title: Epidemiology of dengue in a high-income country: a case study in Queensland, Australia.
abstract: BACKGROUND
  Australia is one of the few high-income countries where dengue transmission regularly occurs. Dengue is a major health threat in North Queensland (NQ), where the vector Aedes aegypti is present. Whether NQ should be considered as a dengue endemic or epidemic region is an ongoing debate. To help address this issue, we analysed the characteristics of locally-acquired (LA) and imported dengue cases in NQ through time and space. We describe the epidemiology of dengue in NQ from 1995 to 2011, to identify areas to target interventions. We also investigated the timeliness of notification and identified high-risk areas.
  
  
  METHODS
  Data sets of notified cases and viraemic arrivals from overseas were analysed. We developed a time series based on the LA cases and performed an analysis to capture the relationship between incidence rate and demographic factors. Spatial analysis was used to visualise incidence rates through space and time.
  
  
  RESULTS
  Between 1995 and 2011, 93.9% of reported dengue cases were LA, mainly in the 'Cairns and Hinterland' district; 49.7% were males, and the mean age was 38.0 years old. The sources of imported cases (6.1%) were Indonesia (24.6%), Papua New Guinea (23.2%), Thailand (13.4%), East Timor (8.9%) and the Philippines (6.7%), consistent with national data. Travellers importing dengue were predominantly in the age groups 30-34 and 45-49 years old, whereas the age range of patients who acquired dengue locally was larger. The number of LA cases correlated with the number of viraemic importations. Duration of viraemia of public health importance was positively correlated with the delay in notification. Dengue incidence varied over the year and was typically highest in summer and autumn. However, dengue activity has been reported in winter, and a number of outbreaks resulted in transmission year-round.
  
  
  CONCLUSIONS
  This study emphasizes the importance of delay in notification and consequent duration of viraemia of public health importance for dengue outbreak duration. It also highlights the need for targeted vector control programmes and surveillance of travellers at airports as well as regularly affected local areas. Given the likely increase in dengue transmission with climate change, endemicity in NQ may become a very real possibility.
authors.affiliation: Research School of Population Health, Australian National University, Canberra, ACT 0200, Australia. elvina.viennet@anu.edu.au.
authors.forename: Elvina
authors.initials: E
authors.lastname: Viennet
authors.forename: Scott A
authors.initials: SA
authors.lastname: Ritchie
authors.forename: Helen M
authors.initials: HM
authors.lastname: Faddy
authors.forename: Craig R
authors.initials: CR
authors.lastname: Williams
authors.forename: David
authors.initials: D
authors.lastname: Harley
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003715:Dengue / Q000453:epidemiology*; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D011793:Queensland / Q000453:epidemiology; D012959:Socioeconomic Factors; D013997:Time Factors; D014766:Viremia; D055815:Young Adult