The disease pattern associated with dengue-like illness from 1780 to 1940 was characterized by relati ely infre!

uent but often large epidemics" #owe er$ it is likely that dengue iruses became endemic in many tropical urban centers during this time because during interepidemic periods$ when there was no apparent disease transmission$ nonimmune isitors in ariably contracted a dengue-like illness within months of their arri al"

The ecologic disruption in the %outheast &sia and 'acific theaters during and following (orld (ar )) created ideal conditions for increased transmission of mos!uito-borne diseases$ and it was in this setting that a global pandemic of dengue began" (ith increased epidemic transmission$ hyperendemicity *the cocirculation of multiple dengue irus serotypes+ de eloped in %outheast &sian cities and epidemic dengue hemorrhagic fe er *,#-+$ a newly described disease$ emerged *.7$ 48$ /1$ /.+" The first known epidemic of ,#- occurred in 0anila$ 'hilippines$ in 191. to 1914$ but within 20 years the disease in epidemic form had spread throughout %outheast &sia3 by the mid-1970s$ ,#- had become a leading cause of hospitalization and death among children in the region *1+" )n the 1970s$ dengue was reintroduced to the 'acific )slands and epidemic acti ity increased there and in the &mericas" ,uring the 1980s and 1990s$ epidemic dengue transmission intensified$ and there is now a global resurgence of dengue fe er$ with e4panding geographic distribution of both the mos!uito ectors and the iruses$ increased incidence of disease caused by an increased fre!uency of epidemic transmission$ and the emergence of ,#- in many new countries *./$ .9$ 41$ 41$ 48$ /1$ /.$ 110$111$ 124+"

)n &sia$ epidemic ,#- has e4panded geographically from %outheast &sian countries west to )ndia$ %ri 5anka$ the 0aldi es$ and 'akistan and east to 6hina *42+" %e eral island countries of the %outh and 6entral 'acific *7iue$ 'alau$ 8ap$ 6ook )slands$ Tahiti$ 7ew 6aledonia$ and 9anuatu+ ha e e4perienced ma:or or minor ,#- epidemics *41+" ;pidemiologic changes in the &mericas$ howe er$ ha e been the most dramatic" )n the 1910s$ 19/0s$ and most of the 1970s$ epidemic dengue was rare in the &merican region because the principal mos!uito ector$ &edes aegypti$ had been eradicated from most of 6entral and %outh &merica *./-.8$ 110+" The eradication program was discontinued in the early 1970s$ and this species then began to rein ade the countries from which it had been eradicated *.8$ 110+" <y the 1990s$ &" aegyptihad nearly regained the geographic distribution it held before eradication was initiated *-ig" 1+" ;pidemic dengue in ariably followed reinfestation of a country by&" aegypti" <y the 1980s$ the &merican region was e4periencing ma:or epidemics of dengue in countries that had been free of the disease for .1 to 1.0 years *./-.8$ 111+" 7ew dengue irus strains and serotypes were introduced *,;7-1 in 1977$ a new strain of ,;72 in 1981$ ,;7-4 in 1981$ and a new strain of ,;7-. in 1994+" 0oreo er$ many countries of the region e ol ed from nonendemicity *no endemic disease+ or hypoendemicity *one serotype present+ to hyperendemicity *multiple serotypes

present+$ and epidemic ,#- emerged$ much as it had in %outheast &sia 21 years earlier *./-.8+" -rom 1981 to 1997$ 24 &merican countries reported laboratoryconfirmed ,#- *-ig" 2+ *42$ 4.$ 111+"