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Antibody-dependent enhancement of infection (ADE) is central to explaining the development of severe disease at the end of post-dengue virus infection. Non-neutralizing anti-dengue antibodies bound to the dengue virion enhances the virus entrance into the target cells via the Fc receptor. The titer of enhancing antibodies in dengue patients is not determined during dengue virus infection. Sensitive flow cytometry detecting dengue virus-infected K562 cells was used to quantitate enhancing activity among Thai DF and DHF patients against four serotypes and the patient's dengue isolate. The titer was defined as the reciprocal of the final dilution that loses enhancing activity. The serum of Thai patients confirmed to have dengue infection were found to have high titers of enhancing antibodies and increased gradually through the convalescent phase of infection. The enhancing antibody titers were not different among the four serotypes or from the infecting isolate. The anti-dengue antibodies from dengue patients can enhance dengue virus infections in a concentration-dependent, serotype-independent manner.

Sera from Thai children immunized with a live-attenuated tetravalent dengue virus vaccine or from naturally infected age-matched site-control subjects were examined for immune enhancement capacity by a highly reproducible flow cytometric assay in Fc receptor-bearing K562 human cells. None of the sera under study corresponded to cases of severe dengue disease. In parallel assays employing each dengue virus serotype, we found no or only minimal antibody-dependent enhancement (ADE) when sera from vaccinated or control subjects were used at a low serum dilution [1/12] that approximated the in vivo condition. Among sera that exhibited homotypic neutralizing antibody activity against DV1-3, the level correlated with absence of ADE or infection with the respective serotype. Similarly, a broad heterotypic neutralizing antibody response that included all four serotypes was linked to complete absence of K562 cell infection. In contrast, at higher serum dilutions a correlation between breadth of antibody response and heightened immune enhancement emerged, a pattern identical to that observed among control subjects. These findings support the use of live dengue vaccines and protocols that induce broad serotype-specific neutralizing antibody responses, but they also suggest that clinically relevant immune enhancement may not be likely if this is not uniformly achieved after the first immunization.