Centre of Research for

Public Health

Dengue Fever Prevention and

Management
Dr. Amir Riaz
M.B.B.S, F.C.P.S (Med)
Consultant Physician & Gastroenterologist
Scientific Chair, Centre of Research for Public Health
Assistant Professor
Lahore College of Pharmaceutical Sciences Lahore, Lahore,
Pakistan

Dengue Prevalence

Programs to minimize the impact of

epidemics
Teaching medical community how to diagnose and manage
dengue hemorrhagic fever (DHF)
Implementing an emergency contingency plan to anticipate
the logistical issues of hospitalizing large numbers of patients
and to outline measures for community-wide vector control
activities.
Educating the general public to encourage and enable them to
carry out vector control in their homes and neighborhoods

What is dengue fever?

Dengue fever is a virus infection caused by the dengue virus.
There are 4 kinds of dengue viruses.

Aedes Aegypti

Aedes Albopictus

Do you know?
Dengue fever and dengue haemorrhagic fever are the most
common mosquito-borne viral disease in the world.
Only the female mosquito feeds on blood. This is because
they need the protein found in blood to produce eggs. Male
mosquitoes feed only on plant nectar.
The mosquito is attracted by the body odours, carbon dioxide
and heat emitted from the animal or humans.

The female Aedes mosquito searches for suitable places to lay

their eggs.
Aedes are day-biters, most active during dawn and dusk.

Life cycle of Aedes mosquito

Extrinsic life cycle in Aedes mosquito

Intrinsic life cycle in human subjects

Transmission of dengue virus by

Aedes Aegypti

Important points learned

Aedes aegypti & Aedes Albopictus - vectors
Dengue transmitted by infected female mosquito
Primarily a daytime feeder
Lives around human habitation
Lays eggs and produces larvae preferentially in artificial
containers

Why prevention is stressed?

No specific treatment is available for virus
DF & DHF has significant morbidity & mortality
Disease is endemic & become epidemic in many parts
of world population

Treatment is only supportive & symptomatic.

No effective vaccine is yet developed which is effective
against all four types of viruses causing DF & DHF

Purpose of control
Reduce female vector density to a level below which
epidemic vector transmission will not occur
Based on the assumption that eliminating or reducing the
number of larval habitats in the domestic environment will
control the vector
Prevent vector bites in humans to control spread of virus to
vectors & humans
The minimum vector density to prevent epidemic
transmission is unknown

Reproduction of Aedes mosquito

Common mosquito breeding grounds

Potential breeding grounds

Potential breeding grounds

Potential breeding grounds

Potential breeding grounds

Potential breeding grounds

Potential breeding grounds

Potential breeding grounds

Potential breeding grounds

Potential breeding grounds

Potential breeding grounds

The 10-minute Mozzie Wipe-Out

Exercise

The 10-minute Mozzie Wipe-Out

Exercise

The 10-minute Mozzie Wipe-Out

Exercise

The 10-minute Mozzie Wipe-Out

Exercise

The 10-minute Mozzie Wipe-Out

Exercise

What else can you do?

Personal prevention
Avoid travel to areas where dengue is endemic.
Wear N,N-diethyl-3-methylbenzamide (DEET)containing
mosquito repellant.
Wear protective clothing, preferably impregnated with
permethrin insecticide.
Remain in well-screened or air-conditioned places.
The use of mosquito netting is of limited benefit, as Aedes are
day-biting mosquitoes.
Eliminate the mosquito vector using indoor sprays.

Control of infection mosquitoes

Application of appropriate insecticides to larval habitats or
use of fish in ponds
During outbreaks, emergency vector control measures like
broad application of insecticides as space sprays using
portable or truck-mounted machines or even aircraft
Regular monitoring of the vectors' susceptibility to widely
used insecticide chemicals.
Active monitoring and surveillance of the natural mosquito
population

Treatment
If the patient has no hemorrhagic manifestations and is wellhydrated, he or she can be sent home with instructions for
"followup."

If there are hemorrhagic manifestations or hydration status is

borderline, the patient should be observed, either in an
outpatient observation center or in the hospital
If warning signs are present even without evidence of shock,
or if DSS is present, the patient should be hospitalized

Treatment Patient follow-up

Patients being treated at home should be instructed regarding
the appearance of danger signs and told to return should any
occur.
Repeat clinical evaluation should be considered, with timing
based on the physician's judgment, remembering that DSS
most commonly occurs at 3-6 days after symptom onset.
Patients with bleeding manifestations should have serial
hematocrit and platelet levels checked at least daily until their
temperature is normal for 1-2 days.

Treatment Patient follow-up

If the blood sample was taken the first five days after the
onset of symptoms, a convalescent-phase sample to measure
IgM antibody is needed between 6-30 days after the onset of
symptoms.
A blood sample should be taken from all hospitalized patients
at the time of discharge or death

Treatment
Rest, in a vector protected envoirment.
Fluids, encouraged to take small, frequent sips of fluids. If the
patient cannot be rehydrated by mouth, fluids should be
administered intravenously. At times large amounts of intravenous
fluids are needed.
Antipyreticsaspirin & NSAIDs drugs such as ibuprofen should be
avoided to prevent platelet dysfunction & bleeding diathesis.
Monitor blood pressure, urine output, hematocrit, platelet count,
and level of consciousness

Treatment
Patients often develop dengue hemorrhagic fever after their fever
disappears. So providers should continue monitoring vital signs and
hydration status for 24 to 48 hours after defervescence.

If any doubt, provide intravenous fluids, guided by serial

hematocrits, blood pressure, and urine output
The volume of fluid needed is similar to the treatment of diarrhea
with mild to moderate isotonic dehydration (5%-8% deficit).

Treatment
Volume required for rehydration is twice the recommended
maintenance requirement.
Formula for calculating maintenance volume:
1500 + 20 x (weight in kg - 20).
For example, maintenance volume for 55 kg patient is: 1500 +
20 x (55-20) = 2200 ml.
For this patient, the rehydration volume would be
2 x 2200, or 4400 ml (4.5 liters).

Treatment
Avoid invasive procedures when possible.
Unknown if the use of steroids, intravenous immune
globulin, or platelet transfusions to shorten the duration
or decrease the severity of thrombocytopenia is effective
Patients in shock may require treatment in an intensive
care unit

 Avoid invasive procedures when possible.

Patients in shock may require treatment in intensive care unit.

Indications for hospital discharge

Absence of fever for 24 hours (without anti-fever therapy) and
return of appetite.
Visible improvement in clinical picture.
Stable hematocrit.
3 days after recovery from shock.
Platelets >50,000/mm.

No respiratory distress from pleural effusions/ascites

Common misconceptions about

Dengue Hemorrhagic Fever
One common belief is that dengue plus bleeding equals
dengue hemorrhagic fever?
There are four established criteria for defining DHF, and the
critical difference between dengue fever and DHF is not
bleeding, but the increased vascular permeability that occurs
in DHFthis causes shock and death.
DHF kills only by hemorrhage?
Patient dies as a result of shock.
Poor management turns dengue into DHF?
Poorly managed dengue can be more severe, DHF is a distinct
condition, that can develop even in well-treated patients.

Common misconceptions about

Dengue Hemorrhagic Fever
Positive tourniquet test = DHF?
No Tourniquet test is a nonspecific indicator of
capillary fragility
DHF is a pediatric disease?
All age groups are involved in the Americas
DHF is a problem of low income families?
All socioeconomic groups are affected
Tourists will certainly get DHF with second infection?
Tourists are at low risk to acquire DHF

References

A. Guidelines and manuals

Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. 2nd edition.
Geneva : World Health Organization. 1997
http://www.who.int/csr/resources/publications/dengue/Denguepublication/en/print.html
Dengue Haemorrhagic Fever: early recognition, diagnosis and hospital management An
audiovisual guide for health care workers responding to outbreaks
Download video http://terrance.who.int:85/streaming/dhf.wmv
DHF video transcript http://www.who.int/csr/don/archive/disease/dengue_fever/dengue.pdf
Guidelines for Treatment of Dengue Fever/Dengue Haemorrhagic Fever in Small Hospitals
http://www.searo.who.int/LinkFiles/Dengue_Guideline-dengue.pdf
Manual for Indoor Residual Spraying: Application of Residual Sprays for Vector Control
http://www.paho.org/English/AD/DPC/CD/mal-who-insecticide-manual.htm
Guidelines for Integrated Vector Management
http://www.afro.who.int/vbc/frameworkguidelines/guide_integrated_vector_management.pdf
Planning Social Mobilization and Communication for Dengue Fever Prevention and Control:
A Step-by-Step Guide
http://www.who.int/tdr/publications/publications/pdf/planning_dengue.pdf

References

B. Strategies and Best Practices

Strengthening implementation of the global strategy for dengue fever/dengue

haemorrhagic fever
http://www.who.int/csr/resources/publications/dengue/whocdsdenic20001.pdf

The International Dengue Task Force: Dedicated to the Fight against Dengue
http://www.paho.org/English/AD/DPC/CD/den-gt-dengue-int.htm

Best Practices for Dengue Control - Environmental Health Project

Best Practices for Dengue Control in the Americas
http://www.ehproject.org/PDF/Strategic_papers/SR7-BestPractice.pdf

C. Contacts

Network of PAHO/WHO Collaborating Centres and National Reference Laboratories for

Dengue in the Americas http://www.paho.org/english/ad/dpc/cd/den-cc.htm

WHOCCNet Global Network of WHO Collaborating Centres for Epidemic infectious and
zoonotic diseases.

http://www.who.int/whoccnet/

References

Thank you
For comments and remarks: feedback@crph.org.pk