It is near midnight and there is a deluge of Dengue patients at one city hospital. It’s a private hospital – very fancy, with Nelson Coconut chairs scattered around the vast lobby that might make a European airport terminal blush – and so it is rare to witness here the deluge there is on show routinely at AIIMS or Safdarjung.
But my friend – now a Dengue patient himself and for whom I have rushed with a box of platelets instead of a bouquet of pansies – tells me it is near impossible to find a spare bed. Dengue fever has gripped the city and everyone is on a platelet drip. He is on his fourth but his neighbour has already had eight. These are transfusions we are talking about, not beers. Each transfusion costs a minimum of 18,000 – the procedure of extracting platelets from blood is lengthy and requires expensive equipment. 8 transfusions translate into a cool Rs.1,50,000. As always, the patient is in no position to go against the wishes of his transfusion-loving doctor.
A normal adult has 1.5 to 4 lac platelets per mm3. During an acute Dengue infection, the platelet level comes down to 20,000 per mm3, sometimes even lower. My friend’s was 20,000 when the doctors decided enough was enough and began administering platelets. The platelet count goes up after every transfusion, naturally, but since the vessels are leaky and the platelet-making machinery temporarily defunct, the level goes down again. No worries: time for another transfusion, and another, and another, till the patient bleeds not blood, but his hard-earned money.
In every hospital across India, the situation is the same: Dengue patients are put on platelet transfusion soon as the levels drop to 20,000. Sometimes, the over-cautious doctors seal the deal at 30,000! Hindustan Times, a newspaper that has been tracking the ongoing Dengue outbreak in Delhi, reported an AIIMS doctor declaring patients “critical” when their platelet count “slumped to 30,000.” (HT, 12 October, 2012).
I ask Dr. Navin Khanna, a colleague, if this is indeed true – that a platelet count of 30,000 means the patient is critical. He should know. He’s spent the last 15 years researching Dengue. The Dengue detection kit that you see being used in every hospital has been developed by him. Together with another colleague, Dr. S. Swaminathan, Dr. Khanna is nearing towards his goal of an effective vaccine against Dengue.
“Platelet transfusion,” he says, “should be used only in critical cases.”
“Critical meaning 30,000?” I ask him.
“Critical meaning between 5,000-10,000,” he says. “The trick is to monitor the BP. That’s all – the rest the body will take care.”
Meanwhile, more weak-kneed rash-swept folks are trawling the city in search of a linen-sheathed bed and hospital corridors are lined with patients, two – sometimes three, if they are children – to every stretcher. While they wait, they pray for dawa, or medicine. But there is no dawa yet for Dengue, and so one might think that the end is nigh – start counting the minutes with the help of a prayer bead, tell relatives how much you’ve always loved them, that sort of thing.
Quite the opposite.
Outside of India, even in developing countries like Sri Lanka and Thailand, Dengue mortality rates are exceedingly low (Case Fatality Rates; http://www.searo.who.int). So in this, too, we’ve managed to come out top. What else does one expect in a nation that, day-in-day-out, frets more about morality than mortality? Life is cheap, izzat isn’t.
Dengue, caused by the Dengue Virus (DV), is endemic in almost 100 countries, with more than two billion people exposed to it. DV has four variants, 1-4, called serotypes. The severity of Dengue is a result of serotype interplay.
When a patient gets Dengue for the first time, it is never severe – our body fights well and wins comfortably in the end. When that same patient gets Dengue a second time, however, and the serotype is different from the one with which he was infected the first time round, things take a turn for the worse, leading to complications like Dengue Hemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS). In the absence of a drug or vaccine, the only recourse is to suffer it out. The key in avoiding mortality is monitoring the patient, hour-by-hour if needed.
In India, however, the key is making as much money as one can from the weak-kneed, rash-swept, sweat-drenched, OPD sightseer.
DV makes blood vessels and capillaries porous, and through these pores, the circulating fluid – that carries red blood cells and platelets – begins to leak out. This lowers the blood pressure, making it that much harder for blood and nutrients to reach our organs. To make matters worse, DV also infects directly the platelet-making bone marrow cells.
At some point the fluid that has seeped out begins to seep back in, restoring the blood pressure. This is why it is crucial to monitor the BP of a Dengue patient. Pumping the patient with intravenous (IV) saline – to compensate for the fluid loss – can exacerbate the situation when “lost” fluid beings to return to the vessels. The extra fluid in the vessels can make the BP shoot up, leading to haemorrhage.
But if it were just the administration of IV saline – Rs 25 a bottle – it wouldn’t have mattered. The problem is something else that is given intravenously: platelet transfusion.
A little bit of follow-up research shows that Dr. Khanna is right. The World Health Organisation (WHO) guidelines state explicitly that transfusion should be administered only when platelet counts are below 10,000 (Comprehensive guidelines for prevention and control of Dengue and DHF, Revised and Expanded Edition, WHO, 2011).
However, worldwide there is real unease on whether prophylactic platelet transfusions should be administered to DV patients in the first place.
A 2012 report published in the prestigious American Journal of Tropical Medicine and Hygiene, that analysed the issue of needless platelet transfusion, had this to say: “Currently, patients with severe thrombocytopenia (platelet count of less than 20,000) receive prophylactic transfusions to prevent bleeding despite a lack of evidence to support this practice…Prophylactic platelet transfusions offer no benefit to patients and there is no associated increase in morbidity or mortality with a conservative approach to transfusion…With proper management of DSS using intravenous fluids, thrombocytopenia seen in dengue resolves spontaneously and independent of any transfusion used.” (Am. J. Trop. Med. Hyg., 86, 531)
Another report is even more damning (When less is more: can we abandon prophylactic platelet transfusion in Dengue fever? Ann. Acad. Med. Singapore, 2011, 40, 539). The authors compared “patients who received prophylactic platelet transfusions with an equal number who did not. There was no significant difference in occurrence of haemorrhage between the two groups.” They proposed that “prophylactic platelet transfusion be safely withheld for platelet counts as low as 5000…Attempting to increase platelet counts via transfusion in the absence of major bleeding has not conferred protective benefits from bleeding in dengue. Rather, early recognition of dengue, especially severe dengue and DHF, with prompt correction of hemodynamic (i.e. BP, heart-rate) parameters, remains the cornerstone of avoiding haemorrhage and ensuring good clinical outcomes.”
The results of a global survey involving 306 physicians conducted in 2012 (PLoS Negl. Trop. Dis. 6(6): e1716), to discover the preferences of doctors in giving platelet transfusion to dengue patients, are striking. No doctor from UK was willing to administer platelet transfusion in absence of bleeding. That’s 0. The figure for Asia was 75. 3 doctors from UK said they would administer transfusion if the platelet count reached below 3,000, while 57 Asian doctors said they would give transfusion under similar circumstances.
I have quoted just a handful of reports from the hundreds that have been published over the past decade on this subject. The evidence is quite conclusive: avoid platelet transfusion unless absolutely essential. It can be more harmful than helpful. It will save money, effort, and avoid risk of infection.
However, there is another – a very Indian problem that our doctors face: the patient’s and his/her relatives’ take on things. WHO guidelines are all very well but as Dr. Sushila Kataria, a clinician at Medanta Hospital who’s been treating Dengue cases for more than a decade, puts it, “I agree – less than 10,000 is well and good, but what does one do when the relatives demand the patient be put on a platelet transfusion? Secondly, in our country one can’t wait till the count drops below the WHO recommended level of action – where will you get an assured supply of platelets in that emergency situation, tell me? As it is, not every hospital that treats Dengue patients has the equipment for extracting platelets, notwithstanding the fact that it takes a minimum of 2 hours for the whole process. I can’t stand and watch helplessly as my patient’s platelet count goes from 10,000 to 8,000 to 2,000…waiting for the platelets to arrive while he battles for his life – no way!”
This is true, as I well know, having had to drive over to my friend’s bedside with the platelets. Dr. Kataria continues “Another thing, we hold back on giving transfusion and immediately our intentions are questioned by the relatives – “why are you not giving the platelets?” “who are you saving them for?”. I agree with what you say about the need for caution as regards prophylactic platelet transfusion, but I feel in India one needs to be more liberal with the threshold value. It can save lives.”
Another doctor, with whom I discuss the topic over phone, concurs with Dr. Kataria’s view. “This isn’t Europe or America where everything is at hand, every hospital has a platelet supply and every clinic has the platelet extracting equipment. Here, we can’t play with lives while we wait for the platelet bag to arrive and watch the count drop down to well below 10,000. Who’ll be responsible?”
Nevertheless, the fact remains that Dengue patients end up spending a lot on their treatment. I ask Dr. Kataria for a solution to this problem.
“Much more awareness of this platelet transfusion issue,” she says, “on the doctors’ as well as the patients’ side. And a platelet extraction and banking facility at every hospital – that’s an absolute must.”
My friend is covered through medical insurance and so he can still buy that Tata Nano – that’s been the equivalent cost of his treatment – with the money that’ll come back to him. But what about those who weren’t insured and who’d now be thinking twice about their child’s education or loan repayments? Were 10 transfusions worth the trouble?
It is time our Health Minister drew up some concrete guidelines for setting up platelet facilities across the cities, especially during the Dengue season. The Dengue guidelines should also be pasted on every Dengue ICU wall and advertised in every major newspaper and magazine. But is he listening, or does he too require a hearing aid?
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