Chikungunya Fever: Epidemiology and Clinical Syndrome in Small Infants in Honduras June-July 2015

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1 Chikungunya Fever: Epidemiology and Clinical Syndrome in Small Infants in Honduras June-July 2015 Flora Flowers MD Emergency and Pediatric Critical Care Service Hospital Escuela Universitario 12th Congress of the WFSICCM 2015

2 Objectives Review epidemiological and clinical aspects of Chikungunya in small infants To characterize the epidemiological and clinical syndrome of Chikungunya in small infants in Honduras

Background Makonde Plateau (1952) Swahili Makonde dialect: To become contorted or That Which Bends Up Ritz N, Hufnagel M, Gerardin P. Chikungunya in Children.

3 Background Makonde Plateau (1952) Swahili Makonde dialect: To become contorted or That Which Bends Up Ritz N, Hufnagel M, Gerardin P. Chikungunya in Children. The Pediatric Infectious Disease Journal 2015;34(7); Burt F, Ralph N, Rulli N, Mahalingam S, Heise M. Chikungunya: A re-emerging virus. The Lancet 2012; 379;

4 Definition PAHO/WHO Suspected Sudden onset fever >38.5 C (101.3 F) Arthralgia Arthritis Recent traveling to an epidemic or endemic area Confirmed Biological Testing

Etiology RNA single-stranded, positive sense RNA virus Genus: Alphavirus Family: Togaviridae Ross River Virus O nyong-nyong Barmah Forest Viruses Mayaro Thiberville

5 Etiology RNA single-stranded, positive sense RNA virus Genus: Alphavirus Family: Togaviridae Ross River Virus O nyong-nyong Barmah Forest Viruses Mayaro Thiberville S, Moyen N, Dupuis L, Nougariede, Goul E, Roques P et al. Chikungunya Fever: Epidemilogy, Clinical Syndrome, Pathogenesis and Therapy. Antiviral Research 2013; 99:345-70

6 Chikungunya: countries and risk areas (1952) Lumsden WHR. An epidemic of virus disease in Southern Province, Tanganyika Territory, in : II. General description and epidemiology. Trans R Soc Trop Med Hyg. 1955;49(1):33-57.

Geographical distribution of outbreaks 2004-2011 Tsersarkin K, Chen R, Sherman M, Weaver S.

7 Geographical distribution of outbreaks Tsersarkin K, Chen R, Sherman M, Weaver S. Chikungunya virus evolution: Evolution and genetic determinants of emergence..curr Opinion Virol 2011; 1(4):310-7

8 Chikungunya in Honduras: Statistics according to Pan American Health Organization

9 Clinical differences of Chikungunya in Children and Adults Children Fever Adults Maculopapular rash % Oral ulcers: rare Myalgia/arthralgia Chronicity up to 2 years 5-11% Severe bleeding: neonates Neurological: % 30-60% 16% Arthritis/Arthralgia Up to 1 year 60% Rare: <0.1% Ritz N, Hufnagel M, Gerardin P. Chikungunya in Children. The Pediatric Infectious Disease Journal 2015;34(7);

10 Stages of Disease Acute febrile phase ± typical ± severe Mother/newborn Subacute phase Persistent arthritis Depression Chronic phase Articular invovelment Persistent Recidivant Asymptomatic

11 Clinical and Laboratorial Differences Chikungunya Dengue Fever (>39 C) Arthralgia +++ +/- Arthritis + - Headache Rash ++ + Myalgia + ++ Hemorrhage +/- ++ Shock - + Lymphopenia Neutropenia Thrombocytopenia Hemoconcentration - ++

12 Atypical Cases Atypical Other symptoms Fever, arthralgya Severe Atypical Organ failure Economopoulou A, Dominguez M,Helynck B, Sissoko D, Wichmann O, Quenel P et al. Atypical Chikungunya virus infections: clinical manifestations, mortality and risk factors for severe disease during the outbreak on Réunion. Epidemiol Infect 2009;137(4):

13 Acquired Chikungunya Fever during Pregnancy Maternal-Fetal Transmission Onset of symptoms 4 days before and 2 days after delivery High transmission rate Friel X, Rollot O, Gerardin P, Gauzere BA, Bedeault J, Lagarde L, et al. Chikungunya virus infection during pregnancy, Reunion, France, Emeerg Infect Dise 2010; 16/3): Gerardin P, Barau G, Machault A, Bintner M, Randrianaivo H, Choker G et al. Multidisciplinary prospective study of mother-to-child chikungunya virus infections on the island of La Réunion. Plos Med 2008; 18;5(e60)

14 Epidemiology General Number Percentaje Age 1-28 days días-11 m m Sex Female Male Neonates Incidence: 2.71% (IC95%: ) Maternal CHK: 20.5% (IC95%: ) Complications: 3.21% (IC95%: )

15 Clinical Symptoms and Signs Symptoms/Signs Number Percentaje Fever Constant crying Nausea Vomit Diarrhea Poor suction Hipoxia Lower extremities edema Rash Dermatitis bullosa Seizures Hyperalgyc syndrome

17 Rash in an infant with Chikungunya

19 Antropometrics and vital signs Number Percentaje Nutritional Status Eutrophyc Underweight Overweight Obesity Heart rate Normal Bradycardia Tachycardia Respiratory rate Normal Tachypnea Bradypnea Blood Pressure Normal Hipotensive Hipertensive Temperature < 38.0 C C > 40.0 C 2 1.1

20 Laboratory Frequency Percentaje Hematocrit Normal Diminished Increased White blood cells Normal Leucopenia Leucocitosis Neutrophils Normal Neutropenia Neutrophilia Lymphocytes Normal Lymphopenia Lymphocitosis Platelets Normal Thrombocytopenia Thrombocytosis

21 Clinical Course Number Percentaje Complications Yes No Type of complication Hypovolemic Shock Sepsis Syndrome Septic Shock Onfalitis Late onset sepsis Viral Myocarditis 2 1 Encephalitis Lenght of stay 1-2 d d > 5 d Still admitted Discharge condition Recovering

22 Encephalitis Polimerase Chain Reaction (PCR) LCR (+) Glucose 24 mg/dl Protein: 750 mg/dl Cells: 313/ml Lymphocytes: 98%

23 Arthritis and Tenosynovitis 1. Bilateral Subacute Metacarpophalangic al Arthritis of 2nd digit 2. Bilateral Tenosynovitis of two digits

24 Summary Incidence in neonates: 2.71% (IC95%: ) Maternal CHK: 20.5% (IC95%: ) Complications: 3.21% (IC95%: ) The presence of thrombocytopenia may have a correlation with complications ( p=0,005, Fisher Test RR 12,9 %, ) Correlation between lenght of stay and complications (p=0,000)

Following the bite of a mosquito infected with CHIKV, most individuals will

3. CLINICAL 3A. Clinical Presentation of Acute Disease Following the bite of a mosquito infected with CHIKV, most individuals will present with symptomatic disease after an incubation period of 3-7 days