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Fulltext Comparing the usefulness of the 1997 and 2009 WHO dengue case classification: a systematic literature review

Horstick O, Jaenisch T, Martinez E, Kroeger A, See LL, Farrar J, et al.

Am J Trop Med Hyg, 2014 Sep;91(3):621-34.
PMID: 24957540 DOI: 10.4269/ajtmh.13-0676

The 1997 and 2009 WHO dengue case classifications were compared in a systematic review with 12 eligible studies (4 prospective). Ten expert opinion articles were used for discussion. For the 2009 WHO classification studies show: when determining severe dengue sensitivity ranges between 59-98% (88%/98%: prospective studies), specificity between 41-99% (99%: prospective study) - comparing the 1997 WHO classification: sensitivity 24.8-89.9% (24.8%/74%: prospective studies), specificity: 25%/100% (100%: prospective study). The application of the 2009 WHO classification is easy, however for (non-severe) dengue there may be a risk of monitoring increased case numbers. Warning signs validation studies are needed. For epidemiological/pathogenesis research use of the 2009 WHO classification, opinion papers show that ease of application, increased sensitivity (severe dengue) and international comparability are advantageous; 3 severe dengue criteria (severe plasma leakage, severe bleeding, severe organ manifestation) are useful research endpoints. The 2009 WHO classification has clear advantages for clinical use, use in epidemiology is promising and research use may at least not be a disadvantage.

Matched MeSH terms: Dengue/classification*; Severe Dengue/classification
Fulltext An evaluation of the World Health Organization's 1997 and 2009 dengue classifications in hospitalized dengue patients in Malaysia

Zakaria Z, Zainordin NA, Sim BL, Zaid M, Haridan US, Aziz AT, et al.

J Infect Dev Ctries, 2014 Jul;8(7):869-75.
PMID: 25022297 DOI: 10.3855/jidc.4283

INTRODUCTION: The latest revised version of the World Health Organization's dengue classification was released in 2009. A handful of studies have taken initiatives to evaluate the old and revised guidelines to determine early signs and symptoms of severe dengue. This retrospective study aimed to compare the classification of dengue using both the 1997 and 2009 guidelines in a selected cohort of dengue patients from Peninsular Malaysia between 2008 and 2012.
METHODOLOGY: Adult dengue patients were recruited from tertiary hospitals in two different states, Selangor and Kelantan, in Peninsular Malaysia. Their clinical manifestations were assessed.
RESULTS: A total of 281 confirmed dengue patients were enrolled; the mean duration of illness at admission was five days. Of these, 88.6%, 10.7%, and 0.7% were classified according to the 1997 guidelines as having dengue fever (DF), dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS), respectively. When the WHO 2009 guidelines were applied, 17.1%, 78.3%, and 4.6% were classified as dengue without warning signs, dengue with warning signs, and severe dengue, respectively.
CONCLUSIONS: Our data suggests that the revised WHO 2009 guidelines stratify a much larger proportion of patients into a category that requires a higher level of medical and nursing care.

Matched MeSH terms: Dengue/classification*; Severe Dengue/classification
Fulltext Classifying dengue: a review of the difficulties in using the WHO case classification for dengue haemorrhagic fever

Bandyopadhyay S, Lum LC, Kroeger A

Trop Med Int Health, 2006 Aug;11(8):1238-55.
PMID: 16903887 DOI: 10.1111/j.1365-3156.2006.01678.x

BACKGROUND: The current World Health Organisation (WHO) classification of dengue includes two distinct entities: dengue fever (DF) and dengue haemorrhagic fever (DHF)/dengue shock syndrome; it is largely based on pediatric cases in Southeast Asia. Dengue has extended to different tropical areas and older age groups. Variations from the original description of dengue manifestations are being reported.
OBJECTIVES: To analyse the experience of clinicians in using the dengue case classification and identify challenges in applying the criteria in routine clinical practice.
METHOD: Systematic literature review of post-1975 English-language publications on dengue classification.
RESULTS: Thirty-seven papers were reviewed. Several studies had strictly applied all four WHO criteria in DHF cases; however, most clinicians reported difficulties in meeting all four criteria and used a modified classification. The positive tourniquet test representing the minimum requirement of a haemorrhagic manifestation did not distinguish between DHF and DF. In cases of DHF thrombocytopenia was observed in 8.6-96%, plasma leakage in 6-95% and haemorrhagic manifestations in 22-93%. The low sensitivity of classifying DHF could be due to failure to repeat the tests or physical examinations at the appropriate time, early intravenous fluid therapy, and lack of adequate resources in an epidemic situation and perhaps a considerable overlap of clinical manifestations in the different dengue entities.
CONCLUSION: A prospective multi-centre study across dengue endemic regions, age groups and the health care system is required which describes the clinical presentation of dengue including simple laboratory parameters in order to review and if necessary modify the current dengue classification.

Matched MeSH terms: Dengue/classification*; Severe Dengue/classification
Problems in diagnosis and classification of dengue virus infection

George R

Malays J Pathol, 1993 Jun;15(1):25-7.
PMID: 8277785
Matched MeSH terms: Dengue/classification*
Neural network diagnostic system for dengue patients risk classification

Faisal T, Taib MN, Ibrahim F

J Med Syst, 2012 Apr;36(2):661-76.
PMID: 20703665 DOI: 10.1007/s10916-010-9532-x

With the dramatic increase of the worldwide threat of dengue disease, it has been very crucial to correctly diagnose the dengue patients in order to decrease the disease severity. However, it has been a great challenge for the physicians to identify the level of risk in dengue patients due to overlapping of the medical classification criteria. Therefore, this study aims to construct a noninvasive diagnostic system to assist the physicians for classifying the risk in dengue patients. Systematic producers have been followed to develop the system. Firstly, the assessment of the significant predictors associated with the level of risk in dengue patients was carried out utilizing the statistical analyses technique. Secondly, Multilayer perceptron neural network models trained via Levenberg-Marquardt and Scaled Conjugate Gradient algorithms was employed for constructing the diagnostic system. Finally, precise tuning for the models' parameters was conducted in order to achieve the optimal performance. As a result, 9 noninvasive predictors were found to be significantly associated with the level of risk in dengue patients. By employing those predictors, 75% prediction accuracy has been achieved for classifying the risk in dengue patients using Scaled Conjugate Gradient algorithm while 70.7% prediction accuracy were achieved by using Levenberg-Marquardt algorithm.

Matched MeSH terms: Dengue/classification*; Severe Dengue/classification
Clinicians' diagnostic practice of dengue infections

Ng CF, Lum LC, Ismail NA, Tan LH, Tan CP

J Clin Virol, 2007 Nov;40(3):202-6.
PMID: 17928264 DOI: 10.1016/j.jcv.2007.08.017

BACKGROUND: Difficulties in the classification of dengue infection have been documented. Such difficulties could be due to the low awareness of the World Health Organization diagnostic guidelines among clinicians.
OBJECTIVE: To study the diagnostic practices of clinicians in classifying patients as dengue fever (DF) or dengue haemorrhagic fever (DHF)/dengue shock syndrome (DSS) at the time of discharge during an outbreak.
METHODS: A prospective descriptive study of clinical features and disease classification in adult and pediatric dengue patients in the University of Malaya Medical Centre.
RESULTS: Five hundred and twenty adult and 191 pediatric patients were enrolled. Thrombocytopenia and evidence of plasma leakage were present in 8% of adult and 19% of pediatric patients. Of these, 93% and 49%, respectively, were given the discharge diagnoses of DF instead of DHF/DSS. Hemoconcentration, serous effusion and thrombocytopenia were not recognized in clinicians' discharge diagnosis of DHF/DSS for adult patients. The receiver operating characteristic (ROC) curve suggested a lack of consistency in the use of WHO guidelines in establishing DHF/DSS in adult patients, while implying otherwise for pediatric patients.
CONCLUSION: DHF/DSS is an under-recognized condition by clinicians managing these patients. This can affect the case fatality rate of DHF/DSS and the economic burden of the disease. The lack of awareness in disease manifestations especially plasma leakage, can lead to delayed recognition of DHF/DSS.
Study site: Outpatient department and inpatients, adult medical and pediatric wards, University Malaya Medical Center (UMMC), Kuala Lumpur, Malaysia

Matched MeSH terms: Dengue/classification; Severe Dengue/classification
Fulltext Cohorting Dengue Patients Improves the Quality of Care and Clinical Outcome

Lum LC, Syed Omar SF, Sri La Sri Ponnampalavanar S, Tan LH, Sekaran SD, Kamarulzaman A

PLoS Negl Trop Dis, 2015 Jun;9(6):e0003836.
PMID: 26047325 DOI: 10.1371/journal.pntd.0003836

INTRODUCTION: The increasing incidence of dengue among adults in Malaysia and other countries has important implications for health services. Before 2004, in order to cope with the surge in adult dengue admissions, each of the six medical wards in a university hospital took turns daily to admit and manage patients with dengue. Despite regular in-house training, the implementation of the WHO 1997 dengue case management guidelines by the multiple medical teams was piecemeal and resulted in high variability of care. A restructuring of adult dengue inpatient service in 2004 resulted in all patients being admitted to one ward under the care of the infectious disease unit. Hospital and Intensive Care Unit admission criteria, discharge criteria and clinical laboratory testing were maintained unchanged throughout the study period.
OBJECTIVES: To evaluate the impact of cohorting adult dengue patients on the quality of care and the clinical outcome in a university hospital in Malaysia.
METHODS: A pre (2003) and post-intervention (2005-6) retrospective study was undertaken.
INTERVENTION: Cohorting all dengue patients under the care of the Infectious Disease team in a designated ward in 2004.
RESULTS: The number of patients enrolled was 352 in 2003, 785 in 2005 and 1158 in 2006. The evaluation and detection of haemorrhage remained high (>90%) and unchanged throughout the study period. The evaluation of plasma leakage increased from 35.4% pre-intervention to 78.8% post-intervention (p = <0.001) while its detection increased from 11.4% to 41.6% (p = <0.001). Examination for peripheral perfusion was undertaken in only 13.1% of patients pre-intervention, with a significant increase post-intervention, 18.6% and 34.2% respectively, p = <0.001. Pre-intervention, more patients had hypotension (21.5%) than detected peripheral hypoperfusion (11.4%), indicating that clinicians recognised shock only when patients developed hypotension. In contrast, post-intervention, clinicians recognised peripheral hypoperfusion as an early sign of shock. The highest haematocrit was significantly higher post-intervention but the lowest total white cell counts and platelet counts remained unchanged. A significant and progressive reduction in the use of platelet transfusions occurred, from 21.7% pre-intervention to 14.6% in 2005 and 5.2% in 2006 post-intervention, p<0.001. Likewise, the use of plasma transfusion decreased significantly from 6.1% pre-intervention to 4.0% and 1.6% in the post-intervention years of 2005 and 2006 respectively, p<0.001. The duration of intravenous fluid therapy decreased from 3 days pre-intervention to 2.5 days (p<0.001) post-intervention; the length of hospital stay reduced from 4 days pre- to 3 days (p<0.001) post-intervention and the rate of intensive care admission from 5.8% pre to 2.6% and 2.5% post-intervention, p = 0.005.
CONCLUSION: Cohorting adult dengue patients under a dedicated and trained team of doctors and nurses led to a substantial improvement in quality of care and clinical outcome.

Matched MeSH terms: Dengue/classification*
Fulltext Severe dengue categories as research endpoints-Results from a prospective observational study in hospitalised dengue patients

Rosenberger KD, Alexander N, Martinez E, Lum LCS, Dempfle CE, Junghanss T, et al.

PLoS Negl Trop Dis, 2020 Mar;14(3):e0008076.
PMID: 32130212 DOI: 10.1371/journal.pntd.0008076

Severe dengue was perceived as one clinical disease entity until the WHO 2009 classification stratified it into severe vascular leakage, severe bleeding, and severe organ dysfunction. The objectives of this study were to investigate the potential use of severe dengue categories as endpoints for intervention research. 271 patients with severe dengue among 1734 confirmed dengue patients were followed prospectively in this hospital-based observational study in Latin America and Asia. We compared the distribution of severe dengue categories according to gender and age (below/above 15y), and determined the relative frequency and the overlap of severe dengue categories in the same patients. In a next step, we extended the analysis to candidate moderate severity categories, based on recently suggested definitions which were adapted for our purposes. Severe vascular leakage occurred in 244 (90%), severe bleeding in 39 (14%), and severe organ dysfunction in 28 (10%) of 271 severe dengue patients. A higher frequency of severe leakage was seen in children or adolescents (<15y) compared to adults. More than 80% of the severe leakage cases, and 30-50% of the cases with severe bleeding or severe organ dysfunction, were defined as severe on the basis of that feature alone. In 136 out of 213 patients with severe leakage alone, neither moderate bleeding manifestation nor hepatic involvement was recorded. On the other hand, moderate leakage manifestations were detected in 4 out of 12 cases that were classified as severe based on bleeding alone. A major proportion of severe dengue patients exhibited clinical manifestations of severe vascular leakage only, which may constitute a useful endpoint for intervention research or pathophysiology studies. Severe bleeding and severe organ manifestation were recorded less frequently and exhibited a higher degree of overlap with severe leakage. Severe bleeding without leakage may be associated with individual predisposition or the presence of comorbidities. More detailed assessments are needed to explore this hypothesis. Candidate moderate disease endpoints were investigated and need to be further validated.

Matched MeSH terms: Severe Dengue/classification*
Dengue hemorrhagic fever in Malaysia: the 1973 epidemic

Wallace HG, Lim TW, Rudnick A, Knudsen AB, Cheong WH, Chew V

Southeast Asian J. Trop. Med. Public Health, 1980 Mar;11(1):1-13.
PMID: 6105712

The first major Malaysian epidemic of dengue hemorrhagic fever with severe manifestations occurred in 1973, with 969 reported cases and 54 deaths. In a detailed study of 138 clinically diagnosed and laboratory confirmed cases at the General Hospital in Kuala Lumpur, hemorrhagic manifestations were observed in 68.7% and shock in 18.1% of the patients. The cases occurred mainly from May to September, largely in urban and suburban areas of the majority of the states in the country. A main focus of infection was Jinjang, a heavily populated outlying district of Kuala Lumpur, where unusually high incidences of morbidity, severe disease and mortality were seen. Severe disease was seen mostly in children under the age of 15 years, although a significant number of adults suffered milder illnesses. The Chinese population was chiefly affected, due to their living in crowded, low-income housing where the vector, Aedes aegypti, occurred in the greatest numbers. All four dengue types were recovered during the epidemic period, although dengue 3 (DEN-3) was incriminated as the major epidemic type. Entomological data revealed high indices of A. aegypti throughout the country and left little doubt that this epidemic was aegypti transmitted. Spraying and fogging operations were carried out in attempts to control vector populations.

Matched MeSH terms: Dengue/classification
Fulltext Validity of International Classification of Diseases (ICD) coding for dengue infections in hospital discharge records in Malaysia

Woon YL, Lee KY, Mohd Anuar SFZ, Goh PP, Lim TO

BMC Health Serv Res, 2018 04 20;18(1):292.
PMID: 29678172 DOI: 10.1186/s12913-018-3104-z

BACKGROUND: Hospitalization due to dengue illness is an important measure of dengue morbidity. However, limited studies are based on administrative database because the validity of the diagnosis codes is unknown. We validated the International Classification of Diseases, 10th revision (ICD) diagnosis coding for dengue infections in the Malaysian Ministry of Health's (MOH) hospital discharge database.
METHODS: This validation study involves retrospective review of available hospital discharge records and hand-search medical records for years 2010 and 2013. We randomly selected 3219 hospital discharge records coded with dengue and non-dengue infections as their discharge diagnoses from the national hospital discharge database. We then randomly sampled 216 and 144 records for patients with and without codes for dengue respectively, in keeping with their relative frequency in the MOH database, for chart review. The ICD codes for dengue were validated against lab-based diagnostic standard (NS1 or IgM).
RESULTS: The ICD-10-CM codes for dengue had a sensitivity of 94%, modest specificity of 83%, positive predictive value of 87% and negative predictive value 92%. These results were stable between 2010 and 2013. However, its specificity decreased substantially when patients manifested with bleeding or low platelet count.
CONCLUSION: The diagnostic performance of the ICD codes for dengue in the MOH's hospital discharge database is adequate for use in health services research on dengue.

Matched MeSH terms: Dengue/classification*
Global dengue death before and after the new World Health Organization 2009 case classification: A systematic review and meta-regression analysis

Low GK, Ogston SA, Yong MH, Gan SC, Chee HY

Acta Trop, 2018 Jun;182:237-245.
PMID: 29545158 DOI: 10.1016/j.actatropica.2018.03.014

BACKGROUND: Since the introduction of 2009 WHO dengue case classification, no literature was found regarding its effect on dengue death. This study was to evaluate the effect of 2009 WHO dengue case classification towards dengue case fatality rate.
METHODS: Various databases were used to search relevant articles since 1995. Studies included were cohort and cross-sectional studies, all patients with dengue infection and must report the number of death or case fatality rate. The Joanna Briggs Institute appraisal checklist was used to evaluate the risk of bias of the full-texts. The studies were grouped according to the classification adopted: WHO 1997 and WHO 2009. Meta-regression was employed using a logistic transformation (log-odds) of the case fatality rate. The result of the meta-regression was the adjusted case fatality rate and odds ratio on the explanatory variables.
RESULTS: A total of 77 studies were included in the meta-regression analysis. The case fatality rate for all studies combined was 1.14% with 95% confidence interval (CI) of 0.82-1.58%. The combined (unadjusted) case fatality rate for 69 studies which adopted WHO 1997 dengue case classification was 1.09% with 95% CI of 0.77-1.55%; and for eight studies with WHO 2009 was 1.62% with 95% CI of 0.64-4.02%. The unadjusted and adjusted odds ratio of case fatality using WHO 2009 dengue case classification was 1.49 (95% CI: 0.52, 4.24) and 0.83 (95% CI: 0.26, 2.63) respectively, compared to WHO 1997 dengue case classification. There was an apparent increase in trend of case fatality rate from the year 1992-2016. Neither was statistically significant.
CONCLUSIONS: The WHO 2009 dengue case classification might have no effect towards the case fatality rate although the adjusted results indicated a lower case fatality rate. Future studies are required for an update in the meta-regression analysis to confirm the findings.

Matched MeSH terms: Dengue/classification*
Fulltext Fulminant hepatitis in dengue infection

Lum LC, Lam SK, George R, Devi S

Southeast Asian J. Trop. Med. Public Health, 1993 Sep;24(3):467-71.
PMID: 8160054

Eight cases of liver failure and encephalopathy were observed among twenty cases of grade 3 and grade 4 dengue hemorrhagic fever/dengue shock syndrome admitted to the Department of Pediatrics, University Hospital, Kuala Lumpur from January 1990 to December 1991. All patients with deterioriation in mental status showed a marked increase in liver enzymes (aspartate and alanine aminotransaminases) and severe coagulopathy. Six patients needed cerebral protection, including ventilation, intravenous sedation and muscle relaxants. There was one death during the period of study and one case of residual hemiparesis in a boy who had, in addition, intracerebral hemorrhage. All other survivors had complete recovery of liver and neurological function.

Matched MeSH terms: Dengue/classification

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