dengue%20(pediatric)
DENGUE (PEDIATRIC)
Dengue infection is caused by the dengue virus that belongs to the family Flaviviridae.
There are 4 serotypes (DENV-1, DENV-2, DENV-3, DENV-4). Each serotype provides specific lifetime protective immunity against reinfection of the same serotype, but only temporary (within 2-3 months of the primary infection) and partial protection against other serotypes.
It is transmitted to humans through the bites of infected Aedes mosquitoes. It is primarily transmitted by female Aedes aegypti, a tropical and subtropical species. Humans are the main host of the virus.
After 4-10 days of incubation period, illness begins immediately.

Monitoring

  • Patients managed at home or admitted in the hospital without warning signs should be monitored daily until they are out of the critical phase
    • Should check for temperature pattern, volume of fluid intake and losses, urine output, warning signs, signs of plasma leakage and bleeding, hematocrit, white blood cell and platelet counts
  • Patients with shock should be monitored frequently until the critical period is over
    • Vital signs and peripheral perfusion should be checked every 15-30 minutes until the patient is out of shock, then every 1-2 hours
    • An indwelling arterial line may be placed for continuous and reproducible blood pressure measurements and regular blood sampling since in shock states, estimation of blood pressure using a cuff is usually inaccurate
    • Urine output should be checked hourly until the patient is stable and then 1-2 hourly
    • Hematocrit should be monitored before and after fluid boluses until the patient is out of shock and then 4-6 hourly
      • Changes in hematocrit must be interpreted together with the hemodynamic status, clinical response to fluid therapy and acid-base balance of the patient
    • Arterial and venous blood gases, lactate, total carbon dioxide or bicarbonate should be checked every 30 minutes to 1 hour until stable, then as needed
    • Blood glucose, renal profile, liver profile, coagulation profile should be monitored before fluid resuscitation, then as required
  • In general, patients given higher fluid infusion rate should be monitored more frequently in order to avoid fluid overload while ensuring sufficient volume replacement

Signs of Recovery

  • Stable vital signs
  • Normal temperature
  • No bleeding
  • Return of appetite
  • No vomiting
  • Good urine output (0.5 mL/kg/hr)
  • Stable hematocrit
  • Convalescent confluent petechial rash

Discharge Criteria for Hospitalized Patients

  • Visible clinical improvement
  • Absence of fever for 48 hours
  • Return of appetite
  • Good urine output
  • Stable hematocrit without intravenous fluids
  • Rising trend of platelet count
  • No respiratory distress

Risk for mortality may be increased with any one of the following:  

  • History of prior dengue infection
  • Hypotension
  • Narrow pulse pressure
  • Significant bleeding
  • Severe plasma leakage
  • DHF grade III and IV
  • Prolonged shock
  • Respiratory, liver or renal failure

Prevention

  • Preventing or reducing the transmission of dengue virus is dependent on controlling mosquito vectors or disturbing human-vector contact
  • Vaccination against dengue viruses is currently being developed, with promising results

Methods of Vector Control

  • Methods to control transmission should target habitats of immature and adult stages of A aegypti in the household and places where human-vector contact occurs
    • A aegypti is one of the most efficient vectors for arboviruses because it is highly anthropophilic, bites several times before oogenesis is complete and usually stays in artificial water containers closely associated with human habitat and commonly indoors
    • These mosquitoes do not fly far and mostly stay within 100 meters from where they emerged
    • Feeds mainly during daylight hours

Environmental Management

  • Aims to change the environment to decrease or prevent vector dissemination and human contact with the vector-pathogen
  • Controlling mosquito vectors are mainly achieved by eradicating container habitats that are favorable oviposition sites and development of aquatic stages through the following:
    • Preventing access of mosquitoes to containers or emptying and cleaning them regularly
    • Using insecticides or biological control agents to kill developing stages or adult vectors
  • To decrease human-vector contact, mosquito screens may be placed on windows or doors, or mosquito nets may be used while sleeping during daytime

Chemical Control

  • Larvicides should be done as complementary to environmental management
  • Adulticides are used to target adult vectors which are applied either as surface treatments or as space treatments
    • Intended to affect mosquito densities, longevity and other transmission parameters
    • Space spraying is done only to control vectors in emergency cases to suppress or prevent an epidemic
  • Individual and household protection such as clothings are advised to minimize exposure of skin and be protected from bites of dengue vectors during their active hours
    • Repellents that contain DEET (N, N-diethyl-3-methylbenzamide), IR3535 (3-[N-acetyl-N-butyl]-aminopropionic acid ethyl ester), or Icaridin (1- piperidinecarboxylic acid-2-(2-hydroxyethyl)-1-methylpropylester) may be applied to skin or to clothes
      • Evidence is insufficient regarding effectivity of citronella-based repellents over DEET-based repellents in decreasing transmission of dengue
    • Mosquito nets that are insecticide-treated also provide good protection
    • Household insecticide aerosol products or mosquito coils may also decrease biting activity

Biological Control

  • Certain species of larvivorous fish and predatory copepods (small freshwater crustaceans) may be introduced to specific container habitats of Aedes to reduce their population
  • Avoids chemical contamination of the environment but has operational limitations and is only effective against immature stages of vector mosquitoes in the larval habitat where they were introduced

Vaccination

  • CYD-TDV is a recombinant, live, attenuated, tetravalent dengue vaccine that is given to individuals aged 9-45 years residing in endemic areas  
    • Helps protect against dengue caused by dengue virus serotypes 1, 2, 3 and 4  
    • Recent analysis of clinical data showed persistent protection against dengue infection in individuals ≥9 years old who had previous infection; however, for individuals who have not had dengue infection (ie seronegatives), severe disease could develop if there will be a subsequent dengue infection  
      • Thus, healthcare providers should first evaluate the possibility of previous dengue infection prior to administering the vaccine and that seronegative individuals should not be vaccinated  
      • If a reliable serologic test is not available to establish serologic status before vaccination, it is recommended that the vaccine be administered only to individuals with documented previous dengue infection following an informed discussion  
      • For partially immunized patients (those who have received 1 or 2 vaccine doses), it is advised to defer further doses in individuals with no documented previous dengue infection and to continue vaccination following an informed discussion in seropositive individuals or those with a documented previous dengue infection  
    • Patient education should be intensified and timely consult encouraged in both seropositive and seronegative individuals who have been vaccinated with any number of doses  
      • Should dengue develop in vaccinated individuals, management is the same as the existing standards of care 
  • Other vaccines under clinical trial evaluation include subunit, DNA and purified inactivated as well as other live-attenuated vaccines
    • Additional vaccines under preclinical study evaluation are the virus-vectored and virus like particles (VLP)-based vaccines
  • The emergence of dengue virus variants, such as the sylvatic strain DENV-5, may impede the dengue vaccine initiative; thus, further studies are needed for the development of an effective dengue vaccine
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