Majority of pediatric dengue virus infections in Kenya do not meet 2009 WHO criteria for dengue diagnosis

Abstract

From 1975–2009, the WHO guidelines classified symptomatic dengue virus infections as dengue fever, dengue hemorrhagic fever, and dengue shock syndrome. In 2009 the case definition was changed to a clinical classification after concern the original criteria was challenging to apply in resource-limited settings and not inclusive of a substantial proportion of severe dengue cases. Our goal was to examine how well the current WHO definition identified new dengue cases at our febrile surveillance sites in Kenya. Between 2014 and 2019 as part of a child cohort study of febrile illness in our four clinical study sites (Ukunda, Kisumu, Msambweni, Chulaimbo) we identified 369 dengue PCR positive symptomatic cases and characterized whether they met the 2009 revised WHO diagnostic criteria for dengue with and without warning signs and severe dengue. We found 62% of our PCR-confirmed dengue cases did not meet criteria per the guidelines. Our findings also correlate with our experience that dengue disease in children in Kenya is less severe as reported in other parts of the world. Although the 2009 clinical classification has recently been criticized for being overly inclusive and non-specific, our findings suggest the 2009 WHO dengue case definition may miss more than 50% of symptomatic infections in Kenya and may require further modification to include the African experience.

Detection of acute dengue virus infection, with and without concurrent malaria infection, in a cohort of febrile children in Kenya, 2014–2019, by clinicians or machine learning algorithms

“…The clinical officers also noted that the tourniquet test was difficult to interpret, as petechiae were difficult to identify in the setting of dark skin. Taken together, these factors limited the utility of WHO diagnostic criteria for diagnosis of DENV in the clinical setting [ 14 ].…”

“…was difficult to interpret, as petechiae were difficult to identify in the setting of dark skin. Taken together, these factors limited the utility of WHO diagnostic criteria for diagnosis of DENV in the clinical setting [14]. Use of the PedsQL™ 4.0 SF15 [18] HrQoL survey to assess infection-associated disability in the acute setting demonstrated high feasibility, with only 0.04% missing responses at the acute visit, and 0% missing at the convalescent visit.…”

“…Inequitable access to diagnostic testing for DENV has prompted investigators to develop clinical prediction models, such as decision trees, that utilize a combination of symptoms and physical exam findings plus laboratory characterization of hematologic parameters, including platelet count and hematocrit, to either diagnose DENV or classify DENV severity [ 12 , 13 ]. However, poor and inconsistent access to such laboratory tests in most Kenyan public health facilities render such aids unusable [ 14 ]. In the absence of available testing, healthcare providers must rely on the reported symptoms and physical exam observations to make management decisions.…”