This document provides guidelines for the clinical management of dengue fever, dengue hemorrhagic fever, and dengue shock syndrome. It begins with an introduction to dengue epidemiology in India, noting that all four dengue virus serotypes are present and outbreaks regularly occur between July and November. Chapter 2 discusses the epidemiological factors involved, including the dengue virus agent, the Aedes aegypti mosquito vector, and environmental factors that determine endemicity. Proper management of dengue cases is important given the lack of treatment or vaccine.
A mosquito-borne viral disease occurring in tropical and subtropical areas.
Spreads by animals or insects
Requires a medical diagnosis
Lab tests or imaging often required
Short-term: resolves within days to weeks
Those who become infected with the virus a second time are at a significantly greater risk of developing severe disease.
Symptoms include high fever, headache, rash and muscle and joint pain. In severe cases there is serious bleeding and shock, which can be life threatening.
Treatment includes fluids and pain relievers. Severe cases require hospital care.
This document provides information about Dengue fever, including:
1) It describes Dengue fever as the most rapidly spreading mosquito-borne viral disease in the world, caused by the Dengue virus which has 4 serotypes.
2) Symptoms and classifications of Dengue fever are discussed according to the WHO, including dengue fever without hemorrhage, dengue hemorrhagic fever, and dengue shock syndrome.
3) Diagnosis, treatment, prevention and control of Dengue fever and its vectors are summarized, highlighting supportive care, intravenous fluids, monitoring for complications, and the importance of vector control measures.
This document provides an overview of dengue fever, including its causes, transmission, global impact, and prevention. Some key points:
- Dengue fever is a viral disease transmitted by Aedes mosquitoes, primarily Aedes aegypti. There are 4 types of dengue viruses.
- It affects over 50 million people annually worldwide and is a major public health challenge in many tropical and subtropical countries, including the Philippines.
- Transmission occurs when an infected mosquito bites a person and transmits the virus. There is typically an incubation period of 4-7 days before symptoms appear.
- Symptoms range from mild fever to severe dengue hemorrhagic fever. Treatment depends on
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
The document provides guidelines on dengue infection, discussing the clinical syndromes of dengue fever and dengue hemorrhagic fever, their diagnosis and classification, management approaches including fluid resuscitation, and treatment of complications. It describes dengue virus and the disease it causes, including its pathophysiology, clinical course, and atypical manifestations. Risk factors, vectors, and the immune response to primary and secondary infections are also covered.
This document summarizes the pathogenesis and morphological features of SARS-CoV-2 in various organs. It begins with an introduction and timeline of the virus. It then discusses the mode of transmission and laboratory handling guidelines. The pathogenesis involves the virus binding to ACE2 receptors in lungs and other organs. This causes cytokine release syndrome and acute respiratory distress syndrome seen in lungs. Effects in other organs like heart, gastrointestinal tract, and kidney are also discussed based on autopsy findings like thrombi, inflammation and necrosis. Long term sequelae could include altered lipid metabolism and cardiovascular complications.
Dengue fever is a mosquito-borne viral disease transmitted by Aedes aegypti and Aedes albopictus mosquitoes. It is caused by the dengue virus, of which there are four serotypes. The disease places a large burden globally, with most cases occurring in Asia. Clinical manifestations range from a self-limiting flu-like illness to severe dengue, which can be fatal if not properly treated. Diagnosis involves virus detection, antigen testing, or serology. There is no vaccine or specific antiviral treatment, so management focuses on fluid replacement and symptom relief. Complications include bleeding, organ impairment, and fluid imbalance.
This document provides information on Dengue fever, including:
- It is caused by Dengue viruses 1-4 and transmitted by Aedes mosquitoes. Infection provides lifetime immunity to one serotype but not others.
- Symptoms range from mild fever to severe dengue hemorrhagic fever/dengue shock syndrome. Secondary infections carry higher risk of severe disease.
- Diagnosis involves physical exam, laboratory tests like platelet count and serology. There is no vaccine or antiviral treatment, only supportive care like fluids and fever control. Prevention focuses on mosquito control and avoidance of bites.
A mosquito-borne viral disease occurring in tropical and subtropical areas.
Spreads by animals or insects
Requires a medical diagnosis
Lab tests or imaging often required
Short-term: resolves within days to weeks
Those who become infected with the virus a second time are at a significantly greater risk of developing severe disease.
Symptoms include high fever, headache, rash and muscle and joint pain. In severe cases there is serious bleeding and shock, which can be life threatening.
Treatment includes fluids and pain relievers. Severe cases require hospital care.
This document provides information about Dengue fever, including:
1) It describes Dengue fever as the most rapidly spreading mosquito-borne viral disease in the world, caused by the Dengue virus which has 4 serotypes.
2) Symptoms and classifications of Dengue fever are discussed according to the WHO, including dengue fever without hemorrhage, dengue hemorrhagic fever, and dengue shock syndrome.
3) Diagnosis, treatment, prevention and control of Dengue fever and its vectors are summarized, highlighting supportive care, intravenous fluids, monitoring for complications, and the importance of vector control measures.
This document provides an overview of dengue fever, including its causes, transmission, global impact, and prevention. Some key points:
- Dengue fever is a viral disease transmitted by Aedes mosquitoes, primarily Aedes aegypti. There are 4 types of dengue viruses.
- It affects over 50 million people annually worldwide and is a major public health challenge in many tropical and subtropical countries, including the Philippines.
- Transmission occurs when an infected mosquito bites a person and transmits the virus. There is typically an incubation period of 4-7 days before symptoms appear.
- Symptoms range from mild fever to severe dengue hemorrhagic fever. Treatment depends on
Dr. Sachin Verma is a young, diligent and dynamic physician. He did his graduation from IGMC Shimla and MD in Internal Medicine from GSVM Medical College Kanpur. Then he did his Fellowship in Intensive Care Medicine (FICM) from Apollo Hospital Delhi. He has done fellowship in infectious diseases by Infectious Disease Society of America (IDSA). He has also done FCCS course and is certified Advance Cardiac Life support (ACLS) and Basic Life Support (BLS) provider by American Heart Association. He has also done a course in Cardiology by American College of Cardiology and a course in Diabetology by International Diabetes Centre. He specializes in the management of Infections, Multiorgan Dysfunctions and Critically ill patients and has many publications and presentations in various national conferences under his belt. He is currently working in NABH Approved Ivy super-specialty Hospital Mohali as Consultant Intensivists and Physician.
The document provides guidelines on dengue infection, discussing the clinical syndromes of dengue fever and dengue hemorrhagic fever, their diagnosis and classification, management approaches including fluid resuscitation, and treatment of complications. It describes dengue virus and the disease it causes, including its pathophysiology, clinical course, and atypical manifestations. Risk factors, vectors, and the immune response to primary and secondary infections are also covered.
This document summarizes the pathogenesis and morphological features of SARS-CoV-2 in various organs. It begins with an introduction and timeline of the virus. It then discusses the mode of transmission and laboratory handling guidelines. The pathogenesis involves the virus binding to ACE2 receptors in lungs and other organs. This causes cytokine release syndrome and acute respiratory distress syndrome seen in lungs. Effects in other organs like heart, gastrointestinal tract, and kidney are also discussed based on autopsy findings like thrombi, inflammation and necrosis. Long term sequelae could include altered lipid metabolism and cardiovascular complications.
Dengue fever is a mosquito-borne viral disease transmitted by Aedes aegypti and Aedes albopictus mosquitoes. It is caused by the dengue virus, of which there are four serotypes. The disease places a large burden globally, with most cases occurring in Asia. Clinical manifestations range from a self-limiting flu-like illness to severe dengue, which can be fatal if not properly treated. Diagnosis involves virus detection, antigen testing, or serology. There is no vaccine or specific antiviral treatment, so management focuses on fluid replacement and symptom relief. Complications include bleeding, organ impairment, and fluid imbalance.
This document provides information on Dengue fever, including:
- It is caused by Dengue viruses 1-4 and transmitted by Aedes mosquitoes. Infection provides lifetime immunity to one serotype but not others.
- Symptoms range from mild fever to severe dengue hemorrhagic fever/dengue shock syndrome. Secondary infections carry higher risk of severe disease.
- Diagnosis involves physical exam, laboratory tests like platelet count and serology. There is no vaccine or antiviral treatment, only supportive care like fluids and fever control. Prevention focuses on mosquito control and avoidance of bites.
Dengue fever is a mosquito-borne viral disease that has rapidly spread worldwide. In Nepal, dengue is endemic and cases have increased in recent years. Between January and September 2022, over 28,000 suspected and confirmed dengue cases and 38 deaths were reported in Nepal, affecting all seven provinces. Dengue virus has four serotypes and infection provides long-term immunity to one serotype but not others, increasing risk for severe dengue from sequential infections. The disease is transmitted by Aedes aegypti mosquitoes and has a 2-7 day viremic phase in humans. Symptoms include an acute flu-like illness that progresses through febrile, critical and recovery phases, with potential for severe
Dengue (pronounced DENG-gay) can affect anyone but tends to be more severe in people with compromised immune systems. Because it is caused by one of four serotypes of virus, it is possible to get dengue fever multiple times. However, an attack of dengue produces immunity for a lifetime to that particular serotype to which the patient was exposed.
Dengue virus: A global human threat:
you'll get full details of dengue fever, like an introduction, etiopathogenesis, classification, orofacial features etc.
1) Dengue fever is caused by mosquitoes of the genus Aedes, mainly A. aegypti, and is prevalent during rainy seasons when mosquito populations increase. Improper waste disposal also contributes to mosquito propagation.
2) Dengue virus consists of 4 serotypes that cause disease in humans. Major epidemics have occurred across Asia and there have been recent outbreaks in Pakistan.
3) Clinical presentation ranges from mild dengue fever to severe dengue hemorrhagic fever/dengue shock syndrome. Outpatient management is usually sufficient but hospitalization may be needed for dehydration, bleeding, or low platelet count. Prevention relies on environmental controls and public education.
This document summarizes clinical manifestations of dengue fever, dengue hemorrhagic fever, and dengue shock syndrome. It describes how dengue is caused by a virus transmitted by Aedes mosquitos. It outlines the disease progression from primary to secondary infection and discusses disease definitions. Key points include four clinical syndromes, hemorrhagic manifestations, thrombocytopenia, and signs of circulatory failure in dengue shock syndrome.
Video presentation - https://www.youtube.com/watch?v=45CjKnJaIC0
Learn Community Medicine along with me : https://t.me/drvkspm
Be my friend by connecting with me through:
Instagram : https://www.instagram.com/drvenkateshkarthikeyan/
Facebook : https://www.facebook.com/drvenkateshkarthikeyan/
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Website : www.drvenkateshkarthikeyan.com
LinkedIn : https://in.linkedin.com/in/dr-venkatesh-karthikeyan-8b1234ab
Learn Community Medicine along with me : https://t.me/drvkspm
This document provides an overview of dengue fever, including:
1. It describes the dengue virus, its vector Aedes aegypti mosquito, and the disease's pathogenesis and clinical presentations ranging from mild dengue fever to severe dengue hemorrhagic fever and dengue shock syndrome.
2. It outlines the laboratory diagnosis and management approach divided into three groups - outpatient, inpatient, and emergency treatment groups.
3. It discusses treatment approaches for different clinical stages of the disease as well as vector control methods and the status of vaccine development.
Dengue fever- clinical features,investigations, diagnosis, treatment and prev...DeepakBhosle
This presentation is for medical students and general practitioner It contains detailed account of epidemiology, causation, clinical features, investigations,diagnosis, treatment of dengue fever. contains pictures. useful latest and comprehensive information about Dengue. It also contains dengue case definitions of WHO.It also lists the complications of dengue. It enumerates the warning signs for more severe form of dengue fever. Includes risk factors for dengue shock syndrome and dengue hemorrhagic fever.It includes a list if clinical markers of dengue. Also details about the habits of the dengue vector , aedes aegypti mosquito
1. Dengue is caused by four related viruses and presents as dengue fever or the more severe dengue hemorrhagic fever and dengue shock syndrome.
2. The virus infects monocytes and macrophages leading to an immune response that causes endothelial dysfunction and plasma leakage in severe cases.
3. Diagnosis involves detecting the virus, viral proteins, or a rise in virus-specific antibodies between acute and convalescent blood samples. Management differs between dengue fever which is symptomatic treatment, and more severe cases involving fluid replacement.
Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
Scrub typhus, also known as bush typhus, is a disease caused by a bacteria called ORIENTIA TSUTSUGAMUSHI.
Scrub typhus is spread to people through bites of infected chiggers (larval mites).
Most cases of scrub typhus occur in rural areas of Southeast Asia, Indonesia, China, Japan, India, and northern Australia. Anyone living in or travelling to areas where scrub typhus is found could get infected
Scrub typhus is not transmitted directly from person to person; it is only transmitted by the bites of vectors
Chiggers are abundant in locales with high relative humidity (60%–85%), low temperature (20°C–30°C), low incidence of sunlight, and a dense substrate-vegetative canopy.
Occupational risk is higher in farmers (aged 50–69 years), females.
Rickettsial infections are re-emerging globally and are difficult to diagnose due to non-specific symptoms. They are prevalent throughout India and are underreported due to lack of diagnostic testing. While symptoms like fever, rash, and headache are common, diagnosis remains challenging due to the lack of sensitive and specific tests. Untreated rickettsial infections can lead to high mortality rates, so timely diagnosis and treatment with antibiotics is important for improving outcomes.
Varicella-zoster virus is responsible for causing a primary varicella infection (chickenpox) and a secondary herpes zoster infection (shingles). Although varicella typically manifests as a mild disease in otherwise healthy children, it can also manifest as a moderate-to-severe disease, most notably in immunocompromised and adult hosts. Acyclovir is the antiviral agent of choice for the management of varicella infections. Routine vaccination with Varivax has been very effective in reducing chickenpox incidence
The document discusses dengue fever, which is caused by a virus transmitted by the Aedes mosquito. It describes the symptoms of dengue fever and characteristics of the Aedes mosquito. It explains that the female Aedes mosquito acquires the virus by biting an infected person and can then transmit the virus to others by biting them. It provides information on preventing the spread of dengue fever by eliminating places where Aedes mosquitoes can breed.
This is a PowerPoint on the Marburg virus, which is a disease similar to Ebola. I very briefly talk about what the disease is, some of the key facts about the structure and death rate, some outbreak history, prevention and treatment and the social-economical impacts that have been caused.
Orientia tsutsugamushi is a gram-negative bacterium that causes scrub typhus, a disease transmitted through the bites of infected chigger mites. The disease is endemic in parts of Asia and the Pacific, including Nepal. It causes non-specific fever and symptoms like eschar, rash, and organ dysfunction. Diagnosis involves serology, culture or PCR on samples. Doxycycline is the treatment of choice. Prevention focuses on avoiding chigger bites through proper clothing and repellents in endemic areas. Scrub typhus outbreaks have increased in Nepal in recent years.
Dengue fever is a mosquito-borne tropical disease caused by the dengue virus. It is transmitted by Aedes mosquitoes, most commonly A. aegypti. Symptoms include high fever, headache, muscle and joint pains, and a skin rash. In severe cases it can develop into life-threatening dengue hemorrhagic fever or dengue shock syndrome. There is no vaccine, so prevention focuses on controlling mosquito habitats and limiting exposure to bites. Treatment involves fluid replacement and blood transfusion in severe cases.
Video presentation - https://www.youtube.com/watch?v=45CjKnJaIC0
Learn Community Medicine along with me : https://t.me/drvkspm
Be my friend by connecting with me through:
Instagram : https://www.instagram.com/drvenkateshkarthikeyan/
Facebook : https://www.facebook.com/drvenkateshkarthikeyan/
Twitter : https://twitter.com/dr_venkatesh_k
Website : www.drvenkateshkarthikeyan.com
LinkedIn : https://in.linkedin.com/in/dr-venkatesh-karthikeyan-8b1234ab
Learn Community Medicine along with me : https://t.me/drvkspm
Dengue fever is a mosquito-borne tropical disease caused by the dengue virus. It is characterized by fever, headache, muscle and joint pains, and a skin rash. Some cases develop into life-threatening dengue hemorrhagic fever or dengue shock syndrome. It occurs widely in tropical areas and an estimated 50 million infections occur annually. The disease progresses through febrile, critical, and recovery phases. During the critical phase, increased capillary permeability can lead to life-threatening plasma leakage and shock.
Guidelines on clinical management of Dengue Fever & Dengue Hemorrhagic SyndromePk Doctors
This document provides guidelines for the clinical management of dengue fever and dengue hemorrhagic fever in Sri Lanka. It begins with an overview of dengue illness, noting that dengue fever is usually a mild disease caused by primary infection, while dengue hemorrhagic fever is a more severe disease more commonly seen in secondary infections. It describes the typical features of dengue hemorrhagic fever including high fever, bleeding tendencies, hepatomegaly, and circulatory disturbance or shock in severe cases. The clinical course is also summarized, with the illness divided into febrile, critical, and convalescent phases.
National guideline for Dengue (Latest) by DGHSJony Hossain
This document provides an introduction and summary of the 4th Edition 2018 of the National Guideline for Clinical Management of Dengue Syndrome published by the National Malaria Elimination & Aedes Transmitted Disease Control Program of Bangladesh.
The summary includes:
1) It is the 4th edition of Bangladesh's national guideline for clinically managing dengue syndrome.
2) It was published in 2018 by the National Malaria Elimination & Aedes Transmitted Disease Control Program under the Directorate General of Health Services.
3) The guideline was updated based on the latest WHO/SEARO guidelines and provides evidence-based recommendations for the clinical diagnosis and management of dengue to standardize care across Bangladesh.
Dengue fever is a mosquito-borne viral disease that has rapidly spread worldwide. In Nepal, dengue is endemic and cases have increased in recent years. Between January and September 2022, over 28,000 suspected and confirmed dengue cases and 38 deaths were reported in Nepal, affecting all seven provinces. Dengue virus has four serotypes and infection provides long-term immunity to one serotype but not others, increasing risk for severe dengue from sequential infections. The disease is transmitted by Aedes aegypti mosquitoes and has a 2-7 day viremic phase in humans. Symptoms include an acute flu-like illness that progresses through febrile, critical and recovery phases, with potential for severe
Dengue (pronounced DENG-gay) can affect anyone but tends to be more severe in people with compromised immune systems. Because it is caused by one of four serotypes of virus, it is possible to get dengue fever multiple times. However, an attack of dengue produces immunity for a lifetime to that particular serotype to which the patient was exposed.
Dengue virus: A global human threat:
you'll get full details of dengue fever, like an introduction, etiopathogenesis, classification, orofacial features etc.
1) Dengue fever is caused by mosquitoes of the genus Aedes, mainly A. aegypti, and is prevalent during rainy seasons when mosquito populations increase. Improper waste disposal also contributes to mosquito propagation.
2) Dengue virus consists of 4 serotypes that cause disease in humans. Major epidemics have occurred across Asia and there have been recent outbreaks in Pakistan.
3) Clinical presentation ranges from mild dengue fever to severe dengue hemorrhagic fever/dengue shock syndrome. Outpatient management is usually sufficient but hospitalization may be needed for dehydration, bleeding, or low platelet count. Prevention relies on environmental controls and public education.
This document summarizes clinical manifestations of dengue fever, dengue hemorrhagic fever, and dengue shock syndrome. It describes how dengue is caused by a virus transmitted by Aedes mosquitos. It outlines the disease progression from primary to secondary infection and discusses disease definitions. Key points include four clinical syndromes, hemorrhagic manifestations, thrombocytopenia, and signs of circulatory failure in dengue shock syndrome.
Video presentation - https://www.youtube.com/watch?v=45CjKnJaIC0
Learn Community Medicine along with me : https://t.me/drvkspm
Be my friend by connecting with me through:
Instagram : https://www.instagram.com/drvenkateshkarthikeyan/
Facebook : https://www.facebook.com/drvenkateshkarthikeyan/
Twitter : https://twitter.com/dr_venkatesh_k
Website : www.drvenkateshkarthikeyan.com
LinkedIn : https://in.linkedin.com/in/dr-venkatesh-karthikeyan-8b1234ab
Learn Community Medicine along with me : https://t.me/drvkspm
This document provides an overview of dengue fever, including:
1. It describes the dengue virus, its vector Aedes aegypti mosquito, and the disease's pathogenesis and clinical presentations ranging from mild dengue fever to severe dengue hemorrhagic fever and dengue shock syndrome.
2. It outlines the laboratory diagnosis and management approach divided into three groups - outpatient, inpatient, and emergency treatment groups.
3. It discusses treatment approaches for different clinical stages of the disease as well as vector control methods and the status of vaccine development.
Dengue fever- clinical features,investigations, diagnosis, treatment and prev...DeepakBhosle
This presentation is for medical students and general practitioner It contains detailed account of epidemiology, causation, clinical features, investigations,diagnosis, treatment of dengue fever. contains pictures. useful latest and comprehensive information about Dengue. It also contains dengue case definitions of WHO.It also lists the complications of dengue. It enumerates the warning signs for more severe form of dengue fever. Includes risk factors for dengue shock syndrome and dengue hemorrhagic fever.It includes a list if clinical markers of dengue. Also details about the habits of the dengue vector , aedes aegypti mosquito
1. Dengue is caused by four related viruses and presents as dengue fever or the more severe dengue hemorrhagic fever and dengue shock syndrome.
2. The virus infects monocytes and macrophages leading to an immune response that causes endothelial dysfunction and plasma leakage in severe cases.
3. Diagnosis involves detecting the virus, viral proteins, or a rise in virus-specific antibodies between acute and convalescent blood samples. Management differs between dengue fever which is symptomatic treatment, and more severe cases involving fluid replacement.
Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
Scrub typhus, also known as bush typhus, is a disease caused by a bacteria called ORIENTIA TSUTSUGAMUSHI.
Scrub typhus is spread to people through bites of infected chiggers (larval mites).
Most cases of scrub typhus occur in rural areas of Southeast Asia, Indonesia, China, Japan, India, and northern Australia. Anyone living in or travelling to areas where scrub typhus is found could get infected
Scrub typhus is not transmitted directly from person to person; it is only transmitted by the bites of vectors
Chiggers are abundant in locales with high relative humidity (60%–85%), low temperature (20°C–30°C), low incidence of sunlight, and a dense substrate-vegetative canopy.
Occupational risk is higher in farmers (aged 50–69 years), females.
Rickettsial infections are re-emerging globally and are difficult to diagnose due to non-specific symptoms. They are prevalent throughout India and are underreported due to lack of diagnostic testing. While symptoms like fever, rash, and headache are common, diagnosis remains challenging due to the lack of sensitive and specific tests. Untreated rickettsial infections can lead to high mortality rates, so timely diagnosis and treatment with antibiotics is important for improving outcomes.
Varicella-zoster virus is responsible for causing a primary varicella infection (chickenpox) and a secondary herpes zoster infection (shingles). Although varicella typically manifests as a mild disease in otherwise healthy children, it can also manifest as a moderate-to-severe disease, most notably in immunocompromised and adult hosts. Acyclovir is the antiviral agent of choice for the management of varicella infections. Routine vaccination with Varivax has been very effective in reducing chickenpox incidence
The document discusses dengue fever, which is caused by a virus transmitted by the Aedes mosquito. It describes the symptoms of dengue fever and characteristics of the Aedes mosquito. It explains that the female Aedes mosquito acquires the virus by biting an infected person and can then transmit the virus to others by biting them. It provides information on preventing the spread of dengue fever by eliminating places where Aedes mosquitoes can breed.
This is a PowerPoint on the Marburg virus, which is a disease similar to Ebola. I very briefly talk about what the disease is, some of the key facts about the structure and death rate, some outbreak history, prevention and treatment and the social-economical impacts that have been caused.
Orientia tsutsugamushi is a gram-negative bacterium that causes scrub typhus, a disease transmitted through the bites of infected chigger mites. The disease is endemic in parts of Asia and the Pacific, including Nepal. It causes non-specific fever and symptoms like eschar, rash, and organ dysfunction. Diagnosis involves serology, culture or PCR on samples. Doxycycline is the treatment of choice. Prevention focuses on avoiding chigger bites through proper clothing and repellents in endemic areas. Scrub typhus outbreaks have increased in Nepal in recent years.
Dengue fever is a mosquito-borne tropical disease caused by the dengue virus. It is transmitted by Aedes mosquitoes, most commonly A. aegypti. Symptoms include high fever, headache, muscle and joint pains, and a skin rash. In severe cases it can develop into life-threatening dengue hemorrhagic fever or dengue shock syndrome. There is no vaccine, so prevention focuses on controlling mosquito habitats and limiting exposure to bites. Treatment involves fluid replacement and blood transfusion in severe cases.
Video presentation - https://www.youtube.com/watch?v=45CjKnJaIC0
Learn Community Medicine along with me : https://t.me/drvkspm
Be my friend by connecting with me through:
Instagram : https://www.instagram.com/drvenkateshkarthikeyan/
Facebook : https://www.facebook.com/drvenkateshkarthikeyan/
Twitter : https://twitter.com/dr_venkatesh_k
Website : www.drvenkateshkarthikeyan.com
LinkedIn : https://in.linkedin.com/in/dr-venkatesh-karthikeyan-8b1234ab
Learn Community Medicine along with me : https://t.me/drvkspm
Dengue fever is a mosquito-borne tropical disease caused by the dengue virus. It is characterized by fever, headache, muscle and joint pains, and a skin rash. Some cases develop into life-threatening dengue hemorrhagic fever or dengue shock syndrome. It occurs widely in tropical areas and an estimated 50 million infections occur annually. The disease progresses through febrile, critical, and recovery phases. During the critical phase, increased capillary permeability can lead to life-threatening plasma leakage and shock.
Guidelines on clinical management of Dengue Fever & Dengue Hemorrhagic SyndromePk Doctors
This document provides guidelines for the clinical management of dengue fever and dengue hemorrhagic fever in Sri Lanka. It begins with an overview of dengue illness, noting that dengue fever is usually a mild disease caused by primary infection, while dengue hemorrhagic fever is a more severe disease more commonly seen in secondary infections. It describes the typical features of dengue hemorrhagic fever including high fever, bleeding tendencies, hepatomegaly, and circulatory disturbance or shock in severe cases. The clinical course is also summarized, with the illness divided into febrile, critical, and convalescent phases.
National guideline for Dengue (Latest) by DGHSJony Hossain
This document provides an introduction and summary of the 4th Edition 2018 of the National Guideline for Clinical Management of Dengue Syndrome published by the National Malaria Elimination & Aedes Transmitted Disease Control Program of Bangladesh.
The summary includes:
1) It is the 4th edition of Bangladesh's national guideline for clinically managing dengue syndrome.
2) It was published in 2018 by the National Malaria Elimination & Aedes Transmitted Disease Control Program under the Directorate General of Health Services.
3) The guideline was updated based on the latest WHO/SEARO guidelines and provides evidence-based recommendations for the clinical diagnosis and management of dengue to standardize care across Bangladesh.
These guidelines provide evidence-based guidance for managing dengue infection in adult patients. They were developed by a multidisciplinary group and reviewed by independent experts. The guidelines aim to improve diagnosis and appropriate care, identify severe cases, provide fluid management guidance, and reduce transmission. Key recommendations include monitoring patients for plasma leakage and bleeding, fluid resuscitation for shock, and blood product transfusion when needed. The guidelines are meant to guide but not replace clinical judgment based on each patient's situation.
The document summarizes current methods for diagnosing dengue virus infection. It discusses the limitations of clinical diagnosis due to non-specific symptoms in early infection. Laboratory diagnostic methods include virus isolation through mosquito inoculation or cell culture, which is sensitive but requires specialized facilities. Reverse-transcriptase PCR detection of viral RNA in blood is now more widely used, as it is rapid, sensitive and specific. Both virus isolation and PCR can detect infection early in the viremic phase. Serological tests detect antibody response and are more useful later in infection or for secondary dengue diagnosis. Improved early diagnosis remains a challenge, especially with development of a dengue vaccine.
This document provides the revised 2019 National Guidelines on Prevention, Management and Control of Dengue in Nepal. It begins with an introduction on dengue epidemiology, noting it is a rapidly emerging disease in Nepal. All 4 dengue virus serotypes exist in Nepal and incidence has increased in recent years. The guidelines aim to provide up-to-date technical advice on dengue using international standards. Chapter 1 provides context on dengue globally and in Nepal, describing transmission via Aedes aegypti and albopictus mosquitoes and noting the increasing disease burden.
This study characterized dengue infections in Pakistan by analyzing hematological and serological markers in 154 suspected dengue cases and 146 control patients with other febrile illnesses. NS1 antigen was detected in 55% of dengue cases, IgM antibodies in 30%, and both in 15%. Control groups primarily had malaria (71%) and enteric fever (20%). Hematological markers (platelet count, hematocrit, WBC) measured before and after treatment showed significant differences for platelet count and hematocrit but not WBC count between the groups. Analysis of clinical symptoms and serological/hematological markers helps diagnose dengue, assess prognosis, and inform prevention efforts to reduce morbidity, mortality and spread of the disease.
The document provides guidelines for managing dengue infection in adults. It was developed by the Dengue Expert Advisory Group and is intended to provide broad recommendations for good clinical practice based on current evidence. The guidelines cover epidemiology, virology, clinical manifestations, diagnosis, disease monitoring and management, high dependency care, discharge criteria, and special considerations for pregnancy, immunocompromised patients, and pediatrics. It aims to improve recognition, diagnosis and appropriate care of dengue patients.
This document provides guidelines for the clinical management of COVID-19 in Bangladesh. It defines suspect, probable and confirmed cases based on symptoms, travel history and contact. It recommends testing suspect cases and managing confirmed cases according to severity at designated COVID-19 hospitals, with an emphasis on infection prevention. Mild cases may be managed at home, while severe cases require hospital admission and supportive care such as oxygen or ventilation. The guidelines recommend drugs like hydroxychloroquine and azithromycin for treatment based on latest evidence.
Diagnosis and management of dengue in children (IAP Infectious Diseases Chapter)Dr Padmesh Vadakepat
This document provides a review and recommendations on the diagnosis and management of dengue in children. It discusses that dengue is endemic in many parts of Asia and the Americas. The virus is transmitted by mosquitoes Aedes aegypti and Aedes albopictus. Dengue classification has changed from dengue fever and dengue hemorrhagic fever to simply dengue, dengue with warning signs, and severe dengue. Diagnosis involves tests for the NS1 antigen, IgG and IgM antibodies. Treatment depends on severity and can involve outpatient, inpatient or emergency care, monitoring for shock and hemorrhage.
This document summarizes information about dengue fever, including its pathophysiology, symptoms, treatment, and prevention. Dengue fever is a mosquito-borne viral disease caused by any of four dengue virus serotypes. It is characterized by high fever, severe joint and muscle pain, and sometimes a rash. While there is no vaccine or antiviral treatment currently available, symptoms are managed with pain relievers, bed rest, and fluid replacement. Prevention relies on measures to control mosquito populations and avoid mosquito bites. The global incidence of dengue has been increasing and it remains a significant public health challenge.
article 4.pdf about CAP pneumonia communitysakirhrkrj
This document analyzes factors influencing the development of deep venous thrombosis (DVT) in elderly patients with community-acquired pneumonia (CAP). The study examined 505 elderly CAP patients, of which 133 were diagnosed with DVT. Severe pneumonia and septic shock were associated with higher rates of DVT. Central venous catheterization, higher D-dimer levels, and higher Padua scores (indicating higher risk of thrombosis) were significantly correlated with the development of DVT. Logistic regression identified central venous catheterization, D-dimer level, and Padua score as significant risk factors for DVT in elderly CAP patients.
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2. CONTENTS
Chapter Name of the Chapter Page No.
Preface (i)
Acknowledgment (ii)
List of contributors (iii)
Chapter 1 Introduction 1-2
1.1 Introduction 1
1.2 Dengue in India 1-2
Chapter 2 Epidemiology 3-6
2.1 Epidemiology 3
2.2 Agent Factor 3
2.3 Vector 3-4
2.4 Environmental Factor 4-5
2.5 Host Factor 6
2.6 Transmission cycle 6
Chapter 3 Clinical Diagnosis of DHF/DSS 7-9
3.1 Immuno-pathogenesis 7
3.2 Clinical manifestation of DF/DHF 8-9
Chapter 4 Laboratory Diagnosis of Dengue 10-13
4.1 Laboratory Diagnosis 10
4.1.1 Isolation of Dengue Virus 10
4.1.2 Serological Tests 10
4.1.2.1 Haemagglutination inhibition (HI) test 11
4.1.2.2 Compliment Fixation Test (CFT) 11
4.1.2.3 Neutralization test (NT) 11
4.1.2.4 IgM Capture ELISA (Mac ELISA) 11-12
4.1.2.5 IgG ELISA 12
4.1.2.6 Rapid Diagnosis Tests (RDTs) 12
4.2 Collection of Specimens 12-13
4.3 NVBDCP strategy for laboatory diagnosis 13
3. Chapter 5 Clinical management 14-24
5.1 Grading the severity of Dengue infection 14
5.2 Management 15
5.2.1 Management of Dengue fever (DF) 15-16
5.2.2 Management of DHF (Febrille Phase) 16
5.2.3 Management of DHF Grade I and II 16-17
5.2.4 Management of DHF Grade III and IV 17
Chart 1 Volume replacement flow chart for patients 18
with DHF Grades I & II
Chart 2 Volume replacement flow chart for patient 19
with DHF Grades III & IV
5.2.5 Criteria for discharge of patients 20
5.3 Requirement of Fluid 20-21
5.4 Ready Reckoner 22
5.4.1 Dengue corner 22
5.4.2 Indications for domiciliary management 22
5.4.3 Admission of patient 23
5.4.4 Lab investigations for patients 23
5.4.5 Lab investigation for diagnosis 23
5.4.6 Investigation for indoor patients 23
5.4.7 Indoor management of patients 24
5.4.7.1 Indications of red cell transfusion 24
5.4.7.2 Indications of platelet transfusion 24
5.4.7.3 Use of fresh frozen plasma/ cryoprecipitate 24
Annexure I Checklist of diagnosis and therapeutic
material for dengue cases management 25
Annexure II List of the Sentinel Hospitals/Apex Referral
Laboratories for Dengue and Chikungunya 26-30
Annexure III Proforma for line listing 31
Annexure IV Lab. requistion form 32
Reference for further information 33
4. i
PREFACE
Dengue Fever/Dengue Haemorrhagic Fever is an acute viral disease having the potential of
causing, large scale outbreaks. The risk of dengue has shown an increase in recent years
due to rapid, urbanization, life style changes and deficient water management including
improper water storage practices in urban, peri-urban and rural areas, leading to proliferation
of mosquito breeding sites. In India, the first evidence about the occurrence of dengue fever
was reported during 1956 from Vellore district in Tamil Nadu. The first DHF outbreak occurred
in Calcutta (Kolkata, West Bengal) in 1963 with 30% of cases showing haemorrhagic
manifestations. In 1996, the country had experienced an outbreak recording a total number
of 16517 cases (suspected) and 545 deaths. During 2003 as well, large number of cases
and deaths had been reported (12754 and 215, respectively). In the year 2006, there was
again upsurge in DF/DHF cases in the country, with a total 11638 cases and 174 deaths
reported by 21 states of the country. All the four serotypes i.e. Dengue 1, 2, 3 and 4 have
been isolated in India.
There is no specific treatment for dengue fever. Besides, the dengue vaccine has a long
way to go. As any of the four dengue viruses can cause the disease, hence the vaccine
must be tetravalent i.e., it needs to protect against all four viruses.
One of the primary problems in management of dengue is misinterpretation and resultant
confusion because of the term “haemorrhagic fever” implying a significant haemorrhagic
component to the patho-physiology and overshadowing the increased permeability, which
causes depletion of the intravascular component. The doctor managing a dengue patient
has to make evaluations of the haemodynamic state to assess for judicious fluid replacement
at several points of time. A broad-angled evaluation involves integration of clinical and
laboratory parameters, which are in turn summation of the disease process as well as the
ongoing treatment. This understanding is crucial in guiding decisions about the volume,
rate and type of fluid infusion. Most, if not all, deaths due to dengue are potentially avoidable.
Thus, it was essential to frame the common guidelines on Clinical Management of Dengue
for the physicians across the country.
These guidelines on clinical management of DF/DHF/DSS have been developed in
consultation with the leading national and international experts in the field of clinical
management of DHF. I am sure these will guide the clinicians for appropriate treatment of
the patients with DF/DHF /DSS and would help in reducing the case fatality rate of DHF/
DSS.
These are only broad guidelines, the treating physician should consider the condition of the
patient in totality and decide the course of treatment to save the life.
(Dr. G.P.S. Dhillon)
5. ACKNOWLEDGMENTS
In recent years Dengue cases are increasing alarmingly in various parts of the country including
rural areas. The disease is now endemic in 21 states/UTs. As the disease is spreading to
newer areas, not only the number of cases and deaths are increasing, but explosive outbreaks
are occurring. In absence of any specific treatment or vaccine, proper management of cases
is utmost crucial in dengue.
Keeping the above in mind these guidelines on clinical management of DF/DHF/DSS has
been developed during a brain storming workshop held on 14th
& 15th
March 2007 at AIIMS in
collaboration with WHO SEARO. Many national and international leading experts in the field of
clinical management of DF/DHF/DSS participated in this workshop and deliberated to frame
the draft guidelines. NVBDCP gratefully acknowledge contributions and technical inputs of all
the experts for developing these guidelines.
Dr. P.L. Joshi, former Director, NVBDCP, is gratefully acknowledged for his keen interest in
developing these guidelines for clinicians to bring about the nuances in dengue management
and technical advice for undertaking the preparation of this document.
NVBDCP is extremely grateful to Dr. Suchitra Nimmannitya, Queen Sirikit National Institute of
Child Health, Thailand, Bangkok for her experienced technical guidance while framing these
guidelines.
Valuable suggestion provided by Dr. Duane J Gubler, Director, Asia-Pacific Institute of Tropical
Medicine and Infectious Diseases, John A Burns School of Medicine, University of Hawaii at
Manoa , Honolulu, Hawaii is also gratefully acknowledged.
Technical support from Dr Chusak Prasittisuk, CDC, WHO/SEARO, New Delhi is sincerely
acknowledged. Financial support provided by WHO (SEARO/Country office, India) towards
the conduction of the workshop at AIIMS is greatly acknowledged.
NVBDCP is grateful to the Faculty of Medicine, AIIMS, specially Dr. Ashutosh Biswas, who has
taken a lead and made enormous effort to make the international workshop successful and
for providing expert & technical inputs while framing these guidelines. We are also thankful to
Dr. Randeep Guleria for his guidance. Efforts put in by Dr. Bimlesh Dhar Pandey, Sr. Resident,
AIIMS and Dr. C.P. Joshi, Consultant, NVBDCP during the preparation of the draft guidelines is
greatly appreciated. Technical scrutiny of the final draft by Dr. Veena Devgan, Hindu Rao
Hospital; Dr. B.D. Gupta, VMMC & Safdarjung Hospital and Dr. S.C. Sharma, Dr R M L Hospital;
are gratefully acknowledged.
NVBDCP sincerely acknowledge its gratitude to Dr R.K. Srivasatava, Director General of Health
Services, Govt of India, for his valuable technical suggestions for finalization of these guidelines.
I am extremely grateful to Dr. G.P.S. Dhillon, Director, NVBDCP for his guidance and support
for bringimg out these guidelines.
Secretarial assistance provided by Ms. Kusum Gairola and Shri Sachin Verma is also
acknowledged.
(Dr. Kalpana Baruah)
Deputy Director,
NVBDCP
ii
6. iii
LIST OF CONTRIBUTORS
List of the Experts
1. Dr. Suchitra Nimmannitya, Queen Sirikit National Institute of Child Health (WHO
Collaborating Centre for case management of DF/DHF/DSS), Bangkok,
Thailand.
2. Dr. Duane J Gubler, Director, Asia-Pacific Institute of Tropical Medicine and
Infectious Diseases, JohnABurns School of Medicine, University of Hawaii at
Manoa , Honolulu, Hawaii.
3. Dr.Ashutosh Biswas,Associate Professor, Department of Medicine,AIIMS,
New Delhi.
4. Dr. Veena Devgan, HOD, Pediatrics, Hindu Rao Hospital, Delhi.
5. Dr. B.D. Gupta, Consultant, Professor & HOD Medicine, VMMC & Safdarjung
Hospital, New Delhi.
6. Dr. S.C. Sharma, Consultant , Department of Medicine, Dr. R. M. L. Hospital,
New Delhi.
Directorate of NVBDCP
7. Dr. G.P.S. Dhillon, Director
8. Dr. P.L. Joshi, former Director
9. Dr. C.M. Agrawal, Joint Director
10. Dr. Kalpana Baruah, Deputy Director
7. CHAPTER 1
INTRODUCTION
1.1 Introduction
Dengue is a self limiting acute mosquito transmitted disease characterized by
fever, headache, muscle, joint pains, rash, nausea and vomiting. Dengue Fever
(DF) is caused by an arbovirus and spread by Aedes mosquitoes. Some infections
result in Dengue Haemorrhagic Fever (DHF) and in its severe form Dengue Shock
Syndrome (DSS) can threaten the patient’s life primarily through increased vascular
permeability and shock.
Over the past two decades, there has been global increase in the frequency of DF,
DHF and its epidemics, with a concomitant increase in disease incidence. Various
factors responsible for the resurgence of dengue epidemic are: (i) un-precedented
human population growth; (ii) un-planned and un-controlled urbanization; (iii)
inadequate waste management; (iv) water supply mismanagement; (v) increased
distribution and densities of vector mosquitoes; (vi) lack of effective mosquito control
has increased movement & spread of dengue viruses and development of hyper
endemicity and (vii) deterioration in public health infrastructure.
1.2 Dengue in India
The first evidence of occurrence of DF in the country was reported during 1956
from Vellore district in Tamil Nadu. The first DHF outbreak occurred in Calcutta
(West Bengal) in 1963 with 30% of cases showing haemorrhagic manifestations.
All the four serotypes i.e. Dengue 1,2,3 and 4 have been isolated in India. As Ae
aegypti breeding is more common in urban areas the disease was observed mostly
prevalent in urban areas. However, the trend is nowchanging due to socio economic
and man made ecological changes, It has resulted in invasion of Ae. aegypti
mosquitoes into the rural areas, which has tremendously increased the chances
of spread of the disease to rural areas.
Recurring outbreaks of DF/DHF have been reported from various States/UTs
namely Andhra Pradesh, Delhi, Goa, Haryana, Gujarat, Karnataka, Kerala,
Maharashtra, Rajasthan, Uttar Pradesh, Pondicherry, Punjab, Tamil Nadu, West
Bengal and Chandigarh. The states that reported DF/DHF in 2007 are shown in
Fig. 1.
1
8. Fig. 1. Dengue endemicity map of the country (2007)
During 1996, one of the most severe outbreaks of DF/DHF occurred in Delhi where,
10,252 cases and 423 deaths occurred. In 2006, the country witnessed another
outbreak of DF/DHF, total 12,317 cases and 184 deaths were reported in 21 states/
UTs. However, in 2007 only 5534 cases and 69 deaths were reported from 18 states.
Among the NE States Manipur has reported Dengue outbreak for the first time in
2007. Every year during the period of July-Nov there is an upsurge in the cases of
Dengue/DHF. The seasonal trends for 2003-07 are depicted in Fig. 2.
Fig. 2. Seasonal trends of Dengue/DHF 2003-07
0
1000
2000
3000
4000
5000
6000
7000
Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec
No.ofCases
2003 2004 2005 2006 2007
2
Rajasthan
Maharashtra
Gujarat
Orissa
Karnataka
UttarPradesh
AndhraPradesh
Tamilnadu
Punjab
WestBengal
Kerala
Haryana
Goa
Chandigarh
Delhi
Manipur
Madhya
Pradesh
Pondicherry
9. CHAPTER 2
EPIDEMIOLOGY
2. 1 Epidemiology
Dengue is one of the most important emerging viral disease of humans in the
world afflicting humanity in terms of morbidity and mortality. Currently the disease
is endemic in all continents except Europe. The Epidemiology of dengue is a
complex phenomenon that mainly depends upon an intricate relationship between
the 3 epidemiological factors: the host (man and mosquito), the agent (virus) and
the environment (abiotic and biotic factors). The complexity of relationship among
these factors eventually determines the level of endemicity in an area.
2.2 Agent Factor
The dengue viruses are the members of the genus flavivirus. These small (50nm)
viruses contain single stranded RNA. There are four virus serotypes, which are
designated as DEN-1, DEN-2, DEN-3 and DEN-4.Although all four serotypes are
antigenicaly similar, they are different enough to elicit cross-protection only for a
few months after infection by any one of them. Infection with any one serotype
confers lifelong immunity to the virus serotype. Man and mosquito are reservoirs
of infection. Transovarian transmission (infection carried over to next progeny of
mosquitoes through eggs) has made the control more complicated.
At present DEN1 and DEN2 serotypes are widespread in India.
2.3 Vector
Dengue viruses are transmitted by the bite of female Aedes (Ae) mosquitoes. Ae.
aegypti is the most potential vector (Fig.3) but other species such as Ae albopictus,
Ae. polynesiensis and Ae. niveus have also been incriminated as secondary
vectors. In India Ae. aegypti is the main vector in most urban areas; however, Ae
albopictus is also found as vector in few areas of southern India.
Dengue is transmitted by the bite of female Aedes mosquito
Female Aedes mosquito deposits eggs singly on damp surfaces just above the
water line. Under optimal conditions the life cycle of aquatic stage of Ae. aegypti
(the time taken from hatching to adult emergence) can be as short as seven days.
3
10. The eggs can survive one year without water.At low temperature, however, it may
take several weeks to emerge. Ae. aegypti has an average adult survival of fifteen
days. During the rainy season, when survival is longer, the risk of virus transmission
is greater. It is a day time feeder and can fly up to a limited distance of 400 meters.
To get one full blood mea the mosquito has to feed on several persons, infecting
all of them.
Fig. 3. Afemale Ae. aegypti mosquito
2.4 Environmental Factors
The population of Ae. aegypti fluctuates with rainfall and water storage. Its life span is
influenced by temperature and humidity, survives best between 16º-30º C and a relative
humidity of 60-80%. Ae. aegypti breeds in the containers, in and around the houses.
Altitude is an important factor in limiting the distribution of Ae. aegypti, it is distributed
between sea level and 1000 ft above sea level. Ae. aegypti is highly anthropophilic and
rests in cool shady places. The rural spread of Ae. aegypti is a relatively recent occurrence
associated with the development of rural water supply schemes, improved transport
systems, scarcity of water and like style changes.
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. In hot and dry regions, overhead tanks and ground
water storage tanks become primary habitats. Unused tyres, flower pots and desert
coolers are among the most common domestic breeding sites of Ae. aegypti (Fig. 4).
4
11. Fig. 4. Few common and favoured breeding places/sites of Ae. aegypti
Desert cooler Water storage pots Tyres
Unused tyres Coconut shells Disposable cups
Open overhead tank Water reservoir Grinding stone
Construction sites Coolers in Multi- Storied
buildings in urban areas
Suburban slums
5
12. 2.5 Host Factor
Dengue virus infects humans and several species of lower primates but in India man
is the only natural reservoir of infection. All ages and both sexes are susceptible to
dengue fever. Secondary dengue infection is a risk factor for DHF including passively
acquired antibodies in infants. Travel to dengue endemic area is an important risk
factor, if the patient develops fever more than 2 weeks after travel, dengue is unlikely.
Migration of patient during viremia to a non endemic area may introduce it into the
area.
2.6 Transmission cycle
The female Ae. aegypti usually becomes infected with dengue virus when it takes
blood meal from a person during the acute febrile (viraemia) phase of dengue illness.
After an extrinsic incubation period of 8 to 10 days, the mosquito becomes infected
and virus is transmitted when the infective mosquito bites and injects the saliva into
the wound of the person (Fig 5). There is evidence that vertical transmission of dengue
virus from infected female mosquitoes to the next generation occurs through eggs,
wihch is known as transovarian transmission.
Fig. 5. Transmission Cycle
6
Man-Mosquito-Man
13. CHAPTER 3
CLINICAL DIAGNOSIS OF DHF/DSS
3.1 Immuno-pathogenesis
Primary or first infection in non immune persons usually causes Dengue fever.
Subsequent dengue infection by different serotype causes more severe illness
like DHF/DSS. The key manifestations of the DHF/DSS are sudden onset of
shock, capillary leakage, haemorrhagic diathesis/ thrombocytopenia occurring
at the time of defervescence of fever. Pathogenesis is not well defined but it is
suggested that it is mediated through soluble mediators, compliment activation
and cytokines that are responsible for various manifestations. Fig. 6 illustrates
the patho-physiology of DHF.
Fig. 6. Patho-physiology of DHF
Dengue Virus infection
<
<
<
Activation of T Cells
Production of various
cytokines
<
<
Antigen antibody reaction
with complement activation
Production of Antibodies
<
<
Increased vascular
permeability
Deposition on vessels and
various tissues and platelets
Clinical Manifestations
<
<
Clinical Manifestations
7
14. 3.2 Clinical manifestations of DF/ DHF/DSS
Clinical manifestations vary from undifferentiated fever to florid haemorrhage and
shock. The clinical presentations depend on age, immune status of the host and
the virus strain. Under NVBDCP the case definitions recomended by WHO are
being followed, which is as under:
Dengue Fever : Clinical description
An acute febrile illness of 2-7 days duration with two or more of the following
manifestations:
Headache, retro-orbital pain, myalgia, arthralgia, rash, haemorrhagic
manifestations.
Criteria for Dengue Haemorrhagic Fever and Dengue Shock Syndrome
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 haematocrit following volume replacement treatment
compared to baseline
3. Signs of plasma leakage (pleural effusion, ascitis, hypoproteinaemia)
Dengue Shock Syndrome :
All the above criteria for DHF plus 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.
8
15. Case classification
Suspected : A case compatible with the clinical description
Probable : A case compatible with the clinical description with one or more
of the following:
- Supportive serology (reciprocal haemagglutination - inhibition
titre, comparable IgG ELISA titre or positive IgM antibody test in
late acute or convalescent-phase serum specimens)
- Occurrence at same location and time as other confirmed cases
of dengue fever
Confirmed : A case compatible with the clinical description that is laboratory
confirmed
Laboratory criteria for diagnosis
One or more of the following:
Isolation of the dengue virus from serum, plasma, leucocytes or autopsy
samples
Demonstration of a fourfold or greater change in reciprocal IgG or IgM
antibody titres to one or more dengue virus antigen in paired serum
samples.
Demonstration of dengue virus antigen in autopsy tissue by
immunohistochemistry or immunoflorescence or in serum samples by
ELISA.
Detection of viral genomic sequences in autopsy tissue, serum or CSF
samples by polymerase chain reaction (PCR).
9
16. CHAPTER 4
LABORATORY DIAGNOSIS OF DENGUE
4.1 Laboratory diagnosis
Early symptoms of dengue fever mimic other diseases often prevalent in areas
where it is endemic, such as chikungunya, malaria and leptospirosis. Hence for
proper management rapid differential diagnosis is very crucial. Laboratory
diagnosis can be carried out by one or more of the following tests:
Isolation of Dengue virus from serum, plasma, leucocytes or autopsy
samples.
Demonstaration 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)
4.1.1 Isolation of Dengue Virus
Isolation of most strains of dengue virus from clinical specimens can be
accomplished in a majority of cases provided the sample is taken in the first few
days of illness and processed without delay. Specimens that may be suitable for
virus isolation include acute phase serum, plasma or washed buffy coat from the
patient, autopsy tissues from fatal cases, especially liver, spleen, lymph nodes and
thymus, and mosquitoes collected in nature. This method is suitable for research
or for other academic purpose not for patient care.
4.1.2 Serological Tests
Following tests are available for the diagnosis of dengue infection
Haemagglutination-Inhibition (HI),
Complement Fixation (CF),
Neutralization test (NT),
IgMcapture enzyme-linked immunosorbent assay (MAC-ELISA), and
Indirect IgG ELISA.
10
17. 4.1.2.1 Haemagglutination inhibition (HI) test
Of the above, HI assay has been the most widely used method for the serological
diagnosis of dengue in the past. However, due to the extensive cross-reaction
encountered and time consuming due to the requirement of both acute and
convalescent sera collected at least seven days apart have limited the general
applicability of this assay.
4.1.2.2 Compliment Fixation Test (CFT)
The testing procedure is cumbersome and require highly trained personnel the
reagents are thermolabile. Due to these, currently it is not used for routine diagnosis.
4.1.2.3 Neutralization test (NT)
Though this is most specific and sensitive serological test for dengue infections,
due to time involved in the testing procedure coupled with technical difficulty has
limited the use of this test.
4.1.2.4 IgM-capture Enzyme-Linked Immunosorbent Assay (MAC-ELISA)
MAC-ELISA has become widely used test in the past few years. It is a simple,
rapid test that requires very little sophisticated equipment. MAC-ELISA is based
on detection of the dengue-specific IgM antibodies in the test serum by capturing
them out of solution using anti-human IgM that was previously bound to the solid
phase. If the IgM antibody from the patient’s serum is anti-dengue, it will bind to the
dengue antigen.An enzyme-substrate is added to give a colour reaction for easy
detection.
The anti-dengue IgM antibody develops a little faster than IgG and is usually
detectable by day five of the illness. However, the rapidity with which IgM develops
varies considerably among patients. Some patients have detectable IgM on days
two to four after the onset of illness, while others may not develop IgM for seven to
eight days after the onset. In some primary infections, detectable IgM may persist
for more than 90 days, but in most patients it wanes to an undetectable level by 60
days. It is reasonably certain, however that the person had a dengue infection
11
18. sometime in the previous two to three months. MAC-ELISA has become an
invaluable tool for surveillance of Dengue. In areas where dengue is not endemic,
it can be used in clinical surveillance for viral illness or for random, population-
based serosurveys, with the certainty that any positives detected are recent
infections. It is especially useful for hospitalized patients, who are generally admitted
late in the illness after detectable IgM is already present in the blood.
4.1.2.5 IgG-ELISA
An indirect IgG-ELISA has been developed that compares well to the HI test. This
test can also be used in comparison with Igm to differentiate primary and secondary
dengue infections. The test is simple and easy to perform and is thus useful for
high-volume testing. The IgG-ELISA is nonspecific and exhibits the same broad
cross-reactivity among flaviviruses as the HI test thus cannot be used to identify
the infecting dengue serotype.
4.1.2.6 Rapid Diagnostic tests
A number of commercial Rapid Diagnostic Test (RDT) kits for anti-dengue IgM
and IgG antibodies are at present commercially available, which produces the
results within 15 to 20 minutes. However, the sensitivity/specificity of most of these
tests is not known since they have not yet been properly validated. Though some of
the RDTs have been independently evaluated, the results showed a high rate of
false positive compared to standard tests, while others have agreed closely with
standard tests. The sensitivity and specificity of some RDTs also found to vary
from lot to lot. According to WHO guidelines, these kits should not be used in the
clinical settings to guide management of DF/DHF cases because many serum
samples taken in the first five days after the onset of illness will not have detectable
IgM antibodies. The tests would thus give a false negative result. Reliance on such
tests to guide clinical management could therefore, result in an increase in case
fatality rate.
4.2 Collection of Specimens
Laboratory diagnosis of dengue depends on proper collection, processing, storage
and shipment of the specimens. While collecting blood for serological studies from
12
19. suspected DF/DHF cases all universal precautions should be taken. Samples could
be collected
as soon as possible after the onset of illness, hospital admission or
attendance at a clinic (acute serum, S1).
shortly before discharge from the hospital or, in the event of a fatality, at the
time of death (convalescent serum, S2).
in the event if hospital discharge occurs within 1-2 days of the subsidence of
fever collect a third specimen 7-21 days after the acute serum (S1) was drawn
(late convalescent serum, S3).
The optimal interval between the acute (S1) and the convalescent (S2 or S3) serum
is 10 days. The above recommendations allow for the collection of at least two
serum samples for comparison and ideally will provide for an adequate interval
between sera. Serological diagnoses are on the identification of changes in
antibody levels over time. Serial (paired) specimens are required to confirm or
refute a diagnosis of acute flavivirus or dengue infection.
4.3 NVBDCP strategy for laboratory diagnosis
The dengue IgM antibody appears quite early in the course of illness. Its detection
requires only a single but properly timed blood sample. IgM responses are also
usually less cross-reactive to other flaviviruses. The procedure involved is
comparativelyeasierthan othermethods available for diagnosis of dengue infections
due to which NVBDCP is currently following IgMAntibody Capture ELISA(MAC-
ELISA) for diagnosis of dengue infection in the network of sentinel surveillance
laboratories it has established/ identified across the country. For details of these
laboratories refer Annexure II.
Available literature suggests that whichever the test, the complexity of flavivirus
diagnosis cannot be disregarded. Hence, a diagnosis of a particular flavivirus
should always be made taking into account the clinical presentation of the patient,
the performance characteristics of the serological test employed and the knowledge
of the flaviviruses circulating in that particular geographical region.
13
20. CHAPTER 5
CLINICAL MANAGEMENT
5.1 Grading the severity of Dengue infection
To decide where to treat the patient, it is important to classify the severity of den-
gue infection as given in the Table 1. The presence of thrombocytopenia with
concurrent haemoconcentration differentiates Grade I and Grade II DHF from DF.
Table1: Grading the severity of Dengue infection
DF/ DHF Grade Symptoms/signs Laboratory findings
DF Fever with two or more of following Leucopenia,
- Headache thrombocytopenia
- Retro-orbital pain
- Myalgia
- Arthralgia
DHF I Above criteria for DF plus positive Thrombocytopenia : Platelet
tourniquet test, evidence of count less than 100,000/cu.mm.
plasma leakage Haematocrit rise 20% or more
DHF II Above signs and symptoms plus Thrombocytopenia platelet
some evidence of spontaneous count less than
bleeding in skin or other organs 100,000/cumm
(black tarry stools, epistaxis, Haematocrit rise 20% or more
bleeding from gums, etc)
and abdominal pain
DHF III Above signs and symptoms plus Thrombocytopenia: Platelet
circulating failure (weak rapid pulse, count less than 100,000/cumm
pulse pressure <20 mm Hg or high Haematocrit rise more
diastolic pressure, hypotension with than 20%
the presence of cold clammy skin
and restlessness)
DHF IV Profound shock with undetectable Thrombocytopenia : Platelet
blood pressure or pulse count less than 100,000/cumm
Haematocrit rise more than20% Haemotocrit rise more than 20%
Note:
DF may sometimes present with bleeding manifestation but without evidence
of heamoconcentration/ plasma leakage. It should not be confused with DHF .
In addition pain and/or tenderness in upper abdomen have been commonly
observed as prominent clinical feature.
14
1
21. Tourniquet test : The tourniquet test is performed by inflating a blood pressure
cuff to a mid point between the systolic and diastolic pressure for five minutes. The
test is considered positive when 10 or more petechiae per 2.5 cm2
are observed.
In DHF, the test usually gives a definite positive test with 20 petechiae or more. The
test may be negative or only mildly positive during the phase of profound
shock (DSS).
A patient showing Petechiae in legs.
If tourniquet test is found negative it should be repeated. Early diagnosis of disease
and admission of DHF patients in hospitals are important in order to reduce case
fatality rates. Treatment can be initiated on clinical suspicion and on the basis of
interpretation of platelet count and haematocrit, confirmation by laboratory diagnosis
is not required.
5.2 MANAGEMENT
5.2.1 Management of Dengue Fever (DF)
Management of Dengue fever is symptomatic and supportive
i. Bed rest is advisable during the acute phase.
ii. Use cold sponging to keep temperature below 39o
C.
iii. Antipyretics may be used to lower the body temperature.Aspirin/NSAID like
Ibuprofen etc should be avoided since it may cause gastritis, vomiting, acidosis
and platelet disfunction. Paracetamol is preferable in the doses as follows:
15
22. 1-2 years: 60 –120 mg/doses
3-6 years: 120 mg/dose
7-12 years: 240 mg/dose
Adult : 500mg/dose
Note : In children the dose is calculated as per 10mg/KG Body Weight per dose
which can be repeated at the interval of 6hrs
iv. Oral fluid and electrolyte therapy are recommended for patients with excessive
sweating or vomiting.
v. Patients should be monitored in DHF endemic area until they become afebrile
for one day without the use of antipyretics and after platelet and haematocrit
determinations are stable, platelet count is >50,000/ cumm.
5.2.2 Management of DHF (Febrile Phase)
The management of febrile phase is similar to that of DF. Paracetamol is
recommended to keep the temperature below 39o
C. Copious amount of fluid
should be given orally, to the extent the patient tolerates, oral hydration solution
(ORS), such as those used for the treatment of diarrhoeal diseases and/or fruit
juices are preferable to plain water. IV fluid may be administered if the patient is
vomiting persistently or refusing to feed.
Patients should be closely monitored for the initial signs of shock. The critical
period is during the transition from the febrile to the afebrile stage and usually
occurs after the third day of illness. Serial haematocrit determinations are essential
guide for treatment, since they reflect the degree of plasma leakage and need for
intravenous administration of fluids. Haematocrit should be determined daily from
the third day until the temperature has remained normal for one or two days. If
haematocrit determination is not possible, haemoglobin determination may be
carried out as an alternative. The details of IV treatment when required for patients
are given in Chart 1.
5.2.3 Management of DHF Grade I and II
Any person who has dengue fever with thrombocytopenia and haemoconcentration
and presents with abdominal pain, black tarry stools, epistaxis, bleeding from the
gums and infection etc needs to be hospitalized. All these patients should be
observed for signs of shock. The critical period for development of shock is
transition from febrile to abferile phase of illness, which usually occurs after third
16
23. day of illness.Arise of haemeoconcentration indicates need for IV fluid therapy. If
despite the treatment, the patient develops fall in BP, decrease in urine output or
other features of shock, the management for Grade III/IV DHF/DSS should be
instituted.
Oral rehydration should be given along with antipyretics like Paracetamol sponging,
etc. as described above. The detailed treatment for patients with DHF Grade I
and II is given at Chart 1.
5.2.4 Management of DHF Grade III and IV
Common signs of complications are observed during the afebrile phase of DHF.
Immediately after hospitalization, the haematocrit, platelet count and vital signs
should be examined to assess the patient’s condition and intravenous fluid therapy
should be started. The patient requires regular and sustained monitoring. If the
patient has already received about 1000 ml of intravenous fluid, it should be
changed to colloidal solution preferably Dextran40/ haemaccele or if haematocrit
is decreasing, fresh whole blood transfusion 10ml/kg/dose should be given.
However, in case of persistent shock when, after initial fluid replacement and
resuscitation with plasma or plasma expanders, the haematocrit continues to
decline, internal bleeding should be suspected. It may be difficult to recognize
and estimate the degree of internal blood loss in the presence of
haemoconcentration. It is thus recommended to give fresh whole blood in small
volumes of 10ml/kg/hour for all patients in shock as a routine precaution. Oxygen
should be given to all patients in shock. The detailed graphical presentation of the
treatment for patients with DHF Grades III and IV is given at Chart 2.
17
Subconjunctival Haemorrhage with
Ecchymosis in a patient with DHF
Chemosis and subconunctival
haemorrhage in a patient with DSS
24. CHART 1
Volume Replacement Flow Chart for Patients with DHF Grades I & II
Haemorrhagic (bleeding) tendencies, Thrombocytopenia,
Initiate IV Therapy 6 ml/kg/hr Crystalloid solution for 1-2 hrs.
Improvement No Improvement
Increase IV 10 ml/kg/h crystalloid duration 2 hrsIV therapy by Crystalloid
successively reducing from
6 to 3 ml/kg/hr
Further Improvement
<<
<
<
<
<
Improvement
<
<
<
<
Discontinue IV
after 24 hrs
No Improvement
Unstable vital signs
<
<
<
Reduce IV to 6 ml/kg/
hr Crystalloid with
further reduction to 3
ml/kg/hr discontinue
after24-28 hrs
Haematocrit
falls*
Haematocrit
rises
<
<
<
IV Colloid Dextran (40) 10
ml/kg/hr duration 1 hr.
Blood transfusion 10ml/
kg/hr duration1hr
IV therapy by Crystalloid successively reducing
the flow from 10 to 6 and 6 to 3 ml/kg/hr
discontinue after 24-48 hrs.
Improvement
<
<
<
* Suspected internal haemorrhage
Improvement : Haematocrit falls, pulse rate and blood pressure stable, urine output rises
No Improvement : Haematocrit or pulse rate rises, pulse pressure falls below 20 mmHg, Urine
output falls
Unstable Vital signs : Urine output falls, signs of shock
18
25. Chart 2. Volume Replacement Flow Chart for Patients With DHF
Grades III & IV
UNSTABLE VITAL SIGNS
Urine output falls, signs of shock
Immediate rapid volume replacement: initiate IV therapy 10-
20 ml/kg/hr crystalloid solution for 1 hrs
Improvement
IV therapy by Crystalloid
successively reducing from 20 to10,
10 to 6 and 6 to 3
Oxygen
Haematocrit Rises
IV Colloid (Dextran (40)) or
plasma 10 ml/kg/hr
(10ml/kg/hr) as intervenous
bolus (repeat if necessary)
Blood transfusion
(10ml/kg/hr)
IV therapy by crystalloid successively reducing the flow from
10 to 6 and 6 to 3 ml/kg/hr. Discontinue after 24-48 hrs
Serial platelet and haematocrit determinations: drop in platelets and rise in haematocrit
are essential for early diagnosis of DHF.
Cases of DHF should be observed every hour for vital signs and urinary output.
No Improvement
<
<
<
<
<
<<
Further Improvement
Discontinue IV after 24 hrs.
<<
<
<
Haematocrit Falls Rapid
(Due to haemorrhage)
<
<
Improvement
<
<
<
19
26. 5.2.5 Criteria for discharge of patients
Absence of fever for at least 24 hours without the use of anti-fever therapy
Return of appetite
Visible clinical improvement
Good urine output
Minimum of 2/3 days after recovery from shock
No respiratory distress from pleural effusion or ascitis
Platelet count > 50,000/ cumm
Checklist of diagnostics and therapeutics necessary for management of dengue
is given at Annexure I.
5.3 Requirement of fluid
The volume of fluid required to be replaced should be just sufficient to maintain
effective circulation during the period of plasma leakage. To ensure adequate fluid
replacement and avoid over-fluid infusion, the rate of intravenous fluid should be
adjusted throughout the 24 to 48 hour period of plasma leakage by periodic
haematocrit determinations and frequent assessment of vital signs.
The require regimen of fluid should be calculated on the basis of body weight and
charted on a 1-3 hourly basis, or even more frequently in the case of shock. The
regimen of the flow of fluid and the time of infusion are dependent on the severity of
DHF. The schedule given below is recommended as a guideline. It is calculated
for moderate dehydration of about 6% deficit (plus maintenance).
ml/lb Weight on admission ml/kg
bodyweight/day Body weight/day
Lbs Kgs
100 <15 <7 220
75 16-25 7-11 165
60 26-40 12-18 130
40 >40 >18 90
In older children who weigh more than 40 kgs, the volume needed for 24 hours
should be calculated as twice that required for maintenance (using the Holiday
20
27. and Segar formula). The maintenance fluid should be calculated as follows:
Holiday and Segar formula
Body weight in kg Maintenance volume for 24 hours
<10 kg 100 ml / kg
10 - 20 1000+50 ml / kg
More than 20 kg 1500+20 ml / kg
For a child weighing 40 kgs, the maintenance is: 1500 + (20x20) = 1900 ml. This
means that the child requires 3800 ml IV fluid during 24 hours.
For intravenous fluid therapy of patients with DHF, four regimens of flow of fluid are
suggested: 3ml/kg/hr; 6ml/kg/hr; 10ml/kg/hr, and 20ml/kg/hr.
For ready reference, the calculated or fluid requirements, based on bodyweight
and rate of flow of fluid volume for the four regimens are given in Table 2.
Table 2: Requirement of fluid based on bodyweight
Body weight Volume of Rate of fluid (ml/hours)
(In kgs) fluid to be
given in 24 hrs R*1 R*2 R*3 R*4
10 1500 30 60 100 200
15 2000 45 60 150 300
20 2500 60 90 200 400
25 2800 75 120 250 500
30 3200 90 150 300 600
35 3500 105 180 350 700
40 3800 120 210 400 800
45 4000 135 240 450 900
50 4200 150 270 500 1000
55 4400 165 300 550 1100
60 4600 180 360 600 1200
*Regimen 1 – 3ml/kg/hr; 2 – 6ml/kg/hr; 3 – 10ml/kg/hr, and 4 – 20ml/kg/hr
The fluid volumes mentioned are approximations.
21
28. Normally change should not be drastic. Do not jump from R-2 to R-4 since this can
overload the patient with fluid. Similarly, reduce the volume of fluid from R-4 to R-
3, from R-3 to R2, and from R-2 to R-1 in a stepwise manner.
Remember that ONE ML is equal to 20 DROPS. In case of MACRO system, one
ml is qual to 15 drops. (if needed adjust fluid speed in drops according to quipment
used)
It is advised to procure only a bottle of 500 ml initially, and order more as and
when required. The decision about the speed of IV fluid should be reviewed every
1-3 hours. The frequency of monitoring should be determined on the basis of the
condition of the patient.
5.4 READY RECKONER
In an outbreak situation where it is not possible to admit every patient it is important
to prioritize to decide who needs in hospital care most. Following points are a
guide to distinguish various situations and the action to be taken:
5.4.1 Consider having a dengue corner in the hospital during transmission season
which is functional round the clock with adequate trained manpower with facility
for
tourniquet test
BP cuff of all sizes
Blood counter for complete blood count and haematocrit
5.4.2 Indications for domiciliary management:
No tachycardia
No hypotension
No narrowing of pulse pressure
No bleeding
Platelet count > 100,000/cumm
Patient should come for follow up after 24 hours for evaluation. In case of the following
complaints patient should report to nearest hospital immediately
Bleeding from any site (fresh red spots on skin, black stools, red urine, nose
bleed, menorrhagia )
SevereAbdominal pain, refusal to take orally/ poor intake, persistent vomiting
Not passing urine for 12 hrs / decreased urinary output
restlessness, seizures, excessive crying (young infant), altered sensorium
22
29. and behavioral changes and severe persistent headache
cold clammy skin
sudden drop in temperature
5.4.3 Consider admission of patient showing the following symptoms and signs
Bleeding from any site
Warning signs:
Persistent high grade fever( 40º C and above)
SevereAbdominal pain, refusal to take orally/ poor intake, persistent vomiting,
any signs of dehydration
Impending circulatory failure – tachycardia, postural hypotension, narrow pulse
pressure(<20 mmHg, with rising diastolic pressure eg 100/90 mmHg),
increased capillary refilling time > 3secs (paediatric age group)
Neurological abnormalities - restlessness, seizures, excessive crying (young
infant), altered sensorium and behavioral changes, severe and persistent
headache.
Drop in temperature and/or rapid deterioration in General Condition
Shock- cold clammy skin, hypotension/ narrow pulse pressure, tachypnoea
However a patient may remain fully conscious until late stage
5.4.4 Lab investigations for all patient assessment
CBC: Hb, Hct, TLC, DLC, Platelet count, Peripheral blood smear
5.4.5 Lab investigations for diagnosis
Serology : to be done on or after day 5 by Mac ELISA (in an outbreak all
suspected patients of dengue need not undergo serology for purpose of clinical
management.)
While sending the sample to the Laboratory fill the lab. requisition from at
Annexure IV and send with the sample.
5.4.6 Investigations for indoor patients
Chest X Ray : Rt lateral decubitus one day after temperature drops
USG abdomen and Chest
Blood Biochemistry: Serum electrolytes , KIDNEY FUNCTION TESTAND
LIVER FUNCTION TEST IF REQUIRED
23
30. Stool examination for occult blood, pleural fluid tapping and Blood culture for
excluding other causes may be done.
5.4.7 Indoor management of Patients
5.4.7.1 Indications of red cell transfusion
Loss of blood(overt blood) -10% or more of total blood volume –
Preferably whole blood/ component to be used
Refractory shock despite adequate fluid administration and declining
haematocrit
Replacement volume should be 10 ml/kg body wt at a time and
coagulogram should be done
If fluid overload is present PCV is to be given
5.4.7.2 Indications of platelet transfusion
In general there is no need to give prophylactic platelets even at < 20,000/
cumm
Prophylactic platelet transfusion may be given at level of <10,000/
cumm in absence of bleeding manifestations
Prolonged shock; with coagulopathy and abnormal coagulogram
In case of Systemic massive bleeding, platelet transfusion may be
needed in addition to red cell transfusion.
5.4.7.3 Use of fresh frozen plasma/ cryoprecipitate in coagulopathy with bleeding as
per advise of Physician and patients condition.
These are only broad guidelines. The treating physician should consider the
condition of the patient in totality and decide
24
31. Annexure 1
Checklist of diagnostic and therapeutic material for dengue case management
1. Minimum of diagnostic materials should be:
Blood pressure cuffs (adult and paediatric)
Thermometers
Haematocrit centrifuge
Haematocrit supplies (lancets, capillary tubes, reader)
Compound microscope and materials for white blood cell and platelet counts
Vacutainers or syringes/needles for obtaining dengue and diagnostic test
samples
2. Minimum of diagnostic therapeutics:
Paracetamol
WHO oral rehydration solution
Lactate Ringer’s solution; 0.9% saline; 5% glucose
Tubes and needles for intravenous therapy
3. Additional facilities for in-patients:
Laboratory test equipment and supplies for blood typing and cross-matching
for measuring arterial blood gases and pH and for measuring serum electrolytes
Portable X-ray and ultrasound equipment
Central venous pressure monitoring kits
Intake-output monitoring charts
4. Therapeutic materials will be same as that of outpatient department plus:
Intravascularvolume expanders (Dextran 40, plasmanate, platelet concentrates,
fresh frozen plasma, whole blood)
7.5% sodium bicarbonate for injection
Chloral hydrate
Oxygen
25
32. Annexure II
To facilitate the diagnostic facilities Government of India (GOI)has identified/established
110 Sentinel Surveillance Hospitals (SSHs) and linked them to 13 Apex Referral
Laboratories (ARLs) for advanced diagnosis, capacity building, quality assurance
and backup support. In addition to the existing network of 110 SSHs, 27 more are
proposed in different endemic areas. Dengue IgM ELISA test kits are being provided
to these institutes as per the technical requirement of the states based on the previous
epidemiological situations by National Institute of Virology (NIV), Pune. Test kits
production capacity of NIV, Pune has been enhanced and the cost of the kits is
reimbursed by GOI. These SSHs and ARLs will maintain the line list of the cases
(confirmed and suspected) and send the report to the respective health authorities for
implementation of remedial vector control measure to interrupt the transmission. Report
should be submitted at the earlist and in the proforma given atAnnexure-III. List of the
Sentinel Surveillance Hospitals andApex Referral Laboratories are as follows:
LIST OF THE SENTINEL HOSPITALS FOR DENGUE AND CHIKUNGUNYA
Name of the States Sentinel Hospitals/Institutes
1. MGM Hospital,Warangal,
2.RuyaHospital,Tirupathi,
3. Govt.Hospital, Guntur,
4. Govt. Hospital,Vijayawada,
1.Andhra Pradesh 5. Govt. Hospital, Karimnagar,
6. Govt. Hospital, Nizamabad,
7. Govt.Hospital,Annanthpur,
8. VBRI, Hyderabad,
9. Medical Collage, Kurnool,
10. Medical Collage, Mahboobnagar.
2. Goa 1. Hospicio Hospital, Margo, South Goa,
2. Goa Medical College, Goa.
1. Govt. Medical Vollege, Nagpur,
2. B.J. Medical College, Pune,
3. Govt. Medical College,Aurangabad,
3. Maharashtra 4. DistrictHospital, Akola,
5. DistrictHospital, Nashik,
6. Govt. Medical College, Nanded,
7. J.J. Hospital, Mumbai,
8. DistrictHospital, Chandrapur,
26
33. 9. Govt.Medical College,Yavatmal,
10. District Hospital, Beed,
11. Govt. Medical College, Kolhapur,
12. Govt.Medical College, Dhule,
13. K.E.M. Hospital, Mumbai,
14. SionHospital, Mumbai,
15. DistrictHospital, Thane.
1. N.H. Municipal Med. College,Ahmedabad,
2. Govt. Medical College,Vadodara,
3. Govt. Medical College, Surat,
4. Gujarat 4. MunicipalMedical College, Surat,
5. M.P. Shah Medical College, Jamnagar,
6. Govt. Medical College, Rajkot,
7. Govt.MedicalCollege,Bhavnagar,
8. GeneralHospital, Palanpur,
9. General Hospital, Dahod,
10. GeneralHospital, Bhuj.
1. GandhiMedical College, Bhopal,
2.G.R.MedicalCollege,Gwalior,
5. Madhya Pradesh 3. S.S. Medical College, Rewa,
4. N. S.C.B Medical college Jabbalpur,
5. M.G.M. Medical College, Indore.
1. B.K. Hospital, Faridabad,
2. GeneralHospital,Ambala,
6. Haryana 3. State Bacteriological Laboratory, Karnal,
4. General Hospital, Gurgaon,
5. GeneralHospital, Panchkula.
1. Swami DayaNand Hospital, Shahadra, Delhi,
2. Raja Harish Chand Hospital, Narela, Delhi,
3. HinduRao Hospital, Delhi,
4.SanjayGandhiMemorialHospital, MangolPuri,Delhi,
5.BSAHospital,Rohini,Delhi,
6. SafdarjungHospital, NewDelhi,
7. MalviyaNagarHospital, MalviyaNagar, Delhi,
7.Delhi 8. SVB Patel Hospital Patel Nagar, New Delhi,
9.ABG Hospital, Moti Nagar, Delhi,
10. Ram ManoharLohia Hospital, New Delhi,
11. Lok Nayak Hospital, Jawahar Lal Nehru Marg, Delhi,
12. Deen Dayal UpadhyayHospital, Hari Nagar, Delhi,
13. GTBHospital,Dilshad Garden, Delhi,
27
34. 14. ChachaNehru Children Hospital, GeetaColony, Delhi,
15.Lal BahadurShastriHospital, Khichirpur, Delhi,
16. Maharishi BalmikiHospital,Pooth Khurd,Delhi,
17. Dr. HedgewarArogya Sansthan, Karkardooma, Delhi,
18. LadyHardinge Medical College and Smt. Sucheeta Kriplani,
New Delhi, Hospital, Panchkuin Road, New Delhi,
19.ArmyBaseHospital, New Delhi,
20.Agrersen Sen Jain Hospital,
7.Delhi 21.GuruGovind SinghGovt.Hospital,RaghuvirNgr,Delhi,
22. BabuJagjivanRamMemorialHosp.,Jahangirpuri, Delhi
23. Bhagwan MahavirHospital,Pitampura,Delhi,
24. Shastri Park Hospital, Delhi,
25. N.C. Joshi Memorial Hospital, Karolbagh, New Delhi,
26. Kasturbha Hospital, Near Jama Masjid, Delhi,
27.ArunaAsafAli Hospital, RajpurRoad, Delhi,
28. NDMC Charak Palika Hospital, Moti Bagh, New Delhi,
29.RaoTulaRam MemorialHospital,Jaffarpur, Delhi,
30. G..B. Pant Hospital, Jawahar Lal Nehru Marg, Delhi,
8 . Punjab 1.CivilHospital,Ludhiyana.
1. S.M.S. Hospital,
2. J.K. Lone Hospital,
3.UmaidHospital,Jodhpur,
9. Rajasthan 4. SMDM, Jaipur,
5. M.B. Hospital, Kota,
6. S.P. Medical College, Bikaner,
7. R.N.T. Medical College, Udaipur,
8. J.L.N. Medical College,Ajmer.
1. Govt. Medical College, Kozhikode,
2. Medical College, Kottayam,
3.Medicalcollege,Thiruvanthapuram,
4.PublicHealthlab,Thiruvanthapuram,
10. Kerala 5.DistrictHospital, Kollam,
6. THQHThodupuzha,Dist. Idukki,
7.PublicHealthlab. Ernakulam,
8. District Hospital, Palakkad,
9. DistrictHospital, Manjeri,Malappuram,
10. DistrictHospital, Mananthavady,Wyanad,
11.West Bengal 1. BurdwanMedical CollegeHospital.
2. School ofTropical Medicine, Calcutta
1. Central Laboratory(Hqrs), Bangalore
28
35. 2.VirusGiagnosticLaboratory, Shimoga
12. Karnataka 3.VijayNagar Institute of Medical Science, Bellary
4.District SurveillanceUnit, SNR hospital,Kollar
5.DistrictSurveillanceUnit,Belgaum
6. District SurveillanceUnit, Mangalore, DKanada
7. NIV, Pune, Field Unit, Bangalore
1.KanniyakumariMedicalCollege,
2.TirunelveliMedicalCollege,
3.ThoothukudiMedicalCollege,
4. ThanjavurMedical College,
5.MohanKumaramangalamMedicalCollege, Salem,
13.Tamil Nadu 6. CoimbatoreMedical College,
7. K.A.P.ViswanathanMedical College,Trichy,
8. TheniMedical College,
9. ChengalpattuMedical College,
10. Madurai Medical College,
11.VelloreMedical College,
12. Madras Medical College,
13. InstituteofVector Control and Zoonoses, Hosur,
14. Bihar 1. Patna Medical College & Hospital.
1. Regional LaboratorySwasthya Bhawan, Lucknow,
2. DistrictHospital, Ghaziabad,
3. L.L.R.M., Medical College, Meerut,
4. M.L.B. Medical College, Jhansi,
15. Uttar Pradesh 5. M.L.N.,Medical College,Allahabad,
6. Institute ofMedical Sciences, B.H.U.,Varanasi,
7. S.N., Medical College,Agra,
8. G..S.B.M., Medical College, Kanpur,
9. K.G.M.U., Lucknow,
10.AuthorityHospital Noida.
1. S.C.B. Medical College, Cuttak,
16. Orissa 2.V.S.S. Medical College, Burla, Sambalpur,
3. MKCG, Medical College, Berhampur, Ganjam.
17.A& N Islands 1. G.B. Pant Hospital, Port Blair.
18. Lakshyadweep 1. IndiraGandhi Hospital, Kavaratti.
19. Manipur 1. Regional InstituteofMedical Sciences, Imphal.
20. Pondicherry 1. JIPMER, Pondicherry,
2. General Hospital, Pondicherry
29
36. LIST OF THE APEX REFERRAL LABORATORIES
1. National Institute of Virology (ICMR), Pune.
2. National Institute of Communicable Diseases, 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, New Delhi.
7. ICMR Virus Unit, Kolkata.
8. Regional Medical Research Centre (ICMR), Dibrugarh,Assam.
9. King Institute of Preventive Medicine, Chennai.
10. Institute of Preventive Medicine, Hyderabad.
11. B J Medical College, Ahmedabad.
12. Kerala State Institute of Virology and Infections Disease,Alappuzha.
13. Defence Research Development and Establishment (DRDE) Gwalior, Madhya
Pradesh.
30
37. Annexure III
NATIONALVECTOR BORNE DISEASE CONTROLPROGRAMME
Proforma for line listing* of Suspected / Clinically Diagnosed Dengue cases at the regional /District Sentinel Centre
State : ………… Sentinel centre : ………………………………… Date : ……………………..
Sl. Name of the Patient & Age/Sex Date of Clinical manifestations Laboratory Investigations IgM capture Remarks
No. Address & Telephone onset of (give numbers ELISA Test
No. if any fever as indicated in (+ ve or - ve)
the foot note) Total Platelet Haematocrit
WBC count count
Foot Note:
SignandsymptomsofDHF/ DSS(pleasefillthenumberinthecolumnforclinicalmanifestations)
1 Positivetourniquettest 2 Petechiae, ecchymosis or purpura 3 Bleedingfrommucosa,injection
site or anyother site(specify)
4 Haematemesisormelena 5 Thrombocytopaenia 6 Evidenceofplasmaleakage
7 Signsofcirculatoryfailure 8 Rash 9 Retro-orbital pain
10 Others (please specify) linelistingshouldbemaintainedat thesentinel centreandcopysent tohigher
authorities (district VBD control officer)onday-to-daybasis
Name & Designation & Signature
31
38. Annexure IV
LAB REQUISITION FORM
State / District……………..........…… Regn. No. …………..…………………..
PHC/Name of Institute ………..………..………..
Name of the patient ……………………………………………Age/Sex……………….
Date of admission …………………………………
Addresss ……………………………….………….
Local …………..
Permanent ………..………….
Telephone No. …………………
Clinical findings ……………………………………………
Fever ……………………… Duration …………………… Days ……………………..
Anyotherfinding ………………………………..
Date of collection of sample ……………………….………..
Nature of Sample
Tick thebox
Serum WholeBlood
Name and Signature of MO……………………..
Results
Patient ID………………..
Patient of Name………………..
Date ofcollection…………………………..Date of reporting………………………..
Tick the box
Test type Positive Negative
IgM Mac ELISA
IgG Paired Sera
RDT
Name and signature of the Investigator
32
39. References (for further information)
(1) Suchitra Nimmannitya: Clinical Manifestations of DF/DHF - WHO Regional
Publication No. 22, Monograph on Dengue/DHF, pp 48-54, WHO/SEARO,
New Delhi.
(2) Suchitra Nimmannitya: Management of DF/DHF- WHO Regional Publication
No. 22 – Monograph on Dengue/DHF-pp 55-61, WHO/SEARO, New Delhi.
(3) Suchitra Nimmannitya: Dengue Haemorrhagic Fever: diagnosis and
management, pp 133-145, in “Dengue and Dengue Haemorrhagic Fever” edited
by D.J. Gubler and G. Kuno, Published by CAB international, 1997.
(4) Dengue Haemorrhagic Fever – diagnosis, treatment, prevention and control,
2nd Edition, WHO Geneva, 1997.
(5) Prevention and Control of Dengue and Dengue Haemorrhagic Fever
Comprehensive Guidelines WHO Regional Publications SEARO No. 29, New
Delhi, 1999 .
(6) Long TermAction Plan for prevention and control of Dengue and Chikungunya
: Directorate of National Vector Borne Disease Control Programme, ( Dte.
General of Health Services), Ministry of Health and Family Welfare, Govt of
India, 2007.
33