Tugaz Bhsa Inggris(DF)

7/30/2019 Tugaz Bhsa Inggris(DF)

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Demam Dengue (Dengue Fever)/Demam Berdarah Dengue

Penyakit ini tercatat pertama kali menjadi endemi pada tahun 1779-1780 di

Asia, Afrika dan Amerika Utara dan terjadi secara hampir bersamaan dengan tingkat

morbiditas dan mortalitas yang tinggi. Hal ini menggambarkan bahwa penyebaran penyakit

ini sudah sangat luas sejak lebih dari 200 tahun lalu dan merupakan penyakit yang cukup

membahayakan. Saat inipun penyakit ini masih merupakan masalah serius di bidang

kesehatan umumnya di daerah tropis dan subtropis dengan tingkat ekonomi dan kesehatan

yang rendah.

APA ITU DEMAM DENGUE?

Demam Dengue atau Dengue Fever (DF) adalah suatu penyakit yang disebabkan oleh virus

Dengue Famili Flaviviridae,dengan genusnya adalah flavivirus. Virus ini mempunyai empat

serotipe yang dikenal dengan DEN-1, DEN-2, DEN-3 dan DEN-4. Penyakit ini tidak

ditularkan secara langsung dari manusia ke manusia melainkan melalui perantaraan melalui

gigitan nyamuk. Spesies nyamuk yang menjadi vektor perantara penyakit ini utamanya adalah

Aedes aegypti dan Aedes albopictus betina.

DF merupakan bentuk paling ringan dari bentuk berikutnya yaitu Demam Berdarah Dengue

atau Dengue Hemorrhagic Fever (DHF) dan Dengue Shock Syndrome (DSS).

BAGAIMANA GEJALA DARI PENYAKIT TERSEBUT?

Manifestasi klinis infeksi virus Dengue pada manusia sangat bervariasi. Spektrum variasinya

begitu luas, mulai dari tanpa gejala, demam ringan yang tidak spesifik, Demam Dengue,

Demam Berdarah Dengue, hingga yang paling berat yaitu Dengue Shock Syndrome (DSS)

Demam Dengue memiliki tanda dan gejala awal berupa panas yang berlangsung antara 4 7

hari setelah gigitan nyamuk pembawa virus tersebut disertai dengan gejala-gejala berikutnya

yang meliputi:

-panas tinggi hingga >38C yang berlangsung hingga 5-7 hari

-Nyeri kepala dan nyeri diretro-orbital (belakang mata)

-Nyeri pada otot dan sendi

-Rasa mual dan muntah, tidak nafsu makan-Adanya ganguan pencernaan (konstipasi atau diare)

-Nyeri perut

-Adanya rash (tanda kemerahan) pada kulit

Sedangkan Demam Berdarah Dengue memiliki tanda dan gejala sebagai berikut:

-Gejala di atas ditambah

-Adanya manifestasi perdarahan spontan, seperti bintik-bintik merah di kulit yang tidak hilang

jika ditekan (utamanya di daerah siku, pergelangan tangan dan kaki), uji tourniquet positif,

mimisan, perdarahan gusi, perdarahan yang sulit dihentikan jika disuntik atau terluka

-Adanya pembesaran organ hepar (hati) dan limpa

-Adanya trombositopenia, yaitu jumlah trombosit < 100.000/mm (normalnya 150-450ribu/mm)


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-Adanya kebocoran plasma yang ditandai dengan nilai Hematokrit (Hct) yang meningkat atau

menurun 20% atau lebih dari nilai normalnya, adanya efusi pleura (cairan dalam paru) dan

ascites (penumpukan cairan dalam rongga perut).

Bentuk paling berat dari infeksi virus ini adalah Dengue Shock Syndrome (DSS) dimanagejalanya meliputi :

-Gejala pada DHF ditambah,

-Adanya penurunan kesadaran

-Tekanan darah sangat rendah

-Nadi cepat dan lemah

-Tangan dan kaki pucat dan dingin

Untuk memudahkan dalam menentukan diagnosis dan mencegah terjadinya overdiagnosis,

maka WHO membagi menjadi 4 derajat manifestasi klinis, yaitu:

-DHF derajat I: Tanda-tanda infeksi virus, dengan menifestasi perdarahan yang tampak hanya

dengan Uji Torniquet positif.

-DHF derajat II: Tanda infeksi virus dengan manifestasi perdarahan spontan (mimisan, bintik-

bintik merah)

-DHF derajat III: Disebut juga fase pre syok, dengan tanda DHF grade II namun penderita

mulai mengalami tanda syok; kesadaran menurun, tangan dan kaki dingin, nadi teraba cepat

dan lemah, tekanan nadi masih terukur.

-DHF derajat IV: Atau fase syok (disebut juga dengue syok syndrome/DSS), penderita syok

dalam dengan kesadaran sangat menurun hingga koma, tangan dan kaki dingin dan pucat, nadi

sangat lemah sampai tidak teraba, tekanan nadi tidak dapat terukur.

BAGAIMANA PERAWATAN PENDERITANYA?

Pada prinsipnya karena ini adalah penyakit karena infeksi virus maka belum ada obat spesifik

untuk mengatasinya. Perawatan yang diberikan hanya berupa penanganan secara simtomatik

saja berupa perbaikan keadaan umum penderitanya dan menjaga jangan sampai dehidrasi

(kekurangan cairan). Perawatannya bisa dilakukan di rumah apabila penderita masih bisa

makan dan minum sendiri dan tidak ada mual atau muntah yang berat (DHF Derajat I-II).

Perawatan dapat dilakukan dengan memberikan kompres hangat, obat turun panas, pereda

nyeri dan antimuntah bila perlu.

Apabila kondisi penderita tidak membaik atau apabila ada tanda-tanda shock (DHF Derajat

III-IV) segera bawa ke fasilitas kesehatan terdekat.

DHF umumnya akan mengalami penyembuhan setelah 7-8 hari, jika tidak ada infeksisekunder dan dasar pertahanan tubuh penderitanya memang baik. Tanda penyembuhan antara

lain meliputi demam yang turun perlahan, nafsu makan dan minum yang membaik, lemas

yang berkurang dan tubuh terasa segar kembali.

BAGAIMANA PENCEGAHAN AGAR TIDAK TERJANGKIT PENYAKIT INI?

Yang harus dilakukan adalah mengetahui kapan biasanya penyakit ini muncul, biasanya pada

awal musim hujan dan selama musim hujan. Laksanakan tindakan pencegahan dengan

melakukan gerakan 3M plus, yaitu menguras bak air minimal seminggu sekali, menutup

tempat-tempat penampungan air, mengubur barang-barang bekas yang dapat menampung air

hujan.


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Demam berdarah (dengue fever)12/05/2010 13:51:00

Definisi

Demam berdarah merupakan penyakit yang disebabkan oleh virus dengue yang ditularkan

melalui nyamuk aedes aegepty.

Jutaan kasus demam berdarah terjadi di seluruh belahan duni. Kebanyakan terjadi pada

daerah tropis dan subtropis.

Gejala

Gejala demam berdarah beragam. Bergantung dari tahapannya. Kasus demam berdarah

ringan menyebabkan gejala demam tinggi, ruam atau bintik merah, serta ngilu pada otot dan

persendian. Sedangkan demam berdarah yang sudah mencapai tahap berat bisa menyebabkan

menyebabkan pendarahan, tekanan darah turun mendadak,shock, bahkan kematian.

Tahap awal : pada tahap awal penyakit ini, si penderita bisa mengalami satu atau lebih dari

gejala berikut ini :

- Demam tinggi. Suhu tubuh ketika demam bisa mencapai lebih dari 40 derajat

celcius.

- Tubuh dipenuhi ruam atau bintik merah. Ruam ini bisa menghilang beberapa hari

kemudian muncul kembali.

- Sakit kepala, punggung, atau keduanya.

- Merasa sakit di belakang bola mata.

- Nyeri otot dan sendi

- Merasa mual dan muntah

Gejala ini muncul setelah empat hingga tujuh hari si penderita terinfeksi virus dengue yang

ditularkan melalui nyamuk. Pada tahap ini, demam berdarah jarang menyebabkan kematian.

Gejalanya seringkali menghilang sendiri setelah seminggu.

Tahap akut : gejalanya mirip dengan demam berdarah ringan. Hanya saja, gejala akan

bertambah

parah setelah beberapa hari. Selain itu, ada gejala lain yang menyertai, seperti :


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- Kerusakan pada saluran darah dan limpa.

- Penurunan jumlah platelet, sel darah yang membantu proses pembekuan darah.

- Pendarahan pada hidung dan mulut.

- Pendarahan di bawah kulit, yang terlihat seperti memar.

- Kematian.

Yang harus diwaspadai dari demam berdarah adalah gejalanya yang muncul dan hilang

seperti pelana kuda. Penderita akan menyangka dirinya sudah mulai membaik ketika gejala

berkurang. Padahal itulah saat kritis dimana fase demam berdarah bisa masuk ke tahap

Dengue Shock Syndrome yang bisa menyebabkan pendarahan berat,shock, dan kematian.

Penyebab

Demam berdarah disebabkan oleh salah satu dari empat jenis virus dengue yang disebarkan

oleh nyamuk aedes aegypti. Nyamuk ini hidup dekat pemukiman manusia. Nyamuk ini juga

berkembang biak di air yang jernih, bukan air kotor. Tiap orang bisa tergigit nyamuk ini lebih

dari sekali. Tiap kali terinfeksi, gejala makin muncul dan lebih parah.

Komplikasi

Jika dibiarkan, si penderita bisa mengalami berbagai komplikasi. Misalnya, komplikasi pada

organ hati, otak, dan rusaknya saluran darah. Bahkan seringkali berakhir dengan kelumpuhan

dan kematian.

Penanganan

Tidak ada penanganan yang spesifik untuk menyembuhkan demam berdarah. Untuk gejala

demam berdarah ringan, dokter biasanya menyarankan atau memberikan resep :

- Minum air yang banyak. Hal ini berguna untuk mencegah dehidrasi akibat muntah

dan demam tinggi.

- Obat asetaminofen untuk mengurangi rasa nyeri dan demam.

- Hindari obat antiperadangan nonsteroid seperti ibuprofen dan aspirin. Obat jenis

tersebut bisa memicu pendarahan lebih parah.

Untuk demam berdarah pada tahap yang lebih berat, dokter akan menyarankan agar si pasien

dirawat di rumah sakit untuk mendapat perawatan optimal seperti infus dan transfuse darah.


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Pencegahan

- Lakukan 3M Plus. Yaitu menutup, menguras, mengubur semua benda yang bisa

menampung genangan air yang berpotensi menjadi sarang nyamuk. Danmenggunakan anti nyamuk terpercaya.

- Hindari beraktifitas di luar ruangan pada saat sore hari antara pukul 16.00 hingga

pukul 18.00. Saat itu merupakan jam nyamuk pembawa virus dengue untuk

berkeliaran dan mencari mangsa.

Gunakan anti nyamuk dan pakaian yang tertutup. Kalaupun terpaksa beraktifitas di luar

ruangan gunakanlah baju lengan panjang dan celana panjang untuk mencegah gigitan

nyamuk.

Dengue fever

Dengue fever (UK:/ d e / , US:/ d i / ), also known as breakbone fever, is an infectioustropical diseasecaused by thedengue virus. Symptoms include fever,headache,muscleand

joint pains, and a characteristic skin rash that is similar to measles. In a small proportion of

cases the disease develops into the life-threatening dengue hemorrhagic fever, resulting in

bleeding,low levels of blood platelets and blood plasma leakage, or into dengue shocksyndrome, where dangerously low blood pressure occurs.

Dengue is transmitted by several species ofmosquito within the genusAedes, principallyA.

aegypti. The virus has four different types; infection with one type usually gives lifelong

immunity to that type, but only short-term immunity to the others. Subsequent infection with

a different type increases the risk of severe complications. As there is no vaccine, prevention

is sought by reducing the habitat and the number of mosquitoes and limiting exposure to

bites.

Treatment of acute dengue is supportive, using either oral or intravenous rehydrationfor mild

or moderate disease, andintravenous fluids andblood transfusion for more severe cases. The

incidence of dengue fever has increased dramatically since the 1960s, with around 50

100 million people infected yearly. Early descriptions of the condition date from 1779, and its

viral cause and the transmission were elucidated in the early 20th century. Dengue has

become a global problem since the Second World Warand is endemic in more than

110 countries. Apart from eliminating the mosquitoes, work is ongoing on a vaccine, as well

as medication targeted directly at the virus.
http://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/Tropical_diseasehttp://en.wikipedia.org/wiki/Tropical_diseasehttp://en.wikipedia.org/wiki/Dengue_virushttp://en.wikipedia.org/wiki/Dengue_virushttp://en.wikipedia.org/wiki/Dengue_virushttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Headachehttp://en.wikipedia.org/wiki/Headachehttp://en.wikipedia.org/wiki/Headachehttp://en.wikipedia.org/wiki/Myalgiahttp://en.wikipedia.org/wiki/Myalgiahttp://en.wikipedia.org/wiki/Arthralgiahttp://en.wikipedia.org/wiki/Skin_rashhttp://en.wikipedia.org/wiki/Morbilliformhttp://en.wikipedia.org/wiki/Bleedinghttp://en.wikipedia.org/wiki/Bleedinghttp://en.wikipedia.org/wiki/Thrombocytopeniahttp://en.wikipedia.org/wiki/Shock_(circulatory)http://en.wikipedia.org/wiki/Mosquitohttp://en.wikipedia.org/wiki/Genushttp://en.wikipedia.org/wiki/Aedeshttp://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Immunity_(medical)http://en.wikipedia.org/wiki/Vaccinehttp://en.wikipedia.org/wiki/Rehydrationhttp://en.wikipedia.org/wiki/Rehydrationhttp://en.wikipedia.org/wiki/Intravenous_therapyhttp://en.wikipedia.org/wiki/Intravenous_therapyhttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Incidence_(epidemiology)http://en.wikipedia.org/wiki/World_War_IIhttp://en.wikipedia.org/wiki/Endemic_(epidemiology)http://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/Tropical_diseasehttp://en.wikipedia.org/wiki/Dengue_virushttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Headachehttp://en.wikipedia.org/wiki/Myalgiahttp://en.wikipedia.org/wiki/Arthralgiahttp://en.wikipedia.org/wiki/Skin_rashhttp://en.wikipedia.org/wiki/Morbilliformhttp://en.wikipedia.org/wiki/Bleedinghttp://en.wikipedia.org/wiki/Thrombocytopeniahttp://en.wikipedia.org/wiki/Shock_(circulatory)http://en.wikipedia.org/wiki/Mosquitohttp://en.wikipedia.org/wiki/Genushttp://en.wikipedia.org/wiki/Aedeshttp://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Immunity_(medical)http://en.wikipedia.org/wiki/Vaccinehttp://en.wikipedia.org/wiki/Rehydrationhttp://en.wikipedia.org/wiki/Intravenous_therapyhttp://en.wikipedia.org/wiki/Blood_transfusionhttp://en.wikipedia.org/wiki/Incidence_(epidemiology)http://en.wikipedia.org/wiki/World_War_IIhttp://en.wikipedia.org/wiki/Endemic_(epidemiology)


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Contents[hide]

1 Signs and symptomso

1.1 Clinical course

o 1.2 Associated problems

2 Cause

o 2.1 Virology

o 2.2 Transmission

o 2.3 Predisposition

3 Mechanism

o 3.1 Viral reproduction

o 3.2 Severe disease

4 Diagnosis

o 4.1 Classification

o 4.2 Laboratory tests

5 Prevention

6 Management

7 Epidemiology

8 History

o 8.1 Etymology

9 Research

10 Notes

11 References

12 External links
http://en.wikipedia.org/wiki/Dengue_feverhttp://en.wikipedia.org/wiki/Dengue_fever#Signs_and_symptomshttp://en.wikipedia.org/wiki/Dengue_fever#Clinical_coursehttp://en.wikipedia.org/wiki/Dengue_fever#Associated_problemshttp://en.wikipedia.org/wiki/Dengue_fever#Causehttp://en.wikipedia.org/wiki/Dengue_fever#Virologyhttp://en.wikipedia.org/wiki/Dengue_fever#Transmissionhttp://en.wikipedia.org/wiki/Dengue_fever#Predispositionhttp://en.wikipedia.org/wiki/Dengue_fever#Mechanismhttp://en.wikipedia.org/wiki/Dengue_fever#Viral_reproductionhttp://en.wikipedia.org/wiki/Dengue_fever#Severe_diseasehttp://en.wikipedia.org/wiki/Dengue_fever#Diagnosishttp://en.wikipedia.org/wiki/Dengue_fever#Classificationhttp://en.wikipedia.org/wiki/Dengue_fever#Laboratory_testshttp://en.wikipedia.org/wiki/Dengue_fever#Preventionhttp://en.wikipedia.org/wiki/Dengue_fever#Managementhttp://en.wikipedia.org/wiki/Dengue_fever#Epidemiologyhttp://en.wikipedia.org/wiki/Dengue_fever#Historyhttp://en.wikipedia.org/wiki/Dengue_fever#Etymologyhttp://en.wikipedia.org/wiki/Dengue_fever#Researchhttp://en.wikipedia.org/wiki/Dengue_fever#Noteshttp://en.wikipedia.org/wiki/Dengue_fever#Referenceshttp://en.wikipedia.org/wiki/Dengue_fever#External_linkshttp://en.wikipedia.org/wiki/Dengue_feverhttp://en.wikipedia.org/wiki/Dengue_fever#Signs_and_symptomshttp://en.wikipedia.org/wiki/Dengue_fever#Clinical_coursehttp://en.wikipedia.org/wiki/Dengue_fever#Associated_problemshttp://en.wikipedia.org/wiki/Dengue_fever#Causehttp://en.wikipedia.org/wiki/Dengue_fever#Virologyhttp://en.wikipedia.org/wiki/Dengue_fever#Transmissionhttp://en.wikipedia.org/wiki/Dengue_fever#Predispositionhttp://en.wikipedia.org/wiki/Dengue_fever#Mechanismhttp://en.wikipedia.org/wiki/Dengue_fever#Viral_reproductionhttp://en.wikipedia.org/wiki/Dengue_fever#Severe_diseasehttp://en.wikipedia.org/wiki/Dengue_fever#Diagnosishttp://en.wikipedia.org/wiki/Dengue_fever#Classificationhttp://en.wikipedia.org/wiki/Dengue_fever#Laboratory_testshttp://en.wikipedia.org/wiki/Dengue_fever#Preventionhttp://en.wikipedia.org/wiki/Dengue_fever#Managementhttp://en.wikipedia.org/wiki/Dengue_fever#Epidemiologyhttp://en.wikipedia.org/wiki/Dengue_fever#Historyhttp://en.wikipedia.org/wiki/Dengue_fever#Etymologyhttp://en.wikipedia.org/wiki/Dengue_fever#Researchhttp://en.wikipedia.org/wiki/Dengue_fever#Noteshttp://en.wikipedia.org/wiki/Dengue_fever#Referenceshttp://en.wikipedia.org/wiki/Dengue_fever#External_links


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[edit] Signs and symptoms

Schematic depiction of the symptoms of dengue fever

Typically, people infected with dengue virus are asymptomatic (80%) or only have mild

symptoms such as an uncomplicated fever.[1][2][3]Others have more severe illness (5%), and in

a small proportion it is life-threatening.[1][3] Theincubation period (time between exposure

and onset of symptoms) ranges from 314 days, but most often it is 47 days.[4] Therefore,

travelers returning from endemic areas are unlikely to have dengue if fever or other

symptoms start more than 14 days after arriving home. [5] Children often experience symptoms

similar to those of the common coldand gastroenteritis (vomiting and diarrhea),[6]

but aremore susceptible to the severe complications.[5]

[edit] Clinical course

The characteristic symptoms of dengue are sudden-onset fever, headache (typically located

behind the eyes), muscle and joint pains, and a rash. The alternative name for dengue, "break-

bone fever", comes from the associated muscle and joint pains.[1][7] The course of infection is

divided into three phases: febrile, critical, and recovery.[8]

The febrile phase involves high fever, often over 40 C (104 F), and is associated with

generalized pain and a headache; this usually lasts two to seven days.[7][8] At this stage, a rashoccurs in approximately 5080% of those with symptoms.[7][9]It occurs in the first or second

day of symptoms as flushed skin, or later in the course of illness (days 47), as a measles-like

rash.[9][10] Somepetechiae (small red spots that do not disappear when the skin is pressed,

which are caused by broken capillaries) can appear at this point,[8] as may some mild bleeding

from the mucous membranes of the mouth and nose.[5][7] The fever itself is classically

biphasic in nature, breaking and then returning for one or two days, although there is wide

variation in how often this pattern actually happens.[10][11]

In some people, the disease proceeds to a critical phase, which follows the resolution of the

high fever and typically lasts one to two days.[8] During this phase there may be significant

fluid accumulation in the chest and abdominal cavitydue to increased capillary permeability

and leakage. This leads to depletion of fluid from the circulation and decreased blood supply
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to vital organs.[8] During this phase, organ dysfunction and severebleeding, typically from the

gastrointestinal tract, may occur.[5][8]Shock(dengue shock syndrome) and hemorrhage

(dengue hemorrhagic fever) occur in less than 5% of all cases of dengue,[5] however those

who have previously been infected with otherserotypes of dengue virus ("secondary

infection") are at an increased risk.[5][12]

The recovery phase occurs next, with resorption of the leaked fluid into the bloodstream. [8]

This usually lasts two to three days.[5] The improvement is often striking, but there may be

severe itching and a slow heart rate.[5][8] During this stage, a fluid overload state may occur; if

it affects the brain, it may cause a reduced level of consciousness orseizures.[5]

[edit] Associated problems

Dengue can occasionally affect several otherbody systems,[8] either in isolation or along with

the classic dengue symptoms.[6] A decreased level of consciousness occurs in 0.56% of

severe cases, which is attributable either toinfection of the brain by the virusor indirectly as

a result of impairment of vital organs, for example, the liver.[6][11]

Other neurological disorders have been reported in the context of dengue, such as transverse

myelitis and Guillain-Barr syndrome.[6]Infection of the heart and acute liver failureare

among the rarer complications.[5][8]

[edit] Cause

[edit] Virology

Main article: Dengue virus

ATEMmicrograph showing dengue virus virions (the cluster of dark dots near

the center)

Dengue fever virus (DENV) is an RNA virus of the familyFlaviviridae; genusFlavivirus.

Other members of the same family include yellow fever virus,West Nile virus, St. Louis

encephalitis virus,Japanese encephalitis virus,tick-borne encephalitis virus, Kyasanur forest

disease virus, and Omsk hemorrhagic fever virus.[11] Most are transmitted by arthropods

(mosquitoes orticks), and are therefore also referred to as arboviruses (arthropod-borneviruses).[11]
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rg/wiki/Fluid_overloadhttp://en.wikipedia.org/wiki/Cerebral_edemahttp://en.wikipedia.org/wiki/Altered_level_of_consciousnesshttp://en.wikipedia.org/wiki/Epileptic_seizurehttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-Peads10-4http://en.wikipedia.org/w/index.php?title=Dengue_fever&action=edit&section=3http://en.wikipedia.org/wiki/Biological_systemhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp25-7http://en.wikipedia.org/wiki/Dengue_fever#cite_note-India10-5http://en.wikipedia.org/wiki/Encephalitishttp://en.wikipedia.org/wiki/Hepatic_encephalopathyhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-India10-5http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Gould-10http://en.wikipedia.org/wiki/Transverse_myelitishttp://en.wikipedia.org/wiki/Transverse_myelitishttp://en.wikipedia.org/wiki/Guillain-Barr%C3%A9_syndromehttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-India10-5http://en.wikipedia.org/wiki/Myocarditishttp://en.wikipedia.org/wiki/Acute_liver_failurehttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-Peads10-4http://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp25-7http://en.wikipedia.org/w/index.php?title=Dengue_fever&action=edit&section=4http://en.wikipedia.org/w/index.php?title=Dengue_fever&action=edit&section=5http://en.wikipedia.org/wiki/Dengue_virushttp://en.wikipedia.org/wiki/Transmission_electron_microscopyhttp://en.wikipedia.org/wiki/Micrographhttp://en.wikipedia.org/wiki/Virionhttp://en.wikipedia.org/wiki/RNA_virushttp://en.wikipedia.org/wiki/Flaviviridaehttp://en.wikipedia.org/wiki/Flavivirushttp://en.wikipedia.org/wiki/Yellow_feverhttp://en.wikipedia.org/wiki/West_Nile_virushttp://en.wikipedia.org/wiki/St._Louis_encephalitishttp://en.wikipedia.org/wiki/St._Louis_encephalitishttp://en.wikipedia.org/wiki/Japanese_encephalitishttp://en.wikipedia.org/wiki/Tick-borne_encephalitis_virushttp://en.wikipedia.org/wiki/Kyasanur_forest_diseasehttp://en.wikipedia.org/wiki/Kyasanur_forest_diseasehttp://en.wikipedia.org/wiki/Omsk_hemorrhagic_feverhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-Gould-10http://en.wikipedia.org/wiki/Arthropodhttp://en.wikipedia.org/wiki/Tickhttp://en.wikipedia.org/wiki/Arbovirushttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-Gould-10


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The dengue virus genome(genetic material) contains about 11,000 nucleotide bases, which

code for the three different types of protein molecules (C, prM and E) that form the virus

particle and seven other types of protein molecules (NS1, NS2a, NS2b, NS3, NS4a, NS4b,

NS5) that are only found in infected host cells and are required for replication of the virus.[12]

[13] There are four strains of the virus, which are called serotypes, and these are referred to as

DENV-1, DENV-2, DENV-3 and DENV-4.[2] All four serotypes can cause the full spectrumof disease.[12]Infection with one serotype is believed to produce lifelong immunity to that

serotype but only short term protection against the others. [2][7]

The severe complications on secondary infection occurs particularly if someone previously

exposed to serotype DENV-1 then contracts serotype DENV-2 or serotype DENV-3, or if

someone previously exposed to type DENV-3 then acquires DENV-2.[13]

[edit] Transmission

The mosquitoAedes aegypti feeding off a human host

Dengue virus is primarily transmitted byAedes mosquitoes, particularlyA. aegypti.[2]These

mosquitoes usually live between the latitudes of 35 North and 35 South below an elevation

of 1,000 metres (3,300 ft).[2] They bite primarily during the day.[14] OtherAedes species that

transmit the disease includeA. albopictus,A. polynesiensis andA. scutellaris.[2] Humans are

the primary host of the virus,[2][11] but it also circulates in nonhumanprimates.[15]An infection

can be acquired via a single bite.[16] A female mosquito that takes a blood meal from a person

infected with dengue fever becomes itself infected with the virus in the cells lining its gut.

About 810 days later, the virus spreads to other tissues including the mosquito's salivary

glands and is subsequently released into its saliva. The virus seems to have no detrimental

effect on the mosquito, which remains infected for life. Aedes aegypti prefers to lay its eggsin artificial water containers, to live in close proximity to humans, and to feed off people

rather than other vertebrates.[17]

Dengue can also be transmitted via infectedblood products and through organ donation.[18][19]

In countries such as Singapore, where dengue is endemic, the risk is estimated to be between

1.6 and 6 per 10,000 transfusions.[20]Vertical transmission (from mother to child) during

pregnancy or at birth has been reported.[21] Other person-to-person modes of transmission

have also been reported, but are very unusual.[7]
http://en.wikipedia.org/wiki/Genomehttp://en.wikipedia.org/wiki/Genomehttp://en.wikipedia.org/wiki/Nucleotide_basehttp://en.wikipedia.org/wiki/Genetic_codehttp://en.wikipedia.org/wiki/Virionhttp://en.wikipedia.org/wiki/Virionhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-Life10-11http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Guzman10-12http://en.wikipedia.org/wiki/Serovarhttp://en.wikipedia.org/wiki/Serovarhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Life10-11http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Life10-11http://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Chen-6http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Guzman10-12http://en.wikipedia.org/w/index.php?title=Dengue_fever&action=edit&section=6http://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Aedeshttp://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Latitudehttp://en.wikipedia.org/wiki/Elevationhttp://en.wikipedia.org/wiki/Elevationhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp59-13http://en.wikipedia.org/wiki/Asian_tiger_mosquitohttp://en.wikipedia.org/wiki/Asian_tiger_mosquitohttp://en.wikipedia.org/wiki/Aedes_polynesiensishttp://en.wikipedia.org/wiki/Aedes_scutellarishttp://en.wikipedia.org/wiki/Aedes_scutellarishttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Host_(biology)http://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Gould-10http://en.wikipedia.org/wiki/Primatehttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-14http://en.wikipedia.org/wiki/Dengue_fever#cite_note-14http://en.wikipedia.org/wiki/Dengue_fever#cite_note-14http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Yellow10-15http://en.wikipedia.org/wiki/Salivary_glandhttp://en.wikipedia.org/wiki/Salivary_glandhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-16http://en.wikipedia.org/wiki/Blood_productshttp://en.wikipedia.org/wiki/Organ_donationhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-17http://en.wikipedia.org/wiki/Dengue_fever#cite_note-17http://en.wikipedia.org/wiki/Dengue_fever#cite_note-18http://en.wikipedia.org/wiki/Singaporehttp://en.wikipedia.org/wiki/Blood_transfusionshttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-19http://en.wikipedia.org/wiki/Dengue_fever#cite_note-19http://en.wikipedia.org/wiki/Vertical_transmissionhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-pmid20130380-20http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Chen-6http://en.wikipedia.org/wiki/File:Aedes_aegypti_biting_human.jpghttp://en.wikipedia.org/wiki/File:Aedes_aegypti_biting_human.jpghttp://en.wikipedia.org/wiki/Genomehttp://en.wikipedia.org/wiki/Nucleotide_basehttp://en.wikipedia.org/wiki/Genetic_codehttp://en.wikipedia.org/wiki/Virionhttp://en.wikipedia.org/wiki/Virionhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-Life10-11http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Guzman10-12http://en.wikipedia.org/wiki/Serovarhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Life10-11http://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Chen-6http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Guzman10-12http://en.wikipedia.org/w/index.php?title=Dengue_fever&action=edit&section=6http://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Aedeshttp://en.wikipedia.org/wiki/Aedes_aegyptihttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Latitudehttp://en.wikipedia.org/wiki/Elevationhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp59-13http://en.wikipedia.org/wiki/Asian_tiger_mosquitohttp://en.wikipedia.org/wiki/Aedes_polynesiensishttp://en.wikipedia.org/wiki/Aedes_scutellarishttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Host_(biology)http://en.wikipedia.org/wiki/Dengue_fever#cite_note-WHOp14-1http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Gould-10http://en.wikipedia.org/wiki/Primatehttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-14http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Yellow10-15http://en.wikipedia.org/wiki/Salivary_glandhttp://en.wikipedia.org/wiki/Salivary_glandhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-16http://en.wikipedia.org/wiki/Blood_productshttp://en.wikipedia.org/wiki/Organ_donationhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-17http://en.wikipedia.org/wiki/Dengue_fever#cite_note-18http://en.wikipedia.org/wiki/Singaporehttp://en.wikipedia.org/wiki/Blood_transfusionshttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-19http://en.wikipedia.org/wiki/Vertical_transmissionhttp://en.wikipedia.org/wiki/Dengue_fever#cite_note-pmid20130380-20http://en.wikipedia.org/wiki/Dengue_fever#cite_note-Chen-6


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[edit] Predisposition

Severe disease is more common in babies and young children, and in contrast to many other

infections it is more common in children that are relatively well nourished. [5]Women are

more at risk than men.[13]Dengue can be life-threatening in people with chronic diseases such

as diabetesand asthma.[13]

Polymorphisms (normal variations) in particulargeneshave been linked with an increased

risk of severe dengue complications. Examples include the genes coding for the proteins

known as TNF,mannan-binding lectin,[1]CTLA4,TGF,[12]DC-SIGN, and particularforms

ofhuman leukocyte antigen.[13]A common genetic abnormality in Africans, known as

glucose-6-phosphate dehydrogenase deficiency, appears to increase the risk.[22]

Polymorphisms in the genes for the vitamin D receptorand FcRseem to offer protection

against severe disease in secondary dengue infection. [13]

[edit] Mechanism

When a mosquito carrying dengue virus bites a person, the virus enters the skin together with

the mosquito's saliva. It binds to and enters white blood cells, and reproduces inside the cells

while they move throughout the body. The white blood cells respond by producing a number

of signaling proteins, such as interferon, which are responsible for many of the symptoms,

such as the fever, the flu-like symptoms and the severe pains. In severe infection, the virus

production inside the body is greatly increased, and many more organs (such as the liverand

thebone marrow) can be affected, and fluid from the bloodstream leaks through the wall of

small blood vessels into body cavities. As a result, less blood circulates in the blood vessels,

and the blood pressure becomes so low that it cannot supply sufficient blood to vital organs.

Furthermore, dysfunction of the bone marrow leads to reduced numbers of platelets, whichare necessary for effective blood clotting; this increases the risk of bleeding, the other major

complication of dengue fever.[22]

[edit] Viral reproduction

Once inside the skin, dengue virus binds toLangerhans cells (a population ofdendritic cells

in the skin that identifies pathogens).[22] The virusenters the cells through binding between

viral proteins and membrane proteinson the Langerhans cell, specifically the C-type lectins

called DC-SIGN, mannose receptorandCLEC5A.[12] DC-SIGN, a non-specific receptor for

foreign material on dendritic cells, seems to be the main point of entry .[13]The dendritic cell

moves to the nearest lymph node. Meanwhile, the virus genome is replicated in membrane-bound vesicles on the cell's endoplasmic reticulum, where the cell's protein synthesis

apparatus produces new viral proteins, and the viral RNA is copied. Immature virus particles

are transported to the Golgi apparatus, the part of the cell where some of the proteins receive

necessary sugar chains (glycoproteins). The now mature new viruses bud on the surface of

the infected cell and are released by exocytosis. They are then able to enter other white blood

cells, such as monocytes and macrophages.[12]

The initial reaction of infected cells is to produce interferon, acytokine that raises a number

of defenses against viral infection through the innate immune system by augmenting the

production of a large group of proteins mediated by theJAK-STAT pathway. Some serotypes

of dengue virus appear to have mechanisms to slow down this process. Interferon also

activates the adaptive immune system, which leads to the generation ofantibodies against the
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virus as well as T cells that directly attack any cell infected with the virus.[12] Various

antibodies are generated; some bind closely to the viral proteins and target them for

phagocytosis (ingestion by specialized cells and destruction), but some bind the virus less

well and appear instead to deliver the virus into a part of the phagocytes where it is not

destroyed but is able to replicate further.[12]

[edit] Severe disease

Further information: Antibody-dependent enhancement

It is not entirely clear why secondary infection with a different strain of dengue virus places

people at risk of dengue hemorrhagic fever and dengue shock syndrome. The most widely

accepted hypothesis is that ofantibody-dependent enhancement (ADE). The exact

mechanism behind ADE is unclear. It may be caused by poor binding of non-neutralizing

antibodies and delivery into the wrong compartment of white blood cells that have ingested

the virus for destruction.[12][13]There is a suspicion that ADE is not the only mechanism

underlying severe dengue-related complications,[1] and various lines of research have implied

a role forT cellsand soluble factors such as cytokines and the complement system.[22]

Severe disease is marked by two problems: dysfunction ofendothelium (the cells that line

blood vessels) and disorderedblood clotting.[6] Endothelial dysfunction leads to the leakage

of fluid from the blood vessels into the chest and abdominal cavities, while coagulation

disorder is responsible for the bleeding complications. Higher viral load in the blood and

involvement of other organs (such as thebone marrow and the liver) are associated with more

severe disease. Cells in the affected organs die, leading to the release of cytokines and

activation of both coagulation and fibrinolysis (the opposing systems of blood clotting and

clot degradation). These alterations together lead to both endothelial dysfunction and

coagulation disorder.

[22]

[edit] Diagnosis

Warning signs[23]

Abdominal pain

Ongoing vomiting

Liver enlargement

Mucosal bleeding

High hematocrit with low

platelets

Lethargy

The diagnosis of dengue is typically made clinically, on the basis of reported symptoms and

physical examination; this applies especially in endemic areas.[1] However, early disease can

be difficult to differentiate from otherviral infections.[5] A probable diagnosis is based on the

findings of fever plus two of the following: nauseaand vomiting, rash, generalized pains,low

white blood cell count, positive tourniquet test, or any warning sign (see table) in someonewho lives in an endemic area.[23]Warning signs typically occur before the onset of severe
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dengue.[8] The tourniquet test, which is particularly useful in settings where no laboratory

investigations are readily available, involves the application of ablood pressure cufffor five

minutes, followed by the counting of anypetechial hemorrhages; a higher number makes a

diagnosis of dengue more likely.[8] It can be difficult to distinguish dengue fever and

chikungunya, a similar viral infection that shares many symptoms and occurs in similar parts

of the world to dengue.[7] Often, investigations are performed to exclude other conditions thatcause similar symptoms, such as malaria,leptospirosis, typhoid fever, andmeningococcal

disease.[5]

The earliest change detectable on laboratory investigations is a low white blood cell count,

which may then be followed by low platelets and metabolic acidosis.[5] In severe disease,

plasma leakage results in hemoconcentration(as indicated by a rising hematocrit) and

hypoalbuminemia.[5]Pleural effusions orascites can be detected by physical examination

when large,[5] but the demonstration of fluid on ultrasound may assist in the early

identification of dengue shock syndrome.[1][5]The use of ultrasound is limited by lack of

availability in many settings.[1]

[edit] Classification

The World Health Organization's 2009 classification divides dengue fever into two groups:

uncomplicated and severe.[1][23]This replaces the 1997 WHO classification, which needed to

be simplified as it had been found to be too restrictive, though the older classification is still

widely used.[23]The 1997 classification divided dengue into undifferentiated fever, dengue

fever, and dengue hemorrhagic fever.[5][24] Dengue hemorrhagic fever was subdivided further

into grades IIV. Grade I is the presence only of easy bruising or a positive tourniquet test in

someone with fever, grade II is the presence of spontaneous bleeding into the skin and

elsewhere, grade III is the clinical evidence ofshock, and grade IV is shock so severe thatblood pressureandpulse cannot be detected.[24] Grades III and IV are referred to as "dengue

shock syndrome".[23][24]

[edit] Laboratory tests

Dengue fever may be diagnosed by microbiological laboratory testing.[23] This can be done by

virus isolation in cell cultures, nucleic acid detection byPCR, viral antigen detection or

specific antibodies (serology).[13][25]Virus isolation and nucleic acid detection are more

accurate than antigen detection, but these tests are not widely available due to their greater

cost.[25] All tests may be negative in the early stages of the disease.[5][13]

These laboratory tests are only of diagnostic value during the acute phase of the illness with

the exception of serology. Tests for dengue virus-specific antibodies, typesIgGandIgM, can

be useful in confirming a diagnosis in the later stages of the infection. Both IgG and IgM are

produced after 57 days. The highest levels (titres) of IgM are detected following a primary

infection, but IgM is also produced in secondary and tertiary infections. The IgM becomes

undetectable 3090 days after a primary infection, but earlier following re-infections. IgG, by

contrast, remains detectable for over 60 years and, in the absence of symptoms, is a useful

indicator of past infection. After a primary infection the IgG reaches peak levels in the blood

after 1421 days. In subsequent re-infections, levels peak earlier and the titres are usually

higher. Both IgG and IgM provide protective immunity to the infecting serotype of the virus.

In the laboratory test the IgG and the IgM antibodies can cross-react with other flaviviruses,such as yellow fever virus, which can make the interpretation of the serology difficult. [7][13][26]
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The detection of IgG alone is not considered diagnostic unless blood samples are collected 14

days apart and a greater than fourfold increase in levels of specific IgG is detected. In a

person with symptoms, the detection of IgM is considered diagnostic.[26]

[edit] Prevention

A 1920s photograph of efforts to disperse standing water and thus decrease

mosquito populations

There are no approved vaccines for the dengue virus.[1] Prevention thus depends on control of

and protection from the bites of the mosquito that transmits it.[14][27] The World Health

Organization recommends an Integrated Vector Control program consisting of five elements:

(1) Advocacy, social mobilization and legislation to ensure that public health bodies and

communities are 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 appropriatelyand (5) capacity-building to ensure an adequate response to the local situation. [14]

The primary method of controllingA. aegypti is by eliminating its habitats.[14] This is done by

emptying containers of water or by adding insecticides orbiological control agents to these

areas,[14]although spraying with organophosphate orpyrethroid insecticides is not thought to

be effective.[3] Reducing open collections of water through environmental modification is the

preferred method of control, given the concerns of negative health effect from insecticides

and greater logistical difficulties with control agents.[14]People can prevent mosquito bites by

wearing clothing that fully covers the skin, usingmosquito netting while resting, and/or the

application ofinsect repellent(DEET being the most effective).[16]

[edit] Management

There are no specific treatments for dengue fever.[1]Treatment depends on the symptoms,

varying from oral rehydration therapy at home with close follow-up, to hospital admission

with administration ofintravenous fluids and/orblood transfusion.[28] A decision for hospital

admission is typically based on the presence of the "warning signs" listed in the table above,

especially in those with preexisting health conditions.[5]

Intravenous hydration is usually only needed for one or two days.[28] The rate of fluid

administration is titrated to a urinary outputof 0.51 mL/kg/hr, stablevital signs andnormalization ofhematocrit.[5] Invasive medical procedures such as nasogastric intubation,
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intramuscular injections and arterial punctures are avoided, in view of the bleeding risk. [5]

Paracetamol(acetaminophen) is used for fever and discomfort whileNSAIDs such as

ibuprofen and aspirin are avoided as they might aggravate the risk of bleeding.[28]Blood

transfusion is initiated early in patients presenting with unstable vital signs in the face of a

decreasing hematocrit, rather than waiting for the hemoglobin concentration to decrease to

some predetermined "transfusion trigger" level.[29]Packed red blood cells orwhole blood arerecommended, whileplatelets and fresh frozen plasma are usually not.[29]

During the recovery phase intravenous fluids are discontinued to prevent a state of fluid

overload.[5] If fluid overload occurs and vital signs are stable, stopping further fluid may be

all that is needed.[29] If a person is outside of the critical phase, a loop diureticsuch as

furosemide may be used to eliminate excess fluid from the circulation. [29]

[edit] EpidemiologySee also: Dengue fever outbreaks

Dengue distribution in 2006.

Red: Epidemic dengue andAe. aegypti

Aqua: JustAe. aegypti

Most people with dengue recover without any ongoing problems.[23]The mortality is 15%

without treatment,[5] and less than 1% with adequate treatment; [23]however severe disease

carries a mortality of 26%.[5] Dengue is endemic in more than 110 countries.[5] It infects 50 to

100 million people worldwide a year, leading to half a million hospitalizations,[1] and

approximately 12,50025,000 deaths.[6][30]

The most common viral disease transmitted byarthropods,[12] dengue has adisease burden

estimated to be 1600 disability-adjusted life years per million population, which is similar to

other childhood and tropical diseases such as tuberculosis.[13]

As a tropical disease dengue isdeemed only second in importance tomalaria,[5] though the World Health Organization

counts dengue as one of sixteen neglected tropical diseases.[31]

The incidence of dengue increased 30 fold between 1960 and 2010.[32] This increase is

believed to be due to a combination of urbanization, population growth, increased

international travel, and global warming.[1] The geographical distribution is around the

equator with 70% of the total 2.5 billion people living in endemic areas from Asia and the

Pacific.[32] In the United States, the rate of dengue infection among those who return from an

endemic area with a fever is 2.98.0%,[16] and it is the second most common infection after

malaria to be diagnosed in this group.[7]
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Until 2003, dengue was classified as a potentialbioterrorism agent, but subsequent reports

removed this classification as it was deemed too difficult to transfer and only caused

hemorrhagic feverin a relatively small proportion of people.[33]

Like most arboviruses, dengue virus is maintained in nature in cycles that involve preferred

blood-sucking vectors and vertebrate hosts. The viruses are maintained in the forests ofSoutheast Asia and Africa by transmission from femaleAedes mosquitoesof species other

thanA. aegyptito her offspring and to lower primates. In rural settings the virus is

transmitted to humans byA. aegypti and other species ofAedes such asA. albopictus. In

towns and cities, the virus is primarily transmitted to humans by A. aegypti, which is highly

domesticated. In all settings the infected lower primates or humans greatly increase the

number of circulating dengue viruses. This is called amplification. [34]The urban cycle is the

most important to infections of humans and dengue infections are primarily confined to

towns and cities.[35] In recent decades, the expansion of villages, towns and cities in endemic

areas, and the increased mobility of humans has increased the number of epidemics and

circulating viruses. Dengue fever, which was once confined to Southeast Asia, has now

spread to Southern China, countries in the Pacific Ocean and America, [35] and might pose athreat to Europe.[3]

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