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Dengue fever pravin yerpude
1. Dr Pravin Yerpude
Professor and Head
Dept of Community Medicine
Chhindwara Institute of Medical
Sciences,Chhindwara(M.P.)
2. Dengue is caused by
a dengue virus
which are
arboviruses which is
carried by a
mosquito.
The mosquito is
scientifically called
Aedes aegypti carry
the virus.
3. Dengue infection have the potential of rapid
spread leading to an acute public health
problem.
It is a notifiable disease
4. Of all the arthropod –borne viral
diseases,dengue fever is the most common
Dengue fever is one of the most important
emerging disease of the tropical and sub-
tropical regions affecting urban and
periurban areas
5. Areas infested with Aedes aegypti
Areas with Aedes aegypti and recent epidemic dengue
6. World
Each year 50 million infections occur
worldwide with 5,00,000 cases of DHF and at
least 12,000 deaths,mainly among children
Increase of dengue and DHF is due to
uncontrolled population growth and
urbanization without appropriate water
management ,to the global spread of dengue
via travel and trade and to the erosion of
vector control programme
7. Currently DFDHF is endemic in-
India, Bangladesh,Indonesia, Madives,
Myanmar, Srilanka, Thailand
Category A: Indonesia, Myanmar, Thailand
-Major public health problem, Multiple
serotypes
-Increased hospitalization & child hood
mortality, -Rural environment affected
Category B: India, Bangladesh, Madives, Srilanka
-DHF emerging,
- Expanding geographically within the country
- Cyclic epidemic---- more frequent multiple
serotype
Category C: Bhutan, Nepal
-No reported cases with uncertain endemicity
Category D: DPR Korea -Non endemic
7
8. India
Dengue/DHF widely prevalent in India and all
4 serotypes are found
It is reported from 18 states/UTS with about
450 million population at risk
2006-12317 cases and 184 deaths
2007-553 cases and 69 deaths
2008-1256 cases and 80 deaths
2009-1553 cases and 96 deaths
2010-2829 cases and 110 deaths
11. Flavi RNA virus
Types- 4 types
Den-1, Den- 2, Den- 3, Den- 4
( All are isolated in India)
Type 2 is the Commonest
Each type has different antigenic strain.
There is no cross immunity
25. Breeding- lays eggs at the bottom of clean
open domestic, Peridomestic containers
Larvae stick to the inside walls; but have to
come up to surface to breathe.
26. Not a disease of the poorest but of those
who use water tanks, flower pots, coolers,
AC.
Children most vulnerable to get DHF as low
immunity and interaction with maternal
antibody in infants.
28. Host
-School going Children
-Office goers
-Urban population
-Over crowding
-Poor sanitation
-All S-E classs
Environment
16- 40 d. C
Humidity
Peri monsoon
Agent
-Dengue virus
- Female Aedes mosquito
29. Increased distribution & densities of vector
infestation,
Unreliable water supply systems
Increasing non-biodegradable containers and
poor solid waste disposal
30. Increased air travel
Increasing population density in urban areas-
unplanned & uncontrlled urbanization
Deterioration of public health infrastructure &
surveillance system
31. 1. Virus transmitted
to human in mosquito
saliva
2. Virus replicates
in target organs
3. Virus infects white
blood cells and
lymphatic tissues
4. Virus released and
circulates in blood
3
4
1
2
32. 5. Second mosquito
ingests virus with
blood
6. Virus replicates
in mosquito midgut
and other organs,
infects salivary
glands
7. Virus replicates
in salivary glands
6
7
5
41. 87% of patients infected were either
asymptomatic or only mildly symptomatic
42. High grade fever, Anorexia, Backache, Rash,
bone breaking severe Bodyache, Retrobulbar
pain,Hepatomegaly, Weakness, Depression.
Dehydration, Abd colic, Constipation, severe
Conjunctivitis, Conjctival H’ge.
Single phase or 2 peak saddle back (Biphasic
curve) fever- 39-400C, last for 7 days
43. Pt. is viremic at the time of fever--- Infective
to mosquito
44. Rash may be diffuse,flushing,mottling or
fleeting pin-point eruptions on the face,neck
and chest during first half of febrile period
and a maculopapular rash on 3rd or 4th day
It starts on the chest and trunk and may
spread to the extremities and rarely to the
face
It may be accompanied by itching
45.
46.
47.
48.
49.
50. 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)
or
20 or more petechiae per 3 cms. diameter
51. Skin eruption- 80% of cases Reddish Measly
Face, Gets Redder at 5-6 Days.
Nose Bleeds occ, Mild Thrombocytopenia &
Leukopenia.
Tourniquet test may be +ve, BP cuff between
S/D pr. for 5 min.
52. Suspected C/O of DF
Acute onset
High grade fever <7 days duration
Severe headache, backache
Joint , post orbital & muscle pain
With or without rash
53.
54. Probable C/O of DF
Suspected case
High vector velocity
Presence of confirmed cases in area
Bd. –ve for Mp, No response to anti-
malarials
55. Isolation of virus from the blood in early
phase
IgM abs. in single serum samples or
4 fold rise of Abs. in paired serum samples.
57. Isolation of Dengue virus from serum, plasma,
leucocytes or autopsy samples.
Demonstration of a fourfold or greater rise in
reciprocal IgG antibody titres to one or more
dengue virus antigen in paired sera samples.
Demonstaration 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)
58. Most cases of early Classical DF can be
treated at OPD & DHF at small hospitals or
pvt H.
Only Paracetamol as anti-pyretic.
No Steroids, aspirin, NSAID, antiplatelet AB eg
cephalosporins, vanco.
Lots of oral fluids in early illness eg ORS,
chhas, tea etc.
Observe twice daily if pt. not well.
DSS in ICU.
58
59. Diagnosis of types of D is purely clinical.
Serrology is no guide to management.
Mx is the fluid- FLUID & FLUID.
It is NOT the bleeding or H’ge mx.
If enough fluids are given early; Platelets
are NOT required even for
Thrombocytopenia.
Blood will increase the viscosity in
Hemoconcentration; may ►thrombosis.
59
61. Continue monitoring after defervescence
If any doubt, provide intravenous fluids,
guided by serial hematocrits, blood pressure,
and urine output
The volume of fluid needed is similar to the
treatment of diarrhea with mild to moderate
isotonic dehydration (5%-8% deficit)
61
62.
63. It is not a complication of dengue
fever but has separate etio-
pathognesis
66. Neutralizing antibody to Dengue 1 virus
Dengue 1 virus
Homologous Antibodies Form
Non-infectious Complexes
Non-neutralizing antibody
Complex formed by neutralizing antibody and virus
68. Non-neutralizing antibody to Dengue 1
virus
Dengue 2 virus
Heterologous Antibodies Form
Infectious Complexes
Complex formed by non-neutralizing
antibody and virus
69. Bitten dengue virus
Specific Antibodies to
dengue virus
Bitten dengue virus
Other sub-type
Immune reaction
Ag-Ab complex
71. Antibody-Ag complex-can enter a greater
proportion of cells of the mononuclear
lineage, thus increasing virus production
Infected monocytes release vasoactive
mediators, resulting in increased vascular
permeability and hemorrhagic manifestations
that characterize DHF and DSS
76. Plasma Leakage as Cap Damage - at 5-7
days. Internal Dehydration ► Giddiness, Low
Pulse Volume, Narrow Pulse pr, ↓ Urine o/p.
This lasts for few hrs in Majority.
Acute Hepatomegaly.
Hemoconcentration
Fine Morbiliform, Annular Rash over Limbs,
78. H/o acute fever
Hemorrhagic manifestations
Low platelet count (100,000/mm3 or less)
Objective evidence of “leaky capillaries:”
◦ elevated hematocrit (>20% over baseline)
◦ low albumin
◦ pleural or other effusions
4 Necessary Criteria:
79. 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)
Presence of thrombocytopenia with haemoconcentration
differentiate DF from other Ds.
80. Oliguria, dark urine.
Children most vulnerable to get DHF as low
immunity and interaction with maternal Ab in
infants.
Cool limbs.
Rt hypochondrial pain.
81. Severe DHF leaks persist for 72 hrs.
fluid leaks into serous cavities
eg Peritoneum, Pleura, Pericardium.
Abdominal distension, colic, low Pulse Pr.
Congestive phase after the leaks stop.
Untreated DHF► DSS ►DIC. So recognize
early.
82. 4 criteria for DHF
Evidence of circulatory failure :
◦ 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
84. Warning Signs for DSS
When Patients Develop
DSS:
• 3 to 6 days after onset of
symptoms
Initial Warning Signals:
• 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 of
consciousness (irritability
or somnolence)
Four Criteria for DHF:
• Fever
• Hemorrhagic manifestations
• Excessive capillary
permeability
• 100,000/mm3 platelets
85. Decreased level of consciousness:
lethargy, confusion, coma
Seizures
Nuchal rigidity
Paresis
86. Blood pressure
Evidence of bleeding in skin or other sites
Hydration status
Evidence of increased vascular
permeability-- pleural effusions, ascites
Tourniquet test
87. 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
88. Virus strain– with two or more serotypes
circulating simultaneously at high levels
(hyperendemic transmission)
Pre-existing anti-dengue antibody
◦ previous infection
◦ maternal antibodies in infants
Host genetics
Age- Children
Higher risk in secondary infections
89. Fever surveillance
Diagnosis based on standared case definitions.
Reporting of DF|DHF to state health authority
5% samples of clinically diagnosed cases during
an epidemic should be tested for confirmatory
lab. Diagnosis.
Instruct peripheral health staff to report
increasing no. of cases clustering of acute
febrile illness compatible with case definition.
90. Primary
Secondary- Early diagnosis & treatment
Tertiary- Mx of shock
Surveillance
91. AIM:-
Early detection of an outbreak
To initiate timely preventive & control
measures
Should be carried out regularly
92. 1) House Index- Percentage of houses
positive for larvae of aedes.
2) Breteau Index- No of containers positive
`for aedes aegypti per 100
houses
3) Container Index- Percentage of
containers positive for aedes breeding
93. Index
High risk of
transmission
Low risk of
transmission
BRETEAU >50 <5
HOUSE >10% < 1%
Intermediate risk of transmission- Between These
value
94.
95.
96. Pre existing heterotypic dengue
antibody is a risk factor for DHF
Tetravalent dengue vaccine –
Phase 2 trial completed successfully in
Thailand
Other approaches-
Infectious cDNA cloned derived vaccine,
inactivated whole virion vaccine
98. 98
Extensive use of fish Scraps/tyre removal
Deweeding of ponds/rivers
Health education
99. 99
Integrated vector control measures
Biological
(larvicidal fish)
Health
awareness
Chemical
(Fogging)
Environmental
(Waste management)
100. 1. Environmental Management
2. Biological Control
3. Chemical Control
4. Improving health standard
Larval control methods are more effective
than adult control measures to achieve
long term sustainable control
10
0
2
101. AIM-
To prevent or minimize vector breeding
Reduce human vector contact
10
1
103. Mosquito proofing of tanks
Covering of storage containers
Cleaning the water storage container of air
cooler every week.
Solid wastes (tins, buckets, automobile
tyres,coconut shells should be buried or
properly disposed to prevent water
collection.)
Personal protective measures e.g. proper
clothing(long sleeves & trousers), use of
mosquito repellants-mats, coils, aerosols &
mosquito nets.
10
3
104. A. Larvivorus Fish: Gambusia affinis,
B. Bacteria: Bacillus thuringiensis, Bacillus
sphaericus- available as powder or slow
release formulation (Tablets, pellets,
briquettes)
C. Cyclopoids (Mesocyclops) are useful for
large containers e.g.-wells, tanks, tyres
D. Larval traps
10
4
105. Adult form of mosquito-
Fenthion,
malathion &
fenitrothion
Larvicide-
Temophos
Methods of application-
Space spray,
larvicide application
10
5
106. 10
6
use of mosquito repellants-mats,
coils, aerosols & mosquito nets.
Mosquito barriers are needed until fever
subsides, to prevent Aedes mosquitoes
from biting patients and acquiring virus
Keep patient in screened sickroom or
under a mosquito net
107. First must educate the
public in the basics of
dengue, such as:
◦ Where the mosquito lays her
eggs
◦ The link between larvae and
adult mosquitoes
◦ General information about
dengue transmission,
symptoms and treatment
10
7
108. Remove water from coolers(weekly), small
containers
Insecticide spray in the house
Wear mosquito bite protecting clothes
Use mosquito Netrepellentsmats
Use coils mats even during day
10
8
109.
110. Diagnosis is purely clinical.
Serology is no guide to management.
Only Paracetamol as anti-pyretic
Mx is the fluid- FLUID & FLUID.
Blood transfusion will increase the viscosity
in Hemoconcentration; may ►thrombosis.
111. Fluids
Rest
Antipyretics (avoid aspirin and non-
steroidal anti-inflammatory drugs)
Monitor blood pressure, hematocrit,
platelet count, level of consciousness
Blood transfusion is contra-indicated
112. Host
-School going Children
-Office goers
-Urban population
-Over crowding
-Poor sanitation
-All S-E classs
Environment
16- 40 d. C
Humidity
Peri monsoon
Agent
-Dengue virus
- Female Aedes mosquito
