Updated until 23rd September 2006

CHIKUNGUNYA FEVER
Dr. R.V.S.N.Sarma., M.D., M.Sc.,
(Canada)
Consultant Physician and Chest
Specialist

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What is this tongue

twister ?

It is CHIKUNGUNYA
To be pronounced as [chick-en-GUN-yah]
It is 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

Refers to the stooped posture of the patient

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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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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, non fatal viral illness
Thanks to the Almighty

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Should we be panicky ?
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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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
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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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The CHIK Virus

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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

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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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The Recent Epidemics

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Notable Outbreaks

1963 to 1965 - An epidemic was reported in Calcutta

4.37% of the people were later found to be seropositive
1973 An epidemic 37.53% in Barsi - Sholapur district
2006 Present epidemic after 33 years is the largest
9,06,360 or more cases in Andhra Pradesh
5,43,286 cases from Karnataka; 66,109 from Blore
Maharashtra 2,02,114 cases; Gujarat 2,500 cases
Tamil Nadu 49,567 cases; Orissa 4,904 cases,
Madhya Pradesh 43,784 and Pune 138 cases

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Distribution in India

The disease is common with periodic epidemics

Sporadic outbreaks described in Madras and Vellore
Cases were reported in Chennai, Pondicherry, Vellore
Vizag in 1964; Rajahmundri, Kakinada, Nagpur in
1965
The last epidemic in India was in 1973
From Yavat village (Pune) in 2000
2.9% in the Andaman & Nicobar Islands are
seropositive
Infected mosquitoes seen in Pune, Maharastra State
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Most Recent Epidemics

Epidemic of CHIKV occurred in Malaysia 1999
French island of Runion in the Indian Ocean2005
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
Maximum # of cases from Andhra Pradesh so far

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The Indian Epidemic

Present epidemic has started in Nov 2005
Andhra Pradesh, Karnataka, Maharashtra,
Madhya Pradesh, Orissa, Gujarat,
Tamilnadu, Rajasthan, Kerala are under its
onslaught
This is spreading far and wide at a rapid
rate
Not much spread to the northern states like
Delhi, Haryana, Punjab as yet.
Not much cry from U.P. and Bihar
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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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Why is this sudden

epidemic ?
Analysis of the recent Indian
epidemic has suggested that the
increased severity of the disease is
due to a change in the genetic
sequence, altering the virus coat
protein, which potentially allows it
to multiply more easily in mosquito
*http//medicine.plosjournal
cells*.

s.org

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Why is this quasipandemic ?

Several distinct variants of the virus
A change at position 226 of the E1 coat protein
This A226V mutation caused the virus to more
easily invade and multiply in the mosquitoes
Three protein changes in non-structural
proteins
nsP1 (T301I), nsP2 (Y642N), and nsP3 (E460
deletion)
This mutant virus - from a neonatal encephalopathy
case
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Clinical Features

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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 (40C or 104F),
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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Kun gunyala

The Contorted
Posture
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Acute CHIKV Fever

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Skin Rash in Dengue

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Skin Rash in CHIKV

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Petechiae on feet

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The Burden of 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
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Pregnancy and CHIKV

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Pregnancy and CHIKV

Mother to fetus transmission can occur

Reported between 3 to 4.5 months of gestation
Maternal IgG develops in 2 weeks after CHIKV
This passes through placenta confers protection
Intra-partum risk is 48% if mother has viremia
Neonatal infections are very mild; fully recover
No miscarriages or congenital malformations

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Vertical Transmission
Vertical maternal-fetal transmission of the
Chikungunya virus. Ten cases in newborns
among 84 pregnant women
Robillard PY, Boumahni B, Gerardin P,
Michault A, Fourmaintraux A, Schuffenecker
I, Carbonnier M, Djemili S, Choker G, RogeWolter M, Barau G.

Pub Med. 2006 May; 35(5 Pt 1):785-8.

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Pregnancy - CHIKV
June 2005 to Jan 2006, 84 pregnant women with
CHIKV
In 88% cases the newborns are asymptomatic
10 newborns had severe attacks, 4 meningoencephalitis
3 with intravascular coagulations; No infants died
One case of severe intra cerebral hemorrhage
Had severe thrombocytopenia
All confirmed by specific serology or PCR or both
Women had severe intra-partum viremia & fever
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Differential Diagnosis
Dengue fever, DHF, DSS
Onyong-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
Presentation

CHIKV
A+F mild
rash

DENGUE
A+F+Rash

Arthralgia
Arthritis
Bone pains

Moderate
Severe
Not common Frequent
None
Break bone
fever

Thrombocytope Mild (Not <

nia
1K)

May be
severe

Hemorrhage

May be
present

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None

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Laboratory Diagnosis

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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 5 th day
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Value of RT -PCR
Real Time PCR scores over conventional PCR
Positive in the phase of viremia up to 5 days
Transportation of sample to be at 2 o to 8o c
It is a confirmatory test with high specificity
Its sensitivity is very high; detects even 1 copy
After the viremia ceases it will be negative
We do not have the HI Ab or Ig M capture

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Treatment of CHIKV

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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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CHIKUNGUNYA DRUG
France develops a new drug to treat

"We are confident today that a drug

to treat Chikungunya will be made
available and we are hopeful that
this drug will be available at the
very end of this year or at the very
start of 2007"
- French Health Minister - Xavier Bertrand
- September 11th 2006
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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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AYUSH
A Ayurvedic or Acupuncture
Y Yoga and or Naturopathy
U Unaani
S Siddha
H Homeopathy
No comments on these alternative
medicines
If no pathy works, finally
Venkatapathy or Tirupathy
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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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Pregnancy and Lactation

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NSAIDs in Pregnancy
Using NSAIDs during early or late stages of
pregnancy is not associated with congenital
anomalies, prematurity, or low birth weight, but
There is a significant link between NSAID use
and miscarriage in the first trimester.
In third trimester may cause premature
delivery
Recommend stopping NSAIDS 6 to 8 weeks
before delivery to prevent premature closure of
fetal ductus arteriosus.
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Lactating Women
Q. Can a woman suffering from early signs of
Chikungunya breast feed her month old baby?
A. It is better if you do not. During very early
stages fever there is viremia. And some of the
virus may be present in the breast milk. As in
newborns the immune system is not mature
particularly monocyte-macrophages system,
these cells may not be able to take care of the
ingested virus absorbed through mucous
membranes.
Answered on 28 August 2006 by Dr. Pradeep Seth
Professor of Virology and Head, Department of Microbiology
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Prevention of Mosquito
bite

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Avoid Mosquito Menace

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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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Correct leaking taps

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Cover overhead tanks

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Domestic Water Collections

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Properly close the garbage

bins

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Peri domestic fumigation

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Out door fumigation

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Mosquito Magnet

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IEC Activities
Awareness of CHIKV
Mass media, TV, Radio, News
papers
Awareness of vector and its control
Involvement of NGOs
Special campaigns
Punishment for non-compliance
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