clinical management of dengue - pgh.gov.ph · 2nd ed presentation d3 illness 21:26: returned for...
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Clinical Management of Dengue
SIIDC 2017 Singapore
Prof (Dr) Yee-Sin LEO
Executive Director National Centre of Infectious Disease NCID
Clinical Director Communicable Disease Centre
Director Institute of Infectious Disease and Epidemiology
Tan Tock Seng Hospital
Communicable Disease Centre
Communicable
Disease Centre 2
Self-contained
No of Beds: 94
Communicable
Disease Centre
No of Beds: 211
Communicable
Disease Centre 1
80 Isolation Rooms
Built in 1907 In the middle of
SARS
Near end of SARS
Interim enhancement of isolation
facilities
Centralised outbreak management centre
1907 1960s 2018 2000s
1907 Smallpox, plaque
1938 Typhoid
1945-46 Polio outbreak
1957 Asian Flu
1958 Polio
1959 Smallpox
1961 Diphtheria
1963 Cholera
1964 Typhoid
1999 Nipah Outbreak
2003 SARS
2005 Worst dengue epidemic
2008 Chikungunya
2009 H1N1
2013 Worst dengue epidemic
2106 Zika
1985 Merged with TTSH
1992 Dept ID formed1907 Isolation camp
1920 Middleton Hospital
National Centre
for Infectious
Diseases (NCID)2012 Formed IIDE
H7N9
EBOLA
MERS CoV
National Centre for Infectious Diseases NCID
Dengue in Singapore
Despite vector
control, low
breeding index,
Singapore faces
successive waves
of dengue epidemic
Predominantly
adult dengue and
increasingly more
senior adults
Increasing
recognition of
atypical dengue
2.5 billion people -40% of world population – are at risk of dengue
100 million dengue virus infections worldwide every year
Half a million with severe dengue
Primary Care
• Early recognition / suspicion of dengue
POCT / rapid combined Ag/Abs
Daily monitoring
•Early recognition of warning signs
Febrile phase
Secondary Care Hospitalization
Critical phase
• Adequate trained staff
• Lab support
• Adequate consumables
Tertiary Care ICU
Final Outcome
Recovery
Dengue management
WHO 2009
Specialized dengue care unit
Hospitalisation
Fluid management
Enhance care at community
Admission criteria
Early predictors
Early diagnosis
Emphasis on early
diagnosis and identify
early predictors to
effectively manage the
entire course of
dengue illness
Simple cheap clinical and or laboratory tools are needed to
better diagnose dengue and able to diagnose dengue early
NS1 only Sen 82%, Spec 98% NS1/IgM,IgG Sen 94%, Spec 92%
Either WHO 1997 or 2009 is sensitive (>90%) but not specific (20-26%)
5th ASEAN Dengue Day Seminar - 2015
13 Jun 2015:Attended by over 140 general practitioners, physicians, researchers, nurses, pharmacists, and other healthcare professionals
Engaging Primary Care
June – Oct 2011
2 hospitals + reference lab
162 enrolled, 157 analysed
85 confirmed, 41 probable
(32DF, 84DHF, 8DSS)
31 negativeK 0.96, 98.1% agreement
K 0.55, 68.8% agreement
Dengue duo NS1/IgM/IgG
Hospital labs: 85.7% Sn,
83.9% Sp, PPV 95.6%,
NPV 59.1%
Reference lab:94.4% Sn,
90% Sp, PPV 97.5%,
NPV77.1%
NS1
Sn 45%,Spc 97%
PLOS NTD 2013;7:e2023
NPV 0.96 in the
absence of any WS
> 3 WS specific
but not sensitive
Predicting DHF
Considerable within-patient variation
Higher UACR values in dengue cases
Peak UACR values for dengue cases observed around day 5
Capillary permeability, age and DHF
Bethell CID 2001; 32: 243-53Gamble Clin Science 2000; 98: 211-16
Age and DHF in SingaporeOoi IJID 2003; 7: 231
Increasing DHF with younger patients; 0.3 in 1997 to 0.07 in 2000
39, Female designer, history of Thalassemia, Prolapsed intervertebral
disc,
No recent travel for the past 2 weeks before illness onset
Consulted GP twice (D1 and D3 illness-> referred to ED)
1st ED presentation at D3 Illness 14:00: T 39.6 C, lowest BP recorded 86/50, HR
91/min
1.5 L NS given, advised admission but patient requested AMA (personal
commitment) BP 94/58, HR 90/min upon ED discharge
2nd ED presentation D3 illness 21:26: returned for admission, BP 78/58, HR
99/min, total 2 L IV NS given, IV dopamine 5 10 mcg/kg/min
Fever and hypotension
WHO 2012
No all hypotension
are due to
hypovolemia
No one size fit all
Study on optimal
fluid management
DHF – age in 2o Infection, 1981 Cuba Outbreak
Guzman IJID 2002;6:118
Age distribution of adult dengue deaths Singapore 2004-2008
0
2
4
6
8
10
12
15-24 25-34 35-44 45-54 55-64 >65
Age group (years)
Fa
taliti
es
Older adults with dengue have more atypical presentations, more organ involvement, more
pre-existing comorbidities, higher mortality, require higher index of suspicion to diagnose,
closer monitoring and careful management