Heidelberg Institute of Global Health, Heidelberg University Hospital, Heidelberg, Germany.
Section Clinical Tropical Medicine, Heidelberg University Hospital, Heidelberg, Germany.
PLoS Negl Trop Dis. 2022 Oct 11;16(10):e0010832. doi: 10.1371/journal.pntd.0010832. eCollection 2022 Oct.
Dengue is not included explicitly in the WHO Integrated Management of Childhood Illness (IMCI) algorithm. However, the assessment, classification and management of dengue has been incorporated into several IMCI country adaptations. We aimed to evaluate the dengue algorithms incorporated into IMCI guidelines and discuss the need for harmonization, including an extension of the age range for IMCI.
This study included three steps. First, we investigated dengue algorithms incorporated into five Southeast-Asian (Myanmar, Philippines, Vietnam, Indonesia, Cambodia) country IMCI guidelines through a desk-based analysis. Second, we conducted an expert survey to elicit opinions regarding the integration of dengue and extension of the age range in IMCI. Third, we compared our findings with data from a large multicentric prospective study on acute febrile illness.
We found considerable heterogeneity between the country specific IMCI guidelines in the dengue algorithms as well as classification schemes. Most guidelines did not differentiate between diagnostic algorithms for the detection of dengue versus other febrile illness, and warning signs for progression to severe dengue. Our expert survey resulted in a consensus to further integrate dengue in IMCI and extend the age range for IMCI guidelines beyond 5 years of age. Most of the interviewees responded that their country had a stand-alone clinical guideline for dengue, which was not integrated into the IMCI approach and considered laboratory testing for dengue necessary on day three of consecutive fever. Using data from a large multicentric study of children 5-15 years of age, we could confirm that the likelihood of dengue increased with consecutive fever days. However, a significant proportion of children (36%) would be missed if laboratory testing was only offered on the third consecutive day of fever.
This study supports the extension of the IMCI age range beyond 5 years of age as well as the inclusion of dengue relevant content in the algorithm. Because of the challenge of distinguishing dengue from other febrile illnesses, simple laboratory testing (e.g., full blood count) should be offered at an early stage during the course of the illness. Testing only children with consecutive fever over 3 days may lead to an underdiagnosis of dengue among those with acute febrile illness in children 5-15 years of age. In addition, specific laboratory testing for dengue should be made available to peripheral health facilities.
登革热并未明确列入世卫组织儿童疾病综合管理（IMCI）算法中。然而，登革热的评估、分类和管理已被纳入若干 IMCI 国家修订版。我们旨在评估纳入 IMCI 指南的登革热算法，并讨论协调统一的必要性，包括扩大 IMCI 的适用年龄范围。
本研究包括三个步骤。首先，我们通过案头分析调查了五个东南亚国家（缅甸、菲律宾、越南、印度尼西亚、柬埔寨）的 IMCI 指南中纳入的登革热算法。其次，我们进行了一项专家调查，以征求关于纳入登革热和扩大 IMCI 适用年龄范围的意见。第三，我们将研究结果与一项关于急性发热性疾病的大型多中心前瞻性研究的数据进行了比较。
我们发现，各国 IMCI 指南中的登革热算法以及分类方案存在相当大的差异。大多数指南没有区分用于检测登革热与其他发热性疾病的诊断算法，以及提示向重症登革热进展的预警信号。我们的专家调查结果达成了一项共识，即进一步将登革热纳入 IMCI，并将 IMCI 指南的适用年龄范围扩大至 5 岁以上。大多数受访者表示，他们的国家有一个单独的登革热临床指南，该指南没有纳入 IMCI 方法，并认为在连续发热的第三天进行登革热实验室检测是必要的。利用一项针对 5-15 岁儿童的大型多中心研究数据，我们可以确认，随着连续发热天数的增加，登革热的可能性会增加。然而，如果仅在连续发热的第三天提供实验室检测，将有很大一部分儿童（36%）被漏诊。
本研究支持将 IMCI 的年龄范围扩大至 5 岁以上，并将与登革热相关的内容纳入算法中。由于区分登革热与其他发热性疾病具有挑战性，因此应在疾病过程的早期阶段提供简单的实验室检测（例如全血细胞计数）。仅对连续发热超过 3 天的儿童进行检测，可能会导致在 5-15 岁儿童的急性发热性疾病中漏诊登革热。此外，应向基层卫生机构提供针对登革热的特定实验室检测。
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