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Clinical Aspect of Dengue
in Pediatric Case
International Symposium: Integrated Research and Action on Dengue
Yogyakarta, 29-30 November 2013
Sri Rezeki S Hadinegoro
Dept of Child Health Faculty of Medicine, University of
Indonesia, Dr Cipto Mangunkusumo Hospital, Jakarta
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Outline
• Global strategy for dengue prevention and
control
• Difficulty in reduced morbidity
• Issues in dengue diagnosis
• Steps for dengue management
• Indonesian experience
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Global strategy for dengue prevention and
control, 2012-2020
Goal : To reduce the burden of dengue*
• To reduce dengue mortality by at least 50% by 2020• To reduce dengue mortality by at least 50% by 2020
• To reduce dengue morbidity by at least 25% by 2020
• To estimate the true burden of the disease by 2015
* The year of 2010 used as the baseline
(WHO, Geneva 2012)
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Re
du
ce d
en
gu
e m
orta
lity b
y a
t lea
st 50
% b
y 2
02
0
CF
R d
en
gu
e ca
ses, In
do
ne
sia 1
96
8-2
01
2
20
25
30
35
40
45
CRF(%)
Ba
selin
e o
f CF
R in
ye
ar 2
01
0 =
0.9
3%
0 5
10
15
20
196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012
CRF(%)
Ye
ar
CF
R
So
urce
: DG
of C
DC
& E
H, In
do
ne
sian
MO
H, 2
01
2
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DHF Cases in Outbreak 2004in six hospitals in Jakarta, Indonesia
Re assessment byWHO dengue criteria diagnosis 1997
DF DHF non shock
DHF w/ shock
Total
DF 232 9 0 241
Dia
gnos
is
in s
ourc
e do
cum
ent
DHF non shock 850 201 0 1051
DHF w/ shock 2 0 200 202
Total 1106 189 200 1494
• Number of DF and DHF w/o shock cases in source document were 241 and 1051, meanwhile in reassessment were 1106 and 189 respectively.
• Reassessment for CFR 1,5% ���� 4,9%• National data 2004: 1,1%.
Dia
gnos
is
in s
ourc
e do
cum
ent
Citraresmi E, Hadinegoro SR. Sari Ped 2007;8:8-14.
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• DF and DHF are different disease entity• DF
• no plasma leakage,• no hypovolemic shock
Important to differentiate between DF and DHF
• no hypovolemic shock• mild bleeding• good outcome
• Key is monitor at time of early shock phase or when fever ceased (day 3-5 of illness)
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After time of fever
defervescence(fever ceased)
Dengue Fever
Time of fever
defervescence
(fever ceased)
DF vs DHF
Dengue Fever
• good clinical conditions,
• good appetite
Dengue Hemorrhagic Fever• worst clinical conditions,
• followed by hypovolemic
shock
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Red
uces d
engu
e mo
rbid
ity b
y at least 2
5%
by
20
20
50
60
70
80
90
IR(cases/100000personyears)
Ba
selin
e o
f IR in
ye
ar 2
01
0 =
27
.09
%S
ou
rce: D
G o
f CD
C &
EH
, Ind
on
esia
n M
OH
, 20
12
0
10
20
30
40
196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012
IR(cases/100000personyears)
Ye
ar
IR
De
ng
ue
case
incid
en
ce is still h
igh
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Incidence Dengue Cases Moved to
Older Age Group
40
50
60
70
DH
F in
cid
ence
(%
)
• Since year of
2000, incidence in
young adult increased
• Since 2008, 50-60%
incidence dengue
0
10
20
30
DH
F in
cid
ence
(%
)
Year
<1 year 1-4 years 5-14 years >15 years
incidence dengue
cases was adult
• Children have higher
mortality compared to
adult cases
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Difficulties to reduce dengue
morbidity• All serotype of dengue virus are circulated in
Indonesia
• Difficulty to sustain vector control activities
• Decrease the community participation in • Decrease the community participation in
support the vector control program
• Increased urbanization
• Crowded public housing in most cities
• Future time: dengue vaccine
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Issues in dengue diagnosis
• How to differentiate between DF with DHF
• When use the “warning signs”
• Monitor at the time of fever defervescence is essential for
early detection of dengue shock
• Unusual manifestation and organ involvement were • Unusual manifestation and organ involvement were
classified as expanded dengue syndrome
• Special attention to high risk group
• International Code of Diseases (ICD) X
• A90 for dengue fever,
• A91 for dengue hemorrhagic fever
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Close monitor at the time of
fever defervescence
Fever shows the days of
illness
Every course of illness has
potential clinical issues
Course of dengue illness
Thrombocytopenia is a good
prognostic value, Hct for
guidance the volume
replacement
Diagnostic laboratory should
be performed in the right time
Case management depends on
phase of dengue illness
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WHO dengue guidelinesGuideline Issues
WHO 1997 Basic knowledge on epidemiology, pathogenesis,
diagnosis and case management, dengue
outbreak, and vector control
WHO-TDR 2009 • Warning signs to catch more dengue cases
• Classification on severe dengue. • Classification on severe dengue.
• Case management depend on disease severity
WHO-SEARO
2011• Use warning signs for early shock detection.
• Classification of expanded dengue syndrome
for unusual manifestation, organ involvement,
co-morbidity.
• Lab investigation for A-B-C-S
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WHO-SEARO
dengue case classification 2011
Source: Comprehensive guideline for prevention and control of dengue and dengue haemorrhagic fever.
Revised and expanded edition. Regional office for South-East Asia, New Delhi, India 2011.
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WHO 1966
WHO
WHO criteria diagnosis guidelineDengue mortality in Indonesia 1968-2009
1975WHO1986 WHO
1997 WHO-TDR 2009
The dengue case mortality reduced significantly within 40 years
WHO-SEARO2011
20
13
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Classification of dengue severity
WHO 1997 vs 2009
Dept of Child Health
Cipto Mangunkusumo hospital,
Jakarta 2010-2011
Suspected dengue cases
(N=194)N (%)
Laboratory-confirmed 152 (78.4)
Age (year) 1 to 4 20 (13.2)
5 to 9 52 (34.2)
> 10 76 (50)
34
(22.4 %)
59
(38.8 %)
59
(38.8 %)
6
(3.9 %)
90
(59.2 %)
56
(36.8 %)
0
10
20
30
40
50
60
70
Dengue Fever ( DF )/Without Warning Signs DHF 1 and 2 ( DHF )/With Warning Signs DHF 3 and 4 ( DSS )/Severe Dengue
Traditional Revised Karyanti RM, 2012 (in progress publication)
> 10 76 (50)
Sex Male 84 (55.3)
Secondary infection 130 (85.5)
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Need harmonization between
guideline 2009 and 2011
• Warning signs (2009)
• is useful for early detection of dengue shock
• use after dengue infection is suggested (2011)
• Severe dengue (2009)
• is including unusual manifestations, organ
involvement, dengue with complication, co-
morbidity, co-infection called expanded dengue
syndrome (2011)
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Steps for dengue management
• Early clinical diagnosis
• OPD with Triage systemo Admission/ observe
o Send home with good follow up
• Monitoring
Proper IV fluid management
Monitoring
• Proper IV fluid management
• Management of complications
• Early diagnosis of expanded dengue syndrome
• Discharge
Siripen Kalayanarooj: Informal Expert Consultation on Case Management of Dengue.
Colombo, Sri Lanka 12-14 August 2013
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Patient with fever 2-7
days, to differentiate
whose patient has
warning signs
TRIAGE
HospitalizedOutpatient
care
1. Need direct hospitalization
2. Need closed monitor
3. Treat as outpatient
Triage System
Actions:
treat, monitor &
observed
Emergency + warning signs
Treat properly
One Day Care (24 hours) for
closed monitor
Discharge:
observation
during fever
• By use the triage system (one day care=ODC),
reduced 76% hospitalization of suspected dengue cases
• ODC is very useful in outbreak situation(Sri Rezeki Hadinegoro, 1998)
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“Warning Signs”
• No clinical improvement
at a-febrile phase
• Refused oral intake
• Recurrent vomiting
• Severe abdominal pain
• Bleeding tendency:
epistaxis, blackstool,
hematemesis, menorrh
agia haemoglobinuria• Severe abdominal pain
• Lethargy, change of
behavior
• Pale, cold hand and foot
agia haemoglobinuria
or hematuria
• Giddines
• Decreased diuresis
within 4-6 hours
Early shock detection
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Suspected Dengue Infection
Warning signs
• No clinical improvement at afebrile phase
• Refused oral intake
• Recurrent vomiting
• Severe abdominal pain
• Lethargy, change of behavior
• Bleeding tendency: epistaxis, black stool, hematemesis,
menorrhagia, black color urine (haemoglobinuria) or
hematuria
• Giddines
• Pale, cold extrimities
• Decreased diuresis within 4-6 hours
• Headache, retroorbital
pain, myalgia, arthralgia
• Leucopenia (≤4000/mL)
• Dengue case in the neighborhood
• Fever <7 days
• Skin rash
• Bleeding manifestations
(tourniquet test/spontaneous)
DHF DHF with
shock
Expanded Dengue
Syndrome
Warning
signsClosed
follow-up• Organ involvement
• Complication
• Co-morbidity
• Co-infection
• Decreased diuresis within 4-6 hours
YesNo
• Co-morbidity
• Social indicationNo Yes Hospitalization
Send home
managed at
out patient
clinic
Clinical & lab follow-up
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Home care advice for patients• Take adequate bed rest
• Adequate intake of fluids: milk, fruit juice, isotonic electrolyte solution, ORS.
• Keep body temperature below 390C, give paracetamol10mg/kg/dose every 6 hours, avoid aspirin, NSAID & ibuprofenibuprofen
• Take to hospital soon� Worst clinical manifestation at a-febrile phase � Severe abdominal pain� Recurrent vomiting, � Cold hand and foot and clamp � Lethargy � Bleeding � Dyspnea� Convulsion
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Rate of infusion in non-shock case
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Compensated
• Tachycardia
• Tachypnea
• Pulse rate <20 mmHg
• Capillary refill time > 2
• Tachycardia
• Hypotensive
• Narrow of pulse rate
Hyperpnea or Kussmaul
Decompensated
Dengue Shock Syndrome
• Capillary refill time > 2
seconds
• Cold skin
• Decreased urine output
• Restless
• Hyperpnea or Kussmaul
• Cyanosis
• Cold and clamp skin
Profound shock un-palpable pulse, un-detectable blood pressure
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Unusual manifestation, dengue with complication, and
several organ involvement
Six hospitals in Jakarta, dengue outbreak 2004
Dengue with complications 205 (46.7%) among 1494 cases
• Recurrent shock 34 (2.7%)
• Prolonged shock 16 (1.3%)
Massive hemorrhage 12 (1.0%)
Prolonged shock 16 (1.3%)
• Massive hemorrhage 12 (1.0%)
• Fluid overload 21 (1.7%)
• Encephalopathy 16 (1.3%)
• DIC 3 (0.2%)
• Others 6 (0.5%)
Ref. Citraresmi E, Hadinegoro SR. Sari Ped 2007;8:8-14.
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Laboratory investigation A-B-C-S
For patients who present with profound shock
or have complications, and cases with no clinical
improvement in spite of adequate
volume replacement
• A cidosis : blood gas
• B leeding : haematocrit
• C alcium : electrolyte, Ca++
• S ugar : blood sugar
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Compensated Dengue Shock Syndrome• Give oxygen 2-4L/minute
• Check hematocrit
•Crystalloid RL/RA 10-20ml/kg.BW within 10-20 minutes
Shock recoveredYes
IVFD 10ml/kg.BW, 1-2 hours
No
Check Ht, blood gas, blood glucose,
calcium, bleeding (ABCS)
Correction soon for acidosis,
Stabile,
Decreased IVFD gradually
7, 5, 3 , and 1,5
ml/kg.BW/hour
Stop IVFD
maximal 48 hours
after shock recover
Correction soon for acidosis,
hypoglycemia, hypocalcaemia
Ht decreasedHt increased
2nd bolus for crystalloid
Or colloid 10-20ml/kg.BW
within 10-20 minutes
Bleeding
Colloid 10-20ml/kg.BB
within 10-20menit, if shock
persist suggested blood
transfusion
Blood transfusion
Unclear
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Rate infusion in DSS case
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Decompensated Dengue Shock Syndrome• Give oxygen 2-4L/minute
• Examine hematocrite, blood gas, blood glucose, calcium, bleeding (ABCS)
• Crystalloid or colloid 10-20ml/kg.BW within 10-20 minutes
Shock recoveredYes
IVFD 10ml/kg.BW, 1-2 hours
No
Evaluated Ht, blood gas, blood glucose,
calcium, bleeding (ABCS)
Correction soon for acidosis,
Stabile,
Decreased IVFD gradually
7, 5, 3 , and 1,5
ml/kg.BW/hour
Stop IVFD
maximal 48 hours
after shock recover
Correction soon for acidosis,
hypoglycemia, hypocalcaemia
Ht decreasedHt increased
2nd bolus for crystalloid
Or colloid 10-20ml/kg.BW
within 10-20 minutes
Bleeding
Colloid 10-20ml/kg.BB
within 10-20menit, if shock
persist suggested blood
transfusion
Blood transfusion
Unclear
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High Risk Group
• Infants, elderly
• Obese patients
• Prolonged shock
• Significant bleeding• Significant bleeding
• Encephalopathy
• Underlying diseases
• Pregnancy
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Shock
DengueYellow fever
CCHFWest Nile feverRift valley fever
Hemorrhage
DengueYellow feverChikungunya
CCHFRift valley fever
Clinical syndrome associated with Flavivirus diseases
Yellow feverCongo-crimean hemorrhagic
fever (CCHF)West Nile fever
Dengue
JETick borne encephalitis
Venezuelan encephalitisWestern equine encephalitisEastern equine encephalitis
Fever
Zinsser Microbiology,1992.p.1020
Hepatitis Encephalitis
Yellow fever
Congo-crimean hemorrhagicfever (CCHF)
West Nile fever
Dengue
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Expanded dengue syndrome(unusual or atypical manifestations)
• Unusual manifestations• uncommon
• neurological (encephalopathy): convulsions, changes in consciousness, transient paresis changes in consciousness, transient paresis
• hepatic, renal, heart, other isolated organ involvement
• Complication of severe profound shock, • co-morbidity
• underlying conditions: DM, asthma, etc.
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• Outbreak:88.3 (71.2 – 116.5) minutes
• Non-outbreak: 48 (max 74,6) minutes
Time of shock recovered
• Inotropic agents: 43 � 18 patients of prolonged or recurrent shockOver
Dengue outbreak in Indonesia, 2004Six referral hospitals in Jakarta
of prolonged or recurrent shock
• Antibiotic used 895 (59.9%); antiviral 78 (5.2%) �useless
Over treatment
• Outbreak 1998 : 6.1%
• Outbreak 2004 : DHF non-shock 0.2%; shock syndrome 8.4%
Increased CFR
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Conclusion
• Established “true burden of disease” is
essential in dengue reported cases
• Calculated mortality rate and morbidity of
dengue infectiondengue infection
• Dengue surveillance: for calculate the
effectiveness of dengue vaccine
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Conclusion
• National policy on dengue management in
Indonesia based on WHO 2011 (harmonization
WHO dengue guideline 2009 and 2011)
• Dengue pediatric case management in Indonesia • Dengue pediatric case management in Indonesia
is sufficient
• Dengue mortality decreased significantly
• Although dengue incidence is still high: need other
preventive intervention (exp. dengue vaccine)
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