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Dengue is a widespread mosquito-borne infection in human beings, which in recent years has become a major international public health concern. Symptomatic dengue virus infections can present with a wide range of clinical manifestations, from a mild febrile illness to a life-threatening shock syndrome. Both viral and host factors are thought to contribute to the manifestations of disease in each infected. It is important to understand its burden on health care, morbidity and mortality. Early diagnosis and suspicion of DF in primary care might reduce the complications if handled properly. We must understand the depth of the problem in terms of its transmission, clinical presentation, diagnosis, management and prevention. Background A pandemic of dengue began in Southeast Asia after The World health Organization (WHO) declares dengue World War II and has spread around the globe since and dengue hemorrhagic fever to be endemic in South then. In the 1980 s, DHF began a second expansion into Asia. WHO currently estimates there may be 50 million Asia when Sri Lanka, India, and the Maldive Islands had dengue infections worldwide every year. In 2007 alone, their first major DHF epidemics. there were more than 890 000 reported cases of dengue in the Americas, of which 26 000 cases were Dengue Local Prevalence Hemorrhagic Fever (DHF) . The disease is now ende- Pakistan first reported an epidemic of dengue fever in mic in more than 100 countries in Africa, Americas, the 1994.The epidemics in Sri Lanka and India were asso- Eastern Mediterranean, South-east Asia and the Wes- ciated with multiple dengue virus serotypes, but DEN-3 tern Pacific. South-east Asia and the Western Pacific are was predominant and was genetically distinct from DEN-3 the most seriously affected. viruses previously isolated from infected persons in those Pakistan is at high risk of being hit by large epidemics countries. In Asian countries where DHF is endemic, the because of many over crowded cities, unsafe drinking epidemics have become progressively larger in the last water, inadequate sanitation, large number of refugees 15 years. In 2005, dengue is the most important mosquito- and low vaccination coverage. These conditions promote borne viral disease affecting humans . the spread of infectious diseases and consequently every Dengue virusisnow endemicin Pakistan, circulating year a large number of epidemics/outbreaks occur in throughout the year with a peak incidence in the post different parts of the country, which result in increased monsoon period. Recent flood in Pakistan made the morbidity and mortality. situation worse. Dengue Surveillance Cell Sind province of Pakistan Epidemiology reports 1,809 suspected Dengue out of which 881 con- th Global Burden firmed till 11 October 2010 with 5 deaths while 16 con- Dengue virus infection is increasingly recognized as one firmed cases reported in Islamabad without any mortality. of the world’s emerging infectious diseases. About Till now 563 confirmed cases were reported at our 50-100 million cases of dengue fever and 500,000 cases institution since January 2010. Reported cases are of Dengue Hemorrhagic Fever (DHF), resulting in usually complicated or with hemorrhagic manifestation. around 24,000 deaths, are reported annually . In primary health care the usual presentation is mild to moderate fever treated as suspected dengue fever. Researchers have identified that co-circulation of Correspondence: firstname.lastname@example.org DEN-2and DEN-3was responsible for the2006out- Family Medicine Department, Aga Khan University Hospital, Stadium Road break in Karachi. Primary and secondary cases were PO Box 3500, Postal Code 74800, Karachi, Pakistan © 2011 Jahan; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Jahan Asia Pacific Family Medicine 2011, 10:1 Page 2 of 4 http://www.apfmj.com/content/10/1/1 seen in both groups. Cases with DHF showed marginal depression. In DHF characteristically, the overall vascu- association with DEN-2. Introduction of a new serotype lar system is damaged, vascular instability, decreased (DEN-3) and or a genotypic shift of endemic serotype vascular integrity and platelet dysfunction resulting in (DEN-2) are the probable factors for the recent out- bleeding from different sites . break of DHF in this region . Clinical presentation may vary from undifferentiated fever, classic dengue fever(DF), Dengue hemorrhagic Transmission fever(DHF) to Dengue shock syndrome(DSS). The risk Aedes Aegypti mosquito, which generally acquires the of severe disease is much higher in sequential rather than primary dengue infection . virus while feeding on the blood of an infected person and transmit the disease to another non infected person. Necessary Criteria for DHF: It is primarily a daytime feeder lives around human habitation. This mosquito rests indoors, in closets and ■ Fever, or recent history of acute fever other dark places. Outside, it rests where it is cool and ■ Hemorrhagic manifestations shaded. The female mosquito lays her eggs in water ■ Low platelet count (100,000/mm or less) containers in and around homes, schools and other ■ Objective evidence of “leaky capillaries:” areas in towns or villages. These eggs become adults in ■ elevated hematocrit (20% or more over about 10 days. Dengue mosquitoes also breed in stored, baseline) exposed, water collection systems. The favored breeding ■ low albumin places are: barrels, drums, jars, pots, buckets, flower ■ pleural or other effusions vases, plant saucers, tanks, discarded bottles/tins, tires, or water coolers, and other places where rainwater col- Grade 1 DHF: Fever and nonspecific constitutional lects or stored. symptoms, Positive tourniquettestisonlyhemorrhagic Dengue infection is caused by any of 4 different sero- manifestation. Thrombocytopenia and rise in haemato- types of the virus (DEN-1, DEN-2, DEN-3, and DEN-4). crit level (more than 20%). After an incubation period of 2-8 days after an infective Grade 2 DHF: Grade 1 manifestations + spontaneous mosquito bite, the disease usually begins with sudden bleeding, circulatory failure manifested by rapid and onset of fever and headache. weak pulse, narrowing of pulse pressure (20 mmHg or less) or hypotension with the presence of cold clammy Clinical Features skin and restlessness, Capillary relief time more than WHO Case definition two seconds. Thrombocytopenia and rise in haematocrit level (more than 20%) Dengue fever is a severe, flu-like illness that affects infants, young children and adults, but seldom causes Grade 3 DHF/DSS: Signs of circulatory failure (rapid/ death. The clinical features of dengue fever vary accord- weak pulse, narrow pulse pressure, hypotension, cold/ ing to the age of the patient. Infants and young children clammy skin) may haveanon-specificfebrile illness with rash. Older Grade 4 DHF/DSS: Profound shock (undetectable children and adults may have either a mild febrile syn- pulse and BP), abdominal pain - intense and sustained, drome or the classical incapacitating disease with abrupt persistent vomiting, abrupt change from fever to onset and high fever, severe headache, pain behind the hypothermia, with sweating and prostration, restlessness eyes, muscle and joint pains, and rash . or somnolence. Common presentations in our clinical practice, high grade fever typically accompanied by any of the follow- Laboratory Tests ing: chilliness, retro-orbicular pain, photophobia, back- Usually clinical suspicion for Dengue fever is sufficient ache, severe muscle ache (one synonym of dengue is for supportive treatment. Complete blood picture may “break-bone fever”), and joint ache, nausea, vomiting, show high hematocrit, leucopenia and thrombocytope- abdominal pain. High fever may be sustained over 5-6 nia. Other laboratory tests include serum albumin, chest days. Other signs and symptoms include a generalized X Ray if required. A normal blood count does not rule maculopapular rash, lymph node enlargement, hepato out DF however platelet <50,000 and leukocyte count splenomegaly, a positive tourniquet test, petechiae, and <3 might be a sign of bad prognosis. other hemorrhagic manifestations, such as epistaxis and Diagnosis of dengue fever or its complications is gastrointestinal bleeding. In some cases it started as established bycultureof thevirus itself, bydetectionof common cold and flu like symptoms. In general, conva- viral DNA with use of PCR, or by serological methods. lescence occurs spontaneously and abruptly, but it Although detection of specific IgM indicates fresh infec- might be prolonged, sometimes taking several weeks, tion, a significant increase in IgG titer in paired serum and may be accompanied by pronounced asthenia and samples is also sufficient for diagnosing dengue fever. Jahan Asia Pacific Family Medicine 2011, 10:1 Page 3 of 4 http://www.apfmj.com/content/10/1/1 Currently employed methods include capture ELISAs, the patients need it is life saving if administered on immunofluorescence tests, and hemagglutination assays. proper time . Low white cell count, low platelet count, abnormal liver Clinical manifestation of impending hemorrhage are, function test, IgM ELISA test for serologic diagnosis, abdominal pain - intense and sustained, persistent IgM detecTable 5, 6 days after the onset of illness, IgG: vomiting, abrupt change from fever to hypothermia, day 14 of illness in primary and day2 in secondary infec- with sweating and prostration, restlessness or somno- tions . lence, Thrombocytopenia <50,000, WBC <3.0, evidence of “leaky capillaries:” high hematocrit (> 20% normal), low albumin, pleural or other effusions needs urgent Pathophysiology Studies has shown that median age of dengue patients referral for hospitalization. has decreased now and younger patients may be more susceptible in the recent outbreak. Total and differential Health education and Prevention leukocyte counts and platelet count may help identify Primary care professionals have the potential and ability patients at risk of hemorrhage. Severity of disease to provide comprehensive care for most patients, given depends on virus strain, pre-existing anti-dengue anti- adequate training, resources, and, when needed, specia- body previous infection maternal antibodies in infants, list advice. General practitioners and community nurses host genetics, age, secondary infections locations with can play a major role in health education and hygiene two or more serotypes circulating simultaneously at . high levels (hyperendemic transmission) and virus strain Effectiveness of Family physicians’ use of specific com- (genotype) . Epidemic potential is dependent on vire- munication skills in enhancing the care of the physical, mia level, infectivity and virus serotype, DHF risk is mental and emotional health of both their patients and greatest for DEN-2, followed by DEN-3, DEN-4 and their families is essential. DEN-1 . Antibody-dependent enhancement is the Our health educational system needs to be updated process in which certain strains of dengue virus, com- regularly, the information regarding Dengue Fever to be plexed with non-neutralizing antibodies, can enter a made more generally available, the popular sources of greater proportion of cells of the mononuclear lineage, information like newspapers and television should be thus increasing virus production. Infected monocytes used to disseminate information on a large scale . release vasoactive mediators, resulting in increased vas- Dengue mosquitoes bite during the daytime. Protec- cular permeability and hemorrhagic manifestations that tion from the bite by wearing full-sleeve clothes and characterize DHF and DSS . long dresses to cover the limbs use of repellents, mos- There are other febrile illness prevalent in Pakistan quito coils and electric vapour mats during the daytime. like other viral infections, Malaria, Enteric fever and Insecticide treated nets (ITNs) are available to protect Congo hemorrhagic fever which can cause leucopenia young children, pregnant women, old people, in addition and thrombocytopenia worth considering during the to others who may rest during the day. Curtains (cloth investigation and relevant investigations are done or bamboo) can also be treated with insecticide and according to the clinical presentation [11,12]. hung at windows or doorways, to repel or kill mosqui- Dengue IgM is a costly investigation not freely avail- toes. Drainage of water from desert/window air coolers able although it confirms the diagnosis but never when not in use, in addition to tanks, barrels, drums, changes the management. and buckets. Remove all objects containing water such as plant saucers from the house. All stored water con- Management tainers should be kept covered at all times. Collect and There is no specific treatment available the management destroy discarded containers in which water collects, is entirely supportive like keeping body temperature such as bottles, plastic bags, tins, tyres, etc. below 39°C, give the patient paracetamol (not more Vector control is implemented using environmental than four times in 24 hours. Avoid Aspirin or Brufen/ management and chemical methods . Proper solid Ponston. Advice to drink large amounts of fluids (water, waste disposal and improved water storage practices, soups, milk and juices) along with the patient’snormal including covering containers to prevent access by egg diet. The patient should rest. Complete blood picture laying female mosquitoes, are encouraged through com- should be done if fever is continue for three days. Oral munity-based programs . The application of appro- rehydration salt (ORS) should be started even there is priate insecticides to larval habitats, particularly those no significant clinical dehydration as patient can go in used by the households, such as water storage vessels rapid deterioration if dehydration commences. Primary can prevent mosquito breeding for several weeks there- fore these insecticides must be used periodically . care physician can start intravenous fluid according to Jahan Asia Pacific Family Medicine 2011, 10:1 Page 4 of 4 http://www.apfmj.com/content/10/1/1 11. Ali N, Nadeem A, Anwar M, Tariq WU, Chotani RA: Dengue fever in malaria Recent outbreaks have shown significant mortality and endemic areas. J Coll Physicians Surg Pak 2006, 16(5):340-2. morbidity in Pakistan. The best health outcome depends 12. Wasay M, Channa R, Jumani M, Zafar A: Changing patterns and outcome upon accurate diagnosis and appropriate treatment. A of Dengue infection; report from a tertiary care hospital in Pakistan. J Pak Med Assoc 2008, 58(9):488-9. patient centered communication provides a more com- 13. Muhammad A, Adel MK, Eman HL, Shahid B, Adnaan YA, Sawsan AU: plete clinical picture which leads to improvement in Characteristics of Dengue Fever in a large public hospital, Jeddah, Saudi health outcomes such as symptom resolution, reduced Arabia. J Ayub Med Coll Abottabad 2006, 18(2):9-13. 14. Syed M, Saleem T, Syeda UR, Habib M, Zahid R, Bashir A, Rabbani M, psychological distress, improvement of health and func- Khalid M, Iqbal A, Rao EZ, Saleem S: Knowledge, attitudes and practices tional status, relief from pain and anxiety control. regarding dengue fever among adults of high and low socioeconomic groups. J Pak Med Assoc 2010, 60(3):243-7. 15. Ageep AK, Malik AA, Elkarsani MS: Clinical presentations and laboratory Conclusion findings in suspected cases of dengue virus. Saudi Med J 2006, Family Physicians have a vital and active role to play in 27(11):1711-3. providing care, support and identifying the sign of 16. Riaz MM, Mumtaz K, Khan MS, Patel J, Tariq M, Hilal H, Siddiqui SA, Shezad F: Outbreak of dengue fever in Karachi 2006: a clinical impending hemorrhage which is serious consequences perspective. J Pak Med Assoc 2009, 59(6):339-44. of Dengue Fever needs referral to tertiary care for intra- 17. Kay BH, Nam VS, Tien TV, Yen NT, Phong TV, Diep VT, Ninh TU, Bektas A, venous fluid replacement, platelet transfusion along with Aaskov JG: Control of aedes vectors of dengue in three provinces of Vietnam by use of Mesocyclops (Copepoda) and community-based supportive care. Family practice also has opportunity for methods validated by entomologic, clinical, and serological surveillance. research-based evidence on Dengue fever more interven- Am J Trop Med Hyg 2002, 66(1):40-8. tional research is required in community to eradicate 18. Hanh TTT, Hill PS, Kay BH, Quy TM: Development of a Framework for Evaluating the Sustainability of Community-based Dengue Control this problem. Projects. Am J Trop Med Hyg 2009, 80(2):312-318. On-going public awareness campaign need to be strengthened and vigorous campaign need to be initiated doi:10.1186/1447-056X-10-1 Cite this article as: Jahan: Dengue Fever (DF) in Pakistan. Asia Pacific at all levels. Family doctors in primary health care set- Family Medicine 2011 10:1. ting have an opportunity not only give the best possible supportive care to their patients but also educate them regarding the spread of Dengue fever and vector control. Competing interests The author declares that they have no competing interests. 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Asia Pacific Family Medicine – Springer Journals
Published: Feb 24, 2011
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