Dengue epidemiology& case management


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dengue fever, epidemiology, aedes, mosquito, vector competence, vector capacity, vector, treatment, case management, diagnosis, DHF, DSS, DF, DENV, arbovirus

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  • Hyperendemicity: All 4 strains present in the communityCat A: If PSM guys teach “dengue” in your country then you are in Cat A,Dengue is leading cause of hospitalizations& deaths among childrenHyperendemicitySpreading to Rural AreasCat B: 2004Uncertain EndemicityCat C: Non endemic
  • In Endemic Areas, +ive tourniquet test and leukopenia (WBC ≤5000 cells/mm3) has a positive predictive value of 70%–80%.GB edema precedes Plasma leak.Amount of Pl effusion is directly correlated with Disease severityA significantly decreased serum albumin >0.5 gm/dl from baseline or <3.5 gm% is indirect evidence of plasma leakage
  • Dengue epidemiology& case management

    2. 2. The Epidemiological Triad Agent- Dengue Virus Environment & Vector Host- Human, Monkey
    3. 3. The Agent • Arbovirus (ss RNA Virus) • Genus Flavivirus • Family Flaviviraede • 4 serotypes- DENV 1, DENV 2, DENV 3& DENV 4 • Micro evolution: Many virulent genotypes are evolving to replace non virulent genotypes • Antigenic similarity but infection with one serotype does not provide lifelong immunity for other serotypes (Cross Immunity lasts only a few months),
    4. 4. DENV Has… • A lipoprotein envelope • 3 structural protein genes encoding: {CME} • Nucleocapsid or core protein (C), • Membrane- associated protein (M), • Envelope protein (E), and • 7 non-structural protein (NS) genes including, envelope glycoprotein, NS 1 • NS 1 is of diagnostic and pathological importance.
    5. 5. The Host • Infective Stage: 1 day before onset of fever to day 5 • Intrinsic Incubation Period: 4- 6 days • High Risk Patients: • Extremes of Age • Pregnancy • Any condition prone to heavy blood loss: Peptic ulcer disease; menstruation; haemolytic anaemia; G- 6PD deficiencies; thalassemia; patients on steroids, NSAIDS • Any chronic condition: DM, HTn, Asthma, Cirrhosis, IHD, CRF
    6. 6. Remember… “Prior immune sensitization worsens the disease scenario” 1st Infectio n with DENV- 1 Asymptomatic/ Non specific manifestations/ DF 2nd Infection with DENV- 2, 3 or 4 DHF/ DSS/ Severe Disease Secondary Infection with DENV 2 or multiple infections with different serotypes causes Severe Disease (DHF/ DSS) DENV 1/ DENV 2 Sequence is the worst
    7. 7. Non neutralizing Ab(s) Mononuclear cells Cytokines, vasoacti ve mediators procoagulants DIC 2nd
    8. 8. The Amplifiers • Man • Monkey
    9. 9. The Transmission Cycles • Enzootic • Monkey- Aedes- Monkey- Aedes • Epizootic • From Epidemic Cycle, DENV Crosses Over To Non Humans Via Bridge Vectors, esply Macaca sinica In Sri Lanka • Epidemic • Human- Aedes- Human- Aedes
    10. 10. Huma ns Mosquito HumansExtrinsic I P Mosquito Intrinsic I P= 4- 6 days (Range: 3- 14 days) Extrinsic I P= 8- 10 days Intrinsic I P
    11. 11. The Environment • Tropical& Sub- tropical • Urban, Peri urban; Rural • Rapid Unplanned uncontrolled urbanization, • Transportation: human movement and congregation • Consumerism- Non biodegradable plastic, mismanaged solid waste disposal • Poor water storage and management • Seasonal Pattern: Post Monsoon (But Perennial in Gujarat& South
    13. 13. An Epidemic, Endemic& Hyper Endemic South- East Asia is divided into 3 Categories: • Cat A: India, Bangladesh, Myanmar, Sri Lanka, Indonesia, Thailand, Maldives • Cat B: Bhutan, Nepal • Cat C: DPR Korea
    14. 14. Global Warming • 2 degree rise in temp- • Shortens extrinsic IP- more infected mosquitos to further spread DENV • Enhances the life cycle of Aedes • Shortens the size of the mosquito • Rise in temp- mosquito bites more frequently due to “dehydration”- further spreads DENV
    15. 15. The Vector • Ae albopictus Eggs Survive Sub Freezing Temp • Ae aegypti- Cosmo tropical species between latitudes 45°N and 35°S • Vector Competency • Vector Capacity • Transovarial Spread • Endophagic, Endophilic • 16- 35 °C, 60- 80% Relative Humidity
    16. 16. Vector Competency • High susceptibility to infecting virus • Ability to replicate the virus • Ability to transmit the virus to another host • Both Ae. aegypti and Ae. albopictus carry high vectorial competency for dengue viruses.
    17. 17. Vectorial Capacity: Depends on the Environmental and Biological characteristics of the Vector Ae. aegypti • Highly domesticated • Strongly anthropophilic • Nervous feeder (i.e. it bites more than one host to complete one blood meal) and • Discordant species (i.e. it needs more than one feed for the completion of the gonotropic cycle) • These habits epidemiologically result in the generation of multiple cases and the clustering of dengue cases in cities. Ae. albopictus • Feral • Feeds on both humans and animals • Aggressive feeder (i.e. it can complete its blood meal in one go on one person) • Concordant species (does not require a second blood meal for the completion of the gonotropic cycle) • So, Ae. albopictus has poor vectorial capacity.
    18. 18. Distribution of Aedes aegypti
    19. 19. Distribution of Aedes albopictus
    20. 20. DSS DHF DF Asymptomatic The Spectrum 2- 5% cases
    21. 21. DF/ DHF Grade Signs and Symptoms Laboratory DF Fever with two of the following: • Headache. • Retro-orbital pain. • Myalgia. • Arthtralgia/bone pain. • Rash. • Haemorrhagic manifestations. • No evidence of plasma leakage. • Leucopenia (wbc ≤5000 cells/mm3). • Thrombocytopenia (Platelet count <150 000 cells/mm3). • Rising haematocrit (5% – 10% ). • No evidence of plasma loss. DHF I Fever and haemorrhagic manifestation (positive tourniquet test) and evidence of plasma leakage Thrombocytopenia <100 000 cells/ mm3; HCT rise ≥20% DHF II As in Grade I plus spontaneous bleeding. Thrombocytopenia <100 000 cells/mm3; HCT rise ≥20%. DHF# III As in Grade I or II plus circulatory failure (weak pulse, narrow pulse pressure (≤20 mmHg), hypotension, restlessness). Thrombocytopenia <100 000 cells/mm3; HCT rise ≥20%. DHF# IV As in Grade III plus profound shock with undetectable BP and pulse Thrombocytopenia < 100 000 cells/mm3; HCT rise ≥20%.
    22. 22. Undifferentiated Fever • Primary dengue infection • May develop a simple fever indistinguishable from other viral infections. • Maculopapular or rubelliform rashes on face, neck and chest may accompany the fever or may appear during defervescence (Day 3-5)
    23. 23. Dengue Fever • Older children, adolescents and adults • Acute (Sudden, sharp) rise in temperature (39°C- 40°C) for 5- 7 days • Biphasic fever with severe headache, myalgia, arthralgia and bone pains (break-bone fever), particularly in adults • Rashes, flushed face, retro-orbital pain on eye movement or eye pressure, photophobia • Altered taste sensation, Anorexia, Sore throat, Dragging pain in inguinal region • Leukopenia and thrombocytopenia- mild • Occasionally, Haemorrhage such as gastrointestinal bleeding, hyper menorrhea, massive epistaxis (DF with Hmrgh)
    24. 24. Sub conjunctival Haemorrhage Petechial Haemorrhages Pale islands in the red sea Maculo- papular Rash
    25. 25. Dengue Haemorrhagic Fever (DHF) • Children less than 15 years of age in hyper endemic areas, in association with repeated dengue infections (secondary dengue infection). Incidence of DHF in adults is increasing • Rarely DHF may occur in Primary infections with DENV-1 and DENV-3 as well as in infants. • Signs and symptoms similar to DF in the early febrile phase. • Pale islands in red sea • Positive tourniquet test (TT), petechiae on extremities, easy bruising and/or GI haemorrhage
    26. 26. Warning Signs That May Occur At Or After Defervescence (The Presence Of One Or More Of These Signs Indicates The Need For Immediate Medical Evaluation): • Abdominal pain or tenderness • Persistent vomiting • Clinical fluid accumulation (i.e., Pleural effusion or ascites) • Mucosal bleeding • Lethargy or irritability, restlessness • Oliguria • Postural Hypotension • Liver enlargement (≥2cm) • Increases in haematocrit concurrent with rapid decrease in platelet count
    27. 27. Dengue Shock Syndrome (DSS) • Hypovolemic shock due to plasma leakage • Pleural effusion, Ascites (plasma leakage to pleural& peritoneal cavities) • Hypothermia- Cold clammy skin • I C Bleeding • Fulminant hepatic failure
    28. 28. DSS • Is of short duration (12- 24 hrs), But can be fatal • Patient is conscious till stage 4 of the shock (BP not recordable) • Usually SBP falls late, but pulse pressure (SBP-DBP) deteriorates much earlier ≤ 20 mmHg • If prolonged, Shock causes metabolic acidosis and multi organ failure
    29. 29. Expanded Dengue Syndrome • Severe organ involvement such as liver, kidneys, brain or heart +/- evidence of plasma leakage • May be associated with co- infections, comorbidities or complications of prolonged shock
    30. 30. Depression, Bradycardia Asthenia Circumoral cyanosis, weak thread pulse
    31. 31. The Management Prevention Vector control Environmental modifications Host modification- Vaccination Treatment Early Diagnosis Symptomatic Management
    32. 32. Clinical Diagnosis • Sub conjunctival haemorrhage, easy bruising, Positive Tourniquet Test, Pulse Pressure≤ 20 mmHg Lab Diagnosis • PCV - the earliest feature of DHF • Platelet • TLC • Serum Albumin • LFT- AST • Chest X ray (Lateral Decubitus): Right Pleural Effusion • USG Abdomen: GB wall edema, Liver enlargement, Ascites; Splenomegaly in Infants only Serology • IgG 4- fold rise in titre (by haemagglutination inhibition test) • IgM against NS- 1 (ELISA) RT PCR or Viral Isolation or Viral Ag Detection by IHC, IF or ELISA Early Diagnosis
    33. 33. Case Management • During an epidemic, every hospital should have Dengue Triage Facility. • High risk Cases should be screened in the special Dengue OPD, on the basis of history of any bleeding episodes, presence of warning signs, spread of dengue infection in the neighbourhood along with fever. • All these cases should be lab investigated • On confirmation they need to be observed and managed in a Special Dengue Wards
    34. 34. Management of Dengue Cases • Fluid Intake- Oral or IV. • ORS and fruit juices Better than water • Antipyretics- PCM. • AVOID ASPIRIN (May cause Rye’s Syndrome); other NSAIDS, e.g. IBUPROFEN (these may cause gastric bleeding) • Monitor for warning signs • Daily check PCV from Day 3 of fever till Day 2 after fever
    35. 35. Indications of Red Cell Transfusion 1. Loss of blood (Overt blood loss)- 10% or more of total blood volume- give whole blood 2. Refractory shock despite adequate fluid administration and declining PCV 3. Replacement Volume should be 10ml/ kg 4. Coagulogram should be done
    36. 36. Indication of Platelet Transfusion • There is no need to give prophylactic platelets even at <20, 000/ cumm • Prophylactic platelets should be given at levels <10, 000/ cumm • Prolonged shock with coagulopathy and abnormal coagulogram • If systemic massive bleeding, platelet transfusion may be
    37. 37. Criteria for Discharge of the Patient • Absence of fever for >24hr (without the use of antipyretics) • Return of appetite • Good urine output • Visible clinical improvement • Minimum 2- 3 days after recovery from shock • No respiratory distress (due to pleural effusion or ascites) • Platelet count > 50, 000/ cumm