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

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Dengue is placing increasing pressure on frontline health services as recurrent transmission, co-circulating serotypes, and expanding outbreaks generate large volumes of clinically similar febrile illnesses. Although most infections remain uncomplicated, deterioration may occur rapidly around defervescence, creating a narrow window in which clinicians must distinguish patients suitable for outpatient care from those requiring observation, stabilization, or referral. This narrative review examines dengue management as a continuous clinical pathway linking early recognition, decision-relevant testing, dynamic triage, phase-specific care, vulnerability assessment, and primary care preparedness in resource-constrained settings. The evidence indicates that diagnostic confirmation and severity prediction are related but distinct tasks: laboratory testing can support diagnosis, but safe disposition depends on repeated assessment of illness day, hemodynamic status, perfusion, urine output, fluid balance, functional decline, and evolving clinical or laboratory trends. Outpatient management should therefore be treated as an active care pathway requiring structured reassessment, explicit safety netting, and feasible return arrangements, while intravenous fluid therapy should be individualized according to disease phase, treatment response, and risk of overload. Children, pregnant and postpartum patients, older adults, people with comorbidities, and those facing transport, communication, or referral barriers, require modified thresholds for observation and escalation. Primary care readiness should be judged by the reliable performance of essential functions, including structured triage, monitoring, patient communication, stabilization, referral coordination, and surveillance-linked surge response, rather than by the nominal availability of guidelines, training, diagnostics, or equipment. However, the evidence remains dominated by hospital-based studies from Asia and Latin America, with major gaps in primary care, Africa, rural settings, fragile systems, and humanitarian contexts. Therefore, the priority is to translate existing clinical guidance into a feasible, consistently delivered frontline pathway across both routine transmission and outbreak surges.

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