Chikungunya fever is caused by the Chikungunya virus (CHIKV), which is spread by mosquito bites from the Aedes aegypti mosquito. The disease causes symptoms of high fever and severe joint pain. The recent epidemic in India from 2005-2006 affected over 1 million people across 16 states. Pregnant women and newborns are at higher risk of complications from the disease. While symptoms are usually self-limiting, joint pain from the virus can persist for months or years in some cases.

1. SANDEEP SINGH JADON
G.R. MEDICAL COLLEGE
GWALIOR
1
CHIKUNGUNYA FEVER
Updated until January 2017

2. 2
Chikungunya is a relatively rare form of viral fever
("debilitating non-fatal viral illness." )
caused by an alphavirus that is spread by mosquito bites
from the Aedes aegypti mosquito.
CHIKV Fever
Buggy Creek virus infection
Knuckle fever
Me Tri virus infection
Semliki Forest virus infection
Synonyms

3. A disease of Africa and Asia
3

4. Asian Distribution
4

5. www.drsarma.in
5
•2005-2006 Re-emergence in India after 32 years
1.39 million cases in 16 states.
•During 2015; 24,997 cases were reported by
government of India.

6. First reported in India in 1963 — had returned after a three-
decade dormancy and 121 districts across seven States were
affected by it with a total of 9,74,541 suspected cases. Of the
10,611 samples sent to laboratories, 992 tested positive.
In 2006, there was a big outbreak in the Andhra Pradesh state in
India.
In Bangalore, the state capital of Karnataka (India), there seems
to be an outbreak of CHIK now (May 2006)
 In the 3rd week of May 2006 the outbreak of Chikungunya in
North Karnataka is severe.
A separate outbreak of chikungunya fever was reported from
Malegaon town in Nasik district, Maharashtra state,
In Orissa state, amost 5000 cases of fever with muscle achesand
headache were reported between February 27 and March 5, 2006.

7. CHIKV and Travelers
1995-2009: 109 lab-confirmed cases in US
 Adult travelers, mean age 48 yrs
 57% female
Gibney et al. CID 2011; 0:1-6

8. Travelers from Indian Ocean Islands, 1997-2010
Savini et al., EID 2013; 19

9. Epidemiological Triangle
9
The HostThe Virus
The Environment
Interaction
The Vector

10. History (Its story)
10
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 Malaysis in 1999

11. What is this virus ?
11
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.

12. Chikungunya Virus (CHIKV): Alphavirus
“That which bends up”
in Swahili
Togaviridae family
Single strand RNA virus,
mosquito-transmitted
New World: Fever, rash,
encephalitis
 Western equine
encephalitis
 Eastern Equine
encephalitis
Old World: Fever, rash,
arthralgias
 Chikungunya
 Ross River Virus (Oceana)
 Barmah Forest Virus
(AUS)
 O’nyong-nyong (Africa)
 Semliki Forest Virus
(Africa)
 Mayoro (South America)
 Sindbis virus (AUS, Africa,
Europe, Asia minor)
www.cdc.gov/ncidod/dvbid/arbor/alphavir.htm

13. Chikungunya Virus - EM
13

14. Transmission
14
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

15. 15
The Vector

16. The Vector
16
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

17. Aedes aegypti
17

18. Aedes albaptycus
18
Tiger Mosquito

19. Madam Aedes - at her Lunch……
19

21. Transmission: Aedes mosquito
Aedes aegypti
 Urban mosquito
 Needs standing water for larvae
 Prefers cool, dark areas for resting
 Feeds through the day, most active at dawn/dusk
 Eggs do not survive winter in temperate climates
Aedes albopictus: Asian Tiger Mosquito
 Urban, periurban, rural habitats
 Feeds through the day, most active dawn/afternoon
 Eggs survive winter in temperate climates
 Invasive- spreading in Europe and Americas
www.cdc.gov

22. Water tap – A disease trap
22

23. Open Overhead Tanks
23

24. Domestic Water Collections
24

25. Why only Aedes Mosquito ?
Scanning Electron Micro-graph
of the mid gut cells of the
mosquito
Location of the Chik Virus
binding proteins.
Not transmitted to the progeny
of the mosquito
25

26. 26
The Recent Epidemics

27. Notable Outbreaks
27
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

28. Distribution in India
28
The disease is common with periodic epidemics
Sporadic outbreaks described in Madras and Vellore
Cases were reported in Chennai, Pondicherry, Vellore
Vizag in 1964; Rajahmundri, Kakinada, Nagpur in 1965
The last epidemic in India was in 1973
From Yavat village (Pune) in 2000
2.9% in the Andaman & Nicobar Islands are seropositive
Infected mosquitoes seen in Pune, Maharastra State

29. Most Recent Epidemics
29
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

30. The Indian Epidemic
30
Present epidemic has started in Nov 2005
Andhra Pradesh, Karnataka, Maharashtra, Madhya Pradesh,
Orissa, Gujarat, Tamilnadu, Rajasthan, Kerala are under its
onslaught
This is spreading far and wide at a rapid rate
Not much spread to the northern states like Delhi, Haryana,
Punjab as yet.
Not much cry from U.P. and Bihar

31. Attack Rates
31
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

32. Why is this sudden epidemic ?
32
 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*.

33. Why is this quasi-pandemic ?
33
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

34. 34
Clinical Features

35. Symptoms
35
Sudden onset of fever, chills
Headache, nausea, vomiting, abdominal pain
Joint pain with or without swelling,
Low back pain and rash
Very similar to those of Dengue but
Unlike in Dengue, no hemorrhagic or shock syndrome

36. Clinical features: Day 1, 7, 25
Thiberville,SDetal.PLOSNegTropDis.2013

37. Clinical Features
37
Incubation period is 2-12 d; usually 3-7 days
Viremia last for 5 days (infective period)
Silent CHIKV – inapparent infections in children
Flu-like symptoms, Severe headache and chills
High grade fever (40°C or 104°F),
Arthralgia or arthritis – lasting several weeks
Conjunctival suffusion and mild photophobia
Nausea, vomiting, abd. pain, severe weakness

38. The Arthralgia
38
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.

39. Kun gunyala
39
The Contorted Posture

40. Acute CHIKV Fever
40

41. Skin Rash in Dengue
41

42. CLINICAL
SIGNS
CHIKUNGUNYA DENGUE
Fever Common Common
Rash Day 1 – Day 4 Day 5 – Day 7
Retroorbital pain Rare Common
Arthralgia Constant Rare
Arthritis Common, edematous Absent
Myalgia Common Common
Tenosynovitis Common Absent
Hypotension Possible Common, Day 5 – Day 7
Minor bleeding Rare Common, Day 5 – Day 7
Outcome Possible Raynaud syndrome,Month2-
Month3
Possible Tenosynovitis,Month2-
Month3.
Common persistence of arthralgia for
months to years.
Possible fatigue for
weeks
Thrombocytopenia Early and mild Delayed and possible
deep.

43. Skin Rash in CHIKV
43

44. Petechiae on feet
44

45. The Burden of CHIKV
45

46. Rare Clinical Features
46
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

47. Rare Clinical Features
47
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

48. Course of Illness
48
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

49. Who are at greater risk ?
49
Pregnant women
Elderly people
Newborns
Women in general
Diabetics
Immuno-compromised patients
Patients with severe chronic illnesses

50. CHIKV Morbidity
50
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

51. Mortality
51
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

52. 52
Pregnancy and CHIKV

53. Pregnancy and CHIKV
53
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

54. Vertical Transmission
54
Vertical maternal-fetal transmission of the
Chikungunya virus. Ten cases in newborns among
84 pregnant women
Robillard PY, Boumahni B, Gerardin P, Michault A,
Fourmaintraux A, Schuffenecker I, Carbonnier M,
Djemili S, Choker G, Roge-Wolter M, Barau G.
Pub Med. 2006 May; 35(5 Pt 1):785-8.

55. Pregnancy - CHIKV
55
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 & fever

56. Differential Diagnosis
56
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.

57. Differential Diagnosis
57
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

58. 58
Laboratory Diagnosis

59. Laboratory Diagnosis
59
1. Four fold or more rise of HI Antibody
2. IgM capture ELISA using MAbs
3. Indirect Immuno Flourescence Test (I IFT)
 On infected cells from tissues
1. Virus Isolation – Infant Swiss Albino mice
 Vero BHK-21 cell lines are used
1. Nucleic acid amplification by PCR & RT PCR

60. Laboratory Diagnosis
60
IgM capture ELISA – Good serological test
Not commercially available
NIV – Pune, NICD – Delhi only
Positive after 5-10 days & lasts up to 6 months
HI Antibody appears on day 3 or 4
RT –PCR confirmatory – before the 5th
day

61. Value of RT -PCR
61
Real Time PCR scores over conventional PCR
Positive in the phase of viremia – up to 5 days
Transportation of sample to be at 2o
to 8o
c
It is a confirmatory test with high specificity
Its sensitivity is very high; detects even 1 copy
After the viremia ceases – it will be negative
We do not have the HI Ab or Ig M capture

62. 62
Treatment of CHIKV

63. Treatment
63
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

64. CHIKUNGUNYA DRUG
France develops a new drug to treat
64
"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

65. Treatment
65
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/od

66. What not to give ?
66
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.

67. A Y U S H
67
A Ayurvedic or Acupuncture
Y Yoga and or Naturopathy
U Unaani
S Siddha
H Homeopathy
No comments on these alternative medicines
If no pathy works, finally
Venkatapathy or Tirupathy

68. Management of cases
68
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

69. 69
Pregnancy and Lactation

70. NSAIDs in Pregnancy
70
Using NSAIDs during early or late stages of pregnancy is
not associated with congenital anomalies, prematurity, or
low birth weight, but
There is a significant link between NSAID use and
miscarriage in the first trimester.
In third trimester may cause premature delivery
Recommend stopping NSAIDS 6 to 8 weeks before delivery
to prevent premature closure of fetal ductus arteriosus.

71. Lactating Women
71
Q. Can a woman suffering from early signs of
Chikungunya breast feed her month old baby?
A. It is better if you do not. During very early stages fever
there is viremia. And some of the virus may be present
in the breast milk. As in newborns the immune system
is not mature particularly monocyte-macrophages
system, these cells may not be able to take care of the
ingested virus absorbed through mucous membranes.

72. 72
Prevention of Mosquito bite

73. Avoid Mosquito Menace
73

74. Prevention from mosquito bites
74
Use insect repellent such as DEET on exposed skin.
Wear long sleeves & pants, treat clothes with permethrin
Have secure screens on windows and doors
Get rid of mosquito breeding sites by
 Emptying standing water from flower pots, buckets etc.,
 Change the water in pet dishes in bird baths weekly
 Drill holes in tire swings so water drains out
 Keep children's wading pools empty

75. Perfect Protection
75

76. Vector Control Measures
76
Cover all tanks, cisterns, barrels, containers
Remove old tyres, tins, buckets and bottles
Clogged gutters and drains need to be cleared
Change water in dip trays, plant pots twice week
Tanks need to be covered and cleaned - 2 weeks
Weeds and tall grass to be cut short – hiding↓
Temephos 1 ppm for large water tanks

77. 77

78. Correct leaking taps & mosquito net
78

79. Cover overhead tanks
79

80. Domestic Water Collections
80

81. Properly close the garbage bins
81

82. Peri domestic fumigation
82

83. Out door fumigation
83

84. Mosquito Magnet
84

85. IEC Activities
85
Awareness of CHIKV
Mass media, TV, Radio, News papers
Awareness of vector and its control
Involvement of NGOs
Special campaigns
Punishment for non-compliance