EMERGING VECTOR-BORNE DISEASES IN CHILDREN

1. EMERGING VECTOR-BORNE DISEASES IN CHILDREN DR SV PATIL PROF AND HEAD PAEDIATRICS BLDE-UNIVERSITY SRI BM.PATIL MEDICAL COLLEGE BIJAPUR

2. EMERGING VECTOR - BORNE DISEASES IN CHILDREN DR SV PATIL PROF AND HEAD PAEDIATRICS

3. Dengue fever • Ricketsial fever • Chickungunya fever • Japanese encephalitis • Malaria

4. Dengue fever

5. Case • Rahul, 4 year male child presents with • Fever high grade, vomiting for 4 days • Treated with paracetamol but little response • Monsoon time and a case of dengue in neighborhood reported recently • How will you proceed in such a case? • Ask • Look • Test

6. Ask for …… • Localizing symptoms: • Cough, cold, ear ache: Tonsillitis, AOM, Sinusitis • Loose stools: Rotaviral, bloody diarrhea • Urinary symptoms: UTI • Boils: SSTI • Without focus: • Pattern of fever, Well between fever spikes, history in contacts, coryza, systemic symptoms (myalgia) • Vaccination: Hib, typhoid, measles, MMR • Danger symptoms: Lethargy, refusal of feeds, irritability, oliguria, convulsion, cold extremities (Serious infections)

7. Look for ….. • Vitals: Pulse, CRT, BP/Pulse pressure, Tourniquete test, Skin rash • Focus like: • Liver/spleen/LN, ascitis • Resp: Conj congestion, Coryza, Throat/Otoscopy, RR, Grunt, retractions, effusions • CNS: Alertness, FND, meningeal signs • Other systems

8. Test for ….. • Test for (now or later?) • CBC, PS for MP (repeat if no response) • Urine analysis – culture SOS • Blood culture?? • X ray chest (If resp signs) • Repeat tests (CBC) SOS • Others: CRP, SGOT, SGPT, Widal, Dengue serology, RMT ????

9. Case continues …. • Rahul’s tests done show: • CBC: • Hb 13 gm%, HCT 40%, • WBC 3200, P 40, L 56 E 3, M1 • Platelets: 1.2 lakhs • PS for MP: Negative • Urine analysis: Albumin nil, Pus cells 2-3/hpf • X ray chest: Normal DD: Malaria, Dengue, Viral fever, Enteric fever, Leptospirosis etc

10. Case continues ….. • Rahul’s fever is persistent • He now has some rash on his body • He seems to have body ache and restlessness • His mother repeats his investigations

11. Case continues …. Mother wants to know whether it is dengue and whether she should ask for dengue tests?

12. Which laboratory tests? • Test for confirming dengue • NS1 Antigen, ELISA for IgG & IgM • Need, timing, interpretation

13. Interpretation of dengue serology * * Exception being congenital dengue (in 1st 3 months of life) • Most important for preventing morbidity and mortality is serial clinical monitoring and CBC • Do not withhold fluid therapy pending labs/-ve labs

14. Case continues ….. • Rahul is drinking and eating though less than before • His fever is better with paracetamol • He has passed urine 3-4 times since morning • Mother wants to know whether she should admit Rahul in hospital?

15. Course of dengue illness Critical phase: Falling WBC & Platelets  Plasma leak & Rising HCT – 3rd spacing  Shock, organ dysf., Acidosis, DIC  Severe bleeding with  HCT &  in WBC  Severe shock, organ damage & death.

16. WHO classification of dengue Not suitable in all situation; severe dengue in absence of criteria

17. Suggested dengue classification Severe Dengue Dengue +/- warning signs Criteria for dengue +/- warning signs With warning signs 1) Severe plasma leakage 2) Severe hemorrhage 3) Severe organ impairment Without Criteria for severe dengue • Probable dengue • Live in/travel to dengue endemic area. Fever and 2 of the following criteria • Nausea, vomiting • Rash • Aches and pains • +ve tourniquete test • Leukopenia • Any warning sign • Warning signs • Abd. Pain & tenderness • Persistent vomiting • Clinical fluid accum. • Mucosal bleeds • Lethargy, restlessness • > 2 cm liver enlarged • Lab:  HCT with rapid  in platelets • Severe plasma leakage • Shock (DSS) • Fluid accumulation with respiratory distress • Severe bleeding • As evaluated by clinician • Severe organ involvement • Liver: AST/ALT > 1000 • CNS: Impaired consc. • Heart & other organs

18. Management principles • Step 1. Overall assessment: • History, examination, labs • Step 2. Diagnose & assess phase/severity of disease • Step 3. Management: • Disease notification • Management decisions: • Group A (to be sent home) • Group B (in-hospital management) • Group C (emergency treatment & referral)

19. Case continues ….. • Rahul is drinking and eating though less than before • His fever is better with paracetamol • He has passed urine 3-4 times since morning • Mother wants to know whether she should admit Rahul in hospital?

20. Group 1 (Home care) • It includes those who: • Can tolerate adequate volume of oral fluids • Pass urine 4-5 times in 24 hours • No warning signs • Rx: 5-6 glasses of ORS, Juices, other fluids, Paracetamol (NO NSAIDs/Mefenimic acid) • FU: Daily FU till defervescence period is over at home by care taker and at clinic by medical professional for • Intake, output, repeat CBC, look for warning signs, response to therapy, deterioration or warning signs

21. Case continues ….. • Rahul is now sick looking • He has vomited several times and is not able to drink well • He has developed cold hands and feet • He is irritable and restless • He has not passed urine for 8 hours • Mother wants to know whether she should admit the child?

22. Group 2 (In-hospital Rx) • Includes those with warning signs: • Abd. Pain & tenderness • Clinical fluid accum. • Lethargy, restlessness • Lab:  HCT/  in platelets • High risk for complications like pregnancy, infancy, old age, obesity, diabetes mellitus, renal failure, chronic hemolytic diseases • Difficult social situation (far away/living alone) • Persistent vomiting • Mucosal bleeds • > 2 cm liver enlarged

23. Management of Group 2 with danger signs 5-7 ml/Kg/hr x 1-2 hr 3-5 ml/Kg/hr x 2-4 hr Worsening Clinical/CBC monitoring 5-10 ml/Kg/hr x 1-2 hr Clinical/CBC monitoring Response seen Response seen Worsening 2-3 ml/Kg/hr x 2-4 hr Taper over 24-48 hr Severe shock Refer to 30 care Monitoring: Clinical q 1-4 hr; Urine output q 4-6 hr; CBC q 6-12 hr; Organ function tests sos

24. Group 3 (Referral to tertiary care) • Includes those with severe dengue (DSS): • severe plasma leakage leading to dengue shock and/or fluid accumulation with respiratory distress • severe hemorrhages • severe organ impairment (hepatic damage, renal impairment, cardiomyopathy, encephalopathy or encephalitis) Need access to intensive care, blood products and colloids

25. Compensated shock (systolic pressure maintained but has signs of reduced perfusion) O2, Fluid resuscitation with isotonic crystalloid 5–10 ml/kg/hr over 1 hour Improvement No improvement Check HCT IV crystalloid 5–7 ml/kg/hr for 1–2 hours, then:  to 3–5 ml/kg/hr for 2–4 hours;  to 2–3 ml/kg/hr for 2–4 hours. Improvement -  fluid further. Monitor HCT 6–8 hourly. Not stable, act according to HCT levels: if HCT , consider bolus or increase fluid administration; if HCT , consider fresh whole blood transfusion. Stop at 48 hours. HCT  or high HCT low 2nd bolus 10-20 ml/Kg for 1 hr Significant Bleeding – consider Fresh whole blood transfusion Improvement  Fluids to 7–10 ml/kg/hr for 1–2 hours then further No improvement Dr. Nitin Shah

26. Hypotensive shock O2, Fluid resuscitation with isotonic crystalloid or colloid @ 20 ml/kg over 15 min Improvement No improvement Check 1st HCT HCT  or high HCT low IV cryst./colloid 10 ml/Kg x 1 hr IV cryst. 5–7 ml/kg/hr x 1–2 hours 3–5 ml/kg/hr x 2–4 hours 2–3 ml/kg/hr x 2–4 hours. Improvement -  fluid further. Monitor HCT 6–8 hourly. Not stable, act according to HCT levels: if HCT , consider bolus or increase fluid administration; if HCT , consider fresh whole blood transfusion. Stop at 48 hours. 2nd bolus colloid 10-20 ml/Kg for ½-1 hr Significant Bleeding – Fresh whole blood transfusion Improvement No improvement Check 2nd HCT HCT  or high HCT low 3rd bolus colloid 10-20 ml/Kg over 1 hr Check 3rd HCT Improvement No improvement Fluid refractory shock

27. Case continues ….. • Rahul was admitted in hospital and treated with IV fluids and he responded well • His serial CBC showed platelets of only 30,000 • He has some skin rash and mild epistaxis • Mother insists on giving platelet transfusion to Rahul

28. Use of blood products • At risk: • Profound shock, hypotension, NSAIds, Trauma (procedures), liver disease • Recognition: • Falling HCT on fluid resuscitation with unstable hemodynamics, • Overt bleeding irrespective of HCT • Refractory/hypotensive shock, worsening metabolic acidosis • Treatment: • Fresh PRBC or whole blood (Rarely platelets, FFP) • No role of prophylactic platelets!!!!

29. Case continues ….. • Rahul is now well • He is eating and drinking well • He is passing urine well • It is 8 days and he is afebrile for 2 days • His CBC shows Hb of 11 gm%, WBC 4200, P40,L56, E4, Platelets of 90,000 • Mother wants to know when can Rahul go home?

30. Criteria for discharge • All of the following must be present • Clinical: • No fever for 48 hours • Improvement in clinical status (general well-being, appetite, haemodynamic status, urine output, no respiratory distress) • Time frame for critical phase over • Laboratory: • Increasing trend of platelet count • Stable hematocrit without intravenous fluids

31. RICKETTSIAL INFECTIONS

32. Rickettsial Infections • Symptoms-- FEVER headache myalgia rash and eschar generalized lymphnodes,and hepatosplenomegaly RASH-PALMS AND SOLES

33. GI- symptoms-Nausea,Vomiting Abd pain, Diarrhoea • RS-Cough, Distress, • CNS-Dizziness,Disorientation, Photphobia and Visual disturbances • Others include-periorbital edema,conjunct congestion Epistaxis,hearing loss and arthralgia

34. SEVERE SYMPTOMS • Interstitial Pneumonia, Pulmonary edema • CNS-Meningoencephalitis syndrome • Renal-ARF • Disseminated Intravascular Coagulation,Hepatic failure and Myocarditis.

35. Laboratory findings • Hematology-TLC-is low and leucocytosis • Platelets less in 60% ESR is high • Hyponatremia,,Hypoalbunemia,Thrombocytopenia • SGOT- elevated • Weil Felix test (5-7) days • PCR- Immunoflorescence(gold standard)

36. Diagnosis • Fever-PUO- Fever with rash(palms and soles) • Tick bite and exposure • Epidemiological data • Lab findings- • Defervescence with antibiotics • DD-Measles,Dengue,Infmono,Malaria Typhoid TSS and CVD

37. Treatment • Tetracyclin,Doxycyclin Chloromycetin, Macrolides and Quinolines • 5mg/kg in 2 doses min 5-7 days, and • Supportive therapy.

38. JAPANESE ENCEPHALITIS

39. JAPANESE ENCEPHALITIS Case Definition of Suspected case: • - Acute onset of fever, not more than 5-7 days duration. • - Change in mental status with/ without •  New onset of seizures (excluding febrile seizures) •  (Other early clinical findings . may include irritability, somnolence • or abnormal behavior greater than that seen with usual febrile • illness)

40. JE

41. JE- CONTD • Laboratory-Confirmed case : A suspected case with any one of the following markers: •  Presence of lgM antibody in serum and/ or CSF to a specific virus including • JE/Entero Virus or others •  Four fold difference in lgG antibody titre in paired sera •  Virus isolation from brain tissue •  Antigen detection by immunofluroscence •  Nucleic acid detection by PCR • In the sentinel surveillance network, AES/JE will be diagnosed by lgM Capture ELISA, and • virus isolation will be done in National Reference Laboratory.

42. CHICKUNGUNYA FEVER

43. Triad of fever, rash and joint manifestations • Clinically-fever>38.5,severe arthralgia(possible) • Epidemiological-visit epidemic area 15 days prior to symptoms.(probable) • Lab-isolation virus, PCR IgM AND IgG (confirmed)

44. Caused by-chik virus, aedes aegypti vector (human-mosq-human)-post mansoon • Monkeys rodents birds and others. • Symptoms-fever(92%),arthralgia(87%),back ache(67%) and head ache(62%) • Differs from adults-

46. SEQUELAE • Arthralgia resolves in 87%,3.7% episodic stiffness and 2.8% persistent stiff • Lab diagnosis–virus isolation PCR IgM antibody and rising IgG titres • Differential diagnosis –Leptospirosis,dengue fever,malaria,meningitis and rheumatic fever

47. Management • First contact-Differential diagnosis should be thought • Assess dehydration(severe,mild to moderate) • Total leucocyte count->10,000-leptospira, and <50,000 –dengue fever peripheral smear-MP • Paracetamol -50-60mg/kg/day • Exercise and physiotherapy

48. Thank you all!