Guía para el Manejo Clínico del Dengue

Objectives

The guideline provides a national clinical framework for timely diagnosis, classification, treatment, observation, referral and follow-up of suspected or confirmed dengue in children and adults attending public or private health facilities. It aims to prevent deterioration and deaths by recognising dengue as a dynamic illness that can progress rapidly from febrile illness to plasma leakage, shock, severe bleeding or organ failure.[1][2][3][4]

• Standardise classification of cases as dengue without warning signs, dengue with warning signs, or severe dengue, using clinical manifestations, haemodynamic assessment and laboratory findings.[5][6][7]
• Prioritise early clinical and haemodynamic assessment and begin management without waiting for laboratory confirmation, while using laboratory testing to support diagnosis and monitor progression.[8][9][10]
• Identify warning signs, plasma leakage, bleeding, shock and serious neurological, renal, hepatic, respiratory or cardiac complications promptly.[11][7][12][13]
• Protect high-risk groups, including pregnant and postpartum patients, neonates, children under two years, older adults, and people with chronic disease, malnutrition, obesity or other clinical and social vulnerabilities.[14][15][16][17][18]
• Promote safe recovery through appropriate hydration, avoidance of harmful medicines and procedures, patient and family education, recognition of warning signs, and continued community follow-up after discharge.[15][19][20][21]
• Support prevention of mosquito-borne disease through household source reduction, protection of water containers, mosquito-net use, covering clothing and education on timely care-seeking and avoiding self-medication.[22]

Implementation

Implementation centres on an organised continuum from triage and 24-hour observation in Febrile Care Units to inpatient, referral-hospital and intensive-care management, supported by multidisciplinary focal points, trained staff, clinical documentation, supply readiness, referral coordination and community follow-up.[2][3][23][19][24]

• Establish triage at each facility entrance to prioritise self-presenting and referred patients by severity; direct patients with fever or recent fever to the Febrile Care Unit for assessment and observation, and move those with warning signs or haemodynamic disturbance rapidly to shock care, febrile wards or intensive care as appropriate.[2][3][23]
• Apply clinical history-taking, physical examination and differential diagnosis, including assessment for malaria, chikungunya, Zika, leptospirosis, bacterial infection and non-infectious causes where relevant.[25][26][27][28]
• Monitor vital signs, peripheral perfusion, mental status, warning signs, respiratory condition, urine output, fluid input and output, haematocrit and relevant blood counts dynamically; use more frequent reassessment during shock and fluid resuscitation.[29][30][31][32][19]
• Manage clinically stable patients with oral rehydration, paracetamol, physical cooling and observation, while advising urgent return for vomiting, abdominal pain, neurological change, bleeding, cold extremities or breathing difficulty.[33][34]
• Provide cautious, response-led crystalloid therapy for warning signs, shock and plasma leakage; reassess after each fluid load, progressively reduce fluids when perfusion and diuresis improve, and limit cumulative fluids to reduce overload.[35][36][31][37]
• Escalate persistent shock to vasoactive treatment and assessment for bleeding, cardiac dysfunction, respiratory failure or other refractory causes; use blood products when clinically indicated and avoid relying on thrombocytopenia alone as a reason for prophylactic platelet transfusion.[38][39][40][41][42]
• Adapt care for comorbidities and pregnancy through multidisciplinary management, maternal-fetal assessment, fetal surveillance, tailored fluid management and reporting of pregnant patients with suspected or confirmed dengue to the national focal point.[43][16][44]
• Observe neonates according to maternal dengue status and infant symptoms, maintain breastfeeding where feasible, assess for sepsis and shock, and arrange neonatal or primary-care follow-up after discharge.[45][46][47]
• Maintain medical and non-medical supplies, including fluids, medicines, oxygen, monitoring equipment, intravenous-access materials, emergency equipment, epidemiological forms and transport resources; keep equipment functional and checked each shift.[3][24][48][49]
• Coordinate referrals with receiving facilities, SILAIS and relevant focal points; stabilise patients before transfer where possible, use qualified escorts, maintain treatment and monitoring en route, and provide formal clinical handover.[50][51][52][53]
• Report febrile-patient status and occupancy of Febrile Care Units and febrile wards daily, report severe febrile cases in real time, notify suspected cases to epidemiology, and communicate discharged patients to Family and Community Health Teams for follow-up.[9][19][54][50]

Monitoring & Evaluation

The guidance establishes an extensive clinical monitoring, documentation and referral system for dengue across primary care, hospital, maternity, neonatal and transport settings. It relies principally on frequent bedside reassessment rather than a consolidated programme-level evaluation framework, although it includes specified notification, reporting and accountability requirements in selected service pathways.[19][50][24]

• Monitor patients dynamically across febrile, critical and recovery phases, with attention to warning signs, haemodynamic stability, mental status, peripheral perfusion, respiratory condition, urine output, fluid balance, haematocrit and relevant laboratory trends.[4][55][5]
• Record vital signs hourly in Febrile Care Units and document care in clinical records through hourly nursing notes, physician observations and evolutionary notes at least every four hours when the patient’s condition is unchanged.[3][24][48]
• Increase monitoring intensity for severe disease: observe patients in initial shock every 30 minutes during the first hour and until shock resolves, and observe hypotensive shock every 15 minutes.[31][38][32][56]
• Measure fluid input and output, urination and cumulative fluid balance, with four-hourly balance recording during fluid resuscitation. A cumulative balance approaching or exceeding 5% of body weight signals risk of fluid overload.[35][36][42][57]
• Use serial haematocrit, platelet and leucocyte counts to support assessment of disease progression, plasma leakage, dehydration, haemodilution and bleeding. For patients with warning signs, undertake full blood counts with platelets every 24 hours; for those without warning signs, undertake them every 48 hours.[9][10]
• Apply diagnostic testing according to illness timing, using reverse-transcription polymerase chain reaction in the first three days of symptoms and dengue immunoglobulin M serology from the sixth day.[10]
• Notify suspected dengue cases immediately to epidemiology and notify cases as part of the clinical assessment pathway, although the extracts do not define a national case-reporting dataset or notification timetable.[27][28][9]
• Report every pregnant patient with suspected or confirmed dengue to the national focal point and provide systematic maternal-fetal follow-up.[16]
• Arrange post-discharge review within 24 hours and community follow-up by Family and Community Health Teams, including daily home visits where indicated.[19][54][50][20]
• Require every health unit to report daily, including on weekends and public holidays, on febrile-patient status and occupancy of Febrile Care Units and febrile wards, and report severe febrile cases in real time.[50]
• Maintain referral accountability through transfer records, documented departure and arrival times, clinical assessments during transport, 30-minute communication with escorting teams, and formal written and verbal handover at the receiving facility. Establishment directors are responsible for compliance with referral and counter-referral procedures.[51][52][53]
• Use dedicated monitoring tools, including haemodynamic assessment sheets, fluid and mineral balance forms, and bedside observation templates that capture patient characteristics, clinical classification, physiological findings, fluid volumes and stability.[58][59][60][61][62]

The extracts do not specify a unified programme indicator set, indicator targets, routine audit cycle, independent evaluation methodology, sanctions, or a comprehensive national accountability framework beyond the clinical documentation, reporting, notification and transfer requirements described above.[38][24][63][64]

Costing & Financing

No budget, costed implementation plan, financing source, resource-mobilisation strategy, funding gap, allocation, unit cost or economic assumption is specified in the supplied material.[65][9][19][63]

• Require facilities to maintain medical and non-medical supplies for acute febrile syndrome care, but provide no financial allocation for these inputs.[3]
• Identify clinical resources required for dengue care, including crystalloids, oral rehydration solution, potassium chloride, oxygen, laboratory testing, blood products, vasoactive medicines, monitoring equipment, transport equipment and emergency or resuscitation supplies.[30][38][24][53]
• Require qualified medical, nursing, paediatric and adult-care personnel, as well as equipped referral transport, without estimating workforce, procurement or transport costs.[19][50][24][51]
• Describe diagnostic equipment such as ultrasound, electrocardiography, blood-gas testing and echocardiography as available-resource-dependent assessments, but do not specify purchase, maintenance or operating costs.[57]
• Provide clinical fluid volumes, drug concentrations and maintenance-fluid calculations that are treatment parameters rather than monetary values.[66][67][68]

Accordingly, the material identifies resource needs for service delivery but does not permit estimation of programme costs, affordability, financing requirements or funding shortfalls.[24][48][49]