Dengue Management and Testing - Mr Zaqy Mohamad

8 July 2013

Question No. 538

Name of Person: Mr Zaqy Mohamad

Question

To ask the Minister for Health (a) whether the Ministry is satisfied that the recent fatal cases of dengue being treated at Tan Tock Seng Hospital have been adequately attended to; and (b) whether there are special measures in place at our hospitals' Accident and Emergency Departments to identify and handle dengue cases with greater expediency.

Answer

1        I wish to express once again our deepest condolences to the families of the two Singaporeans who passed away from Dengue Shock Syndrome.

2        The clinical spectrum of dengue ranges from mild or asymptomatic infections to more severe forms of the disease. The vast majority of dengue patients have mild, self-limiting disease. However, a minority of patients develop more serious Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS), which can result in life-threatening complications.  As of 22 June 2013, MOH has been notified of 10,959 dengue cases. Of these, 46 (or 0.4%) had the more severe DHF.

3        There is currently no specific antiviral medication to treat dengue. The key to managing dengue patients is therefore to ensure that they get sufficient rest and hydration while their body fights the virus, and to closely monitor their clinical status so that additional supportive therapy such as platelet or blood transfusions can be provided if necessary. Unfortunately, despite the best efforts of our doctors, some cases of DHF or DSS will succumb to the disease.

4.       MOH was notified of the first death this year from DSS on 29 May 2013. The deceased presented at Tan Tock Seng Hospital (TTSH) emergency department (ED) on 23 May with fever and flu-like symptoms for one day, and was diagnosed with viral fever with possible early dengue.  He was discharged as he was clinically stable and was keen to go home.  He was advised to have his blood test repeated by a primary care doctor and asked to return to the ED if his symptoms worsened.  He returned to the ED on 24 May but left, at his own request, without seeing the doctor. On 26 May, he visited TTSH ED with complaints of fever, headache and vomiting, and was admitted.  He tested positive for acute dengue infection.  He subsequently developed liver inflammation and confusion and was transferred to the intensive care unit (ICU) on 28 May. However, his condition continued to deteriorate despite maximal supportive therapy, including multiple blood transfusions, and he passed away on 29 May.

5.       The second death from DSS was notified to MOH on 9 Jun.  The deceased, who had a history of diabetes and high blood pressure, presented at TTSH ED on 5 Jun with fever for one day, as well as left leg swelling and redness.  He was clinically stable at the visit. He was diagnosed with cellulitis, discharged with antibiotics, and also advised to be monitored by a primary care provider for possible dengue. He was asked to return to the ED should his symptoms worsen.  He next visited the ED on 7 Jun with weakness of his legs, with worsened swelling and redness of his left leg, and persistent fever.  He was admitted for left leg cellulitis and probable dengue, which was confirmed by laboratory testing. He developed kidney failure and liver inflammation and was subsequently transferred to the ICU on 8 Jun. His condition continued to deteriorate and he passed away on 9 Jun despite maximal treatment. 

6.       MOH sought independent expert opinion on the management of both cases. The experts have advised that the clinical management was consistent with accepted standard clinical practice in both cases.

7.       MOH and our public hospitals continually improve clinical management by sharing and learning good practices.  MOH regularly issues circulars to our doctors and hospitals to provide updates on the dengue situation and reinforce advice about the clinical management of dengue or suspected dengue patients. Doctors are advised to monitor dengue patients closely, and to look out for warning signs and symptoms which may warrant a referral to hospital for further medical evaluation and management. Hospitals are also reminded to ensure that for suspect or confirmed dengue patients who are clinically assessed to not require admission at that point in time, there are outpatient monitoring systems to review them. In addition, hospitals have been informed that suspect and confirmed cases of dengue who return to emergency departments within 24 to 48 hours should be appropriately prioritised at triage.