Utility of warning signs in guiding admission and predicting severe disease in adult dengue

Yee-Sin Leo,Frederico Dimatatac,Kwoon-Yong Pok,Lee-Ching Ng,Ee-Ling Ng,Chi-Jong Go,Victor C Gan,David C Lye,Ying Hao

doi:10.1186/1471-2334-13-498

Abstract

BackgroundThe recommendation from the 2009 World Health Organization guidelines for managing dengue suggests that patients with any warning sign can be hospitalized for observation and management. We evaluated the utility of using warning signs to guide hospital admission and predict disease progression in adults.MethodsWe conducted a prospective cohort study from January 2010 to September 2012. Daily demographic, clinical and laboratory data were collected from adult dengue patients. Warning signs were recorded. The proportion of admitted patients using current admission criteria and warning signs was compared. The sensitivity, specificity, positive and negative predictive values of warning signs in predicting disease progression were also evaluated.ResultsFour hundred and ninety-nine patients with confirmed dengue were analyzed. Using warning signs instead of the current admission criteria will lead to a 44% and 31% increase in admission for DHF II-IV and SD cases respectively. The proportion of non-severe dengue cases which were admitted also increased by 32% for non DHF II-IV and 33% for non-SD cases. Absence of any warning signs had a NPV of 91%, 100% and 100% for DHF I-IV, DHF II-IV and SD. Of those who progressed to severe illness, 16.3% had warning signs on the same day while 51.3% had warning signs the day before developing severe illness, respectively.ConclusionsOur findings demonstrated that patients without any warning signs can be managed safely with ambulatory care to reduce hospital resource burden. No single warning sign can independently predict disease progression. The window from onset of warning sign to severe illness in most cases was within one day.

Highlights

The recommendation from the 2009 World Health Organization guidelines for managing dengue suggests that patients with any warning sign can be hospitalized for observation and management
This study compared the baseline characteristics and outcomes of two cohorts; those admitted from emergency department (ED) who were enrolled as inpatients (ED cohort) and those initially enrolled in outpatient setting at the research clinic
We further identified 49 cases in the outpatient cohort who progressed to severe illness: 8 (16.3%) had warning sign(s) (WS) the same day as they progressed to severe illness and 25

Summary

Introduction

The recommendation from the 2009 World Health Organization guidelines for managing dengue suggests that patients with any warning sign can be hospitalized for observation and management. We evaluated the utility of using warning signs to guide hospital admission and predict disease progression in adults. Dengue is the most common arboviral infection. It has a wide disease spectrum, ranging from a self-limiting fever to severe disease with fatal outcome. The World Health Organization (WHO) estimates that 2.5 billion people are at risk of dengue. A recent model estimates 390 million infections annually with 96 million cases of clinically apparent disease [1]. More than half a million people develop severe illness, i.e., dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS) or severe dengue (SD).

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