Chikungunya: Perspectives and Trends Global and in the Americas Presenter: Dr. Eldonna Boisson PAHO/WHO
Outline What is chikungunya Where did chikungunya start? Chikungunya spread - Africa, Asia, Europe, Americas Chikungunya epidemic drivers Preparedness Response Take away messages Recommendations
What is Chikungunya? Mosquito-borne viral disease Symptoms: o Appear ~2-7 days after being bitten by infected mosquito o Are generally self-limiting o Last initially ~2 3 days o Pain & joint stiffness and pain may last months or years Is rarely fatal Shares some clinical signs with dengue and can be misdiagnosed in areas where dengue is common
What does Chikungunya look like? High fever Rash Fatigue Nausea Headache Joint pain Muscle pain Joint swelling
Chikungunya epidemic: Arbovirus + Alphavirus A double impact The CHIK The Shock The Check Gauzere BA & Aubry P, Path Exot Ed. 2006
Epidemiological cycle Sylvatic cycle non-human primates, rodents, birds, small mammals Urban cycles Tomado de: Tsetsarkin K, Chen R, Sherman M and Weaver S. Chikungunya virus evolution: Evolution and genetic determinants of emergence. Curr Opin Virol.
Where did Chikungunya start? First described during an outbreak in southern Tanzania in 1952 In Africa o Human infections at relatively low levels for many years o 1999-2000: Large outbreak in DR of the Congo o 2007: Large outbreak in Gabon Periodic outbreaks in Africa and Asia since 1960s 2001-2011: Many countries reported outbreaks
Chikungunya spreads East India/Islands of the Indian Ocean: Feb 2005: major outbreak started Since 2005: India, Indonesia, Maldives, Myanmar &Thailand reported >1.9 mill cases 2006: India >1,500,000 cases. Ae. aegypti was presumed vector 2005-2006: >272,000 people infected during outbreak in Indian Ocean islands, Réunion and Mauritius. Ae. albopictus was presumed vector
Chikungunya spreads West Europe: 2006: Peak in number of imported cases in Europe associated with Indian Ocean outbreak 2007: 1 st time autochthonous transmission reported in a localized outbreak in a coastal village in north-eastern Italy - 197 cases recorded Confirmed that mosquito-borne outbreaks by Ae. Albopictus are plausible in Europe
Geography of Chikungunya, 2004-2011 Tomado de: Tsetsarkin K, Chen R, Sherman M and Weaver S. Chikungunya virus evolution: Evolution and genetic determinants of emergence. Curr Opin Virol.
Chikungunya in the Americas Americas in Dec 2013 First 2 laboratory-confirmed locally acquired cases in French St Martin First documented outbreak of chikungunya with autochthonous transmission in the Americas Concern re potential spread to new Caribbean countries, given high indices of Ae. aegypti and confirmed Dengue transmission during 2013
Phylogenic tree Saint Martin, December 2013 Tomado de: Leparc-Goffart, Nougairede A, Cassadou S, Prat C y lamballerie X. Chikungunya in the Americas. The Lancet. Vol 383, Issue 9916, Pag 514, 8 Febrero 2014.
Chikungunya in the Americas (cont d) First half of 2014: o Spread to most of English & Spanish Caribbean territories and countries o Severe outbreaks in Guadeloupe, Dominica, Dominican Republic, Haiti, Jamaica, Suriname Second half of 2014: spread to Andean countries and Brazil Feb 2015: cases confirmed in Bolivia and Paraguay
Chikungunya first autochthonous cases in the Caribbean EW 49, 2013
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Current Situation National and subnational geographic distribution of autochthonous cases Countries with reported imported cases Epidemiological Week 7, 2005 February 15-21, 2015
Chikungunya in the Americas (cont d) As of February 20, 2015: Autochthonous transmission confirmed in 44 countries and territories in the Americas Reported to PAHO/WHO o 1,217,093 suspected autochthonous cases o 27,529 confirmed autochthonous cases o 183 deaths Imported cases reported from Argentina, Bermuda, Canada, Chile, Cuba, Peru
Why an outbreak of this magnitude? Virus has not circulated in the Americas, hence there is no immunity among the population Ae. aegypti and Ae. albopictus mosquitoes widespread in the many areas of the Americas The amount of virus circulating in humans and mosquitoes during an outbreak is very high High levels of international travel All countries with previous history of Dengue transmission are at risk
Preparedness Introduction of the virus was not unexpected PAHO/WHO and partners have been working with countries in the region for several years to strengthen preparedness and response for introduction of CHIK 2010 2012
Same prevention measures used for dengue can also prevent chikungunya Very important are: 1. Elimination and control of breeding sites for A. aegypti 2. Protection against mosquito bites Integrated Management Strategy for dengue prevention and control (IMS-Dengue) Implemented in 26 countries/territories and 4 subregions of Americas
Response - countries Epidemiological surveillance, including syndromic surveillance and surveillance of severe cases Vector control activities implemented in affected countries, rapidly extended to areas around airports, schools, day nurseries, hospitals Communication and social mobilization - information dissemination to: o Health professionals o The public (on individual protection, how to eliminate the larvae breeding ground) o Travellers by specific information in the airports
Response - PAHO/WHO Activated event management team at HQ Network of GOARN regional partners activated to monitor CHIK spread: Institut Pasteur in French Guyana, CARPHA, Inst. E. Chagas, UTMB, INEVH, IPK, CDC Deployment of PAHO staff and GOARN experts (CDC, SSA France): St Maarten, Dominica, Dominican Republic, Haiti, Nicaragua, Paraguay, Peru and Brazil
Response - PAHO/WHO Trainings on CHIK Clinical awareness and Case Management: o Caribbean (Guadeloupe - April 2014) o Central America (Nicaragua - May 2014) o Andean Area (Peru September 2014) o Brazil (Brasilia October 2014) Training on virology techniques: Gorgas Institute Panama, INS Peru, CDC Ft Collins & Puerto Rico
WHO response Formulating evidence-based outbreak management plans Providing technical support & guidance to countries for effective management of cases and outbreaks Supporting countries to improve their reporting systems Providing training on clinical management, diagnosis and vector control at the regional level in partnership with collaborating centres Publishing guidelines and handbooks for surveillance, case management, laboratory detection and vector control for Member States
Take away messages Co-circulation of DEN and CHIK is challenging CHIK mortality is low compared to DEN (mainly patients with co morbidity that may have exacerbated disease) CHIK has double impact on health services delivery: 1 st - wave of acute cases and 2 nd - chronic cases Risk Communication is key even using basic messages: CHIK is transmitted by mosquitoes!
Recommendations Countries are encouraged to: Develop and maintain capacity to detect and confirm cases Manage patients Implement social communication strategies to reduce the presence of the mosquito vectors Combine vector prevention and control efforts for chikungunya with those for dengue
Acknowledgements Thank you to Dr. Sylvain Aldighieri and members of the Communicable Diseases and Health Analysis Department of PAHO/WHO for the provision of data for this presentation
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