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Dengue hemorrhagic fever (DHF) is a syndrome caused by the mosquito-borne dengue virus. It tends to affect children under 10 most severely, causing abdominal bleeding, hemorrhage, and circulatory collapse shock. DHF starts abruptly, presenting like normal dengue fever, with high continuous fever and headache, sore throat, cough, nausea, vomiting, and abdominal pain. Shock, and the transition to DHF, occurs after 2 to 6 days with sudden collapse, cool clammy extremities, weak pulse, and blueness around the mouth. The patient will experience severe bruising, blood spots in the skin, spitting up blood, blood in the stool, bleeding gums and severe nosebleeds. Pneumonia and heart inflammation may be present. The mortality rate for DHF ranges, depending on access to medical care, IV fluids, and age, from 6% to 30%. Most deaths occur in children. Infants under one year of age are especially at risk of death.
Dengue fever is spread in cyclical outbreaks, spiking every 4-5 years. This year’s numbers are peaking: during the whole of 2010 AHC treated a total number of 194 dengue patients; in the whole of 2011 AHC treated 399 dengue patients. This year, in only the months of May and June, AHC has treated 282 patients for DHF and has seen a significant increase in the number of children seen in our Outpatient Department – which now frequently treats over 600 children daily – and that was just the beginning of the rainy season (when dengue spreads most rapidly ).
To better understand the drastic nature of dengue currently at AHC, May 2011 only saw 4 dengue cases, and May 2012 saw 126 dengue cases, 97% of which were cases of the more serious DHF. Currently, over 50% of Inpatient Department patients have DHF. In May alone, we had two dengue-related deaths in young children, and the number is only expected to increase.
The AHC’s Inpatient Ward normally has 30 beds. In early May, 6 beds were added in the corridors to cope with the initial increase in patients who needed to be admitted, soon to be followed by an additional 6 mats on corridor floors.
In early June the number of children affected by DHF further increased, forcing AHC to add extra beds to its Emergency and Intensive Care Units. It became clear that we were facing a full dengue outbreak.
AHC management reacted quickly to the emergency to accommodate more children, providing all of them decent accommodation and ensuring that overcrowding would not affect the quality of care offered by AHC.
To accommodate so many more patients, AHC reorganized the hospital to hold more beds and expand the IPD. Because the permanent IPD is filled to capacity, we have added a total of 24 more beds, expanding the IPD to include the ward usually hosting the Low Acuity Unit (LAU).
As the LAU ward is now filled with children recovering from dengue but still unable to travel back to their villages, we have temporarily moved the LAU out of the main hospital block and into classrooms in the Medical Education Center.
To ensure that our education program – a pillar of AHC – is not affected by this emergency, we have created a classroom in the Visitor Center. It has quickly become the most popular classroom at AHC both for trainers and students.
These changes allow us to use the main hospital block for the sickest children while continuing to provide care to recovering children and continuing our education program (we currently have 60 nursing students in training at AHC).
To care for all these extra patients, we not only needed additional beds but we have had to increase the number of nurses and doctors on duty. We have raised the number of nurses on duty in the IPD from the usual 5 to 12 covering 54 beds plus 10 beds in ICU, maintaining a ratio of no more than 6 beds per nurse, while the 5 doctors on duty are all working overtime, as is the housekeeping team to maintain clean premises, a crucial factor in AHC’s infection control efforts. Finally, additional medical supplies — IV fluids in particular — will be needed throughout the outbreak.
IMPACT OF THE DENGUE OUTBREAK (Jan–Jun 2012 v. 2011):
• ADMISSIONS TO THE INPATIENT DEPARTMENT (IPD) +25%
• ADMISSION TO INTENSIVE CARE UNIT (ICU) +13%
• ADMISSION TO THE LOW CARE UNIT (LAU) for recovery +37%
On average dengue patients spend 2.9 days in the hospital. 5% of this time is spent in Intensive Care.
Once patients are stabilized the main therapy is supportive (IV fluids and blood), as we have no medications that combat the dengue virus directly.
AHC spends on average $290 per dengue patient from first admission to discharge from our facilities. This cost includes salaries and overtime of doctors and nurses and cost of medicines and infection control at the hospital. In particular each child needs medicines (primarily IV fluids) that carry a cost of $82.
Overtime costs were $12,000 in June. We project them to be $12,000 in July and August, and $10,000 in September. Staff involved in the response to the outbreak are 13 doctors, 23 nurses working in IPD and LAU, and 15 nurses working in ER/ICU. Additionally, nurses and doctors in OPD as well as Lab technicians are working overtime to cope with the higher number of outpatients (over 600 daily since July 1) and blood tests.
To date AHC has spent $108,770 on the care of dengue inpatients. These expenses have greatly affected the yearly budgets of the IPD and ICU and we must raise extra funds to cover dengue related costs.
We expect to admit no fewer than 500 new dengue inpatients before the end of the outbreak for a total cost of $145,000.
Our immediate goal is to raise $75,000 to cover doctor and nurse overtime costs (up to $34,000 for July, August, and September) and the purchase of sufficient IV fluids ($41,000).