Dengue, PSM, Community Medicine,DR NARENDRA KUMAR YADAV

Dengue, PSM, Community Medicine,DR NARENDRA KUMAR YADAV

1. Dengue DR NARENDRA KUMAR YADAV MD Community Medicine & Tropical Diseases, BPKIHS

2. Dengue: Outline of the Chapter: Epidemiological triad of dengue Burden of Disease Clinical Presentation Warning signs of dengue Diagnosis: Clinical methods and laboratory methods CONTROL MEASURES Clinical Management

3. Vector Borne Diseases: M/C Vector borne disease in Nepal/India: Malaria M/C VIRAL Vector borne disease in Nepal/India: Dengue M/C Arboviral Vector borne disease in Nepal/India : Dengue

4. Mosquitoes: ANOPHELES CULEX AEDES MANSONIA Malaria Japanese Encephalitis(JE) Lymphatic Filariasis West Nile Fever Dengue CGF YF Zika RVF Brugian Filariasis CLEAN Water DIRTY Water ARTIFICIAL(Man Made) COLLECTION OF RAIN WATER AQUATIC PLANTS Flight range: 3-5 kms 11 kms 100 m

5. Arboviral Diseases Classification: GROUP: A GROUP: B OTHERS: CGF Dengue Japanese Encephalitis(JE) Kyasanur Forest Disease(KFD) West Nile Fever Sandfly Fever

6. Dengue : Dengue is a viral infection caused by dengue virus (DENV) that transmitted to humans through the bite of an infected mosquitoes (Aedes species) Cause: Group B Arbovirus Dengue viruses have 4 serotypes: DENV-1 ( M/C/C of Epidemic ) DENV-2 DENV-3 DENV-4

7. Dengue : VECTOR of Dengue:  Aedes aegypti (Tiger Mosquito) and Aedes Albopictus Feeding Habits: Day Bitter (Bite during day time) Resting Habits: Rest in the dark corners of houses Breeding Habits: ARTIFICIAL(Man Made) COLLECTION OF RAIN WATER

8. Dengue: Reservoir: Man and Aedes Incubation Period: 3-10 days

9. Burden of Disease: Dengue is found in tropical and sub-tropical climates worldwide , mostly in urban and semi-urban areas . About half of the world's population is now at risk of dengue with an estimated 100–400 million infections occurring each year (WHO) Mortality: DF: <1% Severe dengue: 5%

10. Epidemiological triad of dengue : Agent: Dengue virus (DENV) Host: Human & Aedes mosquito . Env : ARTIFICIAL\COLLECTION OF RAIN WATER & Rainy season Dengue

11. DEGUE: Clinical Presentation: 1. Asymptomatic Dengue Viral Infection Most of the cases are asymptomatic 2. Dengue Fever(DF) AKA: Classical Dengue Fever AKA: Break Bone Fever Fever ( ≥ 104 F) Retro-orbital pain/Headache/MYALGIA/ BONE PAIN Nausea/Vomiting RASH ( Macular or Maculopapular ) 3.Dengue Hemorrhagic Fever (DHF): a . Febrile Phase b. Critical Phase c. Recovery Phase Fever Thrombocytopenia ( PLT ≤ 1 lakh/mm 3 ) Hemorrhagic manifestations: Gum bleeding, Epistaxis, Hematemesis, Melena, Hematuria Evidence of leaky capillaries: Elevated Hematocrit ( ≥ 20% ), Pleural effusion, Ascites Leukopenia 4. Dengue Shock Syndrome(DSS): DHF + SHOCK

12. Rash in Dengue: The rash is typically macular or maculopapular and may be associated with pruritus.

13. Severe Dengue: Severe dengue is defined by ≥ 1 of the following: Evidence of leaky capillaries: Shock Fluid accumulation (P. Effusion, ascites): +-Respiratory Distress 2 . Severe Bleeding: Shock 3. Organ failure( single or multiple organ failure )

14. Warning signs of dengue: Restlessness/ OBTUNDATION Persistent Vomiting: Dehydration Mucosal Bleeding Pleural Effusion: Dyspnea Ascites Hepatomegaly (2 cm below the costal margin) Thrombocytopenia Rise in Hematocrit

15. Dengue: Diagnosis: CRITERIA FOR CLINICAL DIAGNOSIS: Fever and ≥  2/6 following features: 1. Retro-orbital pain/Headache/Myalgia/ Bone Pain 2. Nausea / Vomiting 3. Rash (macular or maculopapular) 4. Warning signs of dengue 5. Positive Tourniquet Test 6. Leucopenia

16. TORNIQUET TEST: TORNIQUET TEST(Positive Tourniquet Test) DF: ≥ 10 Petechiae/ sq inch of skin in cubital fossa DHF: ≥ 20 Petechiae/ sq inch of skin in cubital fossa

17. Laboratory Diagnosis: SEROLOGICAL Test: NS-1 Antigen (non-structured protein of dengue virus) IgM antibodies IgG antibodies 2. Hematocrit (PCV) Count: Increases 3. PLT: Decreases 4. TLC: Decreases 5. LFT 6. CXR 7. USG

18. Control Measures: 1. Mosquito Control: A. Physical Methods: Source Reduction (Best): Elimination of breeding place Use of mosquito nets Wearing of full sleeves shirts and full pants Use of mosquito repellent: creams, liquids, coils, mats B. Chemical Methods: Antiadult measures(Nerve/ Contact Poison): DDT, Pyrethrum, Malathion Antilarval measures: Paris Green (Stomach Poison) C. Biological Methods: Gambusia, Lebister , Poecilia (All are Larvivorous Fishes)

19. Control Measures: 2 . Vaccines: DENGVAXIA (Live): 0, 6 months, 12 months Age: 9months- 45 years

20. Clinical Management: Category Intervention Dengue without warning sign : A OPD Dengue with warning sign : B IPD Dengue with risk factors : B IPD Patient with severe dengue : C IPD High risk patients: Infant, Elderly(>65 Years), Pregnancy, DM, HTN, IHD, Asthma, CRF, Liver cirrhosis, PUD, Steroids, NSAIDs

21. Clinical Management: Category A: OPD Dehydration: ORS Fever: Paracetamol & Cold sponging C/I: Aspirin ( acetylsalicylic acid), Ibuprofen, Corticosteroids Use insect repellant on patient & Elimination of breeding place W/F: Bleeding, Signs of Plasma leakage, Warning signs of dengue.

22. Clinical Management: Category B: warning sign +/ risk factors + CRYSTALOIDS: NS/ RL Colloids: iv albumin Blood transfusion (BT) PLT (only when PLT < 50,000 with bleeding OR <10,000 without bleeding): PRP 4hrly vitals monitoring I/O monitoring

23. Clinical Management: Category C: Patient with severe dengue: CRYSTALOIDS: NS/ RL Bolus 1: 10 ml/kg/ hr (1Hr) Bolus 2: 2 ml/kg/ hr (15 min) Colloids: iv albumin Blood transfusion (BT) PLT ( only when PLT < 50,000 with bleeding OR <10,000 without bleeding ): PRP

24. Criteria for discharge of patient: Absence of fever for at least 24 hours without the use of anti-pyretic drugs. Return of appetite. Visible clinical improvement. Good urine output. Minimum of 2-3 days after recovery from shock. No respiratory distress from pleural effusion or ascites. Platelet count > 50000/ cu.mm

25. MCQ: Q . Dengue shock syndrome is characterized by the following except: Hepatomegaly Pleural effusion Thrombocytopenia Decreased hemoglobulin

26. Ans: d (Decreased hemoglobulin)

27. MCQ Q. Which of the following statement is not about dengue: Increase hematocrit Decrease PLT Positive tourniquet test Vector Aedes aegypti usually bite during day time Decrease hematocrit

28. Ans: e (Decrease hematocrit)

29. MCQ: Q. Which is not true about dengue hemorrhagic fever: Thrombocytopenia Hepatomegaly Shock Plasma leaking

30. Ans: c (Shock)

31. MCQ Q . Classical Dengue fever is transmitted by: Culex fatigans Culex vishnuii Culex aegypti Culex palpalis

32. Ans: c (Culex aegypti)

33. The End

34. Dengue Hemorrhagic Fever (DHF): The course of DHF can be divided into 3 phases: Febrile phase, Critical phase and Recovery phase.

35. Dengue Hemorrhagic Fever (DHF): Febrile phase: During the first few days the illness usually resembles classical Dengue fever. High grade fever with facial flushing, headache, anorexia, vomiting, abdomen discomfort, pain abdomen, febrile seizure Retro-orbital pain/Headache/MYALGIA/ BONE PAIN Thrombocytopenia ( PLT ≤ 1 lakh/mm 3 ) Evidence of leaky capillaries: Elevated Hematocrit ( ≥ 20% ) TORNIQUET TEST(Positive Tourniquet Test): DF: ≥ 10 Petechiae/ sq inch of skin in cubital fossa

36. Dengue Hemorrhagic Fever (DHF): 2. Critical phase:

37. Dengue Hemorrhagic Fever (DHF): 3. Recovery phase: