CHIKUNGUNYA FEVERDr. R.V.S.N.Sarma., M.D., M.Sc., (Canada)Consultant Physician and Chest Specialistwww.drsarma.inUpdated until 23rd September 2006

What is this tongue twister ?It is CHIKUNGUNYATo be pronounced as [chick-en-GUN-yah]It is not written as CHICKEN GUINEANothing to do with chicken or mutton eatingDerived from the Makonde verb - Kun gunyalaIn Swahili it means to become contorted or More specifically as that which bends upRefers to the stooped posture of the patient

SynonymsCHIKV FeverBuggy Creek virus infectionKnuckle feverMe Tri virus infectionSemliki Forest virus infection

Blessed are we !!This is not a Dengue epidemic !This is not the SARS which stole all the show !!This is not Bird-Flu hitting Indian economy !!!This is not the Plague epidemic which threatened to sweep our country !!!!Above all - it is not like HIV or Hepatitis B !!!!!This is a self limiting, non fatal viral illness Thanks to the Almighty

Should we be panicky ?A common viral feverSelf limiting non fatal illnessFever, myalgia, arthralgia, lasting 2 - 7 daysShould give big name for it and be panicky ?Should create such media hype and chaos ?Above all, should we politicize to this extent?

CLINICAL EPIDEMIOLOGYwww.drsarma.in

A disease of Africa and Asia

Asian Distribution

Epidemiological TriangleThe HostThe VirusThe EnvironmentInteractionThe Vector

History (Its story)A viral infection transmitted to humansBy the bite of an infected mosquitoIt has become endemic in south and central IndiaFirst outbreak in 1952 on the Makonde PlateauBorder between Tanganyika and MozambiqueFirst published report is from Africa in 1955 by Marion Robinson and W.H.R. LumsdenRecent large epidemic occurred in Malaysis in 1999

The CHIK Virus www.drsarma.in

What is this virus ?Causative agent is an RNA VIRUSClass Arbor Virus (Arthropod Borne) Family Togaviridae Genus Alpha VirusSpecies Chikungunya VirusSimilar to Semliki Forest Viruses (SFV) in Africa and Asia.

Chikungunya Virus - EM

TransmissionReservoir Non-human primates in AfricaNo animal reservoir is found in IndiaMaintained in nature by man mosquito man cycleVector Aedes aegypti, Ae. albapticus mosquitoSame vector as for Dengue and Yellow feversVehicle of transmission NoneNo known mode - other than mosquito biteIncubation Period 2 days to 12 days

The Vector www.drsarma.in

The VectorAedes aegypti mosquito, flight range < 100 metersAggressive daytime biter under lights bites anklesOnce infected it has the virus until death (30 days)It is a man made mosquito prefers its ownerBreeds in man made household containersIndoor, peridomestic, fresh water mosquitoMetallic, plastic, rubber, cement and earthen containers - open, left or unused - get filled with waterAir coolers, ACs, Old oil drums, Over head tanks

Aedes aegypti

Aedes albaptycusTiger Mosquito

Madam Aedes - at her Lunch

Water tap A disease trap

Open Overhead Tanks

Domestic Water Collections

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

The Recent Epidemicswww.drsarma.in

Notable Outbreaks1963 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 largest9,06,360 or more cases in Andhra Pradesh5,43,286 cases from Karnataka; 66,109 from BloreMaharashtra 2,02,114 cases; Gujarat 2,500 casesTamil Nadu 49,567 cases; Orissa 4,904 cases, Madhya Pradesh 43,784 and Pune 138 cases

Distribution in IndiaThe disease is common with periodic epidemics Sporadic outbreaks described in Madras and VelloreCases were reported in Chennai, Pondicherry, Vellore Vizag in 1964; Rajahmundri, Kakinada, Nagpur in 1965 The last epidemic in India was in 1973From Yavat village (Pune) in 20002.9% in the Andaman & Nicobar Islands are seropositiveInfected mosquitoes seen in Pune, Maharastra State

Most Recent EpidemicsEpidemic of CHIKV occurred in Malaysia 1999French island of Runion in the Indian Ocean- 2005 Epidemic was recorded in Mauritius 2005Madagascar, Mayotte and Seychelles 2005Hong Kong and Malaysia early 2006Present indian epidemic is the largest -from Dec 05Maximum # of cases from Andhra Pradesh so far

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

Attack RatesIn urban localities it is more why ?Usual age group is above 15 yearsLess common in children and infantsFamily clustering of cases usualAttack rates vary from 3 to 40% of populationAverage attack rate is 10%Herd immunity restricts further spread

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*. *http//medicine.plosjournals.org

Why is this quasi-pandemic ?Several distinct variants of the virus A change at position 226 of the E1 coat proteinThis A226V mutation caused the virus to more easily invade and multiply in the mosquitoesThree protein changes in non-structural proteinsnsP1 (T301I), nsP2 (Y642N), and nsP3 (E460 deletion) This mutant virus - from a neonatal encephalopathy case

Clinical Featureswww.drsarma.in

SymptomsSudden onset of fever, chills Headache, nausea, vomiting, abdominal painJoint 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

Clinical FeaturesIncubation period is 2-12 d; usually 3-7 daysViremia last for 5 days (infective period)Silent CHIKV inapparent infections in childrenFlu-like symptoms, Severe headache and chills High grade fever (40C or 104F), Arthralgia or arthritis lasting several weeksConjunctival suffusion and mild photophobiaNausea, vomiting, abd. pain, severe weakness

The ArthralgiaThe small joints of the lower and upper limbsMigratory poly arthralgia not much effusionsLarger joints may also be affected (knee, ankle)Pain worse in the morning less by eveningJoints may be swollen & painful to the touchSome patients have incapacitating joint painsArthritis may last for weeks or months.

Kun gunyalaThe Contorted Posture

Acute CHIKV Fever

Skin Rash in Dengue

Skin Rash in CHIKV

Petechiae on feet

The Burden of CHIKV

Rare Clinical FeaturesA 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 extremitiesLichenoid eruption and hyper pigmentation in exposed areas

Rare Clinical FeaturesMultiple aphthous-like ulcers over scrotum, crural areas and axilla Unilateral or bilateral lympoedema of the limbsLymphadenopathy not commonMultiple ecchymotic spots in children Vesiculo-bullous lesions in infants and Sub-ungual hemorrhagesSevere menigo-encephalitis rare; may be fatal

Course of IllnessFever typically lasts for 2 - 3 days and comes downFever may reoccur after 3 days saddle back feverSome rare cases - fever lasts up to a couple of weeksPatients do have prolonged fatigue for several weeks High fever & crippling joint pain marked this epidemicJoint pain, intense headache, insomnia and an extreme degree of prostration may last for 5 to 7 daysLife long immunity, once one suffers this infection

Who are at greater risk ?Pregnant womenElderly peopleNewbornsWomen in generalDiabeticsImmuno-compromised patientsPatients with severe chronic illnesses

CHIKV Morbidity Chikungunya is a self-limiting illness Causes of prolonged morbidity are Severe dehydration Electrolyte imbalance and Loss of glycemic controlRecovery is the rule In about 3 to 5% Incidence of prolonged arthritis

MortalityA few deaths have been reported - ExamplesIt 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 & inflammationThis is dangerous and completely unwarranted

Pregnancy and CHIKVwww.drsarma.in

Pregnancy and CHIKVMother to fetus transmission can occurReported between 3 to 4.5 months of gestationMaternal IgG develops in 2 weeks after CHIKVThis passes through placenta confers protectionIntra-partum risk is 48% if mother has viremiaNeonatal infections are very mild; fully recoverNo miscarriages or congenital malformations

Vertical TransmissionVertical 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.

Pregnancy - CHIKVJune 2005 to Jan 2006, 84 pregnant women with CHIKV In 88% cases the newborns are asymptomatic10 newborns had severe attacks, 4 meningo-encephalitis3 with intravascular coagulations; No infants diedOne case of severe intra cerebral hemorrhage Had severe thrombocytopenia All confirmed by specific serology or PCR or bothWomen had severe intra-partum viremia & fever

Differential DiagnosisDengue fever, DHF, DSSOnyong-nyong viral feverSindbis viral feverOther non specific viral feversAny other acute fever like malaria, UTI etc.

Differential Diagnosis

Laboratory Diagnosiswww.drsarma.in

Laboratory DiagnosisFour fold or more rise of HI AntibodyIgM capture ELISA using MAbsIndirect Immuno Flourescence Test (I IFT)On infected cells from tissuesVirus Isolation Infant Swiss Albino miceVero BHK-21 cell lines are usedNucleic acid amplification by PCR & RT PCR

Laboratory DiagnosisIgM capture ELISA Good serological testNot commercially availableNIV Pune, NICD Delhi onlyPositive after 5-10 days & lasts up to 6 monthsHI Antibody appears on day 3 or 4RT PCR confirmatory before the 5th day

Value of RT -PCRReal Time PCR scores over conventional PCRPositive in the phase of viremia up to 5 daysTransportation of sample to be at 2o to 8o cIt is a confirmatory test with high specificityIts sensitivity is very high; detects even 1 copyAfter the viremia ceases it will be negativeWe do not have the HI Ab or Ig M capture

Treatment of CHIKVwww.drsarma.in

TreatmentThere is no specific treatment for CHIKVNo vaccine or preventive pill is available The illness is usually self-limitingIt will resolve with time over a week to 10 daysNo relapses occur no second attacks Convalescence may take longerSymptomatic treatment only

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 BertrandSeptember 11th 2006

TreatmentRest to the patient and mild movements of jointsCold compresses to inflamed jointsLiberal fluid intake or IV fluidsAnalgesics and NSAIDSParaetamol Ibuprofen or aceclofenac or diclofenac Naproxen sodium (Naprasyn, Xenobid)Aspirin should be avoidedHydroxy chloroquine sulphate (HCQS) 200 mg/odChloroquine phosphate 250 mg/od

What not to give ?No indication for antibioticsNever use costly, large spectrum drugsNo indication for long acting steroidsNo indication for short term steroids also in the acute phase of illnessRarely, if the joint swelling persists we may consider use of steroids in short burst.

A Y U S HAAyurvedic or AcupunctureYYoga and or NaturopathyUUnaaniSSiddhaHHomeopathyNo comments on these alternative medicinesIf no pathy works, finally Venkatapathy or Tirupathy

Management of casesRest in bed will help hasten recoveryInfected persons should be protected from further mosquito exposure staying indoors and/or under a mosquito netduring the first few days of illnessThis is to reduce transmission to others

Pregnancy and Lactationwww.drsarma.in

NSAIDs in PregnancyUsing NSAIDs during early or late stages of pregnancy is not associated with congenital anomalies, prematurity, or low birth weight, butThere 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.

Lactating WomenQ. 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.Answered on 28 August 2006 by Dr. Pradeep Seth Professor of Virology and Head, Department of Microbiology

Prevention of Mosquito bitewww.drsarma.in

Avoid Mosquito Menace

Prevention from mosquito bitesUse 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 weeklyDrill holes in tire swings so water drains outKeep children's wading pools empty

Perfect Protection

Vector Control MeasuresCover all tanks, cisterns, barrels, containersRemove old tyres, tins, buckets and bottlesClogged gutters and drains need to be clearedChange water in dip trays, plant pots twice weekTanks need to be covered and cleaned - 2 weeksWeeds and tall grass to be cut short hidingTemephos 1 ppm for large water tanks

Correct leaking taps

Cover overhead tanks

Domestic Water Collections

Properly close the garbage bins

Peri domestic fumigation

Out door fumigation

Mosquito Magnet

IEC ActivitiesAwareness of CHIKVMass media, TV, Radio, News papersAwareness of vector and its controlInvolvement of NGOsSpecial campaignsPunishment for non-compliance