Volume 97, Issue 4
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



Dengue virus (DENV) is expanding toward previously nonendemic areas. DENV has recently been introduced in Nepal with limited information. We report the clinical features and serotype distribution of DENV in Nepal during the 2010 outbreaks. A total of 1,215 clinical dengue cases at two major hospitals of central and western Nepal were investigated. Demographic, clinical, and laboratory parameters were recorded. Serum specimens were tested for DENV by IgM/IgG enzyme-linked immunosorbent assays (ELISAs) and reverse transcription polymerase chain reaction (RT-PCR). We confirmed DENV infection in 403 (33%) patients from 12 districts with an estimated case fatality rate of 1.5%. DENV infection was more common in adults (87%) and urban settings (74%). We detected all four serotypes but DENV-1 and -2 were mainly responsible for major outbreaks (92%). Overall, 60% of all DENV infections were secondary and 17% were severe dengue; both being more frequent among the DENV-2 infections. Rash, bleeding, abdominal pain, hepatomegaly, elevated liver enzymes, and thrombocytopenia were significantly more common in severe dengue compared with nonsevere infections. We also confirmed the expansion of dengue to hill urban areas (DENV-1 and -2), including the capital Kathmandu (altitude, 1,300 m) though > 90% cases were from southern plains. Differential clinical and laboratory features probably help in clinical decisions. Multiple serotypes circulation and elevated secondary infections pose potential risk of severe outbreaks and deaths in the future. Therefore, a country with recent dengue introduction, like Nepal, urgently requires a systematic surveillance and appropriate control measures in place to respond to any disastrous outbreaks.

[open-access] This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


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  1. Halstead SB, , 2007. Dengue. Lancet 370: 16441652.[Crossref]
  2. WHO, 2009. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control. Geneva, Switzerland: World Health Organization.
  3. Bhatt S, ., 2013. The global distribution and burden of dengue. Nature 496: 504507.[Crossref]
  4. Gubler DJ, , 2012. The economic burden of dengue. Am J Trop Med Hyg 86: 743744.[Crossref]
  5. WHO, 2011. WHO Regional Office for South-East Asia. 2011. Communicable diseases: Dengue/DHF. Available at: http://www.searo.who.int/LinkFiles/Dengue_Dengue_update_SEA_2010.pdf .
  6. WHO, 1997. Dengue Haemorrhagic Fever: Diagnosis, Treatment and Control. Geneva, Switzerland: World Health Organization.
  7. Balmaseda A, ., 2006. Serotype-specific differences in clinical manifestations of dengue. Am J Trop Med Hyg 74: 449456.
  8. Tomashek KM, Gregory CJ, Rivera Sánchez A, Bartek MA, Garcia Rivera EJ, Hunsperger E, Muñoz-Jordán JL, Sun W, , 2012. Dengue deaths in Puerto Rico: lessons learned from the 2007 epidemic. PLoS Negl Trop Dis 6: e1614.[Crossref]
  9. Lee I-K, Liu J-W, Yang KD, , 2012. Fatal dengue hemorrhagic fever in adults: emphasizing the evolutionary pre-fatal clinical and laboratory manifestations. PLoS Negl Trop Dis 6: e1532.[Crossref]
  10. Thomas L, Moravie V, Besnier F, Valentino R, Kaidomar S, Coquet LV, Najioullah F, Lengellé F, Césaire R, Cabié A, , 2012. Clinical presentation of dengue among patients admitted to the adult emergency department of a tertiary care hospital in martinique: implications for triage, management, and reporting. Ann Emerg Med 59: 4250.[Crossref]
  11. Fox A, ., 2011. Immunological and viral determinants of dengue severity in hospitalized adults in Ha Noi, Viet Nam. PLoS Negl Trop Dis 5: e967.[Crossref]
  12. Kumar R, Tripathi P, Tripathi S, Kanodia A, Pant S, Venkatesh V, , 2008. Prevalence and clinical differentiation of dengue fever in children in northern India. Infection 36: 444449.[Crossref]
  13. Mayxay M, ., 2011. Predictive diagnostic value of the tourniquet test for the diagnosis of dengue infection in adults. Trop Med Int Health 16: 127133.[Crossref]
  14. Halsey ES, ., 2012. Correlation of serotype-specific dengue virus infection with clinical manifestations. PLoS Negl Trop Dis 6: e1638.[Crossref]
  15. Potts JA, Rothman AL, , 2008. Clinical and laboratory features that distinguish dengue from other febrile illnesses in endemic populations. Trop Med Int Health 13: 13281340.[Crossref]
  16. Malla S, ., 2008. Identification of all dengue serotypes in Nepal. Emerg Infect Dis 14: 16691670.[Crossref]
  17. Zangmo S, Klungthong C, Chinnawirotpisan P, Tantimavanich S, Kosoltanapiwat N, Thaisomboonsuk B, Phuntsho K, Wangchuk S, Yoon IK, Fernandez S, , 2015. Epidemiological and molecular characterization of dengue virus circulating in Bhutan, 2013–2014. PLoS Negl Trop Dis 9: e0004010.[Crossref]
  18. Dumre SP, ., 2013. Dengue virus and Japanese encephalitis virus epidemiological shifts in Nepal: a case of opposing trends. Am J Trop Med Hyg 88: 677680.[Crossref]
  19. Malla S, Ghimire P, Dumre S, Khanal SP, Subedi BK, Wierzba TF, , 2005. Health Action in Nepal: Health Newsletter: A First Report of Dengue Fever Cases in Nepal. Available at: http://www.who.int/hac/crises/npl/sitreps/2005/Nepal_Health_Action_Issue_III.pdf. Accessed February 5, 2017.
  20. Blacksell SD, Sharma NP, Phumratanaprapin W, Jenjaroen K, Peacock SJ, White NJ, Pukrittayakamee S, Day NPJ, , 2007. Serological and blood culture investigations of Nepalese fever patients. Trans R Soc Trop Med Hyg 101: 686690.[Crossref]
  21. Takasaki T, Kotaki A, Nishimura K, Sato Y, Tokuda A, Lim CK, Ito M, Tajima S, Nerome R, Kurane I, , 2008. Dengue virus type 2 isolated from an imported dengue patient in Japan: first isolation of dengue virus from Nepal. J Travel Med 15: 4649.[Crossref]
  22. Wierzba TF, Ghimire P, Malla S, Banerjee MK, Shrestha S, Khanal B, Sedai TR, Gibbons RV, , 2008. Laboratory-based Japanese encephalitis surveillance in Nepal and the implications for a national immunization strategy. Am J Trop Med Hyg 78: 10021006.
  23. Innis BL, Nisalak A, Nimmannitya S, Kusalerdchariya S, Chongswasdi V, Suntayakorn S, Puttisri P, Hoke CH, , 1989. An enzyme-linked immunosorbent assay to characterize dengue infections where dengue and Japanese encephalitis co-circulate. Am J Trop Med Hyg 40: 418427.[Crossref]
  24. Lanciotti RS, Calisher CH, Gubler DJ, Chang GJ, Vorndam AV, , 1992. Rapid detection and typing of dengue viruses from clinical samples by using reverse transcriptase-polymerase chain reaction. J Clin Microbiol 30: 545551.
  25. Sharma Y, Kaur M, Singh S, Pant L, Kudesia M, Jain S, , 2012. Seroprevalence and trend of dengue cases admitted to a government hospital, Delhi—5-year study (2006–2010): a look into the age shift. Int J Prev Med 3: 537543.
  26. Gupta E, Mohan S, Bajpai M, Choudhary A, Singh G, , 2012. Circulation of dengue virus-1 (DENV-1) serotype in Delhi, during 2010–11 after Dengue virus-3 (DENV-3) predominance: a single centre hospital-based study. J Vector Borne Dis 49: 8285.
  27. Chakravarti A, Arora R, Luxemburger C, , 2012. Fifty years of dengue in India. Trans R Soc Trop Med Hyg 106: 273282.[Crossref]
  28. Mittal H, Faridi M, Arora S, Patil R, , 2012. Clinicohematological profile and platelet trends in children with dengue during 2010 epidemic in North India. Indian J Pediatr 79: 467471.[Crossref]
  29. Tripathi P, Kumar R, Tripathi S, Tambe JJ, Venkatesh V, , 2008. Descriptive epidemiology of dengue transmission in Uttar Pradesh. Indian Pediatr 45: 315318.
  30. Gubler DJ, , 2011. Dengue, urbanization and globalization: the unholy trinity of the 21 (st) Century. Trop Med Health 39: S3S11.[Crossref]
  31. Hales S, de Wet N, Maindonald J, Woodward A, , 2002. Potential effect of population and climate changes on global distribution of dengue fever: an empirical model. Lancet 360: 830834.[Crossref]
  32. Vong S, ., 2010. Dengue incidence in urban and rural Cambodia: results from population-based active fever surveillance, 2006–2008. PLoS Negl Trop Dis 4: e903.[Crossref]
  33. World Health Organization, 2009. Evaluation of Commercially Available Anti-Dengue Virus Immunoglobulin M Tests. Diagnostic Evaluation Series, 3. Geneva, Switzerland: WHO.
  34. Blacksell SD, ., 2007. Prospective study to determine accuracy of rapid serological assays for diagnosis of acute dengue virus infection in Laos. Clin Vaccine Immunol 14: 14581464.[Crossref]
  35. Hang VT, ., 2009. Diagnostic accuracy of NS1 ELISA and lateral flow rapid tests for dengue sensitivity, specificity and relationship to viraemia and antibody responses. PLoS Negl Trop Dis 3: e360.[Crossref]
  36. Khan E, Kisat M, Khan N, Nasir A, Ayub S, Hasan R, , 2010. Demographic and clinical features of dengue fever in Pakistan from 2003–2007: a retrospective cross-sectional study. PLoS One 5: e12505.[Crossref]
  37. Lee LK, Gan VC, Lee VJ, Tan AS, Leo YS, Lye DC, , 2012. Clinical relevance and discriminatory value of elevated liver aminotransferase levels for dengue severity. PLoS Negl Trop Dis 6: e1676.[Crossref]
  38. Potts JA, ., 2010. Classification of dengue illness based on readily available laboratory data. Am J Trop Med Hyg 83: 781788.[Crossref]
  39. Nguyen MT, ., 2016. An evidence-based algorithm for early prognosis of severe dengue in the outpatient setting. Clin Infect Dis 64: 656663.
  40. Porter KR, ., 2005. Epidemiology of dengue and dengue hemorrhagic fever in a cohort of adults living in Bandung, West Java, Indonesia. Am J Trop Med Hyg 72: 6066.
  41. Thai KTD, Nishiura H, Hoang PL, Tran NTT, Phan GT, Le HQ, Tran BQ, Nguyen NV, de Vries PJ, , 2011. Age-specificity of clinical dengue during primary and secondary infections. PLoS Negl Trop Dis 5: e1180.[Crossref]
  42. Verma R, Sharma P, Garg RK, Atam V, Singh MK, Mehrotra HS, , 2011. Neurological complications of dengue fever: experience from a tertiary center of north India. Ann Indian Acad Neurol 14: 272278.[Crossref]

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  • Received : 19 Mar 2017
  • Accepted : 10 Jun 2017

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