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Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 213-214

Dengue guidelines – Is it time for an update?

Department of Critical Care, Division of Pediatric Critical Care, Sheikh Khalifa Medical City, Abu Dhabi, UAE

Date of Submission01-Sep-2021
Date of Acceptance06-Sep-2021
Date of Web Publication28-Sep-2021

Correspondence Address:
Dr. Vijai Williams
Department of Critical Care, Division of Pediatric Critical Care, Sheikh Khalifa Medical City, Abu Dhabi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpcc.jpcc_77_21

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How to cite this article:
Williams V. Dengue guidelines – Is it time for an update?. J Pediatr Crit Care 2021;8:213-4

How to cite this URL:
Williams V. Dengue guidelines – Is it time for an update?. J Pediatr Crit Care [serial online] 2021 [cited 2021 Oct 16];8:213-4. Available from: http://www.jpcc.org.in/text.asp?2021/8/5/213/326872

Dengue is a mosquito-borne viral infection, found in tropical and subtropical climates worldwide. With an estimated 100–400 million infections each year, dengue should be considered in the differential diagnosis of all acute febrile illnesses in endemic countries. Dengue virus infections cause mild dengue fever (DF) in majority but occasionally severe dengue can develop. Early identification of disease, its progression to severe dengue, and access to proper medical care can lower fatality rates of severe dengue. In this issue, the authors explore the effectiveness of the World Health Organization (WHO) dengue 2012 management protocol in a before and after observational study.

The criteria for diagnosing dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) were adopted by the WHO in 1975 and have been updated periodically. In 1997, the WHO classified dengue infections as DF, DHF, and DSS. The classification was useful, however, had its limitations in identifying and classifying atypical presentations (hemorrhagic manifestations without thrombocytopenia or plasma leakage, shock but with normal platelet counts), coinfections and organ dysfunction such as encephalopathy, myocarditis, or hepatic failure.[1] It underwent a revision in 2009, with an update in 2012, to overcome the shortcomings and classified dengue infections into DF, dengue with warning signs, and severe dengue. A multicenter study across 18 countries demonstrated that approximately 14% of cases could not be classified using the DF/DHF/DSS classification compared to only 1.6% with the revised system.[2]

From a clinical viewpoint, the revised system allowed proper triaging as the patient can be classified real-time during admission unlike the 1997 WHO guidelines where most cases tended to be retrospectively classified. Also, it was better for reporting during surveillance and for endpoint measurements in dengue clinical trials. The demerit of the revised classification was that the broad definitions lacked specificity with significant interobserver variability in diagnosing dengue with warning signs and severe dengue.[3],[4],[5] The broad definition was intended to improve early recognition of more severe cases but resulted in increased admissions with the utilization of more resources.[6],[7] However, intriguingly Rajan et al., in their study published in the current issue of Journal of Pediatric critical care, noted a reduction in admission after implementation of revised guidelines.[8] Increase in admissions owing to the epidemic during early part of study and felt needs for close monitoring of all patients irrespective of severity could have contributed to this disparity.

Complications in dengue are related to missed diagnosis at admission, inadequate monitoring signs, late recognition of shock and severe bleeding, and inadequate or overzealous fluid therapy. Fluid overload (FO) is of concern in any critically ill child, more so in dengue, where third spacing may hamper proper assessment. Despite knowing adverse outcomes associated with FO, insufficient attention has been given to it. The present study also highlights the finding of FO with adherence to revised guidelines.

Limiting the duration of intravenous fluid therapy to the minimum necessary is essential to reduce the intravascular FO during the recovery phase. The duration of fluid requirement is 12–24 h in dengue with warning symptoms and 24–48 h in those with shock after resuscitation unless other complications arise. Adequate urine output should be scaled down to 0.5 ml/kg/h to avoid FO. On the other hand, urine output exceeding that may be an indication to reduce intravenous fluid therapy. Thus, avoiding overzealous resuscitation, keeping the intravenous fluid just enough to maintain circulation, and discontinuation of fluids during recovery phase once the patient tolerates oral fluids are cornerstones of dengue management. Optimal fluid management with close monitoring, intensive care support along with active de-resuscitation when needed and identification of expanded dengue that requires additional supportive care needs emphasis. More research is needed to address these limitations that include lack of good clinical or laboratory markers to predict progression to severe dengue, de-escalation of fluid therapy during recovery phase, expanded dengue, and hyperferritinemic states that are increasingly recognized in dengue.[9] The new update in dengue should highlight the limitations of current practice and focus on these key areas of research.

  References Top

Deen JL, Harris E, Wills B, Balmaseda A, Hammond SN, Rocha C, et al. The WHO dengue classification and case definitions: Time for a reassessment. Lancet 2006;368:170-3.  Back to cited text no. 1
Barniol J, Gaczkowski R, Barbato EV, da Cunha RV, Salgado D, Martínez E, et al. Usefulness and applicability of the revised dengue case classification by disease: Multi-centre study in 18 countries. BMC Infect Dis 2011;11:106.  Back to cited text no. 2
Temprasertrudee S, Thanachartwet V, Desakorn V, Keatkla J, Chantratita W, Kiertiburanakul S. A multicenter study of clinical presentations and predictive factors for severe manifestation of dengue in adults. Jpn J Infect Dis 2018;71:239-43.  Back to cited text no. 3
Buonora SN, Passos SR, Daumas RP, Machado MG, Berardinelli GM, de Oliveira DN, et al. Pitfalls in acute febrile illness diagnosis: Interobserver agreement of signs and symptoms during a dengue outbreak. J Clin Nurs 2020;29:1590-8.  Back to cited text no. 4
Sa-Ngamuang C, Haddawy P, Luvira V, Piyaphanee W, Iamsirithaworn S, Lawpoolsri S. Accuracy of dengue clinical diagnosis with and without NS1 antigen rapid test: Comparison between human and Bayesian network model decision. PLoS Negl Trop Dis 2018;12:e0006573.  Back to cited text no. 5
Kalayanarooj S. Dengue classification: Current WHO vs. the newly suggested classification for better clinical application? J Med Assoc Thai 2011;94 Suppl 3:S74-84.  Back to cited text no. 6
Leo YS, Gan VC, Ng EL, Hao Y, Ng LC, Pok KY, et al. Utility of warning signs in guiding admission and predicting severe disease in adult dengue. BMC Infect Dis 2013;13:498.  Back to cited text no. 7
Rajan N, Priya Jose P, Kommu PP, Mani M, Krishnan L. Effectiveness of WHO dengue management protocol – An observational study. J Pediatr Crit Care 2021;8:219-23.  Back to cited text no. 8
  [Full text]  
Williams V, Menon N, Bhatia P, Biswal M, Sreedharanunni S, Rawat A, et al. Serum ferritin predicts neither organ dysfunction nor mortality in pediatric sepsis due to tropical infections. Front Pediatr 2020;8:607673.  Back to cited text no. 9


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