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Outbreak Report: “Dengue Fever,” India

Jade Patel, Alyssa Schmidt, Emergency Management, Health, and Hazards Team; Halle Morel, Tiberius Hernandez, Annabell Knapp, PACOM

Week of Monday, November 22, 2021


Dengue Fever Virus[1]


As of November 20, 2021, Delhi, India, has reported 5,277 cases of dengue fever in 2021.[2] This viral infection cannot be transmitted between humans but is transmitted when a mosquito bites an infected human and later transmits the virus onto another human.[3] Alongside the COVID-19 pandemic, the Dengue outbreak will likely hinder the healthcare system in India as they are overwhelmed with patients.[4] Individuals should follow preventative guidelines such as wearing protective clothing, insect repellent, and avoiding impacted areas. Travel plans to the impacted areas should be cancelled or rescheduled for periods with lower average temperatures as mosquito populations will be lower. Without additional preventative measures to limit the transmission of this virus, treatments will likely become less available, and the mortality rate will likely rise in the country.


Description of Pathogen

Aedes aegypti and Aedes albopictus mosquitoes are the primary vectors of the Dengue virus.[5] The virus is spread by an infected mosquito biting a human, injecting the virus into the body.[6] Humans cannot transmit the virus to other humans, so isolation is unnecessary if someone becomes infected with Dengue. Mosquitoes are more likely to bite during early daylight hours, so individuals should avoid going out before dusk to limit infection.[7] Infected mosquitoes are more likely to be found near still water, such as ponds or marshes.[8] The Dengue virus has a global distribution, but it is more predominant in Asia, the Americas, and the Caribbean.[9]


Common symptoms of infection with Dengue include fever, severe headache, nausea, vomiting, dermatitis, decreased appetite, and pain in the muscles, stomach, joints, and behind the eye.[10] Some symptoms are similar to those of other illnesses, likely making dengue challenging to diagnose. Most infected individuals exhibit mild symptoms for a week with no long-term health issues. In rare cases, those infected can experience severe symptoms such as severe swelling, stomach pain, bloody vomiting, bleeding gums, bleeding under the skin, breathing difficulties, clammy skin, abnormal pulse, dizziness, fatigue, and loss of consciousness. It is essential to monitor patients with severe symptoms as death is more likely.[11] There is no specific treatment for dengue; however, medical professionals recommend pain medication, hydration, and rest until initial symptoms have subsided.[12]


Location


Regional Map of Dengue Fever Outbreaks[13]


Scientists believe that the current dengue outbreak originated in late August in Firozabad, Uttar Pradesh, India but globally, the most recent and severe outbreak of dengue is in Delhi, India. The outbreak has spread to other urban centers with a large concentration of cases in New Delhi and Chandigarh, likely due to high local population density.[14] India is currently in the pre-winter season with humidity levels consistently around 75%, optimal for dengue transmission.[15] Further, with more than 70 degree Fahrenheit temperatures and high humidity projected to persist for at least another week, there is a likely threat of a continued spread of the outbreak.[16]


Response Challenges

India’s neglected healthcare system led to COVID-19 cases severely spiking in early May 2021.[17] COVID-19 cases are decreasing, but the healthcare system is becoming overwhelmed by the Dengue outbreak.[18] India’s healthcare system is likely unable to address the current Dengue outbreak, resulting in further hospitalizations and increased mortality rates.


There is no specific treatment or widely available vaccine for Dengue; as a result it is difficult to contain the spread of this virus.[19] The Dengvaxia vaccine, developed in the US for individuals between 9 and 16 years of age, is not currently accessible outside the US.[20] Medical organizations recommend avoiding areas with mosquito populations and active dengue cases to reduce the risk of infection. The virus is likely widespread as cases are rising in various states across India, including the Punjab, Rajasthan, Haryana, and Tamil Nadu.[21] Cases are also present in major cities such as New Delhi and Mumbai.[22] Cases are likely to further increase if individuals do not follow appropriate preventative guidelines closely.


As the main outbreak is in New Delhi, the political center of India, protests that are likely to take place are likely to act as super spreader events exacerbating the outbreak. While there are no such protests currently, there is a roughly equal chance that sometime within the next month there will be a political situation that causes civil unrest and large gatherings. The tendency of Indian infrastructure to have stagnant water sources is likely one of the sources of outbreaks in India as the Dengue virus has mosquitoes as primary vectors, which are known to be associated with stagnant water.


Travel Warnings

Travel is not advised to areas currently experiencing a Dengue outbreak due to the high risk of contracting the virus. The late monsoon season in October is one reason for the sharp rise in cases, but it is expected that cases will fall once temperatures drop and mosquito breeding season ends.[23] Travelers should cancel their plans and reschedule for a later time when it is colder and cases of dengue decrease. There is no evidence to suggest avoiding certain foods aids in the prevention and transmission of dengue fever. Travelers should avoid all travel at dusk and dawn, and it is recommended to stay indoors. If travelers must go outdoors they should wear protective clothing and use mosquito repellent to make catching the virus less likely.[24]


Political Effects/Effects on Terrorism

The Indian government has raised concerns over the increase in Dengue infection rates due to the lack of action taken by municipal employees to reduce its spread.[25] Dengue media coverage coupled with concerns from health organizations will likely encourage the Indian government to increase pressures on local municipalities to implement effective preventative measures. The Indian government will likely be required to increase coordination efforts to ensure that communication between local municipalities and health organizations is continuous, adequate funding is available for preventative measures, and contingency plans are put in place. Cities taking minimal action to safeguard the health of its people will likely experience social unrest and distrust in local governments. Farmers’ protests in the Indian state of Uttar Pradesh’s capital Lucknow, where infection rates are rising, could likely inspire widespread protests calling for better government management strategies. Prevention efforts will likely worsen if coordination between civilians and the government is not secured as cooperation is almost certainly necessary to reduce the spread of Dengue. It is unlikely that India’s terrorist organizations will use the municipal vulnerabilities from the Dengue outbreak to advance their radicalization efforts or plan an attack.


Recommendations for AOCs

The Emergency Management, Health, and Hazards (EMH2) Team recommends that agencies, organizations, and companies (AOCs) monitor cases and analyze the transmission of the infection, specifically in Delhi and globally in areas with hot and humid climates. The health community should spread awareness and advice on lowering transmission rates to decrease mortality. Government assistance and reevaluation of the healthcare system should take place to limit resource depletion. There is no widely available vaccine for Dengue, so individuals in the impacted area must follow appropriate preventative measures such as use of mosquito repellent, wearing appropriate clothing, and avoiding areas where mosquitoes are present.[26] If individuals are outside, they should use mosquito nets to protect themselves and stay away from open water sources in infected areas as mosquitoes are likely to live there. If people are traveling to areas with dengue cases, they should stay alert and take acetaminophen if they experience any symptoms. Organizations such as the World Health Organization (WHO) and the Center for Disease Control (CDC) should conduct further research into Dengue infections and treatments that can be used in the future to limit transmission and alleviate symptoms.


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[1]Dengue Fever Pathogen” by Girish Khera licensed under Public Domain

[2] Delhi Is Reporting More Dengue Cases Than Daily COVID Tally; 3,740 In Two Weeks Of November, India Times, November 2021, https://www.indiatimes.com/news/india/delhi-dengue-outbreak-more-reported-cases-than-covid-554711.html

[3] Dengue, National Health Services, August 2019, https://www.nhs.uk/conditions/dengue/

[4] What to Know About India’s Coronavirus Crisis, The New York Times, November 2021, https://www.nytimes.com/article/india-coronavirus-cases-deaths.html

[5] Dengue, National Health Services, August 2019, https://www.nhs.uk/conditions/dengue/

[6] Transmission, Center for Disease Control, September 2019, https://www.cdc.gov/dengue/transmission/index.html

[7] Dengue, National Health Services, August 2019, https://www.nhs.uk/conditions/dengue/

[8] Mosquito Bites, Cleveland Clinic, October 2021, https://my.clevelandclinic.org/health/diseases/17695-mosquito-bites

[9] Dengue, National Health Services, August 2019, https://www.nhs.uk/conditions/dengue/

[10] Ibid

[11] Ibid

[12] Symptoms and Treatment, Center for Disease Control, September 2021, https://www.cdc.gov/dengue/symptoms/index.html

[13]Map of Dengue Fever Outbreaks”, by Tiberius Hernandez via MapChart licensed under Creative Commons

[14] Fears grow over dengue outbreak in India, Eastern Eye, November 2021, https://www.easterneye.biz/fears-grow-over-dengue-outbreak-in-india/

[15] The Complex Relationship between Weather and Dengue Virus Transmission in Thailand, US National Library of Medicine, December 2013, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3854883/

[16] 10 Day Weather-New Delhi, Delhi, India, Weather Channel, November 2021, https://weather.com/weather/tenday/l/New+Delhi+Delhi+India?canonicalCityId=a9b5e2e90863da5bd095e14c2876062711b33fae58ae88d1f9cc5bf3f03932c2

[17] In India, fears grow that gatherings for Diwali could prompt another virus spike, The New York Times, November 2021, https://www.nytimes.com/2021/11/05/world/asia/india-diwali-covid.html

[18] India battles spike in dengue cases amid COVID pandemic, Al Jazeera, November 2021, https://www.aljazeera.com/news/2021/11/10/india-new-delhi-dengue-crisis-health

[19] Dengue Vaccine, Center for Disease Control, November, 2021, https://www.cdc.gov/dengue/vaccine/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fdengue%2Fprevention%2Fdengue-vaccine.html

[20] Ibid

[21] India battles spike in dengue cases amid COVID pandemic, Al Jazeera, November 2021, https://www.aljazeera.com/news/2021/11/10/india-new-delhi-dengue-crisis-health

[22]Over six-fold rise in Mumbai’s dengue cases from last year, The Times of India, November 2021, https://timesofindia.indiatimes.com/city/mumbai/mumbai-over-six-fold-rise-in-citys-dengue-cases-from-last-yr/articleshow/87876516.cms

[23] India battles spike in dengue cases amid COVID pandemic, Al Jazeera, November 2021, https://www.aljazeera.com/news/2021/11/10/india-new-delhi-dengue-crisis-health

[24] Ibid

[25] Dengue: Concerns on inefficiency of municipal employees fallen on deaf ears, says Delhi High Court, The Economic Times, November 2021, https://economictimes.indiatimes.com/news/india/dengue-concerns-on-inefficiency-of-municipal-employees-fallen-on-deaf-ears-says-delhi-high-court/articleshow/87873611.cms?from=mdr

[26] Dengue, National Health Services, August 2019, https://www.nhs.uk/conditions/dengue/

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