Dr.

Saida Sharmin
MBBS, MPH (Epidemiology)
Definition:
Dengue is an acute febrile mosquito-borne
disease caused by 4 antigenically related
serotypes of dengue viruses in tropical & sub
tropical areas of the world putting more than 3
billion people at risk of infection.
Agent :
Dengue viruses are member of the flavivirus &
family flaviviridae. It has 4 serotypes dengue
virus 1, 2, 3 & 4.
Vector :
Aedes aegypti & Aedes Albopictus are two
most important vectors of dengue.
Age:
All ages are susceptible in endemic areas.
Sex:
No special predilection exists.
Reservoir:
Man and mosquito are reservoirs of infection.
The population of Aedes aegpti fluctuates with
rainfall and water storage . Its life span is influenced
by temperature and humidity, survives best between
16⁰c -30⁰c & a relative humidity of 60%-80%.
Dengue is found in tropical & subtropical regions
around the world predominantly in urban and semi
urban areas, the highest incidence is in southeast
Asia, India & American tropics.
 Transmission:
It is transmitted by the infective bite of female
Aedes Aegypti mosquito.
Incubation period:
Commonly 5-6 days may vary from 3-15 days.
It occurs in two forms:
 Dengue Fever(DF) and
 Dengue Haemorrhagic Fever(DHF)
➢Abrupt onset of high fever

➢Acute febrile illness with two or more of the

following;
▪ Headache.

▪ Retro-orbital pain.

▪ Myalgia

▪ Arthalgia / bone pain

▪ Rash
▪ Haemorrhagic manifestation.

▪ Leucopenia (wbc ≤5000)

▪ Thrombocytopenia (platelet count <150,000)

Clinical features of Dengue haemorrhagic

fever(DHF)
o Features of dengue fever at initial stage.

o Haemorrhagic manifestation, shown by any of the

following;
✓Positive tourniquet test.

✓Petechiae, purpura, ecchymoses

✓Mucosal bleeding, Nasal bleeding, gum

bleeding.
✓Bleeding from injection or other sites

✓Hematemesis, melena, heaematuria.

✓Thrombocytopenia
 Criteria for dengue haemorrhagic fever as above
with signs of shock including
✓ Tachycardia, cool extremities, delayed capillary

refill, weak pulse, lethargy or restlessness, which

may be a sign of reduced brain perfusion.
✓ Pulse pressure ≤ 20 mm Hg with increased

diastolic pressure e.g. 100/80 mm Hg

✓ Hypotension by age.
DF/DHF Grade Symptoms/signs Lab finding

DF Fever with 2 or more of ▪Leucopenia (WBC≤5000

following
cells/cu.mm)
▪Headache.
▪Thrombocytopenia
▪Retro-orbital pain.
(platelet count <150,000
▪Myalgia
cells/ cu.mm)
▪Arthalgia / bone pain
▪Rash ▪Rising haematocrit (5-
▪Haemorrhagic 10%)
manifestation.
▪No evidence of plasma
leakage
DF/DHF Grade Symptoms/signs Lab finding

DHF i Above criteria for DF & •Thrombocytopenia : platelet

haemorrhagic manifestation count <100,000/cu.mm
plus positive tourniquet test, •Haematocrit rise 20% or
evidence of plasma leakage more.

DHF ii Above signs & symptoms plus •Thrombocytopenia : platelet

some evidence of count <100,000/cu.mm
spontaneous bleeding in skin •Haematocrit rise 20% or
or other organ(black tarry more.
stools, epitaxis, bleeding
from gums etc.)
And abdominal pain
DF/DHF Grade Symptoms/signs Lab finding

DHF iii Above signs & symptoms plus •Thrombocytopenia :

circulating failure (weak rapid platelet count
plus pressure ≤20 mm Hg or high <100,000/cu.mm
diastolic pressure, hypotension •Haematocrit rise
with the presence of cold clammy 20% or more.
skin and restlessness)

DHF iv Signs as grade iii plus profound •Thrombocytopenia :

shock with undetectable blood platelet count
pressure or plus <100,000/cu.mm
•Haematocrit rise
20% or more.

DHF iii and iv are dengue shock syndrome

Few common and favoured
breeding places/sites of Ae.
aegypti
1. Awareness among people: Dengue is spread
through the bite of an infected Ades mosquito.

2. Prevention of mosquito bites

✓ Dengue mosquitoes bite during the day time (before

sun rise & before the sun set)

✓ Wear full sleeve clothes & long dress to cover the

limb.

✓ Use mosquito repellents on young children and

children.
✓ Use mosquito coils and electric vapour or electric

mats during the day time to prevent dengue.

✓ Use mosquito nets for prevent dengue.

3. Prevention of multiplication of mosquitoes

 Drain out the water from window air cooler,

tanks, barrels, buckets, tiers, drums etc.
 Remove all objects containing water from

house.
 All stored water container should be kept

covered all time.

 Destroy discarded container in which water

collects.
4. Treatment
 There is no specific treatment management of

Dengue fever, treatment is symptomatic and

supportive.

 Severe pain can be relived by paracetamol.

 Do not give aspirin or any other NSAIDs.

Main objectives of management of DHF
i. Maintenance of fluid and electrolytes.
ii. Maintenance of blood osmolarity in case of

plasma leakage.

iii. Maintenance of circulatory volume and haemo-

dynamic status.
iv. Prevention of complications.
 There is no satisfactory vaccine to prevention the
discharge by immunization.
Indication of red cell transfusion
 Blood loss -10% or more to total blood volume

preferably give whole blood components to be

used.
 Refractory shocks despite adequate fluid

administration & declining haematocrit.

 Replacement volume should be 10ml/kg body wt

at a time and coagulogram should be done.

 If fluid overload is present packed cells are to be

done.

Indication of platelet transfusion

1. Prophylactic platelet transfusion may be

given at level at <10,000/cu.mm.

2. Coagulopathy with prolonged shock & abnormal

coagulogram.

3. In case of systematic massive bleeding, platelet

transfusion may be needed in addition to RBC

transfusion.
 Absence of fever for at least 24 hrs with out the use of

anti pyretic.

 Return of appetite

 Visible clinical improvement

 Good urine output

 Minimum of 2-3 days after recovery the shock

 No respiratory distress for pleural effusion or ascities.

 Platelet count > 50,000/cu.mm

A-dengue like disease caused by a group
Togaviridae (Alpha virus), the chikungunya
virus and transmitted by Aedes mosquitoes . It
is manifested by high fever & sever articular
pains in the limbs and spinal column.
The clinical features of Chikungunya ( CHK )
are fever, headache, nausea, vomiting,
myalgia, rash and arthralgia. The clinical
diagnosis is often confused with that of
Dengue fever because CHK virus circulates in
regions where Dengue ( DEN ) virus is also
endemic.
➢ Illness is often acute and lasts for 3 to 5 days.

➢ In few cases it may be up to 10 days or more.

➢ Convalescence is usually prolonged and

characterized by marked weakness and

pain in joints.
Agent
 Family – Togaviridae
 Genus - Alpha virus
It is usually 4 -7 days
Age group
The disease affects all age groups.
Seasons
The disease occurs in the rainy seasons,
when the mosquito vector population is at
its peak.
Clinical manifestations
▪ Fever,

▪ Crippling Joint pains

▪ Lymphadenopathy

 Conjunctivitis

 A Maculopapular rash
 May lead to hemorrhagic manifestations.

 Fever is biphasic with remission after 1 - 6 days

of fever.
A prominent symptom, seen specially of the
adult patient is arthropathy, from which the
disease gets its name. The arthropathy is
manifested by pain, swelling and stiffness,
especially of the metacarpophalangeal, wrist,
Elbow , shoulder, knee, ankle and metatarsal
joints. It appears 3rd to 5th day after the onset
of clinical symptoms, and it persists for may
months & even years. No death have been
attribute d to chikungunya fever.
There is no specific treatment of chickungunya
infection and it is self limiting. Analgesics ,
antipyretics like paracitamol, diclofenac
sodium, chloroquine along with
supplementation are recommended to manage
infection and relieve fever, joint pains and
swelling. Drug like aspirin & steroids should
be avoided.
 In serologic diagnosis, which is the approach
most commonly used
 Compliment Fixation test.

 ELISA ( enzyme-linked immunosorbent

assay .
They are used for detection of IgM
 RT-PCR (A reverse-transcription polymerase
chain reaction) and nested PCR technique has
used for rapid diagnosis of disease.
Control :
Vector control:
The Aedes aegypti mosquito should be the main
target of control activities.
It requires active community involvement to
keep water storage containers free of
mosquitoes & eliminate the other breeding
places of mosquitoes in and around house and
dwelling. Organophosphorus , abate is
increasingly used as a larvicide. It prevent
breeding up to 3 month.
Antiviral measures can prevent epidemic but
do not give immediate results when an
epidemic has already broken out. In such cases
anti-adult measures alone can bring about a
rapid interruption of transmission. Aerosol
spray of low-volume of malatheon are effective
for interrupting transmission. No vaccine has
yet developed.
Yellow fever is zoonotic disease caused by an
arbovirus. Affects monkeys and vertebrates (in
tropical America & Africa). Transmitted to
human by culicine mosquitoes. It shares
clinical feature with other viral hemorrhagic
fever ( e.g. dengue, Lassa fever) and further
characterized by more sever hepatic and renal
involvement .
Agent: Flavivirus
Reservoir of infection:
In forest areas, the reservoir of infection is
mainly monkeys & forest mosquitoes. In
urban areas, the reservoir is man (sub
clinical or clinical cases)
Period of communicability:
i. Man : blood of patients is infective during
the first 3-4 days of illness.
ii. Mosquitoes : after an “ extrinsic

incubation period” of 8-12 days, the

mosquito become infective.
Age & sex : All ages & both sexes are
susceptible to yellow fever in the absence of
immunity.
Occupation: Persons whose occupation
brings in contact with forest.
Immunity : One attack of yellow fever gives
lifelong immunity .
Climate : A temperature of 24⁰c or over is
required for multiplication of the virus in the
mosquito.
Social factors: in Africa, urbanization is
leading to the extension of yellow fever. In
addition increase rate of traveller who
transported from endemic areas to receptive
areas.
Incubation period: 3-6 days
 Isolation : Patient are isolated for first four days
of illness.
Treatment:

There is no specific treatment for yellow fever.

i. Treatment is symptomatic, aimed to

reducing the symptoms for the comfort of

the patient.
ii. Analgesics used if required

iii. Maintain urine output & blood pressure is

necessary.
iv. Blood transfusion, peritoneal dialysis may
necessary.
Quarantine : Non immunized person are
placed on quarantine for 6 days.
Vaccination:

Rapid immunization of the population at risk is

the most effective control strategy for yellow
fever. Active immunization by 17D vaccine. It is
a live attenuated vaccine. Single dose .05 ml.
Immunity begins to appear on the 7th day & lasts
for more than 35 yrs.
International measures:
All travellers including infants exposed to
the risk of yellow fever or passing through
endemic zones of yellow fever must possess
a valid international certificate of vaccine
against yellow fever before they are allowed
to enter yellow fever “receptive” areas.
If the traveller arrives before the certificate
becomes valid( valid 6 day after the date of
vaccination), he/she is isolated till the
certificate become valid. The aircraft and
ships arriving from endemic areas are
subjected to aerosol spraying with
prescribed insecticides.
Bangladesh is a yellow fever receptive area and
people are susceptible for yellow fever.
Condition is favourable for the occurrence and
transmission of yellow fever. People are not
vaccinated here & vector Aedes aegypty are
found is abundance all over the country,
reservoir (monkeys) of the disease are available
.The climate are favourable for transmission .
But the yellow fever is non-existent as the
causal agent ( virus ) are absent. Yellow fever
can enter in Bangladesh through infected
person coming by air or ship, or infected
mosquito brought by aircraft or ships.