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Chikungunya
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Purpose
The purpose of this continuing education course is to stress the challenges, and
the increase in reported cases of Chikungunya (CHIK). In addition to educated health
care professional on the prevalence of (CHIK) and how this disease affects individuals
and the communities in that the live.
Objectives
1. Describe how the Chikungunya virus is transmitted.
2. Discuss the signs and symptom of Chikungunya.
3. List laboratory tests performed for diagnosing Chikungunya.
4. Understand the treatment Options for Chikungunya.
5. Discuss the Prognosis for Chikungunya.
6. Describe the educational and preventative measure for Chikungunya.
Authors: Denise R. Eccles, PhD, ED, RN, and Raynel Kinchen, BA, M.Ed
Advance Nursing Institute INC is approved as a provider of continuing education in nursing by Florida Board of Nursing.
Provider # 50-16977 Copyright © 2013 Advance Nursing Institute INC.
1
Chikungunya
Chikungunya virus is a mosquito-borne alpha-virus that has the ability to cause
acute febrile illness, severe pain and stiffness of the joints (polyarthralgia). Mortality is
rare but the joint pains can be debilitating. According to Staples, Breiman, and Powers,
(2009) the acute symptoms typically resolve within 7-10 days. However, some patients
experience persistent joint pains for months to years. According to Panning et al. (2009),
chikungunya virus (CHIKV) is the cause of chikungunya disease. The disease is
primarily transmitted by two mosquito species known as Aaedes aegypti and Aedes
albopictus (Center for Disease Control and Prevention, 2014). The effects of
chikungunya can be widespread in very short amounts of time as mosquitoes are known
to be fundamentally everywhere. In 2005 and 2006 an endemic in south Asia impacted
1.3 million people in India and another 37,000 in Sri Lanka, (Panning et al., 2009).
Because of the ease and increase in transmission, similarities in symptoms to
many other diseases, and the debilitating effects, it is best for western medical
professionals to remain up-to-date on chikungunya-related developments. Furthermore
the widespread appearance of the disease in certain sub-tropical and tropical climates,
have lead a nationwide health alert. Health Notices were issued for many countries, and
healthcare workers should note that patients recently returning from these countries with
appropriate symptoms should be questioned about mosquito bites and tested for
chikungunya as a precaution. Furthermore as of an updated report, most cases in the
United States are from Florida (12) and New York (nine). All other states have none or
less than five. Chikungunya has been found in worldwide in the following continents and
Authors: Denise R. Eccles, PhD, ED, RN, and Raynel Kinchen, BA, M.Ed
Advance Nursing Institute INC is approved as a provider of continuing education in nursing by Florida Board of Nursing.
Provider # 50-16977 Copyright © 2013 Advance Nursing Institute INC.
2
regions: Africa (25 countries), Europe (Italy and France), Oceania/Pacific (nine
countries), Asia (20 countries), Americas (44 countries) (Center for Disease Control and
Prevention, 2014).
Symptoms
Individuals infected with the virus will be symptomatic, and the period of
incubation may last anywhere from 1-12 days, however more commonly 3-7 days after
contact with a vector. Symptoms from chikungunya may include:
a. Severe, high fever of 102 Fahrenheit [39 Celcius]
b. Polyarthralgia [multiple-joint joint pain] which can be so painful a sufferer
cannot function. The pain is typically symmetric and bilateral.
c. Headaches
d. Nausea and vomiting
e. Arthritis
f. Conjunctivitis
g. Myaligia
h. Maculopapular Rash (this rash may only appear on lighter-skinned patients. It
is a red area of skin with similarly raised bumps) (Center for Disease Control
and Prevention, 2014).
Ruiz-Moreno et al. (2012) further clarify that the “debilitating and prolonged joint
pain” can be specific for chikungunya. This is important to note because it is so similar to
dengue fever.
Laboratory tests can find other less obvious symptoms such as:
Authors: Denise R. Eccles, PhD, ED, RN, and Raynel Kinchen, BA, M.Ed
Advance Nursing Institute INC is approved as a provider of continuing education in nursing by Florida Board of Nursing.
Provider # 50-16977 Copyright © 2013 Advance Nursing Institute INC.
3
a. Hepatic transaminases
b. Lymphpenia
c. Elevated creatine
d. Elevated hepatic transaminases (Ruiz-Moreno et al., 2012; Center for Disease
Control and Prevention, 2014).
The CDC, (2014) notes that there can be other atypical symptoms associated with the
virus and should these symptoms occur prompt medical attention is required:
a. Neurological concerns: meningoencephalitis, encephalopathy, neuropathy,
seizures, Gullain-Barré syndrome, cerebellar syndrome, palsies, paresis
b. Cardiovascular: Myocarditis, hemodynamic instability, pericarditis,
arrhythmias, heart failure
c. Dermatological: Hyperpigmentation, photosensitive, intertriginous aphthouslike ulcers, vesiculobullous dermatosis,
d. Ocular concerns: Episcleritis, uveitis, retinitis, optic neuritis, irirdocyclitis
When evaluating these atypical symptoms, it is crucial that medical staff know what key
differences to look for. Chikungunya can easily be mistaken for dengue fever. Amazingly
there can be two viruses that circulate in the same area and can cause occasional coinfections in the same patient because both Chikungunya, and dengue fever are
transmitted by the same type of mosquitoes and have similar clinical features. In addition
health care providers should also be on alert for lab results ruling out other associated
diseases for example; the alphavirus infections, adenovirus, leptospirosis, rickettsia,
Authors: Denise R. Eccles, PhD, ED, RN, and Raynel Kinchen, BA, M.Ed
Advance Nursing Institute INC is approved as a provider of continuing education in nursing by Florida Board of Nursing.
Provider # 50-16977 Copyright © 2013 Advance Nursing Institute INC.
4
malaria, rubella, measles, streptococcus, parvovirus, and enteroviruses (Center for
Disease Control and Prevention, 2014).
Tests
Laboratory tests for chikungunya can be used to rule out the potential for other
diseases such as dengue fever. Blood serum or plasma can be used to find virus-specific
immunoglobulin M, viral nucleic acid, Chikungunya Virus, or neutralizing antibodies. It
is recommended that blood sample be coagulated, and the blood serum be separated from
the coagulation (clot) before submitting the blood for (“Diagnostic testing”, 2014).
Treatment
According to Panning et.al. (2012) vaccination is the most cost-effective means of
protecting the at-risk populations in Chikungunya Virus-endemic developing countries.
As Chikungunya Virus outbreaks occur only sporadically and unpredictably in affected
countries, the vaccine efficacy cannot be proven as a requirement for traditional
regulatory approval by the US FDA at this time (Panning et. al., 2012). Nonetheless there
is no cure for chikungunya. The goal is to treat the symptoms (Ruiz-Moreno et al.,
2012). Joint pain may require analgesic and long-term antiinflammatory therapy (World
Health Organization-South-East Asia Regional Office, 2015). Because of the danger of
dengue overlap, if there is not a confirmed diagnosis refrain from using aspirin and
NSAIDs because they can encourage hemorrhaging in patients that do have dengue.
Additionally, caretakers should monitor the hemodynamic condition, and patients should
also get plenty of rest and have his or her fluids monitored to avoid dehydration (CDC,
“Symptoms” 2014).
Authors: Denise R. Eccles, PhD, ED, RN, and Raynel Kinchen, BA, M.Ed
Advance Nursing Institute INC is approved as a provider of continuing education in nursing by Florida Board of Nursing.
Provider # 50-16977 Copyright © 2013 Advance Nursing Institute INC.
5
Prognosis
Chikungunya was believed to a non-fatal and self-limiting disease (Bonn, 2006).
However there has been several cases on the Indian Ocean island of Reunion, that have
reported Central Nervous System (CNS) and fulminating involvement in one third of the
population that was affected and the disease had caused 237 deaths (Bonn, 2006).
However the mortality from chikungunya is low, and patients that are more affected by
the virus are the elderly, compromised patients, and infants (Ruiz-Moreno et al., 2012).
Prevention
Majra, and Acharya, (2011) current studies have proven that people who had
knowledge about the vector (the two mosquito species known as Aaedes aegypti and
Aedes albopictus) and methods of preventing the disease are less likely to be affected by
chikungunya. Ruiz-Moreno et al. (2012) suggest that the best way to contain the recent
outbreak of chikungunya is to gain control over the mosquito population. Because no
vaccine exists, in order to prevent chikungunya, the CDC (“Prevention”, 2014)
recommends the following steps:
a. Know the species that spread chikungunya are more likely to bite during the
day
b. If you must go outside, wear long sleeve shirts and pants whenever possible
c. Use insect repellant (ex. DEET, picaridin, etc.) (Sunscreen first, than repellant
when using both)
d. Use air conditioning instead of opening windows
Authors: Denise R. Eccles, PhD, ED, RN, and Raynel Kinchen, BA, M.Ed
Advance Nursing Institute INC is approved as a provider of continuing education in nursing by Florida Board of Nursing.
Provider # 50-16977 Copyright © 2013 Advance Nursing Institute INC.
6
e. Use window screens or sleeping nets to prevent mosquitoes from entering
indoor spaces
f. Use items treated with permethrin when outdoors for prolonged activities like
camping
Conclusion
According to a study conducted by Ruiz-Moreno et al. (2012) on highlypopulated locations in the United States on the east coast indicate that, in sub-tropical
climates like Miami, medical workers should anticipate year-round cases, while New
York, and Atlanta should anticipate cases to spike in the rainy and summer months.
Health care workers should remain vigilant and report any suspected cases of
chikungunya to their local health departments so that appropriate tracking and origins of
disease can be surveyed (CDC, “Clinical evaluation”, 2014). Education should heighten
for communities to remove all areas of standing water during the rainy seasons and report
and increase of mosquitos to local cities for fumigation. It is recommended that there
must be increased awareness about the potential of this disease how it can affect all areas
during the summer travel season, because chikungunya is spreading to new areas every
year despite its tropical and sub-tropical tendencies. In the absence of any specific cure or
effective vaccine, health education can prove to be an important tool for the control of
chikungunya epidemic (Bonn, 2006).
Authors: Denise R. Eccles, PhD, ED, RN, and Raynel Kinchen, BA, M.Ed
Advance Nursing Institute INC is approved as a provider of continuing education in nursing by Florida Board of Nursing.
Provider # 50-16977 Copyright © 2013 Advance Nursing Institute INC.
7
References
Bonn, D. (2006). How did chikungunya reach the Indian Ocean? Lancet,6, 543
Center for Disease Control and Prevention. (2014). Chikungunya: atypical and severe
disease manifestations. National center for Emerging and Zoonotic Infectious
Diseases Division of
Vector-Borne Diseases. Retrieved from
http://www.cdc.gov/chikungunya/pdfs/Chikungunya-atypical-severedisease_Healthcare-provider-factsheet-10-07-2014.pdf
Center for Disease Control and Prevention. (2014). Chikungunya virus in the caribbean,
2015. Retrieved from http://wwwnc.cdc.gov/travel/notices/watch/chikungunyasaint-martin.
Center for Disease Control and Prevention. (2014). Chikungunya: What you need to
know. Center for Disease Control and Prevention. Retrieved from http://www.cdc.gov/chikungunya/pdfs/Factsheet_Chikungunya-what-you-needto-know.pdf.
Center for Disease Control and Prevention. (2014). Chikungunya Information for
healthcare providers. National center for Emerging and Zoonotic Infectious
Diseases Division of Vector-Borne Diseases. Retrieved from
http://www.cdc.gov/chikungunya/pdfs/CHIKV_Clinicians.pdf.
Center for Disease Control and Prevention. (2014). Diagnostic testing. Retrieved from
http://www.cdc.gov/chikungunya/hc/diagnostic.html.
Authors: Denise R. Eccles, PhD, ED, RN, and Raynel Kinchen, BA, M.Ed
Advance Nursing Institute INC is approved as a provider of continuing education in nursing by Florida Board of Nursing.
Provider # 50-16977 Copyright © 2013 Advance Nursing Institute INC.
8
Center for Disease Control and Prevention. (2014). Prevention. Retrieved from
http://www.cdc.gov/chikungunya/prevention/
Center for Disease Control and Prevention. (2014). Symptoms, diagnosis & treatment.
Retrieved from http://www.cdc.gov/chikungunya/symptoms/index.html
Lindsey, N. P., Prince, H. E., Kosoy, O., Laven, J., Messenger, S., Staples, J. E., &
Fischer, M. (2015). Chikungunya virus infections among travelers-United
States, 2010-2013. The American Journal of Tropical Medicine and Hygiene,
92(1), 82-87. doi:10.4269/ajtmh.14-0442
Majra, J. P., & Acharya, D. (2011). Impact of knowledge and practices on prevention of
chikungunya in an epidemic area in India. Annals of Tropical Medicine & Public
Health, 4(1), 3-6.
Panning, M., Wichmann, D., Grywna, K., Annan, A., Wijesinghe, S., Kularatne, S.A.M.,
Drosten, C.
(2009). No evidence of chikungunya virus and antibodies shortly
before the outbreak on srilanka. Medical Microbiology and Immunology, 198(2),
103-6.
Ruiz-Moreno, D., Sanchez Vargas, I., Olson, K., Harrington, L. (2012). Modeling
dynamic introduction of chikungunya virus in the united states. PLoS Neglected
Tropical Diseases, 6(11), 1918.
Sharp, T. (2014). Differentiating chikungunya from dengue: A clinical challenge. Center
for Disease
from
Control and Prevention in collaboration with Medscape. Retrieved
http://www.medscape.com/viewarticle/831523
Authors: Denise R. Eccles, PhD, ED, RN, and Raynel Kinchen, BA, M.Ed
Advance Nursing Institute INC is approved as a provider of continuing education in nursing by Florida Board of Nursing.
Provider # 50-16977 Copyright © 2013 Advance Nursing Institute INC.
9
Staples, J., Breiman, R., Powers, A., (2009). Chikungunya fever: an epidemiological
review of a re-emerging infectious disease. Clinical of Infectious Disease 49, 942948.
Weaver, S. C., Osorio, J. E., Livengood, J. A., Chen, R., & Stinchcomb, D. T. (2012).
Chikungunya virus and prospects for a vaccine. Expert Review of Vaccines, 11(9),
1087-101.
World Health Organization-South-East Asia Regional Office. (2015). Chikungunya
Fever, a re-emerging Disease in Asia. Retrieved from http://www.
searo.who.int/en/Section10/Section2246.htm.
Authors: Denise R. Eccles, PhD, ED, RN, and Raynel Kinchen, BA, M.Ed
Advance Nursing Institute INC is approved as a provider of continuing education in nursing by Florida Board of Nursing.
Provider # 50-16977 Copyright © 2013 Advance Nursing Institute INC.
10