Dengue and Dengue Hemorrhagic Fever

Duane J. Gubler*
Division of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, Centers for Disease Control
and Prevention, Public Health Service, U.S. Department of Health and Human Services, P.O. Box 2087, Fort Collins,
Colorado 80522

 SUMMARY
INTRODUCTION
EMERGENCE OF DENGUE AS A GLOBAL PUBLIC HEALTH PROBLEM
    Factors Responsible for the Increased Incidence
    Dengue in the Continental United States
NATURAL HISTORY
    The Viruses
    Transmission Cycles
CLINICAL DIAGNOSIS
    Dengue Fever
    Dengue Hemorrhagic Fever
PATHOGENESIS
    Pathology
    Virologic Factors
    Host Immune Factors
LABORATORY DIAGNOSIS
    Serologic Diagnosis
    Virus Isolation
        Baby mice.
        Mammalian cell culture.
        Mosquito inoculation.
        Mosquito cell culture.
    Virus Identification
    New Diagnostic Technology
        PCR.
        Hybridization probes.
        Immunohistochemistry.
PREVENTION AND CONTROL
    Vaccine Development
    Disease Prevention Programs
        Active surveillance.
        Mosquito control.
    Prevention of Dengue in Travelers
REFERENCES

SUMMARY
Dengue fever, a very old disease, has reemerged in the past 20 years with an expanded geographic distribution of
both theviruses and the mosquito vectors, increased epidemic activity,  the development of hyperendemicity (the
cocirculation of multiple serotypes), and the emergence of dengue hemorrhagic fever in new  geographic regions. In
1998 this mosquito-borne disease is the most important tropical infectious disease after malaria, with  an estimated
100 million cases of dengue fever, 500,000 cases of dengue hemorrhagic fever, and 25,000 deaths
annually. The reasons for this resurgence and emergence of dengue hemorrhagic fever in the waning Top
years of the 20th century are complex and not fully understood, but demographic, societal, and Next
public health infrastructurechanges in the past 30 years have contributed greatly. This paper reviews References
the changing epidemiology of dengue and dengue hemorrhagicfever by geographic region, the
natural history and transmission cycles, clinical diagnosis of both dengue fever and dengue hemorrhagicfever,
serologic and virologic laboratory diagnoses, pathogenesis,  surveillance, prevention, and control. A major challenge
for public health officials in all tropical areas of the world is to devleop  and implement sustainable prevention and
control programs that will reverse the trend of emergent dengue hemorrhagic fever.

INTRODUCTION
Although first reports of major epidemics of an illness thought to possibly be dengue occurred on three continents
(Asia,Africa, and North America) in 1779 and 1780 (73, 75, 109, 128), reports of illnesses clinically compatible with
dengue fever occurred even earlier. The earliest record found to date  is in a Chinese encyclopedia of disease
symptoms and remedies,first published during the Chin Dynasty (265 to 420 A.D.) and formally Top
edited in 610 A.D. (Tang Dynasty) and again in 992 A.D. (Northern Sung Dynasty) (108). The
Previous
disease was called water poison by the Chinese and was thought to be somehow connected with
flying insects associated with water. Outbreaks of illness in the French  West Indies in 1635 and in Next
Panama in 1699 could also have been dengue (75,103). Thus, dengue or a very similar illness had a
    References
wide geographic distribution before the 18th century, when the  first known pandemic of dengue-like illness began.
It is uncertain whether the epidemics in Batavia (Jakarta), Indonesia, and Cairo,  Egypt, in 1779 were dengue, but it
is quite likely that the Philadelphia epidemic of 1780 was dengue (19). A more detailed discussion of the history of
dengue viruses has recently been published (41).

EMERGENCE OF DENGUE AS A GLOBAL PUBLIC

HEALTH PROBLEM
The disease pattern associated with dengue-like illness from 1780 to 1940 was characterized by Top
relatively infrequent but often large epidemics. However, it is likely that dengue viruses Previous
became endemic in many tropical urban centers during this time because  during interepidemic Next
periods, when there was no apparent disease transmission, nonimmune visitors invariably References
contracted a dengue-like illness within months of their arrival.
The ecologic disruption in the Southeast Asia and Pacific theaters during and following World War II created ideal conditions for increased
transmission of mosquito-borne diseases, and it was in this setting that a global pandemic of dengue began. With increased epidemic transmission,
hyperendemicity (the cocirculation of multiple dengue virus serotypes) developed in Southeast Asian cities and epidemic dengue hemorrhagic
fever (DHF), a newly described disease, emerged (37, 48, 61, 63). The first known epidemic of DHF occurred in Manila,
Philippines, in 1953 to 1954, but within 20 years the disease in epidemic form had spread throughout
Southeast Asia; by the mid-1970s, DHF had become a leading cause of hospitalization  and death among children in
the region (1). In the 1970s, dengue was reintroduced to the Pacific Islands and epidemic activity  increased there
and in the Americas. During the 1980s and 1990s, epidemic dengue transmission intensified, and there is now a
global resurgence of dengue fever, with expanding geographic distribution  of both the mosquito vectors and the
viruses, increased incidence of disease caused by an increased frequency of epidemic transmission,  and the
emergence of DHF in many new countries (36, 39, 41, 45, 48, 61, 63, 110, 111, 124).
In Asia, epidemic DHF has expanded geographically from Southeast Asian countries west to India, Sri Lanka, the
Maldives, and Pakistan and east to China (42). Several island countries of the South and Central Pacific (Niue, Palau,
Yap, Cook Islands, Tahiti, New Caledonia, and Vanuatu) have experienced major or minor DHF epidemics (41).
Epidemiologic changes in the Americas, however, have been the most dramatic. In the 1950s, 1960s, and  most of
the 1970s, epidemic dengue was rare in the American region  because the principal mosquito vector, Aedes aegypti,
had been eradicated from most of Central and South America (36-38, 110). The eradication program was discontinued
in the early 1970s, and this species then began to reinvade the countries from which it  had been eradicated
(38, 110). By the 1990s, A. aegypti had nearly regained the geographic distribution it held before eradication  was
initiated (Fig. 1). Epidemic dengue invariably followed reinfestation  of a country by A. 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 (36-38, 111). New dengue virus strains and serotypes were introduced (DEN-1 in 1977,  a new strain
of DEN-2 in 1981, DEN-4 in 1981, and a new strain of DEN-3 in 1994). Moreover, many countries of the region
evolved from nonendemicity (no endemic disease) or hypoendemicity (one  serotype present) to hyperendemicity
(multiple serotypes present),  and epidemic DHF emerged, much as it had in Southeast Asia 25  years earlier (36-38).
From 1981 to 1997, 24 American countries reported laboratory-confirmed DHF (Fig. 2) (42, 43, 111).
FIG. 1.   A. aegypti distribution in the Americas during the
1930s and in 1970 and 1998. 

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 FIG. 2.   DHF in the Americas before 1981 and from
1981 to the present. 

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While Africa has not yet had a major epidemic of DHF, sporadic cases have occurred, with increased epidemic
dengue fever, 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 (41, 48). Outbreaks have been more common in East Africa and the Middle East in the 1990s, with
major epidemics in Djibouti in 1991 and in Jeddah, Saudi Arabia, in 1994; both were the first outbreaks in those
countries in over 50 years (41, 120).
In 1997, dengue viruses and A. aegypti mosquitoes have a worldwide distribution in the tropics (Fig. 3); over
2.5 billion people now live in areas where dengue is endemic (42, 45, 48, 61, 63). Currently, dengue fever causes
more illness and death than any other arbovirus disease of humans (124). Each year, an estimated 100 million cases
of dengue fever and several hundred thousand cases of DHF occur, depending on epidemic activity  (42, 45, 104). DHF
is a leading cause of hospitalization and death among children in many Southeast Asian countries (1).
FIG. 3.   World distribution map of dengue
and A. aegypti in 1998. 

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Factors Responsible for the Increased Incidence

The factors responsible for the dramatic resurgence and emergence of epidemic dengue and DHF, respectively, as a global public health problem
in the past 17 years are complex and not fully understood. However, the resurgence appears to be closely associated with demographic and
societal changes over the past 50 years (36, 41, 42, 48). Two major factors have been the unprecedented global population
growth and the associated unplanned and uncontrolled urbanization, especially in tropical developing countries.
Thesubstandard housing, crowding, and deterioration in water, sewer,  and waste management systems associated
with unplanned urbanization have created ideal conditions for increased transmission of mosquito-borne  diseases in
tropical urban centers.
A third major factor has been the lack of effective mosquito control in areas where dengue is endemic
(36, 38, 42, 48). The emphasis during the past 25 years has been on space spraying with insecticides to kill adult
mosquitoes; this has not been effective (38, 107,115) and, in fact, has been detrimental to prevention and control
efforts by giving citizens of the community and government officials a "false sense of security" (38). Additionally, the
geographic distribution and population densities of A. aegypti have increased, especially in urban areas of the
tropics, because of increased numbers of mosquito larval habitats in the domestic  environment. The latter include
nonbiodegradable plastics and used automobile tires, both of which have increased dramatically  in prevalence
during this period.
A fourth factor responsible for the global emergence of dengue and DHF is increased air travel, which provides the
ideal mechanism for the transport of dengue and other urban pathogens between  population centers of the world
(36, 40, 42, 48). For instance, in 1994, an estimated 40 million persons departed the United States by air, over 50%
of whom traveled for business or holiday to tropical countries where dengue is endemic. Many travelers  become
infected while visiting tropical areas but become ill only  after returning home, resulting in a constant movement of
dengue viruses in infected humans to all areas of the world and ensuring  repeated introductions of new dengue
virus strains and serotypes into areas where the mosquito vectors occur (40, 119).
A fifth factor that has contributed to the resurgence of epidemic dengue has been the decay in public health
infrastructures in most countries in the past 30 years. Lack of resources has led to a critical shortage of trained
specialists who understand and can develop effective prevention and control programs for vector-borne diseases.
Coincident with this has been a change in public health policy that placed emphasis on emergency response  to
epidemics by using high-technology mosquito control methods  rather than on preventing those epidemics by using
larval source reduction through environmental hygiene, the only method that  has been shown to be effective (38).
In summary, demographic and societal changes, decreasing resources for vector-borne infectious disease
prevention and control, and changes in public health policy have all contributed to increased  epidemic dengue
activity, the development of hyperendemicity, and the emergence of epidemic DHF.
Dengue in the Continental United States

Each year, dengue cases imported to the Continental United States are documented by the Centers for Disease Control and Prevention(CDC)
(40, 119). These cases represent introductions of all four virus serotypes from all tropical regions of the world.
Most cases of dengue introduced into the United States come from the American and Asian tropics, reflecting the
increased number of persons traveling to and from those areas. Overall, from 1977  to 1995, a total of
2,706 suspected cases of imported dengue were reported to CDC (21, 40,119). Although adequate blood
samples were received from only some of these patients, 584 (22%) were confirmed in the laboratory as dengue.
These cases represent only the tip of the iceberg, because most physicians in the United States have a low index of
suspicion for dengue, which is often not included in the differential diagnosis  of acute febrile illness, even if the
patient recently returned from a tropical country. As a result, the majority of imported  dengue cases are never
reported (21). It is important to increase awareness of dengue and DHF among physicians in temperate
areas, however, because the disease can be life-threatening. For example,  two cases of dengue shock syndrome
(DSS) were recently described in Swedish tourists returning from holiday in Asia (152). In the United States,
imported cases appear to be increasingly severe  (21). From 1986 to 1993, for example, only 13 of
166 patients (8%) with laboratory-confirmed dengue were hospitalized. In 1994  and 1995, however, 6 of
46 patients (13%) and 11 of 86 patients (13%) with confirmed imported disease required
hospitalization, respectively. Moreover, 3 (7%) of the patients in 1994 had severe, hemorrhagic disease (21).
Therefore, it is important that physicians in the United States consider dengue in the differential diagnosis  of a viral
syndrome in all patients with a travel history to any tropical area.
The potential for epidemic dengue transmission in the United States still exists. After an absence of 35 years,
autochthonoustransmission, secondary to importation of the virus in humans,  occurred on four occasions in the
past 17 years (1980, 1986, 1995, and 1997) (21, 22). Although all of these outbreaks were small, they underscore
the potential for dengue transmission in the United States, where two competent mosquito vectors are found
(48) (Fig. 4). A. aegypti, the most important and efficient epidemic  vector of dengue viruses, has been in the United
States for over 200 years and was responsible for transmitting major epidemics  in the southern states in the 19th
and early 20th centuries (34). Currently, this species is found only in the Gulf Coast states  from Texas to Florida,
although small foci have recently been reported in Arizona (Fig. 4). Aedes albopictus, a secondary vector of dengue
virus, was introduced into the continental United States  from Asia in the early 1980s and has since become
widespread in the eastern half of the country. This species currently is found  in 866 counties in 26 of the continental
states (22, 105); it has also been found in Hawaii for over 90 years, as well asin Guam and Saipan.
Both A. aegypti and A. albopictus can transmit dengue viruses to humans, and their presence in the United
Statesincreases the risk of autochthonous dengue transmission, secondary  to imported cases (37, 40).
FIG. 4.   A. aegypti and A. albopictus distribution in the
United States in 1998. 

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NATURAL HISTORY Top
Previous
The Viruses Next
References
There are four dengue virus serotypes, called DEN-1, DEN-2, DEN-3, and DEN-4. They belong to the genus Flavivirus, familyFlaviviridae (of
which yellow fever virus is the type species), which contains approximately 70 viruses (150). The flaviviruses are relatively small (40-
50 mm) and spherical with a lipid envelope. The flavivirus genome is approximately 11,000 bases long and is made
up of three structural and seven nonstructural proteins. There are three major complexes within this family tick-
borne encephalitis virus, Japanese encephalitis virus, and dengue virus.  All flaviviruses have common group
epitopes on the envelope protein that result in extensive cross-reactions in serologic tests. These  make unequivocal
serologic diagnosis of flaviviruses difficult. This is especially true among the four dengue viruses. Infection  with one
dengue serotype provides lifelong immunity to that virus,  but there is no cross-protective immunity to the other
serotypes. Thus, persons living in an area of endemic dengue can be infected  with three, and probably four, dengue
serotypes during their lifetime (37).
Transmission Cycles

The primitive enzootic transmission cycle of dengue viruses involves canopy-dwelling Aedes mosquitoes and lower primates in the rain forests of
Asia and Africa (Fig. 5) (37). Current evidence suggests that these viruses do not regularly move out of the forest  to
urban areas (116). An epidemic transmission cycle may occur in rural villages or islands, where the human
population is small. Introduced viruses quickly infect the majority of susceptible  individuals in these areas, and
increasing herd immunity causes the virus to disappear from the population. A number of Aedes (Stegomyia) spp.
may act as a vector in these situations, depending on the geographic area,
includingA. aegypti, A. albopictus, A.  polynesiensis and other members of the A. scutellaris group (37). The most
important transmission cycle from a public health standpoint  is the urban endemic/epidemic cycle in large urban
centers of the tropics (Fig. 5). The viruses are maintained in an A. aegypti-human-A.  aegypti cycle with periodic
epidemics. Often, multiple virus serotypes  cocirculate in the same city (hyperendemicity).
FIG. 5.   Transmission cycles of dengue viruses. 

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Humans are infected with dengue viruses by the bite of an infective mosquito (37). A. aegypti, the principal vector,
is a small, black-and-white, highly domesticated tropical mosquito  that prefers to lay its eggs in artificial containers
commonly found in and around homes, for example, flower vases, old automobile  tires, buckets that collect
rainwater, and trash in general. Containers used for water storage, such as 55-gallon drums, cement cisterns,  and
even septic tanks, are important in producing large numbers  of adult mosquitoes in close proximity to human
dwellings. The adult mosquitoes prefer to rest indoors, are unobtrusive, and  prefer to feed on humans during
daylight hours. There are two peaks of biting activity, early morning for 2 to 3 h after daybreak and in the afternoon
for several hours before dark. However, these mosquitoes will feed all day indoors and on overcast days.
The female mosquitoes are very nervous feeders, disrupting the feeding  process at the slightest movement, only to
return to the same or a different person to continue feeding moments later. Because  of this
behavior, A. aegypti females will often feed on several persons during a single blood meal and, if infective, may
transmitdengue virus to multiple persons in a short time, even if they  only probe without taking blood
(46, 112, 114, 135). It is not uncommon to see several members of the same household become  ill with dengue fever
within a 24- to 36-h time frame, suggesting that all of them were infected by a single infective mosquito  (43). It is
this behavior that makes A. aegypti such an efficient epidemic vector. Inhabitants of dwellings in the tropics are
rarely 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 to 7 days), after which the person may experience acute onset of fever accompanied by a variety of
nonspecific signs and symptoms (136). 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 peripheral blood (51). If other A. 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 (37, 46).

CLINICAL DIAGNOSIS
Dengue virus infection in humans causes a spectrum of illness ranging from inapparent or mild febrile illness to severe Top
andfatal hemorrhagic disease (1). Infection with any of the four serotypes causes a similar clinical Previous
presentation that may varyin severity, depending on a number of risk factors (see below).  The Next
incubation period varies from 3 to 14 days (average, 4 to 7 days) (131, 136). In areas where dengue References
is endemic, the illness is often clinically nonspecific, especially in children, withsymptoms of a viral syndrome that
has a variety of local names. Important risk factors influencing the proportion of patients  who have severe disease
during epidemic transmission include the  strain and serotype of the infecting virus and the immune status,  age, and
genetic background of the human host (1, 4, 37, 57, 62, 123).
Dengue Fever

Classic dengue fever is primarily a disease of older children and adults. It is characterized by the sudden onset of fever and a variety of
nonspecific signs and symptoms, including frontal headache, retro-orbital pain, body aches, nausea and vomiting, joint pains, weakness, and rash
(1, 71, 131, 136, 149). Patients may be anorexic, have altered taste sensation, and have  a mild sore throat.
Constipation is occasionally reported; diarrhea and respiratory symptoms are infrequently reported and may be  due
to concurrent infections.
The initial temperature may rise to 102 to 105°F, and fever may last for 2 to 7 days. The fever may drop after a
few days, only to rebound 12 to 24 h later (saddleback). A relative bradycardia may be noted despite the fever. The
conjunctivae may be injected, and the pharynx may be inflamed. Lymphadenopathy is common. Rash  is variable
but occurs in up to 50% of patients as either early or late eruptions. Facial flushing or erythematous mottling
may occur coincident with or slightly before onset of fever and disappears  1 to 2 days after onset of symptoms. A
second rash, varying in form from scarlatiniform to maculopapular, may appear between  days 2 and 6 of illness.
The rash usually begins on the trunk and spreads to the face and extremities. In some cases, an
intense erythematous pattern with islands of normal skin is observed.  The average duration of the second rash is
2 to 3 days. Toward the end of the febrile phase of illness or after the temperature  falls to or below normal,
petechiae may appear; these may be scattered or confluent. Intense pruritus followed by desquamation on
the palms of the hands and soles of the feet may occur.
Hemorrhagic manifestations in dengue fever patients are not uncommon and range from mild to severe. Skin
hemorrhages, includingpetechiae and purpura, are the most common, along with gum bleeding,  epistaxis,
menorrhagia, and gastrointestinal (GI) hemorrhage.Hematuria occurs infrequently, and jaundice is rare.
Clinical laboratory findings associated with dengue fever include a neutropenia followed by a lymphocytosis, often
marked by atypical lymphocytes. Liver enzyme levels in the serum may  be elevated; the elevation is usually mild,
but in some patients, alanine aminotransferase and aspartate aminotransferase levels  reach 500 to 1,000 U/liter. In
one epidemic of DEN-4, 54% of confirmed patients with data reported on liver enzymes had elevated levels  (32).
Thrombocytopenia is also common in dengue fever; in the  above epidemic, 34% of patients with confirmed dengue
fever who were tested had platelet counts of less than 100,000/mm 3 (32).
Dengue fever is generally self-limiting and is rarely fatal. The acute phase of illness lasts for 3 to 7 days, but the
convalescent phase may be prolonged for weeks and may be associated with weakness  and depression, especially in
adults. No permanent sequelae are known to be associated with this infection.
Dengue Hemorrhagic Fever

DHF is primarily a disease of children under the age of 15 years, although it may also occur in adults (1, 32). It is characterized by
sudden onset of fever, which usually lasts for 2 to 7 days, and a variety of nonspecific signs and symptoms. During
the acute phase of illness, it is difficult to distinguish  DHF from dengue fever and other illnesses found in tropical
areas. The differential diagnoses during the acute phase of illness should  include measles, rubella, influenza,
typhoid, leptospirosis, malaria,  other viral hemorrhagic fevers, and any other disease that may present in the acute
phase as a nonspecific viral syndrome. Children frequently have concurrent infections with other viruses and
bacteria causing upper respiratory symptoms. There is no pathognomonic  sign or symptom for DHF during the acute
stage; on the other hand, as fever remits, characteristic manifestations of plasma leakage  appear, making accurate
clinical diagnosis possible in many cases (1).
The critical stage in DHF is at the time of defervescence, but signs of circulatory failure or hemorrhagic
manifestations may occur from about 24 h before to 24 h after the temperature falls to normal or below (1). Blood
tests usually show that the patient has thrombocytopenia (platelet count,  100,000/mm3) and hemoconcentration
relative to baseline as evidence of a vascular leak syndrome. Common hemorrhagic manifestations include  skin
hemorrhages such as petechiae, purpuric lesions, and ecchymoses.  Epistaxis, bleeding gums, GI hemorrhage, and
hematuria occur less frequently. The tourniquet test, which indicates that the patient  has increased capillary
fragility, may be diagnostically helpful to the physician.
Scattered petechiae are the most common hemorrhagic manifestation observed; they appear most often on the
extremities but are also found on the trunk, other parts of the body, and on the  face in patients with severe dengue
shock syndrome (DSS). Purpuric lesions may appear on various parts of the body but are most common  at the site
of venipuncture. In some patients, large ecchymotic  lesions develop on the trunk and extremities; other patients
bleed actively at the site of venipuncture, some profusely. More severely  ill patients have GI hemorrhage. Classic
hematemesis with coffee-ground vomitus and melena usually occur after prolonged shock, but patients  may develop
massive, frank upper GI hemorrhage as well, often  before the onset of shock. Without early diagnosis and
proper management, some patients experience shock from blood loss, which  may be mild or severe (35, 138, 139).
More commonly, shock is caused by plasma leakage; it may be mild and transient or progress  to profound shock
with undetectable pulse and blood pressure (1). Children with profound shock are often somnolent, exhibit
petechiae on the face, and have perioral cyanosis.
In patients with severe DHF or DSS, fever and nonspecific constitutional signs and symptoms of a few days
duration are followed by the sudden deterioration of the patient's condition (1). During or shortly before or after the
fall in temperature, the patient's skin may become cool, blotchy, and congested; circumoral  cyanosis is frequently
observed, and the pulse becomes rapid and weak. Although some patients appear lethargic at first, they
become restless and then rapidly pass into a critical stage of shock.  They frequently experience acute abdominal
pain shortly before the onset of shock (1, 138, 139).
In patients with mild DHF, all signs and symptoms abate shortly after the fever subsides. Subsidence of fever,
however, may be accompanied by profuse sweating and mild changes in pulse rate  and blood pressure, together
with coolness of the extremities and skin congestion. These changes reflect mild and transient  circulatory
disturbances as a result of plasma leakage. Patients  usually recover spontaneously or after fluid and electrolyte
therapy (1). Patients in shock are in danger of dying unless appropriately managed. The duration of shock is usually
short; the patient may die within 8 to 24 h, but recovery is usually rapid following antishock therapy. Convalescence
for patients with DHF, with or without shock, is usually short and uneventful. Once the shock is overcome, even
patients with undetectable pulse and blood pressure  will usually recover within 2 to 3 days (1).
As with dengue fever, leukopenia is common; thrombocytopenia and hemoconcentration are constant findings in
DHF and DSS. A platelet count of  100,000/mm3 is usually found between the days 3 and 8 of illness.
Hemoconcentration, indicating plasma leakage, is almost always present in classic  DHF but is more severe in
patients with shock. Hepatomegaly is a common but not constant finding (35, 138,139). In some countries, most
patients with confirmed DHF and DSS have enlarged livers. In other countries, however, hepatomegaly varies
from one epidemic to another, suggesting that the strain and/or serotype  of virus may influence liver involvement
(35). Elevated liver enzyme levels are common.
The primary pathophysiologic abnormality seen in DHF and DSS is an acute increase in vascular permeability that
leads to leakage of plasma into the extravascular compartment, resulting in hemoconcentration  and decreased
blood pressure (1, 77). Plasma volume studieshave shown a reduction of more than 20% in severe cases.
Supporting evidence of plasma leakage includes serous effusion found postmortem,  pleural effusion on X-ray,
hemoconcentration, and hypoproteinemia. Early diagnosis and aggressive fluid replacement therapy with  good
nursing care can decrease fatality rates to 1% or less. Normal  saline or lactated Ringer's solution can be used in
patients withmild DHF and DSS, but plasma or plasma expanders may be necessary  in those with severe cases.
Details of effective management of DHF and DSS have been published previously (1). There are no apparent
destructive vascular lesions, suggesting that the transient  functional vascular changes are due to a short-acting
mediator (1). Once the patient is stabilized and begins recovery, the  extravasated fluid is rapidly reabsorbed,
causing a drop in the hematocrit.
Hemostatic changes in DHF and DSS involve three factors: vascular changes, thrombocytopenia, and coagulation
disorders (1). Almost all DHF patients have increased vascular fragility and  thrombocytopenia, and many have
abnormal coagulograms, suggesting disseminated intravascular coagulation, which is also evidenced  by concomitant
thrombocytopenia, a prolonged partial thromboplastin  time, a decreased fibrinogen level, and increased levels of
fibrinogen degradation products. GI hemorrhage is found at autopsy in the  majority of patients who die.

PATHOGENESIS
The pathogenesis of DHF and DSS is still controversial. Two theories, which are not mutually exclusive, are frequently citedto explain the
pathogenetic changes that occur in DHF and DSS. The most commonly accepted is known as the secondary-infection or immune enhancement
hypothesis (57, 61, 62). This hypothesis implies that patients experiencing a second infection with a
heterologous dengue virus serotype have a significantly higher risk for developing  DHF and DSS (62). Top
Preexisting heterologous dengue antibody recognizes  the infecting virus and forms an antigen-
antibody complex, which is then bound to and internalized by immunoglobulin Fc receptors on the
   
Previous
cell membrane of leukocytes, especially macrophages. Because  the antibody is heterologous, Next
however, the virus is not neutralized and is free to replicate once inside the macrophage. Thus, it  is References
hypothesized that prior infection, through a process known  as antibody-dependent enhancement (ADE), enhances
the infection and replication of dengue virus in cells of the mononuclear cell  lineage (15, 62, 66, 67, 106). It is thought
that these cells produce and secrete vasoactive mediators in response to dengue infection, which causes increased
vascular permeability leading to hypovolemia and shock (see below).
The other hypothesis assumes that dengue viruses, like all animal viruses, vary and change genetically as a result
of selection pressures as they replicate in humans and/or mosquitoes and that  there are some virus strains that
have greater epidemic potential (37, 49, 123). Phenotypic expression of genetic changes in  the virus genome may
include increased virus replication and viremia, severity of disease (virulence), and epidemic potential.
There is epidemiologic and laboratory evidence to support both of these hypotheses; however, a detailed
discussion is beyond the scope of this review. They are not mutually exclusive, and  both are most probably valid
(37). Excellent reviews have recently been published on both viral pathogenesis and immunopathogenesis  (92, 127),
which have summarized the evidence concluding that  both viral and host immunologic factors are involved in the
pathogenesis of severe dengue disease. This evidence is briefly presented below.
Pathology

The pathology of DHF and DSS has been well studied (6, 7, 9), but that of dengue infections has not. Gross and
microscopic pathologic studies of tissues taken at autopsy in Thailand have  shown diffuse petechial hemorrhages of
most organs, as well as serous effusions in the pericardial, pleural, and peritoneal cavities.  Microscopically,
perivascular edema and loss of integrity of endothelial junctions are found. Dengue antigen can be demonstrated in
endothelial cells, but there is no apparent damage to the blood vessels or  endothelial cells.
In the liver, midzonal necrosis is common and is often indistinguishable from the pathologic changes caused by the
closely related yellow fever virus; Councilman bodies are common. In the  brain, edema and hemorrhage have been
observed but pathologic changes associated with encephalitis have not. However, recent  isolations of dengue virus
from the brain and cerebrospinal fluid and intrathecal antibody production in the latter suggest that  on occasion, the
dengue virus crosses the blood-brain barrier. There is increased proliferation of reticuloendothelial cells  in the bone
marrow, spleen, lymph nodes, and lungs.
Virologic Factors

Unfortunately, there are no good animal models for DHF and DSS, making studies on pathogenesis difficult to interpret. Primates are natural
hosts for dengue virus, but those that have been studied generally show no signs of disease; these animals become infected and develop viremia,
although at a lower titer than humans (126). However, the results obtained with these animals are conflicting.  One of the few
studies cited as evidence that ADE occurs in vivo  showed that rhesus monkeys that experienced a secondary DEN-
2 infection or had been infused with dengue immune serum had higher  viremias than did monkeys with primary
infections (60, 64, 65). All monkeys were infected parenterally by needle inoculation.  These results could not be
repeated in macaque monkeys infected naturally by a mosquito bite or in chimpanzees infected
parenterally; primary and secondary infections of all serotypes and combinations  routinely showed that monkeys
with primary infection had viremia of the same or higher titer and longer duration (126, 134). Clinical and laboratory
studies on humans have shown the same results (35, 47, 49, 51, 87).
In humans, viremias range in titer from barely detectable (10 3), measured as 50% mosquito infection doses (MID50)
(125) to over 108.5MID50 (51). Viremia usually peaks at the time of or shortly after the onset of illness and may remain
detectable for various periods ranging from 2 to 12 days, depending on the strain of virus and the immune status of
the individual (35, 43, 47, 49, 51, 87, 147). It has been suggested that the severity of the disease associated with
dengue infection is determined by the number of cells infected with the virus and that the number  of cells infected is
related to ADE infection of peripheral blood leukocytes in secondary infections (77). It follows that viremias should
be higher in secondary infections, but this is not borne  out by experimental infection of lower primates or by
clinicalstudies on humans (35, 49, 51, 87, 126, 134). In fact, the opposite has usually been observed; that is, viremias
are usually higher in primary infections.
In secondary infections, the virus may be complexed with antibody, making it undetectable by most current virus
isolation techniques. However, studies in humans during an outbreak of DEN-2  on an island in the Pacific (Tonga)
showed great variation in both the magnitude and duration of viremia in primary infections  (49). Some patients were
identified on the day of onset of mild illness and monitored for as long as 8 days. Blood samples were taken daily
for viremia studies, and uninfected mosquitoes were  allowed to feed on some patients. The majority of patients,
confirmed as DEN-2 infection by seroconversion, had undetectable viremia  both by virus isolation and by
isodiagnosis (feeding mosquitoes on patients) (49). When virus was detectable, viremia was at a low titer (
106 MID50) and of short duration (1 to 3 days). The same DEN-2 virus had caused explosive epidemics associated
with severe disease in neighboring islands in the previous 3 years, but in Tonga it circulated for nearly a year
without being detected in a human population that was fully susceptible to DEN-2 virus (silent transmission)  (49).
Two species of vector mosquitoes (A. aegypti and Aedes  tabu) were present in large numbers. The data suggested
that the virus had changed from an epidemic strain to one that circulated  in nature silently, causing mild or
inapparent disease. Similar observations have been made with DEN-3 and DEN-1 viruses (41).
Molecular studies have demonstrated that dengue viruses vary genetically in nature; unfortunately, phenotypic
changes that have been observed in the field have not yet been associated with  genetic changes in the virus
(26, 99, 100, 116, 117, 143). Collectively, however, the data suggest that viral factors play  a significant role in the
pathogenesis of severe dengue disease.
Host Immune Factors

There is a large body of evidence, mostly obtained in vitro, suggesting that heterotypic, nonneutralizing antibody binds with dengue virus,
facilitating the entry of the virus into cells of the monocytic line and hence facilitating infection (15, 61, 62, 67, 68, 83). These data, along
with epidemiologic observations that the majority of patients with reported DHF cases  are experiencing a secondary
infection, form the basis for the hypothesis that preexisting heterotypic dengue antibody is a risk  factor for DHF
(18, 57, 61, 62, 83, 133). The lack of a good animal model for human disease and limitations of human  clinical studies
have made it difficult to confirm this hypothesis. In recent years, however, detailed, well-designed studies
that support the concept of immunopathogenesis of dengue infection  in humans have been conducted. The results
of these studies have been comprehensively reviewed in a recent article (92).
Briefly, the data show that dengue virus-specific memory CD4 + CD8  and CD4  CD8+ lymphocytes are detectable
in humans after natural dengue infections. Infection with a single dengue serotype induces both serotype-
specific and serotype-cross-reactive CD4+ memory T cells, while CD8+ T lymphocytes have virus-specific cytotoxic
activity.
The pathogenetic mechanism responsible for the increased vascular permeability observed in DHF and DSS is not
known, but it has been suggested that cytokines and chemical mediators such  as tumor necrosis factor (TNF),
interleukin-1 (IL-1), IL-2, IL-6, platelet-activating factor (PAF), complement activation products  C3a and C5a, and
histamine may play a role.
CD4+ T lymphocytes produce a number of cytokines, including gamma interferon (IFN- ), IL-2, IL-4, IL-5, IL-6, IL-
10, and lymphotoxin.Moreover, monocytes/macrophages which are infected by dengue viruses  produce TNF, IL-1,
IL-1B, IL-6, and PAF. Finally, cytokine andchemical mediator production is induced by other cytokines. Thus,  once
cytokines are produced, a complex network of induction mayfurther increase the levels of cytokines and chemical
mediators, resulting in even higher levels with synergistic effects on vascularpermeability (92).
Kurane and Ennis have proposed a model of immunopathogenesis based on these observations (92). Briefly, it is
hypothesized that dengue virus infections of monocytes/macrophages is enhanced  by ADE. This enhancement is
facilitated by the fact that the denguevirus-specific CD4 + T lymphocytes produce IFN- , which in turn up-regulates
the expression of FC-  receptors. The increased number of dengue virus-infected  monocytes/macrophages results in
increased T-cell activation, which results in the release of increased levels of cytokines  and chemical mediators.
Kurane and Ennis (92) hypothesized that the rapid increase in the levels and the synergistic effects ofmediators
such as TNF, IL-2, IL-6, IFN- , PAF, C3a, C5a, and histamine induce increased vascular permeability, plasma
leakage, shock,and malfunction of the coagulation system, which may lead to hemorrhage.
In summary, available evidence suggests that both viral and host immune factors are involved in the pathogenesis
of severe dengue disease. Unfortunately, the role of each is not fully understood  and the lack of an animal model
makes this a difficult area to study. It would appear that different clinical pathologic manifestations  of the disease
may be caused by different pathogenetic mechanisms  (37). For example, it has been suggested that hepatic
injury may relate more to viral factors whereas vascular permeability  may be mediated predominantly by the
immune response (92, 127). Clearly, the strain of virus is important since ADE apparently occurs only with selected
virus strains when tested in vitro. Also, the rate of virus replication and infectivity in various  tissues varies with the
strain of virus. Collectively, the data suggest that only certain strains of dengue virus are associated  with major
epidemics and severe disease, and it is most likely  that these are the viruses that infect cells of the monocytic  line
via ADE (12, 37, 49, 116, 117).

LABORATORY DIAGNOSIS Top

A definitive diagnosis of dengue infection can be made only in the laboratory and depends on isolating the virus, detectingviral
Previous
antigen or RNA in serum or tissues, or detecting specific antibodies in the patient's serum (47, 55, 148). There havebeen
two recent reviews of this topic (55, 148). Next
An acute-phase blood sample should always be taken as soon as possible after the onset of References
suspected dengue illness, and aconvalescent-phase sample should ideally be taken 2 to 3 weeks later. Because it is
frequently difficult to obtain convalescent-phasesamples, however, a second blood sample should always be
taken from hospitalized patients on the day of discharge from hospital.
Serologic Diagnosis

Five basic serologic tests have been routinely used for diagnosis of dengue infection; hemagglutination-inhibition (HI), complementfixation (CF),
neutralization test (NT), immunoglobulin M (IgM) capture enzyme-linked immunosorbent assay (MAC-ELISA), and indirectimmunoglobulin G
ELISA (47, 55, 148). Regardless of the test used, unequivocal serologic diagnosis depends upon a significant  (fourfold
or greater) rise in the titer of specific antibodies  between acute- and convalescent-phase serum samples. The
antigen battery for most of these serologic tests should include all four  dengue virus serotypes, another flavivirus
(such as yellow fever virus, Japanese encephalitis virus, or St. Louis encephalitis  virus), a nonflavivirus (such as
Chikungunya virus or eastern equine encephalitis virus), and ideally, an uninfected tissue  control antigen (47).
Of the above tests, HI has been the most frequently used; it is sensitive, is easy to perform, requires only minimal
equipment, and is very reliable if properly done (28). Because HI antibodies persist for long periods (up to 48 years
and probably longer) (58), the test is ideal for seroepidemiologic studies. HI antibody  usually begins to appear at
detectable levels (titer of 10) by day 5 or 6 of illness, and antibody titers in convalescent-phase  serum specimens
are generally at or below 640 in primary infections, although there are exceptions (4, 47). By contrast, there is an
immediate anamnestic response in secondary and tertiary dengue infections, and reciprocal antibody titers increase
rapidly during the first few days of illness, often reaching 5,120 to 10,240 or more. Thus, a titer of  1,280 in an
acute-phase or early convalescent-phase serum sample is considered presumptive evidence  of a current dengue
infection. Such high levels of HI antibodypersist for 2 to 3 months in some patients, but antibody titers generally
begin to wane by 30 to 40 days and fall below 1,280 in most patients (47). The major disadvantage of the HI test is
its lack of specificity, which generally makes it unreliable  for identifying the infecting virus serotype. However, some
patients with primary infections show a relatively monotypic HI response  that generally correlates with the virus
isolated (47).
The CF test is not widely used for routine dengue diagnostic serologic testing. It is more difficult to perform,
requires highly trained personnel, and therefore is not used in most dengue  laboratories. It is based on the principle
that complement is consumed during antigen-antibody reactions (20). CF antibodies generally appear later than HI
antibodies, are more specific in primary infections, and usually persist for short periods, although  low levels of
antibodies persist in some persons (47). It is a valuable test to have in a diagnostic laboratory because of the late
appearance of CF antibodies; some patients thus show a diagnostic rise in antibody titers by CF but have only
stable antibody titers by HI or ELISA (47). The greater specificity of the CF test in primary infections is demonstrated
by the monotypic CF responses when HI responses are broadly heterotypic; it is  not specific in secondary infections.
The CF test is useful for patients with current infections but is of limited value for seroepidemiologic  studies, where
detection of persistent antibodies is important.
The NT is the most specific and sensitive serologic test for dengue viruses (33, 129). The most common protocol
used in dengue laboratories is the serum dilution plaque reduction NT.  In general, neutralizing-antibody titers rise at
about the same time or slightly more slowly than HI and ELISA antibody titers  but more quickly than CF antibody
titers and persist for at least 48 years (58). Because the NT is more sensitive, neutralizing antibodies are present in
the absence of detectable HI antibodies in some persons with past dengue infection.
Because relatively monotypic neutralizing-antibody responses are observed in properly timed convalescent-phase
serum, the NT can be used to identify the infecting virus in primary dengue  infections (4, 47, 129, 148). As noted
above, the HI and CF tests may also give monotypic responses to dengue infection  that generally agree with NT
results. In cases when the responses are monotypic, the interpretation of all these tests is generally  reliable. In
secondary and tertiary infections, determining the  infecting virus serotype by NT or any other serologic test is  not
reliable (90). Because of the long persistence of neutralizing antibodies, the test may also be used for
seroepidemiologic studies. The major disadvantages are the expense, time required to perform  the test, and
technical difficulty. It is therefore not used routinely by most laboratories.
MAC-ELISA has become the most widely used serologic test for dengue diagnosis in the past few years. It is a
simple, rapid test that requires very little sophisticated equipment (17, 47, 78, 89, 97). Anti-dengue IgM antibody
develops a little faster than IgG antibody. By day 5 of illness, most patients (80%) in Puerto Rico whose cases were
subsequently confirmed by HI on paired serum samples or by virus isolation had detectable IgM  antibody in the
acute-phase serum in this assay (47). Nearly all patients (93%) developed detectable IgM antibody 6 to
10 days after onset, and 99% of patients tested between 10 and 20 days had detectable IgM antibody. The rapidity
with which IgM develops varies considerably among patients. Although the dates of onset  are not always recorded
accurately, some patients have detectable IgM on days 2 to 4 after the onset of illness whereas others may not
develop IgM for 7 to 8 days after onset (47). This variation is also reflected in the amount of IgM produced and the
length of time detectable IgM persists after infection. IgM antibody  is produced by patients with both primary and
secondary dengue infections and probably by persons with tertiary infections, although  the response in some
secondary and probably most tertiary infections  is low level and transient (89). IgM antibody titers in
primary infections are significantly higher than in secondary infections,  although it is not uncommon to obtain IgM
titers of 320 in the latter cases (47). In some primary infections, detectable IgM  persists for more than 90 days, but
in most patients, it has waned to an undetectable level by 60 days. A small percentage of patients with secondary
infections have no detectable IgM antibody (89).
MAC-ELISA with a single acute-phase serum sample is slightly less sensitive than the HI test with paired serum
samples for diagnosing dengue infection (47). However, it has the advantage of frequently requiring only a single,
properly timed blood sample. In one series of 288 patients during the 1986 epidemic in Puerto Rico, paired blood
samples were tested by HI and the single acute-phase  sample from the same pairs were tested by MAC-ELISA. The
HI test on the pairs indicated that 228 (79%) were considered positive, while MAC-ELISA on the single samples
indicated that 203 (70%) were positive. Five samples (1.7%) showed a false-positive response  and 30 samples
(10%) showed a false-negative response by MAC-ELISA (47). When one considers the difficulty in obtaining
second blood samples and the long delay in obtaining conclusive results  from the HI test, this low error rate would
be acceptable in most surveillance systems. It must be emphasized, however, that because  of the persistence of
IgM antibody for 1 to 3 months, MAC-ELISA-positive results obtained with single serum samples are only
provisional and do not necessarily mean that the dengue infection was current  (47, 148). These results do mean that
it is reasonably certain that the person had a dengue infection sometime in the previous  2 to 3 months. Similarly, a
negative result with an acute-phase sample may be a false-negative result because the sample was taken  before
detectable IgM appeared. Unfortunately, many dengue diagnostic  laboratories have adopted MAC-ELISA as a
confirmatory test and do not conduct follow-up tests to confirm the presumptive IgM  results. As noted above, this
may be acceptable for surveillance reports, but it is unacceptable in a clinical setting. If this  test is used to make
patient management decisions, it could result  in a higher case fatality rate among patients with false-
negative results.
The specificity of MAC-ELISA is similar to that of HI. In both primary and secondary dengue infections, some
monotypic responses may be observed, but in general, the response is broadly reactive  among both dengue virus
and other flavivirus antigens. With serum samples from patients with other flavivirus infections such as  Japanese
encephalitis, St. Louis encephalitis, and yellow fever,  however, the response is generally more specific; while
there may be some cross-reaction with dengue antigens, most specimens  show relatively monotypic IgM responses
to the infecting flavivirus (47). In dengue infections, monotypic IgM responses frequently do not correlate with the
virus serotype isolated from a patient.  Therefore, MAC-ELISA cannot be reliably used to identify the infecting  virus
serotype.
MAC-ELISA has become an invaluable tool for surveillance of dengue, DHF, and DSS. In areas where dengue is not
endemic, it can be used in clinical surveillance for viral illness or for  random, population-based serosurveys, with the
certainty that any positive results detected indicate recent infections (within  the last 2 to 3 months). A properly
timed serosurvey by MAC-ELISA during an epidemic can determine very quickly how widespread transmission  has
become. In areas where dengue is endemic, MAC-ELISA can be  used as an inexpensive way to screen large
numbers of serum specimens with relatively little effort. It is especially useful for hospitalized  patients, who are
generally admitted late in the illness after detectable IgM is present in the blood (47), but it must be emphasized
again that this test should not be used to make patient  management decisions.
An indirect IgG-ELISA has been developed that is comparable to the HI test and can also be used to differentiate
primary and secondary dengue infections (27). The test is simple and easy to perform and is thus useful for high-
volume testing. The IgG-ELISA is very nonspecific and exhibits the same broad cross-reactivity  among flaviviruses
as the HI test does; therefore, it cannot be used to identify the infecting dengue virus serotype. However,  it has a
slightly higher sensitivity than the HI test. As more  data are accumulated on the IgG-ELISA, it is expected to
replace the HI test as the most commonly used IgG test in dengue laboratories.
A number of commercial test kits for anti-dengue IgM and IgG antibodies have become available in the past few
years. Unfortunately, the accuracy of most of these tests is unknown because proper  validation studies have not
been done. Some evaluations have beenpublished (91, 96, 146, 153), but the sample sizes have been too small to
accurately measure sensitivity and specificity. Moreover, the samples generally used have represented only
strong positives and negatives, with few samples representing optical  densities or positive-negative values in the
equivocal range. One exception to this were kits that were independently evaluated  at CDC; both IgM and IgG test
kits had a high rate of false-positive results compared to standard tests, especially with samples with  optical
densities in the equivocal range (91). Other studies, however, have given results comparable to those of standard
tests (96, 146, 153). It is anticipated that these test kits can  be reformulated to make them more accurate, making
global laboratory-based surveillance for dengue and DHF an attainable goal in the near future.
Virus Isolation

Four isolation systems have routinely been used for dengue viruses; intracerebral inoculation of 1- to 3-day-old baby mice, the use of mammalian
cell cultures (primarily LLC-MK2 cells), intrathoracic inoculation of adult mosquitoes, and the use of mosquito cell cultures (47,55, 148).
Baby mice. Although all four dengue serotypes were initially isolated from human serum by using baby mice (70, 74, 131), this method is
very time-consuming, slow, and expensive. Moreover, because  of the low sensitivity of the method, many wild-type
viruses cannot be isolated with baby mice. Those that are isolated frequently  require numerous passages to adapt
the viruses to growth in mice. This method is no longer recommended for isolation of dengue viruses,  but some
laboratories continue to use it (47). One advantage of using baby mice, however, is that other arboviruses that
cause dengue-like illness may be isolated with this system.
Mammalian cell culture. Mammalian cell cultures have many of the same disadvantages as baby mice for isolation of dengue viruses they
are expensive, slow, and insensitive (47, 55, 148, 155). As with isolation systems that use baby mice, viruses that are isolated
frequently require many passages before a consistent cytopathic effect can  be observed in the infected cultures.
Although the use of this method continues in some laboratories, it is not recommended (47, 148).
Mosquito inoculation. Mosquito inoculation is the most sensitive method for dengue virus isolation (47, 125). Isolation rates of up to
100% of serologically confirmed dengue infections are not uncommon, and  this is the only method sensitive enough
for routine successfulvirologic confirmation of fatal DHF and DSS cases (47, 50, 139, 147). Moreover, there are many
endemic dengue virus strains that can be recovered only by this method (47, 49, 54).
Four mosquito species have been used for virus isolation, A.  aegypti, A.  albopictus, Toxorhynchities amboinensis, and T. splendens. Male and
female mosquitoes are equally susceptible; dengue viruses generally replicate to high titers (106 to 107 MID50) in as little as 4 to 5 days, depending
on the temperature of incubation. Dengue viruses replicate in most mosquito tissues, including the brain. A recent variation on this method
involves intracerebral inoculation of larval and adult Toxorhynchities mosquitoes (95, 142). However, these modifications neither increase
sensitivity nor provide other advantages over intrathoracic inoculation (125).
Virus detection in the mosquito, regardless of the species, is generally performed by the direct fluorescent-antibody DFA test on mosquito tissues,
usually brain or salivary glands (47, 50, 86). The direct conjugate is prepared from pooled human serum and has broadly reactive anti-dengue (or
anti-flavivirus) activity. Alternatively, a polyclonal mouse ascitic fluid or a flavivirus group-reactive monoclonal antibody can be used in
an indirect fluorescent-antibody (IFA) test with an anti-mouse immunoglobulin G-fluorescein isothiocyanate conjugate that is commercially
available.
The mosquito inoculation technique has the disadvantages of being labor-intensive and requiring an insectary to produce large numbers of
mosquitoes for inoculation. Also, unless strict safety precautions are maintained, the chance of laboratory infections increases, although this risk
can be eliminated by using male Aedes mosquitoes or nonbiting Toxorhynchites species for inoculation (47, 125).
Mosquito cell culture. Mosquito cell cultures are the most recent addition to dengue virus isolation methodology (47, 52, 76, 88, 141).Three
cell lines of comparable sensitivity are most frequently used (88). The first cell line developed, and still the
most widely used, is the C6/36 clone of A. albopictus cells (76). The use of these cell lines has provided a rapid,
sensitive, and economical method for dengue virus isolation. Moreover, many serum  specimens can be processed
easily, making the method ideal for routine virologic surveillance (52). However, this system is less sensitive than
mosquito inoculation (47). For example, on average, 10 to 15% more viruses were isolated from patients in Puerto
Rico by the mosquito inoculation technique than by mosquito  cell cultures (22, 43, 47). However, the sensitivity
of the mosquito cell lines may vary with the strain of virus. In  samples from an epidemic in Mozambique, more than
twice as many DEN-3 viruses were isolated by mosquito inoculation than by the  use of mosquito cells (54).
Dengue antigen can be detected in infected-cell cultures by DFA or IFA tests with the conjugates used for mosquito tissues (52). Some workers,
however, prefer to use cytopathic effect to detect infection, especially with AP-61 cells. However, this method alone will miss many dengue
viruses that do not replicate rapidly in mosquito cells (47).
The methods selected for virus isolation depend upon the laboratory facilities available. Because the mosquito inoculation technique is the most
sensitive, it is the method of choice for fatal cases or patients with severe hemorrhagic disease. Use of the mosquito cell lines is the method of
choice for routine virologic surveillance. Even though cell cultures are less sensitive than mosquito inoculation, this disadvantage is more than
offset by the ease with which large numbers of samples can be processed in a relatively short time.
Virus Identification

The method of choice for dengue virus identification is IFA with serotype-specific monoclonal antibodies produced in tissue culture or mouse
ascitic fluids and an anti-mouse immunoglobulin G-fluorescein isothiocyanate conjugate (47, 52, 55, 72). This test can be easily
performed with infected cell cultures, mosquito brain or tissue squashes, mouse brain squashes, or even  on
formalin-fixed tissues embedded in paraffin and sectioned for  histopathologic testing (56). It is simple and reliable
and is the most rapid method. Moreover, it allows the detection of  multiple viruses in patients with concurrent
infections with more than one serotype (53, 94).
The success of isolating dengue virus from human serum depends on several factors (47). First, the manner in
which the specimen has been handled and stored is important. Virus activity can be  inhibited by heat, pH, and
several chemicals; therefore, improper handling is often an important cause of unsuccessful virus isolation.  Second,
the level of viremia may vary greatly depending on the time after onset, the antibody titers, and/or the strain of
the infecting virus. Viremia usually peaks at or shortly before the  onset of illness and may be detectable for an
average of 4 to 5 days (43, 47, 51, 147). The success of virus isolation decreases rapidly with the appearance of IgM
antibody (47, 148). With some virus strains, however, viremia may remain below the  level of detectability throughout
the illness (47,49). Finally, the virus isolation system used influences the success of isolation,  as discussed above.
New Diagnostic Technology

In recent years, several new methods of diagnosis have been developed and have proven very useful in dengue diagnosis. This topic has recently
been reviewed extensively (29). The various methods are discussed briefly below.
PCR. Reverse transcriptase PCR (RT-PCR) has been developed for a number of RNA viruses in recent years and has the potential
torevolutionize laboratory diagnosis; for dengue, RT-PCR provides a rapid serotype-specific diagnosis. The method is rapid, sensitive, simple, and
reproducible if properly controlled and can be used to detect viral RNA in human clinical samples, autopsy tissues, or mosquitoes
(29,55, 98, 148). Although RT-PCR has similar sensitivity to virus isolation systems that use C6/36 cell cultures,  poor
handling, poor storage, and the presence of antibody usually do not influence the outcome of PCR as they do virus
isolation. A number of methods involving primers from different locations  in the genome and different approaches to
detect the RT-PCR products have been developed over the past several years (29, 55, 148).
It must be emphasized, however, that RT-PCR should not be used as a substitute for virus isolation. The availability of virus isolates is important
for characterizing virus strain differences, since this information is critical for viral surveillance and pathogenesis studies. Unfortunately, many
laboratories are now conducting RT-PCR tests without proper quality control, i.e., virus isolation or serologic testing. Since RT-PCR is highly
sensitive to amplicon contamination, without proper controls false-positive results may occur. Improvements in this technology, however,
should make it even more useful in the future (29, 148).
Hybridization probes. The hybridization probe method detects viral nucleic acids with cloned hybridization probes (29, 148). Probes with
variable specificity ranging from dengue complex to serotype specific can  be constructed depending on the genome
sequences used. The method is rapid and relatively simple and can be used on human clinical  samples as well as
fixed autopsy tissues. Unfortunately, hybridization  probes have not been widely used or evaluated in the
diagnostic laboratory. Preliminary data suggest that this method is less  sensitive than RT-PCR, but like PCR, the
outcome of the test is not influenced by the presence of neutralizing antibodies or otherinhibitory substances. Even
so, the difficulties of working with RNA and the technical expertise required to obtain reproducible  results make this
method more suitable as a research tool than as a routine diagnostic test (29, 30, 148).
Immunohistochemistry. A major problem in dengue laboratory diagnosis has been confirmation of fatal cases. In most instances, only a single
serum sample is obtained and serologic testing is therefore of limited value. Also, most patients die at the time of or slightly afterdefervescence,
when virus isolation is difficult. With new methods of immunohistochemistry, it is now possible to detect dengue viralantigen in a variety of
tissues (56, 156). Although immunofluorescence tests were used in the past, newer methods involving enzyme
conjugates such as peroxidase and phosphatase in conjunction with either  polyclonal or monoclonal antibodies are
greatly improved (156). Because tissues can be fresh or fixed, autopsies should be performed  in all cases of
suspected DHF with a fatal outcome (47, 50).

PREVENTION AND CONTROL

Prevention and control of dengue and DHF has become more urgent with the expanding geographic distribution and increased Top
disease incidence in the past 20 years (36, 39, 41, 42, 45, 48, 61, 63, 104). Unfortunately, tools available to Previous
prevent dengue infection are very limited. There is no vaccine currently  available (see below), and Next
options for mosquito control are limited. Clearly, the emphasis must be on disease prevention if the References
trend of emergent disease is to be reversed.
Effective disease prevention programs must have several integrated components, including active laboratory-based
surveillance,emergency response, education of the medical community to ensure  effective case management,
community-based integrated mosquitocontrol, and effective use of vaccines when they become available  (37, 44).
Vaccine Development

The first candidate dengue vaccines were developed shortly after the viruses were first isolated by Japanese and American scientists (81, 132).
Despite considerable work over the years, an effective safe vaccine was never developed (3, 59, 69, 130, 151). The
World Health Organization designated the development  of a tetravalent dengue vaccine a priority for the most cost-
effective approach to dengue prevention (13, 14). Effective vaccination to prevent DHF will most probably require a
tetravalent vaccine, because epidemiologic studies have shown that preexisting heterotypic  dengue antibody is a
risk factor for DHF (18, 57, 61, 62, 133). With the support of the World Health Organization, considerable  progress in
developing a vaccine for dengue and DHF has been made  in recent years (8, 10, 11,145, 154). Promising
candidate attenuated vaccine viruses have been developed and have been evaluated  in phase I and II trials in
Thailand as monovalent, bivalent, trivalent, and tetravalent formulations (8). A commercialization contract has been
signed, and the tetravalent vaccine formulation  is currently undergoing repeat phase I trials in the United
States. Current progress on the live attenuated dengue vaccine has been  recently reviewed (8).
Promising progress in the development of alternative vaccine strategies using new molecular technology has also
been made in recent years. Recent approaches include the use of inactivated  whole-virion vaccines (23), synthetic
peptides (5, 121, 122), subunit vaccines (31, 101, 140), vector expression, recombinant live vector systems (23, 102),
infectious cDNA clone-derived vaccines (16, 25, 79, 80,82, 93, 113), and naked DNA (24, 84). The last two approaches
appear to be the most promising. An infectious clone of the DEN-2, PDK-53  vaccine candidate virus from Thailand
(11) has been constructed, and work is in progress to construct chimeric viruses by inserting  the capsid,
premembrane, and envelope genes of DEN-1, DEN-3 and DEN-4, into the DEN-2 PDK-53 backbone (82). Through
genetic manipulation, these recombinants may be made to grow better and  to be more immunogenic and safer than
the original live attenuated virus vaccine candidates. In addition, chimeras are being constructed  by inserting the
structural proteins of dengue viruses into the infections clones of the 17D yellow fever and the SA14-14-2
Japanese encephalitis vaccine viruses (103a). The development of naked DNA vaccines is in its infancy but shows
great promise (24). This area has been recently reviewed (23, 144).
Despite the promising progress, it is unlikely that an effective, safe, and economical dengue vaccine will be
available in the near future. A major problem has been and continues to be  lack of financial support for dengue
vaccine research. Thus, other approaches to disease prevention must be developed by using the  program
components outlined above.
Disease Prevention Programs

Active surveillance. Active disease surveillance is an important component of a dengue prevention program. In addition to monitoring secular
trends, the goal of surveillance should be to provide an early-warning or predictive capability for epidemic transmission, the rationale being that if
epidemics can be predicted, they can be prevented by initiating emergency mosquito control. For epidemic prediction, health authorities must be
able to accurately monitor dengue virus transmission in a community and be able to tell at any point in time where transmission is occurring,
which virus serotypes are circulating, and what kind of illness is associated with dengue infection (44, 118). To accomplish this, the
system must be active and laboratory based.
This type of proactive surveillance system must have at least three components that place the emphasis on the inter- or preepidemicperiod. These
components include a sentinel clinic and physician network, a fever alert system that uses community health workers, and a sentinel hospital
system (Table 1). The sentinel clinic and physician network and fever alert system are designed to monitor nonspecific viral syndromes in the
community. This is especially important for dengue viruses because they are frequently maintained in tropical urban centers in a silent or
unrecognized transmission cycle, often presenting as nonspecific viral syndromes. The sentinel clinic and physician network and fever alert
system are also very useful for monitoring other common infectious diseases such as influenza, measles, malaria, typhoid, and leptospirosis.
                               TABLE 1.   Components of laboratory-based, proactive surveillance for
View this table:  dengue and DHFa
[in this window]
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In contrast to the sentinel clinic and physician component, which requires sentinel sites to monitor routine viral syndromes, the fever alert system
relies on community health and sanitation workers to be alert to any increase in febrile activity in their community and to report this to the central
epidemiology unit of the health department. Investigation by the health department should be immediate but flexible; it may involve telephone
follow-up or active investigation by an epidemiologist who visits the area to take samples.
The sentinel hospital component should be designed to monitor severe disease. Hospitals used as sentinel sites should include all of those that
admit patients for severe infectious diseases in the community. This network should also include infectious-disease physicians, who usually
consult on such cases. The system can target any type of severe disease, but for dengue, it should include all patients with any hemorrhagic
manifestation; an admission diagnosis of viral encephalitis, aseptic meningitis, or meningococcal shock; and/or a fatal outcome following a viral
prodrome (50).
All three proactive surveillance components require a good public health laboratory to provide diagnostic support in virology, bacteriology, and
parasitology. The supporting laboratory does not have to be able to test for all agents but should know where to refer specimens for testing, e.g., to
the World Health Organization Collaborating Centers for Reference and Research.
This proactive surveillance system is designed to monitor disease activity during the interepidemic period, prior to epidemic transmission.
Individually, the three components are not sensitive enough to provide effective early warning, but when used collectively, they can often
accurately predict epidemic activity (44). Table 1 outlines the proactive surveillance system for dengue and DHF, listing the types of specimens
and laboratory tests required. It must be emphasized that once epidemic transmission has begun, the surveillance system should be refocused on
severe disease rather than viral syndromes. The surveillance system should be designed and adapted to the local conditions where it will
be initiated. However, this system should be closely tied to the mosquito control programs that will be responsible for reacting to surveillance data
to initiate emergency disease prevention in all areas.
Mosquito control. Prevention and control of dengue and DHF currently depends on controlling the mosquito vector, A.  aegypti, in and around
the home, where most transmission occurs. Space sprays with insecticides to kill adult mosquitoes are not usually effective (38,107, 115) unless
they are used indoors. The most effective way to  control the mosquitoes that transmit dengue is larval source
reduction, i.e., elimination or cleaning of water-holding containers that  serve as the larval habitats for A. aegypti in
the domestic environment (38, 115, 137).
There are two approaches to effective A.  aegypti control involving larval source reduction. In the past, the most effective programs have had a
vertical, paramilitary organizational structure with a large staff and budget (137). These successful programs were also facilitated by the
availability of residual insecticides, such as DDT, that contributed greatly to ridding the mosquito from the domestic environment. Unfortunately,
in all of these programs, without exception, there has been no sustainability, because once the mosquito and the disease were controlled,
limited health resources were moved to other competing programs and the A.  aegypti population rebounded to levels where epidemic
transmission occurred. The most recent example of this lack of sustainability is Cuba, where A. aegypti had been effectively controlled and dengue
transmission had been prevented since 1981. The vertically structured Cuban program has recently failed, most probably because of lack of
support; the result was a major dengue epidemic in 1997 (2, 85).
In recent years, emphasis has been placed on community-based approaches to larval source reduction to provide program sustainability(38). The
rationale is that sustainable A. aegypti control can be accomplished only by the people who live in the houses where the problems occur and by
the people who help create the mosquito larval habitats by their lifestyles (38). Community participation in and ownership of prevention programs
require extensive health education and community outreach. Unfortunately, this approach is a very slow process. Therefore, it has been proposed
that a combination top-down and bottom-up approach be used, the former to achieve immediate success and the latter to provide
program sustainability (38). The effectiveness of this approach remains unknown. Mosquito control for dengue prevention has recently
been reviewed (115).
Prevention of Dengue in Travelers

There is no completely effective method of preventing dengue infection in travelers visiting tropical areas. The risk
of infection can be significantly decreased, however, by understanding the  basic behavior and feeding habits of the
mosquito vector and by taking a few simple precautions to decrease exposure to infective  mosquito bites.
Female A. aegypti mosquitoes prefer to feed indoors, with peak biting activity occurring for 2 to 3 hours after
daybreak and for 3 to 4 hours before nightfall. Although the risk may be higher at these times, it is important to
remember that the mosquito may feed indoors at anytime during the day as well as outdoors,  especially on overcast
days. Precautions, therefore, include staying in screened or air-conditioned rooms, spraying these rooms
with aerosol bomb insecticides to kill adult mosquitoes indoors (especially  in bedrooms), using a repellent containing
dimethyl-metatoluamide (DEET) on exposed skin, and wearing protective clothing treated  with a similar repellant.
The risk of exposure may be lower in modern, air-conditioned hotels with well-kept grounds and in rural  areas.

FOOTNOTES
 Mailing address: Division of Vector-Borne Infectious Diseases, National Center for Infectious Diseases, Centers for
*

Disease Control and Prevention, Public Health Service, U.S. Department  of Health and Human Services, P.O. Box
2087, Fort Collins, CO 80522. Phone: (970) 221-6428. Fax: (970) 221-6476. E-mail: [email protected].

REFERENCES 
Top
Previous
1. Anonymous. 1986. Dengue hemorrhagic fever, diagnosis, treatment and control. World
Health Organization, Geneva, Switzerland.
2. Anonymous. 1997. Dengue in the Americas time to talk. Lancet 350:455[Medline].
(Editorial.)
3. Bancroft, W. H., R. M. Scott, K. H. Eckels, C. H. Hoke, T. E. Simms (Editorial.), K.
D. T. Jesrani, P. L. Summers, D. R. Dubois, D. Tsoulos, and P. K. Russell. 1984.
Dengue virus type 2 vaccine: reactogenicity and immunogenicity in soldiers. J. Infect.
Dis.149:1005-1010[Medline].
4. Barnes, W. J. S., and L. Rosen. 1974. Fatal hemorrhagic disease and shock associated
with primary dengue infection on a pacific island. Am. J. Trop. Med. Hyg. 23:495-506.
5. Becker, Y. 1994. Dengue fever virus and Japanese encephalitis virus synthetic peptides,
with motifs to fit HLA class I haplotypes prevalent in human populations in endemic
regions, can be used for applications to skin Langerhans cells to prime antiviral
CD8+cytotoxic T cells (CTLs) a novel approach to the protection of humans. Virus
Genes 9:33-45[Medline].
6. Bhamarapravati, N. 1989. Hemostatic defects in dengue hemorrhagic fever. J. Infect.
Dis. 2(Suppl. 4):S826-S829.
7. Bhamarapravati, N. 1997. Pathology of dengue infections, p. 115-132. In D. J. Gubler,
and G. Kuno (ed.), Dengue and dengue hemmorhagic fever. CAB International, London,
United Kingdom.
8. Bhamarapravati, N. 1997. Live attenuated tetravalent dengue vaccine, p. 367-378. In D. J.
Gubler, and G. Kuno (ed.), Dengue and dengue hemorrhagic fever. CAB International,
London, United Kingdom.
9. Bhamarapravati, N., P. Tuchinda, and V. Boonyapaknavik. 1967. Pathology of
 Thailand hemorrhagic fever: a study of 100 autopsy cases. Ann. Trop. Med.
Parasitol. 61:500-510[Medline].
10. Bhamarapravati, N., and S. Yoksan. 1989. Study of bivalent dengue vaccine in
volunteers. Lancet i:1077.
11. Bhamarapravati, N., S. Yoksan, T. Chayaniyayothian, S. Angsubhakorn, and A.
Bunyaratvej. 1987. Immunization with a live attenuated dengue-2 virus candidate vaccine
(16681-PDK 53): clinical, immunological and biological responses in adult volunteers.
Bull. W. H. O. 65:185-195.
12. Bielefeldt-Ohmann, H. 1997. Pathogenesis of dengue virus diseases: missing pieces in the
jigsaw. Trends Microbiol. 5:409-413[Medline].
13. Brandt, W. E. 1988. Current approaches to the development of dengue vaccines and
related aspects of the molecular biology of flaviviruses. J. Infect. Dis. 157:1105-
1111[Medline].
14. Brandt, W. E. 1990. Development of dengue and Japanese encephalitis vaccines. J. Infect.
Dis. 162:577-583[Medline].
15. Brandt, W. E., J. M. McCown, M. K. Gentry, and P. K. Russell. 1982. Infection
enhancement of dengue-2 virus in the U937 human monocyte cell line by antibodies to
flavivirus cross-reactive determinants. Infect. Immun. 36:1036-
1041[Abstract/Free Full Text].
16. Bray, M., and C.-J. Lai. 1991. Construction of intertypic chimeric dengue viruses by
substitution of structural protein genes. Proc. Natl. Acad. Sci. USA 88:10342-
10346[Abstract/Free Full Text].
17. Burke, D. S., A. Nisalak, and M. A. Ussery. 1982. Antibody capture immunoassay
detection of Japanese encephalitis virus immunoglobulin M and G antibodies in
cerebrospinal fluid. J. Clin. Microbiol. 15:1034-1042.
18. Burke, D. S., A. Nisalak, D. Johnson, and R. M. Scott. 1988. A prospective study of
dengue infections in Bangkok. Am. J. Trop. Med. Hyg. 38:172-180.
19. Carey, D. E. 1971. Chikungunya and dengue: a case of mistaken identity? J. Hist. Med.
Allied Sci. 26:243-262.
20. Casey, H. L. 1965. Standardized diagnostic complement fixation method and adaptation to
micro-test. Public health monograph 74. U.S. Government Printing Office, Washington,
D.C.
21. Centers for Disease Control and Prevention. 1995. Imported dengue United States,
1993 and 1994. Morbid. Mortal. Weekly Rep. 44:353-356[Medline].
22. Centers for Disease Control and Prevention. Unpublished data.
23. Chambers, T. J., T. F. Tsai, Y. Pervikov, and T. P. Monath. 1997. Vaccine development
against dengue and Japanese encephalitis: report of a World Health Organization Meeting.
Vaccine 15:1494-1502[Medline].
24. Chang, G.-J. 1998. Personal communication.
25. Chen, W., H. Kawano, R. Men, D. Clark, and C.-J. Lai. 1995. Construction of intertypic
chimeric dengue viruses exhibiting type 3 antigenicity and neurovirulence for mice. J.
Virol. 69:5186-5190[Abstract/Free Full Text].
26. Chungue, E. 1997. Molecular epidemiology of dengue viruses, p. 93-101. In J. F. Saluzzo,
and B. Dodet (ed.), Factors in the emergence of arbovirus diseases. Elsevier, Paris, France.
27. Chungue, E., R. Marche, R. Plichart, J. P. Boutin, and J. Roux. 1989. Comparison of
immunoglobulin G enzyme-linked immunosorbent assay (IgG-ELISA) and
 hemagglutination inhibition (HI) test for the detection of dengue antibodies. Prevalence of
dengue IgG-ELISA antibodies in Tahiti. Trans. R. Soc. Trop. Med. Hyg. 83:708-
771[Medline].
28. Clarke, D. H., and J. Casals. 1958. Techniques for hemagglutination and
hemagglutination-inhibition with arthropod-borne viruses. Am. J. Trop. Med. Hyg. 7:561-
577.
29. Deubel, V. 1997. The contribution of molecular techniques to the diagnosis of dengue
infection, p. 335-366. In D. J. Gubler, and G. Kuno (ed.), Dengue and dengue hemorrhagic
fever. CAB International, London, United Kingdom.
30. Deubel, V., and V. Pierre. 1994. Molecular techniques for rapid and more sensitive
detection and diagnosis of flaviviruses, p. 227-237. In R. C. Spencer, E. P. Wright, and S.
W. B. Newsom (ed.), Rapid methods and automation in microbiology and immunology.
Intercept, Andover, United Kingdom.
31. Deubel, V., M. Bordier, F. Megret, M. K. Gentry, J. J. Schlesinger, and M.
Girard. 1991. Processing, secretion, and immunoreactivity of caboxy terminally truncated
dengue-2 virus envelope proteins expressed in insect cells by recombinant baculoviruses.
Virology 180:442-447[Medline].
32. Dietz, V., D. J. Gubler, S. Ortiz, G. Kuno, A. Casta-Velez, G. E. Sather, I. Gomez, and
E. Vergne. 1996. The 1986 dengue and dengue hemorrhagic fever epidemic in Puerto
Rico: epidemiologic and clinical observations. P. R. Health Sci. J. 15:201-210[Medline].
33. Dulbecco, R. 1956. A study of the basic aspects of neutralization of two animal viruses,
Western equine encephalitis virus and poliomyelitis virus. Virology 2:162-205.
34. Ehrankramz, N. J., A. K. Ventura, and R. R. Guadrado. 1971. Pandemic dengue in
Caribbean countries and the southern United States: past, present and potential problems.
N. Engl. J. Med. 285:1460-1469.
35. Eram, S., Y. Setyabudi, T. I. Sadono, D. S. Sutrisno, D. J. Gubler, and J. Sulianti-
Saroso. 1979. Epidemic dengue hemorrhagic fever in rural Indonesia: clinical studies. Am.
J. Trop. Med. Hyg. 28:711-716.
36. Gubler, D. J. 1987. Dengue and dengue hemorrhagic fever in the Americas. P. R. Health
Sci. J. 6:107-111[Medline].
37. Gubler, D. J. 1988. Dengue, p. 223-260. In T. P. Monath (ed.), Epidemiology of
arthropod-borne viral diseases. CRC Press, Inc., Boca Raton, Fla.
38. Gubler, D. J. 1989. Aedes aegypti and Aedes aegypti-borne disease control in the 1990s:
top down or bottom up. Am. J. Trop. Med. Hyg. 40:571-578.
39. Gubler, D. J. 1993. Dengue and dengue hemorrhagic fever in the Americas, p. 9-22. In P.
Thoncharoen (ed.), Monograph on dengue/dengue hemorrhagic fever. W.H.O. regional
publication SEARO no. 22. World Health Organization, New Delhi, India.
40. Gubler, D. J. 1996. Arboviruses as imported disease agents: the need for increased
awareness. Arch. Virol. 11:21-32.
41. Gubler, D. J. 1997. Dengue and dengue hemorrhagic fever: its history and resurgence as a
global public health problem, p. 1-22. InD. J. Gubler, and G. Kuno (ed.), Dengue and
dengue hemorrhagic fever. CAB International, London, United Kingdom.
42. Gubler, D. J. The global pandemic of dengue/dengue haemorrhagic fever: current status
and prospects for the future. Ann. Acad. Med. Singapore, in press.
43. Gubler, D. J. Unpublished data.
44. Gubler, D. J., and A. Casta-Velez. 1991. A program for prevention and control of
 epidemic dengue and dengue hemorrhagic fever in Puerto Rico and the U.S. Virgin Islands.
Bull. Pan Am. Health Org. 25:237-247.
45. Gubler, D. J., and G. G. Clark. 1995. Dengue/dengue hemorrhagic fever: the emergence
of a global health problem. Emerg. Infect. Dis. 1:55-57[Medline].
46. Gubler, D. J., and L. Rosen. 1976. A simple technique for demonstrating transmission of
dengue viruses by mosquitoes without the use of vertebrate hosts. Am. J. Trop. Med.
Hyg. 25:146-150.
47. Gubler, D. J., and G. E. Sather. 1988. Laboratory diagnosis of dengue and dengue
hemorrhagic fever, p. 291-322. In A. Homma, and J. F. Cunha (ed.), Proceedings of the
International Symposium on Yellow Fever and Dengue.
48. Gubler, D. J., and D. W. Trent. 1994. Emergence of epidemic dengue/dengue
hemorrhagic fever as a public health problem in the Americas. Infect. Agents Dis. 2:383-
393.
49. Gubler, D. J., D. Reed, L. Rosen, and J. C. J. Hitchcock. 1978. Epidemiologic, clinical
and virologic observations on dengue in the Kingdom of Tonga. Am. J. Trop. Med.
Hyg. 27:581-589.
50. Gubler, D. J., W. Suharyono, Sumarmo, H. Wulur, E. Jahja, and J. Sulianti
Saroso. 1979. Virological surveillance for dengue haemorrhagic fever in Indonesia using
the mosquito inoculation technique. Bull W. H. O. 57:931-936[Medline].
51. Gubler, D. J., W. Suharyono, R. Tan, M. Abidin, and A. Sie. 1981. Viremia in patients
with naturally acquired dengue infection. Bull. W. H. O. 59:623-630[Medline].
52. Gubler, D. J., G. Kuno, G. E. Sather, M. Vélez, and A. Oliver. 1984. Use of mosquito
cell cultures and specific monoclonal antibodies for routine surveillance of dengue viruses.
Am. J. Trop. Med. Hyg. 33:158-165.
53. Gubler, D. J., G. Kuno, G. E. Sather, and S. H. Waterman. 1985. A case of natural
concurrent human infection with two dengue viruses. Am. J. Trop. Med. Hyg. 34:170-173.
54. Gubler, D. J., G. E. Sather, G. Kuno, and J. R. Cabral. 1986. Dengue 3 virus
transmission in Africa. Am. J. Trop. Med. Hyg.35:1280-1284.
55. Guzman, M. G., and G. Kouri. 1996. Advances in dengue diagnosis. Clin. Diagn. Lab.
Immunol. 3:621-627[Free Full Text].
56. Hall, W. C., T. P. Crowell, D. M. Watts, V. L. R. Barros, H. Kruger, F. Pinheiro, and
C. J. Peters. 1991. Demonstration of yellow fever and dengue antigens in formalin-fixed
paraffin embedded human liver by immunohistochemical analysis. Am. J. Trop. Med.
Hyg.45:408-417.
57. Halstead, S. B. 1970. Observations related to pathogenesis of dengue hemorrhagic fever.
VI. Hypotheses and discussion. Yale J. Biol. Med. 42:350-362[Medline].
58. Halstead, S. B. 1974. Etiologies of the experimental dengues of Siler and Simmons. Am.
J. Trop. Med. Hyg. 23:974-982.
59. Halstead, S. B. 1978. Studies on the attenuation of dengue 4. Asian J. Infect. Dis. 2:112-
117.
60. Halstead, S. B. 1979. In vivo enhancement of dengue virus infection in rhesus monkeys by
passively transferred antibody. J. Infect. Dis. 140:527-533[Medline].
61. Halstead, S. B. 1980. Dengue hemorrhagic fever public health problem and a field for
research. Bull. W. H. O. 58:1-21[Medline].
62. Halstead, S. B. 1988. Pathogenesis of dengue: challenges to molecular biology.
Science 239:476-481[Abstract/Free Full Text].
63. Halstead, S. B. 1992. The XXth century dengue pandemic: need for surveillance and
research. Rapp. Trimest. Stat. Sanit. Mond.45:292-298.
64. Halstead, S. B., H. Shotwell, and J. Casals. 1973. Studies on the pathogenesis of dengue
infection in monkeys. I. Clinical laboratory responses to primary infection. J. Infect.
Dis. 128:7-14[Medline].
65. Halstead, S. B., H. Shotwell, and J. Casals. 1973. Studies on the pathogenesis of dengue
infection in monkeys. II. Clinical laboratory responses to heterologous infection. J. Infect.
Dis. 128:15-22[Medline].
66. Halstead, S. B., and E. J. O'Rourke. 1977. Antibody-enhanced dengue virus infection in
primate leukocytes. Nature (London)265:739-741[Medline].
67. Halstead, S. B., and E. J. O'Rourke. 1977. Dengue viruses and mononuclear phagocytes.
I. Infection enchancement by non-neutralizing antibody. J. Exp. Med. 146:210-217.
68. Halstead, S. B., C. N. Venkateshan, M. K. Gentry, and L. K. Larsen. 1984.
Heterogeneity of infection enhancement of dengue 2 strains by monoclonal antibodies. J.
Immunol. 312:1529-1532.
69. Halstead, S. B., A. R. Diwan, J. J. Marchette, N. E. Palumbo, and L. Srisukonth. 1984.
Selection of attenuated dengue 4 viruses by serial passage in primary kidney cells.
1. Attributes of uncloned virus at different passage levels. Am. J. Trop. Med. Hyg. 33:654-
665.
70. Hammon, W. M., A. Rudnick, and G. Sather. 1960. New hemorrhagic fevers of children
in the Philippines and Thailand. Trans. Assoc. Am. Physicians 73:140-155.
71. Hayes, E. B., and D. J. Gubler. 1992. Dengue and dengue hemorrhagic fever. Pediatr.
Infect. Dis. J. 11:311-317[Medline].
72. Henchal, E. A., J. M. McCown, M. C. Sequin, M. K. Gentry, and W. E. Brandt. 1983.
Rapid identification of dengue virus isolates by using monoclonal antibodies in an indirect
immunofluorescence assay. Am. J. Trop. Med. Hyg. 32:164-169.
73. Hirsch, A. 1883. Dengue, a comparatively new disease: its symptoms, p. 55-
81. In Handbook of geographical and historical pathology, vol. 1. Syndenham Society,
London, United Kingdom.
74. Hotta, S., and R. Kimura. 1952. Experimental studies on dengue 1. Isolation
identification and modification of the virus. J. Infect. Dis. 90:1-9.
75. Howe, G. M. 1977. A world geography of human diseases. Academic Press, Inc., New
York, N.Y.
76. Igarashi, A. 1978. Isolation of Singh's Aedes albopictus cell clone sensitive to dengue and
chikungunya viruses. J. Gen. Virol.40:530-544.
77. Innis, B. L. 1995. Dengue and dengue hemorrhagic fever, p. 103-146. In J. S. Porterfield
(ed.), Exotic viral infections 1995. Chapman & Hall, London, United Kingdom.
78. Innis, B. L., A. Nisalak, S. Nimmannitya, S. Kusalerdchariya, V. Chongswasdi, S.
Suntayakorn, P. Puttisri, and C. H. Hoke.1989. An enzyme-linked immunosorbent assay
to characterize dengue infections where dengue and Japanese encephalitis co-circulate. Am.
J. Trop. Med. Hyg. 40:418-427.
79. Kapoor, M., L. Zhang, P. M. Mohan, and R. Padmanabhan. 1995. Synthesis and
characterization of an infectious dengue virus type-2 RNA genome (New Guinea C strain).
Gene 162:175-180[Medline].
80. Kawano, H., V. Rostapshow, L. Rosen, and C.-J. Lai. 1993. Genetic determinants of
dengue type 4 virus neurovirulence for mice. J. Virol. 67:6567-
 6575[Abstract/Free Full Text].
81. Kimura, R., and S. Hotta. 1944. Studies on dengue: anti-dengue active immunization
experiments in mice. Jpn. J. Bacteriol. 1:96-99.
82. Kinney, R. M., S. Butrapet, G. J. Chang, J. T. Roehrig, K. R. Tsuchiya, N.
Bhamarapraviti, and D. J. Gubler. 1997. Construction of infectious cDNA clones for
dengue 2 16681 virus and its attenuated vaccine derivative, strain PDK-53.
Virology 230:300-308[Medline].
83. Kliks, S. C., A. Nisalak, W. E. Brandt, L. Wahl, and D. S. Burke. 1989. Antibody-
dependent enhancement of dengue virus growth in human monocytes as a risk factor for
dengue hemorrhagic fever. Am. J. Trop. Med. Hyg. 40:444-451.
84. Kochel, T., S.-J. Wu, K. Raviprakash, P. Hobart, S. L. Hoffman, and C. G.
Hayes. 1997. Inoculation of plasmids expressing the dengue-2 envelope gene elicit
neutralizing antibodies in mice. Vaccine 15:547-552[Medline].
85. Kouri, G., M. G. Guzman, L. Valdes, I. Carbonel, D. del Rosario, S. Vazquez, J.
Laferte, J. Delgado, and M. V. Cabrera. 1998. Reemergence of dengue in Cuba: a
1997 epidemic in Santiago de Cuba. Emerg. Infect. Dis. 4:89-92[Medline].
86. Kuberski, T. T., and L. Rosen. 1977. A simple technique for the detection of dengue
antigen in mosquitoes by immunofluorescence. Am. J. Trop. Med. Hyg. 26:533-537.
87. Kuberski, T. T., L. Rosen, D. Reed, and J. Mataika. 1977. Clinical and laboratory
observations on patients with primary and secondary dengue type 1 infections with
hemorrhagic manifestations in Fiji. Am. J. Trop. Med. Hyg. 26:775-783.
88. Kuno, G., D. J. Gubler, M. Velez, and A. Oliver. 1985. Comparative sensitivity of three
mosquito cell lines for isolation of dengue viruses. Bull. W. H. O. 63:279-286[Medline].
89. Kuno, G., I. Gomez, and D. J. Gubler. 1991. An ELISA procedure for the diagnosis of
dengue infections. J. Virol. Methods 33:101-113[Medline].
90. Kuno, G., D. J. Gubler, and A. Oliver. 1993. Use of original antigenic sin theory to
determine the serotypes of previous dengue infections. Trans. R. Soc. Trop. Med.
Hyg. 87:103-105[Medline].
91. Kuno, G., C. B. Cropp, J. Wong-Lee, and D. J. Gubler. Dengue IgM Immunoblot. Am.
J. Trop. Med. Hyg., in press.
92. Kurane, I., and F. A. Ennis. 1997. Immunopathogenesis of dengue virus infections, p.
273-290. In D. J. Gubler, and G. Kuno (ed.), Dengue and dengue hemorrhagic fever. CAB
International, London, United Kingdom.
93. Lai, C.-J., B. Zhao, H. Hori, and M. Bray. 1991. Infectious RNA transcribed from stably
cloned full-length cDNA of dengue type 4 virus. Proc. Natl. Acad. Sci. USA 88:5139-
5143[Abstract/Free Full Text].
94. Laille, M., V. Deubel, and F. Flye Sainte Marie. 1991. Demonstration of concurrent
dengue 1 and dengue 3 infection in six patients by the polymerase chain reaction. J. Med.
Virol. 34:51-54[Medline].
95. Lam, S. K., C. B. Chew, G. K. Poon, S. Ramalingam, S. C. Seow, and T. Pang. 1986.
Isolation of dengue viruses by intracerebral inoculation of mosquito larvae. J. Virol.
Methods 14:133-140[Medline].
96. Lam, S. K., M. Y. Fong, E. Chungue, S. Doraisingham, A. Igarashi, M. A. Khin, Z. T.
Kyaw, A. Nisalak, C. Roche, D. W. Vaughn, and V. Vorndam. 1996. Multicentre
evaluation of dengue IgM dot enzyme immunoassay. Clin. Diagn. Virol. 7:93-
98[Medline].
97. Lam, S. K., S. Devi, and T. Pang. 1987. Detection of specific IgM in dengue infections.
Southeast Asian J. Trop. Med. Public Health18:532-538[Medline].
98. Lanciotti, R. S., C. H. Calisher, D. J. Gubler, G.-J. Chang, and A. V. Vorndam. 1992.
Rapid detection and typing of dengue viruses from clinical samples using reverse
transcriptase chain reaction. J. Clin. Microbiol. 30:545-551[Abstract/Free Full Text].
99. Lanciotti, R. S., J. L. Lewis, D. J. Gubler, and D. W. Trent. 1994. Molecular evolution
and epidemiology of dengue-3 viruses. J. Gen. Virol. 75:65-75[Abstract/Free Full Text].
100. Lewis, J. A., G. J. Chang, R. S. Lanciotti, R. M. Kinney, L. W. Mayer, and D. W.
Trent. 1993. Phylogenetic relationships of dengue-2 viruses. Virology 197:216-
224[Medline].
101. Mason, P. W., J. M. Dalrymple, M. K. Gentry, J. M. McCown, C. H. Hoke, D. S.
Burke, M. J. Fournier, and T. L. Mason. 1989. Molecular characterization of a
neutralizing domain of the Japanese encephalitis virus structural glycoprotein. J. Gen.
Virol. 70:2037-2049[Abstract/Free Full Text].
102. Mason, P. W., S. Pincus, M. J. Fournier, T. L. Mason, R. E. Shope, and E.
Paoletti. 1991. Japanese encephalitis virus-vaccinia recombinants produce particulate
forms of the structural membrane proteins and induce high levels of protection against
lethal JEV infection. Virology 180:294-305[Medline].
103. McSherry, J. A. 1982. Some medical aspects of the Darien schema: was it dengue? Scot.
Med. J. 27:183-184.
103a Monath, T. P. Personal communication.
.
104. Monath, T. P. 1994. Dengue: the risk to developed and developing countries. Proc. Natl.
Acad. Sci. USA 91:2395-2400[Abstract/Free Full Text].
105. Moore, C. G., and C. J. Mitchell. 1997. Aedes albopictus in the United States: ten-year
presence and public health implications. Emerg. Infect. Dis. 3:329-334[Medline].
106. Morens, D. M., C. N. Venkateshan, and S. B. Halstead. 1987. Dengue 4 virus
monoclonal antibodies indentify epitopes that mediate immune enhancement of dengue
2 viruses. J. Gen. Virol. 68:91-98[Abstract/Free Full Text].
107. Newton, E. A. C., and P. Rieter. 1992. A model of the transmission of dengue fever with
an evolution of the impact of ultra-low volume (ULV) insecticide application on dengue
epidemics. Am. J. Trop. Med. Hyg. 47:709-720.
108. Nobuchi, H. 1979. The symptoms of a dengue-like illness recorded in a Chinese medical
encyclopedia. Kanpo Rinsho 26:422-425. (In Japanese.)
109. Pepper, O. H. P. 1941. A note on David Bylon and dengue. Ann. Med. Hist. 3rd
Ser. 3:363-368.
110. Pinheiro, F. P. 1989. Dengue in the Americas, 1980-1987. Epidemiol.
Bull. 10:1[Medline].
111. Pinheiro, F. P., and S. J. Corber. 1997. Global situation of dengue and dengue
haemorrhagic fever, and its emergence in the Americas. World Health Stat. Q. 50:161-
169[Medline].
112. Platt, K. B., K. J. Linthicum, K. S. A. Myint, B. L. Innis, K. Lerdthusnee, and D. W.
Vaughn. 1997. Impact of dengue virus infection on feeding behavior of Aedes aegypti.
Am. J. Trop. Med. Hyg. 57:119-125.
113. Polo, S., G. Ketner, R. Levis, and B. Falgout. 1997. Infectious RNA transcripts from full-
length dengue virus type 2 cDNA clones made in yeast. J. Virol. 71:5366-
 5374[Abstract/Free Full Text].
114. Putnam, J. L., and T. W. Scott. 1995. Blood feeding behavior of dengue-2 virus-
infected Aedes aegypti. Am. J. Trop. Med. Hyg.55:225-227.
115. Reiter, P., and D. J. Gubler. 1997. Surveillance and control of urban dengue vectors, p.
425-462. In D. J. Gubler, and G. Kuno (ed.), Dengue and dengue hemorrhagic fever. CAB
International, London, United Kingdom.
116. Rico-Hesse, R. 1990. Molecular evolution and distribution of dengue viruses type 1 and
2 in nature. Virology 174:479-493[Medline].
117. Rico-Hess, R., L. Harrison, R. Salas, D. Tovar, A. Nisalak, C. Ramos, J. R. Boshell, M.
de Mesa, R. Nogueira, and A. Travassos da Rosa. 1997. Origins of dengue type 2 viruses
associated with increased pathogenicity in the Americas. Virology230:244-251[Medline].
118. Rigau-Pérez, J. G., and D. J. Gubler. 1997. Surveillance for dengue and dengue
hemorrhagic fever, p. 405-423. In D. J. Gubler, and G. Kono (ed.), Dengue and dengue
hemorrhagic fever. CAB International, London, United Kingdom.
119. Rigau-Pérez, J. G., D. J. Gubler, A. V. Vorndam, and G. G. Clark. 1994. Dengue
surveillance United States, 1986-1992. Morbid. Mortal. Weekly Rep. 43(SS-2):7-19.
120. Rodier, G., D. J. Gubler, S. E. Cope, R. Bercion, C. B. Cropp, A. K. Soliman, J.
Bouloumie, J.-J. Piccolo, D. Polycarpe, J. A. Abdourhaman, P. Delmaire, J.-P. Bonnet,
J.-P. Parra, G. G. Gray, and D. J. Fryauff. 1995. Epidemic dengue 2 in the city of
Djibouti, Horn of Africa, 1991-1992. Trans. R. Soc. Trop. Med. Hyg. 90:237-240.
121. Roehrig, J. T., A. H. Johnson, A. R. Hunt, B. J. Beaty, and J. H. Mathews. 1992.
Enhancement of the antibody response to flavivirus B-cell epitopes by using homologous
or heterologous T-cell epitopes. J. Virol. 66:3385-3390[Abstract/Free Full Text].
122. Roehrig, J. T., J. H. Mathews, P. A. Risi, J. R. Brubaker, and A. R. Hunt. 1992.
Mapping of biologically active helper T-cell epitopes on the flavivirus envelope
glycoprotein, p. 277-281. In F. Brown, R. M. Chanock, H. Ginsberg, and R. A. Lerner
(ed.), Vaccines 92. Cold Spring Harbor Laboratory, Cold Spring Harbor, N.Y.
123. Rosen, L. 1977. The Emperor's new clothes revisited, or reflections on the pathogenesis of
dengue hemorrhagic fever. Am. J. Trop. Med. Hyg. 26:337-343.
124. Rosen, L. 1982. Dengue an overview, p. 484-493. In J. S. Mackenzie (ed.), Viral diseases
in Southeast Asia and the Western Pacific. Academic Press, Ltd., Sydney, Australia.
125. Rosen, L., and D. J. Gubler. 1974. The use of mosquitoes to detect and propagate dengue
viruses. Am. J. Trop. Med. Hyg.21:1153-1160.
126. Rosen, L., and D. J. Gubler. Unpublished data.
127. Rothman, A. L. 1997. Viral pathogenesis of dengue infections, p. 245-272. In D. J.
Gubler, and G. Kuno (ed.), Dengue and dengue hemorrhagic fever. CAB International,
London, United Kingdom.
128. Rush, A. B. 1789. An account of the bilious remitting fever, as it appeared in Philadelphia
in the summer and autumn of the year 1780. Medical enquiries and observations, p. 104-
117. Prichard and Hall, Philadelphia, Pa.
129. Russell, P. K., and A. A. Nisalak. 1967. Plaque reduction test for dengue virus
neutralizing antibodies. J. Immunol. 99:285-290[Abstract/Free Full Text].
130. Russell, P. K. 1978. Progress toward dengue vaccines. Asian J. Infect. Dis. 2:118-120.
131. Sabin, A. B. 1952. Research on dengue during World War II. Am. J. Trop. Med.
Hyg. 1:30-50.
132. Sabin, A. B., and R. W. Schlesinger. 1945. Production of immunity to dengue with virus
 modified by propagation in mice. Science101:640-642[Abstract/Free Full Text].
133. Sangkawibha, N., S. Rojanasuphot, S. Ahandrink, S. Viriyapongse, S. Jatanasen, V.
Salitul, B. Phanthumachinda, and S. B. Halstead. 1984. Risk factors in dengue shock
syndrome: a prospective epidemiologic study in Rayong, Thailand. Am.
J. Epidemiol.120:653-669[Abstract/Free Full Text].
134. Scherer, W. E., P. K. Russell, L. Rosen, J. Casals, and R. W. Dickerman. 1978.
Experimental infection of chimpanzees with dengue viruses. Am. J. Trop. Med.
Hyg. 27:590-599.
135. Scott, T. W., A. Naksathit, J. F. Day, P. Kittayapong, and J. D. Edman. 1997. A fitness
advantage for Aedes aegypti and the viruses it transmits when females feed only on human
blood. Am. J. Trop. Med. Hyg. 57:235-239.
136. Siler, J. F., M. W. Hall, and A. Hitchens. 1926. Dengue, its history, epidemiology,
mechanism of transmission, etiology, clinical manifestations, immunity and prevention.
Philipp. J. Sci. 29:1-304.
137. Soper, F. L., D. B. Wilson, S. Lima, and W. S. Antunes. 1943. The organization of
permanent nationwide anti-Aedes aegyptimeasures in Brazil. The Rockefeller Foundation,
New York, N.Y.
138. Sumarmo, S. P. S. 1983. Demam berdarah dengue pada anak di Jakarta. Ph.D. thesis.
University of Indonesia, Jakarta.
139. Sumarmo, S. P. S., H. Wulur, E. Jahja, and D. J. Gubler. 1983. Clinical observations on
virologically confirmed fatal dengue infections in Jakarta, Indonesia. Bull.
W. H. O. 61:693-701[Medline].
140. Tan, B.-H., J. Fu, R. J. Sugrue, E.-H. Yap, Y.-C. Chan, and Y. H. Tan. 1996.
Recombinant dengue type 1 virus NS5 protein expressed in Escherichia coli exhibits RNA-
dependent RNA polymerase activity. Virology 216:317-325[Medline].
141. Tesh, R. B. 1979. A method for the isolation and identification of dengue viruses, using
mosquito cell cultures. Am. J. Trop. Med. Hyg. 28:1053-1059.
142. Thet-Win 1982. Detection of dengue virus by immunofluorescence after intracerebral
inoculation of mosquitoes. Lancet i:53-54.
143. Trent, D. W., J. A. Grant, T. P. Monath, C. L. Manske, M. Corina, and G. E.
Fox. 1989. Genetic variation and microevolution of dengue 2 virus in Southeast Asia.
Virology 172:523-535[Medline].
144. Trent, D. W., R. M. Kinney, and C. Y.-H. Huang. 1997. Recombinant dengue virus
vaccines, p. 379-404. In D. J. Gubler, and G. Kuno (ed.), Dengue and dengue hemorrhagic
fever. CAB International, London, United Kingdom.
145. Vaughn, D. W., C. H. Hoke, S. Yoksan, R. LaChance, B. L. Innis, R. Rice, and N.
Bhamarapravati. 1996. Testing of dengue-2 live attenuated vaccine (strain 16681) (PDK-
53) in ten American volunteers. Vaccine 14:329-336[Medline].
146. Vaughn, D. W., A. Nisalak, S. Kalayanarooj, T. Solomon, N. M. Dung, A. Cuzzubbo,
and P. L. Devine. 1998. Evaluation of a rapid immunochromatographic test for diagnosis
of dengue virus infection. J. Clin. Microbiol. 36:234-238[Abstract/Free Full Text].
147. Vaughn, D. W., S. Green, S. Kalayanarooj, B. L. Innis, S. Nimmannitya, S.
Suntayakorn, A. L. Rothman, F. A. Ennis, and A. Nisalak. 1997. Dengue in the early
febrile phase: viremia and antibody responses. J. Infect. Dis. 176:322-330[Medline].
148. Vorndam, V., and G. Kuno. 1997. Laboratory diagnosis of dengue virus infections, p.
313-334. In D. J. Gubler, and G. Kuno (ed.), Dengue and dengue hemorrhagic fever
 1997. CAB International, London, United Kingdom.
149. Waterman, S. H., and D. J. Gubler. 1989. Dengue fever. Clin. Dermatol. 7:117-
122[Medline].
150. Westaway, E. G., and J. Blok. 1997. Taxonomy and evolutionary relationships of
flaviviruses, p. 147-173. In D. J. Gubler, and G. Kuno (ed.), Dengue and dengue
hemorrhagic fever. CAB International, London, United Kingdom.
151. Wisseman, C. L., Jr., B. H. Sweet, E. C. Rosenzweig, and O. R. Rylar. 1963. Attenuated
living type 1 dengue vaccines. Am. J. Trop. Med. Hyg. 12:620-
623[Abstract/Free Full Text].
152. Wittesjo, B., R. Eitrem, and B. Niklasson. 1993. Dengue fever among Swedish tourists.
Scand. J. Infect. Dis. 25:699-704[Medline].
153. Wu, S.-J., B. Hanson, H. Paxton, A. Nisalak, D. W. Vaughn, C. Rossi, E. A. Henchal,
K. R. Porter, D. M. Watts, and C. G. Hayes. 1997. Evaluation of a dipstick enzyme-
linked immunosorbent assay for detection of antibodies to dengue virus. Clin. Diagn. Lab.
Immunol. 4:452-457[Abstract/Free Full Text].
154. Yoksan, S., N. Bhamarapravati, and S. B. Halstead. 1986. Dengue virus vaccine
development: study on biological markers of uncloned dengue 1-4 viruses serially passaged
in primary kidney cells, p. 35-38. In T. D. St. George, B. H. Kay, and J. Blok (ed.),
Arborvirus research in Australia. Proceedings of the Fourth Symposium. CSIRO and
Queensland Institute of Medical Research, Brisbane, Australia.
155. Yuill, T. M., P. Sukkhavachana, A. Nisalak, and P. K. Russell. 1968. Dengue-virus
recovery by direct and delayed plagues in LLC-MK2 cells. Am. J. Trop. Med. Hyg. 17:441-
448.
156. Zaki, S. R., and C. J. Peters. 1997. Viral hemorrhagic fevers, p. 347-364. In D. H.
Connor, F. W. Chandler, D. A. Schwartz, H. J. Manz, and E. E. Lack (ed.), Diagnostic
pathology of infectious diseases. Appleton & Lange, Stamford, Conn.

Clinical Microbiology Reviews, July 1998, p. 480-496, Vol. 11, No. 3

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Gen. Virol. 90: 678-686 [Abstract] [Full Text]  
 Balsitis, S. J., Coloma, J., Castro, G., Alava, A., Flores, D., McKerrow, J. H., Beatty, P. R., Harris, E. (2009). Tropism of Dengue
Virus in Mice and Humans Defined by Viral Nonstructural Protein 3-Specific Immunostaining. Am J Trop Med Hyg 80: 416-
424 [Abstract] [Full Text]  
 Cheng, H.-J., Lin, C.-F., Lei, H.-Y., Liu, H.-S., Yeh, T.-M., Luo, Y.-H., Lin, Y.-S. (2009). Proteomic Analysis of Endothelial Cell
Autoantigens Recognized by Anti-Dengue Virus Nonstructural Protein 1 Antibodies. Exp Biol Med 234: 63-73 [Abstract] [Full Text]  
 Qiu, L.-w., Di, B., Wen, K., Wang, X.-s., Liang, W.-h., Wang, Y.-d., Pan, Y.-x., Wang, M., Ding, Y.-q., Che, X.-y. (2009).
Development of an Antigen Capture Immunoassay Based on Monoclonal Antibodies Specific for Dengue Virus Serotype 2 Nonstructural
Protein 1 for Early and Rapid Identification of Dengue Virus Serotype 2 Infections. CVI 16: 88-95 [Abstract] [Full Text]  
 Yen, Y.-T., Chen, H.-C., Lin, Y.-D., Shieh, C.-C., Wu-Hsieh, B. A. (2008). Enhancement by Tumor Necrosis Factor Alpha of Dengue
Virus-Induced Endothelial Cell Production of Reactive Nitrogen and Oxygen Species Is Key to Hemorrhage Development. J. Virol. 82:
12312-12324 [Abstract] [Full Text]  
 Luz, P. M., Mendes, B. V. M., Codeco, C. T., Struchiner, C. J., Galvani, A. P. (2008). Time Series Analysis of Dengue Incidence in
Rio de Janeiro, Brazil. Am J Trop Med Hyg 79: 933-939 [Abstract] [Full Text]  
 Matheus, S., Meynard, J.-B., Lavergne, A., Girod, R., Moua, D., Labeau, B., Dussart, P., Lacoste, V., Deparis, X. (2008). Dengue-3
Outbreak in Paraguay: Investigations Using Capillary Blood Samples on Filter Paper. Am J Trop Med Hyg 79: 685-687 [Abstract] [Full
Text]  
 Wu, S.-J., Pal, S., Ekanayake, S., Greenwald, D., Lara, S., Raviprakash, K., Kochel, T., Porter, K., Hayes, C., Nelson, W., Callahan, J.
(2008). A Dry-format Field-deployable Quantitative Reverse Transcriptase-polymerase Chain Reaction Assay for Diagnosis of Dengue
Infections. Am J Trop Med Hyg 79: 505-510 [Abstract] [Full Text]  
 Das, S., Pingle, M. R., Munoz-Jordan, J., Rundell, M. S., Rondini, S., Granger, K., Chang, G.-J. J., Kelly, E., Spier, E. G., Larone, D.,
Spitzer, E., Barany, F., Golightly, L. M. (2008). Detection and Serotyping of Dengue Virus in Serum Samples by Multiplex Reverse
Transcriptase PCR-Ligase Detection Reaction Assay. J. Clin. Microbiol. 46: 3276-3284 [Abstract] [Full Text]  
 Nightingale, Z. D., Patkar, C., Rothman, A. L. (2008). Viral replication and paracrine effects result in distinct, functional responses of
dendritic cells following infection with dengue 2 virus. J. Leukoc. Biol. 84: 1028-1038 [Abstract] [Full Text]  
 Bessoff, K., Delorey, M., Sun, W., Hunsperger, E. (2008). Comparison of Two Commercially Available Dengue Virus (DENV) NS1
Capture Enzyme-Linked Immunosorbent Assays Using a Single Clinical Sample for Diagnosis of Acute DENV Infection. CVI 15: 1513-
1518[Abstract] [Full Text]  
 Etemad, B., Batra, G., Raut, R., Dahiya, S., Khanam, S., Swaminathan, S., Khanna, N. (2008). An Envelope Domain III-based
Chimeric Antigen Produced in Pichia pastoris Elicits Neutralizing Antibodies Against All Four Dengue Virus Serotypes. Am J Trop Med
Hyg 79: 353-363 [Abstract] [Full Text]  
 Armien, B., Suaya, J. A., Quiroz, E., Sah, B. K., Bayard, V., Marchena, L., Campos, C., Shepard, D. S. (2008). Clinical
Characteristics and National Economic Cost of the 2005 Dengue Epidemic in Panama. Am J Trop Med Hyg 79: 364-371 [Abstract] [Full
Text]  
 Rajendiran, S., Lakshamanappa, H. S., Zachariah, B., Nambiar, S. (2008). Desialylation of Plasma Proteins in Severe Dengue
Infection: Possible Role of Oxidative Stress. Am J Trop Med Hyg 79: 372-377 [Abstract] [Full Text]  
 Prestwood, T. R., Prigozhin, D. M., Sharar, K. L., Zellweger, R. M., Shresta, S. (2008). A Mouse-Passaged Dengue Virus Strain with
Reduced Affinity for Heparan Sulfate Causes Severe Disease in Mice by Establishing Increased Systemic Viral Loads. J. Virol. 82: 8411-
8421 [Abstract] [Full Text]  
 Kuo, M.-C., Lu, P.-L., Chang, J.-M., Lin, M.-Y., Tsai, J.-J., Chen, Y.-H., Chang, K., Chen, H.-C., Hwang, S.-J. (2008). Impact of
Renal Failure on the Outcome of Dengue Viral Infection. CJASN 3: 1350-1356 [Abstract] [Full Text]  
 Huber, K., Ba, Y., Dia, I., Mathiot, C., Sall, A. A., Diallo, M. (2008). Aedes aegypti in Senegal: Genetic Diversity and Genetic
Structure of Domestic and Sylvatic Populations. Am J Trop Med Hyg 79: 218-229 [Abstract] [Full Text]  
 De Rivera, I. L., Parham, L., Murillo, W., Moncada, W., Vazquez, S. (2008). Humoral Immune Response of Dengue Hemorrhagic
Fever Cases in Children from Tegucigalpa, Honduras. Am J Trop Med Hyg 79: 262-266 [Abstract] [Full Text]  
 Prince, H. E., Yeh, C., Lape-Nixon, M. (2008). Development of a More Efficient Algorithm for Identifying False-Positive Reactivity
Results in a Dengue Virus Immunoglobulin M Screening Assay. CVI 15: 1304-1306 [Abstract] [Full Text]  
 Raviprakash, K., Wang, D., Ewing, D., Holman, D. H., Block, K., Woraratanadharm, J., Chen, L., Hayes, C., Dong, J. Y., Porter, K.
(2008). A Tetravalent Dengue Vaccine Based on a Complex Adenovirus Vector Provides Significant Protection in Rhesus Monkeys against
All Four Serotypes of Dengue Virus. J. Virol. 82: 6927-6934 [Abstract] [Full Text]  
 Lai, C.-Y., Tsai, W.-Y., Lin, S.-R., Kao, C.-L., Hu, H.-P., King, C.-C., Wu, H.-C., Chang, G.-J., Wang, W.-K. (2008). Antibodies to
Envelope Glycoprotein of Dengue Virus during the Natural Course of Infection Are Predominantly Cross-Reactive and Recognize Epitopes
Containing Highly Conserved Residues at the Fusion Loop of Domain II. J. Virol. 82: 6631-6643 [Abstract] [Full Text]  
 Thomas, L., Verlaeten, O., Cabie, A., Kaidomar, S., Moravie, V., Martial, J., Najioullah, F., Plumelle, Y., Fonteau, C., Dussart, P.,
Cesaire, R. (2008). Influence of the Dengue Serotype, Previous Dengue Infection, and Plasma Viral Load on Clinical Presentation and
Outcome During a Dengue-2 and Dengue-4 Co-Epidemic. Am J Trop Med Hyg 78: 990-998 [Abstract] [Full Text]  
 Jarman, R. G., Holmes, E. C., Rodpradit, P., Klungthong, C., Gibbons, R. V., Nisalak, A., Rothman, A. L., Libraty, D. H., Ennis, F.
A., Mammen, M. P. Jr., Endy, T. P. (2008). Microevolution of Dengue Viruses Circulating among Primary School Children in Kamphaeng
Phet, Thailand. J. Virol. 82: 5494-5500 [Abstract] [Full Text]  
 Noisakran, S., Perng, G. C. (2008). Alternate Hypothesis on the Pathogenesis of Dengue Hemorrhagic Fever (DHF)/Dengue Shock
Syndrome (DSS) in Dengue Virus Infection. Exp Biol Med 233: 401-408 [Abstract] [Full Text]  
 Dewi, B. E., Takasaki, T., Kurane, I. (2008). Peripheral blood mononuclear cells increase the permeability of dengue virus-infected
endothelial cells in association with downregulation of vascular endothelial cadherin. J. Gen. Virol. 89: 642-652 [Abstract] [Full Text]  
 Ramos, M. M., Mohammed, H., Zielinski-Gutierrez, E., Hayden, M. H., Lopez, J. L. R., Fournier, M., Trujillo, A. R., Burton, R.,
Brunkard, J. M., Anaya-Lopez, L., Banicki, A. A., Morales, P. K., Smith, B., Munoz, J. L., Waterman, S. H., The Dengue Serosurvey
Working Group, (2008). Epidemic Dengue and Dengue Hemorrhagic Fever at the Texas-Mexico Border: Results of a Household-based
Seroepidemiologic Survey, December 2005. Am J Trop Med Hyg 78: 364-369 [Abstract] [Full Text]  
 Villar-Centeno, L. A., Diaz-Quijano, F. A., Martinez-Vega, R. A. (2008). Biochemical Alterations as Markers of Dengue
Hemorrhagic Fever. Am J Trop Med Hyg 78: 370-374 [Abstract] [Full Text]  
 Simasathien, S., Thomas, S. J., Watanaveeradej, V., Nisalak, A., Barberousse, C., Innis, B. L., Sun, W., Putnak, J. R., Eckels, K. H.,
Hutagalung, Y., Gibbons, R. V., Zhang, C., De La Barrera, R., Jarman, R. G., Chawachalasai, W., Mammen, M. P. Jr. (2008). Safety and
Immunogenicity of a Tetravalent Live-attenuated Dengue Vaccine in Flavivirus Naive Children. Am J Trop Med Hyg 78: 426-
433[Abstract] [Full Text]  
 Bernardo, L., Izquierdo, A., Prado, I., Rosario, D., Alvarez, M., Santana, E., Castro, J., Martinez, R., Rodriguez, R., Morier, L.,
Guillen, G., Guzman, M. G. (2008). Primary and Secondary Infections of Macaca fascicularis Monkeys with Asian and American Genotypes
of Dengue Virus 2. CVI 15: 439-446 [Abstract] [Full Text]  
 Falconar, A. K. I. (2008). Monoclonal Antibodies That Bind to Common Epitopes on the Dengue Virus Type 2 Nonstructural-1 and
Envelope Glycoproteins Display Weak Neutralizing Activity and Differentiated Responses to Virulent Strains: Implications for Pathogenesis
and Vaccines. CVI 15: 549-561 [Abstract] [Full Text]  
 Huang, J.-H., Liao, T.-L., Chang, S.-F., Su, C.-L., Chien, L.-J., Kuo, Y.-C., Yang, C.-F., Lin, C.-C., Shu, P.-Y. (2007). Laboratory-
based Dengue Surveillance in Taiwan, 2005: A Molecular Epidemiologic Study. Am J Trop Med Hyg 77: 903-909 [Abstract] [Full Text]  
 Chen, L., Ewing, D., Subramanian, H., Block, K., Rayner, J., Alterson, K. D., Sedegah, M., Hayes, C., Porter, K., Raviprakash, K.
(2007). A Heterologous DNA Prime-Venezuelan Equine Encephalitis Virus Replicon Particle Boost Dengue Vaccine Regimen Affords
Complete Protection from Virus Challenge in Cynomolgus Macaques. J. Virol. 81: 11634-11639 [Abstract] [Full Text]  
 Hapugoda, M. D., Batra, G., Abeyewickreme, W., Swaminathan, S., Khanna, N. (2007). Single Antigen Detects both Immunoglobulin
M (IgM) and IgG Antibodies Elicited by All Four Dengue Virus Serotypes. CVI 14: 1505-1514 [Abstract] [Full Text]  
 Imrie, A., Meeks, J., Gurary, A., Sukhbataar, M., Kitsutani, P., Effler, P., Zhao, Z. (2007). Differential Functional Avidity of Dengue
Virus-Specific T-Cell Clones for Variant Peptides Representing Heterologous and Previously Encountered Serotypes. J. Virol. 81: 10081-
10091 [Abstract] [Full Text]  
 Tajima, S., Nukui, Y., Takasaki, T., Kurane, I. (2007). Characterization of the variable region in the 3' non-translated region of dengue
type 1 virus. J. Gen. Virol. 88: 2214-2222 [Abstract] [Full Text]  
 Wang, C.-C., Wu, C.-C., Liu, J.-W., Lin, A.-S., Liu, S.-F., Chung, Y.-H., Su, M.-C., Lee, I.-K., Lin, M.-C. (2007). Chest Radiographic
Presentation in Patients with Dengue Hemorrhagic Fever. Am J Trop Med Hyg 77: 291-296 [Abstract] [Full Text]  
 Klungthong, C., Gibbons, R. V., Thaisomboonsuk, B., Nisalak, A., Kalayanarooj, S., Thirawuth, V., Nutkumhang, N., Mammen, M.
P. Jr., Jarman, R. G. (2007). Dengue Virus Detection Using Whole Blood for Reverse Transcriptase PCR and Virus Isolation. J. Clin.
Microbiol.45: 2480-2485 [Abstract] [Full Text]  
 Appanna, R., Huat, T. L., See, L. L. C., Tan, P. L., Vadivelu, J., Devi, S. (2007). Cross-Reactive T-Cell Responses to the
Nonstructural Regions of Dengue Viruses among Dengue Fever and Dengue Hemorrhagic Fever Patients in Malaysia. CVI 14: 969-
977 [Abstract] [Full Text]  
 Wang, C.-C., Liu, S.-F., Liao, S.-C., Lee, I.-K., Liu, J.-W., Lin, A.-S., Wu, C.-C., Chung, Y.-H., Lin, M.-C. (2007). Acute Respiratory
Failure in Adult Patients with Dengue Virus Infection. Am J Trop Med Hyg 77: 151-158 [Abstract] [Full Text]  
 Chen, H.-C., Hofman, F. M., Kung, J. T., Lin, Y.-D., Wu-Hsieh, B. A. (2007). Both Virus and Tumor Necrosis Factor Alpha Are
Critical for Endothelium Damage in a Mouse Model of Dengue Virus-Induced Hemorrhage. J. Virol. 81: 5518-5526 [Abstract] [Full Text]  
 Atkinson, M. P., Su, Z., Alphey, N., Alphey, L. S., Coleman, P. G., Wein, L. M. (2007). Analyzing the control of mosquito-borne
diseases by a dominant lethal genetic system. Proc. Natl. Acad. Sci. USA 104: 9540-9545 [Abstract] [Full Text]  
 Shiryaev, S. A., Ratnikov, B. I., Aleshin, A. E., Kozlov, I. A., Nelson, N. A., Lebl, M., Smith, J. W., Liddington, R. C., Strongin, A.
Y. (2007). Switching the Substrate Specificity of the Two-Component NS2B-NS3 Flavivirus Proteinase by Structure-Based Mutagenesis.J.
Virol. 81: 4501-4509 [Abstract] [Full Text]  
 Yap, T. L., Xu, T., Chen, Y.-L., Malet, H., Egloff, M.-P., Canard, B., Vasudevan, S. G., Lescar, J. (2007). Crystal Structure of the
Dengue Virus RNA-Dependent RNA Polymerase Catalytic Domain at 1.85-Angstrom Resolution. J. Virol. 81: 4753-4765 [Abstract] [Full
Text]  
 Falconar, A. K. I. (2007). Antibody Responses Are Generated to Immunodominant ELK/KLE-Type Motifs on the Nonstructural-1
Glycoprotein during Live Dengue Virus Infections in Mice and Humans: Implications for Diagnosis, Pathogenesis, and Vaccine
Design.CVI 14: 493-504 [Abstract] [Full Text]  
 RAJA, N. U., HOLMAN, D. H., WANG, D., RAVIPRAKASH, K., JUOMPAN, L. Y., DEITZ, S. B., LUO, M., ZHANG, J.,
PORTER, K. R., DONG, J. Y. (2007). INDUCTION OF BIVALENT IMMUNE RESPONSES BY EXPRESSION OF DENGUE VIRUS
TYPE 1 AND TYPE 2 ANTIGENS FROM A SINGLE COMPLEX ADENOVIRAL VECTOR. Am J Trop Med Hyg 76: 743-
751 [Abstract] [Full Text]  
 Chen, Y.-C., Huang, H.-N., Lin, C.-T., Chen, Y.-F., King, C.-C., Wu, H.-C. (2007). Generation and Characterization of Monoclonal
Antibodies against Dengue Virus Type 1 for Epitope Mapping and Serological Detection by Epitope-Based Peptide Antigens. CVI 14: 404-
411 [Abstract] [Full Text]  
 Chu, J. J. H., Yang, P. L. (2007). c-Src protein kinase inhibitors block assembly and maturation of dengue virus. Proc. Natl. Acad. Sci.
USA 104: 3520-3525 [Abstract] [Full Text]  
 Chareonsirisuthigul, T., Kalayanarooj, S., Ubol, S. (2007). Dengue virus (DENV) antibody-dependent enhancement of infection
upregulates the production of anti-inflammatory cytokines, but suppresses anti-DENV free radical and pro-inflammatory cytokine production,
in THP-1 cells. J. Gen. Virol. 88: 365-375 [Abstract] [Full Text]  
 Holman, D. H., Wang, D., Raviprakash, K., Raja, N. U., Luo, M., Zhang, J., Porter, K. R., Dong, J. Y. (2007). Two Complex,
Adenovirus-Based Vaccines That Together Induce Immune Responses to All Four Dengue Virus Serotypes. CVI 14: 182-
189 [Abstract] [Full Text]  
 Clyde, K., Kyle, J. L., Harris, E. (2006). Recent Advances in Deciphering Viral and Host Determinants of Dengue Virus Replication
and Pathogenesis. J. Virol. 80: 11418-11431 [Full Text]  
 Yu, C.-Y., Hsu, Y.-W., Liao, C.-L., Lin, Y.-L. (2006). Flavivirus Infection Activates the XBP1 Pathway of the Unfolded Protein
Response To Cope with Endoplasmic Reticulum Stress. J. Virol. 80: 11868-11880 [Abstract] [Full Text]  
 ANDERSON, J. R., RICO-HESSE, R. (2006). AEDES AEGYPTI VECTORIAL CAPACITY IS DETERMINED BY THE
INFECTING GENOTYPE OF DENGUE VIRUS. Am J Trop Med Hyg 75: 886-892 [Abstract] [Full Text]  
 Dussart, P., Labeau, B., Lagathu, G., Louis, P., Nunes, M. R. T., Rodrigues, S. G., Storck-Herrmann, C., Cesaire, R., Morvan, J.,
Flamand, M., Baril, L. (2006). Evaluation of an Enzyme Immunoassay for Detection of Dengue Virus NS1 Antigen in Human Serum. CVI13:
1185-1189 [Abstract] [Full Text]  
 Umareddy, I., Chao, A., Sampath, A., Gu, F., Vasudevan, S. G. (2006). Dengue virus NS4B interacts with NS3 and dissociates it from
single-stranded RNA. J. Gen. Virol. 87: 2605-2614 [Abstract] [Full Text]  
 Falconar, A. K. I., de Plata, E., Romero-Vivas, C. M. E. (2006). Altered Enzyme-Linked Immunosorbent Assay Immunoglobulin M
(IgM)/IgG Optical Density Ratios Can Correctly Classify All Primary or Secondary Dengue Virus Infections 1 Day after the Onset of
Symptoms, when All of the Viruses Can Be Isolated. CVI 13: 1044-1051 [Abstract] [Full Text]  
 Chen, J.-P., Lu, H.-L., Lai, S.-L., Campanella, G. S., Sung, J.-M., Lu, M.-Y., Wu-Hsieh, B. A., Lin, Y.-L., Lane, T. E., Luster, A. D.,
Liao, F. (2006). Dengue Virus Induces Expression of CXC Chemokine Ligand 10/IFN-{gamma}-Inducible Protein 10, Which Competitively
Inhibits Viral Binding to Cell Surface Heparan Sulfate.. J. Immunol. 177: 3185-3192 [Abstract] [Full Text]  
 Filomatori, C. V., Lodeiro, M. F., Alvarez, D. E., Samsa, M. M., Pietrasanta, L., Gamarnik, A. V. (2006). A 5' RNA element promotes
dengue virus RNA synthesis on a circular genome. Genes Dev. 20: 2238-2249 [Abstract] [Full Text]  
 Hsieh, M.-F., Lai, S.-L., Chen, J.-P., Sung, J.-M., Lin, Y.-L., Wu-Hsieh, B. A., Gerard, C., Luster, A., Liao, F. (2006). Both CXCR3
and CXCL10/IFN-Inducible Protein 10 Are Required for Resistance to Primary Infection by Dengue Virus. J. Immunol. 177: 1855-
1863[Abstract] [Full Text]  
 Takhampunya, R., Ubol, S., Houng, H.-S., Cameron, C. E., Padmanabhan, R. (2006). Inhibition of dengue virus replication by
mycophenolic acid and ribavirin. J. Gen. Virol. 87: 1947-1952 [Abstract] [Full Text]  
 CHANTHAVANICH, P., LUXEMBURGER, C., SIRIVICHAYAKUL, C., LAPPHRA, K., PENGSAA, K., YOKSAN, S.,
SABCHAREON, A., LANG, J. (2006). IMMUNE RESPONSE AND OCCURRENCE OF DENGUE INFECTION IN THAI CHILDREN
THREE TO EIGHT YEARS AFTER VACCINATION WITH LIVE ATTENUATED TETRAVALENT DENGUE VACCINE.. Am J Trop
Med Hyg 75: 26-28 [Abstract] [Full Text]  
 KUNIHOLM, M. H., WOLFE, N. D., HUANG, C. Y.-H., MPOUDI-NGOLE, E., TAMOUFE, U., BURKE, D. S., GUBLER, D. J.
(2006). SEROPREVALENCE AND DISTRIBUTION OF FLAVIVIRIDAE, TOGAVIRIDAE, AND BUNYAVIRIDAE ARBOVIRAL
INFECTIONS IN RURAL CAMEROONIAN ADULTS. Am J Trop Med Hyg 74: 1078-1083 [Abstract] [Full Text]  
 Bennett, S. N., Holmes, E. C., Chirivella, M., Rodriguez, D. M., Beltran, M., Vorndam, V., Gubler, D. J., McMillan, W. O. (2006).
Molecular evolution of dengue 2 virus in Puerto Rico: positive selection in the viral envelope accompanies clade reintroduction.. J. Gen.
Virol. 87: 885-893 [Abstract] [Full Text]  
 HUNG, N. T., LAN, N. T., LEI, H.-Y., LIN, Y.-S., LIEN, L. B., HUANG, K.-J., LIN, C.-F., HA, D. Q., HUONG, V. T. Q., MY, L.
T., YEH, T.-M., HUANG, J.-H., LIU, C.-C., HALSTEAD, S. B. (2006). VOLUME REPLACEMENT IN INFANTS WITH DENGUE
HEMORRHAGIC FEVER/DENGUE SHOCK SYNDROME. Am J Trop Med Hyg 74: 684-691 [Abstract] [Full Text]  
 Lennon, J. L., Coombs, D. W. (2006). Child-invented health education games: A case study for dengue fever. Simulation Gaming 37:
88-97 [Abstract]  
 Aoki, C., Hidari, K. I.P.J., Itonori, S., Yamada, A., Takahashi, N., Kasama, T., Hasebe, F., Islam, M. A., Hatano, K., Matsuoka, K.,
Taki, T., Guo, C.-T., Takahashi, T., Sakano, Y., Suzuki, T., Miyamoto, D., Sugita, M., Terunuma, D., Morita, K., Suzuki, Y. (2006).
Identification and characterization of carbohydrate molecules in Mammalian cells recognized by dengue virus type 2.. J Biochem 139: 607-
614 [Abstract] [Full Text]  
 Calvert, A. E., Huang, C. Y.-H., Kinney, R. M., Roehrig, J. T. (2006). Non-structural proteins of dengue 2 virus offer limited
protection to interferon-deficient mice after dengue 2 virus challenge. J. Gen. Virol. 87: 339-346 [Abstract] [Full Text]  
 KHANAM, S., ETEMAD, B., KHANNA, N., SWAMINATHAN, S. (2006). INDUCTION OF NEUTRALIZING ANTIBODIES
SPECIFIC TO DENGUE VIRUS SEROTYPES 2 AND 4 BY A BIVALENT ANTIGEN COMPOSED OF LINKED ENVELOPE
DOMAINS III OF THESE TWO SEROTYPES. Am J Trop Med Hyg 74: 266-277 [Abstract] [Full Text]  
 AnandaRao, R., Swaminathan, S., Fernando, S., Jana, A. M., Khanna, N. (2006). Recombinant Multiepitope Protein for Early
Detection of Dengue Infections. CVI 13: 59-67 [Abstract] [Full Text]  
 CHEN, L.-C., LEI, H.-Y., LIU, C.-C., SHIESH, S.-C., CHEN, S.-H., LIU, H.-S., LIN, Y.-S., WANG, S.-T., SHYU, H.-W., YEH, T.-
M. (2006). CORRELATION OF SERUM LEVELS OF MACROPHAGE MIGRATION INHIBITORY FACTOR WITH DISEASE
SEVERITY AND CLINICAL OUTCOME IN DENGUE PATIENTS. Am J Trop Med Hyg 74: 142-147 [Abstract] [Full Text]  
 Carrington, C. V. F., Foster, J. E., Pybus, O. G., Bennett, S. N., Holmes, E. C. (2005). Invasion and Maintenance of Dengue Virus
Type 2 and Type 4 in the Americas. J. Virol. 79: 14680-14687 [Abstract] [Full Text]  
 Matheus, S., Deparis, X., Labeau, B., Lelarge, J., Morvan, J., Dussart, P. (2005). Use of Four Dengue Virus Antigens for
Determination of Dengue Immune Status by Enzyme-Linked Immunosorbent Assay of Immunoglobulin G Avidity. J. Clin. Microbiol. 43:
5784-5786[Abstract] [Full Text]  
 Helt, A.-M., Harris, E. (2005). S-Phase-Dependent Enhancement of Dengue Virus 2 Replication in Mosquito Cells, but Not in Human
Cells. J. Virol. 79: 13218-13230 [Abstract] [Full Text]  
 Johnson, B. W., Russell, B. J., Lanciotti, R. S. (2005). Serotype-Specific Detection of Dengue Viruses in a Fourplex Real-Time
Reverse Transcriptase PCR Assay. J. Clin. Microbiol. 43: 4977-4983 [Abstract] [Full Text]  
 Wilder-Smith, A., Schwartz, E. (2005). Dengue in Travelers. NEJM 353: 924-932 [Full Text]  
 Xu, T., Sampath, A., Chao, A., Wen, D., Nanao, M., Chene, P., Vasudevan, S. This Article
G., Lescar, J. (2005). Structure of the Dengue Virus Helicase/Nucleoside Triphosphatase
Catalytic Domain at a Resolution of 2.4 A. J. Virol. 79: 10278-10288 [Abstract] [Full
Abstract 
Text]  
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Williams, J. A., Jiricek, J., Priestle, J. P., Harris, J. L., Vasudevan, S. G. (2005).
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 CHIU, Y.-C., WU, K.-L., KUO, C.-H., HU, T.-H., CHOU, Y.-P., CHUAH, S.-
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POTENTIAL ROLE OF SYLVATIC AND DOMESTIC AFRICAN MOSQUITO
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