The impact of transgenic mosquitoes on dengue virulence to humans and mosquitoes

Temporal Correlation Between Urban Microclimate, Vector Mosquito Abundance, and Dengue Cases

Dengue Hemorrhagic Fever (DHF) is a major mosquito-borne viral disease. Studies have reported a strong correlation between weather, the abundance of Aedes aegypti, the vector of DHF virus, and dengue incidence. However, this conclusion has been based on the general climate pattern of wide regions. In general, however, the human population, level of infrastructure, and land-use change in rural and urban areas often produce localized climate patterns that may influence the interaction between climate, vector abundance, and dengue incidence. Thoroughly understanding this correlation will allow the development of a customized and precise local early warning system. To achieve this purpose, we conducted a cohort study, during January-December 2017, in 16 districts in Bandung, West Java, Indonesia. In the selected areas, local weather stations and modified light mosquito traps were set up to obtain data regarding daily weather and the abundance of adult female Ae. aegypti. A generalized linear model was applied to analyze the effect of local weather and female adult Ae. aegypti on the number of dengue cases. The result showed a significant non-linear correlation among mosquito abundance, maximum temperature, and dengue cases. Using our model, the data showed that the addition of a single adult Ae. aegypti mosquito increased the risk of dengue infection by 1.8%, while increasing the maximum temperature by one degree decreased the risk by 17%. This finding suggests specific actionable insights needed to supplement existing mosquito eradication programs.

Beyond limits – the pitfalls of global gene drives for environmental risk assessment in the European Union

Gene drive organisms (GDOs) have been suggested as approaches to combat some of the most pressing environmental and public health issues. No such organisms have so far been released into the environment, but it remains unclear whether the relevant regulatory provisions will be fit for purpose to cover their potential environmental, human and animal health risks if environmental releases of GDOs are envisaged. We evaluate the novel features of GDOs and outline the resulting challenges for the environmental risk assessment. These are related to the definition of the receiving environment, the use of the comparative approach, the definition of potential harm, the stepwise testing approach, the assessment of long-term and large-scale risks at population and ecosystem level and the post-release monitoring of adverse effects. Fundamental adaptations as well as the development of adequate risk assessment methodologies are needed in order to enable an operational risk assessment for globally spreading GDOs before these organisms are released into environments in the EU.

Cost-effectiveness of dengue vaccination in Yucatán, Mexico using a dynamic dengue transmission model

Background

The incidence of dengue fever (DF) is steadily increasing in Mexico, burdening health systems with consequent morbidities and mortalities. On December 9^th, 2015, Mexico became the first country for which the dengue vaccine was approved for use. In anticipation of a vaccine rollout, analysis of the cost-effectiveness of the dengue vaccination program that quantifies the dynamics of disease transmission is essential.

Methods

We developed a dynamic transmission model of dengue in Yucatán, Mexico and its proposed vaccination program to incorporate herd immunity into our analysis of cost-effectiveness analysis. Our model also incorporates important characteristics of dengue epidemiology, such as clinical cross-immunity and susceptibility enhancement upon secondary infection. Using our model, we evaluated the cost-effectiveness and economic impact of an imperfect dengue vaccine in Yucatán, Mexico.

Conclusions

Our study indicates that a dengue vaccination program would prevent 90% of cases of symptomatic DF incidence as well as 90% of dengue hemorrhagic fever (DHF) incidence and dengue-related deaths annually. We conclude that a dengue vaccine program in Yucatán, Mexico would be very cost-effective as long as the vaccination cost per individual is less than $140 and $214 from health care and societal perspectives, respectively. Furthermore, at an exemplary vaccination cost of $250 USD per individual on average, dengue vaccination is likely to be cost-effective 43% and 88% of the time from health care and societal perspectives, respectively.

The economics of vaccination

The market for vaccinations is widely believed to be characterized by market failures, because individuals do not internalize the positive externalities that their vaccination decisions may confer on other individuals. Francis (1997) provided a set of assumptions under which the equilibrium vaccination pattern is socially optimal. We show that his conditions are not necessary for the welfare theorem to hold but that in general, the market yields inefficiently low vaccination uptake. Equilibrium non-optimality may obtain if (i) agents can recover from infection, (ii) vaccines are imperfect, (iii) individuals are ex ante heterogeneous, (iv) vaccination timing is inflexible or (v) the planning horizon is finite. Apart from the case with heterogeneity, inefficiencies result from the presence of strategic interaction.

Feasible introgression of an anti-pathogen transgene into an urban mosquito population without using gene-drive

Background

Introgressing anti-pathogen constructs into wild vector populations could reduce disease transmission. It is generally assumed that such introgression would require linking an anti-pathogen gene with a selfish genetic element or similar technologies. Yet none of the proposed transgenic anti-pathogen gene-drive mechanisms are likely to be implemented as public health measures in the near future. Thus, much attention now focuses instead on transgenic strategies aimed at mosquito population suppression, an approach generally perceived to be practical. By contrast, aiming to replace vector competent mosquito populations with vector incompetent populations by releasing mosquitoes carrying a single anti-pathogen gene without a gene-drive mechanism is widely considered impractical.

Methodology/Principal Findings

Here we use Skeeter Buster, a previously published stochastic, spatially explicit model of Aedes aegypti to investigate whether a number of approaches for releasing mosquitoes with only an anti-pathogen construct would be efficient and effective in the tropical city of Iquitos, Peru. To assess the performance of such releases using realistic release numbers, we compare the transient and long-term effects of this strategy with two other genetic control strategies that have been developed in Ae. aegypti: release of a strain with female-specific lethality, and a strain with both female-specific lethality and an anti-pathogen gene. We find that releasing mosquitoes carrying only an anti-pathogen construct can substantially decrease vector competence of a natural population, even at release ratios well below that required for the two currently feasible alternatives that rely on population reduction. Finally, although current genetic control strategies based on population reduction are compromised by immigration of wild-type mosquitoes, releasing mosquitoes carrying only an anti-pathogen gene is considerably more robust to such immigration.

Conclusions/Significance

Contrary to the widely held view that transgenic control programs aimed at population replacement require linking an anti-pathogen gene to selfish genetic elements, we find releasing mosquitoes in numbers much smaller than those considered necessary for transgenic population reduction can result in comparatively rapid and robust population replacement. In light of this non-intuitive result, directing efforts to improve rearing capacity and logistical support for implementing releases, and reducing the fitness costs of existing recombinant technologies, may provide a viable, alternative route to introgressing anti-pathogen transgenes under field conditions.

Dengue is transmitted by the Aedes aegypti mosquito. Releases of genetically sterile males have been shown to reduce wild mosquito numbers. An alternative approach is to release mosquitoes carrying genes blocking dengue transmission. It is often assumed that spreading such genes in mosquito populations requires using selfish genetic elements (SGEs - genes that are inherited at higher rates than other genes in the genome). Absent such techniques, the release numbers required to transform mosquito populations is seen as prohibitive. However, strategies that rely on SGEs or related technologies to spread anti-dengue genes are unlikely to be implemented in the near future as a public health response. Using a biologically detailed model of Aedes aegypti populations dynamics and genetics, we assess how many mosquitoes need to be released to spread an anti-pathogen gene in an urban environment without using an SGE. We compare release numbers with two other, currently feasible transgenic strategies: releasing mosquitoes with female-lethal genes, and mosquitoes carrying both female-lethal and anti-pathogen genes. We show that even without using SGEs, releasing mosquitoes in numbers much smaller than those considered necessary for transgenic population reduction can effectively reduce the ability of Aedes aegypti to spread dengue.

Can Horton hear the whos? The importance of scale in mosquito-borne disease

The epidemiology of vector-borne pathogens is determined by mechanisms and interactions at different scales of biological organization, from individual-level cellular processes to community interactions between species and with the environment. Most research, however, focuses on one scale or level with little integration between scales or levels within scales. Understanding the interactions between levels and how they influence our perception of vector-borne pathogens is critical. Here two examples of biological scales (pathogen transmission and mosquito mortality) are presented to illustrate some of the issues of scale and to explore how processes on different levels may interact to influence mosquito-borne pathogen transmission cycles. Individual variation in survival, vector competence, and other traits affect population abundance, transmission potential, and community structure. Community structure affects interactions between individuals such as competition and predation, and thus influences the individual-level dynamics and transmission potential. Modeling is a valuable tool to assess interactions between scales and how processes at different levels can affect transmission dynamics. We expand an existing model to illustrate the types of studies needed, showing that individual-level variation in viral dose acquired or needed for infection can influence the number of infectious vectors. It is critical that interactions within and among biological scales and levels of biological organization are understood for greater understanding of pathogen transmission with the ultimate goal of improving control of vector-borne pathogens.

Braess's paradox in epidemic game: better condition results in less payoff

Facing the threats of infectious diseases, we take various actions to protect ourselves, but few studies considered an evolving system with competing strategies. In view of that, we propose an evolutionary epidemic model coupled with human behaviors, where individuals have three strategies: vaccination, self-protection and laissez faire, and could adjust their strategies according to their neighbors' strategies and payoffs at the beginning of each new season of epidemic spreading. We found a counter-intuitive phenomenon analogous to the well-known Braess's Paradox, namely a better condition may lead to worse performance. Specifically speaking, increasing the successful rate of self-protection does not necessarily reduce the epidemic size or improve the system payoff. The range and degree of the Braess's Paradox are sensitive to both the parameters characterizing the epidemic spreading and the strategy payoff, while the existence of the Braess's Paradox is insensitive to the network topologies. This phenomenon can be well explained by a mean-field approximation. Our study demonstrates an important fact that a better condition for individuals may yield a worse outcome for the society.

Genetic control of mosquitoes

Genetics can potentially provide new, species-specific, environmentally friendly methods for mosquito control. Genetic control strategies aim either to suppress target populations or to introduce a harm-reducing novel trait. Different approaches differ considerably in their properties, especially between self-limiting strategies, where the modification has limited persistence, and self-sustaining strategies, which are intended to persist indefinitely in the target population and may invade other populations. Several methods with different molecular biology are under development and the first field trials have been completed successfully.

Release of genetically engineered insects: a framework to identify potential ecological effects

Genetically engineered (GE) insects have the potential to radically change pest management worldwide. With recent approvals of GE insect releases, there is a need for a synthesized framework to evaluate their potential ecological and evolutionary effects. The effects may occur in two phases: a transitory phase when the focal population changes in density, and a steady state phase when it reaches a new, constant density. We review potential effects of a rapid change in insect density related to population outbreaks, biological control, invasive species, and other GE organisms to identify a comprehensive list of potential ecological and evolutionary effects of GE insect releases. We apply this framework to the Anopheles gambiae mosquito - a malaria vector being engineered to suppress the wild mosquito population - to identify effects that may occur during the transitory and steady state phases after release. Our methodology reveals many potential effects in each phase, perhaps most notably those dealing with immunity in the transitory phase, and with pathogen and vector evolution in the steady state phase. Importantly, this framework identifies knowledge gaps in mosquito ecology. Identifying effects in the transitory and steady state phases allows more rigorous identification of the potential ecological effects of GE insect release.

Wolbachia versus dengue: Evolutionary forecasts

A novel form of biological control is being applied to the dengue virus. The agent is the maternally transmitted bacterium Wolbachia, naturally absent from the main dengue vector, the mosquito Aedes aegypti. Three Wolbachia-based control strategies have been proposed. One is suppression of mosquito populations by large-scale releases of males incompatible with native females; this intervention requires ongoing releases. The other interventions transform wild mosquito populations with Wolbachia that spread via the frequency-dependent fitness advantage of Wolbachia-infected females; those interventions potentially require just a single, local release for area-wide disease control. One of these latter strategies uses Wolbachia that shortens mosquito life, indirectly preventing viral maturation/transmission. The other strategy uses Wolbachia that block viral transmission. All interventions can be undermined by viral, bacterial or mosquito evolution; viral virulence in humans may also evolve. We examine existing theory, experiments and comparative evidence to motivate predictions about evolutionary outcomes. (i) The life-shortening strategy seems the most likely to be thwarted by evolution. (ii) Mosquito suppression has a reasonable chance of working locally, at least in the short term, but long-term success over large areas is challenging. (iii) Dengue blocking faces strong selection for viral resistance but may well persist indefinitely at some level. Virulence evolution is not mathematically predictable, but comparative data provide no precedent for Wolbachia increasing dengue virulence. On balance, our analysis suggests that the considerable possible benefits of these technologies outweigh the known negatives, but the actual risk is largely unknown.

Influence of vectors' risk-spreading strategies and environmental stochasticity on the epidemiology and evolution of vector-borne diseases: the example of Chagas' disease

Insects are known to display strategies that spread the risk of encountering unfavorable conditions, thereby decreasing the extinction probability of genetic lineages in unpredictable environments. To what extent these strategies influence the epidemiology and evolution of vector-borne diseases in stochastic environments is largely unknown. In triatomines, the vectors of the parasite Trypanosoma cruzi, the etiological agent of Chagas’ disease, juvenile development time varies between individuals and such variation most likely decreases the extinction risk of vector populations in stochastic environments. We developed a simplified multi-stage vector-borne SI epidemiological model to investigate how vector risk-spreading strategies and environmental stochasticity influence the prevalence and evolution of a parasite. This model is based on available knowledge on triatomine biodemography, but its conceptual outcomes apply, to a certain extent, to other vector-borne diseases. Model comparisons between deterministic and stochastic settings led to the conclusion that environmental stochasticity, vector risk-spreading strategies (in particular an increase in the length and variability of development time) and their interaction have drastic consequences on vector population dynamics, disease prevalence, and the relative short-term evolution of parasite virulence. Our work shows that stochastic environments and associated risk-spreading strategies can increase the prevalence of vector-borne diseases and favor the invasion of more virulent parasite strains on relatively short evolutionary timescales. This study raises new questions and challenges in a context of increasingly unpredictable environmental variations as a result of global climate change and human interventions such as habitat destruction or vector control.

Navigating the devious course of evolution: the importance of mechanistic models for identifying eco-evolutionary dynamics in nature

In proposing his genetic feedback mechanism, David Pimentel was one of the first biologists to argue that the reciprocal interplay of ecological and evolutionary dynamics is an important process regulating population dynamics and ultimately affecting community composition. Although the past decade has seen an increase in research activity on these so-called eco-evolutionary dynamics, there remains a conspicuous lack of compelling natural examples of such feedback. Here we argue that this lack may be due to an inherent difficulty in detecting eco-evolutionary dynamics in nature. By examining models of virulence evolution, host resistance evolution, and antigenic evolution, we show that the influence of evolution on ecological dynamics can often be obscured by other ecological processes that yield similar dynamics. We then show, however, that mechanistic models can be used to navigate this, in Pimentel's words, "devious" course of evolution when effectively combined with empirical data. We argue that these models, improving upon Pimentel's original mathematical models, will therefore play an increasingly important role in identifying more subtle, but possibly ubiquitous, eco-evolutionary dynamics in nature. To highlight the importance of identifying these potentially subtle dynamics in nature, we end by considering our ability to anticipate the effect of population control strategies in the presence of these eco-evolutionary feedbacks.

West Nile Virus: biology, transmission, and human infection

West Nile Virus was introduced into the Western Hemisphere during the late summer of 1999 and has been causing significant and sometimes severe human diseases since that time. This article briefly touches upon the biology of the virus and provides a comprehensive review regarding recent discoveries about virus transmission, virus acquisition, and human infection and disease.

When does pathogen evolution maximize the basic reproductive number in well-mixed host-pathogen systems?

Pathogen evolution towards the largest basic reproductive number, R0, has been observed in many theoretical models, but this conclusion does not hold universally. Previous studies of host-pathogen systems have defined general conditions under which R0 maximization occurs in terms of R0 itself. However, it is unclear what constraints these conditions impose on the functional forms of pathogen related processes (e.g. transmission, recover, or mortality) and how those constraints relate to the characteristics of natural systems. Here we focus on well-mixed SIR-type host-pathogen systems and, via a synthesis of results from the literature, we present a set of sufficient mathematical conditions under which evolution maximizes R0. Our conditions are in terms of the functional responses of the system and yield three general biological constraints on when R0 maximization will occur. First, there are no genotype-by-environment interactions. Second, the pathogen utilizes a single transmission pathway (i.e. either horizontal, vertical, or vector transmission). Third, when mortality is density dependent: (i) there is a single infectious class that individuals cannot recover from, (ii) mortality in the infectious class is entirely density dependent, and (iii) the rates of recovery, infection progression, and mortality in the exposed classes are independent of the pathogen trait. We discuss how this approach identifies the biological mechanisms that increase the dimension of the environmental feedback and prevent R0 maximization.

Larval nutritional stress affects vector immune traits in adult yellow fever mosquito Aedes aegypti (Stegomyia aegypti)

We report key physiological traits that link larval nutritional experience to adult immune status in the yellow fever mosquito Aedes aegypti L. (Stegomyia aegypti) (Diptera: Culicidae). Many lines of defence make up the innate immune system of mosquitoes. Among defences, the epithelium-lined midgut is the first barrier, circulating haemocytes are cellular components of innate immunity and, when triggered, the Toll and Imd pathways signal production of antimicrobial peptides (AMP) as part of humoral defences. We quantified three lines of defence in Ae. aegypti in response to larval nutritional stress, and our data show that important female immune functions are modified by the larval rearing environment. Adult midgut basal lamina thickness was not affected by larval nutrient stress as has been observed in another Aedes sp. However, nutrient stresses experienced by larvae lead to a reduced number of haemocytes in females. Transcripts of Spaetzle (upstream regulator of Toll pathway that leads to induction of AMPs) and some immune-related genes were less abundant in stressed larvae but showed increased expression in females derived from stressed larvae. Results indicate a potential for compensation by the humoral branch for a reduced cellular branch of innate immunity in adults in response to larval nutrient stress.

Models of the impact of dengue vaccines: a review of current research and potential approaches

Vaccination reduces transmission of pathogens directly, by preventing individual infections, and indirectly, by reducing the probability of contact between infected individuals and susceptible ones. The potential combined impact of future dengue vaccines can be estimated using mathematical models of transmission. However, there is considerable uncertainty in the structure of models that accurately represent dengue transmission dynamics. Here, we review models that could be used to assess the impact of future dengue immunization programmes. We also review approaches that have been used to validate and parameterize models. A key parameter of all approaches is the basic reproduction number, R(0), which can be used to determine the critical vaccination fraction to eliminate transmission. We review several methods that have been used to estimate this quantity. Finally, we discuss the characteristics of dengue vaccines that must be estimated to accurately assess their potential impact on dengue virus transmission.

A protocol for collecting and staining hemocytes from the yellow fever mosquito Aedes aegypti

Mosquitoes are vectors for a number of disease-causing pathogens such as the yellow fever virus, malaria parasites and filarial worms. Laboratories are investigating anti-pathogen components of the innate immune system in disease vector species in the hopes of generating transgenic mosquitoes that are refractory to such pathogens(1, 2). The innate immune system of mosquitoes consists of several lines of defense (3). Pathogens that manage to escape the barrier imposed by the epithelium-lined mosquito midgut (4) enter the hemolymph and encounter circulating hemocytes, important cellular components that encapsulate and engulf pathogens (5, 6). Researchers have not found evidence for hematopoietic tissues in mosquitoes and current evidence suggests that the number of hemocytes is fixed at adult emergence and numbers may actually decline as the mosquito ages (7). The ability to properly collect and identify hemocytes from medically important insects is an essential step for studies in cellular immunity. However, the small size of mosquitoes and the limited volume of hemolymph pose a challenge to collecting immune cells. Two established methods for collecting mosquito hemocytes include expulsion of hemolymph from a cut proboscis (8), and volume displacement (perfusion), in which saline is injected into the membranous necklike region between the head and thorax (i.e., cervix) and the perfused hemolymph is collected from a torn opening in a distal region of the abdomen (9, 10). These techniques, however, are limited by low recovery of hemocytes and possible contamination by fat body cells, respectively (11). More recently a method referred to as high injection/recovery improved recovery of immunocytes by use of anticoagulant buffers while reducing levels of contaminating scales and internal tissues (11). While that method allows for an improved method of collecting and maintaining hemocytes for primary culture, it entails a number of injection and collecting steps that are not necessary if the downstream goal is to collect, fix and stain hemocytes for diagnostics. Here, we demonstrate our method of collecting mosquito hemolymph that combines the simplicity of perfusion, using anticoagulant buffers in place of saline solution, with the accuracy of high injection techniques to isolate clean preparations of hemocytes in Aedes mosquitoes.

Dengue vector control strategies in an urban setting: an economic modelling assessment

BACKGROUND

An estimated 2·5 billion people are at risk of dengue. Incidence of dengue is especially high in resource-constrained countries, where control relies mainly on insecticides targeted at larval or adult mosquitoes. We did epidemiological and economic assessments of different vector control strategies.

METHODS

We developed a dynamic model of dengue transmission that assesses the evolution of insecticide resistance and immunity in the human population, thus allowing for long-term evolutionary and immunological effects of decreased dengue transmission. We measured the dengue health burden in terms of disability-adjusted life-years (DALYs) lost. We did a cost-effectiveness analysis of 43 insecticide-based vector control strategies, including strategies targeted at adult and larval stages, at varying efficacies (high-efficacy [90% mortality], medium-efficacy [60% mortality], and low-efficacy [30% mortality]) and yearly application frequencies (one to six applications). To assess the effect of parameter uncertainty on the results, we did a probabilistic sensitivity analysis and a threshold analysis.

FINDINGS

All interventions caused the emergence of insecticide resistance, which, with the loss of herd immunity, will increase the magnitude of future dengue epidemics. In our model, one or more applications of high-efficacy larval control reduced dengue burden for up to 2 years, whereas three or more applications of adult vector control reduced dengue burden for up to 4 years. The incremental cost-effectiveness ratios of the strategies for two high-efficacy adult vector control applications per year was US$615 per DALY saved and for six high-efficacy adult vector control applications per year was $1267 per DALY saved. Sensitivity analysis showed that if the cost of adult control was more than 8·2 times the cost of larval control then all strategies based on adult control became dominated.

INTERPRETATION

Six high-efficacy adult vector control applications per year has a cost-effectiveness ratio that will probably meet WHO's standard for a cost-effective or very cost-effective intervention. Year-round larval control can be counterproductive, exacerbating epidemics in later years because of evolution of insecticide resistance and loss of herd immunity. We suggest the reassessment of vector control policies that are based on larval control only.

FUNDING

The Fulbright Programme, CAPES (Brazilian federal agency for post-graduate education), the Miriam Burnett trust, and the Notsew Orm Sands Foundation.

Male mating history and body size influence female fecundity and longevity of the dengue vector Aedes aegypti

Male reproductive success is dependent on insemination success and reproductive output. During mating, male mosquitoes transfer not just sperm, but also seminal fluid proteins that may have profound effects on mated female biology and behavior. In this study, we investigated the role of male body size and mating history on semen depletion, female longevity, and reproductive success in Aedes aegypti L. Small and large males were mated in rapid succession with up to five females. Our results indicate that large males had greater mating capacity than small males. A reduction in fecundity by >50% was observed in females that were fourth to mate with small males in comparison with females that mated earlier in sequence. For females mated to large males, this reduction became evident for females that mated fifth in sequence. No loss of fertility (measured as hatch rate) was observed in females that were third-fifth in mating sequence compared with females mated to virgin males. When females were maintained on a low-quality (5% sucrose) diet, those mated to virgin males had a greater longevity compared with females mated third in sequence. We conclude that small males experience more rapid seminal depletion than large males, and discuss the role of semen depletion in the mated female. Our results contribute toward a better understanding of the complexity of Ae. aegypti mating biology and provide refined estimates of mating capacity for genetic control efforts.

Modeling transmission dynamics and control of vector-borne neglected tropical diseases

Neglected tropical diseases affect more than one billion people worldwide. The populations most impacted by such diseases are typically the most resource-limited. Mathematical modeling of disease transmission and cost-effectiveness analyses can play a central role in maximizing the utility of limited resources for neglected tropical diseases. We review the contributions that mathematical modeling has made to optimizing intervention strategies of vector-borne neglected diseases. We propose directions forward in the modeling of these diseases, including integrating new knowledge of vector and pathogen ecology, incorporating evolutionary responses to interventions, and expanding the scope of sensitivity analysis in order to achieve robust results.

Dengue

INTRODUCTION

Dengue is a vector-borne viral infection that endangers an estimated 2.5 billion people. Disease caused by dengue ranges from a relatively minor febrile illness to a life-threatening condition characterized by extensive capillary leak. A greater understanding of dengue has the potential to improve both the clinical management of individual cases and the control of the disease.

SOURCES OF DATA

We searched the available literature using PubMed, Embase and Web of Science for relevant articles and abstracts.

AREAS OF AGREEMENT

Addressing our gaps in the understanding of disease pathogenesis and improving our knowledge of dengue virus biology are necessary in order to develop tools to effectively control, diagnose and treat the disease.

AREAS OF CONTROVERSY

The pathogenesis of dengue is multifactorial and depends on both host and virus factors. A more integrated understanding of disease pathogenesis is necessary.

AREAS TIMELY FOR DEVELOPING RESEARCH

There are many questions related to disease pathogenesis, development of diagnostics, drug and vaccine development and individual case management that need addressing if the disease is to be successfully tackled.