,

"National Guidelines
for

Clinical gement
of
Dengue Syndrome

aIara& YectorBorneUseases LontroI Lnt

Usease LontroIUrectorate
UrectorateGeneraIolHeaIth5ervces

nstryolHeaIth &amIyWeIlare
WorId HeaIthOrganzaton
BangIadesh
2000

Acknowledgement

?
First Edition, 2000

Government of Bangladesh
Printed in Dhaka
ISBN 984-31-1325-X

The Disease Control Directorate of Directorate General of Health Services is gratefully acknowledging the
contributions of SEARO of WHO and WHO Bangladesh, ICDDRB, Dr Siripen Kalayanarooj of Queen Siriket
Children Hospital of Bangkok, for the respective technical, consultancy and logistic supports including generous
permission for the use of the resource materials; Interists and Pediatricians (Professors / Associate Professors /
Assistant Professors) working in different medical colleges of Bangladesh who participated in the National
Workshop; and the Ministry of Health and Family Welfare of Government of Peoples Republic Bangladesh; in
the preparation and finalization of this document.
Copyright & Disclaiming
. The copyright of this document is of Disease Control Directorate of Directorate Gelleral of Health Services,
Ministry of Health Family Welfare of Government of Peoples Republic of Bangladesh. The views expressed
ill this document are esselltially of experts in the relevant jields alld endorsed by the goverment. This is a
public domain document, which can be freely reproduced and distributed only for the professional and
scientijic use with appropriate citation and acknowledgment. Any c011lmercial use is forbidden.

Chairperson
Professor A B M Ahsanullah
Director General of Health Services
Co-Chairperson
Professor Shah Monir Hossain
Director Medical Education & H(alth Manpower Development
Directorate General of Health Services

Editor
Dr Emran Bin Yunus
Associate Professor Nephrology & Officer on Special Duty
Directorate General of Health Services
Managing Editor
Dr Kanak Ranjan Talukdar
Director Disease Control, Directorate General of Health Services
Associate Editor
Dr Abdul Mannan Bangali
Deputy Program Manager Malaria & VBDC
Directorate General of Health Services
Assistant Editors
Dr M Ataul Huq Mahmood
Evaluator, Malaria &VBDC, Directorate General of Health Services
Dr M Mushfiqur Rahman
Evaluator, Malaria & VBDC, Directorate General of Health Services
Moderators
Professor M Tahir
Pro-Vice Chancellor, Bangabandhu Seikh Mujib Medical University, Dhaka
Professor Ferdous Ara J Janan
Head of Medicine, Dhaka Medical College, Dhaka
. Professor Tofayel Ahmed
Professor of Medicine, Dhaka Medical College, Dhaka
Professor C B Mahmud
Head of Pediatrics, Chittagong Medical College, Chittagong

1opcs
. 0 I. Foreword
02. Introduction

03. Manifestations of Dengue Infection

04. Case Definition for Clinical Management
05. Case Definition for Reporting
06. Severity grading of Dengue Syndrome
07. Disease course of Dengue Syndrome

08. Lab investigations for diagnosis

09. Treatment of Dengue Syndrome
09.1 Febrile phase therapy, monitoring & observation
09.2 Afebrile & Critical phase
10. Indication for hospitalization in Dengue Syndrome
II. Main objective of therapy in DHF
12. Critical Phase:. DHF I & II Therapy
13. DHF Grades I & II Volume replacement flow chart
14. Critical Phase: DHF III & IV Therapy
IS. DHF Grades III & IV Volume replacement flow chart
16. Special Clinical situations
17. Fluids required for intravenous therapy
18. Fluid Regimens in DHF: Ready reference
19. Some important instructions
20. Annex I Blood sample collection for
HI test from suspected Dengue Patient
21. Annex 2 Handout for patient with Dengue Fever
\
22. Annex 3 Indication & preparing patient or
family members for Possible blood requirement
23. Annex 4 DF/DHF Hospital Flow Sheets
24. Annex 5 Reference & Further reading
25. Annex 6 Workshop on 'Finalization of National Guidelines
for Clinical Management of Dengue & DHF
26. Annex 7 Dengue Reporting Form for practitioner
27. Annex 8 Dengue Reporting Form for Hospital/Clinic
28. Notes

^^
.

^^^^^

.
^

Iage
7
8
9
10
II
12
13
14
15
15
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16
17
19
21
23
24
25 .
26
27
30
31
32
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38

engue is fairly unfamiliar disease in Bangladesh till Outbreak 2000. There is no specific
treatment for dengue, but there is appropriate one being developed and on practice in
countries where dengue is endemic with frequent epidemic outbreaks. Over the last few
decades the scientific research and development have been successful in reducing the morbidity
and mortality otf dengue in those countries. Based on these experiences SEARO of WHO has
developed guidelines for the clinical management of dengue for resource-limited setups.
The unfamiliarity with dengue leads to ambiguity and controversy in the management amongst
the professional and confusion in the people. In such a situation, the Disease Control
Directorate of Directorate General of Health Services feels the necessity of developing
.
national guidelines for the clinical management of dengue by customizing the SEARO/WHO
guidelines according to the prevailing local situations.
+
The purpose of these guidelines is to provide a uniform, consensus, scientific, affordable and

appropriate clinical management approach for the professional taking care of dengue patients
on one hand and, diffusion of confusions and ambiguity related to dengue by the national
control program endeavors on the other hand.
Experts in fields of interal medicine and pediatrics of the country have taken the troubles of
finalizing these guidelines with the collaboration of expatriate resource persons having wide
clinical and research experience of good standing. ICDDRB and WHO have provided the
logistics and other supports to prepare these guidelines.
These guidelines, 'National Guidelines for Clinical Management of Dengue Syndrome' will fill
the vacuum at this stage in the field of management as well as part of control program at the
beginning when we have so little experience and evidence. It will be updated in due course
based on our own documentation, research and development over the time.
Dengue is now established as most wide spread mosquito borne viral febrile illness in human
and is no doubt has been emerging as a public health problem in Bangladesh. So we need to be
prepared to face this menace with a specific target of reducing the case fatality and morbidity.
These guidelines will be useful in this behalf.
Those who have involved in different capacities to finalize these guidelines and make it public
in such a short time deserve thanks and regards.
\
7
/
Professor A B M Ahsanullah
Director General of Health Services
Government of Peoples Republic of Bangladesh
Dhaka, 21 September 2000
7

hen a disease becomes a public health problem it attracts the attention of national health
agencies. The purpose is to control and prevent the disease in general and to reduce the
morbidity and mortality in particular. This is more so in case of communicable diseases. On
the other hand when a disease is unfamiliar for a particular community or a nation both the
profession and people become perplexed initially. In such a situation the intervention of the
national health agencies is more warranted. .
The Dengue Outbreak 2000 in many parts of Bangladesh has revealed these facts once again.
The Ministry of Health and Family Welfare of Bangladesh through its organ Disease Control
Directorate under the Directorate General of Health Services has come forward to control and
prevent the menace. In doing so it has been felt that a package of uniform, simple, affordable
and applicable guidelines for the clinical management of Dengue is necessary to orient the
health professionals in general and the practicing doctors in particular in shortest possible time.
Because dengue is a condition where there is no specific treatment, so one has to develop the
best appropriate methods.
Dengue has not been a public health problem in Bangladesh till recently so there is little
evidence and knowledge in this regard. Therefore to begin any endeavor, sharing of experience
from others becomes necessary. Based on the experience of dengue endemic countries WHO
has prepared many guidelines and monographs. These guidelines and monographs have been
adopted as baseline concept papers and source of information. Besides these, experience and
publications of Queen Siriket Children Hospital of Bangkok, which is a WHO collaborating
center for clinical management of dengue, has been consulted and used. The experts in the

respective fields of internal medicine and pediatrics of Bangladesh have examined and brain
stormed on these to customize them according to the local prevailing situation to formulate
uniform national guidelines for the clinical management of dengue as a step forward. The
outcome of all these efforts is the 'National Guidelines for Clinical Management of Dengue
Syndrome'. Subsequent gathering of evidence through research and development will logically
update these guidelines in appropriate manner.
These guidelines will provide the much needed knowledge, skill and attitude to the practicing
clinicians for proper management of dengue patients and reporting as well. A uniform
approach hy the clinicians in encountering dengue will help to remove the perplexing situation,
which has engulfed the profession and people alike.
All out efforts and endeavors have been made to make these guidelines as comprehensible as
possible and free of errors with encompassing the most relevant issues pertaining to the case
management of dengue. The editorial board welcomes evidence-based criticisms, suggestions,
comments and contribution to make these guidelines more appropriate in all respect and
regrets any inadvertent errors or omissions.
Editorial Board
Dhaka, 21 oCQ|CHDCi 2
8

There are four sero types of dengue vi rus, Den-I, Den-2, Den-3 and Den-4. Al l four
t ypes fol l owi n g i nfect i on pro
d
uce s i mi l ar man i fes t at i on s , wh i c h may be

- ... . - ,---
asymptomati c, undifferenti ated fever, dengue fever (DF), dengue hemorrhagic fever
(DHF) wi th pl as ma l eakage, that may l ead to hypovol umi c shock, dengue shock
syndrome (DSS). In i ni ti al period manifestations are si mi l ar and deteriorati ng from
one state to another.
nifestations of dengue virus infection

r-
-
- Undi fferenti ated Fever
,-Without hemorrhage
--Dengue Fever
'--- With Hemorrhage
No shock

'-
-
-Dengue Hemorrhagic Fever
L-Shock
engue Syndrome
The symptom,"! i c manifestati ons for al l practical purpose are overl appi ng i n nature
and not differe

n
-
ti
-
a'bre-
-
a- t
-
:
t
'
he
--
b e gi nni ng, some ti me appears progress i ng from one

category to another. So they are grouped i nto ' Dengue Syndrome'. Dengue syndrome

wil encompass the followi ng:

1. Dengue Fever (DF)

2. Dengue Hemorrh'gic Fever (DHF)

3. Dengue Shock Syndrome (DSS)
Purposes of Case definitions
There are two purposes for case defi ni ti on, whi ch are:
I . For cl i ni cal case management i n hospital setups and i n outpatient practice.
2. For reporti ng of the cases to desi gnated appropri ate health authority.

Dengue Fever
Dengue fever i s an acute febri l e i l l ness of 2-7 days durati on sometimes wi th two
peaks having the fol l owing manifestations:

Sudden onset conti nuous fever
.
2

And

Two or more of the fol l owi ng features:

a. Severe headache
b. Retro-orbital pai n
c. Severe myal gi a / arthral gi a / back pain
d. Hemorrhagic manifestations
e. Nausea/vomiting/abdomi nal pai n
f. Leucopeni a
And
High i ndex of suspicion based on Period, Popul ation & Pl ace
And

Absence of convi nci ng evi dence of any other febri l e i l l ness

Dengue Hemorhagic Fever

Dengue Hemorrhagic Fever i s a probabl e manifetation of dengue s ndrome wi th

hemorrhagic manifestations having the fo l owing eatures:

Features of dengue fever at i nitial stage
And
Hemorrhagic manifestations evidenced through one or more of the fol l owi ng:
I,a. Positive tourniquet test
_ b. Petechi ae / ecchymosi s / purpura
. Mucosal bl eedi ng: Epi staxi s, gum bl eeding
/
d. Bleedi ng from i njection or other si te
I
e. Hematemesi s, mel ena, hematuri a, PV bl eeding
I
f. Thrombocytopeni a wi th pl atelets 100,000 /mm3 or l ess

And

.
Any evi dence of pl asma l eakage due to i ncreased c api l l ary permeabi l i ty
manifested by one or more of the fol l owing:
a. A 20% rise i n hematocrit for age or sex '
b. A 20% drop i n hematocrit fol lowing treatment with fluids as compared to
base l i ne
c . Pl eural effusion / ascitis / hypoproteinemi a
The cut-off point between Dengue Fevfr and Dengue Hemorrhagic Fever is the evidence of
plasma leakage, which will not be present in the former but invariably in the later. This is
important in differentiating DF with hemorrhage from DHF.

10

Tourniquet Test
This is a very important clinical test for detecting covert hemorrhage. is performed by
inflating a blood pressure cuff to a point midway between the systolic and diastolic pressures
for five minutes. test is considered positive when 1 or more petechiae per 2.) cm1 are
observed. In DHF, the test usually gives a definitive positive result ie 7 1 petechiae. The test
may be negative or mildly positive during the phase of profound shock.
Dengue Shock Syndrome
Dengue Shock Syndrome i s a presentation of Dengue Syndrome when a case of DHF
mani fests ci rcul atory fai l ure wi th one
'
or
i
ore of the fol l owing features :

.
Hypotensi on for age
Col d cl ammy skin, restl essness, rapi d weak pul se
Narrow pul se pressure (20 mm of Hg)
Profound shock
Dengue i s a notifi abl e di sease. For the purpose of the notifi cati on to appropri ate
health authority the case defi nitions are as fol l ows:
+
1 . 5usgected: Cl i nical l y di agnosed as per ' Cl i ni cal Case defi nition' .

2. Probable: When i n addi ti on to cl i ni cal di agnosi s any serol ogical or rapi d

. w

tesS i s found to be positive.

3. Lqnlrmed:When the case i s confi rmed by virus i sol ati on.
When reporti ng the ' reporting case definiti on' term wi l l be added as a prefix ' !le
'cl i n i cal caSe defini ti on' term of dengue syndrome categori zed as per nati onal
gui del i nes.
A

Example
case is found to be Deng/le Fever as per clinical case definition. For reporting purpose
this will be labeled as 'Suspected Dengue Fever'. If any serological test is found positive this
case will be 'Probable Dengue Fever' and so on .

11

Syndromes Grades
DF
DHF I
DHF II
,
DHF (DSS) III

DHF (DSS) IV
Clinical features
Features of DF as per case definition
Features / History of features of DF

Positive Tourniquet Test

,
Features / History of features of DF

Spataneous bleeding
Features / History of features of DF

Features of circulatory fai lure

Features / History of features of DF

Profound shock

Laboratory features
Leucopenia
Thrombocytopenia
No change i n hematocrit
Thrombocytopenia

S 1 00,000 /mm3
Hematocrit rise : 20%
Thrombocytopenia
_ * 1 00,000/mm
Hematocrit rise: 20%
Thrombocytopenia
* 1 00,000/mm3
Hematocrit rise : 20%

Thrombocytopenia
* 100,000 Imm3
Hematocrit rise : 20%

DHF Grades III & IV are also called Dengue Shock Syndrome (DSS) .
At the i ni ti al phase one cannot di fferenti ate DF and DHF.
The course i s a continuum passi ng from one grade to another.
The transition period is at the afebril e phase
If appropri ate treatment is not i nstituted i n proper time there i s a risk of dean! in
DHF-II, DHF-III and DHF-IY.

12
The disease course i n dengue syndrome has the fol lowi ng characteristics:
I . Ihases: There are two phases from the begi nni ng.
a. Febrile phase: Which lsts from 2-7 days durati on. Various categories of
presentation cannot be differentiated at this stage.
b. Afebrile/Critical phase: This phase fol l ows the febri l e phase and l asts for
2-3 days. The pati ent i s afebri l e. In DF cases this phase may be cal l ed
afebri l e phase and usual l y marks the begi nni ng of conval escence. But i n
DHF cases at this stage al l critical features begi n and i s called the critical
phase.

2. Irogress on: The natural course of progressi on of dengue syndrome i s a

conti nuum, uphi l l , stati onary or downhi l l mostl y not di sti ngui shabl e at the
i nitial stage. It has to be remembered that DHF per see begins as DHF and
not converting from or a complication of DF but indistinguishable from DF
at the beginning.

If appropriate treatment is not provided then there is high risk of death.

13

1heuseluIIabnvestgatonsareasloIIows:
1 . Compl ete Bl ood Count (CBC) i ncl udi ng Total Leucocyte Count, Total
Pl atel et Count and Hematocrit
2. Chest X-Ray right l ateral decubitus view or Ultrasonography (for pl eural
effusi on or ascitis)
3. Other routine tests as i ndi cated eg MP for excl udi ng mal aria i n mal aria
endemic zone
4. Other tests as and when necessary eg Serum Albumi n, Li ver function tests,
Serum el ectrol ytes
1meandlrequencyoldongnvestgatons:
Usual l y before 3 days no hange i n the l ab tests i s expected i n febri l e phase. So no
tests shoul d be done before 3 days i f not otherwi se i ndicated eg unusual hemorrhage.
But once clinically suspected leucocyte and platelet counts plus hematocnt level

should be done at least once per day.

Tests for objective evidence of dengue infection is not helpful for guiding the
management. Moreover doing this at initial period will usually give negative result
there by provides a false sense of securit to the patients and doctors.
Leucocyte count has a very important prognostic guide in early phase of
dengue infection. Leucopenia < 5000 cells/mm. indicates that within the next
.
24 hours the patient will have no fever and he will be entering the critical
phase.
-.
Serial Leucocyte Count, Hematocrit level and Platelet Count are very
important for prognostic purpose .

14

Febrie Phase: Therapy

DF and DHF are not distinguishable in febrile phase and treatment is essentially same. The
modality of treatment is symptomatic and supportive. These are:

Rest

Antipyretic therapy for fever above 39 C.

a. Sponging: With tepid water at room temperature.

b. Paracetamol (not more than 4 times in 24 hours) according to age
A e Dose 500 m tablet Mg ose
* 1 Year 1 /8 tablet 62.5
1- 4 Years 1 /4 tablet 62.5 - 125
.
;:5 Years 112 tablet 250
Do not give Aspirin or any other NSAID. These drugs may cause gastritis and or bleeding.
In children, Reye's syndrome may be a serious complication.
Do not give antibiotics as these do not help.
Oral Rehydration Therapy (ORT) with Oral Rehydration Salt (ORS) or its equivalentl is
recommended for patients with moderate dehydration caused by vomiting and high
temperature .
.

Food should be given according to appetite. But fresh fruit juice should be given frequently.
Avoid commercially available fruit juices because these preservatives.
In case of infant and children if there is febrile convulsion and or history of so appropriate
standard measures should be taken.
Febrile Phase: Monitoring & Observation
Al dengue patients must be carefully observed for complications for at least 2 days after recovery
from fever. This is because life-threatening conditions often occur during this phase. Patients and
households should be informed that severe abdominal pain, passage of black stools, bleeding into
the skin or from the nose or gums, sweating, and cold skin are dangerous signs. If any of these signs
is noticed, the patient should be taken into the hospital. The patient who does not have any evidence
of complications and who has been afebrile for 2-3 days does not need further observation.
Patient and household members should be informed by the doctor that abdominal pain,
passage of black stools, any bleeding including undue PV bleeding, sweating and cold skin
are dangerous signs, and if any sign(s) is noticed, the patient should be taken to hospital
immediately.
.
'1Kequivalent: Home made ORS .

Dt children, with signs of some dehydration, ORS, which i s commonl y used i n the treatment of di arrheal
diseases and or fresh fruit juices, are preferable. lnitially 50 mllkg body weight t1uids should be given during the
first 4-6 hours. After correction of dehydration, the child should be given maintenance tluids orally at the rate of
80- 1 00 mllkg body weight i n the next 24 hours. Children who are breastfed should continue to be breastfed i n
addition to ORS administration. In adults, oral t1uid intake of 2.5-4 l i ters should be given per day.
15 .

Afebrile Phase: Dengue Fever

Constitutional symptoms i n patients wi th DF after the fall of fever are si mi l ar during
the febri l e phase. Most patients wi l l recover wi thout compl i cation. The fol l owi ng
manifestations may present:

Improvement i n general condition

Pl atel et/Hematocri t normal

Appetite rapi dl y regained

Management i s more or l ess same, i e cont i nue bed rest, check pl at el et and
hematocrit; frui t juices, oral flui d and el ectrolytes therapy.
Convalescent Phase: Dengue Fever
The durati on of convalescence phase is 7-10 days after the afebri l e phase. Duri ng this
phas'e further i mprovement i n general condi ti on and return of appeti te occur.
Bradycardi a and confl uent petechi al rash wi th whi te center and or i tchi ng may
persi st. Weakness may remai n up to another week or two. No speci al advi ce i s
necessary. No restr icti on i s al so needed. Normal di et and effort for adj usti ng to
normal l i fe style and work are what is necessary.
Critical Phase: DHF
Duri ng the afebri l e phase usual l y the features of DHF evol ve, whi ch are various
bl e e di ng ma ni festati ons, si gns of ci rculatory fai l ure and, progressi ve
t hrombocytope ni a and pl asma l eakage as mani fested by ri se i n hematocri t .
Dependi ng on t he gradi ng of severi ty the management shoul d be i nsti tuted
i mmediately to avoid fatal i ty. Therefore this peri od i s very cruciaL Moreover the onl y
difference between DF and DHF Grade I is the presence of thrombocytopeni a and
rise i n hematocrit 20%.

DF cases wi th any one or al l of the fol l owi ng condi ti ons: mon i tori ng and
observation cannot be ensured, with hi gh risk associ ated i l l ness, nutri tion and
therapy cannot be maintai ned, and i n speci al situations. Otherwise there i s no .'
i ndication for hospital i zati on for DF cases.

DHF Grades II, III & IV.

DHF Grade I where nutrition and oral flui d el ectrolytes therapy, monitoring and
observati on cannot be ensured, and or presence of concomi tant i l l ness or i n
special situations eg Di abetes, IHD, Pregnancy, etc.

Mai ntenance of fl ui d and el ectrolytes

Mai ntenance of bl ood osmol arity i n face of pl asma leakage

Mai ntenance of circul atory volume and hemodynamic status

Maintenance of nutrition

Prevention of compl ications

16
Duri ng the afebri l e phase of DHF Grades I & II, the patient has the same symptoms
as dur i ng t he febri l e phase . The c l i n i cal si gns pl us t hrombocyt openi a and
hemoconcentration or rise i n hematocrit are sufficient to establ i sh a cl i ni cal diagnosis
of DHF. During this phase, the patient shoul d be observed for at l east 2-3 days after
the fal l i n temperature, for rashes on the ski n, bl eeding from nose or gums, bl ue spots
on the skin or tarry stool s. If any of these signs are observed, the pati ents should be
brought to the hospital without del ay.
LrtcaIIhase
Duration 2-3 days

LonvaIescenceIhase
Duration 2-3 days

UU Grades & 1herapy Lhart

Nanlestatons
- Features of DF
- Positive Tourniquet Test
-Spontaneous bleeding
-Thrombocytopenia
100,000 /mm'
- Hematocrit risc 200

Nanlestatons

- Further i mprovement i n
general condition and
return of appetite
- Bradycardi a
- Confluent petechial
rash with white center/itching
- Asthenia and
depression even
persisting for few
weeks, common i n adults

Nanagement
- OPD or Hospital
- ORS
- Check Platelet / Hematocrit, if
Hematocrit 20%
- Initiate IV therapy 5% DNS 6
ml/Kg/hr for 6 hours
Check hematocrit / vital signs /
urine output after 3 hours, and in
case of i mprovement'
- Reduce IV therapy to 3 ml lkg/hour
for 3 hours
- In case of further i mprovement,
continue [V therapy at 3
ml/kg/hour for 6- 12 hours and then
discontinue IV therapy
- [n case of no i mprovement',
i ncrease IV therapy to 10
mllkg/hour for hour. In case of
improvement now, reduce the
volume of [V from 10 mllkg/hour to
6 m IIkg/hour and further to 3
ml lkg/hour accordi ngly .
- Generally, DHF Grades H do
not give compl ications
Nanagement
- Normal diet
- No need for any medication

` Improvement: Hematocrit fal l s, pul se rate and blood pressure stable, urine output rises
No improvement: Hematocrit or pul se ratf rise, pulse pressure 2 mm of Hg, uri ne output fal l s
17

The only di fference bet ween t he DF and DHF Grade I i s th e pr esence of

thrombocytopeni a and rise i n hematocrit (>20%). Patients with DHF Grade I do not
usual l y require i ntravenous fl ui d therapy and ORT i s sufficient. Intravenous fl ui d

therapy may need to be admi nistered onl y when the patient i s vomiting persistently
or severel y, or refusi ng to accept oral fluids. Patients wi th DHF Gradel who l i ve far
away from the hospital or those who are not l i kel y to be able to fol l ow the medical
advice should be kept i n the hospital for observati on.
During the afebri l e phase of DHF Grade II, the compl icati ons usual l y seen, i n
addi ti on to those observed during DHF Grade I phase, are abdomi nal pai n, bl ack
tarry stool s, epi staxi s, bl eedi ng from the gum, and conti nued bl eedi ng from the
i njection sites. Immediately after hospi tal i zation, hematocrit and pl atelet count must

be carried out to assess the condition of the patient. A reducti on i n pl atel et count to
1 00,000/mm3 or l ess than 1 -2 pl atel ets/oi l fi el d (average of IO oi l fi el d counts)
usua]]y precedes a ri se i n hematocri t. A ri se i n hematocri t of 20% or more (eg
i ncrease from 35% to 45%) reflects a significant pl asma loss and i ndicates the need
.
for i ntravenous fl ui d therapy. Early vol ume repl acement of l ost pl asma wi th
crystalloi ds solution (eg i sotoni c sal i ne sol ution) can reduce the severity of the
di sease and prevent shock. Intravenous fluid therapy before leakage is not
recommended. But i n DHF Grade II dependi ng on the condi ti on IV therapy may
given for 1 2-24 hours. Medical personnel should moni tor patients on hourl y basis.
Based on peri odi c hematocrit/pl atel et count determi nati ons and vi tal si gns, the
treatment shoul d be reviewed and revised.

LrystaIIod5oIutons:
1 . 5% dextrose i n isotonic normal sal i ne solution (5% DNS)
2. 5% dextrose i n hal f-strength normal sali ne solution (5% D/ l /2INS)
3. 5% dextrose i n l actated Ringer's solution (5%D/RL)
4. 5% dextrose i n acetated Ringer's solution (5%DIRA)

18

Reduce 3mVkglh
Crystalloid duration
6-12 hrs

Discontinue IV
after 24 hrs

|nIII8I0|V100f8y6mgl0f
fy8I8II0d 80IuII0nl0f1-Z0f8

Increase 10 mVkglh

Reduce IV to
6mVkglh
crystalloid with
further reduction
to 3 mVkglh
dicontinue after
24-48 hrs
crystalloid duration 2 hrs
IV Colloid (Dextran
(40) 10mVkglhr
duratio 1 hr.
Blood transfusion
10mllkg/hr
duration 1 hr.
IV therapy by crystalloid Successively
reduce the flow from 10 to 6,6 to
3m1kglhr Discontinue after 24-48 hrs

Improvement: Hematocrit falls. pulse rate and blood pressure stable, urine output rises
. No improvement: Hematocrit/pulse rate ri ses, pulse pressure falls below 20 mm Hg, urine output falls
Unstable vital signs: Signs of shock, urine output falls

When hematocrit cannot be done or is not available the following clinical tips may help:

If the patient has/ had deep/massive bleeding form gut or other sites the possibility is
that the patient may have lower hematocrit because of blood loss.

If the patient has/had surface/mild bleeding the possibility is that the patient may have
higher hematocrit . .

Sudden unexplained deterioration of hemodynamic status and or refractory to

adequate fluid therapy the possibility is more of blood loss and hence low hematocrit
level.
19

Common signs of compl ications observed during the afebri l e phase of DHF Grade III
i ncl ude ci rcul atory fai l ure mani fested by rapi d and weak pul se, narrowi ng of the
pul se pressure and hypotensi on, characterized by hi gh di astol ic pressure relative to
systol i c pressure (eg 90/80 mm of Hg) and the presence of col d cl ammy ski n and
restl essness. These compl i cations occur because of thrombocytopen i a, abnormal
hemostasi s and pl asma l eakage, or al so from substantial bl ood l oss. Immedi atel y
after hospi tal i zat i on, the hematocri t, pl atel et count and v i tal si gns shoul d be
exami ned to assess condition of the patient, and i ntravenous fl ui d therapy shoul d be
started. The pati ent requi res- regul ar and sustai ned monitori ng. If the pati ent has
al ready received about 1 000 ml of i ntravenous fl ui ds and the vi tal signs are sti l l not
stabl e, hematocri t shoul d be repeated and: ( a) i f the hematocri t i s i ncreasi ng
i ntravenous fl ui d shoul d be changed to col l oi dal sol ution preferabl y Dextran, or (b) if
hematocrit i s decreasi ng, fresh whol e bl ood transfusion 1 0 ml lkg/dose shoul d be

given.

Duri ng the afebri l e phase of DHF Grade IV vital signs are unstabl e. The patient, i n
the earl y stage of shock, has acute abdomi nal pai n, restlessness, col d and cl ammy
ski n, rapi d and weak pul se. The pati ent shoul d be admi nistered i ntravenous fl ui d
therapy i mmediately. In case of continued or profound shock when pul se and bl ood
pressure are undetectabl e, the patient shoul d be gi ven col l oi dal flui d fol l owi ng the
i niti al fl ui d bolus.
However, i n the case of persistent shock when, after i ni tial fl ui d repl acement and
resuscitati on wi th pl asma expanders, the hematocrit conti nues to decl i ne, i nteral
bl eedi ng shoul d be suspected. It may be difficul t to recognize and estimate the degree
of i nternal bl ood l oss i n the presence of hemoconcentrati on. It i s thus recommended
to gi ve fresh whol e bl ood i n smal l volumes of 1 0 ml/kg body wei ght at one time.
Bl ood groupi ng and matchi ng shoul d be done for al l patients i n shock as a ronti ne
precauti on. Oxygen shoul d be gi ven to al l patients i n shock .

20

LrtcaIIhase
Duration two days
after febri le stage

UH Grades& YheraLhart

Nanlestatons
Nanaeent
In addition to the manifestations
of DHF Grade II
- Circulatory fai lure
manifested by rapid and
weak pul se, narrowing of
pulse pressure (20 mmHg or
less) or hypotension with
the presence of cold
clammy skin and restlessness
- Capillary refi l l time" more
than two seconds
Profound shock with
undetectable pulse and blood
+
pressure

- Mandatory i n Hospital
Check hematocrit/pl atelet
- Initiate IV therapy 5% DNS 10
mllkg/hour
- Check hematocrit, vital signs, urine
output every hours
- If patient i mproves. IV fluids should be
reduced every hour from 10 to 6, and
from 6 to 3 mllkg/hour which can be
maintained up to 24 to 48 hours.
- If patient has already received one hour
treatment of 20 mllkg/hour of IV fluids
and vital signs are not stable, check
hematocrit again and
If hematocrit is increasing change IV
flui d to colloidal solution preferably
Dextran or Plasma at 10 mllkg/hour
- If hematocrit is decreasing from the
i nitial value, gi ve fresh whole blood
transfusion, 10 ml /kg/hour and continue
lluid therapy at 10 ml lkg/hour and
reducing i t stepwise bring down to 3
ml/kg/hour and maintain it up to 24-4! hours
- Initiate IV therapy 5% DNS 20 ml/kg
as a bol us one or two ti mes
- Oxygen therapy should be given to
al l patients'
- In case of continued shock, colloidal
nuids (Dextran or Plasma) should be
given at 10-20 ml lkg/hour
- If shock sti l l persists and hematocrit
level continues decl i ni ng, give fresh
whole blood 10 ml /kg as a bol us
- Vi tal signs should be monitored
every 30-60 mi nutes
- In case of severe bleeding, give fresh
whole blood 20 ml /kg as a bolus
- Gi ve platelet rich plasma transfusion
exceptional l y whn platelet counts are
below 5,000- 1 O,OOO/mlw'
- After blood transfusion, continue
fluid therapy at 10 mllkg/hour
and reduce it stepwise to bring it
down to 3 ml lkg/hour and
maintain it for 24-48 hours.
Capil lary Refi l l Time: It can be measured by pressing the nail of the thumb of left hand i n right handed person
or vice versa ti l l blanching then suddenly release the pressure. The time taken for flushing is the capi l l ary refi l l
t i me.
Oxygen i s obligatory until shock has been overcome. Pulse, blood pressure, and temperature should be recorded
every IS 30 minutes.
21

UHGrades 1 & Y1herapyLhart

Lrta hase Nanestatns Nana ement
=-==
Duration 2-3 days after
recovery from critical
phase

- 6- 12 hours after
critical/shock stage, some
symptoms of respiratory
di stress (pleural effusion
or ascitis)
- 2-3 days after critical
stage, strong pul se, normal
blood pressure
- Improved general
condition/returl1 of
appetite
.
- Good urine output
- Stable hematocrit
- Platelet count
>50,OOO/mm'
- Patient could be
discharged from hospital
2-3 days after critical stage
- Bradycardia/arrhythmi a
- Asthenia and depression
(few weeks) i n adults

22
- Rest for 1-2 days
- Nonal diet
- No need for medication

VlTL5lUN5
UrInoOulpul rlB
5lgnB of5lock
Immediate, rapid volume replacement. litiate IV therapy
10-20 ml/kg/h Crystalloid solution 1-2 hour
IV Therapy by crystalloid
successively reducing from 20

to 10, 10 to , and to 3ml/kg/hr

Discontinue intravenous
therapy after 24-48 hrs

I
IV Colloid (Dextran 40)
or plasma 1OmVkg/hr as
intravenous bolus
(repeat if necessary)
Oxygen
Blood transfusion
(10 ml/kg/hr) if
is
still >35%
IV therapy by crystalloid,
successively reducing the flow
from 10 to , to 3ml/kg/hr
Discontinue ofter 24-48 hrs

In case of acidosis, hyperosmolar or Ringer's lactate solution should not be used.

23

DF and DHF may develop i n a pati ent wi th some other cl i nical situations besides
l eadi ng to others. Some common situations are as fol l ows:

I . Pregnancy and l abor

2. Emergency surgical condition eg Acute appendicitis
3.
.
Associated medical conditions eg Di abetes mel l itus, Myocardial infarcti on
.
.
4. Condi ti ons where pati ents are on mai ntenance therapi es wh i ch are
contraindicated for DFIDHF eg Nephrotic syndrome case on high dose of
steroi d
5. Pati ent i s on some procedure which may be compl icated by DFIDHF eg
Mai ntenance hemodial ysis where heparin is used to i ncrease cl otting time.
6. Hypersensi tivity or anaphyl axis due to fl uid therapy i n DFIDHF
General rule
In such situation the general rul e of risk versus gain shoul d be fol l owed. Which are:
1 . If avoidabl e, concomitant therapy which is contrai ndicated i n dengue and
or may create compl i cat i on shoul d be deferred or be avoi ded eg
maintenance hemodial ysis
2. In case of pregnancy and l abor al l pati ents shoul d be hospi tal i zed and
careful l y monitored. If possi bl e l abor shoul d be avoi ded duri ng critical
phase. Other wise if not possi bl e then al l possi bl e precaution shoul d be
taken to perform the obstetric procedure.
3. In case of emergency surgical condition conservative management shoul d
be adopted and surgery shoul d be avoided i f possi bl e ti l l the patient attai ns
conval escence phase. But i f the acute surgical condition i s more risky than
the DFIDHF then after taki ng adequate precaution l i fe savi ng procedure
may have to be adopted.
4. Concomitant medical condition i f demanding enough to save l i fe than the
management shoul d be continued.
5. If a pati ent i s on mai ntenance therapy ' wi th hi gh dose steroi d then thi s
shoul d be continued.
6. In al l such compl i cated si tuati ons a team approach compri si ng rel evant
speci al i sts shoul d be adopted.
7. Hypersensitivity and anaphyl axis during fl ui d therapy shoul d be dealt wi th
as per standard procedure.
In any complicated situation frequent consultations with other colleagues
and multi disciplinary team approach are warranted.
24

Flu; s Recommended
stalloids
1 . 5% dextrose i n i sotoni c normal sal i ne solution (5%DNS)
2. 5% dextrose i n half strength normal sal i ne solution (5%D/ l /2/NS)
3. 5% dextrose i n lactated Ringer' s solution (5%DRL)
5% dextrose i n acetated Ri nger' s solution (5%DRA)
olloids
1 . Dextran 40
2. Hemacel
3. Pl asma
Precautions

In order to ens ure adequate fl ui d repl acement and avoi d over-fl ui d i nfus i on, the rate of
i ntravenous flui d shoul d be adjusted through out the 24 to 48 hour period of pl asma leakage by
periodic hematocrit detenni nations and frequent assessment of vital si gns. The volume offluid
replacemellt should be just sufficient to maintain effective circulation durillg the period of .
plasma leakage. Excessive flui d replacement and conti nuation for a longer period after cessation
of leakage wi l l cause respi ratory di stress from massi ve pleural effusi on, asci ti s, and pul monary
congestion or edema. Thi s can be dangerous.
Fluid Requirement Calculation: Ready Reference
The requi red regimen of flui d shoul d be calcul ated on the basi s of body weight and charted on a 1 -
'
3 hourly basi s or even more frequently i n the case of shock. The regimen of flow of fl ui d and the
time of infusion are dependent on the severity of DHF. The schedule gi ven here i s recommended as
a gui del i ne. It i s calcul ated for moderate dehydration of about 6% deficit pl us mai ntenance.
ml/lb
.
Weight on admi ssion ml/kg
Body wei ght/day I bs kgs Body weight/day
1 00 <1 5 <7 220

75 1 6-25 7 - I I 1 65
60 25-40 1 2- 1 8 1 30

40 >40 > 1 8 90
In ol der chi l dren who wei gh more than 40 kgs, the vol ume needed for 24 hours shoul d be
cal cul ated as twi ce that requi red for mai ntenance (usi ng Hol l i day and Segar formu l a) . The
mai ntenance fl ui d shoul d be calcul ated as fol l ows:
Body weight (kgs)
+
Maintenance volume (ml )
Admi ni stered over 24 hours
<1 0 1 00/kg
+
1 0-20 1 000+50 for each kc i n excess of 1
>20

1 500+20 for each kg i n excess of 20

Example: For a chi l d wei ghi ng 40 kgs the maintenance i s:
that the chi I d requires 3800 ml IV flui d during 24 hours.
1 500+(20x20)= 1 900 ml . Thi s means
.

25

Fluid Regimens in DHF: Ready Reference

For i ntravenous flui d therapy of patients with DHF, four regimens of flow of fl ui d are
suggested: 3 mllkg/hour, 6 ml lkg/hour, 1 0 mllkg/hour and, 20 ml/kg/hour .

. Body weight Volume of fluid Rate of fluid (mllhour) Regimens (R)

(in kg) to be given in 24 R-l R-2 R-3 R-4
.
hours 3m llglhour 6mllglhour lOmllglour 20mllglhour
1 0
1 5
20
25
30
35
40
45
50
55
60

1 500 30 60 1 00 200
2000 45 60 1 50 300
2500 60 90 200
.
400
2800 75 1 20 250 500
3200 90 1 50 300 600
3500 1 05 1 80 350 700
3800 1 20 2 1 0 400 800
4000 1 35 240 450 900
4200 1 50 270 500 1 000
4400 1 65 300 550 1 1 00

4600 1 80
.
360 600 1 200

The t1ui d mentioned i s approxi mation .

Normally change should not be drastic. Do not jump from R- l to R-4 since thi s can
overload the patient with t1uids. Si mi larly, reduce the volume of flui d from R-4 to
R-3, R-3 te R-2, and from R-2 to R- l i n a stepwise manner.

REMEMBER that ONE ml is equal to 1b drops in standard MACRO infusion

set. In MICRO system (Micro burette infusion set) b drops are equal to 1 mI.

It i s advised to procure onl y a bag of 500 ml i nitially, and order more as and when
required: The deci si on about the speed of t1ui d should be reviewed every l - 3 hour.
The frequency of moni toring should be determi ned on the basi s of the condi t i on of
the patient. The hi gher the t10w rate the more frequent should be the moni tori ng .

26

Check lst

Cases of DHF should be observed every hour.

Seri al pl atelet and hematocri t determi nati ons for drop i n pl atel ets and ri se i n
hematocrit are essential for early diagnosi s of DHF.
Timely i ntravenous thera
p
y - isotonic crystal loid solution - can prevent shock and or
lessen the severi ty.
If pati ent ' s condi t i on becomes worse despi te gi vi ng 20 ml lkg/hour, repl ace
crystall oid sol ution with col l oi d solution such as Dextran or pl asma. As soon as
i mprovement occurs replace with crystal loid.
If i mprovement occurs, reduce the speed from 20 ml to 1 0 ml , then 6 ml , and fi nall y
to
3
mllkg.
If hematocrit fal l s, give bl ood transfusion 1 0 mllkg and then gi ve crystal l oi d IV
fluids at the rate of 10 ml lkg/hour.
I n case of severe bleeding, give bl ood transfusi on about 20 mllkg for two hours.
Then give crystal loid at 1 0 mllkg/hour for a short time (
3
0-60 mi nutes) and l ater
reduce the speed.
In case of shock, give oxygen.
For correction of acidosis (sign: deep breathing), use sodium bicarbonate .
Check for any concomi tant other medi cal or surgi cal condi t i on and or any
mai ntenance therapy.
Don'ts

Do not gi ve aspirin or NSAID for the treatment of fever.

Avoid giving i ntravenous therapy before there i s evi dence of hemorrhage or bleeding.

Avoid giving blood transfusion unless i ndicated, reduction i n hematocrit or severe bleeding.

Avoid giving steroid.

Do not use antibiotics.

Do not change the speed of fluid rapi dl y, i e, avoid rapidly i ncreasing or rapi dl y
sl owing the speed of fluids.

Insertion of nasogastric tube to determine concealed bleeding or to stop bl eedi ng (by

cold l avage) i s not recommended si nce it i s hazardous.

What should not be done is as important as what should be done.

What should be done should not be over done.

Please note that DF and DHF are self-limiting conditions, so one has to provide just
therapeutic and other supportive care to prevent complications.
` In case of acidosis, one-third of the total t1uids should consist of 0. 1 67 mmolll of sodi um bicarbonate.
Avai lable Sodibi carb solution i n Bangladesh i s of the strength 7. 5% i e 1 ml contains 2 mmol/ml . So 85
ml of Sodi bicarb i s to be added to make upto one l i ter of IV fluid of crystalloid and gl ucose.
27

Signs of Recovery

Stable pul se, bl ood pressure and breathi ng rate

Normal temperature
No evidence of external or i nteral bleedi ng
Retur of appetite
Good urinary output
Stable hematocrit
Convalescent stabl e petechial [ash
Criteria for Discharging Patients

Absence of fever for at least 24 hours without the use of anti-fever therapy
Return of appetite
Vi si bl e cl i ni cal improvement
Good uri ne outpu t

Mi ni mum three days after recovery from shock

No respiratory distress from pl eural effusion and no asci tis
Platelet count of more than 50,OOO/mm'
Reporting
Based on case-defi ni ti ons, al I suspected, probable and confirmed cases of DF/DHF shoul d be reported
to the Ci vi l Surgeon of the di strict. For this purpose appropriate report form shoul d be used. In Annex
J and 8 two report forms are provided, one for practitioner another for hospital/cl i ni c. Appropriate one
as the case may be shoul d be photocopied and used. Ci vi l Surgeon after compi l i ng the reports wi l l
send i t to DC regul arly and as and when necessary as per directives. CS wi l l also take other relevant
measures as wel l .
Good Clinical Practice for IV Therapy

Al ways col l ect and check necessary appl iances before proceedi ng to IV puncture.
Use gl oves to protect yoursel f and mask to protect the pati ent. Wash hands wi th antiseptic
before handl i ng cannul a/needl e. Al ways use di sposabl e items. Be careful about needl e stick

II1Jury .
For IV choose a vein at a si te having the fol l owi ng criteria: Distal , rel ativel y less mobi l e and
i nacti ve, away from joi nt wi th overl yi ng heal thy ski n and after shavi ng hai rs. If necessary
immobi l i ze the part wi th sprint. Keep proximlll si tes reserve for future puncture i f necessary.
Preferably use cannul a having wider bore ( 1 8G" or wider), which may al l ow high flow rate ,Ind
bl ood transfusion i f necessity arises for avoi di ng further puncture. Properly fix the cannul a wi th
adhesive tape. Put date and time of infusion/transfusion begi nni ng on bag and on adhesive tape.
Insert the cannul a or needl e al ong the lengths of vein appropriately to avoid extravasation and
check the si te frequentl y for i t. Avoid mul ti pl e punctures.
G or Gauze: Part of an i nch, a uni t of measurement. 18 G means 1 8th part of an i nch. The bigger the number the
smaller the bore and vice versa.
28

Don' t keep the cannul a/needle i n a same si te for more than 48 hours to avoid phl ebi ti s.
If extravasation occurs immediately remove the cannula/needle and keep the part elevated.

Al ways check the llui d bag for deposits, puncture, leaki ng, proper seal s i n the port, di rt and
labels. In such cases discard the bag. Si mi l arly check the i nfusion/transfusion sets and cannul a.
Never reuse any di sposables and remai ni ng tluiti i n bag.
For hi gh flow rate never use cold flui d to avoid chi l l s and di scomfort. Warm the tluid =l to
body temperature by pl aci ng on the cover of the steri l i zer and not immersi ng i n that.
Al ways dispose the disposables and sharps i n a bi n to be managed properly.
Hang the fl ui d bag at appropriate height and check for kinks i n the l ine to al low proper flui d
flow .

29

Annex 1
Blood Sample Collection for HI test from suspected Dengue
patients
I . In the acute stage: 0-5 days after onset, volume 0. 5 - 1 . 0 ml (Serum specimen S 1 ) .
2. Shortly before discharge from hospital : 6- 1 days after onset (Serum specimen S2).
3. If possible, 1 4-2 1 days after the onset of disease (Serum specimen S3).

The serum s houl d be separated from the red bl ood cel l s and stored frozen bdore
exami nati on. If refri geration i s not possi bl e for keepi ng bl ood sampl es, Whatman No
3 fi l ter paper di scs 1 2. 7 mm ( 1 /2 i nch) i n di ameter may be used. Col lect the bl ood on
the fi lter paper and ful l y saturate i t through to the reverse si de. Al l ow the filter paper
to dry i n pl ace that i s protected from di rect sunl i ght and i nsects. Pl ace the dried stri ps
, i n pl astic bags and stapl e them to the l aboratory exami nati on request form. Store
wi thout refri gerati on.
Al l col l ected sampl es shoul d be adequatel y l abel ed wi th name of the patient, their
i dentification number and date of collecti on.

Laboratory Investigation form for Dengue Infection

, Hospi tal / Cl i ni c / Practice: Registration no:

Name of the pati ent Age: Sex: _--

Date of admi ssion/consultation : Date of onset
Suspected di agnosi s:

LIncaIlndngs:
1 . Fever:
oC Durati on: Days
2. Petechi ae Epi staxi s Mel ena

Other bl eedi ng :

3. Tourniquet test

4. Shock:
--
5pecmens
Acute (S 1 )
Early Convalescent (S2)
Late Conval escent (S2)
UateolLoIIecton ResuItolseroIogy

aboratoryUagnoss:
S i gnature:
Date:

30

Annex 2
Handout for Patient with Dengue Fever
(Important information to be given to the patients or family members of outpatients
with suspected dengue fever)

Your chi hi or fami l y member probabl y has dengue fever. Si nce thi s di sease can
rapi dl y become very serious and may l ead to medical emergency, i t i s important for
you to careful l y watch your chi l d or rel ative for the next few days. The compl i cati ons
associ ated wi th dengue fever usual l y appear between the thi rd and fifth days of
i l l nes s . You s houl d t herefore watch the pat i ent for t wo days after the fever
di sappears.

'WhatshouIdyoudo7'
. Keep body temperature bel ow 39C. Gi ve the patient paracetamol (not more than
four ti mes i n 24 hours) as per the dose prescribed bel ow:

Age Dose (tablet 500 mg) Mg/dose

~ 1 year 1 /8 tabl et 60
1 - 4 years 1 /4 tablet 60 - 1 20
5 and above 1 tabl et

240

Uon' tgvcAsprnoranyanaIgcscandantpyrctcsothcrthanparacctamoI

Gi ve l arge amount of fl ui ds (water, soups, mi l k and jui ces) al ong with pati ent' s
normal diet. The patient shoul d rest. Immediately consul t your physi ci an i f any of the
fol l owi ng mani festati ons appear: Red spots or poi nts on ski n; bl eedi ng from nose or
gums; frequent vomi ti ng; vomi ti ng wi th bl ood; bl ack stool s; s leepi ness; constant
cryi ng; abdomi nal pai n; excessive thi rst; pale, col d or cl ammy ski n; or di ffi cul ty i n
hreathi ng.

Don't wait. Immediately consult your physician. It is crucial to quickly treat

anyone with these complications.
It's better and appropriate to translate in local dialect these instructions for
good understanding by the people in a given community or area.
31

Annex 3 '

Indication & preparing patient or family members for possible

blood requirement
Indications for whole blood
I . Hemogl obi n l evel :: 5 gm %
2. Si gnificant bl eeding ;: 1 0% of total bl ood volume (TBV) . TBV of body i s 80
ml lkg.
3. Conceal ed bl eedi ng mani fested by Hematocrit drop and unstabl e vi tal si gns i n
spite of adequate vol ume replacement.
. Dose of whole fresh blood: 10 mllg/dose at a time.
Indication for platelet concentrate
It has been observed that there i s very l imi ted role of pl atel et transfusi on. In most of
the si tuation fresh whol e bl ood transfusi on i s suffice. However it may be required i n
some speci al si tuation. The i ndi cation of whi ch may be as fol l ows:
I . Pl atelet count :: 1 0,000 /mm3

If pl atel et concentrate i s not avai l abl e fresh whol e bl ood may be transfused as per
guidel ines gi ven under DHF management.
Indication for fresh plasma / plasma substitute
I . Serum al bumi n ::2. 0 gm/dl
Preparing patient or Family members for Blood Transfusion

AIert: Tel l the patient or fami l y member that a possi bl e transfusi on may require
when you fi nd that pl atel et count i s ~ 1 00,000 /mm3 or there i s bl eedings .

Attenton: Tel l the patient or fami l y members to contact bl ood donors to remain
i n attention that at any moment onward bl ood may be requi red at short notice
when you fi nd that pl atel et count i s ~ 50,000 Imm3 or there i s progressi ve
unstabl e vi tal si gns.
LoIlcton: Tel l the patient or fami l y members to col l ect bl ood, whi ch may i n
al l possi bi l i ty wi l l be requi red at any moment when you found that pl atel et
count i s ~ 25,000 Imm3 or there i s droppi ng of hematocrit and unstabl e vital
si gns despite adequate volume repl acement.
32

Annex 4
DFIDHF Hospital Flow Sheets
H<spital : Ward: .ed:
Uni t: Date of Admi ssi on: 1 I I I I I I
+
Name: Age: Sex: 0 Male 0 Femal e
Body Wei ght: Mai ntenance Fl ui d: Date Fever: I I Di agnosi s:

Hct: Hb: Day of i l l ness: D DFD DHFD DSS

Pl atelet : M = T Test: o Suspected
WBC : M+5%D= Bleedi ng: o Probabl e
Uate 1me IuIse I 1emp Res Hct 1reatment

5ymptoms Remarks
+
+
Pulse: F = Ful l I M = Mcderate I R = Rapi d I N = Not pal pabl e

Uate }peolIud 5tart1me RateQ/n

nd1me 1otaI ^ote

ntake utput

Date Tme raI 5Cl TotaI Urne Yomt/ nvshIe TotaI BaIance
MY 24 Hours 5ucton 24 Hours
.

DQctor: Nurse:

33

Annex 5
Reference & Further Reading
1 . Monogr aph on Dengue/DHF, WHO Regi on a l . Pub l i c at i on No 22,
WHO/SEARO, New Del hi , 1 993
2. Dengue and Dengue Hemorrhagic Fever, Edited by D J Gubl ar and G Kuno,
Publ i shed by CAB Internati onal , 1 997
3 . Dengue Hemorrhagic Fever - Di agnosi s, treatment, prevention and control , 2nd
Editi on, WHO, Geneva, 1 997
4. Regi on al Gui de l i nes for Prevent i on and Cont r ol of Den gue/DHF,
WHO/SEARO, New Del hi , 1 998
5. Gui del i nes for Treatment of Dengue/Dengue Hemorrhagi c Fever i n Smal l
Hospital s, WHO/SEARO, New Del hi , 1 999
6. Dengue News Letter, Regul ar Publ ication of WHO/SEARO, New Del hi
7. Dengue and Dengue Hemorrhagic Fever: Bangl adesh Perspecti ve, The Journal
of Chittagong Medical Col lege Teachers Association, 1 999; 1 0( 1 ) : 9- 1 9
8. E-Source
a. http: // www. who. i ntltdr
b. http: // www.bmn.com/medl i ne
c. http: // www. ncbi . nl m. ni h. gov
9. Di rectorate General of Health Services of Bangl adesh
Fax: +88-02-988641 5

1 0. Di sease Control Di rectorate, Di rectorate General of Health Services

a. Emai l : vbdc @bdonl i ne. com
b. Telephone: +88-02-9880948 ;
c. Fax: +88-02-6055 1 6

34

Annex 6
Workshop on 'Finalization of National Guidelines for Clinical
Management of Dengue & Dengue Hemorrhagic Fever'
Uate: 1 9 August 2000; Yenue: Sashakawa Hal l , ICDDRB, Dhaka, Bangl adesh
5ponsor : Di s eas e Cont r ol Di rect orate , DGHS , MOHFW, Ban g l ade s h;
LoIIaborators: ICDDRB & WHO, Bangl adesh
Chi ef Guest
Mr Sheikh Fazlul Karim Sel i m, Mi ni ster, Mi ni stry of Health Fami l y Welfare, Bangl adesh
Speci al Guests '
Professor Dr M Amanullah, State Mi ni ster, Mi nistry of Health Fami l y Welfare, Bangladesh
Mr Sayed Al amgi r Farrouk Chowdhury, Secretary, Ministry of Heal th Family Welfare, Bangladesh
Dr V Hardjotanojo, WHO Representative, Bangladesh
.
Dr Davi d A Sack, Di rector, ICDDRB, Dhaka, Bangl adesh
Resource Persons & Faci l itators
Professor A B M Ahsanullah, Director General of Health Services, Bangladesh
Professor M Tahir, Pro-Vice Chancellor, Bangabandhu Sheikh Mujib Medical University, Bangladesh
Professor Shah Monir Hossain, Director Medical Education 6Health Manpower Development, Directorate General of Health Services, Bangladesh
Dr Siripcn Kalayanarooj, Director, WHO Collaborative Center for Clinical Management of DFDHF, Ql':" Siriket Children Hospital, Bangkok, Thailand
Dr Dr Emran Bin Yunus, Associate Professor Nephrology, Officer on Special Duty, Directorate General of Health Services. Bangladesh
Dr Kanak Ranjan Talukdar, Director Disease Control, Di rectorate General of Health Services, Bangladesh
Dr Abdul Mannan Bangali, Deputy. Program Manager, Malaria & VBDC, Directorate General of Health Services, Bangladesh
Dr M Ataul Huq Mahmood, Evaluator, Malaria &VBDC, Directorate General of Health Services, Bangladesh
Dr M Mushfiqur Rahman, Malaria &VBDC, Directorate General of Health Services, Bangladesh
Dr Derek Lobo, Consultant, WHO, Bangladesh
Dr Anowar Hossain, Laboratory Sciences Division, lCDDRB, Dhaka, Bangladesh
artc_ants: nternstsandIedatrcans_AI_habetcaIorder_& nsttutes
Dr A Aziz, Dhaka Sishu Hospital .
Dr A R M Saifuddin Ekram, Rajshahi Medical College
Dr Asit Bhushan Das, Barisal Sere BangIa Medical College
Dr C B Mahmud, Chittagong Medical College
Dr Chandanendu Bhushan Sarkar, Mymenshing Medical College
Dr Choudhury Habibor Rasul, Khulna Medical College
Dr Faisal Ahmed, Sylhet Medical College
Dr Finlous Ara 1Janan, Dhaka Medical College
Dr Ghulum Mahmud, Barisal Sere BangIa Medical College
Dr H A M Nazmul Ahsan, Khulna Medical College
Dr Kazi M J ahangir, Rangpur Medical College .
Dr Khan Abul Kalam Azad, Bogra Medical College
Dr Khan Sarkar, Dhaka Sishu Hospi tal

Dr M A Ahbab, Sylhet M A G Osmani Medical College

Dr M A Azhar, Rajshahi Medical College
Dr M A Faiz, Chi ttagong Medical College
. Dr M A Matin, Sylhet M A G Osmani Medical College '
Dr M Abdul Halim, Sir Salimullah Medical College
Dr M Abdus Shukur, Bogra Medical College
Dr M Abu Bakar, Khulna Medical College
35
Dr M Abu Zafar, Sir Salimullah Medical College
Dr M Azizul Kahhar, Dinajpur Medical College
Dr M Enamul Karim, Faridpur Medical College
Dr M Khalid Hasan, Dinajpur Medical College
Dr M Mahtabuddin Hasan, Mymenshing Medical College
Dr M Mansurdur Rahman, Dinajpur Medical College
Dr M Rafiqul Islam, Bogra Medical College
Dr M Raji bul Alam, Camilla Medical College
Dr M Zakir Hussain, Sir Salimullah Medical College
Dr Manebendra Nath Nag, Rangpur Medical College
Dr Manzoor Hussain, Dhaka Sishu Hospital
Dr Mohammad Azizul Haque, Mymenshing Medical College
Dr Mrinal Kanti Das, Camilla Medical College
Dr Niruzzaman, Farifpur Medical College
Dr Quazi Tarikul Islam, Rajshahi Medical College
Dr Ranji t Kumar Saha, Chittagong Medical College
Dr Syed A Amir, Dhaka Sishu Hospital
Dr Syed Jahirul Islam, Dhaka Medical College
Dr Syed M Arif, Faridpur Medical College
Dr Tofayel Ahmed, Dhaka Medical College

'

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Annex 7
. Dengue Reporting Form for Practtioner
(Ihotocopy& Lse)
From:
.
Postage
D
r

WW
To
Ci vi I Surgeon

Firstfold cc

Patient
Name: 1 I I I I I I I I I I I I I I I I I I Ace: 1 I I Sex: O Male 0 Female
-- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --
I
[Put i n appropriate box]
Guardian: I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
Address : I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
''''--'-'''''''
I I I I I I \ \ I 1 \ \ \ I I \ \ 1 \ \ I 1 \ \ ' \ \ \ \ \ I \ \ \ I
.
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Diagnosis
DSuspectedDProbable I 0 DFDDHF 0 DSS [Put in appropriate boxes]

Outcome
o Recovered 0 Referred 0 Death 0 Not known [Put i n appropriate box]
Date of first Attendance / Admission: I I I I I I I
[dd/mm/yy]

.
Secolld fold here ttQ
~
Date of outcome: I I 1 I I I I [If known]
[dd/mm/yy]
Si gnature:
Ful l name: I I I I I I I I I I I I I I I I I I I

Position: I I I I I I I I I I I I I I I I I I I
.
Date: I I I I I I I
[dd/mm/yy]
36

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O

I
i

Annex B
Dengue Reporting Form for Hospital/Clinic
(Ihotocopy& Lse)
From:
Postage
Dr
@ MM
To

Civil Surgeon
@@@
Report serial no: 1 1 1 1 Date: 1 1 1 1 1 1 1
[dd/mm/yy]

Firstfold here dowll Secondfold at next arrow marks

Name : of
HospitaIlCli ni c:
@ @@@@@ @ -.

Address:
"
Date of Report: 1 1 1 1 1 1 1
[dd/mryy]
Cases i n last 2
Deaths
hours
Category
i n last
2
OPD IPD
hours
+
Sus ected
DF Provable
Total

Suspected
DHF Probable
.
Date of Report Begi nni ng: 1 1 1 1 1 1 1
[dd/mm/yy]
Cumulative from
At
Cumulative from beginning ,
beginning of reporting of reporting
present
admitted KfC0Vf|f0 DORB
Total Total
Deaths
Referred
Cases Deaths |Ch|gf0 Not known
+

Total
Suspected
-

DSS Probable
Total
.
Grand Total
' Signature:
Ful l name: 1 1_1_1 1 1 1_1_1 1 1_1 1_1_1_,_,_1_1
Positi on: 1_1_,_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1_1
Date: 1_1_1_1_1_1_1
[dd/mm/yy]

37
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