History of Early Dengue Research before 1950Narrative

(Prepare by !" #uno$ %epte&ber 1'$ (009)

*nfor&ation about the slies+
For many of you, presentation of historic events in seminar may be refreshingly different,
since today we are too often accustomed to attending seminars or lectures where only
recent, original research data are presented.
This presentation is definitely not designed to burden the audience to digest new data or
difficult concepts. This set of slides was prepared in a story-telling (show-and-tell) style.
All slides are simple, self-explanatory or self-evident. ou can relax and !ust watch
slides.
"bviously, the ma!or casualty of such a style of presentation is any sub!ect that re#uires
presentation of highly complicated data, which, by necessity, re#uires a far lengthy
explanation. "ften, these sub!ects are more scientifically important. $nfortunately, they
are unsuitable for the types of simple presentation this set of slides was designed for and,
therefore, excluded as much as possible because of limited time allotted. %espite the
exclusion, this set of slides was prepared to cover practically all sub!ects of ma!or
importance in the early history of dengue research.
This set of slides may be presented in multiple lectures or seminars, by selecting specific
topics per presentation. &f presented without any modification, the set has a sufficient
information for as many as ' presentations, assuming one hour-meeting consisting of '(
minutes tal) followed by *( minutes of discussion. For some slides, this narrative is too
long, because a lot of bac)ground information is provided. For these slides, spea)ers can
cut short and tal) briefly only the essentials, reserving the rest of the bac)ground
information for discussion.
+ower+oint slides provide spea)ers a tremendous flexibility. ,pea)ers can modify
according to their taste or emphasis by reorgani-ing, revising and.or by inserting another
slides of choice, as they wish. Time constraint is another factor for consideration for
modifications of narrative or selection of topics.
The source references or materials used in this set are all in public domain/ and one does
not need to be concerned about copyright issues. 0owever, regardless of how spea)ers
modify the slides, please ma)e sure that the correct sources are shown clearly on the
slides, if the materials were originally produced by someone other than the spea)ers.
1early all sources identified in the narrative only by author and year are found in the
following publications2 (*) 3uno, 4. A bibliographic database on dengue. $.,. %ept.
0ealth and 0uman ,ervices, ,an 5uan, +uerto 6ico/ *778/ (9) 3uno, 4. :lin. ;icrobiol.
6ev. 992*<=/ 9>>7. For others, full texts of most dengue references cited in the slides are
obtained from the online library at http2..www.afpmb.org.
*
,1- .itle"
:urrently, dengue is un#uestionably the number one vector-borne arbovirus in terms of
the morbidity and mortality, magnitude of global public health problem, amount of
funding for research, number of publication per annum or of the researchers, the
complexity of unraveling the pathogenesis of severe syndromes, and of the uni#ue
difficulty of developing effective vaccines.
%espite the enormous importance of dengue today, however, compared with the early
history of yellow fever research, which is widely )nown not only by the contemporary
researchers but in general public because of abundantly available boo)s and other easily
available documents, the early history of dengue research is poorly understood even
among active dengue researchers today.
,(- Early engue investigation in the shao/ of yello/ fever research"
As most virologists )now well, historically, yellow fever research preceded dengue
investigation.
Although both F and dengue are transmitted in urban areas by the same vector, Aedes
aegypti, there are interesting contrasts that explain why dengue research evolved in the
shadow of yellow fever research.
The history of yellow fever outbrea)s in ?urope and 1orth America has been well
documented for more than a few centuries ever since the contact with tropical countries
by the people in the temperate climate began. @ecause F has captured the interest of
people with its devastating socio-medical-economic impacts, the enormously fascinating
and dramatic events including tragic deaths during F investigations in :uba and Aest
Africa, and ma!or scientific accomplishments not only during the Aalter 6eed
:ommission investigation in :uba at the turn of the 9>
th
century but also thereafter
leading up to the development of an effective F vaccine in *78B by ;ax Theiler, so
many boo)s have been published, and the whole history of F has been immortali-ed in
medical history ever since.
?ven those not in microbiological professions publish boo)s about something related to
the history even today. @ecause of its popularity, some of the legendary figures in F
history were featured in commemorative stamps issued in several countries/ and
0ollywood made a movie, ellow 5ac), which was followed by a @roadway adaptation
and TC dramati-ation.
@ut, for dengue history similarly rich in fascinating events and important discoveries
made in the tropics, no single boo) has ever been published, as far as & remember. 1o
commemorative stamp has ever been issued, and of course, no 0ollywood movie has
been released. %o those dengue researchers deserve such a neglectD
,0- Re&iner"
&n this presentation, except for a small number of laboratory-confirmed outbrea)s,
EdengueF refers to either true dengue or Edengue-li)e illnessF, because in the early
9
history, no reliable laboratory confirmation techni#ue by todayGs standard was available.
As & mention later, diagnosis based on clinical manifestation has been a topic of
controversy.
The period covered in this presentation primarily (but not exclusively) falls between
*<7> and *7(>.
,1- *&portant events+ 1293492"
1ow, & must turn the cloc) bac) to the *<7>s. This last decade of the *7
th
century turned
out to be extremely important for us, arbovirologists, for several reasons. &mportant
scientific discoveries were reported in this decade, in particular between *<7B and *<7<.
First, it was discovered by Hoeffler and Frosch in *<7< that foot and mouth disease was
caused by a new infectious disease entity, or Efilterable agent IJvirusK.F 6emember,
*<7>s was still in the golden age of bacteriology, and non-bacterial infectious agents as
causes of animal diseases was an anomalous, new concept that was not readily accepted
by most microbiologists then.
,econd, 6onald 6oss discovered malaria transmission by mos#uitoes. That followed the
early discovery of filarial transmission by mos#uitoes by +atric) ;anson in the *<B>s in
Asia. These discoveries firmly established that some of human diseases could be carried
by arthropods.
Third, the fortuitous discovery of extrinsic incubation period by 0enry 6ose :arter in
*<7< during his )een observation of F outbrea) in ;ississippi provided a crucial
information which :arlos Finlay in :uba did not have to complete his otherwise near
complete theory on mos#uito-borne transmission of F.
Fourth, ,anarelliGs controversial bacterial etiology of F disturbed medical communities
and stimulated physicians and microbiologists to pay a more serious attention to the
etiology of F.
Fifth, the huge dengue outbrea)s in 4alveston and 0ouston in *<7B reminded medical
communities in the $, that there were a lot more infectious disease problems to be
concerned besides F.
Then, on top of these events, an important political event too) placeL,panish-American
Aar of *<7<. Aith this war, $nited ,tates had to confront for the first time with a host of
unfamiliar tropical diseases (with the only exception of F) prevalent in the former
,panish territories . &t should be clearly understood that, at that time, $, was far behind
the ?uropean colonial powers in terms of medical research on tropical diseases, because
$,, unli)e several ma!or ?uropean countries with a long history of coloni-ation and
hence medical experience to deal with tropical diseases, did not have a coloni-ed territory
in the tropics until that time.
,5- !eorge 5iller %ternberg"
8
As a result of this war, $, ac#uired former ,panish territories in the tropics. This
necessitated the country to deal with unfamiliar tropical diseases. The responsibility fell
on the shoulder of then surgeon general, 4eorge ,ternberg. 0e was an accomplished
bacteriologist and has been called the father of American bacteriology.
,'- 6"%" &ilitary7s t/o sites of tropical isease investigation"
The $, military established two investigative boards (or commissions) of tropical disease
investigation, one in 0avana to deal exclusively with yellow fever and the other in
;anila of the +hilippines to deal with a variety of diseases, in particular malaria, plague,
and dengue. @oth sites are shown in orange dots on the map.
,3- 8alter Ree"
The man chosen to lead the investigation of F in 0avana was none other than Aalter
6eed. @ecause he is such a legendary figure, & guess many in the audience )now #uite
well who he is and what he did. $sually, in a gathering of 9>-(> microbiologists, always
there are a few individuals deeply )nowledgeable about his F investigation. ,o, & do not
need to elaborate at all.
0ere, it suffices to introduce !ust two individuals during the Aalter 6eed :ommission era
(*7>>-*7>*) to ma)e a connection between F and dengue research histories.
,2- 9lara 5aass"
:lara ;aass was the head nurse at the 4erman 0ospital in 1ewar), 1ew 5ersey. Ahen
the ,panish-American Aar bro)e out, military was ill prepared to deal with wounded or
sic) soldiers. ,o, it recruited volunteer nurses and physicians. ,he was one of many
contract nurses hired. ,he first served in a few military camps in the $, and was then
shipped to ,antiago, :uba. @ecause F was very prevalent at that time, she must have
attended soldiers sic) of F there.
0owever, the duration of the Aar was unexpectedly brief, and she was discharged. Then,
she volunteered in the military service again. This time, the $, military shipped her to
;anila. There, she cared for malaria and dengue patients, among others. @ut, after
several months, she contracted dengue herself. Aorried about her health, military #uic)ly
sent her home.

$ndaunted, she volunteered again. This time, she received a telegram from Ailliam
4orgas, then chief sanitation officer in 0avana during the Aalter 6eed :ommission
investigation, to report to duty immediately. ,o, she set sail to 0avana and began to care
for the F patients at that historically famous Has Animas 0ospital. @y mid-*7>*, much
of the :ommission studies were completed and many members of the :ommission
returned home. 0owever, some, including 5ames :arroll and others, stayed to carry on
supplemental human experiments. ,he was one of the volunteers in one of those human
experiments so-called 4orgas-4uiteras experiment for devising an immuni-ation protocol
based on attenuation. ,he was exposed to blood-engorged mos#uitoes several times but
did not develop illness. ,o, the physicians thought she was somehow immune to F.
'
They were dead-wrong. &n her last exposure to mos#uito bite in August, *7>*, she
developed a full-blown F and died *> days later. ,he was only 9(.
The uproar that followed in the aftermath of her tragic death put an end to all human
experiments for the F investigation by the $, military. Anybody who lived in northern
1ew 5ersey may still remember :lara ;aass ;edical :enter established in honor of her
dedication.
,9- 9harles :ran;lin 9raig"
?verybody who attended annual meeting of the American ,ociety of Tropical ;edicine
and 0ygiene probably heard :harles Fran)lin :raig lectures given by distinguished
spea)ers chosen. :raig was one of the pillars of American tropical medicine, speciali-ing
in parasitic diseases. 0owever, & guess, that few people )now the fact that he had a brief
career in F and dengue research. 0e was hired as a contract surgeon by the military
during the Aalter 6eed :ommission period. 0e, li)e :lara ;aass, served in a few
military bases in the $, before he was sent to 0avana and assigned to the :olumbia
@arrac) where Aalter 6eed began his historic investigation. Although & never found any
documents about :raigGs activities there during this period, he must have been assigned
to do something about care of F patients, because that was the only business there and
because his biography clearly records his presence in that @arrac) at that time. A few
years later, he enlisted formally in the military and was sent to ;anila. There, in *7>=->B,
teamed up with +ercy Ashburn, he determined for the first time that the etiologic agent of
dengue was also virus.
,10- <ector4borne trans&ission of hu&an iseases"
The biological transmission, the very basis of all human experiments in dengue
investigation in early history was made possible because of earlier contributions by
;anson, 6oss, Finlay, :arter, and 6eed. Aithout the )nowledge accumulated by those
pioneers, dengue experiments could not have been possible. ,ome of those who made
great contributions are shown in the following slides more or less chronologically.
,11- Patric; 5anson"
0e is regarded the father of tropical medicine. 0is discovery of filarial transmission by
mos#uitoes was a historic discovery. Ahen he was in Miamen, :hina, in *<B9, a dengue
outbrea) occurred. 0is clinical definition of dengue was based on his observation in that
outbrea).
,1(- Ronal Ross"
& already mentioned the importance of his discovery of malaria transmission by
mos#uitoes. Although he received 1obel +ri-e, one of the crucial observations he made
was based on an invaluable suggestion by +atric) ;anson.
,10- 9arlos =uan :inlay"
1ot much introduction is necessary, since his contribution in F investigation is
legendary. 0is theory was almost complete, except that he lac)ed one piece of crucial
(
information, extrinsic incubation period. @ecause of the lac) of this )nowledge, all his
attempts to transmit F with mos#uitoes failed.
,11- Henry Rose 9arter"
%uring an F outbrea) in ;ississippi in *<7<, he assigned an assistant to meticulously
record occurrence of F cases in households in the context of family relation and of
location. The record convinced 0enry :arter to deduce that a period ranging from several
days to as long as 8 wee)s elapsed between the first cluster of cases and the next cluster
of cases. This is what is )nown now as Eextrinsic incubation period re#uired for virus to
replicate sufficiently in mos#uitoes, optimi-ing them to be infective upon bite on
susceptible humans. Adoptation of his fortuitous discovery to complete the hypothesis of
:arlos Finlay was crucial to the success of the Aalter 6eed :ommission studies in
0avana.
,15- Etiologic investigation regaring trans&ission &echanis& of engue"
At the turn of the 9>
th
century, the guiding principle in etiologic investigation was 3ochGs
postulates. For that reason, dengue investigators tried to isolate a putative dengue agent
from patients, propagate it in suitable animal hosts or in humans, re-inoculate the samples
from these inoculated animals or humans bac) to normal humans, to reproduce the
dengue syndrome. @ecause use of humans was always dangerous, researchers loo)ed for
alternative animals for model, but in vain. The need to strictly adhere to the 3ochGs
postulates probably was one of a few reasons why they did not loo) for dengue virus in
mos#uitoes during outbrea)s as a source of dengue agent and relied only on humans for
the source of virus as well as for transmission experiment. This is also due to the fact that
the role of mos#uitoes in dengue transmission was poorly understood in the early history
of dengue research. Thus, one had to wait until *7(< when dengue viruses were isolated
from wild mos#uitoes during a hemorrhagic dengue outbrea) in ;anila by Ailliam
0ammon.
,1'- E>peri&ental esign for engue trans&ission stuies"
&n the early period of dengue transmission studies, li)e in yellow fever investigation,
initially human experiment was the basic approach/ but with a growing )nowledge of the
role of mos#uito vectors, the importance of mos#uito in transmission experiments rose.
Then, to conduct human experiments in dengue endemic locations, first, investigators
needed to decide which )ind of infectious samples they could (or would li)e to) use. The
first )ind was blood sample of acutely-ill patient. 0opefully, the patient at the time of
blood sampling was viremic. 0owever, at that time, investigators did not )now well
about the correct timing of viremia period, because it was un)nown and had to be
determined in human experiments. ,electing a proper location for human experiment was
also an inseparable issue.
@y selecting fresh blood, researchers had to set up a laboratory right in the endemic area
in the tropics. @ut, that compromised the validity of the experiment, because there was no
guarantee that the volunteers of human experiments were free of dengue or not exposed
to infective mos#uitoes prior to human experiments, given abundance of vector
mos#uitoes everywhere. For this reason, investigators chose to build a laboratory made
=
mos#uito-proof. @esides, they had to design isolation rooms in the laboratory to observe
volunteers in isolation for a period, to ensure total absence of dengue-exposure of the
volunteers prior to experimentation. All this cost a lot of money. This is why very few
groups, such as $, Army in ;anila, could conduct such experiments in the endemic
locations.
All other groups of investigators chose the second )ind of infectious materials2 blood-
engorged mos#uitoes. To prepare them, first they needed to have a colony of mos#uitoes.
Then, when they found new dengue patients, they visited clinics or houses carrying cages
of mos#uitoes. &f patients consented, they let mos#uitoes feed on patients until
mos#uitoes were fully-engorged. 0opefully, those mos#uitoes ac#uired virus/ and the
virus would be )ept infectious in mos#uitoes until human experiments. The ma!or
advantage of this approach is that researchers gained mobility. They could carry cages of
engorged mos#uitoes to dengue-free locations far away and safely conduct human
experiments there. Thus, 4raham of @eirut too) cages to high altitude in the nearby
mountain (where mos#uitoes were few and dengue was not )nown to exist) to conduct
experiments. :leland of Australia prepared caged mos#uitoes during outbrea)s in
Nueensland, boarded a train and moved south to dengue-free ,ydney, where he could
safely conduct human experiments. "ne of the most unusual attempts was done by
,ni!ders, a %utch physician in &ndonesia. 0e shipped from ,umatra to Amsterdam many
cages of not only blood-engorged mos#uitoes but normal mos#uitoes on board ships
sailing to Amsterdam. %uring the long !ourney lasting nearly 8 wee)s, on-board
physicians nourished mos#uitoes with cotton swabs soa)ed in sugar solution.
6emar)ably, most mos#uitoes arrived healthy at the destination, and human experiments
were conducted successfully in Amsterdam.
,13- %pecial consierations in hu&an e>peri&ent"
1ow, let me spend a few minutes tal)ing about the essentials of human experiments in
early part of the 9>
th
century for both F and dengue investigations. 0ere, we find sharp
contrasts.
%uring the 0avana experiments, after the tragic death of 5esse Ha-ear, Aalter 6eed was
pressured to draft an &nformed :onsent form. &t is emphasi-ed that this was the first time
in the history of experimental medicine anywhere in the world informed consent form
was prepared for volunteers. Furthermore, in the F investigation in 0avana, each
volunteer was offered a reward of O*>>/ and if a volunteer developed F as a result, he
was offered additional O*>> for compensation. &n contrast, in ;anila, for dengue
investigation no consent form was prepared and the reward was far smaller (only 9( local
pesos.volunteer). This contrast clearly reflected the prevalent perception of F as deadly
illness versus as non-fatal nuisance for dengue.
&n terms of the number of volunteers, the cumulative total in dengue investigations by
nearly 9 do-en groups in several countries is far greater than the total for F
investigations in :uba, Aest Africa, :entral America, and ,outh America combined.
,till, in early days, recruiting volunteers for dengue experiment was not easy due to
strong fear in general public. ,abin ran out of volunteers in :incinnati and moved his
B
experiment to 1ew 5ersey because of more available (and willing) volunteers at the ,tate
+enitentiary. @oth Ashburn.:raig in ;anila and :leland in ,ydney could not complete all
planned experiments due to shortage of volunteers despite monetary incentive. ,imilarly,
in 5apanese experiments, physicians, nurses, and interns were the volunteers in hospitals/
while professors, medical students, friends, and family members were volunteers in
medical schools. Thus, when 0otta isolated dengue virus for the first time in history
during the AA&&, because of acute shortage of laboratory mice necessary for virus
passage, his mother volunteered to )eep the virus infectious.
,12- Early investigators of engue trans&ission &echanis&"
,everal investigators deserve mention for their valuable contributions to unravel the
mechanism when much was poorly )nown about vector-borne transmission. Although &
emphasi-e only biological transmission experiments, actually, many investigators at that
time conducted experiments for direct transmission. :learly, their interest reflected
similar experiments focusing on fomites during F investigations earlier in 0avana.
,ome of dengue investigators reported successful intranasal or corneal transmission by
physical contact with infectious material and even recorded very brief discharge of
infectious agent in urine. ,)in scarification was another method utili-ed to induce dengue
infection. The ma!or ob!ective of those direct transmission studies was to determine if
they were the principal mechanisms by which dengue was transmitted. A small number of
physicians were, however, interested in evaluating direct methods of transmission for
non-invasive vaccination.
,19- Harris !raha&"
0e was a physician in @eirut. 0e conducted biological transmission experiment using
volunteers and mos#uitoes in *7>9 in the mountain in Hebanon. Although his experiment
is historically important for its first attempt for dengue using mos#uitoes, his use of
Culex mos#uitoes and his conclusion of Plasmodium-li)e organism found in blood as
etiologic agent of dengue were both e#uivocal. :learly, he was too much influenced by
6onald 6ossG discovery of malarial parasite (Plasmodium) only a few years earlier.
,(0- ?risties ?gra&onte an =uan !uiteras"
These scientists of :uban descent played important roles as members of the Aalter 6eed
:ommission. After the F studies were terminated in 0avana, these two scientists shifted
their attention to dengue which caused occasional outbrea)s there. Apparently, they were
influenced by the *7>8 report of 4raham. They used the wrong mos#uitoes, Culex
fatigans and obtained pu--ling results. 1aturally, they had trouble drawing a meaningful
conclusion.
,(1- .ho&as @" Aancroft"
0e was a physician in Nueensland, Australia. &n *7>=, he determined that the true vector
of dengue was Ae. aegypti (which was not the name used at that time). $nfortunately,
Tom is not )nown as well as his father. Anybody who too) a parasitology course may still
remember the well-)nown filarial worm, Wuchereria bancrofti, which was named after
his famous father, 5oseph @ancroft.
<
,((- Percy 5" ?shburn"
0e and :raig determined in ;anila in *7>B that the agent of dengue was also filterable
(Jvirus). $nfortunately, there were problems in their experiments. Their use of Culex
mos#uitoes was inappropriate/ and the extrinsic incubation period they observed was too
short. They also had an additional problem of recruiting volunteers, which made repeat
testing impossible.
,(0- 5a;oto #oiBu&i"
0e was a physician in Taipei, Taiwan. @y the time he conducted experiments in *7*B, he
had read the publication of Tom @ancroft which reported Ae. aegypti as vector of dengue.
0owever, in his environment in northern Taiwan there was no Ae. aegypti. Accordingly,
he used several local species of mos#uitoes for experiments and proved that Ae.
albopictus was a good vector of dengue agent. 0e also studied the direct transmission,
intrinsic incubation period, and minimum dose for infection.
,(1- Aurton 9lelan"
0e was a physician in ,ydney, Australia. As & mentioned earlier, around *7*=-*7, he
obtained blood-engorged mos#uitoes during repeated dengue outbrea)s in Nueensland,
boarded train carrying mos#uito cages, moved south, and conducted human experiments
in ,ydney. 0is numerous experiments were described in a *9>-page long !ournal article.
0e also tried to attenuate dengue agent for vaccine preparation, although he was
unsuccessful.
,(5- =oseph %iler"
0e was assigned by the $, military to the ;anila laboratory in *79'. IThis photograph
was actually ta)en in France during his previous assignment for typhoid fever.K @asically,
he conducted very comprehensive and very sound studies in *79'-9( and repeated nearly
everything other groups had conducted earlier. 0is groupGs meticulous !ournal publication
is ama-ingly more than '<>-page long. 1o such a long manuscript is accepted today in
regular !ournals.
,('- =a&es %i&&ons"
0e succeeded ,iler at the $, laboratory in ;anila in *797. %uring the following 9 years,
he conducted more or less the same types of experiments as ,ilerGs. 0e confirmed that
Ae. albopictus was a good vector of dengue. 0e was also involved in vaccine
development. Hi)e ,iler, ,immonsG publication is more than '(>-page long.
,(3- E&ilius Paulus %niCers"
0e was the %utch physician in &ndonesia who & mentioned earlier regarding the story of
mos#uito cage shipment to Amsterdam.
,(2- Hu&an e>peri&ent in ?&stera&"
This is an oil painting commemorating the successful conclusion of the dengue human
experiments in Amsterdam. ,ni!ders is shown to the extreme right. Hoo)ing at this slide,
you may also reali-e that the value of dengue scientists is better appreciated in some
7
countries, such as the 1etherlands, because you rarely find oil painting of dengue
scientists hanging in local museums even in dengue-endemic countries.
,(9- <irus isolation"
Cirus isolation too) place during the Aorld Aar && on both sides of the military conflict in
Asia and the +acific. "n each side, isolation was attempted not only in the battle field but
at home.
,00- %usu&u Hotta"
"n the 5apanese side, when soldiers came down with dengue in large numbers as in the
+hilippines, 1ew 4uinea, ,ingapore, ;alaysia, &ndonesia, and @urma, 5apanese military
physicians tried to isolate virus. &n @urma, physicians inoculated blood samples of the
sic) soldiers with dengue syndrome into chic) embryos and shipped the eggs to their
laboratories in 5apan via military aircraft. At that time, almost nobody )new if dengue
agent would grow in chic) embryos. 0owever, short time earlier, it was reported by a
@ritish physician in &ndia that dengue agent could grow in chic) embryos. 5apanese
military groups claimed that they could isolate more than a do-en of strains of dengue
agents/ but, retrospectively, it is most li)ely that they did not isolate the authentic dengue
viruses, because dengue viruses do not readily replicate in chic) embryos, unless they
were first adapted to other more susceptible vertebrate cell cultures.
The true dengue virus isolation too) place in *7'8 in 1agasa)i, during a summer
outbrea) caused by imported cases. There, ,usumu 0otta isolated %?1C-* in suc)ling
mice, using the blood sample from a woman patient named ;ochi-u)i. This was the first
dengue virus isolated in the world. "ther 5apanese institutions, mostly medical schools,
also claimed to have isolated strains of dengue pathogen in a few cities, including
1agasa)i. The total number of so-called Edengue isolatesF exceeded more than 8>, as far
as published records reveal.
This is a picture of 0otta. 0e did not live in 1agasa)i when he isolated dengue virus. 0e
traveled '>> miles every summer from 3yoto to spend much of summer in 1agasa)i to
investigate the exotic disease.
,01- 5rs" 5ochiBu;i"
This is a photograph of ;rs. ;ochi-u)i from whose blood 0otta isolated the virus for the
first time. The virus strain has been )nown as E;ochi-u)i strainF of %?1C-*. Although
medical ethics today prohibits, in the early part of history, using the patientGs name for
strain designation was a very common practice in microbiology. IThis photograph was
published by 0otta with the full consent of the son of late ;rs. ;ochi-u)iK
,ometimes, in medical history, medical EfirstF or ElastF has some historic significance.
For example, you may remember the face of ;r. Asibi, the source of Asibi strain of FC,
the first isolated yellow fever virus. "r, you may remember the last victim of smallpox at
the end of the A0"Gs successful eradication campaign. +erhaps, ;rs. ;ochi-u)iGs
photograph may have a similar value.

*>
,0(- ?lbert A" %abin"
"n the side of Allied Forces, the man in charge of virus isolation was Albert ,abin. First,
he isolated %?1C-* strain in 0awaii during the *7'' outbrea). 0e further isolated more
strains from the blood samples sent from 1ew 4uinea. @ecause the bac)ground story of
1ew 4uinea isolates is interesting, let me spend a few minutes to tell you the episode.
%uring the heavy fighting in the !ungle of 1ew 4uinea, many Allied Forces soldiers
came down with dengue. +hysicians drew blood samples and put them in an improvised
!ug stuffed with wet ice and shipped the !ug by a military aircraft. The !ug was shipped
across the +acific with numerous stops, often changing plane. At each stop, the !ug was
replenished with fresh wet ice, until the !ug was safely in American soil. Thereafter, the
specimens were pac)ed with dry ice and shipped to ,abin in :incinnati. The whole
!ourney too) B.( days, and virus isolation was attempted more than '> days later.
Fortunately, ' strains were successfully isolated. Anybody who wor)ed with dengue virus
never forgets 1ew 4uinea E:F strain, the prototype of %?1C-9.
This is a picture of ,abin at his youth. %uring the AA&&, 0otta did not )now that
someone in the $, side was competing with him for dengue virus isolation. "n the other
hand, ,abin did )now something about 5apanese dengue research, because the $,
military intelligence units, through interrogation of 5apanese +"As, most li)ely
including military physicians, learned about dengue research in 5apan and routinely
passed the information to ,abin.
,00- Hotta4%abin reunion"
,o, within 9 months after the end of the AA&&, ,abin flew into 5apan to gather
information, collect blood samples, and arrange shipment of isolated dengue strains to his
laboratory. This is not the picture ta)en in *7'(, because no picture of that occasion is
available. & substituted instead with one of the pictures ta)en on his later visits for a
reunion with 0otta that too) place in *7=*. ou see that ,abin, center, did age, since he
now sports silvery hair. 0otta is shown to the right.
,01- 9ornelius Aec;er Philip"
The fellow who coordinated this trans-+acific shipment of blood samples from 1ew
4uinea was :ornelius +hilip. 0e happened to be in 1ew 4uinea for scrub typhus control
for the $.,. military during the AA&&. @efore his heroic achievement for dengue, he had
done another valuable contribution in F investigation in west Africa. Ahen 6oc)efeller
group isolated Asibi strain for the first time in *79B, +hilip was already there as member
of the team. Aithin 9 years, using the Asibi strain, he established firmly that, besides Ae.
aegypti, Ae. africanus and Ae. simpsoni were the vectors of F in Africa.
,05- @aboratory4ientifie engue serotypes"
The serotypes of dengue virus strains identified in this period are shown in this slide.
,0'- %erologically4ientifie serotypes"
Archival blood specimens were retrospectively tested serologically when neutrali-ation
test was developed later. As shown in this slide, %?1C-' was identified earliest.
**
Although %?1C-8 was not isolated or serologically identified, there was a strong
possibility of the existence of all ' serotypes in this period. This speculation was based on
a small number of carefully-studied reports of individuals who experienced multiple
dengue infections. &nterestingly, in those cases, the maximum number of multiple
infections per person in endemic locations, such as +hilippines and &ndonesia, was '.
,03- 9linical efinition of Dengue"E
The early history of dengue is rich in controversies over the clinical definition of
Edengue.F ,ome of the sources of variation of clinical manifestation are shown in the
slide. ,ome physicians strongly speculated that EdengueF was actually a collection of
multiple etiologies all sharing the same set of symptoms and signs.
Ahile many definitions were based on observations during natural outbrea)s, others were
the observations reported in human experiments. @ecause all volunteers in human
experiments were adults, the symptoms more prevalent in children could have been
missed in those definitions. &t should be also stressed that in those human experiments,
the performers of the experiments )new nothing about infectious dose used, serotype,
immunological status of the volunteers, and others. 1aturally, variation in clinical
manifestation among experiments could be partly attributed to those un)nown factors.
Also, it should be noted that as early as in *79<, @lanc, et al. clearly recogni-ed
asymptomatic infection in dengue.
,02- ?typical sy&pto&s"
&n old textboo)s of medicine, dengue was invariably characteri-ed as non-fatal, febrile
illness which was considered a mere nuisance. As a result, when patients died during
dengue outbrea), very often, the causes of death were attributed to something other than
dengue. After *7(>s and even today, it is not uncommon to find a EstandardF statement
that serious syndromes (dengue hemorrhagic fever I%0FK and dengue shoc) syndrome
I%,,K) began to emerge only after *7(> in southeast Asia.
Are they both trueD
0emorrhagic manifestations, such as epistaxis, petechiae, and menorrhagia were very
common in the early history, but even then they are considered less serious. 0owever, in
these patients experiencing extensive hematemesis or other gastrointestinal bleeding (as
manifested in extensive melena) sometimes bradycardia developed, leading to a state of
EcollapseF, EsomnolenceF or Ecoma.F These developments ultimately resulted in death. &n
critically-ill children, sei-ure often developed. Although the word Eshoc)F was not used
in this period, depending on the conditions in terminal phase, such a word as Etyphoid-
li)e syndromeF was used, among some physicians. Although it is unclear what that
meant, it is possible that it actually meant a condition similar to septic shoc) in bacterial
infection.
,09- :"E" Hare"
%r. 0are, then in Nueensland, Australia, is credited to be the first physician to document
in *<7B many cases of severe dengue syndrome most compatible with %0F, as we )now
*9
today. &n this photograph, he is seated at extreme left in the front row. After his invaluable
contributions in Nueensland, he could not secure funding for his wor) and unfortunately
had to return to $3, where he operated a sanatorium.
,10- *nvestigation of vascular per&eability changes in early ays"
As hemorrhagic cases increased in fre#uency, some physicians applied tourni#uet test,
then )nown as 6umpell-Heede test. Alternatively, @orbelyGs test was performed by
applying negative pressure on the s)in. ,ome physicians established a correlation
between increase in vascular permeability, thrombocytopenia, and development of
hemorrhagic manifestation by monitoring the volunteers inoculated with Edengue agentF
(blood of acutely-ill dengue patient).
,11- Histologic stuies an ato&ic bo&b"
Ahen fatal cases occurred, sometimes autopsy was conducted. Abnormalities in
cardiovascular system were reported. Also, histologic slides were prepared, as it occurred
in 1agasa)i, 5apan during the AA&&. Then, atomic bomb dropped over 1agasa)i. Three
professors of the ,chool of ;edicine of 1agasa)i $niversity investigating fatal dengue
cases died instantly, and the slides perished. 0ad the slides survived the blast, they could
have provided interesting materials for a comparative study with the samples obtained
during %0F outbrea)s in the +hilippines and Thailand in the *7(>s.
0otta was supposed to be in 1agasa)i in the summer of *7'(. @ut, because of heavy
bombing raids that destroyed railway trac)s severely, all train services were suspended
indefinitely. ,o, 0otta reluctantly stayed home. That saved his life.
,1(- %electe recors of fatal cases"
This table lists only the selected records of dengue-associated fatality. As you can see,
mortalities in Australia were very high between *<7( and *79=. 0igh mortality was also
reported in *78* in 5apan and in Taiwan.
,10- !eographic &apping of three clusters of engue outbrea; /ith fatality"
0istorical study of dengue outbrea)s reveals an interesting trend that outbrea)s in
multiple locations tended to occur clustered in a relatively short period (mostly within (
year period), disappeared, and re-appeared later in another short period, as shown in this
slide. The slide shows that locations where fatal cases occurred were not the same among
three cluster periods, suggesting that severe dengue had not become a fixed clinical
feature in most urban areas in that period. This is contrasted to post-*7(> period, because
in the latter period, %0F became a perpetuated clinical feature in many large urban
centers in the tropics.
,11- Fther Dunusual sy&pto&s"E
Atypical clinical features observed in the early period include :1, syndrome (including
stiff nec), encephalitis syndrome, meningitis, epilepsy, facial paralysis, paraparesis, and
paraplegia). +ulmonary dysfunctions were invariably reported as Epneumonia-li)e
syndromeF, which was more often observed in eldery patients.
*8
,15- Fphthal&ologic proble&s"
Cision problems ranged from more fre#uent con!unctivitis and hemorrhage to more
serious retinal hemorrhage, central scotoma, and.or total blindness. "ne of the studies
illustrating such an impaired vision is shown in this slide.
,1'- 5eical care"
,alicylates were fre#uently used. &t is noted that even before *7(>, some physicians,
concerned with increasing number of dengue patients with hemorrhagic manifestations,
advised against the use of Aspirin.
Antiserums obtained from individuals who recovered from dengue were sometimes used
to ameliorate the disease condition, but absolutely no benefit was found in the treatment.
@lood transfusion was occasionally attempted by some physicians in desperate attempts
to save lives.
,13- Pane&ic pattern of engue sprea an hu&an &ove&ent"
&t was recogni-ed that ships carrying sic) passengers spread dengue over a long distance
to other locations free of dengue but infested with dengue vectors. "ver years, people
noticed that outbrea) of dengue coincided with the arrival of passenger ships or naval
ships transporting soldiers, after a length of lag period.
This should be clearly distinguished from the fre#uent occurrence of dengue outbrea) in
a large number of healthy individuals (including soldiers) upon arrival at dengue-endemic
locations and subse#uent exposure to infective mos#uitoes, which suggests dengue
endemicity in fixed locations in the tropics rather than dengue spread from one place to
the other.
?ven in the urban centers in temperate climate, arrival of a large number of passengers by
ships from the tropics sometimes signaled the beginning of an outbrea), if the port areas
were infested with competent dengue vectors. As an example, several port cities of 5apan
suffered from outbrea) every summer during the AA&& because of the return of a large
number of dengue-infected soldiers and seamen from the war -ones in the tropics. &n
contrast, after the end of the Aar, this summer outbrea) completely ceased to exist,
obviously because very few people arrived from the tropics.
,12- 6nraveling the &echanis& of engue sprea by the physicians on boar ships"
&n the covered period, when no !et was used for passenger travel or commerce yet, much
of the long-distance travel of people was primarily via ship. %epending on the route and
itinerary, it too) steamers from several days to as long as a few wee)s to reach
destination directly without intermediate stops. &n many parts of the tropics, many sailing
schedules included multiple stopovers before arriving at the final destination. At each
stopover for a few days of rest and restoc)ing of supplies, some passengers disembar)ed
because it was their destination, while other passengers disembar)ed for business,
tourism, or personal rest for a day or two but embar)ed on the same ship again to
continue their travel. Also, at each stop, new passengers boarded.
*'
@ecause of long !ourney, each ship had at least one physician on board to attend the
medical needs of the passengers and crew. 6ecords show that dengue outbrea)s among
passengers erupted occasionally in front of the eyes of on-board physicians. Thus, they
had a uni#ue advantage of analy-ing the transmission mechanism.
,ome of those physicians )ept a meticulous record of the occurrence of dengue among
passengers on board, by paying a special attention to where they boarded, where they
disembar)ed, in which location (port of departure, stopover, or destination) dengue was
endemic at the time of travel, when and where new epidemic was reported shortly after
the shipGs !ourney, etc. ?ach observation recorded only a fragment of information, but
when many observations by multiple physicians were retrospectively pieced together
later, a more complete picture of the mechanism of dengue spread over long distance by
the ship passengers gradually emerged.
Today, much of long-distance travel is by much faster !et planes which do not carry on-
board physicians. 0ere, we find an irony when todayGs epidemiologists need to study how
an exotic disease is imported by passengers of !et planes. @ecause of the fast travel,
practically there is no opportunity to observe the stages in progress before emergence of
an outbrea). @y the time epidemiologists learn emergence of an outbrea) of a new
disease brought in by the passengers, often more than several days have passed since
their disembar)ation at the airports. Hocating the passengers for medical interview based
on passenger list provided by airline companies is time-consuming and difficult because
of mobility of humans and complicated and busy modern life style. These further delay
unraveling how an exotic disease is introduced by !et travel.
&n other words, in the old days, because of much slower travel by ships, physicians on
board ships, with )een eyes on the health of passengers, played a role of medical
detective or investigative epidemiologist. Today, except for certain types of ships carrying
a large number of passengers and crews over a long distance for more than a few days,
such as cruise ships, military ships, and some cargo ships, the roles played by the
physicians and the strategies used for unraveling the transmission mechanism of
emerging, introduced new diseases are somewhat different today.
The important roles of the physicians attending passengers and crews in the early history
should not be forgotten. "ne should remember that +atric) ;anson could ma)e many
valuable contributions to tropical medicine because he was employed at the ,eamenGs
0ospital in Hondon. There, he had rare opportunities and fortuitous access to a large
number of patients presenting a variety of tropical diseases for his studies. &n the $,,
because of the dominant importance of ships in transoceanic travel and commerce and
hence of the health care of passengers, crews, and seamen, ;arine 0ospital :orp Ilater
;arine 0ospital ,erviceK was established. This was the forerunner of the present-day
$.,. +ublic 0ealth ,ervice.
,19- Dengue pane&ic of 1230430" Fccurrence of engue outbrea; in 1230"
*(
1ow, & would li)e to show one of the examples of dengue pandemic in Asia and +acific
that occurred between *<B> and B8. This slide shows that in *<B> dengue outbrea)
recorded only in &ndia. The position of red spot in the center of &ndia is arbitrary, because
the exact western port city (or cities) where the outbrea) occurred was ambiguous in the
old records.
,50- Fccurrence of engue outbrea; in 1231"
This slide shows spread to more locations.
,51- Fccurrence of engue outbrea; in 123("
This slide shows further spread in southeast Asia and semitropical areas. Actually, in the
following year (*<B8), outbrea) was reported even in 1ew ,outh Aales of Australia but
disappeared thereafter.
,5(- Patterns of engue sprea in urban areas"
For studying how dengue spread in urban area, locations of the houses of dengue cases
were sometimes mapped in chronologic order. This was an early application of the
concept of 4&,.
,50- E>a&ples of the case &apping stuy"
&n Australia, it was revealed that dengue spread linearly along houses on street. 0owever,
as in other studies, the pattern of spread was more complicated. This slide shows the
pattern of spread in the *78* outbrea) in ")inawa where more than (>> died.
,51- Recognition of engue as an urban isease"
That dengue was essentially an urban disease was clearly recogni-ed in &ndia. &n this
map, the solid areas with fre#uent dengue occurrence correspond very well with urban
areas/ while the areas with infre#uent occurrence correspond with the shaded areas. The
huge blan) areas without any dengue correspond to rural areas.
&t was also recogni-ed in such places as @aguio of the +hilippines, Hebanon, and Ha
6eunion &sland in the &ndian "cean that dengue occurred only in low altitude in the
tropics, because the communities located at much higher altitude were basically dengue-
free even if they were very close to dengue-endemic communities at low altitude.
,55- *nvestigating the &echanis& of trans&ission in living Guarter"
&n many households and a variety of facilities housing a considerable number of humans
(such as prisons, police station, military barrac)s, etc.), dengue spread #uic)ly. %irect
transmission was one of the early possibilities speculated. &n the following two slides,
interesting observations that intrigued the early investigators are shown.
,5'- .rans&ission in a &ilitary barrac;"
The slide shows the blueprint of a military garrison where an extensive outbrea) of
dengue occurred among soldiers. &n this diagram, each rectangle represents a barrac) for
sleeping #uarter in which beds are laid out in two or three rows and *>-** columns of
*=
beds per row. ?ach dot represents the location of bed whose occupant contracted dengue/
while the open space represents beds whose occupants were not infected.
From this diagram, it is evident that the ma!ority of the soldiers got sic). @ecause soldiers
in contiguous rows or columns of beds were infected, the initial impression signaled a
strong possibility of direct transmission.
,53- Difference in attac; rate bet/een inoor an outoor sleeping"
&n a similar study of another military barrac), the difference in attac) rate between
the soldiers who slept indoor and those who slept outdoor was compared, as shown in this
slide.
The upper structure is the blueprint of the first floor of the sleeping #uarter. The long
rectangle laid out hori-ontally in the middle is the soldiersG sleeping #uarter.
This #uarter is sandwiched on the north and on the south sides with outdoor veranda
which run parallel. &n the right part of the blueprint is a perpendicularly laid rectangle,
which represents a sleeping #uarter for the officers. Hi)e soldiersG #uarter, it is also
surrounded with veranda to the east and to the south.
@ecause it was so hot and humid in this part of &ndia that many soldiers opted to sleep
outdoor in veranda at night, while others slept indoor.
The blueprint below is the bird eye view of the second floor, which is much smaller in the
si-e of floor space. Hi)e in the first floor, some slept outdoor, while others slept indoor.
&n this diagram, each tiny rectangle vertically drawn represents a bed whose occupant
contracted dengue. The blan) space represents the beds whose occupants did not get sic).
This diagram is very difficult to view for the audience, because it is cluttered with hand-
written annotations (name of the soldier occupying the bed and the date of onset of
illness) next to the bed on the diagram. ,o, please focus only on the density of the
number of beds (tiny rectangles) indoor and outdoor sleeping areas and ignore all
illegible annotations next to them.
From this figure, it was interpreted by the investigators that, although soldiers who slept
indoor and those who slept outdoor were both exposed to bite of mos#uitoes, the
fre#uency of dengue in the soldiers who slept indoor was significantly higher. From these
data, a speculation emerged that the vectors of dengue are probably indoor species rather
than outdoor species. Ahy the proportion of the infected soldiers sleeping outdoors was
higher in the second floor than in the first floor was not explained, however.
,52- Epie&iologic reporting"
&n the early period, epidemiologic surveillance and reporting systems were not developed
in nearly all countries endemic with dengue. ?xceptionally, in Aestern Australia, because
of repeated imported outbrea)s, dengue was designated a reportable disease in *7*9. That
*B
mar)ed the first time any government in the world classified dengue as a reportable
disease.
&n the aftermath of the tragic dengue outbrea) in 4reece in *79<, Heague of 1ations
drafted an international sanitary convention that was ratified in *78'. @y this convention,
participating nations were obligated to report occurrence of dengue and to #uarantine at
the port of entry all passengers and crew of ships who were suspected to be infected with
dengue. 0owever, this treaty was a total failure, because, surprisingly, most of the
countries that ratified the convention were ?uropean counties where dengue was not
endemic, while nearly all currently dengue-endemic countries in the tropics were not
invited to ratify. Also, other countries with a strong interest in tropical medicine, such as
$,A, was not a member of the Heague.
,59- 9yclic pattern of epie&ic in engue4ene&ic area (or seasonality)"
,easonality of dengue outbrea) was well recogni-ed in endemic areas.
,'0- %easonality of engue in ene&ic location"
As shown in this figure, cyclical pattern of dengue in endemic location, such as ;anila
of the +hilippines, is very clear.
,'1- 5ultiple engue infection"
;any physicians reported patients who suffered from dengue multiple times in life. &n
some of those reports, each patient was examined by the same physician at every episode
of EdengueF/ and the physicians had absolutely no doubt about the accuracy of dengue
etiology in each episode. 4radually, a small number of physicians conceived a concept of
multiple EimmunotypesF as causes of dengue. &nterestingly, the maximum number of
dengue episodes per patient was '. &n a more convincing report made by the $, Army
laboratory in ;anila, it was estimated statistically that a small faction (much less than
*P) of the $, soldiers serving in the +hilippines would suffer from dengue as many as '
times during 9-year tour of duty.
From these accumulated data, retrospectively, it is reasonable to speculate that all '
dengue serotypes most li)ely existed in highly dengue-endemic tropical locations in this
early period. &t should be noted that this speculation was later confirmed when Am.
0ammon isolated ' serotypes of dengue virus between late *7(>s and early *7=>s in
southeast Asia.
&n other locations, however, physicians observed that the residents who suffered dengue
once rarely suffered dengue again when epidemic returned later. For them, longevity of
immunity against dengue appeared to be very long.
This sharp contrast in observations regarding multiple infections was a source of ma!or
controversy over the duration of immunity conferred by dengue infection. For those
physicians who observed multiple episodes of dengue per person, development of dengue
vaccine was an exercise in futility. &t should be noted that at that time little was )nown
*<
that dengue agents consisted of ' serotypes none of which confers life-time cross-
immunity among serotypes.
,'(- ?ntiboy responses to engue infection"
Aith the advent of neutrali-ation test in vivo using laboratory mice, neutrali-ing antibody
titer could be measured to depict more clearly the dynamic profile of antibody response.
,'0- ?ntiboy response profiles4pri&ary vs re4infection"
@ased on 1T, 0otta and 3imura was able to differentiate the antibody response to
primary from secondary infection, as shown in this slide.
,'1- Develop&ent of serologic tests"
&n this period, complement fixation test (:F) and neutrali-ation test (1T) were developed
and applied for dengue.
0istorically, :F was developed for F earlier in *797. @ut, its application
to dengue was performed only in *7'< by ,abin.
1eutrali-ation test was developed for F in *797. ,aywer and Hloyd applied it in the
*78>s for the survey of neutrali-ation antibody to F in tropical locations in the world.
Their result conclusively ruled out the past existence of F in Asia and the +acific.
After the isolation of dengue virus in the *7'>s, specific 1T for dengue was developed
and became the primary confirmatory serologic techni#ue of dengue outbrea).
,'5- ?ni&al &oel"
;any animals, including cold-blooded vertebrates, were tested to determine if they could
serve as useful animal models. 1one of them were found suitable.
,ubhuman primates (Macaca fasciatus and M. philippinensis) were tested. Although
virus replicated, the absence of dengue syndrome was a ma!or problem.
Fortuitously, a uni#ue breed of ,wiss albino mice, EdbaF (for Edilute brown non-agoutiF)
from @ar 0arbor Haboratory (in the $,A) was discovered by ,abin to be very susceptible
to dengue virus for animal experiments. ?ven with this breed of mice, clinical syndrome
of dengue in humans could not be exactly reproduced.
,''- <ector ientification an biology"
Ae. albopictus is often depicted to be an inferior vector compared with Ae. aegypti. That
is generally true in much of the tropics. 0owever, one has to be extra-careful
elsewhere. %uring the AA&&, every summer, in several port cities in 5apan, dengue
epidemics originating from a large number of sic) soldiers and seamen returning from the
battle grounds in the tropics occurred. The total number of cases over ' summers in
several cities was as many as 9 million. The only vector found was Ae. albopictus, and
absolutely Ae. aegypti was not involved.
Ae. scutellaris was identified as vector in 1ew 4uinea during the AA&&.
*7
@reeding techni#ue for Ae. aegypti was optimi-ed by ,iler, et al., in ;anila.
,'3- !eographic istribution of vectors"
?ntomologic studies were carried out very actively during this period. The compilation of
the geographic distribution of F and dengue vectors in the world by 0. 3umm (*78*)
was a fruit of the arduous field research by many groups.
A survey of infestation by Ae. aegypti in southeast Asia was prompted by the potential
threat of F invasion to Asia as a result of the completion of the +anama :anal. Thus,
,tanton visited several locations (such as @ang)o), Cietnam, &ndonesia) for the
entomologic survey.
As for the mos#uitoes in the +hilippines, :lara Hudlow reported in *7>9 a new species of
mos#uito, Ae. scutellaris samarensis.
This mos#uito discovered by Hudlow was later found to be synonymous with Ae.
albopictus. Although she never did an experiment to prove its vector
competence for dengue, she had a strong suspicion that it was involved in dengue
transmission in the +hilippines/ and in fact, in her dissertation are found annotations with
the word dengue for the collections of this mos#uito from the military posts where
soldiers became sic) of dengue.
,'2- 9lara %" @ulo/"
& would li)e to spend a few minutes to introduce this extraordinary entomologist. ,he
graduated from the prestigious 1ew ?ngland :onservatory of ;usic, ma!oring in piano.
Ae do not )now much records about her professional life. 6emember, in the male-
dominant world of the *7
th
century, for women to pursue a professional career was very
difficult. At least we do )now that she taught music at religious organi-ations such as
seminaries. At the age of '(, she suddenly became interested in mos#uitoes. Then, she
bro)e the gender barrier and enrolled in male-only ;ississippi A Q ; (now ;ississippi
,tate $niversity).
After obtaining bachelor degree, she advanced to masterGs program. $pon completion of
her ;asterGs degree, she traveled to ;anila to visit her brother serving in the military.
"ver there, somehow she convinced the military brass about the importance of mos#uito
studies in the context of malaria and dengue. &t must be emphasi-ed that when she was
there, in *7>*->9, it was before 4raham conducted the first vector-borne transmission of
dengue in @eirut, and still nobody )new if dengue was transmitted by mos#uitoes. &
surmise that she got the idea after reading the Aalter 6eed :ommission 6eport of F
submitted to the :ongress only a short time earlier. Also, she had a correspondence with
Ailliam 4orgas.
Apparently, she got an appointment in the military during her brief visit to ;anila,
because when she left the +hilippines, she headed directly to +residio in ,an Francisco,
the military base. From the base, she re#uested then ,urgeon 4eneral, 4eorge ,ternberg,
9>
his support for her mos#uito study in the +hilippines. ,ternberg then ordered all $,
military posts (nearly several hundred) throughout the archipelago of the +hilippines to
regularly collect mos#uitoes and ship them to :lara in ,an Francisco. ,he was, thus, very
busy shipping mos#uito collection )its to the military posts for replenishment. 1aturally,
in a relatively short time, she amassed a huge collection of mos#uitoes of the +hilippines,
which she used to write her doctoral dissertation. Thus, in her dissertation submitted to
4eorge Aashington $niversity, ,ternberg is listed as her advisor.
,he was later admitted to be the first female member of the American ,ociety of Tropical
;edicine and 0ygiene. At the age of ((, she still tried to enroll in medical school.
,'9- <enereal an vertical trans&issions in &osGuitoes"
The two forms of transmission in mos#uitoes were studied earlier for F, influencing the
minds of early dengue researchers.
,immons, et al. (*78*) were unsuccessful in proving venereal transmission in
mos#uitoes. 0owever, they concluded that it was still possible under natural conditions.
A strong influence of the F study in *7>*->( in @ra-il by French scientists from the
+asteur &nstitute, such as ,imond and ;archoux, was also felt for dengue researchers,
although @auer, +hilip, and others failed to prove for F in west Africa. The first
conclusive proof for F was reported only in *77B.
For dengue, Hegendre (*7**) speculated the possibility of vertical transmission but did
not prove it. ,iler, et al. (*79() failed to demonstrate it using Ae. aegypti. Hi)e in F
studies, the conclusive evidence of vertical transmission of dengue virus was obtained
more than several decades later.
,30- =ean4Paul %i&on"
This is a picture of ,imond.
,31- E&ile 5archou>"
This is a picture of ;archoux.
,3(- <ector co&petence"
The influence of F research was also felt strongly in this sub!ect. For F, @auer in *79<
demonstrated in Aest Africa that a few mos#uito species other than Ae. aegypti could
transmit F.
For dengue, a %utch group (,ni!ders, et al.) in ,umatra demonstrated in late *79>s that
Ae. albopictus could transmit F. 3oi-umi tested in *7*B many species of mos#uitoes
indigenous to northern Taiwan and concluded that Ae. albopictus was a good vector.
,abin similarly tested several species of mos#uitoes in the $, but found none of them to
be competent.
,30- <ector control+ biological control"
9*
@iological control using predatory mos#uitoes, Toxorhynchites spp., was proposed in
Australia as early as in *7**. Ahen ,tanton was visiting @ang)o) for the survey of Ae.
aegypti infestation, he observed Toxorhynchites mos#uitoes eating the larvae of dengue
vector and #uic)ly proposed a biological control strategy utili-ing the predatory
mos#uitoes. "thers emphasi-ed the utility of fishes.
,31- Toxorhynchites larva.
This is a larva of the predatory mos#uito.
,35- #ill fish (Oryzias latipes)"
This fish is small, easy to breed, and has been )nown in 5apan by its common name,
Emeda)a.F &n the *7'>s, a strategy was conceived in 5apan to mass breed the fish,
transport them via railway and apply for larval control in urban areas. Although a small-
scale experiment was encouraging, it was never tested in large scale. ?lsewhere, minnows
(Gambusia, spp.) were used for mos#uito control.
,3'- <ector control+ applications of insecticies incluing inoor resiual
spray of DD."
Traditional insecticides for mos#uito control were used. The efficacy of %%T for the
control of blood-suc)ing insects was proven when it was tested in *7'8 against sandflies
in &taly during the AA&&. Accordingly, it was #uic)ly applied in *7'' for malaria and
dengue control for the protection of Allied soldiers in the +acific. Among several
formulations tested, residual spray was good against dengue.
,33- <ector control+ source reuction$ co&&unity participation$ public eucation
an organiBe ca&paign"
,ource reduction, community participation, and public education were conducted
vigorously in some locations, such as Taiwan and 0awaii. @erraud (*79<) also
emphasi-ed cleaning up gutters to eliminate Ae. aegypti. &n ;anila, depressions in urban
areas were filled to prevent mos#uito breeding. $se of mos#uito net was also stressed.
A more comprehensive campaign encompassing several methods was adopted in Taiwan
in early *78>s. There, the governor proclaimed a dengue control campaign with fre#uent
radio messages. Traditional insecticides were used to control mos#uitoes. +eople were
advised to empty regularly water receptacles in and around house. :iti-ens were
mobili-ed to remove unnecessary water receptacles in residential area. Free copies of
brochure with photographs of vectors and common mos#uito-breeding water containers
as well as instruction for source reduction were distributed to residents. Furthermore,
educational slides were shown in movie theaters at intermission.
&n Nueensland, brigades of sanitation inspectors regularly visited houses to chec)
mos#uito control practice, provide advice, and to determine change in larval density since
last visit for evaluating the efficacy of public educational campaign.
,32- Dengue prevention by other &eans"
99
+reventing or restricting human movement has always been legally difficult or nearly
impossible in most countries. 1onetheless, when faced with a threat of invasion of a
dangerous disease, people may resort to unusual measures for self-defense.
%uring a ma!or dengue outbrea) in ")inawa archipelago of 5apan in the *78>s, outbrea)
first occurred in the largest island of ")inawa. After the news of the outbrea) spread to
the smaller islands nearby, when ships carrying passengers from that disease-devastated
island arrived, residents of those smaller islands bloc)ed disembar)ation of the
passengers at ports. This is reminiscent of a similar incident that happened in the southern
regions of the $, when serious F outbrea)s occurred in Houisiana and ;ississippi in
the *7
th
century. Ahen trains carrying a large number of citi-ens of the cities fleeing in
panic moved north, suddenly a group of armed men appeared on the railway trac), halted
trains, and ordered conductors to turn bac) at gun point.
After the devastating outbrea) in 4reece in *<9<, an international sanitary convention
was drafted in *78' by the Heague of 1ations to obligate participating countries to notify
(imported) dengue cases and to #uarantine all passengers and ship crew suspected of
being infected at the ports of entry. 0owever, the convention was a total failure, as
explained earlier.
Hegislation to ma)e elimination of mos#uito breeding in domestic environment
obligatory was considered in a few countries. @ut, implementation of such laws was
difficult to say the least, and proposals for legislation most often died during debate
among politicians.
,39- <accine evelop&ent4 attenuation or inactivation &ethos"
Attempts to develop vaccine started very early in the history of dengue research. As
mentioned earlier, the controversy over the duration of immunity against
dengue discouraged some physicians from engaging in vaccine development.
This slide shows that both inactivation and attenuation were applied to prepare
candidates.
0uman clinical trial with formalin-inactivated mouse-adapted %?1C-* vaccine candidate
was conducted by 0otta and 3imura in *7''. ,abin and ,chlesinger prepared a huge
amount of attenuated vaccine candidate to protect more than (>,>>> Allied soldiers in
the +acific, but the plan for vaccination was cancelled because the Aar ended
much earlier than they expected.
%uring the vaccine development for an attenuated vaccine, ,abin conceived an
idea of simultaneous vaccination with a mixed vaccine by incorporating F (*B%).
@ased on his evaluation of the efficacy, he concluded that he could not recommend
such a mixed (multivalent) vaccine because of interference. &t is of interest to recall
what happened to the international effort to develop a tetravalent attenuated dengue
vaccine which was initiated in early *7<>s by the Aorld 0ealth "rgani-ation.
&nterference was one of the ma!or causes of failure/ and after nearly 8> years since then,
still no vaccine is available today, although applications of modern technologies are
98
expected to overcome this problem.
,20- Econo&ic cost"
;any economic impact studies on dengue have been published lately. 0owever,
un)nown to many authors of those recent publications, economic impact was
indeed studied in the early period, because economic loss by the devastating dengue
outbrea) was a ma!or concern even at that time.
,21- Econo&ic i&pact stuy in Hueenslan$ ?ustralia"
The slide shows one of such studies conducted in Nueensland, Australia. &n this study,
the author classified occupations into 7 categories and determined the proportion of
people in each category in the affected city. Then, based on the average wage and
the percentage of wor) force sic) of dengue in each category, he could calculate the
economic impact for the affected community.
,2(- 9o&pleting the full circle of the interaction bet/een I: an engue research
histories"
& started this presentation with the interesting influence and crossing of the early histories
of research between the two important vector-borne viral diseases. &n closing this
presentation, once again & touch on the relationship.
Albert ,abin was close to ;ax Theiler, the man of yellow fever vaccine fame. &n fact,
they spent life together briefly at the 6oc)efeller &nstitute of ;edical 6esearch in 1ew
5ersey between *78( and 87. Thus, it is not surprising that ,abin made the second of
three nominations of ;ax Theiler for 1obel +ri-e. Although ,abinGs failed, the third
nomination by a little-)nown ,panish woman, Antonia 1avarro, succeeded in *7(*.
,o, ,abinGs role in dengue research history was to bridge between F and dengue
research. Cery fittingly, ,abin is buried very close to the gravesite of Aalter 6eed at the
Arlington 1ational :emetery in Cirginia.
,20- ?c;no/leg&ents"
The following individuals in the slide provided a variety of valuable assistances during
the preparation of the slides and are deeply appreciated.







9'