Dengue Fever in the Philippines Good day to everyone. I would like to introduce myself. I am Camille Sana , a Masters in Public Health student. Today, I will be giving you an educational presentation on Dengue Fever in the Philippines. Dengue fever has resulted to a significant burden to the Philippines. For many years , it has affected a substantial amount of the population falling ill and even causing death. With this presentation I want to provide you with information to better understand the disease and promote the implementation of measures to control this problem. Dengue is a threat to health and everyone is at risk . Photo Reference: Picture retrieved from: http://www.cdc.gov/dengue/resources/CS_205910-A.Dengue%20patient%20Ed%20Eng.FINAL.pdf 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 I would like to provide a brief over view of what to expect from my presentation for today. I will define Dengue and provide you the common signs and symptoms of the disease and information on the impact of this illness in the Philippines . I will discuss Dengue transmission and prevention . I will provide you examples of anti-Dengue efforts. For those who would like to do further research, I will provide you additional information and the list references and sources I have used for this presentation . We can open the floor for any questions at the end. I expect that you will have a better understanding of the negative consequences of Dengue, recognize the routes of infection and apply the different effective vector control methods after my presentation. The disease burden of dengue in the Philippine community has been pervasive and nationwide. This presentation is to encourage and promote among rural health workers and the general public to importance in taking a positive action in fighting dengue that has plagued the Philippines for many years. The objective of this presentation is to raise public awareness of the current problem , to encourage everyone to actively participate and utilize effective control measures that would eradicate the mosquito and the disease .

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 Dengue Fever is transmitted by a bite from an infected aedes aegypti mosquito. The Aedes mosquito gets infected through biting a Dengue-infected person. Dengue is common in tropical countries like the Philippines. Dengue has also been reported in other regions like America and Africa. Signs of illnesses vary from person to person and may present as flu-like symptoms. It can lead to a complication called Dengue Hemorrhagic fever that can be lethal. (CDC, 2009) Reference: Centers for Disease Control and Prevention (2009). Dengue frequently asked questions. Retrieved from http://www.cdc.gov/Dengue/faqFacts/index.html Photo reference: Mosquito Photo: Retrieved from http://bepast.org/dataman.pl?c=flib&dir=docs/photos/dengue/

Clinical Manifestations Clinical presentations of dengue illness are non specific. They can present as fever, abdominal pain, vomiting, nose or gum bleeding, lethargy and restlessness . For patients presenting with fever, Dengue should be always be considered .Medical management of the illness is simple and inexpensive. And if identified early can lead to a favorable outcome for the patient. There are 3 phases: The Febrile phase is characterized by development of high grade fever usually 2-7 days. Petecchial rashes appear on the different parts of the body. Patient complains of headache and joint and muscle aches. Gum bleeding or nose bleeding can also occur. The Critical phase happens when the fever goes down. This when the platelet count also goes down causing internal bleeding. Without the proper blood work , a patient might feel that they are getting better but is actually going to the second phase of the illness. This phase happens in 2 to 3 days. It is fast and the patient’s condition worsen within this time. The next phase is the Recovery phase. With proper hydration and supportive treatment, the patient recovers. ( WHO, 2009) Reference: World Health Education ( 2009).Dengue guidelines for diagnosis treatment prevention and control. Retrieved from http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf 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 The Dengue Hemorrhagic Fever is divided into 4 grades. Grade 1 is non specific. A simple test using Tourniquet test. This is done by inflating the BP cuff half way between the diastolic and systolic pressure. Leave it inflated for 5 minutes. If more than 10 small red rashes appear in 1 square inch. This is considered a positive tourniquet test ( WHO ,2006). Grade 2 presents bleeding such as nose and gum bleeding. Grade 3 involves internal bleeding resulting to circulation failure. Grade 4 presents severe internal bleeding, the patient can go into hypovolemic shock.( WHO, 2006) Reference: 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 Photo Reference: Skin rash picture retrieved from http://denguefever.co.in/dengue-rash-pictures

Impact of Dengue in the Philippines 1996-2005 Dengue Incidence Manila, Philippines 1996 -2005 Here is a graph of incidence of Dengue in Manila from 1996 to 2005. As you can see Dengue is reported to occur year round but peaks on increased incidence can be seen in July 1996 , July 1998 and July 2005. The Philippines being a tropical country experiences sporadic rainfalls. Higher reported cases coincide with the months considered the rainy season, which is typically around the months June to September ( Sia, 2008). Incidences of Dengue increase during rainy season because the mosquitoes breed in the water. Reference; 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 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 Here is a graphical report from the latest Department of Health Dengue Surveillance. This graph shows comparison of cases by month of 2010 to 2011. In 2010, cases have been reported for the entire year with increased incidence in months of July to September. Although the incidence in 2011 has shown a decrease (DOH, 2011). Reference: Department of Health (2011) Dengue cases disease surveillance report morbidity week 36. Retrieved from http://dev1.doh.gov.ph/sites/default/files/2011Den36WMR_draft.pdf Source: Department of Health Philippines Disease Surveillance Report Morbidity Week 36 ,figure 1 page 1

Impact of Dengue in the Philippines 2010-2011(cont.) Here is a graphical report from the latest Department of Health Dengue Surveillance. Looking at the distribution affected by age group, Dengue can affect equally both male and female genders and all types of ages. However, majority of cases ( 40.9%) belonged to the 1 to 10 age groups ( DOH, 2011). The children are particularly vulnerable because they have weak and undeveloped immune system. They are also less likely to be able to recover from the internal bleeding and has increased risk of dying from the disease ( WHO, 2009). Reference: DOH Disease Surveillance Week 36. Retrieved from http://dev1.doh.gov.ph/sites/default/files/2011Den36WMR_draft.pdf 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 Source: www.CDC.com The figure on the top shows the life cycle of the aedes aegypti mosquito. It is important to note that the egg to pupa stage is spent on water. The mosquito lays its eggs on water and grow in the water from a larvae to pupae. Humans are the hosts of the dengue virus. After being bitten by an infected mosquito, 4-10 days later symptoms of the illness start to show. Each individual host reacts differently to dengue. This varies on age and presence of chronic illnesses like asthma or diabetes. Children are a greater risk than adults because they are unable to recover from the bleeding during the shock phase. Transmission is through a bite of an infected aedes mosquito. (CDC,2010; WHO, 2009,p 15) Reference : 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 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 Photo Reference: Life Cycle picture retrieved from http://www.extension.org/pages/20422/general-household-pests:-mosquitoes (2012) Photo of Mosquito Bite: Retrieved from http://www.everydayhealth.com/skin-and-beauty-pictures/18-home-cures-for-mosquito-bite-itch.aspx#/slide-1 (2012) TRANSMISSION: Humans get infected from bite of infected aedes mosquito. Mosquitos get infected when they bite infected humans. Source: Everyday health.com Reference: CDC, n.d.

Prevention Environmental Management Biological Control Chemical Control There are different methods of preventing Dengue Fever : Environmental management, Biological Control and Chemical control. I will now discuss each method in more detail in the succeeding slides.

Prevention (cont.) ENVIRONMENTAL MANAGEMENT Modification Manipulation Changes in Human Behavior Source: CDC,n.d. Source: CDC,n.d. One way of prevention is through Environmental management . There are 3 different ways environmental management for Dengue. Environmental modification is permanently changing the physical environment that affect the mosquito habitat. Examples of environmental modification is improving water supply and storage systems, provision of piped in water can eliminate the need to store water in containers. Environmental manipulation is a temporary change in physical environment of the mosquito habitat. An example of environmental manipulation is covering water containers prevents the vessels from becoming a breeding ground , disposing old tires that accumulate water from the rain that can also become a breeding ground for mosquitoes . Changes in human behavior can be any actions done by the human to reduce contact with the mosquito. Examples include use of mosquito nets, screening doors and windows and wearing of clothing that cover the skin . (WHO, 2009, p 61) Reference: World Health Education ( 2009).Dengue guidelines for diagnosis treatment prevention and control. Retrieved from http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf Photos Reference: Water bucket, water storage and photo tire Retrieved from http://www.cdc.gov/dengue/resources/Vector%20control%20sheet%20dengue.pdf Mosquito Net: Retrieved from http://blog.travelpod.com/travel-photo/aaronpolarbear/1/1240322880/mosquito-net.jpg/tpod.html Source: CDC,n.d.) Source:travelpod)

Prevention (cont.) CHEMICAL CONTROL Use of insecticides Fogging Use of mosquito coils Repellents Another way is through Chemical control. This is the use of chemical such as insecticides that are sprayed in the area to kill mosquitoes are also effective. Fogging is a type of application of insecticide. Application of mosquito repellents and use of mosquito coils can also drive away the disease causing mosquitoes. ( CDC, 2010) Reference: 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 Photo Reference: Fogging retrieved from http://www.mosquitoesandmore.com/mosquito_fogging.phpR Source: mosquitoes and more.com

Prevention (cont.) BIOLOGICAL CONTROL Fish (poecilia reticulata) Predatory copepods (copepoda cyclopoidea) Lethal ovitraps Source: US Geological Survey Source: US Geological Survey Biological control of Dengue includes use of organisms that prey or interrupt the life cycle of the mosquitoes resulting to reducing the mosquito population. Examples of predatory organisms are the fish Poecilia reticulata and the copepoda cyclopoidea that kill by eating the eggs, larvae and pupa of the mosquitoes ( Elias et al, 1995). The ovicidal and larvicidal traps interrupt the life cycle of the mosquitoes by attracting the female mosquito to lay eggs on the trap. The trap contains substances that kills the eggs. ( WHO, 2009, p 72) Reference: 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 World Health Organization ( 2009). Dengue guidelines for diagnosis and treatment. Vector management and delivery of vector control services. Chapter 3. Retrieved from http://whqlibdoc.who.int/publications/2009/9789241547871_eng.pdf Photos Reference: Poecilia Reticulata Retrieved from http://nas.er.usgs.gov/queries/factsheet.aspx?SpeciesID=863 Cyclopoidea Retried from nas.er.usgs.gov/queries/factsheet.aspx?Specie... Ovitrap: Retrieved from http://www.affordablecebu.com/load/health/how_to_make_a_dengue_carrying_mosquitoes_ovicidal_larvicidal_ol_trap_system_in_the_philippines/24-1-0-1644 Source: DOH

Anti-Dengue Programs in the Philippines June 2011: Dengue Prevention Month Massive anti-dengue campaign Source: www.ifmt.auf.org Due to the alarming increase of Dengue illness in the Philippines, the Department of Health along with different sectors such as media, local government, private sectors have worked together to fight Dengue. In June 2011, the Department of health announces it as the Dengue prevention month. Massive anti-dengue campaigns using media campaigns in such flyers and posters were distributed. Flyers and education materials show how to help eradicate the mosquitoes by removing water sources that can be a breeding ground for mosquitoes. These campaigns are geared towards raising awareness to the communities about the threat of Dengue, to call the public to action and do their share in eliminating the mosquitoes. Photos Reference: Flier: Retrieved from http://www.ifmt.auf.org/IMG/pdf/Dengue-Images-2.pdf Anti dengue poster retrieved from http://www.tacloban.gov.ph/news/anti-dengue-posters-posts-awareness-reminders-to-taclobanons/ 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 The Philippine Department of Science and Technology partnered with the Department of Health in supplying local schools and communities with the Ovicidal-Larvicidal trap. The OL trap was invented by the scientists at the Department of Science and Technology to control the aedes mosquito vector. This was simple to use, inexpensive and is proven to kill the eggs of the mosquito causing dengue. ( DOST, n.d.) Reference: Department of science and technology (n.d.).Mosquioto OL trap. Retrieved from www.science.ph/oltrap/ Photo Reference: Retrieved from http://www.magandangideya.com/2011/07/24/mosquito-traps-installed-in-classrooms/ Retrieved from DOH www.science.ph/oltrap/ Source: DOH

Anti-Dengue Programs in the Philippines ( cont.) Multi-sectoral mosquito “search and destroy” cleanup campaign “Search and destroy” and clean up campaigns are held in various areas of the Philippines. These were participated by local government, churches , public and private schools in different communities. These include cleaning of the streets, picking up trash, emptying old tires and containers that contain water. Removing any possible breeding grounds for mosquitoes.( DOH, 2011) Reference: Department of health ( 2011). Dengue surge in Luzon. Retrieved from http://dev1.doh.gov.ph/content/dengue-surge-luzon Photo Reference: Community health development 2011.University of Makati , College of Nursing 2011 Source: College of Nursing, University of Makati

Conclusion Dengue is a health threat Dengue is Preventable Plan for action Dengue fever is endemic in all regions of the Philippines with epidemics occuring every 3 to 4 years. Since 2001 , the cases of dengue has remained high ( WHO,2012). Dengue illness can lead to a severe negative health outcomes including death. There are tremendous challenges in a developing country such as the Philippines. There are still many individuals who do not understand dengue and how this can be prevented, frequent monsoon rains and flooding in certain areas of the country increases the breeding grounds for the mosquitoes, increasing population growth, urbanization, problems with waste management in the various areas of the Philippines all make vector control a challenge. Dengue is a threat to everybody’s health ,everyone is all at risk and should be everybody’s concern. The key is to winning the fight against Dengue is to increase public awareness through educational campaigns and use effective community partnership programs to work together to apply an effective method to eliminate the vector (DOH, 2011), otherwise the Philippines will continue to be attacked by Dengue causing mosquitoes. Dengue is preventable. It is evident that there are many available opportunities that can be utilized by individuals and communities to eradicate the dengue virus. Reference: 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 Department of health ( 2011). Dengue surge in Luzon. Retrieved from http://dev1.doh.gov.ph/content/dengue-surge-luzon Photos Reference: Retrieved from http://www.adra.org/site/News2?page=NewsArticle&id=11533 Source:ADRA

Thank you Thank you very much. We can open the floor for any questions you may have.

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 There are additional information and resources if you would like to do further readings and research.

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’s pupal-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 Here are the references and sources I used in preparing this presentation.

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