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Underrecognition of Dengue during 2013 Epidemic in Luanda, Angola - Volume 21, Number 8—August 2015 - Emerging Infectious Disease journal - CDC

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Underrecognition of Dengue during 2013 Epidemic in Luanda, Angola - Volume 21, Number 8—August 2015 - Emerging Infectious Disease journal - CDC



Volume 21, Number 8—August 2015

Synopsis

Underrecognition of Dengue during 2013 Epidemic in Luanda, Angola

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Tyler M. SharpComments to Author , Rosa Moreira, Maria José Soares, Lúis Miguel da Costa, Jennifer Mann, Mark DeLorey, Elizabeth Hunsperger, Jorge L. Muñoz-Jordán, Candimar Colón, Harold S. Margolis, Adelaide de Caravalho, and Kay M. Tomashek
Author affiliations: Centers for Disease Control and Prevention, San Juan, Puerto Rico, USA (T.M. Sharp, E. Hunsperger, J.L. Muñoz-Jordán, C. Colón, H.S. Margolis, K.M. Tomashek); Field Epidemiology and Laboratory Training Program–Centers for Disease Control and Prevention, Luanda, Angola (R. Moreira); Ministry of Health of Angola, Luanda (M.S. Soares, L.M. da Costa, A. de Caravalho); Center for Global Health–Centers for Disease Control and Prevention, Luanda (J. Mann); Centers for Disease Control and Prevention, Fort Collins, Colorado, USA (M. DeLorey)

Abstract

During the 2013 dengue epidemic in Luanda, Angola, 811 dengue rapid diagnostic test–positive cases were reported to the Ministry of Health. To better understand the magnitude of the epidemic and identify risk factors for dengue virus (DENV) infection, we conducted cluster surveys around households of case-patients and randomly selected households 6 weeks after the peak of the epidemic. Of 173 case cluster participants, 16 (9%) exhibited evidence of recent DENV infection. Of 247 random cluster participants, 25 (10%) had evidence of recent DENV infection. Of 13 recently infected participants who had a recent febrile illness, 7 (54%) had sought medical care, and 1 (14%) was hospitalized with symptoms consistent with severe dengue; however, none received a diagnosis of dengue. Behavior associated with protection from DENV infection included recent use of mosquito repellent or a bed net. These findings suggest that the 2013 dengue epidemic was larger than indicated by passive surveillance data.
Dengue is a potentially fatal acute febrile illness caused by any of 4 mosquito-transmitted dengue viruses (DENV-1–4). The disease is endemic throughout the tropics (1), but is underrecognized in sub-Saharan Africa (2,3), where an estimated 64 million DENV infections occurred in 2010 (4). Although dengue was identified in travelers returning from Angola in the 1980s (5), locally acquired cases had not been reported until an outbreak in 2013 that was initially thought to have resulted from importation of DENV by immigrant workers from Asia. However, the only virus detected during the outbreak was a strain of DENV-1 that molecular epidemiologic analysis indicated had been circulating in western and west-central Africa for roughly 4 decades (6–9), demonstrating regional endemicity of dengue.
During the 2013 epidemic, the Angola Ministry of Health was notified of a total of 1,214 dengue case-patients, nearly all (98%) of whom resided in the capital, Luanda, which has an estimated population of 3–14 million (Angola Ministry of Health and World Health Organization, unpub. data). Serum specimens from suspected cases were tested with a dengue rapid diagnostic test (RDT; SD BIOLINE Dengue Duo, Standard Diagnostics, Haryana, India), and positive cases were defined by detection of nonstructural protein 1 antigen, anti-DENV IgM, or both. In total, specimens from 811 (67%) persons with suspected dengue tested RDT-positive, including those from 246 (30%) hospitalized patients and from 11 (1.4%) patients who died. The highest weekly incidence occurred during May 17–23, 2013, when 125 cases were reported, of which 101 (81%) were RDT-positive.
Dengue is a focal disease, and cases frequently cluster around the households of infected persons (10,11). Previous household-based cluster investigations in Indonesia (12), Nicaragua (13), Thailand (14), and Vietnam (15) demonstrated DENV infection rates of 2.2%–12.4% among persons residing within 10–100 m of index case-patients. These studies enabled detection of unrecognized dengue cases and identification of household risk factors for DENV infection, such as the presence of uncovered water storage containers (12) and lack of piped household water supply (14). Household-based cluster investigations are therefore a useful tool to estimate the extent of dengue in regions where case reporting may be suboptimal and can also facilitate identification of local risk factors for DENV infection.
Dr. Sharp is a lieutenant commander in the US Public Health Service and a health scientist at CDC Dengue Branch in San Juan, Puerto Rico. His research and public health interests include the epidemiology and pathobiology of dengue and other tropical acute febrile illnesses.

Acknowledgments

We thank Isabel Joao for assistance with field investigation logistics, Victor Luteganya for assistance with data management, Sheryl Shapiro and Jacqueline Weaver for assistance with specimen shipment, Laura Wright for assistance with map creation, and Ray A. Arthur and Serena Fuller for outbreak response support and coordination.
We acknowledge the CDC Global Disease Detection Operations Center Outbreak Response Contingency Fund for financial support of the field investigation.

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Suggested citation for this article: Sharp TM, Moreira R, Soares MJ, da Costa LM, Mann J, DeLorey M, et al. Underrecognition of dengue during 2013 epidemic in Luanda, Angola. Emerg Infect Dis. 2015 Aug [date cited]. http://dx.doi.org/10.3201/eid2108.150368
DOI: 10.3201/eid2108.150368
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