Dengue Fever

Dr. Bhaskar Shenoy, Dr. Archana M
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How Is Dengue Fever Managed?
Proper dengue management has following principles,
• Suspicion of disease
• Assessment and management of early febrile phase
• Identifying patients with early warning signs
• Recognising early critical phase and initiating timely fluid therapy
• Recognising and managing severe dengue shock, massive bleeding and severe organ impairment (5)
The practical treatment plan is produced by World Health Organization (WHO) and is based on the severity of infection.
Group A: These are patients who may be sent home. These patients are able to tolerate adequate volumes of oral fluids, pass urine at least once every six hours and do not have any of the warning signs (particularly when fever subsides). Patients are advised frequent oral fluids. Give paracetamol (10 mg/kg/dose) for high fever, not more than 3-4 times in 24 hours in children. Do not give aspirin, ibuprofen or other non-steroidal antiinflammatory agents (NSAIDs) or intramuscular injections, as these aggravate gastritis or bleeding. Instruct caregivers that the patient should be brought to hospital immediately if any of the warning signs appear. Monitor complete blood counts.

Group B: These are patients who should be admitted for in-hospital management for close observation as they approach the critical phase. These include patients with warning signs, those with co-existing conditions that may make dengue or its management more complicated (such as pregnancy, infancy, old age, obesity, diabetes mellitus, hypertension, heart failure, renal failure, chronic haemolytic diseases such as sickle-cell disease and autoimmune diseases). If the patient has dengue with warning signs or signs of dehydration, judicious volume replacement by intravenous fluid therapy is recommended. Give only isotonic solutions such as 0.9% saline, Ringer's lactate or Hartmann's solution. Start with 5-7 ml/kg/hour for 1-2 hours, then reduce to 3-5 ml/kg/hour for 2-4 hours, and then reduce to 2-3 ml/kg/hour or less according to the clinical response. Give the minimum intravenous fluid volume required to maintain good perfusion and urine output of about 0.5 ml/kg/hour. Intravenous fluids are usually needed for only 24-48 hours. Parameters that should be monitored include vital signs and peripheral perfusion, urine output, hematocrit, blood glucose and other organ functions as indicated

Group C: These are patients with severe dengue. Plasma losses should be replaced immediately and rapidly with isotonic crystalloid solution: in the case of hypotensive shock, colloid solution is preferred. Larger volumes of fluids (e.g. 10-20 ml/kg boluses) are administered for a limited period of time under close supervision, to evaluate the patient’s response and to avoid the development of pulmonary oedema. Then reassess the patient’s condition (vital signs, capillary refill time, haematocrit, urine output). If the adult patient’s condition improves, intravenous fluids should be gradually reduced to 5-7 ml/kg/hour for 1-2 hours; then 3-5 ml/kg/hour for 2-4 hours and finally 2-3 ml/kg/hour which can be maintained up to 24-48 hours. The total duration of intravenous fluid therapy should not exceed 48 hours.

Convalescence is recognised by improvement in clinical wellbeing and appetite of patient. Patient has diuresis, hypokalemia. Patient also develops rash and generalized pruritis (1). Hematocrit decreases with stable hemodynamic status which indicates hemodilution and suggestive of stoppage of IV fluids (5). Once wellbeing is achieved and patient remains afebrile for 48 hours with an increasing platelet count and stable hematocrit, they can be discharged (1).

Platelet transfusions are only required in presence of active bleeding. The clinical value of fresh frozen plasma, corticosteroids, intravenous immunoglobulin and antibodies is controversial and more evidence is required before they can be recommended. (1)

Avoid strenuous activities during convalescence as LFT takes 3 weeks to return to normal (1).

In dengue endemic regions suspected, probable and confirmed cases of dengue fever should be reported to relevant authorities as soon as possible so measures are instituted to prevent transmission.(1)

VECTOR CONTROL OF LARVAE AND ADULT MOSQUITO
Aedes aegypti are more effectively susceptible to temephos, followed by fenthion, malathion and DDT. Peridomestic thermal fogging reduced the resting and biting for the 3 days after treatment, whereas indoor fogging suppressed adult population for 5 days. (3) Plant based repellents against mosquito borne diseases i.e. flavanoid compounds derived from Poncirus trifoliate, larvicidal and ovicidal activities of chloroform leaf extract of Ecliptic alba have shown effective for controlling aedes aegypti mosquitoes (8). Elimination of artificial containers such as plastic cups, used tyres ,broken bottles, flower pots, other water traps reduce mosquito breeding grounds.(2) An alternative approach involves infecting Aedes aegypti with bacterium Wolbachia which reduces life span of adult mosquito by 50%.

INSECT REPELLENTS
Use of insect repellents, mosquito traps and nets in homes is moderately effective in reducing number of bites (2) Wear protective clothing (long pants and long-sleeved shirts). Use insect repellent with DEET (N, N diethylmetatoluamide). The repellent is available in varying strengths up to 100%. The American Academy of Paediatrics (AAP) and other experts suggest that it is safe to use a repellent that contains 10% to 30% DEET on children older than age 2 months. Spray clothing with an insect repellent containing permethrin or DEET, because mosquitoes may bite through thin clothing. (Be aware that DEET can damage plastic items, such as watch crystals or eyeglass frames, and some synthetic fabrics.) Sleep under bed nets (mosquito netting) sprayed with or soaked in an insecticide such as permethrin or deltamethrin. Use flying-insect spray indoors around sleeping areas. (11)

The ideal dengue vaccine should be free of important reactogenecity, induce lifelong protection against infection with anyone of 4 DENV serotypes and be affordable. (4) The first dengue vaccine Dengavaxia (CYD-TDV) by Sanofi Pasteur was first registered in Mexico in December 2015. It is a live recombinant tetravalent dengue vaccine that has been evaluated as a 3 dose series on a 0/6/12 month schedule in phase III clinical studies. It is registered for use in Individuals 9-45 years of age living in endemic areas. (9)


References
Dengue Fever Dengue Fever 06/28/2016
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