INTRODUCTION

engue is the most common mosquito-borne viral disease of humans that in recent years has

become a major international public health concern. Globally, 2.5 billion people live in areas where dengue viruses can be transmitted. The geographical spread of both the mosquito vectors and the viruses has led to the global resurgence of epidemic dengue fever and emergence of dengue hemorrhagic fever (dengue/DHF) in the past 25 years with the development of hyperendemicity in many urban centers of the tropics. Transmitted by the main vector, the Aedes aegytpi mosquito, there are four distinct, but closely related, viruses that cause dengue. Recovery from infection by one provides lifelong immunity against that serotype but confers only partial and transient protection against subsequent infection by the other three. There is good evidence that sequential infection increases the risk of more serious disease resulting in DHF. BACKGROUND DHF was first recognized in the 1950s during the dengue epidemics in the Philippines and Thailand. By 1970 nine countries had experienced epidemic DHF and now, the number has increased more than fourfold and continues to rise. Today emerging DHF cases are causing increased dengue epidemics in the Americas, and in Asia, where all four dengue viruses are endemic, DHF has become a leading cause of hospitalization and death among children in several countries. Currently vector control is the available method for the dengue and DHF prevention and control but research on dengue vaccines for public health use is in process. The global strategy for dengue /DHF prevention and control developed by WHO and the regional strategy formulation in the Americas, South-East Asia and the Western Pacific during the 1990s have facilitated identification of the main priorities: strengthening epidemiological surveillance through the implementation of DengueNet; accelerated training and the adoption of WHO standard clinical management guidelines for DHF; promoting behavioral change at individual, household and community levels to improve prevention and control; and accelerating research on vaccine development, host-pathogen interactions, and development of tools/interventions by including dengue in the disease portfolio of TDR (UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases) and IVR (WHO Initiative for Vaccine Research).
What are dengue fever symptoms and signs?

After being bitten by a mosquito carrying the virus, the incubation period ranges from three to 15 (usually five to eight) days before the signs and symptoms of dengue appear in stages. Dengue starts with chills, headache, pain upon moving the eyes, and low backache. Painful aching in the legs and joints occurs during the first hours of illness. The temperature rises quickly as high as 104 F (40 C), with relatively low heart rate (bradycardia) and low blood pressure (hypotension).

The eyes become reddened. A flushing or pale pink rash comes over the face and then disappears. The glands (lymph nodes) in the neck and groin are often swollen. Fever and other signs of dengue last for two to four days, followed by a rapid drop in body temperature (defervescence) with profuse sweating. This precedes a period with normal temperature and a sense of well-being that lasts about a day. A second rapid rise in temperature follows. A characteristic rash appears along with the fever and spreads from the extremities to cover the entire body except the face. The palms and soles may be bright red and swollen.
How is dengue fever diagnosed?

The diagnosis of dengue fever is usually made when a patient exhibits the typical clinical symptoms of headache, fever, eye pain, severe muscle aches and petechial rash and has a history of being in an area where dengue fever is endemic. Dengue fever can be difficult to diagnose because its symptoms overlap with those of many other viral illnesses, such as West Nile virus and chikungunya fever. In 2011, the U.S. Food and Drug Administration (FDA) approved a blood test to diagnose people with dengue fever, called the DENV Detect IgM Capture ELISA. The FDA notes that the new test may also give a positive result when a person has a closely related virus, such West Nile disease.
What is the treatment for dengue fever?

Because dengue fever is caused by a virus, there is no specific medicine or antibiotic to treat it. For typical dengue, the treatment is purely concerned with relief of the symptoms. Rest and fluid intake for adequate hydration is important. Aspirin and nonsteroidal anti-inflammatory drugs should only be taken under a doctor's supervision because of the possibility of worsening bleeding complications. Acetaminophen (Tylenol) and codeine may be given for severe headache and for joint and muscle pain (myalgia).

Key facts

Dengue is a mosquito-borne infection that causes a severe flu-like illness, and sometimes a potentially lethal complication called dengue haemorrhagic fever. Global incidence of dengue has grown dramatically in recent decades. About two fifths of the world's population are now at risk. Dengue is found in tropical and sub-tropical climates worldwide, mostly in urban and semi-urban areas. Dengue haemorrhagic fever is a leading cause of serious illness and death among children in some Asian countries. There is no specific treatment for dengue, but appropriate medical care frequently saves the lives of patients with the more serious dengue haemorrhagic fever. The only way to prevent dengue virus transmission is to combat the diseasecarrying mosquitoes.

Transmission

WHO/TDR/Stammers

Dengue viruses are transmitted to humans through the bites of infective female Aedes mosquitoes. Mosquitoes generally acquire the virus while feeding on the blood of an infected person. After virus incubation for eight to 10 days, an infected mosquito is capable, during probing and blood feeding, of transmitting the virus for the rest of its life. Infected female mosquitoes may also transmit the virus to their offspring by transovarial (via the eggs) transmission, but the role of this in sustaining transmission of the virus to humans has not yet been defined. Infected humans are the main carriers and multipliers of the virus, serving as a source of the virus for uninfected mosquitoes. The virus circulates in the blood of infected humans for two to seven days, at approximately the same time that they have a fever; Aedes mosquitoes may acquire the virus when they feed on an individual during this period. Some studies have shown that monkeys in some parts of the world play a similar role in transmission.
Characteristics

Dengue fever is a severe, flu-like illness that affects infants, young children and adults, but seldom causes death. The clinical features of dengue fever vary according to the age of the patient. Infants and young children may have a fever with rash. Older children and adults may have either a mild fever or the classical incapacitating disease with abrupt onset and high fever, severe headache, pain behind the eyes, muscle and joint pains, and rash. Dengue haemorrhagic fever (DHF) is a potentially deadly complication that is characterized by high fever, often with enlargement of the liver, and in severe cases circulatory failure. The illness often begins with a sudden rise in temperature accompanied by facial flush and other flu-like symptoms. The fever usually continues for two to seven days and can be as high as 41C, possibly with convulsions and other complications. In moderate DHF cases, all signs and symptoms abate after the fever subsides. In severe cases, the patient's condition may suddenly deteriorate after a few days of fever; the temperature drops, followed by signs of circulatory failure, and the patient may rapidly go into a critical state of shock and die within 12 to 24 hours, or quickly recover following appropriate medical treatment (see below).

Dengue Virus and Dengue Fever:

What is dengue virus? Dengue is an infectious disease of the tropics transmitted by striped Aedes aegypti mosquitoes and is characterized by sudden fever and causing rash and aching head and joints.

About Dengue Fever: Dengue viruses occur in most tropical areas of the world. Dengue hemorrhagic fever is a more severe form of the viral illness. Dengue also goes by other names, including breakbone or dandy fever. Dengue Fever Symptoms: After being bitten by a mosquito carrying the virus, the incubation period ranges from three to 15 (usually five to eight) days before the signs and symptoms of dengue appear in stages. Dengue Fever starts with:

chills, headache, pain upon moving the eyes, and low backache. Painful aching in the legs and joints occurs during the first hours of illness. The temperature rises quickly as high as 104 F (40 C), with relatively low heart rate (bradycardia) and low blood pressure(hypotension). The eyes become reddened. A flushing or pale pink rash comes over the face and then disappears. The glands (lymph nodes) in the neck and groin are often swollen. A characteristic rash appears along with the fever and spreads from the extremities to cover the entire body except the face. The palms and soles may be bright red and swollen. Fever and other signs of dengue last for two to four days, followed by a rapid drop in body temperature (defervescence) with profuse sweating. A second rapid rise in temperature follows.

Because dengue fever is caused by a virus, there is no specific medicine or antibiotic to treat it. Also, there is currently no vaccine available for dengue fever. The prevention of dengue fever requires control or eradication of the mosquitoes that are carrying the virus that causes dengue.

Epidemic of Dengue Virus across the World:

The global prevalence of dengue fever (DF) has grown dramatically in recent decades; DF is now endemic to more than100 countries. During the past decade, DHF epidemics have occurred in China, Sri Lanka, India, the Maldives, Bangladesh, and Pakistan

Expansion of Epidemic Dengue Viral Infections in Pakistan

In Pakistan, an outbreak of DHF was first reported in Karachi in 1994. From September through December 2005, at least 3 major hospitals in Karachi had a sudden increase in the number of patients with signs consistent with that of Dengue Viral Infections.
It is important that the cases of dengue fever have already been reported in all seven tehsils of Rawalpindi district proving existence of female mosquito namely Aedes Aegypti there. We have displayed banners across all main roads in town to make public aware that the infection can only be controlled by eliminating breeding places of mosquitoes in homes, said District Health Officer Dr Khalid Randhawa while talking the infection could not be controlled without active role of community. He said people should be aware that dengue fever is caused by a female mosquito namely Aedes Aegypti that breeds only in clean water containers like barrels, buckets, drums, tanks, flower vases, water coolers, discarded tires, toilet bowls and other such places, including the ones where rainwater collects, which is a practice contrary to that of the malaria-causing mosquito that thrives and procreates in dingy waters. The Aedes Aegyptis breeding places can be eliminated by various means such as by tightly covering water storage containers, draining rainwater regularly and disposing off garbage. With no proper vaccines available to combat Dengue, the only effective and available

method of controlling and eventually eliminating the disease is by destroying the mosquito breeding places along with effectively treating patients identified as carriers.

It is important that the cases of dengue fever have already been reported in all seven tehsils of Rawalpindi district proving existence of female mosquito namely Aedes Aegypti there. We have displayed banners across all main roads in town to make public aware that the infection can only be controlled by eliminating breeding places of mosquitoes in homes, said District Health Officer Dr Khalid Randhawa while talking the infection could not be controlled without active role of community. He said people should be aware that dengue fever is caused by a female mosquito namely Aedes Aegypti that breeds only in clean water containers like barrels, buckets, drums, tanks, flower vases, water coolers, discarded tires, toilet bowls and other such places, including the ones where rainwater collects, which is a practice contrary to that of the malaria-causing mosquito that thrives and procreates in dingy waters. The Aedes Aegyptis breeding places can be eliminated by various means such as by tightly covering water storage containers, draining rainwater regularly and disposing off garbage. With no proper vaccines available to combat Dengue, the only effective and available method of controlling and eventually eliminating the disease is by destroying the mosquito breeding places along with effectively treating patients identified as carriers.

Inside the home, precautionary measures such as regular use of quality pest control products like household insecticide sprays, coils, mats and liquid electrical devices are advised to be taken as seriously as possible in order to ensure adequate prevention from these disease carrying mosquitoes, A number of health experts, however, are of the view that if the government had taken necessary measures well in time, the situation would not have been as alarming as it is. They say that awareness campaigns against dengue fever should have been started soon after the confirmation of occurrence of dengue fever some four months back. The health experts also believe that a rare complication of dengue fever, a more fatal form of the infection, dengue haemorrhagic fever, can occur, most often in small children and elderly adults. If DHF occurs it usually does so by day 3-5 of the fever. Experts say that uncontrolled bleeding distinguishes DHF 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 assiduous correction and replacement of fluid, electrolytes, plasma and sometimes, fresh blood/platelets transfusions. Mortality from DHF ranges from 5-30% (in untreated native populations) and the highest risk is to infants under one year.

Public should be aware that dengue fever could be prevented by mosquito control measures and personal protection measures (long sleeves and mosquito repellents). 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. Experts advise to avoid use of dark coloured clothing, perfumes and colognes in the evening and at night, as all these attract mosquitoes. He added that the use of mosquito repellents such as oils, mosquito coils, vapour mats etc are recommended to reduce human-mosquito contact. During the peak biting time of the mosquito, Aedes Aegypti, at dusk and dawn, families should avoid human-mosquito contact by the use of protective clothing, long sleeve shirts, full-length pants, socks, and boots to avoid mosquito bites.

PREVENTATION IN PAKISTAN. ACCORDING TO Dr Meher Zaidi Prevention is better than cure . Nowhere this motto applies better than to fight or dare Dengue menace in Pakistan. Here are some precautions and must do things: 1.Teach prevention to children and servants and other illiterate people. 2.Remove all open containers, sources of storage of water, pots,covered or otherwise from areas that are not easily manageable. 3. Keep all fresh water in covered containers and check frequently. 4. Clean and wipe all surfaces and floors daily regularly. 5.Use medicated mosquito nets, netting of windows, mats, insect repellent sprays, personal mosquito repellent liquids and creams at least in evening time. Use full sleeves and full length trousers, and socks. mosquito repellent can also be applied over socks and clothes but particularly to face, back of ears and hands and feet. Things to do in case of suspicion of attack: 1. Consult local doctor. Symptoms such as fever, body and joint pain,chills, vomiting headache, bleeding from mouth, nose, spots or patches over body are suspicious. 2. Excessive bleeding and haemorrhage occurs as a result of platelet deficiency which are attacked by the virus. These need to be tested and replaced , therefore hospitalisation is necessary. Be prepared for hospitalisation and keep the contacts

in ready hand.Each city, town and district has its own coordination officer or health officer .

Dengue Fever: Death toll reached 123 in Lahore

LAHORE: Already cursed by floods and suicide bombings, Pakistan now faces a new menace from an unprecedented outbreak of the deadly tropical disease dengue fever.

People generally women and children are constantly visiting city hospitals while the hospital administration said that it is not possible to satisfy each patient due to devastating number of patients. Doctors and Medical Specialists said that the virus capacity increase fast due to load shedding that has again started in the city. Consequently, it is dangerous to control load shedding in order to get control over the virus flow. Punjab Chief Minister Shahbaz Sharif chaired the session of dengue emergency meeting where it was decided that strict action would be taken against school administration that will not follow the instructions regarding school uniform.

In this photograph taken on September 28, 2011 a Pakistani health worker fumigates against dengue carrying mosquitos in Lahore. PHOTO: AFP In less than a month, 126 people have died and more than 12,000 have been diagnosed with the virus, which has spread rapidly among both rich and poor in Pakistans cultural capital Lahore. Dengue affects between 50 and 100 million people in the tropics and subtropics each year, resulting in fever, muscle and joint ache. But it can also be fatal, developing into haemorrhagic fever and shock syndrome, which is characterised by bleeding and a loss of blood pressure. Caused by four strains of virus spread by the mosquito Aedes aegypti, there is no vaccine which is why prevention methods focus on mosquito control. Pakistani authorities in Lahore have blamed the crisis on prolonged monsoon rains and unusually high seasonal temperatures. But furious locals say the outbreak is yet another example of government inefficiency, citing a failure to take preventive measures to kill off the mosquitos and lengthy power cuts. Of the more than 11,584 people afflicted, 10,244 come from Lahore alone, the provincial capital of Punjab, Pakistans most populous province and the countrys political heartland. In northwestern province Khyber Paktunkhwa, at least 130 people have been diagnosed and six have died. Southern province Sindh has seen 400 suspected cases and six deaths.

Banners emblazoned with giant sketches of mosquitos and public warning messages such as Eliminate dengue, Have peace are hung across avenues and crossings in Lahore, a city of eight million. The chief minister of Punjab, Shahbaz Sharif, whose party runs the local governing coalition and whose brother Nawaz is Pakistans opposition leader, has urged doctors to do more to restore calm. You are doing a wonderful job, but we have to bring down the mortality rate so that the people will be calmed, he said at a workshop this week. Hospitals are overwhelmed, treating around 1,113 people and having already sent home another 10,000 to recuperate, said Asif Nadeem, a member of a hastily set up anti-dengue task force. At Lahore General Hospital, where most cases have been reported, the corridors were packed with patients and relatives making it difficult to breathe. Outside, medics set up large tents to accommodate family members and patients waiting for treatment, offering some shelter in the sweltering heat. We have no complaints about the arrangements, but they are not going beyond giving out paracetamol, Rashid Hameed, 27, an accountant, told AFP. Doctor Zafar Ikram said the hospital was working beyond capacity to deal with the influx of patients. I think more people are coming because there is greater awareness about dengue due to the media spotlight and people are scared, so anyone with a normal fever comes to hospital for the (dengue) test, Ikram told AFP. At the Mayo hospital, hundreds of people queued up in front of registration counters, giving blood samples and collecting reports. Teams from the World Health Organisation and Sri Lanka are now helping with the efforts. Schools and colleges initially shut have since reopened. On the control side a huge effort is going on with a public awareness campaign, said Punjab provincial health secretary Jahanzeb Khan. In much of Lahore, known for its rich cultural heritage and popular restaurants, life carries on as normal with some establishments as crowded as ever in the cooler evenings. Others cannot afford to be ruffled.

Conclusion
Adult population of Pakistan has adequate knowledge related to the disease dengue on isolated aspects, but the overall prevalence of sufficient knowledge based on our criteria is poor. We demonstrated adequate prevalence of preventive practices against the disease. Further studies correlating the association between knowledge and its effectiveness against dengue will be helpful in demonstrating the implications of awareness campaigns.

RECOMMANDATION The Health department has recommended the following preventive measures for general public. 1- Dont keep stagnant water in utensils especially in and around the shady areas and houses. 2- Use of bed nets 3- Prevent collection of stagnant water in and around your house 4- Use mosquitoes repellents all over your body when moving outdoors 5- Use full sleeves shirt and full length shalwar and pants 6- Fixation of fine wire mesh screens on windows and doors 7- Use of coil and mats while indoor 8- In case of fever please immediately approach/visit the nearby hospital 9- Avoid taking aspirin and brufen tablets. REFERENCE