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Revista da Sociedade Brasileira de Medicina Tropical

Print version ISSN 0037-8682On-line version ISSN 1678-9849

Rev. Soc. Bras. Med. Trop. vol.54  Uberaba  2021  Epub Feb 26, 2021

http://dx.doi.org/10.1590/0037-8682-0837-2020 

Short Communication

Impact of concurrent epidemics of dengue, chikungunya, zika, and COVID-19

Creuza Rachel Vicente1  2 
http://orcid.org/0000-0003-0182-7969

Theresa Cristina Cardoso da Silva3  4 

Larissa Dell’Antonio Pereira3  4 

Angelica E. Miranda1  4 

1Universidade Federal do Espírito Santo, Departamento de Medicina Social, Vitória, ES, Brasil.

2 Universidade Federal do Espírito Santo, Programa de Pós-Graduação em Doenças Infecciosas, Vitória, ES, Brasil.

3 Secretaria de Estado da Saúde do Espírito Santo, Vigilância em Saúde, Vitória, ES, Brasil.

4 Universidade Federal do Espírito Santo, Programa de Pós-Graduação em Saúde Coletiva, Vitória, ES, Brasil.


Abstract

INTRODUCTION:

This study evaluated the epidemiological implications of arbovirus infections and coronavirus disease (COVID-19) co-occurrences in Espírito Santo, Brazil.

METHODS:

This ecological study of dengue, chikungunya, zika, and COVID-19 was performed from January 1 to July 31, 2020.

RESULTS:

Espírito Santo registered 44,614, 8,092, 3,138, and 91,483 cases of dengue, chikungunya, zika, and COVID-19, respectively (January-July, 2020). In the 27 and four municipalities with a high incidence of dengue and chikungunya, respectively, the incidence of COVID-19 was 647.0-3,721.7 and 1,787.2-3,403.0 cases per 100,000 inhabitants, respectively.

CONCLUSIONS:

Espírito Santo experienced an overlap of epidemics, especially in urban areas.

Keywords: Arbovirus infections; Coronavirus infections; Epidemics; Health services; Brazil

Viral infections transmitted by Aedes aegypti, such as dengue, chikungunya, and zika, are significant public health concerns in Brazil and other countries with the simultaneous occurrence of these diseases. The coronavirus disease (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has imposed additional challenges in territories with overlapping epidemics, increasing the demand for healthcare services1-4. This scenario was observed in areas where the COVID-19 pandemic began during the seasonal transmission of dengue in Latin America1,3,5,6 and Asia7. Quarantine and lockdowns adopted in response to the COVID-19 pandemic may have contributed to arbovirus outbreaks as the population maintained close and long contact with mosquito breeding sites in and around their homes8.

Dengue, chikungunya, zika, and COVID-19 may present with similar clinical manifestations and laboratory features in the early stages of the diseases, such as an acute undifferentiated febrile illnesses1-3,7. Therefore, diagnosis is challenging even when confirmatory tests are available in cases of COVID-19 presenting with false-positive results for dengue infection4,9,10. Consequently, misdiagnosis may delay appropriate care and management of the disease, such as isolation of patients with COVID-19 and hydration in those with dengue, resulting in increased disease spread and worst clinical outcomes8. Moreover, this epidemiological scenario represents a risk of coinfections, as observed in patients diagnosed with dengue and COVID-1911.

In Espírito Santo State, Brazil, an area with co-circulation of dengue, chikungunya, and zika viruses, the first case of COVID-19 was reported in February 2020 during the seasonal period of arboviral transmissions. The local government adopted many actions during the COVID-19 pandemic such as suspension of activities in educational, commercial, financial, and alimentary sectors. The present study evaluated the concurrent occurrence of these arbovirus infections and COVID-19 in the state and the possible implications of this epidemiological scenario.

An ecological study was performed based on the number of probable cases of dengue, chikungunya, and zika and confirmed cases of COVID-19 reported to the Health Department of the Espírito Santo State from January 1, 2020 to July 31, 2020 and accessed on September 1, 2020.

The Espírito Santo State is located in the southeast region of Brazil and has 78 municipalities in a 46.089,390 km2 land area. The state’s population is estimated to be approximately 4,018,650 individuals. Its climate is tropical humid, with an annual precipitation of >1,400 mm and an average temperature of 23°C12.

Publicly available official data on the reports of dengue, chikungunya, and zika were accessed (https://mosquito.saude.es.gov.br/planilhasegraficos) along with those of COVID-19 (https://coronavirus.es.gov.br/painel-covid-19-es). Data on the municipalities’ population were obtained from the same source as that for the arbovirus data.

The definitions of probable and confirmed cases of the diseases used by the Secretary of Health in Espírito Santo State follow the Brazilian Ministry of Health criteria13,14. A case of dengue is characterized by fever, with a duration of 2-7 days, and two or more manifestations, such as nausea or vomiting, exanthema, myalgia or arthralgia, headache with retro-orbital pain, petechia, positive tourniquet test, and leucopenia13. A case of chikungunya is defined as a sudden onset fever (>38.5°C) and arthralgia or severe acute onset arthritis not explained by other conditions. The duration of this acute phase of chikungunya fever is approximately 7 days13. A case of zika presents with a pruritic maculopapular rash accompanied by two or more signs and symptoms, such as low fever, conjunctival hyperemia without secretion or itching, polyarthralgia, and periarticular edema for a duration of 4-7 days13. Probable cases of dengue, chikungunya, and zika were classified according to their clinicoepidemiological criteria. A confirmed case of dengue, chikungunya, and zika was defined as positivity for viral isolation based on non-structural glycoprotein-1 (enzyme-linked immunosorbent assay [ELISA] or rapid test), quantitative reverse transcription polymerase chain reaction (RT-qPCR), or ELISA IgM; RT-qPCR, ELISA IgM, or IgG (ELISA or hemagglutination test); and RT-qPCR or ELISA IgM, respectively13. A case of COVID-19 presents with at least two of the following signs and symptoms: fever associated with sore throat, headache, cough, or runny nose14. A case of COVID-19 can be confirmed using the clinical criteria (flu syndrome or severe acute respiratory syndrome with acute anosmia and ageusia), clinicoepidemiological criteria (flu syndrome or severe acute respiratory syndrome and close contact with a confirmed case of COVID-19 in the last 14 days before the onset of symptoms), clinical criteria with specific alterations on chest computed tomography, or laboratory criteria based on a positive RT-qPCR result, immunology with IgM/IgA/IgG (ELISA, immunochromatography, electrochemiluminescence immunoassay), or antigen detection (immunochromatography)14.

Descriptive analysis of simple frequency was conducted considering the weekly reports between the epidemiological weeks 1 to 31 (January 1, 2020 to July 31, 2020). The incidences of dengue, chikungunya, zika, and COVID-19 per 100,000 inhabitants were calculated for all municipalities for the entire study period. Maps were produced using QGIS 3.14.15 and shapefile (https://geobases.es.gov.br/downloads). The analyses were performed using Microsoft Excel® 2013 (© 2012 Microsoft Corporation). The cumulative incidence of arbovirus infections was presented in three levels-low (<100 cases per 100,000 inhabitants), medium (100-300 cases per 100,000 inhabitants), and high (>300 cases per 100,000 inhabitants), according to the Health Department of Espírito Santo State criteria. The cumulative incidence of dengue was presented similarly according to the Brazilian Ministry of Health criteria15. This study was conducted using online open-access data; therefore, institutional ethics committee approval does not apply.

From January 1, 2020 to July 31, 2020, the Espírito Santo State Surveillance Department registered a high number of cases and incidences of dengue, chikungunya, and zika (Table 1). The incidence per 100,000 inhabitants, considering probable cases, surpassed 300 cases in 27 and four municipalities for dengue and chikungunya, respectively, and was >100 in four municipalities for zika (Figure 1, Supplementary Table 1). The peak incidence of these arbovirus infections was reported between February and April 2020 (Figure 2). The registered deaths due to dengue and chikungunya are shown in Table 1.

FIGURE 1: Incidence of dengue, chikungunya, zika, and COVID-19 cases per 100,000 inhabitants in the municipalities of Espírito Santo State from January to July 2020. Circles correspond to the population size in municipalities with >100,000 inhabitants. COVID-19: coronavirus disease. 

TABLE 1: Characteristics of dengue, chikungunya, zika and COVID-19 cases in Espírito Santo State, Brazil from January to July 2020. 

Reports characteristics Dengue Chikungunya Zika COVID-19
Probable cases 44,614 8,092 3,138 91,483
Laboratory-confirmed cases 6,814 2,351 650 84,278
Incidence per 100,000 inhabitants 1,110.2 201.4 78.1 2,276.5
Confirmed deaths 14 3 0 2,909

COVID-19: coronavirus disease.

From February 29, 2020 to July 31, 2020, the state registered 91,483 confirmed cases of COVID-19. Laboratory confirmation was obtained in 92.1% cases, while the clinicoepidemiological criteria was used to confirm other cases (Table 1). The incidence of COVID-19 was >3,000 cases per 100,000 inhabitants in five municipalities (Figure 1, Supplementary Table 1). The peak incidence of COVID-19 was reported between May and July 2020 (Figure 2). Health professionals accounted for 14.2% of the affected individuals, accounting for 12,974 cases of COVID-19. Of the registered deaths due to COVID-19, 2,885 deaths were caused by COVID-19, while 24 deaths were related to other causes (Table 1).

FIGURE 2: Number of cases of dengue, chikungunya, zika, and COVID-19 per epidemiological week in Espírito Santo State from January to July 2020. Month (epidemiological week): January (1-5), February (5-9), March (10-14), April (14-18), May (18-23), June (23-27), and July (27-31). COVID-19: coronavirus disease. 

Four municipalities experienced a high incidence of dengue and chikungunya, with an incidence of >300 cases per 100,000 inhabitants for both diseases. In these municipalities, the incidence of COVID-19 was 1,787.2-3,403.0 cases per 100,000 inhabitants. In the 27 municipalities with a high incidence of dengue, the incidence of COVID-19 was 647.0-3,721.7 cases per 100,000 inhabitants, while in the four municipalities with a high occurrence of chikungunya, the incidence of COVID-19 was 1,787.2-3,403 cases per 100,000 inhabitants. In the four municipalities with an incidence of zika of >100 cases per 100,000 inhabitants, the incidence of COVID-19 was 1,787.2-2,761.7 cases per 100,000 inhabitants (Figure 1, Supplementary Table 1).

Espírito Santo State experienced an overlap of epidemics with the introduction of SARS-CoV-2 infection by travelers, followed by its local and community transmission during the peak of dengue, chikungunya, and zika seasonal transmissions. Urban areas were more affected than rural areas, especially in the metropolitan region and municipalities that are regional hubs of economic development. Areas with high human population density favored the transmission of COVID-19 and the arbovirus infections reported in this study, since urban environment is propitious for breeding sites for A. aegypti8. This scenario is challenging because of the clinical similarities between the diseases and the limitations related to the confirmatory tests1-4,7,9,10.

Health systems dealing with concomitant infectious disease epidemics tend to experience challenges in their different service areas, including laboratory, primary healthcare, hospital, and epidemiological surveillance systems. The high incidence of COVID-19 among health professionals in Espírito Santo State, which may affect the capacity of the health system, emphasizes the importance of this challenge. In this state, <30% of dengue, chikungunya, and zika cases were confirmed by laboratory tests. Although laboratory confirmation for arbovirus transmission in endemic countries has a surveillance purpose4, the clinical management of arbovirus infections may also require follow-up with laboratory parameters, such as hematocrit levels and platelet counts13. These increase the demand for reagents, specialized professionals, and laboratory structures. The emergence of COVID-19 contributed to overwhelming of laboratory services due to limited resources4. Therefore, despite testing of all suspected cases and contacts, as advised for COVID-19, in Espírito Santo State, many reported cases were evaluated exclusively using the clinicoepidemiological criteria due to the laboratory limitation for performing RT-PCR.

Primary healthcare, the entry-level to the health system for patients, is essential in epidemic situations. Professionals at this level must be well trained to manage co-occurring diseases with similar manifestations4,7. The emergence of COVID-19 in Espírito Santo State may have affected the management of patients with different conditions since the population was advised to seek for health services only for particular cases5. The impact of the lack of diagnosis and clinical follow-up of patients with different diseases on the outcome is unknown. Hospitalization may be required for arbovirus infections, but they were more likely for COVID-19, especially hospitalization to the intensive care unit. Deaths due to dengue, chikungunya, and COVID-19 were reported in the state, but additional deaths may be undetectable by the health system. In addition, coinfections may have occurred, but they were possibly undetected during this complex scenario.

Many infectious disease reports also affect epidemiological surveillance, increasing the efforts required to investigate and follow-up the reported cases5. Epidemiological surveillance service is also dependent on other services, such as the laboratory and outpatient care. Epidemiological surveillance is affected by delayed or absent laboratory results, underreporting of incident cases, or missing data in the case report form, compromising the capacity to capture the real epidemiological scenario and impairing appropriate epidemic responses. Therefore, underreporting of arbovirus infections and COVID-19 is likely in this situation6, and the epidemiological situation was probably far worse than that demonstrated by official data from Espírito Santo State.

This study presents some limitations inherent in ecological studies using secondary data, mainly because COVID-19 continues to affect the state’s health systems. Therefore, the number of reported cases may increase in the months after the study period due to the epidemiological service updates. This study evidences the impact of simultaneous epidemics that went beyond the socio-economic losses and was responsible for numerous deaths in Espírito Santo State, with many municipalities affected by at least two of concurrent epidemics, compromising the health system response. Additional studies should be performed to assess the effects of the COVID-19 pandemic in the state on the epidemiological profiles of non-communicable diseases, such as cardiovascular disease, cancer, chronic respiratory disease and diabetes, and communicable diseases, including dengue, chikungunya, and zika.

ACKNOWLEDGMENTS

We thank Dr. Athena Lam and Dr. Matthew Van Dam for the language review.

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12. Governo do Estado do Espírito Santo. ES em dados [Internet]. Vitória: Governo do Estado do Espírito Santo; 2016. Available from: https://www.es.gov.br/es-em-dados. [ Links ]

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15. Secretaria de Estado da Saúde do Espírito Santo. Saúde divulga 30° boletim epidemiológico da Dengue. Vitória: Secretaria de Estado da Saúde do Espírito Santo; 2020. 2 p. [ Links ]

Financial Support: None.

SUPPLEMENTARY MATERIAL

TABLE 1: Dengue, Chikungunya, Zika and COVID-19 reports and incidence in the municipalities of Espírito Santo state, January to July 2020 

Municipality Dengue Chikungunya Zika COVID-19 Population Inc_Dengue Inc_Chikungunya Inc_Zika Inc_COVID-19
AFONSO CLÁUDIO 32 7 20 541 30586 104,6 22,9 65,4 1768,8
ÁGUA DOCE DO NORTE 34 0 0 118 11019 308,6 0,0 0,0 1070,9
ÁGUIA BRANCA 0 0 0 213 9642 0,0 0,0 0,0 2209,1
ALEGRE 30 20 2 258 30084 99,7 66,5 6,6 857,6
ALFREDO CHAVES 72 3 10 267 14601 493,1 20,5 68,5 1828,6
ALTO RIO NOVO 0 0 0 120 7836 0,0 0,0 0,0 1531,4
ANCHIETA 28 2 0 601 29263 95,7 6,8 0,0 2053,8
APIACA 0 1 0 95 7567 0,0 13,2 0,0 1255,5
ARACRUZ 572 6 6 2544 101220 565,1 5,9 5,9 2513,3
ATÍLIO VIVAQUA 6 10 0 222 11936 50,3 83,8 0,0 1859,9
BAIXO GUANDU 170 182 46 554 30998 548,4 587,1 148,4 1787,2
BARRA DE S. FRANCISCO 64 2 0 351 44650 143,3 4,5 0,0 786,1
BOA ESPERANÇA 1406 15 30 291 15037 9350,3 99,8 199,5 1935,2
BOM JESUS DO NORTE 0 1 0 223 9936 0,0 10,1 0,0 2244,4
BREJETUBA 2 0 0 332 12404 16,1 0,0 0,0 2676,6
CACHOEIRO DE ITAPEMIRIM 5532 1877 132 3917 208972 2647,2 898,2 63,2 1874,4
CARIACICA 4784 1250 418 9369 381285 1254,7 327,8 109,6 2457,2
CASTELO 28 18 2 917 37534 74,6 48,0 5,3 2443,1
COLATINA 762 8 4 4559 122499 622,0 6,5 3,3 3721,7
CONCEIÇÃO DA BARRA 210 1 0 203 31063 676,0 3,2 0,0 653,5
CONCEIÇÃO DO CASTELO 46 0 8 161 12723 361,5 0,0 62,9 1265,4
DIVINO SÃO LOURENÇO 0 0 0 106 4304 0,0 0,0 0,0 2462,8
DOMINGOS MARTINS 20 5 6 529 33850 59,1 14,8 17,7 1562,8
DORES DO RIO PRETO 0 0 0 56 6749 0,0 0,0 0,0 829,8
ECOPORANGA 1046 3 2 374 22923 4563,1 13,1 8,7 1631,5
FUNDÃO 18 2 4 510 21509 83,7 9,3 18,6 2371,1
GOVERNADOR LINDENBERG 4 1 0 138 12709 31,5 7,9 0,0 1085,8
GUAÇUI 0 0 4 258 30867 0,0 0,0 13,0 835,8
GUARAPARI 168 150 4 2273 124859 134,6 120,1 3,2 1820,5
IBATIBA 6 1 0 345 26082 23,0 3,8 0,0 1322,8
IBIRAÇU 28 4 8 432 12479 224,4 32,1 64,1 3461,8
IBITIRAMA 1 1 0 76 8889 11,2 11,2 0,0 855,0
ICONHA 24 1 2 334 13860 173,2 7,2 14,4 2409,8
IRUPI 2 2 0 171 13377 15,0 15,0 0,0 1278,3
ITAGUAÇU 62 3 2 91 14066 440,8 21,3 14,2 647,0
ITAPEMIRIM 96 38 0 762 34348 279,5 110,6 0,0 2218,5
ITARANA 0 1 2 90 10555 0,0 9,5 18,9 852,7
IUNA 120 1 0 498 29161 411,5 3,4 0,0 1707,8
JAGUARÉ 262 0 14 380 30477 859,7 0,0 45,9 1246,8
JERÔNIMO MONTEIRO 6 2 2 163 12192 49,2 16,4 16,4 1336,9
JOÃO NEIVA 40 1 0 330 16668 240,0 6,0 0,0 1979,8
LARANJA DA TERRA 2 2 0 68 10947 18,3 18,3 0,0 621,2
LINHARES 6714 1 6 4720 173555 3868,5 0,6 3,5 2719,6
MANTENÓPOLIS 110 2 2 168 15350 716,6 13,0 13,0 1094,5
MARATAIZES 52 19 2 1029 38499 135,1 49,4 5,2 2672,8
MARECHAL FLORIANO 4 1 0 616 16694 24,0 6,0 0,0 3689,9
MARILÄNDIA 34 4 2 311 12833 264,9 31,2 15,6 2423,4
MIMOSO DO SUL 4 3 2 594 26153 15,3 11,5 7,6 2271,2
MONTANHA 120 0 0 165 18833 637,2 0,0 0,0 876,1
MUCURICI 16 0 0 48 5524 289,6 0,0 0,0 868,9
MUNIZ FREIRE 2 6 0 136 17465 11,5 34,4 0,0 778,7
MUQUI 0 0 4 279 15449 0,0 0,0 25,9 1805,9
NOVA VENÉCIA 216 3 4 671 50110 431,1 6,0 8,0 1339,1
PANCAS 64 1 0 391 23184 276,1 4,3 0,0 1686,5
PEDRO CANÁRIO 280 0 0 310 26184 1069,4 0,0 0,0 1183,9
PINHEIROS 232 0 0 371 27047 857,8 0,0 0,0 1371,7
PIÚMA 8 0 2 411 21711 36,8 0,0 9,2 1893,0
PONTO BELO 14 0 0 47 7863 178,0 0,0 0,0 597,7
PRESIDENTE KENNEDY 6 5 2 633 11574 51,8 43,2 17,3 5469,2
RIO BANANAL 18 1 6 219 19141 94,0 5,2 31,3 1144,1
RIO NOVO DO SUL 6 3 2 285 11622 51,6 25,8 17,2 2452,2
SANTA LEOPOLDINA 6 0 2 176 12224 49,1 0,0 16,4 1439,8
SANTA MARIA DE JETIBÁ 36 0 2 385 40431 89,0 0,0 4,9 952,2
SANTA TERESA 52 1 0 401 23590 220,4 4,2 0,0 1699,9
SÃO DOMINGOS DO NORTE 4 0 2 205 8638 46,3 0,0 23,2 2373,2
SÃO GABRIEL DA PALHA 868 2 102 1048 37947 2287,4 5,3 268,8 2761,7
SÃO JOSÉ DO CALÇADO 2 0 0 244 10556 18,9 0,0 0,0 2311,5
SÃO MATEUS 586 5 10 1732 130611 448,7 3,8 7,7 1326,1
SÃO ROQUE DO CANAÃ 14 0 8 146 12415 112,8 0,0 64,4 1176,0
SERRA 8286 830 120 12215 517510 1601,1 160,4 23,2 2360,3
SOORETAMA 42 0 0 585 30070 139,7 0,0 0,0 1945,5
VARGEM ALTA 16 5 8 330 21402 74,8 23,4 37,4 1541,9
VENDA N. DO IMIGRANTE 12 0 0 639 25277 47,5 0,0 0,0 2528,0
VIANA 482 62 14 1485 78239 616,1 79,2 17,9 1898,0
VILA PAVÃO 14 2 0 52 9208 152,0 21,7 0,0 564,7
VILA VALÉRIO 128 12 6 309 14080 909,1 85,2 42,6 2194,6
VILA VELHA 5762 886 146 13965 493838 1166,8 179,4 29,6 2827,9
VITÓRIA 4722 2616 140 12322 362097 1304,1 722,5 38,7 3403,0
ESPÍRITO SANTO 44614 8092 3138 91483 4018650 1110,2 201,4 78,1 2276,5

Received: November 28, 2020; Accepted: January 21, 2021

Corresponding author: Creuza Rachel Vicente. e-mail:vicentecrachel@gmail.com

Conflict of Interest: The authors declare that there is no conflict of interest.

Authors’ contribution: CRV: Conception and design of the study, Analysis and interpretation of data, Drafting the article; TCCS: Acquisition of data, Analysis and interpretation of data, Final approval of the version to be submitted; LDP: Acquisition of data, Final approval of the version to be submitted; AEM: Drafting the article, Final approval of the version to be submitted.

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