Chikungunya in the western hemisphere: a review of the 2014 epidemic, the potential long-term impact, and research opportunities

OBJECTIVE: The objective of this paper is to present a comprehensive review of the impact of the recent chikungunya virus outbreaks in island nations, including the Caribbean, and explore the potential for further study of the epidemiology and pathogen-host interactions of this emerging virus. DESIGN AND METHODS: We conducted a review of the current literature and data on multiple facets of chikungunya including: acute disease outbreaks, epidemiological and clinical data, comparisons of diagnostic techniques, and virologic strains. RESULTS: Outbreaks of chikungunya (CHIKV) on island nations have seen high attack rates with corresponding increased morbidity and mortality. Severe, persistent and relapsing arthritis and tenosynovitis is common among chikungunya patients. CONCLUSION: Comprehensive surveillance of chikungunya virus is required by the linking of epidemiologic, molecular and immunologic data with information on ecological patterns and vector prevalence if the incidence of chikungunya is to be reduced and prevented. More data on the disease spectrum and persistence in the Caribbean nations, the viral strain, and the incidence rates are sorely needed. Because CHIK can only be prevented by preventing mosquito bites, more research needs to be done locally in Caribbean nations to determine the optimal strategies of Aedes vector control and public health education with subsequent behavior change.

Clinical, molecular and serological outcomes of the Chikungunya outbreak in Grenada

OBJECTIVE: This study evaluated the clinical utility of Chikungunya (CHIKV) test results and clinical symptoms in patients with suspected CHIKV infection. DESIGN AND METHODS: Patients with CHIKV symptoms who presented at a health facility in Grenada during the recent outbreak had a CHIKV diagnostic test form completed by a health professional and a blood sample was drawn. The serum sample was stored at -80oC, shipped to the Naval Infectious Diseases Diagnostic Lab (NIDDL) on dry ice and tested for CHIKV and Dengue (DENV) using PCR real-time assay for viral RNA, and IgM detection by ELISA. RESULTS: Sera from more than 600 patients collected from mid September till mid October, 2014 were drawn and had a CHIKV diagnostic form completed. At the time of writing 112 patients sera have been tested at the NIDDL. 90% of patients had a positive test. PCR only was positive in 8% of patients. IgM only was positive in 83%, and both PCR and IgM were positive in 9% of patients. The major symptoms presented by patients were joint pain (84%), fever (81%), body pain (74%), headache (62%), chills (54%) and rash (49%). CONCLUSION: IgM testing detected 92% of test positive patients while PCR alone detected 17%. The IgM assay was clinically most useful. In an outbreak where dengue is ruled out and CHIKV is the cause, patients with the constellation of symptoms above could be considered positive for CHIKV infection with a 98% accuracy without confirmatory testing.

Lessons learnt from the intense 2014 Chikungunya Epidemic in Grenada

OBJECTIVE: To present an overview of the lessons learnt from the fall 2014 outbreak of Chikungunya (CHIK) in Grenada. DESIGN AND METHODS: A review of newspaper articles, news reports and opinions of clinicians and policy makers on the impact and evolution of the CHIK outbreak in Grenada was conducted. RESULTS: CHIK outbreaks on small island developing nations are characterized by high attack rates. The speed of the spread of the virus is facilitated by the efficient domesticated diurnal vector species Aedes aegypti. Efforts to educate the public and to control this vector stretched resources. Clinical attack rates in the Grenada outbreak impacted manpower resources in every sector including clinical services. CONCLUSION: CHILK infected an estimated 60% of the population in just three months of intense transmission. The resulting morbidity meant that essential lessons were learnt. These included the need for a rapid response in educating the population on the mode of transmission of the virus and its prevention, the implementation of vector control and the demand for diagnostic tests. Essential services were short staffed. The need for an unprecedented rapid response and the impact of the CHIK outbreak in Grenada will be presented.

Introduction of a simulation laboratory to preclinical students at St. George's University in Grenada

OBJECTIVE: To investigate the use of high fidelity simulation mannequins in improving competence and confidence levels of medical students to recognize cardiac and lung sounds. Study design: Observational study. SUBJECTS and METHODS: The students took a pre-test evaluating their ability to recognize cardiac and respiratory sounds. They then rotated through three clinical scenarios using simulation mannequins. They were then given a post-test. Both prior to, and following the session the students completed a Likert scale on their comfort in recognizing the sounds. The pre- and post-test scores were compared. RESULTS: There was a significant improvement in the students' ability to recognize cardiac and respiratory sounds (p<0.0001), as well as in their comfort levels (p<0.0001). Overall, 80% of the studnets felt more comfortable in their ability to recognize the sounds, 17% felt the same and 3% felt less comfortable. CONCLUSION: Use of simulation mannequins improves medical students' abilities, as well as comfort in recognizing cardiac and respiratory sounds.

N,N dimethylglycine and epilepsy.

Nineteen institutionalized patients with frequent seizures (group average two to three per day; seizure types--generalized, akinetic/myoclonic), were treated randomly with either placebo or N,N dimethylglycine (DMG) for 28 days. Dosage was 300 mg/day for the first 14 days and then 600 mg/day. Plasma levels were measured at baseline, days 2, 5, 8, 15, 22, 30, and 1 and 2 weeks after the study ended. No differences in seizure frequency were noted between placebo and DMG or between baseline and test conditions. No toxicity was noted.

The dexamethasone suppression test in depressed retarded adults: preliminary findings.

This study was undertaken to determine the utility of the Dexamethasone Suppression Test (DST) for diagnosing depression in institutionalized mentally retarded persons. Depressed and nondepressed institutionalized mentally retarded persons were given 1 mg dexamethasone for an overnight DST. Serum cortisol concentrations greater than 4 micrograms/dl at both 8:00 AM and 4:00 PM provided discrimination of depressed from nondepressed groups. Also, using the criteria of serum cortisol concentrations greater than 4 micrograms/dl at 8:00 AM and 4:00 PM, at 4:00 PM and 10:00 PM, or at 8:00 AM, 4:00 PM, and 10:00 PM differentiated these groups. These results suggest that the DST may be useful for detecting melancholia among institutionalized retarded persons.

Drug treatment: factors contributing to high risks in institutions.

Because of the widerspread use of drugs in the treatment of exceptional children, investigators are currently studying the efficacy, suitability and safety of the drugs employed. This paper deals with an aspect of pharmacological management which has been largely neglected in the literature: the administration of prescribed drugs. Focusing on the institutional setting, the following three factors contributing to high risk of drug error or misuse, are delineated: (1) Staff training and sophistication, (2) Number and complexity of drugs employed and (3) Vulnerability of the exceptional child. An attempt is made to state and clarify these issues, to report some preliminary programs which appear to be effective, and to offer some concrete suggestions for persons who are involved in the pharmacological management of exceptional children.