Chickungunya - dr

‘‘Chikungunya’ Chikungunya’ ––A short A short Chikungunya Chikungunya ––A short A short presentation with Salient presentation with Salient

FeaturesFeatures

Dr.G.C.Sahu/ROH&FW/Dr.G.C.Sahu/ROH&FW/GoIGoI/Ahmedabad/Ahmedabad 11

ChikungunyaChikungunya is a relatively rare form of viral is a relatively rare form of viral f d b f d b l h il h i h i d b bi h i d b bi fever caused by an fever caused by an alpha virusalpha virus that is spread by bites that is spread by bites of the Aedes aegypti mosquito.of the Aedes aegypti mosquito.

Th i d i d f h Th i d i d f h M k dM k d d d The name is derived from the The name is derived from the MakondeMakonde word word meaning meaning "that which bends up""that which bends up" in reference to the in reference to the stooped posture stooped posture developed as a result of the arthritic developed as a result of the arthritic

f h di f h disymptoms of the disease.symptoms of the disease.

The disease was first described by Marion The disease was first described by Marion R bi d W H R R bi d W H R L dL d i 1955 f ll i i 1955 f ll i Robinson and W.H.R. Robinson and W.H.R. LumsdenLumsden in 1955, following an in 1955, following an outbreak on the outbreak on the MakondeMakonde Plateau, along the border Plateau, along the border between Tanganyika and Mozambique in 1952.between Tanganyika and Mozambique in 1952.

Chikungunya is closely related to Chikungunya is closely related to O'nyong'nyongO'nyong'nyongvirusvirus

Chikungunya is not considered to be fatal…..but Chikungunya is not considered to be fatal…..but can be debilitating.can be debilitating.


SynonymsSynonymsSynonymsSynonyms

CHIKV FeverCHIKV FeverBuggy Creek virus infectionBuggy Creek virus infectionBuggy Creek virus infectionBuggy Creek virus infectionKnuckle feverKnuckle feverKnuckle feverKnuckle feverMe Tri virus infectionMe Tri virus infectionSemliki Forest virus infectionSemliki Forest virus infection


Chikungunya is spread by the bite of an Aedes mosquito,Chikungunya is spread by the bite of an Aedes mosquito,primarily primarily Aedes aegypti Aedes aegypti species.species.p yp y gypgyp pp

Humans are thought to be the major source or reservoir of Humans are thought to be the major source or reservoir of chikungunya virus for mosquitoes.chikungunya virus for mosquitoes.chikungunya virus for mosquitoes.chikungunya virus for mosquitoes.

Therefore, the mosquito usually transmits the disease byTherefore, the mosquito usually transmits the disease bybiting an infected person and then biting someone elsebiting an infected person and then biting someone elsebiting an infected person and then biting someone else. biting an infected person and then biting someone else.

An infected person cannot spread the infection directly to other An infected person cannot spread the infection directly to other Persons (i.e. it is not a contagious disease). Persons (i.e. it is not a contagious disease).

Aedes aegyptiAedes aegyptigypgypmosquitoes bite during the day time.mosquitoes bite during the day time.

Dr.G.C.Sahu/ROH&FW/Dr.G.C.Sahu/ROH&FW/GoIGoI/Ahmedabad/Ahmedabad44

Chikungunya occurs mainly in Africa, India, and SoutheastChikungunya occurs mainly in Africa, India, and SoutheastAsia There have been a number of outbreaks (epidemics) inAsia There have been a number of outbreaks (epidemics) inAsia. There have been a number of outbreaks (epidemics) inAsia. There have been a number of outbreaks (epidemics) inthe Philippines and on islands throughout the Indian Ocean.the Philippines and on islands throughout the Indian Ocean.

Humans act as very efficient reservoirs for the virus. Humans act as very efficient reservoirs for the virus. chikungunya is most prevalent in chikungunya is most prevalent in urban areasurban areas. Currently the . Currently the

disease is being reported from rural areas also due to the disease is being reported from rural areas also due to the d sease s be g epo ted o u a a eas a so due to t ed sease s be g epo ted o u a a eas a so due to t eproliferation of this vector as a result of life style change among proliferation of this vector as a result of life style change among

rural population. Epidemics are sustained by the humanrural population. Epidemics are sustained by the human--mosquitomosquito--human transmission cyclehuman transmission cyclehuman transmission cycle.human transmission cycle.

Anyone who is bitten by an infected mosquito can getAnyone who is bitten by an infected mosquito can gethikhikchikungunya. chikungunya.

Widespread poverty, yearWidespread poverty, year--round tropical climate, environround tropical climate, environ--mental disturbance due to war or natural disaster and lack ofmental disturbance due to war or natural disaster and lack of

public health infrastructure are some of the factors that promotepublic health infrastructure are some of the factors that promoteuncontrolled mosquito breeding and isuncontrolled mosquito breeding and is condusivecondusive toto


uncontrolled mosquito breeding and is uncontrolled mosquito breeding and is condusivecondusive totooutbreaks of chikungunya, outbreaks of chikungunya,

Epidemiological TriangleEpidemiological TriangleEpidemiological TriangleEpidemiological Triangle

The EnvironmentThe Vector

I t tiInteraction

The HostThe VirusDr.G.C.Sahu/ROH&FW/Dr.G.C.Sahu/ROH&FW/GoIGoI/Ahmedabad/Ahmedabad 66

The Indian EpidemicThe Indian EpidemicThe Indian EpidemicThe Indian EpidemicThe last Indian epidemic started in Nov 2005.The last Indian epidemic started in Nov 2005.The last Indian epidemic started in Nov 2005.The last Indian epidemic started in Nov 2005.Andhra Pradesh, Karnataka, Maharashtra, Andhra Pradesh, Karnataka, Maharashtra, Madhya Pradesh, Odisha, Gujarat, Tamilnadu, Madhya Pradesh, Odisha, Gujarat, Tamilnadu, jjRajasthan, Kerala came under its onslaught.Rajasthan, Kerala came under its onslaught.The epidemic spread far and wide at a rapid The epidemic spread far and wide at a rapid

t b t th t t lik D lhi H t b t th t t lik D lhi H rate but northern states like Delhi, Haryana, rate but northern states like Delhi, Haryana, Punjab remained mostly unaffected.Punjab remained mostly unaffected.There was not much cry from U P and Bihar There was not much cry from U P and Bihar There was not much cry from U.P. and Bihar There was not much cry from U.P. and Bihar either. either.

Dr.G.C.Sahu/ROH&FW/GoI/AhmedabadDr.G.C.Sahu/ROH&FW/GoI/Ahmedabad88

S tS tSymptomsSymptoms

The symptoms of The symptoms of chikungunyachikungunya include:include:

••Fever which can reach 39 Fever which can reach 39 °°C C ••Fever which can reach 39 Fever which can reach 39 °°C, C,

••A A petechialpetechial or or maculopapularmaculopapular rash rash usually involving the limbs and trunk,usually involving the limbs and trunk,

••Arthralgia or arthritis affecting multiple Arthralgia or arthritis affecting multiple g g pg g pjoints which can be debilitating. joints which can be debilitating.

••There can also be headache There can also be headache There can also be headache, There can also be headache, conjunctivalconjunctival suffusion and slight suffusion and slight photophobia.photophobia.


Clinical FeaturesClinical FeaturesClinical FeaturesClinical FeaturesIncubation period is 2Incubation period is 2 12 days; usually 312 days; usually 3 7 7 Incubation period is 2Incubation period is 2--12 days; usually 312 days; usually 3--7 7 days.days.Viremia last for 5 days (infective period).Viremia last for 5 days (infective period).Viremia last for 5 days (infective period).Viremia last for 5 days (infective period).Silent CHIKV Silent CHIKV –– inapparent infections in childreninapparent infections in childrenFluFlu--like symptoms, Severe headache and chills. like symptoms, Severe headache and chills. FluFlu like symptoms, Severe headache and chills. like symptoms, Severe headache and chills. High grade fever (40High grade fever (40°°C or 104C or 104°°F).F).Arthralgia or arthritis Arthralgia or arthritis –– lasting several weeks.lasting several weeks.gg ggConjunctival suffusion and mild photophobia.Conjunctival suffusion and mild photophobia.Nausea, vomiting, abdominal pain, severe Nausea, vomiting, abdominal pain, severe weakness.weakness.


The ArthralgiaThe ArthralgiaThe ArthralgiaThe Arthralgia

The small joints of the lower and upper limbs.The small joints of the lower and upper limbs.Migratory poly arthralgia Migratory poly arthralgia –– not much effusions.not much effusions.Larger joints may also be affected (knee, Larger joints may also be affected (knee, ankle).ankle).Pain worse in the morning Pain worse in the morning –– less by evening.less by evening.Joints may be swollen & painful to the touch.Joints may be swollen & painful to the touch.Some patients have incapacitating joint pains.Some patients have incapacitating joint pains.Arthritis may last for weeks or months. Arthritis may last for weeks or months.


Course of illnessCourse of illnessCourse of illnessCourse of illnessFever typically lasts for 2 Fever typically lasts for 2 -- 3 days and comes down.3 days and comes down.Fever may reoccur after 3 days Fever may reoccur after 3 days –– ‘saddle back’ fever.‘saddle back’ fever.Some rare cases Some rare cases -- fever lasts up to a couple of weeksfever lasts up to a couple of weeksSome rare cases Some rare cases -- fever lasts up to a couple of weeks.fever lasts up to a couple of weeks.Patients do have prolonged fatigue for several weeks. Patients do have prolonged fatigue for several weeks. High fever & crippling joint pain marked the last Indian High fever & crippling joint pain marked the last Indian epidemic.epidemic.Joint pain, intense headache, insomnia and an extreme Joint pain, intense headache, insomnia and an extreme degree of prostration may last for 5 to 7 days.degree of prostration may last for 5 to 7 days.deg ee o p os a o ay as o 5 o daysdeg ee o p os a o ay as o 5 o daysLife long immunity, once one suffers this infection.Life long immunity, once one suffers this infection.


Who are at greater risk ?Who are at greater risk ?Who are at greater risk ?Who are at greater risk ?P t P t Pregnant womenPregnant womenElderly peopleElderly peopleNewbornsNewbornsWomen in generalWomen in generalWomen in generalWomen in generalDiabeticsDiabeticsImmunoImmuno compromised patientscompromised patientsImmunoImmuno--compromised patientscompromised patientsPatients with severe chronic Patients with severe chronic illillillnessesillnesses

Dr.G.C.Sahu/ROH&FW/GoI/AhmedabadDr.G.C.Sahu/ROH&FW/GoI/Ahmedabad 1313

Differential DiagnosisDifferential DiagnosisDifferential DiagnosisDifferential Diagnosis

Dengue fever, DHF, DSS.Dengue fever, DHF, DSS.O’nyongO’nyong--nyong viral fevernyong viral feverO nyongO nyong nyong viral fever.nyong viral fever.SindbisSindbis viral fever.viral fever.Other non specific viral fevers.Other non specific viral fevers.Any other acute fever like Any other acute fever like Any other acute fever like Any other acute fever like malaria, UTI etc.malaria, UTI etc.


DIAGNOSISDIAGNOSIS

Chikungunya is diagnosed by blood tests. Chikungunya is diagnosed by blood tests.

Si th li i l f b th Si th li i l f b th Since the clinical appearance of both Since the clinical appearance of both chikungunya and dengue are similar, laboratory chikungunya and dengue are similar, laboratory confirmation is important, especially in areas where confirmation is important, especially in areas where p p yp p ydengue is present.dengue is present.

Key Diagnostic Tests.Key Diagnostic Tests.Key Diagnostic Tests.Key Diagnostic Tests.

Detection of antigens or antibody to the agent in Detection of antigens or antibody to the agent in the blood (serology) the blood (serology) the blood (serology) the blood (serology)

ELISA is available ELISA is available

An An IgMIgM capture ELISA is necessary to distinguish capture ELISA is necessary to distinguish the disease from dengue fever. the disease from dengue fever.

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TreatmentTreatmentTreatment….Treatment….There is no specific treatment for CHIK V There is no specific treatment for CHIK V There is no specific treatment for CHIK V. There is no specific treatment for CHIK V. Symptomatic treatment only.Symptomatic treatment only.No vaccine or preventive pill is available .No vaccine or preventive pill is available .No vaccine or preventive pill is available .No vaccine or preventive pill is available .The illness is usually selfThe illness is usually self--limiting.limiting.It will resolve with time over a week to 10 It will resolve with time over a week to 10 days.days.No relapses occur No relapses occur –– no second attacks. no second attacks. Convalescence may take longer.Convalescence may take longer.

Infected persons should be isolated from mosquitoes in as Infected persons should be isolated from mosquitoes in as much as possible in order to avoid transmission of infection to much as possible in order to avoid transmission of infection to much as possible in order to avoid transmission of infection to much as possible in order to avoid transmission of infection to other people.other people.


TreatmentTreatmentTreatment….Treatment….Rest to the patient and mild movements of joints.Rest to the patient and mild movements of joints.Cold compresses to inflamed joints.Cold compresses to inflamed joints.Liberal fluid intake or IV fluids.Liberal fluid intake or IV fluids.Analgesics and NSAIDS:Analgesics and NSAIDS:

Paraetamol Paraetamol ±± Ibuprofen or aceclofenac or diclofenac .Ibuprofen or aceclofenac or diclofenac .Naproxen sodium (Naprasyn, Xenobid).Naproxen sodium (Naprasyn, Xenobid).Naproxen sodium (Naprasyn, Xenobid).Naproxen sodium (Naprasyn, Xenobid).Aspirin should be avoidedAspirin should be avoided

Hydroxy chloroquine sulphate (HCQS) 200 mg/OD or Hydroxy chloroquine sulphate (HCQS) 200 mg/OD or chloroquine phosphate 250 mg/OD may supplement chloroquine phosphate 250 mg/OD may supplement q p p g/ y ppq p p g/ y ppalleviating the acute symptoms.alleviating the acute symptoms.The role of steroidal preparations in easing the acute The role of steroidal preparations in easing the acute symptoms is still debatable.symptoms is still debatable.y py p


What not to give ?What not to give ?No indication for antibiotics.No indication for antibiotics.Never use costly, large spectrum Never use costly, large spectrum Never use costly, large spectrum Never use costly, large spectrum drugs.drugs.No indication for long acting steroidsNo indication for long acting steroidsNo indication for long acting steroidsNo indication for long acting steroidsNo indication for short term steroids No indication for short term steroids also in the acute phase of illness.also in the acute phase of illness.also in the acute phase of illness.also in the acute phase of illness.Rarely, if the joint swelling persists Rarely, if the joint swelling persists ––we may consider use of steroids in we may consider use of steroids in we may consider use of steroids in we may consider use of steroids in short burst. short burst.


Although it may feed at any time, the mosquito's periods Although it may feed at any time, the mosquito's periods of peak biting activity are few hours after dawn and in the late of peak biting activity are few hours after dawn and in the late of peak biting activity are few hours after dawn and in the late of peak biting activity are few hours after dawn and in the late afternoon until a few hours after dark.afternoon until a few hours after dark.

The mosquito's preferred breeding areas are in areas ofThe mosquito's preferred breeding areas are in areas ofstagnant water, such as flower vases, uncovered barrels, stagnant water, such as flower vases, uncovered barrels, g , , ,g , , ,buckets, and discarded tires, but the most dangerous areas are buckets, and discarded tires, but the most dangerous areas are wet floors, underground tanks, cement tanks and also toilet wet floors, underground tanks, cement tanks and also toilet bowls, as they allow the mosquitos to breed right in the bowls, as they allow the mosquitos to breed right in the residence.residence.


…..THE VECTOR IS AN …..THE VECTOR IS AN AGGRESSIVE BITER…AND AGGRESSIVE BITER…AND

MOSTLY BITES DURING DAY MOSTLY BITES DURING DAY TIME……. WITH A PAINFUL TIME……. WITH A PAINFUL

STING.STING.

JUST WATCH THEJUST WATCH THE……..JUST WATCH THE ……..JUST WATCH THE FEROCITY OF THE STINGFEROCITY OF THE STING


…… HER PARAPHRENALIA…… HER PARAPHRENALIA

THETHETHE THE PLOT IS PLOT IS

HATCHED HATCHED MOSTLY MOSTLY UNDERUNDERUNDER UNDER

WATER !!!WATER !!!

Dr.G.C.Sahu/ROH&FW/Dr.G.C.Sahu/ROH&FW/GoIGoI/Ahmedabad/Ahmedabad

…AND THE CYCLE GOES ON…AND THE CYCLE GOES ON

ONE GENERATIONONE GENERATIONIS BORN ROUGHLY EVERY IS BORN ROUGHLY EVERY

WEEKWEEKEVERY THING IN A EVERY THING IN A

PLATTER !!!PLATTER !!!


URBAN BREEDINGURBAN BREEDINGSITESSITES

(Now a days also found in(Now a days also found in

Dr.G.C.Sahu/ROH&FW/GoI/AhmedabadDr.G.C.Sahu/ROH&FW/GoI/Ahmedabad2323

(Now a days also found in (Now a days also found in rural settings)rural settings)

PERSONAL PROPHYLACTIC MEASURESPERSONAL PROPHYLACTIC MEASURES--PREVENTION OF MOSQUITO BITESPREVENTION OF MOSQUITO BITESPREVENTION OF MOSQUITO BITESPREVENTION OF MOSQUITO BITES

WEAR FULL SLEEVED CLOTHS LONG DRESSES THAT COVER THE WEAR FULL SLEEVED CLOTHS LONG DRESSES THAT COVER THE WEAR FULL SLEEVED CLOTHS, LONG DRESSES THAT COVER THE WEAR FULL SLEEVED CLOTHS, LONG DRESSES THAT COVER THE ARMS AND LEGS DURING THE OUTBREAKS.ARMS AND LEGS DURING THE OUTBREAKS.

USE INSECT REPELLENTS WHILE SLEEPING AT NIGHTUSE INSECT REPELLENTS WHILE SLEEPING AT NIGHTUSE INSECT REPELLENTS WHILE SLEEPING AT NIGHT.USE INSECT REPELLENTS WHILE SLEEPING AT NIGHT.

TAKE ADDITIONAL CARE OF CHILDREN AND ELDERLY.TAKE ADDITIONAL CARE OF CHILDREN AND ELDERLY.

USE MOSQUITO COILS/ELECTRIC VAPOUR MATS.USE MOSQUITO COILS/ELECTRIC VAPOUR MATS.

USE MOSQUITO NETS ESPECIALLY TO PROTECT BABIES AND OLD USE MOSQUITO NETS ESPECIALLY TO PROTECT BABIES AND OLD USE MOSQUITO NETS ESPECIALLY TO PROTECT BABIES AND OLD USE MOSQUITO NETS ESPECIALLY TO PROTECT BABIES AND OLD PEOPLE.PEOPLE.

KEEP PATIENTS PROTECTED FROM MOSQUITO BITES IN ACUTE KEEP PATIENTS PROTECTED FROM MOSQUITO BITES IN ACUTE KEEP PATIENTS PROTECTED FROM MOSQUITO BITES IN ACUTE KEEP PATIENTS PROTECTED FROM MOSQUITO BITES IN ACUTE PHASE WHICH WILL REDUCE NO.OF INFECTIVE MOSQUITO PHASE WHICH WILL REDUCE NO.OF INFECTIVE MOSQUITO POPULATION.POPULATION.


PREVENTION OF MULTIPLICATION OF MOSQUITOPREVENTION OF MULTIPLICATION OF MOSQUITOPREVENTION OF MULTIPLICATION OF MOSQUITOPREVENTION OF MULTIPLICATION OF MOSQUITO

DRAIN WATER FROM COOLERS.TANKS,BARRELS,DRUMS AND DRAIN WATER FROM COOLERS.TANKS,BARRELS,DRUMS AND BUCKETS ETC.BUCKETS ETC.

COOLERS SHOULD BE EMPTIED OF WATER WHEN NOT IN USE.COOLERS SHOULD BE EMPTIED OF WATER WHEN NOT IN USE.

UNUSED WATER CONTAINING OBJECTS/HOLDING OBJECTS UNUSED WATER CONTAINING OBJECTS/HOLDING OBJECTS SHOULD BE REMOVED FROM HOUSE HOLDS.SHOULD BE REMOVED FROM HOUSE HOLDS.

WATER SHOULD BE REMOVED FROM REFRIGERATER DRIP OPANS WATER SHOULD BE REMOVED FROM REFRIGERATER DRIP OPANS EVERY OTHER DAYEVERY OTHER DAYEVERY OTHER DAY.EVERY OTHER DAY.

ALL USABLE AND STORED WATER COINTAINERS SHOULD BE ALL USABLE AND STORED WATER COINTAINERS SHOULD BE KEPT COVERED ALLTHE TIME.KEPT COVERED ALLTHE TIME.

CLEAN UP THE TERRACE, DISCARD SOLID WASTE FROM THECLEAN UP THE TERRACE, DISCARD SOLID WASTE FROM THESORROUNDINGS.SORROUNDINGS.


TAKE LONG TERM MEASURESTAKE LONG TERM MEASURES

INITIATE RECOMMENDED VECTOR CONTROLINITIATE RECOMMENDED VECTOR CONTROLINITIATE RECOMMENDED VECTOR CONTROL INITIATE RECOMMENDED VECTOR CONTROL MEASURES.MEASURES.

IDENTIFY AND MAP OUT THE HIGH RISK AREAS FORIDENTIFY AND MAP OUT THE HIGH RISK AREAS FORPRIORITISATION OF AREA SPECIFIC STRATEGIES.PRIORITISATION OF AREA SPECIFIC STRATEGIES.

PATIENTS SHOULD BE TREATED IN NEARBY HEALTH PATIENTS SHOULD BE TREATED IN NEARBY HEALTH /HOSPITALS./HOSPITALS./HOSPITALS. /HOSPITALS.

EFFECTIVE HEALTH EDUCATION CAMPAIGNS AND EFFECTIVE HEALTH EDUCATION CAMPAIGNS AND FIELD SUPERVISIONFIELD SUPERVISIONFIELD SUPERVISION.FIELD SUPERVISION.


ELIMINATION OF ELIMINATION OF AEDES AEDES AEGYPTIAEGYPTI

BREEDING SITESBREEDING SITES------THE INITIATIVETHE INITIATIVETHE INITIATIVE THE INITIATIVE

MOSTLY LIES WITHMOSTLY LIES WITHINDIVIDUALS/COMMUNITYINDIVIDUALS/COMMUNITY


Is Bangalore in the grip of chikungunya? [ S t d A il 08 2006 12 33 46 TIMES NEWS[ Saturday, April 08, 2006 12:33:46 am TIMES NEWS

NETWORK ]

BANGALORE: The Aedes aegypti mosquito that causes chikungunya now seems to have bitten Bangaloreans. At least 15 persons, suspected to be suffering from the viral infection, have been admitted to the Epidemic Diseases (ED) Hospital ………. At least 80,000 people in Gulbarga, Tumkur, Bidar, Raichur, Bellary, Chitradurga, Davanagere, Kolar and Bijapur are affected since December 2005.

Back after 32 yrs, dengue-like fever: chikungunyaToufiq Rashid

Indian Express.. Thursday, April 27, 2006 at 0000 hrs Mosquito carrier, not known to be fatal, cases sweep Andhra, KarnatakaNEW DELHI, APRIL 26: Thirty two years after its last outbreak in India, chikungunya is back. A relatively rare viral fever with dengue-like symptoms, chikungunya has been sweeping Andhra Pradesh, Karnataka and Maharashtra. In the last three months, the official count of the affected has climbed to a staggering 1.5 lakh people and Health officials concede that figures on the ground may be higher. Caused by an alphavirus spread through bites from the Aedes Aegypti mosquito—the same mosquito behind dengue—chikungunya is not considered fatal. But 77 deaths since 2005 on the Indian Ocean island of Reunion have been linked to chikungunya.

Health officials in Delhi said the last outbreak in the country was reported in 1974. “The virus must have been silent but it has made a comeback,”


Knowing is not enough; we must apply.Knowing is not enough; we must apply.Willing is not enough; we must doWilling is not enough; we must doWilling is not enough; we must do.Willing is not enough; we must do.

(Goethe)(Goethe)


GOVT EFFORTSGOVT EFFORTSCOUPLED WITHCOUPLED WITHCOUPLED WITH COUPLED WITH

THE THE PUBLIC PUBLIC PARTICIPATIONPARTICIPATION…. ….

IS THE IS THE KEYKEY. .

AcknowledgementsAcknowledgements::gg•• WHOWHO•• CDCCDC•• NVBDCPNVBDCP•• NCDCNCDC•• JD(NVBDCP),Gandhinagar.JD(NVBDCP),Gandhinagar.( ), g( ), g•• Dy.Director(Epidemic),GandhinagarDy.Director(Epidemic),Gandhinagar• Dr. R.V.S.N.Sarma. (Canada)

Dr.G.C.Sahu/ROH&FW/Dr.G.C.Sahu/ROH&FW/GoIGoI/Ahmedabad/Ahmedabad…….. THANKS…….. THANKS

Chickungunya - dr

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