CHIKUNGUNYA FEVER

By
Dr. Nazia Shamim
 What is this tongue twister?
• It is CHIKUNGUNYA
• To be pronounced as [chick’-en-GUN-yah]
• Not written as CHICKEN GUINEA
• Nothing to do with chicken or mutton eating
• Derived from the Makonde verb - Kun gunyala
• In Swahili it means ‘to become contorted’ or
• More specifically as ‘that which bends up’
• The intensity of the pain and handicap gave the disease its name: “chikungunya”
• Refers to the stooped posture of the patient

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

Thanks to the Almighty

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 Why panic?
A common viral fever

Self limiting – non fatal illness

Fever, myalgia, arthralgia, lasting 2 - 7 days

Should give big name for it and be panicky ?

Should create such media hype and chaos ?

Above all, should we politicize to this extent?

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 Epidemiology
 First described in Africa (Tanzania) in 1952 and then identified in
Asia, it was responsible for widespread outbreaks on these two
continents from the 1960s till 1980s.

 Its global emergence really started in 2004.

 A major outbreak first spread, to most islands in the Indian Ocean

in 2005–2006. CHIKV spread progressively toward Asia,
affecting India since 2006 and successively most countries of the
Region.

 Within the past 6 years, this global profile has been responsible
for more than 2 million cases, mostly during outbreaks in the
Indian Ocean, India, and South-Eastern Asia, but also in Africa
and in Europe, whereas “only” a few cases were reported.
 Epidemiological Features

Two examples illustrate the strong impact of CHIKV outbreaks. In the Union of
Comoros in 2005 & In India, the national burden of the CHIKV outbreak in 2006.

The situation changed rapidly due to the new A226V-CHIKV strain quickly became
predominant and generated an explosive outbreak.

The A226V-CHIKV is highly efficient at spreading through human populations in

tropical and temperate countries when colonized by Ae. albopictus.

Continued….
 Outbreak of Chikungunya in Pakistan
• Pakistan, along with other Asian countries, is undergoing substantial climate changes. The
summers are getting harsher, whereas the winters are getting milder with every passing
year. The rising temperature has nurtured the outbreak of many arboviral illnesses in the
region, including malaria and dengue.
• The deplorable sanitary conditions of most Asian countries further adds fuel to the fire by
providing excellent breeding grounds for the arthropod vectors.
• Chikungunya virus was found circulating in rodents in Pakistan as early as 1983.
• In fact, a few patients with chikungunya were also reported in Lahore during the 2011
dengue outbreak.
• Three cases of chikungunya were identified in children during a 2011 dengue outbreak.
• The current outbreak is said to have started on the second week of November, 2016 in
Karachi.
• Different healthcare authorities in Karachi estimate the total number of patients to be
more than 30 000.
• The National Institutes of Health, Pakistan, and Armed Forces Institute of Pathology,
Pakistan, have so far confirmed more than 4000 cases through qualitative RT-PCR.
 Virological Aspects

It is positive-sense, single-stranded RNA virus, transmitted via Aedes mosquitoes.

Genus – Alpha virus.

Family – Togaviridae.

Genetic analysis showed distinct lineages: West African cluster,

East-Central and South African cluster and the Asian cluster.

To date, no difference in virulence between the different strains of CHIKV has been shown in humans.
 CHKV Transmission:
 No animal reservoir.

Maintained in nature by man – mosquito cycle.

Vector – Mosquito (Aedes aegypti, Ae. Albapticus)

(Same vector as for Dengue & Yellow fever).

Vehicle of transmission – None

No known mode - other than mosquito bite.

Incubation Period – 2 to 12 days.

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 The Vector
Both mosquitoes species having white strips on black bodies and legs.
 Aedes aegypti:
 Flight range < 100 meters
Aggressive daytime biter, can bite at any time.
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
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 Pathogenesis:
At the early stage of the disease targeted organs for CHIKV
replication are:
(Lymphoid tissues, liver, CNS, joints, and muscles).

The persistence of CHIKV could be found later in the lymphoid

organs, liver, joints, and muscle.
 Macrophages being the main reservoir.

In humans, acute CHIKV infection is characterized by a very early

viremia at fever onset that can increase up to 109 to 1012 RNA
copies/ml and lasts up to 12 days .

Continued….
In vitro studies have shown that:

 Human epithelial and endothelial cells, primary fibroblasts,

and monocyte-derived macrophages are susceptible to CHIKV
infection.

whereas

Activated B and T CD4+ lymphocytes, monocytes, and

monocyte-derived dendritic cells were refractory to CHIKV
infection .
 Attack Rates

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.

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 Clinical Features
 Incubation period: 2-12 days (usually 3-7 days).
 Infective period (Viremia): last for 5 days.
 High grade fever (40°C or 104°F),
 Flu-like symptoms, Severe headache and chills
 Arthralgia or arthritis – lasting several weeks.
 Conjunctival suffusion and mild photophobia
 Nausea, vomiting, abd. pain, severe weakness
 Maculopapular rash :Transient sometimes edematous and/or pruritic, observed on the
face and the trunk of half the patients.
 Cutaneous and mucosal : Photosensitivity, stomatitis, mouth ulcers, exfoliative
dermatitis, vesicles, bullae, and purpura.

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The Arthralgia

• 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 last for weeks or months.

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 Course of Illness
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

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 Clinical Presentation in Children
• To date, few observational studies have detailed the clinical features of
chikungunya in children. However, the ones that do highlight the fact that
children may have a different clinical presentation than adults.

• The magnitude of symptoms and their diversity seem to describe a U-shaped

curve, with a maximum occurring in young infants and the elderly and a
minimum in older children.

• Furthermore, the rate of asymptomatic infection among children varies

according to different outbreak reports(range 35–40%).

Continued….
• Fever –
• After an incubation period of 2–4 days (range 1–12 days), adults typically present
with sudden-onset fever, severe arthralgia,headache, photophobia and skin rash.

• Fever is typically high-grade in both children and adults.

• In children, febrile seizures frequently are described and commonly occur beyond
the typical age range of 6 months to 6 years.

• Typically, these seizures last for 3–5 days, with a maximum of 10 days

Continued….
• Skin and Hemorrhagic Manifestations –
• Skin lesions are reported in approximately 50% of adults. In children, however, they
are less common, particularly in those younger than 2 years of age.
• The skin lesions most frequently reported are pigmentary changes in the
centrofacial area, maculopapular rash and intertriginous aphthous-like ulcers.
• The rash usually is present for 5 days, with hyperpigmentation sometimes following
the rash.

• Infants younger than 6 months of age may exhibit extensive bullous skin lesions with
blistering covering up to 35% of the body surface area.
• Hemorrhagic manifestations including epistaxis, gingival bleeding and purpura are
also observed in approximately 10% of pediatric cases.

Continued….
• Musculoskeletal Manifestations
Myalgia, arthralgia and arthritis often are present in adults with
chikungunya but typically less so in children (between 30% and 50% of
affected children).In adult patients, finger, wrist, ankle, elbow and knee
joints are the most commonly affected sites.
Swelling without other signs of synovitis typically is reported with a
symmetric, distal, polyarticular pattern.
Permanent destruction of affected joints is rarely reported.
Other rheumatic manifestations include tenosynovitis, tendinitis or
bursitis at the acute and subacute stages (<day 90). It is now widely
recognized that in adults arthralgia may persist for years.

Continued….
• Neurological Manifestations
Central nervous system (CNS) involvement potentially is more significant than
previously documented, especially in children.
A high proportion(40–50%) had severe manifestations, including status epilepticus,
complex seizures and encephalitis reported in different outbreaks .
The incidence of encephalitis was U-shaped, with a significant burden for those
younger than 1 year of age, as well as those older than 45 years.
Outbreaks in La Réunion, 2 of the 22 children (9%) with neurological manifestations
died.
Long-term neurological symptoms were reported in both children and adults ,
28%of whom were below 20 years of age. Two years after acute infection, cerebral
disorders(including attention and memory difficulties)were reported in
approximately 75%.
sensorineural disorders (including blurred vision and hearing difficulties) in nearly
50%.
These findings clearly show that chikungunya in children is not always a benign or
non-fatal infection.
Rather, it may result in long-term sequelae.
Continued….
Differences in Clinical Manifestations of Chikungunya in Children and Adults

Reff: ESPID Reports and Reviews

 Morbidity
 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

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 Mortality

A few deaths have been reported - mainly due to

Inappropriate use of antibiotics and NSAIDs

Virus can cause thrombocytopenia.

Drugs can cause gastric erosions - thus

• Leading to fatal upper GI bleed.

• Use of steroids for the joint pains & inflammation.

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 Perinatal Infection
Intrauterine transmission of CHIKV was absent or exceptionally rare in early pregnancy
but it rise to nearly 50% when mothers were viremic in the week just preceding delivery.

Infected neonates developed symptoms around day 4 (range: 3–7) of life , like fever, rash
and edema. Other frequent observations were petechiae, thrombocytopenia and
lymphopenia.

Complications included: IC bleed , Seizures and MOD, which can led to need of
mechanical ventilation in one quarter of the neonates.

Long-term outcome: Poor: half of the children exhibited diminished neurocognitive

performance at 2 years of age.
Initial Hematological changes

 Transient leucopenia and lymphopenia

 Mild thrombocytopenia

 Low rises in C-reactive protein

Differential Diagnosis D/D
 Malaria

 Dengue

 Typhoid fever

 Hepatitis

 In addition , in areas where these viruses are present, infection with West Nile
virus and other viruses belonging to the group of Flavivirus, Togavirus,
Bunyavirus and Reoviruses should be considered, particularly if there is CNS
involvement.
 Differences between Chikungunya and
Dengue fever
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 fatigue for weeks
Possible Tenosynovitis,Month2-Month3.
Common persistence of arthralgia for months to
years.
Thrombocytopenia Early and mild Delayed and possible deep.
When to suspect Chikungunya?
Should be suspected when a child presents with high-grade fever of acute onset, rash or
arthralgia or edema not otherwise explained by a different infectious cause.

A Chikungunya diagnosis becomes more likely if the child has visited or lived in an
endemic/epidemic area. However, it is important to keep in mind that cases may appear in
places where Chikungunya is not endemic.

W H O recommends both serological and virological testing of samples collected during

the first week after onset of symptoms.
 Diagnosis of Chikungunya
SEROLOGY:
Anti-CHIKV IgM and IgG on blood samples by ELISA, indirect Immunofluorescence
assays, haemagglutination inhibition or neutralization techniques.
IgM: 5 days- 3months
IgG: after 1st week of illness and in convalescent samples and persist for years or lifelong
Widely used , cost effective easy to perform
Cross reactivity with other alpha viruses and minimally with flavi virures like dengue.
CULTURE:
Viral culture can detect virus within 3days of illness.
Requires skilled personnel and well equipped facililities.
May not be available everywhere.
MOLECULAR DIAGNOSIS: Reverse transcription-(RT-PCR)
Rapid diagnosis for CHIKV on various fluids and tissues.
It can detect the viral RNA in blood as early as five days after the symptoms appear
However, it will not detect the virus efficiently after days of disease onset.
 Management
There is no specific treatment for CHIKV Bed rest with minimum activity

No vaccine or preventive pill is available Cold compresses to inflamed joints Soothing

Illness is usually self-limiting effect

It will resolve with time over 7 to 10 days Analgesics and NSAIDS

• Paracetamol ± Ibuprofen
No relapses occur – no second attacks
• Naproxen sodium.
Convalescence may take longer
• Aspirin should be avoided ( Bleeding).
Symptomatic treatment only

Liberal fluid intake (Oral /IV)

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 What not to give
• 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 than we may consider use of steroids in short
burst.

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 Prevention
• Vaccines
In 2000, a live-attenuated CHIKV vaccine was developed by the US army and
used in a randomized, double-blind, placebo-controlled trial.
Seroconversion rates were high (98%), but the vaccine temporally was
associated with arthralgia in 8% of vaccines.
For these reasons, further assessment of the vaccine was discontinued.
Currently, alternative strategies for the development of a safe and efficacious
chikungunya vaccine continue to be investigated.
 Eradication of the Vector &
Personal Protection Against
Mosquito Bites
Eradication of the Vector is the main public health strategy.
Preventive measures include reduction of breeding sites for Aedes spp., which
primarily dwell in natural and artificial water-filled container habitats.
Draining stagnant water and keeping stored water covered
Mosquito coils, bed nets, mosquito repellents should be used to avoid
mosquito bites
appropriate clothing minimizes skin exposure.
Have secure screens on windows and doors.
During outbreaks, insecticides and space spraying also may be used.