Open Access Open Badges Research article

Dengue disease severity in Indonesian children: an evaluation of the World Health Organization classification system

Tatty E Setiati1, Albert TA Mairuhu2*, Penelopie Koraka3, Mohamed Supriatna1, Melvin R Mac Gillavry2, Dees PM Brandjes2, Albert DME Osterhaus3, Jos WM van der Meer4, Eric CM van Gorp2 and Augustinus Soemantri1

Author Affiliations

1 Department of Child Health, Dr. Kariadi Hospital, Semarang, Indonesia

2 Department of Internal Medicine, Slotervaart Hospital, Amsterdam, the Netherlands

3 Institute of Virology, Erasmus Medical Centre, Rotterdam, the Netherlands

4 Dept. of Internal Medicine, University Medical Centre St. Radboud, Nijmegen, the Netherlands

For all author emails, please log on.

BMC Infectious Diseases 2007, 7:22  doi:10.1186/1471-2334-7-22

Published: 26 March 2007



Dengue disease severity is usually classified using criteria set up by the World Health Organization (WHO). We aimed to assess the diagnostic accuracy of the WHO classification system and modifications to this system, and evaluated their potential practical usefulness.


Patients, admitted consecutively to the hospital with severe dengue, were classified using the WHO classification system and modifications to this system. Treating physicians were asked to classify patients immediately after discharge. We calculated the sensitivity of the various classification systems for the detection of shock and the agreement between the various classification systems and the treating physician's classification.


Of 152 patients with confirmed dengue, sixty-six (43%) had evidence of circulatory failure. The WHO classification system had a sensitivity of 86% (95%CI 76–94) for the detection of patients with shock. All modifications to the WHO classification system had a higher sensitivity than the WHO classification system (sensitivity ranging from 88% to 99%). The WHO classification system was in only modest agreement with the intuitive classification by treating physicians whereas several modified classification systems were in good agreement.


The use of the WHO classification system to classify dengue disease severity is to be questioned, because it is not accurate in correctly classifying dengue disease severity and it lacks sufficient agreement with clinical practice.