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Background Dengue is one of the newest emerging diseases in Nepal with increasing burden and geographic spread over the last 14 years. The main objective of this study was to explore the spatio-temporal epidemiological patterns of Dengue since its first report (2006) till 2019 in Nepal. Methods This study is a retrospective analysis of dengue data available from the Epidemiological Disease Control Division (EDCD) of Government of Nepal. The data in this study cover the last 14 years (2006-2019) of reported dengue cases in Nepal. Epidemiological trend and spatio-temporal analyses were performed. Maps of reported case incidence were created using QGIS version 3.4. Results Since the first report of dengue in a foreigner in 2004, Nepal reported a total of 17,992 dengue cases in 68 districts of Nepal in 2019. The incidence was approximately five times higher in 2018 (Incidence Rate Ratio (IRR): 4.8; 95% CI: 1.5 – 15.3) and over 140 times higher in 2019 (IRR: 141.6; CI: 45.8 – 438.4). Population density was not a statistically significant predictor of case incidence. Mean elevation had a negative association with case incidence. A one standard deviation increase in elevation was associated with a 90% decrease in reported case incidence (IRR: 0.10; CI: 0.01 – 0.20). However, the association with mean elevation varied across the years. In comparison to 2016, incidence was greater at higher elevations in 2018 (IRR: 22.7; CI: 6.0 - 86.1) and 2019 (IRR: 9.6; CI: 2.6 - 36.1). Conclusion There is a high risk of dengue outbreak in the Terai region with increasing spread towards the mid-mountains and beyond as seen over the last 14 years. Urgent measures are required to increase the availability of diagnostics and resources to mitigate future dengue epidemics. Findings from this study can inform the spatio-temporal distribution of dengue and can help in resource allocation and priority setting for future epidemic. Author summary Dengue in humans is caused by four different serotypes (DENV-1, DENV-2, DENV-3 & DENV-4). Globally it is the most pervasive vector borne diseases with increasing number of cases in recent years. Dengue is one of the youngest emerging diseases in Nepal with increasing cases and spread from the tropical lowland to the highland (hilly) regions. We conducted a spatio-temporal analysis of national data to consolidate the information using QGIS to measure the dengue incidence at district levels of Nepal. Spatio-temporal analysis exploring the incidence and distribution of dengue cases aids in identification of high-risk areas which can ultimately enable national dengue programme to mobilize and allocate resources for the control and treatment. This study shows, the persistent high risk of dengue outbreak in lowland Terai region with annual rise in the risk of spread towards the mid-mountains and beyond. Urgent measures are required to increase the diagnostics and resources to mitigate the epidemic burden of dengue in Terai and peripheral regions.

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