União das Faculdades dos Grandes Lagos, São José do Rio Preto, São Paulo, Brazil.
Laboratório de Modelagens Matemática e Estatística em Medicina, União das Faculdades dos Grandes Lagos, São José do Rio Preto, São Paulo, Brazil.
Trop Med Int Health. 2018 Dec;23(12):1282-1293. doi: 10.1111/tmi.13155. Epub 2018 Oct 24.
To compare WHO's traditional (1997) and revised (2009) guidelines for dengue classification, using a large sample of patients of all ages with varying clinical conditions from a dengue-endemic area in Brazil.
We compared 30 670 laboratory-confirmed dengue cases (1998-2012) using both WHO's dengue classification guidelines. Stereotype ordinal logistic regressions were used to analyse the association between patients' demographics and signs and symptoms related to dengue infection severity, as defined in the 1997 and 2009 guidelines. We then compared the degree of agreement in dengue classification of both guidelines.
Dengue signs and symptoms in patients were poorly correlated to disease severity as defined by both guidelines (Cramer's V test <0.2). Hypotensive shock was the exception for both classifications, presenting dependence (Z = 56.42; P < 0.001, and Z = 55.24; P < 0.001) and high agreement (Cramers's V = 1; P < 0.001, and Cramers's V = 0.97; P < 0.001) for WHO 1997 and 2009, respectively. Last, we also found substantial agreement in disease classification between both guidelines (Kendall tau-b = 0.79; P < 0.001), although 2009 guidelines were more sensitive in the detection of severe cases.
We hope our results will inform the debate about dengue classification guidelines, particularly concerning clinical value, study comparability, and ways in which future guidelines can support the clinical management of dengue. Our results suggest that caution should be taken when using WHO guidelines to assess dengue severity to improve clinical management of patients.
比较世界卫生组织（WHO）的传统（1997 年）和修订（2009 年）登革热分类指南，使用来自巴西登革热流行地区的大量不同年龄和临床情况的患者样本。
我们使用 WHO 的两种登革热分类指南比较了 30670 例实验室确诊的登革热病例（1998-2012 年）。使用典型有序逻辑回归分析患者的人口统计学和与登革热感染严重程度相关的体征和症状与 1997 年和 2009 年指南定义之间的关系。然后，我们比较了两种指南在登革热分类方面的一致性程度。
患者的登革热体征和症状与两种指南定义的疾病严重程度相关性较差（Cramer's V 检验<0.2）。低血压性休克是两种分类的例外，均表现出依赖关系（Z = 56.42；P < 0.001，Z = 55.24；P < 0.001）和高度一致性（Cramers's V = 1；P < 0.001，Cramers's V = 0.97；P < 0.001），分别适用于 WHO 1997 年和 2009 年指南。最后，我们还发现两种指南之间的疾病分类存在实质性一致性（Kendall tau-b = 0.79；P < 0.001），尽管 2009 年指南在检测严重病例方面更为敏感。
我们希望我们的结果将为登革热分类指南的争论提供信息，特别是关于临床价值、研究可比性以及未来指南如何支持登革热的临床管理。我们的结果表明，在使用 WHO 指南评估登革热严重程度以改善患者的临床管理时应谨慎行事。
