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1.  Discriminating Malaria from Dengue Fever in Endemic Areas: Clinical and Biological Criteria, Prognostic Score and Utility of the C-Reactive Protein: A Retrospective Matched-Pair Study in French Guiana 
Background
Dengue and malaria are two major public health concerns in tropical settings. Although the pathogeneses of these two arthropod-borne diseases differ, their clinical and biological presentations are unspecific. During dengue epidemics, several hundred patients with fever and diffuse pain are weekly admitted at the emergency room. It is difficult to discriminate them from patients presenting malaria attacks. Furthermore, it may be impossible to provide a parasitological microscopic examination for all patients. This study aimed to establish a diagnostic algorithm for communities where dengue fever and malaria occur at some frequency in adults.
Methodology/Principal Findings
A sub-study using the control groups of a case-control study in French Guiana – originally designed to compare dengue and malaria co-infected cases to single infected cases – was performed between 2004 and 2010. In brief, 208 patients with malaria matched to 208 patients with dengue fever were compared in the present study. A predictive score of malaria versus dengue was established using .632 bootstrap procedures. Multivariate analysis showed that male gender, age, tachycardia, anemia, thrombocytopenia, and CRP>5 mg/l were independently associated with malaria. The predictive score using those variables had an AUC of 0.86 (95%CI: 0.82–0.89), and the CRP was the preponderant predictive factor. The sensitivity and specificity of CRP>5 mg/L to discriminate malaria from dengue were of 0.995 (95%CI: 0.991–1) and 0.35 (95%CI 0.32–0.39), respectively.
Conclusions/Significance
The clinical and biological score performed relatively well for discriminating cases of dengue versus malaria. Moreover, using only the CRP level turned to be a useful biomarker to discriminate feverish patients at low risk of malaria in an area where both infections exist. It would avoid more than 33% of unnecessary parasitological examinations with a very low risk of missing a malaria attack.
Author Summary
The authors present a retrospective matched-pair study on dengue and malaria performed in French Guiana. These two infections are major public health concerns in tropical regions, especially in South America and Southeast Asia, where they affect neglected populations which makes them interesting to be published in a journal aiming to publish about neglected tropical diseases. Although the pathogeneses of these two arthropod-borne differ, their clinical and biological presentations are unspecific. During dengue epidemics, hundreds of patients are admitted weekly with diffuse pains and fever at the emergency room. Among them, it is difficult to accurately distinguish malaria attacks, which are far less frequent than dengue fever cases. Moreover, it may be impossible to provide a parasitological microscopic examination for all patients. We believe the results of the present study, based on a sample of n = 416 individual are worthwhile as they support evidence that biological factors can help to discriminate between the two, in areas where they co-exist in endemic areas. A simple prognostic score based on clinical and biological criteria was built, interesting and easy-to-use for physicians in tropical areas.
doi:10.1371/journal.pntd.0002420
PMCID: PMC3772026  PMID: 24069477
2.  Cross-reactivities between human IgMs and the four serotypes of dengue virus as probed with artificial homodimers of domain-III from the envelope proteins 
BMC Infectious Diseases  2013;13:302.
Background
Dengue fever is the most important vector-borne viral disease. Four serotypes of dengue virus, DENV1 to DENV4, coexist. Infection by one serotype elicits long-lasting immunity to that serotype but not the other three. Subsequent infection by a different serotype is a risk factor for severe dengue. Domain III (ED3) of the viral envelope protein interacts with cell receptors and contains epitopes recognized by neutralizing antibodies. We determined the serotype specificity and cross-reactivity of human IgMs directed against ED3 by using a well-characterized collection of 90 DENV-infected and 89 DENV-uninfected human serums.
Methods
The recognitions between the four serotypes of ED3 and the serums were assayed with an IgM antibody-capture ELISA (MAC-ELISA) and artificial homodimeric antigens. The results were analyzed with Receiving Operator Characteristic (ROC) curves.
Results
The DENV-infected serums contained IgMs that reacted with one or several ED3 serotypes. The discrimination by ED3 between serums infected by the homotypic DENV and uninfected serums varied with the serotype in the decreasing order DENV1 > DENV2 > DENV3 > DENV4. The ED3 domain of DENV1 gave the highest discrimination between DENV-infected and DENV-uninfected serums, whatever the infecting serotype, and thus behaved like a universal ED3 domain for the detection of IgMs against DENV. Some ED3 serotypes discriminated between IgMs directed against the homotypic and heterotypic DENVs. The patterns of cross-reactivities and discriminations varied with the serotype.
Conclusions
The results should help better understand the IgM immune response and protection against DENV since ED3 is widely used as an antigen in diagnostic assays and an immunogen in vaccine candidates.
doi:10.1186/1471-2334-13-302
PMCID: PMC3701519  PMID: 23815496
Cross-reactivity; Dengue Virus; Discrimination; Flavivirus; Human Serums; Immunoglobulin M; MAC-ELISA; ROC Curve; Serotype; Specificity
3.  Virological Surveillance of Dengue in Saint Martin and Saint Barthélemy, French West Indies, Using Blood Samples on Filter Paper 
To strengthen active dengue surveillance in Saint Martin and Saint Barthélemy, two French Caribbean islands, we evaluated the epidemiological usefulness of collecting blood samples from NS1-positive dengue patients on filter paper to identify the dengue serotypes circulating in these regions during a 27-month period. This approach allowed dengue serotypes to be identified by reverse transcriptase-polymerase chain reaction in 90.1% of the total set of 666 samples analyzed and, in 95.5% of the samples collected during the acute phase of the disease. This prospective virological surveillance using blood samples absorbed onto filter paper, which were stored at 4°C and shipped at ambient temperature to a specialized laboratory for analysis, allowed us to avoid the logistic and financial costs associated with shipping frozen venous blood samples. This surveillance system offers a low-cost alternative for reinforcing dengue prevention in areas where specialized laboratories do not exist, notably by facilitating the early detection of potentially new dengue serotypes.
doi:10.4269/ajtmh.2012.11-0475
PMCID: PMC3247125  PMID: 22232467
4.  Complete Genome Sequence of a Novel Hantavirus Variant of Rio Mamoré Virus, Maripa Virus, from French Guiana 
Journal of Virology  2012;86(9):5399.
We report the first complete genome sequence of Maripa virus identified in 2009 from a patient with hantavirus pulmonary syndrome in French Guiana. Maripa virus corresponds to a new variant of the Rio Mamoré virus species in the Bunyaviridae family, genus Hantavirus.
doi:10.1128/JVI.00337-12
PMCID: PMC3347398  PMID: 22492924
5.  Is dengue and malaria co-infection more severe than single infections? A retrospective matched-pair study in French Guiana 
Malaria Journal  2012;11:142.
Background
Dengue and malaria are two major arthropod-borne infections in tropical areas, but dual infections were only described for the first time in 2005. Reports of these concomitant infections are scarce and there is no evidence of more severe clinical and biological pictures than single infections.
Methods
To compare co-infections to dengue alone and malaria alone, a retrospective matched-pair study was conducted between 2004 and 2010 among patients admitted in the emergency department of Cayenne hospital, French Guiana.
Results
104 dengue and malaria co-infection cases were identified during the study period and 208 individuals were matched in two comparison groups: dengue alone and malaria alone. In bivariate analysis, co-infection clinical picture was more severe than separated infections, in particular using the severe malaria WHO criteria. In multivariate analysis, independent factors associated with co-infection versus dengue were: masculine gender, CRP level > 50 mg/L, thrombocytopaenia < 50 109/L, and low haematocrit <36% and independent factors significantly associated with co-infections versus malaria were red cells transfusion, low haematocrit < 36%, thrombocytopaenia < 50 109/L and low Plasmodium parasitic load < 0.001%.
Conclusions
In the present study, dengue and malaria co-infection clinical picture seems to be more severe than single infections in French Guiana, with a greater risk of deep thrombocytopaenia and anaemia.
doi:10.1186/1475-2875-11-142
PMCID: PMC3403992  PMID: 22549018
Dengue; Malaria; French Guiana; Thrombocytopaenia; Case–control studies
6.  First Human Rabies Case in French Guiana, 2008: Epidemiological Investigation and Control 
Background
Until 2008, human rabies had never been reported in French Guiana. On 28 May 2008, the French National Reference Center for Rabies (Institut Pasteur, Paris) confirmed the rabies diagnosis, based on hemi-nested polymerase chain reaction on skin biopsy and saliva specimens from a Guianan, who had never travelled overseas and died in Cayenne after presenting clinically typical meningoencephalitis.
Methodology/Principal Findings
Molecular typing of the virus identified a Lyssavirus (Rabies virus species), closely related to those circulating in hematophagous bats (mainly Desmodus rotundus) in Latin America. A multidisciplinary Crisis Unit was activated. Its objectives were to implement an epidemiological investigation and a veterinary survey, to provide control measures and establish a communications program. The origin of the contamination was not formally established, but was probably linked to a bat bite based on the virus type isolated. After confirming exposure of 90 persons, they were vaccinated against rabies: 42 from the case's entourage and 48 healthcare workers. To handle that emergence and the local population's increased demand to be vaccinated, a specific communications program was established using several media: television, newspaper, radio.
Conclusion/Significance
This episode, occurring in the context of a Department far from continental France, strongly affected the local population, healthcare workers and authorities, and the management team faced intense pressure. This observation confirms that the risk of contracting rabies in French Guiana is real, with consequences for population educational program, control measures, medical diagnosis and post-exposure prophylaxis.
Author Summary
Until 2008, rabies had never been described within the French Guianan human population. Emergence of the first case in May 2008 in this French Overseas Department represented a public health event that markedly affected the local population, healthcare workers and public health authorities. The antirabies clinic of French Guiana, located at Institut Pasteur de la Guyane, had to reorganize its functioning to handle the dramatically increased demand for vaccination. A rigorous epidemiological investigation and a veterinary study were conducted to identify the contamination source, probably linked to a bat bite, and the exposed population. Communication was a key factor to controlling this episode and changing the local perception of this formerly neglected disease. Because similar clinical cases had previously been described, without having been diagnosed, medical practices must be adapted and the rabies virus should be sought more systematically in similarly presenting cases. Sharing this experience could be useful for other countries that might someday have to manage such an emergence.
doi:10.1371/journal.pntd.0001537
PMCID: PMC3283561  PMID: 22363830
7.  Clinical and Virological Study of Dengue Cases and the Members of Their Households: The Multinational DENFRAME Project 
Background
Dengue has emerged as the most important vector-borne viral disease in tropical areas. Evaluations of the burden and severity of dengue disease have been hindered by the frequent lack of laboratory confirmation and strong selection bias toward more severe cases.
Methodology
A multinational, prospective clinical study was carried out in South-East Asia (SEA) and Latin America (LA), to ascertain the proportion of inapparent dengue infections in households of febrile dengue cases, and to compare clinical data and biological markers from subjects with various dengue disease patterns. Dengue infection was laboratory-confirmed during the acute phase, by virus isolation and detection of the genome. The four participating reference laboratories used standardized methods.
Principal Findings
Among 215 febrile dengue subjects—114 in SEA and 101 in LA—28 (13.0%) were diagnosed with severe dengue (from SEA only) using the WHO definition. Household investigations were carried out for 177 febrile subjects. Among household members at the time of the first home visit, 39 acute dengue infections were detected of which 29 were inapparent. A further 62 dengue cases were classified at early convalescent phase. Therefore, 101 dengue infections were found among the 408 household members. Adding these together with the 177 Dengue Index Cases, the overall proportion of dengue infections among the study participants was estimated at 47.5% (278/585; 95% CI 43.5–51.6). Lymphocyte counts and detection of the NS1 antigen differed significantly between inapparent and symptomatic dengue subjects; among inapparent cases lymphocyte counts were normal and only 20% were positive for NS1 antigen. Primary dengue infection and a specific dengue virus serotype were not associated with symptomatic dengue infection.
Conclusion
Household investigation demonstrated a high proportion of household members positive for dengue infection, including a number of inapparent cases, the frequency of which was higher in SEA than in LA.
Author Summary
Dengue is the most important mosquito-borne viral disease in humans. This disease is now endemic in more than 100 countries and threatens more than 2.5 billion people living in tropical countries. It currently affects about 50 to 100 million people each year. It causes a wide range of symptoms, from an inapparent to mild dengue fever, to severe forms, including dengue hemorrhagic fever. Currently no specific vaccine or antiviral drugs are available. We carried out a prospective clinical study in South-East Asia and Latin America, of virologically confirmed dengue-infected patients attending the hospital, and members of their households. Among 215 febrile dengue subjects, 177 agreed to household investigation. Based on our data, we estimated the proportion of dengue-infected household members to be about 45%. At the time of the home visit, almost three quarters of (29/39) presented an inapparent dengue infection. The proportion of inapparent dengue infection was higher in South-East Asia than in Latin America. These findings confirm the complexity of dengue disease in humans and the need to strengthen multidisciplinary research efforts to improve our understanding of virus transmission and host responses to dengue virus in various human populations.
doi:10.1371/journal.pntd.0001482
PMCID: PMC3265457  PMID: 22292098
8.  Hantavirus Pulmonary Syndrome, French Guiana 
Emerging Infectious Diseases  2010;16(4):739-741.
doi:10.3201/eid1604.090831
PMCID: PMC3321943  PMID: 20350412
Hantavirus; pulmonary infection; zoonoses; rodent-borne; human; virus; French Guiana; letter
9.  Evaluation of Two New Commercial Tests for the Diagnosis of Acute Dengue Virus Infection Using NS1 Antigen Detection in Human Serum 
Background
We compared the performance of two new commercial tests for the detection of dengue NS1 protein during the clinical phase of dengue virus (DENV) infection—an immunochromatographic test allowing rapid detection of the NS1 antigen, Dengue NS1 Ag STRIP (Bio-Rad Laboratories - Marnes La Coquette, France), and a two-step sandwich-format microplate enzyme-linked immunosorbent assay (ELISA), pan-E Dengue Early ELISA (Panbio - Brisbane, Australia)—with a one-step sandwich-format microplate ELISA, the Platelia Dengue NS1 Ag test (Bio-Rad).
Methods
We tested 272 serum samples from patients with dengue disease. Of these, 222 were from patients with acute infection of one of the four dengue serotypes, detected by RT-PCR and/or virus isolation. Forty-eight acute-phase serum samples from patients not infected with dengue virus were also included.
Results
The sensitivity of the Platelia Dengue NS1 Ag test on acute serum samples (n = 222) was 87.4% (95% confidence interval: 82.3% to 91.5%); that of Dengue NS1 Ag STRIP was 81.5% (95% CI: 75.8% to 86.4%) after 15 minutes and 82.4% (95% CI: 76.8% to 87.2%) after 30 minutes. Both tests had a specificity of 100% (97.5% CI, one-sided test: 92.6% to 100.0%). The pan-E Dengue Early ELISA had a sensitivity of 60.4% (95% CI: 53.4% to 66.8%) and a specificity of 97.9% (95% CI: 88.9% to 99.9%).
Conclusion
Our findings support the use of diagnostic tools based on the NS1 antigen detection for the diagnosis of acute DENV infection. The immunochromatographic test, Dengue NS1 Ag STRIP—the first rapid diagnostic test for DENV infection—was highly sensitive and specific, and would therefore be a suitable first-line test in the field. The pan-E Dengue Early ELISA was less sensitive than the Platelia test; this two-step ELISA should be combined with DENV IgM antibody detection for the diagnosis of DENV infection.
Author Summary
Dengue is a viral disease transmitted by mosquitoes that is endemic in more than 100 countries in tropical areas, threatening over 2.5 billion people. It causes a wide range of symptoms and has severe forms. In reference laboratories, dengue disease is confirmed by virus isolation or genome detection during the acute phase, and by serological methods during the early convalescent phase. The viral NS1 protein circulates in the sera of infected patients throughout the clinical phase of the disease. Novel diagnostic tests based on NS1 detection have been recently developed and marketed. We compared the performance of two tests for detecting dengue NS1 protein during the clinical phase of dengue infection (an immunochromatographic test (ICT) from Bio-Rad allowing rapid detection of the NS1 antigen and a two-step sandwich-format ELISA from Panbio) with the one-step sandwich-format microplate ELISA (Bio-Rad). The ICT test performed better than the ELISA test from Panbio. This study confirms that diagnostic tests based on NS1 could be used in routine clinical practice in poorly equipped laboratories and that dengue diagnosis could therefore be confirmed without the need for testing in reference laboratories. This represents a crucial step towards the control of dengue disease in the human population.
doi:10.1371/journal.pntd.0000280
PMCID: PMC2500180  PMID: 18714359
10.  Value of syndromic surveillance within the Armed Forces for early warning during a dengue fever outbreak in French Guiana in 2006 
Background
A dengue fever outbreak occured in French Guiana in 2006. The objectives were to study the value of a syndromic surveillance system set up within the armed forces, compared to the traditional clinical surveillance system during this outbreak, to highlight issues involved in comparing military and civilian surveillance systems and to discuss the interest of syndromic surveillance for public health response.
Methods
Military syndromic surveillance allows the surveillance of suspected dengue fever cases among the 3,000 armed forces personnel. Within the same population, clinical surveillance uses several definition criteria for dengue fever cases, depending on the epidemiological situation. Civilian laboratory surveillance allows the surveillance of biologically confirmed cases, within the 200,000 inhabitants.
Results
It was shown that syndromic surveillance detected the dengue fever outbreak several weeks before clinical surveillance, allowing quick and effective enhancement of vector control within the armed forces. Syndromic surveillance was also found to have detected the outbreak before civilian laboratory surveillance.
Conclusion
Military syndromic surveillance allowed an early warning for this outbreak to be issued, enabling a quicker public health response by the armed forces. Civilian surveillance system has since introduced syndromic surveillance as part of its surveillance strategy. This should enable quicker public health responses in the future.
doi:10.1186/1472-6947-8-29
PMCID: PMC2459153  PMID: 18597694
11.  Evaluation of an Enzyme Immunoassay for Detection of Dengue Virus NS1 Antigen in Human Serum▿  
Clinical and Vaccine Immunology  2006;13(11):1185-1189.
We evaluated a one-step sandwich-format microplate enzyme immunoassay for detecting dengue virus NS1 antigen (Ag) in human serum by use of Platelia Dengue NS1 Ag kits (Bio-Rad Laboratories, Marnes La Coquette, France). We collected 299 serum samples from patients with dengue disease and 50 serum samples from patients not infected with dengue virus. For the 239 serum samples from patients with acute infections testing positive by reverse transcription-PCR and/or virus isolation for one of the four dengue virus serotypes, the sensitivity of the Platelia Dengue NS1 Ag kit was 88.7% (95% confidence interval, 84.0% to 92.4%). None of the serum samples from patients not infected with dengue virus tested positive with the Platelia Dengue NS1 Ag kit. A diagnostic strategy combining the Platelia Dengue NS1 Ag test for acute-phase sera and immunoglobulin M capture enzyme-linked immunosorbent assay for early-convalescent-phase sera increased sensitivity only from 88.7% to 91.9%. Thus, NS1 antigen detection with the Platelia Dengue NS1 Ag kit could be used for first-line testing for acute dengue virus infection in clinical diagnostic laboratories.
doi:10.1128/CVI.00229-06
PMCID: PMC1656554  PMID: 16988003
12.  Reemergence of Dengue Virus Type 4, French Antilles and French Guiana, 2004–2005 
Emerging Infectious Diseases  2006;12(11):1748-1751.
After 10 years of absence, dengue virus type 4 (DENV-4) has recently reemerged in Martinique, Guadeloupe, and French Guiana. Phylogenetic analyses of strains isolated from 2004 to 2005 showed that they belong to DENV-4 genotype II, but to a different cluster than strains isolated from 1993 to 1995.
doi:10.3201/eid1211.060339
PMCID: PMC3372336  PMID: 17283628
Dengue-4; phylogeny; French Antilles; French Guiana; dispatch
13.  Use of Four Dengue Virus Antigens for Determination of Dengue Immune Status by Enzyme-Linked Immunosorbent Assay of Immunoglobulin G Avidity 
Journal of Clinical Microbiology  2005;43(11):5784-5786.
We used an enzyme-linked immunosorbent assay (ELISA) of immunoglobulin G avidity to determine the dengue immune status of 105 pairs of serum samples from patients infected with dengue virus. This study shows that a simple avidity test, for which only one acute-phase serum sample is required, is potentially more useful than the hemagglutination inhibition test for the discrimination of primary from secondary dengue virus infection, whatever the type of dengue antigen used.
doi:10.1128/JCM.43.11.5784-5786.2005
PMCID: PMC1287789  PMID: 16272520
14.  Discrimination between Primary and Secondary Dengue Virus Infection by an Immunoglobulin G Avidity Test Using a Single Acute-Phase Serum Sample 
Journal of Clinical Microbiology  2005;43(6):2793-2797.
For clinical and epidemiological purposes, it is necessary to be able to classify serological responses during dengue virus infection. Thus, it is important to develop a test that can distinguish between primary and secondary serological responses. The hemagglutination inhibition (HI) test, which is currently recommended by the World Health Organization, is complicated to perform. We developed an enzyme-linked immunosorbent assay based on changes in the avidity of immunoglobulin G during the infectious episode. This test can discriminate between primary and secondary infections by using a single serum sample collected during the acute phase of infection. We took 1,140 avidity measurements with 118 pairs of serum samples or sequential samples taken from patients classified as having primary or secondary infection according to World Health Organization laboratory criteria. The mean percent avidity was significantly lower during primary infection (25.9%) than during secondary infection (66.3%) (Student t test, P < 0.001). The test had a sensitivity of 82.7% (95% confidence interval [CI] = 79.0 to 86.6) and a specificity of 77.5% (95% CI = 73.3 to 81.7). Based on analysis of only blood samples collected between the third and seventh days of the illness, during which most clinical complications occur, the sensitivity and specificity of the test were 95.1% (95% CI = 92.6 to 97.7) and 80.0% (95% CI = 75.3 to 84.7), respectively. This rapid and simple test appears to be an excellent alternative to the HI test for discriminating between primary and secondary dengue virus infections during the acute phase of dengue.
doi:10.1128/JCM.43.6.2793-2797.2005
PMCID: PMC1151893  PMID: 15956399
15.  Dengue Spatial and Temporal Patterns, French Guiana, 2001 
Emerging Infectious Diseases  2004;10(4):615-621.
To study a 2001 dengue fever outbreak in Iracoubo, French Guiana, we recorded the location of all patients’ homes and the date when symptoms were first observed. A geographic information system was used to integrate the patient-related information. The Knox test, a classic space-time analysis technique, was used to detect spatiotemporal clustering. Analysis of the relative-risk (RR) variations when space and time distances vary, highlighted the maximum space and time extent of a dengue transmission focus. The results show that heterogeneity in the RR variations in space and time corresponds to known entomologic and epidemiologic factors, such as the mosquito feeding cycle and host-seeking behavior. This finding demonstrates the relevance and potential of the use of GIS and spatial statistics for elaborating a dengue fever surveillance strategy.
doi:10.3201/eid1004.030186
PMCID: PMC3323097  PMID: 15200850
Epidemic; dengue fever; Geographic Information System; space-time analysis; control strategy

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