Dengue guideline 082012, grade dhf, dengue, indonesia
Case 1 Anak perempuan 7 th dirujuk oleh SpA ke RSS dengan: Demam naik turun 4 hari Mual (+), muntah (-), hepatomegali , RL (+) Pada hari dirujuk diperiksa lab dengan hasil : Hct : 39%, Hb:12,4, JL: 4000/uL, diftel DBN, JT: 150.000/uL. NS1 Dengue (-)Q: Apa diagnosis kerja/ DD pasien ini?
Case 2 Anak laki2, 4 th datang ke poli/ IRD RSS dengan : Demam tinggi naik turun , 2 hari Batuk sedikit, tidak pilek Mual/muntah (-) Pusing Menurut ibu ada anak tetangga yang dirawat di RSS 1 minggu yll dengan DBQ: Apa diagnosis kerja/DD anak ini?
Ida Safitri LaksonoDept of Child Health, Faculty of Medicine UGM RSUP Dr. Sardjito, Yogyakarta
Outline of presentation Introduction Overview of the three guidelines Dengue Guideline 1997 Background and evidence related to Dengue Guideline 2009 Dengue Guideline 2011 National Dengue Guideline? Summary
IntroductionGLOBAL burden of dengue Global incidence of dengue has grown dramatically in recent decades About two fifths of the worlds population are now at risk Dengue is found in tropical and sub-tropical climates worldwide, mostly in urban and semi-urban areas Dengue is the most prevalent arboviral disease with high morbidity, mortality & socio-economical costs.
Cont…Case management Despite its complexity in pathogenesis and manifestation the management is relatively simple and inexpensive No specific treatment rely on fluid management. Appropriately and timely implemented, it could save the lives of patients Current situation : the most effective way to prevent dengue transmission is to combat disease-carrying mosquitoes The development of vaccines and drugs is challenging but potential to change this.
Dengue guidelines 1997 2009 2011 Guideline for treatment Dengue – Guidelines for Comprehensive guidelineTitle of DF and DHF in small diagnosis, treatment, for prevention and hospitals – WHO Searo prevention and control – control of Dengue and 1999 WHO TDR 2009 DHF – WHO Searo 2011Pages 33 160 212 Clinical manifestation, Chapters : (6) Chapters : (15) diagnosis, case management Epidemiology and burden of Epidemiology, disease disease, clinical burden,clinical management, vector manifestation and diagnosis,Content management, lab diagnostic lab diagnosis, management, tests, surveillance and surveillance, vector, vector emergency response, new management, IVM, Combi, avenues PHC approach, case investigation, monitoring, strategic plan (bi-regional plan)
Diagnosis Classification 1997 2009 2011Dengue fever Dengue without Dengue fever warning signsDHF grade I Dengue with warning DHF grade I signsDHF grade II DHF grade IIDHF grade III Severe dengue DHF grade III ( severe plasma leakage, severe hemorrhage, severe organ involvement)DHF grade IV DHF grade IV * Expanded dengue syndrome Adult management Adult management
Probable – an acute febrile illness with two or more of the following manifestations: Headache Retro-orbital pain Myalgia Arthralgia Rash Haemorrhagic manifestations Leukopenia; and Supportive serology (a reciprocal HI antibody titre ≥1280, a comparable IgG ELISA titre or a positive IgM antibody test on a late acute or convalescent-phase serum specimen ); or Occurence at the same location and time as other confirmed cases of dengue fever. Confirmed – a case confirmed by laboratory criteria Reportable – any probable or confirmed case should be reported
Grade Sign and Symptomps LaboratoryDF DHF without plasma leakageDHF I Fever with non-specific constitutional Thrombocytopenia symptoms; the only hemorrhagic (platelet count manifestation is a positive tourniquet test 100,000/ L) &/or easy bruising evidence of plasma leakage II DHF grade I plus spontaneous bleeding III Circulatory failure manifested by a rapid, weak pulse, narrowing of pulse pressure, or hypotension, cold & clammy skin, restlessness IV Profound shock with undetectable blood pressure
WHO Dengue Classification 1997 DF DHF1. Fever 2-7 days + +2. Bleeding tendency Positive tourniquet test or Spontaneous bleeding +/- +3. Thrombocytopaenia ≤ 100,000/mm³ +/- +4. Plasma leakage Pleural effusion /ascites - + /hypoproteinaemia ≥ 20% increase in HCT from baseline
The stages of the dengue case classification development1 Numerous publications describing the - numerous reports of the difficulties using9 difficulties using DF/DHF/DSS DF/DHF/DSS: epidemiology has changed9 A systematic review of the issue - confirmation of the above0 Bandyopadhyay S et al., TMIH 2006, Volume 11 no 8 pp 1238–1255´s The DenCo study - clear evidence for classifying in dengue - (dengue and control) and severe dengue2 DF/DHF/DSS application study - large differences of DHF case definitions0 Santamaria R et al. , accepted at TMIH 2009, September between countries; application difficult - dengue is just one disease entity with0 Two expert consensus meetings different clinical presentations and often with La Habana 2007 and Kuala Lumpur 20079 unpredictable clinical evolution and outcome A global expert consensus meeting -further design: 1) dengue with or without Geneva 2008 warning signs and 2) severe dengue Dengue guidelines validation studies - analysis showing user-friendliness (forthcoming publication) and acceptance of dengue/severe dengue A global expert meeting reviewing - final analysis and recommendations "chain of evidence“ (planned for 03/2010) TDR report (summary recommendations) - overall summary report/recommendations (planned for 03/2010)
The full model of the revised WHO dengue case classification Dengue case classification by severity Dengue ± warning signs Severe dengue with 1.Severe plasma leakage Without warning signs 2.Severe haemorrhage 3.Severe organ impairment Criteria for dengue ± warning signs Criteria for severe dengueProbable dengue Warning signs* 1. Severe plasma leakageLive in/travel to dengue • Abdominal pain or leading to:endemic area. Fever and 2 tenderness • Shock (DSS)of the following criteria: • Persistent vomiting • Fluid accumulation with• Nausea, vomiting • Clinical fluid accumulation respiratory distress• Rash • Mucosal bleed• Aches and pains • Lethargy; restlessness 2. Severe bleeding• Tourniquet test positive • Liver enlargement >2cm as evaluated by clinician• Leucopenia • Laboratory: Increase in HCT 3. Severe organ involvement• Any warning sign concurrent with rapid • Liver: AST or ALT>=1000Laboratory confirmed decrease in platelet count WHO/TDR 2009 • CNS: Impaireddengue(important when no sign of plasma * Requiring strict observation consciousnessleakage) and medical intervention • Heart and other organs
Dengue without warning signsProbable denguelive in /travel to dengue endemic area.Fever and 2 of the following criteria:• Nausea, vomiting• Rash• Aches and pains• Tourniquet test positive• Leucopenia• (Any warning sign)
Dengue with warning signsWarning signs ( appear in the critical period)* Abdominal pain or tenderness Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy, restlessness Liver enlargement >2 cm Increase in HCT concurrent with rapid decrease in platelet count back
Severe Dengue Severe plasma leakage leading to: • Shock (DSS) • Fluid accumulation with respiratory distress Severe bleeding as evaluated by clinician Severe organ involvement Liver: AST or ALT ≥ 1000 CNS: Impaired consciousness Heart and other organs
Evidence from 2009 Dengue Guideline Multicentre prospective study on dengue classification in four South-east Asian and three Latin American countries (Neal Alexander et.al, 2011) Evaluation of the Traditional and Revised WHO Classifications of Dengue Disease Severity Sensitivity and specificity to capture Category III care for DHF/DSS were 39.0% and 75.5%, respectively; sensitivity and specificity for SD were 92.1% and 78.5%, respectively (Federico Narvaez et.al, 2011)
Evidence from 2009 Dengue Guideline Usefulness and applicability of the revised dengue case classification by disease: multicentre study in 18 countries (Judit Barniol et.al, 2010) Dengue—How Best to Classify It (Anon Srikiatkhachorn et.al, 2011)• Application of revised dengue classification criteria as a severity marker of dengue viral infection in Indonesia Binary logistic regression showed the revised dengue classification system (p = 0.000, Wald:22.446) was better in detecting severe dengue infections than the WHO classification system (p = 0.175, Wald:6.339) (Basuki PS et.al, 2010)
Dengue virus infection 2011 Asymptomatic Symptomatic Expanded Dengue syndrome/isolatedUndefferentiated organophaty (unusual fever manifestation)(viral syndrome) Dengue Haemorrhagic Dengue Fever Fever (DHF) (DF) (with plasma leakage) Without With unusual DHF non DHF with shock haemorrhage haemorrhage shock Dengue Shock Syndrome (DSS)
WHO classification of Dengue infections and grading of severity of DHF (2011)DF/DHF Grade Signs and Symptoms LaboratoryDF Fever with two of the following: • Leucopenia (WBC <5000 cells/mm3) • Headache • Thrombocytopenia <150.000 • Retro-orbital pain cells/mm3) • Myalgia • Rising Hct (5-10%) • Athralgia/bone pain • No evidence of plasma loss • Rash • Haemorrhagic manifestations • No evidence of plasma leakageDHF I Fever and haemorrhagic manifestation Thrombocytopenia <100.000 cells/mm3 (positive tourniquet test) and evidence Hct rise >20% of plasma leakageDHF II As in Grade I plus spontaneous bleeding Thrombocytopenia <100.000 cells/mm3 Hct rise >20%*DHF III As in Grade I or II plus circulatory Thrombocytopenia <100.000 cells/mm3 failure Hct rise >20%*DHF IV As in Grade III plus profound shock with Thrombocytopenia <100.000 cells/mm3 undetectable bloodpressure and pulse Hct rise >20%*DHF III and IV are DSS
Admission criteria 1997 2009 2011Admission CriteriaSigns of significant - Any warning sign - Shock: Resuscitationdehydration (>10% - Coexisting conditions: and admission.normal body weight) infancy, pregnancy, old -Hypoglycemic patients age, obesity, diabetes without leucopenia mellitus, renal failure, and/or thrombocytopenia hypertension, chronic -Those with warning hemolytic disease etc. signs. - Social circumstances: - High-risk patients with living alone, living far leucopenia and from health facility, thrombocytopenia without reliable means of transport. Home care card 1997 2009 2011 No Yes Yes
Warning signs 2009 & 2011 2009 2011 Abdominal pain + severe + or tenderness Persistent vomiting, + + , lack of water intake Clinical fluid accumulaton + - Bleeding Mucosal Epistaxis, black stool, haematemesis, excessive bleed menstrual bleeding, dark-coloured urine (haemoglobinuria) or haematuria. Lethargy and/or restlessness + + , sudden behavioural changes Liver enlargement > 2 cm + -Increase in Hct concurrent with rapid + - decrease in platelet count No clinical improvement or - + worsening of the situation Giddiness - + Pale,cold, a clammy hands and feet - + Less/no urine output for 4–6 hours - +
The first two clinical criteria, plus thrombocytopenia and hemoconcentration or a rising Hct are sufficient to establish a “clinical diagnosis of DHF”. The presence of liver enlargement in adition to the first two clinical criteria is suggesting of DHF before the onzet of plasma leakage. ( WHO Searo 2011, p.24)
Fluid management 1997 2009 2011DHF grade I-II Dengue with warning DHF grade I-II signs6-7 ml/kg/hour 5 isotonic solutions such as maintenance (for oneml/kg/hour 3 0.9% saline, Ringer’s day) + 5% deficit (oralml/kg/hour – stop after lactate, or Hartmann’s and IV fluid together), to24-48 hours solution. Start with 5–7 be administered over 48 ml/kg/hour for 1–2 hours, hours then reduce to 3–5 ml/kg/hr for 2–4 hours, and then reduce to 2–3 ml/kg/hr or less according to the clinical response
Cont… 1997 2009 2011DSS Severe Dengue- DHF grade III compensated shock10-20 ml/kgBB bolus, isotonic crystalloid 10 ml/kg in children orrepeat if necessary solutionsat 5–10 300–500 ml in adults over algorithm ml/kg/hour over one one hour or by bolus, if hour. →reassess necessary Further, fluid administration should follow the graph
Cont… 2009 2011Severe Dengue – hypotensive shock DHF grade IVStart with crystalloid or colloid 10 ml/kg of bolus fluid (10-15 min)solution (if available) at 20 ml/kg asa bolus given over 15 minutes to When the blood pressure is restored,bring the patient out of shock as further intravenous fluid may be givenquickly as possible. as in Grade 3. If shock is not reversible after the first 10 ml/kg, a repeat bolus of 10 ml/kg and laboratory results should be pursued and corrected as soon as possible.
Transfusion in Severe Bleeding 2009 2011Give 5–10ml/kg of fresh-PRC or 10– 10 ml/kg of FWB or 5 ml/kg of freshly20ml/kg of FWB at an appropriate rate PRCand observe the clinical response. Reassess, repeat if necessary
Discharge criteria Criteria 1997 2009 2011 Absence of fever 24 hours 48 hours 24 hours without the without the use of anti- use of anti- fever therapy fever therapy Clinical + + (general well-being, appetite, + improvement hemodynamic status, urine output, no respiratory distress)Return of appetite + - +Good urine output + - +Stable hematocrit + + (without intravenous fluids) +Elapse from shock At least 2 days - At least 2-3 recovery days No respiratory + - + distress Platelet count > 50,000/ L Increasing trend > 50,000/ L
National guideline Ditjen PPM –PLP 2004 Ditjen Yanmed , IDAI, PAPDI, IDSAI, PERDIC I, PDS PATKLIN, PPNI - 2005
Summary Dengue disease burden is significantly increased across continents Case management is relatively simple and inexpensive could saves the lives of patients Revised guidelines ( 2009 and 2011) are available Proposed National guideline ? Changes might be slowly, difficult but inevitable
Signs of Significant Dehydration- Tachychardia- Increased capillary refill time (>2 second)- Cool, mottled or pale skin- Diminished peripheral pulses- Changes in mental status- Oliguria- Sudden rise in haematocrit or continously elevated haematocrit despite administration of fluids- Narrowing of pulse pressure (< 20 mmHg)- Hypotension (a late finding representing uncorrected shock) back
Warning signs (2011) 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 behavioural changes. Bleeding: Epistaxis, black stool, haematemesis, excessive menstrual bleeding, darkcoloured urine (haemoglobinuria) or haematuria. Giddiness. Pale, cold and clammy hands and feet. Less/no urine output for 4–6 hours. back
Admission criteria 2009 – p 47 backWarning signs Any of the warning signs (Textbox C)Signs & symptoms Dehydrated patient, unable to tolerate oral fluidsrelated to hypotension Giddiness or postural hypotension(possible plasma Profuse perspiration, fainting, prostration during deferescenceleakage) Hypotension or cold extremitiesBleeding Spontaneous bleeding, independent of the platelet countOrgan impairment Renal, hepatic neurological or cardiac - enlarged, tender lier, although not yet in shock - Chest pain or respiratory distress, cyanosisFindings through Rising hematocritfurther investigation Pleural effusion, ascites or asymptomatic gall bladder thickeningCo-existing conditions Pregnancy Co-morbid conditions, such as diabetes mellitus, hypertension peptic ulcer, hamolitic anemias and others Overweight or obese (rapid venous access difficult in emergency) Infancy or old ageSocial circumstances Living alone, living far from healt facility, without reliable means of transport
High-risk patients (2011) infants and the elderly, obesity, pregnant women, peptic ulcer disease, women who have menstruation or abnormal vaginal bleeding, haemolytic diseases such as glucose-6-phosphatase dehydrogenase (G- 6PD) deficiency, thalassemia and other haemoglobinopathies, congenital heart disease, chronic diseases such as diabetes mellitus, hypertension, asthma, ischaemic heart disease, chronic renal failure, liver cirrhosis, patients on steroid or NSAID treatment, and others back