We know that reducing mosquito-breeding grounds and getting the community involved are key to limiting transmission of dengue fever. But the role of primary healthcare doctors to manage dengue in the community setting must not be underestimated.
It does not stop at just providing clinical care, but also contributes greatly to surveillance, research and prevention of dengue.
The roles of primary care doctor in dengue management first start with the ability to suspect patient to have dengue since dengue patients can present similar symptoms as other febrile diseases.
The doctor has to use the right diagnostic tools to confirm dengue, monitor the patient for any progression to severe illness and refer the patient to a hospital if so before notifying the Ministry of Health.
Most primary healthcare doctors have a high level of knowledge on dengue management and good follow-up consultations with dengue patients in the primary healthcare clinics, a study by us in 2014 found.
Another important role of primary healthcare doctors is the early detection of new dengue hotspots. This requires doctors to gather key epidemiological information from patients at their onset of fever. This can help in identifying potential hotspots so that enhanced mosquito control measures can be then taken.
This was indeed what happened during the Chikungunya outbreak in 2008 and Zika outbreak in 2016. While the primary healthcare doctors in these outbreaks did well to pick up unusual trends in the community and notified the relevant authorities early, there remains a need for constant vigilance for dengue as well among primary healthcare doctors.
That is not as easy as it sounds. Acute onset of fever is a non-specific symptom among dengue cases. The classical dengue rash generally appears after only the fourth day of fever. So relying on dengue rash to diagnose the disease may delay appropriate treatment. Hence, blood testing for dengue in laboratory – which takes about one day to process – is always a recommended option.
Indeed, there has been a two-fold increase (from 29.5 per cent to 56 per cent) in doctors here using blood testing to confirm dengue diagnosis from 2011 to 2014.
With the advances in technology, this blood testing has been made possible with a simple point-of-care kit that can be used to detect dengue as rapid as 30 minutes in the clinic without the need to send it to a laboratory.
However, based on our study in 2014, only about 14 per cent of the primary healthcare settings are using point-of-care diagnostic kit for early dengue diagnosis in Singapore.
Two likely factors for the low usage are a lack of awareness about the point-of-care diagnostic kit and its relatively high cost. Each kit costs at least twice more than a laboratory test.
Further research is required to assess cost-effectiveness of the implementation of point-of-care kit in the primary healthcare clinics. The outcome factors to consider include reduction in severe dengue and hospitalisation as well as the economic impact in reducing dengue transmission and burden.
PRIMARY HEALTHCARE ENGAGEMENT
Primary healthcare engagement in community involves the continuous education of both patients and the primary healthcare doctors.
Primary healthcare doctors are likely the first professional contact for patients, and are therefore important sources of information on dengue prevention, early recognition of symptoms, the usefulness of dengue vaccine and to encourage health-seeking behavior among residents in the community.
The engagement between primary healthcare doctors and the patients can and should go beyond the clinical setting into the community, especially with today’s advances in mobile technology and the plan to develop Singapore towards a Smart Nation.
Mobile health applications can be implemented to allow patients to update their primary healthcare doctors in real-time securely of their medical status post-consultation, especially when they are being advised to recuperate at home, or after they are being referred to the hospital.
As part of the continuing medical education on dengue clinical management among primary healthcare doctors, the Institute of Infectious Diseases and Epidemiology at Tan Tock Seng Hospital has been organising a dengue symposium for the past seven years with the support of Ministry of Health.
The aim is to constantly raise the awareness among primary healthcare doctors on the importance of early diagnosis using dengue test and early management of dengue patients in the community.
While we stress the importance of reducing mosquito breeding grounds, it is equally important to emphasise that our primary healthcare system is critical in the overall effort against Dengue.
An efficient primary healthcare system in the community is one that can minimise the risk of overloading the hospitals with too many dengue patients who are non-severe, and on the other hand, increase the chance of recovery among dengue patients who are progressing into severe conditions by referring to hospitals promptly.
This will not be an easy feat, but much research efforts have been invested to predict if dengue patient is more likely to have severe conditions or not in the primary healthcare clinics, using the same blood test for dengue.
However, this prediction would likely be accurate and effective if the patient consults the primary healthcare doctors as early as possible, before their conditions deteriorate.
These initiatives, together with the other multi-pronged approaches, will help to reduce the risk of a large dengue outbreak as we strive to build a more sustainable community-orientated health system in future.
ABOUT THE AUTHORS:
Dr Vincent Pang Junxiong is Assistant Professor at the Saw Swee Hock School of Public Health, and Director, Centre for Infectious Disease Epidemiology and Research, National University of Singapore. Professor Leo Yee Sin is Director, Institute of Infectious Diseases and Epidemiology and Clinical Director, Communicable Disease Centre, at the Tan Tock Seng Hospital.