ARBOVIRAL DISEASES AND

DENGUE

Presented By :
-Prajwol Pathak
-Prakash Magar
-Prakash Paudel
-Pratibha Thapa
-Praveen Thapa
-Mamata Shrestha
 Introduction
• Arboviral disease are those diseases which are caused by
Arboviruses
• Arboviruses(arthropod-borne viruses) are viruses of
vertebrate biologically transmitted by heamatophagus insect
vectors mostly mosquitoes followed by ticks
• No man to man transmission except in yellow fever and
dengue
• Various animal,rodents and birds are reserviors of infection
• Over 500 arboviruses have been listed but only about 100 of
them are capable of infecting human
 WHO definition of Arboviruses

Arboviruses are viruses that are maintained in nature

principally , or to an important extent , through
biological transmission between susceptible vertebrate
host by hematophagous arthropods; they multiply in the
tissues of arthropods, and are passed on to new
vertebrates by the bites of arthropod after a period of
extrinsic incubation
 Diseases caused by Arboviruses
 Encephalitis
 Chikungunya fever
 Dengue
 Haemorrhagic fever
 Sindbis fever
 Yellow fever
 DENGUE
• Dengue is a mosquito-borne disease caused by one of
the following closely related viruses(DENV-1,2,3,4)
• These are single stranded RNA virus belonging to
flaviviridae family.
• These viruses are arboviruses capable of infecting
humans and causing disease.
• The infections caused by dengue viruses maybe
asymptomatic or may lead to :
1. Classical Dengue Fever (CDF)
2. Dengue Hemorrhagic Fever (DHF)
3. Dengue Shock Syndrome (DSS)
Epidemiology
• It is found in tropical and subtropical regions around the
world.

• Two-fifth of world’s population in tropical and sub-

tropical countries are at risk of the disease.

• 50 million dengue infections occur worldwide annually

and 500,000 people with DHF require hospitalization
each year.

• Approximately 90% of them are children aged less than

5 years, and about 2.5% those affected die.
• The south-east Asia and western pacific regions are most
seriously affected.

• The south-east regions are divided into 3 categories:

• Category A:
Bangladesh, India, Indonesia, Maldives,
Myanmar, Srilanka, Thailand
a. Major public health problem
b. Leading cause of hospitalization and death among
children
c. Hyperendemicity with all four serotypes circulating in
urban areas and
d. Spreading to rural areas
• Category B
Bhutan, Nepal
a. Endemicity uncertain
b. Bhutan reported first outbreak in 2004; and
c. Nepal reported first indigenous case in 2004/05

• Category C
DPR Korea
a. No evidence of endemicity
 IN NEPAL
• The earliest cases were detected as early as 2005.
• The sporadic cases continued and outbreaks
occurred in 2006 and 2010.
• Initially most of the reported cases had travel to
neighboring country ( India ) and, however lately
indigenous cases were also reported.
• The affected disease were Kanchanpur, Banke, ,
Bardiya, Dang, Kapilvastu, Parsa, Rupandehi,
Rautahat, Sarlahi, Saptari and Jhapa, indicating
spread throughout the country from west to east
lying in the plain Terai region.
• A total of 134 dengue cases were reported from 26
districts in 2072/2073.
• The most were from Chitwan (70) foloowed by
Nawalparasi and Parsa (12 each).
• Aedes aegypti(mosquito vector) has been identified in
5 peri urban areas of terai region ( Kailali, Dang,
Chitwan, Parsa and Jhapa) during entomological
surveillance conducted by EDCD during the year
2006-2010, indicating local transmission of dengue
EDCD: epidemiology of disease control division
Dengue cases in Nepal, 2006–2015
Epidemiological determinants
 Agent factors
Arbovirus (ss RNA)
Genus – Flavivirus
Family – flaviviridae
4 serotypes- DENV1, DENV2, DENV3, DENV4
Antigenic similarity but infection with one
serotypes doesn’t provide lifelong immunity.
… instead prior immune sensitization worsens
the disease scenario
 DENV has…
A lipoprotein envelope
- 3 structural protein genes {CME}
- 7 non structural
Protein (NS) genes including
Envelope glycoprotein, NS1
- NS1 is of diagnostic and
pathological importance
- associated with viral
haemagglutination and
neutralization activity
 Host factors
• All ages and both sexes are susceptible
• High risk patients:
- Infants and elderly
- Pregnancy
- Any condition prone to heavy blood loss: PUD,
menstruation, haemolytic anemia, G6PD
deficiency, thalassemia , steroid , NSAIDs uses
- Chronic conditions like DM, HTN, asthma ,
cirrhosis , CRF , IHD
 Environmental factors
- Fluctuates with rainfall and water storage
- Survives best between 16-30 degree
centigrade and relative humidity of 60-80%
- Breeds in containers and around the house
Differences between different vectors
The Vector
 Aedes aegypti
• Dengue is mainly
transmitted by Female
Aedes aegypti.
• It can be identified by
white bands or scale
patterns on its legs and
thorax.
• It is primarily a day
feeder.
• Found in tropical and
subtropical region.
Aedes aegypti Aedes albopictus
Life cycle of Aedes aegypti
• Infective stage: 1 day before onset of fever to
day 5
• Intrinsic IP= 4-6 days
• Extrinsic IP= 8-10 days
• Mode of transmission: vector borne
PATHOPHYSIOLOGY
Pathogenesis
Clinical manifestations

1) Undifferentiated fever
2) Classical dengue fever
3) Dengue haemorrhagic fever
a. Febrile phase
b. Critical phase
c. Recovery phase
4) Dengue shock syndrome
 Undifferentiated fever
• Primary dengue infection
• May develop a simple fever indistinguishable
from other viral infections
• Maculopapular rashes accompany the fever or
may appear during defervescence
• URTI and GI symptoms are common
Classical dengue fever
• Incubation period of 3-10 days
• Acute rise in temperature (39-40 deg C)
• Within 24 hrs retro orbital pain, dragging pain in
inguinal region, photophobia develops.
• Fever is typically but not inevitably followed by a
remission of a few hours to 2 days (biphasic curve)
• Skin eruptions - 80% cases during the remission or
during second febrile phase.
• The rash maybe accompanied by itching and
hyperasthesia which lasts usually for 2 hours to 7
days and maybe followed by desquamation.
 Dengue haemorrhagic fever
1) Febrile phase
- Sudden high grade fever accompanied by facial
flushing and headache
- Anorexia, vomiting, epigastric discomfort,
tenderness at right costal margin and
generalized abdominal pain
- Differentiating feature from DF is , there is
plasma leakage and abnormal hemostasis
 Tourniquet test
• A positive Tourniquet test is most common
hemorrhagic phenomenon.
• Its is performed by inflating a BP cuff to a
midpoint between systolic and diastolic
pressure for 5 mins
• The test is considered p ositive when 10 or
more petechiae per 1 inch square are
observed
2) Critical phase
• Condition worsens during the time of
defervescence
• On 3-8 days of illness progressive leukopenia,
followed by rapid decrease in platelet count
usually precedes plasma leakage (24-48 hrs)
• Pleural effusion mostly right side, ascites
• Shock occurs when a critical volume of plasma is
lost through leakage which is preceded by
warning sign
 Warning signs
• Severe abdominal pain or persistent vomiting
• Red spots or patches in the skin
• Bleeding from nose or gums
• Vomiting blood
• Black , tarry stools
• Drowsiness or irritability
• Pale , cold or clammy skin
• Difficulty breathing
• Consequent organ hypoperfusion , leading
to progressive organ impairment,
metabolic acidosis and DIC
3) Recovery phase
• Gradual reabsorption of extravascular fluid(48-
72hrs)
• Improvement in
-general well being
-appetite
-GI symptoms
-hemodynamic status
“isles of white in the sea of red”
-hematocrit stabilizes
Course of dengue illness
 Severe dengue
• Defined by one or more of following:
- Plasma leakage that may lead to shock (dengue
shock) and / or fluid accumulation with or
without respiratory distress
- And / or severe bleeding
- And / or severe organ impairment
• Cold extremities, delayed capillary refill time
• Patient is considered to have shock if pulse
pressure is <20mmhg in children or s/he has
signs of poor capillary perfusion (Cold
extremities, delayed capillary refill time, rapid
pulse rate)
• In adults pulse pressure of less than or equal
to 20 mm hg may indicate a more severe
shock
 Diagnostic Criteria
Dengue without warning signs:
• Fever and 2 of the following:
– Nausea/vomiting
– Rash
– Aches and pains
– Leukopenia
– Positive tourniquet test
 Dengue with warning signs:

Dengue with any of the following:

– Abdominal pain or tenderness
– Persistent vomiting
– Clinical fluid accumulation (e.g., ascites , pleural effusion)
– Mucosal bleeding
– Lethargy/restlessness
– Liver enlargement >2 cm
– Laboratory: increase in hematocrit concurrent with rapid
decrease in platelet count.
• Warning signs require strict observation and medical
intervention.
 Severe dengue:
• Dengue with at least 1 of the following:
– Severe plasma leakage leading to shock (dengue
shock syndrome) or fluid accumulation with
respiratory distress
– Severe bleeding (as evaluated by a clinician)
– Severe organ involvement (i.e., AST or ALT 1000
or greater, impaired consciousness, organ
failure).
 Laboratory diagnosis
VIRUS ISOLATION
Specimen is taken during the fisrt 6 days of illness
Suitable specimens:
1) Acute phase serum
2) Plasma or washed buffy coat from patient
3) Autopsy tissue from fatal case
4) Mosquitoes collected from the affected areas.
 Viral antigen detection
- Ns1 detection by ELISA- rapid diagnostic tests
- Available commercially
- Results within minutes

Viral nucleic acid detection

- Dengue viral genome- RT-PCR assay (better
specificity and sensitivity compared to virus
isolation)
 Immunological response and
serological tests
• Haemagluttination – inhibition
• Complement fixation
• Neutralization test
• IgM capture ELISA
• Indirect IgG – ELISA
• IgM/IgG ratio
 Rapid diagnostic test
• Commercially available serological test kits for
antidengue IgM and IgG
• Uncertain accuracy

Haematological parameters analysis

• Platetet count and hematocrit
 Management
• No specific management
• Based on clinical manifestations , patients can
be divided into :-
i) DF
ii) DHF I & II
iii) DSS ( DHF III & IV)
 Treatment of DF cases
DF patients have:-
-uncomplicated disease
-tolerance to adequate volume of oral fluids
-no warning signs

TREATMENT
i)ORS intake , friut juice and fluids containing
electrolytes
ii)paracetamol for high fever(not other NSAIDs)
 DHF I & II cases
• May require close observation
• With or without warning signs
patients with warning signs

obtain reference haematocrit before fluid

therapy

isotonic crystalloid solution(5-7ml/kg/hr for 1-2

hrs)
- reduce to(3-5 ml/kg/hr ) for 2-4 hrs
- then to (2-3 ml/kg/hr ) or less acc. to clinical
response
- if haematocrit remains same , continue with
same rate (2-3 ml/kg/hr)
- if haematocrit rises rapidly , increase rate to
5-10 ml/kg/hr for 1-2 hrs
- if haematocrit falls , reduce i.v fluids gradually
and transfuse fresh whole blood
• For patients without warning signs
i) encourage patient to take oral fluids
-if not tolerated , start i.v fluid therapy (0.9%
saline with/without dextrose)
ii)after few hours of i.v fluid therapy , switch to
oral fluids
 DSS cases (DHF III & IV)
• Require emergency treatment when they have
-severe plasma leakage
-severe hemorrhages
-severe organ impairment
Treatment
I)iv fluids
II)blood transfusion
(These are done to improve circulation and end
organ perfusion)
 Treatment of shock
- frequent monitoring until danger period is over
- vital signs,peripheral perfusion and urine output to be
checked every 15-30 minutes
- treatment guided by hematocrit level; should be
monitored before and after fluid boluses
high haematocrit- indicates active plasma leakage
low haematocrit- indicates major hemorrhage
Treatment of compensated shock
isotonic crystalloid soln.(starting 5-10ml/kg/hr;for 1 hour)

If no improvement,check hematocrit
If improvement,
-if haematocrit high—start above
-treat as alike DHF cases with warning signs procedure
-if haematocrit low—initiate
transfusion with fresh whole blood
(note ;reference haematocritnis noted
before crystalloid administration)
 PREVENTION AND CONTROL
MEASURES OF DENGUE SYNDROME
1. Mosquito control
a. Anti larval measures
- Environmental control
- Chemical control
- Biological control
b. Anti adult measures
- Residual sprays
- Space sprays
- Genetic control
c. Protection against mosquito bites
- Mosquito net
- Screening
- Repellants
 Continued..
2. Vaccines – No vaccination
3. Other measures
- Isolation of the patient under bed-nets during
the first few days
- Personal prophylactic measures like wearing of
full sleeves shirts and full pants , use of
mosquito repellant creams ,liquids, coils, mats;
- Environmental measures: Detection and
elimination of mosquito breeding places
- A screening program at an airport for persons
with fever
DENGUE CONTROL PROGRAM IN NEPAL
GOAL
-To reduce mortality due to Dengue Fever , Dengue
Hemorrhagic fever and Dengue Shock Syndrome
OBJECTIVES
- To develop an integrated vector control
approach for prevention and control
- To develop capacity on diagnosis and case
management of DF/DHF/DSS
- To intensify health education
- To strengthen the surveillance system for prediction,
early detection , preparedness and early response to
out-break of dengue
 STRATEGIES
- Early case detection, diagnosis management and
reporting of the DF, DHF and DSS
- Regular cases of DF/DHF/DSS surveillance
through
the EWARS
- Mosquito Vector Surveillance in different
municipality
- Integrated vector control approach
 Major activities in 2072/73
• Trained physicians, nurses, paramedics and
laboratory technicians on dengue case detection,
diagnosis, management and reporting.
• Orientated municipality stakeholders in 19
programme districts.
• Supplied rapid diagnostic test kits (IgM).
• Dengue case monitoring and vector surveillance.
• Search and destruction of dengue vector larvae (A.
aegypti) in 19 programme districts.
• Developed and disseminated health education
messages.
 WHO Dengue Control Strategies
- Integrated Vector Management approach:
rational decision making process for the optimal
use of resources for vector control .The ultimate
goal is to prevent the transmission of vector-
borne diseases such as malaria,dengue,Japanese
encephalitis,leishmaniasis,schistosomiasis and
Chagas disease
- Individual and household protection: full sleeves
clothes, repellants, mosquito nets
- Safe use of insecticides:
WHO Pesticide Evaluation Scheme