Decision No. 1905/2003/QÐ-BYT on issuing guidelines for diagnosing and managing acute encephalitis in children

DECISION OF THE MINISTER OF HEALTH

Regarding the issuance of guidelines for diagnosing and managing acute encephalitis in children

____________________

THE MINISTER OF HEALTH

Pursuant to Decree No. 68/CP dated 11/10/1993 of the Government stipulating the functions, tasks, powers, and organizational structure of the Ministry of Health;

At the proposal of the Director of the Treatment Department - Ministry of Health

DECISION:

Article 1. Now hereby promulgating together with this Decision "Guidelines for Diagnosing and Managing Acute Encephalitis in Children"

Article 2. "Guidelines for Diagnosing and Managing Acute Encephalitis in Children" is the guiding material to be applied in all state, semi-state, and private healthcare facilities. Previous regulations that conflict with the provisions of this Decision are abolished.

Article 3.  This Decision shall take effect fifteen days from the date of publication in the Official Gazette. Article 4.

The Heads of the Office, Directors of the Treatment Department, Inspectorate, Heads of other Departments and Bureaus under the Ministry of Health, Directors of hospitals directly under the Ministry of Health, Directors of Provincial and Municipal Health Services, and Heads of health sectors are responsible for implementing this Decision. GUIDELINES FOR DIAGNOSING AND MANAGING ACUTE ENCEPHALITIS IN CHILDREN (Issued pursuant to Decision No. 1905/2003/QÐ-BYT dated June 4, 2003  1. Overview

 Acute encephalitis is an acute infectious disease of the central nervous system. There are many causes of encephalitis, mainly viral.

Depending on the type of virus, the disease can be transmitted through mosquito bites (for Japanese encephalitis), respiratory routes, or gastrointestinal routes...

 of the Minister of Health)

The disease usually occurs in young children of different ages. It often starts acutely, progresses severely, and may lead to rapid death or leave serious sequelae.

2. Epidemiology:

The disease appears sporadically throughout the year in many different regions. The number of cases tends to increase during hot weather from March to August each year.

Japanese encephalitis:

Circulates in almost all provinces and cities. Appears sporadically throughout the year, often occurring in outbreaks in May, June, and July. Transmission occurs through mosquito bites. The disease affects all age groups, but most commonly in children aged 2 to 8 years.

Other viral encephalitides such as:

Enteroviruses (Enterovirus):

Occurs throughout the year, often in March, April, May, and June.

Transmission occurs through the gastrointestinal route.

Commonly seen in young children.

Herpes Simplex Virus:

Usually Herpes Simplex Type 1 (HSV1).

Occurs sporadically throughout the year, transmitted through respiratory routes.

Commonly seen in children over 2 years old.

Other viruses

3. Diagnosis

Based on:

Epidemiological factors

Clinical symptoms and progression

Ancillary tests

Excluding diseases with neurological manifestations but not encephalitis.

3.1. Epidemiological factors:

Based on age, season, place of residence, and number of cases in the same period.

3.2. Clinical

3.2.1. Initial stage:

Fever: Fever is a common symptom, occurring suddenly, continuous fever at 39-40°C but sometimes not high. Headache, irritability, excitement, decreased responsiveness. Nausea, vomiting.

Other possible symptoms include:

Diarrhea, non-mucoid, blood-free stools.

Cough, runny nose.

Rash: red spots, vesicles, or petechiae on palms and soles with mouth ulcers (hand-foot-mouth syndrome, seen in Enterovirus 71 encephalitis).

3.2.2 Full-stage: After the initial stage, neurological manifestations quickly appear:

Altered consciousness ranging from mild to severe, such as somnolence, stupor, delirium, to coma.

Often accompanied by seizures.

Other neurological signs may include meningeal signs, focal neurological signs (hemiparesis or quadriplegia), increased or decreased muscle tone...

Respiratory failure or shock may occur.

3.2.3 Clinical forms:

Fulminant form: Continuous high fever, deep coma, respiratory failure, circulatory collapse, leading to rapid death.

Acute form: Rapid progression with severe clinical manifestations, typical.

Mild form: Mild altered consciousness and quick recovery.

3.3. Ancillary tests:

Cerebrospinal fluid:

Clear fluid, normal or increased pressure.

Normal or increased cells, from several dozen to several hundred/ml, mainly mononuclear cells.

Protein normal or slightly increased below 1g/l.

Glucose normal.

Do not perform lumbar puncture

in cases with signs of increased intracranial pressure, shock, or severe respiratory failure.

Blood:

Blood cell count: slight increase or normal white blood cell count.  Negative for malaria parasites.

Electrolytes and glucose levels usually within normal limits.

Specific etiological tests (applied in facilities with appropriate conditions):

ELISA test of cerebrospinal fluid or serum to detect IgM antibodies.  PCR amplification of viral DNA in cerebrospinal fluid.

Viral isolation from cerebrospinal fluid, blood, vesicle fluid, nasopharyngeal secretions, stool.

Viral isolation from brain tissue in deceased patients.

Other tests:

Electroencephalogram

Computed tomography (CT) or magnetic resonance imaging (MRI) of the brain

(if available)  3.4. Differential diagnosis:

Febrile convulsions

Purulent meningitis

Tuberculous meningitis

Acute poisoning

Malaria cerebral form

Subarachnoid hemorrhage  Epilepsy

Hypoglycemia

Metabolic and electrolyte disorders

4. Treatment

Viral encephalitis is a serious condition with high mortality and morbidity rates, requiring early treatment.

Currently, there is no specific treatment except for herpes simplex encephalitis. Therefore, symptomatic and supportive treatments are primarily used.

Principles of treatment:

Antipyretics

Anticonvulsants

Ensuring ventilation and preventing respiratory failure

Anti-edema

Correcting water, electrolyte, and glucose imbalances (if present)

Ensuring circulation

Ensuring care and nutrition

Treating the cause

Early rehabilitation

4.1. Antipyretics

Give the child sufficient fluids, loosen clothing, diapers, and cool down by wiping.

If fever exceeds 38.5°C, use Paracetamol 15mg/kg/dose orally or rectally (can repeat every 6 hours, up to 4 times a day if fever persists).

4.2. Anticonvulsants:

Diazepam: Administered via one of the following methods:

Intramuscular: dose 0.2 - 0.3 mg/kg

Intravenous: dose 0.2 - 0.3 mg/kg, slowly injected intravenously (only performed in facilities with resuscitation capabilities due to potential respiratory arrest).

Rectal: dose 0.5 mg/kg

Method:

Draw the calculated amount of drug (based on weight) from the Diazepam injection vial into a 1ml syringe. Then remove the needle.

Insert the syringe 4-5 cm into the rectum and inject the drug.

Hold the child's buttocks for a few minutes.

If seizures continue after 10 minutes, administer a second dose of Diazepam.

If seizures persist, administer a third dose of Diazepam or Phenobarbital (Gardenal) 5 - 8 mg/kg/24 hours, divided into three doses, administered intramuscularly.  4.3. Ensuring ventilation and preventing respiratory failure

Intravenous route: dose of 0.2 - 0.3 mg/kg, administered slowly intravenously. (Only to be performed at facilities equipped for resuscitation due to potential risk of respiratory arrest).

Rectal route: dose of 0.5 mg/kg.

Method:        Draw the calculated amount of medication (based on weight) from the Diazepam injection vial into a 1 ml syringe. Then remove the needle.

Insert the syringe into the rectum 4-5 cm and inject the medication.

Hold the child's buttocks for several minutes.

If seizures continue after 10 minutes, administer a second dose of Diazepam.

If seizures persist, administer a third dose of Diazepam, or Phenobarbital (Gardenal) 5 - 8 mg/kg/24 hours divided into three doses, administered intramuscularly.

 4.3. Ensure ventilation, prevent respiratory failure.

Always ensure airway patency: Place the child supine, elevate the shoulders with a pillow, extend the head backward and tilt it to one side, suction secretions when there is airway obstruction due to secretion accumulation.

In case of respiratory failure: administer oxygen, intubate if necessary, use a bag valve mask or mechanical ventilation.

Oxygen administration:

Indications: seizures, respiratory failure, oxygen saturation (SaO2) less than 92% (if measured)

Method: Administer oxygen via nasal cannula or mask at a rate of 1-3 liters per minute depending on age and degree of respiratory failure.

Intubation and mechanical ventilation:

Indications:  Apnea or apneic episodes, failure of oxygen therapy

Method:

Initial settings for mechanical ventilation:

Mode: volume-controlled ventilation

Initial FiO2: 100%

Tidal Volume (TV): 10-15 ml/kg

Respiratory Rate: under 1 year old: 25 breaths per minute; from 1-5 years old: 20 breaths per minute; over 5 years old: 15 breaths per minute.

Inspiratory-to-Expiratory Ratio (I/E): 1/2

Set Positive End-Expiratory Pressure (PEEP): 4 cmH2O.

Adjust parameters based on clinical progression, response, and SaO2, blood gas analysis.

If endotracheal intubation cannot be performed, use a bag valve mask. If there is no ventilator, use a bag valve mask through the endotracheal tube. The frequency of squeezing should be between 20 to 30 times per minute.

Discontinue mechanical ventilation and extubate when the patient can breathe spontaneously, seizures have ceased, hemodynamics are stable, chest X-ray is normal, blood gases are normal with FiO2 less than 40% and PEEP less than 4 cmH2O.

 4.4. Treatment for cerebral edema

Indications: When signs of cerebral edema are present  such as headache accompanied by irritability, agitation or  lethargy, coma; papilledema; unequal pupils; focal paralysis; rigidity; irregular breathing, bradycardia with hypertension.

Method:

Position: Head elevated 30 degrees

Administer oxygen. When using mechanical ventilation, increase ventilation and maintain PaO2 between 90-100 mmHg and PaCO2 below 25-35 mmHg.

Mannitol 20% solution: Dose 0.5g/kg (2.5ml/kg) intravenous infusion over 15 to 30 minutes. Repeat infusion every 8 hours if cerebral edema persists but not more than 3 times in 24 hours and not more than 3 days. Do not use Mannitol  in cases of shock or pulmonary edema.

Monitor clinically and electrolytes (if conditions permit) during infusion to detect signs of overload and electrolyte disorders.

 4.5. Correction of electrolyte imbalance and blood glucose (if present)

Adequate fluid and electrolyte replacement. Be cautious in cases of pulmonary edema.

Use isotonic saline solution. The amount of fluid administered is calculated based on body weight.

Correct electrolyte imbalances and acid-base balance based on electrolyte levels and blood gas analysis.

4.6. Shock treatment:

If shock occurs, use Dopamine intravenous infusion, starting dose 3-5 μg/kg/min and gradually increase up to a maximum of 10 μg/kg/min.

4.7.      4.7.       Ensure nutrition and care, functional recovery

4.7.1.      4.7.1.        Nutrition

Provide easily digestible food, high energy, sufficient minerals and vitamins. Energy should provide 50-60 kcal/kg/day.

Ensure breastfeeding. For children who cannot breastfeed, express breast milk and feed small amounts by spoon or nasogastric tube (in multiple small meals or continuous drip). Be cautious as choking and gastroesophageal reflux are common.

If the child cannot eat independently, feed through a nasogastric tube or parenteral nutrition. Vitamin C and B complex supplements may be added.

4.7.2. Care and monitoring

Pay attention to skin care, mouth hygiene, frequently change positions to prevent pressure sores and perform percussion to prevent atelectasis and pneumonia due to fluid retention.

Regularly suction secretions.

Treat constipation

Urinary retention, bladder distension:  Massage the bladder. Limit catheterization due to  risk of secondary infection.

Frequently monitor vital signs, level of consciousness, signs of cerebral edema, SaO2, electrolyte levels, and blood glucose.

4.7.3. Functional recovery: Initiate early when the patient is clinically stable or when there are residual effects.

4.8. Antiviral drugs:

When diagnosing herpes encephalitis, Acyclovir may be used, dose 20 mg/kg every 8 hours, intravenous infusion over 1 hour. Duration of treatment: at least 14 days.

4.9. Antibiotics:

In cases where bacterial meningitis has not been ruled out

In cases of secondary infection.

5. Treatment Levels

5.1. Commune Level:

Identify suspected cases, provide initial emergency care, treat seizures (if present), and refer to higher levels.

5.2. District Level:

Diagnose and manage mild cases.

Refer severe cases and mild cases without lumbar puncture facilities to higher levels.

5.3. Provincial Level

Receive and treat all acute encephalitis cases.

Refer only if the patient is critically ill and beyond the diagnostic and treatment capabilities of the provincial level.

5.4. Central Level:

Receive and treat all acute encephalitis cases and those referred from lower levels.

Direct and support lower levels in diagnosis and treatment.

Conduct diagnostic tests to determine causes.

6. Prevention

6.1. Environmental Sanitation

Personal hygiene, use mosquito nets.

Food hygiene to avoid transmission of pathogens through the digestive tract.  Environmental sanitation, do not keep livestock near homes or residential areas.

Vector control, eliminate breeding sites, kill mosquitoes.

6.2. Vaccination:

6.2.1 Japanese Encephalitis Vaccination:

Subcutaneous injection;

Dosage: 0.5ml for children under 5 years old; 1ml for children over 5 years old

Dose 1: start injection;

Dose 2: 7 days after dose 1;

Dose 3: 1 year after dose 2.

Booster every 3 to 4 years

6.2.2. Vaccination

against polio, measles, mumps, and chickenpox.  polio, measles, mumps, chickenpox vaccines.