Dengue & Chikungunya Surveillance in Fortaleza

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
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
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
*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)
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)
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)
2012
2013

MAR Tx_inc: n_caso/pop*100000 - quantil
Dengue Incidence Rate/100,000 inhab by Neighborhood in
Fortaleza, 2015.

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

Spatio-temporal distribution of confirmed Dengue cases
in Fortaleza by month, 2016.

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

n. 446
JAN FEV
MAR
n. 443
n. 376
n. 617
MAR
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.

MAR
Kernel Density Estimation of Chikungunya Cases by
Neighborhood. Fortaleza, 2016

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)

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

Dengue & Chikungunya Surveillance in Fortaleza

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