, Volume 41, Issue 4, pp 775–782 | Cite as

Accuracy and applicability of the revised WHO classification (2009) of dengue in children seen at a tertiary healthcare facility in northern India

  • D. Prasad
  • Chandrakanta Kumar
  • A. Jain
  • R. Kumar
Clinical and Epidemiological Study



Revised case definitions of dengue into dengue with/without warning signs (DWS/D) and severe dengue (SD) was proposed by the World Health Organization (WHO)/Tropical Disease Research (TDR) in 2009. To date, there has been no Indian study that has applied this classification.

Aims and objectives

To assess the accuracy and applicability of the revised WHO classification (2009) of dengue in children seen at a tertiary healthcare facility in India.

Materials and methods

Over a period of 1 year children from the pediatric ward and Out Patient Department (OPD) of the King George Medical University Hospital, Lucknow were enrolled in the study according to predefined criteria and tested for dengue. Each dengue-positive patient was classified according to both the older system [dengue fever (DF), dengue hemorrhagic fever (DHF), and dengue shock syndrome (DSS)] and the new system (D, DWS, and SD). The severity of dengue was compared to the level of treatment received.


A total of 56 patients tested positive for dengue—51 from the pediatric ward and five from the OPD. According to the older WHO classification, 42 (75 %) patients were classified as DF and 13 (23.2 %) as DHF/DSS; one patient was unclassifiable. Five patients (8.9 %) received level 1 treatment, ten (17.8 %) received level 2 treatment, and 41 (73.2 %) received level 3 treatment. According to the new WHO/TDR classification, 46 (82.1 %) patients were classified as SD, nine (16 %) as DWS, and only one (1.7 %) as D. Many of the severe manifestations (encephalopathy, shock, mucosal bleed, platelet count <20,000, respiratory distress, liver enzymes >1,000 U/L) were seen in patients who were classified as DF according to old classification, whereas these patients were mostly classified as SD by the new classification. Sensitivity of the older and new classifications was 24.8 and 98 %, respectively.


The revised WHO/TDR (2009) classification has very high sensitivity for identifying severe dengue and is easy to apply.


Dengue Classification Applicability Accuracy Severe dengue 


Conflict of interest


Ethical standard

The study had the approval of Ethics committee of KG Medical University; written informed consent was obtained from patients’ parents.


  1. 1.
    Gubler DJ. Dengue and dengue hemorrhagic fever. Clin Microbiol Rev. 1998;11:480–96.PubMedGoogle Scholar
  2. 2.
    Halstead SB. The XXth century dengue pandemic: need for surveillance and research. World Health Stat Q. 1992;45:292–8.PubMedGoogle Scholar
  3. 3.
    Gubler DJ. Dengue. In: Monath FTP (ed) Epidemiology of arthropod-borne viral diseases. Boca Raton: CRC Press; 1988. p 223–60.Google Scholar
  4. 4.
    World Health Organization. Dengue haemorrhagic fever diagnosis, treatment, prevention and control. Geneva: WHO; 1997. p. 1–84.Google Scholar
  5. 5.
    Bandopadhyay S, Lum LCS, Kroeger A. Classifying dengue: a review of the difficulties in using the WHO case classification for dengue haemorrhagic fever. Trop Med Int Health. 2006;11(8):1238–55.CrossRefGoogle Scholar
  6. 6.
    World Health Organization. Monograph on dengue haemorrhagic fever. WHO Regional Publication, SEA series 31, no. 22. New Delhi: WHO, SEARO; 1993.Google Scholar
  7. 7.
    World Health Organization. Guidelines for dengue surveillance and mosquito control. WHO Regional Publication, Western Pacific Education in Action Series, no.8. Geneva: WHO; 1995Google Scholar
  8. 8.
    World Health Organization. Prevention and control of dengue and dengue haemorrhagic fever in South-east Asia Region. Report of WHO Consultation. SEA/Haem Fev/65. New Delhi: Regional Office for South-East Asia; 1995Google Scholar
  9. 9.
    World Health Organization. Regional guidelines for prevention and control of dengue and dengue haemorrhagic fever. New Delhi: SEARO; 1998. p. 8.Google Scholar
  10. 10.
    World Health Organization. Comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. New Delhi: WHO Regional Office for Southeast Asia; 1999.Google Scholar
  11. 11.
    Pan American Health Organization. Dengue and dengue haemorrhagic fever in the Americas: guidelines for prevention and control. Scientific Publication; no. 548. Washington DC: WHO/Pan American Health Organization; 1994.Google Scholar
  12. 12.
    World Health Organization/Tropical Disease Research. Dengue, guidelines for diagnosis treatment, prevention and control. Geneva: WHO; 2009.Google Scholar
  13. 13.
    Torres EM. Dengue. Estudos Avancados. 2008;22(64):33–52.CrossRefGoogle Scholar
  14. 14.
    Barniol J, Gaczkowski R, Barbato EV, da Cunha RV, Salgado D, Martinez E. Usefulness and applicability of the revised dengue case classification: multi-centre study in 18 countries. BMC Infect Dis. 2011;11:106.Google Scholar
  15. 15.
    Deen JL, Harris E, Wills B, Balmaseda A, Hammond SN, Rocha C, Dung NM, Hung NT, Hien TT, Farrar JJ. WHO dengue classification and case definitions: time for a reassessment? Lancet. 2006;368:170–3.Google Scholar
  16. 16.
    Diaz-Quijano FA, Villar-Centeno LA, Martinez-Vega RAD. Evaluation of IgM determination in acute serum for diagnosis of dengue in an endemic area. Enferm Infec Microbiol Clin. 2006;24:90–2.Google Scholar
  17. 17.
    Gomber S, Ramachandran VG, Kumar S, Agarwal KN, Gupta P. Hematological observations as diagnostic marker in dengue haemorrhagic fever—a reappraisal. Indian Pediatr. 2001;38(5):477–81.Google Scholar
  18. 18.
    Narayanan M, Aravind MA, Thilothammal N, Prema R, Sargunam CS. Dengue fever epidemic in Chennai—a study of clinical profile and outcome. Indian Pediatr. 2002;39:1027–31.Google Scholar
  19. 19.
    Narvaez F, Gutierrez G, Pérez MA, Elizondo D, Nuñez A, Balmaseda A, Harris E. Evaluation of the traditional and revised WHO classifications of dengue disease severity. PLoS Negl Trop Dis. 2011;5(11):1397.Google Scholar
  20. 20.
    Kalyanarooj S. Dengue classification: current WHO vs. the newly suggested classification for better clinical application? J Med Assoc Thai. 2011;94:S74–84.Google Scholar
  21. 21.
    Alexander N. Multicentre prospective study on dengue classification in four South-east Asian and three Latin American Countries. Trop Med Int Health. 2011;16(8):936–48.PubMedCrossRefGoogle Scholar
  22. 22.
    Jeanisch T. Evidence for a revised dengue classification: a multicentre prospective study across Southeast Asia and Latin America. Trop Med Int Health. 2009;14(2):39–40.Google Scholar
  23. 23.
    Srikiatkhachorn A, Gibbons RV, Green S, Libraty DH, Thomas SJ, Endy TP, Vaughn DW, Nisalak A, Ennis FA, Rothman AL, Nimmannitaya S, Kalayanarooj S. Dengue hemorrhagic fever: the sensitivity and specificity of the WHO definition in identifying severe dengue cases in Thailand, 1994–2005. Clin Infect Dis. 2010;50(8):1135–43.Google Scholar
  24. 24.
    Van de Weg P, Van Grop EC, Supriatna M, Soemantri A, Osterhaus AD, Martina BE. Evaluation of the 2009 WHO dengue case classification in an Indonesian pediatric cohort. Am J Trop Med Hyg. 2012;86(1):166.Google Scholar
  25. 25.
    Kumar R, Tripathi S, Tambe JJ, Arora V, Srivastava A, Nag VL. Dengue encephalopathy in children in northern India: clinical features and comparison with non dengue. J Neurol Sci. 2008;269:41–8.Google Scholar
  26. 26.
    Tripathi P, Kumar R, Tripathi S, Tambe JJ, Venkatesh V. Descriptive epidemiology of dengue transmission in Uttar Pradesh. Indian Pediatr. 2008;45:315–8.Google Scholar
  27. 27.
    Sumarmo, Wulur H, Jahja E, Gubler DJ, Suharyono W, Sorensen K. Clinical observation on virologically confirmed fatal dengue infections in Jakarta, Indonesia. Bull WHO. 1983;61(4):693–701.Google Scholar
  28. 28.
    Chairulfatah A, Setiabudi D, Ridad A, Colebunders R. Clinical manifestation of DHF in children in Bandung, Indonesia. Ann Soc Belg Med Trop. 1995;75(4):291–5.Google Scholar
  29. 29.
    Pancharoen C, Thisyakorn V. Neurological manifestations in dengue patients. South Asian J Trop Med Public Health. 2001;32(2):341–5.Google Scholar
  30. 30.
    Rajajee S, Mukundan D. Neurological manifestations in dengue haemorrhagic fever. Indian Pediatr. 1994;31:688–9.Google Scholar
  31. 31.
    Phuong CX, Nhan NT, Kneen R, Thuy PT, van Thien C, Nga NT, Thuy TT, Solomon T, Stepniewska K, Wills B. Dong Nai Study Group. Clinical diagnosis and assessment of severity of confirmed dengue infections in Vietnamese children: is the World Health Organization classification system helpful? Am J Trop Med Hyg. 2004;70(4):172–9.Google Scholar
  32. 32.
    Balmaseda A, Hammond SN, Perez MA. Short report: assessment of the World Health Organization scheme for classification of dengue severity in Nicaragua. Am J Trop Med Hyg. 2005;73(6):1059–62.PubMedGoogle Scholar
  33. 33.
    Sheng CF, Lum LC, Ismail NA, Tan LH, Tan CP. Clinicians’ diagnostic practice of dengue infections. J Clin Virol. 2007;40(3):202–6.Google Scholar
  34. 34.
    Gupta P, Khare V, Tripathi S, Nag VL, Kumar R, Khan MY, Dhole TK. Assessment of World Health Organization definition of dengue hemorrhagic fever in North India. J Infect Dev Ctries. 2010;4(3):150–5.Google Scholar
  35. 35.
    Basuki PS, Budiyanto, Puspitasari D, Husada D, Darmowandowo W, Ismoedijanto, Soegijanto S, Yamanaka A. Application of revised dengue classification criteria as a severity marker of dengue viral infection in Indonesia. Asian J Trop Med Pub Health. 2010;41(5):1088–94.Google Scholar
  36. 36.
    Khursheed M, Ejaz K, Razzak J, Khan UR. P2–430 WHO/TDR new dengue guideline working better for patient care. J Epidemiol Commun Health. 2011;65:A340.Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • D. Prasad
    • 1
  • Chandrakanta Kumar
    • 1
  • A. Jain
    • 2
  • R. Kumar
    • 1
  1. 1.Department of PediatricsKing George Medical UniversityLucknowIndia
  2. 2.Department of MicrobiologyKing George Medical UniversityLucknowIndia

Personalised recommendations