Dengue

Dr. Binod Kumar Yadav

MD Community Medicine
Assistant Professor
 Key facts

• Dengue is a viral infection transmitted to humans through the bite of infected

mosquitoes.
• About half of the world's population is now at risk of dengue with an estimated
100–400 million infections occurring each year.
• Dengue is found in tropical and sub-tropical climates worldwide, mostly in urban
and semi-urban areas.
• While many dengue infections are asymptomatic or produce only mild illness, the
virus can occasionally cause more severe cases, and even death.
• Prevention and control of dengue depend on vector control. There is no specific
treatment for dengue/severe dengue, and early detection and access to proper
medical care greatly lower fatality rates of severe dengue.
Global burden

• Cases reported to WHO increasing cases in 2000 to 5.2 million in 2019

• The highest number of dengue cases was recorded in 2023, affecting
over 80 countries in all regions of WHO.
• Estimate indicates 390 million dengue virus infections per year of
which 96 million manifest clinically.
• The disease is now endemic in more than 100 countries in the WHO
Regions of Africa, the Americas, the Eastern Mediterranean, South-
East Asia and the Western Pacific. The Americas, South-East Asia and
Western Pacific regions are the most seriously affected, with Asia
representing around 70% of the global disease burden.
• Dengue is spreading to new areas in Europe, the Eastern
Mediterranean and South America.
• The largest number of dengue cases reported was in 2023. The WHO
Region of the Americas reported 4.5 million cases, with 2300 deaths.
A high number of cases were reported in Asia: Bangladesh (321 000),
Malaysia (111 400), Thailand (150 000), and Viet Nam (369 000).
 Introduction : Dengue
• Dengue virus is a flavivirus transmitted by the bite of the Aedes mosquito.
• Dengue infections caused by the four antigenically distinct dengue virus
serotypes (DENV1, DENV2, DENV3, DENV4) of the family Flaviviridae

• Important arbovirus diseases in humans, in terms of geographical

distribution, morbidity and mortality.

• Dengue infections may be asymptomatic or may lead to an undifferentiated

fever (or viral syndrome), dengue fever or dengue haemorrhagic fever
(DHF).
Dengue and DHF Global Issues
• 2.5-3 billion people are at risk
• Aedes aegypti is the primary epidemic vector
• Urban disease, but becoming rural
• Estimated 50-100 million cases of dengue fever annually
• 500,000 DHF cases require hospitalization.
• 25,000 deaths due to DHF every year
• Mortality averages 5% of DHF cases
• Epidemics are cyclical
Epidemiology- Global distribution
• DF and DHF are present in urban and suburban areas

• Widely spread in the Americas, South-East Asia, the Eastern

Mediterranean and the Western Pacific

• Several factors have combined to produce epidemiological conditions

in developing countries in the tropics and subtropics
Economic Burden In SEAR
• Estimated an annual average of 2.9 m dengue episodes and
5,906deaths.
• This amounts to an annual cost per capita of US$1.65 (0.03% GDP per
capita in 2010), and
• a disease burden of 372 disability-adjusted life years (DALYs) per
million inhabitants, a rate higher than that of 17 other conditions,
including Japanese encephalitis, upper respiratory infections, and
hepatitis B.
Variable endemicity for DF/DHF in SEA
Region
Factors Responsible for the
Resurgence of the Dengue Epidemic
• Unprecedented human population growth
• Unplanned and uncontrolled urbanization
• Inadequate water supply and waste management
• Increased distribution and densities of vector mosquitoes
• Lack of effective mosquito control
• Increased movement and spread of d. virus
• Development of hyper endemicity
Host and Vector

• Humans main reservoir of virus

• Aedes aegypti wide spread in tropical and sub tropical countries
• Mosquito density fluctuates with rainfall and water storage practices
Transmission Cycle
• Vectors : Aedes aegypti, other Aedes (albopictus) Spp.
• Extrinsic incubation period 8-10 days
• Dengue virus infection in person from mosquito bite
• Intrinsic incubation 3-14 days (Avg.4-7days)
• Viraemia appears before the onset of symptoms and lasts an average
of five days after the onset
• transovarian transmission of dengue virus occurs
• Aedes aegypti is a highly domesticated, strongly anthropophilic,
nervous feeder (i.e., it bites more than one host to complete one
blood meal) and is a discordant species (i.e., it needs more than one
feed for the completion of the gonotropic cycle).
• Ae. albopictus partly invades peripheral areas of urban cities. It is an
aggressive feeder and concordant species, i.e., the species can
complete its blood meal in one go on one person and also does not
require a second blood meal for the completion of the gonotropic
cycle.
• After feeding on a infected person, the virus replicates in the
mosquito midgut before disseminating to secondary tissues, including
the salivary glands. The time it takes from ingesting the virus to actual
transmission to a new host is termed the extrinsic incubation period
(EIP). The EIP takes about 8–12 days when the ambient temperature
is between 25–28°C.
• DHF occurs in areas where multiple dengue serotypes are endemic
• A cyclic pattern of increased transmission coincides with rainy season
• The interaction between environment temperature and rainfall affects
following :
• Mosquito survival
• Mosquito feeding and reproduction
• Population density of vector mosquito
Virus
• Genus flavivirus
• Four viruses serotypes (DEN-1, DEN-2, DEN-3, DEN-4)
• Infection with one serotype confers lifelong immunity
• Cross protection for other serotypes infection only for few months
• All four serotypes associated with Epidemics of DF and DHF
pathogenesis
• Involves pre existing dengue antibody.
• Virus antibodies are formed within a few days of the second dengue
infection.
• Non-neutralizing enhancing antibodies promote infection of higher
numbers of mononuclear cells, followed by the release of cytokines,
vasoactive mediators, and procoagulants, leading to the disseminated
intravascular coagulation seen in the haemorrhagic fever syndrome.
Risk Factors For DHF
Manifestations of dengue virus infections
Diagnosis of DF
• Epidemiological evidences
• Clinical presentations
• Lab tests
Lab Diagnosis of Dengue
Detection of virus in tissue, blood, CSF
& other body fluid Serodiagnosis
• Isolation of virus (Culture) • Detection of dengue specific IgM
• Demonstration of antigen antibodies
• PCR • Rapid Diagnostic Test
• Immunofluorescence • ELISA
• Immunohistochemistry
• Demonstration of a ≥4-fold rise
in reciprocal IgG antibody titer in
paired acute and convalescent
serum samples
Existing Methods in Nepal

Peripheral Lab NPHL

• Perform Rapid Diagnostic test • ELISA for anti-Dengue IgM
for IgM detection detection

• Molecular technique (PCR)

• Send serum sample to NPHL proposed
maintaining cold chain
CLASSICAL DENGUE FEVER BREAK
BONE FEVER
Onset-acute
Caused by dengue virus having four serotype
Occurs both endemically and epidemic
EPIDEMICS ARE EXPLOSIVE
Starts during rainy season
Coincides with breeding of mosquito
VECTOR
Ades group ,peridomistic and day time
Mosquito cannot transmit virus at low temperature below 20 deg C.
• Endemic in south asian countries india,srilanka ,indonesia ,
myanmar ,bhutan ,bangladesh ,thailand,malayasia ,singapor .
• Reservoir of infection –both cases and mosquitoes .
• Mode of transmission ,mosquito man mosquito
• The transovarial transmission of the dengue virus in the Aedes vectors
is now a well-documented phenomenon reported from many parts of
the endemic areas in the world.
• Man to man transmission doesn’t occur .
• Mosquito after sucking blood become infected .
• Once mosquito become infected it remains infected for life.
• HOST FACTOR –all ages and both sexes
• Course is milder in children .
Immunity
1. Antibody mediated
2. Patient gets long standing immunity after recovery .
3. No cross immunity.
4. Gives immunity to homologous strain (so recurrent infection occurs)
Environment –rainy season .
CLINICAL FEATURES
• Incubation period-3-10 days ,varies from 5-6 days .
• Onset- sudden with fever ,chills and rigors (biphasic ) ,39-40deg c ,
intense headache ,muscle ,joint pain with extreme weakness .
• Within 24 hours –retro orbital pain ,restriction of eye movement ,
photophobia ,raised intra occular pressure .
• Pt will have anorexia ,constipation ,altered taste sensation ,colicky
pain and abdominal tenderness.
• Sore throat ,lymphadenopathy .
• Skin eruption occurs in 80% cases ,fleeting pin point erruption on the
face ,neck and chest .
• On 3-4 day maculopapular rash appears on the chest trunk and
spread to the extremities but rarely on the feet .
• Rashes are itching and hyperaesthetic which last for about week
followed by desquamation.
• Fever last for week .
• Recovery is complete (prolonged)
DENGUE HAEMORRHAGIC FEVER
• DHF doesn’t occurs with 1st infection with 1 serotype.
• Usually occurs after 2nd outbreak with another serotype within a short
interval .critical interval is 6 month between two infection .
• Produce severe haemorrhagic manifestations.
• 1st attack sensitize the patient while the 2nd attack produce
immunological catastrophe .
• The disease is mostly confined to children <15 years
• This disease is reported from almost all south east countries .
CLINICAL FEATURES
• Onset abrupt .
• High fever ,headache ,vomiting and anorexia .
• Maculopapular rashes less common .
• Haemorrhagic manifestation from different sites which may appear
early or late in the course .
• Convulsion occurs particularly in children.
• The basic pathological changes is increased capillary permeability and
leakage of plasma in the extra cellular spaces (compartments )
• The plasma leak is activated by the complement system which is
immunologically mediated (formed by antigen antibody reaction).
This may also initiate IV coagulation.
CLINICAL DIAGNOSIS
• High fever 39-40deg C.
• Acute onset lasting for 2-7 days
• Haemorrhagic manifestation
• Tourniquet test + (20 petechiae per 2.5 cm square )
• Liver enlarged .
• The tourniquet test, also known as the Rumpel-Leede capillary
fragility test, is used to assess capillary fragility.
• A positive test indicates an increased risk of bleeding and is defined
by the presence of 20 or more petechiae (small, red or purple spots
caused by bleeding under the skin) within a 2.5 cm square area after
the test is performed.
GRADING OF DHF
GRADE 1
High fever ,non constitutional symptoms ,weakness ,anorexia ,constipation ,altered
taste ,epigastric discomfort .
GRADE 2
Patient with spontaneous bleeding from skin and othet sites .
GRADE 3
Circulatory failure ,rapid weak pulse ,hypotension ,cold clammy skin,
sweating ,restlessness , altered mental status
GRADE 4
Profound shock
LABORATORY DIAGNOSIS
• Leucopenia
• Thrombocytopenia-<1 lakh /cumm or less
• Haemoconcentration - haematocrit value increased by 20% or more
of base –line value .
Diagnosis of dengue shock
syndrome
• Above laboratory criteria
• S/S of shock –rapid weak pulse , hypotension ,cold and clammy
skin ,restlessness , altered mental status .
 TREATMENT
• Treatment of DF and DHF is same in early stages .Treatment is
symptomatic and supportive –bed
rest ,analgesics ,antipyretics(Paracetamol),cold sponging ,fluid and
electrolyte maintainance ,food according to the appetite .Asprin should be
avoided.
• Any drop in serial platelet count or rise of hematocrit value ,patient should
be immediately hospitilized and should be started crystalloid solution IV.
Fluid transfusion should be carefully adjusted .
• RL solution is preferred crystalloid solution given @ 20ml/kg/hr for 2hrs or
any other solution used in diahorrea for isotonic dehydration.
MANAGEMENT OF SHOCK
• Oxygen inahalation
• For correction of acidosis give sodium bicarbonated
• DSS is medical emergency ,it should be managed promptly to prevent
DIC which produce severe haemorrhage and irreversible shock.
• So careful fluid management is very very essential.
CONTROL MEASURES
• Mosquito control measure –anti larval and anti adult control
measures (vector control)
• Personal protective measures
• Vaccines –no satisfactory vaccines
• Isolation of patients under bed nets during first few days.
VACCINATION
• No specific vaccine prepared.
• With one sero type doesn’t produce immunity against other sero
type.
• Vaccine produced with 4 serotype produce hetrologus antibodies
which produce haemorrhagic manifestations.
Classification of south east asian
countries according to endemicity
• Category A-the disease is leading cause of hospitalization and death
among children.it is the major public health problem.(indonesia.
myanmar, thialand , srilanka and timor)
• Category B-in these countries cyclical epidemics occurs and is
extending geographically(Bangladesh, India ,Maldieves )
• Category C-those countries where endemicity is uncertain .(Bhutan
and nepal)
• Category D-no evidence of endemicity (DPR Korea)
 WHO response
• supports countries in the confirmation of outbreaks through its
collaborating network of laboratories;
• provides technical support and guidance to countries for the effective
management of dengue outbreaks;
• supports countries in improving their reporting systems and capture the
true burden of the disease;
• provides training on clinical management, diagnosis and vector control at
the country and regional level with some of its collaborating centres;
• formulates evidence-based strategies and policies;
• support countries in the development of dengue prevention and control
strategies and adopting the Global Vector Control Response (2017–2030)
and the Global Arbovirus Initiative (2022–2025).
• reviews and recommends the development of new tools, including
insecticide products and application technologies;
• gathers official records of dengue and severe dengue from over 100
Member States; and
• publishes guidelines and handbooks for surveillance, case
management, diagnosis, dengue prevention and control for Member
States.
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Thanks 