Challenges in diagnosing Zika-experiences from a reference laboratory in a non-endemic setting

Dorien Van den Bossche, Johan Michiels, Lieselotte Cnops, Nikki Foque, Kathleen Meersman, Ralph Huits, Kevin Ariën, Marjan Van Esbroeck

Research output: Contribution to journalA1: Web of Science-articlepeer-review


Diagnosing a patient with Zika infection is not always straightforward. Here, we aim to describe our data collected from December 2015 to December 2017 and discuss the implemented algorithm and diagnostic challenges we encountered. At the National Reference Center for Arboviruses at the Institute of Tropical Medicine, Antwerp, Belgium (ITM), a commercial Zika virus (ZIKV) enzyme-linked immunosorbent assay (ELISA) detecting immunoglobulin (Ig) M and IgG, a commercial ZIKV immunofluorescence assay (IFA) detecting IgM, and an in-house Zika virus neutralization test (VNT) were implemented. For molecular detection of ZIKV, an in-house and a commercial real-time RT-PCR were applied. An algorithm, adapted from the European Centre for Disease Control and Prevention (ECDC), was implemented. Between December 2015 and December 2017, we tested 6417 patients for ZIKV. Of those, according to ECDC criteria, 127 (2.0%) were classified as a confirmed Zika infection of which 39 by RT-PCR (0.6%), 15 (0.2%) as a probable Zika infection, 73 (1.1%) as undefined, and 65 (1.0%) as false positive reactions. Main challenges were the brief window for detection of IgM, cross-reactivity of antibodies with other flaviviruses and malaria, and low VNT titers in the acute phase. In RT-PCR negative samples, classification of ZIKV infection as recent or past proved difficult, when IgM was negative. The majority of patients could be classified according to ECDC criteria, though 1.1% of patients remained "undefined" and 1.0% were ELISA false positive reactions. Complementary IFA IgM was of added value to increase IgM detection rates. Improved serological assays and more longitudinal data on antibody kinetics are needed.

Original languageEnglish
JournalEuropean Journal of Clinical Microbiology and Infectious Diseases
Issue number4
Pages (from-to)771-778
Number of pages8
Publication statusPublished - 2019


  • Adolescent
  • Adult
  • Aged
  • Algorithms
  • Antibodies, Viral/blood
  • Child
  • Child, Preschool
  • Clinical Laboratory Techniques/methods
  • Cross Reactions
  • Enzyme-Linked Immunosorbent Assay
  • False Positive Reactions
  • Female
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Middle Aged
  • Neutralization Tests
  • Pregnancy
  • Real-Time Polymerase Chain Reaction
  • Sensitivity and Specificity
  • Young Adult
  • Zika Virus Infection/diagnosis
  • Zika Virus/genetics


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