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This article gives information regarding how deadly the dengue virus outbreak is in Uttar Pradesh. A lot of people have died as a result of the virus, and it has severely impacted children, leading to more death. The article also mentions other diseases that can also be linked to higher death rates in children.

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For more than a week now, children in some districts in the northern Indian state of Uttar Pradesh have been waking up with a high fever and drenched in sweat.

Many of them complained of joint pains, headaches, dehydration and nausea. In some cases, they reported rashes spreading across legs and arms.

At least 50 people, mostly children, have died of the fever, and several hundred have been admitted to hospital in six districts in the eastern part of the state. None of the dead tested positive for Covid-19.

At a time when India appears to be slowly recovering from a deadly second wave of coronavirus, the deaths in Uttar Pradesh have provoked a rash of panicky headlines about a "mystery fever" sweeping through the countryside of India's most populous state.

Physicians in a few of the affected districts - Agra, Mathura, Mainpuri, Etah, Kasganj and Firozabad - believe dengue, a mosquito-borne viral infection, could be the main cause of deaths.

They say many of the patients were taken to hospital with a declining platelet - a blood component which helps form clots - count, which characterises a severe form of dengue.

"The patients, especially children, in hospitals are dying very quickly," says Dr Neeta Kulshrestha, the most senior health official of Firozabad district, where 40 people, including 32 children, have died in the past week.

Transmitted by female mosquitoes, dengue is mainly a tropical disease and has been circulating in India for hundreds of years. It is endemic in more than 100 countries, but some 70% of the cases are reported from Asia. There are four dengue viruses, and children are up to five times more likely to die during a second dengue infection than adults.

The mosquito - Aedes aegypti - breeds in and around houses in containers holding fresh water. "Humans provide breeding places and only humans can take them away," says Dr Scott Halstead, one of the world's leading experts on viruses spread by mosquitoes.

Nearly 100 million severe cases of dengue - severe bleeding, impaired organs - are reported worldwide every year. "The combined impact of Covid-19 and dengue epidemics can potentially result in devastating consequences for the populations at risk," according to the World Health Organization (WHO).

Yet it is still not clear whether an epidemic of dengue is alone responsible for the fever-related deaths in Uttar Pradesh.

A state with more than 200 million people and traditionally poor standards of sanitation, high levels of-malnutrition in children and patchy health care routinely reports such "mystery fever" cases after monsoon rains every other year.

Outbreaks of the mosquito-borne Japanese encephalitis - first identified in Uttar Pradesh in 1978 - have claimed more than 6,500 lives since. The disease mainly spread through Gorakhpur and adjoining districts which border Nepal in the foothills of the Himalayas, all low lying and prone to floods and providing a breeding ground for mosquitoes which transmit the virus.

A vaccination campaign, which began in 2013, has led to a drop in cases, but children continue to die. Seventeen children have died of Japanese encephalitis in Gorakhpur so far this year, and 428 cases have been recorded.

In 2014, reacting to increasing cases of children dying of encephalitis and myocarditis - inflammation of the heart muscle - scientists examined 250 afflicted children in Gorakhpur. They found that 160 of them had antibodies to the bacteria that caused scrub typhus.

Scrub typhus, also known as bush typhus, is a bacterial infection spread through bites of infected viral mites.

The mites settle on the thriving vegetation in the villages after monsoon rains. Scientists found the mites on firewood which villagers store inside their homes. A lot of the time, scrub typhus spreads when children handle firewood at home or defecate in the open in the bushes infested with the mites.

In a separate study, scientists also found scrub typhus and dengue were mainly responsible for post-monsoon fever cases in six districts in eastern Uttar Pradesh between 2015 and 2019. Another potentially fatal bacterial infection called leptospirosis transmitted from animals to humans, and chikungunya, a mosquito-borne disease, accounted for the other fever causing pathogens.

"So there was a bunch of fever-related diseases happening in the region after the monsoons ended. You need systemic surveillance to keep a track of these diseases and treat them," says V Ravi, a professor of virology at the National Institute of Mental Health and Neuroscience (Nimhans), who led the second study.

Earlier, in 2006, scientists investigated another "mystery" outbreak of fever-related deaths among children in Uttar Pradesh. This time they found that the children had died after consuming cassia beans, which grew abundantly in the western part of the state.

This food poisoning was the result of "poverty, hunger, lack of parental supervision, ignorance, children playing by themselves, non-availability of toys and easy access to the plant", the scientists concluded.

Clearly, only more investigations and genome analysis will reveal whether the latest spate of "mystery fevers" in India are triggered by dengue alone, or a host of other diseases. This would mean training local clinics and hospitals in collecting samples of people suffering from fever and send them for genome testing to labs.

Also, there is no clear record of how these fevers began and progressed; and whether the severity of the condition was determined by the long, arduous journeys that people have to make to government hospitals for treatment. Or whether the afflicted children were suffering from other conditions such as tuberculosis.

If the cause of the mystery deaths is dengue alone, it points to the government's largely ineffective anti-mosquito control programmes. The intensity of transmission, according to Dr Halstead, can be only determined by antibody tests - called sero surveys - by age groups.

"If we don't investigate properly and regularly, a lot of things will continue to remain a mystery," says an Indian virologist, preferring to remain unnamed.

More stories by Soutik Biswas

Follow Soutik on Twitter at @soutikBBC

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The mystery fever killing children in India

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For more than a week now, children in some districts in the northern Indian state of Uttar Pradesh have been waking up with a high fever and drenched in sweat. Many of them complained of joint pains, headaches, dehydration and nausea.

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This article gives information regarding the dengue fever outbreak also known as "breakbone fever" in the capital of New Delhi. It explains how hospitals which were once packed with Covid-19 patients are now occupied by dengue patients. It also gives some insight about the dengue outbreak in India and some of the struggles faced by governmental hospitals.

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There are four strains of dengue fever, which is spread by mosquitoes, with varying degrees of mortality.

Dr Vikas Singhal, joint director of Uttar Pradesh's vector borne disease unit, confirmed that the most virulent DENV-2 strain was behind 85 per cent of the cases in Firozabad.

However, he said that he could only confirm eight dengue deaths, while an audit into the other deaths is ongoing.

Uttar Pradesh has reported 23,128 cases of dengue this year, its highest toll since 2016. However, several officials said they suspect Uttar Pradesh is underreporting its cases due to limited testing and poor surveillance.

Cases have continued to rise across India as monsoon has lashed the country for an extended period, providing good breeding grounds for the mosquitoes in pools of standing water.

Patients from north Indian states have started pouring into Delhi, which has seen a major spike in cases in recent weeks.

In total, it has logged 5,270 cases, the highest since 2015, with hospitals flooded by dengue patients. Many hospitals are now utilizing their Covid beds for dengue patients.

Dr Ritu Saxena, Chief Casualty Medical Officer (CCMO) at the LNJP hospital, said: "At any given point of time, we have around 100 dengue patients admitted with us. To deal with it, we are utilizing the Covid beds for dengue patients."

Dr Saxena said about 20 per cent of the admitted patients were in a serious condition and 10 per cent need intensive care unit support.

"We mostly receive regular dengue patients, but some of them have hemorrhagic fever, low platelet count, or [are] in shock, which requires ICU beds," she said.

The situation is similar in other Delhi hospitals which are also seeing a rush of patients from Uttar Pradesh and other neighbouring states.

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Fears grow over dengue outbreak in India as hospitals repurpose Covid beds to treat patient influx

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There are four strains of dengue fever, which is spread by mosquitoes, with varying degrees of mortality. Dr Vikas Singhal, joint director of Uttar Pradesh's vector borne disease unit, confirmed that the most virulent DENV-2 strain was behind 85 per cent of the cases in Firozabad.

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This article mentions how the government is trying to come up with a vaccine that can help treat dengue. Dengue has been a burden severely impacting the Indian population, and together with DNDi, they are creating a new treatment idea. The article highlights the process through which they will create the new anti-viral vaccine.

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A collaborative research project between a government institute and a non-profit is aiming to develop a safe, affordable and effective treatment for dengue fever within five years, according to people familiar with the development.

The Transitional Health Science and Technology Institute (THSTI), an autonomous institute of the department of biotechnology in the ministry of science and technology, is working with the Drugs for Neglected Diseases initiative (DNDi) India Foundation to develop the new treatment.

"There are no specific antiviral drugs to treat dengue infection, and limited use of vaccines. Despite research and development to identify treatment for dengue fever, we have not yet achieved sufficient results," Pramod Kumar Garg, executive director of THSTI, said in a statement. "It is important that we join our efforts to tackle the disease which affect millions of people."

"The collaboration with DNDi India Foundation is an important step towards developing an effective treatment of dengue fever," he said. "At the same time, it will coordinate efforts to help overcome knowledge gaps and expedite clinical research and regulatory approvals, including addressing unmet need of the dengue patients."

The partnership will carry out preclinical studies of potential dengue treatments, test the efficacy of several re- purposed drug candidates and implement clinical trials of the most promising compounds to deliver an affordable and accessible treatment solution. The focus will be on combination treatment opportunities, as these have the most potential for increased efficacy at different stages of the disease - increasing the window of opportunity to avoid progression to severe dengue.

Dengue, a climate sensitive, neglected tropical disease, is one of the top 10 threats to global public health worldwide, and India sees frequent outbreaks of the vector- borne disease, especially during the monsoon season. Symptoms can include fever, nausea, vomiting and body ache. If the infection progresses to severe dengue, affected people may experience shock, internal bleeding and organ failure. There is also a risk of death.

Yet, despite an estimated 390 million dengue infections each year in more than 100 countries, there is no specific treatment available. This not only causes suffering, but places significant pressure on already overburdened health systems.

At least 70% of the global dengue burden is in Asia, where severe dengue has become a leading cause of hospitalization and death among children and adults. India reports tens of thousands of dengue cases every year, with outbreaks every 2-3 years in different states of the country. In 2021, a total of 164,103 dengue cases was reported compared with 205,243 cases in 2019, government data show.

Globally, the number of dengue incident cases increased by 85% from 1990 to 2019. Rising temperatures linked to climate change are predicted to see faster viral amplification of the disease, as well as increased survival, reproduction and biting rate of the mosquitoes that carry it.

In certain parts of India, higher dengue infections are being reported well into the winters that health and environment experts attribute to climate change and alterations in rainfall patterns.

"As there is no specific treatment that can prevent progression of the infection to severe dengue, it is critical to find therapeutic solutions to this climate-sensitive disease that spreads at rapid pace," said Kavita Singh, director, DNDi South Asia. "We hope this new partnership will accelerate the development of new dengue treatment that will be safe, accessible and easy to administer,"

Since its creation in 2003, DNDi has developed and registered nine new treatments for neglected diseases such as sleeping sickness, visceral and cutaneous leishmaniasis, Chagas, and paediatric HIV. This is the first time its researchers will dedicate efforts to dengue, the organisation said in a statement.

ABOUT THE AUTHOR

Rhythma Kaul works as an assistant editor at Hindustan Times. She covers health and related topics, including ministry of health and family welfare, government of India.

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transitional health science and technology institute

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Govt looks to develop drug to treat dengue within 5 years

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A collaborative research project between a government institute and a non-profit is aiming to develop a safe, affordable and effective treatment for dengue fever within five years, according to people familiar with the development.

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Dengue burden in India: Recent trends and importance of climatic parameters

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Mutheneni et al. (2017) Dengue Burden in India

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Mutheneni et al. (2017) Dengue Burden in India

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This peer-reviewed article enlists the burden that India has been facing because of dengue and how it has started to spread from urban areas to more rural areas in the recent years. It also explains how different seasons have an impact on the number of dengue cases in India and how it differs from state to state. The article also mentions how a climate-based model should be implemented to get a better idea on how dengue can be prevented during that season.

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Dengue burden in India recent trends and importance of climatic parameters

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Dengue infection in India: A systematic review and meta-analysis

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Ganeshkumar et al. (2018) Dengue Infection in India

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Ganeshkumar et al. (2018) Dengue Infection in India

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This peer-reviewed article provides a general overview of what dengue is and how it spreads along with explaining how it has impacted the Indian population. The article enlists how dengue has been a burden on the country, its prevalence, and some of the possible measures to help reduce the spread of the infection.

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Understanding India's urban dengue surveillance: A qualitative policy analysis of Hyderabad district

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Pilot et al. (2020) India's Urban Dengue Surveillance

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Pilot et al. (2020) India's Urban Dengue Surveillance

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This peer-reviewed article describes the surveillance system in Hyderabad, Telangana. The article provides an understanding into the challenges of the public health authorities system. It also provides a detailed outlook of the organization as well as functioning of the current health pillars. The study found that Hyderabad relies more on the data from public health sectors and does not focus on the data from private hospitals which leads to an inaccurate representation of the prevalence of dengue related cases. The article also mentions the need to improve public health structure.

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Understanding India s urban dengue surveillance A qualitative policy analysis of Hyderabad district

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Explained: Dengue fever, how it spreads & how it can be controlled 

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This video gives information regrading what dengue is, how it spreads and some of the ways in which the spread of dengue can be curbed.

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Explained: Dengue fever, how it spreads & how it can be controlled

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As the number of dengue, a vector-borne disease, cases in the national capital rises, here's a look at what causes the disease and how can we safeguard against it.

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This video provides an overview of  dengue and some of its variants in detail. It also lists which variant is more dominant in India and how it is more dangerous. The video also explains some of the stereotypes related to dengue and its variants.

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Explained: Dengue And Its Variants | FYI

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CDC also provides a brief explanation of dengue and then talks about the areas which are at risk for a dengue outbreak. It also lists information on the new dengue vaccine.

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What is Dengue?

Dengue viruses are spread to people through the bite of an infected Aedes species ( Ae. aegypti or Ae. albopictus) mosquito. Almost half of the world's population, about 4 billion people, live in areas with a risk of dengue. Dengue is often a leading cause of illness in areas with risk.

Areas with Risk of Dengue

Dengue outbreaks are occurring in many countries of the world. Protect yourself from mosquito bites.

New Dengue Vaccine

A new dengue vaccine is approved for use in children aged 9 to 16 years with laboratory-confirmed previous dengue virus infection and living in areas where dengue is endemic (common). Endemic areas include some U.S. territories and freely associated states. The vaccine is not approved for use in U.S. travelers who are visiting but not living in an area where dengue is common.

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Dengue viruses are spread to people through the bite of an infected Aedes species ( Ae. aegypti or Ae. albopictus) mosquito. Almost half of the world's population, about 4 billion people, live in areas with a risk of dengue. Dengue is often a leading cause of illness in areas with risk.

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NIH:National Institute of Allergy and Infectious Diseases

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NIH:National Institute of Allergy and Infectious Diseases

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This organization explains what dengue fever is and what steps are NIAID taking to address the problem. It also explains why it is critical to start getting more insight and research to address the problem.

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Biology & Transmission

Dengue has emerged as a global health threat, while scientists still know little about how the virus infects cells and causes the disease. To answer these questions, NIAID supports a wide-range of basic research activities aimed at better understanding the biology of the dengue virus, the progression of disease in infected people, and the interactions between the virus and the immune system. New research findings are shedding light on the mechanisms of dengue infection, such as how the virus enters the cells and how the human immune system responds to dengue infection. Other NIAID projects are identifying the human and viral factors that determine and contribute to the severity and transmissibility of this disease.

Read more about dengue fever biology and transmission

Prevention

NIAID researchers are actively engaged in the search for an effective vaccine against dengue fever. The vaccine approach that is currently been evaluated at NIAID for efficacy against dengue animal models and human trials is a weakened recombinant version (live-attenuated) of the dengue virus. Other NIAID-funded investigators are working to develop dengue vaccines using different live-attenuated dengue viruses, recombinant proteins, viral vectors, and DNA.

Read more about dengue fever prevention

Diagnosis

NIAID-supported scientists are working to understand the pathology of dengue disease and to develop cost-effective, sensitive, and specific diagnostic tests for use in dengue-endemic countries. The goal of these tests is to provide early detection of the disease, distinguish between the different viral dengue, and predict which people are at highest risk of developing the more severe forms of the disease, dengue hemorrhagic fever and dengue shock syndrome. Quick and effective diagnosis of dengue is critical to effectively control outbreaks, treat the disease, and reduce mortality. In one project supported by NIAID, researchers are developing an automated, portable, point-of-care machine for rapid dengue diagnosis

Read more about dengue fever diagnosis

Treatment

NIAID-supported investigators are pursuing several approaches to treat dengue infection. Some scientists are working to identify cellular and viral proteins to use as targets for drug intervention. In other studies, researchers are generating and evaluating neutralizing monoclonal antibodies and small molecule drugs in animal models. Results from these animal trials may result in new treatment options for people with dengue. In one NIAID-funded contract, researchers evaluated about 7,500 antiviral compounds in vitro to test their efficacy against dengue. So far, 49 have been identified for further evaluation.

Read more about dengue fever treatment

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Dengue has emerged as a global health threat, while scientists still know little about how the virus infects cells and causes the disease. To answer these questions, NIAID supports a wide-range of basic research activities aimed at better understanding the biology of the dengue virus, the progression of disease in infected people, and the interactions between the virus and the immune system.

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This task force is a team made up of professionals who have developed five steps namely: epidemiological surveillance, laboratory procedures, case management, mass communications, and vector-control activities to address and assess the spread of dengue.

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The International Dengue Task Force was created through the Resolution CD44-R9, of the PAHO Directing Council (2003) and supports the efforts made by the countries to face Dengue, one of the biggest health issues in our society. The International Dengue Task Force is incorporated to the work in the countries, to modify the current practices and put underway the new strategy of integrated management for dengue prevention and control. This new strategy is horizontal, intersectoral, inter-programmatic and seeking to change those behaviors that make up the conditioning risk factors for dengue.

Background

In 2001, the PAHO Directing Council adopted Resolution CD43.R4, a political declaration responding to the alarming situation involving dengue. This resolution constitutes a frame of reference for the new generation of programs for the prevention and control of this disease, which share the paradigm of health promotion with emphasis on coordinated activities between the government, the health sector, the economic and social sectors, nongovernmental organizations, and any and all associations-be they traditional or new-capable of helping to strengthen the national prevention and control programs. The activities generated should have as their objective promoting behavioral change, both individual and collective, in all that is related to a better environmental arrangement in relation to preventing dengue.

Rationale for the Formation of the Task Force

By responding to the situation at hand, in the current context of change and following new orientations regarding the ways and means necessary to apply for PAHO technical cooperation, an integrated disease management model was proposed that includes a new form of technical cooperation, with the creation of the International Dengue Task Force (GT-Dengue, from its acronym in Spanish). The GT-Dengue International Task Force is a group of experts whose starting point is to conduct an integrated analysis of the current regional situation, who will join the workforce in the countries to work together to modify existing practices and implement the new Integrated Strategy for Dengue Prevention and Control ( EGI-Dengue, also from its acronym in Spanish). This new strategy is horizontal, intersectoral, interprogrammatic, seeking to change those behaviors that make up the conditioning risk factors for dengue. GT-Dengue International, as a means of technical cooperation to deal with dengue, was adopted at the annual meeting of the Directing Council on 26 September 2003 by the PAHO Member Countries, through Resolution CD44.R9.

The Team

GT-Dengue International is made up of a professional team with experience in each area mentioned as a component in the Strategy of Integrated Management, namely:

1. Epidemiological Surveillance: These experts have excellent knowledge of the principles and recent advances in epidemiology, surveillance, and biostatistics, with demonstrated capacity in the use of epidemiological techniques and of procedures to analyze the magnitude of communicable diseases that affect populational health, determining those factors that influence the magnitude of these interventions. They have prior experience in the management of programs for dengue prevention and control.

2. Laboratory Procedures: These experts have experience in different diagnostic techniques for dengue, in addition to laboratory management, sampling, and other related activities.

3. Case Management (particularly when treating the most serious cases): These medical professionals are versed in early detection of dengue cases and serious case management of dengue hemorrhagic fever/dengue shock syndrome and have the capacity to transmit this knowledge to other health workers.

4. Mass Communications: These professionals are well versed in new communication strategies that have an impact on behavior, which is a vital point for helping the health authorities reach the community, which is the primary unit of prevention in households. They are in harmony with the New Generation of Programs for Dengue Prevention and Control promoted by PAHO. They are capable of conducting training workshops for other communicators who can then replicate their actions.

5. Vector-Control Activities: Basically entomologists, these vector-control experts know how to run programs and are versed in integrated vector-control and environmental management activities; but they are also sensitive to the incorporation of the community in these activities.

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The International Dengue Task Force: Dedicated to the Fight against Dengue

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The International Dengue Task Force was created through the Resolution CD44-R9, of the PAHO Directing Council (2003) and supports the efforts made by the countries to face Dengue, one of the biggest health issues in our society.