engue and dengue hemorrhagic fever (DHF) are caused
by infection with dengue viruses. There are four dengue serotypes: 1, 2, 3, and 4. These viruses are related closely to each other antigenically, and, as a result, serological tests reflect extensive cross-reactivity. However, infection with any seroty-pe does not provide cross-protective immunity against the others. Persons living in an endemic area can be infected with each of the four dengue serotypes during their lifetime. Infection with dengue viruses is transmitted through the bite of an infective AMes aegypti mosquito. Ae aegypti is a small, black and white, highly domesticated mosquito that prefers to lay its eggs in artificial containers commonly found in and around homes in the tropics, for example, containers used for water storage, flower vases, old automobile tires, and buckets that collect rainwater. The adult mosquitoes prefer to rest indoors, are unobtrusive, and prefer to feed on humans during daylight hours. As a result, inhabitants rarely are aware of the presence of this mosquito, making its control difficult. After a person is bitten by an infective mosquito, the virus undergoes an incubation period of 3 to 14 days (average, 4-6 days), after which the person may experience acute onset of fever accompanied by a variety of nonspecific signs and symptoms. During this acute febrile period, which may be as short as 2 days and as long as 10 days, dengue viruses may circulate in the infected person's peripheral blood. If other Ae aegypti mosquitoes bite the ill person during this febrile viremic stage, those mosquitoes may become infected and subsequently transmit the virus to other uninfected persons, after an extrinsic incubation period of 8 to 12 days. 'Dengue viruses and Ae aegypti mosquitoes are distributed throughout the tropical areas of the world (Fig 1); more than 2.5 billion people live in dengue-endemic areas. 1-3 Currently, dengue fever causes more illness and death than any other arboviral disease acquired by humans. Each year, an estimated 50 to 100 million cases of dengue fever and several hundred thousand cases of DHF occur, depending on epidemic activity. 4,5 The severe and fatal form of the disease, DHF, is a leading cause of hospitalization and death among children in many Southeast Asia countriesfi Epidemics of DHF first occurred in Southeast Asia in the 1950s, spread to the South Pacific Islands in the 1970s, and reached the Caribbean basin in the 1980s. 3,5-8 Current evidence suggests that the pattern of severe hemor-
From She Division of Vector-Borne l:@ctious Diseases, National Centerfor
Infectious Diseases, Centers"for Disease Control and Prevention, Public Health Service, US Department ofHealth and Human Services,Fort Collins, CO. Please address correspondenceto Duane J. Gubler, ScD, Director, Dibision of Vector-BorneInfectiousDiseases,National Centerfor InfectiousDiseases, Centersfor Disease Controland Prevention, Public Health Service, U.S. Department ofHealth and Human Services,PO Box 2087, Fort Collins, CO 80522. This is a US government work. There are no restrictionson its"use. 1045-1870/97/0801-000350. 00/0
rhagic disease is evolving in the American region in a manner
similar to the way it did in Southeast Asia in the 1960s. 9
Changing Disease Patterns
Dengue fever has been known in the medical literature for more than 200 years but was characterized by relatively infrequent epidemics until the 1950s. The disease pattern associated with dengue changed with the ecological disruption in Southeast Asia during and after World War II, which created ideal conditions for increased transmission of mosquito-borne diseases in urban areas. In this setting, a global pandemic of dengue began, epidemic transmission increased, hyperendemicity (the cocirculation of multiple dengue virus serotypes) developed in Southeast Asian cities, and DHF, a newly described disease, emerged. 3,5,J~ The first known epidemic of DHF occurred in Manila, Philippines, in 1953 to 1954, but within 20 years it had spread throughout Southeast Asia; by the mid- 1970s, DHF had become a leading cause of hospitalization and death among children in the region. 6 In the 1980s and 1990s, dengue transmission in Asia further intensified, with increased incidence and geographical expansion of epidemic DHF west into India, Pakistan, Sri Lanka, and the Maldive Islands and east into China) ,5,I~At the same time, the geographical distribution of epidemic DHF was expanding into new regions: the Pacific Islands in the 1970s and i980s and the American tropics in the 1980s and 1990s. 2,3,5,7-11 Epidemiological changes in the Americas have been the most dramatic. In the t960s and most of the 1970s, epidemic dengue was rare in the American region because the principal mosquito vector, Ae aegypti, had been eradicated from most of Central and South America. 9,II The eradication program was discontinued in the early 1970s, and this species then began to reinvade those countries in which it had been eradicated. By the 1990s, Ae aegypti had regained the geographical distribution it had before "eradication" (Fig 2). Epidemic dengue invariably developed after reinfestation of a country by Ae aegypti. By the 1980s, the American region was experiencing major epidemics of dengue in countries that had been free of the disease for 35 to 130 years. 3,9,u With increased epidemic actMty came the development of hyperendemicity and the emergence of epidemic DHF, much as had occurred in Southeast Asia 25 years earlier. 9 From 1981 to 1995, 16 American countries reported laboratory-confirmed DHF (Fig 3). 3,5,11 Although Africa has not had a major epidemic of D t t F yet, sporadic cases have occurred because epidemic dengue fever has increased markedly in the past 15 years. Before the 1980s, little was known of the distribution of dengue viruses in Africa. Since then, however, major epidemics caused by all four serotypes have occurred in both East and West Africa. Outbreaks have been more common in East Africa in the 1990s, with major epidemics in Djibouti in 1991 and inJeddah, Saudi Arabia, in
Seminars in _PediatricJ~nJkctiousDiseases, Vol 8, No l (Janua~.y), 1997.'pp 3-9