Dengue & Chikungunya Surveillance in Fortaleza

valéry ridde
valéry riddeProfesseur agrégé à l'université de Montréal
VERDAS Workshop
Cali, Colombia. March 1st
and 2nd
2017
Dengue & Chikungunya Surveillance in Fortaleza
Antonio Silva Lima Neto, MD MSc
Coordinator of Epidemiologic Surveillance
Health Municipal Secretary of Fortaleza
Assistant Professor - University of Fortaleza (UNIFOR)
tanta26@yahoo.com / asneto@sms.fortaleza.ce.gov.br
Cali, Colombia
OBJECTIVES
• To Make a few comments about the demographics and epidemiological
trends of Fortaleza;
• To List daily activities of epidemiological arbovirus surveillance;
• Present Fortaleza Dengue/Zika/CHIK online Monitoring Information
System (SIMDA) as an important tool to detect outbreaks (early) and
to reorient health care and vector control activities;
• To Describe the epidemiology of Dengue and Chikungunya in Fortaleza
(1986-2016);
• To Present data from three Rapid Routine Surveys for Aedes Aegypti -
LIRAa (2015);
• To Present Chalenges, Research gaps (from our perspective) and
potential Incorporation of New Technologies on Vector Control.
Georeferenced Map of Fortaleza
•
FORTALEZA
• Estimated Population of 2,571,896 in 2014 (5th largest city in
Brasil)
• Total area – 331.14 km²
• Population Density – 7,767 inhab/km² (most densely
populated capital city in Brazil)
• 119 neighborhoods
• Fortaleza is divided into six (6) Health Districts
• 109 Primary Health Care Units (PHUs)
FORTALEZA
• According to a recente UN report (2010), Fortaleza was the 5th most
unequal city in the world (income inequality);
• Rapid urbanization, poor sanitation (sewage and water supply),
inadequate garbage collection, low education, huge slum areas
(densely populated) are important social determinants for the
infectious diseases burden in Fortaleza, particularly for the Vector-
Borne Diseases (VBDs);
• Exponential increase of violence is one of the most important
public health problem in Fortaleza at the moment;
• Dengue, Chikungunya Fever, Tuberculosis, Leishmaniasis, Hanseniasis
and Leptospirosis are endemic in Fortaleza (expected new cases every
year).
Dengue & Chikungunya Surveillance
in Fortaleza
Effective surveillance of dengue/chik cases is essential:
i.To detect outbreaks in order to initiate timely and effective
control measures;
ii.Monitor the trends of incidence including temporal and geographic
distribution of cases;
iii.To monitor chronic cases and deaths of Chik and number of
dengue severe cases and deaths;
iv.To assess and confirm possibility of outbreaks;
v.To monitor the impact of control interventions.
Epidemiological surveillance requires on the following indicators
i.Suspected (clinical) cases of dengue/zika/chik;
ii.Confirmed (laboratory-tested) cases of dengue/zika/chik;
iii.Circulating serotypes (DEN-1,-2,-3 or -4), CHIKV, ZIKAV;
Source: WHO, 2015
Dengue & Chikungunya are a notifiable diseases. A form
should be filled out for every suspected case on the
Notifiable Diseases Information System (SINAN online)
In order to integrate information from SINAN and those
produced by vector control department, the Fortaleza
Arbovirus on-line Monitoring System (SIMDA) was
developed in 2009. Initially only for dengue.
SIMDA provides tables, graphs and dynamic maps which
are updated on a daily basis.
http://tc1.sms.fortaleza.ce.gov.br/simda
SIMDA is free to access. Only personal information (name
and address) is password protected.
The data that will be presented today are available on
SIMDA
Epidemiology of Dengue in Fortaleza
1986-2016
Total Dengue Cases, Incidence Rates, Predominant Serotype.
Fortaleza, 1986 - 2016
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
Over the past 8 years Fortaleza
had four major epidemics
DENV1
DENV2 DENV3
DENV2 DENV1
DENV1
DENV4
DENV4
Comments
• Since the re-emergence of dengue fever in 1986, Fortaleza has
experienced five (5) major outbreaks with more than 20,000 cases
per year (1994, 2008, 2011, 2012, 2015);
• Large outbreaks were usually caused by the introduction (1994,
2012) and reintroduction (2011) of serotypes. The exception was the
2015 & 2016 outbreaks (Were Zika cases in 2015 and Chik cases in
2016 wrongly classified as Dengue?);
• DENV3 was not associated to a “large outbreak” but was the
predominat serotype for six consecutive years;
• As a consequence of successive epidemics, Seroprevalence of
Dengue Virus antibodies (IgG) in Fortaleza is estimated in more than
75% (unpublished data).
. Total number of cases, Non–severe and Severe cases,
Deaths, Fatality Rates. Fortaleza 1986 – 2016
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
Dengue Classification / Case Fatality Rates n
Non Severe Dengue cases 302.015
Severe Dengue Cases (Includes all forms of Severe
Dengue including DSS and DHF)
3.329 (11%)
Total Dengue Cases 305.344
Deaths 244
Case Fatality Rate (all cases) 0,08%
Case Fatality Rate (severe cases) 7,3%
Letality Rates of Severe Dengue Cases & Absolute
Number of Deaths
Fortaleza 1986 – 2016
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
12 years (1986-1997)
9 Deaths (3,7)
13 years (1998-2010)
84 Deaths (34,4)
06 years (2011-2016)
151 Deaths (61,9)
2011 – 7,6 (EY)
2012 – 4,6 (EY)
2013 – 37,8
(NE)
2014 – 17,6
(NE)
2015 – 6,1 (EY)
2016 – 5,7
2005 – 7,3
2006 – 5,0
2007 – 5,7
2008 – 3,1 (EY)
2009 – 41,2 (NE)
2010 – 9,1
0
0
0
0
Lethality (%)
Proportion of Dengue cases confirmed by laboratory tests
(RT-PCR, NS1, Elisa-IgM, Immunohistochemistry ).
Fortaleza 2010 - 2016
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
*Brazilian Ministry of Health recomends that at least 10% of the cases should be confirmed by
laboratory tests in epidemic years
Dengue: Control Charts for City of Fortaleza
Epidemic years (2008, 2011, 2012 & 2015)
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
Dengue Incidence by Epidemiological Week:
Green line: moving averages
Blue line: Upper limit
Red line: Specific year (Weekly dengue incidences)
Control Charts (Epidemic Curve / Control Diagram)
To detect outbreaks: three
consecutive weeks higher
than upper limit
2008 2011
2012 2015
Dengue: Control Charts for City of Fortaleza
Non epidemics years (2010, 2013, 2014 & 2016)
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
Dengue Incidence by Epidemiological Week:
Green line: moving averages
Blue line: Upper limit
Red line: Specific year (Weekly dengue incidences)
2010
2014
2016
2013
Dengue Cases and Deaths by epidemiological week. Fortaleza,
2012 (N=21) and 2013 (N=38)
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
2012
2013
MAR Tx_inc: n_caso/pop*100000 - quantil
Dengue Incidence Rate/100,000 inhab by Neighborhood in
Fortaleza, 2015.
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
n. 2229
BONSUCESSO – 56 = 2,51%
PICI – 57 = 2,55%
MONDUBIM – 132 = 5,92 %
SIQUEIRA – 68 = 3,05%
JANGURUSSU – 70 = 3,14%
Kernel Density Estimation of Dengue Cases by Neighborhood.
Fortaleza, 2016
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
Spatio-temporal distribution of confirmed Dengue cases
in Fortaleza by month, 2016.
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
Epidemiology of Chikungunya in
Fortaleza
2015-2016
n. 446
JAN FEV
MAR
n. 443
n. 376
n. 617
MAR
Cases of Dengue and Chikungunya by Epidemiological
Week, 2016
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
n. 446
JAN FEV
MAR
n. 443
n. 376
n. 617
MAR
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
Histogram of Chikungunya Cases, 2016 (per day)
Nº Cases=17,384
Deaths=21
MAR
Chikungunya Incidence Rate/100,000 inhab by Neighborhood
in Fortaleza, 2016.
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
MAR
Kernel Density Estimation of Chikungunya Cases by
Neighborhood. Fortaleza, 2016
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
Aedes Aegypti
Surveillance & Vector Control
Fonte: SMS/COVIS/CEVEPI/SINAN Online/ SIMDA, 2015
Positive strategic points* (around 3000 points) for Aedes aegypti
related to the cases of Dengue Fever, Fortaleza, 2016
• Scrap car (junkyards), tyre repair, construction sites, cemeteries, sewer, etc.
• Strategic points are visited every two weeks (fortnight)
Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
JAN FEV
MAR
n. 376
n. 617
MAR
LIRa2 (July)
LIRAa3 (October)
DENGUE_LIRAa 2 and 3: Spatial distribution of Aedes Aegypti
Positive Households (properties) by neighborhood. Fortaleza,
2016
LIRAa1 (January)
A2 –barrel, cask, tub, clay deposits (filters, jars, pots), tanks, water tanks, tanker
B – Vases / bottles with water, dishes, returnable bottles, defrost containers in
refrigerators, water dispensers in general, small ornamental fountains, construction
materials deposits (stocked toilets, pipes, etc.), religious objects, etc
C –tire repair and vegetable gardens, gutters, drains, sanitary unused, untreated pools,
broken glass on walls, etc.
D2 – plastic containers, PET bottles, cans, scraps, construction debris
E - leaves, holes in trees and rocks, animal remains (shells)
n. 446
JAN FEV
MAR
n. 443
n. 376
n. 617
MAR
Spatial distribution of Positive Households for Aedes
Aegypti and Dengue Cases by neighborhood (LIRAa).
Fortaleza, July, 2015
CASO
n. 194
n. 137
IMOV POS
Spatial distribution of Positive Households for Aedes Aegypti and
Dengue Cases by neighborhood. Health District 3, Fortaleza, 2014
Muchas Gracias!
cevepi@saudefortaleza.ce.gov.br
tanta26@yahoo.com
1 sur 33

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Dengue & Chikungunya Surveillance in Fortaleza

  • 1. VERDAS Workshop Cali, Colombia. March 1st and 2nd 2017 Dengue & Chikungunya Surveillance in Fortaleza Antonio Silva Lima Neto, MD MSc Coordinator of Epidemiologic Surveillance Health Municipal Secretary of Fortaleza Assistant Professor - University of Fortaleza (UNIFOR) tanta26@yahoo.com / asneto@sms.fortaleza.ce.gov.br Cali, Colombia
  • 2. OBJECTIVES • To Make a few comments about the demographics and epidemiological trends of Fortaleza; • To List daily activities of epidemiological arbovirus surveillance; • Present Fortaleza Dengue/Zika/CHIK online Monitoring Information System (SIMDA) as an important tool to detect outbreaks (early) and to reorient health care and vector control activities; • To Describe the epidemiology of Dengue and Chikungunya in Fortaleza (1986-2016); • To Present data from three Rapid Routine Surveys for Aedes Aegypti - LIRAa (2015); • To Present Chalenges, Research gaps (from our perspective) and potential Incorporation of New Technologies on Vector Control.
  • 3. Georeferenced Map of Fortaleza •
  • 4. FORTALEZA • Estimated Population of 2,571,896 in 2014 (5th largest city in Brasil) • Total area – 331.14 km² • Population Density – 7,767 inhab/km² (most densely populated capital city in Brazil) • 119 neighborhoods • Fortaleza is divided into six (6) Health Districts • 109 Primary Health Care Units (PHUs)
  • 5. FORTALEZA • According to a recente UN report (2010), Fortaleza was the 5th most unequal city in the world (income inequality); • Rapid urbanization, poor sanitation (sewage and water supply), inadequate garbage collection, low education, huge slum areas (densely populated) are important social determinants for the infectious diseases burden in Fortaleza, particularly for the Vector- Borne Diseases (VBDs); • Exponential increase of violence is one of the most important public health problem in Fortaleza at the moment; • Dengue, Chikungunya Fever, Tuberculosis, Leishmaniasis, Hanseniasis and Leptospirosis are endemic in Fortaleza (expected new cases every year).
  • 6. Dengue & Chikungunya Surveillance in Fortaleza
  • 7. Effective surveillance of dengue/chik cases is essential: i.To detect outbreaks in order to initiate timely and effective control measures; ii.Monitor the trends of incidence including temporal and geographic distribution of cases; iii.To monitor chronic cases and deaths of Chik and number of dengue severe cases and deaths; iv.To assess and confirm possibility of outbreaks; v.To monitor the impact of control interventions. Epidemiological surveillance requires on the following indicators i.Suspected (clinical) cases of dengue/zika/chik; ii.Confirmed (laboratory-tested) cases of dengue/zika/chik; iii.Circulating serotypes (DEN-1,-2,-3 or -4), CHIKV, ZIKAV; Source: WHO, 2015
  • 8. Dengue & Chikungunya are a notifiable diseases. A form should be filled out for every suspected case on the Notifiable Diseases Information System (SINAN online)
  • 9. In order to integrate information from SINAN and those produced by vector control department, the Fortaleza Arbovirus on-line Monitoring System (SIMDA) was developed in 2009. Initially only for dengue. SIMDA provides tables, graphs and dynamic maps which are updated on a daily basis. http://tc1.sms.fortaleza.ce.gov.br/simda SIMDA is free to access. Only personal information (name and address) is password protected. The data that will be presented today are available on SIMDA
  • 10. Epidemiology of Dengue in Fortaleza 1986-2016
  • 11. Total Dengue Cases, Incidence Rates, Predominant Serotype. Fortaleza, 1986 - 2016 Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE Over the past 8 years Fortaleza had four major epidemics DENV1 DENV2 DENV3 DENV2 DENV1 DENV1 DENV4 DENV4
  • 12. Comments • Since the re-emergence of dengue fever in 1986, Fortaleza has experienced five (5) major outbreaks with more than 20,000 cases per year (1994, 2008, 2011, 2012, 2015); • Large outbreaks were usually caused by the introduction (1994, 2012) and reintroduction (2011) of serotypes. The exception was the 2015 & 2016 outbreaks (Were Zika cases in 2015 and Chik cases in 2016 wrongly classified as Dengue?); • DENV3 was not associated to a “large outbreak” but was the predominat serotype for six consecutive years; • As a consequence of successive epidemics, Seroprevalence of Dengue Virus antibodies (IgG) in Fortaleza is estimated in more than 75% (unpublished data).
  • 13. . Total number of cases, Non–severe and Severe cases, Deaths, Fatality Rates. Fortaleza 1986 – 2016 Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE Dengue Classification / Case Fatality Rates n Non Severe Dengue cases 302.015 Severe Dengue Cases (Includes all forms of Severe Dengue including DSS and DHF) 3.329 (11%) Total Dengue Cases 305.344 Deaths 244 Case Fatality Rate (all cases) 0,08% Case Fatality Rate (severe cases) 7,3%
  • 14. Letality Rates of Severe Dengue Cases & Absolute Number of Deaths Fortaleza 1986 – 2016 Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE 12 years (1986-1997) 9 Deaths (3,7) 13 years (1998-2010) 84 Deaths (34,4) 06 years (2011-2016) 151 Deaths (61,9) 2011 – 7,6 (EY) 2012 – 4,6 (EY) 2013 – 37,8 (NE) 2014 – 17,6 (NE) 2015 – 6,1 (EY) 2016 – 5,7 2005 – 7,3 2006 – 5,0 2007 – 5,7 2008 – 3,1 (EY) 2009 – 41,2 (NE) 2010 – 9,1 0 0 0 0 Lethality (%)
  • 15. Proportion of Dengue cases confirmed by laboratory tests (RT-PCR, NS1, Elisa-IgM, Immunohistochemistry ). Fortaleza 2010 - 2016 Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE *Brazilian Ministry of Health recomends that at least 10% of the cases should be confirmed by laboratory tests in epidemic years
  • 16. Dengue: Control Charts for City of Fortaleza Epidemic years (2008, 2011, 2012 & 2015) Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE Dengue Incidence by Epidemiological Week: Green line: moving averages Blue line: Upper limit Red line: Specific year (Weekly dengue incidences) Control Charts (Epidemic Curve / Control Diagram) To detect outbreaks: three consecutive weeks higher than upper limit 2008 2011 2012 2015
  • 17. Dengue: Control Charts for City of Fortaleza Non epidemics years (2010, 2013, 2014 & 2016) Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE Dengue Incidence by Epidemiological Week: Green line: moving averages Blue line: Upper limit Red line: Specific year (Weekly dengue incidences) 2010 2014 2016 2013
  • 18. Dengue Cases and Deaths by epidemiological week. Fortaleza, 2012 (N=21) and 2013 (N=38) Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE 2012 2013
  • 19. MAR Tx_inc: n_caso/pop*100000 - quantil Dengue Incidence Rate/100,000 inhab by Neighborhood in Fortaleza, 2015. Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
  • 20. n. 2229 BONSUCESSO – 56 = 2,51% PICI – 57 = 2,55% MONDUBIM – 132 = 5,92 % SIQUEIRA – 68 = 3,05% JANGURUSSU – 70 = 3,14% Kernel Density Estimation of Dengue Cases by Neighborhood. Fortaleza, 2016 Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
  • 21. Spatio-temporal distribution of confirmed Dengue cases in Fortaleza by month, 2016. Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
  • 22. Epidemiology of Chikungunya in Fortaleza 2015-2016
  • 23. n. 446 JAN FEV MAR n. 443 n. 376 n. 617 MAR Cases of Dengue and Chikungunya by Epidemiological Week, 2016 Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
  • 24. n. 446 JAN FEV MAR n. 443 n. 376 n. 617 MAR Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE Histogram of Chikungunya Cases, 2016 (per day) Nº Cases=17,384 Deaths=21
  • 25. MAR Chikungunya Incidence Rate/100,000 inhab by Neighborhood in Fortaleza, 2016. Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
  • 26. MAR Kernel Density Estimation of Chikungunya Cases by Neighborhood. Fortaleza, 2016 Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
  • 27. Aedes Aegypti Surveillance & Vector Control Fonte: SMS/COVIS/CEVEPI/SINAN Online/ SIMDA, 2015
  • 28. Positive strategic points* (around 3000 points) for Aedes aegypti related to the cases of Dengue Fever, Fortaleza, 2016 • Scrap car (junkyards), tyre repair, construction sites, cemeteries, sewer, etc. • Strategic points are visited every two weeks (fortnight) Fonte: SMS Fortaleza/Célula de Vigilância Epidemiológica/SINAN ONLINE
  • 29. JAN FEV MAR n. 376 n. 617 MAR LIRa2 (July) LIRAa3 (October) DENGUE_LIRAa 2 and 3: Spatial distribution of Aedes Aegypti Positive Households (properties) by neighborhood. Fortaleza, 2016 LIRAa1 (January)
  • 30. A2 –barrel, cask, tub, clay deposits (filters, jars, pots), tanks, water tanks, tanker B – Vases / bottles with water, dishes, returnable bottles, defrost containers in refrigerators, water dispensers in general, small ornamental fountains, construction materials deposits (stocked toilets, pipes, etc.), religious objects, etc C –tire repair and vegetable gardens, gutters, drains, sanitary unused, untreated pools, broken glass on walls, etc. D2 – plastic containers, PET bottles, cans, scraps, construction debris E - leaves, holes in trees and rocks, animal remains (shells)
  • 31. n. 446 JAN FEV MAR n. 443 n. 376 n. 617 MAR Spatial distribution of Positive Households for Aedes Aegypti and Dengue Cases by neighborhood (LIRAa). Fortaleza, July, 2015
  • 32. CASO n. 194 n. 137 IMOV POS Spatial distribution of Positive Households for Aedes Aegypti and Dengue Cases by neighborhood. Health District 3, Fortaleza, 2014