1. DENGUE VALIDATION STUDY Country site :INDONESIA (Sardjito Hospital & Depok I Health Center) (Sewon HC) BANTUL Sewon BANTUL Banguntapan BANTUL Kasihan BANTUL

2. Population and Dengue Incidence by Proposed Study Location ProvinceHospital/Health Center District Population Population Density/km2 2006 Incidence*2007 Incidence* Jogjakarta provinceSardjito Hospital3.388.733787.26.627.44 Jogjakarta municipality Wirosaban hospital443,11813,606.416.914.5 Pantirapih hospital Wirobrajan health center Sleman districtDepok health center1,008,2951,754.16.928.30 Bantul districtSewon health Center879,8251,625.25.666.67

3. ACTIVITY DATEPlace General DisseminationFeb 14 th 2009Yogyakarta Province Health Office Dissemination to each study unit (Public Health Center/ PHC and hospital) March 03 th 2009 until March 17 th 2009 Depok I PHC, Sewon I PHC, Wirobrajan PHC Panti Rapih Hospital, Sardjito Hospital, Wirosaban Hospital Training for Health Center StaffApril 02 th 2009 Until April 8 th 2009 Panti Rapih Hospital, Sardjito Hospital, Wirosaban Hospital & Yogyakarta Province Health Office Preliminary FeedbackMay 28 th 2009Sardjito Hospital Focus Group DiscussionJune 16 th 2009 Until June 23 th 2009 Depok I PHC, Sewon I PHC, Wirobrajan PHC Panti Rapih Hospital, Sardjito Hospital, Wirosaban Hospital In-depth Interview ActivityJune 25 th 2009 and July 03 th 2009 Yogyakarta Municipal Health Office, Sleman & Bantul District Health Office Final DisseminationJuly 10 th 2009Yogyakarta Province Health Office

4. Participants NOACTIVITYPARTICIPANTS 1.General Dissemination Head of Surveillance Sub-division (MoH) Head of Arbovirus Sub-division (MoH), Head of PHO and DHO, Pediatrician, Internist,Medical Record Unit, General Physician,Nurse 2. Dissemination to each study unit Head of PHCs, Hospital Directors, General Physician, Nurse, Medical Record staff 3. Training for Health Center General Physician,ER Physician,Internist Pediatrician,Medical Record staff 4. Preliminary Feedback General Physician,ER Physician,Internist Pediatrician,Medical Record staff,Head of HC,Medical record Staf 5. Focus Group Discussion General Physician,ER Physician,Internist Pediatrician,Medical Record staff 6. Final Dissemination Head of Surveillance Sub-division Head of Arbovirus Sub-divisio, Pediatrician Internist,Medical Record Unit, General Physician,Nurse

5. Study elements Retrospective chart review Questionnaires Focus Group Discussions

6. Materials used POSTERALGORITHM CLINICAL GUIDE

7. Results ACTIVITYSardjitoWirosabanPanti RapihDepok ISewon IWirobrajan CHART REVIEWS80 160202611 QUESTIONNAIRES421627997 FGD111111 Chart Review: former classification vs revised classification

8. FGD (1) Strengths of revised classification Simple and easy to use Safer for patients Useful for triage of patients Promotes early diagnosis and management Weaknesses of revised classification Too qualitative → no quantitative thresholds Can lead to overdiagnosis → excess hospital admission Not yet in line with existing systems (e.g. ICD, clinical audit, payment schemes)

9. FGD (2) Strengths of revised algorithm More aggressive in management of dengue with warning signs → shorter hospital stay Patient education messages very useful Weaknesses of revised algorithm Too conservative for shock management Too risky for patient outcome Too risky for hospital in legal aspect

10. General recommendations Reconsider adoption of quantitative parameters Reconsider guidance for shock management Facilitate implementation Stronger involvement of professional associations Strengthened training design (e.g. interactive CD-ROM) Synchronization with ICD, billing system and clinical audits