Seroprevalence of Dengue Antibodies in Three Urban Settings in Yucatan, Mexico

The TIRS trial: Enrollment procedures and baseline characterization of a pediatric cohort to quantify the epidemiologic impact of targeted indoor residual spraying on Aedes-borne viruses in Merida, Mexico

Aedes mosquito-borne viruses (ABVs) place a substantial strain on public health resources in the Americas. Vector control of Aedes mosquitoes is an important public health strategy to decrease or prevent spread of ABVs. The ongoing Targeted Indoor Residual Spraying (TIRS) trial is an NIH-sponsored clinical trial to study the efficacy of a novel, proactive vector control technique to prevent dengue virus (DENV), Zika virus (ZIKV), and chikungunya virus (CHIKV) infections in the endemic city of Merida, Yucatan, Mexico. The primary outcome of the trial is laboratory-confirmed ABV infections in neighborhood clusters. Despite the difficulties caused by the COVID-19 pandemic, by early 2021 the TIRS trial completed enrollment of 4,792 children aged 2-15 years in 50 neighborhood clusters which were allocated to control or intervention arms via a covariate-constrained randomization algorithm. Here, we describe the makeup and ABV seroprevalence of participants and mosquito population characteristics in both arms before TIRS administration. Baseline surveys showed similar distribution of age, sex, and socio-economic factors between the arms. Serum samples from 1,399 children were tested by commercially available ELISAs for presence of anti-ABV antibodies. We found that 45.1% of children were seropositive for one or more flaviviruses and 24.0% were seropositive for CHIKV. Of the flavivirus-positive participants, most were positive for ZIKV-neutralizing antibodies by focus reduction neutralization testing which indicated a higher proportion of participants with previous ZIKV than DENV infections within the cohort. Both study arms had statistically similar seroprevalence for all viruses tested, similar socio-demographic compositions, similar levels of Ae. aegypti infestation, and similar observed mosquito susceptibility to insecticides. These findings describe a population with a high rate of previous exposure to ZIKV and lower titers of neutralizing antibodies against DENV serotypes, suggesting susceptibility to future outbreaks of flaviviruses is possible, but proactive vector control may mitigate these risks.

A scoping literature review of global dengue age-stratified seroprevalence data: estimating dengue force of infection in endemic countries

BACKGROUND

Dengue poses a significant burden worldwide, and a more comprehensive understanding of the heterogeneity in the intensity of dengue transmission within endemic countries is necessary to evaluate the potential impact of public health interventions.

METHODS

This scoping literature review aimed to update a previous study of dengue transmission intensity by collating global age-stratified dengue seroprevalence data published in the Medline, Embase and Web of Science databases from 2014 to 2023. These data were then utilised to calibrate catalytic models and estimate the force of infection (FOI), which is the yearly per-capita risk of infection for a typical susceptible individual.

FINDINGS

We found a total of 66 new publications containing 219 age-stratified seroprevalence datasets across 30 endemic countries. Together with the previously available average FOI estimates, there are now more than 250 dengue average FOI estimates obtained from seroprevalence studies from across the world.

INTERPRETATION

The results show large heterogeneities in average dengue FOI both across and within countries. These new estimates can be used to inform ongoing modelling efforts to improve our understanding of the drivers of the heterogeneity in dengue transmission globally, which in turn can help inform the optimal implementation of public health interventions.

FUNDING

UK Medical Research Council, Wellcome Trust, Community Jameel, Drugs for Neglected Disease initiative (DNDi) funded by the French Development Agency, Médecins Sans Frontières International; Swiss Agency for Development and Cooperation and UK aid.

Evidence of Ongoing Transmission of Zika Virus in Mérida, Mexico

Since the Zika virus (ZIKV) pandemic in 2015-2017, there has been a near absence of reported cases in the Americas outside of Brazil. However, the conditions for Aedes-borne transmission persist in Latin America, and the threat of ZIKV transmission is increasing as population immunity wanes. Mexico has reported only 70 cases of laboratory-confirmed ZIKV infection since 2020, with no cases recorded in the Yucatán peninsula. Here, we provide evidence of active ZIKV transmission, despite the absence of official case reports, in the city of Mérida, Mexico, the capital of the state of Yucatán. Capitalizing on an existing cohort, we detected cases in participants with symptoms consistent with flavivirus infection from 2021 to 2022. Serum samples from suspected cases were tested for ZIKV RNA by polymerase chain reaction or ZIKV-reactive IgM by ELISA. To provide more specific evidence of exposure, focus reduction neutralization tests were performed on ELISA-positive samples. Overall, we observed 25 suspected ZIKV infections for an estimated incidence of 2.8 symptomatic cases per 1,000 persons per year. Our findings emphasize the continuing threat of ZIKV transmission in the setting of decreased surveillance and reporting.

Seroprevalence of dengue IgG and associated risk factors in symptomatic and asymptomatic adults in Posadas (Misiones, Argentina), 2017-2019

BACKGROUND

Dengue represents a major public health problem in the Americas in general, and in Posadas (Misiones, Argentina) in particular. This study aimed to assess the seroprevalence of dengue virus infection, analyze associated factors, and determine the proportion of asymptomatic cases.

METHODS

This prospective cross-sectional study took place from November 2017 to April 2019 in the High Complexity Laboratory of Misiones, at the School Hospital Dr. Ramón Madariaga in Posadas. A random sample of 301 adults (≥ 15 years) was selected from the electoral registry and stratified by geographical area of residence. Sociodemographic, clinical, and laboratory data were collected by means of a survey and serology. Results were analyzed using multivariable logistic regression.

RESULTS

The median age of the sample was 33 years; 66% were women, and 46.5% had completed at least secondary school. Anti-dengue IgG antibodies were present in 40.2% of the sample (95% confidence interval [CI] 34.5-45.9%), including 90% of those who reported dengue and 20.5% who did not (odds ratio [OR] 33.25, 95% CI 15.46-71.51, p < 0.001). In the multivariable analysis, adjusted for age, group, gender, and vaccination against yellow fever, seropositivity was associated with having relatives with dengue (adjusted OR 3.96, 95% CI 2.18-7.23; p < 0.001).

CONCLUSION

Seroprevalence for dengue in Posadas was higher than estimates based on the notification records, and there was a high proportion of asymptomatic cases. Educational level and having a family member who had suffered from dengue were associated with positive serology.

Cluster Analysis of Dengue Morbidity and Mortality in Mexico from 2007 to 2020: Implications for the Probable Case Definition

Dengue cases and deaths occur frequently in Mexico, although the trend is not uniform across the country. We performed a Spatio-temporal analysis of dengue cases and deaths in Mexico from 2007 to 2020, and clustered states according to whether there was a low, moderate, or high risk of dengue. A total of 501,600 confirmed dengue cases were registered from 2007 to 2020, with 378,122 cases classified as dengue fever (DF) and 123,478 cases classified as dengue hemorrhagic fever (DHF). For each confirmed case, there were 4.68 probable cases. There were 1,230 dengue deaths, with highest numbers reported in 2009, 2012, 2013, and 2019. The number of deaths had a significant correlation (P ≤ 0.01) with DF (r = 0.82), DHF (r = 0.94), and probable dengue cases (r = 0.84). States were clustered using Machine Learning technique according to select indices associated with dengue. Cluster 1 (low risk) primarily contained states in the northwest, northcentral, and east. Cluster 2 (moderate risk) includes states in the northeast. Cluster 3 (high risk) mostly contained coastal states in the southeast, southwest, and west. The generation of the clusters was supported by the Kruskal-Wallis test. A significant difference was found in the incidence, mortality rates, and case-fatality rates of dengue among the clusters (P ≤ 0.01). Notably, cluster 3 contributed 71.4% of the confirmed cases and 89.2% of the deaths. Public health and vector control strategies designed to mitigate the burden of dengue in Mexico should consider the states in cluster 3 as high priority areas.

Demographic and climatic factors associated with dengue prevalence in a hyperendemic zone in Mexico: an empirical approach

BACKGROUND

Many models for predicting dengue epidemics use incidence and short-term changes in climate variables, however, studies in real-life scenarios for correlations of seroprevalence (SP) with long-term climate variables and with integration of socio-economic factors are scarce. Our objective was to analyse the combined correlation between socio-economic and climate variables with the SP of dengue in Mexico.

METHODS

We performed a seroepidemiological ecological study on the Mexican Pacific coast. Dengue SP was estimated by the presence of immunoglobulin G antibodies in 1278 inhabitants. We implemented multiple correlations with socio-economic, climatic and topographic characteristics using logistic regression, generalized linear models and non-linear regressions.

RESULTS

Dengue SP was 58%. The age-adjusted correlation was positive with the male sex, while a negative correlation was seen with socio-economic status (SES) and scholl level (SL). The annual temperature showed a positive correlation, while the altitude was negative. It should be noted that these correlations showed a marked 'S' shape in the non-linear model, suggesting three clearly defined scenarios for dengue risk.

CONCLUSION

Low SES and SL showed an unexpected paradoxical protective effect. Altitude above sea level and annual temperature are the main determinants for dengue in the long term. The identification of three clearly delineated scenarios for transmission could improve the accuracy of predictive models.

Co-Circulation of All Four Dengue Viruses and Zika Virus in Guerrero, Mexico, 2019

A clinical and entomological investigation was performed to identify flavivirus infections in humans and mosquitoes in impoverished areas of Guerrero, a coastal state in southwestern Mexico. A total of 639 patients with acute febrile illness and 830 resting female mosquitoes in low-income communities of Guerrero in 2019 were tested for evidence of flavivirus infection. Sera were collected from all patients and screened at a dilution of 1:20 by plaque reduction neutralization test (PRNT) using dengue virus (DENV)2. A total of 431 (67.4%) patients were seropositive. Sera from a subset of seropositive patients (n = 263) were tested for flavivirus NS1 by enzyme-linked immunosorbent assay. Forty-eight (18.3%) sera contained viral antigen. All NS1-positive sera were titrated and further tested by PRNT using DENV-1 to -4, St. Louis encephalitis virus, West Nile virus, and Zika virus (ZIKV). Seven patients were seropositive for DENV-1, five patients were seropositive for DENV-2, one patient was seropositive for DENV-3, and two patients each were seropositive for DENV-4 and ZIKV. The remainder had secondary flavivirus infections or antibodies to an undetermined flavivirus. Comparative PRNTs were also performed on 60 randomly selected NS1-negative sera, identifying patients seropositive for DENV-2, DENV-3, and ZIKV. The entomological investigation yielded 736 Aedes aegypti and 94 Culex quinquefasciatus that were sorted into 183 pools and 20 pools, respectively. Mosquitoes were assayed for flavivirus RNA by RT-PCR and Sanger sequencing. DENV-2 RNA was detected in three pools of A. aegypti. In summary, we provide evidence for the concurrent circulation of all four DENVs and ZIKV in Guerrero, Mexico. The public health authorities reported no cases of DENV-3, DENV-4, and ZIKV in Guerrero in 2019 and thus, we provide evidence of under-reporting in the region.

Co-infection of Dengue, Zika and Chikungunya in a group of pregnant women from Tuxtla Gutiérrez, Chiapas: Preliminary data. 2019

INTRODUCTION

Dengue, Zika and Chikungunya are RNA Arboviruses present in some areas of Mexico, mainly in the endemic state of Chiapas that is characterized by presence of the vector that transmit them and an ecology that favors high transmission. According to the national epidemiological surveillance system, Dengue has intensified since 2018 and outbreaks continue in various states while for Zika and Chikungunya a decrease in cases has been reported in recent years. The main objective of this study was to determine the incidence of Dengue, Zika and Chikungunya infections during pregnancy in the state of Chiapas.

PRINCIPAL FINDINGS

The presence of previous and current infections and coinfections diagnosed by molecular (RT-PCR) and immunological (ELISA for IgG determination) techniques indicates a wide circulation of viruses in asymptomatic people, specifically in pregnant women showing that silent infections in dry season contributes to the preservation of viruses.

CONCLUSIONS

From 136 studied samples, 27.7% tested positive for DENV, 8% for ZIKV and 24.1% for CHIKV by RTPCR and the values of IgG in sera show that 83.9% were positive for IgG antibodies against DENV, 65% against ZIKV and 59.1% against CHIKV. Results demonstrated presence of ZIKV and CHIKV, not detected by the epidemiological surveillance system, so the importance of establishing proactive epidemiological systems more strict, especially because these infections in pregnant women can cause severe health problems for newborn children.

The TIRS trial: protocol for a cluster randomized controlled trial assessing the efficacy of preventive targeted indoor residual spraying to reduce Aedes-borne viral illnesses in Merida, Mexico

BACKGROUND

Current urban vector control strategies have failed to contain dengue epidemics and to prevent the global expansion of Aedes-borne viruses (ABVs: dengue, chikungunya, Zika). Part of the challenge in sustaining effective ABV control emerges from the paucity of evidence regarding the epidemiological impact of any Aedes control method. A strategy for which there is limited epidemiological evidence is targeted indoor residual spraying (TIRS). TIRS is a modification of classic malaria indoor residual spraying that accounts for Aedes aegypti resting behavior by applying residual insecticides on exposed lower sections of walls (< 1.5 m), under furniture, and on dark surfaces.

METHODS/DESIGN

We are pursuing a two-arm, parallel, unblinded, cluster randomized controlled trial to quantify the overall efficacy of TIRS in reducing the burden of laboratory-confirmed ABV clinical disease (primary endpoint). The trial will be conducted in the city of Merida, Yucatan State, Mexico (population ~ 1million), where we will prospectively follow 4600 children aged 2-15 years at enrollment, distributed in 50 clusters of 5 × 5 city blocks each. Clusters will be randomly allocated (n = 25 per arm) using covariate-constrained randomization. A "fried egg" design will be followed, in which all blocks of the 5 × 5 cluster receive the intervention, but all sampling to evaluate the epidemiological and entomological endpoints will occur in the "yolk," the center 3 × 3 city blocks of each cluster. TIRS will be implemented as a preventive application (~ 1-2 months prior to the beginning of the ABV season). Active monitoring for symptomatic ABV illness will occur through weekly household visits and enhanced surveillance. Annual sero-surveys will be performed after each transmission season and entomological evaluations of Ae. aegypti indoor abundance and ABV infection rates monthly during the period of active surveillance. Epidemiological and entomological evaluation will continue for up to three transmission seasons.

DISCUSSION

The findings from this study will provide robust epidemiological evidence of the efficacy of TIRS in reducing ABV illness and infection. If efficacious, TIRS could drive a paradigm shift in Aedes control by considering Ae. aegypti behavior to guide residual insecticide applications and changing deployment to preemptive control (rather than in response to symptomatic cases), two major enhancements to existing practice.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04343521 . Registered on 13 April 2020. The protocol also complies with the WHO International Clinical Trials Registry Platform (ICTRP) (Additional file 1).

PRIMARY SPONSOR

National Institutes of Health, National Institute of Allergy and Infectious Diseases (NIH/NIAID).

Serological tests reveal significant cross-reactive human antibody responses to Zika and Dengue viruses in the Mexican population

Zika virus (ZIKV) is a mosquito-borne flavivirus that has caused recent large outbreaks in the Americas. Given its association with severe congenital defects including microcephaly, distinguishing infections caused by ZIKV from those caused by dengue virus (DENV) is of primordial importance. The objectives of this study were to evaluate the recombinant proteins rEIII-ZIKV (Envelope protein domain III) and rNS1ß-leader-ZIKV (non-structural protein 1) for the serological diagnosis of ZIKV in the Mexican population. We also evaluated potential cross-reactivity in commercial enzyme-linked immunosorbent assays (ELISA) based on the ZIKV NS1 and DENV NS1 proteins. rEIII-ZIKV and rNS1ß-leader-ZIKV proteins were tested with sera from 30 PCR-confirmed ZIKV cases, 50 ZIKV-naive, DENV-exposed subjects with no acute febrile disease, (asymptomatic subjects, AS), and 50 ZIKV-naive and DENV naive AS. Commercial ELISA tests were evaluated with sera from 57 ZIKV and 20 DENV PCR-confirmed cases, and 50 ZIKV-naive, DENV-exposed AS. In-house ELISA assays showed that IgM antibody levels against rEIII-ZIKV and rNS1ß-ZIKV were higher in ZIKV naive, DENV-exposed AS than in acutely infected ZIKV individuals. IgG reactivity was highest for rEIII-ZIKV, and indistinguishable between acutely infected ZIKV cases and DENV exposed AS. Positivity for the Euroimmun Zika IgM assay at 7-10 days was considerably higher in DENV-naive ZIKV patients (86%) than in DENV-exposed ZIKV patients (33%), while 39% of the latter had false-negative anti-ZIKV IgG before 7 days of onset. DENV-exposed ZIKV patients presented lower anti-ZIKV IgM and higher IgG responses similar to a secondary dengue response. Forty-four percent of DENV- exposed acute ZIKV patients were DENV IgM positive with the Panbio Dengue assay, and two (15%) of the DENV-naive ZIKV patients presented false DENV IgG conversion. Given the extensive cross-reactivity to both the NS1 and EDIII proteins in current serological methods, the development of sensitive and specific serological tests to distinguish ZIKV from DENV infections is an urgent priority.

Zika Virus Infection in Pregnant Women, Yucatan, Mexico

Infection was associated with a high incidence of symptomatic disease but no congenital syndrome.

We report demographic, epidemiologic, and clinical findings for a prospective cohort of pregnant women during the initial phase of Zika virus introduction into Yucatan, Mexico. We monitored 115 pregnant women for signs of active or recent Zika virus infection. The estimated cumulative incidence of Zika virus infection was 0.31 and the ratio of symptomatic to asymptomatic cases was 1.7 (range 1.3–4.0 depending on age group). Exanthema was the most sensitive clinical sign but also the least specific. Conjunctival hyperemia, joint edema, and exanthema were the combination of signs that had the highest specificity but low sensitivity. We did not find evidence of vertical transmission or fetal anomalies, likely because of the low number of pregnant women tested. We also did not find evidence of congenital disease. Our findings emphasize the limited predictive value of clinical features in areas where Zika virus cocirculates with other flaviviruses.

Estimating absolute indoor density of Aedes aegypti using removal sampling

BACKGROUND

Quantification of adult Aedes aegypti abundance indoors has relied on estimates of relative density (e.g. number of adults per unit of sampling or time), most commonly using traps or timed collections using aspirators. The lack of estimates of the sensitivity of collections and lack of a numerical association between relative and the absolute density of adult Ae. aegypti represent a significant gap in vector surveillance. Here, we describe the use of sequential removal sampling to estimate absolute numbers of indoor resting Ae. aegypti and to calculate calibration coefficients for timed Prokopack aspirator collections in the city of Merida, Yucatan State, Mexico. The study was performed in 200 houses that were selected based on recent occurrence of Aedes-borne viral illness in residents. Removal sampling occurred in 10-minute sampling rounds performed sequentially until no Ae. aegypti adult was collected for 3 hours or over 2 consecutive 10-minute periods.

RESULTS

A total of 3439 Ae. aegypti were collected. The sensitivity of detection of positive houses in the first sampling round was 82.5% for any adult Ae. aegypti, 78.5% for females, 75.5% for males and 73.3% for blood-fed females. The total number of Ae. aegypti per house was on average ~5 times higher than numbers collected for the first sampling round. There was a positive linear relationship between the relative density of Ae. aegypti collected during the first 10-min round and the absolute density for all adult metrics. Coefficients from the linear regression were used to calibrate numbers from 10-min collections into estimates of absolute indoor Ae. aegypti density for all adults, females and males.

CONCLUSIONS

Exhaustive removal sampling represents a promising method for quantification of absolute indoor Ae. aegypti density, leading to improved entomological estimates of mosquito distribution, a key measure in the assessments of the risk pathogen transmission, disease modeling and the evaluation of vector control interventions.

Efficacy of novel indoor residual spraying methods targeting pyrethroid-resistant Aedes aegypti within experimental houses

Challenges in maintaining high effectiveness of classic vector control in urban areas has renewed the interest in indoor residual spraying (IRS) as a promising approach for Aedes-borne disease prevention. While IRS has many benefits, application time and intrusive indoor applications make its scalability in urban areas difficult. Modifying IRS to account for Ae. aegypti resting behavior, named targeted IRS (TIRS, spraying walls below 1.5 m and under furniture) can reduce application time; however, an untested assumption is that modifications to IRS will not negatively impact entomological efficacy. We conducted a comparative experimental study evaluating the residual efficacy of classically-applied IRS (as developed for malaria control) compared to two TIRS application methods using a carbamate insecticide against a pyrethroid-resistant, field-derived Ae. aegypti strain. We performed our study within a novel experimental house setting (n = 9 houses) located in Merida (Mexico), with similar layouts and standardized contents. Classic IRS application (insecticide applied to full walls and under furniture) was compared to: a) TIRS: insecticide applied to walls below 1.5 m and under furniture, and b) Resting Site TIRS (RS-TIRS): insecticide applied only under furniture. Mosquito mortality was measured eight times post-application (out to six months post-application) by releasing 100 Ae. aegypti females /house and collecting live and dead individuals after 24 hrs exposure. Compared to Classic IRS, TIRS and RS-TIRS took less time to apply (31% and 82% reduction, respectively) and used less insecticide (38% and 85% reduction, respectively). Mortality of pyrethroid-resistant Ae. aegypti did not significantly differ among the three IRS application methods up to two months post application, and did not significantly differ between Classic IRS and TIRS up to four months post application. These data illustrate that optimizing IRS to more efficiently target Ae. aegypti can both reduce application time and insecticide volume with no apparent reduction in entomological efficacy.

Vector control is the primary strategy for managing Aedes aegypti and reducing transmission of Aedes-borne diseases; however, the indoor resting behavior of Ae. aegypti and the evolution of insecticide resistance reduces the effectiveness of many vector control tactics. Indoor residual spraying (IRS) is effective against Ae. aegypti, but lengthy application time makes IRS difficult to scale within urban environments. We compared the application and entomological efficacy of Classic IRS against two novel Aedes-targeting IRS application methods (Targeted IRS [TIRS]- insecticide applied to walls below 1.5 m and under furniture and Resting Site TIRS [RS-TIRS]- insecticide applied only under furniture) within experimental houses using a carbamate insecticide. Both TIRS and RS-TIRS took less time to apply and used less insecticide compared to Classic IRS. Mortality of pyrethroid-resistant Ae. aegypti did not differ among treatments out to two months post-application, and there was no difference in mortality between Classic IRS and TIRS out to four months post-application. These data provide evidence that IRS application methods can be improved to take less time and insecticide yet not lose entomological efficacy, making TIRS more scalable within urban environments. However, larger field studies with epidemiologic endpoints are needed to further assess the efficacy of these modified TIRS techniques.

Epidemiology of dengue and other arboviruses in a cohort of school children and their families in Yucatan, Mexico: Baseline and first year follow-up

Dengue is the most prevalent mosquito-borne viral disease of humans and is caused by the four serotypes of dengue virus. To estimate the incidence of dengue and other arboviruses, we analyzed the baseline and first year follow-up of a prospective school-based cohort study and their families in three cities in the state of Yucatan, Mexico. Through enhanced surveillance activities, acute febrile illnesses in the participants were detected and yearly blood samples were collected to evaluate dengue infection incidence. A Cox model was fitted to identify hazard ratios of arboviral infections in the first year of follow-up of the cohort. The incidence of dengue symptomatic infections observed during the first year of follow-up (2015-2016) was 3.5 cases per 1,000 person-years (95% CI: 1.9, 5.9). The incidence of dengue infections was 33.9 infections per 1,000 person-years (95% CI: 31.7, 48.0). The majority of dengue infections and seroconversions were observed in the younger age groups (≤ 14 years old). Other arboviruses were circulating in the state of Yucatan during the study period. The incidence of symptomatic chikungunya infections was 8.6 per 1,000 person-years (95% CI: 5.8, 12.3) and the incidence of symptomatic Zika infections was 2.3 per 1,000 person-years (95% CI: 0.9, 4.5). Our model shows that having a dengue infection during the first year of follow-up was significantly associated with being female, living in Ticul or Progreso, and being dengue naïve at baseline. Age was not significantly associated with the outcome, it was confounded by prior immunity to dengue that increases with age. This is the first report of a cohort in Latin America that provides incidence estimates of the three arboviruses co-circulating in all age groups. This study provides important information for understanding the epidemiology of dengue and other arboviruses and better informing public health policies.