Co-circulation of Chikungunya Virus during the 2015–2017 Zika Virus Outbreak in Pernambuco, Brazil: An Analysis of the Microcephaly Epidemic Research Group Pregnancy Cohort

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  • 1 Health Equity Action Lab, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom;
  • | 2 Departamento de Medicina Interna, Universidade de Pernambuco, Recife, Brazil;
  • | 3 Instituto de Ciências Biológicas, Universidade de Pernambuco, Recife, Brazil;
  • | 4 Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, Brazil;
  • | 5 Departamento de Medicina Social, Universidade Federal de Pernambuco, Recife, Brazil;
  • | 6 Secretaria Estadual de Saúde, Pernambuco, Brazil;
  • | 7 Department of Infectious Diseases and Microbiology, University of Pittsburgh, Pittsburgh, Pennsylvania;
  • | 8 High Treat Pathogens, Infectious Hazard Management, World Health Organisation Health Emergency Program, WHO Regional Office for Europe UN City, Copenhagen, Denmark;
  • | 9 Department of Infectious Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom;
  • | 10 MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom;
  • | 11 Departamento de Medicina Tropical, Universidade Federal de Pernambuco, Recife, Brazil

Co-circulation of arthropod-borne viruses, particularly those with shared mosquito vectors like Zika (ZIKV) and Chikungunya (CHIKV), is increasingly reported. An accurate differential diagnosis between ZIKV and CHIKV is of high clinical importance, especially in the context of pregnancy, but remains challenging due to limitations in the availability of specialized laboratory testing facilities. Using data collected from the prospective pregnancy cohort study of the Microcephaly Epidemic Research Group, which followed up pregnant persons with rash during the peak and decline of the 2015–2017 ZIKV epidemic in Recife, Pernambuco, Brazil, this study aims to describe the geographic and temporal distribution of ZIKV and CHIKV infections and to investigate the extent to which ZIKV and CHIKV infections may be clinically differentiable. Between December 2015 and June 2017, we observed evidence of co-circulation with laboratory confirmation of 213 ZIKV mono-infections, 55 CHIKV mono-infections, and 58 sequential ZIKV/CHIKV infections (i.e., cases with evidence of acute ZIKV infection with concomitant serological evidence of recent CHIKV infection). In logistic regressions with adjustment for maternal age, ZIKV mono-infected cases had lower odds than CHIKV mono-infected cases of presenting with arthralgia (aOR, 99% CI: 0.33, 0.15–0.74), arthritis (0.35, 0.14–0.85), fatigue (0.40, 0.17–0.96), and headache (0.44, 0.19–1.90). However, sequential ZIKV/CHIKV infections complicated discrimination, as they did not significantly differ in clinical presentation from CHIKV mono-infections. These findings suggest clinical symptoms alone may be insufficient for differentiating between ZIKV and CHIKV infections during pregnancy and therefore laboratory diagnostics continue to be a valuable tool for tailoring care in the event of arboviral co-circulation.

Author Notes

Address correspondence to Elizabeth B. Brickley, Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel St., London WC1E 7HT, United Kingdom. E-mail: elizabeth.brickley@lshtm.ac.uk

Joint Senior Authors.

Financial support: This work was supported by the: British Council Newton Fund (527418645); European Union’s Horizon 2020 Research and Innovation Programme ZikaPLAN grant agreement (No. 734584); the Wellcome Trust & the UK Department for International Development (201870/Z/16/Z & 205377/Z/16/Z); Wellcome Trust—Research Enrichment in Epidemic Situations (107779/Z/15/Z, with ER1505 & ER1601); the Medical Research Council on behalf of the Newton Fund and Wellcome Trust (MC_PC_15088); Fundação de Amparo à Ciência e Tecnologia de PE—FACEPE (APQ-0192-4.01/17 to Programa de Pós-graduação em Ciências da Saúde-UPE and APQ-0172-4.01/16); Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brasil (CAPES)—Finance Code 001; Scholarship: Conselho Nacional de Desenvolvimento Científico e Tecnológico (309722/2017-9, 306708/2014-0), Secretaria de Vigilância em Saúde/Ministério da Saúde de Brasil Resposta à Emergência em Saúde Pública—Zika vírus e Microcefalia (837058/2016); Conselho Nacional de Desenvolvimento Científico e Tecnológico, Coordenação de Aperfeiçoamento de Pessoal de Nível Superior; Departamento de Ciência e Tecnologia for Prevenção e Combate ao vírus Zika I (440839/2016-5). The funders had no role in the design and conduct of the study, the collection, management, analysis, and interpretation of the data, the preparation, review, or approval of the manuscript, or the decision to submit the manuscript for publication.

Authors’ addresses: Ludmila Lobkowicz, Nuria Sanchez Clemente, and Elizabeth B. Brickley, Health Equity Action Lab, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom, E-mails: ludmilalobkowicz@gmail.com, nuriasanchezclemente@gmail.com, and elizabeth.brickley@lshtm.ac.uk. Demócrito de Barros Miranda-Filho, Departamento de Medicina Interna, Universidade de Pernambuco, Recife, Brazil, E-mail: demofilho@gmail.com. Ulisses Ramos Montarroyos, Instituto de Ciências Biológicas, Universidade de Pernambuco, Recife, Brazil, E-mail: ulisses.montarroyos@upe.br. Celina Maria Turchi Martelli, Wayner Vieira De Souza, and Rafael Dhalia, Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, Brazil, E-mails: turchicm@gmail.com, waynervieira@gmail.com, and rafael.dhalia@gmail.com. Thalia Velho Barreto de Araújo, Departamento de Medicina Social, Universidade Federal de Pernambuco, Recife, Brazil, E-mail: thalia.velho.barreto@gmail.com. Luciana Caroline Albuquerque Bezerra, Secretaria Estadual de Saúde, Pernambuco, Brazil, E-mail: lua_cad@yahoo.com.br. Ernesto T. A. Marques, Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, Brazil, and Department of Infectious Diseases and Microbiology, University of Pittsburgh, Pittsburgh, PA, E-mail: marques@pitt.edu. Jayne Webster, High Treat Pathogens, Infectious Hazard Management, World Health Organisation Health Emergency Program, WHO Regional Office for Europe UN City, Copenhagen, Denmark, E-mail: jayne.webster@lshtm.ac.uk. Aisling Vaughan, Department of Infectious Disease Control, London School of Hygiene and Tropical Medicine, London, United Kingdom, E-mail: vaughana@who.int. Emily L. Webb, MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, United Kingdom, E-mail: emily.webb@lshtm.ac.uk. Ricardo Arraes de Alencar Ximenes, Departamento de Medicina Interna, Universidade de Pernambuco, Recife, Brazil, and Departamento de Medicina Tropical, Universidade Federal de Pernambuco, Recife, Brazil, E-mail: raaximenes@uol.com.br.

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