Cross-reactive antibodies (Abs) to epitopes that span envelope proteins on the virion surface are hypothesized to protect against dengue. Here, we measured Abs targeting the quaternary envelope dimer epitope (EDE) as well as neutralizing and binding Abs and evaluate their association with dengue virus (DENV) infection, vaccine response, and disease outcome in dengue vaccinated and unvaccinated children (n=252) within a longitudinal cohort in Cebu, Philippines (n=2,996). Abs targeting EDE were prevalent and strongly associated with broad neutralization of DENV1-4 in those with baseline multitypic immunity. Subsequent natural infection and vaccination boosted EDE-like, neutralizing, and binding Abs. EDE-like Abs were associated with reduced dengue risk and mediated the protective effect of binding and neutralizing Abs on symptomatic and severe dengue. Thus, Abs targeting quaternary epitopes help explain broad cross protection in those with multiple prior DENV exposures, making them useful for evaluation and development of future vaccines and therapeutics.

MY, MVC, JVD, KAA, AMC, and AKS report receiving salaries from 2017 onwards as part of an ongoing separate study (effectiveness of the tetravalent dengue vaccine, CYD-TDV [Dengvaxia] in the Philippines) sponsored by the University of the Philippines Manila and funded by Sanofi Pasteur. JD was an unpaid external consultant in the Extended Study Group for dengue vaccine effectiveness evaluation studies in Asia in 2015 convened by Sanofi Pasteur and is an unpaid investigator of an ongoing separate study (effectiveness of the tetravalent dengue vaccine, CYD-TDV [Dengvaxia] in the Philippines) sponsored by the University of the Philippines Manila and funded by Sanofi Pasteur. AMdS is listed as an inventor on pending patent applications filed by the University of North Carolina related to flavivirus diagnostics. All other authors declare no competing interests.

This research was supported by the Division of Intramural Research of the National Institute of Allergy and Infectious Diseases (to LCK). The longitudinal dengue cohort study (clinicaltrials.gov number: NCT03465254) was funded by the Philippine Department of Health, Hanako Foundation, World Health Organization, Swedish International Development Cooperation Agency through the International Vaccine Institute, University of North Carolina - Chapel Hill, La Jolla Institute of Immunology, the Sustainable Sciences Institute, and the US-NIH grant P01AI106695.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The study protocol was approved by the University of the Philippines - Manila Research Ethics Board (UPM-REB, protocol number: UPM REB 2016-435-01) and is registered at clinicaltrials.gov (NCT03465254). Parents or guardians provided written informed consent and children provided documented oral assent before participation in the study, in accordance with local regulations. All data were anonymized such that no patient identifiers were present in the data files received for analysis.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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This study did not generate new unique reagents. All data sources and programs used for analyses are detailed in the Methods section. All immunological data will be deposited in Immport and made available at the time of publication. Further information and requests for resources and reagents should be directed to and will be fulfilled by the lead contact, Leah C. Katzelnick (leah.katzelnick@nih.gov).