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Virtually all DHF/DSS cases are observed in two epidemiological settings, in individuals circulating dengue antibodies passively acquired (infants less than one year) and from previous dengue infection(s). Despite numerous reports, epidemic DHF/DSS has never been associated with a virgin-soil dengue epidemic (Barnes & Rosen L. AJTMH ). Most DHF/DSS cases associated with primary infections occur in areas where two or more dengue viruses are endemic or have been sequentially epidemic. Because dengue vascular permeability is difficult to detect, controversies largely stem from inaccurate case ascertainment.