Chikungunya disease: infection-associated markers from the acute to the chronic phase of arbovirus-induced arthralgia

At the end of 2005, an outbreak of fever associated with joint pain occurred in La Réunion. The causal agent, chikungunya virus (CHIKV), has been known for 50 years and could thus be readily identified. This arbovirus is present worldwide, particularly in India, but also in Europe, with new variants returning to Africa. In humans, it causes a disease characterized by a typical acute infection, sometimes followed by persistent arthralgia and myalgia lasting months or years. Investigations in the La Réunion cohort and studies in a macaque model of chikungunya implicated monocytes-macrophages in viral persistence. In this Review, we consider the relationship between CHIKV and the immune response and discuss predictive factors for chronic arthralgia and myalgia by providing an overview of current knowledge on chikungunya pathogenesis. Comparisons of data from animal models of the acute and chronic phases of infection, and data from clinical series, provide information about the mechanisms of CHIKV infection-associated inflammation, viral persistence in monocytes-macrophages, and their link to chronic signs.

Chikungunya virus isolation using simplified cell culture technique in Mauritius

During the chikungunya outbreak of 2005 - 2006, the only laboratory facilities available in Mauritius were virus isolation in cell culture tubes and serology. The laboratory was submerged with large numbers of blood samples. Comparative isolation was made in human embryonic lung (HEL) and VERO cells grown in 96-well plate. Culture on HEL cells was found to be more sensitive and presence of cytopathic effect (CPE) was observed earlier than in VERO cells. Out of the 18 300 blood samples inoculated on HEL, 11 165 were positive. This virus isolation method was of great help for the surveillance and control of the vectors. In cases of an outbreak a cheap, rapid and simple method of isolating chikungunya virus is described.

Chikungunya infection in India: results of a prospective hospital based multi-centric study

Background

Chikungunya (CHIKV) has recently seen a re-emergence in India with high morbidity. However, the epidemiology and disease burden remain largely undetermined. A prospective multi-centric study was conducted to evaluate clinical, epidemiological and virological features of chikugunya infection in patients with acute febrile illness from various geographical regions of India.

Methods and Findings

A total of 540 patients with fever of up to 7days duration were enrolled at Karnataka Institute of Medical Sciences (KIMS), Karnataka (South); Sawai Man Singh Medical College (SMS) Rajasthan (West), and All India Institute of Medical Sciences (AIIMS) New Delhi (North) from June 2008 to May 2009. Serum specimens were screened for chikungunya infection concurrently through RT-PCR and serology (IgM). Phylogenetic analysis was performed using Bioedit and Mega2 programs. Chikungunya infection was detected in 25.37% patients by RT-PCR and/or IgM-ELISA. Highest cases were detected in south (49.36%) followed by west (16.28%) and north (0.56%) India. A difference in proportion of positives by RT-PCR/ELISA with regard to duration of fever was observed (p<0.05). Rashes, joint pain/swelling, abdominal pain and vomiting was frequently observed among chikungunya confirmed cases (p<0.05). Adults were affected more than children. Anti-CHIK antibodies (IgM) were detected for more than 60days of fever onset. Phylogenetic analysis based on E1 gene from KIMS patients (n = 15) revealed ∼99% homology clustering with Central/East African genotype. An amino acid change from lysine to glutamine at position 132 of E1 gene was frequently observed among strains infecting children.

Conclusions

The study documented re-emergence of chikungunya in high frequencies and severe morbidity in south and west India but rare in north. The study emphasizes the need for continuous surveillance for disease burden using multiple diagnostic tests and also warrants the need for an appropriate molecular diagnostic for early detection of chikungunya virus.

A humanised murine monoclonal antibody protects mice from Venezuelan equine encephalitis virus, Everglades virus and Mucambo virus when administered up to 48 h after airborne challenge

Currently there are no licensed antiviral treatments for the Alphaviruses Venezuelan equine encephalitis virus (VEEV), Everglades virus and Mucambo virus. We previously developed a humanised version of the mouse monoclonal antibody 1A3B-7 (Hu1A3B-7) which exhibited a wide range of reactivity in vitro and was able to protect mice from infection with VEEV. Continued work with the humanised antibody has now demonstrated that it has the potential to be a new human therapeutic. Hu1A3B-7 successfully protected mice from infection with multiple Alphaviruses. The effectiveness of the humanisation process was determined by assessing proliferation responses in human T-cells to peptides derived from the murine and humanised versions of the V(H) and V(L) domains. This analysis showed that the number of human T-cell epitopes within the humanised antibody had been substantially reduced, indicating that Hu1A3B-7 may have reduced immunogenicity in vivo.

Chikungunya virus infection of cell lines: analysis of the East, Central and South African lineage

Chikungunya virus (CHIKV) is a re-emerging mosquito borne alphavirus that has caused large scale epidemics in the countries around the Indian Ocean, as well as leading to autochthonous transmission in some European countries. The transmission of the disease has been driven by the emergence of an African lineage of CHIKV with enhanced transmission and dissemination in Aedes mosquito hosts. Two main genotypes of this lineage have been circulating, characterized by the presence of a substitution of a valine for an alanine at position 226 of the E1 protein. The outbreak, numbering in millions of cases in the infected areas, has been associated with increasing numbers of cases with non-classical presentation including encephalitis and meningitis. This study sought to compare the original Ross strain with two isolates from the recent outbreak of chikungunya fever in respect of infectivity and the induction of apoptosis in eight mammalian cell lines and two insect cell lines, in addition to generating a comprehensive virus production profile for one of the newer isolates. Results showed that in mammalian cells there were few differences in either tropism or pathogenicity as assessed by induction of apoptosis with the exception of Hela cells were the recent valine isolate showed less infectivity. The Aedes albopictus C6/36 cell line was however significantly more permissive for both of the more recent isolates than the Ross strain. The results suggest that the increased infectivity seen in insect cells derives from an evolution of the CHIKV genome not solely associated with the E1:226 substitution.

Impact of Chikungunya on health related quality of life Chennai, South India

BACKGROUND

Chikungunya Virus (CHIKV) infection affects large populations and leads to prolonged and debilitating pain affecting health related quality of life (HRQoL). We assess the impact of CHIKV on HRQoL of clinical CHIKV (C-CHIKV) patients in a suburban locality of Chennai City, South India. Further, we determined factors associated with clinical recovery among C-CHIKV patients.

METHODS

We followed-up 403 of 425 adult C-CHIKV cases identified during an outbreak. On the basis of a reassessment of their current clinical status through self-reporting, we categorized them as 'clinically recovered' (n = 308) or 'not recovered' (n = 95). In the absence of base-line information on HRQoL, we included a comparison group of healthy normal's recruited by frequency matching for age and sex from the neighbourhood (n = 308). We conducted a comparative cross-sectional study of these three groups and estimated HRQoL scores using SF-36 questionnaire. We tested the differences in the median scores by Kruksall Wallistest. We identified factors associated with 'recovery' as compared to not-recovery by calculating Adjusted Odds Ratio (AOR) and 95% Confidence Intervals through multiple regression analysis.

RESULTS

As compared to 'normals', we observed a 20 and five-fold reductions in HRQoL scores for C-CHIKV patients 'not recovered' and 'recovered' respectively. Differences in HRQoL scores for all the domains were statistically significant between three groups (p<0·001). Younger age, male, absence of rashes, affliction of less than five types of joints and two weeks of joint swelling were significantly associated with recovery. HRQoL scores improved with time among those 'clinically recovered'.

CONCLUSION

This study provides evidence for sharp reductions in quality of life not only during active C-CHIKV associated illness but also for several months after clinical recovery compared to healthy normals. This has implications for developing intervention programmes in countries with high risk of CHIKV outbreaks.

Formulations combining CpG containing oliogonucleotides and poly I:C enhance the magnitude of immune responses and protection against pancreas disease in Atlantic salmon

Both CpG oligodeoxynucleotides and double-stranded RNA (poly I:C) have documented effects as treatments against several viral diseases in fish. However, as stand-alone treatments their effects have been modest. We have tested here whether CpG and poly I:C, alone or in combination induce protection against Salmonid Alphavirus (SAV), the causative agent of pancreas disease in Atlantic salmon. Our results revealed a significant reduction of viraemia 2 weeks after ip injection of the combined treatment and 1 week after challenge with SAV subtype 3, followed by reduced SAV induced heart pathology 3 weeks later. The SAV titers in blood samples from the combination group were lower as compared to single treatments with either CpG or poly I:C. Surprisingly, reduced SAV levels could also be found in fish as long as 7 weeks after receiving the combination treatment. The expression of IFNγ and to a lesser extent IFNa and Mx was up-regulated in head kidney and spleen 5 days after the fish had been treated with CpG and poly I:C. Furthermore, the complement factor C4 was depleted in serum 8 weeks post treatment, suggesting complement activation leading to C4 consumption. We hypothesize that the CpG/poly I:C-induced protection against SAV3 is mediated by mechanisms involving type I and type II IFN induced antiviral activity and complement mediated protective responses.

Competitive suppression between chikungunya and dengue virus in Aedes albopictus c6/36 cell line

Aedes albopictus C6/36 cell line was used to evaluate dengue virus serotype-3 (DENV-3) and chikungunya virus (CHIKV) co-infection. Virus infection was determined using a one-step duplex reverse transcriptase polymerase chain reaction (D- RT-PCR). D-RT-PCR was positive for both viruses when equal multiplicity of infection (MOI) was utilized. Co-infection with different titers between a higher CHIKV titer (MOI = 1.0) than DENV-3 titer (MOI = 0.1) showed similar results with that of equal titer. However, co-infection with a lower CHIKV titer (MOI = 0.1) than DENV-3 titer (MOI = 1.0) revealed positive results for only dengue virus infection, suggesting DENV competitive suppression of CHIKV. This competitive suppression occurred in mixed-infection samples but not in individually double infection (super infection) samples which produced both dengue and chikungunya virus progenies. Both virus replications depend on the amount of virus titer rather than serial infection. These findings have provided information regarding pathogen-pathogen interaction in host cell, which could be used to predict outbreaks, and to develop virus detection and vector control.

Group size and nest spacing affect Buggy Creek virus (Togaviridae: Alphavirus) infection in nestling house sparrows

The transmission of parasites and pathogens among vertebrates often depends on host population size, host species diversity, and the extent of crowding among potential hosts, but little is known about how these variables apply to most vector-borne pathogens such as the arboviruses (arthropod-borne viruses). Buggy Creek virus (BCRV; Togaviridae: Alphavirus) is an RNA arbovirus transmitted by the swallow bug (Oeciacus vicarius) to the cliff swallow (Petrochelidon pyrrhonota) and the introduced house sparrow (Passer domesticus) that has recently invaded swallow nesting colonies. The virus has little impact on cliff swallows, but house sparrows are seriously affected by BCRV. For house sparrows occupying swallow nesting colonies in western Nebraska, USA, the prevalence of BCRV in nestling sparrows increased with sparrow colony size at a site but decreased with the number of cliff swallows present. If one nestling in a nest was infected with the virus, there was a greater likelihood that one or more of its nest-mates would also be infected than nestlings chosen at random. The closer a nest was to another nest containing infected nestlings, the greater the likelihood that some of the nestlings in the focal nest would be BCRV-positive. These results illustrate that BCRV represents a cost of coloniality for a vertebrate host (the house sparrow), perhaps the first such demonstration for an arbovirus, and that virus infection is spatially clustered within nests and within colonies. The decreased incidence of BCRV in sparrows as cliff swallows at a site increased reflects the "dilution effect," in which virus transmission is reduced when a vector switches to feeding on a less competent vertebrate host.

Dryland salinity and vector-borne disease emergence in southwestern Australia

Broad-scale clearing of native vegetation for agriculture in southwestern Australia has resulted in severe ecosystem degradation, which has been compounded by the subsequent development of large areas of dryland salinity; decreased transevaporation allows the water table to rise, dissolving ancient aeolian salt deposits and creating saline surface pools. The mosquito-borne disease Ross River virus has been noted as a potential adverse human health outcome in salinity-affected regions because the principal vector, Aedes camptorhynchus, is salt tolerant and thrives preferentially in such systems. To understand the geology and ecology underlying the relationship between land clearing and disease emergence, we examine the relationship between dryland salinity processes that determine the dissolved solids profile of saline pools in affected areas, the mosquito vectors and interactions with the human population within the disease cycle. Aedes camptorhynchus is able to survive in a wide range of salinities in pools created by dryland salinity processes. The link with disease emergence is achieved where population distribution and activity overlaps with the convergence of environmental and ecological conditions that enhance disease transmission.

Novel chikungunya vaccine candidate with an IRES-based attenuation and host range alteration mechanism

Chikungunya virus (CHIKV) is a reemerging mosquito-borne pathogen that has recently caused devastating urban epidemics of severe and sometimes chronic arthralgia. As with most other mosquito-borne viral diseases, control relies on reducing mosquito populations and their contact with people, which has been ineffective in most locations. Therefore, vaccines remain the best strategy to prevent most vector-borne diseases. Ideally, vaccines for diseases of resource-limited countries should combine low cost and single dose efficacy, yet induce rapid and long-lived immunity with negligible risk of serious adverse reactions. To develop such a vaccine to protect against chikungunya fever, we employed a rational attenuation mechanism that also prevents the infection of mosquito vectors. The internal ribosome entry site (IRES) from encephalomyocarditis virus replaced the subgenomic promoter in a cDNA CHIKV clone, thus altering the levels and host-specific mechanism of structural protein gene expression. Testing in both normal outbred and interferon response-defective mice indicated that the new vaccine candidate is highly attenuated, immunogenic and efficacious after a single dose. Furthermore, it is incapable of replicating in mosquito cells or infecting mosquitoes in vivo. This IRES-based attenuation platform technology may be useful for the predictable attenuation of any alphavirus.

[Asymptomatic infections in man: a Trojan horse for the introduction and spread of mosquito-borne arboviruses in non-endemic areas?]

In mosquito-borne arbovirus infections in man the asymptomatic cases are much more frequent than the symptomatic ones, but their true role in the introduction and subsequent spread of such diseases in non-endemic areas remains to be clarified. We have collected pertinent data from English and French literature from 1952 to 2010 through Pubmed and other bibliographic sources. Data were analysed to assess if viremia in asymptomatic human arbovirus infections might be sufficient to represent a true risk for introduction in non-endemic areas. During dengue and chikungunya fever outbreaks, humans are believed to be the only vertebrate hosts. Since a very large number of individuals are infected and since viremic levels are known to vary by many orders of magnitude in symptomatic patients, it is reasonable to augur that a proportion of asymptomatic cases might reach levels of viremia sufficient to infect competent mosquitoes. Moreover, in both dengue and chikungunya fever, nosocomial infections have been identified representing an alternative opportunity for virus introduction in non-endemic areas. In zoonotic mosquito-borne arbovirus infections such as Japanese encephalitis or West Nile infection, the situation is quite different since humans are considered as "dead-end" hosts. However, the very large number of asymptomatic cases arising during outbreaks and the existence of newly recognised ways of contamination (blood transfusion, organ transplantation, transplacental way etc.) may also ensure their introduction and subsequent spread in new areas.

Persistence of multiple genetic lineages within intrahost populations of Ross River virus

We examined the structure and extent of genetic diversity in intrahost populations of Ross River virus (RRV) in samples from six human patients, focusing on the nonstructural (nsP3) and structural (E2) protein genes. Strikingly, although the samples were collected from contrasting ecological settings 3,000 kilometers apart in Australia, we observed multiple viral lineages in four of the six individuals, which is indicative of widespread mixed infections. In addition, a comparison with previously published RRV sequences revealed that these distinct lineages have been in circulation for at least 5 years, and we were able to document their long-term persistence over extensive geographical distances.

A comparative study of marine salmonid alphavirus subtypes 1-6 using an experimental cohabitation challenge model

A comparative challenge study of six marine isolates representing subtypes 1-6 of salmonid alphavirus (salmon pancreas disease virus, Genus Alphavirus, Family Togaviridae) was conducted in Atlantic salmon in a fresh water cohabitation trial. Histopathological lesions typical of pancreas disease were observed with all subtypes, and virus was re-isolated from serum of cohabitant fish in each case. Using a virus neutralization (VN) test neutralizing salmonid alphavirus (SAV) subtype 1 strain F93-125, VN antibodies were detected in all challenge groups, consistent with serological cross-reactivity between these subtypes. Using real-time RT-PCR, SAV RNA was detected in heart tissue from 2 to 3 weeks post-challenge (wpc) in all cohabitant groups excluding controls. The results obtained suggested differences in the dynamics of infection between strains of SAV and potentially between subtypes. Results for SAV subtypes 1 and 3 suggested essentially synchronous infection of cohabitant fish. These two study groups also had the highest virus load in heart tissue as measured by quantitative RT-PCR and also had the most extensive histopathological changes. In contrast, results for SAV subtypes 2 and 6 strains were consistent with asynchronous infection in the cohabitant fish and were characterized by slow spread, low virus loads and mild histopathological changes. The SAV subtype 4 and 5 strains occupied an intermediate position in this regard. Despite the use of concentration procedures, it was not possible to detect SAV RNA in water samples from selected study tanks. However, testing of faeces from the SAV subtypes 1, 3 and 6 challenge groups found positive signals in each beginning at 1-3 wpc and remaining detectable for a further 2-3 weeks. Parallel testing of mucus samples found these became positive at 2-3 wpc and remained positive for a further 1-3 weeks. These results demonstrate for the first time that shedding and transmission of virus may occur by both these routes and suggest that dispersal in these matrices should be included in any disease transmission models.

A DNA vaccine against chikungunya virus is protective in mice and induces neutralizing antibodies in mice and nonhuman primates

Chikungunya virus (CHIKV) is an emerging mosquito-borne alphavirus indigenous to tropical Africa and Asia. Acute illness is characterized by fever, arthralgias, conjunctivitis, rash, and sometimes arthritis. Relatively little is known about the antigenic targets for immunity, and no licensed vaccines or therapeutics are currently available for the pathogen. While the Aedes aegypti mosquito is its primary vector, recent evidence suggests that other carriers can transmit CHIKV thus raising concerns about its spread outside of natural endemic areas to new countries including the U.S. and Europe. Considering the potential for pandemic spread, understanding the development of immunity is paramount to the development of effective counter measures against CHIKV. In this study, we isolated a new CHIKV virus from an acutely infected human patient and developed a defined viral challenge stock in mice that allowed us to study viral pathogenesis and develop a viral neutralization assay. We then constructed a synthetic DNA vaccine delivered by in vivo electroporation (EP) that expresses a component of the CHIKV envelope glycoprotein and used this model to evaluate its efficacy. Vaccination induced robust antigen-specific cellular and humoral immune responses, which individually were capable of providing protection against CHIKV challenge in mice. Furthermore, vaccine studies in rhesus macaques demonstrated induction of nAb responses, which mimicked those induced in convalescent human patient sera. These data suggest a protective role for nAb against CHIKV disease and support further study of envelope-based CHIKV DNA vaccines.

Chikungunya fever epidemics are sustained by a cycle of human-mosquito-human transmission, with the epidemic cycle being similar to those of dengue and urban yellow fever. While the threat of a pandemic continues to engage the public's attention, the peculiar problems associated with the more immediate and very real seasonal epidemics are also worthy of consideration. Specifically, there are limited viral strains that have been characterized and available for laboratory study as well as limited knowledge of immune responses induced to the virus. In this study, we isolated CHIKV virus from an acutely infected human patient and used this new virus to develop a neutralization assay and a challenge stock, which is effective in a mouse model. Furthermore, we analyzed the ability of an envelope-based synthetic DNA-based vaccine to impact viral disease in the mouse model and to generate protective levels of immune responses in nonhuman primates. We observed that this novel vaccine approach generated protective levels of immune responses in both mouse and non-human primate models. We believe that these studies advance the field of Chikungunya vaccine research as well as the study of immune protection to CHIKV.

Chikungunya virus isolates with/without A226V mutation show different sensitivity to IFN-a, but similar replication kinetics in non human primate cells

Chikungunya virus (CHIKV) is a mosquito-transmitted alphavirus responsible for the first autochthonous Italian outbreak in 2007. A226V mutation in E1 has been associated with enhanced replication in A. albopictus vector. Possible involvement of this mutation in enhanced infection capability in primate cells and sensitivity to exogenous interferon (IFN)-a was investigated. No significant differences were observed between the two isolates in terms of replication kinetic, virus yield and cytopathic effect (CPE). Interestingly, the A226V-carrying strain was more susceptible to the antiviral action of recombinant IFN-a. The interplay between A226V mutation and innate defence mechanisms needs further investigation.

Development and evaluation of a one-step SYBR-Green I-based real-time RT-PCR assay for the detection and quantification of Chikungunya virus in human, monkey and mosquito samples

This paper reports the development of a one-step SYBR-Green I-based realtime RT-PCR assay for the detection and quantification of Chikungunya virus (CHIKV) in human, monkey and mosquito samples by targeting the E1 structural gene. A preliminary evaluation of this assay has been successfully completed using 71 samples, consisting of a panel of negative control sera, sera from healthy individuals, sera from patients with acute disease from which CHIKV had been isolated, as well as monkey sera and adult mosquito samples obtained during the chikungunya fever outbreak in Malaysia in 2008. The assay was found to be 100-fold more sensitive than the conventional RT-PCR with a detection limit of 4.12x10(0) RNA copies/μl. The specificity of the assay was tested against other related viruses such as Dengue (serotypes 1-4), Japanese encephalitis, Herpes Simplex, Parainfluenza, Sindbis, Ross River, Yellow fever and West Nile viruses. The sensitivity, specificity and efficiency of this assay were 100%, 100% and 96.8% respectively. This study on early diagnostics is of importance to all endemic countries, especially Malaysia, which has been facing increasingly frequent and bigger outbreaks due to this virus since 1999.

Lack of evidence for vertical transmission of SAV 3 using gametes of Atlantic salmon, Salmo salar L., exposed by natural and experimental routes

Pancreas disease (PD) is an important cause of losses in farmed salmonids in Norway, the United Kingdom and Ireland. As the spread of salmonid alphavirus (SAV), the causal agent, to naïve populations is of major concern to the farming industry, it is important to uncover the transmission routes of the virus. This study was conducted to investigate the potential for vertical transmission of SAV subtype 3. Progeny of broodstock with signs of late-stage PD and persistent RT-PCR signals for SAV were followed from fertilization to smoltification in an experimental facility. Fertilized ova were either not disinfected or taken through one of three different disinfection regimes. Also, ova and milt from uninfected broodfish from a different population were exposed to a cell-cultured strain of SAV 3 immediately before fertilization to simulate a viraemic phase in parent fish. A group of uninfected controls were also included in the study. Fertilized ova from bath exposed and negative control groups were double disinfected. Following fertilization, experimental fish went through a normal freshwater phase. However, fry were stressed at first feeding to enhance replication of possibly latent virus. Smoltification was induced by an artificial light regime, and experimental fish were followed to the late smoltification phase. Selected samples were investigated by real-time RT-PCR for SAV, by histology for evidence of PD and by serology for neutralising antibodies against SAV. All analysed samples of progeny were negative. This result shows that SAV 3 is not readily transmitted vertically from parents to offspring. Additional negative PCR results from salmon sampled in commercial hatcheries support these findings. Also, recent studies have shown that risk factors for the horizontal transmission route explain the vast majority of PD outbreaks in Norway. It is concluded that if it happens at all, vertical transmission is of minor importance in the spread of SAV 3.

Identification of Chikungunya virus strains circulating in Kelantan, Malaysia in 2009

Malaysia experienced its first outbreak of chikungunya virus (CHIKV) infection in late 1998 in Klang District in Selangor; six years later the virus re-emerged in the state of Perak. All the CHIKV isolates in 1988 and 2006 shared high sequence similarities and belonged to the Asian genotype. In 2007 and 2008 CHIKV infection again reemerged but the genotype was the Central/East African genotype. This strain was found to be similar to the strains causing outbreaks in the India Ocean. In 2009, the strains circulating in Malaysia, including the state of Kelantan, based on the partial E1 gene, also belong to the Central/East African genotype.