What are the guidelines for managing dengue fever in the Philippines?

Guidelines for Managing Dengue Fever in the Philippines

The World Health Organization recommends implementing standardized clinical management protocols for dengue in the Philippines, focusing on fluid management, monitoring for warning signs, and early detection of severe cases to reduce mortality and morbidity. 1

Diagnosis and Classification

Dengue should be suspected in patients presenting with:

• Fever plus one or more of the following: nausea/vomiting, rash, headache, retro-orbital pain, myalgia/arthralgia, positive tourniquet test, leukopenia, or warning signs 1
• Recent travel to or residence in endemic areas in the Philippines

Laboratory findings supporting diagnosis:

• Thrombocytopenia (low platelet count)
• Leukopenia
• Elevated hematocrit (indicating hemoconcentration)
• Elevated liver enzymes 1

Diagnostic tests:

• Acute phase: RT-PCR for dengue virus RNA or NS1 antigen detection
• Convalescent phase: IgM antibody detection or demonstration of fourfold rise/fall in IgG or IgM antibody titers 1

Clinical Management

Fluid Management (Critical Component)

For hemodynamically stable patients:

• Encourage oral fluid intake
• Monitor vital signs, urine output, and warning signs

For patients with warning signs:

• Begin IV fluid therapy with crystalloids (first-line) 1, 2
• Initial fluid rate: 5-10 ml/kg/hour, adjusted according to clinical response
• Monitor vital signs every 15-30 minutes during rapid fluid administration 1

For patients with shock (Dengue Shock Syndrome):

• Immediate resuscitation with crystalloid fluid bolus of 20 ml/kg as rapidly as possible
• May need to repeat bolus 2-3 times in profound shock 1
• If not responsive despite adequate crystalloid resuscitation, switch to colloids 2
• Consider vasopressors (e.g., norepinephrine) if fluid restriction is needed due to pulmonary edema 2

Monitoring Parameters

Essential monitoring includes:

• Accurate weight documentation
• Vital signs assessment including pulse pressure
• Serial hematocrit determinations
• Urine output measurement
• Respiratory status assessment 1

Warning Signs Requiring Close Monitoring

• Abdominal pain or tenderness
• Persistent vomiting
• Clinical fluid accumulation
• Mucosal bleeding
• Lethargy or restlessness
• Liver enlargement >2 cm
• Laboratory: Increase in hematocrit concurrent with rapid decrease in platelet count 1

Warning Signs of Fluid Overload

• Increasing respiratory rate with normal or falling hematocrit
• Development of new crackles on lung examination
• Rising JVP
• New onset hepatomegaly
• Peripheral edema 1

If signs of fluid overload develop, reduce or stop intravenous fluids if hemodynamically stable.

Medication Guidelines

• Use acetaminophen for fever and pain relief
• Avoid aspirin and NSAIDs due to increased bleeding risk 1, 3
• No specific antiviral therapy is recommended for routine use 1, 4
• No recommendation for thymosin alpha 1 due to lack of evidence 1

Special Population Considerations

Children

• Require closer monitoring
• More susceptible to fluid overload
• Initial fluid bolus of 20 mL/kg for shock 1

Pregnant Women

• Higher risk of complications
• Require more intensive surveillance 1

Older Adults

• Higher risk of severe dengue due to comorbidities
• May require more aggressive management 1

Discharge Criteria

Patients can be discharged when they have:

• No fever for 48 hours without antipyretics
• Improving clinical status
• Increasing platelet count
• Stable hematocrit
• No respiratory distress
• Good urine output 1

Prevention Strategies

• Protect patients from further mosquito exposure to prevent transmission
• Implement environmental management and enhanced vector control
• Focus on vulnerable communities
• Implement integrated vector management (IVM) 1
• Strengthen vector-borne disease monitoring and surveillance systems 1

Common Pitfalls to Avoid

1. Overhydration: Can lead to pulmonary edema and respiratory distress
2. Underhydration: Can lead to prolonged shock and organ failure
3. Use of NSAIDs/aspirin: Increases bleeding risk 1, 3
4. Prophylactic platelet transfusion: Not recommended 4
5. Fixed fluid protocols: Fluid rates should be adjusted based on clinical response rather than using fixed protocols 1

Remember that after an initial dengue infection, individuals are not fully immune as there are four distinct serotypes. Infection with one serotype provides lifelong immunity against only that specific serotype but only temporary cross-immunity to others 1.