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OTLI SAÚDE AVANÇADO 2016.

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FINAL EVALUATION
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Co-infections with chikungunya and dengue viruses: A
serological study in Karnataka State, India
Reference: Shaikh N, Raut C G, Manjunatha M. Co-infections with chikungunya and dengue
viruses: A serological study in Karnataka State, India. Indian J Med Microbiol 2015;33:459-60.

Dear Editor,

Diseases due to arboviruses are one of the major public health problems worldwide. Out of
many arboviruses, chikungunya virus (CHIKV) and dengue virus (DENV) are the two most rapidly
spreading and medical health important. Both the diseases have some common signs and
symptoms, which include fever with chills, swelling of major and minor joint with pain, difficult to
move limbs, nausea, headache, vomiting, and sometimes appearance of rashes. To date, both
CHIK and DENV are co-circulating in India and Southeast Asia. Co-circulation of CHIKV and DENV
is not uncommon in Southeast Asia. In India, concurrent isolation of CHIKV and DENV had been
reported since 1964 from different states.
The aim of our study was to compare the clinical feature of CHIK, DENV and co-infection cases
and the detection of IgM-antibodies-in infected patients in Karnataka state. The samples were
submitted by the district health authority and by the clinicians of different hospitals, or were
obtained from the admitted cases. The patients presented with typical symptoms of CHIK and
DEN infection, such as high fever (>39°C) with chills, rashes, joint pain, swelling of joints,
nausea/vomiting, headache, myalgia, and retro-orbital pain. Severe arthralgia and swelling of
joints were common only in CHIKV-positive cases, while abdominal pain was mainly associated
with DENV infection. As compared to other symptoms, diarrhoea was reported only in the dual
infected patients. All the samples were subjected to Enzyme Linked Immunosorbent assay
(ELISA) test to detect the presence of immunoglobulin M (IgM) antibodies against both CHIKV
and DENV.
A total of 6,554 blood samples was collected from different government hospitals, private
institutes, as well as from admitted cases. All of them were clinically suspected cases of

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UFSB - OTLI SAÚDE AVANÇADO 2016.2 - FINAL EVALUATION
DENV/CHIKV and were in the acute phase. Blood samples were tested for the detection of IgM
antibody against CHIKV, DENV, and against dual infection. Most of the samples were collected
during 1 to 10 days of the illness onset. Approximately 2-5 ml of blood was collected, the serum
was separated and subjected to ELISA analysis. IgM antibody capture (MAC) ELISA was
performed using the following kits from the National Institute of Virology (NIV), Pune: Dengue
(DEN) and Chikungunya IgM Capture ELISA kit (In-house kit). The test was standardized and
reported by the National Institute of Virology, Pune, in 1984. The test performance was
evaluated by the Christian Medical College (CMC), Vellore, in 2002.
In our study, out of 6,554 samples, 3,202 (48.9%) samples showed IgM antibodies to dengue
virus [Table 1]. Year-wise study shows that a large portion of the population is exposed to dengue
infection, which is reflected by the high prevalence of dengue positivity in Karnataka state. In
our study, dual infection varies from 5.7-9.5%, which is quite interesting.
An extensive increase in CHIKV cases along with DENV was recorded in the 2010 outbreak. In
our study, dual infection is more common in the adult group than in the children group, which is
also documented by others.
Co-infections may result in illness with overlapping signs and symptoms, making diagnosis and
treatment difficult for physicians. A possible reason for dual infection may be the fact that, in
Karnataka, the mosquitoes Ae. aegypti and Ae. albopictus are abundantly present. There are a
few studies on dual infection in different countries like Malaysia, Sri Lanka, which support our
findings. Other studies from some part of India reported patients co-infected with CHIKV and
DENV. In our study, as far as isolation of the virus is concerned, only DENV could be isolated
from a few of the received samples. CHIKV could not be isolated from the same sample, and this
could be due to the viral load of the sample. Molecular analysis are required for further studies.
Successful isolation of both virus is needed to conduct basic and applied research on CHIKV and
DENV biology. To date, there is no specific therapy or vaccine available against any of these
viruses, still, the detection of an outbreak aetiology in the initial stage is very important.
Circulation of CHIKV is common in dengue epidemic areas. DENV can cause severe
haemorrhagic illness, and CHIKV, although generally benign, can cause severe neurological
illness. Therefore, further epidemiological and virological investigations are required for both
viruses, because these diseases may have devastating effects, particularly in children and
young adults who may not possess the CHIKV and DENV antibody. The clinical manifestation of
CHIKV infection mimics DENV infection in these areas and it has been postulated that many
CHIKV infections are misdiagnosed as DENV, thus causing CHIKV infections to be under-reported.
The widespread emergence of DENV, and the exponential increase in CHIKV cases in Karnataka
state warrants the need for more effective surveillance to monitor the spread of these deadly
arboviruses, so that timely control strategies could be implemented.

Table 1: CHIKV, DENV and co-infection infection tested by IgM ELISA

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UFSB - OTLI SAÚDE AVANÇADO 2016.2 - FINAL EVALUATION

SUMMARY
Out of many arboviruses, chikungunya virus (CHIKV) and dengue virus (DENV) are the two most
rapidly spreading and medical health important. To date, both arboviruses are co-circulating in
India and Southeast Asia, and concurrent isolation of CHIKV and DENV had been reported in
India since 1964.
Shaikh, Raut, Manjunatha (2015), in their article, “Co-infections with chikungunya and dengue
viruses: A serological study in Karnataka State, India”, compared the clinical feature of CHIK,
DENV and co-infection cases. They also detected immunoglobulin M (IgM-) antibodies against
both CHIKV and DENV using the Enzyme Linked Immunosorbent assay (ELISA) test in 6,554
blood samples collected from clinically suspected cases of DENV/CHIKV in the acute phase of the
disease in the Karnataka state, India.
About 50% of the tested samples showed IgM-antibodies to dengue virus, which is consistent
with the fact that a large portion of the population is exposed to dengue infection. Dual infection
varied from 5.7-9.5%, and was more common in the adult group, which is also documented by
others.
Co-infections may result in illness with overlapping signs and symptoms, making diagnosis and
treatment difficult for physicians. In addition, the clinical manifestation of CHIKV infection
mimics DENV infection and many CHIKV infections may be misdiagnosed as DENV, thus causing
CHIKV infections to be under-reported. In this work, severe arthralgia and swelling of joints were
common in CHIKV-positive cases, abdominal pain was associated with DENV infection, and
diarrhoea was reported in the dual infected patients.
The widespread emergence of DENV, and the exponential increase in CHIKV cases in Karnataka
state warrants the need for more effective surveillance to monitor the spread of these deadly
arboviruses, so that timely control strategies could be implemented.

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