Primary prevention
The World Health Organization (WHO) recommends strategies for the prevention and control of dengue infection, and dengue-endemic regions also tend to produce their own prevention programs and initiatives. The key to all prevention programs is disease surveillance to detect the occurrence of dengue epidemics. Communities in dengue-endemic regions should be educated about dengue virus infection, how to recognize symptoms, and how to prevent its transmission.[1][2]
Preventive measures include:[1]
Regularly removing all sources of stagnant water to prevent mosquito breeding grounds being established
Preventing mosquito bites by wearing appropriate clothing to cover exposed areas of the skin, especially during the day, and the use of insecticides, mosquito repellents, mosquito coils, and mosquito nets
N,N-diethyl-meta-toluamide (DEET) is generally the repellant of choice; however, there are data to support the use of picaridin as a second-line agent.[55]
Use of mosquito nets and coils around people who are sick with dengue fever to prevent mosquitoes biting infected people and transmitting the infection.
Vaccines
A tetravalent vaccine (Dengvaxia®) is available in approximately 20 countries. The vaccine, also known as CYD-TDV, is a live, attenuated, recombinant vaccine. It is administered as a 3-dose series at 0, 6, and 12 months.[56] Protection is thought to last at least 6 years after the last dose of the series.[57]
The WHO recommends the vaccine in people ages 9 to 45 years with confirmed previous infection.[58]
In the US, it is approved for the prevention of dengue caused by dengue virus serotypes 1, 2, 3, and 4 in people ages 9 to 16 years only who have laboratory-confirmed previous dengue infection and who live in endemic areas (e.g., American Samoa, Guam, Puerto Rico, and the US Virgin Islands).
In Europe, it is approved for the prevention of dengue caused by dengue virus serotypes 1, 2, 3, and 4 in people ages 6 to 45 years who have laboratory-confirmed previous dengue infection.
People not previously infected with dengue virus who receive Dengvaxia® may be at risk for developing severe dengue if they are infected with dengue virus after being vaccinated.
The World Health Organization’s Strategic Advisory Group of Experts on Immunization (SAGE) recommends that the vaccine should only be used in people already infected with the dengue virus (seropositive) identified by a suitable prevaccination screening strategy. This may be difficult to achieve in practice, given that there are no suitable point of care tests available. The recommendation is based on analyses from long-term follow-up that found vaccine efficacy was lower among seronegative patients in the first 25 months after the first dose of vaccine, and an increased risk of hospitalized dengue and severe dengue in seronegative patients starting approximately 30 months after the first dose.[59]
The Centers for Disease Prevention and Control recommends that evidence of previous dengue infection can be obtained with the following: a positive dengue reverse-transcriptase polymerase chain reaction (RT-PCR) test result; a positive dengue NS1 antigen test result; or a positive result on two anti-dengue virus immunoglobulin G tests in a two-step testing algorithm. A single positive immunoglobulin M test result is not sufficient proof of previous dengue infection due to potential cross-reactivity with other circulating flaviviruses in dengue-endemic areas.[60]
Patients with dengue should wait at least 6 months after the dengue infection was confirmed to begin the vaccination series.[56]
In the US, the Advisory Committee on Immunization Practices recommends vaccination with Dengvaxia® for children ages 9 to 16 years with evidence of a previous dengue infection and living in areas where dengue is endemic.[61]
Evidence of previous dengue infection is required for eligible children before vaccination.
Evidence for the efficacy of Dengvaxia® is limited.
Vaccine efficacy against virologically confirmed disease has been reported as 82% in children ages 2 to 16 years, while efficacy against hospitalization has been reported to be 79%, and 84% against severe disease.[62][63]
A systematic review and meta-analysis in children and adolescents ages 2 to 17 years found the overall efficacy of the vaccine to be 60% after 3 doses over a 13-month follow-up period. Serotype-specific efficacy was highest for serotype 3 (75%) and serotype 4 (77%). Immunogenicity was higher for serotype 2 and serotype 3. The vaccine was considered relatively safe as it was found to cause significantly less adverse effects compared to other vaccines currently administered to children (e.g., tetanus, diphtheria). The most common adverse effects were headache and pain at the injection site.[64]
A meta-analysis of seven clinical trials in people ages 2 to 45 years (36,000 participants) found low efficacy of the vaccine against symptomatic dengue (44% - range 25% to 59%), especially serotypes 1 and 2.[65]
Another live attenuated tetravalent vaccine (marketed in Europe as Qdenga®) has been approved by the European Medicines Agency (EMA) to prevent disease caused by all four serotypes in children ≥4 years of age and adults. It is administered as a 2-dose series (0 and 3 months). The EMA has also granted a positive opinion for use of the vaccine outside of the European Union. In the US, the vaccine is currently being evaluated for approval by the Food and Drug Administration.
Consult your local guidelines for information on contraindications, cautions, and use in special patient populations.
Multiple vaccine candidates are currently in clinical development.[66][67]
Other prevention measures
Vector surveillance and control (e.g., larvivorous fish, endotoxin-producing bacteria) and environmental management (e.g., removal of mosquito breeding grounds) are important.[32]
There are various worldwide initiatives to test genetically-modified mosquitoes to help stop the spread of dengue fever and other diseases.[68]
Aedes aegypti mosquitoes infected withWolbachia pipientis have reduced potential to transmit dengue viruses. Introduction of these mosquitoes into specific areas in Indonesia reduced the incidence of symptomatic dengue and led to fewer hospitalizations in these areas.[69]
One Cochrane review found that people living in endemic areas where Wolbachia-carrying Aedes mosquitoes were released were less likely to contract dengue and less likely to be hospitalized due to dengue, compared with people living in areas with no release. However, the review only included one completed randomized controlled trial.[70] [
]
A study in Nicaragua and Mexico involving chemical-free prevention of mosquito production found that community mobilization can add effectiveness to dengue vector control.[71]
Centers for Disease Control and Prevention (CDC): dengue - prevention Opens in new window World Mosquito Program™ Opens in new window
Secondary prevention
Recurrence is possible with different dengue virus serotypes leading to a secondary infection; therefore, the usual primary prevention measures should be followed after recovery from an initial infection.
In dengue-endemic regions, suspected, probable, and confirmed cases of dengue infection should be reported to the relevant authorities as soon as possible, so that appropriate measures can be instituted to prevent dengue transmission.[2]
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