assoChikungunya fever (CF) is an arboviral disease in worldwide expansion due to the plasticity of its pathogen and vector. Chikungunya virus (CHIKV), a positive-sense, single-stranded RNA alphavirus, is transmitted by Aedes (Stegomyia) aegypti and Aedes albopictus mosquitoes, two hegemonic anthropophilic day-biting mosquitoes capable of colonizing very different environments. This expert review discusses the molecular epidemiology, pathophysiology, clinical features, diagnosis, management, and prevention of CF during pregnancy, infancy, and childhood. Specifically, it will focus not only on the issue and challenges of perinatal mother-to-child transmission of CHIKV, its pathogenesis, and effects on neurodevelopment, but also on CHIKV-associated central nervous system disease in children, two previously ill-characterized features of the infection.

1. CHIKUNGUNYA IN PREGNANCY
DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S. INDIA

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause
Society, India, Indian medico-legal & ethics association(IMLEA),
ISOPRB, HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN
2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. CHIKUNGUNYA IN PREGNANCY
Introduction
• Chikungunya fever (CF) - an arthropod – borne viral disease
caused by the chikungunya virus (CHIKV single – stranded
RNA virus of genus alphavirus)
• Severe incapacitating arthralgia.
• Transmittion by the bite of female arboreal aedes
(stegomyia) mosquitoes.
• Primary vector - Ae. Aegypti
• Ae.Albopticus

4. Pathophysiology
• The onset of CF coincides with viremia (incubation period 2-12 days with
median duration 5 days).
• CHIKV replicates in the liver, before reaching joint fibroblasts , muscle
satellite , and skin epithelial cells, causing arthralgia , myalgia , and rash
• Attack the joint capsules , skeletal muscles, myotendinous insertions,
and epidermis
• Clinical Presentation
• Acute phase illness – Two stages are identified
• Viral stage – First 5-7 days in which viremia occurs.
• Stage of convalescent – It follows viral stage for approximately next 10
days during which the symptoms improve and virus cannoty detected in
blood

5. Signs and Symptoms
1. Sudden abrupt onset of high fever above 39 C - 40 C (104F)
2. Joint pain – Reported in 87 % - 98 % following fever , usually last for
weeks or months, but may last for years, often result in stiffness and
immobility of affected Joints, in both hands and legs symmetrically.
3. Maculopapular rash – Occurs in 40% - 50% cases occurring 2-5 days
after onset of symptoms. Muscle pain. Headache, and fatigue.
4. Abdominal pain, nausea, vomiting, diarrhea.
5. Eye inflammations – Iridocystitis, uveitis , retinal lesions.
6. Neurological disorders – Guillian – Barre syndrome , palsies , flaccid
paralysis, neuropatho maningoencephalitis.
7. Chikungunya rarely causes hemorrhagic symptoms, if there, may be co
– infections with dengue.

6. Maternal and Fetal Complication
• To date , there is no reliable epidemiological data liking CHIKV exposure in the
first trimester of gestation to an increased risk for miscarriage, nor to any type of
congenital malformation.
• In the second and third trimester few case reports of antepartum fetal deaths
reported. Developing the infection during pregnancy does not usually harm the
mother or the fetus .
• The riks of vertical transmission is very rare. Importantly, CHIKV can be
transmitted vertically with a probability of approximately 50 % when the
parturient woman has viral load during the early stage of labor.
• Fetal heart rate decelerations and meconium – stained amniotic fluid are
common during labor.
• Neither postponing delivery nor cesarean has been shown to be protective.
• Contrary to dengue, there is also no increased risk obstetric hemorrhage
(placental abruption), preterm birth , or low birth weight.

7. Diagnosis
• Chikungunya infection confirmed by the detection of the virus, viral DNA
, or specific antibodies in patients samples - Blood test
• Virological Method
• Serological Methods - RT – PCR Viral RNA can be detected by reverse
transcriptase polymerase chain reaction (RT- PCR) in specimen obtained
from patient.
• CHIKV- specific IgM and IgG can be detected in serum by enzyme – like
immunosorbent assay (ELISA) immunocapture.
• CHIKV – specific IgM are detectable from 3 to 8 days after the onset of
infection (p.o.i) and may persist for several months to up 2 years.
• CHIKV – specific IgG are detectable from 4 to 10 days p.o.i and may
persist for years.

8. Diagnostic Testing Depends on Timing of IIIness Onset
• The molecular assays (Taqman real – time PCR, RT-
LAMP assay , and reverse transcription PCR) are
more sensitive in the early stage of CF (2-5 days
p.o.i) when CHIKV – specific IgM are not yet
detectable.
• In the later stages of CF(>5 days p.o.i)., CHIKV –
specific IgM is more sensitive than PCR.
• Experts recommend that ELISA IgM be used as an
initial screening test.

9. Management
• Treatment - no specific antiviral treatment for CF.
• CF in pregnant women should be treated with antipyretics
and non – aspirin analgesics for symptoms relief. Aspirin may
increase the risk of bleeding .
• Despite anti-inflammatory effect , corticosteroids are not
recommended in acute phase - immunosuppression and
worsen infection.
• Vaccine - Currently no approved vaccine
• Passive immunotherapy involving administration of anti –
CHIKV hyper-immune human intravenous antibodies
(immunoglobulin) may have potential benefits in treatment
of Chikungunya. Studies are currently in progress.

10. BBV87 Chikungunya Vaccine
• Bharat Biotech BBV87 vaccine candidate is an inactivated whole virion vaccine based on a strain derived
from an East, Central, South African (ECSA) genotype.
• BBIL’s BBV87 vaccine has completed standard pre-clinical studies, and an optimum immune response
was elicited by the adjuvanted vaccine in phase 1 clinical trials in India.
• Bharat Biotech creates innovative vaccines and bio-therapeutics trusted by physicians around the world.
BBIL's manufacturing facilities are approved by USFDA, KFDA, and WHO.
• BBV87 Chikungunya Vaccine Indication
• Inactivated virions technology has a safety profile which potentially makes this vaccine accessible to
special populations, such as the immunocompromised and pregnant women, that some other
technologies cannot reach.
• BBV87 Chikungunya Vaccine Dosage
• A 2-dose live-inactivated vaccine (BBV87) against Chikungunyais being tested.
• June 3, 2020 - The Coalition for Epidemic Preparedness Innovations (CEPI) announced a new partnering
agreement to advance the development of a Chikungunya vaccine. The CEPI will provide the consortium
with up to US $14.1 million for vaccine manufacturing and clinical development of a 2-dose live-
inactivated vaccine (BBV87) against Chikungunya.
• June 2, 2020 - Oslo, Norway; Seoul, South Korea; Telangana, India—CEPI, in collaboration with Ind-CEPI,
has announced a new partnering agreement with a consortium comprising Bharat Biotech (BBIL) and the
International Vaccine Institute (IVI) to advance the development of a Chikungunya vaccine.

11. Prevention and Control
• Community mobilization for eradication of breeding sites of
Ae. Mosquitoes, which primarily dwell in natural and
artificial water – filled habitats.
• During epidemics , peri – domestic spraying of insecticides
by residents and space spraying by vector controls teams
• Appropriate clothing may minimize skin exposure.
• Insect repellents can be applied on exposed skin or clothings
according to product label instructions.
• In addition insecticide – treated nets are important for
pregnant women who take day time naps.

12. Management of Newborn
• Neonates who are prenatally infected with CHIKV are born with low or even
undetectable viremia.
• On an average, it take 4 – 5 days (range ; 3-7 days) for the viral load of CHIKN
transmitted at birth to reach a level signification enough to cause clinical disease.
• Neonatal CHIKV infection - fever pain , and sucking difficulties often requiring
parenteral nutrition, limb edema, petechiae , and a skin rash such as
maculopapular rash and intertriginous aphthous – like ulcers.
• Thrombocytopenia , lymphopenia , and mild – to – moderate increases of serum
aspartate aminotransferase (AST or SGOT)
• Life – threatening complications occur in half of the neonates and display two
main clinical picture: 1. CHIKV – associated CNX disease (formerly reported as
encephalopathy) that in fact consists of an encephalitis and
2. A multiple organ dysfunction (MOD)syndrome that
combines a circulatory collapse (hypovolemic and hyperkinetic profile on
echocardiography), lethargy , hemorrhages, (disseminated intravascular
coagulation), uremia , and cytolysis

13. • Pregnant women, there is no specific treatment for cf.
• Management is symptomatic
• Adequate hydration,
• Antipyretics , and
• Analgesics (paracetamol/ acetaminophen) .
• Experts recommend withholding salicylates , steroidal , and
nsaids , as they may facilitate bleeding manifestations.
• At pediatric ages, neonates and small infants below 6
months of age have the highest risk for case fatality and
lifelong disabilities.

14. Management of Exposed Cases (Pregnant Women and Partner)
• It is vector – born viral disease. There is no direct increased
risk to pregnant women’s partner.
• Conclusion
• Dengue and CF is a tropical arthropod – borne virus
infections whose geographical distribution has grown
steadily over the last decade as a result of global warming
and globalization of transports. Dengue and CHIKV can also
be transmitted vertically from mother – to – child during the
perinatal period when the parturient women is highly
viremic during labor.