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TABLE OF CONTENTS
1. VIROLOGY p1
2. CLINICAL MANIFESTATIONS AND PATHOPHYSIOLOGY p2
3. LABORATORY INVESTIGATIONS p5
4. MANAGEMENT OF DENGUE INFECTION p5
5. MANAGEMENT OF BLEEDING p8
6. HOSPITAL REFERRAL / ADMISSION p9
7. DENGUE INFECTION IN SPECIAL CONDITIONS p10
8. PREVENTION p11
9. FOR HEALTH PROVIDERS p12

APPENDICES

APPENDIX 1– OPD “Form O” APPENDIX 2 – Reporting “Form R”

(Suspected/Probable case)
APPENDIX 3 – Reporting Form for Dengue APPENDIX 4 – SOP for Reporting
Patients (Confirmed) Dengue Patients
APPENDIX 5 – Diagnostic criteria – Non APPENDIX 6 – Diagnostic criteria – For
Epidemic Setting & Epidemic Setting Epidemic Setting

Design and Formatted by M Adil Bin Ali from Central DEAG

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↑Back to
1. VIROLOGY Top

1. What is Dengue Fever?

Dengue fever is viral infection caused by dengue virus. which is a mosquito-borne

flavivirus.

2. How many types of dengue viruses?

There are four distinct serotypes, DEN-1, 2, 3 and 4.

3. How does it spread?

Dengue infection is spread by the bite of an Aedes mosquito. The mosquito transmits
the disease by biting an infected person and then biting someone else.

4. Do all types of viruses can cause disease simultaneously?

It depends upon the types of viruses circulating in population. Mostly one type of virus
causes one time disease. If a person has suffered from one virus, there can be a repeat
occurrence if a different strain is subsequently involved. Subsequent infections with
different serotypes increase the risk of severe complications.

5. Is it possible to get dengue fever twice?

Each episode of infection induces a life-long protective immunity to that causing virus
but also provide partial and transient protection against subsequent infection by the
other three serotypes.

6. What is most favorable season for dengue fever?

Rainy Season is most favorable season for dengue fever because of its temperature,
precipitation, and humidity which is critical to mosquito survival, reproduction, and
development.

7. How soon after mosquito bite do symptoms appear?

The time between the bite of a mosquito carrying dengue virus and the start of
symptoms averages from 4 to 6 days, with a range of 3–14 days.

8. Can an infected person spread the infection to other persons by direct contact?

An infected person cannot spread the infection to other persons by direct contact, but
can be a source of dengue virus for mosquitoes for about 6 days.
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2. CLINICAL MANIFESTATIONS AND PATHOPHYSIOLOGY ↑Back to

Top

9. When should I suspect dengue?

Dengue should be suspected if you have a sudden onset of high fever, which could
reach 39–40°C (103–105°F). It is accompanied by severe headache (mostly in the
forehead), pain behind the eyes, body aches and pains, skin rash and nausea or
vomiting. The symptoms usually last for 5–7 days. In some patients, fever comes down
on the third or fourth day but it may reappear. All these symptoms and signs are unlikely
to be present simultaneously in a patient, but if there is a minimum of two or three
symptoms along with a fever of two to ten days then dengue should be suspected.

10. Can a person have dengue infection but not appear ill?

Yes. There are many people who are infected with the virus and do not suffer from any
signs or symptoms of the disease. For every patient with symptoms and signs there
may be four or five persons with either no symptoms or very mild symptoms.

11. There are several different kinds of fever. When should dengue be suspected?

The characteristics of dengue that differentiate it from other causes of fever are the pain
behind the eyes, severe pain in the muscles, severe bone pain, and skin rashes. These
features point to a likely diagnosis of dengue. The severe bone pain caused by dengue
is why it is also called “break-bone fever”.

12. What is Dengue Hemorrhagic Fever?

Dengue hemorrhagic fever is characterized by a fever that lasts from 2 to 7 days, with
general signs and symptoms consistent with dengue fever. When the fever declines,
symptoms including persistent vomiting, severe abdominal pain, and difficulty breathing,
may develop. This marks the beginning of a 24 to 48 hour period when the smallest
blood vessels (capillaries) become excessively permeable (“leaky”), allowing the fluid
component to escape from the blood vessels into the peritoneum (causing ascites) and
pleural cavity (leading to pleural effusions).

13. What is Dengue Shock Syndrome?

The excessively permeable (“leaky”), causing the fluid to escape from the blood vessels
into the peritoneum and pleural cavity. This may lead to failure of the circulatory system
and shock. In addition, the patient with DHF has a low platelet count and hemorrhagic
manifestations, tendency to bruise easily or other types of skin hemorrhages, bleeding
nose or gums, and possibly internal bleeding.
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manifestations, tendency to bruise easily or other types of skin hemorrhages, bleeding

nose or gums, and possibly internal bleeding.

14. Can dengue fever become dangerous?

During the leaky phase of DHF there may be failure of circulatory system and shock. If
this shock not treated in time, this may become dangerous and can lead to death of
patient.

15. Is dengue fever and DHF same?

DHF is a more severe form of dengue infection. It can be fatal if unrecognized and not
properly treated in a timely manner. DHF is caused by infection with the same viruses
that cause dengue fever. DHF is occurs in second infection caused by another
serotype. With good medical management, mortality due to DHF can be less than 1%.

16. What are stages of Disease?

Subsequent clinical course of dengue disease can be highly variable but can be,
broadly, divided in to three phases:

1. Febrile

It starts with a sudden onset of high fever, which could reach 39–40°C (103–105°F).
It is accompanied by severe headache (mostly in the forehead), pain behind the
eyes, body aches and pains, skin rash and nausea or vomiting. The symptoms
usually last for 5–7 days. In some patients, fever comes down on the third or fourth
day but it may reappear.

2. Critical/Leak

During the second infection/DHF it begins when the fever declines, symptoms
including persistent vomiting, severe abdominal pain, and difficulty breathing, may
develop. This marks the beginning of critical/leaky phase that continued for 48
hours. If not treated properly the patient may develop shock.

3. Convalesce

It comes after febrile phase in dengue fever and critical phase in DHF. The patient’s
general wellbeing improves, appetite returns, gastrointestinal symptoms abate,
hemodynamic status stabilizes and diuresis ensues. Some patients may have a
classical rash of “isles of white in the sea of red”
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17. How to recognition of Dengue Hemorrhagic Fever (DHF)

- Symptoms similar to dengue fever plus, any one of the following:

- Severe and continuous pain in abdomen

- Bleeding from the nose, mouth and gums or skin bruising

- Frequent vomiting with or without blood

- Black stools, like coal tar

- Excessive thirst (dry mouth)

- Pale, cold skin

- Restlessness, or sleepiness

18. What are uncommon presentations?

Hepatitis, liver failure, acute abdomen, encephalitis, myocarditis

19. What happened in Dengue shock syndrome?

- Weak rapid pulse

- Narrow pulse pressure (less than 20 mm Hg) or recordable BP.

- Cold, clammy skin and restlessness.

- Not passed urine during last six hours

20. What are the other co-infections?

Patient may have Typhoid and malaria.

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3. LABORATORY INVESTIGATIONS Top

21. What are the Laboratory diagnosis for dengue fever?

After suspecting the dengue infection get White cell count (WCC), Hematocrit (HCT),
Platelet counts. If WBC is < 4000/cmm3 and Platelet counts is < 100,000 then this is a
probable case of dengue infection it should be confirmed by getting NS1 Antigen or
PCR when the patient having fever and dengue Dengue IgM test, Indirect IgG ELISA
test after Febrile phase.

22. How PCR can be done?

PCR for dengue virus is being done at Institute of public health jail road and Institute of
microbiology Canal bank road Lahore. A three ml non heparinized blood is required. It
should be performed immediately.

23. When IgM will be positive?

IgM becomes detectable by day 5, it rises rapidly and peaks at about 2 weeks after the
onset of symptoms, it wanes slowly in the following months to reach undetectable levels
after a variable interval. 50% + in 3-5 day, 70% on 7th day, 100% day 10-14

24. For how long IgM and IgG remain detectable in blood?

Fully recovered healthy people, who had had an exposure to the dengue virus in the
recent past, might have test positive to the dengue IgM. As it may remained detectable
for a variable period of time lasting upto 3 months. Both in1st and 2nd dengue infection,
dengue IgG becomes detectable in 100% of patients after day seven of onset of fever
and it may remain detectable for whole life.

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4. MANAGEMENT OF DENGUE INFECTION: Top

25. What is the treatment for dengue?

There is no specific medication for treatment of a dengue infection. Persons who think
they have dengue should use analgesics (pain relievers) with acetaminophen and avoid
those containing aspirin. They should also rest, drink plenty of fluids, and consult a
physician. If they feel worse (e.g., develop vomiting and severe abdominal pain) in the
first 24 hours after the fever declines, they should go immediately to the hospital for
evaluation.
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26. Who should be treated at home?

1. Patient who is tolerating orally, passing adequate urine (atleast once six hours)

2. No or mild bleeding manifestation

3. Absence of clinical alarm signals

4. Pink, warm extremities

5. Normal capillary refill time (normal <2 seconds)

6. Good pulse volume Stable blood pressure

7. No abdominal pain and tenderness

8. During first four days of fever

27. What treatment should a dengue patient take at home?

• Adequate bed rest

• Adequate fluid intake (more than 8-10 glasses for an average person)

- Milk, fruit juice (caution with diabetes patients) and isotonic electrolyte solution
(ORS) and barley water

- Plain water alone is not sufficient and may cause electrolyte imbalance.
(Nicaragua 2003, Level 8)

• Take Paracetamol 2 tablets every 6 hourly for adults (not more than 4 gram/day)

• Tepid sponging

• If possible, use mosquito repellent or rest under a mosquito net even during day
time to prevent mosquito bites

• Look for mosquito breeding places in and around the home and eliminate them

28. What medicine should be avoided by dengue patient?

• Do not take non-steroidal anti-inflammatory (NSAIDs) e.g. aspirin / Mefenamic

acid (Ponstan) or steroids. If you are already taking these medications please consult
your doctor.

• Antibiotics and Anti-Malarial are not required.

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29. When should dengue patient go to the hospital?

 On day four of illness and get White cell count (WCC), Hematocrit (HCT), Platelet
counts

 If the patient develops any of the following danger signs at any day of illness
should come immediately to the hospital

1. Bleeding for example:

• Extensive red spots or patches on the skin

• Excessive bleeding from nose or gums

• Black tarry stools

• Heavy menstruation / vaginal bleeding

2. Frequent vomiting

3. Severe abdominal pain

4. Drowsiness or irritability

5. Pale, cold and clammy skin

6. Difficulty in breathing

7. Decrease urine output

30. How to asses a dengue patient?

Ask followings;

1. Date of onset of fever/ illness

2. Oral intake of fluids (estimated)

3. Assess for warning signs; Diarrhea, Bleeding and Change in mental

state/seizure/dizziness

4. Urine output (frequency, volume and time of last voiding)

5. History of dengue in the family or the neighborhood

6. Jogging/walks in the park and swimming in waterparks

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31. What are the important critical/warning signs of dengue infection?

 Abdominal pain or tenderness

 Persistent vomiting
 Pleural effusion, ascites
 Significant manifest bleed
 Restlessness/ lethargy/ Irritability in infants
 Tender enlarged liver
 Decreased urine output

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5. MANAGEMENT OF BLEEDING Top

32. What should I do if I had bleeding?

Bleeding from the gums or vagina, epistaxis and petechiae are common but will usually
cease spontaneously and are often not significant. There is no need of specific
treatment for minor bleeding. Significant bleeding could be consequence of
disseminated intravascular coagulation which usually occurs following prolonged shock
and acidosis. Transfusion of blood and blood components in dengue is indicated when
there is evidence of significant bleeding.

33. Should I have Platelet transfusion in bleeding during dengue infection?

Prophylactic transfusion with platelets and fresh frozen plasma does not produce
sustained changes in the coagulation status and platelet count in patients with
DHF/DSS. Prophylactic transfusion with platelets and fresh frozen plasma does not
change or reduce the bleeding outcome in DHF.

Inappropriate transfusion of blood components increases the risk of pulmonary edema

and respiratory embarrassment.

34. Is there an effective treatment for dengue hemorrhagic fever (DHF)?

As with dengue fever, there is no specific medication for DHF. It can however be
effectively treated by fluid replacement therapy if an early clinical diagnosis is made.
DHF management frequently requires hospitalization. Physicians who suspect that a
patient has DHF must refer or admit.
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6. HOSPITAL REFERRAL / ADMISSION Top

35. When the patient should be referred/admitted to the hospital?

The decision for referral and admission must not be based on a single clinical
parameter but should depend upon the overall assessment of the patient, taking
history, physical examination and labs into consideration. On day 4 of the disease or
any one of the following is present the patient should be referred/admitted in a tertiary
care hospital.

1. Symptoms

 Presence of any warning sign during and at the end of febrile phase (cited
above)

 Inadequate urine output (not passed urine during last 6 hours)

 Seizures
2. Signs

 Shock (cited above)

 End organ failure

3. Special Situations for early referral to the hospital

 Patients with co-morbidity e.g. Diabetes, Hypertension, Ischemic Heart Disease,

Coagulopathies, Morbid Obesity, Renal Failure, Chronic Liver disease, COPD

 Infants < 1 year of age and elderly > 65 years of age

 Pregnancy

 Social factors that limit follow-up e.g. living far from health facility, no transport,
patient living alone, etc.

4. Laboratory Criteria

 Rising HCT accompanied by reducing platelet count

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36. Are there any long-term ill effects of dengue fever?

Most people who suffer from dengue fever recover in one or two weeks. Some may
feel tired for several weeks. If symptoms persist longer than this, consult a doctor.

37. Can children suffer from dengue infection?

Yes. Children may have dengue infection similar to the adults.

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7. DENGUE INFECTION IN SPECIAL CONDITONS Top

38. What pregnant Women should do if got dengue infection?

The signs and symptoms of dengue infection during pregnancy may be confused with
other complications of pregnancy such as toxemia, Hemolysis, Elevated Liver
Enzymes, Low Platelets (HELLP) syndrome. There are some reports of an increased
incidence of prematurity, in-utero death and abruptio placenta in these women. Every
pregnant women with the dengue fever should be hospitalized.

39. Can surgical procedures be performed during dengue infection?

All the elective procedures should be avoided until the platelet count is within the
normal limits however the emergencies surgical procedures can be performed by
maintaining the plate counts with platelet transfusions.

40. Should patient stop medicine for hyper tension during dengue infection?

• Diuretics should be stopped as soon as the probable diagnosis of dengue is made.

• Other anti-hypertensive treatment may be continued if the Pulse Pressure stays above
30 mm of Hg.

• In case the Pulse Pressure drops, ≤30 mm Hg, stop all anti-hypertensive treatment and
introduce monitoring

41. Should patient stop anti-platelet medicine during dengue infection?

As a general rule acetyl salicylic acid should be avoided in patients with DF because of
worsening of complications from thrombocytopenia and bleeding – unless patient is at a
high risk of thromboembolism. Patient should consult to the cardiologist.
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8. PREVENTION Top

42. How can I prevent mosquito bites to prevent dengue?

There is no way to tell if a mosquito is carrying the dengue virus. Therefore, people
must protect themselves from all mosquito bites. Aedes mosquitoes bite during the day,
and the highest biting intensity is about 2 hours after sunrise and before sunset. To
avoid being bitten:

● Wear full-sleeve clothes and long dresses to cover as much of your body as possible.

● Use mosquito repellents

● Use mosquito coils and electric vapour mats during the daytime.

● Use mosquito nets to protect children, old people and others who may rest during the
day. The effectiveness of these nets can be improved by treating them with
insecticide.

43. How does a person with dengue fever prevent it from spreading to others?

Dengue spreads when an infected person is bitten by a mosquito that then bites
others. The patient should thus be protected from contact with mosquitoes. This can be
achieved by ensuring that people follow the preventive measures described above.

44. Is there any danger in travelling to an area where a dengue outbreak has been
reported?

There is no travel restriction. However, it is important to observe the preventive

measures described above, and see a doctor if you develop sudden fever or some of
the other symptoms of dengue.

45. What can the community do to prevent dengue?

Prevention of dengue relies heavily on preventing the mosquito (Aedes aegypti) that
transmits dengue from breeding inside and in the vicinity of homes. Items that collect
rainwater or to store water (for example, plastic containers, drums, buckets, or used
automobile tires) should be covered or properly discarded. Pet and animal watering
containers and vases with fresh flowers should be emptied and cleaned (to remove
eggs) at least once a week. This will eliminate the mosquito eggs and larvae and
reduce the number of mosquitoes present in these areas. Prevention of dengue relies
heavily on preventing the
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46. What is the advice regarding reporting of dengue?

All suspected or probable dengue cases should be reported to the health authorities.

In our clinical practice, all the “suspected cases” have to have a CBC done. If Patient
has WBC count of less than 4000 and platelet count of less than 100,000, patient would
be categorized as “PROBABLE DENGUE”. Case reporting is then, mandatory. (DEAG
“Form R”, Appendix 2)

Confirmatory tests in these patients in the form of viral isolation (PCR), documentation
of NS1, or four fold increases in the immunoglobulin titer on paired sample taken 5 days
apart would clinch the diagnosis as “CONFIRMED DENGUE” – albeit too late for
epidemiological purpose. Filing of a detailed case report form (Appendix 3) is mandatory
here.

All Probable dengue cases, admitted to the hospital or under the care of a GP, must be
notified to the EDO health who in turn will report to DG health within one hour – it is to
be followed by written notification within 24 hours using the standard notification format
(Ref to DEAG “Form R” on Appendix 2).

It is also important to note that re-notification has to be done if the diagnosis is reversed
from DHF/ DF to other diagnosis.

47. Is there a vaccine to prevent dengue fever?

Vaccines to prevent dengue fever are under trial. None is available in the market.

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9. FOR HEALTH PROVIDERS: Top

Detailed information for health providers is available from: Good Clinical Practice
Guidelines published by Dengue Expert Advisory Group (DEAG) for the management of
dengue Infection in adults, as “GCP dengue-guidelines-2012”.

48. What should the doctors treating dengue do?

Doctor should evaluate the patient for any indication of referral/admission. Patients
suspected to be suffering from dengue hemorrhagic fever or dengue shock syndrome
should be hospitalized without delay.

In hospital these patients should be reviewed regularly at 1–2 hour intervals, and their
platelet counts and hematocrits should be monitored frequently.
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A fall of HCT more than 20% as compared with previous levels may be an indication for
blood transfusion.

If the hematocrit values rise, the patient should be given fluids intravenously and the
fluids carefully monitored to ensure that the patient does not get excess. A rise of more
than 20% in hematocrit levels as compared with previous levels may be an indication for
IV fluids.

The doctor should use his/ her judgment based on the patient’s condition. Platelets are
cells in blood that help to stop bleeding. Hematocrit indicates the thickness or
concentration of blood.

49. What should doctors treating dengue avoid?

There are few things to remember:

● Do not prescribe aspirin, ibuprofen or any other medicine that reduces the platelets or
increases the tendency of bleeding.

● Avoid giving intravenous (IV) fluids unless the patient is bleeding or the hematocrit
level is rising progressively.

● Avoid blood transfusion unless the hematocrit is falling dangerously.

● Do not give platelet transfusion unless the platelet count is very low or unless there is
bleeding.

50. When is a patient fit for discharge?

• Must be afebrile for 48 hours (without antipyretics)

• Stable general condition

• Recovery of appetite

• Stable hematocrit for at least 24 hours

• Rising trend in platelet count (minimum 40,000)

• No dyspnea or respiratory distress attributable to pleural effusion or ascites

• No or minimal visible bleeding

• Fully recovered organ dysfunction

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APPENDICES Top

APPENDIX 1 OPD Form

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APPENDIX 2 Reporting for Dengue Patients (Suspected &Probable) Top
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APPENDIX 3 Reporting Form for Dengue Patients (Confirmed)
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APPENDIX 4 Top
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APPENDIX 5 Diagnostic Criteria – Non Epidemic Setting Top
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APPENDIX 6 Diagnostic Criteria – Epidemic Setting Top
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