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Clipes MVS, Vicente CR, Cardoso da Silva TC, Resende LC, Cerutti Junior C. Analysis of spatial and demographic factors associated with chikungunya in Espírito Santo state, Brazil. Trans R Soc Trop Med Hyg 2024:trae019. [PMID: 38650504 DOI: 10.1093/trstmh/trae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 01/08/2024] [Accepted: 03/20/2024] [Indexed: 04/25/2024] Open
Abstract
BACKGROUND Chikungunya (CHIK) emerged in Brazil in 2014 and since then several epidemics have been observed. This study aims to describe the spatial, social and demographic characteristics of individuals affected by CHIK in Espírito Santo state. METHODS A cross-sectional study was performed using data from individuals with a confirmed diagnosis of CHIK in Espírito Santo state, Brazil, from 2018 to 2020. Monthly incidence was calculated and annual spatial distribution maps were constructed. Statistical analysis using the χ2 test identified associations between disease occurrence and sociodemographic variables. RESULTS In the period and area analysed, a CHIK epidemic occurred in 2020, with an incidence of 219.8 cases per 100 000 inhabitants. The southern and central regions of Espirito Santo state harboured a risk five times greater than the others in the epidemic region. Females (odds ratio [OR] 1.65 [95% confidence interval {CI} 1.58 to 1.72]), black people (OR 1.22 [95% CI 1.13 to 1.33]), individuals with ≤11 y of education (OR 1.48 [95% CI 1.37 to 1.61]) and the elderly (OR 7.49 [95% CI 6.53 to 8.59]) had a greater risk for the disease. CONCLUSIONS CHIK stands as an emerging public health problem in Brazil since its introduction in 2014. Espírito Santo suffered a substantial epidemic in 2020, possibly due to outbreaks in neighbouring states. The population at risk should be prioritized in healthcare, considering the morbidity potential of the disease.
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Affiliation(s)
- Marcus Vinicius Salvador Clipes
- Post-Graduate Program of Infectious Diseases, Federal University of Espirito Santo, Vitória, Marechal Campos Avenue, 1468, 29047-105, Espírito Santo, Brazil
| | - Creuza Rachel Vicente
- Post-Graduate Program of Infectious Diseases, Federal University of Espirito Santo, Vitória, Marechal Campos Avenue, 1468, 29047-105, Espírito Santo, Brazil
| | - Theresa Cristina Cardoso da Silva
- Special Nucleus of Epidemiologic Surveillance from the State Department of Health, Vitória, Marechal Mascarenha de Moraes Avenue, 29050-755, Espírito Santo, Brazil
| | - Lilyan Correia Resende
- Post-Graduate Program of Infectious Diseases, Federal University of Espirito Santo, Vitória, Marechal Campos Avenue, 1468, 29047-105, Espírito Santo, Brazil
| | - Crispim Cerutti Junior
- Post-Graduate Program of Infectious Diseases, Federal University of Espirito Santo, Vitória, Marechal Campos Avenue, 1468, 29047-105, Espírito Santo, Brazil
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Watson HR, Duong V, Ly S, Mandron M, Siqueira AM, Ribeiro GS. Household clustering supports a novel chemoprophylaxis trial design for a mosquito-borne viral disease. Int J Infect Dis 2022; 122:169-173. [PMID: 35568359 DOI: 10.1016/j.ijid.2022.05.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/03/2022] [Accepted: 05/07/2022] [Indexed: 10/18/2022] Open
Abstract
Infections because of chikungunya and other mosquito-borne viruses, such as dengue and Zika, represent an area of significant unmet medical need. There are currently no approved medicines for prophylaxis or treatment of these diseases, and the development and implementation of vaccines against these viruses have proved problematic. Although antiviral molecules with treatment and prophylactic potential against the chikungunya virus have been identified, no successful field trials have been reported. Chemoprophylaxis may be attractive for unvaccinated at-risk populations; however, performing a successful chemoprophylaxis trial during a chikungunya outbreak will require a clearly identifiable at-risk population. We propose the application of a household transmission model as used in testing drugs against respiratory viruses. Current evidence on household clustering of chikungunya and other Aedes mosquito-borne viral infections is supportive. We suggest that this model may improve prophylaxis trial feasibility and focus research and future treatment on a population likely to benefit.
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Affiliation(s)
- Hugh R Watson
- Antiviral Research Unit, Evotec ID, 40 avenue Tony Garnier, 69007, Lyon, France; Departments of Clinical Pharmacology, Hepatology and Gastroenterology, Aarhus University, Aarhus, Denmark.
| | - Veasna Duong
- Virology Unit, Institut Pasteur du Cambodge, Pasteur Network, Phnom Penh, Cambodia
| | - Sowath Ly
- Epidemiology and Public Health Unit, Institut Pasteur du Cambodge, Pasteur Network, Phnom Penh, Cambodia
| | | | - André M Siqueira
- Instituto Nacional de Infectologia - Evandro Chagas, Fiocruz, Rio de Janeiro, Brazil
| | - Guilherme S Ribeiro
- Gonçalo Moniz Institute, Oswaldo Cruz Foundation, Salvador, Bahia, Brazil; School of Medicine, Federal University of Bahia, Salvador, Bahia, Brazil
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Paulson W, Kodali NK, Balasubramani K, Dixit R, Chellappan S, Behera SK, Balabaskaran Nina P. Social and housing indicators of dengue and chikungunya in Indian adults aged 45 and above: Analysis of a nationally representative survey (2017-18). Arch Public Health 2022; 80:125. [PMID: 35443704 PMCID: PMC9022351 DOI: 10.1186/s13690-022-00868-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background Dengue and chikungunya (CHIKV) are the two major vector-borne diseases of serious public health concern in India. Studies on socioeconomic and housing determinants of dengue and CHIKV at a pan-India level are lacking. Here, we took advantage of the recently carried out Longitudinal Ageing Study in India (LASI) carried out across all the states and Union Territories of India to study the social indicators of dengue and CHIKV in India. Methods LASI-1 (2017-2018) data on the self-reported period prevalence of dengue and CHIKV from 70,932 respondents aged ≥45 years were used for this analysis. The state-wise distribution of dengue and CHIKV was mapped. Prevalence was estimated for each study variable, and the difference was compared using the χ2 test. The adjusted odds ratios (AOR) of the socioeconomic and housing variables for dengue and CHIKV were estimated using the multiple logistic regression model. Results Urban residence is the major socio-economic indicator of dengue and CHIKV (dengue AOR: 1.57, 95% CI: 1.18-2.11; CHIKV AOR: 1.84, 95% CI: 1.36-2.49). The other notable indicator is wealth; rich respondents have higher odds of dengue and CHIKV. Adults older than 54 years and those with high school education and above are associated with a lower likelihood of dengue and CHIKV. In addition, CHIKV is associated with scheduled and forward castes, households with improper toilet facilities, open defecation, and kutcha house type. Conclusions Despite the limitation that the data is only from adults ≥ 45, this analysis provides important insights into the socioeconomic and housing variables associated with higher odds of dengue and CHIKV in India. Understanding these determinants may assist in the national planning of prevention and control strategies for dengue and CHIKV. Supplementary Information The online version contains supplementary material available at 10.1186/s13690-022-00868-5.
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Affiliation(s)
- Winnie Paulson
- Department of Epidemiology and Public Health, School of Life Sciences, Central University of Tamil Nadu, Tiruvarur, India
| | - Naveen Kumar Kodali
- Department of Epidemiology and Public Health, School of Life Sciences, Central University of Tamil Nadu, Tiruvarur, India
| | - Karuppusamy Balasubramani
- Department of Geography, School of Earth Sciences, Central University of Tamil Nadu, Tiruvarur, India
| | - Rashi Dixit
- Department of Epidemiology and Public Health, School of Life Sciences, Central University of Tamil Nadu, Tiruvarur, India
| | - Savitha Chellappan
- Indian Council of Medical Research- National Institute of Traditional Medicine, Belagavi, India
| | - Sujit Kumar Behera
- Department of Epidemiology and Public Health, School of Life Sciences, Central University of Tamil Nadu, Tiruvarur, India
| | - Praveen Balabaskaran Nina
- Department of Epidemiology and Public Health, School of Life Sciences, Central University of Tamil Nadu, Tiruvarur, India.
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4
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Yan R, Xu Z, Qian J, Zhou Q, Wu H, Liu Y, Guo Y, Zhu G, Chen M. Molecular and functional characterization of a conserved odorant receptor from Aedes albopictus. Parasit Vectors 2022; 15:43. [PMID: 35101118 PMCID: PMC8805257 DOI: 10.1186/s13071-022-05158-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/08/2022] [Indexed: 11/21/2022] Open
Abstract
Background The Asian tiger mosquito Aedes albopictus is a competent vector of several viral arboviruses including yellow fever, dengue fever, and chikungunya. Several vital mosquito behaviors (e.g., feeding, host-seeking, mating, and oviposition) are primarily dependent on the olfactory system for semiochemicals detection and discrimination. However, the limited number of studies hampers our understanding of the relationships between the Ae. albopictus olfactory system and the complex chemical world. Methods We performed RT-qPCR assay on antennae of Ae. albopictus mosquitoes of different sexes, ages and physiological states, and found odorant receptor 11 (AalbOr11) enriched in non-blood-fed female mosquitoes. Then, we examined the odorant preference with a panel of physiologically and behaviorally relevant odorants in Xenopus oocytes. Results The results indicated that AalbOr11 could be activated by ten aromatics, seven terpenes, six heterocyclics, and three alcohols. Furthermore, using post-RNA interference (RNAi) hand-in-cage assay, we found that reducing the transcript level of AalbOr11 affected the repellency activity mediated by (+)-fenchone at a lower concentration (0.01% v/v). Conclusions Using in vitro functional characterization, we found that AalbOr11 was a broadly tuned receptor. Moreover, we found that AalbOr11 shared a conserved odorant reception profile with homologous Anopheles gambiae Or11. In addition, RNAi and bioassay suggested that AablOr11 might be one of the receptors mediating (+)-fenchone repellency activity. Our study attempted to link odor-induced behaviors to odorant reception and may lay the foundation for identifying active semiochemicals for monitoring or controlling mosquito populations. Graphical Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s13071-022-05158-1.
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Keating P, Murray J, Schenkel K, Merson L, Seale A. Electronic data collection, management and analysis tools used for outbreak response in low- and middle-income countries: a systematic review and stakeholder survey. BMC Public Health 2021; 21:1741. [PMID: 34560871 PMCID: PMC8464108 DOI: 10.1186/s12889-021-11790-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 08/29/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Use of electronic data collection, management and analysis tools to support outbreak response is limited, especially in low income countries. This can hamper timely decision-making during outbreak response. Identifying available tools and assessing their functions in the context of outbreak response would support appropriate selection and use, and likely more timely data-driven decision-making during outbreaks. METHODS We conducted a systematic review and a stakeholder survey of the Global Outbreak Alert and Response Network and other partners to identify and describe the use of, and technical characteristics of, electronic data tools used for outbreak response in low- and middle-income countries. Databases included were MEDLINE, EMBASE, Global Health, Web of Science and CINAHL with publications related to tools for outbreak response included from January 2010-May 2020. Software tool websites of identified tools were also reviewed. Inclusion and exclusion criteria were applied and counts, and proportions of data obtained from the review or stakeholder survey were calculated. RESULTS We identified 75 electronic tools including for data collection (33/75), management (13/75) and analysis (49/75) based on data from the review and survey. Twenty-eight tools integrated all three functionalities upon collection of additional information from the tool developer websites. The majority were open source, capable of offline data collection and data visualisation. EpiInfo, KoBoCollect and Open Data Kit had the broadest use, including for health promotion, infection prevention and control, and surveillance data capture. Survey participants highlighted harmonisation of data tools as a key challenge in outbreaks and the need for preparedness through training front-line responders on data tools. In partnership with the Global Health Network, we created an online interactive decision-making tool using data derived from the survey and review. CONCLUSIONS Many electronic tools are available for data -collection, -management and -analysis in outbreak response, but appropriate tool selection depends on knowledge of tools' functionalities and capabilities. The online decision-making tool created to assist selection of the most appropriate tool(s) for outbreak response helps by matching requirements with functionality. Applying the tool together with harmonisation of data formats, and training of front-line responders outside of epidemic periods can support more timely data-driven decision making in outbreaks.
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Affiliation(s)
- Patrick Keating
- London School of Hygiene and Tropical Medicine, London, UK. .,United Kingdom Public Health Rapid Support Team, London, UK.
| | - Jillian Murray
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Anna Seale
- London School of Hygiene and Tropical Medicine, London, UK.,United Kingdom Public Health Rapid Support Team, London, UK
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Dass S, Ngui R, Gill BS, Chan YF, Wan Sulaiman WY, Lim YAL, Mudin RN, Chong CK, Sulaiman LH, Sam IC. Spatiotemporal spread of chikungunya virus in Sarawak, Malaysia. Trans R Soc Trop Med Hyg 2021; 115:922-931. [PMID: 33783526 DOI: 10.1093/trstmh/trab053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 12/11/2020] [Accepted: 03/10/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We studied the spatiotemporal spread of a chikungunya virus (CHIKV) outbreak in Sarawak state, Malaysia, during 2009-2010. METHODS The residential addresses of 3054 notified CHIKV cases in 2009-2010 were georeferenced onto a base map of Sarawak with spatial data of rivers and roads using R software. The spatiotemporal spread was determined and clusters were detected using the space-time scan statistic with SaTScan. RESULTS Overall CHIKV incidence was 127 per 100 000 population (range, 0-1125 within districts). The average speed of spread was 70.1 km/wk, with a peak of 228 cases/wk and the basic reproduction number (R0) was 3.1. The highest age-specific incidence rate was 228 per 100 000 in adults aged 50-54 y. Significantly more cases (79.4%) lived in rural areas compared with the general population (46.2%, p<0.0001). Five CHIKV clusters were detected. Likely spread was mostly by road, but a fifth of rural cases were spread by river travel. CONCLUSIONS CHIKV initially spread quickly in rural areas mainly via roads, with lesser involvement of urban areas. Delayed spread occurred via river networks to more isolated areas in the rural interior. Understanding the patterns and timings of arboviral outbreak spread may allow targeted vector control measures at key transport hubs or in large transport vehicles.
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Affiliation(s)
- Sarat Dass
- School of Mathematical & Computer Sciences, Heriot-Watt University Malaysia, 62200 Putrajaya, Malaysia
| | - Romano Ngui
- Department of Parasitology, Faculty of Medicine, University Malaya, 50603 Kuala Lumpur
| | | | - Yoke Fun Chan
- Department of Medical Microbiology, Faculty of Medicine, University Malaya, 50603 Kuala Lumpur, Malaysia
| | | | - Yvonne Ai Lian Lim
- Department of Parasitology, Faculty of Medicine, University Malaya, 50603 Kuala Lumpur
| | - Rose Nani Mudin
- Vector Borne Disease Sector, Disease Control Division, Ministry of Health Malaysia, Pusat Pentadbiran Kerajaan Persekutuan, 62590 Putrajaya, Malaysia
| | - Chee Kheong Chong
- Office of the Deputy Director General of Health (Public Health), Ministry of Health Malaysia, Pusat Pentadbiran Kerajaan Persekutuan, 62590 Putrajaya
| | - Lokman Hakim Sulaiman
- Department of Community Medicine, School of Medicine, International Medical University, Bukit Jalil, 57000 Kuala Lumpur, Malaysia.,Institute for Research, Development and Innovation, International Medical University, Bukit Jalil, 57000 Kuala Lumpur, Malaysia
| | - I-Ching Sam
- Department of Medical Microbiology, Faculty of Medicine, University Malaya, 50603 Kuala Lumpur, Malaysia
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Yan R, Zhou Q, Xu Z, Wu Y, Zhu G, Wang M, Guo Y, Dong K, Chen M. Pyrethrins elicit olfactory response and spatial repellency in Aedes albopictus. PEST MANAGEMENT SCIENCE 2021; 77:3706-3712. [PMID: 33798266 DOI: 10.1002/ps.6390] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 02/08/2021] [Accepted: 04/02/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Pyrethrum from dry flowers of Chrysanthemum is a well-known botanical insecticide and repellent. Its insecticidal activity attributes to its six insecticidal esters, collectively known as pyrethrins. Pyrethrins and its synthetic analogs pyrethroids exert their toxic action by modifying the function of voltage-gated sodium channels. Aside from insecticidal activity, pyrethrum has also been used to repel mosquitoes for centuries. Today, pyrethrum continues to be used as an active ingredient in mosquito coils and other mosquito-repellent devices globally. However, the mechanism of pyrethrum repellency remains largely unknown. RESULTS Here we report that pyrethrum vapor induced spatial (non-contact) repellency in Aedes albopictus, a major vector of dengue and West Nile viruses. Using electroantennogram (EAG) recordings from adult antennae, we found that pyrethrum elicited EAG response in a dose-dependent manner. We then isolated the six insecticidal esters, pyrethrins I and II, cinerins I and II, jasmolins I and II from pyrethrum extract and discovered that five of the six esters, except jasmolin I, all elicited EAG responses. Furthermore, pyrethrins I and II, cinerin II and jasmolin II induced repellency, whereas cinerin I and jasmolin I did not. CONCLUSION Of the six pyrethrins, four of them, pyrethrins I and II, cinerin II and jasmolin II, activate olfactory-receptor neurons and elicit spatial repellency in Ae. albopictus. Our study provided a foundation for future structure-function studies of pyrethrins, their cognate olfactory receptors and efficacies of repellency and for the development of new and more effective mosquito repellents for controlling vector-borne human diseases. © 2021 Society of Chemical Industry.
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Affiliation(s)
- Ru Yan
- Institute of Pesticide and Environmental Toxicology, Zhejiang University, Hangzhou, China
| | - Qiaoling Zhou
- Institute of Pesticide and Environmental Toxicology, Zhejiang University, Hangzhou, China
| | - Zhanyi Xu
- Institute of Pesticide and Environmental Toxicology, Zhejiang University, Hangzhou, China
| | - Yuyan Wu
- Institute for Communicable Disease Control and Prevention, Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou, China
| | - Guonian Zhu
- Institute of Pesticide and Environmental Toxicology, Zhejiang University, Hangzhou, China
| | - Mengcen Wang
- Institute of Pesticide and Environmental Toxicology, Zhejiang University, Hangzhou, China
| | - Yirong Guo
- Institute of Pesticide and Environmental Toxicology, Zhejiang University, Hangzhou, China
| | - Ke Dong
- Department of Entomology, Genetics and Neuroscience Programs, Michigan State University, East Lansing, MI, USA
- Department of Biology, Duke University, Durham, NC, USA
| | - Mengli Chen
- Institute of Pesticide and Environmental Toxicology, Zhejiang University, Hangzhou, China
- College of Agricultural and Food Sciences, Zhejiang A&F University, Hangzhou, China
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Bonifay T, Godaert L, Epelboin Y, Rousset D, Douine M, Hilderal H, Clavel C, Abel S, Najioullah F, Fagour L, do Socorro Mendonça Gomes M, Lacerda M, Cézaire R, Elenga N, Dramé M, Hoen B, Cabié A, Djossou F, Epelboin L. Contribution of Research in the West Indies and Northeast Amazonia to Knowledge of the 2014-2015 Chikungunya Epidemic in the Americas. CURRENT TROPICAL MEDICINE REPORTS 2021; 8:164-172. [PMID: 34178576 PMCID: PMC8214063 DOI: 10.1007/s40475-021-00242-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2021] [Indexed: 11/02/2022]
Abstract
Purpose of Review Although the chikungunya virus was discovered more than 60 years ago, it has only really been studied since the outbreak in La Reunion in 2005-2006. Ten years later, between 2014 and 2015, the chikungunya virus spread throughout the Americas, affecting millions of people. The objective of this review is to describe the contributions of research on chikungunya virus infection gained from epidemic in the West Indies and the Guiana Shield. Recent Findings Prevalence data were similar to those found in the Indian Ocean or Asia during epidemics. Clinically, there is now a better understanding of the typical, atypical, and severe forms. Several studies have insisted on the presence of neurological forms of chikungunya infection, such as encephalitis or Guillain-Barré syndrome. Cases of septic shock due to chikungunya virus as well as thrombotic thrombocytopenic purpura were described for the first time. Given the magnitude of the epidemic and the large number of people affected, this has led to a better description and new classifications of chikungunya virus infections in specific populations such as pregnant women, the elderly, and children. Several studies also described the behavior of populations faced with an emerging disease. Summary Current epidemiological data from tropical regions highlights the risk of spreading emerging diseases at higher latitudes, especially concerning arboviruses, since the vector Aedes albopictus is already established in many parts of northern countries. A better understanding of the disease and its epidemic dynamics will foster better management, the crucial importance of which was demonstrated during the COVID-19 epidemic.
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Affiliation(s)
- Timothee Bonifay
- Centre d'Investigation Clinique Antilles Guyane, INSERM 1424, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Lidvine Godaert
- Short-stay Unit, Department of Geriatrics, General Hospital of Valenciennes, Valenciennes, France
| | - Yanouk Epelboin
- Unité d'Entomologie Médicale, Institut Pasteur de la Guyane, French Guiana, Cayenne, France
| | - Dominique Rousset
- Virology Laboratory, National Reference Center of Arboviruses, Pastor Institute of Guyana, Cayenne, French Guiana
| | - Maylis Douine
- Centre d'Investigation Clinique Antilles Guyane, INSERM 1424, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Hélène Hilderal
- Centre d'Investigation Clinique Antilles Guyane, INSERM 1424, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Cyril Clavel
- Infectious Diseases Unit, Centre Hospitalier Louis Constant Fleming, Saint-Martin, France
| | - Sylvie Abel
- Department of Infectious Diseases, Centre Hospitalier Universitaire de Martinique, Fort-de-France, Martinique France
| | - Fatiha Najioullah
- Laboratoire de Virologie, Centre Hospitalier Universitaire de Martinique, Fort-de-France, Martinique France
| | - Laurence Fagour
- Virology Laboratory, University Hospital of Martinique, Fort de France, France
| | | | - Marcus Lacerda
- Fundação de Medicina Tropical Dr. Heitor Viera Dourado, Manaus, Amazonas Brazil
| | - Raymond Cézaire
- Laboratoire de Virologie, Centre Hospitalier Universitaire de Martinique, Fort-de-France, Martinique France
| | - Narcisse Elenga
- Service de Médecine et Chirurgie Pédiatrique, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Moustapha Dramé
- Department of Clinical Research and Innovation, University Hospital of Martinique, Fort-de-France, Martinique France
| | - Bruno Hoen
- Service de Maladies Infectieuses et Tropicales, Dermatologie, Médecine Interne, Centre Hospitalier Universitaire de Pointe-à-Pitre/Abymes, Pointe-à-Pitre, France
| | - André Cabié
- Department of Infectious Diseases, Centre Hospitalier Universitaire de Martinique, Fort-de-France, Martinique France
| | - Félix Djossou
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
| | - Loïc Epelboin
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalier de Cayenne, Cayenne, French Guiana
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Freitas LP, Cruz OG, Lowe R, Sá Carvalho M. Space-time dynamics of a triple epidemic: dengue, chikungunya and Zika clusters in the city of Rio de Janeiro. Proc Biol Sci 2019; 286:20191867. [PMID: 31594497 PMCID: PMC6790786 DOI: 10.1098/rspb.2019.1867] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Dengue, an arboviral disease transmitted by Aedes mosquitoes, has been endemic in Brazil for decades. However, vector-control strategies have not led to a significant reduction in the disease burden and have not been sufficient to prevent chikungunya and Zika entry and establishment in the country. In Rio de Janeiro city, the first Zika and chikungunya epidemics were detected between 2015 and 2016, coinciding with a dengue epidemic. Understanding the behaviour of these diseases in a triple epidemic scenario is a necessary step for devising better interventions for prevention and outbreak response. We applied scan statistics analysis to detect spatio-temporal clustering for each disease separately and for all three simultaneously. In general, clusters were not detected in the same locations and time periods, possibly owing to competition between viruses for host resources, depletion of susceptible population, different introduction times and change in behaviour of the human population (e.g. intensified vector-control activities in response to increasing cases of a particular arbovirus). Simultaneous clusters of the three diseases usually included neighbourhoods with high population density and low socioeconomic status, particularly in the North region of the city. The use of space–time cluster detection can guide intensive interventions to high-risk locations in a timely manner, to improve clinical diagnosis and management, and pinpoint vector-control measures.
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Affiliation(s)
- Laís Picinini Freitas
- Escola Nacional de Saúde Pública Sergio Arouca (ENSP), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Oswaldo Gonçalves Cruz
- Programa de Computação Científica (PROCC), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Rachel Lowe
- Centre on Climate Change and Planetary Health, London School of Hygiene and Tropical Medicine, London, UK.,Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK.,Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - Marilia Sá Carvalho
- Programa de Computação Científica (PROCC), Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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10
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Stewart-Ibarra AM, Romero M, Hinds AQJ, Lowe R, Mahon R, Van Meerbeeck CJ, Rollock L, Gittens-St. Hilaire M, St. Ville S, Ryan SJ, Trotman AR, Borbor-Cordova MJ. Co-developing climate services for public health: Stakeholder needs and perceptions for the prevention and control of Aedes-transmitted diseases in the Caribbean. PLoS Negl Trop Dis 2019; 13:e0007772. [PMID: 31658267 PMCID: PMC6837543 DOI: 10.1371/journal.pntd.0007772] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 11/07/2019] [Accepted: 09/10/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Small island developing states (SIDS) in the Caribbean region are challenged with managing the health outcomes of a changing climate. Health and climate sectors have partnered to co-develop climate services to improve the management of emerging arboviral diseases such as dengue fever, for example, through the development of climate-driven early warning systems. The objective of this study was to identify health and climate stakeholder perceptions and needs in the Caribbean, with respect to the development of climate services for arboviruses. METHODS Stakeholders included public decision makers and practitioners from the climate and health sectors at the regional (Caribbean) level and from the countries of Dominica and Barbados. From April to June 2017, we conducted interviews (n = 41), surveys (n = 32), and national workshops with stakeholders. Survey responses were tabulated, and audio recordings were transcribed and analyzed using qualitative coding to identify responses by research topic, country/region, and sector. RESULTS Health practitioners indicated that their jurisdiction is currently experiencing an increased risk of arboviral diseases associated with climate variability, and most anticipated that this risk will increase in the future. National health sectors reported financial limitations and a lack of technical expertise in geographic information systems (GIS), statistics, and modeling, which constrained their ability to implement climate services for arboviruses. National climate sectors were constrained by a lack of personnel. Stakeholders highlighted the need to strengthen partnerships with the private sector, academia, and civil society. They identified a gap in local research on climate-arbovirus linkages, which constrained the ability of the health sector to make informed decisions. Strategies to strengthen the climate-health partnership included a top-down approach by engaging senior leadership, multi-lateral collaboration agreements, national committees on climate and health, and shared spaces of dialogue. Mechanisms for mainstreaming climate services for health operations to control arboviruses included climatic-health bulletins and an online GIS platform that would allow for regional data sharing and the generation of spatiotemporal epidemic forecasts. Stakeholders identified a 3-month forecast of arboviral illness as the optimal time frame for an epidemic forecast. CONCLUSIONS These findings support the creation of interdisciplinary and intersectoral 'communities of practice' and the co-design of climate services for the Caribbean public health sector. By fostering the effective use of climate information within health policy, research and practice, nations will have greater capacity to adapt to a changing climate.
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Affiliation(s)
- Anna M. Stewart-Ibarra
- Institute for Global Health and Translational Science, State University of New York (SUNY) Upstate Medical University, Syracuse, New York, United States of America
- Department of Medicine and Department of Public Health and Preventative Medicine, SUNY Upstate Medical University, Syracuse, New York, United States of America
- InterAmerican Institute for Global Change Research (IAI), Montevideo, Department of Montevideo, Uruguay
| | - Moory Romero
- Institute for Global Health and Translational Science, State University of New York (SUNY) Upstate Medical University, Syracuse, New York, United States of America
- Department of Environmental Studies, SUNY College of Environmental Sciences and Forestry, Syracuse, New York, United States of America
| | | | - Rachel Lowe
- Centre on Climate Change and Planetary Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - Roché Mahon
- The Caribbean Institute for Meteorology and Hydrology, St. James, Barbados
| | | | | | - Marquita Gittens-St. Hilaire
- Faculty of Medical Sciences, University of the West Indies at Cave Hill, Bridgetown, St. Michael, Barbados
- Best-dos Santos Public Health Laboratory, Ministry of Health, St. Michael, Barbados
| | - Sylvester St. Ville
- Environmental Health Division, Ministry of Health and Environment, Roseau, Commonwealth of Dominica
| | - Sadie J. Ryan
- Quantitative Disease Ecology and Conservation Lab Group, Department of Geography and Emerging Pathogens Institute, University of Florida, Gainesville, Florida, United States of America
- School of Life Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Adrian R. Trotman
- The Caribbean Institute for Meteorology and Hydrology, St. James, Barbados
| | - Mercy J. Borbor-Cordova
- Facultad de Ingeniería Marítima y Ciencias del Mar, Escuela Superior Politécnica del Litoral (ESPOL), Guayaquil, Ecuador
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11
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Amaral P, Resende de Carvalho L, Hernandes Rocha TA, da Silva NC, Vissoci JRN. Geospatial modeling of microcephaly and zika virus spread patterns in Brazil. PLoS One 2019; 14:e0222668. [PMID: 31557165 PMCID: PMC6762139 DOI: 10.1371/journal.pone.0222668] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 09/04/2019] [Indexed: 11/29/2022] Open
Abstract
Microcephaly and Zika Virus infection (ZIKV) were declared Public Health Emergencies of International Concern by the World Health Organization in 2016. Brazil was considered the epicenter of the outbreak. However, the occurrence of both ZIKV and microcephaly in Brazil was not evenly distributed across the country. To better understand this phenomenon, we investigate regional characteristics at the municipal level that can be associated with the incidence of microcephaly, our response variable, and its relationship with ZIKV and other predictors. All epidemiological data in this study was provided by the Ministry of Health official database (DATASUS). Microcephaly was only confirmed after birth and the diagnostic was made regardless of the mother’s ZIKV status. Using exploratory spatial data analysis and spatial autoregressive Tobit models, our results show that microcephaly incidence is significantly, at 95% confidence level, related not only to ZIKV, but also to access to primary care, population size, gross national product, mobility and environmental attributes of the municipalities. There is also a significant spatial autocorrelation of the dependent variable. The results indicate that municipalities that show a high incidence of microcephaly tend to be clustered in space and that incidence of microcephaly varies considerably across regions when correlated only with ZIKV, i.e. that ZIKV alone cannot explain the differences in microcephaly across regions and their correlation is mediated by regional attributes.
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Affiliation(s)
- Pedro Amaral
- CEDEPLAR/UFMG, Center for Development and Regional Planning, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- * E-mail:
| | - Lucas Resende de Carvalho
- CEDEPLAR/UFMG, Center for Development and Regional Planning, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Thiago Augusto Hernandes Rocha
- PAHO/WHO, Brasília, Federal District, Brazil
- CEPEAD/UFMG, Center of Higher Studies and Research in Administration, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Núbia Cristina da Silva
- CEPEAD/UFMG, Center of Higher Studies and Research in Administration, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - João Ricardo Nickenig Vissoci
- Duke University, Duke School of Medicine, Department of Surgery, Division of Emergency Medicine, Durham, North Carolina, United States of America
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12
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Whiteman A, Desjardins MR, Eskildsen GA, Loaiza JR. Detecting space-time clusters of dengue fever in Panama after adjusting for vector surveillance data. PLoS Negl Trop Dis 2019; 13:e0007266. [PMID: 31545819 PMCID: PMC6776363 DOI: 10.1371/journal.pntd.0007266] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 10/03/2019] [Accepted: 09/04/2019] [Indexed: 01/04/2023] Open
Abstract
Long term surveillance of vectors and arboviruses is an integral aspect of disease prevention and control systems in countries affected by increasing risk. Yet, little effort has been made to adjust space-time risk estimation by integrating disease case counts with vector surveillance data, which may result in inaccurate risk projection when several vector species are present, and when little is known about their likely role in local transmission. Here, we integrate 13 years of dengue case surveillance and associated Aedes occurrence data across 462 localities in 63 districts to estimate the risk of infection in the Republic of Panama. Our exploratory space-time modelling approach detected the presence of five clusters, which varied by duration, relative risk, and spatial extent after incorporating vector species as covariates. The Ae. aegypti model contained the highest number of districts with more dengue cases than would be expected given baseline population levels, followed by the model accounting for both Ae. aegypti and Ae. albopictus. This implies that arbovirus case surveillance coupled with entomological surveillance can affect cluster detection and risk estimation, potentially improving efforts to understand outbreak dynamics at national scales. Dengue cases have increased in tropical regions worldwide owing to urbanization, globalization, and climate change facilitating the spread of Aedes mosquito vectors. National surveillance programs monitor trends in dengue fever and inform the public about epidemiological scenarios where outbreak preventive actions are most needed. Yet, most estimations of dengue risk so far derive only from disease case data, ignoring Aedes occurrence as a key aspect of dengue transmission dynamic. Here we illustrate how incorporating vector presence and absence as a model covariate can considerably alter the characteristics of space-time cluster estimations of dengue cases.
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Affiliation(s)
- Ari Whiteman
- Smithsonian Tropical Research Institute, Balboa Ancón, Republic of Panama
- Department of Geography and Earth Sciences, Center for Applied Geographic Information Science, University of North Carolina at Charlotte, Charlotte, NC, United States of America
- * E-mail:
| | - Michael R. Desjardins
- Department of Geography and Earth Sciences, Center for Applied Geographic Information Science, University of North Carolina at Charlotte, Charlotte, NC, United States of America
| | | | - Jose R. Loaiza
- Smithsonian Tropical Research Institute, Balboa Ancón, Republic of Panama
- Instituto de Investigaciones Científicas y Servicios de Alta Tecnología, Panama City, Republic of Panama
- Programa Centroamericano de Maestría en Entomología, Universidad de Panamá, Panama City, Republic of Panama
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13
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Lozier MJ, Burke RM, Lopez J, Acevedo V, Amador M, Read JS, Jara A, Waterman SH, Barrera R, Muñoz-Jordan J, Rivera-Garcia B, Sharp TM. Differences in Prevalence of Symptomatic Zika Virus Infection, by Age and Sex-Puerto Rico, 2016. J Infect Dis 2019; 217:1678-1689. [PMID: 29216376 DOI: 10.1093/infdis/jix630] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 11/30/2017] [Indexed: 11/13/2022] Open
Abstract
Background During the outbreak of Zika virus (ZIKV) disease in Puerto Rico in 2016, nonpregnant women aged 20-39 years were disproportionately identified with ZIKV disease. We used household-based cluster investigations to determine whether this disparity was associated with age- or sex-dependent differences in the rate of ZIKV infection or reported symptoms. Methods Participation was offered to residents of households within a 100-m radius of the residences of a convenience sample of 19 laboratory-confirmed ZIKV disease cases. Participants answered a questionnaire and provided specimens for diagnostic testing by reverse transcription-polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA). Results Among 367 study participants, 114 (31.1%) were laboratory positive for ZIKV infection, of whom 30% reported a recent illness (defined as self-reported rash or arthralgia) attributable to ZIKV infection. Age and sex were not associated with ZIKV infection. Female sex (adjusted prevalence ratio [aPR], 2.28; 95% confidence interval [CI], 1.40, 3.67), age <40 years (aPR, 2.39; 95% CI, 1.55, 3.70), and asthma (aPR, 1.63; 95% CI, 1.12, 2.37) were independently associated with symptomatic infection. Conclusions Although neither female sex nor age were associated with an increased prevalence of ZIKV infection, both were associated with symptomatic infection. Further investigation to identify a potential mechanism of age- and sex-dependent differences in reporting symptomatic ZIKV infection is warranted.
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Affiliation(s)
- Matthew J Lozier
- National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention (CDC), Athens, Georgia
| | - Rachel M Burke
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC), Athens, Georgia
| | - Juan Lopez
- National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention (CDC), Athens, Georgia.,College of Medicine, Florida State University, Tallahassee, Florida
| | - Veronica Acevedo
- National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention (CDC), Athens, Georgia
| | - Manuel Amador
- National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention (CDC), Athens, Georgia
| | - Jennifer S Read
- National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention (CDC), Athens, Georgia
| | - Amanda Jara
- National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention (CDC), Athens, Georgia.,College of Veterinary Medicine, University of Georgia, Athens, Georgia
| | - Stephen H Waterman
- National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention (CDC), Athens, Georgia
| | - Roberto Barrera
- National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention (CDC), Athens, Georgia
| | - Jorge Muñoz-Jordan
- National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention (CDC), Athens, Georgia
| | - Brenda Rivera-Garcia
- Office of Epidemiology and Research, Puerto Rico Department of Health, San Juan, Puerto Rico
| | - Tyler M Sharp
- National Center for Emerging Zoonotic and Infectious Diseases, Centers for Disease Control and Prevention (CDC), Athens, Georgia
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14
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Tauro LB, Cardoso CW, Souza RL, Nascimento LC, Santos DRD, Campos GS, Sardi S, Reis OBD, Reis MG, Kitron U, Ribeiro GS. A localized outbreak of Chikungunya virus in Salvador, Bahia, Brazil. Mem Inst Oswaldo Cruz 2019; 114:e180597. [PMID: 30843962 PMCID: PMC6396974 DOI: 10.1590/0074-02760180597] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 02/14/2019] [Indexed: 11/22/2022] Open
Abstract
A localized Chikungunya virus (CHIKV; East/Central/South African genotype) outbreak (50 cases, 70% laboratory-confirmed; attack rate: 5.3 confirmed cases/100 people) occurred in a Salvador, Brazil neighborhood, between Apr-Jun/2017. Highly clustered cases in space and time, mostly along a single street, highlight an increased risk of CHIKV transmission among pockets of susceptible populations. This finding underscores the need for ongoing local level surveillance for arboviral outbreaks.
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Affiliation(s)
- Laura B Tauro
- Fundação Oswaldo Cruz-Fiocruz, Instituto Gonçalo Moniz, Salvador, BA, Brasil.,Instituto de Biologia Subtropical, CONICET, Puerto Iguazú, Misiones, Argentina
| | | | - Raquel L Souza
- Fundação Oswaldo Cruz-Fiocruz, Instituto Gonçalo Moniz, Salvador, BA, Brasil
| | - Leile Cj Nascimento
- Fundação Oswaldo Cruz-Fiocruz, Instituto Gonçalo Moniz, Salvador, BA, Brasil
| | | | - Gubio S Campos
- Universidade Federal da Bahia, Instituto de Ciências da Saúde, Salvador, BA, Brasil
| | - Silvia Sardi
- Universidade Federal da Bahia, Instituto de Ciências da Saúde, Salvador, BA, Brasil
| | | | - Mitermayer G Reis
- Fundação Oswaldo Cruz-Fiocruz, Instituto Gonçalo Moniz, Salvador, BA, Brasil.,Yale University, New Haven, CT, USA.,Universidade Federal da Bahia, Faculdade de Medicina, Salvador, BA, Brasil
| | - Uriel Kitron
- Fundação Oswaldo Cruz-Fiocruz, Instituto Gonçalo Moniz, Salvador, BA, Brasil.,Emory University, Atlanta, GA, USA
| | - Guilherme S Ribeiro
- Fundação Oswaldo Cruz-Fiocruz, Instituto Gonçalo Moniz, Salvador, BA, Brasil.,Universidade Federal da Bahia, Faculdade de Medicina, Salvador, BA, Brasil
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15
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Hsu CH, Cruz-Lopez F, Vargas Torres D, Perez-Padilla J, Lorenzi OD, Rivera A, Staples JE, Lugo E, Munoz-Jordan J, Fischer M, Garcia Gubern C, Rivera Garcia B, Alvarado L, Sharp TM. Risk factors for hospitalization of patients with chikungunya virus infection at sentinel hospitals in Puerto Rico. PLoS Negl Trop Dis 2019; 13:e0007084. [PMID: 30640900 PMCID: PMC6347300 DOI: 10.1371/journal.pntd.0007084] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 01/25/2019] [Accepted: 12/17/2018] [Indexed: 12/27/2022] Open
Abstract
Background Hospitalization of patients during outbreaks of chikungunya virus has been reported to be uncommon (0.5–8.7%), but more frequent among infants and the elderly. CHIKV was first detected in Puerto Rico in May 2014. We enrolled patients with acute febrile illness (AFI) presenting to two hospital emergency departments in Puerto Rico and tested them for CHIKV infection to describe the frequency of detection of CHIKV-infected patients, identify risk factors for hospitalization, and describe patients with severe manifestations. Methodology/Principal findings Serum specimens were collected from patients with AFI and tested by rRT-PCR. During May–December 2014, a total of 3,035 patients were enrolled, and 1,469 (48.4%) had CHIKV infection. A total of 157 (10.7%) CHIKV-infected patients were hospitalized, six (0.4%) were admitted to the intensive care unit, and two died (0.1%). Common symptoms among all CHIKV-infected patients were arthralgia (82.6%), lethargy (80.6%), and myalgia (80.5%). Compared to patients aged 1–69 years (7.3%), infant (67.2%) and elderly (17.3%) patients were nine and two times more likely to be hospitalized, respectively (relative risk [RR] and 95% confidence interval [CI] = 9.16 [7.05–11.90] and 2.36 [1.54–3.62]). Multiple symptoms of AFI were associated with decreased risk of hospitalization, including arthralgia (RR = 0.31 [0.23–0.41]) and myalgia (RR = 0.29 [0.22–0.39]). Respiratory symptoms were associated with increased risk of hospitalization, including rhinorrhea (RR = 1.68 [1.24–2.27) and cough (RR = 1.77 [1.31–2.39]). Manifestations present among <5% of patients but associated with patient hospitalization included cyanosis (RR = 2.20 [1.17–4.12) and seizures (RR = 3.23 [1.80–5.81). Discussion Among this cohort of CHIKV-infected patients, hospitalization was uncommon, admission to the ICU was infrequent, and death was rare. Risk of hospitalization was higher in patients with symptoms of respiratory illness and other manifestations that may not have been the result of CHIKV infection. Chikungunya is an emerging infectious disease caused by a virus (chikungunya virus, CHIKV) transmitted through the bite of infected mosquitos; typical symptoms are fever and joint pain. After CHIKV was first detected in Puerto Rico in 2014, an epidemic quickly spread across the island. Because previous reports identified varying frequencies of hospitalization of CHIKV-infected patients, we used an existing hospital-based disease detection system to better understand the frequency and reasons for hospitalization of CHIKV-infected patients in Puerto Rico. Among 1,469 patients with laboratory-confirmed CHIKV infection, 11% were hospitalized, most of whom were infants or elderly. Six CHIKV-infected patients were admitted to the intensive care unit, and two died. Although several illness characteristics were associated with hospitalization, most of these were not typical of chikungunya and instead suggested underlying or concomitant respiratory disease. By enrolling patients when they presented to the emergency department and testing them for evidence of CHIKV infection, we determined that hospitalization in this population occurred in roughly one-in-ten CHIKV-infected patients, one-in-two hundred were admitted to the intensive care unit, and one-in-one thousand died. These findings provide information on the spectrum of disease caused by CHIKV, and identified underlying or concomitant respiratory illness as a risk factor associated with hospitalization.
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Affiliation(s)
- Christopher H. Hsu
- Centers for Disease Control and Prevention, Poxvirus and Rabies Branch, Atlanta, GA, United States of America
- Centers for Disease Control and Prevention, Epidemic Intelligence Service, Atlanta, GA, United States of America
| | - Fabiola Cruz-Lopez
- Centers for Disease Control and Prevention, Dengue Branch, San Juan, Puerto Rico
- Ponce Health Sciences University, Ponce, Puerto Rico
| | | | - Janice Perez-Padilla
- Centers for Disease Control and Prevention, Dengue Branch, San Juan, Puerto Rico
| | - Olga D. Lorenzi
- Centers for Disease Control and Prevention, Dengue Branch, San Juan, Puerto Rico
| | - Aidsa Rivera
- Centers for Disease Control and Prevention, Dengue Branch, San Juan, Puerto Rico
| | - J. Erin Staples
- Centers for Disease Control and Prevention, Arboviral Diseases Branch, Fort Collins, CO, United States of America
| | - Esteban Lugo
- San Lucas Episcopal Hospital, Ponce, Puerto Rico
| | - Jorge Munoz-Jordan
- Centers for Disease Control and Prevention, Dengue Branch, San Juan, Puerto Rico
| | - Marc Fischer
- Centers for Disease Control and Prevention, Arboviral Diseases Branch, Fort Collins, CO, United States of America
| | - Carlos Garcia Gubern
- Ponce Health Sciences University, Ponce, Puerto Rico
- San Lucas Episcopal Hospital, Ponce, Puerto Rico
| | | | - Luisa Alvarado
- Centers for Disease Control and Prevention, Dengue Branch, San Juan, Puerto Rico
- San Lucas Episcopal Hospital, Ponce, Puerto Rico
| | - Tyler M. Sharp
- Centers for Disease Control and Prevention, Dengue Branch, San Juan, Puerto Rico
- * E-mail:
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16
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Mascarenhas M, Garasia S, Berthiaume P, Corrin T, Greig J, Ng V, Young I, Waddell L. A scoping review of published literature on chikungunya virus. PLoS One 2018; 13:e0207554. [PMID: 30496207 PMCID: PMC6264817 DOI: 10.1371/journal.pone.0207554] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/01/2018] [Indexed: 12/13/2022] Open
Abstract
Chikungunya virus (CHIKV) has caused several major epidemics globally over the last two decades and is quickly expanding into new areas. Although this mosquito-borne disease is self-limiting and is not associated with high mortality, it can lead to severe, chronic and disabling arthritis, thereby posing a heavy burden to healthcare systems. The two main vectors for CHIKV are Aedes aegypti and Aedes albopictus (Asian tiger mosquito); however, many other mosquito species have been described as competent CHIKV vectors in scientific literature. With climate change, globalization and unfettered urban planning affecting many areas, CHIKV poses a significant public health risk to many countries. A scoping review was conducted to collate and categorize all pertinent information gleaned from published scientific literature on a priori defined aspects of CHIKV and its competent vectors. After developing a sensitive and specific search algorithm for the research question, seven databases were searched and data was extracted from 1920 relevant articles. Results show that CHIKV research is reported predominantly in areas after major epidemics have occurred. There has been an upsurge in CHIKV publications since 2011, especially after first reports of CHIKV emergence in the Americas. A list of hosts and vectors that could potentially be involved in the sylvatic and urban transmission cycles of CHIKV has been compiled in this scoping review. In addition, a repository of CHIKV mutations associated with evolutionary fitness and adaptation has been created by compiling and characterizing these genetic variants as reported in scientific literature.
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Affiliation(s)
- Mariola Mascarenhas
- National Microbiology Laboratory at Guelph, Public Health Agency of Canada, Guelph, Ontario, Canada
| | - Sophiya Garasia
- National Microbiology Laboratory at Guelph, Public Health Agency of Canada, Guelph, Ontario, Canada
| | - Philippe Berthiaume
- National Microbiology Laboratory at St. Hyacinthe, Public Health Agency of Canada, St. Hyacinthe, Quebec, Canada
| | - Tricia Corrin
- National Microbiology Laboratory at Guelph, Public Health Agency of Canada, Guelph, Ontario, Canada
| | - Judy Greig
- National Microbiology Laboratory at Guelph, Public Health Agency of Canada, Guelph, Ontario, Canada
| | - Victoria Ng
- National Microbiology Laboratory at Guelph, Public Health Agency of Canada, Guelph, Ontario, Canada
| | - Ian Young
- School of Occupational and Public Health, Ryerson University, Toronto, Ontario, Canada
| | - Lisa Waddell
- National Microbiology Laboratory at Guelph, Public Health Agency of Canada, Guelph, Ontario, Canada
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17
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Desjardins MR, Whiteman A, Casas I, Delmelle E. Space-time clusters and co-occurrence of chikungunya and dengue fever in Colombia from 2015 to 2016. Acta Trop 2018; 185:77-85. [PMID: 29709630 DOI: 10.1016/j.actatropica.2018.04.023] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 04/19/2018] [Accepted: 04/22/2018] [Indexed: 12/29/2022]
Abstract
Vector-borne diseases (VBDs) infect over one billion people and are responsible for over one million deaths each year, globally. Chikungunya (CHIK) and Dengue Fever (DENF) are emerging VBDs due to overpopulation, increases in urbanization, climate change, and other factors. Colombia has recently experienced severe outbreaks of CHIK AND DENF. Both viruses are transmitted by the Aedes mosquitoes and are preventable with a variety of surveillance and vector control measures (e.g. insecticides, reduction of open containers, etc.). Spatiotemporal statistics can facilitate the surveillance of VBD outbreaks by informing public health officials where to allocate resources to mitigate future outbreaks. We utilize the univariate Kulldorff space-time scan statistic (STSS) to identify and compare statistically significant space-time clusters of CHIK and DENF in Colombia during the outbreaks of 2015 and 2016. We also utilize the multivariate STSS to examine co-occurrences (simultaneous excess incidences) of DENF and CHIK, which is critical to identify regions that may have experienced the greatest burden of VBDs. The relative risk of CHIK and DENF for each Colombian municipality belonging to a univariate and multivariate cluster is reported to facilitate targeted interventions. Finally, we visualize the results in a three-dimensional environment to examine the size and duration of the clusters. Our approach is the first of its kind to examine multiple VBDs in Colombia simultaneously, while the 3D visualizations are a novel way of illustrating the dynamics of space-time clusters of disease.
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Affiliation(s)
- M R Desjardins
- Department of Geography and Earth Sciences and Center for Applied Geographic Information Science, University of North Carolina at Charlotte, 2901 University City Blvd, Charlotte, NC, 28223, United States
| | - A Whiteman
- Department of Geography and Earth Sciences and Center for Applied Geographic Information Science, University of North Carolina at Charlotte, 2901 University City Blvd, Charlotte, NC, 28223, United States
| | - I Casas
- School of History and Social Sciences, Louisiana Tech University, 305 Wisteria St, Ruston, LA, 71272, United States
| | - E Delmelle
- Department of Geography and Earth Sciences and Center for Applied Geographic Information Science, University of North Carolina at Charlotte, 2901 University City Blvd, Charlotte, NC, 28223, United States.
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18
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Vissoci JRN, Rocha TAH, da Silva NC, de Sousa Queiroz RC, Thomaz EBAF, Amaral PVM, Lein A, Branco MDRFC, Aquino J, Rodrigues ZMR, da Silva AAM, Staton C. Zika virus infection and microcephaly: Evidence regarding geospatial associations. PLoS Negl Trop Dis 2018; 12:e0006392. [PMID: 29694351 PMCID: PMC5937996 DOI: 10.1371/journal.pntd.0006392] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 05/07/2018] [Accepted: 03/18/2018] [Indexed: 01/06/2023] Open
Abstract
Background Although the Zika virus (ZIKV) epidemic ceased to be a public health emergency by the end of 2016, studies to improve knowledge about this emerging disease are still needed, especially those investigating a causal relationship between ZIKV in pregnant women and microcephaly in neonates. However, there are still many challenges in describing the relationship between ZIKV and microcephaly. The few studies focusing on the epidemiological profile of ZIKV and its changes over time are largely limited to systematic reviews of case reports and dispersal mapping of ZIKV spread over time without quantitative methods to analyze patterns and their covariates. Since Brazil has been at the epicenter of the ZIKV epidemic, this study examines the geospatial association between ZIKV and microcephaly in Brazil. Methods Our study is categorized as a retrospective, ecological study based on secondary databases. Data were obtained from January to December 2016, from the following data sources: Brazilian System for Epidemiological Surveillance, Disease Notification System, System for Specialized Management Support, and Brazilian Institute of Geography and Statistics. Data were aggregated by municipality. Incidence rates were estimated per 100,000 inhabitants. Analyses consisted of mapping the aggregated incidence rates of ZIKV and microcephaly, followed by a Getis-Ord-Gi spatial cluster analysis and a Bivariate Local Moran’s I analysis. Results The incidence of ZIKV cases is changing the virus’s spatial pattern, shifting from Brazil’s Northeast region to the Midwest and North regions. The number of municipalities in clusters of microcephaly incidence is also shifting from the Northeast region to the Midwest and North, after a time lag is considered. Our findings suggest an increase in microcephaly incidence in the Midwest and North regions, associated with high levels of ZIKV infection months before. Conclusion The greatest burden of microcephaly shifted from the Northeast to other Brazilian regions at the beginning of 2016. Brazil’s Midwest region experienced an increase in microcephaly incidence associated with ZIKV incidence. This finding highlights an association between an increase in ZIKV infection with a rise in microcephaly cases after approximately three months. The increasing evidence of a relationship between ZIKV in pregnant women and fetal congenital ZIKV syndrome with microcephaly has been reported in the literature over the last two years. Our findings suggest a spatial dependency between the diseases. Therefore, using the spatial pattern of ZIKV incidence to better understand risk areas for microcephaly may help the design of surveillance policies. Brazil had a large epidemic of ZIKV, leading to several important studies of the ZIKV outbreak and its association with microcephaly. This study used a geospatial analysis approach to examine the association between ZIKV and microcephaly in Brazilian regions. It was possible to highlight a spatial association between ZIKV and microcephaly considering a time lag between diseases. Brazilian regions with the highest incidences of microcephaly were the regions where the highest incidence of ZIKV occurred months before. This finding can help the organization and planning of health services to offer better screening actions dedicated to pregnant women in high-risk areas.
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Affiliation(s)
- João Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Surgery, Division of Emergency Medicine, Duke University Health System, Durham, North Carolina, United States of America
- * E-mail:
| | - Thiago Augusto Hernandes Rocha
- Federal University of Minas Gerais, School of Economics, Center of post-graduate and Research in Administration, Belo Horizonte, Minas Gerais, Brazil
| | - Núbia Cristina da Silva
- Federal University of Minas Gerais, Faculty of Economics, Observatory of Human Resources in Health, Belo Horizonte, Minas Gerais, Brazil
| | | | | | - Pedro Vasconcelos Maia Amaral
- Federal University of Minas Gerais, Centre for Development and Regional Planning, Belo Horizonte, Minas Gerais, Brazil
| | - Adriana Lein
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | - José Aquino
- Federal University of Maranhão, Department of Geosciences, São Luís, Maranhão, Brazil
| | | | | | - Catherine Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- Department of Surgery, Division of Emergency Medicine, Duke University Health System, Durham, North Carolina, United States of America
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Pang CE, Navajas EV, Warner SJ, Heisler M, Sarunic MV. Acute Macular Neuroretinopathy Associated With Chikungunya Fever. Ophthalmic Surg Lasers Imaging Retina 2017; 47:596-9. [PMID: 27327293 DOI: 10.3928/23258160-20160601-15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 03/21/2016] [Indexed: 01/15/2023]
Abstract
A 47-year-old man with recent travel to the Caribbean was admitted with acute febrileillness associated with arthralgia and skin rash followed by sudden onset of bilateral visual field defects. Funduscopy revealed subtle bilateral paracentral dark lesions nasal to the fovea best seen on near infrared imaging as hyporeflective, wedge-shaped, paracentral macular lesions. Spectral-domain optical coherence tomography (SD-OCT) through the lesions revealed hyperreflective bands at the level of the outer plexiform layer and outer nuclear layer (ONL), with concomitant attenuation of the underlying external limiting membrane (ELM), ellipsoid zone (EZ), and interdigitation zone (IZ). Neither fluorescein angiography nor speckle variance OCT angiography (sv-OCTA) showed any defects in retinal circulation. Work up revealed positive Immunoglobulin M for Chikungunya virus (CHIKV). Six months later, the patient had persistent scotomas, although reduced in size. SD-OCT showed subtle ONL thinning and restoration of the ELM, although EZ and IZ remained disrupted. Chikungunya fever may manifest as bilateral acute macular neuroretinopathy (AMN). Clinicians should be aware of possible systemic associations of AMN. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:596-599.].
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Forde MS, Martin F, Mitchell G, Bidaisee S. Public health response and lessons learned from the 2014 chikungunya epidemic in Grenada. Rev Panam Salud Publica 2017. [PMID: 28902270 PMCID: PMC6612745 DOI: 10.26633/rpsp.2017.57] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
In June 2014, the first cases of chikungunya virus (CHIKV) were diagnosed on the island of Carriacou, part of the tri-island state of Grenada. In the three months that followed, CHIKV spread rapidly, with conservative estimates of the population infected of at least 60%. Multiple challenges were encountered in the battle to manage the spread and impact of this high–attack rate virus, including 1) limited indigenous laboratory diagnostic capabilities; 2) an under-resourced health care system; 3) a skeptical general public, hesitant to accept facts about the origin and mode of transmission of the new virus; and 4) resistance to the vector control strategies used. Lessons learned from the outbreak included the need for 1) a robust and reliable epidemiological surveillance system; 2) effective strategies for communicating with the general population; 3) exploration of other methods of mosquito vector control; and 4) a careful review of all health care policies and protocols to ensure that effective, organized responses are triggered when an infectious outbreak occurs.
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Affiliation(s)
- Martin S Forde
- Public Health & Preventive Medicine, St. George’s University, St. George, Grenada
| | | | | | - Satesh Bidaisee
- Public Health & Preventive Medicine, St. George’s University, St. George, Grenada
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21
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Roche B, Duboz R. Individual-Based Models for Public Health. HANDBOOK OF STATISTICS 2017. [PMCID: PMC7148902 DOI: 10.1016/bs.host.2017.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Today, infectious diseases represent a threatening concern for human health. Understanding their transmission, and possibly forecasting the dynamics of these pathogens, represents both a scientific and sanitary emergency. To this goal, mathematical modeling has been a widely used tool. Nevertheless, they have important limitations to explicitly model the mechanisms involved in the infectious processes at the individual level. Thanks to the increase of computing capacity, computational models such as individual-based models (IBMs) are very relevant for understanding the complexity of mechanisms at the individual level that can be involved in disease outbreaks. Their computational formalism allows a large flexibility, while they rely on the same philosophy than current models in mathematical epidemiology that have proved their relevance. In this chapter, we review the main qualities of IBMs, what kind of new knowledge they can bring and they have already produced in epidemiological modeling. Then, we highlight their caveats and what could be developed during the future years to make IBMs a more reliable and useful approach.
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22
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Bloch D, Roth NM, Caraballo EV, Muñoz-Jordan J, Hunsperger E, Rivera A, Pérez-Padilla J, Rivera Garcia B, Sharp TM. Use of Household Cluster Investigations to Identify Factors Associated with Chikungunya Virus Infection and Frequency of Case Reporting in Puerto Rico. PLoS Negl Trop Dis 2016; 10:e0005075. [PMID: 27764085 PMCID: PMC5072658 DOI: 10.1371/journal.pntd.0005075] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/26/2016] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Chikungunya virus (CHIKV) is transmitted by Aedes species mosquitoes and is the cause of an acute febrile illness characterized by potentially debilitating arthralgia. After emerging in the Caribbean in late 2013, the first locally-acquired case reported to public health authorities in Puerto Rico occurred in May 2014. During June-August 2014, household-based cluster investigations were conducted to identify factors associated with infection, development of disease, and case reporting. METHODOLOGY/PRINCIPAL FINDINGS Residents of households within a 50-meter radius of the residence of laboratory-positive chikungunya cases that had been reported to Puerto Rico Department of Health (PRDH) were offered participation in the investigation. Participants provided a serum specimen and answered a questionnaire that collected information on demographic factors, household characteristics, recent illnesses, healthcare seeking behaviors, and clinical diagnoses. Current CHIKV infection was identified by rRT-PCR, and recent CHIKV infection was defined by detection of either anti-CHIKV IgM or IgG antibody. Among 250 participants, 74 (30%) had evidence of CHIKV infection, including 12 (5%) with current and 62 (25%) with recent CHIKV infection. All specimens from patients with CHIKV infection that were collected within four days, two weeks, and three weeks of illness onset were positive by RT-PCR, IgM ELISA, and IgG ELISA, respectively. Reporting an acute illness in the prior three months was strongly associated with CHIKV infection (adjusted odds ratio [aOR] = 21.6, 95% confidence interval [CI]: 9.24-50.3). Use of air conditioning (aOR = 0.50, 95% CI = 0.3-0.9) and citronella candles (aOR = 0.4, 95% CI = 0.1-0.9) were associated with protection from CHIKV infection. Multivariable analysis indicated that arthralgia (aOR = 51.8, 95% CI = 3.8-700.8) and skin rash (aOR = 14.2, 95% CI = 2.4-84.7) were strongly associated with CHIKV infection. Hierarchical cluster analysis of signs and symptoms reported by CHIKV-infected participants demonstrated that fever, arthralgia, myalgia, headache, and chills tended to occur simultaneously. Rate of symptomatic CHIKV infection (defined by arthralgia with fever or skin rash) was 62.5%. Excluding index case-patients, 22 (63%) participants with symptomatic CHIKV infection sought medical care, of which 5 (23%) were diagnosed with chikungunya and 2 (9%) were reported to PRDH. CONCLUSIONS/SIGNIFICANCE This investigation revealed high rates of CHIKV infection among household members and neighbors of chikungunya patients, and that behavioral interventions such as use of air conditioning were associated with prevention of CHIKV infection. Nearly two-thirds of patients with symptomatic CHIKV infection sought medical care, of which less than one-quarter were reportedly diagnosed with chikungunya and one-in-ten were reported to public health authorities. These findings emphasize the need for point-of-care rapid diagnostic tests to optimize identification and reporting of chikungunya patients.
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Affiliation(s)
- Danielle Bloch
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
- Department of Epidemiology of Microbial Disease, Yale School of Public Health, New Haven, Connecticut
| | - Nicole M. Roth
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Elba V. Caraballo
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Jorge Muñoz-Jordan
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Elizabeth Hunsperger
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Aidsa Rivera
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | - Janice Pérez-Padilla
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
| | | | - Tyler M. Sharp
- Dengue Branch, Division of Vector-Borne Diseases, Centers for Disease Control and Prevention, San Juan, Puerto Rico
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Macpherson C, Noël T, Fields P, Jungkind D, Yearwood K, Simmons M, Widjaja S, Mitchell G, Noel D, Bidaisee S, Myers TE, LaBeaud AD. Clinical and Serological Insights from the Asian Lineage Chikungunya Outbreak in Grenada, 2014: An Observational Study. Am J Trop Med Hyg 2016; 95:890-893. [PMID: 27527629 DOI: 10.4269/ajtmh.16-0122] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 07/03/2016] [Indexed: 11/07/2022] Open
Abstract
Chikungunya virus (CHIKV) spread rapidly throughout the Caribbean region in 2014, and the first serologically confirmed case was seen in Grenada in July. This study investigated the outbreak of CHIKV in Grenada to identify the distinguishing clinical manifestations and the symptoms that corresponded the closest with serological test results. Sera were tested by IgM enzyme-linked immunosorbent assay and polymerase chain reaction to distinguish between cases positive or negative for CHIKV. Of 493 cases, 426 (86%) tested positive for CHIKV. The diagnostic decision rule, "Define as CHIKV positive a patient presenting with joint pain and any combination of fever, body pain, or rash," produced the closest agreement (85%) with the serological test results (Cohen's kappa, k = 0.289, P value < 0.001). When laboratory facilities are not available for diagnostic confirmation, syndromic surveillance using these four symptoms could be useful to define cases during a CHIKV outbreak when CHIKV is the predominant circulating arbovirus.
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Affiliation(s)
- Calum Macpherson
- St. George's University School of Medicine, Saint George, Grenada. Windward Islands Research and Education Foundation, Saint George, Grenada.
| | - Trevor Noël
- St. George's University School of Medicine, Saint George, Grenada. Windward Islands Research and Education Foundation, Saint George, Grenada
| | - Paul Fields
- Windward Islands Research and Education Foundation, Saint George, Grenada
| | - Donald Jungkind
- St. George's University School of Medicine, Saint George, Grenada
| | | | | | | | | | - Dolland Noel
- St. George's University School of Medicine, Saint George, Grenada. Ministry of Health, Saint George, Grenada
| | - Satesh Bidaisee
- St. George's University School of Medicine, Saint George, Grenada. Windward Islands Research and Education Foundation, Saint George, Grenada
| | - Todd E Myers
- Naval Medical Research Center, Silver Spring, Maryland
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