Dengue Fever (DF) and Dengue Hemorrhagic Fever (DHF)

Dengue Fever (DF) and Dengue Hemorrhagic Fever (DHF) are acute fever disease caused by the dengue virus, which enters the human blood stream through the bite of the female mosquito from genus Aedes.

Dengue fever and dengue hemorrhagic fever are found in tropical and subtropical regions around the world, especially in the rainy season. The spred of disease carried by Aedes aegypti mosquito (in the city area) and  Aedes albopictus mosquito (in the village area). But, in Indonesia, the main vector of dengue is Aedes aegypti that usually bites during the day.

Dengue hemorrhagic fever has signs and symptoms that are more dangerous than dengue fever. DHF has way very quickly and often become fatal because many patients are dying from the late treatment.

Dengue fever and dengue hemorrhagic fever are acknowledged as one of the world’s major emerging infectious diseases. In fact, the infection is now rightly seen as a global pandemic, with recorded prevalence in 101 countries. In Indonesia, they are still a public health problem that the number of sufferers is likely to increase and spread more widely.

To reduce the spreads of dengue fever and dengue hemorrhagic fever is necessary motions (mosquito nest eradication (Pemberantasan Sarang Nyamuk “PSN”) continuously.

A.            PATHOPHYSIOLOGY
          The main pathophysiological phenomena that determine the seriousness of disease and to distinguish dengue fever with dengue hemorrhagic fever is increases permeability of the capillary walls due to the release of substances anafilaktoksin, histamine and serothin and the kallikrein system activation ekstravasosi result intravascular fluid. This resulted in reduction in plasma volume, hypotension, hemoconcentration, hipeproteinemia, effusion and shock. Plasma during seeps trip diseases from ranging the beginning of fever and peaked at when shock. The signs are not found in dengue fever.

B.            ETIOLOGY

Dengue virus belong to the genus Flavivirus , family Flaviviridae and have  4 types of serotypes , namely: DEN - 1 , DEN - 2 , DEN - 3 , DEN - 4.  Serotype DEN - 3 is the dominant serotype and assume many who showed severe clinical manifestations. In Indonesia, four types of serotypes are existed.

Symptoms of dengue appear when a person who has been infected by one of four types of dengue virus infection by a different dengue virus types. A person can be infected by at least two if not all four types at different times during their lifetime, but only once by the same type because the immune system is already formed. The immune system that already formed in the body after the first infection would likely result in the emergence of a more severe disease symptoms when infected for the second time.

C.            SIGNS AND SYMPTOMS

After an incubation period of ±7 days after an infective mosquito bite, the disease usually characterized by the sudden onset of fever and a variety of nonspecific signs and symptoms, including frontal headache, retro-orbital pain, body aches, nausea and vomiting, joint pains, weakness, and rash. Typically accompanied by any of the following: chilliness, photophobia, backache, severe muscle ache (one synonym of dengue is “break-bone fever”), Patients may be anorexic, have altered taste sensation, and have a mild sore throat. Constipation is occasionally reported; diarrhea and respiratory symptoms are infrequently reported and may be due to concurrent infections. Symptoms include a generalized maculopapular rash, lymph node enlargement, a positive tourniquet test, petechiae, and other hemorrhagic manifestations, such as epistaxis and gastrointestinal bleeding. In general, convalescence occurs spontaneously and abruptly, but it might be prolonged, sometimes taking several weeks, and may be accompanied by pronounced asthenia and depression.

 High fever may be sustained over 5–6 days. The initial temperature may rise to 38°C to 40°C, and fever may last for 2 to 7 days. The fever may drop after a few days, only to rebound 12 to 24 hours later (saddleback). A relative bradycardia may be noted despite the fever. The conjunctivae may be injected, and the pharynx may be inflamed. Lymphadenopathy is common. Rash is variable but occurs in up to 50% of patients as either early or late eruptions. Facial flushing or erythematous mottling may occur coincident with or slightly before onset of fever and disappears 1 to 2 days after onset of symptoms. A second rash, varying in form from scarlatini form to maculo papular, may appear between days 2 and 6 of illness. The rash usually begins on the trunk and spreads to the face and extremities. In some cases, an intense erythematous pattern with islands of normal skin is observed. The average duration of the second rash is 2 to 3 days. Toward the end of the febrile phase of illness or after the temperature falls to or below normal, petechiae may appear; these may be scattered or confluent. Intense pruritus followed by desquamation on the palms of the hands and soles of the feet may occur.

Hemorrhagic manifestations in dengue fever patients are not uncommon and range from mild to severe. Skin hemorrhages, including petechiae and purpura, are the most common, along with gum bleeding, epistaxis, menorrhagia, and gastrointestinal (GI) hemorrhage. Hematuria occurs infrequently, and jaundice is rare.

Clinical laboratory findings associated with dengue fever include a neutropenia followed by a lymphocytosis, often marked by atypical lymphocytes. Liver enzyme levels in the serum may be elevated; the elevation is usually mild, but in some patients, alanine aminotransferase and aspartate aminotransferase levels reach 500 to 1000U/liter. In one epidemic of DEN-4, 54% of confirmed patients with data reported on liver enzymes had elevated levels.  Thrombocytopenia is also common in dengue fever; in the above epidemic, 34% of patients with confirmed dengue fever who were tested had platelet counts of less than 100,000/mm3.

Dengue fever is generally self-limiting and is rarely fatal. The acute phase of illness lasts for 3 to 7 days, but the convalescent phase may be prolonged for weeks and may be associated with weakness and depression, especially in adults. No permanent sequel is known to be associated with this infection.     

Symptoms commonly associated with dengue, such as fever, myalgia, arthralgia, and exanthema can be helpful in making the diagnosis, when present, but the absence of typical symptoms does not exclude infection. Most patients with dengue in this study were symptomatic and reported fever and headache. Myalgias, fatigue, and rashes were common, as well as diarrhea. Thus, the diagnosis of dengue virus infection should be considered for patients who present with a broad variety of symptoms and who reside in or have recently traveled to dengue-endemic regions. Dengue has a short incubation period; thus, in this study, symptoms tended to begin before or just after the return from the journey (median, 1 day after return). The course of illness was benign in most patients. However, clinical complications consistent with DHF were reported in 5 patients (2%). These patients were treated on an inpatient basis; therapy included platelet substitution and intensive care management for 4 patients. Fortunately, all patients recovered.

Shortly, the difference of signs and symptoms between dengue fever and dengue hemorrhagic fever are:

1)             Dengue Fever

·                High fever for 2-7 days, with headache, muscle pain and joint pain

·                Nausea and vomiting

·                Rash

·                Myalgia or arthalgia, fatigue, and diarrhea

·                Respiratory complaints

2)             Dengue Hemorrhagic Fever
         Dengue hemorrhagic fever has signs and symptoms similar as dengue fever, but with addition signs and symptoms:

·               High fever for 2-7 days constantly

·               Thrombocyte  and leukocyte decrease, less than 100.000/mm³ (thrombocytopenia)

·               Hemotokrit increase, rising 20% than amount of normal (hemoconsentrasion)

·               Skin hemorrhages, including petechiae and purpura, are the most common, along with gum bleeding, epistaxis, menorrhagia, and gastrointestinal (GI) hemorrhage.

·               Swelling liver

·               Genitourinary

·               Neurological complaints

·               Psychological complaints

·               Shock

D.            CONTAGIOUS MECANISM

                   There are 3 factors of disease transmission dengue fever and dengue           hemorrhagic fever, that is: human, dengue virus, and the female Aedes       mosquito as an intermediary.

                   Dengue disease contagious mechanism consists of 4 stages, that is:

1)             Infectious period in humans
         People who are infected with Dengue Fever bitten by the female Aedes mosquito when " viremia " ( there is a virus in the blood ) for 4-7 days ( 1-2 days before the fever starts until 3-5 days after fever ) .

2)              Incubation period in mosquitoes
                   Virus that mosquitoes sucked enter to the stomach and the    mosquitoes will reproduce themselves then will migrate to the mosquitoes’ salivary glands.

3)             Future spread of disease
         For ± 7 days after mosquitoes suck the patient's blood, mosquitoes can spread the disease to others. The virus will dry up in the body of mosquito forever.

4)              Transmission period to the new human
         In the human blood, dengue virus will multiply and survive within ± 7 days. During this period, humans have show reveal symptoms of the disease.

E.           PREVENTING

One of method controlling or preventing Dengue Fever and Dengue Hemorrhagic Fever is to control the vector Aedes mosquitoes.         

Mosquito control can be doing by using some right method according to the RI Department of Health (1992), that is:

a.              Environment

Mosquito control methods include the mosquito nest eradication (MNE). Solid wastes management, modification of mosquito breeding sites byproduct of human activity, and improved design of the house, as examples:

1)      Drain the Bathtub or water reservoir once a week.

2)      Replace water in flower vases and pet drinking at least once a week.

3)      Close tightly the water reservoirs.

4)      Bury the wastes, plastics, cans, scrap, used batteries, used tires around the house, etc.

b.             Biology

Biological control such as using mosquito larvae-eating fish (hickey fish) in the water reservoirs that is not possible to drain.

c.              Chemical

             The control measure includes:

1)      Fumigation or fogging (using malathion 95% EC + 3 liter diesel, repeated after 1 week of fumigation to reduce the possibility of transmission to a certain time limit, so it is necessary to continue the steps of MNE.

2)      Provide abate powder (temephose) by sprinkling on the shelter and repeat after 2-3 months at a dose of 1 gram of 100 liters of water) on the places such as barrel-shaped water reservoirs, flower vases, ponds, etc.

Preventive measures from mosquito bites can also be done by:

1)             Mosquito coil and electric mosquito mat or liquid have to be placed near possible entrance, such as window.

2)             Wear long-sleeved clothes and long trousers when going outdoors.

3)             Applying insect repellent (containing DEET) especially when we travel to Dengue Fever endemic areas.

4)             Mosquito bed net could be used when the room is not air-conditioned.

Shortly, we can do “4M plus” (now “3M” changed by “4M plus”), that is:

1)             Wash out. Wash out water container like a bathtub, jars, buckets, flower vases, bird drinking places, refrigerator water reservoir, so that the eggs and larvae of Aedes dead.

2)             Close. Close tightly all water containers so that Aedes mosquitoes can’t enter and spawn.

3)             Pile up. Pill up all used items that can collect rain water such as old tires, tin cans, broken bottles so that not to become a nest Aedes mosquitoes.

4)             Monitor. Monitor all water containers that can become breeding places of Aedes mosquitoes.

5)             Plus:

-                Do not hang clothes

-                Maintain a fish

-                Avoid mosquito bites

-                Affix an abate

F.             THE ROLE HEALTH PROMOTOR

Dengue Fever is an epidemic disease that becomes concern to the government because many people suffer this disease and many of them are dead. To overcome this disease, the government has many efforts to mobilize the people in order to play a role in prevention of Dengue Fever disease. One of the government efforts is mobilize the health promotion because the role of health promotion is very important to give health education and knowledge to the people.

One of the efforts from health promoter is give socialization for people which is contained in the Regional Regulation Number 6 of 2007 that one of the prevention of disease Dengue Fever is socialization. Health promotion is give socialization about what is the dengue fever, sign and symptom, how contagious mechanism, and how to prevent this disease.

Socialization can be implemented through a variety of ways such as by direct socialization to people from sub-district level until neighborhood level. Or with promotion method by make an advertisement in print media or electronic media. For example, an advertisement about the ways to prevent this disease by “4M plus”, an advertisement about the  symptom of dengue fever, and about the best treatment to dengue fever patient.

With socialization and health promotion, the Government hope that people can knows about what is the Dengue Fever, so that the people can do the best treatment to patient appropriate with the symptoms that arise. So, it will decrease the risk of death for patient. Moreover, the people also can take step to prevent this disease according to the procedure.

The Government’s effort can’t give maximal result if there is no rule and awareness from the people. Therefore, the health promotion must be able to mobilize the people in order to play the role for overcome Dengue Fever disease. One of the way can be implemented is mobilize cadres that usually from members of society organization to become larva monitoring. With this larva monitoring, preventing dengue fever disease will be easy because the existence of larva can be caught early. In addition, the government also needs counseling efforts mosquito nest eradication program (Pemberantasan Sarang Nyamuk “PSN”), and mobilize the community to keep the environment around them, because if not them who else will take care of their environment.

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