Economic burden of dengue in Puerto Rico, 2010-2023

Abstract

Background: Dengue remains a major public health challenge, particularly in endemic areas like Puerto Rico, where its economic burden is substantial. This study aimed to update the economic burden of dengue in Puerto Rico using recent data from patients, hospitals, and insurance companies, providing a clearer picture of the current situation. We estimated the total number of dengue cases with fever who sought care by adjusting for underreporting through a robust statistical framework linking island-wide passive surveillance data to sentinel acute febrile illness surveillance.

Methods: We obtained cost data from hospitals and conducted interviews with a random sample of people diagnosed with dengue (n = 101) from December 2021-November 2022, collecting detailed information on direct medical costs, non-medical costs, and indirect costs. We analyzed median, epidemic and long-term dengue incidence patterns from 2010-2023. We conducted a cost-of-illness analysis using Bayesian multiplier methods to adjust for underreporting, followed by a bottom-up costing approach during a typical median incidence year and an epidemic year to illustrate the current economic burden of dengue in Puerto Rico.

Results: In the median incidence year (2014), from 597 reported dengue cases we estimated 4500 [95% credible interval (95% CrI): 3700-5400] outpatient and 3900 (95% CrI: 3200-4700) hospitalized cases. During an epidemic year (2010), these figures rose substantially from the reported 10,359 dengue cases to an estimated 77,300 (95% CrI: 64,600-93,200) outpatient and 67,300 (95% CrI: 56,100-81,700) hospitalized cases. The median cost per hospitalized dengue case was 5200 USD for children and USD 6800 for adults, while outpatient costs were 2300 USD for children and 2700 USD for adults. Direct medical costs and indirect costs constituted the largest share of total costs. The total economic burden was 1.1 billion USD (95% CrI: 785 million-1.6 billion) during the epidemic year, compared to 62.7 million USD (95% CrI: 45.9-95.4 million) in the median incidence year.

Conclusions: These findings highlight the considerable financial strain of dengue, particularly during epidemics, and underscore the urgent need for enhanced resource allocation, effective prevention strategies, and policy interventions to mitigate the economic impact of future outbreaks.

Keywords: Arboviral diseases; Caribbean; Cost of illness; Dengue virus; Economic evaluation; Multiplier model; Puerto Rico; Surveillance system; Underreporting adjustment.

Fig. 1

Dengue underreporting pyramid for the Sentinel Enhanced Surveillance System (SEDSS) and Passive Arboviral Surveillance System (PADSS) in Puerto Rico. The pyramid illustrates the different steps in the process for being reported in either surveillance system within a SEDSS catchment area. Symptomatic individuals with dengue seek care at either SEDSS or non-SEDSS PADSS (PADSS^NS) sites. To be reported in SEDSS ($p_{report.SEDSS}$), individuals must seek care ($p_{\mathit{present}}$), enroll ($p_{\mathit{enroll}}$), and then test positive ($\mathit{sensitivity}$) for dengue at a SEDSS facility. The probability of attending a SEDSS facility can be represented as the product of the probability of presenting and enrolling at that SEDSS site (${p_{attend.SEDSS}=p}_{\mathit{present}}\ast p_{\mathit{enroll}}$). To be reported in PADSS^NS, individuals must attend a PADSS facility ($p_{attend.PADSS}$) and then test positive for dengue ($\mathit{sensitivity}$). Within this catchment area, individuals who are seeking care but do not attend a SEDSS facility (i.e., they either present at SEDSS but then do not enroll, or they present at a PADSS facility) are instead noted as attending a PADSS facility ($p_{attend.PADSS}=1-p_{attend.SEDSS}$). In both surveillance systems, individuals are reported as probable or confirmed dengue cases