Dengue Prevention and Control

Juan Ismael G. Sumagaysay, MD, FPCP

 Dengue Fever
• An estimated 400 million dengue infections
occur worldwide each year, with about 96
million resulting in illness. Most cases occur in
tropical areas of the world,
• Dengue fever is a mosquito-borne tropical
disease caused by the dengue virus.
Symptoms typically begin three to fourteen
days after infection.
• Recovery generally takes two to seven days. In
a small proportion of cases, the disease
develops into severe dengue, also known as
dengue hemorrhagic fever, resulting in
bleeding, low levels of blood platelets and
blood plasma leakage, or into dengue
 BACKGROUND
• Dengue is the fastest spreading vector-borne
disease in the world endemic in 100 countries·
• Dengue virus has four serotypes (DENV1,
DENV2, DENV3 and DENV4)
• First infection with one of the four serotypes
usually is non-severe or asymptomatic, while
second infection with one of other serotypes
may cause severe dengue.
• Dengue has no treatment but the disease can
be early managed.
• The five year average cases of dengue is
185,008;
• five year average deaths is 732; and
• five year average Case Fatality Rate is 0.39
(2012-2016 data).
 TRANSMISSION
• Dengue virus is transmitted by day biting
Aedes aegypti and Aedes albopictus
mosquitoes.
 Symptoms of Dengue Fever

• Symptoms, which usually begin four to six

days after infection and last for up to 10 days,
may include
• Sudden, high fever
• Severe headaches
• Pain behind the eyes
• Severe joint and muscle pain
• )
• Fatigue
• Nausea
• Vomiting
• Skin rash, which appears two to five days after
the onset of fever
• Mild bleeding (such a nose bleed, bleeding
gums, or easy bruising
 Treatment for Dengue Fever

• There is no specific medicine to treat dengue

infection. If you think you may have dengue
fever, you should use pain relievers with
acetaminophen and avoid medicines with
aspirin, which could worsen bleeding.
• You should also rest, drink plenty of fluids, and
see your doctor. If you start to feel worse in
the first 24 hours after your fever goes down,
you should get to a hospital immediately to be
checked for complications.
 Preventing Dengue Fever

• The best way to prevent the disease is to

prevent bites by infected mosquitoes,
particularly if you are living in or traveling to a
tropical area. This involves protecting yourself
and making efforts to keep the mosquito
population down.
• In 2019, the FDA approved a vaccine called
Dengvaxia to help prevent the disease from
occurring in adolescents aged 9 to 16 who
have already been infected by dengue. But,
there currently is no vaccine to prevent the
general population from contracting it.
 To protect yourself:

• Use mosquito repellents, even indoors.

• When outdoors, wear long-sleeved shirts and
long pants tucked into socks.
• When indoors, use air conditioning if
available.
• Make sure window and door screens are
secure and free of holes. If sleeping areas are
not screened or air conditioned, use mosquito
nets.
• If you have symptoms of dengue, speak to
your doctor.
 STRATEGIES

Enhanced 4S Strategy
• S - earch and Destroy
• S - eek Early Consultation
• S - elf Protection Measures
• S - ay yes to fogging only during outbreaks
 ​PHASES OF DENGUE INFECTION
• Febrile Phase
• Usually last 2-7 days
• Mild haemorrhagic manifestations like
petechiae and mucosal membrane bleeding
(e.g nose and gums) may be seen.
• Monitoring of warning signs is crucial to
recognize its progression to critical phase.
 DENGUE CASE CLASSIFICATION AND
LEVEL OF SEVERITY
• Dengue illness is categorized according to
level of severity as dengue without warning
signs, dengue with warning signs and severe
dengue.
• Dengue without warning warnings can be
further classified according to signs and
symptoms and laboratory tests as
suspect dengue, probable dengue and
confirmed dengue.
 dengue without warning signs​​
• a.1 suspect dengue
• - a previously well individual with acute
febrile illness of 1-7 days duration
plus two of the following: headache,
body malaise, retro-orbital pain, myalgia,
arthralgia, anorexia, nausea, vomiting,
diarrhea, flushed skin, rash (petechial,
Hermann’s sign)
• a.2 probable dengue
•- a suspect dengue case plus
laboratory test: Dengue NS1 antigen
test and at least CBC (leukopenia
with or without thrombocytopenia)
or dengue IgM antibody test
(optional)
• a.3 confirmed dengue
• - a suspect or probable dengue case with
positive result of viral
culture and/or Polymerase Chain Reaction
(PCR) and/or Nucleic Acid Amplification Test-
Loop Mediated Amplification Assay (NAAT-
LAMP) and/ or Plaque Reduction
Neutralization Test (PRNT)
 b. dengue with warning signs
• • a previously well person with acute febrile
illness of 1-7 days plus any of the following:
abdominal pain or tenderness, persistent
vomiting, clinical signs of fluid accumulation
(ascites), mucosal bleeding, lethargy or
restlessness, liver enlargement, increase in
haematocrit and/or decreasing platelet count
 c. severe dengue
• severe plasma leakage leading to
• shock (DSS)
• fluid accumulation with respiratory distress
• severe bleeding
• as evaluated by clinician
• severe organ impairment
• Liver: AST or ALT ≥ 1000
• CNS: e.g. seizures, impaired consciousness
• Heart and other organs (i.e. myocarditis, renal
failure)
• C
​ ritical Phase
• Phase when patient can either improve or
deteriorate.
• Defervescence occurs between 3 to 7 days of
illness. Defervescence is known as the period
in which the body temperature (fever) drops
to almost normal (between 37.5 to 38°C).
• Those who will improve after defervescence
will be categorized as Dengue without
Warning Signs, while those who will
deteriorate will manifest warning signs and
will be categorized as Dengue with Warning
Signs or some may progress to Severe
Dengue.
• When warning signs occurs, severe
dengue may follow near the time of
defervescence which usually happens
between 24 to 48 hours.
 Recovery Phase
• Happens in the next 48 to 72 hours in which
the body fluids go back to normal.
• Patients’ general well-being improves.
• Some patients may have classical rash of “isles
of white in the sea of red”.
• The White Blood Cell (WBC) usually starts to
rise soon after defervescence but the
normalization of platelet counts typically
happens later than that of WBC.
 MANAGEMENT (based on patient
type)
• Group A- patients who may be sent home
• These are patients who are able to:
• Tolerate adequate volumes of oral fluids
• Pass urine every 6 hours
• Do not have any of the warning signs
particularly when the fever subsides
• Have stable haematocrit
 Group B- patient who should be
referred for in-hospital management
• Patients shall be referred immediately to in-
hospital management if they have the
following conditions:
• Warning signs\
• Without warning signs but 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,
etc.)
• Social circumstances such as living alone or
living far from health facility or without a
reliable means of transportation.
• The referring facility has no capability to
manage dengue with warning signs and/or
severe dengue
Group C- patient with severe dengue.requiring
emergency treatment and urgent referral

• These are patients with severe dengue who

require emergency treatment and urgent
referral because they are in the critical phase
of the disease and have the following:
•
• Severe plasma leakage leading to dengue
shock and/or fluid accumulation with
respiratory distress;
• Severe haemorrhages;
• Severe organ impairment (hepatic damage,
renal impairment, cardiomyopathy,
encephalopathy or encephalitis)
• Patients in Group C shall be immediately
referred and admitted in the hospital within
24 hours.
LABORATORY TESTS
 Dengue NS1 RDT
• Requested between 1-5 days of illness
• Use to detect dengue virus antigen during
early phase of acute dengue infection
• Test is for free in all health centers and
selected public hospitals nationwide
 Dengue IgM/IgG
• Requested beyond five days of illness
• Use to detect dengue antibodies during acute
late stage of dengue infection (IgM) and to
determine previous infection (IgG)
• May give false positive result due to antibodies
induced by dengue vaccine
• May cross react with other arboviral diseases
such as Chikungunya and Zika
• DOH augmentation is limited to selected
government hospitals only
 Polymerase Chain Reaction (PCR)
• One of the gold standard laboratory tests to
confirm dengue virus.
• Molecular based test confirmatory test
• Available only in dengue sub-national and
national reference laboratories
 Nucleic Acid Amplification Test- Loop
Mediated Isothermal Amplification Assay
(NAAT-LAMP)
• novel molecular-based confirmatory test used
to detect dengue virus.Work just like PCR but
cheaper and simpler in nature.In the pipeline
to be introduced under the National Dengue
Prevention and Control Program novel
molecular-based confirmatory test used to
detect dengue virus. Work just like PCR but
cheaper and simpler in nature.In the pipeline
to be introduced under the National Dengue
Prevention and Control Program
 Plaque Reduction Neutralization Test
(PRNT)
• Gold standard to characterize and quantify
circulating level of anti-DENV neutralizing
antibody (NAb)
• Available only at the dengue national
reference laboratory
 Other tests:
• Total While Blood Cell (WBC) count
• -Platelet
• -Hematocrit
• Routinely used in hospitals as standard
dengue diagnostic tests
• Look for trend of decreasing WBC, decreasing
platelet and increasing hematocrit
 NATIONAL DENGUE PREVENTION AND
CONTROL PROGRAM

• Vision - A dengue free Philippines

•
• Mission - Ensure healthy lives and promote
well-being for all at all ages

• Goal - To reduce the burden of dengue disease

 Objectives

• 1.) To reduce dengue morbidity by at least 25%

by 2022
• Indicators :
• Morbidity rate = No. of suspect, probable &
confirmed cases x100,000 total population
• (baseline: 198.1 per 100,000 population)
• (2015 data: 200,145/100,981,437 x 100,000)
• 2.) To reduce dengue mortality by at least 50%
by 2022
• Mortality rate = No of dengue (probable &
confirmed) deaths x 100,000 total population
• (baseline: 0.59 per 100,000 population)
• (2015 data: 598/100,981.437 x 100,100)
3.) To maintain Case Fatality Rate (CFR) to < 1%
every year.
CFR = no. of dengue (probable & confirmed)
deaths x 100 no. of probable & confirmed cases
 PROGRAM COMPONENTS
• 1. Surveillance
• Case Surveillance through Philippine
Integrated Disease Surveillance and Response
(PIDSR)
• Laboratory-based surveillance/ virus
surveillance through Research Institute for
Tropical Medicine (RITM) Department of
Virology, as national reference laboratory, and
sub-national reference laboratories.
• Vector Surveillance through DOH Regional
Offices and RITM Department of Entomology
• 2. Case Management and Diagnosis
• Dengue Clinical Management Guidelines
training for hospitals.
• Dengue NS1 RDT as forefont diagnosis at the
health center/ RHU level.
• PCR as dengue confirmatory test available at
the sub-national and national reference
laboratories.
• NAAT-LAMP as one of confirmatory tests will
be available at district hospitals, provincial
hospitals and DOH retained hospitals.
• 3. Integrated Vector Management (IVM)
• Training on Vector Management, Training
on Basic Entomology for Sanitary Inspector,
Training on Integrated Vector Management
(IVM) for health workers.
• Insecticide Treated Screens (ITS) as dengue
control strategy in schools.
• 4. Outbreak Response
• Continuous DOH augmentation of
insectides such as adulticides and
larvicides to LGUs for outbreak response.
• 5. Health Promotion and Advocacy
• Celebration of ASEAN Dengue Day every June 15
• Quad media advertisement
• IEC materials

• 6. Research
 STRATEGIES

Enhanced 4S Strategy
• S - earch and Destroy
• S - eek Early Consultation
• S - elf Protection Measures
• S - ay yes to fogging only during outbreaks