ACFrOgCWpRDSNEB2XpR0NCm4CXIQbq3RZAfTx10AyYC - z4FD7sQBCM xiszDPdrJOLlOCZFj Uq1TmdfRzpT0KKLNQp1ACmS5c7wQlZnW 2 9n Xaxwp - ywJw5zxRH9omXSwVaA6Dd53mTdWGPLy

®
Program MCPS/MRCGP/CEFM CME ©
Course Infectious Diseases
Module Pandemics & Epidemics
Topic Dengue Fever
Credit Hours 1 CME Credit Hour

Total
Educational 2 Educational Hours
Hours
MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue
®
©
Prof. Nasir Shah
MCPS, FCPS, MRCGP [INT], FRCGP [INT]
Professor and Head, Department of Family Medicine

University of Health Sciences Lahore
Dean Family Medicine Faculty, College of Physicians and

Surgeons Pakistan
Convener National Family Medicine Committee of

Pakistan
1
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DENGUE ©
MOSQUITO TRANSMITTED VIRAL INFECTION ®

©
2
TRANSMISSION ®
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3
EPIDEMIOLOGY ®
©
• Mosquitoes-borne viral infection
- Female Aedes Aegypti (Most common) or
- Female Aedes Albopictus (lesser extent)
• Half of the world's population is at risk
• Endemic in 100 countries now
• 100-400 million infections/year (WHO - 2020)
• Peaks during and after Rainy Seasons
SEROTYPES ®
©
• Serotypes:
• Four Serotypes (DENV-1, DENV-2, DENV-3 and DENV-4)
• Each serotype can cause disease separately
• A person can be infected four times
• In Pakistan, so far only 3 Serotypes have been seen
4
RISK FACTORS FOR CONTRACTING DENGUE
VIRUS ®
©
For Contracting Dengue Virus:
1. High population density
2. Urban living
3. Poor public hygiene
4. Exposure to mosquitoes in endemic area
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©
5
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EPIDEMIOLOGY ®
©
• Incubation period: 10 days (4 to 10 days)
• Symptoms usually last 2-7 days
6
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7
OLD CLASSIFICATION (WHO) ®
©
Old Classification (WHO)
1. Asymptomatic
2. Non specific fever
3. Dengue fever (DF)
4. Dengue Hemorrhagic Fever (DHF)
5. Dengue Shock Syndrome (DSS)
NEW CLASSIFICATION (WHO) ®

©
New Classification (WHO)
1. Non-severe dengue
2. Dengue with warning signs
3. Severe dengue
8
CLINICAL PHASES OF DENGUE ®
©
• Three phases:
1. Febrile
2. Critical
3. Recovery
®
Supportive ©
Care
9
DENGUE PHASES ®
©
INITIAL PHASE SIMILAR TO DENGUE FEVER AND OTHER FEBRILE
VIRAL ILLNESSES
AFTER FEVER SETTELS, SIGNS OF PLASMA LEAKAGE APPEAR
DEVELOPMENT OF HAEMORRHAGIC SYMPTOMS

Bleeding from sites Gastrointestinal
Haematuria
of trauma bleeding
®
©
10
NEW CLASSIFICATION – JUNE 2020 (WHO) ®
1. NON-SEVERE DENGUE: Fever followed by recovery ©
I. Dengue WITHOUT warning signs:
• Fever (400 C/1040 F) AND 2 of the following;
• Pain behind the eyes
• Nausea/vomiting
• Severe headache
• Aches and pains
• Swollen glands
• Leukopenia
• Rash (Petechiae or Morbilliform or Confluent)
• Tourniquet test (may or may not be positive)
RASH ®
©
A maculopapular or macular confluent rash over the face, thorax,
and flexor surfaces, with islands of skin sparing
11
TORNIQUET TEST ®
©
• Cuff inflated up to
mid systolic pressure
• 5 minutes
• > 10 petechiae in 12
inch
NEW CLASSIFICATION - JUNE 2020 (WHO) ®

©
II. Dengue WITH warning signs
• Symptoms included in I (without warning signs) + any of:
• Abdominal pain
• Persistent vomiting
• Fluid accumulation
• Mucosal bleeding
• Haematemesis
• Lethargy/fatigue
• Liver enlargement > 2cm
• Increasing Haematocrit with Thrombocytopaenia
12
FEATURES ®
©
NEW CLASSIFICATION - JUNE 2020 (WHO) ®

2. SEVERE DENGUE is: Fever followed ©
by complications
(3 – 7 days after illness onset)
I. Plasma Leakage: V. Encephalopathy
• Pleural effusion, ascites and VI. Hepatitis
pericarditis VII. Myocarditis
II. Periorbital oedema and VIII. Severe bleeding
Proteinuria (Haematemesis, Bleeding
III. Maculopathy and Retinal from gums, Melena,
Haemorrhage Haematuria, Epistaxis etc.)
IV. Hypovolaemic shock
13
RISK FACTORS FOR DEVELOPING SEVERE
DENGUE ®
©
For Developing Severe Dengue:
1. Age
2. Repeated dengue infections
3. Genetic factors
4. Virus genotypes
5. Nutritional status
PROGNOSIS & MORTALITY ®

©
Prognosis:
• Self-limited disease
• Recovery provides Life-long immunity
- ONLY against the infecting virus serotype
• Mortality rate < 1%, if left untreated  upto 20%
14
GENERAL INVESTIGATIONS ®
©
General Investigations:
1. Full Blood Count:
I. Thrombocytopaenia
II. Leukopenia
III. High PCV
2. Prolonged PT and APTT
3. Deranged LFTs – raised AST
4. Electrolyte disturbance
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©
15
WHAT IS HEMATOCRIT ®
©
• The ratio of the volume of red blood cells to the total volume of
blood.
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©
16
SPECIAL INVESTIGATIONS ®
©
1. Serological:
- IgM antibodies
- IgG antibodies
©
1. Serological:
- IgM and IgG antibodies
- IgM – Current/recent infection
- IgG – Past/previous infection
- IgM is detectable 1 week after infection and is highest at 2
to 4 weeks after onset of illness
- IgM Detectable for about 3 months
- IgG remains for years
17
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©
©
2. Virological:
- RT-PCR (Reverse Transcriptase – Polymerase Chain Reaction)
- NS1 (A Rapid Antigen Tests) – Result in 20 mins
18
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©
®
©
19
®
©
DENGUE INFECTION AND NATURAL IMMUNITY ®

©
• Infection by one dengue virus provides lifelong immunity
against that particular virus serotype
• Immunity is only partial and transient for other three serotypes
of the virus
• Sequential infection increases the risk of developing severe
dengue
• The time interval between infections and the particular viral
sequence of infections may also be of importance.
20
DECISION MAKING IN DENGUE ®
©
Dengue without Dengue with

Severe Dengue
warning signs warning signs
Outpatient Admit in
Admit in ICU
Management Hospital
CRITERIA FOR HOSPITAL REFERRAL / ADMISSION ®

©
SIGNS: SYMPTOMS:
• Blood pressure <90/60 mmHg • Bleeding manifestations
• Haematocrit >50 percent • Inability to tolerate oral fluids
• Platelet count <50,000/mm3 • Reduced urine output
• Evidence of bleeding other than • Seizure
petechiae
• Narrow pulse pressure <20 mm
Hg
21
DENGUE | MANAGEMENT ®
©
• No specific antiviral medication
• Symptomatic and Supportive treatment
• Bed rest
• Analgesic - Antipyretic therapy
• Acetaminophen (Paracetamol)
• Treat complications (when required)
• Aspirin, other salicylates, and NSAIDs should be avoided
DON’TS IN DENGUE ®
©
1. Do not give IV therapy before leakage or hemorrhage
2. Do not give unnecessary transfusions. Only give when
decreasing hematocrit or severe bleeding
3. Do not give steroid, not benefit
4. Do not give antibiotics
5. Increase and decrease rate of IV fluids very slowly
6. Do not try to stop bleeding
22
OUTPATIENT MANAGEMENT ®
©
• Monitoring during the febrile phase (may last 2–7 days) and
subsequent critical phase (1–2 days)
1. Follow CBCs
2. Watch for dehydration
3. Watch for warning signs, including decreasing platelet count
and increasing hematocrit
4. Watch for defervescence (indicating beginning of critical
phase)
DOES LOW PLATELET MEANS SEVERE

DENGUE? ®
©
• The severity of dengue cannot exactly be estimated with
platelet count
• The symptoms of severe dengue include the following: –
1. Vomiting persistently
2. Low Blood Pressure
3. Restlessness
4. Liver Failure
5. Severe Bleeding
23
OUTPATIENT MANAGEMENT: FEVER ®
©
• Advise patient or their family to do the following
• Control the fever
• Give acetaminophen every 6 hours (maximum 4 doses per day)
• Sponge patient’s skin with tepid water when temperature is
high
• Do not give ibuprofen, aspirin, or aspirin-containing drugs
OUTPATIENT MANAGEMENT: DEHYDRATION ®

©
• Dehydration occurs from high fever, vomiting, or poor oral
intake
• Give plenty of fluids (not only water)
• Watch for signs of dehydration
• Bring patient to clinic or emergency room if signs of dehydration
occur
24
OUTPATIENT MANAGEMENT: SIGNS OF
DEHYDRATION ®
©
1. Decrease in urination
2. Few or no tears when child cries
3. Dry mouth, tongue or lips
4. Sunken eyes
5. Listlessness, agitation, or confusion
6. Tachycardia (>100/min)
7. Cold or clammy fingers and toes
8. Sunken fontanel in an infant
OUTPATIENT MANAGEMENT: FAMILY ®

©
1. Prevent spread of dengue within your house
2. Place patient under bed net or have patient use insect
repellent while febrile to avoid infecting mosquitoes that can
infect others within 2 weeks.
3. KILL all mosquitoes in house.
4. Empty containers that carry water on patio.
5. Put screens on windows and doors to prevent mosquitoes
from coming into house.
25
DENGUE IS NOT CONTAGIOUS ®
©
• Transmitted to humans by infected female mosquito
• Not transmitted through cough or sneeze or body fluids from an
infected person.
• Vector control is still key
START OF CRITICAL PHASE ®

©
• Watch for warning signs as temperature declines 3 to 8 days
after symptoms began.
• Return IMMEDIATELY to clinic or emergency department if any
of the warning signs appear:
26
START OF CRITICAL PHASE ®
©
1. Severe abdominal pain or persistent vomiting
2. Red spots/patches on skin
3. Bleeding from nose or gums
4. Vomiting blood
5. Black, tarry stools
6. Drowsiness or irritability
7. Pale, cold, or clammy skin
8. Difficulty breathing
DENGUE AND PAPAYA LEAVES EXTRACT ®

©
• Papaya leaves aqueous extract exhibit potential activity against
Dengue fever
• Dengue fever treatment with Carica papaya leaves extracts.
Nisar Ahmad, et al. Asian Pac J Trop Biomed. 2011 Aug; 1(4):
330–333.
27
PAPAYA LEAVES ®
©
DENGUE AND PAPAYA LEAVES EXTRACT ®

©
• Reduction in the duration of fever, duration of illness, hospital
stay, most importantly fluid leak and the conversion of Dengue
fever to Dengue hemorrhagic fever, rapid elevation of white
blood cells and platelet counts.
• Dengue fever. BMJ 2015; 351: h4661
28
PREVENTION ®
©
1. Prevention of Mosquito Breeding
I. Preventing mosquitoes from accessing egg-laying
II. Covering, emptying and cleaning of domestic
water storage containers on a weekly basis;
III. Applying appropriate insecticides to water storage
outdoor containers
LARVAL HABITAT ®
©
29
LARVAL HABITAT ®
©
INSECTICIDE SPRAY ®
©
30
LARVACIDAL ®
©
PREVENTION OF MOSQUITO BITES ®

©
31
FULL SLEEVE CLOTHES ®
©
PERMETHRIN IMPREGNATED NETS ®

©
32
MOSQUITO REPELLENTS ®
©
MOSQUITO MAT ®
©
33
MOSQUITO COILS ®
©
COW DUNG SMOKE: MOSQUITO REPELLENT ®

©
34
MUSTARD OIL: NATURAL MOSQUITO
REPELLENT ®
©
PREVENTION ®
©
3. Community Engagement
I. Educating & Engaging community
4. Reactive Vector Control
I. Emergency vector control measures such as applying
insecticides as space spraying during outbreaks
5. Active Mosquito & Virus Surveillance
35
Dengue vaccine (Dengvaxia®) Sanofi ®
©
• Only for persons with confirmed prior dengue
• Not previously infected are at risk of developing severe dengue
if they get dengue after being vaccinated
PROPHYLAXIS FOR DENGUE? ®

©
• No
36
®
©
REFERENCES ®
©
• https://www.who.int/news-room/fact-sheets/detail/dengue-
and-severe-dengue
• https://www.patient.co.uk
• https://www.cdc.gov
• https://www.medscape.com
37

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®

Program MCPS/MRCGP/CEFM CME ©

Course Infectious Diseases

Module Pandemics & Epidemics

Topic Dengue Fever

Credit Hours 1 CME Credit Hour

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

Professor and Head, Department of Family Medicine

Dean Family Medicine Faculty, College of Physicians and

Convener National Family Medicine Committee of

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MOSQUITO TRANSMITTED VIRAL INFECTION ®

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

• In Pakistan, so far only 3 Serotypes have been seen

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

NEW CLASSIFICATION (WHO) ®

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

AFTER FEVER SETTELS, SIGNS OF PLASMA LEAKAGE APPEAR

DEVELOPMENT OF HAEMORRHAGIC SYMPTOMS

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

NEW CLASSIFICATION - JUNE 2020 (WHO) ®

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

NEW CLASSIFICATION - JUNE 2020 (WHO) ®

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

PROGNOSIS & MORTALITY ®

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

- NS1 (A Rapid Antigen Tests) – Result in 20 mins

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

DENGUE INFECTION AND NATURAL IMMUNITY ®

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

Dengue without Dengue with

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue

CRITERIA FOR HOSPITAL REFERRAL / ADMISSION ®

MCPS-MRCGP[INT]-CEFM | Infectious diseases | Pandemic | Dengue