Reducing the risk of Dengue with
Proper Diagnosis, Treatment and Education of People
Sakure Sunita1, Bhosale
Sarika2, Swapnil Shewale3
11Assistant Professor, Department Of Microbiology, S.B.B. alias
Appasaheb Jedhe College, Shukrawar peth, Pune, Maharashtra, India. 22Department of Zoology, University of Pune, Ganeshkhind Road, Pune,
India.
Address for
Correspondence: Mrs. Sunita Satish Sakure,
Email: sakuresunita@gmail.com
Abstract
Aedes aegypti is known to play a significant role in the transmission
of various dreadful diseases such as dengue fever, chikungunya and
yellow fever. Dengue fever (DF) is primarily caused by dengue fever
virus (DENV). As per state health department report released in May,
2014 Maharashtra has reported 722 cases of dengue this year accounting
for 25% of the dengue cases around the country. DENV serotypes are
majorly transmitted by infected female mosquito that takes a blood meal
from an infected person with DF. During the initial 2–10 day
febrile period, DENV spreads within the body of the mosquito infecting
the gut lining and later to salivary gland. Mosquito lay their eggs in
artificial and natural stagnant water containers. When an infected
female mosquito bites a person the virus enters the skin with the
mosquito's saliva and infects leucocytes and reproduces inside these
cells. The leucocytes respond by producing cytokines and interferons,
causing high fever and severe pains. In severe infection, the virus
invades organs like liver and bone marrow thereby lowering the blood
pressure and internal bleeding leading to a risk of dengue hemorrhagic
fever and dengue shock syndrome. Dengue NS-1 Antigen test is
confirmatory for early and immediate diagnosis of dengue. The state of
infection can be monitored by examination of platelet counts. As there
is no antiviral drug discovered against dengue, so causing serious
damage to people of all age groups. People should be educated and
awareness should be carried out to overcome such a disease.
Keywords:
Aedes Aegypti, Dengue, Platelet Count, Septic Shock Syndrome.
Manuscript received:
1st Dec 2014, Reviewed:
8th Dec Aug 2014
Author Corrected:
19th Dec 2014, Accepted
for Publication: 28th Dec 2014
Introduction
Dengue fever is an insect borne viral disease caused by dengue virus
(DENV) transmitted by female Aedes aegypti mosquito to human in a viral
cycle that requires both human and these mosquitoes [1- 3]. Once a
mosquito is infected, it remains infected for whole lifespan (25 to 30
days) [2,3]. Dengue viruses (DENV) belong to the family Flaviviridae,
genus Flevivirus, distinguished into four serotypes (DENV-1, DENV-2,
DENV-3, DENV-4) based on neutralization assay data [4]. Infection with
any of the DENV serotype may be asymptomatic in majority of cases or
may result in a wide spectrum of clinical symptoms, ranging from a mild
flu like syndrome known as dengue fever (DF) to the most severe forms
of the disease, which are characterized by coagulopathy, increased
vascular fragility and permeability known as dengue hemorrhagic fever
(DHF) [4, 5]. DHF may progress to hypo-volemic shock known as dengue
shock syndrome (DSS). Dengue fever is usually manifested as an
incapacitating disease in people of all age groups. It is characterized
by the rapid onset of fever in combination with severe headache,
retro-orbital pain, myalgia, arthralgia, gastro-intestinal discomfort
and usually rash. Minor hemorrhagic manifestations may occur in the
form of petechiae, epitaxis and gingival bleeding [5]. Leukopenia is a
common finding, whereas thrombocytopenia is observed in DF especially
in those with hemorrhagic signs. The World Health Organization (WHO)
classifies DHF in four grades (I to IV) [6]. DHF grades I and II
represents relatively mild cases without shock, whereas grade III and
IV cases are more severe and accompanied by shock. DHF is characterized
by all the symptoms of DF in combination with hemorrhagic
manifestations like positive tourniquet test or spontaneous bleeding,
thrombocytopenia and evidence of increased vascular permeability
characterized by increased hemo-concentration or fluid effusion in
chest or abdominal cavities [7-10]. The life threatening DSS stage
occurs at the time of or shortly after defervescence, which is
characterized by a rapid, weak pulse (≤ 20 mmHg) or hypotension
with cold clammy skin in the early stage of shock (grade III). If
patients do not received prompt and appropriate treatment, a stage of
profound shock may set into undetectable pulse and blood pressure
(grade IV) resulting in death within 12-36 hours after the onset of
shock [11,12].
The treatment of dengue fever is symptomatic and supportive in nature
[3,13]. The important part of the treatment is to eliminate body pain
and control the fever by avoiding extra non necessary medications which
results into an increased risk for hemorrhage and mortality. The
patient’s hydration status during the early febrile phase of
illness can be monitored by performing haemo-dynamic assessments like
baseline hematocrit testing and platelet counts, preventing
complications such as prolonged shock and metabolic acidosis. Bed rest
and mild analgesic-antipyretic therapy are often helpful in relieving
lethargy, malaise and fever associated with the disease. Patients with
dengue hemorrhagic fever or dengue shock syndrome may require
intravenous volume replacement. Plasma volume expanders can be used in
patients who are unresponsive to isotonic fluids [14,15].
Laboratory
Diagnosis
Laboratory diagnosis of Dengue can be done either by isolating virus or
by detecting dengue specific antibodies [16]. For DENV detection, RNA
of serum specimens are extracted and serotype specific reverse
transcriptase polymerase chain reaction (RT-PCR) is carried within 5
days of symptom onset [17,20]. If the virus is not isolated / detected,
a convalescent phase serum is required at least 6 days after the onset
of symptoms to make a serological diagnosis by testing for IgM
antibodies to dengue with an IgM antibody capture enzyme- linked
immune-sorbent assay (MAC-ELISA) [18,19,20]. Non structural protein 1
(NS1) antigen detection kits are now commercially available. NS1 is a
glycoprotein produced by all flaviviruses and is essential for viral
replication and viability secreted into the blood stream. Dengue NS-1
Antigen test or Dengue day 1 test is a rapid solid phase
immuno-chromatographic test for the qualitative detection of Dengue
NS1- Antigen and differential detection of IgM and IgG antibodies to
dengue virus in human plasma or serum [21-25]. This test is for in
vitro diagnostic use only and is intended as an aid in the earlier
diagnosis of dengue infection and presumptive diagnosis between primary
and secondary dengue infection.
Principle
(Antigen-antibody reaction)
Dengue NS1 test in which colloidal gold complexes containing dengue 1-4
antigens prepared from dengue virus culture is captured by the bound
anti-dengue IgM or IgG on respective test bands located in the test
window causing a pale to dark red band to form at the IgG or IgM region
of the test device window. The intensity of the test bands in the
respective device will vary depending upon the amount of antigen/
antibody present in the sample. The appearance of any pink/red colour
in a specific test region should be considered as reactive for that
particular antigen and/or antibody type (IgG or IgM). A red procedural
control line should always develop in the test device window to
indicate that the test has been performed properly.
Specimen collection and
Preparation [25,26]
Serum / plasma samples may be used with this test. The use of
hemolytic, lipemic, icteric or bacterially contaminated samples should
be avoided as it may lead to erroneous results.
Test procedure
Dengue NS1 Antigen Device:
Add 3 drops (100 µl) of sample (serum/ plasma ) using Dengue
Antigen Test sample dropper to the sample well of antigen device and
incubate it for 20 minutes and then analyse the result . Positive
results may appear as early as 2-10 minutes. However, negative results
must be confirmed after 20 minutes only.
Dengue IgM & IgG
Antibodies Device:
Fill the Dengue Antibody lower circular part of the sample dropper with
the sample (serum/plasma) up to the mark provided on the dropper. Then
add the sample to the sample well “S” of antibody
device. This will add 10 µl of sample (serum/plasma) to the
device. Dispose of the dropper considering it to be bio-hazardous.
Incubate for 20 minutes and confirm the results.
Interpretation of the test
A Dengue NS1 Ag Device
Reactive:
Appearance of pink colored line, one each in test region
“T” and control region “C”
indicates that the sample is REACTIVE for Dengue NS1 Ag.
Non-Reactive:
Appearance of one distinct pink line in the control region
“C” only, indicates that the sample is
“NON-REACTIVE” for Dengue NS1 Ag.
Invalid:
When neither control line nor the test line appears on the membrane the
test is treated as invalid.
B Dengue IgM & IgG Antibodies Device
IgM & IgG Reactive:
Appearance of red colored line in the control region
‘C’ and Test region; IgM region
‘M’ and IgG region ‘G’
indicates that the sample is reactive for both IgM & IgG
antibodies. This is indicative of a secondary dengue infection.
IgM Reactive:
Appearance of red colored line in the control region
‘C’ and Test region ; IgM region
‘M’ indicates that the sample is reactive for IgM
antibodies. This is indicative of a primary dengue infection.
IgG Reactive:
Appearance of red colored line in the control region
‘c’ and test region ; IgG region
‘G’ indicates that the sample is reactive for IgG
antibodies. This is indicative of a secondary dengue infection.
Non Reactive :
Appearance of one distinct red color line in the control region
‘c’ only with no line in the IgM region M and Ig G
region ‘G’ indicates that the sample is non
reactive for dengue antibodies.
Invalid:
When neither control line nor the IgM / IgG line appears the test
should be treated as invalid. It may be because of improper storage at
temperature other than recommended temperature, wrong procedure or long
atmospheric exposure of the test device after opening the kit.
Treatment
Generally dengue complications are often termed as dengue shock
syndrome associated with high mortality rate, which can lead to
vascular permeability, dehydration, myocardial dysfunction contributing
to development of shock or even multi-organ failure [27]. The most
dangerous thing about dengue is that there are no specific antiviral
drugs discovered till today and because of this only the symptoms that
can be treated. The treatment involves mainly the part of maintaining
the fluid balance to prevent dehydration which can be done with
adequate rest and fluid intake. Large amounts of fluids (water, soup,
milk, juice) along with patient's normal diet is recommended
[27,28,29]. Acetaminophen (Paracetamol) and codeine can be given for
severe headache and for joint and muscle pain. Taking drugs like
aspirin, other salicylates, and non-steroidal anti-inflammatory drugs
(NSAIDs) are dangerous since the infecting organism in dengue affects
the platelets which are responsible for the clotting of blood.
Spontaneous decrease in platelet count increases a person’s
tendency to bleed excessively resulting in DSS. Prevention is the best
option as there are no specific treatment options. Dengue can be
prevented by avoiding mosquito bites using mosquito repellents
available in commercial medicals and druggists [30,31].
Discussion
As Aedes aegypti mosquitoes are known to bite humans during the day and
their most common breeding grounds are manmade containers, it is
advisable to not have stagnant water around. Turn over the buckets and
pails which are not in use. Adoption of good daily habits such as
clearing blockages from the roof gutter, clearing leaves and stagnant
water from drains, removing water from potted plants daily, avoiding
the use of pot plates and changing the water in vases everyday will
also help to eliminate the chances of mosquito breeding. Windows and
door screens do not have any holes make sure it by blocking those areas
properly to eliminate mosquitoes. If someone had dengue or dengue like
symptoms, try to not let the mosquitoes bite them or others in the
house. Empty and clean the cooler tray regularly, even when not in use.
Natural methods to keep mosquitoes away are to plant Ocimum (tulsi)
near windows which have properties that do not allow mosquitoes to
breed. Light camphor as a repellent in a room for fifteen to twenty
minutes to have a mosquito free environment. Do not throw Styrofoam
cups after drinking tea or water into the dustbins. With a little bit
of water accumulation, dengue mosquitoes can breed easily. Precautions
include wearing long-sleeved clothes, using mosquito coils and electric
vapour mats, and using insect repellent over the exposed parts of the
body during the day as well as night.
Antivirals research work
under investigation
The overall annual burden of dengue as reported by World Health
Organization (WHO ) is an estimated 50-100 million dengue infections
and 5,00,000 hospitalizations for severe form of the disease across the
globe [11,12]. This burden is projected to continue to increase day by
day. Several live attenuated dengue candidate vaccines are proceeding
through various clinical evaluations. The need to induce a balanced
immune response against all four DENV serotypes with a single vaccine
has been a challenge for dengue vaccine developers. A live attenuated
DENV chimeric vaccine produced by Sahofi Pasteur has recently entered
phase lll evaluation in numerous dengue endemic regions of the world
showing 88.5% efficacy after three doses against severe disease dengue
haemorrhagic fever which leads to hospitalization for over half a
million people (mostly children) anually. Once administered, the
vaccine also provided 67% protection against dengue-associated
hospitalization. Researchers also found that the vaccine gave low
protection (35%) against DENV 2 strain, but more than 75% protection
against DENV 3 and 4, and 50% against DENV 1.
Each of the four distinct serotypes is capable of causing the full
spectrum of dengue illness but epidemiological studies have determined
that the risk for more severe dengue illness is higher following a
second, heterotypic DENV infection than for a primary DENV infection.
Although severe dengue illness can occur with a third or fourth DENV
infection, this risk appears to be very low. For these reasons, there
is urgency of a successful DENV vaccine which must ideally protect
against all four DENV serotypes with a limited number of doses given
over a period of weeks to a few months. This vaccine should be
available to high risk group at an affordable cost. Till date several
novel dengue vaccines have been developed including DNA vaccines, viral
vector and protein subunit vaccines [32-35].
Conclusion
Improper treatment of a dengue patient can result into complications
associated with dengue which usually appears between the third and
fifth day of fever. Although fever subsides patients should be
monitored closely for other life threatening signs for another two
days. So if patients have symptoms like bleeding from nose or gums,
frequent vomiting, vomiting with blood, black stool, abdominal pain,
difficulty in breathing should immediately consult a doctor. Even
though fever subsides patients should continue to monitor platelet
count till the drop in count stops. Platelet count below 20,000 has
higher chances of developing bleeding complications as seen in dengue
hemmorrhagic fever. There is also a typical viral fever in which even
though patients have all these symptoms, they are testing negative for
dengue when specific antibody tests like Dengue IgG and Dengue IgM are
conducted indicating that the typical viral fever is on the rise. In
this case try to keep body temperature to normal and monitor continuous
platelet counts at specific time intervals till the platelet counts
rises to normal ranges up to 150-450 x 103 cells/μL in
peripheral blood examination.
Future Aspects
With the sustained dengue prevention and control measures in high risk
places, the number of dengue cases will probably remain lower
ultimately causing low deaths. The launching of dengue prevention
campaign is a serious need to destroy the possible breeding sites of
the dengue vector. There is also need of education of people regarding
transmission, symptoms and treatment of the disease. This will
definitely reduce the cases of life threatening Dengue in future.
Funding:
Nil, Conflict of
interest:
Nil
Permission from IRB:
Yes
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How to cite this article?
Sakure S, Bhosale S, Shewale S. Reducing the risk of Dengue with Proper
Diagnosis, Treatment and Education of People. Int J Med Res Rev
2015;3(1):106-111.doi:10.17511/ijmrr.2015.i01.025