IMA, AHPI, CAHO & DMA Nursing Home Forum releasd a white paper on Dengue Management

Addressing a press meet at the Indian Medical Association today, representatives of IMA, Association of Health Care Providers of India (AHPI), DMA Nursing Home Form and CAHO (Consortium of Accredited Healthcare Organisation) released a white paper on the ongoing dengue menace in the country.

Addressing the press, Padma Shri Awardee Dr. KK Aggarwal–Honorary Secretary General IMA, Dr. Shubnum Singh – Advisor-AHPI, Dr. Girdhar Gyani (AHPI), Dr Vinay Aggarwal – Former President CMAAO, Dr C M Bhagat – Chairman, Delhi Nursing Home Form & Dr Vijay Aggarwal – CAHO, Dr. R.N. Tandon & Dr. V.K. Monga – Health care Experts in a joint statement said, “Instead of continuing to blame other associations, government officials, hospitals and doctors for the mismanagement of dengue cases in the country, we must all work together towards preventing and minimizing further dengue deaths, to stop the disease from spreading in other states, prepare ourselves for an outbreak of flu in the coming season and rationalize the charges, admissions and services of the medical profession”

The guidelines released by the organizations stated:
*Delhi is at present going through a dengue outbreak although the government has not declared it as an epidemic.
*The maximum dengue cases are recorded between 15th September and 15th October.
*Dengue can be classified as dengue fever and severe dengue. A person is said to be suffering from severe dengue when there is capillary leakage. Patients who have dengue fever do not have capillary leakage.
*Any person suffering from fever in this season with a headache, body ache, fatigue, nausea, vomiting is believed to have dengue fever unless proved otherwise.
*Dengue fever can be managed on an outpatient basis and does not need hospitalization.
*Out of the four types of dengue infections, which exist in our country, type 2 and type 4 dengue are more likely to cause capillary leakage. Type 2 dengue is considered to be more dangerous than type 4 dengue.
*The present dengue outbreak is that of dengue 4 as against the outbreak in 2013, when type 2 dengue was more prevalent.
*Given that this is the first time dengue 4 has occurred in Delhi on a large scale. a large number of cases are expected to occur and will continue to occur for next one month.
*Cases of severe dengue are categorized by capillary leakage – (rapid fall of platelets, high liver enzymes with SGOT > SGPT, intravascular dehydration categorized by rise in haematocrit levels, and fall in pulse pressure which is the difference between the upper and lower blood pressure).
*The best treatment for dengue is to administer large amounts of oral fluids to patients. For patients who are unable to take oral fluids, intravenous administration may be necessary.
*Capillary leakage occurs when the fever starts settling down. It occurs a day before the fever comes back to normal and continues for the next one more day. The total duration of capillary leakage often lasts for up to 48 hours. Dengue is never serious when the fever is high.
*Clinically capillary leakage presents with sudden onset of extreme weaknesses or restlessness.
*At the onset of capillary leakage, the patient must immediately receive oral or IV fluids equivalent to 20 ml per kg.
*No dengue patient should ordinarily die if he/she passes urine every few hours (a sign of adequate hydration) and difference of upper and lower blood pressure is kept > 40 mm Hg
*A second occurrence dengue (secondary) is more serious than first infection (primary). In the primary infection, IgM or NS1 will be positive and in secondary infection IgG will also be positive.
*Platelet transfusion is only required in the presence of active bleeding and platelet count less than 10,000.
*In the absence of severe abdominal pain or tenderness, persistent vomiting, abnormal mental status or extreme weakness, the patient may not need hospital admission.
*All medical establishment and doctors should attend to dengue suspected cases immediately.
*Distinguish cases of dengue fever from severe dengue. · Give bolus 20 ml fluid per kg of body weight if capillary leakage is suspected.
*In the absence of capillary leakage, stabilize the patient on oral fluids and observe as outpatient on a daily basis.
*In the presence of capillary leakage or if high risk (pregnancy, age less than 5 years, uncontrolled diabetics, associated co morbid condition), hospitalize or arrange for safe transfer to nearest government hospital or private hospital as the case may be.
*In the absence of a centralized bed management information system, it may not be possible for a private sector hospital to call all nearby private hospitals and arrange for a bed for the patient if bed is not available with them.
*Hospitals should arrange their own ambulances or arrange empanelled ambulances for a safer transfer of the patient to the nearest designated government hospital.
*Unnecessary admission should be avoided. No patient should be admitted to the hospital just because the family of the patient wants admission, or he/she has a reimbursement policy.
*Platelet transfusion is not recommended in most patients and if given when not necessary may be harmful.
*Machine platelet count reading may be less than the actual platelet count.
*Inter-machine variability is also often found to be high while interpreting platelet count.
*Admitting dengue patients on floor and filling more than 90% occupancies may increase the possibility of hospital-acquired infections
*The health authorities should reimburse emergency care for all dengue patients at government entitled rates.
*The chances of severe dengue reduce after the age of 11. Deaths are more common in children.
*It is possible for a child or an adult to be completely healthy just a few hours before he or she develops capillary leakage.
*Whenever a dengue patient’s fever is below 100 degrees, one should observe for capillary leakage.
*With effective and timely treatment, severe dengue mortality can be reduced to *According to data by the WHO, each year around 39 lakh people develop dengue every year, out of which five lakh develop severe dengue with 25,000 deaths. More than 80% of the patients are treated in the private sector.
*Testing platelet levels alone does not account for complete and effective management of dengue.
*A complete blood count (especially hematocrit) is needed to monitor prognosis and increased capillary permeability, which is the starting point of all complications.
*Only PLATELET count requires manual dilution, charging of chamber and manual counting. It is extremely time-consuming and impractical to perform in periods of crisis like this. It is not possible to do a CBC for Rs. 50/-.
*Rapid dengue testing is the need in any outbreak, it cannot be ignored.
*For ELISA confirmatory test, one may send all cases to the designated government or private sector labs.
*IMA has requested the media not go for a Media trial in every dengue case as even in the best of the centers, 1% of patients may not survive with severe dengue.
*A patient who is clinically stable can become serious in a matter of minutes or hours and may succumb to complications even in the best of centers and that is the reason all dengue patients on *OPD management are required to follow up daily with their doctors. The biological behavior of the disease leads to questioning of the care that was provided to a stable patient.
*Medical doctors are under tremendous pressure and are at risk of violence at time of any dengue death and will require protection from appropriate authority.

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