The Never Ending Battle of Dengue Crisis

Professor Lucy LumDepartment of Paediatrics

Faculty of MedicineUniversity of Malaya

11TH MOH –AAM SCIENTIFIC MEETING, 12 August 2015

1

Dengue in Malaysia: Incidence: 1999-2014

1 Adapted from data obtained directly from the Vector Borne Diseases Control Sector, Disease Control Division, MOH; 2. Lam SK, Trop. Med. 1993.35: 195-200.; 3 Al-Muhandis N, Hunter PR, 2011. PLoS Negl Trop Dis 5(8): e1278.; 4 World Health Organization Western Pacific Regional Office based on data provided by the Member States 2014 data from MoH Malaysia

0

20,000

40,000

60,000

80,000

100,000

120,000

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Rep

ort

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engu

e ca

ses

↑159%

2

DENGUE DEATH MALAYSIA 1997 – 2014

52

82

37

45

50

99

72

10

2 107

92

98

112

88

134

36

35

92

0

20

40

60

80

100

120

140

160

199

7

199

8

199

9

200

0

200

1

200

2

200

3

200

4

200

5

200

6

200

7

200

8

200

9

201

0

201

1

201

2

201

3

Nu

mb

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ath

Year

132%

215

20143

Dengue in Malaysia: 2014

108,698

Reported Cases

45,653 Hospitalized

Cases

215

Deaths

4

41% Hospitalization

Malaysia: As of 4 July 2015,

• 59,365 cases of dengue with 165 deaths.

• 33.4% higher compared with the same reporting period of 2014

Number of dengue cases per week 2014-2015, Department of Health, Malaysia 5

Measures to cope with increased patient load

• Full blood count analysers in most health clinics and emergency departments in major hospitals

• Dengue Combo kit NS-1Ag, IgM/IgG testing made available

• Extended working hours of health clinics to relieve the patient load of ED in major hospitals.

• Opening of wards for influx of patients

• Training in case management has been intensified at several levels of health care.

• Volunteers ….

6

Out-patient Clinic, Klang Valley

7

Patients’ long wait

8

Survive95-99.5%

Die0.5 - 5%

Infection Incidence ~ 5% / year

Asymptomatic 75%

Symptomatic 25%

Dengue fever95-99%

Severe dengue1-5%

Adapted from Vaccine 2004; 22: 1275-1280

Natural History of DENV Infections

9

Dengue among ASEAN countries in 2013:Cases, Deaths and Case fatality rate

Country Reported Cases

(deaths)

Case fatality rate

(CFR%)

Cambodia 16,722 (53) 0.35%

Philippines 166,107 (528) 0.32%

Lao PDR 44,171 (95) 0.22%

Malaysia 43,346 (92) 0.21%

Thailand 150,934 (136) 0.09%

Vietnam 60,588 (38) 0.05%

Singapore 22,205 (7) 0.03%

Data from WHO (SEARO) and (WPRO)

0.28% in 2015

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Acknowledgements

This curriculum was developed with technical assistance from the University of Malaya Medical Centre. Materials were contributed by the Ministry of Health, Singapore, the United States Centers for Disease Control and Prevention, and the University of Malaya Medical Centre.

Dengue Clinical Management

MODULE 4: Clinical Course of Disease

MODULE 5: Case Classification and Differential Diagnosis

MODULE 6: Patient Assessment & EvaluationMODULE 7: Outpatient Management

MODULE 8 A – D: IV Fluid therapy

Training in case management

12%

88%

Medical Personnel

Trained (8) Untrained (58)

12

Regular /Compulsory

Dengue Training

Program For Doctors - 2015

13

REALITY

• Dengue Deaths are preventable

• It is not possible to predict the course of illness

• Daily ambulatory follow-up during the febrile phase is necessary to avoid unnecessary admissions and detect patients going into severe dengue

• The most important prognostic factor for severe dengue is a TRAINED and WELL REHEARSED MEDICAL AND NURSING TEAM

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Back to Basics: History taking

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Mr A, came to ED on D4 of illness,referred from GP as ?Dengue Fever

S/B ED MO: Fever 4 days associated with vomiting 2 days, • No abdominal pain• No bleeding• Diagnosis: Dengue Fever, ordered FBC, referred medical

S/B Medical MO: Fever 4 days associated with vomiting 2 days, • No abdominal pain• No bleeding• Diagnosis: Acute Gastroenteritis

Questions? Same patient with same complaints,2 doctors, 2 different diagnosis. WHY?

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VOMITING D3 & D4

FEVER

C

FEVER

VOMITING D1 & D2 ??

A

B

FEVER

VOMITING D2 & D3 ??

Mr A: 4 days history of fever associated with 2 days of vomiting

D1 D2 D3 D4

Fever onset WHEN was the vomiting??

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The Changing Faces of Dengue

• Co-morbid conditions – diabetes mellitus, hypertension, pregnancy, hemolytic diseases

• Treatment with non-steroidal, antibiotics

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• NS1-Ag +ve: Early Intravenous fluid therapy

• Treating the diagnosis vs treating the patient

Malarial parasite positive => antimalarial treatment

16 year old girl, Day 3 of fever

Presented to Primary Care with high fever, 39oC.Headache, myalgia for 2½ days.Poor appetite and reduced fluid intakeDrank ½ glass of milk that morningPassed scanty urineThis morning started to have epigastric pain.

Is the epigastric pain a warning sign?

Yes

No

Not sure

The day before, had poor appetite and reduced oral intake.Drank less than 3 glasses of water

Saw a GP, who suspected she might have dengue, because neighbourhood fogging last week, asked to return for blood test next day.

What other questions would you ask?

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Medications cause “warning signs”

Erythromycin, Mefenemic acid Erythromycin, Sodium Diclofenac

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21

Day 116 Feb

Fever onset Fever, MyalgiaHeadacheDecreased oral intake

Temp 39.2oCGood perfusion

Encourage oral fluid

NJ – 54 yr old female

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Day 217 Feb

Day 318 Feb

NJ – 54 yr old female

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Dizziness,HeadacheDecreased oral intake

Temp 37.9oCGood perfusionWBC 3.1,HCT 39.6 Hb 13.7, Platelet 132

Encourage oral fluid

`

Fever onset

Less oral intake, nausea

Temp 36.5oCGood perfusionWBC 2.9, HCT 39.8 Hb 13.2,Platelet 88

Encourage oral fluid

NJ – 54 yr old female

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Day 419 Feb

Day 116 Feb

WBC 3.1,HCT 39.6 Hb 13.7, Platelet 132

Day 318 Feb

Timeline: Trajectory

Day 1 Day 2 Day 3 Day 416 Feb 17 Feb 18 Feb 19 Feb

Fever onset Fever, MyalgiaHeadacheDecreased oral intake

Temp 39.2oCGood perfusion

Encourage oral fluid

Dizziness,HeadacheDecreased oral intake

Temp 37.9oCGood perfusionWBC 3.1,HCT 39.6 Hb 13.7, Platelet 132

Encourage oral fluid

Less oral intake, nausea

Temp 36.5oCGood perfusionWBC 2.9, HCT 39.8 Hb 13.2,Platelet 88

Encourage oral fluid

NJ – 54 yr old female

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Timeline: Trajectory

Day 1 Day 2 Day 3 Day 416 Feb 17 Feb 18 Feb 19 Feb

Fever onset Fever, MyalgiaHeadacheDecreased oral intake

Temp 39.2oCGood perfusion

Encourage oral fluid

Dizziness,HeadacheDecreased oral intake

Temp 37.9oCGood perfusionWBC 3.1,HCT 39.6 Hb 13.7, Platelet 132

Encourage oral fluid

Less oral intake, nausea

Temp 36.5oCGood perfusionWBC 2.9, HCT 39.8 Hb 13.2,Platelet 88

Encourage oral fluid

Dizziness,

not eaten anything for past 3 days.Temp 36.7oCPoor perfusionWBC 2.6, HCT 46.2,Hb 15.2,

Platelet 56

Dengue shock syndrome

NJ – 54 yr old female

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Day 520 Feb

Back to Basics:

History taking: Impact of disease on food and fluid intake

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The 3 Golden Questions:

1. Drinking – volume, type

2. Pass Urine – frequency

3. Activities

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42 years old, female, 60 kg; 22 Dec, Fever onset 19 Dec

Fever 3 days, associated with nausea, abdominal pain, body aches

PE

Temp: 38oC

BP: 120/70 mmHg

PULSE: 78 /min

Throat: mildly injected

Lungs clear

CVS: Normal

Abdomen: soft,

increased bowel sounds

INVESTIGATION: FULL BLOOD COUNT

Hb: 13.5 g/dl (11.5-16.5)

HCT: 44.1% (35-55)

RBC: 6.03 x106/mm (3.5-5.5)

MCV: 72 mm (75-100)

MCH: 22 pg (25-35)

MCHC: 29.0 (31-38)

PLATELET: 40 x103/mm (150-400)

WBC: 5.8 x103/mm (3.5-11)

IMPRESSION: VIRAL FEVER TRO DENGUE FEVER

MANAGEMENT: REFER TO HOSPITAL

What other questions would you ask?

What is the diagnosis based on FBC? Guess her baseline HCT?

What is the implication?

Been to GP on 20 Dec, Diclofenac x2days

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16:30 @ the GP

Back to Basics: The Physical Examination

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Pearls in clinical examination of dengue patients

The “5-in-1 maneuver” magic touch – CCTV-R

Hold the patient’s hand to evaluate peripheral perfusion.

1.

Colour

2.

Capillary refill

3.

Temperature

4.

Pulse Volume

5.

Pulse Rate

Save life in 30 seconds by recognizing shock

Percussion technique: pleural effusion

32“Fluid finds its own level”: Place percussed finger parallel to fluid level, starting from anterior to mid-axillary and then posterior axillary lines.

Back to Basics: Fluid & Electrolyte therapy

• Oral & IV fluid therapy

• Resuscitation – intravenous therapy

• Rehydration – oral + intravenous

• Maintenance – oral + intravenous

• Not one size fits all!

• See patients not only in real time, but work out the illness trajectory

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Crowd along veranda of Kukum Clinic, Solomon Islands

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Coconut – natural rehydrating fluid

Increasing awareness of oral hydration

Encourage drinking aliquots of 50 ml or less in patients with nausea

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Empowering parents to document intake & output chart

Mother’s documentation of her child’s oral intake, type of drinks, urine frequency

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After training in Dengue clinical management

Doctor’s entry:Oral fluid intake, urine outputCCTVR

Actions:Stop IVFEncourage oral fluids – coconut water

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After training:

Nurse entry at Dengue Desk Triage counter in NRH:

Date of onset of fever, Risk factors, 3 golden questions, CCTVR

Summary

Biggest dengue epidemic in Malaysia

A lot of resources have been channeled; no sign of slowing down

Training in WHO Dengue case management:Back to Basics in clinical practiceLow-tech, high touch approach

Gate-keeping at frontlineTriage in limited resources

The most important prognostic factor for severe dengue is aTRAINED and WELL REHEARSED MEDICAL AND NURSING TEAM

危機

是有危險又有機會的時刻

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Dengue Crisis

Year 2003 (n=352)

(Pre-intervention)

2005 + 2006 (n=1943)

(Post-intervention)

P value

CLINICAL PARAMETERS

Available data on any haemorrhage 349 (99.1) 1931 (99.4) 0.875

Presence of any haemorrhage 202 (57.4) 1111 (57.2) 0.875

GI Bleed 16 (4.6) 112 (5.8) 0.523

Available data on plasma leakage 126 (35.8) 1393 (71.7) <0.001

Presence of plasma leakage 40 (11.4) 650 (34.4) <0.001

Available data on peripheral perfusion 46 (13.1) 537 (27.6) <0.001

Presence of hypoperfusion 40 (11.4) 457 (23.5) <0.001

Hypotension or narrowed pulse pr 75 (21.5) 190 (9.8) <0.001

Ratio of hypoperfusion to hypotension 0.53 2.41

LABORATORY PARAMETERS

Highest HCT before IVF (%) 43 (40 – 47) 45.7 (42-49) <0.001

Highest HCT throughout admission (%) 44 (41-48.75) 46.0 (42-50) 0.001

Lowest WBC (x109/L) 2.8 (2.0-3.9) 2.7 (1.9-3.7) 0.183

Lowest platelet count (x109/L) 31 (18-53) 30 (16-47) 0.672

TREATMENT

Days on IVF 3 (2-4) 2.5 (2-3.0) <0.001

Platelet transfusion 75 (21.7) 174 (9.0) <0.001

Plasma transfusion 21 (6.1) 50 (2.6) 0.003

Blood transfusion 6 (1.7) 21 (1.1) 0.555

Use of antibiotics 44 (12.5) 180 (9.3) 0.046

OUTCOME

LOS (days) 4 (3.0-5.0) 3 (3.0-4.0) <0.001

Intensive Care Unit Admission 20 (5.8) 49 (2.5) 0.002 43

Thank you for your Attention!

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