@article{Schirmer_Oda_Lucero-Obusan_Winters_Saavedra_Martinez_Holodniy_2017, title={Dengue, Chikungunya & Zika Virus in VA Caribbean HCS, Nov. 2015-Aug. 2016}, volume={9}, url={https://ojphi.org/ojs/index.php/ojphi/article/view/7680}, DOI={10.5210/ojphi.v9i1.7680}, abstractNote={<div style="left: 72px; top: 257.94px; font-size: 11.3333px; font-family: sans-serif; transform: scaleX(1.08137);" data-canvas-width="51.022666666666666">Objective</div><div style="left: 84px; top: 269.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.996533);" data-canvas-width="302.5308666666667">We describe surveillance for Dengue virus (DENV), Chikungunya</div><div style="left: 72px; top: 283.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.02483);" data-canvas-width="315.4248">virus (CHIKV) and Zika virus (ZIKV) in VA Caribbean Healthcare</div><div style="left: 72px; top: 296.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.983008);" data-canvas-width="312.07239999999996">System (VACHS) from the start of ZIKV transmission in Puerto Rico.</div><div style="left: 72px; top: 319.273px; font-size: 11.3333px; font-family: sans-serif; transform: scaleX(1.11794);" data-canvas-width="66.10733333333333">Introduction</div><div style="left: 84px; top: 331.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.0266);" data-canvas-width="303.4454666666667">DENV, CHIKV and ZIKV are all transmitted by mosquitoes and</div><div style="left: 72px; top: 344.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.971794);" data-canvas-width="316.04359999999997">have occurred in outbreaks in the Caribbean. Common symptoms</div><div style="left: 72px; top: 357.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.0176);" data-canvas-width="315.23666666666657">(which can be severe and disabling) are similar among the 3 viruses</div><div style="left: 72px; top: 371.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.977529);" data-canvas-width="316.149">and include fever, joint pain/swelling, headache, muscle pain and</div><div style="left: 72px; top: 384.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.980886);" data-canvas-width="314.30846666666656">rash. In December 2015, the first endemic case of ZIKV infection was</div><div style="left: 72px; top: 397.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.00548);" data-canvas-width="314.8150666666666">reported by VACHS. Since that time, an increasing number of ZIKV</div><div style="left: 72px; top: 411.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.960953);" data-canvas-width="316.1376666666665">infections have been reported in Puerto Rico. Due to the growing</div><div style="left: 72px; top: 424.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.00164);" data-canvas-width="291.1419999999998">ZIKV outbreak, we performed ongoing testing and surveillance.</div><div style="left: 72px; top: 449.94px; font-size: 11.3333px; font-family: sans-serif; transform: scaleX(1.07312);" data-canvas-width="46.59133333333333">Methods</div><div style="left: 84px; top: 461.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.01268);" data-canvas-width="303.0782666666667">DENV, CHIKV and ZIKV infection surveillance from November</div><div style="left: 72px; top: 475.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.02419);" data-canvas-width="315.3126000000001">2015 - August 2016 at VACHS was performed from 2 primary data</div><div style="left: 72px; top: 488.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.04972);" data-canvas-width="118.84586666666668">sources: (1) VA Praedico</div><div style="left: 190.798px; top: 488.867px; font-size: 6.8px; font-family: serif; transform: scaleX(1.00932);" data-canvas-width="10.278199999999998">TM</div><div style="left: 201.074px; top: 488.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.04257);" data-canvas-width="186.6724666666667">Public Health Surveillance System for</div><div style="left: 72px; top: 501.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.03194);" data-canvas-width="315.65259999999984">laboratory results documented within the electronic medical record</div><div style="left: 72px; top: 515.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.992295);" data-canvas-width="314.5079333333333">(EMR) and (2) communications with facility clinicians for laboratory</div><div style="left: 72px; top: 528.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.03268);" data-canvas-width="315.60499999999996">results not entered into the EMR. Laboratory tests were considered</div><div style="left: 72px; top: 541.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.03843);" data-canvas-width="315.612933333333">unique tests if they were performed >30 days apart. A positive test</div><div style="left: 72px; top: 555.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.00853);" data-canvas-width="314.82866666666655">was defined as a positive IgM or RT-PCR test result. Serial infection</div><div style="left: 72px; top: 568.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.976281);" data-canvas-width="316.2011333333333">was defined as infection with CHIKV and ZIKV or CHIKV and</div><div style="left: 72px; top: 581.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.982478);" data-canvas-width="316.2759333333333">DENV. Potential cross-reaction of assays was defined as positive</div><div style="left: 72px; top: 595.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.982406);" data-canvas-width="316.5966666666664">DENV and ZIKV IgM results within 30 days. Demographic and</div><div style="left: 72px; top: 608.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.996858);" data-canvas-width="314.6915333333334">clinical data was obtained on all positive ZIKV cases including cases</div><div style="left: 72px; top: 621.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.00256);" data-canvas-width="93.48866666666666">with serial infection.</div><div style="left: 72px; top: 644.606px; font-size: 11.3333px; font-family: sans-serif; transform: scaleX(1.08488);" data-canvas-width="40.93600000000001">Results</div><div style="left: 84px; top: 656.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.01614);" data-canvas-width="303.30039999999997">For the time period evaluated, 2,218 unique tests were performed</div><div style="left: 72px; top: 669.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.986315);" data-canvas-width="314.42066666666653">for DENV (744), CHIKV (741), and ZIKV (744). Five hundred thirty</div><div style="left: 72px; top: 683.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.99957);" data-canvas-width="314.7312">three positive tests were identified for: DENV (34), CHIKV (55) and</div><div style="left: 72px; top: 696.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.996249);" data-canvas-width="314.69833333333327">ZIKV (444) (Figure 1). Demographic and virus breakdown of testing</div><div style="left: 72px; top: 709.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.05067);" data-canvas-width="315.8328">is shown in Table 1. Percent positive range for DENV testing was</div><div style="left: 72px; top: 723.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.982405);" data-canvas-width="316.4980666666666">0-23%, for CHIKV was 0-14%, and for ZIKV 0-73%. Temporal</div><div style="left: 72px; top: 736.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.01092);" data-canvas-width="315.08706666666666">timing of positive tests for each virus by percent positive is depicted</div><div style="left: 72px; top: 749.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.992172);" data-canvas-width="314.5351333333333">in Figure 2. Serial infections were identified in 39 patients (1 CHIKV</div><div style="left: 72px; top: 763.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.989804);" data-canvas-width="312.1347333333333">IgM/ZIKV IgM/PCR+, 7 CHIKV IgM/ZIKV IgM+, 26 CHIKV IgM/</div><div style="left: 72px; top: 776.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.978695);" data-canvas-width="312.04066666666665">ZIKV PCR+, 2 CHIKV IgM/ZIKV PCR/DENV IgM+, 2 DENV IgM/</div><div style="left: 72px; top: 789.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.980756);" data-canvas-width="314.4467333333332">CHIKV IgM+, 1 DENV IgM/CHIKV IgM/ZIKV IgM+). The average</div><div style="left: 72px; top: 803.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.99651);" data-canvas-width="314.6813333333332">age of patients with serial infection was 63.5 years (range 33-85) and</div><div style="left: 72px; top: 816.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.01197);" data-canvas-width="315.061">occurred in 4 females and 35 males. 21 patients were identified with</div><div style="left: 72px; top: 829.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.959336);" data-canvas-width="312.11999999999995">positive DENV and ZIKV IgM tests, which could represent cross-</div><div style="left: 72px; top: 843.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.995491);" data-canvas-width="314.5419333333333">reactivity between the assays or co-infection. Confirmatory testing of</div><div style="left: 72px; top: 856.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.0021);" data-canvas-width="125.91333333333337">these specimens is pending.</div><div style="left: 72px; top: 881.94px; font-size: 11.3333px; font-family: sans-serif; transform: scaleX(1.10259);" data-canvas-width="68.01133333333334">Conclusions</div><div style="left: 84px; top: 893.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.03729);" data-canvas-width="305.56933333333325">Laboratory surveillance demonstrated co-circulation of all 3</div><div style="left: 72px; top: 907.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.0462);" data-canvas-width="317.88753333333307">viruses, although ZIKV was the dominant infection identified</div><div style="left: 72px; top: 920.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.03956);" data-canvas-width="315.47240000000016">during this time period. In addition, laboratory data suggests serial</div><div style="left: 72px; top: 933.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.995351);" data-canvas-width="314.63033333333334">infection with CHIKV and ZIKV while also identifying patients with</div><div style="left: 72px; top: 947.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.01955);" data-canvas-width="315.53360000000004">probable cross-reaction between DENV and ZIKV tests. Additional</div><div style="left: 72px; top: 960.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.991776);" data-canvas-width="316.4923999999999">investigation is needed to determine whether patients with serial</div><div style="left: 72px; top: 973.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.04293);" data-canvas-width="315.8350666666664">infection have increased severity of symptoms or different clinical</div><div style="left: 408px; top: 256.567px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.979329);" data-canvas-width="314.1849333333333">outcomes. Since number of ZIKV infections continues to increase and</div><div style="left: 408px; top: 269.901px; font-size: 11.3333px; font-family: serif; transform: scaleX(0.999067);" data-canvas-width="314.7561333333332">all 3 viruses continue to circulate, continued public health messaging</div><div style="left: 408px; top: 283.234px; font-size: 11.3333px; font-family: serif; transform: scaleX(1.00242);" data-canvas-width="85.62333333333333">remains important.</div><div style="left: 408px; top: 516.262px; font-size: 10px; font-family: serif; transform: scaleX(1.06743);" data-canvas-width="35.83">Figure 1</div><div style="left: 408px; top: 633.436px; font-size: 10px; font-family: serif; transform: scaleX(1.16489);" data-canvas-width="40.538">Table 1:</div><div style="left: 448.523px; top: 633.436px; font-size: 10px; font-family: serif; transform: scaleX(1.08238);" data-canvas-width="277.48500000000007">VA Caribbean Healthcare System Dengue Virus (DENV),</div><div style="left: 408px; top: 644.102px; font-size: 10px; font-family: serif; transform: scaleX(1.00006);" data-canvas-width="316.2199999999999">Chikungunya Virus (CHIKV) and Zika Virus (ZIKV) Demographics and</div><div style="left: 408px; top: 654.769px; font-size: 10px; font-family: serif; transform: scaleX(1.0117);" data-canvas-width="122.77">Testing, Nov. 2015-Aug. 2016</div>}, number={1}, journal={Online Journal of Public Health Informatics}, author={Schirmer, Patricia and Oda, Gina and Lucero-Obusan, Cynthia A. and Winters, Mark and Saavedra, Sonia and Martinez, Mirsonia and Holodniy, Mark}, year={2017}, month={May} }