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Aedes aegyptiMosquito
DENGUE FEVER
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World Distribution of Dengue 1999
Areas infested withAedes aegypti
Areas withAedes aegyptiand recent epidemic dengue
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GLOBAL STATUS
New infections annually: 50 million
Deaths: 24,000 annually People at risk: 2.5-3 billion
Hospitalized cases: 500 000/year
(90% of those affected are children)
Disease burden: 465,000 DisabilityAdjusted Life Years (DALY)
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0
20,000
40,000
60,000
80,000
100,000
Cases
2005 Dengue Outbreak
Cases Deaths
Cases 90,000 3,000 31,000 4,800
Deaths 15,000 0 58 50
India, (West
Bengal)Sri Lanka Thailand Pakistan
DENGUE OUT BREAK IN SOUTHDENGUE OUT BREAK IN SOUTH
EAST ASIA IN 2005EAST ASIA IN 2005
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0
500
1000
1500
2000
2500
3000
3500
Cases
Dengue Fever In 2006
Cases Deaths
Cases 3331 3230 1836 400
Deaths 49 50 30 4
India Pakistan Karachi Lahore
DENGUE OUT BREAK IN SOUTH EASTDENGUE OUT BREAK IN SOUTH EAST
ASIA IN (2006)ASIA IN (2006)
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Manifestation Of Dengue Virus
Infections
ASYMPTOMATICASYMPTOMATIC
DSS
SYMPTOMATICSYMPTOMATIC
Without haemorrhage
With unusual haemorrhage
No shock
Undifferentiated
Fever
Dengue Fever
Dengue
Haemorrhagic
Fever
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2A) Clinical Characteristics
of Dengue Fever
Fever
Headache Muscle and joint pain
Nausea/vomiting
Rash Hemorrhagic manifestations
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2B)Hemorrhagic Manifestations
of Dengue
Skin hemorrhages:
petechiae, purpura, ecchymoses
Gingival bleeding
Nasal bleeding
Gastro-intestinal bleeding:
hematemesis, melena, hematochezia
Hematuria
Increased menstrual flow
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C1) Clinical Case Definition for
Dengue Hemorrhagic Fever
1. Fever, or recent history of acute fever
2. Hemorrhagic manifestations3. Low platelet count (100,000/mm3 or less)
4. Objective evidence of leaky capillaries:
elevated hematocrit (20% or more overbaseline)
low albumin
pleural or other effusions
4 Necessary Criteria:4 Necessary Criteria:
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Four Grades of DHFFour 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)
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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
Martnez Torres E. Salud Pblica Mex 37 (supl):29-44, 1995.
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Warning Signs for Dengue Shock
When Patients Develop
DSS: 3 to 6 days after onset of
When Patients Develop
DSS: 3 to 6 days after onset of
Initial WarningSignals: Disappearance of fever Drop in platelets Increase in hematocrit
Initial WarningSignals: Disappearance of fever Drop in platelets Increase in hematocrit
Alarm Signals: Severe abdominal pain Prolonged vomiting Abrupt change from fever
to hypothermia
Change in level ofconsciousness (irritability
orsomnolence)
Alarm Signals: Severe abdominal pain Prolonged vomiting Abrupt change from fever
to hypothermia Change in level of
consciousness (irritability
or
somnolence)
Four Criteria for DHF: Fever Hemorrhagic manifestations Excessive capillary
permeability 100,000/mm3 platelets
Four Criteria for DHF: Fever
Hemorrhagic manifestations Excessive capillary
permeability 100,000/mm3 platelets
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C2) 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
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Unusual Presentations
of Severe Dengue Fever
Encephalopathy
Hepatic damage Cardiomyopathy
Severe gastrointestinal
hemorrhage
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Risk Factors Reported for DHF
Virus strain
Pre-existing anti-dengue antibody previous infection
maternal antibodies in infants
Host genetics Age
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Risk Factors for DHF (continued)
Higher risk in secondary infections
Higher risk in locations with two or moreserotypes circulating simultaneously at
high levels (hyperendemic transmission)
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Increased Probability of DHF
Hyperendemicity
Increased circulation
of viruses
Increased probability
of secondary infection
Increased probability ofoccurrence of virulent strains
Increased probability ofimmune enhancement
Increased probability of DHF Gubler & Trent, 1994
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Viral Risk Factors
for DHF Pathogenesis
Virus strain (genotype)
Epidemic potential: viremia level,
infectivity
Virus serotype
DHF risk is greatest for DEN-2,
followed by DEN-3, DEN-4 and DEN-1
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Clinical Evaluation in Dengue
Fever
Blood pressure
Evidence of bleeding in skin or other
sites
Hydration status
Evidence of increased vascular
permeability-- pleural effusions, ascites
Tourniquet test
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Petechiae
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Vaughn DW, Green S, Kalayanarooj S, et al. Dengue in the early febrilephase: viremia and antibody responses. J Infect Dis 1997; 176:322-30.
A
B
PEI = A/B x 100
Pleural Effusion IndexPleural Effusion Index
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Tourniquet Test
Inflate blood pressure cuff to a point
midway between systolic and
diastolic pressure for 5 minutes Positive test: 20 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.
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Positive Tourniquet Test
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Laboratory Tests
in Dengue Fever
Clinical laboratory tests CBC--WBC, platelets, hematocrit
Albumin
Liver function tests
Urine--check for microscopic hematuria
Dengue-specific tests Virus isolation
Serology
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Laboratory Methods for Dengue
Diagnosis
Virus isolation to determine
serotype of the infecting virus IgM ELISA test for serologic
diagnosis
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Temperature, Virus Positivity and
Anti-Dengue IgM , by Fever Day
Dengue IgMMean Max. Temperature Virus
Adapted from Figure 1 in Vaughn et al.,J Infect Dis, 1997; 176:322-30.
Fever Day
0
20
40
60
80
100
P
erce
ntVirusPo
sitive
-4 -3 -2 -1 0 1 2 3 4 5 6
39.5
39.0
38.5
38.0
37.5
37.0
Temp er
ature(de g
reesCelsiu
s)
D
engueIgM (
EIA
units)300
150
0
75
225
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Outpatient Triage
No hemorrhagic manifestations and
patient is well-hydrated: home treatment
Hemorrhagic manifestations or hydration
borderline: outpatient observation center
or hospitalization
Warning signs (even without profoundshock) or DSS: hospitalize
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Patient Follow-Up
Patients treated at home Instruction regarding danger signs
Consider repeat clinical evaluation
Patients with bleeding manifestations Serial hematocrits and platelets at least daily
until temperature normal for 1 to 2 days
All patients If blood sample taken in first 5 days after
onset, need convalescent sample betweendays 6 - 30
All hospitalized patients need samples on
admission and at discharge or death
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Treatment of Dengue Fever
& DHF I & II
Fluids
Rest Antipyretics (avoid aspirin and non-
steroidal anti-inflammatory drugs)
Monitor blood pressure, hematocrit,platelet count, level of
consciousness
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Treatment of DHF III & IV
All above treatment +
In case of severe bleeding, give fresh whole
blood 20 ml/kg as a bolus Give platelet rich plasma transfusion
exceptionally when platelet counts are below
5,00010,000/ mm3 .
After blood transfusion, continue fluid therapyat 10 ml/kg/h and reduce it stepwise to bring it
down to 3 ml/kg/h and maintain it for 24-48 hrs
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1 unit of RD(Random Donor) Plt. (50ml) per 10 Kg body
weight.---- expected to increas the Plt. Count 5000-
10000/uL. (If No splenomegaly, Fever or DIC)
Alloimmunized (who have received multiple transfusions andthus sensitized) may have little or no increase in the count.They can be best served by SDAP(Single Donor Apheresis
Platelets) as 1 SDAP unit(150ml)=6 RD units
CCI=Post transfusion count Pre transfusion count X BSA
Number of Platelets transfused X 1011
Evaluation of Refractoriness of RD units
Treatment of DHF III & IV
Appropriate if-CCI is 10X10 9 /ml in 1 hr post transfusion sample and/or
-CCI is 7.5X10 9/ml in 18-24 hr post transfusion sample.
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Treatment of Dengue Fever
Raw papaya leaves, 2 pcs just cleaned and
pound and squeeze with filter cloth. You will onlyget one tablespoon per leaf. So two tablespoon per
serving once a day.Do not boil or cook or rinse with hot water, it will
loose its strength. Only the leafy part and no stemor sap.It is very bitter and you have to swallow it like
Won Low Kat. But it works.
Papaya Juice vs. Dengue ?
Source: from Indonesia March 2005
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Indications for Hospital Discharge
Absence of fever for 24 hours (without
anti-fever therapy) and return of appetite
Visible improvement in clinical picture Stable hematocrit
3 days after recovery from shock
Platelets 50,000/mm3
No respiratory distress from pleural
effusions/ascites
Pan American Health Organization: Dengue and Dengue Hemorrhagic Fever: Guidelines for Prevention and Control.
PAHO: Washington, D.C., 1994: 69.
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Common Misconceptions about
Dengue Hemorrhagic Fever
Dengue + bleeding = DHF Need 4 WHO criteria, capillary permeability
DHF kills only by hemorrhage Patient dies as a result of shock
Poor management turns dengue into DHF Poorly managed dengue can be more severe, but
DHF is a distinct condition, which even well-treatedpatients may develop
Positive tourniquet test = DHF Tourniquet test is a nonspecific indicator of capillary
fragility
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More Common Misconceptions
about Dengue Hemorrhagic Fever
DHF is a pediatric disease All age groups are involved in the Americas
DHF is a problem of low income families All socioeconomic groups are affected
Tourists will certainly get DHF with a
second infection Tourists are at low risk to acquire DHF
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Dengue Vaccine?
No licensed vaccine at present
Effective vaccine must be tetravalent
Field testing of an attenuated tetravalent
vaccine currently underway
Effective, safe and affordable vaccine will not
be available in the immediate future
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Prevention
The main tactic used in fighting Dengue is
eradicating the mosquito.Public spraying for mosquitoes is the most
important aspect of this approach.Personal prevention involces the use of mosquito
nets, repellents, cover exposed skin, use of DEET-
impregnated bednets, and avoiding endemic areas.
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CONTACT
alauddinsarwar@gmail.com
doctoralauddin@yahoo.co.in
mailto:alauddinsarwar@gmail.commailto:doctoralauddin@yahoo.co.inmailto:doctoralauddin@yahoo.co.inmailto:alauddinsarwar@gmail.com