Chikungunya: Number of Cases Continue to Grow in the Country

The high vector density, the presence of susceptible individuals and the intense circulation of people in endemic areas are some of the factors that contribute to the transmission

Imagine neurosurgeons unable to hold a scalpel or musicians unable to play their instruments. Chikungunya, in addition to posing a major threat to public health, causes temporary disability that can leave many professionals unable to work. These are not the only complications, since half of the cases evolve to the chronic form of the disease, in which pain and inflammation last for more than three months.

After a while unnoticed since its discovery in the 1950s, the Chikungunya virus (CHIKV) reemerged during in the late 1900s, accounted for large outbreaks and epidemics in Africa and Asia. After 2005 it quickly spread through the Southeast islands in the Indian Ocean and in late 2013 emerged in the Americas. In 2014, over a million cases were reported int he three Americas, most of them in the Caribbean. In Brazil, autochthonous transmission was confirmed in the second semester of 2014, first in Amapá and Bahia states, and then all states reported the occurrence of autochthonous cases. The high vector density, the presence of susceptible individuals and the intense circulation of people in endemic areas are some of the factors that contribute to the transmission.

Chikungunya fever has become a major public health problem in countries where epidemics occur, as half of the cases develop chronic, persistent and disabling arthritis. Infectious diseases expert, physician Dr. Kleber Giovanni Luz, professor at the Infectious Diseases Department of the Federal University of Rio Grande do Norte (UFRN) and director of the Brazilian Society of Infectology (SBI), remembers that the virus, considered an arthritogenic virus, currently responsible for epidemics in Asia and in the Americas, is still causing relevant outbreaks in Rio de Janeiro and Rio Grande do Norte. He explains that the main clinical characteristic of the virus is to cause an acute febrile disease followed by or accompanied by debilitating articular pains. Besides the pain, other more severe clinical manifestations can occur possibly causing worse evolutions with death, especially in the elderly. These deaths could have been a result of the virus’ direct action, the decompensation of a basis disease or even severe side effects caused by the drugs necessary for the treatment of the disease.

The clinical course of the disease should be divided into acute, post-acute and chronic phase. The acute phase is considered from the first day of the disease until the twenty-first day; the post-acute from the twenty-first day to the ninetieth day and the period of chronicity after the 91st day of the disease. “In all these periods, osteoarticular involvement may be present and have significant importance, and its proper management is fundamental to avoid greater suffering of patients. Establishing a multidisciplinary team is critical. Collaborative and integrated work among general practitioners, infectologists, and rheumatologists, as well as physiotherapists, psychologists, and social workers, among others, is vitally important, as isolated work will certainly yield few results. The use of dipyrone or paracetamol analgesics, often in maximum doses as for example, is also indicated”, says Dr. Kléber

Regarding musculoskeletal injuries secondary to chikungunya virus, Dr. Claudia Marques, Assistant Professor of Rheumatology at the Federal University of Pernambuco (UFPE) and part of the Brazilian Society of Rheumatology (SBR), points out that not all patients have lesions. “Its actually chronic musculoskeletal symptoms (>3 months) after CHIK infection. To understand treatment, one needs to know that there are two types of patients with post-CHIK chronic musculoskeletal symptoms. The first group includes patients with painful symptoms, but with no articular inflammation, and holds most of the cases (95%), and the other group includes those with articular inflammation, which evolves similarly to rheumatoid arthritis. In the first case, the treatment is basically held with common painkillers, anti-inflammatory drugs and more importantly, physical activity and physical therapy. In patients with symptoms of inflammatory disease, the treatment is basically the same as inflammatory joint diseases, such as rheumatoid arthritis”, details Dr. Claudia.

Professor Fabrice Simon, National Consultant for Infectious Diseases and Tropical Medicine in the French Army and Senior Consultant in chikungunya at the Pan American Health Organization (PAHO/WHO), emphasizes that everyone should understand that chikungunya is different from dengue. “There are two diseases in one. For most adults, the disease is twofold. It begins with a brutal fever and acute pain for 7 to 10 days, characterized by polyarthralgia and multiple arthritis. In many cases (more than half), rheumatic problems last for several months and even years, associated with lasting fatigue and poor quality of life. However, each patient has their post-CHIKV status and follow-up should be individualized”, he explains.

Briefly, there are two types of patients with post-CHIKV rheumatic disorders: the first comprises the vast majority of patients suffering from multiple musculoskeletal disorders that accumulate after the disease: tendonitis, fasciitis, bursitis, muscle contractions but no synovitis, and they will not develop destructive rheumatism, but unfortunately is uncomfortable during routine activities. “Across the clinical spectrum, we have a small group, usually women and the elderly, who unfortunately develop chronic inflammatory rheumatism with synovitis that can eventually damage some joints (commonly hands and wrists) like rheumatoid arthritis.

According to the French specialist, many patients report problems at home and at work, but rarely seek medical attention because they mistakenly believe there is no treatment. “The follow-up of patients with post-CHIKV disorders requires steps: a nosological diagnosis based on good clinical evaluation (requires training of physicians to locate key points), initial pre ion of what I call a treatment kit (painkillers, anti-inflammatories and physiotherapy) for at least 4 to 6 weeks and rheumatologist counseling for patients with red alerts (synovitis, hand involvement, refractory cases, corticoid dependence)”, he describes. These principles should be applied as soon as possible after the acute stage of the disease but can be effective even months after the disease. “The principle of this strategy is to progressively lift patients out of distress and ensure a better quality of life. Clinical response should be assessed by the patients words, not by biological or imaging tests”, adds Dr. Fabrice.

In Brazil, the current treatment protocols used to treat chronic musculoskeletal conditions are those of the Brazilian Society of Rheumatology and the Ministry of Health. There are limited data in the literature on specific therapies in the various stages of arthropathy caused by chikungunya virus (CHIKV) infection, and there are no quality randomized trials evaluating the effectiveness of different therapies. There are a few publications on the treatment of musculoskeletal manifestations of chikungunya fever, but with important methodological limitations. The available data do not allow conclusions favorable or contrary to specific therapies, as well as an adequate assessment of the superiority between the different medications employed. There are no clinical studies showing the best treatment for post-Chikungunya pain syndrome, and there are no well-defined protocols on the use of different anti-inflammatory and analgesic drugs. The Recife Health Secretariat has launched a protocol that also includes a model questionnaire to assess pain intensity. Any suspected case of chikungunya should be reported to the epidemiological surveillance service, according to the flow established in each municipality. According to Annex of Ordinance No. 204/2016, Chikungunya Fever is a Compulsory Notification complaint and suspicious cases must be reported and registered in the Diseases Report System (SINAN).

In France, more than half a million patients have been infected since the 2005-2006 outbreak on Réunion Island. Dr. Fabrice says that they faced the clinical challenge of post-CHIKV chronicity and proposed the first protocols for treating the most enduring symptoms. These protocols, as well as others, such as Brazilians (which will be briefly updated), are available on the Internet, explaining the recommendations for better monitoring of both categories of patients. “We know that treatment should be focused on pain, joint stiffness, fatigue and physical load, with progressive reconditioning. This strategy should be practiced by patients and their families, with nursing support, general practitioners and physiotherapists together. The goal is to break the cycle of pain & stiffness, motor limitation, atrophy of social life and sadness”, he points out while saying that in France, a project will soon be started in Guadeloupe (2014-2015 outbreak) to accompany patients with prolonged post-CHIKV disorders. “I am convinced that most patients have good progression through simple home care, without the need for hospitals. We have to do this, as there is no magic potion for them for years to come. Public health officials should bet on this hopeful strategy to break the burden of chikungunya that is far worse than dengue”, concludes the French doctor.

Replick Network

The Chikungunya Clinical and Applied Research Network (Replick), launched in May, aims to follow a cohort of 2,000 patients from diagnosis to clinical management, consolidating data and experiences successfully implemented in the Unified Health System (SUS) to improve the protocols, mitigating the impacts of the disease on the health of the population. The Network is an articulated group that can serve as a model for other actions in the country. Replick involves professionals from 25 research and teaching institutions in nine Brazilian states, such as physicians (infectologists, rheumatologists and clinicians), nurses, pharmacists, biologists, economists, social scientists, among others. The initiative is the result of a partnership between the Evandro Chagas National Institute of Infectious Diseases (INI/Fiocruz), the Ministry of Health and the Pan American Health Organization (PAHO/WHO).…