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Presented By :
-Prajwol Pathak
-Prakash Magar
-Prakash Paudel
-Pratibha Thapa
-Praveen Thapa
-Mamata Shrestha
• Arboviral disease are those diseases which are caused by
• Arboviruses(arthropod-borne viruses) are viruses of
vertebrate biologically transmitted by heamatophagus insect
vectors mostly mosquitoes followed by ticks
• No man to man transmission except in yellow fever and
• Various animal,rodents and birds are reserviors of infection
• Over 500 arboviruses have been listed but only about 100 of
them are capable of infecting human
WHO definition of Arboviruses

Arboviruses are viruses that are maintained in nature

principally , or to an important extent , through
biological transmission between susceptible vertebrate
host by hematophagous arthropods; they multiply in the
tissues of arthropods, and are passed on to new
vertebrates by the bites of arthropod after a period of
extrinsic incubation
Diseases caused by Arboviruses
 Encephalitis
 Chikungunya fever
 Dengue
 Haemorrhagic fever
 Sindbis fever
 Yellow fever
• Dengue is a mosquito-borne disease caused by one of
the following closely related viruses(DENV-1,2,3,4)
• These are single stranded RNA virus belonging to
flaviviridae family.
• These viruses are arboviruses capable of infecting
humans and causing disease.
• The infections caused by dengue viruses maybe
asymptomatic or may lead to :
1. Classical Dengue Fever (CDF)
2. Dengue Hemorrhagic Fever (DHF)
3. Dengue Shock Syndrome (DSS)
• It is found in tropical and subtropical regions around the

• Two-fifth of world’s population in tropical and sub-

tropical countries are at risk of the disease.

• 50 million dengue infections occur worldwide annually

and 500,000 people with DHF require hospitalization
each year.

• Approximately 90% of them are children aged less than

5 years, and about 2.5% those affected die.
• The south-east Asia and western pacific regions are most
seriously affected.

• The south-east regions are divided into 3 categories:

• Category A:
Bangladesh, India, Indonesia, Maldives,
Myanmar, Srilanka, Thailand
a. Major public health problem
b. Leading cause of hospitalization and death among
c. Hyperendemicity with all four serotypes circulating in
urban areas and
d. Spreading to rural areas
• Category B
Bhutan, Nepal
a. Endemicity uncertain
b. Bhutan reported first outbreak in 2004; and
c. Nepal reported first indigenous case in 2004/05

• Category C
DPR Korea
a. No evidence of endemicity
• The earliest cases were detected as early as 2005.
• The sporadic cases continued and outbreaks
occurred in 2006 and 2010.
• Initially most of the reported cases had travel to
neighboring country ( India ) and, however lately
indigenous cases were also reported.
• The affected disease were Kanchanpur, Banke, ,
Bardiya, Dang, Kapilvastu, Parsa, Rupandehi,
Rautahat, Sarlahi, Saptari and Jhapa, indicating
spread throughout the country from west to east
lying in the plain Terai region.
• A total of 134 dengue cases were reported from 26
districts in 2072/2073.
• The most were from Chitwan (70) foloowed by
Nawalparasi and Parsa (12 each).
• Aedes aegypti(mosquito vector) has been identified in
5 peri urban areas of terai region ( Kailali, Dang,
Chitwan, Parsa and Jhapa) during entomological
surveillance conducted by EDCD during the year
2006-2010, indicating local transmission of dengue
EDCD: epidemiology of disease control division
Dengue cases in Nepal, 2006–2015
Epidemiological determinants
Agent factors
Arbovirus (ss RNA)
Genus – Flavivirus
Family – flaviviridae
4 serotypes- DENV1, DENV2, DENV3, DENV4
Antigenic similarity but infection with one
serotypes doesn’t provide lifelong immunity.
… instead prior immune sensitization worsens
the disease scenario
DENV has…
A lipoprotein envelope
- 3 structural protein genes {CME}
- 7 non structural
Protein (NS) genes including
Envelope glycoprotein, NS1
- NS1 is of diagnostic and
pathological importance
- associated with viral
haemagglutination and
neutralization activity
Host factors
• All ages and both sexes are susceptible
• High risk patients:
- Infants and elderly
- Pregnancy
- Any condition prone to heavy blood loss: PUD,
menstruation, haemolytic anemia, G6PD
deficiency, thalassemia , steroid , NSAIDs uses
- Chronic conditions like DM, HTN, asthma ,
cirrhosis , CRF , IHD
Environmental factors
- Fluctuates with rainfall and water storage
- Survives best between 16-30 degree
centigrade and relative humidity of 60-80%
- Breeds in containers and around the house
Differences between different vectors
The Vector
Aedes aegypti
• Dengue is mainly
transmitted by Female
Aedes aegypti.
• It can be identified by
white bands or scale
patterns on its legs and
• It is primarily a day
• Found in tropical and
subtropical region.
Aedes aegypti Aedes albopictus
Life cycle of Aedes aegypti
• Infective stage: 1 day before onset of fever to
day 5
• Intrinsic IP= 4-6 days
• Extrinsic IP= 8-10 days
• Mode of transmission: vector borne
Clinical manifestations

1) Undifferentiated fever
2) Classical dengue fever
3) Dengue haemorrhagic fever
a. Febrile phase
b. Critical phase
c. Recovery phase
4) Dengue shock syndrome
Undifferentiated fever
• Primary dengue infection
• May develop a simple fever indistinguishable
from other viral infections
• Maculopapular rashes accompany the fever or
may appear during defervescence
• URTI and GI symptoms are common
Classical dengue fever
• Incubation period of 3-10 days
• Acute rise in temperature (39-40 deg C)
• Within 24 hrs retro orbital pain, dragging pain in
inguinal region, photophobia develops.
• Fever is typically but not inevitably followed by a
remission of a few hours to 2 days (biphasic curve)
• Skin eruptions - 80% cases during the remission or
during second febrile phase.
• The rash maybe accompanied by itching and
hyperasthesia which lasts usually for 2 hours to 7
days and maybe followed by desquamation.
Dengue haemorrhagic fever
1) Febrile phase
- Sudden high grade fever accompanied by facial
flushing and headache
- Anorexia, vomiting, epigastric discomfort,
tenderness at right costal margin and
generalized abdominal pain
- Differentiating feature from DF is , there is
plasma leakage and abnormal hemostasis
Tourniquet test
• A positive Tourniquet test is most common
hemorrhagic phenomenon.
• Its is performed by inflating a BP cuff to a
midpoint between systolic and diastolic
pressure for 5 mins
• The test is considered p ositive when 10 or
more petechiae per 1 inch square are
2) Critical phase
• Condition worsens during the time of
• On 3-8 days of illness progressive leukopenia,
followed by rapid decrease in platelet count
usually precedes plasma leakage (24-48 hrs)
• Pleural effusion mostly right side, ascites
• Shock occurs when a critical volume of plasma is
lost through leakage which is preceded by
warning sign
Warning signs
• Severe abdominal pain or persistent vomiting
• Red spots or patches in the skin
• Bleeding from nose or gums
• Vomiting blood
• Black , tarry stools
• Drowsiness or irritability
• Pale , cold or clammy skin
• Difficulty breathing
• Consequent organ hypoperfusion , leading
to progressive organ impairment,
metabolic acidosis and DIC
3) Recovery phase
• Gradual reabsorption of extravascular fluid(48-
• Improvement in
-general well being
-GI symptoms
-hemodynamic status
“isles of white in the sea of red”
-hematocrit stabilizes
Course of dengue illness
Severe dengue
• Defined by one or more of following:
- Plasma leakage that may lead to shock (dengue
shock) and / or fluid accumulation with or
without respiratory distress
- And / or severe bleeding
- And / or severe organ impairment
• Cold extremities, delayed capillary refill time
• Patient is considered to have shock if pulse
pressure is <20mmhg in children or s/he has
signs of poor capillary perfusion (Cold
extremities, delayed capillary refill time, rapid
pulse rate)
• In adults pulse pressure of less than or equal
to 20 mm hg may indicate a more severe
Diagnostic Criteria
Dengue without warning signs:
• Fever and 2 of the following:
– Nausea/vomiting
– Rash
– Aches and pains
– Leukopenia
– Positive tourniquet test
Dengue with warning signs:

Dengue with any of the following:

– Abdominal pain or tenderness
– Persistent vomiting
– Clinical fluid accumulation (e.g., ascites , pleural effusion)
– Mucosal bleeding
– Lethargy/restlessness
– Liver enlargement >2 cm
– Laboratory: increase in hematocrit concurrent with rapid
decrease in platelet count.
• Warning signs require strict observation and medical
Severe dengue:
• Dengue with at least 1 of the following:
– Severe plasma leakage leading to shock (dengue
shock syndrome) or fluid accumulation with
respiratory distress
– Severe bleeding (as evaluated by a clinician)
– Severe organ involvement (i.e., AST or ALT 1000
or greater, impaired consciousness, organ
Laboratory diagnosis
Specimen is taken during the fisrt 6 days of illness
Suitable specimens:
1) Acute phase serum
2) Plasma or washed buffy coat from patient
3) Autopsy tissue from fatal case
4) Mosquitoes collected from the affected areas.
Viral antigen detection
- Ns1 detection by ELISA- rapid diagnostic tests
- Available commercially
- Results within minutes

Viral nucleic acid detection

- Dengue viral genome- RT-PCR assay (better
specificity and sensitivity compared to virus
Immunological response and
serological tests
• Haemagluttination – inhibition
• Complement fixation
• Neutralization test
• IgM capture ELISA
• Indirect IgG – ELISA
• IgM/IgG ratio
Rapid diagnostic test
• Commercially available serological test kits for
antidengue IgM and IgG
• Uncertain accuracy

Haematological parameters analysis

• Platetet count and hematocrit
• No specific management
• Based on clinical manifestations , patients can
be divided into :-
i) DF
ii) DHF I & II
iii) DSS ( DHF III & IV)
Treatment of DF cases
DF patients have:-
-uncomplicated disease
-tolerance to adequate volume of oral fluids
-no warning signs

i)ORS intake , friut juice and fluids containing
ii)paracetamol for high fever(not other NSAIDs)
DHF I & II cases
• May require close observation
• With or without warning signs
patients with warning signs

obtain reference haematocrit before fluid


isotonic crystalloid solution(5-7ml/kg/hr for 1-2

- reduce to(3-5 ml/kg/hr ) for 2-4 hrs
- then to (2-3 ml/kg/hr ) or less acc. to clinical
- if haematocrit remains same , continue with
same rate (2-3 ml/kg/hr)
- if haematocrit rises rapidly , increase rate to
5-10 ml/kg/hr for 1-2 hrs
- if haematocrit falls , reduce i.v fluids gradually
and transfuse fresh whole blood
• For patients without warning signs
i) encourage patient to take oral fluids
-if not tolerated , start i.v fluid therapy (0.9%
saline with/without dextrose)
ii)after few hours of i.v fluid therapy , switch to
oral fluids
DSS cases (DHF III & IV)
• Require emergency treatment when they have
-severe plasma leakage
-severe hemorrhages
-severe organ impairment
I)iv fluids
II)blood transfusion
(These are done to improve circulation and end
organ perfusion)
Treatment of shock
- frequent monitoring until danger period is over
- vital signs,peripheral perfusion and urine output to be
checked every 15-30 minutes
- treatment guided by hematocrit level; should be
monitored before and after fluid boluses
high haematocrit- indicates active plasma leakage
low haematocrit- indicates major hemorrhage
Treatment of compensated shock
isotonic crystalloid soln.(starting 5-10ml/kg/hr;for 1 hour)

If no improvement,check hematocrit
If improvement,
-if haematocrit high—start above
-treat as alike DHF cases with warning signs procedure
-if haematocrit low—initiate
transfusion with fresh whole blood
(note ;reference haematocritnis noted
before crystalloid administration)
1. Mosquito control
a. Anti larval measures
- Environmental control
- Chemical control
- Biological control
b. Anti adult measures
- Residual sprays
- Space sprays
- Genetic control
c. Protection against mosquito bites
- Mosquito net
- Screening
- Repellants
2. Vaccines – No vaccination
3. Other measures
- Isolation of the patient under bed-nets during
the first few days
- Personal prophylactic measures like wearing of
full sleeves shirts and full pants , use of
mosquito repellant creams ,liquids, coils, mats;
- Environmental measures: Detection and
elimination of mosquito breeding places
- A screening program at an airport for persons
with fever
-To reduce mortality due to Dengue Fever , Dengue
Hemorrhagic fever and Dengue Shock Syndrome
- To develop an integrated vector control
approach for prevention and control
- To develop capacity on diagnosis and case
management of DF/DHF/DSS
- To intensify health education
- To strengthen the surveillance system for prediction,
early detection , preparedness and early response to
out-break of dengue
- Early case detection, diagnosis management and
reporting of the DF, DHF and DSS
- Regular cases of DF/DHF/DSS surveillance
- Mosquito Vector Surveillance in different
- Integrated vector control approach
Major activities in 2072/73
• Trained physicians, nurses, paramedics and
laboratory technicians on dengue case detection,
diagnosis, management and reporting.
• Orientated municipality stakeholders in 19
programme districts.
• Supplied rapid diagnostic test kits (IgM).
• Dengue case monitoring and vector surveillance.
• Search and destruction of dengue vector larvae (A.
aegypti) in 19 programme districts.
• Developed and disseminated health education
WHO Dengue Control Strategies
- Integrated Vector Management approach:
rational decision making process for the optimal
use of resources for vector control .The ultimate
goal is to prevent the transmission of vector-
borne diseases such as malaria,dengue,Japanese
encephalitis,leishmaniasis,schistosomiasis and
Chagas disease
- Individual and household protection: full sleeves
clothes, repellants, mosquito nets
- Safe use of insecticides:
WHO Pesticide Evaluation Scheme