Previous Dengue Infection among Children in Puerto Rico and Implications for Dengue Vaccine Implementation

Abstract

Limited dengue virus (DENV) seroprevalence estimates are available for Puerto Rico, which are needed to inform the potential use and cost-effectiveness of DENV vaccines. The Communities Organized to Prevent Arboviruses (COPA) is a cohort study initiated in 2018 in Ponce, Puerto Rico, to assess arboviral disease risk and provide a platform to evaluate interventions. We recruited participants from households in 38 study clusters, who were interviewed and provided a serum specimen. Specimens from 713 children aged 1 to 16 years during the first year of COPA were tested for the four DENV serotypes and ZIKV using a focus reduction neutralization assay. We assessed the seroprevalence of DENV and ZIKV by age and developed a catalytic model from seroprevalence and dengue surveillance data to estimate the force of infection for DENV during 2003-2018. Overall, 37% (n = 267) were seropositive for DENV; seroprevalence was 9% (11/128) among children aged 1 to 8 years and 44% (256/585) among children aged 9 to 16 years, exceeding the threshold over which DENV vaccination is deemed cost-effective. A total of 33% were seropositive for ZIKV, including 15% among children aged 0 to 8 years and 37% among children aged 9 to 16 years. The highest force of infection occurred in 2007, 2010, and 2012-2013, with low levels of transmission from 2016 to 2018. A higher proportion of children had evidence of multitypic DENV infection than expected, suggesting high heterogeneity in DENV risk in this setting.

Figure 1.

Estimated dengue seroprevalence by age among children aged 1 to 16 years in Ponce, Puerto Rico, 2018–2019 (A) and estimated proportion with one and multiple previous infections (B). Open circles represent the proportion of participants seropositive to dengue virus. In panel A, colors represent the seroprevalence data (black) and fits to the serosurvey data (gray), the case data (blue), and both data together (red). In panel B, red lines represent the fit from the serosurvey and case data together.

Figure 2.

Proportion of dengue virus–seropositive individuals in Ponce, Puerto Rico, 2018–2019 with evidence for multiple previous infections, among individuals with and without evidence for prior Zika infection. Points and vertical lines represent observed proportions and 95% CIs, whereas solid black line and gray ribbon represent model-estimated median proportions and 95% credible intervals, respectively. Where 95% CIs around the observed proportions are not shown, they are undefined due to zero counts of monotypic or multitypic infections.