Increasing transmission of dengue virus across ecologically diverse regions of Ecuador and associated risk factors

Abstract

The distribution and intensity of viral diseases transmitted by Aedes aegypti mosquitoes, including dengue, have rapidly increased over the last century. Ecuador is an interesting country to study drivers of dengue virus (DENV) transmission given it has multiple ecologically and demographically distinct regions. Here, we analyze province-level age-stratified dengue prevalence data from 2000-2019 using catalytic models to estimate the force of infection of DENV over eight decades and across provinces in Ecuador. We found that provinces established endemic DENV transmission at different time periods. Coastal provinces with the largest and most connected cities had the earliest and highest increase in DENV transmission, starting around 1980 and continuing to the present. In contrast, remote and rural areas with reduced access, like the northern coast and the Amazon regions, experienced a rise in DENV transmission and endemicity only in the last 10 to 20 years. The newly introduced chikungunya and Zika viruses have distinct age-specific prevalence distributions consistent with recent emergence across all provinces. We evaluated factors to the resolution of 1 hectare associated with geographic differences in vector suitability and arbovirus disease in the last 10 years by modeling 11,693 A aegypti presence points and 73,550 arbovirus cases. In total, 56% of the population of Ecuador lives in areas with high risk of Aedes aegypti. Most suitable provinces had hotspots for arbovirus disease risk, with population size, elevation, sewage connection, trash collection, and access to water as important determinants. Our investigation serves as a case study of the changes driving the expansion of DENV and other arboviruses globally and suggest that control efforts should be expanded to semi-urban and rural areas and to historically isolated regions to counteract increasing dengue outbreaks.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This research was supported by the Intramural Research Program of the National Institute of Allergy and Infectious Diseases (to LCK) and the National Institutes of Health Grant R01AI323721 (to JE and JC), and the Secretary of Higher Education, Science, Technology and Innovation (SENESCYT) Grant PIC-12-INH-002 (to PP and VC). LCK was supported in part by the Global Health Equity Scholars Program NIH Fogarty International Center training grant D43TW010540. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Author Declarations

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:

Human subjects data sets were from anonymized public health surveillance data collected by the Ecuadorian Ministry of Health as part of routine care. The Instituto Nacional de Estadistica y Censos (INEC) data used in this study is freely available from an institutional website (https://www.ecuadorencifras.gob.ec/camas-y-egresos-hospitalarios/) and is completely anonymous. According to the international good clinical and research practice and in accordance with Ecuadorian legislation on clinical investigation, ethical approval by an institutional review board was not required. The public surveillance data collected by the Ecuador Ministry of Health (Sistema Nacional de Vigilancia en Salud Publica Ecuador, ViEpi data) was made available for research purposes without confidential information (anonymous), under the "Organic Law of Transparency and Access to Public Information" (Article 4 of Ley Organica de Transparencia y Acceso a la Informacion Publica, LOTAIP, Law 24 of Article 81 of the Ecuadorian Constitution).

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.

Yes

Data Availability

The data sources and programs used for analyses are detailed in the Methods section. The code and data for all force of infection models will be made available on Zenodo at the time of publication.

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