National Guidelines on Prevention, Management and Control of Dengue in Nepal
2019
Introduction
Dengue is a mosquito-borne viral disease that has rapidly spread in many countries worldwide in recent years. Dengue is believed to have originated as a mammalian disease in non-human primates and emerged in the human population roughly 500-1,000 years ago. The disease is widespread throughout the tropics with risk factors influenced by local spatial variations of rainfall, temperature, relative humidity, degree of urbanization and quality of vector control services in urban areas. It is estimated to infect 390 million people annually of which 96 million manifest clinically. One study on prevalence of dengue estimates that 3.9 billion people in 128 countries are at risk of infection with dengue viruses. Before 1970, only 9 countries had experienced severe dengue epidemics, today the disease is endemic in more than 100 countries.
Adult Aedes aegypti, PC: Dr B Nagpal, WHO
Dengue is caused by a flavivirus of 4 virus serotypes (DENV1, DENV2, DENV3, DENV4). Over the past 20 years, these serotypes have spread worldwide from South East Asia and are now found throughout Asia, Africa and the Americas (Figure 2). International travel, trade, migration, decreased access to health care and urbanization are considered among the main drivers behind the rapid dissemination of all four dengue serotypes. Compounding the problem has been the global spread of the dengue mosquito vectors, Ae. aegypti and Ae. albopictus, throughout the last century.
Fig. (A) Enveloped and spherical dengue virion with different structural proteins and (B) Cryo-electron Microscopic structure of the dengue virus (DENV-4). The black triangle shows the icosahedral asymmetric unit. E protein dimers are in blue. Three E proteins reside in one asymmetric unit. Scale bar = 100 Å (Kostyuchenko et al. 2014). Source: https://cdnsciencepub.com/doi/10.1139/cjm-2020-0572#core-ref58
Fig. Life cycle of Ades Mosquito
In Nepal, Dengue has been identified as one of the youngest emerging infectious diseases in Nepal. The first case of dengue was reported in 2004. In 2006, large number of probable cases and 32 laboratory confirmed cases were reported across hospitals in central and western Terai, as well as Kathmandu during the post monsoon season. Most cases were indigenous and confirmed the presence of all 4 serotypes in Nepal. From the years 2007 to 2009, sporadic clinical cases and outbreaks were recorded. Since 2010, dengue epidemics have continued to affect lowland districts as well as mid-hill areas. This trend for increased magnitude has since continued with number of outbreaks reported each year in many districts- Chitwan, Jhapa, Parsa (2012-2013), Jhapa, Chitwan (2015-2016), Rupandehi, Jhapa, Mahottari (2017), Kaski (2018) and Sunsari (2019). The number of dengue cases reported in Nepal from the period 2006-2018.
Prevention, clinical case management, surveillance, vector control and management and outbreak response are ongoing in Nepal, however there is a need to strengthen these especially at a time of national decentralization towards a federalized system. National dengue guidelines was first developed in Nepal in 2008 based on the World Health Organization (WHO) guidelines 1997 which was revised in 2011. This revised national guidelines on dengue prevention, management and control, 2019 aims to provide a technical ‘gold-standard’ advice on all aspects of dengue using the latest internationally adopted definitions, protocols and guidelines. It also provides simple, and easy to reference content, which can be printed and displayed on the walls of doctors rooms, wards or simply held in the hands of health workers who are spreading awareness on dengue within their local communities.
Aim of the guidelines
- To provide current and robust guidelines for each of the core areas of seasonal and epidemic dengue prevention, management and control in Nepal.
- Objectives
- To support dengue control and prevention activities.
- To provide pragmatic country-specific guidelines with reference to international gold
- standards.
- To provide guidance and new standards to all stakeholders.
- To provide country case studies for dengue prevention, management and control.
- To align and build collaboration between stakeholders.
- To provide a number of annexes that can be used as quick reference tools.
Case management of Dengue: Step by step approach
Step-1: Overall Assessment
A. History
- Date of onset of fever/illness
- Quantity of oral fluid intake
- Diarrhea
- Urine output (frequency, volume and time of last voiding)
- Assessment of warning signs
- Change in mental state/seizure/dizziness
- Other important relevant history, such as family or neighborhood dengue, travel to dengue-
- endemic areas, co-existing medical conditions.
B. Physical examination
- Assessment of mental state
- Assessment of hydration status
- Assessment of hemodynamic status
- Checking for quiet tachypnoea/acidotic breathing/pleural effusion
- Checking for abdominal tenderness/hepatomegaly/ascites
- Examination for rash and bleeding manifestations
- Tourniquet test (repeat if previously negative or if there is no bleeding manifestation).
C. Investigation
- CBC: A complete blood count should be done at the first visit (it may be normal), CBC should be repeated daily until the critical phase is over. Decreasing white blood cell and platelet counts make the diagnosis of dengue very likely.
- Hematocrit: The hematocrit in the early febrile phase could be used as the patient’s own baseline.
Step-2: Diagnosis, Assessment of Disease Phase and Severity
On the basis of evaluations of the overall assessment as described above, clinicians should
determine whether the disease is dengue, which phase it is in (febrile, critical or recovery),
whether there are warning signs, the hydration and hemodynamic state of the patient,
and whether the patient requires admission or not.
Step-3: Clinical Management
Disease notification
In dengue-endemic countries like Nepal, cases of suspected, probable/highly suggestive and confirmed dengue should be notified early so that appropriate public-health measures can be initiated. Laboratory confirmation is not necessary before notification, but if available should be reported. Notification of dengue is mandatory in Nepal. It is also a part of early warning and reporting system (EWARS) and should be reported accordingly.
Management decisions
Depending on the clinical manifestations and other circumstances, patients may either
- Be sent home (Group A)
- Be referred for in-hospital management (Group B) or
- Require emergency treatment and urgent referral (Group C)
Methods of Vector Control
Download
References:
1. Government of Nepal: Ministry of Health and Population. Department of Health Services-Epidemiology and Disease control Division. National Guidelines on Prevention,Management and Control of Dengue in Nepal. 2019. Available from http://www.edcd.gov.np/resource-detail/national-guidelines-of-prevention-control-and-management-of-dengue-in-nepal-2019-updated
Post comment