Chikungunya fever outbreak in Guntur, Andhra Pradesh, India

Current Status of Chikungunya in India

Chikungunya fever (CHIKF) is an arbovirus disease caused by chikungunya virus (CHIKV), an alphavirus of Togaviridae family. Transmission follows a human-mosquito-human cycle starting with a mosquito bite. Subsequently, symptoms develop after 2-6 days of incubation, including high fever and severe arthralgia. The disease is self-limiting and usually resolve within 2 weeks. However, chronic disease can last up to several years with persistent polyarthralgia. Overlapping symptoms and common vector with dengue and malaria present many challenges for diagnosis and treatment of this disease. CHIKF was reported in India in 1963 for the first time. After a period of quiescence lasting up to 32 years, CHIKV re-emerged in India in 2005. Currently, every part of the country has become endemic for the disease with outbreaks resulting in huge economic and productivity losses. Several mutations have been identified in circulating strains of the virus resulting in better adaptations or increased fitness in the vector(s), effective transmission, and disease severity. CHIKV evolution has been a significant driver of epidemics in India, hence, the need to focus on proper surveillance, and implementation of prevention and control measure in the country. Presently, there are no licensed vaccines or antivirals available; however, India has initiated several efforts in this direction including traditional medicines. In this review, we present the current status of CHIKF in India.

Laboratory surveillance of chikungunya in Madhya Pradesh, India (2016-2017)

Background & objectives:

Chikungunya (CHIK) is a neglected, re-emerging arboviral disease. Limited information on CHIK-confirmed cases during interepidemic period is available from India. This surveillance study was conducted in Madhya Pradesh (MP), India, during the years 2016-2017, to provide information about CHIK cases.

Methods:

Blood samples collected from patients suspected having CHIK were tested by immunoglobulin (Ig) IgM ELISA or real time reverse transcription-polymerase chain reaction (rRT-PCR) for the detection of CHIK virus (CHIKV)-specific IgM antibodies or viral RNA, respectively. Partial envelope-1 gene sequencing was done. Clinical and demographic data were collected and analyzed.

Results:

Of the 4019 samples tested, 494 (12.2%) were found positive for CHIKV infection. The positivity was detected in both rural and urban areas. The mean age of CHIK-positive cases was 33.12±18.25 yr. Headache and joint pain were the most prominent symptoms, 34.6 per cent (171/494) of the CHIK cases required hospitalization and six patients with CHIKV infection died. The East/Central/South African genotype of CHIKV was found to be circulating in the study area.

Interpretation & conclusions:

Our study recorded a higher CHIK positivity during 2016-2017 in comparison to earlier reports from MP, India. A high proportion of CHIK cases required hospitalization and deaths were also reported, which indicated the severity of the disease in the study area. In-depth molecular analysis of the virus and other risk factors is essential to understand the trends in disease severity.

Antiviral activity of stearylamine against chikungunya virus

Chikungunya, a mosquito-borne disease that causes high fever and severe joint pain in humans, is a profound global threat because of its high rate of contagion and lack of antiviral interventions or vaccines for controlling the infection. The present study was aimed to investigate the antiviral activity of Stearylamine (SA) against Chikungunya virus (CHIKV) in both in vitro and in vivo. The antiviral activity of SA was determined by foci forming unit (FFU) assay, quantitative RT-PCR and cell-based immune-fluorescence assay (IFA). Further in vivo studies were carried out to see the effect of SA treatment in CHIKV infected C57BL/6 mice. The anti-CHIKV activity was evaluated using qRT-PCR in serum and muscle tissues at different time points and by histopathology. In vitro treatment with SA at a concentration of 50 μM showed a reduction of 1.23 ± 0.19 log10 FFU/mL at 16 h and 1.56 ± 0.12 log10 FFU/mL at 24 h posttreatment by FFU assay. qRT-PCR studies indicated that SA treatment at 50μM concentration showed a singnificant reduction of 1.6 ± 0.1 log10 and 1.27 ± 0.12 log10 RNA copies when compared with that of virus control at 16 and 24 h post incubation. Treatments in the C57BL/6 mice model revealed that SA at 20 mg/kg dose per day up to 3, 5 and 7 days, produced stronger inhibition against CHIKV indicating substantially decrease viral loads and inflammatory cell migration in comparison to a dose of 10 mg/kg. This first in vivo study clearly indicates that SA is effective by significantly reducing virus replication in serum and muscles. As a next-generation antiviral therapeutic, these promising results can be translated for the use of SA to rationalize and develop an ideal delivery system alone or in combination against CHIKV.

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

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

Clinical spectrum and outcome of critically ill hospitalized patients with acute febrile illness and new-onset organ dysfunction presenting during monsoon season

Acute febrile illness (AFI) is one of the commonest indications for hospitalization and can present with varying severity including single or multiple organ dysfunction syndrome (MODS). During monsoon season, there is a spurt of AFI often caused by vector borne diseases leading to substantial morbidity and mortality. Our aim was to determine distribution of etiological causes, differential organ involvement and predictors of mortality in critically ill patients with AFI. It was a hospital based observational study which included patients with AFI with dysfunction of at least one organ system. The study was conducted over 4 months during monsoon season. Admitted patients were included who had been subjected to a standard battery of tests and managed with standard hospital based management protocol. 145 patients were included and etiology of fever was ascertained in 81.4% of patients with the most common single infection being chikungunya (20.7%) followed by dengue (20%) fever. Thrombocytopenia and deranged liver biochemistry each were seen in nearly 75% of the patients. Renal (50.3%) and nervous system (46.2%) dysfunction were the predominant organ failures. 49 patients died (33.8%) which correlated with predicted mortality by APACHE (acute physiological assessment and chronic health evaluation) II score. Independent predictors for mortality were older age (> 55 years) (p = 0.01), acidemia (p = 0.01), altered sensorium (p = 0.02) and coagulopathy (p = 0.048). Sub-group analysis revealed that amongst patients with MODS, hypotension could help differentiate between bacterial and non-bacterial causes (p = 0.01). Critically ill patients with AFI suffer from significant morbidity and mortality. Features like the presence of hypotension in MODS may differentiate between a bacterial cause vis-à-vis viral or protozoal etiology.

Understanding the mechanism of Chikungunya virus vector competence in three species of mosquitoes

Chikungunya virus (CHIKV) is primarily transmitted by Aedes spp. mosquitoes. The present study investigated vector competence for CHIKV in Aedes aegypti and Aedes albopictus mosquitoes found in Madurai, South India. The role of receptor proteins on midguts contributing to permissiveness of CHIKV to Aedes spp. mosquitoes was also undertaken. Mosquitoes were orally infected with CHIKV DRDE-06. Infection of midguts and dissemination to heads was confirmed by immunofluorescence assay at different time points. A plaque assay was performed from mosquito homogenates at different time points to study CHIKV replication. Presence of putative CHIKV receptor proteins on mosquito midgut epithelial cells was detected by virus overlay protein binding assay (VOPBA). The identity of these proteins was established using mass spectrometry. CHIKV infection of Ae. aegypti and Ae. albopictus midguts and dissemination to heads was observed to be similar. A plaque assay performed with infected mosquito homogenates revealed that CHIKV replication dynamics was similar in Aedes sp. mosquitoes until 28 days post infection. VOPBA performed with mosquito midgut membrane proteins revealed that prohibitin could serve as a putative CHIKV receptor on Aedes mosquito midguts, whereas an absence of CHIKV binding protein/s on Culex quinquefasciatus midguts can partially explain the non-permissiveness of these mosquitoes to infection.

Molecular and phylogenetic analysis of Chikungunya virus in Central India during 2016 and 2017 outbreaks reveal high similarity with recent New Delhi and Bangladesh strains

Central India witnessed Chikungunya virus (CHIKV) outbreaks in 2016 and 2017. The present report is a hospital based cross-sectional study on the serological and molecular epidemiology of the outbreak. Mutational and phylogenetic analysis was conducted to ascertain the genetic relatedness of the central Indian strains with other Indian and global strains. Chikungunya infection was confirmed in the clinically suspected patients by the detection of anti-CHIKV IgM antibody by ELISA and viral RNA by RT-PCR. A representative set of the RT-PCR positive samples were sequenced for E1 gene and analyzed to identify the emerging mutations and establish their phylogenetic relationship, particularly with other contemporary strains. Phylogenetic analysis revealed the present strains to be of East Central South African (ECSA) genotype. Emergence of a variant strain was observed in the year 2016, which became the predominant strain in this region in 2017. The strains showed significant identity with recent New Delhi strains of 2015 and 2016 and Bangladesh strains of 2017. The epidemic mutation A226V which emerged in 2006 outbreaks of India and Indian Ocean Islands was found to be absent in the current strains. Among the important mutations viz. K211E, M269 V, D284E, I317V & V322A observed in the recent strains. I317V is a novel mutation which has emerged very recently as it was found only in central Indian (2016, 2017), New Delhi strains (2015, 2016) and Bangladesh strains (2017). This study has identified a unique mutation E1:I317V in the Central Indian strains, which is present only in recent New Delhi and Bangladesh strains till date. This study highlights the need for continuous molecular surveillance of circulating CHIKV strains in order to facilitate the prompt identification of novel strains of this virus and enable the elucidation of their clinical correlates.

Comprehensive Genome Scale Phylogenetic Study Provides New Insights on the Global Expansion of Chikungunya Virus

Since the India and Indian Ocean outbreaks of 2005 and 2006, the global distribution of chikungunya virus (CHIKV) and the locations of epidemics have dramatically shifted. First, the Indian Ocean lineage (IOL) caused sustained epidemics in India and has radiated to many other countries. Second, the Asian lineage has caused frequent outbreaks in the Pacific islands and in 2013 was introduced into the Caribbean, followed by rapid spread to nearly all of the neotropics. Further, CHIKV epidemics, as well as exported cases, have been reported in central Africa after a long period of perceived silence. To understand these changes and to anticipate the future of the virus, the exact distribution, genetic diversity, transmission routes, and future epidemic potential of CHIKV require further assessment. To do so, we conducted the most comprehensive phylogenetic analysis to date, examined CHIKV evolution and transmission, and explored distinct genetic factors associated with the emergence of the East/Central/South African (ECSA) lineage, the IOL, and the Asian lineage. Our results reveal contrasting evolutionary patterns among the lineages, with growing genetic diversities observed in each, and suggest that CHIKV will continue to be a major public health threat with the potential for further emergence and spread.

IMPORTANCE

Chikungunya fever is a reemerging infectious disease that is transmitted by Aedes mosquitoes and causes severe health and economic burdens in affected populations. Since the unprecedented Indian Ocean and Indian subcontinent outbreaks of 2005 and 2006, CHIKV has further expanded its geographic range, including to the Americas in 2013. Its evolution and transmission during and following these epidemics, as well as the recent evolution and spread of other lineages, require optimal assessment. Using newly obtained genome sequences, we provide a comprehensive update of the global distribution of CHIKV genetic diversity and analyze factors associated with recent outbreaks. These results provide a solid foundation for future evolutionary studies of CHIKV that can elucidate emergence mechanisms and also may help to predict future epidemics.