2 Faculty of Marine Science, Lasbela University of Agriculture, Water & Marine Sciences Uthal Balochistan, Pakistan.

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1 Lasbela, U. J.Sci.Techl., Vol. VI, pp , 2017 ISSN RESEARCH ARTICLE The Prevalence of Dengue Virus Serotypes and Dengue Cases Reported in District Peshawar Faiz-ur-Rehman 1, Atta-ur-Rehman 1, Noor ul Akbar 1,*, Muhammad Tahir 2, Naveed Ahmad 3, Haroon Rashid 4, Muhammad Waqar 5, Noor-e-Fatima 6, Abdul Wahab 6, Noor Mohammad 7 1 Department of Zoology, Kohat University of Science & Technology, Kohat, Khyber Pakhtunkhwa, Pakistan 2 Faculty of Marine Science, Lasbela University of Agriculture, Water & Marine Sciences Uthal Balochistan, Pakistan. 3 Centre of Excellence in Marine Biology, University of Karachi, Karachi 75270, Pakistan 4 Department of Pharmacy, Kohat University of Science & Technology, Kohat, Khyber Pakhtunkhwa, Pakistan. 5 Genome Center for Molecular Based Diagnostics & Research Lahore Pakistan 6 Department of Microbiology, Kohat University of Science & Technology, Kohat, Khyber Pakhtunkhwa, Pakistan 2 Faculty of Education, Lasbela University of Agriculture, Water & Marine Sciences Uthal Balochistan, Pakistan. ABSTRACT: To study the dengue virus and dengue cases in the capital city of Khyber Pakhtunkhwa, record of 150 patients from January 2013 to December 2014 were taken from most visited hospitals of Peshawar like Lady Reading Hospital & Khyber Teaching Hospital. Among 150 patients 97 (64.66%) were of DENV3 while 53 (35.33%) of DENV2 infection. In most cases 86 % (129/150) anti-denv IgM and/or IgG were found and 34 % (26/129) were RNA positive. From the data we got the result that 67 (45%) contained >100,000 platelets/cmm, 51 (34%) between 50, ,000 and 32 (21%) with less than 50,000. Most cases were referred from district Swat 84 (56%) and 29 (19.33%) from Peshawar. The numbers of male patients were higher than female that 72% were male and 28% were females. The majority of patients were about years of age. The fever is observed in all patients and some other symptoms like abdominal pain (44%), vomiting (62%) and skin rash (5%) were also found. In most cases, the hospital stay duration was about 3-5 days. Our studies show that dengue fever is common during the monsoon season in the months of September and October. The lower middle class and illiterate community were most affected by the dengue fever infection. DENV3 and DENV2 are common in age groups of years with majority of males and most cases in September/October. Key Words: Dengue, Peshawar, Virus, RNA INTRODUCTION Dengue is a virus which causes fever. There are four distinct dengue virus serotypes, all of which originate from the family Flaviviridae and genus Flavivirus (Gubler, 2002, WHO, 2013 and 2011). It belongs to the Arbovirus group of viruses that are transmitted through insect vectors (Gubler, 1997). The serotypes are termed DENV-1, DENV-2, DENV-3, and DENV-4, and infection with any of the four viruses results in lifelong immunity to that specific serotype [WHO, 2013, Halstead, 1974 and Wilder-Smith 2010). Each of the four serotypes has been individually found to be responsible for dengue epidemics and associated with more severe dengue (WHO, 2011). Virions are nm in diameter and spherical in shape with 11kb single-stranded RNA containing a *Corresponding author: noorpak_2005@yahoo.com 124 single open reading frame. Dengue virus consists of ten proteins, three of which are structural and seven non-structural (Gubler, 1997). The subcontinent is mainly affected by DENV2 and DENV3 serotypes. DENV1 and DENV4 were identified by studying neutralizing antibodies in the blood of volunteers in 1973[6] while DENV1 and DENV2 were isolated as a consequence of the failure of viral strains to cross-protect human volunteers (Gibbons, 2002). All four virus serotypes cause similar illness, but severe and fatal hemorrhagic disease is more often associated with DENV2 and DENV3 infections (Gubler, 1997). DEN2 type (genotype IV) and DEN3 (genotype III) are the commonly isolated genotypes (Dash, 2004 and William 2003). Dengue is transmitted to humans by the bite of Aedes aegypti or more rarely by Aedes albopictus mosquito (Thavara, 2001). Dengue is a complex disease with a wide spectrum of clinical presentations, which often goes unrecognized or is misdiagnosed as other fever-

2 causing tropical diseases. Most patients experience a sudden onset of fever which can remain for 2 7 days and is often accompanied with symptoms such as Myalgia, arthralgia, anorexia, sore throat, headaches, and a macular skin rash. The majority of people experience a self-limiting clinical course, which does not progress to the severe forms of dengue, dengue hemorrhagic fever (DHF), or dengue shock syndrome (DSS). Secondary dengue infections or particularly virulent viral strains are two factors thought to be associated with increased risk of severity [WHO, 2013, Gubler, 1986, Amarasinghe, 2011 and Rigau-Perez, 1998). Dengue is now endemic in more than 100 countries (WHO, 2006). During recent outbreaks in Asia, it has been noted that DHF is becoming increasingly common, that the circulation of multiple serotypes appears to be established, and that outbreaks of DHF have become more frequent (George, 1997 and Rai, 2008). During the past decade, DF epidemics have occurred in most of the south East Asian countries including Pakistan (BBC, 2009, Samoa, 2012 and Daily times, 2008). Dengue virus is now endemic in Pakistan, circulating throughout the year with a peak incidence in the post monsoon period. Recent flood in Pakistan made the situation worse. Dengue Surveillance Cell Sind province of Pakistan reports 1,809 suspected Dengue out of which 881 confirmed till 11th October 2010 with 5 deaths while 16 confirmed cases reported in Islamabad without any mortality. Till now 563 confirmed cases were reported at our institution since January Reported cases are usually complicated or with hemorrhagic manifestation. In primary health care the usual presentation is mild to moderate fever treated as suspected dengue fever (Jawad, 2001). During the outbreaks in Lahore from , DENV-2 and DENV-3 were reported as the predominant serotypes (Fatima, 2011). Dengue showed revitalization in 2010, especially in Punjab, Sind and some cities in the Khyber Pakhtunkhwa regions after massive floods occurred during the same year, while in the 2011 outbreak, DENV-2 and DENV-3 were the most prevalent serotypes but also with a lower incidence of DENV-4 (Koo, 2013). In July 2013, a major outbreak of dengue started in 125 Swat district of Khyber Pakhtunkhwa (KPK) which has so far caused 57 deaths and thousands of morbidities (Express Tribune, 2013). MATERIAL AND METHODS Study Area: Khyber Pakhtunkhwa, previously known as the North-West Frontier Province (NWFP), is situated in the north-west of Pakistan and is one of the four provinces of the country. Peshawar is the capital city of Khyber Pakhtunkhwa. It is very busy and city of full activities. Pakhtuns form a major part of the population, followed by a smaller crowd of Hindkowans (Naveed Akhtar, 2014). Study design: It is an explanatory study about dengue fever based on the patients' data collected from the most visited and populous Hospitals of Peshawar i.e. Lady Reading Hospital and Khyber Teaching Hospital. The data consists of all the clinical information about admitted patients. Duration: The duration of the record is from January 2013 to December Sample size & Technique: All confirmed cases of dengue fever were incorporated in studies. Confirmed cases were 150 patients. Their records are taken from different hospitals of Peshawar. Data Collection: The data of dengue fever were collected from the admitted patients in hospitals in which dengue infection symptoms are shown and satisfying the diagnostic criteria of dengue fever and dengue hemorrhagic with having positive IgG, IgM and NS1 anti-dengue antibodies. The detection of anti Dengue antibodies is the most dependable method for diagnosing DF. The data are taken from different gigantic hospitals in Peshawar like Lady Reading Hospital and Khyber Teaching Hospital. Only dengue IgM/IgG positive cases that had complete demographic and laboratory details were included in our studies. The information integrated patient's demography, signs/symptoms and blood complete picture (CP), given treatment including platelets transfused and the ultimate outcome i.e. death or discharge of patients. Statistical analysis: The data analysis was done using SPSS 16 software. Chi-square analysis was used to find out the relationship

3 between gender, age group, stay in hospitals, platelet count etc. A P-value of <0.05 was considered statistically significant. RESULTS Out of 150 patients, the majority (97/150) contained DENV-3 followed by DENV-2 (53/150), while DENV-1 and DENV-4 were not identified (Figure 1). According to table (01), the data collected from different hospitals, among 150 patients 84 people were from Swat, 29 from Peshawar, 09 from Mardan, 06 from Lower Dir, 04 from Swabi,03 from Malakand, 03 from Momand Agency and 08 cases were from other districts. Fig.1. Graph showing types of dengue infection were male and 42 (28%) were females. The Table. 1. Infection rate in different areas of majority of cases belonged to Swat and Khyber Pakhtunkhwa including Peshawar Peshawar was second in the number of infected Location No of Percentage %) cases. The majority of patients were years Patients (Figure 2). Swat The data collected from different Peshawar hospitals also had the information presented in Mardan 9 6 table (03). According to this most dengue Lower Dir 6 4 patients were illiterate (45%) and under Swabi 4 3 matriculate (32%). Because they were not aware Malakand 3 2 about the health conditions and showed less Momand 3 2 safety measurement against dengue infection. Agency Moreover, mostly they were belonging from Others 12 8 lower middle class (41%) and middle class Table (02) shows the clinical information that (31%). Out of 150 infected persons, there were fever and vomiting were common in most patients and their stay at hospital was mostly 3-5 days. Infection of dengue reached to peak during 36 students, 33 housewives- ladies, 57 private job holders and 24 government servants. The table also illustrates that rate of infection in joint the month of October. We investigated 150 family system (64.7%) is greater than nuclear cases of Dengue fever out of which 108 (72%) (35.2%) Table.2. Clinical information Symptoms Fever Abdominal pain Vomiting Splenomegalo Skin rash Percentage Patients stay at Hospital 3-5 days (mostly) Most infection (month) October (45%) 126

4 Fig. 2. Shows dengue infection in male & female of different age groups Table (03) Profile of patients Parameters Category Percentage Qualification Illiterate Under Matriculation Under Graduate Post Graduate Occupation Student Housewives Private job Government Monthly Income servant <10, ,000-20, >20, Family type Joint Nuclear DISCUSSION Dengue is recently raised in the Province of Khyber Pakhtunkhwa. There was a major outbreak in history of this Province in 2013 which has affected population of about 8911 with 57 deaths. Our province is situated on the circuit of mountainous ranges; the larger part of it is covered with hills and mountains. The network of river swat is spreading into all areas of the Khyber Pakhtunkhwa and these areas receives water from river Swat for irrigation and other purposes, which make 127 available sufficient breeding foundation for mosquitoes (Naveed Akhtar, 2014). Peshawar that is the capital of Khyber Pakhtunkhwa is a main and important city. Patients from different areas approach here for treatment of diseases. All four serotypes of DENV have been reported in Pakistan during dengue outbreaks in the last decade. During the outbreak in Punjab, DENV2 and DENV3 were found to be the most prevalent serotypes (Fatima, 2011 and Koo, 2013). Our study also shows that the majority of cases were of DENV3 followed by DENV2. Cases of DENV1 and DENV4 were not found according to our data. Research of Humayoun and colleges indicates that dengue is more common in male (63.6%) and in our studies 72% male are infected. Slightly increased frequency was found in the age group years (Malik Asif,2010). Qureshi et al., studied hospital admitted cases during the course of an outbreak of dengue viral fever in Karachi, Pakistan from June 1994 to September 1995 and reported a higher frequency of DF in the younger population (Qureshi,, 1997).A report from India revealed that the highest incidence during the 2003 outbreak in Delhi was among young adults (Singh, 2005). Whereas various previous studies have reported the highest incidence in children (Kittigu, 2007). Most of the affected patients were of years (Naveed Akhtar, 2014). Our result shows that most affected patients are about years of age.

5 Dengue virus infection presentation is usually variable. It may be asymptomatic or may cause undifferentiated high grade fever. The clinical presentation depends on age, immune status of the host, and the virus strain (Shah, 2004 and Chadwick, 2006). The abdominal pain and vomiting were found prominent presenting symptoms (Anuradha, 1998). Our studies show clinical symptoms that fever is common in all patients and in addition to that with 44% abdominal pain, 62% vomiting and rare skin rash. These results are quite common with (Naveed Akhtar, 2014, Sajid, 2012). The range of patient stay in hospital is 2-10 days. But in most cases the patient stay is 3-5 days. Usually when the patient is not serious, they may be discharged earlier. The most serious cases are referred to ICU (intensive care unit) for prolonged treatment. The climatic conditions provide excellent ground for mosquito breeding, especially during monsoon period when there is abundant rainfall and high humidity, with daily temperature reaching 30 C. In this study, we observed a gradual increase in infection of dengue fever from August to onward and reached to peak during October. These results coincide with studies of (Naveed Akhtar, 2014, Arif Munir, 2014). It means that these monsoon and post-monsoon seasons are ideal for reproduction of Aedes flies (Aedes aegypticus).the dengue cases are common in illiterate and under matriculate, because of unawareness of disease. They do not follow the safety measurement against dengue virus. The infection rate is high in illiterate with 45% and low (06%) in post graduate. It is also high in lower middle class (41.26%), as they have a problem of low economy. They cannot afford the expensive treatment of dengue fever. The result also illustrates that the joint family (64.72%) is at high risk as compared to nuclear (35.28%). Joint families interact with each other and can transfer the infection to other healthy members. CONCLUSION The conclusion of our study is that DENV2 and DENV3 are most common viruses found in patients of district Peshawar. There was 128 no case of DENV1 and DENV4. The majority of cases were from years of age and mostly males were affected by dengue fever. Dengue infection is more common in the months of September and October. As there is no vaccine and antiviral drugs available so only prevention can reduce the Dengue infection. Anti-mosquito measurement is also affective. REFERENCES Gubler, D.J., The global emergence/resurgence of arboviral diseases as public health problems. Arch of Med Res, 33(4): World Health Organization (WHO) (5 th March 2013). International Travel and Health DENGUE. html. WHO Regional Office for South-East Asia Comprehensive Guidelines for Prevention and Control of Dengue and Dengue Hemorrhagic Fever. Revised and Expanded Edition. New Delhi: World Health Organization South East Asia Regional Office. Gubler, D.J., 1997 Dengue and dengue hemorrhagic fever: its history and resurgence as a global public health problem In: Gubler DJ and Kuno G, editors. Dengue and Dengue Hemorrhagic Fever. Wallingford, UK: CAB International, p World Health Organization (WHO) (3 rd March 2013). WHO TDR Global Alert and Response Dengue/Dengue Hemorrhagic Fever. html. Halstead, S.B, Etiologies of the experimental dengue of Siler and Simmons. The Amer J of Trop Med and Hyg, 23(5): Wilder-Smith A, Ooi E.E, Vasudevan S.G, Gubler, D.J., Update on dengue: epidemiology, virus evolution, antiviral drugs, and vaccine development. Cur Infec Dis Rep, 12(3): Gibbons, R.V., Vaughn, D.W., Dengue: an escalating problem. Brit Med J, 324(7353): Dash, P.K., Emergence and continued circulation of dengue-2 (genotype IV) virus strains in northern India. J of Med Viro, 74: William, B. Messer, Duane, J., Gubler, Eva Harris, Kamalanayani Sivananthan, Aravinda M. de Silva Authors and Disclosures., Emergence and Global Spread of a Dengue Serotype 3, Subtype III Virus. Emer Infec Dis, 9: Thavara, U., Tawatsin, A, Chansang C, Kongngamsuk W, Paosriwong S, Boon Long J., Larval occurrence, oviposition behavior and biting activity of potential mosquito vectors of dengue on Samui Island, Thailand. J of Vec Eco, 26:

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