chickengunya prevention, control, treatment etc.........

Chikungunya-History
The word Chikungunya means "that which bends up". It was first described in 1952 in Africa.



The name of this disease ‘Chikungunya’ is derived from the Makonde word that means -"that which bends up" and is in reference to the stooped posture that develops due to the arthritic symptoms of the disease. The first outbreak of the disease was seen in the year 1952, in the Makonde plateau, along the border between Tanzania and Mozambique. The disease was first described by Marion Robinson and W.H.R. Lumsden in 1955 (1,2).The first outbreak in India’s was in the year 1963, in Calcutta. Since the first reported case in India in 1963 there have been sporadic outbreaks in varies parts of India.However recently reports have been shown the re-emergence of the disease in India in 2005, specially in the southern states. Since the outbreak in December 2005 there have been more that 1,80,000 reported cases of Chikungunya in India. Beginning of 2006 between February to March there have been more than 2000 cases reported in Maharashtra . Besides India, outbreaks have also been reported in Central & South Africa, Africa, Southeast Asia and the Caribbean.

Chikungunya-Overview

Chikungunya is a usually self-limiting condition due to a virus. It is important to exclude other dangerous conditions and symptomatic treatment is usually advocated



Chikungunya is a relatively a rare viral fever that is caused by the bite of a common mosquito. Outbreaks have taken place in many tropical countries. Recently it has resurfaced in many parts of South India.It causes high fever with sometimes joint pain and rashes on the body. It is important to exclude other conditions like Dengue before diagnosing it.
"The epidemic to be described occurred on the Makonde Plateau in the Southern Province of Tanganyika. It was clinically indistinguishable from dengue, if allowance is made for the inherent variability of that disease. Dengue has not been reported from the area before and no inhabitant can remember a similar epidemic. Owing to the distinctive severity of the joint pains and the sudden onset a local name was rapidly applied; the disease became known as chikungunya, meaning- "that which bends up". -Robinson Marion 1955
"The disease was at an early time given a Kimakonde name -- chikungunya. According to an educated local chief this word is derived from a root verb -- kungunyala -- meaning to dry up or become contorted, and signifies the cause of a contortion or folding. It is thought to be a new word only as applied to the disease, not as to its other uses which refer to the drying of leaves and the reaction of the sensitive plant"- W. H. R. Lumsden. 1955
Most patients recover fully from Chikungunya virus infection. They get better after a few days, however sometimes joint pain can persist for a longer period after the other symptoms have disappeared.Some deaths have been reported in a few countries but this may have been due to the inappropriate use of antibiotics and anti inflammatory drugs. As this virus can cause decreased platelets and result in bleeding one has to be careful that the drugs that are used do not further drop the platelets or cause bleeding due to gastric inflammation and erosions or ulcers(e.g. effect of Aspirin).

The incubation period is usually 1-12 days. This means the disease manifests 1 to 12 days after the bite of the mosquito. The symptoms and signs include the following Fever (> 40 C, 104 F)

HeadacheJoint pain (or arthralgia)Arthritis affecting multiple joints that can be debilitating.Swelling of JointsRash (May occur rarely)Sometimes there maybe infection of the conjunctiva of the eye and some photophobia.ChillsNauseaVomitingBleeding or hemorrhage (May occur rarely).In one study over 12% of patients who contract Chikungunya virus infection develop chronic joint symptoms(4).

Signs and symptoms
Chikungunya-Symptoms

Chikungunya is rarely a life-threatening disease. Nevertheless widespread occurrence of the disease causes extensive morbidity and financial loss.
One cannot miss the prominent symptoms in a typical case of Chikungunya. After an incubation
period of 3-12 days the following symptoms are noted- High fever typically lasts for two days and may abate all of a sudden Joints pain that are severe and often crippling Petechiae- tiny purplish red spots on the skin or reddish measly rash usually on the extremities and upper body Associated headaches Eye infections Over sensitiveness to light Difficulty to sleep Severe weakness over a variable period of 5-7days after the first onset of symptoms

Chikungunya Causes

Chikungunya is caused by virus that is transmitted by bite of a mosquito.

Chikungunya Virus, also known as Buggy Creek Virus, is transmitted by Aedes aegypti mosquito bites. The virus belongs to the Family -Togoviridae, and the Genus is Alpha virus. Till date there has been no reported direct person-to-person spread. The mosquitoes that cause infection due to the Chikungunya virus in Africa and Asia are the same mosquitoes that cause yellow fever and dengue fever in many parts of the world. Hence many parts of the world could be affected by the Chikungunya virus.Genetic analysis of the Chiungunya viruses reveal that there are two distinct types of the virus - one contains all isolates from western Africa and the second comprising all southern and East African strains, as well as isolates from Asia (3).So far there is no evidence to indicate that there is a person-to-person transmission of the disease.

Chikungunya-Treatment

Supportive care and rest There has been no effective vaccine developed to prevent Chikungunya. Vaccine trials were carried out in 2000,but funding for the project was discontinued.




To relieve symptoms of fever and joint pain the drug commonly used is Paracetamol. Rest is indicated during acute joint symptoms. Movement and mild exercise may improve stiffness and morning joint pains.In unresolved arthritis that does not respond to aspirin and non-steroidal anti-inflammatory drugs, Chloroquine Phosphate (250 mg/day) has given some promising results.Some studies have also shown that Chloroquine has some antiviral activity against this virus. However these are not conclusive studies (5).

About Chikungunya

Chikungunya is a relatively rare form of viral fever caused by an Alpha virus that is transmitted to humans by the infective bite of the Aedes aegyptii mosquito.These mosquitoes bite humans aggressively during the day.They breed in stagnant water.Pasteur Institute in Paris, in its recent research work has gathered data, which shows that this alpha virus has undergone certain transformations, called mutations, enabling its transmission by another mosquito named Aedes albopictus, generally referred as the ‘Tiger Mosquito’. Chikungunya infection is very similar to ‘Yellow Fever’, which is again transmitted by the same mosquito(Aedes aegyptii).Chikungunya is not fatal, and a person suffering from this infection is believed to develop life long immunity.The origin of the term Chikungunya can be traced back to an African language ‘Makonde’ spoken by the ‘Makonde’ people, an ethnic group in Southeast Tanzania and Northern Mozambique. ‘Makonde’ in African language means "that which bends up" referring to the bent posture resulting from the arthritic symptoms of the disease.

Recent Outbreak

According to the WHO, chikungunya has been reported recently, from a number of countries including India, and various Indian Ocean islands like the Mauritius, and Seychelles, after a period of more than 20 years. People living in these areas where the disease is endemic, and travelers to these areas are at high risk.
According to a survey that took place in September 2006 in the islands of the Indian Ocean, particularly Reunion, more than 115 travelers were reported to be infected by the Chikungunya virus. There is an increase of infection reported in India to

The island of Réunion (population 750 000) in the Indian Ocean is experiencing an extensive outbreak of chikungunya fever, an arboviral disease thought by the outbreak investigators to be transmitted by Aedes albopictus mosquitoes. Between 28 March 2005 and 15 January 2006, there have been an estimated 10 750 suspected cases of chikungunya fever in Réunion in patients who consulted a general practitioner. Of the suspected cases, 2424 have been laboratory confirmed. According to a mathematical model based on historical series, the estimated cumulative number of cases with clinical signs compatible with acute chikungunya fever since the beginning of this outbreak (whether or not patients sought medical consultation) could be around 30 000 (upper limit 41 541, 95% CI)
The outbreak of chikungunya fever in Réunion first presented a limited peak from 9-15 May 2005, before the number of cases decreased with the onset of the southern hemisphere winter. From mid-July, the incidence remained stable for a period of over three months, with an estimated 50 to 100 new suspect cases per week. The incidence then rose again, at first moderately, at the beginning of October. In mid-December, the epidemic pattern changed suddenly, as the southern hemisphere summer’s meteorological conditions are favourable for the multiplication of the vector.
Chikungunya virus was circulating in the Comoros archipelago and in Mauritius at the beginning of 2005. The first cases identified on Réunion were imported from the Comoros.
Transmission is now occurring very rapidly on the island. The weekly estimated number of cases has been increasing exponentially since the end of December 2005, and has not yet peaked. The number of cases is estimated to have reached around 5000 for the second week of January 2006. Transmission is occurring in every district of the island, but is particularly active in the district of Saint-Pierre in the south of the island, especially in the city of Saint-Louis.
To date, 15 cases of meningoencephalitis have been notified, of which 12 have been microbiologically confirmed by the French national reference centre for arboviral diseases in Lyon. The other cases are still under investigation. Six cases occurred in newborns, and mother-to-child transmission is strongly suspected in these cases. The other nine identified cases occurred in adults with pre-existing medical conditions. All cases have since progressed favourably. This is the first time that meningoencephalitis forms of chikungunya, and mother-to-child transmission of the chikungunya virus, have been reported in chikungunya outbreaks.
To date, no death has been directly attributed to acute chikungunya infection. Patients with underlying medical conditions, however, are vulnerable and prone to developing complications and organ failure.
Surveillance and controlThe Aedes albopictus mosquito lays its eggs in any water-containing receptacle, in both urban and non-urban areas. Pots, tyres and tin cans are favoured habitats. In spite of the intensification of vector control efforts in communities these past few months, the number of transmission sources has spread across the island. Individual prevention messages have targeted those most at risk and are being reinforced.
The surveillance system implemented to date was based on the investigations of the vector control teams, and case finding at the local level. As the number of cases has greatly increased, surveillance has been switched to a sentinel system of general practitioners since the last week of 2005. This system, however, will allow the monitoring of trends of this outbreak. The surveillance of severe cases has been intensified.
Teams from the Institut de Veille Sanitaire in Frances have been collaborating closely with local authorities and medical practitioners to help monitor and control this outbreak and this collaboration will continue while the outbreak is ongoing.
Special advice is being given for pregnant women, vulnerable people, and newborns to avoid mosquito bites, particularly by using mosquito nets. A list of mosquito repellants that are not contra-indicated for pregnant women and children has been made available. More information is available in French at http://www.sante.gouv.fr/ and http://www.invs.sante.fr/.

Prevention and control

There is no vaccine available against this viral infection. It is imperative to take every precaution to avoid mosquito bites and to identify the sites contusive for mosquito-breeding.A. To avoid mosquito bites:

Use clothes that cover limbs and body sufficiently,

Use mosquito repellents in plenty,

Use mosquito nets when sleeping, even during the day.B.

To prevent mosquito breeding:Discard stagnant water in which Aedes mosquitoes breed. Stagnant Water in open containers, flowerpots, coolers, tanks, drums and buckets, and discarded open plastic food should be periodically emptied.In some places biological vectors have also employed, like fish that feed on larvae of mosquitoes, in order to minimize mosquito breeding.All communities of people in the endemic areas should be made aware of hazards and methods of prevention of mosquito bite- related fevers.National programmes for mosquito control and eradication should be strengthened.

Elimination of stagnant water at home, schools and work place to avoid breeding of mosquitoes. Using insect repellents over the exposed parts of the body.

Using mosquito screens or nets in non - Air-conditioned rooms. Wearing the long sleeved clothes like long trousers of a light shade for protection against mosquitoes
Conventional Treatment

Conventional treatment offers symptomatic treatment for pain and fever using anti-inflammatory drugs, along with rest. While most cases survive the onslaught, healing can be prolonged to over a year, and the unrelenting joint pain may require

medication and long-term anti-inflammatory therapy to reduce the pain.

Recent breakout of CHICKEN GUNIYA in some southern states of India, Kerala in particular, is alarming. I therefore present some facts which could be helpful to common people.(This information has been republished from: I.M.A.G.S.B.NEWSBULLETIN/September 2006)What Is Chicken Guniya or (CHIK or CHIKU) ?Chickenguniya is a debilitating disease caused by a virus of theTogaviridae family(alphavirus genus). The incubation period(time between contamination or infecting bite and the first clinicalsigns) is usually 4-7 days.Chickenguniya is an arbovirosis : thevirus causing the disease is transmitted by a vector, an arthropod(mosquito). This is a heat-sensitive RNA virus. The virus was firstisolated in Tanzania & Uganda in 1953. The name originates fromthe posture of the patients : in Swahili, Chickenguniya means:waiting bent over.How Is The Virus Of CHIK Transmitted ?The virus is transmitted by mosquito only. The main virus reservoirsare monkey, but other species (including humans) can also beaffected. The mosquito picks up the virus by biting a personsuffering from the disease during the viremia phase and in turninfects other people.The virus is contained in the blood during theviremic period or viremia.This period starts on the first day ofsymptoms(D0) and lasts until about D+5. The virus is thereforetransmitted from human to the mosquito when a human is bittenby a mosquito during the viremic period.An infected mosquito will remain infected all its life and cantherefore transmit the virus each time it bites.Can The Virus Be Transmited From One Person To Another?No. Transmission takes place uniquely through vector mosquitos. Thisvector is a daytime vector with highest activity at the beginning and atthe end of the day.However,artificial transmission through blood-transfusion and graft surgery is possible in theory.Hence as theprecautionary measure the patient should be prevented from donatingthe blood.SYMPTOMS OF CHICKENGUNIYAThe symptoms of Chickenguniya( Chicken Guinea) include fever which canreach 39 C i.e.,102.2 F, a petechial or maculopapular rash usually involvingthe limbs and the trunk, and arthralgia or arthritis affecting multiple jointswhich can be debilitating.There can also be headache,conjunctival infectionand slight photophobia.In the present epidemic in the state of Andhra Pradeshin India, high fever and crippling joint pain was the prevalent complaint.Fever typically lasts for two days and abruptly comes down,however jointpain,intense headache,insomnia and an extreme degree of prostration lastsfor a variable period,usually for about 5-7 days.Dermatological manifestations observed in a recent outbreak of Chickenguniyain Southern India includes the following:1. Maculopapular rash2. Nasal blotchy erythema3. Freckle-like pigmentation over centro-facial area4. Flagellate pigmentation on face and extremities5. Lichenoid eruption and hyperpigmentation in photodistributed areas6. Multiple aphthous-like ulcers over scrotum,curual areas and axilla7. Lympoedema in acral distribution (bilateral/unilateral)8. Multiple ecchymotic spots (Children)9. Vesiculobullous lesions (Infants)10.Subungual haemorrhageVACCINES & IMMUNIZATIONSince the beginning of the outbreak in La Reunion, 243 deaths directlyor indirectly related to Chickenguniya have been reported-most of themoccurring among elderly patients with underlying medical condition. About755 of the deaths occured in persons over the age of 70 years.There are 273 patients(older than 10 days of age) who presented with a severe formof Chickenguniya,246 of whom were confirmed. Of these,67 patients have died. The signs of severity include respiratory failure, cardio-vasculardecompensation, or meningo-encephalitis. As for infants less than 10 daysold, 40 tnfections have been confirmed, one of whom has died. Chikungunyainfection was confirmed in the mothers of 39 of these infants.Like in other arboviruses,Chickenguniya infection can either go totallyunnoticed(i.e. the person is symptom-free; infection is then said to beasymptomatic) or cause painful and persisting symptoms.

WHAT SHOULD YOU DO WHEN FIRST SYMPTOMS APPEAR

?You should immediately see a doctor who will prescribe a suitable treatmentfor your particular symptoms. You must also avoid contact with mosquitosso as not to transmit the disease to people around you.

CAN YOU BE INFECTED AGAIN?No. Any person infected once acquires durable immunity naturally.However,some joint pain(arthralgia) may persist or reappear over variable periods oftime.This is a reaction of the joints and is not due to any re-infection by thevirus.

ARE CERTAIN POPULATION GROUPS MORE LIKELYTO DEVELOP CHICKENGUNIYA ?

No single catagory of population ( age, sex, occupation, ethnic group, etc. )is more immune from Chickenguniya than others.

IS THERE A HUMAN VACCINE? CAN IT BE DEVELOPED IN SHORT TERM?No. There is currently no marketed vaccine available for humans.It takesseveral years to complete a vaccine research, development and marketingcampaign.

IS THERE AN EFFICIENT THERAPY FOR PEOPLE?Treatment is symptomatic-rest, fluids,and ibuprofen, naproxen,acetamenophen, or paracetamol may relieve symptoms of fever and aching. Aspirin should be avoided.There is possible role for chloroquine in the treatment of Chikenguniya.There is an interesting dialogue, mostly in French(on Internet), about the possible use of chloroquine in the treatment of the arthralgia associated with Chikenguniya.Supportive care with rest is indicated during the acute joint symptoms.Movement and mild exercise tend to improve stiffness and morning arthralgia, but heavy exercise may exacerbate rheumatic symptoms.Use of steroids for the control of joint npains and inflammation is dangerous and completely unwarranted.Following a recent outbreak (2006) of the disease in Southern India, several homeopathy practitioners in the region have been handing out medicine that is supposed to prevent the disease. However, there have been no scientific studies to confirm the effectiveness of homeopathy against the Chikenguniya.

HOW TO AVOID BEING INFECTED ?Because there is no vaccine or preventive treatment, the only way not to be infected is to reduce exposure tu mosquito-bite as far as possible. This entails destroying larva-breeding grounds in order to reduce vector density, and protecting oneself against insect-bite.

WHERE DOES THE FEMALE Aedes albopictus LAY EGGS?The female Aedes albopictus lays its eggs in a breeding ground or "nest" consisting of standing waterpools.Females lay their eggs in fresh water containing little organic matter(clean water).There are different types of these nests:*Household Nests: rain barrels, flowerpot saucers,cut-in pots,etc.*Quasi-household Nests: rain-exposed containers, cluttered rain gutters that do not drain completely, unmaintained swimming-pools and basins, old tyres, refuse abandoned in gardens, cut bamboo stalks, plants with sheathing leaves, etc.*Natural Pockets:ravines,holes in boulders, holes or nooks of trees, swamps, ruts,etc. About 80% of nests are man-made(household and quasi-household). The aedes mosquito is sedentary: it will not fly more than 100 metre from itd original shelter.

AT WHICH TIME OF THE DAY IS THE Aedes albopictus MORE LIKELY TO BITE?The adult(female) is active during the day, with two major periods of activity: one in the morning at sunrise, the other in late afternoon at sunset(when the mosquito is often more aggrassive).Aedes albopictus generally bites outdoors( it is "exophagic") but it can also fly into the house and bite people inside.

IS A VIRUS-INFECTED MOSQUITO ITSELF AFFECTED BY THE DISEASE?No.Mosquitos do not seem to be affected by the virus in their bodies.Once a female is infected( and infecting), it remains so throughout its life. There is no evidence of the female transmitting the Chikenguniya virus to its eggs(however, transmission of the dengue fever virus to eggs has been evidenced.

HOW TO REDUCE RISK?

Short of an available vaccine or preventive drugs, the only way to reduce the risk of catching the disease is to reduce exposure to infected mosquitos. You must therefore(i) protect your body against bites and(ii) reduce the number of mosquitos around your home by destroying larva nests(discussed above).

HOW TO PROTECT ONESELF FROM MOSQUITO-BITES ?Several options are available to you:-Ventilation with fans or air conditioners.-Electric insecticide diffusers or coils for outside use.-Repellant creams and sprays.Mosquito repellant based on a 30% DEFT concentration is recommended.Aphysician should be consulted before using repellants if there are children under 12 years or/and a pregnant woman.Repellants are not advisible for children under three months.Insecticide-treated bed-nets are recommended for them.-In the evening, long-sleeved clothes and long trousers should be worn to reduce direct skin exposure(especially legs and ankles).-Mosquito screens should be placed on windows; mosquito nets over baby-cots and prams and over the beds of people confined to bed.RECENT OUTBREAKS:In February 2005, an outbreak was recorded on the French Island of Reunion in the Indian Ocean. As on May 18,2006, some 258,000 residents have been hit by the virus in the past year(out of about 777,000). 219 official deaths have been associated with Chikenguniya.Mauritius-3500 islanders have been hit in 2005.In 2006,there was a big outbreak in Andhra Pradesh(India). The initial cases were reported from Hyderabad and Secunderabad as well as from Anantpur district as early as in Nov and Dec,2005 and it is continuing unabated. In Hyderabad alone an average practitioner sees and treats somewhere between 10 to 20 cases every day.On average there are around 5300 cases being treated daily. This figure is only from public-sector. The figures combined with the private sector (clinics) would be much higher.There have been reports of large scale outbreak of this virus in Southern India.At least 80000 people in Gulbarga, Tumkur, Bidar, Raichur, Bellary, Chitradurga, Davangere, Kolar and Bijapur districts in Karnataka State are known to have been affected since Dec 2005.In Bangalore,the capital of Karnataka State(India), there seems to be an outbreak of Chikenguniya now(May 2006) with arthralgia /arthritis and rashes. So also in the neighbouring State of Andhra Pradesh. In the third week of May 2006 the outbreak of Chikenguniya in North Karnataka was severe.As of July 2006, nearly 50000 people were affected in Salem, Tamilnadu.On 24 August 2006,"The Hindu" daily reported that the Indian States of Tamilnadu,Karnataka,Andhra Pradesh, Maharashtra, Madhya Pradesh, Gujarat and Kerala had reported 1.1 million cases.Analysis of the rcent outbreak has suggested that the increased severity of the disease may be due to a change in the genetic sequence, altering the virus' coat protien, which potentially allows it to multiply more in mosquito cell.PLENTY OF ORAL FLUIDSNONSTEROIDAL ANTI-INFLAMMATORY DRUGSNO ASPIRINNO STEROIDS