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Chikungunya Surveillance WHO: Chikungunya is a mosquito-borne viral disease first described during an outbreak in southern Tanzania in 1952. It is an RNA virus that belongs to the alphavirus genus of the family Togaviridae. The name ‘chikungunya’ derives from a word in the Kimakonde language (language of the Makonde people on the eastern border between Mozambique and Tanzania) meaning "to become contorted" and describes the stooped appearance of sufferers with joint pain (arthralgia). Presented by: LT Tony H. Hughes, Entomologist, NMCPHC Ms. Asha Riegodedios, Epidemiologist, NMCPHC

Chikungunya Objectives: Chikungunya (CHIK) mosquito vectors: behavior, vector competence and other relevant factors for CHIK surveillance and control. Installation pest and vector management program requirements and how to enhance those programs for CHIK response. Enhanced clinical surveillance and reporting recommendations (AFHSC and Service recommendations). Navy and Marine Corps Public Health Center

Mosquito Vectors: Aedes aegypti (yellow fever mosquito). Chikungunya Mosquito Vectors: Aedes aegypti (yellow fever mosquito). Aedes albopictus (Asian tiger mosquito). Vector identification: Navy and Marine Corps Public Health Center 3 3

CONUS Mosquito Vector Distribution: Chikungunya CONUS Mosquito Vector Distribution: Aedes aegypti (yellow fever mosquito) Aedes albopictus (Asian tiger mosquito) Note the wider distribution of Ae. albopictus in the US. It appears that in some parts of the world, introduced Ae. albopictus have outcompeted Ae. aegypti. This is not to imply that Ae. aegypti are completely displaced where the two cohabitate. For example, in the US, parts of Arizona, California, Florida, and Texas have witnessed re-emergences of Ae. aegypti. Many factors influence the prevalence of each species, such as climate, urban landscape, and mosquito control measures. Scientists are still studying the complex vector-ecology of these two species and interaction. Ae. aegypti are considered to have the closer relationship with human geography in both native and introduced habitats. She will feed indoors and out, and oviposit in such manner as well. Ae. albopictus is domestic but more peri-domestic, preferring outdoor natural and artificial containers. Ae. albopictus is also considered to be the more aggressive biter. Navy and Marine Corps Public Health Center 4 4

Disease vector competence: Chikungunya Disease vector competence: Three described genotypes of CHIKV West African East/Central/South African (ECSA) Asian Ae. aegypti & Ae. albopictus are competent for all genotypes of CHIKV. Caribbean/Americas have experienced local transmission of Asian strain. Although Ae. aegypti more competent, Ae. albopictus is a competent vector for the Asian strain. The spread of CHIK and threat to CONUS US is real References: High vector competence of Aedes aegypti and Aedes albopictus from ten American countries as a crucial factor of the spread of Chikungunya; Mar 2014; http://jvi.asm.org/content/early/2014/03/20/JVI.00370-14.full.pdf+html?ijkey=r15WuAincAeuw&keytype=ref&siteid=asmjournals Chikungunya in the Americas; Isabelle Leparc-Goffart a, Antoine Nougairede b, Sylvie Cassadou c, Christine Prat a, Xavier de Lamballerie; Feb 2014; http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)60185-9/fulltext Navy and Marine Corps Public Health Center 5 5

Disease vector surveillance: Chikungunya Disease vector surveillance: Both vectors are active during daylight hours Particularly morning and late afternoon Surveillance must be tailored to vector Biogents Sentinel Trap (BGS) or CDC light trap during daylight hours BGS superior in terms of attraction/capturing Ae. aegypti and Ae. albopictus The Biogents Sentinel mosquito trap (BGS) utilizes an attractive visual cue (black cup) which attracts gravid female Ae. aegypti and Ae. albopictus. A required and scented lure is placed inside the trap which emanates out as signified by red arrows. Mosquitoes are sucked into trap bag as indicated by yellow arrows. This trap is very effective for capturing Ae. aegypti and Ae. albopictus, and may be employed without CO2 for aforementioned vectors. As an alternate, the CDC light trap may be used during daylight hours. The addition of the Biogents lure and CO2 will attract Ae. aegypti and Ae. albopictus. NSNs adult mosquito surveillance traps and required accessories: BG Sentinel Trap - 3740-01-628-9326 BG-Lure® for BG Sentinel Trap (Note: trap will not work without lure) - 3740-01-628-9325 Catch Bag for BG Sentinel Trap - 3740-01-628-9327 Wall charger for BG Sentinel Trap - 3740-01-628-9324 CDC Light Trap - 3740-00-134-9229 Navy and Marine Corps Public Health Center 6 6

Disease vector surveillance: Chikungunya Disease vector surveillance: Per DoD Instruction, all installations are required to have Integrated Pest Management Plans (IPMPs). DODI 4150.07 Navy: OPNAV 6250.4C; Air Force: AFI 32-1053; Army: AR 40-5 Service specific guidance/relationships IPMPs ideally incorporate emergency vector control plans (EVCPs). Military entomologists available to assist with creation & implementation. Relationship b/t Medical Departments and Facilities (ie NAVFAC/Public Works) for surveillance of pests and vectors of public health importance. Bottomline: Installation Medical Depts must be familiar with and ensure disease vector surveillance is conducted. Per DODI 4150.07: IPM programs must be reviewed annually, and on-site every 3 years. In the Navy, NAVFAC is responsible for tech assistance, tech review, and preparing IPMPs. In the route of establishing these plans, all plans are routed to NECE for input. This is important in particular for those sections pertaining to medical entomology. Navy and Marine Corps Public Health Center 7 7

Disease vector surveillance and control: Chikungunya Disease vector surveillance and control: Common means of assessing Ae. aegypti and Ae. albopictus populations are egg, larval, adult, or container surveys (i.e. Breteau index). See the Navy Entomology Center of Excellence CHIK Vector Surveillance and Control Plan for more complete details at: - http://www.med.navy.mil/sites/nmcphc/Documents/program-and-policy-support/Chik-Vector-Surv.pdf NOTE: Source reduction of breeding habitat for these two vectors is of utmost importance and first line of defense. If CHIK cases present near or on installation, larval and adult control should be implemented, to include chemical control. Contact your POCs for guidance. Removing and emptying containers plus sanitation are first. Continuing surveillance is key to determine if these efforts suffice. If abundant Ae. aegypti and Ae. albopictus are found, ie >5 adults per BGS traps, then additional efforts and larval/adult control are warranted. For larvae in containers, the Breteau Index is the number of positive containers per 100 sites surveyed. One site can defined as a structure or an area where containers are present. For example, a site can be a house with containers surrounding it, or it can be a yard with a pile of tires. The Breteau Index establishes a relationship between positive containers and surveyed sites. It is possible to use these data to profile the relative abundance of various container types in the surveillance area (e.g. the number of infested containers per 100 sites). The Breteau Index has also been used to estimate the risk of disease transmission. There is some risk of disease transmission when BI > 5. Emergency vector control should be implemented when BI > 50. Navy and Marine Corps Public Health Center 8 8

Disease surveillance and control resources: Chikungunya Disease surveillance and control resources: Armed Forces Health Surveillance Center recommendations: - http://www.afhsc.mil/home Navy and Marine Corps Public Health Center Chikungunya webpage: - http://www.med.navy.mil/sites/nmcphc/program-and-policy-support/Pages/Chikungunya.aspx Army: U.S. Army Public Health Command, Chikungunya Fact Sheet: http://phc.amedd.army.mil/PHC%20Resource%20Library/Chikungunya_FS_18-029-0714.pdf USPHC Army Vector-borne Disease Report: http://phc.amedd.army.mil/whatsnew/Pages/PublicationDetails.aspx?type=Army%20Vector-borne%20Disease%20Report Navy and Marine Corps Public Health Center 9 9

Disease surveillance and control resources: Chikungunya Disease surveillance and control resources: Armed Forces Pest Management Board: Chikungunya Preparation: http://www.afpmb.org/content/chikungunya-preparation Dengue and Chikungunya Vector Control Pocket Guide: http://www.afpmb.org/sites/default/files/pubs/techguides/tg47.pdf Navy and Marine Corps Public Health Center Chikungunya webpage: http://www.med.navy.mil/sites/nmcphc/program-and-policy-support/Pages/Chikungunya.aspx Rutgers-USDA Asian Tiger Mosquito Area Wide Management Project: - http://www.rci.rutgers.edu/~AWATM/index.html Navy and Marine Corps Public Health Center 10 10

Disease surveillance and control: Chikungunya Disease surveillance and control: Diagnostic considerations: travel, differential diagnoses, dengue considerations Suspicious symptoms: acute onset of fever and polyarthralgia, especially travelers who returned within two weeks from areas with virus transmission Can be lab confirmed via: Viral isolation Detection of viral RNA by RT-PCR. Detection of IgM in a single serum sample (collected during acute or convalescent phase). Four-fold increase in chikungunya-specific antibody titers (samples collected at least two weeks apart). Note: Since clinical presentations of chikungunya and dengue are very similar, dengue must be ruled out. Send blood for serology and/or RT-PCR Navy and Marine Corps Public Health Center 11 11

Disease surveillance and control: Chikungunya Disease surveillance and control: Clinical Diagnostic Testing USAMRIID Special Pathogens Laboratory NMRC Navy Infectious Disease Diagnostic Laboratory If using a non-DoD lab, recommend saving an aliquot of refrigerated serum Mosquito surveillance and testing: Army: USAPHC regional commands Air Force: USAFSAM Epidemiology Consult Service Entomology Program Information https://gumbo2.wpafb.af.mil/epi-consult/entomology/ Also, Contact your MAJCOM Entomologist Navy: regional NEPMUs and Navy Entomology Center for Excellence Navy and Marine Corps Public Health Center 12 12

Disease surveillance and control: Chikungunya Disease surveillance and control: Report Chikungunya cases via Disease Reporting System internet as “Any Other Unusual Event” or “Arboviral Encephalitis” depending on Service-specific guidance Include in the report: clinical presentation, travel history, hospital admission status/dates, deployment information Report in a timely manner to enable rapid implementation of control measures If you suspect a case, call your service surveillance hub Can advise on and assist with case investigation, lab testing and vector control measures Know your local civilian reporting requirements as well as what mosquito control measures localities have in place. ***Situation is fluid: expect reporting guidance to evolve *** Navy and Marine Corps Public Health Center 13 13

US Navy Points of Contact: Chikungunya US Navy Points of Contact: US Navy Entomology Center of Excellence Jacksonville, FL, USA E-mail: NECE-FleetSupport@med.navy.mil (904) 542-2424, DSN: (312) 942-2424 Navy Environmental Preventive Medicine Unit 2 Norfolk, VA, USA (757) 953-6600; DSN: (312) 377-6600 Navy Environmental Preventive Medicine Unit 5 San Diego, CA, USA (619) 556-7070, DSN: (312) 526-7070 Navy and Marine Corps Public Health Center 14 14

US Navy Points of Contact: Chikungunya US Navy Points of Contact: Navy Environmental Preventive Medicine Unit 6 Pearl Harbor, HI, USA (808) 471-0237, DSN: (315) 471-0237 Navy Environmental Preventive Medicine Unit 7 Rota, Spain DSN: (314) 727-2230 US Naval Facilities Engineering Command ATLANTIC Norfolk, VA (757) 322-8000, DSN: (312) 262-8000 Navy and Marine Corps Public Health Center 15 15

Army Points of Contact: Chikungunya Army Points of Contact: US Army Public Health Command; Army Institute of Public Health; Entomological Sciences Program (410) 436-3613, DSN 584-3613 Email: usarmy.apg.medcom-phc.mbx.pesticide-hotline@mail.mil Mr. Thomas Burroughs, Manager, Entomological Sciences Program email: thomas.m.burroughs.civ@mail.mil   US Army Public Health Command PHCR-North Entomological Sciences Division Fort George G. Meade, MD 20755 Email: PHCR-NorthESD@amedd.army.mil (301) 677-3932, DSN: 622-3932 Mr. Ben Pagac, Chief, Entomological Sciences Division email: benedict.pagac.civ@mail.mil US Army Public Health Command PHCR-South Entomological Sciences Division Joint Base San Antonio, Texas 78234 (210) 221-4942, DSN: 471-4942 CPT Travis Gilchriest , Chief, Entomological Sciences Division email: travis.r.gilchriest.mil@mail.mil More??? Ento POCs? Army regional commands? Navy and Marine Corps Public Health Center 16 16

Air Force Points of Contact: Chikungunya Air Force Points of Contact: USAF School of Aerospace Medicine/PHR Wright-Patterson AFB, OH Email: will.reeves@us.af.mil (937) 938-2716, DSN: (312) 798-2716 USAFSAM - Epidemiology Consult Service Email: episervices@wpafb.af.mil Website (CAC-required): https://gumbo2.wpafb.af.mil/epi-consult/ (937) 938-3207; DSN: 798-3207 Navy and Marine Corps Public Health Center 17 17

Questions: Additional references consulted listed in notes below. Chikungunya Questions: Additional references consulted listed in notes below. References: Navy and Marine Corps Public Health Center webpage for CHIKUNGUNYA, DENGUE, AND OTHER ARBOVIRAL INFECTIONS; http://www.med.navy.mil/sites/nmcphc/program-and-policy-support/Pages/Chikungunya.aspx Armed Forces Pest Management Board; http://www.afpmb.org/ Vector competence of Florida mosquitoes for chikungunya virus; Dec 2010; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3076135/ A Single Mutation in Chikungunya Virus Affects Vector Specificity and Epidemic Potential; Dec 2007; http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2134949/ CDC; Transcontinental Movement of Asian Genotype Chikungunya Virus; http://wwwnc.cdc.gov/eid/article/20/8/14-0268_article CID 2009:49 (15 September) • EMERGING INFECTIONS; May 2009. Chikungunya Fever: An Epidemiological Review of a Re-Emerging Infectious Disease; J. Erin Staples,1 Robert F. Breiman,2 and Ann M. Powers1 Monitoring of dengue and chikungunya viruses in field-caught Aedes aegypti (Diptera: Culicidae) in Surat city, India Mandar S. Paingankar, Mangesh D. Gokhale, Keshav G. Vaishnav and Paresh S. Shah; April 2014 Genetic divergence of Chikungunya viruses in India (1963–2006) with special reference to the 2005–2006 explosive epidemic Vidya A. Arankalle, Shubham Shrivastava, Sarah Cherian, Rashmi S. Gunjikar, Atul M. Walimbe, Santosh M. Jadhav, A. B. Sudeep and Akhilesh C. Mishra; 2007. Navy and Marine Corps Public Health Center 18 18