Societal impact of dengue outbreaks: Stakeholder perceptions and related implications. A qualitative study in Brazil, 2015

Background: The growing burden of dengue in many countries worldwide and the difficulty of preventing outbreaks have increased the urgency to identify alternative public health management strategies and effective approaches to control and prevent dengue outbreaks. The objectives of this study were to understand the impact of dengue outbreak on different stakeholders in Brazil, to explore their perceptions of approaches used by governmental authorities to control and prevent dengue outbreaks and to define the challenges and implications of preventing future outbreaks. Methods: In 2015, a qualitative study was conducted in two urban states in Brazil: São Paulo, which was experiencing an outbreak in 2015, and Rio de Janeiro, which experienced outbreaks in 2011 and 2012. Face-to-face interviews using a semi-structured questionnaire were conducted with nine different categories of stakeholders: health workers (physicians, nurses), hospital administrators, municipal government representatives, community members and leaders, school administrators, business leaders and vector control managers. Interviews were focused on the following areas: impact of the dengue outbreak, perceptions of control measures implemented by governmental authorities during outbreaks and challenges in preventing future dengue outbreaks. Results: A total of 40 stakeholders were included in the study. Health workers and community members reported longer waiting times at hospitals due to the increased number of patients receiving care for dengue-related symptoms. Health workers and hospital administrators reported that there were no major interruptions in access to care. Overall financial impact of dengue outbreaks on households was greatest for low-income families. Despite prevention and control campaigns implemented between outbreak periods, various stakeholders reported that dengue prevention and control efforts performed by municipal authorities remained insufficient, suggesting that efforts should be reinforced and better coordinated by governmental authorities, particularly during outbreak periods. Conclusion: The study shows that a dengue outbreak has a multisectorial impact in the medical, societal, economic and political sectors. The study provides useful insights and knowledge in different stakeholder populations that could guide local authorities and government officials in planning, designing and initiating public health programs. Research focused on a better understanding of how communities and political authorities respond to dengue outbreaks is a necessary component for designing and implementing plans to decrease the incidence and impact of dengue outbreaks in Brazil. Author summary: Since the beginning of the 21st century, dengue fever has been a significant vector-borne arboviral disease; actually more than 3.9 billion people are at risk of infection in 128 countries. Dengue has become an increasing public health concern in Latin America, especially in Brazil, which has the highest incidence rate of dengue. Researches are needed to gain in-depth understanding of stakeholder and community reactions to outbreak and to explore the societal impact of dengue outbreaks. In 2015, a qualitative study was conducted in two urban states in Brazil, which experienced recent outbreaks. Longer waiting times at hospitals due to the increased number of patients receiving care for dengue-related symptoms were reported, but without interruptions in access to care. Various stakeholders reported that dengue prevention and control efforts performed by municipal authorities remained insufficient. The consequences of a dengue outbreak reach far beyond the patients, undermining medical, social, economic and political sectors. Research focused on a better understanding of how communities and political authorities respond to dengue outbreaks is a necessity for designing and implementing plans to control dengue outbreaks.