Hidden burden of chikungunya in North India; A prospective study in a tertiary care centre

Beyond the Bite: Detailed findings on Chikungunya and Dengue co-detection in Punjab, North India - clinical insights and diagnostic challenges

OBJECTIVES

The co-circulation of Chikungunya virus (CHIKV) and Dengue virus (DENV) in India poses a challenge for the diagnosing clinician, as they share similar clinical signs and symptoms and geographical distribution. Both arthropod-borne viruses are maintained in the environment by the Aedes mosquito, commonly found in tropical countries including India. Here we aim to investigate the clinical and laboratory aspects of Chikungunya/Dengue suspected cases in Punjab, India during 2021-2022, focusing on the differential diagnosis of Dengue.

METHODS

All suspected cases were submitted to serological differential diagnosis approaches to arboviruses like Chikungunya and Dengue. For the detection of Chikungunya Infection, CHIK IgM Capture ELISA was employed. Whereas, for Dengue NS1 antigen ELISA and IgM Capture ELISA assays were employed.

RESULTS

A total of 370 cases suspected of arboviral infection were investigated and 38.3% (142/370) were confirmed as Chikungunya. Chikungunya cases were slightly more prevalent in males (54%) and the most frequently affected age group was adults between 16 and 30 years old (45.7%). Polyarthralgia affected 79.5% of patients, 63.3% exhibited headache and 50% presented with retro-orbital pain. 28.9% (107/370) had serological evidence of DENV exposure by detection of specific anti-DENV IgM or NS1 and 9.1% (34/370) cases of co-detection of Chikungunya and Dengue were reported. Urban populations had a higher infection rate of co-detection of Chikungunya and Dengue than rural populations with 83% versus 17%, respectively.

CONCLUSIONS

Despite an initial clinical diagnosis of Dengue, most patients with fever and arthralgia were serologically confirmed as Chikungunya cases, with a notable prevalence of CHIKV/DENV co-detection. Strengthening differential diagnosis of circulating arboviruses is crucial for improving patient care and enhancing vector control and environmental management strategies.

Seropositivity of Chikungunya in Hospital Setting, India: A Systematic Review and Meta-Analysis

Backround

Information about the chikungunya disease burden by age groups and geographic distribution is necessary to guide appropriate control measures. With this, we conducted a systematic review and meta-analysis to estimate the disease burden of chikungunya fever in India.

Material and Methods

We conducted this systematic review according to the Cochrane Collaboration guidelines. We retrieved relevant articles from PubMed and a free online search. Two investigators screened titles and abstracts and extracted data from the relevant articles. Our primary outcome is the proportion of laboratory-confirmed Chikungunya fever among clinically suspected patients. We used a random effect model to estimate the pooled proportion of Chikungunya fever.

Result

A total of 20 articles were included in the quantitative syntheses. The pooled proportion of laboratory-confirmed chikungunya fever from 20 studies estimated using the random effects model is 24% (95%CI: 15-34%). We found the pooled proportion in the southern region was 35% (95%CI: 4-66%), 28% (95%CI: 3-58%) in the western region, 24% (95%CI: 1-48%) in the eastern region, 20% (95%CI: 12-29%) in the northern region, and 4% (95%CI: 1-6%) in North-eastern region.

Conclusion

This review emphasizes the need to strengthen the surveillance of disease burden using multiple diagnostic tests and the need for an appropriate molecular diagnostic for early detection of the chikungunya virus.

Dengue-chikungunya infection in the tertiary care hospital of northern India: Cross-sectional latent class cluster analysis in viral infection

Cases of dengue and chikungunya fever are escalating all over India. Both viruses share a common vector, the "Aedes" mosquito. Due to similar clinical symptoms, both the dengue (DENV) and chikungunya (CHIKV) virus can circulate as co-infection. There is very limited data available on dengue-chikungunya co-infection in Uttarakhand, India. The purpose of this study was to determine the seroprevalence of dengue and chikungunya virus infections, as well as their co-infection, in patients presenting with clinical symptoms. Serum samples of clinically suspected patients from the tertiary care hospital of Uttarakhand were collected, and Latent Class Cluster Analysis was performed for clinical profiling. ELISA was performed for DENV and CHIKV. 279 cases were enrolled, out of which 222 (79.5%) came positive for dengue NS1 Ag, 143 (51.2%) for dengue IgM, 98 (35.1%) for IgG followed by 16 (5.7%) of CHIKV IgM, and 4 (1.4%) were NS1 Ag with CHIKV IgM. Among the clinical features, fever (n = 270, 96.8%) was the most common symptom in all suspected dengue and chikungunya cases. Other symptoms like chills (n = 254, 91.0%), arthralgia (n = 241, 86.4%), and headache (n = 240, 86.0%) were present in a significant number. Results showed fewer odds of getting both DENV and CHIKV infection simultaneously, but the risk is still not negligible. This study explores the clinical presentation of the suspected dengue-chikungunya case. The increasing incidence of dengue and chikungunya and their co-infection necessitate the authorities' active surveillance of endemic regions and effective patient care management.

Chikungunya Virus: Priority Pathogen or Passing Trend?

Chikungunya virus (CHIKV) is considered a priority pathogen and a major threat to global health. While CHIKV infections may be asymptomatic, symptomatic patients can develop chikungunya fever (CHIKF) characterized by severe arthralgia which often transitions into incapacitating arthritis that could last for years and lead to significant loss in health-related quality of life. Yet, Chikungunya fever (CHIKF) remains a neglected tropical disease due to its complex epidemiology and the misrepresentation of its incidence and disease burden worldwide. Transmitted to humans by infected Aedes mosquitoes, CHIKV has dramatically expanded its geographic distribution to over 100 countries, causing large-scale outbreaks around the world and putting more than half of the population of the world at risk of infection. More than 50 years have passed since the first CHIKV vaccine was reported to be in development. Despite this, there is no licensed vaccine or antiviral treatments against CHIKV to date. In this review, we highlight the clinical relevance of developing chikungunya vaccines by discussing the poor understanding of long-term disease burden in CHIKV endemic countries, the complexity of CHIKV epidemiological surveillance, and emphasising the impact of the global emergence of CHIKV infections. Additionally, our review focuses on the recent progress of chikungunya vaccines in development, providing insight into the most advanced vaccine candidates in the pipeline and the potential implications of their roll-out.

Global prevalence of dengue and chikungunya coinfection: A systematic review and meta-analysis of 43,341 participants

Dengue and chikungunya virus are important arboviruses of public health concern. In the past decades, they have accounted for numerous outbreaks of dengue and chikungunya in different parts of the world. Several cases of concurrent infection of dengue and chikungunya have been documented. However, the true burden of this concurrent infection is unknown. Here, a systematic review and meta-analysis of published data on the prevalence of dengue and chikungunya coinfection in the human population was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Six electronic databases (Web of science, Embase, PubMed, ScienceDirect, Scopus, and Google Scholar) were searched without year or language restrictions for relevant studies. The study protocol was registered with PROSPERO (CRD42020175344). Eighty-three studies involving a total of 43,341 participants were included. The random-effects model was employed to calculate the summary estimates. A pooled global prevalence of 2.5% (95% CI: 1.8-3.4) was obtained for dengue and chikungunya coinfection. Males and females appear to be coinfected at a fairly similar rate. Among the regions, Asia accounted for the highest prevalence (3.3%, 95% CI: 2.3-4.6) while North America was the least (0.8%, 95% CI: 0.3-2.4). The prevalence estimates varied across different countries. A much higher prevalence rates were obtained for Colombia (37.4%, 95% CI: 9.1-78.1), Madagascar (18.2%, 95% CI: 10.1-30.6), Laos (12.5%, 95% CI: 5.3-26.7), Maldives (4.5%, 95% CI: 1.5-13.0) and Thailand (3.7%, 95% CI: 0.4-26.3). This first extensive systematic review and meta-analysis reveals dengue and chikungunya coinfection as a global problem worthy of consideration. It is therefore pertinent that both infections be assessed during diagnosis, mosquito vector control practices be implemented, and vaccine development strides be supported globally.

Computational analysis of human host binding partners of chikungunya and dengue viruses during coinfection

Mosquito-borne viral diseases like chikungunya and dengue infections can cause severe illness and have become major public health concerns. Chikungunya virus (CHIKV) and dengue virus (DENV) infections share similar primary clinical manifestations and are transmitted by the same vector. Thus, the probability of their coinfection gets increased with more severe clinical complications in the patients. The present study was undertaken to elucidate the common human interacting partners of CHIKV and DENV proteins during coinfection. The viral-host protein-protein interactome was constructed using Cytoscape. Subsequently, significant host interactors were identified during coinfection. The network analysis elucidated 57 human proteins interacting with both CHIKV and DENV, represented as hub-bottlenecks. The functional and biological analyses of the 40 hub-bottlenecks revealed that they are associated with phosphoinositide 3-kinases (PI3K)/AKT, p53 signaling pathways, regulation of cell cycle and apoptosis during coinfection. Moreover, the molecular docking analysis uncovered the tight and robust binding of selected hub-bottlenecks with CHIKV/DENV proteins. Additionally, 23 hub-bottlenecks were predicted as druggable candidates that could be targeted to eradicate the host-viral interactions. The elucidated common host binding partners during DENV and CHIKV coinfection as well as indicated approved drugs can support the therapeutics development.

Burden of Dengue and Chikungunya – A Retrospective Study

Arboviral infections like dengue fever and chikungunya are the most common infections that share the same Aedes mosquito vectors. Clinical presentations of these two infections are also similar, especially in initial stages. Non-structural antigen (NS1 Ag)detection for dengue and detection of IgM antibodies by capture ELISA for chikungunya and dengue infection may help in the early diagnosis. Early diagnosis is essential for the treatment and control measures. The present study was conducted to know the burden of dengue and chikungunya. A retrospective study was conducted for a period of 1 year from Dec 2017 to Nov 2018 to know the burden of dengue and chikungunya in Chamarajanagar. Dengue (> 5 days fever) and chikungunya testing was done by IgM antibody capture ELISA kits produced by NIV. Dengue samples (< 5 days fever) were subjected to NS1 antigen detection by microwell enzyme-linked immunosorbent assay (ELISA) from Qualpro diagnostics. The tests were carried out following manufacturer’s instruction. Samples received for dengue NS1 Ag testing was 446, of which, 49(11.0%) were positive and of 730 samples received for IgM antibody, 53 (7.3%) were positive. Age group commonly affected was 0-20 years 44(43.1%). Of 668 samples received for chikungunya test, 86 (12.9%) were positive. Maximum number of cases was seen in age group of 21-40 years 45(52.3%). Males 56(54.9%) were affected higher than female 46(45.1%) in dengue infection while in chikungunya, females 45(52.3%) were more affected than males 41(47.7%). Both infections are high in the month of June and July. Early detection of dengue by NS1 antigen and detection of Ig M antibodies by capture ELISA chikungunya and dengue infection helps in appropriate treatment and initiation of prevention and control measures by community awareness and vector control.

Standardization of ELISA for anti-chikungunya-IgG antibodies and age-stratified prevalence of anti-chikungunya-IgG antibodies in Pune, India

Chikungunya (CHIKV) reemerged in India after a gap of 32 years, in 2005-2006 and has established endemicity in Pune. To assess the degree of CHIKV exposure, we estimated age-stratified prevalence of IgG antibodies to CHIKV in Pune population. This retrospective study utilized age-stratified serum samples collected from 15 wards of Pune in 2017 for dengue (DENV) virus study. Indirect anti-CHIKV-IgG ELISA was developed and used to test 1904 samples. Exposure to CHIKV and DENV was compared in the same population. CHIKV-specific plaque reduction neutralization test (PRNT) was employed to evaluate ELISA positivity and neutralizing potential of anti-CHIKV-IgG antibodies. Indirect ELISA showed 98.5% concordance with commercial ELISA. Seropositivity to CHIKV was 46.4%, one-third children < 15 years being antibody positive. A significant increase (45%, p = 0.026-0.038) was noted at 16-25 years and varied between 48 and 56% until the age 65. In elderly (65 + years), antibody positivity was reduced (41%, p = 0.01). In children, CHIKV-PRNT₅₀ titers increased with age and remained comparable from the age group 11-15 until > 65. Exposure to DENV was higher than CHIKV. Lower exposure of children and elderly could be due to lesser exposure to the vectors. High prevalence of IgG antibodies needs to be addressed while planning vaccine studies for CHIKV.

Antibody response patterns in chikungunya febrile phase predict protection versus progression to chronic arthritis

Chikungunya virus (CHIKV) infection causes acute febrile illness in humans, and some of these individuals develop a debilitating chronic arthritis that can persist for months to years for reasons that remain poorly understood. In this study from India, we characterized antibody response patterns in febrile chikungunya patients and further assessed the association of these initial febrile-phase antibody response patterns with protection versus progression to developing chronic arthritis. We found 5 distinct patterns of the antibody responses in the febrile phase: no CHIKV binding or neutralizing (NT) antibodies but PCR positive, IgM alone with no NT activity, IgM alone with NT activity, IgM and IgG without NT activity, and IgM and IgG with NT activity. A 20-month follow-up showed that appearance of NT activity regardless of antibody isotype or appearance of IgG regardless of NT activity during the initial febrile phase was associated with a robust protection against developing chronic arthritis in the future. These findings, while providing potentially novel insights on correlates of protective immunity against chikungunya-induced chronic arthritis, suggest that qualitative differences in the antibody response patterns that have evolved during the febrile phase can serve as biomarkers that allow prediction of protection or progression to chronic arthritis in the future.

Antibody-based therapeutic interventions: possible strategy to counter chikungunya viral infection

Chikungunya virus (CHIKV), a mosquito-transmitted disease that belongs to the genus Alphaviruses, has been emerged as an epidemic threat over the last two decades, and the recent co-emergence of this virus along with other circulating arboviruses and comorbidities has influenced atypical mortality rate up to 10%. Genetic variation in the virus has resulted in its adaptability towards the new vector Aedes albopictus other than Aedes aegypti, which has widen the horizon of distribution towards non-tropical and non-endemic areas. As of now, no licensed vaccines or therapies are available against CHIKV; the treatment regimens for CHIKV are mostly symptomatic, based on the clinical manifestations. Development of small molecule drugs and neutralizing antibodies are potential alternatives of worth investigating until an efficient or safe vaccine is approved. Neutralizing antibodies play an important role in antiviral immunity, and their presence is a hallmark of viral infection. In this review, we describe prospects for effective vaccines and highlight importance of neutralizing antibody-based therapeutic and prophylactic applications to combat CHIKV infections. We further discuss about the progress made towards CHIKV therapeutic interventions as well as challenges and limitation associated with the vaccine development. Furthermore this review describes the lesson learned from chikungunya natural infection, which could help in better understanding for future development of antibody-based therapeutic measures.

Dengue infection in North India: An experience of a tertiary care center from 2012 to 2017

OBJECTIVE

Recently, an alarming rise of dengue has been seen in India which remains a major public health concern. This study has been designed for a comprehensive overview of the epidemiology, gender, age, area distribution, symptomology, and seasonal variability.

MATERIALS AND METHODS

Retrospective analysis of 900 suspected dengue cases of all age groups of either sex from 2012 to 2017 at a North Indian tertiary care hospital revealed 461 (51.22%) cases seropositive for dengue.

RESULTS

The age group of 20-30 years was the most affected group with male predominance. The urban population was more affected as 75.05%, and maximum cases were detected in October month followed by November. Common abnormal laboratory parameters were thrombocytopenia (99.1%), hepatic dysfunction (59%), and leukopenia (26.68%). Two uncommon findings, pancytopenia and pancreatic dysfunction were reported in 7 and 3 cases respectively.

CONCLUSION

Dengue infection in India has evolved rapidly, and regular outbreaks have been observed with a changing epidemiology, as the disease is rapidly spreading from urban to rural areas with increasing atypical manifestations.

Epidemiological trends and molecular dynamics of dengue, chikungunya virus infection, coinfection, and other undifferentiated fever during 2015-2016 in Odisha, India

Chikungunya virus (CHIKV) infection is spatiotemporally related to dengue virus (DENV) infection and mostly undiagnosed due to similar primary symptoms. In 2013, a high rate (36%) of coinfection of DENV and CHIKV was reported in Odisha. Hence, the hospital-based study was continued to synthesis current epidemiological understanding of their single distribution or coinfection. Suspected DENV patients serum samples were tested for DENV and CHIKV by serology and reverse-transcription polymerase chain reaction. The positive samples were used for analysis of mutation, selection pressure, and phylogenetic relationship. Clinical information was also analyzed. Among 648 (2015 and 2016) suspected DENV patients, 141 (21.7%) were positive for DENV (serotypes 1-3), 22 (3.4%) were positive for CHIKV (ECSA) and 4 (2.8%) were coinfected with both. Sequence analysis showed four consistent mutations (M104V, V112A, K166N, and F169L) in CprM gene of DENV 2 and two consistent mutations (M269V, D284E) in E1 gene of CHIKV. Interestingly, the CHIKV- E1 A226V mutation was absent in the studied population. It was also noticed that the peak incidence of both the infections occurs in August-September in 2015-16. Moreover, Plasmodium species, Salmonella typhi, and Rickettsial typhi infections were also observed in DENV patients. Different etiology was also detected in other undifferentiated fever patients as mixed infections (malaria, S. typhi, and R. typhi ). Hence, this investigation shows the significant reduction of DENV-CHIKV coinfection as compared with previous report, the burden of arboviruses and acute undifferentiated fever in Odisha in 2015-2016, highlighting the importance of epidemiological picture of febrile patients for appropriate patient management.

Knowledge of Chikungunya Fever Among Medical Students of Jinnah Sindh Medical University, Karachi, Pakistan

Objective

Chikungunya is a viral disease characterized by severe arthralgia, fever, rash, muscle pain, and neurological symptoms. Warm and humid weather, poor sanitary conditions, and improper water storage and disposal can lead to an uncontrolled outbreak of the Chikungunya virus in South Asia. Because a vaccine against the Chikungunya virus has not yet been developed, we must rely on appropriate awareness and suitable preventive measures to prevent its spread. A review of the literature shows that knowledge of the Chikungunya virus among medical students in Karachi is scarce. Because medical students are future medical practitioners, they should be adequately aware of this growing issue.

Materials and methods

We performed a single-center, cross-sectional study at the Jinnah Sindh Medical University in Karachi, Pakistan, in which 200 students were assessed on their knowledge of the Chikungunya virus and fever via a structured questionnaire.

Results

A total of 200 students participated in the study. The mean age of the study participants was 20 ± 1 years. Only 50% of the study participants had an adequate knowledge score related to the Chikungunya virus and fever. We found that 43% had an average knowledge, and 7% had poor knowledge. The study also revealed a strong association between year of study and knowledge score (p=0.003); those in the higher age group had more knowledge (p=0.014).

Conclusion

A low percentage of medical students have sufficient knowledge about Chikungunya virus and fever, which is alarming because Pakistan has recently faced a severe epidemic of Chikungunya virus fever and is a country prone to further outbreaks. Multiple training programs and lectures are necessary to prepare and educate medical students about both basic and clinical knowledge of Chikungunya.

Clinical profile of dengue fever and coinfection with chikungunya

OBJECTIVE

Arthropod-borne viral diseases are a major burden on the health-care system worldwide. Only a few studies have reported on coinfection of dengue fever (DF) with the chikungunya virus in North India. We investigated the seroprevalence and significance of the clinicobiochemical profile of dengue and chikungunya coinfection. Besides this, the authors try to emphasize rationalize platelets transfusion.

MATERIAL AND METHODS

The present study was conducted at the Heritage Institute of Medical Science, Varanasi, India, from July to December 2016. A total of 1800 suspected cases with acute viral febrile illness (age >18 years) were investigated to exclude other causes of acute febrile illnesses. Of these, 121 patients (6.72%) were diagnosed as seropositive for dengue and chikungunya mono or coinfection using IgM ELISA and were included in the study.

RESULTS

The male gender was predominant. The majority were in the 20-30-year age group with cases peaking in November. There were 102 (84.29%) cases of dengue, 6 (4.95%) cases of chikungunya, and 13 (10.74%) cases positive for coinfection. Fever was present in all cases. Headache followed by nausea/vomiting and generalized weakness were the most common symptoms in patients with DF while body aches and joint pain were most common in those with chikungunya fever. Deranged liver function and leukopenia were the most common complications in dengue.

CONCLUSION

Joint-related symptoms (pain and restricted movements) were statistically significant in chikungunya monoinfection. Two patients with DF were died. There was no significant added severity of clinical features and blood investigations in patients with coinfection with dengue and chikungunya compared to those with monoinfections.