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Health Ambassadors University-School of Nursing Review Communicable and Infectious Diseases- Module Series Mosquito-Borne Infections By: Franklin C. Barberan, R.N.
DENGUE HEMORRHAGIC FEVER

OTHER NAMES: H·FEVER, BREAKBONE FEVER, DANDY FEVER DESCRIPTION: A disease that is characterized by fever and bleeding tendencies. It is caused by a virus which is transmitted to humans by day biting mosquitoes that lay egg on a clear water. This infection is now considered by the DOH as a reemerging disease. AGENT: Dengue virus Types 1,2,3, & 4 and Chikungunya virus, O’Nyong-Nyong virus. RESERVOIR OF INFECTION: Man together with the Aedes mosquitoes: Aedes Aegypti (Philippines) Aedes Albopictus (Philippines), Aedes Escutellaris (Polynesia). Aedes mosquitoes are widely spread in the tropics and subtropics part of the world. CHARACTERISTIC 1. Day biting with increased biting activity starting two hours after sunrise up to two hours before sunset. However, research conducted by RITM experts suggests that there is strong possibility that these mosquitoes may also bite at night. 2. Low Flying. 3. Prefers clear water for laying eggs (reproduction). MODE OF TRANSMISSION: K! Vector- borne, mainly acquired through the bite of Aedes Mosquitoes. Direct person-to-person transmission has not been documented. Other less common modes of transmissions include: 1. Exposure to dengue-infected blood, organs, or other tissues via blood transfusion, solid organ, or bone marrow transplantation. 2. Nosocomial injury (needlestick or mucous membrane contact with spilled blood). 3. From an infected mother to her fetus in utero (vertical transfer), or 4. Mother to newborn during childbirth (perinatal transfer).
(FROM: Dengue Hemorrhagic Fever: Mode of Transmission. The Centers for Disease Control & Prevention. August 20, 2011).

INCUBATION PERIOD: 2-7 days (Harrison’s Principles of Internal Medicine, 17th Edition). PERIOD OF COMMUNICABILITY Communicability from man to mosquitoes: Not exactly known. Patients are usually infective for most mosquitoes from the day before to the end of the febrile period. An average of about 5 days. From mosquitoes to man: Mosquitoes become infective for life starting 8-12 days after the blood meal. SUSCEPTIBILITY AND RESISTANCE Apparently universal BUT children have usually a milder disease than adults. Recovery from infection, with one serotype provides homologous immunity of long duration but does not provide protection against another serotype, and instead may exacerbate the second infection. PATHOGENESIS:

Health Ambassadors University-School of Nursing Review Communicable and Infectious Diseases- Module Series Mosquito-Borne Infections By: Franklin C. Barberan, R.N.
The pathogenesis that leads to spontaneous bleeding or hemorrhage results from many factors as follows: 1. Increased capillary permeability brought about by strong immune complex reaction similar to anaphylactoid reactions. 2. Thrombocytopenia due to faulty maturation of the megakaryocytes which results in diminished production of platelets. 3. Acute excessive consumption of platelets due to generalized intravascular clotting. 4. Decreased blood coagulation factors especially fibrinogen and factors II, V, VII and IX. K! Prolonged bleeding and clotting time, prothrombin time, and partial thromboplastin time with severe thrombocytopenia, and fibrinogenopenia are indications of disseminated ( intravascular coagulation (DIC) initiated by the lesions of the capillary wall. CLINICAL MANIFESTATIONS The onset; K! The patient is acutely ill with sudden onset of hyperpyrexia (39-40 degrees Celsius) accompanied by severe frontal headache. Appearance is flushed and the conjunctiva are injected. There is also, anorexia, nausea, vomiting; and abdominal, retro-orbital, muscle, and bone pain. K! Bigger children may complain of retrobulbar and body aches. On the 2nd or 3rd day;  Hyperpyrexia persists and all the earlier symptoms increase.  Temperature often shows a biphasic curve.  Palms and soles are noticeably flushed.  Tourniquet test is often positive from the onset or alter the few days.  Petechiae may be observed in pressure areas. On the 5th to the 7th day:  Fever subsides.  Rashes appear on the lower and upper extremities lasting 2 to 3 days.  Pathognomonic sign (Herman Sign) appears: purplish rash with blanched areas about 1 cm in size.  Pruritus may be present and at time annoying. CLINICAL ALERT: A second dengue infection may lead to severe manifestations: 1. Encephalitic symptoms such as increasing restlessness, vomiting, anxiety, and disturbed sensorium. 2. Hemorrhagic manifestations: of different degrees like epistaxis, ecchymosis, hematemesis, melena. 3. Hypotension which may proceed to shock, coma, and death. CLASSIFICATIONS OF DENGUE FEVER ACCORDING TO SEVERITY CLASSIFICATION Grade 1 Grade 2 Grade 3 DESCRIPTION  Fever accompanied non specific constitutional symptoms.  The only hemorrhagic manifestation is a positive tourniquet test.  All manifestations of Grade 1 plus: spontaneous bleeding elsewhere in the body. All manifestations of Grade 1 and 2 plus:  Circulatory failure manifested by rapid and weak pulse, narrowing of pulse

Health Ambassadors University-School of Nursing Review Communicable and Infectious Diseases- Module Series Mosquito-Borne Infections By: Franklin C. Barberan, R.N.
pressure, (20 mmHg or less) or  Hypotension with the presence of cold clammy skin, & restlessness.  Profound shock (Dengue Shock Syndrome-DDS) with undetectable blood pressures and pulse in addition to all the manifestations of Grades 1 to 3.

Grade 4

DIAGNOSTIC EVALUATION: 1. Tourniquet Test (Rumpel Leede Test) Procedure: a. Apply BP cuff to the upper arm just like obtaining the blood pressure. b. Inflate midway between the systolic and diastolic pressure for 5 minutes. c. Release cuff and make an imaginary 2.5 cm square or 1 inch square just below the cuff at the antecubital fossa. d. Count the number of petechiae inside the box. e. K! A test is positive when 20 or more petechiae per 2.5 cm square are present. NOTE: The Tourniquet Test (Rumpel Leede Test) does not confirm the presence of Dengue infection. It only indicates that there is an increased fragility of the capillaries which could indicate increased bleeding tendency. 2. Detection of Antibodies against any of the Dengue Virus through Anti- dengue IgM ELISA. 3. Confirmation of the Dengue Virus Antigen in all serotypes by: a. Immunoflourescence antibody test (IFAT) or b. Immunoperoxidase test. MANAGEMENT MEDICAL CONTEXT MANAGEMENT: Supportive care. No specific cure for dengue is available. 1. Supportive and symptomatic management. There is no specific curative treatment for dengue. 2. Paracetamol for fever. N! NEVER give aspirin. RATIONALE: (1) Aspirin is a platelet deaggregator. It can induce bleeding. (2) Aspirin is highly associated with Reye’s syndrome. 3. Provide fluids and fruit juices. 4. Monitor sign and symptoms of impending or actual bleeding. E.g. petechiae, ecchymosis, epistaxis; 5. Monitor blood clotting and laboratory work out especially the platelet count. 6. Protect patient from injuries that could lead to bleeding. 7. Vitamin C is given to support capillary integrity. 8. For patients whose Blood Platelets are extremely low, packed platelet may be necessary or a whole blood transfusion specially if already bleeding. NOTE: In order to obtain a potent platelet, whole blood must be transfused within 24 hours after extraction. HANDLING THE PATIENT: 1. Protect patient from mosquito bite. RATIONALE: All Aedes mosquitoes that will bite the patient becomes infected and could pass the dengue virus to other persons. 2. ISOLATION: Blood precautions. 3. Concurrent disinfection: none 4. Quarantine; none. 5. Immunization of contact: none

Health Ambassadors University-School of Nursing Review Communicable and Infectious Diseases- Module Series Mosquito-Borne Infections By: Franklin C. Barberan, R.N.
IN THE COMMUNITY 1. Eliminate vector by: Changing water and scrubbing sides of the flower vases as frequently as possible (every three days is acceptable considering the developmental period of the larva into an adult mosquito). 2. Destroy breeding places of the mosquitoes by cleaning the surroundings and getting rid of tires, empty bottles and anything that could accumulate stagnant water. 3. Fogging is not considered effective in killing the mosquitoes. 4. Keep water containers covered to prevent mosquitoes from laying their eggs on it. 5. Use mosquito repellants as to eradicate mosquitoes. RESPONSIBILITIES OF THE NURSE IN A COMMUNITY SETTING 1. Report immediately to the Municipal Health Office any suspected case. 2. Refer immediately to the nearest hospital any patient exhibiting signs and symptoms of bleeding tendencies like epistaxis, petechiae, ecchyrnosis. 3. Assist in early diagnosis of suspect based on the signs and symptoms. 4. Conduct health and sanitation education to residents in an endemic area. 5. Educate the public about the mode of transmission of the virus. 6. Keep water containers covered. 7. Avoid too many hanging clothes inside the house. THE MOST RECENT DOH DENGUE CONTROL PROGRAMS A. National Ovi-Larvi Trap System (August 10, 2011) The Ovi-Larvi trap system is made of three (3) components: 1. a ontainer (about the size of drinking glass) 2. a small strip of "lawanit" measuring 1 inch by 5 inches for the mosquitoes to lay eggs 3. a larvicidal solution to kill the mosquito larvae which will be hatch in the "lawanit" and in the solution. B. “D.E.N.G.U.E.” strategy: This is a simplified strategy developed by the Department of Health which advocates homecare of mild dengue patients. The approach is as follows: D= daily monitoring of patient’s status. E= encourage oral intake of fluids like oresol. N= note any dengue warning signs like persistent vomiting and bleeding G= give paracetamol for fever and not aspirin because aspirin can induce bleeding. U= use mosquito nets E= early consultation for any warning signs of dengue. (FROM: DENGUE STRATEGY. The Official Gazette of the Republic of the Philippines, September 1, 2010). References:
1. 2. 3. 4. W.H.O. Technical Report on Dengue Hemorrhagic Fever Southeast Asian and Western Pacific regions 1975). DENGUE STRATEGY. The Official Gazette of the Republic of the Philippines, September 1, 2010. W. Lawrence Drew, MD, PhD. Current Diagnosis & Treatment in Infectious Diseases 1st edition. McGraw-Hill/Appleton & Lange (June 22, 2001). p550 Dengue Hemorrhagic Fever: Mode of Transmission. The Centers for Disease Control and Prevention. August 20, 2011. http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-3-infectious-diseases-related-to-travel/dengue-fever-anddengue-hemorrhagic-fever.htm Harrison’s Principles of Internal Medicine, 17th Edition

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Health Ambassadors University-School of Nursing Review Communicable and Infectious Diseases- Module Series Mosquito-Borne Infections By: Franklin C. Barberan, R.N.
6. The blue book: Guidelines for the control of infectious diseases: Guidelines for the Control of Infectious Diseases. 2005, pp 45-46. Published by the Communicable Diseases Section Victorian Government Department of Human Services Melbourne Victoria. Dengue, 70 to 71. The Encyclopedia of Infectious Diseases. Copyright 1998. Carol Turkington and Bonnie Ashby. ISBN: 08160-3512-1

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