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CHIKUNGUNYA FEVER
Objectives
• Historical epidemiology of CHIKUNGUNYA
• Regional scenario
• What is CHKV
• Clinical presentation
• Vector borne diseases, Differential Diagnosis, Transmission
• At risk groups ,Dengue /CHIKV dengue snapshot
• Treatment
Francis Morey MD.MPH
Lorna Perez Surveillance Officer Epi-Unit
History (Its story)
A viral infection transmitted to humans
By the bite of an infected mosquito
It has become endemic in south and central
India
First outbreak in 1952 on the Makonde Plateau
Border between Tanganyika and Mozambique
First published report is from Africa in 1955 by
Marion Robinson and W.H.R. Lumsden
Recent large epidemic occurred in Malaysia in
1999 www.drsarma.in 3
A disease of Africa and Asia
www.drsarma.in 4
INTRODUCTION
 Caused by an Alpha Virus is a relatively rare form of viral
fever ("debilitating non-fatal viral illness."
 Spread by bite of Aedes aegypti mosquito which usually bite
during day light hours.
 the name is derived from Swahili word meaning “that which
bends up”
 Chikungunya (CHIK) virus first isolated from the serum of a
febrile human in Tanzania in 1953.
 Chik virus has caused numerous out breaks in Africa and
South Eastern Asia, involving hundreds and thousands of
people.
• Chikungunya is a
Makonde word (one of
the local languages in
Tanzania) meaning
‘that which bends up’.
• Describes the posture
patient assumes to
relieve the severe joint
pains
• Buggy Creek virus
Synonyms
• CHIKV Fever
• Buggy Creek virus infection
• Knuckle fever
• Me Tri virus infection
• Semliki Forest virus infection
www.drsarma.in 7
The Recent Epidemics
8
www.drsarma.in
9
195
4
200
4
200
6
African profile Asian profile
Current global profile
A226V-CHIKV
Humans
Peridomestic mosquitoes
Ae.aegypti
Ae.albopictus

Focal urban outbreaks
Wild primates
Forest
dwelling mosquitoes
Ae. furcifer
Ae. taylori…
Humans

Sporadic cases
Focal urban outbreaks
Humans
Peridomestic mosquitoes
Ae. albopictus
Ae.aegypti

Massive urban outbreaks
Simon F et al. Curr Infect Dis Rep 2011 (in press)
Notable Outbreaks
1963 to 1965 - An epidemic was reported in Calcutta –
4.37% of the people were later found to be seropositive
1973 – An epidemic 37.53% in Barsi - Sholapur district
2006 – Present epidemic after 33 years is the largest
9,06,360 or more cases in Andhra Pradesh
5,43,286 cases from Karnataka; 66,109 from B’lore
Maharashtra 2,02,114 cases; Gujarat 2,500 cases
Tamil Nadu 49,567 cases; Orissa 4,904 cases,
Madhya Pradesh 43,784 and Pune 138 cases
www.drsarma.in 10
Most Recent Epidemics
• Epidemic of CHIKV occurred in Malaysia – 1999
• French island of Réunion in the Indian Ocean- 2005
• Epidemic was recorded in Mauritius – 2005
• Madagascar, Mayotte and Seychelles – 2005
• Hong Kong and Malaysia early 2006
• Present indian epidemic is the largest -from Dec ’05
• Maximum # of cases from Andhra Pradesh so far
www.drsarma.in 11
12
Chikungunya, 2005-2012, more than
three millions cases ?
South of France, 09/2010
2 autochtonous cases
New Caledonia, 03/2011
33 autochtonous cases
Yemen - Saudi
Arabia, 2010-11
Hundreds of cases
South China, 10/2010
>10 cases
Reunion, 2010
120 cases
www.drsarma.in 13
Why is this sudden epidemic ?
Analysis of the recent Indian epidemic has
suggested that the increased severity of the
disease is due to a change in the genetic
sequence, altering the virus’ coat protein,
which potentially allows it to multiply more
easily in mosquito cells*.
www.drsarma.in 14
*http//medicine.plosjournals.org
Why is this quasi-pandemic ?
• Several distinct variants of the virus
• A change at position 226 of the E1 coat protein
• This A226V mutation caused the virus to more easily
invade and multiply in the mosquitoes
• Three protein changes in non-structural proteins
– nsP1 (T301I), nsP2 (Y642N), and nsP3 (E460 deletion)
– This mutant virus - from a neonatal encephalopathy
case
www.drsarma.in 15
Regional scenario
16
CHIKUNGUNYA
The MOH/PAHO Belize request your Boarding pass
The CHIK Virus
19
www.drsarma.in
What is this virus ?
• Causative agent is an RNA – VIRUS
• Class – Arbor Virus (Arthropod Borne)
• Family – Togaviridae
• Genus – Alpha Virus
• Species – Chikungunya Virus
• Similar to Semliki Forest Viruses (SFV) in Africa
and Asia.
www.drsarma.in 20
Epidemiological Triangle
www.drsarma.in 21
The HostThe Virus
The Environment
Interaction
The Vector
Vector Borne diseases
• Mosquitoes
• Aedes
– Dengue fever
– Rift Valley fever
– Yellow fever
– Chikungunya
• Anopheles
– Malaria
• Culex
– Japanese encephalitis
– Lymphatic filariasis
– West Nile fever
• Sandflies
• Leishmaniasis
• Sandfly fever (phelebotomus fever)
• Ticks
• Crimean-Congo haemorrhagic fever
• Lyme disease
• Relapsing fever (borreliosis)
• Rickettsial diseases (spotted fever and Q fever)
• Tick-borne encephalitis
• Tularaemia
• Triatomine bugs
• Chagas disease (American trypanosomiasis)
• Tsetse flies
• Sleeping sickness (African trypanosomiasis)
• Fleas
• Plague (transmitted by fleas from rats to humans)
• Rickettsiosis
• Black flies
• Onchocerciasis (river blindness)
• Aquatic snails
• Schistosomiasis (bilharziasis
Arbovirus (arthropod-borne virus) applies to any virus that is transmitted to humans and/or other
vertebrates by certain species of blood-feeding arthropods, chiefly insects (flies and mosquitoes)
and arachnids (ticks)
• Bunyaviridae (comprising the bunyaviruses, phleboviruses, nairoviruses, and hantaviruses)
• Flaviviridae (comprising only the flaviviruses)
• Reoviridae (comprising the coltiviruses and orbiviruses)
• Togaviridae (comprising the alphavirus)
Fever, malaise, headaches, myalgias
Additional features: none Colorado tick fever Reoviridae (Coltivirus) Ticks
Dermacentor sp
Western US, western
Canada
Phlebotomus fever Bunyaviridae (Phlebovirus) Sand flies
Phlebotomus sp
Mediterranean basin,
Balkans, Middle East,
Pakistan, India, China,
eastern Africa, Panama,
Brazil
Venezuelan equine
encephalitis
Togaviridae (Alphavirus) Mosquitoes
Culex sp
Argentina, Brazil, northern
South America, Panama,
Mexico, Florida
Lymphadenopathy, rash Dengue fever Flaviviridae Mosquitoes
Aedes sp
Southeast Asia, West Africa,
Oceania, Australia, South
America, Mexico,
Caribbean, US
West Nile fever Flaviviridae Mosquitoes
Culex sp
Africa, Middle East,
southern France, Russia,
India, Indonesia, US
Arthralgia, rash Chikungunya disease Togaviridae (Alphavirus) Mosquitoes
Aedes sp
Africa, India, Guam,
Southeast Asia, New
Guinea, limited areas of
Europe
Mayaro virus Togaviridae (Alphavirus) Mosquitoes
Haemogus sp
Brazil, Bolivia, Trinidad
Hemorrhagic signs‡
Yellow fever Flaviviridae Mosquitoes
Aedes spp
Central and South
America, Africa
Dengue hemorrhagic
fever
Flaviviridae Mosquitoes
Aedes sp
Southeast Asia, West
Africa, Oceania,
Caribbean
Machupo virus Arenaviridae Rodent Bolivia
Junin virus Arenaviridae Rodent Argentina
Guanarito virus Arenaviridae Rodent Venezuela
Fever and CNS involvement
Eastern equine
encephalitis
Togaviridae (Alphavirus) Mosquitoes
Culex sp
Atlantic and Gulf coasts
of US, Caribbean, upper
New York, western
Michigan
Western equine
encephalitis
Togaviridae (Alphavirus) Mosquito US, Canada, Central and
South America
West Nile virus Flaviviridae Mosquitoes
Culex sp
Africa, Middle East,
southern France, former
Soviet Union, India,
Indonesia, US
St. Louis encephalitis Flaviviridae Mosquitoes
Culex sp
US, Caribbean
Venezuelan equine
encephalitis
Togaviridae (Alphavirus) Mosquitoes
Culex sp
Argentina, Brazil,
northern South America,
Panama, Mexico, Florida
La Crosse encephalitis Bunyaviridae Mosquitoes
Aedes spp.
North Central States,
New York
Transmission
Reservoir – Non-human primates in Africa
No animal reservoir is found in India
Maintained in nature by man – mosquito – man
cycle
Vector – Aedes aegypti, Ae. albapticus mosquito
Same vector as for Dengue and Yellow fevers
Vehicle of transmission – None
No known mode - other than mosquito bite
Incubation Period – 2 days to 12 days
www.drsarma.in 27
Main mode of transmission: mosquito bite
Other modes of transmission
• Uncommon
– In utero transmission, can cause miscarriage in the 1st
trimester
– Intra birth transmission, newborn of a viremic mother
– Needle prick
– Laboratory exposure
• Public Health Considerations
– Blood transfusion
– Organ or tissue transplant
– No evidence of the virus in breast milk
CHIKV in the Americas28
The Vector
Aedes aegypti mosquito, flight range < 100 meters
Aggressive daytime biter – under lights – bites ankles
Once infected – it has the virus until death (30 days)
It is a man made mosquito – prefers its owner
Breeds in man made household containers
Indoor, peridomestic, fresh water mosquito
Metallic, plastic, rubber, cement and earthen
containers - open, left or unused - get filled with water
Air coolers, ACs, Old oil drums, Over head tanks
www.drsarma.in 30
The Virus and its Vector
The Criminal and It’s Accomplice
How Do Aedes Mosquitoes Transmit Diseases...
Mosquito bites and sucks
blood containing the virus
from an infected person.
Virus is carried in its body.
And passes the virus
to healthy people
when it bites them.
Attack Rates
• In urban localities it is more – why ?
• Usual age group is above 15 years
• Less common in children and infants
• Family clustering of cases usual
• Attack rates vary from 3 to 40% of population
• Average attack rate is 10%
• Herd immunity restricts further spread
www.drsarma.in 32
Aedes aegypti/albaptycus/Tiger mosquito
www.drsarma.in 33
Clinical Features
34
www.drsarma.in
CHIKV Infection
a disease of two phases
ACUTE PHASE
•The majority of persons infected (72% 97%)‒
are symptomatic.
•Incubation period: 3–7 days (range of 1 12‒
days).
•Main symptoms: acute onset of fever and
polyarthralgia.
CHIKV Infection
a disease of two phases
CHRONIC PHASE
• Early exacerbations,
inflammatory relapses,
longstanding rheumatism and
loss in quality of life
• More common in:
– Those over 40 years old
– Rheumatic or traumatic
history
– High viral load
Simon F et al. Chikungunya virus infecion. Curr Infect Dis Rep DOI 10.1007/s11908-011-0180-1
CLINICAL FEATURES
 Acute viral infection of abrupt onset.
 sudden onset of fever >38.5 degrees and severe
arthralgia( ankle ,wrist, phalanges). Chills, flu like symptoms.
 other constitutional symptoms like head ache, back pain,
myalgia,photo phobia, retrorbital pain, conjunctival infection
and rash. Nausea, vomiting, abd. pain, severe weakness
 Incubation period is usually 1 to 12 days, symptoms
( average 4-7days).
 Lasting for period of 7 to 10 days.
 Rarely can result in meningo – encephalitis,
Cardiovascular alt,death in elderly-weak immune system.
Chronic phase of severe arthralgia
Fever and polyarthralgia
• Fever
– Acute onset
– ≥38.5°C
• Joint pain
– Sometimes serious and debilitating
– Multiple joints
– Bilateral and symmetric (usually)
– Most commonly in hands and feet
http://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=16985&Itemid=
Other signs and symptoms
• Headache
• Myalgia
• Arthritis
• Conjunctivitis
• Nausea and vomiting
• Maculopapular rash
http://wfffun.info/diseases/chikungunya-rash-photos-2/
41
Subacute stage, persisting distal inflamatory arthralgias
Simon F et coll. Medicine 2007;86: 123-37
42
Subacute stage, tenosynovitis
43
Simon F et coll. Medicine 2007;86: 123-37
Subacute stage, bursitis
44
Subacute stage, associated rheumatic disorders
45
Simon et al. Medicine 2007; 86 (3)
Peripheral vascular disorders
• Erythermalgia
• Raynaud’s syndrome
– High susceptibilty to the cold
– De novo and transient
– Commonly bilateral
– Associated with mixed cryoglobulinemia
The Arthralgia
• The small joints of the lower and upper limbs
• Migratory poly arthralgia – not much effusions
• Larger joints may also be affected (knee, ankle)
• Pain worse in the morning – less by evening
• Joints may be swollen & painful to the touch
• Some patients have incapacitating joint pains
• Arthritis may last for weeks or months.
www.drsarma.in 47
Kun gunyala
www.drsarma.in 48
The Contorted Posture
Skin Rash in Dengue CHIKV
www.drsarma.in 49
Rare Clinical Features
• A petechial or maculo papular rash usually
involving the limbs may occur.
• Hemorrhage is rare
• Nasal blotchy erythema, freckle-like
pigmentation over centro-facial area,
• Flagellate pigmentation on face and extremities
• Lichenoid eruption and hyper pigmentation in
exposed areas
www.drsarma.in 51
Rare Clinical Features
Multiple aphthous-like ulcers over
scrotum, crural areas and axilla
Unilateral or bilateral lympoedema of the limbs
Lymphadenopathy not common
Multiple ecchymotic spots in children
Vesiculo-bullous lesions in infants and
Sub-ungual hemorrhages
Severe menigo-encephalitis – rare; may be
fatal
www.drsarma.in 52
Course of Illness
Fever typically lasts for 2 - 3 days and comes down
Fever may reoccur after 3 days – ‘saddle back’ fever
Some rare cases - fever lasts up to a couple of weeks
Patients do have prolonged fatigue for several weeks
High fever & crippling joint pain marked this epidemic
Joint pain, intense headache, insomnia and an extreme
degree of prostration may last for 5 to 7 days
Life long immunity, once one suffers this infection
www.drsarma.in 53
Who are at greater risk ?
• Pregnant women
• Elderly people
• Newborns
• Women in general
• Diabetics
• Immuno-compromised patients
• Patients with severe chronic illnesses
www.drsarma.in 54
CHIKV Morbidity
• Chikungunya is a self-limiting illness
• Causes of prolonged morbidity are
– Severe dehydration
– Electrolyte imbalance and
– Loss of glycemic control
• Recovery is the rule
• In about 3 to 5%
– Incidence of prolonged arthritis
www.drsarma.in 55
Mortality
• A few deaths have been reported - Examples
• It was thought to be due mainly to
– Inappropriate use of antibiotics and NSAIDs
– Virus can cause thrombocytopenia
– These drugs can cause gastric erosions - thus
– Leading to fatal upper GI bleed
– Use of steroids for the joint pains &
inflammation
– This is dangerous and completely unwarranted
www.drsarma.in 56
Outcome
• Acute symptoms: resolved in 7-10 days
• Mortality: rare (elderly)
• Some patients have relapses of rheumatic
symptoms in the months following the acute
illness
• Chronic illness of varying degrees, with pain
persisting for months or years
CHIKV in the Americas57
DIAGNOSIS
Suspect Case
 Characteristic triad of fever, rash and rheumatic
manifestations
Probable Case
 As above with positive serology from single sample
Confirmed Case
 A probable case with any of the following
 Four fold HI antibody difference in paired serum samples.
Detection of IgM antibodies.
 Virus isolation from serum.
 Detection of Chikungunya virus nucleic acid in sera by RT -
PCR
Laboratory
• Transient lymphopenia
• Thrombocytopenia (early and
moderate)
• C-reactive protein elevation
• Elevated liver
transaminases
Risk factors for severe disease
• Infant exposure during birth
• Elderly (>65 y.o.)
• Medical history (e.g., diabetes,
hypertension, or
cardiovascular disease)
WHO case definitions
Algorithm for suspected CHIKV CASE
Epidemiological scenario: First introduction of virus in a specific area 1
This algorithm is intended to be followed by those reference laboratories with established capacity for CHIKV
detection.
Samples should be processed taking into account the number of days after the onset of symptoms. If the sample
was taken between 1 and 8 days after the onset of symptoms, then it will be processed for both RT-PCR and IgM
serology.
Samples should be coming from suspected cases, defined as “A patient with acute onset of fever > 38.5 C (101.3 F)
and severe arthralgia or arthritis not explained by other medical conditions, and who resides or visit epidemic or
endemic areas within two weeks before the onset of the symptoms”.
2
Algorithm Dengue/CHIKV
Pregnancy and CHIKV
65
www.drsarma.in
Pregnancy and CHIKV
• Mother to fetus transmission can occur
• Reported between 3 to 4.5 months of gestation
• Maternal IgG develops in 2 weeks after CHIKV
• This passes through placenta – confers protection
• Intra-partum risk is 48% if mother has viremia
• Neonatal infections are very mild; fully recover
• No miscarriages or congenital malformations
www.drsarma.in 66
Pregnancy - CHIKV
June 2005 to Jan 2006, 84 pregnant women with
CHIKV
In 88% cases the newborns are asymptomatic
10 newborns had severe attacks, 4 meningo-
encephalitis
3 with intravascular coagulations; No infants died
One case of severe intra cerebral hemorrhage
Had severe thrombocytopenia
All confirmed by specific serology or PCR or both
Women had severe intra-partum viremia & feverwww.drsarma.in 67
Differential Diagnosis
• Dengue fever, DHF, DSS
• O’nyong-nyong viral fever
• Sindbis viral fever
• Other non specific viral fevers
• Any other acute fever like malaria, UTI etc.
www.drsarma.in 68
69
MALARIA
DENGUE
FEVER
CHIKUNGUNYA FEVER
Jaundice
Renal failure
Fever
Myalgia
Rash
Bleedings
Retro-orbital pain
Transient arterial
hypotension
Acute polyarthritis
Tenosynovitis
Anemia
LEPTOSPIROSIS
Adapted from Simon et al, Schwartz, Infections in travelers, Ed 2009
BACTERIAL
SEPSIS
Myalgia
Myocarditis
ADRS
Chikungunya outbreak, high risk for misdiagnosis
Dengue and CHIK
• Virus transmitted by the same
mosquitos
• Similar clinical picture
• The viruses can circulate in the same
areas–- co-infection
• Discarding dengue is important, for an
adequate clinical care that improves
the prognosis of dengue
Differential Diagnosis
Feature CHIKV DENGUE
Presentation A+F ± mild rash A+F+Rash
Arthralgia Moderate Severe
Arthritis Not common Frequent
Bone pains None Break bone fever
Thrombocytopenia Mild (Not < 1K) May be severe
Hemorrhage None May be present
Shock syndrome Never May occur
Immunity (IgG) Life long 2nd
attack fatality
www.drsarma.in 71
Table 1: Total number of Febrile cases positive for Dengue per District for 2014
District Confirmed probable clinical Suspected Total
WHO case
definition
% dengue of
febrile cases
% District
febrile cases
Corozal 3 5 7 76 91 15 16.5 11.0
Orange Walk 0 1 0 13 14 1 7.1 1.7
Belize 9 16 22 346 393 47 12.0 47.4
Cayo 8 6 6 142 162 20 12.3 19.5
Stann Creek 6 3 2 87 98 11 11.2 11.8
Toledo 6 0 1 63 70 7 10.0 8.4
Unknown 0 0 0 1 1 0 0.0 0.1
Total 32 31 38 728 829 101 12.2 100.0
Laboratory description of Dengue Test
Test description Rapid test requested Eliza test Requested Total percent
Test requested 644 282 926 100.0
Test Done 622 242 864 93.3
RESULTS IgM positives NS1 positives Total IgM/NS pos
Total positive test 32 40 72 100.0
positivity rate % 5.1 16.5 8.3 91.7 negative
Treatment of CHIKV
74
www.drsarma.in
CHIKUNGUNYA DRUG
France develops a new drug to treat
"We are confident today that a drug to treat
Chikungunya will be made available and we
are hopeful that this drug will be available at
the very end of this year or at the very start
of 2007"
- French Health Minister - Xavier Bertrand
- September 11th
2006
www.drsarma.in 75
Treatment
• There is no specific treatment for CHIKV
• No vaccine or preventive pill is available
• The illness is usually self-limiting
• It will resolve with time over a week to 10
days
• No relapses occur – no second attacks
• Convalescence may take longer
• Symptomatic treatment only
www.drsarma.in 76
Treatment
Rest to the patient and mild movements of joints
Cold compresses to inflamed joints
Liberal fluid intake or IV fluids
Analgesics and NSAIDS
Paraetamol ± Ibuprofen or aceclofenac or
diclofenac
Naproxen sodium (Naprasyn, Xenobid)
Aspirin should be avoided
Hydroxy chloroquine sulphate (HCQS) 200 mg/od
Chloroquine phosphate 250 mg/odwww.drsarma.in 77
What not to give ?
• No indication for antibiotics
• Never use costly, large spectrum drugs
• No indication for long acting steroids
• No indication for short term steroids also
in the acute phase of illness
• Rarely, if the joint swelling persists – we
may consider use of steroids in short
burst.
www.drsarma.in 78
Management of cases
• Rest in bed will help hasten recovery
• Infected persons should be protected
– from further mosquito exposure
– staying indoors and/or under a mosquito net
– during the first few days of illness
– This is to reduce transmission to others
www.drsarma.in 79
The Virus and its Vector
The Criminal and It’s Accomplice
CHIKUNGUNYA

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Chikungunya Presentation by Belize Ministry of Health

  • 1.
  • 2. CHIKUNGUNYA FEVER Objectives • Historical epidemiology of CHIKUNGUNYA • Regional scenario • What is CHKV • Clinical presentation • Vector borne diseases, Differential Diagnosis, Transmission • At risk groups ,Dengue /CHIKV dengue snapshot • Treatment Francis Morey MD.MPH Lorna Perez Surveillance Officer Epi-Unit
  • 3. History (Its story) A viral infection transmitted to humans By the bite of an infected mosquito It has become endemic in south and central India First outbreak in 1952 on the Makonde Plateau Border between Tanganyika and Mozambique First published report is from Africa in 1955 by Marion Robinson and W.H.R. Lumsden Recent large epidemic occurred in Malaysia in 1999 www.drsarma.in 3
  • 4. A disease of Africa and Asia www.drsarma.in 4
  • 5. INTRODUCTION  Caused by an Alpha Virus is a relatively rare form of viral fever ("debilitating non-fatal viral illness."  Spread by bite of Aedes aegypti mosquito which usually bite during day light hours.  the name is derived from Swahili word meaning “that which bends up”  Chikungunya (CHIK) virus first isolated from the serum of a febrile human in Tanzania in 1953.  Chik virus has caused numerous out breaks in Africa and South Eastern Asia, involving hundreds and thousands of people.
  • 6. • Chikungunya is a Makonde word (one of the local languages in Tanzania) meaning ‘that which bends up’. • Describes the posture patient assumes to relieve the severe joint pains • Buggy Creek virus
  • 7. Synonyms • CHIKV Fever • Buggy Creek virus infection • Knuckle fever • Me Tri virus infection • Semliki Forest virus infection www.drsarma.in 7
  • 9. 9 195 4 200 4 200 6 African profile Asian profile Current global profile A226V-CHIKV Humans Peridomestic mosquitoes Ae.aegypti Ae.albopictus  Focal urban outbreaks Wild primates Forest dwelling mosquitoes Ae. furcifer Ae. taylori… Humans  Sporadic cases Focal urban outbreaks Humans Peridomestic mosquitoes Ae. albopictus Ae.aegypti  Massive urban outbreaks Simon F et al. Curr Infect Dis Rep 2011 (in press)
  • 10. Notable Outbreaks 1963 to 1965 - An epidemic was reported in Calcutta – 4.37% of the people were later found to be seropositive 1973 – An epidemic 37.53% in Barsi - Sholapur district 2006 – Present epidemic after 33 years is the largest 9,06,360 or more cases in Andhra Pradesh 5,43,286 cases from Karnataka; 66,109 from B’lore Maharashtra 2,02,114 cases; Gujarat 2,500 cases Tamil Nadu 49,567 cases; Orissa 4,904 cases, Madhya Pradesh 43,784 and Pune 138 cases www.drsarma.in 10
  • 11. Most Recent Epidemics • Epidemic of CHIKV occurred in Malaysia – 1999 • French island of Réunion in the Indian Ocean- 2005 • Epidemic was recorded in Mauritius – 2005 • Madagascar, Mayotte and Seychelles – 2005 • Hong Kong and Malaysia early 2006 • Present indian epidemic is the largest -from Dec ’05 • Maximum # of cases from Andhra Pradesh so far www.drsarma.in 11
  • 12. 12 Chikungunya, 2005-2012, more than three millions cases ? South of France, 09/2010 2 autochtonous cases New Caledonia, 03/2011 33 autochtonous cases Yemen - Saudi Arabia, 2010-11 Hundreds of cases South China, 10/2010 >10 cases Reunion, 2010 120 cases
  • 14. Why is this sudden epidemic ? Analysis of the recent Indian epidemic has suggested that the increased severity of the disease is due to a change in the genetic sequence, altering the virus’ coat protein, which potentially allows it to multiply more easily in mosquito cells*. www.drsarma.in 14 *http//medicine.plosjournals.org
  • 15. Why is this quasi-pandemic ? • Several distinct variants of the virus • A change at position 226 of the E1 coat protein • This A226V mutation caused the virus to more easily invade and multiply in the mosquitoes • Three protein changes in non-structural proteins – nsP1 (T301I), nsP2 (Y642N), and nsP3 (E460 deletion) – This mutant virus - from a neonatal encephalopathy case www.drsarma.in 15
  • 17.
  • 18. CHIKUNGUNYA The MOH/PAHO Belize request your Boarding pass
  • 20. What is this virus ? • Causative agent is an RNA – VIRUS • Class – Arbor Virus (Arthropod Borne) • Family – Togaviridae • Genus – Alpha Virus • Species – Chikungunya Virus • Similar to Semliki Forest Viruses (SFV) in Africa and Asia. www.drsarma.in 20
  • 21. Epidemiological Triangle www.drsarma.in 21 The HostThe Virus The Environment Interaction The Vector
  • 22. Vector Borne diseases • Mosquitoes • Aedes – Dengue fever – Rift Valley fever – Yellow fever – Chikungunya • Anopheles – Malaria • Culex – Japanese encephalitis – Lymphatic filariasis – West Nile fever • Sandflies • Leishmaniasis • Sandfly fever (phelebotomus fever) • Ticks • Crimean-Congo haemorrhagic fever • Lyme disease • Relapsing fever (borreliosis) • Rickettsial diseases (spotted fever and Q fever) • Tick-borne encephalitis • Tularaemia • Triatomine bugs • Chagas disease (American trypanosomiasis) • Tsetse flies • Sleeping sickness (African trypanosomiasis) • Fleas • Plague (transmitted by fleas from rats to humans) • Rickettsiosis • Black flies • Onchocerciasis (river blindness) • Aquatic snails • Schistosomiasis (bilharziasis
  • 23. Arbovirus (arthropod-borne virus) applies to any virus that is transmitted to humans and/or other vertebrates by certain species of blood-feeding arthropods, chiefly insects (flies and mosquitoes) and arachnids (ticks) • Bunyaviridae (comprising the bunyaviruses, phleboviruses, nairoviruses, and hantaviruses) • Flaviviridae (comprising only the flaviviruses) • Reoviridae (comprising the coltiviruses and orbiviruses) • Togaviridae (comprising the alphavirus)
  • 24. Fever, malaise, headaches, myalgias Additional features: none Colorado tick fever Reoviridae (Coltivirus) Ticks Dermacentor sp Western US, western Canada Phlebotomus fever Bunyaviridae (Phlebovirus) Sand flies Phlebotomus sp Mediterranean basin, Balkans, Middle East, Pakistan, India, China, eastern Africa, Panama, Brazil Venezuelan equine encephalitis Togaviridae (Alphavirus) Mosquitoes Culex sp Argentina, Brazil, northern South America, Panama, Mexico, Florida Lymphadenopathy, rash Dengue fever Flaviviridae Mosquitoes Aedes sp Southeast Asia, West Africa, Oceania, Australia, South America, Mexico, Caribbean, US West Nile fever Flaviviridae Mosquitoes Culex sp Africa, Middle East, southern France, Russia, India, Indonesia, US Arthralgia, rash Chikungunya disease Togaviridae (Alphavirus) Mosquitoes Aedes sp Africa, India, Guam, Southeast Asia, New Guinea, limited areas of Europe Mayaro virus Togaviridae (Alphavirus) Mosquitoes Haemogus sp Brazil, Bolivia, Trinidad
  • 25. Hemorrhagic signs‡ Yellow fever Flaviviridae Mosquitoes Aedes spp Central and South America, Africa Dengue hemorrhagic fever Flaviviridae Mosquitoes Aedes sp Southeast Asia, West Africa, Oceania, Caribbean Machupo virus Arenaviridae Rodent Bolivia Junin virus Arenaviridae Rodent Argentina Guanarito virus Arenaviridae Rodent Venezuela
  • 26. Fever and CNS involvement Eastern equine encephalitis Togaviridae (Alphavirus) Mosquitoes Culex sp Atlantic and Gulf coasts of US, Caribbean, upper New York, western Michigan Western equine encephalitis Togaviridae (Alphavirus) Mosquito US, Canada, Central and South America West Nile virus Flaviviridae Mosquitoes Culex sp Africa, Middle East, southern France, former Soviet Union, India, Indonesia, US St. Louis encephalitis Flaviviridae Mosquitoes Culex sp US, Caribbean Venezuelan equine encephalitis Togaviridae (Alphavirus) Mosquitoes Culex sp Argentina, Brazil, northern South America, Panama, Mexico, Florida La Crosse encephalitis Bunyaviridae Mosquitoes Aedes spp. North Central States, New York
  • 27. Transmission Reservoir – Non-human primates in Africa No animal reservoir is found in India Maintained in nature by man – mosquito – man cycle Vector – Aedes aegypti, Ae. albapticus mosquito Same vector as for Dengue and Yellow fevers Vehicle of transmission – None No known mode - other than mosquito bite Incubation Period – 2 days to 12 days www.drsarma.in 27
  • 28. Main mode of transmission: mosquito bite Other modes of transmission • Uncommon – In utero transmission, can cause miscarriage in the 1st trimester – Intra birth transmission, newborn of a viremic mother – Needle prick – Laboratory exposure • Public Health Considerations – Blood transfusion – Organ or tissue transplant – No evidence of the virus in breast milk CHIKV in the Americas28
  • 29.
  • 30. The Vector Aedes aegypti mosquito, flight range < 100 meters Aggressive daytime biter – under lights – bites ankles Once infected – it has the virus until death (30 days) It is a man made mosquito – prefers its owner Breeds in man made household containers Indoor, peridomestic, fresh water mosquito Metallic, plastic, rubber, cement and earthen containers - open, left or unused - get filled with water Air coolers, ACs, Old oil drums, Over head tanks www.drsarma.in 30
  • 31. The Virus and its Vector The Criminal and It’s Accomplice How Do Aedes Mosquitoes Transmit Diseases... Mosquito bites and sucks blood containing the virus from an infected person. Virus is carried in its body. And passes the virus to healthy people when it bites them.
  • 32. Attack Rates • In urban localities it is more – why ? • Usual age group is above 15 years • Less common in children and infants • Family clustering of cases usual • Attack rates vary from 3 to 40% of population • Average attack rate is 10% • Herd immunity restricts further spread www.drsarma.in 32
  • 35. CHIKV Infection a disease of two phases ACUTE PHASE •The majority of persons infected (72% 97%)‒ are symptomatic. •Incubation period: 3–7 days (range of 1 12‒ days). •Main symptoms: acute onset of fever and polyarthralgia.
  • 36. CHIKV Infection a disease of two phases CHRONIC PHASE • Early exacerbations, inflammatory relapses, longstanding rheumatism and loss in quality of life • More common in: – Those over 40 years old – Rheumatic or traumatic history – High viral load Simon F et al. Chikungunya virus infecion. Curr Infect Dis Rep DOI 10.1007/s11908-011-0180-1
  • 37.
  • 38. CLINICAL FEATURES  Acute viral infection of abrupt onset.  sudden onset of fever >38.5 degrees and severe arthralgia( ankle ,wrist, phalanges). Chills, flu like symptoms.  other constitutional symptoms like head ache, back pain, myalgia,photo phobia, retrorbital pain, conjunctival infection and rash. Nausea, vomiting, abd. pain, severe weakness  Incubation period is usually 1 to 12 days, symptoms ( average 4-7days).  Lasting for period of 7 to 10 days.  Rarely can result in meningo – encephalitis, Cardiovascular alt,death in elderly-weak immune system. Chronic phase of severe arthralgia
  • 39. Fever and polyarthralgia • Fever – Acute onset – ≥38.5°C • Joint pain – Sometimes serious and debilitating – Multiple joints – Bilateral and symmetric (usually) – Most commonly in hands and feet http://www.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=16985&Itemid=
  • 40. Other signs and symptoms • Headache • Myalgia • Arthritis • Conjunctivitis • Nausea and vomiting • Maculopapular rash http://wfffun.info/diseases/chikungunya-rash-photos-2/
  • 41. 41 Subacute stage, persisting distal inflamatory arthralgias Simon F et coll. Medicine 2007;86: 123-37
  • 43. 43 Simon F et coll. Medicine 2007;86: 123-37 Subacute stage, bursitis
  • 44. 44 Subacute stage, associated rheumatic disorders
  • 45. 45 Simon et al. Medicine 2007; 86 (3) Peripheral vascular disorders • Erythermalgia • Raynaud’s syndrome – High susceptibilty to the cold – De novo and transient – Commonly bilateral – Associated with mixed cryoglobulinemia
  • 46.
  • 47. The Arthralgia • The small joints of the lower and upper limbs • Migratory poly arthralgia – not much effusions • Larger joints may also be affected (knee, ankle) • Pain worse in the morning – less by evening • Joints may be swollen & painful to the touch • Some patients have incapacitating joint pains • Arthritis may last for weeks or months. www.drsarma.in 47
  • 49. Skin Rash in Dengue CHIKV www.drsarma.in 49
  • 50.
  • 51. Rare Clinical Features • A petechial or maculo papular rash usually involving the limbs may occur. • Hemorrhage is rare • Nasal blotchy erythema, freckle-like pigmentation over centro-facial area, • Flagellate pigmentation on face and extremities • Lichenoid eruption and hyper pigmentation in exposed areas www.drsarma.in 51
  • 52. Rare Clinical Features Multiple aphthous-like ulcers over scrotum, crural areas and axilla Unilateral or bilateral lympoedema of the limbs Lymphadenopathy not common Multiple ecchymotic spots in children Vesiculo-bullous lesions in infants and Sub-ungual hemorrhages Severe menigo-encephalitis – rare; may be fatal www.drsarma.in 52
  • 53. Course of Illness Fever typically lasts for 2 - 3 days and comes down Fever may reoccur after 3 days – ‘saddle back’ fever Some rare cases - fever lasts up to a couple of weeks Patients do have prolonged fatigue for several weeks High fever & crippling joint pain marked this epidemic Joint pain, intense headache, insomnia and an extreme degree of prostration may last for 5 to 7 days Life long immunity, once one suffers this infection www.drsarma.in 53
  • 54. Who are at greater risk ? • Pregnant women • Elderly people • Newborns • Women in general • Diabetics • Immuno-compromised patients • Patients with severe chronic illnesses www.drsarma.in 54
  • 55. CHIKV Morbidity • Chikungunya is a self-limiting illness • Causes of prolonged morbidity are – Severe dehydration – Electrolyte imbalance and – Loss of glycemic control • Recovery is the rule • In about 3 to 5% – Incidence of prolonged arthritis www.drsarma.in 55
  • 56. Mortality • A few deaths have been reported - Examples • It was thought to be due mainly to – Inappropriate use of antibiotics and NSAIDs – Virus can cause thrombocytopenia – These drugs can cause gastric erosions - thus – Leading to fatal upper GI bleed – Use of steroids for the joint pains & inflammation – This is dangerous and completely unwarranted www.drsarma.in 56
  • 57. Outcome • Acute symptoms: resolved in 7-10 days • Mortality: rare (elderly) • Some patients have relapses of rheumatic symptoms in the months following the acute illness • Chronic illness of varying degrees, with pain persisting for months or years CHIKV in the Americas57
  • 58. DIAGNOSIS Suspect Case  Characteristic triad of fever, rash and rheumatic manifestations Probable Case  As above with positive serology from single sample Confirmed Case  A probable case with any of the following  Four fold HI antibody difference in paired serum samples. Detection of IgM antibodies.  Virus isolation from serum.  Detection of Chikungunya virus nucleic acid in sera by RT - PCR
  • 59. Laboratory • Transient lymphopenia • Thrombocytopenia (early and moderate) • C-reactive protein elevation • Elevated liver transaminases Risk factors for severe disease • Infant exposure during birth • Elderly (>65 y.o.) • Medical history (e.g., diabetes, hypertension, or cardiovascular disease)
  • 62. Epidemiological scenario: First introduction of virus in a specific area 1 This algorithm is intended to be followed by those reference laboratories with established capacity for CHIKV detection. Samples should be processed taking into account the number of days after the onset of symptoms. If the sample was taken between 1 and 8 days after the onset of symptoms, then it will be processed for both RT-PCR and IgM serology. Samples should be coming from suspected cases, defined as “A patient with acute onset of fever > 38.5 C (101.3 F) and severe arthralgia or arthritis not explained by other medical conditions, and who resides or visit epidemic or endemic areas within two weeks before the onset of the symptoms”. 2
  • 64.
  • 66. Pregnancy and CHIKV • Mother to fetus transmission can occur • Reported between 3 to 4.5 months of gestation • Maternal IgG develops in 2 weeks after CHIKV • This passes through placenta – confers protection • Intra-partum risk is 48% if mother has viremia • Neonatal infections are very mild; fully recover • No miscarriages or congenital malformations www.drsarma.in 66
  • 67. Pregnancy - CHIKV June 2005 to Jan 2006, 84 pregnant women with CHIKV In 88% cases the newborns are asymptomatic 10 newborns had severe attacks, 4 meningo- encephalitis 3 with intravascular coagulations; No infants died One case of severe intra cerebral hemorrhage Had severe thrombocytopenia All confirmed by specific serology or PCR or both Women had severe intra-partum viremia & feverwww.drsarma.in 67
  • 68. Differential Diagnosis • Dengue fever, DHF, DSS • O’nyong-nyong viral fever • Sindbis viral fever • Other non specific viral fevers • Any other acute fever like malaria, UTI etc. www.drsarma.in 68
  • 69. 69 MALARIA DENGUE FEVER CHIKUNGUNYA FEVER Jaundice Renal failure Fever Myalgia Rash Bleedings Retro-orbital pain Transient arterial hypotension Acute polyarthritis Tenosynovitis Anemia LEPTOSPIROSIS Adapted from Simon et al, Schwartz, Infections in travelers, Ed 2009 BACTERIAL SEPSIS Myalgia Myocarditis ADRS Chikungunya outbreak, high risk for misdiagnosis
  • 70. Dengue and CHIK • Virus transmitted by the same mosquitos • Similar clinical picture • The viruses can circulate in the same areas–- co-infection • Discarding dengue is important, for an adequate clinical care that improves the prognosis of dengue
  • 71. Differential Diagnosis Feature CHIKV DENGUE Presentation A+F ± mild rash A+F+Rash Arthralgia Moderate Severe Arthritis Not common Frequent Bone pains None Break bone fever Thrombocytopenia Mild (Not < 1K) May be severe Hemorrhage None May be present Shock syndrome Never May occur Immunity (IgG) Life long 2nd attack fatality www.drsarma.in 71
  • 72. Table 1: Total number of Febrile cases positive for Dengue per District for 2014 District Confirmed probable clinical Suspected Total WHO case definition % dengue of febrile cases % District febrile cases Corozal 3 5 7 76 91 15 16.5 11.0 Orange Walk 0 1 0 13 14 1 7.1 1.7 Belize 9 16 22 346 393 47 12.0 47.4 Cayo 8 6 6 142 162 20 12.3 19.5 Stann Creek 6 3 2 87 98 11 11.2 11.8 Toledo 6 0 1 63 70 7 10.0 8.4 Unknown 0 0 0 1 1 0 0.0 0.1 Total 32 31 38 728 829 101 12.2 100.0
  • 73. Laboratory description of Dengue Test Test description Rapid test requested Eliza test Requested Total percent Test requested 644 282 926 100.0 Test Done 622 242 864 93.3 RESULTS IgM positives NS1 positives Total IgM/NS pos Total positive test 32 40 72 100.0 positivity rate % 5.1 16.5 8.3 91.7 negative
  • 75. CHIKUNGUNYA DRUG France develops a new drug to treat "We are confident today that a drug to treat Chikungunya will be made available and we are hopeful that this drug will be available at the very end of this year or at the very start of 2007" - French Health Minister - Xavier Bertrand - September 11th 2006 www.drsarma.in 75
  • 76. Treatment • There is no specific treatment for CHIKV • No vaccine or preventive pill is available • The illness is usually self-limiting • It will resolve with time over a week to 10 days • No relapses occur – no second attacks • Convalescence may take longer • Symptomatic treatment only www.drsarma.in 76
  • 77. Treatment Rest to the patient and mild movements of joints Cold compresses to inflamed joints Liberal fluid intake or IV fluids Analgesics and NSAIDS Paraetamol ± Ibuprofen or aceclofenac or diclofenac Naproxen sodium (Naprasyn, Xenobid) Aspirin should be avoided Hydroxy chloroquine sulphate (HCQS) 200 mg/od Chloroquine phosphate 250 mg/odwww.drsarma.in 77
  • 78. What not to give ? • No indication for antibiotics • Never use costly, large spectrum drugs • No indication for long acting steroids • No indication for short term steroids also in the acute phase of illness • Rarely, if the joint swelling persists – we may consider use of steroids in short burst. www.drsarma.in 78
  • 79. Management of cases • Rest in bed will help hasten recovery • Infected persons should be protected – from further mosquito exposure – staying indoors and/or under a mosquito net – during the first few days of illness – This is to reduce transmission to others www.drsarma.in 79
  • 80. The Virus and its Vector The Criminal and It’s Accomplice

Editor's Notes

  1. The most common form of transmission is by mosquito bit, but occasionally, there are other forms of transmission relevant to clinical management and/or to taking preventative measures in public health.
  2. We all know by now that the Aedes mosquito spreads the dengue virus, but how exactly do they do it? Mosquitoes cannot transmit the dengue virus amongst themselves, they need to first bite a person who is already infected with the dengue virus. The infected mosquito will then carry the dengue virus and pass it onto a healthy person when it bites him/her and causing them to fall sick. The cycle then continues with the new victim.
  3. The most characteristic symptoms are onset of acute fever with polyarthralgia/ polyarthritis.
  4. DJI is a small spot in the Eastern Africa. The fame of this country comes from its geographic situation. A crossroad between Africa and Arabic countries, between earth and sea This location induces a highly strategic position. Like Gibraltar, Panama, Suez…
  5. Clinical laboratory data are completely unspecific. The degree of thrombocytopenia is not as severe as in dengue,it is earlier in evolution and is moderate. NOTA: The microbiology laboratory diagnostic (including virus isolation, PCR and serology) are included in another presentation.