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SANDEEP SINGH JADON
G.R. MEDICAL COLLEGE
GWALIOR
1
CHIKUNGUNYA FEVER
Updated until January 2017
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
A disease of Africa and Asia
3
Asian Distribution
4
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.
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.
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
Travelers from Indian Ocean Islands, 1997-2010
Savini et al., EID 2013; 19
Epidemiological Triangle
9
The HostThe Virus
The Environment
Interaction
The Vector
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
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.
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
Chikungunya Virus - EM
13
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
The Vector
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
Aedes aegypti
17
Aedes albaptycus
18
Tiger Mosquito
Madam Aedes - at her Lunch……
19
Chikungunya 2017 india
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
Water tap – A disease trap
22
Open Overhead Tanks
23
Domestic Water Collections
24
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
The Recent Epidemics
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
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
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
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
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
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*.
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
Clinical Features
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
Clinical features: Day 1, 7, 25
Thiberville,SDetal.PLOSNegTropDis.2013
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
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.
Kun gunyala
39
The Contorted Posture
Acute CHIKV Fever
40
Skin Rash in Dengue
41
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.
Skin Rash in CHIKV
43
Petechiae on feet
44
The Burden of CHIKV
45
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
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
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
Who are at greater risk ?
49
Pregnant women
Elderly people
Newborns
Women in general
Diabetics
Immuno-compromised patients
Patients with severe chronic illnesses
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
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
Pregnancy and CHIKV
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
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.
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
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.
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
Laboratory Diagnosis
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
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
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
Treatment of CHIKV
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
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
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
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.
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
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
Pregnancy and Lactation
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.
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
Prevention of Mosquito bite
Avoid Mosquito Menace
73
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
Perfect Protection
75
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
Correct leaking taps & mosquito net
78
Cover overhead tanks
79
Domestic Water Collections
80
Properly close the garbage bins
81
Peri domestic fumigation
82
Out door fumigation
83
Mosquito Magnet
84
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

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Chikungunya 2017 india

  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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.
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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.
  • 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
  • 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
  • 81. Properly close the garbage bins 81
  • 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

Notas del editor

  1. Cdc data plus 2 commercial labs performing chik serologies Recent Italy data: 42% imported cases from Indian ocean Islands 42% Asia
  2. GeoSentinal Surveillance Network 1415 ill travelers
  3. Also, Fort Morgan Virus -- affects birds only
  4. Also transmit Dengue, Yellow fever
  5. 54 outpatient adults on Reunion Island during 2006 outbreak
  6. Main clinical and biological differences between chikungunya and dengue fever