Dengue hemorrhagic fever is caused by a bite of a vector mosquito called, Aedes Aegypti.
This mosquito is
considered to be a day- biting and low flying mosquito and commonly be found inside the household.
Incubation Period: Approximately one week
Period of Communicability: Upon infection of virus in the blood, within the first week of illness.
Susceptibility, Resistance, and Occurrence: It is universal with both sexes equally affected. It primarily
involves children aging 5- 9 years, especially those in preschool and school ages. However, it does not exempt
adults and infants. It is an acquired illness through the said vector with temporary immunity, though to some
cases it is permanent.
It is sporadic throughout the year according to statistics and becomes epidemic during the months of June to
November.
Classification of Dengue Hemorrhagic Fever: (Depending on Severity)
1. Mild Client may manifest fever, with or without petechial hemorrhage.
2. Moderate Client may experience high fever, but with less hemorrhage and no progression to shock.
3. Severe, frank type- Sudden onset of fever may occur with severe hemorrhage; which is accompanied by an
abrupt decrease in temperature, shock and termination of recovery.
4. DHF Grade I: Fever accompanied by non- specific symptoms like anorexia, vomiting, and abdominal pain;
the only hemorrhagic manifestation is (+) tourniquet test and/ or easy bruising
5. DHF Grade II: Spontaneous bleeding plus the manifestations with Grade I (usually observed in GIT or
mucocutaneous
6. DHF Grade III (DSS): Presence of circulatory failure as evidenced by rapid, weak pulse, narrowing of pulse
pressure or hypotension, and cold clammy skin.
7. DHF Grade IV (DSS): Profound shock with undetectable blood pressure or pulse.
Dengue Hemorrhagic Fever Nursing Considerations and Nursing Care
Management
Preventive and control measures that would involve health education and strongly advocating the
implementation of 4S, recognition of disease, case finding and reporting for cases in the community.
The Four S drive implemented by the Department of Health corresponds to:
Search and destroy the mosquito dengue carriers breeding sites (recently pinpointing buko shell or
coconut shells, tires, and bromeliads)
It may also involve frequent changing of water and scrubbing sides of vases and keeping water containers covered at
all times, destroying of breeding places stated above by cleaning the surroundings (3Oclock habit) and proper
disposal of tires and containers.
Self protection against mosquito (use of loose clothing with long sleeves and long socks, use of mosquito
nets, tested mosquito repellants and the like)
Seek early consultation (Early detection of condition means treatment could be administered readily to
prevent fatal complications of dengue)
Say NO to indiscriminate fogging (Fogging is not advised nowadays because it does not really eliminate
mosquitoes but it only scares them away. It is also not recommended because of its respiratory
consequences.)
Supportive management which could be symptomatic in nature may involve:
Rapid replacement of fluids: clients are encouraged to increase their fluid intakes as much as possible if
tolerated; In the community, ORS is given to halt moderate dehydration at 75ml/ kg in 4 -6 hours or up to 2- 3
liters in adults.
Administration of antipyretic/ analgesics as indicated by the physician
Close observation and intensive monitoring of vital signs
Early detection for signs of bleeding and immediate referral
Use of Tourniquet test (Rumpel Leade test) to detect petechial hemorrhage
Health education on the prevention of hemorrhage may include:
Avoidance of dark colored foods and liquids
Client is encouraged to prevent from using sharp- bristled toothbrushes, instead advised to gargle with saline
solution
Clients are educated not to use hot liquids for alleviation of chills etc.
Avoidance of sharp objects like razors are emphasized on adults
The use of ASPIRIN is strictly prohibited.
In cases that hemorrhage sets in, nursing care may involve the following:
Keep the client at bed rest and ensure safety to prevent from injury
Client is usually placed in dorsal recumbent position.
Hourly monitoring noting for narrowing pulse pressure, sudden drop in temperature, decreased blood pressure
and pulse rate and other signs of deterioration.
Administration of blood products and monitoring client for signs of adverse reactions.
Strict monitoring of fluid intake and output
Immediate referral for any change in clients status and proper documentation of procedures given.
WHO
Dengue is transmitted by the bite of an Aedes mosquito infected with any one of the four dengue viruses.
It occurs in tropical and sub-tropical areas of the world. Symptoms appear 314 days after the infective
bite. Dengue fever is a febrile illness that affects infants, young children and adults.
Symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain behind the
eyes, muscle and joint pain, and rash. There are no specific antiviral medicines for dengue. It is important
to maintain hydration. Use of acetylsalicylic acid (e.g. aspirin) and non steroidal anti-inflammatory drugs
(e.g. Ibuprofen) is not recommended.
Dengue haemorrhagic fever (fever, abdominal pain, vomiting, bleeding) is a potentially lethal
complication, affecting mainly children. Early clinical diagnosis and careful clinical management by
experienced physicians and nurses increase survival of patients.
Where does the disease occur?
Dengue is mainly transmitted by a mosquito (Aedes aegypti) and is distributed across all tropical countries (map
available). Ae. aegypti and other species such as Ae. albopictus are highly adaptive and their combined
distribution can spread dengue higher up north across Europe or North America during summer. (Note:
Travellers already infected with the virus also spread the disease when they get bitten by the
local Aedes mosquito population).
Dengue outbreaks can occur anytime, as long as the mosquitoes are still active. However, in general, high
humidity and temperature are conditions that favour mosquito survival, increasing the likelihood of transmission.
The disease
Epidemiology
Monitoring and evaluation
Information resources
Dengue/Severe dengue frequently asked questions
What are the symptoms of dengue fever and severe dengue?
Dengue fever
Dengue causes flu-like symptoms and lasts for 2-7 days. Dengue fever usually occurs after an incubation period
of 4-10 days after the bite of the infected mosquito.
High Fever (40C/ 104F) is usually accompanied by at least two of the following symptoms:
Headaches
Pain behind eyes
Nausea, vomiting
Swollen glands
Joint, bone or muscle pains
Rash
Severe dengue
When developing into severe dengue, the critical phase takes place around 3-7 days after the first sign of illness.
Temperature will decrease; this does NOT mean the person is necessarily recovering. On the other hand, special
attention needs to be given to these warning signs as it could lead to severe dengue:
Severe abdominal pain
Persistent vomiting
Bleeding gums
Vomiting blood
Rapid breathing
Fatigue/ restlessness
When severe dengue is suspected, the person should be rushed to the emergency room or to the closest health
care provider as it causes:
Plasma leaking that may lead to shock and/or fluid accumulation with/without respiratory distress;
Severe bleeding;
Severe organ impairment.
What is the treatment for dengue?
There is no vaccine or specific medication for dengue fever.
Patients should seek medical advice, rest and drink plenty of fluids. Paracetamol can be taken to bring down
fever and reduce joint pains. However, aspirin or ibuprofen should not be taken since they can increase the risk
of bleeding.
Patients who are already infected with the dengue virus can transmit the infection via Aedes mosquitoes after the
first symptoms appear (during 4-5 days; maximum 12). As a precautionary approach, patients can adopt
measures to reduce transmission by sleeping under a treated net especially during the period of illness with
fever.
Infection with one strain will provide life-time protection only against that particular strain. However, it is still
possible to become infected by other strains and develop into severe dengue.
When warning signs of severe dengue are present (listed above), it is imperative to consult a doctor and seek
hospitalization to manage the disease.
With proper medical care and early recognition, case-fatality rates are below 1%. However, the overall
experience remains very discomforting and unpleasant.
Epidemiology
Monitoring and evaluation
Information resources
Dengue/Severe dengue frequently asked questions
What should I do if I suspect I have dengue?
If you suspect you have dengue you need to see a doctor immediately. To diagnose dengue fever, your doctor
will:
Evaluate your signs and symptoms;
Test your blood for evidence of a dengue virus;
Review your medical and travel history.
Persons who had travelled to dengue endemic countries during the past two weeks should inform the doctor
about it.
Who spreads dengue and severe dengue?
Dengue is spread through the bite of the female mosquito (Aedes aegypti). The mosquito becomes infected when
it takes the blood of a person infected with the virus. After about one week, the mosquito can then transmit the
virus while biting a healthy person. The mosquito can fly up to 400 meters looking for water-filled containers to
lay their eggs but usually remains close to the human habitation.
Aedes aegypti is a daytime feeder: The peak biting periods are early in the morning and in the evening before
dusk.
Dengue cannot be spread directly from person to person. However, a person infected and suffering from dengue
fever can infect other mosquitoes. Humans are known to carry the infection from one country to another or from
one area to another during the stage when the virus circulates and reproduces in the blood system.
Aedes aegypti has evolved into an intermittent biter and prefers to bite more than one person during the feeding
period. This mechanism has made Aedes aegypti a very highly efficient epidemic vector mosquito.
Where do the mosquitoes breed?
The mosquitoes thrive in areas close to human population (urban areas).
The dengue mosquito lays its eggs in water-filled containers inside the house and surrounding areas of
dwellings (this includes non-used bottles, containers, discarded waste, tyres etc which hold water).
The eggs hatch when in contact with water. Eggs can withstand very dry conditions and survive for months.
Female mosquitoes lay dozens of eggs up to 5 times during their lifetime.
Adult mosquitoes usually rest indoors in dark areas (closets, under beds, behind curtains). Here it is protected
from wind, rain and most predators, which increases its life expectancy and the probability that it will live long
enough to pick up a virus from one person and pass it on to the next.
What can be done to reduce the risk of acquiring dengue?
The best preventive measure for areas infested with Aedes mosquito is to eliminate the mosquitoes egg laying
sites called source reduction. Lowering the number of eggs, larvae and pupae will reduce the number of
emerging adult mosquitoes and the transmission of the disease. Examples of the following habitats are listed:
Indoor
o Ant traps
o Flower vases and saucers
o Water storage tank (domestic drinking water, bathroom, etc)
o Plastic containers
o Bottles
Outdoor
o Discarded bottles and tins
o Discarded tyres
o Artificial containers
o Tree holes, potholes, construction sites
o Drums for collecting rainwater
o Shells, husks, pods from trees
o Leaf axils of various plants
o Boats, equipment
Items that collect rainwater or are used to store water should be covered or properly discarded. The remaining
essential containers should be emptied and cleaned and scrubbed (to remove eggs) at least once a week. This will
avoid the adult mosquitoes to emerge from the egg/ larva/ pupa stage.
In fact, the community participation is the key to dengue prevention. As every household aims to reduce vector
density, the transmission rate will decrease or maybe even stop.
Personal and household protection
Protecting yourself from mosquito bites is most effective by reducing exposed skin to mosquitoes to bite on.
Long-sleeved clothing and mosquito repellents (containing DEET, IR3535 or Icaridin) are the most viable
options.
Window and door screens, air conditioning reduces the risk of mosquitoes coming into contact with the
household members. Mosquito nets (and/or insecticide-treated nets) will also provide additional protection to
people sleeping during the day, or protect against other mosquitoes which can bite at night (such as malaria).
Household insecticides aerosols, mosquito coils or other insecticide vaporizers maybe also reduce biting activity.
