2. Brunilda Lugo, PhD student Walden University PUBH-8165-10 Instructor: Dr. Robert Marino Spring term, 2010

4. Table of Content ContentSlides Learning objectives Learning objectives Learning outcomes Learning outcomes Dengue and causative agent Dengue and causative agent Transmission and vectors Transmission and vectors Geographic distribution Geographic distribution Breeding sites & life cycle of Aedes Breeding sites & life cycle of Aedes Signs and symptoms of Dengue Signs and symptoms of Dengue Diagnostic, treatment, prevention Diagnostic, treatment, prevention Epidemiology Epidemiology Dengue and Public Health Dengue and Public Health Final words Final words References References Credits Credits456-78-1213-1516-1820-2324-2627-2829-323335-3637

5. Learning Objectives The learning objectives of this presentation are to: The learning objectives of this presentation are to: Understand what is Dengue Fever, Dengue Hemorrhagic fever and Dengue Shock Syndrome Understand what is Dengue Fever, Dengue Hemorrhagic fever and Dengue Shock Syndrome Understand the modes of transmission and how to prevent exposure Understand the modes of transmission and how to prevent exposure Understand the geographic importance of the disease Understand the geographic importance of the disease Understand the importance of dengue from a public health point of view Understand the importance of dengue from a public health point of view

6. Learning Outcomes Learning Outcomes By the end of the presentation the audience will be able to: Define dengue fever Define dengue fever Describe vectors, breeding sites and life cycles Describe vectors, breeding sites and life cycles Recognized the signs and symptoms of the clinical manifestation of dengue Recognized the signs and symptoms of the clinical manifestation of dengue Describe diagnostics, treatment and preventive measures of dengue Describe diagnostics, treatment and preventive measures of dengue Demonstrate knowledge about the epidemiology of dengue Demonstrate knowledge about the epidemiology of dengue Discuss what public health is doing about this disease Discuss what public health is doing about this disease

7. What is Dengue? Is an acute fever producing infectious disease Is an acute fever producing infectious disease Mostly found in the tropics Mostly found in the tropics Pronounce DEN-ghee Pronounce DEN-ghee Complications can be fatal Complications can be fatal It is also known as Dengue fever, breakbone fever or It is also known as Dengue fever, breakbone fever or Dengue hemorrhagic fever Dengue hemorrhagic fever Bauman, R., (2006). Microbiology disease by systems. San Francisco, CA: Pearson Benjamin Cumming Publishers

8. Causative agent of Dengue Dengue is cause by a RNA virus This virus is a member of the viral family Flaviviridae. This virus is a member of the viral family Flaviviridae. Dengue virus Bauman, R., (2006). Microbiology disease by systems. San Francisco, CA: Pearson Benjamin Cumming Publishers

9. Transmission of Dengue A mosquito is the biological vector A mosquito is the biological vector This mosquito is the obligate intermediate host for some viruses This mosquito is the obligate intermediate host for some viruses Aedes albopictus/aegypti are generally associated with the spread of dengue fever Aedes albopictus/aegypti are generally associated with the spread of dengue fever Biting around the ankles and knees close to the ground in the daytime. Biting around the ankles and knees close to the ground in the daytime. Only female mosquitoes will bite; mostly in the daytime Only female mosquitoes will bite; mostly in the daytime Akram, W., (n.d.). Aedes as a vector of Dengue: a possible threat to our lives. Khwarzimig Science Society. University of Agriculture, Faisalabad. Retrieved April 19, 2010 from http://www.khwarzimic.org/takveen/dengue_kss.pdf

10. Aedes albopictus The Asian tiger mosquito was found in Florida at a tire dump site near Jacksonville The Asian tiger mosquito was found in Florida at a tire dump site near Jacksonville The species has spread rapidly throughout the eastern states, including all Florida’s 67 counties The species has spread rapidly throughout the eastern states, including all Florida’s 67 counties Aedes albopictus is a vector for many viruses including dengue fever and Eastern equine encephalitis virus Aedes albopictus is a vector for many viruses including dengue fever and Eastern equine encephalitis virus Currently this mosquito is established in 866 counties in 26 states Currently this mosquito is established in 866 counties in 26 states Rios, L., Maruniak, J.E. (2008). Asian tiger mosquito. University of Florida Institute of Food and Agricultural Sciences. Retrieved April 19, 2010 from http://www.entemdept.ufl.edu/creatures/aqutic/asian_tiger.htm

11. Aedes albopictus

12. Aedes aegypti Currently is limited to the southeastern quadrant of the U.S., and small areas in New York and Arizona Currently is limited to the southeastern quadrant of the U.S., and small areas in New York and Arizona The most competent vector of dengue virus and yellow fever The most competent vector of dengue virus and yellow fever As A. albopictus, this mosquito depend greatly on stored water for breeding sites. As A. albopictus, this mosquito depend greatly on stored water for breeding sites. Male and Females adults feed on nectar of plants Male and Females adults feed on nectar of plants Females bloodfeed primarily on humans in order to produce eggs Females bloodfeed primarily on humans in order to produce eggs A. aegypti bites during the day, indoor as well as outdoors A. aegypti bites during the day, indoor as well as outdoors Zettel, C., Kaufman, P. (2008). Yellow fever mosquito. University of Florida Institute of Food and Agricultural Sciences. Retrieved April 19, 2010 from http://entnemdept.ufl.edu/creatures/aqutic/aedes_aegypti.htm

13. Aedes aegypti

14. Geographic distribution of Dengue Dengue disease occurs in tropical and subtropical areas Dengue disease occurs in tropical and subtropical areas Endemic in over 100 countries in the Caribbean, South, Central and North America, Africa, the Pacific Islands, Hawaii, Asia, Eastern Mediterranean and Australia Endemic in over 100 countries in the Caribbean, South, Central and North America, Africa, the Pacific Islands, Hawaii, Asia, Eastern Mediterranean and Australia Before 1970 only nine countries had experience dengue hemorrhagic fever epidemics, a number that had increased more than four-fold by 1995 Before 1970 only nine countries had experience dengue hemorrhagic fever epidemics, a number that had increased more than four-fold by 1995 World Health Organization, (2009). Dengue and Dengue haemorrhagic fever. Retrieved April 19, 2010 from http://www.who.int/mediacentre/factsheets/fs117/en/

15. Geography distribution of Dengue BBB Blue dot: Geographic extension of dengue 2000-2007 Blue shaded areas: Risk of dengue transmission Lines: Lines demarcate the area where the vector for dengue exists

16. Dengue in the United States Dengue reported in the U.S. were acquired elsewhere by travelers or immigrants Dengue reported in the U.S. were acquired elsewhere by travelers or immigrants The majority of dengue cases in U.S. citizens occur in Puerto Rico, the U.S. Virgin Island, Samoa and Guam The majority of dengue cases in U.S. citizens occur in Puerto Rico, the U.S. Virgin Island, Samoa and Guam In Puerto Rico, and most of the Caribbean Basin, the dengue vector is Aedes aegypti, this vector is abundant year-round In Puerto Rico, and most of the Caribbean Basin, the dengue vector is Aedes aegypti, this vector is abundant year-round Dengue transmission in Puerto Rico follows a seasonal pattern, high transmission begins in August until November Dengue transmission in Puerto Rico follows a seasonal pattern, high transmission begins in August until November Center for Disease Control and Prevention, (2009)Dengue epidemiology. Retrieved April 22, 2010 from http://www.cdc.gov/Dengue/epidemiology/index.html

17. Common breeding sites Dengue cases usually increase during the rainy season Dengue cases usually increase during the rainy season The spread of the mosquito is attributed to poor environmental sanitation The spread of the mosquito is attributed to poor environmental sanitation When it rains the water gets stored in any place such as discarded tires, broken bottles, and even shoes When it rains the water gets stored in any place such as discarded tires, broken bottles, and even shoes Other examples are soda cans, birdbaths, rain gutters, toys, pool covers, tree stumps, and garbage cans. Other examples are soda cans, birdbaths, rain gutters, toys, pool covers, tree stumps, and garbage cans. Illinois Environmental Protection Agency, (2007). Mosquito-Borne illnesses prevention techniques. Retrieved April 22, 2010 from http://www.epa.st.il.us /land/tires/mosquito-borne-illness.htmlhttp://www.epa.st.il.us

19. Aedes aegypti life cycle 2-7 days >4 days 2 days

21. Signs and Symptoms of Dengue Fever High fever, up to 105 F (40.6 C) High fever, up to 105 F (40.6 C) A rash over most of your body, can subside after a couple of days and then reappear A rash over most of your body, can subside after a couple of days and then reappear Sever headache, backache or both Sever headache, backache or both Pain behind your eyes Pain behind your eyes Severe joint and muscle pain (breakbone fever) Severe joint and muscle pain (breakbone fever) Nausea and vomiting Nausea and vomiting Signs and symptoms usually begin about four to seven days after being bitten by A. aegypti. Signs and symptoms usually begin about four to seven days after being bitten by A. aegypti. Mild dengue fever rarely causes death, it is usually self-limiting Mild dengue fever rarely causes death, it is usually self-limiting Mayo clinic, (2010). Dengue fever symptoms. Retrieved April 19, 2010 from http://www.mayoclinic.com/health/dengue_fever/DS01028/DSECTION=symptoms

22. Signs and Symptoms of Dengue Hemorrhagic fever (DHF) A more severe form of dengue that begins the same way as dengue fever but become worse after several days A more severe form of dengue that begins the same way as dengue fever but become worse after several days Significant damage to your blood and lymph vessels Significant damage to your blood and lymph vessels A decrease in the number of blood cells that help your blood clot (platelets) A decrease in the number of blood cells that help your blood clot (platelets) Bleeding from nose and mouth Bleeding from nose and mouth Bleeding under the skin, which gives the appearance of bruising Bleeding under the skin, which gives the appearance of bruising Death Death Mayo clinic, (2010). Dengue fever symptoms. Retrieved April 19, 2010 from http://www.mayoclinic.com/health/dengue_fever/DS01028/DSECTION=symptoms

23. Signs and Symptoms of Dengue Shock Syndrome (DSS) The most severe form of the disease The most severe form of the disease It may start with the signs and symptoms of mild dengue plus It may start with the signs and symptoms of mild dengue plus Severe abdominal pain Severe abdominal pain Frequent vomiting Frequent vomiting Disorientation Disorientation Fluid (plasma) leakage from blood vessels Fluid (plasma) leakage from blood vessels Heavy bleeding Heavy bleeding A sudden drop in blood pressure (shock) A sudden drop in blood pressure (shock) Death Death Mayo clinic, (2010). Dengue fever symptoms. Retrieved April 19, 2010 from http://www.mayoclinic.com/health/dengue_fever/DS01028/DSECTION=symptoms

24. Why does different clinical manifestations of Dengue exists? There are four different types (serotypes) of the dengue virus There are four different types (serotypes) of the dengue virus These are DEN-1, DEN-2, DEN-3 and DEN-4 These are DEN-1, DEN-2, DEN-3 and DEN-4 Recovery from infection by one provides lifelong immunity against that virus, confers only partial and transient protection against subsequent infection by the other three viruses Recovery from infection by one provides lifelong immunity against that virus, confers only partial and transient protection against subsequent infection by the other three viruses There is evidence that sequential infection increases the risk of developing dengue hemorrhagic fever There is evidence that sequential infection increases the risk of developing dengue hemorrhagic fever World Health Organization, (2009). Dengue and dengue haemorrhagic fever. Retrieved April 19,2010 from http://www.who.int/mediacentre/factsheet/fs117/en/

25. Diagnosis for Dengue Travel history and symptom profile Travel history and symptom profile Detection of antibodies against the virus Detection of antibodies against the virus Complete blood count Complete blood count Chemistry panel Chemistry panel Liver function test Liver function test Occult blood in stool Occult blood in stool DIC panel DIC panel Price, D.D., Wilson, S.R., (2009). Dengue fever: differential diagnoses and workout. Medscape. Retrieved April 19, 2010 from http://emedicine.medscape.com/article/781961-diagnosis

26. Treatment for Dengue No specific therapeutic agents exist for dengue infections No specific therapeutic agents exist for dengue infections Bed rest and hydration therapy Bed rest and hydration therapy Fever control with acetaminophen. Narcotics may be necessary if headaches are very severe Fever control with acetaminophen. Narcotics may be necessary if headaches are very severe Aspirin should be avoid because of anticoagulant properties, children should avoid aspirin when a viral infection is suspected Aspirin should be avoid because of anticoagulant properties, children should avoid aspirin when a viral infection is suspected Monitoring of signs and symptoms for warning signs of DHF or DSS Monitoring of signs and symptoms for warning signs of DHF or DSS Price, D.D., Wilson, S.R., (2009). Dengue fever: differential diagnoses and workout. Medscape. Retrieved April 19, 2010 from http://emedicine.medscape.com/article/781961-diagnosis

27. Preventive Measure for Travelers No vaccine or drugs are available for the prevention of dengue No vaccine or drugs are available for the prevention of dengue Preventive measure should be taken to avoid the bite of the mosquito Preventive measure should be taken to avoid the bite of the mosquito Well screen accommodations or air conditioning Well screen accommodations or air conditioning Use of insecticide indoors Use of insecticide indoors Apply insect repellent to skin and clothing. The most effective are the ones with DEET Apply insect repellent to skin and clothing. The most effective are the ones with DEET Empty, clean or cover any standing water that can be a mosquito-breeding site Empty, clean or cover any standing water that can be a mosquito-breeding site Center for Disease Control and Prevention, (2009). Other infectious disease related to travel, dengue fever (DF) and dengue hemorrhagic fever (DHF). Retrieved April 19, 2010 from http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/dengue-fever-dengue- hemorrhagic-fever.aspx

28. Incidence of Dengue Fever Global incidence of dengue has grown dramatically Global incidence of dengue has grown dramatically 2500 million people- two fifths of the world’s population- are now at risk from dengue 2500 million people- two fifths of the world’s population- are now at risk from dengue WHO estimates 50 million to 100 million cases of dengue infection worldwide every year WHO estimates 50 million to 100 million cases of dengue infection worldwide every year In 1998,there were 616,000 cases of dengue in the Americas of which 11,000 cases were DHF In 1998,there were 616,000 cases of dengue in the Americas of which 11,000 cases were DHF In 2007, there were more than 890,000 reported cases of dengue in the Americas, of which 26000 were DHF In 2007, there were more than 890,000 reported cases of dengue in the Americas, of which 26000 were DHF World Health Organization, (2009) Dengue and dengue haemorrhagic fever. Retrieved April 19, 2010 from http://www.who.int/mediacentre/factsheets/fs117/en/

29. More Statistics An estimated 500,000 people with DHF require hospitalization each year, a large proportion are children, about 2.5% of these die An estimated 500,000 people with DHF require hospitalization each year, a large proportion are children, about 2.5% of these die DHF fatality rates can exceed 20% without proper treatment DHF fatality rates can exceed 20% without proper treatment World Health Organization, (2009) Dengue and dengue haemorrhagic fever. Retrieved April 19, 2010 from http://www.who.int/mediacentre/factsheets/fs117/en/

30. Dengue and Public Health Dengue fever is a major public health problem Dengue fever is a major public health problem The reasons for the emergence of this disease are complex The reasons for the emergence of this disease are complex Effective mosquito control is virtually nonexistent in most dengue-endemic countries Effective mosquito control is virtually nonexistent in most dengue-endemic countries Major global demographic changes have occurred Major global demographic changes have occurred Uncontrolled urbanization Uncontrolled urbanization Concurrent population growth Concurrent population growth Substandard housing, inadequate water, sewer, and waste management systems Substandard housing, inadequate water, sewer, and waste management systems Gubler, D.J., Clark, G.G., (1995)Dengue/dengue hemorrhagic fever: The emergence of a global health problem. Retrieved April 19, 2010 from ftp://ftp.cdc.gov/pub/EID/vol1no2/adobe/gubler.vol1no2.pdf

31. Dengue Branch in Puerto Rico Provides global leadership in dengue risk, assessment, research and effective public health practices Provides global leadership in dengue risk, assessment, research and effective public health practices The branch has collected, analyzed and reported dengue cases from Puerto Rico, U.S. Virgin Island and the continental U.S. The branch has collected, analyzed and reported dengue cases from Puerto Rico, U.S. Virgin Island and the continental U.S. Serves as the primary reference laboratory for state health departments and the World Health Organization Serves as the primary reference laboratory for state health departments and the World Health Organization Center for Disease Control and Prevention, (2009). About CDC’s dengue branch. Retrieved April24, 2010 from http://www.cdc.gov/Dengue/about/index.html

32. Public Health Prevention and Control of Dengue The importance of the activities of the Dengue Branch can translate to: The importance of the activities of the Dengue Branch can translate to: New technologies into real-time New technologies into real-time Rapid diagnosis to treat patient earlier and effectively Rapid diagnosis to treat patient earlier and effectively Improving surveillance that will allow an effective and targeted public response to dengue outbreaks Improving surveillance that will allow an effective and targeted public response to dengue outbreaks Clearer picture of the burden of dengue in Puerto Rico, the continental U.S. and internationally Clearer picture of the burden of dengue in Puerto Rico, the continental U.S. and internationally Center for Disease Control and Prevention, (2009). About CDC’s dengue branch. Retrieved April24, 2010 from http://www.cdc.gov/Dengue/about/index.html

33. Prevention and Control cont. Providing training to the medical community to improve their knowledge of the disease Providing training to the medical community to improve their knowledge of the disease Conducting mosquito control interventions that allow the CDC to make recommendations to vector control program Conducting mosquito control interventions that allow the CDC to make recommendations to vector control program Improving quality of surveillance data Improving quality of surveillance data Analyzing all the clinical manifestation of the disease to conduct studies to improve the knowledge of the dengue virus Analyzing all the clinical manifestation of the disease to conduct studies to improve the knowledge of the dengue virus Center for Disease Control and Prevention, (2009). About CDC’s dengue branch. Retrieved April24, 2010 from http://www.cdc.gov/Dengue/about/index.html

34. Final word of advice for travelers The times of higher risk of being bitten by the female mosquito is 2 to 3 hours after daybreak and 3 to 4 hours before nightfall The times of higher risk of being bitten by the female mosquito is 2 to 3 hours after daybreak and 3 to 4 hours before nightfall The mosquito can feed indoors as well as outdoors The mosquito can feed indoors as well as outdoors Precautions as mention before should be taken especially at peak biting activity time Precautions as mention before should be taken especially at peak biting activity time The risk of exposure may be lower in modern, air- conditioned hotels with well-kept grounds The risk of exposure may be lower in modern, air- conditioned hotels with well-kept grounds Gubler, D., (1998). Dengue and dengue hemorrhagic fever. Clinical Microbiology Reviews, July 1998, p.480-496. Retrieved April 24, 2010 from http:/www.cmr.asm.org/cgi/repreint/11/3/480

35. Thank you for your time I hope that this presentation was informative and useful especially when traveling to countries where dengue is endemic

36. References: Akram, W., (n.d.). Aedes as a vector of Dengue: a possible threat to our lives. Khwarzimig Science Society. University of Agriculture, Faisalabad. Retrieved April 19, 2010 from http://www.khwarzimic.org/takveen/dengue_kss.pdfhttp://www.khwarzimic.org/takveen/dengue_kss.pdf Bauman, R., (2006). Microbiology disease by systems. San Francisco, CA: Pearson Benjamin Cumming Publisher Center for Disease Control and Prevention, (2009)Dengue epidemiology. Retrieved April 22, 2010 from http://www.cdc.gov/Dengue/epidemiology/index.htm Center for Disease Control and Prevention, (2009). Other infectious disease related to travel, dengue fever (DF) and dengue hemorrhagic fever (DHF). Retrieved April 19, 2010 from http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/dengue-fever-dengue-hemorrhagic- fever.aspx http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-5/dengue-fever-dengue-hemorrhagic- fever.aspx Center for Disease Control and Prevention, (2009). About CDC’s dengue branch. Retrieved April24, 2010 from http://www.cdc.gov/Dengue/about/index.html Gubler, D.J., Clark, G.G., (1995)Dengue/dengue hemorrhagic fever: The emergence of a global health problem. Retrieved April 19, 2010 from ftp://ftp.cdc.gov/pub/EID/vol1no2/adobe/gubler.vol1no2.pdf ftp://ftp.cdc.gov/pub/EID/vol1no2/adobe/gubler.vol1no2.pdf Gubler, D., (1998). Dengue and dengue hemorrhagic fever. Clinical Microbiology Reviews, July 1998, p.480-496. Retrieved April 24, 2010 from http:/www.cmr.asm.org/cgi/repreint/11/3/480

37. Reference: Mayo clinic, (2010). Dengue fever symptoms. Retrieved April 19, 2010 from http://www.mayoclinic.com/health/dengue_fever/DS01028/DSECTION=symptoms http://www.mayoclinic.com/health/dengue_fever/DS01028/DSECTION=symptoms Price, D.D., Wilson, S.R., (2009). Dengue fever: differential diagnoses and workout. Medscape. Retrieved April 19, 2010 from http://emedicine.medscape.com/article/781961-diagnosishttp://emedicine.medscape.com/article/781961-diagnosis Rios, L., Maruniak, J.E. (2008). Asian tiger mosquito. University of Florida Institute of Food and Agricultural Sciences. Retrieved April 19, 2010 from http://www.entemdept.ufl.edu/creatures/aqutic/asian_tiger.htm http://www.entemdept.ufl.edu/creatures/aqutic/asian_tiger.htm World Health Organization, (2009). Dengue and Dengue haemorrhagic fever. Retrieved April 19, 2010 from http://www.who.int/mediacentre/factsheets/fs117/en/http://www.who.int/mediacentre/factsheets/fs117/en/ Zettel, C., Kaufman, P. (2008). Yellow fever mosquito. University of Florida Institute of Food and Agricultural Sciences. Retrieved April 19, 2010 from http://entnemdept.ufl.edu/creatures/aqutic/aedes_aegypti.htm

38. List of recommended sources: Dengue Fever, disease information: http://www.cdc.gov/ncidod/Diseases/submenus/su b_dengue.htm Dengue Fever, disease information: http://www.cdc.gov/ncidod/Diseases/submenus/su b_dengue.htm http://www.cdc.gov/ncidod/Diseases/submenus/su b_dengue.htm http://www.cdc.gov/ncidod/Diseases/submenus/su b_dengue.htm CDC-Dengue: http://www.cdc.gov/ncidod/dvbid/dengue/ CDC-Dengue: http://www.cdc.gov/ncidod/dvbid/dengue/ http://www.cdc.gov/ncidod/dvbid/dengue/ WHO/Dengue/dengue haemorrhagic fever: http://www.who.int/csr/disease/dengue/en/ WHO/Dengue/dengue haemorrhagic fever: http://www.who.int/csr/disease/dengue/en/

39. Credits Slide 7: Google images dengue virus Slide 7: Google images dengue virus Slide 10: Google images-cdc-gathaway-aedes-albopictus Slide 10: Google images-cdc-gathaway-aedes-albopictus Slide 12: Google images- Aedes aegypti Slide 12: Google images- Aedes aegypti Slide 14: Google images Figure 1: Dengue Transmission Slide 14: Google images Figure 1: Dengue Transmission Slide 17: Google images a mosquito breeding site, mosquito breeding areas Slide 17: Google images a mosquito breeding site, mosquito breeding areas Slide 18: Google images – Aedes aegypti life cycle Slide 18: Google images – Aedes aegypti life cycle Slide 19: Google images- mosquito breeding ground Slide 19: Google images- mosquito breeding ground Slide 34: Google images- beach photo Slide 34: Google images- beach photo