Implementation of Dengue Vaccine in 

Puerto Rico

Dr. Iris Cardona

Chief Medical Officer

Puerto Rico Department of Health

June, 2021
Population under VFC

Children 7-18 years

VFC 45%

Medicaid 41%

Uninsured 4%

Private 55%
Regions and VFC providers

Lares

Utuado

Camuy

Hatillo

San 

Sebastián

Isabela

Aguada

Rincón

Añasco

Moca

Las Marías

Mayagüez

Maricao Adjuntas

Sabana 

Grande

San Yauco

Germán

Arecibo

Ciales Morovis

Vega 

Baja Vega 

Alta

Orocovis

Corozal

Dorado

Toa

Alta

Barranquitas

Aibonito

Ponce Juana 

Díaz

Coamo

Santa 

Isabel Salinas

Jayuya

Lajas

Guánica

Cabo 

Rojo

Villalba

Guayama

Cayey

Cidra

Aguas 

Buenas

Patillas

Caguas

San 

Lorenzo

Las 

Piedras

Gurabo

Yabucoa

Juncos

Humacao

Naguabo

Ceiba

Luquillo

Río

Grande

Cataño Loíza

Comerío

Maunabo

Culebra

Manati

Aguadilla

Quebradillas

HORMIGUEROS

1000 Aguadilla Region

2000 Arecibo Region

3000 Bayamon Region

4000 Caguas Region 

Arecibo Region Bayamon Region

Metro Region

Fajardo Region

Caguas Region

Ponce Region

5000 Fajardo Region 

7000 Mayaguez Region

8000n Metro Region

9000 Ponce Region

9 VFC Providers

5 VFC Providers 

2 FQHC

2 Nursery

Mayagüez Region

9 VFC Providers

17 VFC Providers 

4 FQHC

4 Nursery

39 VFC Providers 3 FQHC

7 Nursery 28 VFC Providers

12 VFC Providers 

12 FQHC

3 Nursery

1 Hospital

41 VFC Providers

27 VFC Providers 

7 FQHC

6 Nursery

1 Hospital 

Aguadilla Region

13 VFC Providers

10 VFC Providers 

2 FQHC

1 Nursery

34 VFC Providers

19 VFC Providers 

12 FQHC

3 Nursery

34

39 9

39

39 VFC Providers

25 VFC Providers 

10 FQHC

3 Nursery

1 Hospital

28

13

17 41

29 VFC Providers 

• 209 VFC providers

• 296 Private providers
A child is eligible for the VFC Program if he or she is younger than 19 years of age and is 

one of the following:

✔Medicaid eligible

✔Un-insured

✔Under-insured

✔American Indian or Alaska native

Uninsured and underinsured children are eligible to receive only at Federally Qualified 

Health Centers (FQHC) or Rural Health Clinics (RHC). An FQHC is a type of provider that 

meets certain criteria under Medicaid programs.

VFC Program
PRDoH Immunization Program

Mission and Vision

Mission

To prevent the development of vaccine preventable diseases through strategic 

implementation and intervention facilitating services in accordance with the vaccine 

schedule for children, adolescents and adults of Puerto Rico.

Vision

To maintain a protected population against vaccine preventable diseases thus 

reducing outbreaks, hospitalizations and deaths. 
PRDoH Immunization Program

What we do?

• Recommend immunization public policy

• Guarantee immunization quality services

• Supply vaccines funded by the federal government to vaccine providers for Medicaid 

• Audit vaccine management, storage, handling and administration

• Promote and educate parents on importance and security of vaccines

• Implement the PR Immunization Law (#25)

• Do not offer direct patient care services except during public health emergencies
Enacted on September 1983

For all day care centers, 

schools and universities

Secretary of Health determines all 

immunization school requirements 

adhering to ACIP 

recommendations

Allow for medical and religious 

exemptions only

Puerto Rico 

Immunization Law

https://adobe.ly/31wTyVv
Estimated vaccination coverage adolescents 

13-17 years, Puerto Rico, 2019

58%

84%

96%

85%

87%

97%

0 10 20 30 40 50 60 70 80 90 100

HPV 2

HPV 1

MCV4

Tdap

VAR

Hep B

Percent Vaccinated

Fuente: Registro de Inmunización de PR (PRIR), Programa de Vacunación, Departamento de Salud de PR
Estimated coverage HPV vaccine adolescents 

13-17 years, Puerto Rico, 2007-2019

0

10

20

30

40

50

60

70

80

90

100

2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Percent Vaccinated

HPV1

HPV2

84%

Fuente: Registro de Inmunización de PR (PRIR), Programa de Vacunación, Departamento de Salud de PR

58%
Dengue vaccine 

implementation in Puerto Rico
Reported dengue cases in the Americas by 

year, 1980–2020 

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

Number of Dengue Cases by Year

Year

Source: Pan American Health Organization, PLISA Health Information Platform
Suspect 

Dengue in 

Puerto Rico, 

1986-2013

Dengue epidemics 

occur every 3-5 years 

in Puerto Rico
Education of providers and parents

• Assemble education materials for physicians 

• Training sessions

• Pediatric associations

• College of physicians

• College of nurses 

• Educational material for parents

• Post materials for doctor’s office and vaccination 

clinics

• Media campaign to inform the public
Who will pay?

• Vaccine costs covered by VFC and insurance

• Medicaid will cover the cost of the test for Medicaid eligible

• Insurance will cover the cost of the test for those with private

insurance

• For those uninsured or underinsured sources of funding will be

identified 
Pre-vaccination screening serologic testing 

• Puerto Rico laboratories have experience using non-FDA approved tests 

under Clinical Laboratory Improvement Amendments (CLIA) 

• The PR health department will consider providing specific guidance on 

the test approved locally for pre-vaccination

• After FDA approval pediatricians can apply for permission to run the test 

in their clinics

• Standing orders for dengue IgG pre-vaccination screening tests in 

immunization clinics will be considered

• Testing orders and results can be received online
Arbovirus surveillance system

• Dengue testing is currently centralized

• Arbovirus surveillance system will be updated to receive reports from 

private laboratories

• Test results will be linked to data from the immunization registry

Arbovirus

Surveillance 

database 

Immunization 

Registry
Negative

17

Health care provider

Interprets lab test 

Clinical 

laboratory

draw sample

Health care provider

orders lab test 

Testing at clinical 

laboratory Administer Vx 

Record in PRIR

Schedule next Vx

9-16-years old

Scenario 1: Provider with onsite 

laboratory and vaccination services

Arbovirus

Surveillance 

database 

Positive

END

Logistics of dengue vaccination in Puerto Rico

Immunization 

Registry

Pediatrician/MD Laboratory visit Pediatrician/MD Immunization provider 

Visit 1 Visit 1 Visit 1 Visit 1 
Negative

18

Health care provider

Interprets lab test 

Clinical 

laboratory

draw sample

Health care provider

orders lab test 

Testing at clinical 

laboratory Administer Vx 

Record in PRIR

Schedule next Vx

9-16-years old

Laboratory Process

Scenario 2: Provider does not have 

lab or vaccination services

Arbovirus

Surveillance 

database 

Positive

END

Logistics of dengue vaccination in Puerto Rico

Vaccine covered by VFC or insurance

Test cost covered by Medicaid or insurance

Immunization 

Registry

Pediatrician/MD Lab visit Email with MD Immunization provider 

Visit 1 Visit 2 or visit 3 Visit 4 
FQHC and CDT have all services 

Phased-in implementation can 

start at these sites

Pediatrician Laboratory Vaccination
How will we 

monitor for 

vaccine safety 

events postapproval?
Detection through VAERS

▪ Puerto Rico has an appointed and experienced VAERS coordinator

▪ Events regularly reported to VAERS

• 817 events reported in 2021 as of 5/22 (CDC WONDER)

▪ Likely to detect events immediately after vaccination
Long term vaccine safety

▪ Hospitalizations and severe dengue

▪ Will likely happen several years after vaccination

▪ Reported through the existing passive dengue surveillance system
DENV case surveillance in 

Puerto Rico

▪ All DENV testing centralized at Puerto 

Rico Department of Health Laboratory

• Biological and Chemical Emergency 

Laboratory (BCEL)

▪ Specimens submitted with case 

investigation form 

▪ All cases captured in Arboviral Database

▪ Under-reporting exists, ratio of 1 

reported for every 5–9 hospitalized 

(Shankar, 2018)
Enhancing surveillance for dengue cases after 

vaccination

▪ Conduct outreach to hospitals to educate about the dengue vaccine

▪ Retrain doctors on clinical suspicion of dengue

▪ Streamline and reinforce reporting of hospitalizations for suspected 

dengue cases

▪ Consider enhanced surveillance at children’s hospitals
Ascertaining vaccination information for 

hospitalized cases

▪ Add dengue vaccine history to arboviral case investigation form

▪ Confirm status with vaccine registry

▪ Monitor reported numbers of hospitalizations among vaccinated 

children to identify potential safety signals
• PRDoH adopts ACIP recommendations for local vaccine schedule- reviewed annually

• Immunization registry reporting is mandatory by administrative order

• Population 9-10 years old receive limited vaccines as no routine vaccines recommended

• Dengue testing can be incorporated to annual wellness visit

• About 25% of VFC providers have lab capability in house (FQHCs & CDTs), can start pilot 

dengue vaccination at these sites

• Vaccine series completion in age cohort is lower for 2nd and 3rd dose

Summary 
Summary

▪ VAERS in place to detect adverse events short-term after vaccination

▪ Existing DENV surveillance system can capture cases years after 

vaccination

• Need to prepare and strengthen infrastructure

▪ Can monitor overall numbers and use modeling to assess expected 

numbers
Questions?