1. PROF. DR. MUHAMMAD YAQUB KAZI MBBS, MCPS (Family Medicine) DCH (Pb), MCPS (Paeds), FCPS (Paeds), FRCP (Edin), FRCP (London), FRCPCH (UK) Ex Dean, Institute of Public Health, Former Professor of Paediatrics King Edward Medical University Lahore

2. Arising as a major public health issue in Pakistan

3. How it reached us In Chinese dynasty (AD 265- 420) known as water poison Epidemics reported from 1779-80 World’s largest epidemic 1981 Cuba In Pakistan, 1980s and so on

4. First documented report in 1985 – DENV2 isolated in a sero epidemiological study for encephalitis Outbreaks in Karachi – 1994, 1996 Sporadic cases since then Hyper – endemic situation NOT NEW IN PAKISTAN

5. Journey of Aedes Aegypti from Africa to Pakistan

6. Commerce

7. Gravity of situation 2.5 Billion people at risk worldwide 50 million new cases annually worldwide 500,000 hospitalized annually 2.5% of the affected DIE

8. No age is immune Perinatal transmission Bimodal peaks during age group < 1 yr and between 5 – 7 years. Bangladesh and Chenai studies – 35% and 20% infants In South East Asia DHF commonly seen in children AGE GROUP

9. Symptoms DF: Aute fever (2-7 days) without any other focus Headache, mylagia, retro-orbital pain, arthralgia, bleeding/petechiae. DHF: Fever Haemorrhagic manifestations (Thrombocytopenia, Positive Tourniquet test) Signs of increased vascular permeability/circulatory failure (effusion, HCT, Pulse pressure) Hepatomegaly.

10. Dengue Viral Infection Asymptomatic (majority) (90 %) Asymptomatic (majority) (90 %) Symptomatic (10 %) Symptomatic (10 %) Viral Syndrome (5%) Viral Syndrome (5%) DF (4%) DF (4%) DHF (1%) DHF (1%) Plasma leakage DHF (98%) DHF (98%) DSS (1-2%) DSS (1-2%) Unusual dengue. Expanded dengue syndrome With bleeding No bleedin g

11. More symptoms Vomiting Centrifugal maculopapular rash Weakness Altered taste sensation Anorexia Sore throat Mild hemorrhagic manifestations (eg, petechiae, bleeding gums, epistaxis, menorrhagia, hematuria) Lymphadenopathy Children younger than 15 years usually have a nonspecific febrile syndrome, which may be accompanied by a maculopapular rash.

12. Infants Obesity Hemolytic diseases such as G6PD and thalassemia. Congenital heart disease. Chronic diseases such as diabetes mellitus, chronic renal failure. Patients on steroid or NSAID treatment. HIGH RISK PATIENTS

13. CLINICAL COURSE: DHF Febrile phase (both DF & DHF) 2 – 7 days Clinical features (Tender hepatomegaly – DHF) Hemorrhagic manifestations TLC – normal … <5000 later part Platelets – normal … < 100,000 (50% DF, 100% DHF) Critical phase D 4-7 Clinical Features Lasts only for 24 – 48 hours Convalescent phase Begins after the critical phase & lasts for 5 - 7 days

14. IgM: Detectable by 5-6 days Sharp rise by 2 weeks Undetectable after 2-3 months. IgG: Detectable by end of first week – low level Increase and remain for many years. Secondary Dengue Infection IgG detectable at high levels even in initial phase Persist for several months to a lifelong period IgM low in secondary infection. Ratio of IgM/IgG differentiates (<1.2) Primary Vs Secondary infection

15. LABS Reduced platelets Increase in blood haematocrit, CBC includes the following: Leukopenia, often with lymphopenia,. Lymphocytosis, with atypical lymphocytes A hematocrit level rise of greater than 20%. Thrombocytopenia. (less than 100,000 cells/μL) Hyponatremia Metabolic acidosis Elevated BUN Liver function test Transaminase levels may be mildly elevated. Low albumin levels are a sign of hemoconcentration.

16. Clinical and Laboratory Criteria for patients who can be treated at home Able to tolerate orally well, good urine output and no history of bleeding Absence of clinical alarm signals Physical examination

17. Hemodynamically stable Pink, warm extremities Normal capillary filing time (normal < 2 seconds) Good pulse volume Stable blood pressure Normal pulse pressure (>20 mmHg) No disproporationate tachycaradia No tachypnea or acidotic breathing No hepatomegaly or abdominal tenderness No bleeding manifestation No sign of pleural effusion ascites No alterations in metnal state and full GCS score

18. Investigation: Stable serial HCT In the absence of a baseline HCT level, a HCT value of >40% in female adults and >46% in male adults should raise the suspicion of plasma leakage. Therefore admission may be required.

19. Warning signals No clinical improvement or worsening of the situation just before or during the transition to afebrile phase or as the disease progresses. Persistent vomiting, not drinking. Severe abdominal pain. Lethargy and/or restlessness, sudden behavioral changes.

20. Bleeding: Epistaxis, black colored stools, hematemesis, excessive menstrual bleeding, dark colored urine (hemoglobinuria) or hematuria. Giddliness. Pale, cold and clammy hands and feet. Less/no urine output for 4-6 hours.

21. Complications Possible Complications Shock Encephalopathy Residual brain damage Seizures Liver damage Rare complications include the following: Depression Pneumonia Iritis Orchitis Oophoritis Secondary reinfection is unlikely because of pre-existing antibodies.

22. DIET No specific diet is necessary for patients with dengue fever. Patients may become dehydrated from fever, lack of oral intake, or vomiting. Patients who are able to tolerate oral fluids should be encouraged to drink oral rehydration solution, fruit juice, or water to prevent dehydration. Return of appetite after dengue hemorrhagic fever or dengue shock syndrome is a sign of recovery. Activity Bedrest is recommended for patients with symptomatic dengue fever, dengue hemorrhagic fever, or dengue shock syndrome.

23. Drugs Aspirin and Brufen should be avoided in dengue fever, as it is known to increase the bleeding tendency and also it increases the stomach pain. Paracetamol has both analgesic and antipyretic properties similar to aspirin and other NSAIDs. Has no peripheral anti- inflammatory activity or effects on platelet function.

24. Future Vision Selective integrated mosquito control Active disease surveillance Emergency preparedness Capacity building & training Training of health care staff Training courses on infectious diseases Inclusion of basic health principles in various syllabi Intensive research on vector control National/ provincial programs for infectious disease monitoring & awareness

26. Isotonic crystalloids to be used – Normal saline or 5% dextrose in saline Infants < 6 months – 5% dextrose in ½ saline. Volume of about maintenance + 5% dehydration (M + 5%) to maintain a “just adequate” intravascular volume and circulation. Duration of IV fluid should not exceed 24 – 48 hrs for those with shock. GENERAL PRINCIPLES OF FLUID THERAPY

27. Rate ml/kg/hr Half the maintenance M/21.5 Maintenance (M)3 M + 5% deficit5 M + 7% deficit7 M + 10% deficit10 RATE OF IV FLUIDS

28. Fluid allowance (Oral + IV) = Maintenance (For one day) + 5% deficit given over 48 hrs. Example: 20 Kg child. Maintenance= 1500 ml for one day 5% deficit = 50 x 20= 1000 ml Total= 2500 ml Given over 48 hrs. MANAGEMENT OF DHF GRADE I, II (NONSHOCK CASES)

29. Identify the beginning of leaking phase Predicting the end of leaking phase. Meticulous monitoring Accurate fluid management in critical phase. Early detection and treatment of concealed bleeding and complications. MANAGEMENT OF DHF

30. Managing Dengue Shock Syndrome

31. MANAGEMENT OF SHOCK : DHF Grade III Unstable vitals, decreased urine output, signs of shock 10 ml/kg/hr of Normal saline for 1-2 hrs ImprovementNo Improvement Reduce rate from 10 ml/kg/hr to 7,5,3,1.5 ml Check for ABCS and Correct Further Improvement Discontinue IV therapy over 24-48 hrs HCT Rises HCT Falls IV Colloid Blood transfusion, whole blood 10 ml/kg, PRC 5ml /kg Improvement Reduce Rate from 10ml/kg/hr to 7,5,3,1.5

32. NO PLACE FOR STEROIDS AND IV IMMUNOGLOBULINS IN DENGUE

33. Prevention