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Original research
The frequency and clinical presentation of Zika virus coinfections: a systematic review
  1. Ludmila Lobkowicz1,
  2. Anna Ramond1,
  3. Nuria Sanchez Clemente1,
  4. Ricardo Arraes de Alencar Ximenes2,
  5. Demócrito de Barros Miranda-Filho2,
  6. Ulisses Ramos Montarroyos3,
  7. Celina Maria Turchi Martelli4,
  8. Thalia Velho Barreto de Araújo5,
  9. Elizabeth B Brickley1
  1. 1Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
  2. 2Departamento de Medicina Interna, Universidade de Pernambuco, Recife, Pernambuco, Brazil
  3. 3Instituto de Ciências Biológicas, Universidade de Pernambuco, Recife, Pernambuco, Brazil
  4. 4Instituto Aggeu Magalhães, Fundação Oswaldo Cruz, Recife, Pernambuco, Brazil
  5. 5Departamento de Medicina Social, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
  1. Correspondence to Dr Elizabeth B Brickley; elizabeth.brickley{at}lshtm.ac.uk

Abstract

Background There is limited knowledge on the influence of concurrent coinfections on the clinical presentation of Zika virus (ZIKV) disease.

Methods To better understand the types, frequencies and clinical manifestations of ZIKV coinfections, we did a systematic review of four databases (PubMed, Embase, Web of Science, LILACS) without restrictions for studies on ZIKV coinfections confirmed by nucleic acid (quantitative real-time-PCR) testing of ZIKV and coinfecting pathogens. The review aimed to identify cohort, cross-sectional, case series and case report studies that described frequencies and/or clinical signs and symptoms of ZIKV coinfections. Conference abstracts, reviews, commentaries and studies with imprecise pathogen diagnoses and/or no clinical evaluations were excluded.

Results The search identified 34 articles from 10 countries, comprising 2 cohort, 10 cross-sectional, 8 case series and 14 case report studies. Coinfections were most frequently reported to have occurred with other arthropod-borne viruses (arboviruses); out of the 213 coinfections described, ZIKV infections co-occurred with chikungunya in 115 cases, with dengue in 68 cases and with both viruses in 19 cases. Other coinfecting agents included human immunodeficiency, Epstein-Barr, human herpes and Mayaro viruses, Leptospira spp, Toxoplasma gondii and Schistosoma mansoni. ZIKV-coinfected cases primarily presented with mild clinical features, typical of ZIKV monoinfection; however, 9% of cases in cohort and cross-sectional studies were reported to experience complications.

Conclusion Based on the evidence collated in this review, coinfections do not appear to strongly influence the clinical manifestations of uncomplicated ZIKV infections. Further research is needed to confirm whether risk of severe complications is altered when ZIKV infection co-occurs with other infections.

PROSPERO registration number CRD42018111023.

  • systematic review
  • arboviruses
  • epidemiology
https://creativecommons.org/licenses/by/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjgh-2020-002350

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    Footnotes

    • Handling editor Alberto L Garcia-Basteiro

    • Twitter @ebbrickley

    • Contributors All authors contributed substantially to the design of the work and/or the acquisition, analysis and interpretation of the data, contributed meaningfully to the drafting and/or revision of the manuscript, provided final approval for the version published and share responsibility for the published findings.

    • Funding This project was supported by the European Union’s Horizon 2020 research and innovation programme (https://ec.europa.eu/programmes/horizon2020/) under ZikaPLAN grant agreement No. 734 584 (https://zikaplan.tghn.org/), and the Wellcome Trust & the UK’s Department for International Development (205377/Z/16/Z; https://wellcome.ac.uk/). CMTM receives CNPq scholarship #308974/2018‐2.

    • Disclaimer 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.

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting or dissemination plans of this research.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. This systematic review is based on published articles. All abstracted data are provided in the text and supplementary materials.