From the Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada.
Epidemiology. 2021 Jul 1;32(4):541-550. doi: 10.1097/EDE.0000000000001353.
The clinical presentation of dengue ranges from self-limited mild illness to severe forms, including death. African ancestry is often described as protective against dengue severity. However, in the Latin American context, African ancestry has been associated with increased mortality. This "severity paradox" has been hypothesized as resulting from confounding or heterogeneity by socioeconomic status (SES). However, few systematic analyses have been conducted to investigate the presence and nature of the disparity paradox.
We fit Bayesian hierarchical spatiotemporal models using individual-level surveillance data from Cali, Colombia (2012-2017), to assess the overall morbidity and severity burden of notified dengue. We fitted overall and ethnic-specific models to assess the presence of heterogeneity by SES across and within ethnic groups (Afro-Colombian vs. non-Afro-Colombians), conducting sensitivity analyses to account for potential underreporting.
Our study included 65,402 dengue cases and 13,732 (21%) hospitalizations. Overall notified dengue incidence rates did not vary across ethnic groups. Severity risk was higher among Afro-Colombians (risk ratio [RR] = 1.16; 95% Credible Interval [95% CrI] = 1.08, 1.24) but after accounting for underreporting by ethnicity this association was nearly null (RR = 1.02; 95% CrI = 0.97, 1.07). Subsidized health insurance and low-SES were associated with increased overall dengue rates and severity.
The paradoxically increased severity among Afro-Colombians can be attributed to differential health-seeking behaviors and reporting among Afro-Colombians. Such differential reporting can be understood as a type of intersectionality between SES, insurance scheme, and ethnicity that requires a quantitative assessment in future studies.
登革热的临床表现从自限性轻度疾病到严重形式不等，包括死亡。非洲裔通常被描述为对登革热严重程度具有保护作用。然而，在拉丁美洲背景下，非洲裔与死亡率增加有关。这种“严重程度悖论”被假设为是由社会经济地位（SES）的混杂或异质性引起的。然而，很少有系统分析来调查这种差异悖论的存在和性质。
我们使用来自哥伦比亚卡利的个体水平监测数据（2012-2017 年）拟合贝叶斯分层时空模型，以评估通知的登革热的总体发病率和严重程度负担。我们拟合了总体和族裔特异性模型，以评估 SES 在族裔群体内和族裔群体之间的异质性（非裔哥伦比亚人与非非裔哥伦比亚人），并进行敏感性分析以考虑潜在的漏报。
我们的研究包括 65402 例登革热病例和 13732 例（21%）住院病例。总体通知的登革热发病率在不同族裔群体之间没有差异。非裔哥伦比亚人患严重疾病的风险较高（风险比[RR] = 1.16；95%可信区间[95% CrI] = 1.08，1.24），但在考虑到族裔报告漏报后，这种关联几乎为零（RR = 1.02；95% CrI = 0.97，1.07）。补贴医疗保险和低 SES 与总体登革热发病率和严重程度增加有关。
非裔哥伦比亚人严重程度增加的悖论可以归因于非裔哥伦比亚人不同的就医行为和报告。这种差异报告可以被理解为 SES、保险计划和族裔之间的一种交叉性，需要在未来的研究中进行定量评估。
