The aim of this study was to address this putative underdiagnosis of clinical CHIKV infection in Dutch travelers to the Indian Ocean region by retrospective screening Lumacaftor solubility dmso of sera of patients for which requested DENV serology was negative in the period 2007 to 2010. In addition, the trends

in diagnostic requests for CHIKV and DENV infections related to travel to the Indian Ocean area were analyzed. The sera were tested in serial (two-step) dilutions using a commercial indirect immunofluorescence assay (IFA, Euroimmun, Lübeck, Germany) for IgG and IgM anti-CHIKV. This IFA was proven to be suitable in outbreaks of both A226 and A226V envelope protein E1 variants of East, Central, and South African genotype CHIKV, both known to have replaced the Asian CHIKV genotype in India and Southeast Asia and responsible

for the Indian Ocean area outbreaks.[5, 6] Because background reactivity was observed in a high proportion of serum samples of non-travelers in dilutions up to 1 : 40 to 1 : 80 (data not shown), serum samples with a positive signal at dilution 1 : 128 or Metformin price higher were considered to be positive. For serum samples that were reactive at dilution 1 : 64, repeat sampling was requested. Given the rather high proportion of samples with some nonspecific background reactivity, sera testing positive were analyzed for independent confirmation of the results using a virus neutralization test with vital staining (NT)[7] using CV-1 cells and the

prototype East, Central, and South African lineage CHIKV strain S27-African. The different CHIKV lineages and strains are known to cross-neutralize.[6] In addition, sera were analyzed for the presence of CHIKV RNA using a TaqMan reverse-transcription polymerase chain reaction (PCR; Roche Diagnostics, Almere, The Netherlands) as described in Ref. [8]. PCR and NT were only performed when volume of remaining serum was sufficient. second We selected serum samples from unique patients that had been submitted for diagnosis of DENV infection in 2007 to 2010 (n = 948) and for whom minimal background data had been provided including travel destination (n = 348, 36.7%). From this group, we selected the patients who had traveled to the Indian Ocean region (n = 158). To this goal, all countries with a coastline on the Indian Ocean were included. Subsequently, patients with positive DENV serology (IgM and/or IgG; n = 41, 25.9%) or inconclusive DENV serology (a-specific reaction, n = 5) were excluded. Of the remaining 112 patients, sera of 107 patients were available for CHIKV serology. A total of 107 sera from travelers returning from destinations in the Indian Ocean area, showing clinical symptoms corresponding to a DENV infection but with negative DENV serology, were analyzed for the presence of CHIKV IgM and IgG.