Inter-outbreak stability reflects the size of the susceptible pool and forecasts magnitudes of seasonal epidemics

For dengue fever and other seasonal epidemics we show how the stability of the preceding inter-outbreak period can predict subsequent total outbreak magnitude, and that a feasible stability metric can be computed from incidence data alone. As an observable of a dynamical system, incidence data contains information about the underlying mechanisms: climatic drivers, changing serotype pools, the ecology of the vector populations, and evolving viral strains. We present mathematical arguments to suggest a connection between stability measured in incidence data during the inter-outbreak period and the size of the effective susceptible population. The method is illustrated with an analysis of dengue incidence in San Juan, Puerto Rico, where forecasts can be made as early as three to four months ahead of an outbreak. These results have immediate significance for public health planning, and can be used in combination with existing forecasting methods and more comprehensive dengue models.Directly measuring the size of the susceptible population is usually unfeasible before dengue outbreaks. Here, the authors show that the stability of low-incidence periods provides a proxy measure, which can be estimated from incidence data, and show its utility for forecasting outbreaks.