CRISBERT I. CUALTEROS, M.D. - Dengue Fever Management
   
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CRISBERT I. CUALTEROS, M.D. (+63919)8586556

Management of dengue fever in children

CLINICAL PRACTICE GUIDELINES

DECEMBER 2004 MOH/P/PAK/95.04

MANAGEMENT

OF

DENGUE FEVER IN CHILREN

i

Management of dengue fever in children

MINISTRY OF HEALTH MALAYSIA ACADEMY OF MEDICINE MALAYSIA

GUIDELINES DEVELOPMENT AND OBJECTIVES

Guidelines Development

The work group for the development of these guidelines comprised paediatricians from various Ministry of Health and Ministry of Education facilities, and a public health specialist. These guidelines are an update of the existing guidelines on dengue. For this purpose, a systematic review of current evidence was carried out. The ranking of evidence is based on a modified version of that suggested by the Catalonia Agency for Health Technology Assessment and Research (CAHTAR) Spain (Appendix 1). These guidelines have been presented to the Chairman, Health Technology Assessment and Clinical Practice Guidelines Council, Ministry of Health Malaysia for review and approval.

Objectives

The aim of these guidelines are to aid health care providers and paediatricians in clinical decision making, by providing evidence-based information on the management of children with dengue.

Clinical Questions

The clinical questions for these guidelines are:

i. What is the clinical spectrum of dengue infection?

ii. How is dengue infection diagnosed?

iii. How can patients with dengue be treated successfully?

Target Population

These guidelines are developed to apply to children with dengue.

Target Group

These guidelines are meant for all health care providers.

ii

Management of dengue fever in children

GUIDELINES COMMITTEE

Dr Hussain Imam - Chairman

Head & Consultant Paediatrician

Hospital Kuala Lumpur

Dr Hung Liang Choo

Consultant Paediatrician

Hospital Kuala Lumpur

Dr Che Abdullah Hassan

Principle Assistant Director

Disease Control Division

Ministry of Health Malaysia

Dr S Sushila

Consultant Anesthesiologist

Hospital Kuala Lumpur

Dr Sharmila Kylasam

Consultant Anesthesiologist

Hospital Kuala Lumpur

Prof Lucy Lum Chai See

Consultant Paediatrician

Medical Faculty

University Malaya

A/Prof Dr Tang Swee Fong

Consultant Paediatrician

Medical Faculty

National University of Malaysia

Prof Dr Shamala Devi

Department of Microbiology

Medical Faculty

University Malaya

Dr Kamarul Azhar Mohd Razali

Consultant Paediatrician

Hospital Kuala Lumpur

Guidelines Coordinator

Ms Sin Lian Thye

Nursing Officer

Health Technology Assessment Unit

Medical Development Division

Ministry of Health Malaysia

Reviewed and Edited by

Dr S Sivalal

Head of Health Technology Assessment Unit

Deputy Director

Medical Development Division

Ministry of Health Malaysia

iii

Management of dengue fever in children

TABLE OF CONTENTS

1.

INTRODUCTION

1

2.

CLINICAL DIAGNOSIS

2

2.1

Classification

2

2.2. Guidance for Diagnosis of Dengue Infection

2

2.2.1 Clinical

3

2.2.2 Laboratory

3

3.

NOTIFICATION OF DENGUE

4

4.

MANAGEMENT

4

4.1 Clinical Course of Dengue Haemorrhagic Fever

4

4.2. Problems during Different Phases of DHF/ DSS

5

4.3 Ambulatory Monitoring of Suspected Dengue Patients

5

4.3.1 Clinical parameters

5

4.3.2 Laboratory parameters

5

4.4 Criteria for Admission to Hospital

5

4.5 Indications for Admission to ICU /HDU

6

4.6 Monitoring of Suspected Dengue Patients in Wards

6

4.6.1 Clinical parameters

6

4.6.2 Bedside investigations

6

4.6.3 Laboratory investigations

6

4.7 Management of the Acute Phase

6

4.7.1. Fluid management

6

4.7.2. Blood transfusion

9

4.8 Management of the Convalescent Phase

9

4.8.1 Indicators that patient is in the convalescence phase

9

4.8.2 Treatment

9

4.9 Discharge Criteria for Hospitalized Patients

10

4.10 Complications of DHF/DSS

10

5.

HEALTH EDUCATION

10

5.1 Patient and Family

10

5.2. Informational pamphlets

11

6.

PREVENTION STRATEGIES

11

6.1 Dengue Free Schools Programme

11

6.2 Dengue Free Health Facilities (including hospitals) Programme

11

6.3 Dengue Alerts

11

6.4 Circulars

12

6.5 Insecticide Aerosol Spraying In Public Transport

12

REFERENCES

13

Appendix 1 LEVELS OF EVIDENCE SCALE

15

Appendix 2 WHO CLASSIFICATION OF DHF AND DSS

16

Appendix 3 DEFINITION OF HYPOTENSION FOR AGE

17

Appendix 4 BLOOD PRESSURE TABLES FOR GIRLS AND BOYS BY AGE AND HEIGHT PERCENTILES

18

Appendix 5 LABORATORY DIAGNOSIS OF DENGUE

20

Appendix 6 FLOWCHART OF DENGUE NOTIFICATION

21

Appendix 7 ACTIVITIES AFTER NOTIFICATION

22

Appendix 8 COMMUNITY MOBILISATION

23

Table 1: Dengue Fever in Malaysia (1999-2003)

1

Table 2: Dengue Deaths and Case Fatality Rates by Age in Malaysia (1999-2003)

1

iv

Management of dengue fever in children

1. INTRODUCTION

Dengue fever is caused by a virus belonging to the

Flaviviridae family. There are four serotypes of dengue virus (Den 1, Den 2, Den 3, Den 4) that can be distinguished serologically. While infection by one serotype produces life-long immunity against re-infection by that same serotype, there is only temporary and partial protection against other serotypes. The incubation period of dengue varies from 3-10 days with an average of 4-6 days (WHO, 1997, level 6; Kabra et al, 1999, level .

The incidence of both dengue fever (DF) and dengue haemorrhagic fever (DHF) in Malaysia appears to show an increasing trend. The case fatality rates (CFR) i.e. the proportion of deaths to the total number of cases, however, seem to be stable. Many reported cases cannot be confirmed due to the lack of a second blood specimen. Of the confirmed cases, about 5 % were DHF as seen in Table 1 below:

Table 1: Dengue Fever in Malaysia (1999-2003)

Confirmed cases

Year

Population (mid-year)

Reported cases

DF

DHF

Incidence

(/100,000)

Deaths

CFR (%)

-

-

1999

22,711,900

10,146

4,718

20.77

37

0.78

3,312

411

2000

23,226,700

7,118

3,723

16.03

45

1.21

8,277

392

2001

23,795,300

16,368

8,669

36.43

50

0.58

14,694

799

2002

24,374,300

32,767

15,493

63.56

99

0.64

14,761

681

2003

25,048,300

31,545

15,442

61.65

72

0.47

DF=dengue fever DHF=dengue hemorrhagic fever CFR=case fatality rate

(Source: Annual Report, Vector-Borne Diseases Section, Ministry of Health Malaysia)

Considering the age distribution, the CFR in children below 15 years of age is consistently higher than that of the adult population as seen in Table 2 below:

Table 2: Dengue Deaths and Case Fatality Rates by Age in Malaysia (1999-2003)

Age < 5 years

Age 0 - 14 years

Age

Year

Total cases

Total deaths

CFR

Total cases

Total deaths

CFR

Total cases

Total deaths

CFR

15 years

1999

457

3

0.66

2,045

19

0.93

8,101

18

0.22

2000

373

12

3.22

1,432

19

1.33

2,291

26

1.13

2001

863

7

0.81

3,605

23

0.64

5,064

27

0.53

2002

130

17

13.08

2,284

47

2.07

13,209

52

0.39

2003

469

11

2.35

3,096

29

0.94

12,346

43

0.35

CFR=case fatality rate

(Source: Ministry of Health Malaysia, Vector-Borne Diseases Section, Annual Report)

1

Management of dengue fever in children

2. CLINICAL DIAGNOSIS

A child with dengue virus infection may have asymptomatic infection, or present with mild undifferentiated fever (especially in the toddler age group) or with the classical signs and symptoms of dengue fever (DF), dengue haemorrhagic fever (DHF) or dengue shock syndrome (DSS). The main clinical problem in children with DHF and DSS is the increased vascular permeability causing hypovolaemia (Pancharoen et al

, 2002, level 8; WHO, 1997, level 3; Lall & Dhanda, 1996, level .

2.1 Classification

The World Health Organization (1997,

The following is a suggested classification of dengue infection:

level 3) classification of DHF and DSS and their staging is indicated in Appendix 2. However, while the sensitivity and negative predictive values were 100%, the specificity was 21.21 %, and positive predictive value 63.38% according to the WHO case definition of DF (Sawasdivorn et al, 2001, level 6). Recent studies have found that 18% of children with DSS failed to meet all 4 necessary criteria for DHF as per WHO case definition It has also been suggested that less emphasis be placed on bleeding or a specific platelet count (Phuong, 2004, level 9).

- without increased vascular permeability

Dengue Fever

- increased vascular permeability and fragility – evidence of pleural effusion or ascites or haemoconcentration > 20%

DHF can be further graded as follows:

Dengue haemorrhagic fever (DHF)

DHF with no shock

DHF with shock (DSS) which can be further graded into:

- DHF with compensated shock

o

signs of shock - tachycardia out of proportion to body temperature, decreased tissue perfusion as evidenced by cool extremities, increased capillary refill time, narrowing of pulse pressure, weak distal pulses, oliguria and altered conscious level.

o

systolic pressure within the normal range (see Appendix 3 for details of hypotension, and Appendix 4 for normal blood pressure in relation to age, height and weight)

- DHF with decompensated shock

o

signs of shock – tachycardia, cool extremities, increased capillary refill time, weak or absent pulses, oliguria and altered conscious level.

o

systolic hypotension

2

Management of dengue fever in children

2.2 Guidance for Diagnosis of Dengue Infection

The criteria for a provisional diagnosis of dengue infection are indicated below.

2.2.1 Clinical

High fever of acute onset of 3 days or more (Kabra et al, 1999, level 8).

Altered sensorium

Shock in an afebrile patient who had fever over the previous 3-5 days

Petechial rash - generalized flushing, with maculo-papular rash (islets of white in a sea of red) occurring in the convalescent phase

Haemorrhagic manifestations

o

a positive tourniquet test* that precedes defervescence or thrombocytopenia (Soni et al, level 3; Kalayanarooj, 1997, level 5; Kabra et al, 1999, level 8).

o

epistaxis (Kabra et al, 1999, level 8).

o

gum bleeding (Kabra et al, 1999, level 8).

Convulsions

Headache,(Kabra et al,1999,level 8; Srivastava et al,1990; level 8 ).backache or retro-orbital pain (in older children)

Abdominal pain, vomiting, (Kabra et al, 1999, level 8; Teelucksingh et al, 1999, level 8; Srivastava et al, 1990, level 8). loose stools or diarrhoea

It has been found that children with the dengue illness are more likely to have anorexia, nausea and vomiting and a positive tourniquet test, with lower total white cell count, absolute neutrophil and monocyte counts, and higher plasma alanine and aspartate aminotransferase (AST) levels, than children with other febrile illnesses. Plasma AST levels were also found to be higher in children with DHF than in those with DF (Kalayanarooj, 1997,

Vertical transmission in newborns has also been reported (Chye et al, 1997,

Hepatomegaly (Kabra et al, 1999, level 8; Teelucksingh et al, 1999; level 8; Srivastava et al, 1990; level 8).level 6)level 3).

*

In children above 4 years of age, the tourniquet test is a useful test for dengue infection, a positive reading being an indication of capillary fragility. Blood pressure cuffs of appropriate sizes should be used, with a blood pressure level between the systolic and diastolic readings being maintained for 5 min. The presence of more than 20 petechiae per sq. in.(or per 6.25 cm2) area indicates a positive reading.

2.2.2 Laboratory

Down-trending of platelet count on the 3rd -5th day of illness

Normal white cell count or leucopenia

Thrombocytopenia (100 000 cells per mm3 or less) during defervescence and the critical phase of DHF/DSS (Kabra et al, 1999, level 8).

Haemoconcentration (elevated haematocrit - at least 20% or more than the average for age, sex and population, which ranges from a mean of 50% at 2 weeks of life to about 38% at 7-12 years of age) (Kabra et al, 1999, level 8 )

Four-fold or greater change in reciprocal IgG titres to one or more dengue virus antigens in paired serum samples

Detection of IgM antibody after the 3rd -5th day of illness, or after defervescence.

3

Management of dengue fever in children

Isolation of the dengue virus from serum (the virus is present in the acute phase of the disease and can be isolated in cultures for up to 5 days)

Demonstration of the dengue virus antigen in autopsy tissue, serum or cerebrospinal fluid samples by immunohistochemistry, immunofluorescence or ELISA

Further details of laboratory diagnosis can be found in Appendix 5.

Detection of dengue virus genomic sequences in autopsy tissue serum or cerebrospinal fluid samples by polymerase chain reaction (PCR) (WHO, 1997, level 3)

It is essential that the date of onset of illness as well as date of collection be indicated on all samples to assist in interpretation. Paired samples are also preferred.

3. NOTIFICATION OF DENGUE

All suspected dengue cases must be notified by telephone to the nearest health office within 24 hours, followed by written notification within a week using the standard notification format

[Borang RKPBV(AM)1 Pindaan 1/84] as illustrated in the flow chart for dengue notification in Appendix 6 Failure to notify is liable to be compounded under the law [Akta Pemusnahan Serangga Pembawa Penyakit, 1975 (Pindaan 2000); Prevention and Control of Infectious Diseases Act, 1988]. Subsequent activities by public health personnel after notification are detailed in Appendix 7.

4. MANAGEMENT

4.1 Clinical Course of Dengue Haemorrhagic Fever

The clinical course consists of 3 phases:

Febrile phase - very high body temperature, sometimes exceeding 40oC,

Critical phase – starts with defervescence* which is towards the end of the febrile phase, and lasts for 24 to 48 hours.

Resorption/convalescent phase - plasma that has leaked into pleural and peritoneal surfaces is reabsorbed.

*

Defervescence (abatement of fever) usually occurs on the third to fifth day of fever, when the temperature is less than 38oC. It is usually preceded by vomiting, abdominal pain and restlessness. Unlike other illnesses, in DHF, the patient’s condition worsens as the temperature abates. The body temperature may drop to sub-normal levels in established shock, and then rises again slightly above the baseline. The patient may have a saddle-shaped fever curve towards the end of the critical period. It is common to have 3-5 episodes of shock during this period, preceded by vomiting, abdominal pain and restlessness. There is increased vascular permeability and the platelet count begins to drop as the haematocrit rises. The viral load decreases and antibodies may begin to be detected. Studies have shown a change in the level of soluble cell surface protein and lymphokines in DHF (Kurane, 1991).

4

Management of dengue fever in children

4.2. Problems during Different Phases of DHF/ DSS

Febrile period – high fever, vomiting, diarrhoea, dehydration, seizures

Critical period – hypovolaemic shock, multi-organ dysfunction and bleeding in cases of prolonged shock, electrolyte imbalance, metabolic acidosis (may simulate respiratory distress presenting as Kussmaul’s breathing, but auscultation will indicate clear lung fields with good air entry)

Convalescent phase – respiratory distress from massive pleural effusion and ascites, pulmonary oedema.

4.3 Ambulatory Monitoring of Suspected Dengue Patients

4.3.1 Clinical parameters:

temperature

oral fluid intake

urine output

hydration status

bleeding including tourniquet test

4.3.2 Laboratory parameters

haemoglobin/haematocrit

total white cell (TWC) count , platelet count

Patients should be suspected to have dengue infection if the following are present:

IgM (may be negative in the febrile phase, although virus isolation / detection may be positive)

TWC is low or borderline normal

signs of defervescence

downward trend of platelet count

4.4 Criteria for Admission to Hospital

Any of the following should be an indication for hospitalization:

Shock – feeble pulses, cold extremities, capillary refill time > 2 seconds, hypotension (Soni et al, level

Altered conscious level – lethargy, delirium, combativeness.

Bleeding (Soni et al, level 8; Kabra et al, 1999, level 8).

Inability to tolerate oral fluids or vomiting, diarrhoea with signs of dehydration.

Abdominal tenderness or enlarged liver (Soni et al, level 8; Kabra et al, 1999, level 8).

Obesity or overweight

Falling platelet count/rising haematocrit (Soni et al, level 8; Kabra et al, 1999, level 8).

It is suggested that patients with suspected dengue infection referred by private medical practitioners be admitted to hospital for observation (Director General of Health, 2003).

Social factors e.g. living far from hospital, no transport, etc.

5

Management of dengue fever in children

4.5 Indications for Admission to ICU /HDU

Impending respiratory failure

Persistent shock not responding to 60ml/kg of fluid resuscitation

Cerebral protection

Need for close monitoring

4.6 Monitoring of Suspected Dengue Patients in Wards

4.6.1 Clinical parameters:

Hydration

???;;???;;

mucosal and skin turgor

???;;???;;

oral fluid intake

???;;???;;

urine volume, and other fluid losses such as vomiting or diarrhoea.

Haemodynamics

???;;???;;

skin perfusion – temperature of extremities

???;;???;;

capillary refill time,

???;;???;;

pulse volume

???;;???;;

heart rate

???;;???;;

blood pressure

???;;???;;

pulse pressure

???;;???;;

level of consciousness.

Body Temperature

4.6.2 Bedside investigations

Haematocrit - 4-6 hourly, depending on severity

4.6.3 Laboratory investigations

Haematocrit - Hb, TWDC, Platelet count,

BUSE, Creatinine

Dengue Serology

4.7 Management of the Acute Phase

4.7.1. Fluid management

Prompt and adequate fluid resuscitation is the key to the successful management of DHF/DSS. However,

fluid infusion has to be judiciously controlled to maintain an effective circulation, but at the same time, avoid over-replacement, that could lead to massive pleural effusion and ascites. Fluid therapy has to be adjusted according to

haematocrit level (pre-existing anaemia, severe haemorrhage, and capillary leakage can affect haematocrit levels)

urine volume – 0.5 to 1.0 ml/kg/hour

For children with signs of shock, two fluid therapy lines should be established:

vital signs and tissue perfusion

first fluid line

o

for replacement of fluid lost in the plasma leakage

o

in decompensated shock, rapid bolus of normal saline based on 20ml/kg body weight should be given

o

in compensated shock, normal saline based on 10-20 ml/kg body weight should be given over 30-60 minutes

6

Management of dengue fever in children

o

volume and infusion rate has to be adjusted every 2-6 hours based on clinical assessment and haematocrit of the patient

second fluid line

o

to administer maintenance fluids

o

5% Dextrose ½ saline with or without KCl, in the maintenance volume according to the child’s weight for height-centile-for-age

o

most children with DSS will be physiologically stressed, and some may not be able to handle the glucose load. Blood glucose should be checked regularly and if found to be high, dextrose should be omitted or infusion rate reduced.

If patient is still in shock, a second rapid normal saline bolus dose should be administered

If still no improvement, rapid fluid bolus should be repeated with colloids or blood/blood products depending on whether there is a rise or fall in haematocrit

When patient improves (patient is warm and has a good pulse volume), the fluid therapy is reduced to maintenance, and tapered off, finally discontinuing IV therapy, usually 24 to 48 hours after the start of plasma leakage. This is to avoid fluid overload and pulmonary oedema which may be fatal

For obese patients, the weight adjusted to height-centile-for-age should be closely followed to avoid fluid overload.

During rapid fluid therapy, the following need to be frequently assessed to determine the physiologic status:

The use of albumin and plasma is not recommended.

heart rate

pulse volume and pulse pressure

peripheral colour

temperature

capillary refill time

A flow chart for fluid therapy in patients with DHF and DSS is indicated below (Halstead, 2002,

blood pressurelevel 8; Soni et al, 2001, level .

7

Management of dengue fever in children

Fluid Therapy for Patients with DHF and DSS

SIGNS OF SHOCK

Compensated / decompensated shock

٭

Establish 2 IV lines

Line 1: replacement fluid- rapid fluid bolus of normal saline (10-20ml/kg or 20ml/kg)

Line 2: maintenance fluid 5% dextrose

Total volume of IV fluid = 1½-2 X maintenance

½ normal saline ± KCl٭ ٭

FBC, BUSE,RBS , GXM

PCV1-2hrly

IMPROVEMENT

Yes No

IMPROVEMENT

HCT falls

PR, BP stable

Urine output rises

HCT or PR rises, or

Signs of shock, or

Pulse pressure < 25mmHg, or

Urine output falls

If improvement present

No improvement

CONDITION DETERIORATES

Unstable vital signs or HCT rises

No improvement

if improvement present

if further improvement present

Reduce IV fluid therapy to 1X maintenance 5%D ½ NS ± KCl

Reduce IV therapy to ½ X maintenance 5%D ½NS ± KCl

Discontinue IV therapy after 24-48 hrs.

Vital signs & HCT stable

adequate diuresis

Administer 2

(10-20 ml/kg or 20ml/kg

Maintenance fluid 5%D ½NS ± KCl

Unstable vital signs

Urine output falls

Signs of shock still present

nd rapid fluid bolus٭ of NS٭ ٭ ٭

HCT rises

HCT falls

Rapid bolus with IV colloids eg. Haemaccel or Gelafundin 20ml/kg

Transfusion of

blood/blood products

Yes

No

PICU

8

٭

- in compensated shock give 10-20ml/kg over 30-60 minutes if patients is warming up

Rapid fluid bolus -in decompensated shock, give 20ml/kg fast

٭ ٭

use weight adjusted to height –centile – for age to calculate the volume of maintenance fluids

٭ ٭ ٭

ensure good IV, check urinary catheter

Management of dengue fever in children

4.7.2. Blood transfusion

Significant haemorrhage should be recognised early, and prompt transfusion of fresh whole blood administered at 10 to 20 ml/kg. The emphasis is on fresh whole blood because of plasma loss from plasma leakage. Preventive transfusion with platelet concentrates and fresh frozen plasma in non-bleeding or fluid responsive DHF/DSS has not been shown to sustain the increase in platelet counts, prothrombin time or partial prothrombin time (PT/PPT). This practice has, in fact, been shown to increase the incidence of fluid overload and pulmonary oedema, and puts the patient at risk of blood-borne infections from multiple donors (Lum et al, 2003,

Bleeding should be suspected if any of the following features are present.

level 5; Chuansumrit et al, 2000, level 5)

shock more severe than expected for the rise in haematocrit.

GIT bleeding which may be occult or obvious

a drop in haematocrit with no clinical improvement e.g. a drop from 50% to 45% (or from 0.50 to 0.45)

decompensated shock after infusion of 40 ml/kg of isotonic crystalloids or colloids

worsening metabolic acidosis.

history of prolonged shock (Lum et al, 2002)

A delay in blood transfusion and continued infusion of crystalloids or non-blood colloids (such as FFP and platelets) will give rise to more plasma leakage and a poor outcome

presence of multi-organ failure e.g. high creatinine, restlessness

4.8 Management of the Convalescent Phase

Most cases of DHF will enter into the convalescent phase 24 – 48 hours after the onset of plasma leakage, and recover spontaneously with appropriate management (WHO 1997, 2001,

level 3).

4.8.1 Indicators of patients being in the convalescent phase:

Stable vital signs - wide pulse pressure, strong pulse, no tachycardia (warm extremities, sinus bradycardia and hypertension).

Return of haematocrit to baseline values.

Increase in urine output (may be delayed if tense ascites is present)

Confluent petechial rash with multiple small, white, round areas among the rash over the extremities (islets of white in a sea of red).

Improvement in general condition with gradual return of appetite

Afebrile state (unless nosocomial infection is present)

4.8.2 Treatment

Discontinuation of intravenous fluids (to avoid pulmonary oedema)

Hypokalaemia may occur during the diuretic phase. A check should be carried out for evidence of ileus arising from hypokalaemia that may occur with diuresis. This can be corrected with fruits and fruit juices. Potassium chloride supplementation should be considered if patient refuses or is unable to take these.

9

Management of dengue fever in children

Invasive procedures such as dental extractions or intramuscular injections are not advisable during this period

4.9 Discharge Criteria for Hospitalized Patients

The following are the suggested criteria for discharge from hospital:

visible improvement in clinical picture

absence of fever for 24 hours without the use of antipyretics

complete recovery from shock (after 3 days)

stable haematocrit

rising platelet counts greater than 50, 000/mm3

return of appetite

absence of respiratory distress

normal urine output

4.10 Complications of DHF/DSS

Primary complications

Gastrointestinal bleeding (Hongsiriwon, 2002, level 3)

Liver failure ( Lum et al, 1993, level 3)

Dengue encephalopathy (Solomon et al, 2000; Pancharoen et al, 2001, level 3)

Acute renal failure

Secondary Complications

Respiratory failure secondary to massive pleural effusion and gross ascites (Soni et al, 2001, level 3)

Acute pulmonary oedema (Soni et al, 2001, level 3)

Acute respiratory distress syndrome (Soni et al, 2001,level 3)

Nosocomial infection

5. HEALTH EDUCATION

5.1 Patient and Family

The following information about the disease should be provided by health personnel to the patient and family members

Disease

o

causal agent

o

signs and symptoms

o

treatment including need for follow up of ambulatory patients

o

risks and complications

o

prognosis

o

duration of infectiveness and need to stay under a mosquito net during infective phase

o

duration of hospitalisation

Vector

o

Aedes mosquito - breeding environment, brief life cycle, role in transmission of dengue, rationale of ‘Tiada Aedes Tiada Denggi’.

10

Management of dengue fever in children

Expected behaviour to prevent dengue (see Appendix 9 )

Enforcement against breeding of Aedes – details of liability if evidence of breeding Aedes is found

5.2. Informational pamphlets

Information pamphlets on dengue that may be obtained from the nearest health office, should be made available and distributed widely.

6. PREVENTION STRATEGIES

6.1 Dengue Free Schools Programme

Since about 30 % of dengue cases occur among school going children between the ages of 7 and 18 years, it is hoped by this programme to turn school children into change agents for the prevention and control of dengue in the community towards. The exposure to information and prevention and control activities is started in the school environment. (Ministry of Health and Ministry of Education, 2001)

6.2 Dengue Free Health Facilities Programme

Dengue transmission can occur within health facilities (including hospitals), and so this programme was initiated in 1993 to prevent dengue transmission and

Aedes breeding in various zones of the facilities, including living quarters and hostels. The mainstay of the programme is the setting up of work teams, daily Aedes larval survey and regular surveillance (Vector-Borne Diseases Section, 2002)

6.3 Dengue Alerts

Dengue alerts are issued from time to time by the Director of Disease Control, or by the Vector-Borne Diseases Section, Ministry of Health Malaysia. These alerts advise through mass media on the need to take proactive action if there is a sharp rise in dengue incidence in the country or region, re-emergence of a particular dengue serotype, or when there is weather conducive to

Aedes breeding. Action to be taken may include promotion of increased awareness, surveillance and enforcement; improved clinical vigilance at points of service and early dengue notification; organised campaigns to search for and destroy Aedes breeding sites including newly recognized
   

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