SURVEILLANCE AND MANAGEMENT OF CHIKUNGUNYA DISEASE

Coordinated by: Disease Control Division MINISTRY OF HEALTH MALAYSIA

March 2006

EDITORIAL BOARD
ADVISORS: Dato Dr. Hj. Ramlee Bin Hj. Rahmat Director of Disease Control Dr. Mohd Raili bin Hj. Suhaili Deputy Director of Disease Control (Vector) Disease Control Division, MOH Dr. Zainudin Abd Wahab Deputy Director of Disease Control (Surveillance) Disease Control Division, MOH Dr. Christopher Lee Consultant Physician (Infectious Disease) Hospital Kuala Lumpur Dr. Chua Kaw Bing Senior Consultant Pathologist National Public Health Laboratory Dr. Mohamad Ikhsan bin Selamat Principal Assistant Director (Vector), Disease Control Division, MOH. Dr. Rohani bte Jahis Principal Assistant Director (Surveillance) Disease Control Division, MOH.

MEMBERS:

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CONTENT 1. 2. 3. 4. 5. 6. Introduction. Epidemiology Clinical manifestation Diagnosis Treatment Prevention CHIKUNGUNYA DISEASE SURVEILLANCE 1. 2. Objectives Case definition i Suspected Chikungunya disease ii Confirmed Chikungunya disease Notification of cases i Clinics and hospitals ii Laboratory iii Flow of surveillance data Public Health response i Case management ii Vector control iii Entomological surveillance iv Community empowerment and mobilisation. v Enforcement of Destruction of Disease Bearing Insects Act (DDBIA), 1975 (Amendment 2000).

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3.

4.

REFERENCES

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1.0

INTRODUCTION

Chikungunya is a viral disease. The illness was observed for the first time in 1952 in Tanzania. The name comes from the local dialett, Swahili which means that which bend up for stooped walk, reflecting the physic of a person suffering from the disease. 2.0 EPIDEMIOLOGY

Chikungunya is caused by an Arborvirus, belongs to the genus Alphavirus under the Togaviridae family. The virus is transmitted to human by infected Aedes mosquitoes, Aedes albopictus in the rural area and Aedes aegypti in the urban area. The urban outbreaks are sporadic but explosive in nature. It then disappears and reappears at irregular intervals. In some parts of Africa, Chikungunya virus was isolated from zoophilic mosquitoes. It suggests that the virus circulates in rodents and cattle in the region. Virus was also obtained from a squirrel, chiroptera, and ticks (Alectorobius sonrai), as well as the presence of antibodies specific for Chikungunya virus in rodents and birds, support the assumption that secondary wild cycles exist in animals. The existence of such cycles could contribute to maintaining of the virus in an endemic region in Africa. In a study in Africa, the transmission cycle of Chikungunya virus is characterised by a periodicity of occurrence with silence intervals of 34 years. These cycles, which characterise the movement of this virus in monkeys, are probably related in part to the immune status of the monkeys and to the percentage of the simian population susceptible to the infection. Following the circulation of the virus, nearly all monkeys might be infected and immunologically protected. The disease passes from monkey to monkey by Aedes furcifer and Aedes africanus. Vertical transmission, which was never observed in nature or demonstrated in the laboratory, could not be taken into account in a maintenance cycle. In the Sahelian region, the absence of Chikungunya virus in a place call Barkedji despite the presence of Aedes aegypti, could be explained by the scarcity of sylvatic vectors, the absence of monkeys, and by the low density of human populations. The disease is endemic in most of sub-Saharan Africa, southern India and Pakistan, Southeast Asia, Indonesia and Philippines. Malaysia reported first outbreak in 1999 which was detected in Myammar immigrants. However the antibody to Chikungunya was detected in 51 people of the urban area near Kuala Lumpur in 1960s. It occurs principally during the rainy season.

In early 2006, WHO reported Chikungunya outbreak in islands of Indian Ocean i.e. Maldives, Mauritius, Madagascar, Mayotte, Seycelle and La Reunion Islands; as well as the coastal region of India. Chikungunya outbreak was reported in Kampung Bagan Panchor, Pantai Remis, District of Larut, Matang dan Selama (LMS), Perak on 27 Mac 2006 involving 30 people. 3.0 CLINICAL MANIFESTATION

The incubation period of the disease is 2 to 4 days. The symptoms is less severe and fewer in children than adults. Infected patients manifest sudden onset of fever, chills, severe arthralgia and headache. Patients also have maculopapular rash mostly in trunk. Migratory polyarthritis (commonly swelling and reddening) occurs in 70 % of cases and mainly affected the small joints. They may also manifest photophobia, anorexia, nausea, conjunctival injection and abdominal pain. The acute illness usually last for 5 to 7 days. Chikungunya has not been reported causing severe haemorrhagic manifestation or death. Older patients usually continue to suffer recurrent joint pain and effusion for several years. The persistent arthralgic forms were first described in 1980 in South Africa. A retrospective study done in 1983, on case of proven cases of Chikungunya infection identified this region in the last 3 years noted 87.9 % were completely cured, 3.7 % had stiffnesses or a moderate embarrassment in an episodical way, 2.8% had persistent articular stiffnesses without pain and 5.6 % had painful and stiff articulations in a persistent way. These patients with persistent arthritis had high level of antibody against the Chikungunya virus. 4.0 DIAGNOSIS

Chikungunya infection may be mistaken for dengue and / or West Nile disease. Provisional diagnosis is often made based on the clinical features. Acute or viraemic phase serum samples collected within 2 to 4 days of onset have yielded positive virus isolates and detection of viral nucleic acids. Paired sera drawn 1 to 3 weeks apart will demonstrate rising antibody titre. Rapid diagnosis can be used to detect Chikungunya antibody (IgM) after 5 days of onset i.e. ELISA, immunofluorescene etc. Reverse transcriptase polymerase chain reaction (RT-PCR) tests may yield diagnoses based on samples without detectable antibodies and may also provide genetic information of the virus.

5.0

TREATMENT

The disease is self-limiting. There is no specific treatment or vaccine for Chikungunya, patients are only given symptomatic or supportive treatment. To avoid further transmission, patients who is in the viraemic phase (first 4 days of onset) should be protected from mosquito bites especially from Aedes species. Aedes mosquito feeding time is during dawn (5.00 am to 8.00 am) and dust (5.00 pm to 8.00 pm). 6.0 PREVENTION

To date, there is no vaccine available for the control and prevention of Chikungunya.. The control measures are based on the general measures in the control of mosquito-borne diseases; i.e. use of repellant and mosquito net, vector control through search and destroy of the potential mosquito breeding site, larvaciding and adulticiding using chemical and / or biological agents such as abate, insecticide, fish, bacteria etc.

CHIKUNGUNYA DISEASE SURVEILLANCE 1. 1. 2. 3. 4. OBJECTIVES To predict impending outbreak of Chikungunya in the future. To estimate the magnitude of Chikungunya disease in the population. To reduce Aedes mosquitoes density in the community. To increase public support and community participation in the prevention and control of dengue. CASE DEFINITION Suspected Chikungunya disease A case with sudden onset of high grade fever, polyarthritis and maculopapular rashes. 2(ii) Confirmed Chikungunya (CHIK) disease The above 1(i) with laboratory confirmation of Chikungunya virus infection either; occurrence at same location and time as other confirmed cases of Chikungunya case; OR detection of anti-CHIK-IgM antibody in serum , 2 fold rise of IgM; OR detection of CHIK nucleic acids in serum by RT-PCR test; OR isolation of Chikungunya virus. 3. 3(i) NOTIFICATION OF CASES Clinics and Hospital.

2. 2(i)

Chikungunya disease is not a notifiable disease. However medical practitioners is required to notify any case suspect or confirmed Chikungunya infection within 24 hours, as to reduce the morbidity and to curb Chikungunya outbreak. It is an administrative mandatory notification.

3(ii)

Laboratory

Any laboratory with a positive laboratory CHIK result should inform the nearest District Health Office for further investigation and field management. 3(iii) Flow of information

The flow of information of a Chikungunya case is as shown in figure 1. Figure 1: Flow Of Surveillance Data LABORATORY HOSPITALS / CLINICS

Private

Government
Positive test

Private

Government

Notification within 24 hrs

Fulfilled criteria . case definition.

District Health Office

Follow up with the laboratory on patients result.

Investigate and Investigate control activities

Progress report

Inform state
Progress report

Inform Vector Control Section DCD, MOH

4. 4(i)

PUBLIC HEALTH RESPONSE Case management

Investigate the contacts of cases through active case detection. Search for unreported or undiagnosed cases where the patient lived during the 2 weeks period prior to onset of notified case. Any new case* (refer note) which fulfilled the clinical case definition detected during the ACD activities should be referred for further management. 4(ii) Vector Control

The source of infection should be sought. (a) House and Premise Inspection House and premise in the area where patient lives should be inspected for potential mosquito breeding sites, to get the Aedes Index (normal < 1 %) and the Bruteau Index (normal < 5) of the area. The source reduction activities should be carried out to reduce breeding sites in all premises. Fogging Fogging should be done in areas where the Chikungunya case is reported, after doing the Aedes survey. Activity should be targeted to Aedes mosquito i.e. it should be done at dawn and dust time. Larviciding Larviciding e.g. using temephos to destroy the larval stage of Aedes mosquito should be carried out to potential breeding sites that could not be destroyed.

(b)

(c)

4(iii) Entomological surveillance Adult mosquito and larval survey should be conducted in the area where patient lives. Larval survey for Chikungunya virus is important to evaluate the transovarian / vertical transmission of the virus; even though at present moment there is no evidence of vertical transmission. Intermittent entomological study for Chikungunya virus in adult mosquitos and larvae should be carried out. It is especially important in area where the possibility of sustained transmission occurred in animal e.g. monkeys, as in Africa and areas with many foreign workers from endemic area of Chikungunya disease.
* a new case of Chikungunya virus infection is a case who fulfilled the case definition and manifest the symptoms for the first time. As demonstrated in Perak outbreak, some relapse cases had similar symptoms as new case.

4(iv)

Community empowerment and mobilisation. Exhibitions, dialogue sessions, demonstrations and distribution of pamphlets, posters should be enhanced; to inform the public about the disease and the prevention measures. Stress on treatment seeking behaviour of cases, eliminating the breeding sites and notification of cases by private clinic and head of community should be made. Interagency cooperation and community participation in keeping the environment free from mosquitos especially Aedes is also one component that should be enhanced.

4(v)

Enforcement of Destruction of Disease Bearing Insects Act (DDBIA), 1975 (Amendment 2000) Enforcement of law for those found breeding Aedes mosquitoes within their premises is usually taken as a last resort. The Act is enforced to unco-operative section of the public in the gazetted areas after all efforts to destroy the potential breeding sites of Aedes failed.

Please refer to Manual Panduan Pencegahan dan Kawalan Penyakit Demam Denggi / Demam Denggi Berdarah 1986 and Garis Panduan Pelaksanaan Program Komunikasi Untukl Perubahan Tingkah Laku (COMBI): Pencegahan dan Pengawalan Demam Denggi for details of the vector control activities.

REFERENCES: J. Chin. 2000. Control of Communicable Disease Manual. 17th Edition. Page 30 39. Directorate-General of Health Department Of The Situations Medical Durgence, Paris. Zoonoses:Chikungunya. March 2006. Fauci et all. 1998. Harrisons Principle of Internal Medicine, Volume 1. 14th edition. Page 1140. Guerrant R.L. 2001. Essentials of Tropical Infectious Diseases. Page 587- 590. J.S. Mackenzie, K.B. Chua, P.W. Daniels, B.T. Eaton, H.E. Field, R.A. Hall, K. Halpin, C.A. Johansen, P.D. Kirkland, S.K. Lam, P. McMinn, D.J. Nisbet, R. Paru, A.T. Pyke, S.A. Ritchie, P. Siba, D.W. Smith, G.A. Smith, A.F. van den Hurk, L.F. Wang, D.T. Williams. Emerging Viral Diseases of Southeast Asia and the Western Pacific. Emerging Infectious DiseasesVol. 7, No. 3 Supplement, June 2001 497 504. M. Diallo, J. Thonnon, M. Traore-Lamizana, D. Fontenille. 1999. Vectors of chikungunya virus in Senegal: current data and Transmission cycles. Am. J. Trop. Med. Hyg., 60(2), 1999, pp. 281286. Ministry of Health Malaysia. 1986. Panduan Pencegahan dan Kawalan Penyakit Demam Denggi / Demam Denggi Berdarah. Ministry of Health Malaysia. Garis Panduan Pelaksanaan Program Komunikasi Untuk Perubahan Tingkah Laku (COMBI): Pencegahan dan Pengawalan Demam Denggi. WHO. 2006. Chikungunya in La Reunion Island (France). 17 February 2006.