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Rate of Infusion in DSS (2011)backIntroductionGLOBAL burden of dengueGlobal incidence of dengue has grown dramatically in recent decadesAbout two fifths of the world's population are now at riskDengue is found in tropical and sub-tropical climates worldwide, mostly in urban and semi-urban areasDengue is the most prevalent arboviral disease with high morbidity, mortality & socio-economical costs.

ContCase managementDespite its complexity in pathogenesis and manifestation the management is relatively simple and inexpensiveNo specific treatment rely on fluid management. Appropriately and timely implemented, it could save the lives of patientsCurrent situation : the most effective way to prevent dengue transmission is to combat disease-carrying mosquitoesThe development of vaccines and drugs is challenging but potential to change this.

1997 2009 2011Dengue guidelines 199720092011TitleGuideline for treatment of DF and DHF in small hospitals WHO Searo 1999Dengue Guidelines for diagnosis, treatment, prevention and control WHO TDR 2009Comprehensive guideline for prevention and control of Dengue and DHF WHO Searo 2011Pages 33160212ContentClinical manifestation, diagnosis, case managementChapters : (6)Epidemiology and burden of disease, clinical management, vector management, lab diagnostic tests, surveillance and emergency response, new avenuesChapters : (15)Epidemiology, disease burden,clinical manifestation and diagnosis, lab diagnosis, management, surveillance, vector, vector management, IVM, Combi, PHC approach, case investigation, monitoring, strategic plan (bi-regional plan)Diagnosis Classification199720092011Dengue feverDengue without warning signsDengue feverDHF grade IDengue with warning signsDHF grade IDHF grade IIDHF grade IIDHF grade IIISevere dengue ( severe plasma leakage, severe hemorrhage, severe organ involvement)DHF grade IIIDHF grade IVDHF grade IV* Expanded dengue syndrome Adult managementAdult management1997 classificationProbable an acute febrile illness with two or more of the following manifestations:HeadacheRetro-orbital painMyalgiaArthralgiaRashHaemorrhagic manifestationsLeukopenia; andSupportive 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 ); orOccurence at the same location and time as other confirmed ases of dengue fever.

Confirmed a case confirmed by laboratory criteriaReportable any probable or confirmed case should be reported

GradeSign and SymptompsLaboratoryDFDHF without plasma leakageDHF IFever with non-specific constitutional symptoms; the only hemorrhagic manifestation is a positive tourniquet test &/or easy bruising evidence of plasma leakageThrombocytopenia (platelet count 100,000/L)IIDHF grade I plus spontaneous bleedingIIICirculatory failure manifested by a rapid, weak pulse, narrowing of pulse pressure, or hypotension, cold & clammy skin, restlessnessIVProfound shock with undetectable blood pressureWHO Dengue Classification 1997

DFDHF1. Fever 2-7 days++2. Bleeding tendencyPositive tourniquet test orSpontaneous bleeding+/-+3. Thrombocytopaenia 100,000/mm +/-+4. Plasma leakagePleural effusion /ascites /hypoproteinaemia 20% increase in HCT from baseline-+112009 classification

Lancet Inf Dis 2006; 6: 297-302

Lancet 2006; 368: 170-1731313Rationale for the denco study: there are increasing number of publications about the shortcomings of the current ( 1997) classification

The stages of the dengue case classification developmentNumerous publications describing thedifficulties using DF/DHF/DSS A systematic review of the issueBandyopadhyay S et al., TMIH 2006, Volume 11 no 8 pp 12381255 The DenCo study (dengue and control) Two expert consensus meetingsLa Habana 2007 and Kuala Lumpur 2007 A global expert consensus meetingGeneva 2008 Dengue guidelines validation studies(forthcoming publication)TDR report (summary recommendations)(planned for 03/2010)- numerous reports of the difficulties using DF/DHF/DSS: epidemiology has changed

- confirmation of the above

- clear evidence for classifying in dengueand severe dengue

large differences of DHF case definitionsbetween countries; application difficult - dengue is just one disease entity with different clinical presentations and often with unpredictable clinical evolution and outcomefurther design: 1) dengue with or withoutwarning signs and 2) severe dengue

analysis showing user-friendlinessand acceptance of dengue/severe dengue

final analysis and recommendations

overall summary report/recommendations

DF/DHF/DSS application studySantamaria R et al. , accepted at TMIH 2009, September1990s-2009 A global expert meeting reviewing "chain of evidence (planned for 03/2010)

The full model of the revised WHO dengue case classification

Dengue without warning signsProbable denguelive in /travel to dengue endemic area. Fever and 2 of the following criteria:Nausea, vomitingRashAches and painsTourniquet test positiveLeucopeniaAny warning signDengue with warning signsWarning signsAbdominal pain or tenderness Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy, restlessness Liver enlargement >2 cmIncrease in HCT concurrent with rapid decrease in platelet countbackSevere DengueSevere plasma leakage leading to:Shock (DSS)Fluid accumulation with respiratory distressSevere bleeding as evaluated by clinicianSevere organ involvementLiver: AST or ALT 1000CNS: Impaired consciousnessHeart and other organsEvidence from 2009 Dengue GuidelineMulticentre 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)Usefulness and applicability of the revised dengue case classification by disease: multicentre study in 18 countries (Judit Barniol et.al, 2010)DengueHow Best to Classify It (Anon Srikiatkhachorn et.al, 2011)Evidence from 2009 Dengue GuidelineApplication 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)2011 classificationDengue virus infectionAsymptomaticSymptomaticUndefferentiated fever (viral syndrome)Dengue Fever (DF)Dengue Haemorrhagic Fever (DHF)(with plasma leakage)Without haemorrhageWith unusual haemorrhageDHF non shockDHF with shockDengue Shock Syndrome (DSS)Expanded Dengue syndrome/isolated organophaty (unusual manifestation)2011DF/DHFGradeSigns and SymptomsLaboratoryDFFever with two of the following:HeadacheRetro-orbital painMyalgiaAthralgia/bone painRashHaemorrhagic manifestationsNo evidence of plasma leakageLeucopenia (WBC 50,000/LIncreasing trend> 50,000/LNational guideline

Ditjen PPM PLP 2004Ditjen Yanmed , IDAI, PAPDI, IDSAI, PERDICI, PDS PATKLIN, PPNI - 2005SummaryDengue disease burden is significantly increased across continentsCase management is relatively simple and inexpensive could saves the lives of patientsRevised guidelines ( 2009 and 2011) are available Proposed National guideline ?

Changes might be slowly, difficult but inevitableTerima kasihAdmission criteria 2009 p 47backWarning signsAny of the warning signs (Textbox C)Signs & symptoms related to hypotension (possible plasma leakage)Dehydrated patient, unable to tolerate oral fluidsGiddiness or postural hypotensionProfuse perspiration, fainting, prostration during deferescenceHypotension or cold extremitiesBleeding Spontaneous bleeding, independent of the platelet countOrgan impairmentRenal, hepatic neurological or cardiacenlarged, tender lier, although not yet in shockChest pain or respiratory distress, cyanosisFindings through further investigationRising hematocritPleural effusion, ascites or asymptomatic gall bladder thickeningCo-existing conditionsPregnancyCo-morbid conditions, such as diabetes mellitus, hypertension peptic ulcer, hamolitic anemias and othersOverweight or obese (rapid venous access difficult in emergency)Infancy or old ageSocial circumstancesLiving alone, living far from healt facility, without reliable means of transport

Dengue case classification by severity
Without
withwarning signs
1.Severe plasma leakage 2.Severe haemorrhage3.Severe organ impairment
Severe dengue
Dengue warning signs
Probable 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 signLaboratory confirmed dengue(important when no sign of plasma leakage)
Warning signs* Abdominal pain or tenderness Persistent vomiting Clinical fluid accumulation Mucosal bleed Lethargy; restlessness Liver enlargement >2cm Laboratory: Increase in HCT concurrent with rapid decrease in platelet count

* Requiring strict observation and medical intervention
1. Severe plasma leakage leading to: Shock (DSS) Fluid accumulation with respiratory distress

2. Severe bleeding as evaluated by clinician

3. Severe organ involvement Liver: AST or ALT>=1000 CNS: Impaired consciousness Heart and other organs
Criteria for dengue warning signs
Criteria for severe dengue
WHO/TDR 2009