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. 2025 Feb 18;20(2):e0317854.
doi: 10.1371/journal.pone.0317854. eCollection 2025.

Investigation of severe dengue outbreak in Maumere, East Nusa Tenggara, Indonesia: Clinical, serological, and virological features

Marsha S Santoso  1   2 , Mario B R Nara  3 , Dwi Kurniawan Nugroho  3 , Benediktus Yohan  2 , Asep Purnama  3 , Angela M B Boro  3 , Rahma F Hayati  2 , Erlinda P Gae  3 , Dionisius Denis  2 , Bunga Rana  2 , Martin L Hibberd  4 , R Tedjo Sasmono  1
Affiliations

Investigation of severe dengue outbreak in Maumere, East Nusa Tenggara, Indonesia: Clinical, serological, and virological features

Marsha S Santoso et al. PLoS One. .

Abstract

Background: Dengue, an acute febrile disease caused by dengue virus (DENV) infection, is endemic to Indonesia. During early 2020, an outbreak of severe dengue occurred in Maumere, East Nusa Tenggara province, a region with low dengue endemicity with limited data on the characteristics of the circulating DENV. By 18 March 2020, 1396 cases were reported with 14 fatalities. Investigation was conducted to understand the cause and characteristics of the outbreak.

Methods: Sera were collected from 133 patients with dengue-like symptoms through random sampling at TC Hillers Hospital, Maumere during outbreak between February and June 2020. Dengue was confirmed using NS1 and/or RT-PCR detection. Serological status was determined using IgG/IgM ELISA and plaque reduction neutralization test (PRNT). DENV serotyping and genome sequencing were performed to identify the DENV serotype and genotype.

Results: We recruited suspected dengue patients attending the hospital during the outbreak. Dengue was confirmed in 72.2% (96/133), while 18.8% (25/133) were diagnosed as probable dengue. Children under 18 years old accounted for 85.1% (103/121) of dengue cases. Severe dengue accounted for 94.2% (81/86) of cases. Secondary infections made up 92.6% (112/121) of cases. Serotyping detected 87.3% (62/71) as DENV-3, 7.0% (5/71) as DENV-4, 2.8% (2/71) as DENV-1, and 2.8% (2/71) as DENV-2. Phylogenetic analysis revealed close evolutionary relationship of Maumere DENV to viruses from other Indonesian regions, especially Bali and Kupang. PRNT on DENV-3 secondary infections patients detected the presence of DENV-2 and DENV-4 neutralizing antibodies.

Conclusion: The severe dengue outbreak in Maumere is caused by DENV-3 introduced from nearby islands. The high proportion of secondary infections likely contributes to the severity of the disease. The high percentage of anti-dengue neutralizing antibodies for multiple serotypes and the high proportion of anti-dengue IgG in young children suggests a history of dengue transmission with a high infection rate in the area.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Incidence rate of dengue in East Nusa Tenggara province compared to national incidence rate of dengue in Indonesia.
Fig 2
Fig 2. Demographic, clinical, and laboratory characteristics of dengue patients in Maumere.
Age distribution of acutely febrile recruited patients (A). Reported symptoms of recruited acutely febrile patients (B). Plaque reduction neutralization test (PRNT) titers to four DENV serotypes on samples with secondary DENV-3 infections (C). Detailed antibody titer for each serotype is shown in S1 Table.
Fig 3
Fig 3. Phylogenetic analysis of Maumere DENV-1 (red font) together with closest strains from Indonesia (blue font) and strains from surrounding countries (black font).
Fig 4
Fig 4. Phylogenetic analysis of Maumere DENV-2 (red font) together with closest strains from Indonesia (blue font) and strains from surrounding countries (black font).
Fig 5
Fig 5. Phylogenetic analysis of Maumere DENV-3 (red font) together with closest strains from Indonesia (blue font) and strains from surrounding countries (black font).
Fig 6
Fig 6. Phylogenetic analysis of Maumere DENV-4 (red font) together with closest strains from Indonesia (blue font) and strains from surrounding countries (black font).
See this image and copyright information in PMC

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