Applying a multiplex electrochemiluminescence NS1 assay to detect and differentiate Zika and dengue virus exposures in long-term community cohorts in Brazil and Thailand

Background: Distinguishing Zika virus (ZIKV) from dengue virus (DENV) infection remains a major diagnostic challenge in co-endemic regions due to antigenic cross-reactivity. We evaluated a multiplex electrochemiluminescence Meso Scale Discovery System (MSD) NS1 assay to define ZIKV infection with high specificity across diverse immune backgrounds. Methods: We analyzed longitudinal samples from PCR-confirmed ZIKV and DENV infections across multiple cohorts, assessed correlations between MSD NS1 signal intensities and PRNT50 titres, and performed ROC analyses to derive seroconversion thresholds. We then applied these criteria to identify ZIKV seroconversions in Brazil (2015-2024) and Thailand (2015-2025). Findings: ZIKV infections produced sustained NS1 responses, whereas primary DENV infections showed minimal ZIKV cross-reactivity and secondary DENV infections exhibited only transient, low-level increases. MSD NS1 signal intensities correlated with PRNT50 titres for ZIKV and all four DENV serotypes (rho = 0.54-0.84). ROC analyses identified a fold-change of at least 10.96 as the optimal ZIKV seroconversion cutoff, with an AUC of 100% among DENV-naive and 90.7% among DENV-exposed participants. Adding a second criterion - ZIKV/DENV fold-change ratio > 1 - further increased specificity. Application of this dual-threshold framework revealed high ZIKV incidence during the 2015-2016 epidemic in Brazil and very low incidence in the post-epidemic period. In the Thailand cohort, synchronous seroconversion among household members suggested potential intra-household transmission. Interpretation: The MSD NS1 multiplex assay provides a scalable, quantitative, and highly specific approach for identifying ZIKV infection and estimating seroincidence in co-endemic settings. The dual-threshold framework (fold-change of at least 10.96 and ZIKV/DENV ratio > 1) enhances diagnostic precision, offering a robust tool for surveillance and transmission studies in flavivirus-endemic regions.