Journal of Global Infectious DiseasesOfficial Publishing of International Infectiologists Network Users online:9  
Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size     
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
 


 
   Table of Contents     
ORIGINAL ARTICLE  
Year : 2011  |  Volume : 3  |  Issue : 3  |  Page : 221-226
Clinical profile of chikungunya patients during the epidemic of 2007 in Kerala, India


Department of Community Medicine, Government Medical College, Thiruvananthapuram, Calicut, Kerala, India

Click here for correspondence address and email

Date of Web Publication6-Aug-2011
 

   Abstract 

Background: The association of the present Chikungunya pandemic with a mutation in the Chik virus is already established in many parts of the world, including Kerala. Kerala was one of the worst-affected states of India in the Chikungunya epidemic of 2006-2007. It is important to discuss the clinical features of patients affected by Chikungunya fever in the context of this change in the epidemiology of the disease. Aim: This study tries to analyze the clinical picture of the Chikungunya patients in Kerala during the epidemic of 2007. Setting and Design: A cross-sectional survey was carried out in five of the most affected districts in Kerala, India. Materials and Methods: A two-stage cluster sampling technique was used to collect the information. Ten clusters each were selected from all the five districts, and the size of the clusters were 18 houses each. A structured interview schedule was used for data collection. Diagnosis based on clinical signs and symptoms was the major case-finding strategy. Results and Conclusion: Of the 3623 residents in the surveyed households, 1913 (52.8%) had Chikungunya clinically. Most of the affected were in the adult age group (73.4%). Swelling of the joints was seen in 69.9% of the patients, followed by headache (64.1%) and itching (50.3%). The knee joint was the most common joint affected (52%). The number of patients with persistence of any of the symptoms even after 1 month of illness was 1388 (72.6%). Taking bed rest till the relief of joint pain was found to be a protective factor for the persistence of the symptoms. Recurrence of symptoms with a period of disease-free interval was complained by 669 (35.0%) people. Older age (>40 years), a presentation of high-grade fever with shivering, involvement of the small joints of the hand, presence of rashes or joint swelling during the first week of fever and fever lasting for more than 1 week were the significant risk factors for recurrence of symptoms predicted by a binary logistic regression model. In conclusion, we found that there is substantial acute and chronic morbidity associated with the Chikungunya epidemic of 2007.

Keywords: Chikungunya, Clinical feature, Epidemic, India, Kerala

How to cite this article:
Vijayakumar KP, Anish TS, George B, Lawrence T, Muthukkutty SC, Ramachandran R. Clinical profile of chikungunya patients during the epidemic of 2007 in Kerala, India. J Global Infect Dis 2011;3:221-6

How to cite this URL:
Vijayakumar KP, Anish TS, George B, Lawrence T, Muthukkutty SC, Ramachandran R. Clinical profile of chikungunya patients during the epidemic of 2007 in Kerala, India. J Global Infect Dis [serial online] 2011 [cited 2015 Mar 5];3:221-6. Available from: http://www.jgid.org/text.asp?2011/3/3/221/83526



   Introduction Top


Chikungunya is described as an acute illness, with fever, skin rash and incapacitating arthralgia. [1] Arthralgia is the salient feature of Chikungunya that distinguishes it from Dengue, which otherwise shares the same vectors, symptoms and geographical distribution. [2] The disease itself is rarely fatal [3] and is sometimes confused with Dengue, O'nyong-nyong or Sindbis virus infection. [4] Typical features of the disease include abrupt, massive outbreaks with a high attack rate [5],[6] followed by slow decline of cases as herd immunity develops. [7],[8],[9]

In India, the first Chikungunya outbreak was recorded in Calcutta in1963, [10] followed by multiple epidemics in different parts of the country till 1973. [11],[12],[13] Because of its long absence since 1973, it was postulated that the Chikungunya virus had disappeared from the Indian subcontinent and from South-East Asia. [14],[15] However, the epidemic resurfaced in December 2005, [16] with several states reporting massive outbreaks during the period 2005-2006. Thailand, Indonesia, Malaysia and Philippines [17],[18],[19],[20] also experienced a re-emergence of Chikungunya. Kerala, the southern state of India, was heavily affected by the pandemic during 2006-2007. The viruses isolated in Kerala in the latter part of 2007 were shown to have undergone an A226V mutation. [21] It was postulated that this mutation was associated with the increased virulence of Chikungunya in reunion islands [22],[23] and in the Indian subcontinent. [24]

The clinical onset of Chikungunya is abrupt, with high fever, headache, back pain, myalgia and arthralgia after a short incubation period of 2-4 days. [25] The symptoms generally resolve within 7-10 days, except for joint stiffness and pain. Fever and arthralgia have been reported in all patients with Chikungunya in the epidemics reported recently in India and in the reunion islands. [26],[27],[28] Erratic, relapsing and incapacitating arthralgia is the hallmark of Chikungunya, affecting the extremities (ankles, wrists, phalanges) mainly but targeting the large joints as well. [25],[26],[27],[28] Joints appear normal radiologically, and the biological markers of inflammation are either normal or moderately elevated. [29],[30] There are a few precise descriptions of Chikungunya virus-associated joint disorders, and the underlying mechanism is unknown. [29],[30] Skin involvement is present in a significant number of cases, and consists of maculopapular rash, facial edema, bullous eruptions with pronounced sloughing, localized petechiae and bleeding gums (mainly in children). [25],[26],[27]

The association of the present Chikungunya pandemic with a mutation in the Chik virus is already established in many parts of the world, including Kerala. [21],[22] But, the extent of contribution of this mutation to the epidemiology of this Chikungunya outbreak is an issue of debate. This study tries to analyze the clinical picture of the Chikungunya patients in Kerala in the backdrop of the possible presence of the virulent type of virus (A226V mutation).


   Materials and Methods Top


A cross-sectional survey was conducted during October-November, 2007, in the five districts of Kerala, namely Kollam, Alappuzha, Kottayam, Pathanamthitta and Idukki. These five districts were among the worst hit during the 2007 epidemic. A two-stage sampling technique was used to collect the information. From each district, 10 panchayaths (jurisdiction of Local Self Governments) were selected at random (Lot method). A cluster consisting of 18 houses from each panchayath was selected for the study. The area most heavily affected with Chikungunya fever was found out with the help of the heads of the panchayaths and primary health centers (the Department of Health under the jurisdiction of Local Self Governments). From the area, the first house was selected arbitrarily and the next 17 houses were selected serially based on the distance shortest from the previous house.

The case definition of Chikungunya used for including patients in the study was "an attack of joint pain affecting more than one joint with appearance of fever within a period of two days prior to and two days after the onset of joint pain." The information about the infants and children was collected from their mothers. The inclusion of patients using a clinical case definition was carried out because of resource constraints. But, the predictive power of clinical diagnosis will be high during an epidemic because of an increased background prevalence of the disease. A study conducted by a multidisciplinary team from Medical College, Thiruvananthapuram, revealed that the positive predictive value of this case definition was as high as 82% during the epidemic when compared with IgM ELISA for Chikungunya.

A structured interview schedule was used for data collection. The tool was prepared by a group comprising of epidemiologists, entomologists and sociologists. The content validity of the questionnaire was assessed qualitatively with the help of entomologists, sociologists and epidemiologists in the Department of Community Medicine and the faculty of the Clinical Epidemiology Unit of Medical College, Thiruvananthapuram.

The data collection was carried out by household visits and by interviewing the patients. The data were collected by volunteers of the Kerala Sastra Sahitya Parishad (KSSP) who were trained in administering the questionnaire, selection of clusters and interview techniques. The KSSP volunteers were asked to collect information from 180 houses in each district (an overall sample size of 900). When the patients were not available during the house visit, the information was collected from their family members. The medical records of the patients were also used to ensure the consistency of the data. The questionnaires were collected back after verifying all the entries.

Ethics

The study protocol was submitted to the ethical committee of the KSSP and ethical approval was obtained. The study was carried out in consultation with the local Panchayath heads. The written informed consent of the head of the family was obtained before the commencement of the interview. Consent was obtained from the patient if he/she was available at the time of the interview. Information was collected from children below 12 years of age with the consents of the parents.

Statistical analysis

Frequencies and proportions were used to interpret the data. Chi-square test and t-test were used to interpret the statistical significance of associations and Odd's ratio (OR) with 95% Confidence interval (CI) was used to estimate the strength of association between the dichotomous variables. Adjusted OR with 95% CI for the risk factors of recurrence of Chikungunya was obtained by logistic regression.


   Results Top


Of the total 900 households from which information was collected, 43 (4.8%) were excluded from the final analysis as the data were incomplete. In the 857 households included in the study, there were 3623 members, with the average family size being 4.23 persons. The number of people affected with Chikungunya fever as per the case definition was 1913 (52.8%). Mean age standard deviation of these patients was 40.25 (18.76) years. Women constituted (50.6%) 969 of these patients. The age distribution of the affected people is shown in [Table 1]. Most of the affected were in the adult age group (73.4%), and 11% of the cases occurred in persons <15 years of age.
Table 1: Age distribution of the affected subjects

Click here to view


Fifty-two percent of the patients reported fever along with joint pain as the initial symptom. Fever alone (without joint pain) and joint pain alone (without fever) were seen as the initial symptoms in 31.1% and 16.9% of the patients, respectively. Patients having fever alone as the initial symptom were younger (t=6.48, df=1911, P< 0.001) compared with those presenting initially with joint pain alone. The distribution of the first symptom against age is given in [Table 2].
Table 2: First appearance of symptoms with respect to the age categories

Click here to view


Major symptoms during the first week of the disease are presented in [Table 3]. Fever and joint pain were seen in all the patients included in the study because these were a part of the case definition. Swelling of joints was seen in 69.9% of the patients, being closely followed by head ache (64.1%) and itching (50.3%). The distribution of symptoms was not significantly different across the gender groups. Persistence of joint pain even after the first week of illness was present in 74.8% of the males and in 70.5% of the females. This difference was found to be statistically significant (P=0.035).
Table 3: Major symptoms in the first week of illness*

Click here to view


More than 52% of the subjects had involvement of the knee joints, while 8.1% had shoulder joint involvement. The frequency of different joint involvement is shown in [Table 4]. Shoulder joint was affected in 9.7% of the women compared with 6.4% among the men (P=0.007). There is no significant gender difference in the case of the other joints.
Table 4: Pattern of joint involvement

Click here to view


The number of patients with persistence of any of the symptoms even after 1 month of illness was 1388 (72.6%). Persistence of a symptom means that there is no disease-free interval during a period of 1 month from the appearance of the first symptom. Common persistent symptoms after 1 month of illness are shown in [Table 5]. The persistence of symptoms was an unusual presentation in case of children. Children often presented with fever without joint pain [Table 2], and the joint pain developed was not persistent. Taking bed rest till the joint pain subsided was found to be a protective factor (OR [95% CI=0.19 [0.13-0.28]], P<0.001) from the persistence of the symptoms [Table 6]. People already having any debilitating illness that hindered their ambulation were excluded from this analysis. The data of preschool children (<5 years) were also not included because the interviewers could not document their daily activities, including the hours spent in bed.
Table 5: Persistent symptoms

Click here to view
Table 6: Taking rest and persistence of symptoms

Click here to view


Recurrence of symptoms with a period of disease-free interval was complained by 669 (35.0%) people. According to the binary logistic regression, those people with age more than 40 years, those who presented with fever associated with shivering, rashes or joint swelling in the first week of the illness, those who had fever that did not subside within 1 week and those with small joints of hands affected by the illness were found to be prone for recurrence of symptoms [Table 7].
Table 7: Significant determinants for recurrence of Chikungunya fever

Click here to view



   Discussion Top


It is well documented that the environmental factors of Kerala are still favoring an outbreak of arboviral disease. [31] Because of the lack of specific symptoms, often, Chikungunya infection cannot be differentiated from Dengue fever or Leptospirosis. [32] This study tried to identify the key clinical features and sociodemographic profile of patients affected with Chikungunya in Kerala, South India, along with factors associated with recurrence. The majority of the patients in this study were in the 15-59 year age group. Only 11% of the cases were children below 15 years, which is very low compared with the population proportion (21.4%). [32] More than 15% of the affected people were elderly, with an age of 60 years or above, but the population proportion of this age group is 11%. [33] This difference in the clinical spectrum with respect to the age group has been documented in other studies also. [34] The causal mechanism of this age shift may be immunological or sociocultural. Factors including occupation and clothing habits may have an influence on the disease pattern. The age and gender profile of cases was similar to that reported in other epidemics in India [25],[33] and reunion islands. [26] Nearly 2/3 rd of the patients were found to spend most of their time indoors - either in their home or workplace - during the daytime. This pattern could be explained by the fact that the breeding places of Aedes mosquitoes are either domestic or peridomestic, and that the flight ranges of these mosquitoes are short. [35]

Unlike many other reported epidemics of Chikungunya in India and in the reunion islands, [25],[26],[27] the current study found that fever was the most common initial symptom among children <15 years of age. As age increased, more people presented with joint involvement as the initial symptom. Among the >60 years age category, 77% had joint involvement as the first symptom. Swelling of the joints was very high (69.3%) compared with other epidemics in India. [25],[33] The percentage of Chikungunya patients reporting rashes in the current study was similar to those of other Indian epidemics, [23] while it was lower compared with the epidemics in reunion island. [24],[27] Headache, vomiting and diarrhea were seen in a higher proportion compared with other epidemics. [22],[23],[24],[25],[26],[27] Ulcers in the mouth (20%) or in the body (7.3%) were present in a significant fraction. Approximately 22% of the patients had redness of the eye, which makes Leptospirosis a common differential diagnosis. Unlike the previous reports, 50.3% of the Chikungunya patients in our study reported itching as a predominant symptom in the first week of illness.

Nearly 3/4 th of the subjects had recurrence of symptoms after at least 1 week of symptom-free interval thus contributing to the morbidity burden. Prolonged arthralgia was noted in other studies also. [34] Incapacitating joint involvement is considered to be the main culprit contributing to the chronic morbidity associated with Chikungunya.

Limitations of the study

The sampling technique used in this study is a two-stage cluster sampling. But, this may not be the appropriate sampling technique for this study since Chikungunya is a communicable disease that tends to cluster and, thereby, affect the estimation of prevalence. The cases had been included in the study based on a purely clinical definition and confirmation using IgM ELISA was not performed. Information collected could be incomplete because the subjects might have forgotten some details of the disease. This was minimized by correlating the history of the patients with the clinical case records. The case definition may have induced some underreporting of symptoms and signs in case of infants and children. The study includes only cases having newly developed joint pain and fever (case definition), which excludes the preexisting joint pain. But, other co-morbidities like diabetes and their impact on the symptomatic outcome were not quantified in the present study.

The volunteers were advised to collect information either directly from the patients or from the family member if the patient was not available physically. And, they were advised to triangulate the data with the help of medical records. The information collected from the surrogates may have contributed some bias.


   Conclusion Top


We found that there is substantial acute and chronic morbidity associated with the present Chikungunya epidemic. It has affected more than half of the population in the epidemic-hit areas. The proportion of patients with persistence of any of the symptoms even after 1 month of illness was 72.6%. Taking bed rest till the joint pain subsided was found to be a protective factor from the persistence of the symptoms. Recurrence of symptoms with a period of disease-free interval was complained by 35% of the people. According to the binary logistic regression, those people with age more than 40 years, those who presented with fever associated with shivering, rashes or joint swelling in the first week of the illness, those who had fever that did not subside within a week and those with small joints of the hands affected by the illness were found to be prone for recurrence of symptoms.


   Acknowledgement Top


We acknowledge the help rendered by Dr. S. Remadevi, Professor of Medical Sociology and Clinical Epidemiology Unit, Medical College, Thiruvananthapuram and Dr. P. B. Jayageetha, Assistant Professor, Biostatistics, Department of Community Medicine, Medical College, Thiruvananthapuram, for their valuable help in preparing the tool and in the statistical analysis. We would like to express our gratitude to the volunteers of the KSSP.

 
   References Top

1.Robinson MC. An epidemic of virus disease in Southern Province, Tanganyika Territory, in 1952-53. I. Clinical features. Trans R Soc Trop Med Hyg 1955;49:28-32.  Back to cited text no. 1
    
2.Carey DE. Chikungunya and dengue: A case of mistaken identity? J Hist Med Allied Sci 1971;26:243-62.   Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Fields BN, Knipe DM, Howley PM, editors. Fields' Virology. 3 rd ed. Philadelphia: Lippincott Raven Publishers; 1996.   Back to cited text no. 3
    
4.Harley D, Sleigh A, Ritchie S. Ross River virus transmission, infection, and disease: A cross-disciplinary review. Clin Microbiol Rev 2001;14:909-32.   Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Powers AM, Brault AC, Tesh RB, Weaver SC. Re-emergence of chikungunya and o'nyong-nyong viruses: Evidence for distinct geographical lineages and distant evolutionary relationships. J Gen Virol. 2000;81:471-9.   Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Padbidri VS, Gnaneswar TT. Epidemiological investigations of chikungunya epidemic at Barsi, Maharashtra state, India. J Hyg Epidemiol Microbiol Immunol 1979;23:445-51.   Back to cited text no. 6
[PUBMED]    
7.Laras K, Sukri NC, Larasati RP, Bangs MJ, Kosim R, Djauzi, et al. Tracking the re-emergence of epidemic chikungunya virus in Indonesia. Trans R Soc Trop Med Hyg 2005;99:128-41.   Back to cited text no. 7
[PUBMED]    
8.Mackenzie JS, Chua KB, Daniels PW, Eaton BT, Field HE, Hall RA, et al. Emerging viral diseases of southeast Asia and the western Pacific. Emerg Infect Dis 2001;7:497-504.   Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Mackenzie JS, Smith DW. Mosquito-borne viruses and epidemic polyarthritis. Med J Aust 1996;164:90-3.   Back to cited text no. 9
[PUBMED]    
10.Shah KV, Gibbs CJ, Banerjee G. Virological investigation of the epidemic of haemorrhagic fever in Calcutta: Isolation of three strains of Chikungunya virus. Indian J Med Res 1964;52:676-83.   Back to cited text no. 10
    
11.Rao TR. Recent epidemics caused by Chikungunya virus in India, 1963- 1965. Sci Cult 1966;32:215-20.   Back to cited text no. 11
    
12.Rodrigues FM, Patankar MR, Banerjee K, Bhatt PN, Goverdhan MK, Pavri KM, et al. Etiology of the 1965 epidemic of febrile illness in Nagpur city, Maharashtra State, India. Bull World Health Organ 1972;46:173-9.   Back to cited text no. 12
[PUBMED]  [FULLTEXT]  
13.Mourya DT, Thakare JP, Gokhale MD, Powers AM, Hundekar SL, Jaykumar PC, et al. Isolation of Chikungunya virus from aedes aegypti mosquitoes collected in the town of Yawat, Pune district, Maharashtra state, India. Acta Virol 2001;45:305-9.   Back to cited text no. 13
    
14.Pavri KM. Disappearance of Chikungunya virus from India and South East Asia. Trans R Soc Trop Med Hyg 1986;80:491.   Back to cited text no. 14
    
15.Neogi DK, Bhattacharya N, Mukherjee KK, Chakraborty MS, Banerjee P, Mitra K, et al. Serosurvey of chikungunya antibody in Calcutta metropolis. J Commun Dis 1995;27:19-22.   Back to cited text no. 15
[PUBMED]    
16.Yergolkar PN, Tandale BV, Arankalle VA, Sathe PS, Sudeep A, Gandhe SS, et al. Chikungunya outbreaks caused by African genotype, India. Emerg Infect Dis 2006;12:1580-3.   Back to cited text no. 16
    
17.Fukunaga T, Rojanasuphot S, Pisuthipornkul S, Wungkorbkiat S, Thammanichanon A. Seroepidemiologic study of arbovirus infections in the north-east and south of Thailand. Biken J 1974;17:169-82.   Back to cited text no. 17
[PUBMED]    
18.Thaikruea L, Charearnsook O, Reanphumkarnkit S, Dissomboon P, Phonjan R, Ratchbud S, et al. Chikungunya in Thailand: A re-emerging disease? Southeast Asian J Trop Med Public Health 1997;28:359-64.   Back to cited text no. 18
[PUBMED]    
19.Porter KR, Tan R, Istary Y, Suharyono W, Sutaryo, Widjaja S, et al. A serological study of chikungunya virus transmission in Yogyakarta, Indonesia: Evidence for the first outbreak since 1982. Southeast Asian J Trop Med Public Health 2004;35:408-15.   Back to cited text no. 19
[PUBMED]    
20.Lam SK, Chua KB, Hooi PS, Rahimah MA, Kumari S, Tharmaratnam M, et al. Chikungunya infection-an emerging disease in Malaysia. Southeast Asian J Trop Med Public Health 2001;32:447-51.   Back to cited text no. 20
[PUBMED]    
21.Kumar PN, Joseph R, Kamaraj T, Jambulingam P. A226V mutation in virus during the 2007 chikungunya outbreak in Kerala, India. J Gen Virol 2008;89:1945-8.   Back to cited text no. 21
    
22.Schuffenecker I, Iteman I, Michault A, Murri S, Frangeul L, Vaney MC, et al. Genome microevolution of Chikungunya viruses causing the Indian Ocean outbreak. PLoS Med 2006;3:e263.  Back to cited text no. 22
[PUBMED]  [FULLTEXT]  
23.Vazeille M, Moutailler S, Coudrier D, Rousseaux C, Khun H, Huerre M, et al. Two Chikungunya isolates from the outbreak of la Reunion (Indian Ocean) exhibit different patterns of infection in the mosquito Aedes albopictus. PLoS One 2007;2:e1168.  Back to cited text no. 23
[PUBMED]  [FULLTEXT]  
24.Santosch SR, Dash PK, Parida MM, Khan M, Tiwari M, Rao Lakshmana PV. Comparative full genome analysis revealed E1: A226V shift in 2007 Indian Chikungunya virus isolates. Virus Res 2008;135:36-41.  Back to cited text no. 24
    
25.Lakshmi V, Neeraja M, Subbalaxmi MV, Parida MM, Dash PK, Santosh SR. Clinical features and molecular diagnosis of chikungunya fever from South India. Clin Infect Dis 2008;46:1436-42.   Back to cited text no. 25
    
26.Pialoux G, Gaüzère BA, Jauréguiberry S, Strobel M. Chikungunya, an epidemic arbovirosis. Lancet Infect Dis 2007;7:319-27.   Back to cited text no. 26
    
27.Pialoux G, Gaüzère BA, Strobel M. Chikungunya virus infection: Review through an epidemic. Med Mal Infect 2006;36:253-63.   Back to cited text no. 27
    
28.Brighton SW, Prozesky OW, de la Harpe AL. Chikungunya virus infection: A retrospective study of 107 cases. S Afr Med J 1983;63:313-5.   Back to cited text no. 28
[PUBMED]    
29.Kennedy AC, Fleming J, Solomon L. Chikungunya viral arthropathy: A clinical description. J Rheumatol 1980;7:231-6.   Back to cited text no. 29
[PUBMED]    
30.Jeandel P, Josse R, Durand JP. Exotic viral arthritis: Role of alphavirus. Med Trop 2004;64:81-8.   Back to cited text no. 30
    
31.Vijayakumar K, Anish TS, Sreekala KN, Ramachandran R, Philip RR. Environmental factors of households in five districts of Kerala affected by the epidemic of Chikungunya fever in 2007. Natl Med J India 2010;23:82-4  Back to cited text no. 31
    
32.Jupp PG, McIntosh BM. Chikungunya virus disease. In: Monath TP, editor. The arboviruses: Epidemiology and ecology. BocaRaton, FL: CRC Press;1988. p. 137-57.   Back to cited text no. 32
    
33.Aravindan KP. Keralapadanam: Keralam engane jeevikkunnu? Keralan engane chinthikkunnu?. 1 st ed. Kozhikode, India: Kerala Sastra Sahithya Parishad; 2006.   Back to cited text no. 33
    
34.Kannan M, Rajendran R, Sunish IP, Balasubramaniam R, Arunachalam N, Paramasivan R, et al. A study on chikungunya outbreak during 2007 in Kerala, South India. Indian J Med Res 2009;129:311-5.  Back to cited text no. 34
[PUBMED]  Medknow Journal  
35.Harrington LC, Scott TW, Lerdthusnee K, Coleman RC, Costero A, Clark GG, et al. Dispersal of Dengue vector Aedes aegypti within and between rural commuities. Am J Trop Med Hyg 2005;72:209-20.  Back to cited text no. 35
[PUBMED]  [FULLTEXT]  

Top
Correspondence Address:
Thekkumkara Surendran Nair Anish
Department of Community Medicine, Government Medical College, Thiruvananthapuram, Calicut, Kerala
India
Login to access the Email id


DOI: 10.4103/0974-777X.83526

PMID: 21887052

Get Permissions




 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

This article has been cited by
1 Chikungunya Vaccine Candidate Is Highly Attenuated and Protects Nonhuman Primates Against Telemetrically Monitored Disease Following a Single Dose
C. J. Roy,A. P. Adams,E. Wang,K. Plante,R. Gorchakov,R. L. Seymour,H. Vinet-Oliphant,S. C. Weaver
Journal of Infectious Diseases. 2014;
[Pubmed]
2 Economic impact of chikungunya epidemic: Out-of-pocket health expenditures during the 2007 outbreak in Kerala, India
Vijayakumar, K. and George, B. and Anish, T.S. and Rajasi, R.S. and Teena, M.J. and Sujina, C.M.
Southeast Asian Journal of Tropical Medicine and Public Health. 2013; 44(1): 54-61
[Pubmed]
3 Chikungunya Fever: A Clinical and Virological Investigation of Outpatients on Reunion Island, South-West Indian Ocean
Thiberville, S.-D. and Boisson, V. and Gaudart, J. and Simon, F. and Flahault, A. and de Lamballerie, X.
PLoS Neglected Tropical Diseases. 2013; 7(1)
[Pubmed]
4 Molecular Mechanisms Involved in the Pathogenesis of Alphavirus-Induced Arthritis
Iranaia Assunção-Miranda,Christine Cruz-Oliveira,Andrea T. Da Poian
BioMed Research International. 2013; 2013: 1
[Pubmed]
5 Chikungunya virus and prospects for a vaccine
Scott C Weaver,Jorge E Osorio,Jill A Livengood,Rubing Chen,Dan T Stinchcomb
Expert Review of Vaccines. 2012; 11(9): 1087
[Pubmed]
6 Arthritogenic alphaviruses—an overview
Andreas Suhrbier,Marie-Christine Jaffar-Bandjee,Philippe Gasque
Nature Reviews Rheumatology. 2012; 8(7): 420
[Pubmed]
7 Chikungunya virus and prospects for a vaccine
Weaver, S.C. and Osorio, J.E. and Livengood, J.A. and Chen, R. and Stinchcomb, D.T.
Expert Review of Vaccines. 2012; 11(9): 1087-1101
[Pubmed]
8 Arthritogenic alphaviruses-an overview
Suhrbier, A. and Jaffar-Bandjee, M.-C. and Gasque, P.
Nature Reviews Rheumatology. 2012; 8(7): 420-429
[Pubmed]
9 Clinical Profile of Chikungunya Patients during the Epidemic of 2007 in Kerala, India.
Vijayakumar KP, Nair Anish TS, George B, Lawrence T, Muthukkutty SC, Ramachandran R
Journal of global infectious diseases. 2011; 3(3): 221-6
[Pubmed]
10 Corrected statistical analysis suggests casual transmission of AIDS in the African study on the Centers for Disease Control.
Cameron P
Psychological reports. 1987; 60(1): 177-8
[Pubmed]
11 Positive B lymphocyte crossmatch and glomerular rejection in renal transplant recipients.
Russ GR, Nicholls C, Sheldon A, Hay J
Transplantation proceedings. 1987; 19(1 Pt 1): 785-8
[Pubmed]
12 Male baldness: immediate single-stage rotation of very long arterialized temporo-parieto-occipital flaps.
Rizzetto-Stubel A, Ellenbogen R
Plastic and reconstructive surgery. 1986; 77(2): 215-21
[Pubmed]
13 Genetic variability in Norwegian wild reindeer (Rangifer tarandus L.).
Røed KH
Hereditas. 1986; 104(2): 293-8
[Pubmed]
14 [Hormonal evaluation of the functional state of the gonads, thyroid and adrenal glands in obese children].
Krawczuk-Rybakowa M, Urban M
Pediatria polska. 1985; 60(8): 558-64
[Pubmed]



 

Top
  
 
  Search
 
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusion
   Acknowledgement
    References
    Article Tables

 Article Access Statistics
    Viewed3224    
    Printed163    
    Emailed0    
    PDF Downloaded9    
    Comments [Add]    
    Cited by others 14    

Recommend this journal

Sitemap | What's New | Feedback | Copyright and Disclaimer | Contact Us
© 2008 Journal of Global Infectious Diseases | Published by Wolters Kluwer - Medknow
Online since 10th December, 2008