B.
PHARMACY FINAL YEAR
SOCIAL AND PREVENTIVE PHARMACY
UNIT-II-DENGUE
Dr..D.Kiran Khanna
Assistant Professor
Dept. of Pharmacy Practice
Sri Ramachandra Faculty of Pharmacy
1
INTRODUCTION
• Dengue is a mosquito-borne viral infection that causes a severe flu-like illness.
• sometimes causes a potentially lethal complication called severe dengue.
• Severe dengue has a higher risk of death if not managed appropriately.
• Dengue virus is transmitted by the vector, Aedes aegypti mosquito.
• The viruses are passed on to humans through the bites of infected female Aedes mosquitoes, which
acquire the virus while feeding on the blood of an infected person.
• The infected individuals suffer from high fever, headache, joint and muscle pain, vomiting. and
rashes.
CAUSATIVE AGENT:
• Dengue is caused by group B arborvirus (dengue types 1, 2, 3, 4), which was first isolated in India in
1945 by Sabin.
• DEN-2 and DEN-3 are associated with shock syndrome.
• Dengue Hemorrhagic Fever (DHF) was first recognized in Manila in 1954,
• It may be stated that the same virus (Dengue types 1, 2, 3, 4) causes two disease syndromes, i.e.,
classical dengue and DHF.
MODE OF TRANSMISSION:
• A. aegypti is a domestic mosquito, and the most common and efficient vector .
• The female mosquitoes bite humans during the daytime.
• They feed on an infected individual's blood, and transmit the infection to another host when the blood
meal is interrupted or after an incubation period of 8-10 days during which the virus multiplies in the
salivary glands.
• A. albopictus. A. polynesiensis, and A scutellaris are the less efficient vectors.
SYMPTOMS:
Dengue virus infection may be asymptomatic or may cause undifferentiated febrile illness (viral
syndrome), Dengue Fever (DF), Dengue Haemorrhagic Fever (DHF), or Dengue Shock
Syndrome (DSS).
UNDIFFERENTIATED FEVER:
• The infants, children, and adults who have got primary dengue infection (means infected with
dengue virus for the first time) may develop a simple fever like any other viral infection.
• Maculopapular rashes also occur after fever or during defervescence.
• Upper respiratory and gastrointestinal symptoms occur commonly.
2) CLASSICAL DENGUE FEVER:
• People of all ages and both sexes are vulnerable to dengue fever.
• Children have a milder disease than adults.
• It is characterized by sudden onset of chills, high fever, severe headache, and muscle and joint
pains.
• Within 24 hours, the victim experiences retro-orbital pain, particularly on eye movements or eye
pressure, and photophobia.
• Other symptoms include extreme weakness, anorexia, constipation, altered taste sensation, colicky
pain and abdominal tenderness, dragging pain in inguinal region, sore throat, and general
depression.
• The body temperature is between 39-40°C Fever is followed by a remission of a few hours to 2
days.
• Skin eruptions appear in 80% of patients during the remission or during second tebrile phase that
lasts for 1-2 days.
• Rashes are followed by similar but milder symptoms.
• It may also be a maculopapular or scarlatiniform starting on the 3 or 4 day on the chest and trunk
and spreading to extremities and face (rarely).
• It may be accompanied by itching and hyperaesthesia.
3.DENGUE HAEMORRHAGIC FEVER:
DHF is a severe form of dengue fever, which is divided into the following three phases
FEBRILE PHASE:
• The illness begins after an incubation period of 4-6 days.
• It starts with high fever. followed by facial flushing, headache, anorexia. vomiting, epigastric
discomfort, tenderness at the right costal margin. and generalized abdominal pain.
• The body temperature may be 40-41°C and febrile convulsions may occur, especially in infants
CRITICAL PHASE:
This phase begins during the defervescence period. when the temperature is 37.5-38°C or below this
level on 3 to 7 day of illness, and the capillary permeability increases with increasing haematocrit
levels.
• The period of clinically significant plasma leakage lasts for 1-2 days.
• Progressive leukopenia is followed by a rapid decline in platelet count which is again followed by
plasma leakage.
• At this point patient without increased capiliary permeability will show signs of improvement,
while the condition of patients with increased capillary permeability worsens due to lost plasma
volume.
• Pleural effusion on right side and ascites can be clinically detected.
• Gall bladder oedema is followed by plasma leakage; hence, the disease can be diagnosed with
chest X-ray and abdominal ultrasound.
• The degree of increase above the baseline haematocrit reflects the severity of plasma leakage.
RECOVERY PHASE:
• If the patient survives 24-48 hours of critical phase, a gradial reabsorption of extravascular
compartment fluid occurs in the next 48-72 hours.
• The general well-being of the patients improves, appetite returns, gastrointestinal symptoms
subside. haemodynamic status stabilizes, and diuresis proceeds.
IV) SEVERE DENGUE:
It is manifested by plasma leakage that may lead to shock (dengue shock) and/or fluid accumulation,
with or without respiratory distress, and/or severe bleeding, and/or severe organ impairment.
General Principles of Prevention and Control Mosquito Control:
• The vectors of dengue fever and DHF, i.e., A. aegypti, breed in and around houses
• It can be controlled by individual and community action with anti-adult and anti-larval measures.
VACCINES:
Till today there is no satisfactory vaccine and immediate prospect of preventing the disease by
immunisation.
OTHER MEASURES:
The infected individuals should be isolated under bed-nets for the first few days to protect against
mosquitoes.
Personal prophylactic measures include wearing clothes that cover the body entirely.
Use mosquito repellent creams, liquids, coils, mats, etc.; and using bed-nets for sleeping infants and
young children during day time to prevent mosquito bites.
Environmental measurements include detection and elimination of mosquito breeding places
management of roof tops, porticos and sunshades, proper covering of stored water, and observation
of weekly dry day.
• 1. GENERAL SUPPORTIVE MANAGEMENT
• (EXPAND)
• Bed Rest: Essential during the febrile phase.
• Hydration: Oral rehydration with fluids like ORS, coconut water, and
soup. Monitor urine output (>0.5 mL/kg/hr is ideal).
• Fever and Pain Control:
• Paracetamol (Acetaminophen):
• Adults: 500–1000 mg every 6 hours (max 4 g/day)
• Children: 10–15 mg/kg/dose every 6 hours
• Avoid NSAIDs (aspirin, ibuprofen, diclofenac): May cause bleeding.
FLUID MANAGEMENT STRATEGIES
a. Dengue Without Warning Signs
• Encourage oral fluids (ORS, juices, water).
• Daily monitoring of hematocrit, platelets.
• Outpatient care unless deterioration occurs.
• b. Dengue With Warning Signs (e.g., abdominal pain, persistent
vomiting, fluid accumulation, mucosal bleeding, lethargy, liver
enlargement >2 cm, increase in hematocrit with decreasing platelets)
• Hospitalization recommended
• IV fluids:
• Start with isotonic crystalloid solutions (0.9% saline or Ringer’s lactate)
• Initial rate: 5–7 mL/kg/hour for 1–2 hours, then reduce based on clinical
response
• Monitor vital signs, hematocrit every 4–6 hours
Severe Dengue (shock, severe bleeding, organ failure)
• Immediate hospitalization and aggressive fluid resuscitation
• First 1–2 hours: 10–20 mL/kg crystalloid bolus over 15–30 minutes
• Reassess for shock resolution: If no improvement, repeat bolus or switch to
colloids (Dextran 40, 6% Hydroxyethyl starch)
• Monitor urine output hourly and hematocrit every 1–2 hours initially
ADJUNCTIVE THERAPIES
• Antiemetics:
• Ondansetron: 4–8 mg IV/PO every 8 hours (adults)
• Children: 0.15 mg/kg/dose
• Gastroprotection:
• Pantoprazole 40 mg IV/PO once daily for stress ulcer prevention in hospitalized patients
• Antibiotics:
• Only if superadded bacterial infection is suspected (e.g., persistent fever >5 days, clinical
sepsis, leukocytosis)
Platelet Transfusion
When to Transfuse Platelets:
• Platelet count <10,000/mm³ without bleeding – to prevent
spontaneous bleeding (rare).
• Platelet count <20,000/mm³ with active bleeding – e.g., epistaxis,
gum bleeding, GI bleed.
• Any platelet count with life-threatening bleeding – e.g., intracranial
hemorrhage.
When NOT to Transfuse:
• Routine prophylactic transfusion for counts >20,000/mm³ without
bleeding is not recommended.
• Platelet count does not correlate well with bleeding risk unless
clinically bleeding.
Dose:
• Adult: 1 unit of platelets per 10 kg body weight (usually ~6–8 random
donor platelets or 1 single donor apheresis unit).
• Expected rise: ~10,000–20,000/mm³ per unit.
2.Packed Red Blood Cells (PRBCs)
✅ Indications:
• Severe bleeding causing symptomatic anemia (e.g., Hb <7 g/dL).
• Hemodynamic instability not corrected by fluids alone.
• Rapid fall in hemoglobin or evidence of internal bleeding (e.g.,
gastrointestinal).
Dose:
• Adults: 10 mL/kg PRBCs increases Hb by ~1–1.5 g/dL.
• Transfuse slowly over 2–4 hours unless in shock.
3.Fresh Frozen Plasma (FFP)
✅ Indications:
• Disseminated intravascular coagulation (DIC) or prolonged
PT/INR/aPTT with active bleeding.
• Used when there’s documented coagulopathy on labs and clinical
bleeding.
💉 Dose:
• 10–15 mL/kg
• Must be ABO compatible
. Cryoprecipitate (rarely used in dengue)
✅ Indications:
• If fibrinogen <100 mg/dL and bleeding.
• Used more in DIC situations.
Each unit of cryoprecipitate contains:
• Fibrinogen (most important): Helps form blood clots
• Factor VIII: Deficiency causes hemophilia A
• von Willebrand factor (vWF): Important in platelet adhesion
• Factor XIII: Stabilizes the clot
• Fibronectin: A glycoprotein involved in wound healing and
coagulation
Indications:
1.Hypofibrinogenemia (fibrinogen <100 mg/dL) with bleeding
2.Disseminated Intravascular Coagulation (DIC) with low fibrinogen
3.Massive transfusion protocols
4.Liver failure (if fibrinogen is low)
5.Bleeding in uremic patients (off-label, rarely)
⚠️It is not the first-line treatment in dengue fever but may be used in critical care if fibrinogen is severely deplete
DISCHARGE CRITERIA
• Afebrile for 48 hours
• Platelet count rising above 50,000/mm3
• Stable hematocrit without IV fluids for at least 24 hours
• Good oral intake and urine output
• No respiratory distress
PATIENT EDUCATION
• Advise patients to report immediately if warning signs develop
• Avoid NSAIDs and intramuscular injections
• Emphasize fluid intake and rest
• Use mosquito nets and repellents to prevent further spread
References:
• WHO Guidelines for Dengue, 2009 & 2023 update
• National Vector Borne Disease Control Programme (India)
• AIIMS and ICMR clinical protocols
THANK YOU
