𝐼𝐹 𝑇𝐻𝐸𝑌 𝐵𝑅𝐸𝐸𝐷, 𝑌𝑂𝑈 𝑊𝐼𝐿𝐿 𝐵𝐿𝐸𝐸𝐷.

UNDER GUIDENCE OF : DR. ALPESH PATEL

A SMALL PPT ON :

Dengue - Reason behind this name….

According to one theory……….

Dengue is a Spanish word (?)

• “Dengue" means fastidious or careful, which would describe the gait of a person suffering the bone pain

of dengue fever.

DENGUE

• Also known as break bone fever.

• It is mosquito born tropical disease

cause by “DENGUE VIRUS”

• Transmitted by “AEDES AEGYPTI”

mosquito.

EPIDEMIOLOGY AND HISTORY

• IN WORLD : About 50 million cases annually worldwide

Incidence of dengue fever highest in tropical and subtropical regions

Recent increase in disease activity worldwide

• IN INDIA : First outbreak of dengue was recorded in 1812

A double peak hemorrhagic fever epidemic occurred in India for the first time in Calcutta between July 1963 & March 1964

5

Regions with dengue fever

0

10000

20000

30000

40000

50000

60000

70000

80000

20092010

20112012

20132014

2015 cont.

15535

28292

18860

50222

75808

40571

9874

96110

169242

193137

25

2009 2010 2011 2012 2013 2014 2015 cont.

CASES 15535 28292 18860 50222 75808 40571 9874

DEATHS 96 110 169 242 193 137 25

Column1

Cases & Death rate (2009-2015 cont.)

CASES DEATHS Column1

INDIA

0

1000

2000

3000

4000

5000

6000

7000

2009 2010 2011 2012 2013 2014 2015 cont.

CASES 2461 2568 1693 3067 6272 2320 657

DEATHS 2 1 9 6 15 3 0

Column1

2461 2568

1693

3067

6272

2320

657

2 1 9 6 15 3 0

Cases & Death rate (2009-2015 cont.)

CASES DEATHS Column1

GUJARAT

WE NEED TO KNOW ABOUT…

AGENT – DENGUE VIRUS

VECTOR – AEDES MOSQUITO

ENVIRONMENT

DENGUE virus

Family Flaviviridae

Genus Flavivirus

Species Dengue

DANGUE VIRUS

• It is arbovirus.• Composed of single-stranded RNA• Has 4 serotypes (DEN-1, 2, 3, 4)• In india : DEN-1,2 are most common

• Aedes aegypti is a mosquitothat can spread :

dengue fever, chikungunya, and yellow fever viruses etc.

• Tiger mosquito : The mosquito can be recognized by white markings on its legs and a marking in the form of a lyre on the thorax

AEDES AEGYPTI (MC AEDES)

• Originated in Africa.

• Primarily a daytime feeder

• Lays eggs and produces larvaepreferentially in artificial containers

AEDES AEGYPTI (MC AEDES)

Other vector is Aedes Albopictus

• The population of Ae. aegypti fluctuates with rainfall and water storage

• survives best between 160-300 C and a relative humidity of 60-80%.

• Ae. aegypti breeds almost entirely in domestic man-made water receptacles found in and around households, construction sites and factories; natural larval habitats are tree holes, leaf axils and coconut shells

ENVIRONMENT

16

ENVIRONMENT

TYRES COOLER CONSTRUCTION SITE

WATER STORAGE POTS

OVERHEAD TANK

SUBURBAN AREA

TRANSMISSION

Infected

person

Healthy person

Infected

mosquito

Incubation Period: 3 to 14 days

Most commonly 4 to 7 days

PATHOGENESISD

ENG

UE

INFE

CTI

ON PRODUCTION OF Ab

Ag-Ab INTERACTION WITH COMPLEMENT

ACTIVATION

DePOSITION IN VESSELS, VARIOUS

TISSUE AND PLATELETS

CLINICAL MENIFESTATIONS

ACTIVATION OF T-CELLPRODUCTION OF

CYTOKINES

VASCULAR PERMIABILITY

INCREASE

CLINICAL MENIFESTATION

CLINICAL FEATURES

DENGUE (TYPES)

UNDIFFERNTIATED FEVER

CLASSICAL DENGUE

DENGUE HAEMORRHAGIC FEVER

DENGUE SHOCK SYNDROME

NEWER CLASSIFICATION (WHO)

DENGUE

NON-SEVERE

WITH WARNING SIGN

WITHOUT WARNING SIGN

SEVERE

• Non-severe dengue without warning signs:

1) Live in/travel to endemic area

2) Fever and two of the following criteria:

- Nausea and Vomiting

-Rash

-Aches and pains

- Tourniquet test positive

- Leucopenia

- No warning sign

• Non-severe dengue with warning signs:

• Presence of warning signs

- Abdominal pain or tenderness

- Persistent Vomiting

- Clinical fluid accumulation

- Mucosal bleed

- Lethargy and restlessness

- Liver enlargement >2cm

- Laboratory: Increase in haematocrit concurrent with rapid decrease in platelet count.

NEWER CLASSIFICATION (WHO)

• Severe Dengue:

1) Severe plasma leakage leading to

- Shock(DSS)

- Fluid accumulation with respiratory distress

2) Severe bleeding

NEWER CLASSIFICATION (WHO)

• Fever: continuous for 3 to 5

days

• Severe headache

• Painful limbs, joint pain,

muscle pain, back pain,

pain behind eyeballs

HEAD ACHE

MUSCLE ACHE

JOINT ACHE

BACK ACHE

CLINICAL FEATURES

RETROBULBAR PAIN

• Rash appears on the 3rd to 4th

day after onset.

• Nausea, vomiting.

• Slight gum bleeding and nasal bleeding.

• Extreme fatigue and depression may follow recovery.

HEAD ACHE

MUSCLE ACHE

JOINT ACHE

BACK ACHE

CLINICAL FEATURES

RASH

CLINICAL FEATURES

MANAGEMENT OF DENGUE

DIAGNOSIS

METHODS

Isolation of Dengue virus from serum, plasma, leucocytes or autopsy samples.

Demonstration of a fourfold or greater rise in reciprocal IgG antibody titers to one or more dengue virus antigen in paired sera

samples.

Demonstration of dengue virus antigen in autopsy tissue by immunohistochemistry or immunofluorescence or in serum samples

by EIA

Detection of viral genomic sequences in autopsy tissue, serum or CSF sample by PCR (Polymerase Chain Reaction)

MAC-ELISA for the detection of IgM antibodies to dengue

• MAC-ELISA – Avidin Biotin Complex IgM Antibody Capture ELISA

• Test is used for rapid detection of dengue.

• Available as a kit provided by NIV, pune to all state laboratories.

Serum NS-1 antigen : highly specific

DIAGNOSIS

Dengue Haemorrhagic Fever :

a) A probable or confirmed case of dengue

plus

b) Haemorrhagic tendencies evidenced by one or more of the following

1. Positive tourniquet test

2. Petechiae, ecchymoses or purpura

3. Bleeding from mucosa, gastrointestinal tract, injection sites or other sites

4. Haematemesis or malena

Plus

c). Thrombocytopenia (<100,000 cells per cumm)

plus

d). Evidence of plasma leakage due to increased vascular permeability, manifested by one or more of the following :

1. A rise in average haematocrit for age and sex > 20%

2. A more than 20% drop in haematocritfollowing volume replacement treatment compared to baseline

3. Signs of plasma leakage (pleural effusion, ascitis, hypoproteinaemia)

DIAGNOSIS (criteria)

Dengue Shock Syndrome :a) All the above criteria for DHF.

plus

b) Evidence of circulatory failure manifested by rapid and weak pulse and narrow pulse pressure (<20 mm Hg) or hypotension for age, cold and clammy skin and restlessness.

DIAGNOSIS (criteria)

TREATMENT• Fluid therapy

• Treatment is according to clinical stage of disease

OBTAIN BASELINE HEMATOCRIT

GIVE ONLY ISOTONIC FLUID

REASSESS AND REPEATE

HEMATOCRIT

I.V. FLUID USUSALLY

REQUIRED FOR 24-48 HOURS

PREVENTION

PREVENTION OF DENGUE

LARVAL CONTROL

MOSQUITO CONTROL

PREVENT BITTING

39

Avoid going out in the hours when Aedes feed or wear

light-coloured, long-sleeved clothing and

trousers.

Prevention of Mosquito Bites

40

•Apply DEET-containingmosquito-repellents over exposed parts of the body and clothes every 4 to 6 hours.

•For DEET products used by children, its concentration should be less than 10%.

Prevention of Mosquito Bites

DEET - diethyltoluamide

Your place of accommodation should have air-conditioners or mosquito nets. Otherwise, hang mosquito screens around your

bed, use insecticides or coil incenses to repel mosquitoes.

Prevention of Mosquito Bites

Install mosquito nets to doors and windows so that mosquitoes can’t get in.

Prevention of Mosquito Bites

43

The most effective way to eliminate mosquitoes is to

keep the environment clean and to remove

stagnant water so that mosquitoes can’t breed.

Elimination of Mosquitoes

44

Cover water containers tightly so that mosquitoes

can’t get in to lay eggs.

Elimination of Mosquitoes

45

• Dispose of domestic wastes properly to

prevent the accumulation of stagnant water.

• Dispose of empty bottles,cans and lunchboxes

properly, such as into a covered bin.

Elimination of Mosquitoes

46

•Change water for vases and aquatic plants at

least once a week, leaving no water under

the pots or in the bottom saucers.

•Scrub the container surfaces thoroughly to prevent mosquito eggs

sticking on them.

Elimination of Mosquitoes

47

Remove or puncture any dumped tyres to prevent the accumulation of stagnant water.

Elimination of Mosquitoes

48

Ditches should be free from blockage.

Elimination of Mosquitoes

49

Fill up uneven ground surfaces to prevent the accumulation of stagnant water.

Elimination of Mosquitoes

50

Remove stagnant water immediately if mosquitoes are found to be breeding.

Use environmentally friendly insecticides such as lavicidal

oil if necessary.

Elimination of Mosquitoes

51

In cultivation ponds, water tanks or large

containers, biological controls such as keeping

fishes to eat mosquito larvae would be a good

option.

Elimination of Mosquitoes

Gambusia affinis

• Insecticide-treated materials

• Insecticide-treated window curtains and sheet covers can also reduce dengue vector densities and transmission.

• In studies in Mexico and Venezuela, ITMs (particularly curtains) were well accepted by the communities as their efficacy was reinforced by the reduction of other biting insects as well as cockroaches, houseflies and other pests. Window curtains, screens, and doorway or wardrobe curtains, etc. all appear to have promising results in different settings.

Prevention research

• Lethal ovitraps

• Ovitraps or oviposition traps collect the eggs laid by the mosquitoes which develop into larva, pupa and adult mosquitoes. Ovitraps are often used for surveillance of Aedes vectors can be modified to render it lethal to immature or adult populations of Ae. aegypti.

• Lethal ovitraps (which incorporate an insecticide on the oviposition substrate), autocidal ovitraps (which allow oviposition but prevent adult emergence), and sticky ovitraps (which trap the mosquito when it lands) have been used on a limited basis. Studies have shown that population densities can be reduced with sufficiently large numbers of frequently-serviced traps.

• Life expectancy of the vector may also potentially be shortened, thus reducing the number of vectors that become infective.

Prevention research

• Genetically-modified mosquitoes

• Population suppression: reduce mosquito population such that it would not be able to sustain pathogen transmission. This includes sterility, reduced adult longevity, or decrease larva/pupa survival.

• Population replacement: Reduce inherent ability to transmit the pathogen. Mating will alter the genetic pool of the wild population.

Prevention research

• No vaccine is currently approved for the prevention of dengue infection.

• Because immunity to a single dengue strain is the major risk factor for dengue hemorrhagic fever and dengue shock syndrome, a vaccine must provide high levels of immunity to all 4 dengue strains to be clinically useful.

• Immunogenic, safe tetravalent vaccines have been developed and are undergoing clinical trials.

Vaccine

• Developed a Long Term Action Plan for Prevention and Control of Dengue in the country and sent to the State(s) on January 2007 for implementation.

• National guidelines for clinical management of Dengue Fever, Dengue HaemmorragicFever, Dengue Shock Syndrome has been sent to the State(s) April 2007 for circulation in all hospitals.

• Established 110 Sentinel Surveillance Hospitals with laboratory support for augmentation of diagnostic facility for Dengue in endemic State(s) in 2007 which has been increased to 170 in 2009. All these are linked with 13 Apex Referral Laboratories with advanced diagnostic facilities for back up support.

• To maintain the uniformity and standard of diagnostics in these laboratories IgM MAC ELISA test kits are provided through National Institute of Virology (NIV), Pune. Cost is borne by GOI.

• Diagnosis of Dengue and Chikungunya is provided to the community at free of cost.

Government of India has taken various steps for prevention and control of Dengue and Chikungunya in the country.

• Since 2007, every year in the 1st quarter Directorate of NVBDCP prepare the tentative allocation of test kits based on the previous epidemiological situation of Dengue and Chikungunya in the states and communicate to both NIV, Pune and States.

• Kits are supplied by NIV, Pune on receipt of requirement from the respective states.

• Buffer stocks are also maintained to meet any exigency.

• State wise allocation of Dengue and Chikungunya during 2010 was communicated to the states on 15th February 2010.

• Ensuring the diagnostic facility and availability of kits is the responsibility of the respective State Programme Officers, NVBDCP.

Government of India has taken various steps for prevention and control of Dengue and Chikungunya in the country.

1) National Institute of Virology, Pune.

2) National Center for Disease Control (former NICD), Delhi.

3) National Institute of Mental Health & Neuro-Sciences, Bangalore.

4) Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow.

5) Post- Graduate Institute of Medical Sciences, Chandigarh.

6) All India Institute of Medical Sciences, Delhi.

7) ICMR Virus Unit, National Institute of Cholera & Enteric Diseases, Kolkata.

8) Regional Medical Research Centre (ICMR), Dibrugarh, Assam.

9) King’s Institute of Preventive Medicine, Chennai.

10) Institute of Preventive Medicine, Hyderabad.

11) B J Medical College, Ahmedabad.

12) State Public Health Laboratory, Thiruvananthapuram, Kerala.

13) Defence Research Development and Establishment, Gwalior.

14) Regional Medical Research Centre for Tribals, (ICMR) Jabalpur, Madhya Pradesh.

15) Regional Medical Research Centre, (ICMR), Bhubaneswar, Odisha

A POWERPOINT PRESENTATION BY :Dr. MAYUR PATELDr. DHRUV PATELDr. KRUNAL PATEL

Dr. DHARMIN PATELDr. DARSHAK PATELDr. MAITRIK PATEL

Dr. DISHA PATELDr. ISHANI PATEL