Leveraging multiple data types to estimate the size of the Zika epidemic in the Americas

Several hundred thousand Zika cases have been reported across the Americas since 2015. Incidence of infection was likely much higher, however, due to a high frequency of asymptomatic infection and other challenges that surveillance systems faced. Using a hierarchical Bayesian model with empirically-informed priors, we leveraged multiple types of Zika case data from 15 countries to estimate subnational reporting probabilities and infection attack rates (IARs). Zika IAR estimates ranged from 0.084 (95% CrI: 0.067–0.096) in Peru to 0.361 (95% CrI: 0.214–0.514) in Ecuador, with significant subnational variability in every country. Totaling infection estimates across these and 33 other countries and territories, our results suggest that 132.3 million (95% CrI: 111.3-170.2 million) people in the Americas had been infected by the end of 2018. These estimates represent the most extensive attempt to determine the size of the Zika epidemic in the Americas, offering a baseline for assessing the risk of future Zika epidemics in this region.Author summary: During the recent Zika epidemic in the Americas millions of people were likely infected, but the true size of the epidemic is unknown because of gaps in the surveillance system. The infection attack rate (IAR)—defined as the proportion of the population that was infected over the course of the epidemic—has important implications for the longer-term epidemiology of Zika in the region, such as the timing, location, and likelihood of future outbreaks. To estimate the IAR and the total number of people infected, we leveraged multiple types of Zika case data from 15 countries and territories where subnational data were publicly available. Datasets included confirmed and suspected Zika cases in pregnant women and in the total population, Zika-associated Guillan-Barré syndrome cases, and cases of congenital Zika syndrome. We used a hierarchical Bayesian model with empirically-informed priors that leveraged the different case report types to simultaneously estimate national and subnational reporting probabilities, the fraction of symptomatic infections, and subnational IARs. In these 15 countries and territories, estimates of Zika IAR ranged from 0.084 (95% CrI: 0.067–0.096) in Peru to 0.361 (95% CrI: 0.214–0.514) in Ecuador. Totaling these infection estimates across these and 33 other countries and territories in the region, our results suggest that 132.3 million (95% CrI: 111.3-170.2 million) people in the Americas were infected with ZIKV by the end of 2018.