Abstract
Dengue fever (DF) is a common mosquito-borne viral infection caused by any of the four dengue virus (DENV) serotypes. In recent years, the global incidence of DF has risen rapidly, which has widely threatened the health of millions of people in the United States, Southeast Asia, and the Western Pacific. The challenges for the prevention and control of DENV infection have become increasingly severe. Over the years, advances in the area of DF research have been continuously updating. In this review, we provide an updated and more in-depth overview of dengue epidemiology and pathogenesis, along with recent progress in diagnostic approaches (including methods to address cross-reactivity with other flaviviruses) and an expanded discussion of current dengue vaccine development, such as CYD-TDV (Dengvaxia), TV003/TV005, and the new TAK-003. This comprehensive perspective aims to offer references for the prevention, clinical diagnosis, and control of the disease.
Introduction
Dengue fever (DF) is an acute febrile disease caused by infection with any one of the four related single-stranded RNA viruses of the Flaviviridae family, dengue virus (DENV) 1, 2, 3, or 4. DENVs are usually transmitted between humans through the bite of infected Aedes aegypti (Paz-Bailey et al., 2024), which causes almost 390 million infections each year. Worryingly, more than half of the world’s population has been threatened (Tsheten et al., 2021). According to the WHO report, cases of DENV infection have increased 30-fold in the past 5 years, and consequently, the WHO has listed DF as one of the top 10 health threats in 2019. Globalization and climate warming further exacerbate dengue spread, making DF one of the most widespread mosquito-borne diseases in the world (Sinha et al., 2024). The clinical symptoms of the disease can be asymptomatic or febrile with varying degrees of severity. The incubation period for the DENV is between 3 and 14 days (average 7 days) and the main symptoms of DENV are severe fever, abdominal tenderness/pain, vomiting, mucosal bleeding, and hepatomegaly (Byard, 2016). The first confirmed case of DF has been reported in Kolkata located on the east coast of India around 1963–1964 (Wang et al., 2020b). To date, no specific antiviral treatment for DF exists, beyond symptomatic relief (Goethals et al., 2023). The urgent need for prevention has driven extensive research on vaccine development. In 2015, Sanofi’s CYD-TDV (Dengvaxia) was approved as a live-attenuated vaccine for preventing dengue, but it carries a risk for those who have never been exposed to DENV (Swaminathan and Khanna, 2019). Hence, the development of a safer and more efficacious dengue vaccine remains a common goal for researchers.
Below, we provide a structured overview of DF, from epidemiology and pathogenesis to the latest laboratory diagnostic techniques and vaccine advances (including ongoing trials such as TAK-003). We also discuss strategies for disease prevention and control, highlighting how integrated efforts are needed to address the global burden of dengue.
Epidemiology
Historically, the virus was first isolated in Ibadan, Western Nigeria, in 1960 (Bhatt et al., 2021). Each year, ∼3.97 billion people in 128 developing countries are at risk (Qazi and Siddiqui, 2024). A previous estimate suggests ∼390 million dengue infections annually (Khetarpal and Khanna, 2016).
Aedes aegypti and Ae. albopictus are the main mosquito vectors, possessing strong transmission capability and wide geographic distribution (Wiemer et al., 2017). Coinfections with other flaviviruses can occur in certain regions, further complicating epidemiological patterns (Fatima and Wang, 2015). Since there is no specific antiviral yet, control relies heavily on preventing mosquito bites and reducing mosquito breeding sites (Nealon et al., 2020).
Since there are no specific drugs to treat DF, prevention of dengue viral transmission entirely depends on preventing mosquito bites and controlling larvae and adult mosquitoes (Wong et al., 2023; Khan et al., 2023). Nevertheless, this method was limited, calling for a novel approach such as a vaccine.
Pathogenesis
Etiology
DENV has four distinct serotypes (DENV1–4), each with its own specific antigenic profile, belonging to the Flaviviridae family, genus Flavivirus (Kok et al., 2023). The virus is enveloped and has a single-stranded RNA genome encoding three structural proteins (capsid C, premembrane [prM], and envelope [E]) and seven nonstructural proteins ([nonstructural prototype, NS] NS1, NS2A, NS2B, NS3, NS4A, NS4B, and NS5) (Hwang et al., 2020). Among them, NS1 has diagnostic importance and has been used as an early diagnostic marker for dengue infection for many years (Sitthisuwannakul et al., 2024). Emerging evidence underscores the role of host lipid metabolism in DENV pathogenesis. Specifically, DENV NS1 interacts with high-density and low-density lipoproteins (HDL and LDL), altering their composition and triggering proinflammatory responses in monocyte-derived macrophages. This interaction may contribute to immune evasion and disease progression, particularly in severe cases of dengue hemorrhagic fever (DHF) (Dayarathna et al., 2024). E protein derived from the glycoprotein shell of the virus is the main envelope glycoprotein, locates on the surface of virus particle, and plays an important role in the process of viral infection and pathogenesis (Wilder-Smith, 2022). The prM protein is considered to be the chaperone protein of the E protein, preventing premature fusion of immature virions with the host (Ajlan et al., 2019).
Clinical manifestation
Historically, WHO’s 1997 classification recognized DF, DHF, and dengue shock syndrome. In 2009, this was refined into dengue without warning signs, dengue with warning signs, and severe dengue (Ajlan et al., 2019). The vulnerable population in new endemic areas is often adults, while in older endemic areas children can be more susceptible (McFee, 2018).
Dengue infection typically has an abrupt onset, with three identifiable phases as follows: febrile, critical, and recovery (Roy and Bhattacharjee, 2021). The febrile phase usually presents with sudden high fever, facial flushing, rash, myalgia, arthralgia, and other systemic symptoms. If the disease progresses to a critical phase, patients may develop plasma leakage, organ failure, or shock (Amin et al., 2018; Cristodulo et al., 2023). After 24–48 h of critical risk, many patients enter a recovery phase marked by fluid reabsorption and clinical improvement (Kularatne and Dalugama, 2022).
Critical warning signs
Several warning signs, including persistent vomiting, abdominal pain, fluid accumulation, lethargy, mucosal bleeding, and rapid platelet decrease, indicate the risk of severe dengue (Thein et al., 2013; Juliansen et al., 2022; Sreenivasan et al., 2018; Sreenivasan et al., 2020; Sreenivasan et al., 2018; Ahmad et al., 2018; Tsai et al., 2013; Mahabala et al., 2023; Narvaez et al., 2011). However, these signs can be nonspecific. Usually, five or more warning signs are collectively used to predict severity (Tukasan et al., 2017; Morra et al., 2018). Because coinfections with other viruses or previous immunity states can complicate the disease, timely recognition of these warning signs is crucial for appropriate intervention (Jayaratne et al., 2012).
Laboratory Diagnosis
The definitive diagnosis of dengue can be made by virus isolation, reverse transcription-polymerase chain reaction (RT-PCR), NS1 antigen detection, or serological methods (IgM/IgG). However, cross-reactivity with other flaviviruses (e.g., Zika, West Nile, Japanese encephalitis virus) poses a major challenge (Raafat et al., 2019).
Virus isolation
Virus isolation was a traditional detection method for DENV infection. Due to the long detection time, it is not particularly practical and has been replaced by RT-PCR, enzyme-linked immunosorbent assay (ELISA), and other methods (Landry and St George, 2017).
Reverse transcription-polymerase chain reaction
Molecular techniques, such as RT-PCR and nucleic acid hybridization, have been successfully used to diagnose DENV infections and are considered the gold standard for DENV infection (Nunes et al., 2022). As RT-PCR is characterized by more sensitive, specific, faster, and simpler steps and is cheaper than virus isolation methods, it is easier to perform than other methods for detecting pathogens. Its quality depends on the samples, human operator, nucleic acid test kit, and PCR equipment (Borghetti et al., 2019). In remote areas, it is difficult to detect the DENV large scale for the reason that RT-PCR equipment is expensive and testing personnel need professional training.
NS1 antigen capture
NS1 is a 43–48 kDa glycoprotein secreted by infected cells, detectable from days 1 to 9 of illness (Wang et al., 2020a). NS1 detection can be earlier than IgM seroconversion, making it valuable for early diagnosis (Muller et al., 2017). However, NS1 tends to be less sensitive in secondary infections, where preexisting antibodies may alter the test performance (Garcia et al., 2024; Poletti-Jabbour and Elejalde-Farfán, 2019).
Serology (IgM/IgG)
Methods include hemagglutination inhibition, IgM/IgG (immunoglobulinM/immunoglobulinG)-capture ELISA, neutralization assays, and more (Lima et al., 2022; Hosseini et al., 2018). IgM typically appears in the first week of illness, while IgG rises more slowly (Harapan et al., 2020). In areas where cocirculating flaviviruses exist, cross-reactivity can yield false positives (Ndiaye et al., 2023; Fagbami and Onoja, 2018; Wong et al., 2020). The IgM:IgG ratio can distinguish primary from secondary infections but does not always predict severity (Versiani et al., 2023).
Addressing Cross-Reactivity
To overcome the diagnostic complexity in regions where Zika or West Nile virus circulates, combining NS1 antigen detection with RT-PCR or using virus-specific neutralization tests is often recommended (Nasar et al., 2020; Kazachinskaya et al., 2019; Lustig et al., 2020; Steinhagen et al., 2016; Tyson et al., 2019; Nurtop et al., 2018). Plaque reduction neutralization tests, although more labor-intensive, remain the gold standard for differentiating among flaviviruses (Cabezas-Falcon et al., 2021).
Treatment
DF is a global health issue with over 50 million reported cases each year (Pierson and Diamond, 2020). Without appropriate medical management, the mortality rate of severe dengue can reach 15% (Troost and Smit, 2020; Anasir et al., 2020). Currently, no licensed antiviral specifically targets DENV (Hamel et al., 2019). Management relies on supportive care, including fluid replacement, electrolyte management, antipyretics (e.g., acetaminophen), and hemodynamic monitoring (Tayal et al., 2023; Tejo et al., 2024).
Potential drug candidates. Although certain drugs such as ketotifen have been explored (Hamel et al., 2019), no robust data confirm their broad efficacy (Low et al., 2018). Caution is advised when using NSAIDs（nonsteroidal anti-inflammatory drugs) for symptomatic relief, owing to potential hemorrhagic risk (Kellstein and Fernandes, 2019; Organización Panamericana de la S, 2022).
Supportive fluid therapy. Timely intravenous fluid replacement can be lifesaving for patients who develop hemorrhagic complications or shock. Hemodynamic stability, lactic acid levels, and platelet counts guide the intensity of fluid therapy (Low et al., 2018).
Integrated TCM (traditional Chinese mediciline) approaches. In some regions such as Taiwan, Chinese herbal medicine is integrated to manage symptoms and improve recovery, although further controlled studies are needed (Zhang et al., 2018; Ahmed et al., 2020; Chen et al., 2020).
Control and Prevention
Vector control
Because no specific antiviral exists, vector control remains the main preventive measure. Physical control strategies focus on removing or cleaning water containers weekly, reducing breeding sites (Rather et al., 2017). Biological control methods include the sterile insect technique, where male mosquitoes are irradiated to become sterile; upon mating, the local mosquito population declines (Li et al., 2024; Mishra et al., 2018). Gene-driven approaches also show promise, although ecological concerns persist (Hammond and Galizi, 2017).
Chemical control
Residual insecticide spraying and larvicides are effective but can have environmental drawbacks. Plant extracts (e.g., essential oils) are being investigated as safer alternatives (Procopio et al., 2024; Ramkumar et al., 2015).
Horizontal versus vertical transmission
While horizontal transmission is primary, vertical transmission from adult females to offspring can contribute to persistent local outbreaks (Golding et al., 2023). Genetic changes in vectors or viruses might enhance vertical transmission, thereby complicating control measures (Murillo et al., 2019).
Vaccine Development
Overview of current vaccines
In 2015, Sanofi’s CYD-TDV (Dengvaxia) became the first licensed dengue vaccine, recommended for individuals 9–45 years old with previous DENV exposure (Wilder-Smith, 2020; Wong et al., 2022; Thomas et al., 2022; Ylade et al., 2024). However, limited protection in seronegative recipients and children <9 years old has raised safety concerns (Kallás et al., 2024). The WHO thus recommends prior serological testing to ensure that the vaccine is administered to those with prior infection (Diaz-Quijano et al., 2024).
TAK-003 (DENvax), developed by Takeda Pharmaceuticals, recently completed Phase 3 trials, showing promising efficacy and safety in multicountry studies (Tricou et al., 2023). NIH-developed TV003/TV005 (live-attenuated tetravalent vaccine) is also in advanced trials, with reported robust immunogenicity (Huang et al., 2021). In addition, Brazil’s Butantan-DV is being evaluated in large-scale trials (Kallás et al., 2024) Table 1.
Major Dengue Vaccine Candidates and Their Development Status
DENV, dengue virus.
Future directions
DNA vaccines are under Phase I testing, offering advantages such as stable storage and easy production (Deng et al., 2020; Akter et al., 2024). Heterologous prime/boost regimens, combining different platforms (e.g., live-attenuated prime + DNA/subunit boost), aim to achieve balanced immunity (Zeyaullah et al., 2022; Redoni et al., 2020). Ongoing research also explores novel approaches, such as mosquito-targeted vaccines or paratransgenic strategies, although most remain in preclinical stages (Wilson et al., 2020).
Summary
DF, a major mosquito-borne disease, continues to spread globally due to climate change, urbanization, and global travel. While supportive therapy is currently the mainstay of clinical management, recent research on dengue vaccines is progressively narrowing the gap toward an effective prophylactic solution. Integrated control measures, including vector control, next-generation vaccine technologies, and improved diagnostic tools that address cross-reactivity challenges, are collectively essential to reduce the public health burden of dengue. With ongoing multipronged efforts, it is reasonable to expect further breakthroughs in the next decade, ultimately enabling safer vaccines and more effective prevention strategies.
Footnotes
Authors’ Contributions
B.D.: Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work (equal). S.F.: Drafting the work or revising it critically for important intellectual content; final approval of the version to be published (equal). X.F.: Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors have read and agreed to the published version of the review.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
The authors declared no competing financial interests. This work was supported by the Education Department Foundation of Jilin Province (JJKH20210487KJ).