A REPORT ON DENGUE HEMORRHAGIC FEVER

Submitted By: Dave Jay S. Manriquez RN.

Submitted to: Dr. Robert Denopol

December 2009 DENGUE HEMORRHAGIC FEVER

Introduction: Philippine Hemorrhagic Fever was first reported in 1953. In 1958, hemorrhagic became a notifiable disease in the country and was later reclassified as Dengue Hemorrhagic Fever. Dengue is primarily a disease of the tropics, and the viruses that cause it are maintained in a cycle that involves humans and Aedis Aegypti. Infection with dengue viruses produces a spectrum of clinical illness ranging from a nonspecific viral syndrome to severe and fatal hemorrhagic disease.

Identification: A severe mosquito transmitted viral illness endemic in the tropics, much in South and Southeast Asia especially in the Philippines. It is characterized by increased vascular permeability, hypovolemia and abnormal blood clotting mechanisms. WHO case definition for DHF: 1) fever or history of recent fever, 2) thrombocytopenia (platelet count equal to or less than 100 x 10 /cu mm), 3) hemorrhagic manifestations such as petechiae or overt bleeding phenomena, and 4) evidence of plasma leakage due to increase vascular permeability. Illness is biphasic; it begins abruptly with fever, and in children, with mild upper respiratory complaints often anorexia, facial flush and mild GI disturbances. Coincident with defervescence and decreasing platelet count, the patients condition suddenly worsens, with marked weakness, severe restlessness, facial pallor and often diaphoresis, severe abdominal pain and circumoral cyanosis. GI hemorrhage is an ominous prognostic sign that usually follows a prolonged period of shock. Infectious Agent: The viruses of dengue fever are flaviviruses and include serotypes 1, 2, 3 and 4 (dengue 1, -2, -3, -4); Chikungunya virus Occurrence: Dengue occurrence is sporadic throughout the year. Epidemic usually occurs during the rainy seasons June November. Peak months are September and October. It occurs wherever vector mosquito exists. DHF / DSS are observed most exclusively among children of the indigenous population under 15 years of age. Occurrence is greatest in the areas of high Ae. Aegypti prevalence.

Reservoir: The viruses are maintained in a human Aedes Aegypti mosquito cycle in the tropical urban centers

Mode of Transmission: By the bite of infective mosquitoes, principally Ae. Aegypti. This is day biting specie, with increased biting activity for 2 hours after sunrise and several hours before sunset. Incubation Period: From 3 to 14 days, commonly 4-7 days (one week). Period of Communicability: Not directly transmitted from person to person. Patients are infective for mosquitoes from shortly before to the end of the febrile period, usually a period of 3-5 days. The mosquito becomes infective 8-12 days after the viremic blood meal and remains so for life. Susceptibility and resistance: All persons are susceptible. Both sexes are equally affected. The age groups predominantly affected are the preschool age and school age. Adults and infants are not exempted. Peak age affected 5-9 years. Susceptibility is universal. Acquired immunity may be temporary but usually permanent. Diagnostic Test: 1.) Tourniquet Test (Rumpel Leads Tests) Inflate the blood pressure cuff on the upper arm to a point midway between the systolic and diastolic pressure for 5 minutes Release cuff and make an imaginary 2.5 cm square or 1 inch just below the cuff, at the antecubital fossa Count the number of petechiae inside the box A test is (+) when 2 or more petechiae per 2.5 cm square or 1 inch square are observed 2.) A con firmed diagnosis is established by culture of the virus, polymerase-chainreaction (PCR) tests, or serologic assays. The diagnosis of dengue hemorrhagic fever is made on the basis of the following triad of symptoms and signs: Hemorrhagic manifestations; a platelet count of less than 100, 000 per cubic millimeter; and objective evidence of plasma leakage, shown either by

fluctuation of packed-cell volume (greater tan 20 percent during the course of the illness) or by clinical signs of plasma leakage, such as pleural effusion, ascites or hypoproteinemia. Hemorrhagic manifestations without capillary leakage do not constitute dengue hemorrhagic fever. Clinical Manifestations (Public Health Nursing in the Philippines, 2007): An acute febrile infection of sudden onset with 3 stages: 1st-4th day (febrile or invasive stage) -high fever, abdominal pain and headache; later flushing which may be accompanied by vomiting, conjunctiva infection and epistaxis. 4th-7th day (toxic or hemorrhagic stage) -lowering of temperature, severe abdominal pain, vomiting and frequent bleeding from gastrointestinal tract in the form of hematemesis or melena. Unstable blood pressure, narrow pulse pressure and shock. Death may occur. Tourniquet test which may be positive may become negative due to low or vasomotor collapse. 7th-10th day (convalescent or recovery stage) -generalized flushing with intervening areas of blanching, appetite regained and blood pressure already stable. Dengue shock syndrome is defined as dengue hemorrhagic fever plus: *Weak rapid pulse, *Narrow pulse pressure (less than 20 mm Hg) or, Cold, clammy skin and restlessness

Grading of Dengue Fever: The severity of DHF is categorized into four grades: grade I, without overt bleeding but positive for tourniquet test grade II, with clinical bleeding diathesis such as petechiae, epistaxis and hematemesis grade III, circulatory failure manifested by a rapid and weak pulse with narrowing pulse pressure (20 mmHg) or hypotension, with the presence of cold clammy skin and restlessness; and Grade IV, profound shock in which pulse and blood pressure are not detectable. It is note-worthy that patients who are in threatened shock or shock stage, also known as dengue shock syndrome, usually remain conscious. * Grade III and IV are considered to be Dengue Shock Syndrome MANAGEMENT: Supportive and symptomatic treatment should be provided: Promote rest Medication

Paracetamol for fever Analgesic (Acetaminophen (Tylenol) and codeine) for severe headache and joint and muscle pains Aspirin and nonsteroidal anti-inflammatory drugs should be avoided Rapid replacement of body fluids is the most important treatment Give ORESOL to replace fluid as in moderate dehydration at 75ml/kg in 4-6 hours or up to 2-3L in adults. Continue ORS intake until paients condition improves. Intravenous fluid For hemorrhage Keep patient at rest during bleeding periods For epistaxis maintain an elevated position of trunk and promote vasoconstriction in nasal mucosa membrane through an ice bag over the forehead. For melena ice bag over the abdomen. Provide support during the transfusion therapy Diet Low fat, low fiber, non-irritating, non-carbonated Noodle soup may be given Observe signs of deterioration (shock) such as low pulse, cold clammy perspiration, prostration. For shock Place in dorsal recumbent position to facilitate circulation Provision of warmth through lightweight covers (overheating causes vasodilation which aggravates bleeding)

PREVENTION: The best way to prevent dengue fever is to take special precautions to avoid contact with mosquitoes. Eliminate vector by: Changing water and scrubbing sides of lower vases once a week Destroy breeding places of mosquito by cleaning surroundings Proper disposal of rubber tires, empty bottles and cans Keep water containers covered Because Aedes mosquitoes usually bite during the day, be sure to use precautions especially during early morning hours before daybreak and in the late afternoon before dark. Other precautions include: When outdoors in an area where dengue fever has been found Use a mosquito repellant containing DEET, picaridin, or oil of lemon eucalyptus Dress in protective clothing-long-sleeved shirts, long pants, socks, and shoes Keeping unscreened windows and doors closed Keeping window and door screens repaired

 Use of mosquito nets

Sources: http://www.nscb.gov.ph/secstat/d_vital.asp http://www.who.int/csr/resources/publications/dengue/012-23.pdf Public Health Nursing in the Philippines by the Publications Committee, National League of Philippine Government Nurses, Incorporated