Research Article: The Burden of Dengue Fever and Chikungunya in Southern Coastal Ecuador: Epidemiology, Clinical Presentation, and Phylogenetics from the First Two Years of a Prospective Study

Date Published: May 5, 2018

Publisher: The American Society of Tropical Medicine and Hygiene

Author(s): Anna M. Stewart-Ibarra, Sadie J. Ryan, Aileen Kenneson, Christine A. King, Mark Abbott, Arturo Barbachano-Guerrero, Efraín Beltrán-Ayala, Mercy J. Borbor-Cordova, Washington B. Cárdenas, Cinthya Cueva, Julia L. Finkelstein, Christina D. Lupone, Richard G. Jarman, Irina Maljkovic Berry, Saurabh Mehta, Mark Polhemus, Mercy Silva, Timothy P. Endy.


Here, we report the findings from the first 2 years (2014–2015) of an arbovirus surveillance study conducted in Machala, Ecuador, a dengue-endemic region. Patients with suspected dengue virus (DENV) infections (index cases, N = 324) were referred from five Ministry of Health clinical sites. A subset of DENV-positive index cases (N = 44) were selected, and individuals from the index household and four neighboring homes within 200 m were recruited (N = 400). Individuals who entered the study, other than the index cases, are referred to as associates. In 2014, 70.9% of index cases and 35.6% of associates had acute or recent DENV infections. In 2015, 28.3% of index cases and 12.8% of associates had acute or recent DENV infections. For every DENV infection captured by passive surveillance, we detected an additional three acute or recent DENV infections in associates. Of associates with acute DENV infections, 68% reported dengue-like symptoms, with the highest prevalence of symptomatic acute infections in children aged less than 10 years. The first chikungunya virus (CHIKV) infections were detected on epidemiological week 12 in 2015; 43.1% of index cases and 3.5% of associates had acute CHIKV infections. No Zika virus infections were detected. Phylogenetic analyses of isolates of DENV from 2014 revealed genetic relatedness and shared ancestry of DENV1, DENV2, and DENV4 genomes from Ecuador with those from Venezuela and Colombia, indicating the presence of viral flow between Ecuador and surrounding countries. Enhanced surveillance studies, such as this, provide high-resolution data on symptomatic and inapparent infections across the population.

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The region of the Americas is facing an unprecedented public health crisis of co-occurring epidemics of illness due to dengue virus (DENV), chikungunya virus (CHIKV), and Zika virus (ZIKV). These arboviruses cause acute febrile illness and are transmitted to humans by the female Aedes aegypti and Aedes albopictus mosquitoes.

From January 1, 2014 through December 31, 2015, we recruited 324 index cases with suspected DENV infections from the five clinical sites in Machala, Ecuador (Figures 1 and 2). A subset of 310 index cases (186 in 2014 and 124 in 2015) had valid test results and were included in this study (Table 1). A total of 72 index cases were positive by NS1 RT, and from these, we randomly selected 44 initiate index cases, from which 400 associates were recruited into the study. A subset of 384 associates (298 in 2014, 86 in 2015) had valid test results and were included in this study.

In this study, we characterized the epidemiology and clinical characteristics of DENV and CHIKV infections, and the phylogenetics of DENV through an enhanced surveillance study design in an endemic region. We found that the burden of SA DENV in associates was greatest in children aged less than 10 years. In 2014, for every SA DENV infection detected by passive surveillance (initiate index cases), we detected an additional three AR DENV infections in associates by active surveillance. Two-thirds of associates with acute DENV infections presented with dengue-like symptoms. The prevalence of DENV decreased from 2014 to 2015 with the emergence of CHIKV. Genetic analyses indicate that there is movement of the DENV between Ecuador and neighboring countries, highlighting the importance of sentinel surveillance sites, such as Machala, in border regions. The rapid surveillance methods developed in this study could be applied to estimate the burden of other underreported febrile diseases, allowing the public health sector to more effectively and equitably conduct disease control interventions.




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