Send to

Choose Destination
PLoS One. 2017 Jul 7;12(7):e0180220. doi: 10.1371/journal.pone.0180220. eCollection 2017.

Risk of bias and confounding of observational studies of Zika virus infection: A scoping review of research protocols.

Author information

Pan American Health Organization, Washington, D.C., United States of America.
Department of Chemical and Biological Sciences, Universidad de Sonora, Sonora, Mexico.
Escuela de Medicina, Universidad de Santander, Bucaramanga, Colombia.
Grupo de Investigación de Salud, Universidad de La Sabana, Bogotá, Colombia.
Subdirección de Producción de Guías de Práctica Clínica, Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá, Colombia.
Yale School of Public Health, New Haven, Connecticut, United States of America.
Cochrane Skin Group, The University of Nottingham, Nottingham, United Kingdom.
World Health Organization, Geneva, Switzerland.
Center for Global Health, Institut Pasteur, Paris, France.



Given the severity and impact of the current Zika virus (ZIKV) outbreak in the Americas, numerous countries have rushed to develop research studies to assess ZIKV and its potential health consequences. In an effort to ensure that studies are comprehensive, both internally and externally valid, and with reliable results, the World Health Organization, the Pan American Health Organization, Institut Pasteur, the networks of Fiocruz, the Consortia for the Standardization of Influenza Seroepidemiology (CONSISE) and the International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) have generated six standardized clinical and epidemiological research protocols and questionnaires to address key public health questions on ZIKV.


We conducted a systematic search of ongoing study protocols related to ZIKV research. We analyzed the content of protocols of 32 cohort studies and 13 case control studies for systematic bias that could produce erroneous results. Additionally we aimed to characterize the risks of bias and confounding in observational studies related to ZIKV and to propose ways to minimize them, including the use of six newly standardized research protocols.


Observational studies of ZIKV face an array of challenges, including measurement of exposure and outcomes (microcephaly and Guillain-Barré Syndrome). Potential confounders need to be measured where known and controlled for in the analysis. Selection bias due to non-random selection is a significant issue, particularly in the case-control design, and losses to follow-up is equally important for the cohort design.


Observational research seeking to answer key questions on the ZIKV should consider these restrictions and take precautions to minimize bias in an effort to provide reliable and valid results. Utilization of the standardized research protocols developed by the WHO, PAHO, Institut Pasteur, and CONSISE will harmonize the key methodological aspects of each study design to minimize bias at different stages of the study. Biases need to be considered by researchers implementing the standardized protocols as well as by users of observational epidemiological studies of ZIKV.

[Indexed for MEDLINE]
Free PMC Article

Supplemental Content

Full text links

Icon for Public Library of Science Icon for PubMed Central
Loading ...
Support Center