Rising trend of cases of dengue fever admitted in a tertiary care hospital in Vadodara – A retrospective study

Rising trend of cases of dengue fever admitted in a

tertiary care hospital in Vadodara - A retrospective

study

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Original Article

Rising trend of cases of dengue fever admitted in atertiary care hospital in Vadodara e A retrospectivestudy

Varsha Godbole a,*, Himanshu Rana b, Kedar Mehta c, Falgun Gosai d

a Professor & Head, Internal Medicine, GMERS Medical College, Gotri, Vadodara, Gujarat, Indiab Associate Professor, Internal Medicine, GMERS Medical College, Gotri, Vadodara, Gujarat, Indiac Assistant Professor, Community Medicine, GMERS Medical College, Gotri, Vadodara, Gujarat, Indiad Assistant Professor, Internal Medicine, GMERS Medical College, Gotri, Vadodara, Gujarat, India

a r t i c l e i n f o

Article history:

Received 20 October 2014

Accepted 30 October 2014

Available online xxx

Keywords:

Dengue

Dengue haemorrhagic fever

Thrombocytopenia

* Corresponding author. Tel.: þ91 9879181E-mail address: [email protected] (V

Please cite this article in press as: GodbolVadodara e A retrospective study, Apollo

http://dx.doi.org/10.1016/j.apme.2014.10.0010976-0016/Copyright © 2014, Indraprastha M

a b s t r a c t

Background & objective: Dengue has become a serious public threat globally. Increasing

number of cases are seen during the monsoon season. The incidence is increasing each

year. We undertook this study to document the rise in cases during 2013 and to study the

clinical spectrum of patients admitted in a tertiary care hospital.

Material and methods: It was a retrospective study of cases admitted from July to December

2013. The clinical profile, complications and outcome of the patients was studied. The

number of cases were compared with all the admitted as well as fever patients of 2013 and

with cases of the previous two consecutive years.

Results: Out of 63 patients, 30 (47.6%) belonged to the age group of 13e23 years, predomi-

nantly males (84%) and from urban areas. The presenting symptoms included, fever (100%),

myalgia (61.9%) vomiting (49.2%), abdominal pain, nausea and headache. Sixty patients

(95.2%) had non-severe dengue while 3 (4.8%) had dengue haemorrhagic fever.

Sevenpatients (11%)hadcomplications in the formofascites,pleural effusionandbleeding.

Discussion: Ourstudyconfirmstheseasonaloccurrenceof thecases. It isalso inaccordancewith

the other studies as regards the overall clinical spectrum. Most of our patients were from the

urban areas which is not comparable with other studies. Comparison with the previous

2 years as well as with the total admitted and fever cases revealed a statistically significant (p

value < 0.0001) rise in the number of cases during 2013. The clinical profile showed mostly

uncomplicated cases with good prognosis, who responded well to early treatment with hy-

dration and supportive therapy.

Conclusion: Documentation of a rise in the number of cases will have a major impact on

recognizing the burden of the disease and in formulating a plan for containment of cases in

the community.

Copyright © 2014, Indraprastha Medical Corporation Ltd. All rights reserved.

673; fax: þ91 265 2398009. Godbole).

e V, et al., Rising trend oMedicine (2014), http:/

edical Corporation Ltd. A

.

f cases of dengue fever admitted in a tertiary care hospital in/dx.doi.org/10.1016/j.apme.2014.10.001

ll rights reserved.

mailto:[email protected]

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http://dx.doi.org/10.1016/j.apme.2014.10.001



Fig. 1 e Age-wise distribution.


1. Introduction

Dengue is one of the major arboviral infections in the world.

The past few years have seen a rapid spread of the disease.

According to WHO, approximately 50 million cases occur

annually and the incidence has increased 30 times in the past

50 years.1 Dengue has been occurring throughout the tropical

regions of the world with 75% of the disease burden being in

the South-East Asia and Western Pacific region. More than

25,000 cases have been reported from India with a CFR of

0.87%.2

Dengue has a wide spectrum of clinical manifestations,

ranging from non-severe symptoms to severe complications.

We undertook this study in a tertiary care hospital with the

aim of studying the clinical and investigative profile of pa-

tients admitted in the medical wards and to document the

increase in the number of cases by comparing with the data

from the previous two consecutive years.

Fig. 2 e Sex ratio.

2. Material and methods

A total of 63 patients of dengue admitted in themedical wards

of GMERS, medical college and hospital, Gotri, Vadodara,

Gujarat between July 2013 to December 2013 were included in

the study.

An ethical clearance was obtained from the institutional

ethics committee.

A detailed clinical history was taken and a complete

physical examination was done in all patients. Investigations

included complete blood count including haematocrit and

platelet count, urine analysis, peripheral blood smear for

detecting malarial parasites, liver function tests, renal func-

tion tests, coagulation profile, serum electrolytes, ECG, X-ray

chest and abdominal sonography.

Diagnosis of dengue was done by detection of viral antigen

NS1 and dengue specific IgM or IgG by ELISA.

The number of indoor dengue cases during the monsoon

and post-monsoon period (June to December) in years 2011,

2012 and 2013, were compared with the total number of

admitted patients during the same period. The dengue cases

in the same years were also compared with the number of all

fever patients admitted during that time, so as to document

the absolute rise in number.

Data was entered in Microsoft Excel worksheet and then

statistical analysis was carried out by Med Calc Software

version 11.5.0.

Fig. 3 e Demographic distribution.

3. Results

As seen from Fig. 1, the age range of patients was 13e65 years.

Fifty seven patients (91%) belonged to the age group of 13e33

years, with 30 (47.6%) patients in the 13e23 years range.

As per Fig. 2, out of total 63 confirmed cases of dengue, 53

(84.1%) were males and 10 (15.9%) were females.

As per Fig. 3, forty nine patients (77.8%) belonged to the

urban area while 14 (22.2%) patients were from the rural

settings.

Please cite this article in press as: Godbole V, et al., Rising trend oVadodara e A retrospective study, Apollo Medicine (2014), http:/

As per Fig. 4, all patients presentedwith fever (100%). Other

symptoms included, myalgia in 39 (61.9%), vomiting in 31

(49.2%), abdominal pain in 20 (31.7%), nausea in 13 (20.6%) and

headache in 12 (19.1%) patients. Only 7 (11%) had backache.

Six (9.5%) patients had joint pains. Four patients had hepato-

splenomegaly.

As per Fig. 5, 60 patients (95.2%) had dengue fever while 3

(4.8%) had dengue haemorrhagic fever. No cases were recor-

ded with dengue shock syndrome.

As per Fig. 6, complications were found in 7 (11.11%) pa-

tients. They included pleural effusion, ascites and

haemorrhage.

As per the Fig. 7, the outcome is very good with early

detection and prompt treatment. 90.4% patients were treated




Fig. 4 e Symptomatology.

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e6 3

and discharged while 9.4% were transferred to higher centre

for platelets or on patient request.

As shown in Fig. 8a, there is very drastic rise in the no of

cases of Dengue haemorrhagic fever. This is also showing the

· DengueFever

· DengueHemorrhagic

Fever

· DengueShock Syndrome

N (n=63) 60 3 0Percent (%) 95.2 4.8 0

0102030405060708090

100

Axis

Titl

e

Fig. 5 e Diagnostic classification.

Fig. 6 e Complications.


seasonal variation which suggest monsoon as the peak

season.

As per the Table 1, leucopenia was observed in 34 (53.96%)

patients, with TLC < 4000/cmm. Nineteen (30.15%) patients

had platelet count <50,000/cmm on presentation. Only 2

(3.17%) patients had raised HCT which was >45%. Liver func-

tion tests showed elevated transaminases in 23 (36.5%)

patients.

All patients were diagnosed by confirmation of viral anti-

gen NS1 and dengue specific IgM and IgG by ELISA.

Sixty patients (95.2%) had non-severe dengue fever and 3

(4.8%) patients had dengue haemorrhagic fever.

Table 2 shows the rising trend in the number of dengue

cases on comparing with all admitted cases in the medicine

wards, from 2011 to 2013. It is found to be statistically signif-

icant with p value of <0.0001.Table 3 shows the comparison of dengue cases in 2011,

2012 and 2013, with all the indoor fever cases. The observed

Fig. 7 e Outcome.




Fig. 8 e Rising trend of dengue cases from 2011 to 2013. a:

Rising trend of dengue cases from July 2013 to December

2013.

Table 1 e Clinical profile and demographic details.

Parameters No. (n ¼ 63) Percent (%)

Median age (in years) 24 years

Age group

� 13e23 years 30 47.6

� 24e33 years 27 42.8

� 34e65 years 6 9.6

Gender

� Male 53 84.1

� Female 10 15.9

Address

� Rural 14 22.2

� Urban 49 77.8

Presenting symptoms

� Fever 63 100

� Myalgia 39 61.9

� Vomiting 31 49.2

� Abdominal pain 20 31.7

� Nausea 13 20.6

� Headache 12 19.1

� Backache 7 11

� Jt. Pain 6 9.5

� Others 5 7.9

Diagnosis

� Dengue fever 60 95.2

� Dengue hemorrhagic fever 3 4.8

� Dengue shock syndrome 0 0

Complications

� Pleural effusion 2 3.17

� Ascites 2 3.17

� Bleeding 3 4.76

Outcome

� Mortality 0

� Referral to higher centres 6 9.6

� Discharged/DAMA 57 90.4


rising trend in the number of cases is found to be statistically

significant with p value of <0.0001.Table 4 and Table 5 show the month wise comparison of

dengue cases with all indoor as well as fever cases in year

2013. Here also, the increasewas statistically significantwith p

value of 0.003 and 0.0002, respectively.

Table 6 is showing the haematological and biochemical

parameters. There are significant no. of patients having fall in

Haemoglobin, alteration in HCT, Leucopenia and thrombocy-

topenia. There is also alteration in the Liver function test as

well.

Table 2 e Comparison of dengue cases with all patientsadmitted in Gotri General Hospital.

Year Dengue positiveindoor cases

Dengue negativeindoor cases

Total X2 test fortrend

(p value)

2011 3 5726 5729 55.83 (<0.0001)2012 18 6206 6224

2013 63 6630 6693

Total 84 18562 18646

4. Discussion

Dengue is one of the important mosquito borne viral diseases,

especially in the tropical countries. However, in recent years it

is not confined only to the tropics, but is being reported from

nontropical countries aswell.1 The reasonmay be due to a rise

in international travel and trade.

Thus it has now become a major global issue.

The initial epidemic of dengue fever was reported from the

Eastern coast of India in 1963e64. It then spread to Delhi and

other parts of Northern India. Gradually the whole country

was involved.3

In Gujarat a major epidemic occurred in 1988 and 1989 in

both urban and rural areas.3,4

Epidemiologically dengue had always shown an urban and

peri-urban predominance. This was due to high density of


population in these areas. But, outbreaks such as in Cambodia

in 20071 and in various states of India, as reported in different

studies,5e8 suggest that cases are occurring in rural areas as

well. It now affects urban and rural areas alike. Most of the

studies have shown a high rate of prevalence in the rural

setting.5e8 However, in our study, most of the patients (77.8%)

belonged to the city, but few (22.2%) were from nearby vil-

lages. This could be because of the catchment area of our

hospital being predominantly an urban setting and the pres-

ence of another medical college with an attached tertiary care

hospital within the same city of Vadodara.

All our patients of dengue were admitted during the

monsoon and post-monsoon period. This is consistent with

the other outbreaks such as the one in Delhi in 2003, as re-

ported by Gupta E et al.6 and the West Bengal epidemic in




Table 3 e Comparison of dengue cases with all FEVERcases admitted in Gotri General Hospital.

Year Dengue positiveindoor cases

Feverindoorcases

Total X2 test for trend(p value)

2011 3 2665 2668 103.45 (<0.0001)2012 18 2569 2587

2013 63 1607 1670

Total 84 6841 6925

Table 4 e Comparison of Dengue cases with all patientsadmitted in Gotri General Hospital in 2013 year.

Month Denguepositive

indoor cases

Denguenegative

indoor cases


(p value)

July 2 650 652 8.39 (¼0.003)

August 8 604 612

September 14 618 632

October 12 566 578

November 20 523 543

December 7 496 503

Total 63 3457 3520

Table 6 e Laboratory parameters.

Laboratory parameters No. (%)

Hb > 16 g% 5 (7.93%)

Hct > 45% 2 (3.17%)

Total WBC (TLC) < 4000/cmm 34 (53.96%)

Platelet count < 10,000/cmm 2 (3.17%)

Platelet count < 50,000/cmm 19 (30.15%)

AST > 45 IU/L 23 (36.5%)

a p o l l o m e d i c i n e x x x ( 2 0 1 4 ) 1e6 5

2012.9 Ukey PM in 20107 and Nandini Chaterjee et al., in 2014,5

have also shown highest number of cases during July to

November. This increase is mainly due to the favourable

breeding conditions for Aedes aegypti mosquitoes during the

monsoon season. The year 2013 also witnessed excessive and

prolonged rainfall in Vadodara district and other areas of

Gujarat. This may have contributed to the significant rise in

the number of patients as compared to the previous two years.

The gender distribution of patients in our study showed a

male predominance. This is in accordance with other stud-

ies.5e7 A study done by B Bandyopadhyay in Kolkata to analyse

the outbreak of dengue in 2012, also shows a high number of

male patients.9

Dengue has been seen predominantly affecting the

younger population. Our study corroborates this. Most of our

patients belonged to the age group of 13e23 years.

All our patients presented with fever. Gastrointestinal

symptomswere also common. Abdominal painwas present in

32% patients which was close to 38%, as reported by Sharma

et al. in the outbreak of dengue in Delhi in 1996.10 However, in

Table 5 e Comparison of Dengue cases with FEVERpatients admitted in Gotri General Hospital in 2013 year.

Month Denguepositive

indoor cases

Denguenegative

indoor cases


(p value)

July 2 274 276 13.62 (¼0.0002)

August 8 263 271

September 14 280 294

October 12 246 258

November 20 194 214

December 7 153 160

Total 63 1410 1473


a study by Rachel Daniel et al., a high incidence of abdominal

pain (64.2%) was noted in the epidemic from Kollam, Kerala.11

None of our patients had rash which is in contrast to most of

the studies.

Bleeding in the form of epistaxis and haematemesis, was

found only in 3 (4.76%) patients which may point towards a

less severe form of infection. All three patients had platelet

count less than 30,000/cmm.

None of our patients died and those with complications

also responded well to treatment.

We compared the number of patients in 2013, with the

previous two consecutive years. The comparison showed a

definite rise in the cases. In addition, the data was also

compared with all fever and other admitted patients in the

medicine wards, so as to demonstrate a true increase in the

numbers. The comparison showed that the increase in the

overall hospital admissions was not the reason for the rise.

5. Conclusion

Our study has shown a statistically significant increase of

dengue patients attending our hospital in Vadodara city in

2013. This documentation is important as it may help in

developing a comprehensive plan in the community for the

early detection and treatment of cases so as avoid

complications.

Conflicts of interest

All authors have none to declare.

Acknowledgement

Wewould like to sincerely acknowledge the contribution from

lot of people for this research article.

First and foremost we would like to thank our patients for

their full co-operation without whom this research work

would not have been reality. We would like to extend our

sincere thanks to Dean of the institute, Dr. Indira Parmar and

Medical Superintendent Dr. Bipin Nayak for their kind

approval and guidance. We would like to thank Dr. C.B. Tri-

pathi, chairman of IHEC and the whole INSTITUTIONAL

HUMAN ETHICS COMMITTEE for their approval and encour-

agement. We sincerely extend our gratitude to our colleagues,

laboratory personnel, support staff and all those who have

helped us during this research.





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4. Mahadev PV, Kollali VV, Rawal ML, et al. Dengue in GujaratState, India during 1988 &1989. Indian J Med Res.1993;97:135e144.

5. Chaterjee Nandini, Mukhopadhyay Mainak, Ghosh Sinjon. Anobservational study of denguefever in a tertiary care hospitalof eastern India. JAPI. March 2014;62:224e227.


6. Gupta E, Dar L, Narang P. Indian J Med Res. 2005 Jan;121:36e38.7. Ukey PM, Bondade SA, Akulwar SL. Study of seroprevalence of

dengue fever in central India. Indian J Community Med. 2010OcteDec;35:517e519.

8. Mehandale SM, Risbud AR, Rao JA. Outbreak of dengue feverin rural areas of Parbhani district of Maharashtra (India).Indian J Med Res. 1991 Jan;93:6e11.

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Rising trend of cases of dengue fever admitted in a tertiary care hospital in Vadodara – A retrospective study