Dengue Clinical Practice Guideline from Household to Hospital: A Case Study of Development and Evaluation in Southern Thailand

Dengue is an important health problem in southern Thailand. However, the area has a surveillance-only prevention system, and there are no continuing guidelines for dengue treatment from households to primary care units (PCUs) or district hospitals. The objectives were to develop and evaluate the dengue clinical practice guideline (DCPG) from household to hospital. The study design used community participatory action research that integrated the IOWA model in 44 villages in the Lansaka district of southern Thailand. The DCPG was developed and tested with 26 health providers in five steps: 1) community preparation, 2) development of the guidelines, 3) use and monitoring, 4) evaluation and conclusion, and 5) referring technology. The questionnaires for evaluating opinion, knowledge, and practice contained 84 items. The content validity was verified by three experts (CVI= 0.80), and reliability was verified by 30 participants (Cronbach’s alpha = 0.90). The Wilcoxon signed rank test was used to compare the situation before and after the use of DCPG, and guidelines were developed with accompanying diagrams.


Abstract Background
Dengue is an important health problem in southern Thailand. However, the area has a surveillance-only prevention system, and there are no continuing guidelines for dengue treatment from households to primary care units (PCUs) or district hospitals. The objectives were to develop and evaluate the dengue clinical practice guideline (DCPG) from household to hospital.

Methods
The study design used community participatory action research that integrated the IOWA model in 44 villages in the Lansaka district of southern Thailand. The DCPG was developed and tested with 26 health providers in five steps: 1) community preparation, 2) development of the guidelines, 3) use and monitoring, 4) evaluation and conclusion, and 5) referring technology. The questionnaires for evaluating opinion, knowledge, and practice contained 84 items. The content validity was verified by three experts (CVI= 0.80), and reliability was verified by 30 participants (Cronbach's alpha = 0.90). The Wilcoxon signed rank test was used to compare the situation before and after the use of DCPG, and guidelines were developed with accompanying diagrams.

Results
Two results were found: 1) DCPG consisted of four steps: guidelines at households, primary care units, outpatient departments and emergency rooms, and inpatient departments in hospitals. A total of 39 dengue patients were divided into 20 cases admitted for IPD; observation at home, 18 cases; and one patient referred to province hospital; with no deaths during the study period. 2) The 26 health providers from the PCUs and hospital increased their knowledge, and attitude increase was not significantly different ( P>0.05 ). The 5 components of practice increased significantly ( P<0.05 ), but the practice of only taking intravascular fluid was not significantly different ( P>0.05 ).

Conclusion
DCPG was an appropriate dengue solution from household to hospital. However, all stakeholders need to participate, integrate, and coordinate for continued use, monitoring and evaluation.

Background
The pathology of dengue is not fully understood; there are two main factors: 1) increased vascular permeability resulting in plasma leakage, hypovolaemia and shock and 2) abnormal haemostasis due to vasculopathy, thrombocytopenia and coagulopathy, leading to various haemorrhagic manifestations. There are four serotypes of dengue viruses, DEN 1, DEN 2, DEN 3, and DEN 4, which are transmitted by Aedes aegypti mosquito [1]. There have been more than 200 outbreaks in tropical zones and subtropical zones. An estimated 2.5 billion people are at high risk infection, and signs and symptoms have been observed in 50-100 million people. A total of 20,000 fatal cases of dengue are found in every 100,000 dengue cases [2,3]. The severity of dengue could be death because of nonspecific treatment, and its threats followed signs and symptoms. However, dengue patients with dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS) have a shock stage of 44% and a mortality rate of 1-5% from of overload intravascular fluid [2], respectively.
Although there are serious efforts for dengue prevention, the effects of dengue fever are still very severe. There are many related factors, such as specific treatment, unspecific dengue vaccine development and acceptability [4], insecticide resistance [5], and climate change [6]. Social, demographic and environmental factors strongly influence the transmission patterns of vector-borne pathogens, with major outbreaks of dengue since 2014 [7]. Moreover, socioeconomic factors that increase dengue outbreaks include the lifestyle of humans in the community and population density [8]. Then, the cost impact of dengue incidence and mortality rate from populations who had symptomatic dengue cases found 36 million populations per year in the world. There were 12 countries in southeast Asia in 2001-2010 that had dengue morbidity of 2.9 million, and the mortality of 5,906 patients per year results in the loss of 950 million ($US) per year [9]. Moreover, the disability adjusted life year (DALY) was responsible for 1.14 million (0.73 million-1.98 million) disability-adjusted life-years in 2013 [10]. As such, the dengue solution needs to prevent morbidity and use the appropriate treatment to decrease mortality.
The World Health Organization (WHO 1997) [1] set the guidelines for dengue diagnosis and treatment as the traditional/original classification into 3 types: 1) DF, 2) DHF and 3) DSS [1]. It was almost always used in children, but there are limitations to patient classification in primary care settings, such as HCT [11]. Some units do not have equipment or repeat testing, and some time tourniquet tests do not identify the status of plasma leakage and bleeding [12,13]. The WHO 2009 [2] then issued new guidelines and treatments that define the three groups: 1) group A is dengue infection (probable dengue): travelling in the dengue outbreak area, two signs, and laboratory tests. 2) Group B is dengue with warning signs: DW has risk signs such as abdominal pain, continuous vomiting, increasing HCT, and decreased platelets. 3) Group C is severe dengue with leakage of plasma, bleeding, and dysfunction of several organs such as liver and kidney.
However, a comparison of the guidelines of a dengue study found that the WHO 2009 guidelines are less complicated than other guidelines due to easy classification and case management [14]. Moreover, the 2009 WHO guidelines are an accurate standard that presented a sensitivity of 59-98% and a specificity of 41-99%. However, the 1997 WHO dengue guidelines had a sensitivity of 24.8-89.9% and specificity of 25%-100% [12].
However, the 2009 WHO dengue guidelines may be inappropriate for poor countries that lack equipment, personnel, and resources. Because of the criteria of dengue diagnosis for admission to the hospital, every patient needs laboratory tests when they have warning signs. Then, there were several more cases in the hospital that lacked health care providers in some context. In addition, there was showed 20-30% of DSS cases had no warning signs [15]. A study suggested that the dengue guidelines need to be appropriate in the context, and health care providers should be educated on the guidelines for health care (warning signs) [16]. Health care providers must have the capacity to diagnose signs and symptoms of dengue patients (Gibson et al., 2013;WHO, 2009b). Thus, the DCPG needs to be integrated between evidence-based data and the context of the health care system for development, use and monitoring, which relates to the concept of the IOWA model and participation of all stakeholders [17].
Health providers have the role of dengue diagnosis and treatment at the primary and secondary health care level and referral system [2]. A research study that interviewed 236 dengue patients found that 83.9% went to primary care hospitals, with a mean length of stay of 1.4 days; they visited several health care units (68.7%), received the education regarding dengue prevention (96-98%), described with drug use (94.9%), drank water (79.7%), dengue infection (51.9%), and had blood tests [16]. A related study showed that health care providers need to develop skills and knowledge dengue disease, cause of infection, signs and symptoms, and complications of disease [14] related to dengue clinical practice, which can be used for decreasing severity and mortality rate [2].
In Thailand, the clinical dengue classification is based on the WHO 1997 guidelines (DF/DHF/DSS model), and the disease is divided into three phases: 1) fever phase: acute fever onset that is high and continuous and lasts 2 to 7 days; 2) critical /shock phase: 1/3 of patients in the fever decreasing range. The shock stage is characterized by rapid and weak pulse with narrowing of the pulse pressure or hypotension, cold, clammy skin and restlessness. These signs and symptoms are emerging leakages of plasma into the pleural and peritoneal cavities as hypovolemic shock within 24-48 hours (hrs.). In this phase, there is thrombocytopenia and haemoconcentration from decreasing platelets. Then, 3) the leakage of plasma stops in the convalescent phase, and it enters the vascular vessels, and pulse and blood pressure revert to normal, urine production increases, and pleural effusion occurs if the patient has severe shock [3,18]. Based on these signs and symptoms, health providers need to correctly assess, diagnose, and treat dengue to decrease the length of stay and complications [16] because the death rate of dengue patients is 30% [14]. A study showed the necessity of appropriate health provider treatment and/or evidence-based management guidelines [19]. Then, the area needs to develop the appropriate DCPG. According to the above mentioned studies, dengue is an important health problem in the Lansaka district. However, the area has had the surveillance-only prevention system, and they do not have the continuing guidelines for dengue treatment from households to PCUs or district hospitals. To address the dengue problem solution, this research study had two objectives: 1) to develop and 2) to evaluate a DCPG connecting households, PCUs and district hospitals.

Methods
The study design used an integrated IOWA model and community participatory action The population and participants were divided into three groups as follows: 1) The supportive group included the director of community hospital, head official in district public health, director of the PCUs, and community leaders.
2) The health provider group included government officials in primary care related to dengue solutions in the district, such as public health officials of health promotion hospitals, nurse practitioners, and registered nurses.
3) The dengue patient group included dengue patients who received care service with the dengue clinical practice guideline.
The process of developing the DCPG showed that the conceptual framework of the study used the IOWA model of evidence-based practice to promote quality care) [17] and was divided into 5 phases: 1) The preparation phase identified the situation of practice and knowledge in the organization. The assessment consisted of (1) problem-focused triggers related to dengue issues, such as dengue problems, risk of dengue patient care management, dengue clinical practice guidelines, dengue patient referral systems, and standards for nursing 3) The testing and monitoring phase included the participation of all health professionals using the DCPG of 8 PCUs in the district.
4) The evaluation and conclusion of the DCPG phase included the routine work in 8 PCUs and connected the referral system from household to PCU and district hospital.
5) The technology phase consisted of referring the DCPG to health providers in other districts that are interested. All five steps are shown in Fig. 1.
Questionnaire for measurement before and after using DCPG The validity index and measure of reliability (Cronbach's alpha) from the questionnaire were 0.93 and 0.87, respectively. The content validity was checked by 3 experts. The measure of reliability was conducted on a sample of 30 nurses in Nakhon Si Thammarat province. The components of the questionnaire included 1) sociodemographic characteristics, 2) opinion, 3) knowledge, 4) practice from 6 perspectives, and 5) availability of equipment, medical supplies and support.
Dengue opinion components consisted of ten questions about viewpoints of the severity, prevention and primary care of dengue fever. The opinion was divided into positive opinions when answering "yes" and negative opinions when answering "no", and they could answer "unknown" if they had no opinion. Dengue's knowledge components included 14 questions about dengue patient care as causes, signs and symptoms. The health provider's knowledge was divided into correct, incorrect, and unknown. The basic practice if they met dengue patients comprised 47 questions that were divided into 6 aspects. The rating scale consisted of 5 levels in which every time (100% practices if met dengue patient), almost time (60-99% practices if met dengue patient), sometime (1-50% practices if met dengue patient), no action (0% practice if met dengue patient), and N/A (no appearance of meeting dengue patient). The aspects of dengue patient care were as follows: 1) initial assessment of primary care, 2) practices in the first 2 days of fever, 3) practice in diagnosing dengue fever shock patients, 4) practice in intravenous infusion, 5) practice in referring patients, and 6) guidance practice to prevent dengue fever.

Data analysis
Data were analysed, and the personal information with descriptive statistics (frequencies, percentages) and the scores of opinion, knowledge, and practices before and after using dengue clinical practice guidelines were compared with the Wilcoxon signed rank test. The steps of the dengue solution guidelines were developed and accompanied by diagrams.

Results
1. The dengue clinical practice guideline (DCPG) from household to hospital DCPG was used for 12 weeks (June-August 2017), with 39 dengue patients who were admitted to Lansaka Hospital (72%) from the total dengue patients (54 cases) reported in the area by Nakhon Si Thammarat province's public health officials. They were divided into 16 males and 23 females, with ages ranging from 3 to 66 years and an average age of 23 years. The signs and symptoms of 39 cases were fever (39 patients), weakness (8 patients), nausea (5 patients), headache (5 patients), stupor (3 patients), and eating less than normal (5 patients). The 39 dengue patients admitted to the IPD were divided into 30 cases visiting directly to the OPD, 4 cases visiting the ER of the district hospital, and 5 cases visiting the PCU 2 .
All 30 dengue patients visited the OPD and were divided into the OPD 1 (go back home for continuous observation) (9 cases) and OPD 2 (admitted to IPD 1 ) (20 cases), and one patient was referred to the province (tertiary) hospital. For the 20 patients who visited the IPD 1 , a care map plan and DCPG grades I and II and fluid replacement guidelines were used based on disease severity. The implementation of DCPG covered eight PCUs and Lansaka Hospital. The dengue morbidity rate at 12 weeks was 124 cases/100,000 populations (54 cases), and there was no mortality rate or severe complications, such as prolonged shock.
However, the DCPG's record form of the PCUs needs to be completed. Finally, the new lines of dengue patient care are from the household to the district hospital, and they can possibly go to province hospital. Then, the conclusion of DCPG consisted of four steps of the guidelines related from household to hospital. The second step was dengue clinical practice guidelines at the PCUs. If fever lasted > 48 hrs. and/or weakness, nausea, and vomiting were present, the patient needed to go to the primary care unit. There were two patterns: 1) PCU 1 refers to a district hospital if fever ≥ 48 hr. Health care providers need to test (1) HCT. If weakness increased, and there was no fever, (2) the haemogluco test (HGT/DTX) was performed; if the patient showed signs of shock, (3) the tourniquet test ≥ 10 points/in² was performed; (4) assess signs of hypovolemic shock and bleeding, (5) fluid replacement following DCPG, and (6) practice following PCU 2 . 2) PCU 2 needs continuous observation if fever <48 hrs., (1) give only paracetamol 10-15 mg/kg/dose, may be repeated every 4-6 hrs., (2) demonstration with tepid sponge, drinking fluid juice, electrolyte solution and voiding red or black food, and 3) avoiding mosquito bite, using lotion, and destroying mosquito breeding site.
The third step was dengue clinical practice guidelines at the outpatient department (OPD) and emergency room (ER) in secondary care hospital (Lansaka hospitals). Patient care at the OPD and ER for assessing signs of hypovolemic shock and bleeding included PE, BT, PR, RR, BP, shock signs, tourniquet test, and CBC (WBC < 5,000 cell/mm 3 ). There were two options in OPD and IPD in that each channel was divided into 3 patterns: Dengue patient care at OPD consisted of 1) OPD 1 : for dengue patients, health assessment and screening were needed for advising and continuing observation; 2) OPD 2 : health assessment and DHF diagnosis for admission to IPD in district hospitals; and 3) OPD 3 : health assessment showed severe signs and symptoms as DSS and the patients were sent to tertiary (province) hospital. Dengue patient care occurred in the ER when dengue patients visited the hospital from 16.00 pm. to 8.00 am. There were three patterns: 1) ER 1 pattern was health assessment and discharge to go home for observing dengue signs and symptoms, 2) ER 2 : taking health assessment and diagnostic DHF for admission to the IPD in secondary hospitals, and 3) ER 3 pattern was a health assessment and diagnosis of dengue with severe symptoms and sending them to a tertiary hospital.

The fourth step was dengue clinical practice guidelines in the patient department
(IPD) at the secondary care hospital. There were two patterns that consisted of 1) IPD 1 treatment with a care team, such as Care Map, as the dengue practice guideline in grades I and II and dengue infection, guideline of fluid replacement in dengue grades I and II, and filling out referral form and recording intake and output of fluid, 2) the IPD 2 pattern was a guideline for severe dengue or dengue grades III and IV, which are referred to province hospital with the referral form. The guidelines for dengue prevention and control in the community and clinical practice guidelines in primary-to the tertiary care (province) hospital (Maharaj nakhon si thammarat hospital) need to be integrated and communicated to all stakeholders. Moreover, SRRT needs to monitor the outbreak situation at the case index of dengue fever in the community as community mobilization and perform outbreak activity as soon as the case index of fever is known. Figure 2 2. The evaluation of health providers' opinions, knowledge, and practices for dengue patients after using DCPG from households to hospitals The implementation of DCPG was preparedness for the research team, and 26 participants from eight PCUs consisted of professional nurses and health care officials of district hospitals. However, tertiary level hospitals support fast channels for referring critical cases of dengue. All documents, such as the DCPG manual, flow chart, and dengue manual, were prepared. DCPG was conducted over three months (June-August 2017).
During the testing period, the monitoring and support by the research team was completed one month before and after the opinion, knowledge and practice of DCPG in 12 weeks for the use of DCPG.

Personal information of health providers
There were 26 health providers who were representative of eight PCUs and district hospitals. There were five phases and testing before and after using DCPG.

Dengue's opinion of health providers before and after using the DCPG from household to hospital
The dengue's opinions mean awareness/perception of the severity and impact of dengue disease. They showed positive opinion in 9 items from a total of 10 items, with almost all answers "yes". Only item number 9 was negative, with "Quick notification of health officials in 72 hrs. as soon as dengue patients were found". Item number 10 showed an increasing positive significant statistic after using DCPG (p<0.05) ( Table 1).

Health providers' knowledge of dengue before and after using DCPG from household to hospital
The comparison of 26 health providers' dengue knowledge for 14 items found that three items, 2, 4, and 10, were significantly different before and after development guidelines were implemented (p<0.05). The differences in 11 items of dengue knowledge were not statistically significant (p>0.05) ( Table 2).

Practices for dengue patients before and after DCPG
1) Practice to initially assess patient visits to the PCU/hospital for screening dengue infection. The results showed that most of the practices to initially assess patients were significantly different (p<0.001). It showed frequency of activities after more than before using DCPG, such as (1) vital signs (T, P, R, BP); (2) body weight, length (if children); (3) tourniquet test for investigation platelets; (4) history of related dengue infection, such as friend or family member, and those who were contacted in 2 weeks; (5) assessment sign and symptoms of dengue, such as headache, myalgia, eye pain, positive tourniquet test and CBC, and if fever was more than 2 days (Table 3).
2) Basic practice if the health care practitioner met dengue patient in 2 days. There were practices if health care practitioners met dengue patient in first 2 days of the fever phase, and the difference was statistically significant (p<0.001). The results showed frequency of practice after more than before using DCPG, such as (1) dehydration assessment, (2) force drinking fluid and fruit juice, (3) take paracetamol 10-15 mg/kg/dose repeated every 4-6 hr, (4) take antipyretic drug if high fever ≥ 38 °C, (5) caution invasive of treatment and fall, (6) drink fruit juice or mineral fluid if patient was dehydrated, and (7) do not take aspirin (Table 4).
3) Practice guidelines for dengue diagnosis with the dengue shock phase, with drowsy sign after 3 days, showed the 12 practices if health providers met patients on after more than before using DCPG was statistically significant for every item (p<0.001), such as (1) assess decreasing of fever and no alert, (2) bleeding status such as petechial, 3) severe vomiting and abdominal pain, (4) continuous severe thirst, (5) drowsy and not drinking water, (6) fidgeting or fumbling if the child cries, (7) cold hands and feet sweating, (8) little urine or no urination for more than 4-6 hours, (9) measure body temperature 39°C, (10) diastolic and systolic blood pressure were narrow at 20 mmHg, (11) evaluate the wrist pulse for light, fast, or not catching, and (12) evaluate immediately whether cold or striped body and test HCT., deliver blood sugar intravenously, and ready to be delivered to the hospital immediately (Table 5).

4) Practice guidelines for administering intravascular fluid for initial resuscitated
shock. Three items were different in practice if they met patients (p <0.01) (item 1). A 5% D/NSS IV drip rate of 120 cc/hr was used (30 drop/minute) for adult patients or children ≥ 6 years, and they were then referred to the tertiary hospital (item 2). A 5% D/NSS IV rate of 60 cc/hr was used (15 drop/minute) for children < 6 years, and they were then referred to tertiary hospital. A 0.9% NSS IV drip was taken in 5-10 minutes in dengue shock, which did not measure BP (item 3). After that, a pulse should decrease the IV rate to 60 cc/hr, and then the patient should be referred to a tertiary hospital. Referral to the tertiary hospital stat, if dengue was found in a patient with weakness and blood pressure was not different before and after DCPG (item 4) ( Table 6).

5)
Practice if health care provider met the patient following the practice guideline for referral to tertiary (province) hospital. Comparison between before and after using practice if the patient met the practice guideline for referral to province hospital found that the practices were increasing after using DCPG and were statistically significant (p<0.001) in 6 of 8 sub-items of activities in number 3 (criteria for referral a severe dengue patient), and they can increase the practice "Go with patient during referral to province hospital". 6) Practice if met patient following the guideline of suggestion for dengue prevention. Participants followed the practice if they met patient every time for all 8 activities both before and after. The differences between before and after for three activities were statistically significant (p<0.001), including item (1) "Suggestion with prevention mosquito bite", (2) "Report dengue case index (Report 506 of Control Disease Centre, Thai Ministry of Public Health)", and (6) "Monitoring BI, HI, and CI in community for dengue outbreak prevention". In addition, three activities increased significantly (p<0.01), including (3) "Communicating the dengue control information for local organization administration such as fogging insecticide radius 100 metre around house index", (4) "Monitoring dengue case in the area around house of case index in 28 days", and (5) "Communicating and enhancing the community for destroying mosquito breeding site every 7 days" (Table 8).

Evaluation of the preparedness of the medical equipment and supplies for dengue treatment in the PCUs and secondary care hospital.
The medical equipment and supplies for dengue treatment were significantly increased after DCPG was used, such as "Mercury sphygmomanometer and cuff 3 level" and "Blood glucose metre" (P<0.01), and "Health care providers were trained with dengue clinical practice guideline" (p<0.05). However, "5% D/NSS or 5% DLR or 5% DAR capacity 500 cc", "Dengue case management manual", and "Dengue clinical practice guideline in primary care unit" were not significantly increased after DCPG was used. In addition, "Haematocrit centrifuge" and "Set IV fluid, Medicut No. 18, 20, 21, 22, and 23" did not change between before and after (Not Table).

Discussion
The results of the first objective were a DCPG from household to hospital consisting of patient DCPG development and the four steps of DCPG after testing. The DCPG appropriated the context of people in 44 villages in 5 sub-districts because it was developed based on the five steps of the IOWA model [17] and WHO 1997 [3]. Then, guidelines based on dengue knowledge were divided three phases: 1) fever phase: acute fever onset high and continuous lasting 2 to 7 days; 2) critical /shock phase: 1/3 of patients in the fever decreasing range. The shock stage is characterized by rapid and weak pulse with narrowing of the pulse pressure or hypotension and cold, clammy skin and restlessness. These signs and symptoms are emerging leakages of plasma into the pleural and peritoneal cavities as hypovolemic shock within 24-48 hrs. 3) the convalescent phase stops leakage of plasma, but it enters the vascular vessel, and pulse and blood pressure revert to normal, urine production increases, and plural effusion occurs if the patient has severe shock [3, 18].
The DCPG is specific guidelines relating four steps, such as guidelines in households for prevention, eight PCUs, OPD and ER, and IPD in Lansaka hospital. In the following steps of DCPG in 12 weeks, 39 dengue patients were used to follow the treatment steps from household to hospital. It was only 70% of the total patients (54 dengue patients) at this time, and almost all dengue patients directly visited the OPD/ER of the hospital. Because of there were stays near the hospital and easy travel to hospitals by themselves. However, 30% (15 dengue patients) did not participate in the DCPG because they could go to any other clinic/health centre/hospital. This is consistent with the results of a study that found that 83.9% went to primary care hospitals, and 68.7% visited several health care units [16]. However, the signs and symptoms of 39 cases were fever (39 patients), weakness (8 patients), nausea (5 patients), headache (5 patients), stupor (3 patients), and eating less than normal (5 patients). All patients had the signs and symptoms of dengue diagnosis when fever was more than 48 hr. and needed to go to the PCU 1,2 . Then, they were assessed and diagnosed with dengue and admitted to the IPD district hospital, with decreased WBC, platelet and HCT. following the pathology of dengue [1][2][3].
According to the testing of DCPG with 39 dengue patients in each phase, patients had mild levels of signs and symptoms and then received the initial treatment. Moreover, they directly visited the district hospital, and they did not delay diagnosis or treatment. Then, the DCPG included four steps that integrated the district context, WHO 1997 case by experience because a laboratory is needed for diagnosis [12], health providers in Thailand have been trained using dengue classifications of DF/DHF/DSS since WHO 1997 in Thailand for a long time, and they have accepted and perceived user-friendliness of the local DCPG, which has been integrated and applied in the local context [1,15].
The local DCPG is an easy guideline for dengue patient understanding but follows Thai Ministry of Public Health guideline, WHO 1997 and 2009 dengue case classifications. A study suggests that the dengue guidelines need be appropriate in the context, and health care providers need to be trained on the new guidelines (warning signs) [16]. All four steps describe the role of health providers in the primary care level in the context.
The second objective was evaluation the results of opinion, knowledge, and practices before and after using DCPG. The 26 health providers increased their dengue opinion and knowledge after testing DCPG, but it did not differ significantly. It may be that the content Practices for dengue patients before and after using DCPG included 6 perspectives of practice guidelines: 1) initial assessment of patients at the household, 2) basic practice for dengue infection in 2 days of fever at the PCUs/district hospital, 3) shock resuscitation, 4) taking intravascular fluid in initial resuscitated shock, 5) referral to the province hospital, and 6) suggestion for dengue prevention. All perspectives were associated with dengue management of WHO 1997 and 2009 [1][2][3]. The 26 health providers increasing their practice after testing DCPG in 5 perspectives of practice, and the difference was significant (p < 0.05); only taking the intravascular fluid component was not significant (p > 0.05). There were a few critical cases of dengue at the primary care level, and half of the health providers (13 of 26 health providers) were public health officials who were experts with dengue prevention in the community. Moreover, almost 13 nurses who participated in the testing step of DCPG were practising in the PCUs.
Health providers play an important role in providing health care services in communities and hospitals. Adequate knowledge can help health providers provide health education to the general public and patients. Primary care providers were more involved in dengue solution in the community [14,16]. Based on dengue's signs and symptoms, health providers need to correctly assess, diagnose, and treat to decrease the length of stay and complications because they represent 30% of the partial factor for dengue patient death [14]. It showed that the necessity of appropriating knowledge for health provider treatment was consistent with a study of health providers' reflections showing the themes

Ethics approval and consent to participate
The study was approved by the Ethical Review Committee for Research Subjects was received from the Health Science Group of Walailak University, Thailand (protocol number 59/068). Respondents were recruited after giving written informed consent, and written informed consent for participation in the study was obtained where participants are children (under 16 years old) from their parent or guardian.

Availability of data and material
The table of data described in "evaluation the preparedness the medical equipment and supplies for dengue treatment in PCU and district hospital". This Data note can be freely and openly accessed via Appendix A.

Competing interests
The authors declare that they have no competing interests.

Funding
This work was supported by Thai Research Fund and Walailak University (WU-TRF_ABC5905) from October 2016 to September 2017. They did not have any role in the study design, data collection analysis and interpretation and in writing the manuscript.

Availability of data and materials
The dataset used and/or analysed during the current study are available from the corresponding author on reasonable request.

Authors' contributions
Study design, data acquisition and drafting the work were performed by suwanbamrung, C. revised the manuscript by suwanbamrung C, and Cua Ngoc Le. All authors conducted the research, read and approved the analysis, and interpretation of data. Tables Table 1 Dengue's opinion of the health providers before and after using the DCPG from household to hospital  Table 6 Comparison between before and after using practice if met patient following the guideline for taking intravascular fluid for initial resuscitated shock  Figure 1 The 5 phases of developing DCPG based on applying the IOWA model The DCPG after using with 39 dengue patients from household to PCU, district hospital, and province hospital

Supplementary Files
This is a list of supplementary files associated with the primary manuscript. Click to download.
2 Appendix A Availability of data and eterial 130120.docx