{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T12:40:15Z","timestamp":1791463215346,"version":"4.3.4"},"update-to":[{"DOI":"10.1371\/journal.pntd.0009359","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2021,5,6]],"date-time":"2021-05-06T00:00:00Z","timestamp":1620259200000}}],"reference-count":46,"publisher":"Public Library of Science (PLoS)","issue":"4","license":[{"start":{"date-parts":[[2021,4,26]],"date-time":"2021-04-26T00:00:00Z","timestamp":1619395200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100004440","name":"Wellcome Trust","doi-asserted-by":"publisher","award":["106698\/Z\/14\/Z"],"award-info":[{"award-number":["106698\/Z\/14\/Z"]}],"id":[{"id":"10.13039\/100004440","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100005416","name":"Norges Forskningsr\u00e5d","doi-asserted-by":"publisher","award":["285188"],"award-info":[{"award-number":["285188"]}],"id":[{"id":"10.13039\/501100005416","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosntds.org"],"crossmark-restriction":false},"short-container-title":["PLoS Negl Trop Dis"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Dengue is the world\u2019s most common mosquito-borne virus but remains diagnostically challenging due to its nonspecific presentation. Access to laboratory confirmation is limited and thus most reported figures are based on clinical diagnosis alone, the accuracy of which is uncertain. This systematic review assesses the diagnostic accuracy of the traditional (1997) and revised (2009) WHO clinical case definitions for dengue fever, the basis for most national guidelines.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methodology\/Principal findings<\/jats:title>\n<jats:p>PubMed, EMBASE, Scopus, OpenGrey, and the annual Dengue Bulletin were searched for studies assessing the diagnostic accuracy of the unmodified clinical criteria. Two reviewers (NR\/SL) independently assessed eligibility, extracted data, and evaluated risk of bias using a modified QUADAS-2. Additional records were found by citation network analysis. A meta-analysis was done using a bivariate mixed-effects regression model. Studies that modified criteria were analysed separately. This systematic review protocol was registered on PROSPERO (CRD42020165998). We identified 11 and 12 datasets assessing the 1997 and 2009 definition, respectively, and 6 using modified criteria. Sensitivity was 93% (95% CI: 77\u201398) and 93% (95% CI: 86\u201396) for the 1997 and 2009 definitions, respectively. Specificity was 29% (95% CI: 8\u201365) and 31% (95% CI: 18\u201348) for the 1997 and 2009 definitions, respectively. Diagnostic performance suffered at the extremes of age. No modification significantly improved accuracy.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Conclusions\/Significance<\/jats:title>\n<jats:p>Diagnostic accuracy of clinical criteria is poor, with significant implications for surveillance and public health responses for dengue control. As the basis for most reported figures, this has relevance to policymakers planning resource allocation and researchers modelling transmission, particularly during COVID-19.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pntd.0009359","type":"journal-article","created":{"date-parts":[[2021,4,26]],"date-time":"2021-04-26T19:44:30Z","timestamp":1619466270000},"page":"e0009359","update-policy":"https:\/\/doi.org\/10.1371\/journal.pntd.corrections_policy","source":"Crossref","is-referenced-by-count":29,"title":["Diagnostic accuracy of the WHO clinical definitions for dengue and implications for surveillance: A systematic review and meta-analysis"],"prefix":"10.1371","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6452-1273","authenticated-orcid":true,"given":"Nader","family":"Raafat","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8679-4734","authenticated-orcid":true,"given":"Shanghavie","family":"Loganathan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5036-6583","authenticated-orcid":true,"given":"Mavuto","family":"Mukaka","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6576-726X","authenticated-orcid":true,"given":"Stuart D.","family":"Blacksell","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5355-0562","authenticated-orcid":true,"given":"Richard James","family":"Maude","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2021,4,26]]},"reference":[{"issue":"7446","key":"pntd.0009359.ref001","doi-asserted-by":"crossref","first-page":"504","DOI":"10.1038\/nature12060","article-title":"The global distribution and burden of dengue","volume":"496","author":"S Bhatt","year":"2013","journal-title":"Nature"},{"issue":"8","key":"pntd.0009359.ref002","doi-asserted-by":"crossref","first-page":"e0008426","DOI":"10.1371\/journal.pntd.0008426","article-title":"Simultaneous dengue and COVID-19 epidemics: Difficult days ahead?","volume":"14","author":"M Nacher","year":"2020","journal-title":"PLoS Negl Trop Dis"},{"issue":"2","key":"pntd.0009359.ref003","doi-asserted-by":"crossref","first-page":"570","DOI":"10.4269\/ajtmh.20-0480","article-title":"Preventing Dengue Epidemics during the COVID-19 Pandemic","volume":"103","author":"A Wilder-Smith","year":"2020","journal-title":"Am J Trop Med Hyg"},{"issue":"7","key":"pntd.0009359.ref004","doi-asserted-by":"crossref","first-page":"e879","DOI":"10.1016\/S2214-109X(20)30210-2","article-title":"Diagnosing malaria and other febrile illnesses during the COVID-19 pandemic","volume":"8","author":"S Dittrich","year":"2020","journal-title":"Lancet Glob Health."},{"issue":"7","key":"pntd.0009359.ref005","doi-asserted-by":"crossref","first-page":"840","DOI":"10.1111\/tmi.12498","article-title":"Dengue epidemiology in selected endemic countries: factors influencing expansion factors as estimates of underreporting","volume":"20","author":"NT Toan","year":"2015","journal-title":"Trop Med Int Health"},{"key":"pntd.0009359.ref006","article-title":"A review of dengue diagnostics and implications for surveillance and control","author":"N Raafat","year":"2019","journal-title":"Transactions of The Royal Society of Tropical Medicine and Hygiene"},{"issue":"11","key":"pntd.0009359.ref007","doi-asserted-by":"crossref","first-page":"e890","DOI":"10.1371\/journal.pntd.0000890","article-title":"Best practices in dengue surveillance: a report from the Asia-Pacific and Americas Dengue Prevention Boards","volume":"4","author":"ME Beatty","year":"2010","journal-title":"PLoS neglected tropical diseases"},{"key":"pntd.0009359.ref008","unstructured":"Pan American Health Organization. Reported Cases of Dengue Fever in The Americas 2019 [cited 2020 12 January 2020]. Available from: http:\/\/www.paho.org\/data\/index.php\/en\/mnu-topics\/indicadores-dengue-en\/dengue-nacional-en\/252-dengue-pais-ano-en.html."},{"issue":"10","key":"pntd.0009359.ref009","doi-asserted-by":"crossref","first-page":"e0005050","DOI":"10.1371\/journal.pntd.0005050","article-title":"Factors Associated with the Time of Admission among Notified Dengue Fever Cases in Region VIII Philippines from 2008 to 2014","volume":"10","author":"JE Abello","year":"2016","journal-title":"PLoS Negl Trop Dis"},{"issue":"4","key":"pntd.0009359.ref010","doi-asserted-by":"crossref","first-page":"e0006425","DOI":"10.1371\/journal.pntd.0006425","article-title":"Data quality and timeliness of outbreak reporting system among countries in Greater Mekong subregion: Challenges for international data sharing","volume":"12","author":"S Lawpoolsri","year":"2018","journal-title":"PLoS Negl Trop Dis"},{"key":"pntd.0009359.ref011","volume-title":"Dengue haemorrhagic fever: diagnosis, treatment, prevention and control","author":"World Health Organization","year":"1997","edition":"2"},{"key":"pntd.0009359.ref012","unstructured":"World Health Organization. Dengue: Guidelines for Diagnosis, Treatment, Prevention and Control: New Edition. 2009. NBK143157 [bookaccession]."},{"issue":"2","key":"pntd.0009359.ref013","doi-asserted-by":"crossref","first-page":"94","DOI":"10.1179\/2047773212Y.0000000017","article-title":"Reviewing the development, evidence base, and application of the revised dengue case classification","volume":"106","author":"O Horstick","year":"2012","journal-title":"Pathogens and Global Health"},{"issue":"8","key":"pntd.0009359.ref014","doi-asserted-by":"crossref","first-page":"529","DOI":"10.7326\/0003-4819-155-8-201110180-00009","article-title":"QUADAS-2: a revised tool for the quality assessment of diagnostic accuracy studies","volume":"155","author":"PF Whiting","year":"2011","journal-title":"Ann Intern Med"},{"key":"pntd.0009359.ref015","volume-title":"MIDAS: Stata module for meta-analytical integration of diagnostic test accuracy studies","author":"B. Dwamena","year":"2007"},{"issue":"8","key":"pntd.0009359.ref016","doi-asserted-by":"crossref","first-page":"e2385","DOI":"10.1371\/journal.pntd.0002385","article-title":"Evaluation of the diagnostic utility of the traditional and revised WHO dengue case definitions","volume":"7","author":"G Guti\u00e9rrez","year":"2013","journal-title":"PLoS neglected tropical diseases"},{"issue":"1","key":"pntd.0009359.ref017","first-page":"170","article-title":"Development of clinical algorithms for the diagnosis of dengue in Colombia","volume":"39","author":"DM Caicedo","year":"2019","journal-title":"Biomedica"},{"key":"pntd.0009359.ref018","first-page":"56","article-title":"Efficacy of clinical diagnosis of dengue fever in paediatric age groups as determined by WHO case definition 1997 in Thailand","volume":"25","author":"S Sawasdivorn","year":"2001","journal-title":"Dengue Bulletin"},{"issue":"3","key":"pntd.0009359.ref019","first-page":"412","article-title":"Evaluation of the World Health Organization clinical definition of dengue","volume":"25","author":"RA Mart\u00ednez","year":"2005","journal-title":"Biomedica"},{"issue":"6_Suppl","key":"pntd.0009359.ref020","first-page":"398","article-title":"RAPID DIAGNOSIS OF DENGUE IN A HOSPITAL-BASED COHORT","volume":"85","author":"VC Gan","year":"2011","journal-title":"Am J Trop Med Hyg"},{"issue":"SUPPL. 1","key":"pntd.0009359.ref021","first-page":"248","article-title":"Dengue virus infection in Tuscany, Italy: Evaluation of ICT rapid test and clinical criteria for the diagnosis of acute dengue fever","volume":"16","author":"F Lagi","year":"2011","journal-title":"Tropical Medicine and International Health"},{"issue":"5","key":"pntd.0009359.ref022","first-page":"334","article-title":"Evaluation of the performance of clinical and laboratorial dengue diagnosis during an epidemic in a medium-sized city in southeast brazil","volume":"87","author":"BA Fonseca","year":"2012","journal-title":"American Journal of Tropical Medicine and Hygiene"},{"key":"pntd.0009359.ref023","first-page":"94","article-title":"Performance of WHO probable case definition of dengue in Kerala, India, and its implications for surveillance and referral","volume":"36","author":"ZT Nujum","year":"2012","journal-title":"Dengue Bulletin"},{"issue":"7","key":"pntd.0009359.ref024","doi-asserted-by":"crossref","first-page":"e2331","DOI":"10.1371\/journal.pntd.0002331","article-title":"Dengue and other common causes of acute febrile illness in Asia: an active surveillance study in children","volume":"7","author":"MR Capeding","year":"2013","journal-title":"PLoS Negl Trop Dis"},{"key":"pntd.0009359.ref025","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1186\/1471-2334-13-77","article-title":"Clinical and laboratory features that discriminate dengue from other febrile illnesses: a diagnostic accuracy study in Rio de Janeiro, Brazil","volume":"13","author":"RP Daumas","year":"2013","journal-title":"BMC Infect Dis"},{"issue":"3","key":"pntd.0009359.ref026","doi-asserted-by":"crossref","first-page":"e90037","DOI":"10.1371\/journal.pone.0090037","article-title":"Diagnosing dengue at the point-of-care: utility of a rapid combined diagnostic kit in Singapore","volume":"9","author":"VC Gan","year":"2014","journal-title":"PLoS One"},{"issue":"2","key":"pntd.0009359.ref027","doi-asserted-by":"crossref","first-page":"103","DOI":"10.1179\/2047773214Y.0000000131","article-title":"Comparative performance of the probable case definitions of dengue by WHO (2009) and the WHO-SEAR expert group (2011)","volume":"108","author":"ZT Nujum","year":"2014","journal-title":"Pathogens and global health"},{"issue":"5","key":"pntd.0009359.ref028","doi-asserted-by":"crossref","first-page":"e0127998","DOI":"10.1371\/journal.pone.0127998","article-title":"Accuracy of Clinical Diagnosis of Dengue Episodes in the RV144 HIV Vaccine Efficacy Trial in Thailand","volume":"10","author":"P Pitisuttithum","year":"2015","journal-title":"PLoS One"},{"issue":"8","key":"pntd.0009359.ref029","doi-asserted-by":"crossref","first-page":"e0004918","DOI":"10.1371\/journal.pntd.0004918","article-title":"Symptomatic Dengue Disease in Five Southeast Asian Countries: Epidemiological Evidence from a Dengue Vaccine Trial","volume":"10","author":"J Nealon","year":"2016","journal-title":"PLoS Negl Trop Dis"},{"issue":"10","key":"pntd.0009359.ref030","doi-asserted-by":"crossref","first-page":"2983","DOI":"10.1007\/s00705-017-3429-7","article-title":"Serological, molecular and clinical correlates of dengue from a tertiary care centre in Chennai, India","volume":"162","author":"V Seshan","year":"2017","journal-title":"Arch Virol"},{"issue":"7","key":"pntd.0009359.ref031","doi-asserted-by":"crossref","first-page":"876","DOI":"10.3201\/eid0907.020496","article-title":"Probable dengue virus infection among Italian troops, East Timor, 1999\u20132000","volume":"9","author":"MS Peragallo","year":"2003","journal-title":"Emerg Infect Dis"},{"issue":"3","key":"pntd.0009359.ref032","first-page":"205","article-title":"Evaluaci\u00f3n de la definici\u00f3n de caso probable de dengue cl\u00e1sico durante el brote de dengue en Lima, 2005","volume":"22","author":"J Ju\u00e1rez","year":"2005","journal-title":"Rev Peru Med Exp Salud Publica"},{"issue":"5","key":"pntd.0009359.ref033","first-page":"e1191","volume":"5","author":"JGH Low","year":"2011","journal-title":"The early clinical features of dengue in adults: challenges for early clinical diagnosisPLoS neglected tropical diseases"},{"issue":"8","key":"pntd.0009359.ref034","doi-asserted-by":"crossref","first-page":"1023","DOI":"10.1111\/j.1365-3156.2012.03020.x","article-title":"Dengue in travellers: Applicability of the 1975\u20131997 and the 2009 WHO classification system of dengue fever","volume":"17","author":"RW Wieten","year":"2012","journal-title":"Tropical Medicine and International Health"},{"key":"pntd.0009359.ref035","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1186\/s40249-016-0120-2","article-title":"Presence of three dengue serotypes in Ouagadougou (Burkina Faso): research and public health implications","volume":"5","author":"V Ridde","year":"2016","journal-title":"Infect Dis Poverty"},{"issue":"2","key":"pntd.0009359.ref036","doi-asserted-by":"crossref","first-page":"e0006258","DOI":"10.1371\/journal.pntd.0006258","article-title":"Evaluation of the WHO 2009 classification for diagnosis of acute dengue in a large cohort of adults and children in Sri Lanka during a dengue-1 epidemic.","volume":"12","author":"CK Bodinayake","year":"2018","journal-title":"PLoS neglected tropical diseases"},{"issue":"9","key":"pntd.0009359.ref037","doi-asserted-by":"crossref","first-page":"e0005859","DOI":"10.1371\/journal.pntd.0005859","article-title":"Clinical and epidemiologic characteristics of dengue and other etiologic agents among patients with acute febrile illness, Puerto Rico, 2012\u20132015","volume":"11","author":"KM Tomashek","year":"2017","journal-title":"PLoS Negl Trop Dis"},{"issue":"3","key":"pntd.0009359.ref038","doi-asserted-by":"crossref","first-page":"622","DOI":"10.4269\/ajtmh.18-0407","article-title":"Etiologies of Acute Undifferentiated Febrile Illness in Bangkok, Thailand","volume":"100","author":"V Luvira","year":"2019","journal-title":"Am J Trop Med Hyg"},{"issue":"9","key":"pntd.0009359.ref039","doi-asserted-by":"crossref","first-page":"e1000139","DOI":"10.1371\/journal.pmed.1000139","article-title":"The impact of the demographic transition on dengue in Thailand: insights from a statistical analysis and mathematical modeling","volume":"6","author":"DA Cummings","year":"2009","journal-title":"PLoS Med"},{"issue":"8","key":"pntd.0009359.ref040","doi-asserted-by":"crossref","first-page":"827","DOI":"10.1016\/j.cmi.2018.05.001","article-title":"Epidemiology of acute febrile illness in Latin America","volume":"24","author":"J Moreira","year":"2018","journal-title":"Clin Microbiol Infect"},{"issue":"5","key":"pntd.0009359.ref041","doi-asserted-by":"crossref","first-page":"536","DOI":"10.1016\/S1473-3099(20)30158-4","article-title":"Covert COVID-19 and false-positive dengue serology in Singapore","volume":"20","author":"G Yan","year":"2020","journal-title":"Lancet Infect Dis"},{"issue":"5","key":"pntd.0009359.ref042","doi-asserted-by":"crossref","first-page":"e177","DOI":"10.1016\/j.jaad.2020.03.036","article-title":"COVID-19 can present with a rash and be mistaken for dengue","volume":"82","author":"B Joob","year":"2020","journal-title":"J Am Acad Dermatol"},{"key":"pntd.0009359.ref043","unstructured":"World Health Organization. Public Health Surveillance for COVID-19: Interim guidance. 2020."},{"issue":"8","key":"pntd.0009359.ref044","doi-asserted-by":"crossref","first-page":"1164","DOI":"10.1093\/cid\/cix966","article-title":"Impact of Dengue Vaccination on Serological Diagnosis: Insights From Phase III Dengue Vaccine Efficacy Trials","volume":"66","author":"E Plennevaux","year":"2018","journal-title":"Clin Infect Dis"},{"key":"pntd.0009359.ref045","article-title":"Potential antigenic cross-reactivity between SARS-CoV-2 and Dengue viruses","author":"Y Lustig","year":"2020","journal-title":"Clin Infect Dis"},{"issue":"1","key":"pntd.0009359.ref046","doi-asserted-by":"crossref","first-page":"e54842","DOI":"10.1371\/journal.pone.0054842","article-title":"Decision support system for the response to infectious disease emergencies based on WebGIS and mobile services in China","volume":"8","author":"YP Li","year":"2013","journal-title":"PLoS One"}],"updated-by":[{"DOI":"10.1371\/journal.pntd.0009359","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2021,5,6]],"date-time":"2021-05-06T00:00:00Z","timestamp":1620259200000}}],"container-title":["PLOS Neglected Tropical Diseases"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0009359","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,5,6]],"date-time":"2021-05-06T18:49:26Z","timestamp":1620326966000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pntd.0009359"}},"subtitle":[],"editor":[{"given":"Rhoel Ramos","family":"Dinglasan","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2021,4,26]]},"references-count":46,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2021,4,26]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pntd.0009359","relation":{"new_version":[{"id-type":"doi","id":"10.1371\/journal.pntd.0009359","asserted-by":"object"}]},"ISSN":["1935-2735"],"issn-type":[{"value":"1935-2735","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,4,26]]}}}