CHIKUNGUNYA

AN UPDATE
Dr.T.V.Rao MD

DR.T.V.RAO MD 1
 WHAT IS CHIKUNGUNYA
• Manifest with Crippling
Arthritic disease of sudden
onset.
• Name is derived from
Swahili – Chikungunya
meaning that which bends
up
• Virus isolated in 1953 from
serum and Aedes
mosquitoes and Culex spp

DR.T.V.RAO MD 2
 WHAT IS CHIKUNGUNYA?

• Chikungunya is a virus that is transmitted from human to

human mainly by infected Aedes albopictus and Aedes
aegypti mosquitoes (later referred to as Aedes
mosquitoes) acting as the disease-carrying vector
• Chikungunya causes sudden onset of high fever, severe
joint pain, muscle pain and headache
• As no vaccine or medication is currently available to
prevent or cure the infection, control of Chikungunya
involves vector control measures and encouraging people
to avoid mosquito bites

DR.T.V.RAO MD 3
 EMERGING DISEASE
• Change in vector
distribution due to
global warming/
changing weather
patterns
• Endemicity to
epidemic
DR.T.V.RAO MD 4
 HISTORY
• Isolated in Aedes aegypti
mosquitoes and man in
1952 in Tanzania
• Appeared in India in 1963
• Major epidemic outbreaks
in Calcutta, madras and
other areas
• Manifested with Major
epidemics till 1973

DR.T.V.RAO MD 5
 CURRENT DISTRIBUTION OF
CHIKUNGUNYA

DR.T.V.RAO MD 6
 CHIKUNGUNYA RISK ZONES
Outbreaks of Chikungunya virus are usually found in:
• Africa
• Southeast Asia
• Indian subcontinent and islands in the Indian Ocean

DR.T.V.RAO MD 7
WHAT IS IMPORTANT IN CHIKUNGUNYA?
• Togaviridae alphavirus
• RNA virus able to
evolve rapidly and
expand vector
• Endemic in Africa and
Asia, especially India
• Vectored by Aedes
species (albopictus,
aegypti)
DR.T.V.RAO MD 8
 CHIKUNGUNYA VIRUS

• Family –
Togaviridae
• Genus - Alpha
virus
• Chikungunya viral
infection manifests
with febrile illness

DR.T.V.RAO MD 9
CHIKUNGUNYA VIRUS
• Enveloped virions
spherical, 60 to 70
nm in diameter
positive-sense,
single-stranded RNA
genome, ca. 11.7
kilobases long.

DR.T.V.RAO MD 10
 CHIKUNGUNYA VIRUS
• Two changes to the
structure of E1 Makes
the virus more likely
to enter mosquito
cells and replicate
after the insect has fed
on the blood of an
infected person.

DR.T.V.RAO MD 11
 EPIDEMIOLOGICAL TRIAD
AGENT

VECTOR

HOST ENVIRONMENT

DR.T.V.RAO MD 12
 EPIDEMICS OF CHIKUNGUNYA

Large epidemics were

recognized in Transvaal of
South Africa, Zambia, India
and South east Asia,
Philippines.
DR.T.V.RAO MD 13
 OUT BREAKS OF CHIKUNGUNYA

• Out breaks occur during

rainy season with
increasing densities of
Aedes aegypti mosquito
• Mosquitos bites infect
the Humans
• Laboratory acquired
infection can also occur

DR.T.V.RAO MD 14
 RECENT HISTORY
• 2005-2007 epidemic in
India 1.4 million
infected in 2006, 56K
infected 2007 Cases
continuing to be
reported every month
• Outbreak in Italy in
2007 OMG!

DR.T.V.RAO MD 15
NATURAL CYCLE
• Aedes mosquitoes
• Feed in daytime
• Breed in stagnant
water
• Small puddle
• Reservoir
• Primates
• Transient viremia 3-7
DR.T.V.RAO MD days 16
 CYCLE OF INFECTION

DR.T.V.RAO MD 17
 OTHER VECTORS
• Both Ae. aegypti and Ae. albopictus have been implicated in
large outbreaks of Chikungunya. Whereas Ae. aegypti is
confined within the tropics and sub-tropics, Ae. albopictus
also occurs in temperate and even cold temperate regions. In
recent decades Ae. albopictus has spread from Asia to
become established in areas of Africa, Europe and the
Americas.
• In Africa several other mosquito vectors have been implicated
in disease transmission, including species of the A. furcifer-
taylori group and A. luteocephalus. There is evidence that
some animals, including non-primates, may act as reservoirs

DR.T.V.RAO MD 18
 CLINICAL FEATURES
• Incubation 3 – 12 days
• Fever may rise to 1030c
to 1040c with rigors
• Viremia lead to fever.
Fever leads to release
of large amount of
Interferons

DR.T.V.RAO MD 19
 CLINICAL EVENTS IN
CHIKUNGUNYA

DR.T.V.RAO MD 20
 CLINICAL MANIFESTATIONS
• Fever,
• Crippling Joint pains
• Lymphadenopathy
• Conjunctivitis
• A Maculopapular rash
• May lead to hemorrhagic manifestations,
• Fever is biphasic with remission after 1 - 6 days
of fever.
DR.T.V.RAO MD 21
 CLINICAL DISEASE
• Significant
morbidity, minimal
mortality
• Fever, rash, nausea,
fatigue, arthralgia
lasting days to
weeks
• Arthritis may be
long-term sequellae
DR.T.V.RAO MD 22
 HOW SOME INDIAN PATIENTS
PRESENTED
• In India but not in
Africa, patients
presented with
Inguinal
lymphadenopathy
and red swollen
ears, and are
observed as part of
clinical picture.

DR.T.V.RAO MD 23
 DIAGNOSIS OF CHIKUNGUNYA
( WHO )
• Several methods can be used for diagnosis. Serological tests,
such as enzyme-linked immunosorbent assays (ELISA), may
confirm the presence of IgM and IgG anti-Chikungunya
antibodies. IgM antibody levels are highest three to five weeks
after the onset of illness and persist for about two months. The
virus may be isolated from the blood during the first few days of
infection. Various reverse transcriptase–polymerase chain
reaction (RT–PCR) methods are available but are of variable
sensitivity. Some are suited to clinical diagnosis. RT–PCR
products from clinical samples may also be used for genotyping
of the virus, allowing comparisons with virus samples from
various geographical sources.

DR.T.V.RAO MD 24
 DIAGNOSIS
• The primary differential
diagnosis of
Chikungunya, should
be made from Dengue,
and O’Nyong nyong
fevers
• Chikungunya manifest
with Myalgia rather
than Arthritis.

DR.T.V.RAO MD 25
 LABORATORY CRITERIA
Laboratory criteria: at least one of the following
tests in the acute phase:
• Virus isolation
• Presence of viral RNA by RT-PCR
• Presence of virus specific IgM/IgG
antibodies in single serum sample
collected
• Seroconversion to virus-specific antibodies
in samples collected at least one to three
weeks apart
DR.T.V.RAO MD 26
 MICROBIOLOGICAL DIAGNOSIS
• Isolation of Virus
• Amplification of Nucleic acid
• Routine Diagnosis with serology
Detection of IgM antibody provides a
specific and reliable means for early diagnosis
ELISA and Dot blotting methods are used

DR.T.V.RAO MD 27
 TREATMENT
• Chikungunya fever is not a life threatening
infection. Symptomatic treatment for mitigating
pain and fever using anti-inflammatory drugs
along with rest usually suffices. While recovery
from Chikungunya is the expected outcome,
convalescence can be prolonged (up to a year or
more), and persistent joint pain may require
analgesic (pain medication) and long-term anti-
inflammatory therapy

DR.T.V.RAO MD 28
 CDC GUIDELINES FOR MANAGEMENT OF
CHIKUNGUNYA
• There is no vaccine or specific antiviral treatment
currently available for Chikungunya fever. Treatment is
symptomatic and can include rest, fluids, and
medicines to relieve symptoms of fever and aching
such as ibuprofen, naproxen, acetaminophen, or
paracetamol. Aspirin should be avoided. Infected
persons should be protected from further mosquito
exposure (staying indoors in areas with screens and/or
under a mosquito net) during the first few days of the
illness so they can not contribute to the transmission
cycle.
DR.T.V.RAO MD 29
 VACCINES FOR CHIKUNGUNYA

• An experimental – live attenuated vaccine

( TSI – GSD – 218 ) enveloped by passage
of an isolate from Thailand in MRC – 5 cell.
• At present used in some laboratory workers
who can be protected,
Vaccine produces neutralizing
antibodies
DR.T.V.RAO MD 30
 PREVENTIVE MEASURES
SEEKING PROTECTION FROM CHIKUNGUNYA
When staying in affected areas:

• Wear long-sleeved shirts and long trousers

• Use mosquito repellents, coils or other devices that will help

fend off mosquitoes

• If possible, sleep under bed nets pre-treated with insecticides

• If possible, set the air-conditioning to a low temperature at night

– mosquitoes do not like cold temperatures

• Pregnant women, children under 12 years old, and people with

immune disorders or severe chronic illnesses should be given
personalised advice
DR.T.V.RAO MD 31
 HOW CHIKUNGUNYA CAN BE
PREVENTED
• There is neither Chikungunya virus vaccine nor drugs
are available to cure the infection. Prevention,
therefore, centres on avoiding mosquito
bites. Eliminating mosquito breeding sites is another
key prevention measure. To prevent mosquito bites,
do the following:
• Use mosquito repellents on skin and clothing
• When indoors, stay in well-screened areas. Use bed
nets if sleeping in areas that are not screened or air-
conditioned.
• When working outdoors during day times, wear long-
sleeved shirts and long pants to avoid mosquito bite.

DR.T.V.RAO MD 32
 BREEDING PLACES OF AEDES MOSQUITOS
TRY TO ELIMINATE ….

DR.T.V.RAO MD 33
 REDUCING THE SPREAD OF THE
VECTOR
• The vector lives in a number of different habitats
• The presence of water is of great importance for
mosquitoes’ breeding as their eggs require water in order
to develop into adult mosquitoes

DR.T.V.RAO MD 34
 USE OF LARVICIDES

(i) Where the water cannot be removed but

used for cattle or other purposes, Temephos
can be used once a week at a dose of 1 ppm
(parts per million).
(ii) Pyrethrum extract (0.1% ready-to-use
emulsion) can be sprayed in rooms (not
outside) to kill the adult mosquitoes hiding in
the house.

DR.T.V.RAO MD 35
 SEVERITY OF INDIAN EPIDEMIC

• Till 10 October 2006, 151 districts of eight

states/provinces of India have been affected by
Chikungunya fever. The affected states are Andhra
Pradesh, Andaman & Nicobar Islands, Tamil Nadu,
Karnataka, Maharashtra, Gujarat, Madhya Pradesh,
Kerala and Delhi.
• More than 1.25 million cases have been reported from the
country with 752,245 cases from Karnataka and 258,998
from Maharashtra provinces. In some areas attack rates
have reached up to 45%.

DR.T.V.RAO MD 36
 CURRENT RESEARCH ON
CHIKUNGUNYA
• Researchers at the Institute Pasteur have managed to
retrace the origin and evolution of the Chikungunya
virus in the Indian Ocean through complete
sequencing of the genome of six viral strains isolated
from patients from Reunion Island and the
Seychelles, as well as through partial sequencing of
the viral protein E1 from 127 patients from the Indian
Ocean islands (Reunion, Madagascar, Seychelles,
Mauritius, Mayotte). Their study, published in PLoS
Medicine, opens up new research paths that should
help to explain the magnitude of the epidemic and the
occurrence of severe forms of the disease.
DR.T.V.RAO MD 37
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DR.T.V.RAO MD 38
 • Created by Dr.T.V.Rao MD for ‘e’
learning resources for Medical and
Public Health Personal in the
Developing World
• Email
• doctortvrao@gmail.com

DR.T.V.RAO MD 39