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15 April 2007

Volume 195, Number 8
The Journal of Infectious Diseases 2007;195:1089–1096
© 2007 by the Infectious Diseases Society of America. All rights reserved.
0022-1899/2007/19508-0004$15.00
DOI: 10.1086/512680
MAJOR ARTICLE

Severe Dengue Virus Infection in Travelers: Risk Factors and Laboratory Indicators

Ole Wichmann,1,3

Joaquim Gascon,7

Mirjam Schunk,4

Sabino Puente,8

Heli Siikamaki,11

Ida Gjørup,12

Rogelio Lopez‐Velez,9

Joannes Clerinx,13

Gabriele Peyerl‐Hoffmann,5

Anders Sundøy,14

Blaise Genton,15

Peter Kern,6

Guido Calleri,16

Miguel de Górgolas,10

Nikolai Mühlberger,2 and

Tomas Jelinek,2 for the

European Network on Surveillance of Imported Infectious Diseases

1Institute of Tropical Medicine, Charité University Medicine, 2Berlin Center for Travel and Tropical Medicine, and 3Department for Infectious Disease Epidemiology, Robert Koch Institute, Berlin; 4Department of Infectious Diseases and Tropical Medicine, University of Munich, Munich, 5Infectious Disease Clinic, Abteilung Innere Medizin II, University of Freiburg, Freiburg, and 6Sektion Infektiologie und Klinische Immunologie, University of Ulm, Ulm, Germany; 7Centre Salut Internacional, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic Barcelona, and 8Department of Infectious Diseases and Tropical Medicine, Hospital Carlos III, 9Tropical Medicine and Clinical Parasitology Unit, Infectious Diseases–Microbiology Department, Hospital Ramon y Cajal, and 10Fundación Jiménez Díaz, Division of Infectious Disease, Madrid, Spain; 11Helsinki University Central Hospital, Department of Medicine, Division of Infectious Diseases, Helsinki, Finland; 12Rigshospitalet Copenhagen, University of Copenhagen, Denmark; 13Prins Leopold Instituut voor Tropische Geneskunde, Clinical Services, Antwerp, Belgium; 14Sorlandet Hospital, Kristiansand, Norway; 15Travel Clinic at the Policlinique Médicale Universitaire, University of Lausanne, Lausanne, Switzerland; 16Division “A” Malattie Infettive, Ospedale Amedeo di Savoia, Torino, Italy

Background.Dengue fever is the most common arboviral disease in travelers. In countries where dengue virus is endemic, sequential (secondary) infections with different dengue virus serotypes are associated with disease severity. Data on severity and secondary infection rates in a population of travelers are lacking.

Methods.Intensified surveillance of dengue fever in travelers was performed within the European Network on Surveillance of Imported Infectious Diseases. Data were collected at 14 European clinical referral centers between 2003 and 2005.

Results.A total of 219 dengue virus infections imported from various regions of endemicity were reported. Serological analysis revealed a secondary immune response in 17%. Spontaneous bleeding was observed in 17 (8%) patients and was associated with increased serum alanine and aspartate aminotransferase levels and lower median platelet counts. Two (0.9%) patients fulfilled the World Health Organization (WHO) case definition for dengue hemorrhagic fever. However, 23 (11%) travelers had severe clinical manifestations (internal hemorrhage, plasma leakage, shock, or marked thrombocytopenia). A secondary immune response was significantly associated with both spontaneous bleeding and other severe clinical manifestations.

Conclusions.In travelers, severe dengue virus infections are not uncommon but may be missed if the WHO classification is strictly applied. High liver enzyme levels and low platelet counts could serve as indicators of disease severity.

Received 30 June 2006; accepted 26 September 2006; electronically published 2 March 2007.

Reprints or correspondence: Dr. Ole Wichmann, Robert Koch Institute, Dept. for Infectious Disease Epidemiology, Seestr. 10, 13353 Berlin, Germany ().

Cited by

Annelies Wilder-Smith, Jacqueline L Deen. (2008) Dengue vaccines for travelers. Expert Review of Vaccines 7:5, 569-578
Online publication date: 1-Aug-2008.
CrossRef
Adriana O. Guilarde, Marilia D. Turchi, Joao Bosco Siqueira Jr., Valeria C. R. Feres, Benigno Rocha, Jose E. Levi, Vanda A. U. F. Souza, Lucy Santos Vilas Boas, Claudio S. Pannuti, and Celina M. T. Martelli. (2008) Dengue and Dengue Hemorrhagic Fever among Adults: Clinical Outcomes Related to Viremia, Serotypes, and Antibody Response. The Journal of Infectious Diseases 197:6, 817-824
Online publication date: 15-Mar-2008.
Abstract-Full Text-PDF Version (143 kB)
Annelies Wilder-Smith and Paul Ananth Tambyah. (2007) Severe Dengue Virus Infection in Travelers. The Journal of Infectious Diseases 195:8, 1081-1083
Online publication date: 15-Apr-2007.
Citation-Full Text-PDF Version (176 kB)

  • Potential conflicts of interest: none reported.

    Presented in part: 9th Conference of the International Society of Travel Medicine, Lisbon, 1–5 May 2005 (poster 06.22).

    Financial support: Society for Tropical and Travel Medicine.

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