DENGUE FEVER EPIDEMIC IN INDIA -A REVIEW OF CLINICAL FEATURES, DIAGNOSIS, PREVENTION & MEDICATIONS Debjit bhowmik, K.K.Tripathi,Dipak Biswas, Karpagam University,Coimbatore

K.P.Sampath Kumar, Department of Pharmaceutical sciences, Coimbatore medical college, Coimbatore,Tamilnadu

Email-bhowmikdebjit6@gmail.com ABSTRACT Dengue fever is an infectious disease carried by mosquitoes. It is found mostly during and shortly after the rainy season in tropical and subtropical areas of: Africa ,Southeast Asia , China ,India ,Middle East Caribbean , Central ,South America, Australia and the South and Central Pacific .Dengue fever was previously 'break-bone fever' because it sometimes causes severe joint and muscle pain Though dengue is a very highly infectious disease, its mortality rate is very low. Deaths usually occur due to ignorance of the methods of treatment. In advanced countries, the mortality rates of dengue are almost zero. However it is necessary to prevent the disease due to the painful symptoms that it causes as long as it lasts. Dengue fever can be caused by any one of four types of dengue virus: DEN-1, DEN-2, DEN-3, and DEN-4. Infection with one virus does not protect a person against infection with another. Dengue virus is prevalent in the tropical and subtropical regions of the world and each year infects about 50 million to100 million people. It accounts for 25,000 deaths annually, most of them in children. People contract dengue fever from the bite of an infected Aedes mosquito. Mosquitoes become infected when they bite infected humans, and later transmit infection to other people they bite. The risk factors for dengue fever are as follows: traveling to or living in endemic or outbreak areas, especially if no mosquito control is attempted by the people or government; mosquito bites a repeated infection with another serovar of dengue virus with antibodies in the serum active against the first infecting serovar and not taking precautions to avoid mosquito bites. The WHO says some 2.5 billion people, two fifths of the world's population, are now at risk from dengue and estimates that there may be 50 million cases of dengue infection worldwide every year. The disease is now endemic in more than 100 countries. There is no specific medication for treatment of a dengue infection. Persons who think they have dengue should use analgesics (pain relievers) with acetaminophen and avoid those containing aspirin. They should also rest, drink plenty of fluids, and consult a physician. After more than a decade of development at the National Institutes of Health in U.S, a vaccine to prevent infection by the mosquito-borne dengue virus has begun human clinical testing INTRODUCTION Dengue fever is a disease caused by viruses that are transmitted to people by mosquitoes. Dengue fever usually causes fever (high, about 104 F-105 F), skin rash (see Figure 1), and pain (headaches and often severe muscle and joint pains). The disease has also been termed "breakbone" or "dandy fever" because the unusually severe muscle and joint pains can make people assume distorted body positions or exaggerated walking movements in an effort to reduce their pain.Dengue is an acute fever caused by a virus transmitted by the bite of an Aedes Argypti mosquito. The mosquitoes are found indoors, in the closet and other dark places. Outdoors they rest in cool and shaded areas. Contrary to popular belief, it is not only a danger during the rainy season (when eggs hatches faster), but the whole year through. The World Health

Organization (WHO) says, "The female mosquitoes lay their eggs in water containers in and around the homes, and other dwellings. These eggs will develop, become larvae, and further develop into adults in about 10 days."Incurring in tropical and sub-tropical parts of the world, dengue fever is severe, flu-like illness that affects infant, young children, and adults. It spreads rapidly, and in the event of epidemic, it will affect a large number of people and eventually cause the loss of lives. Another cause for alarm: More than 2.5 billion people (or 40 percent of the world's population), including 1 billion children lives in areas where there is a risk of dengue transmission. The centers for disease control and prevention in the United States says there is no specific medication for treatment of a dengue infection. However, proper and early treatment can relieve the symptoms,

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and prevent complications. If you suspect dengue: Give analgesics (pain relievers) with paracetamol. Avoid close containing aspirin, as well as ibuprofen, since these can increase the risk of bleeding. Rest and plenty of fluids are also recommended. Even if you're not sure that it's dengue, it's best to consult a physician. A trip to the hospital is a must if vomiting and severe abdominal pain develops in the first 24 hours after the fever declines. For DHF, fluid replacement therapy is and option for treatment if the condition is detected early. However, this frequently requires hospitalization.

PATHOPHYSIOLOGY Dengue viral infections frequently are not apparent. Classic dengue primarily occurs in nonimmune, nonindigenous adults and children. Symptoms begin after a 5- to 10-day incubation period. DHF/DSS usually occurs during a second dengue infection in persons with preexisting actively or

passively (maternally) acquired immunity to a heterologous dengue virus serotype. Illness begins abruptly with a minor stage of 2-4 days' duration followed by rapid deterioration. Increased vascular permeability, bleeding, and possible DIC may be mediated by circulating dengue antigen-antibody complexes, activation of complement, and release of vasoactive amines. In the process of immune elimination of infected cells, proteases and lymphokines may be released and activate complement coagulation cascades and vascular permeability factors.

TYPES OF DENGUE FEVER There are three different types of dengue fever classified according to their symptoms. The following table gives a comprehensible overview of these types of dengue fever and the symptoms associate with them.

Types of Dengue Fever

Symptoms Features

1. Classic Dengue Fever

There is a high fever that can go up to 105 degrees Fahrenheit. Headache is common, with a throbbing pain behind the eyes. Rash is present all over the body, but mainly on the chest and limbs. Nausea and vomiting is present. There is acute pain in the joints.

This is the simple dengue fever, i.e. only dengue fever with no complications attached. This type of dengue begins showing its symptoms five or six days after the person has been infected by the mosquito. In this type, the rash may get completely healed once, but there may be an onset of a second rash episode.

2. Dengue Hemorrhagic Fever

High fever of up to 105 degrees Fahrenheit is caused. There is headache and pain behind the eyes. There is acute pain in the joints. Rash is developed on the chest and limbs. There is nausea and vomiting. There is bleeding from the nose,

Dengue hemorrhagic fever is a usually fatal type of dengue. This is dengue complicated by vascular problems. Due to these vascular problems, there is bleeding from various parts of the body.

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gums and subcutaneous (i.e. under the skin). There is malfunctioning of the blood and the lymph vessels.

3. Dengue Shock Fever

There is high fever, reaching up to 105 degrees Fahrenheit.

There is headache with pain behind the eyes.

There is acute pain in the joints.

Rash is developed. There is feeling of nausea and

actual vomiting. Low blood pressure is caused;

this is known as shock. There is internal leaking of

blood from the blood vessels.

This is a very fatal type of dengue fever. It is the type of dengue that mostly affects children and young teenagers.

SYMPTOMS OF DENGUE FEVER Symptoms of typical dengue usually start with fever and includes

High fever, up to 105 degrees Fahrenheit.

Severe headache. Retro-orbital (behind the eye) pain. Severe joint and muscle pain. Nausea and vomiting. Rash - The rash may appear over

most of your body 3 to 4 days after the fever begins. You may get a second rash later in the disease. Symptoms of dengue hemorrhagic fever include all of the symptoms of classic dengue.

Marked damage to blood and lymph vessels.

Bleeding from the nose, gums or under the skin, causing purplish bruises.

Exams and Tests A physical examination may reveal:

Enlarged liver (hepatomegaly)

Low blood pressure Rash Red eyes Red throat Swollen glands Weak, rapid pulse

Tests may include: Arterial blood gases Coagulation studies Electrolytes Hematocrit Liver enzymes Platelet count Serologic studies (demonstrate

antibodies to Dengue viruses) Serum studies from samples taken

during acute illness and convalescence (increase in titer to Dengue antigen)

Tourniquet test (causes petechiae to form below the tourniquet)

X-ray of the chest (may demonstrate pleural effusion)

DENGUE FEVER PROGNOSIS For the large majority of people infected with dengue fever viruses, the prognosis is

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excellent, although they are likely to feel very ill during the first one or two weeks of the acute illness and weak for about one month. Patients with underlying illness or immune depression have a fair to good prognosis because they are more likely to get complications. Also, people who have been infected by one dengue viral serovar are still able to be infected by the remaining three serovars; a second infection increases the possibility that complications will develop so patients with second-time dengue fever have a less optimal prognosis. Patients who develop DHF or DSS have a range of outcomes from good to poor, depending on their underlying medical problems and how quickly supportive measures are given. For example, DHF and DSS have about 50% fatality rate if untreated but about a 3% rate if treated with supportive measures. Overall, the fatality rate is about 1% of all dengue fever infections. While this rate may seem low, worldwide it means that about 500,000 to 1 million people die each year from dengue fever. This is a concern since the worldwide case numbers and outbreaks are increasing. DENGUE FEVER PREVENTION Dengue fever can be prevented by stopping mosquitoes from biting because they are the vectors the dengue viruses require for transfer to humans. The CDC (2010) has supplied these general rules to prevent transfer of viruses and other pathogens by mosquitoes and other biting vectors: Avoid outbreaks: To the extent possible, travelers should avoid known foci of epidemic disease transmission. The CDC Travelers' Health web page provides alerts and information on regional disease transmission patterns and outbreak alerts. Be aware of peak exposure times and places: Exposure to arthropod bites may be reduced if travelers modify their patterns of activity or behavior. Although mosquitoes

may bite at any time of day, peak biting activity for vectors of some diseases (for example, dengue, chikungunya) is during daylight hours. Vectors of other diseases (for example, malaria) are most active in twilight periods (for example, dawn and dusk) or in the evening after dark. Avoiding the outdoors or focusing preventive actions during peak hours may reduce risk. Place also matters; ticks are often found in grasses and other vegetated areas. Local health officials or guides may be able to point out areas with greater arthropod activity. Wear appropriate clothing: Travelers can minimize areas of exposed skin by wearing long-sleeved shirts, long pants, boots, and hats. Tucking in shirts and wearing socks and closed shoes instead of sandals may reduce risk. Repellents or insecticides such as permethrin (Elimite) can be applied to clothing and gear for added protection; this measure is discussed in detail below. Check for ticks: Travelers should be advised to inspect themselves and their clothing for ticks during outdoor activity and at the end of the day. Prompt removal of attached ticks can prevent some infections. Bed nets: When accommodations are not adequately screened or air conditioned, bed nets are essential to provide protection and to reduce discomfort caused by biting insects. If bed nets do not reach the floor, they should be tucked under mattresses. Bed nets are most effective when they are treated with an insecticide or repellent such as permethrin. Pretreated, long-lasting bed nets can be purchased prior to traveling, or nets can be treated after purchase. The permethrin will be effective for several months if the bed net is not washed. (Long-lasting pretreated nets may be effective for much longer.) Insecticides: Aerosol insecticides, vaporizing mats, and mosquito coils can

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help to clear rooms or areas of mosquitoes; however, some products available internationally may contain pesticides that are not registered in the United States. Insecticides should always be used with caution, avoiding direct inhalation of spray or smoke.

Optimum protection can be provided by applying repellents. The CDC recommends insect repellent should contain up to 50% DEET (N,N-diethyl-m-toluamide) which is the most effective mosquito repellent for adults and children over 2 months of age.There are no vaccines currently available commercially for dengue virus serovars. However, researchers are actively trying to produce vaccines that will protect people from all dengue viral serovars. DENGUE FEVER COMPLICATIONS The complications of dengue fever are usually associated with the more severe forms of dengue fever, hemorrhagic and shock syndrome. The most serious complications, although infrequent, are as follows:dehydration;bleeding (hemorrhage);low platelets;low blood pressure (hypotension);bradycardia;liver damage;neurological damage (seizures, encephalitis);and death. DENGUE HAEMORRHAGIC FEVER / DENGUE SHOCK SYNDROME 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 / DSS occurs it will usually do so by day 3-5 of the fever. In children, the progression of disease is not always characteristic. A relatively mild first phase with an abrupt onset of fever, malaise, vomiting, headache anorexia and cough is succeeded 2-5 days later by weakness and, sometimes, physical collapse. Frequently, spots appear on the

forehead, arms and legs, along with spontaneous bruises and bleeding from punctures where blood was taken. The more ill child may breathe rapidly and often effortfully; the pulse may be weak, rapid, and thready. Almost always patients have a positive tourniquet test (where a tourniquet i.e. a blood pressure cuff is applied and the skin demonstrates petechiae and / or bruising).The WHO criteria for DHF are a platelet count of less than 100,000 and a haematocrit 20% greater then normal. Such children need to be hospitalized and watched for potential DSS. Such shock can be a mortal illness and requires rapid and careful in-hospital management with assiduous correction and replacement of fluid, electrolytes, plasma and sometimes fresh blood / platelet transfusions. The most useful laboratory test in suspected DHF is estimation of thrombocytes (platelets) which will be very low. In contrast to uncomplicated dengue fever the white cell count is more often high. Mortality ranges from 5 - 30% (in untreated native populations) and the highest risk is to infants under 1 year. DENGUE FEVER MEDICATION Dengue fever is usually a self-limited

illness, and only supportive care is required. Acetaminophen may be used to treat patients with symptomatic fever. Aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids should be avoided.

Patients with known or suspected dengue fever should have their platelet count and hematocrit measured daily from the third day of illness until 1-2 days after defervescence. Patients with a rising hematocrit level or falling platelet count should have intravascular volume deficits replaced. Patients who improve can continue to be monitored in an outpatient setting. Patients who do not improve

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should be admitted to the hospital for continued hydration.

Patients who develop signs of dengue hemorrhagic fever warrant closer observation. Patients who develop signs of dehydration, such as tachycardia, prolonged capillary refill time, cool or mottled skin, diminished pulse amplitude, altered mental status, decreased urine output, rise in hematocrit levels, narrowed pulse pressure, or hypotension, require admission for intravenous fluid administration.

Successful management of severe dengue requires careful attention to fluid management and proactive treatment of hemorrhage. Intravascular volume deficits should be corrected with isotonic fluids such as Ringers lactate solution. Boluses of 10-20 mL/kg should be given over 20 minutes and may be repeated. If this fails to correct the deficit, the hematocrit value should be determined, and, if it is rising, limited clinical information suggests that a plasma expander may be administered. Starch, dextran 40, or albumin 5% at a dose of 10-20 mL/kg may be used. One recent study has suggested that starch may be preferable because of hypersensitivity reactions to dextran.35 If the patient does not improve after this, blood loss should be considered. Patients with internal or gastrointestinal bleeding may require transfusion. Patients with coagulopathy may require fresh frozen plasma.

After patients with dehydration are stabilized, they usually require intravenous fluids for no more than 24-48 hours. Intravenous fluids should be stopped when the hematocrit level falls below 40% and adequate intravascular volume is present. At this time, patients reabsorb extravasated fluid and are at risk for volume overload if intravenous fluids are continued. Do not interpret a falling

hematocrit value in a clinically improving patient as a sign of internal bleeding.

Platelet and fresh frozen plasma transfusions may be required to control severe bleeding. A recent case report demonstrated good improvement following intravenous anti-D globulin administration in two patients. The authors proposed that, similarly to nondengue forms of immune thrombocytopenic purpura, intravenous anti-D produces Fc receptor blockade to raise platelet counts.36

Patients who are resuscitated from shock rapidly recover. Patients with dengue hemorrhagic fever or dengue shock syndrome may be discharged from the hospital when they meet the following criteria: o Afebrile for 24 hours without antipyretics o Good appetite, clinically improved condition o Adequate urine output o Stable hematocrit level o At least 48 hours since recovery from shock o Absence of respiratory distress

NATURAL HOME REMEDIES FOR THE TREATMENT OF DENGUE FEVER Traditional natural home remedy for dengue fever - Normal dengue fever is not that dangerous. The symptom-based treatment should be resorted to i.e., wet pads could be used if the temperature is high. Antidotes could be administered as per the necessity. Pain-killers should not be given to the patient of hemorrhagic dengue. Pain-killers tend to increase hemorrhage. Maintaining the water balance of the body and controlling the blood pressure of the patient is also necessary. The standard conventional analgesic treatment for dengue. Simple home remedy for dengue fever -

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Dhatura is the Ayurvedic version of the homeopathic belladonna. Its leaves have potency in reducing the seriousness of the dengue fevers. However, the dosage must not exceed 2 decigrams, or it will lead to severe negative symptoms like dryness of the mouth and dilation of the pupils. Good home remedy for dengue fever - The orange juice helps with digestion, increased urinary output, promotes antibodies for faster healing and recovery. It gives energy and vitamins, over all a great source for fighting fevers. Effective home remedy for dengue fever - The raw papaya leaves, 2pcs just cleaned and pound and squeeze with filter cloth. You will only get one tablespoon per leaf. So two tablespoons per serving once a day. Do not boil or cook or rinse with hot water, it will loose its strength. This will prevent dengue fever. The affected person is treated with Paracetamol to bring down the fever.

DIET TIPS FOR DENGUE FEVER Porridge and baked toasts (not fried) can be had for allaying hungers in the course of the day. Biscuits with tea can be had. The tea must be herbal, with tulsi, ginger, cardamom and other such fever-reducing herbs in it. Learn how to prepare simple recipes believed to be miracle cure for dengue fever. There is no harm in trying as they are all the gift of nature that can be used to ease the suffering of dengue patients and probably could also save some lives. Dengue is an acute infectious viral disease transmitted by the Aedes mosquitoes. Common in tropical climates, the dengue fever is also known as break-bone fever due to the severe joint and muscle pain suffered by the patients. Other symptoms of dengue include severe headache, fever, and intense joint pain, which will usually last about a week. The fever will usually subside after 2 to 5 days and thereafter will rise again followed by

rashes on the skin. The dengue hemorrhagic fever is another form of the disease, which is more serious and can be fatal.

RECENT ADVANCES IN VACCINE DEVELOPMENT FOR THE TREATMENT OF DENGUE Dengue virus belongs to the Flavivirus family characterized by single stranded, positive sense RNA genome. Mutation rates in RNA viruses are exponentially greater than agents with DNA genomes due to the lack of proof reading mechanisms in the RNA dependant RNA polymerases of the former. This leads to the development of antigenic diversity because of varying levels of inter-virus genetic recombination. Although no licensed vaccine is currently available to combat dengue, a substantial amount of research has been undertaken over many years and in several countries. As a result, a number of conventional and novel vaccines are being developed and several are undergoing clinical trials. In theory, an effective vaccine against dengue is possible because it causes an acute infection and the viral levels are effectively controlled in a span of 3 to 7 days. Further, an individual exposed to a particular type of dengue is immune against re-infection with that subtype, thus leading to experiments in animal models, which have shown that passive transfer of virus specific antibodies are protective against subsequent challenge with that specific viral subtype. The major obstacles relating to the development of an effective dengue vaccine include a lack of complete understanding regarding the pathogenesis of dengue hemorrhagic fever and the absence of a representative animal model. Pre-existing heterotypic dengue antibody is a risk factor for DHF; therefore, an effective vaccine will have to be tetravalent and needs to prevent infection with all four DV serotypes. Recent advances in molecular biology and recombinant DNA

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technology have made it possible to create new strains that have the non-structural proteins of a certain subtype flanked by envelope antigens from a combination of different strains. This has lead to the emergence of the chimeric dengue vaccine. Recent studies have shown that by means of DNA shuffling and screening techniques, an envelope antigen capable of inducing neutralizing antibodies against all 4 types of dengue virus has been developed. Another approach has been the introduction of antibody inducing plasmid into DNA vaccines. This has also shown to produce significant antibody response in animal trials. Some other areas of interest include recombinant envelope vaccine, whole cell inactivated dengue vaccine and the development of a tetravalent live attenuated vaccine. Studies have shown that non-structural proteins in comparison to envelope antigens do not elicit efficient immune response on exposure. Novel approaches to find attenuated strains that selectively identify infected dendritic cells are underway. This increases the

effectiveness and the safety of the vaccine. The importance of understanding the correlation between protection and mechanisms of pathogenesis cannot be neglected. However, there is an escalating need to provide a solution to the global threat of dengue infection and the complications associated with the same. Better disease management, vector control and improved public health measures will help reduce the current disease burden, but a safe and effective vaccine is probably the only long-term solution to this problem. AYURVEDIC TREATMENT FOR DENGUE FEVER Dengue fever is a very serious disease and self-medication should not be done. Medical attention is extremely important. But in presence of continued symptoms, there are several Ayurvedic herbs that can provide relief. The following is a list of some herbs which are used for the treatment of common fevers (not dengue fever in particular).

Ayurvedic Name of the Herb

Biological Name of the Herb

Common English Name of the Herb

Action on the Human Body

Amaltas Cassia fistula Cassia The root of the cassia tree is used as a tonic for reducing dengue fever.

Chirayata Swertia chirata

Chirayata Chirayata has tremendous medicinal properties in the reduction of fevers. It is used for remedying the convulsions that accompany fevers in dengue.

Datura Datura stramonium

Dhatura Dhatura is the Ayurvedic version of the homeopathic belladonna. Its leaves have potency in reducing the seriousness of the dengue fevers. However, the dosage must not exceed 2 decigrams, or it will lead to severe negative symptoms like dryness of the mouth and dilation of the pupils.

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Hara dhania Coriandrum sativum

Coriander The leaves of the coriander can be taken in the form of a tonic to reduce the fevers in dengue.

Hermal Peganum harmala

Hermal The seeds of hermal are powdered and taken as either an infusion or as a decoction to treat intermittent and recurrent fevers that are observed in dengue.

Kanghi Arbutilan indicum

Indian Mallow

An infusion of the Indian Mallow is used as an efficacious treatment for reducing the dengue fevers.

Methi Trigonella foenum graecum

Fenugreek Fenugreek leaves are taken as herbal tea in order to reduce fevers. This drink acts as a soothing and cleansing tea for the human system. Fenugreek herbal tea has similar properties as those of quinine.

Punarnava Boerhaavia diffusa

Hogweed Hogweed is used to bring down temperatures. Hogweed produces plenty of perspiration which flushes the toxins and brings the fever down.

Rojmari Achillea millefolium

Bloodwort Bloodwort is a traditionally used remedy for all types of fevers in Ayurvedic medicine. Bloodwort when used in the form of a hot infusion brings out sweat, which expels the toxins from the body and reduces the fever.

Shaitan ka jhhad

Alstonia scholaris

Devils Tree Devils tree is used in Ayurveda for the treatment of recurrent fevers as is seen in dengue. The herb is analogous in function to cinchona and quinine. A hot infusion of the devils tree can bring down high temperatures without making the person break out into a sweat.

Tulsi Ocimum sanctum

Holy Basil Tender leaves of the holy basil boiled in water is a very effective prophylactic (preventive) treatment for the rainy season fevers, which include malaria and dengue. For better taste, the tender tulsi leaves can be taken as a tea with a pinch of cardamom powder in it. This is also a very popular recipe for Indian herbal tea.

CONCLUSION Dengue is an infectious disease causing frequent epidemics. There are various factors that contribute like lack of effective mosquito control, lack of public health systems to control the epidemic, the increase usage of plastic items which are the

breeding sites of the mosquitoes.Most people infected with dengue virus experience no symptoms at all or only a mild fever. Others develop flu-like symptoms, headache, and joint and muscle pain. A smaller portion of those infected

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experience the more severe dengue hemorrhagic fever/shock syndrome (DHF/DSS), which can cause high fever, pain, bleeding, a drop in blood pressure, and, in some cases, coma or death. As far as the treatment is concerned there is no specific course, However the affected person is treated with Paracetamol to bring down the fever. The person is usually adviced to drink lots of fluids. The infected person should be isolated until recovery from the rest of the family to prevent further infections. Although there is no vaccine to prevent this epidemic certain preventive measures as specified below can be taken to control the epidemic. REFERENCE 1) DM Morens and AS Fauci. Dengue and

hemorrhagic fever: A potential threat to public health in the United States. JAMA DOI:10.1001/jama.299.2.214 (2007).

2) Naides SJ. Arthropod-borne viruses causing fever and rash syndromes. In: Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 405.

3) SS Whitehead, JE Blaney, AP Durbin, and BR Murphy. Prospects for a dengue virus vaccine. Nature Reviews Microbiology DOI: 10.1038/nrmicro1690 (2007).

4) Apt D, Raviprakash K, Brinkman A, Semyonov A, Yang S, Skinner C, Diehl L, Lyons R, Porter K, Punnonen J. Vaccine. 2006 Jan 16; 24(3): 335-44. Epub 2005 Aug 10.

5) Non-structural proteins of dengue 2 virus offer limited protection to interferon-deficient mice after dengue 2 virus challengeCalvert AE, Huang CY, Kinney RM, Roehrig JT.J Gen Virol. 2006 Feb; 87(Pt 2): 339-46.

6) Stephens on, Understanding dengue

pathogenesis: implications for vaccine design Bull World Health Organ.2005 Apr; 83(4): 308-14. Epub 2005 Apr 25

7) Chaturvedi U C, Shrivastava R, Nagar RDengue vaccines: problems and prospectsIndian J Med Res. 2005 May;121(5): 639-52. Review.

8) Canada. Public Health Agency of Canada. "Dengue in South East Asia." Aug. 23, 2007. .

9) "Dengue Fever in Key West." Florida Department of Health. .

10) Switzerland. World Health Organization. "Planning Social Mobilization and CommunicationforDengueFeverPreventionandControl.".

11) Switzerland. World Health Organization. "Vector-Borne Viral Infections." .

12) United States. Centers for Disease Control and Prevention. "Dengue." May 20, 2010. .

13) United States. Centers for Disease Control and Prevention. "Locally Acquired Dengue -- Key West, Florida, 2009-2010." Morbidity and Mortality Weekly Report 59.19 May 21, 2010: 577-581.

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PATHOPHYSIOLOGYDengue viral infections frequently are not apparent. Classic dengue primarily occurs in nonimmune, nonindigenous adults and children. Symptoms begin after a 5- to 10-day incubation period. DHF/DSS usually occurs during a second dengue infection in per...SYMPTOMS OF DENGUE FEVER Symptoms of typical dengue usually start with fever and includesExams and Tests A physical examination may reveal:DENGUE FEVER PROGNOSISDENGUE FEVER PREVENTIONDENGUE FEVER COMPLICATIONS

DENGUE HAEMORRHAGIC FEVER / DENGUE SHOCK SYNDROMENATURAL HOME REMEDIES FOR THE TREATMENT OF DENGUE FEVER Traditional natural home remedy for dengue fever - Normal dengue fever is not that dangerous. The symptom-based treatment should be resorted to i.e., wet pads could be used if the temperature is ...DIET TIPS FOR DENGUE FEVER Porridge and baked toasts (not fried) can be had for allaying hungers in the course of the day. Biscuits with tea can be had. The tea must be herbal, with tulsi, ginger, cardamom and other such fever-reducing herbs in it. Le...RECENT ADVANCES IN VACCINE DEVELOPMENT FOR THE TREATMENT OF DENGUE