Chikungunya Case Classification after the Experience with Dengue Classification: How Much Time Will We Lose?

In 2013, cases of chikungunya virus (CHIKV) infection were first detected in the Caribbean. Chikungunya virus rapidly spread through Central and South America, causing explosive outbreaks in naive populations. Since its emergence in 2004, the number of case and series reports describing severe, atypical manifestations seen in chikungunya patients has increased substantially, calling into question whether clinicians and health services are failing to diagnose these atypical cases because of not only insufficient knowledge but also limitations in the case classification. Although this classification based on the duration of the musculoskeletal (acute, subacute, and chronic forms) complaints helped guide therapeutic approaches directed to these manifestations, patients presenting severe or complicated forms, which are less frequent but produce most of the fatal outcomes, were not properly addressed. In Brazil and the Caribbean, a clear temporal and spatial association between excess overall mortality and the occurrence of chikungunya epidemics has been shown, supporting the hypothesis that many of these excess deaths were a consequence of CHIKV infections. Thus, accumulated experience has highlighted that the current chikungunya case classification does not encompass the actual needs presented by certain cases with atypical features nor does it contribute to early detection and management of potentially severe cases. With continued CHIKV circulation in three continents and recent reemergence in Asia and Europe, we need a classification that is prospective and informed both by initial clinical presentation and by progression of signs and symptoms.

Long-term Chikungunya Sequelae in Curaçao: Burden, Determinants, and a Novel Classification Tool.

Background: Beyond the acute illness phase, chikungunya constitutes a public health problem given its chronic disease phase, which may include long-term arthralgia, arthritis, fatigue, and depression. Currently, there is no consensus on how to define chikungunya chronicity. Methods: A comprehensive cross-sectional survey was performed in Curaçao in June and July 2015 to evaluate 304 adult laboratory-confirmed chikungunya patients 3-16 months after diagnosis. We developed a novel tool, the Curaçao Long-Term Chikungunya Sequelae (CLTCS) score, to classify chronic chikungunya disease and estimate its burden regarding disease duration, clinical presentation, and impact on quality of life. Results: Disease persistence was estimated to be 79% one month after symptom onset and 64% after 400 days. Chikungunya persistence was characterized by higher proportions of arthralgia, weakness, myalgia, and age 41-60 years. Individuals were classified as "highly affected," "mildly affected," and "recovered." "Highly affected" disease status was associated with clinical complaints (arthralgia, weakness, loss of vitality, and being diabetic) and major decreases in quality-of-life scores. Conclusions: In the Caribbean, a high proportion of chikungunya patients remains chronically affected. We propose the CLTCS as a suitable score to easily and rapidly classify the severity of chikungunya chronic disease and to assess the need for symptom-alleviating treatment.

Guía para el manejo clínico de la enfermedad producida por el virus del Chikungunya / Guidelines for clinical management of the disease produced by the Chikungunya virus

Introducción: La febre Chikungunya es una enfermedad viral emergente descrita por primera vez en Tanzania en 1952. Es una enfermedad endémica en Asia, África y Oceanía y a fnales del 2013, apareció en América, donde ha ocasionado epidemias en República Dominicana, Colombia, Venezuela, Brasil, Bolivia, entre otros. En Paraguay, la presencia de los dos vectores, mosquitos del género Aedes (Aegypti y Albopictus) facilitan la transmisión y diseminación de esta enfermedad. En febrero de 2015, se detecta un brote de la enfermedad, por el Virus Chikungunya, en Fernando de la Mora, Departamento Central, con 8 casos positivos, autóctonos. Ante tal circunstancia, la Dirección General de Desarrollo de Servicios y Redes de Salud del Ministerio de Salud Pública y Bienestar Social ha elaborado esta guía para ser utilizada por todos los profesionales de salud en las todas instituciones sanitarias del país. El documento contempla conceptos epidemiológicos, aspectos clínicos de la enfermedad, grupos considerados de mayor riesgo, el diagnóstico diferencial con otras enfermedades principalmente con el Dengue, las pruebas de laboratorio y el tratamiento médico, los cuales permitirán reforzar los conocimientos del profesional para la atención y el abordaje adecuado de pacientes afectados por el Virus Chikungunya. Objetivo: Aplicar los lineamientos técnicos de la Guía en los diferentes servicios de salud del nivel nacional, regional y local para garantizar el abordaje adecuado de los pacientes con la enfermedad por el Virus Chikungunya. Objetivos específcos. 1. Identifcar las manifestaciones clínicas, priorizando los pacientes graves y grupos de riesgo. 2. Establecer el diagnóstico diferencial con otras afecciones prevalentes, en especial el Dengue. 3. Remitir oportunamente los casos graves y pacientes de riesgo a los niveles de mayor complejidad establecidos, debiendo estos ser contra-referidos al nivel de origen, una vez estabilizados para su seguimiento. Palabras Claves: Virus Chikungunya. Fiebre Chikungunya. Guías Clínicas. Recomendaciones

Introduction: Chikungunya fever is an emerging viral disease frst described in Tanzania in 1952. It is endemic in Asia, Africa and Oceania and in late 2013, began to appear in the Americas, where it has caused epidemics in the Dominican Republic, Colombia, Venezuela, Brazil, and Bolivia, among other countries. In Paraguay, the presence of the two Aedes mosquitoe vectors (Aedes albopictus andAegypti) facilitate the transmission and spread of this disease. In February 2015, an outbreak of the disease wasdetected in Fernando de la Mora, Central Department, with 8 positive cases, all native cases. Because of this event, the General Directorate for Development and Health Services Network of the Ministry of Public Health and Social Welfare has prepared this guide to be used by all health professional in all health-care facilities in the country. The document includes epidemiological concepts, clinical aspects of the disease, groups considered most at risk, the differential diagnosis with other diseases, mainly with Dengue, laboratory tests and medical treatment, information which will improve the care and the proper approach to patients with Chikungunya virus. Objective: To implement the technical guidelines of the Guide at health-care facilities at all levels (national, regional and local) to ensure proper management of patients with the Chikungunya Virus disease. Specifc objectives 1. Identify the clinical manifestations, prioritizing critical patients and risk groups. 2. Establish the differential diagnosis with other prevalent diseases, especially dengue. 3. Refer more severe cases and patients at risk of complications to more higher levels of care and to return these patients to the original level and location of care for monitoring once stabilized. Keywords: virus Chikungunya. Fever chikungunya. Clinical guidelines. Recommendations