Dengue disease severity in Indonesian children: an evaluation of the World Health Organization classification system

Tatty E Setiati,Augustinus Soemantri,Albert Ta Mairuhu,Jos Wm Van Der Meer,Melvin R Mac Gillavry,Dees Pm Brandjes,Penelopie Koraka,Albert Dme Osterhaus,Mohamed Supriatna,Eric Cm Van Gorp

doi:10.1186/1471-2334-7-22

Abstract

BackgroundDengue disease severity is usually classified using criteria set up by the World Health Organization (WHO). We aimed to assess the diagnostic accuracy of the WHO classification system and modifications to this system, and evaluated their potential practical usefulness.MethodsPatients, admitted consecutively to the hospital with severe dengue, were classified using the WHO classification system and modifications to this system. Treating physicians were asked to classify patients immediately after discharge. We calculated the sensitivity of the various classification systems for the detection of shock and the agreement between the various classification systems and the treating physician's classification.ResultsOf 152 patients with confirmed dengue, sixty-six (43%) had evidence of circulatory failure. The WHO classification system had a sensitivity of 86% (95%CI 76–94) for the detection of patients with shock. All modifications to the WHO classification system had a higher sensitivity than the WHO classification system (sensitivity ranging from 88% to 99%). The WHO classification system was in only modest agreement with the intuitive classification by treating physicians whereas several modified classification systems were in good agreement.ConclusionThe use of the WHO classification system to classify dengue disease severity is to be questioned, because it is not accurate in correctly classifying dengue disease severity and it lacks sufficient agreement with clinical practice.

Highlights

Dengue disease severity is usually classified using criteria set up by the World Health Organization (WHO)
The WHO set up a classification system to differentiate between the self-limiting though debilitating dengue fever (DF), and the potentially lethal dengue haemorrhagic fever (DHF) [2]
By comparing the various classification systems with an intuitive classification done by treating physicians, we evaluated the practical usefulness of the WHO classification system and the various modified classification systems

Summary

Introduction

Dengue disease severity is usually classified using criteria set up by the World Health Organization (WHO). Each year an estimated 100 million infections occur and between 250.000 and 500.000 severe cases are reported to the World Health Organization (WHO) [1]. The WHO set up a classification system to differentiate between the self-limiting though debilitating dengue fever (DF), and the potentially lethal dengue haemorrhagic fever (DHF) [2]. According to these criteria, DHF is defined by the presence of fever, a haemorrhagic tendency, thrombocytopenia and some evidence of plasma leakage due to increased vascular permeability. DHF is further subdivided, with most severe cases categorized as dengue shock syndrome (DSS) when circulatory failure is present [2]

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