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Community beliefs and practices about dengue in Puerto Rico
Pérez-Guerra,Carmen L.; Zielinski-Gutierrez,Emily; Vargas-Torres,Danulka; Clark,Gary G.;
Revista Panamericana de Salud Pública , 2009, DOI: 10.1590/S1020-49892009000300005
Abstract: objective: in spite of long-term endemicity and repeated government and private efforts, effective, sustained community participation for dengue prevention remains a challenge in puerto rico. this study explored differences found in interviews conducted in 2001 in attitudes toward dengue and its prevention by respondents' gender and whether they had a prior dengue infection. findings may be used to develop messages to promote aedes aegypti control practices. methods: from september to october 2003, 11 focus groups were conducted in san juan, puerto rico. fifty-nine persons (35 women, 24 men), > 18 years of age, who had been identified through the puerto rico dengue surveillance system participated in the focus groups. analysis was based on grounded theory. results: women considered dengue important because of its economic, emotional, and health impact, and they were concerned more often than men about insufficient garbage removal and water disposal. participants with a previous dengue diagnosis were more concerned about risk of the disease, were more knowledgeable about dengue and its prevention, and recommended use of repellents more often than their counterparts without a previous dengue diagnosis. barriers to sustained dengue prevention included misconceptions from outdated educational materials, " invisibility" of dengue compared with chronic diseases, and lack of acceptance of responsibility for dengue prevention. conclusion: suggested strategies to motivate residents' actions included working with government agencies to address structural problems that increase mosquito populations, improving access to information on garbage collection and water disposal through telephone hotlines, increasing publicity and information about dengue by mass media campaigns, and educating health professionals.
Dengue Deaths in Puerto Rico: Lessons Learned from the 2007 Epidemic  [PDF]
Kay M. Tomashek ,Christopher J. Gregory,Aidsa Rivera Sánchez,Matthew A. Bartek,Enid J. Garcia Rivera,Elizabeth Hunsperger,Jorge L. Mu?oz-Jordán,Wellington Sun
PLOS Neglected Tropical Diseases , 2012, DOI: 10.1371/journal.pntd.0001614
Abstract: Background The incidence and severity of dengue in Latin America has increased substantially in recent decades and data from Puerto Rico suggests an increase in severe cases. Successful clinical management of severe dengue requires early recognition and supportive care. Methods Fatal cases were identified among suspected dengue cases reported to two disease surveillance systems and from death certificates. To be included, fatal cases had to have specimen submitted for dengue diagnostic testing including nucleic acid amplification for dengue virus (DENV) in serum or tissue, immunohistochemical testing of tissue, and immunoassay detection of anti-DENV IgM from serum. Medical records from laboratory-positive dengue fatal case-patients were reviewed to identify possible determinants for death. Results Among 10,576 reported dengue cases, 40 suspect fatal cases were identified, of which 11 were laboratory-positive, 14 were laboratory-negative, and 15 laboratory-indeterminate. The median age of laboratory-positive case-patients was 26 years (range 5 months to 78 years), including five children aged <15 years; 7 sought medical care at least once prior to hospital admission, 9 were admitted to hospital and 2 died upon arrival. The nine hospitalized case-patients stayed a mean of 15 hours (range: 3–48 hours) in the emergency department (ED) before inpatient admission. Five of the nine case-patients received intravenous methylprednisolone and four received non-isotonic saline while in shock. Eight case-patients died in the hospital; five had their terminal event on the inpatient ward and six died during a weekend. Dengue was listed on the death certificate in only 5 instances. Conclusions During a dengue epidemic in an endemic area, none of the 11 laboratory-positive case-patients who died were managed according to current WHO Guidelines. Management issues identified in this case-series included failure to recognize warning signs for severe dengue and shock, prolonged ED stays, and infrequent patient monitoring.
Knowledge and attitudes in Puerto Rico concerning dengue prevention
Pérez-Guerra,Carmen L.; Seda,Hilda; García-Rivera,Enid J.; Clark,Gary G.;
Revista Panamericana de Salud Pública , 2005, DOI: 10.1590/S1020-49892005000400005
Abstract: objective: dengue has been endemic in puerto rico for three decades. multiple educational and community-based efforts have been developed to inform the population about dengue prevention. we undertook this study to understand the community members' knowledge, attitudes, and practices related to dengue prevention and to elicit their ideas for future prevention campaigns. methods: a qualitative study based on grounded theory analysis was conducted between february and may of 2001. the study involved a total of 34 participants in four group interviews who had been identified through the puerto rico dengue surveillance system. results: in general, participants had correct knowledge about dengue prevention, but they did not associate the mosquitoes inside their houses with aedes aegypti. participants insisted that "neighbors" needed to control larval habitats, and the participants also asked the government to fumigate. conclusions: the patterns of knowledge and opinion that emerged in the discussions can be arranged along an axis going from high levels of correct knowledge to low levels of correct knowledge about dengue and dengue hemorrhagic fever and related practices. there were few participants at either extreme. three themes explained these patterns: misconceptions about dengue (based on previously delivered information), the "invisibility" of dengue (as compared to other diseases), and responsibility (individual and government). four strategies for preventive behaviors were recommended: developing community groups to identify community priorities on prevention, developing volunteer groups to deliver prevention messages, making house visits to demonstrate specific control measures, and conducting a complementary media campaign to support these strategies.
Perinatal transmission of dengue virus in Puerto Rico: a case report  [PDF]
Janice Pérez-Padilla, Rafael Rosario-Casablanca, Luis Pérez-Cruz, Carmen Rivera-Dipini, Kay Marie Tomashek
Open Journal of Obstetrics and Gynecology (OJOG) , 2011, DOI: 10.4236/ojog.2011.13016
Abstract: We report a laboratory confirmed case of vertical transmission of dengue in a mother-child pair in the eastern part of Puerto Rico. The clinical course of the pregnant female suggested a GBS infection, but laboratory tests confirmed it was dengue infection, one week after delivery. The male infant was healthy at birth, but one week after birth developed clinical complications related to vertical transmission of dengue. This report targets physicians in dengue endemic countries like Puerto Rico to be aware of the possibility of vertical transmission of dengue in symptomatic pregnant patients, especially around the time of delivery.
Physician Survey to Determine How Dengue Is Diagnosed, Treated and Reported in Puerto Rico  [PDF]
Kay M. Tomashek ,Brad J. Biggerstaff,Mary M. Ramos,Carmen L. Pérez-Guerra,Enid J. Garcia Rivera,Wellington Sun
PLOS Neglected Tropical Diseases , 2014, DOI: 10.1371/journal.pntd.0003192
Abstract: Dengue is a major cause of morbidity in Puerto Rico and is well-known to its physicians. Early case identification and timely initiation of treatment for patients with severe dengue can reduce medical complications and mortality. To determine clinical management and reporting practices, and assess knowledge of dengue and its management, a survey was sent to 2,512 physicians with a medical license in Puerto Rico. Of the 2,313 physicians who received the survey, 817 (35%) completed the questionnaire. Of the respondents, 708 were currently practicing medicine; 138 were board certified (Group 1), 282 were board eligible (Group 2), and 288 had not finished residency (Group 3). Although respondents clinically diagnosed, on average, 12 cases of dengue in the preceding three months, 31% did not report any suspected cases to public health officials while about half (56%) reported all cases. Overall, 29% of respondents correctly identified early signs of shock and 48% identified severe abdominal pain and persistent vomiting as warning signs for severe dengue with the proportion of correct respondents highest in Group 1. Reportedly about sixty percent (57%) appropriately never give corticosteroids or prophylactic platelet transfusions to dengue patients. One third (30%) of respondents correctly identified administration of intravenous colloid solution as the best treatment option for dengue patients with refractory shock and elevated hematocrit after an initial trial of intravenous crystalloids, and nearly one half (46%) correctly identified administration of a blood transfusion as the best option for dengue patients with refractory shock and decreased hematocrit after a trial of intravenous crystalloids. Even though dengue has been endemic in Puerto Rico for nearly 4 decades, knowledge of dengue management is still limited, compliance with WHO treatment guidelines is suboptimal, and underreporting is significant. These findings were used to design a post graduate training course to improve the clinical management of dengue.
Local and Global Effects of Climate on Dengue Transmission in Puerto Rico  [PDF]
Michael A. Johansson ,Francesca Dominici,Gregory E. Glass
PLOS Neglected Tropical Diseases , 2009, DOI: 10.1371/journal.pntd.0000382
Abstract: The four dengue viruses, the agents of dengue fever and dengue hemorrhagic fever in humans, are transmitted predominantly by the mosquito Aedes aegypti. The abundance and the transmission potential of Ae. aegypti are influenced by temperature and precipitation. While there is strong biological evidence for these effects, empirical studies of the relationship between climate and dengue incidence in human populations are potentially confounded by seasonal covariation and spatial heterogeneity. Using 20 years of data and a statistical approach to control for seasonality, we show a positive and statistically significant association between monthly changes in temperature and precipitation and monthly changes in dengue transmission in Puerto Rico. We also found that the strength of this association varies spatially, that this variation is associated with differences in local climate, and that this relationship is consistent with laboratory studies of the impacts of these factors on vector survival and viral replication. These results suggest the importance of temperature and precipitation in the transmission of dengue viruses and suggest a reason for their spatial heterogeneity. Thus, while dengue transmission may have a general system, its manifestation on a local scale may differ from global expectations.
Clinical manifestations of dengue hemorrhagic fever in Puerto Rico, 1990-1991
Rigau-Pérez,José G.; ,;
Revista Panamericana de Salud Pública , 1997, DOI: 10.1590/S1020-49891997000500007
Abstract: the aim of the study reported here was to demonstrate that dengue hemorrhagic fever occurs in puerto rico, that it is underreported, and that this underreporting is due partly to underdiagnosis in hospitals. surveillance for severe dengue identified 986 hospitalizations for suspected dengue in 1990-1991. at the time, on the basis of available clinical and laboratory data, the surveillance system routinely identified 20 dhf cases, including three with dengue shock syndrome (dss). our subsequent review of these 986 patients' hospital records identified 102 whose records supported a clinical diagnosis of dhf (88) or dss (14). of the 102, there were 57 with positive virologic or serologic results for dengue and that met the world health organization criteria for dhf (fever, hemorrhagic manifestations, thrombocytopenia, and excessive capillary permeability). this group of 57 patients had a mean age of 38 years, contained a preponderance of males (34, 59.3%), included eight cases of dss, and involved two (3.5%) fatalities (in females 16 and 55 years old). hemorrhagic manifestations were mild; hemoconcentration, hypoalbuminemia, and elevated aspartate and alanine aminotransferase (ast and alt) levels were frequently encountered. the median duration of hospitalization was five days. the clinical description of these laboratory-positive dhf cases in puerto rico is consistent with previous descriptions of dhf in the medical literature; but the patients' age distribution is similar to the pattern typically found in the americas (where all age groups tend to be affected), as opposed to southeast asia (where mostly younger children are affected). the number of dhf cases identified by our study was nearly three times that reported through the established surveillance system. our findings indicate that recognition and reporting of dhf by local clinicians needs to be improved.
Clinical manifestations of dengue hemorrhagic fever in Puerto Rico, 1990-1991  [cached]
Rigau-Pérez José G.
Revista Panamericana de Salud Pública , 1997,
Abstract: The aim of the study reported here was to demonstrate that dengue hemorrhagic fever occurs in Puerto Rico, that it is underreported, and that this underreporting is due partly to underdiagnosis in hospitals. Surveillance for severe dengue identified 986 hospitalizations for suspected dengue in 1990-1991. At the time, on the basis of available clinical and laboratory data, the surveillance system routinely identified 20 DHF cases, including three with dengue shock syndrome (DSS). Our subsequent review of these 986 patients' hospital records identified 102 whose records supported a clinical diagnosis of DHF (88) or DSS (14). Of the 102, there were 57 with positive virologic or serologic results for dengue and that met the World Health Organization criteria for DHF (fever, hemorrhagic manifestations, thrombocytopenia, and excessive capillary permeability). This group of 57 patients had a mean age of 38 years, contained a preponderance of males (34, 59.3%), included eight cases of DSS, and involved two (3.5%) fatalities (in females 16 and 55 years old). Hemorrhagic manifestations were mild; hemoconcentration, hypoalbuminemia, and elevated aspartate and alanine aminotransferase (AST and ALT) levels were frequently encountered. The median duration of hospitalization was five days. The clinical description of these laboratory-positive DHF cases in Puerto Rico is consistent with previous descriptions of DHF in the medical literature; but the patients' age distribution is similar to the pattern typically found in the Americas (where all age groups tend to be affected), as opposed to Southeast Asia (where mostly younger children are affected). The number of DHF cases identified by our study was nearly three times that reported through the established surveillance system. Our findings indicate that recognition and reporting of DHF by local clinicians needs to be improved.
Guidelines on the cost-effectiveness of larval control programs to reduce dengue transmission in Puerto Rico
McConnell,K. John; Gubler,Duane J.;
Revista Panamericana de Salud Pública , 2003, DOI: 10.1590/S1020-49892003000600003
Abstract: objective: in the past 20 years, the emphasis for avoiding dengue epidemics has focused on larval control of aedes aegypti, the principal mosquito vector of dengue viruses. a general consensus is that mosquito larval control holds the best promise for reducing dengue epidemics, although its actual effectiveness is still unknown and subject to a great deal of uncertainty. the objective of this research was to assess the cost-effectiveness of emergency larval control programs for reducing dengue transmission in the caribbean island of puerto rico and to develop guidelines to help choose between carrying out a rapid-response, emergency larval control intervention and not conducting such an intervention. design and methods: data on dengue transmission and its likely impacts in puerto rico were used as a case study to develop intervention guidelines. a distribution of economic impacts was simulated using available data on disease rates and economic variables, including the costs of treating patients and the opportunity costs represented by lost wages. successful larval control interventions were assessed by determining two parameters: (1) the costs of an intervention and (2) the expected reduction in the reported case rate of dengue. in addition, we examined how these guidelines would change with an early warning system that provides information on a possible outbreak of dengue. results: in puerto rico, larval control programs that are expected to reduce dengue transmission by 50% and cost less than us$ 2.50 per person will be cost-effective. programs that cost more per person but that further reduce transmission are still likely to be cost-effective. having an early warning system, even one that provides a low level of accuracy, can extend the range of larval control programs that are cost-effective. for example, with an early warning system, a larval control program that reduces dengue transmission by 50% and that costs less than us$ 4.50 per person would be expected t
Guidelines on the cost-effectiveness of larval control programs to reduce dengue transmission in Puerto Rico
McConnell K. John,Gubler Duane J.
Revista Panamericana de Salud Pública , 2003,
Abstract: OBJECTIVE: In the past 20 years, the emphasis for avoiding dengue epidemics has focused on larval control of Aedes aegypti, the principal mosquito vector of dengue viruses. A general consensus is that mosquito larval control holds the best promise for reducing dengue epidemics, although its actual effectiveness is still unknown and subject to a great deal of uncertainty. The objective of this research was to assess the cost-effectiveness of emergency larval control programs for reducing dengue transmission in the Caribbean island of Puerto Rico and to develop guidelines to help choose between carrying out a rapid-response, emergency larval control intervention and not conducting such an intervention. DESIGN AND METHODS: Data on dengue transmission and its likely impacts in Puerto Rico were used as a case study to develop intervention guidelines. A distribution of economic impacts was simulated using available data on disease rates and economic variables, including the costs of treating patients and the opportunity costs represented by lost wages. Successful larval control interventions were assessed by determining two parameters: (1) the costs of an intervention and (2) the expected reduction in the reported case rate of dengue. In addition, we examined how these guidelines would change with an early warning system that provides information on a possible outbreak of dengue. RESULTS: In Puerto Rico, larval control programs that are expected to reduce dengue transmission by 50% and cost less than US$ 2.50 per person will be cost-effective. Programs that cost more per person but that further reduce transmission are still likely to be cost-effective. Having an early warning system, even one that provides a low level of accuracy, can extend the range of larval control programs that are cost-effective. For example, with an early warning system, a larval control program that reduces dengue transmission by 50% and that costs less than US$ 4.50 per person would be expected to be cost-effective. CONCLUSIONS: Guidelines such as the ones that we developed for Puerto Rico can be useful to public health authorities in helping to decide whether or not to spend resources for a larval control program to reduce dengue transmission. The range of larval control interventions that are cost-effective can be increased by having an early warning system that provides even a small amount of information regarding possible outbreaks.
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