67

Dengue fever is a very hot topic nowadays, 
not only among health professionals but 
among politicians as well. And it is rightly so 
because since 2010, Pakistan has been 
experiencing an epidemic of dengue fever 
that has caused 16 580 confirmed cases and 
257 deaths in Lahore and nearly 5000 cases 
and 60 deaths reported from the rest of the 
country. The three provinces facing the 
epidemic are Khyber Pakhtunkhwa, Punjab 
and Sindh. This year Punjab has reported 
2300 cases, of which 50% alone are from 
Rawalpindi District. In spite of allocation of 
additional funds it has resulted in draining 
much of the already meager health 
resources.
While handling the epidemic a lot of 
emphasis was on providing indoor 
treatment facilities including platelet 
transfusions to as many patients as possible. 
While doing so important principals of 
community medicine for dealing with 
epidemics were largely ignored because of 
the political pressure on the hospital 
administrators and doctors.
It is not only Pakistan facing this menace, it 
is estimated that about 2.5 billion people 
(over 40% of the world population) are at 
risk. There are about 50-100 million cases 
occurring in the population at risk every 
year. Dengue is transmitted by an 
Arthropod (mosquito Aedes aegypti ) and 
caused by a Flavivirus infection, the primary 
host of which are human. Therefore the 
emphasis for controlling the disease should 

be on the vector control (mainly Aedes 
aegypti mosquito) and protection from 
mosquito bite. This is what the WHO 
recommends. Obviously the responsibility 
for vector control rests on Civic bodies and 
the society itself. In a country where leaking 
fresh water pipes, broken roads and ditches 
holding rain water, tyres and pottery shops 
are abundant with no sense of responsibility 
for regular garbage disposal and mosquito 
control, there is abundant space for breading 
of vector. This is added by underground 
fresh water tanks, most favorite site for 
Aedes to breed is in almost every house. The 
money which is spent upon providing 
treatment facilities, which are expensive, 
should be diverted towards improving civic 
services and creating awareness about the 
preventive measures, which are far less 
expensive. Prevention is better than 
treatment as it also reduces morbidity 
whereas treatment will only reduce 
mortality.
T h e  Wo r l d  H e a l t h  O r g a n i z a t i o n  
recommends an Integrated Vector Control 
program consisting of five elements. If these 
are practiced in an integrated manner, the 
disease can be prevented. These are:
1. Advocacy, social mobilization and 

legislation to ensure that public health 
b o d i e s  a n d  c o m m u n i t i e s  a r e  
strengthened;

2. Collaboration between the health and 
other sectors (public and private);

3. An integrated approach to disease 
control to maximize use of resources;

4. Evidence-based decision making to 
ensure any interventions are targeted 

EDITORIAL

-------------------------------------------------

Masood Anwar

Correspondence:
Prof. Masood Anwar
Dean Faculty of Health and Medical Sciences
Riphah International University
Islamabad

Dengue Fever: A Drain on Health Resources



68

appropriately; and
5. C a p a c i t y - b u i l d i n g  t o  e n s u re  a n  

adequate response to the local situation.
This should also be remembered that not 
every person suffering from fever, body 
aches and thrombocytopenia is suffering 
f r o m  D e n g u e .  M a l a r i a ,  e s p e c i a l l y  
falciparum malaria which is also caused by 
mosquito bite and which also occurs in 
about the same season has similar signs and 
symptoms. It is essential that all blood slides 
from suspected patient must be seen by a 
well-trained technician, if not by a 
haematologist. I have yet to see a case of 
falciparum malaria which does not have 
some degree of thrombocytopenia. Another 
i m p o r t a n t  d i ff e re n t i a l  d i a g n o s i s  i s  
Chickengunya  virus infection. It is also 
caused by bite of Aedes mosquito and has 
sign and symptoms very similar to Dengue. 
Therefore appropriate laboratory diagnosis 
is also important to establish the diagnosis 
of Dengue fever.
Even if the diagnosis is confirmed, patient 
needs not to be admitted in the hospital and 
if admitted he needs not to be in an isolation 
ward. Patients of Dengue are best isolated 
under a mosquito net in the same ward. 
WHO in 2009 gave new Dengue case 
definition to facilitate decision regarding 
indoor management of patients. These are:
A. D e n g u e  w i t h o u t  Wa r n i n g  S i g n s  

expanded: When there is fever and two 
of the following:

! Nausea, vomiting
! Rash
! Aches and pains
! Leukopenia

! Positive tourniquet test
B. Dengue with Warning Signs expanded: 

Dengue as defined above with any of 
the following:

! Abdominal pain or tenderness
! Persistent vomiting
! Clinical fluid accumulation (ascites, 

pleural effusion)
! Mucosal bleeding
! Lethargy, restlessness
! Liver enlargement >2 cm
! L a b o r a t o r y :  i n c r e a s e  i n  H C T  

concurrent with rapid decrease in 
platelet count

C. Severe Dengue expanded: Dengue with 
at least one of the following criteria:

! Severe Plasma Leakage leading to:
– Shock (DSS)
– F l u i d  a c c u m u l a t i o n  w i t h  

respiratory distress
! Severe Bleeding as evaluated by 

clinician
! Severe organ involvement

– Liver: AST or ALT ≡ 1000
– CNS: impaired consciousness
– Failure of heart and other 

organs
In (A) hospital admission is not required. 
Second stage requires close supervision and 
medical intervention but admission and 
vigorous treatment is essential in third case. 
Following WHO guidelines, both for 
prevention and treatment with strict 
monitoring and audit will not only 
substantially reduce the cost of Dengue 
control but may completely eliminate the 
disease.


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