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Dengue hemorrhagic fever

Diagnosis, Treatment,
Prevention and Control
Why Dengue–Emerging Health Problem

Almost 1/3rd of the world in endemic

areas – mostly SEAR countries (52%)
Increase in Incidence and Frequency of
Among 10 leading causes of pediatric
hospitalization & death in SEAR
Economic Burden – both Direct &
Indirect cost
Sporadic cases in Non-Endemic
population poses diagnostic difficulty
South-East Asia
Indian Perspective
Presently a category B country
Endemic Transmission of all 4
serotypes leading on to heterotypicity
and hence DHF
Spreading of Geographic distribution
of endemicity
Absence of a concrete National
Program – both Epidemic control as
well as Endemic Surveillance
No of Cases & CFR - INDIA
Acute Febrile Arthopod-borne
Arboviral illness
Humans are the main amplifying host
Dengue virus belongs to Flaviviridae
with 4 serotypes (DEN-1 … DEN-4)
Aedes aegypti, a day biting urban
thriving mosquito is the primary vector
Affects mainly tropical and sub-tropical
Clinical Features
High fever with maculo-papular rash
Severe headache/retro-orbital pain
Hemorrhagic phenomenon
– Epistaxis, gum bleeds, G I bleeding,
hematuria, menorrhagia, ICH
Dengue hemorrhagic fever
High fever 1/3rd cases of
Hemorrhagic DHF progress
phenomenon to shock
Hepatomegaly Clinical
Hypovolemic indicators
shock Laboratory
Dengue shock syndrome
Cold and blotchy skin
Circum-oral cyanosis
Rapid pulse
Hypotension/narrow pulse pressure
Acute abdominal pain
Interal bleeding
Internal bleeding
Pleural effusion/ascites
Liver failure
– Sepsis
– Pneumonia
– Overhydration
Laboratory findings
Increased SGOT
Coagulation defects
Heaptomegaly/pleural effusion/ascites
Laboratory Diagnosis
Sample collection time
– Acute sera (S1)
– Convalescent sera (S2)
– Late Convalescent sera (S3)
Sampling methods
– Tubes/Vials, Filter-paper
– Virus
– Antigen
– Antibody
– Genomic sequence
Viral culture
In-situ hybridization
Reverse Transcriptase PCR
amplification assay
Serological methods
– Cross-reactivity
– Original Antigenic Sin
Serological methods
Neutralization test
Heme-agglutination inhibition test
Complement fixation test
Dot-Blot immunoassay
Case definition- Dengue fever
Acute febrile illness with 2 or more of
– Headache/retro-orbital pain
– Arthralgia/myalgia
– Rash
– Hemorrhagic manifestation
– Leukopenia
Either of
– Supportive serology/positive IgM
– Occurrence at the same location and
time as other confirmed cases of DF
Dengue Hemorrhagic Fever
1. Fever or H/O acute fever lasting 2-7 days
2. Hemorrhagic tendencies evidenced by at-
least one of
– Positive tourniquet test
– Petechiea / Ecchymosis
– Bleeding from mucosa /GIT/ injection sites
or other locations
3. Thrombocytopenia
4. Evidence of plasma leakage
– Rise in hematocrit
– Drop in hematocrit after hydration
– Pleural effusion, ascites &
Dengue shock syndrome
All 4 criteria for DHF must be present
Evidence of circulatory failure
manifested by
– Rapid weak pulse
– Narrow pulse pressure (<20 mm Hg)
– Hypotension, cold, clammy skin
– restlessness
WHO Grading of DHF
Grade I – fever accompanied by non-
specific constitutional symptoms with a
positive tourniquet test and/or easy
Grade II – acute febrile illness with
spontaneous bleeding
Grade III – Circulatory failure indicated
by rapid weak pulse & hypotension or
narrowing of pulse pressure
Grade IV – profound shock with
undetected blood pressure or pulse
Fluid loss correction
– 10ml per kg x % body weight loss
Fluid maintanence
For shock
– 10-20 ml/kg bolus upto 20-30ml/kg
– Plasma/plasma substitute/5% albumin
– Fresh whole blood
– Correction of electrolyte and acid-base
Prevention and Control
Vector surveillance and control
Fever surveillance
Viral surveillance
Case notification
Control of outbreaks
Vaccination – tetravalent live
attenuated dengue vaccine
Vector Surveillance
Objectives and Uses
– Geographical distribution & density
– Evaluate Control Programs
Sampling methods
– Larval study, Collection on humans/of resting
mosquitoes, Ovitrap, Tyre larvitrap &
insecticide susceptibility
– House, Container, Breteau
– landing rate, Indoor resting density
Vector Control
Environmental management
– Improvement of water supply & storage
– Solid waste management
• Reduce, Reuse, Recycle
– Modification of man-made larval habitats
Chemical control
– Against Lavae, pupae & ovum
– Against adult mosquitoes
Biological control
Chemical Control
Larvicide application
– 1% temephos sand granules
– methoprene
Perifocal treatment
– malathion, fenthion, fenitrothion
Space spraying
– Thermal fog
– Mist
Biological Control
No chemical Expense of raising
contamination the organism
Specificity against Difficulty in
target organism application and
Self-dispersion into production
sites not easily Limited utility
treated by other Effective only
means against immature
Confinement of an Outbreak
At the individual level
– Repellants, nets, coils & dresses
At the family level
– Empty/cover/drain/apply larvicide
At the community level
– Chemical control, community
participation, supervision of houses
Pubic info through media
W H O publication 1997
Nelson text book of paediatrics
Harrison’s text book of internal
Park’s text book of S P M