Physician characteristics overall and by level of training group.

<p>* Percentages incorporate survey design weights, and thus may not equal the crude proportions. Fewer than 12% of respondents failed to answer any individual question; the denominator includes only those who answered the question in order to give the most conservative estimate.</p><p>Physician characteristics overall and by level of training group.</p

Reported knowledge of and adherence to 1997 World Health Organization treatment guidelines^.*

<p>*Percentages incorporate survey design weights, and thus may not equal the crude proportions.</p><p>Reported knowledge of and adherence to 1997 World Health Organization treatment guidelines^{<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003192#nt104" target="_blank">.*</a>}</p

Knowledge of early signs of shock and warning signs for severe dengue, how to make laboratory diagnosis and reported criteria for referral to hospital^.*

<p>* Percentages incorporate survey design weights, and thus may not equal the crude proportions. Fewer than 12% of respondents failed to answer any individual question; the denominator includes only those who answered the question in order to give the most conservative estimate.</p>†<p>1997 WHO case definition defined dengue as an acute febrile illness of 2 to 7 days duration with 2 or more of the following: headache, retro-orbital pain, myalgia, arthralgia, rash, hemorrhagic manifestations, leucopenia. Warning signs include: severe abdominal pain, persistent vomiting, cold and clammy skin/extremities, narrowing pulse pressure, hypotension, change in mental status (e.g., irritability, lethargy).</p><p>Knowledge of early signs of shock and warning signs for severe dengue, how to make laboratory diagnosis and reported criteria for referral to hospital^{<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003192#nt102" target="_blank">.*</a>}</p

Reported and estimated number of clincial dengue cases in Puerto Rico, 2005–2010 (with 95% CI).

<p>Panel A: Reported and Estimated Dengue Inpatients; Panel B: Reported and Estimated Dengue Outpatients. Notes: MA = Medically Attended patient classification sub-model which includes all patients who either had a completed Dengue Case Information Form (DCIF), or had some indication in their medical records (such as specimens sent to a laboratory for dengue testing) as potentially having a clinical case of dengue. DO = In this patient classification sub-model, labeled “DCIF Only (DO),” we included only those patients (in or out) definitively recorded as potential dengue case on a DCIF. See text for further details. The 95% CI (confidence interval) is the range between the 2.5% and 97.5% confidence estimates.</p

Estimates of dengue overall multiplier for inpatients in Puerto Rico: 2005 to 2010^a.

<p>Estimates of dengue overall multiplier for inpatients in Puerto Rico: 2005 to 2010<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0006650#t002fn001" target="_blank">^a</a>.</p

Schematic of model to estimate multipliers to correct for under-reporting of outpatient and hospitalized dengue cases.

<p>Notes; Multiplier D (only) is used for the inpatient module. Multiplier D and Multiplier E are used for the outpatient module. See text for further details. PDSS = Passive dengue surveillance system. EDSS = Enhanced dengue surveillance system. CDC-DB = U.S. Centers for Disease Control and Prevention, Dengue Branch (stationed in San Juan, Puerto Rico).</p

Clinical and laboratory diagnosis and reporting of dengue patients.

<p>Clinical and laboratory diagnosis and reporting of dengue patients.</p

Study population.

<p>The number of physicians residing in Puerto Rico who had an active license to practice medicine is shown in the first box. A random sample of 2,512 physicians who were likely to diagnose and treat dengue patients were sent a survey as shown in the second box. Of the 2,313 physicians who received the survey (third box), 817 completed the questionnaire (fourth box). Of the 817 respondents, 109 were excluded because they were no longer practicing medicine (fifth box). For the analysis, the 708 physicians were separated into three mutually exclusive groups: board certified, residency training only, and no residency training.</p

Reported and estimated rate of medically attended dengue per 1,000 general population in Puerto Rico (2005 to 2010).

<p>Reported and estimated rate of medically attended dengue per 1,000 general population in Puerto Rico (2005 to 2010).</p

Sensitivity analysis: Relative importance of individual multipliers in calculating the overall multiplier for reported dengue inpatients: Puerto Rico, 2010.

<p>Notes: a: Graph plots relative importance of the individual multipliers used to calculate the overall multiplier. The wider the plotted range (i.e., bar), the greater the change in the overall multiplier. b: Results calculated for MA = Medically Attended patient classification sub-model which includes all patients who either had a completed Dengue Case Information Form (DCIF), or had some indication in their medical records (such as specimens sent to a laboratory for dengue testing) as potentially having a clinical case of dengue. PDSS = Passive dengue surveillance system. EDSS = Enhance dengue surveillance system. IgM = Immunoglobulin M. Test indicates presence of dengue IgM antibodies using an antibody capture enzyme-linked immunosorbent assay. PCR = Polymerase chain reaction. Test indicates evidence of dengue RNA using by a Reverse transcription polymerase chain reaction (RT-PCR) test. See main text for detailed description of individual multipliers and how they are used to calculate the overall multiplier.</p