The Next Imported Mosquito Virus: Rift Valley fever, chikungunya ...
Chikungunya Fever: Re-emerging vector-borne disease
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Transcript of Chikungunya Fever: Re-emerging vector-borne disease
Chikungunya Fever:Re-emerging vector-
borne diseaseMargaret McLees, M.D., DTMH
Denver Public HealthJanuary 17, 2014
OutlineCase Presentation
Epidemiology
Presentation
Diagnosis
Treatment and Prevention
Implications for our Travelers
Case65 yo female with fevers, rash, and arthralgias
12-day trip to Bali, Indonesia, returned 2 days prior
Day 12 developed severe arthralgias and arthritis
Sick contact: landlord found down, dx’d with viral illness
Traveled from Bali to Hong Kong
Admitted in Hong Kong for 3 days Persistent severe arthralgias, 1 day diarrhea Rash Paracetamol, diclofenac, ranitidine
Case, continuedReturned to Denver with ongoing rash and
arthralgias, resolution of fevers
Medications: oral hormone replacement
PMH: Migraines
Social Hx: tourist activities while traveling, no bad habits, +insect bites, no animal exposures, no freshwater/saltwater exposures
Afebrile on exam Conjunctival erythema Facial edema and rash Upper and lower extremity edema
Case: Rash
Case: Rash
Case: Laboratory dataWBC 3.4, 8% bands, plt 109, AST 68
Malaria smear negative
Electrolytes, kidney, liver function, urinalysis normal
Typhoid & paratyphoid by Widal test, Influenza A&B, Dengue IgM, Brucella abortus Ag by Weil Felix, respiratory virus panel negative
CXR: blunted right costophrenic angle, no infiltrates or consolidation
Clinical diagnosis: Chikungunya Fever
Serologies sent to CDC for arboviruses likely to be present in SE AsiaRoss River virusDengueChikungunya Japanese encephalitis virus
IgM positive to multiple viruses on acute sampleChikungunya, Barmah Forest and Ross River Virus
Chikungunya IgM, IgG positive on convalescent samples in May
Chikungunya Virus (CHIKV): Alphavirus
“That which bends up” in Swahili
Togaviridae family
Single strand RNA virus, mosquito-transmitted
New World: Fever, rash, encephalitis Western equine
encephalitis Eastern Equine
encephalitis
www.cdc.gov/ncidod/dvbid/arbor/alphavir.htm
Old World: Fever, rash, arthralgias Chikungunya Ross River Virus
(Oceana) Barmah Forest Virus
(AUS) O ’nyong-nyong (Africa) Semliki Forest Virus
(Africa) Mayoro (South America) Sindbis virus (AUS, Africa,
Europe, Asia minor)
Mosquito Transmission: Aedes aegypti and Aedes
albopictus
Transmission: Aedes mosquito
Aedes aegypti Urban mosquito Needs standing water for larvae Prefers cool, dark areas for resting Feeds through the day, most active at dawn/dusk Eggs do not survive winter in temperate climates
Aedes albopictus: Asian Tiger Mosquito Urban, periurban, rural habitats Feeds through the day, most active dawn/afternoon Eggs survive winter in temperate climates Invasive- spreading in Europe and Americas
www.cdc.gov
CHIKV: Geographic Distribution
As of January 6, 2014
www.cdc.gov
Aedes: Geographic distribution and CHIKV
imported cases
Soumahoro at al EID 2010
Transmission CycleAfrica
Sylvatic transmission cycle Maintained in non-human primates, small mammals,
Aedes mosquitos Human reservoirs during epidemics without animal
reservoirs Outbreaks usually associated with heavy rainful and
increased mosquito population
Asia Human-mosquito cycle Urban epidemics Aedes aegypti and Aedes albopictus
Burt FJ et al. Lancet 2012; 379:662-71www.cdc.gov
Transmission by corneal graft
La Reunion Outbreak, Indian Ocean 2005-2007
Implementation of screening of organ and tissue donors in 2005 12 of 69 asymptomatic corneal donors were viremic or
IgM positive for CHIK 4 of 12 corneas from these donors were infected with
CHIK (qRT-PCR) No correlation with systemic symptoms, viremia, or
presence of anti-CHIK IgM Mouse models showed ocular innoculation of CHIK
produced systemic infection
Corneal collection and transplantation suspended
Couderc et al. JID 2012
Lumsden WH. Trans Roy Soc Trop Med Hyg 1955;49:33-57
Clinical Findings Incubation period 1-12 days, average 2-4
Abrupt onset fever, myalgias, headache and photophobia
Rash: maculopapular, lasting 2-3 days Aphthous ulcers Vesiculobullous lesions with desquamation Vasculitic lesions
Diarrhea, nausea vomiting may occur
Neurologic symptoms (up to 16%) Encephalopathy, seizures, meningoencephalitis Acute flacid paralysis Guillan-Barre like syndrome
Rarely: myocarditis, hepatitis, nephritis, anterior uveitis, retinitis, optic neuritis
Mahendradas et al. J Ophth Inflam Infec 2013; 3:35Burt FJ et al. Lancet 2012; 379:662-71
Clinical features: Day 1, 7, 25
Thib
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Joint disease Severe Arthralgias
Polyarticular, usually symmetric, small joints Swelling but no large effusions Some improvement in 1-2 weeks, but may persist for years
Malaysia retrospective review Mean duration of arthralgia 3 months 45% had arthralgias beyond 4 months 22% with arthralgias beyond 1 year
Réunion: Persistence at 36 months Risk increases with age >35 years old Presence of arthralgia at 4 months was predictor of chronic
disease
Mouse models suggest due to viral persistence in tissuesZim MA et al. J Clin Virol. 2013; 56:141-45.Thiberville, SD et al. PLOS Neg Trop Dis. 2013Schilte et al. Plos Neg Trop Dis. 2013Hawman et al. J. Virology 2013; 87:13878
DiagnosisDifferential
Dengue Ross River virus, O’nyong-nyong and other alphaviruses Leptospirosis, malaria, group A strep, rickettsia, rubella,
measles, parvovirus, enterovirus, adenovirus, rheumatologic diseases
Clinical findings, epidemiology, lab confirmation Viral culture in 1st 3 days of illness RT-PCR for viral RNA in 1st 8 days Serology for IgM and IgG by end of 1st week Convalescent titers with four-fold increase in IgG Samples to CDC through CDPHE
www.cdc.gov
Treatment and Prevention
Acute Illness Supportive care NSAIDS Case reports of short steroid courses for severe early disease
Persistent arthralgias: no good data for treatment Chloroquine, hydroxychloroquine
No sig difference in efficacy for acute arthralgias between chloroquine and meloxicam in 509 indiv in India
Sulfasalazine, methotrexate, ribavirin, interferon-alpha
Mosquito avoidance
Vaccines in research, not licensed
Monoclonal antibodies as prophylaxis effective in mouse models
Mosquito avoidance on return home to prevent local transmission
Chopra et al. Arthritis and Rheum 2012. Accepted Article, doi: 10.1002/art.38221 Chopra et al. Arthritis and Rheum 2008;9:2921-2Selvarajah et al. PLoS Neg Trop Dis 2013;7:e2423Janu et al. J. Assoc. Phys India 2011; 59:83-6
CHIKV: re-emerging disease
Initial descriptions in 1950s
2000 Epidemic in Kinshasa, DRC, 1st in 39 years
2001-2003 epidemic in Indonesia, 1st in 20 years
2004 Coastal Kenya E226V mutation more
efficiently transmitted by Aedes albopictus
2005 Spread to Comoros Islands
2005-2007 Epidemic in Réunion: 35% attack rate 266,000 cases 0.1% mortality
2006 Maldives
2008 Singapore
2012 Rural Cambodia 44.7% prevalence 5.3% asymptomatic
2012 Bhutan 1st cases reported Index case recent travel
from India East/Central/South African
genotype
2012 Papua New Guinea 1st cases reported
MMWR 2012; 61: 737-40www.cdc.gov/eid 2013 vol 19
CHIKV Epidemics 2005-2006 Re-emergence in India after 32 years
1.3 million cases in 13 states
2007 Northern Italy: Emilia-Romagna 254 locally acquired infections Index case just returned from India
2010 French Riviera: Frejús, Nice Index case young girl with recent return from India
December 2013 Carribbean isle of St. Martin Dec 6th: 2 cases of locally acquired chikungunya 1st cases reported in the Americas Dec 10th: 2 confirmed, 4 probable, 20 suspected cases of
chikungunya reported to WHO
www.who.int/scr/don/2013_12_10a/en/index.html; accessed 1/12/14Tomasello et al. Travel Med and Inf Dis 2013; 11, 274-284
CHIKV and US Travelers1995-2009: 109 lab-confirmed cases in US
Adult travelers, mean age 48 yrs57% female
Gibney et al. CID 2011; 0:1-6
CHIKV and Travelers1995-2009: 109 lab-confirmed cases in US
Adult travelers, mean age 48 yrs57% female
Gibney et al. CID 2011; 0:1-6
CHIKV Cases in the US
Gibney et al. CID 2011; 0:1-6
US Distribution of Imported CHIKV
Gibney et al. CID 2011; 0:1-6
Travelers from Indian Ocean Islands, 1997-2010
Savini et al., EID 2013; 19
Implications for Travelers
Increased education regarding expanding geographic distribution of vectors for chikungunya (and dengue) virus, especially Europe and Caribbean
Emphasis on need for mosquito avoidance in areas that are not tropical or traditional risk areas
Prompt evaluation of return travelers with fever and awareness of CHIKV
Avoidance of mosquitos after diagnosis of chikungunya to decrease risk of local transmission