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

Monaíse M.O. Silva, Laura B. Tauro, Mariana Kikuti, Rosângela O. Anjos, Viviane C. Santos, Thaiza S.F. Gonçalves, Igor A.D. Paploski, Patrícia S.S. Moreira, Leile C.J. Nascimento, Gúbio S. Campos, Albert I. Ko, Scott C. Weaver, Mitermayer G. Reis, Uriel Kitron, Guilherme S. Ribeiro

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74 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)1353-1359
Number of pages7
JournalClinical Infectious Diseases
Issue number8
StatePublished - Sep 27 2019

Bibliographical note

Funding Information:
Financial support. This work was supported by the Brazilian National Council for Scientific and Technological Development (grant numbers 400830/2013-2 and 440891/2016–7 to G. S. R.; and scholarships to I. A. D. P., L. B. T., U. K., M. G. R., and G. S. R.); the Bahia Foundation for Research Support (grant numbers PET0026/2013, APP0044/2016, and PET0022/2016 to G. S. R., and scholarship to M. M. O. S.); the Coordination for the Improvement of Higher Education Personnel, Brazilian Ministry of Education (grant number 440891/2016–7 to G. S. R. and scholarship to M. K.); the US National Institutes of Health (grant numbers R01 TW009504, R01 AI121207, and U01 AI088752 to A. I. K. and R24 AI AI120942 to S. C. W.); the Yale School of Public Health; the Federal University of Bahia; and the Oswaldo Cruz Foundation.

Publisher Copyright:
© 2019 The Author(s).


  • Zika virus
  • arbovirus
  • chikungunya virus
  • coinfection
  • dengue virus


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