Epidemiology of Chikungunya in Bangladesh and review of an article

1. “Chikungunya”
An Emerging Arboviral Threat
1 Group A (Pinnacle)
Upendra Raj Dhakal Arjun Chapai
Fatema Tuz Zohra Fahmida Rashid
Sabrina Sultana Dr Syeda Umme Sadia
Dr. Md. Ferdous Rahman Abdullah Enam
Syed Asif Abdullah

2. Organization of presentation
• Introduction
• Epidemiology
• Causes
• Symptoms
• Risk Factors
• References
• Acknowledgement
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3. Introduction
Name derived from Swahili word meaning “that which
bends up”, referring to stooped posture of Chikvirus
patients/”Hallmark of Chikvirus”
First isolated from serum of febrile human after a
1952-1953 outbreak in Tanzania
Detected in large outbreaks with high attack rates in
Africa, Asia, Indian Ocean Islands, and Italy since
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4. Contd …
Chikungunya (CHIK): Viral, Mosquito-Borne Disease
transmitted to humans
Single-Stranded RNA
Class: Arbovirus, Family: Togaviridae, Gene: Alpha
Virus
Transmitted by: Two mosquito species/Female,
Aggressive Day Time Biters
- Aedes aegypti (Primary Vector)
- Aedes albopictus
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5. Epidemiology
 First reported from Makonde , Tanzania during 1952-53.
 Early outbreaks :
 small outbreaks in Africa.
 Massive outbreaks in Thailand in the late 1950s and early 1960s .
 India from the early 1960s into the 1970s.
 Current epidemic :
 since 2004, involves tropical and sub-tropical areas of Africa, Asia,
Europe and the Americas.
 In Island of Reunion, 272,000 cases were reported among 770,000
population in 2005.
 1.5 million cases were suspected in India in 2006 outbreak.
 In late 2013, local transmission in the Americas was identified in
Caribbean countries and territories.
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6. Contd …
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 total 45 countries have been affected till 2017 .
 Most cases are Identified in Urban region.
Due to:
 Association with age, gender & blood group :
Higher in Rh positive blood group , in adults belonging to the age
group > 30 years and also higher in males as compared to females.
 Population density .
 Migration.
 Vector type, density & infectivity .
 Available breeding places for vectors around human habitations.

7. 7

8. Transmission cycle :
 According to geographical distribution there are 3 viral genotypes :
 West African genotype,
 East Central South African (ECSA) genotype,
 Asian genotype.
 Sylvatic cycle : involving non-human primates and forest-dwelling in
rural areas of Africa.
Human outbreak is be small and dependent on environmental
conditions.
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9. Contd …
 Urban cycle : human-mosquito-human transmission .
It can produce massive outbreaks. (in Asia and other substantial
affecting areas)
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Fig : Sylvatic & Urban transmission cycle.

10. Epidemiology in Bangladesh
• First detected in 2008 (Health and Science Bulletin,
Volume 7, March 2009)
• First outbreak in Rajshahi district (32 affected)
• Second outbreak in Shathiva Upazilla of Pabna in 2009
• Institute of Epidemiology, Disease Control and Research
(IEDCR) noticed the disease in Dhaka in 2011
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11. Contd ….
• Third outbreak in Bangladesh in 2017.
• 2700 cases reported in outbreak of 2017 at
Dhaka.
• 984 cases confirmed by real-time, and
• More than 13,176 clinically confirmed cases
in 17 of 64 districts.
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12. Case definition
• Possible Case: A patient meeting only clinical
criteria
• Probable case: A patient meeting both the clinical
and epidemiological criteria
• Confirmed case: A patient meeting the laboratory
criteria, irrespective of the clinical presentation
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13. Symptoms
Symptoms appear between 4 - 7 days after the patient has been
bitten by the infected mosquito and these include:
• High fever (40°C/ 104°F) (Acute onset)
• Severe Joint pain and/or swelling (ankle, knees, wrists or
phalanges)
• Rash
• Headache ,Muscle pain, back ache
• Nausea
• Fatigue
(Bullet 1 and Bullet 2 are Clinical Criteria as per CDC, 2017)
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14. Contd …
Infrequent Symptoms
•Stomatitis, Oral Ulcers, Exfoliative dermatitis,
Photosensitive, Hyperpigmentation.
Rare in adults but seen in children
•Photophobia, Retro – orbital pain, Vomiting,
Diarrhea, Mental confusion, Signs of
meningeal irritation
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15. 15

16. Epidemiological criteria
•Residing or history of visiting epidemic area
•Reported transmission within 15 days prior to
the onset of symptoms
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17. Laboratory Criteria
• Cell culture
• Presence of viral RNA by real time RT – PCR (within 5 days
of onset of illness)
• Presence of viral specific IgM antibody in single serum
sample collected within 5 to 28 days of onset of Fever.
• Four-fold Rise of IgG antibody in samples collected at
least three weeks apart (1st sample after 7 days)
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18. Risk Factors
• The proximity of mosquito breeding sites to human
habitation.
• Natural and artificial water-filled container
• Hot rainy season.
• Immunocompromised patients.
• Viral mutation.
• Increased air travel, tourism.
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19. Diagnosis
Several methods can be used for diagnosis. such as -
•Enzyme-linked immunosorbent assays (ELISA), may
confirm the presence of IgM and IgG anti-
chikungunya antibodies.
•RT-PCR
Chikungunya is often confused with Dengue fever,
Reactive Arthritis, Serum Sickness Illness, Rickettisial
disease, Rheumatic fever, Malaria, Leptospirosis
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20. Treatment
• There is no specific antiviral drug treatment
for chikungunya.
• Treatment is directed primarily at relieving
the symptoms, including joint pain using anti-
pyretic, optimal analgesics and fluids.
• There is no commercial chikungunya vaccine
till date.
• Drink plenty of water, Cold compression, Mild
exercise
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21. Prevention
• Risk communication to the household members
• Controlling mosquito populations by limiting their habitat,
Insecticides or biological control agents can be used. Eg.
Dry day celebration.
• Minimizing vector – people contact: Using insect
repellents with substances such as DEET, icaridin, PMD or
IR3535, Wearing bite-proof long sleeves and trousers also
offers protection, Securing screens on windows and doors
at house will help to keep mosquitoes out of the house.
• Reporting to the nearest public health authority/ or the
DPMO
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22. Preventive Measures
 No vaccine or medication currently available to prevent infection
 Mosquito Control: Most effective preventative measure. BG Sentinel
trap most effective for surveillance.
 Health Education: Advise high-risk individuals (e.g.
immunocompromised) to avoid travelling to areas with ongoing
outbreaks and infected individuals protect from further mosquito
exposure during the first week of illness.
 Inform travelers going to regions with known virus transmission
about risk of disease
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23. Mosquito Control Prevention
 Seal window/door screens and use air conditioning
 Apply mosquito repellant on exposed skin
 Wear long-sleeved clothing
 Empty standing water from containers, old tires, coolers,
pools, buckets, etc.
 Insecticide treated curtains & clothing
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24. Review of related Literature
Title of research: “Chikungunya: an emerging viral infection with varied
clinical presentations in Bangladesh: Reports of seven cases”
Authors: Muhammad Abdur Rahim and Khwaja Nazim Uddin
Authors Affiliation: Bangladesh Institute of Research and Rehabilitation
in Diabetes, Endocrine and Metabolic Disorders (BIRDEM), Shahbagh,
Dhaka
Printed on: BMC journal on 15 August 2017 Volume 10, issue
410, DOI: 10.1186/s13104-017-2723-5
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25. Methodology
• Case series study with admitted middle aged patients at
Department of Internal Medicine, BIRDEM General
hospital.
• Sample population: 7 (4 male and 3 female)
• Confirmation diagnosis by:
• A positive “Anti – Chikungunya antibody (IgM) ICT” test, or
• A positive “RT – PCR” test
• Limitation: Dengue was excluded in 6 patients.
• Separate register was maintained and lab – findings were
analyzed and interpreted.
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26. Clinical findings
Co – infection with dengue fever was reported, and 6 patients were
excluded and 7 were taken.
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27. Lab Findings27

28. Conclusion
 Chikungunya is a relatively new entity in Bangladesh.
 During the post rainy season, an acute febrile illness
with joint pain should raise suspicion
 In spite of being a self-limiting disease, chikungunya may
have different presentations and a protracted clinical
course-specifically a prolonged period of joint pain
 Typical laboratory findings may not be seen in all
patients
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29. Implications of Review of related
literature
➢Physicians should be aware that exclusion of differential
diagnoses such as dengue fever, zika infection are equally
important to establishing a diagnosis of chikungunya-
dengue-chikungunya co-infections.
➢Intensive public health initiatives including clearing
households and mosquito breeding sites and public
awareness are necessary to break the disease transmission.
➢Small sample size does not implicit the generalization of
study.
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30. Reference
• Rahim, Muhammad & Uddin, Khwaja. (2017).
Chikungunya: An emerging viral infection with varied
clinical presentations in Bangladesh: Reports of seven
cases. BMC Research Notes. 10. 10.1186/s13104-017-
2723-5.
• CDC 2017, National Guideline on Clinical Management
of Chikungunya Fever, Disease Control Unit (CDC),
Directorate of General Health Services, Ministry of
health and Family Welfare, Bangladesh, 15th May, 2017
• Health and Science Bulletin, Volume 7, March 2009
• https://en.wikipedia.org/wiki/Epidemiology_of_chik
ungunya
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31. Questions and Feedback
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