title: Enhanced Surveillance for Fatal Dengue-Like Acute Febrile Illness in Puerto Rico, 2010-2012.
abstract: BACKGROUND
  Dengue is a leading cause of morbidity throughout the tropics; however, accurate population-based estimates of mortality rates are not available.
  
  
  RESULTS
  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, 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
  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.
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico.
authors.forename: Kay M
authors.identifier: http://orcid.org/0000-0001-7741-7072
authors.initials: KM
authors.lastname: Tomashek
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico.
authors.forename: Aidsa
authors.initials: A
authors.lastname: Rivera
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico.
authors.forename: Brenda
authors.initials: B
authors.lastname: Torres-Velasquez
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico.
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Hunsperger
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico.
authors.forename: Jorge L
authors.initials: JL
authors.lastname: Munoz-Jordan
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico.
authors.forename: Tyler M
authors.initials: TM
authors.lastname: Sharp
authors.affiliation: Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico.
authors.forename: Irma
authors.initials: I
authors.lastname: Rivera
authors.affiliation: Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico.
authors.forename: Dario
authors.initials: D
authors.lastname: Sanabria
authors.affiliation: Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, CDC, Atlanta, Georgia, United States of America.
authors.forename: Dianna M
authors.initials: DM
authors.lastname: Blau
authors.affiliation: Bacterial Special Pathogens Branch, Division of High Consequence Pathogens, CDC, Atlanta, Georgia, United States of America.
authors.forename: Renee
authors.initials: R
authors.lastname: Galloway
authors.affiliation: Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico.
authors.forename: Jose
authors.initials: J
authors.lastname: Torres
authors.affiliation: Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico.
authors.forename: Rosa
authors.initials: R
authors.lastname: Rodriguez
authors.affiliation: Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico.
authors.forename: Javier
authors.initials: J
authors.lastname: Serrano
authors.affiliation: Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico.
authors.forename: Carlos
authors.initials: C
authors.lastname: Chávez
authors.affiliation: Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico.
authors.forename: Francisco
authors.initials: F
authors.lastname: Dávila
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico.
authors.forename: Janice
authors.initials: J
authors.lastname: Perez-Padilla
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico.
authors.forename: Esther M
authors.initials: EM
authors.lastname: Ellis
authors.affiliation: Demographic Registry of Puerto Rico, San Juan, Puerto Rico.
authors.forename: Gladys
authors.initials: G
authors.lastname: Caballero
authors.affiliation: Geospatial Research, Analysis, and Services Program, Division of Toxicology and Human Health Sciences, ATSDR, Atlanta, Georgia, United States of America.
authors.forename: Laura
authors.initials: L
authors.lastname: Wright
authors.affiliation: Infectious Diseases Pathology Branch, Division of High Consequence Pathogens and Pathology, CDC, Atlanta, Georgia, United States of America.
authors.forename: Sherif R
authors.initials: SR
authors.lastname: Zaki
authors.affiliation: Puerto Rico Department of Health, San Juan, Puerto Rico.
authors.forename: Carmen
authors.initials: C
authors.lastname: Deseda
authors.affiliation: Puerto Rico Institute of Forensic Sciences, San Juan, Puerto Rico.
authors.forename: Edda
authors.initials: E
authors.lastname: Rodriguez
authors.affiliation: Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention (CDC), San Juan, Puerto Rico.
authors.forename: Harold S
authors.initials: HS
authors.lastname: Margolis
mesh_terms: D000208:Acute Disease / Q000453:epidemiology; D000293:Adolescent; D000328:Adult; D060085:Coinfection / Q000453:epidemiology; D003715:Dengue / Q000453:epidemiology / Q000401:mortality* / Q000821:virology; D003716:Dengue Virus / Q000235:genetics / Q000276:immunology / Q000302:isolation & purification; D004196:Disease Outbreaks / Q000706:statistics & numerical data*; D062665:Epidemiological Monitoring; D005260:Female; D006801:Humans; D007919:Leptospira / Q000235:genetics / Q000276:immunology; D007922:Leptospirosis / Q000453:epidemiology / Q000382:microbiology; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D009026:Mortality; D011647:Puerto Rico / Q000453:epidemiology; D013997:Time Factors; D014902:West Nile virus / Q000235:genetics / Q000276:immunology; D055815:Young Adult