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Global Spread and Persistenceof DengueJennifer L. Kyle and Eva
HarrisDivision of Infectious Diseases, School of Public Health, and
Graduate Groupin Microbiology, University of California, Berkeley,
California 94720-7354;email: [email protected],
[email protected]
Annu. Rev. Microbiol. 2008. 62:7192
First published online as a Review in Advance onApril 22,
2008
The Annual Review of Microbiology is online
atmicro.annualreviews.org
This articles doi:10.1146/annurev.micro.62.081307.163005
Copyright c 2008 by Annual Reviews.All rights reserved
0066-4227/08/1013-0071$20.00
Key Words
avivirus, mosquito-borne, Aedes, emergence, genotype, RNA
virus
AbstractDengue is a spectrum of disease caused by four serotypes
of the mostprevalent arthropod-borne virus affecting humans today,
and its in-cidence has increased dramatically in the past 50 years.
Due in partto population growth and uncontrolled urbanization in
tropical andsubtropical countries, breeding sites for the
mosquitoes that trans-mit dengue virus have proliferated, and
successful vector control hasproven problematic. Dengue viruses
have evolved rapidly as they havespread worldwide, and genotypes
associated with increased virulencehave expanded from South and
Southeast Asia into the Pacic and theAmericas. This review explores
the human, mosquito, and viral factorsthat contribute to the global
spread and persistence of dengue, as well asthe interaction between
the three spheres, in the context of ecologicaland climate changes.
What is known, as well as gaps in knowledge, isemphasized in light
of future prospects for control and prevention ofthis pandemic
disease.
71
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DENV: dengue virus
DF: dengue fever
DHF/DSS: denguehemorrhagicfever/dengue shocksyndrome
Contents
INTRODUCTION . . . . . . . . . . . . . . . . . . 72THE HUMAN
SPHERE . . . . . . . . . . . . . 72
Introduction . . . . . . . . . . . . . . . . . . . . . . .
72History and Spread of Dengue . . . . . . 73Risk for DENV
Infection . . . . . . . . . . 74Risk Factors for DHF/DSS . . . . .
. . . . 75
THE MOSQUITO SPHERE. . . . . . . . . 76Introduction . . . . . .
. . . . . . . . . . . . . . . . . 76The Sylvatic Cycle and
Emergence/Re-Emergenceof DENV . . . . . . . . . . . . . . . . .
. . . . . 77
Vector Competence . . . . . . . . . . . . . . . . 77Vertical
Transmission
of DENV in Mosquitoes . . . . . . . . 78Past Experience with
Vertical Vector
Control Measures . . . . . . . . . . . . . . . 78Community-Based
Vector
Control Programs . . . . . . . . . . . . . . 79THE VIRUS SPHERE
. . . . . . . . . . . . . . . 81
Introduction . . . . . . . . . . . . . . . . . . . . . . .
81Viral Genotypes and Virulence . . . . . 81Virus Evolution and
Host Immunity 83
OTHER FACTORS . . . . . . . . . . . . . . . . . . 84Climate . .
. . . . . . . . . . . . . . . . . . . . . . . . . 84Public Policy .
. . . . . . . . . . . . . . . . . . . . . 84
INTRODUCTION
Globally, as many as 1 in 100 people are infectedeach year by
one or more of four serotypes ofdengue virus (DENV14), a
mosquito-borne,positive-strand RNA virus in the genus Fla-vivirus,
family Flaviviridae. Tens of millions ofcases of dengue fever (DF)
are estimated tooccur annually, including up to 500,000 casesof the
life-threatening dengue hemorrhagicfever/dengue shock syndrome
(DHF/DSS)(156). Epidemic DHF/DSS emerged 50 yearsago in Southeast
Asia (60) but was rst seenin the Americas only in 1981 (75) and in
SouthAsia in 1989 (88). Since the 1950s, the incidenceof DHF/DSS
has increased over 500-fold, withmore than 100 countries affected
by outbreaksof dengue (156). DHF/DSS has become one of
the top ten causes of pediatric hospitalization inSoutheast Asia
(155), and the number of casesof DHF/DSS in the Americas alone has
growndramatically (98).
Dengue is associated with explosive urbanepidemics and has
become a major public healthproblem, with signicant economic,
political,and social impact (46). Some of the reasons forthe
dramatic increase in the geographic spreadof dengue, including its
more severe forms, areknown with some certainty, whereas other
rea-sons remain a subject of debate and speculation.This review
highlights the epidemiological his-tory of dengue and explores the
various reasonsfor its dramatic spread and persistence duringthe
past 50 years. To this end, aspects of human,mosquito, and virus
biology, ecology, and evo-lution are discussed, along with the
interactionbetween these spheres (Figure 1).
THE HUMAN SPHERE
Introduction
DF is a self-limited though debilitating febrileillness
characterized by headache, retro-orbitalpain, myalgia, arthralgia,
and rash. DHF ismarked by increased vascular permeability(plasma
leakage), thrombocytopenia, and hem-orrhagic manifestations; DSS
occurs when uidleakage into the interstitial spaces results in
Human Mosquito
Virus
Ecology
Climate
Figure 1The interplay of human, mosquito, and virus
biologycontributes to the clinical spectrum and
geographicdistribution of dengue. Each sphere inuences andaffects
the others, all in the context of ecology andagainst the backdrop
of climate and climate change.
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AsymptomaticDENV infections
DF(unreported)
DF
DHFDSS
Figure 2DENV infections and disease are represented by apyramid.
An estimated 100 million infections occureach year, 10%50% of which
are symptomatic, butonly a fraction of DF cases are reported.
Finally,severe disease due to DENV infection representsthe tip of
the pyramid. The most severe forms ofdengue are DHF and DSS, which
present withhigher frequency in secondary than in primaryDENV
infections.
hypovolemic shock, which without appropri-ate treatment may lead
to death (43, 56). Ap-parent disease due to dengue has been
de-scribed as the tip of the iceberg (78), as lessthan 10% of
symptomatic dengue cases arereported (156) and 50%90% of all
DENVinfections are asymptomatic (10, 17, 29, 140)(Figure 2). The
most severe disease, DHF/DSS, is found at the very tip of the
pyramid, andits incidence varies signicantly between pri-mary and
secondary DENV infections. A sec-ondary DENV infection results when
a personpreviously infected with one serotype is exposedto a
different serotype, and it has been docu-mented as the single most
important risk fac-tor for severe dengue (17, 29, 39, 53, 58,
125,140). For example, Thai data of DENV infec-tions in children
under 15 years of age demon-strated that 0.18% of primary
infections and 2%of secondary infections manifest as DHF/DSS(78).
In this section, we describe dengue andreview the reasons for the
spread and persis-tence of epidemic DF and DHF/DSS and whatis known
about the risk for infection and severedisease.
Secondary infection:a subsequent infectionwith a
heterotypicserotype of DENV,occurring months toyears after the
primaryinfection
Hyperendemic: thepresence of numerousserotypes of denguevirus
cocirculating inone location
History and Spread of Dengue
Clinical descriptions of a dengue-like syn-drome were recorded
as far back as a.d. 992in China, although the rst epidemics of
well-documented cases of what are believed to bedengue occurred in
17791780 (42). The viraletiology of dengue was suggested
experimen-tally a century ago (7), but it was not until WorldWar II
that technical advances enabled Japanese(67) and American (122)
investigators to iso-late DENV. The rst two DENV serotypeswere
identied at this time, followed by thethird and fourth serotypes
when DHF/DSSemerged in urban centers in the Philippinesand Thailand
in 1954 (60, 103). It has been hy-pothesized that the movement of
troops dur-ing World War II, together with destruction ofthe
environment and human settlements, con-tributed to the spread of
the viruses and, to acertain extent, their mosquito vectors
through-out Southeast Asia and the Western Pacic(42, 114). Since
then, Southeast Asia has re-mained hyperendemic for all four
DENVserotypes. In the Americas, the decline andreemergence of
epidemic dengue since the1980s has been even more closely linked to
thepresence of its mosquito vectors, Aedes aegyptiand A. albopictus
(Figure 3).
Increases in human population, uncon-trolled urbanization, and
international travelcan explain much of the spread and persis-tence
of dengue in the twentieth and earlytwenty-rst centuries (42, 114).
It has beenestimated that the minimum population sizerequired to
sustain dengue transmission is10,0001,000,000 (76), and early
epidemics ofdengue in Southeast Asia were linked to townswith
populations over 10,000 (133). A math-ematical model examining the
spatiotemporalincidence of DHF over a 15-year period inThailand
estimated that epidemics of DHForiginate in the capital city of
Bangkok every3 years and travel outward to the rest of thecountry
at a rate of 148 km per month (23),stressing the role of cities in
dengue transmis-sion dynamics. In the tropical and subtrop-ical
areas where A. aegypti and A. albopictus
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a b 1970 2002
Prior to 1981 19812003
Presence of Aedes aegypti Reported cases of DHF
Figure 3The spread of Aedes aegypti and DHF in the Americas. (a)
The shaded areas represent the regions in theAmericas where A.
aegypti was present in 1970 (left) and in 2002 (right). (b) Shaded
areas represent thecountries that reported cases of DHF prior to
1981 (left) and between 1981 and 2003 (right). The
increaseddistribution of DHF mirrors the dissemination of A.
aegypti. Reprinted with permission from the U.S.Centers for Disease
Control and Prevention.
mosquitoes are present, urban growth has notbeen accompanied by
well-organized water andwaste management programs because of
thesheer numbers of people migrating from thecountryside and
because of the lack of resourcesavailable for infrastructure and
public healthmeasures in these regions (72, 119). In settingswhere
the availability of water is intermittentand piped water supplies
may be nonexistent,both indoor and outdoor containers used forwater
storage comprise key Aedes breeding sites(112). The
indestructibility of discarded plas-tics and the increased numbers
of unused tires,combined with poor garbage disposal systems,have
led to the accumulation of numerous addi-tional breeding sites.
Commercial shipping hasbeen linked to the spread of both A. aegypti
andA. albopictus between regions (63, 133, 135), andplane travel
has greatly increased the dissem-ination of dengue viruses via
rapid transit ofviremic individuals around the world (42). Inother
words, much of the increase in DENVinfections in recent decades can
be explainedby an increase in both human population andmosquito
breeding habitats, combined with thedissemination of both
mosquitoes and dengueviruses to new geographic regions.
Risk for DENV InfectionAn estimated 3.5 billion people, or half
theworlds population, are at risk for DENV infec-tion in tropical
and subtropical countries (12).Fundamentally, exposure to an
infected A. ae-gypti mosquito determines an individuals riskfor
acquiring dengue. By avoiding the mosquitoand eliminating breeding
sites around the homeand workplace, an individual can mitigate
thatrisk to some extent, although there are factorsbeyond an
individuals immediate control. Inthe past, epidemics of dengue have
occurredin the United States as far north as Philadel-phia (42),
and A. aegypti as well as A. albopic-tus are present in the
southern and centralUnited States today. Yet, most dengue cases
inthe United States are reported in travelers re-turning from
endemic countries (110). This canbe attributed to improved
infrastructure, suchas reliable sources of piped water that
removethe need for Aedes-friendly water storage con-tainers, air
conditioning powered by an electricgrid with few interruptions, and
screens cover-ing windows and enclosing patios. These vari-ables
greatly reduce the exposure of people tomosquitoes, so that if a
viremic individual re-turns to the United States, the possibility
of that
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person contacting an appropriate vector is fairlylow, and thus
the potential of DENV transmis-sion to the community is low. Even
in the con-text of a region highly endemic for dengue, suchas
Puerto Rico, a higher incidence of disease iscorrelated with lower
socioeconomic status andlack of window and door screens (149).
The risk of a dengue epidemic can be mod-eled mathematically by
the basic reproduc-tive rate of the virus (R0), which correspondsto
the number of subsequent infections thatwould be produced in a
group of susceptibleindividuals given the introduction of one
in-fected person (4). For vector-borne diseases,R0 takes into
account measures of transmis-sion capacity, specically the number
of femalemosquitoes per human host, the human-bitingrate of the
mosquito species, the proportionof bites that produce an infection,
the averageduration of infection in humans, the propor-tion of
bites of viremic humans that result ininfected mosquitoes, mosquito
mortality rates,and latent periods of incubation in both hosts(4).
When R0 < 1, transmission is interrupted;R0 = 1 results in
endemicity; and R0 > 1 re-sults in an increase in cases (i.e., a
potential epi-demic). R0 values for dengue in endemic regionsare
estimated to range between 1.33 and 11.6(57). An additional factor
to consider is herdimmunity, or the number of immune individu-als
in the population, which can be representedas p, such that (1-p)R0
determines the effec-tive R0. This equation is useful in
vaccinationprograms in terms of estimating the numberof vaccinated
individuals (p) needed to inter-rupt transmission (R0 < 1) for a
given disease(4, 37).
Risk Factors for DHF/DSS
Risk factors for developing DHF/DSS includepre-existing immunity
from a previous DENVinfection, time between infections, age,
eth-nicity and host genetic background, sequenceof infecting
serotypes, and viral genotype(43, 55). In response to a primary
infection withDENV, protective immunity to the infecting
R0: basic reproductiverate
Herd immunity: thethreshold level ofcollective immunity ina
population, abovewhich transmission ofa particular pathogenwill be
disrupted andnot be maintained
Neutralizingantibodies:antibodies capable ofpreventing infection
ofa cell/host by apathogen
ADE: antibody-dependentenhancement
serotype is believed to last a lifetime. As evi-dence,
serotype-specic immunity was protec-tive for up to 18 months in
human volunteers(121), and neutralizing antibodies and
serotype-specic T cells have been found in patientsin Cuba, Greece,
and Japan 2040 years af-ter an isolated dengue epidemic (51, 68,
129).However, complete cross-protective immunityfrom a secondary
infection was present in hu-man volunteers for only 12 months after
aprimary DENV infection, with partial immu-nity present up to 9
months, resulting in amilder disease of shorter duration upon
reinfec-tion (121). After the emergence of DHF/DSS,studies seeking
to explain the cause of this newand more severe manifestation of
dengue iden-tied a second, heterologous DENV infectionas a risk
factor for DHF/DSS (58). Prospec-tive studies in Thailand, Burma,
and Indone-sia (17, 29, 39, 125, 140), as well as stud-ies of
sequential epidemics of dengue in Cuba(53), conrmed the association
of secondaryinfection with more severe disease. Evidencefrom Cuba
has suggested that increased timebetween infections may also
increase diseaseseverity (53). After an isolated DENV1 epi-demic in
Cuba in 1977, two separate DENV2epidemics caused by closely related
SoutheastAsian DENV2 strains occurred in 1981 and1997 on the
island. Strikingly, death rates werealmost 40 times greater when
the interval be-tween infections was 20 years, compared with4
years.
The pathogenic mechanism of DHF/DSS isstill poorly understood. A
predominant theoryregarding DHF/DSS pathogenesis attributesthe
higher incidence of DHF/DSS amongsecondary infections to the
phenomenon ofantibody-dependent enhancement (ADE) (56).The ADE
theory postulates that after an initialperiod of cross-reactive
protection, antibodiesfrom a primary infection remain
cross-reactivewith other DENV serotypes but have wanedto
nonneutralizing levels. These nonneutraliz-ing antibodies could
then mediate an increaseduptake of virus into
monocyte/macrophagecells via the Fc receptor, leading to in-creased
viral replication and immune activation
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HLA: humanleukocyte antigen
accompanied by cytokine release (56). Fieldstudies have found
evidence of higher levels ofviremia in DHF patients, which supports
theassertion that increased viral replication is as-sociated with
more severe disease (8, 83, 93,145). A different but complementary
theoryof immunopathology involves reactivation ofcross-reactive
memory T cells specic for theprevious rather than the current DENV
in-fection, resulting in delayed viral clearanceand/or increased
cytokine secretion along withincreased apoptosis of both infected
and un-infected bystander cells (118). There is im-munological
evidence that this phenomenon oforiginal antigenic sin may occur
during sec-ondary DENV infections (91). In both theories,cytokines
are believed to play a direct role inthe immunopathogenesis of
DENV, owing totheir proinammatory effects on vascular en-dothelial
cells that presumably lead to leakyjunctions and increased
capillary permeability(118).
Most epidemiologic studies nd that chil-dren under age 15 are at
increased risk forDHF/DSS, independent of other risk factors(17,
52, 61, 125, 140), which may be related toincreased capillary
fragility and decreased tol-erance for insult to microvascular
integrity inthis age group (38). A few studies have indicatedthat
Africans and people of African descent mayhave genetic
polymorphisms that confer partialprotection against severe dengue
(59, 130). Re-cent work has identied DENV epitopes that,in the
context of specic human leukocyte anti-gen (HLA) types, may be
associated with im-mune enhancement (92, 131, 159). Other stud-ies
have more broadly correlated certain HLAtypes with disease severity
and/or protectionfrom severe disease (128, 136). Dening thelink
between disease risk and HLA type, race,or DENV cellular receptor
(123) and cytokinepolymorphisms (32) has the potential not onlyto
provide important information regarding thepathogenesis of
secondary DENV infection,but also to serve as a potential
prognostic tool toidentify individuals at increased risk for
severedisease.
THE MOSQUITO SPHERE
Introduction
The principal vector of DENV is the A. aegyptimosquito, an
anthropophilic species that hasadapted extremely well to the urban
environ-ment, which is found both indoors and outdoorsin close
proximity to human dwellings (112).A. aegypti is believed to have
originated in thejungles of Africa and was most likely
spreadthroughout the rest of the world via slave andtrading ships
during the seventeenth to nine-teenth centuries (112, 133). It was
noted sometime ago that epidemics of dengue seemedto correlate with
the spread of A. aegypti inSouth and Southeast Asia, appearing rst
inport towns and moving inland over time alongwaterways (133). Now
a fully domesticatedmosquito, A. aegypti is an efcient vector
ofDENV because of its preference for laying itseggs in articial
containers, biting humans, andremaining indoors, where it has
access to its fa-vorite host (112).
A. albopictus is a secondary vector of DENVin Southeast Asia,
the Western Pacic, andincreasingly in Central and South
America(40), but it has also been documented as thesole vector
during certain dengue epidemics(3, 28). Prior to 1979, this species
was foundonly in Asia and in the Western Pacic, but ithas spread to
much of the rest of the worldin recent decades (40, 133). The
invasion ofNorth America by A. albopictus was rst con-rmed with its
discovery in Houston, Texas, in1985 (18), probably arriving in
shipments ofused tires from Japan (63, 70). The range ofA.
albopictus stretches farther north than thatof A. aegypti, and its
eggs are somewhat resis-tant to subfreezing temperatures (63),
raisingthe possibility that A. albopictus could mediatea
re-emergence of dengue in the United Statesor Europe. For example,
A. albopictus can sur-vive the winters in northern Italy (113) and
wasrecently implicated in an outbreak of Chikun-gunya virus in
Italy (117). In this section, wedescribe the mosquitoes that
transmit dengue,the hypothesis of DENV emergence from the
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jungles of Southeast Asia, the potential forre-emergence,
variations in vector competencebetween Aedes strains, mechanisms of
viral per-sistence in mosquitoes between epidemics, pastvertical
control programs for A. aegypti, andcurrent community-based
strategies for vectorcontrol.
The Sylvatic Cycle andEmergence/Re-Emergence of DENV
A number of forest-dwelling Aedes mosquitoes,known as tree-hole
mosquitoes, have been iden-tied as vectors of a sylvatic cycle of
DENV inthe jungles of Africa (DENV2) and SoutheastAsia (DENV14),
involving mainly nonhumanprimates. The viruses in this sylvatic
cycle arephylogenetically distinct from those in the ur-ban cycle
of dengue involving A. aegypti (147),though sylvatic strains of
DENV may occasion-ally cause disease in humans (111, 124). It
isthought that DENV emerged from the junglesof Southeast Asia, with
A. albopictus or perhapsother Aedes species maintaining the virus
in asylvatic cycle involving nonhuman primates andhumans living in
the countryside. This hypoth-esis was reached in part on the basis
of studies inthe 1950s that documented high levels of anti-DENV
antibodies in both nonhuman primatesand rural inhabitants in the
apparent absenceof disease (120, 133, 134). Neutralizing
anti-bodies against DENV1 and DENV2, the onlyserotypes known at the
time, were present inabout 50% of children up to 15 years of age
indiverse rural communities in Malaysia, in con-trast with much
lower levels (3%9%) in thecities of Singapore and Kuala Lumpur
(134).In Southeast Asia in the 1950s, A. aegypti wasstill primarily
found only in towns and cities,whereas A. albopictus was common in
coastaland inland rural areas (133). Thus, the com-bined evidence
argues for a rural source for thedengue viruses in Southeast Asia,
possibly withA. albopictus as the primary vector.
In Africa, a nondomesticated, forest-dwelling subtype of A.
aegypti, A. aegypti for-mosus, is present that demonstrates a low
bit-ing rate for humans; however, sylvatic DENV2
Vector competence:the capacity of a vectorto transmit a
pathogenby virtue of beingsusceptible to infectionand dissemination
andsubsequently capableof transmission to anappropriate host
strains have been recovered primarily fromother Aedes species in
the jungles of West Africa,including A. luteocephalus, A. furcifer,
A. taylori,and A. vittatus (25, 111). The potential for epi-demic
DENV strains to re-emerge has been ad-dressed experimentally in
several studies thatsuggested that viral adaptation to the vec-tor
was required for efcient transmission byA. aegypti and A.
albopictus (90), but that adap-tation to vertebrate hosts was not
required forthe emergence of DENV from a sylvatic cy-cle (144). Two
sylvatic Aedes species from WestAfrica, A. furcifer and A.
luteocephalus, werehighly susceptible to both sylvatic and
endemicDENV2, raising the possibility that adaptationof DENV to
peridomestic mosquitoes does notnecessarily result in loss of
infectivity for somesylvatic Aedes species (26). However, both
do-mestic and forest-dwelling A. aegypti fromSenegal were poorly
infected by sylvatic andendemic DENV strains, and another
investiga-tion found that populations of A. aegypti formo-sus from
different parts of Africa were less sus-ceptible to DENV2 than were
A. aegypti fromSoutheast Asia, South America, and the SouthPacic
(30). These studies illustrate the com-plexity of the coevolution
of DENV with itsmosquito vectors.
Vector Competence
Variations in vector competence among strainsof A. aegypti and
between A. aegypti andA. albopictus have received a fair amount
ofattention. Early studies had shown that A. ae-gypti, though
clearly correlated with epidemicdengue, was not as easily infected
with DENVas A. albopictus (69, 115), leading to the hypoth-esis
that the adaptation of DENV to A. aegyptihad selected for viruses
that caused higherviremia (112). However, other studies
usingeld-caught mosquitoes, as opposed to labo-ratory strains,
demonstrated comparable sus-ceptibility between the two species
(153) ora higher susceptibility by A. aegypti (89, 146).Although
differences between the use of lab-oratory strains versus
eld-caught mosquitoesmay explain some of these discrepant
results
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Verticaltransmission:transfer of DENVfrom an infectedfemale
mosquito toher offspring, either bytransovarialtransmission or
byinfection of the egg attime of oviposition
Vector controlprogram (verticalversus horizontal):a vertical
controlprogram is a top-downapproach in its designand
implementationand is usuallygovernment led;whereas a horizontalor
community-led(bottom-up) programmay have institutionalsupport, but
focusesprimarily on includingcommunityparticipation
House index (HI):the percentage ofhouses with containersinfested
with mosquitolarvae and/or pupae
(146), the question remains what might ac-count for different
vector competence amongmosquitoes, and whether coevolution
betweendengue viruses and A. aegypti has occurred sinceDENV emerged
from the jungle. Substantialvariation in susceptibility exists
between differ-ent strains of both A. aegypti (14, 47, 138) andA.
albopictus (48, 85) mosquitoes from differ-ent locations. This
suggests that genetic dif-ferences in the vector may be responsible
forvarying susceptibilities to DENV, and specicquantitative trait
loci (QTLs) in A. aegypti havebeen linked to vector competence
(13). Recentsequencing of the A. aegypti genome (94) willfacilitate
identication of genes linked to pre-viously described QTLs
associated, for exam-ple, with midgut and other barriers to
infection.Comparative genomics analyses are also nowpossible with
sequenced Drosophila melanogasterand Anopheles gambiae genomes
(148).
Vertical Transmissionof DENV in Mosquitoes
In most endemic countries, dengue displaysa seasonal pattern
related to temperature andrainfall (33, 57, 112). This has led many
in-vestigators over the years to question how thevirus overwinters,
or persists during dry or coldseasons. One possibility is that a
populationof infected mosquitoes could survive through-out the
interim and introduce the virus dur-ing the next season. Aedes
mosquitoes remaininfected with DENV for life, and the
longestlifespan recorded to date is 174 days, althougha more
typical survival rate is 12 weeks (112).A second possibility is
passage of the virus tothe next generation of mosquitoes via
survivalin an infected egg. Early studies had shownno evidence of
vertical transmission of DENVin Aedes mosquitoes (112), but more
recentstudies have demonstrated that vertical trans-mission is
possible both in the laboratory andin the wild (49). Some evidence
exists thatA. albopictus mosquitoes are more efcient atvertical
transmission than A. aegypti, whichwould make them a candidate for
main-taining DENV during interepidemic periods
(116). Thus, vertical transmission of DENVin mosquitoes is
possible, whether or not themechanism is truly transovarial or
mediated byinfection of the mature egg at the time of ovipo-sition
(112). Finally, given the high number ofasymptomatic cases of
dengue (10, 17, 29, 140),it is also possible that silent
transmission in hu-mans by a reduced number of vectors
maintainsDENV transmission between epidemics.
Past Experience with Vertical VectorControl Measures
Because A. aegypti facilitated the emergence ofepidemic dengue
in urban centers around theworld and is still the primary vector of
denguetoday, most control efforts have focused on thisspecies.
Mosquito control measures are par-ticularly important given the
current lack ofdengue-specic vaccines or therapeutics (66,71, 154),
and they play a central role world-wide. A fundamental distinction
in the designof a vector control program is whether it takes
agovernment-led, vertical (top-down) approachor a community-led,
horizontal (bottom-up)approach (41).
A vertical, Pan-American Health Organiza-tionled campaign
focused on controlling ur-ban yellow fever in the mid-twentieth
centurysucceeded in eliminating A. aegypti from mostcountries in
the Americas by 1965 (135) andhad the additional benet of reducing
the inci-dence of dengue in the region. Nonetheless, themosquito
remained in the northernmost coun-tries of South America and in
some locations inthe Caribbean, as well as in the United
States(135), which discontinued its program in 1969without having
achieved the goal of eradica-tion (132). This campaign established
the useof larval source reduction as a means of con-trolling
mosquito populations, as well as threeindices used to monitor
larval density that arestill in use today (35, 155), in particular
thehouse index (HI). The control program alsoincluded the use of
outdoor insecticidal sprays(DDT and malathion) in and around all
breed-ing sites (98). However, since the program wasdiscontinued in
the early 1970s, A. aegypti has
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returned to almost all countries in the Americas(43).
Two other successful vertical control pro-grams were undertaken
by the governments ofSingapore and Cuba. DHF was rst reportedin
Singapore in 1960 (19), and beginning in1968, the Vector Control
Unit of the Ministryof Health established a program of
entomologicsurveillance, larval source reduction, public
ed-ucation, and law enforcement targeted to con-trol both A.
aegypti and A. albopictus (97). Thisprogram succeeded in bringing
the HI downfrom almost 50% to approximately 2% by 1973,where it has
remained until the present time.The seroprevalence of DENV
infection in thegeneral population declined to 43% in 1996,with
only 6.7% of primary school children pos-itive for anti-DENV
antibodies, compared with71% in some locations in Thailand (141),
69%in Yogyakarta, Indonesia (39), and 90% in ur-ban Nicaragua (10).
However, after 15 years oflow incidence, Singapore has recently
experi-enced a resurgence in dengue, without a con-current change
in HI values (97). This increasehas been attributed in part to
lowered herd im-munity, increased virus transmission outside
thehome, and a shift in policy from vector surveil-lance to case
detection. Another element con-tributing to this resurgence likely
includes tensof millions of people who visit, transit through,and
commute to work in Singapore every year,leading to a high potential
for reintroductionby viremic individuals.
In the case of Cuba, a devastating epidemicof DHF/DSS in 1981,
the rst in the Americas,resulted in over 10,000 cases of severe
illnessand 158 deaths. The Cuban government ini-tiated a vertical,
systematic campaign aimed ateradicating the A. aegypti vector from
the island,and A. aegypti was eliminated from 13 of Cubas14
provinces (75). Some 10,000 health work-ers remained committed to
the control pro-gram, and for 15 years no dengue cases werereported
in Cuba (74, 75). However, dengue(due to DENV2) re-emerged in Cuba
in 1997,though it was detected early and conned toSantiago de Cuba.
In 2000, DENV3 was iso-lated in Cuba for the rst time, and it
caused
an epidemic of DF/DHF in the city of Havanaduring 20012002. Once
again, the Cuban gov-ernment mobilized a major vector control
cam-paign, and every house in Havana was inspected10 times.
Starting with an HI of 0.49% at thebeginning of the epidemic,
within three monthsthe house index had been reduced to 0.01%(50).
In 2006, another outbreak of DF/DHFwas reported from 4 of 14
provinces (105); how-ever, few details about this epidemic are
publiclyknown. Unfortunately, even these vector con-trol programs
that maintained an HI of less thanone percent were not able to
prevent the recur-rence of epidemic dengue, probably due to lowherd
immunity combined with constant rein-troduction of DENV from
international visi-tors and Cuban medical workers returning
fromendemic countries.
With their past successes, Singapore andCuba had long been
considered to have modeldengue control programs, owing in part to
theirunique political and geographical situations.These two
countries implemented consistentprograms and policies that made
possible thelong-term control of dengue, rather than re-lying only
on emergency responses to manageepidemics. However, both locales
have facedreintroductions of dengue in spite of low re-ported
vector indices, likely due in large part tothe continued inux of
people from endemic re-gions either as tourists, migrant workers,
or re-cipients of cultural exchange, combined with ahighly
susceptible native population that, ironi-cally, resulted from the
success of vector controlprograms in these countries.
Community-Based VectorControl Programs
In Southeast Asia, the World Health Organi-zation established an
Aedes Research Unit inBangkok, Thailand, in 1966 to investigate
con-trol measures for A. aegypti after it was identiedas a vector
of the newly emerging epidemics ofhemorrhagic fever in the region
(60, 84). Thesemeasures included a new method of
pesticideapplication, ultralow-volume spraying, to re-duce adult
mosquito populations (84), as well as
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scaling up the more labor-intensive, but highlyeffective,
targeting of breeding sites in resi-dences by health workers (11,
99). Originallyintended as a measure to control or halt an on-going
epidemic by drastically reducing densitiesof adult mosquitoes in a
short period of time(84), ultralow-volume spraying became
widelyused as a preventive measure in many parts ofthe world during
the next two decades (41), de-spite accumulating evidence of its
having littleimpact on reducing incidence of disease (95).
Various factors eroded the effectiveness ofoverreliance on both
mass pesticide sprayingand government-led vertical models for
vec-tor control, including increases in pesticide re-sistance, an
awareness of the detrimental sideeffects of pesticide use,
decreased governmentfunding for public health services, and a
pushfrom the global health community to move to-ward horizontal
programs integrating educa-tion and community participation (72).
How-ever, no alternative community-based modelswere available at
the time for vector controlprograms. Early attempts to establish
such aprogram in Thailand were unsustainable be-cause the community
was not involved in theprogram design and had no stake or
under-standing of the program and thus did not con-tinue it in the
absence of government support(44). Early community-based programs
weredesigned with strong educational components;however, many of
them were not successful inmotivating community participation. The
les-son of early control programs throughout the1980s and early
1990s was that community-based programs need to incorporate a sense
ofownership to be sustainable (44).
The key to dengue control is to closethe motivational gap
between communityknowledge and sustainable practice in reduc-ing
mosquito breeding sites. New evidence-based methodologies focus on
furnishing com-munity members with key concepts andtraining so they
can gather their own data,evaluate control programs, and generate
andimplement their own improved interventionsbased on successes and
challenges encounteredin their specic geographical and cultural
set-
tings. Thus, theoretical education about dengueand its vectors
is not enough; people are mo-tivated to change behavior by informed
dia-logue based on their own evidence that formsthe basis for their
own decisions. Evidence-based approaches, such as
Communication-for-Behavioural-Impact (COMBI) (100) andthe SEPA
(Socializing Evidence for Participa-tory Action) program based on
CIET meth-ods (5) (http://www.ciet.org/en/), are provingmore
successful in effecting behavioral changeand reduction of
entomological indices andhold promise as community-based vector
con-trol programs, especially in conjunction withsome degree of
institutional support, thoughtheir long-term sustainability and
impact ondengue incidence are still under evaluation (L.Lloyd,
personal communication; E. Harris, J.Arostegui, J. Coloma & N.
Andersson, unpub-lished results).
Equally important to a successful controlprogram is the ability
to effectively target andmonitor A. aegypti populations as part of
asource reduction strategy. A method of identify-ing highly
productive breeding sites that facili-tates targeted source
reduction efforts has beendeveloped to replace the more traditional
lar-val indices, thus maximizing the effect of con-trol measures
(34, 35). This pupal/demographicsurvey method involves counting the
num-bers of pupae (the stage between larvae andadult mosquitoes)
per container, thus identi-fying which container types are
responsiblefor the largest output of adult mosquitoes, aswell as
relating the results to the density oflocal human populations.
Input from the pu-pal/demographic survey can be combined
withtemperature and herd immunity values to createmathematical
models of transmission thresh-olds [the container-inhabiting
mosquito simu-lations model (CIMSiM) and the dengue sim-ulation
model (DENSIM)] that can providetarget values of pupal densities to
interrupttransmission for control programs (33, 34, 36).The hope is
that these indices will provide amore precise ability to monitor
and predictthe potential for dengue epidemics than hasthe
traditional HI, which does not necessarily
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correlate with dengue transmission (35).Another promising avenue
has been the devel-opment of biological control methods as
alter-natives to pesticides, including larvivorous sh,larvae-eating
copepods (Mesocyclops), toxins, in-sect growth hormones, and
viruses targeted tomosquito larvae (reviewed in Reference 86).The
principal goal of all vector control pro-grams is to minimize the
populations of adultmosquitoes to interrupt or at least minimizethe
transmission threshold, R0. Even reducingthe vector population
without eliminating it canmitigate the impact of an epidemic
(33).
THE VIRUS SPHERE
Introduction
The four dengue viruses fall into a distinctserogroup among the
mosquito-borne a-viviruses, showing a phylogenetic relationshipwith
the Japanese encephalitis virus group andmore distantly with yellow
fever virus (77,82). The current DENV serogroup progeni-tor is
estimated to have arisen approximately1000 years ago using
molecular clock tech-niques (142), and most phylogenies show
thatDENV4 is the most divergent serotype, fol-lowed by DENV2, and
then DENV1 andDENV3 as the most closely related serotypes(82, 142,
157). Phylogenetic analysis of syl-vatic and endemic/epidemic
strains suggeststhat each serotype emerged separately from
asylvatic ancestor (147), and this emergence isestimated to have
occurred about 125320 yearsago, varying by serotype (142).
Based on sequences of the complete enve-lope (E) gene or the
E-NS1 boundary usinga cutoff of 6% divergence (106), DENV1
iscurrently divided into four to ve genotypes,including a sylvatic
clade (27, 158). DENV2is divided into six subtypes, designated as
Syl-vatic, American, Cosmopolitan, Asian 1, Asian2, and
Asian-American (27, 64, 82, 147), al-though the two Asian subtypes
have on occa-sion been collapsed into a single Asian geno-type
(108). DENV3 has been divided into fourgenotypes (IIV) (64, 80,
87), sometimes in-
cluding a genotype V (27). Finally, DENV4is divided into two
endemic genotypes (III)and one sylvatic genotype and shows the
leastgenetic diversity among the serotypes, at leastamong available
strains (27, 64, 79, 147). Over-all, as further sequences become
available, thesegenotypic structures are likely to be
revised,possibly with the appearance of a new geno-type or the
collapse of two or more genotypesinto one. In this section, we
discuss the associ-ation of certain DENV genotypes or subtypeswith
disease severity or increased tness in thecontext of host
immunity.
Viral Genotypes and Virulence
With only 62%67% homology based onamino acid sequences (152),
the four dengueviruses could have been classied as sepa-rate viral
groups but instead are treated asfour DENV serotypes pertaining to
a singlegroup. Nonetheless, differences in severity as-sociated
with individual serotypes or particu-lar sequences of serotypes in
sequential infec-tion have been observed, and it remains anopen
question whether some serotypes are in-herently more pathogenic
than others. DENV2viruses have most commonly been associatedwith
DHF/DSS (9, 17, 53, 96, 125, 140), alongwith DENV1 and DENV3
viruses (9, 39, 50,62, 88); DENV4 appears to be the most
clin-ically mild, although it too can cause severedisease (96).
DENV2 and DENV4 have beenassociated with increased disease severity
asa secondary infection, whereas DENV1 andDENV3 seem to cause more
severe diseasein primary infection than do the other twoserotypes
(9, 62, 96, 145).
In most studies, secondary infection by anyof the four DENV
serotypes remains the great-est risk factor for severe disease
(56). Nonethe-less, the association of some DENV geno-types with
increased disease severity, whetheror not in the context of
secondary infection,has now been well documented, in
particularinvolving certain genotypes of DENV2 andDENV3. In
general, Southeast Asia appears toserve as a source for viral
diversity, generating
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UTR: untranslatedregion
a multitude of strains, some of which areinherently more
virulent and perhaps more suc-cessful than others, as evidenced by
their world-wide spread and possible displacement of earlierDENV
strains. Compelling evidence from phy-logenetic studies suggests
that only DENV2strains that originated in Southeast Asia are
as-sociated with DHF/DSS in the Americas, andnot the native
American strains that were orig-inally imported from the South
Pacic (27,109). Subsequent functional analysis revealedthat Thai
DENV strains (Asian genotype) repli-cated to higher titers than
American genotypeDENV2 strains in human monocyte-derivedmacrophages
and dendritic cells (21, 102).Full-length sequencing of Asian and
Americangenotypes revealed several key nucleotidedifferences,
particularly at position 390 in theE protein and in the 5 and 3
untranslated re-gions (UTRs) (81). Substitution of N390 foundin the
Asian genotype by the American geno-type D390 reduced virus output
from both hu-man monocyte-derived macrophage and den-dritic cell
cultures (21, 102), and this reductionwas enhanced by replacing the
Asian genotype5 and 3 UTRs with those from the Ameri-can genotype
(21). The Asian DENV2 strainsalso disseminated in a larger
percentage of eld-caught A. aegypti mosquitoes compared
withAmerican DENV2 strains (6), and when themosquitoes were
coinoculated with equal titersof Asian and American strains, the
Asian strainswere consistently recovered from a larger per-centage
of mosquitoes than were the Americanstrains (20). Thus, it is
possible that the suc-cess of the Southeast Asian DENV2 strains
isdue in part to more efcient replication in hu-man target cells as
well increased transmissionby vector mosquitoes. Only one exception
tothis paradigm has been reported; Shurtleff et al.(127) described
the association of DHF with anAmerican genotype DENV2 from
Venezuela,as determined by analysis of the 3 UTR.
Another recent example involves a clade re-placement within the
DENV2 Asian-Americangenotype identied by phylogenetic analysisof
full-length genomes from Nicaraguan pa-tients; interestingly, this
correlates temporally
with a large increase in disease severity, and thenew clade is
signicantly associated with severedisease (A. Balmaseda, T. Gomez,
M. Henn,C. Rocha & E. Harris, unpublished results).The
mechanism(s) responsible for the increasedtness and/or virulence of
the new DENV2clade is currently under investigation. Althoughan
increase in viral virulence must be consideredin the context of
host immunity, the possibil-ity exists that more virulent dengue
viruses willcontinue to evolve in Southeast Asia and
spreadworldwide, displacing more benign genotypesin the years to
come (107, 157).
The DENV3 serotype provides anotherconvincing example of how
increased viral di-versity has led to the emergence or evolu-tion
of a clade of viruses strongly associatedwith DHF/DSS. DENV3
genotype III in-cludes isolates from East Africa, South Asia,and
Latin America and has been associatedwith an increase in DHF/DSS in
these regions(27, 87). Emergence of epidemic DHF/DSS inSri Lanka in
1989 led investigators to questionthe reasons for this occurrence.
After eliminat-ing the possibility of a general increase in
viruscirculation or a change in serotype prevalenceon the island
(88), the decisive factor was iden-tied as a clade replacement
event (87). BothDENV3 III subtypes A and B were presentin Sri Lanka
in 1989, but only one subtype(B) persisted after 1989 and was
involved inall subsequent cases of DHF/DSS on the is-land.
Additionally, DENV3 III subtype B hassince spread to the Americas,
where it has alsobeen associated with epidemics of DHF/DSS(27, 50,
87). Other genotypes of DENV3 mayalso be associated with increased
severity ofdisease; genotype I viruses reintroduced intoislands of
the Western Pacic have been as-sociated with DHF/DSS, in contrast
to pastepidemics of DF associated with genotype IV(80). As viral
strains with increased virulenceare identied via the marriage of
phylogeneticand epidemiologic analyses, the next challengewill be
to dene the molecular basis of thisincreased pathogenesis. With
this informationin hand, a combination of active surveillancefor
and rapid detection of viral genotypes with
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potential for increased virulence could helpidentify at-risk
populations and individuals,respectively.
Virus Evolution and Host Immunity
Intriguing evidence to explain differences inviral virulence in
relation to pre-existing hostimmunity of native and introduced
DENV2genotypes derives from observations in Iq-uitos, Peru. After
years of DENV1 circula-tion, a large number of secondary
infectionswith DENV2 were documented in Iquitos inthe complete
absence of severe dengue (150),which was unexpected given the
increasedrisk of DHF/DSS typically observed in sec-ondary DENV
infections. The DENV2 geno-type present in Iquitos belonged to the
nativeAmerican genotype (150), in contrast to theDENV2 strains that
have caused epidemics ofDHF/DSS in the Caribbean and
throughoutLatin America (27, 61, 75, 109). The questionarose
whether the lack of DHF/DSS due tothese secondary DENV2 infections
with nativeAmerican strains was caused by an inherent lackof
virulence compared with Southeast AsianDENV2 strains, and/or
whether anti-DENV1antibodies present among the population ofIquitos
neutralized or at least mitigated sec-ondary American DENV2
infection by virtueof cross-reacting, neutralizing antibodies.
Infact, sera from Iquitos residents characterizedby a monotypic,
anti-DENV1 response havehigher cross-reactive neutralizing titers
againstAmerican DENV2 strains than against AsianDENV2 strains (73).
Antibodies arising froma DENV1 infection in Cuban patientsalso
demonstrated higher neutralizing abilityagainst the American DENV2
genotype thanagainst the Asian DENV2 genotype (51), rais-ing the
possibility that the Asian DENV2strains have epitopes divergent
from those thatmay be shared between DENV1 and AmericanDENV2
strains (73).
Several investigators have taken advantageof detailed
information available from Bangkok,Thailand, which has remained
hyperendemicfor all four DENV serotypes since at least 1958
(60), to tease out the correlations between theperiodicity of
dengue epidemics and potentialcross-protection between serotypes.
Serotype-and severity-specic data collected between1973 and 1999
showed that each serotype dis-plays a somewhat different pattern of
oscillationacross this time period, and that together thefour
serotypes exhibit rather complex dynam-ics (96). Mathematical
models have been de-signed to test the theory that the interaction
be-tween the periodicity of alternating epidemicsdue to different
serotypes and host immunitycan explain the patterns seen in Bangkok
(2,151). One model describes a scenario in whichtemporary
cross-immunity between serotypesand seasonal uctuations in vector
populationsexplains serotype dynamics in Bangkok (151),and posits
that ADE and differences in viral vir-ulence are less important in
shaping patterns oftransmission (although it does not exclude
bothplaying a key role in disease). Another modelpostulates that
moderate cross-immunity alonecan explain the oscillations and
periodicity ofindividual serotypes (2), and that clade replace-ment
events seen within each serotype are alsoassociated with
serotype-specic periodicityin combination with cross-reactive
protection(2, 158). In particular, the authors propose thatclade
replacements within DENV1 serotypes inThailand are best explained
by a combination ofmutations xed by stochastic events plus
cross-protective immunity to an incipient increasein DENV4 (158),
as these two serotypes showa striking out-of-phase periodicity with
oneanother.
The studies discussed above would sug-gest that viral evolution
must then be con-sidered in the context of cocirculation
ofdifferent serotypes and the presence of cross-protective
immunity. Alternatively, other the-ories have been proposed
suggesting that thephenomenon of ADE could explain the pe-riodicity
and alternating epidemics caused bymultiple serotypes in Mexico and
Thailand(24, 31). Although most studies of DENV evo-lution have
shown strong evidence for neg-ative or purifying selection (157,
158), sup-port for adaptive evolution has been reported
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Extrinsic incubationperiod: the latentperiod in a vectormosquito
before thevirus has disseminatedto the salivary glands,from where
it can betransmitted to avertebrate host as themosquito takes a
bloodmeal
(15, 16, 143), as well as some examples ofrecombination (1, 65).
Even so, most studiessuggest that positive selection and
recombina-tion have not played a decisive role in the over-all
evolution of DENV. To date, it appears thata combination of random
genetic drift, rapidevolution, an ever-increasing number of
in-fections, and perhaps the sporadic selectivelydriven replacement
of viral clades character-izes DENV evolution, along with a
complexinteraction with serotype-specic host immu-nity that is only
now beginning to be unrav-eled (2, 79, 114, 157). A better
understandingof this last interaction is crucial in the face
ofimminent large-scale tetravalent dengue vac-cine trials, because
selection pressures due tohost immunity will be greatly increased
by tri-als and the eventual implementation of denguevaccines.
OTHER FACTORS
Climate
The term climate change refers to multiyear,large-scale changes
in climate patterns, includ-ing uctuations in both rainfall and
temper-ature; global warming refers to an increasein the average
global temperature related tothe greenhouse effect, whereby solar
radia-tion is trapped beneath the earths atmosphere.Changes in the
composition of the atmospherehave been predicted to lead to a
2.0C4.5Crise in global temperatures by the year 2100(126), which
could have an impact on vector-borne diseases (137). There has been
a greatdeal of debate on the implications of globalwarming for
human health (22, 139). Modelsthat discuss the specic impact on
dengue fo-cus particularly on humidity (54) and tempera-ture (101)
in an attempt to predict the impacton the geographic range of
mosquito vectors.Other perspectives highlight the overriding
im-portance of infrastructure and socioeconomicdifferences that
exist today and already preventthe transmission of vector-borne
diseases, in-cluding dengue, even in the continued presenceof their
vectors (104). At the moment, there is
no consensus, but in the case of dengue it isimportant to note
that even if global warmingdoes not cause the mosquito vectors to
expandtheir geographic range, there could still be asignicant
impact on transmission in endemicregions. For instance, a 2C
increase in temper-ature would simultaneously lengthen the
life-span of the mosquito and shorten the extrinsicincubation
period of DENV, resulting in moreinfected mosquitoes for a longer
period of time(33).
Public Policy
A great deal of work is currently directed towardthe development
of tetravalent dengue vaccinesand specic antivirals, which will
hopefully pro-vide additional tools for reducing the health im-pact
of dengue in the near to mid-term future(66, 71, 154). At present,
sustainable vector con-trol programs that can maintain low
mosquitodensities, as well as good surveillance programsthat can
quickly identify incipient epidemicsand thus trigger mobilization
of emergencycontrol measures, will continue to be our mostimportant
tools for controlling dengue for sometime. Inevitably, these
measures will face thechallenge that much of public health faceshow
to convince both policymakers and res-idents that only their
vigilance now can pre-vent the need to cope with large epidemics
inthe future. Dengue will continue to be a chal-lenge for public
health ofcials and policymak-ers for the reasons discussed in this
review,namely, increases in human population, urban-ization, and
international travel; the plethora ofmosquito habitats due to
daunting challenges invector control; and the increasing
occurrenceof DF and DHF/DSS epidemics related in partto changes in
viral virulence and to host im-mune status. Although we understand
the gen-eral principles behind the spread and persis-tence of
dengue, and further research questionsremain to be explored,
knowledge alone is notenough. The overriding question is, Can
wetake this knowledge and use it to contain or re-verse the trend,
or will the prevalence of denguecontinue to increase in the years
to come?
84 Kyle Harris
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SUMMARY POINTS
1. The incidence of DF and of DHF/DSS has increased dramatically
in the past 50 years,and key reasons for this increase include
population growth, uncontrolled urbanization,spread of the mosquito
vectors, and movement of the virus in conjunction with the
rapidtransit of people around the globe.
2. The risk for acquiring dengue relates foremost to the hosts
immune status and exposureto an infected mosquito. Risk factors for
DHF/DSS include most importantly previousexposure to a heterotypic
dengue virus, as well as the time between infections, age,ethnicity
and genetic background, and the genotype and serotype of the
infecting virus.
3. Originally found in the jungles and rural areas of Southeast
Asia, dengue virus is nowmaintained primarily in an urban cycle
involving humans and A. aegypti and A. albopictusmosquitoes, and
the challenge of controlling urban breeding sites for these vectors
hashindered progress in containing the dengue pandemic.
4. Dengue virus may be maintained between epidemic cycles by
silent transmission inhumans (asymptomatic infections) and/or
vertical transmission or overwintering in themosquito vectors.
5. Past vertical or government-led vector control programs have
been somewhat success-ful using intensive source reduction
techniques combined with targeted insecticide use.Ultimately, these
programs are either unsustainable and/or unable to prevent
denguetransmission. New approaches that encompass both community
participation and tar-geting of highly productive breeding
containers via pupal/demographic surveys holdpromise to minimize
dengue epidemics in the future.
6. Some genotypes and subtypes of dengue virus appear to cause
more severe disease;functional analysis in vitro conrms that
certain strains may be inherently more virulentin both mammalian
cells and mosquitoes. However, there is also clearly a role for
hostimmunity in determining the tness of dengue virus strains and
thus inuencing viralevolution.
7. Although development and evaluation of dengue-specic vaccines
and therapeutics arecurrently underway, these tools will not be
available for general use in the immediatefuture. Therefore, our
best hope for confronting the continued spread of dengue atthe
moment is to use the knowledge we already have to design more
effective controlmeasures, while pursuing remaining research
questions that will allow the design ofmore effective measures in
the future through a better understanding of the complexinteraction
of human, mosquito, and viral biology.
DISCLOSURE STATEMENT
The authors are not aware of any biases that might be perceived
as affecting the objectivity of thisreview.
ACKNOWLEDGMENTS
The authors wish to thank Josena Coloma, Scott Balsitis, and
Eddie Holmes for critical readingof the manuscript.
www.annualreviews.org Global Persistence of Dengue 85
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