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Clin Infect Dis. 2018 Dec 18. doi: 10.1093/cid/ciy1083. [Epub ahead of print]

Concomitant transmission of dengue, chikungunya and Zika viruses in Brazil: Clinical and epidemiological findings from surveillance for acute febrile illness.

Author information

Instituto Gonçalo Moniz, Fundação Oswaldo Cruz, Salvador, Brazil.
Instituto Nacional de Medicina Tropical, CONICET, Puerto Iguazú, Argentina.
Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brazil.
University of Minnesota, St. Paul, USA.
Instituto de Ciências da Saúde, Universidade Federal da Bahia, Salvador, Brazil.
Yale School of Public Health, New Haven, USA.
University of Texas Medical Branch, Galveston, USA.
Faculdade de Medicina, Universidade Federal da Bahia, Salvador, Brazil.
Emory University, Atlanta, USA.



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.


Surveillance for arboviral diseases among febrile patients was performed at an emergency health unit of Salvador, Brazil between Sep/2014-Jul/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 non-specific flavivirus (FLAV) diagnosis.

Results :

f 948 participants, 247 (26.1%) had an acute infection, of which 224 (23.6%) were single infections (DENV: 32, or 3.4%; CHIKV: 159, 16.7%; ZIKV: 13, 1.4%; and FLAV: 20, 2.1%), and 23 (2.4%) co-infections (DENV/CHIKV: 13, 1.4%; CHIKV/FLAV: 9, 0.9%; and DEN/ZIKV: 1, 0.1%). An additional 133 (14.0%) patients had serological evidence for a recent arboviral infection. Patients with Zika presented rash (69.2%) and pruritus (69.2%) more frequently than those with dengue (37.5% and 31.2%, respectively) and chikungunya (22.9% and 14.7%, respectively) (P<0.001 for both comparisons). Conversely, arthralgia was more common in chikungunya (94.9%) and FLAV/CHIKV (100.0%) than in dengue (59.4%) and Zika (53.8%) (P<0.001). A correct presumptive clinical diagnosis was made for 9-23% of the confirmed patients.


Arboviral infections are frequent causes of febrile illness. Co-infections 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.


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