Current Capacity for Case Management of Dengue Haemorrhagic Fever in Provincial Hospitals in Southern Viet Nam¶ Nguyen Thanh Hung! and Dengue Study Group Department of Dengue Haemorrhagic Fever, Department of Emergency and Intensive Care Unit, Children's Hospital No. 1, 341 Su Van Hanh St., Dist. 10, Ho Chi Minh City, Viet Nam
Abstract The study on the current capacity for case management of dengue haemorrhagic fever (DHF) was carried out in 21 provincial hospitals in southern Viet Nam. Proper organization and good triage in hospital, supplying enough essential equipment and intravenous (IV) fluids and well-trained medical staff were essential factors for the reduction of case-fatality rates (CFR) in DHF/dengue shock syndrome (DSS). With the strengthening of the capacity for case management of DHF in provincial hospitals, the CFR of DHF/DSS was significantly reduced to 0.16% and that of DSS to 0.79% in 2004 in southern Viet Nam. Keywords: DHF/DSS, case-fatality rate, case management, Viet Nam.
Introduction Dengue haemorrhagic fever (DHF) has been a leading cause of hospitalization and deaths in children in southern Viet Nam in the past 30 years. In 2004, a widespread DHF epidemic with 66 151 cases and 103 deaths was reported in 20 provinces in southern Viet Nam[1]. All levels of the heath care system in southern Viet Nam are involved in the management of DHF/DSS patients from the referral hospitals (Children’s Hospital No. 1 and 2; Hospital for Tropical Diseases, Ho Chi Minh City) down to provincial and district hospitals and finally to commune health centres (Figure 1). Each province has one provincial hospital which receives all severe DHF/DSS
patients with complications referred from district hospitals of the province. Almost 82.1% of death cases of DHF/DSS in southern Viet Nam in 2004 were reported at the provincial hospitals[1]. In southern Viet Nam, the National DHF Control Programme was commenced in 1998 with the primary objective of reducing mortality due to DHF[1]. Factors contributing to the reduction of case-fatality rates (CFR) in DHF/ DSS call for proper organization and good triage in hospital; supply of enough essential equipments and intravenous (IV) fluids for use in hospital; well-trained medical staff; and education for mothers/caretakers of DHF patients[4]. These practices are in vogue in provincial hospitals in southern Viet Nam since
The study was approved by the Scientific and Ethical Committee of Children's Hospital No. 1, Ho Chi Minh City, Viet Nam. ! hungdhf@hcm.fpt.vn; " 84-8-9271119; Fax: 84-8-9270053 ¶
Dengue Bulletin – Vol 29, 2005
151
Current Capacity for Case Management of DHF in Provincial Hospitals in Southern Viet Nam
1998 under the National DHF Control Programme. In the previous papers, we presented the measures taken to improve case management of DHF/DSS patients by medical staff at all levels of the health care system, and the impact of health education on the knowledge, attitude and practice (KAP) of mothers about DHF[2,3]. In order to assess the current capacity for case management of DHF in provincial hospitals, a study was carried out in respect of the above-mentioned requirements.
Materials and Methods This was a descriptive, cross-sectional study. The survey was carried out in 21 provincial hospitals in southern Viet Nam from September to November 2004. Every provincial hospital was assessed on a prepared questionnaire. Doctors of the Dengue Study Group from the Children’s Hospital No.1 conducted this survey. The data collected were analysed by software SPSS version 12.0.
Figure 1. The levels of the health care system in southern Viet Nam involved in case management of dengue haemorrhagic fever/dengue shock syndrome patients Commune health centres Early recognition and correct management of mild DHF patients District hospitals Treat moderate DHF/DSS patients without complications Provincial hospitals Treat DHF/DSS patients with or without complications Referral hospitals Treat DHF/DSS patients with or without severe complications
Results There were 21 Paediatric departments, 15 Emergency departments and Intensive Care units and 14 Infectious Diseases departments involved in the management of DHF/DSS patients in the 21 provincial hospitals in the study. All the Emergency departments and Intensive Care units treated severe DSS patients. Among the 21 Paediatric departments, there were 16 departments treating both nonshock DHF and DSS patients. The five remaining Paediatric departments only treated non-shock DHF patients. Fourteen Infectious Diseases departments served for the management of DHF adult patients, in which there were two departments also treating DSS grade III.
Organization and triage for DHF/DSS patients in the provincial hospitals The implementation of the organization and triage for DHF/DSS patients and supplying enough equipment and IV fluids in the provincial hospitals was commenced in four provinces in 1998, and since then it was expanded to other provinces. The organization for case management of DHF/DSS patients in 16 out of 21 provincial hospitals is demonstrated in Figure 2. In these hospitals, a suspected DHF patient can be managed as an outpatient if the patient does not require admission. If the patient has indication for admission and without shock, he/she will be admitted to the Paediatric department or Infectious Diseases department for follow-up.
152
Dengue Bulletin – Vol 29, 2005
Current Capacity for Case Management of DHF in Provincial Hospitals in Southern Viet Nam
Figure 2. The demonstration of the organization for case management of DHF/DSS patients in most provincial hospitals in southern Viet Nam Outpatient department Patients with suspected DHF Having indications for admission Yes Non-shock DHF patients DSS patients No Managed as outpatients
Paediatric department/ Infectious Diseases department Non-shock DHF; DSS patients
Emergency department & Intensive Care Unit Severe DSS patients with complications
If the patient is in shock (DSS), he/she will be admitted immediately to the Emergency department for initial resuscitation. After the initial resuscitation, if the patient’s condition becomes stable he/she will be referred to the Paediatric department for further intravenous fluid therapy. In contrast, if the patient is still in shock or has complications (such as respiratory failure, severe bleeding) he/she will be referred to the Intensive Care unit for intensive management. In the remaining five hospitals the Paediatric department and the Infectious Diseases department only treated non-shock DHF patients. All DSS patients were managed at the Emergency department and Intensive Care units.
in the Table 1. All the hospitals had enough essential equipment, fluids and drugs needed for treatment of DHF/DSS patients such as oxygen with mask or nasal cannula, catheter for measuring central venous pressure (CVP), Ringer’s lactate, Dextran 40, Dextran 70, fresh whole blood, furosemide, Dopamine, and Dobutamine. There were 17 (80.9%) hospitals having bedside haematocrit centrifuge machine. 14 (66.6%), 17 (80.9%) and 19 (90.4%) hospitals had bedside X-ray, nasal continuous positive airway pressure (N-CPAP) and mechanical ventilations, respectively, which were essential for the treatment of DSS patients with respiratory failure (Table 1).
Supplying equipment and IV fluids for case management of DHF/DSS in provincial hospitals A number of provincial hospitals supplied enough equipments and IV fluids for case management of DHF/DSS and these are listed Dengue Bulletin – Vol 29, 2005
The capacity of medical staff for case management of DHF/DSS patients in 21 provincial hospitals in southern Viet Nam Training courses on case management of DHF/ DSS for doctors and nurses of provincial hospitals have been organized each year at Children’s Hospital No. 1, Ho Chi Minh City, for the past 10 years. A total of 496 doctors 153
Current Capacity for Case Management of DHF in Provincial Hospitals in Southern Viet Nam
Table 1. Supplying equipment and intravenous fluids for case management of dengue haemorrhagic fever/dengue shock syndrome in 21 provincial hospitals in southern Viet Nam
and nurses were trained by organizing 20 courses during 2001–2004. Training of trainers has been organized and on-site intervention teams have been set up in provincial and referral hospitals. The training activities have also been conducted at provincial and district hospitals and finally at commune health centres. An important training activity is the training of trainers for provincial hospitals to train staff in provincial and district hospitals and commune health centres[2]. The capacity of medical staff in 21 provincial hospitals for case management of DHF/DSS patients is summarized in Table 2. Two hundred and ninety-five out of 383 doctors (77.0%) who directly took care of DHF/DSS patients were retrained on case management of DHF/DSS in the official training courses in the National DHF Control Programme in 2003– 2004. There were 262 out of 383 doctors (68.4%) assessed as experienced doctors who had the ability to manage severe DHF/DSS patients with complications (Table 2).
Table 2. The capacity of medical staff in 21 provincial hospitals in southern Viet Nam
Doctors/ nurses were retrained on the case management of DHF/DSS in the official training courses in the National DHF Control Programme in 2003–2004 †
Experienced doctors assessed as doctors had the ability to manage severe DHF/DSS patients with complications ††† Experienced nurses assessed as nurses had the ability to take care for severe DHF/DSS patients with complications ††
154
Dengue Bulletin – Vol 29, 2005
Current Capacity for Case Management of DHF in Provincial Hospitals in Southern Viet Nam
For nurses, only 524 out of 919 nurses (57.0%) were retrained on DHF/DSS in the official training courses in the National DHF Control Programme in 2003–2004. The number of experienced nurses who had the ability to take care of severe DHF/DSS patients with complications was estimated at 528 (57.4%). Besides the official training courses under the National DHF Control Programme, each provincial and district hospital has to organize training for all doctors and nursing staff who participate in the management of DHF/DSS patients each year.
Discussion Proper organization and good triage in hospital is an important factor contributing to the reduction of CFR in DHF/DSS[4]. During the widespread DHF epidemic in 2004 with 66 151 cases reported in southern Viet Nam, the outpatient and inpatient facilities in many hospitals were optimal. Good organization of triage of DHF patients in the outpatient departments in these hospitals allowed the medical staff to follow the patients carefully. We developed strict indications for hospitalization in the national guidelines on case management of DHF/DSS patients; only those patients requiring hospital care were admitted. The organization for case management of DHF/DSS patients in almost all provincial hospitals in southern Viet Nam (Figure 2) followed a proper pattern. Good facilities at the hospitals helped reduce the CFR in DHF/DSS patients. In order to improve the case management of DHF/DSS patients, supplies and equipment for intensive care, IV fluids (crystalloids, colloids), medications and blood products need to be carefully planned, ensured and maintained. DHF/DSS patients generally, in southern Viet Nam, died of severe complications such as prolonged shock, respiratory failure and massive bleeding (unpublished data) so the provincial hospitals had to have enough essential equipment for intensive care and IV fluids. The result of our study showed that only 17 (80.9%) hospitals had bedside haematocrit centrifuge machine. Fourteen (66.6%), 17 (80.9%) and 19 (90.4%) provincial hospitals had bedside X-ray, nasal continuous positive airway pressure (N-CPAP) and mechanical ventilations respectively. Those hospitals, which lacked the essential equipment, were asked to quickly arrange for supplies in 2005.
Contribution of increased capacity for case management of DHF/DSS in provincial hospitals in reducing the CFR of DHF/DSS in southern Viet Nam Southern Viet Nam is an endemic area for DHF/DSS. Thousands of cases of DHF/DSS have been reported each year. During the period 1998–2003, the lowest number (18 740 cases) and the highest number (123 997 cases) were recorded during 2000 and 1998 respectively. With efforts to strengthen the capacity for case management of DHF in provincial hospitals in southern Viet Nam, the CFR of DHF/DSS in recent years has been significantly reduced to 0.24% and that of DSS to 1.24–2.47% during 1998–2003[1]. In 2004, there was a widespread epidemic of DHF caused by all the four serotypes (DENV1: 12.41%; DENV-2: 71.89%; DENV-3: 10.89%; and DENV-4: 4.79% of the virus isolations) in southern Viet Nam. In this epidemic, out of 66 151 DHF/DSS patients only 103 deaths were reported, lowering the CFR of DHF/DSS to only 0.16% and that of DSS to 0.79%[1].
Dengue Bulletin – Vol 29, 2005
155
Current Capacity for Case Management of DHF in Provincial Hospitals in Southern Viet Nam
Well-trained medical staff was the key factor contributing to the reduction of CFR. All doctors and nurses who care for DHF patients have been trained in clinical skills for the management of DHF/DSS. Even though there were many training courses on case management of DHF/DSS for doctors and nurses every year in the National DHF Control Programme, the results of the study showed that 77% of doctors and only 57% of nurses had been retrained on DHF/DSS in the past two years. It is necessary that training on DHF/DSS case management should be organized for medical staff more frequently. Training activities should be organized continuously every year before, during and after an outbreak of DHF[2]. The fact that 68.4% of doctors and 57.4% of nurses were assessed as ‘experienced’ persons who had the ability to manage severe DHF/DSS patients with complications (Table 2), we constituted dengue groups in each hospital in order to share their experiences with other doctors/nurses. A hotline to connect all health care facilities by telephone, fax and e-
mail has been set up in order to exchange information and experience on DHF/DSS case management in southern Viet Nam[2]. This report presents a good model on how to increase capacity building for DHF case management in southern Viet Nam. However, more efforts to strengthen the capacity for case management of DHF/DSS in provincial and district hospitals in southern Viet Nam should be continued to further reduce the CFR of the disease.
Acknowledgements We thank the doctors and nurses of the Department of Dengue Haemorrhagic Fever and the Department of Emergency and Intensive Care Unit, Children’s Hospital No. 1, Ho Chi Minh City, for their participation in the National DHF Control Programme and in the study. Thanks are also due to our colleagues in provincial hospitals for their cooperation in the study.
References [1] Pasteur Institute, Ho Chi Minh City. Report of national target DHF control programme in Southern Viet Nam in 2004, Ho Chi Minh City, January, 2005. Nguyen Thanh Hung and Nguyen Trong Lan. Improvement of case-management – a key factor to reduce case fatality rate of dengue haemorrhagic fever in Southern Viet Nam. Dengue Bulletin. 2003; 22: 144-148.
[3]
[2]
Tran Tan Tram, Nguyen Thi Ngoc Anh, Nguyen Thanh Hung, Nguyen Trong Lan, Le Thi Cam, Nguyen Phuoc Chuong , Le Tri, Fonsmark L, Poulsen A and Heegaard ED. The impact of health education on mother’s knowledge, attitude and practice (KAP) of dengue haemorrhagic fever. Dengue Bulletin. 2003; 22: 174-180. World Health Organization. Dengue haemorrhagic fever: diagnosis, treatment, prevention and control, 2nd edition, Geneva, WHO, 1997.
[4]
156
Dengue Bulletin – Vol 29, 2005