Trends in Patterns of Dengue Transmission over 4 Years in a Pediatric Cohort Study in Nicaragua Susan M. Samuel,RN. Julian P. Midgley, M.D.

RN Dengue is a major public health problem worldwide, caused by 4 dengue virus serotypes of the Flavivirus genus. DENV is transmitted principally by Aedes aegypti and Aedes albopictus mosquitoes and causes dengue fever and the more severe dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS) throughout tropical and subtropical regions. Forty million dengue cases are estimated to occur annually worldwide, with 250,000500,000 hospitalizations and 25,000 fatalities . In the Americas, the incidence, distribution, and severity of dengue have increased dramatically over the past 3 decades, and dengue is now endemic throughout the region . In Nicaragua, the first documented dengue epidemic occurred in 1985 [3]; since 1990, dengue has been endemic, with circulation of all 4 serotypes and tens of thousands of cases each year .

A number of multiyear cohort studies have documented incidence and transmission patterns of DENV in Southeast Asia. However, in the Americas, few long-term prospective cohort studies have been performed; most have been short-term, spanning 12 years. Given the variations in DENV transmission and disease severity between Southeast Asia and the Americas, a large-scale, cohort study in the Americas is needed to more fully understand the epidemiology of dengue and prepare for possible vaccine and drug trials

Since 2004, a seroepidemiological cohort study of 3800 children aged 212 years has been ongoing in Managua, Nicaragua, to document the natural history of pediatric dengue transmission, measure symptomatic and in apparent DENV infections, identify circulating DENV serotypes, and maintain a biobank of clinical specimens and viruses. Additionally, this study serves to establish infrastructure for potential dengue vaccine and drug trials. Here, we present the epidemiological observations for 20042008, years that encompassed substantial variation in overall DENV infection, the ratio of symptomatic to in apparent infection, disease severity, circulating serotypes, and geographical clustering. This is a community-based prospective seroepidemiological cohort study, with passive surveillance for illnesses among participants at the study health center enhanced by periodic home visits. Participants were observed closely for all illnesses, and children presenting with fever were screened for signs and symptoms of dengue. Those presenting with World Health Organization (WHO) criteria for dengue syndromes and those with undifferentiated fever were evaluated for acute DENV infection using virological, serological, and molecular biological assays. A blood sample was collected annually from all subjects in July-August, prior to the dengue season. The study was initiated in August 2004 and continues to date; this report includes data through July 2008 Study site and population. The study is being conducted in the catchment area of the Health Center Scrates Flores Vivas (HCSFV), the principal primary care facility serving neighborhoods along Lake Xolotln in District II in Managua. Children aged 29 years were recruited in August-September of 2004, and new 2-year-old children were recruited each year in July. Parents or legal guardians of participants signed informed consent forms, and children aged >5 years provided verbal assent. The cohort population varied between 3693 and 3947, with the increase in size attributable to the aging of participants up to 12 years old. This study was approved by the institutional review boards of the

Nicaraguan Ministry of Health, the study hospital Hospital Infantil Manuel de Jess Rivera (HIMJR), the University of California, Berkeley, and the International Vaccine Institute. Symptomatic dengue cases and annual sample collection. To facilitate identification of symptomatic dengue, participants were urged to attend the HCSFV at the onset of fever or illness, where study physicians classified them into 1 of 4 clinical categories (AD). Febrile illnesses were classified as those that met the WHO's dengue case definition (category A) , those with undifferentiated fever (category B), or those with an apparent focus other than dengue (category C). Nonfebrile complaints were classified as category D. Category A and B cases (possible dengue cases) were followed by study physicians and nurses daily while fever and symptoms persisted, either at the HCSFV or by home visits. A complete blood cell count was determined every other day, and acute- and convalescent-phase blood samples were sent for virological testing at the National Virology Laboratory of the Nicaraguan Ministry of Health. Possible dengue cases presenting signs of alarm were transferred to the HIMJR, where hospital-based study physicians and nurses provided case management and continued data collection. Each July, blood samples were collected from all children to determine DENV infection incidence and seroprevalence through serological testing of paired samples from the current and previous year

Sample management and laboratory assays Blood samples from category A and B patients were sent to the National Virology Laboratory of the Nicaraguan Ministry of Health for processing and storage [14]. After separation from red blood cells, acute-phase serum samples were tested for DENV RNA using a nested reverse transcriptase-polymerase chain reaction (RT-PCR) assay that targets the capsid gene and allows both DENV detection and serotyping [19]. Positive samples were confirmed by a second RTPCR amplification and then viral isolation was attempted by inoculation onto Aealbopictus C6/36 cells [20]. Serotyping after viral isolation was performed by indirect immunofluorescence or, from 2007, by RT-PCR. Acute- and convalescent-phase samples were paired and tested simultaneously for anti-DENV IgM antibodies using an in-house IgM capture ELISA (MAC-ELISA) [21] and for total anti-DENV antibodies by an Inhibition ELISA containing antigens from DENV1-4 . Annual serum samples were processed by Inhibition ELISA.

Summary Dengue is the most prevalent mosquito-borne viral disease in humans and a major urban public health problem worldwide. A prospective cohort study of 3800 children initially aged 29 years was established in Managua, Nicaragua, in 2004 to study the natural history of dengue transmission in an urban pediatric population. Blood samples from healthy subjects were collected annually prior to the dengue season, and identification of dengue cases occurred via enhanced passive surveillance at the study health center Over the first four years of the study, seroprevalence of anti-dengue virus (DENV) antibodies increased from 22%40% in the 2-year-old cohort and 90%95% in the 9-year-old cohort. The incidence of symptomatic dengue cases and the ratio of in apparent to symptomatic DENV infection varied substantially from year to year. The switch in dominant transmission from DENV-1 to DENV-2 was accompanied by an increase in disease severity but, paradoxically, a decrease in transmission. Phylogeographic analysis of full-length DENV-2 sequences revealed strong geographic clustering of dengue cases Conclusion This large-scale cohort study of dengue in the Americas demonstrates year-to-year variation of dengue within a pediatric population, revealing expected patterns in transmission while highlighting the impact of interventions, climate, and viral evolution Importance to Nursing practice This study serves to establish infrastructure for potential dengue vaccine and drug trials. To become updated about the epidemiological observations yearly, & the ratio of symptomatic to in apparent infection, disease severity, circulating serotypes, and geographical clustering. To be familiarized about viruses that cause and to be able to recognize complications related, in order to render such nursing education to clients. To facilitate identification of symptomatic dengue by knowing how to categorized each cases. Importance to the society The study to review the evidence on the application of tools for dengue outbreak prediction/detection and trend monitoring in passive and active disease surveillance systems in order to develop recommendations for endemic countries and identify research needs. The classification of has been used effectively to recognize severe dengue, to assess epidemiologic trends, to investigate dengue pathogenesis, and to guide clinical management. The society will become alert to stop or to slow down the transmission it may be supplemented by "thermal fogging", using fogging machines. Therefore, measures undertaken by the society, for the society, to prevent the breeding of mosquitoes is far more cost-effective than containment measures once an outbreak occurs.

Importance to health education By issuing medical alerts to all medical practitioners by conducting grand rounds and other lectures on dengue at local medical centers. It improved health promotion efforts included 1) issuing

frequent press releases, including daily case counts and messages about eliminating mosquito breeding sites around the home; 2) giving multiple news interviews by HDOH staff with radio, television, and print media; producing public service announcements by HDOH for radio and television; 3) conducting joint town meetings by HDOH and Department of Education health educators; 4) developing a dengue education Web site, which provided the public and officials with information on the latest developments; 6) establishing checkpoints along the Hana Highway staffed by public health nurses and others who distributed educational materials and mosquito repellent. Importance to people It will serve as information to the people in order for them to be updated and to become sensitive about the possible outcome of dengue. After reading the journal people will be inspired to do the preventive measures such as draining out the water from desert coolers/window air coolers (when not in use), tanks, barrels, drums, buckets etc. Remove all objects containing water (e.g. plant saucers etc.) from the house. Collect and destroy discarded containers in which water collects e.g. bottles, plastic bags. Use mosquito nets to protect specially in children.