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Review Article

Dengue Fever its Diagnosis, Treatment, Prevention and Control

Muhammad Anwar Sulehri, Riaz Hussain, Najaf Imtiaz Gill !stra"t #a"$ground% Dengue virus has emerged as a maj'r &u#li" health &r'#lem w'rldwide in the re"ent de"ades( ,he in"iden"e 'f this infe"ti'n has in"reased in tr'&i"s and su#tr'&i"s in"luding 0a)istan( It is 'ne the m'st "'mm'n and &erha&s the m'st danger'us viral disease transmitted #% m's$uit'es( 6urrent e&idemi" 'f dengue fever 'f 23** in 0a)istan has highlighted the la") 'f dire"ti'n and negle"t 'f this devastating disease( N'w it is 'f fundamental im&'rtan"e t' im&lement &u#li" health measures and als' t' im&r've management 'f Dengue Hem'rrhagi" ever and Dengue sh'") s%ndr'me in 'ur h's&itals( O!&e"tives% ,he '#je"tives 'f this review arti"le are t'9 *( Des"ri#e the e&idemi'l'g%, vir'l'g%, ris) fa"t'rs, "lini"al features, diagn'sis and management 'f dengue fever( 2( Determine the "'m&li"ati'ns 'f dengue fever( 1( ind 'ut different m'dalities f'r &reventi'n and "'ntr'l 'f dengue fever( 4( 0r'vide awareness t' the &u#li" a#'ut this disease and t' dis&el undue fears( Con"lusion% ever is the s%m&t'm &resent in alm'st all &atients (:leeding leads t' seri'us "'m&li"ati'ns in dengue fever( N' effe"tive va""ine 'r antiviral agents are availa#le t' treat dengue infe"ti'n at the m'ment( Prognosis and Control% Attem&ts t' "'ntr'l dengue ve"t'r (m's$uit'es! and effe"tive va""ine remain the im&'rtant &reventive measures( 'e( )ords% Dengue virus, Dengue fever, Dengue Hem'rrhagi" ever , Dengue sh'") s%ndr'me, GI, manifestati'ns, Retr' 'r#ital &ain, Internal #leeding(

INTRODUCTION Dengue fever (D ! is an a"ute fe#rile viral disease fre$uentl% &resenting with heada"hes, #'ne, j'int and mus"ular &ains, rash and leu"'&enia( It is als' )n'wn as #rea) #'ne fever *( Dengue hem'rrhagi" fever (DH ! is "hara"terized #% f'ur maj'r "lini"al manifestati'ns+ high grade fever, hem'rrhagi" &hen'mena, 'ften with he&at'megal% and, in severe "ases, signs 'f "ir"ulat'r% failure( Su"h &atients ma% devel'& h%&'v'laemi" sh'") resulting fr'm &lasma lea)age (,his is "alled dengue sh'") s%ndr'me (DSS! and "an #e fatal2( DH is n'w a signifi"ant &u#li" health &r'#lem in m'st 'f the "'untries in the tr'&i"al areas 'f the S'uth-.ast Asia and /estern 0a"ifi" Regi'ns( ,he disease is am'ng the ten leading "auses 'f h's&italizati'n and death in "hildren in at least eight tr'&i"al Asian "'untries1( EPIDEMIOLOGY Dengue 'r dengue-li)e e&idemi"s were re&'rted thr'ugh'ut the nineteenth and earl% twentieth "enturies
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in the Ameri"as, s'uthern .ur'&e, N'rth Afri"a, the eastern Mediterranean, Asia and Australia, and 'n vari'us islands in the Indian 2"ean, and "entral 0a"ifi"( Annuall%, it is estimated that there are 23 milli'n "ases 'f dengue infe"ti'n, resulting in ar'und 24333 deaths( It esta#lished seas'nal and "%"li"al e&idemi" &atterns, with large 'ut#rea)s '""urring at 2-1 %ears intervals m'stl% in "hildren1( .&idemi'l'gi"all% im&'rtant new intr'du"ti'ns 'f DH 5DSS were re&'rted in 6hina, Maldives, India, New 6aled'nia, Sri 7an)a and ,ahiti( ,he e8&erien"es in India and Sri 7an)a are &arti"ularl% interesting, #e"ause vir'l'gi"al surveillan"e d'"umented the endemi" transmissi'n 'f all f'ur dengue ser't%&es a""'m&anied #% D "ases( DH 5DSS &ri'r t' the a#'ve-menti'ned 'ut#rea)s1( All f'ur dengue ser't%&es are &resent in these tw' Regi'ns, and in"reasing internati'nal travel serves t' intr'du"e new virus strains and ser't%&es ra&idl% int' sus"e&ti#le &'&ulati'ns( DH 5DSS is graduall% #e"'ming endemi"


in several "'untries 'f the Ameri"as, f'll'wing the trend '#served in Asia1( DENGUE IN T*E FRIC N ND E +TERN MEDITERR NE N REGION+ INCLUDING P 'I+T N Dengue disease has #een &revalent and its virus re&'rted in the Afri"an and .astern Mediterranean Regi'ns in"luding 0a)istan, Saudi Ara#ia, Senegal, Se%"helles, Sierra 7e'ne, S'malia, Sudan and the ;nited Re&u#li" 'f ,anzania sin"e *<=>( ,he first "ase 'f Dengue fever in 0a)istan was re&'rted in the s'uthern &'rt "it% 'f ?ara"hi in *<<41( An'ther stud% re&'rted ten "'nfirmed "ases 'f dengue with f'ur deaths fr'm the n'rth eastern "it% 'f 0a)istan in 2331(4 ,he &r'vin"e 'f 0unja#, &arti"ularl% its "a&ital, 7ah're have seen a gr'wing num#er 'f "ases sin"e 233>( ,his %ear in the f'rm 'f e&idemi" m're than 4,333 "ases 'f dengue fever have #een re&'rted, a signifi"ant in"rease 'ver &revi'us %ears( As the w'rld tem&eratures rise the e&idemi" is m'ving n'rth@( RI+' F CTOR+ OF DENGUE EPIDEMIC IN P 'I+T N Ris) fa"t'rs in 0a)istan "'uld in"lude &assenger traffi" and trade with India and in"reased traffi" fr'm India( 0a)istan is #eing used as a "'nduit in its trade with Afghanistan( (,his r'ute 'f infe"ti'n is highl% sus&e"ted #e"ause a re"ent stud% d'ne #% Agha ?han ;niversit%=( Sh'ws the &revalen"e 'f Dengue virus ser't%&e 1 in re"ent infe"ti'ns "'m&ared t' dengue ser't%&e 2 usuall% is'lated in the &ast!( ,his ser't%&e is the same whi"h have #een is'lated in Dehli, India in the &ast( S' it is n' w'nder that 7ah're is the e&i"enter 'f this infe"ti'n( Alth'ugh it is understanda#le that it is diffi"ult t' &revent its s&read t' 'ther "ities #ut sim&le measures li)e fumigati'n 'f all trans&'rt "'ming 'ut 'f e&idemi" z'ne has #een tried in the &ast in e&idemi"s w'rld wide with varia#le su""ess>( In view 'f its deadl% nature a l'ng term &lanning is needed t' "'ntain this disease #e"ause alth'ugh in the m're "'lder &arts 'f the "'untr% it is li)el% t' remain a seas'nal threat #ut in the warmer s'uth and east 'n"e the reserv'ir 'f the infe"ti'n is esta#lished it "an #e"'me a &erennial nightmare( Alth'ugh the lifes&an 'f an adult Aedes-aegypti is #etween tw' t' f'ur wee)s de&ending 'n "'nditi'ns, Aedes-aegyptis eggs "an #e via#le f'r 'ver a %ear in a dr% state, whi"h all'w the m's$uit' t' re-emerge after a "'ld winter 'r dr% s&ell A(
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,IROLOGY Dengue viruses #el'ng t' famil% flaviviridae 'f the genus flavivirus( ,he Dengue virus has f'ur "l'sel% related #ut distin"t ser't%&es, D.N* t' D.N49 within whi"h are several gen't%&es( ,he viri'n is "'m&'sed 'f 1 stru"tural &r'teins )n'wn as "'re, mem#rane and envel'&e and > n'n-stru"tural (NS*, NS2a, NS2#, NS1, NS4, NS4#, and NS@! &r'teins <( As the infe"ti'n with 'ne dengue virus &r'vides life l'ng immunit%( ,here is n' "r'ss &r'te"tive immunit% t' the 'ther dengue viruses, theref're all dengue virus t%&es ma% infe"t a &ers'n in an endemi" area( Aedes-aeg%&ti (A( aeg%&ti! is a ve"t'r whi"h infe"ts the human h'st, wh' in turn serves as s'ur"e 'f viral am&lifi"ati'n( ,he A(aeg%&ti is a small highl% d'mesti"ated, #la") and white tr'&i"al inse"t that &refers t' feed 'n humans during the da%time( ,here are tw' &ea)s 'f #iting a"tivit%9 earl% m'rning f'r 2 t' 1 h'urs and in the aftern''n f'r several h'urs #ef're dar)( It #reads in artifi"ial "'ntainers in and ar'und h'mes( emales A(aeg%&ti feeds 'n several &ers'ns and ma% transmit dengue virus t' man% &ers'ns in sh'rt "'urse 'f time-,./ TR N+MI++ION 01 Dengue viruses are transmitted t' vulnera#le human h'st thr'ugh the #ites 'f infe"tive female Aedesaeg%&ti m's$uit'es( ,he% generall% a"$uire the virus while feeding 'n the #l''d 'f an infe"ted &ers'n( After in"u#ati'n f'r A-*3 da%s, an infe"ted m's$uit' is a#le t' transmit the virus #% #iting sus"e&ti#le individual f'r the rest 'f its life( Infe"ted female m's$uit'es ma% als' transmit the virus t' their 'ffs&ring #% trans-'varian (via eggs! transmissi'n( Humans are the main am&lif%ing h'st 'f the virus( ,he virus "ir"ulates in the #l''d 'f infe"ted humans f'r 2-> da%s during whi"h the% have fever( emale Aedes-aeg%&ti m's$uit'es ma% a"$uire the virus #% feeding 'n infe"ted &ers'n during this &eri'd*3( ,here are several 'ther &'ssi#le r'utes 'f transmissi'n with'ut m's$uit' ve"t'r su"h as mu"'-"utane'us transmissi'n #% #l''d 'f infe"ted &atient with dengue, needle sti") injuries, #'ne marr'w trans&lant, #l''d transfusi'n, intra-&artum and verti"al transmissi'n<(


CLINIC L FE TURE+ 2 DI GNO+I+ C3ara"teristi"s o4 Dengue Fever 2 Dengue *emorr3agi" Fever Dengue Fever It is a severe, flu-li)e illness that affe"ts infants, %'ung "hildren and adults, #ut seld'm "auses death( ,he "lini"al features 'f dengue fever var% a""'rding t' the age 'f the &atient( Infants and %'ung "hildren ma% have a n'ns&e"ifi" fe#rile illness with rash( 2lder "hildren and adults ma% have either a mild fe#rile s%ndr'me 'r the "lassi"al in"a&a"itating disease with a#ru&t 'nset and high fever, severe heada"he, &ain #ehind the e%es, mus"le and j'int &ains, and rash*3( Dengue *emorr3agi" Fever It is a &'tentiall% deadl% "'m&li"ati'n that is "hara"terized #% high grade fever, hem'rrhagi" &hen'mena, 'ften with enlargement 'f the liver and in severe "ases, "ir"ulat'r% failure( ,he illness "'mm'nl% #egins with a sudden rise in tem&erature a""'m&anied #% fa"ial flush and 'ther n'n-s&e"ifi" "'nstituti'nal s%m&t'ms 'f dengue fever( ,he fever usuall% "'ntinues f'r tw' t' seven da%s and "an #e as high as 43-4* 6, &'ssi#l% with fe#rile "'nvulsi'ns and hem'rrhagi" &hen'mena


fun"ti'n testsCserum amin'transferase, serum alanine Amin'transferases Renal un"ti'n tests Ser'l'gi"al tests- dengue anti#'dies Serum 6h'lester'l D Al#umen 6hest E-Ra% 0A view A#d'minal ;ltras'und Fir'l'gi"al Studies


Ta!le60 Results and Clini"al Inter7retation5 Possi!le results and t3eir "lini"al inter7retation in"lude/
Result s IgM 0'sitive 2nl% IgM and IgG 0'sitive IgG 0'sitive IgM and IgG Negative Clini"al Inter7retation 0rimar% Dengue infe"ti'n 7ate &rimar% 'r earl% se"'ndar% infe"ti'n 0revi'us Dengue infe"ti'n 'r se"'ndar% infe"ti'n N' Dengue Firal infe"ti'n at &resent( Re&eat the test @ da%s if it is still sus&e"ted(

Figure60 Primar( and +e"ondar( immunologi"al res7onse in dengue virus in4e"tion5

IN MODER TE D*F C +E+ All signs and s%m&t'ms a#ate after the fever su#sides( In severe "ases, the &atientBs "'nditi'n ma% suddenl% deteri'rate after a few da%s 'f fever when the tem&erature dr'&s, f'll'wed #% signs 'f "ir"ulat'r% failure, and the &atient ma% ra&idl% g' int' a "riti"al state 'f sh'") and die within *2-24 h'urs, 'r $ui")l% re"'ver f'll'wing a&&r'&riate v'lume re&la"ement thera&%*3( L #OR TORY DI GNO+I+ Essential La!orator( Tests 5 In assessing a &atientBs "'nditi'n, the f'll'wing tests are re"'mmended+ Haemat'"rit Serum ele"tr'l%tes and #l''d gas studies 0latelet "'unt, &r'thr'm#in time, &artial thr'm#'&lastin time and thr'm#in time
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(A! 0rimar% Res&'nse

(:! Se"'ndar% Res&'nse

M N GEMENT Indi"ations 4or *os7itali8ation5 H's&italizati'n f'r #'lus I5F fluid is ne"essar%, where signifi"ant deh%drati'n (G*3H 'f n'rmal #'d% weight has '""urred( Sign D S%m&t'ms in"lude( ,a"h%"ardia In"reased "a&illar% refill time (G2s!( 6''l, m'ttled 'r &ale s)in( Diminished &eri&heral &ulses 6hanges in mental status 2liguria Sudden rise in haemat'"rit


Narr'wing 'f &ulse &ressure (I23mmHg ! H%&'tensi'n 5

Ta!le69 Guidelines 4or t3e Families o4 44e"ted Persons 01

ge I * %ear *-4 %ears @ and a#'ve Dose :Ta!le 9;1mg< J ,a#let K ,a#le * ,a#let M=dose =3 =3-*23 243

M N GEMENT OF DENGUE FE,ER ?ee& #'d% tem&erature #el'w 1< 6entigrade Give the &atient &ara"etam'l (n't m're than f'ur times in 24 h'urs! a""'rding t' the d'se &res"ri#ed #el'w/ D' n't give the &atient As&irin 'r I#u&r'fen( Give large am'unts 'f fluids (water, s'u&s, mil) and jui"es! al'ng with the &atientBs n'rmal diet 01/ Immediatel( Consult t3e P3(si"ian i4 an( o4 t3e Follo>ing Mani4estations a77ear 01 Red s&'ts 'r &'ints 'n the s)in( :leeding fr'm the n'se 'r gums( re$uent v'miting9 v'miting with #l''d9 #la") st''ls( Slee&iness9 "'nstant "r%ing9 a#d'minal &ain9 e8"essive thirst (dr% m'uth!( 0ale9 "'ld 'r "lamm% s)in9 'r diffi"ult% in #reathing(1,*3,**( M N GEMENT OF DENGUE *EMORR* GIC FE,ER 2 DENGUE +*OC' +YNDROME Dengue hem'rrhagi" fever D dengue sh'") s%ndr'me is a medi"al emergen"%( ,he immediate administrati'n 'f intraven'us fluid t' e8&and &lasma v'lume is essential( Immediate Re7la"ement o4 Plasma Loss luids used f'r ra&id v'lume e8&ansi'n in"lude the f'll'wing+ 0h%si'l'gi"al saline RingerBs la"tate 'r RingerBs a"etate @H glu"'se s'luti'n diluted * + 2 'r * + * in &h%si'l'gi"al saline 0lasma, &lasma su#stitutes (e(g(, de8tran 43! 'r @ H al#umin (@3g5l! Continues Re7la"ement o4 Furt3er Plasma Loss 0lasma l'ss ma% "'ntinue f'r 24-2A h'urs, re$uiring
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"'ntinued fluid administrati'n( Determinati'n 'f "entral ven'us &ressure ma% #e ne"essar% in the management 'f refra"t'r% sh'")( ,he administrati'n 'f intraven'us fluid sh'uld #e dis"'ntinued when the haemat'"rit level dr'&s t' a&&r'8imatel% 43H, with sta#le vital signs( 6'rre"ti'n 'f ele"tr'l%te and meta#'li" distur#an"es in h%&'natraemia and meta#'li" a"id'sis Sedative thera&% is needed in s'me "ases t' restrain an agitated "hild( A single d'se 'f "hl'ral h%drate (*2(@-@3mg5)g!, 'rall% 'r re"tall%, is re"'mmended( 28%gen thera&% sh'uld #e given t' all &atients in sh'")( :l''d transfusi'n is 'nl% indi"ated in "ases with signifi"ant "lini"al #leeding( resh fr'zen &lasma 'r "'n"entrated &latelets ma% #e indi"ated in "ases where "'agul'&ath% "auses massive #leedings( M'nit'ring 'f &atients in sh'") with fre$uent re"'rding 'f the vital signs and determinati'n 'f the haemat'"rit are im&'rtant in evaluating the results 'f treatment1( Com7li"ations o4 t3e Dengue Fever 7iver failure, m%'"arditis, a"ute renal failure, hem'l%ti" uremi" s%ndr'me, a"ute transverse m%elitis, en"e&hal'&ath%, disseminated intravas"ular "'agulati'n, a"ute res&irat'r% distress s%ndr'me, a#d'minal "'m&artment s%ndr'me, neur'l'gi"al s%m&t'ms, refra"t'r% sh'"), a"ute disseminated en"e&hal'm%elitis *2( Criteria 4or Dis"3arging Patients 5 ,his "riteria sh'uld #e met #ef're &atients re"'vering fr'm DH 5DSS are dis"harged( A#sen"e 'f fever f'r at least 24 h'urs with'ut the use 'f anti&%reti"s Return 'f a&&etite Fisi#le "lini"al im&r'vement G''d urine 'ut&ut and Sta#le haemat'"rit N' res&irat'r% distress fr'm &leural effusi'n 1 0latelet "'unt 'f m're than @3,333 &ermm 1 At least 2 da%s after re"'ver% fr'm sh'") Prevention 2 Control Measures 0resentl%, the 'nl% meth'd 'f "'ntr'lling 'r &reventing Dengue ever D Dengue Hem'rrhagi" ever is t' "'m#at the ve"t'r m's$uit'es(


Aedes aeg%&ti #reeds &rimaril% in man-made

Drain 'ut the water fr'm desert5wind'w air "''lers

"'ntainers li)e earthenware jars, metal drums and "'n"rete "isterns used f'r d'mesti" water st'rage, as well as dis"arded &lasti" f''d "'ntainers, used aut'm'#ile t%res and 'ther items that "'lle"t rainwater( ,e"tor Control It is im&lemented using envir'nmental management and "hemi"al meth'ds( 0r'&er s'lid waste dis&'sal and im&r'ved water st'rage &ra"ti"es, in"luding "'vering "'ntainers t' &revent a""ess #% egg la%ing female m's$uit'es, are en"'uraged thr'ugh "'mmunit%-#ased &r'grams( ,he a&&li"ati'n 'f a&&r'&riate inse"ti"ides t' larval ha#itats, &arti"ularl% th'se used #% the h'useh'lds, su"h as water st'rage vessels "an &revent m's$uit' #reeding f'r several wee)s theref're these inse"ti"ides must #e used &eri'di"all%( ,he use 'f famil% size inse"ti"ide treated nets (I,Ns! is als' re"'mmended( General inse"ti"ide s&ra%ing targeting m's$uit' #reeding ha#itats need t' #e "arried 'ut t' )ill adults using &'rta#le 'r tru")-m'unted ma"hines( Prevention o4 Mos?uito #ites Dengue m's$uit'es #ite during da% time( M's$uit' re&ellants sh'uld #e used t' &revent m's$uit' #ites( /ear full-sleeve "l'ths, s'")s and l'ng dresses t' "'ver the lim#s( 6are sh'uld #e ta)en in using re&ellents 'n ver% %'ung "hildren 'r the elderl%( ;se m's$uit' "'ils and ele"tri" va&'r mats during the da%time t' &revent m's$uit' #ites( ;se inse"ti"ide treated nets (I,Ns! t' &r'te"t %'ung "hildren, &regnant w'men, 'ld &e'&le, in additi'n t' 'thers wh' ma% rest during the da%( 6urtains ("l'th 'r #am#''! "an als' #e treated with inse"ti"ide and hung at wind'ws 'r d''rwa%s, t' re&el 'r )ill m's$uit'es( Prevent Multi7li"ation o4 Mos?uitoes :,e"tor Control< M's$uit'es whi"h s&read Dengue live and #reed in stagnant water in and ar'und h'uses, and &la"es where s'lid waste is dum&ed(
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when n't in use, in additi'n t' tan)s, #arrels, drums, and #u")ets( Rem've all '#je"ts "'ntaining water su"h as &lant sau"ers fr'm the h'use( All st'red water "'ntainers sh'uld #e )e&t "'vered at all times( 6'lle"t and destr'% dis"arded "'ntainers in whi"h water "'lle"ts, su"h as #'ttles, &lasti" #ags, tins, tires,et"( .ffi"ient dis&'sal 'f all s'lid waste5gar#age*3( ,he m'st effe"tive wa% t' "'ntr'l the m's$uit'es is the redu"ti'n 'f larva #% eliminating 'r "leaning 'f water h'lding "'ntainers as stated a#'ve that serve as the larval ha#itat f'r A(aeg%&ti( 0u#li" inv'lvement is ne"essar% t' im&lement m's$uit' "'ntr'l &r'gram (It "an #e a"hieved #% &u#li" edu"ati'n and law enf'r"ement*1(

, CCINE An effe"tive tetravalent va""ine remains a signifi"ant "hallenge( ,w' live attenuated dengue virus va""ines, attenuated #% &assing several times in n'n-human "ells, have #een devel'&ed( ,rial 'f a tetravalent va""ine sh'wed signifi"ant ser'-"'nversi'n rates (A<H! against all 4 ser't%&es 'f DF after the third d'se( H'wever, tw' d'ses 'f this va""ine "'nfer A3-<3H &r'te"ti'n in "hildren *4( 2ther va""ine, &re&ared #% /alter Reed Arm% Institute 'f Resear"h, &r'du"ed similar ser'"'nversi'n rates in adult v'lunteers *@( Several ris) fa"t'rs are ass'"iated with live attenuated RNA va""ine su"h as reversal t' a virulent &hen't%&e, and sh'rt life( CONCLU+ION Dengue viral infe"ti'ns are a maj'r and emerging gl'#al &u#li" health &r'#lem( ,he re"ent e&idemi" 'f this disease in 0a)istan has "aused harassment in all the "'mmunities 'f 'ur "'untr%( ever is the s%m&t'm &resent in alm'st all &atients( :leeding leads t' seri'us "'m&li"ati'ns in dengue fever( N' effe"tive va""ine 'r antiviral agents are availa#le f'r &reventi'n and treatment 'f dengue infe"ti'ns at the m'ment( Sin"e these infe"ti'ns are 'n the "'ntinu'us rise, s' it is 'f &aram'unt im&'rtan"e t' des"ri#e and "ateg'rize the "'mm'n manifestati'ns 'f these infe"ti'ns and dis&el undue &u#li" fears, em&l'% la#'rat'r% tests f'r its diagn'sis and utilize all &'ssi#le res'ur"es and ad'&t all a&&r'&riate measures f'r the management and


&reventi'n 'f this disease( Health edu"ati'n 'f the &u#li" "an &la% )e% r'le in the "'ntainment and "'ntr'l 'f this danger'us disease( REFERENCE+ *( Gu#ler DL( Dengue Firal Infe"ti'ns( Mah% :/L, Fan Regenm'rtel MHF( Des) .n"%"l'&edia 'f Human and Medi"al Fir'l'g%( :'st'n 23*39 A"ademi" 0ress( IS:N 3-*2-1>@*4>-3 htt&+55#'')s(g''gle("'m5#'')s(6ited23**(De"em #er <! 2( /'rld Health 2rganizati'n (/H2! Dengue guidelines f'r diagn'sis, treatment, &reventi'n and "'ntr'l( 233<9*4C=( htt&+55wh$li#d'"(wh'(int5&u#li"ati'ns5233<5<>A<2 4*@4>A (6ited 23**(De"em#er *3! 1( /'rld Health 2rganizati'n (/H2!( Dengue Hem'rrhagi" ever, Diagn'sis, ,reatment, 0reventi'n and "'ntr'l(2nd .diti'n(23*39 4-4@( 4( Ali N,Nadeem A, Anwar M, ,ari$ /;, 6h'tani RA( Dengue fever in malaria endemi" areas( L 6'll 0h%si"ians Surg 0ar) 233=9 *=+143-2( @( /ils'n N, Slane% D, :a)er MG, Hales S, :ritt'n .( Rev .nvir'n Health( 6limate "hange and infe"ti'us diseases in New Mealand+ a #rief review and tentative resear"h agenda( 23**9 2=+ <1-<( =( Ilahi A, Mansur I( Dengue 'nl% this %ear 'r ever% %ear (Isra Medi"al L'urnal (Ma%-August 23**9 1+4=-4>( >( 0hilli&s M7( Dengue Re#'rn+ /ides&read Resurgen"e 'f a Resilient Fe"t'r( .nvir'n Health 0ers&e"t 233A9 **=+ 1A2-A( A( R'denhuis- M%#ert IA, /ils"hut L, Smit LM NDengue virus life "%"le+ viral and h'st fa"t'rs m'dulating infe"tivit%O( 6ell( M'l( 7ife S"i( 23*39 =>+ 2>>1 - A=( <( Raja NS, Singh N N , Mehm''d ,, Sethi H, Raja NH,Lanjua ?A( Dengue Firal Infe"ti'ns( A Maj'r 0u#li" Health Issue( Internati'nal j'urnal 'f 0ath'l'g% 233<9 >+4-*2( *3( /'rld Health 2rganizati'n+ 0reventi'n and 6'ntr'l 'f Dengue ever and Dengue Hem'rrhagi" ever+ :asi" fa"ts f'r &u#li" edu"ati'n and guidelines f'r the families 'f affe"ted &ers'ns /'rld Health 2rganizati'n 5 Nati'nal Institute 'f Health Islama#ad, 23*3( **( .gger LR, 6'leman 0G( age and "lini"al dengue illness( .merg Infe"t Dis 233>9 *1+<24-@(
A.P.M.C Vol: 6 No.1 January-June 2012

*2( Seet R6, 7im .6, /ilder-Smith .0( A"ute transverse m%elitis f'll'wing dengue virus infe"ti'n( L 6lin Fir'l( 233=9 1@+ 1*3-2( *1( 2'i .., G'h ?,, Gu#ler DL( Dengue &reventi'n and 1@ %ears 'f ve"t'r "'ntr'l in Singa&'re( .merg Infe"t Dis 233=9 *2+AA>-<1( *4( M'nath ,,M"6arth% ?, :edf'rd 0, L'hns'n 6,, Ni"h'las R, P')san S, et al( 6lini"al &r''f 'f &rin"i&al f'r 6himeriva8 ,M+ re"'m#inant live, attenuated va""ine against lavivirus infe"ti'ns( Fa""ine 23329 23+*334-*A( *@( Singhi S, ?iss'n N, :ansal A( Dengue and Dengue hem'rrhagi" fever+ management issues in an intensive "are unit( L 0ediatr (Ri' L! 233>9 A1+ 22-1@( UT*OR+ Dr/ Mu3ammad n>ar +ule3ri M( 0hil (6'mmunit% Medi"ine! Assistant 0r'fess'r D Head 'f 6'mmunit% Medi"ine 0unja# Medi"al 6'llege, aisala#ad Pro4/ Dr/ Ria8 *ussain R6S (.din! 60S 0a) (H'n! 0r'fess'r 'f Surger% 0rin"i&al, 0unja# Medi"al 6'llege, aisala#ad Dr/ Na&a4 Imtia8 Gill Seni'r Dem'nstrat'r 0ath'l'g% 0unja# Medi"al 6'llege, aisala#ad ddress 4or Corres7onden"e Dr( Muhammad Anwar Sulehri Assistant 0r'fess'r D Head 'f 6'mmunit% Medi"ine 0unja# Medi"al 6'llege, aisala#ad 0h( 3133-==<=>4> .-mail+ anwarsulehri>1Q%ah''("'m