Denge Fever

8/6/2019 Denge Fever

1/39

Aedes aegyptiMosquito

DENGUE FEVER


2/39

World Distribution of Dengue 1999

Areas infested withAedes aegypti

Areas withAedes aegyptiand recent epidemic dengue


3/39

GLOBAL STATUS

New infections annually: 50 million

Deaths: 24,000 annually People at risk: 2.5-3 billion

Hospitalized cases: 500 000/year

(90% of those affected are children)

Disease burden: 465,000 DisabilityAdjusted Life Years (DALY)


4/39

0

20,000

40,000

60,000

80,000

100,000

Cases

2005 Dengue Outbreak

Cases Deaths

Cases 90,000 3,000 31,000 4,800

Deaths 15,000 0 58 50

India, (West

Bengal)Sri Lanka Thailand Pakistan

DENGUE OUT BREAK IN SOUTHDENGUE OUT BREAK IN SOUTH

EAST ASIA IN 2005EAST ASIA IN 2005


5/39

0

500

1000

1500

2000

2500

3000

3500

Cases

Dengue Fever In 2006

Cases Deaths

Cases 3331 3230 1836 400

Deaths 49 50 30 4

India Pakistan Karachi Lahore

DENGUE OUT BREAK IN SOUTH EASTDENGUE OUT BREAK IN SOUTH EAST

ASIA IN (2006)ASIA IN (2006)


6/39

Manifestation Of Dengue Virus

Infections

ASYMPTOMATICASYMPTOMATIC

DSS

SYMPTOMATICSYMPTOMATIC

Without haemorrhage

With unusual haemorrhage

No shock

Undifferentiated

Fever

Dengue Fever

Dengue

Haemorrhagic

Fever


7/39


8/39

2A) Clinical Characteristics

of Dengue Fever

Fever

Headache Muscle and joint pain

Nausea/vomiting

Rash Hemorrhagic manifestations


9/39

2B)Hemorrhagic Manifestations

of Dengue

Skin hemorrhages:

petechiae, purpura, ecchymoses

Gingival bleeding

Nasal bleeding

Gastro-intestinal bleeding:

hematemesis, melena, hematochezia

Hematuria

Increased menstrual flow


10/39

C1) Clinical Case Definition for

Dengue Hemorrhagic Fever

1. Fever, or recent history of acute fever

2. Hemorrhagic manifestations3. Low platelet count (100,000/mm3 or less)

4. Objective evidence of leaky capillaries:

elevated hematocrit (20% or more overbaseline)

low albumin

pleural or other effusions

4 Necessary Criteria:4 Necessary Criteria:


11/39

Four Grades of DHFFour Grades of DHF

Grade 1

Fever and nonspecific constitutional symptoms

Positive tourniquet test is only hemorrhagic manifestation Grade 2

Grade 1 manifestations + spontaneous bleeding

Grade 3

Signs of circulatory failure (rapid/weak pulse, narrow pulse

pressure, hypotension, cold/clammy skin)

Grade 4

Profound shock (undetectable pulse and BP)


12/39

Danger Signs in


Abdominal pain - intense and

sustained

Persistent vomiting

Abrupt change from fever to

hypothermia, with sweating and

prostration

Restlessness or somnolence

Martnez Torres E. Salud Pblica Mex 37 (supl):29-44, 1995.


13/39

Warning Signs for Dengue Shock

When Patients Develop

DSS: 3 to 6 days after onset of

When Patients Develop

DSS: 3 to 6 days after onset of

Initial WarningSignals: Disappearance of fever Drop in platelets Increase in hematocrit

Initial WarningSignals: Disappearance of fever Drop in platelets Increase in hematocrit

Alarm Signals: Severe abdominal pain Prolonged vomiting Abrupt change from fever

to hypothermia

Change in level ofconsciousness (irritability

orsomnolence)

Alarm Signals: Severe abdominal pain Prolonged vomiting Abrupt change from fever

to hypothermia Change in level of

consciousness (irritability

or

somnolence)

Four Criteria for DHF: Fever Hemorrhagic manifestations Excessive capillary

permeability 100,000/mm3 platelets

Four Criteria for DHF: Fever

Hemorrhagic manifestations Excessive capillary

permeability 100,000/mm3 platelets


14/39

C2) Clinical Case Definition for

Dengue Shock Syndrome

4 criteria for DHF

Evidence of circulatory failure manifested

indirectly by all of the following:

Rapid and weak pulse

Narrow pulse pressure ( 20 mm Hg) OR

hypotension for age

Cold, clammy skin and altered mental status

Frank shock is direct evidence of circulatory

failure


15/39

Unusual Presentations

of Severe Dengue Fever

Encephalopathy

Hepatic damage Cardiomyopathy

Severe gastrointestinal

hemorrhage


16/39

Risk Factors Reported for DHF

Virus strain

Pre-existing anti-dengue antibody previous infection

maternal antibodies in infants

Host genetics Age


17/39

Risk Factors for DHF (continued)

Higher risk in secondary infections

Higher risk in locations with two or moreserotypes circulating simultaneously at

high levels (hyperendemic transmission)


18/39

Increased Probability of DHF

Hyperendemicity

Increased circulation

of viruses

Increased probability

of secondary infection

Increased probability ofoccurrence of virulent strains

Increased probability ofimmune enhancement

Increased probability of DHF Gubler & Trent, 1994


19/39

Viral Risk Factors

for DHF Pathogenesis

Virus strain (genotype)

Epidemic potential: viremia level,

infectivity

Virus serotype

DHF risk is greatest for DEN-2,

followed by DEN-3, DEN-4 and DEN-1


20/39

Clinical Evaluation in Dengue

Fever

Blood pressure

Evidence of bleeding in skin or other

sites

Hydration status

Evidence of increased vascular

permeability-- pleural effusions, ascites

Tourniquet test


21/39

Petechiae


22/39

Vaughn DW, Green S, Kalayanarooj S, et al. Dengue in the early febrilephase: viremia and antibody responses. J Infect Dis 1997; 176:322-30.

A

B

PEI = A/B x 100

Pleural Effusion IndexPleural Effusion Index


23/39

Tourniquet Test

Inflate blood pressure cuff to a point

midway between systolic and

diastolic pressure for 5 minutes Positive test: 20 or more petechiae

per 1 inch2 (6.25 cm2)

Pan American Health Organization: Dengue and Dengue

Hemorrhagic Fever: Guidelines for Prevention and Control.

PAHO: Washington, D.C., 1994: 12.


24/39

Positive Tourniquet Test


25/39

Laboratory Tests

in Dengue Fever

Clinical laboratory tests CBC--WBC, platelets, hematocrit

Albumin

Liver function tests

Urine--check for microscopic hematuria

Dengue-specific tests Virus isolation

Serology


26/39

Laboratory Methods for Dengue

Diagnosis

Virus isolation to determine

serotype of the infecting virus IgM ELISA test for serologic

diagnosis


27/39

Temperature, Virus Positivity and

Anti-Dengue IgM , by Fever Day

Dengue IgMMean Max. Temperature Virus

Adapted from Figure 1 in Vaughn et al.,J Infect Dis, 1997; 176:322-30.

Fever Day

0

20

40

60

80

100

P

erce

ntVirusPo

sitive

-4 -3 -2 -1 0 1 2 3 4 5 6

39.5

39.0

38.5

38.0

37.5

37.0

Temp er

ature(de g

reesCelsiu

s)

D

engueIgM (

EIA

units)300

150

0

75

225


28/39

Outpatient Triage

No hemorrhagic manifestations and

patient is well-hydrated: home treatment

Hemorrhagic manifestations or hydration

borderline: outpatient observation center

or hospitalization

Warning signs (even without profoundshock) or DSS: hospitalize


29/39

Patient Follow-Up

Patients treated at home Instruction regarding danger signs

Consider repeat clinical evaluation

Patients with bleeding manifestations Serial hematocrits and platelets at least daily

until temperature normal for 1 to 2 days

All patients If blood sample taken in first 5 days after

onset, need convalescent sample betweendays 6 - 30

All hospitalized patients need samples on

admission and at discharge or death


30/39

Treatment of Dengue Fever

& DHF I & II

Fluids

Rest Antipyretics (avoid aspirin and non-

steroidal anti-inflammatory drugs)

Monitor blood pressure, hematocrit,platelet count, level of

consciousness


31/39

Treatment of DHF III & IV

All above treatment +

In case of severe bleeding, give fresh whole

blood 20 ml/kg as a bolus Give platelet rich plasma transfusion

exceptionally when platelet counts are below

5,00010,000/ mm3 .

After blood transfusion, continue fluid therapyat 10 ml/kg/h and reduce it stepwise to bring it

down to 3 ml/kg/h and maintain it for 24-48 hrs


32/39

1 unit of RD(Random Donor) Plt. (50ml) per 10 Kg body

weight.---- expected to increas the Plt. Count 5000-

10000/uL. (If No splenomegaly, Fever or DIC)

Alloimmunized (who have received multiple transfusions andthus sensitized) may have little or no increase in the count.They can be best served by SDAP(Single Donor Apheresis

Platelets) as 1 SDAP unit(150ml)=6 RD units

CCI=Post transfusion count Pre transfusion count X BSA

Number of Platelets transfused X 1011

Evaluation of Refractoriness of RD units

Treatment of DHF III & IV

Appropriate if-CCI is 10X10 9 /ml in 1 hr post transfusion sample and/or

-CCI is 7.5X10 9/ml in 18-24 hr post transfusion sample.


33/39

Treatment of Dengue Fever

Raw papaya leaves, 2 pcs just cleaned and

pound and squeeze with filter cloth. You will onlyget one tablespoon per leaf. So two tablespoon per

serving once a day.Do not boil or cook or rinse with hot water, it will

loose its strength. Only the leafy part and no stemor sap.It is very bitter and you have to swallow it like

Won Low Kat. But it works.

Papaya Juice vs. Dengue ?

Source: from Indonesia March 2005


34/39

Indications for Hospital Discharge

Absence of fever for 24 hours (without

anti-fever therapy) and return of appetite

Visible improvement in clinical picture Stable hematocrit

3 days after recovery from shock

Platelets 50,000/mm3

No respiratory distress from pleural

effusions/ascites

Pan American Health Organization: Dengue and Dengue Hemorrhagic Fever: Guidelines for Prevention and Control.

PAHO: Washington, D.C., 1994: 69.


35/39

Common Misconceptions about


Dengue + bleeding = DHF Need 4 WHO criteria, capillary permeability

DHF kills only by hemorrhage Patient dies as a result of shock

Poor management turns dengue into DHF Poorly managed dengue can be more severe, but

DHF is a distinct condition, which even well-treatedpatients may develop

Positive tourniquet test = DHF Tourniquet test is a nonspecific indicator of capillary

fragility


36/39

More Common Misconceptions

about Dengue Hemorrhagic Fever

DHF is a pediatric disease All age groups are involved in the Americas

DHF is a problem of low income families All socioeconomic groups are affected

Tourists will certainly get DHF with a

second infection Tourists are at low risk to acquire DHF


37/39

Dengue Vaccine?

No licensed vaccine at present

Effective vaccine must be tetravalent

Field testing of an attenuated tetravalent

vaccine currently underway

Effective, safe and affordable vaccine will not

be available in the immediate future


38/39

Prevention

The main tactic used in fighting Dengue is

eradicating the mosquito.Public spraying for mosquitoes is the most

important aspect of this approach.Personal prevention involces the use of mosquito

nets, repellents, cover exposed skin, use of DEET-

impregnated bednets, and avoiding endemic areas.


39/39

CONTACT

[email protected]

[email protected]
mailto:[email protected]:[email protected]:[email protected]:[email protected]

Documents

Denge Fever