|Year : 2021 | Volume
| Issue : 5 | Page : 219-223
Effectiveness of WHO dengue management protocol: An observational study
Nishanth Rajan1, Priya Jose1, Peter Prasanth Kumar Kommu1, Manikandan Mani2, Lalitha Krishnan1
1 Department of Pediatrics, Pondicherry Institute of Medical Sciences, Puducherry, India
2 Department of Preventive and Social Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India
|Date of Submission||14-Jun-2021|
|Date of Decision||25-Aug-2021|
|Date of Acceptance||04-Sep-2021|
|Date of Web Publication||28-Sep-2021|
Dr. Priya Jose
Department of Pediatrics, Pondicherry Institute of Medical Sciences, Puducherry - 605 014
Source of Support: None, Conflict of Interest: None
Background: Dengue fever (DF) has become a worldwide health problem. There are only a few studies assessing management based on the classification by the World Health Organization (WHO). Hence, we aimed at assessing the outcome of children with DF before and after the implementation of the WHO protocol.
Subjects and Methods: A retrospective hospital-based comparative study was done in a tertiary care center, Puducherry, to study the outcome of children diagnosed with DF before and after the implementation of WHO management 2012 protocol in the year 2014. All children (0–14 years) who were diagnosed with DF (NS1Ag or IgM ELISA positivity) during 2012–2016 were included. Medical records with incomplete data were excluded. They were divided into two groups: Group I – Children admitted for treatment of DF between January 2012 and December 2013 (24 months) and managed by close clinical monitoring and Group II – Children admitted for treatment of DF between January 2014 and December 2016 (36 months) and managed as per WHO protocol.
Results: There was no statistically significant difference in the signs of shock and mortality between the groups. There was statistically significant difference of children with fluid overload during the recovery phase in Group II when compared with Group I.
Conclusions: Close clinical monitoring during the critical phase may reduce the signs of fluid overload during the recovery phase.
Keywords: Clinical monitoring, fluid overload, intensive care, WHO protocol
|How to cite this article:|
Rajan N, Jose P, Kommu PP, Mani M, Krishnan L. Effectiveness of WHO dengue management protocol: An observational study. J Pediatr Crit Care 2021;8:219-23
|How to cite this URL:|
Rajan N, Jose P, Kommu PP, Mani M, Krishnan L. Effectiveness of WHO dengue management protocol: An observational study. J Pediatr Crit Care [serial online] 2021 [cited 2021 Nov 27];8:219-23. Available from: http://www.jpcc.org.in/text.asp?2021/8/5/219/326865
| Introduction|| |
Dengue fever (DF) has become a worldwide health problem. This has been identified as the most common and one of the important infectious diseases in children. Annually, 100 million cases of DF and half a million cases of dengue hemorrhagic fever (DHF) have been reported. DF was classified as DF, DHF, and dengue shock syndrome as per the World Health Organization (WHO) 1997 management protocol. It was revised in 2009 and was classified as probable dengue, dengue with warning signs, and severe dengue. Despite several modifications in the guidelines over the years, there are several limitations that still need to be addressed. Few include lack of good clinical or laboratory markers to predict progression to severe dengue, fluid overload, de-escalation of fluid therapy during the recovery phase, and expanded dengue syndrome that may occur in some children. Furthermore, the generalizability of WHO management protocols in different health-care settings and children needs to be studied.
There are 3 phases in DF viz. febrile phase, critical phase, and recovery phase. The critical phase is the most crucial, because of plasma leakage following increased capillary permeability. Fear of depletion of intravascular volume, prompted immediate replacement of fluids which often ended up in excess plasma volume during the recovery phase. This often led to worsening of ascites, pleural effusion, and pulmonary edema. Deaths due to these complications can be avoided if management during the critical phase is rationalized with close monitoring and de-escalation of fluid therapy when warranted. There are only a few studies assessing management based on the classification by the WHO. Hence, we aimed at assessing the outcome of children with DF before and after the implementation of WHO protocol 2012.
| Materials and Methods|| |
A retrospective hospital-based observational study was done in the Department of Pediatrics, in a Medical College Hospital in Puducherry. The review board and Institutional Ethics Committee (No. IEC/RC/16/148 dated 01/04/2017) have approved this observational study. The aim was to study the outcome of children diagnosed with DF before and after the implementation of the WHO management 2012 protocol in the year 2014.
All children (0–14 years) who were diagnosed with DF (NS1Ag or IgM ELISA positivity) during 2012–2016.
Medical records with incomplete data.
Data of patients were collected from the medical records department for 2012–2016. Demographic details, clinical presentations, laboratory and radiological investigations and line of management were collected from the case files.
Management strategy before World Health Organization 2012 protocol implementation
As per records, till 2014, DF in the Department of Pediatrics was managed symptomatically with close clinical monitoring for hemodynamic instability (tachycardia appropriate for age, narrow pulse pressure (<20 mm Hg), CFT >3 s, hypotension (SBP <70 + 2× age in years), and signs of bleeding during the critical phase. Children with severe thrombocytopenia (platelet <10,000/ml), high PCV (thrice than the baseline hemoglobin or >42), ≥2 warning signs were shifted to intensive care and monitored closely. PCV and platelet counts were monitored twice a day or more depending on the clinical picture. If the child was not tolerating orally, maintenance intravenous (IV) fluids were given. All children with shock received 10 ml/kg of normal saline as IV bolus in the intensive care. The child was monitored for hemodynamic stability – If stable, IV maintenance fluid was continued. One more bolus of 10 ml/kg of normal saline was given if the shock was persisting. It was considered refractory shock when the child was not responding to 2 boluses of normal saline (10 ml/kg). Colloids and blood transfusion were given for refractory shock. Packed cells were transfused if there was hemorrhage. Children with severe shock and hemorrhage were monitored with serial hematocrit and platelet counts. If platelet counts were <10,000/ml, platelet transfusion was also given.
Management strategy after World Health Organization 2012 protocol implementation
In 2014, the Department switched to the WHO dengue management protocol renewed in 2012. Patients admitted for treatment were allocated to one of the groups as per WHO dengue classification 2012 (probable dengue, dengue with no warning signs, dengue with warning signs, and severe dengue). The protocol flow chart laid by WHO was followed for all children according to the category of DF.
The outcome variables were signs of shock, fluid overload, intensive care stay, and mortality. Signs of shock were rapid weak pulse, narrow pulse pressure (<20 mmHg), or hypotension with cold clammy skin and restlessness. Signs of fluid overload include puffy eyelids, abdominal distension and abdominal discomfort, tachypnea and late signs include dyspnea and respiratory distress, wide pulse pressure, very tense abdomen, hypertension, strong and bounding pulse, and crepitations on auscultation. Fluid overload was documented by daily weight monitoring and clinical observation of these symptoms.
Available data were collected using a predesigned proforma and entered into Microsoft excel sheet. Analysis was done using SPSS software 20 version. Descriptive statistics like frequency and percentage were used for qualitative variables. Mean and standard deviation were used for quantitative variables. Independent t-test was used if data are normal. Mann–Whitney U test for two groups and Kruskal–Wallis test for more than two groups if the data and was skewed. Chi-square test was used to find the association between signs of shock, third space loss and duration of pediatric intensive care unit stay in both groups. A P < 0.05 was considered statistically significant. The anonymized data collected were kept confidential and private.
| Results|| |
A total of 1018 patients were admitted with a suspected diagnosis of dengue. Among them, 606 patients were diagnosed to have DF based on positive dengue serology (NS1Ag and/or IgM antibodies). Another 412 patients had features of probable dengue but were seronegative and hence excluded. Because of the missing data, 88 patients (of 2013 and 2016) were excluded from the study. Hence, a total of 518 patients were included in the final analysis. They were divided into two groups as per the difference in management. Group I had 338/518 (65.2%) and Group II had 180/518 (34.8%) patients.
The mean age in months in each group was 52.44 ± 33.88 and 71.64 ± 44.94, respectively. Boys were more affected than girls (287/518 vs. 201/518) though not statistically significant. The clinical features and laboratory parameters of children diagnosed with DF are enlisted in [Table 1]. When compared with Group II, Group I had more children with clinical features of retro-orbital pain, positive Hess test, hepatomegaly, splenomegaly, and features of hepatitis. All the other baseline clinical and laboratory characteristics were similar in both groups. This clearly states the changing trends of the clinical features of DF during different epidemics.
The two groups were compared for the outcome – signs of shock, signs of fluid overload during the recovery phase, need for intensive care, and death [Table 2]. There is no statistically significant difference in the signs of shock between the groups. There was a statistically significant difference of children with signs of fluid overload during the recovery phase in group II when compared with Group I. Patients with warning signs were closely monitored in intensive care and accounted for 32.2%, hence, there is a statistically significant difference in the number of children in ICU stay when compared with Group II. While there was no death in Group II, 3 children died in Group I (critical phase was managed at the local hospital and referred during recovery phase because of severe pulmonary edema and gastrointestinal hemorrhage), but this difference was not statistically significant.
|Table 2: Comparing the outcome of both groups as per the management protocol|
Click here to view
| Discussion|| |
Our study aimed at estimating the outcome of children diagnosed with DF before and after the implementation of the WHO management 2012 protocol in the year 2014. There is no statistically significant difference in the signs of shock between the groups but there was a statistically significant difference in children with signs of fluid overload during the recovery phase in Group II when compared with Group I.
DF is a benign infectious disease caused by the arthropod dengue viruses 1, 2, 3, and 4. India being one of the epidemic countries, and the burden can increase further because of global warming, globalization, and lack of vaccines. There have been outbreaks of DF every year in different parts of Tamil Nadu where 9500 patients were diagnosed with DF in 2012. In children, it is characterized mainly by biphasic fever, myalgia, rash, vomiting, and abdominal pain. The clinical manifestations vary every year with more atypical features becoming common in recent times. Our study also revealed the features of expanded dengue syndrome are increasing as years passes. Children in Group I were of younger age group and had more positive Hess test, hepatitis, hepatomegaly, splenomegaly, etc., when compared to children in Group II.
Most of the dengue cases have a good prognosis, but hemorrhage and shock can be life-threatening and lead to a very high mortality rate if not monitored properly. Early diagnosis and management by close clinical monitoring and appropriate treatment decrease mortality and morbidity. As we have monitored all the patients with thrombocytopenia, high PCV and ≥2 warning signs in the intensive care, the number of patients in intensive care was high in Group I. Hence, the children who had fluid overload during the recovery phase is less compared with Group II, but the number of patients in intensive care became more and is statistically significant. Children in Group II were managed as per WHO management protocol renewed in 2012. Intravenous fluids were started for children with warning signs and monitored as per protocol. Hence, fluid overload during the recovery phase was more in this group. Only patients with severe complications such as hemorrhage, refractory shock were managed in intensive care. Three children died here were managed aggressively with fluids and blood products for severe dengue from primary care hospitals. One had severe gastrointestinal hemorrhage and DIC, one with severe pulmonary edema because of fluid overload, and another with refractory shock and severe myocarditis. There is a statistically significant difference in the signs of fluid overload because of the vascular leakage during the recovery period. It emphasizes the need for judicious fluid management during the critical phase.
There are only a few studies assessing the dengue protocol established by WHO. Gupta et al. assessed the WHO definition of DHF in North India and concluded that all the severe cases cannot be properly classified by using WHO protocol in the Indian population. Ajlan et al. also assessed the classification and the ability to predict the severity of dengue as per WHO in Saudi Arabians and proposed a few modifications which included an age and geography-specific protocol. Our study proves that treatment protocol might also require some modifications like emphasizing on close clinical monitoring. According to an observational study done by Ghazala et al. in 2014 about the pattern of management and outcome of DF revealed that supportive care with judicious fluid management during the critical phase is the best management required which was similar to our results. Hence, we recommend close clinical monitoring and de-escalation when appropriate to avoid fluid overload.
Dengue is a complex disease with its clinical features, management can be very simple by close clinical monitoring. It is very effective in saving lives if timely intervention is instituted. The use of multiple fluid boluses and adherence to the protocol without consideration of clinical monitoring may increase morbidity and mortality. Management of these patients needs to be revised as and when new knowledge is available.
Since the study spanned over 5 years, the unit-wise practice on management may have improved over this study period leading to the Hawthorne effect. Furthermore reporting errors could have occurred as the health-care provider could have changed over the period. The number of patients included in group II could have been more to match almost equally with the other group.
| Conclusions|| |
Implementation of WHO protocol could change the management of dengue in health-care centers. Intensive care stays and mortality have come down after the implementation of WHO protocols in our study. Close clinical monitoring has significantly reduced the number of patients with fluid overload during the recovery phase. Revision at regular intervals by the National Health Committee would help in the reduction of fluid overload during the recovery phase.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nisalak A, Endy TP, Nimmannitya S, Kalayanarooj S, Thisayakorn U, Scott RM, et al
. Serotype-specific dengue virus circulation and dengue disease in Bangkok, Thailand from 1973 to 1999. Am J Trop Med Hyg 2003;68:191-202.
Gupta P, Khare V, Tripathi S, Nag VL, Kumar R, Khan MY, et al
. Assessment of World Health Organization definition of dengue hemorrhagic fever in North India. J Infect Dev Ctries 2010;4:150-5.
Pang J, Thein TL, Leo YS, Lye DC. Early clinical and laboratory risk factors of Intensive Care Unit requirement during 2004-2008 dengue epidemics in Singapore: A matched case-control study. BMC Infect Dis 2014;14:649.
Hung NT. Fluid management for dengue in children. Paediatr Int Child Health 2012;32 Suppl 1:39-42.
Scott T, Velayudhan R. Handbook for Clinical Management of Dengue WHO and Special Programme for Research and Training in Tropical Diseases (TDR) Report.WHO; 2012.
Kalayanarooj S. Clinical manifestations and management of dengue/DHF/DSS. Trop Med Health 2011;39:83-7.
Kumar H, Mansoor SM. A study of clinico demographic profile of dengue cases in A teaching hospital. Natl J Community Med 2015;13557:2038-2043.
Bandyopadhyay B, Bhattacharyya I, Adhikary S, Konar J, Dawar N, Sarkar J, et al
. A comprehensive study on the 2012 dengue fever outbreak in Kolkata, India. Int Sch Res Notices 2013;2013:1-5. https://doi.org/10.5402/2013/207580
Ajlan BA, Alafif MM, Alawi MM, Akbar NA, Aldigs EK, Madani TA. Assessment of the new World Health Organization's dengue classification for predicting severity of illness and level of healthcare required. PLoS Negl Trop Dis 2019;13:e0007144.
Ghazala Z, Anuradha HV, Shivamurthy MC. Pattern of management and outcome of dengue fever in pediatric in-patients in a tertiary care hospital: A prospective observational study. Int J Basic Clin Pharmacol 2017;3:534-8.
Biswas A, Pangtey G, Devgan V, Singla P, Murthy P, Dhariwal AC, et al. Indian national guidelines for clinical management of dengue fever. J Indian Med Assoc 2015;113:196-205.
[Table 1], [Table 2]