TOOL FOR THE DIAGNOSIS AND CARE OF PATIENTS WITH SUSPECTED ARBOVIRAL DISEASES DENV 40 c CHIKV ZIKV a b TOOL FOR THE DIAGNOSIS AND CARE OF PATIENTS WITH SUSPECTED ARBOVIRAL DISEASES DENV 40 c CHIKV ZIKV Pan American Health Organization Pan American Sanitary Bureau Regional Office of the World Health Organization Washington, D.C., 2017 i Original version in Spanish Instrumento para el diagnóstico y la atención a pacientes con sospecha de arborisosis ISBN 978-92-75-31936-9 PAHO HQ Library Cataloguing-in-Publication Data Pan American Health Organization Tool for the diagnosis and care of patients with suspected arboviral diseases. Washington, D.C. : PAHO; 2017. 1. Arbovirus Infections. 2. Patient Care. 3. Zika Virus. 4. Chikungunya Virus. 5. Dengue. ISBN 978-92-75-11936-5 (NLM Classification: WC 524) © Pan American Health Organization 2017 All rights reserved. Publications of the Pan American Health Organization are available on the PAHO website (www.paho.org). 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In no event shall the Pan American Health Organization be liable for damages arising from its use. ii CONTENTS Foreword ................................................................................................ v Methodology ........................................................................................ vii Acknowledgments ................................................................................ ix Abbreviations and acronyms ................................................................ xi Introduction ............................................................................................ 1 1. Clinical description of dengue, chikungunya, and Zika virus infections ................................................................. 3 1.1. Dengue ..................................................................................... 3 1.2. Chikungunya ............................................................................ 7 1.3. Zika .........................................................................................11 2. Signs and symptoms of DENV, CHIKV, and ZIKV infection ....................................................................... 15 3. Suspected DENV, CHIKV, or ZIKV infection ............................. 17 5. Clinical diagnosis of patients with suspected arboviral disease ............................................................................ 21 6. Clinical care for patients ............................................................... 23 6.1. Clinical care for suspected dengue virus infection ................ 24 6.2. Clinical care for suspected chikungunya virus infection ....... 34 6.3. Clinical care for suspected Zika virus infection .................... 40 7. Recommendations for laboratory diagnosis of DENV, CHIKV, and ZIKV infection ........................................ 43 7.1. Algorithm for the detection of DENV, CHIKV, or ZIKV ..... 44 7.2. Sample collection and shipment ............................................ 45 7.3. Observations and additional recommendations ..................... 48 iii 8. Other arboviral diseases with epidemic potential ......................... 51 8.1 West Nile Virus ...................................................................... 51 8.2 Yellow Fever .......................................................................... 55 8.3 Oropouche Fever .................................................................... 58 8.4 Mayaro Fever ......................................................................... 61 8.5 The Equine Encephalitides ................................................... 63 9 References ..................................................................................... 67 10 Annexes .......................................................................................... 77 Annex 1. Analgesics: dosages in children and adults and administration to pregnant women ....................... 77 Annex 2: WHO analgesic ladder ................................................. 82 Annex 3. Scientific literature search strategy.............................. 83 iv FOREWORD Dengue is the most common mosquito-borne viral disease in the Americas and the most suspected in patients with fever. However, the recent introduction of two new arboviral diseases (chikungunya virus in late 2013 and Zika virus in 2014) has created a new challenge for public health in the Americas. The three arboviral diseases (dengue, chikungunya, and Zika) can produce very similar clinical symptoms, mainly during the acute phase (the first days of the disease), hindering clinical diagnosis by health workers, creating problems for appropriate case management, and sometimes triggering fatal events. Serological diagnosis has presented further difficulties, due to the cross-reaction between IgM/IgG antibodies of the dengue and Zika viruses, complicating laboratory confirmation and compromising epidemiological surveillance. This new and complex panorama makes it essential to provide health workers with methods for clinical diagnosis of patients suspected of dengue, chikungunya, or Zika infection, particularly at the primary care level. For this reason, in January 2016 the Pan American Health Organization/World Health Organization (PAHO/WHO) organized a meeting with a group of clinical experts from the Americas responsible for the diagnosis and management of these diseases. After the meeting, a document was prepared on the basis of experiences in the Americas, supported by the best available scientific evidence, in order to serve as tool to support health workers in the clinical diagnosis of dengue, chikungunya, and Zika cases. The end result is this tool for the diagnosis and care of patients suspected of arboviral diseases (dengue, chikungunya, and Zika), which offers valuable information on the v clinical manifestations of the three diseases and facilitates differential diagnosis among them. This tool also contains recommendations for the proper management of each of the three diseases, as well as the necessary elements for laboratory confirmation of diagnosis, which will be a valuable contribution to epidemiological surveillance. As part of current efforts to achieve an appropriate and comprehensive approach to infections caused by dengue, chikungunya, and Zika viruses, PAHO/WHO is pleased to offer the countries and territories of the Americas this first edition of the Tool for the Diagnosis and Care of Patients with Suspected Arboviral Diseases. This tool is intended to contribute to public health in the Americas by providing health workers with the clinical information necessary for the detection and timely management of the three diseases, with the main objective of saving patients’ lives. Dr. Marcos A. Espinal Director Communicable Diseases and Health Analysis vi METHODOLOGY This Tool for the Diagnosis and Care of Patients with Suspected Arboviral Diseases was prepared by a team of specialists, including clinical physicians in the prepared by a team of specialists, including clinical physicians in the Americas specialized in the care of patients with chikungunya and Zika virus infection; members of the International Technical Group of Experts on Dengue (GT-Dengue); and technical staff from the Pan American Health Organization/World Health Organization (PAHO/WHO). In a meeting held at PAHO/WHO Headquarters in Washington, D.C., from 23 to 25 January 2016, participants reviewed the descriptions and clinical information on dengue, chikungunya, and Zika, as well as the documentation, clinical guidelines, and scientific tests available as of that date for each of the three diseases. They also looked at epidemiological, clinical, and laboratory aspects of these pathologies as they relate to clinical, epidemiological, and laboratory surveillance. The participants’ contributions and conclusions are reflected in the present document. For dengue, the material was mainly drawn from the second edition of Dengue guidelines for patient care in the Region of the Americas (11). The definition of a dengue case, the description of its clinical evolution, and guidelines on treating the disease have been adapted for specific risk