Guiidelliines ffor Reporttiing and Hospiittall Case Managementt off
Gu de nes or Repor ng and Hosp a Case Managemen o
Dengue Fever and Dengue Hemorrhagiic Fever
Dengue Fever and Dengue Hemorrhag c Fever
Introduction o Positive tourniquet test-The tourniquet test is
performed by inflating a blood pressure cuff to
Dengue is the most widespread mosquito-borne a point mid-way between the systolic and
infection in human beings, which in recent years has diastolic pressures for five minutes. A test is
become a major international public health concern. considered positive when 10 or more
It is usually found in tropical and sub-tropical regions petechiae per 2.5 cm (1 inch) are observed.
around the world, particularly in urban and semi- In DHF, the test usually gives a definite
urban areas. Over the last 15 years, we have positive result (i.e. >20 petechiae). The test
witnessed a dramatic increase in the global may be negative or mildly positive during the
incidence of dengue and its severe manifestations phase of profound shock.
such as Dengue Hemorrhagic Fever (DHF) and o
Dengue Shock Syndrome (DSS). Almost 95% of o
Dengue cases are amongst children under the age bleeding from gums), injection sites or other
of 15 years. Without proper management, Dengue sites
Hemorrhagic Fever case fatality rates can exceed o
20%, however, with modern intensive supportive o Thrombocytopaenia (platelets 100,000/cu.mm
therapy these rates can be reduced to less than 1%. or less) and
o Evidence of plasma leakage due to increased
capillary permeability manifested by one or
more of the following:
Clinical Presentation of DF/DHF A > 20% rise in haemotocrit for age and
I- Asymptomatic: Patients may not present
A >20% drop in haemotocrit following
treatment with fluids as compared to
o Undifferentiated Fever
Signs of plasma leakage such as pleural
o Dengue Fever
effusion, ascites or hypoproteinaemia.
1. Without hemorrhage
2. With unusual hemorrhage
o Dengue Hemorrhagic Fever
1. No shock Dengue Shock Syndrome (DSS)
2. DSS All the above criteria of DHF plus signs of circulatory
failure manifested by rapid and weak pulse, narrow
pulse pressure (< or equal to 20 mm Hg);
hypotension for age, cold and clammy skin and
Recognition of Dengue Fever/Dengue
Hemorrhagic Fever (DF/DHF)
Dengue Fever is an acute febrile illness of 2-7 days
duration (sometimes with two peaks) with two or
more of the following manifestations: Disease Course
Most patients have a febrile phase lasting 2 -7
days, followed by a critical phase of about 2-3 days
o retro-orbital pain
duration. During this phase, the patient is afebrile,
and is at risk of developing DHF/DSS which may
prove fatal if prompt and appropriate treatment is not
o hemorrhagic manifestation
provided. Since haemorrhage and or shock can
occur rapidly, arrangements for rapid and
In children, DF is usually mild. In some adults, DF appropriate treatment should be always available.
may be the classic incapacitating disease with By doing this, the case fatality rate can be
severe bone pain and recovery may be associated substantially reduced. The disease course of
with prolonged fatigue and depression. DF/DHF is summarized below:
Dengue Hemorrhagic Fever is a probable case of
Dengue with hemorrhagic tendency evidenced by
one or more of the following:
Grading the Severity of Dengue Infection (2) Dengue Hemorrhagic Fever (DHF) Grades I and II
DF/DHF Grade Symptoms Laboratory As in DF, during the afebrile phase of DHF Grades I and II,
Leucopenia the patient has the same symptoms as during the febrile
Fever with two or phase. The clinical signs plus thrombocytopenia and
more of the following haemoconcentration or rise in haematocrit are sufficient to
DF signs: headache,
may be present, no establish a clinical diagnosis of DHF. During this phase,
retro -orbital pain,
evidence of plasma the patients should be observed for at least 2-3 days after
loss the fall in temperature, for rashes on the skin, bleeding
Above signs plus Thrombocytopenia from nose or gums, blue spots on the skin or tarry stools. If
DHF I positive tourniquet <100,000, Hct rise any of these signs are observed, the patients should be
brought to the hospital without delay. The only difference
Above signs plus Thrombocytopenia
DHF II spontaneous <100,000, Hct rise between the DF and DHF Grade I is the presence of
bleeding >20% thrombocytopenia and rise in haematocrit (>20%).
Above signs plus Patients with DHF Grade I do not usually require
circulatory failure Thrombocytopenia intravenous fluid therapy and ORT is sufficient.
DHF III (weak pulse, <100,000, Hct rise Intravenous fluid therapy may need to be administered
hypotension, >20% only when the patient is vomiting persistently or severely,
restlessness) or refusing to accept oral fluids. Patients with DHF Grade I
Profound shock with Thrombocytopenia who live far away from the hospital or those who are not
DHF IV undetectable blood <100,000, Hct rise
likely to be able to follow the medical advice should be
pressure and pulse >20%
kept in the hospital for observation.
Management of DF and DHF
During the afebrile phase of DHF Grade II, the
Febrile Phase complications usually seen, in addition to those observed
In the early febrile phase, it is not possible to distinguish during the DHF Grade I phase, are abdominal pain, black
DF from DHF. Their treatments during the febrile phase tarry stools, epistaxis, bleeding from the gums, and
are the same, symptomatic and largely supportive: continued bleeding from injection sites. Immediately after
o Rest. hospitalization, haematocrit and platelet count must be
o Paracetamol (not more than 4 times in 24 hours) carried out to assess the patient’s condition. A reduction in
according to age for fever above 39 C. the platelet count to 100,000/mm or less than 1-2
o Do not give Aspirin or Ibuprofen. Aspirin can platelets/oil field (average of 10 oil field counts) usually
cause gastritis and/or bleeding. In children, precedes a rise in haematocrit. A rise in haematocrit of
Reye’s syndrome (encephalopathy) may be a 20% or more (e.g. increase from 35% to 42%) reflects a
serious complication. significant plasma loss and indicates the need for
o Do not give antibiotics as these do not help. intravenous fluid therapy. Early volume replacement of lost
o Oral rehydration therapy is recommended for plasma with isotonic solution can reduce the severity of
patients with moderate dehydration caused by the disease and prevent shock. Intravenous fluid therapy
vomiting and high temperature. before leakage is not recommended. In mild to moderate
o Food should be given according to appetite. cases of DHF Grade II, intravenous fluid therapy may be
given for a period of 12-24 hours in hospital. Patients
In Children, with signs of some dehydration, oral should be monitored on an hourly for vital signs, the
rehydration solution which is commonly used in the treatment should be reviewed and revised.
treatment of diarrhoeal diseases and/or fresh juices are
preferable (50ml/kg bodyweight fluids should be given (3) DHF Grades III and IV
during the first 4-6 hr)s. After correction of dehydration, the Common signs of complications observed during the
child should be given maintenance fluids orally at the rate afebrile phase of DHF Grade III include circulatory failure
of 80-100 ml/kg bodyweight in the next 24 hrs. Children manifested by rapid and weak pulse, narrowing of the
who are breastfed should continue to be breastfed in pulse pressure and hypotension, characterized by high
addition to ORS administration. In adults, oral fluid intake diastolic pressure relative to systolic pressure (for example
of 2.5-4 liters should be given per day. 90/80) and the presence of cold clammy skin and
restlessness. These complications occur because of
All dengue patients must be carefully observed for
thrombocytopenia, abnormal haemostasis and plasma
complications for at least 2 days after recovery from
leakage, or also from substantial blood loss. Immediately
fever. This is because life threatening complications
after hospitalization, the haematocrit, platelet count and
often occur during this phase. Patients and
vital signs should be examined to assess the patient’s
households should be informed that severe abdominal
condition and intravenous fluid therapy should be started.
pain, passage of black stools, bleeding into the skin or
The patient requires regular and sustained monitoring. If
from the nose or gums, sweating, and cold skin are
the patient has already received about 1,000 ml of
danger signs. If any of these signs is noticed, the
intravenous fluids and the vital signs are still not stable,
patient should be taken to the hospital.
the haematocrit should be repeated and: (a) if the
The patient who does not have any evidence of haematocrit is increasing, intravenous fluid should be
complications and who has been afebrile for 2-3 days changed to colloidal solution preferably Dextran, or (b) if
does not need further observation and may be discharged. haematocrit is decreasing, fresh whole blood transfusion
10ml/kg/dose should be given. During the afebrile phase
Protocol for management according to Phases of of DHF Grade IV, vital signs are unstable. The patient, in
DHF the early stage of shock, has acute abdominal pain,
restlessness, cold and clammy skin, rapid and weak pulse.
(1) Dengue Fever
Constitutional symptoms in patients with DF after the fall of
fever are as during the febrile stage. Most patients will
recover without complication.
A chart illustrating the volume replacement for patients with DHF with Grade III and IV
UNSTABLE VITAL SIGNS
Urine Output Falls
Signs of Shock
Immediate rapid volume replacement initiate IV therapy 10-20 ml/kg/h Isotonic solution for 1 hr
Improvement No Improvement
IV Therapy by isotonic successively reducing Oxygen
from 20 to 10, 10 to 6, and 6 to 3 ml/kg/h
Further Improvement Haematocrit Haematocrit
therapy after 24-48 hrs IV Colloid (Dextran 40) or
plasma 10ml/kg/hr as Blood transfusion (10ml/kg/hr) if
intravenous bolus (repeat if haematocrit is still >35%
IV Therapy by isotonic,
successively reducing the flow
from 10- to 6, 6 to 3ml/kg/hr
Discontinue after 24-48 hrs
Important Instructions for Treatment of o For correction of acidosis (sign: deep breathing),
use sodium bicarbonate.
o Cases of DHF should be observed every hour.
What not to do
o Serial platelet and haematocrit determinations, o Do not give Aspirin or Ibuprofen for treatment of
drop in platelets and rise in haematocrit are fever.
essential for early diagnosis of DHF. o Avoid giving intravenous therapy before there is
o Timely intravenous therapy – isotonic crystalloid evidence of haemorrhage and bleeding.
solution – can prevent shock and/or lessen its o ed,
severity. reduction in haematocrit or severe bleeding.
o o Avoid giving steroids. They do not show any
giving 20ml/kg/hr for one hour, replace benefit.
crystalloid solution with colloid solution such as o Do not use antibiotics
Dextran or plasma. As soon as improvement o Does not change the speed of fluid rapidly, i.e.
occurs replace with crystalloid. avoid rapidly increasing or rapidly slowing the
o If improvement occurs, reduce the speed from speed of fluids.
20 ml to 10 ml, then to 6 ml, and finally to 3 o sogastric tube to determine
ml/kg. concealed bleeding or to stop bleeding (by cold
o lavage) is not recommended since it is
ml/kg and then give crystalloid IV fluids at the hazardous.
rate of 10ml/kg/hr.
o In case of severe bleeding, give fresh blood Reporting
transfusion about 20 ml/kg for two hours. Then
give crystalloid at 10 ml/kg/hr for a short time Based on case-definitions, all suspected, probable
(30-60 minutes) and later reduce the speed. and confirmed cases of DF/DHF should be reported
o to relevant health authorities at district, provincial
and national level.
Annex I Hospital Daily Reporting Form
Annex II Laboratory Request Form