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Raza S, Poria R, Kala D, Sharma N, Sharma AK, Florien N, Tuli HS, Kaushal A, Gupta S. Innovations in dengue virus detection: An overview of conventional and electrochemical biosensor approaches. Biotechnol Appl Biochem 2024. [PMID: 38225854 DOI: 10.1002/bab.2553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/27/2023] [Indexed: 01/17/2024]
Abstract
Globally, people are in great threat due to the highly spreading of viral infectious diseases. Every year like 100-300 million cases of infections are found, and among them, above 80% are not recognized and irrelevant. Dengue virus (DENV) is an arbovirus infection that currently infects people most frequently. DENV encompasses four viral serotypes, and they each express comparable sign. From a mild febrile sickness to a potentially fatal dengue hemorrhagic fever, dengue can induce a variety of symptoms. Presently, the globe is being challenged by the untimely identification of dengue infection. Therefore, this review summarizes advances in the detection of dengue from conventional methods (nucleic acid-based, polymerase chain reaction-based, and serological approaches) to novel biosensors. This work illustrates an extensive study of the current designs and fabrication approaches involved in the formation of electrochemical biosensors for untimely identifications of dengue. Additionally, in electrochemical sensing of DENV, we skimmed through significances of biorecognition molecules like lectins, nucleic acid, and antibodies. The introduction of emerging techniques such as the CRISPR/Cas' system and their integration with biosensing platforms has also been summarized. Furthermore, the review revealed the importance of electrochemical approach compared with traditional diagnostic methods.
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Affiliation(s)
- Shadan Raza
- Department of Bio-Sciences and Technology, Maharishi Markandeshwar (Deemed to Be) University, Mullana, Ambala, India
| | - Renu Poria
- Department of Bio-Sciences and Technology, Maharishi Markandeshwar (Deemed to Be) University, Mullana, Ambala, India
| | - Deepak Kala
- Centera Laboratories, Institute of High Pressure Physics PAS, Warsaw, Poland
| | - Nishant Sharma
- Department of Bio-Sciences and Technology, Maharishi Markandeshwar (Deemed to Be) University, Mullana, Ambala, India
| | - Anil K Sharma
- Department of Biotechnology, Amity University of Punjab, Mohali, Punjab, India
| | - Nkurunziza Florien
- Department of Bio-Sciences and Technology, Maharishi Markandeshwar (Deemed to Be) University, Mullana, Ambala, India
| | - Hardeep S Tuli
- Department of Bio-Sciences and Technology, Maharishi Markandeshwar (Deemed to Be) University, Mullana, Ambala, India
| | - Ankur Kaushal
- Department of Bio-Sciences and Technology, Maharishi Markandeshwar (Deemed to Be) University, Mullana, Ambala, India
| | - Shagun Gupta
- Department of Bio-Sciences and Technology, Maharishi Markandeshwar (Deemed to Be) University, Mullana, Ambala, India
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Santos JD, Garcia BCC, Rocha KLS, Silva TJ, da Silva Lage SL, de Souza Macedo M, Teixeira RA, Rocha-Vieira E, de Oliveira DB. Seroprevalence of Dengue, Chikungunya, and Zika viruses antibodies in a cohort of asymptomatic pregnant women in a low-income region of Minas Gerais, Brazil, 2018-2019. Braz J Microbiol 2023; 54:1853-1858. [PMID: 37454038 PMCID: PMC10484836 DOI: 10.1007/s42770-023-01054-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023] Open
Abstract
Dengue, Chikungunya, and Zika viruses are arthropod-borne viruses (arboviruses) that infect millions of individuals in tropical and subtropical regions. In the Americas, arboviruses represent a major public health problem, especially among vulnerable groups such as the elderly, children, and pregnant women. In this study, the seroprevalence of IgM or IgG against these arboviruses in pregnant, young women in the city of Diamantina, Minas Gerais, Brazil, and the influence of sociodemographic factors on the incidence/prevalence of infection in this group were investigated. A cross-sectional investigation was conducted on a total of 135 pregnant women for Dengue and Chikungunya IgM and 88 pregnant women for Zika IgG. Dengue IgM was found on the serum of twenty participants (14.8%) and only one woman (0.7%) tested positive for Chikungunya IgM. Zika IgG was found in three (3.4%) participants and 2 women who tested positive for Zika virus were also positive for Dengue virus IgM. Although the arboviruses seroprevalence was higher frequency among young (20-25 years old), brown and high school women, with a monthly income of 1-3 minimum wages, no association between these sociodemographic factors and arboviruses seroprevalence was found.
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Affiliation(s)
- Juliane Duarte Santos
- Programa Multicêntrico de Pós-Graduação Em Ciências Fisiológicas, Universidade Federal Dos Vales Do Jequitinhonha E Mucuri, Diamantina, MG, Brazil
| | - Bruna Caroline Chaves Garcia
- Programa Multicêntrico de Pós-Graduação Em Ciências Fisiológicas, Universidade Federal Dos Vales Do Jequitinhonha E Mucuri, Diamantina, MG, Brazil
| | - Kamila Lorene Soares Rocha
- Programa de Pós-Graduação Em Microbiologia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Thyago José Silva
- Programa de Pós-Graduação Em Ciências da Saúde, Universidade Federal Dos Vales Do Jequitinhonha E Mucuri, Diamantina, MG, Brazil
| | - Sanny Lara da Silva Lage
- Programa Multicêntrico de Pós-Graduação Em Ciências Fisiológicas, Universidade Federal Dos Vales Do Jequitinhonha E Mucuri, Diamantina, MG, Brazil
| | - Mariana de Souza Macedo
- Departamento de Nutrição, Universidade Federal Dos Vales Do Jequitinhonha E Mucuri, Diamantina, MG, Brazil
| | - Romero Alves Teixeira
- Departamento de Nutrição, Universidade Federal Dos Vales Do Jequitinhonha E Mucuri, Diamantina, MG, Brazil
| | - Etel Rocha-Vieira
- Programa Multicêntrico de Pós-Graduação Em Ciências Fisiológicas, Universidade Federal Dos Vales Do Jequitinhonha E Mucuri, Diamantina, MG, Brazil.
- Programa de Pós-Graduação Em Ciências da Saúde, Universidade Federal Dos Vales Do Jequitinhonha E Mucuri, Diamantina, MG, Brazil.
| | - Danilo Bretas de Oliveira
- Programa Multicêntrico de Pós-Graduação Em Ciências Fisiológicas, Universidade Federal Dos Vales Do Jequitinhonha E Mucuri, Diamantina, MG, Brazil.
- Programa de Pós-Graduação Em Ciências da Saúde, Universidade Federal Dos Vales Do Jequitinhonha E Mucuri, Diamantina, MG, Brazil.
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Braga C, Martelli CMT, Souza WV, Luna CF, Albuquerque MDFPM, Mariz CA, Morais CNL, Brito CAA, Melo CFCA, Lins RD, Drexler JF, Jaenisch T, Marques ETA, Viana IFT. Seroprevalence of Dengue, Chikungunya and Zika at the epicenter of the congenital microcephaly epidemic in Northeast Brazil: A population-based survey. PLoS Negl Trop Dis 2023; 17:e0011270. [PMID: 37399197 DOI: 10.1371/journal.pntd.0011270] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 06/03/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND The four Dengue viruses (DENV) serotypes were re-introduced in Brazil's Northeast region in a couple of decades, between 1980's and 2010's, where the DENV1 was the first detected serotype and DENV4 the latest. Zika (ZIKV) and Chikungunya (CHIKV) viruses were introduced in Recife around 2014 and led to large outbreaks in 2015 and 2016, respectively. However, the true extent of the ZIKV and CHIKV outbreaks, as well as the risk factors associated with exposure to these viruses remain vague. METHODS We conducted a stratified multistage household serosurvey among residents aged between 5 and 65 years in the city of Recife, Northeast Brazil, from August 2018 to February 2019. The city neighborhoods were stratified and divided into high, intermediate, and low socioeconomic strata (SES). Previous ZIKV, DENV and CHIKV infections were detected by IgG-based enzyme linked immunosorbent assays (ELISA). Recent ZIKV and CHIKV infections were assessed through IgG3 and IgM ELISA, respectively. Design-adjusted seroprevalence were estimated by age group, sex, and SES. The ZIKV seroprevalence was adjusted to account for the cross-reactivity with dengue. Individual and household-related risk factors were analyzed through regression models to calculate the force of infection. Odds Ratio (OR) were estimated as measure of effect. PRINCIPAL FINDINGS A total of 2,070 residents' samples were collected and analyzed. The force of viral infection for high SES were lower as compared to low and intermediate SES. DENV seroprevalence was 88.7% (CI95%:87.0-90.4), and ranged from 81.2% (CI95%:76.9-85.6) in the high SES to 90.7% (CI95%:88.3-93.2) in the low SES. The overall adjusted ZIKV seroprevalence was 34.6% (CI95%:20.0-50.9), and ranged from 47.4% (CI95%:31.8-61.5) in the low SES to 23.4% (CI95%:12.2-33.8) in the high SES. The overall CHIKV seroprevalence was 35.7% (CI95%:32.6-38.9), and ranged from 38.6% (CI95%:33.6-43.6) in the low SES to 22.3% (CI95%:15.8-28.8) in the high SES. Surprisingly, ZIKV seroprevalence rapidly increased with age in the low and intermediate SES, while exhibited only a small increase with age in high SES. CHIKV seroprevalence according to age was stable in all SES. The prevalence of serological markers of ZIKV and CHIKV recent infections were 1.5% (CI95%:0.1-3.7) and 3.5% (CI95%:2.7-4.2), respectively. CONCLUSIONS Our results confirmed continued DENV transmission and intense ZIKV and CHIKV transmission during the 2015/2016 epidemics followed by ongoing low-level transmission. The study also highlights that a significant proportion of the population is still susceptible to be infected by ZIKV and CHIKV. The reasons underlying a ceasing of the ZIKV epidemic in 2017/18 and the impact of antibody decay in susceptibility to future DENV and ZIKV infections may be related to the interplay between disease transmission mechanism and actual exposure in the different SES.
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Affiliation(s)
- Cynthia Braga
- Department of Parasitology, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife, Pernambuco, Brazil
| | - Celina M T Martelli
- Department of Public Health, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife, Pernambuco, Brazil
| | - Wayner V Souza
- Department of Public Health, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife, Pernambuco, Brazil
| | - Carlos F Luna
- Department of Public Health, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife, Pernambuco, Brazil
| | | | - Carolline A Mariz
- Department of Parasitology, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife, Pernambuco, Brazil
| | - Clarice N L Morais
- Department of Virology, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife, Pernambuco, Brazil
| | - Carlos A A Brito
- Department of Clinical Medicine, Federal University of Pernambuco, Recife, Pernambuco, Brazil
| | | | - Roberto D Lins
- Department of Virology, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife, Pernambuco, Brazil
| | - Jan Felix Drexler
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Virology, Berlin, Germany
- German Centre for Infection Research (DZIF), associated partner site Charité, Berlin, Germany
| | - Thomas Jaenisch
- Section Clinical Tropical Medicine, Department of Infectious Diseases, Heidelberg University Hospital, Germany
- German Centre for Infection Research (DZIF), Heidelberg Site, Heidelberg, Germany
- Center for Global Health, Colorado School of Public Health, Aurora, Colorado, United States of America
| | - Ernesto T A Marques
- Department of Virology, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife, Pernambuco, Brazil
- Department of Infectious Diseases and Microbiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Isabelle F T Viana
- Department of Virology, Institute Aggeu Magalhães, Oswaldo Cruz Foundation, Recife, Pernambuco, Brazil
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Serology as a Tool to Assess Infectious Disease Landscapes and Guide Public Health Policy. Pathogens 2022; 11:pathogens11070732. [PMID: 35889978 PMCID: PMC9323579 DOI: 10.3390/pathogens11070732] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 06/10/2022] [Accepted: 06/16/2022] [Indexed: 01/27/2023] Open
Abstract
Understanding the local burden and epidemiology of infectious diseases is crucial to guide public health policy and prioritize interventions. Typically, infectious disease surveillance relies on capturing clinical cases within a healthcare system, classifying cases by etiology and enumerating cases over a period of time. Disease burden is often then extrapolated to the general population. Serology (i.e., examining serum for the presence of pathogen-specific antibodies) has long been used to inform about individuals past exposure and immunity to specific pathogens. However, it has been underutilized as a tool to evaluate the infectious disease burden landscape at the population level and guide public health decisions. In this review, we outline how serology provides a powerful tool to complement case-based surveillance for determining disease burden and epidemiology of infectious diseases, highlighting its benefits and limitations. We describe the current serology-based technologies and illustrate their use with examples from both the pre- and post- COVID-19-pandemic context. In particular, we review the challenges to and opportunities in implementing serological surveillance in low- and middle-income countries (LMICs), which bear the brunt of the global infectious disease burden. Finally, we discuss the relevance of serology data for public health decision-making and describe scenarios in which this data could be used, either independently or in conjunction with case-based surveillance. We conclude that public health systems would greatly benefit from the inclusion of serology to supplement and strengthen existing case-based infectious disease surveillance strategies.
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Medina FA, Vila F, Premkumar L, Lorenzi O, Paz-Bailey G, Alvarado LI, Rivera-Amill V, de Silva A, Waterman S, Muñoz-Jordán J. Capacity of a Multiplex IgM Antibody Capture ELISA to Differentiate Zika and Dengue Virus Infections in Areas of Concurrent Endemic Transmission. Am J Trop Med Hyg 2022; 106:585-592. [PMID: 34929668 PMCID: PMC8832915 DOI: 10.4269/ajtmh.20-1651] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 06/28/2021] [Indexed: 11/21/2022] Open
Abstract
Serological cross-reactivity has proved to be a challenge to diagnose Zika virus (ZIKV) infections in dengue virus (DENV) endemic countries. Confirmatory testing of ZIKV IgM positive results by plaque reduction neutralization tests (PRNTs) provides clarification in only a minority of cases because most individuals infected with ZIKV were previously exposed to DENV. The goal of this study was to evaluate the performance of a ZIKV/DENV DUO IgM antibody capture ELISA (MAC-ELISA) for discriminating between DENV and ZIKV infections in endemic regions. Our performance evaluation included acute and convalescent specimens from patients with real-time reverse transcription polymerase chain reaction (RT-PCR)-confirmed DENV or ZIKV from the Sentinel Enhanced Dengue Surveillance System in Ponce, Puerto Rico. The ZIKV/DENV DUO MAC-ELISA specificity was 100% for DENV (N = 127) and 98.4% for ZIKV (N = 275) when specimens were tested during the optimal testing window (days post-onset of illness [DPO] 6-120). The ZIKV/DENV DUO MAC-ELISA sensitivity of RT-PCR confirmed specimens reached 100% for DENV by DPO 6 and for ZIKV by DPO 9. Our new ZIKV/DENV DUO MAC-ELISA was also able to distinguish ZIKV and DENV regardless of previous DENV exposure. We conclude this novel serologic diagnostic assay can accurately discriminate ZIKV and DENV infections. This can potentially be useful considering that the more labor-intensive and expensive PRNT assay may not be an option for confirmatory diagnosis in areas that lack PRNT capacity, but experience circulation of both DENV and ZIKV.
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Affiliation(s)
- Freddy A. Medina
- Surveillance and Research Laboratory, Dengue Branch, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Frances Vila
- Surveillance and Research Laboratory, Dengue Branch, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Lakshmanane Premkumar
- Department of Microbiology and Immunology University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Olga Lorenzi
- Surveillance and Research Laboratory, Dengue Branch, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Gabriela Paz-Bailey
- Surveillance and Research Laboratory, Dengue Branch, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | | | | | - Aravinda de Silva
- Department of Microbiology and Immunology University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Steve Waterman
- Surveillance and Research Laboratory, Dengue Branch, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Jorge Muñoz-Jordán
- Surveillance and Research Laboratory, Dengue Branch, Centers for Disease Control and Prevention, San Juan, Puerto Rico;,Address correspondence to Jorge Muñoz-Jordán, Surveillance and Research Laboratory, Dengue Branch, Centers for Disease Control and Prevention, 1324 Calle Cañada, San Juan, Puerto Rico 00920. E-mail:
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Fischer C, Jo WK, Haage V, Moreira-Soto A, de Oliveira Filho EF, Drexler JF. Challenges towards serologic diagnostics of emerging arboviruses. Clin Microbiol Infect 2021; 27:1221-1229. [DOI: 10.1016/j.cmi.2021.05.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 05/19/2021] [Accepted: 05/27/2021] [Indexed: 12/26/2022]
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Morales I, Rosenberger KD, Magalhaes T, Morais CNL, Braga C, Marques ETA, Calvet GA, Damasceno L, Brasil P, Bispo de Filippis AM, Tami A, Bethencourt S, Alvarez M, Martínez PA, Guzman MG, Souza Benevides B, Caprara A, Quyen NTH, Simmons CP, Wills B, de Lamballerie X, Drexler JF, Jaenisch T. Diagnostic performance of anti-Zika virus IgM, IgAM and IgG ELISAs during co-circulation of Zika, dengue, and chikungunya viruses in Brazil and Venezuela. PLoS Negl Trop Dis 2021; 15:e0009336. [PMID: 33872309 PMCID: PMC8084345 DOI: 10.1371/journal.pntd.0009336] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 04/29/2021] [Accepted: 03/26/2021] [Indexed: 12/30/2022] Open
Abstract
Background Serological diagnosis of Zika virus (ZIKV) infection is challenging because of the antibody cross-reactivity among flaviviruses. At the same time, the role of Nucleic Acid Testing (NAT) is limited by the low proportion of symptomatic infections and the low average viral load. Here, we compared the diagnostic performance of commercially available IgM, IgAM, and IgG ELISAs in sequential samples during the ZIKV and chikungunya (CHIKV) epidemics and co-circulation of dengue virus (DENV) in Brazil and Venezuela. Methodology/Principal findings Acute (day of illness 1–5) and follow-up (day of illness ≥ 6) blood samples were collected from nine hundred and seven symptomatic patients enrolled in a prospective multicenter study between June 2012 and August 2016. Acute samples were tested by RT-PCR for ZIKV, DENV, and CHIKV. Acute and follow-up samples were tested for IgM, IgAM, and IgG antibodies to ZIKV using commercially available ELISAs. Among follow-up samples with a RT-PCR confirmed ZIKV infection, anti-ZIKV IgAM sensitivity was 93.5% (43/46), while IgM and IgG exhibited sensitivities of 30.3% (10/33) and 72% (18/25), respectively. An additional 24% (26/109) of ZIKV infections were detected via IgAM seroconversion in ZIKV/DENV/CHIKV RT-PCR negative patients. The specificity of anti-ZIKV IgM was estimated at 93% and that of IgAM at 85%. Conclusions/Significance Our findings exemplify the challenges of the assessment of test performance for ZIKV serological tests in the real-world setting, during co-circulation of DENV, ZIKV, and CHIKV. However, we can also demonstrate that the IgAM immunoassay exhibits superior sensitivity to detect ZIKV RT-PCR confirmed infections compared to IgG and IgM immunoassays. The IgAM assay also proves to be promising for detection of anti-ZIKV seroconversions in sequential samples, both in ZIKV PCR-positive as well as PCR-negative patients, making this a candidate assay for serological monitoring of pregnant women in future ZIKV outbreaks. Zika virus (ZIKV) is transmitted through the bite of infected Aedes mosquitos but can also be transmitted sexually or vertically from mother-to-child. The same mosquitoes transmit dengue virus (DENV) and chikungunya virus (CHIKV), which cause similar clinical syndromes. The ZIKV epidemics in the Pacific and the Americas that occurred between 2015 and 2017 were linked to congenital abnormalities, most prominently microcephaly, in newborns. Because most infections are asymptomatic, diagnosis via indirect serological assays is an important strategy. On the other hand, many serological assays are affected by cross-reactivity resulting from prior infections by closely related viruses, such as DENV. This study evaluated three commercially available and widely used immunoassays that detect IgG, IgM or IgA and M (IgAM) antibodies to ZIKV. Our results suggest that the IgAM test performs best by detecting around 90% of RT-PCR confirmed infections. We also detected additional infections that were not detected by RT-PCR. The strength of this study is that it was carried out in two different countries of the American region where several arboviruses are endemic and that sequential blood samples from individual patients were available to evaluate the performance of the tests over time.
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Affiliation(s)
- Ivonne Morales
- Section Clinical Tropical Medicine, Department for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- German Centre for Infection Research (DZIF), associated partner Heidelberg University Hospital, Heidelberg, Germany
| | - Kerstin D. Rosenberger
- Section Clinical Tropical Medicine, Department for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- German Centre for Infection Research (DZIF), associated partner Heidelberg University Hospital, Heidelberg, Germany
| | - Tereza Magalhaes
- Center for Vector-Borne Infectious Diseases (CVID), Department of Microbiology, Immunology and Pathology, Colorado State University (CSU), Fort Collins, Colorado, United States of America
| | - Clarice N. L. Morais
- Laboratory of Virology and Experimental Therapeutics, Aggeu Magalhaes Institute, Oswaldo Cruz Foundation, Recife, Brazil
| | - Cynthia Braga
- Department of Parasitology, Aggeu Magalhaes Institute, Oswaldo Cruz Foundation, Recife, Brazil
- Institute of Integral Medicine Professor Fernando Figueira (Instituto de Medicina Integral Professor Fernando Figueira-IMIP), Recife, Brazil
| | - Ernesto T. A. Marques
- Laboratory of Virology and Experimental Therapeutics, Aggeu Magalhaes Institute, Oswaldo Cruz Foundation, Recife, Brazil
- Department of Infectious Diseases, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Guilherme Amaral Calvet
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Luana Damasceno
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Patricia Brasil
- Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | | | - Adriana Tami
- University of Groningen, University Medical Center Groningen, Department of Medical Microbiology and Infection Prevention, Groningen, The Netherlands
- Facultad de Ciencias de la Salud, Universidad de Carabobo,
Valencia, Venezuela
| | - Sarah Bethencourt
- Facultad de Ciencias de la Salud, Universidad de Carabobo,
Valencia, Venezuela
| | | | | | | | | | | | - Nguyen Than Ha Quyen
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Cameron P. Simmons
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Institute for Vector-Borne Disease, Monash University, Melbourne, Australia
| | - Bridget Wills
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
| | - Xavier de Lamballerie
- Unité des Virus Emergents (UVE Aix Marseille Université, IRD 190, Inserm 1207-IHUMéditerranée Infection), Marseille, France
| | - Jan Felix Drexler
- Institute of Virology, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Sechenov University, Martsinovsky Institute of Medical Parasitology, Tropical and Vector-Borne Diseases, Moscow, Russia
- German Centre for Infection Research (DZIF), associated partner Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Jaenisch
- Section Clinical Tropical Medicine, Department for Infectious Diseases, Heidelberg University Hospital, Heidelberg, Germany
- German Centre for Infection Research (DZIF), associated partner Heidelberg University Hospital, Heidelberg, Germany
- Heidelberg Institute of Global Health (HIGH), Heidelberg University Hospital, Heidelberg, Germany
- * E-mail:
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Oidtman RJ, España G, Perkins TA. Co-circulation and misdiagnosis led to underestimation of the 2015-2017 Zika epidemic in the Americas. PLoS Negl Trop Dis 2021; 15:e0009208. [PMID: 33647014 PMCID: PMC7951986 DOI: 10.1371/journal.pntd.0009208] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 03/11/2021] [Accepted: 02/05/2021] [Indexed: 02/07/2023] Open
Abstract
During the 2015-2017 Zika epidemic, dengue and chikungunya-two other viral diseases with the same vector as Zika-were also in circulation. Clinical presentation of these diseases can vary from person to person in terms of symptoms and severity, making it difficult to differentially diagnose them. Under these circumstances, it is possible that numerous cases of Zika could have been misdiagnosed as dengue or chikungunya, or vice versa. Given the importance of surveillance data for informing epidemiological analyses, our aim was to quantify the potential extent of misdiagnosis during this epidemic. Using basic principles of probability and empirical estimates of diagnostic sensitivity and specificity, we generated revised estimates of reported cases of Zika that accounted for the accuracy of diagnoses made on the basis of clinical presentation with or without laboratory confirmation. Applying this method to weekly reported case data from 43 countries throughout Latin America and the Caribbean, we estimated that 944,700 (95% CrI: 884,900-996,400) Zika cases occurred when assuming all confirmed cases were diagnosed using molecular methods versus 608,400 (95% CrI: 442,000-821,800) Zika cases that occurred when assuming all confirmed cases were diagnosed using serological methods. Our results imply that misdiagnosis was more common in countries with proportionally higher reported cases of dengue and chikungunya, such as Brazil. Given that Zika, dengue, and chikungunya appear likely to co-circulate in the Americas and elsewhere for years to come, our methodology has the potential to enhance the interpretation of passive surveillance data for these diseases going forward. Likewise, our methodology could also be used to help resolve transmission dynamics of other co-circulating diseases with similarities in symptomatology and potential for misdiagnosis.
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Affiliation(s)
- Rachel J. Oidtman
- Department of Biological Sciences and Eck Institute for Global Health, University of Notre Dame, Notre Dame, Indiana, United States of America
| | - Guido España
- Department of Biological Sciences and Eck Institute for Global Health, University of Notre Dame, Notre Dame, Indiana, United States of America
| | - T. Alex Perkins
- Department of Biological Sciences and Eck Institute for Global Health, University of Notre Dame, Notre Dame, Indiana, United States of America
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9
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Low SL, Leo YS, Lai YL, Lam S, Tan HH, Wong JCC, Tan LK, Ng LC. Evaluation of eight commercial Zika virus IgM and IgG serology assays for diagnostics and research. PLoS One 2021; 16:e0244601. [PMID: 33497414 PMCID: PMC7837473 DOI: 10.1371/journal.pone.0244601] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/11/2020] [Indexed: 11/18/2022] Open
Abstract
Several commercial Zika virus (ZIKV) serology assays have been developed since the recognition of ZIKV outbreaks as a Public Health Emergency of International Concern in 2016. However, test interpretation for ZIKV serology can be challenging due to antibody cross-reactivity with other flaviviruses like dengue virus (DENV). Therefore, we sought to evaluate the performance of eight commercially available ZIKV IgM and IgG assays across three testing platforms, namely, immunochromatographic tests (ICT), ELISAs and immunofluorescence tests (IIFT). The test panel comprised of 278 samples, including acute and convalescent sera or plasma from ZIKV-confirmed, DENV-confirmed, non-ZIKV and non-DENV patients, and residual sera from healthy blood donors. The ZIKV IgM and IgG serology assays yielded higher test sensitivities of 23.5% - 97.1% among ZIKV convalescent samples as compared to 5.6% - 27.8% among ZIKV acute samples; the test specificities were 63.3% - 100% among acute and convalescent DENV, non-DENV samples. Among the ELISAs and IIFTs, the Diapro ZIKV IgM ELISA demonstrated high test sensitivity (96%) and specificity (80%) when tested on early convalescent samples, while the Euroimmun ZIKV IgG ELISA yielded the highest test specificity of 97% - 100% on samples from non-ZIKV patients and healthy blood donors. For rapid ICTs, the LumiQuick IgM rapid ICT yielded low test sensitivity, suggesting its limited utility. We showed that commercial ZIKV IgM and IgG serology assays have differing test performances, with some having moderate to high test sensitivities and specificities when used in a dengue endemic setting, although there were limitations in IgG serology.
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Affiliation(s)
- Swee Ling Low
- Environmental Health Institute, National Environment Agency, Singapore, Singapore
| | - Yee Sin Leo
- National Centre for Infectious Disease, Singapore, Singapore
| | - Yee Ling Lai
- Environmental Health Institute, National Environment Agency, Singapore, Singapore
| | - Sally Lam
- Blood Services Group, Health Sciences Authority, Singapore, Singapore
| | - Hwee Huang Tan
- Blood Services Group, Health Sciences Authority, Singapore, Singapore
| | | | - Li Kiang Tan
- Environmental Health Institute, National Environment Agency, Singapore, Singapore
| | - Lee Ching Ng
- Environmental Health Institute, National Environment Agency, Singapore, Singapore
- School of Biological Sciences, Nanyang Technological University, Singapore, Singapore
- * E-mail:
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10
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Henriques DF, Nunes JAL, Anjos MV, Melo JM, Rosário WO, Azevedo RSS, Chiang JO, Martins LC, Dos Santos FB, Casseb LMN, Vasconcelos PFC, Rodrigues SG. Evaluation of immunoglobulin M-specific capture enzyme-linked immunosorbent assays and commercial tests for flaviviruses diagnosis by a National Reference Laboratory. J Virol Methods 2020; 286:113976. [PMID: 32971183 DOI: 10.1016/j.jviromet.2020.113976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 09/04/2020] [Accepted: 09/15/2020] [Indexed: 12/16/2022]
Abstract
Zika and Dengue viruses present considerable immunological cross-reactivity, resulting in a troublesome serodiagnosis due to occurrence of false positive results. Due to Brazil's wide variety of circulating flaviviruses we aimed to access the use of in house serological tests adapted by National Reference Laboratory for Arboviruses in Brazil and evaluate commercial tests available. We evaluated in house IgM ELISAs for the individual detection of anti-ZIKV, -DENV, and -YFV IgM, against a panel of samples positive for dengue, zika, yellow fever, Rocio, Ilheus, Saint Louis encephalitis, West Nile and chikungunya. We also evaluated two commercial kits for dengue and zika IgM detection recommended by the Brazilian Ministry of Health in 2015. The sensitivity and specificity for the in house ZIKV IgM ELISA was 60.0 % and 88.6 % and for the in house DENV IgM ELISA was 100 % and 82.2 %, respectively. The in house YFV IgM ELISA presented 100 % for both sensitivity and specificity. The Novagnost Zika Virus IgM test presented a sensitivity of 47.3 % and specificity of 85.3 % and the Serion ELISA classic Dengue Virus IgM, 92.8 % and 58.9 %, respectively. Overall, both in house ELISAs for ZIKV and DENV adapted and evaluated here, presented better performances than the commercial kits tested.
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Affiliation(s)
- Daniele Freitas Henriques
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, 67030-000, Pará, Brazil.
| | - Juliana A L Nunes
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, 67030-000, Pará, Brazil
| | - Maura V Anjos
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, 67030-000, Pará, Brazil
| | - Juliana M Melo
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, 67030-000, Pará, Brazil
| | - Wallace O Rosário
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, 67030-000, Pará, Brazil
| | - Raimunda S S Azevedo
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, 67030-000, Pará, Brazil
| | - Jannifer O Chiang
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, 67030-000, Pará, Brazil
| | - Lívia C Martins
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, 67030-000, Pará, Brazil
| | - Flavia B Dos Santos
- Viral Immunology Laboratory, Oswaldo Cruz Institute, Rio de Janeiro, 21040-900, Rio de Janeiro, Brazil
| | - Livia M N Casseb
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, 67030-000, Pará, Brazil
| | - Pedro F C Vasconcelos
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, 67030-000, Pará, Brazil
| | - Sueli G Rodrigues
- Department of Arbovirology and Hemorrhagic Fevers, Evandro Chagas Institute, Ananindeua, 67030-000, Pará, Brazil
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11
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Khan E, Prakoso D, Imtiaz K, Malik F, Farooqi JQ, Long MT, Barr KL. The Clinical Features of Co-circulating Dengue Viruses and the Absence of Dengue Hemorrhagic Fever in Pakistan. Front Public Health 2020; 8:287. [PMID: 32626679 PMCID: PMC7311566 DOI: 10.3389/fpubh.2020.00287] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/01/2020] [Indexed: 12/12/2022] Open
Abstract
Dengue virus (DENV) is the most common and widespread arboviral infection worldwide. Though all four DENV serotypes cocirculate in nature, the clinicopathological framework of these serotypes is undefined in Pakistan. A cross-sectional, observational study was performed to document the circulation of various arboviruses in the Sindh region of Pakistan. Here we describe a population of patients diagnosed with DENV spanning a 2-year period. This study used an orthogonal system of NS1 antigen ELISA followed by RT-PCR for DENV detection and subtyping. A total of 168 NS1 positive patients were evaluated of which 91 patients were serotyped via RT-PCR. There was no significant difference between sex or age for infection risk and peak transmission occurred during the Autumn months. DENV2 was the most common serotype followed by DENV1 then DENV3, then DENV4. The data show that DENV1 patients were more likely to have abnormal liver function tests; DENV2 infected patients were more likely to exhibit arthralgia and neurological symptoms; DENV3 patients were more likely to complain of burning micturition and have elevated lymphocyte counts and low hematocrit; and DENV4 patients were more likely to report headaches and rash. Notably, no dengue hemorrhagic fever or other manifestations of severe dengue fever were present in patients with primary or secondary infections. We were able to identify significantly more NS1 antigen positive patients than RT-PCR. This study demonstrates that all four DENV serotypes are co-circulating and co-infecting in Pakistan.
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Affiliation(s)
- Erum Khan
- Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Aga Khan University, Karachi, Pakistan
| | - Dhani Prakoso
- Department of Comparative Diagnostic and Population Medicine, College of Veterinary Medicine, University of Florida, Gainesville, FL, United States
| | - Kehkashan Imtiaz
- Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Aga Khan University, Karachi, Pakistan
| | - Faisal Malik
- Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Aga Khan University, Karachi, Pakistan
| | - Joveria Q Farooqi
- Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Aga Khan University, Karachi, Pakistan
| | - Maureen T Long
- Department of Comparative Diagnostic and Population Medicine, College of Veterinary Medicine, University of Florida, Gainesville, FL, United States
| | - Kelli L Barr
- Department of Biology, Baylor University, Waco, TX, United States
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12
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Evaluation of the LIAISON XL Zika Capture IgM II for the Diagnosis of Zika Virus Infections. Viruses 2020; 12:v12010069. [PMID: 31936013 PMCID: PMC7019915 DOI: 10.3390/v12010069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/27/2019] [Accepted: 01/03/2020] [Indexed: 11/29/2022] Open
Abstract
The aim of this study is to evaluate the performance characteristics of the LIAISON XL Zika Capture IgM II. For this purpose we tested 128 samples obtained from recent infections caused by the Zika (ZIKV; 74 samples), dengue (DENV; 10 samples), chikungunya (CHIK V; 11 samples), rubella (RUBV; 10 samples) and measles (MeV; 10 samples) viruses, as well as human parvovirus B19 (HPVB19; 13 samples). The results of the assay under evaluation are compared with those obtained from an indirect immunofluorescence (IIF) assay, and the discrepancies are resolved by considering other laboratory results (PCR and a plaque-reduction neutralization test). The LIAISON showed excellent sensitivity (100%). The specificity (91.25%) was hampered by some false-positive results in recent dengue virus, chikungunya virus, measles virus and human parvovirus B19 infections. The method evaluated is adequate, but the low specificity makes it necessary to consider the clinical and epidemiological contexts of patients, as well as other laboratory results.
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13
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Peters R, Stevenson M. Immunological detection of Zika virus: A summary in the context of general viral diagnostics. J Microbiol Methods 2020. [DOI: 10.1016/bs.mim.2019.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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14
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Performance of InBios ZIKV Detect™ 2.0 IgM Capture ELISA in two reference laboratories compared to the original ZIKV Detect™ IgM Capture ELISA. J Virol Methods 2019; 271:113671. [PMID: 31181219 PMCID: PMC7176032 DOI: 10.1016/j.jviromet.2019.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 05/23/2019] [Accepted: 05/25/2019] [Indexed: 11/22/2022]
Abstract
ZIKV Detect™ 2.0 IgM Capture ELISA (InBios International, Seattle, WA) recently replaced the ZIKV Detect™ IgM Capture ELISA and a number of significant changes have been made to the original version. This study compares data generated from the ZIKV Detect™ 2.0 IgM Capture ELISA, to data generated using the original version of the kit. The same sample sets were used in this comparison, and reference test results for these samples were used to assess sensitivity, specificity, accuracy and concordance of results across two laboratories. Average sensitivity increased from 90.4% to 92.5% with the updated kit where the increase was not statistically different, and specificity increased from 79.5% to 97.4%, a statistically-significant difference. Accuracy of the ZIKV Detect™ 2.0 IgM Capture ELISA was 89% compared to 63.9% for the original version of the kit, and agreement across the laboratories increased from 79.5% to 97.4%. With secondary dengue virus infections, specificity increased from 9.3% to 82.6% with the updated kit, primarily due to the change in interpretation criteria that no longer includes “Possible Zika positive.”
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15
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Van der Beken Y, De Geyter D, Van Esbroeck M. Performance evaluation of the Diasorin LIAISON® XL Zika capture IgM CLIA test. Diagn Microbiol Infect Dis 2019; 95:144-148. [PMID: 31171395 DOI: 10.1016/j.diagmicrobio.2019.05.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 01/10/2023]
Abstract
Because Zika virus (ZIKV) can cause serious birth defects and is involved in cases of Guillain-Barré syndrome, the ZIKV outbreak in the American continent in 2015 resulted in an enormous need for ZIKV diagnostic tools. We evaluated the LIAISON® XL Zika Capture IgM test on 106 samples from patients, mainly travelers, with a confirmed or probable ZIKV infection. Sensitivity between 0 and 84 days after onset of symptoms was 92.5%. Specificity was evaluated on a panel of 56 samples known to cause possible cross-reactions. Cross-reaction with DENV antibodies was limited (10.5%) but false-positive results occurred in samples from patients with malaria, CMV and EBV infections.
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Affiliation(s)
- Y Van der Beken
- National Reference Center for Arboviruses, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel, Department of Microbiology, Brussels, Belgium.
| | - D De Geyter
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel, Department of Microbiology, Brussels, Belgium
| | - M Van Esbroeck
- National Reference Center for Arboviruses, Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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16
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Collins MH. Serologic Tools and Strategies to Support Intervention Trials to Combat Zika Virus Infection and Disease. Trop Med Infect Dis 2019; 4:tropicalmed4020068. [PMID: 31010134 PMCID: PMC6632022 DOI: 10.3390/tropicalmed4020068] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/11/2019] [Accepted: 04/15/2019] [Indexed: 12/30/2022] Open
Abstract
Zika virus is an emerging mosquito-borne flavivirus that recently caused a large epidemic in Latin America characterized by novel disease phenotypes, including Guillain-Barré syndrome, sexual transmission, and congenital anomalies, such as microcephaly. This epidemic, which was declared an international public health emergency by the World Health Organization, has highlighted shortcomings in our current understanding of, and preparation for, emerging infectious diseases in general, as well as challenges that are specific to Zika virus infection. Vaccine development for Zika virus has been a high priority of the public health response, and several candidates have shown promise in pre-clinical and early phase clinical trials. The optimal selection and implementation of imperfect serologic assays are among the crucial issues that must be addressed in order to advance Zika vaccine development. Here, I review key considerations for how best to incorporate into Zika vaccine trials the existing serologic tools, as well as those on the horizon. Beyond that, this discussion is relevant to other intervention strategies to combat Zika and likely other emerging infectious diseases.
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Affiliation(s)
- Matthew H Collins
- Hope Clinic of the Emory Vaccine Center, Division of Infectious Diseases, Department of Medicine, School of Medicine, Emory University, Decatur, GA 30030, USA.
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17
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Challenges in diagnosing Zika-experiences from a reference laboratory in a non-endemic setting. Eur J Clin Microbiol Infect Dis 2019; 38:771-778. [PMID: 30680570 DOI: 10.1007/s10096-019-03472-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/02/2019] [Indexed: 10/27/2022]
Abstract
Diagnosing a patient with Zika infection is not always straightforward. Here, we aim to describe our data collected from December 2015 to December 2017 and discuss the implemented algorithm and diagnostic challenges we encountered. At the National Reference Center for Arboviruses at the Institute of Tropical Medicine, Antwerp, Belgium (ITM), a commercial Zika virus (ZIKV) enzyme-linked immunosorbent assay (ELISA) detecting immunoglobulin (Ig) M and IgG, a commercial ZIKV immunofluorescence assay (IFA) detecting IgM, and an in-house Zika virus neutralization test (VNT) were implemented. For molecular detection of ZIKV, an in-house and a commercial real-time RT-PCR were applied. An algorithm, adapted from the European Centre for Disease Control and Prevention (ECDC), was implemented. Between December 2015 and December 2017, we tested 6417 patients for ZIKV. Of those, according to ECDC criteria, 127 (2.0%) were classified as a confirmed Zika infection of which 39 by RT-PCR (0.6%), 15 (0.2%) as a probable Zika infection, 73 (1.1%) as undefined, and 65 (1.0%) as false positive reactions. Main challenges were the brief window for detection of IgM, cross-reactivity of antibodies with other flaviviruses and malaria, and low VNT titers in the acute phase. In RT-PCR negative samples, classification of ZIKV infection as recent or past proved difficult, when IgM was negative. The majority of patients could be classified according to ECDC criteria, though 1.1% of patients remained "undefined" and 1.0% were ELISA false positive reactions. Complementary IFA IgM was of added value to increase IgM detection rates. Improved serological assays and more longitudinal data on antibody kinetics are needed.
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