CHIKUNGUNYA/ZIKA

VIRUS
Dr. Gregorio MD, MPH, FPAFP
4

OUTLINE

o
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High level of viremia in humans
Worldwide distribution of A. aegypti and A.
• Chikungunya (CHICKV) albopictus
o History, The virus & Epidemiology • Transmission has also been documented periodically in
o Modes of transmission temperate areas:
o Course of the disease o Italy (2007) and France (2010)
o Natural History, Pathogenesis, and Pathology o 2013, the first locally acquired case of chikungunya
o Comparison against Dengue were reported in the Americas on islands in the
o Diagnosis and Reporting Caribbean
o Detection, Treatment, Prognosis and • Most epidemics occur during the tropical rainy season
Complications and abate during the dry season
• Zika (ZikV) • Outbreaks in Africa have occurred after periods of
o Background, History and Molecular Evolution drought
o A Global Health Crisis o Open water containers served as vector breeding
o Pathophysiology, Epidemiology sites
o Zika-Affected Countries Around the World • Risk of CHIKV infection exists throughout the day, as the
o Clinical Features and Sequelae primary vector, A. aegypti, aggressively bites during the
o Measuring Head Circumference daytime
o Differential Diagnosis • A. aegypti mosquitoes bite indoors or outdoors near a
o Approach Considerations and ZikV Testing dwelling. They typically breed in domestic containers that
o Treatment and Prevention hold water, including buckets and flower pots
o India have reported outbreaks and is still continuing

CHIKUNGUNYA MODES OF TRANSMISSION
• An insect borne viral infection of the genus 'Alphaviridae' • Chikungunya virus is primarily transmitted to humans
• Transmitted by the 'Aedes' mosquito through the bites of infected mosquitoes A. aegypti and
• Chikungunya (in the Makonde language "that which A. albopictus
bends up") • Blood-borne transmission is possible
o Cases have been documented among laboratory
CHIKUNGUNYA HISTORY, THE VIRUS AND EPIDEMIOLOGY personnel handling infected blood and a health care
• The disease was first described by Marlon Robinson and worker drawing blood from an infected patient.
W.H.R. Lumsden in 1955, following an outbreak in 1952 • Rare in utero transmission
on the Makonde Plateau o Mostly during the second trimester. Intrapartum
• Since its discovered in Tanganyika, Africa, in 1952, transmission has also been documented when the
chikungunya virus outbreaks have occurred occasionally mother was viremic around the time of delivery.
in Africa, South Asia, and Southeast Asia, but recent Studies have not found CHIKV in breastmilk.
outbreaks have spread the disease over a wider range • The risk of a person transmitting the virus to a biting
• The CHIKV is an RNA virus belonging to the family mosquito or through blood is highest when the patient is
Togaviridae, genus Alphavirus viremic during the first week of illness
• Major epidemics occur cyclically
o A disease free period may exist in between COURSE OF THE DISEASE
outbreaks • The incubation period
o Ex. India – well-documented outbreaks occur in o 2-6 days with symptoms usually appearing 4-7 days
1963, 1964, and 1973. For the past 30 years, a few post-infection
cases were documented. In 2005, several states in • 2 Phases of CHIKV
India have reported outbreaks and is still continuing o Acute
• Since the disease reemerged in 2004, millions of cases o Chronic
have occurred and continue to occur throughout
countries in and around the Indian Ocean and in ACUTE PHASE
Southeast Asia • Infection typically lasts from a few days to a couple of
• Risk of importation of CHICKV into new areas is high weeks

CDX 4 and 5: WHO CRITERIA, TABLES AND INTERPRETATION 1

Dr. Gregorio (August 7, 2018)
• Abrupt onset of Table 1: Comparison of the clinical features of Chikungunya and
o Chills Dengue Fever (Symbols indicate the percentage of patients exhibiting
o Fever reaching up to 40 °C each feature: +++ =70-100% of Pxs, ++ = 40-69% of Px, + = 10-39% of
Px and +/- = 0-9%. Adopted from CID 2009;49:942
o Vomiting, nausea, headache, arthralgia

o In some cases, maculopapular rash characterized by
Clinical Features Chikungunya Dengue Fever
raised, spotted lesions
Fever +++ ++
o Severe joint and muscular pain is the most
Arthralgias +++ +/-
problematic symptom. The pain is so intense that
Lymphopenia +++ ++
makes movement very difficult and prostates its Rash ++ +
victims. The virus has been shown to infect epithelial Leukopenia ++ +++
and endothelial cells, primary fibroblasts and Myalgias + ++
monocyte-derived macrophage, explaining the Headache + ++
involvement of muscles, joints, connective tissue and Neutropenia + +++
skin Thrombocytopenia + +++
o Typically, the fever lasts for 2 days and then ends Bleeding Dyscrasia +/- ++
abruptly. However, other symptoms like joint pain, Shock - +/-
intense headache, insomnia and an extreme degree
of prostration, can last for about 5-7 days. DIAGNOSING AND REPORTING
o During the acute phase, the viral load can reach 10^8 • Chikungunya virus infection should be considered in
viral particles per mL of blood patients with acute onset of fever and poly-arthralgia,
especially travelers to endemic areas
CHRONIC PHASE
• The differential diagnosis of chikungunya virus infection
• The chronic stage of chikungunya is characterized by varies based on place of residence, travel history, and
poly-arthralgia that exposures
o Can last from weeks to years beyond the acute stage • Dengue and chikungunya viruses are transmitted by the
o 95% of infected adults are symptomatic after same mosquitoes and have similar clinical features. The
infection, and of these, most become disabled for two viruses can circulate in the same area and can cause
weeks to months as a result of decreased dexterity, occasional co-infections in the same patient
loss of mobility, and delayed reaction
• Chikungunya virus infection is more likely if there is the
o Recurrent joint pain is experienced by 30-40% of presence of High Fever, severe arthralgia, arthritis, rash
those infected
and lymphopenia

• Dengue virus infection is more likely if there is the
NATURAL HISTORY, PATHOGENESIS, AND PATHOLOGY presence of Neutropenia, thrombocytopenia,
• Rarely fatal (prognosis depends on the patient’s immune hemorrhage, shock, and death. It is important to rule
states and co-morbidities out dengue virus infection because proper clinical
• Bite of an infected mosquito à viremia à management of dengue can improve outcome
resolution/Chronic arthralgia • Other considerations
o Leptospirosis
o Malaria
o Rickettsia
o Group A streptococcus
o Rubella
o Measles
o Parvovirus
o Enteroviruses
o Adenovirus
o Other alphavirus infections (e.g. Mayaro, Ross River,
Barmah Forest, O’nyong-nyong, and Sindbis viruses)
o Post-infections arthritis
o Rheumatologic Conditions

CHIKV DETECTION
• Reverse Transcriptase-Polymerase Chain Reaction (RT-
Figure 1: Natural history, pathogenesis and Pathology of PCR) in serum specimens obtained from patients during
Chikungunya. Bite of an infected mosquito (when replication starts) the acute phase of infection detects viral RNA.
à Viremia (Max replication and symptomatic phase) à
Resolution/Chronic Arthralgia (High levels of IL-6 and Granulocyte
colony stimulating factor)

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Dr. Gurango
 o Can be done within the first 7 days on an acute- • Skin
phase specimen to confirm chikungunya virus o Discoloration and rash can be treated with
infection sunscreens and topical corticosteroids. Skin rash on
o May also be used for genotyping of the virus, the face appears to resolve completely within about 3
allowing comparisons with virus samples from weeks, whilst resolution is a little longer when other
various geographical sources parts of the body are affected
o Results can be available within one to two days o Ulcers should be cleaned and treated with topical
• Enzyme-linked immunosorbent assays (ELISA) detects antimicrobials to prevent secondary infections. These
both anti-CHIKV IgM and IgG antibodies from either usually heal within 7-10 days. More severe lesions
acute or convalescent phase samples may require systemic steroid treatment
o Results require 2-3 days and the test is quite specific
with very little cross reactivity with related PROGNOSIS
alphaviruses • Recovery: Varies by age.
o IgM antibodies appear in just a few days and persist o Younger patients recover within 5 to 15 days
for months o Middle aged patients recover in 1-2.5 months
• Immunofluorescence assays are sensitive and specific o Elderly takes longer
but lack the ability to quantify antibodies, are subjective • The severity of the disease as well as its duration is less in
and require special equipment and training younger patients and pregnant women. In pregnant
• Plaque Reduction Neutralization Tests (PRNT) are very women, no untoward effects are noticed after the
useful because they are quite specific for alphaviruses infection.
and are the gold standard for confirmation of serologic • Ocular inflammation from Chikungunya may present as
test results iridocyclitis, and have retinal lesions as well
o The major drawback: it requires the use of live virus. • Pedal edema is observed in many patients, the cause of
The test must be carried out in a Biosafety level 3 which remains obscure as it is not related to any
laboratory (BSL-3) that requires special laboratory cardiovascular, renal or hepatic abnormalities
containment equipment • Persons at risk for severe disease: neonates exposed
• Haemagglutination-inhibition tests intrapartum, older adults (e.g. >65 years old), and
o Chikungunya is confirmed when symptoms such as persons with underlying medical conditions (e.g.
fever and joint pain seen along with a 4 fold hypertension, DM or CVD).
Haemagglutination inhibition antibody difference in • Some patients might have relapse of rheumatologic
paired serum samples. This turns positive within 5-8 symptoms (e.g. poly-arthralgia, polyarthritis,
days of infection tenosynovitis) in the months following acute illness.
• To confirm the infection: testing of both acute- and Studies report variable proportions of patients with
convalescent-phase samples, collected at least 3 weeks persistent joint pains for months to years
apart, from a patient presenting with a high fever • Mortality is rare and occurs mostly in older adults
combined with severe joint pain and recent travel to a
chikungunya outbreak area should be sufficient COMPLICATIONS
• Cryoglobulinemia has recently been reported in several • During early epidemics, rare but serious complications of
patients. Therefore, if a patient presents with the disease were noted including myocarditis,
appropriate clinical syndrome and travel to an affected meningoencephalitis, and mild hemorrhage
area, this should be considered if serologic test results • Other complications = Uveitis and Retinitis
are negative. Health care providers should contact their • Death caused by chikungunya infections appears to be
state/local health department or the CDC for assistance rare. However, increases in crude death rates have been
with diagnostic testing reported during 2004-2008 epidemics
• More than half of patients who suffer from severe
TREATMENT OF CHIKUNGUNYA FEVER chikungunya fever are over 65 years old, and more than
• No vaccine 33% of them die. Most of these adults have underlying
• Treated symptomatically medical conditions and appear to be more likely to suffer
o Usually with bed rest, fluids, and medicines to complications
relieve symptoms of fever and aching such as • Children are also disproportionately affected by severe
ibuprofen, naproxen acetaminophen, or chikungunya fever
paracetamol
• Aspirin should be avoided
• Infected persons should be protected from further
mosquito exposure during the first few days of illness so
they cannot contribute to the transmission cycle. Since

chikungunya is cured by the immune system in almost all

cases (Don’t worry about it)

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Dr. Gurango
 ZIKA VIRUS INFECTION • William Bearcroft, a researcher at the West African
BACKGROUND Council for Medical Research Laboratories in Lagos,
• Zika virus (ZIKV) belongs to the Flavivirus genus; like other Nigeria, wanted to know more. Bearcroft decided to
flaviviruses. inoculate a human volunteer with the virus.
• In most cases, Zika virus infection causes a mild, self- o The volunteer had received a yellow fever vaccine 3
limited illness. months before traveling to Nigeria.
• The incubation period is likely 3-12 days. o The Zika virus was isolated from the man's blood
• Owing to the mild nature of the disease, more than 80% during the acute stage of infection. By the morning
of Zika virus infection cases likely go unnoticed. of the seventh day, the patient felt quite well and
• The spectrum of Zika virus disease overlaps with other his temperature returned to normal.
that of arboviral infections, but rash (maculopapular and • 1962-1963: new strains of the Zika virus were isolated
likely immune-mediated) typically predominates from arboreal mosquitoes in the Zika Forest.
• In April 2016, a deputy director at the Centers for Disease o Three out of five strains came from infected
Control and Prevention (CDC) warned that the risk of Zika mosquitoes collected above the forest canopy
virus infection in the United States may have been during the 3 hours after sunset.
previously underestimated, citing the increased range of o These observations showed that these insects can
the mosquito vectors (now in 30 US states, up from 12 as disseminate over large distances when convection
previously thought) and the travel risks associated with currents occur at treetop level
the 2016 Olympics in Brazil. • Subsequent 20 years: the Zika virus was isolated from
numerous species of Aedes mosquitos in Africa (A
HISTORY africanus) and in Malaysia.
• 1968 and 2002: a total of 606 viral strains (including 10
that were isolated in patients in Central and West Africa)
were reported by the World Health Organization (WHO).
• In addition, Zika infections have been reported in Asia
(Cambodia, Indonesia, Malaysia, Micronesia, Pakistan,
Thailand, and Vietnam).
• 2013: Zika virus emerged in French Polynesia in the South
Pacific, where dengue is endemic.
o the outbreak in French Polynesia was complicated

by Guillain-Barré syndrome. The first case of
Guillain-Barré syndrome was reported to have
Figure 2. Zika virus Timeline occurred immediately after a Zika virus infection
(concomitant with a dengue epidemic caused by
• 1947: The Zika Forest serotypes 1 and 3).
o In Lugandan (the major language of Uganda), the • 2014: Zika virus infections were reported in Japan, France,
word "Zika" means "overgrown." and Norway.
o Scientists were studying this forest to identify the o These cases emphasize the capacity of the Zika virus
causative agent of yellow fever. to spread to areas where it is not endemic, but
o Sent out monkeys to be bitten by mosquitoes. where the right mosquito vector might be present.
o Rhesus 766 developed fever, his blood was It appears that any area with the right vectors now
collected and the serum was inoculated into the poses a risk for infection with Zika virus.
mice: intracerebral and intraperitoneal. Another • 2015: patients exhibiting a "dengue-like syndrome"
part was given to rhesus 771. presented to the public health service in the city of Natal,
in the state of Rio Grande do Norte in northeastern Brazil.
A New Strain Named ‘ZIKA’ o A physician and specialist in infectious diseases
• The isolated viral strain was named "Zika" for the forest evaluated the patients, in whom biological results
where it was isolated. indicated a non-dengue and non-chikungunya virus
• 1952: Dick, Kitchen, and Haddow published their results infection.
on the Zika virus in two articles in Transactions of the o February 2015, the Zika virus infection affected
Royal Society of Tropical Medicine and Hygiene more than 6000 persons in six states in
o Found that Zika virus was not related to yellow northeastern Brazil.
fever. • Recent reports from the Ministry of Health of Brazil
o Zika virus was related to dengue virus. suggest an unusual increase in cases (by a factor of
• 1954: a 10 year old African girl got sick and 2 other men, approximately 20) of microcephaly among newborns in
infection at this time was still associated with yellow the northeast region of Brazil, which indicates a possible
fever. association between Zika infection in pregnancy and
microcephaly.

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Dr. Gurango
• February 1, 2016: the WHO declared that the recent system, (3) Virus enters salivary glands in proboscis, (4) Proboscis
association of Zika infection with clusters of microcephaly perces epidermis to find blood vessels, virus enters cells of new host.
and other neurologic disorders (eg, Guillain-Barré Mostly bites during the day time. It can be transferred from mother
to baby causing birth defects such as microcephaly. Virus can also be
syndrome) constituted a public health emergency of
transferred through sexual intercourse.
international concern.
• Research was actively engaged to evaluate the role of Zika • Like many other flaviviruses, Zika virus is transmitted by
virus in this severe fetal brain injury. No scientific an arthropod: the Aedes mosquito, including Aedes
evidence to date confirms a link between Zika virus and aegypti,Aedes africanus, Aedes luteocephalus, Aedes
microcephaly, nor between the virus and Guillain-Barré albopictus, Aedes vittatus, Aedes furcifer, Aedes
syndrome. hensilli, and Aedesapicoargenteus.

• Sexual transmission among humans has also been
The Molecular Evolution of Zika described.
• The findings reveal at least two independent viral • Zika virus is well adapted to grow in various hosts, ranging
lineages: from arthropods to vertebrates.
o East Africa (in agreement with the two previously
proposed African clades) EPIDEMIOLOGY
o Asian lineage.
• This third Zika virus lineage originated with a viral
migratory flow from Eastern Africa. More precisely, it
appeared to be from Uganda, and probably spread to
Malaysia around 1945. From there, the virus reached
Micronesia around 1960, forming the Asian cluster,
according to a study conducted by researchers from the
Institut Pasteur de Dakar (Senegal) and the University of
Sao Paulo (Brazil).

A Global Health Crisis
• The brief history of the Zika virus resembles that of
another emerging virus, the chikungunya virus.
• Once confined to a narrow equatorial belt across Africa
Figure 4. Zika affected countries around the world. First detected in
and into Asia, the Zika virus is now present everywhere
Africa.
that the right mosquito vectors circulate.
• One is the tiger mosquito, A. albopictus; this rapidly
expanding Aedes species lives in close contact with
humans and feeds not only at dusk and dawn but also in
the daytime—a fact that underscores its dangerous
character.
• In a world marked by globalization and trends of
urbanization—which imply a potential source of human-
caused perturbations in ecologic balance, and a constant
increase in international air travel—Zika virus appears to
have a large capacity to spread (like dengue and
chikungunya viruses) and colonize new environments.

PATHOPHYSIOLOGY
Figure 5. Countries with reported confirmed Zika virus case.
Philippines has widespread transmission in the past 3 months

• Since 2015, and as of 6 October 2016, there have been 69
countries and territories reporting mosquito-borne
transmission of the virus. According to WHO and as of 6
October 2016, 22 countries or territories have reported
microcephaly and other central nervous system (CNS)
malformations in newborns potentially associated with
Zika virus infection.

Figure 3. Transmission cycle of Zika Virus. (1) Mosquito feeds on
virus-infected blood, (2) Virus carried to the gut, enters circulatory

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Dr. Gurango
• The Philippines of Guillain–Barré syndrome incidence, coinciding with the
o On 4 October, the Philippines reported three new Zika virus outbreaks, were reported in several countries in
autochthonous cases, bringing the total to 15. the Americas and French Polynesia.
• Update on microcephaly and/or central nervous system • Infants born with congenital microcephaly and suspected
(CNS) malformations potentially associated with Zika vertical acquisition of Zika virus have also been found to
virus infection have various ophthalmologic abnormalities, including loss
o As of 6 October 2016, microcephaly and other of foveal reflex, macular pigment mottling, chorioretinal
central nervous system (CNS) malformations macular atrophy, optic nerve head hypoplasia, and optic
associated with Zika virus infection or suggestive of nerve double-ring sign.
congenital infection have been reported by 22
countries or territories. Brazil reports the highest
number of cases. Nineteen countries and territories
worldwide have reported an increased incidence of
Guillain-Barré syndrome (GBS) and/or laboratory
confirmation of a Zika virus infection among GBS
cases.

CLINICAL FEATURES
• The incubation period likely ranges between three and 12
days after the bite by an infected mosquito. Most of the
infections remain asymptomatic (approximately 80%).
• Disease symptoms are usually mild, and the disease is
Figure 7. Measuring Head Circumference affected by Zika virus
commonly short-lasting and self-limiting. Its duration is
between 2–7 days without severe complications, with no DIFFERENCIAL DIAGNOSIS
associated fatalities and a low hospitalisation rate.
• Signs and symptoms of Zika virus (ZIKV) infection are
• The main symptoms are maculopapular rash (+/-itchy), nonspecific and mimic other infection.
with or without mild fever, arthralgia, fatigue, non-
• Dengue virus infection is the most serious and may be
purulent conjunctivitis/conjunctival hyperaemia, myalgia
life-threatening.
and headache.
• Other etiologies include Chikungunya virus, yellow fever
• The maculopapular rash often starts on the face and then
virus, parvovirus, enterovirus, Ross River virus,
spreads throughout the body. Less frequently, retro-
plasmodia (malaria), and rickettsia.
orbital pain and gastro-intestinal signs might be present.




APPROACH CONSIDERATIONS
• Diagnosis of Zika virus (ZIKV) infection is typically based on
serologic testing, although the CDC now recommends
urine testing.
• The viral level may be higher in urine and for a longer
duration than in serum.
• Zika virus infection is diagnosed based on detection and
isolation of Zika virus RNA from serum using reverse-
transcriptase polymerase chain reaction (RT-PCR). The
highest sensitivity of PCR testing is during the initial week
of illness, which is characterized by high viremia.
• After the initial week of illness, serological testing for
virus-specific immunoglobin M (IgM) and neutralizing
antibodies against Zika virus infection can be performed
using enzyme-linked immunosorbent assay (ELISA). The
utility of this test is limited owing to cross-reactivity with
other flaviviruses (dengue and yellow fever).
• Antibodies directed toward individual flaviviruses can be
Figure 6: Clinical Features of Zika
measured using plaque reduction neutralization tests
(PRNTs) to facilitate accurate diagnosis of primary
• Among women infected during pregnancy, congenital flavivirus infection.
central nervous system malformations of the fetus (such
as microcephaly) and fetal losses were notified during
several recent Zika disease outbreaks. Unusual increases

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Dr. Gurango
 URINE TESTING • If your patient is: Ask the following questions
• Urine can be tested via real-time reverse transcription- o Experiencing or has recently experienced symptoms
polymerase chain reaction (rRT-PCR) using samples of Zika (Red eyes,fever, joint pain, rash)
collected less than 2 weeks following symptom onset. o An asymptomatic pregnant woman
• Urine should be tested in conjunction with serum if 1. Does the patient live in or has the patient recently
specimens were obtained less than one week following traveled to an area with Zika?
symptom onset. A positive result on either test confirms 2. Has the patient had unprotected sex with a partner
Zika virus infection. who has lived in or traveled to an area with Zika?
• if yes, then test for Zika virus
TESTING FOR ZIKA VIRUS INFECTION IN PREGNANT WOMEN • CDC does not recommend Zika virus testing for
• All pregnant women should be screened for a travel asymptomatic men, children, and women who are not
history to Zika virus–affected areas. Symptomatic pregnant.
pregnant women with a positive travel history should
undergo RT-PCR or serological testing for detection of Zika TREATMENT
virus infection. Refer to the flowchart. • Zika virus (ZIKV) infection is usually mild and self-limited.
• Regardless of symptoms and test results, all pregnant There are no specific treatment options for Zika virus
women with a history of travel to an area of active Zika infection.
virus infection should undergo fetal ultrasonography to • Supportive care with rest and adequate fluid hydration is
evaluate for microcephaly or intracranial calcifications. advised. Symptoms such as fever and pain can be
controlled with acetaminophen (paracetamol). Use of
*The flowchart is at appendix of this trans. nonsteroidal anti-inflammatory drugs (NSAIDs) in-
patient with unconfirmed Zika virus infection should be
avoided since the use of such drugs in dengue fever is
associated with hemorrhagic risk.
• The WHO recommends optimal supportive care in
patients with Guillain-Barré syndrome, including frequent
neurologic examinations, testing of vital complications
(eg. Blood clots, respiratory failure). Patient whose
symptoms are escalating rapidly or who are unable to
walk should receive intravenous immunoglobulin therapy
or therapeutic plasma exchange.

PREVENTION
• Avoidance of travel to areas of active Zika virus
transmission.
o The best method for preventing Zika virus infection
Figure 8. Only some people need Zika testing is to avoid travel to areas with active Zika virus
transmission.
• Mosquito control and prevention of mosquito bites
o Different strategies to prevent mosquito bites
include wearing full-sleeved shirts and long pants,

sleeping under mosquito bed net, and treating

clothing with permethrin.

• Certain other measures to control mosquitoes, including
the use of genetically engineered Aedes aegypti
mosquitoes as previously performed to prevent dengue
infection by reducing the natural population of
mosquitoes, is under investigation.
• Activities supporting the reduction of mosquito breeding

sites in outdoor/indoor areas by draining or discarding

sources of standing water at the community level include:

o Removal of all open containers with stagnant water
in and surrounding houses on a regular basis (e.g.
Figure 9. When to test for Zika virus flower plates and pots, used tyres, tree holes and
rock pools), or, if that is not possible, treatment
with larvicides),
o Tight coverage of water containers, barrels, wells
and water storage tanks, and the

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Dr. Gurango
 o Wide use of physical barriers that reduce the risk of è Usual baseline risk or slightly above baseline
exposure to mosquitos bites (such as mosquito risk for destination and limited impact to
nets, window/door screens and air conditioning). the traveler.
o During an outbreak, elimination of adult mosquitoes II. Level 2: Alert – follow enhanced precautions for this
through aerial spraying with insecticides can be destination.
considered but efficacy seems very limited. è Increased risk in defined settings or
• In areas where the vector is active, the following is associated with specific risk factors; certain
recommended: high-risk populations may wish to delay
o Symptomatic patients should strictly follow travel to these destinations.
personal protection measures to prevent mosquito III. Level 3: Warning – avoid all non-essential travel to
bites for at least the first week of illness to decrease this destination.
the risk for human-to-mosquito-to-human è High risk to travelers.
transmission.
o Asymptomatic individuals returning from an area <List of Alert level 2, practice enhanced precautions areas>
with Zika virus outbreaks should follow personal • Saba
protection measures against mosquito bites for • Antigua and Barbuda
three weeks after their return. • Turks and Caicos Islands
o Caution should be exercised to prevent local • Argentina
transmission of Zika virus from infected patients to • Anguilla
uninfected mosquitoes. Mosquito bites should be • Sint Eustatius
avoided during initial stages of Zika infection owing • British Virgin Islands
to high viremia. • Angola
• Guinea-Bissau
<In summary>
• Solomon Islands
1. Preventing other modes of Zika virus transmission
• Singapore
2. As the infection spreads, new possible routes of
• Saint Kitts and Nevis
transmission facilitating human-to-human spread of the
• Montserrat
virus without an intermediate vector have been
• Grenada
discovered. The CDC has issued interim guidelines
advising sexual abstinence or regular use of condoms to • Saint Vincent and the Grenadines
prevent the spread of Zika virus to sexual partners, • Aruba and Samoa
especially during pregnancy. • Barbados
3. The CDC advises that women with Zika virus infection • Bonaire
should wait at least 8 weeks after any symptom onset • Curacao
before attempting to get pregnant. Asymptomatic • Saint Martin, Saint Maarten and Saint Lucia
women with a possible exposure (who have been in an • Dominica
area of active transmission) should also wait 8 weeks • Belize
before attempting pregnancy. They suggest that men • Cuba
wait at least 6 months before attempting to conceive. • Tonga
• Trinidad and Tobago
TRAVEL NOTICE DEFINITIONS • US Virgin Islands
• Owing to high rates of microcephaly among infants born
to women with Zika virus infection, South American REFERENCES
governments (Brazil, Colombia, El Salvador) have advised 1. Dr. Gregorio PPT 2018
women to avoid pregnancies until 2018. 2. Recording
• A travel alert has been issued for pregnant women in any TRANSCRIBERS
trimester to avoid or postpone travel to areas with 1. TRANS GROUP: 9A
ongoing Zika virus infection. 2. SUBTRANSHEAD: Lance Cua
• CDC issues different types of notices for international
travelers. As of April 5, 2013, these definitions have been
refined to make the announcements more easily
understood by travelers, health-care providers, and the
general public. The definitions are laid out below. They
describe both levels of risk for the traveler and
recommended preventive measures to take at each level
of risk.
I. Level 1: Watch – reminder to follow usual
precautions for this destination.

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Dr. Gurango
 REVIEW QUESTIONS 8. In differentiating Chikungunya and Dengue Fever, which of
2019 the following will Point more on CHIKV infection?
1. Which of the following statements is true regarding A. High grade fever, shock, hemoconcentration
Chikungunya virus infections? B. High grade fever, arthritis, headache
A. Self-limiting viral illness having frequent outbreaks in C. High grade fever, myalgia, headache
tropical countries D. High grade fever, neutropenia, rash
B. Global attention is not necessary since it is limited to
Asian Countries 9. Which of the following is NOT correctly paired?
C. There was no re-emergence of the viral transmission A. Serological testing – antibodies are detected using
beginning 2015 Enzyme Linked Immunoassay that appear after viremic
D. Historically, outbreak was described in Asia phase
B. Viral Culture – virus can be isolated after 5 days of
2. Chikungunya virus is characterized as: illness
A. Coming from Togaviridae family C. Molecular Diagnostics – molecular assay detects viral
B. Single stranded RNA alpha virus DNA during the first 7-8 days of illness
C. 3 distinct groups were identified: West African, East
Central South African and Asian 10. In preventing the spread of Chikungunya, which of the
D. All of the choices following should be considered?
A. Using repellents is the main method of control
3. The spread of Chikungunya virus is correctly described in B. People suspected of CHIKV infection should avoid being
which of the following choices? bitten by mosquito
A. Even if there is worldwide distribution, there was no C. Vaccine can be used for prevention
known mortality for Chikungunya
B. Spread to Europe and United States of America is 11. Which of the following statements is true of Zika Virus?
recorded between 2013 and 2014 A. It is a double stranded RNA virus
C. Chikungunya spread is limited to temperate countries B. This virus belongs to genus Flavivirus
only C. Primary transmitted through a bite of an infected
D. None of the above Anopheline mosquito species
D. It is a single stranded DNA virus
For numbers 4-7: refer to the case below
CV, 65, female, known diabetic came to your clinic complaining of 12. Zika virus can be transmitted through the following:
severe joint pains. History revealed that 4 days prior to consult, A. Bite from a mosquito
she experienced headache and sore throat. 3 days prior to B. Maternal transmission from an infected mother
consult when high-grade fever was noted; this has persisted until C. Sexual contact
the day of consult. She developed severe joint pains and rash D. Breastfeeding
distributed along her body which prompted consultation
13. In recognizing Zika virus infection, which of the following
4. A typical arthralgia characterizing Chikungunya: must be considered?
A. Monoarticular, single location, limited to small joints A. Infection rate is less than 50% therefore there is no
B. Polyarticular, migratory, limited to knees and hip joints need for disease surveillance
C. Monoarticular, migratory, often involves the hands and B. Zika virus commonly cause severe disease and needs
wrists hospitalization for infected individuals
D. Polyarticular, migratory, often involves the hands and C. Only the extremes of age are infected
wrists D. Symptomatic attack rate is approximately 18%

5. On PE, the following are commonly seen among patients 14. This neurologic disorder is closely associated with Zika virus
with Chikungunya EXCEPT: infection
A. Cardiac murmurs A. Meningitis
B. Flushed appearance of face and trunk B. Encephalitis
C. Urticaria C. Guillain-Barre Syndrome
D. Conjunctivitis D. Reye’s syndrome

6. In identifying a case of Chikungunya, this case is under 15. Zika, Dengue, and Chikungunya are closely related. Which of
category: the following symptom are common to all 3 infections?
A. Suspected case A. Rash
B. Probably case B. Conjunctivitis
C. Confirmed case C. Shock
D. Hemorrhage
7. The Prognosis of this case will depend on which of the
following patient characteristics?
A. Age
B. Presence of comorbidities
C. State of Immunity
D. All of the choices

CDX 4 and 5: WHO Criteria, Tables and Interpretation 9

Dr. Gurango
For number 16-18, refer to the case below: 2. One of these symptoms is the most notable for patients with
ZV, 250year-old male, came in to your clinic due to fever. History Chikungunya virus infections:
reveals that 2 days PTC, patient developed low -grade fever A. Fever
associated with muscle pains. His wife also noted his eye were B. Headache
“red”. Patient came back from a vacation in Brazil and was C. Rash
concerned if he contracted Zika virus during his travel. D. Severe joint pains

16. During this time, the BEST diagnostic test to perform to ZV 3. There symptoms will indicate that the Chikungunya viral
is: load is at its highest:
A. Complete blood count A. During the presence of fever, headache and nausea
B. Immunohistochemical staining from tissue sample B. Presence of joint pains after disappearance of rash
C. Real-Time Reverse transcriptase Polymerase Chain C. Right after the infected mosquito bites the human host
Reaction on serum and urine D. None of the choices
D. Plaque Reduction Neutralization Test
4. Dengue fever is one important differential diagnosis for
17. Based on the CDC, is patient ZV eligible to be treated? Chikungunya virus infection due to the following reasons:
A. Yes A. Both viruses have the same vectors
B. No B. Dengue fever may cause hemorrhagic shock
C. More parameters needed to answer this question C. Chikungunya virus infection and dengue fever may
occur at the same time
18. ZV and his wife is planning to have a baby, how long should D. All of the choices are correct
they wait after he had the symptom before trying to have
one? 5. This test can be done in the first 7 days of Chikungunya virus
A. 1 ½ months infection to detect viral RNA:
B. 2 months A. Reverse Transcriptase polymerase chain reaction
C. 4 months B. Enzyme linked immunoassay
D. 6 months C. Plaque recognition neutralization test
D. Haemagglutination inhibition test
19. For Pregnant patients, which of the following statement/s
about Zika transmission is/are TRUE? 6. As you strongly consider Chikungunya virus infection in your
A. The virus is transmitted to the fetus during pregnancy patient, the following treatments is considered, EXCEPT:
B. The virus is transmitted around the time of birth A. Paracetamol tablets
C. The virus can cause other problems to the newborn B. Protection from mosquito bites
such as eye defects and hearing loss C. Acetyl salicylic acid
D. All statements are correct D. Rest

20. For preconception guidance among women with possible 7. Which of the following is true regarding the prognosis of
Zika virus exposure, which of the following statements is Chikungunya virus infection:
correct? A. Younger patients recover for a longer period of time as
A. If no symptoms of Zika virus was noted, there is no compared to middle aged patients
need to wait before trying to conceive B. Persons at risk for severe disease: neonates exposed
B. If symptoms of Zika infection was noted, she could wait intrapartum and elderly patients
at least 8 weeks after onset or last exposure before C. Most patients recover with a lot of sequelae
trying to conceive D. All patients experience chronic arthralgia
C. If symptoms of Zika infection was noted, there should
be a serologic evidence of infection before advising the 8. Which of the following statements is true about Zika virus
patient to wait infection:
A. Zika virus infection causes a mild disease that most
ANSWER KEY: A-D-B-D-A/B-D-B-A-B/B-B-D-C-A/C-A-D-D-B cases go unnoticed
B. As compared to Dengue and Chikungunya, Zika virus
infection does not cause a rash
2018 C. The occurrence of Zika virus infection started in the
th
20 century
1. Most Chikungunya virus infection epidemics occur during D. In most cases, Zika virus infection will lead to death
rainy season but outbreaks also happen during drought
season due to which of the reasons? 9. In 2016, the World Health Organization declared that Zika
A. Vector mosquito bites throughout the day virus infection is an international concern for the following
B. Open water containers serve as breeding sites for reason/s:
vector mosquito A. Increasing cases of microcephaly associated with the
C. Vector mosquito can survive in temperate countries infection
D. None of the choices B. The association of neurologic disorder such as Guillain-
Barre syndrome
C. All of the choices

CDX 4 and 5: WHO Criteria, Tables and Interpretation 10

Dr. Gurango

10. Aside from congenital microcephaly, infants known to have 17. A female patient arrived from an area with Zika virus
vertical transmission of Zika virus are also known to have transmission, she would like to know how long should she
which malformation: wait; from the time of her arrival and for symptoms to
appear before attempting to get pregnant?
A. Ophthalmologic abnormalities A. 6 weeks
B. Adrenal hypoplasia B. 7 weeks
C. Congenital heart disease C. 8 weeks
D. Missing limbs D. 9 weeks

11. Owing to the complications or association of Zika virus 18. A male patient arriving from an area with Zika virus
infection which examination is of prime importance to transmission how long should he wait before symptoms
perform in a patient with suspected infection? appear and try to get someone pregnant?
A. Hearing test A. 3 months
B. Neurologic examination B. 4 months
C. 12 lead ECG C. 5 months
D. Cranial computed tomography D. 6 months

12. It is recommended to measure a newborn’s head 19. This diagnostic modality is recommended for asymptomatic
circumference from a mother who had Zika virus infection is pregnant woman who lives or traveled from an area with
during which time? Zika virus infection:
A. First day of life A. Abdominal ultrasound
B. Second day of life B. Cranial computed tomography
C. Third day of life C. 12 Lead ECG
D. Fourth day of life D. Amniocentesis

13. Aside from serologic testing, the CDC recommends which 20. A 6-year-old child brought to your clinic with 2 days of
specimen to be tested for Zika Virus remittent fever and arthralgia, which of the following signs
A. Spinal Fluid and symptoms will make you favor Chikungunya virus
B. Urine instead of dengue fever?
C. Sputum A. Arthralgia and Lymphopenia
D. Feces B. Rash and thrombocytopenia
C. Fever and shock
14. CDC recommends that this person be tested for Zika virus D. Myalgia and blood dyscrasia
infection
A. Asymptomatic pregnant women without history of
traveling to an area with Zika
B. Asymptomatic pregnant women who had unprotected
sexual intercourse with a partner who travel in an area ANSWER KEY: B-D-A-D-A/C-B-A-C-A/B-A-B-B-D/A-C-D-A-A
with Zika
C. Symptomatic pregnant woman without a history of
traveling to an area with Zika
D. None of the choices

15. The following are measures in preventing Zika virus
infection:
A. Prevention of mosquito bites
B. Avoidance of travel to areas with Zika
C. Reduction of mosquito breeding sites
D. All of the choices

16. For persons returning from areas with Zika virus infection
the following recommendation should be followed:
A. Symptomatic patients should strictly follow personal
protection to avoid being bitten by mosquitoes
B. Asymptomatic individuals may not follow personal
protection measures to avoid being bitten by
mosquitoes
C. There is no need for personal protection measures
against mosquitoes in both symptomatic and
asymptomatic individuals
D. None of the choices are correct

CDX 4 and 5: WHO Criteria, Tables and Interpretation 11

Dr. Gurango
 CHIKUNGUNYA/ZIKA VIRUS
Dr. Gregorio MD, MPH, FPAFP
4

Figure 10. TESTING FOR ZIKA VIRUS INFECTION IN PREGNANT WOMEN

CDX 4 and 5: WHO CRITERIA, TABLES AND INTERPRETATION 1

Dr. Gregorio (August 7, 2018)