MANAJEMEN DENGUE DAN CHIKUNGUNYA

ANGGRAINI ALAMDept. IK Anak RSUP Dr. Hasan Sadikin/FK Unpad

Dengue Virus DEN-1Kimura & Hotta, 1943Sabin & schlesinger, 1945(Haw-Den-1) as a prototype

DEN-2Isolates from New GuineaNew Guinea C (NG”C”-DEN-2) as prototype

DEN-3From patient with hemorrhagic disease in Manila, 1956

DEN-4From patient with hemorrhagic disease in Manila, 1956

Purdue univ computer illustration

Virus Dengue Serotype at 19 cities in Indonesia (2003-2005)

D2,3

D2,3,4

D2,4

D1,2,4

D1,2

D2

D2

D3

D1,3

D4,3

D3,2

D2,3,4

D2 D2,4

D2,4,3 D2 D2

INDONESIA’S SEROTYPE

DEN-1 : 8% DEN-2 : 65% DEN-3 : 15% DEN-4 : 12%

AryatiTropical Disease Unair/Bagian Patologi Klinik FK Unair-RSU dr Soetomo

Grafik 2. Jumlah kasus DBD dan CFR di regional Asia Tenggara 2006-2008

Sumber WHO 2009

Case 2006

Case 2007 Case 2008

140000 9

CfR% 2006

8 120000

CfR% 2007

CfR% 2008

7 100000

6

80000 5

4 60000

3 40000

2

20000 1

0 0

Country

0

50

100

150

200

250

300

350

400

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

1968

1969

1970

1971

1972

1973

1974

1975

1976

1977

1978

1979

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

KASUS

TAHUN

Grafik 3 Jumlah Kasus & Kab/Kota Terjangkit DBD Per Tahun di Indonesia Tahun 1968-2009 (22 Juli 2009) sumber Dirjen PPL DEPKES 2009

KASUS KAB/KOTA TERJANGKIT

KAB/KOTA

Mortalitas DHF di RSHS 2007 s/d 2010

Demam Dengue

Hari sakit

emp

Time of fever defervescence(Saat suhu reda)

Suhu reda, klinis membaik, nafsu makan membaik

Demam Berdarah Dengue

Hari sakit

emp

Klinis memburuk, lemah, gelisah, tangan kaki dingin, nafas cepat, diuresis berkurang, tidak ada nafsu makan

Fase syokFase demam Fase konvalesens

Time of fever Time of fever defervescencedefervescence

Pearls in Diagnosis (1)

In a child with acute onset of high fever:

flushed face without coryza, with petechiae and/or Torniquet test (+) suggest the possibility of dengue infection.

TT (+) together with WBC < 5,000 /mm3: 60-70% PPV for diagnosis dengue /DHF (day 2-3 fever)

If Hepatomegaly (+) increases the possibility of DHF

Torniquet testWidely divergent and probably

reflect inter-observer variability as well as the day of illness

TT was positive in: 46% four days, 56% three days 67% two days, 78% one day before defervescence and in 90% on the day of

defervescence

A drop in platelet counts concurrently with rising Hct (> 20%) confirms diagnosis of DHF and signals the need for intervention therapy

A drop in WBC (leukopenia) with decrease in PMN and a relative increase in lymphocyte (+ atypical lymphocyte) predict the end of febrile period (24 hrs before temp drop) in DHF

The presence of pleural effusion and ascites support the diagnosis of DHF/DSS cases

in whom rising Hct is less than 20% (mostly due to early volume replacement or bleeding)

FOTO RONTGEN TORAKS RLD

Posisi anak saat pengambilan foto

Hasil yang didapat

Vaughn DW, Green S, Kalayanarooj S, et al. Dengue in the early febrilephase: viremia and antibody responses. J Infect Dis 1997; 176:322-30.

CENTERS FOR DISEASE CONTROLAND PREVENTION

AB

PEI = A/B x 100

Pleural Effusion IndexPleural Effusion Index

ULTRASONOGRAFI TORAKS tranversal

Efusi pleura kananEfusi pleura kanan

ULTRASONOGRAFI abdomen

Dinding kandung empedu menebal

Pitfalls in Diagnosis (1)

No or low index of suspicion for dengue/DHF lead to delay or misdiagnosis.

Although the incidence of DHF is high in older children (5-9 and 10-15 years), DHF can occur in younger infants, even newborn (from vertical transmission)

Failure to appreciate the value of tourniquet test and routine WBC which help screening dengue from non-dengue in early febrile phase

Misdiagnosis DF as DHF: not using evidence of plasma leakage

(pleural effusion/ ascites or hypoproteinemia/albuminemia)

for case definition of DHF

Over diagnosis of dengue/DHF : not using criteria for diagnosis

Misjudgement of critical stage, which could begin as early as day 3 (if fever drop on day 3).

A delay in doing the WBC, platelets and Hct determination which help predict the critical stage/shock lead to misdiagnosis and/or delay until shock occur

Delay to recognize DSS as most of them remain in good conscious and have narrowed pulse pressure (eg BP 110/90; 100/80 mmHg) without hypotension

Misdiagnosis of DHF in infants (< 1 yr) who may present with convulsion as CNS infections which may lead to unnecessary and invasive procedure (eg LP)

Failure to think of internal (concealed) bleeding that need blood transfusion because of high Hct (from plasma loss)

Failure to diagnose other associated condition that may be risk factors e.g. peptic ulcer, menstruation that may increase bleeding tendency

Rapid sero-diagnosis by ELISA may give

false negative on the first 2-3 days of fever

while the PCR is specific and sensitive but cannot differentiate DHF from DF

Pearls in Management (1)

With early clinical recognition and frequent monitoring of patient for

plasma leakage, early volume replacement when Hct rises significantly can prevent shock

and/or modify disease severity

The period of plasma leakage/shock is short.

The time that need close observation and monitoring of vital signs, Hct and urine

output is approximately 24-48 hours

A rising Hct is a good indicator for plasma loss

Hct is simple procedure for use to adjust I.V. fluid rate/volume

DSS can be succesfully resuscitated: About 60% by using crystalloid solution only 25% need colloidal and 15% need blood transfusion (+ blood

components) Children Hospital Bangkok (2002)

Pediatrics department Hasan Sadikin Hospital:

April 2005 – Maret 2006 175 DSS cases 63% crystalloid only; 13% crystalloid and

colloid 9,5% crystalloid, colloid and inotropic ( 22.5% need colloid) 4 % crystalloid and inotropic

With rapid recognition of shock and proper treatment, rapid and dramatic recovery is the rule

If shock is rapidly and appropriately managed usually there is no massive bleeding even though the platelets are lower than 50,000/mm3

Stable Hct and vital signs, diuresis, and rapid return of appetite are good indicators to stop I.V. fluid

Pitfalls in management (1)

Abuse of antibiotics when not suspicion of dengue/DHF

These unnecessary drugs use may contribute to:

increase chance for hemorrhage (aspirin,ibuprofen)

precipitate Reye syndrome (aspirin) hepatic dysfunction (acetaminophen if

overdose)

Over use of platelet transfusion as prophylaxis

for bleeding in all shock cases

Thrombocytopenia and Platelet Transfusions in DengueHaemorrhagic Fever and Dengue Shock SyndromeAlex Chairulfatah, Djatnika Setiabudi, Ridad Agoes andRobert Colebunders

In conclusion, a large number of patients with DHF/DSS in Bandung hospitals receive platelet transfusions, even if thrombocyte counts are above 25,000/ml.

This study suggests that in most DHF/DSS cases,

platelet transfusions do not influence the incidence of severe bleeding.

Treatment costs for DHF/DSS cases could be reduced if these unnecessary platelet transfusions are avoided.

Dengue Bulletin – Vol 27, 2003

PENATALAKSANAANPENATALAKSANAAN

- Terlalu dini/agresif memberi IVFDTerlalu dini/agresif memberi IVFD

- Terlambat menghentikan/ Terlambat menghentikan/

memperlambat tetesan IVFDmemperlambat tetesan IVFD

- Terlambat memberikan cairan koloid pada Terlambat memberikan cairan koloid pada kebocoran plasma yang hebatkebocoran plasma yang hebat

PENATALAKSANAANPENATALAKSANAAN

- Terlalu dini/agresif memberi IVFDTerlalu dini/agresif memberi IVFD

- Terlambat menghentikan/ Terlambat menghentikan/

memperlambat tetesan IVFDmemperlambat tetesan IVFD

- Terlambat memberikan cairan koloid pada Terlambat memberikan cairan koloid pada kebocoran plasma yang hebatkebocoran plasma yang hebat

Beberapa hal yang perlu diperhatikanBeberapa hal yang perlu diperhatikan

PENATALAKSANAAN

- Terlambat memberi transfusi darah pada perdarahan masif tersembunyi

- Terlalu agresif memberi suspensi trombosit

- Terlambat/lupa memberi Oksigen pada DSS

Jangan lupa membuat laporan KDRS

PENATALAKSANAAN

- Terlambat memberi transfusi darah pada perdarahan masif tersembunyi

- Terlalu agresif memberi suspensi trombosit

- Terlambat/lupa memberi Oksigen pada DSS

Jangan lupa membuat laporan KDRSJangan lupa membuat laporan KDRSJangan lupa membuat laporan KDRS

pelaporan Isi formulir KDRS: Diserahkan 24 jam setelah penegakkan

diagnosis Memerlukan pemeriksaan laboratorium

termasuk serologi

terlambat?Perlu form TERSANGKA DBD sebagai

laporan awal

pelaporan 30% pelaporan RS di Kota Bandung

(RSHS dan RS Swasta) ke Dinkes Jabar (2003)

peralatanTensimeter dengan berbagai ukuran cuff

(3 macam), untuk: Pengukuran tekanan darah Tourniquette test

Pemeriksaan hematokrit Di puskesmas (minimal PKM DTP)

What the heck is Chikungunya?Togaviridae

alphavirusRNA virus able to

evolve rapidly and expand vector

Endemic in Africa and Asia, especially India

Vectored by Aedes species (albopictus, aegypti)

Natural cycleAedes mosquitoes

Feed in daytime Breed in stagnant

water Small puddle

Reservoir Primates Transient viremia 3-

7 days

Clinical criteria: Acute onset of fever >38.5°C and severe arthralgia/arthritis not explained by other medical conditions.

Epidemiological criteria: Residing or having visited epidemic areas, having reported transmission within 15 days prior to the onset of symptoms.

Laboratory criteria: At least one of the following tests in the acute phase:- Virus isolation.- Presence of viral RNA by RT-PCR.- Presence of virus-specific IgM antibodies in single

serum sample collected in acute or convalescent stage.- Four-fold increase in IgG values in samples

collected at least three weeks apart.

case definition

CASES CATEGORIZED Possible case: A patient meeting

clinical criteria. Probable case: A patient meeting both

the clinical and epidemiological criteria. Confirmed case: A patient meeting the

laboratory criteria, irrespective of the clinical presentation.

Algorithm for ascertainment of suspected Chikungunya case

Source: ECDC Mission Report: Chikungunya in Italy, Joint ECDC/WHO visit for a European risk assessment 17 – 21 September 2007

It may be noted that during an epidemic:

all patients need not be subjected to confirmatory tests as aboveAn epidemiological link may be enoughClinical management as of now does not differ between a probable case and a confirmed case

Clinical diseaseSignificant

morbidity, minimal mortality

Fever, rash, nausea, fatigue, arthralgia lasting days to weeks

Arthritis may be long-term sequellae

Manifestasi Klinis

WHO Guidelines for Prevention and Control of Chikungunya Fever; 2009

Complications Possible complications include gastro-

intestinal complications, cardiovascular decompensation or meningo-ecephalitis

Fatalities have been reported mainly in aged patients or where the patient’s immune system was weakened by underlying conditions

Treatment

In the absence of treatment for Chikungunya fever, focus is set on: symptomatic treatment only (non-steroid

anti-inflammatories, non-salicylic analgesics)

surveillance of the patient for complications

prevention of further transmission

In order to prevent further transmission, infected persons should avoid further mosquito bites (e.g. use of repellents or sleeping under bed nets as much as possible)

CASE MANAGEMENT

rest acetaminophen or paracetamol to relieve

fever ibuprofen, naproxen or other non-

steroidal anti-inflammatory agent (NSAID) to relieve the arthritic component

drink plenty of fluids to replenish fluid lost from sweating, vomiting, etc.

Cases that have prolonged arthralgia and joint stiffness may benefit from a regimen of graduated physiotherapy

Dengue vaccines in clinical trials

Swaminathan S, Khanna N. Current Science 2010;98(3)

Morrison et al. JID 2010:201

CYD Vaccine Trial

R.Z. Capeding et al. / Vaccine 29 (2011) 3863–3872

CYD Vaccine Trial

DENGUE VACCINES The live attenuated dengue vaccines may

eventually be licensed for human use. Current indications are that these vaccines

will need to be administered in 2 or 3 doses to achieve tetravalent seroconversion.

In dengue-endemic areas, partially seroconverted recipients are likely to face the possibility of infection before completion of the immunization schedule; it needs not only safe and efficacious, but also inexpensive

Swaminathan S, Khanna N. Current Science 2010;98(3)