Announcements
On 6 June 2017, the World Health Organization (WHO) published updates to its ‘Essential Medicines List’ (EML). Read more here.

Eurosurveillance is on the updated list of the Directory of Open Access Journals and in the SHERPA/RoMEO database. Read more here.

Follow Eurosurveillance on Twitter: @Eurosurveillanc


In this issue


Home Eurosurveillance Edition  2016: Volume 21/ Issue 50 Article 1
Back to Table of Contents
Download (pdf)
Next

Eurosurveillance, Volume 21, Issue 50, 15 December 2016
Rapid communication
Eldin, Gautret, Nougairede, Sentis, Ninove, Saidani, Million, Brouqui, Charrel, and Parola: Identification of dengue type 2 virus in febrile travellers returning from Burkina Faso to France, related to an ongoing outbreak, October to November 2016

+ Author affiliations


Citation style for this article: Eldin C, Gautret P, Nougairede A, Sentis M, Ninove L, Saidani N, Million M, Brouqui P, Charrel R, Parola P. Identification of dengue type 2 virus in febrile travellers returning from Burkina Faso to France, related to an ongoing outbreak, October to November 2016. Euro Surveill. 2016;21(50):pii=30425. DOI: http://dx.doi.org/10.2807/1560-7917.ES.2016.21.50.30425

Received:03 December 2016; Accepted:15 December 2016


Dengue fever in returning travellers to non-endemic areas has been mainly reported after visits to South-east Asia, Central Asia, or South America [1]. In Africa, its epidemiology is poorly described even if the disease has long been known to exist [2]. We report two cases of dengue fever identified in travellers returning from Ouagadougou, Burkina Faso, to Marseille, France, in late autumn 2016, reflecting a large ongoing local outbreak.

Case descriptions

The first case was a woman in her mid-twenties, who travelled to Burkina Faso as a logistician for a medical non-governmental organisation (NGO). She spent 10 days in Ouagadougou from 23 October to 3 November 2016 and used atovaquone/proguanil for malaria prophylaxis. Three days after her arrival, she developed fever, headache, myalgia, nausea and diarrhoea. Two days after she came back to France, she presented at our centre with persisting diarrhoea on day 9 after symptom onset. At examination she had no fever, complained of weakness and had a painful abdomen. Dengue nonstructural protein 1 (NS1) antigen (Ag) and serology (IgM) was negative (SD BIOLINE Dengue Duo Combo Device, Standard Diagnostics Inc, Korea) and malaria rapid diagnostic tests (Palutop+4, All. Diag, France) were negative, as was serology with an in-house MAC ELISA for IgM and in-house indirect ELISA for IgG [3]. A serum sample was positive for dengue viral RNA [4] and typed as dengue 2 viral RNA [5]. Blood and stool cultures, parasitological examination of stools and RealStar Chikungunya RT-PCR kit 1.1 (Altona Diagnostics, Germany) were negative. Convalescent serum was not collected because the patient did not attend the follow-up visit (Table).

Table

Laboratory test results, two cases of dengue fever in travellers returning from Ouagadougou, Burkina Faso, to Marseille, France, October to November 2016a

Laboratory results (norm) Case 1 Case 2
Leukocyte count/μl (4,000-10,000) 1,650 2,700
Platelet count/μl (150,000-400,000) 296,000 142,000
ALT/AST IU/L (10-40) 62/53 1,800/NA
Dengue NS1 Ag (NA) Negative Positive
Dengue serology (IgM and IgG)b (NA) Negative Negative
Real-time RT-PCR detecting all dengue virus RNA (NA) Positive Negative
Type specific real-time RT-PCR (NA) Positive serotype 2 Negative

Ag: antigen; ALT: alanine transaminase; AST: aspartate aminotransferase; NA: not available NS 1: non-structural protein RT: reverse transcription.

a Only values deviating strongly from the norm are presented.

b MAC ELISA for IgM and in-house indirect ELISA for IgG [3].

The second case was a woman in her 50s who travelled from 12 October to 10 November 2016 to Ouagadougou, where she worked with the organisation of a theatre festival. One week after arrival, she presented fever up to 40.5 °C, arthralgia and diarrhoea. She presented at a local medical centre and was treated by quinine for malaria without blood tests performed. Fever and diarrhoea persisted and on day 3 of illness dark urine appeared. She thus consulted the International Medical Center in Ouagadougou where blood sample analysis revealed severely elevated liver transaminases (Table). Malaria was ruled out by microscopic blood smear examination and Dengue NS1 Ag testing was performed and found positive. She came back to France and consulted a cardiologist because of chest pain. Chest computerised tomography (CT)-scan ruled out pulmonary embolism and pericarditis was diagnosed by echocardiography. She presented at our centre two weeks after resolution of symptoms because she had questions about the prevention of dengue fever.

Epidemiological situation in Burkina Faso and neighbouring countries

The first dengue fever outbreak in Burkina Faso was reported in 1925 [2]. In 1982, a second outbreak was described between September and December, with 30 cases reported (mainly European expatriate patients), and two strains of dengue virus serotype 2 were isolated for the first time in this country [6]. In 2013, another epidemic occurred between October and November, and serotype 3 was isolated [7]. On 18 November 2016, the World Health Organization (WHO) reported 1,061 suspected cases of dengue fever in Burkina Faso between August and November 2016, including 15 fatal cases [8]. Serotype 2 has been identified in the current outbreak, but further investigations are in progress.

Concerning other West African countries, data are scarce. The last epidemic in Senegal was reported in 2009, caused by dengue type 3 virus [9]. In Sierra Leone, Mali and the Ivory Coast, seroprevalence studies among febrile patients reflect the circulation of the virus [10-12]. Cases from Togo and Benin have been reported only in travellers [2,13].

Discussion

We report two cases of dengue fever in travellers returning from Burkina Faso to France in late autumn 2016. The first patient had a non-complicated dengue fever according to the WHO dengue fever classification criteria [14]. The second one fulfilled the criteria for severe dengue fever, with ALT > 1,000 IU/L, and a pericarditis was diagnosed when she came back to France. Pericarditis has been rarely reported after dengue fever, possibly because of a lack of detection in endemic areas. Some ten cases have been reported from Malaysia, Sri Lanka, Singapore, Brazil in total and one case in a French traveller returning from Guadeloupe [15-18].

The two cases here should remind us that dengue screening should be performed in malaria-negative travellers with history of fever returning from Africa [1,19]. For systematic screening of returning travellers for dengue fever, rapid diagnostic tests (as commonly done for malaria) are available and should be used. Rapid and early detection of cases could allow implementing measures to prevent further spread i.e. mosquito control around the residence of the returning travellers in areas where competent vectors are present and adapting the prevention message for travellers who wish to visit Africa.

It is a well-known fact that travellers may serve as sentinels to local risks and this has been proven in numerous instances. In countries with scarce public health reporting, they may inform the international community on the onset of epidemics. Data from the African continent on dengue fever illustrates this phenomenon: dengue infections have been detected in 34 African countries, and for 12 of them the only available information was from travellers [2]. At the time we diagnosed our first case, the outbreak in Burkina Faso had not yet been notified by the WHO and the serotype involved was not known.

An international festival of theatre named ’Les récréâtrales’ took place in Ouagadougou, from 29 October to 5 November. This festival occurs every two years in the capital between October and November, the months in which all previous dengue outbreaks were described. Our second patient mentioned that two other members of the festival staff were diagnosed with dengue fever during her stay. This festival takes place in a popular district of Ouagadougou (Bougsemtenga) and some presentations are organised in familial yards surrounding houses. A recent entomological survey in Ouagadougou identified that these yards were major places of vectors’ breeding sites [20]. The most frequent breeding sites identified were water storage containers, garbage such as food tins, and tyres [20]. In this survey, Aedes aegypti specimens were captured from breeding sites but no Ae. albopictus was identified [20]. Aedes mosquitoes bite during daytime. Hence, clinicians should remind travellers to endemic areas, including those in Africa, of the importance to protect themselves against mosquito bites during the day.


Conflict of interest

None declared.

Authors’ contributions

Carole Eldin and Philippe Gautret wrote the manuscript. Philippe Parola and Philippe Brouqui critically revised the manuscript Antoine Nougairede, Laetitia Ninove and Remi Charrel performed the virological anaysis. Melanie Sentis, Matthieu Million, and Nadia Saidani made the clinical diagnosis and description of cases.


References

  1. Leder K, Torresi J, Brownstein JS, Wilson ME, Keystone JS, Barnett E,  et al. , GeoSentinel Surveillance Network. Travel-associated illness trends and clusters, 2000-2010.Emerg Infect Dis. 2013;19(7):1049-73. DOI: 10.3201/eid1907.121573 PMID: 23763775

  2. Amarasinghe A, Kuritsk JN, Letson GW, Margolis HS. Dengue virus infection in Africa.Emerg Infect Dis. 2011;17(8):1349-54.PMID: 21801609

  3. Peyrefitte CN, Pastorino BAM, Bessaud M, Gravier P, Tock F, Couissinier-Paris P,  et al.  Dengue type 3 virus, Saint Martin, 2003-2004. Emerg Infect Dis. 2005;11:757-61.

  4. Huhtamo E, Hasu E, Uzcátegui NY, Erra E, Nikkari S, Kantele A,  et al.  Early diagnosis of dengue in travelers: comparison of a novel real-time RT-PCR, NS1 antigen detection and serology. J Clin Virol. 2010;47(1):49-53. DOI: 10.1016/j.jcv.2009.11.001 PMID: 19963435

  5. Leparc-Goffart I, Baragatti M, Temmam S, Tuiskunen A, Moureau G, Charrel R,  et al.  Development and validation of real-time one-step reverse transcription-PCR for the detection and typing of dengue viruses. J Clin Virol. 2009;45(1):61-6. DOI: 10.1016/j.jcv.2009.02.010 PMID: 19345140

  6. Gonzalez JP, Du Saussay C, Gautun JC, McCormick JB, Mouchet J . (Dengue in Burkina Faso (ex-Upper Volta): seasonal epidemics in the urban area of Ouagadougou). Bull Soc Pathol Exot Filiales. 1984;78:7-14. French.

  7. Tarnagda Z, Congo M, Sangaré L. Outbreak of dengue fever in Ouagadougou, Burkina Faso, 2013.Int J Microbiol Immunol Res. 2014;2:101-8.

  8. World Health Organization (WHO). Dengue Fever – Burkina Faso. Geneva: WHO. [Accessed 28 Nov 2016]. Available from: http://www.who.int/csr/don/18-november-2016-dengue-burkina-faso/en/

  9. Faye O, Ba Y, Faye O, Talla C, Diallo D, Chen R,  et al.  Urban epidemic of dengue virus serotype 3 infection, Senegal, 2009. Emerg Infect Dis. 2014;20:456-9.

  10. de Araújo Lobo JM, Mores CN, Bausch DG, Christofferson RC. Short Report: Serological Evidence of Under-Reported Dengue Circulation in Sierra Leone.PLoS Negl Trop Dis. 2016;10:e0004613.

  11. Phoutrides EK, Coulibaly MB, George CM, Sacko A, Traore S, Bessoff K,  et al.  Dengue virus seroprevalence among febrile patients in Bamako, Mali: results of a 2006 surveillance study. Vector Borne Zoonotic Dis. Larchmt. N. 2011;11:1479-85.

  12. L’Azou M, Succo T, Kamagaté M, Ouattara A, Gilbernair E, Adjogoua E,  et al.  Dengue: etiology of acute febrile illness in Abidjan, Côte d’Ivoire, in 2011-2012. Trans R Soc Trop Med Hyg. 2015;109:717-22.

  13. Gautret P, Botelho-Nevers E, Charrel RN, Parola P. Dengue virus infections in travellers returning from Benin to France, July-August 2010.Euro Surveill. 2010;15(36).

  14. World Health Organization (WHO). Handbook for clinical management of dengue. Geneva: WHO. [Accessed 28 Nov 2016]. Available from: http://www.who.int/denguecontrol/9789241504713/en/

  15. Miranda CH, Borges M de C, Matsuno AK, Vilar FC, Gali LG, Volpe GJ,  et al.  Evaluation of cardiac involvement during dengue viral infection. Clin Infect Dis. 2013;57(6):812-9. DOI: 10.1093/cid/cit403 PMID: 23784923

  16. Sam S-S, Omar SFS, Teoh B-T, Abd-Jamil J, AbuBakar S. Review of Dengue hemorrhagic fever fatal cases seen among adults: a retrospective study.PLoS Negl Trop Dis. 2013;7(5):e2194. DOI: 10.1371/journal.pntd.0002194 PMID: 23658849

  17. Tayeb B, Piot C, Roubille F. Acute pericarditis after dengue fever.Ann Cardiol Angeiol (Paris). 2011;60(4):240-2. DOI: 10.1016/j.ancard.2011.05.008 PMID: 21664601

  18. Nagaratnam N, Siripala K, de Silva N. Arbovirus (dengue type) as a cause of acute myocarditis and pericarditis.Br Heart J. 1973;35(2):204-6. DOI: 10.1136/hrt.35.2.204 PMID: 4266127

  19. Wilson ME, Weld LH, Boggild A, Keystone JS, Kain KC, von Sonnenburg F,  et al. , GeoSentinel Surveillance Network. Fever in returned travelers: results from the GeoSentinel Surveillance Network.Clin Infect Dis. 2007;44(12):1560-8. DOI: 10.1086/518173 PMID: 17516399

  20. Ridde V, Agier I, Bonnet E, Carabali M, Dabiré KR, Fournet F,  et al.  Presence of three dengue serotypes in Ouagadougou (Burkina Faso): research and public health implications. Infect Dis Poverty. 2016;5(1):23. .DOI: 10.1186/s40249-016-0120-2 PMID: 27044528



Back to Table of Contents
Download (pdf)
Next

The publisher’s policy on data collection and use of cookies.

Disclaimer: The opinions expressed by authors contributing to Eurosurveillance do not necessarily reflect the opinions of the European Centre for Disease Prevention and Control (ECDC) or the editorial team or the institutions with which the authors are affiliated. Neither ECDC nor any person acting on behalf of ECDC is responsible for the use that might be made of the information in this journal. The information provided on the Eurosurveillance site is designed to support, not replace, the relationship that exists between a patient/site visitor and his/her physician. Our website does not host any form of commercial advertisement. Except where otherwise stated, all manuscripts published after 1 January 2016 will be published under the Creative Commons Attribution (CC BY) licence. You are free to share and adapt the material, but you must give appropriate credit, provide a link to the licence, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.

Eurosurveillance [ISSN] - ©2007-2016. All rights reserved
 

This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information:
verify here.