Estimating dengue under-reporting in Puerto Rico using a multiplier model

Dengue is a mosquito-borne viral illness that causes a variety of health outcomes, from a mild acute febrile illness to potentially fatal severe dengue. Between 2005 and 2010, the annual number of suspected dengue cases reported to the Passive Dengue Surveillance System (PDSS) in Puerto Rico ranged from 2,346 in 2006 to 22,496 in 2010. Like other passive surveillance systems, PDSS is subject to under-reporting. To estimate the degree of under-reporting in Puerto Rico, we built separate inpatient and outpatient probability-based multiplier models, using data from two different surveillance systems—PDSS and the enhanced dengue surveillance system (EDSS). We adjusted reported cases to account for sensitivity of diagnostic tests, specimens with indeterminate results, and differences between PDSS and EDSS in numbers of reported dengue cases. In addition, for outpatients, we adjusted for the fact that less than 100% of medical providers submit diagnostic specimens from suspected cases. We estimated that a multiplication factor of between 5 (for 2010 data) to 9 (for 2006 data) must be used to correct for the under-reporting of the number of laboratory-positive dengue inpatients. Multiplication factors of between 21 (for 2010 data) to 115 (for 2008 data) must be used to correct for the under-reporting of laboratory-positive dengue outpatients. We also estimated that, after correcting for underreporting, the mean annual rate, for 2005–2010, of medically attended dengue in Puerto Rico to be between 2.1 (for dengue inpatients) to 7.8 (for dengue outpatients) per 1,000 population. These estimated rates compare to the reported rates of 0.4 (dengue outpatients) to 0.1 (dengue inpatients) per 1,000 population. The multipliers, while subject to limitations, will help public health officials correct for underreporting of dengue cases, and thus better evaluate the cost-and-benefits of possible interventions.Author summary: The number of global cases of dengue has increased an estimated 30-fold from 1962 to 2012, and two-fifths of the world’s population are thought to be at risk for dengue. It has been recently estimated that the global incidence of dengue is between 50 and 100 million cases per year. These estimates of burden and impact are, however, are not considered very reliable. It has been previously established and reported that there is notable under-reporting of clinical cases of dengue, even those who sought medical treatment. This includes under-reporting of those hospitalized with laboratory-confirmed dengue. This lack of reliable estimates hampers efforts of public health officials in determining the of burden of disease and the costs-and-benefits of potential interventions. We estimated that multiplication factors ranging from 5 to 9 must be used to correct for under-reporting of laboratory-positive dengue inpatient cases reported to public health officials in Puerto Rico. Multiplication factors ranging from 21 to 115 must be used to correct for the underreporting of laboratory-positive dengue outpatients. Our results illustrate the need for, and thus potential benefits of, using our methodology to estimate the degree of under-reporting in passive dengue systems during epidemic and non-epidemic years.