Capacity building: Dengue fever in 15 minutes

1

Epidemiological Situation in the World

2

• Last five decades an 300% increase occurred in the disease incidence;

• Estimates:– 50-100 million infections a year; – 20.000 deaths a year;– Outpatient and hospital costs: 514 – 1.394 dollars;– 264 life years lost per million inhabitants.

• Overburden on tropical countries: health system and economy.

Fonte: Global Strategy for dengue prevention and control, 2012-2020 , OMS.

Scenario

3

• The emergence and diffusion of all dengue serotypes from Asia to America, Africa, and Eastern regions of the Mediterranean represent a threat of pandemics.

Results of the Evaluation of Deaths

• Alarm and shock signs of dengue fever are not routinely researched.

• Health professionals have not been using the clinical staging prescribed by the Ministry of Health (MoH).

• Patient hydration levels were lower than those prescribed by the handbook.

• Laboratorial tests, such as blood cell count, which are necessary for the proper hydration and platelets’ dosage, were not solicited in the recommended frequency.

• Test results took longer than they should for the appropriate care of patients with dengue fever.

• The type of assistance (supervised) and the gap between reassessments were lower than the established by the Ministry of Health.

4

Conclusion: the high levels of mortality are correlated with the non-following of technical rules for the diagnosis and treatment of

cases of dengue fever, as established by the MoH

Dengue

• Dengue fever is a dynamic and systemic disease.

• The proper care depends on the early recognition of the alarm signs, the continued monitoring, the restaging of cases (dynamic and continued) and the prompt water reposition.

• The determinant factor of the severe forms of dengue fever are the vascular endothelial alterations, with plasmatic leakage, which leads to shock, expressed by hemoconcentration, hypoalbuminnemy and/or cavity spillage.

5

Alarm Signs: intense and continued abdominal pain, persistent vomiting, postural hypotension and/or lipothymy, painful hepatomegaly, mucosal bleeding or important hemorrhages (hematemesis and/or melena), drowsiness and/or irritability, decrease of diuresis, sudden decrease of body temperature or hypothermia, sudden increase of hematocrit, sudden drop of platelet count and breathing discomfort.

Dengue – Step by Step.

It is necessary to revise the clinical history of the patient, along with the complete physical exam at each reevaluation with the proper registration in pertinent instruments and consultation of the patient’s flow chart.

General Evaluation: clinical history, physical examination, fever characterization.

Search of alarm and/or shock signs.

Search of spontaneous or induced skin bleeding (Tourniquet test)

Search of comorbidities, special clinical situations and/or social risk ones.

Laboratorial exams (complete blood count) and specific exams for dengue fever.

Treatment

Follow-up plan

Notification

6

História Clínica

EXAME FÍSICO

HIPÓTESE DIAGNÓSTICACASO SUSPEITO CONDUTA

Dengue

• In dengue fever, the leukogram is variable (leucopenia may indicate another viral infection and leukocytosis does not eliminate the disease);

•Thrombocytopenia does not necessarily constitute a risk factor to bleeding in patients with suspected dengue fever, but the progressive decrease in platelet count indicates the need for closer monitoring, for it indicates the patient may suffer complications, which will be considered an alarm sign.

7

Warning: The complete blood count (CBC) is mainly used to assess the hematocrit, to identify hemoconcentration.

Hemoconcentration indicates the likely alteration of capillary permeability (plasmatic leakage), associated with severity, as well as defining the need for hydration and response to instituted reposition therapy.

Dengue - CBC Hematocrit One hematocrit at the beginning of the feverish phase establishes the personal basal

value of the patient; From first through third day - generally normal; Rising hematocrit: establishes the beginning of the Critical Phase; The value is directly proportional to the severity; An increase of the hematocrit, compared to the prior result, is highly suggestive of an evolution to the critical phase of the disease, with plasma leakage.

Hct Increased Hematocrit

Children > 38 %

Women > 44 %

Men > 50%

Increase of the usual value above 10%

8

IMMUNOPATHOGENESIS OF DENGUE FEVER

Immune Response

SEVERE CASES

HEALING

IMMUNE RESOPONSE

MICROENVIRONMENT OF CYTOTOXINS

GENETIC FACTORS

Unregulated Response

DEATH

9

1 2 3 4 5 6 7 8 9

40

Viraemia

Phases of the Disease

Feverish Critical Recovery

ShockBleeding

Reabsorption

Risk of Liquid OverflowDehydration

Organic Damage

Day of the Disease

Temperature

Clinical Manifestations

Unspecific Laboratorial

Exams

Secific Laboratorial Exams

Platelets

Hematocrit

Plasma Leakage

Ac IgM

Dengue – Phases of the Disease

10

Negative tourniquet test, without spontaneous bleeding, without comorbidity or at risk group or special clinical conditions, lack of alarm signs.

Positive tourniquet test or spontaneous skin bleeds (petechiae), or with comorbidities, or at risk groups or special clinical conditions. Lack of alarm signs.

Presence of one or more alarm signs. Bleeding present or not. No hypotension.

Hypotension or shock. Bleeding present or not.

Group A

Group B

Group C

Group D

Clinical Staging of the Disease

13

Presence of one or more alarm signs. Bleeding present or not. No hypotension.

Post Exam

Post-exam – 1st question

• ABC, male, 28 years old, fever for 5 days, headache,

myalgia, persistent vomiting, continued abdominal pain,

absence of spontaneous bleeding. At examination presents

regular general condition, hydrated, normo-chrome.

Tourniquet negative. BP normal. Analyzing the case, which

is the clinical staging of the patient?

( ) Group A ( ) Group B ( ) Group C ( ) Group D

Post-exam – 1st question

• ABC, male, 28 years old, fever for 5 days, headache, myalgia, persistent vomiting, continued abdominal pain, absence of spontaneous bleeding. At examination presents a regular general condition, hydrated, normo-chrome. Tourniquet test negative. BP normal. Analyzing the case, which is the clinical staging of the patient?

• Group A• Group B• Group C• Group D

Presence of one or more alarm signs. Presence or not of spontaneous bleeding. No hypotensionGrupo C

• Based on your classification, which is the therapeutic conduct?

a) Antiemetic, paracetamol or dypirone and at home rehydration.

b) Supervised oral rehydration of 80ml/Kg/day, of which 1/3 in 4 hours. Keep in observation bed, with clinical and hematocrit reassessment 4 hours after hydration

c) Volume replacement: 20ml/Kg/day in 1 hour with saline. Monitoring in hospital bed. Clinical and hematocrit reassessment every 2 hours. Repeat expansion phase up to 03 phases if there is no improvement in hematocrit (hemoconcentration) and clinical parameters.

d) IV hydration: 20ml/Kg in 20 minutes. ICU bed. Repeat this phase up to 3 times. Clinical reassessment every 15-30 minutes and hematocrit after 2 hours.

Post-exam – 2nd question

Post-exam – 3rd question

The alarm signs must be searched and the Dengue Fever Card handed to patients with suspected dengue fever, who are discharged following the MoH protocol.

• Which of the following symptoms are considered alarm signs?

a) Persistent vomiting, continued abdominal pain, postural hypotension;

b) Breathing discomfort, drowsiness and/or irritability, painful hepatomegaly

c) Important bleedingsd) Sudden increase in hematocrit or sudden drop

in platelet counte) All the above

Post-exam