title: Utility of warning signs in guiding admission and predicting severe disease in adult dengue.
abstract: BACKGROUND
  The recommendation from the 2009 World Health Organization guidelines for managing dengue suggests that patients with any warning sign can be hospitalized for observation and management. We evaluated the utility of using warning signs to guide hospital admission and predict disease progression in adults.
  
  
  METHODS
  We conducted a prospective cohort study from January 2010 to September 2012. Daily demographic, clinical and laboratory data were collected from adult dengue patients. Warning signs were recorded. The proportion of admitted patients using current admission criteria and warning signs was compared. The sensitivity, specificity, positive and negative predictive values of warning signs in predicting disease progression were also evaluated.
  
  
  RESULTS
  Four hundred and ninety-nine patients with confirmed dengue were analyzed. Using warning signs instead of the current admission criteria will lead to a 44% and 31% increase in admission for DHF II-IV and SD cases respectively. The proportion of non-severe dengue cases which were admitted also increased by 32% for non DHF II-IV and 33% for non-SD cases. Absence of any warning signs had a NPV of 91%, 100% and 100% for DHF I-IV, DHF II-IV and SD. Of those who progressed to severe illness, 16.3% had warning signs on the same day while 51.3% had warning signs the day before developing severe illness, respectively.
  
  
  CONCLUSIONS
  Our findings demonstrated that patients without any warning signs can be managed safely with ambulatory care to reduce hospital resource burden. No single warning sign can independently predict disease progression. The window from onset of warning sign to severe illness in most cases was within one day.
authors.affiliation: Department of Infectious Disease, Communicable Disease Center, Institute of Infectious Disease and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore. Yee_Sin_Leo@ttsh.com.sg.
authors.forename: Yee-Sin
authors.initials: YS
authors.lastname: Leo
authors.forename: Victor C
authors.initials: VC
authors.lastname: Gan
authors.forename: Ee-Ling
authors.initials: EL
authors.lastname: Ng
authors.forename: Ying
authors.initials: Y
authors.lastname: Hao
authors.forename: Lee-Ching
authors.initials: LC
authors.lastname: Ng
authors.forename: Kwoon-Yong
authors.initials: KY
authors.lastname: Pok
authors.forename: Frederico
authors.initials: F
authors.lastname: Dimatatac
authors.forename: Chi-Jong
authors.initials: CJ
authors.lastname: Go
authors.forename: David C
authors.initials: DC
authors.lastname: Lye
mesh_terms: D000328:Adult; D015331:Cohort Studies; D003715:Dengue / Q000175:diagnosis*; D018450:Disease Progression; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D055815:Young Adult