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In one of the paper titled Dengue and Dengue Hemorrhagic Fever: It ‘s History and Resurgence As a Global Public Health Problem by Gubler ( 1997 ) , both DENV and its primary vector, the Aedes aegypti originated in either Africa or Asia continent. During the 17th, 18th and 19th centuries, Aedes aegypti migrate from Africa in H2O container on slave ships during African slave trade ( Lee, 2004 ) . However, due to hanker journey clip, epidemics of disease were less reported. Numbers of tropical states with active transportation ports experienced eruption of dandy fever by 1800.

Probable instances of dandy fever epidemics that occurred at the same time in Asia, Africa and North America was foremost reported on 1779 to 1800. In 1823, the word ‘dinga ‘ was used for the first clip to portray dengue disease in Zanzibar. Thomas Lane Bancroft proposed that Aedes aegypti mosquito was responsible in dengue spread in 1906. In 1907, two scientists, Percy Ashburn and Charles Franklin Craig confirmed that ‘filterable virus ‘ is the causative agent of dandy fever, the 2nd human viral infection after xanthous febrility.

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In 1939-1945, during World War II, due to immense demographic transmutation and ecological break in Asia part, including tonss of suited genteelness home grounds for mosquitoes, break supply of H2O, and rush in people mobility from rural carbamide to urban had led to outbreak of disease. Endemic of disease occurred in Southeast Asia and Pacific during the same period of WWII. On 1944-1945, isolation of many dandy fever strains by inoculating virus sera into voluntaries was done by Albert and his co-workers.

In Malaysia, first instance of DF was reported in 1902 by Skae, followed by DHF in 1962. Since so, many dandy fever epidemics are reported. Paper published by Skae titled Dengue Fever in Penang stated that first dandy fever eruption that is in 1901 happened in Penang. Dengue has become endemic in Malaya by 1960 ‘s and in 1962, the first laboratory-confirmed DHF instance was reported in Penang. DENV was foremost isolated by Sabin and Schlesinger in 1944.

Type of dandy fever

Dengue can be classified based on instance definition. In instance definition categories, dandy fever can be categorized into three, which are authoritative dandy fever ( uniform febrility ) , DHF and DSS. DHF can be farther classified into class I to rate IV ( WHO, 2009 ) . A few standards need to be determined by wellness attention professional earlier classified patient into that peculiar class.

In authoritative dandy fever, clinician must be able to place symptom such as ague febrility for two to seven yearss accompanied by two or more marks of retro-ocular hurting, myodynia, arthralgias, roseola, haemorrhagic manifestations or leukopenia. DHF is defined by more terrible clinical manifestations, which is marks of bleeding and any grounds of vascular escape such as positive compression bandage, trial, petechiae, thrombopenia and so on that can take to DSS and decease. In DSS, patients may show standards such as DHF in add-on of circulatory failure than can be detected by rapid and/or weak pulsation, cold tegument and hypotension ( Avila-Aguero et Al, 2004 ) .

Harmonizing to WHO, DHF can be classified based on badness of instances. In class I, symptom such as febrility accompanied by broad symptoms may show plus grounds of haemorrhagic manifestation such as positive compression bandage trial. In class II, all mark stated in class I in add-on with self-generated shed blooding. Grade III and IV, DSS is diagnosed with patient in class III present marks of

Etiology

Dengue is caused by DENV that is transmitted through spit of septic female Aedes mosquito that act as vector to human as a host. Two common species are Aedes aegypti and Aedes albopictus. DENV has four serotypes that go arounding concomitantly, which is DENV-1 to DENV-4.

Viral serotypes

There are four serotypes that are related with DENV worldwide including in Malaysia, which are DEN-1 to DEN-4 ( Guzman, 2002 ) . Harmonizing to Zamberi sekawi et Al ( 2005 ) , even though in the same season all the serotypes may concomitantly go around, one of those serotypes appears to be ruling over other serotypes at one peculiar clip. In Malaysia, if patient nowadays symptoms such as high febrility and roseola, wellness attention supplier will handle symptoms as dandy fever until all the laboratory trial or clinical advancement come back negative. However, presently Numberss of patients show unusual clinical manifestation such as symptoms related to cardinal nervous symptoms. McMinn ( 1997 ) conclude that this may be due to the mutant of specific E protein cistron along with other cistron and non-coding part of ribonucleic acid ( RNA ) .

From 1985 to 2004, DEN-4 had non showed laterality. From one of the survey conducted that affecting DEN-2, the DEN-2 strain had evolved from preexistent DEN-2 cistron pool for three decennaries make it hibernating and this strain became prevailing in the undermentioned rhythm if it encounter favourable status for it to mutate. Familial recombination between different specific dandy fever serotypes is ineluctable since it may hold dissimilar virulency features and clinical manifestation. Dengue epidemic in Malaysia such as in old ages of 1993 to 1994 may consequences of globalisation and easiness of travel between states that introduce new strains from foreign states ( Kobayashi et al,1999 ) .

Transmission

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Figure 1: Transmission of dandy fever virus. Adapted from Dengue Fever Management Plan, 2000

Figure 2: Viral rhythm in mosquito organic structure. Adapted from hypertext transfer protocol: //activity.ntsec.gov.tw

Dengue virus is transmitted by female Aedes mosquitoes. It circulates among host-Aedes mosquito-host rhythm. Figure 1 show the rhythm of virus transmittal. DENV-infected female mosquito bites human and transmit dandy fever virus to homo ‘s blood. Figure 2 shows that the virus invasion in homo ‘s organic structure system starts when dandy fever viruses enter the human organic structure via the salivary secretory organ of the mosquito during blood-feeding period of the mosquito. In mosquito itself, the DENV in the septic human blood that enter the mosquito will retroflex in mosquito ‘s organ ( s ) such as midgut, nervous tissue and so on. Then, the viruses will come in organic structure pit of the mosquito that will eventually migrate to salivary secretory organ of the vector and the rhythm repeated once more.

In figure 3, in homo, after DENV has been transmitted to blood circulation, human as a natural host will has period of viraemia that last three to twelve yearss but in mean, four to five yearss. However, during extrinsic incubation period, DENV can last eight to ten yearss. In this period, DENV will retroflex in host and vector ‘s organ ( s ) and in most instances, no important mark has been reported in host. DENV infects white blood cells and lymphatic tissue and when it reach adulthood, it will be released to the blood circulation and infect other variety meats. Cycle of DENV transmittal will goes on when another clean female Aedes mosquito bites infected host and get DENV.

Figure 3: Incubation period of DENV in host. Adapted from hypertext transfer protocol: //en.citizendium.org

Prevalence

Number of dandy fever instances keeps increasing from old ages to old ages. From old ages 1999 to 2003, there are 6,577 instances of DF were reported in one of the authorities infirmary, Hospital Tengku Ampuan Rahimah ( HTAR ) , Klang with most of the instances occurs among male patients aged above 12 old ages old with 5,742 instances. Among all races, Malay population is most earnestly affected ( Jamaiah et al, 2005 ) .

Harmonizing to statistics of DF and DHF by Ministry of Health, there are additions in incidence rate per 100,000 populations. Table 1 shows that from twelvemonth of 1999 until 2006, incidence rate of DF is increasing but in instance of DHF, incidence rate is fluctuate but from 2003 to 2006, Numberss are keeps lifting.

Table 1: Incidence rate ( per 100 000 population ) of catching diseases.

Adapted from MoH.

Year

Dengue Fever

Dengue Haemorrhagic Fever

1999

41.40

2.70

2000

30.20

1.80

2001

64.32

3.84

2002

63.17

7.99

2003

58.93

2.72

2004

50.92

2.69

2005

60.71

3.82

2006

64.37

4.10

Survey on epidemiology and new enterprises in the bar and control of dandy fever in Malaysia done on 2001 stated that the largest, 8.1 per centums from 1,966,722 premises of Aedes genteelness is mills followed by 6.8 per centums is abandoned lodging undertakings and the lowest is houses or stores that constitutes less than one per centum. In dandy fever control programme that the main intents is to cut down the morbidity and mortality rate of DF/DHF, six facets that are disease surveillance and control, vector surveillance and control, public instruction, inter-agency coaction and community engagement, quality confidence and research and developing demand to be covered. Eight schemes have been developed and one of them is public instruction through wellness instruction activities in the community and with community engagement because it require everyone attempt from public to authorities in order to command this infective disease ( Ang & A ; Singh, 2001 ) .

Pathogenesis of DHF/DSS

After infected by DENV, organic structure will get down to response by bring forthing one of classical symptoms of dandy fever during acute stage of infection, which is fever. Mediator, heat-inducible factors such as cytokines, will be go arounding in blood and bring on organic structure thermic homeostasis ( Leon, 2002 ) .

In innate immune system theory, Lei et Al ( 2001 ) and Noisakran & A ; Perng ( 2008 ) propose hypothesis of DENV may trip CD4/CD8 ratio inversion that interfere with the ability of organic structure defence system to eliminate viral burden but besides consequences in overly produced cytokine that will farther take to progressive harm of monocytes, endothelial cells and hepatocytes consequences in cell programmed cell death. Bleeding mechanism is triggered by thrombocyte devastation that takes topographic point when organic structure develops autoimmunity against platelet-specific antigen with the assistance of dengue antibody-virus composite that binds to the HPA glycoprotein leads to cross-reactivity of anti-platelet antibodies ( Soundravally, 2007 ) .

Harmonizing to Avirutnan et Al ( 2008 ) , complement system is responsible in pathogenesis of flavivirus infection. In CR3 expressed cells, activation of antibody-dependent complement might heighten viral infection. There is a theory that formulated that septic cells express DENV antigen on their cell surface that enhances formation of immune composite and deposition of complement ( Mehlhop et al, 2007 ) . Avirutnan et al once more revealed that DENV NS1, one of the DENV ‘s antigens might be responsible in complement activation but in farther survey done by the same research worker shown that DENV NS1 requires specific anti-NS1 antibodies for complement use.

Lab probes

Disease supervising research lab trials

When a patient is admitted or seek for medical attending, clinician will order research lab to carry on full blood count ( FBC ) and Liver Function Test ( LFT ) .

In FBC, check of White cell count ( WCC ) , Haematocrit ( HCT ) , and Thrombocytopenia will be done ( CPG, 2010 ) . In WCC, as addition in WCC will demo positive consequence of presence of infection in organic structure but normally, WCC is normal in the early febrile stage. HCT is early finding of plasma escape. Increase in HCT will demo that patients is losing control of their blood flow hemostasis but doctors must foremost put patient ‘s baseline during early term of infection since disposal of unstable replacing therapy may impact the consequence. In dengue infection, thrombocytopaenia is common parametric quantity. As disease advancement, the figure of white blood cell may diminish suddenly.

In Liver Function Test, AST keeps significantly inclined as compared to ALT that maintain path of neglecting in map of liver. As disease advancement from DF to DHF, elevated liver enzymes is common and expected.

Diagnostic trial

Introduction

In working paper for the Scientific Working Group on Dengue Research done by Buchy and his co-workers ( 2006 ) , there are three techniques to observe DENV in being ‘s system. There are technique for virus isolation and designation, serological method and molecular method.

Virus isolation and designation

In technique for virus isolation and designation, it is the lone manner to name viral infection in early phase. Serotype of DENV is identified after viral elaboration phases in mosquito cell lines by utilizing serotypes specific monoclonal antibodies. The restriction of this technique is it merely sensitive when comparatively high degree of infective atoms in serum. A few cell lines can be used in this technique that are mosquito cell line C6/36 ( Igarashi, 1978 ) , Aedes Pseudoscutellaris cell line AP61, and less efficient Mammalian cell civilizations such as Vero cells, LLCMK2 ( Guzman & A ; Kouri, 1996 ) and so on.

Designation of DENV can be done by utilizing immunofluorescence technique. Serotype-specific monoclonal anti-dengue antibodies are used. However, due to low viral burden in serum, some strains are non easy identified ( Buchy et al, 2006 )

Serologic method

The most common used method is serological method ( Guzman et al, 2004 ) . In serological method, five trials can be conducted and each of them offers broad assortment of advantages every bit good as restrictions. The mentioned methods are Hemagglutination-inhibition ( HI ) , Complement Fixation ( CF ) , Neutralization Test ( NT ) , Immunoglobulin M ( IgM ) , Capture enzme-linked immunosorbent Assay ( MAC-ELISA ) , and Indirect Immunoglobulin G ELISA ( Guzman & A ; Kouri, 1996 ) .

In HI, it is the most normally used due to sensitiveness, cost-saving and dependability. HI antibodies remains for long period and this make it entitled to be used in seroepidemiologic surveies. By twenty-four hours of five to six post-dengue infections, HI antibody can be noticeable to a certain degree. Titers of a‰?1,280 are an grounds of a current dandy fever infection. However, degree of HI antibody may worsen with addition in clip. The disadvantage of this trial is it is non serotype-specific, therefore it is hard to find which serotypes had infect patients ( Gubler, 1998 ) .

The more hard to execute trial, CF trial, is non widely used worldwide. The rule behind this trial is that complement is consumed during antigen-antibody reaction. This trial is more serotype-specific in primary infection but non in secondary infection ( Gubler, 1998 ) .

In NT trial, it is more specific and sensitive trial. The serum dilution plaque decrease NT is the common used process in research lab. Neutralizing-antibody titres rise equal to or somewhat easy than HI and ELISA antibody titres but more rapidly than CF antibody titres ( Gubler, 1998 ) .

Mac Elisa technique uses dengue-specific antigens in order to gaining control of anti-dengue IgM-specifuc antibodies in serum samples. Antigens are obtained from DENV envelope protein in all dandy fever serotypes. This trial is limited since it can non be used in instances of multiple flaviviruses presence ( Buchy et al, 2006 ) .

IgG Elisa use the same antigen as MAC Elisa and it is been used to observe past infection DENV. Multiple dilutions of the sera tested is used in order to find an end-point dilution and in the consequence, as high-point dilution is addition, the more terrible the degree of infection in the host organic structure is ( Buchy et al, 2006 ) . This trial is simple and simple to transport out and can be used in high-volume check but yet improbably nonspecific every bit good as show cross-sensitivity among flaviviruses correspondent to HI trial ( Gubler, 1998 ) .

Molecular method

This method is considered new diagnostic engineering. By and large, there are two checks that demonstrate the ability to name DENV that are reverse-transcriptase polymerase concatenation reaction ( RT-PCR ) and real-time RT-PCR.

Lanciotti et Al ( 1991 ) had developed rapid sensing and typewriting of dandy fever viruses from serum samples by RT-PCR technique. There a few stairss need to be accomplished before research worker can find which genotype of DENV is go arounding. First and first, RNA extraction from DENV-infected cell of the serum sample is obtained before amplified. In amplification measure, we need to choose and synthesis of oligonucleotide primers, D1 and D2. After first amplification measure is complete and DENV is successfully typing by point smudge filter hybridisation, 2nd elaboration reaction is initiated by carry oning similar measure as earlier. A few advantages of this check are it is rapid, easy to carry on, sensitive and consistent. However, it should non replace virus isolation method ( Gubler, 1998 ) .

In one-step check, real-time PCR, it uses brace of serotype-specific primers and investigations. It can extinguish cataphoresis by replacement it with fluorescent investigation. It present in either ‘singleplex ‘ or ‘multiplex ‘ . All four serotypes can be identified without presenting contamination during sample use in manifold check. Real-time PCR can place the badness of disease since pathologists can cognize viral burden in one ‘s serum sample ( Buchy et al, 2006 ) .

Sign and Symptom

Many dandy fever patients develop fever after infection. Harmonizing to WHO, in babies and young persons, they frequently have undifferentiated feverish disease accompanied by roseola that can be depend on badness of instances and twenty-four hours of post-infection as shown in figure 4, while older kids and grownups may hold a mild feverish status but other usually have high febrility, throbbing concern, hurting behind the oculus, myodynia and arthralgia every bit good as roseola. Mild shed blooding such as nose or gum bleed and easy bruising besides may happen during DF ( CDC, 2011 ) . Some patients may describe rubing and abnormalcies in the sense of gustatory sensation, usually metallic gustatory sensation. Furthermore, in certain instances, encephalitic and encephalopathic manifestation besides may happen, including lassitude, confusion, ictus, nuchal rigidness and paresis.

Figure 4: Symptom of dandy fever harmonizing to twenty-four hours of post-infection. Adapted from DengueVirusNet.com

DF if non managed decently may come on to DHF ( Guzman & A ; Kouri, 2002 ) . In more terrible instances, DHF, clinical manifestation is same with DF but patient may see sudden oncoming of febrility and their organic structure temperature may make until 41 °C. Coughing and sore pharynx might or might non happen. These symptoms may followed by bleeding, particularly at tegument, in signifier of roseola that can be either maculopapular, patechial or erythematous, megalohepatia, circulatory prostration, and feverish paroxysm when febrility is down. Another symptom such as emesis, terrible abdominal hurting, black stools and take a breathing trouble may happen. There are four compulsory standards in clinical instance categorization of DHF. They are fever or past history of sudden oncoming of febrility, thrombopenia ( 100.000/mm3 or less ) , haemorrhagic mark, and nonsubjective grounds of “ leaky capillaries ” , including low albumen, elevated haematocrit more or equal to 20 per cents from baselines, and pleural or other gushs ( Avila-Aguero et al. , 2004 ; Phuong et Al, 2004 ; WHO, 2009 ) .

If symptoms are non well-managed or treated, DHF may come on to DSS in twenty-four hours 12 that can take to decease due to circulative failure. In DSS, clinical manifestation is quite same but more terrible. Patients may see restlessness, cold due to weak blood circulation, pale tegument and low pulse force per unit area ( less than 20 mm Hg ) every bit good as weak rapid pulsation ( WHO,2009 ) .

Management of disease

Pharmacological

Most intervention of dandy fever is symptom-based intervention. There is no definite intervention of dandy fever until now. Harmonizing to Malaysia Clinical Practice Guidelines ( CPG ) , in grownups, there is a bit-by-bit attack on outpatient direction of dandy fever infection. In first measure, overall appraisal in term of history, physical scrutiny, and probe will be done by accompanied wellness attention professional. In history portion, wellness attention professional will inquire patient about their oncoming of unwellness, buttocks for any alarm signal, diarrhea, hemorrhage, alteration in mental watchfulness and of import relevant histories. Besides history pickings, physical scrutiny besides will be done in term of mental province, hydration position, haemodynamic position, abdominal tenderness, happening of hemorrhage and Tourniquet trial. Tourniquet trial is the trial that indicate hemorrhagic inclination. A positive consequence that is when 20 or more petechiae per 2.5 centimeter square are observed and it will bespeak hemorrhagic inclination. Further probe will be done by buttocks FBC and HCT every bit good as dandy fever serology trial.

In 2nd measure, diagnosing, disease theatrical production and badness appraisal can be conducted. Bases on measure one consideration, the accompanied clinicians should be able to verify dengue diagnosing, rating the unwellness, hydration and haemodynamic status of patients every bit good as decide whether patient must be admitted to the infirmary or non. Before patient is admitted to guard, clinician should see entire appraisal of the patient which are patient with symptoms of alarm signal, shed blooding presentation, can non digest unwritten fluids, oliguria, and ictus. Signs of desiccation, daze, and any organ failure every bit good as in particular state of affairss such as patients with co-morbidity, elderly, pregnant female parent and societal factor are another consideration before patient can be admitted. All of these factors might be accompanied by research lab standards such as addition in HCT but thrombopenia.

In measure three, program of direction must be initiated. District wellness office must be notified through phone and followed by disease presentment signifier. If admittance is necessary, wellness attention suppliers need to stabilise the patients at the primary attention installations before transportation and communicate with the having establishment before transportation to advise them about patient attending. If no admittance is required, frequent follow up is necessary from twenty-four hours three of unwellness onwards until the patients become afebrile for at least 24 to 48 hours without any febrifuges medicine.

In dengue patients who non necessitate to be admitted, place attention advice should be given harmonizing to Malaysia CPG. Adequate bed rest, sufficient fluid consumption ( more than five spectacless for a regular individual ) , take paracetamol ( non more than four gms per twenty-four hours ) , and lukewarm sponging are among advises can be given to patients. Avoidance of NSAIDS and antibiotic consumption is mandatory advice demand to given to patients.

Patients that present with alarm signal may see marks such as changeless emesis, abdominal hurting or tenderness, fluid buildup in certain organic structure portion such as in venters and lung, shed blooding at mucosal site, unease, lassitude, megalohepatia ( expansion of liver size more than 2 centimeter ) , and laboratory verification of HCT increase and thrombopenia.

In patient who required unstable disposal, particularly in patient with warning marks, patients may better with early endovenous rehydration. However, some might non and deteriorate to terrible phase. Health attention professional supposed to obtain a baseline HCT prior to fluid therapy and administer crystalloids solution such as 0.9 per cents saline to patients that presented with warning marks. Crystalloid governments may get down with five to seven ml/kg/hour for one to two hours, later cut down to three to five ml/kg/hour for two to four hours and so farther lessen to two to three ml/kg/hour or less depend on patient response to intervention. If patient continue to acquire worse, clinicians may see increasing the extract rate and this must depend on patient ‘s HCT degree.

In non-shock patient, which is DHF class I and II, patient can be advised to take plentifulness of unwritten fluid if patient is haemodynamically stable and non purging, but if degree of HCT is increasing, IV fluid is recommended. However, in DSS patient that is DHF class III and IV, clinician must oversee them in ICU, whereby unstable resuscitation must be initiated without hold. Severity of daze will find volume of unstable resuscitation and can change from 10-20 mL/kg IBW. Rate of extract must be monitored carefully and titration of dosage must be harmonizing to clinical response. Clinical parametric quantity every bit good as research lab parametric quantity may bespeak whether unstable resuscitation is adequate or non. If patients still deteriorate after two rhythms of unstable resuscitation with crystalloids, patients may necessitate to be administered with colloids in the 3rd rhythm. Gelatin solution and amylum solution is colloids of choose in dandy fever therapy. See any hemorrhage manifestation if all unstable direction therapy is failed to demo any positive effects.

In patients who haemorrhage is suspected, hemostasis direction must be implemented to forestall any blood loss that farther will take to circulative prostration. Drop in HCT degree is an index of bleeding presentation. Patient may necessitate blood transfusion in terrible instances. Transfusion of five to ten ml/kg of fresh-packed ruddy cells or 10 to 20 ml/kg of fresh whole blood at equal rate might be good in important bleeding patient. Patients with DHF or DSS need no contraceptive transfusion of thrombocytes and fresh frozen plasma since no effects has been documented on shed blooding result.

Non-pharmacological

Dengue-infected patient is advised to devour plentifulness of H2O, particularly those who experience feverish disease in order to cut down organic structure temperature to digest scope. Patients besides advised to bed remainder during recovery period. Preventive step must be taken to forestall farther mosquito bite by use of insect powder sprays, mosquito cyberspaces and so on might be helpful. In traditional belief, crab soup can be used to handle dandy fever. HPA claims that through their Jawi Herbs, one of their merchandises which are herb tea that contain pennywort can be used in dengue intervention. However, it must be concentrated readying by immerse 10 sachets of herbs tea in a jug and must be imbibe within 24 hours. Another herbs that believe can handle dengue symptom is natural papaia leaves juices. In Philippines, one species of local weed that Filipinos used to name Tawa Tawa or it scientific name is Eurphobia hirta is believed to be utile in direction of dandy fever febrility. This is still ongoing research on this species of herbs due to it benefits.

2.2 Knowledge, Awareness and Practices ( KAP ) surveies of dandy fever

In Puerto Rico, survey on belief and patterns about dandy fever was conducted by Perez-Guerra et Al ( 2003 ) in order to seek disagreement among adult male and adult females of specific group with or without history of dandy fever infection in term of cognition, beliefs, attitude and patterns about dandy fever bar and to compare the obtained consequences with the old, 2001 survey. From the obtained consequences, adult females were more concerned as respects of dandy fever menace, more educated about disease and it expectancy, and suggested utilize of repellants more frequently compared to those same group without history of dandy fever. In Puerto Rico ‘s civilization and norms, duty for the family and well-being of household member is in adult females ‘s manus while work forces are taking portion in domestic and wellness matter. In order to aim this population, different attacks need to be implemented in both genders. Experience is the best manner to educate people. This is proven by those who had been diagnosed with dandy fever before, he or she are more knowing about dandy fever and it bar every bit good as more concern about other people hazard of infected by this virus.

In one of tropical state, Jamaica, where is dengue had became major wellness quandary, KAP survey was performed in 2010 by Faisal Shuaib et Al. Most of participants are unable to find accurate marks and symptoms of DF similar as old designated survey done in Thailand by Leera et Al. 54.4 per centums, 46.6 per centums and 28.5 per centums of respondent responds to had at least 80 per centums on cognition, attitude and bar on dandy fever, severally. From the figures, even though more than half of respondents had knowledge about dandy fever, but merely little per centums of them willing to set in action to pattern preventative action against dandy fever. Sing educational backgrounds profile, as degree of instruction higher, score of cognition besides rose. As a decision, a good cognition does non vouch a positive attitude and pattern against dandy fever.

374 peoples willing to take part in KAP survey in Male ‘ , Maldives with 60 per centums of them are female. Nahida ( 2008 ) in her study found that most of them are educated in degree of primary ( 43.9 per centums ) and secondary ( 43.9 per centums ) instruction. Merely 12.2 per centums are graduate or post-graduate and most of them are employed. 80.5 per centums had history with dandy fever either straight or indirectly. Most of them had heard about dandy fever. Respondent ‘s cognition of dandy fever is low even though many of them, approximately 42 per centums claimed to have their information from telecasting and wireless. This proven by 46 per centums of them scored in scope of low cognition. However, in term of attitude, 42.5 per centums of them has positive attitude. Merely 8.8 per centums of them have good pattern and most of them ( 48.1 per centums ) autumn in just pattern. From the analyzed informations, no matching relationship between pattern degree towards dandy fever and history of dandy fever either straight or indirectly. Compared to males, female sex has more degree of pattern towards dandy fever.

Ahmed Itrat and his co-researchers ( 2006 ) were successfully distribute questionnaire to the 447 respondents that were willing to take portion in their cross-sectional survey rubric cognition, consciousness and patterns sing dandy fever febrility among the grownup population of dandy fever hit cosmopolites in Civil Hospital ( CHK ) and Aga Khan University Hospital ( AKUH ) located at Karachi, Pakistan. 89.9 per centums had heard of dandy fever and bulk ( 81.5 per centums ) agreed of febrility is the common symptoms. Data shows that most of respondents are cognizant of this fatal disease nevertheless, something must be done in order to educate those who ne’er heard of dandy fever. In facets of grade of cognition, more than half of them knew that vector strains in standing clean H2O, most of them agreed that mosquito spray ( 54.9 per centums ) and mosquito mat, spiral or liquid vaporiser ( 50.1 per centums ) are the preventative step that can be taken to forestall against mosquito bite. Some of the respondents, due to the high prevalence of malaria, assume Anopheles mosquito is indistinguishable as Aedes mosquito in term of features and home ground. As old surveies, telecasting is the major beginnings of information about dandy fever.

In other survey by Madiha Syed and co-workers in Karachi, Pakistan on cognition, attitudes and patterns sing DF among grownups of high and low socioeconomic groups, 400 respondents, which are reasonably distributed among two socioeconomic positions and 244 of them are males, were involved. 35.5 per centums of chosen respondents had sufficient cognition about dandy fever. Those that have sufficient cognition are 68 per centums from high socioeconomic position and 32 per centums from low socioeconomic position. Many respondents agreed that authorities should take answerability to forestall spread of disease and preventative measuring. Meaningful correlativity had been detected between cognition and instruction backgrounds ( p=0.004 ) and socioeconomic position ( p=0.02 ) . Peoples with high socioeconomic background had more cognition, high attitude and pattern more than people with low socioeconomic backgrounds.

In another portion of Pakistan, in the Multan territory, Naeem-Ullah and Akram ( 2007 ) disclosed that 23.7 per centums from 270 peoples are illiterate, alumnus and supra. This information is of import because there are a important relationship between degree of instruction and consciousness every bit good as between degree of instruction and cognition. Percentages show that important figure of respondents from Multan population are non well-educate about dandy fever. This proven by merely 21.5 per centums of them knew that dandy fever is transmitted by mosquito and 12.6 per centums agreed that vector is breed in rainy season. 68.15 per centums were cognizant of DF and out of them, 82.6 per centums said that the primary resources of their information are wireless and telecasting followed by printed media and friends. Similar as other portion of universe, preventative step such as fans, mats and spirals are taken to forestall mosquito bite.

In 2009 published paper on cognition, attitude and pattern sing dandy fever among people in Pakse, Laos, 230 topics that had experienced from DF and/or were treated within less than two old ages from nine small towns are involved in this survey. From the distributed questionnaire, analysis shows that merely a few of them ( 4.3 % per centums ) are illiterate and most of them are housewife ( 32.6 per centums ) and merchandiser ( 30.4 per centums ) . In term of cognition sing dandy fever, a few parametric quantities are measured. In term of symptoms, 75.2 per centums of respondents agreed that febrility is symptom of dandy fever followed by 18.7 per centums agreed on tegument roseola. 93.5 per centums knew that mosquito bites is manner of transmittal of dandy fever and 65.2 per centums agreed that mosquitoes are bite in daylight. Most of the respondents were cognizant that DF is terrible disease and they need to seek medical attending if they affected. As a decision of survey done, a good cognition and attitude of dandy fever does non guarantee good pattern to forestall dandy fever ( Soodsada et al, 2009 ) .

In Ang Thong, Thailand, cross-sectional KAP survey on DHF had been conducted by Leera et Al ( 1999 ) . Throughout this a twelvemonth of period survey, 131 caretakers took portion in this study since this survey involves dengue virus-infected, non-dengue virus-infected and healthy kids under age of 15 old ages old. From the ascertained consequences, ratio of onslaught rate of 1.5:1 between male child and miss shows that male is susceptible to dengue virus onslaught compared to female. In term of cognition, caretakers that has history of dandy fever had more cognition about dandy fever ( the transmittal vector, engendering site and so on ) compared to those who had no history of dandy fever. Even though most of them have false attitude towards marks and symptoms of dandy fever ( p=0.006 ) , but they have positive attitude in transmittal, intervention and bar of dandy fever. In last portion of study, consequences show that the caretakers of dengue patient tonss better than other two groups in facet of pattern of bar, intervention and control of dandy fever. Caretakers with history of dandy fever had more cognition, positive attitude and use good pattern compared to non history and healthy population.

Indonesia is one of south-east Asia states that besides encounters dengue epidemic job. In August 2000, one of the research workers from US Naval Medical Research Unit No.2, Beckett and his co-researchers conduct a survey on heightening cognition and consciousness of dandy fever during a prospective survey of dandy fever febrility. Employees from two workss that consist of 1373 males and 967 females were involved in this pre- and post-test that includes comparing between before they were given information about dandy fever and after 18 months after information were given to them. System of point was given that farther categorized as first-class until really bad. On the pre-test, most of respondent scored just ( 39.9 per centums ) and good ( 38.4 per centums ) , and on the post-test, mean mark became better with 42.5 per centums scored good and 23.8 per centums scored really good. This betterment is extremely correlative with degree of instruction ( Pearson rank correlativity =0.389, p=0.01 ) .

In another survey done in 2004 by Acharya et Al, bulk of occupants of an urban relocation settlement of south Delhi are cognizant of dandy fever. Survey was done and divided into four subdivisions: demographic profile, cognition about dandy fever, patterns on control of dandy fever, and beginnings of information sing dandy fever. In socio-demographic position, 20.2 per centums of the population was in scope of 35 to 44 old ages old with 64.1 per centums of female return parts in this survey. 25.6 per centums from them are illiterate and merely 5.9 per centums are graduate and above. In term of cognition about dandy fever, 90 per centums out of the 641 respondents of the selected population had heard about dandy fever with 68 per centums of them mention the most common causes of dandy fever is mosquito bite, 48 per centums soiled imbibing H2O, and 20 per centums environment. 68 per centums knew that dandy fever can be spread but merely 55 per centums knew that mosquito bite is mode of spread. 23.4 per centums of the populations have no cognition on symptom of the dandy fever, more than 90 per centums knew fever entirely or 19 per centums say it accompanied by iciness and 38 per centums say concern are one of the symptoms of dandy fever. In last portion of the study, which are beginnings of information sing dandy fever, from 577 multiple responses, 102.58 per centums were educated from mass media ( telecasting, newspaper, magazines, wireless ) while other beginnings are through wellness forces, streamers, school, friends and neighbors and others beginnings.

In Malaysia, Wan Rozita and her co-workers had done cross-sectional survey on cognition, attitude and pattern in urban Malay lodging country that was done in Kampung Datuk Keramat, Kuala Lumpur. From this three months study that was done from August to November 2005, revealed that there is weak positive relationship between cognition and pattern ( r = 0.271, P = 0.002 ) but undistinguished correlativity between attitude and pattern every bit good as between attitude and cognition ( p & gt ; 0.05 ) . From 133 respondents, 79.7 per centums of them ne’er contract or had any past history of dandy fever. 98.5 per centums had heard of dandy fever with 85 per centums said that telecasting is the chief beginnings of information. In this survey country, somewhat better per centum of participants had heard about dandy fever if compared to in South Delhi reported by Archarya, A. 94.7 per centums said that precautional steps were required to forestall dandy fever febrility and 96.2 per centums were willing to work hand-on-hand on extinction plan of Aedes mosquito vector. Respondents that have history of dandy fever either themselves of holding household members with dandy fever shows that high dependability in cognition, attitude and pattern compared to those who ne’er had history of dandy fever. From this survey, it can be concluded that good cognition and good pattern are non contribute to correlativity of good attitude.

2.3 Impact of Dengue

In Singapore, a survey on post-infectious fatigue syndrome in dengue infection was done by Seet et Al ( 2006 ) in order to entree one of the symptoms at acute phase of dandy fever. In this survey, often appeared clinical manifestations are fever, hapless appetency, fatigue, concerns, sickness, icinesss, musculus, hurting, and roseolas. This supported by research lab characteristics ( haematological parametric quantities: white blood cell count, haemoglobin, haematocrit, and thrombocyte ) and biochemistry parametric quantities ( degree of Na, K, urea, creatinine, albumen, entire hematoidin, aspartate aminotransferase, alkalic aminotransferase, and lactate dehydrogenase ) . However, there are no important relationship between hematologic and biochemical parametric quantities with badness of dandy fever. From the obtained consequences, 19.7 per centums from 127 patients have DHF and staying 80.3 per centums were suffered of DF. 24.4 per centums experience weariness and hazard factors for development of weariness are increased age, female, and the presence of icinesss every bit good as absence of roseolas. Extra factors that can predispose fatigue syndrome in female sex are map of generative, familial makeup, and the manner they deal with their emphasis.

Survey on the economic impact of dandy fever hemorrhagic febrility on household degree in Southern Vietnam in 2005 was conducted and revealed that household with kid holding DHF require disbursement big sum of money during class of therapy. In norm, the cost is about USD 32.73 for direct cost and for indirect cost is USD 28.73. Direct cost takes history of infirmary measures, physician assignment entree fees, and research lab trials, while indirect cost screens loss of net incomes, conveyance and nutrient because most of kids that seeks for intervention are accompanied by their parents or caretaker. Compared to gross national income per capita of Vietnam ( USD 620 ) , the mean cost of USD 61 to teat dandy fever infected kid is considered as big figure. Between badnesss of the disease, they require different cost of intervention that must be paid by kid ‘s household ( Harving, 2007 ) .

In touristry industry, legion popular tourer finishs such as Indonesia, Thailand, Malaysia and other brilliant tropical states encountered dandy fever epidemics job particularly during raining season. Travelers who visit those outbreak countries are at high hazard to develop DF and it ought to be suspected in those patients who visit doctor when they returned to their fatherland. In Korea, informations collected by Korea Centers for Disease Control and Prevention ( KCDC ) throughout twelvemonth of 2001 to 2008 reported that 22 instances of paediatricss DF and all of them were imported instances. 65.6 per centums from 517 patients that visited paediatric infective disease clinic at Samsung Medical Center were took portion in this questionnaire and out of them, 29.8 per centums has international going history within two old ages. From those informations, there are seven patients present one of dandy fever symptoms and merely four of them were suspected of DF due to presented symptoms and history of going to epidemic countries. Number of imported dandy fever rise as figure of travellers sing epidemic countries increasing ( Soo et al, 2010 ) .

2.4 Drumhead

Since dandy fever can do many complications and impacts, as portion of community, Malayan should take preventative measuring to forestall transmittal and epidemicity of DENV. Furthermore, when you experience some of the symptoms of dandy fever, ignorance is the attitude that needs to be eliminated before disease advancement to more complicated instances. Seek advice from you doctors before self-medicated with nonprescription drug ( s ) .

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