DENGUE VIRUS AND ITS TRANSMISSIOND engue is caused by four related RNA viruses of the genus Flavivirus, dengue virus (DENV)-1, -2, -3, and -4. Infection with DENV is usually asymptomatic but each DENV is capable of causing the full spectrum of clinical disease from mild, undifferentiated acute febrile illness, to classic dengue fever and more severe disease including dengue hemorrhagic fever and dengue shock syndrome. Severe disease manifestations including hypovolemic shock and clinically significant hemorrhage are more commonly observed among patients during their second or subsequent episodes of DENV infection. 1 Infection with one DENV produces lifelong immunity against that DENV type and short-term (Յ2 months) cross-protection against infection with the other three DENVs. Therefore, an individual has a lifetime risk of up to four DENV infections.DENVs are transmitted from person to person through the bite of an infected Aedes aegypti mosquito (less commonly Aedes albopictus or Aedes polynesiensis). 2 Unlike other related flaviviruses such as West Nile virus, humans are the main amplifying host for DENV. While there is a sylvatic nonhuman primate cycle of DENV transmission, it rarely crosses to humans, and antibodies to the sylvatic virus appear to protect against human DENV. The transmission cycle begins when a mosquito ingests DENV in a blood meal from an infected person (Fig. 1). DENV replicates and disseminates within the mosquito and reaches the salivary glands after 8 to 12 days (extrinsic incubation period). Higher ambient temperatures may reduce the extrinsic incubation period and increase the chance they will infect a human before dying. 3 The mosquito remains infectious for life (typically less than 1 month) and can transmit infection with 10 2 viral particles. 4 DENV replicates in humans for an intrinsic incubation period of 3 to 14 days before symptom onset. Infected persons can transmit DENV to mosquitoes as early as 1 to 2 days before symptoms develop 5 and throughout the approximately 7-day viremic period. Infected persons, even those who remain asymptomatic, have concentrations as high as 10 7 viral RNA copies per milliliter of blood. 6,7 During the viremic period, which occurs in symptomatic and asymptomatic infections, DENV can become a blood-borne infection. 8 Cases of dengue after receipt of blood products or donor organs or tissue and after occupational exposure in a health care setting have been reported. 8-10 However, the true incidence of transfusiontransmitted dengue is unknown because there is no surveillance for such events, and if a case is suspected, it is difficult to prove transfusion transmission (vs. vector-borne transmission) in recipients from endemic countries. Nevertheless, transfusion risk models and assessments of viremia prevalence among blood donations indicate the potential for transfusion transmission of DENV in endemic areas. [6][7][8]11,12 Risk is high in endemic areas as most DENV infections are asymptomatic and the viremia is high titered, long lasting, and detec...