Severe dengue was perceived as one clinical disease entity until the WHO 2009 classification stratified it into severe vascular leakage, severe bleeding, and severe organ dysfunction. The objectives ...of this study were to investigate the potential use of severe dengue categories as endpoints for intervention research. 271 patients with severe dengue among 1734 confirmed dengue patients were followed prospectively in this hospital-based observational study in Latin America and Asia. We compared the distribution of severe dengue categories according to gender and age (below/above 15y), and determined the relative frequency and the overlap of severe dengue categories in the same patients. In a next step, we extended the analysis to candidate moderate severity categories, based on recently suggested definitions which were adapted for our purposes. Severe vascular leakage occurred in 244 (90%), severe bleeding in 39 (14%), and severe organ dysfunction in 28 (10%) of 271 severe dengue patients. A higher frequency of severe leakage was seen in children or adolescents (<15y) compared to adults. More than 80% of the severe leakage cases, and 30-50% of the cases with severe bleeding or severe organ dysfunction, were defined as severe on the basis of that feature alone. In 136 out of 213 patients with severe leakage alone, neither moderate bleeding manifestation nor hepatic involvement was recorded. On the other hand, moderate leakage manifestations were detected in 4 out of 12 cases that were classified as severe based on bleeding alone. A major proportion of severe dengue patients exhibited clinical manifestations of severe vascular leakage only, which may constitute a useful endpoint for intervention research or pathophysiology studies. Severe bleeding and severe organ manifestation were recorded less frequently and exhibited a higher degree of overlap with severe leakage. Severe bleeding without leakage may be associated with individual predisposition or the presence of comorbidities. More detailed assessments are needed to explore this hypothesis. Candidate moderate disease endpoints were investigated and need to be further validated.
Background Dengue is a systemic and dynamic disease with symptoms ranging from undifferentiated fever to dengue shock syndrome. Assessment of patients' severity of dehydration is integral to ...appropriate care and management. Urine colour has been shown to have a high correlation with overall assessment of hydration status. This study tests the feasibility of measuring dehydration severity in dengue fever patients by comparing urine colour captured by mobile phone cameras to established laboratory parameters. Methodology/Principal findings Photos of urine samples were taken in a customized photo booth, then processed using Adobe Photoshop to index urine colour into the red, green, and blue (RGB) colour space and assigned a unique RGB value. The RGB values were then correlated with patients' clinical and laboratory hydration indices using Pearson's correlation and multiple linear regression. There were strong correlations between urine osmolality and the RGB of urine colour, with r = -0.701 (red), r = -0.741 (green), and r = -0.761 (blue) (all p-value 0.05). There were strong correlations between urine specific gravity and the RGB of urine colour, with r = -0.759 (red), r = -0.785 (green), and r = -0.820 (blue) (all p-value 0.05). The blue component had the highest correlations with urine specific gravity and urine osmolality. There were moderate correlations between RGB components and serum urea, at r = -0.338 (red), -0.329 (green), -0.360 (blue). In terms of urine biochemical parameters linked to dehydration, multiple linear regression studies showed that the green colourimetry code was predictive of urine osmolality (beta coefficient -0.082, p-value 0.001) while the blue colourimetry code was predictive of urine specific gravity (beta coefficient -2,946.255, p-value 0.007). Conclusions/Significance Urine colourimetry using mobile phones was highly correlated with the hydration status of dengue patients, making it a potentially useful hydration status tool.
Summary
Objective To evaluate the existing WHO dengue classification across all age groups and a wide geographical range and to develop a revised evidence‐based classification that would better ...reflect clinical severity.
Methods We followed suspected dengue cases daily in seven countries across South‐east Asia and Latin America and then categorised them into one of three intervention groups describing disease severity according to the overall level of medical and nursing support required. Using a pre‐defined analysis plan, we explored the clinical and laboratory profiles characteristic of these intervention categories and presented the most promising options for a revised classification scheme to an independent group of WHO dengue experts for consideration. Potential warning signs were also evaluated by comparing contemporaneous data of patients who progressed to severe disease with the data of those who did not.
Results A total of 2259 patients were recruited during 2006–2007 and 230 (13%) of the 1734 laboratory‐confirmed patients required major intervention. Applying the existing WHO system, 47/210 (22%) of patients with shock did not fulfil all the criteria for dengue haemorrhagic fever. However, no three‐tier revision adequately described the different severity groups either. Inclusion of readily discernible complications (shock/severe vascular leakage and/or severe bleeding and/or severe organ dysfunction) was necessary to devise a system that identified patients requiring major intervention with sufficient sensitivity and specificity to be practically useful. Only a small number of subjects (5%) progressed to severe disease while under observation; several warning signs were identified, but much larger studies are necessary to fully characterize features associated with disease progression.
Conclusions Based on these results, a revised classification system comprised of two entities, ‘Dengue’ and ‘Severe Dengue’, was proposed and has now been incorporated into the new WHO guidelines.
Objectif: Evaluer la classification actuelle de l’OMS pour la dengue dans tous les groupes d’âge et sur une vaste étendue géographique et élaborer une classification révisée, fondée sur des preuves permettant de mieux tenir compte de la sévérité clinique.
Méthodes: Nous avons suivi quotidiennement des cas suspects de dengue dans 7 pays d’Asie du sud‐est et d’Amérique latine, puis les avons classé en trois groupes d’intervention décrivant la sévérité de la maladie en fonction du niveau général du soutien médical et infirmier nécessaire. En utilisant un plan d’analyse prédéfini, nous avons exploré les profils cliniques et de laboratoire, caractéristiques de ces catégories d’intervention et avons soumis pour avis, les options les plus prometteuses pour un système révisé de classification, à un groupe d’experts indépendants de l’OMS pour la dengue. Les signes avant‐coureurs potentiels ont également étéévalués en comparant les données contemporaines de patients qui ont évolué vers une maladie sévère avec les données de ceux qui n’ont pas évolué de cette façon.
Résultats: 2259 patients ont été recrutés en 2006–2007 et 230 (13%) des 1734 patients avec une confirmation de laboratoire ont nécessité une intervention majeure. En appliquant le système actuel de l’OMS, 47/210 (22%) patients atteints de choc ne remplissaient pas tous les critères de dengue hémorragique. Toutefois, aucune révision tertiaire non plus n’a pu décrire adéquatement les différents groupes de sévérité. L’inclusion de complications facilement reconnaissables (choc/pertes vasculaires sévères et/ou saignements sévères et/ou dysfonctionnement sévère d’un organe) a été nécessaire pour concevoir un système permettant d’identifier les patients nécessitant une intervention majeure, avec une sensibilité et une spécificité suffisantes pour être utiles dans la pratique. Seul un petit nombre de sujets (5%) a progressé vers une maladie sévère alors qu’ils étaient sous observation; plusieurs signes d’alerte ont été identifiés, mais beaucoup plus d’études sont nécessaires pour caractériser complètement les caractéristiques associées à la progression de la maladie.
Conclusions: Sur base de ces résultats, un système de classification révisé, composé de deux entités, “Dengue” et “ dengue sévère “, a été proposé et a été intégré dans les nouvelles directives de l’OMS.
Summary
Background The current World Health Organisation (WHO) classification of dengue includes two distinct entities: dengue fever (DF) and dengue haemorrhagic fever (DHF)/dengue shock syndrome; ...it is largely based on pediatric cases in Southeast Asia. Dengue has extended to different tropical areas and older age groups. Variations from the original description of dengue manifestations are being reported.
Objectives To analyse the experience of clinicians in using the dengue case classification and identify challenges in applying the criteria in routine clinical practice.
Method Systematic literature review of post‐1975 English‐language publications on dengue classification.
Results Thirty‐seven papers were reviewed. Several studies had strictly applied all four WHO criteria in DHF cases; however, most clinicians reported difficulties in meeting all four criteria and used a modified classification. The positive tourniquet test representing the minimum requirement of a haemorrhagic manifestation did not distinguish between DHF and DF. In cases of DHF thrombocytopenia was observed in 8.6–96%, plasma leakage in 6–95% and haemorrhagic manifestations in 22–93%. The low sensitivity of classifying DHF could be due to failure to repeat the tests or physical examinations at the appropriate time, early intravenous fluid therapy, and lack of adequate resources in an epidemic situation and perhaps a considerable overlap of clinical manifestations in the different dengue entities.
Conclusion A prospective multi‐centre study across dengue endemic regions, age groups and the health care system is required which describes the clinical presentation of dengue including simple laboratory parameters in order to review and if necessary modify the current dengue classification.
Données de base La classification actuelle de l'organisation Mondiale de la Santé (OMS) pour la dengue comprends deux entités: la fièvre dengue et la fièvre hémorragique dengue/syndrome de choque dengue; elle est largement basée sur des cas pédiatriques du sud‐est asiatique. La dengue s'est pourtant étendue à différentes zones tropicales et à des groupes plus âgés. Des variations à la description originale des manifestations de la dengue sont couramment rapportées.
Objectifs Analyser les expériences des cliniciens dans la classification des cas de dengue et identifier les défis dans l'application des critères en pratique clinique de routine
Méthodes Revue systématique des publications anglaises depuis 1975 sur la classification de la dengue
Résultats 37 articles ont été revus. Plusieurs études ont strictement appliqué tous les 4 critères de l'OMS dans les cas de fièvre hémorragique dengue. Cependant, la plupart des cliniciens ont rapporté des difficultés à rassembler tous les 4 critères et ont alors utilisé une classification modifiée. Le test positif du tourniquet représentant le minimum requis pour une manifestation hémorragique ne distinguait pas entre fièvre hémorragique dengue et fièvre dengue. Dans les cas de fièvre hémorragique dengue, de la thrombocytopénie était observée chez 8,6 à 96% des cas, de l’écoulement de plasma chez 6 à 95% des cas et des manifestations hémorragiques chez 22 à 93% des cas. La faible sensibilité de la classification de la fièvre hémorragique de la dengue pourrait être due au manque de répétition des tests ou d'examens physiques à des moments appropriés, à l'instauration très tôt d'un traitement intraveineux des fluides et au manque de ressources adéquates dans les situations d’épidémie et peut être aussi à une superposition des manifestations cliniques dans différentes entités de dengue.
Conclusion Une étude multi centre prospective dans les régions endémiques de la dengue sur les groupes d’âge et le système des soins de santé est nécessaire pour décrire les présentations cliniques de la dengue incluant de simples paramètres de laboratoire afin de corriger et si nécessaire de modifier la classification actuelle de la dengue.
Antecedentes La clasificación actual de la Organización Mundial de la Salud (OMS) para el dengue incluye dos entidades diferentes: la fiebre del dengue (FD) y la fiebre hemorrágica del dengue (FHD)/síndrome de shock por dengue (SSD). Esta clasificación está principalmente basada en casos pediátricos del sureste asiático. El dengue se ha extendido a diferentes áreas tropicales y a grupos con mayor edad. Las variaciones de la descripción original de las manifestaciones del dengue se reportan en este artículo.
Objetivos Analizar la experiencia de los clínicos en el uso de la clasificación del caso de dengue e identificar los retos en aplicar los criterios en una práctica clínica de rutina.
Método Revisión sistemática de publicaciones en ingles desde 1975 que tratasen el tema de la clasificación del dengue.
Resultados Se revisaron 37 publicaciones. Algunos estudios aplicaban estrictamente los cuatro criterios de la OMS en casos de FHD; sin embargo, la mayoría de los clínicos reportaron dificultades para cumplir los cuatro criterios y utilizaron una clasificación modificada. El test positivo del torniquete, que representa el requerimiento mínimo para la manifestación hemorrágica no distinguió entre FHD y SSD. En los casos de FHD se observó trombocitopenia en un rango de 8.6% a 96%, fuga de plasma en 6% a 95% y manifestaciones hemorrágicas en 22% a 93%. La baja sensibilidad en la clasificación de FHD podría deberse a un fallo en la repetición de las pruebas o exámenes físicos en el momento apropiado, a una terapia temprana de fluidos intravenosos y falta de recursos adecuados en una situación epidémica y tal vez a un solapamiento considerable de manifestaciones clínicas en las diferentes entidades del dengue.
Conclusión Se requiere un estudio prospectivo, multicéntrico que incluya todas las regiones endémicas para dengue, grupos de edad y sistemas sanitarios, que describa la presentación clínica del dengue incluyendo parámetros de laboratorio simples, con el fin de revisar y si fuese necesario modificar la clasificación actual del dengue.
Despite the growing worldwide burden of dengue fever, the global economic impact of dengue illness is poorly documented. Using a common protocol, we present the first multicountry estimates of the ...direct and indirect costs of dengue cases in eight American and Asian countries. We conducted prospective studies of the cost of dengue in five countries in the Americas (Brazil, El Salvador, Guatemala, Panama, and Venezuela) and three countries in Asia (Cambodia, Malaysia, and Thailand). All studies followed the same core protocol with interviews and medical record reviews. The study populations were patients treated in ambulatory and hospital settings with a clinical diagnosis of dengue. Most studies were performed in 2005. Costs are in 2005 international dollars (I$). We studied 1,695 patients (48% pediatric and 52% adult); none died. The average illness lasted 11.9 days for ambulatory patients and 11.0 days for hospitalized patients. Among hospitalized patients, students lost 5.6 days of school, whereas those working lost 9.9 work days per average dengue episode. Overall mean costs were I$514 and I$1,394 for an ambulatory and hospitalized case, respectively. With an annual average of 574,000 cases reported, the aggregate annual economic cost of dengue for the eight study countries is at least I$587 million. Preliminary adjustment for under-reporting could raise this total to $1.8 billion, and incorporating costs of dengue surveillance and vector control would raise the amount further. Dengue imposes substantial costs on both the health sector and the overall economy.
In view of the long term discussion on the appropriateness of the dengue classification into dengue fever (DF), dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS), the World Health ...Organization (WHO) has outlined in its new global dengue guidelines a revised classification into levels of severity: dengue fever with an intermediary group of "dengue fever with warning sings", and severe dengue. The objective of this paper was to compare the two classification systems regarding applicability in clinical practice and surveillance, as well as user-friendliness and acceptance by health staff.
A mix of quantitative (prospective and retrospective review of medical charts by expert reviewers, formal staff interviews), semi-quantitative (open questions in staff interviews) and qualitative methods (focus group discussions) were used in 18 countries. Quality control of data collected was undertaken by external monitors.
The applicability of the DF/DHF/DSS classification was limited, even when strict DHF criteria were not applied (13.7% of dengue cases could not be classified using the DF/DHF/DSS classification by experienced reviewers, compared to only 1.6% with the revised classification). The fact that some severe dengue cases could not be classified in the DF/DHF/DSS system was of particular concern. Both acceptance and perceived user-friendliness of the revised system were high, particularly in relation to triage and case management. The applicability of the revised classification to retrospective data sets (of importance for dengue surveillance) was also favourable. However, the need for training, dissemination and further research on the warning signs was highlighted.
The revised dengue classification has a high potential for facilitating dengue case management and surveillance.
Abstract
Background
Platelet transfusion is common in dengue patients with thrombocytopenia. We previously showed in a randomized clinical trial that prophylactic platelet transfusion did not reduce ...clinical bleeding. In this study, we aimed to characterize the predictors and clinical outcomes of poor platelet recovery in transfused and nontransfused participants.
Methods
We analyzed patients from the Adult Dengue Platelet Study with laboratory-confirmed dengue with ≤20 000 platelets/μL and without persistent mild bleeding or any severe bleeding in a post hoc analysis. Poor platelet recovery was defined as a platelet count of ≤20 000/μL on Day 2. We recruited 372 participants from 5 acute care hospitals located in Singapore and Malaysia between 29 April 2010 and 9 December 2014. Of these, 188 were randomly assigned to the transfusion group and 184 to the control group.
Results
Of 360 patients, 158 had poor platelet recovery. Age, white cell count, and day of illness at study enrollment were significant predictors of poor platelet recovery after adjustment for baseline characteristics and platelet transfusion. Patients with poor platelet recovery had longer hospitalizations but no significant difference in other clinical outcomes, regardless of transfusion. We found a significant interaction between platelet recovery and transfusion; patients with poor platelet recovery were more likely to bleed if given a prophylactic platelet transfusion (odds ratio 2.34, 95% confidence interval 1.18–4.63).
Conclusions
Dengue patients with thrombocytopenia who were older or presented earlier and with lower white cell counts were more likely to have poor platelet recovery. In patients with poor platelet recovery, platelet transfusion does not improve outcomes and may actually increase the risk of bleeding. The mechanisms of poor platelet recovery need to be determined.
Clinical Trials Registration
NCT01030211.
Dengue fever commonly results in thrombocytopenia. In this post hoc analysis, poor platelet recovery was associated with older ages, lower white cell counts, and earlier stages of illness at presentation, and resulted in longer hospitalizations.
The increasing incidence of dengue among adults in Malaysia and other countries has important implications for health services. Before 2004, in order to cope with the surge in adult dengue ...admissions, each of the six medical wards in a university hospital took turns daily to admit and manage patients with dengue. Despite regular in-house training, the implementation of the WHO 1997 dengue case management guidelines by the multiple medical teams was piecemeal and resulted in high variability of care. A restructuring of adult dengue inpatient service in 2004 resulted in all patients being admitted to one ward under the care of the infectious disease unit. Hospital and Intensive Care Unit admission criteria, discharge criteria and clinical laboratory testing were maintained unchanged throughout the study period.
To evaluate the impact of cohorting adult dengue patients on the quality of care and the clinical outcome in a university hospital in Malaysia.
A pre (2003) and post-intervention (2005-6) retrospective study was undertaken.
Cohorting all dengue patients under the care of the Infectious Disease team in a designated ward in 2004.
The number of patients enrolled was 352 in 2003, 785 in 2005 and 1158 in 2006. The evaluation and detection of haemorrhage remained high (>90%) and unchanged throughout the study period. The evaluation of plasma leakage increased from 35.4% pre-intervention to 78.8% post-intervention (p = <0.001) while its detection increased from 11.4% to 41.6% (p = <0.001). Examination for peripheral perfusion was undertaken in only 13.1% of patients pre-intervention, with a significant increase post-intervention, 18.6% and 34.2% respectively, p = <0.001. Pre-intervention, more patients had hypotension (21.5%) than detected peripheral hypoperfusion (11.4%), indicating that clinicians recognised shock only when patients developed hypotension. In contrast, post-intervention, clinicians recognised peripheral hypoperfusion as an early sign of shock. The highest haematocrit was significantly higher post-intervention but the lowest total white cell counts and platelet counts remained unchanged. A significant and progressive reduction in the use of platelet transfusions occurred, from 21.7% pre-intervention to 14.6% in 2005 and 5.2% in 2006 post-intervention, p<0.001. Likewise, the use of plasma transfusion decreased significantly from 6.1% pre-intervention to 4.0% and 1.6% in the post-intervention years of 2005 and 2006 respectively, p<0.001. The duration of intravenous fluid therapy decreased from 3 days pre-intervention to 2.5 days (p<0.001) post-intervention; the length of hospital stay reduced from 4 days pre- to 3 days (p<0.001) post-intervention and the rate of intensive care admission from 5.8% pre to 2.6% and 2.5% post-intervention, p = 0.005.
Cohorting adult dengue patients under a dedicated and trained team of doctors and nurses led to a substantial improvement in quality of care and clinical outcome.
Quality of life of dengue patients Lum, Lucy C S; Suaya, Jose A; Tan, Lian H ...
The American journal of tropical medicine and hygiene,
06/2008, Volume:
78, Issue:
6
Journal Article
Peer reviewed
Although the disease burden of dengue is increasing, the impact on the quality of life (QoL) has not been investigated. A study to determine the QoL of confirmed dengue patients using the EuroQol ...visual thermometer scale was carried out at the University Malaya Medical Center. Of the 207 participants, 40% were ambulatory and 60% were hospitalized. Of eight health domains, 6.2 and 5.0 domains were affected in the hospitalized and ambulatory cohorts, respectively (P < 0.001), with cognition and interpersonal activities affected most. All patients experienced a drastic decrease in their QoL from the onset of symptoms. The QoL deteriorated to the lowest point (40% of healthy status) between the third and seventh days of illness. The duration of impaired QoL (9 days for ambulatory or 13 days for hospitalized patients) was longer than the duration of fever (5 and 7 days, respectively). Symptomatic dengue has major effects on patients' health.
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