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Dengue activity in Puerto Rico during an interepidemic period (1995-1997).
From 1995 to 1997 dengue was reported in Puerto Rico at an average annual rate of 1.75/1,000 population, compared to 6.73 in 1994, an epidemic year. Dengue virus serotypes 1 (DEN-1), -2, and -4 were isolated each year, with DEN-2 predominating in 1995 and 1996, and DEN-4 in 1997. From 1995 through 1997 incidence was highest (0.61-0.77/1,000) in persons under 30 years of age; males and females were equally affected. Among positive cases, 28.3% to 37.9% were hospitalized; 28.9% to 35.2% had hemorrhagic manifestations; at least 1.1% to 1.6% fulfilled the criteria for dengue hemorrhagic fever/dengue shock syndrome; and 0.2% to 0.3% died. Neither hurricane preparations (1995) nor widespread floods (1996) seem to have affected dengue incidence. Most municipalities with the highest laboratory-diagnosed dengue rates in 1995 were in the eastern foothills of the central mountains, an area relatively spared by the 1994 epidemic. In the next two years, at least half of the municipalities with the highest laboratory-diagnosed dengue rates were in the west. The most intense municipal outbreak of this period (DEN-2, Villalba, 1995, rate of 11.67/1,000) is described to highlight the importance of local conditions and epidemiologic history in determining the risk of dengue.