Casepres Final+Ebn 1 Dengue

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    INTRODUCTION

    Dengue is transmitted by the bite of anAedes mosquito infected with any one of the four dengueviruses. It occurs in tropical and sub-tropical areas of the world. Symptoms appear 314 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 years old

    Gender : Male

    Address : 53 Pangako st. Bagong Barrio, Caloocan City Religion : Roman Catholic

    II. Nursing History

    A. Past Health HistoryThe 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 heexperiences asthma attack. He does not take any vitamins only drug maintenance which issalbutamol ventolin for asthma. The client has once been admitted and confined in the hospitalabout a year ago due to difficulty of breathing.

    B. History of Present IllnessThe 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 anddifficulty of breathing and was advised by the health care provider to go to a hospital afterobtaining a laboratory tests which indicates a low platelet count. He was requested for anadmission but was not been admitted since the illness that occurred can be maintained asexplained by a health care provider in the said clinic since no signs and symptoms of denguewere seen. The client was advised to have drug maintenance such as antibiotics, vitamin C, andanalgesics if fever occurs again.

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    C. Family History

    Genogram:

    Legends:

    - Female - client

    - Male - with asthma

    - deceased

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    III. PATTERNS OF FUCTIONING

    A. Coping Patterns

    The grandmother who stands as the guardian of the child said that the client experiencesdifficulty in breathing and wasnt 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. Theguardian said that she maintains the health of the child by complying with the medicationsprescribed by the physician for asthma. She sometimes gets worried and afraid for hergrandchild 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 hasplaymates in the neighborhood with the same age as his. Palakaibigan yang apo ko na yan kasonga lang minsan eh sinusumpong iyak ng iyak tuloy lagging hirap huminga kaya hinihingalpalagi.. Para bang nauubusan ng hangin.. the grandmother said. The child mingles with others ifhe 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 walangsumpong, 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 wellbalanced diet but her mind setting at times changes when the client becomes ill and so does notfunction properly. For the childs cognitive functioning, the client learns more words asverbalized during the interview. According to the grandmother, the client uses any forms ofsymbols to remember several thought processes. The grandmother verbalized that Marami ngnatututunan yung apo ko. Madali niyang natatandaan yung mga nakikita niya sa TV lalo na pagcartoon 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 hisacts and gestures especially when his with other children. Minsan kasi pag may kasamang batayan bigla nalang iiyak.. pati kalaro niya.. eh siguro ganun lang talaga syempre bata yan eh.. Thegrandmother sees the health of her grandchild in a way that it changes like for example whenthe client gets ill, she thinks that her grandson is unhealthy but when the child plays actively andeats well her perception changes.

    E. Emotional Pattern

    According to the grandmother, when the client feels unhappy, he usually cries anddemands for something he wants. When the client experiences joy, it too shows through hisreactions and features. Mabait yang apo ko. Masayahin pag walang sumpong tsaka pagnandyan yung mga kalaro niya.. kaya lang pag tinoyo nako! magwawala yan lalo na pag hindinasunod gusto niya.. said the grandmother.

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    IV. Physical Assessment

    BODY PARTS Norms Actual Findings Interpretation

    and AnalysisGeneral Appearance

    Personalhygiene/Grooming

    Neat and cleanNo distress noted inpostureHealthy in appearance

    Dirty and unkemptNo distress notedWeakness andpresence of lesions

    Poor personalhygieneNormalPresence of illness inbreathing

    Measurements

    Temperature

    Pulse Rate

    Respiratory Rate

    36.5-37.5C75-120bpm1-25cpm

    36.8C105bpm14cpm

    NormalTachycardiaBradypnea

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    V. Laboratory Results (N/A)

    VI. Drug Study

    SKULL Nodules or massesand depressions inthe skull

    Smooth, uniform,consistency; absenceof nodules or masses

    There are presentnodules or massesseen and palpatedon his skull.

    Presence of skindisease

    Palpebral conjunctiva Shiny, smooth, pink orred in color

    Shiny, smooth, andpale in color.

    Possible anemia

    Nose External nose Symmetric and straight

    No discharge or flaring

    Uniform color

    Not tender, no lesions

    It is symmetric andstraight.

    Discharges present

    It has uniform color.

    There is notenderness andlesions.

    Normal

    Presence of discharges myindicate an illness(colds)

    Normal

    Normal

    Teeth Smooth, white, shinytooth enamel.

    Brown discolorationof the enamel

    Indicates dentalcaries

    Thorax

    Anterior thorax Quite, rhythmic, andeffortless respiration

    Quite, abnormallyslow, and difficultbreathing

    Indication of bradypnea, anddyspnea

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    VII. Ecologic Model

    Hypothesis: The Dengue Feveris caused by a bite of the mosquito particularly the Aedes

    Aegypti which is carrying a virus.

    Generic/Trade

    Action Dosage Indication Contraindication

    AdverseRreaction

    NursingResponsibilit

    esAmoxicillin(Amoxil)

    Preventsbacterialcell wall

    synthesisduringreplication.Bactericidal.

    Oraladministration, 3

    ml 3x aday

    Treatmentof infections of

    respiratorytract, skinto skinstructure.

    Hypersensitivity to penicillin,cephalosporino

    r imepenem.Not use totreat severepneumonia,empyema,bacterimia,pericarditis,meningitis andprululent orseptic arthritisduring acutestage.

    Dizziness,fatigue,insomnia,

    urticaria,maculopapularto exfoliativedermatitis,vesiculareruptions, skinrashes, sore ordry mouth ortongue.

    Obtainpatientshistory of

    allergy.Assess thepatient forsigns andsymptoms ofinfection,woundcharacteristicsurine andstool.Assess patientfor previoussensitivityreaction topenicillin orothercephalosporin.Assess forallergicreactionsduring thetreatment.Assess forbowel patternand signs andsymptoms ofdehydration.Monitor forbleeding.Assess for ovegrowth ofinfection.

    Agent:Aedes

    Aegypti

    Host: Patient X

    Age

    Low level of

    immunity

    Environment:

    -climate(rainy

    season)

    -stagnant water

    -improper

    garbage disposal

    - Filthy house

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    Explanation:

    With the clients age of only 2 yrs old and 8 months, we all know that the child still

    has a low level of immunity thus making him prone to acquire the said communicable

    disease, the dengue 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 to 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, and 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

    had helped the vector to have a breeding site near to her possible victims.

    VIII. Pathophysiology

    Pathophysiology of Dengue Fever

    Predisposing

    Factors:

    -age

    climate(rainy

    season)

    -stagnant water

    -improper garbage

    disposal

    - Filthy house

    Signs and Symptoms:

    Headaches

    Severe pain behind the eyes

    Fever, chills

    Red throat

    Nasal congestion

    Muscle pain

    Bone pain

    Skin symptoms:

    Reddened skin

    Increased sensitivity of skin to touch

    Skin rash

    Loss of appetite

    Nausea

    Vomiting

    Minor bleeding from, nosebleeds

    Liver and spleen enlargement

    Malaise

    Dengue Fever

    Caused by a bite of female Aedes

    Aegypti who is infected (carrying a

    arbovirus)

    Once in the body, the virus travels to various

    glands where it multiplies

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    Spleen and lymph nodes become

    enlarged, and patches of liver tissue die

    Vessels swell and leak.

    Presence of the virus within the blood

    vessels causes changes to these blood

    vessels

    Virus can then enter the bloodstream

    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, andsevere aches in the legs and joints, lose

    of appetite,nose bleeding

    Given immediate Intervention but stillunder observation

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    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 multipliesThe 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 andleak. The spleen and lymph nodes become enlarged, and patches of liver tissue die. A processcalled disseminated intravascular coagulation (DIC) occurs, where chemicals responsible forclotting 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. Duringthis time (lasting about five to eight days) the virus multiplies. Symptoms of the disease appearsuddenly and include high fever, chills, headache, eye pain, red eyes, enlarged lymph nodes, ared 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

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    X.Nursing Care Plan

    Cues NursingProblem

    Analysis Goal/Objective

    Intervention

    Rationale

    Evaluation

    O:36.8C105bpm14cpm

    Discharges present

    S: Theguardianof thechild saidthat theclientexperiencesdifficultyinbreathing

    Ineffective

    airwayclearancerelatedtoasthma

    Inabilityto clear

    secretionorobstruction fromtherespiratory tract tomaintaina clearairway

    Goal: Afterthe shift, the

    patient willbe able tomaintainairwaypatency

    Objectives:1. After 10

    minutesofnursingintervention, thenursewill beable tomonitorrespiration andbreathsounds

    2. After 10minutesofnursingintervention, thepatientwill beable toknowhow topositionhis head

    3. After 30minutesofnursingintervention, thepatientwill beable todo thedeep-breathing and

    Monitorrespiration andbreathsounds

    Positionhis headappropriate forage/condition

    Encourage deep-breathingandcoughingexercise

    Encourage toincreasefluid

    Indicativeofrespiratory distressand/oraccumulation ofsecretions

    To openormaintainopenairway inat-rest orcompromisedindividuals

    Tomaximizeeffort

    Forhydration

    After theshift, the

    client wasbe able tomaintainairwaypatency

    Nursing Diagnosis Rank Justification

    Ineffective AirwayClearance

    1 This problem must begiven the first prioritybecause this will lead tomore serious problems.Airway must give moreattention than otherproblems. If this problemresolve, we will be ablemanage and promote

    clients health andwellness.

    Risk for Infection 2 Even though this problemwas just a risk, we wouldlike to manage this nextbecause complicationmight occur if this problem

    will not give attention.

    Risk for Injury 3 This was given the leastpriority because the clientcan assist by his guardianand prevent from anyinjury.

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    coughingexercise

    4. After 10minutesofnursingintervention, theclient willbe abletoincreasefluidintake atleast200ml/day

    5. After 20minutesofnursingintervention, theclient willbe ableto haveadequaterestperiods

    intake atleast200ml/day

    Encourageopportunities forrest; limitactivitiesto level ofrespiratorytolerance

    Prevents/reducesfatigue

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    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 suchas rainfall, temperature and relative humidity during the dengue fever epidemic in the year2003. Blood samples were collected from 1550 patients experiencing a febrile illness clinicallyconsistent with dengue infection. Serological confirmation of Dengue Infection was done usingDengue Duo IgM and IgG Rapid Strip test (Pan Bio, Australia), which detected dengue-specificantibodies. Monthly data of total rainfall, temperature and relative humidity for the year 2003was 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. Thedifference between numbers of serologically positive cases during different months wassignificant (p < 0.05). Larger proportions of serologically positive cases were observed amongadults. Outbreak coincided mainly with the post monsoon period of subnormal rainfall. Thedifference between serologically positive cases as compared to serologically negative ones inpost monsoon period was significantly higher (p < 0.001). The difference in the rainfall andtemperature between three seasonal periods was significant (p < 0.05).

    Conclusion

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

    Background

    Dengue infection (DI) is amongst the most important emerging viral diseases transmitted bymosquitoes to humans, in terms of both illness and death [1]. The worldwide large-scalereappearance of dengue for the past few decades has turned this disease into a serious publichealth 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 beencirculating in this region, ecological and climatic factors are reported to influence the seasonalprevalence of the dengue vector, Aedes aegypti, on the basis of which countries in this regionare divided in to four zones with different DF/DHF transmission potential [5]. In most of thecountries, 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-limiteddisease. In recent years, the disease has changed its course manifesting in the severe form asDHF, with increasing frequencies [10] Delhi City (India) is home to more than 13 million peopleand is endemic for DI [11]. Overpopulation has consequently led to poor sanitary conditions andwater logging at various places. A major epidemic of DHF from Delhi was last reported in the

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    year 1996 after which DI became a notifiable disease and a number of policies were formulatedto bring the DI as well as its vector under control. The retrospective studies, one conducted by usduring the period, 19972001 and another by National Institute of Communicable Diseases(NICD), New Delhi during the year 1997, have observed a decline in the number of cases havingeither DF or DHF in the following years [12,13]. Although, the vector mainly responsible for thespread of DI is present all the year around in Delhi, studies on the relative prevalence anddistribution have shown the highestA. aegypti larval indices during the monsoon and postmonsoon period [13-15].

    In the year 2003, India had experienced one of the wettest monsoons in 25 years, which led to aspate of mosquito growth creating an alarming situation of mosquito borne diseases in manystates. Delhi experienced an outbreak of DF this year, after 6 years of silence. Studies conductedin the countries like Brazil, Indonesia and Venezuela, where DI is present either in epidemic orendemic form have suggested a correlation between weather and pattern of DI. Rain,temperature and relative humidity are suggested as important factors attributing towards thegrowth and dispersion of this vector and potential of dengue outbreaks [2-4]. Since limited datais available on the association of climatic conditions and the pattern of DI from this geographicalregion, this study was conducted to find out the relationship of dengue infection with climaticfactors such as the rainfall, temperature and relative humidity during the dengue outbreak in theyear 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 thePan Bio Rapid Strip Test procedure manual. During the outbreak period, blood samples werecollected from 1550 patients experiencing a febrile illness clinically consistent with DI over theperiod 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 fordengue-specific IgM antibodies indicating primary infection and 381 (42. 67%) cases were

    positive for both dengue-specific IgM and IgG antibodies indicating secondary infection (Figure1). IgG antibodies alone were also detected in 313 (35.05%) cases and these cases werepresumed to be either suspected secondary dengue infection as IgG positivity alone could alsobe due to cross reactivity with other flaviviruses. The difference between numbers ofserologically positive cases reported during different months was significant (p < 0.05).

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

    DI is observed to be a seasonal disease in Delhi. According to intensity of rainfall, weather datawas 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 clinicallysuspected of dengue infection in the pre monsoon period were later found to be serologicallynegative for dengue-specific antibodies. During the monsoon period, only 3 cases (0.34%) wereconfirmed serologically positive in the month of August, and 68 cases (7.6%) in the September.

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    Dengue-specific antibody positive cases were mainly reported during the post monsoon periodwith maximum number of cases 583 (65.3%) cases reported during the month of Octoberfollowed by 230 (25.76%) cases in the November (Table 1). The difference between numbers ofserologically positive cases as compared to serologically negative ones in post monsoon periodwas significantly higher (p < 0.001), than during the remaining period with 92% of total annualcases reported during this period.

    Table 1. Month wise distribution of clinically diagnosed and serologically positive cases amongstprimary 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 ofserologically positive cases were observed among adults, with a positive prevalence of 56.4%among children and 58% among adults, distribution was however, not significantly differentwhen compared with pediatric age group (p > 0.05). The difference between numbers ofserologically positive cases among adult and pediatric group in post monsoon period ascompared 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 adultsduring the DF outbreak, 2003

    Climatic influence

    Fig. 2a indicates that outbreak coincided mainly with the post monsoon period of subnormalrainfall (Cumulative rainfall = 30.3 mm) from October to December 2003 and was followed byrelatively heavy rainfall during the monsoon period; from June to September 2003. Thedifference in the rainfall and temperature between three seasonal periods was found to besignificant (p < 0.05) (Fig. 2a &2b). Mean ambient temperature was 25.4C during the premonsoon period, which increased to 30.9C during the monsoon period; the period preceding theoutbreak and decreased to 20.3C (Mean temperature from October to December) in the actual

    outbreak months during the post monsoon period. The difference between relative humidityduring the three periods was not significant. The mean relative humidity was 71.2% during thepre monsoon period. It increased during the monsoon period to 85% and increased furtherduring the post monsoon period to 90% (Fig. 2c).

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

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    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 aspate of mosquito growth creating an alarming situation of mosquito borne diseases in Delhi andmany 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 bornediseases exhibit a distinctive seasonal pattern and climatic factors such as rainfall, temperatureand 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 theseasonal prevalence of both theA. aegypti and dengue virus [2-4]. The vector mainly responsiblefor the spread of DI is present at the basal level all the year around in Delhi, however, studies onthe relative prevalence and distribution have shown the highestA. aegypti larval indices duringthe monsoon and post monsoon period [13-15]. Since limited data is available on the affect ofclimatic factors on the pattern of DI, this study was planned to carry out the month wise detailedanalysis of three important climatic factors such as rainfall, temperature and relative humidity onthe pattern of DI.

    Observations on the seasonality were based on a single year's data as the intensity of samplingwas at its maximum during this outbreak period. The outbreak coincided mainly with the postmonsoon period of subnormal rainfall, which was followed, by relatively heavy rainfall during themonsoon period; from June to September 2003. The difference in the total rainfall andtemperature during three seasonal periods was found to be statistically significant (p < 0.05).Monthly weather data showed that temperature variations were more amongst different monthsduring the pre monsoon and post monsoon period as compared to the monsoon period. Eventhough, the monsoon season began in mid- June, there was no respite from the heat as therewas not much difference in the temperature during the last month of pre monsoon; May andbeginning of monsoon in the June. Unusual heavy rainfall subsequently led to decrease intemperature during the later part of monsoon period. The temperature showed a decline andremained almost constant during the months of July and August (30.2C), continuous heavy

    rainfall subsequently led to further decrease in the temperature during the month of Septemberto 29C. Relative humidity increased during the rainy season and remained high for severalweeks. An in-depth analysis of these three factors thus led to a proposal that optimumtemperature with high relative humidity and abundant stocks of fresh water reservoirs generateddue to rain, developed optimum conditions conducive for mass breeding and propagation ofvector and transmission of the virus.

    Our study was in tune with a previous study by NICD of seasonal variations and breeding patternofA. aegypti in Delhi, which showed that there are two types of breeding foci, namely; primaryand secondary breeding foci. Primary breeding foci served as mother foci during the premonsoon period.A. aegypti larvae spread to secondary foci like discarded tyres, desert coolersetc., 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 creatingthe conducive condition required for breeding and propagation of this vector, the basal level ofwhich is present all round the year. This prospective study therefore highlighted the majorimportant 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 postmonsoon period, which is in agreement with our previous study [12]. Our findings were incoordination with study by other groups from this geographical region [13-15]. The seasonaloccurrence of positive cases has shown that post monsoon period is the most affected period inBangladesh as well [18]. However, a retrospective study from Myanmar during 19962001reported the maximum cases of dengue during the monsoon period [19]. Study by group of

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    Rebelo from Brazil has also emphasized the importance of season. They have observed thatdengue cases were higher during rainy season showing the importance of rain in forming primebreeding sites forA. aegypti thus spread of DI [20]. Study of eco-epidemiological factors byBarrera et al [21] showed that DF has a positive correlation with the relative humidity andnegative relation with evaporation rate. Peaks of dengue cases were observed to be nearconcurrent with rain peaks in this study from Venezuela showing a significant correlation ofintensity of DI with the amount of rain [21]. In this study we have observed that temperaturetends to decrease towards the end of monsoon period, specially remains moreover constantduring the later months of rainy season. India and Bangladesh fall in the deciduous, dry and wetclimatic zone. The temperature remains high during the pre monsoon period. It is continuous rainpour for a couple of days that brings down the temperature during the monsoon period, whichmay also be responsible for an increase in the relative humidity and decrease in the evaporationrate thus maintaining secondary reservoirs containing rain water. More studies are needed toestablish the relationship between the climatic changes and dengue outbreaks, which would helpin 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 completeprotective immunity after multiple DI as children [1], as DI is highly endemic in Thailand [22]. Onthe other hand, DI especially DHF is an emerging disease in India; probably this may be thereason 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 ofpositive 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 year1996 caused by the serotype Den-2 [23]. Serotype Den-2 is reported to be the one mainlyassociated with DHF, the more severe form of the disease [24,25]. More studies in this regardcan further elucidate correlation of serotypes with severity of disease from this geographicalregion.

    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. Morestudies in this regard could further reveal the correlation between the climatic changes anddengue outbreaks, which would help in making the strategies and plans to forecast any outbreakin 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 recentoutbreak of dengue fever in Delhi in the year 2003. The study population comprised individualsof 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 afebrile illness clinically consistent with dengue infection, selected according to the followinginclusion and exclusion criteria.

    Case-inclusion criteria

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

    Case-exclusion criteria

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    A case was excluded, if routine laboratory testing suggested bacterial or any viral infection otherthan dengue infection or any other disease [26].

    Microscopy for malaria identification

    Venous blood was used for blood slide preparation for malaria parasite examination. Thick andthin blood films were prepared on the same slide, stained with Giemsa and examined for thepresence 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 ofdengue-specific antibodies. 1 l of serum was mixed with 75 l of buffer (supplied in the kit) andtest 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 IgGimmobilized in two lines across the test strip. Colloidal gold-labeled anti-dengue monoclonalantibodies form complexes with the dengue antigen that is captured by dengue specific IgM orIgG in the patient's serum. These complexes were visualized as pink/purple line(s). The presenceof 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 withother 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 andretrospectively analyzed in relation to total number of dengue cases. According to the intensityof the rainfall, weather data was divided in three periods namely; pre-monsoon period: fromFebruary- 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 anddesign, or acquisition of data, or analysis and interpretation of data; 2) have been involved indrafting the article or revising it critically for important intellectual content; and 3) have givenfinal approval of the version to be published.

    Acknowledgements

    We thank the Metrological Department of Delhi, Mausum Bhawan, India for providing themonthly weather details of rainfall, temperature and relative humidity for the year 2003.

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    EVIDENCED BASED NURSING

    I. Clinical QuestionWhat 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 includedThe study population comprised individuals of all age groups, attending the

    outpatient and inpatient departments of Lok Nayak Hospital, a tertiary care hospita

    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 tobe negative. Analytical interpretations presented in this study were based uponinstructions mentioned in the Pan Bio Rapid Strip Test procedure manual. During theoutbreak period, blood samples were collected from 1550 patients experiencing afebrile illness clinically consistent with DI over the period of one year from Januaryto December 2003. Eight hundred ninety three cases (57.36%) were confirmed asserologically positive, out of which 199 (22.28%) cases were positive for dengue-specific IgM antibodies indicating primary infection and 381 (42. 67%) cases werepositive for both dengue-specific IgM and IgG antibodies indicating secondary

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    infection (Figure 1). IgG antibodies alone were also detected in 313 (35.05%) casesand these cases were presumed to be either suspected secondary dengue infectionas IgG positivity alone could also be due to cross reactivity with other flaviviruses

    The difference between numbers of serologically positive cases reported duringdifferent 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 wil

    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 l of serum was mixed with 75 l

    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. DesignPopulation-based case-control study.

    c. SettingIn 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

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    From Department of Microbiology, Maulana Azad Medical College, AssociatedLok 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 thattheir 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/ interventionstested 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 factorswhich 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

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    significantly higher (p < 0.001), than during the remaining period with 92% of total

    annual cases reported during this period.

    VI. Authors Conclusions/Recommendations

    a. What contribution to the client health status does the nursingaction/intervention make?

    Persons who have stag e dengue can be treated with cleaning of surroundingsand by placing cover on the container with water.. The higher stage of gangue shouldbe 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 interms 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.

    Reviewers 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

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    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 providerPrevention through proper health teaching is one major role of a health care

    provider.

    c. AcceptabilityThe initial treatments made by the said study make an assurance that there is

    really a relationship between climate factors especially rainy seasons with dengueoutbreaks.

    d. EffectivenessThe study is effective enough to determine whether there is a relationship between

    climate factors with dengue

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

    be.

    f. EfficiencyThis 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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