INTRODUCTION

Dengue is transmitted by the bite of an Aedes mosquito infected with any one of the four dengue
viruses. It occurs in tropical and sub-tropical areas of the world. Symptoms appear 3—14 days after the
infective bite. Dengue fever is a febrile illness that affects infants, young children and adults.

Symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain behind the
eyes, muscle and joint pain, and rash. There are no specific antiviral medicines for dengue. It is important
to maintain hydration. Use of acetylsalicylic acid (e.g. aspirin) and non steroidal anti-inflammatory drugs
(e.g. Ibuprofen) is not recommended.

Dengue hemorrhagic fever (fever, abdominal pain, vomiting, bleeding) is a potentially lethal complication,
affecting mainly children. Early clinical diagnosis and careful clinical management by experienced
physicians and nurses increase survival of patients.

I. Biographic Data

 Name : MJV
 Age : 2 ½ years old
 Gender : Male
 Address : 53 Pangako st. Bagong Barrio, Caloocan City
 Religion : Roman Catholic

II. Nursing History

A. Past Health History

The child has no complete immunizations and has no other illness/disease aside
from asthma which occurred during his childbirth and occasional fever that arises whenever he
experiences asthma attack. He does not take any vitamins only drug maintenance which is
salbutamol ventolin for asthma. The client has once been admitted and confined in the hospital
about a year ago due to difficulty of breathing.

B. History of Present Illness

The client had a fever for 3 consecutive days but subsided when he took
paracetamol. After a day, the client went to the health center for check-up due to epistaxis and
difficulty of breathing and was advised by the health care provider to go to a hospital after
obtaining a laboratory tests which indicates a low platelet count. He was requested for an
admission but was not been admitted since the illness that occurred can be maintained as
explained by a health care provider in the said clinic since no signs and symptoms of dengue
were seen. The client was advised to have drug maintenance such as antibiotics, vitamin C, and
analgesics if fever occurs again.
C. Family History

Genogram:

Legends:

- Female - client

- Male - with asthma

- deceased
III. PATTERNS OF FUCTIONING
A. Coping Patterns

The grandmother who stands as the guardian of the child said that the client experiences
difficulty in breathing and wasn’t able to tolerate the pain brought by the high fever he have
been. This situation is nothing new to the guardian since asthma often attacks the child. The
guardian said that she maintains the health of the child by complying with the medications
prescribed by the physician for asthma. She sometimes gets worried and afraid for her
grandchild but she got used with it as time passes by.

B. Interaction Pattern

According to the grandmother, the client is very playful even inside the house. He also has
playmates in the neighborhood with the same age as his. “Palakaibigan yang apo ko na yan kaso
nga lang minsan eh sinusumpong iyak ng iyak tuloy lagging hirap huminga kaya hinihingal
palagi.. Para bang nauubusan ng hangin..” the grandmother said. The child mingles with others if
he is comfortable with that person but if not, he cries and looks for his close relative. The
grandmother verbalized that “nangingilala kasi yang batang yan minsan pero pag walang
sumpong, okay naman yan kausapin ng kahit na sino.”

C. Cognitive Pattern

The guardian perceives a healthy body for her grandson if he is active and eats a well
balanced diet but her mind setting at times changes when the client becomes ill and so does not
function properly. For the child’s cognitive functioning, the client learns more words as
verbalized during the interview. According to the grandmother, the client uses any forms of
symbols to remember several thought processes. The grandmother verbalized that “Marami ng
natututunan yung apo ko. Madali niyang natatandaan yung mga nakikita niya sa TV lalo na pag
cartoon na makukulay.” She also added “Kapag napanod niya o nakita niya yung isang bagay
tinuturo niya yun.. Naaalala niya kapag ka ganun..”

D. Self-concept Pattern

According to the grandmother, the child acts inferiorly among others as seen through his
acts and gestures especially when his with other children. “Minsan kasi pag may kasamang bata
yan bigla nalang iiyak.. pati kalaro niya.. eh siguro ganun lang talaga syempre bata yan eh..” The
grandmother sees the health of her grandchild in a way that it changes like for example when
the client gets ill, she thinks that her grandson is unhealthy but when the child plays actively and
eats well her perception changes.

E. Emotional Pattern

According to the grandmother, when the client feels unhappy, he usually cries and
demands for something he wants. When the client experiences joy, it too shows through his
reactions and features. “Mabait yang apo ko. Masayahin pag walang sumpong tsaka pag
nandyan yung mga kalaro niya.. kaya lang pag tinoyo… nako! magwawala yan lalo na pag hindi
nasunod gusto niya..” said the grandmother.
IV. Physical Assessment
BODY PARTS Norms Actual Findings Interpretation
and Analysis
General Appearance
 Personal Neat and clean Dirty and unkempt Poor personal
hygiene/Groomin No distress noted in No distress noted hygiene
g posture Weakness and Normal
Healthy in appearance presence of lesions Presence of
illness in
breathing
Measurements
 Temperature 36.5-37.5°C 36.8°C Normal
 Pulse Rate 75-120bpm 105bpm Tachycardia
 Respiratory Rate 1-25cpm 14cpm Bradypnea
 SKULL
• Nodules or masses Smooth, uniform, There are present Presence of skin
and depressions in consistency; absence nodules or masses disease
the skull of nodules or masses seen and palpated
on his skull.
Palpebral conjunctiva Shiny, smooth, pink or Shiny, smooth, and Possible anemia
red in color pale in color.
Nose
● External nose Symmetric and straight It is symmetric and Normal
straight.
No discharge or flaring Presence of
Discharges present discharges my
Uniform color indicate an illness
(colds)
It has uniform color.
Not tender, no lesions Normal

There is no
tenderness and Normal
lesions.

• Teeth Smooth, white, shiny Brown discoloration Indicates dental

tooth enamel. of the enamel caries

Thorax
• Anterior thorax Quite, rhythmic, and Quite, abnormally Indication of
effortless respiration slow, and difficult bradypnea, and
breathing dyspnea
V. Laboratory Results (N/A)

VI. Drug Study

Generic/ Action Dosage Indication Contraindicat AdverseRrea Nursing
Trade ion ction Responsibiliti
es
Amoxicill Prevents Oral Treatment Hypersensitivit Dizziness, Obtain
in bacterial administr of infection y to penicillin, fatigue, patients
(Amoxil) cell wall ation, 3 s of cephalosporino insomnia, history of
synthesis ml 3x a respiratory r imepenem. urticaria, allergy.
during day tract, skin Not use to maculopapular Assess the
replicatio to skin treat severe to exfoliative patient for
n. structure. pneumonia, dermatitis, signs and
Bactericid empyema, vesicular symptoms of
al. bacterimia, eruptions, skin infection,
pericarditis, rashes, sore or wound
meningitis and dry mouth or characteristics,
prululent or tongue. urine and
septic arthritis stool.
during acute Assess patient
stage. for previous
sensitivity
reaction to
penicillin or
other
cephalosporin.
Assess for
allergic
reactions
during the
treatment.
Assess for
bowel pattern
and signs and
symptoms of
dehydration.
Monitor for
bleeding.
Assess for over
Agent: Aedes growth of
Aegypti infection.
VII. Ecologic Model
Hypothesis: The Dengue Fever is caused by a bite of the mosquito particularly the Aedes
Aegypti which is carrying a virus.

Environment:

-climate(rainy
Host: Patient X season)

Age -stagnant water

Low level of -improper

immunity garbage disposal

- Filthy house
 Signs and Symptoms:

Explanation:
Headaches
With the client’s age of only 2 yrs old and 8 months, we all know that the child still
Severe pain behind the eyes
has a low level of immunity thus making him prone to acquire the said communicable
disease,Fever,
the dengue
chills fever. In addition to that, the environment the patient is exposed
to also contribute to the development of the disease. The factors which had helped the
patient Red
to throat
acquire the disease are mostly of environmental factors and these are
climate (of rainy season), the house is filthy, the family is practicing improper garbage
disposal, andcongestion
Nasal the family stocked water which they left uncovered which later on
became stagnant. These all had contributed to the acquiring of the disease because it
Muscle
had helped thepain
vector to have a breeding site near to her possible victims.
Predisposing
Bone pain
Factors:
Skin symptoms: -age
VIII. Pathophysiology
Reddened skin climate(rainy
Pathophysiology of Dengue season)
Fever
Increased sensitivity of skin to touch
-stagnant water
Skin rash
-improper garbage
disposal

- Filthy house
Loss of appetite

Nausea

Vomiting Dengue Fever

Minor bleeding from, nosebleeds

Caused by a bite of female Aedes
Liver and spleen enlargementAegypti who is infected (carrying a
arbovirus)
Malaise

Once in the body, the virus travels to various

glands where it multiplies
Virus can then enter the bloodstream

Presence of the virus within the blood

vessels causes changes to these blood
vessels

Vessels swell and leak.

Spleen and lymph nodes become

enlarged, and patches of liver tissue die

Disseminated intravascular coagulation

(DIC) occurs

Lead to severe bleeding (hemorrhage).

Symptoms of the disease appear

suddenly and include high fever, chills,
headache, eye pain, red eyes, enlarged
lymph nodes, a red flush to the face,
lower back pain, extreme weakness, and
severe aches in the legs and joints, lose
of appetite,nose bleeding

Given immediate Intervention but still

under observation
Explanation:

Dengue fever can occur when a mosquito carrying the arbovirus bites a human, passing the
virus on to the new host. Once in the body, the virus travels to various glands where it multiplies.
The virus can then enter the bloodstream. The presence of the virus within the blood vessels,
especially those feeding the skin, causes changes to these blood vessels. The vessels swell and
leak. The spleen and lymph nodes become enlarged, and patches of liver tissue die. A process
called disseminated intravascular coagulation (DIC) occurs, where chemicals responsible for
clotting are used up and lead to a risk of severe bleeding (hemorrhage).

After the virus has been transmitted to the human host, a period of incubation occurs. During
this time (lasting about five to eight days) the virus multiplies. Symptoms of the disease appear
suddenly and include high fever, chills, headache, eye pain, red eyes, enlarged lymph nodes, a
red flush to the face, lower back pain, extreme weakness, and severe aches in the legs and
joints, lose of appetite and nose bleeding.

IX. Problem Prioritization

X.Nursing Care Plan

Cues Nursing Analysis Goal/Object Interven Rational Evaluati

Proble ive tion e on
m
Ineffecti Inability Goal: After After the
ve to clear the shift, the shift, the
O: airway secretion patient will client was
36.8°C clearanc or be able to be able to
105bpm e obstructio maintain maintain
14cpm related n from airway airway
to the patency patency
Discharge asthma respirator Monitor Indicative
s present y tract to Objectives: respiratio of
maintain 1. After 10 n and respirator
S: The a clear minutes breath y distress
guardian airway of sounds and/or
of the nursing accumula
child said intervent tion of
that the ion, the secretions
client Nursing Diagnosis nurseRank Justification
experienc will be
es Ineffective Airway able to1 This problem must be
Clearance
difficulty monitor given the first priority
in respirati because this will lead to
breathing on and Position more serious problems.
To open
breath his head Airway
or must give more
sounds appropria attention
maintainthan other
2. After 10 te for problems.
open If this problem
minutes age/condi airway in will be able
resolve, we
of tion manage and promote
at-rest or
nursing client’s
compromihealth and
intervent wellness.
sed
ion, the individual
patient s
will be
able to
know Encourag
Risk for Infection how to2 e deep- Even though this problem
position breathing was
To just a risk, we would
his head and like to manage this next
maximize
3. After 30 coughing because
effort complication
minutes exercise might occur if this problem
of will not give attention.
nursing
intervent
ion, the
patient
will be
Risk for Injury 3 This was given the least
able to
priority because the client
do the Encourag
can assist by his guardian
deep- e to For
and prevent from any
breathin increase hydration
injury.
g and fluid
 coughing intake at
exercise least
4. After 10 200ml/da
minutes y
of
nursing
intervent
ion, the Prevents/r
client will educes
be able Encourag fatigue
to e
increase opportuni
fluid ties for
intake at rest; limit
least activities
200ml/da to level of
y respirator
5. After 20 y
minutes tolerance
of
nursing
intervent
ion, the
client will
be able
to have
adequate
rest
periods
 Eco-epidemiological analysis of dengue infection during an
outbreak of dengue fever, India

By Anita Chakravarti and Rajni Kumaria

Background

This study was designed to find out a relationship of dengue infection with climatic factors such
as rainfall, temperature and relative humidity during the dengue fever epidemic in the year
2003. Blood samples were collected from 1550 patients experiencing a febrile illness clinically
consistent with dengue infection. Serological confirmation of Dengue Infection was done using
Dengue Duo IgM and IgG Rapid Strip test (Pan Bio, Australia), which detected dengue-specific
antibodies. Monthly data of total rainfall, temperature and relative humidity for the year 2003
was obtained from Meteorological Department of Delhi, New Delhi and retrospectively analyzed.

Results

Out of 1550 suspected cases, 893 cases (57.36%) were confirmed as serologically positive. The
difference between numbers of serologically positive cases during different months was
significant (p < 0.05). Larger proportions of serologically positive cases were observed among
adults. Outbreak coincided mainly with the post monsoon period of subnormal rainfall. The
difference between serologically positive cases as compared to serologically negative ones in
post monsoon period was significantly higher (p < 0.001). The difference in the rainfall and
temperature between three seasonal periods was significant (p < 0.05).

Conclusion

This prospective study highlighted rain, temperature and relative humidity as the major and
important climatic factors, which could alone or collectively be responsible for an outbreak. More
studies in this regard could further reveal the correlation between the climatic changes and
dengue outbreaks, which would help in making the strategies and plans to forecast any outbreak
in future well in advance.

Background

Dengue infection (DI) is amongst the most important emerging viral diseases transmitted by
mosquitoes to humans, in terms of both illness and death [1]. The worldwide large-scale
reappearance of dengue for the past few decades has turned this disease into a serious public
health problem, especially in the tropical and subtropical countries [2-4]. It is estimated that 52%
of the global population are at the risk of contracting Dengue fever (DF) or dengue hemorrhagic
fever (DHF) lives in the South East Asian Region. Although all the four serotypes have been
circulating in this region, ecological and climatic factors are reported to influence the seasonal
prevalence of the dengue vector, Aedes aegypti, on the basis of which countries in this region
are divided in to four zones with different DF/DHF transmission potential [5]. In most of the
countries, dengue epidemics are reported to occur, during the warm, humid and rainy seasons,
which favor abundant mosquito growth and shorten the extrinsic incubation period as well [6-9].

DF has been known to be endemic in India for over two centuries as a benign and self-limited
disease. In recent years, the disease has changed its course manifesting in the severe form as
DHF, with increasing frequencies [10] Delhi City (India) is home to more than 13 million people
and is endemic for DI [11]. Overpopulation has consequently led to poor sanitary conditions and
water logging at various places. A major epidemic of DHF from Delhi was last reported in the
year 1996 after which DI became a notifiable disease and a number of policies were formulated
to bring the DI as well as its vector under control. The retrospective studies, one conducted by us
during the period, 1997–2001 and another by National Institute of Communicable Diseases
(NICD), New Delhi during the year 1997, have observed a decline in the number of cases having
either DF or DHF in the following years [12,13]. Although, the vector mainly responsible for the
spread of DI is present all the year around in Delhi, studies on the relative prevalence and
distribution have shown the highest A. aegypti larval indices during the monsoon and post
monsoon period [13-15].

In the year 2003, India had experienced one of the wettest monsoons in 25 years, which led to a
spate of mosquito growth creating an alarming situation of mosquito borne diseases in many
states. Delhi experienced an outbreak of DF this year, after 6 years of silence. Studies conducted
in the countries like Brazil, Indonesia and Venezuela, where DI is present either in epidemic or
endemic form have suggested a correlation between weather and pattern of DI. Rain,
temperature and relative humidity are suggested as important factors attributing towards the
growth and dispersion of this vector and potential of dengue outbreaks [2-4]. Since limited data
is available on the association of climatic conditions and the pattern of DI from this geographical
region, this study was conducted to find out the relationship of dengue infection with climatic
factors such as the rainfall, temperature and relative humidity during the dengue outbreak in the
year 2003.

Results

Seropositivity

All blood smears microscopically screened for malarial parasite were found to be negative.
Analytical interpretations presented in this study were based upon instructions mentioned in the
Pan Bio Rapid Strip Test procedure manual. During the outbreak period, blood samples were
collected from 1550 patients experiencing a febrile illness clinically consistent with DI over the
period of one year from January to December 2003. Eight hundred ninety three cases (57.36%)
were confirmed as serologically positive, out of which 199 (22.28%) cases were positive for
dengue-specific IgM antibodies indicating primary infection and 381 (42. 67%) cases were
positive for both dengue-specific IgM and IgG antibodies indicating secondary infection (Figure
1). IgG antibodies alone were also detected in 313 (35.05%) cases and these cases were
presumed to be either suspected secondary dengue infection as IgG positivity alone could also
be due to cross reactivity with other flaviviruses. The difference between numbers of
serologically positive cases reported during different months was significant (p < 0.05).

Figure 1. Month wise distribution of primary and secondary serologically positive cases during
the outbreak period in the year 2003.

DI is observed to be a seasonal disease in Delhi. According to intensity of rainfall, weather data

was divided in three periods, namely; pre monsoon period: from February- May, monsoon period:
from June – September and post monsoon period: from October – January. Few cases clinically
suspected of dengue infection in the pre monsoon period were later found to be serologically
negative for dengue-specific antibodies. During the monsoon period, only 3 cases (0.34%) were
confirmed serologically positive in the month of August, and 68 cases (7.6%) in the September.
Dengue-specific antibody positive cases were mainly reported during the post monsoon period
with maximum number of cases 583 (65.3%) cases reported during the month of October
followed by 230 (25.76%) cases in the November (Table 1). The difference between numbers of
serologically positive cases as compared to serologically negative ones in post monsoon period
was significantly higher (p < 0.001), than during the remaining period with 92% of total annual
cases reported during this period.

Table 1. Month wise distribution of clinically diagnosed and serologically positive cases amongst
primary and secondary cases during the DF outbreak, 2003

Distribution by age

Out of 893 serologically positive cases, 687 cases belonged to the adult's age group (> 12 years)
and 206 cases to pediatric age group (≤ 12 years) in this study. Larger proportions of
serologically positive cases were observed among adults, with a positive prevalence of 56.4%
among children and 58% among adults, distribution was however, not significantly different
when compared with pediatric age group (p > 0.05). The difference between numbers of
serologically positive cases among adult and pediatric group in post monsoon period as
compared to the rest of the season was also not significant (p > 0.05) (Table 2).

Table 2. Month wise distribution of serologically positive cases amongst children and adults
during the DF outbreak, 2003

Climatic influence

Fig. 2a indicates that outbreak coincided mainly with the post monsoon period of subnormal
rainfall (Cumulative rainfall = 30.3 mm) from October to December 2003 and was followed by
relatively heavy rainfall during the monsoon period; from June to September 2003. The
difference in the rainfall and temperature between three seasonal periods was found to be
significant (p < 0.05) (Fig. 2a &2b). Mean ambient temperature was 25.4°C during the pre
monsoon period, which increased to 30.9°C during the monsoon period; the period preceding the
outbreak and decreased to 20.3°C (Mean temperature from October to December) in the actual
outbreak months during the post monsoon period. The difference between relative humidity
during the three periods was not significant. The mean relative humidity was 71.2% during the
pre monsoon period. It increased during the monsoon period to 85% and increased further
during the post monsoon period to 90% (Fig. 2c).

Figure 2. a: Month wise distribution of serologically positive cases of dengue fever /dengue
hemorrhagic fever and rainfall in Delhi for the year 2003 b: Month wise distribution of
serologically positive cases of dengue fever /dengue hemorrhagic fever and temperature in Delhi
for the year 2003 c: Month wise distribution of serologically positive cases of dengue fever
/dengue hemorrhagic fever and relative humidity in Delhi for the year 2003

Discussion

In the year 2003, India had experienced one of the wettest monsoons in 25 years, which led to a
spate of mosquito growth creating an alarming situation of mosquito borne diseases in Delhi and
many other states [16]. As a consequence to this unusually heavy rain, an outbreak of dengue
fever was once again reported from Delhi after a silence of six long years. Most of vector borne
diseases exhibit a distinctive seasonal pattern and climatic factors such as rainfall, temperature
and other weather variables affect in many ways both the vector and the pathogen they transmit
[17]. Worldwide studies have proposed that ecological and climatic factors influence the
seasonal prevalence of both the A. aegypti and dengue virus [2-4]. The vector mainly responsible
for the spread of DI is present at the basal level all the year around in Delhi, however, studies on
the relative prevalence and distribution have shown the highest A. aegypti larval indices during
the monsoon and post monsoon period [13-15]. Since limited data is available on the affect of
climatic factors on the pattern of DI, this study was planned to carry out the month wise detailed
analysis of three important climatic factors such as rainfall, temperature and relative humidity on
the pattern of DI.

Observations on the seasonality were based on a single year's data as the intensity of sampling
was at its maximum during this outbreak period. The outbreak coincided mainly with the post
monsoon period of subnormal rainfall, which was followed, by relatively heavy rainfall during the
monsoon period; from June to September 2003. The difference in the total rainfall and
temperature during three seasonal periods was found to be statistically significant (p < 0.05).
Monthly weather data showed that temperature variations were more amongst different months
during the pre monsoon and post monsoon period as compared to the monsoon period. Even
though, the monsoon season began in mid- June, there was no respite from the heat as there
was not much difference in the temperature during the last month of pre monsoon; May and
beginning of monsoon in the June. Unusual heavy rainfall subsequently led to decrease in
temperature during the later part of monsoon period. The temperature showed a decline and
remained almost constant during the months of July and August (30.2°C), continuous heavy
rainfall subsequently led to further decrease in the temperature during the month of September
to 29°C. Relative humidity increased during the rainy season and remained high for several
weeks. An in-depth analysis of these three factors thus led to a proposal that optimum
temperature with high relative humidity and abundant stocks of fresh water reservoirs generated
due to rain, developed optimum conditions conducive for mass breeding and propagation of
vector and transmission of the virus.

Our study was in tune with a previous study by NICD of seasonal variations and breeding pattern
of A. aegypti in Delhi, which showed that there are two types of breeding foci, namely; primary
and secondary breeding foci. Primary breeding foci served as mother foci during the pre
monsoon period. A. aegypti larvae spread to secondary foci like discarded tyres, desert coolers
etc., which collect fresh water during the monsoon period [14]. This study supported the
proposal that all the three climatic factors studied could be playing an important role in creating
the conducive condition required for breeding and propagation of this vector, the basal level of
which is present all round the year. This prospective study therefore highlighted the major
important factors, which could alone or collectively be responsible for an outbreak.

In our study, the largest proportion of serologically positive cases was recorded in the post
monsoon period, which is in agreement with our previous study [12]. Our findings were in
coordination with study by other groups from this geographical region [13-15]. The seasonal
occurrence of positive cases has shown that post monsoon period is the most affected period in
Bangladesh as well [18]. However, a retrospective study from Myanmar during 1996–2001
reported the maximum cases of dengue during the monsoon period [19]. Study by group of
Rebelo from Brazil has also emphasized the importance of season. They have observed that
dengue cases were higher during rainy season showing the importance of rain in forming prime
breeding sites for A. aegypti thus spread of DI [20]. Study of eco-epidemiological factors by
Barrera et al [21] showed that DF has a positive correlation with the relative humidity and
negative relation with evaporation rate. Peaks of dengue cases were observed to be near
concurrent with rain peaks in this study from Venezuela showing a significant correlation of
intensity of DI with the amount of rain [21]. In this study we have observed that temperature
tends to decrease towards the end of monsoon period, specially remains moreover constant
during the later months of rainy season. India and Bangladesh fall in the deciduous, dry and wet
climatic zone. The temperature remains high during the pre monsoon period. It is continuous rain
pour for a couple of days that brings down the temperature during the monsoon period, which
may also be responsible for an increase in the relative humidity and decrease in the evaporation
rate thus maintaining secondary reservoirs containing rain water. More studies are needed to
establish the relationship between the climatic changes and dengue outbreaks, which would help
in formulating the strategies and plans to forecast any outbreak in future, well in advance.

Very little dengue is found in adults in Thailand, presumably because people acquire complete
protective immunity after multiple DI as children [1], as DI is highly endemic in Thailand [22]. On
the other hand, DI especially DHF is an emerging disease in India; probably this may be the
reason that people of all the age are found to be sensitive to infection in our study. Even though
more adults were reported of having anti dengue antibodies, the difference in the number of
positive cases was not significant as compared to pediatric age group.

The severity of this outbreak was lesser as compared to the DHF epidemic that occurred in year
1996 caused by the serotype Den-2 [23]. Serotype Den-2 is reported to be the one mainly
associated with DHF, the more severe form of the disease [24,25]. More studies in this regard
can further elucidate correlation of serotypes with severity of disease from this geographical
region.

Conclusion

This prospective study highlighted rain, temperature and relative humidity as the major and
important climatic factors, which could alone or collectively be responsible for an outbreak. More
studies in this regard could further reveal the correlation between the climatic changes and
dengue outbreaks, which would help in making the strategies and plans to forecast any outbreak
in future well in advance.

Materials and methods

Study design, population and sample size

The present study was conducted retrospectively for a period of one year during the recent
outbreak of dengue fever in Delhi in the year 2003. The study population comprised individuals
of all age groups, attending the outpatient and inpatient departments of Lok Nayak Hospital, a
tertiary care hospital in Delhi. Blood samples were collected from 1550 patients experiencing a
febrile illness clinically consistent with dengue infection, selected according to the following
inclusion and exclusion criteria.

Case-inclusion criteria

A case was included if there was high fever with clinical symptoms suggestive of dengue
infection as per WHO criteria [26].

Case-exclusion criteria
A case was excluded, if routine laboratory testing suggested bacterial or any viral infection other
than dengue infection or any other disease [26].

Microscopy for malaria identification

Venous blood was used for blood slide preparation for malaria parasite examination. Thick and
thin blood films were prepared on the same slide, stained with Giemsa and examined for the
presence of malaria parasite.

Laboratory confirmation of dengue infection by serology

Dengue Duo IgM and IgG Rapid Strip test (Pan Bio, Australia) was used for the detection of
dengue-specific antibodies. 1 μl of serum was mixed with 75 μl of buffer (supplied in the kit) and
test strip was dipped in to the diluted serum. Results of the test were read after 30 minutes.
Serum antibodies of the IgM or IgG class, when present bind to anti-human IgM or IgG
immobilized in two lines across the test strip. Colloidal gold-labeled anti-dengue monoclonal
antibodies form complexes with the dengue antigen that is captured by dengue specific IgM or
IgG in the patient's serum. These complexes were visualized as pink/purple line(s). The presence
of anti-dengue IgM antibodies alone indicated primary infection. In contrast, presence of anti-
dengue IgG antibodies with or without IgM indicated secondary infection. (IgG antibodies alone
was considered as suspected secondary infection as it could also be due to cross reactivity with
other flaviviruses).

Analysis of metrological data

Monthly details of total rainfall, temperature and relative humidity for all the months of the year,
2003 were obtained from Meteorological Department of Delhi, Mausum Bhawan, New Delhi and
retrospectively analyzed in relation to total number of dengue cases. According to the intensity
of the rainfall, weather data was divided in three periods namely; pre-monsoon period: from
February- May, monsoon period: from June – September and post monsoon period: from October
– January.

Competing Interests

The author(s) declare that they have no competing interests.

Authors' contributions

It is stated that both the authors 1) have made substantial contributions to conception and
design, or acquisition of data, or analysis and interpretation of data; 2) have been involved in
drafting the article or revising it critically for important intellectual content; and 3) have given
final approval of the version to be published.

Acknowledgements

We thank the Metrological Department of Delhi, Mausum Bhawan, India for providing the
monthly weather details of rainfall, temperature and relative humidity for the year 2003.
 EVIDENCED BASED NURSING
I. Clinical Question
What is the relationship of dengue infection with climatic factors?

II. Citation:

Eco-epidemiological analysis of dengue infection during an outbreak of dengue

fever, India, By Anita Chakravarti and Rajni Kumaria
III. Study Characteristics:
a. Patients included
The study population comprised individuals of all age groups, attending the
outpatient and inpatient departments of Lok Nayak Hospital, a tertiary care hospital
in Delhi. Blood samples were collected from 1550 patients experiencing a febrile
illness clinically consistent with dengue infection.

b. Intervention compared

All blood smears microscopically screened for malarial parasite were found to
be negative. Analytical interpretations presented in this study were based upon
instructions mentioned in the Pan Bio Rapid Strip Test procedure manual. During the
outbreak period, blood samples were collected from 1550 patients experiencing a
febrile illness clinically consistent with DI over the period of one year from January
to December 2003. Eight hundred ninety three cases (57.36%) were confirmed as
serologically positive, out of which 199 (22.28%) cases were positive for dengue-
specific IgM antibodies indicating primary infection and 381 (42. 67%) cases were
positive for both dengue-specific IgM and IgG antibodies indicating secondary
 infection (Figure 1). IgG antibodies alone were also detected in 313 (35.05%) cases
and these cases were presumed to be either suspected secondary dengue infection
as IgG positivity alone could also be due to cross reactivity with other flaviviruses.
The difference between numbers of serologically positive cases reported during
different months was significant (p < 0.05).
c. Outcome monitored
To investigate the on what is the relationship of dengue infection with
climatic factors.

d. Does the study focus on the significant problem in clinical practice?

The study, itself play a very vital role in clinical scenario nowadays. We are
aware that many people are having dengue nowadays because it is rainy season.
And if this study will pursue to know if what is the relationship of dengue infection
with climatic factors, it will be a more concern issue, and through this, they will
have a chance to improve their way on how to approach on this kind of case and if
this happens. There will also be a possibility to lessen the prevalence and incidence
of the disease acquired.

IV. Methodology/Design

a. Methodology

Venous blood was used for blood slide preparation for malaria parasite
examination. Thick and thin blood films were prepared on the same slide, stained
with Giemsa and examined for the presence of malaria parasite.

Dengue Duo IgM and IgG Rapid Strip test (Pan Bio, Australia) was used
for the detection of dengue-specific antibodies. 1 μl of serum was mixed with 75 μl
of buffer (supplied in the kit) and test strip was dipped in to the diluted serum.
Results of the test were read after 30 minutes. Serum antibodies of the IgM or IgG
class, when present bind to anti-human IgM or IgG immobilized in two lines across
the test strip. Colloidal gold-labeled anti-dengue monoclonal antibodies form
complexes with the dengue antigen that is captured by dengue specific IgM or IgG
in the patient's serum. These complexes were visualized as pink/purple line(s). The
presence of anti-dengue IgM antibodies alone indicated primary infection. In
contrast, presence of anti-dengue IgG antibodies with or without IgM indicated
secondary infection. (IgG antibodies alone was considered as suspected secondary
infection as it could also be due to cross reactivity with other flaviviruses).

b. Design
Population-based case-control study.

c. Setting
In the year 2003, India had experienced one of the wettest monsoons in 25
years, which led to a spate of mosquito growth creating an alarming situation of
mosquito borne diseases in Delhi and many other states.

d. Data sources
 From Department of Microbiology, Maulana Azad Medical College, Associated
Lok Nayak Hospital, Bahadur Shah Zafar Marg New Delhi-110002, India

e. Has the original study been replicated?

The original study became the basis of thought about the relationship of
climate factors with dengue. The study had been replicated as we also have
compilation of information of the data about the disease. We have found out that
their study is not replication of the original one but an emphasis that climate has
something to do in having a dengue outbreak.

f. What were the risks and benefits of the nursing actions/ interventions
tested in the study?

This study supported the proposal that all the three climatic factors studied
could be playing an important role in creating the conducive condition required for
breeding and propagation of this vector, the basal level of which is present all round
the year. This prospective study therefore highlighted the major important factors,
which could alone or collectively be responsible for an outbreak.

V. Results of the study

All blood smears microscopically screened for malarial parasite were found to
be negative. Analytical interpretations presented in this study were based upon
instructions mentioned in the Pan Bio Rapid Strip Test procedure manual. During
the outbreak period, blood samples were collected from 1550 patients experiencing
a febrile illness clinically consistent with DI over the period of one year from January
to December 2003. Eight hundred ninety three cases (57.36%) were confirmed as
serologically positive, out of which 199 (22.28%) cases were positive for dengue-
specific IgM antibodies indicating primary infection and 381 (42. 67%) cases were
positive for both dengue-specific IgM and IgG antibodies indicating secondary
infection (Figure 1). IgG antibodies alone were also detected in 313 (35.05%) cases
and these cases were presumed to be either suspected secondary dengue infection
as IgG positivity alone could also be due to cross reactivity with other flaviviruses.
The difference between numbers of serologically positive cases reported during
different months was significant (p < 0.05).

DI is observed to be a seasonal disease in Delhi. According to intensity of

rainfall, weather data was divided in three periods, namely; pre monsoon period:
from February- May, monsoon period: from June – September and post monsoon
period: from October – January. Few cases clinically suspected of dengue infection
in the pre monsoon period were later found to be serologically negative for dengue-
specific antibodies. During the monsoon period, only 3 cases (0.34%) were
confirmed serologically positive in the month of August, and 68 cases (7.6%) in the
September. Dengue-specific antibody positive cases were mainly reported during
the post monsoon period with maximum number of cases 583 (65.3%) cases
reported during the month of October followed by 230 (25.76%) cases in the
November (Table 1). The difference between numbers of serologically positive cases
as compared to serologically negative ones in post monsoon period was
 significantly higher (p < 0.001), than during the remaining period with 92% of total
annual cases reported during this period.

VI. Author’s Conclusions/Recommendations

a. What contribution to the client health status does the nursing

action/intervention make?

Persons who have stag e dengue can be treated with cleaning of surroundings
and by placing cover on the container with water.. The higher stage of gangue should
be treated with drugs to reduce blood pressure

b. What contribution to nursing knowledge does the study make?

It gave the nurse more additional knowledge on the health implication on the
said condition further it makes the nurse more prepared on certain ideas and
practices on how to avoid the said condition

VII. Applicability

a. Does the study provide a direct enough answer to your critical question in
terms of type of patients, interventions and outcome?

Clinical questions have been supplemented. The only thing is that the subject
involved in the said study is only focusing on one point of view rather it is specific
study. But the interventions and outcomes has been spoon fed and supplied.

b. Is it feasible to carry out the nursing action in the real world?

As the group, brain storming, we thought that it can be carry out by primary
care giver in the real setting, but there are some considerations. National and
international groups have issued guidelines for the treatment of dengue and its
relationship to climate factors.

Reviewer’s Conclusion/ Commentary

This prospective study highlighted rain, temperature and relative humidity as

the major and important climatic factors, which could alone or collectively be
responsible for an outbreak. More studies in this regard could further reveal the
correlation between the climatic changes and dengue outbreaks, which would help
 in making the strategies and plans to forecast any outbreak in future well in
advance.

VIII. Evaluating Nursing Practices

a. Safety
• Search and destroy
• Self- Protection measures
• Seek early consultation
• Say no to indiscriminate fogging
• Use insecticide
.
b. Competence of the care provider
Prevention through proper health teaching is one major role of a health care
provider.

c. Acceptability
The initial treatments made by the said study make an assurance that there is
really a relationship between climate factors especially rainy seasons with dengue
outbreaks.

d. Effectiveness
The study is effective enough to determine whether there is a relationship between
climate factors with dengue

e. Appropriateness
This study is appropriate in most dengue clients and even those who are prone to
be.

f. Efficiency
This study is useful in every aspect of living of an individual since it explains the
importance proper living and having a clean environment especially in rainy
seasons in order to attain a healthful body.

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