Dengue fever and DHF

Burden of the disease - World

• Major public health concern
• Tropical and subtropical regions
• Urban and semi-urban areas
• Spreading to rural areas
• South East Asian and Western Pacific regions
are hyperendemic
 Burden of the disease - India
• Increasing trend in recent years
 Rapid urbanization
 Lifestyle changes
 Improper water storage practices
 Improper town planning
 Deforestation and global warming
 Epidemiology
• Dengue is a Viral Disease like Flu spread by bite
of infected mosquitoes (Aedes).

• It is a arboviral disease caused by Flavivirus

(Dengue 1,2,3,4).

• Dengue virus manifests as:

– a) Dengue Fever: Flu like illness spread by the
bite of an infected mosquito.
– b) Dengue Hemorrhagic Fever: Severe often
fatal complication of dengue fever.
RECENT DENGUE EPIDEMIC ACTIVITY
Epidemiology
• b) DHF an emerging disease, cyclical epidemics
becoming more frequent with multiple virus
serotype in the country.

• It is to note that over the past 15 years Dengue is a

major source of death among infants and children.

• In India we have all the types of Dengue serotypes.

 Agent Factors
• Dengue virus is a single stranded RNA virus in
Flavivirus group in family Flaviviridae.

• There are 4 Dengue serotypes,1-2-3-4.

• They are antigenically distinct there is some

evidence that serological sub-complexes may
exist with the group.

• Secondary infection with DENV 2 or multiple

infection with different serotypes lead to severe
form of dengue.
Reservoir of Infection
• Man is the main reservoir of virus.

• Monkey is the jungle reservoir in

Malaysia and Africa.

• Host: Human

• Sex: Both

• Age: All Age groups

Mode of Transmission
• Dengue virus is transmitted from human to human by
mosquito bite.

• AEDES AEGYPTI is the most efficient of mosquito vector

because of its domestic habits and anthropophilic nature.

• A polynesiensis, A sentellaris, A pseudosentellaris, A

albopictus are the vectors.

• Female mosquitoes bites human during the day.

• Mosquito can be infected until 4th day of illness and

become infected after 8-11 days of extrinsic IP.
• It remains infective for life.

• In nature, trans ovarian transmission of

dengue type 2 and 4 by A aegypti has been
demonstrated.

• An infected person can’t spread the

infection to others but can be a source of
dengue virus for mosquitoes for 6 days.
 Risk Factors

• Persons age and immunity status as well as

type of infecting virus.

• Incubation period: 3-10 days (commonly 5-6

days).
 Environmental factors
• Dengue transmission occurs through out the year in
the endemic tropical areas however in most
countries there is a distinct seasonal pattern with
rainy season.

• Mosquitoes that transmit dengue among humans

breed in discarded types flower pots, tyres, water
storage containers.

• Aedes breed in artificial collections

of water.
 High risk patients
• Infants and elderly
• Pregnant
• Obese
• Peptic ulcer d/s
• Haemolytic d/s
• Congenital heart d/s
• Chronic d/s
• Patients on NSAIDs/steroid treatment
 Clinical manifestations
Undifferentiated fever
Classical dengue fever
Dengue haemorrhagic fever
Dengue shock syndrome
 Undifferentiated Fever
• May be the most common manifestation of
dengue.

• Simple fever
• May or may not have rashes
• Upper respiratory and GI symptoms
 Classical Dengue Fever
• All ages and both sexes are susceptible
• Children usually have a milder d/s
• Case fatality is exceedingly very low
• IP  5-6 days
Clinical Characteristics
of Dengue Fever
• Fever 39.5

• Headache 390

• Muscle and joint 38.5

pain 38.0

• Nausea/vomiting 37.5

• Rash 37.0

• Anorexia 0 1 2 3 4 5 6

Fever Day
• Retro orbital pain
• Facial flushing
 Fever
• Sudden onset
• High fever (39-40°C)
• Also called
-saddle back fever
-break bone fever

Rash
 Pin point ,fleeting type
 Maculo-papular rash
 Dengue Haemorrhagic fever
• Severe form of dengue
• 3 phases
 Febrile phase
 Critical Phase
 Recovery phase
 Risk Factors Reported for
DHF
• Virus strain
• Pre-existing anti-dengue antibody
– previous infection
– maternal antibodies in infants
• Age
• Higher risk in secondary infections
• Higher risk in locations with two or more
serotypes circulating simultaneously at high
levels (hyper endemic transmission).
 Increased Probability of DHF
Hyperendemicity

Increased circulation Increased probability

of viruses of secondary infection

Increased probability of Increased probability of

occurrence of virulent strains immune enhancement

Increased probability of DHF

Gubler & Trent, 1994
Clinical features of DHF
 IP: 4-6 days
 High fever
 Head ache
 Anorexia
 Tenderness at the Rt costal
margin
 Facial flushing
 Maculopapular rash
 Haemorrhagic manifestations
Hemorrhagic Manifestations
of Dengue
• Skin hemorrhages:
petechiae, purpura, ecchymoses
• Gingival bleeding
• Nasal bleeding
• Gastro-intestinal bleeding:
hematemesis, melena,
hematochezia
• Hematuria
• Increased menstrual flow
Petechiae
Haematoma
 Clinical Case Definition for
Dengue Hemorrhagic Fever
4 Necessary Criteria:
• Fever, or recent history of acute fever
• Hemorrhagic manifestations
• Low platelet count (100,000/mm3 or less)
• Objective evidence of “leaky capillaries:”
– elevated hematocrit (20% or more over baseline)
– low albumin
– pleural or other effusions
Clinical manifestations of
Dengue Shock Syndrome
 Restlessness
 Lethargy
 Cyanosis
 Hepatomegaly
 Pleural
effusion
 Ascitis
 GI bleeding
Pleural
 Clinical Case Definition for
Dengue Shock Syndrome
• 4 criteria for DHF
• Evidence of circulatory failure manifested
indirectly by all of the following:
– Rapid and weak pulse
– Narrow pulse pressure (≤ 20 mm Hg) OR
hypotension for age
– Cold, clammy skin and altered mental status
• Frank shock is direct evidence of
circulatory failure.
 Four Grades of DHF
• Grade 1
– Fever and nonspecific constitutional symptoms
– Positive tourniquet test is only hemorrhagic
manifestation
• Grade 2
– Grade 1 manifestations + spontaneous bleeding
• Grade 3
– Signs of circulatory failure (rapid/weak pulse,
narrow pulse pressure, hypotension, cold/clammy
skin)
• Grade 4
– Profound shock (undetectable pulse and BP)
 Tourniquet Test
• Inflate blood pressure cuff to a
point midway between systolic and
diastolic pressure for 5 minutes.

• Positive test: 10 or more petechiae

per 1 inch2 (6.25 cm2).

Pan American Health Organization: Dengue and Dengue

Hemorrhagic Fever: Guidelines for Prevention and
Control. PAHO: Washington, D.C., 1994: 12.
Positive Tourniquet Test
 Danger Signs in
Dengue Hemorrhagic Fever
• Abdominal pain - intense and sustained.
• Persistent vomiting.
• Abrupt change from fever to hypothermia,
with sweating and prostration.
• Restlessness or somnolence.
 Unusual Presentations
of Severe Dengue Fever
• Encephalopathy

• Hepatic damage

• Cardiomyopathy

• Severe gastrointestinal
hemorrhage
Diagnosis
1. Virus isolation
2. Viral nucleic acid detection – RT PCR
3. Viral antigen detection - ELISA
4. Rapid Diagnostic Test – IgM, IgG
5. Platelet count , PCV
 Virus Isolation:
Fluorescent Antibody Test
ELISA Plate
Treatment guidelines
 DENGUE FEVER
TREATMENT

DENGUE FEVER

DENGUE HEMORRHAGIC FEVER

DENGUE SHOCK SYNDROME

 1. Management of Dengue fever
• Those with stable haematocrit can be send
home.
1.Encourage adequate fluid intake – water, ORS,
fruit juices
2.Paracetamol for pyrexia – not <6hr dosing
3.Tepid sponging
4.No NSAIDS
5.Inform warning signs to care takers
 2. Management of DHF (Febrile
phase)
1. Adequate rest
2. Paracetamol
3. Adequate fluid intake, IV if not tolerating
orally
 Daily haematocrit
 Monitor for danger signs
 3.Management of DHF 1 and 2
• Any person with dengue fever with
thrombocytopenia and haemoconcentration
and presents with abdominal pain, black tarry
stools, epistaxis, bleeding from gums need to
be hospitalized.
• Look for signs of shock
• Rise of PCV  IV fluid therapy
 4. Management of DHF 3 and 4
• Oxygen support
• Regular and sustained monitoring
• Start on volume expanders – Dextran
40/haemacele
• If PCV decreasing  fresh whole blood
transfusion @ 10 – 20 ml/kg/hr
 Criteria for discharge of patients
Absence of fever for atleast 24 hrs without the
use of anti-pyretic drugs
Return of appetite
Visible clinical improvement
Good urine output
No resp: distress
Platelet count > 50,000/mm3
 PREVENTION AND
CONTROL MEASURES
 MOSQUITO CONTROL
MEASURES
ANTI LARVAL

ANTI ADULT PERSONAL PROTECTION

INTEGRATED APPROACH
• BIOLOGICAL METHOD.
GAMBUSIA & LEBISTER RETICULATUS.
ADV-easy & cost effective
DISAD-effective only in conjunction with
other methods.
Recently BIOCIDES like BACILLUS
THURINGIENSIS being used.
 ANTI ADULT MEASURES

ANTI ADULT

RESIDUAL SPRAYING

SPACE SPRAYING

GENETIC METHODS
 RESIDUAL SPRAYING
• By DDT(Dichloro diphenyl trichloroethane)
1-2gm/sq.mt. sprayed to walls 1-3 times a year.
If resistant-Malathion, Lindane
Disad - Periodic tests are required to test if mosquitoes
have become resistant.
 SPACE SPRAYS

• Insecticidal formulation is
sprayed into atmosphere like
mist.eg.PYRETHRUM-1
oz/1000cubic ft. of space.
MOA - Nerve poison
Disad - No residual action
 GENETIC METHODS

• Sterile male techniques

• Chromosomal translocation
• Sex distortion.
--Still in RESEARCH PHASE.
Adv-Cheap, No chance of vector
resistance.
 PERSONAL PROTECTION
• Nets – shd not exceed 0.047 inch in any
diameter
• mosquito coils (For DAY TIME as
AEDES bites during day.)
• Screening of buildings with COPPER/BRONZE
GUAZE.
Disad - Costly
Adv - Excellent results.

Repellants-DEET(DIETHYL TOLUAMIDE).
 VACCINATION
Is very difficult as any 4 different virus can cause
disease & b’coz prevention against only 1 or 2 virus
could increase the RISK of more serious disease.

THERE IS NO LEGALISED VACCINE AT

PRESENT.

New serotypes & strains will continue to be

introduced. Therefore we must develop
improved,proactive,lab.based surveillance system
that can provide early warning of an impending
dengue epidemic.
 Dengue vaccine
• CYD-TDV is a prophylactic, tetravalent, live
attenuated viral vaccine
• Sanofi-Pasteur in 2015
• Schedule – 3 doses 6 months apart – 0.5 ml
• Subcutaneously
• 2 to 8°C
• To be used within 6hrs of reconstitution.
 SURVEILLANCE

SURVEILLANCE

EPIDEMIOLOGICAL ENTOMOLOGICAL

ACTIVE PASSIVE
• ACTIVE SURVEILLACE
Is a lab. based surveillance to provide information
about virus serotype & disease severity.

 PASSIVE SURVEILLANCE
Reporting of all cases by hospitals.

ENTOMOLOGICAL SURVEILLANCE
Used to find changes in geographical distribution
of vectors, get data & measure the
population to implement control measures.
•Thank you…