Dengue Vaccine 

Knowledge and Attitudes 

in Puerto Rico

Ines Esquilin, MD

Professor of Pediatrics, University of Puerto Rico

ACIP, June 23, 2021
Outline

• General Population 2021

• Opinions on a generic dengue vaccine 

• From household survey in Southern Puerto Rico

• Physicians 2020

• Online vaccine knowledge and attitudes survey in Puerto Rico

• Sponsored by the Puerto Rico Academy of Pediatrics

• Parents of children ages 9-16 years 2020 and 2021

• Focus groups and discussion groups

• Behavioral Science Team, Dengue Branch, San Juan

 Community-based 

cohort study, 

using data from 

Nov 2020 to June 

2021

 Participants 

recruited from 

selected 

households in 38 

cluster areas
 Enrollment offered to all household members that meet eligibility 

requirements:

• 1–50 years old

 Survey included questions on interest in a free or low cost (≤$10) dengue 

vaccine if approved and available in Puerto Rico
Interest in dengue vaccine among adult participants in COPA, 2020-2021 (N = 

1,082)

84%

6%

11%

83%

8% 8%

0%

20%

40%

60%

80%

100%

Would receive dengue vaccine Unsure if would receive dengue

vaccine

Would not receive dengue vaccine

Percentage of participants 

For themselves

For their children (where applicable, n = 659)
Reasons would not or unsure if would vaccinate children among adult 

participants in COPA, 2021 (N = 111)

7%

5%

1%

1%

2%

2%

2%

4%

14%

17%

50%

0% 20% 40% 60% 80% 100%

No reason or unspecified

Other

Cost

Need to consult with my doctor

Not worried about getting dengue

Have heard negative things about vaccine

Don't believe that it works

Need more info on use in other countries

Don't believe in vaccines

Need more info on how it works

Not safe/worried about side effects

Percentage of participants
Dengue and general vaccine perceptions among adult participants in COPA by 

reported willingness to vaccinate children against dengue, 2021 (N = 659)

92%

98%

92% 95%

89%

77%

61%

87%

0%

20%

40%

60%

80%

100%

Believe that dengue is

severe and can cause

death

Believe that vaccines are

important to prevent

certain diseases

Believe that vaccines

approved by the FDA are

safe

Children's vaccines are upto-date

Percentage of participants

Would vaccinate children against dengue (n = 548)

Unsure or would not vaccinate children against dengue (n = 111)
Dengvaxia Vaccine Knowledge 

and Attitudes Survey- Puerto 

Rico Physicians
Puerto Rico physician survey on Dengvaxia

Methods

• Sponsored by the Puerto Rico Academy of Pediatrics, the Puerto Rico 

College of Physicians, the Puerto Rico Science and Technology Trust and the 

University of Georgia 

• Presentations by CDC Dengue Branch pediatrician to local pediatric 

associations during continuing education meetings in 2019 and 2020

• Survey includes info on risks of hospitalization and severe illness in 

vaccinated seronegatives and implications for pre-vaccination test 

specificity 

• Number of participants 114
Do you administer vaccines in your office? (n=114)

31% 

69% 

Missing: 4
Do you think dengue is a significant public health 

problem in the Puerto Rico? (n=114)

98% 

1% 

1% 

Missing: 4
Do you know there is an FDA approved vaccine for 

dengue known as Dengvaxia? (n=114)

57%

43%

Missing: 3
Assuming a laboratory test with acceptable specificity were available, 

would you recommend Dengvaxia to your pediatric patients? (n=114)

73% 

6% 

21% 

Missing: 10
If yes, why would you recommend Dengvaxia to your pediatric patients? 

(n=76)

Response No. Rank

Dengue is an important public health 

problem

70 1

Laboratory testing sufficiently reduces 

the risk

29 2

Other 1 3
If no or unsure, why? (n=28)

Response Number Rank

I need to get more information 21 1

Concern about the risks of vaccination 20 2

I would prefer to wait until a better vaccine comes along 11 3

The vaccine is not sufficiently efficacious 2 4

I have heard negative things about the vaccine 1 5

Dengue is not an important enough health problem 1 5
For the patients you have diagnosed with dengue, do you have 

documentation of positive dengue laboratory tests in the medical 

record? (n=114)

5% 

43% 

38% 

9% 

5% 

Missing: 13
Would you favor a phased in (e.g., slowly scaling up starting with 

discrete high risk populations) approach of dengue vaccination with 

Dengvaxia before implementing a large-scale program in school age 

children throughout Puerto Rico? (n=114)

76% 

8% 

16% 

Missing: 13
Assessing acceptability of 

Dengvaxia vaccination by 

parents and physicians

Behavioral Science/Communications Team

CDC Dengue Branch, San Juan
Objectives 

 Assess acceptability to vaccinate children with Dengvaxia by parents and 

physicians
Methods

2020 - Assessment of Dengvaxia acceptability

 5 focus group discussions with parents

 15 in-depth interviews with pediatricians, researchers and school officials

2021 - Validation of messages

 4 group discussions (GD) 

• Physicians – 2 GD 

• Parents – 2 GD 

 Data collection

• Written notes and recording 

 Analysis

• Category-based content analysis of notes

• Unit of analysis – participants’ comments
Opinions about dengue vaccines

 Most participants had questions about dengue and a dengue 

vaccine

• “Parents should be given support [information] about the types [of 

dengue]. That they understand that the vaccine is important, they 

must be clear that there are different types [of dengue] and even if 

you have already got one, you can get another.” 

 A few participants had mixed opinions about having a dengue 

vaccine

• “I would love it if there was a dengue vaccine; I would use it, but I 

would wait to see the effects it would have in other children.”

• “I don’t find this vaccine necessary.”

• “It (the vaccine) should be optional. ”
Willingness to vaccinate

• Yes

• “If he had a previous dengue infection, yes.”

• “...the blood test gives me peace of mind, and yes, I would consider it.”

• No

• “No, because there is not enough research and data... There needs to be 

something longitudinal where we can see the effects.”

• Unsure

• “I will continue to inform myself a little more, for a little while.”
Pediatricians’ opinions about a dengue vaccine

 Almost all pediatricians had a positive 

opinion about having a dengue vaccine for 

children between 9 to 16 years of age.

− Participants said it would be ideal to have a broader 

age range (i.e. infants)

− One participant thought that if morbidity and 

hospitalized dengue cases was low among children, 

parents would hesitate to vaccinate 

“I agree the vaccine be added; it is a health problem we have in 

Puerto Rico and if there is a way to prevent it, then yes. "
Pediatricians’ motivators and barriers 

Dengvaxia Vaccination Program

 Barriers

—Payment for vaccine or test

—Prolonged time to receive dengue 

test results

 Motivators

– Support of vaccines

– Dengue prevention is a priority

– Dengvaxia studies showed a decrease 

in hospitalizations and serious clinical 

outcomes "There are several strategies such as 

repeating the test, to reduce risks. 

I would be willing to be part of it 

because preventing dengue should 

be priority number 1." 

“I prefer to prevent than to treat.”

 Most mentioned they would participate in a vaccination program with Dengvaxia.
Information needs about Dengvaxia

 Justification for age range 

(9-16)

 Studies in other countries 

 Approval process 

 Vaccine type / components

 Dosage / schedule

 Effectiveness

 Side effects

 Risk and benefits 

 Interaction with medications 

and medical conditions

 Reactions of vaccine with 

subsequent dengue infection

 Countries using the vaccine

 Justification of use in US 

territories

 PR Department of Health’s 

scheduled vaccines requirement

 Dengue lab tests
Best Sources of Information

Best Sources 

Information

Doctors Nurses

Academy
Conclusions

General population

• Participants demonstrated interest in the dengue vaccine among 

most adult participants for themselves and their children.

• Side effects and possible adverse reactions were the most important 

reason for those not wanting to receive the dengue vaccine.
Conclusions

Physician’s survey

• Most participants were pediatricians

• Almost all physicians recognize that dengue is a significant public health problem 

in PR, 44% were not aware that there is a FDA approved dengue vaccine.

• Further physician education needed regarding Dengvaxia vaccine, its schedule 

and efficacy, and safety

• Most physicians would recommend the vaccine if a laboratory test with 

acceptable specificity were available to document prior dengue infection.

• Medical record documentation of past positive dengue laboratory diagnostic tests 

for patients is limited
Conclusions

Focus groups and discussion groups

• Most parents would agree to vaccinate if they have information on 

Dengvaxia including efficacy, side effects, rationale for use in Puerto Rico 

and current use in other countries

• Having the support of the Universities, PRDH and CDC is important. Main 

influencers will be pediatricians.

• Pediatricians showed overall support, recognized that dengue is a 

priority and that Dengvaxia has shown efficacy against hospitalization. 
Thank You!