Fluid intake and risk for hospitalization for dengue fever, Nicaragua. (Dispatches).In a hospital and health center-based study in Nicaragua, fluid intake during the 24 hours before being seen by a clinician was statistically associated with decreased risk for hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun)
1. the placing of a patient in a hospital for treatment.
2. the term of confinement in a hospital. of dengue fever dengue fever (dĕng`gē, –gā), acute infectious disease caused by four closely related viruses and transmitted by the bite of the Aedes mosquito; it is also known as breakbone fever and bone-crusher disease. patients. Similar results were obtained for children < 15 years of age and older adolescents and adults in independent analyses.
Dengue fever (DF) and dengue dengue
or breakbone fever or dandy fever
Infectious, disabling mosquito-borne fever. Other symptoms include extreme joint pain and stiffness, intense pain behind the eyes, a return of fever after brief pause, and a characteristic rash. hemorrhagic Hemorrhagic
A condition resulting in massive, difficult-to-control bleeding.
Mentioned in: Hantavirus Infections
pertaining to or characterized by hemorrhage. fever/dengue shock syndrome (DHF/DSS) are major public health problems worldwide (1). In addition to causing considerable illness and death, dengue epidemics also have a major economic impact, attributable primarily to the cost of medical care, plus vector control Vector control is any method to limit or eradicate the vectors of vector born diseases, for which the pathogen (e.g. virusor parasite) is transmitted by a vector which can be mammals, birds or arthropods, especially insects, and more specifically mosquitoes. programs and lost productivity (2,3). DF and DHF/DSS are indistinguishable in the initial febrile febrile /feb·rile/ (feb´ril) pertaining to or characterized by fever.
Of, relating to, or characterized by fever; feverish. phase, and few reliable clinical prognostic prog·nos·tic
1. Of, relating to, or useful in prognosis.
2. Of or relating to prediction; predictive.
1. A sign or symptom indicating the future course of a disease.
2. indicators of DHF/DSS exist (4). Near the time of defervescence defervescence /def·er·ves·cence/ (def?er-ves´ens) the period of abatement of fever.
The abatement of a fever. , the plasma leakage syndrome of DHF/DSS can develop suddenly and be fatal if not managed properly. As a result, in areas relatively new to dengue, such as Latin America Latin America, the Spanish-speaking, Portuguese-speaking, and French-speaking countries (except Canada) of North America, South America, Central America, and the West Indies. where DF and DHF/DSS have been spreading over the last 2 decades, high hospitalization rates for DF can occur because of the fear of discharging a patient whose case may progress to DHF/DSS. As DHF/DSS becomes hyperendemic, as in Southeast Asia Southeast Asia, region of Asia (1990 est. pop. 442,500,000), c.1,740,000 sq mi (4,506,600 sq km), bounded roughly by the Indian subcontinent on the west, China on the north, and the Pacific Ocean on the east. , and extensive experience is garnered in case management, most hospitalizations for dengue are due to frank DHF/DSS. We conducted a study to assess the extent of hospitalization attributable to dengue in Nicaragua and to examine the role of factors such as prior fluid intake on the risk for hospitalization.
Participating hospitals and health centers in urban centers of the Pacific region of Nicaragua included the Hospital Escuela Oscar Danilo Rosales Arguello in Leon, the pediatric pediatric /pe·di·at·ric/ (pe?de-at´rik) pertaining to the health of children.
Of or relating to pediatrics. reference Hospital Infantil Manuel de Jesus Rivera in Managua, and four health centers in Managua, which serve a combined population of 1.95 million people. A cross-sectional study cross-sectional study
See synchronic study.
n the scientific method for the analysis of data gathered from two or more samples at one point in time. of 2,820 suspected dengue cases was conducted from January 1 to December 31, 1999. Enrollment criteria consisted of acute febrile illness acute febrile illness A nonspecific term for an illness of sudden onset accompanied by fever accompanied by two or more of the following symptoms of DF: fever, severe headache, retroorbital pain, myalgias, arthralgias, and rash (4,5). A standardized questionnaire was used to collect demographic and clinical information, including ingestion ingestion /in·ges·tion/ (-chun) the taking of food, drugs, etc., into the body by mouth.
1. The act of taking food and drink into the body by the mouth.
2. of fluids in the 24 hours before first being seen by a clinician, as reported by the patient or parent. Of the 1,312 patients who tested positive for DENV DENV Department of Environment (Canada) infection, the mean age was 15.3 years (range 0-85), and 557 (42%) were male (Table 1). Venous blood venous blood
n. Abbr. v
Blood that has passed through the capillaries of various tissues other than the lungs, is found in the veins, in the right chambers of the heart, and in pulmonary arteries, and is usually dark red as a result of a was drawn at the first visit, and convalescent-phase serum specimens were obtained when possible (19% of patients). Clinical evolution of the illness among hospitalized patients was documented by chart review with standardized data-entry forms. This study was approved by the Institutional Review Boards of both University of California, Berkeley The University of California, Berkeley is a public research university located in Berkeley, California, United States. Commonly referred to as UC Berkeley, Berkeley and Cal (#99-4-38) and the Centro Nacional de Diagnostico y Referencia of the Nicaraguan Ministry of Health (#99-04).
Dengue virus dengue virus
A virus of the genus Flavivirus that is the cause of dengue. (DENV) infection was identified in 1,312 patients by serologic se·rol·o·gy
n. pl. se·rol·o·gies
1. The science that deals with the properties and reactions of serums, especially blood serum.
2. methods (immunoglobulin immunoglobulin: see antibody; immunity; immunology.
Any of the glycoproteins in the blood serum that are induced in response to invasion by foreign antigens and that protect the host by eradicating pathogens. M-capture enzyme-linked immunosorbent assay enzyme-linked immunosorbent assay
Enzyme-linked immunosorbent assay (ELISA)
A diagnostic blood test used to screen patients for AIDS or other viruses. [ELISA ELISA (e-li´sah) Enzyme-Linked Immuno-Sorbent Assay; any enzyme immunoassay using an enzyme-labeled immunoreactant and an immunosorbent.
n. ] or inhibition ELISA for total anti-DENV antibodies), virologic means (virus isolation, reverse transcriptase-polymerase chain reaction), or both (5). DENV2, DENV4, and DENV3 accounted for 79%, 17%, and 5% of the typed viruses, respectively. Dengue fever was divided into classic DF and DF with hemorrhagic manifestations (DFHem); severe dengue was defined as DHF DHF dihydrofolate or dihydrofolic acid. (World Health Organization classification DHF grades I and II), DSS (1) (Digital Signature Standard) A National Security Administration standard for authenticating an electronic message. See RSA and digital signature.
(2) (Digital Satellite S (World Health Organization DHF grades III and IV) (1), or an additional classification designated "dengue with signs associated with shock" (DSAS DSAS Database Security Audit System (IPlock)
DSAS Division of Substance Abuse Services
DSAS Direct Support Aviation Section
DSAS Data Set Analysis System ). DSAS was designated when either hypotension hypotension
or low blood pressure
Condition in which blood pressure is abnormally low. It may result from reduced blood volume (e.g., from heavy bleeding or plasma loss after severe burns) or increased blood-vessel capacity (e.g., in syncope). for age or narrow pulse pressure pulse pressure
The variation in blood pressure occurring in an artery during the cardiac cycle; the difference between systolic and diastolic pressures. plus clinical signs of shock were present and serial hematocrit Hematocrit Definition
The hematocrit measures how much space in the blood is occupied by red blood cells. It is useful when evaluating a person for anemia.
Blood is made up of red and white blood cells, and plasma. and platelet counts failed to document thrombocytopenia Thrombocytopenia Definition
Thrombocytopenia is an abnormal drop in the number of blood cells involved in forming blood clots. These cells are called platelets. and hemoconcentration, potentially attributable to fluid replacement therapy (5). The relationship between hospitalization and fluid intake was assessed by unconditional logistic regression In statistics, logistic regression is a regression model for binomially distributed response/dependent variables. It is useful for modeling the probability of an event occurring as a function of other factors. . Because virtually every patient with severe dengue was hospitalized, such risk factor analysis was not suitable for these patients as a separate group. Thus, the analysis was restricted to DF and DFHem patients. Univariate and multivariate analyses were performed separately on children (< 15 years of age) and older adolescents and adults ([greater than or equal to] 15 years of age). Covariates found to be significant in univariate analyses were included in the initial multivariate models (Table 2).
Although a much higher proportion of severe dengue patients were hospitalized compared with DF and DFHem patients, larger absolute numbers of hospitalizations were due to classic DF and DFHem because many more cases of DF/DFHem than of severe dengue occur (Table 1). Thus, of all the laboratory-confirmed DENV-positive hospitalized patients, classic DF (23.5%) and DFHem (50.0%) cases comprised three times as many as DHF, DSS, and DSAS combined (23.6%). These profiles have been maintained from year to year, with 28% and 20% of hospitalized cases due to classic DF and 51% and 58% due to DFHem in 1998 and 2000, respectively (5). Furthermore, the mean duration of hospitalization was similar for patients with DF and those with severe dengue (Table 1).
Among children with DF or DFHem, ingestion of fluid in the 24 hours before being seen by a clinician was found to be protective against hospitalization after adjusting for distance from health facility, date of symptom onset, and thrombocytopenia (odds ratio [OR]=0.74 per each additional glass consumed, 95% confidence intervals [Cl] 0.66 to 0.83, p<0.01) (Table 2). Similar results were obtained for older adolescents and adults after adjusting for date of symptom onset and thrombocytopenia, with an OR of 0.71 (95% CI 0.59 to 0.85, p<0.01). In analyses with a statistical model that did not assume a linear relationship between number of glasses ingested in·gest
tr.v. in·gest·ed, in·gest·ing, in·gests
1. To take into the body by the mouth for digestion or absorption. See Synonyms at eat.
2. and hospitalization, additional benefit was noted for each glass up to five, after which the incremental benefit remained constant. Thus, in a model that compared the fluid intake of five glasses or less than five glasses with ingestion of more than five glasses, the adjusted OR for hospitalization was 0.19 (95% Cl 0.09 to 0.39, p<0.01) among DF and DFHem cases in children and 0.20 (95% CI 0.07 to 0.57, p<0.01) in those [greater than or equal to] 15 years of age (Table 2). We also performed the analysis with all disease states, including severe dengue cases, and the results were virtually identical to those obtained with only DF/DFHem cases (data not shown).
The most common liquid ingested was water (70%), followed by fruit juice (42%), lemonade (27%), milk (25%), coffee (14%), oral dehydration serum (6%), and tea (2%). The mean number of glasses ingested by nonhospitalized DF/DFHem case-patients was 5.2, whereas the mean number glasses ingested by hospitalized DF/DFHem patients was 2.8, similar to the mean of 2.9 glasses ingested by hospitalized severe patients (DHF/DSS/DSAS). These findings suggest that maintaining hydration hydration /hy·dra·tion/ (hi-dra´shun) the absorption of or combination with water.
1. The addition of water to a chemical molecule without hydrolysis.
2. may lead to reduced hospitalizations of patients with DF/DFHem. Other independent risk factors for hospitalization included in the final multivariate model were increasing distance from the healthcare facility, later date of symptom onset, and the presence of thrombocytopenia. The risk conferred by later date of symptom onset reflects increased awareness of dengue by medical staff as the annual epidemic intensified. Because thrombocytopenia is an indication for hospitalization (especially for pediatric dengue patients), its emergence as a risk factor is not surprising.
Because inpatient medical care of DF and DFHem patients can contribute significantly to the economic impact of dengue, we sought to define outpatient measures that could decrease DF hospitalization rates. Dengue patients are likely to be susceptible to dehydration because of high fever and concomitant anorexia. While oral rehydration therapy oral rehydration therapy
Treatment for diarrhea-related dehydration in which an electrolyte solution containing fluids and vital ions is administered. is listed as standard outpatient management for DHF (1), little discussion exists on the use of such therapy for DF and DFHem cases (4), and no published studies have examined the effect of fluid intake at home. Our results show that this simple measure may have a significant protective effect against hospitalization and potentially on the severity of DF/DFHem, although causality causality, in philosophy, the relationship between cause and effect. A distinction is often made between a cause that produces something new (e.g., a moth from a caterpillar) and one that produces a change in an existing substance (e.g. cannot be confirmed because of the observational nature of this study. To definitively demonstrate this effect, this question must be investigated by prospective intervention studies intervention studies,
n.pl the epidemiologic investigations designed to test a hypothesized cause and effect relation by modifying the supposed causal factor(s) in the study population. . However, our data do suggest that promoting a high fluid intake at home could help reduce the need for hospitalization and thus attenuate To reduce the force or severity; to lessen a relationship or connection between two objects.
In Criminal Procedure, the relationship between an illegal search and a confession may be sufficiently attenuated as to remove the confession from the protection afforded by the economic impact of dengue in countries experiencing epidemics of dengue fever.
Table 1. Characteristics of all hospitalized and unhospitalized dengue patients Hospitalized cases Mean (sd) or Data n % of group Demographic data Age (y) 478 9.4 (8.9) Male 229 47.8% Distance (km) to health facility 464 10.0 (25.0) Disease classification (a) Classic DF 113 23.5% DFHem 240 50.0% DHF 67 14.0% DSS 16 3.3% DSAS 30 6.3% No classification 14 2.9% Duration of hospitalization (days) (b) Classic DF 52 5.7 (1.7) DFHem 95 5.1 (1.7) DHF 56 6.1 (c) (1.5) DSS 15 6.9 (c, d) (1.9) DSAS 28 6.1 (c) (1.8) No classification 11 6.2 (1.9) Clinical data at presentation No. of glasses of fluid ingested during previous 24 h (e) 331 2.9 (2.3) Thrombocytopenia 289 60.2% Anorexia 239 50.9% Stomach pain 271 58.4% Days since onset of symptoms 476 5.5 (5.6) Unhospitalized cases Mean (sd) or Data n % of group Demographic data Age (y) 834 18.7 (15.5) Male 328 39.2% Distance (km) to health 831 2.7 (6.1) Disease classification (a) Classic DF 706 84.4% DFHem 129 15.4% DHF 0 0% DSS 1 0.1% DSAS 0 0% No classification 1 0.1% Duration of hospitalization (days) (b) Classic DF DFHem DHF DSS DSAS No classification Clinical data at presentation No. of glasses of fluid ingested during previous 24 h (e) 757 5.6 (3.9) Thrombocytopenia 58 6.9% Anorexia 422 53.3 % Stomach pain 404 51.5% Days since onset of symptoms 826 5.2 (5.7) Total Mean (sd) or Data n % of group Demographic data Age (y) 1,312 15.3 (14.2) Male 557 42.3% Distance (km) to health 1,295 5.3 (16.1) Disease classification (a) Classic DF 819 62.1% DFHem 369 28.0% DHF 67 5.1% DSS 17 1.3% DSAS 30 2.3% No classification 15 1.1% Duration of hospitalization (days) (b) Classic DF DFHem DHF DSS DSAS No classification Clinical data at presentation No. of glasses of fluid ingested during previous 24 h (e) 1,088 4.8 (3.7) Thrombocytopenia 347 26.4% Anorexia 661 52.4% Stomach pain 675 54.4% Days since onset of symptoms 1,302 5.3 (5.7) (a) DF, dengue fever; DFHem, DF with hemorrhagic manifestations; DHF, dengue hemorrhagic fever; DSS, dengue shock syndrome; DSAS, dengue with signs associated with shock. (b) Information on the duration of hospitalization was available from 52 (46%) of hospitalized classic DF patients; 95 (40%) of hospitalized DFHem patients; 56 (84%) of hospitalized DHF patients; 15 (94%) of hospitalized DSS patients; and 28 (93%) of hospitalized DSAS patients. Outliers ([greater than or equal to] 12 days) were removed before analysis. (c) The mean duration of hospitalization was significantly longer for DHF cases, DSS cases, and DSAS cases as compared with duration for DFHem cases (p<0.05 for each, Student t test). (d) The mean duration of hospitalization was significantly longer for DSS cases compared with duration for classic DF cases (p<0.05, Student t test). (e) The average glass contains approximately 8 oz. Table 2. Crude and adjusted odds ratios and 95% confidence intervals for factors potentially associated with hospitalization for classic dengue fever or dengue fever with hemorrhagic manifestations Children (<15 years of age) (a) No. of OR (95% CI) (c) Characteristic patients (b) Crude Fluid intake during 24-h 587 period before presentation For each additional glass 0.68 (0.62 to 0.75) >5 glasses 0.14 (0.08 to 0.25) Age 719 For each additional year 0.93 (0.8 to 0.97) Sex 718 Male 395 1.43 (1.06 to 1.94) Female 323 Distance from healthcare 701 facility For each additional 5 km 2.13 (1.68 to 2.69) Date of onset of symptoms 709 For each additional 1.26 (1.16 to 1.37) month Days between onset of 713 symptoms and being seen at facility For each additional day 1.04 (1.0 to 1.07) Thrombocytopenia 499 Yes 189 6.5 (4.25 to 9.96) No 310 Stomach pain 681 Yes 370 0.94 (0.69 to 1.28) No 311 Older adolescents and adults ([greater Children than or equal (<15 years of to] 15 years age( (a) of age) (a) OR (95% CI) (c) No. of Characteristic Adjusted (d) patients (b) Fluid intake during 24-h 405 period before presentation For each additional glass 0.74 (0.66 to 0.83) >5 glasses 0.19 (0.09 to 0.39) (e) Age -- (h) 464 For each additional year Sex 464 Male 291 Female 173 Distance from healthcare 460 facility For each additional 5 km 1.46 (1.12 to 1.91) Date of onset of symptoms 455 For each additional 1.51 (1.26 to 1.81) month Days between onset of 457 symptoms and being seen at facility For each additional day -- Thrombocytopenia 227 Yes 6.16 (3.57 to 10.64) 33 No 194 Stomach pain 439 Yes -- 216 No 223 Older adolescents and adults ([greater than or equal to] 15 years of age) (a) OR (95% CI) (c) OR (95% CI) (c) Characteristic Crude Adjusted (f) Fluid intake during 24-h period before presentation For each additional glass 0.67 (0.5 to 0.79) 0.71 (0.59 to 0.85) >5 glasses 0.16 (0.06 to 0.43) 0.20 (0.07 to 0.57) (g) Age -- For each additional year 0.98 (0.96 to 1.00) Sex Male 1.27 (0.74 to 2.17) Female Distance from healthcare facility For each additional 5 km 1.16 (0.92 to 1.46) Date of onset of symptoms For each additional 1.87 (1.53 to 2.29) 2.08 (1.53 to month 2.83) Days between onset of symptoms and being seen at facility For each additional day 0.98 (0.93 to 1.03) Thrombocytopenia Yes 3.31 (1.53 to 7.15) 3.62 (1.24 to 10.52) No Stomach pain Yes 1.50 (0.89 to 2.56) -- No (a) The age distribution of children <15 years of age was 7.2 (SD 3.9) with a range from 0 to 14 years and that of older adolescents and adults was 30.6 (SD 13.9) with a range of 15 to 85 years. (b) The numbers differ based on completeness of information for each variable. (c) OR, odds ratios; CI, 95% confidence intervals. (d) Adjusted for glasses of liquid consumed (continuous variable), distance from healthcare facility, date of onset of symptoms, and thrombocytopenia. (e) The adjusted OR and 95% CI for glasses of liquid consumed (dichotomous variable) were obtained from a separate model that adjusted for the same factors as footnote d. (f) Adjusted for glasses of liquid consumed (continuous variable), date of onset of symptoms, and thrombocytopenia. (g) The adjusted OR and 95% CI for glasses of liquid consumed (dichotomous variable) were obtained from a separate model that adjusted for the same factors as footnote f. (h) Dash indicates that this variable did not significantly contribute to the multivariate model.
We are grateful to the hospital and health center staff, personnel in the Centro Nacional de Diagnostico y Referencia virology virology, study of viruses and their role in disease. Many viruses, such as animal RNA viruses and viruses that infect bacteria, or bacteriophages, have become useful laboratory tools in genetic studies and in work on the cellular metabolic control of gene expression laboratory, and the persons who participated in the study. We thank Art Reingold, Albert Ko, Scott Halstead, Michael Diamond For the Australian Trap shooter, see .
Michael Diamond, also known as Mike D (born November 201965), is a founding member of New York hip hop trio the Beastie Boys. , and Laurel Imhoff for helpful discussions or editorial comments.
This work was supported by grant #TW-00905 from the Fogarty International Center, National Institutes of Health.
(1.) World Health Organization. Dengue haemorrhagic fever Noun 1. haemorrhagic fever - a group of illnesses caused by a viral infection (usually restricted to a specific geographic area); fever and gastrointestinal symptoms are followed by capillary hemorrhage : diagnosis, treatment, prevention, and control. 2nd ed. Geneva Geneva, canton and city, Switzerland
Geneva (jənē`və), Fr. Genève, canton (1990 pop. 373,019), 109 sq mi (282 sq km), SW Switzerland, surrounding the southwest tip of the Lake of Geneva. : The Organization; 1997.
(2.) Von Allmen SD, Lopez-Correa RH, Woodall JP, Morens DM, Chiribiga J, Casta-Velez A. Epidemic dengue fever in Puerto Rico Puerto Rico (pwār`tō rē`kō), island (2005 est. pop. 3,917,000), 3,508 sq mi (9,086 sq km), West Indies, c.1,000 mi (1,610 km) SE of Miami, Fla. , 1977: a cost analysis. Am J Trop Med Hyg 1979;28:1040-4.
(3.) Ferrando JE. Estimate of the costs of the dengue epidemic in 1994 in Nicaragua. Pan American Health Organization The Pan American Health Organization (PAHO) is an international public health agency with 100 years of experience in working to improve health and living standards of the countries of the Americas. It serves as the specialized organization for health of the Inter-American System. Consultancy Report. OPS/HCP/HCT/95.64. Washington, DC: Pan American Health Organization; 1995.
(4.) Pan American Health Organization. Dengue and dengue hemorrhagic fever hemorrhagic fever (hĕm'ərăj`ĭk), any of a group of viral diseases characterized by sudden onset, muscle and joint pain, fever, bleeding, and shock from loss of blood. in the Americas: guidelines for prevention and control. Scientific pub. no. 548. 1994. Washington, DC: The Organization; 1994.
(5.) Harris E, Videa E, Perez L, Sandoval E, Tellez Y, Perez ML, et al. Clinical, epidemiologic, and virologic features of dengue in the 1998 epidemic in Nicaragua. Am J Trop Med Hyg 2000;63:5-11.
Eva Harris Eva Harris is an Associate Professor in the School of Public Health at the University of California, Berkeley, and the founder and president of the Sustainable Sciences Institute. , * Leonel Perez, ([dagger]) Christina R. Phares, * Maria de los Angeles Maria de los Angeles (literally: Maria of the angels ) (1997) was a Venezuelan telenovela that was produced by and seen on Venezuela's Radio Caracas Televisión. Julio César Mármol came up with the idea for this telenovela. Perez, ([double dagger double dagger
A reference mark () used in printing and writing. Also called diesis.
Noun 1. ]) Wendy Idiaquez, ([double dagger]) Julio Rocha, ([section]) Ricardo Cuadra, ([section]) Emelina Hernandez, ([paragraph]) Luisa Amanda Campos Campos (käm`ps), city (1996 pop. 391,299), Rio de Janeiro state, SE Brazil, on the Paraíba River near its mouth. , ([dagger]) Alcides Gonzalez, ([dagger]) Juan Jose Amador, ([dagger]) and Angel Balmaseda ([dagger])
* University of California, Berkeley, California, USA; ([dagger]) Ministerio de Salud, Managua, Nicaragua; ([double dagger]) Hospital Infantil Manuel de Jesus Rivera, Managua, Nicaragua; Hospital Escuela Oscar Danilo Rosales Arguello, Leon, Nicaragua; and ([paragraph]) Centro de Salud Francisco Buitrago, Managua, Nicaragua
Dr. Harris is an assistant professor in the Division of Infectious Diseases infectious diseases: see communicable diseases. in the School of Public Health at the University of California, Berkeley, where her research program focuses on the pathogenesis and epidemiology of dengue virus. Over the past 8 years, she has collaborated with scientists at the Nicaraguan Ministry of Health to strengthen dengue surveillance and investigate the epidemiology of dengue in Nicaragua.
Address for correspondence: Eva Harris, Division of Infectious Diseases, School of Public Health, University of California, Berkeley, 140 Warren Hall, Berkeley, CA 94720-6350, USA; Fax: (510) 642-6350; email: firstname.lastname@example.org