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Tan KW, Tan B, Thein TL, Leo YS, Lye DC, Dickens BL, Wong JGX, Cook AR. Dynamic dengue haemorrhagic fever calculators as clinical decision support tools in adult dengue. Trans R Soc Trop Med Hyg 2021; 114:7-15. [PMID: 31943116 DOI: 10.1093/trstmh/trz099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/21/2019] [Accepted: 08/15/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND The objective of this study was to develop multiple prediction tools that calculate the risk of developing dengue haemorrhagic fever. METHODS Training data consisted of 1771 individuals from 2006-2008 admitted with dengue fever whereby 304 developed dengue haemorrhagic fever during hospitalisation. Least absolute shrinkage and selection operator regression was used to construct three types of calculators, static admission calculators and dynamic calculators that predict the risk of developing dengue haemorrhagic fever for a subsequent day (DAily Risk Tomorrow [DART]) or for any future point after a specific day since fever onset (DAily Risk Ever [DARE]). RESULTS From 119 admission covariates, 35 were in at least one of the calculators, which reported area under the curve (AUC) values of at least 0.72. Addition of person-time data for DART improved AUC to 0.76. DARE calculators displayed a large increase in AUC to 0.79 past day 7 with the inclusion of a strong predictor, maximum temperature on day 6 since onset, indicative of a saddleback fever. CONCLUSIONS All calculators performed well when validated with 2005 data. Addition of daily variables further improved the accuracy. These calculators can be used in tandem to assess the risk of dengue haemorrhagic fever upon admission and updated daily to obtain more precise risk estimates.
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Affiliation(s)
- Ken Wei Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore 117549
| | - Ben Tan
- Ministry of Education, 1 North Buona Vista Drive, Singapore 138675
| | - Tun L Thein
- National Centre for Infectious Diseases, 16 Jln Tan Tock Seng, Singapore 308442
| | - Yee-Sin Leo
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore 117549.,National Centre for Infectious Diseases, 16 Jln Tan Tock Seng, Singapore 308442.,Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore 308433.,Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597.,Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Singapore 636921
| | - David C Lye
- National Centre for Infectious Diseases, 16 Jln Tan Tock Seng, Singapore 308442.,Tan Tock Seng Hospital, 11 Jln Tan Tock Seng, Singapore 308433.,Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore 117597.,Lee Kong Chian School of Medicine, Nanyang Technological University, 59 Nanyang Drive, Singapore 636921
| | - Borame L Dickens
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore 117549
| | | | - Alex R Cook
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, 12 Science Drive 2, Singapore 117549
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Lee LK, Earnest A, Carrasco LR, Thein TL, Gan VC, Lee VJ, Lye DC, Leo YS. Safety and cost savings of reducing adult dengue hospitalization in a tertiary care hospital in Singapore. Trans R Soc Trop Med Hyg 2013; 107:37-42. [PMID: 23296696 PMCID: PMC4023275 DOI: 10.1093/trstmh/trs009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background Previously, most dengue cases in Singapore were hospitalized despite low incidence of dengue hemorrhagic fever (DHF) or death. To minimize hospitalization, the Communicable Disease Centre at Tan Tock Seng Hospital (TTSH) in Singapore implemented new admission criteria which included clinical, laboratory, and DHF predictive parameters in 2007. Method All laboratory-confirmed dengue patients seen at TTSH during 2006–2008 were retrospectively reviewed for clinical data. Disease outcome and clinical parameters were compared over the 3 years. Results There was a 33.0% mean decrease in inpatients after the new criteria were implemented compared with the period before (p < 0.001). The proportion of inpatients with DHF increased significantly from 31.7% in 2006 to 34.4% in 2008 (p = 0.008); 68 DHF cases were managed safely on an outpatient basis after compared with none before implementation. DHF inpatients had more serious signs such as clinical fluid accumulation (15.5% vs 2.9% of outpatients), while most DHF outpatients had hypoproteinemia (92.7% vs 81.3% of inpatients). The eight intensive care unit admissions and five deaths during this time period all occurred among inpatients. The new criteria resulted in a median cost saving of US$1.4 million to patients in 2008. Conclusion The new dengue admission criteria were effective in sustainably reducing length of hospitalization, yielding considerable cost savings. A minority of DHF patients with mild symptoms recovered uneventfully through outpatient management.
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Affiliation(s)
- Linda K Lee
- Tan Tock Seng Hospital, Communicable Disease Centre, 11 Jalan Tan Tock Seng, 308433 Singapore.
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Thein TL, Leo YS, Lee VJ, Sun Y, Lye DC. Validation of probability equation and decision tree in predicting subsequent dengue hemorrhagic fever in adult dengue inpatients in Singapore. Am J Trop Med Hyg 2011; 85:942-5. [PMID: 22049054 DOI: 10.4269/ajtmh.2011.11-0149] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We developed a probability equation and a decision tree from 1,973 predominantly dengue serotype 1 hospitalized adult dengue patients in 2004 to predict progression to dengue hemorrhagic fever (DHF), applied in our clinic since March 2007. The parameters predicting DHF were clinical bleeding, high serum urea, low serum protein, and low lymphocyte proportion. This study validated these in a predominantly dengue serotype 2 cohort in 2007. The 1,017 adult dengue patients admitted to Tan Tock Seng Hospital, Singapore had a median age of 35 years. Of 933 patients without DHF on admission, 131 progressed to DHF. The probability equation predicted DHF with a sensitivity (Sn) of 94%, specificity (Sp) 17%, positive predictive value (PPV) 16%, and negative predictive value (NPV) 94%. The decision tree predicted DHF with a Sn of 99%, Sp 12%, PPV 16%, and NPV 99%. Both tools performed well despite a switch in predominant dengue serotypes.
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Affiliation(s)
- Tun L Thein
- Communicable Disease Center, Tan Tock Seng Hospital, Singapore.
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Carrasco LR, Lee LK, Lee VJ, Ooi EE, Shepard DS, Thein TL, Gan V, Cook AR, Lye D, Ng LC, Leo YS. Economic impact of dengue illness and the cost-effectiveness of future vaccination programs in Singapore. PLoS Negl Trop Dis 2011; 5:e1426. [PMID: 22206028 PMCID: PMC3243704 DOI: 10.1371/journal.pntd.0001426] [Citation(s) in RCA: 96] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 10/27/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Dengue illness causes 50-100 million infections worldwide and threatens 2.5 billion people in the tropical and subtropical regions. Little is known about the disease burden and economic impact of dengue in higher resourced countries or the cost-effectiveness of potential dengue vaccines in such settings. METHODS AND FINDINGS We estimate the direct and indirect costs of dengue from hospitalized and ambulatory cases in Singapore. We consider inter alia the impacts of dengue on the economy using the human-capital and the friction cost methods. Disease burden was estimated using disability-adjusted life years (DALYs) and the cost-effectiveness of a potential vaccine program was evaluated. The average economic impact of dengue illness in Singapore from 2000 to 2009 in constant 2010 US$ ranged between $0.85 billion and $1.15 billion, of which control costs constitute 42%-59%. Using empirically derived disability weights, we estimated an annual average disease burden of 9-14 DALYs per 100 000 habitants, making it comparable to diseases such as hepatitis B or syphilis. The proportion of symptomatic dengue cases detected by the national surveillance system was estimated to be low, and to decrease with age. Under population projections by the United Nations, the price per dose threshold for which vaccines stop being more cost-effective than the current vector control program ranged from $50 for mass vaccination requiring 3 doses and only conferring 10 years of immunity to $300 for vaccination requiring 2 doses and conferring lifetime immunity. The thresholds for these vaccine programs to not be cost-effective for Singapore were $100 and $500 per dose respectively. CONCLUSIONS Dengue illness presents a serious economic and disease burden in Singapore. Dengue vaccines are expected to be cost-effective if reasonably low prices are adopted and will help to reduce the economic and disease burden of dengue in Singapore substantially.
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Affiliation(s)
- Luis R. Carrasco
- Department of Statistics and Applied Probability, National University of Singapore, Singapore, Singapore
| | - Linda K. Lee
- Communicable Disease Centre, Tan Tock Seng Hospital, Singapore, Singapore
| | - Vernon J. Lee
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Biodefence Centre, Ministry of Defence, Singapore, Singapore
- Centre for Health Services Research, National University of Singapore, Singapore, Singapore
| | - Eng Eong Ooi
- Program in Emerging Infectious Diseases, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Donald S. Shepard
- Brandeis University, Waltham, Massachusetts, United States of America
| | - Tun L. Thein
- Communicable Disease Centre, Tan Tock Seng Hospital, Singapore, Singapore
| | - Victor Gan
- Communicable Disease Centre, Tan Tock Seng Hospital, Singapore, Singapore
| | - Alex R. Cook
- Department of Statistics and Applied Probability, National University of Singapore, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- Program in Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore
- * E-mail:
| | - David Lye
- Communicable Disease Centre, Tan Tock Seng Hospital, Singapore, Singapore
- Department of Medicine, School of Medicine, National University of Singapore, Singapore, Singapore
| | - Lee Ching Ng
- Environmental Health Institute, National Environment Agency, Singapore, Singapore
| | - Yee Sin Leo
- Communicable Disease Centre, Tan Tock Seng Hospital, Singapore, Singapore
- Department of Medicine, School of Medicine, National University of Singapore, Singapore, Singapore
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Leo YS, Thein TL, Fisher DA, Low JG, Oh HM, Narayanan RL, Gan VC, Lee VJ, Lye DC. Confirmed adult dengue deaths in Singapore: 5-year multi-center retrospective study. BMC Infect Dis 2011; 11:123. [PMID: 21569427 PMCID: PMC3112097 DOI: 10.1186/1471-2334-11-123] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 05/12/2011] [Indexed: 12/26/2022] Open
Abstract
Background Dengue re-emerges in Singapore despite decades of effective vector control; the infection predominantly afflicts adults. Severe dengue not fulfilling dengue hemorrhagic fever (DHF) criteria according to World Health Organization (WHO) 1997 guideline was increasingly reported. A new WHO 2009 guideline emphasized warning signs and a wider range of severe dengue manifestations. We aim to evaluate the utility of these two guidelines in confirmed adult dengue fatalities. Methods We conducted a multi-center retrospective chart review of all confirmed adult dengue deaths in Singapore from 1 January 2004 to 31 December 2008. Results Of 28 adult dengue deaths, median age was 59 years. Male gender comprised 67.9% and co-morbidities existed in 75%. From illness onset, patients presented for admission at a median of 4 days and death occurred at a median of 12 days. Intensive care admission was required in 71.4%. Probable dengue was diagnosed in 32.1% by WHO 1997 criteria and 78.6% by WHO 2009. The earliest warning sign was persistent vomiting at a median of 1.5 days. Hematocrit change ≥20% concurrent with platelet count <20 × 10^9/L was associated with the shortest interval to death at a median of 3 days. Only 35.7% of death cases fulfilled DHF criteria by WHO 1997 versus severe dengue in 100.0% by WHO 2009 criteria. Deaths were due to shock and organ failure. Acute renal impairment occurred in 71.4%, impaired consciousness 57.1% and severe hepatitis 53.6%. Conclusions In our adult fatal dengue cohort, WHO 2009 criteria had higher sensitivity in diagnosing probable dengue and severe dengue compared with WHO 1997. As warning signs, persistent vomiting occurred early and hematocrit change ≥20% concurrent with platelet count <20 × 10^9/L preceded death most closely.
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Affiliation(s)
- Yee-Sin Leo
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore.
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