Health-Related Quality of Life after Dengue Fever, Morelos, Mexico, 2016–2017

We adapted the EQ-5D-3L questionnaire and visual analog scale to assess health-related quality of life (HRQOL) and persistent symptoms in 79 patients with laboratory-confirmed dengue in Morelos, Mexico. The lowest HRQOLs were 0.53 and 38.1 (febrile phase). Patients recovered baseline HRQOL in ≈2 months.

We analyzed changes in HRQOL over time using survival and Cox regression analyses. We defined recovery as baseline HRQOL (before DENV infection) and calculated the time it took each patient to recover. We estimated HRQOL recovery time for subgroups of patients using Kaplan-Meier with log-rank test statistic and identified significant predictors of HRQOL using Cox regression analyses.
We tested differences in HRQOL recovery time using Kaplan-Meier curves for individual subgroups (Appendix Figure 1). Survival curves showed slower recovery times for hospitalized participants (≈40% recovered baseline HRQOL) than for ambulatory participants (≈75%) after 30 days (p = 0.012). Participants with severe symptoms (≈30%) also showed slower recovery than did participants without severe symptoms (≈75%) after 20 days (p = 0.001), as did participants with >1 warning signs (≈40%) compared with participants without warning signs (≈85%) after 15 days (p<0.001). Participants with higher education had a faster recovery of HRQOL than did participants with less education (p<0.001).
We used a Cox regression analysis ( Table 2) to identify factors associated with HRQOL recovery (model: proportionality confirmed; mean variance inflation factor = 1.09, all variables variance inflation factor <1.21; final model χ 2 37.8, p<0.001; McFadden pseudo-R 2 = 0.11). Recovery rates were higher for men than for women (hazard ratio [HR] 1.87; p = 0.036), patients with more education (HR 2.06; p = 0.042), and patients with no severe symptoms (HR 2.82; p = 0.001). In the first 15 days of disease, dengue patients without skin ache had a 63% lower likelihood (HR 0.37; p = 0.002) and patients without scaling had a 67% lower likelihood (HR 0.33, p = 0.038) of recovering to baseline HRQOL.

Conclusions
Dengue significantly reduces HRQOL beyond the febrile phase. Mobility, pain, and usual activities were the most affected domains, consistent with previous studies (8,12). The proportion of patients reporting problems remained stable among patients with persistent symptoms of dengue. HRQOL decreased abruptly during the febrile phase; most patients then steadily recovered, with some exceptions for those who had not reached baseline HRQOL at 6 months. Other studies have found larger reductions of HRQOL than we found; mean EQ-VAS score was 7 for children 0-14 years of age in Cambodia (13) and 10 for hospitalized patients and 20 for ambulatory patients in Brazil (7). Our findings were comparable to those of Armien et al. (14) in Panama (EQ-VAS 35.2 for children; 31.9 for adults). Female sex was significantly associated with dengue severity in our study, and education (a proxy for socioeconomic status) might be a protective factor. We found skin symptoms to be associated with a faster recovery, possibly because of a lower inflammatory or immune response (15).
Our findings are subject to limitations: an adultsonly sample; limited socioeconomic characterization of participants; lack of data about previous DENV infections; limitations of the EQ-5D-3L instrument; possible recall bias for baseline HRQOL; response-, recalibration-, and reconceptualization responseshift biases; and a relatively small sample of patients with laboratory-confirmed dengue. Despite these limitations, our findings are relevant for clinical practice and health services research and can help researchers and other stakeholders improve estimates of dengue effects.