Technical Report Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minas Gerais, Brazil

2 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Submitted by:

Observatório de Saúde Urbana de Belo Horizonte Belo Horizonte Observatory for Urban Health Universidade Federal de Minas Gerais (UFMG) www.medicina.ufmg.br/osubh Brazil

About the Project This technical report was the final product of a research project funded by the World Health Organization (WHO). This was a joint collaboration between the WHO Centre for Health Development (WHO Kobe Centre - WKC) and the WHO Regional Office for the Americas/Pan American Sanitary Bureau (WHO AMRO/PAHO). The research project was carried out officially through the work of the Belo Horizonte Observatory for Urban Health and Universidade Federal de Minas Gerais (UFMG), which implemented the research project. The research project provided a case study to address the knowledge gap on the impact of climate change on the occurrence of dengue, a vector-borne disease. It was based on a generic research protocol entitled “Protecting Health from Climate Change: Vulnerability and Adaptation Assessment”1, previously referred to as Guidance for Conducting Assessments of Health Vulnerability and Public Health and Health Care Interventions to Address Climate Change Project.The project was approved by the Belo Horizonte Municipal Health Department’s Research Ethics Committee in February of 2011, CAAE 0017.0.000.410.11A. Project Objectives The general objective of the research project was to assess the vulnerability of human health, taking the dengue infection model, with emphasis on vulnerability, adaptive capacity and mitigation in the light of climate change in Belo Horizonte, Minas Gerais state, Brazil.The specific objectives were to: 1) test the adequacy of the guidelines developed by the World Health Organization (WHO) to assess the vulnerability of public health and health issues arising

1

Protecting health from climate change: Vulnerability and adaptation assessment (WHO, 2013). http://apps.who.int/iris/bitstream/10665/104200/1/9789241564687_eng.pdf?ua=1 [Accessed on 1 April 2015].

3 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

from climate change in urban settings; and 2) identify the necessary actions to protect the health of the population of Belo Horizonte, Minas Gerais, Brazil to face climate change.

Project Team Members (SMSA-BH: Belo Horizonte City Health Department, UFMG: Federal University of the State of Minas Gerais, Brazil; OSUBH: UFMG Belo Horizonte Observatory for Urban Health) Waleska Teixeira Caiaffa–(UFMG/OSUBH) - coordinator Amanda de Castro e Silva–(SMSA-BH) Fernanda Carvalho de Menezes–(SMSA-BH) Maria Cristina de Mattos Almeida–(SMSA-BH/OSUBH) Maria da Consolação Magalhães Cunha-(SMSA-BH/OSUBH) José Eduardo Marques Pessanha-(SMSA-BH/OSUBH) Silvana Tecles Brandão-(SMSA-BH) Project Peer Reviewers (WHO) Dr Jostacio M. Lapitan, Technical Officer, Innovation for Healthty Ageing, WHO Centre for Health Development (WHO Kobe Centre) Dr Luiz Augusto Galvao, Manager, Sustainable Development and Environmental Health Area, WHO Regional Office for the Americas/Pan American Sanitary Bureau (WHO AMRO) Dr Carlos Corvalan, Senior Adviser, Risk Assessment and GE Change, AMRO/PWR Brazil Dr Ana Rivière-Cinnamond, Advisor, Eco-Health Regional Technical Team on Water and Sanitation (ETRAS), AMRO/PWR Peru Dr Carlos Pedro Santos-Burgoa, Senior Advisor, Violence, Injuries and Human Security, AMRO/SDE/ER Dr Agnes Soares da Silva, Advisor, Environmental Epidemiology, AMRO/SDE/ER Dr Luis G. Castellanos, Unit Chief, CHA/VT, Neglected, Tropical and Vector-borne Diseases (WHO AMRO/PAHO)

4 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

WHO Library Cataloguing-in-Publication Data Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minas Gerais, Brazil: technical report. 1.Dengue – epidemiology. 2.Climate Change. 3.Disease Outbreaks. 4.Prevalence. 5.Risk Assessment. 6.Environmental Health. 7.Brazil. I.World Health Organization. II.Universidade Federal de Minas Gerais. Belo Horizonte Observatory for Urban Health. ISBN 978 92 4 150970 1

(NLM classification: WC 528)

© World Health Organization 2015

All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications –whether for sale or for noncommercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Printed in Japan.

5 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Acknowledgements This is the final report on the “Protecting health from climate change: Vulnerability and adaptation assessment (WHO, 2013)” previously referred to as Guidance for Conducting Assessments of Health Vulnerability and Public Health and Health Care Interventions to Address Climate Change Project, financed by the Pan American Health Organization (Service Contract BR/CNT/1001517.001, November 2010) through the WHO Centre for Health Development (WHO Kobe Centre).

The collection and analysis of the data presented here were made possible by the Zoonoses Control Information Data System (SCZOO), developed in 1999, in a partnership between the Zoonoses Control and Management Department from the Belo Horizonte City Health Department and the Information Technology and Information Enterprise of the Municipality (Prodabel). Other official dengue database from the Ministry of Health was also used in order to consolidate and analyze dengue cases in Belo Horizonte city. The project was approved by the Belo Horizonte Municipal Health Department’s Research Ethics Committee in February of 2011, CAAE 0017.0.000.410.11A.

Participants Waleska Teixeira Caiaffa–(UFMG/OSUBH) - Coordinator Amanda de Castro e Silva–(SMSA-BH) Fernanda Carvalho de Menezes–(SMSA-BH) Maria Cristina de Mattos Almeida–(SMSA-BH/OSUBH) Maria da Consolação Magalhães Cunha-(SMSA-BH/OSUBH) José Eduardo Marques Pessanha-(SMSA-BH/OSUBH) Silvana Tecles Brandão-(SMSA-BH) SMSA-BH: Belo Horizonte City Health Department UFMG: Federal University of the State of Minas Gerais, Brazil OSUBH: UFMG Belo Horizonte Observatory for Urban Health

6 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Table of Contents Executive Summary Introduction and Context Climate variations and climate change in the urban context Belo Horizonte’s historical and geographical context Contextualizing dengue in an urban area Dengue in Belo Horizonte Current knowledge about dengue based on climate change Definition of the problem

Objectives General objective Specific objectives

Methods Empirical analysis of existing data Expert Discussion Groups (EDGs)

Results

7 10 10 12 14 15 17 19 19 19 19 20 20 21

Empirical analysis of existing data Expert Discussion Groups (EDGs)

23 23 32

Conclusions and Recommendations

40

References

43

7 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Executive Summary This study aimed to test, in a pilot fashion, the “Guidance for conducting assessments of health vulnerability and public health and health care interventions to address climate change” (GUIDE) using an infectious health condition transmitted by a vector and the relationship with climate variability in an urban environment.

In the first step, dengue was defined as the health condition and a review of major studies and reports available was performed. Also, the history of dengue epidemic in Belo Horizonte, Brazil was described, contextualized in the history of the city and climatic variations related to temperature, altitude and humidity.

Based on the available information, the first expert discussion group (EDG) was organized with experts in the field of health, epidemioloy, parasitology, entomology, geography, metereology and statistics. In the meeting, it was proposed a theoretical model, composed of horizontal variables in the same level (climate-vectordengue) modulated by others at different levels. Climate, urbanization and viral behavior related to viral subtypes were modulated by the Brazilian Unified Health System actions, composed by areas of health care and interventions toward vector control, including community participation, health education and governance models.

The goals of the GUIDE were then re-ordered, considering the EDG (Chart 1 and 2) and the availability of more climate and weather information. The time variable was expanded and represented by years, months and seasons. Depending on climate interactions with vector and the disease, rainfall, relative humidity and temperature were aggregated as the meteorological variables set and altitude was used as a proxy for geographical variable.

The chronological distribution of dengue cases over time was the dependent variable, as well as the Aedes aegypti infestation and entomological features of the vector. The information brought more consistent evidence between rainfall and vector behavior than that with confirmed cases of dengue, which peaks usually, in the end of the periods of greater precipitation.

8 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

From the graphical overlay of the information and the analysis of the positivity of ovitraps, a correlation of the concentration of positive traps and the rainfall was observed. Furthermore, it was observed that larvae breeding of Aedes aegypti were modulated by human behavior. During rainy season, the presence of positive deposits was detected outside home while in dry season, a predominance of positive reservoirs was detected within households, mainly in potted plants.

The final activity was a critical appraisal of the results generated by the second round of analysis during a second meeting with the group of experts (2nd EDG). The large experience of participants either from the point of dengue research or monitoring climate and environmental events, was fundamental in advancing the knowledge of the dynamics of disease transmission. Given the epidemiological and environmental issues, topics were selected for discussion on the current burden of dengue as a sensitive disease to climate. It includes the following: (1) the vulnerability of the disease to climate variability; (2) the social and environmental factors in determining vulnerability; (3) the mechanisms that explain the seasonality of disease in the city; and (4) how the current epidemiological profile could be modified according to climate change projections for the coming decades.

Finally, an extensive interactive process with representatives of environment and health sectors, through the discussion of epidemiological data reached the following consensual information: (1) considering the vector’s ubiquitous behavior and its correlation with rainfall, it is crucial to perform systematically vector and rainfall monitoring, especially within micro-areas of the city; (2) geographical areas of intense urban expansion in the city should be monitored with appropriate tools aiming at vector control, such as the north region of the city - the area of persistence of the majority of epidemics since the introduction of dengue in the city in 1996; (3) geographical relief and winds should be explored in future analysis; and (4) the necessity to monitor temperatures of the the city, given the small but persistent increase of minimun temperature since 1980, under the model of urban heat island effect, focusing on analysis at micro-regions and microclimates levels.

9 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Initiatives were proposed for the adaptation and mitigation due to climate change, together with the need for further studies investigating the combined effects of rainfall, altitude and human behavior, especially in a still booming urban context.

A gap was identified in the use of climatological measurement units from the National Institute of Meteorology (INMET) in Belo Horizonte. Since information generated were limited to their catchment areas, restricted only around the region where they were located, there was insufficient information to evaluate and compare the ideal microclimate for breeding of the vector, the Aedes aegypti. Such micro-information would allow comparisons with variables regarding the vector infestation and disease occurrence, geo-referenced by address and census tract, a challenge for further understanding of this urban disease.

We also identified opportunities for interaction within the municipality beyond health sector including new projects with the Secretary of Environment aiming at the acquisition of specific equipment for climatological assessment of small areas, contributing to generate useful micro-data for monitoring the vector.

It was proposed to continue the intersectoral approach with special discussion on the issue by the Municipal Board on Climate Change and Eco-efficiency of Belo Horizonte besides the development of a network for exchanging information, experiences, scientific production and structuring of health services. It was also deeply discussed the possibility of raising funds to adapt and optimize designs for intersectoral and multidisciplinary monitoring experiences for both vector and disease.

This document aims to facilitate an intersectoral and integrative discussion and further creation of useful protocols of intervention for stakeholders, public health workers as well as environmental technicians.

10 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Introduction and Context Climate variations and climate change in the urban context The World Health Organization (WHO) considers the impact of climate change on health a priority for this century. Climate change can increase the frequency and magnitude of extreme climatic events, causing disasters like overflows, floods, droughts, hurricanes, and tornados (Patz et al., 2005), with severe repercussions for morbidity and mortality. The majority of health impacts caused by climate change are difficult to detect and perceive, as they are modulated by environmental, social, and political processes (McMichael et al., 2006).

Changes in the patterns of distribution and magnitude of climatic variables alter the frequency and distribution of distal determinants that, in turn, have ramifications for health events. Such indirect climate-event impacts vary by time and place and have been worsening under the process of global climate change.

Any population worldwide is potentially exposed to the inherent risks of climate change. However, health impacts are greater in lower-income countries, not only because of the elevated prevalence of illnesses that are climate-sensitive but also because of inequities in health, associated with inadequate infrastructure due to deficient social and political management.

Dengue, malaria and other vector-borne diseases are important causes of morbidity and mortality and can be directly or indirectly affected by environmental and climate change. Conversely, these diseases can be controlled or have their impact minimized through multisectoral actions in the sense of identifying vulnerabilities to climate change, working in advance to strengthen programs and health planning actions.

The future impacts of climate change on health can vary on different spatial and temporal scales, depending on aggravating or mitigating conditions determined by local socioeconomic and environmental factors.

11 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Three important concepts for understanding this phenomenon emerge: vulnerability, mitigation, and adaptation.

Vulnerability is understood as a population or place susceptibility to a hazard. From the health point of view, it may be defined as the summation of risk factors that result, even considering protective factors within the set, in adverse impacts on health because of climate change (Balbus, 2009). With regard to social groups, vulnerability to climate change is strongly associated with environmental, demographic and technological contexts.

Mitigation is a set of policies and measures brought about to reduce greenhouse gas emissions, and adaptation is the process by which strategies and measures are implemented with the intention of restricting or minimizing the negative consequences of climatic events.

Mitigation and adaptation to adverse effects are complementary strategies. In conjunction with knowledge of vulnerabilities, they may permit interaction between programs aiming simultaneously at sustainable development, revitalizing the productive systems and reducing harm derived from the contemporary way of life.

Knowledge about climate must be included to the public health scope, with policies and intervention strategies intended to bring about a reduction in health vulnerability. Consequently, health actions must be planned by means of strategies capable of proposing programs that permit mitigation of and adaptation to the effects of climate and environmental changes, taking into account regional and local characteristics and peculiarities.

In the urban context, urban heat island effect, defined when a metropolitan area is significantly warmer than its rural surroundings, stands out. The phenomenon, investigated and described by Luke Howard in 1810, shows that the difference generally is greater at nighttime than during the day and is most apparent when winds are slight. It can be observed in summer and winter, and the principal cause is related to

12 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

modification of the ground surface in areas of intense urban development, which use materials that effectively retain heat (Bornstein, 1967).

With the growth of urban areas, although the heat island effect does not necessarily occur in all of them, a tendency is observed to modify green areas, with a corresponding rise in average temperature. The predominance of forests, agriculture, and residential areas associated with varying degrees of tree cover contrasts with the commercial and service ground uses found generally in the center of large cities, which favor the development of urban heat islands (Lo et al., 1997). Despite the disputed effect on average global temperature, heat islands are associated with lower quality of air, water, and their respective ecosystems, along with a rise in the production of pollutants, such as ozone.

Belo Horizonte’s historical and geographical context Belo Horizonte, capital of the State of Minas Gerais, is situated between the 43 rd and 45th meridians west of Greenwich. It is located between two geomorphological entities, the Serra do Curral mountain range and the Belo Horizonte Depression, in the microbasins of the two tributaries of the Rio das Velhas (Belo Horizonte, 2003).

Inaugurated in 1897, it was foreseen as being a natural and clean city, inspired by models of cities like Paris and Washington. The construction plans revealed concerns, principally with hygiene and traffic, and divided the city into three zones—the central urban area, the suburban area, and the rural area (PMBH, 1997). The central area would contain the entire urban transportation, education, cleaning, and medical assistance infrastructure, as well as administrative and commercial buildings.

The suburban area, separated from the central area by a wide avenue, would be occupied later, and the rural area would be composed of six agricultural settlements with granges operating as a greenbelt for supplying the city with agricultural products. The laid-out capital was an elitist locale, with spaces reserved exclusively for government employees and wealthy people. The city was conceived as holding a

13 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

maximum of 200,000 inhabitants. The activities developed would be those necessary to meet residents’ demands for goods and services (Pádua, 1994). However, in the 1930s, with Brazilian President Getúlio Vargas’s policy of economic modernization, a Belo Horizonte industrial zone was created. In the 1940s, the capital acquired various industries, abandoning its profile as an administrative city, and began to suffer real estate speculation downtown. In the 1950s, a great rural exodus resulted in the doubling of the city’s population, from 350,000 to 700,000 inhabitants. It was in that decade that the first master plan for the city was drawn up. In the 1960s, the city suffered intense urbanization with a reduction in green areas, followed by the arrival of new industries. Social inequalities would worsen and innumerable favelas would be constructed (PMBH, 1997).

Beginning in the 1980s, as a reflection of the national situation, unemployment would rise, as would social exclusion and the concentration of profits. The population rose more in neighboring municipalities, and city planning and the city public development policies were challenged to respond to the city demands, taking into account the metropolitan and regional dimensions (Pádua, 1994). Today, Belo Horizonte is located in Brazil’s third largest metropolitan area, composed of 34 municipalities and a population of about 5,000,000. It is Brazil’s sixth-largest city and has a population of 2,375,444, who live in 738,384 households, according to the 2010 census data (IBGE, 2010). The city has favelas and precarious settlements containing 471,344 inhabitants living in 129,702 households (PMBH, 2011). It has an area of 331 square kilometers and a population density of 7,198 per square kilometer. The municipality’s Human Development Index (HDI) rose from 0.686 in 1970 to 0.838 in 1990 and 0.880 in 2008 (João Pinheiro Foundation, 2008), pointing to political and social advances in the city’s structuring.

The climate is classified as elevated tropical. It is located at an average elevation of 900 meters above sea level, at latitude 19º55’S and longitude 43º56’W (Figure 1). This set

14 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

of meteorological conditions results in a rainy summer with high temperatures and a dry winter with low temperatures.

World Meteorological Organization (WMO) studies define climatic norms in terms of 30year averages in precipitation and minimum and maximum temperatures. According to the WMO, this is sufficient time to accept the representativeness of data collected at a particular time and place, which will characterize the first year of each decade. Observing these criteria, the National Meteorology Institute (INMET) registered, between 1961 and 1990, an average monthly temperature in Belo Horizonte ranging from 13° to 29° C. Rainfall reached a high of 320 millimeters per month in the rainy season, with an average annual precipitation of approximately 1,450 millimeters (Belo Horizonte, 2009).

Figure 1. Latitude and longitude of Belo Horizonte (Source: IBGE)

Contextualizing dengue in an urban area Dengue is considered the most important arboviruses in humans (Arthropod Borne Viruses) transmitted by a Flavivirus of the Flaviviridae family (yellow = Flavus), with four serotypes: DEN-1, DEN-2, DEN-3 and DEN-4. About 80 million people annually in 100 countries are estimated with the disease, leading to approximately 550,000 hospitalizations and 20,000 deaths (CDC, 2003). Dengue’s principal vector is the Aedes aegypti mosquito, a culicid with an extremely high capacity to adapt to modern urban settings (Brazil, 2002; Gubler, 1997). Although once believed to have been eradicated in Brazil (from 1955 to 1973), the vector was detected anew in 1975.

15 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Epidemics of the disease have been recorded since 1982 in the urban areas of every Brazilian region. The reasons for dengue’s reemergence are complex and not completely understood (Nelson, 1986). The magnitude of the risk has led to a high degree of investment in vector control, epidemiological monitoring, and patient care. In the absence of an efficacious vaccine and effective etiological or chemical-prophylactic treatments, combating the vector has been considered a basic strategy for controlling the disease (Tauil, 2001).

Siqueira-Junior et al. (2008), using home survey data in a spatial analysis study, identified potentially high-risk areas for intra-urban dengue infection in the City of Cuiabá, in the state of Mato Grosso. The prevalence of dengue virus antibodies was 37.3% (with a confidence interval of 95% between 35.5% and 39.1%) in 2002, a rise of 7.8% from the preceding year. The spatial variation of dengue infection risk changed significantly between 2001 and 2002.

Considering the continuous variability of the determinants of illness, taking into account the typical urban characteristic of the disease, it is necessary to focus on the urban poor and intra-urban comparisons with a subfocus on vulnerable groups. These categories bring up the concept of interactions in cities with intra-urban differentials and differences within and between households, featuring the physical and social environments, vulnerable to climate change.

Dengue in Belo Horizonte The first report of dengue occurred in 1996, setting an epidemic in the region north of the city (Corrêa et al, 2005). At this time, the Municipal Health Department reported 1,806 cases of the disease. The viral typing revealed the circulation of DEN-1 serotype and was diagnosed at the time only the classic dengue. The first autochthonous cases were confirmed in a single region, the Sanitary District of Venda Nova, and 88% of cases there were circumscribed at that area. In the following years, the spread of the disease occurred gradually and, in 1998, one of the largest epidemics was ever recorded in major urban areas of Brazil, from which the city acquired a profile of endemic transmission of the disease (Cunha et al., 2008).

16 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Since then, epidemics have been occurring in the municipality, first affecting well defined regions, and then followed by an unequal dispersion throughout the urban area. With the progressive introduction of various dengue viral serotypes, three (DEN-1, DEN2 and DEN-3) of the four existing serotypes circulate (Almeida et al., 2004) until 2012, when DEN-4 was also detected (Pessanha, personal communication, 2013). Since the virus’s introduction into the city, annual variations have been observed, with cycles of high and low incidence. In the last six years (2005 to 2010) there was a rise in reported dengue cases in Belo Horizonte, an average of 300% per year. Although in 2005, 2006, and 2009 no deaths were recorded, in 2007 two people died, in 2008 three, and in 2010 there were 15 deaths reported as of 8 November 2010. Of the latter, six were from complications of dengue and nine of dengue hemorrhagic fever (DHF). The coefficient of reported dengue cases within the municipality in 2010 was 222 per 10,000 inhabitants (52,810 cases reported).

Two surveys, in 2000 and 2007, aiming to determine dengue seroprevalence were developed by the Municipal Health Department together with the Belo Horizonte Observatory for Urban Health. Their goal was to determine and quantify the infection’s seropositivity in the municipality. The results obtained were, respectively, 23.3% and 11.9% (Cunha et al., 2008; Pessanha et al., 2010).

Health Care and Dengue in Belo Horizonte The municipality’s health services are coordinated by a central unit, with a territorial organization subdivided into nine Sanitary Districts corresponding to the nine politicaladministrative regions of the city. Within these districts are distributed 146 basic health units, whose catchment area is set on the basis of the 2,563 contiguous census tracts drawn up by the Brazilian Institute of Geography and Statistics (IBGE).

The Management of Health Surveillance and Information Management and Service, from the City Health Department, are responsible for the development of the National Dengue Control (PNCD) regulated by the Ministry of Health. The vector control and

17 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

patient care are decentralized activities undertaken by health Districts in their basic health units.

Current knowledge about dengue based on climate change In studies of dengue’s occurrence, discussions frequently arise about the association between Aedes aegypti infestation and factors related to the manner in which urban space is occupied, to how basic public health services are provided, to how habits and behaviors of urban dwellers may modulate the disease and how control practices may change its occurrence (Ribeiro et al., 2006; Rangel, 2008). The publications usually describe the influence, or lack thereof, of a climate with high temperature and rainfall in the magnitude of the disease. The fragmented form of the studies of these variables makes it difficult to discern the elements of climate change in the incidence of dengue.

Winch et al. (1991) developed an investigation in Mérida, Mexico, to evaluate governmental dengue control programs and identified anecdotal reports from residents on the causes of dengue occurrence. Among others, interviewees cited the presence of "the north wind" and the "water wind," which precede rains.

Gonçalves Neto and Rebêlo (2004) described the importance of the rains and their influence in the seasonal determination of occurrence of the disease in the northern Brazilian state of Maranhão. Albeit, they observed that rainfall increased considerably the number of reservoirs for development of the vector’s larvae and created favorable environmental conditions for the cultivation of adult insects, as did the relative humidity, they found a negative correlation between temperature and dengue occurrence.

Depradine and Lovell (2004) developed a retrospective study to determine the relationship between the incidence of dengue cases and climatic variation in Barbados, in the Caribbean. They sought to establish the prediction of dengue cases according to rainfall data over the five-year period, 1995-2000. Using correlation analysis, an important correlation with relative humidity was described. Although a lesser correlation with rainfall measurements was observed, low temperatures presented a strong

18 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

correlation with dengue occurrence; moreover, the study identified a negative correlation with wind velocity.

In the municipality of Toledo, in the southern Brazilian state of Paraná, Oliveira et al. (2007) described a strong association between the incidence of dengue and rainy seasons, high temperatures, geographical elevations and winds. In Cuiabá, Mato Grosso state, Miyazaki et al. (2009) concluded that rain is the only abiotic factor that influences the infestation level of dengue vectors in the area.

In Belo Horizonte, Almeida et al. (2008) studied seven dengue epidemic outbreaks from 1996 to 2002 and suggested that draining containers, monitoring vectors, and lowering the temperature and humidity reduce the vector population and have played an important role in interrupting dengue transmission in the city.

Vianello et al. (2006), in studies also carried out in Belo Horizonte, compared the vector infestation and the corresponding meteorological data collected at the Principal Climatological Station of the National Institute of Meteorology from 2002 to 2005. The authors identified the rise in the maximum and minimum percentages of the occurrence of dengue vectors throughout the year, accentuated during the hot and rainy season. The authors’ conclusion leads to the pertinence in utilizing a model to foresee the occurrence of dengue mosquitoes sufficiently beforehand to issue alerts to the population and engage in preventive actions that will avoid dengue outbreaks and its complications.

However, the topic of dengue infection and the possible correlation with climate change has not been exhausted in the studies carried out in Belo Horizonte, justifying new studies.

This study aimed to provide subsidies for managers, researchers and health and environment workers to build protocols with timely and efficient action on the occurrence of climate change and vector-borne diseases, especially dengue.

19 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Definition of the problem Is the intensity of dengue transmission in Belo Horizonte correlated with climate change? How can we advance knowledge in determining the health risk for dengue from the perspective of climate change?

Objectives 1. General objective To assess the vulnerability of human health, taking the dengue infection model, with emphasis on vulnerability, adaptive capacity,2 and mitigation in light of climate change in Belo Horizonte, Minas Gerais state, Brazil.

2. Specific objectives 2.1 Test the adequacy of the guidelines developed by the World Health Organization (WHO) to assess the vulnerability of public health and health issues arising from climate change in urban settings through: 2.1.1 Empirical analysis of existing data, based on prior scientific knowledge on the situation of the municipality and the suggestions of the expert discussion group (EDG); 2.1.2 Literature review and Expert discussion group (EDG) 2.2 Identify the necessary actions to protect the health of the population of Belo Horizonte, Minas Gerais, Brazil to face climate change and adjust the protocols currently used in dengue control in the city in order to mitigate the adverse effects of climate.

2

Adaptive capacity: ability of institutions, systems, and individuals to adjust to the potential deleterious effects of a disease, utilizing opportunities beforehand and/or living with the consequences of climate change or variability.

20 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Methods Empirical analysis of existing data A retrospective research study of a mixed ecological type was undertaken, utilizing variables related to epidemiological and entomological diagnosis. The spatial variable included the municipality and its geographical and political representations, from the Health District to a smaller area encompassed by the Basic Health Units and census tracts. The Zoonoses Control Management inventory database was used to provide the ovitraps’ current coverage areas.3

The temporal variable was depicted by year, month, and seasons, depending on climate/vector/risk interactions. Rainfall, relative humidity, and temperature comprised the set of meteorological variables. Altitude was the geographical variable. The chronological distribution of dengue cases reported was the outcome variable and Aedes aegypti infestation over time permitted the exploration of entomological characteristics. The temporal study was developed with data from 1996 to 2010. It evaluated municipal climatic data and their relation to cases of the disease. The following secondary data were used: 1. The National Information System for Reportable Diseases (SINAN) database; 2. The Hospitalization Authorization System (SAIH) database of the Municipal Health Department from the Epidemiological Monitoring, Information and Regulation department; 3. Vector infestation databases from the Zoonoses Control Management department;

3

Ovitraps are traps designed to attract the female Aedes aegypti mosquito with the objective of georeferencing the presence of vector, quantifying the number of eggs dispersed in the surroundings, and directing control actions.

21 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

4. The population base, disclosed by the Brazilian Institute of Geography and Statistics (IBGE); 5. National Institute of Meteorology climatic database. The interaction between the number of cases and climatic conditions as rainfall, temperature, humidity, and altitude were investigated. Vector infestation also was evaluated, being superimposed on the prior data.

Expert Discussion Groups (EDGs) According to the WHO report Protecting Health effects of Climate Change Vulnerability Assessment and Adaptation (2010), policy makers should build platforms able to monitor environmental risk situations and vulnerability of populations, proposing and implementing timely interventions and effective continuous communication process, besides reviewing results of the proposed measures.

Based upon the above, an agenda of discussions on dengue was built together with a group of experts composed by researchers and government officials (EDGs). Two workshops were held from December 2010 to April 2011 with the participation of 27 experts.

The workshops, headed by the Municipal Health Department of Belo Horizonte together with the Belo Horizonte Observatory for Urban Health, represented spaces for an ample discussion of strategies for monitoring of climate and health, particularly for dengue. Participants included technicians from the Epidemiology and Control of Zoonoses and Environment and Urban Policies of the municipality and guests from the following institutions: State Foundation of the Environment, Research Institute René Rachou from FIOCRUZ, State Institute of Historical and Artistic Heritage of Minas Gerais, Mining Institute of Weather and Water Management Institute, Catholic University of Minas Gerais, and the Federal University of Minas Gerais (Institute of Biological Sciences, Geosciences, Mathematical Sciences ) and the Federal University of Ouro Preto.

22 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Participants followed a script starting with the exhibition on dengue occurrence in Belo Horizonte. This introduction allowed each expert to identify aspects of the harm of the disease and the interventions in the health sector, according to their area of expertise, and then they reported their experiences and propose joint interventions. To achieve this goal, the group chose an exploratory study of the reported experiences and a review of the literature as well. The scientific production were then consolidated and referred to the context of climate change and control vector-borne diseases, especially dengue in the specific urban setting.

The project was approved by the Review Board Ethics Committee of the Municipal Health Department of Belo Horizonte in February 2011, CAAE 0017.0.000.410.11A.

23 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Results Empirical analysis of existing data The exploratory time trend study comprised the period from 1996 to 2010, since dengue cases were reported in the city. However, limitations on data, sometimes limited the analysis.

Also, a separate description of the temperature, precipitation and dengue-occurrence variables precluded meaningful interpretations. Nevertheless, the simple description below aims to introduce the subject-matter for more complex analyses (Table 1). In the period 2001-2007, there was an average ratio of 70.9% of days with temperatures below 30º. On other days (29.0%), the average values ranged from 30° to 35°. The year 2007 was the one with the largest number of hot days with highs above 30º and 20º above minimum. The total average rainfall for the period was 1532 mm; the year 2004 showed the highest value for precipitation 1950 mm and the year 2007 the lowest value of 1160 mm. This latter year recorded 283 days without rain (Belo Horizonte, 2009).

Table 1. Maximum and minimum temperatures by number of days, annual rainfall and total dengue cases, Belo Horizonte, 2001-2007.

Year

Mean max temp (days)

Mean min temp (days)

Annual rain

Dengue

(mm)

cases

Below 30°

30° a 35°

15° a 20°

Above 20°

2001

290

75

310

55

1490

4578

2002

283

82

316

49

1450

4140

2003

269

96

307

58

1470

1555

2004

298

68

351

15

1950

406

2005

290

75

313

52

1640

68

2006

291

74

304

61

1570

668

2007

260

105

293

72

1160

5236

Source: climatic data from the Final Inventory Municipal Report on Greenhouse Gas Emissions, 2009. Disease data: SINAN/SMSA.

24 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Given the results above, the further challenge was to identify the possible correlation measure between these and other climatic variables, in order to cast new lights on the knowledge of dengue transmission in Belo Horizonte city.

Temporal dengue distribution and viral circulation

The epidemic that records the entry of dengue virus in the city occurred in 1996, when there were 1,806 reported cases (Corrêa et al., 2005). Viral typing showed circulation of the DEN-1 serotype and clinically it was diagnosed as solely classic dengue. The first autochthonous cases were confirmed in the Venda Nova Sanitary District, where 88% of the reported cases occurred. Between February and October 1997, during which again was verified circulation of serotype DEN-1, the notification of 2,327 cases showed the second epidemic in the city, predominantly in West Sanitary District with 56% of the total cases reported (Costa et al.,1999). Dengue cases 1,E+05

Den 1 & 2

9,E+04

8,E+04

7,E+04

6,E+04

Den 1, 2 & 3

Den1 & 4

5,E+04

Den 1

4,E+04

3,E+04

2,E+04

1,E+04

0,E+00

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

Source: Belo Horizonte Municipal Health Department, Epidemiology, Information and Monitoring Management

Graph 1. Confirmed dengue cases, 1996-2012 (incomplete data for 2012), Belo Horizonte, Minas Gerais, Brazil

25 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

In 1998, there were 86,791 of classic dengue cases reported, confirmed by laboratory criteria or mainly epidemiological link (Corrêa et al., 2005), with the circulation of serotypes DEN-1 and DEN-2, predominantly the latter. In addition, 27 cases of haemorrhagic fever were reported and the first three deaths attributed to the disease in the municipality. Health Districts East, Northeast, Northwest and Venda Nova reported rates higher than the municipal average, which was 4,085.9 per 100,000 inhabitants, about 50 times higher than the first epidemic and 40 times higher than the second, in 1997.

The third epidemic, in 1998, was one of the highest magnitudes ever recorded in large urban centers of Brazil (Corrêa et al., 2005). At that time point, Belo Horizonte was characterized as a region of endemic transmission, with the regular occurrence of viral transmission, keeping the notifications of the disease within their geographic area, even during the winter months, when the known infestation index vector is, usually, smaller.

From 1999 to 2002, the occurrence of the disease remained low, especially for the years 2001 and 2002, respectively 4,578 and 4,110 cases, when it recorded the entry of the virus DEN-3.

In 2007 the number of reported cases of the disease reached 5,236. The following years, 2008 and 2009, the occurrence of cases was 2.5 times higher than in 2007, and in 2010 nearly four times more cases than in the previous years. DEN-1 was the most predominant serotype. In 2012, the serotype DEN-4 was detected, although the dengue cases reported remained relatively small (Graph 1).

26 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Temporal distribution of dengue and seasonality

In an eight-year study (2002-2010), observing the distribution of confirmed cases by month of onset of symptoms (Graph 2), the seasonality of the cases can be discerned. Starting gradually, from September, the distribution peaks in March and April of the following year. In July and August, it is common to have no reported cases of the disease.

Graph 2. Confirmed dengue cases by month of symptom onset, Belo Horizonte, 2002-2010

Temporal distribution of dengue, rainfall, and temperature

By observing the seasonality described above, during the period 2002-2010, there is a tendency to correlate the increased occurrence of cases with the rainy months. However, visually assessing the superimposition of confirmed cases of dengue and rainfall (Graph 3), it is found that the increase in the number of cases occurs just after the onset of the rains.

27 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Rainfall (mm) and temperature (degrees Celsius) for the years 2001–2010 were obtained from weather station of the 5th District of Brazilian Meteorological Institute (INMET).

Dengue cases and Rainfall precipitation, by months, seasons and years, Belo Horizonte, Minas Gerais State, Brazil, 2001 to 2010

900

20000

mm 18000

800

16000 700

14000 600

12000 500 10000 400 8000

300 6000

200 4000

100

2000

2001

2002

2003

Source - INMET/5º District and SMSA/BH

2004

2005

Rainfall

2006

2007

2008

2009

winter

summer

winter

summer

winter

summer

winter

summer

winter

summer

winter

summer

winter

summer

winter

summer

winter

summer

winter

0

summer

0

2010

Dengue cases

Graph 3. Confirmed dengue cases number and rainfall, Belo Horizonte, 2001-2010

Considering the vector’s biology, one perceives the relationship between precipitation and vector infestation. Analyses of the positivity ovitraps already pointed to the predominance and concentration of positive traps in relation to rainfall (Figure 3).

28 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Figure 3. Ovitraps Eggs Density, comparing the months of lowest rainfall (August and September) with the early rainfall months (October and November), Belo Horizonte, second half of 2009. Following the guidance of the National Dengue Control (NPDC) surveys of infestation (LI) vector have been performed systematically in the city since 1999. However, during winter and drought periods infestation indicators become insufficient for vector monitoring. Due to the need for vector differential diagnosis for this period, the municipality established in 2001, the system for ovitraps monitoring. Ovitraps are small pots containing water and an attractant capable to direct the posture of the female mosquito. The method allows evaluating the density of eggs of Aedes aegypti guiding the vector control services in a timely manner to prevent dengue transmission.There are approximately 1,700 ovitraps distributed in nine regions of the city, set 400 meters apart. Each one covers a 200-meter radius.

29 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Rainfall levels of precipitation allowed direct observation toward other areas of knowledge with proper statistical analyses. The studies done by Vianello, Pessanha, and Sediyama (2006) discuss the annual cycle of the occurrence of Aedes aegypti vectors and the relationship with meteorological variables. The authors investigated the influence of temperature on the transmission of the disease by analyzing the interference of thermal energy with blood-meal activities of female mosquitoes’ lifetimes

800

8

700

7

600

6

500

5

4,7 4,2

3,9

400 3,5 3,2

3,9

4

%

PRECIPITATION (MM)

and the period of extrinsic incubation of the virus. (Graph 4).

3,4

3,2

3 2,8

300

3 2,6

2,3

1,8

200

1,8

2,3

2,5

2,3

1,9

2,2

1,9

1,9

1,8

2,2

1,9

1,8

2

1,6

1,1

1

1

0,9

100 0,6

0,6

0,4

_1998

0,3

_1999

_2000

0,3

_2001

1

0,4

0,3

J AN FEV MAR ABR MAI J UN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI J UN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI J UN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI J UN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI J UN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI JUN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI JUN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI JUN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI JUN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI JUN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI J UN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI J UN J UL AGO SET OUT NOV DEZ J AN FEV MAR ABR MAI J UN JUL AGO SET OUT NOV DEZ

0

0,9

0,6

_2002

_2003

RAINFALL

_2004

_2005

_2006

_2007

_2008

_2009

0

_2010

BUILDING LARVAL INDEX (%)

Graph 4. Measurements of Building Larval Index and monthly rainfall, Belo Horizonte, 1998-2010 Maximum and minimum percentages of occurrence of dengue vectors throughout the year were most accentuated during the hot and rainy season. Therefore, during these seasons, the effects of global warming may generate situations of full-fledged infections, which will require health authorities considerable additional efforts. On the other hand, in the dry and cold season, the required precautions, which today are almost dispensable, may rise markedly. Vianello, Pessanha e Sediyama (2006)

30 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Using multiple linear regression between the positive ovitrap data and average temperatures, relative humidity, and rainfall data in the city in the weeks before collecting the ovitraps, positive ovitrap values (predicted by the model) were observed, showing a good correlation, mainly in the maximum values of seasonal cycles. It led to a linear regression equation slope almost unitary (0.999) and a coefficient of transmission of 0.84. (Vianello, Pessanha, and Sediyama, 2006) (Graph 5).

31 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Graph 5. Multiple linear regression between positive ovitrap data and delayed average

temperature, relative humidity and rainfall data (all retroactive) in Belo Horizonte, 1 Aug. 2002–24 Oct. 2004. [The left scale is for positive ovitraps, the blue line represents observed values, and the red line represents expected values.]

These findings complement observations already made by the Health Department of Belo Horizonte on the types of preferential breeding of Aedes aegypti in relation to two main seasons, rainy and dry. During the rainy season, the presence of positive deposits were located outside the home while in dry season, there was a predominance of positive reservoirs within households, mainly characterized by potted plants. Therefore, the female oviposition was directly related to a favorable environment for hatching and maturation of the larvae. Dengue’s temporal distribution and the influence of topography

Besides temperature, humidity, and rainfall, it is necessary to discuss the influence of topography as a variable involved with vector infection and dengue cases. Belo Horizonte lies on the Brazilian Plateau, which is characterized by rugged terrain, with hills and lowlands. The city is located to the north of the Serra do Curral mountain range, occupying part of its slopes and the Ribeirão Arrudas Valley, a tributary of the Rio das Velhas river, in a section in which the valley opens to form a very wide basin. To the north and west extend large areas of flat terrain; to the

32 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

south and east dominates a rugged topography, with the mountain framing the city. Larousse Cultural (1998) p. 722

The average altitude of the capital is around 900 meters above sea level. To south of the municipality is the highest elevations, reaching 1000 to 1500 meters. The flat terrain north reaches 700 meters (Costa et al., 2009). Temperatures and rainfall in the northern region of the city are higher compared to the south and east. Climate, topography, biogeography, and land use must be explored in an effort to explain the larger vector infestations and occurrence of dengue cases in warmer temperature and rainy regions.

Studying another important disease in the municipality, also vector transmitted, Menezes (2011) found a higher percentage (58.9%) of seropositive animals for Canine Visceral Leishmaniasis in the lowest-elevation regions, between 780 and 879 meters. The bands from 680 to 770 and 980 to 1079 meters (10.7% and 7.3% respectively) showed an intermediate level of prevalence of seropositivity, and the elevation band from 1080 to 1179 meters showed the lowest percentage (0.1%). The author draws attention to the population densities in this area as a possible factor sustaining the vector in the region, triggering determinants for Aedes aegypti breeding as well as dengue transmission.

Expert Discussion Groups (EDGs) The information regarding climate, environment and dengue in the city of Belo Horizonte were presented to participants of the EDGs in two stages. As previously established representatives of governmental institutions, academe, and researchers participated. Civil society, although relevant, should be included in a third session should the project expand.

The EDGs contributed to relevant discussions on the relationship between climate and environment, notably temperature and rainfall patterns related to the persistence of

33 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

dengue in an urban setting, mindful of the great mass of population yet susceptible to viral subtypes.

The EDGs made use of the studies of dengue epidemiological profile, historical features and socio-economic conditions of the city as well as the situation of the health care services. Finally, the discussions created a foundation regarding health conditions in the city, notably for dengue, in the face of climate and environmental changes.

The experience of participants, coupled with monitoring of climatic and environmental events, was fundamental to the recognition of these relationships, mainly considering that the issue of climate change and its impacts on health is still insufficient to generate effective responses to minimize the consequences of these changes. The inhabitants of Belo Horizonte may become increasingly adapted to high temperatures and lower seasonal variations, as a "normal" occurrence of dengue fever in certain periods of the year.

The EDGs, despite reflecting a diversity of opinions and perceptions, were unanimous in agreeing that dengue, with its epidemiological and environmental profile, may be a possible climate-sensitive disease, given its variability in relation to climate change and the environmental and social factors that may explain the mechanisms involved in the marked seasonality of the disease in the city. They recognized, moreover, that the current epidemiological situation maybe changed according to climate change projections for the coming decades.

Consensual information were generated on: 1. considering the ubiquitous behavior of the vector and its correlation with rainfall, it is important to have vector and rainfall monitoring, especially in microareas; 2. geographic areas of intense urban sprawl within the municipality must be monitored with appropriate approaches for vector control, such as region north of the city— the place of persistence of most epidemics, since the introduction of dengue in the city; 3. topography and winds should be explored in future analyses; 4. minimum temperatures in the city of Belo Horizonte increased since 1980, and the urban heat island effect should be investigated, especially from the perspective of the need for further analysis aimed at micro-regions and microclimates,

34 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

which may have relevance in the observed widening reach of epidemic peaks and other aspects of dengue’s profile in the city.

Initiatives were proposed for adaptation and mitigation of damage attributable to climate change, as well as the need for further studies investigating the combined effects of rainfall, altitude and human behavior, notably in the context of a still booming urban environment.

Data from National Institute of Meteorology (INMET) meteorological stations in Belo Horizonte is still insufficient to permit evaluation of the microclimate of the city, since the information available is limited to their coverage areas, representing only the surroundings of the region where the stations are located. The monitoring of ideal microclimates for Aedes aegypti reproduction enable comparisons with variables of vector infestation and disease occurrence, georeferenced by address or by census tract.

Several opportunities for interaction with other segments were identified, including new projects of the Municipal Secretary of Environment with the acquisition of specific equipment for climatological assessment of small areas, contributing with useful microdata useful for vector monitoring. It was proposed to continue the discussion intersectorally and preferentially permeated by the Municipal Committee on Climate Change and Eco-efficiency of Belo Horizonte, and the construction of information networks, exchange of experiences, scientific production and structuring of services. It was also discussed the possibility of raising funds to bring up intersectoral and multidisciplinary projects for vector monitoring and disease.

35 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

First EDG–03/12/2010 The first workshop was carried out on 3 December 2010, with technicians in the area of health, entomology and statistics, and it produced a model to be explored as follows:

VECTOR

CLIMATE .

Popular & technician participation

Braz. Health Sys & vector control

DENGUE Health Education

Virus type

Governance

In this model, the horizontal variables (climate-vector-dengue) are commonly discussed. However, the community participation in dengue prevention events is an unknown variable. Given the reality of Brazilian cities, it may be one variable that needs to be unveiled. From the political point of view, questions were raised about the Brazilian Unified Health System’s role in controlling the vector and the progress made by the National Dengue Control Program (PNCD). What can reduce vector infestation beyond recommended by the PNCD? What is the role of health education on vector control? Is it necessary to know what communities think about this? How can the community prepare for, despite the weather, for facing dengue epidemics? On the horizontal plane (climate-vector-dengue), can the public sector influence a reduction in harm and risk? Are these situations capable of adaptation?

36 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Invitees to the first Expert Discussion Group (EDG) Participants

Institution

Title

Amanda de Castro e Silva

Belo Horizonte City Health Department FIOCRUZ Foundation FIOCRUZ Foundation Belo Horizonte City Health Department Belo Horizonte City Health Department Observatory for Urban Health – Federal University Federal Univeristy of Ouro Preto Belo Horizonte City Health Department Belo Horizonte City Health Department Belo Horizonte City Health Department Belo Horizonte City Health Department Belo Horizonte City Health Department Institute of Biological Science Federal University Belo Horizonte City Health Department FIOCRUZ Foundation Institute of Exact Science Federal University Institute of National Metereology Belo Horizonte City Health Department Belo Horizonte City Health Department Belo Horizonte City Health Department Observatory for Urban Health – Federal University

Specialty on Health Policy

Christovam Barcellos Diego Xavier Silva Fernanda Carvalho de Menezes Fernanda Rodrigues Fernando Augusto Proietti

George Luiz Machado Coelho José Eduardo Marques Pessanha Márcia Costa O. Mendes Maria Cristina de Mattos Almeida Maria da Consolação Magalhães Cunha Maria Helena Franco Morais Mauro Teixeira

Paulo Roberto Lopes Corrêa Paulo Filemon Paolucci Pimenta Renato Marins Assunção

Rubens Vianello Silvana Tecles Brandão Solange Nonatto Valdelaine Etelvina Miranda de Araújo Waleska Teixeira Caiaffa

Doctor in Geoscience Master in Epidemiology Master in Health Science Doctoral student in Geography Doctor in Epidemiology

Doctor in Parasitology Doctor in Public Health Master in Microbiology Master in Public Health Master in Public Health Doctor in Science Doctor in Immunopharmacology

Master of Public Health Doctor in Science Doctor in Statistics

Post doctor in Metereology Specialty on Health Policy Specialty in Epidemiology Doctor in Science Post doctor in Epidemiology

37 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Second EDG–29/04/2011 The second workshop, on 29 April 2011, developed an interactive process with climate experts, absent in the first meeting. Data enhanced after the 2010 meeting received a critical analysis of the technical representatives of the sectors of the environment, weather and health. There was finally consensus on the information that the minimum temperatures in the city of Belo Horizonte increased since 1980 and the territory north of the city is suffering an increased change from urban sprawl determined by the construction of the Green Line and Administrative City (North Vector). These facts require due consideration from those responsible for vector control.

With regard to utilizing climatological measurements from the National Institute of Meteorology (INMET) of Belo Horizonte, for comparison with variables related to vector infestation and disease occurrence, a new approach will be necessary, since these units generate information limited to their coverage areas. The existing meteorological stations of the Avenida Raja Gabáglia and Federal University of Minas Gerais (UFMG) units only represent their surroundings therefore providing insufficient data to assess the ideal microclimate for Aedes aegypti breeding. Interaction possibilities were identified with other segments, including new projects of the Municipal Environmental Department involving the acquisition of specific equipment for climatological assessment of small areas, contributing with useful microdata for vector monitoring. The Municipal Health and Municipal Environment departments should initiate discussions to tailor and optimize new projects.

An example of an interactive possibility was identified through the studies of Wellington Lopes Assis at the Federal University of Minas Gerais (UFMG), Geosciences Institute. The research brought an interesting perspective on the analysis of climate correlations and the occurrence of dengue in urban microareas. The author mapped out natural and urban climatic units within Belo Horizonte and identified mesoclimates within the city, broken down into topoclimates and identified for each local climate through spatial and time-based meteorological and geological data analysis. The author identified six mesoclimates that are broken down into thirty-five (35) topoclimates in the municipality.

38 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

These urban climate units were based on field studies for the collection of meteorological data superimposed with information on land use, population density and digital terrain model (Assis, 2010).

It was proposed the continuity of intersectoral discussion preferably facilitated by the Belo Horizonte Municipal Committee on Climate change and Eco-efficiency and the construction of information networks, exchanges of experiences and scientific productions. Funding should, be sought from international agencies for climate and vector monitoring. This group was invited to join the “Urban Health Observatory,” a partnership between the Federal University of Minas Gerais (UFMG) School of Medicine and the Belo Horizonte Municipality.

39 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Invitees to the second Expert Discussion Group (EDG): Participants

Institution

Title

Amanda de Castro e Silva

Belo Horizonte City Health Department State Institute of Waters

Specialty on Health Policy

Catholic University of Minas Gerais Institute of National Meteorology Belo Horizonte Environmental Department State Institute of Historical and Artistic Heritage

Master in Geography

Adma Raia Alecir Antonio Maciel Moreira Anete dos Santos Fernandes Cyleno Reis Guimarães Daniele Gomes Ferreira

Edna Afonso Reis Felipe S. de Miranda Nunes Fernanda Carvalho de Menezes Fernanda Gonçalves Rodrigues George Luiz Machado Coelho José Eduardo Marques Pessanha Magda Luzimar de Abreu Márcia Costa O. Mendes Maria Cristina de Mattos Almeida Maria da Consolação Magalhães Cunha, Maria Helena Franco Morais Mauro MartinsTeixeira Paulo Correa Paulo Filemon Paolucci Pimenta Renato Martins Assunção Ricardo Aroeira Silvana Tecles Brandão. Solange Maria Nonatto Valdelaine Etelvina Miranda de Araújo Waleska Teixeira Caiaffa Wellington Lopes Assis

Institute of Exact Science Federal University State Foundation of the Environment Belo Horizonte City Health Department Belo Horizonte City Health Department Federal Univeristy of Ouro Preto Belo Horizonte City Health Department Institute of Geoscience Federal University Belo Horizonte Environmental Department Belo Horizonte City Health Department Belo Horizonte City Health Department City Environmental Department Institute of Biology Science Federal University Belo Horizonte Environmental Department FIOCRUZ Foundation Institute of Exact Science Federal University Belo Horizonte Urban Policies Department Belo Horizonte City Health Department Belo Horizonte City Health Department Belo Horizonte Environmental Department Observatory for Urban Health Federal University Institute of Geoscience Federal University

Doctor in Metereology

Mestre em Meteorologia Specialty on Geoprocessing data Master in Building Envrionment and Historical Heritage Doctor in Statistics Master in Analysis and Modelling of Envt.Systems Master in Health Science Doutoral Student in Geography Doctor in Parasitology Doctor in Public Health Doctor in Metereology Master in Microbiology Master of Public Health Master of Public Health Doctor in Science Doctor in Immunopharmacology Master in Public Health Doctor in Science Doctor in Statistics Sanitary Engineering Specialty on Health Policy Specialty in Epidemiology Doctor in Science Post doctor in Epidemiology Doctor of Geoscience

40 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

Conclusions and Recommendations This section summarizes the purpose of identifying the necessary actions to protect the health of the population of Belo Horizonte, Minas Gerais, Brazil in the face of climate change, working with empirical data derived for this report as connected to local stakeholders’ understanding as a result of the two Expert Discussion Groups (EDGs). When testing the “Guidance for conducting assessments of health vulnerability and public health and health care interventions to address climate change” (GUIDE), an action protocol was built up by the team involved based upon the analysis of available data allowing to equip health and environment workers for a sensitive, timely and effective discussion aiming at interventions. The research translation of the environment findings related to the occurrence of a possible climate-sensitive disease to the population was identified by the expert discussion group as the most relevant challenge.

Faced with so many variables necessary to understand the factors responsible for vectorial infestations and maintenance of dengue infections, new challenges are presented to the team of this project under the guidance document entitled “Protecting health from climate change: Vulnerability and adaptation assessment (WHO, 2013)” previously referred to as the “Guidance for Conducting Assessments of Health Vulnerability and Public Health and Health Care Interventions to Address Climate Change.”

Nonetheless, the information brought more evidence between the precipitation or rainfall, the behavior of the vector and disease occurrence. On the basis of the graphical superimposition of meteorological data and the analyses of positive ovitraps, the correlation between the concentration of positive traps and rainfall became clearer. Moreover, it was observed that Aedes aegypti larvae breeding is modulated by human behavior in as much as the presence of positive deposits was located outside the home during rainy season and there was a predominance of positive reservoirs within households during dry season, mainly characterized by potted plants

41 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

The epidemiological and environmental profiles of dengue present as a possible climate-sensitive disease based on expert opinions, given its variability in relation to climate change permeated by environmental and social factors. The current epidemiological picture may change according to climate change projections for the coming decades.

Exposing the analyses of health indicators through maps and charts to a group of specialists from different fields allowed the unraveling of scenarios. During the workshops, a wide-ranging interactive process with the specialists occurred, with great critical appreciation.

The meeting of experts has created a favorable environment for the debate on how to investigate dengue and monitor climate and environmental events, critical to understanding the dynamics of disease producing consensual information from different fields of knowledge.

Researchers and health professionals who attended the meetings worked actively to propose initiatives for reducing harm related to climate change. It was agreed that there is a need for further studies investigating the combined effects of rainfall, altitude and human behaviours, principally in urban settings with a marked population density and disorderly occupation of the territory.

From the perspective of the health sector, even recognizing the limits of urban equipment for measuring environmental variables and identifying conditions favorable to vectors (e.g., existence of mosquito breeding sites) and hence causing diseases, it was important to recognize, by sharing experiences, the possibility of new and potential directions in controlling endemic conditions in urban settings, especially for vector-borne diseases such as dengue and leishmaniasis.

The interaction with other parts of the government and the development of joint projects are proposals that harmonize with the Belo Horizonte Municipal Committee on Climate Change and Eco-efficiency decisions (Law No. 10.175/2011). The ordinance provides, in Section 12:

42 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

The Executive must investigate and monitor the risk factors to life and health stemming from climate change and implement necessary prevention and treatment measures, so as to avoid or minimize their impact on public health. (Law No. 10.175/2011).

The legislation has defined the responsibility of the public sector in shedding light on harms related to the effects of climate change, promoting and providing incentives for research targeting environmental, epidemiological and entomological surveillance and improvement of disease control programs of infectious diseases with high levels of endemicity and sensitivity to the climate, especially malaria, leishmaniasis and dengue. The above mentioned precepts strengthened the discussions at the meetings carried out for this project.

43 Dengue in an urban setting: vulnerability assessments and forecasts of the impact of climate change on health in the City of Belo Horizonte, Minais Gerais, Brazil

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