INTRODUCTION:

Dengue is a mosquito-borne viral infection caused by the Dengue virus (DENV), a member of the Flaviviridae family.

The virus has four distinct serotypes (DENV-1, DENV-2, DENV-3, and DENV-4), which are transmitted predominantly by Aedes aegypti mosquitoes, with Aedes albopictus serving as a secondary vector. Dengue infection presents in various clinical forms, ranging from mild dengue fever to severe complications such as dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS)¹.

The proliferation of dengue is facilitated by urbanization, poor sanitation, and climatic conditions favorable for vector breeding, including high humidity and temperatures². Globally, the World Health Organization (WHO) estimates that 390 million infections occur annually, with approximately 96 million cases manifesting clinically^3,4. Southeast Asia and the Western Pacific bear a significant proportion of this burden, with India among the countries most severely affected. The region reported the highest number of dengue cases in 2023, with countries like Bangladesh, Malaysia, Thailand, and Vietnam documenting alarming incidence rates⁵.

Dengue imposes a considerable economic and healthcare burden worldwide. The annual global economic toll of dengue is estimated at $8.9 billion, with hospitalization, lost productivity, and public health interventions contributing significantly⁶. In India, the recurring outbreaks lead to substantial public health and economic challenges. The National Vector Borne Disease Control Programme (NVBDCP) reports that India accounts for approximately 34% of global dengue cases annually, with South India contributing disproportionately to this burden ⁷.

South India's warm climate, high population density, and frequent monsoons create ideal conditions for Aedes mosquito breeding. States such as Tamil Nadu, Kerala, Karnataka, Andhra Pradesh, and Telangana report high incidence rates, often with severe outcomes due to delays in diagnosis and inadequate vector control measures [8, 9]. Furthermore, out-of-pocket expenses for dengue management significantly impact low-income households, underscoring the need for cost-effective solutions¹⁰.

This narrative review explores the incidence, risk factors, clinical manifestations, and economic burden of dengue in South India. It also highlights existing control measures and identifies cost-effective strategies to reduce the incidence and alleviate the economic strain on affected communities.

Incidences of Dengue:

Dengue fever remains a major global public health concern, with significant implications for India, particularly in South India. Globally, approximately 3.9 billion people are at risk of dengue infection, with an estimated 100 million cases annually. However, the actual number is likely much higher due to underreporting and misclassification⁴. The World Health Organization (WHO) reported an 8-fold increase in dengue cases, rising from 505,430 in 2000 to over 5.2 million in 2019, driven by factors like urbanization, global travel, and climate change⁵.

India bears a significant share of the global dengue burden. Estimates suggest approximately 5.8 million clinically diagnosed dengue cases annually, with a high prevalence of underreporting⁶. A 2017 cross-sectional serosurvey revealed an overall seroprevalence of 48.7%, indicating that nearly half of India’s population had been exposed to the dengue virus¹¹. Dengue outbreaks in India exhibit a cyclical pattern every 3–4 years, with all four dengue virus (DENV) serotypes co-circulating¹².

South India has a particularly high seroprevalence of dengue compared to other regions of the country, with cyclical outbreaks occurring every five years. Tamil Nadu, Karnataka, and Andhra Pradesh accounted for 60% of India’s dengue cases in 2022, similar to the surges seen in 2012 and 2017. The 2017 serosurvey indicated a seroprevalence of 76.9% in South India, underscoring widespread exposure¹¹.

In Tamil Nadu, a retrospective study from 2012 to 2018 highlighted a significant increase in dengue cases, peaking in 2017. The study underscored the critical need for continuous surveillance and vector control¹³. In Puducherry, a 2019 study identified all four DENV serotypes in circulation, with DENV-4 being predominant (64%). Concurrent infections, particularly involving DENV-4 and DENV-2, accounted for 77.8% of cases, reflecting the complexity of serotype dynamics¹⁴.

Kerala has experienced recurrent dengue outbreaks, with a notable spike in 2017. The co-circulation of multiple serotypes has been implicated in heightened transmission and disease severity¹⁵. In Karnataka, dengue incidence has steadily increased, particularly in urban areas, as evidenced by data from 2010 to 2016 ¹⁶. Andhra Pradesh and Telangana have also reported periodic dengue outbreaks, with a significant surge in 2019. Studies from these regions highlight the co-circulation of multiple serotypes, complicating control measures^{17, 18}.

Risk factors for high Dengue incidence in South India:

The high incidence of dengue in South India is attributed to a combination of climatic, ecological, and sociocultural factors. The region's warm and humid tropical climate provides an ideal environment for the proliferation of the Aedes aegypti mosquito, the primary vector for dengue. Prolonged monsoon seasons and stagnant water from rainfall further enhance mosquito breeding ¹⁹. Additionally, rapid urbanization and population growth have led to unplanned urban settlements with poor waste management and water storage practices, creating abundant breeding grounds for mosquitoes²⁰. The adaptability of Aedes aegypti and Aedes albopictus mosquitoes to urban and peri-urban environments, particularly their ability to breed in artificial containers and small water collections, has further increased dengue transmission in the region¹³.

Compounding the issue, all four dengue virus serotypes (DENV-1, DENV-2, DENV-3, and DENV-4) circulate in South India, leading to secondary infections that increase the risk of severe disease manifestations¹⁴. Inadequate implementation of vector control measures and insufficient community participation in mosquito control efforts have also contributed to sustained transmission²¹. High levels of human mobility between rural and urban areas further facilitate the spread of dengue, particularly during peak transmission seasons²². Lastly, limited public awareness about dengue prevention and improper waste disposal practices exacerbate the issue, highlighting the need for stronger community engagement and education initiatives²¹.

Common types of dengue reported in South India:

The most common type of dengue reported in South India is influenced by the prevalence of different dengue virus (DENV) serotypes, including DENV-1, DENV-2, DENV-3, and DENV-4. Among these, DENV-2 and DENV-1 are frequently documented as the predominant serotypes in outbreaks. Studies have consistently identified DENV-2 as a leading cause of severe dengue cases in South India. This serotype is associated with severe clinical manifestations, including dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). A notable surge of DENV-2 cases was reported during outbreaks in Tamil Nadu and Karnataka [11 & 14]. DENV-1, on the other hand, is often linked to less severe cases but remains highly prevalent, contributing significantly to the case load. It was the primary serotype in earlier outbreaks before DENV-2 became dominant in certain regions²³. Serotype dynamics often shift over time, with mixed infections and the emergence of multiple serotypes during outbreaks. For example, outbreaks in Tamil Nadu and Kerala have occasionally reported DENV-3 and DENV-4, although these are less common⁶. Co-circulation of multiple serotypes has also been observed, increasing the risk of secondary infections and severe forms of the disease¹³. Regional studies further highlight the dominance of DENV-2, with a study in Tamil Nadu identifying it as the most prevalent serotype during recent outbreaks¹¹ Similarly, research from Kerala and Karnataka reported the predominance of DENV-2, with occasional co-circulation of other serotypes¹⁸.

A study conducted at JSS Medical College and Hospital in Mysuru, Karnataka, India, from January 2022 to January 2023, analyzed 316 confirmed dengue cases. The findings revealed that 56.32% of patients tested positive for the NS1 antigen, 20.88% for IgM antibodies, and 23.41% for both NS1 and IgM. Additionally, 60.6% of patients exhibited thrombocytopenia, defined as platelet counts below 100,000 cells/mm³.²⁴ A study at Teni Tamil Nadu found that, In Theni, Tamil Nadu, all four DENV serotypes were detected, with DENV-1 as the predominant serotype (41.9%). Genotyping revealed the circulation of DENV-1 (Genotype I), DENV-2 (Cosmopolitan, Genotype IV), DENV-3 (Genotype III), and DENV-4 (Genotype I) during the outbreak. Cases with multiple serotype infections were also reported ²⁵. In Madurai, a study tested 135 suspected cases for DENV infection, with 76 samples testing positive. Among these, DENV-4 was the dominant serotype, followed by DENV-2, DENV-1, and DENV-3 ²⁶. A study in Puducherry found DENV-4 predominant (64%) and identified a distinct new clade (Clade E). DENV-4/DENV-2 co-infections accounted for 77.8% of 18 concurrent¹⁴.

Clinical Presentation of Dengue in South India:

Mixed infections with multiple serotypes lead to diverse clinical presentations¹³. Studies in Karnataka and Puducherry reported dengue co-infections with other pathogens like chikungunya and leptospirosis, complicating clinical features¹⁴. The clinical presentation of dengue in South India varies from asymptomatic infections to severe forms such as dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS).

Common Clinical Features: Fever is the most consistent symptom, often accompanied by headache, retro-orbital pain, myalgia, and arthralgia. Studies from Tamil Nadu and Kerala have reported that more than 90% of patients present with acute febrile illness¹⁶. Rash, petechiae, and ecchymoses are frequently observed. A study in Karnataka found that up to 20% of cases exhibited a maculopapular rash²⁴. Abdominal pain, nausea, vomiting, and hepatomegaly are common in severe cases. A study in Puducherry reported gastrointestinal symptoms in 55% of patients¹⁴. Epistaxis, gum bleeding, hematemesis, and melena are frequently reported, particularly in DHF. In a study conducted in Andhra Pradesh, 25% of dengue patients had bleeding manifestations. Thrombocytopenia (platelet count <100,000/µL) is a hallmark laboratory finding, reported in 60–70% of patients in various studies across South India. Hemoconcentration is also observed in severe cases¹⁸.

Severe Dengue and Complications: Severe manifestations like Dengue Hemorrhagic Fever and Shock Syndrome are associated with higher mortality. A study from Kerala indicated that severe dengue accounted for 12% of total cases during the 2017 outbreak²⁷. Hepatic dysfunction, acute kidney injury, and myocarditis have been observed in severe cases. A retrospective study from Tamil Nadu identified hepatic involvement in 40% of severe cases ²⁸.

Cost Analysis of Dengue from State of South India:

Between 2006 and 2012, India reported an annual average of 20,474 dengue cases. Despite being notifiable since 1996, these figures substantially underrepresent the disease's true burden. Regional data and adjustments for underreporting, such as a case study in Madurai district and an expert Delphi panel, estimate an annual average of 5,778,406 clinically diagnosed dengue cases for the same period—282 times the reported numbers. The total direct annual medical cost of dengue was approximately US$548 million. Outpatient care accounted for 67% of cases but only 18% of costs, while 33% of cases required hospitalization, representing 82% of costs. Notably, 80% of expenditures were incurred in private healthcare facilities.

Including non-medical and indirect costs, as extrapolated from other dengue-endemic countries, raises the total economic burden to US$1.11 billion or $0.88 per capita. This highlights the stark discrepancy between reported and actual disease impact, emphasizing the need for enhanced control measures²⁹. Dengue fever imposes a significant economic burden on South Indian states, encompassing costs related to treatment, prevention, and fatalities. In Kerala, a study estimated the total cost of dengue in 2016 to be approximately ₹2,432 million (US$38 million). This includes ₹137 million (US$2.16 million) for treatment, ₹535 million (US$8.3 million) for prevention, and ₹1,760 million (US$27.7 million) attributed to fatalities. Notably, the cost of fatalities was twelve times higher than treatment costs, underscoring the substantial economic impact of dengue-related deaths [30]. In Tamil Nadu, an economic evaluation assessed the cost-effectiveness of implementing a decentralized dengue screening strategy at primary healthcare facilities compared to the existing centralized approach at tertiary health centers. The study concluded that the decentralized strategy was cost-saving, with an incremental cost-effectiveness ratio of -₹41,197 per quality-adjusted life year gained. This finding suggests that early screening at primary healthcare levels can reduce overall costs associated with dengue management [31].. Further, research conducted in Vellore, Tamil Nadu, analyzed hospitalization rates and direct medical costs for febrile illnesses among children. The study reported that the median cost for a dengue-related hospitalization episode was ₹5,627, highlighting the financial strain on households due to dengue³².

Approach to Control and Prevent Dengue in South India:

In South India, the government has implemented a multifaceted approach to control and prevent dengue, with Integrated Vector Management (IVM) being the cornerstone of the strategy. IVM, recommended by the WHO, focuses on reducing mosquito breeding sites through several key measures. These include larval source reduction, involving regular inspection and elimination of stagnant water in both urban and rural areas, fogging operations during outbreaks to target adult mosquito populations, and biological control methods such as introducing larvivorous fish and using bacterial agents like Bacillus thuringiensis israelensis (Bti)³³. In addition to vector control, state governments have launched extensive public awareness campaigns to educate the community about dengue prevention. For instance, Tamil Nadu observes a "Dengue Awareness Month," which includes school-based programs and mass communication efforts via media channels. Similarly, Kerala and Karnataka have implemented community-focused campaigns to promote personal protection and clean environment practices.

Dengue surveillance and early warning systems have also been strengthened through real-time case reporting under the National Vector Borne Disease Control Programme (NVBDCP). States like Tamil Nadu and Andhra Pradesh use geographic information systems (GIS) to monitor outbreaks and identify hotspots for targeted interventions. Legislation for mosquito control is enforced in local communities, with Tamil Nadu’s Public Health Act mandating regular inspections of households, and Kerala imposing fines for uncovered water storage containers, especially in urban areas. In the healthcare sector, South Indian states have improved dengue management by setting up fever clinics, providing free diagnostic tests, and creating dengue-specific wards in tertiary care centers to handle severe cases³⁴.

In addition to these efforts, community participation is integral to ensuring sustainable dengue control. Tamil Nadu’s "Clean Home, Dengue-Free Home" campaign encourages households to cover water containers and dispose of waste properly. Andhra Pradesh has trained community health workers, especially Accredited Social Health Activists (ASHA workers), to mobilize local communities and raise awareness about vector control and prevention measure³⁵. Finally, rapid response teams are deployed in affected areas to conduct intensive fogging and insecticide spraying, as well as to set up emergency medical camps for treating severe dengue cases⁵.

Cost-Effective Solutions to Control and Prevent Dengue:

The National Centre for Vector Borne Diseases Control (NCVBDC) emphasizes that increased community ownership can help prevent dengue transmission and reduce dengue morbidity and mortality³⁶. A study conducted in Tamil Nadu (2013) showed that community-based initiatives significantly reduced the incidence of dengue. By educating communities about eliminating mosquito breeding sites, such as stagnant water, and promoting the use of mosquito nets, the transmission rate was reduced by up to 30% ³⁷. Community engagement is low-cost compared to other interventions. Public health campaigns, though requiring an initial investment in resources, are a sustainable and low-budget approach to long-term prevention.

A study conducted in Kerala estimated the cost of dengue prevention, including the use of insecticide-treated nets, to be ₹535 million (8.3 million US$) over one year. This investment in prevention was found to be cost-effective when compared to the higher costs associated with treatment and fatalities¹⁰. While insecticide-treated nets may have a higher upfront cost, they are long-lasting, easy to deploy, and provide continuous protection, making them a cost-effective intervention in areas with high mosquito density. A study in Andhra Pradesh highlighted the effectiveness of source reduction, where households were encouraged to clean water containers, eliminate discarded tires, and other potential mosquito habitats. After a year of continuous source reduction efforts, dengue cases dropped by approximately 40%³⁸. Source reduction strategies involve little to no cost and are highly sustainable, as they rely on community participation rather than expensive infrastructure or chemical interventions.

A study in Chandigarh assessed the use of Bacillus thuringiensis israelensis (Bti) as a biological larvicide. The study found that Bti significantly reduced mosquito larvae populations in both urban and rural areas, lowering the risk of dengue outbreaks³⁹. Biological control using Bti is cost-effective as it targets mosquito larvae without harming other wildlife or the environment. It can be applied in targeted areas like water bodies or drains, thus limiting costs.

A study in Tamil Nadu evaluated the cost-effectiveness of a decentralized dengue screening strategy at primary healthcare facilities. The study found that early diagnosis followed by early treatment resulted in the prevention of acute and prolonged cases, making it a cost-saving strategy⁴⁰. Surveillance systems, while initially requiring investment in infrastructure and training, help in identifying outbreaks early, thus preventing larger-scale epidemics and reducing healthcare costs in the long term.

The NCVBDC recommends fogging and indoor residual spraying as part of integrated vector management strategies to control adult mosquito populations during dengue outbreaks³⁶. Fogging is more expensive compared to source reduction but can be used as a complementary measure in high-risk areas. Indoor residual spraying, although slightly more expensive, provides long-term protection, making it a cost-effective measure when combined with other strategies.

The World Mosquito Program has implemented the release of Wolbachia-infected mosquitoes in various countries, leading to significant reductions in dengue cases. While specific studies in India are limited, this method shows promise as a cost-effective strategy for dengue control⁴¹. Genetic modification and Wolbachia release can be resource-intensive at first, but they are cost-effective in the long run because they can drastically reduce mosquito populations and reduce the need for ongoing interventions like insecticides.

A study from Maharashtra (2020) showed that timely access to diagnostics and early treatment significantly reduced mortality from dengue. The study found that rapid diagnostic tests were crucial in identifying dengue early, leading to quicker treatment and fewer hospitalizations⁴². Improving healthcare infrastructure, though initially costly, reduces overall healthcare expenditures by decreasing the severity of outbreaks and preventing complications through early diagnosis.

CONCLUSION:

Dengue remains a significant public health challenge in South India, with high incidence rates, severe clinical manifestations, and a substantial economic burden. The region's unique climate, urbanization patterns, and mosquito vectors contribute to the persistence of dengue transmission. Cost-effective solutions, including early diagnosis, decentralized screening, improved vector control, and community engagement, are critical to reducing the impact of dengue and alleviating the economic burden on affected communities. Enhanced surveillance and targeted interventions can further help mitigate the public health threat posed by dengue in South India.

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Received on 05.05.2025 Revised on 18.08.2025

Accepted on 23.10.2025 Published on 21.02.2026

Available online from February 23, 2026

Asian J. Nursing Education and Research. 2026;16(1):54-60.

DOI: 10.52711/2349-2996.2026.00012

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