Dengue fever outbreak in a recreation club, Dhaka, Bangladesh.An outbreak of dengue fever dengue fever (dĕng`gē, –gā), acute infectious disease caused by four closely related viruses and transmitted by the bite of the Aedes mosquito; it is also known as breakbone fever and bone-crusher disease. occurred among employees of a recreation club in Bangladesh. Occupational transmission was characterized by a 12% attack rate, no dengue dengue
or breakbone fever or dandy fever
Infectious, disabling mosquito-borne fever. Other symptoms include extreme joint pain and stiffness, intense pain behind the eyes, a return of fever after brief pause, and a characteristic rash. among family contacts, and Aedes vectors in club areas. Early recognition of the outbreak likely limited its impact.
Large outbreaks of dengue fever are rarely reported from occupational or institutional settings (1), probably because a small proportion of Aedes mosquitoes are infected with dengue viruses dengue virus
A virus of the genus Flavivirus that is the cause of dengue. (2), and in dengue-endemic areas, many adults are immune. Dengue has recently reemerged in Bangladesh; in contrast with the situation in countries where dengue has long been endemic, adults appear to become ill with dengue more often than children (3).
We investigated an outbreak of dengue fever among employees of a Recreation Club for expatriates in Dhaka. The 636-member club, which occupied 92,820 sq ft within a residential area, had 107 employees. Initial cases were evaluated by an embassy physician in early October 2001. Club management requested our investigation to define the magnitude of the outbreak and recommend prevention and control strategies.
We defined a case of dengue as a febrile febrile /feb·rile/ (feb´ril) pertaining to or characterized by fever.
Of, relating to, or characterized by fever; feverish. illness lasting [greater than or equal to] 3 days during September or October, 2001, with confirmation of dengue infection by presence of antibodies in sera consistent with dengue infection or with presence of dengue viruses in acute-phase sera, detected by reverse transcriptase--polymerase chain reaction (RT-PCR RT-PCR
reverse transcriptase-polymerase chain reaction. See PCR1. ). Cases were identified through occupational absentee logs and through results of initial laboratory testing of acute-phase sera (as ordered by physicians).
Two batches of serum specimens were tested: 18 serum specimens were collected from ill persons by their physicians, and all consenting employees were asked to provide serum specimens 1 month after the outbreak (specimens were collected on November 21, 25, and 26, 2001). Among acute-phase sera, specimens from five patients, collected during the first 5 days of illness, were evaluated for dengue viruses by RT-PCR for serotype-specific dengue viral RNA RNA: see nucleic acid.
in full ribonucleic acid
One of the two main types of nucleic acid (the other being DNA), which functions in cellular protein synthesis in all living cells and replaces DNA as the carrier of genetic (4).
Acute- and convalescent-phase sera were tested for immunoglobulin immunoglobulin: see antibody; immunity; immunology.
Any of the glycoproteins in the blood serum that are induced in response to invasion by foreign antigens and that protect the host by eradicating pathogens. (Ig) G and IgM dengue antibodies through capture enzyme-linked immunosorbent assay enzyme-linked immunosorbent assay
Enzyme-linked immunosorbent assay (ELISA)
A diagnostic blood test used to screen patients for AIDS or other viruses. (5,6) (MACELISA). Specimens with [greater than or equal to] 40 units of IgG or IgM antibodies were considered positive for dengue infection. Ratios of IgM to IgG antibodies of <1.8 were considered indicative of secondary exposure (i.e., previous exposure to dengue virus), and a ratio of [greater than or equal to] 1.8 was considered suggestive of suggestive of Decision making adjective Referring to a pattern by LM or imaging, that the interpreter associates with a particular–usually malignant lesion. See Aunt Millie approach, Defensive medicine. primary (first-time) exposure (5).
Written informed consent was taken from each study participant. This study was approved by the ethical review committee of International Centre for Diarrhoeal Disease Research, Bangladesh The International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) is an international health research organisation. It is located in Dhaka, Bangladesh and was established in 1978. (ICDDR ICDDR International Centre for Diarrhoeal Disease Research (Bangladesh) ,B). Interviews with consenting employees were from November 21 through 26, 2002; standardized questionnaires collected sociodemographic information, recent illnesses, febrile illnesses among family members, behaviors and activities, severity of illness, health-seeking behavior, and medications. Detailed information was collected about activities in and around the club. Weight and height were measured; body mass index <20 kg/[m.sup.2] was defined as underweight Underweight
An situation where a portfolio does not hold a sufficient amount of securities to satisfy the accepted benchmark of the portfolio's asset allocation strategy.
Notes: (7). Data were entered into FoxPro, Version 2.6 (Microsoft Corporation (company) Microsoft Corporation - The biggest supplier of operating systems and other software for IBM PC compatibles. Software products include MS-DOS, Microsoft Windows, Windows NT, Microsoft Access, LAN Manager, MS Client, SQL Server, Open Data Base Connectivity (ODBC), MS Mail, , Redmond, WA) and analyzed using SPSS A statistical package from SPSS, Inc., Chicago (www.spss.com) that runs on PCs, most mainframes and minis and is used extensively in marketing research. It provides over 50 statistical processes, including regression analysis, correlation and analysis of variance. , Version 10.0 (SPSS Inc., Chicago, IL).
A larval larval
1. pertaining to larvae.
see cutaneous and visceral larva migrans. survey was conducted on October 20, 2001. All objects containing water (wet containers) were noted, and water from each was sampled and investigated for presence of larvae Larvae, in Roman religion
Larvae: see lemures. (larvae were reared to adult stage for species identification).
One hundred (94%) of 107 employees consented to participate. Dengue fever was confirmed in 13 (12%) of 107 employees, including 12 employees who experienced illness onset within a 10-day period in October (Table 1). One case occurred 10 days earlier (13% attack rate). Twelve (92%) case-employees were male. No severe cases of dengue hemorrhagic fever hemorrhagic fever (hĕm'ərăj`ĭk), any of a group of viral diseases characterized by sudden onset, muscle and joint pain, fever, bleeding, and shock from loss of blood. occurred according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. World Health Organization criteria (8), but insufficient data were available to rule out grades 1 and 2. One employee was hospitalized; none died. Eleven other employees had febrile illnesses of [greater than or equal to] 3 days duration in September or October (Figure); however, their dengue serologic se·rol·o·gy
n. pl. se·rol·o·gies
1. The science that deals with the properties and reactions of serums, especially blood serum.
2. assays were negative.
Ten (77%) participants had dengue antibodies in convalescent-phase sera. Samples from three participants had antibodies present in acute-phase sera only. One patient had dengue virus detected by RT-PCR with PCR PCR polymerase chain reaction.
polymerase chain reaction
Polymerase chain reaction (PCR) pattern consistent with dengue serotype serotype /se·ro·type/ (ser´o-tip) the type of a microorganism determined by its constituent antigens; a taxonomic subdivision based thereon.
v. 3 (den-3).
Ratios of IgM to IgG suggested first-time infection among seven (54%) participants and secondary infection in six participants. In addition to the 13 cases of dengue, samples from two employees had dengue antibodies detected during the November serosurvey; the employees had not been ill. One had evidence of primary infection and one of secondary infection on the basis of the IgM/IgG ratio.
In addition to fever in all 13 dengue-positive case-employees (as required by the case definition), 11 (85%) had headache, 5 (39%) had myalgias, and 3 (23%) reported gum bleeding. Nine (69%) patients sought care from clinic or hospital; four persons with dengue did not seek care and reported using medication to alleviate symptoms.
Among 308 family members residing with the 100 employees, 21 (7%) family members were reported to be ill with fever during September and October. The rate (14%) of febrile illnesses among family members was significantly higher among 11 employees with febrile illness with negative dengue assays than among the 13 dengue patients (2%; p = 0.04; Table 2).
The first three dengue cases occurred among security guards. They spent most working hours on the perimeter of the club, particularly around the east and west sides. Overall 3 (23%) of 13 security guards were cases compared with 10 (11%) of 87 other participating employees. Three case-patients (gardener, receptionist, and tennis ball boy) shared significant time, i.e., > 1 hour, with the first three case-patients around the main entrance, as well as within the canteen, west side and laundry room A laundry room (also called a utility room) is a room where clothes are washed. In a modern home, a laundry room would be equipped with an automatic washing machine and clothes dryer,and often a large basin, called a laundry tub, for hand-washing delicate articles of clothing such , and changing room changing room n (BRIT) → vestuario
changing room change n (Brit) (in shop) → salon m d'essayage: (Sport) → areas. Subsequent case-patients represented a wide variety of occupations, and these employees spent time in a variety of locations around the club. The staff did not have living quarters at the club.
Epidemic dengue did not occur among club members. While surveillance was not systematically conducted, 2 (0.3%) of 636 members were known to have had dengue fever during October.
We compared data from case-employees with 76 other employees (noncase-employees) who did not have febrile illnesses during September or October. Age distribution was similar for case-employees (mean 32 years) and noncase-employees (mean 36 years). Differences in sex, duration of employment, body mass index, working hours, time spent indoors or outdoors, medications, or smoking were not significant.
Case-employees (100%) were more likely than noncase-employees (83%) to spend any time within the canteen area during break time (Kendall's [tau], p < 0.01). Case-employees (62%) were also more likely than noncase-employees (33%) to come to the club by walking (odds ratio = 3.3; 95% confidence interval confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. 1.0 to 11.0; p < 0.05). Mosquito repellent re·pel·lent
Capable of driving off or repelling.
A substance used to drive off or keep away insects.
able to repel or drive off; also, an agent that repels. Refers usually to insect repellent. use was associated with a slightly reduced likelihood of dengue infection (0% in case-employees and 9% in noncase-employees; Kendall's [tau], p < 0.05).
A total of 23 larvae-positive containers were found among 34 wet containers (container index = 68) (Table 3); 364 larvae (103 Ae. aegypti and 261 Ae. albopictus) were identified in stagnant water covering surface lids of 20 metal drums used for security (to block traffic) at the west perimeter.
Intense focal transmission of dengue viruses occurred within an occupational setting in a community experiencing endemic dengue. Focal intensity is highlighted by a 12% attack rate among employees for a 2-week period, compared with no known cases of dengue among nuclear family members. In other Asian countries where dengue is established and where multiple serotypes circulate, outbreaks of dengue fever in occupational settings are uncommon since adults are usually immune; disease is highest in children (8). Other febrile illnesses were occurring simultaneously among employees; these illnesses were probably caused by another communicable disease communicable disease
A disease that is transmitted through direct contact with an infected individual or indirectly through a vector. Also called contagious disease. , as suggested by a higher attack rate of febrile illnesses among family members of febrile employees who did not have dengue.
Dengue viruses are transmitted by infected mosquitoes during feeding, which may occur several times a day, for a 1- to 4-week lifetime (9). The larval survey showed that Aedes mosquitoes were present in working areas. High concentrations of Aedes larvae in water on security drum surfaces may have provided a mechanism for this outbreak. The first three cases were among security guards who were often in close proximity with the security drums. The guards also spent time inside the club (eating, praying, changing clothes, and taking breaks). The security guards may have been exposed to dengue while on patrol outside of the club, and once infected, transmitted dengue viruses to adult Aedes mosquitoes feeding on them while they spent time inside the club. Mosquitoes, thus infected, were able to quickly infect other employees working or resting within the club, perhaps within the staff canteen, resulting in a burst of illnesses. The end of intense transmission coincided with recognition of the outbreak, aggressive use of insecticides insecticides, chemical, biological, or other agents used to destroy insect pests; the term commonly refers to chemical agents only. Chemical Insecticides
, and removal of breeding sites.
The outbreak likely resulted from conditions which promoted rapid transmission of dengue viruses, such as high vector density and many susceptible (nonimmune) people within close quarters close quarters
at close quarters
a. engaged in hand-to-hand combat
b. very near together
Noun 1. . Primary infection among seven cases supports the notion that dengue has recently emerged in Bangladesh. No club members were case-patients, reflecting the importance of duration of exposure in risk for transmission.
Early recognition of the outbreak may have helped limit its impact (10). Institutional or systematic monitoring of suspected cases, i.e., surveillance, supported by prompt laboratory confirmation, may help to contain such outbreaks. Integrating and targeting vector control Vector control is any method to limit or eradicate the vectors of vector born diseases, for which the pathogen (e.g. virusor parasite) is transmitted by a vector which can be mammals, birds or arthropods, especially insects, and more specifically mosquitoes. as soon as a cluster of cases is detected can suppress transmission and minimize numbers of cases.
Table 1. Characteristics of 13 dengue fever patients (a) (b) MACELISA PCR (Oct 17, (peak outbreak 2001; with fever period; Oct within the Case no. Age Sex 21, 2001) (c) past 5 days) 1 26 Male Primary -- 2 35 Male Secondary -- 3 40 Male Primary Negative 4 26 Male Secondary -- 5 24 Male Primary Negative 6 22 Male Secondary Negative 7 27 Male Negative Negative 8 33 Male Primary -- 9 30 Male Primary -- 10 38 Male -- -- 11 38 Female Secondary -- 12 38 Male Negative Den-3 13 34 Male -- -- MACELISA (Nov Case no. 21-26, 2001) Onset of illness Occupation 1 Primary 10/01/01 Assistant security 2 Secondary 10/10/01 Security guard 3 Negative 10/11/01 Security guard 4 Secondary 10/11/0l Gardener 5 Negative 10/12/01 Receptionist 6 Secondary 10/13/01 Tennis ball boy 7 Secondary 10/14/01 Waiter 8 Primary 10/14/01 Cook 9 Negative 10/15/01 Baker 10 Secondary 10/15/01 Laundry staff 11 Secondary 10/16/01 Laundry staff 12 Primary 10/17/01 Confectioner 13 Primary 10/19/01 Gardener (a) Serologic survey on Nov 21-26 indicated two more employees, not included in this table, who had dengue antibodies (one primary and one secondary pattern). They did not have symptoms; thus, they were not included as case-employees. (b) ELISA, enzyme-linked immunosorbent assay; PCR, polymerase chain reaction. (c) Fever duration > 3 days and serologically confirmed. Those who reported in the table were only for those continuously worked from October 17 to November 2001 (4 employees were no longer working at the club and not available on Nov 21-26, 2001; their MACELISA results on October 17 included one specimen positive for primary infection and the others negative). Table 2. Illness reported among employees and family members during the outbreak period, September-October 2001 Family members with history of febrile illnesses Employee categories during outbreak period 13 employees with confirmed dengue 2.0% (1/51) (a) 76 employees who did not have 6.5% (14/215) (a) dengue and did not have a febrile illness during outbreak period 11 employees who did not have 14.3% (6/42) (b) dengue and who had a febrile illness during outbreak period Total employees = 100 6.8% (21/308) (a) Dengue laboratory test confirmation done for febrile Employee categories illnesses among family members 13 employees with confirmed dengue No laboratory confirmation done 76 employees who did not have 6 febrile patients had laboratory dengue and did not have a febrile tests and 2 were serologically illness during outbreak period confirmed as having dengue fever at commercial pathology laboratories 11 employees who did not have No laboratory confirmation done dengue and who had a febrile illness during outbreak period Total employees = 100 (a) Number of febrile illnesses/number of family members. (b) p = 0.04 when compared with the percentage of febrile illness among family members of case-patients. Table 3. Survey of wet containers for Aedes larvae within and outside of the club (a) No. of No. of wet con- positive No. of Place Container type tainers containers larvae Outside of premise Metallic drum 26 20 364 boundary cover Outside of club Plastic glass 1 1 19 building Manhole cover 6 1 4 Inside of club No wet container 0 0 0 building found Rooftop of club Stagnant water 1 1 5 building on rooftop floor Total 34 23 (a) 392 Mosquito species Aedes Ae. Place Container type aegypti albopictus Others Outside of premise Metallic drum 103 261 0 boundary cover Outside of club Plastic glass 0 19 0 building Manhole cover 4 0 0 Inside of club No wet container 0 0 0 building found Rooftop of club Stagnant water 5 0 0 building on rooftop floor Total 112 280 0 (a) Overall container index (CI) was 68 (23/34 x 100).
We acknowledge the assistance of Kimberly Ottwell and the ICDDR,B Dengue Scientific Working Group; Rajib Chowdhury, Shirin Sultana, and Tanjin Akter for assisting in interviews and entomological en·to·mol·o·gy
The scientific study of insects.
ento·mo·log assessment; Rabindranath Sarker for blood collection; Mahmuda Khatun for technical assistance with laboratory assays; and the Armed Forces Research Institute of Medical Sciences for providing training and reagents for serologic studies.
The work was supported by the United States Agency for International Development The United States Agency for International Development (or USAID) is the U.S. government organization responsible for most non-military foreign aid. An independent federal agency, it receives overall foreign policy guidance from the U.S. .
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Dr. Wagatsuma is an assistant scientist in the department of International Health, Bloomberg School of Public Health, Johns Hopkins University Johns Hopkins University, mainly at Baltimore, Md. Johns Hopkins in 1867 had a group of his associates incorporated as the trustees of a university and a hospital, endowing each with $3.5 million. Daniel C. . She has been based at ICDDR,B for more than 3 years. Before that, she conducted infectious disease Infectious disease
A pathological condition spread among biological species. Infectious diseases, although varied in their effects, are always associated with viruses, bacteria, fungi, protozoa, multicellular parasites and aberrant proteins known as prions. research in Africa for more than 10 years.
Address for correspondence: Robert Breiman, ICDDR,B: Centre for Health and Population Research, Mohakhali, GPO Box 128, Dhaka-1000, Bangladesh; fax: 880-2-8823963; email: firstname.lastname@example.org
Yukiko Wagatsuma, * Robert F. Breiman, * Anowar Hossain, * and Mahbubur Rahman Mahbubur Rahman (born February 1, 1969, Mymensingh District, Dhaka) is a former Bangladeshi cricketer who played in one ODI in 1999. In the 1980's Mymensingh was a great hub for producing cricketing talent in Bangladesh. *
* ICDDR,B--Centre for Health and Population Research, Dhaka, Bangladesh