Denguelike illness was first noted in the New World as a major outbreak in Philadelphia in 1780 (1), and similar episodes occurred in the United States for more than 150 years. In 1922, the disease struck many major cities in the southern states, including an estimated 500,000 cases in Texas. Another widespread outbreak occurred in 1947–48 (2). In the past 50 years, however, autochthonous cases have been rare, despite an abundance of Aedes aegypti in the southeastern United States, and the arrival of millions of travelers from neighboring countries where the disease is endemic. From 1980 to 1999, only 64 locally acquired cases were confirmed in Texas, whereas 62,514 suspected cases were recorded in three adjoining Mexican states—Coahuila, Nuevo León, and Tamaulipas. In the same period, immigration authorities reported < 70 million personal crossings from these states into Texas in a single year (3). Thus, the international border separates a dengue-endemic region from one in which the disease is rare.

Laredo, Texas, United States (population 200,000), and Nuevo Laredo, Taumalipas, Mexico (population 289,000), are essentially a single city (locally known as “los dos Laredos”) divided by a small river, the Rio Grande (Figure). The rapid growth of this metropolitan area—70% in the past decade—is mainly due to massive cross-border traffic across three multilane bridges (Laredo Chamber of Commerce. Laredo, Texas; available from: URL: http://www.laredochamber.com/contact-information.htm). In the summer of 1999, toward the end of a local dengue outbreak, we conducted a seroepidemiologic survey to examine factors affecting dengue transmission on both sides of the border.

Binational teams, each composed of an epidemiologist, a nurse, and an entomologist, conducted the surveys. A blood sample was obtained by fingerstick from a randomly selected resident (ages 18–65)¹. A short questionnaire solicited general household information (number of inhabitants, type of construction, proximity to neighboring houses, number of bedrooms, presence and type of air-cooling system, and the presence and quality of window screens). Demographic data and travel histories of the blood donors were also recorded. Yards and patios were searched for Ae. aegypti breeding sites.

Univariate analysis indicated a significant association between IgM seropositivity and five variables: absence of air-conditioning, fewer room air-conditioning units, the presence of an evaporative cooler, no travel outside the Laredo/Nuevo Laredo area, and shorter distances to neighboring houses (Table 3). IgG seropositivity was significantly associated with absence of central air-conditioning, fewer room air-conditioning units, smaller plot size, and a shorter distance to neighboring houses (Table 4).

Despite mosquito control campaigns on both sides of the border, Ae. aegypti infestation rates in Laredo were remarkably high. The Breteau Index was on a par with that observed during major dengue epidemics in Puerto Rico (CDC, unpub. data). The House Index (the percentage of houses with at least one infested container) was 37%, seven times higher than the level (5%) equated with a “high risk” of dengue transmission by the World Health Organization (7). Thus, vector populations cannot account for the low rate of transmission on the Texas side of the border.

Ae. aegypti is closely associated with human habitation and readily enters buildings to feed and to rest during periods of inactivity (8). In this context, casual observation supported the association of lack of air-conditioning with dengue transmission. In Laredo, most shops, restaurants and other public places are air conditioned and have closed windows and self-closing doors, as do houses in residential areas, even in low income neighborhoods. By contrast, in Nuevo Laredo, many shops, bars, and restaurants are open to the street, and the windows and doors of houses are left open, particularly in the daytime. Thus, there is less opportunity for mosquito/human contact in Laredo than in the Mexican city.

More than 85% of all buildings in Texas are fully air conditioned (American Society of Heating, Refrigerating and Air-Conditioning Engineers, Inc., Atlanta, GA; available from: URL: http://www.ashrae.org/). Indeed, air-conditioning is ubiquitous in many parts of the United States. To maximize heating/cooling efficiency, windows are usually fully glazed and are often kept permanently closed. Thus, most people spend much of their daily life sequestered in sealed buildings. Even if infected mosquitoes gain entry to such buildings, the artificially dry atmosphere lowers their survival rate, and the cool temperature extends the extrinsic incubation period, reducing the likelihood of transmission. Presumably, when denied access to humans, mosquitoes must seek other hosts. In Puerto Rico and Thailand, some Ae. aegypti feed on dogs, even when humans are readily accessible (9,10). In Laredo, we observed that large dogs were housed in outdoor kennels at many homes. Whether these animals are an important blood source for the species would be an interesting topic for future research.

The dollar cost of electricity is similar in Laredo and Nuevo Laredo, but income, as indicated by per capita gross domestic product, is much higher in Texas than in Taumalipas (Table 5). The proportional cost of maintaining air-conditioning for an entire dengue season is therefore much higher for the average family in Mexico and is unaffordable for the majority. Thus, the ultimate determinant of dengue prevalence in this setting is socioeconomic rather than environmental.