DENGUE & DENGUE

HEMORRHAGIC FEVER
 Dengue Virus
Dengue is a mosquito born infection which in
recent year has become major international public
health concern.

Dengue hemorrhagic fever (DHF), a potentially

lethal complication found first time in 1950s in
Phillipines and Thailand.

The spread of Dengue is rapid in urban

populations where household water storage is
common and where solid waste disposal services
are inadequate.
 Dengue Virus
Member of Flaviviridae
Uses mosquito (Aedes aegypti) as a vector
for infecting humans
4 strains DENV1, 2, 3, 4
Each serotype provides specific lifetime
immunity, and short-term cross-immunity
All serotypes can cause severe and fatal
disease
Genetic variation within serotypes
 Anatomy of the Dengue Virus

Enveloped virus
Has a lipid bilayer
coat
Genetic material is
ssRNA virus (+ive
sense)
RNA is covered by
nucleocapsid

Nature Structural Biology 10, 907 - 912 (2003)

Transmission of Dengue Fever
Dengue virus is transmitted to humans through the bites of
infective female Aedes mosquitoes.

Mosquitoes generally acquire virus while feeding on the blood

on an infected person.

After virus incubation for 8-10 days, an infected mosquito is

capable , during probing and blood feeding, of transmitting
the virus, to susceptible individuals for the rest of its life.
Aedes mosquito

Primarily a daytime feeder (appear during dawn & dusk)

Lives around human habitation

Lays eggs and produces larvae preferentially in artificial containers

Transmission Process
 Symptoms of Dengue Fever
Fever
Headache
Muscle and joint pain
Nausea/vomiting
Rash
Hemorrhagic manifestations
Patients may also report other symptoms, such as
itching and aberrations in the sense of taste,
particularly a metallic taste. In addition, there
have been reports of severe mouth dryness after
the acute phase of the illness.
1.The virus is inoculated into
humans with the mosquito
saliva.

2.The virus localizes and

replicates in various target
organs, for example, local lymph
nodes and the liver.

3.The virus is then released from

these tissues and spreads
through the blood to infect
white blood cells and other
lymphatic tissues.

4.The virus is then released from

these tissues and circulates in
the blood.
5.The mosquito ingests blood containing the virus.

6.The virus replicates in the mosquito midgut, the ovaries,

nerve tissue and fat body. It then escapes into the body cavity,
and later infects the salivary glands.

7.The virus replicates in the salivary glands and when the

mosquito bites another human, the cycle continues.
Transmission Illustration Diagram
 Four 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)
 Preventions
Keep your homes and offices protected against mosquitoes.
Keep homes and offices airy, bright and safe from moisture.
Fix nets on doors and windows.
Wear full sleeves clothes.
Use mosquito nets while sleeping.
Don't leave the overhead tanks open & avoid using swimming pools.
Don't keep water in containers for more than a week. Instead, empty them
every week, let them dry and then fill again.
Don't let the water accumulate in any case both inside or outside the home.
Be mindful of your home's cleanliness.
Keep the fence and hedge boundaries duly cut both inside and outside the
home, and spray over them with insecticides, particularly in the evening.
Don't let the water stay all the time in the flower pots. Instead water them
only in the morning every alternate day.
The best way to fight dengue is through sustained cleanliness and
sanitation.
 Programs to Minimize the Impact of Epidemics
Education of the medical community

Implementation of emergency contingency plan

Education of the general population

Facts about Dengue Fever in Pakistan
First outbreak in Pakistan was in 1994 probably came from
Thailand and Malaysia.

Punjab is the most victimized province from Dengue fever.

Approx. 900 cases are reported daily in Lahore.

Sindh & Islamabad are 2nd and 3rd largest victimized areas of
Pakistan.

In Karachi, total 1500+ cases has been reported.

KPK does not lie in the traditional endemic belt, but

witnessed major outbreak in 2014.
Death toll due to dengue in KP rises to 23 (September 13, 2017)
 Death toll due to dengue in KP rises to 23
(September 13, 2017)
 Age wise distribution of dengue cases
during 20092014 in Pakistan

No. of P-
No. of positiv No. of positive samples
Age Positive value
tested e
groups rate (%)
samples sample 2009 2010 2011 2012 2013 2014
s
010 279 81 29.0 12 36 16 1 9 7

1120 1 230 429 34.9 34 171 79 6 72 67

2130 5897 2199 37.3 61 668 1249 10 155 56

3140 929 382 41.1 16 201 67 0 55 43 0.019*

4150 587 238 40.5 9 127 36 2 40 24

5160 361 115 31.9 3 65 20 0 20 7

>60 210 60 28.6 1 35 10 1 5 8
Total 9493 3504 36.9 136 1303 1477 20 356 212
Geographical map of Pakistan showing
districts with dengue postive cases
during 2009-2014
Sri Lankan experts advice on dengue
The team comprises doctors, clinical experts, epidemiologist, physicians and communication
specialists that visited Pakistan on the invitation of the Punjab government to make
suggestions on treating and controlling the dengue fever as Sri Lanka has an excellent
experience of defeating it.

Fumigation, being done officially or unofficially, can help overcome

the spread of ailment by just 15 per cent while preventive measures
taken by the community at homes can defeat it by 85 per cent.

The experts said Sri Lanka has successfully grappled with the disease
over the past thirty years mainly by creating 100% public awareness.

They said that the panic created in Pakistan has led to most deaths
because some affected who are already suffering from diabetes or
heart problems can't physically and psychologically bear the pressure
of the disease and collapse having cardiac arrest.

They said effect of dengue would ease by October and would end in
December.
Efforts of Government Health Departments
Government of Punjab had developed Punjab Health Line
Project for Dengue whose number is 0800-99000. Any person
can take information on dengue by calling on it.

The government has raised awareness for spraying. Article

144 is implemented in Lahore for the prevention of dengue.

Close liaison has been established with hospitals and

National Institute of Health (NIH), Islamabad in order to work
in coordination. A separate team comprising of a dispenser
and a malaria worker has been deputed to create awareness
amongst general public who are visiting the communities
and advising them about the precautionary and preventive
measures against the diseases.
Frequently Asked Questions:

Q1:How soon After Exposure do Symptoms appear:

Ans: Normally 4-6 days with a range of 3-14 days.

Q2: How is Dengue Diagnosed?

Ans: By blood test of followings
Platelets
White Blood Cells (WBC)
Virus Isolation

Q3: How is Dengue Treated?

Ans: There is no specific treatment. Maintenance of the circulating fluid
volume is the central feature of DHF case management. Use lot of fresh
juices e.g. Apple juice, pomegranate juice, Papaya leaves syrup etc. are
helpful in increasing platelets against fever. Panadol and use of
paracetamol is the only drug of choice to bring down fever.
Q4: Can a person get Dengue from another person?
Ans: It does not spread from person to person, but only spread by bites of
infected mosquitoes.

Q5: Can fever become dangerous?

Ans: Virus effects bone marrow, causes reduction of WBCs and platelets and
also damage to blood vessels.

Q6: When should a patient suffering from Dengue go to the hospital or consult
a doctor?
Ans: Right from the day of fever. Generally progress towards dengue fever occur
after 3-5 days of fever. At this time, fever has often come down and we think it
is recovering. In fact, this is the most dangerous period that requires high
vigilance from care-givers.

Q7: Is there a vaccine to prevent dengue fever?

Ans: Yet, no vaccine available in the market, please avoid using any vaccine.
Chikungunya virus
 Chikungunya fever
Chikungunya fever is a viral disease caused by
an arthropod-borne virus.
Chikungunya is the name derived from a work
in non-famous language makonde. It means
to bend out of shape, explains the
appearance of people suffering from
polyarthralgia because of chikungunya virus
(CHIKV) fever
The virus spreads through mosquitoes: Aedes
albopictus and Aedes aegypti.
 Virus classification
Group: Group IV (+ssRNA)
Family: Togaviridae
Genus: Alphavirus
 Epidemiology
Chikungunya risk zones

Outbreaks of Chikungunya virus are usually found in:

Africa
Southeast Asia
Indian subcontinent and islands in the Indian Ocean

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 Epidemiology
There are historical reports of chikungunya fever
epidemics in Tanzania during the mid-1950s.
Previous outbreaks were reported between 1920
and 1950 in South Asia.
The recent epidemic was reported during 2005 in
India.
Lately, chikungunya outbreak started in
November 2016 in Karachi, Pakistan, infecting
more than 30,000 inhabitants of Karachi and only
803 cases were reported to World Health
Organisation (WHO) since December 2016
 Pathology
The infection is generally symptomatic, and
characterised by an abrupt onset of fever
followed by severe polyarthralgia.
Other common symptoms include rash,
headache, nausea, fatigue, and myalgia.
Although the illness is self-limiting, joint pain
can persist for months and even several years in
some cases.
Complications
Possible complications include gastro-intestinal complications,
cardiovascular decompensation or meningo-ecephalitis
Fatalities have been reported mainly in aged patients or
where the patients immune system was weakened by
underlying conditions
Treatment
In the absence of treatment for Chikungunya fever, focus is set
on:
symptomatic treatment only (non-steroid anti-
inflammatories, non-salicylic analgesics)
surveillance of the patient for complications
prevention of further transmission

In order to prevent further transmission, infected persons

should avoid further mosquito bites (e.g. use of repellents or
sleeping under bed nets as much as possible)
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