Asaduzzaman, Md

Ashrafi, Shah Ali Akbar

Haider, Najmul

Hasan, Mohammad Nayeem

Lee, Shui Shan

Rahman, Mahbubur

Sharif, Ahmed Raihan

Zumla, Alimuddin

English

UCL Discovery

International Journal of Infectious Diseases 136 (2023) 1–4 Contents lists available at ScienceDirect International Journal of Infectious Diseases journal homepage: www.elsevier.com/locate/ijid Editorial Bangladesh’s 2023 Dengue outbreak – age/gender-related disparity in morbidity and mortality and geographic variability of epidemic burdens iretstiderMc[nhvrwd  SaTagdar  iocfttssfsmdmittiVBadeoimmDommiDatpmatmtietobhatotcdth1(Bangladesh is currently grappling to control its most devastat- ng dengue fever outbreak recorded since the dengue virus (DENV) eappeared in the country in 20 0 0 [1–3] . Although dengue is ndemic in Bangladesh, the current dengue surge is unusual in erms of case burden and mortality, seasonality, and the early harp increase [1] . Between 1 January and 25 August 2023, a to- al of 110,224 DENV infections including 528 deaths (case fatal- ty ratio [CFR]: 0.48%) were recorded [2] . The reported number of engue cases and deaths this year so far is already the highest ver recorded in the country, while the numbers are continuing to ise [1–3] . The Bangladesh Ministry of Health and Family Welfare’s anagement Information System (MIS) provides daily reports on ases, deaths, and the district-wise distribution of DENV infections 2] . Analyses of data from inpatient records and geographic coordi- ates of residence locations between 1 January and 17 August 2023 ighlight four important findings that require further epidemic in- estigation: First , approximately half of the cases (n = 52,656) were ecorded in the capital city Dhaka, and 86% of them were located ithin a 2-km radius of hospitals, raising concern about the high ensity of DENV patients in the proximity of the hospitals ( Fig. 1 ).econd , although 62% of the cases are males, 58% of the deaths re females indicating a higher risk of mortality among females. hird , we identified a possible age-specific disparity in morbidity nd mortality indicating more severe infections in the older age roup. People ≥30 years old accounted for 38% of cases and 64% of eaths in 2023. Fourth, out of 528 deaths, 391 (74%) were recorded mong the patients hospitalized in the capital city, Dhaka ( Fig. 2 ). Currently, Dhaka accounts for approximately 48% (n = 52,656) of eported dengue cases and 74% (n = 391) of deaths ( Fig. 2 ), show-ng a higher CFR of 0.74% compared to that of 0.24% in the rest f the country, while the percentage distribution of cases had hanged over time. Initially, 76% (n = 6,014) of cases were reported rom Dhaka up until 28 June when Eid-al-Adha was celebrated by he Muslims in the country. To celebrate the festival, people left he capital city for rural family homes. This probably allowed the pread of DENV from Dhaka to the rest of the country. The rea- on for more fatal outcomes of dengue in female patients needs urther study. The median age of infected males and females are imilar, at 25 years and 26 years respectively. Compared to fe- ales, males spend more time outdoors, especially during the awn and dusk, when Aedes mosquitoes remain active [3] . Further- ore, males are often earners and decision-makers of the families ttps://doi.org/10.1016/j.ijid.2023.08.026 201-9712/© 2023 The Authors. Published by Elsevier Ltd on behalf of International Socie http://creativecommons.org/licenses/by/4.0/ ) n Bangladesh, and are more likely to get admitted to the hospital han their female counterparts. It may be that only a small frac- ion of females who have severe dengue are hospitalized render- ng a lower denominator for the gender among admitted patients. itamin D deficiency is more frequent in females than males in angladesh [4] due to less exposure to sunlight, which might be ssociated with susceptibility to severe disease. People living in engue-endemic countries experience a higher cumulative lifetime xposure to DENV and thus older people have a higher likelihood f secondary (when infected with 2 nd serotype) or tertiary dengue nfection (when infected with a third serotype) which can lead to ore fatal outcomes. The prevention and control of dengue depends on effective osquito control measures [ 3 , 5–7 ]. The mosquito vectors for ENV, Aedes aegypti and Aedes albopictus , have a short flying range f 500-750m, which breed with the dispersal of eggs within 840  radius [8] . People with dengue remain viremic for up to a maxi- um of 12 days [5] . With a concentration of DENV, hospitals treat- ng dengue patients may serve as reservoirs setting up cycles of ENV transmission to people living in hospitals and surrounding reas. Living close to hospitals had been identified as a risk fac- or for DENV infection [9] and might be associated with a dense opulation around developed areas, construction sites, and catch- ent areas of the hospitals. Control of mosquito breeding sites round hospitals should be a priority to reduce hospital-associated ransmission of DENV. Emphasis should be given to reducing the osquito bites of DENV-infected patients by improving bed-net for he DENV-infected patients receiving medical care at hospitals or n the communities. The ongoing outbreak reveals major gaps in surveillance and arly warning systems, data collection, and analyses, and highlights he importance of health service development and conduct of pri- rity epidemiological research. The current Dengue surveillance is ased on 20 public and 57 private hospitals in Dhaka and 1-2 main ospitals from each district outside Dhaka [2] . This represents only  small fraction ( ∼5%) of the total number of hospitals in the coun- ry. This limited surveillance system does not fully capture the verall picture of the dengue outbreak in Bangladesh. Proactive na- ionwide geographic-based surveillance with the collection of clini- al, demographic, and socioeconomic data is required to better un- erstand age and gender-related disparity in morbidity and mor- ality, and the characteristics of DENV transmission hotspots. En- ty for Infectious Diseases. This is an open access article under the CC BY license N. Haider, M. Asaduzzaman, M.N. Hasan et al. International Journal of Infectious Diseases 136 (2023) 1–4 Figure 1. Geographical distribution of dengue cases in Bangladesh: 1 January – 17 August 2023. GPS coordinates of patients’ addresses recorded in the hospital registration were extracted using Google Sheet’s add-ons ‘Geocode by Awesome Table’. More than 48% of dengue cases were recorded in the capital city Dhaka and 86% of the cases in Dhaka city were located within a 2 km radius of the 77 hospitals included in the dengue surveillance system. (Data source: Management Information System, Ministry of Health and Family Welfare, Bangladesh [2] ). Figure 2. Comparison of proportion of Dengue cases and deaths reported from Dhaka and from outside Dhaka on 28 th June (Eid-Al-Adha festival) and on 25 th August 2023. Although the percentage of cases changes over time (76% vs. 48%. P < 0.05) in Dhaka city, the percentage of deaths remains similar over time (78% vs. 74%). (Data source: Management Information System, Ministry of Health and Family Welfare, Bangladesh [2] ) ttmtiimt  l[Bahwcotctpoltegantomological surveillance is needed to assess the breeding poten- ial of Aedes mosquitoes in environmental containers as well as to onitor insecticide resistance to help inform insecticide-based in- erventions [1] . Case surveillance should continue to be enhanced n all affected areas and across the country. In Bangladesh, specialized health care management is central- zed in the country’s capital city Dhaka. Current data shows that ore than 44% of the patients admitted to hospitals in Dhaka had raveled from outside Dhaka city ( Fig. 1 ). More than 80% of peopleiving in the capital city are exposed to the DENV in their lifetime 10] . All four serotypes of the dengue virus have been recorded in angladesh at different times since 20 0 0. In 2023, DENV-2 became  predominant serotype (51%) along with DENV-3 (44%) [1] and ospitals were overwhelmed with patients with Dengue [11] . There as an acute shortage of electrolytes in the hospitals and pharma- 2 ies in Dhaka [11] . All these factors could have contributed to sub- ptimal management and increased mortality of severe dengue pa- ients [11] . The health systems in other Southeast and South Asian ountries also have a similar structure with a high dependency on he capital or larger cities. Decentralizing healthcare facilities with roactive community education and full engagement is the key to ptimizing outbreak management and this should be a mandatory ong-term objective for the Bangladesh government. On a community level, there’s the need for community educa- ion, community engagement for risk reduction, and the strength- ning of prevention measures. Insecticide-treated bednets offer ood protection to people against mosquito bites while sleeping s has been highlighted recently for malaria [7] . However, the eco- omic cost of these measures per household makes it unlikely that hey will be used unless these are provided free of charge. Recent N. Haider, M. Asaduzzaman, M.N. Hasan et al. International Journal of Infectious Diseases 136 (2023) 1–4 WpfiBaeos[rsapciitg(ipmgAt(ibcltAecstiesmsCA(doatppsf0glErdIpItSttdnR orld Bank support for Bangladesh is encouraging [12] and the rovision of free bednets and insecticides would be prudent. Mosquito control is challenging even in countries that have unctioning mosquito control programs. There are several promis- ng vector-control programs that dengue endemic countries like angladesh might consider implementing in the short, medium nd long term [13] . Vector control activities should focus on all ar- as where there is a risk of human-vector contact such as the place f residence, workplaces, schools, and hospitals. WHO promotes a trategic approach known as Integrated Vector Management (IVM) 13] which should be enhanced to remove potential breeding sites, educe vector populations, and minimize individual exposure. This hould involve vector control strategies for both mosquito larvae nd adults such as source reduction, especially of water storage ractices, covering, draining, and cleaning household water storage ontainers on a weekly basis; larvicide in non-potable water us- ng WHO-prequalified larvicides at correct dosages; distribution of nsecticide-treated nets (ITNs) for fever/dengue inpatients to con- ain the spread of the virus from health facilities; as well as strate- ies for protecting people and households. Indoor space spraying fogging) is another approach for rapid containment of dengue- nfected mosquitoes but may be challenging to deliver in densely opulated areas such as camps. Another promising intervention is the Wolbachia-mediated osquito control program initiated by the World Mosquito Pro- ram [14] . The use of Wolbachia in Brazil, Indonesia, Viet Nam, and ustralia resulted in a significant drop in dengue cases in interven- ion sites of over 69% [15] . Biological larvicides using Bacillus thuringiensis vs. israelensis B.T.I) is another encouraging mosquito control intervention. Erad- cation of mosquito breeding sites by community initiatives led y voluntary mosquito control groups (such as secondary school, ollege, and university students) and local city/town/village/ward eaders/councillors should be enhanced. Earlier studies showed hat mosquito control intervention in Bangladesh should start in pril [6] . Finally, dengue vaccines are now available [13] and their ffectiveness and safety require evaluation in field research and ontrolled trials for their role in the prevention of DENV transmis- ion and the reduction of dengue-related morbidity and mortality. The 2023 dengue outbreak in Bangladesh is a call for atten- ion to dengue epidemic control, not just in Bangladesh but also n other endemic countries in South East Asia which have experi- nced surges of dengue cases amidst the COVID-19 pandemic. The cientific knowledge and the experiences from epidemic manage- ent in Bangladesh would be important in guiding dengue control trategies on a regional, if not global, level. onflicts of Interest The authors declare no conflict of interest. cknowledgments We are grateful to the Ministry of Health and Family Welfare MoHFW) of Bangladesh for publicly sharing the dengue cases and eaths data. We acknowledge the Management Information System f MoHFW for sharing the patient address dataset for developing nalyses. NH, and AZ, are part of the PANDORA-ID-NET Consor- ium (EDCTP 373 Reg/Grant RIA2016E-1609) funded by the Euro- ean and Developing Countries Clinical Trials Partnership (EDCTP2) rogramme. NH is a member of the International Development Re- earch Centre, Canada’s grant on West African One Health Actions or understanding, preventing, and mitigating outbreaks (109810- 01). AZ is a National Institutes of Health Research senior investi- ator, and a Mahathir Science Award and Pascoal Mocumbi Award aureate. 3 thics statement We used data that are publicly available in the daily press elease of the Ministry of Health and Family Welfare ( https://old. ghs.gov.bd/index.php/bd/home/5200- daily- dengue- status- report ). n addition, we extracted the anonymized location data of the atients from the hospital registration through the Management nformation System (MIS) of MoHFW. The coordinates of the pa- ient’s locations are approximate positions extracted from Google heet’s add-ons ‘Geocode by Awesome Table’ and do not indicate he actual location of the case household. We obtained permission o use the patient’s address to prepare maps as a part of the engue outbreak response in Bangladesh. Najmul Haider ∗School of Life Sciences, Faculty of Natural Sciences, Keele University, Keele, Staffordshir e, United Kingdom, ST5 5BG Md Asaduzzaman School of Digital, Technologies, and Arts, Staffordshir e University, Staffordshir e, UK Mohammad Nayeem Hasan Department of Statistics, Shahjalal University of Science and Technology, Sylhet, 3114, Bangladesh Mahbubur Rahman, Ahmed Raihan Sharif Institute of Epidemiology, Disease Control and Research (IEDCR), Ministry of Health and Family Welfare, Mohakhali, Dhaka, Bangladesh Shah Ali Akbar AshrafiManagemnet Information System, Ministry of Health and Family Welfare, Dhaka, Bangladesh Shui Shan Lee International Society for Infectious Diseases Stanley Ho Centre for Emerging Infectious Diseases, The Chinese University of Hong Kong, Shatin, Hong Kong Alimuddin Zumla Division of Infection and Immunity, Centre for Clinical Microbiology, University College London and NIHR-BRC, University College London Hospitals, London, United Kingdom ∗Corresponding author: Dr Najmul Haider PhD, School of Life Sciences, Keele University, Huxley Building, Room 122, Keele, Staffordshire, ST5 5BG, United Kingdom, Phone: ( ±44) 01782 734414 E-mail addresses: n.haider@keele.ac.uk (N. Haider), Md.Asaduzzaman@staffs.ac.uk (M. Asaduzzaman), ayeem5847@gmail.com (M.N. Hasan), dr_mahbub@yahoo.com (M. Rahman), drraihan@gmail.com (A.R. Sharif), drshahashrafi@gmail.com (S.A .A . Ashrafi), sslee@cuhk.edu.hk (S.S. Lee), a.zumla@ucl.ac.uk (A. Zumla) eferences [1] World Health Organization Dengue – Bangladesh 11 August 2023 . Geneva: WHO; 2023 https:// www.who.int/ emergencies/ disease- outbreak- news/item/ 2023-DON481# . [2] Ministry of Health and Family Welfare (Management Information System ). Daily Press release on dengue outbreak . Dhaka: DGHS; 2023 https://old.dghs.gov. bd/ index.php/ bd/ home/ 5200- daily- dengue- status- report. [3] Hossain MS, Noman A Al, Mamun SA Al, Mosabbir A Al. Twenty-two years of dengue outbreaks in Bangladesh: epidemiology, clinical spectrum, serotypes, and future disease risks. Trop Med Health 2023; 51 (1):37. doi: 10. 1186/s41182- 023- 00528- 6 . [4] Das S, Hasan MdM, Mohsin M, Jeorge DH, Rasul MdG, Khan AR, et al. 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The Daily Star 2023 Aug 8:1 . 12] World Bank. Bangladesh - Country Partnership Framework for the Period FY2023 - FY2027. Washington, D.C.: World Bank Group. http://documents.worldbank.org/curated/en/099040523102036987/ BOSIB037c73db00920ae960a4e78fa47587 13] Centers for Disease Control and Prevention Surveillance and Control of Aedes aegypti and Aedes albopictus in the United States . Atlanta: CDC; 2022 https:// www.cdc.gov/chikungunya/resources/vector-control.html . 14] World Mosquito Program Our Wolbachia method . Melbourne: Monash Aus- tralia; 2023 https:// www.worldmosquitoprogram.org/ en/ work/ wolbachia-method . 15] Al Noman A, Das D, Nesa Z, Tariquzzaman Md, Sharzana F, Rakibul Hasan Md,et al. Importance of Wolbachia-mediated biocontrol to reduce dengue in Bangladesh and other dengue-endemic developing countries. Biosaf Health 2023; 5 (2):69–77. doi: 10.1016/j.bsheal.2023.03.003 . 

Bangladesh's 2023 Dengue outbreak - age/gender-related disparity in morbidity and mortality and geographic variability of epidemic burdens

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Bangladesh's 2023 Dengue outbreak - age/gender-related disparity in morbidity and mortality and geographic variability of epidemic burdens

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