Multicentre prospective study on dengue classification in four South-east Asian and three Latin American countries

Authors: Alexander, Neal¹; Balmaseda, Angel²; Coelho, Ivo C. B.³; Dimaano, Efren⁴; Hien, Tran T.⁵; Hung, Nguyen T.⁶; Jänisch, Thomas⁷; Kroeger, Axel⁸; Lum, Lucy C. S.⁹; Martinez, Eric¹⁰; Siqueira, Joao B.¹¹; Thuy, Tran T.¹²; Villalobos, Iris¹³; Villegas, Elci¹⁴; Wills, Bridget¹⁵; on behalf of the European Union World Health Organization WHO-TDR supported DENCO Study Groupcr16,

Source: Tropical Medicine & International Health, Volume 16, Number 8, 1 August 2011 , pp. 936-948(13)

Publisher: Wiley-Blackwell

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Abstract:

<title type="main">Summary</title>

Objective To evaluate the existing WHO dengue classification across all age groups and a wide geographical range and to develop a revised evidence-based classification that would better reflect clinical severity.

Methods We followed suspected dengue cases daily in seven countries across South-east Asia and Latin America and then categorised them into one of three intervention groups describing disease severity according to the overall level of medical and nursing support required. Using a pre-defined analysis plan, we explored the clinical and laboratory profiles characteristic of these intervention categories and presented the most promising options for a revised classification scheme to an independent group of WHO dengue experts for consideration. Potential warning signs were also evaluated by comparing contemporaneous data of patients who progressed to severe disease with the data of those who did not.

Results A total of 2259 patients were recruited during 2006-2007 and 230 (13%) of the 1734 laboratory-confirmed patients required major intervention. Applying the existing WHO system, 47/210 (22%) of patients with shock did not fulfil all the criteria for dengue haemorrhagic fever. However, no three-tier revision adequately described the different severity groups either. Inclusion of readily discernible complications (shock/severe vascular leakage and/or severe bleeding and/or severe organ dysfunction) was necessary to devise a system that identified patients requiring major intervention with sufficient sensitivity and specificity to be practically useful. Only a small number of subjects (5%) progressed to severe disease while under observation; several warning signs were identified, but much larger studies are necessary to fully characterize features associated with disease progression.

Conclusions Based on these results, a revised classification system comprised of two entities, `Dengue' and `Severe Dengue', was proposed and has now been incorporated into the new WHO guidelines.

Document Type: Research article

DOI: http://dx.doi.org/10.1111/j.1365-3156.2011.02793.x

Affiliations: 1: London School of Tropical Medicine and Hygiene, London, UK 2: Departmento de Virología, Centro Nacional de Diagnóstico y Referencia, Managua, Nicaragua 3: Universidade Federal de Cearà, Fortaleza, Brazil 4: San Lazaro Hospital, Manila, Philippines 5: Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam 6: Children's Hospital No.1, Ho Chi Minh City, Vietnam 7: Section of Clinical Tropical Medicine, University Hospital, Heidelberg, Germany 8: Special Programme for Research and Training in Tropical Diseases, TDR-WHO, Geneva, Switzerland 9: Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia 10: Instituto Pedro Kouri, La Habana, Cuba 11: Universidade Federal de Goìas, Goianìa, Brazil 12: Children's Hospital No. 2, Ho Chi Minh City, Vietnam 13: Hospital Central de Maracay, Maracay, Venezuela 14: Universidad de los Andes, Nucleo Trujillo, Venezuela 15: Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam

Publication date: 2011-08-01

Multicentre prospective study on dengue classification in four South-east Asian and three Latin American countries

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