Dengue approach, classification and management.pptx

Dengue in Nepal, major outbreak, epidemiology, classification, approach, management

1. Dengue Dr. Sarmita Shrestha Intern Ninth Batch Patan Academy of Health Sciences School of Medicine

2. Case Definition Probable Dengue The person lived or travelled in an area of dengue transmission in last 14 days and has following signs and symptoms with or without any warning signs: Fever and two or more of following: Nausea, vomiting, rash, aches and pains, tourniquet test positive, leukopenia Confirmed Dengue Probable case with positive lab test – NS1 antigen positive or IgM positive

3. V ector-borne (mosquito-borne) viral disease. Dengue virus ( DENV)- single stranded RNA virus.  G enus Flavivirus & family Flaviviridae . 4 virus serotypes of DENV → DENV1, DENV2, DENV3, DENV4 Mosquito vectors: Aedes aegypti (primary) Aedes albopictus /Asian Tiger Mosquito (secondary )

4. EDCD Nepal

5. Since 2010, dengue epidemics have continued to affect lowland districts as well as mid-hill areas Reported outbreaks:  Chitwan , Parsa , Jhapa (2012-2013) Chitwan , Jhapa (2016) Rupandehi , Jhapa , Mahottari (2017) Kaski (2018) Sunsari , Kaski , Chitwan (2019)

6. Natural Course of Dengue Illness 1. Febrile Phase 2 . Critical Phase 3 . Recovery Phase

7. Tourniquet test

8. Investigations Following investigations should be sent for the patient with suspected Dengue visiting emergency 1. Dengue WITHOUT warning sign: CBC with hematocrit, Dengue serology (NS1, IgM, IgG) 2. Dengue WITH warning signs: Dengue serology (NS1, IgM, IgG), CBC with hematocrit, LFT (or SGPT/SGOT/Bili total), RFT, RBG

9. Immunological response Primary response  IgM antibodies appear about 5 days after symptoms onset and continue to rise up to 21 days and decrease gradually  IgG antibodies appear about 14 days after symptoms onset , persist for life in low level Secondary response  Weaker and shorter IgM response  Rapid IgG response (usually 2 days after reinfection)  High IgG level persists for 30-40 days

10. Early Stages of the disease: Virus can be detected in blood (serum, plasma) or tissues; methods employed are virus isolation, nucleic acid or antigen detection . At the end of Acute phase of infection: Serology is the method of choice . Dengue NS1 Antigen detection useful for the diagnosis of acute dengue infections . has been detected in the serum of DENV infected patients as early as 1 day post onset of symptoms (DPO ), and up to 18 DPO.

11. Serological tests Detection of Anti-dengue antibodies. IgM detection: Diagnosis of primary disease and in distinguishing dengue from other flavivirus infections. IgM antibodies are detectable in 99% of patients by day 10 after onset of illness. Sensitivity : 65-75% sensitive in single acute serum sample IgG Detection: useful in diagnosing secondary disease .

12. A variety of methods are available; IgM or IgG ELISA, Hemagglutination inhibition test, Rapid Diagnostic kits etc . Molecular diagnosis Nucleic Acid Amplification Test (NAATs) RT-PCR based methods for rapid identification and serotyping of dengue virus.

13. Differential diagnoses of dengue

14. Admission criteria from Emergency 1. Severe dengue or 2. Patients with following warning signs and/or comorbidities: a. Platelet: Adult < 50,000/cu mm, Children < 100,000/cu mm, or rapidly decreasing platelet counts b. BP< 90/60 mmHg, Children < 50th percentile or early signs of shock (tachycardia, cold clammy peripheries) c. Hematocrit > 50% or rising hematocrit above 20% of the baseline d. Pregnancy e. Infant

15. f. Elderly (over 65 years) g. Inability to tolerate oral fluid h. Intractable vomiting i. Severe abdominal pain or tenderness j. Clinical fluid accumulation (ascites, pleural effusion) k. Mucosal bleeding l. Lethargy, restlessness m. Comorbidities- Diabetes, Immunocompromised, Renal failure, Chronic liver disease, Malignancies ( active)

16. Admission Process 1. Patient with warning signs can be admitted to the ward by emergency team. The handover of the admission should be given to major duty resident of medicine. 2. Patient with severe dengue will be admitted by medical team from emergency 3. Pediatrics patient will be admitted by pediatric on duty from emergency

17. Management of Dengue Dengue without warning sign 1. May be sent home 2. Adequate bed rest 3. Adequate fluid intake 4. Tablet Paracetamol 1 gm 6 hourly for adult and 15mg/kg/dose 6 hourly for children 5. Patient needs to come back if: a . Development of warning signs b . No clinical improvement

18. c . Severe abdominal pain or persistent vomiting d. Lethargy or irritability or restlessness e. Bleeding f. Shortness of breath g. Not passing urine for more than 6 hours 6. Inform patient that this disease is due to virus and supportive management is the standard of care. So, patients usually improve on paracetamol, adequate amount of fluids , and antibiotics is not required.

19. Dengue with warning signs 1. Obtain HCT before fluid therapy 2. Give Normal Saline or Ringer lactate Start with 5-7 ml/kg/hour for 1-2 hour then Reduce to 3-5 ml/kg/hour for 2-4 hour then Reduce to 2-3 ml/kg/hour per hour 3. Reassess clinical status and repeat HCT If HCT remains the same or rises only minimally, continue with 2-3 ml/kg/hour for another 2-4 hour

20. If worsening of vital signs and rapidly rising HCT increase rate to 5-10 ml/kg/hour for 1-2 hour 4 . Reassess clinical status, repeat HCT and review fluid infusion rates accordingly Reduce IV fluids gradually when the rate of plasma leakage decreases towards the end of critical phase Adequate fluid output and/or fluid intake HCT decreases below baseline in a stable patient May use DNS for maintenance

21. 5. Monitoring a. Vital signs and peripheral perfusion b. Urine output and input-output charting c. Warning signs d. HCT (once a day in wards, 12-hourly in HDU, 4-6 hourly or as needed in ICU) e. Platelets (once a day) f. Blood glucose g. Other organ functions (renal profile, liver profile, coagulation profile as indicated )

22. Severe Dengue Treatment of Compensated shock 1. Give Normal Saline or Ringer lactate Start with 5-10 ml/kg/hour over 1 hour then Reduce to 5-7 ml/kg/hour for 1-2 hour then Reduce to 3-5 ml/kg/hour for 2-4 hour then Reduce to 2-3 ml/kg/hour per hour for 2-4 hour then reduce depending on hemodynamic status IV fluid can be maintained for up to 24-48 hours

23. 2 . If patient is still unstable Check HCT after first bolus If HCT >50% repeat second bolus at 10-20ml/kg/hour for 1 hour If improvement reduce to 7-10 ml/kg/hour for 1-2 hour then reduce as above 3. Decrease in HCT indicates bleeding and needs cross matching and blood transfusion

24. Treatment of Hypotensive Shock 1. Initiate IV fluid crystalloid/colloid solution at 20ml/kg in 15 minutes as a bolus If patient improves, give crystalloid/colloid solution at 10ml/kg/hour for 1 hour and reduce as above If patient is unstable, review the HCT taken before the first bolus HCT was low (<40% in children/adult females, < 45% in adult males): This indicates bleeding and needs crossmatching and blood transfusion HCT was high compared to the baseline value, change to I.V. colloids at 10-20 ml/kg as a second bolus over to 1 hour; reassess after second bolus

25. If improving reduce the rate to 7-10 ml/kg/hr. for 1-2 hours, then back to I.V. crystalloids and reduce rates as above. If condition still unstable, repeat Hct after second bolus. I f HCT decreases , this indicates bleeding I f HCT increases/ remains high (> 50%), continue colloid infusion at 10-20 ml/kg as a third bolus over 1 hour, then reduce to 7-10 ml/kg /hour for 1- 2 hours, then change back to crystalloid solution and reduce rate as above.

26. When to stop intravenous fluid therapy When any of the following signs are present, intravenous fluids should be reduced or discontinued: stable BP, pulse and peripheral perfusion hematocrit decreases in the presence of a good pulse volume apyrexia (without the use of antipyretics) for more than 24–48 hours resolving bowel/abdominal symptoms; improving urine output . Continuing intravenous fluid therapy beyond the 48 hours of the critical phase will put the patient at risk of pulmonary edema and other complications such as thrombophlebitis

27. Dengue infection with thrombocytopenia • Platelet transfusion if evidence of bleeding or platelet count less than 10,000 • Inform supervisor urgently Dengue Shock Syndrome • Inform supervisor urgently • If low hematocrit, blood transfusion • If normal hematocrit: Use colloid- 10 % dextran 40 in normal solution; 10ml/kg/hour in children ( 500 ml/hour in adults ) for 1 to 2 hours

28. The World Health Organization has established the following grading system for severity of dengue hemorrhagic fever: DHF Grade I – Fever, hemorrhagic manifestation (positive tourniquet test), and evidence of plasma leakage. DHF Grade II – DHF Grade I plus spontaneous bleeding. DHF Grade III – DHF Grade I or DHF Grade II plus narrowing pulse pressure or hypotension. DHF Grade IV – DHF Grade III plus profound shock with undetectable blood pressure and pulse .

29. Dengue shock syndrome consists of DHF Grade III and DHF Grade IV. Shock due to plasma leakage often presents with a narrow pulse pressure or elevated diastolic pressure with preserved systolic pressure, whereas S hock due to bleeding often presents with hypotension or low systolic pressure. Other causes of shock must also be considered (such as hypoglycemia, excessive vomiting, or bacterial coinfection).

30. Discharge criteria from ward 1. No fever for 48 hours 2. Clinical improvement 3. Increase in trend of platelet count 4. Stable hematocrit without IV fluid 5. No respiratory distress

31. Prevention advice to the patient going home Keep the family member with dengue fever in net all the time including day time Fumigate or spray with insecticide inside house and surroundings Cover any open containers and pour out water from any open pots or containers twice a week

32. Reporting All case of dengue needs to be reported to EWARS through record section of the hospital.

33. Dengue during pregnancy Pregnant people can transmit dengue virus to the fetus during pregnancy or around the time of birth. Dengue can have harmful effects, including death of the fetus, low birth weight, and premature birth . The potential for vertical transmission should be considered for mothers with dengue who are symptomatic late in pregnancy or at delivery. Newborns usually develop symptoms within 14 days of birth (commonly within the first week), but most babies are asymptomatic. Clinical presentation in babies varies from mild common symptoms of dengue to severe dengue with shock and hemorrhagic manifestations.

34. Challenges in recognition of dengue and plasma leakage in pregnancy Hyperemesis during the first trimester of pregnancy can resemble the warning signs of severe dengue and this may delay the recognition of severe dengue . After the second trimester of pregnancy it is normal to see an increase in circulating blood volume with generalized vasodilatation, resulting in an increased baseline heart rate and lower baseline BP, as well as a lower baseline hematocrit .

35. This can confuse the diagnosis of dengue and therefore clinicians need to be alert to the following: The lower BP and tachycardia of normal pregnancy could be misinterpreted as hypotensive shock. The lower baseline hematocrit after the second trimester of pregnancy should be noted. Establishing the baseline hematocrit during the first 2–3 days of fever is essential for early recognition of plasma leakage. Clinical signs of plasma leakage such as pleural effusion and ascites could be difficult to elicit in the presence of a gravid uterus.

36. Management of dengue in infants

37. Vaccine The first dengue vaccine, Dengvaxia ® ( CYD- TDV ) developed by Sanofi Pasteur was licensed in December 2015 and has now been approved by regulatory authorities in ~ 20 countries . Dengvaxia has been licensed and made available in some countries for people between the ages of 9 to 45 years . TAK-003 ( Qdenga )

38. CDC

39. Relevant article

40. References: Consensus Guideline for Management of Dengue at Patan Academy of Health Sciences (Department of Pediatrics, Medicine, GP and Emergency ) National Guidelines on Prevention, Management and Control of Dengue in Nepal, Epidemiology and Disease Control Division CDC WHO Uptodate

41. Thank You!