Survey on Dengue Disease: An Attempt to Highlight Changing

Symptomatic Pattern and Patient Response

A dissertation submitted to the department of Pharmacy, University of Dhaka, as the

partial fulfillments to the B. Pharm. Professional degree

Submitted By:

Exam Roll: 438

B. Pharm. Professional Year-V Examination-2019

Date of Submission: 27.06.2020

 Table of Contents
Abstract ........................................................................................................................................... 3

Introduction ..................................................................................................................................... 3

History and Distribution of Dengue Virus .................................................................................. 4

Epidemiology of Dengue ............................................................................................................ 6

Classification of Dengue ............................................................................................................. 7

Structure and Serotypes of Dengue Virus ................................................................................... 8

Mode of Transmission ............................................................................................................... 10

Pathogenesis of Dengue ............................................................................................................ 10

Febrile Phase.......................................................................................................................... 11

Critical Phase ......................................................................................................................... 12

Convalescent Phase ............................................................................................................... 12

Laboratory Diagnosis of Dengue Infection ............................................................................... 12

Symptoms of Dengue ................................................................................................................ 14

Management of Dengue Infections ........................................................................................... 15

Management of Febrile Phase ............................................................................................... 15

Management of Critical Phase ............................................................................................... 15

Immunization ............................................................................................................................ 16

Prevention and Control.............................................................................................................. 17

Environment Control Methods .............................................................................................. 17

Biological Control Method .................................................................................................... 17

Chemical Control Method ..................................................................................................... 17

Personal Control Methods ..................................................................................................... 17

Dengue Situation in Bangladesh ............................................................................................... 17

Dengue Outbreak 2019 in Bangladesh ...................................................................................... 18

1
Rationale ....................................................................................................................................... 20

Materials and Methods .................................................................................................................. 20

Result ............................................................................................................................................ 21

Analysis of Symptoms Developed in Patients .......................................................................... 21

Analysis of Hematological Parameters ..................................................................................... 22

Analysis of Patient Responses to Symptoms ............................................................................ 24

Discussion ..................................................................................................................................... 26

Conclusion and Future Direction .................................................................................................. 27

References ..................................................................................................................................... 27

2
Abstract
Introduction
Dengue has been spreading rapidly and changing its pattern in the past few years. Till now,
hemorrhagic dengue was considered as the most life-threatening form of dengue. Especially in
Bangladesh, severity of dengue used to be interpreted with low count of platelets and presence of
skin rash. But in the year of 2019, dengue attack in Bangladesh was not confined to only dengue
hemorrhagic fever (DHF), but also reached to the stage of shock syndrome very fast which
confused the sufferer as well as the doctors. The time spent to realize this pattern already cost
many innocent lives. This study summarizes the findings of a survey that included 100 dengue
patients and focuses on the changes in hematological parameters and symptoms that may help to
understand the risk of changing pattern of this disease in Bangladesh.

Methods

From July to September 2019, survey was carried out on 100 dengue virus affected patients who
were admitted in Dhaka Medical College and Hospital (DMCH). A questionnaire was developed
and distributed to the patients. Data on the symptoms the patient observed were collected by
interviewing participants face-to-face. Blood reports were collected from each patient to analyze
blood parameters.

Results
Most common symptoms were fever, low blood pressure and body/joint pain. The observed
prevalence were 97% for fever, 78% for low blood pressure and 65% for body or joint pain. 15%
of patients had skin rash and itching which means 85% did not develop any skin rash. As for
hematological parameters, 79% of sample size had low platelet counts, 67% had low hematocrit
and 36% had low white blood cell count. 8% patients came to physician with fever only and rest
92% patients came with two or more complains including fever.
This analysis may help to identify the symptomatic pattern and hematological findings which could
be beneficial to patients and physicians to distinguish dengue from other undifferentiated fever.

Introduction
Dengue fever, known as most common arthropod-borne infection, is a systemic viral infection
transmitted between humans and non-human primates by mosquitoes. The cause of this fever is a

3
single-stranded positive sense ribonucleic acid (RNA) virus of the family Flaviviridae; part of
genus Falvivirus (Schaefer et al, 2019). The transmission cycle of this virus between humans and
Aedes mosquitoes causes infection in humans by any of its four major serotypes (Teo et al, 2009).
Each serotype is capable of causing the full spectrum disease.

Though Aedes aegypti is associated with most infections as the primary vector, A. albopictus is
also an important carrier with an upcoming expanding range. An infected human can also deliver
virus to mosquito depending on the viral load of the mosquito’s blood meal.

Infectious virus and non-structural proteins are found in blood during acute phases of infection
exhibiting symptoms like high fever, severe joint pain, headache, abdominal pain, vomiting and
characteristic skin rashes. This disease ranges from asymptomatic dengue fever to hemorrhagic
dengue and shock syndrome (Teo et al, 2009). Hemorrhagic dengue is characterized by bleeding,
decreased platelet count, blood plasma leakage and shock syndrome is associated with low blood
pressure, loss of fluid, pleural effusion and sometimes secondary viral or bacterial infection
(Schaefer et al, 2019). Dengue fever can be diagnosed by detecting the presence of NS1, IgG, IgM
(Simmons et al, 2012).

More than 100 million people get infected and approximately 20 to 20000 die annually suffering
from this disease (Schaefer et al, 2019). This fastest spreading disease is found in more than 100
countries (Teo et al, 2009).

History and Distribution of Dengue Virus

Dengue virus was transmitted to human from monkey by Aedes mosquito (Web-10). Though it
has a history of more than 200 years, it first emerged as a public health problem in 1954, when the
first epidemic occurred in Manila (Malavige et al, 2004). This was the first time it outbroke as
severe dengue. Before 1970, only 9 countries had experienced severe dengue epidemics. In 2001-
2010, an annual average of 2.9 million cases and 5906 deaths due to dengue were found in 12
Southeast Asian counties including Bhutan, Brunei, Cambodia, East Timor, Indonesia, Laos,
Malaysia, Myanmar, Philippines, Singapore, Thailand and Vietnam. The annual economic burden
was US$$ 950 million (Shepard at el, 2013). The distribution and economic burden of dengue
throughout the Southeast Asian countries in the year of 2010 are shown in figure 1.

4
Figure 1: Estimated economic burden in the Southeast Asia region (Adopted from Mutsuddy et
al, 2019).

This disease is now prevalent in more than 100 countries in the World Health Organization (WHO)
regions (African region, American region, Southeast Asia region, European region, Eastern
Mediterranean region, Western pacific region). Figure 2 is showing the dengue situation
worldwide in 2010-2016.

Figure 2: Average number of reported cases of dengue and affected countries from 2010-2016
(Web-6)
5
In 2012, a serious outbreak of dengue in Madeira Island of Portugal occurred. In 2015, Delhi, India
had a worst outbreak since 2006 with more than 15,000 cases. The Island in Hawaii, USA was
affected with more than 181 cases in 2015 and 2016. (Web-4)

In 2017/18 a significant reduction in the number of cases worldwide was noticed but sharp increase
has been observed in 2019, mostly in western pacific region and Indian subcontinent region (Web-
4). Figure 3 shows the increased distribution of cases of dengue reported worldwide in 2019.

Figure 3: Worldwide distribution of cases of dengue in 2019 (Figure adopted from Web-9)

Epidemiology of Dengue
Dengue, which was thought to be a virus caused flu like illness has grown dramatically both in
complication and incidence. From 1960 to 2010, the world has faced a 30-fold increase in the
incidence of dengue and now it is prevalent in 128 countries with 3.9 billion people being at risk
of dengue (Web-4). In 1998, 1.2 million people from 56 countries were reported to be infected
with dengue virus (Malavige et al, 2004) whereas 2.2 million cases were reported from WHO’s
African American, Eastern Mediterranean, Southeast Asia and Western Pacific regions in 2010
and the number increased to 3.34 million in 2016 (Web-4). The reason behind this dramatically
growing spread of dengue fever is the prevalence of the carrier Aedes mosquitoes. Though Aedes
aegypti was originated in Africa, (Web-4) now a days distribution of this vector has increased in

6
subtropical and tropical areas. Reasons behind the dense distribution through these tropical areas
are:

 Rainfall and tropical warm temperature

 Unplanned and rapid urbanization
 Uncontrolled population growth
 Lack of proper waste management
 Failure in effective mosquito control (Web-4, Malavige et al, 2004).

High risk areas are:-

 Central and South America

 Southeast Asia, including Bangladesh, Indonesia, Philippines, Thailand
 The Caribbean
 Northern Australia (Web-9).

Classification of Dengue
According to WHO 1997 guidelines for dengue, it was previously classified as undifferentiated
fever, dengue fever, dengue hemorrhagic fever. Dengue classification according to WHO 2009
guidelines is shown in figure 4.

7
 Figure 4: Classification of dengue according to WHO, 2009 (Adopted from Dmpuk and
Kularatne, 2015)

In 2009, the world health organization issued another guideline on which dengue was classified as
dengue with or without warning signs and severe dengue (Srikiatkachoron et al, 2011). Even WHO
2009 guideline has proposed to include dengue encephalopathy and dengue encephalitis under
severe dengue (Ghosh, 2017).

Structure and Serotypes of Dengue Virus

Dengue virus (DENV) is a 50 nm virus enveloped with a lipid membrane (Web-9). Figure 5
demonstrates a three dimentional representation of dengue virus obtained by cryo-electron
microscope.

Figure 5: DENV particle with two outer layers (light and dark blue), a lipid bilayer (green), a
nucleocapside (orange), genomic RNA (pink) (adopted from Zonetti et al, 2018)

The genomic structure consists of a positive sense RNA of ~11 kb. The RNA is further translated
and encoded for three structural proteins- capsid (C), pre-membrane (prM), envelope (E) and 7
Non-Structural proteins (NS1, NS2A, NS2B, NS3, NS4A, NS4B and NS5) (Figure 6, Zonetti et
al,2018).

8
 Figure 6: DENV genome structure with the structural and nonstructural genes (Adopted from
Zonetti et al, 2018)

Dengue virus has an outer protein shell (E and M) a lipid bilayer and a less characterized
nucleocapsid core (C and RNA genome) (Khetrapal and Khanna, 2016).

The E glycoprotein helps in the virion attachment to receptor and fusion of the virus envelop inside
the target cell (Figure 7).

Figure 7: Arrangement of E protein on the surface of dengue virus during its lifecycle (Adopted
from Khetrapal and Khanna, 2016).

Till now four antigenic different serotypes of the virus has been found.

 DENV-1
 DENV-2
 DENV-3
 DENV-4

In 2013, the existence of a fifth serotypes have been reported. The four subtypes have 60-80%
homology between each other (da Costa Barros and de-Oliver-Pinto, 2018).

9
Mode of Transmission
The primary vector of dengue is the Aedes aegypti mosquito. Aedes albopictus is a secondary
dengue vector in tropical countries (Figure 8, Web-4). Daytime feeder female Aedes mosquito
contributes to the transmission of this disease because-

 This mosquito breeds in clean tropic water close to human habitation.

 It inserts virus while sucking blood from hosts
 Completes its life cycle in very short period
 Eggs of Aedes mosquito can survive dry condition and hatch after coming in contact with
water (Alwabi et al, 2019).

Infected humans whether symptomatic or asymptomatic are both carriers and multipliers of the
virus (Web-4). After a female mosquito bites an infected human, dengue virus enters its system.
The virus replicates in the midgut epithelium, reaches the haemocoel and haemolymph and then
spread to different tissue of the insects. After replication in salivary glands for 10-14 days, the
infected mosquito transmit virus to other hosts. (Malavige et al, 2004, Nedjadi et al, 2015).

a) Aedes aegypti b) Aedes albopictus

Figure 8: Vector of dengue virus a) Aedes aegypti and b) Aedes albopictus (Adopted from Web-
9)

An infected pregnant woman can pass the virus to her fetus during pregnancy. Infected mother is
encouraged to breastfeed because of the benefits of breastfeeding inspite of one report of dengue
may spread through breast milk (Wiwanikit, 2010).

Pathogenesis of Dengue
The virus enters the host cell via endocytosis. The virus uncoats intracellulary. Then the membrane
fuses with lysosome which causes the release of the RNA into the cell. Then this RNA is translated

10
by the host ribosomes. After the translation, replication of all the positive-stranded RNA virus is
observed. The virus RNA genome get assembled with newly formed nucleocapside as a lipid
bilayer envelop using host endoplasmic reticulum. In this phase, the virus also acquires structural
proteins prM and E. During maturation stage, the prM proteins stabilize E protein in order to
prevent conformational changes. Before release, the prM breaks down into soluble pr peptide and
virion associated M proteins. After exposal to a neutral pH, pr protein dissociates from the virus
resulting in production of virions. Then the cycle repeats (Rodenhuis-Zybert et al, 2010).

Figure 9: Lifecycle of dengue virus (Adopted from Rodenhuis-Zybert et al, 2010)

After being bitten by a mosquito vector, the host undergoes an incubation period of 7-10 days
followed by a viraemic phase where the patient becomes febrile. Then the patient may either
recover or progress to severe dengue. It is differences in the amount of antibody, cytokine and T-
cell responses which lead different patients to different fates (Malavige et al, 2004).

Febrile Phase
Fever begins after incubation period. Leukopenia, lymphopenia may be observed near the end of
the febrile phase. Thrombocytopenia is very common in this phase. These phenomena are
considered to be caused by direct destructive effects of virus on bone marrow precursor cells. (Ojha
et al, 2017, da Costa Barros and de-Oliveira-Pinto, 2018)

11
Critical Phase
This may be an afebrile phase. Patient enters the phase of highest risk for developing plasma
leakage and hemorrhage. This phase may last between 24-48 hours (Deen et al, 2009). According
to some theories, antibody dependent enhancement is responsible behind this critical phase. Total
and dengue specific IgE antibody level in patients with dengue hemorrhagic fever and shock
syndrome are higher than others with dengue fever. When antibodies are in high levels, they form
complexes with dengue virus and their Fc portion then may binds to FcγRI and FcγRII bearing
cell which results in increased entry of dengue virus. The increased viral entry into macrophages
cause release of vasoactive mediators from affected macrophages leading to increased capillary
permeability and abnormalities in coagulation is seen which results in bleeding (Malavige et al,
2004, Web-7).

Adding to the complexity, cytokine response and T-cell immunopathology is triggered to release
different mediators. The level of TNF-α, TNF receptor can be correlated with the severity
(Sellahewa, 2012). As for platelet depletion, mainly two events are responsible: decrease in the
production of platelets in the bone marrow and increase in clearance or destruction from blood
vessels. Dengue virus replicates inside platelet cell and leaves a high number of virus genome
which contribute to platelet destruction leading to bleeding (Ojha at el, 2017) Thus bleeding is
observed in this phase due to capillary fragility and thrombocytopenia and plasma leakage, shock,
hypovolemia is seen as a result of increased capillary permeability (Sellohewa, 2012).

Convalescent Phase
Patient who survives the critical period will start to reabsorb the leakage fluid that maybe
characterized by normal or low percentage of hematocrit and will recover soon. (Deen et al, 2009).

Laboratory Diagnosis of Dengue Infection

Common diagnosis of dengue can be classified into two stages.

 Fever and viraemia accompanied by presence of NS1 antigens in blood within first two
days of fever.
 Identifying IgM and IgG antibodies within a few weeks (Halstead, 2007).

Mostly NS1 antigen tests are performed if patient comes within 3 days of fever. For early post-
febrile period, dengue specific IgM and IgG tests are widely used as it is inexpensive, quick and

12
simple and has good sensitivity. Patients have detectable IgM antibodies by the fifth day of
infection (Malavige et al, 2004).

To avoid the dilemma of which test the patient should go for, now-a-days a three-in-one test
package for detection of NS1, IgG and IgM is now available in tropical and sub-tropical countries
(Khetarpal and Khanna, 2016).

During the febrile phase, viruses can be isolated by using virus isolation techniques. But blood
should be collected before the fifth day of illness. Molecular detection techniques such as reverse
transcription polymerase chain reaction (RT-PCR) is used to detect dengue viral material in early
periods when antibodies are not detected. RT-PCR has more sensitivity than virus isolation
(Malavige et al, 2004).

Figure 10: Choice of diagnostic methods according to course of dengue infection (Adopted from
Halstead, 2007)

Classification of diagnostic methods for detecting dengue virus as given below:

Virus Isolation:

 Mosquito cell lines

 Mosquito inoculation technique
 Vertebral cell culture

Serological diagnosis:

13
  Haemagglutination inhibition test
 Enzyme-linked immunosorbent assay (ELISA)
 Complement fixation test
 Antigen capture enzyme immunosorbent assay

Molecular diagnostic methods:

 RT-PCR

Symptoms of Dengue
The sign and symptoms of dengue fever (Table 1) vary according to age, immunity and the
serotype of the virus. According to WHO guidelines, a person must be diagnosed for dengue if he
or she possesses high fever (40⁰ C/124⁰ F) and at least two of these following symptoms-

 Headache
 Pain behind the eyes
 Nausea
 Vomiting
 Swollen glands
 Muscle and joint pains
 Body ache
 Cutaneous rash

Alongside these symptoms, hemorrhagic episodes and circulatory shock are also seen. Few
patients may have only asymptomatic fever (Hasan et al, 2016). Features of general symptoms,
hemorrhagic phenomena, circulatory failure and other complications are mentioned in Table 1.

Table 1: Clinical manifestation of dengue infection (Malavige et al, 2004).

Features of plasma
General Bleeding manifestation Complications
leakage

High fever Epitaxis Low blood pressure Liver failure

Severe headache Bleeding from gums Tachycardia Myocarditis

Flushing Haematemesis and maelena Pleaural effusion Encephalopathy

14
 Myalgia and Spotting or menorrhagia in
Ascites Encephalitis
arthralgia females

Vomiting Petechiae and eccymoses

Management of Dengue Infections

There is no specific drug therapy for dengue infection which makes the management mainly
symptomatic. Medical care by experienced physicians and nurses can save lives and decrease
mortality rates from more than 20% to less than 1% (Malavige et al, 2004, Web-4).

Management of Febrile Phase

The febrile phase is managed with antipyretic and fluid replacement therapy. The only
recommended antipyretic drug is paracetamol with dose of 60mg/kg/day. No other nonsteroidal
anti-inflammatory drugs are allowed to be taken. Antiemetic may be prescribed if patient has
nausea and vomiting. Gastric mucosal protective agents may be given when there is risk of
gastrointestinal bleeding due to low platelet count or patient claims to have abdominal discomfort.
A balanced diet should be recommended with plenty of fluids. Administration of intravenous fluid
is not recommended unless patients have severe vomiting or dehydration (Malavige et al, 2004,
Nedjadi et al, 2015).

Management of Critical Phase

Adequate fluid administration, electrolyte balance assessment and monitoring vitals every 1-2
hours are necessary to prevent progression to shock. The hematocrit or packed cell volume should
be monitored at least twice a day. Administration of fluid should be adjusted according to these
values.

Maintenance fluid requirements in severe dengue-

 <10 kg body weight: 100ml/kg.

 10-20 kg body weight: 1000ml + 50 ml for each kg in excess of 10 kg.
 >20 kg body weight: 1500 ml + 20 ml for each kg in excess of 20 kg. (Malavige et al, 2004)

Patients with serious hemorrhagic manifestation or very low platelet counts maybe provided with
platelet transfusion. Platelet maybe transfused at a level of <1000/mm3 prophylactically even if
there is no bleeding. In case of continuous and massive bleeding, whole blood may be transfused
(Malavige et al, 2004, Hasan et al, 2016).

15
For the management of shock syndrome, vital signs like blood pressure, pulse rate and oxygen
saturation should be monitored. Though crystalloids are the first line of choice, both crystalloids
and collides may be used for fluid management. Normal saline, 5% glucose diluted in normal
saline, plasma, plasma substitutes, 5% albumin and Ringer’s Lactate are routinely administered
fluids for patients in critical phase. Persistent shock despite of adequate fluid replacement may be
a result of massive bleeding or myocarditis. Patient should immediately be transferred to intensive
care setting in this situation (Hasan et al, 2016).

Immunization
No effective, commercially available vaccine for dengue virus has been developed till date.
Different vaccine candidates are using various approaches such as live attenuated viruses,
inactivated viruses, subunit vaccines, DNA vaccines and chimeric viruses using yellow fever
vaccine and attenuated dengue viruses (Nedjadi et al, 2015).

Figure 11: Classification of approaches to dengue vaccine (Adopted from Khetrapal and
Khanna, 2016)

Sanofi pasture developed the first dengue vaccine, Dengvaxia® which was licensed in December
2015. It got approval by regulatory authorities in 20 countries to be used in endemic areas. World
Health Organization (WHO) imposed conditional recommendation for the vaccine to be used in
highly endemic areas. In November 2017, an additional analysis was carried out and the results
showed that a number of trial participants had a higher risk of more severe dengue than
unvaccinated participants (Web-4).

16
Prevention and Control
As no effective vaccine has been developed against dengue, the prevention and control depends
on minimizing the vector propagation and vector-human contact. Numerous strategies should be
adopted including environmental, biological, chemical and personal control for successful control
programs (Malavige et al, 2004, Web-4).

Environment Control Methods

These methods include preventing mosquito from breeding, solid waste management, reduction of
manmade breeding sites of vector, improvement in urban designing (Malavige et al, 2004).

Biological Control Method

These methods target at destroying the dengue vector at larval stage. Larvivorous fishes like
Gambusia affinis and Poecilia recticulate and endotoxin producing bacteria like Bacillus
thuringiensis serotype H-14 (Malavige et al, 2004).

Chemical Control Method

This includes applying insecticides on breeding sites (Malavige et al, 2004).

Personal Control Methods

Wearing light-colored cloths, installing mosquito net on windows, keeping household dry and
clean, emptying water tank storage which can serve as larval habitats may work as personal control
methods (Web-5).

Dengue Situation in Bangladesh

Bangladesh being situated in sub-tropical region and a densely populated country has always been
prone to dengue outbreak. During 2000-2017, 49.73% of the dengue cases were found during the
monsoon season (May-August) and 49.22% occurred during post-monsoon season (September-
December). But since 2014, cases are also being found during the pre-monsoon season. During
2015-17, the number of cases were more than previous 14 years (Mutsuddy et al, 2019). But from
2018 dengue season is lengthening more and more due to poor urban planning. The majority of
the cases are being seen between June and September but more cases are being reported earlier in
the year and later through to November and December (Web-1).

17
Dengue drew an attention of all in 2000 when a sudden outbreak of 5551 cases and 93 deaths
occurred in the country, after that, 2002, 2016 and 2018 showed peak rises (Figure 12, Mutsuddy
et al, 2019).

Figure 12: Dengue situation in Bangladesh (Adopted from Mutsuddy et al, 2019)

Dengue Outbreak 2019 in Bangladesh

After the number of dengue cases dropped globally in 2017-18, but there has been a sharp rise in
2019 especially in Australia, Cambodia, China, Laos, Malaysia, Philippines, Singapore and
Vietnam and Bangladesh. 2019 is considered as the deadliest year for Bangladesh with its worst
outbreak of dengue fever (Web-1). The number of dengue patient admission in 2019 is almost
double the number found in previous 18 years (Web-7).

Figure 13: Confirm dengue cases and deaths in Bangladesh from 2002-2018 (Adopted from
Web-7)
18
About 50176 dengue cases where reported between 2000 and 2018, whereas a total of 101354
confirm cases were reported only in 2019. In 2018, almost 7450 cases of dengue with 17 deaths
had been reported by mid-October. But the number by mid-October, 2019 turns to be 918666 cases
with 93 deaths (Web-3, Web-7).

Figure 14: Reported dengue cases throughout the year of 2019 (Adopted from Web-2)

In the year, 2019, dengue attack did not wait for monsoon or pre-monsoon season and started from
January with 38 cases. Number of cases took a massive form in June, July, August and September
with 1884, 16253, 52636 and 16856 cases respectively (Web-8).

19
 Figure 15: Reported dengue cases in August’19 (Adopted from Web-2)

From 2000 to 2018 end, 296 people died from dengue whereas year 2019 alone took 266 lives
(Web-8).

Rationale
After the year 2000, dengue situation in Bangladesh was quite in control. Nobody gave importance
to the increased number of cases in 2018 which resulted in a massive outbreak in 2019. This study
assumes 2019 outbreak as a warning and aims at analyzing the changing pattern so that it can be
helpful to prevent another bigger outbreak and to decrease the number of deaths due to dengue.

Materials and Methods

100 subjects were selected randomly among the dengue patients admitted into Dhaka Medical
College and Hospital. The survey was carried out among individuals of 13-45 years old patients
who came from different parts of Bangladesh. Among them 42 were male subjects and 58 were
female.

The duration of the survey was 3 months including July, August and September, which were
considered as the peak time of dengue outbreak in 2019. A 30-items questionnaire was developed
with the goal of evaluating the symptoms and the responses of the patients towards the symptoms.
The questionnaire was developed according to WHO module, structured in English language and

20
were translated into local language (Bengali) for the convenience of the subjects. Face-to-face
interview was conducted. Subjects had consent to participate in the survey and in case of patients
below 18 years, the approval of their guardians were taken.

No hematological or biochemical tests were done. The hematological data were collected by
collecting and evaluating the blood test reports from the patients that they obtained from pathology
departments of well-established hospitals and diagnostic centers.

Data were analyzed using Microsoft Office-Excel.

Result
Analysis of Symptoms Developed in Patients
Of the planed sample size of 100 dengue patients of 13-45 years for the face to face interview, it
was seen that 97% patients had fever, 65% had body or joint pain, 41% had headache, 46% had
suffered from abdominal discomfort or diarrhea, 59% faced nausea and vomiting, 68% patients
had systolic blood pressure between 90-120 mmHg and diastolic pressure between 60-80 mmHg.
10% had systolic pressure lower than 90mmHg and diastolic pressure lower than 60mmHg which
means a total of 78% of subjects had blood pressure lower than normal. 15% of patients had
developed rash and itching and 9% claimed to have anorexia. Different types of bleeding (nose
bleeding, abdominal bleeding, P/V (per vaginal) bleeding, gum bleeding, and hematuria) were
observed in 19% patients. Few of the patients were seen to suffer from pleural effusion (4%) and
respiratory distress (1%) (Figure-16).

21
 Respiratory diseases 1%
Aneroxia 19%
Pleural Effusion 4%
Mouth infection 5%
Gum bleeding 3%
Hematuria bleeding 4%
P/V bleeding 7%
Abdominal bleeding 3%
Symtoms

Nose bleeding 2%
Excessive Low blood Pressure 10%
Slightly low blood pressure 68%
Rash, Itching 15%
Sweating, Shivering 9%
Nausea, Vomiting 59%
Abdominal Discomfort 46%
Headache 41%
Body/ Joint pain 65%
Fever 97%

0% 20% 40% 60% 80% 100% 120%

% of patients

Figure 16: Symptoms wise distribution of cases

Analysis of Hematological Parameters

As for white blood cells (WBC), 36% had low, 62% had normal and 2% had high WBC count.
26% of subjects had low red blood cell (RBC) count and rest 84% had normal count. Hemoglobin
was normal in 85% patients. A large percentage of subjects (79%) showed low platelet count.
Percentage of hematocrit/packed cell volume (HCT/PCV) was below the normal range in 64% of
patients whereas 12% had higher than the normal range (Figure-17).

22
 90% 85%
79%
80%

70% 64%
62%
60%

50%

40% 36%

30% 26%
24%
21%
20%
12% 13%
10% 4%
2% 1%
0% 0%
0%
WBC Count RBC count Platelet count HCT/PCV Haemoglobin
% below normal range 36% 26% 79% 64% 13%
% within normal range 62% 4% 21% 24% 85%
% above normal range 2% 0% 1% 12% 0%

% below normal range % within normal range % above normal range

Figure 17: Hematological distribution of dengue cases

Analysis of lowest observed platelet count showed a prevalence of 14% for platelet count of 0-
10×103 unit/µL, 44% for 10-100×103 unit/µ`L, 21% for 100-150×103 unit/µL, 12% for 150-
200×103 unit/µL and 9% for beyond 200×103 unit/µL. It is to be noted that a normal value of
platelet count in a healthy adult is between 150-400×103 unit/L.

Table 2: Lowest observed platelet counts in patients

Platelet count No. of patients

0-10×103 /µ𝐿 14

10-100×103 /µ𝐿 40

100-150×103 /µ𝐿 21

150-200 ×103 /µ𝐿 12

>200 ×103 /µ𝐿 9

23
Normal Range in a healthy adult :

White Blood Cell count : 4-11×103 /µ𝐿

Red Blood Cell count :

Male Adult : 4.7-6.1×106 /µ𝐿

Female Adult : 4-11×106 /µ𝐿

Platelet count : 150-450×103 /µ𝐿

HCT :

Male adult : 40-52×103 /µ𝐿

Female adult : 37-48×103 /µ𝐿

Hemoglobin :

Male adult : 13.5-17.5 𝑔/𝑑𝐿

Female adult : 12-15.5 𝑔/𝑑𝐿

** All data was collected within 4 days since the first exhibition of the warning signs of the dengue.

Analysis of Patient Responses to Symptoms

22% of the subjects went to doctor or hospital of third day of fever, 37% on the fourth day 33%
on the fifth day and 11% on the sixth day of fever. (Figure 18)

24
 37

33
NUMVER OF PATIENTS

22

11
7
0

1ST DAY 2ND DAY 3RD DAY 4TH DAY 5TH DAY 6TH DAY
DAYS

Figure 18: Day of physician consultation

Only 8% patients were conscious enough to go to a physician after having fever, 21% waited for
one more symptoms other than fever to be appeared and rest 71% waited until two or more
symptoms appeared (Figure 19).

8%

Only due to fever

21%
After one more symptoms
other than fever appeared
After two or more symptoms
71% other than fever appeared

Figure 19: Response of patients to symptoms of dengue

25
Discussion
It was observed that most of the patients did not consult any physician for their fever and a total
of 92 out of 100 patients waited for one or more symptoms to be appeared specially rash and
itching. In Bangladesh a huge percentage of people do not give any importance to fever even if it
is a high-grade fever. They prefer to wait for 7 days before consulting with physicians and some
people start to take antibiotics on their own or by consulting with any C-grade pharmacist from
the nearest retail pharmacy. Almost everyone including physicians had a thought set in their mind
that dengue fever must be accompanied by rash or itching within 3-4 days of fever. But this survey
showed that 85% dengue patient did not develop rash and some patient among the rest 15%
developed rash and itching after 6-7 days of fever. Anorexia, headache/pain behind eye, body ache,
nausea and vomiting, abdominal discomfort were common symptoms other than fever. But these
symptoms may also be found in fever due to seasonal flue or other reasons. So it becomes really
difficult to assume any symptomatic pattern that will distinguish dengue from other fever. This is
where the danger hides. Dengue may not be fatal if it is detected early. But the later it is diagnosed,
the higher the chance of plasma leakage, bleeding and hypovolemic shock. As Bangladesh has
already been a high-risk zone for dengue outbreak due to poor urban planning, large number of
population and this country has faced a significant change in the symptomatic pattern and length
of dengue season, the strategy to reduce morbidity and mortality due to dengue should be “test
without any delay”. Whenever anyone is having persistent fever for more than 2 days, he must go
for a dengue test and complete blood count test.

By analyzing hematological parameter, it was seen that most patient had low platelet count, which
has always been considered as warning sign. Low platelet count is obviously a matter of concern
but a normal count of platelet does not rule out the possibility of plasma leakage or hypovolemic
shock. In this matter hematocrit or packed cell volume (HCT/PCV) percentage may help a lot.
Increase in PCV indicates the risk of active plasma leakage and the possible need for fluid
administration whereas normal or decreased PCV indicates extravagated fluid is being reabsorbed
i.e. the patient is recovering. The physician should take decision based on these two hematological
parameters whether the patient should be admitted and given IV fluid or blood/platelet transfusion
or it is enough to rest at home and have plenty of fluids. Even if the patient has good platelet and
HCT values, he should be advised to go for complete blood count test every day until fever and
other symptoms subside. In this survey 64 out of 100 patients had low HCT, 24 had normal value

26
and 12 had high HCT value which means that 12 patients with high HCT value had risk of
developing hypovolemic shock. As for other parameters, 36 patients had low WBC count. This
can be correlated to dengue as dengue can result in leukopenia. But for RBC count and
hemoglobin, most patients had normal values. Few patient who had low RBC count (26) and low
level of hemoglobin, might face these reductions due to dengue or other medical conditions. So
reduction in RBC and hemoglobin level cannot be correlated to dengue fever.

Conclusion and Future Direction

This report contains analysis of only symptoms and basic hematological investigation. In future
studies, abnormal coagulation profile, electrolytic disturbances, elevated liver enzymes and low
albumin levels may be analyzed to predict the prevalence of severe dengue among patients.
Evaluating electrolyte imbalance especially hyponatremia, prothrombin time, levels of
alanineaminotransferase and aspartate aminotransferase in blood might be helpful to assess the
percentage of patients with organ damage caused by dengue. Correlating these biochemical
findings to symptoms might be helpful to understand if patients have developed warnings signs
according to the severity.

References
Alwabli, A.S., Alattas, S.G., Alhebshi, A.M., Zabermawi, N.M. and Alkenani, N., 2019.
Methyltransferase activity of dengue RNA virus by using purified protein. International Journal
Of Drug Development And Resources,11:16. 16-20.

Das, S., Pingle, M.R., Munoz-Jordan, J., Rundell, M.S., Rondini, S., Granger, K., Chang, G.J.,
Kelly, E., Spier, E.G., Larone, D. and Spitzer, E., 2008. Detection and serotyping of dengue virus
in serum samples by multiplex reverse transcriptase PCR-ligase detection reaction assay. Journal
of Clinical Microbiology, 46(10). 3276-3284.

da Costa Barros, T.A. and de-Oliveira-Pinto, L.M., 2018. A view of platelets in dengue.
Thrombocytopenia, 7.

Deen, J., Lum, L., Martinez, E. and Tan, L.H., 2009. Clinical management and delivery of clinical
services. WHO Dengue Guidelines for Diagnosis, Treatment, Prevention and Control. 23-55.

27
Dmpuk, R. and Kularatne, S.A.M., 2015. Current management of dengue in adults: a review. Iium
Medical Journal Malaysia, 14(1).

Gamakaranage, C., Gamakaranage, C. and Satharasinghe, R, 2018. Changes in coagulation profile

in dengue patients with hepatitis attending to a tertiary care hospital in Sri Lanka. iMedPub
Journals.

Ghosh, A., 2017. Dengue or japanese encephalitis-an emerging diagnostic dilemma for tropical
world clinicians. Journal of Medicine Microbiology and Immunology Research, 1. 103.

Halstead, S.B., 2007. Dengue. The Lancet, 370(9599), 1644-1652.

Hasan, S., Jamdar, S.F., Alalowi, M. and Al Beaiji, S.M.A.A., 2016. Dengue virus: A global
human threat: Review of literature. Journal of International Society of Preventive & Community
Dentistry, 6(1), 1.

Horstick, O., Tozan, Y. and Wilder-Smith, A., 2015. Reviewing dengue: still a neglected tropical
disease? PLOS Neglected Tropical Diseases, 9(4), 0003632.

Khetarpal, N. and Khanna, I., 2016. Dengue fever: causes, complications, and vaccine strategies.
Journal of immunology research, 2016.

Malavige, G.N., Fernando, S., Fernando, D.J. and Seneviratne, S.L., 2004. Dengue Viral
Infections. Postgraduate Medical Journal, 80(948), 588-601.

Mutsuddy, P., Tahmina Jhora, S., Shamsuzzaman, A.K.M., Kaisar, S.M. and Khan, M.N.A., 2019.
Dengue situation in Bangladesh: An epidemiological shift in terms of morbidity and mortality.
Canadian Journal of Infectious Diseases and Medical Microbiology, 2019.

Nedjadi, T., El-Kafrawy, S., Sohrab, S.S., Desprès, P., Damanhouri, G. and Azhar, E., 2015.
Tackling dengue fever: current status and challenges. Virology Journal, 12(1). 212.

Ojha, A., Nandi, D., Batra, H., Singhal, R., Annarapu, G.K., Bhattacharyya, S., Seth, T., Dar, L.,
Medigeshi, G.R., Vrati, S. and Vikram, N.K., 2017. Platelet activation determines the severity of
thrombocytopenia in dengue infection. Scientific Reports, 7(1), 1-10.

Rodenhuis-Zybert, I.A., Wilschut, J. and Smit, J.M., 2010. Dengue virus life cycle: viral and host
factors modulating infectivity. Cellular and Molecular Life Sciences, 67(16), 2773-2786.

28
Sellahewa, K.H., 2012. Pathogenesis of dengue haemorrhagic fever and its impact on case
management. ISRN Infectious Diseases, 2013.

Schaefer, T.J., Panda, P.K. and Wolford, R.W., 2019. Dengue Fever. StatPearls Publishing.

Shepard, D.S., Undurraga, E.A. and Halasa, Y.A., 2013. Economic and disease burden of dengue
in Southeast Asia. PLoS Neglected Tropical Diseases, 7(2), 2055.

Simmons, C.P., Farrar, J.J., van Vinh Chau, N. and Wills, B., 2012. Dengue. New England Journal
of Medicine, 366(15), 1423-1432.

Srikiatkhachorn, A., Rothman, A.L., Gibbons, R.V., Sittisombut, N., Malasit, P., Ennis, F.A.,
Nimmannitya, S. and Kalayanarooj, S., 2011. Dengue-how best to classify it. Clinical Infectious
Diseases, 53(6), 563-567.

Teo, D., Ng, L.C. and Lam, S., 2009. Is dengue a threat to the blood supply? Transfusion Medicine,
19(2), 66-77.

Wiwanitkit, V., 2010. Non vector-borne transmission modes of dengue. Journal of Infection in
Developing Countries, 4(1).

Zonetti, L.F., Coutinho, M.C. and de Araujo, A.S., 2018. Molecular aspects of the dengue virus
infection process: a review. Protein and Peptide Letters, 25(8), 712-719.

Web-1: Bangladesh struggles with worst outbreak of dengue fever. Website:

https://mobile.reuters.com/article/amp/idUSKCN1UR4UQ. Accessed: 10 June 2020

Web-2: Daily dengue status report.

Website:https://dghs.gov.bd/index.php/bd/component/content/article/81-english-root/5200-daily-
dengue-status-report. Accessed: 10 June 2020

Web-3: Deadliest year for dengue fever in Bangladesh as cases explode in Dhaka.
Website:https://www.google.com/amp/s/amp.theguardian.com/global-development/2018/nov/21/
deadliest-year-for-dengue-fever-in-bangladesh-as-cases-explode-in-dhaka. Accessed: 10 June
2020
Web-4: Dengue and severe dengue. Website: https://www.who.int/news-room/fact-
sheets/detail/dengue-and-severe-dengue. Accessed: 17 September 2019

29
Web-5: Dengue control. Website: https://www.who.int/denguecontrol/disease/en/. Accessed: 17
September 2019

Web-6: Dengue control: Epidemiology. Website:https://www.who.int/denguecontrol/epidemiolo

gy/en/. Accessed: 17 September 2019

Web-7: Dengue outbreak shatters all records. Website:

https://www.dhakatribune.com/bangladesh/2019/10/13/dengue-outbreak-shatters-all-records.
Accessed: 10 June 2020

Web 8: Health Bulletin on current Dengue situation published by CDC, DGHS. Website:
https://dghs.gov.bd/index.php/bd/component/content/article/86-english-root/home-page/5175-
health-bulletin-on-current-dengue-situation-published-by-cdc-dghs. Accessed: 10 June 2020

Web 9: Dengue. Website: https://www.cdc.gov/dengue/index.html. Accessed: 20 March 2020

Web-10: Worldwide geographical distribution of dengue cases. Website:

https://www.ecdc.europa.eu/en/publications-data/geographical-distribution-dengue-cases-
reported-worldwide-2019. Accessed: 17 September 2019

30