Recent Advances in Dengue: Relevance to Puerto Rico

Abstract

Dengue represents an increasingly important public health challenge in Puerto Rico, with recent epidemics in 2007, 2010, and 2012-2013. Although recent advances in dengue vaccine development offer hope for primary prevention, the role of health professionals in the diagnosis and management of dengue patients is paramount. Case definitions for dengue, dengue with warning signs, and severe dengue provide a framework to guide clinical decision-making. Furthermore, the differentiation between dengue and other acute febrile illnesses, such as leptospirosis and chikungunya, is necessary for the appropriate diagnosis and management of cases. An understanding of dengue epidemiology and surveillance in Puerto Rico provides context for clinicians in epidemic and non-epidemic periods. This review aims to improve health professionals' ability to diagnose dengue, and as highlight the relevance of recent advances in dengue prevention and management in Puerto Rico.

Keywords: Dengue; Epidemiology; Public Health.

Figure 1

Schematic of World Health Organization guidelines (1) for clinical management of patients suspected of having dengue.

Figure 2

Suspected dengue cases reported to the passive dengue surveillance system during 1986–2013. The dotted horizontal line indicates the epidemic threshold.

Figure 3

Schematic of how the passive dengue surveillance system (PDSS) operated until 2012. PDSS is initiated when a patient seeks medical care, following which the patient’s medical provider suspects dengue as a cause of the patient’s illness. When this occurs, the clinician orders a blood specimen be collected from the patient and the Dengue Case Investigation Form (DCIF) is completed; both the specimen and DCIF are transported by the Puerto Rico Department of Health (PRDH) to the Centers for Disease Control and Prevention, Dengue Branch (CDC-DB). Specimens are tested, and the patient information from the DCIF is entered into a database at the CDC-DB. Diagnostic test results are sent to the health care provider who reported the case, who then relays the results to the patient and, if necessary, requests that the patient return to provide a convalescent serum specimen. Patient demographic information is compiled into weekly reports that CDC-DB and PRDH disseminate to stakeholders and the public via weekly reports. PRDH uses data from these reports to direct response activities in the areas most affected by dengue. After 2012, all activities indicated as being conducted by CDC-DB began instead to be conducted by PRDH.

Figure 4

Median number of days needed for a specimen to arrive at Centers for Disease Control and Prevention, Dengue Branch (CDC-DB), according to a particular patient’s municipality of residence in 2009 (A), 2010 (B) and 2011 (C). Light green, dark green, yellow, and red regions indicate municipalities with an average transport time of 0–2, 3–4, 5–7, and >8 days, respectively.