Battle against the dengue epidemic: Pakistan’s ongoing struggle

Over the past two decades, dengue fever (DF), which is caused by the dengue virus (DENV), has become a serious public health concern. Globally, there are about 400 million cases of dengue each year, resulting in 22 000 deaths1. Dengue is an infectious disease caused by any of the four dengue virus serotypes: DENVs 1–4. DENV is a positive, RNA-containing flavivirus belonging to the genus Flavivirus in the Flaviviridae family. The Malaysian state of Sarawak was the first to contain the recently identified fifth serotype, DENV-5. These serotypes can cause dengue, an infectious disease carried by mosquitoes, with the female Aedes mosquito being the main vector1,2. This article aims to highlight the challenges in DF eradication in Pakistan and to recommend solutions to mitigate these challenges. Dengue is the most common arthropod-borne viral disease in the world, spread by mosquitoes. Because of the severity of the muscular spasms and joint pain, it is often referred to as 'breakbone fever', 'dandy fever', or 'seven-day fever' due to the typical duration of symptoms. Although the majority of cases have no symptoms; however, deaths and serious illness can occur. The virus is spread by Aedes mosquitoes, which are widespread in tropical and subtropical regions of the world. Over the last several decades, dengue has become much more common and is now endemic in various regions of the world. A small number of individuals who had previously contracted one subspecies of dengue virus go on to develop severe bleeding and capillary permeability when they contract another subspecies of the virus. This illness is known as dengue hemorrhagic fever3. The WHO reports that the first case of DF was reported in Pakistan in 1994. However, in Karachi, the pattern of annual outbreaks began in November 2005. Dengue was confined to specific regions of Pakistan before 2006. Dengue outbreaks have impacted Pakistan every year since 2010, peaking during the postmonsoon season4. Pakistan is endemic for DF; however, the peak cases were observed shortly after the monsoon. Since 2010, this nation has experienced several horrific dengue epidemics that have resulted in serious health problems and fatalities among people. Reports of local dengue transmission is likely to play a significant role in the disease's reintroduction, reports of it have been made. The largest recent dengue pandemics were recorded for the first time in Lahore (2011) with 22 562 cases and 363 fatalities, and for the second time in Swat (2013) causing 8343 morbidities along with 57 deaths. Recently, in 2017, another huge dengue outbreak was recorded in Peshawar with 23 541 cases5. According to the National Institute of Health, there were ~22 938 DF cases reported in 2017. In 2018, over 3200 cases were reported; in 2019, there were 24 547 instances; and in 2020, there were 3442 cases. There were 48 906 confirmed cases in 2021. As of 11 October 2022, there were 41 746 confirmed cases of dengue in Pakistan, and the number of cases is increasing daily. Most of the cases were in Sindh, the region that saw the most floods6. The Punjab Health Department reports that there were 143 new cases of the dengue virus on 8th October 2023, indicating that the fight against the virus is still ongoing in Punjab. Details indicate that 52 new cases of dengue were reported in Lahore, 47 in Rawalpindi, 10 in Multan, 11 in Gujranwala, 10 in Faisalabad, and 3 in Sheikhupura. One new case of dengue was confirmed in each of Kasur, Gujrat, Chakwal, Okara, Bahawalnagar, Bahawalpur, and Rajanpur. In Punjab's 36 districts, a total of 5469 confirmed dengue cases have been reported so far this year. With an astounding 2130 cases, Lahore tops the list, closely followed by Rawalpindi (1561), Multan (620), Gujranwala (268), and Faisalabad (245) cases. One hundred eighteen dengue patients are undergoing treatment in different hospitals in Punjab. Thirty-six of them are in hospitals in Lahore alone. The Punjab Health Secretary has made a strong appeal to the public, urging them to keep their surroundings dry and clean as a critical dengue prevention measure7. The Official statistics reveal a total of 13 555 dengue cases reported across the country. Among the provinces, Punjab reported the highest number with 6866 cases, followed by Baluchistan with 2658 cases, ICT (Islamabad Capital Territory) with 1799 cases, and Sindh with 1603 cases. The Health Department of Khyber Pakhtunkhwa (KP) has successfully controlled a dengue outbreak despite financial constraints, according to KP health authorities. The department's unique and effective strategy has led to significant improvements in dengue control compared to other provinces. Secretary of Health in Khyber Pakhtunkhwa commended the department's efforts in designing and implementing a specialized strategy, which involved collaboration and engagement with various community sectors8. WHO recommends acetaminophen or paracetamol for antipyretics, with a dose of 10 mg/kg/dose and a maximum of 4 g/day for adults. Patients should maintain fluid intake during the febrile phase and use paracetamol as an antipyretic. NSAIDs medications should be avoided due to bleeding risks. During the crucial period of DF, proper fluid administration is necessary to guarantee optimal tissue perfusion. For moderate cases, oral rehydration with fluids such as milk, fruit juice, or ORS is advised. Careful fluid resuscitation is the cornerstone, especially during the crucial stage. The first-line treatment is crystalloids; if the response is insufficient, colloids are used. Maintaining adequate perfusion and a urine production of roughly 0.5 ml/kg/h is the goal. During the clinical course of dengue, guidelines offer algorithms for correcting acidosis, blood sugar, and calcium (ABC) and managing dengue shock9,10. Expanded or unusual dengue is defined as involving multiple systems besides plasma leakage. Complications of this condition include neurological issues, such as encephalitis; gastrointestinal issues, such as hepatitis; renal issues, such as nephritis; cardiac issues, such as myocarditis; musculoskeletal issues, such as myositis; and hematological issues, such as hemophagocytic lymphohistiocytosis9. As of now, Dengvaxia is the only Food and Drug Administration (FDA)-approved and licensed live-attenuated vaccine that can be used to prevent any serotype of dengue in anyone aged 9 to 45 who has already been diagnosed with dengue. A significant risk associated with this vaccine is increased infection in seronegative people and lowered Vaccine Efficacy (VE) against DENV2. In contrast, TAK-003, a potential live-attenuated vaccine that is presently undergoing phase 3 trials, has the highest VE against DENV2, is currently receiving priority review from the US FDA, and poses no safety risks to seronegative persons. TAK-003 is a novel vaccine that shows promise in the fight against dengue, together with TK003 and TK005. The initial results of this vaccine should be available in the coming months. The dengue virus is proving to be a very promising vaccine target, with several formulations in the works that will expedite attempts to reduce transmission and fulfill the WHO's worldwide dengue preventive and control strategy11. DF has emerged as a significant concern in Pakistan, prompting the need for immediate actions to combat its prevalence. To effectively tackle DF, multiple strategies must be implemented. Firstly, the Pakistani government should prioritize infrastructure improvement, including the development of better roads, housing, and healthcare facilities. This improvement will not only enhance living conditions but also contribute to reducing the breeding grounds for disease-carrying mosquitoes. Moreover, the Ministry of Environment in Pakistan needs to collaborate closely with key stakeholders to oversee the construction of proper drainage systems and sanitation facilities. Ensuring effective waste management and sanitation infrastructure plays a critical role in preventing the proliferation of mosquitoes that transmit DF. Additionally, enacting legislation to prohibit the illegal disposal of refuse and rigorously enforcing these laws by the legislature is imperative in controlling the disease's spread and fostering a cleaner environment. The Malaysian government's mitigation of DF employs a comprehensive approach known as Integrated Vector Management (IVM). This involves systematic and routine spraying in areas most susceptible to dengue outbreaks. Additionally, there is an effective strategy in place involving the distribution of sprays and mosquito repellents, creating a multifaceted defense against the disease12. Drawing inspiration from this, the Pakistani government could consider implementing similar measures. The government should collaborate with nongovernmental organizations (NGOs) and international bodies in executing widespread awareness campaigns. This collaborative effort is not only to educate the population about preventive measures but also to distribute essential resources such as mosquito repellents and sprays. The synergy between the government, NGOs, and international organizations can establish a robust front against DF. By fostering awareness and providing accessible preventive tools, could significantly reduce the incidence of dengue in Pakistan, safeguarding public health and well-being. DF, a global public health concern, affects millions of people annually and causes numerous deaths. Aedes mosquitoes are the main carriers. Pakistan has experienced recurrent outbreaks, with Punjab being the hardest-hit region. Treatment focuses on fever control and fluid management, with acetaminophen recommended. Dengvaxia is the only approved vaccine, but efforts are ongoing to control the disease. Vaccines such as TAK-003 are also being developed. Public awareness and prevention measures are crucial. Ethical statement Ethics approval was not required for this editorial. Informed consent Informed consent was not required for this editorial. Sources of funding No funding was received for this work. Author contributions FNU.V.: conceptualisation, data curation, formal analysis, investigation, methodology, visualization, writing – original draft, and writing – review and editing; M.K.: investigation, resources, writing – original draft, and writing – review and editing; S.D.: investigation and writing – review and editing; R.K.: investigation, writing – original draft, and writing – review and editing; R.K.: investigation and writing – review and editing; M.O.O.: investigation and writing – review and editing; U.O.A.: writing – review and editing. Conflicts of interest disclosure Not applicable. Research registration unique identifying number (UIN) Name of the registry: not applicable. Unique identifying number or registration ID: not applicable. Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable. Guarantor Malik Olatunde Oduoye. Availability of data and materials Not applicable. Provenance and peer review Not commissioned, externally peer-reviewed.