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03NTD 2022 - COVID-19 VS Dengue

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03NTD 2022 - COVID-19 VS Dengue

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This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.

Presenter: Dr Ong Hang Cheng, Infectious Disease Physician at University Malaya Medical Center
#dengue #WorldNTDDay #BeatNTDs #BestScienceforAll

This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.

Presenter: Dr Ong Hang Cheng, Infectious Disease Physician at University Malaya Medical Center
#dengue #WorldNTDDay #BeatNTDs #BestScienceforAll

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03NTD 2022 - COVID-19 VS Dengue

  1. 1. COVID-19 vs DENGUE Differentiating the Two Severe Diseases Dr Ong Hang Cheng 12th February 2022
  2. 2. Disclaimer • This slide was prepared for the Webinar Series on COVID-19 session on 3rd March 2021, by Dr Ong Hang Cheng, Infectious Disease Physician at University Malaya Medical Center, Malaysia. • This is intended to share within healthcare professionals, not for public. • This webinar is organised by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research, NIH in conjunction of World NTD Day 2022.
  3. 3. Outline • Introduction – Dengue Fever and Covid-19 • Epidemiology of dengue and Covid-19 • Similarities of both diseases • Differences of both diseases • Management of both diseases • Prevention of both diseases • Conundrums
  4. 4. Dengue Fever • Mosquito-borned Viral infection • Tropical and sub- tropical climates • Urban and semi-urban areas. • The virus responsible for causing dengue, is called dengue virus (DENV). • 4 DENV serotypes and CAN be infected 4 times. • DENV infection can develop potentially lethal complications.
  5. 5. Dengue virus • Flaviviridae family • 4 closely related but distinct serotypes (DEN-1, DEN-2, DEN-3, DEN-4) • Recover from one serotype provide lifelong immunity against that serotype • Cross immunity to other serotypes is partial and temporary • Secondary infection with other serotypes increase risk of developing severe dengue
  6. 6. Dengue virus under the electron microscope Nature, 2005
  7. 7. Dengue Fever: Global incidence and deaths • Estimated that 390 million dengue virus infections per year • 96 million manifest clinically (with any severity of disease) with 70% of actual burden is in Asia. • Increasing incidence 8-fold over the last 20 years. • 505,430 in 2000 > 2.4 million in 2010> 5.2 million in 2019. • Africa, the Americas, the Eastern Mediterranean, South-East Asia and the Western Pacific. • The Americas, South-East Asia and Western Pacific regions are the most seriously affected, with Asia representing ~70% of the global burden of disease. Bhatt, S., et al., The global distribution and burden of dengue. Nature, 2013. 496(7446): p. 504–507.
  8. 8. Dengue Fever: Malaysia statistics
  9. 9. Vector
  10. 10. Life cycle Source: CDC
  11. 11. Dengue Fever: Clinical Disease WIDE SPECTRUM • Subclinical disease (may not even be aware they are being infected) • Severe flu-like symptoms • Severe dengue with complications • Severe bleeding • Organ impairment • Plasma leakage
  12. 12. 3 Phases of dengue fever
  13. 13. Diagnosis 1. Viral components or 2. Serology
  14. 14. NS-1 (Non-structural protein-1) • NS1 protein is a hallmark of flavivirus infecting mammalian cells • Can be found in dengue , yellow fever and West Nile virus infection. • False positive results have been reported in chronic diseases and haematological malignancies • The detection rate of primary infection (75%-97%) and secondary infection (60%-70%) • The sensitivity of NS1 antigen detection drops from day 4-5 of illness onwards and undetectable in the convalescence phase (may predict severe dengue if present beyond 5 days)
  15. 15. Dengue Viral RNA Detection (Real time RT-PCR) • Viral genotype • Molecular method - target specific genome of the virus for amplification and detection. • Viraemic stage ONLY – 5 days from symptom • Expensive • Special storage temperatures and short transportation time between collection and extraction • Limited centres and trained personnel
  16. 16. Virus Isolation • Institute for Medical Research (IMR), • National Public Health Laboratory • University Malaya Medical Centre for research
  17. 17. Serological tests • IgM - detected 4 days of illness by LFA or IgM antibody capture enzyme- linked immunosorbent assay • IgM seroconversion : paired acute and convalescent phase (10 to 14 days after the acute phase); 4-fold or greater rise in antibody titre.
  18. 18. Management • Outpatient • Inpatient
  19. 19. Outpatient or inpatient?
  20. 20. Management of dengue fever 1. Oral fluids (Don’t forget the electrolytes) 2. Intravenous crystalloids 3. Intravenous colloids 4. Blood products if bleeding
  21. 21. How about Dengue Vaccine? • Dengvaxia • Pre-Vaccination Screening- Laboratory confirmation of previous dengue virus infection required
  22. 22. Dengue Vaccine anyone? Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Vector-Borne Diseases (DVBD). Last reviewed: December 20, 2021:
  23. 23. Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Vector-Borne Diseases (DVBD). Last reviewed: December 20, 2021:
  24. 24. Hemophagocytic Syndrome in Dengue • Haemophagocytic syndrome (HPS) is a potentially fatal syndrome • Extreme immune activation leading to cytokine storm. • Increased IL-2, TNF-α, IL-6, IL-8, interferon γ generated by uncontrolled activation of histiocytes and T-cells. • Clinical course is generally severe and may mimic sepsis • Milder forms of HPS recover spontaneously. • Severe HPS, may need IV methylprednisolone or dexamethasone (KIV IVIg)
  25. 25. Dengue: Prevention and Control • Prevention of mosquito breeding • Personal protection from mosquito bites • Community engagement • Active mosquito and virus surveillance
  26. 26. COVID-19 Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus
  27. 27. Why is it important? Isn’t it “just another flu”? Many people lost their lives or lost their loved ones
  28. 28. Why is it important? • Planet earth turned topsy turvy • Businesses closed • Borders closed • Vehicles stopped – air, water and land • Everybody must take vaccines • Everybody must mask up • Then vaccine again • Then vaccine again
  29. 29. COVID-19 Global Cases and Deaths Confirmed cases: 398 241 445 Confirmed deaths: 5 769 246 WHO: Last update: 8th February 2022, 00:06 am GMT+8
  30. 30. COVID-19 Malaysia Total Cases: 2,906,232 Total Deaths: 32,043 WHO: Last update: 8th February 2022, 00:06 am GMT+8
  31. 31. What is a coronavirus? • Coronaviruses are widespread among birds and mammals, with bats being host to the largest variety of genotypes (Anthony, 2017) • COVID-19: A novel coronavirus discovered at the end of 2019, previously designated 2019-nCoV
  32. 32. Coronaviruses phylogenetic tree
  33. 33. Model of coronavirus structure: A schematic diagram of virion structure
  34. 34. Coronaviruses under electron microscopy CDC;JHU Magnification 144,000x
  35. 35. Variants? Why so many? tenor.com Variants being monitored Variants of interest Variants of concern Variants of high consequence Ability to spread Severity of symptoms How variants respond to treatment How well vaccines protect against the variant What are the variants How are they classified?
  36. 36. Covid-19 Symptoms • Fever or chills • Cough • Shortness of breath or difficulty breathing • Fatigue • Muscle or body aches • Headache • New loss of taste or smell • Sore throat • Congestion or runny nose • Nausea or vomiting • Diarrhea • Difficulty breathing • Persistent pain or pressure in the chest • Confusion • Delirious • Cyanosis
  37. 37. Covid staging ovid-19.moh.gov.my/garis-panduan/garis-panduan- kkm/ANNEX_2e_CLINICAL_MANAGEMENT_OF_CONFIRMED_COVID- 19_CASE_IN_ADULT_AND_PAEDIATRIC_13082021.pdf
  38. 38. Diagnosis • Respiratory specimens for nucleic acid amplification testing (NAAT) i.e: reverse transcription polymerase chain reaction (RT-PCR). • Repetitive testing of upper respiratory tract (URT) and/or lower respiratory tract (LRT) might be needed • If deceased, consider the collection of post-mortem specimens. • SARS-CoV-2 antibody tests are not recommended for diagnosis of current infection with COVID-19. (please don’t ask again) WHO, 23rdNov 2021
  39. 39. Risk factors associated with severe disease • Age > 60 years (increasing with age). • (NCDs): DM, HTN, cardiac disease, chronic lung disease, cerebrovascular disease, dementia, mental disorders, CKD, immunosuppression, HIV, obesity and cancer have been associated with higher mortality. • smoking • Higher (SOFA) score and D-dimer >1 µg/L on admission were associated with higher mortality • In pregnancy, increasing maternal age, high BMI, non-white ethnicity, chronic conditions and pregnancy specific conditions such as gestational diabetes and pre-eclampsia
  40. 40. Management of Covid-19 Isolation measures Mild COVID-19: • Symptomatic treatment: antipyretics for fever and pain, • Adequate nutrition • Appropriate rehydration. Moderate COVID-19: pneumonia treatment For patients at high risk for deterioration, isolation and management in hospital is preferred. WHO, 2021
  41. 41. Antivirals? • Favipiravir • Nirmatrelvir/Ritonavir (Paxlovid) and • Molnupiravir
  42. 42. When should corticosteroids be used in Covid-19? • Corticosteroid is NOT recommended in non-hypoxic cases (unless for other indications) • Category 4 : IV Dexamethasone phosphate 8mg od (12mg if BMI >30) • Duration 10-14 days or until discharge • (Note: 8mg of IV dexamethasone phosphate = 6 mg of IV dexamethasone base = 6mg of oral dexamethasone) • Step-down to oral dexamethasone 6mg PO once there is improvement
  43. 43. Antivirals and immune modulators • Dexamethasone AND IV Remdesivir 200 mg loading and 100 mg daily (D2-D5) • Corticosteroid AND Tocilizumab OR • Corticosteroid AND Baricitinib (If Tocilizumab is not available)
  44. 44. Prevention of COVID-19 • Get vaccinated • Stay at least 1 metre apart • Wear properly fitted mask when physical distancing is not possible or when in poorly ventilated settings. • Choose open, well-ventilated spaces over closed ones. • Open a window if indoors. • Wash hands regularly with soap and water or clean them with alcohol-based hand rub. • Cover mouth and nose when coughing or sneezing. • If unwell, stay home and self-isolate until recover WHO 2022
  45. 45. Vaccination worldwide • 9 620 105 525 Vaccine doses administered WHO: Last update: 25 January 2022, 00:06 am GMT+8
  46. 46. Vaccination Malaysia
  47. 47. Similarities and differences at a glance
  48. 48. What are the similarities? Both are caused by viruses Both cause fever and myalgia Symptoms range from mild to severe for both
  49. 49. • Shortness of breath and diarrhoea were more common in COVID-19 patients than in influenza patients, while fever, cough, running nose and sore throat were less common. • Cough, shortness of breath, running nose and sore throat were more common in COVID-19 patients than in dengue patients. • A lower proportion of COVID-19 patients had fever, diarrhoea, muscle aches, fatigue/malaise, abdominal pain, bleeding, conjunctivitis, headache, joint pain, skin rash and vomiting/nausea compared with dengue patients.
  50. 50. Who are at risk? • Travelling to or living in an area with uncontrolled community spread of the virus • Seniors and those with underlying medical condition Covid-19 • Travelers or locals in tropical and subtropical regions • Previous dengue infection Dengue
  51. 51. Differences Can you tell them apart? Dengue Fever Covid 19 Transmission Mosquito bite Infected droplets
  52. 52. How to protect against COVID-19 • Wear mask • Wash hands • Avoid crowded areas especially indoors • Physical distancing How to protect against dengue • Remove mosquito breeding areas • Wear long sleeve clothing • Use mosquito repellents
  53. 53. Dengue and COVID-19 conundrums
  54. 54. False positive dengue serology Serological tests for dengue have been shown to cross-react with: • Other flavivirus – Japanese Encephalitis • Non-flavivirus – malaria, leptospirosis, toxoplasmosis, syphilis • Connective tissue diseases – rheumatoid arthritis Malaysia Dengue CPG, 2015
  55. 55. How about COVID-19 and dengue co- infection?
  56. 56. What about dengue incidence during the Covid-19 pandemic?
  57. 57. Stay safe Ecdc 2022
  58. 58. References • World Health Organization. https://www.who.int/news-room/fact- sheets/detail/dengue-and-severe-dengue • Bhatt, S., et al., The global distribution and burden of dengue. Nature, 2013. 496(7446): p. 504–507. • Anthony SJ, Johnson CK, Greig DJ, et al. Global patterns in coronavirus diversity. Virus Evol 2017; 3:vex012. • CDC • Covid-19.moh.gov.my/garis-panduan/garis-panduan- kkm/ANNEX_2e_CLINICAL_MANAGEMENT_OF_CONFIRMED_COVID- 19_CASE_IN_ADULT_AND_PAEDIATRIC_13082021.pdf
  59. 59. Thank you

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