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Dengue
DR NARENDRA KUMAR YADAV
MD Community Medicine & Tropical Diseases, BPKIHS
Dengue:
Outline of the Chapter:
 Epidemiological triad of dengue
 Burden of Disease
Clinical Presentation
Warning signs of dengue
Diagnosis: Clinical methods and laboratory methods
CONTROL MEASURES
Clinical Management
Vector Borne Diseases:
M/C Vector borne disease in Nepal/India: Malaria
M/C VIRAL Vector borne disease in Nepal/India: Dengue
M/C Arboviral Vector borne disease in Nepal/India : Dengue
Mosquitoes:
ANOPHELES CULEX AEDES MANSONIA
 Malaria  Japanese Encephalitis(JE)
 Lymphatic Filariasis
 West Nile Fever
 Dengue
 CGF
 YF
 Zika
 RVF
 Brugian Filariasis
 CLEAN Water  DIRTY Water  ARTIFICIAL(Man
Made) COLLECTION
OF RAIN WATER
 AQUATIC PLANTS
Flight range:
3-5 kms 11 kms 100 m
Arboviral Diseases Classification:
GROUP: A GROUP: B OTHERS:
 CGF  Dengue
 Japanese Encephalitis(JE)
 Kyasanur Forest Disease(KFD)
 West Nile Fever
 Sandfly Fever
Dengue:
Dengue is a viral infection caused by dengue virus (DENV) that transmitted to
humans through the bite of an infected mosquitoes (Aedes species)
Cause: Group B Arbovirus
Dengue viruses have 4 serotypes:
1. DENV-1 (M/C/C of Epidemic)
2. DENV-2
3. DENV-3
4. DENV-4
Dengue:
VECTOR of Dengue: Aedes aegypti (Tiger Mosquito) and Aedes
Albopictus
Feeding Habits: Day Bitter (Bite during day time)
Resting Habits: Rest in the dark corners of houses
Breeding Habits: ARTIFICIAL(Man Made) COLLECTION OF RAIN WATER
Dengue:
Reservoir: Man and Aedes
Incubation Period: 3-10 days
Burden of Disease:
Dengue is found in tropical and sub-tropical climates worldwide,
mostly in urban and semi-urban areas.
About half of the world's population is now at risk of dengue with
an estimated 100–400 million infections occurring each year(WHO)
Mortality:
DF: <1%
Severe dengue: 5%
Epidemiological triad of dengue:
Agent: Dengue virus (DENV)
Host: Human & Aedes mosquito. Env: ARTIFICIALCOLLECTION OF RAIN WATER & Rainy season
Dengue
DEGUE: Clinical Presentation:
1. Asymptomatic Dengue Viral Infection Most of the cases are asymptomatic
2. Dengue Fever(DF)
AKA: Classical Dengue Fever
AKA: Break Bone Fever
 Fever (≥ 104 F)
 Retro-orbital pain/Headache/MYALGIA/ BONE PAIN
 Nausea/Vomiting
 RASH (Macular or Maculopapular)
3.Dengue Hemorrhagic Fever (DHF):
a. Febrile Phase
b. Critical Phase
c. Recovery Phase
 Fever
 Thrombocytopenia (PLT ≤ 1 lakh/mm3)
 Hemorrhagic manifestations: Gum bleeding, Epistaxis,
Hematemesis, Melena, Hematuria
 Evidence of leaky capillaries: Elevated Hematocrit (≥ 20%), Pleural
effusion, Ascites
 Leukopenia
4. Dengue Shock Syndrome(DSS):
 DHF +
 SHOCK
Rash in Dengue: The rash is typically macular or maculopapular and
may be associated with pruritus.
Severe Dengue:
Severe dengue is defined by ≥ 1 of the following:
1. Evidence of leaky capillaries:
 Shock
Fluid accumulation (P. Effusion, ascites): +-Respiratory Distress
2. Severe Bleeding: Shock
3. Organ failure( single or multiple organ failure)
Warning signs of dengue:
1. Restlessness/ OBTUNDATION
2. Persistent Vomiting: Dehydration
3. Mucosal Bleeding
4. Pleural Effusion: Dyspnea
5. Ascites
6. Hepatomegaly (2 cm below the costal margin)
7. Thrombocytopenia
8. Rise in Hematocrit
Dengue: Diagnosis:
CRITERIA FOR CLINICAL DIAGNOSIS:
Fever and ≥ 2/6 following features:
1. Retro-orbital pain/Headache/Myalgia/ Bone Pain
2. Nausea / Vomiting
3. Rash (macular or maculopapular)
4. Warning signs of dengue
5. Positive Tourniquet Test
6. Leucopenia
TORNIQUET TEST:
TORNIQUET TEST(Positive Tourniquet Test)
DF: ≥ 10 Petechiae/sq inch of skin in cubital fossa
DHF: ≥ 20 Petechiae/sq inch of skin in cubital fossa
Laboratory Diagnosis:
1. SEROLOGICAL Test:
NS-1 Antigen(non-structured protein of dengue virus)
IgM antibodies
IgG antibodies
2. Hematocrit (PCV) Count: Increases
3. PLT: Decreases
4. TLC: Decreases
5. LFT
6. CXR
7. USG
Control Measures:
1. Mosquito Control:
A. Physical Methods:
Source Reduction (Best): Elimination of breeding place
Use of mosquito nets
Wearing of full sleeves shirts and full pants
Use of mosquito repellent: creams, liquids, coils, mats
B. Chemical Methods:
Antiadult measures(Nerve/ Contact Poison): DDT, Pyrethrum, Malathion
Antilarval measures: Paris Green (Stomach Poison)
C. Biological Methods: Gambusia, Lebister, Poecilia (All are Larvivorous Fishes)
Control Measures:
2. Vaccines:
DENGVAXIA (Live): 0, 6 months, 12 months
Age: 9months- 45 years
Clinical Management:
Category Intervention
Dengue without warning sign: A OPD
Dengue with warning sign: B IPD
Dengue with risk factors: B IPD
Patient with severe dengue: C IPD
High risk patients: Infant, Elderly(>65 Years), Pregnancy, DM, HTN, IHD,
Asthma, CRF, Liver cirrhosis, PUD, Steroids, NSAIDs
Clinical Management:
Category A: OPD
Dehydration: ORS
Fever: Paracetamol & Cold sponging
C/I: Aspirin ( acetylsalicylic acid), Ibuprofen, Corticosteroids
Use insect repellant on patient & Elimination of breeding place
W/F: Bleeding, Signs of Plasma leakage, Warning signs of dengue.
Clinical Management:
Category B: warning sign +/ risk factors +
CRYSTALOIDS: NS/ RL
Colloids: iv albumin
Blood transfusion (BT)
 PLT (only when PLT < 50,000 with bleeding OR <10,000 without bleeding):
PRP
4hrly vitals monitoring
I/O monitoring
Clinical Management:
Category C: Patient with severe dengue:
CRYSTALOIDS: NS/ RL
 Bolus 1: 10 ml/kg/hr (1Hr)
 Bolus 2: 2 ml/kg/hr (15 min)
Colloids: iv albumin
 Blood transfusion (BT)
PLT (only when PLT < 50,000 with bleeding OR <10,000 without bleeding):
PRP
Criteria for discharge of patient:
1. Absence of fever for at least 24 hours without the use of anti-pyretic drugs.
2. Return of appetite.
3. Visible clinical improvement.
4. Good urine output.
5. Minimum of 2-3 days after recovery from shock.
6. No respiratory distress from pleural effusion or ascites.
7. Platelet count > 50000/cu.mm
MCQ:
Q. Dengue shock syndrome is characterized by the following except:
a. Hepatomegaly
b. Pleural effusion
c. Thrombocytopenia
d. Decreased hemoglobulin
Ans: d (Decreased hemoglobulin)
MCQ
Q. Which of the following statement is not about dengue:
a. Increase hematocrit
b. Decrease PLT
c. Positive tourniquet test
d. Vector Aedes aegypti usually bite during day time
e. Decrease hematocrit
Ans: e (Decrease hematocrit)
MCQ:
Q. Which is not true about dengue hemorrhagic fever:
a. Thrombocytopenia
b. Hepatomegaly
c. Shock
d. Plasma leaking
Ans: c (Shock)
MCQ
Q. Classical Dengue fever is transmitted by:
a. Culex fatigans
b. Culex vishnuii
c. Culex aegypti
d. Culex palpalis
Ans: c (Culex aegypti)
The End
Dengue Hemorrhagic Fever (DHF):
The course of DHF can be divided into 3 phases:
1. Febrile phase,
2. Critical phase and
3. Recovery phase.
Dengue Hemorrhagic Fever (DHF):
1. Febrile phase:
During the first few days the illness usually resembles classical Dengue fever.
 High grade fever with facial flushing, headache, anorexia, vomiting, abdomen discomfort,
pain abdomen, febrile seizure
Retro-orbital pain/Headache/MYALGIA/ BONE PAIN
Thrombocytopenia (PLT ≤ 1 lakh/mm3)
Evidence of leaky capillaries: Elevated Hematocrit (≥ 20%)
TORNIQUET TEST(Positive Tourniquet Test):
DF: ≥ 10 Petechiae/sq inch of skin in cubital fossa
Dengue Hemorrhagic Fever (DHF):
2. Critical phase:
Dengue Hemorrhagic Fever (DHF):
3. Recovery phase:

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Dengue, PSM, Community Medicine,DR NARENDRA KUMAR YADAV

  • 1. Dengue DR NARENDRA KUMAR YADAV MD Community Medicine & Tropical Diseases, BPKIHS
  • 2. Dengue: Outline of the Chapter:  Epidemiological triad of dengue  Burden of Disease Clinical Presentation Warning signs of dengue Diagnosis: Clinical methods and laboratory methods CONTROL MEASURES Clinical Management
  • 3. Vector Borne Diseases: M/C Vector borne disease in Nepal/India: Malaria M/C VIRAL Vector borne disease in Nepal/India: Dengue M/C Arboviral Vector borne disease in Nepal/India : Dengue
  • 4. Mosquitoes: ANOPHELES CULEX AEDES MANSONIA  Malaria  Japanese Encephalitis(JE)  Lymphatic Filariasis  West Nile Fever  Dengue  CGF  YF  Zika  RVF  Brugian Filariasis  CLEAN Water  DIRTY Water  ARTIFICIAL(Man Made) COLLECTION OF RAIN WATER  AQUATIC PLANTS Flight range: 3-5 kms 11 kms 100 m
  • 5. Arboviral Diseases Classification: GROUP: A GROUP: B OTHERS:  CGF  Dengue  Japanese Encephalitis(JE)  Kyasanur Forest Disease(KFD)  West Nile Fever  Sandfly Fever
  • 6. Dengue: Dengue is a viral infection caused by dengue virus (DENV) that transmitted to humans through the bite of an infected mosquitoes (Aedes species) Cause: Group B Arbovirus Dengue viruses have 4 serotypes: 1. DENV-1 (M/C/C of Epidemic) 2. DENV-2 3. DENV-3 4. DENV-4
  • 7. Dengue: VECTOR of Dengue: Aedes aegypti (Tiger Mosquito) and Aedes Albopictus Feeding Habits: Day Bitter (Bite during day time) Resting Habits: Rest in the dark corners of houses Breeding Habits: ARTIFICIAL(Man Made) COLLECTION OF RAIN WATER
  • 8. Dengue: Reservoir: Man and Aedes Incubation Period: 3-10 days
  • 9. Burden of Disease: Dengue is found in tropical and sub-tropical climates worldwide, mostly in urban and semi-urban areas. About half of the world's population is now at risk of dengue with an estimated 100–400 million infections occurring each year(WHO) Mortality: DF: <1% Severe dengue: 5%
  • 10. Epidemiological triad of dengue: Agent: Dengue virus (DENV) Host: Human & Aedes mosquito. Env: ARTIFICIALCOLLECTION OF RAIN WATER & Rainy season Dengue
  • 11. DEGUE: Clinical Presentation: 1. Asymptomatic Dengue Viral Infection Most of the cases are asymptomatic 2. Dengue Fever(DF) AKA: Classical Dengue Fever AKA: Break Bone Fever  Fever (≥ 104 F)  Retro-orbital pain/Headache/MYALGIA/ BONE PAIN  Nausea/Vomiting  RASH (Macular or Maculopapular) 3.Dengue Hemorrhagic Fever (DHF): a. Febrile Phase b. Critical Phase c. Recovery Phase  Fever  Thrombocytopenia (PLT ≤ 1 lakh/mm3)  Hemorrhagic manifestations: Gum bleeding, Epistaxis, Hematemesis, Melena, Hematuria  Evidence of leaky capillaries: Elevated Hematocrit (≥ 20%), Pleural effusion, Ascites  Leukopenia 4. Dengue Shock Syndrome(DSS):  DHF +  SHOCK
  • 12. Rash in Dengue: The rash is typically macular or maculopapular and may be associated with pruritus.
  • 13. Severe Dengue: Severe dengue is defined by ≥ 1 of the following: 1. Evidence of leaky capillaries:  Shock Fluid accumulation (P. Effusion, ascites): +-Respiratory Distress 2. Severe Bleeding: Shock 3. Organ failure( single or multiple organ failure)
  • 14. Warning signs of dengue: 1. Restlessness/ OBTUNDATION 2. Persistent Vomiting: Dehydration 3. Mucosal Bleeding 4. Pleural Effusion: Dyspnea 5. Ascites 6. Hepatomegaly (2 cm below the costal margin) 7. Thrombocytopenia 8. Rise in Hematocrit
  • 15. Dengue: Diagnosis: CRITERIA FOR CLINICAL DIAGNOSIS: Fever and ≥ 2/6 following features: 1. Retro-orbital pain/Headache/Myalgia/ Bone Pain 2. Nausea / Vomiting 3. Rash (macular or maculopapular) 4. Warning signs of dengue 5. Positive Tourniquet Test 6. Leucopenia
  • 16. TORNIQUET TEST: TORNIQUET TEST(Positive Tourniquet Test) DF: ≥ 10 Petechiae/sq inch of skin in cubital fossa DHF: ≥ 20 Petechiae/sq inch of skin in cubital fossa
  • 17. Laboratory Diagnosis: 1. SEROLOGICAL Test: NS-1 Antigen(non-structured protein of dengue virus) IgM antibodies IgG antibodies 2. Hematocrit (PCV) Count: Increases 3. PLT: Decreases 4. TLC: Decreases 5. LFT 6. CXR 7. USG
  • 18. Control Measures: 1. Mosquito Control: A. Physical Methods: Source Reduction (Best): Elimination of breeding place Use of mosquito nets Wearing of full sleeves shirts and full pants Use of mosquito repellent: creams, liquids, coils, mats B. Chemical Methods: Antiadult measures(Nerve/ Contact Poison): DDT, Pyrethrum, Malathion Antilarval measures: Paris Green (Stomach Poison) C. Biological Methods: Gambusia, Lebister, Poecilia (All are Larvivorous Fishes)
  • 19. Control Measures: 2. Vaccines: DENGVAXIA (Live): 0, 6 months, 12 months Age: 9months- 45 years
  • 20. Clinical Management: Category Intervention Dengue without warning sign: A OPD Dengue with warning sign: B IPD Dengue with risk factors: B IPD Patient with severe dengue: C IPD High risk patients: Infant, Elderly(>65 Years), Pregnancy, DM, HTN, IHD, Asthma, CRF, Liver cirrhosis, PUD, Steroids, NSAIDs
  • 21. Clinical Management: Category A: OPD Dehydration: ORS Fever: Paracetamol & Cold sponging C/I: Aspirin ( acetylsalicylic acid), Ibuprofen, Corticosteroids Use insect repellant on patient & Elimination of breeding place W/F: Bleeding, Signs of Plasma leakage, Warning signs of dengue.
  • 22. Clinical Management: Category B: warning sign +/ risk factors + CRYSTALOIDS: NS/ RL Colloids: iv albumin Blood transfusion (BT)  PLT (only when PLT < 50,000 with bleeding OR <10,000 without bleeding): PRP 4hrly vitals monitoring I/O monitoring
  • 23. Clinical Management: Category C: Patient with severe dengue: CRYSTALOIDS: NS/ RL  Bolus 1: 10 ml/kg/hr (1Hr)  Bolus 2: 2 ml/kg/hr (15 min) Colloids: iv albumin  Blood transfusion (BT) PLT (only when PLT < 50,000 with bleeding OR <10,000 without bleeding): PRP
  • 24. Criteria for discharge of patient: 1. Absence of fever for at least 24 hours without the use of anti-pyretic drugs. 2. Return of appetite. 3. Visible clinical improvement. 4. Good urine output. 5. Minimum of 2-3 days after recovery from shock. 6. No respiratory distress from pleural effusion or ascites. 7. Platelet count > 50000/cu.mm
  • 25. MCQ: Q. Dengue shock syndrome is characterized by the following except: a. Hepatomegaly b. Pleural effusion c. Thrombocytopenia d. Decreased hemoglobulin
  • 26. Ans: d (Decreased hemoglobulin)
  • 27. MCQ Q. Which of the following statement is not about dengue: a. Increase hematocrit b. Decrease PLT c. Positive tourniquet test d. Vector Aedes aegypti usually bite during day time e. Decrease hematocrit
  • 28. Ans: e (Decrease hematocrit)
  • 29. MCQ: Q. Which is not true about dengue hemorrhagic fever: a. Thrombocytopenia b. Hepatomegaly c. Shock d. Plasma leaking
  • 31. MCQ Q. Classical Dengue fever is transmitted by: a. Culex fatigans b. Culex vishnuii c. Culex aegypti d. Culex palpalis
  • 32. Ans: c (Culex aegypti)
  • 34. Dengue Hemorrhagic Fever (DHF): The course of DHF can be divided into 3 phases: 1. Febrile phase, 2. Critical phase and 3. Recovery phase.
  • 35. Dengue Hemorrhagic Fever (DHF): 1. Febrile phase: During the first few days the illness usually resembles classical Dengue fever.  High grade fever with facial flushing, headache, anorexia, vomiting, abdomen discomfort, pain abdomen, febrile seizure Retro-orbital pain/Headache/MYALGIA/ BONE PAIN Thrombocytopenia (PLT ≤ 1 lakh/mm3) Evidence of leaky capillaries: Elevated Hematocrit (≥ 20%) TORNIQUET TEST(Positive Tourniquet Test): DF: ≥ 10 Petechiae/sq inch of skin in cubital fossa
  • 36. Dengue Hemorrhagic Fever (DHF): 2. Critical phase:
  • 37. Dengue Hemorrhagic Fever (DHF): 3. Recovery phase:

Editor's Notes

  1. OBTUNDATION: A dulled or reduced level of alertness or consciousness.
  2. TORNIQUET TEST:: Wait for 5 minute
  3. Serological tests can be used to detect viral & bacterial antigens and antibodies (IgG and IgM), to help diagnose diseases
  4. Dichlorodiphenyltrichloroethane (DDT)