Dengue Hemorrhagic Fever

by Ellennor F. Abrigo, BSN III-SLSU

Introduction

Philippine hemorrhagic fever was first reported in 1953. In 1958,

hemorrhagic fever became a notifiable diseasein the country and was later
reclassified as Dengue Hemorrhagic Fever.

The morbidity rate of dengue fever in 2003 was much lower at 13 cases per
100, 000 population compared to the highest ever recorded rate of 60.9 per 100,
000 in 1998. The case fatality ratio for dengue fever and dengue hemorrhagic
fever in 2003 is also lower at 0.8% compared to the highest recorded ratio of 2.6%
in 1998. While there were 12 outbreaks of dengue fever in 1998, there were
averages of one to three outbreaks a year during the period of 1999-2004. The
sudden increases in the incidence of dengue in 1993, 1998 and 2001 were
expected because of the cyclical nature of the disease. The reason dengue
remains a threat to public health despite low incidences reported in recent years,
Dengue cases usually peaks in the months of July to November and lowest during
the month of February to April.

Signs and Symptoms

An acute febrile infection of sudden onset with clinical manifestationof 3 stages:

• First 4 days—Febrile or invasive stage starts abruptly as high fever,

abdominal pain and headache; later flushing which may be accompanied by
vomiting, conjunctival infection and epistaxis.
• 4th-7th days—Toxic or hemorrhagic stage—lowering of temperature, severe
abdominal pain, vomiting and frequent bleeding from gastrointestinal tract in
the form of hematesis or melena. Unstable BP, narrow pulse pressure and
shock may occur. Tourniquet test which may be negative due to low or
vasomotor collapse.
• 7th-10th days—convalescent or recovery stage generalized flushing with
intervening areas of blanching appetite regained and blood pressure already
stable.

Classification

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 • Severe, frank type—with flushing, sudden high fever, severe hemorrhage,
followed by sudden drop of temperature, shock and terminating in recovery
or death.
• Moderate—with high fever but less hemorrhage, no shock
• Mild—with slight fever, with or without petechial hemorrhage but
eoidemiologically related to typical cases usually discovered in the course of
investigation of typical cases

Grading of Dengue Fever

The severity of DHF is categorized into four grades:

• Grade I, without overt bleeding but positive for tourniquet test

• Grade II, with clinical bleeding diathesis such as petechiae, epistaxis
and hematemesis
• Grade III, circulatory failure manifested by a rapid and weak pulse with
narrowing pulse pressure (20 mmHg) or hypotension, with the presence of
cold clammy skin and restlessness; and
• Grade IV, profound shock in which pulse and blood pressure are not
detectable. It is noteworthy that patients who are in threatened shock or
shock stage, also known as dengue shock syndrome, usually remain
conscious.
• Grade III and IV are considered to be Dengue Shock Syndrome

Etiologic Agent: Dengue virus types 1, 2, 3, and 4 and Chikunguya virus

Source of Infection

• Immediate source is a vector mosquito, the Aedes Aegy6pti or the common

household mosquito.
• The infected person.

Mode of Transmission: Mosquito bite (Aedes Aegypti)

Incubation Period: Uncertain. Probably 6 days to one week

Period of Communicability: Unknown. Presumed to be on the 1st week of

illness—when virus is still present in the blood.

Susceptibility, Resistance and Occurrence

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 All persons are susceptible. Both sexes are equally affected. Age groups
predominantly affecred are the preschool and school age. Adults and infants are
not exempted. Peak age affected 5-9 years.

Occurrence is sporadic throughout the year. Epidemic usually occur during

the rainy seasons—June-November. Acquired immunity may be temporary but
usually permanent.
Diagnostic Tests

1.) Tourniquet Test (Rumpel Leads Tests)

• Inflate the blood pressure cuff on the upper arm to a point midway betwe
en the systolic and diastolic pressure for 5 minutes
• Release cuff and make an imaginary 2.5 cm square or 1 inch just below th
e cuff, at the antecubital fossa
• Count the number of petechiae inside the box
• A test is (+) when 20 or more petechiae per2.5 cm square or 1 inch
square are observed.

2.) A confirmed diagnosis is established by culture of the virus, polymerase-

chainreaction (PCR) tests, or serologic assays.

The diagnosis of dengue hemorrhagic fever is made on the basis of the

following triad of symptoms and signs: Hemorrhagic manifestations; a platelet
count of less than 100, 000 per cubic millimeter; and objective evidence of plasma
leakage, shown either by fluctuation of packedcell volume (greater than 20
percent during the course of the illness) or by clinical signs of plasma leakage,
such as pleural effusion, ascites or hypoproteinemia. Hemorrhagic manifestations
without capillary leakage do not constitute dengue hemorrhagic fever.

Management

Supportive and symptomatic treatment should be provided:

• Promote rest
• Medication
 Paracetamol – for fever
 Analgesic (Acetaminophen (Tylenol) and codeine) – for severe
headache and joint and muscle pains
 Aspirin and nonsteroidal antiinflammatory drugs should be avoided
• Rapid replacement of body fluids is the most important treatment
 Give ORESOL to replace fluid as in moderate dehydration at 75ml/kg in
46 hours or up to 23L in adults. Continue ORS intake until paient’s
condition improves.
 Intravenous fluid

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 • For hemorrhage
 Keep patient at rest during bleeding periods
 For epistaxis – maintain an elevated position of trunk and promote
vasoconstriction in nasal mucosa membrane through an ice bag over the
forehead.
 For melena – ice bag over the abdomen. Provide support during the
transfusion therapy

• Diet
 Low fat, low fiber, nonirritating, noncarbonated
 Noodle soup may be given

• Observe signs of deterioration (shock) such as low pulse, cold clammy

perspiration, prostration.

• For shock
 Place in dorsal recumbent position to facilitate circulation
 Provision of warmth through lightweight covers (overheating causes
vasodilatation which aggravates bleeding)

Prevention

The best way to prevent dengue fever is to take special precautions to avoid
contact with mosquitoes.

• Eliminate vector by:

 Changing water and scrubbing sides of lower vases once a week
 Destroy breeding places of mosquito by cleaning surroundings
 Proper disposal of rubber tires, empty bottles and cans
 Keep water containers covered

Because Aedes mosquitoes usually bite during the day, be sure to use preca
utions
especially during early morning hours before daybreak and in the late afternoon be
fore dark.

Other precautions include:

• When outdoors in an area where dengue fever has been found

 Use a mosquito repellant containing DEET, picaridin, or oil of lemon eu
calyptus
 Dress in protective clothinglongsleeved shirts, long pants, socks, and s
hoes

• Keeping unscreened windows and doors closed

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 • Keeping window and door screens repaired
• Use of mosquito nets

Sources:
http://www.nscb.gov.ph/secstat/d_vital .asp
http://www.who.int/csr/resources/publications/dengue/01 223.pdf
Public Health Nursing in the Philippines by the Publications Committee, National League of
Philippine Government Nurses, Incorporated

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