Dengue

Haemorrhagic
Fever
WHO SEARO
2011
By :
Luthfia Rahmadita
10 / 304682 / KU / 14101

KEY FACTS

Some 2.5 billion people two fifths of the world's population in tropical
and subtropical countries are at risk.
An estimated 50 million dengue infections occur worldwide annually.
An estimated 500 000 people with DHF require hospitalization each year. A
very large proportion (approximately 90%) of them are children aged less
than five years, and about 2.5% of those affected die.
Dengue and DHF is endemic in more than 100 countries in the WHO
regions of Africa, the
Americas, the Eastern Mediterranean, South-East Asia and the Western
Pacific. The South-East Asia and Western Pacific regions are the most
seriously affected.
Epidemics of dengue are increasing in frequency. During epidemics,
infection rates among those who have not been previously exposed to the
virus are often 40% to 50% but can also reach 80% to 90%.
Primarily an urban disease, dengue and DHF are now spreading to rural
areas worldwide.

Dengue Virus
The dengue viruses are members of the genus Flavivirus and
family Flaviviridae. These small (50 nm) viruses contain
single-strand RNA as genome.
Genome: core (C), membrane-associated protein (M),
envelope protein (E), nonstructural protein (NS) genes
There are four virus serotypes, which are DENV-1, DENV-2,
DENV-3 and DENV-4
Aedes (Stegomyia) aegypti (Ae. aegypti) and Aedes
(Stegomyia) albopictus (Ae. albopictus) are the two most
important vectors of dengue

Transmission

Transmission of DHF

For transmission to occur the female Ae. aegypti must bite

an infected human during the viraemic phase of the illness
that manifests two days before the onset of fever and lasts
45 days after onset of fever. After ingestion of the infected
blood meal the virus replicates in the epithelial cell lining of
the midgut and escapes into haemocoele to infect the
salivary glands and finally enters the saliva causing
infection during probing. The genital track is also infected
and the virus may enter the fully developed eggs at the
time of oviposition. The extrinsic incubation period (EIP)
lasts from 8 to 12 days and the mosquito remains infected
for the rest of its life. The intrinsic incubation period covers
five to seven days. During dry season: extrinsic incubation period
shortened, mosquitoes bite more frequently due to dehydration

Clinical Manifestation

Diagnosis Criteria

Disease Course

Laboratory Diagnosis
Virus isolation
serotypic/genotypic characterization
Viral nucleic acid detection
Viral antigen detection
Immunological response based tests
IgM and IgG antibody assays
Analysis for haematological parameters

 Thrombocytopenia, below 100 000 per l, may be

occasionally observed in dengue fever but is a
constant feature in DHF. Thrombocytopenia is usually
found between the third and eighth day of illness often
before or simultaneously with changes in haematocrit.
Haemoconcentration with an increase in the
haematocrit of 20% or more (for the same patient or
for a patient of the same age and sex) is considered to
be a definitive evidence of increased vascular
permeability and plasma leakage.
IgM / IgG ratio is to determined whether primary of
secondary dengue infection.

Management
Dengue Fever
1.Bed rest
2.Adequate fluid intake: milk, fruit juice, ORS,
isotonic electrolyte solution (no plain water)
3.Keep body temperature below 39C. If
temperature goes beyond 39C, give
paracetamol (10mg/kg/dose, max 4gr/day)
4.Tepid sponging of forehead, armpits, and
extremities

Management
DHF Grade I, II (Non-shock Cases)
1.Same as DF management
2.Fluid allowance (oral + IV) is about
maintenance (for one day) + 5% deficit (oral
and IV fluid together), to be administered
over 48 hours

p.s. deficit of 5% is 50ml/kg

Management
DHF Grade III, IV (Shock Cases/DSS)
1.Fluid resuscitation: 10ml/kg in children or 300-500ml in adults over 1 hour or by bolus
2. continued for a minimum duration of 24 hours and discontinued by 36 to 48 hours.
Excessive fluids will cause massive effusions due to the increased capillary permeability.
3. Lab investigations:
A Acidosis: Blood gas analysis
B Bleeding: Haematocrit
C Calcium: Electrolyte, Calcium ion
S Blood Sugar: RBG

Isotonic crystalloid solutions should be used throughout the

critical period except in the very young infants <6 months of
age in whom 0.45% sodium chloride may be used
Hyper-oncotic colloid solutions (osmolarity of >300 mOsm/l)
such as dextran 40 or starch solutions may be used in
patients with massive plasma leakage, and those not
responding to the minimum volume of crystalloid
Platelet
transfusion
is
not
recommended
for
thrombocytopenia (no prophylaxis platelet transfusion). It
may be considered in adults with underlying hypertension
and very severe thrombocytopenia (less than 10 000
cell/mm3).
The duration of intravenous fluid therapy should not exceed
24 to 48 hours for those with shock. However, for those
patients who do not have shock, the duration of intravenous
fluid therapy may have to be longer but not more than 60 to
72 hours.

Complications

Fluid overload
Encephalopathy
Renal failure
DIC
Acute pulmonary oedem
Encephalitis
Hepatic and renal dysfunction
Acidosis metabolic
Electrolite and metabolic imbalance

CRITERIA FOR
DISCHARGING PATIENTS
Absence of fever for at least 24 hours without the use of
anti-fever therapy.
Return of appetite.
Visible clinical improvement.
Satisfactory urine output.
A minimum of 23 days have elapsed after recovery from
shock.
No respiratory distress from pleural effusion and no
ascites.
Platelet count of more than 50 000/mm3. If not, patients
can be recommended to avoid traumatic activities for at
least 12 weeks for platelet count to become normal. In
most uncomplicated cases, platelet rises to normal within
35 days.

Prevention and Control

THANK YOU