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The use of a geoprocessing system that can determine geographic clusters and associate symptomatic cases and infected mosquitoes is an important factor in demonstrating how environmental parameters modulate the transmission chain and the spatial heterogeneity. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. First, the foci were limited to a small geographical area and evaluated for only a 6-week period. Despite these caveats, this study is critical in understanding the epidemiology of ZIKV in an outbreak situation. The goals of the study were to identify the household infection prevalence, quantify the percentage of cases that were asymptomatic, identify infection risk factors, and characterize patients who sought treatment, all in context with other endemic arboviral diseases. In addition, caution must be used when extrapolating these findings to other populations with different population densities, travel capabilities, mosquito species, and prevalence of other endemic arboviruses. The concurrent circulation of these arboviruses has become an important public health concern [ 21 ] and has led to difficulties in accurately diagnosing ZIKV infection. The most frequently reported symptoms and signs included fever, conjunctivitis, headache, myalgia, and pruritus for 4—7 days. Despite these key findings, there are some limitations of the study by Lozier et al.

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The first documented evidence of ZIKV autochthonous transmission in Brazil occurred in May , after some patients presented with a dengue-like syndrome in the city of Natal, located in the state of Rio Grande do Norte [ 6 ]. The use of a geoprocessing system that can determine geographic clusters and associate symptomatic cases and infected mosquitoes is an important factor in demonstrating how environmental parameters modulate the transmission chain and the spatial heterogeneity. The first documented ZIKV outbreak, on Yap Island, Micronesia, in [ 3 ], was followed by a large epidemic in French Polynesia in —, before spreading across the Pacific and eventually to the Americas. On 1 February , the World Health Organization declared ZIKV infection and its association with neurologic complications as a public health emergency of international concern [ 11 ]. The majority of homes in the observed foci of transmission in the study by Lozier et al were tested Interestingly, one unique hallmark of the western hemisphere outbreak was the high incidence of neurological disease, primarily newborn microcephaly, in the northeastern states of Brazil, which led to the association between ZIKV infection during pregnancy and fetal malformations [ 10 ]. The goals of the study were to identify the household infection prevalence, quantify the percentage of cases that were asymptomatic, identify infection risk factors, and characterize patients who sought treatment, all in context with other endemic arboviral diseases. Potential conflicts of interest. First, the foci were limited to a small geographical area and evaluated for only a 6-week period. Second, the study could not address rarer neurological outcomes because of the small sample size. This resulted in an older, female-predominant data set that was somewhat unlike the rest of the population in Puerto Rico. The study developed by Lozier et al [ 22 ] in this issue of The Journal of Infectious Diseases is a retrospective case-control study, based on household-based clusters, that describes the distribution of ZIKV infection and estimates the proportion of symptomatic ZIKV infections and risk factors associated with the Zika outbreak in Puerto Rico in Despite these caveats, this study is critical in understanding the epidemiology of ZIKV in an outbreak situation. The household and participant rates were low, although the study was conducted after the peak of the Zika outbreak in Puerto Rico. Despite these key findings, there are some limitations of the study by Lozier et al. ZIKV is currently considered to be an emerging arthropod-borne virus [ 2 , 4 , 5 ]. Like previous reports, ZIKV was associated with fever, rash, arthralgia, and arthritis. Viremia levels were not different between patients with and those without symptoms. Less frequently reported symptoms included retro-orbital pain, anorexia, vomiting, diarrhea, and abdominal pain [ 9 ]. The most frequently reported symptoms and signs included fever, conjunctivitis, headache, myalgia, and pruritus for 4—7 days. Importantly, understanding the rates of symptomatic and asymptomatic ZIKV infections allows the investigators to derive inferences about the transmission chain of the epidemic and its impact in the studied population and, thus, to link social and environmental factors as determinants of illness. Intrauterine growth restriction, ocular abnormalities, placental damage, and fetal demise are other findings that may be associated with ZIKV infection in pregnancy [ 10 , 17—19 ]. Microcephaly represents only a part of the broad spectrum of teratogenic outcomes of intrauterine ZIKV infection, now called congenital Zika syndrome [ 16 ]. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. The concurrent circulation of these arboviruses has become an important public health concern [ 21 ] and has led to difficulties in accurately diagnosing ZIKV infection. In addition, caution must be used when extrapolating these findings to other populations with different population densities, travel capabilities, mosquito species, and prevalence of other endemic arboviruses.

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    Microcephaly represents only a part of the broad spectrum of teratogenic outcomes of intrauterine ZIKV infection, now called congenital Zika syndrome [ 16 ]. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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