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. 2019 Sep 27;69(8):1353-1359.
doi: 10.1093/cid/ciy1083.

Concomitant Transmission of Dengue, Chikungunya, and Zika Viruses in Brazil: Clinical and Epidemiological Findings From Surveillance for Acute Febrile Illness

Monaíse M O Silva  1 , Laura B Tauro  1   2 , Mariana Kikuti  1   3 , Rosângela O Anjos  1 , Viviane C Santos  1 , Thaiza S F Gonçalves  1 , Igor A D Paploski  3   4 , Patrícia S S Moreira  1 , Leile C J Nascimento  1 , Gúbio S Campos  5 , Albert I Ko  1   6 , Scott C Weaver  7 , Mitermayer G Reis  1   8 , Uriel Kitron  1   9 , Guilherme S Ribeiro  1   3   8
Affiliations

Concomitant Transmission of Dengue, Chikungunya, and Zika Viruses in Brazil: Clinical and Epidemiological Findings From Surveillance for Acute Febrile Illness

Monaíse M O Silva et al. Clin Infect Dis. .

Erratum in

  • Erratum.
    [No authors listed] [No authors listed] Clin Infect Dis. 2019 Nov 27;69(12):2238. doi: 10.1093/cid/ciz588. Clin Infect Dis. 2019. PMID: 31774513 Free PMC article. No abstract available.
  • Erratum.
    [No authors listed] [No authors listed] Clin Infect Dis. 2019 Nov 27;69(12):2238. doi: 10.1093/cid/ciz588. Clin Infect Dis. 2019. PMID: 33507246 No abstract available.

Abstract

Background: Since their emergence in the Americas, chikungunya (CHIKV) and Zika (ZIKV) viruses co-circulate with dengue virus (DENV), hampering clinical diagnosis. We investigated clinical and epidemiological characteristics of arboviral infections during the introduction and spread of CHIKV and ZIKV through northeastern Brazil.

Methods: Surveillance for arboviral diseases among febrile patients was performed at an emergency health unit of Salvador, Brazil, between September 2014 and July 2016. We interviewed patients to collect data on symptoms, reviewed medical records to obtain the presumptive diagnoses, and performed molecular and serological testing to confirm DENV, CHIKV, ZIKV, or nonspecific flavivirus (FLAV) diagnosis.

Results: Of 948 participants, 247 (26.1%) had an acute infection, of which 224 (23.6%) were single infections (DENV, 32 [3.4%]; CHIKV, 159 [16.7%]; ZIKV, 13 [1.4%]; and FLAV, 20 [2.1%]) and 23 (2.4%) coinfections (DENV/CHIKV, 13 [1.4%]; CHIKV/FLAV, 9 [0.9%]; and DENV/ZIKV, 1 [0.1%]). An additional 133 (14.0%) patients had serological evidence for a recent arboviral infection. Patients with ZIKV presented with rash and pruritus (69.2% each) more frequently than those with DENV (37.5% and 31.2%, respectively) and CHIKV (22.9% and 14.7%, respectively) (P < .001 for both comparisons). Conversely, arthralgia was more common in CHIKV (94.9%) and FLAV/CHIKV (100.0%) than in DENV (59.4%) and ZIKV (53.8%) (P < .001). A correct presumptive clinical diagnosis was made for 9%-23% of the confirmed patients.

Conclusions: Arboviral infections are frequent causes of febrile illness. Coinfections are not rare events during periods of intense, concomitant arboviral transmission. Given the challenge to clinically distinguish these infections, there is an urgent need for rapid, point-of-care, multiplex diagnostics.

Keywords: Zika virus; arbovirus; chikungunya virus; coinfection; dengue virus.

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Figures

Figure 1.
Figure 1.
Flowchart of 948 patients enrolled during an acute febrile illness surveillance study in an emergency health unit, according to the arboviral diagnosis—Salvador, Brazil, September 2014 to July 2016. Of the 247 cases of acute arboviral infection, 39 showed evidence of a recent arboviral infection. These are in addition to the other 133 recent arboviral infections shown in the figure. Abbreviations: CHIKV, chikungunya virus; DENV, dengue virus; FLAV, flavivirus; ZIKV, Zika virus.
Figure 2.
Figure 2.
Distribution (percentage) of 948 acute febrile illness patients according to the arboviral diagnosis by month—Salvador, Brazil, September 2014 to July 2016. Abbreviations: CHIKV, chikungunya virus; DENV, dengue virus; FLAV, flavivirus; ZIKV, Zika virus.
See this image and copyright information in PMC

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