Dear, Auntie: Why Dengue Matters to Me (and You)

Dear, Auntie:

As you know, this term I spent some time researching and writing to you about Dengue Fever, or Bone Break Fever as you call it in Guyana.

This blog is for Carla, Tuwana, and my students who were ill with Dengue Fever as some point during the two years I spent teaching in Port Kaituma:

I wrote this for my dear friend Carla who became ill with Dengue Fever twice in the two years that I taught Biology and Chemistry in Guyana, South America. The illness devastated her and made caring for her two children as a single-mother nearly impossible. I was glad that I had the opportunity to help watch her children while she flew out of the village to receive treatment at the hospital in "town" (Georgetown, Guyana). I also wrote this blog for her daughter, Tuwana, who became ill with Dengue about two weeks after I started researching for this assignment.

Why is Dengue such an issue in Guyana? -- What do all of these pictures have in common?

 

Quick Facts about Dengue Fever:

• 3 billion people in the world are at risk of contracting Dengue Fever
• 1% of the 100 million annual cases of dengue develop into Dengue Hemorrhagic Fever. 

• There is currently no targeted treatment for Dengue Fever -- tylenol and water are the current "standard"

• More research needs to be done to help people who suffer and/or die from this painful condition. Just because it affects people far away doesn't mean the impacts are not real. 

Dengue Fever: Nursie!

Dear Auntie:

If you or someone you love has dengue, you may want to know what the nurse who is at your bedside most of the day is doing to take care of you.

Let's talk about the major priorities of nursing care for patient's with Dengue Fever.

Nurses are primarily concerned about managing the side effects of the disease while other treatments given to you by physicians help to stop the dengue virus from spreading in your body.

Let's talk about what the nurse might do to help manage the symptoms of dengue:
1. Nausea,vomiting: The nurse might offer a prescribed medication to help control these feelings and assist the dengue patient to find a diet that they can tolerate that does not cause feelings of nausea.
2. Constipation: The nurse will suggest walking to help relieve constipation
3. Bleeding: The nurse will look for the source of the bleeding and stop it if possible. However, with dengue the bleeding may be from multiple sources or internal. In that case, the nurse will administer IV saline or red blood cells by order of the physician. The nurse will also try to minimize chances for bleeding by having the patient brush his or her teeth with a soft tooth brush or soft sponge, reduce the chances of the patient falling and bruising himself, offer stool softeners (not to the extent that the patient gets diarrhea), the nurse will also suggest that the patient try not to blow the nose to prevent nose bleeds.
4. Joint and Muscle Pains: The nurse will offer inflammation reducing medications by order of the physician, such as acetaminophen or ibuprofen. These may help to reduce the pain. The nurse will also suggest a mixture of warm and cold on the joints to help reduce the pain.
5. Signs of Shock: The nurse will monitor your blood pressure, temperature, pulses, and capillary refill time frequently to ensure that the fluid volume in the body is not so low that the patient is going into hypovolemic (too little volume) shock. The nurse will also monitor anxiety level because this can be a sign of shock. If the nurse feels that the fluid volume in the body is too low based on these indicators, normal saline will be given through an IV.

Those are just some of the things the nurse will be doing at the bedside to take care of anyone with dengue fever. The goal is to prevent bleeding, fluid loss, and shock as well as reduce the amount of dengue virus in the body so that the patient begins to feel better and can be sent home from the hospital.

References:
1. Nursing Management for Dengue Hemorrhagic Fever. Nanda Care Plan. Available from: http://nandacareplan.blogspot.com/2013/12/nursing-management-for-dengue-fever.html Accessed: May 5, 2015

Dengue Fever: Treatment

Dear Auntie:

I know all this talk about Dengue Fever has you worried. The following is the flow-chart clinicians use to determine the clinical picture for a patient with dengue.

That is super complicated and scary! So let's talk about treatment in place and simple terms.

Dengue patients are categorized into three groups - Group A, group B, and group C.

Patients in Group A may be sent home while they recover. Patients are categorized intro group A if they can take oral fluids and pass urine at least every 6 hours. These patients require a lot of rest too. They may be offered acetaminophen (tylenol) at no more than 4 grams a day to manage the pain and other side effects of acute infection, but generally it will resolve on its own with adequate rest and hydration.

Patients in Group B require encouragements and close monitoring for oral fluid intake to prevent dehydration. They may need IV fluid therapy with normal saline to keep their fluid volume in the blood at an appropriate level and prevent dehydration if they cannot drink enough fluid. After the fluid volume is correct, as evidenced by a normal blood pressure and heart rate, the patient can be sent home just like a Group A patient.

Patients in Group C have a more difficult course of treatment, usually in the hospital. These patients are generally hemorrhagic, so they are losing a lot of blood. They require an IV to be started right away for administration of either normal saline OR a blood transfusion. If a lab value called the hematocrit is low, they need blood that is type and cross matched to their blood in order to save their life. They will continue receiving blood until their hematrocrit starts to increase and remain stable without blood transfusions. The patient can be sent home, like a group A patient, when their hematrocrit is stable and they are able to manage without IV fluids.

Aunite, the very best treatment for Dengue Fever is prevention! We really want to keep from getting sick altogether. The following video outlines some basic Dengue Fever prevention strategies.

References:

1. World Health Organization (2012). Handbook for Clinical Management of Dengue.  Accessed from the World Health Organization Web site. http://www.wpro.who.int/mvp/documents/handbook_for_clinical_management_of_dengue.pdf

Dengue Fever: Nursie! Save me!

Dear Auntie:

I know it can be confusing when a nurse comes and pokes and prods with all of those fancy machines. I am sure you want to know what information your nurse is gathering and how that information will be used to help determine your course of treatment.

Here is some information about how nurses use the information to diagnose actual and potential problems and anticipate or prevent further complications from illness with dengue fever. 

Nursing Diagnosis 1. Risk for deficient fluid volume related to fever as evidenced by fast heart rate, low blood pressure, change in mentation, bleeding.

Problem	Related to	Evidence	Desired Outcome	Nursing Intervention
Deficient fluid volume	Sweating, bleeding	Fast heart rate Pallor Cold, clammy skin Low blood pressure Altered mental status	Patient is able to intake enough fluid to compensate for fluid loss through bleeding. -        Drinking fluid -        Blood transfusion	Monitor fluid intake and encourage fluid intake during fever and sweating. Monitor for bleeding and the need for blood transfusion with packed red blood cells.

Nursing Diagnosis 2. Acute pain related to dengue infection as evidenced by the feeling that bones and muscles will break.

Nursing Diagnosis 3. Increased body temperature related to the process of dengue virus infection.

Nursing Diagnosis 4. Risk for bleeding related to dengue hemorrhagic fever infection and thrombocytopenia.

Nursing Diagnosis 5. Deficient Knowledge about the disease process and prevention strategies rleated to lack of information.

References:
1. NANDA Nursing Diagnoses. Dengue Fever. http://www.nanda.org/ Accessed 5/3/2015. 

Dengue Fever: How the Infection Works

Dear, Auntie:

In your last letter you asked me what happen in the body of a person with a Dengue virus infection. This is referred to as the pathophysiology of the infection, essentially how the infection takes a normal body and makes it sick.

There are about 3 billion people in the world who are at risk of getting infected with Dengue fever. Every year, the World Health Organization reports about 100 million cases of dengue fever. Of these cases about 1% go on to develop Dengue Hemorrhagic Fever (indicated by blood in the feces and vomit) or Dengue Shock Syndrome (due to dehydration). Dengue Hemorrhagic Fever and Dengue Shock Syndrome are the very concerning forms of dengue infection because they are the ones that too often result in death.[1]

Dengue virus is a small virus composed of a single-strand of genetic material. When the virus enters the body, it begins to make copies of itself (replication). It does this by attaching to the surface of the cells in our bodies, entering the cells, hijacking the cell's energy and machinery to make copies of itself, forming packets containing a large amount of dengue virus within our cells, then breaking open our cells and spreading those viral packets to nearby cells.[2]

Here is a cool video about how the virus affects humans:

References:
1. Leong AS, Wong KT, Leong TY, et al. The pathology of Dengue Hemorrhagic Fever.Semin Diagn Pathol 2007; 24(4): 227-236. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18085063
2. Rothman AL, Hirsch MS, Baron EL. Pathogenesis of dengue virus infection. UpToDate Website. Updated: March 2015. Accessed: April 2015. 

Dengue Fever: At the hospital

Dear, Auntie:

I know that going to the hospital for your Dengue test can be very scary for two reasons: 1) You are unsure whether you have dengue or not, and 2) it is hard to tell what the doctors and nurses are looking for in your blood in order to diagnose you.

Unlike malaria, which is caused by a parasite that is visible in the blood cells under the microscope, dengue is caused by a virus which had to be detected by testing the blood or, more recently, saliva.

Since dengue infection can be very serious and life-threatening, it is important that the doctors can diagnose it early in order to begin treatment and offer better outcomes for the ill person. The World Health Organization has set a goal to reduce the number of dengue fever related deaths by 50% as early as 2020.

Recent research in Vietnam has focused on creating a faster and more sensitive tool for diagnosing Dengue Fever from small amounts of blood. Currently, a test that comprises antibody testing called an ELISA (similar to the test they use to screen for HIV in patients in Guyana) which tests the body's immune response after exposure to the dengue virus, realtime polymerase chain reaction (RT-PCR) testing used to detect specific genetic sequences of the dengue virus, and additional first-response antibody testing for something called IgM is used. I know this sounds complicated, Auntie. Essentially, when a person becomes infected with the dengue virus their body starts to build an army of soldiers called "antibodies" to fight off the infection. Unfortunately, the dengue virus is sneaky and smart and can spread faster that the body's army is able to destroy it which causes the illness [1].

Dengue infections can range in severity from mild to life threatening. Doctors use the following standards to classify dengue and how serious the infection is:

Figure 1. The criteria doctors use to diagnose dengue and how severe the infection is.[2]

The following video explains a test similar to the one described above (but using saliva) and how it may be used to diagnose Dengue more rapidly. That would be a great relief to Dengue Fever patients and their families. Early diagnosis and treatment will very likely reduce the number of deaths associated with this infection world wide.

References:
1. Nguyen MT, Ho TN, Nguyen VVC, et al. Sensitivity and Specificity of a Novel Classifier for Early Diagnosis of Dengue. PLOS. April 2, 2015. DOI: 10.1371/journal.pntd.0003638
2. Suggested Dengue Case Classification and Levels of Severity. Accessed from: http://new.medicine.com.my/2015/01/dengue-dont-just-blame-the-primary-care-doctors/

Dengue Fever: Signs and Symptoms

Dear, Auntie:

In  your last note, you asked me to tell you what it is like to be sick with Dengue Fever or: what are the Signs and Symptoms of Dengue Infection?

 The video above tells you a little bit about what it is like to have dengue, but we will talk about the details below. 

Figure 1. These are some of the common symptoms associated with
the different stages of Dengue Fever.

The most common symptoms of dengue are a high fever (greater than 100.4 degrees Fahrenheit) and at least two of the following [1]:

• Severe headache
• Severe eye pain (behind the eyes)
• Joint pain
• Muscle and/or bone pain
• Rash
• Loss of desire to eat food
• Mild bleeding of nose or gums, easy bruising
• Low white blood cell count when laboratory blood tests are performed

The fever, rash, and join pain are the symptoms which most commonly cause people to seek treatment at a hospital. However, there are several signs that are very serious and require emergency medical treatment. Those are [1]:

• Stomach ache or continued vomiting
• Vomiting blood
• Black, tarry feces
• Drowsiness
• Pale, cool, clammy skin
• Trouble breathing

There are widely considered to be three stages of Dengue Fever. The first is the invasive stage where the infected person may have a fever, abdominal pain, and headache. The patient will usually attribute these symptoms to another illness, such as influenza. However, they usually seek treatment in the invasive stage. The second stage is the toxic/hemorrhagic stage where the client as a risk for bleeding, they usually also have severe abdominal pain/stomach ache, and a low blood pressure. This is the dangerous time, because this is when Dengue Fever is most often fatal. The final stage of Dengue Fever infection is the recovery stage when the patient starts to feel better, the fever goes down, and the blood pressure rises. 

Figure 2. This figure summarizes the stages of Dengue Fever.

References:
1. Symptoms and What to do if You Think You Have Dengue. Centers for Disease Control and Prevention Web site. Available from: http://www.cdc.gov/dengue/symptoms/ Updated Sept 27. 2012.

Dengue Fever: Who, Where, and When

Dear, Auntie:

Today you asked me What Causes Dengue and How is it Transmitted? This is the study of epidemiology.

Dengue is transmitted from person to person by the Aedes aegypti and Aedes albopictus mosquitoes.[1] These mosquitoes are known as "vectors" because they pass the Dengue virus from one person to another. Many people distinguish the mosquitoes which transmit malaria from the mosquitoes which transmit Dengue by the white stripes on the legs.

Figure 1. This is the Aedes albopictus mosquito which is
responsible for infecting people with the Dengue virus. 

In order to pass the virus from person to person, the mosquito must bite the Dengue infected person while they are showing signs of Dengue infection and the mosquito will be able to infect other humans about 8 days after biting the infected person.[1] It usually takes a week after a mosquito bite to start showing signs of Dengue infection and the illness lasts about 3-10 days.[1]

Dengue Fever is endemic (or common) in tropical or subtropical places like Guyana and other South American countries. However, in the United States it is not common, despite the tropical weather in some Southern states and the closeness to Mexico, simple because of infrequent exposure to Dengue infected persons in the US.[1,2]

Figure 2. The countries in orange are those who had reported cases of Dengue in 2010 according to the World Health Organization. As you can see, most of these areas are just North and South of the equator where the climate is tropical.[2]

References:
1. Epidemiology: Transmission of the Dengue Virus. Centers for Disease Control and Prevention Web site. Updated. Jun 9, 2014. Accessed on: April 6, 2015. Accessed From: http://www.cdc.gov/dengue/epidemiology/
2. Murray NE, Quam MB, Wilder-Smith A. 2013. Epidemiology of dengue: past, present, and future propects. Clin Epidemiol 5: 299-309. doi: 10.2147/CLEP.S34440. 

Dengue Fever: "Ah, Lawd! Me bones bun an bruk."

Dear, Auntie:

You asked me to tell you more about Dengue Fever, known as Break-Bone Fever in many parts of the world. So I decided to write you a whole, interactive blog about it!

I am sure you have seen Dengue fever in action - the terrible fever and the pain in the joints and bones that makes the illness feel almost unbearable. Guyana joins one-third of the world's population in living in an area where dengue fever is common [1]. Auntie, if you are interested in learning more about Dengue around the world, click here!

Here is a summary of the important points you should keep in mind as we learn more about Dengue together [2]:
 - Humans get sick with Dengue from a virus carried by mosquitoes
 - People with Dengue have flu-like symptoms: fever, bone/joint pain, etc.
 - Dengue is found in tropical climates (like Guyana)
 - There is no specific treatment for Dengue, but most people will not die from Dengue is they seek early treatment.
 - Controlling mosquitoes is the most effective way to guard yourself against Dengue.

Here is a cool video to help you understand a little more about Dengue, but we will talk more about it over the next few weeks.

References:
1. Dengue. Centers for Disease Control and Prevention (CDC). Web site. Accessed online from: http://www.cdc.gov/Dengue/
2. Dengue and Severe Dengue. The World Health Organization (WHO). Web site. Accessed online from: http://www.who.int/mediacentre/factsheets/fs117/en/.