, several dengue vaccine candidates are in an advanced stage of development

(Morrison et al., 2010). For example, Sanofi Pasteur’s ChimeriVax-DENV vaccine has

recently entered phase 3 clinical testing (Guy et al., 2010; Coller and Clements, 2011).

1.2 Problem Statement

Dengue virus infection is a complex disease with symptoms being difficult to distinguish

from other common febrile illnesses during acute phase and can progress from a mild, non-

specific viral disease to severe cases characterized by thrombocytopenia, hemorrhage

manifestations and hemo-concentration due to plasma leakages. Majority of febrile illnesses

in Mombasa County are treated as presumptive malaria, often without proper medical

examination and a laboratory diagnosis. Therefore, many patients with fever are designated

as having fever of unknown origin or malaria and remain without a laboratory diagnosis even

if they fail to respond to antimalarial drugs. This situation is generally due to lack of

affordable diagnostic reagents. The scenario indicates that many cases of DENV infections

are undiagnosed or even misdiagnosed.

 3

Additionally, presence of dengue vector Aedes aegypti in the coastal region of Kenya as

reported by Mwangangi et al., (2012). Individual exposure differences to dengue infective

bites may be related to prevalence with specific demographic factors such as age and gender

that have not been reported among febrile patients in the County of Mombasa.

1.3 Justification of the Study

Dengue virus serotypes 1, 2, and 3 have been identified and invariably caused outbreaks in

eastern Africa region (Amarasinghe et al., 2011). These outbreak reports highlighted the

vulnerability of the Mombasa County to DENV transmission and their capacity for rapid

expansion across the entire coastal region. Since, Mombasa County shares similar conditions

as those of the neighboring countries or islands in eastern Africa region that favor the dengue

transmission. These include environmental conditions that favor mosquito proliferation and

interaction with humans, such as warm climate, high rainfall, and overcrowding. Other

factors that may facilitate dengue transmission are presence of principle vector Aedes aegypti

in the coastal region, inadequate and deteriorating public health infrastructure, and lack of

effective mosquito control (Mwangangi et al., 2012).

Additionally, outbreak of classical dengue fever was reported in the coastal towns of Malindi

and Kilifi in 1982, with subsequent isolates of DENV-2 made from Mombasa and Diani

showing a wide distribution of DENV infection along the Kenyan coast (Johnson et al., 1982;

Sang and Dunster, 2001). Since then sporadic cases of DENV infections have been ignored

indicating potential endemicity of the dengue infection in the general population of county.

This was a significant public health problem because of the clinical oversight and lack of

appropriate laboratory diagnostic reagents. Implying that there was a potential risk for dengue

cases as multiple serotypes could be circulating among the human population in the study
 4

region putting them at risk of immune mediated DSS when previously infected persons

become re-infected with a heterologous serotype (Gubler et al., 2002).

However, gender disparities affect the county of Mombasa with females main work

being domestic. Hence, presence of a highly domesticated dengue vector Aedes aegypti, the

females and pre-school children are at a higher risk of dengue infection as they spend most of

their time at home. Therefore, it was important to understand the local prevalence of dengue

infection in the county of Mombasa.

1.4 Significance of Study

Exposure to the dengue virus generally occurs in the infantile to juvenile period among

residents in dengue endemic areas, and the prevalence of DENV infection increases with age

and reaches its peak before adolescence. Collecting information on the prevalence among

persons with febrile illness would be an initial step in determining the extent of dengue

infections. This will help the physicians to consider possibility of dengue cases when

handling febrile patients, thereby proper management of the dengue patient to avoid fatal

complications. Dengue prevalence is usually attributed to gender related differences in

exposures, as gender roles and exposures change over the human lifespan. Examining both

age and gender will provide prevalence of dengue stratified data that will help on targeting

specific preventive measures. Additionally, the study findings will deliver effective

communication and coordination to the government and non-governmental partners, and the

community to implement policy on adequate infection prevention practices and improve

vector control programmes to reduce the dengue burden in the County.

1.5 Research Questions

i) What is the prevalence of DENV infections among febrile patients in Mombasa

County?
 5

ii) What age and gender is most affected by DENV infections among febrile patients in

Mombasa County?

iii) What is the proportion of primary and secondary DENV infection among febrile

patients in Mombasa County?

iv) Which month has the highest prevalence of dengue cases in Mombasa County?

1.6 Null Hypothesis

Dengue virus infection is not a health problem among febrile patients in Mombasa County.

1.7 General Objective

To determine the prevalence of DENV infection among febrile patients in Mombasa County.

1.8 Specific Objectives

i) To determine the prevalence of DENV infection by age and gender of among febrile

patients in Mombasa County.

ii) To determine the proportion of primary and secondary DENV infection among febrile

patients in Mombasa County.

iii) To determine the month-wise distribution of DENV infection among febrile patients

in Mombasa County.
 6

CHAPTER TWO: LITERATURE REVIEW

2.1 Dengue Viral Infection

Dengue virus (DENV) infection is an acute febrile illness, which occurs after an incubation

of 4-10 days. Infection parity is known to be a critical factor of disease severity. Primary

DENV infection with any of the four DENV serotypes is believed to elicit lifelong immunity

against that serotype, but confers partial or transient immunity against other serotypes. Cross-

reactive, but sub-neutralizing DENV-reactive IgG acquired by a previous heterotypic

serotype infection may enhance DENV infectivity which may result in higher viral burden

and contribute to induced disease severity. Heterologous secondary DENV infections have

been associated with large, clinical outbreaks of Dengue hemorrhagic fever or Dengue shock

syndrome (DHF/DSS), where severe dengue occurs most frequently in children (WHO,

1997).

2.2 Clinical Manifestations

Most DENV infections are asymptomatic, but may result in a wide spectrum of disease that

differs in severity from mild undifferentiated fever, the classical DF (Guha-Sapir and

Schimmer, 2005), to the potentially fatal complications known as DHF and DSS (Figure 2.1).

Clinical presentation in both children and adults may vary in severity depending on the

immune status, age and the genetic background of the patient (WHO, 2009).
 7

Figure 2.1 Clinical Manifestations of DENV infection (WHO, 2009)

2.2.1 Dengue Fever

Most patients display mild fever or remain asymptomatic. However, symptomatic infection

presents as classic dengue fever (DF) with an incubation period of 4 to 10 days. The clinical

features of DF frequently depend on the age of the patient (Hammond et al., 2005). Children

are often asymptomatically infected with DENV but may demonstrate several clinical

syndromes. Infants and young children most often present with an undifferentiated febrile

illness accompanied by a maculopapular rash seen on the trunk and inside of the arms

(George and Lum, 1997). Older children and adults typically present with classic DF

characterized by an acute sudden onset saddleback fever, severe headache, nausea and

vomiting, myalgia, retro-orbital pain, an early maculopapular rash, low grade

thrombocytopenia and hepatomegaly (Henchal and Putnak, 1990). Patients with DF recover
 8

in two to seven days and suffer no short- or long-term sequelae of illness. The virus disappear

from bloodstream at approximately the same time that the fever dissipates (Rothman, 1999).

2.2.2 Dengue Hemorrhagic Fever

Dengue Hemorrhagic Fever (DHF) usually follows a secondary dengue infection. In infants,

it may follow a primary infection due to maternally acquired dengue antibodies (Halstead et

al., 2002). The clinical course of DHF is divided into three phases, namely, febrile, critical,

and convalescent phases (Figure 2.2). The febrile phase begins with sudden onset of fever

accompanied by generalized constitutional symptoms and facial flush. The fever is high

grade (usually >38.5°C), intermittent, and associated with rigors. The fever lasts for 2-7 days

and then falls to normal when the patient either recovers or progresses to the plasma leakage

phase (CDC, 2012a; Srikiatkhachorn et al., 2007).

Some patients remain ill despite normalization of temperature and therefore progresses to

DHF. Onset of plasma leakage is characterized by tachycardia and hypotension. The patient

sweats, becomes restless, and has c extremities. In less severe cases, the changes are minimal

and transient, reflecting a mild degree of plasma leakage. Most patients recover from this

stage spontaneously or after a short period of fluid and electrolyte replacement. In severe

cases with high plasma leakage, patients may develop full-blown circulatory shock

characterized by prolonged capillary refill time and narrow pulse pressures (WHO, 2009).
 9

Figure 2.2 Phases of infection resulting in DHF (CDC, 2012a)

During the phase of plasma leakage, pleural effusions and ascites are common. Pericardial

effusions may also be seen. Myocarditis is associated with increased morbidity and mortality.

Fever and hemo-concentration due to plasma leakage is most commonly observed before the

subsidence of fever and the onset of shock (Kalayanarooj et al., 2002).

 10

2.2.3 Dengue Shock Syndrome

Dengue shock syndrome (DSS) is associated with almost 50% mortality. After a certain level

of plasma leakage, the compensatory mechanisms become insufficient and blood pressure

drops rapidly. Pulse pressure drops below 20 mmHg and symptoms of hypovolemic shock

develop; sudden collapse, cool clammy skin, rapid weak pulse, circumoral, easy bruising and

bleeding (hematemesis, melena, epistaxis), and myocarditis. Warning signs include severe

abdominal pain, vomiting, irritability and somnolence, fall in body temperature and severe

thrombocytopenia (Gibbons and Vaughn, 2002). Patients die from multi-organ failure and

disseminated intravascular coagulation. Most patients remain fully conscious to the terminal

stage. The duration of shock is short and the patient rapidly recovers with appropriate

supportive therapy. DSS may be accompanied by encephalopathy caused by metabolic and

electrolyte disturbances (Gurugama et al., 2010).

2.3 Dengue Case Classification

2.3.1 Dengue Case Classification

World Health Organisation devised a formal classification scheme that defined dengue as

either asymptomatic, DF or DHF/DSS. The DHF category is further classified based on the

degree of haemorrhagic manifestations and plasma into four grades of severity (Figure 2.3).
 11

Figure 2.3 Grades of DHF (WHO, 1997)

Dengue Hemorrhagic Fever (DHF) grades III and IV can lead to DSS and total fatal outcome.

DHF grade I is characterized by a severe fever with non-specific constitutional symptoms.

The only required manifestation of hemorrhage is a positive tourniquet test. A patient is

diagnosed as DHF grade II if they exhibit spontaneous bleeding in addition to a positive

tourniquet test or easy bruising such as melena and hematemesis, epistaxis, gingival bleeding,

gastro intestinal bleeding, hematuria and menorrhagia. Patients receive the more serious

diagnosis as DHF grade III and IV if they exhibit signs of circulatory failure and massive

bleeding. DSS is sometimes observed among DHF grade III and IV if they exhibit profound
 12

shock characterized by an undetectable blood pressure or pulse. However, in the absence of

rash and thrombocytopenia signs of hemo-concentration and vascular permeability, these

patients were not to be diagnosed with DHF. Instead, they were assigned the diagnosis of DF

with hemorrhage (WHO, 1997).

Many physicians treating dengue patients criticized the WHO 1997 diagnostic criteria

because of its rigidity and difficulties of application in clinical practice (Deen et al., 2006). In

a number of retrospective chart studies, the sensitivity of the WHO 1997 diagnostic criteria

approached only 80%, suggesting that a vast number of DHF/DSS cases are under-diagnosed

and under-reported (Rigau-Perez, 2006). Firstly, there were many case reports of patients

with severe dengue with shock who did not fulfill all the 4 grades of DHF (Figure 2.3). These

patients would be classified as dengue fever, if the WHO criteria were to be strictly applied.

Secondly, patients with severe organ impairment such as liver, respiratory, cardiac and brain

dysfunction were not captured as having severe disease based on the previous classification.

Lastly, the requirement of 20% increase in hematocrit (HCT) as one of the evidence of

plasma leakage was difficult to fulfill since the baseline HCT was not available in most

patients and therefore, the interpretation of plasma leak was only retrospectively and early

fluid administration could affect the level of HCT.

2.3.2 Revised Dengue Case Classification

In 2006, WHO Dengue Scientific Working Group recommended additional research into

dengue diagnostics and triaging of patients for optimized clinical management. Further

studies on the use of clinical guidelines for dengue diagnosis, including the Dengue Control

(DENCO) study, led to the re-classification of dengue according to levels of severity as

having dengue without warning signs, dengue with warning signs, and severe dengue based

on clinical manifestations with or without laboratory parameters (Figure 2.4). Patients who
 13

recover following defervescence are considered to have non-severe dengue, but those who

deteriorate tend to manifest warning signs. However, further deterioration is classified as

severe dengue, though recovery is possible if appropriate and timely treatment is given

(WHO, 2009).

Figure 2.4. Criteria for dengue and severe dengue. Dengue fever cases can be classified as
probable dengue or dengue with warning signs. The presence of warning signs indicates that
the patients will require strict observation and medical intervention as these patients are likely
to develop into severe dengue cases. Those without warning signs may, however, also
develop into severe dengue cases. Severe dengue cases are characterized by severe plasma
leakage, severe bleeding or severe organ impairment (WHO, 2009).
 14

2.4 Transmission of Dengue Virus Infection

2.4.1 Mosquito Vectors

All the known vectors of DENV are mosquitoes belonging to genus Aedes (Ae.), subgenus

Stegomyia (Figure 2.5). The species involved in transmission include Ae. aegypti usually in

an urban environment and globally exists in tropical area. However, Ae. albopictus is present

in Asia and the pacific. Ae. polynesiensis only exists in the Pacific (Rodhain and Rosen,

1997).

Figure 2.5 Mosquito vectors for DENV transmission (Rodhain and Rosen, 1997)

The life cycle of a mosquito consists of four separate stages: egg, larva, pupa and adult

(Figure 2.6), the first three stages requiring an aqueous environment. The duration of the

developmental stages depend on the environment’s temperature, water and availability of

food at the larval stage. For Ae. aegypti, it takes 8-10 days at room temperature (Gubler,

1997). Adult male mosquito feed on flower nectar and juices of fruits for flight energy. The

female requires a blood meal for egg development. Human blood is preferred and the ankle

area is a favoured feeding site (Monath, 1994).

 15

Figure 2.6 Life cycle of Aedes mosquito (Wongkoon et al., 2007)

Aedes aegypti female mosquito is highly anthropophilic (Huber et al., 2008) and prefers to

feed during the day - two hours after sunrise and few hours before sunset is the most

appropriate time, although they feed all day indoors and on overcast days. Female Ae. aegypti

mosquito shows a preference for laying their eggs in domestic containers, but may also use

rainwater-accumulating containers present in peridomestic environments (Wongkoon et al.,

2007; El-Badry and Al-Ali, 2010). Its adaptation to human habitats and its desiccation-

resistant eggs have allowed it to flourish in urban centers. They have a life span of 8 to 15

days and flight range for females is about 30 to 50 meters per day. These mosquitoes are

unique in that they feed on more than one person per gonadotropic cycle and will resume

feeding on a second individual if interrupted (El-Badry and Al-Ali, 2010).

 16

2.4.2 Dengue Virus Transmission Cycles

Two transmission cycles are known for DENV, one of them involving non-human primates

(monkeys) and jungle mosquitoes, referred to as the sylvatic cycle, and the second being the

urban cycle that involves Ae. aegypti - human - Ae. aegypti which is most important

transmission cycle that causes huge outbreaks in the tropics (Gubler and Meltzer, 1999)

(Figure 2.7).

The life cycle of DENV involves a replication step in both mosquito and human hosts.

Infected humans are the main carriers and multipliers of the virus, serving as a source of the

virus for uninfected mosquitoes (Monath, 1994). The virus circulates in the blood of infected

humans for two to seven days and at approximately the same time patient develop fever.

Uninfected Aedes mosquitoes acquire the virus when they feed on an individual during this

period (Monath, 1994).

Figure 2.7 Transmission cycle of DENV (Whitehead et al., 2007)

Once a mosquito has fed on a viremic human, the virus replicates in the arthropod mid-gut

and disseminates to the salivary glands within 8-12 days. Following dissemination to the
 17

salivary glands, female Aedes mosquitoes are able to transmit DENV to new hosts. However,

for the virus infection to be sustained in the vector mosquito, virus titer in the human host

should exceed 105 – 107 virus particles per ml (Monath, 1994). The vector itself is thought to

function as an important biological filter for maintaining the virus titers at high level

(Monath, 1994). In periods of low virus transmission, the DENV may survive through

transovarial transmission from parent to progeny and possibly also between mosquitoes

sexually (Khin and Khan, 1983).

Direct person-to-person transmission has not been documented. Although, a few case reports

have been published on transmission of DENV through exposure to DENV-infected blood,

organs, or other tissues from blood transfusions, solid organ or bone marrow transplants,

percutaneous and mucous membrane contact with dengue-infected blood (De Wazieres et al.,

1998; Chen and Wilson, 2004; Tan et al., 2005; Wilder-Smith et al., 2009).

2.5 Factors Influencing DENV Transmission

Many factors contribute to the emergence and sustained transmission of DENV. Uncontrolled

urbanization, expanding urban population, poverty, ineffective public health infrastructure,

faster modes of transportation, globalization of trade and increased international travel have

all been implicated as factors leading to the spread of dengue around the world (Gubler and

Clark, 1995). Rapid urbanization is probably the single most important contributing factor

especially where the resulting populated centers tend to lack piped water and residents have

to resort to using containers to store water that often end up as breeding sites for the Ae.

aegypti vector. The lack of adequate sewage systems often leads to the same result.

Relaxation of vector control efforts, expansion of the vector range, and the build-up of vector

resistance to insecticides are some of the recognised factors affecting the contribution of the

mosquito vector (Gubler and Clark, 1995). The impact of environmental factors on the
 18

transmission and spread of mosquito-borne diseases as exemplified by effects of temperature,

rainfall and humidity on vector transmission cycles are also well known (Nakhapakorn and

Tripathi, 2005). Besides the effect of generalised climatic factors (global warming, for

example) the local ecology probably plays an equal, if not more important, role in a disease

as complex as dengue (Reiter, 2001; Johansson et al., 2009). Inherent differences in the

virulence of the introduced DENV strains have also been suggested as being a contributing

factor in causing outbreaks and in the emergence of the severe form of dengue disease

(Rodhain and Rosen, 1997).

2.6 Global Geographical Distribution

Dengue virus is the world’s most geographically widespread arthropod-borne virus and its

geographical distribution is inherently tied to the range and habitat of its principal vector

mosquitoes. Dengue infections are reported in more than one hundred tropical and sub-

tropical countries worldwide, mostly in urban and semi-urban areas where the vectors are

widely found (WHO, 2007a). Dengue is hyperendemic in many of these urban centers with

co-circulation of multiple DENV serotypes. In non-tropical regions, dengue is usually the

result of infection from international travelers that have visited dengue-endemic areas (WHO,

2007a). The larvae of the principal vector Ae. aegypti under naturally changing temperature

are capable of developing into adults in conditions lower than 10°C, whereas those of Ae.

albopictus can survive even lower temperatures. As shown in Figure 2.8, the southern parts

of the United States and Europe, and major parts of Australia and Africa are among the

endemic areas of dengue transmissions.

In Africa, DENV transmission is endemic to 34 countries. Local transmissions have been

reported in 22 countries, with most transmission occurring in Eastern Africa (Table 2.1)

(Amarasinghe et al., 2011). Nearly 300,000 cases were reported in 5 large epidemics in the
 19

Seychelles (1977–1979), Réunion Island (1977–1978), Djibouti (1992–1993), Comoros

(1992–1993), and Cape Verde (2009). In the remaining 12 countries, dengue was diagnosed

only for travelers returning to countries to which dengue was not endemic but never reported

as occurring locally in these 12 countries (Table 2.1) (Amarasinghe et al., 2011).

Figure 2.8 Countries or areas with active dengue transmission and principal vector Ae.
aegypti (CDC, 2012a). Light-coloured (yellow) areas indicate dengue endemic
countries and areas

Dengue virus transmission in Kenya dates back to 1982 when an outbreak of DENV 2 was

reported in the coastal towns of Malindi and Kilifi (Johnson et al., 1982). Additional isolates

of DENV 2 were made from Mombasa and Diani showing a wide distribution of DENV

infection along the Kenyan coast (Sang and Dunster, 2001). However, all the four DENV

serotypes have been isolated in Africa. DENV-2 has been reported to cause most epidemics,

followed by DENV-1 (Amarasinghe et al., 2011).

 20

Table 2.1 Countries in Africa with evidence of DENV transmission

(Source: Amarasinghe et al., 2011)

 21

2.7 Impact of Dengue Virus infections

2.7.1 Public Health Impact

The real public health impact of DF/DHF occurs during epidemics of this disease. Due to the

similarity of clinical symptoms with other febrile illnesses, the early stages of epidemic

transmission are usually not detected, with cases grossly under-reported until the epidemic is

recognized as dengue, which is usually near peak transmission; it then becomes grossly over

reported. Emergency mosquito control is usually initiated at that time, but these efforts are

usually misdirected, and are too little and too late to have any impact on the epidemic. Thus,

the public health impact of epidemic DF/DHF is amplified because of no effective preventive

measures, no public health planning and no properly implemented emergency response plans

(Gubler, 2002).

2.7.2 Social Impact

Dengue afflicts all levels of society but the burden may be higher among the poorest who

grow up in communities with inadequate water supply and solid waste infrastructures, and

where conditions are most favourable for multiplication of the main vector, Ae. aegypti

(WHO, 2012).

2.7.3 Economic Impact

Dengue causes a substantial burden to the patients not only physical pain but also economic

hardship to them and their family because of health clinic visits, hospitalization, medication,

travel expenses, and parents’ time seeking for treatment of their children and disruption of

earning potential. The government also has to allocate vast amounts of money for public

awareness campaigns, medical services and vector eradication efforts. Another indirect cost

comes in the form of loss of revenue through reduced tourism (Gubler, 2002).
 22

2.8 Dengue Virus

Dengue Virus (DENV) is a member of the family Flaviviridae, genus Flavivirus that consists

of 55 identified virus species (ICTVdB, 2006). DENVs are composed of four flaviviruses that

are closely related but antigenically distinct groups known as serotypes, denoted as dengue

virus type 1 (DENV-1), dengue virus type 2 (DENV-2), dengue virus type 3 (DENV-3) and

dengue virus type 4 (DENV-4). They have common epitopes on the envelope protein that

result in extensive cross-reactions in serologic tests. These make unequivocal serological

diagnosis of flavivirus difficult, which is especially true among the four dengue viruses

(Zanotto et al., 1996).

The virus is a spherical particle approximately 40-60 nm in diameter consisting of a 30 nm

isometric nucleocapsid core surrounded by envelope approximately 10 nm thick. The

nucleocapsid is composed of core proteins and houses the viral genomic RNA (Figure 2.9).

The genome is a non-segmented, single-stranded, positive-sense RNA and is 10.7 kb in

length (Chambers et al., 1990). The DENV open reading frame (ORF) is flanked at its 5’

terminus by an untranslated region (UTR) of about 100 nucleotides and a longer UTR of

about 500 nucleotides at its 3’ terminus. The 5’ terminus of the genome has a type I cap

(m7GpppAmp) and there is no polyadenylation of the 3’ terminus (Perera and Kuhn, 2008).
 23

Figure 2.9 Dengue virus (Chambers et al., 1990)

The translated polyprotein is cleaved co- and post-translationally by viral and host proteases

into ten viral proteins: three structural proteins (C, capsid; prM/M, precursor of

membrane/membrane; E, envelope) encoded at the 5’ end of the ORF, and seven non-

structural proteins (NS1, NS2A, NS2B, NS3, NS4A, NS4B and NS5) encoded at the 3’ end

(Figure 2.10).The three structural proteins constitute the DENV virion: the capsid protein

surrounds the viral RNA genome to form the nucleocapsid, whereas the prM and E proteins

are embedded in the cell-derived lipid bilayer membrane that forms the viral envelope (Perera

and Kuhn, 2008)

 24

Figure 2.10 Schematic diagram showing: (top) gene organisation in the dengue virus
RNA genome, (bottom) the membrane topology and proteolytic cleavage
sites of the transcribed polyprotein. Cellular and viral proteases, which are
denoted by arrows, process the immature polyprotein into ten separate proteins
(Perera and Kuhn, 2008).

2.9 Pathogenesis Mechanisms of DENV

The mechanisms leading to the severe manifestations of DENV infections are still not

completely understood but are likely to be multifactorial. These include: pre-existing DENV

immunity and viral genotype. Based on these observations, it has been proposed that viral

virulence and aberrant host immune responses are responsible for the development of severe

disease (Guzman and Kouri, 2003).

Once the virus is introduced into a human host through the bite of an infected mosquito,

released viral particles infect tissue-resident cells via the mannose receptor on macrophages,

dendritic cells-specific ICAM-3-grabbing non-integrin 1 (DC-SIGN) on dendritic cells (DC)

and activate resident immune cells such as mast cells (Tassaneetrithep et al., 2003; Miller et
 25

al., 2008; John et al., 2011). Langerhans cells have also been identified to be permissive to

DENV infection (Wu et al., 2000). The activated mast cell mediates a local inflammatory

response to DENV in the skin that prompts the recruitment of leukocytes from the

vasculature, including natural killer (NK) cells and NK T cells, which promote the killing of

virus-infected cells at the site of injection (Figure 2.11) (John et al., 2011).

However, the infected DC mature and migrate to local or regional lymph nodes where they

present viral antigens to T cells. The infected cells releases virus that infect other cell types

in the draining lymphnode such as monocyte/macrophages, B cells, and other DCs. DENV

replicates in DC, macrophages, and other monocytes, seeding a viremia. From the draining

lymph nodes, the virus enter the bloodstream, possibly via infected B cells, which mediates

infection of secondary organs such as liver, kidneys, and spleen (Jessie et al., 2004).

Figure 2.11 Host responses to cutaneous dengue virus injection (John et al., 2011)
 26

Symptomatic infections leading to DF are preceded by an incubation period generally ranging

from 4 to 10 days. The acute phase of illness lasts for 3 to 7 days post onset of fever and is

generally self-limiting (WHO, 2009). Resolution of DENV infection is associated with virus

clearance by cytotoxic T cells and virus neutralization by antibodies that can block virus-

mediated cell membrane fusion or virus attachment by targeting DII and DIII of the E protein

respectively (Crill and Roehrig, 2001; Yauch et al., 2009).

Around the time of defervescence, DF can progress to DHF and DSS, which are

characterized by thrombocytopenia, hemorrhagic manifestations, and increased vascular

permeability that can lead to hypovolemic shock (Gubler, 1998; WHO, 2009). The four

theories explaining why disease pathogenesis can progress to DHF and DSS include;

Antibody Depended Enhancement (ADE), virus virulence, T-cell mediated and molecular

mimicry that result in increased virulence.

Table 2.2 Existing hypotheses to explain DENV pathogenesis

Hypothesis Mechanism Result

Enhancement of infection of target
Antibody Depended Immune-complexes
cells
Enhancement

Viral virulence Highly virulent strains Increased infection of target cells

T-cell mediated Cytokine production Increased vascular permeability

Molecular mimicry Autoimmune reactions Hemorrhagic manifestations

The ADE hypothesis states that upon secondary infection with a heterologous DENV

serotype, pre-existing, sub-neutralizing, and non-protective antibodies will bind to viruses

and will enhance their uptake in FcR-bearing monocytic cells, resulting in enhanced infection

and greater burden of disease (Figure 2.12) (Whitehead et al., 2007). Concurrent with the

antibody response to heterologous infection, activation of memory T-cells specific for the

previous infection (original antigenic sin) is postulated to delay viral clearance and increase
 27

cytokine production, thereby skewing the immune response away from the current infection

(Mongkolsapaya et al., 2003). However, original antigenic sin is not always associated with

ADE disease progression. Infants can develop DHF without experiencing a prior infection,

suggesting that ADE associated disease in infants is mediated primarily by maternal

antibodies (Halstead et al., 2002). Additionally, infants who have no maternal antibodies

between ages 1-3 years also have a potential to develop DHF due to unknown mechanisms

aside from ADE (Ngwe Tun et al., 2013).

Figure 2.12 Model for antibody-dependent enhancement (ADE) of dengue virus

replication (Whitehead et al., 2007).

The memory CD4+ T cells activated by infection release Interferon gamma, which will up-

regulate expression of FcR on monocytes, and further perpetuate the infection of these cells

(Figure 2.12) (Pang et al., 2007). In response to infection with DENV, macrophages,

dendritic cells and other infected mononuclear cells, secrete vasoactive mediators, which

cause vascular permeability and may lead to shock, the most important feature of severe

DENV infection. It is hypothesized that a complicated network of cytokines and other

mediators, involving TNF, interleukin-1 (IL-1), IL-2, IL-6 IL-8, macrophage inflammatory
 28

protein (MIP)-1α, interferon-inducible protein (IP)-10, and platelet activation factor (PAF) as

well as complement activation products such as C3a and C5a and histamine may be

responsible for increased haemorrhage and vascular permeability (Chaturvedi et al., 2000;

Espina et al., 2003).

During DENV infection, viral antigens are presented by infected cells, in the context of MHC

antigens resulting in priming and stimulation of CD4+ and CD8+ T cells. A consequence of

T cell activation is the production of several cytokines including IL-2, IL-4, IL-5 and IL-6,

whereas infected macrophages produce TNF, PAF, IL-1 and IL-6 while monocytes produce

TNF-α, IL-1β, IL-6, and IL-8 and anti-inflammatory cytokines IL-10 and TGFβ. This

complicated network acts synergistically, resulting in increased vascular permeability

observed during DHF and DSS (Chaturvedi et al., 2000; Gerber and Mosser, 2001).

In addition, the production of IFN-α during DENV infection up-regulates the expression of

Fc receptors and MHC expression, which results in increased numbers of DENV infected

cells. These chain reactions and production of the cytokine cascade results in

immunopathology seen in DHF and DSS (Figure 2.13) (Chaturvedi et al., 2000; Gerber and

Mosser, 2001). Amongst the up-regulated cytokines in severe dengue cases, TNFα is of

particular interest because of its ability to increase endothelial permeability (Yen et al.,

2009). Notably, TNFα308A allele, which leads to overproduction of this cytokine, is

associated with DHF (Perez et al., 2010). Another cytokine, IL-10 result in reduced levels of

nitric oxide and hence increased levels of pro-inflammatory cytokines. IL-10 has also been

shown to correlate with platelet decay and reduced function, resulting in enhanced disease

severity (Libraty et al., 2002). IL-6 elevates level of tissue plasminogen activator which is

important in the control of fibrinolysis (Duchini et al., 1996).

 29

Figure 2.13 Model of T cell mediated immunopathogenesis in DHF leading to plasma

leakage. According to this model, during secondary infection, memory DENV
specific T cells are able to recognize DENV infected cells more rapidly than
naive cells, become activated in shorter time and secrete high amounts of the
cytokines leading to increased vascular permeability and plasma leakage
(Chaturvedi et al., 2000).
Effects from produced by different cytokines suggests that it is likely that multiple cytokines

and soluble factors contribute simultaneously in a complex way to result in DHF/DSS. On the

other hand, overproduction of matrix metalloproteinase (MMP) 9 by immature DC infected

by the dengue virus is involved in the enhanced endothelial permeability (Luplerdlop et al.,

2006)

The existences of genotypic variations that make some strains more virulent and are

associated with greater severity of illness have been proposed. The analysis of whole genome

sequence of DENV-2 causing either DF of DHF revealed that determinants of DHF occur at

amino 390 of envelope (E) protein, the downstream loop (nucleotides 68-80) of the 5’

noncoding region and the upstream 300 nucleodites of the 3’ NCR. These changes in the
 30

virus genome implicated risk factors for the development of severe disease (Leitmeyer et al.,

1999; Fried et al., 2010; Ty Hang et al., 2010). Disease severity has also been associated with

high viremia titers in the infected human and differences in virus output from infected

monocytes (Vaughn et al., 2000; Cologna and Rico-Hesse, 2003).

Molecular mimicry resulting in autoimmune reactions has also been an alternative to explain

the pathogenesis of DHF and DSS. It has been demonstrated that part of the DENV envelope

protein, a 20-amino acid sequence, shares a sequence similarity with a family of clotting

factors, including plasminogen and in addition, cross-reactive antibodies to plasminogen

appeared during DENV infections (Markoff et al., 1991). These findings indicate that a

relation between these cross-reactive antibodies and development of haemorrhagic

manifestations may exist. In addition, antibodies to the NS 1 protein have been found to

cross-react with epitopes on human blood clotting factors and integrins and bind to

endothelial cells (Falconar, 1997). In addition, formation of platelet-associated

immunoglobulins play a critical role in the mechanisms of thrombocytopenia and the

accompanying increased vascular permeability. It has been demonstrated that increased

platelet activation IgG (PAIgG) levels which involve anti-DENV IgG, were closely

associated with thrombocytopenia during the acute phase of secondary infection (Oishi et al.,

2003; Saito et al., 2004)

2.10 Laboratory diagnosis of Dengue Virus infection

The current laboratory diagnosis of dengue is based on the detection of markers of DENV

infection in patient serum (Peeling et al., 2010). These include the viral components and

antibodies that are present in the serum at different time points of the infection (Figure 2.14).
 31

Figure 2.14 Diagnostic markers of DENV infection in a patient serum (modified

from Peeling et al., 2010)

The tests are based on the immunological response after exposure to an external agent such as

virus. Immunoglobulin M (IgM) and immunoglobulin G (IgG), singly or in combination, are

usually the key factors to be detected in the diagnosis of dengue primary infection and

secondary infection (Figure 2.14). Detection of DENV IgM in the low titer of DENV IgG

(i.e. an IgM positive and IgG negative reactivity pattern) is a clear indicator of primary

DENV infection (De Souza et. al. 2007). An IgM positive and high titer IgG reactivity

pattern is an accurate marker of secondary infection among patients whose serum samples

were collected after 7 days from onset of fever. In DHF and DSS, antibody response has been

grouped depending on the disease severity. This includes; high IgM titer with low anti-flavi

IgG titer, low IgM titer with high anti-flavi IgG titer, and high IgM titer with high anti-flavi

IgG titer (Ngwe Tun et al., 2013).

 32

Immunoglobulin M is a reliable marker in infants for primary immune response since it does

not cross react with the flaviviruses. However, positivity of anti-dengue IgG usually

implicates the maternal protective antibody transmitted through the placenta during gestation

period (Hammond et al., 2005).

Other antibodies such as DENV specific IgA antibodies are also present during acute phase

DENV infection; however they disappear early in convalescence, approximately three to four

weeks after infection (Nawa et al., 2005).

The following are serologic tests used for the diagnosis of DENV infection.

a) Haemagglutination Inhibition Test

The haemagglutination inhibition (HI) test has been the most frequently used test for routine

serologic diagnosis of dengue. It is sensitive, easy to perform, requires only minimal

equipment, and is very reliable if properly done. The HI test is based on the fact that the

DENV, under controlled conditions of pH and temperature, can agglutinate goose red blood

cells, and this effect can be inhibited by specific antibodies (Figure 2.15). The antigens

employed are prepared from infected suckling mice brains by extraction with acetone to

remove the lipids, or from infected mosquito cell cultures fluid that have been concentrated.

Serum specimens must be treated at 56°C for 30 minutes to remove non-specific inhibitors,

followed by adsorption to 20% goose erythrocytes to observe natural hemagglutination. The

major disadvantage of the HI test is lack of specificity, which makes the test unreliable for

identifying the infecting virus serotype. However, some primary infections may show a

relatively monotypic HI response that generally correlates with the virus isolated (WHO,

2009; Inoue et al., 2010).

 33

Figure 2.15 Haemagglutination inhibition test

b) Neutralization Test

The neutralization test (NT) is the most specific serologic test for dengue viruses. The most

common protocol used in most dengue laboratories is the serum dilution plaque reduction

neutralization test (PRNT). It is based on the fact that dengue viruses produce cytopathic

effects (CPE) which can be observed as plaques in susceptible cell cultures. This CPE is

neutralized by the presence of specific antibodies. Since NT is more specific than HI, it can

be used to identify the infecting virus in primary dengue infections, provided the serum

samples are properly timed. Relatively monotypic responses are observed in properly timed

convalescent-phase serum. In secondary and tertiary infections, it is not possible to reliably

determine the infecting virus serotype by NT. The major disadvantages are time required to

perform the test, and technical difficulty (WHO, 2009).

c) IgM-Capture Enzyme Linked Immunosorbent Assay

IgM-capture enzyme-linked immunosorbent assay (MAC-ELISA) is widely used. It is based

on detecting the dengue-specific IgM in the test serum by capturing them out of solution

using anti-human IgM that was previously bound to the solid phase. If the IgM from the

patient’s serum is anti-dengue antibody, it will bind the dengue antigen that is added in the

next step and can be detected by subsequent addition of a horseradish peroxidase labeled anti-
 34

dengue antibody, which may be monoclonal antibody. An enzyme o-phenylenediamine

complex substrate is added to give a colour reaction (Figure 2.16). MAC-ELISA is a valuable

tool for the dengue diagnosis and surveillance. During epidemics, MAC-ELISA has the

advantage of fast detection in propagation of the transmission. In areas where dengue is

endemic, MAC-ELISA can be used as a valuable tool in the evaluation of a great number of

clinical samples, with relative ease (WHO, 2009).

Figure 2.16 IgM-capture ELISA

d) Indirect IgG-ELISA

An indirect IgG-ELISA has been developed and has higher sensitivity than the HI test. It can

be used for the differentiation of primary and secondary infections by dengue (Figure 2.17).

The test is simple and easy to do, and it can be used in the analysis of a large number of

samples (WHO, 2009). The indirect IgG-ELISA exhibits the same broad cross-reactivity

among flaviviruses. Therefore, it cannot be used to identify the infecting dengue serotype.
 35

Figure 2.17 Indirect IgG-ELISA

e) Non-structural protein 1(NS1) ELISA

NS1 of the dengue viral protein has been shown to be useful as a tool for the diagnosis of

acute dengue infections. Although NS 1 protein is not structural protein to form virus, it is

well known to be secrected from infected cells. Thus, DENV NS1 antigen has been detected

in the serum of DENV infected patients as early as 1-day post onset of fever, and up to 18

days post onset of fever. The NS1 ELISA based antigen assay has been introduced recently

for DENV detection and many investigators are evaluating its sensitivity and specificity. The

NS1 assay is useful for differential diagnostics between flaviviruses because of its specificity

(CDC, 2012b)

f) Rapid diagnostic tests (RDT)

A number of RDT kits for anti-dengue IgM and IgG antibodies are commercially available

(WHO, 1997).

2.11 Dengue Treatment

It is recommended that patients with DF have rest. Doctors can treat symptoms of DF with

antipyretics and anti-emetics (WHO, 2009). Aspirin (Acetylsalicylic acid) is not

recommended in dengue patients due to its anticoagulation effects and the risk of Reyes
 36

Syndrome in children. Hospitalization and admission to the intensive care unit is

recommended if patients present with signs of severe hemo-concentration or shock (WHO,

2009). The mainstay of DHF/DSS treatment is intravenous fluid in the form of isotonic

solutions or Ringers for twenty-four hours or until the patient’s hematocrit drops (WHO,

2009). Patients may also be transfused if they lose excessive amounts of blood due to

hemorrhage (WHO, 2009). Hospitalization is recommended for at least twenty-four hours

following defervescence and patients should not be discharged until they meet the following

criteria: return of appetite, clinical improvement, no respiratory distress, stable hematocrit,

platelets greater than 50,000/mm3, and good urine output (WHO, 2009). DSS patients should

remain hospitalized for at least two days following their recovery from shock (WHO, 2009).

2.12 Dengue Vaccine and Drug Development

There are difficulties in the production of dengue vaccine because of the concerns about

antibody dependent enhancement and increased severity of secondary infections (Stephenson,

2005). Immune response to heterologous dengue antigens has potential to tilt the balance

from protection to immunopathology (Huisman et. al, 2009; Rothman, 2004; Durbin and

Whitehead, 2010). The lack of an appropriate animal model and the poor understanding of

the pathogenesis of dengue have made the development of an effective and safe dengue

vaccine difficult (Yauch and Shresta, 2008). An optimal vaccine need to meet many

requirements to produce balanced immunity to all four serotypes, to cause minimal vaccine-

induced severe type of DENV infection, to produce lifelong protection, and be economically

feasible (Whitehead et al., 2007).

Compounds inhibiting DENV replication, enzymatic activity, receptor binding and fusion are

currently under investigation (Morrison et al., 2010).The aim of these studies is to identify

potential drugs that can prevent development of DHF and DSS from DF (Noble et al., 2010).
 37

Additionally, therapeutic antibodies are currently being studied for their potential in treatment

of dengue (Shrestha et al., 2010). The current approaches of dengue vaccine development

include chimeric, live attenuated, inactivated, sub-unit vaccine and DNA vaccine. Sanofi

Pasteur’s ChimeriVax-DENV vaccine has recently entered phase 3 clinical testing (Coller

and Clements, 2011). This chimeric vaccine consists of structural genes (prM and E) from

four DENV serotypes inserted into the yellow fever virus 17D vaccine strain as a backbone

(Figure 2.19) (Guy et al., 2010). Results from phase 1 and 2 have been positive as the vaccine

was shown to be safe and immunogenic, with cell-mediated immunity biasing towards

interferon-gamma (IFNγ) rather than tumour necrosis factor-alpha (TNFα) (Guy et al., 2010).

Presently, two leading live-attenuated tetravalent formulations have been tested in phase 1

and 2 clinical testing but these vaccines have been put on hold as the vaccinees experienced

adverse reactions and imbalanced serological response towards the four DENV serotypes

(Kitchener et al., 2006, Sanchez et al., 2006), possibly attributed to interference between

dengue serotypes in tetravalent formulations (Anderson et al., 2011). Inviragen Inc, in

collaboration with the Centers for Disease Control and Prevention, USA, tapped on the

DENV-2 (16681-PDK53) strain that was derived through serial passage in primary dog

kidney cells as the genomic backbone. prM and E genes of DENV1, 3 and 4 replaced the

DENV 2 genes to form chimeras that make up the rest of the tetravelant formulation (Figure

2.18). This vaccine, named DENVax, has also entered phase 2 clinical trials (Osorio et al.,

2011). Other inactivated vaccines have also been considered, such as psoralen-inactivated

vaccines which have been shown to be immunogenic and can reduce viraemia after

experimental challenge in vivo (Maves et al., 2011).

 38

Figure 2.18 Different dengue vaccines currently developed.

The Sanofi Pasteur vaccine uses a yellow fever virus backbone with prM and E segments

from the other four DENV serotypes. The NIH vaccine is a chimeric dengue vaccine that

uses DENV-4 (with 30 nucleotides deleted at the 3’ end of the genome) as the backbone. The

CDC Inviragen vaccine is a mixture of four recombinant DENV-2 genomes. In contrast, the

Merck/Hawaii Biotech is a subunit vaccine containing E proteins from four DENV serotypes.

Another type of vaccine under clinical development is DNA vaccine (Rothman, 2011).

DNA vaccines developed by the US Naval Medical Research Center have completed a phase-

1 trial testing a DENV-1 prM/E DNA vaccine (Thomas SJ, 2011). To improve

immunogenicity and protection, different vector and adjuvant combinations have been

considered. For example, DNA vaccines comprising of prM-E genes in a Venezuelan equine

encephalitis virus replicon particle system is under clinical development (Chen et al., 2007).

The use of better adjuvants, such as Vaxfectin®, has been shown to improve DNA vaccines

by increasing their immunogenicity and protection, highlighting its potential to improve

tetravalent dengue DNA vaccines (Porter et al., 2012).

 39

2.13 Methods of Vector Control

The most effective way for preventing DENV transmission depends entirely on control of the

mosquito vectors (Aedes mosquitoes) or interruption of human–vector contact. Activities to

control transmission should target Ae. aegypti in habitats of its immature and adult stages in

the household and immediate vicinity, as well as other settings where human vector contact

occurs (Henchal and Putnak, 1990).

2.13.1 Environmental Management

Environment management seeks to change the environment in order to prevent or minimize

vector propagation and human contact with the vector-pathogen by destroying, altering,

removing, or recycling non-essential containers that provide larval habitats. The choice of

approach should be effective, practicable, and appropriate to local circumstances (WHO,

2009).

2.13.2 Chemical Control

Current methods for applying insecticides include larvicide application, perifocal treatment,

and space spraying. Three larvicides have been used to treat water containers; 1% temephos

sand granules, insect growth regulator methoprene in form of briquettes, and BTI (baccilus

thurungiensis H-14), which is considered below in the section on biological control. Perifocal

treatment involves the use of hand or power sprayers to apply wettable power or emulsifiable

concentrated formulations of insecticide as spray to larval habitats and peripheral arrears. The

insecticides currently in the perifocal treatment are; Malathion, Fenitrothion, Fenthion and

some Pyrethroids. Space spraying is the spreading of microscopic droplets of insecticides in

the air to kill adult mosquitoes and is used in emergency situations when an outbreak of

dengue fever is already in progress. Two forms of spray are generally used, ultra-low volume

aerosols (cold fogs and mist). However, Insecticide resistance must be considered as a
 40

potentially serious threat to effective dengue vector control. Routine monitoring of insecticide

susceptibility should be an integral part of any control programme (WHO, 2009).

2.13.3 Personal Protection

Pyrethroid-impregnated bed nets or curtains are effective against night feeding mosquitoes

and are useful for bed-ridden, infants or day sleep persons. Commercially available insect

repellents can be used for tourists and short-term visitors to dengue endemic areas. For

residents and those staying longer in endemic areas, clothing can be impregnated with

Permethrin (WHO, 2009).

2.13.4 Biological Control

Larvivorous fish and the biocide Bacillus thruringiensis H-14 (BTI) are the two organisms

most frequently employed (WHO, 2009).

2.13.5 Integrated Control

Intergrated vector control is the combination of available control methods in the most

effective, economical and safe manner to maintain vector population at acceptable levels.

Environmental management of DENV vectors can be successfully combined with health

education and public awareness, where source reduction activities are promoted by local

health care workers (WHO, 2009).

 41

CHAPTER THREE: MATERIALS AND METHODS

3.1 Study Site

This study was conducted at the Coast Provincial General Hospital (CPGH) that provides the

health care services to the local people and serves as a referral center to the entire County.

The facility provides a variety of health care services through inpatient and outpatient

departments under the units of medicine, surgery, gynecology, and other medical sub-

specialties (e.g. pediatrics, obstetrics, and microbiology). CPGH facility is located in the

County of Mombasa, found on Kenya’s eastern coastline bordering Indian Ocean. The

County is one of Africa’s major tourist destinations, with some of the best beaches in the

world. It has an international airport and a prominent busy seaport linking east and central

Africa to rest of the world. The County covers an area of 2,755km2 and lies between latitudes

3°56’ and 4°10’ south of equator and longitudes 39°34’ and 39°46’ east. It is characterized by

a distinctive hot and humid climate influenced by South East and North East monsoons. This

area receives heavy downpours between April and May and the occasional showers towards

the end of the year. The rainfall ranges from moderate to high, with an average of 1,162 mm

annually. The average temperature is 26.5 °C (20 °C – 33 °C). Mean relative humidity for an

average year is recorded as 77.6%.

The total population size is 939,370 as per the 2009 census (Kenya National Bureau of

Statistics, 2009) with human population density of 4,292 per km2 and 37.6% of this

population live below the poverty line (Kenya Integrated House Budget Survey, 2007). The

literacy levels may be upto 86.2%, being higher in urban than rural areas. The increase in

human population density and widespread poverty at the coastal region of Kenya, contribute

to conditions that modify the environment and directly influence the risk of DENV

transmission. These conditions include; poor physical planning that result into haphazard
 42

building, inadequate sewage and waste management systems, and deficiencies in water

supply systems leading to water storage practices. Furthermore, poor garbage control, mass

production of non-biodegradable plastic containers and used automobile tires discarded in

environment provide important sites for mosquito breeding.

However, Mombasa County attracts a large number of visitors/tourists, and migrants most of

whom are employed in the commercial port and the industrial zones of the County, thus

increasing the vulnerability of the county for DENV. Lastly, globalization also results to

more international contact and travel through the exchange in population and goods which

increases the risk of imported dengue in County, thus increasing the domestic spread of the

disease.

3.2 Study Design

This was a hospital-based prospective study conducted for a period of 6 months (February to
July 2012).

3.3 Variables

The variable in the present study included age, gender, and month as independent variables,

while dengue patient as dependent variable in this study.

3.4 Study Population

This study was performed among febrile patients seeking medical care at both the inpatient

and outpatient departments. The patients were selected according to the following criteria:

a) Case inclusion criteria:

The study included patients aged above 2 months with symptoms of fever (38.5–41.4°C)

and with more than or equal to two of the following; 1) Joint pain, 2) Rash, 3) Myalgia,

4) Headache, 5) Retro-ocular pain 6) Abdominal pain and 6) Hemorrhagic manifestation

 43

(WHO, 2009). Before recruitment in the study, the patient, parent, or guardian provided a

written informed consent.

b) Case exclusion criteria

The study excluded children less than 2 months old, patients with fevers of known cause, and

those patients who were unable or unwilling to give a written consent.

3.5 Sample Size

It was assumed that the patients attending CPGH during the study period were a

representation of the total Mombasa County population. The sample size was determined

using the Cochran formula with estimated prevalence of 50% (Bartlett et al., 2001; Cochran,

1977)

N = Z2P (1-P) D
d2

Where; N - Minimum number of sample required

Z - Standard normal distribution at 5% significance level (1.96)

P - Estimated prevalence of Dengue fever for the coastal region (50%, 0.5)

D-Design effect (1)

d- Degree of precision (5%, 0.05)

N = 1.962(0.5) (1-0.5)1
0.052

N = 384

Therefore, the minimum blood samples required for the study was 384 = 390 samples. Since,

there were anomalies in patients’ response.

 44

3.6 Study Procedure

3.6.1 Recruitment of Patients

A trained study clinical officer recruited eligible patients and collected data at pediatric,

outpatient and inpatient departments of CPGH. The study clinical officer introduced himself

and explained to the parents and guardians the purpose of the study. Informed verbal and

written consent was obtained from parents and guardians who allowed their children to take

part in the study (Appendix A). The patients with the guardian were assured of confidentiality

of the information. Participation in the study was on a voluntary basis.

3.6.2 Clinical and Demographic Data Collection

A structured assessment form was used to obtain the clinical history regarding febrile illness

including clinical symptoms and signs (Appendix B).

3.6.3 Blood Sample Collection Procedure

The study clinical officer collected venous blood samples aseptically from the study

participants as follows: The veins in the antecubital fossa or dorsum of the hand were

identified and a tourniquet applied to make the veins visible. The area was then cleansed with

an alcohol swab and allowed to air dry, 3-5ml of blood was drawn from each febrile patient

using a sterile needle and syringe or vacutainer needle and serum separating tube (SST)

(Becton Dickinson, SA).

3.6.4 Sample Handling, Transport and Storage

The blood samples were centrifuged at 1,300 x g for 10 minutes at 4°C. A sterile, graduated,

disposable transfer pipette was used to transfer serum into two sterile screw-capped cryotubes

(1.5 ml per tube, Greiner Bio-One, Germany) and stored at -80°C until testing. The serum

samples were collected and delivered to the Kenya Medical Research Institute, Production

Department (KEMRI-PD) laboratories, Nairobi.

 45

3.7 Laboratory Procedures

3.7.1 Cell Lines and Virus Strains

Aedes albopictus mosquito derived C6/36 cells and African green monkey kidney derived

Vero cells were cultured in Minimum Essential Medium (MEM) supplemented with 10% v/v

heat inactivated fetal bovine serum (FBS Sigma, USA) and 100units/ml penicillin, 100µg/ml

streptomycin and 292 µg/ml L-glutamine (GIBCO), 0.1% non-essential amino acids

(Gibco/Invitrogen, UK) and 2-3% Sodium bi-carbonate. C6/36 and Vero cells were cultured

in 25 cm2, 75 cm2 tissue culture flasks (Nunc, Denmark) at 28°C and 37°C, respectively. The

cell lines were passaged every 5-7 days. The cell monolayer was washed with 0.1% trypsin in

0.02% EDTA solution was added for 3 minutes at 28°C and 37°C, respectively. After

addition of trypsin-EDTA solution, the flask was tapped to detach and disperse cells. Equal

volume of culture medium was added to stop the enzyme activity and cell suspension

centrifuged at 1,400 rpm for 4 minutes. The cell precipitate was re-suspended with growth

medium and transferred into flasks.

The DENV strains used in this study were: DENV-1 (Hawaii), DENV-2 (00St-22A), DENV-

3 (SLMC-50), and DENV-4 (SLMC-318). All the strains were grown in the C6/36 cells at

28°C for 7-10 days and stored in aliquots at -80°C as seed virus stock until use.

3.7.2 Antigen Production

3.7.2.1 Propagation and Harvesting of the Virus

Aedes albopictus clone C6/36 cell line was grown at 28°C in MEM with 10% FBS in Roux

bottles. At 80% confluence, growth medium was removed and 1 ml of seed virus inoculated

in each bottle, followed by 2 hours virus adsorption at 28°C. The inoculum was spread over

the cell sheet every 20 minutes. Thereafter, maintenance medium was added to cell sheet and

incubated at 28°C. After 14 days for DENV-1, 9 days for DENV-2, 12 days for DENV-3, and
 46

10 days for DENV-4, the infected culture fluids (ICF) were collected in centrifuge bottles

(Beckman Instruments, USA) and spun at 5000 rpm for 10 minutes at 4°C in a JLA-10.500

rotor (Beckman Instruments, USA) in Avanti J-26 XP centrifuge to remove cell debris.

3.7.2.2 Virus Concentration Using Jumbosep™ Centrifugal Devices

a) Principle of the procedure

Centrifugation up to 3,000 x g provides the driving force for filtration, moving sample toward

the highly selective, low protein-binding Omega™ membrane. Molecules larger than the

membrane’s nominal molecular weight cutoff of 30K (MWCO-30K) are retained in the

sample reservoir. Solutes and molecules smaller than the MWCO-30K of the membrane pass

through the membrane surface into the membrane insert and through the filtrate port into the

filtrate receiver (Pall Life Sciences, 2007).

Figure 3.1 Jumbosep device components (Pall Life Sciences, 2007).

b) Procedure

The procedure was performed by following manufacturer’s instruction. The filtrate receiver

was separate from the sample reservoir and membrane insert with the filtrate port facing

down dropped into the sample reservoir (Figure 3.1). The sample reservoir was placed on a
 47

hard surface and membrane insert pressed down firmly to rest on the knobs at the bottom of

the sample reservoir. Empty filtrate receiver was attached to the bottom of the sample

reservoir, 60 ml of ICF was added to the sample reservoir and capped to prevent evaporation

during centrifugation. The Jumbosep devices were placed in a swinging-bucket rotor (B438-

29) that accepted standard 250 ml bottles and spun at 4,200rpm for 60 minutes at 4 °C in

Tomy AX-311 versatile refrigerated centrifuge (Tomy, Japan). Jumbosep devices were

removed at the end of spun time and sample reservoir separated from the filtrate receiver.

Retentate was recovered by pouring off the retentate into pre-labeled 15 ml centrifuge tubes,

a pipette tip sledded under the dislodged membrane insert and remaining retentate removed.

The retentate fluid was then stored at -80 °C.

3.7.3 Sandwich ELISA to Assay Dengue Antigen Titer

The principle of Voller et al., (1976) was used with some modifications (Bundo and Igarashi,

1985) A 96-well ELISA flat bottom plate was coated with anti-flavivirus IgG (20µg/ml) in

coating buffer (0.05 M carbonate–bicarbonate buffer, pH 9.6, containing 0.02% sodium

azide) at 4 °C overnight. The plate wells were blocked with Blockace (Yukijirushi, Japan) at

room temperature (r.t). After washing with PBS-Tween 3 times, test samples, standard

antigen, and negative control (MEM) were distributed in duplicate. The plate was incubated

at 37 °C and washed as above, and horseradish peroxide (HRPO)-conjugated anti-flavivirus

IgG original (1:500 dilution in PBS-Tween) was distributed into all wells except blanks.

Unbound conjugate was washed off as above, and the plate was incubated with substrate

solution containing o-phenylenediamine dihydrochloride (OPD) and 0.05% hydrogen

peroxide for 30 minutes at room temperature in the dark. The reaction was stopped by adding

1N sulfuric acid and optical density (OD) read at 492nm using Multiskan EX ELISA Reader

(Thermo Scientific, China).

 48

3.7.4 Preparation of Dengue Tetravalent Antigen

The DENV tetravalent antigen for IgM capture ELISA was prepared by mixing equal titer of

DENV 1, 2, 3 and 4 ICF to make 100 ELISA units. The mixture was aliquated in 10ml and

stored at -80°C.

3.7.5 Dengue IgM-capture ELISA

An in-house DENV IgM-capture ELISA (in-house IgM ELISA) was carried out following

the protocol described by Bundo and Igarashi, (1985). The 96-well flat-bottomed microplate

(Maxisorp Nunc, Denmark) was coated with anti-human IgM (µ-chain specific) 5.5 µL/100

µL/well (Cappel, Germany) and diluted with ELISA coating buffer in all wells except blanks.

The plate was incubated at 37 °C for 1 h or at 4 °C overnight. All wells except the blank were

blocked with 100 µl of the original concentration of Blockace, and were incubated at room

temperature (r.t) for 1 h. The reagents were removed from all of the wells by washing three

times with phosphate buffered saline containing 0.05% Tween 20 (PBS-T). The test serum

samples as well as positive and negative control sera at 1:100 dilutions in PBS-Tween were

distributed in duplicate wells and incubated at 37°C for 60 minutes. After the reaction and

washing, the DEN tetravalent antigen was distributed into the wells. The plate was incubated

at 37 °C for 1h and washed as above. HRPO-conjugated anti-flavivirus IgG monoclonal

antibody 12D11/7E8 (1:500 dilution in PBS-T and 10% Blockace) was added into all wells

except blanks. After the incubation at 37 °C for 1h, the unbound conjugate was washed off

and substrate solution containing OPD and 0.03% hydrogen peroxide was added to all wells

to proceed in the dark at r.t. The reaction was stopped by adding 1N sulfuric acid and OD

read at 492nm by ELISA plate reader. The ratio of the absorbance of the positive serum and

negative serum (P/N) was calculated by dividing OD of serum sample by the OD of the

negative control serum. The P/N ratio above or equal to 2.0 was considered positive.
 49

3.7.6 Flavivirus Indirect IgG ELISA

An in-house flavivirus IgG indirect ELISA modified by Inoue et al., (2010) was used in

detecting flavi IgG to determine primary and secondary dengue virus infections. In this

modified procedure, purified Japanese encephalitis virus (JEV) antigen (strain: ML-17) was

applied as an assay antigen (Bundo et al., 1986). A 96-well microplate (Nunc International)

was coated with 250ng/100µl per well of virus antigen at 4 °C overnight. The wells were

blocked with 100µl/well of Blockace at r.t for 1h, washed three times with PBS-T for 3 min

each. Test sera were diluted at 1:1000 and standard serum was diluted by two serial from

1:100 upto 212 with PBS-T with 10% Blockace were each placed in duplicate wells and

incubated at 37°C for 1h. The plate wells were washed as above, and then reacted with

100µl/well of 1: 2000 diluted HRPO-conjugated anti-human IgG goat serum (American

Qualex, CA) in PBS-T with 10% Blockace. After 1h incubation at 37 °C, the plates were

washed as above and 100µl/wellof substrate solution was added in each well. The substrate

solution used was described in section 3.7.5. After 30 minutes incubation at r.t in the dark,

the reaction was terminated by adding 100µl/well of 1 N sulphuric acid to each well. The OD

was read at 492nm by ELISA plate Reader. The IgG titers of patient sera were determined

from a positive standard curve. A sample titer ≥ 1:52,000 was considered to be a DENV

secondary infection, whereas a sample titer < 1:52,000 was considered to be a DENV primary

infection (Inoue et al., 2010).

3.9 Serological Definitions of DENV Infection

a) Laboratory-positive DENV infection case: a single positive anti-dengue IgM with

P/N ratio equal to or greater than 2.0 according to the WHO case definition (Bundo

and Igarashi, 1985; WHO, 2009).

b) Primary DENV infection case: A laboratory-positive case in which the IgG-ELISA

titer was <1:52,000 (Inoue et al., 2010).

 50

c) Secondary DENV infection case: A laboratory-positive case in which the IgG-

ELISA titer was ≥1:52,000 (Inoue et al., 2010).

3.10 Data Storage and Analysis

The data collected and generated in the laboratory was entered in excel spreadsheets in a

password protected computer. The data was then converted to Statistical Package for Social

Science (SPSS) version 16.0 (SPSS Inc., Chicago, USA) for analysis. The data for the IgG

titers from the in-house IgG ELISA were expressed as the geometric mean. An analysis of

variance (ANOVA) was used to compare geometric mean of the DENV cases across the age

groups and months. A p-value less or equal to 0.05 (p ≤ 0.05) was considered as statistically

significant. Microsoft Excel was used to generate all graphs and tables. The relationship of

less than or equal to 5% between gender and dengue cases was analyzed using of Fishers

exact tests between two categorical variables.

3.11 Ethical Consideration

The protocol of the study for data collection was reviewed and approved by Kenyatta

University Ethical Review Committee and KEMRI Scientific Steering Committee (Appendix

C). The study was described in more detail to the participants and a written informed consent

(Appendix A) obtained from participants ≥18 years, and from parents/guardians of

participants younger than 18 years. In addition, assent was obtained from participants 6–17

years of age. If participants were unable to read and sign the consent form, oral consent was

obtained and documented in the presence of a witness. The consent form provided a

description of the study, participant’s name, date of birth, sex, and name of parent or

guardian, details on risks associated with venipuncture, the name, and address of investigator.

Each participant was assigned with a unique study number to be used for all laboratory and

data analyses to ensure patient confidentiality.

 51

CHAPTER FOUR: RESULTS

4.1 Prevalence of Dengue Infection Cases among Febrile Patients

During the study period (Feb – July 2012), a total of 390 serum samples from febrile patients

were tested for dengue antibodies using an in-house IgM-capture ELISA and indirect IgG

ELISA. The patients were diagnosed for primary DENV infection, secondary DENV

infection and non-dengue infection depending on antibody titer against DENV. Fifty four

(13.9%) cases were confirmed as dengue infection while 336 (86.1%) cases were found to be

non-dengue (Table 4.1).

4.2 Distribution of Dengue Positive Cases by Age

The age of all patients ranged from 2 month to 82 years. The mean age was 24.9 years, with

median age of 25 years and standard deviation of 17.2 years. The age was grouped to capture

the most vulnerable age group, as it is known that undifferentiated febrile illnesses is more

often common among the pre-school children (1-5 years) and infants (< 1 year), therefore

may experience more severe clinical outcome after primary dengue infection. (Guzman et al.,

2002; Hammond et al., 2005).. The highest affected group in the present study were patients

aged between 36 - 45 years with 11 (20.4%) and least being children aged 6 - 15 year with 6

(8.3%). There was a significant difference in occurrence of DENV infection by age groups (p

= 0.021) as shown in Table 4.1.

 52

Table 4.1 Prevalence of Dengue Virus Infection among Febrile Patients

Primary DENV infection was mainly observed among patients aged between 36-45 years

with 8 (14.8%) and least in patients aged between 1-5 years with 3 (6.1%) (Table 4.1). The

difference between primary DENV infection by age groups was statistically significant (p =

0.049).

The highest secondary DENV infection was observed among patients aged between 26-35

years with 7 (7.8%) and infants (< 1 year) were the least affected 0 (0.0%) (Table 4.1). There

was significance difference between secondary DENV infection by age groups (p = 0.027)
 53

4.3 Proportion of Primary verses Secondary Dengue Cases

The highest primary DENV infection was observed among patients aged less than 1 year

(100.0%) and the lowest among age group 1-5 years (50.0%) (Figure 4.2). Secondary DENV

infection was highest in 1-5 years age group (50.0%), followed by 26-35 years age group

(43.8%). There was no significant correlation between primary and secondary DENV

infection (p = 0.057).

Figure 4.1 Primary verses secondary DENV infection

4.4 Correlation of IgM with IgG Titer among Dengue Positive Patients

Analysis of correlations between IgM and IgG titers for 54 dengue positive cases was divided

into four groups depending in the dengue IgM and IgG titer Group A comprised of 1 case of

high IgM titer (P/N ratio ≥ 20) and low anti-flavi IgG titer (<1:52,000), group B with 36

cases of low IgM titer and low anti-flavi IgG titer, and group C with 17 cases of low IgM titer
 54

(2 < P/N ratio < 20) and high anti- flavi IgG titer (≥1:52,000) and group D with no case of

high IgM titer and high anti-flavi IgG titer (Figure 4.2).

Thirty seven cases found in group A and B were classified as primary DENV infections due

to low anti-dengue IgG titers with both high and low anti-dengue IgM levels. The remaining

17 cases in group C were classified as secondary DENV infections due to high anti-dengue

IgG titers. There was no correlation between anti DENV IgM and anti-flavi levels among the

54 DENV patients (y = 4.538 - 0.03lx, R2 = 0.0001, p = 0.068).

Figure 4.2 Correlation of the anti-DENV IgM and anti-flavi IgG levels among
dengue cases. The solid line indicates the correlation curve of all 54 cases (y =
4.538 - 0.03lx, R2 = 0.0001, p = 0.068). The dashed horizontal line indicates the
division line between the high and low anti-DENV IgM P/N ratios at 20. The
dashed vertical line shows 1:52,000 as the cut-off value for anti-dengue IgG
titers between primary and secondary DENV infections.
 55

4.5 Anti-flavivirus IgG responses among febrile patients

Anti-flavi IgG titers among 390 febrile patients were distributed among the age groups and

plotted individually as shown in Table 4.3 and Figure 4.3 A. The highest geometric mean titer

(GMT) was observed in the age group of 26-35 years and the lowest in the age group of 1-5

years . The difference of GMT between two age groups were statistically significant (p =

0.035) (Table 4.3 and Figure 4.3 A). However, the difference of GMTs between age groups

6-15 years and 26-35 years was not statistically significant (p = 0.105).

Table 4.2 Geometric mean titer (GMT) of anti-flavivirus IgG among febrile patients

n - number of cases
* Geometric mean titer showed statistical significant
** Geometric mean titer showed no statistical differences

The anti-flavi IgG titers were further divided into two categories based on the cut off value as

dengue case (≥ 52,000) and non-dengue case (< 52,000) respectively (Inoue et al., 2010). The

anti-flavi IgG titers among the 54 DENV cases were distributed and plotted individually

depending on the age group. The highest GMT was in the age group of ≥ 46 years and the

lowest in the age group 6-15 years as shown in Table 4.3 and Figure 4.3 B. The GMT
 56

between these two age groups did not differ significantly (p = 0.356). In addition, there was

no significant difference in GMT between age groups 6-15 years and 26-35 years (p = 0.464).

Among the non DENV cases, the highest GMT was observed among the age group 26-35

years and the lowest in age group 1-5 years (Table 4.3). There was a significant difference in

the GMT between these two mentioned age groups (p = 0.047). Similarly, there was

significant difference in GMT between age groups 6-15 years and 26-35 years (p = 0.006)

Figure 4.3 A. Distribution of anti-flavi IgG ELISA titers among 390 febrile patients.
Closed diamonds represent individually plotted anti-flavi IgG titer in each age
group. The dashed horizontal line indicates the cut-off value of which ≥52,000
was secondary DENV infection.
 57

Figure 4.3 B. Distribution of anti-flavi IgG ELISA titers among 54 DENV infection
cases. Closed diamond represents individually plotted anti-flavi IgG titer in
each age group. The dashed horizontal line indicates the cut-off value of
which ≥52,000 was secondary DENV infection.
4.5 Distribution of Dengue Positive Cases by Gender

The distribution of 54 dengue positive cases between male and female were 28

(51.9%) and 26 (48.1%), respectively (Table 4.1). The male:female ratio was found to be

1:0.93. The relationship between gender and DENV infection was not statistically significant

(p = 0.936). However, significant gender differences were observed in the age group 26-35 (p

= 0.010) and ≥ 46 years (p = 0.012), respectively (Figure 4.4).

 58

Figure 4.4 Distribution of DENV infections by age and gender.

* p = 0.010
** p = 0.012

Out of 37 patients suffering from primary DENV infections, 51.4% were males and 48.6%

were females (Table 4.5). The most affected groups were females aged between 26- 35 years

with 44.4% (p = 0.005) and least cases of DENV infection noted in those above 46 years.

Majority of males affected with primary DENV were above 36 years (p = 0.019), with the

least prevalence observed in those less than 1 year. Gender differences in primary DENV

infection was not statistically significant (p = 0.911).

 59

Table 4.3 Distribution of primary dengue cases by age group and gender

Gender
Age group
Total cases p-value
(years) Male Female
n (%) n (%)

<1 1 (5.3) 0 (0.0) 1 (2.7)

1–5 2 (10.5) 1 (5.6) 3 (8.1)

6 – 15 3 (15.8) 2 (11.1) 5 (13.5)

16 – 25 2 (10.5) 4 (22.2) 6 (16.2)

26 – 35 1 (5.3) 8 (44.4) 9 (24.6) 0.005

36 – 45 5 (26.3) 3 (16.7) 8 (21.6)

≥ 46 5 (26.3) 0 (0.0) 5 (13.5) 0.019

Total 19 (100) 18 (100) 37 (100) 0.911

Out of 17 patients that suffered from secondary DENV infection, 52.9% were males and

47.1% were females (Table 4.6). Males of age group 26-35 years were most affected at

33.3% and least affected group was aged less than 1 year at 0.0%. However, majority of

females affected were aged between 26-35 years (50.0%) with least secondary dengue cases

in age group < 1 year and ≥ 46 years (0.0%). Gender differences in secondary infection was

not significant by age groups (p = 0.737).

 60

Table 4.4 Distribution of secondary dengue cases by age and gender

Age group Gender Total cases

(years) n (%)
Male n (%) Female n (%)

<1 0 (0.0) 0 (0.0) 0 (0.0)

1–5 2 (22.2) 1 (12.5) 3 (17.6)

6 – 15 1 (11.1) 0 (0.0) 1 (5.9)

16 – 25 1 (11.1) 1 (12.5) 2 (11.8)

26 – 35 3 (33.3) 4 (50.0) 7 (41.2)

36 – 45 1 (11.1) 2 (25.0) 3 (17.6)

≥ 46 1 (11.1) 0 (0.0) 1(5.9)

Total cases 9 (100) 8 (100) 17(100)

4.6 Month-wise Distribution of DENV Infection Cases

The highest number of DENV infection was observed during the month of February (24.1%),

and the least in the month of July (5.6%). The association between the month and occurrence

of disease was not statistically significant (p = 0.325). The relationship between DENV

infection and month was as follows; Feb and July (p = 0.007), Feb and May (p = 0.007), May

and June (p = 0.118), Jun and July (p = 0.118). There was no significant correlation between

DENV infection cases with environmental temperature (p = 0.077) and rainfall (p = 0.270)

as shown in Figure 4.5.

 61

Figure 4.5 Correlation between monthly DENV infection and environmental

conditions.
 62

CHAPTER FIVE: DISCUSSION

5.1 Prevalence of Dengue Viral Infection

The present study found a prevalence of dengue viral infections to be 13.9 % with 9.5 %

as primary dengue cases and 4.4% as secondary dengue cases. The present study findings

appeared to be higher as compared to study findings from the neighboring country (Tanzania)

that reported 4.5% and 9.5% of dengue cases among the febrile patients (Vairo et al., 2012;

Hertz et al., 2012). The present findings may be as due to the spatial diffusion of the virus

and vector proliferation within the region. Since recent studies have reported dengue

outbreaks. In 2010, Comoros, Mayotte and Tanzania reported outbreak of dengue fever

caused by DENV-3 (Issack et al., 2010; Sante-plus.org, 2010; Klaassen, 2010; Sissoko et al.,

2010). DENV infection has also been reported in Mogadishu, Somalia (WHO, 2011).

Additionally, the heavy sea bound commercial traffic between eastern Africa and Indian sub-

continent where all four serotypes exist, and increased number of tourists and migrants from

other endemic areas exposed the coastal region to vulnerability of imported dengue resulting

to domestic spread of the disease (Matlani and Chakravarti, 2011).

5.2 Distribution of Dengue Viral Infections by Age

Dengue affects humans of all age groups worldwide and poses a pediatric public health

problem in some parts of the world (Gubler, 1998). During the present study, comparison

between the different age groups revealed that adults were infected disproportionately to

children. The most susceptible age group for DENV infection was 36-45 years and followed

by 26-35 years suggesting that the individuals in these age groups were actively involved in

outdoor activities that increased their chances of exposure to the infective DENV vector bite.

Similar observations have been reported from South East Asia regions where adults were

more affected than children (Tank and Jain, 2012).

 63

Regarding children, a lower DENV infection was observed in age group < 1 year (9.1%) in

respect to 1-5 years (12.2%). Since the vector Ae.aegypti, is a predominantly day biting

outdoor vector, Children < 1 year were at a lower risk of dengue infection as they spend

most of their time indoors, completely covered or sleep under bed nets unlike the children

aged 1-5 year who were able to play and spend more time outdoors within and around the

residential areas. A higher DENV infection was observed among children aged 1-5 years

with DENV infection cases reaching a low point in the age group 6-15 years before

rising again. Similar findings were observed from southeast India and Caribbean

(Akram, 1998; Kumar et al. 2013). The present findings may be explained by the fact

that children aged 1-5 years spent most of their time either at home or at a nursery or

kindergarten of which operates within residential areas or shop-houses. However, formal

half-day schooling starts at the age of 6 years, often with afterschool extracurricular

activities which lead to reduced exposure to mosquito bites among children aged 6-15

years.

Although, secondary infection was highest in children aged 1-5 years, younger children aged

< 1 year were at higher risk of severe dengue infection than children age 1-5 years. This was

because of maternal antibody enhancement of disease, as maternal antibodies wanes from

protective to enhancing levels (Halstead et al., 2002; Hammond et al., 2005). The present

study identified striking association of secondary DENV infection with dengue outbreaks.

The peak of secondary DENV infection observed among younger children aged 1-5 years

could be related to dengue outbreak that occurred in the neighboring Tanzania and Comoros

Island in 2010 (Sante-plus.org, 2010; Klaassen, 2010). Another important finding was the

evidence of the second peak among adults aged 26-35 years that suggested a link to the major

dengue outbreak which affected the coastal region in 1982 (Johnson et al., 1982).
 64

In relation to the antibody levels and dengue severity, dengue IgM P/N ratios were scattered

against IgG titers. IgM and IgG levels in groups A-B were considered as having primary

DENV infection and group C with secondary DENV infection. This was in agreement with

the description given by WHO (2009). However, IgM level in a 9 year patient in group A was

remarkably high. This is known to correlate with clinical severity (Lin et al., 2001). Studies

have demonstrated that high anti-dengue IgM was involved in the formation of platelet

associated IgM (PAIgM) which was associated independently with the development of DHF,

representing a possible predictor of DHF with a high specificity(Saito et. al., 2004).

However, in contrast high IgM levels in the present study did not correlated to severe

infection.

Anti-flavi IgG titers from 390 febrile cases were plotted to their age groups. Studies have

shown that anti-flavi IgG correlates with severe DENV infections, DHF and DSS (Saito et

al., 2004). In the present study, it was observed that adults within the age of 26-35 years , not

only had the highest DENV infection but also the highest GMT. The results reflected that

most adults in this age group were among previous exposures to DENV that occurred during

the outbreak in 1982 before quiescence of the disease (Johnson et al., 1982). Additionally,

high GMT observed among children aged less than 1 year was because of maternal antibodies

to DENV present at birth due to high prevalence of anti-flavi IgG among adult population.

In the present study, there were no severe cases of DENV infection despite the occurrence of

secondary DENV infection. The findings are also in agreement with studies carried out in

Nepal, Haiti and Brazil where severe forms were not found among the patients of African

origin, despite serologic pre-conditions hypothesized to be precursors for DHF (evidence of

secondary DENV infection) (Pun et al., 2011; Rico-Hesse et al., 2006; Cardoso et al., 2011).

These authors concluded that this was due to polymorphism of human leukocyte antigen
 65

(HLA) and other host genes (for example, transporter associated with antigen processing

(TAP) and human platelet antigen (HPA) in black populations. However, the present study

gave the snapshot of the disease spectrum during a non-epidemic period.

5.3 Distribution of Dengue Viral Infections by Gender

Gender differences in DENV infection have been inconsistent worldwide, while some studies

reporting a higher prevalence in men, others have shown a higher prevalence in women and

others no gender difference (Yew et al., 2009; Anker and Arima, 2011). The present study

found that both genders were equally susceptible to the DENV infection. The present study

finding was in harmony with studies from Nigeria and Madagascar (Sissoko et al., 2010;

Dawurung et al., 2010). An increase of DENV infection cases among women aged 26 - 35

years as compared to male of same age group, reflected exposure differences to infected

mosquito bites. Indeed, Ae. aegypti breed and rest in human dwellings and surroundings.

Therefore, the present findings showed that females in the county of Mombasa were more

likely than men to remain in and around the home, carrying out domestic activities during the

day when the mosquitoes are most active. Men were exposed only when they return the home

by end of day. However, male predominance in adults above 46 years could be partly

explained by accumulation of multitypic immunity among the female of the same age. The

present study finding was similar studies from India that suggested that exposure to multiple

serotypes over a period resulted in development of multitypic immunity in adults (Sharma et

al., 2012; Tomashek et al., 2009).

Among the children, gender distribution was reversed with a considerably higher DENV

infection among boys aged 0-15 years than girls. The underlying causes of gender differences

were not clear but multiple factors could play a role. Plausible explanations could be a biased

parents' health seeking behaviour towards males, differences in innate susceptibility and
 66

clinical presentations. Healthcare-seeking behavior might have accounted for the gender bias

observed with more than two times as many boys as girls affected among children less than

15 years. There has been a growing recognition that biological differences between males and

females based on genetic, immunological, and hormonal factors may determine the

susceptibility to disease and clinical outcomes, including for DENV infection (WHO, 2007b).

Other studies have reported a gender disparity of similar magnitude among children, but the

relative contributions of innate susceptibility and healthcare seeking behavior have remained

unclear (Goh et al., 1987; Agarwal et al., 1999).

5.4 Distribution of Dengue Viral Infections by Month

A number of mathematical models have been developed to account for the seasonality of the

disease and the vector. These have incorporated factors such as rain, temperature, humidity,

type of land, mosquito density, bite rate and life span (Bartley et al., 2002; Nakhapakorn and

Tripathi, 2005). In the present study, highest peak of DENV infection was observed in the

month of February, followed by April and March. The finding was in agreement with studies

from Saudi Arabia and Pakistan (Ahmed et al., 2008; Siddiqui et. al. 2009). Contrary to the

present study, other studies have shown that dengue cases coincided mainly with the post

monsoon period of subnormal rainfall. This was because of the relatively high prevalence and

distribution of Ae. aegypti larval indices after post monsoon rains (Baba and Talle, 2011; Pun

et al., 2011).

Occurrence of DENV infection in present study appeared to be independent of rainfall and

temperature, implying that factors for DENV transmission were spatially heterogeneous.

Presence of DENV infection cases during dry month of March as seen in present study could

probably be reflective of the year-round activity of the mosquito vector. The possible reasons

influencing the DENV transmission in coastal region of Kenya could include lack of safe
 67

water supply necessitating the storage of water for domestic use that provided suitable

breeding sites for Ae. aegypti. Additionally, poor garbage control resulted in accumulation of

vast numbers of non-biodegradable plastic containers and used automobile tires within the

environment that could collect fresh water during the rainy period thereby favoring vector

breeding and maintenance of the vector population throughout the year.

The findings of the present study revealed weak temperature induced DENV transmission

variations that may have determined vector efficiency. A higher DENV infection during the

dry months as compared to rainy months with a monthly peak in February was in support of

reports suggesting that temperature affected the rate of development in different mosquito life

stages, as well as dengue viral development (Keating, 2001; Yang et al., 2009; CDC, 2010).

Similarly, other studies have shown that mosquito survival rates were temperature dependent.

Studies in Puerto Rico that showed dengue incidence increase one week after every 1○C

increase in a weekly maximum temperature (Johansson et. al. 2009; Jury, 2008). However,

the low DENV infection cases during the month of July in the present study, indicated that

low temperatures may have slowed viral development and mosquitoes were unlikely to

survive long enough to become infectious (Hales et al., 2002).

5.5 Limitations of the Study

The present study had several limitations. Sample collection was done for only 6 months and

this could have been an unusually high or low period for DENV infection, as DENV infection

have annual variations. Additionally, the present study findings were based on laboratory-

confirmed cases; it was assumed that the actual contribution of asymptomatic cases to the

local spread of dengue was unknown and uncertainty about their potential to infect Ae.

aegypti mosquitoes while viremic. Therefore, the findings might be the tip of the iceberg in

the overall pattern of dengue spread in the coast region of Kenya.

 68

CHAPTER SIX: SUMMARY, CONCLUSION AND RECOMMENDATION

6.1 Summary

Dengue is an important emerging disease of the tropical and sub-tropical regions today. It is a

complex disease whose symptoms are difficult to distinguish from other common febrile

illnesses and can progress from a mild, non-specific viral disease to irreversible shock and

death within a few hours. This makes the differential diagnosis problematic especially in the

coastal region, where there is a high incidence of febrile illnesses such as typhoid fever and

malaria. The study aimed at determining the prevalence of DENV infection and describe the

month-wise trend of the disease. A total of 390 serum samples from febrile patients in a

period of 6 months (February - July 2012). Dengue antibodies were tested using an in-house

IgM-capture ELISA and indirect IgG ELISA. Fifty-four (13.9%) were found to be dengue

cases with 37 (9.5%) as primary dengue and 17 (4.4%) as secondary dengue. Majority

dengue infections were observed among 36-45 years. Both genders were equally susceptible

to the DENV infection. Predominance among female aged 26 -35 years. Lastly, DENV

infection occurred throughout the study period with peak dengue infection cases in February.

6.2 Conclusion

The present study concluded that;-

i) A dengue virus infection was one of the causes of acute undifferentiated fever

among febrile patients in the county Mombasa.

ii) Children aged less than 5 years were vulnerable to dengue infection and had a

greater risk than adults in developing severe forms of the disease when they

acquire a second dengue virus infection with a different serotype.

iii) Female predominance in dengue cases among age group 26-25 years would have

been masked when collapsing the data over all age groups. Therefore, the present
 69

study findings indicated the importance of reporting age and gender stratified data

for dengue surveillance to help in targeting specific preventive measures.

iv) Occurrence of dengue infection during dry month of March reflected a year-round

activity of the mosquito vector.

6.3 Recommendations

The present study recommends that;-

i) The government should provide resources at hospital laboratories in County to

facilitate early diagnosis and management of dengue patients.

ii) All patients presenting with febrile illness should be tested for dengue antibodies.

iii) Clinicians/physicians consider the possibility of dengue cases when examining febrile

patients.

iv) The government should initiate dengue surveillance and commence an integrated

vector control programme.

6.4 Further Research

The present study suggested the need to conduct RT- PCR or other antigen based assay in

samples collected within short clinical duration (< 6 days) and IgM in those with longer

duration, to identify the maximum number of dengue cases. Additionally, research on the

circulating serotypes and their genotypes to help in addressing the probabilities of DSS/DHF

incidence in future.
 70

REFERENCES

Agarwal R, Kapoor S, Nagar R, Misra A, Tandon R and Mathur A. (1999). A clinical study
of the patients with dengue hemorrhagic fever during the epidemic of 1996 at Lucknow,
India. Southeast Asian J Trop Med Public Health. 30(4): 735–740.
Ahmed S, Arif F, Yahya Y, Rehman A, Abbas K and Ashraf S. (2008). Dengue fever
outbreak in Karachi: A study profile and outcome of children under 15 year of age. J Pak
Med Assoc. 58:4-8.
Akram DS, Igarashi A and Takasu T. (1998). Dengue virus infection among children with
undifferentiated fever in Karachi. Indian J Pediatr. 65: 735-740.
Amarasinghe A, Kuritsk JN, Letson GW and Margolis HS. (2011). Dengue virus infection in
Africa. Emerg Infect Dis. 17: 1349–1354.
Anderson KB, Gibbons RV, Edelman R, Eckels KH, Putnak RJ, Innis BL and Sun W. (2011).
Interference and facilitation between dengue serotypes in a tetravalent live dengue virus
vaccine candidate. J Infect Dis. 204: 442-450.
Anker M and Arima Y. (2011). Male-female differences in the number of reported incident
dengue fever cases in six Asian countries. Western Pacific Surveil & Res J. 2(2):17-23.
Baba MM and Talle M. (2011). The effect of climate on dengue virus infections in Nigeria.
New York S. J. 4(1):28-33
Bartlett E, Kotrlik WJ, and Higgins CC. (2001). Organizational research: determining
appropriate sample size in survey research. Information technology, learning, and
performance. J Spring. 19(1): 43-50
Bartley LM, Donnelly CA, and Garnett GP. (2002). The seasonal pattern of dengue in
endemic areas: mathematical models of mechanisms. Trans R Soc Trop Med Hyg. 96: 387-
397.
Beatty M, Letson W, Edgil D, and Margolis H. (2007). Estimating the total world population
at risk for locally acquired dengue infection. Abstract presented at the 56th Annual Meeting
of the American Society of Tropical Medicine and Hygiene. Am J Trop Med Hyg. 77(5):
170–257.
Bundo K and Igarashi A. (1985). Antibody-capture ELISA for detection of immunoglobulin
M antibodies in sera from Japanese encephalitis and dengue hemorrhagic fever patients. J.
Virol., Methods. 11: 15–22
Bundo K, Morita K, Torres CA, Chanyasanha C, Linn ML, Igarashi A. (1986). Antibody
response in Japanese encephalitis and dengue hemorrhagic fever patients measured by
indirect ELISA. Trop Med. 28:101–114.
Cardoso IM, Cabidelle AS, Borges PC, Lang CF, Calenti FG, Nogueira, LO, Falqueto A
and Junior CC. (2011). Dengue: clinical forms and risk groups in a high incidence city in the
southeastern region of Brazil. Revista da Sociedade Brasileira de Med Trop. 44(4):430-435.
CDC. (2010). Dengue and climate. http://www.cdc.gov/dengue/entamologyEcology/climate
 71

CDC. (2012a). Update: Dengue in tropical and subtropical regions. Centers for Disease
Control and Prevention, Atlanta.
CDC. (2012b). Laboratory guidance and diagnostic testing. Centers for Disease Control and
Prevention, Atlanta.
Chambers TJ, Hahn CS, Galler R and Rice CM. (1990). Flavivirus genome organization,
expression, and replication. Annu Rev Microbiol. 44:649–688.
Chaturvedi UC, Agarwal R, Elbishbishi EA and Mustafa AS. (2000). Cytokine cascade in
dengue hemorrhagic fever: implications for pathogenesis. FEMS Immunol Med Microbiol.
28(3):183-188.
Chen LH and Wilson ME. (2004).Transmission of dengue virus without a Mosquito vector,
nosocomial mucocutanoes transmission and other routes. Clin Infe Dis. 39:56-60.
Chen L, Ewing D, Subramanian H, Block K, Rayner J, Alterson KD, Sedegah M, Hayes C,
Porter K, and Raviprakash K.(2007). A heterologous DNA prime-Venezuelan equine
encephalitis virus replicon particle boost dengue vaccine regimen affords complete protection
from virus challenge in cynomolgus macaques. J Virol. 81:11634-9.
Cochran WG. (1977). Sampling techniques. 3rd ed. John Wiley & Sons, Inc. New York:
Coller BA and Clements DE. (2011). Dengue vaccines: progress and challenges. Curr Opin
Immunol. 23:391-398.
Cologna R and Rico-Hesse R. (2003). American genotype structures decrease dengue virus
output from human monocytes and dendritic cells. J Virol. 77: 3929–38.
Crill WD and Roehrig JT. (2001). Monoclonal antibodies that bind to domain III of dengue
virus E glycoprotein are the most efficient blockers of virus adsorption to Vero cells. J Virol,
75:7769-7773.
Durbin AP and Whitehead SS. (2010). Dengue Vaccine Candidates in Development. In
Dengue Virus. 338: 129-143.
Dawurung JS, Baba MM, Stephen G, Jonas SC, Bukbuk DN and Dawurung CJ. (2010).
Serological evidence of acute dengue virus infection among febrile patients attending Plateau
State Specialist Hospital Jos, Nigeria. Report and Opin. 2(6)
Deen JL, Harris E, Wills B, Balmaseda A, Hammond SN, Rocha C, Dung NM, Hung NT,
Hien TT, Farrar JJ. (2006). The WHO dengue classification and case definitions: time for a
reassessment. Lancet. 368: 170 – 173 .
De Wazieres B, Gil H, Vuitton DA and Dupond JL. (1998). Nosocomial transmission of
dengue from a needlestick injury. Lancet. 14:351(910):498
De Souza V. (2007). Sensitivity and specificity of three ELISA based assays for
discriminating primary from secondary acute dengue virus infection. J. Clin. Virol. 39:230 –
233.
Duchini A, Govindarajan S, Santucci M, Zampi G and Hofman FM. (1996). Effects of tumor
necrosis factor and interleukin-6 on fluid-phase permeability and ammonia diffusion in CNS-
derived endothelial cells. J Investig Med. 44: 474 – 482.
 72

El-Badry AA and Al-Ali KH. (2010). Prevalence and seasonal distribution of dengue
mosquito, Aedes aegypti (Diptera: Culicidae) in Al- Madinah Al-Munawwarah, Saudi
Arabia. J Med Entomol. 7: 80-88.
Espina LM, Valero NJ, Hernandez JM and Mosquera JA. (2003). Increased apoptosis and
expression of tumor necrosis factor-alpha caused by infection of cultured human monocytes
with dengue virus. Am J Trop Med Hyg. 68: 48-53.
Falconar AK. (1997). The dengue virus nonstructural-1 protein (NS1) generates antibodies to
common epitopes on human blood clotting, integrin/adhesin proteins and binds to human
endothelial cells: potential implications in haemorrhagic fever pathogenesis. Arch Virol.
42(5): 897-916.
Fried JR, Gibbons RV, Kalayanarooj S, Thomas SJ, Srikiatkhachorn A, Thomas SJ,
Srikiatkhachorn A, Yoon IK, Jarman RG, Green S, Rothman AL, Derek A and Cummings
T. (2010). Serotype-Specific Differences in the Risk of Dengue Hemorrhagic Fever: An
Analysis of Data Collected in Bangkok, Thailand from 1994 to 2006. PLoS Negl Trop Dis.
4(3): 617.
Gerber JS, Mosser DM. (2001). Reversing lipopolysaccharide toxicity by ligating the
macrophage Fc gamma receptors. J Immunol.166: 6861–6868
George R and Lum LCS. Clinical spectrum of dengue infection. In: Gubler DJ, Kuno G, eds.
(1997). Dengue and dengue hemorrhagic fever. CAB International: New York. pp 89-113.
Gibbons RV and Vaughn DW. (2002). Dengue: an escalating problem. BMJ. 324: 1563 –
1566.
Goh KT, Ng SK, Chan YC, Lim SJ and Chua EC. (1987). Epidemiological aspects of an
outbreak of dengue fever/dengue haemorrhagic fever in Singapore. Southeast Asian J Trop
Med Public Health. 18(3):295–302.
Gubler DJ. (1997). Dengue and dengue haemorrhagic fever: its history and resurgence as a
global public health problem. In Dengue and dengue haemorrhagic fever, Edited by Gubler,
DJ and Kuno, G. CAB International:Oxford. pp. 1-22.
Gubler DJ, and Clark GG. (1995). Dengue/Dengue Hemorrhagic Fever: The emergence of a
global health problem. Emerg Infect Dis. 1: 55-57.
Gubler DJ. (1998). Dengue and dengue hemorrhagic fever. Clin Microbiol Rev. 11: 480–496.
Gubler DJ. (2002). Epidemic dengue/dengue hemorrhagic fever as a public health, social and
economic problem in the 21st century. Trends Microbiol. 10: 100-103.
Gubler DJ and Meltzer M. (1999). Impact of dengue/dengue haemorhagic fever on the
developing world. ADENV Virus Res. 53: 35-70.
Guha-Sapir D and Schimmer B. (2005) Dengue fever: new paradigms for a changing
epidemiology. Emerg Themes Epidemiol. 2(1): 1 - 10
Gurugama P, Garg P, Wijewickrama A and Seneviratne SL. (2010). Dengue viral infections.
Indian J Deratol. 55: 68 –78.
 73

Guy B, Guirakhoo F, Barban V, Higgs S, Monath TP and Lang J. (2010). Preclinical and
clinical development of YFV 17D-based chimeric vaccines against dengue, West Nile and
Japanese encephalitis viruses. Vaccine. 28: 632-649.
Guzman MG, Halstead SB, Artsob H, Buchy P, Farrar J, Gubler DJ, Hunsperger E, Kroeger
A, Margolis HS, Martinez E, Nathan MB, Pelegrino JL, Simmons C, Yoksan S and Peeling
RW. (2010). Dengue: a continuing global threat. Nat Rev Microbiol. 8: 7-16.
Guzman MG, Kouri G, Bravo J, Valdes L, and Vazquez S. (2002) Effect of age on outcome
of secondary dengue 2 infections. Int J Infect Dis. 6: 118–124.
Guzman MG and Kouri G. (2003). Dengue and dengue hemorrhagic fever in the Americas:
lessons and challenges . Clin Virol. 27:1-13.
Hales S. De Wet N, Maindonald J and Woodward A. (2002). Potential effect of population
and climate changes on global distribution of dengue fever: an empirical model. Lancet 360:
830–834.
Halstead SB. (2002). Dengue. Curr Opin Infect Dis. 15: 471–476.
Halstead SB, Lan NT, Myint TT, Shwe TN, Nisalak A and Kalyanarooj S. (2002). Dengue
hemorrhagic fever in infants: Research opportunities ignored. Emerg Infect Dis. 8:1474–
1479.
Hammond SN, Balmaseda A, Perez L, Tellez Y, Saborio SI and Mercado JC. (2005).
Differences in dengue severity in infants, children, and adults in a 3-year hospital-based study
in Nicaragua. Am J Trop Med Hyg. 73:1063–1070.
Henchal EA and Putnak JR. (1990). The dengue viruses. Clin. Microbiol. Rev. 3: 376-396.
Hertz JT, Munishi OM, Ooi EE, Howe S, Lim WY, Chow A, Morrissey AB, Bartlett JA,
Onyango JJ, Maro VP, Kinabo GD, Saganda W, Gubler DJ and Crump JA. (2012).
Chikungunya and dengue fever among hospitalized febrile patients in northern Tanzania. Am
J Trop Med Hyg. 86(1):171-177.
Huber K, Ba Y, Dia I, Mathiot C, Sall AA, and Diallo M. (2008). Aedes aegypti in Senegal:
genetic diversity and genetic structure of domestic and sylvatic populations. Am J Trop Med
Hyg. 79: 218-229.
Huisman W, Martina BE, Rimmelzwaan GF, Gruters RA, and Osterhaus AD. (2009).
Vaccine-induced enhancement of viral infections. Vaccine. 27: 505-512.
ICTVdB - The Universal Virus Database, version 4. (2006). Virus Taxonomy, Classification
and nomenclature of viruses. Columbia University: New York.
Issack MI, Pursem VN, Barkham TMS, Lee-Ching N, and Manraj SS. (2010). Reemergence
of Dengue in Mauritius. Emerg Infe Dis. 16(4).
Inoue S, Alonzo MT, Kurosawa Y, Mapua CA, Reyes JD, Dimaano EM, Alera MT, Saito M,
Oishi K, Hasebe F, Matias RR, Natividad FF and Morita K. (2010). Evaluation of a dengue
IgG indirect enzyme-linked immunosorbent assay and a Japanese encephalitis IgG indirect
enzyme-linked immunosorbent assay for diagnosis of secondary dengue virus infection. Vect
Born Zoo Dis. 10:143–150.
 74

Jessie K, Fong MY, Devi S, Lam SK and Wong KT. (2004). Localization of dengue virus in
naturally infected human tissues, by immunohistochemistry and in situ hybridization. J Infect
Dis 189(8):1411–1418
Johansson M, Dominici F and Glass G. (2009). Local and Global effect of climate on dengue
transmission in Puetro Rico. PLoS Negl Trop Dis. 3(10):1371.
John ALS, Rathore APS, Yap H. (2011). Immune surveillance by mast cells during dengue
infection promotes natural killer (NK) and NKT-cell recruitment and viral clearance. Nat
Acad Sc. 108(22): 9190–9195.
Johnson BK, Ocheng D, Gichogo A, Okiro M, Libondo D, Kinyanjui P, Tukei PM. (1982).
Epidemic dengue fever caused by dengue type 2 virus in Kenya: preliminary results of human
virological and serological studies. East Afr Med J. 59: 781–784.
Jury MR. (2008). Climate influence on dengue epidemics in Puerto Rico. Intl J Environ
Health Research. 18: 323–334.
Kalayanarooj S, Chansiriwongs V and Nimmannitya S. (2002). Dengue patients at the
Children's Hospital, Bangkok: 1995-1999. Review. Dengue Bulletin. 26: 33–43.
Keating J. (2001). An investigation into the cyclical incidence of dengue fever. Soc Sci Med.
53(12): 1587-1597.
Kitchener S, Nissen M, Nasveld P, Forrat R, Yoksan S, Lang J and Saluzzo JF. (2006).
mmunogenicity and safety of two live-attenuated tetravalent dengue vaccine formulations in
healthy Australian adults. Vaccine. 24: 1238-12341.
Klaassen B. (2010). Dengue/DHF update (23). ProMed. 2010 May 17 [cited 2010 Jun 10].
http://www.promedmail.org, archive no. 20100517.1620
Kenya Integrated House Budget Survey. (2007). Basic report. ISBN: 9966-767-07-X
Kenya National Bureau of Statistics. (2009). The 2009 Kenya Population and Housing
Census, volume 1A: population distribution by administrative units.
Khin MM and Than KA. (1983). Transovarial transmission of dengue 2 virus by Aedes
aegypti in nature. Am J Trop Med Hyg. 32: 590-594.
Kumar A, Hilaire MG and Nielsen AL. (2013). Epidemiological trends and clinical
manifestations of Dengue among children in one of the English-speaking Caribbean
countries. Trans R Soc Trop Med Hyg. 10:1093
Leitmeyer KC, Vaughn DW, Watts DM, Salas R, de Chacon VI, Ramos C and Rico-Hesse R.
(1999). Dengue virus structural differences that correlate with pathogenesis. J. Virol.
73:4738–4747.
Libraty DH, Endy TP, Houng HS, Green S, Kalayanarooj S, Suntayakorn S, Chansiriwongs
W, Vaughn DW, Nisalak A and Ennis FA (2002) Differing influences of virus burden and
immune activation on disease severity in secondary dengue-3 virus infections. J Infect Dis.
185:1213–1221
 75

Lin CF, Lei HY, Liu CC, Liu HS, Yeh TM, Wang ST, Yang TI, Sceu FC, Kao CF and Lin
YS. (2001). Generation of IgM antiplatelet autoantibody in dengue patients. J Med Viol
63:143– 149.
Luplerdlop N, Misse D, Bray D, Deleuze V, Gonzalez JP and Leard K. (2006). Dengue-virus-
infected dendritic cells trigger vascular leakage through metalloproteinase overproduction.
EMBO Rep. 7:1176–1181.
Maves RC, Ore RM, Porter KR and Kochel TJ. (2011). Immunogenicity and protective
efficacy of a psoralen-inactivated dengue-1 virus vaccine candidate in Aotus nancymaae
monkeys. Vaccine. 29: 2691-2696.
Markoff LJ, Innis BL, Houghten R, Henchal LS. (1991). Development of cross-reactive
antibodies to plasminogen during the immune response to dengue virus infection. J Infect
Dis. 164(2):294-301.
Matlani M and Chakravarti A. (2011). Changing trends of dengue disease: a brief report from
a tertiary care hospital in New Delhi. Braz J Infect Dis. 15: 184-185.
Miller JM, Barend J. M deWet,Luisa Martinez-Pomares,Catherine M Radcliffe,Raymond A
Dwek,Pauline M Rudd,Siamon Gordon. (2008). The Mannose Receptor Mediates Dengue
Virus Infection of Macrophages PLoS Pathog. 4: e17.
Monath TP. (1994). Dengue: the risk to developed and developing countries. Proc Natl Acad
Sci. 91:2395 -2400.
Mongkolsapaya J, Dejnirattisai W, Xu Xn, Vasanawathana S, Tangthawornchaikul N,
Chairunsri A, Sawasdivorn S, Duangchinda T, Dong T, Rowland-Jones S, Yenchitsomanus
PT, Mcmichael A, Malasit P and Screaton G. (2003). Original antigenic sin and apoptosis in
the pathogenesis of dengue hemorrhagic fever. Nat Med. 9:921-927.
Morrison D, Legg TJ, Billings CW, Forrat, R Yoksan S, Lang J. (2010). A novel tetravalent
dengue vaccine is well tolerated and immunogenic against all 4 serotypes in flavivirus naïve
adults. J. Infect. Dis. 201(3):370-377.
Mwangangi JM, Midega J, Kahindi S, Njoroge L, Nzovu J, Githure J, Mbogo CM, and Beier
JC. (2011). Mosquito species abundance and diversity in Malindi, Kenya and their potential
implication in pathogen transmission. Parasitol Res. 110:61–71
Nakhapakorn K and Tripathi NK. (2005). An information value based analysis of physical
and climatic factors affecting dengue fever and dengue haemorrhagic fever incidence. Int J
Health Geogr. 4: 13.
Nawa M, Takasaki T, Ito M, Inoue S, Morita K, and Kurane I. (2005). Immunoglobulin A
Antibody Responses in Dengue Patients: a Useful Marker for Serodiagnosis of Dengue Virus
Infection. Clin Diagn Lab Immunol. 12(10): 1235–1237
Ngwe-Tun MM, Thant KZ, Inoue S, Kurosawa Y, Lwin L, Lin S, Aye KT, Khin PT, Myint
T, Htwe K, Mapua CA, Natividad FF, Hirayama K, and Morita K. (2013). Serological
Characterization of Dengue Virus Infections Observed Among Dengue Hemorrhagic
Fever/Dengue Shock Syndrome Cases in Upper Myanmar. Journal of Medical Virology.
9999:1–9
 76

Noble CG, Chen YL, Dong H, Gu F, Lim SP and Schul W. (2010). Strategies for
development of dengue virus inhibitors. Antiviral Res. 85(3): 203-209.
Osorio JE, Huang CY, Kinney RM and Stinchcomb DT. (2011). Development of DENVax: a
chimeric dengue-2 PDK-53-based tetravalent vaccine for protection against dengue fever.
Vaccine. 29: 7251-7260.
Oishi K, Inoue S, Cinco MTDD, Dimaano EM, Alera MT, Alfon JA, Abanes F, Cruz DJ,
Matias RR, Matsuura H, Hasebe F, Tanimura S, Kumatori A, Morita K, Natividad FF,
Nagatake T. (2003).. Correlation between increased platelet-associated IgG and
thrombocytopenia in secondary dengue virus infections. J Med Virol. 71:259–64.

Pang T, Cardosa MJ, Guzman MG. (2007). Of cascades and perfect storms: the
immunopathogenesis of dengue haemorrhagic fever-dengue shock syndrome (DHF/DSS).
Immunol Cell Biol. 85:43-45.

Perera R, and Kuhn RJ. (2008). Structural proteomics of dengue virus. Annu Rev Microbiol.
11: 369–377.
Perez AB, Sierra B, Garcia G, Aguirre E, Babel N, Alvarez M, Sanchez L, Valdes L, Volk H
D, and Guzman MG. (2010). Tumor necrosis factor-alpha, transforming growth factor-β1,
and interleukin-10 gene polymorphisms: implication in protection or susceptibility to dengue
hemorrhagic fever. Hum Immunol. 71: 1135–1140.
Peeling RW, Artsob H, Pelegrino JL, Buchy P, Cardosa MJ, Devi S, Enria DA, Farrar J,
Gubler DJ, Guzman MG, Halstead SB. (2010). Evaluation of diagnostic tests: Dengue. Nat
Rev Microbiol. 8(12): s30-8
Porter KR, Ewing D, Chen L, Wu SJ, Hayes CG, Ferrari M, Teneza-Mora N, and
Raviprakash K. (2012). Immunogenicity and protective efficacy of a vaxfectin-adjuvanted
tetravalent dengue DNA vaccine. Vaccine. 30:336-341.
Pun R, Pant KP, Bhatta DR and Pandey BD. (2011). Acute Dengue Infection in the Western
Terai Region of Nepal. J Nepal Med Assoc. 51(181): 11-14
Reiter P. (2001). Climate change and mosquito-borne disease. Environ Health Perspect.
109(1): 141-61.
Rigau-Perez JG. (2006). Severe dengue: the need for new case definitions. Lancet Infect Dis.
6:297-302.
Roiz D, Eritja R, Molina R, Melero-Alcibar R and Lucientes J. (2008) Initial distribution
assessment of Aedes albopictus (Diptera: Culicidae) in the Barcelona, Spain, Area. J Med
Entomol. 45: 347-352.
Rothman AL. (2004). Dengue: defining protective versus pathologic immunity. J Clin Invest.
113: 946-951.
Rothman AL. (2011). Immunity to dengue virus: a tale of original antigenic sin and tropical
cytokine storms. Nat Rev Immunol. 11: 532-543.
 77

Rodhain F and Rosen L. (1997). Mosquito vectors and dengue virus-vector relationships. In:
Gubler DJ, Kuno G. Dengue and Dengue Hemorrahgic Fever. CAB International, New York:
USA. 45 - 60.
Rothman AL. (1999). Viral pathogenesis of dengue infections. In Anonymous Dengue and
dengue hemorrhagic fever. CABI Publishing, New York.
Saito M, Oishi K, Inoue S, Dimaano EM, Alera MTP, Robles MP, Estrella JR, Kumatori A,
Moji K, Alonzo BMT, Buerano CC, Matias RR, Morita K, Natividad FF, Nagatake T. (2004).
Association of increased platelet-associated immunoglobulins with thrombocytopenia and the
severity of disease in secondary dengue virus infections. Clin Exp Immunol 138: 299–303.
Sang R and Dunster LM. (2001). The growing threat of arbovirus transmission and outbreaks
in Kenya: a review. East Afr Med J. 78(12):655-661.

Sante-Plus.Org. (2010). [in French, trans. ProMed Mod.TY, edited] <http://sante-

plus.org/breve663.html>
Sanchez V, Gimenez S, Tomlinson B, Chan P K, Thomas G, Forrat R, Chambonneau L.,
Deauvieau F, Lang J and Guy B. (2006). Innate and adaptive cellular immunity in flavivirus-
naive human recipients of a live-attenuated dengue serotype 3 vaccines produced in Vero
cells (VDV3). Vaccine. 24: 4914-4926.
Sharma Y, Kaur M, Singh S, Pant L, Kudesia M, Jain S. (2012). Seroprevalence and trend of
dengue cases admitted to a government hospital, Delhi – 5-year study (2006-2010): A look
into the age shift. Int J Prev Med. 3:537-43.
Shrestha B, Brien JD, Sukupolvi-Petty S, Austin SK, Edeling MA and Kim T. (2010). The
development of therapeutic antibodies that neutralize homologus and heterologous genotypes
of dengue virus type 1. PLoS Pathog. 6(4): e1000823.
Siddiqui FJ, Haider SR, and Bhutta ZA. (2009). Endemic Dengue Fever: a seldom recognized
hazard for Pakistani children. J Infect Dev Ctries. 3(4): 306-312
Soundravally R and Hoti SL. (2007). Immunopathogenesis of dengue hemorrhagic fever and
shock syndrome: role of TAP and HPA gene polymorphism. Hum Immunol. 68: 973
Srikiatkhachorn A, Krautrachue A, Ratanaprakarn W, Wongtapradit L, Nithipanya N and
Kalayanarooj S. (2007). Natural history of plasma leakage in dengue hemorrhagic fever: a
serial ultrasonographic study. Pediatr Infect Dis J. 26:283–290.
Sissoko D, Ezzedine K, Giry C, Moendandze A, Lernout T, D’Ortenzio E, Pettinelli F,
Malvy D. (2010) Seroepidemiology of Dengue Virus in Mayotte, Indian Ocean, 2006. PLoS
ONE 5(11): 14141.
Stephens HA. 2010. HLA and other gene associations with dengue disease severity. Curr Top
Microbiol Immunol. 338: 99-114.
Stephenson JR. (2005). Understanding dengue pathogenesis: implications for vaccine design.
Bull World Health Organ 83:308–314.
Tan FL, Loh DL, Prabhakaran K, Tambyah PA and Yap HK. (2005). Dengue haemorrhagic
fever after living donor renal transplantation. Nephrol Dial Transplant. 20:447–448.
 78

Tank AG, Jain MR. (2012). Trend of dengue in a tertiary care hospital of surat city, western
india. Nat J Comm Med. 3(2): 302-304
Tassaneetrithep B, Burgess TH, Granelli-Piperno A, Trumpfheller C, Finke J, Sun W, Eller
MA, Pattanapanyasat K, Sarasombath S, Birx DL, Steinman RM, Schlesinger S and
Marovich MA. (2003). DC-SIGN (CD209) mediates dengue virus infection of human
dendritic cells. J Exp Med. 197(7): 823-829
Thomas SJ. (2011). The necessity and quandaries of dengue vaccine development. J Infect
Dis, 203: 299-303.
Tomashek KM, Rivera A, Muñoz-Jordan JL, Hunsperger E, Santiago L, Padro O, Garcia E
and Wellington S. (2009). Description of a large island-wide outbreak of dengue in Puerto
Rico, 2007. 81:467–474.
Ty Hang VT, Holmes EC, Veasna D, Quy NT and Tinh Hien T. (2010). Emergence of the
Asian 1 Genotype of Dengue Virus Serotype 2 in Viet Nam: In Vivo Fitness Advantage and
Lineage Replacement in South-East Asia. PLoS Negl Trop Dis. 4(7): 757.
Vairo F, Nicastri E, Meschi S, Schepisi MS, Paglia MG, Bevilacqua N, Mangi S, Sciarrone
MR, Chiappini R, Mohamed J, Racalbuto V, Di Caro A, Capobianchi MR and Ippolito G.
(2012). Seroprevalence of dengue infection: a cross-sectional survey in mainland Tanzania
and on Pemba Island, Zanzibar. Int J Infect Dis. 16(1):44-46.
Vaughn DW, Green S, Kalayanarooj S, Innis BL, Nimmannitya S, Suntayakorn S, Endy TP,
Raengsakulrach B, Rothman AL, Ennis FA and Nisalak A. (2000). Dengue viraemia titre,
antibody response pattern, and virus serotype correlate with disease severity. J Infect Dis.
181: 2
Voller A, Bidwell O, and Bartlett A. (1976). Mricroplate enzyme immunoassays for the
immunodiagnosis of viral infections. 506 – 512. In NR Rose and Friedman (ed). Manual of
Clinical Immunology, Amer Soc Microbiol, Washington D.C.
Whitehead SS, Blaney JE, Durbin AP and Murphy BR. (2007). Prospects for a dengue virus
vaccine. Nat Rev Microbiol. 5: 518-528.
WHO. (1997). Dengue Haemorrhagic Fever: Diagnosis, Treatment, Prevention and Control.
2nd edition. WHO. Geneva, Switzerland
WHO. (2007a) Scientific Working Group Report on Dengue. WHO. Geneva, Switzerland.
WHO. (2007b). Addressing sex and gender in epidemic-prone infectious diseases. WHO.
Geneva, Switzerland.
WHO. (2009). Dengue: guidelines for diagnosis, treatment, prevention and control. WHO.
Geneva, Switzerland.
WHO. (2011). Somalia Emergency Health Update. Weekly Highlights 19-25 November 2011
WHO. (2012). Report on the Subregional meeting on dengue fever in the Red Sea rim. WHO.
Regional Office for the Eastern Mediterranean.
Wilder-Smith A, Chen LH, Massad E and Wilson ME. (2009).Threat of dengue to blood
safety in dengue-endemic countries. Emerg Infect Dis.
 79

Wongkoon S, Jaroensutasinee M, Jaroensutasinee K and Preechaporn W. (2007).

Development sites of Aedes aegypti and Ae. albopictus in Nakhon Si Thammarat, Thailand.
Dengue Bull. 31: 141-152.
Wu SJ, Grouard-Vogel G, Sun W, Mascola JR, Brachtel E, Putvatana R, Louder MK,
Filgueira L, Marovich MA, Wong HK, Blauvelt A, Murphy GS, Robb ML, Innes BL, Birx
DL, Hayes CG and Frankel SS. (2000). Human skin Langerhans cells are targets of dengue
virus infection. Nat Med. 6(7):816-20.
Yang HM, Macoris MLG, Galvani KC, Andrighetti MTM and Wanderley DMV. (2009).
Assessing the effects of temperature on the population of Aedes aegypti, the vector of dengue.
Epidemiol Infect. 137:1188-202.
Yauch LE and Shresta S. (2008). Mouse models of dengue virus infection and disease.
Antiviral Res. 80(2): 87-93.
Yauch LE, Zellweger RM, Kotturi MF, Qutubuddin A, Sidney J, Peters B, Prestwood TR,
Sette A and Shresta S. (2009). A protective role for dengue virus-specific CD8+ T cells. J
Immunol. 182(8):4865-73.
Yen TY, Chen HC, Lin YD, Shieh CC, and Wu-Hsieh BA. (2009). Enhancement by Tumor
Necrosis Factor Alpha of Dengue Virus-Induced Endothelial Cell Production of Reactive
Nitrogen and Oxygen Species Is Key to Hemorrhage Development J. Virol. 83:18
Yew Y, Ye T, Ang L, Ng L, Yap G, A and James L. (2009). Seroepidemiology of dengue
virus infection among adults in Singapore. Annual Acad Med. 38: 667-675.
Zanotto PM, Gould EA, Gao GF, Harvey PH and Holmes EC. (1996). Population dynamics
of flaviviruses revealed by molecular phylogenies. Proc Natl Acad Sci. 93:548–553.
 80

APPENDICES

Appendix A: Informed Consent Form

CONSENT FORM (Hospital Based Study)

Consent to Participate in a Research Study

PROJECT TITLE: PREVALENCE OF DENGUE VIRAL INFECTIONS AMONG FEBRILE

PATIENTS IN MOMBASA COUNTY, KENYA

Name of Clinic/Health Facility: _____________________________________________

Study Number: ______________________ Date of Hospital Visit: _________________

1. PURPOSE: The purpose of this study is to assess the prevalence of dengue virus infection.

I would like to ask you to volunteer and take part in this research project, which will include a minimum of 384
patients.

2. PROCEDURES: If you agree to participate in this study, we will ask you/your child for a small sample of
blood if you/your child has high-grade fever of >39.50C. A blood sample (3 ml) will be taken from
the arm (venipuncture). The blood will be used to attempt to identify dengue antibodies.

3. RISK TO PARTICIPANT: Blood will be drawn from your/child’s arm with a needle by an experienced
phlebotomist. The risk that you/your child may be injured during collection of blood is minimal, but it is
possible that there may be some pain and discomfort when the blood is removed from the arm; afterwards there
may be some bruising or swelling and a very small possibility of infection at the site where the blood was
collected. You/your child may feel faint when the sample is taken but this is uncommon and the feeling will
pass quickly.

4. POTENTIAL BENEFITS: The possible benefit to you/your child from taking part in this study is that the
blood samples they tell you/your child have or had dengue infections.

5. COST AND COMPENSATION: There is no cost to you to participate in the study.

6. MEDICAL CARE FOR RESEARCH RELATED INJURY: If you/your child is injured as a direct result
of taking part in this research project, you/your child will be given medical care for that injury. This will be
given to you/your child at no cost. You/your child will not receive any injury compensation, only medical care.
Signing this document does not limit you/your child rights to seek legal remedies through the legal
system.

7. SUBJECT CONFIDENTIALITY: All the information related to this project will be confidential. The data
may be reviewed by the Institutional Review Committee and Scientific Steering Committee. We will keep them
private to the extent legally as possible.

8. VOLUNTARY PARTICIPATION: You/your child can decide not to take part in this study without any
negative consequences.
 81

9. POINTS OF CONTACT: If you/your child want to talk to someone about this study or if you/your child
have been injured from taking part in this study, please contact Prof. Matilu Mwau (Principal Researcher) of
KEMRI at 02027222541 ext 2256/2290

10. CONSENT: THE PROJECT HAS BEEN EXPLAINED TO ME IN A LANGUAGE AND LEVEL I CAN
UNDERSTAND. I HAVE BEEN ENCOURAGED TO ASK QUESTIONS ABOUT THE RESEARCH STUDY. MY
SIGNATURE BELOW WILL INDICATES THAT I HAVE CONSENTED TO VOLUNTEER TO TAKE PART IN
THIS STUDY.

My Name: _______________________________________________________________________________________________________

Age: ________________________________________ Sex: _______________________________________________

Signature: ______________________________________________________________________________________________________

It is possible that after we have completed the laboratory tests on your blood samples, there will be some
leftover. What do you want us to do with this leftover blood sample? (Initial only one option)

A. _______ After the study is completed destroy all remaining specimens.

B. _______ After the study is complete the remaining specimens can be used for any scientific purpose
provided that the scientific purpose is approved by an Scientific Steering Committee and that my specimen
will not be identified by name but only by a number.

I also understand that there will be no compensation for the future use of my specimen(s).

If you change your mind at any time, and would like their leftover blood samples destroyed contact Dr. Matilu
Mwau (Principal Researcher) of KEMRI at 02027222541 ext 2256/2290.

If the parent or guardian is illiterate, an adult must witness the consent process.

Name of Witness: ________________________________________________________ Age:______________

Signature of Witness: _____________________________________________ Date: _____________________

Name of Investigator: _______________________________________________________________________

Signature of Investigator: _________________________________________ Date: ______________________

 82

Appendix B: Clinical Investigation Questionnaire of Febrile Illnesses

PREVALENCE OF DENGUE VIRUS INFECTION AMONG FEBRILE

PATIENTS IN MOMBASA COUNTY
Clinic/ health facility name:

…………………………………………………………………………………………….
Clinic Code: Study Number: Date of hospital visit: Age: Sex:

……………………….… ………………….…… …………………………….... ……..yrs M ( ) F( )

Village of residence: Location: County: Province:

………………………… ..…………..……… ……………………………….. …….……………………….

Marital status: Indicate whether: Occupation:

Single ( ) 1. Head of the househ ( )

………………………………
Married ( ) 2. Mother ( )
3. Caretaker ( )
Have you ever been vaccinated for any Arbovirus If yes, which one? If Yes, when:
infection?
Yes ( ) No ( ) ................................................. ………………………………
Clinical signs and symptoms:

Fever If Yes, Duration of symptoms:

Yes ( ) No ( )
……………………………………………………………………..
Skin rashes If Yes, Duration of symptoms (in days)
Yes ( ) No ( )
…………………………………..…………………………………
Abdominal pain If Yes, Duration of symptoms (in days)
Yes ( ) No ( )
…………………………………..…………………………………
Myalgia If Yes, Duration of symptoms (in days)
Yes ( ) No ( )
…………………………………..…………………………………
Headache If Yes, Duration of symptoms (in days)
Yes ( ) No ( )
…………………………………..…………………………………
Bleeding diathesis: If Yes, Duration of symptoms (in days)
Yes ( ) No ( )
…………………………………..…………………………………
List any other symptoms
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Name of person completing form: Signature: Date:

……………………………………………………… …………….………………….. ……………………………..

 83

Appendix C: KEMRI Ethical Review Clearance