1. Andrea Montelibano Isabelle Escobillo

2. The Virus Flavivirus Single strand RNA 4 serotypes – DENV-1 – DENV-2 – DENV-3 – DENV-4 Infection with one serotype confers lifelong immunity to that serotype but not for the other Secondary infection leads to severe form

3. The Virus Vectors – Aedes aegypti – Aedies alpobtica

4. Transmission Female mosquito infects human during the viremic phase Virus replicates in the epithelial cell lining of the midgut  hemocele  salivary glands Usually occurs during the rainy season High vector population is also found in man- made storage containers

5. Clinical Features Incubation: 4-6 days (range 3-14) Constitutional symptoms Sharp rise in temperature Flushing, headache, chills, retro-orbital pain, photophobia, joint pains, anorexia, constipations, colicky pain, abdominal tenderness

6. Clinical Features Fever – Usually between 39C and 40C, biphasic, lasting 5- 7 days Rash – Day 1-3: Diffuse flushing or fleeting eruptions on the face neck and chest – Day 3-4: Maculopapular or rubelliform – Convalescence: confluent petechiae surround scattered pale areas or normal skin

7. Clinical Features Hemorrhagic manifestations – Positive tourniquet test – Massive epistaxis, hypermenorrhea, GI bleeding

8. Laboratory Features Leukopenia: WBC =< 5000 cells/mm3 Mild thrombocytopenia (100,000 to 150,000 cells/mm3) Mild hematocrit rise (=10%) Elevated liver enzymes

9. Classification

10. Dengue without Warning Signs Lives in or travels to dengue-endemic area, with fever, plus any 2 of the following: – Headache, body malaise, myalgia, arthralgia, retro-orbital pain, anorexia, nausea, vomiting, diarrhea, flushed skin, rash, positive Tourniquet test – CBC with leukopenia, with or without thrombocytopenia and/or dengue NS1 antigen test or dengue IGM antibody test

11. Dengue with Warning Signs Lives in or travels to dengue-endemic area, with fever of 2-7 days, plus any of the following: – Abdominal pain or tenderness, persistent vomiting, clinical signs of fluid accumulation, mucosal bleeding, lethargy or restlessness, liver enlargement, decreased or no urine output within 6 hours – Increase in hematocrit and/or decreasing platelet

12. Severe Dengue Lives in or travels to dengue-endemic area, with fever of 2-7 days and any of the manifestations of dengue with/without warning signs, plus any of the following – Severe plasma leakage: shock, fluid accumulation with respiratory distress – Severe bleeding – Severe organ impairment Liver: AST or ALT >= 1000 CNS: Seizures, impaired consciousness Heart: Myocarditis Kidneys: Renal failsure

13. Laboratory Diagnosis Dengue NS1 – Detectable on Day 1 to 5 Dengue IgM/ IgG – Day 3-5 onwards

14. Clinical Course

18. Management

20. When sending home a patient, patient and family advice should be given:

21. Management Follow-up: – Daily follow-up is recommended for all patients except those who have resumed normal activities or are normal when the temperature subsides

22. Fluid Management

23. Fluid management for patients who are not admitted Calculation of Oral Rehydration Fluids Using Weight (Ludan Method)

24. Fluid management for patients who are admitted without shock Isotonic solutions: D5 LRS, D5 NSS, D5 0.9 NaCl, PLR, 0.9 NaCl Infants <6 months: Dr 0.45 NaCl Calculation of Maintenance IV Fluid Infusions (Holliday and Segar Method)

25. Fluid management for patients who are admitted without shock Signs of mild dehydration – TFR = Maintenance IVF + Fluids for Mild Dehydration – Infant (age =< 12 months): 50 ml/kg – Older Child or Adult (age > 12 months): 30 ml/kg Clinical parameters should be monitored and correlated with hematocrit Use Ideal body weight for overweight patients

26. Fluid Management for Patients with Compensated Shock

27. Hemodynamic Assessment: Continuum of Hemodynamic Changes

28. Fluid Management for Patients with Hypotensive Shock

29. Prevention Success is dependent on – Effectiveness of the initiatives to control the breeding sites of the vector – Improving public and household environmental sanitation and water supply, – Sustained modification of human behaviour

30. Prevention Community Participation – active voluntary engagement of individuals and groups to change problematic conditions and influence policies and programmes that affect the quality of their lives or the lives of others – households which do follow the recommended actions for prevention may still harbour Ae. aegypti or other mosquitoes

31. Prevention Surveillance Vector Control (Future) Vaccination

32. Thank You!!