Dengue fever
(By Dr Thimappa Hegde, Head of the Department of
Neurosurgery, HOSMAT Hospital, Bangalore and Dr Arvind Bhateja,
Consultant Neurosurgeon, Hosmat Hospital)
Dengue
(pronounced 'Dhen gey') is a mosquito-borne infection, which in
recent years has become a major international public health
concern. Dengue is found in tropical and sub-tropical regions
around the world, predominantly in urban and semi-urban areas.
Dengue
fever is found mostly during and shortly after the rainy season
in tropical and subtropical areas of
-
Africa
-
Southeast Asia and China
-
India
-
Middle East
-
Caribbean and Central and South America
-
Australia
and the South and Central Pacific
Dengue fever
is an infectious disease caused by a virus, called the dengue
fever virus.
The virus
Viruses are
extremely small infectious particles consisting of an outer
envelope, composed of proteins. Within this envelope of proteins
is a string of molecules, called nucleic acid, which helps the
virus replicate (form numerous copies of itself), in the animal
it infects.
There are
four types of dengue fever virus. These are classified based on
the presence of certain proteins found in the virus, called
antigens. These antigens are recognized by the human immune
system, which produces substances against them, called
antibodies.
Based on its
antigens, the four types of dengue fever virus are called DEN-1,
DEN-2, DEN-3, and DEN-4.
A person can
get infected by any one of these subtypes, and infection with
one does not prevent infection with another, from occurring.
However, once a person has been infected with a particular type,
he is protected from infection from the same type for the rest
of his life.
Unfortunately, infection by the several types in sequence
predisposes an individual to a more severe form of the illness,
called dengue hamorrahgic fever.
The virus is
transmitted from an individual infected with the virus to
another via a vector (which transmits the infecting
agent, but does not show signs of the disease itself). In the
case of dengue fever, the vector is a day-biting female of the
mosquito called Aedes aegyptii and Aedes albopictus.
The mosquito gets infected when it bites a person infected with
the virus and then transmits the infection to a healthy
individual. Once the mosquito sucks the blood of an infected
person, it takes approximately 8-10 days for it to become
infective. This is called the vector incubation period. Once
infective, the mosquito remains infective for the rest of its
life span. Once the virus enters the human blood stream, it
circulates in the blood for 2-7 days, during the phase of fever.
It is during this time, that a person can transmit the infection
to a mosquito.
It is
believed that the interaction between the antibodies and
antigens leads to the formation of complexes, which are
responsible for the bleeding seen during the disease.
The
disease
Dengue fever
often occurs in epidemics every three to five years. The world's
largest known epidemic occurred in Cuba in 1981, when more than
116,000 people were hospitalized, some 11,000 in a single day.
We are presently in the midst of a dengue fever pandemic (an
epidemic across several countires), primarily affecting India,
Vietnam and the Caribbean.
Dengue
commonly occurs in children, because adults, having been exposed
to the virus at sometime in their lives, develop immunity.
The illness
can vary in severity from a mild flu-like illness to a life
threatening condition.
The clinical
features of dengue fever vary according to the age of the
patient. Infants and young children may have a non-specific
fever with rash.
Older
children and adults may have either a mild fever or the
classical incapacitating disease with abrupt onset and high
fever, severe headache, pain behind the eyes, muscle and joint
pains, and rash. It is often called 'breakbone fever' because of
the severe muscle and joint pains. The rash usually comes in two
waves- the first occurs as a generalized rash lasting 1-2 days
followed 1-2 days later by a rash, which spares the palms and
soles, lasting for around 5 days.
Dengue
hemorrhagic fever is a potentially deadly complication that is
characterized by high fever, bleeding (haemorrhagic
phenomena)-often with enlargement of the liver-and in severe
cases, shock (circulatory failure). The illness commonly begins
with a sudden rise in temperature accompanied by facial flush
and other non-specific symptoms of dengue fever. The fever
usually continues for two to seven days and can be as high as
40-41°C, possibly with febrile seizures and bleeding.
In moderate
cases, all signs and symptoms abate after the fever subsides. In
severe cases, the patient's condition may suddenly worsen after
a few days of fever; the temperature drops, followed by signs of
shock (inadequate blood supply), and the patient may rapidly go
into a critical state of shock and die within 12-24 hours, or
quickly recover following appropriate therapy.
Several
complications may arise as a result of the infection such as
chest complications (like pneumonia or collection of fluid
within the chest), brain haemorrhage due to the bleeding
tendency, bleeding from other sites, kidney failure and shock.
Treatment
Unfortunately, there is no known treatment for dengue fever.
Most treatment is supportive- that is, treatment of the symptoms
and treatment of anticipated complications.
Mild forms
of the disease are virtually indistinguishable from any minor
viral illness and do not require hospitalization.
Severe forms
including the dengue haemorrhagic fever and the dengue shock
syndrome need hospitalization, investigations such as blood
tests to look for any bleeding tendency and imaging such as an
X-ray of the chest and CT scan of the brain. These tests may
need to be repeated often during the hospital stay to monitor
the progress of the illness. Once appropriately treated the
mortality for the severe forms of the illness is around 3%.
Prevention
Prevention
is the best form of treatment. Unfortunately, at present there
are no effective vaccines to prevent the disease, mainly because
there are four different types of virus.
At present,
the only method of controlling or preventing dengue is to combat
the vector mosquitoes.
In Asia and
the Americas, Aedes aegypti breeds primarily in man-made
containers like earthenware jars, metal drums and concrete
cisterns used for domestic water storage, as well as discarded
plastic food containers, used automobile tyres and other items
that collect rainwater. In Africa it also breeds extensively in
natural habitats such as tree holes and leaf axils.
Vector
control is implemented using environmental management and
chemical methods. Proper solid waste disposal and improved water
storage practices, including covering containers to prevent
access by egg laying female mosquitoes are among methods that
are encouraged through community-based programs.
The
application of appropriate insecticides to larval habitats,
particularly those which are considered useful by the
householders, e.g. water storage vessels, prevent mosquito
breeding for several weeks but must be re-applied periodically.
Small, mosquito-eating fish and copepods (tiny crustaceans) have
also been used with some success. During outbreaks, emergency
control measures may also include the application of
insecticides as space sprays to kill adult mosquitoes using
portable or truck-mounted machines or even aircraft. However,
the killing effect is only transient, variable in its
effectiveness because the aerosol droplets may not penetrate
indoors to microhabitats where adult mosquitoes are sequestered,
and the procedure is costly and operationally very demanding.
Regular monitoring of the vectors' susceptibility to the most
widely used insecticides is necessary to ensure the appropriate
choice of chemicals. Active monitoring and surveillance of the
natural mosquito population should accompany control efforts in
order to determine the impact of the program.
Personal
protection should be used in endemic areas such as the use of
protective clothing, use of mosquito nets and use of mosquito
repellents such as DEET and pyrethrin extracts. Keep clean
surroundings, eliminate potential areas for mosquito breeding,
and
just plain good old common sense!!
Expert: Dr.
Thimappa Hegde |