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Fact sheet for healthcare providers National Center for Emerging and Zoonotic Infectious Diseases Division of Vector-Borne Diseases --- http://www/cdc.gov/ncezid/dvbd CHIKUNGUNYA Information for healthcare providers x Background • Mosquito-borne viral disease characterized by acute onset of fever and severe polyarthralgia • Often occurs as large outbreaks with high attack rates • Outbreaks have occurred in countries in Africa, Asia, Europe, and the Indian and Pacific Oceans • In late 2013, first local transmission in the Americas was reported on islands in the Caribbean Chikungunya virus • Single-stranded RNA virus • Genus Alphavirus; Family Togaviridae Mosquito vectors • Aedes aegypti and Aedes albopictus are the primary vectors (above) • Both are aggressive daytime biting mosquitoes Animal hosts • Humans are the primary host of chikungunya virus during epidemic periods Clinical findings • Majority of infected people become symptomatic • Incubation period usually 3–7 days (range 1–12 days) • Acute onset of fever and polyarthralgia are the primary clinical findings • Joint symptoms usually symmetric and often occur in hands and feet; they can be severe and debilitating • Other symptoms: Headache, myalgia, arthritis, conjunctivitis, nausea/vomiting, maculopapular rash • Lymphopenia, thrombocytopenia, elevated creatinine, and elevated hepatic transaminases are the most common clinical laboratory findings Countries with reported local transmission of chikungunya virus (as of May 2014) Laboratory testing • Evaluate serum or plasma by: o Viral culture to detect virus in first 3 days of illness o RT-PCR to detect viral RNA in first 8 days of illness o Serology to detect IgM, IgG, and neutralizing antibodies that develop toward the end of the first week of illness (≥4 days post illness onset) • Chikungunya testing is performed at CDC, several state health departments, and one commercial laboratory • Contact your state health department for more information and to facilitate testing Clinical course and outcomes • Acute symptoms typically resolve within 7–10 days • Rare complications include uveitis, retinitis, myocarditis, hepatitis, nephritis, bullous skin lesions, hemorrhage, meningoencephalitis, myelitis, Guillain-Barré syndrome, and cranial nerve palsies • Persons at risk for severe disease include neonates exposed intrapartum, older adults (e.g., > 65 years), and persons with underlying medical conditions (e.g., hypertension, diabetes, or cardiovascular disease) • Some patients might have relapse of rheumatologic symptoms (e.g., polyarthralgia, polyarthritis, tenosynovitis) in the months following acute illness • Studies report variable proportions of patients with persistent joint pains for months to years Fact sheet for healthcare providers Revised May 5, 2014 Chikungunya and dengue • Difficult to distinguish chikungunya and dengue based on clinical findings alone • Chikungunya and dengue viruses are transmitted by the same mosquitoes • The viruses can circulate in the same area and cause occasional co-infections in the same patient • Chikungunya virus more likely to cause high fever, severe polyarthralgia, arthritis, rash, and lymphopenia • Dengue virus more likely to cause neutropenia, thrombocytopenia, hemorrhage, shock, and deaths • Patients with suspected chikungunya should be managed as dengue until dengue has been ruled out o Proper clinical management of dengue reduces the risk of medical complications and death o Aspirin and other NSAIDs can increase the risk of hemorrhage in patients with dengue Treatment and clinical management • No specific antiviral therapy; treatment is symptomatic • Assess hydration and hemodynamic status and provide supportive care as needed • Evaluate for other serious conditions (e.g., dengue, malaria, and bacterial infections) and treat or manage appropriately • Collect specimens for diagnostic testing • Use acetaminophen or paracetamol for initial fever and pain control o If inadequate, consider using narcotics or NSAIDs o If the patient may have dengue, do not use aspirin or other NSAIDs (e.g., ibuprofen, naproxen, toradol) until they have been afebrile ≥48 hours and have no warning signs for severe dengue* • Persistent joint pain may benefit from use of NSAIDs, corticosteroids, or physiotherapy ____________________________________________________ *Warning signs for severe dengue include severe abdominal pain, persistent vomiting, mucosal bleeding, pleural effusion or ascites, lethargy, enlarged liver, and increased hematocrit with decrease in platelet count Differential diagnosis • Depends on residence, travel history, and exposures • Consider dengue, leptospirosis, malaria, rickettsia, group A streptococcus, rubella, measles, parvovirus, enteroviruses, adenovirus, other alphavirus infections (e.g., Mayaro, Ross River, Barmah Forest, O’nyong-nyong, and Sindbis viruses), post-infections arthritis, and rheumatologic conditions Surveillance and reporting • Chikungunya virus infection should be considered in patients with acute onset of fever and polyarthralgia, especially travelers who recently returned from areas with known virus transmission • Healthcare providers are encouraged to report suspected chikungunya cases to their state or local health department to facilitate diagnosis and mitigate the risk of local transmission • Health departments should perform surveillance for chikungunya cases in returning travelers and be aware of the risk of possible local transmission in areas where Aedes species mosquitoes are active • State health departments are encouraged to report confirmed chikungunya virus infections to CDC Prevention and control • No vaccine or medication is available to prevent chikungunya virus infection or disease • Reduce mosquito exposure o Use air conditioning or window/door screens o Use mosquito repellents on exposed skin o Wear long-sleeved shirts and long pants o Wear permethrin-treated clothing o Empty standing water from outdoor containers o Support local vector control programs • People suspected to have chikungunya or dengue should be protected from further mosquito exposure during the first week of illness to reduce the risk of local transmission • People at increased risk for severe disease should consider not traveling to areas with ongoing chikungunya outbreaks FOR MORE INFORMATION VISIT: www.cdc.gov/chikungunya/