Division of Molecular Diagnosis and Clinical Genetics Research, BioIcon Dengue is a severe and widespread disease transmitted by female Aedes mosquitoes, particularly the Aedes aegypti species.  It is caused by any of the four serotypes (DENV1, DENV2, DENV3, or DENV4) of the dengue virus, genus Flavivirus from the family of Flaviviridae and is transferred among humans (Jansen & Beebe, 2010; Trivedi & Chakravarty, 2022). Each year, there are around 400 million cases of dengue worldwide, resulting in over 22,000 deaths (Roy & Bhattacharjee, 2021). Though dengue is prevalent in Asia, South America and African countries, nearly 75% of the current global disease burden due to dengue viruses is reported in the Southeast Asia (SEA) region together with Western Pacific (WP) region (Singh et al., 2017). Since 2000, Bangladesh has had recurrent occurrences of dengue outbreaks (Bhowmik et al., 2023; Mamun et al., 2019) and it has experienced 1393 deaths from 277 801 dengue cases in 2023 (Sharif et al., 2024). 

Aedes aegypti, the primary carrier of the dengue virus, reproduces in or near houses by depositing eggs in both artificial and natural water containers. Individuals who remain at home, such as women and children, are more vulnerable to infection during the daytime, as the mosquito requires 8 to 12 days of incubation before it can transmit the virus to susceptible individuals (Scott et al., 2000) (Morsy, 2018). The transmission of DENV from the human host to mosquitoes necessitates the synchronization of various biological variables in both time and location (Carrington & Simmons, 2014). In natural conditions, a susceptible mosquito can only contract DENV after consuming blood from a viremic person. Viremic blood enters the mosquito midgut, where extracellular virus attaches to unidentified receptors on the epithelial surface (Carrington & Simmons, 2014) (Ponlawat & Harrington, 2005). If the virus infects and replicates in midgut epithelial cells, additional virus progeny are spread into the hemocoel (a body cavity that houses either blood or hemolymph). After a significant amount of virus replication takes place in the salivary glands, the virus can be transmitted to a new host through the saliva of the infected mosquito during its next probing or feeding episode (Carrington & Simmons, 2014). Fever, Headache, Nausea, Vomiting, rashes and aches are some of the common symptoms of dengue soon after infection while warning signs of dengue includes abdominal pain, clinical fluid accumulation, mucosal bleed, liver enlargement (>2 cm), and lethargy. In severe cases dengue patients can experience shock, severe bleeding and impaired consciousness (Htun et al., 2021) (Deshwal et al., 2015). Currently, a variety of conventional methods are employed for the detection of Dengue virus (DENV) (Mohammad et al., 2021; Kabir et al., 2021). 

These include NS1-based antigen testing, which identifies the presence of the non-structural protein 1 (NS1) produced during viral replication (Zhang et al., 2014). Additionally, IgM/IgG antibody testing is widely used to detect the bodys immune response to the virus. Another crucial method is Polymerase Chain Reaction (PCR), a molecular technique that amplifies and detects the viral RNA, providing a highly specific and sensitive approach to DENV diagnosis (Vongsouvath et al., 2016). These testing methods are integral to the effective management and control of dengue infections. Currently, there are no targeted therapies or remedies available for the treatment of dengue. Present treatment alternatives are primarily palliative, with the objective of mitigating the consequences and intensity of symptoms. Currently, the US Food and Drug Administration (FDA) has not approved any medications specifically for treating dengue (Harapan et al., 2020). Multiple potential therapeutic agents for treating dengue, which focus on either the viral or host components, have undergone clinical trials. These include carbazochrome sodium sulfonate, which aims to prevent capillary leakage (Tassniyom et al., 1997), oral prednisolone, which acts as an anti-inflammatory agent (Tam et al., 2012), and lovastatin (a statin), which has both anti-DENV and anti-inflammatory effects on the endothelium (Martínez-Gutierrez et al., 2011). The use of paracetamol, ibuprofen, acetylsalicylic acid (aspirin), and other non-steroidal anti-inflammatory drugs is not recommended for dengue fever due to their limited pain-relieving effects, which can worsen gastritis or bleeding (Deen & von Seidlein, 2019). The consumption of certain fruits, such as papaya, apples, and guava, has been demonstrated to be beneficial for dengue patients, particularly in augmenting platelet levels. These fruits, rich in essential nutrients and bioactive compounds, play a supportive role in the clinical management of dengue, potentially mitigating the risk of severe thrombocytopenia and enhancing patient recovery outcomes (Uddin et al., 2022; Deshpande et al., 2021). 

A minimum of seven DENV vaccines have undergone various stages of clinical testing; yet, only three of them (Dengvaxia®, TV003, and TAK-003) have demonstrated encouraging outcomes. Currently, the only vaccine that has been authorized for clinical use in certain countries is a live attenuated vaccine called chimeric yellow fever 17D-tetravalent dengue vaccine (CYD-TDV) (Huang et al., 2021). To achieve and maintain a decrease in dengue-related morbidity, effective vector control strategies are essential. The primary strategy for controlling dengue vectors has been source reduction, which involves getting rid of any containers that provide an ideal environment for oviposition and the growth of the aquatic stages. Insecticides can be used to kill the aquatic stages or lids or coverings can be placed on containers to do this (Organization & others, 2012). This study aimed to assess the knowledge, attitudes, and practices of participants from diverse sociodemographic backgrounds regarding dengue, its vector, prevention methods, and vaccination

Study Setting

A community-based cross-sectional study was conducted among students and professionals in Dhaka (23.6850° N, 90.4152° E), the capital of Bangladesh (Fig. 1). Dhaka is centrally positioned in the country and is known as a hotspot for the spread of dengue fever and the number of people affected (Bonna et al., 2023). The population of the area is around 44,215,107, with a significant population density of 2,200 individuals per square kilometer. The presence of indoor and outdoor receptacles that collect stagnant water between the tall and short residential buildings could be a significant factor contributing to the high number of dengue cases in this study location (Mutsuddy et al., 2019).  

Fig. 1: Map of the Study Area in Dhaka (ArcMap).

Participants and Sample Size

513 randomly selected replies were obtained in Dhaka, Bangladesh, between October 2023 and January 2024 from men and women of diverse ages, marital statuses, and sociodemographic backgrounds. The online survey was intended to be descriptive and cross-sectional in nature. Social media users (Facebook, WhatsApp, Instagram, Gmail, and so on) were included in the survey and completed this form; some of the participants did the survey through group discussions, observation, and other means. Both people who refused to participate in the study and those who submitted incomplete questionnaires were excluded from the study. The participation was entirely voluntary and anonymous, and there were no incentives or other types of payment given to the participants.

Knowledge, attitude, and practice questionnaire 

The researchers utilized a self-administered close-ended questionnaire as a tool to assess the residents initial knowledge, attitude, and practice (KAP). The study team produced the questionnaire using a new and modernized pattern that is well-suited for the Bangladeshi community. The questionnaire consists of four sections. Section A pertains to the sociodemographic data, which encompasses the fundamental information of the participants. Section B covers the fundamental understanding of the participants regarding dengue illness and its vector. Sections C and D are dedicated to knowledge of participants on the prevention and vaccination of dengue.

Statistical analysis

All categorical variables, such as participant demographics, professional background, and opinions on genetic testing, were presented as frequencies and percentages. Data analysis was conducted using R studio, SPSS version 25 (SPSS Inc., Chicago, IL) and Microsoft Excel. Descriptive statistics were used to calculate proportions. Spearmans correlation test was performed to assess the relationship between willingness to receive vaccines with varying efficacies. All statistical tests were conducted with a significance threshold of 5%, and the correlation coefficient (ρ) along with the corresponding 95% confidence intervals (CI) were reported where applicable.

Sociodemographic profile of study population

Table 1: Sociodemographic characteristics of study population.

Notably, 91.71% of respondents correctly identified that dengue is transmitted through mosquito bites. However, there was a lack of awareness regarding the virus types, with nearly half (44.83%) of the respondents unaware of this aspect. Only 147 respondents (28.65%) out of a total of 513 demonstrated a clear understanding of the different virus types.

Regarding the symptoms of dengue, a high-grade fever was the most frequently observed symptom, reported by 97.86% of the study participants. This was followed by reports of headache (76.80%), pain (73.88%), vomiting (65.50%), nausea (64.32%), rash (63.35%), and aches (41.52%). The majority of respondents (79.92%) believed that Aedes mosquitoes primarily breed in standing water during the rainy season (July-August). Approximately 88.50% of respondents considered dengue to be treatable. When asked about the use of specific medications, 40.93% of participants believed aspirin should be prohibited, followed by paracetamol (10.52%) and ibuprofen (7.99%). However, a significant portion of respondents (38.60%) lacked knowledge about which medications should be avoided. Only 1.94% of respondents indicated that dengue patients should avoid Nimesulide. Furthermore, 73.68% of participants correctly understood that dengue does not transmit from person to person, compared to 22.02% who held the opposite view. A negligible percentage of respondents (4.28%) had no opinion on this matter.

Knowledge and practices toward dengue diagnosis and prevention

Although the majority of participants (66.47%) did not engage in health education related to dengue, they demonstrated satisfactory knowledge of dengue diagnosis and prevention (Table 3). A significant portion of respondents (85.38%) believed that dengue diagnosis should be conducted in a hospital or clinic, rather than through medical scans (1.17%), assessment of medical history (0.19%), or the use of home test kits (2.72%). Additionally, 6.23% of participants recognized the importance of monitoring clinical signs and symptoms, such as sore throat, cough, and fever. A substantial proportion of participants (81.87%) were aware of the beneficial effects of papaya for dengue patients. Moreover, nearly 60% of participants believed that dengue patients sometimes require hospitalization, compared to 30.02% who thought that hospitalization should be mandatory. Regarding dengue prevention, 42.69% of participants reported that cleaning water-filled containers, coolers, and ditches around the house and workplace should be performed every alternate day. Some participants preferred weekly cleaning (33.72%), while others opted for fortnightly (7.60%) or monthly (8.19%) cleaning. Mosquito vector control was commonly practiced among participants, with 89.28% using mosquito sprays and repellents, followed by preventing standing water in and around the house (89.08%), and using bed nets, window, and door screens (88.89%). Other preventive measures included preventing garbage accumulation (78.36%), regular cleaning of coolers (77.39%), and wearing full-sleeved clothing (72.51%). Additionally, 60.23% of respondents emphasized the need for a combination of these preventive measures.

 

Table 3: Opinion and practices towards dengue fever diagnosis and prevention.

Opinion about the vaccination dengue

The majority of respondents demonstrated strong support for dengue vaccination, with 40.94% and 35.67% strongly agreeing and agreeing, respectively, on its importance for prevention. A small minority expressed disagreement, with 5.65% disagreeing and 1.75% strongly disagreeing Table 4.

Table 4: Opinion about dengue fever vaccination among the participants.

Notably, 15.98% of respondents remained neutral in their views on the necessity of dengue vaccination. Despite nearly half of the population (47.17%) being unaware of the availability of a dengue vaccine, a significant majority (85.58%) expressed confidence that a vaccine could cure dengue. Approximately 65% of respondents believed or strongly believed in the potential of the dengue vaccine to increase immunity, and over 60% of respondents believed that all registered vaccines are medically safe. Most participants placed trust in vaccines prescribed by doctors and believed that pharmaceutical companies produce safe and effective vaccines. Additionally, they indicated a readiness to accept vaccines approved in Bangladesh. A considerable proportion of the study population (82.46%) supported the implementation of a national vaccination program, and 43.08% were willing to purchase the vaccine if available in private hospitals. The acceptance rates for vaccines with low side effects and 50% and 75% efficacy were 19.69%, 49.18%, and 69.01%, respectively. There was a significant positive correlation (r = 0.9937) found between vaccination desire and vaccine effectiveness (p < 0.05).

Dengue is the world most rapidly spreading viral infectious illness spread by mosquitoes, with a high rate of morbidity and mortality. Significant advancements in the understanding of its epidemiology, including risk factors, control and prevention strategies, illness load and distributions, have been accomplished in recent decades (Jing & Wang, 2019). Bangladesh is sporadically facing the pandemic from the year of 1964 (Sharmin et al., 2015) and its outbreak still remain in recent years (2019-2023). It also experienced more than 10million to 3.2 million confirmed cases with less or more than 0.5% fatalities (Roney et al., 2024). This study performed an online survey among 513 of nearly equal portion of male and female in Dhaka which is considered to be dengue hotspot to check their knowledge, attitudes and practices towards dengue, vectors and vaccination and tried to confirm their willingness of accepting different vaccines with different efficacy. Major chunk of the study population (almost 80%) received college and graduate education and majority (82.26%) of them were native city dwellers albeit many (63.74%) of them remained unemployed and the internet, as predicted, was the greatest knowledge source (32.36%) compared to other platforms such as newspapers, radio, TV, schools, and family. The participants knew that dengue can cause fever, headaches, nausea, vomiting, rash, aches, and pains, as well as common breeding locations and seasons. However, some participants were still ignorant of the different types of dengue viruses, how they spread, whether or not they can be treated, which medications are best for treating dengue, and which ones should be avoided.

Fig. 2: correlation between vaccine efficacy and eagerness to get vaccinated.

The majority of respondents (66.47%) did not actively participate in the dengue health program, although they did follow appropriate hygiene practices regarding water-filled containers, coolers, and ditches surrounding the home and office, as well as the hospitalization requirements and dengue diagnosis procedures. Additionally, they were well-versed in the prevention of dengue, including the use of insect repellents and sprays, bed nets, window and door screens, full-sleeve clothing, regular cooler cleaning, avoiding garbage collection, and the advantages of eating papaya over most other fruits like bananas, apples, and mangos during dengue season. This survey also demonstrated the value of dengue vaccination, since most participants (82.46%) believed that dengue could be cured through immunization and that vaccination should be provided free of charge across the country. They also trust Bangladeshi pharmaceutical companies to provide safe and effective vaccines, and they are willing to purchase even if it is only available in private hospitals. This shows how serious dengue is in Bangladesh and how urgently effective vaccines are needed. Doctors will recommend the safest vaccine for their patients. Remarkably, a strong positive connection (r = 0.9937) was observed between the effectiveness of vaccines and the desire to be vaccinated (p < 0.05), indicating the population under study has the discriminatory potential to select vaccines that work (Fig. 2). 

Bangladesh has a very high dengue incidence rate, with Dhaka ranking highest due to factors like a large population living in a small area, environ-mental pollution, ignorance, and a lack of regulations and implementation. The general publics understanding of dengue fever in Dhaka is adequate but still has to be increased through educational initiatives in hospitals, schools, and universities. In reality, this survey only included educated people; nonetheless, Dhaka is home to a sizable community of uneducated people who are ignorant of the scientific way of life. Social professionals, the government, and individuals all need to raise public knowledge of dengue fever from all angles.

The authors have contributed to the data collecting, analysis, and manuscript writing processes. Md. Monirul Islam gave the work a thorough review and offered insightful comments. All authors reviewed and approved the final manuscript.

The studys participants have our sincere gratitude, the authors write. Additionally, they would like to thank the distinguished professors from different universities who were instrumental in motivating their students to participate in this study in Bangladesh.

Every author declared that they have no conflicting interests.