Occurrence of severe dengue in Rio de Janeiro: an
                    ecological study

Gibson, Gerusa; Souza-Santos, Reinaldo; Pedro, Alexandre San; Honório, Nildimar Alves; Sá Carvalho, Marilia

doi:10.1590/0037-8682-0223-2014

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Major Articles • Rev. Soc. Bras. Med. Trop. 47 (6) • Nov-Dec 2014 • https://doi.org/10.1590/0037-8682-0223-2014 copy

Occurrence of severe dengue in Rio de Janeiro: an ecological study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Introduction

This study aimed to analyze the relationship between the incidence of severe dengue during the 2008 epidemic in Rio de Janeiro, Brazil, and socioeconomic indicators, as well as indicators of health service availability and previous circulation of the dengue virus serotype-3 (DENV-3).

Methods

In this ecological study, the units of analysis were the districts of Rio de Janeiro. The data were incorporated into generalized linear models, and the incidence of severe dengue in each district was the outcome variable.

Results

The districts with more cases of dengue fever in the 2001 epidemic and a higher percentage of residents who declared their skin color or race as black had higher incidence rates of severe dengue in the 2008 epidemic [incidence rate ratio (IRR)= 1.21; 95% confidence interval (_95%CI)= 1.05-1.40 and IRR= 1.34; _95%CI= 1.16-1.54, respectively]. In contrast, the districts with Family Health Strategy (FHS) clinics were more likely to have lower incidence rates of severe dengue in the 2008 epidemic (IRR= 0.81; _95%CI= 0.70-0.93).

Conclusions

At the ecological level, our findings suggest the persistence of health inequalities in this region of Brazil that are possibly due to greater social vulnerability among the self-declared black population. Additionally, the protective effect of FHS clinics may be due to the ease of access to other levels of care in the health system or to a reduced vulnerability to dengue transmission that is afforded by local practices to promote health.

Severe dengue; Health inequities; Self-declared skin color; Family Health Strategy; Epidemiology

Age group (years)	Dengue fever		Severe dengue		NM+	Total
Age group (years)	cases	incidence*	cases	incidence*	NM+	Total
≤ 5	1,016	204.1	410	82.4	3,668	5,094
6-15	3,269	364.1	2,632	293.1	11,017	16,918
16-20	1,099	308.8	365	102.6	3,810	5,274
21-35	2,956	194.8	784	51.7	10,667	14,407
36-50	2,335	180.6	766	59.2	7,101	10,202
51-60	1,141	159.9	377	52.8	2,888	4,406
> 60	804	90.8	387	43.7	1,903	3,094
Total	12,620	204.8	5,721	92.9	41,054	59,395

Indicator	Univariate analysis		Multivariate analysis
Indicator	IRR	95% CI	IRR	95% CI
Previous circulation of DENV-3 serotype (number of dengue cases in the 2001 epidemic)^* * Variables with statistical significance in the univariate analysis; IRR reflects the variation in the incidence rate per each 1-standard-deviation increment in the mean of the predictive variable. The indicator domestic waste collection service in substandard settlements lost statistical significance as an explanatory variable in the multivariate analysis and was therefore eliminated from the final model.	1.23	[1.04-1.46]	1.21	[1.05-1.40]
Family Health Strategy clinics^* * Variables with statistical significance in the univariate analysis; IRR reflects the variation in the incidence rate per each 1-standard-deviation increment in the mean of the predictive variable. The indicator domestic waste collection service in substandard settlements lost statistical significance as an explanatory variable in the multivariate analysis and was therefore eliminated from the final model.	0.89	[0.58-0.92]	0.81	[0.70-0.93]
Self-declaration of race or skin color as black^* * Variables with statistical significance in the univariate analysis; IRR reflects the variation in the incidence rate per each 1-standard-deviation increment in the mean of the predictive variable. The indicator domestic waste collection service in substandard settlements lost statistical significance as an explanatory variable in the multivariate analysis and was therefore eliminated from the final model.	1.30	[1.12-1.51]	1.34	[1.16-1.54]
Number of dengue fever cases in 2008	1.28	[1.11-1.48]	1.21	[1.05-1.39]
Water supply	1.15	[0.99-1.33]
Population density	1.04	[0.89-1.20]
Population living in favelas	1.10	[0.95-1.28]
Primary health care clinics	0.99	[0.86-1.15]
Low income	1.07	[0.87-1.31]
Domestic waste collection service	1.02	[0.88-1.19]
Domestic waste collection service in substandard settlements^* * Variables with statistical significance in the univariate analysis; IRR reflects the variation in the incidence rate per each 1-standard-deviation increment in the mean of the predictive variable. The indicator domestic waste collection service in substandard settlements lost statistical significance as an explanatory variable in the multivariate analysis and was therefore eliminated from the final model.	0.84	[0.73-0.98]

Variables/indicators per district	Mean	Standard deviation	Range [min-max]
Population per district in 2008	38,807.9	54,491.6	[160-321,949]
Number of severe dengue cases in 2008	36.6	42.7	[0-241]
Number of dengue fever cases in 2008	80.6	154.0	[0-1,575]
Water supply service^a a Proportion of permanent private domiciles that store rain water in cisterns.	0.02	0.05	[0-0.47]
Number of Family Health Strategy clinics	0.21	0.59	[0.0-4.0]
Previous circulation of the DENV-3 serotype^b b Number of cases in the 2001 dengue epidemic.	65.7	197.23	[1.0-898.0]
Population density^c c Ratio of the district population to its area in km2.	14,878.6	12,402.7	[17.4-96,515.8]
Population living in favelas^d d Proportion of residents living in substandard settlements.	16.07	15.76	[0.0-71.7]
Number of primary health care clinics	0.47	0.90	[0.0-6.0]
Low-income population^e e Proportion of residents in permanent private domiciles with no exclusive bathroom access and no toilet.	0.11	0.42	[0.0-4.2]
Self-declared black population^f f Percentage of residents who declared their skin color or race as black.	11.15	4.68	[1.5-27.7]
Domestic waste collection service^g g The proportion of permanent private domiciles that discharge domestic waste on empty lots or on the street.	0.54	1.32	[0.0-10.6]
Domestic waste collection service in substandard settlements^h h Proportion of permanent domiciles in substandard settlements in which domestic waste is collected by open skip.	34.69	31.82	[0.0-98.7]

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