Epidemiology of Dengue

Official reprint from UpToDate

www.uptodate.com ©2015 UpToDate

AuthorAlan L Rothman, MD

Section EditorMartin S Hirsch, MD

Deputy EditorElinor L Baron, MD, DTMH

Epidemiology of dengue virus infections

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2015. | This topic last updated: Dec 11, 2014.

INTRODUCTION — The viral etiology of dengue was established in the 1940s, and records of dengue-like illness

date back more than 200 years [1]. Major changes in the epidemiology of dengue virus infections began after World

War II and have continued to date. Given estimates of 390 million infections worldwide each year and over 2.5 billion

individuals at risk for infection [2], the dengue viruses are arguably the most important arthropod-borne viruses from

a medical and public health perspective.

The cardinal features of the dengue virus transmission cycle, the characteristics of the mosquito vectors, and the

factors that contribute to dengue virus transmission in the major affected regions will be reviewed here. The

pathogenesis, clinical manifestations, diagnosis, treatment, and prevention of dengue virus infection are discussed

separately. (See "Pathogenesis of dengue virus infection" and "Clinical manifestations and diagnosis of dengue virus

infection" and "Prevention and treatment of dengue virus infection".)

CLASSIFICATION — Dengue viruses are members of the family Flaviviridae, genus Flavivirus [3,4]. The dengue

virus complex comprises at least four antigenically related but distinct viruses, designated dengue virus serotypes 1

through 4. All dengue viruses are mosquito-borne human pathogens that exclusively cause acute infection.

TRANSMISSION CYCLE — Both epidemic and endemic transmission of dengue viruses are maintained through a

human-mosquito-human cycle involving mosquitoes of the genus Aedes (Stegomyia) [5]. Transmission of dengue

viruses between mosquitoes and nonhuman primates has been demonstrated in Asia and Africa, but there is no

evidence that such transmission is an important reservoir for transmission to humans [5,6].

Susceptible humans become infected after being bitten by an infected female Aedes mosquito. Viremia in humans

begins toward the end of a four- to six-day incubation period and persists until fever abates, which is typically three

to seven days [7,8]. An uninfected Aedes mosquito may acquire the virus after feeding during this viremic period.

The mosquito has an incubation period of 8 to 12 days before it is capable of transmitting the virus to susceptible

individuals. Once infected, mosquitoes carry the virus for their lifespan and remain infective for humans.

MOSQUITO VECTORS — Aedes (Stegomyia) aegypti mosquitoes, the principal vector for the transmission of

dengue virus, have many characteristics that make them ideal for dissemination of the virus [5,9]. A. aegypti typically

breed in or close to houses, laying eggs in both man-made and natural water containers. The typical flight distance

is relatively short [10]. A. aegypti are daytime feeders that prefer to bite humans and are frequently unnoticed. They

are easily interrupted in their feeding and move on to another host, frequently taking multiple blood meals in a single

breeding cycle [11]. Thus, an infected A. aegypti mosquito may transmit dengue virus to several individuals in a

small area. For these reasons, family members who are at home during the daytime, typically women and young

children, are at particularly high risk for infection.

A. aegypti are widely distributed in tropical and subtropical areas from latitude 45º North to 35º South. Yellow fever is

also principally transmitted by A. aegypti; efforts to control urban yellow fevers in the Americas in the 1970s greatly

restricted the distribution of the mosquitoes in the Western hemisphere, but the mosquitoes have since reinfested

nearly all of their former habitats [7].

A. albopictus mosquitoes are also a competent vector for the transmission of dengue virus under both experimental

and natural conditions [5,12]; they are more tolerant of the cold and have a wider geographic distribution than A.

aegypti [12,13]. However, they are less likely to transmit since they do not bite humans as frequently as A. aegypti

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and appear to be less efficient natural vectors for dengue virus. Endemic transmission or large outbreaks in regions

that have A. albopictus but not A. aegypti mosquitoes are both rare. Both A. albopictus and A. aegypti are also

competent vectors for transmission of chikungunya virus, which has led to simultaneous outbreaks of both diseases

in some areas [14]. (See "Chikungunya fever".)

Other Aedes mosquitoes have been suspected of dengue virus transmission in isolated outbreaks in the Pacific

islands [15]. However, these species appear to play an insignificant role in the global transmission of dengue virus.

DISTRIBUTION OF A. AEGYPTI MOSQUITOES — A. aegypti and dengue viruses are endemic in many countries

(figure 1) [4,16], although epidemic dengue hemorrhagic fever (DHF) occurs predominantly in certain parts of Asia

and South America. The risk for exposure to A. aegypti is often higher in urban areas. Many tourist facilities present

a lower risk than local residential areas because of air conditioning, groundskeeping, elevation, or combinations of

these factors.

The number of cases of dengue fever (DF) and DHF reported globally varies considerably from year to year,

although the overall trend is one of increasing incidence. Global epidemics of disease have occurred at intervals of

several years [17-19].

The reported dengue activity in specific regions is described further below. Most available information is gathered

through passive surveillance activities and must be interpreted cautiously in light of underreporting of cases [20] and

lack of laboratory confirmation (table 1).

Asia and Pacific

Southeast Asia — A. aegypti mosquitoes are present throughout the region, extending to southern China and

the south of the island of Taiwan, and all countries in the region are affected by dengue virus infection.

Hyperendemic transmission of all four dengue serotypes (with cases of DHF) has occurred in Thailand, Vietnam,

and Indonesia for over 40 years. Epidemic dengue reemerged in China during the 1980s and the 1990s after an

absence of several decades and was associated with the first occurrence of DHF in that country [21]. Nepal had the

first cases detected in 2004.

Over 140 locally acquired cases of dengue were detected in Japan in 2014, representing the first occurrence of

transmission in that nation since World War II [22]. More than 80 percent of cases have been associated with visiting

a single location in Tokyo, and A. albopictus is the apparent vector in this outbreak.

Dengue virus transmission occurs year round but typically reaches a seasonal peak that varies in timing between

countries (for example, between June and November in Thailand, between January and February in Indonesia).

More than 200,000 cases of DHF were reported from the region each year from 2012 with the exception of 2011

(177,500 cases); Indonesia and Thailand accounted for the majority of cases in each of these years [23].

South Asia — A. aegypti are widely distributed in India, Pakistan, and Sri Lanka. Dengue virus transmission,

particularly in India and Sri Lanka, increased substantially during the 1980s and 1990s. Hyperendemic circulation of

all four dengue serotypes appears to be established, and outbreaks of DHF have become more frequent. Over

50,000 cases were reported from India in 2012, more than twice the average over the previous decade. Pakistan

has reported several outbreaks since 2011.

Western Pacific islands — A. aegypti mosquitoes are present in most of the region. Hyperendemic transmission

of all four dengue serotypes is present in Malaysia and the Philippines. Other islands experience frequent dengue

outbreaks; high incidence rates were reported from 14 island nations for 2009, including American Samoa, Cook

Islands, French Polynesia, New Caledonia, and Tonga [24]. (See "Potential health hazards in travelers to Australia,

New Zealand, and the southwestern Pacific (Oceania)".)

Australia — A. aegypti mosquitoes are present in the northeastern corner of Australia. Dengue viruses are not

endemic to the continent, but periodic introduction of dengue viruses from neighboring islands has led to epidemics

in urban areas of north Queensland [25,26]. (See "Potential health hazards in travelers to Australia, New Zealand,

and the southwestern Pacific (Oceania)".)


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Africa and Eastern Mediterranean — A. aegypti mosquitoes are present in much of sub-Saharan Africa and the

Middle East. Data are scant on dengue virus transmission. However, documented infections in visitors to the area

indicate that there is ongoing dengue virus transmission [27,28]. Several outbreaks were reported from Central

Africa, East Africa, and the Middle East during the 1990s and 2000s [14,16].

Europe — A. albopictus is present across much of southern Europe [29]. Most dengue cases reported from the

region have been acquired during travel to endemic countries. However, local transmission of dengue virus was

documented in both southern France and Croatia in 2010 [30]. In 2012, an outbreak of dengue was reported on

Madeira Island (Portugal), associated with the presence of A. aegypti [30].

Americas

North America — A. aegypti mosquitoes are present in most areas of Mexico and in the southeastern United

States. A. albopictus is also present in these areas, but its range extends further north, nearly to the Great Lakes.

Hyperendemic transmission of all four dengue virus serotypes is present throughout the range of A. aegypti in

Mexico. Dengue virus transmission is seasonal, with peak activity in late summer and fall. In 2013, over 230,000

cases of dengue infection were reported from Mexico, including more than 18,000 cases of severe dengue and 104

deaths [19].

Most dengue virus infections identified in the continental United States and all cases identified in Canada were

acquired during travel abroad or to Puerto Rico or the United States Virgin Islands [31-34]. Limited transmission of

dengue virus within southern Texas has been described since the 1980s [35], and an outbreak involving over 120

cases of locally acquired dengue infection occurred in Hawaii in 2001 [36]. In 2007, the Centers for Disease Control

and Prevention reported a case of DHF in a resident native to Texas who lived in a bordering area with Mexico [37];

this prompted a serosurvey of 346 households in the immediate neighborhood, which demonstrated that 38 percent

of the residents had IgG antibodies to dengue. In 2010, dengue fever was reported in 28 residents of Key West,

Florida, who had not traveled abroad [38], and a serosurvey of 240 participants living in Key West found that 5

percent had evidence of recent dengue infection. Local transmission of dengue virus continues to occur in south

Florida but thus far appears to be very limited in scope. Of 543 cases reported across the United States in 2013, 24

were locally acquired [19].

Central America — A. aegypti mosquitoes and hyperendemic transmission of all four dengue virus serotypes

are present throughout the region. The region experienced a major outbreak in 2013; Nicaragua and Costa Rica

reported among the highest numbers of cases of dengue (77,000 and 49,000, respectively) and incidence rates

(over 1000 cases per 100,000 population) that year [19]. However, all of these countries have had one or more years

of heavy dengue activity during the past five years.

Caribbean — A. aegypti mosquitoes are present throughout the region. Hyperendemic circulation of dengue

virus serotypes 1, 2, and 4 has been present on the larger islands (other than Cuba) for several decades and

dengue virus serotype 3 has been present since 1998. In Puerto Rico, peak dengue virus transmission usually

occurs between October and December; over 21,000 cases of dengue virus infection were reported there in 2010,

representing the largest outbreak ever recorded. The Dominican Republic (16,000 cases), French Guiana (16,000

cases), Guadeloupe (12,000 cases), Martinique (7,000 cases), and St. Martin (3,000 cases) all reported major

outbreaks in 2013 [19]. Other islands have experienced periodic dengue epidemics.

South America — A. aegypti mosquitoes are present in every South American country except Chile [16].

Hyperendemic circulation of all four dengue virus serotypes has been present in the north of the continent since the

reintroduction of dengue virus serotype 3 was detected in Brazil and Venezuela during 2000. Brazil, Venezuela, and

Colombia have reported the largest number of dengue cases. Low-level, year-round transmission has been

observed, but most cases follow an epidemic pattern; in Brazil, peak dengue transmission occurs between February

and May [39].

Brazil experienced a major outbreak in 2013, with nearly 1.5 million cases nationwide, including almost 7,000 cases

of severe dengue [19]. Colombia (127,000 cases) and Paraguay (144,000 cases) also reported major dengue


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outbreaks in 2013.

PATTERNS OF TRANSMISSION — Dengue virus transmission follows two general (but not mutually exclusive)

patterns, with different implications for disease risk in both the local population and travelers.

Epidemic dengue — Epidemic dengue transmission occurs when the introduction of dengue virus into a region is

an isolated event involving a single virus strain. If sufficiently large populations of susceptible hosts and mosquitoes

are present, transmission of dengue is explosive, leading to a recognizable epidemic. The incidence of infection

among susceptible individuals often reaches 25 to 50 percent [40] and can be considerably higher. Herd immunity,

changes in weather, and mosquito control efforts can all contribute to the termination of the epidemic [5].

Prior to World War II, transmission of dengue viruses almost exclusively followed this pattern [41]. Seaports

frequently were the point of initial introduction of dengue viruses, and these port cities then acted as distribution

points to nearby inland areas.

In smaller island nations, certain areas of South America and Africa, and in the areas of Asia where dengue virus

transmission has reemerged, epidemic activity is the predominant pattern of dengue virus transmission. The

incidence of dengue virus infections in these locations varies considerably from year to year. Intervals of several

years or more usually pass between epidemics, allowing the number of susceptible individuals to accumulate so that

the next epidemic can be perpetuated.

In the setting of epidemic transmission, adults and children in the local population are affected. Among travelers, the

risk for acquisition of dengue virus is high during an epidemic but low at other times. The frequency of dengue

hemorrhagic fever (DHF) is usually low, with some exceptions [42]. The viral serotype and strain and the interval

since the previous epidemic seem to influence the risk for DHF. (See "Pathogenesis of dengue virus infection".)

Hyperendemic dengue — "Hyperendemic" transmission refers to the continuous circulation of multiple dengue

virus serotypes in the same area. This requires the year-round presence of competent vector mosquitoes and either

a large population or steady movement of individuals into the area to maintain a pool of susceptible individuals.

Hyperendemic circulation involves the occurrence of multiple epidemics in a smaller geographic scale (eg, village or

school) [43].

Seasonal variation in virus transmission is common. The incidence of infection also varies from year to year, with

increased dengue transmission at intervals of three to four years, but this variation is not as dramatic as in areas

where transmission predominantly follows the epidemic pattern. A mathematical analysis of data from Thailand

suggested that these surges in dengue transmission originate in waves from major urban centers [44].

Areas with hyperendemic dengue virus transmission contribute to the majority of cases of dengue virus infection

globally. In some regions, 5 to 10 percent of the susceptible population experiences dengue virus infection annually

[45-47]. Urban areas are particularly affected.

In the setting of hyperendemic transmission, the prevalence of antibody against dengue virus rises with age.

Children are more likely than adults to experience disease, and most adults in the local population are immune to

infection. Among travelers, the risk for acquisition is higher than in areas that experience epidemic transmission, but

the seasonal variation in risk is somewhat predictable. Hyperendemicity is a major factor contributing to the

occurrence of DHF.

FACTORS INFLUENCING TRANSMISSION — The worldwide incidence of dengue and DHF has been increasing

in the past several decades, and the geographic distribution of these diseases has expanded. The emergence of

DHF as a public health problem has largely been a result of human behaviors including population growth, poor

urban planning with overcrowding and poor sanitation, modern transportation which allows increased movement of

humans, mosquitoes and viruses, and lack of effective mosquito control [7].

The potential effects of global climate change are a major source of concern for the future. Increased dengue virus

transmission has been associated with El Nino/Southern Oscillation events [48,49]. Mathematical models predict

that increased global temperatures will further expand the range of A. aegypti and dengue virus [50,51].


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The transmission cycle for dengue viruses is dependent upon the interaction between infective mosquitoes and

susceptible humans and between susceptible mosquitoes and viremic humans. Dengue virus transmission is

enhanced by the following factors [5]:

OTHER ROUTES OF TRANSMISSION — Given the high titers of infectious dengue virus found in blood and tissues

during acute infection, the potential exists for virus transmission by routes other than mosquito vectors.

Nosocomial transmission — At least four well-documented cases of transmission of dengue virus in the healthcare

setting via needlestick and one case of transmission by nonpercutaneous exposure have been reported [56]. Some

blood donors, although asymptomatic, have levels of viremia sufficient to transmit infection to recipients of their

blood components [57]. Cases of nosocomial transmission in dengue-endemic regions (also likely to encompass the

majority of exposures) would usually be overlooked due to the inability to distinguish nosocomial transmission from

mosquito transmission.

Vertical transmission — Vertical transmission of dengue has been reported in a few small case series [58]; based

on these cases and the known pattern of viremia, this possibility should be considered in cases where illness in the

mother occurs within the 10 days before delivery (including onset on the day of delivery). Illness presented in these

newborns up to 11 days (median 4 days) after birth.

Pregnancy does not appear to increase the incidence or severity of dengue [59]. In a prospective study conducted in

Kuala Lumpur of 2958 parturients, 2531 paired maternal-umbilical cord blood samples were tested for dengue-

specific IgM to determine the prevalence of infection and the vertical transmission rate [60]. Sixty-three women (2.5

percent) had a positive IgM serology. Only one (1.6 percent, 95% CI 0-9.5%) of the paired umbilical cord samples

was seropositive for dengue. None of the maternal and fetal blood samples had evidence of viral RNA by

polymerase chain reaction.

Breastfeeding has also been proposed as a route of vertical transmission of dengue virus [61].

SUMMARY

Increased vector density – One study of naturally infected humans estimated that viremia levels of

approximately 6 to 8 log10 RNA copies/mL led to infection of half of A. aegypti mosquitoes that took a blood

meal under laboratory conditions [52]. In many tropical countries, seasonal increases in rainfall contribute to an

increased density of mosquitoes. One factor that can be modified is the presence of open water storage

containers in or near the home.

●

Shorter mosquito incubation – The length of the incubation time in the mosquito (known as the extrinsic

incubation period) is inversely associated with the ambient temperature. Warmer temperatures increase the

length of time that a mosquito remains infective.

●

Increased movement of mosquito vectors and viruses – Air, land, and water transportation of mosquitoes or

viremic humans facilitate the dissemination of dengue viruses.

●

Increased density of susceptible hosts – Crowded conditions probably increase the potential for virus

transmission. However, as the prevalence of prior infection increases, the fraction of the population that

remains susceptible is reduced.

●

Increased duration and magnitude of viremia in humans – Attenuated virus strains produced in the laboratory

have been shown to produce low titers of virus in the blood, which are not efficiently transmitted to mosquitoes

[53,54]. It is unclear whether natural strains of dengue virus differ in the viremia titers they produce [55].

●

Dengue viruses are members of the family Flaviviridae, genus Flavivirus. The dengue virus complex comprises

four antigenically related but distinct viruses, which are mosquito-borne human pathogens. (See 'Classification'

above.)

●

Susceptible humans become infected after being bitten by an infected female Aedes mosquito. Viremia in

humans begins toward the end of a four- to six-day incubation period and persists until fever abates. An

●


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GRAPHICS

Map of global dengue burden

Reproduced from: Guzman MG, Harris E. Dengue. Lancet 2014. Illustration used with the permission of Elsevier Inc. All rights reserve

Graphic 60722 Version 2.0


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Alphabetical listing of countries and territories with reported dengue

transmission since 2000

Anguilla

Antigua and Barbuda

Argentina

Aruba

Australia

Bahamas

Bangladesh

Barbados

Belize

Bhutan

Bolivia

Brazil

Brunei Darussalam

Cambodia

Cameroon

Cape Verde

Chile (Easter Island)

China

Colombia

Cook Islands

Costa Rica

Côte d'Ivoire

Croatia

Cuba

Dominica

Dominican Republic

Ecuador

El Salvador

Fiji

France

French Guiana

French Polynesia

Gabon

Grenada

Malaysia

Maldives

Martinique

Mauritius

Mexico

Micronesia

Montserrat

Myanmar

Nepal

New Caledonia

New Zealand

Nicaragua

Northern Mariana Islands

Pakistan

Palau

Panama

Papua New Guinea

Paraguay

Peru

Philippines

Portugal (Madeira)

Puerto Rico

Rarotonga

Samoa

Saudi Arabia

Senegal

Singapore

Solomon Islands

Sri Lanka

St. Kitts & Nevis

St. Lucia

St. Vincent & the Grenadines

Suriname

Tahiti


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Guadeloupe

Guatemala

Guyana

Haiti

Honduras

India

Indonesia

Jamaica

Japan

Kiribati

Lao People's Democratic Republic

Madagascar

Taiwan

Thailand

Timor-Leste

Tonga

Trinidad & Tobago

United States of America

Vanuatu

Venezuela

Viet Nam

Virgin Islands (UK)

Virgin Islands (US)

Yemen

Courtesy of Alan L Rothman, MD.

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Disclosures: Alan L Rothman, MD Consultant/Advisory Boards: Sanofi Pasteur [Prevention and treatment of dengue virus infections(Tetravalent live-attenuated dengue vaccine Chimerivax-DEN)]. Martin S Hirsch, MD Nothing to disclose. Elinor L Baron, MD, DTMHNothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through amulti-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content isrequired of all authors and must conform to UpToDate standards of evidence.

Conflict of interest policy

Disclosures


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Epidemiology of Dengue

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