CHIKUNGUNYA FEVER

Infection and Tropical Pediatric Division

Department of Child Health
Medical Faculty, University of Sumatera Utara

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 Synonyms
• CHIKV Fever
• Buggy Creek virus infection
• Knuckle fever
• Me Tri virus infection
• Semliki Forest virus infection

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 • A common viral fever
• Self limiting – non fatal illness
• Fever, myalgia, arthralgia, lasting 2 - 7 days

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CLINICAL EPIDEMIOLOGY

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 A disease of Africa and Asia

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 Asian Distribution

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 Epidemiological Triangle
The Environment
The Vector

Interaction

The Virus The Host

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 History (Its story)
• 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
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 What is this virus ?
• 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.
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 Chikungunya Virus - EM

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 Transmission
• 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
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 The Vector
• 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
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 Aedes aegypti

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 Aedes albaptycus

Tiger Mosquito

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 Madam Aedes - at her Lunch

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 Water tap – A disease trap

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 Open Overhead Tanks

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 Domestic Water Collections

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 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

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 Most Recent Epidemics
• 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
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 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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 Symptoms
• 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
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 Clinical Features
• 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
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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 may last for weeks or months.
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 Skin Rash in Dengue

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 Skin Rash in CHIKV

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 Rare Clinical Features
• 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
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 Rare Clinical Features
• 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
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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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 Who are at greater risk ?
• Pregnant women
• Elderly people
• Newborns
• Women in general
• Diabetics
• Immuno-compromised patients
• Patients with severe chronic illnesses

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 CHIKV Morbidity
• 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
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 Mortality
• 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 32
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 Differential Diagnosis
• 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.

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 Differential Diagnosis
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
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 Laboratory Diagnosis
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
4. Virus Isolation – Infant Swiss Albino mice
– Vero BHK-21 cell lines are used
5. Nucleic acid amplification by PCR & RT PCR

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 Laboratory Diagnosis
• 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
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 Treatment
• 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
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 Treatment
• 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
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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 – we
may consider use of steroids in short burst.
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 Management of cases
• 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

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 Prevention from mosquito bites
• 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

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 Perfect Protection

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 Vector Control Measures
• 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

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