• 1.

    Leder K, Torresi J, Libman MD, Cramer JP, Castelli F, Schlagenhauf P, Wilder-Smith A, Wilson ME, Keystone JS, Schwartz E, Barnett ED, von Sonnenburg F, Brownstein JS, Cheng AC, Sotir MJ, Esposito DH, Freedman DO; GeoSentinel Surveillance Network, 2013. GeoSentinel surveillance of illness in returned traveler, 2007–2011. Ann Intern Med 158: 456468.

    • Search Google Scholar
    • Export Citation
  • 2.

    Sharp TM, Pillai P, Hunsperger E, Santiago GA, Anderson T, Vap T, Collinson J, Buss BF, Safranek TJ, Sotir MJ, Jentes ES, Munoz-Jordan JL, Arguello DF, 2012. A cluster of dengue cases in American missionaries returning from Haiti, 2010. Am J Trop Med Hyg 86: 1622.

    • Search Google Scholar
    • Export Citation
  • 3.

    Pan American Health Organization Wkly Epidemiol Rep, 2012. Number of reported cases of dengue and severe dengue (SD) in the Americas, by country - 15 December 2012 (EW 48). Available at: http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=19582&Itemid=2518.

    • Search Google Scholar
    • Export Citation
  • 4.

    Lombardo J, Burkom H, Elbert E, Magruder S, Lewis SH, Loschen W, Sari J, Sniegoski C, Wojcik R, Pavlin J, 2003. A systems overview of the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE II). J Urban Health 80 (2 Suppl 1): i32i42.

    • Search Google Scholar
    • Export Citation
  • 5.

    Santiago GA, Vergne E, Quiles Y, Cosme J, Vazquez J, Medina JF, Medina F, Colon C, Margolis H, Munoz-Jordan JL, 2013. Analytical and clinical performance of the CDC real time RT-PCR assay for detection and typing of dengue virus. PLoS Negl Trop Dis 7: e2311.

    • Search Google Scholar
    • Export Citation
  • 6.

    Vorndam V, Beltran M, 2002. Enzyme-linked immunosorbent assay-format microneutralization test for dengue viruses. Am J Trop Med Hyg 66: 208212.

    • Search Google Scholar
    • Export Citation
  • 7.

    World Health Organization, 2009. Dengue Guidelines for Diagnosis, Treatment, Prevention, and Control. Geneva: World Health Organization.

    • Search Google Scholar
    • Export Citation
  • 8.

    Lyerla R, Rigau-Perez JG, Vorndam AV, Reiter P, George AM, Potter IM, Gubler DJ, 2000. A dengue outbreak among camp participants in a Caribbean island, 1995. J Travel Med 7: 5963.

    • Search Google Scholar
    • Export Citation
  • 9.

    Centers for Disease C, 2010. Prevention: dengue fever among U.S. travelers returning from the Dominican Republic - Minnesota and Iowa, 2008. MMWR Morb Mortal Wkly Rep 59: 654656.

    • Search Google Scholar
    • Export Citation
  • 10.

    Guzman MG, Alvarez M, Halstead SB, 2013. Secondary infection as a risk factor for dengue hemorrhagic fever/dengue shock syndrome: an historical perspective and role of antibody-dependent enhancement of infection. Arch Virol 158: 14451459.

    • Search Google Scholar
    • Export Citation

 

 

 

Dengue Among American Missionaries Returning from Jamaica, 2012

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  • Tennessee Department of Health, Nashville, Tennessee; Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia; Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico; Travelers' Health Branch, Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, Georgia; Florida Department of Health, Tallahassee, Florida

Dengue is an acute febrile illness caused by any of four mosquito-transmitted dengue virus (DENV) types. Dengue is endemic in Jamaica, where an epidemic occurred in 2012. An investigation was conducted by multiple agencies for 66 missionaries traveling from nine US states to Jamaica after 1 missionary from the group was confirmed to have dengue. Travelers were offered diagnostic testing, and a survey was administered to assess knowledge, behaviors, and illness. Of 42 survey respondents, 9 (21%) respondents reported an acute febrile illness during or after travel to Jamaica. Of 15 travelers that provided serum specimens, 4 (27%) travelers had detectable anti-DENV immunoglobulin M antibody, and 1 traveler also had DENV-1 detected by reverse transcriptase polymerase chain reaction. Recent or past infection with a DENV was evident in 93% (13 of 14) missionaries with available sera. No behavioral or demographic factors were significantly associated with DENV infection. This investigation shows that even trips of short duration to endemic areas present a risk of acquiring dengue.

Dengue is an acute febrile illness caused by four mosquito-transmitted dengue virus (DENV) types (1–4) that are endemic throughout the tropics and a leading cause of morbidity among travelers returning from the Caribbean.1,2 Dengue is endemic in Jamaica, where an epidemic occurred in 2012.3 The Pan American Health Organization reported DENV-1 to be circulating in Jamaica during this outbreak.3

On August 2, 2012, a woman presented to a Florida emergency department because of an acute febrile illness and was clinically diagnosed with dengue. After being identified by the Electronic Surveillance System for the Early Notification of Community-Based Epidemics–Florida (ESSENCE-FL), a syndromic surveillance system operated by the Florida Department of Health (FDOH), subsequent investigation revealed recent travel to Jamaica.4 Dengue diagnostic testing performed at the FDOH detected anti-DENV immunoglobulin M (IgM) antibodies in a serum specimen. After learning that the traveler was part of a larger missionary organization based in Tennessee, the FDOH notified the Centers for Disease Control and Prevention (CDC) and the Tennessee Department of Health (TDH) of the case. With assistance from the CDC, the TDH ascertained that 66 missionaries traveled from nine US states to Old Harbor, Jamaica (49 missionaries from July 13 to 21, 2012 and 17 missionaries from July 21 to 29, 2012) to provide medical services and religious education in the community. The TDH initiated an investigation to describe the clinical and laboratory characteristics of DENV-infected and -uninfected travelers and document travelers' pre-travel knowledge about dengue and mosquito avoidance practices while in Jamaica.

A survey was developed using Survey Monkey (SurveyMonkey Inc., Palo Alto, CA) and distributed to travelers by e-mail from missionary group leaders. Travelers were asked whether they received a pre-travel health consultation and about their pre-travel knowledge of dengue, mosquito avoidance strategies used while in Jamaica, and illness during or after travel. All travelers were offered diagnostic testing for current or recent DENV infection by reverse transcriptase polymerase chain reaction (RT-PCR)5 and anti-DENV IgM enzyme-linked immunosorbent assay (ELISA; InBios International, Inc., Seattle WA), respectively. Serum specimens were tested by multiplex, DENV type-specific, real-time RT-PCR. Microneutralization assays6 were performed on all specimens to characterize antibody profiles. Survey data were entered into Microsoft Excel (Microsoft Corp., Redmond, WA) and analyzed using SAS, v.9.3 (SAS Institute, Cary, NC).

Of 66 travelers, 42 (64%) travelers returned the survey, and 15 (23%) travelers submitted a serum specimen for dengue diagnostic testing. All respondents were born in the United States, and most (76%) had previously lived and/or traveled outside of the continental United States. One (2%) respondent reported having been diagnosed with West Nile virus infection before traveling to Jamaica, and another (2%) traveler reported vaccination against yellow fever virus; neither respondent provided a serum specimen.

Nine (21%) respondents reported an acute febrile illness during or after travel to Jamaica. The most frequently reported symptoms were fever and chills (100%) and loss of appetite and weakness (89%). Of 15 travelers who provided serum specimens, 4 (27%) travelers had detectable anti-DENV IgM antibodies (i.e., recent DENV infection), and 1 of those travelers also had DENV-1 detected by RT-PCR (i.e., current DENV infection) (Table 1). All travelers with current or recent DENV infection reported an illness consistent with dengue.7 Recent or past infection with DENV was evident in 13 (93%) of 14 missionaries with available sera, including 3 of 7 missionaries with evidence of prior infection with DENV-4 who had only previously traveled to Jamaica.

Table 1

Diagnostic test results of travelers (N = 15) who visited Jamaica in July of 2012 and submitted a serum specimen for dengue diagnostic testing

Traveler no.Days from return to specimen collectionRT-PCRIgM ELISAMicroneutralization titersOverall interpretationFebrile illness after travel?*Past travel to dengue-endemic area?
DENV-1DENV-2DENV-3DENV-4
131NegNeg< 40< 40< 40160Past infection with DENV-4NoYes
26DENV-1Neg> 2,560> 2,560> 2,5601,280Current infection with DENV-1YesYes
 19NPPos> 2,56032040160   
325NPPos> 2,560640> 2,5601,280Recent DENV infectionYesYes
418NegNegQNSQNSQNSQNSUNKNoYes
5UNKNegNeg160< 40160160Past DENV infectionUNKUNK
6UNKNegNeg< 40< 401,28080Past infection with DENV-3UNKUNK
7UNKNPPos> 2,560> 2,560> 2,560> 2,560Recent DENV infectionUNKUNK
8UNKNegNeg< 40< 40160640Past infection with DENV-4UNKUNK
937NegNeg< 40< 40160> 2,560Past infection with DENV-4NoYes
1037NPNeg< 40< 40< 40160Past infection with DENV-4NoYes
1137NegNeg< 40< 40< 40> 2,560Past infection with DENV-4NoNo
1234NegNeg40< 40< 40> 2,560Past infection with DENV-4NoYes
1331NegNeg< 40< 40< 40< 40NoneNoYes
1430NPNeg< 40< 40< 4080Past infection with DENV-4NoYes
1516NegPos> 2,560> 2,5603201,280Recent DENV infectionYesYes

Fever within 2 weeks of return from travel.

Traveler likely acquired the infection during the recent trip to Jamaica, because there was no past travel to a dengue-endemic area.

Neg = negative; NP = not performed; Pos = positive; QNS = quantity not sufficient; UNK = missing value.

Ten (24%) of forty-two respondents had a pre-travel health consultation with a healthcare provider. Of these 10 respondents, 1 (10%) respondent reported consultation at a travel clinic, and the other 9 (90%) respondents reported consultation at a private clinic or doctor's office. During the consultation, three (30%) individuals received information about mosquito bite avoidance, and one (10%) individual received information about dengue. While in Jamaica, 17 (40%) of 42 travelers used insect repellent, and 17 (40%) of 42 travelers wore long pants all of the time. Nine (21%) travelers had heard of dengue before the trip. None of these factors were significantly associated with DENV infection.

This is the fourth recent investigation of a cohort of travelers returning from the Caribbean with dengue2,8,9 and the first report of travelers returning from Jamaica with dengue. Detection of the initial dengue case was enabled by a syndromic surveillance system that uses statistical modeling and daily downloads from almost 200 statewide emergency and urgent care departments to flag possible cases of diseases with epidemic potential. Subsequent investigation enabled identification of a multistate travel-associated dengue outbreak. Although these travelers spent just 1 week in Jamaica, one-quarter of survey respondents had symptoms consistent with dengue, and more than one-quarter of those respondents who submitted a serum specimen had evidence of acute or recent DENV infection. Several travelers also had evidence of prior DENV infection, likely from previous trips to dengue-endemic areas.

Any travel to dengue-endemic areas presents risk of DENV infection, even trips of short duration. Few respondents in this investigation had a pre-travel healthcare visit or were aware of dengue before the trip, and less than one-half used mosquito repellent while in Jamaica. Less than one-quarter of respondents had heard of dengue, and none acknowledged previous illness caused by dengue. Nonetheless, nearly all travelers that provided a serum specimen had evidence of prior DENV infection, which is a risk factor for severe illness after subsequent infection with DENV.10 Travelers to dengue-endemic areas, including Jamaica, should be aware of the risk of dengue at their destination, receive dengue education during pre-travel health consultations, follow mosquito avoidance recommendations, and seek medical care for febrile illness during or after travel. Because there is currently no vaccine available to prevent dengue, travelers should be made aware of the importance of reducing mosquito bites as the sole means of dengue prevention during travel to endemic areas. To better prepare for introduction of a dengue vaccine, future studies should identify the types of travelers most at risk of DENV infection to enable vaccine recommendations based on level of risk.

  • 1.

    Leder K, Torresi J, Libman MD, Cramer JP, Castelli F, Schlagenhauf P, Wilder-Smith A, Wilson ME, Keystone JS, Schwartz E, Barnett ED, von Sonnenburg F, Brownstein JS, Cheng AC, Sotir MJ, Esposito DH, Freedman DO; GeoSentinel Surveillance Network, 2013. GeoSentinel surveillance of illness in returned traveler, 2007–2011. Ann Intern Med 158: 456468.

    • Search Google Scholar
    • Export Citation
  • 2.

    Sharp TM, Pillai P, Hunsperger E, Santiago GA, Anderson T, Vap T, Collinson J, Buss BF, Safranek TJ, Sotir MJ, Jentes ES, Munoz-Jordan JL, Arguello DF, 2012. A cluster of dengue cases in American missionaries returning from Haiti, 2010. Am J Trop Med Hyg 86: 1622.

    • Search Google Scholar
    • Export Citation
  • 3.

    Pan American Health Organization Wkly Epidemiol Rep, 2012. Number of reported cases of dengue and severe dengue (SD) in the Americas, by country - 15 December 2012 (EW 48). Available at: http://www.paho.org/hq/index.php?option=com_docman&task=doc_view&gid=19582&Itemid=2518.

    • Search Google Scholar
    • Export Citation
  • 4.

    Lombardo J, Burkom H, Elbert E, Magruder S, Lewis SH, Loschen W, Sari J, Sniegoski C, Wojcik R, Pavlin J, 2003. A systems overview of the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE II). J Urban Health 80 (2 Suppl 1): i32i42.

    • Search Google Scholar
    • Export Citation
  • 5.

    Santiago GA, Vergne E, Quiles Y, Cosme J, Vazquez J, Medina JF, Medina F, Colon C, Margolis H, Munoz-Jordan JL, 2013. Analytical and clinical performance of the CDC real time RT-PCR assay for detection and typing of dengue virus. PLoS Negl Trop Dis 7: e2311.

    • Search Google Scholar
    • Export Citation
  • 6.

    Vorndam V, Beltran M, 2002. Enzyme-linked immunosorbent assay-format microneutralization test for dengue viruses. Am J Trop Med Hyg 66: 208212.

    • Search Google Scholar
    • Export Citation
  • 7.

    World Health Organization, 2009. Dengue Guidelines for Diagnosis, Treatment, Prevention, and Control. Geneva: World Health Organization.

    • Search Google Scholar
    • Export Citation
  • 8.

    Lyerla R, Rigau-Perez JG, Vorndam AV, Reiter P, George AM, Potter IM, Gubler DJ, 2000. A dengue outbreak among camp participants in a Caribbean island, 1995. J Travel Med 7: 5963.

    • Search Google Scholar
    • Export Citation
  • 9.

    Centers for Disease C, 2010. Prevention: dengue fever among U.S. travelers returning from the Dominican Republic - Minnesota and Iowa, 2008. MMWR Morb Mortal Wkly Rep 59: 654656.

    • Search Google Scholar
    • Export Citation
  • 10.

    Guzman MG, Alvarez M, Halstead SB, 2013. Secondary infection as a risk factor for dengue hemorrhagic fever/dengue shock syndrome: an historical perspective and role of antibody-dependent enhancement of infection. Arch Virol 158: 14451459.

    • Search Google Scholar
    • Export Citation

Author Notes

* Address correspondence to Abelardo C. Moncayo, 630 Hart Lane, Nashville, TN 37216. E-mail: [email protected]

Authors' addresses: Abelardo C. Moncayo, Vector-Borne Diseases Section, Communicable and Environmental Diseases Services, Tennessee Department of Health, Nashville, TN, E-mail: [email protected]. Jane Baumblatt, Vector-Borne Diseases Section, Communicable and Environmental Diseases Services, Tennessee Department of Health, Nashville, TN, and Epidemic Intelligence Services, Centers for Disease Control and Prevention, Atlanta, GA, E-mail: [email protected]. Dana Thomas, Kira A. Harvey, and Mark Sotir, Division of Global Migration and Quarantine, Traveler's Health Branch, Centers for Disease Control and Prevention, Atlanta, GA, E-mails: [email protected], [email protected], and [email protected]. David Atrubin and Danielle Stanek, Division of Disease Control and Prevention, Florida Department of Health, Tallahassee, FL, E-mails: [email protected] and [email protected]. Elizabeth Hunsperger, Tyler M. Sharp, and D. Fermin Arguello, Division of Vector-Borne Infectious Disease, Dengue Branch, Centers for Diseases Control and Prevention, San Juan, Puerto Rico, E-mails: [email protected], [email protected], and [email protected]. Jorge L. Muñoz-Jordan, Dengue Branch, Centers for Diseases Control and Prevention, San Juan, Puerto Rico, E-mail: [email protected]. Emily S. Jentes, Division of Global Migration and Quarantine, Centers for Diseases Control and Prevention, Atlanta, GA, E-mail: [email protected].

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