Dengue fever, a very old disease, has reemerged in the past 20 years with an expanded geographic distribution of both

the viruses 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. n !""# this mosquito$borne disease is the most important tropical infectious disease after malaria, with an estimated !00 million cases of dengue fever, %00,000 cases of dengue hemorrhagic fever, and 2%,000 deaths annually. &he reasons for this resurgence and emergence of dengue hemorrhagic fever in the waning years of the 20th century are complex and not fully understood, but demographic, societal, and public health infrastructure changes in the past '0 years have contributed greatly. &his paper reviews the changing epidemiology of dengue and dengue hemorrhagic fever by geographic region, the natural history and transmission cycles, clinical diagnosis of both dengue fever and dengue hemorrhagic fever, serologic and virologic laboratory diagnoses, pathogenesis, surveillance, prevention, and control. ( ma)or challenge for public health officials in all tropical areas of the world is to devleop and implement sustainable prevention and control programs that will reverse the trend of emergent dengue hemorrhagic fever. (lthough first reports of ma)or epidemics of an illness thought to possibly be dengue occurred on three continents ((sia, (frica, and *orth (merica) in !++" and !+#0 (73,75, 109, 128), reports of illnesses clinically compatible with dengue fever occurred even earlier. &he earliest record found to date is in a ,hinese encyclopedia of disease symptoms and remedies, first published during the ,hin Dynasty (2-% to .20 (.D.) and formally edited in -!0 (.D. (&ang Dynasty) and again in ""2 (.D. (*orthern /ung Dynasty) (108). &he disease was called water poison by the ,hinese and was thought to be somehow connected with flying insects associated with water. 0utbrea1s of illness in the 2rench 3est ndies in !-'% and in 4anama in !-"" could also have been dengue (75,103). &hus, dengue or a very similar illness had a wide geographic distribution before the !#th century, when the first 1nown pandemic of dengue$li1e illness began. t is uncertain whether the epidemics in 5atavia (6a1arta), ndonesia, and ,airo, 7gypt, in !++" were dengue, but it is quite li1ely that the 4hiladelphia epidemic of !+#0 was dengue (19). ( more detailed discussion of the history of dengue viruses has recently been published (41).