Dengue in an era of hyperendemicity: clinical triage, case management, and primary care preparedness in resource-constrained settings: a narrative review

1 Introduction

Dengue is a major frontline clinical challenge and an expanding public health threat. Its range has widened to more than 100 countries, while climate-sensitive vector spread, rapid urbanization, international mobility, recurrent epidemics, and circulation of multiple serotypes are increasing both case volume and clinical complexity at first-contact facilities (1, 2). Recent estimates underscore the scale of this pressure: the World Health Organization (WHO) received reports of more than 14 million dengue cases and 11,201 deaths globally in 2024, while Global Burden of Disease (GBD) 2021 analysis indicated substantial long-term increases in incidence, mortality, and disability burden (3, 4).

Although most infections are asymptomatic or self-limiting, a clinically important minority progresses to severe disease, characterized by plasma leakage, shock, severe bleeding, respiratory compromise, or organ dysfunction (5, 6). Early dengue is often a non-specific febrile illness that overlaps with other arboviral and endemic infections, making early recognition difficult. Clinically important deterioration may begin around defervescence, when the resolution of fever can be mistaken for recovery (1, 7, 8). Therefore, the practical challenge for frontline clinicians is not only to suspect dengue but also to judge, within a narrow decision window, who can be managed safely at home, who requires structured observation, and who needs immediate stabilization and referral (9).

These decisions become harder in resource-constrained services, where limited diagnostic and laboratory capacity, high outbreak caseloads, inadequate monitoring, and unreliable referral pathways can disrupt risk assessment and continuity of care (1, 8). Such constraints can produce two opposing failures: unnecessary admission of lower-risk patients, which further overwhelms hospitals, and missed or delayed recognition of those progressing towards severe dengue (1, 10).

Primary care should therefore be understood as the coordinating center of dengue management, not merely as its entry point. First-contact facilities must connect early recognition and dynamic risk stratification with safe outpatient care, planned reassessment, patient education, pre-referral stabilization, and communication across levels of care (9, 11). The central argument of this review is that preventable severe dengue and death are shaped not only by viral and host factors but also by failures across the clinical pathway, from delayed recognition and static triage to inadequate follow-up and delayed referral. Accordingly, this review critically examines how clinical recognition, dynamic triage, phase-specific case management, modified thresholds for vulnerable patients, and primary care preparedness can reduce preventable deterioration and death in resource-constrained settings. Understanding these priorities requires examining how hyperendemic and recurrent transmission reshapes the volume, timing, and complexity of clinical demand. The review is organized around an integrated pathway linking evolving clinical risk, repeated triage, phase-specific management, patient vulnerability, and the functional capacity of primary care and referral systems (Figure 1).

2 Methods

2.1 Search strategy

This narrative review used a structured, focused, and non-systematic approach to identify evidence relevant to dengue clinical management and frontline health-service preparedness. Peer-reviewed literature was identified through targeted searches of PubMed and Scopus, supplemented by searches of World Health Organization (WHO) guidance and technical publications and backward citation searching of relevant reviews, guidelines, and primary studies.

Searches were organized around the principal domains of the review, including dengue and severe dengue, hyperendemicity, clinical recognition and differential diagnosis, illness day, hematological and inflammatory parameters, warning signs, severity assessment, triage, outpatient management, fluid therapy, complications, referral, vulnerable populations, primary health care, facility readiness, surveillance, and outbreak preparedness. Search concepts were combined and adapted according to the clinical or health-system topic being examined and the functionality of each information source. The purpose of the search was to identify evidence relevant to an integrative narrative synthesis rather than to achieve exhaustive retrieval of all dengue-related literature.

2.2 Selection criteria

Sources were considered for inclusion when they contributed directly to one or more of the clinical, implementation, or health-system domains addressed in the review. Priority was given to WHO and other authoritative guidance, systematic reviews and meta-analysis, multicenter studies, clinical studies, and implementation or health-services research relevant to frontline dengue care.

Particular consideration was given to evidence applicable to resource-constrained, primary-care, rural, underserved, or outbreak settings. Where direct evidence from these settings was limited, evidence from other settings was considered when it offered clinically or operationally relevant insights, while limitations in generalizability were taken into account during interpretation. Sources were not retained when they were unrelated to the objectives of the review, provided insufficient information to inform the synthesis, or substantially duplicated evidence already represented by a more relevant or informative source.

2.3 Selection process

Potentially relevant publications were assessed iteratively according to their relevance to the main domains and objectives of the review. Sources were examined in sufficient detail to determine whether they contributed meaningfully to the clinical, implementation, or health-system questions being addressed. Reference lists of particularly relevant guidelines, reviews, and primary studies were also examined to identify additional sources.

Selection was therefore relevance-driven and iterative, consistent with the purpose of a narrative review, rather than an exhaustive systematic-review screening process. No PRISMA-style study-selection procedure or duplicate-independent screening was applied.

2.4 Evidence extraction and narrative synthesis

Relevant information from selected sources was organized according to the major themes of the review, including hyperendemicity and changing clinical demand; clinical recognition and diagnostic uncertainty; illness-day assessment and dynamic triage; phase-specific case management; biological and operational vulnerability; referral and escalation; primary-care preparedness; and surveillance-linked outbreak readiness.

For each source, emphasis was placed on the clinical or operational question addressed, the study or guidance context, the principal findings, and their relevance to dengue care in resource-constrained settings. Particular attention was given to areas of agreement across the literature, clinically important uncertainty, implementation constraints, contextual limitations, and gaps in the available evidence.

The evidence was synthesized narratively to integrate clinical and health-system perspectives across the dengue care pathway. No meta-analysis, formal evidence grading, or structured risk-of-bias assessment was undertaken, because the objective was to provide an integrative narrative synthesis rather than a systematic review.

3 Hyperendemicity and changing clinical demand

The frontline pressures outlined above intensify when dengue shifts from sporadic or geographically contained outbreaks to sustained, recurrent, or multi-serotype transmission. Epidemiologically, hyperendemicity differs from simple endemicity, seasonal recurrence, or a single large epidemic and generally involves the sustained co-circulation of multiple dengue virus serotypes within the same population or geographical setting (12). This transition is sustained by interacting ecological and social forces, including urban density, human mobility, climate-sensitive Aedes expansion, and repeated serotype importation, which together create increasingly stable conditions for multi-serotype persistence, rather than isolated transmission episodes (12, 13).

Hyperendemic transmission may increase the clinical risk because infection with one serotype confers durable protection only to that serotype, while cross-protection against heterologous serotypes is temporary and population susceptibility shifts over time (12, 14). Secondary heterologous infection is associated with a greater risk of severe dengue in epidemiological cohorts and reviews, although the magnitude of risk varies by infection sequence, time interval, age, and setting (14–16). Antibody-dependent enhancement is one recognized mechanism, supported by human cohort data, animal studies, and immunological models; however, it does not fully explain severe disease, which is also shaped by viral factors, host biology, timing of presentation, and care quality (15, 17, 18). Serotype replacement and shifting dominance further complicate the risk because changes in herd immunity can create ecological space for heterologous serotypes and alter the age and immunity profiles of clinically apparent cases (13, 16).

For frontline services, the main consequence is not only more infections but also more recurrent waves of febrile demand. Hyperendemic settings can generate prolonged or repeated surges of suspected dengue, repeated consultations, observation needs, and pressure on referral hospitals and supplies, while many patients remain diagnostically uncertain at the first presentation (19). This burden is not captured by confirmed case counts alone; in one Nepalese outbreak cohort, 538 dengue-suspected patients required assessment, and 74.5% were confirmed, illustrating that frontline workload extends beyond laboratory-confirmed cases (20). Broad admission criteria can further increase the demand for inpatient care. In a Sri Lankan tertiary care cohort of 1,064 hospitalized patients with confirmed dengue, only a minority developed severe dengue, leading the authors to call for improved algorithms to distinguish patients suitable for ambulatory from inpatient management (10).

These pressures are amplified where dengue overlaps clinically with malaria and other acute febrile illnesses, especially in Africa and other under-surveilled settings, where misdiagnosis, weak laboratory capacity, and incomplete reporting can make the apparently low incidence misleading (14, 21). Under-recognition is especially plausible in rural, peri-urban, conflict-affected, and fragile settings. In 2023, seven of the 18 African Union member states reporting dengue outbreaks were experiencing armed conflict, and most reported continental cases occurred in countries with large displaced populations (21). Epidemiological burden describes infections, severe cases, and deaths, whereas the clinical-service burden includes patient flow, repeated reassessment, diagnostic uncertainty, observation demand, admission decisions, referral pressure, and continuity of care. The clinical importance of hyperendemicity lies not only in the infections it produces but also in the persistent requirement for frontline facilities to identify a small proportion of deteriorating patients among many with clinically similar, usually uncomplicated febrile illnesses. When services face this volume and uncertainty, the next priority is to recognize probable dengue early, use available tests judiciously, and apply dynamic rather than static risk stratification.

4 Clinical recognition, diagnosis, and dynamic triage

The recurrent febrile demand described above means that frontline facilities must usually recognize probable dengue and make early management decisions before definitive confirmation is available. Early dengue presents as a non-specific acute febrile illness, and overlapping manifestations with malaria, chikungunya, leptospirosis, influenza-like illness, and other locally prevalent infections make purely syndromic diagnoses unreliable (8, 22). Although fever, headache, retro-orbital pain, myalgia, arthralgia, nausea, vomiting, rash, and mild bleeding are familiar manifestations, individual symptoms have limited ability to distinguish dengue from other febrile illnesses during the first few days of the disease (22). Diagnostic uncertainty is reduced less by isolated symptoms than by integrating local epidemiology, exposure history, illness trajectory, physical examination, and repeated review, while remaining alert to dangerous mimics such as malaria, meningococcal infection, bacterial sepsis, and non-infectious conditions that may initially resemble dengue (8, 22, 23).

4.1 Recognizing dengue under diagnostic uncertainty

Recording the day of illness is central because the diagnostic value of symptoms and laboratory findings changes across the early febrile period, while test selection, interpretation of defervescence, and anticipation of the critical phase all depend on the timing (22, 24). The initial assessment should integrate illness day with hydration and oral intake, vomiting, abdominal symptoms, urine output, bleeding, mental status, peripheral perfusion, hemodynamic findings, respiratory status, pregnancy, and relevant comorbidities (9, 22).

Investigations serve three distinct purposes: confirming dengue, excluding important alternatives, and detecting evolving plasma leakage, bleeding, and organ dysfunction (8, 25). Molecular tests are most informative early; in a 2025 meta-analysis, the pooled sensitivity of reverse-transcription polymerase chain reaction (RT-PCR) at 0–4 days after symptom onset was 95% and the pooled specificity was 89%, but access remains limited outside better-equipped laboratories (8, 26). Non-structural protein 1 (NS1) also performs best early and can approach RT-PCR in some settings, with a pooled sensitivity of 90% and specificity of 93% for NS1 enzyme-linked immunosorbent assay (ELISA) in the same meta-analysis (26–28). However, the performance of rapid NS1 assays varies by product, illness timing, serotype, viral load, and primary or secondary infection; therefore, a negative result should not exclude dengue when clinical suspicion remains high (26, 29). Immunoglobulin M (IgM) becomes more informative later but performs poorly early in the illness, while combining NS1 with IgM generally improves detection in both reviews and field studies (26, 30, 31). Simple laboratory markers also add value: the International Research Consortium on Dengue Risk Assessment, Management and Surveillance (IDAMS) multicenter cohort showed that platelet count, white cell count, and their serial change improved discrimination between dengue and other febrile illnesses, outperforming clinical-only models (22). Complementing these multicenter findings, a retrospective Thai study found significant differences in complete blood count patterns between dengue and other acute febrile illnesses, including leukopenia, thrombocytopenia, and hemoconcentration, with these differences varying according to the day of fever (32). Because hematological and inflammatory parameters vary across the disease course, their interpretation should be anchored to illness day rather than to isolated thresholds. The neutrophil-to-lymphocyte ratio (NLR) also changes during dengue illness and may provide complementary information alongside the differential blood count; however, it should not be interpreted independently of the patient’s clinical trajectory and other laboratory findings (32). However, platelet count alone is not a severity proxy and must be interpreted with hematocrit, bleeding, hemodynamics, urine output, and disease phase (33, 34). Therefore, diagnostic certainty and clinical risk overlap, but they are not the same decision.

4.2 Dynamic risk stratification and disposition

Dengue triage is a repeated process that determines whether a patient is suitable for outpatient care with structured follow-up, requires observation or admission, or needs immediate stabilization and urgent referral. The WHO 2009 classification remains clinically useful because it provides a practical shared framework for dengue without warning signs, dengue with warning signs, and severe dengue; however, individual warning signs have variable predictive performance across settings and should not be used as static binary rules (9, 33, 34). Findings associated with deterioration include persistent vomiting, abdominal pain or tenderness, mucosal bleeding, clinical fluid accumulation, lethargy or restlessness, hepatomegaly, and rising hematocrit with falling platelet count. Impaired perfusion, reduced urine output, respiratory distress, altered consciousness, major bleeding, and organ dysfunction indicate advanced or severe disease rather than merely an increased risk (9, 33). These findings represent associations rather than universally transportable prediction rules, and much of the available evidence is derived from hospital-based or pediatric populations (33, 34).

The absence of warning signs at one encounter does not guarantee a benign course, particularly early in the illness; therefore, repeated assessment around defervescence and attention to trends in perfusion, urine output, functional status, hematocrit, and platelet count are essential (9, 11). Patients considered for outpatient care should be hemodynamically stable, able to maintain oral intake and urine output, free of warning signs, and able to return promptly. Warning signs, inability to maintain hydration, progressive laboratory abnormalities, pregnancy, relevant comorbidities, or unreliable follow-up favor observation or admission, whereas shock, major bleeding, respiratory compromise, altered consciousness, or major organ involvement require urgent stabilization and referral (9, 11). Disposition is therefore both clinical and logistical, because distance, transport, caregiver support, communication access, cost, and referral reliability determine whether apparent stability is actually safe outside the hospital. One recent pediatric outpatient prediction study showed promising but moderate discrimination and relied substantially on clinical and laboratory variables, with areas under the receiver operating characteristic curve (AUROCs) of 0.789 for dengue shock syndrome and 0.741 for moderate plasma leakage and/or shock (35). Effective triage therefore integrates the disease phase, clinical trajectory, hemodynamic findings, laboratory trends, host vulnerability, social context, and facility capacity. Dynamic risk classification improves outcomes only when linked to phase-specific outpatient care, controlled fluid management, repeated monitoring, and timely referral.

5 Phase-specific case management

5.1 Febrile-phase and outpatient management

Most patients with uncomplicated dengue can be managed outside the hospital when they are hemodynamically stable, can maintain oral intake and urine output, have no warning signs, and can return reliably for reassessment (9, 11).

Outpatient care is an active pathway rather than a simple discharge. Guideline-based reviews consistently frame early management around oral fluids, paracetamol, and avoidance of non-steroidal anti-inflammatory drugs (NSAIDs) with escalation to observation or intravenous support only when oral intake is not sustained or the risk increases (36–38). Hydration advice should not be reduced to a single universal volume because the risk of dehydration varies with age, body size, vomiting, environmental heat, and comorbidity, while the available primary care evidence supports feasibility more strongly than precise dosing targets (38).

Follow-up should be timed to the illness day and the anticipated transition around defervescence rather than being left to vague instructions to return only if symptoms worsen, because clinically important deterioration may begin as fever settles (9, 11). Therefore, safe ambulatory review depends on repeated assessment of oral intake, urine output, vomiting, abdominal symptoms, bleeding, lethargy, respiratory effort, cold extremities, and functional decline, with laboratory testing used selectively when it will alter disposition rather than as isolated platelet surveillance (35).

Discharge education is part of treatment because patients and caregivers need clear instructions on expected symptoms, medicines to avoid, warning features, the date of reassessment, and how to obtain urgent care if deterioration occurs (36, 38). Evidence for specific support tools remains limited but suggests that low-cost structured follow-up can be feasible. A Malaysian pilot trial found a fluid chart acceptable in primary care and associated with numerically fewer admissions and less intravenous fluid use, although differences were not statistically significant, while a Brazilian outbreak study reported no adverse events among low-to-moderate risk patients triaged by nurses and reviewed through telemedicine (38, 39). Structured outpatient models can also preserve hospital capacity; a recent Singaporean program saved a mean of 3.3 bed-days per patient, but this evidence comes from a well-resourced tertiary system and should not be generalized uncritically to weaker referral settings (40). Patients who develop warning signs, worsening perfusion, inability to maintain hydration, concerning laboratory trends, or who cannot be followed safely, require observation, admission, or referral (36).

5.2 Critical-phase management, severe disease, and referral

The critical phase usually begins around defervescence and is defined by transient vascular leakage, hemoconcentration, and risk of shock, followed by reabsorption during recovery (36, 37, 41). Therefore, bedside management depends on recognizing compensated shock before hypotension becomes obvious, because important circulatory compromise can evolve rapidly despite initially normal observations (42).

Intravenous fluid therapy is the cornerstone of severe dengue management; however, the evidence supports a feedback-controlled rather than a fixed approach (36, 37). Reviews and guidelines favor isotonic crystalloids as first-line therapy, with reassessment against perfusion, urine output, hemoconcentration, respiratory findings, and clinical trajectory to match fluid administration to the leak while avoiding overload (36, 37). Landmark pediatric trials have shown that colloids can normalize hematocrit and cardiovascular status faster in some children with shock, but a larger randomized study found Ringer’s lactate to be appropriate for moderately severe dengue shock syndrome (DSS) and noted more adverse reactions with dextran; therefore, colloid use should remain selective rather than prolonged (43, 44). More recent pediatric observational data reinforce this caution: among 691 children across seven Southeast Asian hospitals, mixed or liberal colloid strategies were associated with more respiratory compromise and ventilation, and in a Vietnamese pediatric intensive care unit (PICU) cohort of 1,278 DSS cases, larger early fluid loads and higher colloid-to-crystalloid ratios were associated with mechanical ventilation and acute kidney injury (45, 46).

Hematocrit trends are useful only in context; rising values with worsening circulation suggest ongoing plasma leakage, whereas falling values during instability suggest significant bleeding, particularly if clinical improvement does not accompany fluid therapy (42, 47). Evidence for blood transfusion remains limited and largely observational. A small case series reported hemodynamic improvement after transfusion in selected patients with severe dengue and suspected major or occult bleeding. Isolated thrombocytopenia without clinically significant bleeding is not an indication for prophylactic platelet transfusion (47–49).

A major danger in the late critical and recovery phases is fluid overload, especially when intravenous fluids continue after leakage resolves or in patients with renal, cardiac, hepatic, pregnancy-related, or age-related vulnerability (42, 50). Severe organ involvement, including acute liver failure, encephalopathy, acute kidney injury, myocarditis, respiratory compromise, and intracranial bleeding, is well described in case series and should trigger early stabilization and urgent referral rather than prolonged low-capacity management (36, 42, 51). Much of the available fluid management evidence comes from pediatric patients, tertiary hospitals, and predominantly Asian settings; therefore, safe dengue management requires sufficient standardization to reduce errors while remaining responsive to disease phase, patient vulnerability, monitoring capacity, and referral access (45, 46). Because age, pregnancy, comorbidities, and barriers to follow-up can alter both clinical risk and treatment tolerance, standard management thresholds must be adapted for biologically and operationally vulnerable patients. The principal assessment priorities, management actions, and escalation triggers across the dengue clinical pathway are summarized in Table 1.

Table 1. Essential assessment, management, and escalation priorities across the dengue clinical pathway.

CBC, complete blood count. Recommendations are synthesized from WHO dengue clinical-management and primary-care guidance and should be adapted to the patient’s clinical trajectory, biological and operational vulnerability, and local monitoring and referral capacity.

6 Modifying care for high-risk patients

Phase-specific management cannot be applied uniformly because baseline physiology, tolerance of fluid shifts, clinical reserve, and the practical ability to obtain reassessment differ substantially between patients.

6.1 Biological vulnerability

Infants and young children require modified thresholds because severe dengue remains an important cause of pediatric morbidity, children have limited physiological reserves, and shock can evolve quickly once capillary leak accelerates (52). Age-dependent vital signs further complicate triage, and pediatric studies associate severe disease with lethargy, low systolic blood pressure, prolonged capillary refill, ascites, and hepatomegaly, findings that are clinically useful but are derived mainly from hospital cohorts rather than primary care (53). In practice, limited physiological reserve and reliance on caregivers to detect reduced intake, urine output, or behavioral changes justify earlier observation and more frequent reassessment in children (52, 53).

Pregnancy and the postpartum period alter the presentation and management of dengue. Gestational hemodilution, widened pulse pressure, leukocytosis, and gestational thrombocytopenia can obscure the usual diagnostic and triage cues, while pre-eclampsia, eclampsia, hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and hyperemesis may mimic or delay recognition of dengue-related deterioration (5). Pregnancy is associated with higher odds of severe dengue and adverse maternal and fetal outcomes, including maternal mortality, postpartum hemorrhage, preterm birth, fetal distress, and stillbirth, although much of this evidence comes from observational cohorts and small series (5, 54, 55). Therefore, these patients need closer fluid balance assessment, fetal and obstetric consideration, and coordinated medical-obstetric care, especially near term and in the early postpartum period, when bleeding risk and fluid overload are particularly concerning (5, 56).

Older adults and patients with comorbidities present a different problem: symptoms may be atypical or muted, baseline blood pressure, hematocrit, renal function, and functional status may already be abnormal, and reduced cardiac or renal reserve narrows the tolerance of rapid plasma leakage and intravenous fluid therapy (5, 57). Meta-analytic and population-based evidence links severe dengue with diabetes, renal disease, and childhood, while broader observational literature suggests added risk with cardiovascular disease, chronic liver disease, obesity, stroke, and hematological or autoimmune comorbidity; however, these associations are heterogeneous and should not be treated as universal individual predictors (52, 58, 59). Chronic kidney disease (CKD) illustrates this clearly: in a Brazilian population-based analysis of 5.8 million confirmed dengue cases from 2024, CKD was independently associated with increased odds of death, supporting early assessment, kidney function monitoring, and individualized fluid management to avoid both renal deterioration and overload (58). Across these groups, trends and clinical trajectories are often more informative than isolated values, and safer care generally requires earlier observation, more frequent reassessment, cautious fluid administration, and lower referral thresholds (58, 59).

6.2 Operational vulnerability

Safe outpatient management depends not only on biological stability but also on whether deterioration can be recognized and urgent care can be reached. Evidence from rural and remote health services research consistently identifies distance, transport barriers, high costs, limited staff, service complexity, technology constraints, low awareness, and weak communication networks as obstacles to accessing timely care (60, 61). In displaced and refugee populations, health literacy, language barriers, disrupted social support, and weak inter-organizational communication further reduce the likelihood of early recognition and action in response to worsening illness (62).

These constraints are clinically consequential rather than merely social. A patient who appears stable at one consultation may still be unsafe for home management if return at defervescence is unlikely because of long travel distance, flooding, conflict, seasonal isolation, restricted opening hours, absent caregiver support, or unreliable telephone contact (61, 63). Therefore, operational vulnerability should lower thresholds for observation or referral and favor explicit follow-up arrangements, transport planning, and community-supported monitoring where feasible, because rigid discharge criteria can widen inequities for poor, rural, mobile, or displaced populations that already face greater barriers to reassessment (60, 61, 63). Thus, high-risk dengue care requires a combined assessment of biological susceptibility, treatment tolerance, household capacity, geography, and referral access. Recognizing vulnerability is clinically useful only when primary care facilities possess trained staff, monitoring tools, protocols, supplies, and referral arrangements required to respond appropriately.

7 Building dengue-ready primary care

Recognizing biological and operational vulnerabilities is clinically useful only when frontline facilities can act on them. In this sense, dengue readiness is the reliable ability of primary care services to identify suspected cases, recognize deterioration, manage uncomplicated illness safely, observe patients who need short-term monitoring, stabilize severe presentations, and secure timely referral under both routine and surge conditions (64, 65).

7.1 Minimum facility-readiness package

Therefore, preparedness is a functional rather than an inventory-based concept. Guidelines, training workshops, rapid tests, or blood pressure devices do not, by themselves, demonstrate readiness if staff cannot use these resources correctly and consistently during seasonal pressure. Qualitative work from Malaysia suggests that awareness of dengue guidelines is necessary but not sufficient because limited experience, weak referral practices, and inconsistent application constrain case management (66). The strongest direct facility-level evidence comes from Nepal, where 63.4% of 131 primary care facilities had suboptimal dengue preparedness. Better readiness was associated with facility type, regular facility meetings, and review and trend analysis practices, whereas supervision and quality assurance emerged as important facilitators (67).

Therefore, workforce preparation must be competency-based and continuous. Dengue care depends on clinicians, nurses, laboratory personnel, and, where relevant, community health workers’ ability to assess illness day, repeat triage, detect compensated shock, educate patients for home care, monitor fluids, and stabilize patients before transfer (68). Broader primary-care and humanitarian workforce literature supports the same principle: service capacity is undermined by workforce shortages and fragmentation, while durable improvement requires localized training, interdisciplinary collaboration, cascade teaching, and support for non-clinical systems change rather than one-off courses alone (69, 70). This aligns with dengue-specific qualitative evidence that regular updated training, including nursing staff and referring departments, is needed to use the guidelines appropriately across different clinical scenarios (66). Reliable care also requires standardized clinical processes. First-contact facilities need documentation that consistently captures illness day, complete vital signs, perfusion, hydration, relevant comorbidity or pregnancy, and disposition, because triage decisions in dengue are concentrated at the initial evaluation, admission choice, and management of recurrent shock or fluid overload (68). The WHO guidance identifies illness duration, warning features, vital signs, peripheral perfusion, hydration status, and context-appropriate laboratory access as the core elements of structured dengue assessment and monitoring (9, 11). Therefore, equipment and diagnostic capacity should be matched to the decisions a facility is expected to make, not expanded without purpose, because stock-outs, weak laboratory turnaround, and absent pediatric-appropriate equipment can make technically sound guidance unsafe in practice (65, 71, 72).

Communication is an integral part of clinical care. Patients and caregivers need understandable instructions on hydration, medicines to avoid, when to return, and how to access urgent review. Where literacy or geography limits conventional follow-up, pictorial materials, telemedicine, or community-supported models may help, although implementation evidence remains limited and comes mainly from outbreak or better-resourced settings (39, 66, 72). Therefore, the minimum package should remain deliberately narrow: facilities are safer when they can sustain a small set of essential functions reliably than when they claim a broader capability that they cannot maintain (64, 73).

7.2 Referral, surveillance, and surge capacity

Primary care should coordinate the dengue clinical pathway, not merely identify cases and pass responsibility upwards. Process-mapping work from Vietnam shows that key decisions in dengue occur at the first evaluation, during deterioration, and when balancing fluids against overload, while Malaysian qualitative data highlight poor referral and communication pathways as barriers to effective care (66, 68). Functional referral systems therefore require explicit referral criteria, pre-referral stabilization, direct communication with the receiving facility, documentation of status and fluids already given, transport planning, and confirmation that the destination can accept the patient; without these steps, delays, duplicated assessments, uncontrolled fluid administration, and arrival at facilities without beds or monitoring capacity become more likely (74).

Outbreak preparedness must also be incorporated into routine service organizations. Seasonal epidemics can markedly increase hospitalizations and overwhelm health systems, and recent dengue surge commentaries from hospital settings argue for designated fever clinics, observation space, adjusted staffing, strengthened triage, stock monitoring, and linkage of clinical operations with real-time surveillance data (2, 74). These recommendations are largely guideline-based or operational rather than trial-proven; however, they are consistent with ecological evidence from Brazil suggesting that stronger outpatient performance, early monitoring, and learning from hospitalization patterns are associated with fewer dengue deaths and less severe system stress (73).

Surveillance should trigger clinical preparedness actions rather than operate separately from care delivery. Integrated surveillance systems can support earlier resource allocation, hotspot detection, and operational targeting, and the work on arbovirus preparedness in Brazil argues that surveillance data should inform timely interventions and resource deployment during outbreaks (75). The same logic supports routine review and trend analysis at the facility level, which in Nepal was associated with better readiness, while broader resilience literature argues that systems perform better when they continuously monitor, anticipate, and learn rather than mobilizing only once a crisis is obvious (67, 73). Parallel outbreak systems that vanish after emergency funding are therefore a poor model; dengue readiness should reinforce enduring primary care capacities in triage, monitoring, referral, and patient communication, which also improves care for malaria, sepsis, and other acute febrile illnesses (64, 73).

Preparedness should finally be judged through performance indicators that measure whether care was delivered correctly. Practical metrics include documentation of illness day and vital signs, planned reassessment, discharge instructions, observation records such as fluid balance, pre-referral communication, and maintenance of essential stocks, whereas counting printed guidelines, distributed devices, or completed workshops mainly measures inputs rather than readiness (67, 73). Evidence for formal dengue readiness packages remains much thinner than evidence for individual clinical management, especially in African, rural, fragile, and humanitarian settings; therefore, several recommendations here are extrapolated from implementation, primary-care strengthening, and emergency-care literature rather than from comparative dengue trials (65, 69, 76). Therefore, dengue-ready primary care depends on the dependable performance of a limited number of essential functions across both routine and surge conditions. The remaining challenge is to translate these readiness requirements into feasible, measurable, and sustainable implementation strategies, while identifying the research gaps that continue to limit frontline dengue care. The minimum functional capabilities and pragmatic performance indicators for dengue-ready primary care are presented in Table 2.

Table 2. Minimum functional package and performance indicators for dengue-ready primary care.

The proposed indicators are pragmatic process measures derived from current clinical guidance and implementation evidence. They should be adapted to local disease burden, workforce capacity, service organization, referral arrangements, and data systems and are not presented as universally validated quality standards. Evidence sources are provided within the relevant table rows. CBC, complete blood count; PHC, primary health care; WHO, World Health Organization.

8 Discussion

This review reframes dengue management as a continuous clinical pathway extending from the first presentation and outpatient follow-up to stabilization, referral, and surge preparedness. The main problem is not the absence of guidance but the difficulty in delivering it consistently when diagnostic uncertainty, fluctuating severity, limited monitoring, and weak referral systems converge.

8.1 Integrating clinical risk with primary-care capacity

Hyperendemic and recurrent transmission compress large numbers of clinically similar febrile presentations into frontline services, while only a minority progress to severe disease, creating simultaneous risks of over-admission and missed deterioration (10, 40). In one Vietnamese tertiary referral hospital, most presenting patients were managed as outpatients with daily follow-up, although frequent reassessment remained necessary because disease trajectories were uncertain and patients could move between care settings (68).

Therefore, confirmation of dengue and prediction of deterioration are related but distinct decisions. Reviews from West Africa and tertiary pathway analysis indicate that diagnosis is often constrained by limited testing, co-circulating febrile illnesses, and poor infrastructure, while clinical decision-making still depends heavily on repeated bedside evaluation rather than diagnostics alone (8, 68). Dynamic triage is the organizing principle that connects diagnosis, outpatient review, observation, fluid management, and referral because the most consequential decisions occur at the initial assessment, during emerging complications, and when balancing circulatory support against fluid overload (68).

Standardization remains necessary, but rigid thresholds are unsafe. Systematic reviews support the clinical relevance of WHO warning signs and major risk markers; however, hospital and guideline-based evidence also show that children, patients with diabetes or renal disease, and those with comorbidities require modified thresholds rather than uniform protocol application (33, 52). Primary care preparedness is therefore a clinical intervention because the capacity to monitor, communicate, stabilize, and refer determines whether evidence-based recommendations can improve outcomes. The main contribution of this review is to link bedside risk assessment with facility and referral capability, rather than treating case management and preparedness as separate problems.

8.2 Evidence limitations and transferability

The evidence base is clinically useful but inconsistent. Much of the literature on severity prediction, fluid decisions, and complications comes from tertiary hospitals, single-center cohorts, and admitted populations in Asia or Latin America, and pathway studies explicitly caution that their findings are not directly transferable to other institutions or settings (10, 68). Many studies are retrospective or observational, and cohorts based on hospitalized or laboratory-confirmed dengue likely over-represent more severe illness relative to the far larger group of suspected patients seen in first-contact care (8, 77). In African, rural, and humanitarian settings, adaptation should prioritize functions that remain feasible when laboratory, observation, transport, or referral capacity is limited. Greater emphasis may therefore be placed on illness-day assessment, repeated clinical evaluation, recognition of perfusion abnormalities and warning features, clear safety-netting, and locally feasible follow-up and referral arrangements, while diagnostic testing and monitoring should be used according to available capacity. These adaptations should not be interpreted as lower standards of care, but as context-sensitive approaches to delivering the essential elements of dengue management where resources and access are constrained.

Heterogeneity further limits the transportability. Differences in illness timing, laboratory access, admission practices, and health-system organization complicate comparisons across studies and reduce the portability of prediction tools (6). Operational vulnerability is also underrepresented in prediction research, despite evidence from primary care resilience and community engagement literature that distance, staffing, communication systems, and community participation shape whether follow-up and referral are safe (78, 79). Facility-readiness evidence is even thinner: recent Nepal data show suboptimal readiness in most facilities, but much of the broader literature remains guideline-based, qualitative, ecological, or extrapolated from emergency care and primary health care (PHC) resilience research rather than intervention trials (67, 80). This narrative review is interpretive rather than systematic and did not include formal risk-of-bias assessment or meta-analysis; however, its value lies in integrating otherwise fragmented evidence across diagnosis, triage, management, vulnerability, and preparedness.

8.3 Clinical, implementation, and research implications

Based on this synthesis, we propose a dynamic dengue-readiness framework that integrates four interdependent functions across the clinical pathway: severity-informed triage, scheduled reassessment, phase-adjusted supportive management, and predefined escalation and referral. These functions should be supported by a minimum set of primary-care capabilities, including competent staff, structured documentation, observation capacity, essential diagnostics and supplies, patient communication, referral coordination, and surveillance-linked surge preparedness. The central premise is that dengue outcomes are shaped not only by the accuracy of individual clinical decisions but also by the continuity and reliability of care across successive decision points. This framework is intended as a pragmatic implementation concept rather than a validated clinical prediction tool, and its feasibility, acceptability, and effect on patient outcomes should be evaluated prospectively in resource-constrained settings. For practical use, Figure 1 translates this framework into a simplified clinical pathway, while Table 1 summarizes the essential assessment, management, and escalation decisions required at successive points of care. For practice, the consistent priorities are documentation of illness day, repeated hemodynamic assessment, structured outpatient review, cautious phase-specific fluids, and referral decisions that incorporate biological and operational vulnerability (9, 11). For health services, readiness should be judged by the reliable performance of core processes rather than by the number of trainings, printed guidelines, or devices distributed, because facility meetings, review of trends, supervision, and responsive updating mechanisms appear more relevant to functioning care (67, 81). A phased implementation approach is more plausible than a comprehensive redesign: first, standardize a small set of essential processes, then strengthen observation, follow-up, referral, and surge response, and only then evaluate digital decision support or other tools against strengthened basic care rather than poorly supported usual practice (78, 81). Priority research gaps include primary care validation of simplified triage, minimum safe diagnostic and monitoring packages, outpatient and nurse-led models, referral interventions, facility indicators linked to outcomes, and implementation studies in Africa, rural areas, fragile systems, and humanitarian settings, where preparedness gaps remain substantial (8, 40). The most immediate opportunity is not more complex guidance but more reliable delivery of a limited number of essential functions during routine transmission and outbreak surges. Therefore, the central priority is to move from knowledge of appropriate dengue care to reliable delivery of care across the entire frontline clinical pathway.

9 Conclusion

Hyperendemic dengue creates sustained pressure on frontline services because clinical severity may evolve after an uncomplicated presentation. Therefore, safe care depends not on a single diagnostic or treatment decision but on a continuous clinical pathway that links early recognition, accurate illness-day assessment, dynamic triage, repeated reassessment, phase-specific management, adaptation of thresholds for biologically and operationally vulnerable patients, and timely referral when deterioration exceeds local capacity. This review argues that preventable severe dengue arises as much from failures in continuity, monitoring, communication, and escalation as from the biological behavior of the infection itself. Laboratory confirmation and written guidelines remain important, but they cannot avert clinical decline when primary care facilities lack dependable observation, trained staff, essential supplies, structured follow-up, clear patient communication, and functional referral pathways. Therefore, preparedness should be judged by the consistent delivery of a limited number of essential clinical functions rather than by the nominal availability of protocols, training sessions, diagnostic tests, or devices. Simultaneously, the evidence base remains weighted towards hospital-based studies from Asia and Latin America, with important gaps in primary care, Africa, rural settings, fragile systems, and humanitarian contexts. The immediate priority is not to produce increasingly elaborate guidance but to ensure that frontline services can reliably deliver a feasible core package of dengue care across the full pathway of assessment, monitoring, management, and referral during both routine transmission and outbreak surges.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Footnotes

Edited by: Collins Okoyo, Kenya Medical Research Institute, Kenya

Reviewed by: Adhi Kristianto Sugianli, Padjadjaran University, Indonesia

Edmund Ong, Newcastle University, United Kingdom