Prevention and Control of Dengue and

Dengue Haemorrhagic Fever

International Public Health Issues
Susilowati, S.KM., M.KM
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Comprehensive Guidelines for Prevention and Control of Dengue and
Dengue Haemorrhagic Fever (Revised and Expanded Edition)
© World Health Organization 2011
1. Introduction
2. Disease Burden of Dengue Fever
and Dengue Haemorrhagic Fever
3. Epidemiology of Dengue Fever and
Dengue Haemorrhagic Fever
4. Clinical Manifestations and
Diagnosis
5. Laboratory Diagnosis
6. Clinical Management of Dengue/
Dengue Haemorrhagic Fever
7. Disease Surveillance:
Epidemiological and Entomological
8. Dengue Vectors
9. Vector Management and Control
10. Integrated Vector Management
(IVM)
11. Communication for Behavioural
Impact (COMBI)
12. The Primary Health Care Approach
to Dengue Prevention and Control
13. Case Investigation, Emergency
Preparedness and Outbreak
Response
14. Monitoring and Evaluation of
DF/D HF Prevention and Control
Programmes
15. Strategic Plan for the Prevention
and Control of Dengue in the
Asia-Pacific Region: A Bi-regional
Approach (2008–2015)
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The Viruses
• Dengue is a mosquito-borne disease caused by any one of four
closely related dengue viruses (DENV-1, -2, -3, and -4).
• Infection with one serotype of DENV provides immunity to that
serotype for life, but provides no long-term immunity to other
serotypes.
• Thus, a person can be infected as many as four times, once with
each serotype.
• Dengue viruses are transmitted from person to person by Aedes
mosquitoes (most often Aedes aegypti) in the domestic
environment.
• Epidemics have occurred periodically in the Western Hemisphere for
more than 200 years. In the past 30 years, dengue transmission and
the frequency of dengue epidemics have increased greatly in most
tropical countries in the American region.
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Transmission Cycles

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Clinical Diagnosis
Manifestations of Dengue Virus Infection

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Clinical Diagnosis
1. Dengue
• Classic dengue fever, or “break bone fever,” is characterized by acute
onset of high fever 3–14 days after the bite of an infected mosquito.
• Symptoms include frontal headache, retro-orbital pain, myalgias,
arthralgias, hemorrhagic manifestations, rash, and low white blood
cell count.
• The patient also may complain of anorexia and nausea.
• Acute symptoms, when present, usually last about 1 week, but
weakness, malaise, and anorexia may persist for several weeks.
• A high proportion of dengue infections produce no symptoms or
minimal symptoms, especially in children and those with no
previous history of having a dengue infection.
• The main medical complications of classic dengue fever are febrile
seizures and dehydration.
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Clinical Diagnosis
1. Dengue
Treatment of dengue fever emphasizes
• Relieving symptoms of pain.
• Controlling fever.
• Telling patients to avoid aspirin and other
nonsteroidal, anti-inflammatory medications
because they may increase the risk for
hemorrhage.
• Reminding patients to drink more fluids,
especially when they have a high fever.

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Clinical Diagnosis
2. Dengue Hemorrhagic Fever
• Some patients with dengue fever go on to develop dengue hemorrhagic fever
(DHF), a severe and sometimes fatal form of the disease.
• Around the time the fever begins to subside (usually 3–7 days after symptom
onset), the patient may develop warning signs of severe disease.
• Warning signs include severe abdominal pain, persistent vomiting, marked
change in temperature (from fever to hypothermia), hemorrhagic manifestations,
or change in mental status (irritability, confusion, or obtundation).
• The patient also may have early signs of shock, including restlessness, cold
clammy skin, rapid weak pulse, and narrowing of the pulse pressure (systolic
blood pressure − diastolic blood pressure).
• Patients with dengue fever should be told to return to the hospital if they
develop any of these signs.

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Clinical Diagnosis
2. Dengue Hemorrhagic Fever
DHF is currently defined by the following four WHO criteria:
• Fever or recent history of fever lasting 2–7 days.
• Any hemorrhagic manifestation.
• Thrombocytopenia (platelet count
• of <100,000/mm3).
• Evidence of increased vascular permeability.

The most common hemorrhagic manifestations are mild and include a positive tourniquet
test, skin hemorrhages (petechiae, hematomas), epistaxis (nose bleed), gingival bleeding
(gum bleed), and microscopic hematuria.

More serious types of hemorrhage include vaginal bleeding, hematemesis, melena, and
intracranial bleeding.
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Clinical Diagnosis
2. Dengue Hemorrhagic Fever
Evidence of plasma leakage due to increased vascular
permeability consists of at least one of the following:
• An elevated hematocrit ≥20% above the population
mean hematocrit for age and sex.
• A decline in hematocrit after volume-replacement
treatment of ≥20% of the baseline hematocrit.
• Presence of pleural effusion or ascites detected by
radiography or other imaging method.
• Hypoproteinemia or hypoalbuminemia as determined
by laboratory test.
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Clinical Diagnosis
2. Dengue Hemorrhagic Fever
• WHO is currently reevaluating the clinical case
definition for dengue fever and DHF.
• Studies from different countries have reported life-
threatening complications from dengue in the absence
of one or more of the current criteria for DHF.
• Despite the name, the critical feature that distinguishes
DHF from dengue fever is not hemorrhaging, but rather
plasma leakage resulting from increased vascular
permeability.

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Clinical Diagnosis
3. Dengue Shock Syndrome (DSS)
• Dengue shock syndrome (DSS) is defined as any case that
meets the four criteria for DHF and has evidence of
circulatory failure manifested by (1) rapid, weak pulse and
narrow pulse pressure (≤20 mmHg [2.7 kPa]) or (2)
hypotension for age, restlessness, and cold, clammy skin.
• Patients with dengue can rapidly progress into DSS, which, if
not treated correctly, can lead to severe complications and
death.
• Fatality rates among patients with DSS can be 10% or higher
but, with early recognition and treatment, can be less than
1%. DHF and DSS can occur in both children and adults.

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Clinical Diagnosis
Major Manifestations/Pathophysiological Change of DHF

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Prevention and Control
• Prevention and control of dengue and DHF has become more urgent with the
expanding geographic distribution and increased disease incidence in the
past 40 years.
• Unfortunately, tools available to prevent dengue infection are very limited.
There is no vaccine currently available, and options for mosquito control are
limited.
• Clearly, the emphasis must be on disease prevention if the trend of emergent
disease is to be reversed.
• Effective disease prevention programs must have several integrated
components, including active laboratory-based surveillance, emergency
response, education of the medical community to ensure effective case
management, community-based integrated mosquito control, and effective
use of vaccines when they become available. 15
Prevention and Control
Vaccine Development
• The first candidate dengue vaccines were developed shortly after the viruses were first
isolated by Japanese and American scientists.
• Despite considerable work over the years, an effective safe vaccine was never
developed.
• With the support of the World Health Organization, considerable progress in
developing a vaccine for dengue and DHF has been made in recent years.
• Promising progress in the development of alternative vaccine strategies using new
molecular technology has also been made in recent years.
• Despite the promising progress, it is unlikely that an effective, safe, and economical
dengue vaccine will be available in the near future.
• A major problem has been and continues to be lack of financial support for dengue
vaccine research. Thus, other approaches to disease prevention must be developed by
using the program components outlined above.
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Disease Prevention Programs
Disease Surveillance
The objectives of public health surveillance applicable to
dengue are to:
• detect epidemics early for timely intervention;
• measure the disease burden;
• monitor trends in the distribution and spread of dengue
over time;
• assess the social and economic impact of dengue on the
affected community;
• evaluate the effectiveness of prevention and control
programmes; and
• facilitate planning
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Disease Prevention Programs
1. Passive Surveillance
Passive surveillance should require case reports from every
clinic, private physician and health centre or hospital that
provides medical attention to the population at risk.

However, passive surveillance for DF/DHF has two problems.

• First, there is no consistency in reporting standards. Some
countries report only DHF while others report both DF and
DHF.
• Secondly, the WHO case definitions are also not strictly
adhered to while reporting the cases. These problems lead
to both underreporting and overreporting that actually
weakens the surveillance systems.
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Disease Prevention Programs
2. Active Surveillance
• Active disease surveillance is an important component of a dengue
prevention program.
• In addition to monitoring secular trends, the goal of surveillance should be to
provide an early-warning or predictive capability for epidemic transmission,
the rationale being that if epidemics can be predicted, they can be prevented
by initiating emergency mosquito control.
• For epidemic prediction, health authorities must be able to accurately monitor
dengue virus transmission in a community and be able to tell at any point in
time where transmission is occurring, which virus serotypes are circulating,
and what kind of illness is associated with dengue infection.
• To accomplish this, the system must be active and laboratory based.

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Disease Prevention Programs
2. Active Surveillance
• This type of proactive surveillance system must have at least three components
that place the emphasis on the inter- or preepidemic period.
• These components include a sentinel clinic and physician network, a fever alert
system that uses community health workers, and a sentinel hospital system (see
table).
• The sentinel clinic and physician network and fever alert system are designed to
monitor nonspecific viral syndromes in the community.
• This is especially important for dengue viruses because they are frequently
maintained in tropical urban centers in a silent or unrecognized transmission cycle,
often presenting as nonspecific viral syndromes.
• The sentinel clinic and physician network and fever alert system are also very
useful for monitoring other common infectious diseases such as influenza,
measles, malaria, typhoid, and leptospirosis.
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Disease Prevention Programs
2. Active Surveillance
• The fever alert system relies on community health and sanitation workers to
be alert to any increase in febrile activity in their community and to report this
to the central epidemiology unit of the health department. Investigation by
the health department should be immediate but flexible; it may involve
telephone follow-up or active investigation by an epidemiologist who visits
the area to take samples.
• The sentinel hospital component should be designed to monitor severe
disease. Hospitals used as sentinel sites should include all of those that admit
patients for severe infectious diseases in the community.
• All three proactive surveillance components require a good public health
laboratory to provide diagnostic support in virology, bacteriology, and
parasitology.
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Disease Prevention Programs
2. Active Surveillance

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Disease Prevention Programs
3. Vector Surveillance
• Larval surveys
• Pupal/demographic surveys
• Adult surveys
- Landing collections
- Resting collections
• Oviposition traps
• Tyre section larvitraps

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Disease Prevention Programs
3. Vector Surveillance: Indexes

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Disease Prevention Programs
3. Vector Surveillance: Ovitrap

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Disease Prevention Programs
4. Sampling Approaches

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Disease Prevention Programs
5. Monitoring Insecticide Resistance
• Information on the susceptibility of Ae. aegypti to insecticides is of
fundamental importance for the planning and evaluation of control.
• During the past 50 years, chemicals have been widely used to control
mosquitoes and other insects from spreading diseases of public health
importance.
• As a result, Ae. aegypti and other dengue vectors in several countries have
developed resistance to commonly-used insecticides, including DDT,
temephos, malathion, fenthion, permethrin, propoxur and fenitrothion.
• It is, therefore, advisable to obtain baseline data on insecticide susceptibility
before insecticidal control operations are started, and to continue periodically
monitoring susceptibility levels of larval or adult mosquitoes.

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Disease Prevention Programs
6. Additional Information for Entomological Surveillance
• In addition to the evaluation of aspects such as vector density and
distribution, community-oriented, integrated pest management strategies
require that other parameters be periodically monitored.
• The monitoring of these parameters is relevant and of importance to planning
purposes and for assessing the dengue risk.
• Knowledge of changes over time in the distribution of water supply services,
their quality and reliability, as well as in domestic water-storage and solid
waste disposal practices is also particularly relevant.
• In the case of meteorological data, especially rainfall patterns, humidity and
temperature, a more frequent analysis is warranted if it is to be of predictive
value in determining seasonal trends in vector populations and their short-
term fluctuations.
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Vector Management and Control
1. Environmental Management
Environmental modification • Managing mandatory water storage for
• Improved water supply fire-fighting
• Mosquito-proofing of overhead tanks/cisterns • Managing discarded receptacles
or underground reservoirs • Managing glass bottles and cans
• Filling, land levelling and transformation of • Tyre management
impoundment margins • Filling up of cavities of fences
• Managing public places
Environmental manipulation
• Draining water supply installations Personal protection
• Covering domestic water-storage containers • Protective clothing
• Cleaning flowerpots/vases and ant-traps • Mats, coils and aerosols
• Cleaning incidental water collections • Repellents
• Managing construction sites and building • Insecticide-treated materials: Mosquito nets
exteriors and curtains
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Vector Management and Control
1. Environmental Management
Insect repellents and length of duration

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Vector Management and Control
2. Biological Control
• Larvivorus fish (Gambusia affinis and Poecilia reticulata) have been
extensively used for the control of An. stephensi and/or Ae. aegypti.
• Two species of endotoxin-producing bacteria, Bacillus thuringiensis serotype
H-14 (Bt.H-14) and Bacillus sphaericus (Bs), are effective mosquito control
agents.
• The predatory role of copepod crustaceans (cyclopods) was documented.
Trials in crab burrows against Ae. polynesiensis and in water tanks, drums and
covered wells met with mixed results.
• Autocidal ovitraps were successfully used in Singapore as a control device in
the eradication of Ae. aegypti from the Paya Lebar International Airport.124 In
Thailand, the autocidal trap was further modified as an auto-larval trap using
plastic material available locally.
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Vector Management and Control
3. Chemical Control
• Chemical larviciding
- Temephos 1% sand granules
- Insect growth regulators (IGR)/pyriproxyfen
- Bacillus thuringiensis H-14 (Bt.H-14)
• Space sprays
- Thermal fogs
- Ultra-low volume (ULV), aerosols (cold fogs)
and mists
- Performance of fogging machines
- Insecticide formulations for space sprays
• Safety precautions for chemical
control
• Monitoring and evaluation of space
spray
• Integrated control approach
• Preparedness for minimizing
magnitude of transmission during
seasonal peaks
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Vector Management and Control
4. Geographical Information System

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Integrated Vector Management (IVM)
The key elements of IVM

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Integrated Vector Management (IVM)
Genesis and key elements IVM implementation

Approach IVM monitoring and evaluation

• Community participation
- Community participation approaches Budgeting
• Model development
• Social mobilization
• Health education
• Intersectoral coordination
- Resource sharing
- Activities by government
ministries/departments and NGOs
• Legislative support 35
Communication for Behavioural Impact (COMBI)
HICDARM and Behaviour Adoption

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Communication for Behavioural Impact (COMBI)
Fifteen steps of COMBI planning

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Communication for Behavioural Impact (COMBI)
COMBI’s integrated actions

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Communication for Behavioural Impact (COMBI)
Formative research

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Communication for Behavioural Impact (COMBI)
Key steps for conducting a formative research

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Communication for Behavioural Impact (COMBI)
Objectives, strategies, activities

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Communication for Behavioural Impact (COMBI)
MS.CREFS components

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Communication for Behavioural Impact (COMBI)
Basic sections of a strategic implementation plan

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Communication for Behavioural Impact (COMBI)
Basic sections of a strategic implementation plan

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Communication for Behavioural Impact (COMBI)
Basic sections of a strategic implementation plan

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Communication for Behavioural Impact (COMBI)
Basic sections of a strategic implementation plan

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