A PROJECT REPORT

ON

DENGUE FEVER

Submitted for the Partial Fulfillment of the Degree

Of
Master of Public Health
 ACKNOWLEDGEMENT

Every work constitutes great deal of assistance and guidance from the people concerned and this

particular research is of no exception.

A report of the nature is surely a result of tremendous support, guidance, encouragement and

help.

Wish to place on record my sincere gratitude to my project guide …………,

……………………………………... I thank them for constructive help and encouragement

throughout the project. Without their support and guidance taking this would not have been

possible.

Also, wish to acknowledge enthusiastic encouragement and support extended to me by my

family members.

I’m also thankful to my friends who provided me their constant support and assistance.

Name

MPH, 3rd Semester

Roll No.:

2
 DECLARATION BY CANDIDATE

I HEREBY DECLARE THAT THE

……………………………………………………………. SHALL HAVE THE

RIGHT TO PRESERVE USE AND DISSEMINATE THIS PROJECT WORK IN

PRINT OR ELECTRONIC FORMAT FOR ACADEMIC/RESEARCH

PURPOSE.

DATE: SIGNATURE OF THE CANDIDATE

PLACE: …………….. …………………..

3
 ENDORSEMENT BY THE HEAD OF THE INSTITUTE

THIS IS TO CERTIFY THAT THE DISSERTATION ENTITLED

“DENGUE FEVER”

IS BONIFIED RESEARCH WORK DONE BY ………………….. UNDER THE

GUIDANCE OF

………………………………………………………………………………………

………..

DATE: ……………………….

PLACE: ………………… ………………..

…………………………………………………

4
 ABSTRACT

The epidemiology of dengue fever (DF) is complex in the Indian subcontinent as all the four

serotypes are circulating. This study reports observations on dengue cases from a virus

diagnostic laboratory of a north Indian tertiary care hospital catering to areas in and around

Lucknow, Uttar Pradesh.

During the last decade, more frequent and severe epidemics of dengue have hit several Indian

cities. Over the last few years we were engaged in a hospital based surveillance for dengue as

part of study conducted here. A large number of patients were systematically screened for

dengue infection. Since both the studies throw light on the epidemiology of dengue, this aspect

of both studies is combined here to report the descriptive epidemiology of dengue infection in

and around Lucknow.

The present study aimed to evaluate the knowledge and practices regarding dengue infections

Lucknow, Uttar Pradesh. A cross sectional design was adopted for this investigation.

Convenience samples of Seventy six (76) residents who were visiting the health units in different

municipalities of Lucknow, Uttar Pradesh were taken as participants in study.

Television/Radio was cited as the main source of information on dengue infections. Findings

suggest that better knowledge does not necessarily lead to better practice of dengue measures.

Educational campaigns should give more emphasis dengue transmissions and on cost effective

ways of reducing mosquito and preventing dengue such as environmental measures and control.

Furthermore, wide range of information, skills and support must be provided by the government

to increase dengue awareness among residents.

5
 TABLE OF CONTENT

Certificate

Acknowledgement 2

Declaration 3

Endorsement by the head of the institute 4

Abstract 5

 Chapter-1: Introduction 7

 Chapter 2: Dengue Fever 12

 Chapter 3: Literature Review 22

 Chapter 4: Objectives of the study 32

 Chapter 5: Research methodology 34

 Chapter 6: Result & Discussions 36

 Chapter 7: Findings 52

 Chapter 8: Conclusion 54

Annexure 57

 Bibliography

 Questionnaire
6
 CHAPTER -1

INTRODUCTION

7
 INTRODUCTION
Dengue viruses (DV) belong to family Flaviviridae and have four serotypes (1 to 4). They are

transmitted mainly by the Aedes aegypti mosquito and also by Aedes albopictus. Biologically,

DV are highly adapted to the mosquito and are maintained by vertical transmission. DV

produces from a subclinical infection to a mild self limiting disease, the dengue fever (DF) and a

severe disease that may be fatal, the dengue haemorrhagic fever/ dengue shock syndrome

(DHF/DSS). The mosquito vectors are present in tropical and subtropical regions of the earth

that determines the prevalence of DV in a region. Prior to 1970, only 9 countries had experienced

cases of DHF; since then the number has increased more than 4-fold and continues to rise (fi

gure 1a). The WHO published a global map of the distribution of the dengue epidemic activity

during the year 2016 that shows whole India in red colour.

A comparison with similar maps prepared in earlier years shows that the activity of both the

vector and the virus has spread to newer areas, acquiring global public health importance. An
8
estimated 2.5 billion people in more than 100 countries are at risk of acquiring dengue viral

infection with more than 50 million new infections being projected annually, 500000 cases of

DHF that must be hospitalized and 20000–25000 deaths, mainly in children (Halstead 2002,

2007; Chaturvedi and Shrivastava 2004). Dengue has been an urban disease but now has spread

to rural areas of India as well (Mehendale et al 1991; Kumar et al 2001; Arunachalam et al 2004;

Tewari et al 2004). The factors considered responsible for Global resurgence of DF/DHF are

unprecedented population growth, unplanned and uncontrolled urbanization, increased Air travel,

absence of an effective mosquito control programme and deterioration of Public Health

infrastructure. The risk factors for infection with DV are the increased density of the mosquito

vector, reinfestation with Ae. aegypti of a new geographical area, warm and humid climate,

increased population density, water storage pattern in houses, storage of junk in open spaces,

including tyres, coconut shells etc that trap rain water and introduction of new serotype of the

virus, etc. Vaccines or antiviral drugs are not available for dengue viruses; the only effective way

to prevent epidemic DF/DHF is to control the mosquito vector, Ae. aegypti and prevent its bite.

DENGUE VIRUS AND IMMUNE RESPONSE

DV is a positive-stranded encapsulated RNA virus and is composed of three structural protein

genes, which encode the nucleocapsid or core (C) protein, a membrane-associated (M) protein,

an enveloped (E) glycoprotein and seven nonstructural (NS) proteins. Anti-E antibodies

neutralize DV infectivity in vitro and protect mice from DV challenge on passive transfer and

show a variable degreeof cross-reactivity among the DV serotypes. Antibodies against NS1 can

trigger complement-mediated lysis of DV-infected cellsin vitro and protect mice from DV

challenge. At the same time these antibodies may cross-react with endothelial cells leading to

their activation and expression of cytokine, chemokine, and adhesion molecules resulting in cell

9
damage. NS3 protein is the main antigen that stimulates DV-reactive CD4+ and CD8+ T cells

that produce high levels of IFN-γ as well as TNF-α, TNF-β, and chemokines including

macrophage inhibitory protein-1β upon interaction with DV-infected antigen presenting cells,

and are effi cient at lysis of DV-infected cells in vitro (reviewed by Chaturvedi et al 2006a).

CLINICAL PRESENTATION

The patients initially develop an abrupt onset of high fever (39–40°C) with headache, retro-

orbital pain, malaise, nausea, vomiting, and myalgia. The acute febrile stage lasts 2–7 days and

may be followed by recovery but patients feel weakness. During defervescence some patients

develop haemorrhagic manifestation that may be mild petechial haemorrhage, and bleeding at

the nose, gastrointestinal tract and gums, which may be severe. Menorrhagia has been more

prevalent due to the increasing number of affected adolescents, but haematuria is rare.

Hepatomegaly is common with soft and tender liver. Thrombocytopoenia and rising haematocrit

due to plasma leakage are usually detectable before the onset of the subsequent stage of shock

(DSS) with an abrupt fall to normal or subnormal levels of temperature, varying degrees of

circulatory disturbances lasting for 24–48 h. In recent publications a number of atypical

manifestations of dengue, such as encephalitis/encephalopathy (Kumar et al 2008) and

myocarditis, hepatitis and cholecystitis etc. have been reported (Gulati and Maheshwari 2007).

The majority of patients have rapid uneventful recovery without sequelae in the convalescent

stage. The sequence of events in a patient after bite of infected mosquito is summarized in fi gure

2. The clinical diagnosis of DHF is based on four main characteristic manifestations (WHO

1997): (i) continuous high fever lasting 2–7 days; (ii) haemorrhagic tendency as shown by a

positive tourniquet test, petechiae or epistaxis; (iii) thrombocytopoenia (platelet count less than

100 × 109 /l); and (iv) evidence of plasma leakage manifested by hemoconcentration (an increase

10
in haematocrit 20% above average for age, sex and population), pleural effusion and ascites etc.

But some patients with bleeding or anemia may not have a rising haematocrit. Therefore, close

observation, serial haematocrit and daily platelet count monitoring are suggested to fulfi ll the

clinical diagnostic criteria. The severity of DHF is categorized into four grades (WHO 1997):

grade I, being the mildest and grade IV being most severe, with circulatory failure manifested by

a rapid and weak pulse with narrowing of pulse pressure (20 mmHg) or hypotension, with the

presence of cold clammy skin and restlessness. There may be profound shock in which pulse and

blood pressure are not detectable (DSS). In such patients the mortality rate is high.

11
 CHAPTER -2

DENGUE FEVER

12
 DENGUE FEVER

Dengue fever is an infectious disease carried by mosquitoes and caused by any of four related

dengue viruses. This disease used to be called break-bone fever because it sometimes causes

severe joint and muscle pain. Dengue Fever is a flu-like illness spread by the bite of an infected

mosquito and an acute febrile viral disease characterized by sudden onset, fever of 3-5 days,

intense headache, myalgia, anthralgic retro-orbital pain, anorexia, GI disturbances and rash.The

viruses are transmitted to man by the bite of infective mosquitoes, mainly Aedes aegypti. The

incubation period is 4-7 days (range 3-14 days).

13
 Sign and Symptoms of Dengue Fever

 Chills

 Headache

 Pain upon moving the eyes

 Low backache

 Painful aching in the legs and joints

 Fever (temperature rises as 104° F (40° C))with relative low heart rate

(bradycardia) and low blood pressure (hypotension)

 The eyes become reddened

 A flushing or pale pink rash comes over the face

 The glands (lymph nodes) in the neck and groin are often swollen

 The palms and soles may be bright red and swollen

 Dengue Fever diagnosis

A doctor or other health care worker can diagnose dengue fever by doing a blood test.

The test can show whether the blood sample contains dengue virus or antibodies to the virus. In

epidemics, dengue is often clinically diagnosed by typical signs and symptoms.

 Dengue test

If one has persistent fever for more than two days then one should go for CBC

(Complete Blood Count) check up. If the platelet count and WBC count are below than there

usual range one should go for a dengue antigen test. If one has continues fever for more than two

days and / or constant headaches one should go for CBC check up. And one should decide

whether to go for dengue test depending on the result of CBC counts.

14
 Etiology

Dengue fever is cause by dengue virus (DENV), mosquito–borne flavivirus. DENV nssRNE

positive – strand virus of the family flaviviradae; genusflavivirus. There are four serotype of

DENV. The virus has a genome of about 11000 bases that codes for three structural proteins, C,

prM, E; seven nonstructural proteins, NS1, NS2a, NS2b, NS3, NS4a, NS4b, NS5; and short non-

coding regions on both the 5’ and 3’ ends.

 Treatment of Dengue Fever

There is no specific treatment for dengue fever, because dengue is caused by a virus and most

people recover completely within 2 weeks. To help with recovery, health care experts

recommend.

 Getting plenty of bed rest.

 Drinking lots of fluids to prevent dehydration.

 Taking medicine to reduce fever.

15
  Platelet transfusions if the platelet level drops significantly (below 20000) or if

there are significant bleeding.

 Epidemiology

Dengue is transmitted by Aedes mosquitoes, particularly A. aegypti and A.

albopictus. Dengue may also be transmitted via infected blood products (blood transfusions,

plasma, and platelet), but the scale of this problem is unknown.

 Prevention

Methods of prevention of Dengue fever mentioned in various sources include those listed

below. This prevention information is gathered from various sources, and may be inaccurate or

incomplete. None of these methods guarantee prevention of Dengue fever.

 Avoid mosquito bites

 Mosquito repellant

 Protective clothing

 Window screens

 Remove water-filled mosquito breeding areas

 Avoid heavily populated residential areas.

 When indoors, stay in air-conditioned or screened areas. Use bed nets if sleeping areas

are not screened or air-conditioned.

 Dengue vaccine - not yet available but being researched.

 If you have symptoms of dengue, report your travel history to your doctor

 Prognosis

Most people who develop dengue fever recover completely within two weeks. Some, however,

may go through several weeks of feeling tired and/or depressed.

16
DENGUE STATUS IN INDIA
Source: http://nvbdcp.gov.in/
Dengue Cases and Deaths in the Country since 2015

Sl. Affected 2015 2016 2017 2018( Prov.) 2019( till Nov.)
No. States/UTs C D C D C D C D C D

1 Andhra Pradesh 3159 2 3417 2 4925 0 4011 0 4647 0

2 Arunachal Pradesh 1933 1 13 0 18 0 1 0 123 0

3 Assam 1076 1 6157 4 5024 1 166 0 167 0

4 Bihar 1771 0 1912 0 1854 0 2142 0 6193 0

5 Chattisgarh 384 1 356 0 444 0 2674 10 681 0

6 Goa 293 0 150 0 235 0 335 1 874 0

7 Gujarat 5590 9 8028 14 4753 6 7579 5 14835 16

8 Haryana 9921 13 2493 0 4550 0 1898 0 937 0

9 Himachal Pradesh 19 1 322 0 452 0 4672 7 320 2

10 J&K 153 0 79 1 488 0 214 0 435 0

11 Jharkhand 102 0 414 1 710 5 463 1 803 0

12 Karnataka 5077 9 6083 8 17844 10 4427 4 15232 13

13 Kerala 4075 25 7439 13 19994 37 4083 32 3940 16

14 Madhya Pradesh 2108 8 3150 12 2666 6 4506 5 3645 2

15 Meghalaya 13 0 172 0 52 0 44 0 61 0

16 Maharashtra 4936 23 6792 33 7829 65 11011 55 12374 25

17 Manipur 52 0 51 1 193 1 14 0 334 0

18 Mizoram 43 0 580 0 136 0 68 0 42 0

19 Nagaland 21 1 142 0 357 0 369 0 8 0

20 Odisha 2450 2 8380 11 4158 6 5198 5 3251 0

21 Punjab 14128 18 10439 15 15398 18 14980 9 8949 0

17
22 Rajasthan 4043 7 5292 16 8427 14 9587 10 12664 14

23 Sikkim 21 0 82 0 312 0 320 0 243 0

24 Tamil Nadu 4535 12 2531 5 23294 65 4486 13 6577 5

25 Tripura 40 0 102 0 127 0 100 0 100 0

26 Telangana 1831 2 4037 4 5369 0 4592 2 12072 6

27 Uttar Pradesh 2892 9 15033 42 3092 28 3829 4 9280 20

28 Uttrakhand 1655 1 2146 4 849 0 689 3 10500 8

29 West Bengal 8516 14 22865 45 37746 46 - -

30 A& N Island 153 0 92 0 18 0 49 0 168 0

31 Chandigarh 966 1 1246 0 1125 0 301 0 235 0

32 Delhi 15867 60 4431 10 9271 10 7136 4 4155 0

33 D&N Haveli 1154 0 4161 2 2064 0 493 0 954 2

34 Daman & Diu 165 0 89 0 59 0 163 0 128 2

35 Puduchery 771 0 490 2 4568 7 592 2 1495 1

Total 99913 220 129166 245 188401 325 101192 172 136422 132

 C=Cases | D=Deaths | NR=Not Reported

For any scientific publication, if this quoated or used for any analysis purposes, Dte.NVBDCP prior

permission must be sought.

18
ACTION ON DENGUE URGED IN UTTAR PRADESH

The Uttar Pradesh government has urged officials to take action to curb dengue fever in the

state. 

Dengue fever is considered the fastest-growing mosquito-borne disease in the world by the

World Health Organization. Across India, more than 67,000 cases of the vector-borne disease

— transmitted by the Aedes aegypti and Aedes albopictus species of mosquito — have been

reported. In Uttar Pradesh, 792 cases of the disease were reported till September according to the

National Vector Borne Disease Control Programme. State capital Lucknow alone saw 551 cases

by the end of October.

To counteract the spread of the disease, officials being exhorted by the state government to take

action on dengue. “All the district magistrates and divisional commissioners are directed to take

effective steps for prevention and control of dengue and other vector-borne diseases in the

state,” explained state Chief Secretary Rajendra Kumar Tiwari. These steps include fogging,

spraying larvicides, ensuring the provision of medicines in government-run hospitals to be

administered to dengue patients, running awareness campaigns, and setting up health camps. 

Action on dengue is vital following the withdrawal of the monsoon rains, enabling the

proliferation of conditions such as pockets of stagnant water which are prime opportunities for

vector species to breed. Exacerbating the situation this year was the fact that rainfall during the

prolonged monsoon reached a 25-year high leading to many states – Uttar Pradesh included –

being ravaged by floods. 

As such, action on dengue fever is vitally needed in the interest of public health. This is

imperative at the national, state, and local levels, with the onus being upon officials – as

instructed by the Uttar Pradesh government – to take proactive measures to control the disease,

19
ensure the provision of treatment to patients, and raise awareness among the public to safeguard

their wellbeing. 

DENGUE FEVER IN LUCKNOW

With 14 new dengue cases being reported on Friday, Lucknow's tally rose up to 1,519 since

January and 1,504 since July 2019. Of the new cases, three patients - one woman and two men -

-were admitted to King George's Medical University and private hospital on Raebareli Road.

The Lucknow bench of the Allahabad High Court has rapped the Uttar Pradesh government for

poor work in controlling the menace of dengue, for not spending central funds and for faking

statistics on the death toll in the vector borne disease.

At a hearing on Monday the High Court not only expressed its displeasure on the statistics

submitted to it but also said it did not trust the data following which it has decided to form its

own committee of experts to look into the matter.

A bench of Justice AP Shahi and Justice DK Upadhyaya observed that while the court has time it

has again given chances to the health department and concerned official over the matter. 

More than 200 people have reportedly died due to dengue in the city alone and more than 2,000

are said to be tested positive for it but the state agencies are not admitting of the casualties. It

would have been better had the government and authorities worked in curbing the menace rather

than giving fake statistics

20
 CHAPTER -3

LITERATURE REVIEW  

21
 LITERATURE REVIEW

HISTORY OF DENGUE

Dengue fever is an ancient disease. The earliest record found to date is in a Chinese encyclopedia

of disease, symptoms and remedies, edited in 610 A.D and again in 992 A.D (Nobuchi 1979).

The vast expansion of shipping and the development of port cities in the 18th and 19th centuries,

the mosquito vector, Aedes aegypti and the dengue viruses spread to new geographic areas

causing major epidemics. The ecological disruption occurred in the Southeast Asia and pacific

theaters during and following World War II, created ideal conditions for viral transmission and

an increase of mosquito borne disease and it was in the setting that a global pandemic of dengue

began. Dengue virus was first isolated in Japan in 1943, by inoculation of serum of patients in

suckling mice (Kimura and Hotia 1944). In 1944, the virus was isolated from the sera of US

soldiers at many parts of the world including Calcutta (Sabin and Schlesinger, 1945). The severe

form of dengue, called DHF epidemic occurred first time in Manila, Philippines in 1953 to 1954

( Rigau-Perez et al., 1998).

In Asia, epidemic dengue has expanded geographically from Southeast Asian countries west to

India, Srilanka, the Maldives and Pakistan and east to China (Gubler, 1998a, 1998b). By the

1980s, the American region was experiencing major epidemics of dengue in countries that had

been free of the disease for 35 to 130 years (Gubler, 1987). Before 1980, little was known about

the distribution of dengue virus in Africa. Since then, however, major epidemics caused by all

four serotypes have occurred in both East and West Africa (Gubler and Trent 1994). In 1997,

dengue viruses and Aedes aegypti mosquitoes had a worldwide distribution in tropical and

subtropical countries of the world .Fig 1.

22
DENGUE IN INDIA

Dengue viruses have been persisting in India year after year since 1956. In Tamilnadu, the first

major outbreak of dengue was noticed in Vellore, South Arcot district in 1961 and the viral

etiology was established later by the isolation of dengue virus (Carey et al., 1966). The first

virologically proved epidemic of DF in India occurred in Calcutta and eastern coast of India in

1963 - 1964 (Sarkar et al., 1964; Chatterjee et al., 1965; Carey et al., 1966). Then, the dengue

infection spread northwards and reached Delhi in 1967 (Balaya et al., 1969). Subsequently, the

whole country was involved with wide spread epidemics followed by endemic or hyper endemic

prevalence of all four serotypes of dengue virus. After the occurrence of first epidemic in 1961,

Vellore experienced outbreaks in the year 1964, 1966 and 1968. The virological investigations

23
carried out during that period proved the presence of dengue 2 in 1964 outbreak (De Ranitz et

al., 1965; Carey et al., 1969). Dengue 3 virus was isolated in 1966 outbreak (Myer et al., 1969)

and all four types of dengue virus in 1968 outbreak (Myer et al., 1970). The epidemic at

Vishakapatnam in 1964 was due to dengue 2 virus (Krishnamurthy et al., 1965; Paul et al.,

1965).

The epidemic of dengue in Nagpur in 1965 documented the presence of dengue 4 virus in that

region (Rodrigues et al., 1972). In the same year, another outbreak was observed in Madras

which was caused by dengue 3 viruses (Myers et al., 1968). Later, outbreaks of dengue occurred

in Jabalpur (MP) by dengue virus 3 in 1966 (Sehgal et al., 1967, Rodrigues et al., 1973) in

Asansol in 1967 by dengue 2 and 4, in Delhi in 1967 by dengue 2 (Balya et al., 1969), in Kanpur

in 1968 and 1969 by dengue 4 and dengue 2 (Chaturvedi et al.,1970 ; Chaturvedi et al.,1972), in

Ajmeer in 1969 by dengue 1 and dengue 3 (Ghosh et al., 1974), in Gwalior in 1970 by dengue 3

(Arora et al., 1970), in Bangalore in 1971 by dengue 1 and dengue 2 (George and Soman, 1975 );

(Raghavan et al.,1970) in Jaipur in 1971 and 1973 by dengue 1 and 2 (Padbiri et al., 1973;

Mathew et al., 1976), in Jammu in 1974 by dengue 2 (Mathew et al., 1977) and in Trichur in

1974 by dengue 2 (Sreenivasan et al.,1979). Dengue 3 has been isolated during the epidemic at

Calcutta in 1983 (Mukerjee et al., 1987). An epidemic of dengue at Rajasthan in 1985 was due to

dengue 3 virus (Chouhan et al., 1990). Dengue 2 was isolated during the epidemics of dengue in

urban and rural areas of Gujarat state during 1988 and 1989 (Mahadev et al., 1993). Outbreaks

occurred at Gwalior in 2003 and 2004 by dengue 3 (Dash et al., 2005, 2006). Padbiri et al.,

(1995) reported dengue in Mangalore, Karnataka in 1993. In Punjab, there was an outbreak of

dengue in 1996 (Kuldip et al., 1997). The outbreak of dengue in Delhi in 1996 was due to

24
dengue 2 (Chusak et al., 1993; Dar et al., 1999). Hence, the presence of all four types of dengue

virus and occurrence of the disease all over the India were well documented (Fig -2).

25
CLINICAL DIAGNOSIS OF DENGUE INFECTION

Dengue virus infection in human causes a spectrum of illness ranging from inapparent or mild

febrile illness to severe and fatal haemorrhagic disease. Typical clinical symptoms noted during

outbreaks in India were pyrexia of 3 to 5 days duration which at times prolonged to 10 days,

gastro intestinal disorders, myalgia, arthralgia and rash. In recent years, several studies on

clinical manifestation of dengue infection have been published (Hayes et al., 1988) which

provide the basis for the prompt diagnosis of dengue infection.

Virological investigation was made by Bhattacharjee et al., (1995) to establish the etiologic agent

of a febrile outbreak amongst a floating population of C.R.P.F. Jawans, stationed at Calcutta

during May-July, 1993. The illness was associated with fever, severe headache, body ache and

arthralgia which lasted for 2-4 days in most of the cases.

An epidemic of febrile illness with haemorrhagic manifestation occurred in Mangalore city,

Karnataka, India in 1993. The most observed clinical symptoms were pyrexia, myalgia,

arthralgia and headache, palatile petechia, maculopapular, rash and facial flush. (Padbiri et al.,

1995).

A prospective observational study conducted by Kalayanarooj et al, (1997) in Bangladesh in

1994 revealed that 18 % of the dengue fever patients had anorexia, 61 % had nausea, 66 % had

vomiting, 28 % had abdominal pain and 80 % had headache. A comparative analysis of clinical

symptoms between DF patients and patients with OFI showed that DF patients were more likely

to report anorexia, nausea and vomiting than patients with OFI. However, the history of

headache, abdominal pain and bleeding were not significantly different between these groups.

Among the study groups the male: female ratio for dengue and OFI patients were 1:1.12 and

26
1:1.45 respectively. The mean ages for DF and OFI patients were 8.01(±3.15) and 6.2 (±3.0)

years respectively.

Clinical symptoms of 57 hospitalised laboratory positive patients with DHF in Puerto Rico in

1991 were fever (100 %), rash (47.4 %), hepatomegaly (10.5 %) and petechiae (45.6 %). The

male to female ratio was 1.5:1 and the mean age of the patients was 38 years (Rigau-Perz 1997).

Deparis et al., (1998) conducted a prospective study from 1996 to 1997 in Polynesia and found

that fever (90 %), headache (92.5 %), arthralgia (84 %), abdominal pain (61 %) and vomiting (57

%) were the commonest symptoms. Appearance of rash (18 %), prutus (17 %), diarrhea (17 %),

hepatomegaly (8 %) and respiratory illness (19.5 %) were also observed. The association of

macular rash, purities, low platelet count and leukocytopenia was statistically predictive of

dengue but not clinically since these four signs occur in many viral infections.

Banerjee et al., (2008) studied 50 cases of fever clinically suspected to be dengue in Pune, India.

The commonest clinical feature was fever with rash (85 %). Retro orbital and headache were

reported by 63 % of the patients. Myalgia was seen in 81 % of the patients. Hepatomegaly was

seen in 15 % of the patients. Conjunctival congestion was observed in 37 % of the patients. The

frequencies of clinical symptoms were comparatively higher in IgM positive patients than IgM

negative patients.

Kumar et al., (2008) conducted a study with 27 dengue positive children in Lucknow, India in

2006. Clinical features of dengue IgM positive cases included bleeding (57 %), convulsion (50

%), rash (14.3 %), swelling (28.6 %), headache (21.4 %) and vomiting (35.7 %). No one was

found to have diarrhea and there was no significant differences in clinical feature among dengue

IgM positive and negative cases. Hepatomegaly was observed in 64.3 % of the patients.

27
SERODIAGNOSIS OF DENGUE INFECTION

Serodiagnosis and seroepidemilogical survey on dengue infections have been carried out mostly

by Haemagglutination Inhibition (HI) test for many years. This technique was developed for

demonstrating an increase in antibody titer during infections with arboviruses (Sabin and

Buscher 1950). Then, HI test was perfected by Clarke and Casals (1958) and was adapted to

microtitre plate by Sever (1962).This technique is highly sensitive but it lacks specificity and

requires paired samples for accurate diagnosis (Vorndam et al., 1997).

Innis et al., (1989) found that in Jharkand, anti dengue IgM appeared in most cases by the 3rd

day of febrile illness and declined to undetectable level after 30 – 60 days. IgM capture ELISA

showed 78 % sensitivity in acute serum and 97 % in paired sera. Dengue infections could be

classified as primary or secondary by determining the ratio of units of dengue IgM to IgG

antibody.

According to Henchel and Putnak, (1990), ELISA has been the most widely used method in the

past, the extensive cross reaction encountered and the non availability of results within a short

period of time due to requirement of both acute and convalescent sera collected at least seven

days apart, have compromised the general applicability of this assay in the diagnosis of dengue.

Chouhan et al., (1990) detected IgM antibodies to dengue viruses in 70 % of sera collected in

Rajasthan in 1985.

Ram et al., (1998) carried out an investigation on an outbreak of dengue fever occurred in

Ludhiana in 1996 and 1997. Serological examination was performed by dengue IgG and IgM

blot with single serum samples of 189 patients. Of these 129 (68.25 %) samples were detected

positive for anti dengue antibodies.

28
An outbreak of DHF/DSS occurred in 1996 in New Delhi, India was studied by Dar et al., (1999)

and they reported that out of 270 serum samples tested by MAC – ELISA for the detection of

IgM antibodies against dengue virus, 140 (51.9 %) showed anti dengue IgM antibodies. All the

samples from patients with duration of fever > 5 days were tested for anti–dengue IgM

antibodies. In some samples, antibodies could be detected as early as the fifth day of fever. Three

of the culture positive acute phase serum samples were also positive by MAC ELISA.

A hospital based cross – sectional serodiagnostic survey under taken by Chakravarthi et al.,

(2002) during 1999-2001 in Delhi, India showed that, out of 345 patients experiencing a febrile

episode, 85 cases (25 %) were confirmed as serologically positive, with 15 cases showing IgM

antibodies indicating primary infection and 19 cases showing both IgM and IgG antibodies

indicating secondary infection.

During October to December 2003 in northern India, Dash et al., (2005) observed that 12 out of

76 (22 %) patients had a positive IgM response, indicative of primary infection, and 22 of them

(42 %) revealed only IgG antibodies, indicative of secondary infection.

IraShah and Katira (2005) reported that in Mumbai, India in 2003, out of 69 suspected dengue

cases tested by ELISA for dengue IgM antibodies. 34 (49.3 %) patients had a positive dengue

IgM titre. Similarly, Kalita et al., (2005) reported that in Lucknow, diagnosis of dengue was

based on the results obtained by IgM ELISA.

A large outbreak of dengue and DHF occurred from August to November 2005 involving all

districts of West Bengal, India. Altogether, 6293 persons were serologically diagnosed to be

suffering from dengue through the detection of IgM antibodies by ELISA (Hati, 2006).

29
Banerjee et al., (2008) reported that in Pune, India, out of 50 dengue suspected patients 27(54 %)

had IgM antibodies for dengue and it was stated that the serological sensitivity of ELISA (Panbio

diagnostics) kit used in that study was 85.4 % - 98.9 % for the detection of primary infection and

the specificity was 95.7 % -100 %.

Faridi et al., (2008), in their study on clinical and biochemical profile of dengue haemorrhagic

fever in children in Delhi reported that IgM dengue serology was positive in 68.5 % of the cases.

Over a period of 10 weeks from July to September 2006, children admitted in hospital with acute

hepatic failure in Lucknow, India were examined for the presence of IgM to dengue virus by

IgM capture ELISA (Panbio, Australia). Out of 27 children, 13 (48.1 %) were positive for

dengue IgM. Serum samples of 7 randomly selected IgM positive patients were subjected to real

time PCR assay of which 4 were positive. (Kumar et al., 2008).

Priyadarshini et al., (2010) in their study conducted in Pune ,India tested sera from 372 dengue

suspected cases by IgM capture ELISA and found that 195 (52.4 %) patients were positive for

dengue specific IgM.

30
 CHAPTER -4
OBJECTIVE OF THE
STUDY

31
 OBJECTIVES OF THE STUDY
Primary objectives of the study are to assess the knowledge, attitude and perception towards

Dengue Fever.

Other Objectives of the study are as follows:-

 To study about the Dengue fever.

 To examine the symptoms of Dengue fever.

 To examine the causes of Dengue fever.

 To study about the level of awareness about the Dengue fever in Lucknow.

32
 CHAPTER -5

RESEARCH

METHODOLOGY

33
 RESEARCH METHODOLOGY

Research in common parlance prefers to a search for knowledge. Once can also define research

as a scientific and systematic search for pertinent information on a specific topic. In fact research

is an art of scientific investigation. Research is an academic activity and as such the term should

be used in a technical sense.

Study design:

A community-based cross sectional study has designed for this study.

Study setting:

The study will be conducted in Lucknow. 76 samples will be selected & will approach for an

interview with predesigned printed schedule.

Data Analysis & Interpretation-

After collection of information from all 76 samples, data analysis will be done & finding will be

incorporated in dissertation.

Reference-

All references will be also incorporated in the dissertation.

34
 CHAPTER 6:

RESULT & DISCUSSION

35
 RESULT & DISCUSSION

DEMOGRAPHIC

Demographic information is presented in Table 1. Forty-one percent of participants were male

and 59 % were female. Ages ranged from under 30 years old to less than 70 years old, with a

median age group of 41 to 50 years old and a median of 10 to 14 years of healthcare experience.

Participants consisted of physicians (82 %), nurses (14 %), and other healthcare professionals

(4 %). There are 93 physicians working in the public health sector in Lucknow including 63

doctors at 17 public health clinics, 15 in the central hospital, and 15 in the social security

hospital, giving an inclusion rate of 67 % of all potential physician subjects in the city.

Healthcare providers worked primarily in public health clinics (58 %) and the Private Hospital

(34 %).

Table 1: Characteristics of Study Participants (n = 76)

Category Response selected n (%)

Male 31 (41 %)
Gender
Female 45 (59 %)

<30 24 (32 %)

31–40 10 (14 %)

41–50 17 (23 %)
Age (years)
51–60 17 (23 %)

61–70 6 (8 %)

>70 0 (0 %)

Medical role Doctor 62 (82 %)

Nurse 11 (14 %)

36
Category Response selected n (%)

Other 3 (4 %)

<1 6 (8 %)

1–4 26 (34 %)

5–9 5 (7 %)
Years of Medical experience
10–14 7 (9 %)

15–19 10 (13 %)

>19 22 (29 %)

Community Health Center 43 (58 %)

Hospital 25 (34 %)
Practice setting (n = 74)
Diagnostic Laboratory 2 (3 %)

Other 4 (5 %)

37
Healthcare provider views of dengue burden

As seen in Table 2, healthcare providers in Lucknow were concerned with dengue infections,

with 89 % of participants agreeing that it is a “major problem for my patient population”. Of

those in agreement, the majority reported that dengue is a significant threat because the virus is

endemic to the region and has the potential to cause high morbidity. One participant reported that

dengue may cause “the deterioration of the [individual], family and community health”. The

majority of respondents (78 %) also agreed with the statement, “My patients feel that dengue

infection is a major problem for their health,” with 34 % citing health complications and

mortality as the major concerns in the general population. Seventeen percent of participants

suggested that public health measures within the city, including disease prevention efforts, local

infrastructure, and education were inadequate for controlling disease transmission. A small

subset (6 %) of providers reported that dengue is not a major problem because the region already

has effective prevention and treatment interventions in place. A similar proportion of providers

also felt that a dengue diagnosis creates an unnecessary sense of fear among patients.

Table 2: Physician responses to the statement “I think that dengue is a major problem for

my patient population” (n = 71)

Categorical responses Open-ended responses

Agree or Strongly Agree (n =  The region is an endemic zone

63, 88 %) Dengue has a high morbidity

There is a lack of preventative measures

Patients self-medicate

There exists poor infrastructure

Dengue poses a high risk to others

There is a lack of education about dengue

38
Categorical responses Open-ended responses

There is a lack of social consciousness regarding dengue

Neutral (n = 4, 6 %) There is adequate education about dengue

Disagree or Strongly Disagree Good preventative measures are in place

(n = 4, 6 %) Good medical attention is available

39
Providers’ views of the community response to dengue and self-medication

The majority (76 %) of healthcare providers perceived that patients exhibiting symptoms of

dengue would seek attention at a healthcare facility. An equal proportion also reported that

patients are aware of the steps needed to prevent dengue infection (See Tables 2, 3 and 4 for

physician attitudes toward dengue); of those who agreed with this statement, 30 % suggested that

public health awareness campaigns were successful. For example, one participant reported, “due

to constant [educational] campaigns, [patients] know to seek out medical help before they

develop alarms signs”.

Table 3: Physician responses to the statement “My patients feel that dengue infection is a major

problem for their health” (n = 68)

Categorical responses Open-ended responses

Dengue has a high morbidity

Dengue is considered an alarming diagnosis

Dengue decreases economic productivity

Agree or Strongly Agree (n = 53,
Dengue is difficult to detect
78 %)
The environment is conducive to disease

transmission

Dengue poses a high risk to others

Neutral (n = 7, 10 %) Adequate medical attention is available

Disagree or Strongly Disagree (n = 8, Patients believe self-medication is adequate

12 %) There is a lack of education about dengue

Table 4: Physician responses to the statement “In my experience, a member of the

community who exhibits dengue symptoms will seek medical attention” (n = 71)

40
 Categorical responses Open-ended responses

Patients believe that dengue has a high morbidity if

untreated

Dengue symptoms are severe

Agree or Strongly Agree (n = 54, 76 %)
Patients want to prevent complications

There is adequate education about dengue

There is easy access to medical attention

Some patients will seek attention while others self-

Neutral (n = 7, 10 %)
medicate

Patients do not seek medical attention until

Disagree or Strongly Disagree (n = 10,
complications develop
14 %)
Medical care is delayed by self-treatment
Clinical scenario scores and cumulative knowledge scores

The Cumulative Knowledge Score analysis results are presented in Tables 5 and 6

(Table 6 consists of the Clinical Scenario subset of questions). The mean Cumulative Knowledge

Score was 10.5 of 14 possible points (SD ± 1.73). Using a Bonferroni correction, the statistical

significance level for CKS was determined to be p <0.01. The Cumulative Knowledge Score

correlated positively with: 1) reporting familiarity with the WHO Dengue Guide (r = 

0.427, p <0.01), 2) agreeing with the statement “I believe that dengue is a major problem for my

patient population” (r = 0.433, p <0.01), and 3) agreeing to the statement “My patients feel that

dengue infection is a major problem for their health” (r = 0.282, p <0.01). Notably, having

previous dengue training was not significantly correlated with the CKS (p = 0.225). These

associations provide evidence of the interrelatedness of a practitioner’s knowledge, patient care,

41
and concern for dengue infection. Clinician education must not only focus on basic knowledge,

but also emphasize dengue’s burden on individual health and communities.

Table 5: Knowledge-Based Questions (n = 76)

n (%) with correct

Question Correct response
response

1. How is dengue spread? Aedes mosquito 75 (99 %)

2. At what time of day are people most

Any answer other than “Night” 57 (75 %)
likely to be infected by dengue?

3. Which of the dengue serotypes have

DENV 1–4 are all present
been found in Ecuador?

DENV 1 54 (71 %)

- Note: 0.25 point given per correct DENV 2 54 (71 %)

answer, with a total of 1 point available DENV 3 48 (63 %)

DENV 4 34 (45 %)

4. What advice do you give your patients 1. Frequently change the water in
66 (87 %)
to prevent dengue infection? flower vases

- Note: Question is worth a total of 2 2. Remove containers that

69 (91 %)
points accumulate clean water

- 0.25 point given per correct answer, with 3. Eliminate tanks or puddles
55 (72 %)
a maximum of 1 point. Column to the with stagnant water

4. Keep drinking water

right indicates the n (%) of respondents
containers (cisterns, tanks) 67 (88 %)
receiving
tightly closed
- 1 point given for not selecting “Take
Did not select “Take 54 (71 %)
Paracetamol”
42
 n (%) with correct
Question Correct response
response

Paracetamol”

5. Which group of patients should be 1. Dengue without warning signs

76 (100 %)
hospitalized? (F)

- Note: Each response is worth 1 point. 2. Dengue without warning

17 (22 %)
Question is worth a total of 4 points signs but with comorbidities (T)

- If the answer is correctly selected, the 3. Dengue with warning signs

59 (78 %)
respondent gains 1 point (T)

4. Severe dengue (T) 58 (76 %)

- If the answer is correctly left blank, the

respondent gains 1 point

- Responses that are correct are marked Percent answering all 4

15 (20 %)
here as (T) and if incorrect are marked as correctly

(F)

6. According to the WHO’s 2010 Clinical

Management of Dengue guidebook, what

n (%) selecting
signs and symptoms can be used to Correct Responses
response
identify an infection of dengue without

alarm signs?

- Note: Question is worth 1 point Headache 59 (78 %)

- Each response is worth 1/19 point, Muscle pain 60 (79 %)

which is given for either correctly Retro-orbital pain 62 (82 %)

Positive tourniquet test 45 (59 %)

selecting a true response or correctly
Fever/subjective warmth 64 (84 %)
43
 n (%) with correct
Question Correct response
response

Petechial rash 33 (43 %)

Vomit 25 (33 %)

Incorrect

Ascites 1 (1 %)

Constipation 5 (7 %)

Diarrhea 10 (13 %)

Dyspnea 3 (4 %)

Dysuria 2 (3 %)
leaving a false response blank
Chest pain 1 (1 %)

Edema 2 (3 %)

Icterus 1 (1 %)

Lymphadenitis 3 (4 %)

Nasal secretions 11 (14 %)

Persistent cough 3 (4 %)

Thrombocytopenia 15 (22 %)

7. Select any the treatments you could use

Oral Hydration 70 (92 %)
in a patient suspected to have dengue

- Note: Question is worth 1 point IV Hydration 12 (16 %)

- 0.5 points given for hydration (either Paracetamol 71 (93 %)

oral and/or IV) and 0.5 points given for Anti-bacterial 1 (1 %)

Anti-viral 1 (1 %)
paracetamol. Recipient is given 0 points if
Any of the following (listed 0 (0 %)
anti-bacterial or anti-viral medication is
individually in survey): Aspirin,

44
 n (%) with correct
Question Correct response
response

NSAIDs/Steroids/Immunosuppr

essants (methotrexate,

cyclosporine,
selected
etc.)/Opioids/Platelets/Plasma/

Whole blood transfusion

Note: One point given per question, unless otherwise specified

45
Table 6: Clinical Knowledge Questions

Question Response Selected n (%)

1. An 8-year old male patient presents to your office with a (n = 73)

4 day history of fever, nausea, vomiting three times per day,

Dengue fever 0 (0 %)
and joint aches. He is accompanied by his mother, who Dengue hemorrhagic
5 (7 %)
reports that he has been less active over the past few days fever
and seems to be getting more uncomfortable. You note the Dengue shock
0 (0 %)
following abnormalities on physical exam: The patient has syndrome

bleeding of the oral mucosa, a palpable mass on the right Dengue without
2 (3 %)
side 2 cm below the ribs, and winces when you palpate his warning signs

abdomen. You do not observe fluid in the abdomen or Dengue with warning
61 (83 %)
difficulty breathing. Based on current WHO guidelines, this signs (T)

patient is best classified as: Severe dengue 5 (7 %)

(n = 73)

Order dengue lab

2. A 5-year-old girl patient presents to your office with a tests, tell the patient
few days of fever and a distended, painful abdomen. Her to get rest at home,
10 (14 %)
mother states that she has been less active over the past and ask the patient to
3 days. It is currently February and you have seen six return to your office
patients in the past 3 weeks with dengue infections. The in 24 h
best course of action in managing this patient is to: Order dengue lab

tests and admit the 54 (74 %)

patient to the hospital

46
Question Response Selected n (%)

for 24 h of

observation (T)

Order dengue lab

tests and admit the

patient to the

Intensive Care Unit 9 (12 %)

for close monitoring

and access to

emergency care

3. A 27-year-old male patient presents to your office in (n = 71)

February with two days of fever and complaints of muscle

Order dengue lab
aches. He notes that he has had three episodes of non-
tests, tell the patient
bloody vomiting in the past two days. The patient notes that
to get rest at home,
52 (73 %)
his younger sister has similar symptoms. You recall hearing
and ask the patient to
numerous reports of dengue infection during the last month.
return to your office
The best course of action in managing this patient is to:
in 24 h (T)

Order dengue lab

tests and admit the

patient to the hospital 19 (27 %)

for 24 h of

observation

Order dengue lab 0 (0 %)

47
Question Response Selected n (%)

tests and admit the

patient to the ICU for

close monitoring and

access to emergency

care

Note: Each question is worth 1 point. (T) if placed next to the correct response

48
CHAPTER 7

FINDINGS

49
 FINDINGS

Dengue virus infection is endemic in India with frequent epidemics of DF/DHF. All the four

serotypes are circulating resulting in concurrent infection with two DV. In the last few years the

predominant serotype is DV-3. The vector has adapted to extremes of warm and cold weather

resulting in occurrence of dengue cases round the year. Dengue and the vector have been

reported in the arid zones of Rajasthan (Chouhan et al 1990; Angel and Joshi 2008). There are

large number of reports on atypical clinical presentations but they are not backed by virological

studies due to lack of such facilities at most parts of the country. There is no adequate animal

model for DHF and a number of hypotheses have been put forward to explain the vascular

leakage. With massive efforts all over the world the vaccine is round the corner. The problem of

dengue is mammoth in this country that is compounded by the huge population, poor medical

and diagnostic facilities, inadequate mosquito control and all the ground conditions that favour

expansion of the vector. This country needs a large number of virus laboratories that may

provide quick and reliable diagnosis. Efforts will have to be made to develop improved,

proactive, laboratory-based surveillance systems that can forecast impending dengue epidemics.

This will alert the public to take action and physicians to diagnose and properly treat DF/DHF

cases. There is need to have a strong epidemiology/ pathology/experimental pathology backup.

Are our efforts adequate? Our efforts are limited only to the stage of crisis management. We

need dedicated teams to solve the problems and minimize the human suffering.

50
CHAPTER 8

CONCLUSION

51
 CONCLUSION

Dengue is one of the major re-emerging viral infections; the global incidence of dengue has

shown a 30-fold increase over the past 50 years and the disease has become one of the most

rapidly spreading mosquito-borne viral diseases Several factors like urbanization, transport

development, changing habitats and improper water storage practices, which facilitate breeding

of Aedes aegypti, contribute to its rapid spread. The demographic, economic, behavioural and

societal factors greatly influence the key epidemiological determinants including host, viral and

vector status.

In the present study, adults and children were similarly affected by dengue. Dengue was typically

thought to be a paediatric disease in South-east Asian countries with rare adult clinical cases of

dengue fever (DF). However, in recent years, an increasing incidence of DV infection was found

in the adults. This age shift has been observed in other Asian countries including Singapore,

Indonesia, Bangladesh and Thailand where dengue has been epidemic for several years.

Males were more commonly affected than females in the present study. Another hospital based

study from India also suggested a higher male to female ratio in DV infected hospitalized cases.

However, this may represent only those who access the healthcare facilities and may not be

applicable to the general population.

All four serotypes of DV are known to be circulating in North India. We have earlier reported

DV-2, DV-3 and DV-1 to be the dominant circulating serotypes in 2008, 2009 and 2010,

respectively1 in the Lucknow region. DV-2, DV-1 and DV-3 were the dominant circulating

serotypes in the present study. Similar periodic serotype shift has been seen in Delhi and may

contribute to increased severity of dengue cases.

52
The present study also demonstrated that number of cases presenting as dengue with warning

signs/severe dengue was almost equal to cases presenting as dengue fever without warning signs.

A comparison of year 2011-2013 NVBDCP (National Vector Borne Disease Control

Programme) data with that of previous years indicated a shift from mild illness towards a more

severe manifestation of the disease, which could be interpreted as an epidemiologic transition

pattern and is a sign of hyperendemicity of the dengue virus in UP. In addition, genotypic

changes in dengue viruses may contribute further to emergence of severe dengue.

The modalities available for diagnosis of dengue infection include isolation of the virus,

serological tests and molecular methods. The detection of dengue virus genes in serum sample

by PCR coincides with the viraemia and the febrile phase of disease. However, the limitation of

this test is that the test remains positive only when the serum is collected from patients during the

first five days of symptoms. On the contrary, DV-NS1Ag can be detected upto 18 days post

onset of symptoms. Most of the cases in the present study had post illness day varying from 5-15

days. This might explain the low PCR positivity as compared to NS1Ag positivity in the present

study.

In conclusion, involvement of a high proportion of adult population and predominantly male

involvement are the main findings of the study. Annual change in the predominant circulating

serotype and increase in the number of severe dengue cases were also observed.

53
ANNEXURE

54
 BIBLIOGRAPHY

REFERENCES:-

 Pandey N, Nagar R, Gupta S, Omprakash, Khan D, Singh DD, et al. Trend of dengue

virus infection at Lucknow, north India (2008- 2010): a hospital based study. Indian J

Med Res. 2012;136:862–7.[PMC free article] [PubMed]

 Tripathi P, Kumar R, Tripathi S, Tambe JJ, Venkatesh V. Descriptive epidemiology of

dengue transmission in Uttar Pradesh. Indian Pediatr. 2008;45:315–8. [PubMed]

 World Health Organization (WHO) and the Special Programme for Research and

Training in Tropical diseases (TDR) Dengue: guidelines for diagnosis, treatment,

prevention, and control”. 2009. [accessed on January 10, 2014]. Available

from: http://whqlibdoc.who.int/publications/2009/9789241547871,eng.pdf .

 Kumar A, Sharma SK, Padbidri VS, Thakare JP, Jain DC, Datta KK. An outbreak of

dengue fever in rural areas of northern India. J. Commun Dis. 2001;33:274–

81. [PubMed]

 Gupta N, Srivastava S, Jain A, Chaturvedi UC. Dengue in India. Indian J Med

Res. 2012;136:373–90.[PMC free article] [PubMed]

 Balaya S, Paul SD, D’Lima LV, Pavri KM. Investigations on an outbreak of dengue in

Delhi in 1967. Indian J Med Res. 1969;57:767–74. [PubMed]

 Chaturvedi UC, Mathur A, Kapoor AK, Mehrotra NK, Mehrotra RM. Virological study

of an epidemic of febrile illness with haemorrhagic manifestations at Kanpur, India,

during 1968. Bull World Health Organ. 1970;43:289–93. [PMC free article] [PubMed]

55
 Myers RM, Carey DE, DeRanitz CM, Reuben R, Bennet B. Virological investigations of

the 1966 outbreak of dengue type 3 in Vellore, Southern India. Indian J Med

Res. 1969;57:1392–401. [PubMed]

 Lanciotti RS, Calisher CH, Gubler DJ, Chang GJ, Vorndam AV. Rapid detection and

typing of dengue viruses from clinical samples by using reverse transcriptase-polymerase

chain reaction. J Clin Microbiol. 1992;30:545–51. [PMC free article] [PubMed]

 Gubler DJ. The changing epidemiology of yellow fever and dengue, 1900 to 2003: full

circle? Comp Immunol Microbiol Infect Dis. 2004;27:319–30. [PubMed]

 Bhatia R, Dash AP, Sunyoto T. Changing epidemiology of dengue in South-East

Asia. WHO South-East Asia J Public Health. 2013;2:23–7.

 Murray NE, Quam MB, Wilder-Smith A. Epidemiology of dengue: past, present and

future prospects. Clin Epidemiol. 2013;5:299–309. [PMC free article] [PubMed]

 Lakshmi K, Deepti GN, Chitralekha S. Dengue - changing trends and the need for

research. Res J Pharm Biol Chem Sci. 2014;5:144–8.

 Matlani M, Chakravarti A. Changing trends of dengue disease: a brief report from a

tertiary care hospital in New Delhi. Braz J Infect Dis. 2011;15:184–5. [PubMed]

 Dar L, Gupta E, Narang P, Broor S. Cocirculation of dengue serotypes, Delhi, India,

2003. Emerg Infect Dis. 2006;12:352–3. [PMC free article] [PubMed]

 Dash PK, Parida MM, Saxena P, Abhyankar A, Singh CP, Tewari KN, et al.

Reemergence of dengue virus type-3 (subtype-III) in India: implications for increased

incidence of DHF & DSS. Virol J. 2006;6:3–55. [PMC free article] [PubMed]

 Dengue: Dengue cases and deaths in the country since 2009. National Vector Borne

Disease Control Programme (NVBDCP), Directorate General of Health Services.

56
 Ministry of Health and Family Welfare, Government of India, New Delhi, India.

[accessed on January 10, 2014]. Available from:http://www.nvbdcp.gov.in/dencd.html .

 Chaturvedi UC, Mathur A, Kapoor AK, Tandon HO, Mehrotra RM. Clinico-virological

study of the recurrence of dengue epidemic with haemorrhagic manifestations at Kanpur

during 1969. Indian J Med Res. 1972;60:329–33. [PubMed]

 Dar L, Broor S, Sengupta S, Xess I, Seth P. The first major outbreak of dengue

hemorrhagic fever in Delhi, India. Emerg Infect Dis. 1999;5:589–90. [PMC free

article] [PubMed]

 Mishra G, Jain A, Prakash O, Prakash S, Kumar R, Garg RK, et al. Molecular

characterization of dengue viruses circulating during 2009-2012 in Uttar Pradesh, India. J

Med Virol. 2015;87:68–75. [PubMed]

 Messer WB, Vitarana UT, Sivananthan K, Elvtigala J, Preethimala LD, Ramesh R, et al.

Epidemiology of dengue in Sri Lanka before and after the emergence of epidemic dengue

hemorrhagic fever. Am J Trop Med Hyg. 2002;66:765–73. [PubMed]

 Centres for Disease Control and Prevention, Dengue, laboratory guidance and diagnostic

testing. [accessed on January 10, 2014]. Available

from: http://www.cdc.gov/dengue/clinicalLab/laboratory.html .

57
WEBSITES:-

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4795350/

 http://medind.nic.in/ibv/t08/i4/ibvt08i4p315.pdf

 http://shodhganga.inflibnet.ac.in/bitstream/10603/37122/9/09_chapter%202.pdf

 http://www.ias.ac.in/article/fulltext/jbsc/033/04/0429-0441

 http://www.ndtv.com/india-news/allahabad-high-court-raps-up-government-over-dengue-

toll-1475689

 http://pubs.sciepub.com/ajphr/1/2/2/

 https://tdtmvjournal.biomedcentral.com/articles/10.1186/s40794-016-0024-y

 https://www.iamat.org/country/india/risk/dengue

 https://www.healthissuesindia.com/2019/11/06/action-on-dengue-urged-in-uttar-pradesh/

58
 QUESTIONNAIRE

1. Do you think that dengue has a high morbidity rate?

a. Agree

b. Strongly Agree

c. Disagree

d. Highly disagree

2. Do you think that Dengue is difficult to detect?

a. Agree

b. Strongly Agree

c. Disagree

d. Highly disagree

3. Do you think that there exists poor infrastructure?

a. Agree

b. Strongly Agree

c. Disagree

d. Highly disagree

59
4. Do you think that there is lack of education about dengue?

a. Agree

b. Strongly Agree

c. Disagree

d. Highly disagree

5. Do you think that there is adequate education about dengue?

a. Agree

b. Neutral

c. Disagree

6. Do you think that Good preventative measures are in place?

a. Agree

b. Strongly Agree

c. Disagree

d. Strongly disagree

7. Do you think that Good medical attention is available?

a. Agree

b. Strongly Agree

c. Disagree

d. Strongly disagree

60
8. Do you think that Patients believe self-medication is adequate?

a. Agree

b. Strongly Agree

c. Disagree

d. Strongly disagree

9. Do you think that Dengue symptoms are severe?

a. Agree

b. Strongly Agree

c. Disagree

d. Strongly disagree

10. Do you think that Patients do not seek medical attention until complications develop?

a. Agree

b. Strongly Agree

c. Disagree

d. Strongly disagree

Other questions:-

11. How is dengue spread?

12. At what time of day are people most likely to be infected by dengue?

13. Which of the dengue serotypes have been found in Ecuador?

THANK YOU
61