DENGUE/DHF UPDATE – AFRICA
E Schwartz, E Meltzer , M Mendelson, A Tooke, F Steiner, P Gautret, B Friedrich-Jaenicke, M Libman, H Bin, A Wilder-Smith, D J Gubler, D O Freedman, P Parola. Detection on four continents of Dengue fever cases related to an ongoing outbreak in Luanda, Angola, March to May 2013.
In April 2013, 10 cases of dengue fever in travellers returning from Luanda, Angola to 5 countries on 4 continents were reported to the globally distributed GeoSentinel Surveillance network. Dengue virus serotype 1 was identified in 2 cases. The findings indicate that a major dengue outbreak is currently ongoing in Luanda. This report illustrates how cases from an emerging arboviral epidemic focus can spread internationally and highlights the risk of dissemination of a vector-borne disease into receptive areas.
GeoSentinel provides a sentinel sample of returning travellers at 56 clinics in 24 countries on 6 continents. During April 2013, GeoSentinel sites in Canada, France, Germany, Israel and South Africa reported a total of 10 cases of dengue in business travellers returning from Angola, with Luanda as the only likely place of exposure. Meanwhile, on 15 Apr , the Instituto de Higiene e Medicina Tropical in Lisbon, Portugal reported 19 cases of dengue acquired in Luanda since late March 2013, in 4 of whom dengue virus (DENV)-1 was detected by polymerase chain reaction (PCR) The nearly simultaneous reports of dengue cases related to travel to Luanda from 5 GeoSentinel sites on 4 continents, as well as Portugal, suggest that a large scale outbreak of dengue may in fact be unfolding in Angola.
In Angola, DENV activity has been reported sporadically. Early surveys in the 1960s revealed no evidence of DENV activity, while outbreaks of clinically suspected dengue in the 1970s were proven to be caused by chikungunya. In the 1980s, an outbreak of dengue was reported from Luanda, with subsequent reports of travel-related dengue acquired in Angola by travellers from the Netherlands and Brazil. For a Brazilian travel-related case, the serotype identified was DENV-2. Since then, there has been little information on the risk of dengue in Angola. This may represent an absence of disease activity or a lack of awareness, diagnostic resources and active surveillance.
Travellers may serve as sentinels to local epidemic risks, and this role is especially important in areas with scarce public health reporting and resources. Thus, cases of dengue among European travellers returning from the Comoros islands in east Africa and Benin in west Africa have called attention to local DENV transmission. In a recent review, 12 of 27 countries in Africa where travellers/expatriates had acquired dengue had not reported local DENV transmission.
Here, we report on an apparent outbreak of dengue in Luanda, Angola diagnosed among travellers presenting to travel clinics on 4 continents.
Overall, the male/female ratio of cases reported to GeoSentinel was 9:1 and the traveller's age was 41.3 plus-minus 10.7 (mean plus-minus SD) years.
All cases presented with an acute febrile illness and symptoms suggestive of classic dengue, including headache and joint pain. In 3 of the 10 cases, a rash was reported. Laboratory studies during the febrile period revealed leucopenia (range: 1.2-2.9 x 10e9/L, norm: 4.0-10.0 x 10e9/L) and thrombocytopenia (range: 13-124 x 10e9/L, norm: 140-440 x 10e9/L) in all the cases. None of the cases had features of severe dengue, and all recovered without complications.
Dengue diagnosis was confirmed by one or more of 3 methods; non-structural protein 1 (NS1) antigen, DENV IgM enzyme-linked immunosorbent assay (ELISA) serology or DENV viraemia by quantitative (Qt)-PCR. DENV IgM was detected in all 10 cases, whereas 5 cases also tested positive for NS1 antigen. For all these latter cases except one from Germany, NS1 antigen and DENV IgM were detected in a single sample. For the German case, a blood sample drawn at 4 days post symptom onset was NS1 antigen positive, but seroconversion was verified in subsequent samples. In 2 viraemic Israeli patients, Qt-PCR revealed the virus to be DENV-1 similar to the imported cases seen in Portugal.
Dengue has long been known to exist in Africa, but its epidemiology is poorly documented. Recent prediction models of dengue suggest that the true burden of dengue in Africa may approach that of South America. Moreover, limited serological surveys in locations such as Burkina Faso have suggested that the disease is far more prevalent than previously recognised. In the last 4 years, large dengue epidemics were reported on the Macronesian islands of Cape Verde (DENV-3) and Madeira (DENV-1) off the northwest African coast. Common models of dengue epidemiology suggest that clinically diagnosed cases of classic dengue represent the tip of an iceberg, with actual case numbers being much higher.
On 1 Apr 2013, local health authorities in Luanda reported 6 cases of dengue fever acquired in the city . The true extent of the dengue outbreak in Luanda is likely to be much higher than currently acknowledged. Anecdotally, returning Israeli travellers with dengue have maintained that multiple additional cases of similar febrile illness were [occurring] in the expatriate community in Luanda.
The origin of the present DENV-1 strain responsible for the current Luanda outbreak is as yet undetermined, but the possibility of an imported strain is of concern. Of the 190 000 ill returned travellers in the GeoSentinel database since 1997, no previous cases of dengue acquired in Angola have been reported. Strains of DENV appear to be circulating between east Africa and the Indian subcontinent, and recent DENV-1 isolates from Madeira appear to be closely related to strains circulating in Central or South America. Thus, it is well established that dissemination of dengue from DENV endemic countries in America and Asia occurs both in east Africa and off the northwest African coast. In this regard, it is important to note that according to World Tourism Organization (WTO) data, major source countries of travellers to Angola included DENV endemic China and Brazil, with 69 900 and 29 700 travellers respectively during 2011.
Another source of concern is the possibility of the spread of dengue to susceptible countries by returning, viraemic travellers._Aedes albopictus_, one of the DENV vectors, is currently endemic throughout most of the Mediterranean basin and has recently been documented as far north as the Netherlands . In Israel, for example, the presence of_Aedes albopictus_ in dense population centres creates prime conditions for a dengue outbreak.
At present, health practitioners should be aware of the possibility of dengue in febrile travellers returning from Angola. Such travellers would be best served by clinicians with access to rapid diagnostic tests and should be advised to implement measures to avoid mosquito bites for the likely duration of viraemia [3-5 days: Control of Communicable Diseases Manual 2008. - Mod.JW].
This report serves to illustrate the possible speed of global dissemination of cases from an emerging arboviral epidemic focus and the potential for introduction of novel viruses or novel strains into receptive countries.
Communicated by: ProMED-EAFR
This report highlights the gaps in local surveillance and response capacities to the dengue fever outbreak in Angola. As a result of these gaps, at least 29 international travellers from 7 countries including Germany, Canada, France, South Africa, Israel, and Portugal have been confirmed to have dengue fever, with Angola being the most likely source of the exposure. This report also indicates that the dengue fever outbreak in Angola is most likely caused by dengue virus serotype 1.
The risk of international spread, therefore, is real, particularly from viraemic international travellers returning from Angola to countries with competent vectors for dengue virus transmission. In the spirit of the international health regulations of 2005 (IHR (2005)), the global community needs to work with the national authorities in Angola to institute adequate measures for surveillance and response to prevent further international spread of the outbreak and to foster international public health security.
South African Society of Travel Medicine (SASTM)
Phone: +27 (011) 025 3297
Fax: +27 087 9411350 / 1
Postal address: SASTM, PO Box 8216, Greenstone, 1616, South Africa
Physical address: SASTM, 27 Linksfield Road Block 2 a Dunvegan Edenvale
Registered as a Nonprofit Organisation 063-296-NPO
The content and opinions are neither pre-screened nor endorsed by the SASTM. The content should neither be interpreted nor quoted as inherently accurate or authoritative.
The information provided in SASTM Newsflashes is collected from various news sources, health agencies and government agencies. Although the information is believed to be accurate, any express or implied warranty as to its suitability for any purpose is categorically disclaimed. In particular, this information should not be construed to serve as medical advice for any individual. The health information provided is general in nature, and may not be appropriate for all persons. Medical advice may vary because of individual differences in such factors as health risks, current medical conditions and treatment, allergies, pregnancy and breast feeding, etc. In addition, global health risks are constantly evolving and changing. International travelers should consult a qualified physician for medical advice prior to departure.