Abstract
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.
Highlights
The World Health Organization (WHO), with its Special Program for Research and Training in Tropical Diseases (WHO/TDR), issued new dengue guidelines in 2009,1 including the 2009 WHO dengue case classification: dengue and severe dengue (D/SD)
Three additional studies were excluded after full assessment of the text, because they only assessed DF/DHF/DSS without comparison with D/SD32,33 or dealt with a particular subgroup of cases not representative of dengue-endemic countries
If the future pathogenesis research is based on clinical responses included in SD, such patients will exhibit an a mixture of dengue disease syndromes and/or complications of treatment, such as (1) the distinct syndromes contained within the clinical category severe bleeding and (2) inclusion of clinical endpoints that may confuse natural with iatrogenic evolution of disease
Summary
The World Health Organization (WHO), with its Special Program for Research and Training in Tropical Diseases (WHO/TDR), issued new dengue guidelines in 2009,1 including the 2009 WHO dengue case classification: dengue and severe dengue (D/SD). Warning signs (WS) have been established for triage to help clinicians with symptomatic cases in need of closer surveillance and/or hospitalization (dengue with warning signs [D+WS]). The 1997 WHO dengue case classification (dengue fever (DF), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) was developed in 1975 by expert consensus based on studies on Thai children in the 1950s and £60s, with modifications in 1986 and 1997.2 In the last modification in 1997, four grades of DHF were defined (DHF1, −2, −3, and −4), with DHF1 and −2 being DHF and DHF3 and −4 being DSS.[3]. The reasons for developing D/SD were the shortcomings of DF/DHF/DSS, which were established in many studies and summarized in a systematic review.[2].
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