Denga si febra hemoragica tip denga

Denga si febra hemoragica tip denga

Denga este o boala virala transmisa de tantarii din genul Aedes.

Virusul dengai este un arbovirus din genul Flavivirus caruia ii apartine si virusul febrei galbene. Exista patru tipuri de virus sau serotipuri ale dengai: virusul denga 1, 2, 3 si 4 (DEN 1, 2, 3 si 4) (Plansa     86).

Infectia de catre un serotip antreneaza o imunitate definitiva contra acelui serotip, dar nu exista imunitate incrucisata intre serotipuri. Astfel, este posibila imbolnavirea de 4 cu denga. Boala se manifesta prin simptome asemanatoare gripei, in special febre, dureri de cap, dureri musculare, dureri ale articulatiilor, dureri in spatele ochilor si usoare eruptii cutanee. Febra dureaza de la trei la cinci zile si rar mai mult de sapte zile. Totusi ea poate avea si o forma foarte grava febra denga hemoragica, ce se manifesta prin pierderea apetitului, ameteli, dureri abdominale intense, simptome de soc, sangerari nazale si subcutanate. Persoanele cu riscurile cele mai mari sunt cele care sufera de o a doua infectie sau sunt imunodeficitare. Uneori maladia este mortala.

Dintre arboviroze, denga constituie astazi cea mai serioasa problema de sanatate publica in regiunile tropicale si intertropicale (Plansa 87)

In 1995 Organizatia Mondiala a Sanatatii (OMS) a facut din lupta contra acestei maladii in plina expansiune geografica (semnalata in peste 100 de tari) in Asia, Pacific, in America de Sud, in America Centrala, in Caraïbe ca si in Africa, una dintre principalele sale prioritati. Se estimeaza ca, dintre cele 2 miliarde de persoane expuse riscului de a face denga, mai mult de 100 de milioane de cazuri vor fi declarate responsabile de peste 100.000 de decese.

Astfel denga face parte din grupul de boli infectioase hemoragice emergente ce pot evolua catre un soc hipovolemic ireversibil.

Pentru a reduce transmisia acestei infectii nu este disponibil nici un vaccin. Lupta contra vectorilor constituie la ora actuala singura strategie.

Aceasta infectie este raportata din ce in ce mai frecvent ca o boala a turistului si de aceea se impune uniformizarea mijloacelor de diagnostic clinic si biologic pentru a evalua incidenta dengai de import. Pe plan clinic, infectia poate fi asimptomatica intr-un mare numar de cazuri. Daca infectia este simptomatica, manifestarile sunt destul de polimorfe.

OMS, intr-un ghid publicat regulat inca din anii 70, distinge denga clasica sau DF (dengue fever) si denga hemoragica (DH)

Patogenul: Arbovirus, Familia Flaviviridae (Togaviridae); patru serotipuri, denga 1, 2, 3 si 4.

Vectorii: sunt tantarii, in special Aedes aegypti, Aedes albopictus,, Aedes scutellaris si Aedes polynesiensis.

Rezervoarele: nu sunt clar definite dar probabil este omul si unele maimute de padure din Malaiezia.

Denga este endemica in zona tropicelor, particular in Asia, Pacific si zona Caraibelor, dar tinde sa apara sub forma unor epidemii periodice. Forma clasica este o boala benigna caracterizata prin febra bifazica, mialgie sau artralgie si urticarie.

Febra hemoragica tip denga este o boala severa, adesea fatala, caracterizata de febra, soc, hemoragie acuta si mortalitate ridicata, in mod uzual afecteaza copiii de varsta frageda.

Caracteristicile clinice asociate cu febra denga includ neutropenia urmata de limfocitoza, semnalata adesea de limfocitele atipice.

A fost descrisa pentru prima data in Filipine in 1953, se stie ca apare in centre urbane din Asia de Sud-Est si este una dintre cauzele spitalizarii si a mortalitatii copiilor din Asia tropicala. In zona Caraibelor, ea fost semnalata prima data in forma epidemica in Cuba (1981), apoi a crescut numarul cazurilor sporadice din regiune. Se crede ca aceasta forma a bolii este un fenomen imunopatologic datorat infectiei cu mai multe serotipuri.

Este posibil ca denga sa fi existat si in zona Mediteraneana (de unde a disparut prin eradicarea lui Aedes aegypti Sunt dovezi ce sugereaza ca denga isi are originea in focare din Asia tropicala de unde s-a raspandit catre Africa. La origine serotipurile denga 1 si 2 au fost gasite in Africa de Vest, denga 2 in Africa de Est, Seychelles si La Reunion, denga 3 in Mozambic si denga 4 in Pacific. Se presupune ca transporturile aeriene rapide au introdus denga 1 din Africa si denga 4 din Pacific in zona Caraibelor unde se intalnesc ambele serotipuri.

Aedes aegypti este principalul vector pentru toate serotipurile si singurul vector din Lumea noua si Australia. In toate zonele in care este prezent Aedes aegypti acestea raman ca zone de risc potential pentru denga.

Aedes albopictus poate fi singurul vector din unele zone rurale din Sud-estul Asiei. Un episod de denga 2 din Seychelles s-a datorat lui Aedes albopictus, care a invadat Americile, raspandindu-se in 16 state din SUA, in Mexic si patru state din Brazilia. In Pacificul de Sud-vest, Aedes aegypti precum si alti membri ai complexului Aedes scutellaris, sunt principalii sau singurii vectori. Daca pana recent omul a fost considerat ca singura gazda pentru virusurile denga, Knudsen et al. (1977) si Rudnick (1983), lucrand in Malaiezia, au descoperit ciclul de jungla al dengai ce implica maimutele ce traiesc in canopeea padurii si tantarii din grupul Aedes niveus care se hranesc pe aceste maimute si pe om.

Transmisia transovariana a virusului a fost demonstrata pentru Aedes aegypti si Aedes albopictus, iar recuperarea virusului din larve de Aedes aegypti recoltate din teren in Birmania sugereaza posibilitatea transmisiei transovariene in natura.

Diagnosticul de laborator

Diagnoza definitiva a infectiei cu denga poate fi realizat numai in laborator si depinde de izolarea virusului, detectarea antigenului sau a ARN-ului viral in ser sau in tesuturi sau prin detectarea anticorpilor specifici in serul pacientilor.

Diagnosticul serologic

Urmatoarele teste serologice sunt utilizate de regula pentru diagnozarea infectiilor cu denga; inhibarea hemaglutinarii (HI), fixarea complementului (CF), testul de neutralizare (NT), capturarea imunoglobulinei M (IgM) (MAC-ELISA) si indirect imunoglobulina G ELISA.

Prevenire si control

Prevenirea si controlul dengai si a DHF este urgentata de extinderea distri­butiei sale geografice si de cresterea numarului de imbolnaviri in ultimii 20 de ani. Din nefericire, instrumentele pe care le avem la dispozitie pentru a preveni infectiile cu denga sunt foarte limitate. Nu exista nici un vaccin utilizabil in mod curent iar optiunile pentru controlul tantarilor sunt reduse. De aceea, este clar ca accentul trebuie pus pe masurile de prevenire a imbolnavirilor.

Programele eficiente de prevenire trebuie sa integreze cateva componente ce includ: supravegherea activa in laboratoare, raspunsul in caz de urgente, instruirea personalului medical pentru a asigura managementul eficient al cazurilor, controlul integrat al populatiilor de tantari si folosirea eficienta a vaccinurilor daca vor fi disponibile.

Dezvoltarea vaccinurilor

Primele vaccinuri-candidat contra dengai au fost produse la scurt timp de la prima izolare a virusului de catre oamenii de stiinta japonezi si americani. Cu toate eforturile depuse in timp nu s-a reusit realizarea unui vaccin sigur si eficient. OMS considera ca dezvoltarea unui vaccin tetravalent pentru a preveni denga constituie o prioritate.

Progrese promitatoare in dezvoltarea unor strategii alternative vaccinarii au fost obtinute recent cu ajutorul noilor tehnologii moleculare. Acestea se bazeaza pe utilizarea vaccinurilor-virion inactivate, a peptidelor sintetice si altele.

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Tabel 21. Tarile sau teritoriile unde s-au semnalat cazuri de febra
denga sau de febra denga hemoragica, 1975-1998.

PLANSA    86.

Ciclul virusului denga

Ciclurile de transmisie ale virusului denga.

PLANSA    87.

dupa Halstead

Evolutia geografica a dengai in treizeci de ani.