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Objectives

To be able to gain knowledge and understanding about the disease process of dengue, its classification and its prevention and management.

SCOPE OF PRESENTATION Definition of terms Alternative Names Etiologic Agent Mode of Transmission Epidemiology ources of infection !ncidence !ncubation "eriod and "eriod of #ommunicability Disease "rocess of Dengue Dengue #ase #lassification "hases of Dengue illness $aboratory E%aminations "revention, Management,Treatment and #ontrol Nursing !nterventions "rognosis #heck on $earning ummary

DEFINITION OF TERMS
Defervescence & Abatement of a fever as indicated by a reduction in body temperature DENV & dengue virus Epidemiolo ! ' deals with transmission and control of the disease. Etiolo ic " ent & it includes viruses, fungi, proto(oa, bacteria Incidence ' the number of cases of the disease Inc#b"tion Period & The period between infection and the appearance of symptoms of the disease Mode of Tr"nsmission ' it indicates the potential of the disease) conveyance of the agent to the host Pro nosis &A prediction of the course of a disease Reservoir ' the environment in which the agent is found Vector ' any agent that carries a disease

DEN$%E
An infectious disease caused by any of the four serotypes of flavivirus *DEN+,,DEN+-,DEN+.,DEN+/0 which are spread by mos1uitoes in tropical and subtropical areas. #haracteri(ed by severe pain behind the eye and in the 2oints and bones and accompanied by an initial erythema and a terminal rash.

A&TERNATIVE NAMES 3reakbone 4ever


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Dandy 4ever "hilippine 5emorrhagic 4eve ETIO&O$IC A$ENT 4lavivirus * DEN+ ,, - , . , /0 Arbovirus namely 6nyong&onyong, #hikungunya, 7est Nile

MODE OF TRANSMISSION 3ite of infective mos1uitoes principally female Aedes aegypti (urban areas) and Aedes albopictus (rural areas). Described as8 Day biting, low flying mos1uito with increased biting activity for two hours after sunrise and two hours before sunset 3reeds on clear, stagnant water 5as gray wings and white stripes on the body

Aedes "e !pti

EPIDEMIO&O$' Dengue is the most rapidly spreading mos1uito&borne viral disease in the world. !n the last 9: years, incidence has increased .:&fold with increasing geographic e%pansion to new countries and in the present decade from urban to rural settings. An estimated 9: million dengue infections occur annually and appro%imately -.9 billion people live in dengue endemic countries. 3etween -::, and -::;, ,,:-:,... cases were reported in #ambodia, Malaysia, "hilippines and +ietnam& the four countries in the 7estern "acific <egion with the highest numbers of cases and deaths. The combined death toll for these four countries was /=>; *official country reports0. #ompared with other countries in the same region, the number of cases and deaths remained highest in #ambodia and the "hilippines in -::;. 6verall, case management has improved in the 7estern "acific <egion, leading to decrease in case fatality rates. !ncrease of ; ? from @anuary May -:,, reported cases of -.,::: according to the Department of 5ealth.

SO%RCES !nfected persons The virus is present in the blood of patients during the acute phase of the disease and will become a reservoir of virus accessible to mos1uitoes which may then transmit the disease. tanding water within the household and premises are usual breeding places. INCIDENCE
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AAE8 The infection may occur at any age but common among school children with the peak between / and B years old

EC8 3oth se%es e1ually affected EA 6N8 More fre1uent during rainy season or months

AE6A<A"5!#A$8 More prevalent in urban communities or localities INC%(ATION PERIOD .&,/ days, commonly =&,: days

PERIOD OF COMM%NICA(I&IT' "atients are usually infective to mos1uito from a day before the febrile period to the end of it Mos1uito become infective ;&,- days after blood meal and infective all throughout life PAT)OP)'SIO&O$' OF DEN$%E

PREDISPOSIN$ FACTORS & Aeographical *Tropical and ubtropical Areas0 & #limate change

PRECIPITATIN$ FACTORS & Mos1uito infected by dengue virus & weaty skin & !mmunocompromised & oldiers

Aedes Aegypti +iral replication about


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;&,- days on the salivary gland of the mos1uito

"ortal of Entry in the kin * Mos1uito 3ite 0

+irus in the blood stimulates the release of the 73#Ds including 3 lymphocytes

Antibodies attach to viral antigen and Performs phagocytosis and dengue virus replication

<elease of #ytokines consist of vasoactive agents

DENAEE !N4E#T!6N

$iver !n2ury

#ellular direct destruction !n the <ed bone marrow

#oagulation defect 3leeding

Thrombocytopenia !ncreased +ascular "ermeability

5emoconcentration "leural Effusion

$eakage of "lasma

5ypotension

hock

DEAT5

DEN$%E CASE C&ASSIFICATION ACCORDIN$ TO *)O FM"T6MAT!# DENAEE +!<E !N4E#T!6N + CATE$ORIES Endifferentiated fever Dengue fever *D40 Dengue hemorrhagic fever *D540 / E+E<!TF A<ADE Arade !
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Arade !! Arade !!! Arade !+ Dengue hock yndrome

#urrently the classification into DF/DHF/DSS continues to be widely used. Dengue 4ever ' the type without significant hemorrhages Dengue 5emorrhagic 4ever ' characteri(ed by abnormal vascular permeability, hypovolemia, and abnormal blood clotting mechanism. $r"de I ' 4ever accompanied by non&specific constitutional symptoms and the only hemorrhagic manifestation is *G0positive tourni1uet test. $r"de II ' All signs of grade ! plus spontaneous bleeding from the nose, gums, A!T. $r"de III ' "resence of circulatory failure as manifested by weak pulse, narrow pulse pressure, hypotension, cold clammy skin and restlessness. $r"de IV ' "rofound shock) undetectable blood pressure and pulse

+ P)ASES OF DEN$%E I&&NESS I, FE(RI&E $ast -&= days 5igh&grade fever 4acial flushing kin erythema Aenerali(ed body ache
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5eadache Anore%ia Nausea and vomiting *G0 positive tourni1uet test "etechiae and mucosal membrane bleeding *e.g. nose and gums0 Decreased in total white cell count Enlarged and tender liver 5ermanDs sign * pathognomonic sign0 maculopapular or petechial rash maybe present that usually start in the distal proportion of the e%tremities) the skin appear purple with blanched areas with varied si(es

II,CRITICA& Time of defervescence *temperature drops to .=.9&.;H#0 on days .&= of illness I capillary permeability)I hematocrit level *marks the beginning of critical phase0 "rogressive leukopenia)J platelet count "leural effusion and ascites *seen in chest %&ray and abdominal ultrasound0 hock when critical volume of plasma is lost through leakage)preceded by warning signs * subnormal body temperature0 The conse1uent organ perfusion results in progressive organ impairment,metabolic acidosis and disseminated intravascular coagulation which leads to hemorrhage causing J hematocrit in severe shock. !ncreased total white cell count in patients with severe bleeding. !mprovement after defervescence said to have non severe dengue and some progress to critical phase without defervescence. Those who deteriorate with warning signs are called dengue with warning signs. III, RECOVER' "atient survives the -/&/; critical phase, a gradual reabsorption of e%travascular compartment fluid takes place in the following /;&=- hours.
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!mprovement on general well being, appetite returns and gastrointestinal symptoms abate tabili(ed hematocrit or may be lower due to dilutional effect of reabsorbed fluid

SEVERE DEN$%E Defined as one or more of the following8 "lasma leakage that may lead to shock *dengue shock0 and or fluid accumulation with or without respiratory distress evere bleeding evere organ impairment produces tachycardia and

During the initial stage of shock, the compensatory mechanism which maintains a normal systolic blood pressure peripheral vasoconstriction "ulse pressure of -:mm5g or less and rapid weak pulse or hypotension 5igh or progressively rising hematocrit "leural effusion or ascites #irculatory compromise or shock * tachycardia, cold and clammy e%tremities 0 #apillary refill time greater than . secs. 7eak or undetectable pulse or in late shock ) unrecordable blood pressure ignificant bleeding

Altered level of consciousness

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&A(ORATOR' E-AMINATIONS Test may include the following8 5ematocrit , "latelet count Electrolytes #oagulation studies $iver en(ymes Torni1uet test C&ray of the chest *may demonstrate pleural effusion0 erologic studies *demonstrate antibodies to Dengue viruses0 erum studies from samples taken during acute illness and convalescence *5igh in titer to Dengue antigen0 PREVENTION AND CONTRO& Early detection and treatment of cases #ase finding and reporting 5ealth teaching !solation of patient *Ese of mos1uito nets0 Destroy the breeding places a. #hanging water and srubbing sides of lower vases once a week b. Destroy breeding places of mos1uito by cleaning surroundings, proper disposal of rubber tires, empty bottles and cans c. Avoid too many hanging clothes inside the house d. <esidual spraying with insecticides
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TREATMENT Mainly symptomatic and supportive There are no specific antiviral drugs I,DEN$%E )EMORR)A$IC FEVER .*IT)O%T S)OC/0 6ral fluid and electrolyte ' should be encouraged to prevent and correct dehydration which results from hyperpyre%ia, anore%ia and vomiting. Anti& pyretics Kacetaminophen *do not use aspirin0 Anti& convulsant drugs *i.e dilantin0 5ematocrit *5ct0 determination 5emoglobin *5gt0 determination "atientDs should be hospitali(ed and treated immediately when signs and symptoms of shock are noted. II, DEN$%E S)OC/ S'NDROME 3lood transfusion !ndicated when significant signs of bleeding as melena and hematemesis 7hen thrombocytopenia sets in *platelet count L 9:,:::Kmm. 0 "repare fresh whole blood Transfuse if active bleeding occurs or both 5ct and 5gb level falls "ersistent bleeding and disseminated intravascular coagulopathy follow whole blood transfusion with cryoprecipitate 6%ygen

!ndicated for all patients in shock edatives May be needed to allay apprehension or agitation N%RSIN$ INTERVENTIONS #ontrol measure8 eradication of mos1uitoes
4or 5emorrhage ' 13

a. Meep the patient at rest during bleeding episodes. b. 4or nose bleeding, maintain an elevated position of trunk and put an ice bag over the forehead. 4or melena, ice bag over the abdomen. c. !f transfusion is given, support the patient during the therapy. 6bserve signs of deterioration *shock0 such as low pulse, cold clammy skin. hock a. "revention is the best treatment b. Trendelenburg position facilitates greater blood volume to the head part 4or an%iety of "atient and 4amily&e%plain thoroughly the nature, discomforts and limitations of activity associated with diagnostic procedures Diet a. $ow fat, low fiber, non&irritating, non&carbonated and avoid dark colored foods 4ever a. #ooling measures through sponges and administer prescribed drugs. b. Encouraged fluid intake unless contraindicated PRO$NOSIS A<ADE ! AND !! & Aood "rognosis A<ADE !!! & Auarded A<ADE !+ ' erious *mortality rate very high0

S#mm"r!
N At the end of the lecture, the participants gained knowledge and understanding about8 Definition of dengue Etiologic Agent Mode of Transmission Epidemiology !ncubation "eriod of #ommunicability Disease "rocess of Dengue Dengue #ase #lassification
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$aboratory E%aminations "revention and #ontrol Treatment and Nursing !nterventions "rognosis

REFERENCES #ommunity 5ealth Nursing >th Edition, -::: MimDs Medical Microbiology /th Edition -::; #ompilation of #ommunicable Diseases in Nursing Abraham Edition ,>>: *ebsites1 #enters for Disease #ontrol and "revention www.cdc.gov 7orld 5ealth 6rgani(ation www.who.int 7ikipedia The 4ree Encyclopedia http8KKen.wikipedia.orgKwikiKDenguefever . 3enenson, O #ontrol of #ommunicable Diseases in Man ,9 th ervices in the "hilippines, Department of 5ealth

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