Comparison between the traditional (1997) and revised (2009) WHO classifications of dengue disease: a retrospective study of 30 670 patients

Abstract

Objective To compare WHO's traditional (1997) and revised (2009) guidelines for dengue classification, using a large sample of patients of all ages with varying clinical conditions from a dengue‐endemic area in Brazil. Methods We compared 30 670 laboratory‐confirmed dengue cases (1998–2012) using both WHO's dengue classification guidelines. Stereotype ordinal logistic regressions were used to analyse the association between patients’ demographics and signs and symptoms related to dengue infection severity, as defined in the 1997 and 2009 guidelines. We then compared the degree of agreement in dengue classification of both guidelines. Results Dengue signs and symptoms in patients were poorly correlated to disease severity as defined by both guidelines (Cramer's V test <0.2). Hypotensive shock was the exception for both classifications, presenting dependence (Z = 56.42; P < 0.001, and Z = 55.24; P < 0.001) and high agreement (Cramers's V = 1; P < 0.001, and Cramers's V = 0.97; P < 0.001) for WHO 1997 and 2009, respectively. Last, we also found substantial agreement in disease classification between both guidelines (Kendall tau‐b = 0.79; P < 0.001), although 2009 guidelines were more sensitive in the detection of severe cases. Conclusions We hope our results will inform the debate about dengue classification guidelines, particularly concerning clinical value, study comparability, and ways in which future guidelines can support the clinical management of dengue. Our results suggest that caution should be taken when using WHO guidelines to assess dengue severity to improve clinical management of patients.

Primary Dengue Infection in Patients Requiring Hospitalization During an Outbreak in a Low Incidence Mexican Region

“…This is compatible with results from Thailand where PI and SI were similar between DHF-I and DHF-II (Wichmann et al 2004). In addition, we found a good agreement in case classification with the 1997 and 2009 WHO guidelines, similar to a recent report (da Silva et al 2018).…”

“…Because many clinically severe cases did not qualify as DHF, new guidelines were issued in 2009, now grouping cases into dengue without warning signs, dengue with warning signs (DWWS), and severe dengue (SD) that includes DSS (WHO 2009a). The advantages of the new classification have been discussed (Abello et al 2016, da Silva et al 2018; however, the 1997 classification remains in use among some clinicians and in literature.…”

Pulmonary manifestations of dengue

“…The dengue virus (DENV) belongs to the Flaviviridae family, and humans can be infected with any of the four antigenically distinct serotypes (DENV 1-4). (1)(2)(3)(4)(5)(6)(7) The prevalence of DENV infection has increased dramatically in recent decades; the disease is now endemic in > 100 countries worldwide. The global resurgence of dengue is thought to be due to the failure to control Aedes spp.…”

“…Severe dengue is characterized by at least one of the following: severe plasma leakage leading to shock, with or without fluid accumulation with respiratory distress, and severe bleeding or severe involvement of organs (liver, central nervous system, heart, or other). (1)(2)(3)(4)7) Dengue has a wide spectrum of clinical signs and symptoms, ranging from asymptomatic infection to severe, lethal manifestations. The disease usually presents as acute fever with headache, rash, myalgia, arthralgia, retro-orbital pain, prostration, lymphadenopathy, and dry cough.…”

The World Health Organization dengue case classifications

“…Retrospective studies from Brazil and South-East Asia have compared the two WHO dengue case classification systems (Table 2 ( [11][12][13][14][15][16]). In 2011, Barniol, et al, included patients from the Eastern Mediterranean, American and South-East Asian regions and concluded the 2009 classification had greater clinical usefulness in dengue case management and surveillance (16).…”