DENGUE

Dengue is a viral infection transmitted to humans through the bite of infected mosquitoes. The primary
vectors that transmit the disease are aedes aegypti mosquitoes and, to a lesser extent, ae. Albopictus.

Incidence:

In 2022, and as of 9 March, the Pan American Health Organization (PAHO) reported 148 981 dengue
cases, including 46 864 confirmed cases and 33 associated deaths, in the Americas. The five countries
reporting most cases are: Brazil (115 317), Peru (11 200), Colombia (7 380), Nicaragua (5 157) and
Mexico (1 960).

EPIDEMIOLOGICAL FACTORS

Agent Factors

1. Agent: Dengue virus belongs to favivirus group and has four serotypes, Le. DENV-1, DENV-2,
DENV-3 and DENV-4. These are arboviruses. All four sero types are antigenetically same but they
provide only partial cross immunity after infection by any one of them.
2. Reservoir of infection: Both man and mosquito. The transmission cycle is man-mosquito-man.
Aedes aegypti and Aedes albopictus are the vectors.

HOST FACTORS

All ages and both sexes are susceptible to dengue fever. Children usually have a milder disease than the
adults.

Environmental Factors

Seasonal epidemics or endemics of dengue usually occur during rainy season when mosquitoes (Aedes
aegypti) breed Mosquitoes survives best between 16°C-30°C and relative humid ity of 60-80%.
Urbanization, slum development with poor civic amenities, poor drainage, stagnant water, not emptying
air coolers regularly, increased rural water supply schemes, improved transpor tation and changed life-
style have all contributed to increased incidence of dengue fever cases.

TRANSMISSION OF DISEASE

The Vector-Aedes aegypti mosquito becomes infective by feeding on a patient from the day before
onset to the 5th day (Viremia stage) of illness due to multiplication of the virus in its body. After an
extrinsic incubation period of 8-10 days, the mosquito becomes infective and is able to transmit the
infection. Trans ovarian transmission of dengue fever has been demonstrated in the laboratory, ie the
virus enters fully developed eggs at the time of ovi position. Mode of spread is by the bite of the
infective female aedes aegypti and aedes albopictus mosquitoes.
CLINICAL MANIFESTATIONS (Clinical Spectrum)

Dengue fever has a wide spectrum of clinical manifestations. These include the followings:

1. Asymptomatic dengue viral infection

2. Undifferentiated viral fever
3. Classical Dengue Fever (DF)
4. Dengue fever with unusual hemorrhage
5. Dengue Hemorrhagic Fever (DHF)
6. Dengue hemorrhagic fever with shock (Dengue Shock Syndrome [DSS])

Asymptomatic Dengue Viral Infection

Asymptomatic dengue viral infection is without any symptom may be subclinical infection, even through
there is infection.

Undifferentiated Fever

It is characterized by a mild fever like any other viral infection. There may be maculopapular rashes
along with fever or may appear after 3 rd day when fever subsides, headache, bodyache and anorexia.

Classical Dengue Fever

Definition

It is an acute viral infection caused by dengue virus, transmitted by aedes aegypti mosquito.

INCUBATION

3-10 days, (commonly 5-6 days).

Clinical Characteristic

1. Onset is sudden with chills and high fever 39°C-40°C, intense headache, muscle and joint pains
(arthralgia).
2. Retro- orbital pain(within 24 hours)
3. Extreme weakness, anorexia, constipation and alerted taste sensation
4. Colicky abdominal pain
5. Bi- phasic fever – Temperature declines on 2 nd day and rises again on 4th or 5th day and declines
again
6. Skin eruptions in 80%, Macular rash in chest, trunk, neck and may spread to extremities and
rarely to the face. The rash lasts for 2 hours to several days and may be followed by
desquamation.
7. Fever lasts for 5 days but rarely more than 7 days.

Dengue fever with unusual hemorrhage

It has clinical features similar to classical dengue fever but also has unusual hemorrhages such as
cutaneous, epistaxis, gingival bleeding hematuria and bleeding from gut.

DENGUE HEMORRHAGIC FEVER (DHF)

DHF is a severe form of dengue fever, caused by infection with more than one dengue virus.

1.This phase begins abruptly after an incubation period of 4-6 days with high fever, facial flushing and
headache.

2. During the first few days, the illness resembles classical DF, but maculopapular rash which is rubilli
form type, is less common. Occasionally the temperature 40°C to 41°C and febrile convulsions may occur
in infants.

There are tendencies for hemorrhages to occur as evidenced by positive tourniquet test A tourniquet
test (also known as a Rumpel-Leede capillary-fragility test or simply a capillary fragility test)
determines capillary fragility. It is a clinical diagnostic method to determine a patient's haemorrhagic
tendency. It assesses fragility of capillary walls and is used to identify thrombocytopenia (a reduced
platelet count).

Petechiaea (small red or purple spot caused by bleeding into the skin.)

and purpura(A rash of purple spots due to small blood vessels leaking blood into the skin, joints,
intestines or organs.)

There is marked thrombocytopenia (100,000 cells per mm³ or less).

The major difference in this form classical dengue fever is that there is plasma leakage due to increased
vascular permeability, manifested by increased hematocrit value and signs of plasma leakage into the
pleural cavity (pleurisy), peritoneal cavity (ascites) and hypoproteinemia.

Dengue Hemorrhagic Fever with Shock (Dengue Shock Syndrome [DSS])

1. All the signs and symptoms of DHF are present in DSS.

2. There is significant loss of plasma which causes hypovolemia and shock. It is manifested by
tachycardia or restlessness, it may be due to reduced brain perfusion, low blood pressure and
not passing urine for 4 to 6 hours. Patient is usually conscious.

Laboratory Diagnosis

The following laboratory tests are available to diagnose DF and DHF:

1.Virus isolation of dengue virus from specimens of serum during the acute phase.

2 Viral nucleic acid detection: Dengue viral genome consisting of RNA detection by reverse transcriptase
polymerase chain reaction (RT-PCR) assay.
3.Immunological response and serological tests, ie hemagglutination inhibition, compliment fixation,
neuralization test, IgM capture enzyme-linked immunosorbent assay (MAC-EUISA), indirect IgG-ELISA
and IgM/IgG ratio.

4.Viral antigen detection.

5. Rapid Diagnostic Test (RDT)

6.Platelet count is <100,000 cells/mm³ (normal = 2 to 5 lakhs cells/mm³). 7. 7. Hemocrit value is

increased by 20% or more due to hemoconcentration.

Management of Dengue (Treatment)

There is no specific treatment for dengue. Symptomatic treatment is given as below:

1. Before starting the treatment, full blood count of the patient is done to establish his baseline
hematocrit and platelet count. Bed rest during acute febrile phase.

2.Antipyretics are given or sponging is done to keep the body temperature below 40°C. Aspirin is
avoided as it may cause gastritis, bleeding and acidosis. Paracetamol is given for high fever. The interval
of dosing of paracetamol should not be less than six hours. Vital signs should be checked and observe
for signs of shock.

3. Encourage oral rehydration therapy with ORS, fruit juice and fluids to replace losses due to fever And
vomiting. Patients whose hematocrit is stable are sent home.

4. Instruct the care givers to bring the patient to hospital immediately if any warning signs develop, e.g.
abdominal pain, vomiting, cold and clammy extremities, lethargy and bleeding and oliguria.These are
indications of DHF.

Patients who are sent to home should be monitored by health care providers daily to see any Untoward
signs and symptoms. Patients with dengue fever who have thrombocytopenia and increased hematocrit
value and warning signs mentioned above should be observed for signs of Shock.

5.Hematocrit is determined daily from the third day onward which is the critical period of transition
from the febrile to the afebrile phase. It should be done daily until the temperature has remained
normal for 1-2 days. If hematocrit determination cannot be done then hemoglobin test should be done.

6.I/V fluids are also indicated if the patient is in shock and there is a rise in hematocrit value (hemo
concentration is high). I/V fluid are also indicated if patient is vomiting persistently

. 7. If there is no improvement despite the I/V therapy, i.e. patient has already recieved about 1000 ml
IV fluids, blood pressure falls and urinary output decreases and there are other signs of shock then
colloidal solution is given, preferably Dextran 40 haemaccel.

8. If hematocrit falls, then fresh whole blood transfusion is given.

9. Oxygen is given for patients in shock.
CONTROL OF DENGUE

The control measures are as following:

1. Mosquito control: Anti-adult and anti-larval measures should be used to control mosquito, e.g.
A. Aegypti breading. These include:
a. Anti-larvae measures such as:
i. Environmental control: Eliminate mosquito breeding places, Cover the stored water prop
erly. Let there be no accumulated water on the roof tops. Empty the containers of filled with
water and room cooler should be cleaned once in a week
ii. Chemical control
iii. Biological control

B .Anti-adult and anti-larval measures such as:

I) Residual spray with chemicals

II) Space spray with chemicals
III) Genetic control

C.Protection against mosquito bites by:

i.Using mosquito net for sleeping

ii Screening doors and windows

iii Using mosquito repellents

iv Wearing full sleeves shirts and full pants

2.There is no satisfactory vaccine by which this disease can be prevented.

3. All cases of suspected, probable and confirmed dengue should be notified as soon as possible to
the health authority by the medical officer/health worker or community health nurse for the
treatment or control of cases
4. . 4. Other measures: Isolation of the patient under bed nets during the first few days, individual
protection against mosquitoes as stated above.

Nursing Care

1. Bed rest: Admit to hospital if patient has warning signs such as abdominal pain,
vomiting, cold and clammy extremities, oliguria bleeding and shock. Isolation under bed-
nets during the first few days if at home if no warning signs are present.
2. Record of 1 hourly vital sings and report abnormality.
3. Watch for signs of hemorrhage and shock. Provide care during
Shock, ie keep the patient warm By blankets, etc.
4 Strict intake and output record.
5 Sponging with tepid water to reduce fever, maintain good ventilation.
 6 Do not give Aspirin and ibuprofen or other Non-Steroidal Anti-Inflammatory
Drugs (NSAIDs) as these may cause gastritis and bleeding. Paracetamol is
given on physician’s prescription
7 Plenty of oral fluids in case of excessive sweating, vomiting or diarrhea and as
patient can tolerate

. 8. Maintain IV fluids as prescribed. Watch for signs of respiratory distress.

9.Watch for urinary output. Patient should pass urine at least once in 4-6 hours.

10. Health education to families and community regarding mosquito control.

MALARIA
Definition
Malaria is a communicable disease caused by infection with protozoal parasites of the genus
plasmodium and transmitted to man by infected female Anopheles mosquito.

Incidence of malaria

According to WHO’s latest World malaria report, there were an estimated 241 million malaria cases and
627 000 malaria deaths worldwide in 2020. This represents about 14 million more cases in 2020
compared to 2019, and 69 000 more deaths.

Epidemiological Factors

Agent Factors

1. Agent:

Agent causing malaria is malaria parasite-it has four distinct species, Le. P. Malariae, P. Ovale, P.
Falciparum and P. Vivax. P. Vivax infections are the most common in the world. In India about 50% of
the infections are due to P. Falciparum and 4-8 % due to mixed infections and the remaining due to P.
Vivax. P. Malariae causes less than 1% of the infections in India.

2. Reservoir of Infection: Human being

3. Host factors:

A) Age: All ages are affected by malaria, but newborns are not affected with p.falciparum
because of high HB level in them which suppress the development of p.falciparum
B) Sex: Males more affected than females
C) Pregnancy: Increases the risk of malaria in women
D) Occupation: Farmers have more chances of being bitten by mosquitoes in the fields and
have malaria, even though it is not an occupational disease.

Environmental factors:
 1. Climate: July to November, rainfall increases mosquito breeding

2. Altitude: An altitude above 2000-2500 metres, is unfavorable for Anopheline mosquitoes.

3. Man-made malaria: Construction of irrigation channels dams, cess pools, etc. Have
encouraged breeding of mosquitoes and increase in malaria.

Vector of Malaria

Factors of importance related to mosquitoes:

1. Anopheline mosquitoes-the vector of malaria, has about 45 species, of which two are of major im
portance, i.e. An. Culicifacies in rural areas and An. Stephensi in urban areas. Their density should be
adequate.

2. A very high density is required for An culicifacies but a low density of An fluviatilis is enough for
transmission of malaria.

3. The vector mosquito must live for at least 10-12 days after an infective blood meal to become
infective. An culicifacies has 2-80% human blood feeds and An. Fluviatilis have a high preference for
human blood and they are better vectors of malaria than zoophilic species which prefer animal blood
feed.

4. Some mosquitoes rest indoors after blood meal for sometime, it is known as “endophilly”. Whereas
some rest outdoor, which is known as exophily. Knowledge of resting habit is important in order to
organize vector control measures.

5. An fluviatilis breed in moving water An. Stephensi breed in wells, cisterns, fountains and overhead
tanks.
Cisterns: A tank for storing water, especially one supplying taps or as part of a flushing toilet.

Mode of Transmission

Vector transmission: By the bite of certain species of infected female anopheline mosquitoes.
Mosquito is infective when sporozites are present in its salivary glands.

1. Direct transmission: By intradermal, intramuscular or intra venous injections of infected

blood or plasma containing sporozoites.

2. Vertical transmission: Malaria can be transmitted from an infected pregnant mother to its
new born, but it is rare. It is called congenital malaria.

Incubation Period

This is the period between the infective mosquito bite (inoculation of sporozoites) to the onset of first
clinical signs of which fever is the most common. It is usually not less than 10 days. Incubation period
differs according to the type of parasite involved as follows:

P.vivax – 14 days
P.falciparum 12 days

P.malariae-28 days

Povale-17 days

Clinical Features

Fever-which is marked by paroxysms. These coincide with the release of merozoites into the blood
stream.

A typical malaria attack has three stages, Le. The cold stage, the hot stage and the sweating stage. These
are followed by an a febrile period, during which the patient feels greatly relieved.

1 Cold stage:

A)Lassitude, headache, nausea and shivering (rigors). Shivering lasts for about 15 minutes to an hour.

B)The temperature rises rapidly to 39-41°C. Headache is often severe and commonly there isVomiting.

C. Pulse is rapid and weak. Skin is cold in the early phase then it becomes hot.

D)Parasite can be seen in the blood.

This stage lasts for about 4-1 hour.

2.Hot stage:

A) Patient feels burning hot. Skin is hot and dry to touch.

B)Headache is severe but nausea diminishes.

C) pulse is full and respiration is rapid.

This stage lasts for 2-6 hours

3.Sweating stage:

A Fever comes down rapidly to normal with profuse sweating, skin is cool and moist.

B. Pulse rate is slower and the patient feels better and often falls asleep due to exhaustion.

This stage lasts for 2-4 hours.

Febrile paroxysms occur intermittently after 48 hours in P. Vivax and P. Falciparum infection whereas in
P. Malariae infection fever occurs after 72 hours.

Relapse: The disease has a tendency to relapse and is characterized by enlargement of spleen anemia,
Febrile herpes is common in all malaria patients.
Complications

Complication of P. Falciparum malaria include cerebral malaria, acute renal failure, liver damage, gastro
intestinal symptoms, dehydration, shock and anemia. Complications of P. Vivax, P. Ovale and P. Malariae
infections include anemia, splenomegaly, liver enlargement, herpes and renal complications, etc.

Diagnosis

1.Microscopy: Microscopy of blood for malaria parasite in the blood. During an attack of fever, two
types of blood films, ie. Thick and thin are made on the same slide. These are stained and exam ined
under the microscope. This is a highly sensitive and specific test.

2.Rapid Dipstick Test (RDT): Dipstick (antigen capture) assay for detection of P. Falciparum evalu ated in
field trials and compared favorably with microscopy- is a simple and rapid diagnostic technique. In this
the circulating parasite antigens are detected with a simple dipstick format or test strip. The test takes
only about 15 minutes to be performed. The RDT is performed when microscopy result cannot be made
available within 24 hours in Pf (P. Flaciparum). RDT kits are supplied to ASHA workers and CHVS in
villages to facilitate early detection of malaria cases.

Measurement of Malaria

Pre-eradicaiton Era

The following measures were used before the malaria eradication programme was started. It was done
mostly on the basis of reports of the clinically diagnosed malaria cases. These were as the fol lowing:

1. Spleen rate: Percentage of children between 2-10 years showing enlargement of the spleen

2. Average enlarged spleen: It denotes average size of enlarged spleen.

3. Parasite rate: It is the percentage of children between 2-10 years showing malaria parasite in
Their blood films.

4.Parasite density index: It indicates the average degree of parasitaemia in a sample of well-de fined
group of population.

5.Infant parasite rate: It is defined as the percentage of infants (children below the age of 1
year)Showing malaria parasite in their blood films. It is the most sensitive index of malaria transmission
in an area.

6. Proportional case rate: It is defined as the number of cases diagnosed as clinical malaria for every 100
patients attending the hospitals and dispensaries.

Eradication era(current incident levels):

During the eradication era, the microscopic diagnosis of malaria cases became the main method of
diagnosis. The methods were mostly parasitogical in nature. These are being used at present also.
These include:

1. Annual Parasite Incidence Rate (API): Formula is given below:

API=Confirmed cases during one year X 1000

Population under surveillance

2. Annual Blood Examination Rate (ABER): Formula is given below:

ABER= Number of slides examined X 100

Population

In modified plan of operation, the minimum prescribed number of slides is 10% of the population in a
year.

3. Annual Falciparum Incidence (AFI): It refers to the new cases of P. falciparum malaria per 1000
population

4. Slide Positivity Rate (SPR): The slide positivity rate is the percentage of slides found positive for
malaria parasite, irrespective of the type of species.

5. Slide Falciparum Rate (SFR): It is the percentage of slides positive for P. falciparum.

Approaches and Strategies of Malaria Control

In India malaria has been a problem since ancient times. It has used many strategies to control ma laria
as a public health problem. Historical development of malaria control measures are listed be low in
sequence after independence.

1. In 1953 The National Malaria Control Programme (NMCP) launched by the Govt. of India.

2. In 1958 The NMCP was converted into National Malaria Eradication Programme (NMEP).

3. In 1977 The Modified Plan of Operation for Malaria Control Launched.

4. In 1999 The national programme renamed as The National Anti Malaria Programme.

5. In 2007 The Strategic Action Plan for Malaria Control (2007-12 and Beyond) launched in India.

6. In 2010 New Drug Policy introduced.

The present approach to control malaria is based on the Strategic Action Plan for Malaria Control (2007-
12 and beyond).