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Acta Tropica
journal homepage: www.elsevier.com/locate/actatropica
a r t i c l e
i n f o
Article history:
Received 5 June 2015
Received in revised form
19 September 2015
Accepted 27 September 2015
Available online 1 October 2015
Keywords:
Dengue
Index case
Asymptomatic infection
Primary dengue infection
Secondary dengue infection
a b s t r a c t
Delhi, the capital of India, is an important metropolitan hub for major nancial and sociocultural
exchanges, offering challenging threats to current public health infrastructure. In recent past, an upsurge
of dengue cases in Delhi posed a signicant menace to the existing dengue control policies. To reform
the control strategies and take timely intervention to prevent future epidemics, an epidemiological study
on the proportion of both asymptomatic and symptomatic dengue infections in selected population was
conducted. The aim of the study was to investigate and assess the epidemiology of dengue infection and
to estimate the proportion of asymptomatic and symptomatic dengue infections in Delhi. In this study,
around 50 conrmed dengue cases, a total of 2125 individuals as household and neighbourhood contacts,
with or without dengue febrile illness, were nger pricked and serologically detected as dengue positive
or negative using SD Duo Bioline Rapid Diagnostic Test (SD Inc, Korea) with NS1, IgM & IgG combo test,
which detected dengue virus antigen and antibodies to dengue virus in human blood. Out of 2125 individuals, 768 (36.1%) individuals showed positive dengue test with past (25.5%), primary (1.88%) or secondary
(8.8%) dengue infections. Higher percentage of IgG was found in age groups 1524 years and 2550 years
(36% each). Infants (<1 year) presented higher incidence of new infections (22% of NS1 + IgM positives) as
compared to adults. Further analysis revealed that out of the 226 newly infected cases (including NS1 and
IgM positives), 142 (63%) were asymptomatic and 84 (37%) were symptomatic, as per WHO guidelines.
Our ndings also suggest that out of the total population screened, 10.6% dengue infection was either
primary or secondary. On the basis of these results, it may be hypothesized that there are large number of
asymptomatic dengue infections in the community as compared to reported symptomatic cases in Delhi.
For the effective control of dengue transmission in such community like Delhi where dengue epidemics
have frequently been encountered, it is essential to ascertain the proportion of asymptomatic dengue
infections which may act as a reservoir for dengue transmission, as well as threat for developing dengue
haemorrhagic fever (DHF).
2015 Published by Elsevier B.V.
1. Introduction
Dengue infection is one of the most common arbo-viral diseases
worldwide. It is prevalent in most of the tropical and sub-tropical
countries and is caused by four serotypes (DEN-1, DEN-2, DEN-3
and DEN-4) in humans. All four serotypes can cause a spectrum
of illness ranging from inapparent or mild febrile dengue fever to
Corresponding author at: GIS, Taxonomy and OVBD Division, National Institute
of Malaria Research, New Delhi 110 077.
E-mail address: bnnagpal57@gmail.com (B.N Nagpal).
http://dx.doi.org/10.1016/j.actatropica.2015.09.025
0001-706X/ 2015 Published by Elsevier B.V.
22
The study was conducted in collaboration with Pasteur Institut, Paris, France and Municipal Corporation of Delhi (MCD). MCD
assisted in selection of 18 localities (suburbs) and their categorization as Low, Medium and High income group on the basis of socio
economic status, family annual income and housing pattern dened
by Delhi Development Authority (DDA). Six localties each from Low
Income Group (LIG) i.e. Mangolpuri, Budha Vihar, Prem Nagar, Hastsal Village, Najafgarh (Jai Vihar), Sangam Vihar; Medium Income
Group (MIG) i.e. Bapanagar, Madhu Vihar, Palam Colony, Kotala
MubarkPur, Raghubir Nagar, Rani Garden and High Income Group
(HIG) i.e. Paschim Vihar, Rajouri Garden, RK Puram, Kirti Nagar,
Vasant Kunj, Mukherjee Nagar were selected, as shown in the map
(Fig. 1).
2.2. Study design
A community based descriptive study was conducted in the
identied localities during the period June December, 2013. For
the diagnosis of dengue cases, MCD had identied 37 sentinel
hospitals in Delhi to facilitate management of such cases. Fifty conrmed cases of dengue reported by these sentinel hospitals, from
the identied 18 localities, covering maximum zones of Delhi, were
investigated. For the purpose of the study, index case is dened
as any serologically positive dengue case reported by MCD. After
the identication of index cases, all household and neighbourhood
contacts of a dengue case were screened for asymptomatic DENV
infection. Household contacts i.e. the index case and co-habiting
family members and neighborhood contacts i.e. those residents
living in close vicinity (within 200 m radius of the index case)
were included in the study (Mammen et al., 2008). Symptomatic
DENV infection was dened as fever with at least two symptoms of dengue (myalgia, headache, retro-ocular pain, arthralgia
and rash) as per WHO guidelines (World Health Organization,
2009). Asymptomatic DENV infectionno clinical signs or symptoms of disease as mentioned above in symptomatic infection
(World Health Organization, 2009).
The aim and procedure of the study was briey described to
all the participants and their legal guardians prior to taking their
consent for the enrollment in this study. Upon enrollment, ngerprick blood samples were obtained from all consenting individuals
and serologically tested. Each individual was also administered a
questionnaire including presence or absence of any dengue like
symptoms. All serologically positive symptomic dengue infections
were reffered to respective sentinel hospitals for further management while individuals with asymptomatic infections were
provided appropriate counselling.
2.3. Serological test
The rapid detection of DENV infection was performed by commercially available kits provided by Pasteur Institut, Paris, France.
Total 2125 individuals (household and neighborhood individuals)
with or without dengue febrile illness, were nger pricked and
serologically diagnosed as dengue positive or negative by using
SD BIOLINE Dengue Duo combo device (Standard Diagnostic Inc.,
Korea). The kit provides two windows, one detection of NS1 antigen and other for dengue specic IgM and IgG antibodies. All tests in
this study were carried out in accordance with the manufacturers
instructions and results were examined and interpreted accordingly; the blood sample of individuals containing IgM or/and NS1
were considered as primary/acute dengue infection, i.e. they were
infected by DENV for the rst time. The tests indicating IgG + IgM/
NS1 were considered as secondary infection, i.e. such patient was
already infected by dengue in past. If the individual was detected
positive for IgG but negative for other tests (IgM and NS1), were
considered as past infection or secondary DENV infection with
23
symptoms. The presence color line (control) in each result window indicates a negative result. NS1 antigen is found from the rst
day and up to 9 days after onset of fever in sample of primary or
secondary dengue infected patients. Usually IgM does not become
detectable until 510 days after the onset of illness in cases of primary dengue infection and until 45 days after onset of illness in
secondary infections. In primary infections, IgG appear the 14th day
and persist for life. Secondary infections show that IgG rise with in
12 days after the onset of symptoms and induce IgM response
after 20 days of infection (as per SD Bioline Dengue Kit manual).
Limitation of the study: Those individuals in which only IgG
was found positive but without any symptoms of DENV infection
were considered as past infections, while those having symptoms
of DENV infection were considered as secondary infections.
3. Results
A total of 2125 individuals as household and neighbourhood
contacts consisted of 932 males and 1193 females from 18 localities
against the 50 index cases of Delhi were tested and analyzed with
the NS1IgMIgG RDT kit. The data was further grouped into three
income groups i.e. High, Medium and Low. In LIG 711 individulas
comprised of 314 males and 397 females, in MIG 870 individuals
comprised of 374 males and 496 females, in HIG 544 individulas comprised of 244 males and 300 females were serologically
tested for dengue infection. Out of total 2125 individulas tested, 768
individualscomprising 59% (451/768) females and 41% (317/768)
maleswere found positive for either IgG, IgM or NS1 test. We
noted that sero-prevalence of the DENV infection was equal to
36.14% of all tested individuals (768/2125). Out of the these, 542
(25.5% of all individuals tested) cases were past infections as they
were only IgG positive without any symptoms, 40 primary infections (1.88%) and 186 (8.8%) secondary dengue infections. Total 226
individuals(29.4%) were found positive for either primary or secondary dengue infection. It is to note that 63% of the primary and
secondary infections were asymptomatic(Table 1).
The study showed that individuals people in the age group of
1524 and 2550 had maximum (36% each) past or secondary infections. Individuals aged >50 years and young children aged 914
years had 35% past or secondary infections. Infants <1 year old
showed least (17%) past or secondary infections. On the contrary,
primary infection was found highest (22%) in the age group <1
year old. The proportion of primary cases generally declined with
increase in age (Fig. 2).
Out of 711 individuals tested from LIG, 212 were past infection
and 103 were primary/secondary out of which 72 were asymptomatic infections. For MIG, 232 were past infections and 81 were
either primary or secondary out of which 45 were asymptomatic.
While for HIG, 98 were past infections, 42 were either primary or
secondary out of which 25 were asymptomatic. Odds of getting
asymptomatic DENV infections in three income groups was esti-
24
Table 1
Number and percentage of test positives to IgG, IgM and NS1 tests.
Test positives
No. of individuals
% of total
Sympt. (S)
Asympt. (AS)
Category of infection
IgG
NS1
IgM
NS1 + IgM
IgM + IgG
NS1 + IgG
NS1 + IgM + IgG
IgG
Negative results
542
16
23
1
118
1
5
62
1357
25.5%
0.75%
1.08%
0.05%
5.55%
0.05%
0.24%
2.9%
63.86%
3
4
1
13
0
1
62
13
19
0
105
1
4
Past infection
Primary
infection
Secondary
infection
80%
Total
2125
100%
84
142
59%
63%
Fig. 2. Percentage of IgG and IgM or/and NS1 positive per age group.
4. Discussion
In present study, we have demonstrated that IgG was positive in
34.2% of all tested individuals (either past or secondary infections).
This is less than the percentage detected in Kolkata, where 73.51%
of tested individuals from 2005 to 2007 were IgG positive (Hati,
2009). In Rio de Janeiro (Honorio et al., 2009) similar percentage of
past antibodies were found in the population (between 67 and 85%
of positives IgG). This shows that population of Delhi has been less
exposed to dengue virus than some of other high endemic cities.
We can observe that with the increasing age of the individuals,
the positivity for IgG increased accept in age group >50 indicating
the past exposure of dengue infection. On the other hand the new
infection was observed more in young children and declined with
the advancement of age.
25
Fig. 3. Proportion of symptomatic and asymptomatic cases over various age groups in males and females.
Fig. 4. Mean lowest temperature recorded during day in Rio (Brasil), Bangkok (Thaland), Kolkata and Delhi (India).
26
5. Conclusion
The main aim of this study was to identify the proportion of
asymptomatic DENV infection in localities of Delhi. On the basis of
our data, we estimated the proportion to be 63% among individuals
of all 18 localities of Delhi. The risk of acquiring DENV infection is
signicantly higher in residents of low income group as compared
to medium income groups and high income groups of Delhi. Our
ndings suggests that 10.6% of the total population screened confered DENV infection either primary or secondary. On the basis of
these results, we can hypothesize the unestimated dengue infection
shouldered by 1.6 million people residing in Delhi.
This study facilitated collection of clinical information and rapid
detection of DENV infection in Delhi metropolitan area. The results
of this study can be helpful in planning and implementing adequate preventative measures against DENV infection in the city of
Delhi. There is a need for further study to demonstrate the role
of asymptomatic dengue infection in transmission of DENV in the
community.
Ethics
The study protocol and consent forms were approved by the
Scientic Advisory Committee and Ethics Review Committee of the
National Institute of Malaria Research, New Delhi, India.
Acknowlegment
Authors are thankful to Paster Institut, Paris, France for the funding support ANR. We are also thankful to MCD for helping us in
selection of study sites in Delhi. We thank the entire eld staff
for their careful performance in serological testing and data collection. We would like to thank Ms Shruti Bahadur for giving her
critical overview to the manuscript. Acknowledgement is also due
to Mr. Mrityunjay Prasad and Mr. Rakesh Jacob for data management. Institute Publication Committee is acknowledged for giving
consent for publication of manuscript vide Approval No. 027/2015.
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