Dengue,

Chikungunya
Yellow fever
Dr. Saida Sharmin
MBBS, MPH (Epidemiology)
Dengue

Definition:
Dengue is an acute febrile mosquito-borne
disease caused by 4 antigenically related
serotypes of dengue viruses in tropical & sub
tropical areas of the world putting more than 3
billion people at risk of infection.
Agent factors

Agent :
Dengue viruses are member of the flavivirus &
family flaviviridae. It has 4 serotypes dengue
virus 1, 2, 3 & 4.
Vector :
Aedes aegypti & Aedes Albopictus are two
most important vectors of dengue.
 Host factors
Age:
All ages are susceptible in endemic areas.
Sex:
No special predilection exists.
Reservoir:
Man and mosquito are reservoirs of infection.
Environmental factors

The population of Aedes aegpti fluctuates with

rainfall and water storage . Its life span is influenced

by temperature and humidity, survives best between

16⁰c -30⁰c & a relative humidity of 60%-80%. Dengue

is found in tropical & subtropical regions around the

world predominantly in urban and semi urban areas,

the highest incidence is in southeast Asia, India &

American tropics.
 Cont...

Transmission:

It is transmitted by the infective bite of female Aedes

Aegypti mosquito.

Incubation period:

Commonly 5-6 days may vary from 3-15 days.

It occurs in two forms:

 Dengue Fever(DF) and

 Dengue Haemorrhagic Fever(DHF)

 Clinical features of Dengue fever(DF)

Abrupt onset of high fever

Acute febrile illness with two or more of the

following;
 Headache.

 Retro-orbital pain.

 Myalgia

 Arthalgia / bone pain

 Cont....
 Rash

 Haemorrhagic manifestation.

 Leucopenia (wbc ≤5000)

 Thrombocytopenia (platelet count <150,000)

Clinical features of Dengue haemorrhagic

fever(DHF)
o Features of dengue fever at initial stage.

o Haemorrhagic manifestation, shown by any of the

following;
 Cont....
Positive tourniquet test.

Petechiae, purpura, ecchymoses

Mucosal bleeding, Nasal bleeding, gum

bleeding.
Bleeding from injection or other sites

Hematemesis, melena, heaematuria.

Thrombocytopenia
 Dengue shock syndrome

Criteria for dengue haemorrhagic fever as above with

signs of shock including

Tachycardia, cool extremities, delayed capillary

refill, weak pulse, lethargy or restlessness, which

may be a sign of reduced brain perfusion.

Pulse pressure ≤ 20 mm Hg with increased diastolic

pressure e.g. 100/80 mm Hg

Hypotension by age.
 WHO classification of Dengue fever & dengue syndrome
DF/DHF Grade Symptoms/signs Lab finding

DF Fever with 2 or more of

following Leucopenia (WBC≤5000
cells/cu.mm)
Headache.
Retro-orbital pain. Thrombocytopenia
(platelet count <150,000
Myalgia
cells/ cu.mm)
Arthalgia / bone pain
Rash Rising haematocrit (5-
Haemorrhagic 10%)
manifestation.
No evidence of plasma
leakage
 WHO classification of Dengue fever & dengue
syndrome
DF/DHF Grade Symptoms/signs Lab finding

DHF i Above criteria for DF & •Thrombocytopenia : platelet

haemorrhagic manifestation
plus positive tourniquet test, count <100,000/cu.mm
evidence of plasma leakage •Haematocrit rise 20% or
more.

DHF ii Above signs & symptoms •Thrombocytopenia : platelet

plus some evidence of
spontaneous bleeding in skin count <100,000/cu.mm
or other organ(black tarry •Haematocrit rise 20% or
stools, epitaxis, bleeding more.
from gums etc.)
And abdominal pain
 WHO classification of Dengue fever & dengue
syndrome
DF/DHF Grade Symptoms/signs Lab finding

DHF iii Above signs & symptoms plus •Thrombocytopenia :

circulating failure (weak rapid platelet count
plus pressure ≤20 mm Hg or high <100,000/cu.mm
diastolic pressure, hypotension •Haematocrit rise
with the presence of cold clammy 20% or more.
skin and restlessness)

DHF iv Signs as grade iii plus profound •Thrombocytopenia :

shock with undetectable blood platelet count
pressure or plus <100,000/cu.mm
•Haematocrit rise
20% or more.

DHF iii and iv are dengue shock syndrome

Few common and favoured
breeding places/sites of Ae.
aegypti
 Prevention & control of DF & DHF
1. Awareness among people: Dengue is spread
through the bite of an infected Ades mosquito.

2. Prevention of mosquito bites

 Dengue mosquitoes bite during the day time (before

sun rise & before the sun set)

 Wear full sleeve clothes & long dress to cover the

limb.
 Use mosquito repellents on young children and

children.
 Prevention & control of DF & DHF
 Use mosquito coils and electric vapour or electric

mats during the day time to prevent dengue.

 Use mosquito nets for prevent dengue.

3. Prevention of multiplication of mosquitoes

 Drain out the water from window air cooler,

tanks, barrels, buckets, tiers, drums etc.

 Prevention & control of DF & DHF

Remove all objects containing water from

house.
All stored water container should be kept

covered all time.

Destroy discarded container in which water

collects.
 Cont…

4. Treatment
There is no specific treatment management of

Dengue fever, treatment is symptomatic and

supportive.
 Severe pain can be relived by paracetamol.

Do not give aspirin or any other NSAIDs.

Main objectives of management of DHF

i. Maintenance of fluid and electrolytes.

ii. Maintenance of blood osmolarity in case of

plasma leakage.

iii. Maintenance of circulatory volume and haemo-

dynamic status.

iv. Prevention of complications.

 Vaccine
There is no satisfactory vaccine to prevention the
discharge by immunization.

Indication of red cell transfusion

Blood loss -10% or more to total blood volume

preferably give whole blood components to be

used.
Refractory shocks despite adequate fluid

administration & declining haematocrit.

 Indication of red cell transfusion

Replacement volume should be 10ml/kg body wt

at a time and coagulogram should be done.

If fluid overload is present packed cells are to be

done.

Indication of platelet transfusion

1. Prophylactic platelet transfusion may be

given at level at <10,000/cu.mm.

 Indication of platelet transfusion

2. Coagulopathy with prolonged shock & abnormal

coagulogram.
3. In case of systematic massive bleeding, platelet

transfusion may be needed in addition to RBC

transfusion.
 Criteria for discharge of patient
Absence of fever for at least 24 hrs with out the use of

anti pyretic.
Return of appetite

Visible clinical improvement

Good urine output

Minimum of 2-3 days after recovery the shock

No respiratory distress for pleural effusion or ascities.

Platelet count > 50,000/cu.mm

Chikungunya
A-dengue like disease caused by a group
Togaviridae (Alpha virus), the chikungunya
virus and transmitted by Aedes mosquitoes . It
is manifested by high fever & sever articular
pains in the limbs and spinal column.
Chikungunya

The clinical features of Chikungunya ( CHK )

are fever, headache, nausea, vomiting,
myalgia, rash and arthralgia. The clinical
diagnosis is often confused with that of
Dengue fever because CHK virus circulates in
regions where Dengue ( DEN ) virus is also
endemic.
Period of Illness

Illness is often acute and lasts for 3 to 5 days.

In few cases it may be up to 10 days or more.

Convalescence is usually prolonged and

characterized by marked weakness and

pain in joints.
Agent

Family – Togaviridae

Genus - Alpha virus
Incubati
onperiod

It is usually 4 -7 days
Age group
The disease affects all age groups.
Seasons
The disease occurs in the rainy seasons,
when the mosquito vector population is at
its peak.
Clinical manifestations
 Fever,

 Crippling Joint pains

 Lymphadenopathy

Conjunctivitis

A Maculopapular rash
Clinical manifestations

May lead to hemorrhagic manifestations.

Fever is biphasic with remission after 1 - 6 days of

fever.
A prominent symptom, seen specially of the
adult patient is arthropathy, from which the
disease gets its name. The arthropathy is
manifested by pain, swelling and stiffness,
especially of the metacarpophalangeal, wrist,
Clinical manifestations

Elbow , shoulder, knee, ankle and metatarsal

joints. It appears 3rd to 5th day after the onset
of clinical symptoms, and it persists for may
months & even years. No death have been
attribute d to chikungunya fever.
Treatment

There is no specific treatment of chickungunya

infection and it is self limiting. Analgesics ,
antipyretics like paracitamol, diclofenac sodium,
chloroquine along with supplementation are
recommended to manage infection and relieve
fever, joint pains and swelling. Drug like aspirin &
steroids should be avoided.
Diagnosis

In serologic diagnosis, which is the approach

most commonly used
Compliment Fixation test.

ELISA ( enzyme-linked immunosorbent

assay .
They are used for detection of IgM
Diagnosis

RT-PCR (A reverse-transcription polymerase

chain reaction) and nested PCR technique has
used for rapid diagnosis of disease.
Control :
Vector control:
The Aedes aegypti mosquito should be the main
target of control activities.
cono
trl

It requires active community involvement to

keep water storage containers free of
mosquitoes & eliminate the other breeding
places of mosquitoes in and around house and
dwelling. Organophosphorus , abate is
increasingly used as a larvicide. It prevent
breeding up to 3 month.
Control

Antiviral measures can prevent epidemic but do

not give immediate results when an epidemic has
already broken out. In such cases anti-adult
measures alone can bring about a rapid
interruption of transmission. Aerosol spray of low-
volume of malatheon are effective for interrupting
transmission. No vaccine has yet developed.
Yellow fever

Yellow fever is zoonotic disease caused by an

arbovirus. Affects monkeys and vertebrates (in
tropical America & Africa). Transmitted to
human by culicine mosquitoes. It shares clinical
feature with other viral hemorrhagic fever ( e.g.
dengue, Lassa fever) and further characterized
by more sever hepatic and renal involvement .
Yellow fever
Agent: Flavivirus
Reservoir of infection:
In forest areas, the reservoir of infection is
mainly monkeys & forest mosquitoes. In
urban areas, the reservoir is man (sub
clinical or clinical cases)
Cont...

Period of communicability:
i. Man : blood of patients is infective during
the first 3-4 days of illness.
ii. Mosquitoes : after an “ extrinsic

incubation period” of 8-12 days, the

mosquito become infective.
Host factors

Age & sex : All ages & both sexes are

susceptible to yellow fever in the absence of
immunity.
Occupation: Persons whose occupation
brings in contact with forest.
Immunity : One attack of yellow fever gives
lifelong immunity .
Environmental factors
Climate : A temperature of 24⁰c or over is required for
multiplication of the virus in the mosquito.
Social factors: in Africa, urbanization is leading to
the extension of yellow fever. In addition increase rate of
traveller who transported from endemic areas to
receptive areas.
Incubation period: 3-6 days
 Control of Yellow Fever

Isolation : Patient are isolated for first four

days of illness.
Treatment:
There is no specific treatment for yellow fever.
i. Treatment is symptomatic, aimed to
reducing the symptoms for the comfort of
the patient.
Control of Yellow Fever

ii. Analgesics used if required

iii. Maintain urine output & blood pressure is

necessary.
iv. Blood transfusion, peritoneal dialysis may

necessary.
Quarantine : Non immunized person are
placed on quarantine for 6 days.
Control of Yellow Fever

Vaccination:

Rapid immunization of the population at risk is

the most effective control strategy for yellow
fever. Active immunization by 17D vaccine. It is
a live attenuated vaccine. Single dose .05 ml.
Immunity begins to appear on the 7th day & lasts
for more than 35 yrs.
Control of Yellow Fever

International measures:
All travellers including infants exposed to
the risk of yellow fever or passing through
endemic zones of yellow fever must possess
a valid international certificate of vaccine
against yellow fever before they are allowed
to enter yellow fever “receptive” areas.
Control of Yellow Fever

If the traveller arrives before the certificate

becomes valid( valid 6 day after the date of
vaccination), he/she is isolated till the
certificate become valid. The aircraft and
ships arriving from endemic areas are
subjected to aerosol spraying with prescribed
insecticides.
Bangladesh situation

Bangladesh is a yellow fever receptive area and

people are susceptible for yellow fever. Condition
is favourable for the occurrence and transmission
of yellow fever. People are not vaccinated here &
vector Aedes aegypty are found is abundance all
over the country, reservoir (monkeys) of the
disease are available .The climate are favourable
for transmission .
Cont...

But the yellow fever is non-existent as the

causal agent ( virus ) are absent. Yellow fever
can enter in Bangladesh through infected
person coming by air or ship, or infected
mosquito brought by aircraft or ships.
Thank You