Dengue in Malaysia: An All Out War in Public Health and Clinical Settings

As part of the social responsibility towards the Malaysia's dire scenario in dengue, MedPBL has agreed upon to feature another article on dengue management.

However, I would like to put forward a chart depicting the current situation nationwide as of feb 5th, 2014. From 1st Jan until 5th Feb 2014, we have more than 10,000 cases nationwide, with 19 reported dengue deaths, more than 3 times the number last year. Given the current trend, we would expect a 4-fold rise at the very least until the end of the year. The current situation had caused most government hospitals running short of beds, as well as private healthcare centers.

*Click on image to enlarge*

Source: VektorKL

With the introduction of lab-based confirmation of dengue infection, there may be "hiccups" expected in the aspect of reporting of dengue cases. First and foremost, dengue notification remains the same in Malaysia, all suspected dengue cases should be notified immediately within 24 hours. Failure in compliance to the said act is an offence under the Prevention and Control of Infectious Diseases Act 1988(Part V Section 24) and you are liable on conviction of inprisonment up to 5 years and compoundable offence of RM1,000. However, not all notified cases are reported as dengue cases. After thorough investigation from the health office, the notified cases will be registered in the registry after being verified by the Health Office's epidemiological officer. However, with the new ruling starting from Jan 2014 onwards, all registered cases would required laboratory confirmation, the common ones being dengue IgM/IgG serology and NS1 antigen. For those notified cases whereby the tests were not done, the health offices would be required to contact these patients and perform the test on them. However, these patients can be hard to catch-by after the first contact, so medical personnel are advised to perform the serology/virology tests if the facility is available in your settings.

For primary healthcare personnel, it is vital to establish the severity of dengue fever. Malaysia's CPG on dengue management is sufficient as a guide for you to recognise the warning signs of dengue infection. Of course, the more important is to recognise if the patient is in compensated or decompensated shock as this would affect your initial resuscitation, IV fluids, etc. Remember, your clinical evaluation is very important and do not based on a single parameter. Look at the patient as a whole!

 Source: Malaysia CPG: Management of Dengue Infection in Adults, Revised 2010 edition

Source: Malaysia CPG: Management of Dengue Infection in Adults, Revised 2010 edition

As a start, one may use the Dengue Clerking Sheet as a quick checklist for subsequent assessment aand management. A dengue monitoring card is equally as important as patients may travel from one clinic to another more often than not, so the card helps to keep track of the necessary investigations and vital signs.

Dengue Clerking Sheet: Box.net | Mediafire

 Front side of dengue monitoring card

 Reverse side of dengue monitoring card

 
In hospital settings, fluids and electrolytes are of utmost important aspect of the management of dengue infection. While assessing the patient's clinical hydration, remember that oral fluids are the best fluid regime, not IV fluids, unless necessary! Patients tend to get fluid overload quicker with IV fluids regime than oral regime, stressing on the importance of our physiological homeostasis at work.
Electrolyte supplement/replenishment are advised should there be plenty of IV fluids planned. Ensure that the patient's fluid input/output charting is monitored to ensure appropriate fluid balance to be maintained, not a positive balance of 2-3 liters/day unless approved by your consultant. While our focus had been on the critical phase for fear of dengue shock syndrome, the fluid reabsorption phase during the defervescent/recovery phase can be equally as deadly, leading to fluid overload and cardiogenic shock. Recognizing occult hemorrhage is also important, but focusing solely on platelet count may not reduce the risk of major bleed. 

A research was done by Lum et al, JPed, 2002 on the risk factors for major bleed in severe dengue and here are the results:

 

 With this study, it has suggested that protracted shock is a more significant risk for major bleed in severe dengue than low platelet count, along with the initial elevated hematocrit, which may also indicated the presence of plasma leakage. Of course, shock in this sense does not imply relying on blood pressure measurement alone, while clinical assessment should be taken into account, such as pulse volume, capillary refill time, warm peripheries, etc.

As a general rule, it is vital to monitor the trend of your dengue patient so you could keep track of the progress, including vital signs, blood parameters as well as fluids balance.

A general dengue monitoring chart should be in place for any hospital setting. A sample guide which can be used is as below:

Dengue Monitoring Chart (Guide): Box.net | Mediafire
 
Common pitfalls:

1. Underresuscitation during critical phase leading to Dengue Shock Syndrome (Too much fluid loss from intravacular volume) 
2. Overresuscitating during critical phase leading to fluid overload during defervescent phase (Fluid reabsorption into intravascular volume)

With all the materials provided, we wish you all the best in the management of dengue patients. Do try to avoid causing dengue deaths, as it is part of national statistics emphasied upon. Dengue death notification is compulsory, with at least a phone call to the nearest district health office followed by a written notification. A state level mortality meeting will have to be called upon within 7 days from the notification of dengue death, with compulsory attendance from the attending physicians. Let's do our part in the war against dengue.