FEVER FOR EVALUATION

1.Demographic data:
• Name
• Age
• Sex
• Residence:
Informant:
Reliability:
2. Chief Complaint:
● C/o fever how many days
● C/o associated symptoms how many days

3. History of Presenting Illness:

Verify presence of fever- True or factitious fever

Factitious fever is engineered by patient by manipulating the thermometer or temperature chat apparently to
obtain medical care. The factitious disorder is usually medical but any may relate to psychiatric illness with
reports of depressive illness.

→ Fever onset (acute/progressive)

→ Fever grade(high /low),
Site of measurement: Rectal , oral , axillary , tympanic , temporal

FEVER CELCIUS

NORMAL 36.5-37.5°C

LOW GRADE 37.5-38.3°C

HIGH GRADE 39.4°C

HYPERPYREXIA 38.3-41.1°C
 → Nature (continuous/intermittent),

PATTERN OF FEVER
● Sustained (Continuous) Fever: UTI, Pneumonia, Typhus, brucellosis ,viral fever (Step ladder pattern in
Typhoid )
● Intermittent Fever (Hectic Fever); Malaria , Kalaazar , septicaemia.
● Remittent Fever: Infective Endocarditis
● Relapsing Fever:
Tertian Fever ; P.Vivax
Quartan Fever; P.Ovale, P.Malariae
Pel Ebstein Fever (Days of Fever Followed by a Several Days Afebrile); Hodgkins Lymphoma
Biphasic fever in dengue.

→ Associated with any(rash/chills and rigor)

Rigors. profound chills accompanied by chattering of the teeth and severe shivering, implies a rapid rise in body
temperature.

Can be produced by :

1) brucellosis
2) sepsis with abscess
3) malaria
4) dengue
5) leptospirosis
6) lymphoma

→ H/o night sweats

Excessive sweating. Night sweats are characteristic of tuberculosis, but sweating from any cause is usually worse at night.

→ Showing any Diurnal variation(morning/Night),

→ Relieved on medication or not
→ H/o recurrent fever
Recurrent fever. Source is often a focus of bacterial infection such as cholecystitis or cholangitis or urinary tract infection
especially associated with an obstruction or calculi

→ H/o headache
Fever from any cause may provoke headache.,

Causes

 Meningitis(along with photophobia )

 Scrub typhus
 Malaria
 Dengue
 leptospirosis

→ H/o myalgia
Myalgia is characteristics of viral infections such as Influenza , malaria , scrub typhus ( diffuse myalgia ), dengue ,
leptospirosis ( calf muscle tenderness )

→ H/o Joint Pain

Joint symptoms: joint pain, swelling or limitation of movement is suggestive of active arthritis., dengue , malaria.
 → H/o skin rashes
Enquire about appearance and distribution

● Macular- Measles, Rubella, toxoplasmosis ,typhoid ( rose spots )

● Haemorrhagic- Meningococcal infections, viral haemorrhagic fever.
● Vesicular- Chickenpox, Shingles, herpes simplex
● Nodular- Erythema nodosum ( TB and Leprosy)
● Erythematous- Drug rashes, Dengue fever, scrub typhus ( papule followed by eschar )

→ H/o Cough or cold

o Indicates Upper or lower respiratory tract infections
o May be present in scrub typhus , typhoid , malaria, leptospirosis.

→ H/o refusal to take food

 In case of malaria, dengue and hepatitis B infection ( anorexia )
→ H/o nausea and vomiting (frequency , projectile or not , bile /blood stained or not)
 In case of scrub typhus , malaria ,dengue ( persistent vomiting is a warning sign )
→ H/o neck stiffening
● Indication of meningitis
→ H/o Loose stools
 In case of scrub typhus , typhoid ( watery stools ) , malaria , hepatitis B viral infection .
→ H/o abdominal pain
 In case of typhoid , malaria, leptospirosis, hepatitis B , dengue (colicky pain )
Abdominal symptoms: diarrhoea, with or without blood, weight loss and abdominal pain –

Suggesting

● Gastroenteritis,
● Intra-abdominal sepsis
● Inflammatory bowel disease,
● Malignancy

→ H/o breathlessness
 Suggestive of lung infections like pneumonia ,bronchitis ; in case of malaria .

→ H/o decreased urine output

 In case of leptospirosis (due to acute renal failure )

→ H/o Burning sensation while passing urine

Genitourinary symptoms: Frequency of micturition, dysuria, loin pain, and vaginal or urethral discharge-suggesting

● Urinary tract infection,

● Pelvic inflammatory disease
● Sexually transmitted infection (STI).
 H/o dark coloured urine
In case of hepatitis B infection.
 H/o seizure
In case of hepatitis B infection .
 H/o irritability
In case of Hepatitis B infection
 H/o constipation
In case of dengue
  H/o sore throat
In case of dengue
 H/o altered taste sensation
In case of dengue .
 H/o mucosal bleed
In case of dengue
 H/o retro orbital pain
In case of dengue
 H/o restlessness
In case of dengue
 H/o chest pain .
In case of leptospirosis.
 H/o hemoptysis
In case of leptospirosis.
 H/o lethargy
In case of malaria, Hepatitis B

4. Past History:
→ H/o Similar episodes
→ H/o Previous surgery
E.g. time/place/ what type of operation. Note any blood transfusion / blood grouping.
H/O dental extractions/circumcision & any excessive bleeding during these procedures. Patient known to
have rheumatic heart disease is at risk to develop infective endocarditis if not given prophylaxis.
→ H/o TB, Epilepsy,Asthma,Jaundice ,Allergy,drug intake
→ H/o tattoo piercing

5.Contact History:
→ H/o similar episodes in neighbourhood

6. Travel History :
Fever in endemic areas:
1. MALARIA
2. DENGUE FEVER
3. VIRAL FEVERS
4. TYPHOID
5. TUBERCULOSIS
6. SCHISTOSOMIASIS

Name of the area

Duration of stay

Onset of illness

(Always ask about foreign travel)

a) Where have you been? …Endemic area or not ? b) What have you done? c) How long were you there? d) Did you have
insect bites or contact with animals? e) Did you take precautions/prophylaxis ?

If the patient has been in an endemic area, the most common diagnoses :
 Malaria, Typhoid fever, Viral hepatitis, Dengue fever .

Personal History
→ Diet
→ H/o smoking
→ H/o alcohol
→ H/o drug abuse
Illicit drug usage- injections and sharing of needles (HIV, hepatitis B &C, infective endocarditis), site of
injection (e.g Femoral vein-septic arthritis, ilio-psoas abscess)
→ H/o allergy
dosage, timing &how long.
Drug fever is uncommon and therefore easily missed
The drugs include : Penicillin
Cephalosporin
Sulphonamide
Anti tuberculous agents
Anticonvulsants particularly phenytoin
→ Recent immunization
→ Sleep pattern
→ Bowel and bladder habits
→ Occupational history
▪ BIRDS – SARS, PSITTACOSIS
▪ ANIMALS CONTACT- TOXOPLASMOSIS (CAT), BRUCELLOSIS (CATTLE),LEPTOSPIROSIS
(RAT)
▪ UNCOOKED MEAT/SEA FOOD/ - HEPATITIS –A & E, SALMONELLA
▪ UNPASTEURIZED MILK – SALMONELLA , INTESTINAL TB, BRUCELLOSIS
▪ HIGH RISK BEHAVIOURS - STDS, HIV, HBV, HCV, IV ABUSE

6.Birth History:
a.Antenatal History:
Mother registered and immunised
IFA events
H/o GDM,PIH or any complications/Risk factors
 b.Intranatal History:
Birth weight
∙Place of delivery
∙Birth order

c.Postnatal History:
∙Breastfeeding details
∙Compliment feed details
∙Immunisation
∙Congenital abnormality
7. Menstural History:(if female)

8.Developmental History:
∙Development of milestones

9. Family History:
Relation to Monthly Health
S.No Name Sex/Age Education Occupation
Index case income status
1. Index Case

2.
3.
4.
5.

Type of Family:
Family Size :
Total family income:Rs………/month
Per capita income:Rs…………
Any familial disease/running in families e.g. breast cancer, IHD, DM, Asthma, Arthritis
Infections running in families as TB, Leprosy.
Cholera, typhoid in case of epidemics.
9.Socio-Economic Status :
SES Scale Used :
Score : Class: I / II / III / IV /V

10. Socio-Environmental Factors

Area of Residence : Urban / Rural
Housing:
Ownership: Own/Rented
Type: Pucca / Semi-Pucca / Katcha (serviceable) /Katcha (non-serviceable)
 Floor:
Number of Rooms:
S.No Type of Room Area Proportion of
Floor Area windows/doors windows/doors to
floor space

Ventilation : Adequate / Not adequate

Cross Ventilation : 1. Yes 2. No
Lighting :

Water Supply:

● Source :…………………………………………
● Protection:…………………………
● Potability:……………………………
● Adequacy:…………………………..
● Storage :……………………………

Kitchen
∙Type of Fuel
∙Methods of Cooking
∙Smoke Vent
∙Storage of Food Articles
∙Food hygiene practices
∙Disposal of Sullage

Sanitation
∙Type of Toilet
∙Location of Toilet
∙Type of Drainage
∙Excreta Disposal
∙Disposal of night soil
∙Solid waste disposal
∙Animal wastes disposal
∙Waste water disposal
∙Vector Breeding Sites
∙Personal hygiene
∙Pet Animals

11.Socio-cultural Factors:
Life style

→ Personality – Type A / Type B

 → Physical exercise
→ Stress management
→ Motivation and state of mind
→ Tobacco
→ Alcohol
→ Substance abuse
→ Sleep habits
→ Family planning practices
→ Sexual promiscuity
→ Knowledge , attitude and practices about common diseases
→ Health seeking behaviour and knowledge of healthcare system
→ Myths , Misconceptions and Social aberrations

12.Diet History:
Type of Diet:(veg/nonveg/mixed)
∙Food
∙Food T
Dietary intake assessment - 24-hr recall method

BREAKFAST

S.No Food item Food group Dry Energy Protein

wieght
(K.cal) (gms)

LUNCH
S.No Food item Food group Dry Energy Protein
wieght
(K.cal) (gms)

DINNER
S.No Food item Food group Dry Energy Protein
wieght
(K.cal) (gms)
 SNACKS

S.No Food item Food group Dry Energy Protein

wieght
(K.cal) (gms)

BREASTFEEDING

S.No Food item Food group Dry Energy Protein

wieght
(K.cal) (gms)

S.No Total Energy (Kcal) Total protein (gms)

1 Breakfast
2 Lunch
3 Dinner
4 Snacks
Breastfeeding

Total Calorie intake:

RDA of Calorie:
Calorie deficit:
Total Protein intake:
Protein deficit:

13. Clinical Examination:

General Examination:
Alert,Active
Built and nourished
Afebrile
No pallor
 No Icterus
No Cyanosis
No Clubbing
No Lymphadenopathy
No Pedal Edema

Head to Foot Examination:

Vital:
Temperature:
BP:
RR:
HR:

Anthrometric Measurement:
Length:
Weight:
Head Circumference:
Chest Circumference:
MUAC:

Systemic Examination:

Abdomen:
Soft or not,
Tender or not
Organomegaly present or not

Cardiovascular System:
S1,S2 heard,
Murmers present /not

Respiratory System:
Normal Vesicular sounds heared
Any Added sounds present or not(like wheeze,rales)

Central Nervous System:

Focal neurological deficit present or not

14.Investigations:
Complete hemogram
Platelet count
QBC
Widal
Urine examination

15. Clinical diagnosis

16. Epidemiological triad of the condition under study

Agent factors
Host factors
Environmental factors
Vectors/Fomites/Behaviour factors
17. Clinico-Social Diagnosis
18.Treatment:
● Bed rest and intake of plenty of fluids
● Paracetamol ( children : 10-15 mg/ kg/ dose; adults : 500mg/kg/dose 6-8 hourly )
● Supportive treatment wherever required ( typhoid, filariasis, malaria, rheumatic fever, meningitis,
urinary tract infection, pneumonia,etc )

19.Advice to Mother:
▪ Drinkboiled water
▪ Practise personal hygiene
20.Advice to Family:
▪ Prophylaxis follow up
▪ Regular health check up
21.Advice to Community:
▪ Use of mosquito nets / repellants
▪ Provide health education
▪ Improve sanitation

22. Relevant National Programmes

NVBDCP - National Vector Borne Disease Control Programme

IMNCI - Integrated Management of Neonatal and Childhood Illness
ICDS - Integrated Child Development Service
RCH II - Reproductive and Child Health
RMNCH+A - Reproductive, Maternal, Newborn, Child and Adolescent Health

Done by

91-Varsha. T. - National health program

92-Varshini devi . K. -Diet, environmental history, epidemiology triad understudy
93-Varthini.B. -History of presenting illness
94-VenenshiyaBenedict.V.- Birth history with immunization,family composition table
95-Vidhubala .G.K. -Clinical examination,clinico social diagnosis
96-Vignesh A.K.- Demographic data,chief complaint
97-Vignesh .R. -Past,travel,contact history
98-Yogesh Meena - Types of family, socioeconomic asssets
99-Youvashree.V.- Treatment, remedial advice at different level
100-Yuwashree.J. - Investigation and diagnosis
 ASSIGNMENT

The normal human body temperature ranges between 97.7°F – 99.5°F (36.5°C – 37.5°C).
Fever: >99.5°F or100.9°F (37.5°C or 38.3°C).

Warning signs of fever:

● Sweating
→ Chills and shivering
→ Headache
→ Muscle aches
→ Loss of appetite
 Irritability
→ Dehydration
→ General weakness
 Seizure (infants and children)
 VIRAL HEPATITIS
Hepatitis is an inflammation of the liver that can cause a range of health problems and can be fatal. There
are five main strains of the hepatitis virus, referred to as types A, B, C, D and E
In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are
the most common cause of liver cirrhosis, cancer and viral hepatitis-related deaths.
An estimated 325 million people worldwide live with hepatitis B and/or C, and for most, testing and
treatment remains beyond reach.

MODE OF TRANSMISSION:
Hepatitis A and E:
Ingestion of contaminated food and water or through direct contact with an infectious person.
Hepatitis B,C and D:
Transmitted from mother to child during birth and delivery, as well as through contact with blood or
other body fluids, including sex with an infected partner, injection-drug use that involves sharing needles,
syringes, or drug-preparation equipment and needle sticks or exposures to sharp instruments.

SYMPTOMS AND SIGNS:

Many people with hepatitis A, B, C, D or E exhibit only mild symptoms or no symptoms at all
Symptoms and sign of hepatitis A, B and C may include
● Fever
 ● Malaise
● Loss of appetite
● Nausea
● Diarrohea
● Abdominal discomfort
● Jaundice
● Dark coloured urine

Signs
● Cirrhosis and liver cancer

Symptoms of Hepatitis D
Hepatitis D (HDV) is only found in people already infected with hepatitis B (HBV)
→ It accelerate the progression of cirrhosis

Symptoms of Hepatitis E
 Mild fever
 Reduced appetite
 Nausea and vomitting
 Abdominal pain
 Itching (without skin lesions)
 Skin rash or joint pain
 Pale stools ,dark coloured urine and jaundice

Signs
→ Tender liver
→ Hepatomegaly
→ Acute liver failure

High Risk Groups:

→ Poor sanitation
→ Lack of safe water
▪ Living in a household with an infected person
● Being a sexual partner of someone with acute Viral hepatitis infection
 Use of recreational drugs
● Sex between men
→ Travelling to areas of high endemicity without being immunized.

Diagnosis:
The viral hepatitis is diagnosed by the symptoms, physical examination, blood tests, imaging studies such
as sonogram or CATscan and liver biopsy.

i. Non-specific or absent symptoms: (90% of cases)

 fever
 pain in hypochondrium
 nausea and vomiting
  arthralgia
 utricaria

ii. Specific symptoms:

 Icterus
iii. Severe form: fulminant hepatitis:
 Clinical signs: Hepatic encephalopathy
 Biological level: prothrombin level <50%

Serological markers:

Situation Hepatitis Serological Markers

A Anti- HAV IgM

B HBs Ag/ Anti-HBc IgM/ Anti-HBc Total/

Hbe Ag/ Anti-HBe
Acute Hepatitis C Anti HCV

D HDV IgM, Ag Delta

E HEV IgM/ HEV IgG

Chronic hepatitis B HBs Ag/ Anti-HBc, then HBe Ag/ Anti-HBe

C Anti-HCV

Prenatal B HBs Ag
If positive then,
HBV screening
Mother monitored for HBe Ag/ Anti-HBe
New born: quantitative anti-HBs after
vaccination.

At risk groups B Anti-HBc

 If –ve : vaccinate
 If +ve: quantitative HBsAg/Anti-HBs

C Anti-HCV

HBV vaccination B Pre vaccination: Quantiative Anti-HBs Total

 if –ve : vaccinate
 If +ve: quantitative HBs Ag/ Anti-
HBc Total

Post vaccination: Quantiative Anti-HBs

Total.

HAV vaccination A Patient >30years: Total Anti-HAV

If –ve: Vaccinate.
Imaging studies:

1. CAT scan (Computerized Axial Tomography): An abdominal CT scan detct the changes in the
size and density of the liver and visualize masses or sign of early cancer ( a potential complication of
hepatitis).
2. MRI scan(Magnetic Resonance Imaging): It pick up on the abnormalities that suggest liver
dysfunction or cancer .
3. Sonogram: The ultrasound patterns will help to evaluate patients with suspected acute and chronic
hepatitis and more accurately define intrahepatic causes of jaundice.
 Acute hepatitis: Accentuated brightness and more extensive demonstration of the portal
vein radicle walls and overall decreased echogenicity of the liver.
 Chronic hepatitis: Decreased brightness and number of portal vein radicle wall and overall
increased liver echogenicity.

Liver biopsy: Liver biopsy is rarely performed in hepatitis. It is used to estimate the degree of liver
damage, to grade and stage Hepatitis B and C.

TREATMENT:
Hepatitis A
There is no specific treatment for hepatitis A. Recovery from symptoms following infection may be
slow and may take several weeks or months.
Therapy is aimed at maintaining comfort and adequate nutritional balance, including replacement of
fluids that are lost from vomiting and diarrhea.
Acetaminophen / Paracetamol and medication against vomiting should not be given.
Hepatitis B
There is no specific treatment for acute hepatitis B.
Chronic hepatitis B infection can be treated with medicines, including oral antiviral agents.Treatment can
slow the progression of cirrhosis, reduce incidence of liver cancer and improve long term survival.
WHO recommends the use of oral treatments - tenofovir or entecavir(rarely leads to drug resistance
-one pill a day).
Hepatitis C
The goal of hepatitis C treatment is cure.
WHO’s updated 2018 guidelines recommend therapy with pan-genotypic direct-acting antivirals
(DAAs). DAAs can cure most persons with HCV infection, and treatment duration is short (usually 12 to 24
weeks), depending on the absence or presence of cirrhosis.
Currently, the pangenotypic DAAs glecaprevir-pibrentasvir (8 week course), sofosbuvir-daclatasvir (12
week course), and sofosbuvir-velpatasvir (12 week course)
Hepatitis D
Current guidelines generally recommend Pegylated interferon alpha for at least 48 weeks irrespective
of on-treatment response patterns.
Hepatitis E
There is no specific treatment capable of altering the course of acute hepatitis E. As the disease is
usually self-limiting, hospitalization is generally not required.
Immunosuppressed people with chronic hepatitis E benefit from specific treatment using ribavirin,
an antiviral drug. In some specific situations, interferon has also been used successfully.

PREVENTION:
Hepatitis A and E
 Maintaining quality standards for public water supplies
 Establishing proper disposal systems for human faeces.

On an individual level, infection risk can be reduced by:

→ Maintaining hygienic practices
→ Personal hygiene practices such as regular hand-washing before meals and after going to the
bathroom.
→ Avoiding consumption of water and ice of unknown purity.

Hepatitis B
The hepatitis B vaccine is the mainstay of hepatitis B prevention
WHO recommends that all infants receive the hepatitis B vaccine as soon as possible after birth,
preferably within 24 hours – followed by two or three doses of hepatitis B vaccine at least four weeks apart
to complete the series.
People in high-risk groups may acquire the infection and they should also be vaccinated. This includes:
● People who frequently require blood or blood products, dialysis patients and recipients of solid organ
transplantations.
● People in prisons.
→ People who inject drugs.
● Household and sexual contacts of people with chronic HBV infection.
 People with multiple sexual partners.
→ Healthcare workers and others who may be exposed to blood and blood products through their work.
▪ Travellers who have not completed their HBV series, who should be offered the vaccine before
leaving for endemic areas.

Hepatitis C
Primary prevention interventions recommended by WHO:
→ Safe and appropriate use of health care injections.
 Safe handling and disposal of sharps and waste.
7. Provision of comprehensive harm-reduction services to people who inject drugs including sterile
injecting equipment and effective and evidence-based treatment of dependence.
→ Testing of donated blood for HBV and HCV (as well as HIV and syphilis).
▪ Training of health personnel.
 Prevention of exposure to blood during sex.

Secondary prevention:
▪ For people infected with the hepatitis C virus, WHO recommends.
 Education and counselling on options for care and treatment.
 ● Immunization with the hepatitis A and B vaccines to prevent coinfection from these hepatitis viruses
and to protect their liver.
→ Early and appropriate medical management including antiviral therapy and

regular monitoring for early diagnosis of chronic liver disease.

Hepatitis D
Prevention and control of HDV infection requires prevention of HBV transmission through hepatitis B
immunization, blood safety, injection safety, and harm reduction services. Hepatitis B immunization does
not provide protection against HDV for those already HBV infected.
Immunization :
Hepatitis A : Injectable inactivated hepatitis A vaccine
Hepatitis B : Hepatitis B Vaccine(INDIA-At birth or as early as possible within 24 hours(0.5ml-
intramuscular)
Adult -0-1-6
Hepatitis C and D: No effective vaccine
Hepatitis E: In 2011, a recombinant subunit vaccine to prevent hepatitis E virus infection was
registered in China. It has not yet been approved in other countries.

WHO RESPONSE:
WHO also marks World Hepatitis Day on 28 July every year to increase awareness and understanding
of viral hepatitis.
The theme for World Hepatitis Day 2020 is “Hepatitis-free future”
“Global Health Sector Strategy on Viral Hepatitis, 2016-2021”.
The strategy has a vision of eliminating viral hepatitis as a public health problem and this is encapsulated
in the global targets of reducing new viral hepatitis infections by 90% and reducing deaths due to viral
hepatitis by 65% by 2030. Actions to be taken by countries and WHO Secretariat to reach these targets are
outlined in the strategy.
 DENGUE FEVER
Dengue is a mosquito borne viral disease that has spread rapidly in all regions of the world. It is a mosquito
borne disease.

CLINICAL SPECTRUM :

SIGNS AND SYMPTOMS :

There are actually four dengue clinical syndromes:
  Undifferentiated fever
 Classic Dengue Fever
 Dengue Hemorrhagic Fever( DHF )
 Dengue Shock Syndrome ( DSS )

Undifferentiated fever :
 Simple fever indistinguishable from other viral infection.
 Maculopapular rashes may occur.
 Upper respiratory and gastrointestinal symptoms.

Classic Dengue Fever :

 Sudden chills and high fever ( 39 – 40 deg F ) and fever is typically biphasic.
 Intense headache
 Muscle and joint pains that prevent all movements.
 Retro- orbital pain occur within 24 hrs ( particularly on eye movements )
 Extreme weakness
 Anorexia
 Constipation
 Altered taste sensation
 Sore throat
 Colicky pain and abdominal tenderness
 Dragging pain in inguinal region
 General depression
 Rashes may occur during the first half of febrile phase( it may be diffuse flushing, mottling or
fleeting pin point eruptions ) and maculopapular rashes on 3rd or 4th days.

DENGUE HEMORRHAGIC FEVER ( DHF ) AND

SHOCK SYNDROME :
 Symptoms similar to dengue fever
 Severe continuous stomach pains
 Skin becomes pale, cold
 Bleeding from nose, mouth, and gums
 Skin rashes
 Frequent vomitting with or without blood
 Sleepiness and restlessness
 Patient feels thirsty and mouth becomes dry
 Rapid weak pulse
 Difficulty in breathing
 At the time of defervescence, an increase in capillary permeability in parallel with increasing
hematocrit levels occur thus the patient becomes worse and pleural effusion mostly on right side and
ascites and gall bladder edema may be seen on chest X ray and abdominal tool diagnosis.
Breeding sites:
Dengue mosquitoes:
Aedes aegypti, Aedes albopictus breed in artificial water accumulations around human dwelling in
fluctuating climate with rain fall and water storage.
Bite during day.

WARNING SIGNS :
 Abdominal pain or tenderness
 Persistent vomiting
 Clinical fluid accumulation
 Mucosal bleed
 Lethargy or restlessness
 Liver enlargement > 2 cm
 Laboratory findings of increasing hematocrit and decrease in platelet count.

INVESTIGATION :
The following laboratory tests are available to diagnose dengue fever and DHF :
 Virus isolation :
Isolation of dengue virus from clinical specimens is possible provided the specimen is taken
during the first six days of illness and processed without delay.Specimens that are suitable for
virus isolation are – acute phase serum, plasma or washed Buffy coat from the patient, etc,
 Viral nucleic acid detection :
Dengue viral genome which consists of RNA, can be detected by reverse transcriptase
polymerase chain reaction ( RT- PCR ) assay and real time RT- PCR.
 Immunological response and serological tests:
Following tests are available for diagnosis of dengue infection :
a. Hemagglutination inhibition assay ( HIA)
b. Complement fixation ( CF )
c. Neutralization Test ( NT )
d. IgM capture enzyme linked immunosorbent assay ( MAC-ELISA )
e. Indirect IgG- ELISA
f. IgM / IgG ratio
 Viral antigen detection :
ELISA and dot blog assays directed against the envelop / membrane ( EM ) antigens and non
structural protein 1 ( NS1 ) can be detected both in primary and secondary dengue infection upto
6 days after the onset of illness.
 Rapid diagnostic test ( RDT ) :
A number of commercial rapid format serological test- kits for anti- dengue IgM and IgG
antibodies have become available in the past few years.
 Analysis of haemotological parameters :
Platelet count and hematocrit are important standard haematological parameters. They should
be closely monitored.
MANAGEMENT :
It is based on the severity of dengue infection
Management of dengue fever :
 These are patients who are able to tolerate adequate volumes of oral fluids and pass urine at least once

every six hours and do not have any warning signs, particularly when fever subsides.
Those with stable hematocrit can be sent home after being advised to return to the hospital immediately if
they develop any warning signs and to adhere to the following action of plans :
1. Encourage intake of oral rehydration solution ( ORS) , fruit juice and other fluids containing
electrolytes and sugar to replace losses from fever and vomiting.
2. Give paracetamol for high fever if the patient is uncomfortable. Dose interval should not be less than
six hours . Do not give Aspirin, Ibuprofen or other NSAIDS as they aggravate gastritis or bleeding.
3. Patient should be monitored daily by health care providers for temperature pattern, volume of fluid
intake and losses, urine output , warning signs, signs of plasma leakage and bleeding, hematocrit
,wbc and platelet counts.

Management of DHF Grade I and II :

Any person who has dengue fever with thrombocytopenia and hemoconcentration and presents with
abdominal pain, black starry stools, epistaxis, bleeding from the gums, and infection ,etc.needs to be
hospitalized.
All these patients should be observed for signs of shock.
A rise in hemoconcentration indicates need for iv fluid therapy.
MANAGEMENT OF DHF GRADE III AND IV :
Immediately after hospitalization, the hematocrit, platelet count, and vital signs should be examined and iv
fluid should be started.
If the patient has already received 1000 ml of iv , it should be changed to colloidal solution preferably
Dextran 40/ haemocele, or
If the hematocrit is decreasing , fresh whole blood transfusion 10 -20 ml/kg/ hour should be given.
Oxygen should be given to all patients in shock.
Prevention :
Dengue:
1. Mosquito control
2. Vaccines CYD- TDV
Other measures such as individual protection against mosquito, wearing full sleeves, bed nets for sleeping
infants, environmental measures

Malaria
Five species of Plasmodium (single-celled parasites) can infect humans and cause illness:
Plasmodium falciparum (or P. falciparum)
Plasmodium malariae (or P. malariae)
Plasmodium vivax (or P. vivax)
Plasmodium ovale (or P. ovale)
Plasmodium knowlesi (or P. knowlesi

Breeding sites :
Malarial mosquitoes:
Anopheles culicifacies, An. fluviatilus, An. Stephensi breed in moving water, wells, brackish water, cistern,
fountain, overhead tanks.
Bite between dusk and dawn.
Signs and symptoms :
● . Piques of very high fever
● . Shaking chills
● . Sweats
● . Paroxysms – sudden recurrences or attacks of fever, shaking chills and sweats together – occur
every 24, 48 or 72 hours, depending on the parasite species. Each paroxysm lasts approximately one
to two hours and occurs in three successive stages. The first is characterized by shivering and a
feeling of cold. This is followed by a pique of high fever. After the patient experiences excessive
sweating to an unusual degree, the temperature goes back to normal or even below normal.
Sometimes, in early infection, patients don’t experience this, but may have several piques of fever
during the day.

● . Headache
● . Cough
● . Fatigue
● . Arthralgia (painful joints)
● . Muscle pain and also less common symptoms are-
● Abdominal pain
 ● Lethargy, meaning sleeplessness or deep unresponsiveness and inactivity
● Nausea
● Vomiting
● Diarrhea, especially in children
● Anemia
● Jaundice
● Shortness of breath
● Loss of appetite

WARNING SIGNS OF MALARIA:

1. Warning signs are clinical indicators of severity and are useful to predict complications or death.
2. In the malaria patient, clinical or parasitological signs can be easily be recognized during the acute
phase of the illness that indicate serious complications. Danger signs include
○ neurological change,
○ abnormal breathing pattern,
○ persistent vomiting and
○ diarrhea,
○ jaundice,
○ bleeding,
○ dark urine,
○ delayed capillary refill,
○ intense pallor,
○ hyperpyrexia,
○ hyperparasitemia and
○ schizontemia.

Timely recognition of these signs can lead to a decrease in cases with complications and deaths.
CLINICAL SPECTRUM:

INVESTIGATION OF
MALARIA:
MANAGEMENT OF UNCOMPLICATED

SEVERE MALARIA:
 ● Severe malaria occurs when infections are complicated by serious organ failures or abnormalities in
the patient's blood or metabolism.
● The manifestations of severe malaria include the following:

● Cerebral malaria, with abnormal behavior,

● impairment of consciousness,
● seizures,
● coma, or other neurologic abnormalities

Prevention:
1. Vector control strategy
2. Malaria vaccine
3. Chemoprophylaxis

Chemoprophylaxis of malaria:
Unreliable due to drug resistance
Indicated for travellers from non endemic area, short term measure for soldiers, police, labor forces in
endemic areas.
Recommendations for short term(< 6 weeks) prophylaxis:
1. Dose of children based on their body weight
2. Antimalarial taken daily ( doxycycline) before 1 day of arrival to risky area
3. Weekly chloroquine started 1 week before
4. Weekly mefloquine started 2-3 weeks departure, to achieve pre travel blood level and to allow side
effects to be detected before travel
5. Drug should be taken regularly and 4 weeks after last exposure as they may emerge from liver during
this period
Recommendations for long term (> 6 weeks) prophylaxis:
1. Risk of serious side effects with long term prophylactic use of chloroquine and proguanil is low.
 300 mg / week for 5 years screened twice yearly for retinala changes
 100 mg users are screened after 3 years
2. No increased risk of side effects with long term mefloquine use if it is tolerated in short term as it
doesn’t accumulate during long term usage
3. Date on chemoprophylaxis with doxycycline is limited
 CONTRAINDICATIONS:

1. Mefloquine in convulsions, neuropsychiatric disorders, cardiac conditions.

Drug regimens:
 Chloroquine (100 mg / 150 mg tablet or capsule) 300 mg / week on same day or 100
mg for 6 days/ week
 Proguanil (100 mg tablet or capsule) 200 mg / day
 Mefloquine (250 mg tablet or capsule) 250 mg/ week on same
 Doxycycline(100 mg tablet or capsule) 100 mg/ day

Mosquito control measures – integrated approach

 Antilarval measures

Environmental control:
1. Eliminate breeding places - ' source reduction'
2. Intermittent irrigation
3. Abolishing domestic and predomestic sources
Chemical control:
1. Mineral oil
2. Paris green
3. Synthetic insecticides
Biological control:
Gambusia affins
Lebister reticularis
 Anti adult measures
Residual sprays:
1-2 g of pure DDT per sq m for 1-3 times ayear
Space spray:
1. Pyrethrum extract
2. Residual insecticides
Genetic control:
1. Sterile male techniques
2. Cytoplasmic incompatibility
3. Chromosomal translocation
4. Sex distortion
5. Gene replacement
 Protection against mosquito bites:
Mosquito net
1. Size of hole <0.0475 inch
2. 150 holes in one square inch
Screening
 1. 16 meshes to inch needed
2. Hole size< 0.0475 inch
3. Costly but excellent results
Repellent
1. Diethyltoluamide
2. Indalone
3. Dimethyl phthalate
4. Dimethyl carbate
5. Ethyl hexanediol
6. Culicifuges

Typhoid
Typhoid is a systemic infection caused by Salmonella Typhi, usually through ingestion of contaminated
food or water.According to the most recent estimates, between 11 and 21 million cases and 128 000 to 161
000 typhoid-related deaths occur annually worldwide.It occurs predominantly in association with poor
sanitation and lack of clean drinking water. The disease is most common in India.Children are most
commonly affected.

Signs and symptoms :

Typhoid typically has incubation period of 10-14 days.

 Fever
 Malaise
 Headache
 Cough
 Abdominal pain
 Leukopenia
 Bradycardia
 Delirium
 Diarrhoea
 Hepatosplenomegaly
 Rose spots appear on chest and abdomen

Complications
 Intestinal bleeding
 Encephalitis
 Pneumonia and acute bronchitis
 Endocarditis
  Cholecystitis

Mode of transmission :
Humans are the only known carriers of the bacteria. S. Typhi is spread through the fecal-oral route
from individuals who are currently infected and from asymptomatic carriers of the bacteria.

Diagnosis:
Diagnosis is made by blood, bone marrow, or stool cultures.

Widal test:
Widal test is used to identify specific antibodies in serum of people with typhoid by using antigen-
antibody interactions.In this test, the serum is mixed with a dead bacterial suspension of salmonella having
specific antigens on it. If the patient's serum is carrying antibodies against those antigens then they get
attached to them forming clumping which indicated the positivity of the test. If clumping does not occur
then the test is negative.The Widal test is positive if TO antigen titer is more than 1:160 in an active
infection, or if TH antigen titer is more than 1:160 in past infection or in immunized persons.

Radio diagnostic test:

Rapid diagnostic tests such as Tubex, Typhidot, and Test-It has shown moderate diagnostic accuracy.

Treatment :
Treatment of choice is a fluoroquinolone such as ciprofloxacin. Otherwise, a third-generation
cephalosporin such as ceftriaxone or cefotaxime is the first choice. Cefixime is a suitable oral alternative.

Prevention :
Sanitation and hygiene are important to prevent typhoid. It can only spread in environments where
human feces are able to come into contact with food or drinking water. Careful food preparation and
washing of hands are crucial to prevent typhoid. Industrialization, and in particular, the invention of the
automobile, contributed greatly to the elimination of typhoid fever, as it eliminated the public-health hazards
associated with having horse manure in public streets, which led to large number of flies, which are known
as vectors of many pathogens, including Salmonella spp.

Chemoprophylaxis:
Two typhoid vaccines are licensed for use for the prevention of typhoid: the live, oral Ty21a vaccine
(sold as Vivotif by Crucell Switzerland AG) and the injectable typhoid polysaccharide vaccine (sold as
Typhim Vi by Sanofi Pasteur and Typherix by GlaxoSmithKline). Both are efficacious and recommended
for travellers to areas where typhoid is endemic. Boosters are recommended every five years for the oral
vaccine and every two years for the injectable form.
 Leptospirosis
Leptospira interrogans
Source : urine of infected animals
Mode of transmission:
Direct contact: through impact mucous membrane contact with urine or tissue of infected animal
Inder contact: through contact of broken skin with soil water for vegetation contaminated by urine of
infected animals
Droplet infection: inhalation women milking infected cows are goats of air containing infected droplets of
urine
Clinical features:
Anicteric leptospirosis:
Chills, myalgia, conjunctival suffusion, headache, renal manifestation, pulmonary manifestation,
hemorrhagic tendencies
Icteric leptospirosis:
Jaundice with fever, myalgia, headache, conjunctival suffusion, acute renal failure, nausea, vomiting,
diarrhoea, abdominal pain, hypertension, circulatory collapse, pulmonary insufficiency, combined renal
and liver failure associated with leptospirosis is referred to as weil's disease

Diagnosis:
Blood and urine culture organisms can be seen in dark field examination- culture on a semi solid medium
Serological test
Agglutination test
Indirect haemagglutination
Immunofluorescent antibody test
ELISA

Treatment:
Antibiotics - penicillin( dosage 6 million units daily intravenously) is the drug of choice other antibiotics
can be given are tetracycline, amoxicillin, ampicillin, doxycycline
Prevention:
 Environmental measures: preventing exposure to contaminated water, reducing contamination by
rodent control and protection of workers in hazardous occupation, measures taken to control rodents,
proper disposal of wastes and health education
 Vaccination: immunization of farmers and pets prevent disease

Scrub Typhus
 Most widespread of Rickettsial disease in India
 It is zoonotic disease , the chief reservoir is Trombiculid mites
 Scrub typhus caused by Orientia tsutsugamushi
 Found in areas where they harbour the infected chiggers particularly areas of heavy scrub vegetation
 Scrub typhus is a re-emerging disease in India

MODE OF TRANSMISSION
 TRANSOVARIAN TRANSMISSION

MITE  RATS AND MITE  MITE  RATS AND MICE


MAN (accidental host)
CLINICAL FEATURES
Incubation period: 1-3 wks(usually6-21 days)
SYMPTOMS
 Fever (104F – 105F)
 Intense Generalized Headache
 Diffuse myalgias
 Nausea, Vomiting, Diarrhea
 Cough
 Maculopapular rash
 Blood-shot eyes
 Papule followed by an eschar at the site of chigger feeding (typical feature)

SIGNS
  Relative bradycardia
 Lymphadenopathy - Tender lymph node, usually proximal to site of mite bite
 Lymphocytosis
 Hepatomegaly and splenomegaly can be observed

COMPLICATIONS
 Acute Respiratory Distress.
 Involvement of blood vessels in the central nervous system may produce meningitis
 slight intellectual blunting to coma or delirium
 In severe cases, evolution to a multiple-organ dysfunction syndrome with hemorrhage can be
observedg
 Disseminated intravascular coagulation (DIC).

Some patient recover spontaneously. Case-fatality rate for untreated classic cases is 70% (the fatality rate
ranges from 0 to 30%.)

INVESTIGATIONS
Weil-feilx test positive-proteus strain oxk
• Indirect immunofluorescence.
• PCR for Orientia tsutsugamushi from blood of feverish patients.•Some studies have used PCR on
specimens obtained from eschars.
TREATMENT
Tetracycline is Drug of choice
Dose: 500mg 3 times a day for 1 week
PROPHYLAXIS
 Control of vectors is by clearing the vegetation (grass) around the human dwellings and out-door
application of 10 percent DDT or BHC dusting powder on grasslands, will control larva, nymph and
adult stages of this mite.
 Personal prophylaxis is by application of repellents like DEET, DET to the skin and impregnation of
cloths and blankets with miticidal chemicals like benzyl benzoate.
 Presently no vaccine is available.

Done by

91. T.Varsha – Warning signs of fevr, Viral hepatitis- Treatment, prevention and chemoprophylaxis.

92. K.Varshini devi- Dengue and Malaria- Breeding sites, prevention, and chemoprophylaxis

93. B.Varthini- Dengue - signs and symptoms, warning signs, investigation and management.

94. V.Venenshiya Benedict – Malaria- signs and symptoms, warning signs, investigation and management.

95. G.K.Vidhubala – Addtn of symptoms of Dengue, Malaria, leptospirosis, scrub typhus, hepatitis, typhoid in HOPI

96. A.K.Vignesh – Typhoid- signs and symptoms, warning signs, investigation and management.

97. R.Vignesh – Leptospirosis- signs and symptoms, warning signs, clinical spectrum, investigation and management.

98. Yogesh Meena- Integrated Vector Control Measures, Clinical spectrum of Dengue, Malaria, Typhoid, Scrub typhus
99. V.Youvashree- Scrub Typhus- signs and symptoms, warning signs, investigation and management.

100 J.Yuwashree – Viral Hepatitis- signs and symptoms, mode of transmission, Diagnosis

COVID’19
SIGNS AND SYMPTOMS :-
More than 80 to 90% of the covid positive patients are asymptomatic,
only 5% of the positives need hospitalisation.

1. Fever (chills)
2. Sore Throat
3. Cough
4. Difficulty in Breathing
5. Tiredness / Easy Fatiguability
6. Headache
7. Diarrhoea
8. Anosmia & Ageusia
9.Conjuntivitis (less common )

WARNING SYMPTOMS :-
→ Difficulty in breathing or shortness of breath.
→ Chest pain or pressure .
→ Loss of speech or movement.

HIGH RISK GROUPS :-

→ Elder people ( age above 60 )
→ Hypertension
 → Diabetes(type 1 )
→ Cardiovascular disease
→ Obesity ( BMI >25 kg /m2 but < 30 kg/m2).
→ Severe obesity (40 kg /m2 )
→ Pregnancy
→ Sickle cell disease
→ Thalassemia
→ Pulmonary fibrosis
→ Asthma
→ Chronic obstructive pulmonary disease
→ Smoking
→ Chronic kidney disease
→ Cancer
→ Immunocompromised state
→ Cystic fibrosis
→ Cerebrovascular disease
→ Other heart conditions.
→ Health care workers.

COMPLICATIONS :-
▪ Acute respiratory failure
▪ Pneumonia
▪ Acute respiratory distress syndrome (ARDS )
▪ Acute cardiac injury
▪ Acute liver injury
▪ Acute kidney injury
▪ Secondary infection
▪ Septic shock
▪ Disseminated intravascular coagulation
▪ Blood clots
▪ Chronic fatigue
▪ Rhabdomyolysis
▪ Multisystem inflammatory syndrome in children.

MANAGEMENT :-
INVESTIGATIONS :-
1. Complete blood count
2. Neutrophil to Lymphocyte Ratio
3. prothrombin time and international normalized ratio (PT – INR)
4. Blood Glucose
5. Liver Function Test
6. Renal Function Test
7. Real time Reverse Transcriptase Polymerase Chain Reaction ( RT PCR)
8. Electrocardiogram ( ECG )
9. X- Ray Chest PA view
10. CT Scan Chest
11. Inflammatory Markers:
i. C – Reactive Protein (CRP)
ii. Interleukin 6
iii. Lactate Dehydrogenase (LDH)
iv. Serum Ferritin
v. D-Dimer
vi. Pro-calcitonin
12. Troponin
13. Arterial blood gas analysis
TREATMENT :-
ASYMPTOMATIC WITH COVID POSITIVE STATUS
Asymptomatic patients can be treated as outpatient

1. T.Ivermectin 12 mg 1bd x 5 days

2. Cap. Doxy 100mg 1bd x 5 days
3. T. Azithromycin 250mg 1bd x 5 days
4. Cap. Omeperazole 20mg 1bd x 5 days
5. T.Cetrizine 10mg 1od x 5 days
(or)
T.Allegra 120mg 1od x 5 days
6. T.Zinc 55mg 1bd x 5 days
7. T. Vitamin C 500mg 1bd x 5 days
8. HCQS 400mg 1bd on 1st day followed by 200mg 1bd from 2 to 5
days. If ECG normal it can be taken even at home especially in
patients with comorbities.
After 5 days Zinc & Vitamin C tablets to be continued for another 7 to 10
days.

Steam inhalation can be advised.

ASYMPTOMATIC WITH MINIMAL XRAY / CT SCAN FINDINGS (CT Scan finding Score I – 5%
area involved)
Asymptomatic patients with minimal Xray or CT scan findings can be treated as outpatient.
1. T.Ivermectin 12 mg 1bd x 5 days
2. Cap. Doxy 100mg 1bd x 5 days
3. T. Azithromycin 250mg 1bd x 5 days
4. Cap. Omeperazole 20mg 1bd x 5 - 7 days
5. T.Cetrizine 10mg 1od x 5 days
(or)
T.Allegra 120mg 1od x 5 days
6. T.Zinc 55mg 1bd x 10 days
7. T. Vitamin C 500 mg 1bd x 10 days
8. T. Vitamin D 2500 IU 1od x 10 days
9. HCQS 400mg 1bd on 1st day followed by 200mg 1bd from 2 to 5
days. If ECG normal it can be taken even at home especially in
patients with comorbities.

Steam inhalation can be advised.

MILD SYMPTOMATIC COVID POSITIVE STATUS (SPO2 >94%, RR < 20/mt, PR < 100/mt) (CT
Scan finding Score I – II / 5 – 25 % area involved)
1. T. Ivermectin 12 mg 1bd x 5 days
2. Cap. Doxy 100mg 1bd x 5 days
3. T. Azithromycin 250mg 1bd x 5 days
4. T. Dexamethasone 6 mg 1od x 5 - 7 days
5. Cap. Omeperazole 20mg 1bd x 5 - 7 days
6. T.Cetrizine 10mg 1od x 5 days
(or)
T.Allegra 120mg 1od x 5 days
7. T.Zinc 55mg 1bd x 10 days
8. T. Vitamin C 500mg 1bd x 10 days
9. T. Vitamin D 2500 IU 1od x 10 days
10. HCQS 400mg 1bd on 1st day followed by 200mg 1bd from 2 to 5
days. If ECG normal it can be taken even at home especially in
patients with comorbities.
Steam inhalation can be advised.

MODERATE COVID STAGE

(SPO2 < 94 – 90%, RR 24 – 30/mt, PR > 100mt)
(CT Scan finding Score II – IV / 25 to 75% area involved)

1. Nasal 02
Nasal Prongs 2 to 5 L/mt
Face mask 5 to 10 L/mt
Non Rebreather mask 2 to 10 L/mt
High flow nasal cannula 30 to 60 L/mt
CPAP
Intubation / Mechanical Ventilation
(Prone position preferred provided no contraindication)
2. IVF - 0.9% Normal saline 25ml/kg/24 hours.

3. Inj. Remdesivir 200mg IV st followed by 100mg IV od x 4 days

(infusion for 60 to 120 mts in total volume of 250ml of NS)

4. Inj. Enoxaparin 60mg IV bd x 5 to 7 days

(or)
Inj. Heparin 5000 units IV bd x 5 to 7 days.

5.Inj. Ceftriaxone 2gm IV bd x 5 to 7 days.

6. Inj. Dexamethasone 8mg IV bd x 5 – 7 days.

For DM: Inj.Dexamethasone 8mg IV od x 5 to 7 days.
(or)
Inj. Methyl prednisolone 125mg IV st (in 250ml of NS infusion for 1
hour) 12 hrs later 40mg IV od on first day followed by 40-60 mg IV
bd for 5 – 6 days.
For DM: 125mg IV st (in 250ml of NS infusion for 1 hour) on first
day followed by 40-60mg IV od for 5-6 days.
7. Inj. Tocilizumab (8mg/kg maximum of 800mg)
400mg in 200ml of normal saline infusion for 2 hours.
After 12 hours
400mg in 200ml of normal saline infusion for 2 hours.

8. T. Ivermectin 12mg 1bd x 5days

Cap. Doxy 100mg 1bd x 5 days
T. N-Acetyl Cysteine 600 mg 1bd x 5 days
Cap. Omeperazole 20mg 1bd
T.Vitamin C 500mg 1bd
T.Zinc 55mg 1bd
T. Vitamin D 2500 IU 1od

9. Convalescent plasma therapy 200ml IV infusion – od.

(Methylprednisolone given in bd dosage found to be more effective than
od dosage.
If oxygen requirement is progressively increasing despite use of
steroids, plasma therapy can be started.)

Steam inhalation can be advised.

SEVERE COVID STAGE

(SPO2 < 90, RR >30/mt, PR >100/mt, Hypotension / Septic Shock)
(CT Scan finding Score IV – V /> 50% area involved)

1. Nasal O2
Nasal Prongs 2 to 5 L/mt
Face mask 5 to 10 L/mt
Non Rebreather mask 2 to 10 L/mt
High flow nasal cannula 30 to 60 L/mt
CPAP
Intubation / Mechanical Ventilation
(Prone position preferred provided no contraindication)
2. IVF – 30ml/kg (infusion over 30 – 60mts) followed by
25ml/kg/24hours (Fluid restriction with loop diuretics in
hypervolemic ARDS)

3. Inj. Piperacillin – Tazobactam 4.5gm IV bd. (Dose to be adjusted in renal impairment). (or)
Inj. Meropenem1gm IV 1bd.

4. Inj. Remdesivir 200mg IV st followed by 100mg IV od x 4 days

(infusion for 60 to 120 mts in total volume of 250ml of NS)

5. Inj. Enoxaparin 60mg IV bd x 5 to 7 days

(or)
Inj. Heparin 5000 units IV bd x 5 to 7 days
14

6. Inj. Dexamethasone 8mg IV bd x 5 – 7 days.

For DM: Inj.Dexamethasone 8mg IV od x 5 to 7 days.
(or)
Inj. Methyl prednisolone 250mg IV st (in 250ml of NS infusion for 1
hour) on first day followed by 40-60 mg IV bd for5 – 6 days.
For DM: 250mg IV st (in 250ml of NS infusion for one hour) on first
day followed by 40-60 mg IV od for 5 – 6 days.

7. Norepinephrine 0.2 to 1.5microgram/kg/mt

&
Dobutamine 5 to 20 microgram/kg/mt
(If sign of poor perfusion and cardiac dysfunction persist despite
achieving MAP with fluids and other vasopressors)

8. Inj. Tocilizumab (8mg/kg maximum of 800mg)

400mg in 200ml of normal saline infusion for 2 hours.
After 12 hours
400mg in 200ml of normal saline infusion for 2 hours.
9. T. Ivermectin 12mg 1bd x 5days
Cap. Doxy 100mg 1bd x 5 days
T. N-Acetyl Cysteine 600 mg 1bd x 5 days
Cap. Omeperazole 20mg 1bd
T.Vitamin C 500mg 1bd
T.Zinc 55mg 1bd
T. Vitamin D 2500 IU 1od

10. Convalescent plasma therapy 200ml IV infusion for 2 hours-od.

(If oxygen requirement is progressively increasing despite use of steroids, Plasma therapy can be started.)

PREVENTION :-

1. Avoid touching your eyes, nose and mouth

2. Avoid close contact with people who are sick
a. Remember that some people without symptoms can still spread the virus
3. Stay at home when you are sick
4. Cover your cough or sneeze with a tissue, then dispose of it properly
5. Use a face covering when physical distancing is difficult or when going into closed spaces8
a. Physical distancing should be at least 1 meter (3 ft)
6. Clean and disinfect frequently touched objects and surfaces
7. Perform hand hygiene with soap and water or use alcohol-based hand rub
a. Hand Rub should contain at least 60% alcohol9
b. Hand washing should be done for at least 40-60 seconds based on WHO’s recommendations

IPC for COVID-19

Infection prevention and control (IPC) is the practice of preventing or stopping the spread of infections
during healthcare delivery in facilities like hospitals, outpatient clinics, dialysis centers, long-term care
facilities, or traditional practitioners.

COVID-19: IPC Priorities

▪ Rapid identification of suspect cases

o Screening/Triage at initial healthcare facility encounter and rapid implementation of source
control
o Limiting the entry of healthcare workers and/or visitors with suspected or confirmed COVID-
19
▪ Immediate isolation and referral for testing
o Group patients with suspected or confirmed COVID-19 separately
o Test all suspected patients for COVID-19
▪ Safe clinical management
o Immediate identification of inpatients and healthcare workers with suspected COVID-19
▪ Adherence to IPC practices
 o Appropriate use of Personal protective equipment (PPE)

VACCINE
Multiple strategies are adopted in the development of CoV vaccines; most of these target the surface-
exposed spike (S) glycoprotein or S protein as the major inducer of neutralizing antibodies. Several S-
protein-based strategies have been attempted for developing CoV vaccines.
HEALTHCARE WORKERS AND COVID :
“The COVID-19 pandemic has reminded all of us of the vital role health workers play to relieve
suffering and save lives,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “No
country, hospital or clinic can keep its patients safe unless it keeps its health workers safe. WHO’s
Health Worker Safety Charter is a step towards ensuring that health workers have the safe working
conditions, the training, the pay and the respect they deserve.
Mounting reports of infections, illness and attacks among health workers fighting COVID-19
COVID-19 has exposed health workers and their families to unprecedented levels of risk. Although
not representative, data from many countries across WHO regions indicate that COVID-19 infections
among health workers are far greater than those in the general population.
While health workers represent less than 3% of the population in the large majority of countries and
less than 2% in almost all low- and middle-income countries, around 14% of COVID-19 cases
reported to WHO are among health workers. In some countries, the proportion can be as high as
35%.  However, data availability and quality are limited, and it is not possible to establish whether
health workers were infected in the work place or in community settings. Thousands of health
workers infected with COVID-19 have lost their lives worldwide.
In addition to physical risks, the pandemic has placed extraordinary levels of psychological stress on
health workers exposed to high-demand settings for long hours, living in constant fear of disease
exposure while separated from family and facing social stigmatization. Before COVID-19 hit, medical
professionals were already at higher risk of suicide in all parts of the world. A recent review of health
care professionals found one in four reported depression and anxiety, and one in three  suffered
insomnia during COVID-19.  WHO recently highlighted an alarming rise in reports of verbal
harassment, discrimination and physical violence among health workers in the wake of COVID-19.
5 steps to improve health worker safety and patient safety:
On World Patient Safety Day, WHO reminds governments that they have a legal and moral
responsibility to ensure the health, safety and wellbeing of health workers. The Organization’s health
worker charter  calls on all Member States and relevant stakeholders to take steps to:
Establish synergies between health worker safety and patient safety policies and strategies:
→ Develop linkages between occupational health and safety, patient safety, quality improvement,
and infection prevention and control programmes.
→ Include health and safety skills in personal and patient safety into education and training
programmes for health workers at all levels.
→ Incorporate requirements for health worker and patient safety in health care licensing and
accreditation standards.
→ Integrate staff safety and patient safety incident reporting and learning systems.
→ Develop integrated metrics of patient safety, health worker safety and quality of care
indicators, and integrate with health information system.  

Develop and implement national programmes for occupational health and safety of health workers:
→ Develop and implement national programmes for occupational health for health workers in
line with national occupational health and safety policies.
→ Review and upgrade, where necessary, national regulations and laws for occupational health
and safety to ensure that all health workers have regulatory protection of their health and
safety at work.
→ Appoint responsible officers with authority for occupational health and safety for health
workers at both the national and facility levels.
→ Develop standards, guidelines, and codes of practice on occupational health and safety.
→ Strengthen intersectoral collaboration on health worker and patient safety, with appropriate
worker and management representation, including gender, diversity and all occupational
groups.
Protect health workers from violence in the workplace
● Adopt and implement in accordance with national law, relevant policies and mechanisms to
prevent and eliminate violence in the health sector.
● Promote a culture of zero tolerance to violence against health workers
● Review labour laws and other legislation, and where appropriate the introduction of specific
legislation, to prevent violence against health workers.
● Ensure that policies and regulations are implemented effectively to prevent violence and
protect health workers.
● Establish relevant implementation mechanisms, such ombudspersons and helplines to enable
free and confidential reporting and support for any health worker facing violence.

Improve mental health and psychological well-being

8. Establish policies to ensure appropriate and fair duration of deployments, working hours, rest
break and minimizing the administrative burden on health workers.
9. Define and maintain appropriate safe staffing levels within health care facilities.
10. Provide insurance coverage for work-related risk, especially those working in high-risk areas.
11. Establish a ‘blame-free’ and just working culture through open communication and including
legal and administrative protection from punitive action on reporting adverse safety events.
 12. Provide access to mental well-being and social support services for health workers, including
advice on work-life balance and risk assessment and mitigation.

Protect health workers from physical and biological hazards

→ Ensure the implementation of minimum patient safety, infection prevention and control, and
occupational safety standards in all health care facilities across the health system.
→ Ensure availability of personal protective equipment (PPE) at all times, as relevant to the roles
and tasks performed, in adequate quantity and appropriate fit and of acceptable quality.
Ensure an adequate, locally held, buffer stock of PPE. Ensure adequate training on the
appropriate use of PPE and safety precautions.
→ Ensure adequate environmental services such as water, sanitation and hygiene, disinfection
and adequate ventilation at all health care facilities.
→ Ensure vaccination of all health workers at risk against all vaccine-preventable infections,
including Hepatitis B and seasonal influenza, in accordance with the national immunization
policy, and in the context of emergency response, priority access for health workers to newly
licenced and available vaccines.
→ Provide adequate resources to prevent health workers from injuries, and harmful exposure to
chemicals and radiations; provide functioning and ergonomically designed equipment and
work stations to minimize musculoskeletal injuries and falls.

In addition to the Health Worker Safety Charter, WHO has also outlined specific World Patient
Safety Day 2020 Goals for health care leaders to invest in, measure, and improve health worker safety
over the next year. The goals are intended for health care facilities to address five areas:  preventing
sharps injuries; reducing work-related stress and burnout; improving the use of personal protective
equipment; promoting zero tolerance to violence against health workers, and reporting and analyzing
serious safety related incidents.  
EPIDEMIOLOGY:
Globally, as of from 20 December to 12 November 2020, there have been 51,848,261 confirmed cases of
COVID-19, including 1,280,868 deaths, reported to WHO.
Global situation:
Since the first reports of cases from Wuhan, a city in the Hubei Province of China, at the end of
2019, cases have been reported in all continents, except for Antarctica.
EPIDEMIOLOGICAL SITUATION IN THE WORLD
REGIONS:
COUNTRIES WITH WORST HIT:

Currently we can witness the second wave of Covid 19 in USA,UK

 France, Italy, Spain, Iran
Cases and deaths are reported steadily high in the second wave of the pandemic compared to
the first hit