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 Fazlina Binti Mohamed Yusoff, Family Medicine Specialist at Klinik Kesihatan (Health Clinic) Anika, Klang, Selangor, Malaysia. #dengue #WorldNTDDay #BeatNTDs #BestScienceforAll

1. Management of Dengue in
Primary Care
Dr Fazlina Binti Mohamed Yusoff
Family Medicine Specialist
Klinik Kesihatan Anika
Klang, Selangor

2. Disclaimer
•This slide was prepared for the Webinar Series on COVID-19 session on
3rd March 2021, by Dr Fazlina Binti Mohamed Yusoff, Family
Medicine Specialist at Anika Health Clinic, Malaysia.
•This is intended to share within healthcare professionals, not for public.
•This webinar is organized by Malaysian Society of Infection Control and
Infectious Diseases (MyICID) & Institute for Clinical Research, NIH in
conjunction of World NTD Day 2022.

3. Introduction
• Dengue is one of the most important arthropod-borne viral diseases
with high morbidity and mortality.
• It affects tropical and subtropical regions around the world,
predominantly in urban areas.

4. Clinical management
of dengue in Malaysia
We have existing clinical management guidelines
at hospital and national level
4

5. Case Scenario
• 20 years old man, no known medical illness
• c/o fever for 5 days.
• Joint pain x 2 days.
• Living in dengue area where there was
fogging at his house area last week.
• No warning signs.
• O/E: Pink.
• Temperature: 37.6
• Bp: 120/70mmHg
• PR: 90/ min.
• All other systemic
examinations: normal
• Investigations: WBC: 2.8, Hb:
12, Platelet: 110, Hct: 38.
• Dengue combo:
• NS1 Antigen: Positive,
• IgG: Negative,
• IgM: Negative
5

6. Dengue cases and incidence rate in Malaysia
(2000 – 2017)
Decrease in cases
16.1% in 2016
17.3% in 2017
6

7. Current situation in dengue
• As up to Oct 25 — Malaysia recorded a 74.4% drop in
dengue cases in January to September 2021.
• In end of 2021, 26,365 cases, with 20 deaths.
2020 2021
75,804 cases 19,423 cases
7

8. Dengue Serotype From 2013 To 26 May 2018
8

9. 9
CONTENTS
•How to diagnose?
•When to notify?
•How to follow-up & monitor?
•When & how to refer?
•Conclusion
9

10. Dengue is diagnosed
using WHO criteria 2009
that is fever plus 2 other
symptoms
We define dengue disease
severity using WHO
criteria 2009
10
Diagnosis of dengue in Malaysia

11. 11
STEPWISE APPROACH
Step 1: Overall assessment
a. History
b. Physical examination
c. Investigations
Step 2 : Diagnosis, disease staging and severity
assessment
Step 3 : Plan of management
11

12. Clinical course of dengue infection
12

13. Febrile phase
Critical Phase
Recovery Phase
Last for 2 – 7 days
• Occurs after the 3rd
day of fever
• Clinical presentation depends on the
presence and degree of plasma leakage
• Lasts for about 24-48 hours
In severe dengue – plasma leakage stops and
is followed by reabsorption of extravascular
fluid
• Dengue infection is a dynamic disease
• Its clinical course changes as the disease progresses
Clinical course of dengue infection

14. STEPWISE APPROACH
Step 1: Overall assessment
a. History
b. Physical examination
c. Investigations
Step 2 : Diagnosis, disease staging and severity
assessment
Step 3 : Plan of management
14

15. Step 1 - Physical examination
1. Assess mental state & GCS
2. Assess hydration
3. Assess hemodynamic
15

16. Haemodynamic Assessment (CCTVR)
The “5-in-1 maneuver” magic touch – CCTV-R
• Hold the patient’s hand to evaluate peripheral perfusion.
• Save life in 30 seconds by recognizing shock
CPG Management of Dengue Infection in Adults (3rd Edition) 16

17. Haemodynamic assessment
Delayed capillary refill time.
BP & pulse pressure
17

18. 120
110
100
90
80
70
60
Blood pressure, pulse pressure, heart rate in
hypovolemic shock
Time
Decompensated
shock
Compensated shock
HR
BP
18

19. Step 1 - Physical examination 2
4. Look out for tachypnoea/ pleural effusion
5. Check for abdominal tenderness/
hepatomegaly/ ascites
6. Examine for bleeding manifestation
19

20. 20
STEPWISE APPROACH
Step 1: Overall assessment
a. History
b. Physical examination
c. Investigations
Step 2 : Diagnosis, disease staging and severity
assessment
Step 3 : Plan of management
20

21. INVESTIGATIONS
1. FBC
• WBC and platelet
• There is no correlation between disease severity and
platelet count, and it is not predictive of bleeding.
• In recovery phase, the WCC normalizes followed by
platelet.
• Hematocrit (HCT):
• A rising HCT is a marker of plasma leakage in dengue
infection.
• Values of normal HCT level
• Male < 60 years – 46%
• Male > 60 years – 42%
• Female (all age groups) – 40%
• Serial FBC and HCT must be monitored as dengue infection
progresses.
21

22. INVESTIGATIONS -DIAGNOSTIC TESTS
1. Rapid Combo Test (RCT)
― Consist of dengue NS1 antigen and dengue IgM and IgG antibodies
2. Dengue Viral RNA Detection (Real time RT-PCR)
― can detect the viral RNA after 5 days after onset of the symptoms
― The test is useful for determination of circulating dengue serotypes in the country.
22
Non-Structural Protein-1
(NS1 Antigen)
• Appears at 4-5 of illness
onwards and negative at
recovery phase.
• Positive test indicates ptn
has acute dengue infection.
• If present after day 5 🡪 may
predict severe dengue
Dengue IgM test
• Usually positive after day
5-7 of illness
• Positive test suggestive of
recent dengue infection
Dengue IgG test
• Positive after day 7 of onset
of fever.
• Positive test suggestive of
acute or past infections.
• A titre of > 1:2560 is
consistent with acute
secondary infection.

23. Type of dengue tests recommended based
on clinical history
Clinical History Test Result Interpretation
History of fever less
than 5 days
Dengue NS1 Ag
or RCT
Positive Acute dengue infection.
Negative Dengue infection still cannot rule out.
Suggest to send second sample for Dengue IgM after day 5
of fever
Dengue Viral
RNA Detection
(Real time
RT-PCR)
It can detect the viral RNA after 5 days after onset of the
symptoms
The test is useful for determination of circulating dengue
serotypes in the country.
History of fever more
than 5 days
Dengue IgM Positive Suggestive of recent dengue infection
Indeterminate Advice to repeat the test.
Negative The result does not rule out dengue infection. Advice to send
repeat sample for dengue IgM after day 7 of fever or ask for
Dengue IgG test
History of fever more
than 5 days and
Dengue IgM and /or
NS1 was negative
Dengue IgG Positive Suggestive of acute or past infections.
A titre of equal or more than 1:2560 is consistent with acute
secondary infection.
Indeterminate Advice to repeat the test if clinically indicated.
Negative Presumptive evidence that the patient does not have
23

24. 24
STEPWISE APPROACH
Step 1: Overall assessment
a. History
b. Physical examination
c. Investigations
Step 2 : Diagnosis, disease staging and severity
assessment
Step 3 : Plan of management
24

25. What phase is the patient now ?
1. Diagnosis? Day of fever?
2. Which phase?
3. +/- warning signs
4. Shock/ stable?
• Assessment : CCTVR
• Hemodynamic parameters?
5. Severe dengue?
25

26. 26
STEPWISE APPROACH
Step 1: Overall assessment
a. History
b. Physical examination
c. Investigations
Step 2 : Diagnosis, disease staging and severity
assessment
Step 3 : Plan of management
26

27. Clinical and Laboratory Criteria for Patients
Who Can Be Treated at Home
1. Able to tolerate orally well, good urine output and no history
of bleeding
2. Absence of warning signs
3. Physical examination:
o Hemodynamically stable
o No tachypnoea or acidotic breathing
o No tender liver or abdominal tenderness
o No bleeding manifestation
o No sign of third space fluid accumulation
o No alterations in mental state
4. Investigation:
o Stable serial HCT
5. No other criteria for admission
o (i.e. co-morbidities, pregnancy, social factors)
27

28. 28
IF ADMISSION IS NOT INDICATED WHAT NEXT?
•Symptomatic and supportive
•Daily or more frequent f/u is necessary especially from
day 3 onwards until afebrile for at least 24–48 hours
without antipyretics
•Use Dengue Clerking Sheet
•Provide Outpatient Dengue monitoring record &
Home Care Advice Leaflet for Dengue Patients
•Advise patient to return to hospital as soon as the
warning signs arise
28

29. OUTPATIENT DENGUE MONITORING RECORD
29

30. HOME CARE ADVICE LEAFLET FOR DENGUE PATIENTS
30

31. Criteria for hospital referral/admission
• Symptoms:
• Warning signs
• Bleeding manifestations
• Inability to tolerate oral fluids
• Reduced urine output
• Seizure
• Signs:
• Dehydration
• Shock
• Bleeding
• Any organ failure
31
• Special situations:
• Patients with co-morbidity e.g. Diabetes,
Hypertension, Ischaemic Heart Disease,
Coagulopathy, Morbid Obesity, Renal
failure, Chronic Liver disease, COPD
• Elderly more than 65 years old
• Patients who are on anti-platelet and/or
anticoagulants
• Pregnancy
• Social factors that limit follow-up e.g.
living far from health facility, no transport,
patient living alone, etc.
• Laboratory criteria:
• Rising HCT accompanied by reducing
platelet count

32. Fluid management in dengue
• In non shock dengue patients, increased oral fluid intake may be
sufficient in those who are hemodynamically stable and not vomiting.
• IV fluid, 0.9% saline is recommended
• in patients with increasing HCT with evidence of ongoing plasma
leakage, despite increased oral intake
• in patients who are vomiting, severe diarrhoea and not tolerating
orally.
32

33. Calculations for maintenance of intravenous fluid infusion
Non-obese patients 1.2 to 1.5 ml/kg/hour
Obese patients
(BMI >27.5 kg/m2 )
Adjusted bodyweight (ABW) can be
calculated:
ABW = IBW + 0.4 (actual weight - IBW)
Ideal bodyweight (IBW) can be estimated
based on:
Female: 45.5 kg + 0.91(ht in cm -152)
Male: 50.0 kg + 0.91(ht in cm -152)
Fluid Bolus Regime Start with 5 ml/kg/hour for 1–2 hours, then
reduce to 3 ml/kg/hr for 2–4 hours and then
reduce to 2 ml/kg/hr or less according to the
clinical response.
33

34. INTER FACILITY TRANSFER
Prerequisites for transfer
•All efforts must be taken to optimise the patient’s condition before and
during transfer
•The ED, ICU and Medical Department of the receiving hospital must be
informed prior to transfer
•Adequate and essential information must be sent together with the
patient that includes fluid chart, monitoring chart and investigation results

35. • Dengue is a Notifiable Disease.
• All suspected and confirmed dengue cases from private and
public health facilities must be notified by the attending
doctor via telephone/fax/e-notification to the nearest health
office within 24 hours of diagnosis.
• We notify by using disease category as
• Dengue fever (9)
• Dengue hemorrhagic fever (10)
• Failure to notify is liable to be compounded under the
Prevention and Control of Infectious Diseases Act, 1988 (Act
342).25
Notification

36. Notification
form
36

37. Dengue Surveillance
e notification
• Real time web based system used to
notify ALL notifiable diseases based on
MOH requirement.( Dengue, malaria,
TB, Measles, Leptospirosis, Pertussis,
HFMD, HIV, Food poisoning, Typhoid,
Cholera , Hepatitis, Filariasis, etc )
e dengue V2
• specific web based system to
REGISTER Dengue cases
• Dengue cases are registered into this
system by respective District Health
Office after verification &
investigation.
37

38. Criteria Yes No Details
Fever
Joint pain
Nausea/vomiting
Rash
Leucopenia
Any warning signs
Warning signs Yes Details
Persistent vomiting or diarrhoea
( >3 times over 24 hours
Abdominal pain/tenderness
Lethargy/restlessness/confusion
Tender liver
Third space fluid accumulation
Spontaneous bleeding tendency
Raised HCT with rapid drop in
platelet
Special group Yes Details
Obese
Pregnancy /children
Heart failure/CKD/CLD
DM/ HPY/COPD/
Age >65
Smoking
SEVERE DENGUE Yes Details
Hypotension SBP<90 or MAP<60
or SBP drop >40 from baseline
Shock index: HR>SBP or
abnormal CCTVR
Third space fluid accumulation
with respiratory distress
Altered conscious level
Any bleed GI/ non mucosa non
cutaneous non physiological
Specific organ dysfunction
Vital sign Blood
Temp: CRT: TWBC: Platelet:
BP/MAP: RR: Hb: NSI:
HR: HCT: IgG/IgM:
Name
Address
IC / Phone
Diagnosis
Fever onset
Critical phase onset
Phase: febrile / critical / recovery
Warning sign (yes/no)
Severe dengue (yes/no) stable or not
Management
Notification date
Dengue alert card and monitoring card
Signature doctor
Dengue clerking sheet
38

39. Common errors at primary care
• Failure to recognise dengue infection in a febrile patient
• Have high index of suspicion in
• Febrile patients coming from dengue areas
• Patients with symptoms of dengue

40. Common errors at primary care
• Failure to recognize dengue shock in an afebrile patient
• Have high index of suspicion for
• Nausea, vomiting, abdominal pain & warning signs
• Manifestations of compensated and decompensated shock
• Changing HCT (rather than platelet count)

41. WARNING SIGNS
• Any abdominal pain/tenderness
• Persistent vomiting ( >3 times over 24 hours)
• Persistent diarrhoea ( >3 times over 24 hours)
• Third space fluid accumulation (such as ascites, pleural and pericardial effusion)
• Spontaneous bleeding tendency
• Lethargy/restlessness/confusion
• Tender liver
• Raised HCT with rapid drop in platelet.
• HCT male 60 years – 42%
• HCT female (all age groups) – 40%

42. During
febrile
phase
Fever:
influenza, measles,
chikungunya, adenovirus,
acute HIV
Rashes
Rubella, measles,
meningococcal meningitis,
chicken pox, drug induced .
Diarrhea
Rotavirus, food poisoning
42

43. During critical phase
• Acute abdomen:
• Acute appendicitis, acute cholecystitis, perforated
bowel, viral hepatitis
• Shock:
• Septic shock.
• Respiratory depression:
• DKA, Acute renal injury, lactate acidosis, covid, drug
poisoning
• Leucopenia and thrombocytopenia and bleeding:
• Malaria, leptospirosis, acute leukemia, TTP, SLE.
43

44. Challenges in clinical management
1. Atypical and nonspecific patient’s presentation. The
presentation can mimic many other diseases, thus delaying
the diagnosis.
2. Regular training on clinical management of dengue is
needed to update the health care providers as there are also
high turn over of health care providers in health facilities.
3. Patient has other co morbid. May have co-infection. Some
patients come at late presentation. Thus, causing acute
progression with multi organ dysfunctions.
44

45. TAKE HOME MESSAGE
In Primary Care Setting:
Accurate and prompt diagnosis & notification
Appropriate monitoring
Proper patient education & home mx
Alert to dengue warning signs & criteria for admission
Stabilise the patient before transfer (with prompt iv fluid resuscitation)
Good interfacility communication & handover
45

46. 46
Thank you