General office of the national health and family planning commission about dengue fever guidelines "(2014 edition) 
 
 
The national health and family planning commission of the People's Republic of China 

 
The 2014-08-26

Countries who do medical letter [2014] no. 746 

Provinces, autonomous regions and municipalities directly under the central government health and family planning commission (bureaus) of health medical administration (medical), the xinjiang production and construction corps health medical administration:
 
Present a tendency of increasing outbreak of dengue fever in recent years, in order to further strengthen dengue cases of diagnosis and treatment work, guide completes the dengue fever, medical treatment, medical institutions to protect people's health and life safety, by commission to make a "dengue fever clinic guide (2014 edition)" (which can be downloaded from the national health and family planning commission web site). Hereby printed and distributed to you for reference for use in clinical diagnosis and treatment of medical institutions. 

General office of national health and family planning commission
 
On August 19, 2014 

Dengue fever guidelines (2014 edition) 

Dengue fever is an acute infectious disease caused by the dengue virus, mainly transmitted by aedes aegypti and aedes albopictus bites. Dengue fever prevalent in tropical and subtropical regions around the globe. To guide clinicians dengue fever, diagnosis and treatment for reference by the world health organization in 2009, the diagnosis, treatment, prevention and control of dengue guide, according to our country's outbreak of dengue fever and clinical characteristics of this guide.
 
A, etiology,
 
Dengue virus belong to yellow virus flavivirus genus. Dengue virus particles are spherical, 45 ~ 55 nm in diameter. There are 4 serotype dengue virus (DENV - 1, 2 DENV DENV - - 3 and DENV - 4), four kinds of serotype all can affect people.
 
Dengue virus is sensitive to heat, 56 ℃ for 30 minutes can be inactivated, but in 4 ℃ under the condition of its infectious can stay for several weeks. Ultrasound, uv, 0.05% formaldehyde solution, lactic acid, potassium permanganate, gentian violet can be inactivated virus. The virus the most stable at pH 7 ~ 9, in 70 ℃ or freeze drying condition can survive for a long time.
 
Second, the epidemiology
 
(a) infection. Dengue fever, recessive infected with dengue virus infection in patients with nonhuman primates and poisoned medium aedes mosquitoes.
 
(2) the route of transmission. Is mainly transmitted by aedes mosquito. Media mainly aedes aegypti and aedes albopictus.
 
(3) the vulnerable groups. People generally susceptible, but only some people after infection disease. Dengue virus infection, the human body on the same virus, lasting immunity, but could not form effective protection for different virus infections, if again alien or more different serum virus infection, the body's immune response may occur, leading to severe clinical manifestations.
 
(4) popular characteristics. Dengue fever epidemic in tropical and subtropical regions, especially in southeast Asia, the Caribbean and Pacific islands more than 100 countries and regions. Provinces have input case report in our country, guangdong, yunnan, fujian, zhejiang, hainan and other southern provinces can cause local endemic disease, mainly in summer fall, unemployed and retired workers more at home.
 
Three, clinical manifestation
 
Dengue fever is the incubation period is commonly 3 ~ 15 days, most of the 5 ~ 8 days.
 
Dengue virus infection can be shown as asymptomatic recessive infection, severe infection and severe infection. Dengue fever is a systemic disease, complex and varied clinical manifestations. Typical dengue course is divided into three phases, namely acute fever period, period and recovery period. According to the illness severity, dengue infection can be divided into general dengue fever and severe dengue fever two clinical types.
 
(a) acute fever. Patients with acute onset, usually starting symptoms are fever, can be associated with chills, body temperature of 40 ℃ within 24 h. Some cases of fever for 3 to 5 days after the temperature dropped to normal, 1-3 rise again in the future, heat type called twin peaks. When fever associated with headache, whole body muscle, bone and joint pain, apparent lack of power, and can appear nausea, vomiting, abdominal pain, diarrhea and other gastrointestinal symptoms.
 
Acute fever lasts 2 ~ 7 days. In the course of 3 ~ 6 days in facial limbs congestive rash or dotted hemorrhage rash. Typical rash to tip in the limbs and bleeder "PiDao" sample performance, etc. Can appear different degree of bleeding, such as subcutaneous hemorrhage, the injection site, petechiae, ecchymoses, bleeding gums, epistaxis and arm beam test results, etc.
 
(2) phase. Part of the patients with high fever last not ease, or fever after illness, but obviously caused by the increase of blood capillary permeability of the plasma leakage, serious shock and other important viscera damage can occur.
 
A period usually appear in the disease of 3 ~ 8 days. Such as abdominal pain, vomiting severe warning indications often prompts period begins.
 
In front of the plasma leakage occurs, patients are often characterized by progressive leukopenia and platelet count down quickly. Patients with different degree of plasma leakage difference is very big, such as chemosis, pericardial effusion, pleural effusion and ascites. Elevated erythrocyte hematocrit (HCT), margin often reflect the severity of the plasma leakage.
 
If the plasma leakage cause serious lack of capacity, plasma shock patients can occur. Long time shock can occur in patients with metabolic acidosis and multiple organ dysfunction and disseminated intravascular coagulation.
 
A few patients without obvious leakage of plasma, but still can appear serious bleeding such as subcutaneous hematoma, gastrointestinal bleeding, vaginal bleeding, intracranial hemorrhage, haemoptysis, macroscopic haematuria, etc; Patients also can appear encephalitis or encephalopathy (e.g., severe headache, drowsiness, restlessness, delirium, convulsions, coma, neck stiffness, etc.), ARDS, acute myocarditis, acute liver failure, acute renal failure and so on.
 
(3) the recovery period. After 2 ~ 3 days, patients better, gastrointestinal symptoms, into the recovery period. Some patients bleeder visible tip samples, lower limb, can have itchy skin. White blood cell count began to rise, the platelet count gradually restored.
 
Most patients characterized by ordinary dengue fever, a few patients develop severe dengue fever, only individual patients fever period and recovery period.
 
Four, severe dengue fever warning indications
 
(a) the high risk population.
 
1. Patients with secondary infection;
 
2. Accompanied by diabetes, high blood pressure, coronary heart disease, liver cirrhosis, peptic ulcers, asthma, copd, chronic kidney function not entire basic diseases;
 
3. The elderly or infants and young children;
 
4. Obesity or severely malnourished;
 
5. Pregnant women.
 
(2) clinical indications.
 
1. His condition deteriorated after fever;
 
2. Abdominal pain;
 
3. Vomiting;
 
Plasma leakage performance; 4.
 
5. Lethargy, irritability;
 
6. Obvious bleeding tendency;
 
7. Hepatomegaly > 2 cm;
 
8. Oliguria.
 
(3) the laboratory indications.
 
1. The rapid decline in platelet;
 
2. HCT.
 
Five, complications,
 
Can appear in viral hepatitis, myocarditis, infusion excess, electrolyte and acid-base imbalance, double infection, acute intravascular hemolysis, etc.
 
Six, laboratory examination
 
1. Blood routine: total number of white blood cells decreased, most cases of early began to decline, 4 ~ 5 of heaven to the lowest point, WBC count is given priority to with neutrophils decline. Most of the cases with thrombocytopenia, the minimum can be dropped to under 10 x 109 / L.
 
2. Routine urine: a small protein, red blood cells, such as pipe type can occur.
 
3. Blood biochemical examination: more than half of the patients with elevated aminotransferase, lactate dehydrogenase, part of the patients with myocardial enzyme, urea nitrogen and creatinine increased, etc. Alanine amino transaminase (ALT) and aspartate amino transaminase (AST) in mild-to-moderate rise, a few patients with elevated total bilirubin, serum albumin. Some patients can appear hypokalemia electrolyte disorder; The blood coagulation function checks visible fibrinogen decrease, prothrombin time and clotting enzyme live longer, severe cases of clotting factor Ⅱ, Ⅴ, Ⅶ, Ⅸ and Ⅹ reduced.
 
4. The etiology and serological detection: acute stage and convalescence blood samples inspection. Sick of the original testing conditions of medical institutions should test as soon as possible, without etiology detection conditions of medical institutions shall return the specimen to send designated institutions detection.
 
Acute dengue fever period applicable antigen (NS1) detection and virus nucleic acid detection for early diagnosis, there are conditions for virus isolation.
 
First infected patients, the disease can be detected 3 ~ 5 days after the IgM antibody, reach a peak incidence after 2 weeks, can maintain 2 ~ 3 months; Disease can be detected IgG antibody after 1 week, IgG antibody can maintain several years or even a lifetime; Within 1 week, detected in serum in patients with high levels of specific IgG antibody tip secondary infection, also can be combined with capture method to detect the IgM/IgG antibody ratio of comprehensive judgment.
 
Seven, imaging examination
 
CT or chest radiograph can be found on one side or double side pleural effusion and some patients with interstitial pneumonia. Ultrasound visible liver splenomegaly, critically ill patients can also be performance was observed in the gallbladder wall thickening, and fibrin, abdominal cavity and pelvic cavity accumulates fluid performance. Computed tomography (CT) and magnetic resonance imaging (mri) can be found that the brain edema and intracranial hemorrhage, subcutaneous tissue, leakage, etc.
 
Eight, diagnosis and differential diagnosis
 
(a) the diagnosis of dengue fever.
 
According to the history of epidemiology, clinical manifestations and laboratory test results, to make the diagnosis of dengue fever. In the case of epidemiology history is unknown, according to clinical manifestation, auxiliary examination and laboratory test results to make the diagnosis.
 
Suspected cases: in line with the clinical manifestations of dengue, has a history of epidemiology (onset within 15 days prior to the dengue fever epidemic areas, or where dengue cases), or there are white blood cells and thrombocytopenia.
 
2. Clinical diagnosis cases: in line with the clinical manifestations of dengue, has a history of epidemiology, and white blood cell, platelet reduce at the same time, a single copy of dengue virus specific IgM antibody positive serum.
 
3. Confirmed cases, suspected or clinical diagnosis cases, acute phase serum NS1 antigen or virus nucleic acid detection or isolate dengue virus or recovery of serum specific IgG antibody positive transfer or drop degree is more than four times higher.
 
(2) the diagnosis of severe dengue fever.
 
One of the following situations:
 
1. Severe bleeding including subcutaneous hematoma, hematemesis, black, vaginal bleeding, macroscopic haematuria, intracranial hemorrhage, etc.;
 
2. Shock;
 
3. The important viscera dysfunction or failure: liver damage (ALT and/or the AST > 1000 IU/L), ARDS, acute heart failure, acute renal failure, encephalopathy (such as encephalitis, meningoencephalitis).
 
(3) of the differential diagnosis.
 
The clinical manifestations of dengue fever is diversiform, pay attention to identify with the following diseases. With such as chikungunya fever associated with bleeding disease syndrome, kidney syndrome hemorrhagic fever, fever with thrombocytopenia and other identification; And fever with a rash diseases such as measles, urticaria, scarlet fever, meningitis, typhus, tsutsugamushi disease identification; Have cases of encephalopathy performance to identify with other central nervous system infection; White blood cells and platelets to reduce obviously, and blood system diseases identification.
 
Nine, treatment,
 
There is no special effects of antiviral drugs, mainly adopt measures to support and symptomatic treatment. Treatment principle is early detection, early treatment, early anti-mosquito segregation. Severe cases of early recognition and timely treatment is the key to reduce the case fatality rate. Severe dengue diagnosis flow chart see attachment.
 
(a) general treatment.
 
1. Bed rest, light diet;
 
2. The anti-mosquito isolation to symptoms and relieving fever;
 
3. Monitoring consciousness, vital signs, urine, blood platelet, HCT, etc.
 
(2) of symptomatic treatment.
 
1. The antifebrile: mainly physical cooling;
 
2. The rehydration: oral rehydration is given priority to;
 
3. Calm the pain: can give stable, cranial pain on symptomatic treatment, etc.
 
(3) the treatment of severe dengue fever.
 
Besides general monitoring indexes which are mentioned in the treatment of severe dengue cases should also be dynamic monitoring for electrolyte. Of plasma leakage, shock, severe ARDS, severe bleeding, or other important viscera function disorder should actively take corresponding treatment.
 
1. The rehydration principle: severe dengue rehydration principle is to maintain good tissue perfusion. Can give balance salt liquid crystal, such as severe leakage shall timely supplement albumin colloidal liquid, etc. According to the patients with HCT, platelet, electrolyte, adjust the amount and type of rehydration in urine volume up to about 0.5 ml/kg/h, under the premise of should try to reduce the amount of intravenous rehydration.
 
2. Anti-shock treatment: a shock for liquid recovery treatment as soon as possible, types of infusion and transfusion volume see rehydration principle, at the same time actively correcting acid-base imbalances. Liquid recovery treatment unable to maintain blood pressure, vascular active drugs should be used; Severe bleeding caused by shock, should be timely infusion of red blood cells or whole blood. Conditional hemodynamic monitoring can be performed and guiding treatment.
 
3. The treatment of bleeding:
 
(1) bleeding clear, such as severe epistaxis give local bleeding. Gastrointestinal bleeding is given acid drugs. Try to avoid a gastric tube, urine tube and other invasive diagnosis and treatment;
 
(2) the serious bleeding, transfusion of red blood cells in time according to the condition;
 
(3) severe hemorrhage with platelets should significantly reduce platelet transfusion.
 
4. Other treatment: the loop support treatment and bleeding at the same time, should pay attention to other state organ function monitoring and treatment; Prevent and treat various complications in a timely manner.
 
10 and syndrome differentiation of traditional Chinese medicine treatment
 
(a) the choice of oral Chinese medicine syndrome differentiation one.
 
1. Who with disease
 
Clinical manifestation: evil cold fever, headache, body bone pain, facial blushing, limb burnout, micro thirsty. Red tongue tip, moss white or yellow and turbidity, pulse number or moist.
 
Treatment: clear heat, wet, through table muscle.
 
Reference: the formulas new Chinese mosla herb drinks muscle chai ge dissociation and tonga. Kudzu root, honeysuckle, forsythia, bupleurum, scutellaria, herba lophatheri, Chinese mosla herb, liquorice, white hyacinth bean, etc.
 
2. Heat yu chi points
 
Clinical manifestation: strong hot face red, the skin is spotted, polydipsia sweat is much, muscle aches, urine short red. Moss yellow red tongue, pulse hong.
 
Treatment: heat protection, XuanYu evil.
 
Reference: the formulas white tiger decoction and gardenia fish in tonga. Plaster stone, rhizoma anemarrhenae, gardenia, SSP, artemisinin, licorice, etc.
 
3. The evil film the original license
 
Clinical manifestations: chills strong hot, or cold but not hot, and heavy headache, red red face, limbs heavy sour, stay, bosom frowsty, often with hiccups or vomiting, urine short red. Tongue red, moss Bai Hou greasy turbidity or white, such as powder, pulse and moist.
 
Treatment: scanty profit through, monarch indecent material.
 
Reference: the formulas of the original drink to add and subtract. Betelnut, annua, rhizoma anemarrhenae, radix scutellariae, radix paeoniae alba, magnolia bark, amomum, pinellia, honeysuckle, etc.
 
4. The stasis poison knot
 
Clinical manifestations: fever or body has the fever, dizziness, fatigue, stay to ou, refuse to by abdominal pain, skin ecchymosis, purulent blood or and see other fact. Dark red tongue, less moss, pulse fine acerbity.
 
Treatment: cold blood hemostasis, blood detoxification.
 
When reference drugs: horn to add and subtract. Buffalo horn, gardenia, radix rehmanniae, radix paeoniae rubra, cortex moutan, big field thistle, purple beads grass, charcoal, garden burnet, sophora japonica, herba agrimoniae, etc.
 
5. Sun be the spirit and anxiety
 
Clinical manifestations: body heat, pale face, and shortness of breath, sweating, limbs cold, faint delirious speech agitated or god, skin maculae or see all kinds of bleeding. Tongue reddish, micro pulse.
 
Treatment: yiqi solid.
 
Reference: the formulas pulse dispersion and four inverse tonga subtraction. Red ginseng (Fried) against another, dwarf lilyturf, schisandra fruit, ripe aconite root, dried ginger, cinnamon, etc.
 
6. Poisonous defect pericardium
 
Clinical manifestation: body heat burning hands, god faint delirious speech, neck stiffness, skin ecchymosis, or limbs twitch. Tongue is purple, moss yellow dry, smooth of arteries and veins.
 
Treatment: qing Yin, nutrition and clear phlegm begin to understand.
 
Reference: the formulas tonga qing. Buffalo horn, antelope horn, ginseng, radix ophiopogonis, lotus plumule, bamboo, forsythia, stone calamus, turmeric, etc.
 
More than 7. Evil is not a net card
 
Clinical manifestation: tired fatigue, skin rashes, often the new stay, make water shortage. Coating on the tongue is not clean, pulse fine slightly.
 
Treatment: qi and nourishing Yin, detoxicating and rash.
 
Reference: the formulas bamboo leaves gypsum soup. Bamboo leaves, gypsum, dwarf lilyturf, ginseng, perrin, reed rhizome, radix paeoniae rubra, radix arnebiae seu lithospermi, radix rehmanniae, lentils, liquorice etc.
 
(2) the choice of oral proprietary Chinese medicine syndrome differentiation injection or intravenous drip of traditional Chinese medicine.
 
Choice of heat-clearing and detoxifying, cooling blood to remove stasis and replenishing qi, awake brain begin to understand the class preparation.
 
Eleven, prognosis,
 
Dengue fever is a self-limited disease, usually good prognosis. Factors that affect prognosis include patients with history of dengue virus infection, age, basic diseases, complications, and so on. A handful of severe dengue cases can die in important viscera function failure.
 
Twelve, remove anti-mosquito isolation criteria
 
Course of more than 5 days, and heat may be discharged back more than 24 hours.
 
13, discharge standard
 
Patients with dengue fever heat back more than 24 hours at the same time the clinical symptoms can be discharged from hospital.
 
 
 
Attachment: severe dengue diagnosis flowchart. Doc