The

n e w e ng l a n d j o u r na l

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Original Article

Symptomatic Dengue in Children in 10

Asian and Latin American Countries
Mana LAzou, M.Sc., Annick Moureau, M.Sc., Elsa Sarti, Ph.D.,
Joshua Nealon, M.Sc., Betzana Zambrano, M.D., T.Anh Wartel, M.D.,
Luis Villar, M.D., MariaR.Z. Capeding, M.D., and R.Leon Ochiai, Ph.D.,
for the CYD14 and CYD15 Primary Study Groups*

A BS T R AC T
BACKGROUND

The control groups in two phase 3 trials of dengue vaccine efficacy included two
large regional cohorts that were followed up for dengue infection. These cohorts
provided a sample for epidemiologic analyses of symptomatic dengue in children
across 10 countries in Southeast Asia and Latin America in which dengue is endemic.
METHODS

We monitored acute febrile illness and virologically confirmed dengue (VCD) in

3424 healthy children, 2 to 16 years of age, in Asia (Indonesia, Malaysia, the Philippines, Thailand, and Vietnam) from June 2011 through December 2013 and in
6939 children, 9 to 18 years of age, in Latin America (Brazil, Colombia, Honduras,
Mexico, and Puerto Rico) from June 2011 through April 2014. Acute febrile episodes were determined to be VCD by means of a nonstructural protein 1 antigen
immunoassay and reverse-transcriptasepolymerase-chain-reaction assays. Dengue
hemorrhagic fever was defined according to 1997 World Health Organization
criteria.
RESULTS

Approximately 10% of the febrile episodes in each cohort were confirmed to be

VCD, with 319 VCD episodes (4.6 episodes per 100 person-years) occurring in the
Asian cohort and 389 VCD episodes (2.9 episodes per 100 person-years) occurring
in the Latin American cohort; no trend according to age group was observed. The
incidence of dengue hemorrhagic fever was less than 0.3 episodes per 100 personyears in each cohort. The percentage of VCD episodes requiring hospitalization
was 19.1% in the Asian cohort and 11.1% in the Latin American cohort. In comparable age groups (9 to 12 years and 13 to 16 years), the burden of dengue was
higher in Asia than in Latin America.

From Global Epidemiology, Sanofi Pasteur, Lyon (M.L., R.L.O.), and the Global
Clinical Department, Sanofi Pasteur, Marcy
lEtoile (A.M.) both in France; Sanofi
Pasteur Latin America, Coyoacn, Mexico
(E.S.); Sanofi Pasteur Asia Pacific Region,
Singapore, Singapore (J.N., T.A.W.); Sanofi
Pasteur Uruguay, Montevideo (B.Z.); Clinical Epidemiology Unit, School of Medicine, Universidad Industrial de Santander,
Bucaramanga, Colombia (L.V.); and the
Research Institute for Tropical Medicine,
Alabang, Muntinlupa City, Philippines
(M.R.Z.C.). Address reprint requests to
Dr. Ochiai at Global Epidemiology, Sanofi
Pasteur, 2 Ave. Pont Pasteur, 69367 Lyon,
France, or at leon.ochiai@sanofipasteur
.com.
* The complete list of the members of the
CYD14 and CYD15 Primary Study Groups
is provided in the Supplementary Appendix, available at NEJM.org.
N Engl J Med 2016;374:1155-66.
DOI: 10.1056/NEJMoa1503877
Copyright 2016 Massachusetts Medical Society.

CONCLUSIONS

The burdens of dengue were substantial in the two regions and in all age groups.
Burdens varied widely according to country, but the rates were generally higher
and the disease more frequently severe in Asian countries than in Latin American
countries. (Funded by Sanofi Pasteur; CYD14 and CYD15 ClinicalTrials.gov numbers,
NCT01373281 and NCT01374516.)

n engl j med 374;12nejm.org March 24, 2016

1155

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n e w e ng l a n d j o u r na l

n the past several decades, the burden of dengue has expanded to place almost
3.9 billion people at risk for infection.1,2
From an evidence-based global map, it was estimated that 390 million infections occur annually, 96 million of which are symptomatic.1
Furthermore, dengue is essentially endemic
throughout the tropics and has expanded into
128 countries as dengue virus serotypes continue to spread into new areas.2 In areas where
dengue is endemic, all populations and age
groups are at risk, and the burden of cases that
require hospitalization can be substantial, especially during outbreaks, with attendant strains
on health care resources and utilization.3-5 Dengue has no specific treatment, and the vaccine
that was most advanced in its clinical development was licensed in Mexico, the Philippines,
and Brazil in 2015.6-8
Precise estimates of the burden of dengue
disease have been difficult to determine.1,2 Although dengue is generally a reportable disease,
the totals that are reported by national health
authorities are likely to underestimate the true
burden of disease because medical care is not
sought for many mild-to-moderate cases.9 Furthermore, national surveillance, reporting, and
laboratory-confirmation practices vary considerably,10-14 and the clinical definitions recommended by the World Health Organization (WHO)
have not been used or applied consistently.15,16
Prospective longitudinal cohort studies that have
used active surveillance allow the incidence of
symptomatic dengue in a defined population to
be measured with precision and reliability.1,10-13
Disease burdens in such cohorts vary over time
but tend to be higher than nationally reported
totals. However, because locations, periods, and
methods usually differ among cohort studies,
these studies are often difficult to compare.
Sanofi Pasteur developed a recombinant live,
attenuated, tetravalent dengue vaccine (chimeric
yellow feverdenguetetravalent dengue vaccine
[CYD-TDV]).6,7,17 Two phase 3 clinical trials that
included more than 30,000 children, 2 to 16 years
of age, were conducted in Southeast Asia and
Latin America.6,7 Recruitment of the participants,
active surveillance, definition of episodes, clinical assessment, and laboratory confirmation
were standardized across all the study sites.
Thus, the unvaccinated control groups in the two

1156

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studies could be considered to be two comparable

cohorts for the study of dengue disease across
10 countries in which dengue is endemic. Here,
we present data regarding the burdens of symptomatic dengue and seropositivity results in the
various age groups in these two cohorts during
25 months of follow-up that occurred in the
period from June 2011 through April 2014.

Me thods
Study Population and Design

The children included in the descriptive analyses

presented here were in the control groups of two
phase 3, randomized, observer-blind, placebocontrolled clinical trials to assess the safety and
efficacy of CYD-TDV in preventing dengue infection and reducing disease severity.6,7 Details of
the study procedures have been reported previously.6,7 In brief, the studies began in 2011 and
included healthy children 2 to 14 years of age in
Southeast Asia, with multiple centers in Indonesia, Malaysia, the Philippines, Thailand, and Vietnam (Fig. S1A in the Supplementary Appendix,
available with the full text of this article at
NEJM.org), and children 9 to 16 years of age in
Latin America, with multiple centers in Brazil,
Colombia, Honduras, Mexico, and Puerto Rico
(Fig. S1B in the Supplementary Appendix). These
countries and the age ranges of the participants
were selected because they had a high incidence
of dengue disease, which was confirmed for
most countries in two prospective cohort studies
that were conducted before the vaccine trials.18,19
Participants were randomly assigned, in a 2:1
ratio, to receive three doses of CYD-TDV (treatment group) or placebo (0.9% sodium chloride;
control group) within 1 year. In addition, 20% of
the participants in Asia and 10% of those in
Latin America were randomly assigned to a subgroup for the assessment of vaccine reactogenicity, immunogenicity, and baseline seropositivity.
Participants were followed for 25 months after
the first dose of vaccine or placebo.
Each study was conducted in compliance with
Good Clinical Practice guidelines, the principles
of the Declaration of Helsinki, and the regulations of the relevant country. Each study was
approved by the appropriate ethics review committee. Written informed consent was obtained
from a parent or guardian for all the partici-

n engl j med 374;12nejm.org March 24, 2016

Symptomatic Dengue in Children in Asia and Latin America

pants in the two trials, with assent obtained

depending on the participants age.
With respect to the current analysis, the sponsor (Sanofi Pasteur) participated in the design of
the study and the collection, analysis, and interpretation of the data. The sponsor also participated in the writing of the report and in the
decision to submit the manuscript for publication. Medical writing services were provided by
4Clinics France, with funding from the sponsor.
Study Procedures

Children were actively monitored for acute febrile illness (temperature 38C for 2 consecutive days) by means of weekly contact with
parents or guardians in each cohort and by
surveillance of school absenteeism in the Asian
cohort. Participants who had an acute febrile
episode were provided standard care, and routine
biologic tests were performed; children were hospitalized if necessary, according to local practices. Consecutive febrile episodes were considered to be independent if they occurred more
than 14 days apart.
To confirm the presence of dengue virus infection, a blood sample obtained within 5 days
after the onset of fever was tested by an enzymelinked immunosorbent assay for nonstructural
protein 1 antigen (Platelia, Bio-Rad Laboratories),
by a quantitative reverse-transcriptasepolymerasechain-reaction (PCR) screening assay for dengue,
and by a serotype-specific real-time PCR assay
(Simplexa Dengue, Focus Diagnostics). Febrile
episodes were considered to be virologically confirmed dengue (VCD) if any of these tests had a
positive result.
Dengue hemorrhagic fever was defined according to the 1997 WHO criteria, which included
fever persisting for 2 to 7 days accompanied
byhemorrhage (or a positive tourniquet test),
thrombocytopenia (100,000 cells per cubic millimeter), and evidence of plasma leakage (hematocrit that is 20% above the normal value for age
or that decreased by 20% after fluid-replacement therapy), pleural effusion, ascites, or hypoproteinemia.20 Dengue hemorrhagic fever was
classified in four grades of severity. Grade 1 is
defined by fever accompanied by nonspecific
constitutional symptoms; the only hemorrhagic
manifestation is a positive tourniquet test, easy
bruising, or both. Grade 2 is defined by sponta-

neous bleeding (usually in the forms of skin or

other hemorrhages) in addition to the manifestations of grade 1. Grade 3 is defined by circulatory failure manifested by a rapid, weak pulse
and narrowing of pulse pressure or hypotension,
with the presence of cold, clammy skin and restlessness. Grade 4 is defined by profound shock
with undetectable blood pressure or pulse.20
The seropositivity analysis was performed with
baseline data from participants in the immunogenicity subgroup who received at least one injection of vaccine or placebo. The baseline titers
of dengue-neutralizing antibodies in the blood
samples obtained before vaccination were measured with the use of a plaque-reduction seroneutralization assay, in which the titer was the
reciprocal of the serum dilution that reduced the
number of plaques in the control by 50%, and
seropositivity was defined as a titer of 10 or
more.21 Assays were performed under blinded
conditions at the Global Clinical Immunology
laboratories of the sponsor, at the Center for
Vaccine Development at Mahidol University in
Bangkok, Thailand, and at Focus Diagnostics.
Statistical Analysis

Descriptive analyses of the acute febrile episodes,

VCD, hospitalization, and dengue hemorrhagic
fever according to country and age group included all the participants in the control group
of each study who received at least one injection
of placebo. All the initial and recurrent episodes of VCD were considered in the incidencedensity calculation for the entire follow-up period.
Incidence density was determined according to
age group on the basis of the age at fever onset
for the episode and the number of person-years
followed, which was determined weekly as the
cumulative time in years that each participant
contributed to each age group during the active
surveillance period.
Participants were stratified according to age
groups that were applicable to each cohort according to the age at the onset of fever (2 to 4 years,
5 to 8 years, 9 to 12 years, 13 to 16 years, and
17 to 18 years); thus, some children were outside
the inclusion age range of each cohort, and only
the age groups of 9 to 12 years and 13 to 16 years
were comparable across the two cohorts. The
95% confidence intervals for incidence density
and percentages were computed with the exact

n engl j med 374;12nejm.org March 24, 2016

1157

1158

* Plusminus values are means SD. Participants were in the control groups of two phase 3, randomized, placebo-controlled clinical trials of the chimeric yellow feverdenguetetravalent
dengue vaccine (CYD-TDV). NA denotes not applicable.

2771 (39.9)
219 (49.8)
453 (38.6)
68 (14.6)
1316 yr

54 (8.7)

195 (16.7)

55 (14.0)

84 (10.8)

456 (13.3)

1296 (39.9)

353 (37.9)

450 (39.2)

NA

4168 (60.1)

NA

221 (50.2)

NA

699 (60.8)
578 (62.1)

NA
NA

1949 (60.1)

NA

721 (61.4)

1179 (34.4)

1201 (35.1)

289 (37.1)

338 (43.4)
130 (33.2)

129 (32.9)
337 (28.9)

361 (31.0)

155 (33.3)

168 (36.1)

269 (43.2)

204 (32.7)

NA
67 (8.6)
78 (19.9)
273 (23.4)
74 (15.9)
96 (15.4)
24 yr

Age group no. (%)

58 yr

NA
NA
588 (17.2)

NA

9.016.9

9.017.0

12.52.2
12.42.1
8.83.4

2.215.0
2.014.8

9.33.0
8.73.6

2.015.0

8.73.8
9.03.5

2.015.0

8.53.0

Range

Mean

2.115.0

2.015.0

0.91
0.98
0.90
0.98
1.00
Male:female ratio

Age yr

912 yr

NA

9.017.0

NA

12.52.1

9.017.0
9.017.0

13.02.2
12.32.1

9.017.0

12.42.1

0.97
1.00
0.99
0.97
0.94
0.94

0.96

8/11
3/14
Surveillance
period

6/11
12/13
6/11
11/13
6/11
9/13

10/11
12/13

9/11
12/13

6/11
3/14
8/11
3/14

6/11
4/14

6/11
3/14

100
6.3
16.6
16.9
100
Percent of
participants

34.1
13.6
18.2

11.4

22.7

46.8

Brazil
(N=1174)

13.4

Mexico
Puerto Rico
(N=1149) (N=440)
Honduras
(N=931)

n e w e ng l a n d j o u r na l

Total
(N=3424)
Vietnam
(N=778)
Thailand
(N=392)
Philippines
(N=1166)
Malaysia
(N=465)
Indonesia
(N=623)

Asia
Characteristic

Table 1. Characteristics of the Study Populations at Inclusion in the Asian and Latin American Cohorts.*

Colombia
(N=3245)

Latin America

Total
(N=6939)

The

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binomial distribution for percentages (Clopper

Pearson method).22 Statistical analyses were performed with the use of SAS software, version 9.2
(SAS Institute).

R e sult s
Demographic Characteristics of the Cohorts

The Asian cohort included 3424 participants, 2 to

14 years of age, who were followed for 25 months
in the period between June 3, 2011, and December 16, 2013 (Table1).6 The country subcohorts
in Asia varied in size, with the smallest in Thailand and the largest in the Philippines. The
Latin American cohort included 6939 participants, 9 to 16 years of age, who were followed
for 25 months in the period between June 8,
2011, and April 3, 2014. The smallest country
subcohort in Latin America was in Puerto Rico
and the largest was in Colombia. The mean age
of the participants was 8.8 years in the Asian
cohort and 12.5 years in the Latin American
cohort. The mean ages and the sex ratios of the
country subcohorts were similar at inclusion
within each geographic region.
Acute Febrile Episodes

In the Asian cohort, 3109 febrile episodes were

observed during 6934 person-years (2.03 years
per participant), for an overall incidence of
44.8 episodes per 100 person-years (Table2, and
Table S1 in the Supplementary Appendix). In the
Latin American cohort, 3615 febrile episodes
were observed during 13,527 person-years (1.95
years per participant), for an overall incidence of
26.7 episodes per 100 person-years. The incidence of febrile episodes in the subcohorts
ranged from 20.7 episodes per 100 person-years
(in Mexico) to 60.0 episodes per 100 personyears (in the Philippines); the incidence decreased
with increasing age of the participants. The
overall incidence in each comparable age group
(9 to 12 years and 13 to 16 years) was similar in
the two cohorts, although the incidence rates
varied according to subcohort.
Virologically Confirmed Dengue

The overall incidence of VCD in the Asian cohort

was 4.6 episodes per 100 person-years (range,
2.2 [in Malaysia] to 6.6 [in the Philippines]);
the incidence in the Latin American cohort was
2.9 episodes per 100 person-years (range, 1.5 [in

n engl j med 374;12nejm.org March 24, 2016

Symptomatic Dengue in Children in Asia and Latin America

Puerto Rico] to 4.1 [in Honduras]) (Table2, and

Table S1 in the Supplementary Appendix). The
age groups that were most affected varied according to subcohort, with no clearly observable
trends.
The percentages of VCD episodes among febrile episodes in each cohort were similar (10.3%
in Asia and 10.8% in Latin America), with percentages in the subcohorts ranging from 6.3%
(in Malaysia) to 12.3% (in Indonesia) in Asia and
from 7.0% (in Puerto Rico) to 14.7% (in Brazil) in
Latin America. Overall, and within most countries, this percentage tended to increase with
increasing age, but in the two comparable age
groups (9 to 12 years and 13 to 16 years), the
percentage was slightly higher in the Asian cohort than in the Latin American cohort.

[in Colombia, Honduras, and Puerto Rico]) in

the Latin American cohort, with no episodes of
dengue hemorrhagic fever occurring in Brazil or
Mexico. The percentage of VCD episodes that
were diagnosed as dengue hemorrhagic fever was
6.3% (range, 3.9 [in Vietnam] to 18.2 [in Indonesia]) in Asia and 2.6% (range, 0.0 [in Mexico
and Brazil] to 7.7 [in Puerto Rico]) in Latin
America. The percentage in Indonesia (18.2%)
was much higher than that in any other country
(all other countries, <7.7%). There were no agegroup trends with respect to the incidence of
dengue hemorrhagic fever or the percentage of
episodes of VCD that were diagnosed as dengue
hemorrhagic fever. No deaths due to dengue occurred in either cohort.
Serotype Distribution

Hospitalization and Dengue Hemorrhagic

Fever

The overall incidence of hospitalization for VCD

episodes was 0.9 hospitalizations per 100 person-years (range, 0.2 [in Vietnam] to 1.6 [in Indonesia and Thailand]) in the Asian cohort and 0.3
hospitalizations per 100 person-years (range, 0.1
[in Mexico and Puerto Rico] to 0.4 [in Colombia
and Honduras]) in the Latin American cohort
(Table3, and Table S2 in the Supplementary Appendix). The percentage of VCD episodes requiring hospitalization was 19.1% (range, 5.9 [in Vietnam] to 45.5 [in Indonesia]) in the Asian cohort
and 11.1% (range, 4.9 [in Brazil] to 17.0 [in Colombia]) in the Latin American cohort. There
was no age-group trend for either the incidence
or the percentage of VCD episodes that required
hospitalization. However, both these values in
the two comparable age groups tended to be
higher in the Asian cohort than in the Latin
American cohort.
A total of 30 episodes of VCD were diagnosed
as dengue hemorrhagic fever, as defined according to the 1997 WHO criteria, with 20 episodes
occurring in the Asian cohort and 10 in the
Latin American cohort (Table3, and Table S2 in
the Supplementary Appendix). Most episodes of
dengue hemorrhagic fever (28 of 30) were classified as grade 1 or 2. The overall incidence of
episodes of dengue hemorrhagic fever was 0.3 episodes per 100 person-years (range, 0.1 [in Malaysia and Vietnam] to 0.6 [in Indonesia]) in the
Asian cohort and 0.1 episodes per 100 personyears (range, 0.0 [in Mexico and Brazil] to 0.1

All four dengue virus serotypes cocirculated in

the five Asian countries during the study period,
although the distributions and predominant
serotypes differed among countries (Fig.1A).
Shifts in serotype predominance occurred in
Indonesia (serotype 2 to serotype 1), the Philippines (serotype 1 to serotype 4), and Thailand
(serotype 2 to serotype 3) (Fig. S2 in the Supplementary Appendix).
In the Latin American cohort, serotype distributions also varied according to country
(Fig.1B). Single serotypes predominated in
Brazil (serotype 4) and Puerto Rico (serotype 1),
whereas two or more serotypes predominated in
Mexico, Honduras, and Colombia (which was
the only Latin American subcohort affected by
all four serotypes). No clear changes in serotype
predominance occurred in the Latin American
subcohorts (Fig. S3 in the Supplementary Appendix).
Dengue Seropositivity

In the Asian immunogenicity subgroup, 1345 of

1999 participants (67.3%) were seropositive at
baseline. In the Latin American subgroup, 1585
of 2000 participants (79.2%) were seropositive
(Table4). Overall rates of seropositivity varied
according to country and were between 47.0%
(Malaysia) and 80.9% (Indonesia) in the Asian
cohort and between 52.6% (Mexico) and 92.3%
(Colombia) in the Latin American cohort. The
rates of seropositivity according to age group
were similar overall in the Asian cohort and the
Latin American cohort: in the group of partici-

n engl j med 374;12nejm.org March 24, 2016

1159

1160
937

1232

332

520

171

NA

357

912 yr

1316 yr

1718 yr

n engl j med 374;12nejm.org March 24, 2016

(95% CI)

4.5

5.6

2.5

1.2

NA

24 yr

912 yr

1316 yr

1718 yr

3.6
(2.64.8)

58 yr

Age group

Overall

NA

1.7

3.1

1.7

2.5

2.2
(1.43.4)

21

Incidence no./100 person-yr

44

NA

13.6

VCD episodes no.

NA

1718 yr
332

12.3

1316 yr

31.0

NA

5.0

7.3

7.4

6.3

6.6
(5.67.7)

156

1420

NA

32.8

48.8

75.7

98.9

60.0

1421

NA

618

703

701

NA

4.7

6.2

6.8

5.3

5.9
(4.47.8)

47

388

NA

22.3

37.8

57.8

116.8

50.1

397

NA

193

241

263

95

792

Thailand
(N=392)

NA

3.0

3.5

3.0

2.4

3.2
(2.44.2)

51

602

NA

26.8

30.4

48.3

82.9

37.6

602

NA

336

717

468

82

1603

Vietnam
(N=778)

NA

3.6

4.5

5.3

5.0

4.6
(4.15.1)

319

3099

NA

25.0

34.8

56.2

89.1

44.8

3109

NA

1560

2507

2151

716

6934

4.7

3.5

3.5

NA

NA

3.5
(2.84.4)

81

551

15.7

22.2

27.2

NA

NA

24.1

552

127

1129

1034

NA

NA

2290

Total
Brazil
(N=3424) (N=1174)

2.0

2.4

2.9

NA

NA

2.6
(2.23.0)

165

1486

18.3

20.8

27.1

NA

NA

23.5

1486

398

3029

2887

NA

NA

6313

Colombia
(N=3245)

1.8

3.7

4.6

NA

NA

4.1
(3.25.1)

73

919

51.3

47.3

54.5

NA

NA

51.1

919

113

802

884

NA

NA

1799

Honduras
(N=931)

3.1

2.8

2.1

NA

NA

2.5
(1.93.2)

57

472

14.6

19.3

23.0

NA

NA

20.7

473

130

1101

1048

NA

NA

2280

Mexico
(N=1149)

Latin America

2.1

1.6

1.3

NA

NA

1.5
(0.82.6)

13

185

8.3

22.7

24.9

NA

NA

21.9

185

96

440

309

NA

NA

845

Puerto Rico
(N=440)

2.5

2.8

3.0

NA

NA

2.9
2.63.2)

389

3613

20.6

24.2

30.2

NA

NA

26.7

3,615

864

6,501

6,162

NA

NA

13,527

Total
(N=6939)

of

357

22.9

912 yr

49.0

70.4

35.4

242

326

348

2370

Philippines
(N=1166)

Asia

n e w e ng l a n d j o u r na l

Tested for dengue

no.

52.7

36.9

24 yr

29.0

58 yr

Age group

Overall

Incidence no./100 person-yr

Febrile episodes no.

NA

431

58 yr

288

110

81

Malaysia
(N=465)

Indonesia
(N=623)

24 yr

Age group person-yr

Person-yr no.

Variable

Table 2. Incidences of Febrile Episodes and Episodes of Virologically Confirmed Dengue (VCD) in the Asian and Latin American Cohorts.*

The

m e dic i n e

11.4

12.4

7.0

25.0
21.1
3.4
* All age groups were defined according to age at episode onset. CI denotes confidence interval.

7.9

Discussion

11.0

11.6

pants 9 to 12 years of age, the rates were 75.7%

in the Asian cohort and 76.4% in the Latin
American cohort, and in the group of those 13
to 16 years of age, the rates were 87.4% and
84.0%, respectively.

30.0

15.5
14.4

NA
NA

11.1
20.9

NA
NA

15.3

NA
1718 yr

12.1
9.5
1316 yr

NA

14.6

NA

10.0

NA

5.2

NA

9.1
8.5

NA
NA

10.7
12.9

NA
9.4

13.1
11.5

6.2
12.2

17.2
14.9
9.9

9.8
15.1
58 yr

3.5
8.6
24 yr

Age group

3.5

NA
NA
NA
NA
NA
NA
5.7
2.9
4.5
6.4

11.0
(9.412.7)
6.3
(4.09.5)
12.3
(9.116.2)
(95% CI)
Overall

Percent of VCD episodes among febrile episodes

10.9

10.8
(9.811.8)
7.0
(3.811.7)
12.1
(9.315.4)
7.9
(6.39.9)
11.1
(9.612.8)
12.1
8.5
10.3
14.7
(9.015.8) (6.411.0) (9.311.4) (11.917.9)

Total
Brazil
(N=3424) (N=1174)
Vietnam
(N=778)
Thailand
(N=392)
Philippines
(N=1166)
Indonesia
(N=623)

Malaysia
(N=465)

Asia
Variable

912 yr

Total
(N=6939)
Puerto Rico
(N=440)
Mexico
(N=1149)
Honduras
(N=931)
Colombia
(N=3245)

Latin America

Symptomatic Dengue in Children in Asia and Latin America

These two studies, conducted across 10 countries in which dengue is endemic, were similarly
designed and used the same methods and case
definitions, which enabled the capture of data
regarding symptomatic dengue episodes as well
as comparisons across countries, regions, and
age groups. We found that dengue-specific burdens varied extensively within each geographic
region and that all pediatric age groups were
affected.
The overall incidences of febrile episodes varied according to country and decreased with
increasing age. Although the overall incidence
appeared to be higher in the Asian cohort than
in the Latin American cohort, this disparity was
probably due in part to the younger age range of
the participants included in this cohort, among
whom the incidence of acute febrile disease is
expected to be higher.23,24 The similar overall
incidence in the comparable age groups (9 to 12
years of age and 13 to 16 years of age) suggests
that the burden of febrile disease among children 9 to 16 years of age was similar in the two
cohorts.
We found substantial burdens of dengue disease in all 10 countries; however, the incidence
of VCD overall and in the two comparable age
groups across the subcohorts was generally
higher in the Asian cohort than in the Latin
American cohort. Although the incidence rates
of dengue differ according to location and fluctuate according to year and season, our results
(4.6 episodes per 100 person-years in the Asian
cohort and 2.9 per 100 person-years in the Latin
American cohort) fall within the incidence ranges observed in other dengue cohort studies conducted in some of the same countries.18,19,25-27 For
example, the incidence of VCD among children
was reported to be 1.77 to 5.74 episodes per 100
person-years in Thailand in the period from
2006 through 2009,26 1.69 to 4.04 episodes per
100 person-years in Vietnam in the period from
2005 through 2007,25 and 1.34 episodes per 100
person-years in Puerto Rico in the period from

n engl j med 374;12nejm.org March 24, 2016

1161

1162

20

Indonesia
(N=623)

(95% CI)

NA

1718 yr

NA

0.4

n engl j med 374;12nejm.org March 24, 2016

NA

1718 yr

Overall

(95% CI)

0.6
(0.31.3)

Incidence no./100 person-yr

100.0

No. of episodes

DHF

40.0

53.8

912 yr

1316 yr

0.1
(0.00.6)

NA

25.0

60.0

40.0

37.5

24 yr

58 yr

0.3
(0.10.6)

NA

9.7

17.6

9.6

0.0

10.9
(6.516.9)

0.3
(0.00.9)

NA

33.3

33.3

22.2

20.0

27.7
(15.642.6)

NA

NA

NA

0.6

1.1

1.0

0.4

0.9
(0.71.1)

61

Total
(N=3424)

0.1
(0.00.5)

NA

10.0

8.0

0.0

0.0

0.3
(0.20.5)

20

NA

17.9

23.7

18.6

8.3

5.9
19.1
(1.216.2) (15.023.9)

NA

0.3

0.3

0.0

0.0

0.2
(0.00.6)

Vietnam
(N=778)

0.0
(0.00.2)

0.0

2.6

8.3

NA

NA

4.9
(1.412.2)

0.0

0.1

0.3

NA

NA

0.2
(0.10.5)

Brazil
(N=1174)

0.1
(0.00.2)

12.5

17.8

16.7

NA

NA

17.0
(11.623.6)

0.3

0.4

0.5

NA

NA

0.4
(0.30.6)

28

Colombia
(N=3245)

0.1
(0.00.4)

50.0

3.3

12.2

NA

NA

9.6
(3.918.8)

0.9

0.1

0.6

NA

NA

0.4
(0.20.8)

Honduras
(N=931)

0.0
(0.00.2)

0.0

6.5

4.5

NA

NA

5.3
(1.114.6)

0.0

0.2

0.1

NA

NA

0.1
(0.00.4)

Mexico
(N=1149)

0.1
(0.00.7)

50.0

0.0

0.0

NA

NA

7.7
(0.236.0)

1.0

0.0

0.0

NA

NA

0.1
(0.00.7)

0.1
(0.00.1)

10

13.6

9.4

12.3

NA

NA

11.1
(8.114.6)

0.3

0.3

0.4

NA

NA

0.3
(0.20.4)

43

Puerto Rico
Total
(N=440) (N=6939)

of

0.0

45.5
38.1
(95% CI) (30.461.2) (18.161.6)

1.6

2.1

1.5

1.1

1.6
(0.92.8)

13

0.5

1.3

0.7

0.0

0.7
(0.41.2)

17

Thailand
(N=392)

Latin America

n e w e ng l a n d j o u r na l

Age group

Overall

Asia
Philippines
(N=1166)

Percent of hospitalizations among VCD episodes

1.2

1316 yr

1.2

1.0

2.1

1.3

58 yr

0.0

0.9
(0.41.7)

Malaysia
(N=465)

1.8

1.6
(1.02.5)

912 yr

24 yr

Age group

Overall

Incidence no./100 person-yr

Total no.

Hospitalization

Variable

Table 3. Incidences of Hospitalization and Dengue Hemorrhagic Fever (DHF) among Participants with VCD in the Asian and Latin American Cohorts.*

The

m e dic i n e

NA

NA

(95% CI)

NA

NA

6.5

5.9

3.9

0.0

4.5
(1.89.0)

NA

0.3

0.4

0.3

0.0

Philippines
(N=1166)

NA

0.0

0.4

0.4

0.0

Thailand
(N=392)

NA

0.0

6.7

5.6

0.0

4.3
(0.514.5)

Asia

* Age groups were stratified according to age at episode onset.

NA

1718 yr

0.0

0.0

15.4

50.0

912 yr

1316 yr

20.0

20.0

16.7

0.0

4.8
(0.123.8)

24 yr

18.2
(8.232.7)

58 yr

Age group

Overall

Percent of DHF episodes among VCD episodes

1718 yr

0.0

0.0

0.4

0.6

912 yr

1316 yr

0.3

0.9

0.9

0.0

Malaysia
(N=465)

24 yr

Indonesia
(N=623)

58 yr

Age group

Variable

Table 3. (Continued.)

NA

0.0

8.0

0.0

0.0

3.9
(0.513.4)

NA

0.0

0.3

0.0

0.0

Vietnam
(N=778)

NA

5.4

7.0

7.1

2.8

6.3
(3.99.5)

NA

0.2

0.3

0.4

0.1

Total
(N=3424)

0.0

0.0

0.0

NA

NA

0.0
(0.04.5)

0.0

0.0

0.0

NA

NA

Brazil
(N=1174)

0.0

5.5

3.6

NA

NA

4.2
(1.78.6)

0.0

0.1

0.1

NA

NA

Colombia
(N=3245)

50.0

3.3

0.0

NA

NA

2.7
(0.39.6)

0.9

0.1

0.0

NA

NA

Honduras
(N=931)

0.0

0.0

0.0

NA

NA

0.0
(0.06.3)

0.0

0.0

0.0

NA

NA

Mexico
(N=1149)

Latin America

50.0

0.0

0.0

NA

NA

7.7
(0.236.0)

1.0

0.0

0.0

NA

NA

9.1

2.8

1.6

NA

NA

2.6
(1.24.7)

0.2

0.1

0.0

NA

NA

Puerto Rico
Total
(N=440) (N=6939)

Symptomatic Dengue in Children in Asia and Latin America

n engl j med 374;12nejm.org March 24, 2016

1163

The

n e w e ng l a n d j o u r na l

A Asian Cohort
Serotype 1

Serotype 2

Serotype 3

Serotype 4

100

Participants (%)

80

60

40

20

Indonesia
(N=42)

Malaysia
(N=20)

Philippines
(N=159)

Thailand
(N=46)

Vietnam
(N=48)

B Latin American Cohort

Serotype 1

Serotype 2

Serotype 3

Serotype 4

100

Participants (%)

80

60

40

20

Brazil
(N=81)

Colombia
(N=167)

Honduras
(N=65)

Mexico
(N=57)

Puerto Rico
(N=13)

Figure 1. Serotype Distributions in Episodes of Virologically Confirmed

Dengue, According to Country Subcohort in Asia and Latin America.
Dengue virus serotypes in blood samples that were obtained during episodes
of virologically confirmed dengue were determined by means of reversetranscriptasepolymerase-chain-reaction assay with the use of serotypespecific primers. The overall serotype distributions during the surveillance
period are shown for each country. Results include five episodes in the Asian
cohort (one in Indonesia and four in the Philippines) and eight in the Latin
American cohort (four in Colombia, one in Honduras, two in Mexico, and
one in Puerto Rico) that were coinfections with two dengue virus serotypes.

2005 through 2006.28 VCD accounted for approximately 10% of the febrile episodes across
the two cohorts. This percentage tended to increase with age in the two cohorts and within
most countries; in some of the oldest age groups,
it was more than 20%.
A total of 30 episodes of dengue hemorrhagic
1164

of

m e dic i n e

fever were observed in the studies. The incidence

in the Asian cohort (0.3 episodes per 100 person-years) was similar to the incidence of severe
dengue that has been found in other Asian cohort studies (0.1 to 0.7%).27 Owing to the active
nature of the surveillance used in our studies,
we consider these incidence rates of dengue
hemorrhagic fever to be accurate measures of
this disease in these otherwise-healthy, pediatric
community-based cohorts.
Although the indicators of dengue severity
(i.e., incidences of hospitalizations for VCD or
dengue hemorrhagic fever and the percentages
of VCD episodes for which the participant was
hospitalized or was found to have dengue hemorrhagic fever) varied according to country, they
were generally higher in Asia than in Latin
America, both overall and in the comparable age
groups. Whether this means that VCD is more
severe in Asia than in Latin America continues
to be a topic of discussion that involves complex
factors, including differences in disease burden
and virus genotype.29,30 Finally, since more than
70% of the hospitalizations for VCD episodes
(74 of 104 episodes overall) were not associated
with dengue hemorrhagic fever, it appears that
this milder presentation exerts a substantial hospitalization burden in some countries.
All the age groups in the subcohorts were affected by dengue. Overall, no age group in either
regional cohort was more clearly affected than
any other, although some age groups had higher
incidence rates in some countries. In the Asian
subcohorts, the incidence of VCD appeared to be
highest in either the group of participants who
were 5 to 8 years of age or the group of those
who were 9 to 12 years of age (depending on
country). In the Latin American cohort, the
highest incidence rates occurred in different age
groups (the group that was 17 to 18 years of age
in Brazil, Mexico, and Puerto Rico and the group
that was 9 to 12 years of age in Colombia and
Honduras). These findings are consistent with
recent reviews of reports that were based on
national surveillance.3,10-13,31-33 There were no observable trends according to age group with respect to the percentages of VCD episodes that
either required hospitalization or were found to
be dengue hemorrhagic fever.
Between 60 and 98% of the children who
were older than 13 years of age in these countries had been exposed to dengue before the

n engl j med 374;12nejm.org March 24, 2016

630 (84.0)
* Age groups were stratified according to age at inclusion. The value in parentheses is the seropositivity rate in the age group of the country subcohort.

43 (61.4)
75 (59.5)
105 (92.9)
324 (94.7)
83 (83.8)
256 (87.4)
17 (77.3)
32 (84.2)
119 (93.0)
56 (98.2)
1316 yr

32 (66.7)

955 (76.4)
42 (51.2)
97 (48.3)
154 (82.4)
526 (90.9)
136 (67.7)
482 (75.7)
90 (62.1)
93 (79.5)
139 (88.5)
101 (87.1)
912 yr

59 (57.8)

NA

NA
NA

NA
NA

NA
NA

NA
NA

NA
NA

NA
235 (50.0)

372 (62.1)
70 (49.3)

43 (44.3)
33 (48.5)

73 (61.9)
125 (74.9)

87 (58.0)
22 (32.4)
50 (57.5)

76 (84.4)

24 yr

58 yr

Age group no. (%)*

28 (34.1)

79.2
(77.481.0)

1585
85

55.9
(47.764.0)
52.6
(47.058.1)

172
259

86.3
(81.990.0)
92.3
(90.493.9)

850
219
1345
220
231
470
141

80.9
47.0
78.1
67.7
54.2
67.3
73.0
(76.384.9) (41.252.8) (74.681.3) (62.572.7) (49.259.1) (65.269.3) (67.677.9)

283
Total no.

% (95% CI)

2000
152
327
300
921
300
1999
406
341
602
300
350
Blood samples no.

n engl j med 374;12nejm.org March 24, 2016

Seropositive specimens

Puerto Rico
(N=440)
Mexico
(N=1149)
Honduras
(N=931)
Malaysia
(N=465)
Indonesia
(N=623)

Philippines
(N=1166)

Thailand
(N=392)

Vietnam
(N=778)

Total
(N=3424)

Brazil
(N=1174)

Colombia
(N=3245)

Latin America
Asia
Variable

Supported by Sanofi Pasteur.

Table 4. Dengue Seropositivity at Inclusion in the Asian and Latin American Cohorts.

start of the study. However, a link between the

various seropositivity rates in the subcohorts
and the incidence of VCD was not evident, which
further highlights the extensive geographic and
temporal variability of dengue epidemiology.
All four virus serotypes cocirculated in all
five Asian countries, with variations according
to country and over time. Serotype distributions
in the Latin American countries usually consisted of one or two predominant serotypes,
with minor changes over time. The different
serotype-distribution profiles in these two geographic regions have been linked to their different histories of dengue, with sustained hyperendemicity in Southeast Asia since World War II
versus widespread eradication of the Aedes aegypti
vector in Latin America in the 1950s, followed by
progressive reintroduction of the mosquito and
of dengue viruses.29 As serotypes continue to
spread in Latin America, serotype distributions
and the epidemiologic features of dengue may
eventually resemble those in Asia.
Our analysis has a few limitations. First, since
the countries were chosen for their high burdens
of dengue,20,21 generalization of these findings
to other countries in the region may be limited.
Furthermore, the cohorts included only healthy
children whose parents were willing to have
their children participate in a vaccine trial; the
disease-burden estimates in these children may
differ from those in other children in these
countries. Second, the ages of the participants
were selected on the basis of the highest incidence of dengue in each cohort but did not include the youngest children (<2 years of age) in
either geographic region and were not the same
across the two regions, which limited some
comparisons. Finally, with only 30 episodes of
dengue hemorrhagic fever observed in the two
cohorts, interpretations of the incidence of this
disease should be made with caution.
Our analysis of these pediatric cohorts showed
substantial and varied burdens of dengue disease among participants 2 to 16 years of age in
five Asian countries and among participants 9 to
18 years of age in five Latin American countries.
The disease burden was severe enough to cause
considerable rates of hospitalization and accounted for up to approximately 15% of the episodes of febrile disease in some countries.

Total
(N=6939)

Symptomatic Dengue in Children in Asia and Latin America

1165

Symptomatic Dengue in Children in Asia and Latin America

Disclosure forms provided by the authors are available with

the full text of this article at NEJM.org.
We thank all the parents and children who agreed to participate in these trials; the trial staff in the countries; the clinical
research organization staff who contributed to the successful

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Copyright 2016 Massachusetts Medical Society.

n engl j med 374;12nejm.org March 24, 2016

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