Prevalence of Dengue and Chikungunya in Malaria-Suspected Febrile Patients: Mosquito-Borne Diseases’ Knowledge, Practices and Diagnostic Challenges in Selected Districts of Afar National Regional State, Northeast Ethiopia
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Date
2025
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Addis Ababa Universtity
Abstract
Dengue virus (DENV) and chikungunya virus (CHIKV) infections are an emerging burden to rising non-malarial febrile illnesses in tropical and subtropical regions, including Ethiopia. Ethiopia has experienced several significant outbreaks of arboviral diseases over the past two decades, particularly in the eastern and northeastern regions, including in the Afar National Regional State. Given the overlap in symptoms and the risk of co-infection, it is important to assess the true burden of these diseases among malaria-suspected patients during non-outbreak periods and understand community awareness and healthcare worker (HCW) challenges to improve public health intervention and strengthen healthcare response to these diseases. Hence, this study was designed to assess the prevalence of DENV and CHIKV infection in malaria-suspected febrile patients, community knowledge, attitudes, and practices (KAP) about these arboviral diseases and healthcare workers’ (HCWs) knowledge, practices and challenges in diagnosing and managing arboviral and non-malarial febrile illnesses in malaria-endemic selected districts of the Afar National Regional State, northeast Ethiopia.
Methods: Between September 2022 to March 2023, a cross-sectional study was conducted among malaria-suspected febrile patients, with axillary body temperature of ≥37.5°C, attending healthcare facilities to assess the prevalence of CHIKV and DENV infection. Socio-demographic and clinical features were collected using a structured questionnaire. Five milliliters of venous blood were collected and thick and thin blood films were prepared for the diagnosis of malaria on-site. Sera were separated from remaining blood and stored appropriately. It was tested for anti-DENV and anti-CHIKV IgM and IgG antibodies using enzyme-linked immunosorbent assay (ELISA). IgM-positive sera were pooled and screened for viral RNA using in-house reverse transcription-polymerase chain reaction (RT-PCR) and a one-step multiplex RT-PCR. Those positive pools were disaggregated and retested individually to identify specific RNA-positive patient serum. To assess community KAP and HCWs’ knowledge, practices, and challenges, structured questionnaires, as well as focus group discussions (FGDs) with community members, in-depth interviews (IDIs) with frontline HCWs were conducted. Additionally, secondary data on febrile patient diagnosis and management were reviewed from public healthcare facilities to evaluate HCW diagnostic practices and trends. Quantitative data were coded and entered into EpiData 3.1, and exported and analyzed using Stata 14, with p-value < 0.05 statistically significant. Thematic analysis was applied to qualitative data.
Results: A total of 411 malaria-suspected febrile patients (55.5% female, age ranged from 5-80 years, with a mean age ± SD of 27.3± 13.9) years participated in the prevalence study. Among 368 sera tested for anti-CHIKV antibodies, 176(47.8%) were IgM positive, indicating acute CHIKV infection and 23(6.3%) were IgG positive, suggesting previous exposure. Non-married patients and those having back pain were associated with positivity for acute CHIKV infection (AOR = 2.34, 95% CI: 1.14- 4.96 and AOR = 1.78, 95% CI: 1.08-2.95), respectively. Among 410 sera tested for anti-DENV IgM, 101(24.6%) were positive, indicating acute DENV infection. Of 367 sera tested for IgG, 142 (38.7%) were positive, indicating a previous exposure. Previous DENV exposure was significantly associated with being female (AOR = 2.24; 95% CI: 1.32-3.26) and employed (AOR = 1.90; 95% CI: 1.03-8.15) participants. From all 411 febrile patients, only 44 (10.7%) were positive for Plasmodium infection, mainly due to P. falciparum (84.1%). Co-infections were observed in 15.8% of patients for acute DENV-CHIKV, 4.4% for acute DENV-malaria and 4.3% for acute CHIKV-malaria among those tested for both infections. Out of 53-pooled samples positive for one or both viruses’ IgM, three were confirmed positive for DENV RNA, two of which were from DENV-CHIKV dual IgM-positive samples and the remaining one from a CHIKV IgM-positive only pooled sample by in-house RT-PCR, while two CHIKV RNA samples were identified from DENV-CHIKV dual IgM-positive pools using commercial RT-PCR methods.
In the KAP study, 296 community members (mean age 34.2 ± 10.6 years; 36.8% female) and 116 FGD participants were included. While 67.3% of the community had heard of CHIK, only 44.7% recognized it as viral, 48.7% identified Aedes mosquitoes as vectors, and 16.5% knew they bite during the day. The mean KAP scores were moderate, with knowledge at 63.2%, attitudes at 60% and practices at 60%. Higher education (9-12) and student status were linked to good knowledge; age 45–59 and being single were associated with positive attitudes. Among 82 HCWs surveyed (plus 10 in IDIs), 93.9% had heard of CHIKV and DENV, with the overall mean knowledge score of 13.1 ± 3.9 (62.4%), showing a moderate knowledge level, but only 36.4% demonstrated good knowledge, while 35.1% showed moderate knowledge of the diseases. Higher knowledge was significantly associated with higher educational levels. The patient record review revealed over-diagnosis of malaria infection and low diagnosis of non-malarial febrile illness, while limited differential testing capability for arbovirus infections, inadequate training for HCWs, low community involvement and low awareness of arboviral and non-malarial mosquito-borne febrile diseases were identified as challenges.
Conclusion: The seroprevalence of DENV and CHIKV infections is substantial among malaria-suspected acute febrile patients, highlighting the need for integration of arbovirus infections in regular screening, management and control of the infections in the study area. Limited awareness and diagnostic capability demand strengthening diagnostic capacity, updating fever case management and diagnosis policies, such as availing rapid test kits, serological tests (IgM tests) and affordable PCR tests for arboviral infections and scaling up HCW training and community sensitization are critical for effective arboviral and other mosquito-borne diseases control in malaria-endemic settings.
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Keywords
Seroprevalence Dengue fever Dengue virus Chikungunya virus Febrile illness Konwledge Attitude Practice Afar Region