DENGUE

FEVER
INTRODUCTION

Dengue is an acute viral infection with potential fatal

complications. Dengue fever was first referred as "water
poison" associated with flying insects in a Chinese medical
encyclopedia in 992 from the Jin Dynasty (265-420 AD).
The word "dengue" is derived from the Swahili phrase Ka-
dinga pepo, meaning "cramp-like seizure".
HISTORY
Dengue virus was isolated in Japan in 1943 by inoculation of serum of patients in suckling
mice and at Calcutta (now Kolkata) in 1944 from serum samples of US soldiers. The first
epidemic of clinical dengue-like illness was recorded in Madras (now Chennai) in 1780 and
the first virologically proved epidemic of DF in India occurred in Calcutta and Eastern Coast
of India in 1963-19645-1. The first major epidemic of the DHF occurred in 1953-1954 in
Philippines followed by a quick global spread of epidemics of DF/DHF. DHF was occurring
in the adjoining countries but it was absent in India for unknown reasons as all the risk
factors were present. The DHF started simmering in various parts of India since 19882-11.
The first major wide spread epidemics of DHF/DSS occurred in India in 1996 involving
areas around Delhi and Lucknow and then it spread to all over the countryragraph text
HISTORY

In 1943, Ren Kimura and Susumu Hotta first isolated the

dengue virus. These two scientists were studying blood
samples of patients taken during the 1943 dengue
epidemic in Nagasaki, Japan. A year later, Albert B. Sabin
and Walter Schlesinger independently isolated the dengue
virus.
IMPORTANT CONCEPTS IN THE FORMULATION OF
GUIDELINES
The Working Group identifies a number of important concepts that
need to be taken into consideration in the formulation of the
current treatment guidelines for DF and DHF. They are:

1. Identification of clinical and laboratory parameters that will

warrant hospital confinement and predict outcome.
IMPORTANT CONCEPTS IN THE FORMULATION OF
GUIDELINES

2. Precise fluid replacement estimation for children and adults.

3. Indications for use of blood and blood products.
4. Evaluation of other treatment options.
5. Simple, practical treatment matrix.
6. Ability of health-care providers to conform to these guidelines.
POINTS OF REFERENCE FOR THE TREATMENT
GUIDELINES:
-Hemoconcentration a rise in the hematocrit of >20% above average of age,
sex, and population or greater than 20% drop in hematocrit following
treatment with fluids as compared to baseline;
• Hemorrhagic manifestation include:
-A positive tourniquet test
-Petechiae, echymoses or purpuric rashes,
-Bleeding like epistaxis, gum bleeding, hematemesis or melena or from other
sites.
 CASE DEFINITION FOR DENGUE SHOCK
SYNDROME (DSS)
All of the above four criteria for DHF must be present, plus evidence of
circulatory failure manifested by:

• Rapid and weak pulse, and

• Narrow pulse pressure (<20 mmHg) or manifested by:
• Hypotension for age (<80 mmHg systolic pressure for 5 years of age and
<90 mmHg systolic pressure for 25 years of age), and
• Cold, clammy skin and restlessness
GRADING SEVERITY OF DHF
DHF is classified into four grades of severity, where grades III and IV are
considered to be Dengue Shock Syndrome (DSS).

Grade I: Fever accompanied by non-specific constitutional symptoms: the

only hemorrhagic manifestation is a positive tourniquet test and/ or easy
bruising.

Grade II: Spontaneous bleeding in addition to the manifestations of Grade I

patients, usually in the forms of skin or other hemorrhages
GRADING SEVERITY OF DHF

Grade III: Circulatory failure manifested by a rapid, weak pulse

and narrowing of pulse pressure or hypotension, with the
presence of cold, clammy skin and restlessness.

Grade IV: Profound shock with undetectable blood pressure or

puise.
 • Probable

A case compatible with the suspected case classification with

one or more of the following:

- Supportive serology (a reciprocal hemogglu- tination-

inhibition antibody titer ≥1280, a comparable IgG enzyme-
linked immunosorbent assay (ELISA) titer or a positive IgM
antibody
 • Probable

A case compatible with the suspected case classification with one or

more of the following:

- Supportive serology (a reciprocal hemogglu- tination-inhibition

antibody titer ≥1280, a comparable IgG enzyme-linked
immunosorbent assay (ELISA) titer or a positive IgM antibody test
on a late acute or convalescent-phase serum specimen), or
-Occurrence at the same location and time as
other confirmed cases of dengue fever

• Confirmed a case compatible with the

clinical description, laboratory-confirmed
(see below)
LABORATORY CRITERIA FOR CONFIRMATION OF
DENGUE FEVER ARE:
A. Serological confirmation
• Demonstration of a fourfold or greater change in IgG antibody titres to one or more
dengue virus antigens in paired serum samples.
• Anti-dengue IgM ELISA positive (P/N ≥2)

•Samples for Serological Confirmation

a. 3-5 mL serum sample; refrigerated (sterile) obtained during early, acute and
convalescent phase.
b. complete clinical information.
LABORATORY CRITERIA FOR CONFIRMATION OF
DENGUE FEVER ARE:
B. Virological confirmation
• Isolation of the dengue virus from serum or autopsy samples
• Demonstration of the Dengue Virus Antigen by Immunofluorescence
(IFAT) or Immunopero- xidase test.
• Demonstration of Dengue Virus Genome by RT- PCR using Dengue
Consensus and Serotype specific primers
• Samples for Virological Confirmation
a. 1-2 mL serum sample preferably obtained 3-5 days after onset of fever.
b. Serum samples
CASE DEFINITION FOR DENGUE HEMORRHAGIC
FEVER (DHF)

The following must all be present:

• Fever, or history of acute fever lasting 2-7 days;

• Thrombocytopenia (<100,000 cells per mm³ or less) or 1-2
platelets/oil immersion field;
•The consensus defined two categories of patients: those that can be
treated at home and those who will require hospitalization.
CASE DEFINITION FOR DENGUE HEMORRHAGIC
FEVER (DHF)

• Hospitalization will be required if danger sign(s) is/are

present; these danger signs anticipate bleeding or occurrence
of shock.
• Those requiring hospitalization are further subdivided into
those with no evidence of shock and those with significant
blood loss with or without shock.
CASE DEFINITION FOR DENGUE HEMORRHAGIC
FEVER (DHF)

•Platelet count, hematocrit, bleeding time, partial thromboplastin time (PTT)

must be monitored when available; vital signs, urine output are also included.

•IV fluids (crystalloids) such as D,LRS, plain LRS and D,NSS are used to
prevent or in early treatment of shock; estimates are based on existing WHO
protocol.

• Aside from replacement of fluids, fluid maintenance shall be given.

CASE DEFINITION FOR DENGUE HEMORRHAGIC
FEVER (DHF)

•Colloids (albumin, plasma or plasma substitutes) may be given if IV fluids are

inadequate.

• Whole blood or blood components may be required when there is significant

blood loss or when DIC is suspected.

•Patients are sent home if they become clinically stable and remain afebrile for
72 hours and have a platelet count of at least 100,000/cu mm.
SYMPTOMS

FEVER WITH 40°C FATIGUE

HEADACHE NAUSEA/VOMITING
TEMPERATURE

NOSEBLEEDING MUSCLE PAIN PAIN BEHIND THE

RASH
EYES
WORK RATE

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