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Enhanced Surveillance for Fatal Dengue-Like Acute Febrile Illness in Puerto Rico, 2010-2012
BackgroundDengue is a leading cause of morbidity throughout the tropics; however, accurate population-based estimates of mortality rates are not available.Methods/principal findingsWe established the Enhanced Fatal Acute Febrile Illness Surveillance System (EFASS) to estimate dengue mortality rates in Puerto Rico. Healthcare professionals submitted serum and tissue specimens from patients who died from a dengue-like acute febrile illness, and death certificates were reviewed to identify additional cases. Specimens were tested for markers of dengue virus (DENV) infection by molecular, immunologic, and immunohistochemical methods, and were also tested for West Nile virus, Leptospira spp., and other pathogens based on histopathologic findings. Medical records were reviewed and clinical data abstracted. A total of 311 deaths were identified, of which 58 (19%) were DENV laboratory-positive. Dengue mortality rates were 1.05 per 100,000 population in 2010, 0.16 in 2011 and 0.36 in 2012. Dengue mortality was highest among adults 19-64 years and seniors ≥65 years (1.17 and 1.66 deaths per 100,000, respectively). Other pathogens identified included 34 Leptospira spp. cases and one case of Burkholderia pseudomallei and Neisseria meningitidis.Conclusions/significanceEFASS showed that dengue mortality rates among adults were higher than reported for influenza, and identified a leptospirosis outbreak and index cases of melioidosis and meningitis
Measuring the water and soil environments
<p>Characteristics of all fatal laboratory-positive dengue case-patients detected by the Enhanced Fatal AFI Surveillance System, Puerto Rico, 2010–2012.</p
Enhanced Surveillance for Fatal Dengue-Like Acute Febrile Illness in Puerto Rico, 2010-2012
<div><p>Background</p><p>Dengue is a leading cause of morbidity throughout the tropics; however, accurate population-based estimates of mortality rates are not available.</p><p>Methods/Principal Findings</p><p>We established the Enhanced Fatal Acute Febrile Illness Surveillance System (EFASS) to estimate dengue mortality rates in Puerto Rico. Healthcare professionals submitted serum and tissue specimens from patients who died from a dengue-like acute febrile illness, and death certificates were reviewed to identify additional cases. Specimens were tested for markers of dengue virus (DENV) infection by molecular, immunologic, and immunohistochemical methods, and were also tested for West Nile virus, <i>Leptospira spp</i>., and other pathogens based on histopathologic findings. Medical records were reviewed and clinical data abstracted. A total of 311 deaths were identified, of which 58 (19%) were DENV laboratory-positive. Dengue mortality rates were 1.05 per 100,000 population in 2010, 0.16 in 2011 and 0.36 in 2012. Dengue mortality was highest among adults 19–64 years and seniors ≥65 years (1.17 and 1.66 deaths per 100,000, respectively). Other pathogens identified included 34 <i>Leptospira spp</i>. cases and one case of <i>Burkholderia pseudomallei</i> and <i>Neisseria meningitidis</i>.</p><p>Conclusions/Significance</p><p>EFASS showed that dengue mortality rates among adults were higher than reported for influenza, and identified a leptospirosis outbreak and index cases of melioidosis and meningitis.</p></div
Diagnostic laboratory results for fatal laboratory-positive dengue cases detected by the Enhanced Fatal Acute Febrile Illness Surveillance System, Puerto Rico 2010–2012.
<p>Diagnostic laboratory results for fatal laboratory-positive dengue cases detected by the Enhanced Fatal Acute Febrile Illness Surveillance System, Puerto Rico 2010–2012.</p
Number of laboratory-positive dengue cases reported to the Passive Dengue Surveillance System and fatal laboratory-positive dengue cases detected by the Enhanced Fatal AFI Surveillance System by month of illness onset, Puerto Rico 2010–2012.
<p>Number of laboratory-positive dengue cases reported to the Passive Dengue Surveillance System and fatal laboratory-positive dengue cases detected by the Enhanced Fatal AFI Surveillance System by month of illness onset, Puerto Rico 2010–2012.</p
Incidence of laboratory-positive dengue, and observed and expected number of fatal laboratory-positive dengue cases by municipality of residence and year, Puerto Rico, 2010–2012.
<p>Left panels: Incidence per 100,000 population of non-fatal, laboratory-positive dengue cases reported to the Passive Dengue Surveillance System, and number of fatal laboratory-positive dengue cases identified by the Enhanced Fatal AFI Surveillance System. Right panels: the standard deviation (SD) of the standard residuals are displayed. Differences >2 SD denotes significantly fewer than expected fatal laboratory-positive dengue cases, while ≤2 SD denotes significantly more than expected fatal laboratory-positive dengue cases.</p