PROF. DR. MUHAMMAD YAQUB KAZIMBBS, MCPS (Family Medicine)

DCH (Pb), MCPS (Paeds), FCPS (Paeds),

FRCP (Edin), FRCP (London), FRCPCH (UK)

Ex Dean , Institute of Public Health,

Former Professor of Paediatrics

King Edward Medical University Lahore

Arising as a major public health issue in

Pakistan

How it reached us

In Chinese dynasty (AD 265- 420) known as water poison

Epidemics reported from 1779-80 World’s largest epidemic 1981 Cuba In Pakistan, 1980s and so on

First documented report in 1985 – DENV2 isolated in a sero epidemiological study for encephalitis

Outbreaks in Karachi – 1994, 1996

Sporadic cases since then

Hyper – endemic situation

NOT NEW IN PAKISTAN

Journey of Aedes Aegypti from Africa to Pakistan

Slave Trade

Commerce

Gravity of situation

2.5 Billion people at risk worldwide 50 million new cases annually worldwide 500,000 hospitalized annually 2.5% of the affected

DIE

No age is immunePerinatal transmissionBimodal peaks during age group < 1 yr

and between 5 – 7 years.Bangladesh and Chenai studies – 35%

and 20% infants In South East Asia DHF commonly

seen in children

AGE GROUP

Symptoms

DF: Aute fever (2-7 days) without any other focus Headache, mylagia, retro-orbital pain, arthralgia, bleeding/petechiae.

DHF: Fever Haemorrhagic manifestations (Thrombocytopenia, Positive Tourniquet test)

Signs of increased vascular permeability/circulatory failure (effusion, HCT, Pulse pressure)

Hepatomegaly.

Dengue Viral Infection

Asymptomatic(majority) (90 %)

Symptomatic(10 %)

Viral Syndrome(5%)

DF(4%)

DHF(1%)

Plasma leakage

DHF(98%)

DSS(1-2%)

Unusual dengue.

Expanded dengue

syndrome

With bleeding

No bleedin

g

More symptoms

Vomiting Centrifugal maculopapular rash Weakness Altered taste sensation Anorexia Sore throat Mild hemorrhagic manifestations (eg, petechiae, bleeding gums,

epistaxis, menorrhagia, hematuria) Lymphadenopathy

Children younger than 15 years usually have a nonspecific febrile syndrome, which may be accompanied by a maculopapular rash.

InfantsObesityHemolytic diseases such as G6PD and

thalassemia.Congenital heart disease.Chronic diseases such as diabetes

mellitus, chronic renal failure.Patients on steroid or NSAID

treatment.

HIGH RISK PATIENTS

CLINICAL COURSE: DHF Febrile phase (both DF & DHF)

2 – 7 days Clinical features (Tender hepatomegaly – DHF) Hemorrhagic manifestations TLC – normal … <5000 later part Platelets – normal … < 100,000 (50% DF, 100%

DHF)

Critical phase D 4-7 Clinical Features Lasts only for 24 – 48 hours

Convalescent phase Begins after the critical phase & lasts for 5 - 7

days

IgM: Detectable by 5-6 days Sharp rise by 2 weeks Undetectable after 2-3 months.

IgG: Detectable by end of first week – low level Increase and remain for many years.

Secondary Dengue Infection IgG detectable at high levels even in initial phase Persist for several months to a lifelong period IgM low in secondary infection. Ratio of IgM/IgG differentiates (<1.2)

Primary Vs Secondary infection

LABS

Reduced platelets Increase in blood haematocrit, CBC includes the following:

Leukopenia, often with lymphopenia,. Lymphocytosis, with atypical lymphocytes A hematocrit level rise of greater than 20%. Thrombocytopenia. (less than 100,000 cells/μL) Hyponatremia Metabolic acidosis Elevated BUN Liver function test Transaminase levels may be mildly elevated. Low albumin levels are a sign of hemoconcentration.

Clinical and Laboratory Criteria for patients who can be treated at home

Able to tolerate orally well, good urine output and no history of bleeding

Absence of clinical alarm signals Physical examination

Hemodynamically stable Pink, warm extremities Normal capillary filing time (normal < 2 seconds) Good pulse volume Stable blood pressure Normal pulse pressure (>20 mmHg) No disproporationate tachycaradia

No tachypnea or acidotic breathing No hepatomegaly or abdominal tenderness No bleeding manifestation No sign of pleural effusion ascites No alterations in metnal state and full GCS score

Investigation: Stable serial HCT In the absence of a baseline HCT level, a HCT value

of >40% in female adults and >46% in male adults should raise the suspicion of plasma leakage. Therefore admission may be required.

Warning signals

No clinical improvement or worsening of the situation just before or during the transition to afebrile phase or as the disease progresses.

Persistent vomiting, not drinking. Severe abdominal pain. Lethargy and/or restlessness, sudden

behavioral changes.

Bleeding: Epistaxis, black colored stools, hematemesis, excessive menstrual bleeding, dark colored urine (hemoglobinuria) or hematuria.

Giddliness. Pale, cold and clammy hands and feet. Less/no urine output for 4-6 hours.

Complications Possible Complications    Shock Encephalopathy Residual brain damage Seizures Liver damage Rare complications include the following:

Depression Pneumonia Iritis Orchitis Oophoritis

Secondary reinfection is unlikely because of pre-existing antibodies.

DIET

No specific diet is necessary for patients with dengue fever. Patients may become dehydrated from fever, lack of oral intake,

or vomiting. Patients who are able to tolerate oral fluids should be encouraged to drink oral rehydration solution, fruit juice, or water to prevent dehydration.

Return of appetite after dengue hemorrhagic fever or dengue shock syndrome is a sign of recovery.

Activity Bedrest is recommended for patients with symptomatic dengue

fever, dengue hemorrhagic fever, or dengue shock syndrome.

Drugs

Aspirin and Brufen should be avoided in dengue fever, as it is known to increase the bleeding tendency and also it increases the stomach pain.

Paracetamol has both analgesic and antipyretic properties similar to aspirin and other NSAIDs. Has no peripheral anti-inflammatory activity or effects on platelet function.

Future Vision Selective integrated mosquito control Active disease surveillance Emergency preparedness Capacity building & training

Training of health care staff Training courses on infectious diseases Inclusion of basic health principles in various syllabi

Intensive research on vector control National/ provincial programs for infectious

disease monitoring & awareness

Isotonic crystalloids to be used – Normal saline or 5% dextrose in saline

Infants < 6 months – 5% dextrose in ½ saline.

Volume of about maintenance + 5% dehydration (M + 5%) to maintain a “just adequate” intravascular volume and circulation.

Duration of IV fluid should not exceed 24 – 48 hrs for those with shock.

GENERAL PRINCIPLES OF FLUID THERAPY

Rate ml/kg/hr

Half the maintenance M/2 1.5 Maintenance (M) 3 M + 5% deficit 5 M + 7% deficit 7 M + 10% deficit 10

RATE OF IV FLUIDS

Fluid allowance (Oral + IV) = Maintenance (For one day) + 5% deficit

given over 48 hrs. Example: 20 Kg child.

Maintenance = 1500 ml for one day

5% deficit = 50 x 20= 1000 ml

Total = 2500 mlGiven over 48 hrs.

MANAGEMENT OF DHF GRADE I, II (NONSHOCK CASES)

Identify the beginning of leaking phase

Predicting the end of leaking phase.Meticulous monitoringAccurate fluid management in critical

phase.Early detection and treatment of

concealed bleeding and complications.

MANAGEMENT OF DHF

Managing Dengue Shock

Syndrome

MANAGEMENT OF SHOCK : DHF Grade IIIUnstable vitals, decreased urine output, signs of shock

10 ml/kg/hr of Normal saline for 1-2 hrs

Improvement No Improvement

Reduce rate from 10 ml/kg/hr to 7,5,3,1.5 ml

Check for ABCS and Correct

Further Improvement

Discontinue IV therapy over 24-48 hrs

HCT Rises HCT Falls

IV Colloid Blood transfusion, whole blood 10 ml/kg, PRC 5ml /kg

Improvement

Reduce Rate from 10ml/kg/hr to 7,5,3,1.5

NO PLACE FOR STEROIDS AND IV

IMMUNOGLOBULINS IN DENGUE

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention

Prevention