Dengue hemorrhagic fever is an emerging health problem. Endemic to mainly tropical and sub-tropical areas. Aedes aegypti, a day biting urban thriving mosquito is the primary vector. High fever with maculo-papular rash Severe headache / retro-orbital pain Arthralgia / myalgia Nausea / vomiting Petechiae / purpurae Hemor
Dengue hemorrhagic fever is an emerging health problem. Endemic to mainly tropical and sub-tropical areas. Aedes aegypti, a day biting urban thriving mosquito is the primary vector. High fever with maculo-papular rash Severe headache / retro-orbital pain Arthralgia / myalgia Nausea / vomiting Petechiae / purpurae Hemor
Dengue hemorrhagic fever is an emerging health problem. Endemic to mainly tropical and sub-tropical areas. Aedes aegypti, a day biting urban thriving mosquito is the primary vector. High fever with maculo-papular rash Severe headache / retro-orbital pain Arthralgia / myalgia Nausea / vomiting Petechiae / purpurae Hemor
Diagnosis, Treatment, Prevention and Control Why Dengue–Emerging Health Problem
Almost 1/3rd of the world in endemic
areas – mostly SEAR countries (52%) Increase in Incidence and Frequency of epidemics Among 10 leading causes of pediatric hospitalization & death in SEAR Economic Burden – both Direct & Indirect cost Sporadic cases in Non-Endemic population poses diagnostic difficulty South-East Asia Indian Perspective Presently a category B country Endemic Transmission of all 4 serotypes leading on to heterotypicity and hence DHF Spreading of Geographic distribution of endemicity Absence of a concrete National Program – both Epidemic control as well as Endemic Surveillance No of Cases & CFR - INDIA KI DENGA PEPO Acute Febrile Arthopod-borne Arboviral illness Humans are the main amplifying host Dengue virus belongs to Flaviviridae with 4 serotypes (DEN-1 … DEN-4) Aedes aegypti, a day biting urban thriving mosquito is the primary vector Affects mainly tropical and sub-tropical areas Clinical Features High fever with maculo-papular rash Severe headache/retro-orbital pain Arthralgia/myalgia Nausea/vomiting Petechiae/purpurae Hemorrhagic phenomenon – Epistaxis, gum bleeds, G I bleeding, hematuria, menorrhagia, ICH Dengue hemorrhagic fever High fever 1/3rd cases of Hemorrhagic DHF progress phenomenon to shock Hepatomegaly Clinical Hypovolemic indicators shock Laboratory indicators Dengue shock syndrome Cold and blotchy skin Circum-oral cyanosis Rapid pulse Hypotension/narrow pulse pressure Acute abdominal pain Interal bleeding complications Shock Internal bleeding Pleural effusion/ascites Encephalopathy Liver failure Iatrogenic – Sepsis – Pneumonia – Overhydration Laboratory findings Thrombocytopenia Hemoconcentration Leukopenia Hypoproteinemia Hyponatremia Increased SGOT Coagulation defects Heaptomegaly/pleural effusion/ascites Laboratory Diagnosis Sample collection time – Acute sera (S1) – Convalescent sera (S2) – Late Convalescent sera (S3) Sampling methods – Tubes/Vials, Filter-paper Approaches – Virus – Antigen – Antibody – Genomic sequence Approaches Viral culture In-situ hybridization Immuno-cytochemistry Reverse Transcriptase PCR amplification assay Serological methods – Cross-reactivity – Original Antigenic Sin Serological methods MAC-ELISA Neutralization test Heme-agglutination inhibition test Complement fixation test Dot-Blot immunoassay Case definition- Dengue fever Acute febrile illness with 2 or more of – Headache/retro-orbital pain – Arthralgia/myalgia – Rash – Hemorrhagic manifestation – Leukopenia Either of – Supportive serology/positive IgM – Occurrence at the same location and time as other confirmed cases of DF Dengue Hemorrhagic Fever 1. Fever or H/O acute fever lasting 2-7 days 2. Hemorrhagic tendencies evidenced by at- least one of – Positive tourniquet test – Petechiea / Ecchymosis – Bleeding from mucosa /GIT/ injection sites or other locations 3. Thrombocytopenia 4. Evidence of plasma leakage – Rise in hematocrit – Drop in hematocrit after hydration – Pleural effusion, ascites & hypoproteinemia Dengue shock syndrome All 4 criteria for DHF must be present Evidence of circulatory failure manifested by – Rapid weak pulse – Narrow pulse pressure (<20 mm Hg) – Hypotension, cold, clammy skin – restlessness WHO Grading of DHF Grade I – fever accompanied by non- specific constitutional symptoms with a positive tourniquet test and/or easy bruising Grade II – acute febrile illness with spontaneous bleeding Grade III – Circulatory failure indicated by rapid weak pulse & hypotension or narrowing of pulse pressure Grade IV – profound shock with undetected blood pressure or pulse Treatment Anti-pyretics Fluid loss correction – 10ml per kg x % body weight loss Fluid maintanence For shock – 10-20 ml/kg bolus upto 20-30ml/kg – Plasma/plasma substitute/5% albumin – Fresh whole blood – Correction of electrolyte and acid-base imbalance Prevention and Control Vector surveillance and control Fever surveillance Viral surveillance Case notification Control of outbreaks Vaccination – tetravalent live attenuated dengue vaccine Vector Surveillance Objectives and Uses – Geographical distribution & density – Evaluate Control Programs Sampling methods – Larval study, Collection on humans/of resting mosquitoes, Ovitrap, Tyre larvitrap & insecticide susceptibility Indices – House, Container, Breteau – landing rate, Indoor resting density Vector Control Environmental management – Improvement of water supply & storage – Solid waste management • Reduce, Reuse, Recycle – Modification of man-made larval habitats Chemical control – Against Lavae, pupae & ovum – Against adult mosquitoes Biological control Chemical Control Larvicide application – 1% temephos sand granules – methoprene Perifocal treatment – malathion, fenthion, fenitrothion Space spraying – Thermal fog – ULV – Mist Biological Control No chemical Expense of raising contamination the organism Specificity against Difficulty in target organism application and Self-dispersion into production sites not easily Limited utility treated by other Effective only means against immature stages Confinement of an Outbreak At the individual level – Repellants, nets, coils & dresses At the family level – Empty/cover/drain/apply larvicide At the community level – Chemical control, community participation, supervision of houses Pubic info through media legislation References www.denguenet.com www.whosea.org Pubmed W H O publication 1997 Nelson text book of paediatrics Harrison’s text book of internal medicine Park’s text book of S P M