key: cord-0916174-efasa7q6 authors: Costa, Ana Carla dos Santos; Hasan, Mohammad Mehedi; Xenophontos, Eleni; Mohanan, Parvathy; Bassey, Esther Edet; Hashim, Hashim Talib; Ahmad, Shoaib; Essar, Mohammad Yasir title: COVID‐19 and Zika: An emerging dilemma for Brazil date: 2021-04-23 journal: J Med Virol DOI: 10.1002/jmv.27006 sha: 0da698ef5f89f5cf5420c9f78bc7493e4b34be14 doc_id: 916174 cord_uid: efasa7q6 Brazil has faced one of the greatest public health emergencies in its history due to the unprecedented rise in the number of COVID-19 cases in the country. This situation is aggravated due to the pandemic's coexistence with a Zika virus epidemic. The Zika epidemic has affected the country since 2015 and added a significant burden to the health system owing to the complications and sequelae resulting from Zika. The public health implications of these two diseases' coexistence can be painful, mainly due to the similarity in the clinical picture and the consequent possibility of underdiagnosis. The overlap of these two diseases can be a dangerous combination. Therefore, for such a catastrophe in public health to be avoided, urgent measures must be taken by the different spheres of government and society. This article is protected by copyright. All rights reserved. Brazil is currently facing one of the biggest public health crises in its history. It is widely accepted that the coronavirus disease 2019 (COVID-19) pandemic is testing the resilience of health systems as the demand for resources, laboratories, and task force allocation is increasing, as well as the number of cases requiring hospitalization in intensive care units (ICU). In addition, the fact that residues from previous epidemics caused by arboviruses-such as the Zika virus (ZIKV)-coexist in Brazil increases the burden health sector in the country. The outbreak of Zika infection began in Brazil in 2015, quickly reaching many cases due to lack of access to water, sanitation, and unequal access to health care for the most impoverished families. 1 In 2019, a total of 10 768 plausible cases of Zika infection were identified in Brazil. 2 A few months later, in February 2020, the health system was severely hit by the first cases of COVID-19 in the country. The absence of stricter social distance measures made the disease spread more quickly in Brazil, placing the country as one of the most affected nations in the world, with more than 270 thousand deaths and 10 million COVID-19 cases in early March 2021. 3 As the contagion curve of coronavirus grows sharply, the pandemic increases the burden already imposed by Zika on the Brazilian public health system. The similarities in the clinical presentations of these two diseases, illustrated in Table 1 , [3] [4] [5] [6] [7] aggravate this situation since the initial stages of Zika correspond to the clinical manifestations of SARS-CoV2 infection, makes the diagnostic approach more difficult. Therefore, there may be a delay in diagnosis and appropriate treatment, worsening clinical outcomes and potentially increasing the spread of infection. Diagnostic delay due to overlapping symptoms of COVID-19 and other infectious diseases, such as Dengue, 8 and Typhoid fever, 9 has also been reported in India and Pakistan, where the similarity between COVID-19 symptoms and these diseases has led to their underdiagnosis. The deterioration of the clinical picture in both cases, due to the delay in the start of treatment, may require monitoring employing numerous complementary tests, such as monitoring the levels of hematocrit and platelet count, which puts the capacity of the laboratories in difficulty, concerning the shortage of reagents, facilities and human resources. 10 Besides, there is the fact that both diseases can present as a coinfection, which can lead to underdiagnosis of Zika after a positive diagnostic test for COVID-19. This is mainly because many laboratories have redirected all their efforts to diagnose coronavirus, which has directly impacted on the detection of arboviruses. In addition, it is important to highlight that the pandemic has weakened the surveillance and epidemiological and entomological control services for arboviruses and their vector, due to the redirection of efforts to control COVID-19. Thus, although 7387 cases of Zika were registered in Brazil in 2020, the actual numbers may be much higher. 11 Associated with this is that the weakening of entomological Consequently, ICU will be challenged since the incidence of the arboviruses and its complications is increasing simultaneously with the need to accommodate patients with severe SARS-CoV-2. As reported, the possibility of patients with COVID-19 presenting with severe acute respiratory syndrome resides in 15%. 15 In contrast, ZIKV contamination during pregnancy, for example, can cause microcephaly and other intrinsic conditions in newborn children. It is also worth mentioning that recently, researchers identified a new African strain of the ZIKV that was first detected in Brazil. 16 It is predicted that most people will not have antibodies against this new strain of Zika, and, therefore, this new strain represents a massive threat to the resurgence of the Zika epidemic in Brazil. To deal with the situation, health awareness campaigns aimed at the general public, especially the population most affected and at greatest risk for both diseases, are also needed. With regard to COVID-19 and dengue, co-epidemics in Ecuador and other countries in Latin America: Pushing strained health care systems over the edge New Zika Cases in Brazil Overshadowed by Covid-19 Monitoramento Dos Casos de Arboviroses Urbanas Transmitidas Pelo Aedes (Dengue, Chikungunya e Zika) Epidemiology of COVID-19: a systematic review and meta-analysis of clinical characteristics, risk factors, and outcomes Zika virus infection among symptomatic patients from two healthcare centers in Sao Paulo State, Brazil: prevalence, clinical characteristics, viral detection in body fluids and serodynamics The prevalence of symptoms in 24 COVID-19): a systematic review and meta-analysis of 148 studies from 9 countries Prevalence of Gastrointestinal symptoms and fecal viral shedding in patients with coronavirus disease 2019: a systematic review and meta-analysis Dengue amidst COVID-19 in India: the mystery of plummeting cases A skeleton in the closet: the implications of COVID-19 on XDR strain of typhoid in Pakistan Diagnostic laboratory testing and clinical preparedness for dengue outbreaks during the COVID-19 pandemic WHO Region of the Americas records highest number of dengue cases in history; cases spike in other regions Dengue and COVID-19: a double burden to Brazil Chikungunya and COVID-19 in Brazil: the danger of overlapping crises Characteristics of and Important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention A recursive subtyping screening surveillance system detects the appearance of the ZIKV African lineage in Brazil: Is there a risk of a new epidemic?