Características clínico-epidemiológicas dos casos graves e óbitos por dengue, Minas Gerais, 2008 a 2010

Abstract

Dengue is an acute benign or severe febrile disease and it can cause death, depending on its presentation: inapparent, classic dengue (CD), dengue hemorrhagic fever (DHF) or dengue with complications (DWC). The World Health Organization estimates that 80 to 100 million infections occur annually, 400,000 cases of DHF and 22,000 deaths from dengue, especially in children. Due to the dengue explosive epidemics in large urban centers, the rapid viral dispersion and potential severity of DHF cases, the disease is characterized as re-emerging, with high-impact and economic importance to international public health. Objectives: To analyze the clinical and epidemiological profile of severe cases and deaths from dengue in Minas Gerais in the period 2008 to 2010 and to describe the occurrence of severe cases, deaths and the factors associated with the occurrence of deaths due to dengue. Methods: We conducted a descriptive epidemiological study of deaths from dengue and a case-control to identify factors associated with death from dengue patients with severe dengue (DHF and DWC), based on secondary data from the Health Secretary of Minas Gerais State, Health Information System and Mortality Information System. The following variables were evaluated: age, gender, population, residence city, region, hospital, patient outcomes, final classification, clinical signs and symptoms (hemorrhagic manifestations: positive tourniquet test, epistaxis, menorrhagia, gingival bleeding, hematuria, spontaneous petechiae, gastrointestinal bleeding, signs of plasma leakage, cavity effusion, hemoconcentration, hypoproteinemia), criteria for case confirmation (epidemiological or clinical laboratory), tests results performed specific and unspecific, symptoms onset dates, hospitalization and death, and comorbidities complications. We analyzed the frequency of severe cases and deaths by demographic and clinical variables, incidence and mortality rates, central tendency and dispersion measures for continuous variables. Univariate logistic regression analysis according to the occurrence of death or cure permitted the identification of variables associated with death and with a significance level p<0.05, for inclusion in the multivariate logistic regression analysis. Results: The total 2214 cases, with 156 deaths and 2058 healing. The severe dengue lethality in 2008 was 7.4%, 4.8% in 2009 and 8.0% in 2010. The major death reports were in Belo Horizonte Region (27.6%), Zona da Mata (24.4%) and Vale do Rio Doce (17.3%), and higher incidence of severe cases occurred in the Vale do Mucuri (57.0%), Vale do Rio Doce (37.3%) and Central Region (21.0%). 28.8% of the deaths were from municipalities between 10,000 and 50,000 inhabitants, 24.4% between 100,000 and 500,000 and 25.0% of cities over 500,000 inhabitants. Mortality due to dengue was higher in municipalities with up to 100,000. Among the serious cases, 48.3% were men, 49.4% among deaths. The cases of severe dengue were classified as DWC (82.7%) and FHD (27.4%). Among the deaths, 62.2% were DWC and 37.8% were FHD. In 40.2% of deaths from DWC missed only one criterion for their classification in DHF. The severe case and mortality incidence were higher after 65 years (incidence of 20.2 cases per 100,000 inhabitants, and 16.0% mortality). The second higher fatality was among children under 5 years (8.5%) and the lowest occurred between 6 and 14 years (4.6%). High percentage of signs and symptoms ignored or blank were observed. The most frequently reported signs were petechiae (51.0% of severe cases and 45.5% of deaths), positive tourniquet test (44.0% of severe cases and 43.1% of deaths) and epistaxis (26.0% of severe cases and 35.6% of deaths). The minus sign reported was hypoproteinemia (2.9% of severe cases and 8.6% of deaths). The median interval between symptom onset and hospitalization was 5 days, and between onset symptom and death was 8 days. Comorbidities more reported were cardiovascular disease and hypertension. They introduced themselves individually and significantly associated with increased chances of death from dengue: city of residence less than 100,000 population (OR 2,46; IC95% 1,71-3,55), age> 65 years (OR 3,05; IC95% 1,99-4,68), plasma extravasation (OR 1,69; IC95% 1,16-2,46), confirmed by specific laboratory tests (OR 2,34; IC95% 1,34-4,07) and classification in DHF (OR 3,0 IC95% 2,02-4,47). Conclusion: The severe cases and deaths from dengue were distributed throughout the state of Minas Gerais, more often in extreme age groups, reinforcing the recommendation of treatment manuals for these patients receive special care from the onset of the disease. It is necessary to increase the sensitivity of the surveillance system of severe cases and deaths by promoting appropriate interventions for its reduction