Dengue outbreak amongst travellers returning from Cuba—GeoSentinel surveillance network, January

Dengue outbreak amongst travellers returning from Cuba—

GeoSentinel surveillance network, January–September 2022

Marta Díaz-Menéndez, MD, PhD

, Kristina M. Angelo, DO, MPH&TM

, Rosa de Miguel

Buckley, MD, PhD

, Emmanuel Bottieau, MD, PhD, DTMH

, Ralph Huits, MD, PhD

, Martin

P. Grobusch, MD, PhD, FRCP

, Federico Giovanni Gobbi, MD, PhD, DTM&H

, Hilmir

Asgeirsson, MD

6,7

, Alexandre Duvignaud, MD

, Francesca F. Norman, MD

, Emilie Javelle,

MD, PhD

, Loïc Epelboin, MD, PhD

, Camilla Rothe, MD

, Francois Chappuis, MD, PhD,

DTMH

, Gabriela Equihua Martinez, MScPH

, Corneliu Popescu, MD, PhD

15,16

, Daniel

Camprubí-Ferrer, MD

, Israel Molina, PhD

, Silvia Odolini, MD, PhD

, Sapha Barkati, MD,

MSc

, Susan Kuhn, MD

, Stephen Vaughan, MD

, Anne McCarthy, MD

, Mar Lago, MD

Michael D. Libman, MD

, Davidson H. Hamer, MD

Tropical Medicine Department, Hospital Universitario La Paz Carlos III, CIBERINFECT, Pso de la

Castellana, 261, 28046 Madrid, Spain

Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, 1600

Clifton Rd NE, Atlanta, GA 30329, USA

Department of Clinical Sciences, Institute of Tropical Medicine, 155 Nationalestraat, Antwerp

2000, Belgium

Department of Infectious Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria

Hospital, Via don A. Sempreboni, 5, 37024 Negrar, Verona, Italy

Center of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Amsterdam

University Medical Center, AMC, Amsterdam Infection & Immunity, Amsterdam Public Health,

Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands

Department of Infectious Diseases, Karolinska University Hospital, 14186 Stockholm, Sweden

Division of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, 14186

Stockholm, Sweden

Department of Infectious Diseases and Tropical Medicine, Hôpital Pellegrin, CHU Bordeaux,

Place Amélie Raba Léon, 33076 Bordeaux, France

To whom correspondence should be addressed. [email protected].

Author contributions

All authors contributed substantially to the study design, analysis, interpretation, reporting and manuscript writing. The authors also

played a significant role in manuscript revisions and approved the final version of the paper.

Case contribution: M.D.M., R.M.B., E.B., M.P.G., F.G.G., H.A., A.D., F.F.N., E.J., C.R., F.C., G.E.M., C.P., D.C.F., I.M., S.O., S.B.,

S.K., S.V., A.M., M.L., M.D.L.

Data analysis: K.M.A., R.H.

Drafting manuscript: M.D.M., K.M.A.

Providing significant contribution to manuscript content and editing: M.D.M., K.M.A., R.M.B., E.B., R.H., M.P.G., F.G.G., H.A.,

A.D., F.F.N., E.J., L.E., C.R., F.C., G.E.M., C.P., D.C.F., I.M., S.O., S.B., S.K., S.V., A.M., R.M., M.L., D.H.H.

Disclaimer

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers

for Disease Control and Prevention.

HHS Public Access

Author manuscript

J Travel Med

. Author manuscript; available in PMC 2024 April 05.

Published in final edited form as:

J Travel Med

. 2023 April 05; 30(2): . doi:10.1093/jtm/taac139.

Author Manuscript Author Manuscript Author Manuscript Author Manuscript

Unidad de Medicina Tropical—Servicio de Enfermedades Infecciosas—Hospital Ramon y Cajal,

C’tra de Calmenar Km. 9,1, Madrid 08001, Spain

IHU—Méditerranée Infection, 19-21 Boulevard Jean Moulin, Marseille 13005, France

Centre Hospitalier Andree Rosemon, Av des flamboyants, Cayenne 97036, France

Department of Infectious Diseases and Tropical Medicine, Ludwig-Maximilians-Universität

München, Leopoldstrasse 5, 80802 Munich, Germany

Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, 6 rue Gabrielle

Perret Gentil, Geneva 1205, Switzerland

Institute of Tropical Medicine and International Health—Charité—Universitätsmedizin Berlin,

Spandauer Damm 130, Berlin 10117, Germany

Carol Davila University of Medicine and Pharmacy, Dionisie Lupu St., 37, Sector 2, Bucharest

050474, Romania

Dr Victor Babes Clinical Hospital and Infectious Diseases, Strada Gheorghe Adam 13,

Timişoara 300310, Romania

ISGlobal, Hospital Clinic Universitat de Barcelona, Roselló, 132, 08036 Barcelona, Spain

Hospital Universitari Vall d’Hebron, P° Vall d’Hebron 119, Barcelona 08035, Spain

University Division of Infectious and Tropical Diseases, University of Brescia and ASST Spedali

Civili Hospital, Brescia 25123, Italy

J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, 1001 boul Decarie,

Montreal, QC H4A 3J1, Canada

Alberta Children’s Hospital, 2888 Shaganappi Trail NW, Calgary, AB T3B 6A8, Canada

The Ottawa Hospital Civic Campus, 501 Smyth Road, Ottawa, ON K1H 8L6, Canada

Department of Global Health, Boston University School of Public Health; Section of Infectious

Diseases, Boston University School of Medicine; Center for Infectious Disease Policy and

Research, Boston University; and National Emerging Infectious Disease Laboratory, Crosstown

308, 801 Massachusetts Avenue, Boston, MA 02118, USA

Abstract

Increasing numbers of travellers returning from Cuba with dengue virus infection were reported to

the GeoSentinel Network from June to September 2022, reflecting an ongoing local outbreak. This

report demonstrates the importance of travellers as sentinels of arboviral outbreaks and highlights

the need for early identification of travel-related dengue.

Background

In summer 2022, GeoSentinel Surveillance Network sites noticed an increase in patients

with dengue virus (DENV) who had recently travelled to Cuba. In July 2022, the Cuban

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Ministry of Health issued an alert describing the largest outbreak of dengue reported in Cuba

in the last 15 years, with evidence of the co-circulation of four DENV serotypes.

1,2

We describe travellers from Cuba with travel-related DENV infection diagnosed from 1

January to 20 September 2022 seen at GeoSentinel sites.

Methods

GeoSentinel is a collaboration between the US Centers for Disease Control and Prevention

and the International Society of Travel Medicine that comprises 71 clinical sites globally and

monitors infectious diseases in international travellers and migrants.

We included cases of confirmed and probable travel-related complicated and uncomplicated

dengue acquired in Cuba from 1 January to 20 September 2022 reported to GeoSentinel.

Confirmed cases were defined as a compatible clinical illness and appropriate exposure

history according to expert assessment (recent travel to Cuba) with either DENV isolation,

a positive DENV nucleic acid test, positive NS-1 antigen detection or seroconversion with a

4-fold rise in IgG anti-dengue antibody titres. Probable cases were defined as a compatible

clinical illness and appropriate exposure history with either a single positive dengue IgM

or high positive dengue IgG. ‘Complicated’ dengue was defined as a case with evidence

of clinically significant plasma leakage or bleeding, organ failure or shock (i.e. severe

dengue per World Health Organization (WHO) guidelines), or patients with warning signs

(i.e. dengue with warning signs per defined in WHO guidelines).

Uncomplicated dengue

was defined as a compatible clinical illness and no evidence of complications. Data were

analysed using SAS v9.4 (Cary, North Carolina).

Results

In total, 83 travellers from Cuba with DENV infection (73 confirmed and 10 probable) were

identified (Figure 1); most infections occurred from June to August. The median age was 34

years (range: 13–65 years); 44.6% were female (Table 1). Patients were seen after returning

from Cuba at 18 GeoSentinel sites in 10 countries (most frequently Spain; 61.5%). The

median time between travel and presentation to a GeoSentinel site was 5 days (interquartile

range: 3–7 days). Most patients travelled to Cuba for tourism (79.3%); 19.5% were born

in Cuba and were visiting friends and relatives. Destinations visited in Cuba were available

for 35 patients; 28 (80.0%) reported visiting Havana or Varadero as well as Cayo Coco,

Cienfuegos, Holguín, Pinar del Río, Playa Giron, Playa Larga, Santa Clara, Santo Espiritu,

Trinidad and Viñales. The median trip duration was 15 days (range: 5–226; interquartile

range: 12–22). Of 74 patients with information available, only 23.0% reported a pre-travel

consultation.

The most frequently reported symptoms were fever, chills and sweats (82; 98.8%) (Table

2). Three patients (3.6%) were co-infected with DENV and SARS-CoV-2 including one

who was admitted to the intensive care unit due to severe dengue. Seven patients (8.4%)

had complicated dengue; of these, four had warning signs, one had severe dengue and two

had missing details. Of the seven patients with complicated dengue, five had data available

to classify the dengue episode as primary, based on absent IgG in serum samples during

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the acute phase. Twenty-four patients (28.9%) were hospitalized; one was admitted to the

ICU. DENV serotypes were available for 11 patients; these included DENV-1 (3; 27.3%),

DENV-3 (7; 63.6%) and DENV-4 (1; 9.1%). There were no deaths.

GeoSentinel sites recorded 188 patients with travel-related DENV infections from Cuba

between 2014 and 2022 (Figure 2). When comparing the number of DENV cases in Cuba

reported to the Pan American Health Organization (PAHO) to GeoSentinel patients with

DENV infection by year, peaks occurred in 2019 and 2022.

Discussion

From 1 January to 20 September 2022, GeoSentinel sites have reported the largest number

of patients with DENV from returning travellers to Cuba since 2014. Cuba has been

particularly affected with more cases in 2022 than in the past 8 years.

Cuba has reported several major DENV outbreaks since 1977, especially in the eastern

provinces and the capital, Havana.

In the past 2 years, vector control measures have

been negatively affected by the COVID-19 pandemic. In 2022, full-scale fumigation was

restricted to homes where there was a person with a fever or who tested positive for DENV.

However, fumigation alone is likely insufficient.

With rainy season in Cuba running from

May to October, it remains unclear whether number of travel-related DENV infections will

continue to rise.

The increase of imported dengue cases by travellers is occurring in a year that has not yet

achieved the volumes of pre-pandemic tourism. Cuba’s Ministry of Tourism expects to reach

2.5 million visitors before the end of 2022,

so early reporting to raise awareness about this

ongoing outbreak in Cuba is imperative to prevent and detect potential infection amongst

international travellers.

In recent years, some European countries with competent local vectors such as

Ae.

albopictus

(Croatia, France, Italy and Spain) have identified autochthonous transmission

of DENV from viraemic travellers.

Therefore, early identification of cases through traveller

surveillance with local vector monitoring, and rapid public health response is needed in

areas at risk for local transmission.

Less than a quarter of patients received a pre-travel consultation before travelling to Cuba,

a lost opportunity to receive the appropriate preventive measures information to protect

against mosquito bites.

GeoSentinel sites specialize in travel and tropical medicine; therefore, these data may not be

generalizable to all persons who acquire DENV in Cuba. Comparisons between the number

of dengue cases acquired in Cuba reported to GeoSentinel, the number of tourist arrivals

and the number of dengue cases in Cuba reported by PAHO were made using unequal time

periods due to the availability of data at the time of this report.

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This report highlights the importance of sentinel surveillance of returned travellers to

identify cases and monitor for travel-related DENV infections. GeoSentinel surveillance

data can help alert clinicians, public health officials and international travellers of outbreaks.

Funding

This project was funded through a Cooperative Agreement between the US Centers for Disease Control and

Prevention and the International Society of Travel Medicine (Federal Award Number: 1 U01CK000632-01-00).

References

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y programas priorizados [cited 30 August 2022]. Available from: https://salud.msp.gob.cu/ofrece-

ministro-de-salud-publica-actualizacion-sobre-situacion-epidemiologica-y-programas-priorizados/.

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Americas [cited 30 August 2022]. Available from: https://www3.paho.org/data/index.php/en/mnu-

topics/indicadores-dengue-en/dengue-nacional-en/252-dengue-pais-ano-en.html.

5. Revista Cubana de Medicina Tropical. Vigilancia de laboratorio de dengue y otros arbovirus

en Cuba, 1970–2017 [cited 31 August 2022]. Available from: http://scielo.sld.cu/scielo.php?

script=sci_arttext&pid=S0375-07602019000100008.

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largest-number-of-outbreaks-in-the-last-fifteen-years/.

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dengue among ill returned travelers, 1997–2006. Emerg Infect Dis 2008; 14:1081–8. 10.3201/

eid1407.071412 PMID: 18598629; PMCID: PMC2600332. [PubMed: 18598629]

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invita-a-empresarios-mexicanos-a-ampliar-vinculos-economicos.

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autochthonous-transmission-dengue-virus-eueea.

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Figure 1.

Number of patients with uncomplicated and complicated dengue acquired in Cuba by month

of illness onset, reported to GeoSentinel, 1 January–20 September 2022 (

= 83)

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Figure 2.

Number of confirmed and probable dengue cases acquired in Cuba reported to GeoSentinel

by year in the context of the annual number of tourist arrivals to Cuba

and reported number

of DENV cases in Cuba reported to PAHO

, 2014–2022. DENV = dengue virus, PAHO

= Pan American Health Organization,

Reported through 20 September 2022,

Reported

to the World Bank at: https://data.worldbank.org/indicator/ST.INT.ARVL?locations=CU

and Trading Economics https://tradingeconomics.com/cuba/tourist-arrivalsthroughJuly2022,

Reported to PAHO through epidemiological week 26 (26 June–2 July), 2022

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Table 1.

Patient and travel characteristics among patients with confirmed and probable dengue acquired in Cuba reported to GeoSentinel, 1 January–20 September

2022 (

= 83)

Characteristic

Median age, years (range) 34 (13–65)

Female sex 37 44.6

GeoSentinel site country

Spain 51 61.5

Germany 11 13.3

Canada 5 6.0

France 4 4.8

Italy 3 3.6

Belgium 2 2.4

The Netherlands 2 2.4

Romania 2 2.4

Sweden 2 2.4

Switzerland 1 1.2

Travel reason

Tourism (vacation) 65 79.3

Visiting friends and relatives 16 19.5

Missionary/humanitarian/volunteer 1 1.2

Median trip duration, days (range; IQR) 15 (5–226; 12–22)

Had a pretravel consultation

17 23.0

IQR = interquartile range

All patients were residents of the GeoSentinel site country that diagnosed them, except for one patient who was a resident of The Bahamas seen in Germany.

Of 82 with information available.

Of 74 with information available.

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Díaz-Menéndez et al. Page 9

Table 2.

Clinical information for patients with confirmed and probable dengue acquired in Cuba reported to GeoSentinel, 1 January–20 September 2022 (

= 83)

Clinical information

Co-infection with SARS-CoV-2 (confirmed) 3 3.6

Severity of dengue Uncomplicated 76 91.6

Complicated 7 8.4

Symptoms

Fever, sweats, chills 82 98.8

Headache 48 57.8

Acute diarrhoea 35 42.2

Exanthem 34 41.0

Myalgia 32 38.6

Nausea 28 33.7

Fatigue 26 313

Arthralgia 23 27.7

Abdominal pain 15 18.1

Vomiting 13 15.7

Anorexia 8 9.6

Non-exanthematous skin lesion 8 9.6

Eye symptoms 6 7.2

Dizziness 4 4.8

Itching 4 4.8

Cough 3 3.6

Focal musculoskeletal pain 3 3.6

Focal rash 3 3.6

Arthritis 2 2.4

Dysuria 2 2.4

Sore throat 2 2.4

Bloody diarrhoea 1 1.2

Confusion 1 1.2

Dysgeusia 1 1.2

Lymphadenopathy 1 1.2

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Díaz-Menéndez et al. Page 10

Clinical information

Urinary frequency 1 1.2

Syncope 1 1.2

Other, not specified 6 7.2

Hospitalized

24 28.9

The three patients with DENV and COVID-19 co-infection reported fever/sweats/chills (

= 3), myalgias (

= 3), arthralgias (

= 2), abdominal pain (

= 1), acute diarrhoea (

= 1), fatigue (

= 1), focal

musculoskeletal pain (

= 1), headache (n = 1) and sore throat (n = 1).

Of 24, 1 (4.2%) was hospitalized in the intensive care unit.

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