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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 64-68

Analysis of Transfusion Support in Dengue Epidemic in Military Setting of Sri Lanka


Army Hospital Blood Bank, Colombo, Sri Lanka

Date of Submission06-Aug-2019
Date of Acceptance01-Jan-2020
Date of Web Publication13-Mar-2021

Correspondence Address:
Dr. Samantha Kumarage
Army Hospital Blood Bank, Colombo
Sri Lanka
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bbrj.bbrj_114_19

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  Abstract 


Background: Severe dengue affects most Asian and Latin American countries and becomes a leading cause of hospitalization and death among children and adults in these regions. During the year 2017, a total of 186,101 suspected dengue cases were reported, and as of May 24, 2018, a total of 19,459 suspected dengue cases were reported to the Ministry of Health of Sri Lanka with over 320 deaths in 2017 and 202 deaths in 2018. The aim of the study was to evaluate whether the blood and component transfusion for the dengue patients and the routine inventory management at our blood bank were affected by the nonfollowed transfusion guidelines in dengue management of Sri Lanka. Methods: This retrospective descriptive study analyzed the distribution of relative frequencies of variables in the requests received and tangible transfusions done from January 1, 2017, to December 31, 2017. Results: A total of 717 transfusion requests received from the confirmed dengue patients in 2017. In this cohort, 73 requests were for dengue fever, 494 requests for dengue hemorrhagic fever (DHF), 97 requests for DHF leaking phase, 46 requests for DHF critical phase, and 7 requests for dengue shock syndrome. Conclusions: Even though 60% of the actual transfusion requests followed the guidelines of the dengue management, 40% (13 requests) violated the guidelines in the actual transfusions. However, compared to the 717, total requests for transfusions this number is very minimal (0.97%). Of 3601 inventories managed at blood bank during 2017, additional dengue-related 717 requests, less than 1% violated the guidelines of transfusion requests according to the current guidelines of dengue management. No extra burden was created to inventory management due to nonfollowed guidelines. An unusual preponderance of transfusion requirements of AB patients was highlighted. Comparing the published data, dengue management at our hospital is exemplary.

Keywords: Blood and component requests, dengue fever, dengue hemorrhagic fever, dengue hemorrhagic fever critical phase, dengue hemorrhagic fever leaking phase


How to cite this article:
Kumarage S, Jayamanna R, Mahendra I. Analysis of Transfusion Support in Dengue Epidemic in Military Setting of Sri Lanka. Biomed Biotechnol Res J 2021;5:64-8

How to cite this URL:
Kumarage S, Jayamanna R, Mahendra I. Analysis of Transfusion Support in Dengue Epidemic in Military Setting of Sri Lanka. Biomed Biotechnol Res J [serial online] 2021 [cited 2021 Sep 16];5:64-8. Available from: https://www.bmbtrj.org/text.asp?2021/5/1/64/311085




  Introduction Top


Dengue is an infectious disease with a recurring incidence, especially in developing countries. Despite recent economic growth, success in disease control has not been achieved, and dengue has evolved from cyclic epidemic outbreaks to a lack of seasonality.[1] The classic clinical presentation is characterized by the abrupt onset of headache, myalgia, and high fever, in addition to arthralgia, retro-orbital pain, and hemorrhagic manifestations.[1] The classical presentation differs from dengue hemorrhagic fever (DHF), which is characterized by fluid leakage into the interstitium.[2] Clinically, dengue ranges from asymptomatic, nonspecific febrile illness, classic dengue, to DHF/dengue shock syndrome (DSS).[3] Dengue fever (DF) and DHF are 2 apparently distinct clinical manifestations of dengue virus infection, and each may be caused by any of the 4 antigenically related dengue virus serotypes.[4] AS a conclusion ,it have been suggested that a better description of the clinical and laboratory presentations of cases with fatal outcome may lead clinicians to an earlier recognition of the warning signs of severe dengue resulting in timely and improved management.[5] One estimate indicates 390 million dengue infections per year (95% credible interval 284–528 million), of which 96 million (67–136 million) manifest clinically (with any severity of disease).[6] Another study, of the prevalence of dengue, estimates that 3.9 billion people, in 128 countries, are at risk of infection with dengue viruses.[7] Today, severe dengue affects most Asian and Latin American countries and has become a leading cause of hospitalization and death among children and adults in these regions.[8] During the year 2017 a total of 186,101 suspected dengue cases were reported, and as of May 24, 2018, a total of 19,459 suspected dengue cases were reported to the Epidemiology Unit of the Ministry of Health of Sri Lanka with over 320 deaths in 2017 and 202 deaths in 2018. Over 40% of dengue cases were reported from the Western province.[9]

The aim of the study was to evaluate:

  • Whether the blood and component transfusion for the dengue patients followed the current guidelines on management of DF and DHF of Sri Lanka[10]
  • Whether the routine inventory management at our blood bank was affected by non-followed transfusion guidelines in dengue management of Sri Lanka.



  Methods Top


This was a retrospective descriptive study. We analyzed the distribution of relative frequencies of variables in the requests received and tangible transfusions done at Army Hospital Colombo, from January 1, 2017, to December 31, 2017. This study was reviewed and granted a waiver of individual informed consent by the Ethical Review Committee of the Army Hospital Blood Bank, Colombo, Sri Lanka.


  Results Top


A total of 717 blood and component requests received from the confirmed dengue patients, during the stipulated time period.

In this cohort, 73 requests for DF, 494 requests for DHF, 97 requests for DHF leaking phase, 46 requests for DHF critical phase, and 7 requests for DSS [Table 1].
Table 1: Transfusion requests received according to the stages of the dengue fever

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Blood and component requests received to our blood bank from January 1, 2017, to December 31, 2017, related to DF.

The age range was 5–85 years [Table 3].
Table 3: Age distribution

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628 requests were males and 89 females.

524 requests were urgent requests and 192 were routine requests.

142 patients were blood group A, 240 patients were B, 43 were AB, and 292 were blood group O [Table 4].
Table 4: Blood group-wise distribution of requests received

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Actual transfusion of all components performed for these request was 23 of which 14 (60.8%) followed the guidelines [Table 5].
Table 5: Actual transfusions

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Sixteen actual red blood cell transfusions were performed of which 11 followed the guideline.

In our cohort, various components were transfused to 19 patients. 84.21% of the actual transfusions were done to less than 40 years of age group. Blood group-wise distribution was compiled [Figure 1].
Figure 1: Actual transfusion preformed according to the blood group

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We manage inventories of 3601 requests for other transfusion requirements in addition to 717 dengue-related requests during the year under review of which 7 (10%) of the requests were not followed the guidelines [Table 6].
Table 6: Categories of dengue fever according to the blood group

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  Discussion Top


A total of 186,101 cases of confirmed dengue patients reported nationwide during the year under review.[11] In our cohort, 717 patients confirmed dengue patients taken into account that is 0.38% of the reported cases of the country.

Males were predominant in our study. 87.58% were males and 12.41% were females, whereas in the study done at Brazil, females were predominant accounting for 57% cases and 48% reported in Indonesia.[12] This male preponderance at our study may be related to predominance of males in the military in our setup.

The mean patient age was 31.66 years in our study [Table 2]. The mean age of the patient was 38.2 years in Brazil[1] and 25 years in India.[13] These differences in age groups can be attributed to the case selection criteria and the types of existing coverage in the hospitals where the studies were conducted. It is highlighted that most patients were reported in 21–30 years of age group and the second most is 31–40 years of group [Figure 2]. They are the most active group in any community and therefore possible to expose to mosquito bites than the other groups. In military settings, young soldiers are actively participating most of the military-related activities, and this may be the reason that in our cohort, 21–40 years of age group is more prevalent to the disease. However, published data indicated that the disease prevalence is more in children and young adult.
Table 2: Demographic data

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Figure 2: Age-wise analysis of dengue fever

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Actual transfusions performed (any components) predominance in less than 40 years of age group (84.21%). This indicated that the severe complications of DF are higher in the young military population in our cohort. Although, previous studies showed more complications in children and than young adults.

We have analyzed any transfusions performed according to the blood group [Figure 1]. It was highlighted that the unusual preponderance of transfusion requirements among AB blood group patients (11.62%). This AB preponderance of transfusion is best to be evaluated further [Table 7],[Table 8],[Table 9].
Table 7: Total inventory management at blood bank

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Table 8: Association of blood groups and actual transfusions

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Table 9: Complications of dengue fever versus blood group

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The data of this study showed a possible association between blood groups of the study population with dengue infection. One study published, stated that dengue infections were higher in individuals with O positive blood group 42.8% when compared with controls 32%.(P = 0.043) [13, 14] which is comparable with our data (40.75%) [Tables 7 and 8].

The analysis of bleeding manifestations

In our study, the magnitude of bleeding manifestation was very low compared to that reported in the literature that is 1.11%. Most commonly displayed as petechiae, gingival bleeding, and epistaxis.

In Thailand, the occurrence of hemorrhagic manifestations was reported in 50.2% of 175 pediatric patients.[15] In Indonesia, bleeding occurred in 6% of the cases with gastrointestinal sites being the most common. Another study from India reported that 15.1% of patients exhibited bleeding, with petechiae (9.3%) and epistaxis (2.7%).[13]

Despite the concern of hemorrhagic manifestations, Chaudhary et al. concluded that there was no correlation between hemorrhagic manifestations and serum platelet counts.[16]

Low magnitude of the bleeding manifestation of our study may be due to better management of the patient by strict adherence to the National Dengue Guidelines of Sri Lanka and better treatment facilities available at our hospital.

Analysis of transfusion

In the present study, 3.2% of patients received some form of transfusion; 0.13% of those patients received platelet concentrate, 0.69% received fresh frozen plasma (FFP), 0.13% patients received cryoprecipitate, and only 2.23% received packed red blood cells.

In Brazilian study, 32.1% of patients received some form of transfusion, 22.3% of those patients received platelet concentrate, 21.2% received FFP, and only 2.6% received packed red blood cells.[1]

In Thailand, 10.6% of patients with DHF received some form of transfusion, and 6.9% of these received platelet concentrate, 5% received FFP, and 3.1% received packed red blood cells.[15]

In India, a group of patients received platelet concentrate; among these cases, 31.8% were considered inappropriate transfusions, and 26.9% received FFP.[9]

In an observational study of dengue patients in Martinique with 350 evaluated cases, 9 (2.6%) received platelet transfusions, with a mean of 3.66 IU per patient (range 2.8–13.2 IU), 3 (8.6%) received packed red blood cells, and 2 (0.6%) received FFP.[17]

Due to awareness of the current dengue management guidelines and the close supervision of the patents at our setup, transfusion of the blood and component is minimal in our study compared to the other available global data.

Mortality

The reported mortality our study was 0.41%.

Figure from Thailand was 1.14%, while mortality rates in Martinique and India were less than 1% and 2%, respectively.[13],[15],[17]

Reported mortality is highest in Brazil (7.3%) among the published data.[1]

The apparent association with minimal trend of transfusions with better patent outcome is an area to be discussed. Our figures insinuate us that the requirement of transfusion we feel at the bedside for these patients is impending doom.

Lee et al. stated that randomized clinical trials suggest that a decrease in platelets counts of up to 10 × 109/L may be tolerated without the need for prophylactic platelet transfusion in the absence of major bleeding provided additional bleeding risks (significant coagulopathy, sepsis, anatomic aberrations, platelet function impairments) are absent.[18]

The British Committee for Standards in Hematology, in its most recent guidelines on platelet transfusion, states that a threshold of 10 × 109/L is safe.[19]

The mechanisms of hemorrhage in dengue are multifactorial and incompletely understood. It is not, however, solely attributed to thrombocytopenia. Studies have demonstrated that the presence or degree of thrombocytopenia alone is not associated with increased bleeding risks in dengue.

Direct activation of fibrinolysis by the dengue virus has been implicated, a process that distinguishes hemorrhage in dengue from that seen in classic disseminated intravascular coagulopathy.

It should be noted that dengue patients have preserved bone marrow function as opposed to their hematology and oncology counterparts, alarming us that the requirement of red cell concentrate and platelets much lower even what we practiced today.

However, changes in transaminases should be taken in to account as there is a correlation between the increase in these parameters and mortality.

Early recognition of dengue, especially severe DF and DHF, with prompt correction of hemodynamic parameters, remains the cornerstone of avoiding hemorrhage and ensuring good clinical outcomes.

Even though 60% of the request followed the guidelines of the dengue, 40% (13 requests) violated the guidelines in the actual transfusions.

However, we received 717 dengue-related blood and component requests during the year under review and total of 3601 inventories we managed at Army Hospital Blood Bank.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fujimoto DE, Koifman S. Clinical and laboratory characteristics of patients with dengue hemorrhagic fever manifestations and their transfusion profile. Rev Bras Hematol Hemoter 2014;36:115-20.  Back to cited text no. 1
    
2.
Brasil – Dengue: Diagnosis and Clinical Management. Adult and Child. 3rd ed. Brasília: Séria A. Standards and Technical Manuals.2007.  Back to cited text no. 2
    
3.
Guzmán MG, Kourí G. Dengue: An update. Lancet Infect Dis 2002;2:33-42.  Back to cited text no. 3
    
4.
Wills BA, Oragui EE, Stephens AC, Daramola OA, Dung NM, Loan HT, et al. Coagulation abnormalities in dengue hemorrhagic fever: Serial investigations in 167 Vietnamese children with dengue shock syndrome. Clin Infect Dis 2002;35:277-85.  Back to cited text no. 4
    
5.
Lee IK, Liu JW, Yang KD. Fatal dengue hemorrhagic fever in adults: Emphasizing the evolutionary pre-fatal clinical and laboratory manifestations. PLoS Negl Trop Dis 2012;6:e1532.  Back to cited text no. 5
    
6.
Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature 2013;496:504-7.  Back to cited text no. 6
    
7.
Brady OJ, Gething PW, Bhatt S, Messina JP, Brownstein JS, Hoen AG, et al. Refining the global spatial limits of dengue virus transmission by evidence-based consensus. PLoS Negl Trop Dis 2012;6:e1760.  Back to cited text no. 7
    
8.
Dengue and Severe Dengue; WHO report. World Health Organization; 15 April 2019.  Back to cited text no. 8
    
9.
Dengue DREF Final Report Sri Lanka: Dengue the International Federation of Red Cross and Red Crescent Societies; 31 May, 2018.  Back to cited text no. 9
    
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11.
Available from: http://www.epid.gov.lk/web/index.php?option=com_casesanddeaths and Itemid=448&lang=en#. [Last accessed on 2021 Mar 5].  Back to cited text no. 11
    
12.
Chairulfatah A, Setiabudi D, Agoes R, Colebunders R. Thrombocytopenia and platelet transfusions in dengue haemorrhagic fever and dengue shock syndrome. Dengue Bull 2003;27:138-43.  Back to cited text no. 12
    
13.
Makroo RN, Raina V, Kumar P, Kanth RK. Role of platelet transfusion in the management of dengue patients in a tertiary care hospital. Asian J Transfus Sci 2007;1:4-7.  Back to cited text no. 13
[PUBMED]  [Full text]  
14.
Khode V, Kabbin G, Ruikar K. Association of ABO Rh blood group with dengue fever and dengue hemorrhagic fever: A case-control study. J Appl Hematol 2013;4:145-8.  Back to cited text no. 14
  [Full text]  
15.
Chuansumrit A, Phimolthares V, Tardtong P, Tapaneya-Olarn C, Tapaneya-Olarn W, Kowsathit P, et al. Transfusion requirements in patients with dengue hemorrhagic fever. Southeast Asian J Trop Med Public Health 2000;31:10-4.  Back to cited text no. 15
    
16.
Chaudhary R, Khetan D, Sinha S, Sinha P, Sonker A, Pandey P, et al. Transfusion support to dengue patients in a hospital based blood transfusion service in north India. Transfus Apher Sci 2006;35:239-44.  Back to cited text no. 16
    
17.
Thomas L, Kaidomar S, Kerob-Bauchet B, Moravie V, Brouste Y, King JP, et al. Prospective observational study of low thresholds for platelet transfusion in adult dengue patients. Transfusion 2009;49:1400-11.  Back to cited text no. 17
    
18.
Lee LK, Thein TL, Kurukularatne C, Gan VC, Lye DC, Leo YS, et al. Dengue knowledge, attitudes, and practices among primary care physicians in Singapore. Ann Acad Med Singapore 2011;40:533-8.  Back to cited text no. 18
    
19.
Available from: https://b-s-h.org.uk/media/2641/bcsh_platelet_guideline. [Last accessed on 2019 May 06].  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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