Neutralizing antibody titers against dengue virus correlate with protection from symptomatic infection in a longitudinal cohort

The four dengue virus serotypes (DENV1–4) are mosquito-borne flaviviruses that infect ∼390 million people annually; up to 100 million infections are symptomatic, and 500,000 cases progress to severe disease. Exposure to a heterologous DENV serotype, the specific infecting DENV strains, and the interval of time between infections, as well as age, ethnicity, genetic polymorphisms, and comorbidities of the host, are all risk factors for severe dengue. In contrast, neutralizing antibodies (NAbs) are thought to provide long-lived protection against symptomatic infection and severe dengue. The objective of dengue vaccines is to provide balanced protection against all DENV serotypes simultaneously. However, the association between homotypic and heterotypic NAb titers and protection against symptomatic infection remains poorly understood. Here, we demonstrate that the titer of preinfection cross-reactive NAbs correlates with reduced likelihood of symptomatic secondary infection in a longitudinal pediatric dengue cohort in Nicaragua. The protective effect of NAb titers on infection outcome remained significant when controlled for age, number of years between infections, and epidemic force, as well as with relaxed or more stringent criteria for defining inapparent DENV infections. Further, individuals with higher NAb titers immediately after primary infection had delayed symptomatic infections compared with those with lower titers. However, overall NAb titers increased modestly in magnitude and remained serotype cross-reactive in the years between infections, possibly due to reexposure. These findings establish that anti-DENV NAb titers correlate with reduced probability of symptomatic DENV infection and provide insights into longitudinal characteristics of antibody-mediated immunity to DENV in an endemic setting.Dengue virus (DENV) is a mosquito-borne flavivirus that infects up to 390 million individuals each year (1). Although most infections are inapparent, ∼25% of infections cause acute febrile illness, which progresses to severe disease in half a million individuals annually (2). DENV consists of four evolutionarily distinct, antigenically related DENV serotypes, DENV1–4, and neutralizing antibodies (NAbs) against the four serotypes are considered a critical component of the protective immune response (3, 4). Primary (1°) DENV infection induces a NAb response that is described as increasingly type-specific over time, providing long-term protection against the 1° infecting serotype, but only transient protection against other DENV serotypes (5, 6). Cross-serotype protection against symptomatic infection is observed for up to 2 years after 1° infection, after which point individuals are at increased risk of symptomatic infection and severe dengue upon subsequent heterologous infection (7–10). Over time, cross-serotype–reactive antibodies are thought to decay to subneutralizing levels, binding, but not neutralizing, DENV and contributing to enhanced replication during heterologous infection by facilitating virus entry into target cells expressing Fc receptors (11). However, after subsequent infection with a different serotype, the NAb response becomes broadly neutralizing and is thought to reduce incidence of severe disease (12).There has been limited success in establishing the relationship between the level of preinfection NAb titers to DENV and risk of disease upon subsequent DENV infection in endemic settings. In recent vaccine trials, symptomatic disease was observed in individuals with relatively high NAb titers, raising concerns that the current immunologic assays do not measure the NAbs critical for protection (13). In studies of infants, who receive IgG antibodies by transplacental transfer from DENV-immune mothers, infants with higher NAb titers at birth generally, although not always, experienced symptomatic disease later than those with lower titers (14–16). Recent studies in children and adults have made important advances in demonstrating an association between the quantity of cross-reactive preinfection NAb titers and reduced risk of symptomatic secondary (2°) infection, defined as two or more infections, but have not been conclusive: the association did not hold for all DENV serotypes (15, 17); exposure could not be proven for DENV-negative individuals (18); or the magnitude of preinfection NAb titers was not directly studied (12, 19). Thus, there is an urgent need to definitively establish whether NAb titers correlate with protection in endemic settings. Here, we estimated the relationship between preinfection NAb titers and probability of symptomatic infection and characterized determinants of long-term protection in children with multiple DENV infections in a pediatric dengue cohort study in Nicaragua.