BackgroundDengue is a potentially fatal acute febrile illness (AFI) caused by four mosquito-transmitted dengue viruses (DENV-1–4) that are endemic in Puerto Rico. In January 2010, the number of suspected dengue cases reported to the passive dengue surveillance system exceeded the epidemic threshold and an epidemic was declared soon after.Methodology/Principal FindingsTo characterize the epidemic, surveillance and laboratory diagnostic data were compiled. A suspected case was a dengue-like AFI in a person reported by a health care provider with or without a specimen submitted for diagnostic testing. Laboratory-positive cases had: (i) DENV nucleic acid detected by reverse transcriptase-polymerase chain reaction (RT-PCR) in an acute serum specimen; (ii) anti-DENV IgM antibody detected by ELISA in any serum specimen; or (iii) DENV antigen or nucleic acid detected in an autopsy-tissue specimen. In 2010, a total of 26,766 suspected dengue cases (7.2 per 1,000 residents) were identified, of which 46.6% were laboratory-positive. Of 7,426 RT-PCR-positive specimens, DENV-1 (69.0%) and DENV-4 (23.6%) were detected more frequently than DENV-2 (7.3%) and DENV-3 (<0.1%). Nearly half (47.1%) of all laboratory-positive cases were adults, 49.7% had dengue with warning signs, 11.1% had severe dengue, and 40 died. Approximately 21% of cases were primary DENV infections, and 1–4 year olds were the only age group for which primary infection was more common than secondary. Individuals infected with DENV-1 were 4.2 (95% confidence interval [CI]: 1.7–9.8) and 4.0 (95% CI: 2.4–6.5) times more likely to have primary infection than those infected with DENV-2 or -4, respectively.Conclusions/SignificanceThis epidemic was long in duration and yielded the highest incidence of reported dengue cases and deaths since surveillance began in Puerto Rico in the late 1960's. This epidemic re-emphasizes the need for more effective primary prevention interventions to reduce the morbidity and mortality of dengue.

Our findings illustrate the importance of evaluating work-related injuries separately for aides and nurses, given differences in injury risk profiles and injury outcomes. It is particularly important that occupational safety needs of aides be addressed as this occupation experiences significant job growth.

Records from the Office of the North Carolina Chief Medical Examiner were used to describe 3955 deaths, both on and off the job, between 1988 and 1994 from external causes of injury (E-codes) among individuals whose usual occupation was in the construction trades. For the calculation of rates, population sizes were estimated using 1980 and 1990 census data. Deaths from injuries occurred at an average rate of 226 per 100,000 population; 213 per 100,000 for non-work-related fatalities and 13 per 100,000 for work-related fatalities. Overall, deaths were most often from guns or motor vehicle accidents. Work-related deaths were most often caused by motor vehicles (21%); falls (20%), most commonly from roofs or scaffolds; and machinery (15%), electrocutions (14%), and falling objects (10%). Three major causes of work-related motor vehicle accidents were identified including injuries to pedestrians in highway work zones and in backovers on construction sites, and injuries to drivers caused by shifting loads while transporting construction materials. The circumstances surrounding deaths involving scaffolding document the need for training and safety procedures for erecting, moving, and disassembling scaffolds, but also for safe work practices on scaffolds. Training and safety procedures to avoid electrocutions must involve workers who are not in the electrical trades, as these deaths often occurred among individuals who were not electricians or linemen. Significant differences were observed in the proportion of victims having elevated blood-alcohol levels depending on whether the injury was work-related; 57 percent of victims were impaired at the time of fatal non-work-related injuries compared to 5 percent of work-related injuries. Interventions to treat and prevent alcohol abuse among construction workers could have a significant public health impact in the prevention of premature death from injury, particularly outside the workplace.

Hospital workers are known to be at risk of physical assault. The objective of this study is to characterize injuries resulting from physical assault among hospital nursing staff and to identify associated risk factors. Workers' compensation reports linked to human resources data were used to identify a cohort of aides and nurses employed in acute care units at a major healthcare system from 1997 to 2004 and their reported physical assault events. Poisson regression methods were used to estimate rates and rate ratios (RR) by occupation, gender, race, age, tenure, and hospital unit. During the study period 220 assaults were reported; the overall incidence rate was 1.65 (95% CI: 1.45-1.89) per 100 full-time-equivalent employees (FTEs). Assault risk was higher among those with shorter tenure (< 5 years vs. 15 or more) (RR=1.35, 95% CI: 0.83-2.19) and younger workers (under age 30 vs. 50 or older) (RR=1.30, 95%CI: 0.78-2.19), and lower among Black workers (vs. non-Blacks) (RR=0.63, 95% CI: 0.45-0.90). Incidence rates were highest in Psychiatry (12.65, Neurology (4.43, and Rehabilitation (3.63, 95% CI: 1.51-8.71) units. Interventions targeting Psychiatry, Neurology, and Rehabilitation units, and younger and newly hired staff are warranted. More detailed data are needed to develop targeted interventions.

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.