Curriculum Vitae
Prof Dr dr Sri Rezeki S Hadinegoro Sp.A(K)
Staf pengajar
Departemen Ilmu Kes Anak FKUI/RSCM Jakarta
• Pendidikan
– Dokter umum – FK.UNPAD 1972
– Spesialis anak – FK.UI 1983
– Doktor – FK.UI 1996
– Guru Besar – FK.UI 2000
• Organisasi
– Ketua Indonesian Technical Advisory Group on Immunization (ITAGI)
– Anggota Satuan Tugas Imunisasi IDAI
– Anggota KOMNAS PP KIPI – KEMKES
– Board member of Asian Society of Pediatric Infectious Disease (ASPID)
– Member of Asia-Pacific Dengue Prevention Board (APDPB)
– Member of Asia Dengue Vaccine Advocacy (ADVA)
– President of International Society of Tropical Pediatrics (ISTP)
Slide Sri Rezeki
WHO 2009
Dengue Classification
Sri Rezeki S Hadinegoro
Department of Child Health
FKUI-RSCM Jakarta
The 2nd ASMPID, Bandung 19-20 April
Topics
• Countries/areas at risk of dengue transmission
• WHO dengue guidelines: Global Strategy for
Dengue Prevention and Control
• The development of the 2009 WHO Dengue Case
Classification (DCC)
– Evidence for WHO 2009 dengue case classifcation
development
– The steps for the development of the WHO 2009 dengue
case classification
• International Classification of Disease-11 (ICD-11)
• Conclusions
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Countries/Areas at Risk of
Dengue Transmission, 2008
The Challenges
• Case definition (dengue classification)
• Laboratory diagnostic tools
• Surveillance system
• Integrated with other prevention
strategies
• Economic data
• Dengue vaccine introduction
– Dengue seroprevalence
– Indication
– Post vaccination impact
Global Strategy for Dengue
Prevention and Control, 2012-2020
1. To reduce dengue deaths
by at least 50% by 2020*
2. To reduce dengue
morbidity by at least 25%
by 2020*
3. To better ascertain the true
burden of the disease by
2015
*2010 as baseline
WHO, Geneva 2012
WHO dengue guidelines
Guideline Main Issues
WHO 1997 • Basic knowledge on epidemiology,
pathogenesis, diagnosis and case
management, dengue outbreak, and vector
control
WHO-TDR 2009 • Warning signs to catch more dengue cases
• Classification on severe dengue
• Case management depend on disease
severity
WHO-SEARO • Use warning signs for early shock
2011 detection.
• Classification of expanded dengue
syndrome
• Lab investigation for A-B-C-S
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What are the issues (1)
• Pathogenesis of the disease: did the DF and
DHF come from the one disease entity?
• The difficulty in using the WHO 1997 case
diagnosis classification for DHF
• Difficulty of using the parameter of diagnosis
such as tourniquet test, hematocrit, bleeding
tendency, and shock.
• To catch and refer more dengue cases with
warning signs to reduce dengue mortality.
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What are the issues (2)
• Difficulties in decide the grade of illness
because bleeding tendency did not occur in
all dengue cases
• Difficulties to put severe dengue classification
into clinical spectrum
• How to detect more dengue cases
particularly in the outbreak period
• Organ involvement in the severe dengue
course illness did not classified yet.
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Evidence used for the development of the WHO
2009 dengue case classification:
An expert consensus – four regional meetings, followed by one global meeting
Ref. Horstick O. WHO 2009 dengue classification. Presented at The Asia Dengue Summit 2018, Kuala Lumpur Malaysia, 5-6 July 2018
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The steps for the development of the WHO
2009 dengue case classification
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Lancet Inf Dis 2006; 6: 297-302
Lancet 2006; 368: 170-173
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1–5 October 2006
Report of the Scientific Working Group meeting on
The Special Programme for Research and Training in Tropical Diseases
(TDR) is a global programme of scientific collaboration established in
1975. Its focus is research into neglected diseases of the poor, with
Geneva, Switzerland
Dengue
the goal of improving existing approaches and developing new ways to
prevent, diagnose, treat and control these diseases. TDR is sponsored
by the following organizations:
Special Programme for Research & Training www.who.int/tdr
in Tropical Diseases (TDR) sponsored by
Geneva, 1-5 October 2006
U N I CEF / U N D P / Wo r l d B a n k / WH O
TDR/SWG/08
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Dengue Case Classification
Overview
Dengue is one disease entity with different clinical
presentations
and often with unpredictable clinical evolution and
outcome
1. Non-severe dengue 2. Severe dengue
1.1. Mild 1.2. Moderate
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Dengue Case Classification
Dengue is one disease entity with different clinical
presentations
and often with unpredictable clinical evolution and
outcome
1. Non-severe dengue 2. Severe dengue
Severe dengue is defined by either
one of the following
1. Severe plasma leakage
1.1. Mild 1.2. Moderate • Clinical shock
• Any evidence of fluid
Non-severe mild dengue Non-severe moderate accumulation
Is defined by 2 criteria Is defined by 3 criteria • With respiratory distress
• Fever 1. Clinical
• Retro orbital pain • Evidence of clinical fluid 2. Severe bleeding as evaluated by
• Myalgia accumulation clinician
• Artharalgia • Evidence of mucosal bleeding
• Rash • Skin flush or rash 3. Severe organ involvement
• Haemorrhagic manifestations • Abdominal pain or tenderness • Severe liver involvement with
• Leucopenia • ’Tourniquet test pos AST>1000 or ALT >1000
Supporttive serology 2. Laboratory • Impaired consciousness with
Or occurrence & time as • WBC < 2.000 GCS < 15 or BCS < 5
Other cases of dengue • Hct increase
• Platelet <50.000
All non severe cases have a risk to develop severe dengue, but there is a higher risk for severe
dengue with the following (predictive) risk factors: DENCO and Expert Consensus
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Dengue Case Classification
Expert Dengue is one disease entity with different clinical
consensus
& literature presentations
and often with unpredictable clinical evolution and
outcome
1. Non-severe dengue 2. Severe dengue
DENCO
1.1. Mild 1.2. Moderate
Non-severe mild dengue Case definition
Is defined by 2 criteria
• Fever DENCO based on
Case definition • Retro orbital pain DENCO
of dengue in • Myalgia Case definition analysis
WHO 1997 • Artharalgia based on
• Rash
guide
• Haemorrhagic manifestations
DENCO
DENCO
• Leucopenia analysis
Supporttive serology
Or occurrence & time as
Other cases of dengue
All non severe cases have a risk to develop severe dengue, but there is a higher risk for severe
dengue with the following (predictive) risk factors: DENCO and Expert Consensus
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The development of the 2009 WHO DCC
Dengue case classification by severity
DENGUE ± Warning Signs SEVERE DENGUE
With
Without 1.Severe plasma leakage
WARNING 2.Severe haemorrhage
SIGNS 3.Severe organ impairment
Warning Signs* 1. Severe plasma leakage leading to
• Abdominal pain or tenderness • Shock (DSS)
• Persistent vomiting • Fluid accumulation with
• Clinical fluid accumulation respiratory distress
• Mucosal bleed 2. Severe bleeding
• Lethargy; restlessness as evaluated by clinician
• Liver enlargement >2cm 3. Severe organ involvement
• Laboratory: Increase in HCT Liver: AST or ALT>=1000
concurrent with rapid decrease CNS: Impaired consciousness
in platelet count Heart and other organs
* Requiring strict observation and medical intervention
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Dengue case classification by severity
Dengue ± warning signs Severe dengue
with 1.Severe plasma leakage
Without warning signs 2.Severe haemorrhage
3.Severe organ impairment
Criteria for dengue ± warning signs Criteria for severe dengue
Probable dengue Warning signs* 1. Severe plasma leakage
Live in/travel to dengue • Abdominal pain or leading to:
endemic area. Fever and 2 tenderness • Shock (DSS)
of the following criteria: • Persistent vomiting • Fluid accumulation with
• Nausea, vomiting • Clinical fluid accumulation respiratory distress
• Rash • Mucosal bleed
• Aches and pains • Lethargy; restlessness 2. Severe bleeding
• Tourniquet test positive • Liver enlargement >2cm as evaluated by clinician
• Leucopenia • Laboratory: Increase in HCT
3. Severe organ involvement
• Any warning sign concurrent with rapid
• Liver: AST or ALT>=1000
Laboratory confirmed decrease in platelet count
WHO/TDR 2009
• CNS: Impaired
dengue
(important when no sign of plasma * Requiring strict observation consciousness
leakage) and medical intervention • Heart and other organs
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Evidence used for the development of the 2009
WHO dengue case classification
The analysis has shown that the revised dengue case
classification is better able to:
• Standardized clinical management
• Raise awareness about unnecessary interventions
• Match patient categories with specific treatment
instructions
• Make the key messages of patient management
understandable for all health care staff
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TDR-WHO 2009
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WHO-TDR 2009 Literature
• Horstick O, Farrar J, Lum L, Martinez E, San Martin JL, Ehrenberg J, Velayudhan
R, Kroeger A. Pathog Glob Health; 2012 May;106(2):94-101Reviewing the
development, evidence base, and application of the revised dengue case
classification..
• Prasad D, Kumar C, Jain A, Kumar R. Infection; 2013 Aug;41(4):775-82.Accuracy
and applicability of the revised WHO classification (2009) of dengue in children
seen at a tertiary healthcare facility in northern India.
• Tsai CY, Lee IK, Lee CH, Yang KD, Liu JW. Comparisons of dengue illness
classified based on the 1997 and 2009 World Health Organization dengue
classification schemes. J Microbiol Immunol Infect; 2013 Aug;46(4):271-81.
• Lima FR, Croda MG, Muniz DA, Gomes IT, Soares KR, Cardoso MR, Tauro RL,
Croda. Evaluation of the traditional and revised World Health Organization
classifications of dengue cases in Brazil. J. Clinics (Sao Paulo); 2013
Oct;68(10):1299-304
• Horstick O, Martinez E, Guzman MG, Martin JL, Ranzinger SR. WHO dengue
case classification 2009 and its usefulness in practice: an expert consensus in the
Americas. Pathog Glob Health; 2015 Feb;109(1):19-25.
• Horstick O, Jaenisch T, Martinez E, Kroeger A, See LL, Farrar J, Ranzinger SR.
Comparing the usefulness of the 1997 and 2009 WHO dengue case classification:
a systematic literature review. Am J Trop Med Hyg; 2014 Sep;91(3):621-34.
• Horstick O, Ranzinger SR. Reporting progress of the use of the WHO 2009
Dengue Case Classification: a review. Southeast Asian J Trop Med Public Health;
2015;46 Suppl 1:49-54.
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Studies analysing sensitivity/specificity
of dengue/severe dengue
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WHO Diagnosis Case Classification
1997 2009 2011
Dengue fever Dengue without Dengue fever (no plasma
(no plasma leakage) warning signs leakage)
DHF grade I (no shock) DHF grade I (no shock)
DHF grade II (no shock, Dengue with warning DHF grade II (no shock,
spontaneous bleeding) signs spontaneous bleeding)
DHF grade III/DSS DHF grade III /DSS
(dengue shock (dengue shock syndrome)
syndrome) Severe dengue
DHF grade IV (DSS with (severe plasma leakage, DHF grade IV
profound shock) hemorrhage, organ
involvement) Expanded dengue
syndrome (unusual
manifestation, organ
involvement, co-morbidity
Adult management Adult management
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Comparing the WHO 2009 and 1997 DCCs
WHO 2009 DCC WHO 1997 DCC
Development Series of studies, both quantitative and Expert consensus
qualitative
Validation Tested in many different countries No validation process
Focus Towards severity of disease and early No relation to severity
detection of severe cases (especially DHF)
Usefulness Especially for clinical management, but also
for improved surveillance
Strength Inclusion of all severe clinical pictures of
dengue
Helpful for clinical management without
laboratory facilities
ICD ICD 11 Previous ICDs
Outlook Further studies soon available on warning
signs and case definitions
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Justification
• WHO recommended the WHO 2009
dengue classification for ICD X
• International Code of Diseases XI (ICD XI)
use the WHO 2009 Dengue Classification
– Dengue with warning signs
– Severe Dengue I
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https://icd.who.int/br
owse11/l-
m/en#/http://id.who.i
nt/icd/entity/1959883
044
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https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1959883044
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Kesimpulan
• Menanggapi perubahan klasifikasi dengue WHO
2009 dan revisi International Classification of
Disease-11 (ICD-11) yang dikemukakan oleh
WHO, maka UKK IPT perlu mengkaji dan
melakukan pembaruan
• Berdasarkan kesepakatan global yang ditunjang
oleh WHO, UKK IPT harus segera mengubah
kesepakatan nasional mempergunakan Klasifikasi
Dengue WHO 2009
• Diperlukan sosialisasi tenaga kesehatan dan
pelatihan untuk klinisi serta pihak pengelola
program
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