Guidelines for clinical management of arboviral diseases: dengue, chikungunya, Zika and yellow fever

What this guideline says

GMJ summary

These guidelines provide the first comprehensive GRADE-methodology recommendations for managing dengue, chikungunya, Zika and yellow fever. They address both non-severe (outpatient) and severe (hospitalized) disease, recognizing that clinical differentiation between arboviruses is often impossible at presentation, particularly in resource-limited settings without rapid diagnostics.

Key recommendations include using crystalloids over colloids for intravenous resuscitation, measuring capillary refill time and lactate to guide fluid therapy, and avoiding NSAIDs due to bleeding risk. For symptom control, paracetamol or metamizole are suggested; corticosteroids are not recommended for non-severe disease. For yellow fever with liver failure, N-acetylcysteine is suggested while specific antivirals remain investigational.

The guidance emphasizes that most evidence derives from dengue studies but is applied across arboviruses given diagnostic uncertainty at presentation. Recommendations balance benefits and harms in the context of limited certainty evidence, with strong emphasis on individualized clinical decision-making and careful monitoring to prevent both under- and over-resuscitation.

Key points

For clinicians — doses and thresholds as stated in the guideline

1. Protocolized oral fluids (measured intake, ~3000 ml/24h in adults) suggested for non-severe disease to potentially reduce hospitalization
2. Paracetamol 500 mg–1 g every 4–6 hours (max 4 g/day adults; 10–15 mg/kg every 4–6h in children, max 60 mg/kg/day) suggested for fever/pain
3. NSAIDs strongly recommended against in all suspected arboviral disease (any severity) due to bleeding risk, unless dengue definitively ruled out
4. Crystalloids recommended over colloids for IV resuscitation in severe disease; colloids associated with 27 more adverse events per 1000 patients
5. Capillary refill time >3 seconds (measured on index finger at heart level, 10-second pressure) recommended to guide IV fluid therapy
6. Lactate monitoring (target ≥10–30% decrease every 2 hours) recommended to guide resuscitation where available; unreliable in liver failure
7. Passive leg raise test (cardiac output increase >10%) suggested when uncertain if more IV fluids warranted in shock
8. Prophylactic platelet transfusion not recommended for thrombocytopenia <50,000/µL without active bleeding; corticosteroids and IVIG not recommended for severe disease

Recommendations summary by disease severity

Table extracted from the guideline

Source: World Health Organization, Guidelines for clinical management of arboviral diseases: dengue, chikungunya, Zika and yellow fever. Reproduced in summary form.

What changed in this edition

Versus the previous edition

• First WHO global guideline using GRADE methodology for arboviral disease management; previous guidance was expert opinion-based
• Supersedes all specific recommendations in Dengue guidelines for diagnosis, treatment, prevention and control (2009)
• Integrates evidence across four arboviral diseases (dengue, chikungunya, Zika, yellow fever) recognizing diagnostic uncertainty
• Strong recommendation against NSAIDs replaces previous conditional guidance, based on bleeding risk despite low certainty evidence
• New recommendations on fluid resuscitation monitoring (CRT, lactate, PLR) based on sepsis literature applied to arboviral context
• Explicit recommendations against corticosteroids and IVIG where previously practice varied by region

From the guideline

Verbatim

“WHO recommends against the use of non-steroidal anti-inflammatory medications (NSAIDs) in patients with acute suspected or confirmed arboviral disease, irrespective of severity.”

Editor’s perspective

Why this matters for Georgia and the region

Applicability

Georgia and the South Caucasus

Questions this guideline answers

Quick answers

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Interconnected resources

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