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Introduction

Dengue infection is one of the most common mosquito borne viral diseases of public health significance. It has been identified as a clinical entity since 1780. Clinical descriptions of the Australian outbreak in 1897 reported that 30 children died. The clinical manifestations of Dengue infection range from asymptomatic infection to undifferentiated fever, an influenza-like symptom known as dengue fever, and a severe, sometimes fatal disease characterized by hemorrhage and shock known as dengue hemorrhagic fever (DHF). The first and second epidemics of DHF occurred in Manila in 1954 and 1956, followed by the third in Bangkok in 1958. Since then, DHF has spread throughout tropical Asian countries and has expanded globally. Dengue virus is a positive-stranded encapsulated RNA virus that belongs to the flavivirus genus of the Flaviviridae family. The genomic RNA is approximately 11 kb in length and is composed of three structural protein genes that encode the nucleocapsid or core (C) protein, a membraneassociated (M) protein, an enveloped (E) protein and seven non-structural (NS) proteins, NS1, NS2a, NS2b, NS3, NS4a, NS4b and NS5. The NS proteins are assumed to be involved in the replication of viral RNA. The proteins are synthesized as a large and single-polyprotein precursor of approximately 3400 amino acids. They are transmitted among humans by Aedes mosquitoes such as Aedes aegypti and Aedes albopictus . There are four distinct serotypes, namely dengue 1 to 4. Infection with any of the four serotypes causes similar clinical symptoms that may vary in severity, depending on a number of risk factors including virus virulence, viral load and host response.

Etiologic Agent
Dengue Virus types 1,2,3 and 4 Chikungunya virus

Mode of Transmission 1. By bite of an infected mosquito, principally the Aedes Egypti


Aedes egypti is a day biting mosquito (they appear 2 hours after sunrise and 2 hours before sunset) It breeds on stagnant water It has a limited low-flying movement It has fine white dots at the base of the wings; with white bands on the legs 2. Aedes albopictus may contribute to transmission of dengue in rural areas 3. Other contributory mosquitoes: a. Aedes polynesis b. Aedes Scutellaris simplex

Incubation Period
The incubation period is 3-14 days; commonly 7-10 days

Period of Communicability
a. Patients are usually infective to mosquito from a day before the febrile period to the end of it. b. The mosquito becomes infective from day 8-12 after the blood meal and remains infective all throughout life.

Sources of Infection
Immediate source is a vector mosquito, the Aedes Aegypti or the common household mosquito The infected person 1. Age- Dengue fever may occur at any age, but is common among children and peaks between four to nine years old. 2. Sex- Both sexes can be affected. 3. Season- It is more frequent during the rainy season June-November. Peak months September and October. 4. Location- Dengue fever is more prevalent in urban communities.

Incidence

Pathophysiology Evidence of plasma leakage The plasma leakage is due to the increased vascular permeability induced by several mediators such as C3a, C5a during the acute febrile stage and prominent during the toxic stage. The evidence of plasma leakage includes hemoconcentration, hypoproteinemia/hypoalbuminemia, pleural effusion, ascites, threatened shock and profound shock. The rising hematocrit may not be evidenced because of either severe bleeding or early intravenous fluid replacement. Bleeding tendency The bleeding diathesis is caused by vasculopathy, thrombocytopenia, platelet dysfunction and coagulopathy. Vasculopathy A positive tourniquet test indicating the increased capillary fragility is found in the early febrile stage. It may be a direct effect of dengue virus as it appears in the first few days of illness during the viremic phase. Thrombocytopenia and platelet dysfunction Patients with DHF usually have platelet counts less than 100109/L. Thrombocytopenia is most prominent during the toxic stage. The mechanisms of thrombocytopenia include decreased platelet production and increased peripheral destruction. ???

Clinical Manifestation The 3 stages of clinical presentation are named febrile, toxic and convalescent Stage 1: Febrile The patient initially develop an abrupt onset of high fever (39-40 degress C) with malaise, During the acute febrile stage, which usually lasts for 2-7 days, hemorrhagic manifestation is
invariably present but usually mild. Petechial hemorrhage on the skin is commonly found. A positive tourniquet test is observed. headache,nausea and vomiting, headache, myalgia and sometimes abdominal pain.

Stage 2: Toxic The fever has subsided at this stage. Patients feel drowsy with profuse sweating, cold hands and feet, weak but rapid pulse rate, pain at the right coastal margin, reduced urine output, and easy bleeding such as nose-bleed, vomiting of blood and bloody stool. In severe cases, blood pressure drops drastically resulting in shock and can lead to death. This phase lasts 24-48 hours.

Stage 3: Convalescent
Patients' conditions are improved as shown by good appetite, normal blood pressure, strong and slow pulse, and normal urine output. Bleeding spots under skin are still present over the body in some cases.

Classification Acccording to Severity i.


ii.

Grade 1

Without overt bleeding but positive for tourniquet test Grade 2 With clinical bleeding diathesis such as petechiae, epistaxis and hematemesis.

iii. iv.

Grade 3 Circulatory failure manifested by a rapid and weak pulse with narrowing pulse pressure
(<20) or hypotension, with the presence of cold clammy skin and restlessness.

Grade 4 Profound shock in which pulse and blood pressure are not detectable. It is noteworthy that patients who are in threatened shock or shock stage usually remains conscious.

Complications Though rare, may occur in DHF or DSS and are as follows Damage to brain due to bleeding or prolonged shock Liver failure Inflammation of the heart muscles (Myocarditis) Encephalopathy

Diagnostic Tests
1. Tourniquet Test (Rumpel Leads Test) Inflate the blood pressure cuff on the upper arm to a point midway between the systolic and diastolic pressure for 5 minutes. Release cuff and make an imaginary 2.5 cm square or 1 inch square just below the cuff, at the antecubital fossa.

Count the number of petechiae inside the box. A test is (+) when 20 or more petechiae per 2.5 cm square or 1 inch square are observed. 2.Complete Blood Count 3.Physical Examination may reveal the following: Low blood pressure Weak, rapid pulse Rash Enlarged liver Red eyes Swollen glands

4.Chest x-ray -may demonstrate pleural effusion 5.Occult blood 6.Hemoconcentration 7. Serologic studies > demonstrate antibodies to Dengue viruses

Treatment Modalities
There is no specific treatment for Dengue Hemorrhagic Fever. Treatment for DHF is wholly symptomatic and aims at controlling the clinical manifestations of shock and haemorrhage. Patients who do not receive proper treatment usually die within 12-24 hours after shock ensues. The most important aspect in managing patients with DHF is close observation by the attending physician and the nurses with frequent clinical and laboratory monitoring. 1. During the febrile stage, nurturing parental care for the patient is essential. For preventing starvation and dehydration, ingestion of adequate soft diet and drink is encouraged. For reducing fever, frequent tepid sponge bath and paracetamol are provided. Aspirin and non-steroidal antiinflammatory drugs (NSAIDS) such as ibuprofen are prohibited. 2. Initial phase may require intravenous infusion to prevent dehydration and replacement of plasma. 3. Blood Transfusion is indicated in patient with severe bleeding Platelet concentrate from either single or random donors is indicated for controlling massive bleeding. Packed RBCs are indicated for patients manifesting massive bleeding. Fresh frozen plasma is indicated for patients who have massive bleeding due to coagulopathy, or circulatory failure. It is helpful in maintaining effective intravascular volume and restoring coagulation factors. 4. Oxygen therapy is indicated in all patients in shock. 5. Sedatives maybe needed to allay anxiety and apprehension Nursing Management Any disease or condition associated with haemorrhage is enough cause for alarm. Immediate control of haemorrhage and close observation of the patient for vital signs leading to shock are the nurses primary concern. Nursing measures are directed towards the symptoms as they occur but immediate medical attention must be sought:

1. For Hemorrhage Keep patient at rest during bleeding episodes. For nose bleeding, maintain an elevated position of trunk and promote vasoconstriction in nasal mucosa membrane through an ice bag over the forehead. For melena, ice bag over the abdomen. Avoid any unnecessary movement. If transfusion is given, support the patient during therapy. Observe signs of deterioration such as low pulse, cold clammy perspiration, prostration. 2. For shock Prevention is the best treatment. Dorsal recumbent position facilitates circulation. Adequate preparation of the patient, mentally and physically prevents occurrence of shock Provision of warmth- through lightweight covers (overheating cause vasodilation which aggravates bleeding). 3. Diet Low fat, low fiber, non-irritating, non-carbonated. Noodle soup may be given. 4. Give ORESOL to replace fluid as in moderate dehydration at 75ml/kg in 4-6 hours or up to 2-6 Litres in adults. Continue ORS intake until patients condition improves

Prevention and Control


1. 2. 3. 4. Early detection and treatment of cases will not worsen the victims condition Treat mosquito nets with insecticides. House spraying is advised Eliminate vector by: Changing water and scrubbing sides of lower vases once a week Destroying the breeding places of mosquitoes by cleaning the surroundings Keeping the water containers covered. 5. Avoid too many hanging clothes inside the house. 6. Use of Mosquito repellents. Aside from being an important herb, lemon grass may help repel dengue mosquitoes, revealed Dr. Manuel Mapue, Department of Health (DOH) Regional Medical Dengue Coordinator for Metro Manila during the Ovicidal/Larvicidal (OL) Mosquito Trap Orientation held in Caloocan City on 28 May 2012. According to the study DEET-based repellents has 81% efficacy compare to 51% efficacy of lemon grass extract. However, the study concluded that although lemon grass has lower efficacy, many people are too sensitive to the DEET chemical used in repellent.