DENGUE HEMORRHAGIC

FEVER

By:

Dave Jay Sibi. Manriquez BSN, RN

Philippine Hemorrhagic Fever was first reported in 1953. In 1958, hemorrhagic became a notifiable disease in the country and was later reclassified as Dengue Hemorrhagic Fever.

IINTRODUCTION:IINTRODUCTION:

What is Dengue Hemorrhagic Fever?

• A severe mosquito transmitted viral illness endemic in the tropics.

• It is characterized by increased vascular permeability, hypovolemia and abnormal blood clotting mechanisms.

WHO case definition for DHF:WHO case definition for DHF: • fever or history of recent fever

• thrombocytopenia (platelet count equal to or less than 100 x 10 / cu mm)

• hemorrhagic manifestations such as petechiae or overt bleeding phenomena, and

• evidence of plasma leakage due to increase vascular permeability

Infectious Agent / Etiologic Agent:Infectious Agent / Etiologic Agent:

Flaviviruses; Dengue Virus Types 1, 2, 3, and 4

Occurrence:Occurrence:

Dengue occurrence is sporadic throughout the year.

Epidemic usually occurs during the rainy seasons June – November.

Peak months are September and October.

DHF are observed most exclusively among children of the indigenous population under 15 years of age.

Occurrence is greatest in the areas of high Aedis Aegypti prevalence.

  2001 2002 2003 2004

Notifiable Diseases Reported Reported Reported Reported

  Cases Deaths Cases Deaths Cases Deaths Cases Deaths

Dengue Fever

23,235   13,187  

18,039  

15,838  

Notifiable Diseases and Deaths by Cause in the Philippines (2001 – 2004)

Source: National Statistics Office

Selected Number of New Cases Number of Deaths Year

Communicable              

Disease: total male female total male female  

               

Dengue / DHF 43, 350 … … 416 … … 2007

INCIDENCE OF DENGUE HEMORRHAGIC FEVER IN CEBU CITY (YEAR 2007)

Source: Department of Health Region VII

Reservoir / Source of Infection:Reservoir / Source of Infection:

• Some source is a vector mosquito, the Aedes Aegypti or the common household mosquito

• The infected person

Mode of Mode of Transmission:Transmission:

Mosquito bite (Aedis Aegypti)

Incubation Period:Incubation Period: Probably 6 days to one week

Period of Period of Communicability:Communicability:

Presumed to be on the 1st week of illness – when virus is still present in the blood

Susceptibility and Susceptibility and resistance:resistance:

All persons are susceptible. Both sexes are equally affected. The age groups predominantly affected are the preschool age and school age. Adults and infants are not exempted. Peak age affected 5-9 years. Susceptibility is universal. Acquired immunity may be temporary but usually permanent.

Diagnostic Diagnostic Test:Test:

1.) Tourniquet Test (Rumpel Leads Tests)• Inflate the blood pressure cuff on the upper

arm to a point midway between the systolic and diastolic pressure for 5 minutes

• Release cuff and make an imaginary 2.5 cm square or 1 inch just below the cuff, at the antecubital fossa

• Count the number of petechiae inside the box

• A test is (+) when 2 or more petechiae per 2.5 cm square or 1 inch square are observed

2.) A con firmed diagnosis is established by culture of the virus, polymerase-chain-reaction (PCR) tests, or serologic assays.

Clinical ManifestationsClinical Manifestations (Public Health Nursing (Public Health Nursing in the Philippines, 2007):in the Philippines, 2007):An acute febrile infection of sudden onset with 3 stages:

• 1st-4th day (febrile or invasive stage)

-high fever, abdominal pain and headache; later flushing which may be accompanied by vomiting, conjunctiva infection and epistaxis.

• 4th-7th day (toxic or hemorrhagic stage)

-lowering of temperature, severe abdominal pain, vomiting and frequent bleeding from gastrointestinal tract in the form of hematemesis or melena. Unstable blood pressure, narrow pulse pressure and shock. Death may occur. Tourniquet test which may be positive may become negative due to low or vasomotor collapse.

• 7th-10th day (convalescent or recovery stage)

-generalized flushing with intervening areas of blanching, appetite regained and blood pressure already stable.

• Dengue shock syndrome is defined as dengue hemorrhagic fever plus:

*Weak rapid pulse, *Narrow pulse pressure (less than 20 mm Hg) or, *Cold, clammy skin and restlessness

Grading of Dengue Fever:Grading of Dengue Fever:

The severity of DHF is categorized into four grades:

• grade I, without overt bleeding but positive for tourniquet test

• grade II, with clinical bleeding diathesis such as petechiae, epistaxis and hematemesis

• grade III, circulatory failure manifested by a rapid and weak pulse with narrowing pulse pressure (20 mmHg) or hypotension, with the presence of cold clammy skin and restlessness; and

• Grade IV, profound shock in which pulse and blood pressure are not detectable. It is note-worthy that patients who are in threatened shock or shock stage, also known as dengue shock syndrome, usually remain conscious.

* Grade III and IV are considered to be Dengue Shock Syndrome

MANAGEMENTMANAGEMENT

Promote restPromote rest MedicationMedication

Paracetamol – for Paracetamol – for fever and muscle fever and muscle pains.pains.

Analgesic – for Analgesic – for headacheheadache

DON’T GIVE ASPIRINDON’T GIVE ASPIRIN

Rapid replacement of body Rapid replacement of body fluids is the most fluids is the most important treatmentimportant treatmentGive ORESOL to replace Give ORESOL to replace

fluid as in moderate fluid as in moderate dehydration at 75ml/kg dehydration at 75ml/kg in 4-6 hours or up to 2-in 4-6 hours or up to 2-3L in adults. Continue 3L in adults. Continue ORS intake until paient’s ORS intake until paient’s condition improves.condition improves.

Intravenous fluidIntravenous fluid

For hemorrhage For hemorrhage Keep patient at rest Keep patient at rest

during bleeding periodsduring bleeding periodsFor epistaxis – maintain For epistaxis – maintain

an elevated position of an elevated position of trunk and promote trunk and promote vasoconstriction in nasal vasoconstriction in nasal mucosa membrane mucosa membrane through an ice bag over through an ice bag over the forehead.the forehead.

For melena – ice bag over For melena – ice bag over the abdomen.the abdomen.

Provide support during the Provide support during the transfusion therapytransfusion therapy

DietDietLow fat, low fiber, non-Low fat, low fiber, non-

irritating, non-carbonatedirritating, non-carbonatedNoodle soup may be Noodle soup may be

givengiven Observe signs of Observe signs of

deterioration (shock) such deterioration (shock) such as low pulse, cold clammy as low pulse, cold clammy perspiration, prostration.perspiration, prostration.

PREVENTIONPREVENTIONPREVENTIONPREVENTION

• Eliminate vector by:–Changing water and scrubbing sides of lower vases once a week

–Destroy breeding places of mosquito by cleaning surroundings

–Proper disposal of rubber tires, empty bottles and cans

–Keep water containers covered

OTHER PRECAUTIONS:

• When outdoors in an area where dengue fever has been found–Use a mosquito repellant–Dress in protective clothing-long-sleeved shirts, long pants, socks, and shoes

• Keeping unscreened windows and doors closed

• Keeping window and door screens repaired

• Use of mosquito nets