Factsheet for health professionals about dengue

Case definition 

Dengue in humans is a notifiable disease at the EU/EEA level. The case definition is according to the Commission Implementing Decision (EU) 2018/945 of 22 June 2018 [6].

The pathogen

Dengue virus, scientifically known as Orthoflavivirus denguei, is a member of the Orthoflavivirus genus within the Flaviviridae family. This pathogen is closely related to other medically significant vector-borne orthoflaviviruses such as yellow fever, Zika, West Nile, and tick-borne encephalitis viruses. There are four phylogenetically and antigenically distinct DENV serotypes (denoted DENV-1–4), which are sufficiently different genetically and antigenically (approximately 65-70% sequence homology at the amino acid level) to elicit distinct immune responses, providing long-term immunity against reinfection with the same serotype, but not with heterologous serotypes [7]. A fifth serotype of DENV has been isolated in Malaysia in 2013, however its epidemiological impact remains unclear [8].

DENV pathogenesis is a complex process, involving the interplay among viral replication in the person infected, host immune responses, and vascular effects. Following mosquito-mediated inoculation, DENV initially replicates in dendritic and Langerhans cells, which subsequently migrate to lymph nodes, facilitating viral dissemination. Primary viraemia results in infection of various organs, particularly the liver and spleen. The innate immune recognition of DENV activates a strong inflammatory response. Moreover, DENV–associated factors, mainly the non-structural protein 1 (NS1), can disrupt the integrity of the endothelial glycocalyx. This together contributes to endothelial dysfunction and vascular hyperpermeability, leading to vascular leakage, which may result in pleural effusions, ascites, hypotension and shock. [9,10]. The adaptive immune response involves both antibody and cell-mediated responses. A key feature in DENV pathogenesis is antibody-dependent enhancement (ADE), which can occur in subsequent dengue infections. ADE is a phenomenon where non-neutralising or sub-neutralising antibodies from a previous infection with a different DENV serotype form DENV-antibody complexes with the new virus. These complexes are then recognized by specific receptors on immune cells that facilitate viral entry into the cell, leading to increased viral uptake and replication. This results in a more severe infection and an exacerbated immune response. Excessive immune activation can lead to a cytokine storm, contributing to increased vascular permeability and plasma leakage [11]. Besides endothelial dysfunction, DENV infection can also lead to thrombocytopenia and liver damage. In secondary dengue infections, ADE and cross-reactive T cells may further amplify the immune response, leading to more severe clinical manifestations, including vascular leakage syndrome and multiple organ dysfunction.

Clinical features and sequelae

Between 50% to 80% of DENV infections are asymptomatic or subclinical [12,13]. These proportions are influenced by various factors, including geographical area (endemic vs. non-endemic), definition used for asymptomatic / subclinical infections, epidemiologic context, immunological status of patients, and types of circulating DENV [14-17]. According to the revised 2009 World Health Organization guidelines, symptomatic dengue is classified as dengue without warning signs, dengue with warning signs, or severe dengue [18]. Around 25-50% of individuals with a dengue infection develop dengue fever without warning signs - an acute febrile illness accompanied by haematological abnormalities such as thrombocytopenia and leukopenia, as well as mild to moderate biochemical disturbances. Symptoms usually begin 4–10 days after infection and last for 2–7 days, characterised by abrupt onset of a high fever (>38.5 °C) that can be accompanied by severe headache, retro-orbital pain, arthralgia, myalgia, nausea, vomiting, lympho-adenopathy, and skin rash and other mucocutaneous manifestations, which appear 3–6 days post-fever onset [13]. About 10% of symptomatic dengue cases may develop warning signs indicating an increased risk of progression to severe disease, including persistent vomiting, severe abdominal pain, mucosal bleeding, lethargy or restlessness, hepatomegaly, and increasing haematocrit. About 2–5% patients with warning signs progress to severe dengue, which can manifest as severe plasma leakage leading to shock (dengue shock syndrome) or respiratory distress, severe haemorrhagic manifestations, and/or severe organ impairment involving the liver (acute liver failure), central nervous system (seizures, encephalitis), and heart (arrhythmias and cardiac impairment). With timely recognition and appropriate supportive care, most patients recover within 1–2 weeks, including many of those who develop complications [19]. The reported case fatality rate for patients with dengue is usually below 1%, but varies considerably by setting, surveillance system, case definition and access to appropriate clinical care [18,20,21]. Severe dengue, particularly dengue shock syndrome, severe bleeding and organ impairment, is associated with a substantially higher risk of death than non-severe dengue [20]. With good clinical management, mortality among severe cases can be reduced substantially, and dengue case fatality can be kept below 0.5% in well-managed settings [22]. Risk of progression to severe disease and mortality are highly variable and affected by factors like age (infancy and old age), underlying comorbidities (diabetes, asthma, hypertension, renal failure), immune status and previous infection with DENV or antigenically related orthoflaviviruses such as Zika virus , the clinical management of the disease, and the infecting DENV serotype and genotype (DENV-4 is generally less associated with disease than other serotypes; risk of severe disease associated with the order of infecting serotypes and the antigenic distance between primary and subsequent dengue infections) [12,13,21,23-27]. 

Epidemiology

DENV was first isolated in 1943 in Japan by researchers studying World War II epidemics [28]. Evidence suggests that DENV originated approximately a millennium ago, initially circulating between non-human primates and mosquitoes. The transition to human hosts is believed to have occurred more recently, likely within the past few centuries, with each of the four virus serotypes making the jump to humans independently [29]. Dengue early history is unclear due to its similarity with other febrile illnesses. It was recognised as a distinct disease in the late 18th century, with mosquito transmission confirmed in the early 20th century, when dengue epidemics were reported in areas from India to the Pacific Islands. During the 18th and 19th centuries, outbreaks occurred in European ports and occasionally inland, with a major outbreak in Greece and Türkiye in 1927–28 affecting over 1 million people [30]. In the latter half of the 20th century, with increased urbanisation and globalisation, DENV transmission followed the spread of its main mosquito vector, Aedes aegypti [29]. Following its first isolation in 1943, DENV-1 accelerated its spread in Asia from the 1950s and in the Americas from the 1970s. DENV-2, first isolated in 1945 in Hawaii, became widespread in Asia by the 1960s and the Americas by the late 1960s/early 1970s. DENV-3 and DENV-4 were both first detected in 1953, with DENV-3 spreading gradually across Asia and later into the Americas from the 1960s onward, while DENV-4 dispersed more slowly but established transmission in the Americas by the 1980s. Over time, increasing co-circulation of multiple DENV serotypes occurred, particularly in Asia and the Americas, signifying greater risk of severe dengue disease [29]. 

Currently, DENV is endemic in over 100 countries worldwide in Africa, the Americas, South and South-east Asia, and the Western Pacific region. The virus annually infects between 50 and 100 million individuals, with approximately half a million individuals hospitalized and 12,500–25,000 deaths. The global incidence has nearly doubled in the last three decades and is expected to continue growing, especially in Asia, sub-Saharan Africa, and Latin America [13]. The geographical range of dengue and the number of infections is expected to further expand in the next decades due to ongoing global phenomena including climate change and urbanization [4].

In Europe, most dengue infections are imported by travellers coming from endemic areas, including from EU outermost regions, like Martinique, Guadeloupe, and Réunion [31]. However, Europe is at risk of introduction and local transmission (i.e. autochthonous) of DENV in areas where competent mosquito vectors are present. Indeed, while the presence of Aedes aegypti, one of the main DENV vectors, is still geographically limited in the surroundings of Europe, being locally established in Cyprus, on the eastern shores of the Black Sea, and in the outermost region of Madeira [32], Ae. albopictus, which is also a competent vector for DENV transmission, is established in a large part of Europe and neighbouring areas [32]. Since 2010, several autochthonous DENV transmission events have been identified in European countries, with an upward trend in number of transmission events and number of cases in outbreaks [5], though changes in numbers show interannual variability.  Specifically, local outbreaks sustained by Ae. albopictus have been reported in France since 2010 [33-37], in Croatia in 2010 [38,39], in Spain since 2018 [40], and in Italy since 2020 [41-45]. Moreover, a large dengue outbreak occurred in Madeira in 2012–2013, where Ae. aegypti was established since 2006. [46].

Dengue is not endemic in Europe. Most reported cases involve individuals who have acquired the infection while traveling abroad. The European Centre for Disease Prevention and Control (ECDC) monitors dengue cases and outbreaks occurrences, as it is classified as a notifiable disease within the European Union. Data on dengue cases are collected through the ECDC EpiPulse Cases platform.

Transmission

DENV primarily affects humans, with some Aedes mosquito species serving as the main vectors, especially Ae. aegypti and Ae. albopictus which can also transmit chikungunya virus, yellow fever virus and Zika virus. During outbreaks, the virus follows a human-mosquito-human cycle, with humans serving as the primary amplifying hosts. Transmission patterns are influenced by factors such as vector density, human behaviour, and environmental conditions.  

There are two DENV transmission cycles: rural-sylvatic and urban, which are separate and involve evolutionary divergent viral strains [47]. The sylvatic cycle of DENV represents the ancestral transmission cycle from which the human transmission cycles emerged. This sylvatic cycle occurs in the forests of Southeast Asia and West Africa, where DENV is maintained between non-human primates, such as macaques and leaf monkeys (acting as a reservoir), and arboreal Aedes mosquitoes, particularly the Ae. niveus group in Asia and Ae. furcifer in Africa. In these areas in Asia and Africa, humans may encounter sylvatic DENV strains, which can cause isolated infections or transient spillover in urban settings [47]. The urban cycle is the most relevant from the public health perspective in Europe, and occurs in heavily anthropised areas, characterised by a mosquito-human infection cycle, and is primarily sustained by Ae. aegypti [48]. This mosquito lives in proximity to populated areas and uses stagnant water deposits to lay eggs. Ae. albopictus can also serve as a vector in areas where it is prevalent and is the most important DENV vector in EU/EEA, in the case of local transmission events. Transmission to humans by both vectors occurs mainly in domestic contexts adjacent to these deposits, preferably after dawn and before sunset. 

The primary mode of DENV transmission is through the bite of infected Aedes mosquitoes. The intrinsic incubation period for dengue, i.e. the time between the infective mosquito bite and the onset of symptoms in humans ranges from 3 to 14 days, with an average of 4–7 days [49]. Humans become infectious shortly before the onset of symptoms and remain so for approximately 4–5 days [50]. During this period, the virus can be transmitted to female mosquitoes that feed on the individual with the infection. Research on patients with a DENV infection shows that their ability to transmit the virus to Ae. aegypti mosquitoes depends on the amount and duration of virus in their blood (viraemia), as well as their antibody response. To infect half of exposed mosquitoes, a blood meal needs at least 10⁶–10⁷ DENV RNA copies/mL, which is about 1000-fold lower than the peak viral load in acute dengue patients [51,52]. Severe DENV cases typically have higher viral loads than mild or asymptomatic cases. However, at the same viral load, symptomatic patients are less infectious to mosquitoes than asymptomatic or pre-symptomatic individuals, likely due to a stronger immune response [50]. In infected mosquitoes, the virus spreads through the midgut to other tissues over 5–12 days, eventually reaching the salivary glands (this is called ‘extrinsic incubation period’). This process is affected by temperature, viral strain, and mosquito type. Once the salivary glands are infected, the mosquito can transmit the virus to humans for the rest of its life. Infected female mosquitoes may also pass the virus to their offspring through eggs, although the epidemiological impact of transovarial transmission might be limited [53]. This mechanism potentially allows the virus to persist in mosquito populations during unfavourable conditions (for example, during winter in Europe) and could contribute to initiating new outbreaks or maintaining the virus during inter-epidemic periods. The efficiency of transovarial transmission varies depending on factors such as dengue serotype and mosquito species [54].  

Other less common modes of human-to-human transmission of DENV include transmission through substances of human origin (SoHO), in particular through blood transfusion, stem cell transplantation, and organ transplantation [55-57]. It is not clear what viraemia levels are needed for DENV transmission via transfusion or transplantation. Studies among blood donors in endemic countries indicate that donations with viraemia levels above 10⁴ viral RNA copies/mL are potentially infectious [58-60]. Importantly, asymptomatic individuals can have viraemia levels sufficiently high to transmit DENV through SoHO, with viraemia potentially lasting up to two weeks after infection [58,61]. Despite the possibility for asymptomatic donors to transmit DENV, the rate of transmission through transfusion of blood components from donors with DENV remains uncertain as the number of reported transfusion cases is very low, including in high incidence areas. However, a study retrospectively testing samples collected during a large DENV-4 epidemic in Brazil, estimated that approximately one-third of DENV RNA-positive components resulted in transfusion-transmission [60]. Hypotheses for this low number of reported cases in endemic areas include undetected and unreported transmission events, which could be associated with misdiagnosis due to non-specific symptoms in recipients, mild disease manifestations in individuals infected through non-vectorial routes, presence of protective immunity in recipients in endemic areas, and co-transfusion of antibody-positive units neutralising the infectivity of viraemic donations [58,60,62]. Transmission of DENV from donors through solid organ transplantation have been reported in liver, kidney, and hearth transplant recipients. Transmission through kidney transplantation appears to be the most frequent [57,63]. Transmission through stem cell transplantation is very rare, but has been reported in Germany, from a donor returning from Sri Lanka a few days before the apheresis. The donor was symptomatic on the day of the donation, but the transplantation could not be postponed due to the urgent need for the recipient [56].  

While rare, other suspected routes of DENV transmission have been documented, such as sexual transmission [64-66], needlestick injuries in healthcare settings [67-70], and laboratory-acquired infections [71,72]. The risk of transmission from mother to child is low, and most infants born to mothers with DENV do not acquire the infection.

Symptomatic or severe DENV infections during pregnancy have been associated with increased risk of miscarriage, foetal death, still death and other complications. However, most dengue infections do not result in adverse pregnancy outcomes, and the overall risk for any individual pregnancy remains low [73-76].

Diagnostics 

The laboratory diagnosis of DENV infection relies on direct detection of the virus, its components, or the host's specific antibody response. The choice of diagnostic method depends on the timing of sample collection relative to symptom onset and the clinical context. 

In the acute phase of infection, typically within the first week of symptom onset, direct detection methods are most effective. These include molecular tests, such as real-time RT-PCR for the detection of viral RNA, antigen detection tests and virus isolation in cell culture. 

The primary clinical sample for direct diagnosis of DENV infection is blood (whole blood, plasma, or serum). Other biological samples, such as urine and saliva, can support the detection of the virus or viral RNA [41], advantages being that their collection is non-invasive, and they may stay positive in later stages of disease. DENV RNA has also been detected in cerebrospinal fluid (CSF) [77,78] and in genital fluids (semen and vaginal fluid) [77,79-81]. Molecular tests offer high sensitivity and specificity, with the added advantage of distinguishing between DENV serotypes [77,78]. However, they require specialised equipment and expertise, which may limit their availability in resource-constrained settings.

Antigen detection tests, particularly those targeting the NS1 protein, provide a rapid and accessible alternative for early diagnosis. While generally less sensitive than molecular tests, NS1 antigen tests are valuable in field settings or low-resource areas. However, their performance may be reduced in subsequent dengue infections, where pre-existing cross-reactive antibodies can bind to NS1 antigen, limiting its detection and increasing the likelihood of false-negative results. [82].

Virus isolation, once considered the gold standard, is now less commonly used due to its time-consuming nature and the requirement for specialised biosafety facilities (because DENV is classified in the EU as a risk group 3 pathogen). However, it remains valuable for research purposes and surveillance activities [80].

As the infection progresses, serological tests become increasingly important. IgM antibodies are typically detectable from 3-5 days after symptom onset, while IgG antibodies appear a few days later. In primary infections, IgM levels peak around two weeks post-onset of symptoms and persist for several months, while IgG remains detectable indefinitely. The antibody response pattern differs in subsequent dengue infections, with a rapid increase in IgG titres and lower or undetectable IgM levels [83].

A significant challenge in serological diagnosis is the cross-reactivity of antibodies with other orthoflaviviruses. This is particularly problematic in areas where multiple orthoflaviviruses co-circulate or in patients with previous orthoflavivirus infections or vaccinations. To address this, neutralisation tests are recommended to confirm positive serological results and minimise the risk of false positives. These tests evaluate the ability of antibodies to inhibit viral infection in vitro and should be performed simultaneously against DENV and other relevant orthoflaviviruses [41].

Each diagnostic approach has limitations. Molecular and antigen tests are most useful in the early stages of infection but may yield false-negative results later or in secondary infections. Serological tests can be affected by cross-reactivity and may not distinguish between current and past infections, especially in areas with high orthoflavivirus circulation. Although neutralisation tests improve specificity, their interpretation can remain challenging in individuals with pre-existing immunity due to cross-reactive neutralising antibodies. This is because these tests may show significant neutralising activity against more than one virus, making it difficult to determine if DENV is the one causing the current infection.[84,85].

For comprehensive diagnosis, especially in complex cases or for surveillance purposes, a combination of direct and indirect methods may be necessary. The choice of test should consider the patient's clinical presentation, time since symptom onset, travel history, previous orthoflavivirus vaccinations or infections, and the local epidemiological context. Healthcare providers and public health authorities should be aware of these factors when interpreting test results and making clinical or public health decisions [86].

In recent years, metagenomics next generation sequencing has become increasingly common and represents valuable support for diagnosis and surveillance; however, it is not suitable as a first-line diagnostic test due to the complexity of analysis and required resources.

In the EU DENV is classified as a risk group 3 pathogen in terms of Biosafety Level (BSL) [87]. In routine diagnostic practice DENV-infected samples should be handled in a Biosafety Level 2 (BSL-2) laboratory at minimum. Some procedures may require BSL-3 practices, especially those involving high concentrations of virus or potential for aerosol generation, such as virus isolation in cell culture and neutralisation tests. 

For more detailed technical information on DENV laboratory diagnostics, readers are referred to comprehensive guidelines such as those provided by the World Health Organization [88].

Case management and treatment 

For dengue patients, there are no effective antiviral drugs, so treatment remains supportive [13]. The WHO recommends a stepwise approach based on the presence of warning signs. Patients without warning signs can be managed as outpatients with advice on fever control, hydration, rest, and monitoring for deterioration. Those with warning signs or comorbidities require hospitalisation and IV fluid therapy to manage plasma leakage. Severe cases with shock, haemorrhage, or organ impairment need emergency treatment with aggressive fluid resuscitation and management of complications. Judicious fluid replacement is lifesaving but must be carefully monitored to avoid overload. Prophylactic platelet transfusion is not recommended. In areas where competent Aedes mosquitos are present, patients should also be advised to avoid mosquito bites during the viraemic phase (e.g. by using repellents, bed nets, or staying in screened or air-conditioned environments) to reduce the risk of onward transmission.

Public health prevention and control measures (for the authorities)

The prevention of dengue primarily focuses on an integrated vector management approach and risk communication.

Integrated vector management aims to achieve sustainable reduction of mosquito population density where Ae. albopictus and/or Ae. aegypti are established, or to achieve local elimination of introduced mosquito populations to prevent establishment. This multifaceted strategy combines environmental management, biological control, chemical interventions, and community engagement tailored to local contexts [89,90]. Effective implementation requires intersectoral collaboration and robust public communication strategies to actively engage communities.

European regions with established Aedes albopictus and/or Ae. aegypti populations warrant environmental management strategies, including public awareness campaigns and community-based clean-up initiatives to reduce container habitats [91]. During the virus transmission season, early case detection is essential to limit the risk of onward transmission by implementing adult and larval mosquito control, while vector surveillance monitors for competent species introduction in non-endemic areas [89,90]. During outbreaks, intensified efforts may involve adult mosquito control through targeted indoor residual spraying, space spraying/fogging, and aerial insecticide application, albeit with environmental caveats. Larval control intensifies with increased larviciding and container inspections/treatments in high-risk areas. 

Chemical control methods using biocides are recommended as part of an integrated vector management approach against Aedes aegypti and Aedes albopictus mosquitoes in Europe [89]. Larvicides, specifically insect growth regulators like pyriproxyfen, should be applied to breeding sites. For adult mosquito control, space spraying or residual treatments with pyrethroid adulticides such as deltamethrin can be used, but only in cases of high mosquito population levels posing epidemic risk or during outbreaks. Biological larvicides containing Bacillus thuringiensis israelensis (Bti) and Lysinibacillus sphaericus (Lsph) are important components of integrated mosquito control, with Bti having been successfully implemented across many European countries by treating catch basins and other larval habitats.

Novel techniques like the sterile insect technique (SIT) and Wolbachia-based approaches show potential but require further evaluation. SIT involves area-wide releases of (irradiated) sterile male mosquitoes to suppress wild populations by rendering eggs infertile. While pilot studies in some EU countries demonstrated significant reductions in egg densities in some areas [92,93], results were inconsistent. The use of the bacteria Wolbachia to reduce mosquito vector competence and populations through cytoplasmic incompatibility is still experimental, with uncertainties around its effectiveness and sustainability. Notably, a cluster-randomised trial in Indonesia which found that releases of Aedes aegypti mosquitoes infected with the wMel strain of Wolbachia pipientis were effective in reducing the incidence of symptomatic dengue virus infection by 77.1% and dengue-related hospitalisations by 86.2% compared to control clusters [94]. 

In the EU/EEA, dengue prevention also relies on reducing the risk of virus importation and onward transmission through targeted risk communication. This should address both residents in areas where competent Aedes vectors are established and travellers to dengue-endemic areas. Key messages should include timely information on dengue risks in affected areas, the importance of personal protective measures to avoid mosquito bites during travel, and the need for continued protection from mosquito bites of returning travellers for three weeks after return to avoid potential virus transmission in areas where competent vectors are present.

Infection control, personal protection and prevention

General protective measures

The prevention of DENV infection primarily focuses on minimising exposure to Aedes vector mosquitoes. These mosquitoes exhibit diurnal biting patterns in both indoor and outdoor settings, necessitating continuous protective measures throughout the day, with heightened vigilance during peak mosquito activity periods (morning and late afternoon to twilight). Personal protection measures include the use of screened or air-conditioned accommodations, wearing of protective clothing that covers most of the body, and the application of mosquito repellents.

Infection control measures in health care settings

In healthcare settings, universal infection control precautions should be maintained for all patients, including the use of appropriate personal protective equipment. In addition, maintaining clean environments to prevent mosquito breeding and using screens on windows is also important. Education for healthcare workers should include training on transmission, prevention, and management of dengue and other Aedes-borne diseases, the proper use of personal protective equipment and infection control protocols.

Prevention of dengue virus transmission through substances of human origin (SoHO)

Current recommendations for preventive measure of DENV transmission through SoHO in the EU are primarily based on guidelines from national health authorities. These recommendations usually include the deferral of donors returning from a DENV-endemic area. There are few recommendations currently available for donors returning from DENV-affected areas in the EU/EEA [95,96]. The 22nd edition of the Guide to the preparation, use and quality assurance of blood components published by the European Directorate for the Quality of Medicines & HealthCare provides recommendations for dengue for the council of Europe Member States [97]. These include the deferral for 28 days of donors returning from regions endemic for dengue and the deferral of donors suffering from dengue for 120 days after resolution of the symptoms. 

Vaccines

There is currently only one dengue vaccine available and approved by the European Medicines Agency (EMA) for use in the European Union: Qdenga, developed by Takeda GmbH. Routine vaccination against dengue is not currently recommended by any EU/EEA country. Individuals planning travel to dengue endemic areas or areas with high risk of dengue transmission can discuss dengue vaccination with a travel medicine specialist.

Qdenga (TAK-003), was authorised by the EMA for use in the EU on December 5, 2022, and is indicated for dengue prevention in individuals aged four years and older. Qdenga is a live attenuated vaccine that covers all four dengue serotypes. It utilises an attenuated DENV-2 (DEN2-PDK-53) as a backbone, into which chimeric viruses containing pre-membrane M and envelope proteins from DENV-1, DENV-3, and DENV-4 are inserted. Qdenga includes non-structural proteins due to its DENV2-backbone, which is a key distinguishing feature. Qdenga follows a two-dose schedule with a three-month interval between doses. As a live attenuated vaccine, it cannot be administered to individuals who have weakened immune systems due to disease, medication or HIV infection, nor to pregnant or breastfeeding women. Vaccine efficacy has been demonstrated in children, adolescents and adults living in dengue endemic areas [98,99]. WHO recommends the use of Qdenga in children aged 6–16 years in settings with high DENV transmission intensity. In addition, WHO recommends that countries consider introducing Qdenga into their routine immunisation programmes in geographical locations where high transmission intensity of DENV poses a significant public health problem. Until the efficacy–risk profile for DENV3 and DENV4 in seronegative persons has been more thoroughly assessed, WHO does not recommend the programmatic use of Qdenga vaccine in low to moderate DENV transmission settings [100]. 

Advice to travellers 

Disclaimer: Travel health physicians and travellers should always first consult national travel guidelines and recommendations as the primary source of information. 

Travellers to dengue endemic regions or countries should consult travel health professionals or clinics before their trip for up-to-date advice, including whether dengue vaccination is advised. During their stay, travellers should avoid mosquito exposure during daytime when Aedes mosquitoes are most active. Use of insect repellents, wearing long clothing that covers most of the body, and staying in well-screened or air-conditioned accommodations are recommended. Travellers should continue protective measures for at least two weeks after returning, irrespective of symptoms, to account for the virus incubation period. Seeking prompt medical care if dengue symptoms such as fever, rash, or muscle and joint pain develop is crucial. In EU/EEA countries reporting local DENV transmission, similar preventive measures are advised for residents in affected areas.

References

1. Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature. 2013 Apr 25;496(7446):504-7. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23563266
2. Nakase T, Giovanetti M, Obolski U, Lourenço J. Population at risk of dengue virus transmission has increased due to coupled climate factors and population growth. Communications Earth & Environment. 2024 2024/08/30;5(1):475. Available at: https://doi.org/10.1038/s43247-024-01639-6
3. Lambrechts L, Scott TW, Gubler DJ. Consequences of the expanding global distribution of Aedes albopictus for dengue virus transmission. PLoS Negl Trop Dis. 2010 May 25;4(5):e646. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20520794
4. Messina JP, Brady OJ, Golding N, Kraemer MUG, Wint GRW, Ray SE, et al. The current and future global distribution and population at risk of dengue. Nat Microbiol. 2019 Sep;4(9):1508-15. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31182801
5. Cattaneo P, Salvador E, Manica M, Barzon L, Castilletti C, Di Gennaro F, et al. Transmission of autochthonous Aedes-borne arboviruses and related public health challenges in Europe 2007-2023: a systematic review and secondary analysis. Lancet Reg Health Eur. 2025 Apr;51:101231. Available at: https://www.ncbi.nlm.nih.gov/pubmed/40213502
6. European Union. Document 32018D0945. Commission Implementing Decision (EU) 2018/945 of 22 June 2018 on the communicable diseases and related special health issues to be covered by epidemiological surveillance as well as relevant case definitions (Text with EEA relevance). . 2018. Available at: http://data.europa.eu/eli/dec_impl/2018/945/oj  
7. Holmes EC, Twiddy SS. The origin, emergence and evolutionary genetics of dengue virus. Infect Genet Evol. 2003 May;3(1):19-28. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12797969
8. Mustafa MS, Rasotgi V, Jain S, Gupta V. Discovery of fifth serotype of dengue virus (DENV-5): A new public health dilemma in dengue control. Med J Armed Forces India. 2015 Jan;71(1):67-70. 
9. Wang C, Puerta-Guardo H, Biering SB, Glasner DR, Tran EB, Patana M, et al. Endocytosis of flavivirus NS1 is required for NS1-mediated endothelial hyperpermeability and is abolished by a single N-glycosylation site mutation. PLoS Pathog. 2019 Jul;15(7):e1007938. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31356638
10. Malavige GN, Ogg GS. Molecular mechanisms in the pathogenesis of dengue infections. Trends in Molecular Medicine. 2024;30(5):484-98. Available at: https://doi.org/10.1016/j.molmed.2024.03.006
11. Sarker A, Dhama N, Gupta RD. Dengue virus neutralizing antibody: a review of targets, cross-reactivity, and antibody-dependent enhancement. Front Immunol. 2023;14:1200195. 
12. Salje H, Cummings DAT, Rodriguez-Barraquer I, Katzelnick LC, Lessler J, Klungthong C, et al. Reconstruction of antibody dynamics and infection histories to evaluate dengue risk. Nature. 2018 May;557(7707):719-23. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29795354
13. Paz-Bailey G, Adams LE, Deen J, Anderson KB, Katzelnick LC. Dengue. Lancet. 2024 Feb 17;403(10427):667-82. Available at: https://www.ncbi.nlm.nih.gov/pubmed/38280388
14. Wang T, Wang M, Shu B, Chen XQ, Luo L, Wang JY, et al. Evaluation of inapparent dengue infections during an outbreak in Southern China. PLoS Negl Trop Dis. 2015 Mar;9(3):e0003677. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25826297
15. Asish PR, Dasgupta S, Rachel G, Bagepally BS, Girish Kumar CP. Global prevalence of asymptomatic dengue infections - a systematic review and meta-analysis. Int J Infect Dis. 2023 Sep;134:292-8. Available at: https://www.ncbi.nlm.nih.gov/pubmed/37463631
16. Rovida F, Faccini M, Molina Grane C, Cassaniti I, Senatore S, Rossetti E, et al. The 2023 dengue outbreak in Lombardy, Italy: A one-health perspective. Travel Med Infect Dis. 2025 Mar-Apr;64:102795. Available at: https://www.ncbi.nlm.nih.gov/pubmed/39755224
17. De Santis O, Bouscaren N, Flahault A. Asymptomatic dengue infection rate: A systematic literature review. Heliyon. 2023 Sep;9(9):e20069. Available at: https://www.ncbi.nlm.nih.gov/pubmed/37809992
18. World Health Organization. Dengue: guidelines for diagnosis, treatment, prevention and control - New edition. . 2009. Available at: https://iris.who.int/bitstream/handle/10665/44188/9789241547871_eng.pdf?sequence=1
19. Wilder-Smith A, Ooi EE, Horstick O, Wills B. Dengue. Lancet. 2019 Jan 26;393(10169):350-63. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30696575
20. Chagas GCL, Rangel AR, Noronha LM, Veloso FCS, Kassar SB, Oliveira MJC, et al. Risk factors for mortality in patients with dengue: A systematic review and meta-analysis. Trop Med Int Health. 2022 Aug;27(8):656-68. Available at: https://www.ncbi.nlm.nih.gov/pubmed/35761748
21. Asaduzzaman M, Khan EA, Hasan MN, Rahman M, Ashrafi SAA, Haque F, et al. The 2023 dengue fatality in Bangladesh: Spatial and demographic insights. IJID Reg. 2025 Jun;15:100654. Available at: https://www.ncbi.nlm.nih.gov/pubmed/40469930
22. Lam PK, Tam DT, Diet TV, Tam CT, Tien NT, Kieu NT, et al. Clinical characteristics of Dengue shock syndrome in Vietnamese children: a 10-year prospective study in a single hospital. Clin Infect Dis. 2013 Dec;57(11):1577-86. 
23. Alexander N, Balmaseda A, Coelho IC, Dimaano E, Hien TT, Hung NT, et al. Multicentre prospective study on dengue classification in four South-east Asian and three Latin American countries. Trop Med Int Health. 2011 Aug;16(8):936-48. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21624014
24. Halstead S, Wilder-Smith A. Severe dengue in travellers: pathogenesis, risk and clinical management. J Travel Med. 2019 Oct 14;26(7) Available at: https://www.ncbi.nlm.nih.gov/pubmed/31423536
25. Katzelnick LC, Narvaez C, Arguello S, Lopez Mercado B, Collado D, Ampie O, et al. Zika virus infection enhances future risk of severe dengue disease. Science. 2020 Aug 28;369(6507):1123-8. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32855339
26. Wang L, Huang AT, Katzelnick LC, Lefrancq N, Escoto AC, Duret L, et al. Antigenic distance between primary and secondary dengue infections correlates with disease risk. Sci Transl Med. 2024 Apr 24;16(744):eadk3259. Available at: https://www.ncbi.nlm.nih.gov/pubmed/38657027
27. Kandel S, Dahal G, Das CL, Thapa S, Karna AK, Parajuli A, et al. Retrospective analysis of dengue-related fatalities in Nepal, 2022. PLOS Glob Public Health. 2025;5(6):e0004694. Available at: https://www.ncbi.nlm.nih.gov/pubmed/40455708 
28. Hotta S. Experimental studies on dengue. I. Isolation, identification and modification of the virus. J Infect Dis. 1952 Jan-Feb;90(1):1-9. Available at: https://www.ncbi.nlm.nih.gov/pubmed/14888958
29. Messina JP, Brady OJ, Scott TW, Zou C, Pigott DM, Duda KA, et al. Global spread of dengue virus types: mapping the 70 year history. Trends Microbiol. 2014 Mar;22(3):138-46. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24468533
30. Schaffner F, Mathis A. Dengue and dengue vectors in the WHO European region: past, present, and scenarios for the future. Lancet Infect Dis. 2014 Dec;14(12):1271-80. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25172160
31. European Centre for Disease Prevention and Control. Dengue contracted during travel: likely places of infection reported by travellers to the EU/EEA. Available at: https://www.ecdc.europa.eu/en/dengue/surveillance/dengue-virus-infections-travellers
32. European Centre for Disease Prevention and Control. Distribution maps of invasive mosquitoes. Stockholm: ECDC; 2026. Available at: https://www.ecdc.europa.eu/en/disease-vectors/surveillance-and-disease-data/invasive-mosquito-maps
33. La Ruche G, Souares Y, Armengaud A, Peloux-Petiot F, Delaunay P, Despres P, et al. First two autochthonous dengue virus infections in metropolitan France, September 2010. Euro Surveill. 2010 Sep 30;15(39):19676. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20929659
34. Marchand E, Prat C, Jeannin C, Lafont E, Bergmann T, Flusin O, et al. Autochthonous case of dengue in France, October 2013. Euro Surveill. 2013 Dec 12;18(50):20661. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24342514
35. Succo T, Noel H, Nikolay B, Maquart M, Cochet A, Leparc-Goffart I, et al. Dengue serosurvey after a 2-month long outbreak in Nimes, France, 2015: was there more than met the eye? Euro Surveill. 2018 Jun;23(23) Available at: https://www.ncbi.nlm.nih.gov/pubmed/29897042
36. Cochet A, Calba C, Jourdain F, Grard G, Durand GA, Guinard A, et al. Autochthonous dengue in mainland France, 2022: geographical extension and incidence increase. Euro Surveill. 2022 Nov;27(44) Available at: https://www.ncbi.nlm.nih.gov/pubmed/36330819
37.  Zatta M, Brichler S, Vindrios W, Melica G, Gallien S. Autochthonous Dengue Outbreak, Paris Region, France, September-October 2023. Emerg Infect Dis. 2023 Dec;29(12):2538-40. Available at: https://www.ncbi.nlm.nih.gov/pubmed/37967048
38. Schmidt-Chanasit J, Haditsch M, Schoneberg I, Gunther S, Stark K, Frank C. Dengue virus infection in a traveller returning from Croatia to Germany. Euro Surveill. 2010 Oct 7;15(40) Available at: https://www.ncbi.nlm.nih.gov/pubmed/20946759
39. Gjenero-Margan I, Aleraj B, Krajcar D, Lesnikar V, Klobucar A, Pem-Novosel I, et al. Autochthonous dengue fever in Croatia, August-September 2010. Euro Surveill. 2011 Mar 3;16(9) Available at: https://www.ncbi.nlm.nih.gov/pubmed/21392489
40. Monge S, Garcia-Ortuzar V, Lopez Hernandez B, Lopaz Perez MA, Delacour-Estrella S, Sanchez-Seco MP, et al. Characterization of the first autochthonous dengue outbreak in Spain (August-September 2018). Acta Trop. 2020 May;205:105402. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32088276
41. Barzon L, Gobbi F, Capelli G, Montarsi F, Martini S, Riccetti S, et al. Autochthonous dengue outbreak in Italy 2020: clinical, virological and entomological findings. J Travel Med. 2021 Dec 29;28(8) Available at: https://www.ncbi.nlm.nih.gov/pubmed/34409443
42. Cassaniti I, Ferrari G, Senatore S, Rossetti E, Defilippo F, Maffeo M, et al. Preliminary results on an autochthonous dengue outbreak in Lombardy Region, Italy, August 2023. Euro Surveill. 2023 Sep;28(37) Available at: https://www.ncbi.nlm.nih.gov/pubmed/37707980
43. De Carli G, Carletti F, Spaziante M, Gruber CEM, Rueca M, Spezia PG, et al. Outbreaks of autochthonous Dengue in Lazio region, Italy, August to September 2023: preliminary investigation. Euro Surveill. 2023 Nov;28(44) Available at: https://www.ncbi.nlm.nih.gov/pubmed/37917030
44. Sacco C, Liverani A, Venturi G, Gavaudan S, Riccardo F, Salvoni G, et al. Autochthonous dengue outbreak in Marche Region, Central Italy, August to October 2024. Euro Surveill. 2024 Nov;29(47) Available at: https://www.ncbi.nlm.nih.gov/pubmed/39574388
45. Santilli L, Canovari B, Balducci M, Corbelli G, Maracci M, Polenta A, et al. Outbreak of autochthonous dengue in Fano, Pesaro-Urbino Province - Marche region, Italy, September 2024. Infection. 2025 Jun;53(3):1213-8. Available at: https://www.ncbi.nlm.nih.gov/pubmed/39883264
46. Wilder-Smith A, Quam M, Sessions O, Rocklov J, Liu-Helmersson J, Franco L, et al. The 2012 dengue outbreak in Madeira: exploring the origins. Euro Surveill. 2014 Feb 27;19(8):20718. Available at: https://www.ncbi.nlm.nih.gov/pubmed/24602277
47. Vasilakis N, Cardosa J, Hanley KA, Holmes EC, Weaver SC. Fever from the forest: prospects for the continued emergence of sylvatic dengue virus and its impact on public health. Nat Rev Microbiol. 2011 Jun 13;9(7):532-41. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21666708
48. Gubler DJ. Dengue, Urbanization and Globalization: The Unholy Trinity of the 21(st) Century. Trop Med Health. 2011 Dec;39(4 Suppl):3-11. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22500131
49. Guzman MG, Gubler DJ, Izquierdo A, Martinez E, Halstead SB. Dengue infection. Nat Rev Dis Primers. 2016 Aug 18;2:16055. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27534439
50. Duong V, Lambrechts L, Paul RE, Ly S, Lay RS, Long KC, et al. Asymptomatic humans transmit dengue virus to mosquitoes. Proc Natl Acad Sci U S A. 2015 Nov 24;112(47):14688-93. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26553981
51. Nguyen NM, Thi Hue Kien D, Tuan TV, Quyen NTH, Tran CNB, Vo Thi L, et al. Host and viral features of human dengue cases shape the population of infected and infectious <i>Aedes aegypti</i> mosquitoes. Proceedings of the National Academy of Sciences. 2013;110(22):9072-7. Available at: https://www.pnas.org/doi/abs/10.1073/pnas.1303395110
52. Martina BE, Barzon L, Pijlman GP, de la Fuente J, Rizzoli A, Wammes LJ, et al. Human to human transmission of arthropod-borne pathogens. Curr Opin Virol. 2017 Feb;22:13-21. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27915056
53. Grunnill M, Boots M. How Important is Vertical Transmission of Dengue Viruses by Mosquitoes (Diptera: Culicidae)? J Med Entomol. 2016 Jan;53(1):1-19. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26545718
54. Thongrungkiat S, Maneekan P, Wasinpiyamongkol L, Prummongkol S. Prospective field study of transovarial dengue-virus transmission by two different forms of Aedes aegypti in an urban area of Bangkok, Thailand. J Vector Ecol. 2011 Jun;36(1):147-52. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21635652
55. Giménez-Richarte Á, Ortiz de Salazar MI, Giménez-Richarte M-P, Collado M, Fernández PL, Clavijo C, et al. Transfusion-transmitted arboviruses: Update and systematic review. PLOS Neglected Tropical Diseases. 2022;16(10):e0010843. Available at: https://doi.org/10.1371/journal.pntd.0010843
56. Punzel M, Korukluoğlu G, Caglayik DY, Menemenlioglu D, Bozdag SC, Tekgündüz E, et al. Dengue virus transmission by blood stem cell donor after travel to Sri Lanka; Germany, 2013. Emerg Infect Dis. 2014 Aug;20(8):1366-9. 
57. Gajurel K, Dhakal R, Deresinski S. Arbovirus in Solid Organ Transplants: A Narrative Review of the Literature. Viruses. 2024;16(11):1778. Available at: https://www.mdpi.com/1999-4915/16/11/1778
58. Stramer SL, Linnen JM, Carrick JM, Foster GA, Krysztof DE, Zou S, et al. Dengue viremia in blood donors identified by RNA and detection of dengue transfusion transmission during the 2007 dengue outbreak in Puerto Rico. Transfusion. 2012 Aug;52(8):1657-66. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22339201
59. Levi JE, Nishiya A, Felix AC, Salles NA, Sampaio LR, Hangai F, et al. Real-time symptomatic case of transfusion-transmitted dengue. Transfusion. 2015 May;55(5):961-4. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25605570
60. Sabino EC, Loureiro P, Lopes ME, Capuani L, McClure C, Chowdhury D, et al. Transfusion-Transmitted Dengue and Associated Clinical Symptoms During the 2012 Epidemic in Brazil. J Infect Dis. 2016 Mar 1;213(5):694-702. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26908780
61. Linnen JM, Vinelli E, Sabino EC, Tobler LH, Hyland C, Lee TH, et al. Dengue viremia in blood donors from Honduras, Brazil, and Australia. Transfusion. 2008 Jul;48(7):1355-62. Available at: https://www.ncbi.nlm.nih.gov/pubmed/18503610
62. Almeida FJ, Pacheco JT, Farias CGA, de Matos SF, de Morais CO, Guerra GG, et al. Dengue: a hidden threat in blood transfusions amidst Brazil's largest outbreak? Lancet Infect Dis. 2025 Jan;25(1):e10. Available at: https://www.ncbi.nlm.nih.gov/pubmed/39622264
63. Cedano JA, Mora BL, Parra-Lara LG, Manzano-Nunez R, Rosso F. A scoping review of transmission of dengue virus from donors to recipients after solid organ transplantation. Trans R Soc Trop Med Hyg. 2019 Aug 1;113(8):431-6. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31034049
64. Lee C, Lee H. Probable female to male sexual transmission of dengue virus infection. Infect Dis (Lond). 2019 Feb;51(2):150-2. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30318968
65. Liew CH. The first case of sexual transmission of dengue in Spain. J Travel Med. 2020 Feb 3;27(1) Available at: https://www.ncbi.nlm.nih.gov/pubmed/31776571
66. Grobusch MP, van der Fluit KS, Stijnis C, De Pijper CA, Hanscheid T, Gautret P, et al. Can dengue virus be sexually transmitted? Travel Med Infect Dis. 2020 Nov-Dec;38:101753. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32473313
67. Langgartner J, Audebert F, Scholmerich J, Gluck T. Dengue virus infection transmitted by needle stick injury. J Infect. 2002 May;44(4):269-70. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12099738
68. Wagner D, de With K, Huzly D, Hufert F, Weidmann M, Breisinger S, et al. Nosocomial acquisition of dengue. Emerg Infect Dis. 2004 Oct;10(10):1872-3. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15504282
69. Lee C, Jang EJ, Kwon D, Choi H, Park JW, Bae GR. Laboratory-acquired dengue virus infection by needlestick injury: a case report, South Korea, 2014. Ann Occup Environ Med. 2016;28:16. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27057314
70. Nemes Z, Kiss G, Madarassi EP, Peterfi Z, Ferenczi E, Bakonyi T, et al. Nosocomial transmission of dengue. Emerg Infect Dis. 2004 Oct;10(10):1880-1. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15515246
71. Britton S, van den Hurk AF, Simmons RJ, Pyke AT, Northill JA, McCarthy J, et al. Laboratory-acquired dengue virus infection--a case report. PLoS Negl Trop Dis. 2011 Nov;5(11):e1324. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22140587
72. Sharp TM, Fisher TG, Long K, Coulson G, Medina FA, Herzig C, et al. Laboratory-Acquired Dengue Virus Infection, United States, 2018. Emerg Infect Dis. 2020 Jul;26(7):1534-7. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32568040
73. U E, Sivakumar T, Krithika C, Sridhar C, Hercules A. A Systematic Review and Meta-Analysis of Maternal Dengue Infection and Adverse Pregnancy Outcomes. Cureus. 2025 Nov;17(11):e96888. 
74. Vélez Jaramillo Y, Reveiz Montes MA, Galván-Barrios JP, Picón-Jaimes YA. Maternal and foetal outcomes in women with gestational Dengue: A systematic review. Infez Med. 2025;33(1):15-28. 
75. Zavattoni M, Rovida F, Campanini G, Percivalle E, Sarasini A, Cristini G, et al. Miscarriage following dengue virus 3 infection in the first six weeks of pregnancy of a dengue virus-naive traveller returning from Bali to Italy, April 2016. Euro Surveill. 2016 Aug 4;21(31) Available at: https://www.ncbi.nlm.nih.gov/pubmed/27526349
76. Paixao ES, Costa M, Teixeira MG, Harron K, de Almeida MF, Barreto ML, et al. Symptomatic dengue infection during pregnancy and the risk of stillbirth in Brazil, 2006-12: a matched case-control study. Lancet Infect Dis. 2017 Sep;17(9):957-64. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28845800
77. Milhim B, da Rocha LC, Terzian ACB, Mazaro CCP, Augusto MT, Luchs A, et al. Arboviral Infections in Neurological Disorders in Hospitalized Patients in Sao Jose do Rio Preto, Sao Paulo, Brazil. Viruses. 2022 Jul 7;14(7) Available at: https://www.ncbi.nlm.nih.gov/pubmed/35891468
78. Leng X, Yang H, Zhao L, Feng J, Jin K, Liao L, et al. Dengue encephalopathy in an adult due to dengue virus type 1 infection. BMC Infect Dis. 2024 Mar 15;24(1):319. Available at: https://www.ncbi.nlm.nih.gov/pubmed/38491361
79. Iannetta M, Lalle E, Musso M, Carletti F, Scorzolini L, D'Abramo A, et al. Persistent detection of dengue virus RNA in vaginal secretion of a woman returning from Sri Lanka to Italy, April 2017. Euro Surveill. 2017 Aug 24;22(34) Available at: https://www.ncbi.nlm.nih.gov/pubmed/28857045
80. Matusali G, Manica M, D'Abramo A, Carletti F, Maffongelli G, Colavita F, et al. Dengue Virus Dynamic and Persistence in Body Fluids of Infected Patients in Italy, 2018-2023. J Med Virol. 2025 Apr;97(4):e70322. Available at: https://www.ncbi.nlm.nih.gov/pubmed/40145293
81. Mons J, Mahe-Poiron D, Mansuy JM, Lheureux H, Nigon D, Moinard N, et al. Effects of Acute Dengue Infection on Sperm and Virus Clearance in Body Fluids of Men. Emerg Infect Dis. 2022 Jun;28(6):1146-53. Available at: https://www.ncbi.nlm.nih.gov/pubmed/35608553
82. Ngwe Tun MM, Kapandji M, Wada A, Yamamoto K, Dumre SP, Nwe KM, et al. Performance of Fujifilm Dengue NS1 Antigen Rapid Diagnosis Kit Compared to Quantitative Real-Time Polymerase Chain Reaction. Pathogens. 2024 Sep 23;13(9) Available at: https://www.ncbi.nlm.nih.gov/pubmed/39339009
83. de Oliveira CM, Takahashi FY, Silva RS, Soika M, Ribeiro JN, Francisco GL, et al. Evaluation of the performance of a dengue NS1 assay during the 2024 epidemic in Brazil. J Virol Methods. 2025 Jun;335:115143. Available at: https://www.ncbi.nlm.nih.gov/pubmed/40054739
84. Charrel RN. Diagnosis of arboviral infections--A quagmire of cross reactions and complexities. Travel Med Infect Dis. 2016 Jan-Feb;14(1):11-2. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26869533
85. Montoya M, Collins M, Dejnirattisai W, Katzelnick LC, Puerta-Guardo H, Jadi R, et al. Longitudinal Analysis of Antibody Cross-neutralization Following Zika Virus and Dengue Virus Infection in Asia and the Americas. J Infect Dis. 2018 Jul 13;218(4):536-45. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29618091
86. Macedo JVL, Frias IAM, Oliveira MDL, Zanghelini F, Andrade CAS. A systematic review and meta-analysis on the accuracy of rapid immunochromatographic tests for dengue diagnosis. Eur J Clin Microbiol Infect Dis. 2022 Sep;41(9):1191-201. Available at: https://www.ncbi.nlm.nih.gov/pubmed/35988010
87. Commission Directive (EU) 2019/1833 of 24 October 2019 amending Annexes I, III, V and VI to Directive 2000/54/EC of the European Parliament and of the Council as regards purely technical adjustments, (2019).
88. World Health Organization. Laboratory testing for dengue virus: interim guidance, April 2025. 2025. Available at: https://doi.org/10.2471/B09394
89. European Centre for Disease Prevention and Control. Vector control with a focus on Aedes aegypti and Aedes albopictus mosquitoes: literature review and analysis of information. 2017. Available at: https://www.ecdc.europa.eu/sites/default/files/documents/Vector-control-Aedes-aegypti-Aedes-albopictus.pdf
90. European Centre for Disease Prevention and Control. Organisation of vector surveillance and control in Europe. Available at: https://www.ecdc.europa.eu/sites/default/files/documents/Organisation-vector-surveillance-control-Europe_0.pdf
91. Bellini R, Michaelakis A, Petric D, Schaffner F, Alten B, Angelini P, et al. Practical management plan for invasive mosquito species in Europe: I. Asian tiger mosquito (Aedes albopictus). Travel Med Infect Dis. 2020 May-Jun;35:101691. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32334085
92. Bellini R, Carrieri M, Balestrino F, Puggioli A, Malfacini M, Bouyer J. Field Competitiveness of Aedes albopictus (Diptera: Culicidae) Irradiated Males in Pilot Sterile Insect Technique Trials in Northern Italy. J Med Entomol. 2021 Mar 12;58(2):807-13. Available at: https://www.ncbi.nlm.nih.gov/pubmed/33179753
93. Balatsos G, Karras V, Puggioli A, Balestrino F, Bellini R, Papachristos DP, et al. Sterile Insect Technique (SIT) field trial targeting the suppression of Aedes albopictus in Greece. Parasite. 2024;31:17. Available at: https://www.ncbi.nlm.nih.gov/pubmed/38530210
94. Utarini A, Indriani C, Ahmad RA, Tantowijoyo W, Arguni E, Ansari MR, et al. Efficacy of Wolbachia-Infected Mosquito Deployments for the Control of Dengue. N Engl J Med. 2021 Jun 10;384(23):2177-86. Available at: https://www.ncbi.nlm.nih.gov/pubmed/34107180
95. European Centre for Disease Prevention and Control. Repository of Policy and Practice Resources.: European Centre for Disease Prevention and Control,; 2025.
96. European Centre for Disease Prevention and Control. Deferral criteria and testing strategies for dengue virus in blood donors returning from affected areas. Stockholm: 2025 
97. European Directorate for the Quality of Medicines & HealthCare of the Council of Europe (EDQM). The Guide to the preparation, use and quality assurance of blood components 22nd edition. Strasbourg: EDQM; 2025.
98. Tricou V, Yu D, Reynales H, Biswal S, Saez-Llorens X, Sirivichayakul C, et al. Long-term efficacy and safety of a tetravalent dengue vaccine (TAK-003): 4.5-year results from a phase 3, randomised, double-blind, placebo-controlled trial. Lancet Glob Health. 2024 Feb;12(2):e257-e70. Available at: https://www.ncbi.nlm.nih.gov/pubmed/38245116
99. Borja-Tabora C, Fernando L, Lopez Medina E, Reynales H, Rivera L, Saez-Llorens X, et al. Immunogenicity, Safety, and Efficacy of a Tetravalent Dengue Vaccine in Children and Adolescents: An Analysis by Age Group. Clin Infect Dis. 2025 Feb 5;80(1):199-206. Available at: https://www.ncbi.nlm.nih.gov/pubmed/38995684
100. World Health Organization. WHO position paper on dengue vaccines – May 2024. Weekly epidemiological record, 2024. 2024. Available at: https://iris.who.int/bitstream/handle/10665/376641/WER9918-eng-fre.pdf?sequence=1 .