2 current treatment of dengue virus infection

8/10/2019 2 Current Treatment of Dengue Virus Infection

1/45

Current Treatment of Dengue

Virus Infection

Nur Farhanah

SPEED-1SEMARANG, 26-27 MEI 2012


2/45

Epidemiology

Of the 2.5 billion people in the world living in dengue

endemic area

At risk of DF/DHF 1.3 billion live in 10 dengue endemic

countries of WHO SEA Region

In ASEAN countries 51 million people are infected /year

and 20,000 people (especially children) die

WHO SEARO (South-East Asia Region) Dengue SPEED-1SEMARANG, 26-27 MEI 2012


3/45

Source: WHO SEARO Dengue Guideline 2011

Average Annual Number of Cases of DF/DHF reported to WHO



4/45

Indonesia

The Ministry of Indonesian Health (ASEANDengue Conference 1st :15 June 2011) reported

in 2010 Indonesia has the largest number of

dengue patients among the ASEAN

150,000 people were infected

1,400 people, mostly children, died

(Thailand 57,000 people were infected and 70

died)

ASEAN Dengue day June 15th



5/45

http://www.pppl.depkes.go.id/_asset/_download/DBD_2011.gif



6/45

http://www.pppl.depkes.go.id/_asset/_download/DBD_2011.gif



7/45

IR DBD IND, JATENG & SEMARANG

Souce:P2B2 Dinkes Kota SemarangSPEED-1

SEMARANG, 26-27 MEI 2012


8/45

Source; P2B2 Dinkes Kota Semarang SPEED-1SEMARANG, 26-27 MEI 2012


9/45

Dengue Virus Pathogenesis

BEE Martina, P. Koraka, OsterhausClin.Microbiol. Rev 2009, 22 (4):564



10/45

SPEED-1



11/45

SPEED-1



12/45

Thrombocytopenia

Haemorrhagic

manifestationsHypotension

/shock

Platelet

aggregation

clusterin

C3a,C5a



13/45

1997 2009 2011

WHO Dengue Guidelines



14/45

WHO Dengue guidelines

1997 2009 2011

Title

Guideline for treatment of

DF and DHF in small

hospitals WHO Searo

1999

Dengue Guidelines for

diagnosis, treatment,

prevention and control

WHO TDR 2009

Comprehensive guideline

for prevention and

control of Dengue and

DHF WHO Searo 2011

Page

33 160 212

Content

Clinical manifestation,

diagnosis, case

management

Chapters : (6)

Epidemiology and burden of

disease, clinical

management, vectormanagement, lab

diagnostic tests,

surveillance and emergency

response, new avenues

Chapters : (15)

Epidemiology, disease

burden,clinical

manifestation anddiagnosis, lab diagnosis,

management, surveillance,

vector, vector management,

IVM, Combi, PHC

approach, case

investigation, monitoring,

strategic plan (bi-regionallan

1997 2009 2011



15/45

WHO Dengue Guidelines

Diagnosis Classification

1997 2009 2011Dengue fever Dengue without

warning signs

Dengue fever

DHF grade I Dengue with warning

signs

DHF grade I

DHF grade II DHF grade II

DHF grade III Severe dengue

( severe plasma

leakage, severe

hemorrhage, severeorgan involvement)

DHF grade III

DHF grade IV DHF grade IV

Expanded dengue

syndrome

Adult management Adult management

SPEED-1



16/45

WHO Dengue Guideline 1997

Manifestation of Dengue Virus Infection



17/45

Probable an acute febrile illness with two or more of the followingmanifestations:

Headache

Retro-orbital pain Myalgia

Arthralgia

Rash

Haemorrhagic manifestations

Leukopenia;and

Supportive serology (a reciprocal HI antibody titre 1280, acomparable IgG ELISA titre or a positive IgM antibody test ona late acute or convalescent-phase serum specimen );

or

Occurence at the same location and time as other confirmedcases of dengue fever.

Confirmed a case confirmed by laboratory criteria

Reportabl e any probable or confirmed case should be reported


18/45

DF DHF

1. Fever 2-7 days + +

2. Bleeding tendency Positive tourniquet test or Spontaneous bleeding

+/- +

3. Thrombocytopaenia 100,000/mm +/- +

4. Plasma leakage Pleural effusion /ascites

/hypoproteinaemia 20% increase in HCT from baseline

20% decrease in HCT from baseline

after volume-replacement treatment

- +

WHO Dengue Classification 1997

WHO Dengue Classification 1997



19/45

Grade Sign and Symptomps Laboratory

DF DHF without plasma leakage

DHF I Fever with non-specific constitutional

symptoms; the only hemorrhagic

manifestation is a positive tourniquet test

&/or easy bruisingevidence of plasma leakage

Thrombocytopenia

(platelet count

100,000/L)

II DHF grade I plus spontaneous bleeding

III Circulatory failure manifested by a rapid,

weak pulse, narrowing of pulse pressure,

or hypotension, cold & clammy skin,

restlessness

IV Profound shock with undetectable blood

pressure

WHO 1997



20/45

WHO Dengue Guideline 2009

Suggested dengue case classification and

level of severity

Source: WHO Dengue Guideline 2009 SPEED-1SEMARANG, 26-27 MEI 2012


21/45


22/45

Neurological

Gastrointestinal/

hepatic

Renal

Cardiac

Ecpanded dengue syndromeExpanded Dengue Syndrome or unusual manfestation

WHO SEARO Dengue Guideline 2011 SPEED-1SEMARANG, 26-27 MEI 2012


23/45

Respiratory

Musculoskeletal

Lymphoreticular/bonemarrow

Eye

others

Expanded Dengue Syndrome or unusual manfestation



24/45

DF/

DHFGrade Signs and Symptoms Laboratory

DF Fever with two of the following:

HeadacheRetro-orbital pain

Myalgia

Athralgia/bone pain

Rash

Haemorrhagic manifestations

No evidance of plasma leakage

Leucopenia (WBC


25/45

The Course of Dengue Illness



26/45



27/45

Dengue Infection : immune response

WHO Dengue Guideline 2009 SPEED-1SEMARANG, 26-27 MEI 2012


28/45

Diagnostic Tests

EASY to USE

Confidence



29/45

CASE MANAGEMENTWHO Guideline



30/45

Admission criteria

1997 2009 2011

Signs of significant

dehydration (>10%

normal body weight)

-Any warning sign

-Coexisting condition :

infancy, pregnancy,oldage, obesity, DM,

renal failure,

hpertension, chronic

hemolytic disease etc

-Social circumstance :living alone, far from

health facility, without

reliable means of

transport

-Any warning signs

-sign and symptom

related to hypotension-Bleeding

-Organ impairment

-Finding through

further investigations

-Coexisting conditions

-Social economic


31/45

Fluid Management

1997 2009 2011

DHF grade I-II Dengue with warning

signs

DHF grade I-II

6-7ml/kg/hour

5ml/kg/hour3ml/kg/hourstop after

24-48hours

start 5-7ml/kg/hour

for 1-2hours, reduceto 3-5ml/kg/hour for

2-4hours, reduce to

2-3ml/kg/hour or less

according to clinical

respons

Maintenance (for 1

day)+5% deficit (oraland i.v together) to

be administered over

48 hours



32/45

Fluid Management

1997 2009 2011

DSS Severe Dengue-

Compensated Shock

DHF grade III

10-20ml/kgBB bolus

repeat if necessary

Isotonic crystalloid sol

5-10ml/kg/hour over

one hourreassess

10ml/kg in children or

300-500ml in adult

over one hour or by

bolus, if necessary .

Further fluid

administration should

follow the graph



33/45

Fluid Management

2009 2011

Severe Dengue-hypotensive

shock

DHF grade IV

Initiate i.v fluid with crystalloid or

colloid (if available) at 20ml/kg as

bolus over 15 mnt

10ml/kg bolus fluid as fast as

possible, ideally within 10-1mnt.

When BP is restored, futher iv fluid

may be given as in grade 3. If

shock isnt reversible after the first

10ml/kg, repeat bolus 10 ml/kgand lab results should be pursued

and corrected as soon as possible


34/45

Transfusion in Severe Bleeding

2009 2011

5-10ml/kg of fresh PRC

or 10-20ml/kg of freshwhole blood of an

appropriate rate and

observe clinical

response

5ml/kg of PRC or

10ml/kg of fresh wholeblood

Reassess, repeat if

necessary


35/45

High Risk Patients (2011)

- Infants and the elderly- Obesity

- Pregnant women

- Peptic ulcer disease

- Woman who have menstruation or abnormal vaginal

bleeding- G-6PD deficiency

- Thalassemia and other haemoglobinopathies

- Congenital heart disease

- Chronic diseases (DM, hypertension, asthma, IHD)- CRF, liver cirrhosis

- Patients on steroid or NSAID treatment

Discharge criteria


36/45

Discharge criteria

Criteria 1997 2009 2011

Absence of fever 24hours without

antipyretic

48 hours 24hours without

antipyretic

Clinical

improvement

+ +general well

being,

apetite,hemodyna

mic status, urine

output,no respdistress

+

Return of Apetite + - +

Good urine output + - +

Stable Ht + +(without iv fluid) +

Elapse from

shock recovery

Al least 2 days - 2-3 days

No resp distress + - +

Platelet count >50.000/ul Increasing trend >50.000/ul


37/45

National Guideline



38/45

Tatalaksana

Protokol 1 : Penanganan tersangka

(probable)DBD dewasa tanpa syok

Protokol 2 : Pemberian cairan pada tersangka

DBD dewasa di ruang rawatProtokol 3 : Penatalaksanaan DBD dengan

peningkatan Ht >20%

Protokol 4 : Penatalaksanaan Perdarahan

Spontan pada DBD dewasa

Protokol 5 : Tatalaksana SSD pada dewasa


39/45

Protokol 2 Pemberian Cairan pada Tersangka DBD


40/45

Protokol 2. Pemberian Cairan pada Tersangka DBD

dewasa di Ruang Rawat



41/45

Protokol 3 PENATALAKSANAAN DBD dengan Ht >20%

SPEED-1


Protokol 4 Penatalaksanaan Perdarahan Spontan


42/45

Protokol 4. Penatalaksanaan Perdarahan Spontan

pada DBD DewasaSPEED-1


Protokol 5. Tatalaksana Syok pada Dewasa


43/45

Protokol 5. Tatalaksana Syok pada Dewasa

Koloid maksimal

30ml/Kg

Transfusi PRC

10ml/KgBB

Inotropik:vasoaktif Koreksi as bs,elektr, glikemia,

anemiaInfx sekunder, KID

SPEED-1



44/45

Conclusion

The dengue pathogenesis is very multicomplex

Case management is simple and inexpensiveThe cornerstone of treatment is early management offluid, and it could save the patients life

Revised guideline (2009 and 20011) are available andcould be applied according to clinical setting

The WHO guidelines 2009 has higher sensitivity indiagnosing dengue cases (earlier hospitalization, fluidadministration and could be decrease of fatal cases)

WHO SEARO Guidelines 2011 has similar contents and

classifications as WHO Guidelines 1997Be aware to dengue diagnosis and early managemenet

SPEED-1


45/45


2 current treatment of dengue virus infection

Documents