DENGUE FEVER FACT SHEET

DENGUE FEVER
Dengue fever is a relatively common problem that periodically reaches epidemic
proportions, usually every 4-5 years. Dengue occurs due to infection by a FLAVIVIRUS,
which is transmitted by the bite of the Aedes aegypti mosquito. It is very rarely fatal in
healthy and fit individuals. The patient is often left debilitated and requires considerable
convalescence. Dengue is not transmitted from person to person.
Recurrent infections with Dengue fever, especially when they are from different strains of
the Flavivirus, are associated with a higher risk of complications, in particular Dengue
Haemorrhagic shock syndrome (covered later in this bulletin).

The most useful laboratory test in suspected DHF is the estimation of
thrombocytes (platelets) which will be very low. In contrast to uncomplicated
dengue fever the white cell count is more often high in patients with DHF.

PREVENTIVE MEASURES AGAINST MOSQUITOS
All varieties of mosquitoes breed in or near water that is stagnant or slow moving.
The importance of mosquitoes in transmission of disease makes adequate control
of mosquito-breeding sites very important, especially those close to human
habitation.
Personal protective measures can greatly reduce the risk of being bitten.
1. The use of mosquito deterrents in bedrooms is effective to reduce the
number of mosquitoes in the room, but it does not prevent mosquito bites
all together. The chemical deterrent is released through an electronically
heated impregnated pad or gel, and its effectiveness depends largely on the
size and ventilation of the room.
2. Correct use of mosquito nets (essential if accommodation is not air-
conditioned). For added protection for up to 3 months or longer, mosquito
nets can be soaked in 1 % solution of PERMETHRIN (or other repellent /
insecticide). If resident in a dengue or malaria affected areas, curtains can
be treated in a similar manner. Windows can be closed with fine insect
screens, which may or may not be treated with PERMETHRIN, to keep
mosquito away from bedrooms.
3. Use of mosquito coils and "knockdown spray" (containing pyrethoids) -
spray insecticide in cool dark places where mosquitoes lurk. After spraying
do not enter the room and keep all doors and windows closed.
4. Avoid use of dark coloured clothing, perfumes and colognes as all these
attract mosquitoes, especially at night.
5. Use of an effective mosquito repellent on exposed skin and clothing if you
are sitting outside. DEET (diethylmethylbenzamide) is still an effective safe
component of good repellents. The actual concentration of DEET varies
widely between different manufacturers, and can be as high as 90% (too
high for safety). Choose a repellent with between 30-45% DEET and take
the following precautions against adverse reactions:
a. apply sparingly and only to exposed skin
b. never apply high concentrations to skin (use those for clothing)
c. do not inhale / swallow repellent or get in eyes or mucous
membranes
d. do not apply to hands that may touch eyes or mouth
e. do not apply to wounds, rashes, or abrasions
f. wash repellent off after coming indoors to stay
g. if skin starts to burn, wash repellent off and seek medical advice
6. DEET-based repellents should last for up to 4 hours.

DESTROY MOSQUITOES AND THEIR LARVAE (YOUNG).
Clear the neighbourhood of ponds & pits.
Cover all water containers and any objects that can trap rain water (tires,
pots, rubbish piles)
Filling or drain areas of stagnant water except for swimming pools and
ornamental pools if they are aerated by a pump or fountain or similar.
Use of mosquito larvicides (ABATE) or mosquito larvae-eating fish in waters
that cannot be drained.
Installation of mosquito screens on doors and windows and mosquito nets on
beds.
Change water in flower pots once a week and wash them thoroughly. Do not
let plants stand in trays containing water. Scrub trays weekly to get rid of any
mosquito eggs.
Cover all water containers and eliminate objects that can trap rainwater. This
includes areas underneath elevated walkways and accommodations.
Avoid the uncontrolled use of residual and space insecticides, and the use of
toxic materials.
Fogging is effective to kill mosquitoes but does not kill larvae. Fogging will not
stop mosquitoes entering your premises, however, it may deter them from
establishing breeding grounds at premises where fogging is performed.

Do not allow indiscriminate use of insecticides unless possible risks of their use
are clearly understood. Know what you are doing and / or what chemical is being
used.

Dr. Uwe Stocker,
Medical Advisor
International SOS, J akarta

Should you wish to arrange a briefing on Dengue Fever for your
company employees and/ or families, please contact the Sales and
Marketing department at International SOS on (21) 750 5973
(J akarta) or (361) 710 505 (Bali) to arrange a quotation.

The briefing can be provided in Bahasa I ndonesia or English.

SYMPTOMS
Following an incubation period of 2 - 14 days (usually 4 - 8), the onset of symptoms is
usually abrupt with chills, headache, backache, weakness and pain behind the eyes. The
joint and back pains can be very bad indeed; hence the older name 'backbone fever'. The
temperature rapidly rises, often to 40C (104F), and there is a low heart rate (compared
to the other causes of high fever). The blood pressure is often also low.
The rash is
made up of
small red
dots
After 2 - 4 days, a temporary improvement can occur with a sudden drop in temperature
and subjective improvement, usually for 24 hours until there is a second rapid
temperature rise, and the appearance of a characteristic rash on the trunk, limbs, palms
and soles especially. The skin in these areas turns bright red (the rash is usually a series
of dots) and may peel. (This second phase of fever does not always occur). Thereafter
there is slow improvement. An attack produces immunity for a year or more, but only to
the one of the four FLAVIVIRUS strains responsible.

CONFIRMING THE DIAGNOSIS
There are no immediate useful tests for diagnosing dengue fever. The white blood cell
count is often low unlike in bacterial causes of fever. The dengue antibody test can give
both false positive and false negative results, especially in the first week of the disease.
The diagnosis will, in a large proportion of cases, be based on clinical presentation and a
characteristic drop of platelets in the blood.
Convalescence can take weeks, and bed rest and fever lowering medications are required.
Do not use Asprin.

DENGUE HAEMORRHAGIC FEVER (DHF)
A rare complication of dengue fever, dengue haemorrhagic fever, can occur, most often in
small children and elderly adults. This can sometimes be a serious illness. If DHF occurs
it will usually do so by day 3-5 of the fever.
It has been suggested that DHF is more likely if the patient has previously had an attack
of dengue within the last calendar year, and that the occurrence of DHF relates to this
previous exposure. The relationship between DHF and previous dengue infection is not
this clear-cut, however previous exposure does raise the incidence of subsequent DHF, in
particular when this involves different strains of the virus.

SYMPTOMS OF DHF
Uncontrolled bleeding distinguishes this from uncomplicated dengue fever. Bleeding can
occur from the gums, nose, intestine, or under the skin as bruises or spots of blood
especially under a tourniquet - this test should be employed if there is any suspicion. The
liver is often enlarged.
Patients can have rapid onset of marked drowsiness, lethargy or restlessness or the
presence of shock as manifested by a rapid and weak pulse, low blood pressure and cold
clammy skin. Such patients should be immediately referred to a good hospital for further
management. DHF shock can be a mortal illness and requires rapid and careful in-
hospital management with replacement of fluid, electrolytes, plasma and sometimes fresh
blood / platelet transfusions.