chikungunya indian guidelines

8/10/2019 Chikungunya Indian Guidelines

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Chapter 8 Chikungunya: Indian Guidelines and ProtocolsSection 1

and nongranulomatous anterior uveitis, optic neuritis, retrobulbarneuritis and dendritic lesions. Te visual prognosis was generallygood, with most patients recovering good vision.4 Tere is nosignificant sex predilection and causes illness in almost all age groups.

Laboratory Findings3

No significant pathognomonic hematological finding is seen.Leukopenia with lymphocyte predominance is the usual observation.Trombocytopenia is rare. Erythrocyte sedimentation rate is usuallyelevated. C-reactive protein is increased during the acute phaseand may remain elevated for a few weeks. A small proportion ofpatients have tested positive for rheumatoid factor during and afterCF. Blood samples collected during acute febrile illness can be usedfor viral isolates and polymerase chain reaction (PCR) studies.Immunoglobulin M (IgM) antibodies demonstrable by enzyme-linked immunosorbent assay (ELISA) may appear within 2 weeks. Itmay not be advisable to do the antibody test in the first week. In somepersons, it may take 612 weeks for the IgM antibodies to appear insufficient concentration to be picked up in ELISA.

Sequelae

Persistent arthralgic forms had been described in 1980 in SouthAfrica, where a retrospective study has shown complete resolutionin 87.9%, 3.7% had stiffness and pain in an episodic way, 2.8% hadpersistent stiffness without pain and 5.6% had painful restrictionof joint movements in a persistent manner. Enthesopathy andtendinitis of tendoachilles was observed in up to 53% of those whohad musculoskeletal involvement. Neurological, emotional anddermatologic sequelae are also described.5,6

Case Definition

Although case diagnosis can only be made by laboratory means,chikungunya should be suspected when epidemic occurs with thecharacteristic triad of fever, rash and joint manifestations. o suspect a case, it does not have to be an epidemic situation.If a given case satisfies the case definition for suspect case, i.e.acute onset of fever of greater than or equal to 38.5C associated

with severe arthralgia/arthritis not explained by any other medicalconditions in a patient residing in or visited within 15 days prior tothe onset of symptoms a geographic area where both the vector andthe virus are prevalent, he or she should be labeled as a suspectcase and tested for the presence of viremia [tissue culture orreverse transcription-PCR (R-PCR)] or IgM antibodies or for the4-fold rise in CHIK-specific IgG titer. In an epidemic situation, i.e.

with a history of exposure to the time and place of epidemic, such apatient automatically becomes a probable case and it would not benecessary to confirm the diagnosis in a laboratory to include him orher as one of the cases for reporting as CF. Te Chikungunya case definition here is adapted from thatproposed by European Centre for Disease Prevention and Control(ECDC):7

Clinical criteria: Acute onset of fever greater than 38.5C and severearthralgia/arthritis not explained by other medical conditions

Epidemiological criteria: Residing or having visited epidemicareas, having reported transmission within 15 days prior to theonset of symptoms

Laboratory criteria: At least one of the following tests in the acutephase: Virus isolation Presence of viral RNA by R-PCR Presence of virus-specific IgM antibodies in single serum

sample collected in acute or convalescent stage. Increase in IgG values in samples collected at least 3-week

apart.

On this basis, cases are to be categorized as:

Possible case: A patient meeting 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. It may be noted that during an epidemic, all patients need not besubjected to confirmatory tests as above. An epidemiologic link maybe enough. Clinical management as of now does not differ between aprobable case and a confirmed case.

Clinical Management

Clinical management should be instituted in all suspect cases withoutwaiting for serological or viral confirmation. During an epidemic, itis not imperative that all cases should be subjected for virologic/serologic investigations. It may be stressed that all suspected casesshould be kept under mosquito nets during the febrile period along

with other control measures. All persons in the affected areas shouldbe sensitized about the mosquito control measures to be adoptedin hospital premises and houses. During acute stage of the disease,steroids are not usually indicated because of the adverse effects.

Aspirin is preferably avoided for fear of gastrointestinal and otherside effects like Reyes syndrome.

Clinical management of CF is discussed at two stages:

Acute stage of the illness Sequelae. As CF produces illnesses in an epidemic pattern, large numbersof persons are likely to be affected simultaneously in the family andin the community. It may not be feasible to offer institutionalizedcare to all of them at the same time. Besides, many symptoms willdisappear with good home care. It may also be imperative that earlygraded ambulation and mild exercises might benefit the personsafter the acute phase.

Domiciliary (Home Based)

All cases of fev er cared in their own homes should be advised the

following: Adequate rest in a warm environment; avoid damp surroundings Refrain from exertion Cold compresses may help in reducing joint damage Consume plenty of water with electrolytes (approximately 2 liters of

home available fluids with salt in 24 hours). If possible a measuredurine output of more than a liter in 24 hours should be ensured.

Take paracetamol tablets during periods of fever (up to two500 mg tablets four times daily) in an average sized adult. Ingeneral, childrens dosages are based on a single dose of 10 mgparacetamol per kilogram body weight, which can be repeated46 hourly, not exceeding four doses per 24 hours.

Avoid self-medication with aspirin or other pain killers.

When to Seek Medical Help?

Fever persisting for more than 5 days

Intractable pain Postural dizziness, cold extremities Decreased urine output Any bleeding under the skin or through any orice Incessant vomiting. Te diagnoses of dengue fever, leptospirosis, malaria andother illnesses excluded by history, clinical examination and basicinvestigations should be carried out. Te following points may benoted. Chikungunya fever may not have the typical manifestationsor coexist with other infectious diseases like dengue fever ornoninfectious diseases like rheumatoid arthritis.


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Chapter 8 Chikungunya: Indian Guidelines and ProtocolsSection 1

skin and intertriginous areas may be managed by saline compresses,topical or systemic antibiotics if secondarily infected.

Emotional Problems

Neuropsychiatric/emotional problems have been observed in up to

15% cases. Tese are more likely in persons with premorbid disordersand those with a family history of mood disorders. Tey may takedifferent forms: When all family members are incapacitated with inability to walk

even for their toilet needsimpairment in activities of daily living(ADL); nobody from the relations or neighborhood is free fromthe illness to help them.

Even somebody who tries to oer help may be inhibited by thefears that arise from the panic prevalent at the time of the outbreak.

e families and villages are starved from lack of job, lack ofmaterial supplies and from diversion of funds to clinical care andtransport.

Patients also present with confusion regarding the condition andthis frequently leads to doctor shopping and negative thoughtslike nothing works, nothing is making me feel better . Tis givesrise to feelings of helplessness, hopelessness and fear of beingincapacitated for life. Some patients also have irrational fears(I may die because of this condition). Also often seen is loss ofinterest in pleasurable activities and appetite.

e sorrow and helplessness make persons lose sleep and thistogether with starvation, dehydration, metabolic disturbancesand illness precipitates hidden premorbid mood disorders likedepression to crop up.

Alcohol withdrawal phenomena and eects of prolonged conne-ment may tilt the balance toward delirium or suicidal ideation.

Te emotional and psychosocial issues need individual assess-ment and have to be considered in the social context of the patient and

community. Often patients have inadequate information regardingChikungunya. Te most common being I will die because of thisillness. It is important to clarify these and similar misconceptions.Broadly, psychosocial support and reassurance may solve some ofthe problems. A well thought about plan for community support,

occupational and social rehabilitation may hold the key for achievinga success in the remaining life.

REFERENCES

1. Angelini R, Finarelli AC, Angelini P, et al. (2007). An outbreak ofchikungunya fever in the province of Ravenna, Italy. [online].Eurosurveillance website. Available from http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3260 [Accessed October, 2012].

2. setsarkin KA, Vanlandingham DL, McGee CE, et al. A single mutationin chikungunya virus affects vector specificity and epidemic potential.PLoS Pathog. 2007;3(12):e201.

3. Meta-analysis of presentations from various parts of India in theNational workshop on emerging fevers with focus on Chikungunyaheld in Kochi on December 28, 2007.

4. Mahendradas P, Ranganna SK, Shetty R, et al. Ocular manifestationsassociated with chikungunya. Ophthalmology. 2008;115(2):287-91.

5. Rampal, Sharda M, Meena H. Neurological complications in

Chikungunya fever. J Assoc Physicians India. 2007;55:765-9. 6. Inamadar AC, Palit A, Sampagavi VV, et al. Cutaneous manifestationsof chikungunya fever: observations made during a recent outbreak insouth India. Int J Dermatol. 2008;47(2):154-9.

7. Te ECDC case definition. Available from http://www.enivd.de/VHFDISEASES/fs_chiku_cadef.htm on 02-08-2008.

8. Morrison E, Fraser RJ, Smith PN, et al. Complement contributes toinflammatory tissue destruction in a mouse model of Ross River virus-induced disease. J Virol. 2007;81:5132-43.

9. Ziegler SA, Lu L, da Rosa AP, et al. An animal model for studying thepathogenesis of chikungunya virus infection. Am J rop Med Hyg.2008;79:133-9.

chikungunya indian guidelines

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