Dengue Fever- is an acute infectious mosquito-borne viral disease that cause a severe

flu-like illness, also known as “Breakdown Fever, Dandy Fever, Hemorrhagic Fever, infectious
Thrombocytopenic Purpura”
-dengue is found in tropical and sub-tropical climates worldwide, mostly in urban and
semi-urban areas. The disease occurs most often during the rainy season in areas with
numbers of infected mosquitoes.

Causative Agent:
-transmitted by Mosquitoes Genus Aedes.
-also termed Dengue Vasculopathy
-the virus is responsible for causing dengue is Dengue Virus (DENV)
-aedes albopictus may contribute to transmission of dengue virus in rural areas
-aedes polynensi in south island of Australia
-aedes scutellaris simplex in papua new geinie

Sources of Infection:
1. Infected persons- the virus is present in the blood of patient during the acute phase of
the disease & will become the reservoir of virus sucked by mosquitoes which may then
transmit the disease. 2. Standing Water-any stagnant water along the household &
premises are usual breeding places

Incidence:
1. Age- may occur at any age , but it is common among children with the peak between 4-9
years old.
2. Sex- both sexes can be affected 3. Season- more frequent during rainy season 4. Location-
more prevalent in urban communities

Pathogenesis and Pathology:

-Infectious virus is deposited in the skin by the vector & initial replication occurs at the site
of infection & in local lymphatic system. Within a few days Viremia occurs, lasting until 4th
or 5th day after onset of symptoms. Evidence indicates that macrophages are the principal
site of replication. At the site of petechial rash, non- specific changes, has been noted which
include: Endothelial Swelling; Perivascular edema (in petechiae) extravasation of blood
Marked increase in vascular permeability, hypotension, hemoconcentration of
thrombocytopenia, with increased platelet agglutinability, & or moderate disseminated
intravascular coagulation .The most serious pathophysiological abnormality is
hypovolemic shock resulting from increased permeability of the vascular endothelium &
loss of plasma from the intravascular space

Dengue Hemorrhagic Fever-is a severe, sometimes fatal manifestations of dengue

virus infection characterized by a bleeding diathesis and hypovolemic shock
Etiologic Agent: Flaviviruses 1, 2, 3, 4 a family of Togaviridae. These are small
viruses that contain single strand RNA.

Types:
1. DENV-1
2. DENV-2
3. DENV-3
4. DENV-4

Classification:
 1. Undifferentiated fever
2. Dengue fever
3. Dengue hemorrhagic fever
4. Arboviruses group b-group of viruses

Mode of Transmission
-by bite of an infected mosquito (aedes egypti), a day biting mosquito (2 hours after sunrise
and 2 hours before sunset)
-breeds on stagnant water, with limited movement and a low flying and with fine white
dots at the base of the wings with white bands on the legs
- When a patient suffering from dengue fever and is bitten by a vector mosquito, the
mosquito is infected and it may spread the disease by biting other people

Incubation Period:
-symptoms begin 3-14 days after infection and symptoms last for 2-7 days
-7-10 days after the bite of an infected mosquito

Period of Communicability:
1. Patients are usually infective to mosquito from a day before the febrile period to the end
of it.
2. The mosquito become infective from day 8-12 after the blood meal & remains infective
all throughout life

Clinical Manifestations:
I. DENGUE FEVER:
1. Prodromal symptoms characterized by malaise & anorexia up to 12 hours; fever & chills
accompanied by severe frontal headache, ocular pain, myalgia with severe backache, &
arthralgia.
2. Nausea & vomiting
3. fever is non- remitting & persist for 3-7 days.
4. Rash is prominent on the extremities & the trunk
5. It may involve the face in some isolated cases.
6. Petechiae usually appear near the end of the febrile period & most common on the lower
extremities.

II. DENGUE HEMORRHAGIC FEVER(DHF):

-this severe form of dengue virus infection is manifested by fever, hemorrhagic diathesis,
hepatomegaly & hypovolemic shock.

Phases of Illness:
1. Initial febrile Phase: lasting from 2-3 days: with fever (39-40C )accompanied by
headache febrile convulsions may appear palms & sole are usually flushed positive
tourniquet test anorexia, vomiting, myalgias, maculopapular or petechial rash maybe
present that usually start in the distal portion of the extremities, 9sparing the axilla &
chest), skin appear purple with blanched areas with varied sizes, the HERMAN'S SIGN
known as PATHOGNOMONIC SIGN to the disease, generalized abdominal pain, hemorrhagic
manifestations, like positive tourniquet test, purpura, epistaxis & gum bleeding maybe
present.

2. Circulatory Phase: Fall of temperature accompanied by profound circulatory changes

usually on the 3rd-5th day, patient become restless, with cool clammy skin, cyanosis is
present, profound thrombocytopenia( deficiency of platelets in the blood this causing
bleeding into tissues, bruising & should clotting after injury) accompanies the onset of
shock, bleeding diathesis may become more severe with GIT hemorrhage, shock may occur
due to loss of plasma from the intravascular spaces & hemoconcentration with markedly
elevated hematocrit is present, pulse is rapid & weak, pulse pressure become narrow & BP
may drop to unobtainable level, untreated shock may result to comma, metabolic acidosis
and death may occur within 2 days, with effective therapy, recovery may follow in 2 -3 days

Classification According to Severity (Halstead and Nimmanitya)

Grade 1: Fever accompanied by non-specific constitutional symptoms and the only

hemorrhagic manifestation is positive (+) tourniquet test
Grade 2: All signs of grade 1 plus spontaneous bleeding from the nose, gums, GIT
Grade 3: Presence of circulatory failure as manifested by weak pulse, narrow pulse
pressure, hypotension, cold clammy skin and restlessness
Grade 4: Profound shock, undetectable blood pressure or pulse

COMPLICATIONS

I. DENGUE FEVER:
1. Epistaxis; menorrhagia(abnormally heavy bleeding at women)
2. GIT bleeding
3. Concomitant GI disorder (Peptic Ulcer)

II. DHF:
1. Metabolic acidosis
2. Hyperkalemia
3. Tissue anoxia
4. Hemorrhage into the CNS or Adrenal Glands
5. Uterine bleeding may occur, 6. Myocarditis

III. SEVERE MANIFESTATIONS: DENGUE ENCEPHALOPATHY

- manifested by increasing restlessness, apprehension or anxiety, disturbed sensorium,
convulsions, spacity, & hyporeflexia

Diagnostic Tests or Procedures:

1. Enzyme-linked immunosorbent assay (ELISA)=Detects and measures the antibodies
in the blood. Tests may be used to distinguish primary dengue infections from infections
that occur in persons immune to another dengue virus or to other flaviviruses (secondary
infections)
2. Complete blood count (CBC)= Measures the concentration of WBC, RBC and Platelets in
the blood (Platelet Count (decreased- considered confirmatory test);
Hemoconcentration=an increase in at least 20% in hematocrit or steady rise in hematocrit
and Hemoglobin determination
3. Stool exam (Occult Blood) =Detect the presence of abdominal bleeding. 4. Urine test=
to detect the presence of infection

Treatment Modalities:
-There is no effective anti-viral therapy for Dengue Fever. Treatment is entirely
symptomatic;
1. Analgesic drugs- Acetaminophen for the treatment of pain and fever.
2. Oresol – treatment of dehydration due to diarrhea and vomiting.
3. NSAID should be avoided
4. Initial Phase may require intravenous infusion to prevent from dehydration &
replacement of plasma
5. Blood Transfusion- is indicated in patient with severe bleeding, 6. Oxygen therapy is
indicated to all patients in shock, 7. Sedatives maybe needed to allay anxiety &
apprehension.

Nursing Management:
1. Patient should be kept in mosquito-free environment to avoid further transmission of
infection
2. Keep patient at rest during bleeding episodes
3. Prompt monitoring of vital signs
4. For nose bleeding= maintain patient's position in elevated trunk, apply ice bag to nose
bridge of nose & to the forehead. Do not hyperextend the neck to avoid swallowing of blood
thereby resulting in bloody stools
5. Observe signs of shock, such as slow pulse, cold clammy skin, prostration (extremely
physical weakness or emotional exhaustion) & fall of BP
6. If signs of shock occurs restore blood volume, put patient in a trendelenberg position to
provide greater blood volume to the head part

Prevention and Control:

1. Early detection & treatment of cases
2. Insecticide treatment of mosquito nets
3. House spraying
4. Eliminate vector by:
a.) Changing water & scrubbing sides of lower vases at least once a week
b.) Destroy breeding places of mosquitoes by cleaning the surroundings
c.) Keep water containers covered,
5. Avoid too many hanging clothes inside the house

Malaria- is a mosquito-borne disease caused by a parasite

- Malaria is a life-threatening disease caused by parasites that are transmitted to people
through the bites of infected female Anopheles mosquitoes. It is preventable and curable.
- The most severe form is caused by P. falciparum; variable clinical features include fever,
chills, headache, muscular aching and weakness, vomiting, cough, diarrhoea and abdominal
pain. Other symptoms related to organ failure may supervene, such as acute renal failure,
pulmonary edema, generalized convulsions, circulatory collapse, followed by coma and
death.

Causative Agent:
-Malaria is caused by Plasmodium parasites family. The parasites are spread to people
through the bites of infected female Anopheles mosquitoes, called "malaria vectors."
-There are 5 parasite species that cause malaria in humans
Plasmodium falciparum
P. vivax,
P. ovale,
P. malariae 
P. knowlesi

Incubation Period:
Symptoms usually appear 10–15 days after the infective mosquito bite.

Period of communicability:
Humans are infectious to mosquitoes as long as infectious gametocytes remain in the
person’s blood. Gametocytes usually appear within 3 days of parasitaemia with P.
vivax and P. ovale and after 10 - 14 days with P. falciparum

Pathogenesis:
After a mosquito takes a blood meal, the malarial sporozoites enter hepatocytes (liver
phase) within minutes and then emerge in the bloodstream after a few weeks. These
merozoites rapidly enter erythrocytes, where they develop into trophozoites and then into
schizonts over a period of days (during the erythrocytic phase of the life cycle). Rupture of
infected erythrocytes containing the schizont results in fever and merozoite release. The
merozoites enter new red cells, and the process is repeated, resulting in a logarithmic
increase in parasite burden

Pathology:
Malaria, serious relapsing infection in humans, characterized by periodic attacks of chills
and fever, anemia, splenomegaly (enlargement of the spleen), and often fatal complications.
It is caused by one-celled parasites of the genus Plasmodium that are transmitted to
humans by the bite of Anopheles mosquitoes.  The most common worldwide is P. vivax. The
deadliest is P. falciparum. Plasmodium parasites are spread by the bite of infected
female Anopheles mosquitoes, which feed on human blood in order to nourish their own
eggs. While taking its meal (usually between dusk and dawn), an infected mosquito injects
immature forms of the parasite, called sporozoites, into the person’s bloodstream. The
sporozoites are carried by the blood to the liver, where they mature into forms known
as schizonts. Over the next one to two weeks each schizont multiplies into thousands of
other forms known as merozoites. The merozoites break out of the liver and reenter the
bloodstream, where they invade red blood cells, grow and divide further, and destroy the
blood cells in the process. The interval between invasion of a blood cell and rupture of that
cell by the next generation of merozoites is about 48 hours for P. falciparum, P. vivax, and P.
ovale. In P. malariae the cycle is 72 hours long. P. knowlesi has the shortest life cycle—24
hours—of the known human Plasmodium pathogens, and thus parasites rupture daily from
infected blood cells.

Mode of Transmission:
- malaria is transmitted through the bites of female Anopheles mosquitoes.
-There are more than 400 different species of Anopheles mosquito; around 30 are malaria
vectors of major importance.
- All of the important vector species bite between dusk and dawn
- Transmission also depends on climatic conditions that may affect the number and
survival of mosquitoes, such as rainfall patterns, temperature and humidity
- transmission is seasonal, with the peak during and just after the rainy season

Risk Factors:
-  Most malaria cases and deaths occur in sub-Saharan Africa.
- South-East Asia, Eastern Mediterranean, Western Pacific, and the America
-children under 5 years of age
-pregnant women and patients with HIV/AIDS
-non-immune migrants,
-mobile populations
- travelers

Clinical Manifestations:
-Fever may be mild and difficult to recognize as malaria.
-headache If not treated within 24 hours, P. falciparum malaria
- chills can progress to severe illness, often leading to death
-anemia
- In malaria endemic areas, people may develop partial immunity, allowing asymptomatic
infections to occur.
In children: severe anemia, respiratory distress in relation to metabolic acidosis, or
cerebral malaria.
In adults: multi-organ failure is also frequent.

Diagnostic Laboratory:
1. Malaria antigen detection tests are a group of commercially available rapid
diagnostic tests of the rapid antigen test type that allow quick diagnosis
of malaria by people who are not otherwise skilled in traditional laboratory
techniques for diagnosing malaria or in situations where such equipment is not
available.
2. ELISA (enzyme-linked immunosorbent assay) is a plate-based assay technique
designed for detecting and quantifying peptides, proteins, antibodies and hormones.
In an ELISA, an antigen must be immobilized to a solid surface and then complexed
with an antibody that is linked to an enzyme.
3. Real-time PCR uses an increase in the intensity of a fluorescent signal generated by
an intercalating dye or from the breakdown of a dye-labeled probe during
amplification of a target sequence to detect nucleic acids either for their presence or
absence or for their amount
4. Giemsa stain is used in cytogenetics and for the histopathological diagnosis of
malaria and other parasites
5. Serologic tests are blood tests that look for antibodies in your blood. They can
involve a number of laboratory techniques. Different types of serologic tests are
used to diagnose various disease conditions. Serologic tests have one thing in
common. They all focus on proteins made by your immune system
6. A nucleic acid test is a technique used to detect a particular nucleic acid sequence
and thus usually to detect and identify a particular species or subspecies of
organism, often a virus or bacteria that acts as a pathogen in blood, tissue, urine, etc
7. A blood film—or peripheral blood smear—is a thin layer of blood smeared on a
glass microscope slide and then stained in such a way as to allow the various blood
cells to be examined microscopically

Treatment Modalities
1. Artemisinin-based combination therapies (ACTs). ACTs are, in many cases, the first
line treatment for malaria. There are several different types of ACTs. Examples include
artemether-lumefantrine (Coartem) and artesunate-amodiaquine. Each ACT is a
combination of two or more drugs that work against the malaria parasite in different
ways.
2. Chloroquine phosphate. Chloroquine is the preferred treatment for any parasite that
is sensitive to the drug. But in many parts of the world, the parasites that cause malaria
are resistant to chloroquine, and the drug is no longer an effective treatment.
Other common antimalarial drugs include:
 Combination of atovaquone and proguanil (Malarone)
 Quinine sulfate (Qualaquin) with doxycycline (Vibramycin, Monodox, others)
 Mefloquine
 Primaquine phosphate

Nursing Management:
 Ensure meticulous nursing care. This can be life-saving, especially for the unconscious
patient. Maintain a clear airway. Nurse the patient in the lateral or semi-prone
position to avoid aspiration of fluid.
 Keep a careful record of fluid intake and output. If this is not possible, weigh the
patient daily in order to calculate the approximate fluid balance.
 Note any appearance of black urine (haemoglobinuria).
 Check the speed of infusion of fluids frequently. Too fast or too slow an infusion can
be dangerous.
 Monitor the temperature, pulse, respiration, blood pressure and level of
consciousness (use the Glasgow coma scale for adults, or a pediatric scale for a child;
see Annexes 2 and 3). These observations should be made at least every 4 hours until
the patient is out of danger.
 Report changes in the level of consciousness, occurrence of convulsions or changes in
behavior of the patient immediately. All such changes suggest developments that
require additional treatment

Complications

 Cerebral malaria. If parasite-filled blood cells block small blood vessels to your
brain (cerebral malaria), swelling of your brain or brain damage may occur. Cerebral
malaria may cause seizures and coma.
 Breathing problems. Accumulated fluid in your lungs (pulmonary edema) can
make it difficult to breathe.
 Organ failure. Malaria can cause your kidneys or liver to fail, or your spleen to
rupture. Any of these conditions can be life-threatening.
 Anemia. Malaria damages red blood cells, which can result in anemia.
 Low blood sugar. Severe forms of malaria itself can cause low blood sugar
(hypoglycemia), as can quinine — one of the most common medications used to
combat malaria. Very low blood sugar can result in coma or death.

Prevention:
1.Health education for travelers
It is important to reduce the risk to travelers both for their own protection and to reduce
the risk of acquiring malaria. Pre-travel advice for travelers to malaria-endemic countries
should include the use of appropriate anti-malarial prophylactic medication, strictly in
accordance with the prescriber's instructions, and advice on protection from mosquitoes
by the use of repellents, protective clothing and mosquito nets if rooms are not screened or
air-conditioned.

2. Insecticide-treated mosquito nets. Sleeping under an insecticide-treated net (ITN) can

reduce contact between mosquitoes and humans by providing both a physical barrier and
an insecticidal effect. Population-wide protection can result from the killing of mosquitoes
on a large scale where there is high access and usage of such nets within a community.

3.Indoor residual spraying (IRS) with insecticides is another powerful way to rapidly
reduce malaria transmission. It involves spraying the inside of housing structures with an
insecticide, typically once or twice per year. 

3. Community health education by:

 avoid exposure during peak mosquito activity; the Anopheles mosquito is mainly
active between sunset and sunrise

 use personal insect repellents

 wear loose-fitting, light-colored, long-sleeved clothing and long trousers
 avoid strong scents eg. perfumes, aftershaves
 live in mosquito-proof accommodation or use a (treated) mosquito net over the bed,
and insect spays and mosquito coils at night.

4.As outlined by Bradley et al. the A, B, C, D of malaria prevention, is essential to prevent

the risk of malaria infection among UK travelers

Awareness Know about the risk of malaria infection

Bites Prevent or avoid

Compliance With appropriate malaria chemoprophylaxis

Diagnose Breakthrough malaria swiftly and obtain treatment promptly