Divergent Barmah Forest Virus from Papua New Guinea.

We report a case of Barmah Forest virus infection in a child from Central Province, Papua New Guinea, who had no previous travel history. Genomic characterization of the virus showed divergent origin compared with viruses previously detected, supporting the hypothesis that the range of Barmah Forest virus extends beyond Australia.

Improving public health intervention for mosquito-borne disease: the value of geovisualization using source of infection and LandScan data.

Epidemiological studies use georeferenced health data to identify disease clusters but the accuracy of this georeferencing is obfuscated by incorrectly assigning the source of infection and by aggregating case data to larger geographical areas. Often, place of residence (residence) is used as a proxy for the source of infection (source) which may not be accurate. Using a 21-year dataset from South Australia of human infections with the mosquito-borne Ross River virus, we found that 37% of cases were believed to have been acquired away from home. We constructed two risk maps using age-standardized morbidity ratios (SMRs) calculated using residence and patient-reported source. Both maps confirm significant inter-suburb variation in SMRs. Areas frequently named as the source (but not residence) and the highest-risk suburbs both tend to be tourist locations with vector mosquito habitat, and camping or outdoor recreational opportunities. We suggest the highest-risk suburbs as places to focus on for disease control measures. We also use a novel application of ambient population data (LandScan) to improve the interpretation of these risk maps and propose how this approach can aid in implementing disease abatement measures on a smaller scale than for which disease data are available.

The assessment of risk factors for the Central/East African Genotype of chikungunya virus infections in the state of Kelantan: a case control study in Malaysia.

BACKGROUND: The aims of the study were to assess the risk factors in relation to cross border activities, exposure to mosquito bite and preventive measures taken.An outbreak of chikungunya virus (CHIKV) infection in Malaysia has been reported in Klang, Selangor (1998) and Bagan Panchor, Perak (2006). In 2009, CHIKV infection re-emerged in some states in Malaysia. It raises the possibilities that re-emergence is part of the epidemics in neighbouring countries or the disease is endemic in Malaysia. For this reason, A community-based case control study was carried out in the state of Kelantan. METHODS: Prospective case finding was performed from June to December 2009. Those who presented with signs and symptoms of CHIKV infection were investigated. We designed a case control study to assess the risk factors. Assessment consisted of answering questions, undergoing a medical examination, and being tested for the presence of IgM antibodies to CHIKV. Descriptive epidemiological studies were conducted by reviewing both the national surveillance and laboratory data. Multivariable logistic regression analysis was performed to determine risk factors contributing to the illness. Cases were determined by positive to RT-PCR or serological for antibodies by IgM. CHIKV specificity was confirmed by DNA sequencing. RESULTS: There were 129 suspected cases and 176 controls. Among suspected cases, 54.4% were diagnosed to have CHIKV infection. Among the controls, 30.1% were found to be positive to serology for antibodies [IgM, 14.2% and IgG, 15.9%]. For analytic study and based on laboratory case definition, 95 were considered as cases and 123 as controls. Those who were positive to IgG were excluded. CHIKV infection affected all ages and mostly between 50-59 years old. Staying together in the same house with infected patients and working as rubber tappers were at a higher risk of infection. The usage of Mosquito coil insecticide had shown to be a significant protective factor. Most cases were treated as outpatient, only 7.5% needed hospitalization. The CHIKV infection was attributable to central/east African genotype CHIKV. CONCLUSIONS: In this study, cross border activity was not a significant risk factor although Thailand and Malaysia shared the same CHIKV genotype during the episode of infections.

Economic impact of chikungunya epidemic: out-of-pocket health expenditures during the 2007 outbreak in Kerala, India.

The southern state of Kerala, India was seriously affected by a chikungunya epidemic in 2007. As this outbreak was the first of its kind, the morbidity incurred by the epidemic was a challenge to the state's public health system. A cross sectional survey was conducted in five districts of Kerala that were seriously affected by the epidemic, using a two-stage cluster sampling technique to select households, and the patients were identified using a syndromic case definition. We calculated the direct health expenditure of families and checked whether it exceed the margins of catastrophic health expenditure (CHE). The median (IQR) total out-of-pocket (OOP) health expenditure in the study population was USD7.4 (16.7). The OOP health expenditure did not show any significant association with increasing per-capita monthly income.The major share (47.4%) of the costs was utilized for buying medicines, but costs for transportation (17.2%), consultations (16.6%), and diagnoses (9.9%) also contributed significantly to the total OOP health expenditure. The OOP health expenditure was high in private sector facilities, especially in tertiary care hospitals. For more than 15% of the respondents, the OOP was more than double their average monthly family income. The chikungunya outbreak of 2007 had significantly contributed to the OOP expenditure of the affected community in Kerala.The OOP health expenditure incurred was high, irrespective of the level of income. Governments should attempt to ensure comprehensive financial protection by covering the costs of care, along with loss of productivity.

[From donor to recipient: transfusion chain specificities in the French ultra-marine areas]. / Du donneur au receveur: particularités de la chaîne transfusionnelle dans les DOM.

Besides specific organisational requirements, the transfusional chain in French ultra-marine areas has specificities related to the epidemiology of infectious diseases and to population characteristics. We focus on some of these sociodemographic and medical peculiarities: the challenge of autosufficiency in relation to demographic trends; epidemiologic risks associated to emergent viruses such as dengue and Chikungunya, and the strategies that had been implemented to face last outbreaks; inappropriate selection criteria for eligibility to blood donation (biologic characteristics of Afro-Caribbeans not taken into account for the low hemoglobin deferral threshold; absence of guidelines for the screening of hemoglobinopathies AS/AC, present in 8% of the target population); specific indications for transfusion, such as platelet use in dengue fever or RBC transfusion in sickle cell disease. Due to the high polymorphism of erythrocyte antigens in Afro-Caribbeans, intra-ethnic transfusion facilitates compatibility for common antigens, but is responsible for the emergence of allo-antibodies difficult to identify in the absence of specific antisera or panels; molecular typing of erythrocyte antigens would allow detection of those patients at risk for immunization, expressing variant antigens or lacking high frequency antigens, as well as the characterization of RBC expressing immunogenic so called low frequency antigens. In an era of periodic emergence of new viruses in Europe (dengue, Chikungunya, West Nile virus...) and with the spreading of diseases with high transfusional requirements, such as sickle cell disease, ultra-marine services represent laboratories for the study of future trends and problems in transfusion medicine.

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.

Chikungunya virus and prospects for a vaccine.

In 2004, chikungunya virus (CHIKV) re-emerged from East Africa to cause devastating epidemics of debilitating and often chronic arthralgia that have affected millions of people in the Indian Ocean Basin and Asia. More limited epidemics initiated by travelers subsequently occurred in Italy and France, as well as human cases exported to most regions of the world, including the Americas where CHIKV could become endemic. Because CHIKV circulates during epidemics in an urban mosquito-human cycle, control of transmission relies on mosquito abatement, which is rarely effective. Furthermore, there is no antiviral treatment for CHIKV infection and no licensed vaccine to prevent disease. Here, we discuss the challenges to the development of a safe, effective and affordable chikungunya vaccine and recent progress toward this goal.

Mayaro virus infection in amazonia: a multimodel inference approach to risk factor assessment.

BACKGROUND: Arboviral diseases are major global public health threats. Yet, our understanding of infection risk factors is, with a few exceptions, considerably limited. A crucial shortcoming is the widespread use of analytical methods generally not suited for observational data--particularly null hypothesis-testing (NHT) and step-wise regression (SWR). Using Mayaro virus (MAYV) as a case study, here we compare information theory-based multimodel inference (MMI) with conventional analyses for arboviral infection risk factor assessment. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional survey of anti-MAYV antibodies revealed 44% prevalence (n = 270 subjects) in a central Amazon rural settlement. NHT suggested that residents of village-like household clusters and those using closed toilet/latrines were at higher risk, while living in non-village-like areas, using bednets, and owning fowl, pigs or dogs were protective. The "minimum adequate" SWR model retained only residence area and bednet use. Using MMI, we identified relevant covariates, quantified their relative importance, and estimated effect-sizes (ß ± SE) on which to base inference. Residence area (ß(Village)  =  2.93 ± 0.41; ß(Upland) = -0.56 ± 0.33, ß(Riverbanks)  =  -2.37 ± 0.55) and bednet use (ß = -0.95 ± 0.28) were the most important factors, followed by crop-plot ownership (ß  =  0.39 ± 0.22) and regular use of a closed toilet/latrine (ß = 0.19 ± 0.13); domestic animals had insignificant protective effects and were relatively unimportant. The SWR model ranked fifth among the 128 models in the final MMI set. CONCLUSIONS/SIGNIFICANCE: Our analyses illustrate how MMI can enhance inference on infection risk factors when compared with NHT or SWR. MMI indicates that forest crop-plot workers are likely exposed to typical MAYV cycles maintained by diurnal, forest dwelling vectors; however, MAYV might also be circulating in nocturnal, domestic-peridomestic cycles in village-like areas. This suggests either a vector shift (synanthropic mosquitoes vectoring MAYV) or a habitat/habits shift (classical MAYV vectors adapting to densely populated landscapes and nocturnal biting); any such ecological/adaptive novelty could increase the likelihood of MAYV emergence in Amazonia.

[Critical analysis of requirements for scientific assessment as a basis for good governance: case of the chikungunya epidemic on Reunion Island and Mayotte in 2005 and 2006]. / L'analyse critique du respect des conditions de bonne gouvernance en matière d'evaluation scientifique des risques: le cas de l'epidémie de chikungunya a La Réunion et a Mayotte en 2005 et 2006.

The constitutional precautionary principle as applied in laws governing health care at the community level requires rigorous scientific assessment. The goal of this assessment is to provide authorities with sound evidence as a basis for implementing precautionary measures in function of degree of risk and other parameters such as the level of public health protection that is high in the EU. As the political authority, the government can act independently of conclusions issued by scientific commissions provided that the commission's level of expertise meets national and European standards and that research methodology and findings are consistent with scientific data published in the international literature. These requirements were not meet for the chikungunya pandemic that struck France on Reunion Island and Mayotte from 2004 to 2006. This epidemic that was preceded by many outbreaks in Indonesia between 2001 and 2003 began in Africa and then swept across the Indian Ocean to India and Asia. After an overview of the scientific assessment, this article raises arguments supporting possible allegations of gross misgovernance by the state and experts.

[Epidemiological surveillance du chikungunya on Reunion Island from 2005 to 2011]. / La surveillance epidémiologique du chikungunya a la Réunion entre 2005 et 2011.

INTRODUCTION: The largest chikungunya epidemic in history hit Reunion Island in 2005/6. At that time, a specific monitoring system was set up. Since the end of the epidemic, this monitoring system has continued to operate and has been enhanced. The main objectives of the system are early detection of any case of chikungunya virus infection and epidemiological monitoring. METHODS: During nonepidemic periods, surveillance is focused on active detection of all cases. During epidemic periods, weekly incidence is estimated using data collected via a sentinel physician network. Occurrence of severe and fatal forms is tracked during all epidemiologic situations. RESULTS: In 2005-2006, the estimated number of symptomatic chikungunya-virus infections diagnosed on Reunion Island was 266 000, i.e., an attack rate of 34%. A total of 222 severe cases and 44 mother-to-child transmissions were recorded. Since the end of the outbreak, two clusters have been detected in the western region of the island in 2010 and 2011. The second cluster was non-negligible since it involved 164 cases including 112 that were biologically confirmed. CONCLUSION: Based on results recorded from 2005 to 2006, the chikungunya monitoring system appears to have good sensitivity and reactivity. Recent detection of two disease clusters confirms the system's efficacy.

[Perceived morbidity and community burden of chikungunya in La Reunion]. / Morbidité perçue et impact communautaire du chikungunya a l'île de La Réunion: enquête de cohorte en population TELECHIK.

BACKGROUND: Persistence of clinical manifestations, especially polyarthralgia and fatigue, is a characteristic feature of chikungunya virus (CHIK-v) infection. The purpose of this study was to measure the impact of prolonged or late-onset manifestations of CHIK-v infection on the self-perceived health of people on Reunion Island. METHODS: This retrospective cohort survey, dubbed TELECHIK survey, was conducted eighteen months after the end of the chikungunya outbreak on a representative random sample from the SEROCHIK population-based survey conducted on Reunion Island. A total of 1094 subjects whose CHIK-v specific IgG antibody status had been documented were interviewed about current symptoms. RESULTS: Analysis of data showed 45% of CHIK+ vs 14% of CHIK- subjects reporting musculoskeletal pain (P < 0.001), 56% vs. 44% reporting fatigue (P = 0.003), 77% vs. 53% reporting cerebral manifestations (P < 0.001), 51% vs. 34% reporting sensorineural impairments (P < 0.001), 18% vs. 13% reporting digestive complaints (P = 0.06), and 38% vs. 32% reporting skin involvement (P = 0.13). The mean delay between infection and interview was two years (range, 15-34 months). Analysis of data after correction for age, gender, body mass index and comorbidity indicated that rheumatic pain, fatigue, cerebral manifestations and sensorineural impairments were more likely in CHIK+ than CHIK- subjects but the likelihood of digestive and skin manifestations was the same. CONCLUSION: With a mean delay of two years after infection, 45% to 77% of CHIK+ subjects reported prolonged or late-onset symptoms attributable to CHIK-v. These results indicate that persistent manifestations of chikungunya infection have a heavy impact on rheumatologic, neurological and sensorineural health.

[Coverage of the chikungunya epidemic on Reunion Island in 2006 by the French healthcare system]. / Prise en charge de l'épidémie de chikungunya de 2006 a l'île de la réunion par l'Assurance Maladie.

The chikungunya epidemic that occurred on Reunion Island between 2005 and 2006 was covered by the French health insurance system. This coverage involved a major increase in the number of paid sick leave days and prescription drug refunds in the first quarter of 2006. Special governmental measures such as full reimbursement of certain medications and waiving of the waiting period for sick leave in case of relapse greatly reduced the impact of the epidemic. Five years after, the database of the health insurance systems indicates a low incidence of chronic forms. Only cases managed on an outpatient basis were included in this study.

[Administrative issues linked to health insurance coverage of chronic post-chikungunya rheumatism]. / Aspects médico-administratifs nouveaux liés a la phase chronique du chikungunya.

The chikungunya outbreak on Reunion Island in 2005-2006 was followed by a high incidence of persistent arthralgia. A small group of patients developed chronic, sometimes destructive, post-chikungunya inflammatory rheumatism presenting as rheumatoid polyarthritis or spondylarthritis that required disease-modifying antirheumatic drugs such as methotrexate. We describe two patients under this treatment confronted with financial health insurance issues due to the lack of administrative recognition of post-chikungunya rheumatism as a long-term affliction or an occupational disease.

[Physiopathology of chronic arthritis following chikungunya infection in man]. / L'epidémie de chikungunya a La Réunion ou le parcours du combattant d'une elue de la République.

This article relates the problems initially encountered by an elected official of the French Republic in drawing the attention of authorities to the ravages of the chikungunya epidemic that occurred on Reunion Island in 2005-2006. Due to inadequate medical knowledge, the benign reputation of the disease, and slow reaction of authorities, the virus affected more than one third of the population. A great deal of further study will be needed to understand this public health crisis and to transform the lessons learned into a decisive breakthrough that will doubtless be of equal benefit for mainland France.

The Chikungunya epidemic on La Réunion Island in 2005-2006: a cost-of-illness study.

BACKGROUND: This study was conducted to assess the impact of chikungunya on health costs during the epidemic that occurred on La Réunion in 2005-2006. METHODOLOGY/PRINCIPAL FINDINGS: From data collected from health agencies, the additional costs incurred by chikungunya in terms of consultations, drug consumption and absence from work were determined by a comparison with the expected costs outside the epidemic period. The cost of hospitalization was estimated from data provided by the national hospitalization database for short-term care by considering all hospital stays in which the ICD-10 code A92.0 appeared. A cost-of-illness study was conducted from the perspective of the third-party payer. Direct medical costs per outpatient and inpatient case were evaluated. The costs were estimated in Euros at 2006 values. Additional reimbursements for consultations with general practitioners and drugs were estimated as € 12.4 million (range: € 7.7 million-€ 17.1 million) and € 5 million (€ 1.9 million-€ 8.1 million), respectively, while the cost of hospitalization for chikungunya was estimated to be € 8.5 million (€ 5.8 million-€ 8.7 million). Productivity costs were estimated as € 17.4 million (€ 6 million-€ 28.9 million). The medical cost of the chikungunya epidemic was estimated as € 43.9 million, 60% due to direct medical costs and 40% to indirect costs (€ 26.5 million and € 17.4 million, respectively). The direct medical cost was assessed as € 90 for each outpatient and € 2,000 for each inpatient. CONCLUSIONS/SIGNIFICANCE: The medical management of chikungunya during the epidemic on La Réunion Island was associated with an important economic burden. The estimated cost of the reported disease can be used to evaluate the cost/efficacy and cost/benefit ratios for prevention and control programmes of emerging arboviruses.

[Public health surveillance and assessment of emerging infectious threats: method and criteria for risk analysis]. / Veille sanitaire et appréciation du risque infectieux émergent: méthode et critères d'analyse du risque.

One of the objectives of the surveillance systems implemented by the French National Institute for Public Health Surveillance is to detect communicable diseases and to reduce their impact. For emerging infections, the detection and risk analysis pose specific challenges due to lack of documented criteria for the event. The surveillance systems detect a variety of events, or "signals" which represent a potential risk, such as a novel germ, a pathogen which may disseminate in a non-endemic area, or an abnormal number of cases for a well-known disease. These signals are first verified and analyzed, then classified as: potential public health threat, event to follow-up, or absence of threat. Through various examples, we illustrate the method and criteria which are used to analyze and classify these events considered to be emerging. The examples highlight the importance of host characteristics and exposure in groups at particular risk, such as professionals in veterinarian services, health care workers, travelers, immunodepressed patients, etc. The described method should allow us to identify future needs in terms of surveillance and to improve timeliness, quality of expertise, and feedback information regarding the public health risk posed by events which are insufficiently documented.

Perceived morbidity and community burden after a Chikungunya outbreak: the TELECHIK survey, a population-based cohort study.

BACKGROUND: Persistent disabilities are key manifestations of Chikungunya virus (CHIKV) infection, especially incapacitating polyarthralgia and fatigue. So far, little is known about their impact on health status. The present study aimed at describing the burden of CHIKV prolonged or late-onset symptoms on the self-perceived health of La Réunion islanders. METHODS: At 18 months after an outbreak of Chikungunya virus, we implemented the TELECHIK survey; a retrospective cohort study conducted on a random sample of the representative SEROCHIK population-based survey. A total of 1,094 subjects sampled for CHIKV-specific IgG antibodies in the setting of La Réunion island in the Indian Ocean, between August 2006 and October 2006, were interviewed about current symptoms divided into musculoskeletal/rheumatic, fatigue, cerebral, sensorineural, digestive and dermatological categories. RESULTS: At the time of interview, 43% of seropositive (CHIK+) subjects reported musculoskeletal pain (vs 17% of seronegative (CHIK-) subjects, P < 0.001), 54% fatigue (vs 46%, P = 0.04), 75% cerebral disorders (vs 57%, P < 0.001), 49% sensorineural impairments (vs 37%, P = 0.001), 18% digestive complaints (vs 15%, P = 0.21), and 36% skin involvement (vs 34%, P = 0.20) on average 2 years after infection (range: 15-34 months). After controlling for confounders such as age, gender, body mass index or major comorbidities in different Poisson regression models, 33% of joint pains were attributable to CHIKV, 10% of cerebral disorders and 7.5% of sensorineural impairments, while Chikungunya did not enhance fatigue states, digestive and skin disorders. CONCLUSIONS: On average, 2 years after infection 43% to 75% of infected people reported prolonged or late-onset symptoms highly attributable to CHIKV. These manifestations carry a significant burden in the community in the fields of rheumatology, neurology and sensorineural health.

[Health alert management and emerging risk]. / Gestion des alertes sanitaires et risque émergent.

Following health crisis that have occurred in the nineties (contaminated blood, mad cow, asbestos, etc.) and more recently those generated by the heat wave in 2003 or by emerging infectious pathogens (SARS, West Nile, Chikungunya, H5N1, H1N1…), a real health vigilance system has been progressively developed in France. After a brief historical overview of the health alert system, this article will give the guiding principles of its current organization in France and will present two examples of recent health alerts (Chikungunya in the Reunion Island in 2005-2006 and hepatitis A outbreak in the Côtes-d'Armor in August 2007), that have needed the implementation of preventive measures regarding the blood donor selection. These two examples have shown that the position of the alert in the French health vigilance system needs to be very close to the event. In that case, health alert is a very useful tool for decision making especially when measures have to be taken to prevent transfusion-transmitted pathogens.