Chikungunya Virus Infections and Children
Chikungunya Virus Infections and Children
Abstract & Commentary
By Philip Fischer, MD, DTM&H
Professor of Pediatrics, Division of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
Dr. Fischer reports no financial relationship relevant to this field of study.
Synopsis: Chikungunya virus infection is usually self-limited with acute fever but potentially prolonged arthralgia. An epidemic has been raging around the Indian Ocean for more than a year. There is new evidence that the epidemic is associated with increases in death rates. Anyone, including travelers and pre-born children, may be affected.
Source: Josseran L, et al. Chikungunya disease outbreak, Reunion Island. Emerg Infect Dis. 2006;12:1994-1995.
Since early 2005, approximately one-third of the 770,000 people living on Reunion Island, a French territory in the Indian Ocean, have become ill with Chikungunya virus-associated disease. Even by early 2006, 18% of pregnant women had evidence of recent infection. While the illness is usually self-limited with acute fever and arthralgia, the crude death rate has been elevated significantly above expected levels in recent months. The death rate has been particularly increased in persons older than 75 years. While death has not been seen often during Chikungunya disease, the increase in death rate raises the possibility that "Chik" can be a fatal disease.
Commentary
Chikungunya virus infections became common on Indian Ocean islands and in areas bordering the Indian Ocean during 2005 and 2006. The infection became prevalent on Reunion Island during January 20061 and has gone on to affect more than 30% of the residents of that island. Widespread cases have been reported in other areas including India. As reported in last month's Travel Medicine Advisor2 and in the medical literature3, cases have increasingly been reported in returned travelers. As noted by Josseran, and as suspected by others1,Chikungunya can contribute to increased death rates, especially in older people with other medical problems.
Anyone bitten by infected Aedes mosquitoes may develop the illness. Interestingly, however, children seem to be less affected than older individuals, with 4% of cases on Reunion Island being seen in individuals more than 65 years old, and only 1% of cases being seen in those less than 30 years of age.1
Vertically transmitted infection, however, has been reported.1 In fact, 3 miscarriages prior to 22 weeks of gestation have been linked to Chikungunya virus infections.4 When women are viremic at delivery, approximately half of thenewborns present with neonatal disease; none of 188 offspring of women who had cleared their viremia by the time of delivery showed clinical illness.4 Women traveling internationally during pregnancy expose their developing babies to several infectious risks, and preventive interventions may decrease the risk of adverse outcomes.5
Since Denis Burkitt's pioneering work in Uganda 5 decades ago, we have grown to understand that some childhood cancers (including the lymphoma that bears Burkitt's name) result from multiple "hits" on the immune system. Traditionally, Burkitt's lymphoma was found to occur when malaria-stimulated lymphocytes were further provoked by Epstein Barr virus infection. Recently, a "3 hit" hypothesis was proposed — children with Burkitt's lymphoma in Malawi, where both malaria and Epstein Barr virus infection are common, were more likely to be seropositive for Chikungunya (69%) than were hospital (47%) or local (51%) controls.6
Thus, while children seem to be less affected by Chikungunya virus infection than are adults, and especially older adults, some children do become sick during these infections. Some affected fetuses don't survive until delivery, and others are sick during the early weeks of life. Infection among older children may predispose to an increased risk of subsequent malignancy. So, children are affected by the problem of Chikungunya virus infection, but can they also be part of the solution? Yes! In India, school children have been recruited as "health ambassadors" to go door-to-door providing community education directed at controlling the spread of Chikungunya disease.7 Indeed, careful attention to avoidance of mosquito bites, by using clothing, insect repellant on exposed skin, and permethrin treatment of clothes, can reduce the risk of acute infection and potentially debilitating chronic joint pains.
References:
- Cordel H. Chikungunya outbreak on Reunion: update. Euro Surveill. 2006;11:E060302.3.
- Shenoi S, Shaw A. Fever, rash and severe arthralgias on return from India. Travel Medicine Advisor. 2007; 17:1:1-3.
- Krastinova E, et al. Imported cases of chikungunya in metropolitan France: update to June 2006. Euro Surveill. 2006;11:E060824.1.
- Lenglet Y, et al. Chikungunya infection in pregnancy: evidence for intrauterine infection in pregnant women and vertical transmission in the parturient - survey of the Reunion Island outbreak. J Gynecol Obstet Biol Reprod. 2006;35:578-583.
- Fischer PR, et al. Congenital infections associated with international travel during pregnancy. J Travel Medicine. 2007;in press.
- van den Bosch C, et al. Chikungunya fever as a risk factor for endemic Burkitt's lymphoma in Malawi. Trans R Soc Trop Med Hyg. 2000;94:704-705.
- Staff Reporter. Children to spread awareness of chikungunya. The Hindu online edition of India's national newspaper. September 16, 2006. http://www.hindu.com, accessed 12-19-06.
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