presentation in dengue

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• Dengue fever

Dengue (DENG-gey) fever is a mosquito-borne illness that occurs in tropical and subtropical areas of the world. Mild dengue fever causes a high fever and flu-like symptoms. The severe form of dengue fever, also called dengue hemorrhagic fever, can cause serious bleeding, a sudden drop in blood pressure (shock) and death.

Millions of cases of dengue infection occur worldwide each year. Dengue fever is most common in Southeast Asia, the western Pacific islands, Latin America and Africa. But the disease has been spreading to new areas, including local outbreaks in Europe and southern parts of the United States.

Researchers are working on dengue fever vaccines. For now, in areas where dengue fever is common, the best ways to prevent infection are to avoid being bitten by mosquitoes and to take steps to reduce the mosquito population.

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Many people experience no signs or symptoms of a dengue infection.

When symptoms do occur, they may be mistaken for other illnesses — such as the flu — and usually begin four to 10 days after you are bitten by an infected mosquito.

Dengue fever causes a high fever — 104 F (40 C) — and any of the following signs and symptoms:

• Muscle, bone or joint pain
• Pain behind the eyes
• Swollen glands

Most people recover within a week or so. In some cases, symptoms worsen and can become life-threatening. This is called severe dengue, dengue hemorrhagic fever or dengue shock syndrome.

Severe dengue happens when your blood vessels become damaged and leaky. And the number of clot-forming cells (platelets) in your bloodstream drops. This can lead to shock, internal bleeding, organ failure and even death.

Warning signs of severe dengue fever — which is a life-threatening emergency — can develop quickly. The warning signs usually begin the first day or two after your fever goes away, and may include:

• Severe stomach pain
• Persistent vomiting
• Bleeding from your gums or nose
• Blood in your urine, stools or vomit
• Bleeding under the skin, which might look like bruising
• Difficult or rapid breathing
• Irritability or restlessness

When to see a doctor

Severe dengue fever is a life-threatening medical emergency. Seek immediate medical attention if you've recently visited an area in which dengue fever is known to occur, you have had a fever and you develop any of the warning signs. Warning signs include severe stomach pain, vomiting, difficulty breathing, or blood in your nose, gums, vomit or stools.

If you've been traveling recently and develop a fever and mild symptoms of dengue fever, call your doctor.

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Dengue fever is caused by any one of four types of dengue viruses. You can't get dengue fever from being around an infected person. Instead, dengue fever is spread through mosquito bites.

The two types of mosquitoes that most often spread the dengue viruses are common both in and around human lodgings. When a mosquito bites a person infected with a dengue virus, the virus enters the mosquito. Then, when the infected mosquito bites another person, the virus enters that person's bloodstream and causes an infection.

After you've recovered from dengue fever, you have long-term immunity to the type of virus that infected you — but not to the other three dengue fever virus types. This means you can be infected again in the future by one of the other three virus types. Your risk of developing severe dengue fever increases if you get dengue fever a second, third or fourth time.

Risk factors

You have a greater risk of developing dengue fever or a more severe form of the disease if:

• You live or travel in tropical areas. Being in tropical and subtropical areas increases your risk of exposure to the virus that causes dengue fever. Especially high-risk areas include Southeast Asia, the western Pacific islands, Latin America and Africa.
• You have had dengue fever in the past. Previous infection with a dengue fever virus increases your risk of severe symptoms if you get dengue fever again.

Complications

Severe dengue fever can cause internal bleeding and organ damage. Blood pressure can drop to dangerous levels, causing shock. In some cases, severe dengue fever can lead to death.

Women who get dengue fever during pregnancy may be able to spread the virus to the baby during childbirth. Additionally, babies of women who get dengue fever during pregnancy have a higher risk of pre-term birth, low birth weight or fetal distress.

Dengue fever vaccines may be available for people ages 6 to 60. Dengue vaccination is a series of two or three doses, depending on the vaccine you get, over the course of months. These vaccines are for use by people who live where the viruses that cause dengue are common, and who have already had dengue fever at least once.

The vaccines are not available in the continental United States. But in 2019, the U.S. Food and Drug Administration approved a dengue vaccine called Dengvaxia for people ages 9 to 16 who have had dengue fever in the past and who live in U.S. territories and freely associated states where dengue fever is common.

Prevent mosquito bites

The World Health Organization stresses that the vaccine is not an effective tool on its own to reduce dengue fever in areas where the illness is common. Preventing mosquito bites and controlling the mosquito population are still the main methods for preventing the spread of dengue fever.

If you live in or travel to an area where dengue fever is common, these tips may help reduce your risk of mosquito bites:

• Stay in air-conditioned or well-screened housing. The mosquitoes that carry the dengue viruses are most active from dawn to dusk, but they can also bite at night.
• Wear protective clothing. When you go into mosquito-infested areas, wear a long-sleeved shirt, long pants, socks and shoes.
• Use mosquito repellent. Permethrin can be applied to your clothing, shoes, camping gear and bed netting. You can also buy clothing made with permethrin already in it. For your skin, use a repellent containing at least a 10% concentration of DEET.
• Reduce mosquito habitat. The mosquitoes that carry the dengue virus typically live in and around houses, breeding in standing water that can collect in such things as used automobile tires. You can help lower mosquito populations by eliminating habitats where they lay their eggs. At least once a week, empty and clean containers that hold standing water, such as planting containers, animal dishes and flower vases. Keep standing water containers covered between cleanings.
• AskMayoExpert. Viral hemorrhagic fever. Mayo Clinic; 2019.
• Dengue. Centers for Disease Control and Prevention. https://www.cdc.gov/dengue/index.html. Accessed Oct. 26, 2020.
• Dengue and severe dengue. World Health Organization. https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue. Accessed Oct. 26, 2020.
• Ferri FF. Dengue fever. In: Ferri's Clinical Advisor 2021. Elsevier; 2021. https://www.clinicalkey.com. Accessed Oct. 26, 2020.
• Wilder-Smith A, et al. Dengue. The Lancet. 2019; doi:10.1016/S0140-6736(18)32560-1.
• Thomas SJ, et al. Dengue virus infection: Prevention and treatment. https://www.uptodate.com/contents/search. Accessed Oct. 30, 2020.
• WHO position paper on dengue vaccines. World Health Organization. https://www.who.int/news-room/questions-and-answers/item/dengue-vaccines. Accessed June 3, 2024.

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• Signs and Symptoms
• How It Spreads
• Areas with Risk
• Dengue in the United States
• Dengue Print Resources
• Dengue Vaccine
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• Clinical Testing and Diagnosis
• Dengue Clinical Care
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Clinical Features of Dengue

• About 1 in 4 dengue virus infections are symptomatic.
• Approximately 1 in 20 patients with dengue progress to develop severe, life-threatening disease called severe dengue.
• Because there are four dengue viruses, people can be infected with DENV multiple times in their life.

Clinical presentation

Dengue begins abruptly after a typical incubation period of 5–7 days, and the course follows 3 phases: febrile , critical , and convalescent .

Early clinical findings are nonspecific. Dengue requires a high index of suspicion because recognizing early signs of shock and promptly initiating intensive supportive therapy with intravenous fluids can reduce risk of death among patients with severe dengue to <0.5%.

Laboratory findings commonly include leukopenia, thrombocytopenia, hyponatremia, elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and a normal erythrocyte sedimentation rate (ESR).

Infection with one DENV type generally induces life-long protection against infection from that specific type, but only short-lived protection to other DENV types for several months to years.

Febrile Phase

• Fever typically lasts 2–7 days and can be biphasic.
• Other signs and symptoms may include severe headache, retro-orbital pain, myalgia and arthralgia, macular or maculopapular rash; and minor hemorrhagic manifestations including petechia, ecchymosis, purpura, epistaxis, gingival bleeding, hematuria, or a positive tourniquet test result.
• Some patients have injected oropharynx and facial erythema in the first 24–48 hours after onset.

Warning Signs

Warning signs of progression to severe dengue usually occur in the late febrile phase around the time of defervescence, and include persistent vomiting, severe abdominal pain, fluid accumulation, mucosal bleeding, lethargy/restlessness, postural hypotension, liver enlargement, and progressive increase in hematocrit (i.e., hemoconcentration).

Critical Phase

• The critical phase of dengue begins at defervescence and typically lasts 24–48 hours.
• Most patients clinically improve during this phase, but those with substantial plasma leakage can, within a few hours, develop severe dengue.
• Initially, physiologic compensatory mechanisms maintain adequate circulation, which narrows pulse pressure as diastolic blood pressure increases.
• Patients with severe plasma leakage may have pleural effusions, ascites, hypoproteinemia, or hemoconcentration.
• Patients may appear to be well despite early signs of shock. However, once hypotension develops, systolic blood pressure rapidly declines, and irreversible shock and death may ensue despite resuscitation.
• Patients can also develop severe hemorrhagic manifestations, including hematemesis, hematochezia, or menorrhagia, especially if they have been in prolonged shock. Uncommon manifestations include hepatitis, myocarditis, pancreatitis, and encephalitis.

Convalescent Phase

• As plasma leakage subsides, the patient enters the convalescent phase and begins to reabsorb extravasated intravenous fluids and pleural and abdominal effusions.
• As a patient's well-being improves, hemodynamic status stabilizes (although he or she may manifest bradycardia), and diuresis ensues. The patient's hematocrit stabilizes or may fall because of the dilutional effect of the reabsorbed fluid, and the white cell count usually starts to rise, followed by a recovery of platelet count.
• The convalescent-phase rash may desquamate and be pruritic.

WHO 2009 Dengue Classification

Dengue is defined by a combination of ≥2 clinical findings in a febrile person who lives in or traveled to (in the last 14 days) a dengue-endemic area. Clinical findings include nausea, vomiting, rash, aches and pains, a positive tourniquet test, leukopenia, or any warning sign.

Dengue warning signs include abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleeding, lethargy, restlessness, and liver enlargement. Patients with warning signs should be monitored closely as they can be more likely to progress to severe disease.

Severe dengue is defined by dengue with any of the following clinical manifestations: severe plasma leakage leading to shock or fluid accumulation with respiratory distress; severe bleeding; or severe organ impairment such as hepatitis (elevated transaminases ≥1,000 IU/L), impaired consciousness, or heart impairment.

• Dengue guidelines, for diagnosis, treatment, prevention and control (who.int)

Learn about dengue viruses, how dengue spreads, how to prevent dengue, and the areas with risk of dengue.

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Dengue Clinical Presentation

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Patients with dengue will have a history of living in, or recent travel to, a region where the disease is endemic. The incubation period is 3-14 days (average, 4-7 days); symptoms that begin more than 2 weeks after a person departs from an endemic area probably are not due to dengue.

Many patients experience a prodrome of chills, erythematous mottling of the skin, and facial flushing (a sensitive and specific indicator of dengue fever). The prodrome may last for 2-3 days. Children younger than 15 years usually have a nonspecific febrile syndrome, which may be accompanied by a maculopapular rash. Classic dengue fever begins with sudden onset of fever, chills, and severe (termed breakbone) aching of the head, back, and extremities, as well as other symptoms. The fever lasts 2-7 days and may reach 41°C. Fever that lasts longer than 10 days probably is not due to dengue.

Pain and other accompanying symptoms may include any of the following:

• Retro-orbital pain
• General body pain (arthralgias, myalgias)
• Nausea and vomiting (however, diarrhea is rare)
• Altered taste sensation
• Sore throat
• Mild hemorrhagic manifestations (eg, petechiae, bleeding gums, epistaxis, menorrhagia, hematuria)
• Lymphadenopathy

Rash in dengue fever is a maculopapular or macular confluent rash over the face, thorax, and flexor surfaces, with islands of skin sparing. The rash typically begins on Day 3 and persists 2-3 days.

Fever typically abates with the cessation of viremia. Occasionally, and more commonly in children, the fever abates for a day and then returns, a pattern that has been called saddleback fever. A second rash may occur within 1-2 days of defervescence, lasting 1-5 days; it is morbilliform, is maculopapular, spares the palms and soles, and occasionally desquamates.

Recovery is complete but slow, with fatigue and exhaustion often persisting after the fever has subsided. The convalescent phase may last for 2 weeks.

Patients are at risk for development of dengue hemorrhagic fever or dengue shock syndrome at approximately the time of defervescence. Abdominal pain in conjunction with restlessness, change in mental status, hypothermia, and a drop in the platelet count presages the development of dengue hemorrhagic fever.

Of patients with dengue hemorrhagic fever, 90% are younger than 15 years. The initial phase of dengue hemorrhagic fever is similar to that of dengue fever and other febrile viral illnesses. Shortly after the fever breaks (or sometimes within 24 hours before), signs of plasma leakage appear, along with the development of hemorrhagic symptoms such as bleeding from sites of trauma, gastrointestinal bleeding, and hematuria. Patients may also present with abdominal pain, vomiting, febrile seizures (in children), and a decreased level of consciousness.

If left untreated, dengue hemorrhagic fever most likely progresses to dengue shock syndrome. Common symptoms in impending shock include abdominal pain, vomiting, and restlessness. Patients also may have symptoms related to circulatory failure.

Dengue fever presents in a nonspecific manner and may not be distinguishable from other viral or bacterial illness. According to the Pan American Health Organization (PAHO), the clinical description of dengue fever is an acute febrile illness of 2-7 days duration associated with 2 or more of the following:

• Severe and generalized headache
• Severe myalgias, especially of the lower back, arms, and legs
• Arthralgias, usually of the knees and shoulders
• Characteristic rash
• Hemorrhagic manifestations

Additional findings may include the following:

• Injected conjunctivae
• Facial flushing, a sensitive and specific predictor of dengue infection
• Inflamed pharynx
• Nausea and vomiting
• Nonproductive cough
• Tachycardia, bradycardia, and conduction defects

Up to half of patients with dengue fever develop a characteristic rash. The rash is variable and may be maculopapular or macular. Petechiae and purpura may develop as hemorrhagic manifestations. Hemorrhagic manifestations most commonly include petechiae and bleeding at venipuncture sites.

A tourniquet test often is positive. This test is performed by inflating a blood pressure cuff on the upper arm to midway between diastolic and systolic blood pressures for 5 minutes. The results are considered to be positive if more than 20 petechiae per square inch are observed on the skin in the area that was under pressure. Other hemorrhagic manifestations include nasal or gingival bleeding, melena, hematemesis, and menorrhagia.

Neurologic manifestations such as seizures and encephalitis/encephalopathy have been reported in rare cases of dengue infection. Some of these cases did not display other typical features of dengue infection. Other neurologic complications associated with dengue infection include neuropathies, Guillain-Barré syndrome, and transverse myelitis.

Dengue hemorrhagic fever

Findings for dengue hemorrhagic fever are similar to those for dengue fever and include the following:

Biphasic fever curve

Hemorrhagic findings more pronounced than in dengue fever

Signs of peritoneal effusion, pleural effusion, or both

Minimal criteria for the diagnosis of dengue hemorrhagic fever, according to the World Health Organization (WHO), are as follows [ 65 ] :

Hemorrhagic manifestations (eg, hemoconcentration, thrombocytopenia, positive tourniquet test)

Circulatory failure, such as signs of vascular permeability (eg, hypoproteinemia, effusions)

Hepatomegaly

In addition, conjunctival injection develops in approximately one third of patients with dengue hemorrhagic fever. Optic neuropathy has been reported and occasionally results in permanent and significant visual impairment. [ 66 ] Pharyngeal injection develops in almost 97% of patients with dengue hemorrhagic fever. Generalized lymphadenopathy is observed.

Hepatomegaly is present more often in dengue shock syndrome than in milder cases. Hepatic transaminase levels may be mildly to moderately elevated. Encephalopathy is a rare complication that may result from a combination of cerebral edema, intracranial hemorrhage, anoxia, hyponatremia, and hepatic injury.

Dengue shock syndrome

Findings of dengue shock syndrome include the following:

Hypotension

Bradycardia (paradoxical) or tachycardia associated with hypovolemic shock

Hypothermia

Narrow pulse pressure (< 20 mm Hg)

Signs of decreased peripheral perfusion

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• Drawing of Aedes aegypti mosquito. Courtesy of the Centers for Disease Control and Prevention (CDC).
• Aedes albopictus. Courtesy of the Centers for Disease Control and Prevention (CDC).
• Worldwide distribution of dengue in 2000. Courtesy of the Centers for Disease Control and Prevention (CDC).
• Worldwide distribution of dengue in 2003. Courtesy of the Centers for Disease Control and Prevention (CDC).
• Worldwide distribution of dengue in 2005. Courtesy of the Centers for Disease Control and Prevention (CDC).
• Increasing rates of dengue infection by regions of the world. Courtesy of the World Health Organization (WHO).
• Dengue transmission cycle. Courtesy of the Centers for Disease Control and Prevention (CDC).
• Reinfestation by Aedes aegypti in the Americas after the 1970 (left) mosquito eradication program and most recent distribution as of 2002 (right). Courtesy of the Centers for Disease Control and Prevention (CDC).
• A child with dengue hemorrhagic fever or dengue shock syndrome may present severely hypotensive with disseminated intravascular coagulation (DIC), as this severely ill pediatric ICU patient did. Crystalloid fluid resuscitation and standard DIC treatment are critical to the child's survival.
• Delayed capillary refill may be the first sign of intravascular volume depletion. Hypotension usually is a late sign in children. This child's capillary refill at 6 seconds was delayed well beyond a normal duration of 2 seconds.
• Signs of early coagulopathy may be as subtle as a guaiac test that is positive for occult blood in the stool. This test should be performed on all patients in whom dengue virus infection is suspected.
• Aedes aegypti mosquito. Courtesy of Wikimedia Commons (https://commons.wikimedia.org/wiki/File:Aedes_aegypti.jpg; author Muhammad Mahdi Karim).
• Global map of dengue risk. Frequent or continuous risk = frequent outbreaks or ongoing transmission. Sporadic or uncertain risk = variable and unpredictable risk, country-level data are unavailable. Courtesy of the Centers for Disease Control and Prevention (CDC) (https://www.cdc.gov/dengue/areaswithrisk/around-the-world.html).

Contributor Information and Disclosures

Darvin Scott Smith, MD, MSc, DTM&H, FIDSA Chief of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, Kaiser Permanente Medical Group Darvin Scott Smith, MD, MSc, DTM&H, FIDSA is a member of the following medical societies: American Medical Association , American Society of Tropical Medicine and Hygiene , Infectious Diseases Society of America , International Society of Travel Medicine Disclosure: Nothing to disclose.

David J Mariano, BS, MS MD Candidate, University of California, San Diego, School of Medicine Disclosure: Nothing to disclose.

Micah Lynne Trautwein, BS MD Candidate, Geisel School of Medicine at Dartmouth Disclosure: Nothing to disclose.

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha , American College of Physicians , American Medical Association , Association of Professors of Medicine , Infectious Diseases Society of America , Oklahoma State Medical Association , Southern Society for Clinical Investigation Disclosure: Nothing to disclose.

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM Professor of Emergency Medicine, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine; Medical Director, Fast Track, Department of Emergency Medicine Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha , American Academy of Emergency Medicine , American Society of Tropical Medicine and Hygiene , International Society of Travel Medicine , Society for Academic Emergency Medicine , Wilderness Medical Society Disclosure: Nothing to disclose.

Patrick B Hinfey, MD Emergency Medicine Residency Director, Department of Emergency Medicine, Newark Beth Israel Medical Center; Clinical Assistant Professor of Emergency Medicine, New York College of Osteopathic Medicine Patrick B Hinfey, MD is a member of the following medical societies: American Academy of Emergency Medicine , Wilderness Medical Society , American College of Emergency Physicians , Society for Academic Emergency Medicine Disclosure: Nothing to disclose.

William H Shoff, MD, DTM&H Former Director, PENN Travel Medicine; Former Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians , American Society of Tropical Medicine and Hygiene , International Society of Travel Medicine , Society for Academic Emergency Medicine , Wilderness Medical Society Disclosure: Nothing to disclose.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha , American Academy of Pediatrics , American Society for Microbiology , Infectious Diseases Society of America , Pediatric Infectious Diseases Society , and Phi Beta Kappa

Disclosure: Nothing to disclose.

Hagop A Isnar, MD, FACEP Department of Emergency Medicine, Crouse Hospital

Hagop A Isnar, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians , American Medical Association , and Society for Academic Emergency Medicine

Thomas M Kerkering, MD Chief of Infectious Diseases, Virginia Tech, Carilion School of Medicine, Roanoke, Virginia

Thomas M Kerkering, MD is a member of the following medical societies: Alpha Omega Alpha , American College of Physicians , American Public Health Association , American Society for Microbiology , American Society of Tropical Medicine and Hygiene , Infectious Diseases Society of America , Medical Society of Virginia , and Wilderness Medical Society

Deborah Sentochnik, MD Consulting Staff, Department of Internal Medicine, Division of Infectious Disease, The Mary Imogene Bassett Hospital

Deborah Sentochnik, MD is a member of the following medical societies: American College of Physicians , Infectious Diseases Society of America , and Medical Society of the State of New York

Russell W Steele, MD Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics , American Association of Immunologists , American Pediatric Society , American Society for Microbiology , Infectious Diseases Society of America , Louisiana State Medical Society , Pediatric Infectious Diseases Society , Society for Pediatric Research , and Southern Medical Association

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Reference Salary Employment

Mary L Windle, PharmD, Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

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• v.104(1); 2021 Jan

Dengue Infections and the Surgical Patient

Umesh jayarajah.

1 Department of Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka;

Malintha Lahiru

2 Faculty of Medicine, University of Colombo, Colombo, Sri Lanka

Ishan De Zoysa

Suranjith l. seneviratne, associated data.

Supplemental materials

Dengue infections are increasing globally and account for significant morbidity and mortality. Severe dengue results in microvascular changes and coagulopathy that may make surgical intervention risky and the overall surgical management challenging. We outline the potential surgical manifestations and complications following dengue infections and describe the clinical, pathogenetic, diagnostic, and treatment aspects of dengue and surgical patients. The main surgical presentations were acute cholecystitis, acute pancreatitis, acute appendicitis, splenic rupture, bowel perforation, gastrointestinal bleeding, and hematomas. Dengue may also mimic an acute abdomen without any true surgical complications. A majority were treated nonoperatively. Misdiagnosis and unnecessary surgical intervention resulted in poor outcomes. Better knowledge of the potential surgical complications would help in early diagnosis, treatment, and referral to specialized centers and thus improve outcomes. A high degree of suspicion of dengue fever is necessary when patients in a dengue-epidemic area present with acute abdomen or bleeding manifestations. In endemic areas, early dengue antigen testing and abdominal imaging before surgical intervention may help in the diagnoses. Multidisciplinary team involvement with case-by-case decision-making is needed for optimal care.

INTRODUCTION

The dengue virus is a single-stranded non-segmented RNA virus, belonging to family Flaviviridae and genus Flavivirus . It consists of four serotypes. Dengue infections are increasing globally and account for significant morbidity and mortality. 1 Dengue is endemic in tropical and subtropical regions 2 , 3 and causes regular epidemics in countries within the tropical belt. 4 , 5 Dengue infections cause a wide spectrum of clinical manifestations, from an asymptomatic state to severe dengue with organ dysfunction and death. 1 , 6 Classical dengue fever is characterized by an acute onset of fever associated with headache, retro-orbital pain, severe arthralgia, and myalgia. The more severe forms are dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). 7 There has been a change in disease patterns with increasing involvement of gastrointestinal, hepatic, renal, hematological, neurological, respiratory, and cardiac systems. 8 – 15 Abdominal pain is a recognized feature during the critical phase of DHF. 1 , 7 Some patients with dengue may present with surgical complications such as gastrointestinal bleeding, acute pancreatitis, and splenic rupture, and others may mimic an acute abdomen without any true complications. 16 , 17

Severe dengue results in microvascular changes and coagulopathy, which may make surgical intervention risky and the overall surgical management challenging. Better knowledge of the potential surgical complications would help in early diagnosis, treatment, and referral to specialized centers and thus improve outcomes. Early identification of dengue in some patients presenting as acute abdominal emergencies to a surgical unit would help prevent unnecessary surgical interventions. We have critically analyzed the reported surgical complications following dengue and described the clinical, pathogenetic, diagnostic, and treatment aspects of dengue and surgical patients.

MATERIALS AND METHODS

An extensive search of the published literature before March 31, 2020 was carried out using PubMed, Embase, Scopus, and Google Scholar databases ( Supplemental Figure S1 ). We used the keywords “dengue” OR “dengue viral infections” OR “dengue infections” AND “surgical complications” OR “acute abdomen,” OR “appendicitis,” OR “pancreatitis,” OR “cholecystitis,” OR “splenic rupture” OR “gastrointestinal bleeding” OR “peritonitis” OR “gastrointestinal perforation” OR “peptic ulcer” OR “abdominal wall hematoma.” Only articles published in English language were considered. Initial screening for eligibility (based on titles, abstracts, and keywords of citations from electronic databases) was performed by two investigators. The full-text articles of all relevant records were then evaluated. In doubtful situations, the opinions of senior investigators were sought. All data relating to the clinical presentation, investigation, treatment, and outcomes of dengue in the surgical patient were extracted, categorized, tabulated, and presented descriptively. The studies describing all types of acute surgical presentations were pooled and described qualitatively. Case reports of surgical manifestations in dengue were described separately.

Common causes of acute abdomen in dengue infections.

Abdominal pain is a known clinical manifestation of DHF. An acute abdomen is less common and may mislead the clinician assessing the patient. In general, the studies described acute abdomen as rapid onset abdominal pain and fever as the main complaint with evidence of peritonism on examination. 17 Table 1 shows the case series and case reports of patients with acute abdomen and dengue. 16 – 38 A total of 22 studies were found; most were from South Asia (India [ n = 13], Sri Lanka [ n = 3], and Pakistan [ n = 3]) and a few were from Taiwan ( n = 3). A total of 9,365 dengue patients were studied and 1,501 (16%) presented with an acute abdomen. The patients’ age ranged from 10 to 76 years. The main causes were acute cholecystitis (45.4%, n = 681), acute pancreatitis (7.7% n = 116), acute appendicitis (2.7% n = 40), appendicular perforation (0.2% n = 3), splenic rupture (0.1% n = 2), and nonspecific peritonitis (3.1% n = 46). Twenty surgical procedures were carried out in these patients (appendectomy [ n = 10], cholecystectomy [ n = 6], laparotomy [ n = 3], and splenectomy [ n = 1]). The rest were managed conservatively using intravenous fluids, analgesics, and antibiotics. Most patients recovered, 30 died, and a prolonged hospital stay was reported in 39 patients.

Common causes of acute abdomen in dengue infections

n = dengue cases with acute abdomen; N = total number of DF/DHF cases; NA = not available.

Most of the studies described a minority of dengue patients having an acute abdomen, although a few described a higher prevalence. Shashirekha et al. 22 reported an acute abdomen in 85.5% of 214 dengue patients; a majority ( n = 122) developed acute acalculous cholecystitis. In the study by Jayasundara et al., 17 of 3,309 dengue patients, 17 developed acute abdominal symptoms (acute appendicitis [ n = 8], acute cholecystitis [ n = 5], acute pancreatitis [ n = 1], and nonspecific peritonitis [ n = 3]). Some studies described acute cholecystitis as the only surgical complication observed in dengue patients. Seeramulu et al. 24 reported 68 patients presenting with acute abdomen among 955 DHF patients from India over a 35-month period; all had acute cholecystitis and were managed conservatively. Four studies from India (Jhamb et al., 26 Laul et al., 27 Sharma et al., 29 and Chakravarti et al. 37 ) and one from Pakistan (Bhatty et al. 38 ) describe a total number of 121 dengue patients presenting with acute abdomen. All had acute acalculous cholecystitis and were managed conservatively.

Acute appendicitis associated with dengue infections.

Supplemental Table S1 outlines the reports of acute appendicitis in dengue. 39 – 46 Six of the eight patients were male. Common clinical presentations include fever, abdominal pain mainly in the right lower quadrant, and tenderness. Blood pressure, pulse rate, and respiratory rate were normal in all patients. On imaging, two had ultrasonic evidence suggesting appendicitis and in the others, the appendix was not visualized. Three were managed conservatively, and one had a planned interval appendectomy. One underwent reexploration 36 hours after appendicectomy because of increasing peritonism, but no bowel pathology was found. A ruptured appendicular mass was noted in another. Of the five where histology was available, two had a normal appendix and three had acute appendicitis with transmural neutrophil infiltration. All patients recovered, and the hospital stay ranged from 6 to 13 days.

Acute cholecystitis associated with dengue infections.

Supplemental Table S2 outlines the reports of acute cholecystitis in dengue. 47 – 60 The age of the patients was between 18 and 59 years, and 80% were female. Fever and right upper quadrant abdominal pain were seen in all, one patient was in shock, and the others were hemodynamically stable. Five had a positive Murphy’s sign, thrombocytopenia was seen in all, and alkaline phosphatase levels were high. One patient had an abnormal coagulation profile. Imaging (ultrasonography, computed tomography, or magnetic resonance imaging) showed acute acalculous cholecystitis in all. Of the 15 patients, four underwent cholecystectomy and the others were managed conservatively. One of the operated patients died after surgery following severe bleeding, and another had a perforated gall bladder at fundus/body junction. Histology showed changes of acute cholecystitis. Two of the patients were pregnant at the time of diagnosis and later went on to have successful vaginal deliveries.

Pancreatitis associated with dengue infections.

Supplemental Table S3 outlines the reports of acute pancreatitis in dengue. 61 – 78 Most of them were from Sri Lanka and India, age range was 10–66 years, and 12 of the 18 were male. Most had fever for > 3 days and epigastric pain, one had melena, and two had hematemesis at the time of admission. On examination, most had low blood pressure, a rapid pulse and respiratory rate, and tender epigastrium. All had low platelet counts and a raised serum amylase or lipase level or both. Liver enzymes were abnormal in most. Imaging (computed tomography, ultrasonography, or magnetic resonance imaging (MRI) scan of the abdomen) showed evidence of acute pancreatitis such as pancreatic edema and acute fluid collection in the majority. Some studies have failed to exclude/mention about other commonest causes of acute pancreatitis such as alcohol and gall stones. Nine developed complications such as bilateral massive pleural effusion, acute lung injury, gastrointestinal bleeding, and liver failure with cerebral edema. Two developed acute kidney injury, shock, and multi-organ dysfunction syndrome, and one patient died. All were managed conservatively. One needed a chest drain, and other interventions included mechanical ventilation, anti-liver failure regime, and blood product transfusion according to their need. Hospital stay ranged from 8 to 21 days.

Splenic rupture associated with dengue infections.

Supplemental Table S4 outlines the reports of splenic rupture in dengue. 79 – 94 A majority were from Asia, age ranged from 20 to 52 years, and 15 of 19 were male. All presented with fever for five or more days and abdominal pain, and a majority had signs of shock. Thrombocytopenia, low hemoglobin levels, and low packed cell volume were common. Liver enzymes were abnormal in five patients, and one had an abnormal clotting profile. Imaging showed a splenic hematoma or rupture. There were four deaths: three after a laparotomy and splenectomy and the other before surgical intervention (24 hours after admission). Of the other 15 patients, five were managed conservatively and ten had a laparotomy and splenectomy. There was normal splenic architecture with a capsular tear and no evidence of granuloma or malignancy. Hospital stay ranged from 7 to 30 days.

Other surgical manifestations in patients with dengue fever.

Supplemental Table S5 summarizes the other less common surgical manifestations in dengue. 16 , 23 , 95 – 114 Seven studies and several case reports/series were found mainly from Asian countries. A total of 296 patients were described. Upper gastrointestinal bleeding was reported in 245 patients (82.7%), and rectal bleeding was reported in 11 patients (3.7%). A total of 147 patients had upper gastrointestinal endoscopic findings of peptic ulcer, hemorrhagic/erosive gastritis, and duodenal and esophageal ulceration. Two patients needed a laparotomy, and 25 patients were managed with endoscopic injections. Two patients with rectal bleeding needed ligation of actively bleeding hemorrhoids. Apart from surgical interventions, a majority needed blood product transfusions, intravenous crystalloids, and intravenous proton pump inhibitors, and a few needed inotropic support and intravenous antibiotics.

Seven (2.4%) patients had a hollow viscous perforation. A previous history of peptic ulcer diseases was not mentioned in these cases. Three patients had a gastric perforation, and one had ileal and two patients had jejunal perforations. Almost all of them had air fluid levels and gas under diaphragm on abdominal X-rays. All needed emergency laparotomies for repair of the perforation.

Abdominal wall hematomas, predominantly in the rectus sheath, were reported in eight patients. These were managed with percutaneous drainage ( n = 1), ultrasound-guided aspiration ( n = 1), and surgical repair of inferior epigastric artery leak ( n = 1). The rest were managed conservatively. Three cases of retroperitoneal hematomas were reported, and one was managed with endovascular embolization under general anesthesia. Two psoas muscle hematomas were also reported, which were managed conservatively. Fourteen patients developed abscesses which were drained via an incision. Abdominal compartment syndrome was reported in two patients. Surgical wound bleeding was reported in two patients with thrombocytopenia, and one of the patients died.

Abdominal symptoms are not uncommon in dengue. 115 A large multicenter prospective study found nausea, vomiting, diarrhea, and abdominal pain in 35%, 20%, 16%, and 15% of dengue patients, respectively. 115 Right hypochondrial and epigastric tenderness were noted in 26% and 12% patients, respectively. Most of these abdominal symptoms were associated with severe forms of the disease. 115 An acute abdomen in dengue has been well-described. Most are single-center reports and involve a small percentage of the total cohort of dengue patients. Most are managed nonoperatively but may have a prolonged hospital stay with complications. Diagnosis of an acute abdomen can be difficult in a critically ill dengue patient. Worsening biochemical parameters, features of edema or inflammation on imaging, clinical deterioration with abdominal guarding, and rigidity would point to the diagnosis. However, similar imaging features may occur secondary to fluid leakage. With borderline presentations, repeated assessments by a multidisciplinary team of specialists would help decide if the patient requires any invasive procedures. The risks of any invasive procedure such as bleeding, secondary infections, surgical stress, and exposure to anesthesia should be weighed against the benefits of removing the source of sepsis or stopping further bleeding. The patients’ general health, their clinical condition, and comorbidities would impact on deciding whether invasive procedures should be considered.

Dengue infections may associate with true or apparent surgical acute abdomen because of several reasons. A true acute abdomen may occur as a complication of dengue fever (e.g., ruptured splenic hematomas, upper and lower gastrointestinal bleeding, and abdominal wall hematomas due to coagulopathy associated with dengue). Dengue infections may occur with simultaneous surgical disease (i.e., dual pathology). Such dual pathologies may occur either pathophysiologically unrelated to dengue (e.g., dengue patient with a perforation of a hollow viscus) or pathophysiologically related to it (e.g., or acute acalculous cholecystitis related to dengue). Furthermore, dengue fever may mimic a surgical acute abdomen and may present to surgical specialties. Moreover, surgical complications may be iatrogenic (e.g., abdominal compartment syndrome due to overzealous fluid resuscitation or gastric perforation related to nonsteroidal anti-inflammatory drug [NSAID] use). Some complications may occur because of complications of dengue and also iatrogenically (e.g., abdominal compartment syndrome due to rectus sheath hematoma 116 or due to excessive fluid resuscitation 117 ).

A substantial number of cases of acute abdomen seen in dengue are not because of true complications of dengue or dual pathology but because of clinicians getting deceived by the presentation of dengue to misdiagnose as an acute abdomen. 17 – 19 , 21 Therefore, it is important for clinicians (both physicians and surgeons) to be vigilant, specially in tropics, not only to avoid getting deceived by abdominal symptoms of dengue but also not to miss true acute surgical concerns associated with dengue.

The pathophysiological mechanisms for acute abdomen in dengue are poorly understood. 18 It may be because of direct viral invasion of the abdominal organs such as the appendix, gallbladder wall, pancreas, or spleen leading to inflammation and edema. 21 A systemic inflammatory response may be another reason. As the vast majority of patients who presented with an acute abdomen had features of DHF or DSS, the systemic inflammatory response and plasma leakage may have led to the edematous and inflammatory changes within organs. 18 , 21 An edematous appendix with luminal obstruction may precipitate a secondary bacterial infection and cause appendicitis. The pathogenesis of acute acalculous cholecystitis may be multifactorial. 18 The systemic inflammatory response, endotoxemia, cholestasis, secondary bacterial translocation, spasms of the ampulla of Vater, microangiopathic changes, and ischemia reperfusion injury may contribute. 18 Edema of splenic parenchyma due to fluid leakage or bleeding with expansion of a hematoma within a non-yielding splenic capsule may cause spontaneous splenic rupture. The systemic inflammatory response with coagulopathy may cause spontaneous bleeding or bleeding with trivial trauma, particularly when there is an underlying pathology such as mucosal ulceration.

Most cases of acute abdomen in DHF patients may be treated nonsurgically using fluids and symptom/supportive care. 19 , 21 Fever, body aches and pain, nausea, and vomiting could be treated symptomatically. 21 Aspirin and other NSAIDs should be strictly avoided. Intravenous fluids should be used and the patient kept nil orally. 118 Nasogastric decompression may be needed. Routine prophylactic antibiotics should be avoided but may be needed if the patient requires surgery or an invasive procedure. 17 , 118 , 119 Daily monitoring of packed cell volume, platelet counts, and coagulation tests should be carried out in all patients, and liver and renal function tests and blood gases in selected patients. 19 , 21 Occult or overt bleeding may need transfusion of packed red cells, fresh frozen plasma, and/or platelets. 19 , 21 , 119 Appropriate organ support may be needed in critically ill patients (e.g., ventilator support in patients with acute severe pancreatitis and acute respiratory distress syndrome). 21

Appendectomy and/or intravenous antibiotics is the treatment of choice for uncomplicated acute appendicitis. Surgery is the treatment of choice in the case of complicated appendicitis (due to rupture or peritonitis). In some centers, surgery is performed early for uncomplicated acute appendicitis to minimize local and systemic complications. 120 , 121 Surgery for acute appendicitis in the context of dengue fever has negative consequences. Khor et al. 19 and Shamim et al. 21 noted bleeding requiring blood transfusions, and a prolonged hospital stay was observed. 20 Furthermore, of the five patients for whom histology was available, two had a normal appendix and three had acute appendicitis with transmural neutrophil infiltration. Therefore, it is clear that the histopathology does not correlate with the clinical suspicion indicating how clinicians have been misled. Thus, with acute appendicitis in a dengue patient, nonsurgical management with intravenous antibiotics should be considered. If needed, a planned interval appendectomy may be considered.

Acute acalculous cholecystitis was more frequently noted than the calculous form. Acute calculous cholecystitis is managed conservatively followed by delayed cholecystectomy or by emergency cholecystectomy depending on the clinical findings and associated complications. 16 , 17 By contrast, acute acalculous cholecystitis is usually managed conservatively with supportive care and intravenous broad spectrum antibiotics and rarely needs cholecystectomy (in cases of gangrenous perforation). Such complications tend to occur in critically ill, hemodynamically unstable, or immunocompromised patients. They may not be fit for surgery and thus managed with minimally invasive procedures such as percutaneous aspiration and drainage. 16 , 17 Failing to diagnose and manage DHF in acute cholecystitis may lead to detrimental outcomes. Schmidt-Chanasit et al. 49 described a German patient who was initially diagnosed with acute acalculous cholecystitis and had a cholecystectomy. The diagnosis of DHF was missed, and the patient died of massive bleeding due to coagulopathy. Thus, DHF needs to be ruled out in such cases with cholecystitis, especially in dengue-endemic regions or in patients with recent travel history to such areas. As plasma leakage with peri-cholecystic edema is a known manifestation in DHF, there may be diagnostic difficulty in identifying acalculous cholecystitis in DHF by ultrasonography. Gallbladder wall thickening and peri-cholecystic edema may be noted in the leaking phase of dengue, raising a diagnostic dilemma among dengue patients. Therefore, clinicians should be cautious in diagnosing acute cholecystitis in dengue patients.

The main stay of management of acute pancreatitis is supportive care. Only very selected patients need surgery within the first few days of symptoms. Similarly, acute pancreatitis in a patient with DHF would only rarely need surgical intervention. Acute pancreatitis in a dengue patient is associated with prolonged hospital stay and complications such as acute lung injury, massive pleural effusion, gastrointestinal bleeding, and acute kidney injury. Because aggressive fluid resuscitation is needed in acute pancreatitis, DHF patients may be at risk of life-threatening fluid overload, especially in the convalescent phase. Intensive monitoring of fluid management may be needed in an intensive care unit setting.

A majority of the splenic ruptures in dengue presented as an emergency. Most needed surgical intervention (laparotomy and splenectomy). Splenic rupture may cause massive hemorrhage, especially in critically ill dengue patients with coagulopathy. In such patients, diagnosing intra-abdominal bleeding may be difficult by ultrasonography, and contrast enhanced computed tomography (CT)computed tomography (CT) scanning may be needed. At present, the exact etiology of splenic rupture in dengue is unclear. Fluid leakage may make lead to a congested/edematous spleen. Bleeding within the spleen (due to coagulopathy) precipitated by minor trauma may lead to rapid expansion of the hematoma. A rigid and non-yielding splenic capsule may trigger rupture of the otherwise normal spleen. Surgery is the mainstay of treatment, but minimally invasive procedures such as angioembolization of the splenic artery may be considered in patients not fit for surgery.

Uncomplicated appendicitis and cholecystitis in dengue usually resolve spontaneously. Wu et al. 18 found the gallbladder wall thickening to return to normal following recovery and cholecystectomy was not necessary. However, any complications such as gangrene or perforation would need surgical intervention. Performing surgery in a critically ill patient is challenging and has more complications. Minimally invasive approaches such as image-guided percutaneous drainage may be considered. 19 , 21 , 119 The bleeding tendency due to coagulopathy, both during and after surgery, is challenging to manage. At present, guidance on the perioperative correction of coagulopathy in critically ill dengue patients is limited. Thromboelastography with targeted correction would avoid excessive transfusion of blood products and fluid overload. Studies identifying factors that predict a failure of conservative management in acute abdomen in dengue are lacking. Thus decisions need to be taken on a case-by-case basis by a multidisciplinary team involving a physician, surgeon, critical care specialist, radiologist, and anesthetist. Postoperative complications such as intra-abdominal bleeding, wound hematoma, wound dehiscence, and surgical site infection have been reported in critically ill dengue patients. Thus, correction of coagulopathy should be carried out throughout the perioperative period.

Misinterpretation of acute abdominal signs/symptoms may occur frequently in dengue fever. 17 A prior history of gallstone disease or pancreatitis may confuse clinical decision-making. Furthermore, neutropenia, lymphocytosis, and thrombocytopenia may not be seen in all dengue patients at an early stage of disease. Jayasundara et al. 17 found the hematological changes of dengue fever in only two-thirds of patients at an early stage of the disease (i.e., in the first 24 hours). Misdiagnosing dengue as a surgical acute abdomen may result in significant morbidity and mortality. Surgical intervention during the critical phase of dengue may significantly compromise disease homeostasis. Failure of recognition of the critical phase of dengue may lead to DSS and even death. Also, it is important to note that dengue guidelines may not comply with other surgical disease guidelines. For example, limited fluid management in dengue does not comply with liberal fluid management in pancreatitis, making the management of pancreatitis in a dengue patient challenging. Intramuscular analgesia and NSAIDs which are commonly used analgesics for perceived acute abdomen may worsen coagulopathy and give rise to hematomas and other bleeding manifestations in a dengue patient. Furthermore, thromboembolism prophylaxis in surgical abdomens does not comply with DF management because of the bleeding tendency. A big risk with misdiagnosing dengue fever as an acute abdomen is an invasive surgical procedure, which may lead to severe complications. 17

Recommendations.

Dengue fever should be considered as a possible cause in patients from a dengue-endemic area presenting with acute abdomen or bleeding manifestations or patients with a relevant travel history. Such patients should be evaluated with basic hematological tests, early dengue antigen/serology, and imaging. Aspirin and other NSAIDs should be strictly avoided. Routine prophylactic antibiotics should be avoided, except when surgery is needed or invasive procedures are to be undertaken. Daily monitoring of full blood count, coagulation tests and, liver and renal function tests should be performed. Because surgery is risky and challenging in dengue patients, this should be reserved for highly selected patients with perforation, gangrene, and uncontrollable hemorrhage. Minimally invasive methods such as percutaneous drainage for abscesses and collections and angioembolization for splenic rupture or bleeding should be considered. Uncomplicated cases of acute cholecystitis, appendicitis, and pancreatitis should be managed conservatively. From a surgical point of view, unless there is gangrenous appendicular/gallbladder/viscus perforation, surgery could be avoided in the hyperacute setting. Thromboelastography with targeted correction of coagulopathy would be beneficial to avoid excessive transfusion of blood products and fluid overload. Decisions on care and invasive procedures should be taken on a case-by-case basis by a multidisciplinary team involving a physician, surgeon, critical care specialist, radiologist, and anesthetist.

We have outlined the surgical manifestations and complications following dengue infections and described the clinical, pathogenetic, diagnostic, and treatment aspects of dengue and surgical patients. Surgical manifestations are not uncommon, and a majority can be managed nonoperatively or by minimally invasive procedures. Common surgical manifestations include acute acalculous cholecystitis, acute pancreatitis, acute appendicitis, splenic rupture, bowel perforation, gastrointestinal bleeding, and hematomas. A high degree of suspicion of dengue fever is necessary when a patient from a dengue-endemic area presents with acute abdomen or bleeding manifestations. Misdiagnosis and unnecessary surgical procedures lead to poor outcomes. Such misdiagnoses can be prevented by evaluation with basic hematological tests, early dengue antigen tests/serology, and imaging. Multidisciplinary team involvement with case-by-case decision-making is needed for optimal care.

Supplemental figure and tables

Acknowledgments:.

The American Society of Tropical Medicine and Hygiene (ASTMH) assisted with publication expenses.

Note: Supplemental figure and tables appear at www.ajtmh.org .

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Epidemiology, Prevention & Control of Dengue Fever / DHF

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DENGUE HEMORRHAGIC FEVER

Flight Surgeon RSV Day I n t e g r i t y - S e r v i c e - E x c e l l e n c e ANGRC Joint Base Andrews UNCLASSIFIED.

2 Module 1 Pathophysiology Clinical course WHO classification & limitation Other manifestations Dr Suresh Kumar Infectious Diseases Unit Hospital Sungai.

III. Clinical Manifestations of Dengue and Dengue Hemorrhagic Fever CENTERS FOR DISEASE CONTROL AND PREVENTION.

(Pronounced as Dhen Gey)

Tropical Diseases Tropical diseases encompass all diseases that occur solely, or principally, in the tropics. In practice, the term is often taken to refer.

Controlling the risk of Chikungunya

Dengue Divya Bappanad Karapitya Hospital Galle, Sri Lanka.

Arthropod-borne Viruses

Management of Dengue Fever Dr David Tran 16/09/09.

Diseases are of various types.Presently the whole world is facing many new viral diseases such as Aids,Hepatitis,dengue etc. The global prevalence of dengue.

Dengue Hemorrhagic Fever Ms. Belton October 2014.

Judith Pinkham (Ph.D. Student) Walden University PUBH 8165 Instructor: Dr. Fredric Grant Summer 2013.

Arthropod-borne Viruses Arthropod-borne viruses (arboviruses) are viruses that can be transmitted to man by arthropod vectors. Arboviruses belong to three.

DENGUE: EPIDEMIOLOGY PART 1

Virus, Vector and Epidemiology

Common Viral Haemorrhagic Fevers include:  R R R Rift valley fever, Dengue fever, Lassa fever,.  E E E Ebola and marburg viral disease.  B B

1. Outline Introduction Epidemiology transmission Clinical manifestation Treatment Prevention 2.

VIRAL HEAMORRHAGIC FEVERS Ahmed Mandil Prof of Epidemiology Dept of Family & Community Medicine College of Medicine, King Saud University.

Dengue Virus Causes dengue and dengue hemorrhagic fever

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• Public Health

Dengue Is Rising in the U.S. Here’s How to Protect Yourself

D engue isn't normally a disease that people in the U.S. are concerned about. But cases in the U.S. this year are already closing in on the total number of cases in all of 2023 . More than 9.7 million cases have been reported in North and South America, which is twice as many cases as were reported throughout last year. The global picture is also alarming: The World Health Organization (WHO) reported 6.5 million cases in 2023, a record high.

Here's what to know about the rise of dengue in the U.S.

What is dengue?

The infection can have very different effects, ranging from no symptoms to death. But its nickname is break-bone fever, for the severe chills that accompany a fever that can spike as high as 104°F. While not fatal in most cases, it can be if it progresses to severe dengue, in which people develop dangerous bleeding as their blood vessels become compromised and start leaking, and clotting factors begin dropping.

Why cases are increasing

Since dengue is carried by the Aedes mosquito, anything that contributes to increased mosquito populations will also fuel rises in dengue (along with other mosquito-borne diseases like West Nile Virus, Zika, and malaria.) In 2023, 43 states in the U.S. reported West Nile cases, and so far in 2024, 11 states have. Mosquito populations are booming around the world, thanks to climate change, which is providing more of the warmer climates that mosquitos favor, as well as heavy rains, which provide the pools of water where the insects lay their eggs. The dengue virus is taking full advantage of these fertile circumstances.

Dr. Gabriela Paz-Bailey, chief of the U.S. Centers for Disease Control and Prevention’s (CDC) dengue branch, says there’s another reason for the dengue surge this year. Dengue outbreaks tend to be cyclical, caused by any combination of four main virus types, known simply as dengue 1, 2, 3, and 4. “People who get infected with one type of dengue are protected for a couple of years, but the immunity wears off and they are susceptible to getting another type,” she says. “In 2019, the large epidemic in the Americas was caused mainly by dengue 1 and 2, and now dengue 3 is circulating, so people have less immunity.”

Read More: The Scents and Colors Mosquitoes Are Drawn To

How many cases of dengue have been reported in the U.S.?

According to the CDC, more than 2,500 cases have been reported so far this year. About 800 of them were contracted when people were traveling abroad, and the rest were locally transmitted. Most of the U.S. cases occur in Puerto Rico, where high concentrations of mosquitos led health authorities there to declare dengue a public health emergency in March.

Infectious disease experts say that most local cases in the continental U.S. likely occur when a mosquito that has bitten an infected recent traveler then passes the disease to someone else. In the continental U.S., locally acquired cases of dengue have been reported in Florida.

“The reservoir is already seeded, and mosquito populations [in the continental U.S.] already have [the virus],” says Dr. Robert Murphy, professor of infectious diseases and executive director of the Robert J. Havey, MD Institute for Global Health at Northwestern University. “There is very little in the way of stopping it, other than being more aware and ready to diagnose cases.”

What is the government doing?

The CDC issued a Health Alert Network advisory on June 25 urging doctors to be aware of the rise in cases and to test people who report symptoms of fever and chills and who have recently traveled, especially to parts of the world where dengue is endemic, like Puerto Rico, the U.S. Virgin Islands, Micronesia, the Marshall Islands, and Palau. Identifying people who are infected can also help limit spread of the virus if they restrict their time outdoors when they might be bitten by local mosquitos that would then become additional vectors for the disease.

Paz-Bailey says the blood test is available at public health labs and a few commercial labs. For now, “there is no expectation that there will be large outbreaks within the continental U.S.," she says. "But there can be small chains of transmission, so we need to do everything we can so clinicians can identify dengue early, order the right tests, and help everyone protect themselves.”

Is there a treatment for dengue?

There is no antiviral treatment; care involves lowering fever and making sure people remain hydrated. Doctors should closely monitor patients who have other health conditions, such as heart disease or diabetes, as the infection can make those conditions worse. “Dengue is a systemic illness, and the virus can hit any part of the body,” says Dr. Sharon Nachman, professor of pediatrics at Stony Brook Children’s Hospital. “There is no part of you dengue doesn’t touch.”

While most people will recover from the infection after two to seven days, some will develop severe dengue and require hospitalization. In those cases, patients continue to vomit, feel extremely fatigued and lethargic, and develop dangerous bleeding that can lead to shock. Doctors should watch for these warning signs 24 to 48 hours after the fever subsides.

Is there a dengue vaccine?

There is a vaccine, Dengvaxia , approved in the U.S., but only for children 9 to 16 years old who have already had a dengue infection and lived in areas where the disease was endemic. The shot involves three doses given six months apart. The vaccine, made by Sanofi, was approved in 2019 , but because of the small population it targets, demand for it has been low. A spokesperson said the company has decided to stop manufacturing the vaccine by 2026 “due to low global demand.”

Other countries around the world have approved vaccines that the WHO recommends and that can protect against severe disease, but those are not approved in the U.S. One, made by a Japanese manufacturer, is effective against dengue 1 and dengue 2 but not against dengue 3, and the company is currently studying its effectiveness against dengue 4, says Paz-Bailey.

Read More: Why You Can Get So Many Diseases from Mosquitoes

If I’ve had dengue before, do I have immunity?

Yes, to a certain extent. But because there are four types of dengue, people can be infected multiple times and become equally sick if a different version of the virus infects them each time. And the dengue virus has a unique feature that makes repeated infections potentially more severe. “Something interesting happens after you get infected the first time,” says Paz-Bailey. “After the first infection, the antibodies you develop actually help the virus infect cells during a second infection, which results in more virus produced, a higher viral load, and a higher risk of severe dengue. Because of how the immune system behaves, the antibodies you develop after a first infection will not help you during a second infection, but may actually make that infection worse.”

Is there anything I can do to protect myself?

The best advice is to avoid getting bitten by a mosquito in the first place, since so many of them now carry different diseases. Using insect repellent, and wearing long sleeves and long pants to cover any exposed skin, can protect them from feeding off your blood. And if possible, Paz-Bailey suggests using an air conditioner and closing windows to prevent mosquitos from flying indoors. Getting rid of their breeding grounds is also critical. "Inspect your home for any standing water and empty, scrub and turn over any receptacles that can hold water," she says. "Even a bottle cap and can hold 100 mosquito eggs.”

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Dengue reaches historic levels in the Americas and closer to home

Mosquitoes are infecting people across the Americas with dengue at historic levels and U.S. travelers are bringing the potentially life-threatening virus home with them. The alarming rise in infections has spurred American health officials to warn about the risk .

In South America, cases of the tropical disease are now decreasing during cooler winter months after record numbers of people were sickened by dengue. But experts warn more people will get infected across Central America, Mexico and the Caribbean as summer and hurricane season take their holds in the Northern Hemisphere.

While risk of local transmission in the contiguous U.S. remains low, officials are concerned about the extent to which the country will be able to harbor dengue in the years ahead. Climate change is creating scorching droughts followed by intense rainfall ‒ which could sustain dengue’s transmission vector, the pesky Aedes egypti mosquito, never fully eradicated from the United States.

A. egypti loves to feast on people’s blood and dense urban areas offer opportunities for it to spread, posing a risk for sustained local dengue transmission in this country.

“It’s to be expected that we’re going to have increases,” said Dr. Albert Ko, an infectious disease epidemiologist at the Yale School of Public Health, who specializes in dengue fever. Climate change, he added, “will drive the expansion of dengue and other viruses transmitted. I think the question is, what do we do about it?”

The number of people in the U.S. and its territories sickened by dengue in just the first half of 2024 has surpassed any year in the last decade. The cases are occurring via travel, with people bitten by the pesky Aedes egypti mosquito in foreign countries, as well as in Puerto Rico, where local transmission led officials to declare a public health emergency in March .

In late June, the Centers for Disease Control and Prevention issued a health advisory warning about increased risk of dengue in the U.S.

Recent extreme weather events, such as Hurricane Beryl , pose additional risks with just tiny amounts of standing water making suitable bases for mosquitoes to breed and spread dengue.

Dengue symptoms, cause

Most people who get dengue never show symptoms. But those who do can get high fever, body aches, nausea and rash. Most recover in a couple weeks, according to the World Health Organization .

Some infections are so severe they can require hospitalization or even, in rare instances, kill. Severe dengue occurs in about 1 in 20 infections and can include vomiting, restlessness, rapid breathing and bloody gums, nose or stool. Infants, elderly people and pregnant women are at increased risk for severe disease, the CDC said.

Severe dengue is more likely with repeat infections.

There are four different types of dengue virus, with immunity to each lasting only a few years.

The same A. egypti species that caries dengue is notorious for triggering historic epidemics of deadly diseases such as yellow fever and Zika.

While mosquitoes carrying dengue can infect people, infected people – including those who show no symptoms – can also introduce the virus to local mosquito populations. And once infectious, a mosquito can transmit the virus for the rest of its short life, WHO said. This helps sustain dengue’s spread.

Spread fast and far

A. egypti mosquitoes can lay eggs in standing water as small as a bottle cap, pipes, broken pots or anywhere that collects water.

“They’re really good at being everywhere,” said Dr. Gabriela Paz Bailey, the CDC's dengue branch chief.

Dengue’s increase is apparent globally, after international campaigns to eradicate dengue and the A. egypti in decades past failed. In 2000, there were half a million dengue cases. By 2019, there were 5.2 million. The year 2023 reached a historic high of over 6.5 million cases, with 7,300 dengue-related deaths.

“It’s increasing rapidly, and it’s also appearing in areas that didn’t have dengue before,” said Paz Bailey, who is based in San Juan, Puerto Rico.

The U.S. has seen nearly 2,700 cases so far this year, CDC data shows. The majority of those infections have been in Puerto Rico, during what’s normally considered the island’s dry season.

Nearly 900 Americans have contracted dengue while traveling abroad, returning to states such as Florida, Texas, Arizona and California, where A. egypti mosquitoes thrive and therefore the potential for local transmission is high. Northern states have also seen cases, with over 140 in New York and 35 in Illinois. Neither state is suitable for A. egypti.

Paz Bailey said increased travel since the COVID-19 pandemic has helped drive up infections. In Puerto Rico, she said dengue rates are high in part because immunity provided by the 2015-2016 Zika epidemic has waned. Meanwhile, the type of dengue virus is shifting, from dengue 1 to dengue type 2 and 3, she said.

Risk ahead in U.S.

Much of the southern U.S. has environments that allow A. egypti mosquitos to thrive. Climate change is expanding the range of such hot and humid habitats, officials said.

“We have to recognize the unique vulnerability to this part of the country,” Dr. Peter Hotez, co-director of the Texas Children's Hospital Center for Vaccine Development and dean of Baylor College of Medicine's National School of Tropical Medicine, told USA TODAY.

Along with climate change, he points to urbanization in areas such as Houston, a sprawling metropolitan area that's the nation's fourth-largest city, and poverty that can help foster dengue’s reintroduction into the U.S.

Hotez said a discarded tire can be the “Ritz-Carlton” for A. egypti mosquitoes, which are endemic throughout the region. Additionally, Texas' international airports allow travel to and from areas with widespread local transmission.

In muggy Houston, the recent effects of Hurricane Beryl, coupled with severe heat for days, are ideal scenarios for dengue and other vector-borne diseases to thrive , state officials said. There have been 10 cases of dengue in Texas this year, state health officials said. So far, all these are believed to be travel-related, not locally transmitted.

The U.S. currently doesn’t have a widely available vaccine to prevent dengue. The best way to prevent illness is to protect against mosquito bites, which can occur day and night.

Hotez said before he sets out on his morning walks, he covers himself in sweatpants and a sweatshirt, and sprays insect repellant to reduce mosquito exposure.

• Case Report
• Open access
• Published: 16 July 2024

Airway breathing circulation dengue: a case of multifactorial shock due to major trauma and severe dengue infection

• Bui Hai Hoang 1 , 2 ,
• Thomas Vu Tang 3 ,
• Nguyen Dai Nghia Phan 2 ,
• Anh Dung Nguyen 1 &
• Michael Minh Quoc Dinh 4  

International Journal of Emergency Medicine volume  17 , Article number:  90 ( 2024 ) Cite this article

66 Accesses

Metrics details

Dengue is the most common arboviral illness reported globally, endemic to most tropical and sub-tropical regions of the world. Dengue Shock Syndrome is a rare complication of severe Dengue infection resulting in haemorrhagic complications and refractory hypotension. We report on a case of severe dengue diagnosed in a patient with major trauma and illustrate some of the potential challenges and considerations in the clinical management of such cases.

Case Presentation

A 49-year-old female presented following a road trauma incident with multiple abdominal injuries requiring urgent laparotomy. Her recovery in Intensive Care Unit was complicated by the development of Dengue Shock Syndrome characterised by a falling haemoglobin and platelet count, multiorgan dysfunction and prolonged hospital stay.

Conclusions

Dengue Shock Syndrome may complicate fluid management and bleeding control in major trauma cases. Awareness of Dengue, particularly in endemic areas and returned travellers may help facilitate early diagnosis and management of complications.

Introduction

Dengue is the most common arboviral illness reported globally, endemic to most tropical and sub-tropical regions of the world [ 1 ]. The Dengue flavivirus is transmitted by the A aegypti mosquito with an incubation period of one to two weeks. Although most dengue cases result in a mild, self-limiting febrile illness, around 5% develop severe dengue, characterised by severe vomiting, haemorrhagic manifestations (petechial rash, gastrointestinal bleeding), which can progress to dengue shock syndrome (DSS) in 1% of dengue cases. DSS is characterised by refractory hypotension and multiorgan dysfunction. with a mortality of around 25% [ 2 ].

There are no reports of intercurrent severe dengue infection complicating cases of major trauma. Such cases may become more prevalent in the coming decade as cases of Dengue continue to increase due to urbanisation, international travel and climate change[1]. We report on a case of severe dengue diagnosed in a patient with major trauma and illustrate some of the potential challenges and considerations in the clinical management of such cases.

A 49-year-old female self-presented to an emergency department of a tertiary hospital in Hanoi Vietnam with severe right flank pain after being struck by a motorcycle as a pedestrian. The speed of the motorcyclist was not known. The initial triage was ESI (Emergency Severity Index) category 2. Her medical background comprised chronic hepatitis B infection with no other known comorbidities. On examination, her Glasgow Coma Scale (GCS) was 15, blood pressure was 120/70 mmHg, oxygen saturations were 98% on room air, afebrile, respiratory rate 28 breathes/min, and heart rate 89 bpm. She had extensive bruising and tenderness to the right abdomen on examination. Within 30 min of her initial assessment, her blood pressure fell to 80/50 mmHg and pulse increased to 110 bpm. Trauma CT imaging (head, cervical spine, chest, abdomen and pelvis) revealed grade V right kidney injury, subcapsular laceration grade III liver injury (Fig.  1 ), fractures of ribs 10, 11, and 12 on the right, and fractures of vertebrae T12 to L2 with no clinical evidence of spinal cord injury. She did not have a head injury. Injury Severity Score was estimated to be 34.

Abdominal CT (portal venous phase) imaging demonstrating high grade right kidney laceration with haemoperitoneum and liver laceration

She was given 2 L of crystalloid, 2 units of fresh frozen plasma and 2 units of packed red cells in the emergency department prior to CT imaging and before urgent transfer to the operating room for emergency trauma laparotomy with repair of descending duodenum (segment D2), formation of jejunostomy and right total nephrectomy followed postoperatively by Intensive Care Unit admission. Her liver laceration was managed conservatively.

On day 4 of admission, the patient developed a fever of 38.7 degrees Celsius which persisted to day 7, when her fever reached 40 degrees C despite prophylactic broad-spectrum antibiotics. There was no rash or gastrointestinal manifestations such as diarrhoea. During this time, her haemoglobin had dropped from 124 to 70 g/L, platelets from 368 to 62 g/L, white cell count decreased from 24.3 to 6.4 g/L, haematocrit fell from 0.38 to 0.21, serum creatinine increased from 72 to 124 umol/L and serum urea increased from 8.8 to 20.8 mmol/L. Her lactate and fibrinogen levels remained stable, changing from 3.6 to 3.1U/L and 2.43 to 3.78 g/L respectively. Blood pressure in ICU dropped from 115/60 to 90/60 mmHg on day 7 of admission.

Dengue was suspected once she developed fever because of a concurrent seasonal outbreak of Dengue in Hanoi at the time and her NS1 antigen test returned positive for Dengue virus on day 4 post operation. Serum IgM and IgG levels for Dengue were also positive. There was no history of prior history of Dengue vaccination. On day 7 she was diagnosed with DSS. Lower limb ultrasound demonstrated bilateral deep vein thromboses on Day 8. Blood cultures on the same day were positive for Acinetobacter calcoaceticus-baumannii complex which was resistant to ceftazidime and meropenem but susceptible to trimethoprim-sulfamethoxazole, which was used in this case. Progress CT imaging revealed no further intraabdominal bleeding. Her hypotension was responsive to noradrenaline, which was maintained at 0.15 microg/kg/min. Platelet and pack cell transfusion was commenced, however she developed ascites and pulmonary oedema on day 10 which was treated with a trial of frusemide but subsequently became anuric on day 12 requiring continuous venovenous hemofiltration. Her ICU stay was further complicated by Candida Albicans fungemia which was treated with voriconazole. Her renal function and urine output eventually normalised on day 14 and she was extubated on day 19 of admission and eventually discharged home on day 30.

The differential diagnoses of shock during the acute and perioperative phase of major trauma in the context of this case were broad and multifactorial, including ongoing haemorrhage, sepsis due to intraabdominal collections or nosocomial pneumonia, systemic inflammatory response syndrome, Disseminated Intravascular Coagulopathy, fat embolism and concurrent infections [ 3 ]. In this instance, the patient developed DSS complicated by multiorgan dysfunction and sepsis which complicated her recovery.

DSS may affect injury management and complicate recovery on a number of levels. Firstly, diagnosis of DSS may be delayed leading to inappropriate diagnosis of post operative haemorrhage and inappropriate fluid resuscitation. This was an important consideration in this patient whose blood pressure and haemoglobin dropped postoperatively coinciding with the onset of severe dengue. It was not known when the patient contracted the infection, however, with an incubation of around a week, this likely occurred prior to hospital admission. Secondly, any fluid resuscitation for presumed bleeding may further exacerbate intravascular fluid shifts leading to ascites and pulmonary oedema. Thirdly, thrombocytopaenia may exacerbate perioperative and postoperative bleeding and reduce rates of successful non-operative management of solid organ injuries such as liver lacerations observed in this case [ 4 ]. Fourthly, the relative neutropenia that may develop as part of DSS may increase susceptibility to nosocomial infections. All these factors can confound the management of complex polytrauma cases.

The pathogenesis of DSS involves increased vascular permeability, thrombocytopaenia and leukopenia which can complicate ongoing recovery from major trauma. Hypovolemic shock seen in DSS results due to gastrointestinal losses due to vomiting or bloody stools associated with severe dengue in addition to fluid shifts, ongoing bleeding and multiorgan dysfunction [ 5 ]. This patient faced several challenges with respect to fluid management. Initially, she required management of haemorrhagic shock secondary to major trauma. However, with the onset of DSS, judicious administration of intravenous fluids in conjunction with vasopressor support were required to manage third spacing fluid shifts and pulmonary oedema. Our patient tested positive for both Dengue IgM and IgG, suggesting previous infection. It is known that previous Dengue Infection increases the risk of severe dengue with subsequent infections with a different serotype of Dengue virus [ 2 ]. Infection with a different serotype of Dengue virus in secondary infection was thought to result in highly specific antibodies that can bind to the virus but lack neutralising capacity [ 1 ]. These antibodies trigger Fc-gamma receptor-mediated antibody-dependent enhancement (ADE) and a cytokine storm, resulting in more severe illness [ 1 ]. The patient’s clinical presentation is supportive of this mechanism, having developed severe illness with a background of prior infection.

We report a rare case of multi-factorial shock, involving both major trauma and concurrent severe dengue infection. Judicious fluid management, vasopressor and renal support, and diligence in suspecting concurrent infection in such cases is important in achieving good patient outcomes. Dengue complicating acute injury should be considered in returned travellers and those living in endemic areas.

Data availability

No datasets were generated or analysed during the current study.

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Bui Hai Hoang: Research idea, analyzing clinical case participated in writing, editing manuscript. Thomas Vu Tang: Participated in writing, analyzing clinical cases, and editing English. Nguyen Dai Nghia Phan: Participated in clinical case analysis, and editing the manuscript. Anh Dung Nguyen: Participated in clinical case analysis, writing and editing the manuscript. Michael Dinh: Participated in clinical case analysis, writing and editing the manuscript.

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Hoang, B.H., Tang, T.V., Phan, N.D.N. et al. Airway breathing circulation dengue: a case of multifactorial shock due to major trauma and severe dengue infection. Int J Emerg Med 17 , 90 (2024). https://doi.org/10.1186/s12245-024-00673-7

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Recent dengue infection may increase odds of COVID infection, hospital care

In Open Forum Infectious Diseases , researchers link dengue infection to a slightly increased risk of subsequent COVID-19 infection and a significantly higher risk of severe COVID-19 illness and hospitalization.

For the  study , investigators at the National Centre for Infectious Diseases in Singapore used data from national registries to evaluate COVID-19 infections and outcomes among almost 3.4 million adults from July 2021 to October 2022, when waves of the SARS-CoV-2 Delta and Omicron variants followed a dengue outbreak.

"Elucidating whether prior dengue potentially confers cross-protection against COVID-19 is of public health importance in tropical countries at-risk of overlapping dengue and COVID-19 epidemics," the authors wrote.

Triple the risk of severe COVID-19

In total, 13,434 dengue infections were documented, and nearly all (96.8%) were mild and didn't require hospitalization. 

During the same period, 1,253,520 subsequent COVID-19 cases were recorded, of which 9.2% occurred during the Delta wave and 90.8% amid Omicron. Most cases (82.3%) occurred in people who received a booster vaccine dose before infection. The average time from dengue to COVID-19 infection was 94.7 days.

Elucidating whether prior dengue potentially confers cross-protection against COVID-19 is of public health importance in tropical countries at-risk of overlapping dengue and COVID-19 epidemics.

Dengue infection was tied to a modestly elevated risk of subsequent COVID-19 infection (adjusted hazard ratio [aHR], 1.13) and a more than triple risk of severe COVID-19 (aHR, 3.39) and hospitalization (aHR, 3.25) across vaccination subgroups.

In adults without previous dengue, the unadjusted incidence of COVID-19 was 894.7 cases per million person-days, compared with 1,537.5 per million person-days among those with dengue.

A lower risk of severe COVID-19 reinfection and hospitalization was seen with a longer time since dengue infection, with lower risk of COVID-19 hospitalization among those with dengue 1 or 2 years (adjusted odds ratio [aOR], 0.39) and 3 or more years before (aOR, 0.33), versus less than 1 year before.

"Increased risk of adverse COVID-19 outcomes following dengue infection may potentially be attributable to overlapping sociodemographic factors predisposing at-risk individuals to both dengue infection and severe COVID-19; or may suggest the possibility of increased risk of subsequent severe COVID-19 through an antibody dependent-like enhancement mechanism, after a preceding infection," the researchers wrote.

FDA OKs temporary import of Portuguese syphilis drug for newborns to ease US shortage

Mark Cuban's Cost Plus Drug Company announced yesterday that it has received temporary approval from the US Food and Drug Administration (FDA) to import penicillin G benzathine into the United States to ease demand-driven shortages for babies born with syphilis.

The drug is produced by Portugal-based Atral Laboratories under the Lentocilin brand name, according to a June 11 letter from the company to healthcare providers. The adult and pediatric versions of the drug in the United States are made by Pfizer as Bicillin-LA.

Lentocilin is available as a powder and diluent for injection. In its letter, the company noted some differences between its drug and the US version, including labeling and the fact that it contains soy, which may cause allergic reactions in some people. It also said the packaging doesn't contain a warning that the drug could be fatal if given by other routes, but that the prescribing information emphasizes that Lentocilin must be administered only by deep muscular injection.

On X yesterday , Cuban said the shortage of the drug for babies with syphilis was worsened by the high price for the drug, which will be available through Cost Plus as a fraction of the cost, just $15 instead of $500. 

Second temporary import approval for syphilis treatment

Lentocilin is the second drug the FDA has approved for temporary import to address US shortages. In January it allowed the temporary import of a similar drug from a French pharmaceutical company that makes penicillin G benzathine, which in the United States is made by Pfizer under the Extenciline brand name.

US syphilis rates are climbing, with notable spikes in 2020 and 2021. Rates of infections in newborns are 10 times higher than the 10-year average, the highest in three decades. 

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Paratek Pharmaceuticals today announced promising findings in a phase 3 clinical trial that compared its broad-spectrum antibiotic omadacycline to moxifloxacin for treating patients with moderate to severe community-acquired bacterial pneumonia (CABP). 

The Food and Drug Administration (FDA) approved the drug, a modified tetracycline antibiotic sold under the Nuzrya brand name, in 2018 for the treatment of CABP and skin infections. Omadacycline is designed to overcome tetracycline resistance and has shown activity against both gram-positive and gram-negative bacteria, including antibiotic-resistant strains. 

In the lead-up to FDA approval, clinical trials had shown that the drug was noninferior to moxifloxacin for treating CABP. 

Support for updating clinical guidelines

In a press release , Randy Brenner, MS, Partek's chief development and regulatory officer, said the new trial confirms that omadacycline is an effective and well-tolerated option for treating CABP. "With the completion of this post-marketing study, our clinical study database now includes data from 1,438 pneumonia patients and is the largest clinical trial dataset in pneumonia across all antibiotics approved by the FDA in the last decade," he said.

He said the company believes the latest findings support a potential update to American Thoracic Society/Infectious Diseases Society of America guidelines for treating CABP. Paratek said the firm will submit the results for publication.

Two phase 3 studies in 2019 showed the omadacycline was just as effective as standard antibiotics for treating CABP and skin infections, but some experts said the clinical value of the new drug is unclear.

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Chest radiographic presentation in patients with dengue hemorrhagic Fever

Affiliation.

• 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, 123 Dabi Road, Niaosung Shiang, Kaohsiung, Taiwan.
• PMID: 17690401

There has been no previously reported case series study regarding chest radiographic (CXR) presentations in dengue hemorrhagic fever (DHF) patients. We retrospectively studied 363 DHF patients from June to December 2002 in southern Taiwan, and a total of 468 CXRs were obtained and reviewed. More than 50% of these showed abnormalities after the 3rd day, with infiltration only and small pleural effusion as the major findings. Progressive changes during the first week and improvements during the second week were observed in these abnormal CXRs. The CXR presentation was also significantly correlated with laboratory findings (white blood cell count, platelet levels, activated partial thromboplastin time, and alanine aminotransferase and albumin levels), as well as the clinical course (renal insufficiency, liver function impairment, upper gastrointestinal bleeding, combination bacterial infection, and duration of admission) and outcome (mortality). The CXR may therefore be a modality for evaluating the clinical course of DHF and should be made during first week after the onset of illness.

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Dengue: An Overview of Precautions, Symptoms, Common Tests, and Neurological Effects

Curated By : Swati Chaturvedi

Last Updated: July 15, 2024, 14:54 IST

New Delhi, India

Dengue cases peak between July and November.

Understanding the precautions, symptoms, diagnostic tests, and potential neurological effects of dengue is crucial for effective prevention and management

Dengue fever, caused by the dengue virus and transmitted primarily by Aedes mosquitoes, is a significant global health concern, particularly in tropical and subtropical regions. Understanding the precautions, symptoms, diagnostic tests, and potential neurological effects of dengue is crucial for effective prevention and management.

Dengue symptoms typically appear 4-10 days after being bitten by an infected mosquito and can range from mild to severe. Dr Vigyan Mishra, Chief of lab, Neuberg Diagnostics, Noida shares common symptoms that include:

• High Fever Sudden onset of high fever, often reaching up to 104°F (40°C).
• Severe Headache Intense pain behind the eyes.
• Joint and Muscle Pain Severe muscle and joint pain, often referred to as “breakbone fever.”
• Rash A characteristic rash may appear a few days after the fever starts.
• Nausea and Vomiting Gastrointestinal symptoms like nausea, vomiting, and abdominal pain.
• Fatigue Severe fatigue and weakness can persist for weeks after the acute phase.
• Bleeding Mild bleeding (such as nosebleeds, gum bleeding, or easy bruising) may occur in some cases.

In severe cases, dengue can progress to dengue haemorrhagic fever (DHF) or dengue shock syndrome (DSS), which are life-threatening conditions requiring immediate medical attention.

Neurological Effects

While dengue is primarily known for its systemic symptoms, it can also have neurological effects, though these are relatively rare. Dr Vinit Banga, Director, Neurology, Fortis Hospital, Faridabad shares neurological complications associated with dengue that would include:

• Dengue Encephalitis Inflammation of the brain can lead to symptoms like seizures, altered mental status, and focal neurological deficits.
• Meningitis Inflammation of the membranes surrounding the brain and spinal cord, causing headache, neck stiffness, and photophobia.
• Acute Disseminated Encephalomyelitis (ADEM) ADEM is a rare inflammatory condition affecting the brain and spinal cord, resulting in symptoms such as weakness, sensory changes, and impaired coordination.
• Guillain-Barre Syndrome (GBS) This autoimmune disorder can be triggered by dengue, leading to muscle weakness, tingling, and paralysis.
• Neuropathy Peripheral neuropathy, characterized by numbness, tingling, and pain in the limbs, can also occur.

Understanding the potential neurological effects of dengue is essential for early detection and appropriate management. Patients exhibiting neurological symptoms should receive prompt medical evaluation and care to prevent complications.

Precautions

Preventing dengue largely revolves around avoiding mosquito bites and reducing mosquito populations. Dr  Mishra shares key precautions:

• Using Insect Repellents Applying insect repellents containing DEET, picaridin, or oil of lemon eucalyptus can help deter mosquito bites.
• Wearing Protective Clothing Long-sleeved shirts, long pants, socks, and shoes can reduce skin exposure.
• Mosquito Nets and Screens Using mosquito nets while sleeping, especially in areas without air conditioning or screened windows, is effective.
• Eliminating Breeding Sites Regularly emptying, cleaning, or covering containers that hold water (such as buckets, flower pots, and tires) can reduce mosquito breeding sites.
• Community Efforts Participating in community clean-up campaigns and reporting standing water to local authorities can help control mosquito populations.

Common Tests

Diagnosing dengue involves clinical evaluation and laboratory tests. Dr Mishra explains common diagnostic tests:

• NS1 Antigen Test Detects the presence of the dengue virus antigen and is most effective in the early stages of infection.
• PCR Test Polymerase chain reaction (PCR) tests detect viral RNA and are highly specific, and useful for confirming dengue infection.
• IgM and IgG Antibody Tests These tests detect antibodies produced in response to the infection. IgM antibodies appear early, while IgG antibodies indicate past or recent infection.
• Complete Blood Count (CBC) A CBC can help identify dengue by revealing low platelet counts (thrombocytopenia) and other characteristic changes in the blood.

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• Section 11 - General Approach to the Returned Traveler
• Section 11 - Perspectives : Screening Asymptomatic Returned Travelers

Rapid Diagnostic Tests for Infectious Diseases

Cdc yellow book 2024.

Author(s): Elizabeth Rabold, Jesse Waggoner

Rapid diagnostic tests (RDTs) refer to a group of diagnostics categorized by performance characteristics rather than the specific analyte or test platform. Such assays have relatively short performance times, provide results to inform clinical decision making, and enable management at the point-of-care (POC). RDTs are available in a variety of test formats and platforms and for various detection targets. RDTs are designed for detecting pathogen-specific antigens or nucleic acid sequences, as well as host antibody responses against certain pathogens ( Table 11-05 ).

To select an appropriate RDT, factor in the pros and cons of the different analytes, timing of patient presentation, and specifics of the disease or syndrome under investigation (e.g., acute versus chronic infection). RDTs described here include any pathogen-specific or syndrome-based test that can be incorporated into a POC testing protocol for a given infection or clinical syndrome.

Tests that meet the definition of an RDT may be performed under a certificate of waiver (so-called “waived” tests) indicating they are simple to perform with a low risk for yielding an incorrect result. The certificate of waiver is specific to the United States. Nevertheless, some of its requirements are useful when considering using RDTs in international settings. For example, although mandated personnel requirements for such tests are minimal, testers must be trained and document proficiency on use of the assay. Waived tests can only be performed on unmodified specimens (whole blood, saliva, urine) according to the most recent manufacturer recommendations. Deviations from the specimen type or manufacturer protocol make the test high-complexity and require that it be performed in a dedicated laboratory setting. Finally, RDT reagents might have specific storage requirements and a limited shelf life. These factors impact accuracy of the test and necessitate oversight and quality assessments to ensure proper performance.

Some tests with performance characteristics of an RDT might not be readily compatible with POC testing. For instance, an increasing number of waived, sample-to-answer molecular diagnostics (nucleic acid amplification tests) are becoming available. At a given institution, these assays might only be performed in a central laboratory at specific times, thereby limiting their applicability at the POC. These assays typically must be performed with dedicated bench-top equipment; adding this capacity at clinical sites, therefore, might not be feasible.

Table 11-05 Common rapid diagnostic test analytes & testing formats: advantages & disadvantages

Abbreviations: LAMP, loop-mediated amplification; PCR, polymerase chain reaction; RPA, recombinase polymerase amplification; RT, reverse transcription; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2

Rapid Diagnostic Tests for Clinical Syndromes

RDTs, including multiplex molecular panels ( Table 11-06 and Table 11-07 ), are available for many common clinical syndromes among travelers, the etiologies of which can overlap substantially with those of non-travel–associated syndromes. Thus, clinics might augment RDT diagnosis of common pathogens with specialized or follow-up testing for rare pathogens or positive results.

In general, RDTs for antigen and antibody detection are less sensitive than standard laboratory assays. Rapid HIV tests that use blood and cheek swab samples are widely available and perform well in identifying individuals with chronic infections. Even later-generation antigen/antibody tests remain less sensitive than molecular testing for acute HIV infection, however, and in high-risk patients, molecular testing or repeat testing is warranted. The sensitivity of rapid antigen tests for influenza and certain gastrointestinal pathogens (e.g., norovirus, rotavirus) are notably poor. Negative results should not dictate therapy decisions, and positive results should be confirmed with molecular testing.

Multiplex molecular panels are becoming more common for central nervous system (CNS), gastrointestinal, and respiratory infections, and new panels are under evaluation for febrile returning travelers. These panels often are very sensitive and can test for many pathogens in a single sample. These tests are expensive, however, and results must be interpreted in the clinical context; certain pathogens might require additional testing when there is high clinical suspicion. Notably, available multiplex assays do not test for common bacterial causes of pneumonia. Also, detection of emerging or novel pathogens is not feasible with large, preconstructed testing panels. When interpreting results provided by multiplex molecular panels, consider the prolonged shedding periods of certain pathogens, the possibility of multiple positive results or co-infections, the detection of asymptomatic carriage, and the variable accuracy for different agents on the panel (e.g., cryptococcus in CNS panels, adenovirus in respiratory panels).

Undifferentiated acute febrile illness is a common and potentially life-threating clinical presentation among returning travelers that poses a diagnostic challenge and requires prompt evaluation, diagnosis, and management. RDTs might be unavailable or insufficient to diagnose the many possible causes of febrile illness. For example, a commercial RDT for malaria has been cleared for use in hospitals and laboratories but not for individual clinics; microscopy is still the diagnostic tool of choice in malaria cases to identify the species and calculate the level of parasitemia (see Sec. 5, Part 3, Ch. 16, Malaria ). Furthermore, patients with malaria can be co-infected with other pathogens that can contribute to and complicate diagnosis and management. RDTs are not available in the United States for other common causes of undifferentiated acute febrile illness in travelers (e.g., dengue, leptospirosis).

Table 11-06 Lateral-flow immunochromatographic tests & small panels for pathogens in returning international travelers: selected features

Abbreviations: FDA, US Food and Drug Administration; IDSA, Infectious Disease Society of America; RDT, rapid diagnostic test; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2; WHO, World Health Organization

Table 11-07 Multiplex molecular panels for pathogens in returning international travelers: selected features

Abbreviations: CSF, cerebrospinal fluid; SARS-CoV-2, severe acute respiratory syndrome coronavirus 2

Coronavirus Disease 2019

High demand for diagnostics for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), combined with an emphasis on decreasing exposures to people infected with the virus, led the US Food and Drug Administration (FDA) to issue an Emergency Use Authorization for several RDTs and multiplex panels that include SARS-CoV-2. RDTs include rapid antigen diagnostics and the first molecular diagnostic for home use. These can be performed with self- or caregiver-collected samples. Some home test kits require that users download a smartphone application that provides test interpretation for the user and reports de-identified data for public health surveillance. These diagnostic kits perform best in symptomatic people; results in asymptomatic people should be interpreted with caution.

Diagnostic Testing Performed During Travel

People who become ill while traveling might seek medical care abroad; development and availability of RDTs for diagnosis of tropical infectious diseases has expanded greatly in recent years, and travelers might return home having been diagnosed based on results from these tests. RDTs for tropical infections typically are lateral-flow immunochromatographic tests that detect antigens from or antibodies to certain pathogens. Because only 1 such test (for malaria) is cleared for use in the United States, the diagnostic characteristics of RDTs used overseas are unfamiliar to most providers. Additionally, a variety of RDTs might be available for certain pathogens (e.g., dengue) in other countries, with widely varying or poorly studied performance characteristics. Institutions that do not have continuous access to a single brand of test further complicates interpretation of results provided by the laboratory.

The following is an illustrative, though by no means exhaustive, list of several common infections for which RDTs are available.

Dengue. Rapid, lateral-flow assays are available to detect the dengue nonstructural protein 1 (NS1) antigen, and IgM and IgG. Dengue tests have widely variable performance characteristics depending on the manufacturer, circulating dengue types, a patient’s past medical history, and symptom duration.

Emerging Infections. Emerging pathogens represent a diagnostic challenge. Rapid assays became available after outbreaks of chikungunya, Ebola, and Zika. Such assays might not be available or well-studied at the peak of an outbreak, however.

Leishmaniasis. Assays to detect antibodies against the rK39 antigen (visceral leishmaniasis) have demonstrated good specificity in endemic regions, and highest sensitivity for detecting disease in South Asia.

Leptospirosis. Because of the many pathogenic and intermediate Leptospira serotypes that result in human disease worldwide, the usefulness of serologic assays for diagnosing leptospirosis is limited.

Malaria. An FDA-cleared RDT for malaria is available, and malaria RDTs are widely used throughout the world. In general, these tests perform best for Plasmodium falciparum , with variable or poor performance for other Plasmodium species.

Typhoid. Rapid serologic tests have demonstrated only moderate accuracy to diagnose typhoid. Additionally, these tests are designed to detect Salmonella enterica serotype Typhi only.

Future Directions

The number of assays compatible with POC testing will undoubtedly continue to increase. Building upon testing milestones achieved during the COVID-19 pandemic, “at home” testing, including molecular testing, is expected to increase in the coming years for both respiratory viruses and other pathogens. Because of the wide breadth and diversity of infecting pathogens in returned travelers, use of POC testing for nondomestic infectious diseases might not be practical for most centers once test volume, personnel training, and cost are taken into consideration. POC testing for common syndromes that affect travelers and nontravelers alike (e.g., respiratory tract and gastrointestinal infections) could provide rapid diagnosis, inform triage decisions, and limit unnecessary laboratory testing.

The following authors contributed to the previous version of this chapter: Elizabeth Rabold, Jesse Waggoner

Bibliography

Babady NE. The FilmArray respiratory panel: an automated, broadly multiplexed molecular test for the rapid and accurate detection of respiratory pathogens. Expert Rev Mol Diagn. 2013;13(8):779–88.

Centers for Disease Control and Prevention. Ready? Set? Test! Patient testing is important. Get the results right. Atlanta: The Centers; 2019. Available from: www.cdc.gov/labquality/images/waived-tests/RST-Booklet_Dec-2019.pdf .

Gonzalez MD, McElvania E. New developments in rapid diagnostic testing for children. Infect Dis Clin North Am. 2018;32(1):19–34.

 Hunsperger EA, Yoksan S, Buchy P, Nguyen VC, Sekaran SD, Enria DA, et al. Evaluation of commercially available diagnostic tests for the detection of dengue virus NS1 antigen and anti-dengue virus IgM antibody. PLoS Negl Trop Dis. 2014;8(10):e3171.

Infectious Disease Society of America. IDSA practice guidelines. Available from: www.idsociety.org/practice-guideline/practice-guidelines .

Pai NP, Vadnais C, Denkinger C, Engel N, Pai M. Point-of-care testing for infectious diseases: diversity, complexity, and barriers in low- and middle-income countries. PLoS Med. 2012;9(9):e1001306.

US Food and Drug Administration. CLIA—Clinical Laboratory Improvement Amendments—currently waived analytes. Available from: www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfClia/analyteswaived.cfm .

US Food and Drug Administration. In vitro diagnostics EUAs. Available from: www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas .

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Dengue Fever in the Philippines

Jul 11, 2014

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Dengue Fever in the Philippines. Camille Sana MPH Student Walden University PUBH 6165-4 :Environmental Health Dr. Howard Rubin February 2012. Source: Centers for Disease Control and Prevention . Goals/Objectives. Audience Expected Learning outcome Objective of Presentation.

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• dengue prevention month
• waste management practices
• female aedes aegypti mosquito

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Dengue Fever in the Philippines Camille Sana MPH Student Walden University PUBH 6165-4 :Environmental Health Dr. Howard Rubin February 2012 Source: Centers for Disease Control and Prevention

Goals/Objectives • Audience • Expected Learning outcome • Objective of Presentation

What is Dengue Fever? • Mosquito: Aedes Aegypti • Common in tropical countries like Philippines • Symptoms : mild to high grade fever, headache, joint and muscle pain, rash • Complication: Dengue Hemorrhagic Fever --Lethal ! Source: Bepast.org

Clinical Manifestations Reference: WHO, 2009

Clinical Manifestations cont. Dengue Fever Symptoms: Fever headache muscle and joint aches Skin rash Dengue Hemorrhagic Fever: High fever, hemorrhage, has 4 grades: Petecchial rash Grade 1: Fever, non specific Source: Denquefever.co.in Grade 2: Grade 1 manifestation + spontaneous bleeding Grade 3: Signs of circulatory failure Grade 4: Profound shock,death Reference: WHO, 2009

Impact of Dengue in the Philippines 1996-2005 Dengue Incidence Manila, Philippines 1996 -2005 Source : Sia, S.(2008)AMBIO - A Journal of the Human Environment, Jun2008, Vol. 37 Issue 4, p292-294, 3p, 1 Chart, 2 Graphs, 1 Map Graph; found on p293

Impact of Dengue in the Philippines 2010-2011 Source: Department of Health Philippines Disease Surveillance Report Morbidity Week 36 ,figure 1 page 1

Impact of Dengue in the Philippines 2010-2011(cont.) Source: Department of Health Philippines Disease Surveillance Report Morbidity Week 36 ,Figure 2 page 2

Transmission of Dengue VECTOR: Transmitted to humans by bite of female aedes aegypti mosquito. Dengue mosquitos lay eggs in areas with water (see left) HOST: Humans become host of virus. Virus incubation is 4-10 days then produce dengue symptoms TRANSMISSION: Humans get infected from bite of infected aedes mosquito. Mosquitos get infected when they bite infected humans. Source: www.CDC.com Source: Everyday health.com Reference: CDC, n.d.

Prevention • Environmental Management • Biological Control • Chemical Control

Prevention (cont.) ENVIRONMENTAL MANAGEMENT • Modification • Manipulation • Changes in Human Behavior Source: CDC,n.d. Source: CDC,n.d. Source: CDC,n.d.) Source:travelpod)

Prevention (cont.) CHEMICAL CONTROL • Use of insecticides • Fogging • Use of mosquito coils • Repellents Source: mosquitoes and more.com

Prevention (cont.) BIOLOGICAL CONTROL • Fish (poeciliareticulata) • Predatory copepods (copepodacyclopoidea) • Lethal ovitraps Source: US Geological Survey Source: US Geological Survey Source: DOH

Anti-Dengue Programs in the Philippines • June 2011: Dengue Prevention Month • Massive anti-dengue campaign Source: www.ifmt.auf.org Source:www.tacloban.gov.ph Source:DOH

Anti-Dengue Programs in the Philippines • Distribution and training on use of mosquito OL trap (ovicidal-larvicidal trap) Source : DOH Source: DOH

Anti-Dengue Programs in the Philippines ( cont.) • Multi-sectoral mosquito “search and destroy” cleanup campaign Source: College of Nursing, University of Makati

Conclusion • Dengue is a health threat • Dengue is Preventable • Plan for action Source:ADRA

Additional Information/Resources WEBSITES: • World Health Organization http://www.who.int/topics/dengue/en/ • Centers for Disease Control and Prevention http://www.cdc.gov/dengue/ • WHO. Dengue Haemorrhagic fever ealy recognition diagnosis and hospital management. An audiovisual guide for healthcrae workers responding to outbreaks.http://www.who.int/csr/don/archive/disease/dengue_fever/dengue.pdf • WHO. Global Alert and response. http://www.who.int/csr/disease/dengue/en/ • World Heath Organization. Guidelines for treatment of demgue fever/dengue hemorrhagic fever in small hospitals. http://www.searo.who.int/LinkFiles/Dengue_Guideline-dengue.pdf • CDC, Clinicians Reference card.http://www.cdc.gov/Dengue/resources/Dengue%20Case%20Management_card_125085_12x6_Zcard_Dengue.pdf • CDC. Information for health care practitioners. http://www.cdc.gov/dengue/resources/Dengue&DHF%20Information%20for%20Health%20Care%20Practitioners_2009.pdf • CDC. Basic facts on Dengue http://www.cdc.gov/dengue/resources/CS_205910-A.Dengue%20patient%20Ed%20Eng.FINAL.pdf

Additional Information/Resources ( cont.) JOURNALS/ARTICLES: • Bernardo, E. C. (2008). Solid-Waste Management Practices of Households in Manila, Philippines. Annals Of The New York Academy Of Sciences, 1140420-424. doi:10.1196/annals.1454.016 • Johansson, MA, F Dominici, & GE Glass. Local and global effects of climate on dengue transmission in Puerto Rico. PLoS Neglected Tropical Diseases. 3(2): e382 (2009). • Barrera R. 2009. Simplified Aedes aegypti’spupal-surveys for entomological surveillance and dengue control. American Journal of Tropical Medicine and Hygiene 81: 100-107. http://www.ajtmh.org/cgi/reprint/81/1/100 • Barrera R, Amador M, Díaz A. Joshua Smith, Muñoz-Jordán JL, Rosario Y. 2008. Unusual productivity of Aedes aegypti in septic tanks and its implications for dengue control. Medical and Veterinary Entomology 22:62-69. http://www3.interscience.wiley.com/cgi-bin/fulltext/119401311/PDFSTART • Group on Dengue Meeting 1-5 October 2006, Special Programme for Research and Training in Tropical Diseases UNICEF/UNDP/World Bank and WHO.

References World Health Education ( 2009).Dengue guidelines for diagnosis treatment prevention and control. Retrieved from http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf Centers for Disease Control and Prevention (2009). Dengue frequently asked questions. Retrieved from http://www.cdc.gov/Dengue/faqFacts/index.html World Health Organization (2006). Dengue hemorrhagic fever early recognition diagnosis and hospital management an audiovisual guide for health care workers responding to outbreaks. retrieved from http://www.who.int/csr/don/archive/disease/dengue_fever/dengue.pdf Department of Health (2011) Disease surveillance report morbidity week 36. Retrieved from http://dev1.doh.gov.ph/sites/default/files/2011Den36WMR_draft.pdf Sia Su, G. L. (2008). Correlation of Climatic Factors and Dengue Incidence in Metro Manila, Philippines. AMBIO - A Journal Of The Human Environment, 37(4), 292-294. Retrieved from http://web.ebscohost.com.ezp.waldenulibrary.org/ehost/detail?vid=5&hid=12&sid=c81b1f84-903a-4856-81e3-d2a7b75da458%40sessionmgr14&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#db=a9h&AN=33116717

References ( cont.) Centers for Disease and Control Prevention ( 2010) . Transmission of dengue virus retrieved from http://www.cdc.gov/Dengue/epidemiology/index.html#transmission Centers for Disease and Control Prevention ( n.d.) how to prevent the spread of mosquito that causes dengue. Retrieved from http://www.cdc.gov/dengue/resources/Vector%20control%20sheet%20dengue.pdf Centers for disease control and prevention (2010). Larval control and other vector control preventions. Retrieved from http://www.cdc.gov/malaria/malaria_worldwide/reduction/vector_control.html Elias, M. Islam, M. Kabir, M & Rahman,M. ( 1995, August). Biological control of mosquito larvae by guppy fish. Bangladesh medical research council bulletin.21(2):81-6. Department of medical entomology. Institute of preventative and social medicine Mohakhali, Dhaka.Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8815867 Department of health ( 2011). Dengue surge in Luzon. Retrieved from http://dev1.doh.gov.ph/content/dengue-surge-luzon

References ( cont.) Department of science and technology (n.d.).Mosquioto OL trap. Retrieved from www.science.ph/oltrap/ Department of Health (2011) . National dengue prevention and control program. Retrieved form http://www.doh.gov.ph.content/national-dengue-prevention-and-control-program World Health Organization (2012) Dengue epidemiology philippines. World health organization Western pacific region Retrieved from http://www.wpro.who.int/sites/mvp/epidemiology/dengue/phl_profile.htm

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Daily English Newspaper

Secretary Health reviews preparedness for dengue control, containment in J&K

SRINAGAR: Secretary of Health and Medical Education, Dr. Syed Abid Rasheed Shah, today chaired a meeting to review the preparedness for dengue control and containment in Jammu and Kashmir.

The meeting was attended by Commissioner, Jammu Municipal Corporation, Managing Director, JKMSCL, Principals Government Medical College Jammu/Doda/Kathua/Rajouri/Udhampur, Director Health Services, Jammu, Chief Medical Officers of all districts of Jammu Division, State Surveillance Officer, Jammu/ Kashmir, Medical Superintendents of Associated Hospitals of New GMCs/District Hospitals, State Nodal Officer, NHM, J&K and Divisional Nodal Officer, NHM, Kashmir while the outstation officers participated virtually.

On the occasion, a PowerPoint presentation (PPT) was made by Dr. D.J Raina, State Malariologist, J&K, Jammu, highlighting the strategies being adopted by the department for the control of dengue, epidemiological data, key Octalogue strategies for control of dengue besides facilities being provided to the people.

The Secretary emphasised the collective efforts of all the stakeholders to tackle this looming threat through better disease management. He also enumerated various actions need to be taken immediately like launching of an aggressive IEC/BCC campaign for awareness of the community on local Radio /Television/ through JMC hoardings and garbage collection Vans. Besides, hiring of Domestic Breeding Checkers/ engaging regular staff for source reduction activities of vectors was also stressed upon. The Urban Local bodies were also directed to initiate source reduction and related activities for control of dengue.

It was informed that Blood Component facility is available in GMC Jammu, Government Hospital Gandhi Nagar, Jammu, GMC Rajouri, GMC Kathua for patients requiring platelet transfusion in case of severe disease. The District Hospitals were asked to earmark separate Dengue Ward to ensure effective management of the cases. It was also instructed that indiscriminate Fogging/Spray will not be carried out and it will be done only as per the protocols of Vector-Borne Diseases.

All the Private Laboratories/Nursing Homes were asked to mandatorily upload the data of dengue cases on Integrated Health Information Platform (IHIP).

The Secretary asked for stratifying identification of the high-risk areas so that requisite strategies are worked out for integrated vector management (IVM). He also directed for ensuring availability of diagnostic kits/ drugs, insecticides and other logistics.

It was informed that 104 Health Helpline of National Health Mission, J&K will be utilised during the dengue breakout for effective surveillance and communication with the public.

All the districts were directed to conduct inter-sectorial meetings at the earliest for control and containment of dengue.

Kashmir Images is an English language daily newspaper published from Srinagar (J&K), India. The newspaper is one of the largest circulated English dailies of Kashmir and its hard copies reach every nook and corner of Kashmir Valley besides Jammu and Ladakh region.

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