COVID-19, the emerging disease caused by the novel coronavirus SARS-CoV-2, has impacted all sectors of society, above all the health systems, due to its rapid spread across all the continents, the capacity to causes deaths in vulnerable populations, and incomplete knowledge on the virus, its pathogenesis, and treatment. As of May 14, 2020, there had been 4,307,287 confirmed cases worldwide, with 295,101 deaths ¹1. World Health Organization. Coronavirus disease (COVID-19) outbreak. https://www.who.int/emergencies/diseases/novel-coronavirus-2019 (acessado em 14/Mai/2020).
https://www.who.int/emergencies/diseases... ^,22. Williams G, Cañon-Montañez W. COVID-19: what we've learned so far. Rev Cuid (Bucaramanga) 2020; 11:e1225.^,33. The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) - China, 2020. China CDC Weekly 2020; 2:113-22.^,44. Walker PGT, Whittaker C, Watson O, Baguelin M, Ainslie KEC, Bhatia S, et al. The global impact of COVID-19 and strategies for mitigation and suppression. https://spiral.imperial.ac.uk:8443/handle/10044/1/77735 (acessado em 11/Mai/2020).
https://spiral.imperial.ac.uk:8443/handl... .

In Brazil, precarious housing and sanitation conditions with overcrowding and inconsistent access to safe running water, unfavorable socioeconomic indicators that reflect the poor living standards of the majority of the population, and the high prevalence of chronic diseases like hypertension and diabetes (risk factors for COVID-19), exacerbate the impacts and hinder strategies for confronting the disease. Several Brazilian states are already risking the imminent collapse of their health services ⁵5. Barreto ML, Barros AJD, Carvalho MS, Codeço CT, Hallal PRC, Medronho RA. O que é urgente e necessário para subsidiar as políticas de enfrentamento da pandemia de COVID-19 no Brasil? Rev Bras Epidemiol 2020; 23:e200032..

Besides the COVID-19 epidemic, Brazil has faced seasonal dengue epidemics from March to June since 1986. The increase in rainfall and gaps in Aedes aegypti mosquito vector control have contributed to the rise in dengue during this period. The situation is similar with respiratory diseases like influenza, which display seasonal outbreaks, especially in the cooler autumn and winter months. With the spatial and temporal coincidence of these diseases, the Brazilian Unified National Health System (SUS), which already presented deficiencies in clinical care for dengue and other diseases, was forced to quickly expand its physical infrastructure, purchase equipment and supplies, build field hospitals, train healthcare professionals, and increase its testing capacity ⁶6. Lorenz C, Azevedo TS, Chiaravalloti-Neto F. COVID-19 and dengue fever: a dangerous combination for the health system in Brazil. Travel Med Infect Dis 2020; [Epub ahead of print].^,77. Monteiro ESC, Coelho ME, Cunha IS, Cavalcante MAS, Carvalho FAA. Aspectos epidemiológicos e vetoriais da dengue na cidade de Teresina, Piauí - Brasil, 2002 a 2006. Epidemiol Serv Saúde 2009; 18:365-74.^,88. Croda J, Oliveira WK, Frutuoso RL, Mandetta LH, Baia-da-Silva DC, Brito-Sousa JD, et al. COVID-19 in Brazil: advantages of a socialized unified health system and preparation to contain cases. Rev Soc Bras Med Trop 2020; 53:e20200167.^,99. Ferreira RCB, Papini S, Luchini LC, Vieira E. Persistence of malathion used in dengue control on household surfaces. Arq Inst Biol 2019; 86:e0042018.^,1010. Barbosa IR, Tavares AM, Torres UPS, Nascimento CA, Moura MCBM, Vieira VB, et al. Identificação de áreas prioritárias para a vigilância e controle de dengue e outras arboviroses transmitidas pelo Aedes aegypti no Município de Natal - RN: relato de experiência. Epidemiol Serv Saúde 2017; 26:629-38.^,1111. Azevedo JVV, Santos CAC, Silva MT, Olinda RA, Santos DAS. Análise das variações climáticas na ocorrência de doenças respiratórias por influenza em idosos na região metropolitana de João Pessoa - PB. Sociedade & Natureza 2017; 29:123-35.^,1212. Oliveira WK, Duarte E, França GVA, Garcia LP. How Brazil can hold back COVID-19. Epidemiol Serv Saúde 2020; 29:e2020044.. Still, the impact of COVID-19 on the public healthcare system appears most acutely in the high demand for hospitalization, exhausting the supply of intensive care beds and mechanical ventilators in some regions of Brazil ¹³13. Moreira RS. COVID-19: unidades de terapia intensiva, ventiladores mecânicos e perfis latentes de mortalidade associados à letalidade no Brasil. Cad Saúde Pública 2020; 36:e00080020..

COVID-19 and dengue present several clinical and laboratory similarities. Yan et al. ¹⁴14. Yan G, Lee CK, Lam LTM, Yan B, Chua YX, Lim AYN, et al. Covert COVID-19 and false-positive dengue serology in Singapore. Lancet Infect Dis 2020; 20:536. observed that patients infected with SARS-CoV-2 and diagnosed with dengue via rapid tests evolved to more serious clinical status, delaying effective treatment. False-positive diagnoses and less sensitive laboratory methods can lead to health complications for patients and favor the spread of COVID-19, further overloading the public healthcare system ⁶6. Lorenz C, Azevedo TS, Chiaravalloti-Neto F. COVID-19 and dengue fever: a dangerous combination for the health system in Brazil. Travel Med Infect Dis 2020; [Epub ahead of print].^,1414. Yan G, Lee CK, Lam LTM, Yan B, Chua YX, Lim AYN, et al. Covert COVID-19 and false-positive dengue serology in Singapore. Lancet Infect Dis 2020; 20:536.^,1515. Velasco MS, Chilet CC, Rodriguez RP, Urbina AG, Berrospi FI. Coinfección entre dengue y COVID-19: necesidad de abordaje en zonas endémicas. Rev Fac Cienc Méd (Córdoba) 2020; 77:52-4..

The number of reported dengue cases in Brazil as of epidemiological week (EW) 17 of 2020 exceeded the number of cases in EW 7 of 2015 and EW 11 of 2019. However, starting in EW 10 there was a decline in the number of reported dengue cases, coinciding with the period in which health measures in Brazil were stepped up for the fight against COVID-19, suggesting possible underreporting during a period in which a seasonal increase in dengue cases would have been expected in the country ¹⁶16. Ministério da Saúde. Monitoramento dos casos de arboviroses urbanas transmitidas pelo Aedes aegypti (dengue, chikungunya e zika), Semanas Epidemiológicas 1 a 17, 2020. Bol Epidemiol 2020; 51(18). https://www.saude.gov.br/images/pdf/2020/May/04/Boletim-epidemiologico-SVS-18.pdf.
https://www.saude.gov.br/images/pdf/2020... .

The Northeast of Brazil showed the second lowest dengue incidence of all the country’s regions (82.5/100,000 inhabitants) in EW 17 of 2020. In the state of Piauí in the Northeast, accumulated dengue incidence was 20.2/100,000 inhabitants in EW 17 of 2020, or a decrease of 74.5% compared to the same period in 2019 ¹⁶16. Ministério da Saúde. Monitoramento dos casos de arboviroses urbanas transmitidas pelo Aedes aegypti (dengue, chikungunya e zika), Semanas Epidemiológicas 1 a 17, 2020. Bol Epidemiol 2020; 51(18). https://www.saude.gov.br/images/pdf/2020/May/04/Boletim-epidemiologico-SVS-18.pdf.
https://www.saude.gov.br/images/pdf/2020... ^,1717. Secretaria de Saúde do Estado do Piauí. Dengue, chikungunya, zika e microcefalia. Boletim da 17ª Semana Epidemiológica 2020. http://www.saude.pi.gov.br/uploads/warning_document/file/530/Boletim_Epidemiol%C3%B3gico_PI_SE_17%C2%AA_2020.pdf.
http://www.saude.pi.gov.br/uploads/warni... . Observing the recent historical dengue series in Piauí, dengue incidence in 2020 was close to the pattern of occurrence of the disease according to the mean coefficient for the years 2016 to 2019 ¹⁷17. Secretaria de Saúde do Estado do Piauí. Dengue, chikungunya, zika e microcefalia. Boletim da 17ª Semana Epidemiológica 2020. http://www.saude.pi.gov.br/uploads/warning_document/file/530/Boletim_Epidemiol%C3%B3gico_PI_SE_17%C2%AA_2020.pdf.
http://www.saude.pi.gov.br/uploads/warni... . However, starting in the week in which the first confirmed cases of COVID-19 were reported in Piauí (EW 12) ¹⁸18. Secretaria de Saúde do Estado do Piauí. Painel epidemiológico COVID-19 Piauí. https://datastudio.google.com/reporting/a6dc07e9-4161-4b5a-9f2a-6f9be486e8f9/page/2itOB (acessado em 11/Mai/2020).
https://datastudio.google.com/reporting/... , there was an exponential increase in COVID-19 cases, simultaneously with a reduction in recorded dengue incidence (Figure 1).

This abrupt change in the behavior of epidemiological data on dengue reinforces the hypothesis of underreporting of cases in Piauí. Based only on the currently available incidence rates, the estimated risk of COVID-19 (incidence of 12.6 cases/100,000 inhabitants) in the population of the state of Piauí would be 25 time greater than the risk of dengue (incidence of 0.5 cases/100,000 inhabitants) in the same population in EW 18.

This observation reinforces the need to alert health professionals to suspect and report cases. An additional challenge is to understand the progression of the “underestimated” dengue epidemic simultaneously with the occurrence of COVID-19 cases, with the health systems experiencing signs of exhaustion and incomplete knowledge on the effects of co-infection in the same patient, which may further overload the system ⁶6. Lorenz C, Azevedo TS, Chiaravalloti-Neto F. COVID-19 and dengue fever: a dangerous combination for the health system in Brazil. Travel Med Infect Dis 2020; [Epub ahead of print].^,1414. Yan G, Lee CK, Lam LTM, Yan B, Chua YX, Lim AYN, et al. Covert COVID-19 and false-positive dengue serology in Singapore. Lancet Infect Dis 2020; 20:536..

The fight against these diseases requires effective awareness-raising strategies with the population to eliminate mosquito breeding sites, wash hands, wear masks, and above all practice social distancing. It is also essential to strengthen the SUS and focus resources to organize health systems in order to reduce inequalities in access and offer quality care to the entire population both in primary healthcare, where mild cases of both diseases are treated, and in hospital care, reserved for cases with higher complexity. Since primary care is defined as the preferred point of access to care for persons with suspicion of dengue and COVID-19, primary healthcare is an essential component of the health system and should be strengthened and prepared for timely treatment, adequate clinical management, and referral of severe cases, as well as for comprehensive treatment of primary healthcare-sensitive conditions ¹⁹19. Souza CDF, Gois-Santos VT, Correia DS, Martins-Filho PR, Santos VS. The need to strengthen primary health care in Brazil in the context of the COVID-19 pandemic. Braz Oral Res 2020; 34:e047..

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