title: Epidemiological risk factors for adult dengue in Singapore: an 8-year nested test negative case control study.
abstract: Understanding changes in the ecology and epidemiology of dengue is important to ensure resource intensive control programmes are targeted effectively as well as to inform future dengue vaccination strategies.
  
  
  
  We analyzed data from a multicentre longitudinal prospective study of fever in adults using a nested test negative case control approach to identify epidemiological risk factors for dengue disease in Singapore. From April 2005 to February 2013, adult patients presenting with fever within 72 h at selected public primary healthcare clinics and a tertiary hospital in Singapore were recruited. Acute and convalescent blood samples were collected and used to diagnose dengue using both PCR and serology methods. A dengue case was defined as having a positive RT-PCR result for DENV OR evidence of serological conversion between acute and convalescent blood samples. Similarly, controls were chosen from patients in the cohort who tested negative for dengue using the same laboratory methods.
  
  
  
  The host epidemiological factors which increased the likelihood of dengue disease amongst adults in Singapore were those aged between 21 and 40 years old (2 fold increase) while in contrast, Malay ethnicity was protective (OR 0.57, 95%CI 0.35 to 0.91) against dengue disease. Spatial factors which increased the odds of acquiring dengue was residing at a foreign workers dormitory or hostel (OR 3.25, 95 % CI 1.84 to 5.73) while individuals living in the North-West region of the country were less likely to get dengue (OR 0.50, 95%CI 0.29 to 0.86). Other factors such as gender, whether one primarily works indoors or outdoors, general dwelling type or floor, the type of transportation one uses to work, travel history, as well as self-reported history of mosquito bite or household dengue/fever were not useful in helping to inform a diagnosis of dengue.
  
  
  
  We have demonstrated a test negative study design to better understand the epidemiological risk factors of adult dengue over multiple seasons. We were able to discount other previously speculated factors such as gender, whether one primarily works indoors or outdoors, dwelling floor in a building and the use of public transportation as having no effect on one's risk of getting dengue.
authors.affiliation: Infectious Disease Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore. cheefu.yung@gmail.com.|Communicable Disease Centre, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore. cheefu.yung@gmail.com.
authors.forename: Chee Fu
authors.initials: CF
authors.lastname: Yung
authors.affiliation: Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.|Faculty of Science, Technology and Engineering, La Trobe University, Melbourne, Australia.
authors.forename: Siew Pang
authors.initials: SP
authors.lastname: Chan
authors.affiliation: Communicable Disease Centre, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore.
authors.forename: Tun Linn
authors.initials: TL
authors.lastname: Thein
authors.affiliation: Communicable Disease Centre, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore.
authors.forename: Siaw Ching
authors.initials: SC
authors.lastname: Chai
authors.affiliation: Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.|Communicable Disease Centre, Institute of Infectious Diseases and Epidemiology, Tan Tock Seng Hospital, Singapore, Singapore.|Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, Singapore, Singapore.|Saw Swee Hock School of Public Health, National University Singapore, Singapore, Singapore.
authors.forename: Yee Sin
authors.initials: YS
authors.lastname: Leo
mesh_terms: D000328:Adult; D017677:Age Distribution; D000368:Aged; D016022:Case-Control Studies; D003715:Dengue / Q000453:epidemiology* / Q000209:etiology; D003716:Dengue Virus / Q000302:isolation & purification; D005260:Female; D005334:Fever; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012044:Regression Analysis; D012111:Residence Characteristics; D012307:Risk Factors; D017678:Sex Distribution; D012846:Singapore / Q000453:epidemiology; D014195:Travel; D017132:Workplace; D055815:Young Adult
keywords: Adult; Dengue; Epidemiology; Public health; Risk factors; Singapore; Test-negative