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INTRODUCTION

Infectious disease will last as long as humanity itself


-K .Park
In the world, continuous change of new concepts is bound to emerge based on
new patterns of thought. Health concept will differ from people to people. Health
means freedom from any sickness of disease or it may mean harmonious functioning
of all body systems.1 There is a popular saying ``Health is wealth.A healthy person
has a sound body and he is happy and contented, but health continuous to be a
neglected entity despite lip service.2
Dengue syndrome is a arboviral mosquito borne disease which may present as
(a)classical dengue fever (b) dengue hemorrhagic fever without shock (c) dengue
hemorrhagic fever with shock. Majority of cases present as dengue fever which is a
self-limiting disease.3
Dengue fever is mainly caused by Arbo virus and is mainly transmitted to
human by aedesegypti and aedesalbopictus mosquito which fed during the day.3
The incidence of dengue fever has grown dramatically around the world in
recent decades. Around 2-5 billions of people in world population are now at risk
from dengue. WHO currently estimates there may be 50 million dengue infection
worldwide every year.4
In India dengue infection occured several times. Dengue surveillance units
shows current statistical report of 3400 cases of dengue fever reported around 11
states of India. Dengue surveillance unit shows there are more incidence in New
Delhi. Nearly it is more than 590 positive cases, 500 cases including 7 death in
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Karnataka state and 355 suspected cases and 59 positive cases of dengue fever in
Kolar district.5
In Kerala Trivandrum district was the most affected. In 2001 there are about
1281 cases of Dengue fever identified and 10 death occurred in Kerala. In 2012 there
are about 54 cases reported in Thaluk headquarters hospital Kottarakara in the month
of June and July.4
The clinical features of dengue fever can be studied under three headings.

Dengue viral fever (DVF)


Dengue hemorrhagic fever (DHF)
Dengue shock syndrome(DSS)
In dengue viral fever manifestation include

fever ,chills, malaise, intense

headache, colicky pain, abdominal tenderness, depression, post orbital pain lead to
photophobia, sore throat, pain in extremity, myalgia and arthralgia.6
In dengue hemorrhagic fever, a severe form of dengue fever involved in
anorexia, nausea, vomiting, epigastric discomfort, pharyngitis, cough, petechial rash
appears on third day of illness and tenderness at right costal margin.6
Dengue shock syndrome occurs between 2-6 days and often suddenly occurs
between cold and clammy extremities, weak thready pulse, epistaxis, malena,
haematamesis, subarachanoid hemorrhage and petechial purpura at site of injection6
There is no vaccine is currently available for dengue fever. But symptomatic
management is posible. The vector control is implemented using environmental
hygiene and chemical methods. Proper solid waste disposal, elimination of stagnant
water in domestic environment and chemical methods such as aerosol and liquid spray

for mosquito, mosquito coils and electrical nets etc. Personal protection by wearing
long sleeved cloths and long trousers when going outdoors, using mosquito nets and
avoid staying in scrubby area are commonly used mosquito control methods.7
NEED AND SIGNIFICANCE
Dengue viral infection increasingly recognized as one of the worlds emerging
infectious disease. It is a topical disease which affecting 110 countries throughout the
world and placing over 3 billion people at risk of infection. Children are at high risk
for death. There is no specific vaccine for dengue fever. Management of severe forms
depend upon symptomatic treatment of complication and hypovolemic shock.
Prevention requires control of vector mosquitoes.4
The incidence of dengue fever has grown dramatically around the world in
recent decades.

WHO currently estimates that there may be 50 million dengue

infection worldwide per year. In 2007 there were more than 890000 reported cases of
dengue in the America of which 26000 cases were dengue hemorrhagic fever. The
disease now endemic in more than 100 countries like Africa , America, the East
Mediterranean, South East Asia &Western Pacific. Today dengue fever is considered
one of the most important arthropod borne viral diseases in human in terms of
morbidity and mortality.8
Dengue fever was first reported in Kerala in 1997 in Kottayam district. First
epidemic occured in 2003 with 3546 cases and 68 deaths. Trivandrum was the most
affected district. Dengue fever was endemic in Kerala. In 2009 there were 1425cases
identified and 6 deaths occurred in the same year. In 2010 about 2597 cases were
identified and 17 deaths were reported. In2011 about 1281 cases of dengue fever
identified and 10 deaths occurred in Kerala.4
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A health personnel with adapted knowledge of preventive concept has a major


role in reducing intensity of complication caused by dengue fever and prevent death
of affected victims.
The above facts and studies created in insight in the investigators mind that by
improving the knowledge of patient in the outpatient department and medical ward of
Mercy Hospital ,

Valakom will reduce the inscidence of dengue fever in the

community. During our clinical posting in Mercy Hospital, Valakom we witnessed


several patients, admitted with the case of dengue fever and most of them were
unaware of contributing factors and mosquito control measures. In these
circumstances we selected the study.
Statement of the problem
A Study to assess the knowledge regarding Dengue fever among patients in out
patient department and medical ward of Mercy Hospital,Valakom.
Objectives of Study

Assess the level of knowledge among patients in outpatient department and medical
ward of Mercy Hospital, Valakom regarding dengue fever.

To find out the association between the level of knowledge regarding Dengue fever
and selected demographic variables.

Operational Definitions
Assess
The act which is planned by the researcher to evaluate the level of knowledge
regarding dengue fever among patients in outpatient department and medical ward of
Mercy Hospital, Valakom
Knowledge
It refers to correct responses from participants on causes, signs and symptoms,
management and prevention of dengue fever as elicited through closed ended multiple
choice questionnaire.
Dengue fever
It is a viral disease of group B arbo virus which is transmitted by bites of mosquito
Aedesaegypti characterized by fever, purpura spot etc.9
Patient
Patient who are in 15 and above, of both sexes.
Hospital
Person who receiving medical treatment from outpatient department and medical
ward of Mercy Hospital, Valakom.
Hypothesis
There is a significant association in level of knowledge regarding Dengue fever with
selected demographic variables.

Asssumption

The instrument which is prepared by the researcher is adequate to measure the

knowledge regarding dengue fever .


The self-instructional module which is prepared by the researcher is adequate

to create knowledge regarding dengue fever.


Knowledge create awareness .
Awareness promotes practice in life.

Delimitations

The study is limited to the patients came in outpatient department and medical

ward of Mercy Hospital, Valakom


Sample size is limited to 50
Data collection is limited through semi structured multiple choice
questionnaire.

Summary
This chapter deals with the introduction, need and significance, statement of
problem, objectives, operational definitions, assumptions, hypothesis, delimitations
and following chapters gives an ideas on the review of relevant literatures related to
incidence, knowledge and prevention of dengue fever.

REVIEW OF LITERATURE
INTRODUCTION
Review of literature is a key step in research process. Review of
literature refers to an extensive, exhaustive and systematic examination of
publications relevant to the research project.40
The review of literature should be focused, selective and directed
towards the specific purpose. The researcher has to select the kind of literature to be
reviewed and determine the purpose for which he has to study.40
REVIEW RELATED TO INCIDENCE OF DENGUE FEVER
A study was conducted on Queensland University of Technology in Australia
[2005] to review the scientific evidence about impact of climate change and socioenvironmental factors on dengue transmission particularly in the Asia-Pacific region.
However, empirical evidence linking dengue fever to climate change is inconsistent
across geographical locations and absent in some countries where dengue is
endemic.10
A study was conducted in Kasturba hospital Manipal [2004] to assess the
incidence of

dengue fever shows that ,out of 100 clinically suspected cases of

dengue fever ,44% were tested positive for dengue IgM antibody.11
A study was conducted in rural background in Kanyakumari ,Tamilnadu
[2001] , to assess the incidence of dengue fever by collecting a total of 76 plasma
samples screened for the presence of IgM antibodies by pan bio Elisa kit ,revealed
that 15 were found positive for dengue virus antibody.12

A study was conducted in Christian medical college ,Vellor [2003] to


demonstrate specific antibodies in blood and samples were obtained over a period of 5
years , shows that, out of 1430 samples, 423 [29.5%] samples were positive for
dengue IgM.13
A study was conducted in all the localities in Delhi ,India [2003] to
demonstrate effect of seasonal fluctuation of dengue fever vector revealed that out of
103,778 houses surveyed, 20,513 houses and 3,547 containers were reported positive
for Aedesaegypti.14
A study was conducted in coastal district of Karnataka [2002] to determine the
clinical manifestations, trend and outcome of all confirmed dengue cases admitted in
a tertiary hospital shows that among 466 patients, the most common presentation was
fever, myalgia, vomiting, headache and abdominal pain and most common
hemorrhagic manifestation was petechiae.The increasing number of dengue cases
seen during peri- monsoon period.15
A study was conducted in India [2005] for epidemiological analysis of dengue
infection, shows that, out of 1550 suspected cases 893[57.6%] cases were confirmed
as serological positive for dengue IgM. Highlighted rain, temperature and relative
humidity are the major and important climatic factors for the outbreak of dengue
infection.16
A study was conducted in Veerannapet village, Andhrapradesh[2004] on an
outbreak of dengue fever.The study showed that all age groups and both sexes were
affected with the disease; Out of 19 serum samples, five samples were positive for
IgM antibodies to dengue virus.17

A study was conducted in Government Stanley hospital, Chennai [2001] to assess


the correlation between platelet counts and bleeding in classical dengue cases, shows
that fever, vomiting, bleeding, body pain and hepatomegaly are commonest clinical
features of dengue fever and elevated liver enzymes and low platelet counts were
common laboratory findings and revealed that there was no correlation between
platelet counts and bleeding in classical dengue cases.18
A study was conducted in childrens hospital New Delhi [2006] to determine
clinical profile and outcome of children of dengue hemorrhagic fever and dengue
shock syndrome, shows that common symptoms were fever, abdominal pain,
vomiting and hemorrhagic manifestation was hematemesis followed by epistaxis and
skin bleeds. Hematocrit >40%was observed in only 25[18%] patients and hence
management protocol was based on clinical signs and symptoms and not on
hematocrit.19
A study was conducted by International Council for Medical Research in Kerala
[2006] about the incidence of Dengue fever in Kerala shows that, cyclic Dengue
epidemics have been occurring since 2001, even though the first Dengue report was
brought on record from Kottayam district in 1997 with 14 cases and 4 deaths. This
was followed by a more severe Dengue outbreaks implicating 67 cases and a total of
13 deaths in 1998.In 2001 epidememic Dengue reoccurred mainly in Kottayam,
Idukki and Ernakulam districts reporting 70 cases, followed by 219 cases in 2002 .20
A descriptive study was conducted by Rachel Daniel, Rajamohan and Aby
Zachariah Phlip in Kollam city of Kerala [2003] on Dengue fever shows that ,of the
250 seroalogicallyconfirmed cases, 166[66.4%] conformed to Dengue fever and 84
[33.6%] to Dengue Haemorragic fever and Dengue Shock syndrome. The disease
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incidence was equally distributed among both sexes that is 130 males and 120
females.21
REVIEW RELATED TO KNOWLEDGE
A cross sectional survey was conducted in the Parish of West Moreland to assess
the knowledge regarding dengue fever in parents attending child health clinics
showed that out of 192 parents more than half of parents had good knowledge about
signs, symptoms and modes of transmission of dengue fever.22
A cross sectional survey was conducted in Karachi, Pakistan [2002] among
selected communities with different socioeconomic background shows that, out of
440 samples, knowledge about dengue fever is inadequate in the low socioeconomic
status but better preventive practices prevalent in the high socioeconomic groups23
A study was conducted in Colombia [2010] to understanding dengue virus
replication shows that the epidemiology of dengue has undergone profound changes
in recent years, due to several factors such as expansion of the geographical
distribution of the insect vector, increase in travelling, and demographic pressure. The
recently acquired knowledge is an in-depth understanding of the molecular and
cellular biology of the virus which ishelpful to prepare efficient strategies for the
control of dengue.24
A study was conducted in Netherland[2002] on dengue fever as an arthropod
borne disease of global importance, shows that increased incidence and geographical
distribution of dengue in last 50 years, dengue becoming increasingly recognized as
one of the world major infectious disease. The study presents current knowledge of

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the pathophysiology of severe dengue and address the importance of dengue virus
infection in those travelling to parts of the world where dengue in endemic.25
A study was conducted on community and school based health education in rural
Cambodia [2004] for dengue control, suggested the need for sustained routine
education for dengue prevention and control and the need for approaches to ensure the
translation of knowledge in to practice.26
A study was conducted in Brazil [2004] to contribute dengue control programs
through a review of recent studies on knowledge, beliefs and practices, shows that
adequate knowledge of dengue and prevention methods are found in close association
with high rates of domiciliary infestation by aedesaegypti. Qualitative studies reveal
two important issues that appear to explain representations of dengue and risk
associated with mosquitoes and difficulties in avoiding infestation of household water
recipient due to sanitation problems in communities.27
A cross sectional study was conducted among people visiting tertiary care hospital
in New Delhi [2005] to assess the difference in knowledge and practices based on sex
and literacy shows that out of 215 individuals around 89% of the study participants
considered dengue as serious problem, 86% participants were aware of the spread of
dengue by mosquitoes while 73% were aware of one of the correct breeding sites of
aedes mosquito.28
According to the report of The Hindu newspaper published on August 17, 2012, a
programme was conducted by Dr. Joseph, former Professor of the Community
Medicine at the Thiruvananthapuram Medical College on knowledge about the
Aedesaegypti and the Aedesalbopictus, the causative organism of dengue fever.
Knowledge about the Aedesaegypti and the Aedesalbopictus, the main agents of
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dengue, required a strategy that took into account the peculiarities of the species, Dr.
Joseph said. The Aedes species, also called `container breeders', are known to have
their blood meal during day-time as opposed to the habit of the Anopheles species of
entering households between 5 p.m. and 9-30 p.m. and preying on humans at night or
during the wee hours. Rapid urbanisation and densely populated habitats marked by
poor environment hygiene had set up the perfect stage for an explosion in the density
of the vector population responsible for diseases ranging from malaria, dengue Sand
Japanese encephalitis, he said. The Aedes species could make breeding sites in
flowerpots, discarded tyres, cups, coconut shells and concrete slabs of construction
sites where water collects. ``Moreover, the `plastic culture' has been a major
contributor to the explosion in the density of the vector population.29
REVIEW RELATED TO PREVENTION
A study was conducted in U.S [2000] on an outbreak of dengue fever in
travelers, revealed increased risk of dengue infection in travelers and suggest
alternative preventive methods such as proper clothing and use of mosquito
repellents.30
A study was conducted in Florida [2009] on an outbreak of dengue fever,
revealed that improper sanitary measures are responsible for the outbreak and calls for
a suitable prevention and engage the local community in vector control by using
sanitary measures.31
A study was conducted on Taivan at airports for the early detection of febrile
passengers with dengue infection [2007] to assess the performance of the airport
screening procedure, shows that ~44.9% of the confirmed imported dengue cases with
an apparent symptom in the viremicstage.The researchers recommended the
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reinforcement of mosquito bites prevention and household vector control in dengue


endemic or dengue competent hotspots during an epidemic season.32
A study was conducted in USA [2011] to identify families at risk includes
screening of the underlying basis for reluctance to apply insect repellent, revealed
nurses and physicians can participate in a positive role by assisting families to
determine the proper prophylaxis by recommending insect repellent choices that are
economical, safe, and easy to use.33
A study was conducted in Latin America [2012] for dengue prevention and
control and integrated vector management revealed that the concept of community
participation has been employed in Mexico to raise awareness of the consequences of
dengue and training local people to identify, eliminate, monitor and evaluate vector
breeding sites systematically in household under their supervision.34
A study was conducted in Cuba [2012] to test the effectiveness of a
community empowerment strategy interwined with the routine dengue vector control
programmerevealedthat the empowerment strategy increased community involvement
and added effectiveness to routine aedesaegypti control.35
A study was conducted in New Delhi, India [2003] on an outbreak of dengue
fever, revealed more stringent measures in the form of vector control, improved
sanitation and health education are needed to decrease morbidity, mortality and health
care costs caused by a preventable disease.36
A study was conducted in CMC,Vellore[2000] on an outbreak of dengue fever
revealed the occurance of recurrent epidemic in this region in the last few years with

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associated high case fatality emphasizes the urgent need for public health measures to
curtail further epidemics.13
A study was conducted in Pondicherry, India [2004] to assess the productivity
of defective rainwater harvesting structures and other peridomestic habitats for
dengue vector revealed the need for source reduction involving community and
prioritizing control measures towards the highly productive water-holdings.37
A study was conducted in rural areas of Northern India [2000] on an outbreak
of dengue fever, revealed the changing lifestyle of the rural population as a result of
urbanization process as the causes of dengue fever and calls for a suitable prevention
and control policy based on strengthened surveillance, appropriate health education to
the community.38
According to the report of The Hindu newspaper published on October 21 st
2012, Thiruvananthapuram city corporation proposes to deploy 5,000 health squads
to detect and eliminate mosquito breeding areas. The squads will begin visits to
households in all 100 wards. This comes in the backdrop of possible threat of an
epidemic outbreak since garbage mounds under various stages of decay are now
getting exposed to northeast monsoon rain. At least 50 squads would be formed in
each ward comprising volunteers from the Kudumbasree, Asha workers and from
residents associations. They will turn up at each household to spread the message of
dengue prevention and advise dwellers todestroy vector breeding points by covering
the water storage, avoid the stagnation of water, and use of mosquito repellants.29
According to the report of MalayalaManoramanewspaperon 25-11-12, a
programme on prevention of dengue feverwas organized by Edamullakkalpanchayath
in Kollam District They took preventive measures such as fogging,removal of
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stagnant water and health education for the people. They also took measures to avoid
the spreading of mosquitoes in town. The health department are planning strict actions
against the hotels,andrestaurants that drain pollutant water into the public sewage
system.39
Summary
Review of literature is a beacon, lighting the way for the
investigator to a greater understanding of the research problem and
its main aspects. This chapter covers the

studies related to

incidence of dengue fever , knowledge regarding dengue fever and


prevention related to dengue fever .

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METHODOLOGY
The methodology of research indicate general pattern of the procedure for
gathering valid and realistic data for the purpose of investigation.40
In this chapter, methodology include research design and approach, setting,
sample, sampling technique, developmental description of tool, method and plan for
data analysis.
RESEARCH DESIGN AND APPROACH
The research design is the plan, structure and strategy of investigation of
answering the research question and overall plan or blueprint the researcher select to
Carry out their studies.41
A descriptive design with cross sectional survey approach is used to assess the
level of knowledge regarding dengue fever among patients in outpatient department
and medical ward of Mercy Hospital,Valakom.
SETTING OF THE STUDY
The study was undertaken in Mercy Hospital,Valakom.
POPULATION
Population is defined as the entire set of individual or objects having some common
characteristics.40
The patient present in outpatient department and medical ward of Mercy
Hospital,Valakom was selected as population for the present study.

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Sample &sampling technique


Samples
Sample is a subset of population selected for a particular study and the
members of sample are the study subject 40. 50 patients present in outpatient
department and medical ward of Mercy Hospital, Valakom were the sample for the
study.
Sample size
The sample size is approximately 50 patients in outpatient department and
medical ward of Mercy Hospital, valakom.
Sampling technique
The sampling technique for the present study was convenient sampling
which is a nonprobability sampling. Patients present in outpatient department and
medical ward of Mercy Hospital, Valakom during the period of data collection was
selected as samples.
Criteria for selection of sample
Inclusion criteria
The study was limited to patients of both sexes who were,

Present during the time of data collection


Willing to participate in the study
Able to write and read Malayalam

Exclusion criteria
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Patients who are admitted in pediatric ward and casualty


Children below 15 years of age.

Development of tool
Closed ended questionnaire was used to assess the knowledge regarding dengue
fever among patients in OPD section &medical ward of Mercy Hospital, Valakom.
The steps of preparing the tool were,

After receiving the related literature.


Guidance and consultation with experts internet based research.
Books , journals , magazines.
Based on the knowledge questionnaire on dengue fever.

Review of related literature


Books, journals, reports, internet, articles published and unpublished research
studies in nursing and consultation with guide was used to develop the tool.
Preparation of the tool
Tool pertaining of dengue fever was prepared as per objective.
Consultation with guide and research committee
The tool was given to the guide and research committee.Theiropinion and suggestion
were considered to modify the tool.

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Preparation of the final draft.


Final draft of the tool was prepared after consultation with research guide and
experts.
Description of the tool
The closed ended questionnaire was prepared after receiving related literature
and in consultation with guide. The tool consist of two sections; section A & section
B.
Section A
It consist of demographic characteristics of patients such as age, sex, religion,
educational status, type of family, residence, previous knowledge about the topic and
its source.
Section B
It consist of items pertaining to knowledge of patients in OPD and medical
ward in Mercy Hospital, Valakom. Each item has four options with one most
appropriate answer. In each item, the correct response carry the score `one(1) and
wrong response carry `zero(0) score. The total number of questions in section B is
20.
Scoring
The level of patients knowledge will be grouped as excellent, good, average,
poor.

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Table 3.1 showing score of level of knowledge of samples.

GRADE

PERCENTAGE

SCORE

Poor

0-25%

0-5

Average

26-50%

6-10

Good

51-75%

11-15

Excellent

76-100%

16-20

Validity
The content validity of the tool was established in consultation with guide and
experts from Medicines, Nursing and Biostatistics
Data collection procedure

Prior to the data collection written permission was obtained from concerned

authority.
The subjects were informed the purpose of study to obtain permission to

participate.
Introduction related to tool was given to facilitate co-operation.

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Plan for data analysis


The data collected was organized, tabulated and analyzed by descriptive and
inferential statistics such as percentage, mean and standard deviation. The data was
presented in the form of table and figure.
SUMMARY
This chapter dealt with research approach and design, setting, sample,
sampling technique, developmental description of tool, method of data collection and
plan for data analysis in relation with the objectives stated.

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