Clinical Features of Acute Chikungunya Virus Infection in Children and Adults during an Outbreak in the Maldives

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  • 1 Mahidol-Osaka Center for Infectious Diseases, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand;
  • | 2 Department of Viral Infections, Research Institute for Microbial Diseases, Osaka University, Osaka, Japan;
  • | 3 POCT Products Business Unit, TANAKA Kikinzoku Kogyo, Hiratsuka, Japan;
  • | 4 Indira Gandhi Memorial Hospital, Malé, Maldives;
  • | 5 Health Protection Agency, Ministry of Health, Malé, Maldives;
  • | 6 Tropical Medicine Diagnostic Reference Laboratory, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand;
  • | 7 Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand;
  • | 8 Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand

The chikungunya virus is an arthritogenic arbovirus that has re-emerged in many tropical and subtropical regions, causing explosive outbreaks. This re-emergence is due to a genomic polymorphism that has increased the vector susceptibility of the virus. The majority of those infected with chikungunya virus exhibit symptoms of fever, rash, and debilitating polyarthralgia or arthritis. Symptoms can persist for weeks, and patients can relapse months later. Fatalities are rare, but individuals of extreme age can develop severe infection. Here, we describe the 2019 outbreak, the second-largest since the virus re-emerged in the Maldives after the 2004 Indian Ocean epidemic, in which a total of 1,470 cases were reported to the Health Ministry. Sixty-seven patients presenting at the main referral tertiary care hospital in the Maldives capital with acute undifferentiated illness were recruited following a negative dengue serology. A novel point-of-care antigen kit was used to screen suspected cases, 50 of which were subsequently confirmed using real-time reverse transcription–polymerase chain reaction. We describe the genotype and polymorphism of Maldives chikungunya virus using phylogenetic analysis. All isolates were consistent with the East Central South African genotype of the Indian Ocean lineage, with a specific E1-K211E mutation. In addition, we explored the clinical and laboratory manifestations of acute chikungunya in children and adults, of which severe infection was found in some children, whereas arthritis primarily occurred in adults. Arthritides in adults occurred irrespective of underlying comorbidities and were associated with the degree of viremia.

Author Notes

Address correspondence to Hisham Ahmed Imad, Mahidol-Osaka Center for Infectious Diseases, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand. E-mail: imad@biken.osaka-u.ac.jp

Disclosure: This study was conducted according to the Declaration of Helsinki, and ethical approval was obtained from the National Health Research Committee in the Maldives, and the Ethics Committee of the Faculty of Tropical Medicine, Mahidol University, approved the protocol (Certificate of Ethical Approval No. MUTM 2020-009-01). The data presented in this study are available on request from the corresponding author. The data are not publicly available to ensure the privacy of study participants.

Financial support: This research was funded by the Japan Agency for Medical Research and Development (AMED) JP19fm0108003 and 20wm0225010h0101.

Authors’ addresses: Hisham Ahmed Imad, Juthamas Phadungsombat, and Emi E. Nakayama, Mahidol-Osaka Center for Infectious Diseases, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand, and Department of Viral Infections, Research Institute for Microbial Diseases, Osaka University, Osaka 565-0871, Japan, E-mails: imad@biken.osaka-u.ac.jp, juthamasps@gmail.com, and emien@biken.osaka-u.ac.jp. Keita Suzuki, Department of Viral Infections, Research Institute for Microbial Diseases, Osaka University, Osaka 565-0871, Japan, and POCT Products Business Unit, TANAKA Kikinzoku Kogyo, Hiratsuka 254-0076, Japan, E-mail: keita-s@ml.tanaka.co.jp. Ahmed Mifthah Ibrahim, Aminath Afaa, Aminath Azeema, Aminath Nazfa, Aminath Yazfa, Anoosha Ahmed, Athifa Saeed, Azna Waheed, Fathimath Shareef, Mohamed Moinul Islam, and Shausha Mohamed Anees, Indira Gandhi Memorial Hospital, Malé, 20002, Maldives, E-mails: ahmedmifthah21@gmail.com, afaa.alee@gmail.com, a.axyma@gmail.com, a.naxpha@gmail.com, yaxfa7@gmail.com, anushaahmed@live.com, athifasaeed@gmail.com, aznawaheed.05@gmail.com, fathisharyf99@gmail.com, sobuzmmc@gmail.com, and shauz.anys@hotmail.com. Sana Saleem, Aminath Aroosha, and Ibrahim Afzal, Health Protection Agency, Ministry of Health, Malé 20002, Maldives, E-mails: sana_saleem@health.gov.mv, aroosha.aminath@health.gov.mv, and afzal@health.gov.mv. Pornsawan Leaungwutiwong, Tropical Medicine Diagnostic Reference Laboratory, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand, and Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand, E-mail: pornsawan.lea@mahidol.ac.th. Watcharapong Piyaphanee and Weerapong Phumratanaprapin, Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand, E-mails: watcharapong.piy@mahidol.ac.th and weerapong.phu@mahidol.ac.th. Tatsuo Shioda, Mahidol-Osaka Center for Infectious Diseases, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand, and Department of Viral Infections, Research Institute for Microbial Diseases, Osaka University, Osaka 565-0871, Japan, E-mail: shioda@biken.osaka-u.ac.jp.

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