Dr. Humayun Chaudhry MPH, M.

Phil (Community Medicine)

Eggs 2 days

Adult

Complete Metamorphosis

Larva 6 to 8 days

Pupa 2 days

Eggs

Black in colour Small air bubbles like cavities on the surface which they fl

Larvae

Suspend obliquely in water, head downward Siphon tube is short, open at the surface for respiration

Pupae

Comma shaped Black in colour

 Black in colour with alternate white bands (tiger mosquito) Wings are unspotted Does not make noise while flying Bites during the daytime. Bites are not painful.

Only the female Aedes mosquito feeds on blood. This is because they need the protein found in blood to produce eggs. Male mosquitoes feed only on plant nectar. On average, a female Aedes mosquito can lay about 300 eggs during her life span of 14 to 21 days.

Agent factors
Human Dengue Virus evolved separately from monkey dengue one to four viruses beginning about 1000 years ago.

The four dengue viruses single-stranded, enveloped, RNA viruses. Belong to the family of Flavivirdae This Family composed of 54 serologically related viruses. Dengue virus are spherical, 50-nm virions Consisting of nucleocapsid core (30 nm) surrounded by lipoprotein envelope.

 Adese agypti universally distributed in tropics between 30 degrees North and 20 degrees South latitude. (latitudeof a location on the Earth is the angular distance of that location south or north of the Equator.) This area nearly constitutes half of the world population. Most transmission occurs at altitudes below 2,000 feet and during rainy seasons. Frost or sustained cold weather destroys adult mosquitoes and interrupts transmission. Adese agypti has a short flight range (20-50m) Spread of Dengue virus is almost entirely due to the movement of viremic (infected) humans.

 After the bite of infected mosquito, the virus multiplies for six days.
Patient is infectious to mosquito during this period. After ingestion of infected human blood, eight to ten days are required for the virus to multiply in the insect body. The mosquito remains infectious for life. Incubation period 3-10 days(commonly 5-6 days).

Host factors

Age: Primary Dengue Infection is milder in children than in adults The severity of secondary dengue infection is higher in youngest chil and risk of developing DHF-DSS Ethnicity Blacks are intrinsically less susceptible to severe and fatal disease after second dengue infection of different sero types. Sex Females are at higher risk for severe disease and death than males Immunity First attack only gives temporary and partial protection against other three sero types

Environmental factors
Transmission only occurs if the temperature is above 16C to 28 C Transmission subsides during winter.

Transmission risk factor

When a member of a household is infected, other family members are at risk.

Dengue spread is facilitated in places where people assemble like sch emples, mosques, cinema halls etc, where vector is in abundance.

Dengue infection of pregnant women results in congenital infection to etus.

Those born with maternal antibody against Dengue virus are at a high risk of developing DHF-DSS.

Spectrum of Dengue fever

Dengue Virus Infection

Symptomatic

Asymptomatic

Fever only

Dengue fever

Dengue Hemorrhagic Fever

With unusual hemorrhage

without hemorrhage

With shock

Without shock

DF

DHF

Symptoms of Dengue Fever

First 12-24 hours
Sudden onset. Progressive severe malaise, chills, fever, headache, backache and generalized myalgia.

Second Day

Patient acutely ill and prostrate. Fever up to 40C Severe headache Retrorbital pain Photophobia Generalized muscle aches and joint stiffness

Third Fourth Day

Temperature falls briefly on third or fourth day. A saddleback (bi-phasic) fever curve. Maculopapular or scarlatiniform rash appears Beginning on the trunk and spreading in centripetal fashion. Last for several days Becomes itchy when fades.

Example of a skin rash due to dengue fever

Fifth, Sixth and Seventh Day.

Fever subsides. Full recovery takes several weeks due to weakness and depression Towards the end of febrile period, small clusters of petechiae may appear

Symptoms of DHF.
First 24 hours The onset is similar to that of dengue fever
Usually abrupt with fever. Nausea, vomiting Throat appears injected Dry Cough

Second /Third Day

Petchiae appears Face is involved first and distal portions of the extremities Axillae and chest is spared. Tourniquet test is conspicuously positive. Occasionally, purpura and large ecchymoses as well as other manifestation of bleeding present.

Tourniquet Test
Most common hemorrhagic phenomena can be detected by tourniquet test. Done by tying a blood pressure cuff on the upper arm Inflate it to the pressure between systolic and diastolic pressure. Inflation is maintained for five minutes and then released. Occurrence of more than 10 petechiae in a one inch square marked on the same forearm is considered as positive.

Third or Fourth Day

Vomiting coffee-ground Melina present but gross bleeding from intestine is rare Shock is likely to occur in severe cases about fourth day and last 12-24 hours. During this period (12-24 hours), temperature falls to normal. Blood pressure and pulse pressure are low or immeasurable.

Limbs are cool and presents a purple or brownish mottled appearance. Perspiration is profuse. The face and hands appear edamatous. Restlessness and apprehension are evident and patient enters into shock. Thrombocytopenia is noted during this period. Bleeding time is prolonged.

Grading the severity of DHF

It has been classified into four grades according to patho-physiological hallmark- shock and bleeding

Grade 1
Fever and non-specific constitutional symptoms
positive tourniquet test

Grade 2.
Manifestation of grade 1 Spontaneous bleeding from the skin and other hemorhages

Grade 3. Circulatory failure resulting in:

a. rapid and weak pulse b. Narrowing of pulse pressure (20 mm Hg or less) Hypotension a. Presence of cold and clammy skin b. restlessness

Grade 4
Profound shock. Undetectable blood pressure and pulse. The presence of thrombocytopenia with concurrent haemo-concentration differentiate grade 1 and grade 2 DHF from dengue fever.

Laboratory findings

Most common hematologic abnormalities during clinical shock are 1. 20% or greater increase in hematocrit value over the base line value 2. Thrombocytopenia (< 100,000 per mm3) Mild leucocytosis

Prolonged bleeding time Moderately decreased prothrombin level.

Mild metabolic acidosis with hyponatrimia. Radiograph of chest reveals plural effusions in all patients.

Sonograms reveal plural and pericardium effusion, ascities and peri-gallbladder edema.

Diagnosis
A. Clinical According to WHO, following are the features of DHF: 1. Acute onset of high-grade fever. 2. Evidence of haemostatic abnormalities a. Most frequently a positive tourniquet test. b. Thrombocytopenia (< 100,000 per mm3) c. Hematocrit elevated to at least 20% above base line value.
DSS includes: 1. All the above mentioned features. 2. Evidence of hypotension or pulse pressure of 20 mm Hg or less. 3. Prognosis and treatment should be based on pulse pressure.

B. Virus Isolation
Blood should be obtained during febrile period Preferably before the fifth day after the onset of illness The acute face serum or plasma sample maybe frozen at -65C or colder

C. Serologic Diagnosis
The most widely used test is the immunoglobulin M (IgM) capture ELISA Dengue IgM anitbodies. (if present more than 5 days and in less than 90 days after onset of fever) are both found with primary and secondary infection. In the ELISA, the ratio of IgM to IgG is greater than 1:1 in the acute phase of primary infection and less than 1:1 in secondary infection.

PCR
Reverse transcriptase PCR (RT-PCR) has been developed for a number of RNA viruses in recent years. RT-PCR provides a rapid serotype-specific diagnosis. The method is rapid, sensitive, simple, and reproducible if properly controlled. It be used to detect viral RNA in human clinical samples, autopsy tissues, or mosquitoes

Treatment of Dengue Fever

Symptomatic and supportive Bed rest is advisable during febrile phase Anti-pyretic and sponging is advisable to keep the body temperature below 40C. Aspirin should be avoided. Oral fluid and electrolyte for patient with excessive sweating, vomiting or diarrhea.

Treatment of Dengue Hemorrhagic Fever

The major pathological abnormality seen in DHF/DSS is ncreased vascular permeability, leading to leakage of Plasma.

This results in hemoconcentration.

Treatment is directed as early as possible and with effective eplacement of losses with plasma, plasma expanders or fluids

Live threatening thrombocytopenia is treated with platelets oncentrates.

Clinical bleeding needs blood transfusions

Disease control
This term describes operations aimed at reducing: 1. The incidence of disease 2. Duration of disease. Consequently, the risk of transmission. 3. Effects of infections like physical and psychosocial complications. 4. The financial burden in the community

 The disease control activities focus on primary prevention and secondary prevention. In control a state of equilibrium exist between disease agent,host and environment. The disease agent is allowed to persist in the community at a level where it ceases to be a public health problem

Disease Elimination
Interruption of transmission of disease from a particular region.

Disease Eradication
Termination of all transmission of infection by extermination of the infectious agent.

The word eradication is reserved to cessation of infectio and disease from the whole world.

Prevention and Control

1. Anti-larval measures
a. Environmental control Most important step also known as source reduction involves:

Mosquito Control Measures

i) filling ii) Leveling and drainage of breeding places iii) Water management (intermittent irrigation) iv) Channeling

b. Chemical control It involves use of oiling, Paris green and larvaecides. i) Oiling - Kerosine oil when applied on water , it spreads and forms a thin film. - it cuts off the air supply of the mosquito, larvae and pupa. - 40-90 liters'/ Hectares (10000 m2) - Oiling is needed once a week

ii) Paris green It is a stomach poison must be ingested by larvae applied as 2% dust Prepared by mixing of two grams of Paris green with 98 kg of diluents solution in a rotary mixer. 1 kg of Paris green per hectare of water is sufficient. iii) Larvaecides the most effective larvae sides are abate, fenthion and chlorpyrifos (organophosphorus compounds) The dosage of abate is 56 112 gram per hectare.

c. Biological control Consists of using larvaecidal fish Gambusia affinis, lebister reticulatus and haplochilus pancchax. Gambusi aaffins is an American introduced fish. It is the best choice as larvaecidal fish. Thrive well in local condition. Male and female ratio is 1:3 Twelve fish are enough for an ordinary well.

2. Anti-adult measures
a. Residual spray - In case of DDT (organocholrine compound), 1 -2 grams per meter square and lasts for 6 12 months. - Due to resistance developed among mosquitoes, organophosphorus compounds like melathine is recommended. - Dosage of melathine is 2 gram per meter square and lasts for 3 months. - Melathine is a contact poison. - Melathine is used in indoors and outdoors as well. - It is used as ultra low volume spray to control dengue fever (fogging). - Other residual sprays are lindane, BHC, OMS 33.

b. Space sprays - are those where the insecticidal formulation is sprayed into the atmosphere in the form of mist or fog as mentioned above in case of melathine. - Perithrum is also used as space spray - the most extensively used insecticides for ultra low volume space spray are melathine and fenitrothion in the form of fogging. c. Genetic Control - this consists of reduction (or loss) of the reproductive capacity of the mosquito - Chromosomal aberrations, hybrid male technique and sterile male technique are under research phase

3. Protection against mosquito bites

a. Mosquito nets - The net should have at least 150 perforations per square inch and of white colour. - The use of insecticides treated bed nets is recommended. b. Screening of building - Screening of building by galvanised iron or aluminium mesh, protects the inmate by warding off the flies and mosquitoes.

c.

Repellants - The common repellants are oil of citronella, effective for 2 hours. - Diethyltoluamide, Dimethylcarbate, Ethylhexanediol, Indalone are effective for 4 hours. - Use of mosquitoes coil is also in practice.

4. Vaccine - Different vaccines are under research and no success has been made so far against dengue fever.

Change of water on alternate days

Remove water from pots on alternate days

Turn over all pails and water storage containers.

Do not litter. Rubbish such as cups and bottles can collect rain water and breed mosquitoes.

Ex ot ic

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Insect growth regulators

Adulticides

Integrate d Disease vector control

School children T.V

Mass m edia

Bed nets

Repellants

Integrated Vector Control (IVC)

Consists of combining two or more vector control methods Whether these are directed only to the larvae or adults or both. Purpose is to obtain maximum results with minimum effort To avoid the excessive use of one method

This strategy (IVC) was used to counter the following:

Technical problems such as development of resistance to older insecticides .

Financial problems e.g. cost of newer insecticides Environmental problems e.g. Environmental pollution by insecticides Operational problems for e.g. lack of public cooperation for spraying insecticides in their houses.

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