Sentinel Enhanced Dengue Surveillance System - Puerto Rico, 2012-2022

Abstract

Problem/condition: Dengue is the most prevalent mosquitoborne viral illness worldwide and is endemic in Puerto Rico. Dengue's clinical spectrum can range from mild, undifferentiated febrile illness to hemorrhagic manifestations, shock, multiorgan failure, and death in severe cases. The disease presentation is nonspecific; therefore, various other illnesses (e.g., arboviral and respiratory pathogens) can cause similar clinical symptoms. Enhanced surveillance is necessary to determine disease prevalence, to characterize the epidemiology of severe disease, and to evaluate diagnostic and treatment practices to improve patient outcomes. The Sentinel Enhanced Dengue Surveillance System (SEDSS) was established to monitor trends of dengue and dengue-like acute febrile illnesses (AFIs), characterize the clinical course of disease, and serve as an early warning system for viral infections with epidemic potential.

Reporting period: May 2012-December 2022.

Description of system: SEDSS conducts enhanced surveillance for dengue and other relevant AFIs in Puerto Rico. This report includes aggregated data collected from May 2012 through December 2022. SEDSS was launched in May 2012 with patients with AFIs from five health care facilities enrolled. The facilities included two emergency departments in tertiary acute care hospitals in the San Juan-Caguas-Guaynabo metropolitan area and Ponce, two secondary acute care hospitals in Carolina and Guayama, and one outpatient acute care clinic in Ponce. Patients arriving at any SEDSS site were eligible for enrollment if they reported having fever within the past 7 days. During the Zika epidemic (June 2016-June 2018), patients were eligible for enrollment if they had either rash and conjunctivitis, rash and arthralgia, or fever. Eligibility was expanded in April 2020 to include reported cough or shortness of breath within the past 14 days. Blood, urine, nasopharyngeal, and oropharyngeal specimens were collected at enrollment from all participants who consented. Diagnostic testing for dengue virus (DENV) serotypes 1-4, chikungunya virus, Zika virus, influenza A and B viruses, SARS-CoV-2, and five other respiratory viruses was performed by the CDC laboratory in San Juan.

Results: During May 2012-December 2022, a total of 43,608 participants with diagnosed AFI were enrolled in SEDSS; a majority of participants (45.0%) were from Ponce. During the surveillance period, there were 1,432 confirmed or probable cases of dengue, 2,293 confirmed or probable cases of chikungunya, and 1,918 confirmed or probable cases of Zika. The epidemic curves of the three arboviruses indicate dengue is endemic; outbreaks of chikungunya and Zika were sporadic, with case counts peaking in late 2014 and 2016, respectively. The majority of commonly identified respiratory pathogens were influenza A virus (3,756), SARS-CoV-2 (1,586), human adenovirus (1,550), respiratory syncytial virus (1,489), influenza B virus (1,430), and human parainfluenza virus type 1 or 3 (1,401). A total of 5,502 participants had confirmed or probable arbovirus infection, 11,922 had confirmed respiratory virus infection, and 26,503 had AFI without any of the arboviruses or respiratory viruses examined.

Interpretation: Dengue is endemic in Puerto Rico; however, incidence rates varied widely during the reporting period, with the last notable outbreak occurring during 2012-2013. DENV-1 was the predominant virus during the surveillance period; sporadic cases of DENV-4 also were reported. Puerto Rico experienced large outbreaks of chikungunya that peaked in 2014 and of Zika that peaked in 2016; few cases of both viruses have been reported since. Influenza A and respiratory syncytial virus seasonality patterns are distinct, with respiratory syncytial virus incidence typically reaching its annual peak a few weeks before influenza A. The emergence of SARS-CoV-2 led to a reduction in the circulation of other acute respiratory viruses.

Public health action: SEDSS is the only site-based enhanced surveillance system designed to gather information on AFI cases in Puerto Rico. This report illustrates that SEDSS can be adapted to detect dengue, Zika, chikungunya, COVID-19, and influenza outbreaks, along with other seasonal acute respiratory viruses, underscoring the importance of recognizing signs and symptoms of relevant diseases and understanding transmission dynamics among these viruses. This report also describes fluctuations in disease incidence, highlighting the value of active surveillance, testing for a panel of acute respiratory viruses, and the importance of flexible and responsive surveillance systems in addressing evolving public health challenges. Various vector control strategies and vaccines are being considered or implemented in Puerto Rico, and data from ongoing trials and SEDSS might be integrated to better understand epidemiologic factors underlying transmission and risk mitigation approaches. Data from SEDSS might guide sampling strategies and implementation of future trials to prevent arbovirus transmission, particularly during the expansion of SEDSS throughout the island to improve geographic representation.

FIGURE 1

Confirmed or probable dengue, chikungunya, and Zika virus cases, by year — Sentinel Enhanced Dengue Surveillance System, Puerto Rico, May 2012–December 2022* * Cases were deemed to be laboratory-confirmed if a serum or urine specimen was polymerase chain reaction– or immunoglobulin M–positive for a particular arbovirus.

FIGURE 2

Acute respiratory virus cases, by year — Sentinel Enhanced Dengue Surveillance System, Puerto Rico, May 2012–December 2022* * Respiratory viruses were identified and confirmed by reverse transcription–polymerase chain reaction testing of nasopharyngeal swabs.

FIGURE 3

Number and proportion of acute febrile illness cases with participants testing positive for any arbovirus, by municipality — Sentinel Enhanced Dengue Surveillance System, Puerto Rico, 2012–2022*^,† Abbreviation: SEDSS = Sentinel Enhanced Dengue Surveillance System. * Arboviruses included dengue, chikungunya, and Zika viruses; the number of tests for any arbovirus in each municipality is shown. ^† The proportion of acute febrile illness cases testing positive for arboviruses is divided into intervals of equal size (5%).

FIGURE 4

Confirmed dengue cases, by serotype and year — Sentinel Enhanced Dengue Surveillance System, Puerto Rico, May 2012 – December 2022* * Dengue cases were assigned a serotype if a participant’s serum specimen was polymerase chain reaction–positive for a specific dengue virus serotype.

FIGURE 5

Number and proportion of acute febrile illness cases with participants testing positive for any acute respiratory virus, by municipality — Sentinel Enhanced Dengue Surveillance System, Puerto Rico, 2012–2022*^,† Abbreviation: SEDSS = Sentinel Enhanced Dengue Surveillance System. * Respiratory viruses included influenza A and B, respiratory syncytial virus, human adenovirus, human metapneumovirus, human parainfluenza viruses 1 and 3, human coronavirus, and SARS-CoV-2; the number of tests for any arbovirus in each municipality is shown. ^† The proportion of acute febrile illness cases testing positive for respiratory viruses is divided into intervals of equal size (5%).

FIGURE 6

Number and proportion of dengue cases, by participant age group without warning signs, with warning signs without progressing to severe dengue, and severe dengue — Sentinel Enhanced Dengue Surveillance System, Puerto Rico, 2012–2022