Dengue is one of the burning issues in our country today. A day does not pass without some account of this much dreaded disease in the media. There are reports of a rise in cases of Dengue in Colombo and other parts of the country over the last several years. Dengue is a disease that could affect children, irrespective of caste, creed, religion or social status.
There are four types of the virus that causes dengue in humans. Outbreaks of the disease are due to one or more of these four serotypes. The disease is transmitted by one of two species of mosquitoes known as Aedes aegypti and Aedes albopictus.
* Type of Disease
The disease has a very wide range of severity and presentation. In some children it could present as ordinary flu or viral fever while in others it could be a severe life-threatening illness. It all depends on several factors like the virulence of the infecting virus, immunity of the individual and whether it is the first attack or not. Attack by one type of virus does not confer immunity to any of the other three types.
* The Start & Progression of Dengue
Dengue fever starts just like any other viral fever with high swinging fever associated with intense muscle and joint pains. Fever often responds poorly to simple fever-lowering medications like paracetamol. The child may feel ill at the times of fever but in milder cases, the child may not feel too bad. Anyhow, after a couple of days, the fever appears to get better only to flare up again within a day or so. This second phase is the one that is associated with the dreaded complications of the disease.
The dengue virus induces a peculiar increase in permeability characteristics of the blood vessels leading to uncontrolled movement of fluid from the blood stream to the surrounding tissues. It is also known as “leaking” of fluid from the blood stream into the adjacent areas. This leads to a reduction of fluid within the circulating compartment and is associated with a fall in the blood pressure and cardiovascular malfunctioning. The patient develops a state of collapse or shock. This is known as the “Dengue Shock Syndrome”. In addition, the virus causes a certain amount of direct damage to the blood vessels, leading to a bleeding tendency. The disease also causes a fall in the platelets of the blood which enhances the bleeding as platelets are involved in the clotting of normal blood. This component of the problem is known as “Dengue Haemorrhagic Fever”. The bleeding manifests as spots on the skin or internal haemorrhage, particularly into the stomach and intestines and this presents as brownish or blackish “coffee grounds” type of material in the vomitus or black faeces.
All these complications are associated with an increased rate of fatalities. However, with competent management, these deaths could be reduced drastically. The child remains conscious and alert right throughout the illness, even when he or she is quite ill with the dreaded complications. The period around the 3rd to the 7th day is the crucial one for the development of the complications. It is essential to realise that many children get dengue fever but only very few get the much feared complications that threaten life.
* How is Dengue Diagnosed?
Making a definitive diagnosis could be quite difficult in the early stages of the disease. Although there are some sophisticated tests that could detect the virus antigen in the first 2 to 3 days of the illness, these are not absolutely fool-proof. The standard full blood counts show typical features of any viral infection in the first couple of days. Subsequently these counts show evidence of thickening of the blood caused by uncontrolled shifting of fluids out of the blood stream and a fall in the platelet count. Additional tests to detect antibodies become positive from about the 3rd or 4th day but once again, they are not absolutely fool-proof. Negative antigen and antibody tests do not exclude dengue fever. A characteristic feature in the leaking phase is the development of a collection of fluid in the chest around the lung, particularly in the right side. This feature, seen in a chest x-ray, is of diagnostic value.
* Treatment of Dengue
It is crucial that a child with dengue comes under medical supervision as soon as possible. Many of them who do not develop any complications will only need simple measures to control the temperature and would just need further observation. However, if a complication develops, the recovery is determined by how quickly a medical team intervenes with aggressive active management. Many of them would need judicious use of intravenous fluids to control the shifting of fluids within the different compartments of the body. This is essential as this phase may rapidly bring on death unless the child is effectively treated. Delay in the management of shock could also lead to malfunctioning of many organs, which may manifest a little while later. There is no specific drug or antibiotic that is directly effective against the virus.
A lot can be done in the acute phase especially if and when complications develop. Although fatalities are highlighted in the media, in experienced hands the mortality rate is quite low and is now under one per cent. Experienced clinicians are a boon to the management of severely ill dengue patients and countless numbers of extremely ill patients who have been saved by dedicated staff in our hospitals are generally not even acknowledged.
* Prevention of Dengue
Unfortunately, up to now, there is no vaccine to prevent dengue and it is most unlikely that one would be discovered in the near future. Thus preventive measures are directed towards controlling the mosquito population.
The rains do come from time to time and mosquitoes are everywhere. The usual nonchalance and lack of public consciousness of the people are also there in abundance. This means the three cardinal ingredients for perpetuation of Dengue Fever are in place right round the country.
It is absolutely essential that the public in the community cooperate with the authorities in their efforts towards eliminating the breeding places and habitats of the mosquitoes that transmit this disease. This is certainly not an enterprise that could be successfully undertaken by the state alone. Civic consciousness, collaboration and support on the part of the general populace are of paramount importance in any control measures undertaken by the authorities.
This article was provided by Dr. B.J.C.Perera MBBS, DCH, MD, FRCP, FRCPCH, FSLCPaed, FCGP, Consultant Paediatrician, Asiri Medical Hospital, 181, Kirula Road, Colombo 5.
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