Arrogante, Regine, O.

October 24, 2017

TTH(10:00-11:30) Microbiology Lecture

Dengue Fever
Dengue is caused by Dengue virus (DENV), a mosquito-borne flavivirus. DENV is an single
stranded RNA positive-strand virus of the family Flaviviridae, genus Flavivirus. This genus
includes also the West Nile virus, Tick-borne Encephalitis Virus, Yellow Fever Virus, and
several other viruses which may cause encephalitis. DENV causes a wide range of diseases in
humans, from a self limited Dengue Fever (DF) to a life-threatening syndrome called Dengue
Hemorrhagic Fever (DHF) or Dengue Shock Syndrome (DSS).

There are four antigenically different serotypes of the virus (although there is report of 2013 that
a fifth serotype has been found):

DENV 3, DENV 2, DENV 3, DENV 4

Here, a serotype is a group of viruses classified together based on their antigens on the surface of
the virus. These four subtypes are different strains of dengue virus that have 60-80% homology
between each other. The major difference for humans lies in subtle differences in the surface
proteins of the different dengue subtypes. Infection induces long-life protection against the
infecting serotype, but it gives only a short time cross protective immunity against the other
types. The first infection cause mostly minor disease, but secondary infections has been reported
to cause severe diseases (DHF or DSS) in both children and adults. This fenomenon is
called Antibody-Dependent Enhancement.

Mode of Transmission

Dengue viruses are transmitted to humans through the bites of infective female Aedesmosquitoes.
Most commonly, the mosquitoes involved are Aedes aegypti and Aedes albopictus, two species
which can also transmit other mosquito-borne viruses, including zikaand chikungunya. Other
infection routes are reported from mother to child as well as blood transmission.

The main transmission is through mosquitoes that generally acquire the virus while feeding on
the blood of an infected person. After virus incubation for eight to ten days, an infected mosquito
is capable, during probing and blood feeding, of transmitting the virus for the rest of its life.
There is no way to tell if a mosquito is carrying the dengue virus. Infected female mosquitoes
may also transmit the virus to their offspring by transovarial (via the eggs) transmission, but the
role of this in sustaining transmission of the virus to humans has not yet been defined.

Infected humans are the main carriers and multipliers of the virus, and serving as a source of the
virus for uninfected mosquitoes. The virus circulates in the blood of infected humans for two to
seven days, at approximately the same time that they have a fever (see also clinical
symptoms). Aedes mosquitoes may acquire the virus when they feed on an individual during this
period. In parts of South East Asia and Africa, the transmission cycle may also involve jungle
primates that act as a reservoir for the virus

Dengue is most widely transmitted by the mosquito named Aedes aegypti (see video 1 and 2).
The Aedes albopictus mosquito and other Aedes species also transmit disease in specific
areas. Aedes polynesiensis, Aedes scutellaris and Aedes pseudoscutallaris in the Pacific Islands
and New Guinea. Aedes polynesiensis in the Society Islands and Aedes niveus in the Philippines.

The Aedes mosquito prefers to breed in water-filled receptacles, usually close to human
habitation. They often rest in dark rooms (e.g. in bathrooms and under beds) and breed in small
pools that collect in discarded human waste. Although they are most active during daylight hours,
biting from dawn to dusk, mosquitoes will feed throughout the day indoors and during overcast
weather.

Signs and Symptoms

After being bitten by a mosquito carrying the dengue virus, the incubation period ranges from 3
to 14 (usually 4 to 7) days before the signs and symptoms of dengue appear. Dengue occurs in
two forms:

Dengue Fever
Dengue Hemorrhagic fever (DHF)

The disease manifests as a sudden onset of severe headache, chills, pain upon moving the eyes,
and low backache. Painful aching in the legs and joints (myalgias and arthralgiassevere pain
that gives it the nick-name break-bone fever or bonecrusher disease) occurs during the first hours
of illness. The temperature rises quickly as high as 40 C, with relative low heart rate
(bradycardia) and low blood pressure (hypotension). The dengue rash is characteristically bright
red petechiae and usually appears first on the lower limbs and the chest (see figure 2). The glands
(lymph nodes) in the neck and groin are often swollen. In some patients, it spreads to cover most
of the body. There may also be gastritis with some combination of associated abdominal pain,
nausea, vomiting, or diarrhea. Some cases develop much milder symptoms which can be
misdiagnosed as influenza, chikungunya, or other viral infection when no rash is present. The
classic dengue fever lasts about six to seven days, with a smaller peak of fever at the trailing end
of the disease (the so-called biphasic pattern). Clinically, the platelet count will drop until the
patient's temperature is normal.

Recognition of Dengue fever

- Sudden onset of high fever
- Severe headache (mostly in the forehead)
- Pain behind the eyes which worsens with eye movement
- Body aches and joint pains
- Nausea or vomiting

Because dengue is caused by a virus, there is no specific medicine or antibiotic to treat it, the
only treatment is to treat the symptoms. For typical dengue, the treatment is purely concerned
with relief of the symptoms (symptomatic). Rest and fluid intake for adequate hydration is
important.

The mainstay of treatment is timely supportive therapy to tackle shock due to hemoconcentration
and bleeding. Close monitoring of vital signs in critical period (between day 2 to day 7 of fever)
is critical. Increased oral fluid intake is recommended to prevent dehydration. Supplementation
with intravenous fluids may be necessary to prevent dehydration and significant concentration of
the blood if the patient is unable to maintain oral intake. A platelet transfusion is indicated in rare
cases if the platelet level drops significantly (below 20,000) or if there is significant bleeding.
The presence of melena may indicate internal gastrointestinal bleeding requiring platelet and/or
red blood cell transfusion.

People who suffer from dengue fever have no risk of death but some of them develop Dengue
Haemorrhagic Fever (DHF) or Dengue Shock Syndrome (DSS). In some of these cases death can
occur. If a clinical diagnosis is made early, a health care provider can effectively treat DHF using
fluid replacement therapy. Adequately management of DHF generally requires hospitalization.

Aspirin
Aspirin, Brufen and non-steroidal anti-inflammatory drugs should be avoided as these drugs may
worsen the bleeding tendency associated with some of these infections. Patients may receive
paracetamol preparations to deal with these symptoms if dengue is suspected. Doctors should be
very careful when prescribing medicines. Any medicines that decrease platelets should be
avoided.

Traditional treatment
In Brazilian traditional medicine, dengue is treated with cat's claw herb, which is for
inflammation and does not prevent dengue. In Malaysia, dengue is treated by some using natural
medicine. The treatment is speculated to be able to arrest and reverse the viral infection and
prevent the disease from advancing into a critical stage, though no evidence has yet shown
effectiveness. In Philippines dengue patients use tawa-tawa herbs and sweet potato tops juice to
increase the platelets counts and revived the patients. These are traditional treatments nd are
often not based on scientific medicine research.

Prevention

The best way to reduce mosquitoes is to eliminate the places where the mosquito lays her eggs,
like artificial containers that hold water in and around the home (see figure 2, video 2 and 3). In
urban areas, Aedes mosquitos breed on water collections in artificial containers such as plastic
cups, used tires, broken bottles, flower pots, etc (see also transmission of dengue). Periodic
draining or removal of artificial containers is the most effective way of reducing the breeding
grounds for mosquitos. Larvicide treatment is another effective way to control the vector larvae
but the larvicide chosen should be long-lasting and preferably. There are some very effective
insect growth regulators (IGRs) available which are both safe and long-lasting (e.g.
pyriproxyfen). For reducing the adult mosquito load, fogging with insecticide is somewhat
effective.
To eliminate standing water:
- Unclog roof gutters;
- Empty children's wading pools at least once a week;
- Change water in birdbaths at least weekly;
- Get rid of old tires in your yard, as they collect standing water;
- Empty unused containers, such as flower pots, regularly or store them upside down;
- Drain any collected water from afire pit regularly.