CHIKUNGUNYA VIRUS RE-EMERGES IN INDIA - MAN VS.

UNCLAS SECTION 01 OF 05 NEW DELHI 001098

SIPDIS

SIPDIS

DEPT FOR SCA/INS, HHS FOR OGHA STEIGER/BHAT, CDC FOR
BLOUNT/COX, NIH FOR GLASS/HILEMAN, OES/PCI FOR STEWART,
OES/IHA FOR SINGER, GENEVA FOR WHO, APHIS/KOREA FOR ANDY
BALL

E.O. 12958: N/A
TAGS: PGOV AMED EAGR IN KFLU ECON PREL SENV TBIO PTER
SUBJECT: CHIKUNGUNYA VIRUS RE-EMERGES IN INDIA - MAN VS.
MOSQUITO FIGHT CONTINUES

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1. (U) Summary: After a 32 year hiatus, the chikungunya virus
is making a comeback in India. While the Government of India
(GOI) estimates over 180,000 cases of chikungunya infection
since December 2005, the actual number of cases is difficult
to assess. The GOI,s lack of transparency in reporting,
problems with effective diagnosis, and the states' seeming
inability to track the virus make chikungunya a very serious
public health problem. This time the virus has spread
widely, with infections cropping up in rural and urban areas,
as well as areas that attract mass tourism. Previous
outbreaks were limited. One of our Mission officers
contracted chikungunya, putting a personal face on this
horrid disease. This cable looks at the state of the public
health system for diagnosis and reporting, and speculates on
chikungunya as a possible bioterrorism agent. End Summary

WHAT IS CHIKUNGUNYA?
--------------


2. (U) The chikungunya virus was first recognized in epidemic
form in Tanzania, East Africa in 1952. This virus is spread
from the bite of an infected mosquito. In Asia, (including
India) the main vector is the mosquito species, Aedes
Aegypti. In other parts of the world, chikungunya is
transmitted through the Aedes Albopictus species. Kolkata
reported India,s first chikungunya virus outbreak in 1963.
At that time, scientists identified the virus as being of
Asian origin. For the current outbreak, scientists from the
Indian Council of Medical Research,s (ICMR) premier virology
laboratory, the National Institute of Virology (NIV) in Pune
determined the virus is of African origin.


3. (U) The disease, first described after the outbreak on the
Makonde Plateau, along the border between Tanganyika and
Mozambique, is derived from a Makonde word meaning &that
which bends up.8 Victims of the viral disease abruptly
manifest symptoms--acute onset of moderate-to-high fever
accompanied with body ache, backache, and joint pain
affecting primarily the knees, ankles, wrists, hands and
feet. Joint pain is severe and incapacitating, causing the
infected individual to &bend8 or hunch over from the pain,
hence its name. According to the Centers for Disease Control
(CDC),the incubation period (time from infection to illness)
is anywhere from 3-7 days.


4. (U) Symptoms and incubation period were directly
experienced by New Delhi Poloff, bitten by a mosquito

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infected with the virus, after arriving in Chennai on
November 28, 2006. A mosquito infected with the virus bit
Poloff Saturday, December 2, 2006 and she began manifesting
symptoms 3-4 days later on Tuesday, December 5. Symptoms
included excruciating and incapacitating muscle and joint
pain, high fever (reaching 105 degrees Fahrenheit),nausea,
headache, vomiting, swelling of the muscles and joints,
general fatigue, and a full body rash. The joint pain and
fatigue has been prolonged, lasting several months. The
joint pain subsided only after 3-4 months.

MISSION IMPACT
--------------


5. (U) New Delhi PolOff is among one of three confirmed
chikungunya infections among the staff of Mission India.
Embassy New Delhi has documented three confirmed cases among
EFMs and Mission personnel; Consulate Chennai has also
documented 4 suspected cases among FSNs; there are no
reported cases among Mission Personnel in Kolkata or Mumbai.

DIAGNOSIS, TREATMENT, AND PREVENTION
--------------


6. (U) There are critical problems with diagnosis due to poor
infrastructure at labs in India and chikungunya,s
similarities with dengue. Typically, diagnosis is based on a
process of elimination. Once typhoid, malaria, and dengue
are ruled out, the assumption is then that the symptoms are a
result of chikungunya. In India both the National Institute
for Communicable Diseases in Delhi (NICD) and the NIV at Pune
provide testing facilities which take 3-4 weeks for a result.
This process is long, frustrating, not widely accessible,
and often inaccurate. In the case of our PolOff, it took 5
weeks to return a negative result for chikungunya from NICD.
New Delhi Health Unit resent PolOff,s blood sample to the
Armed Forces Research Institute of Medical Services (AFRIMS)
lab in Thailand, which returns the most reliable results. Two
months after being infected, PolOff finally got a positive
diagnosis of the virus. Consulate Chennai also reports no
accurate, quality testing lab there for chikungunya.
Additionally, the virus is often misdiagnosed as dengue due
to the similar co-circulation, antibodies, and manifestation
of symptoms. On the positive side, infection of chikungunya
is thought to confer lifelong immunity to the individual
infected.


7. (U) CDC,s Outbreak Notice and information to travelers is

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available at webaddress:
http://www.cdc.gov/travel/other/2006/chikungu nya india.htm.
Present treatment includes rest, fluids, and drugs such as
ibuprofen, naproxen, acetaminophen, or paracetamol to relieve
symptoms of fever and joint pain. Infected Poloff took
approximately 1200 mg of ibuprofen (anti-inflammatory) and
2000-3000 mg of acetaminophen and Tramadol daily, which only
helped to take the edge off the pain. The best way to avoid
infection is to prevent mosquito bites, including wearing
long sleeves and pants and wearing mosquito repellent.
Additionally, a person with chikungunya should limit exposure
to mosquito bites to avoid further spread of the mosquito
borne infection.

WHERE DID INDIA,S 2005-2006 OUTBREAKS OCCUR?
--------------


8. (U) In India, the first documented recent report of
chikungunya came in December 2005, in Andhra Pradesh. By
mid-April of 2006, the suspected cases numbered over 25,000
in Andhra Pradesh, over 36,000 in Karnataka, and over 65,000
in Maharashtra. Families reported multiple cases across all
age groups. Eventually, chikungunya found its way to Kerala,
where the press reported Kerala,s Chief Minister V.S.
Achuthanandan as saying that deaths due to chikungunya had
occurred in Kerala. In 2006, after the floods and heavy
rains in the north, cases of chikungunya were reported all
over Rajasthan, Gujarat, and Madhya Pradesh.


9. (U) The re-emergence of the virus is a cause for concern
as it could become a major public health problem. Its
re-emergence could be linked to a variety of social,
environmental, behavioral, and biological changes. It may
also indicate the existence of a low-level, asymptomatic,
persistent infection in India which was not being documented.
The current outbreak is different than previous ones, which
predominantly affected urban areas. Now chikungunya
outbreaks are found in both urban and rural areas. It is
important to note that active surveillance for chikungunya
has not occurred during lulls in major outbreaks and that the
virus is spreading throughout India.

DEADLY VIRUS COULD KILL TOURISM
--------------


10. (U) In 2006, GOI pulled together a team of experts to
probe the cause of reported chikungunya-related mortalities
in Kerala. The team had officials from the NICD, NIV, World

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Health Organization (WHO),and the National Vector Borne
Disease Control Program (NVBDCP). This team submitted a
report to the Ministry of Health (MOH) which ruled out
chikungunya as a cause for death. NVBDCP Chief P.L. Joshi
said &There is no death due to chikungunya in the country
and the deaths in Kerala and other places are due to other
related diseases such as TB, cancer and cardiac problems.8
WHO,s India Representative, Salim Habayeb, and GOI Health
Minister Anbumani Ramadoss both corroborated this statement.


11. (SBU) ICMR,s NIV director, however, shared the results
of its epidemiological, clinical, and laboratory
investigations of the chikungunya outbreak with a visiting
Centers for Disease Control and Prevention (CDC) delegation.
These results showed at least a ten fold increase in the
number of chikungunya cases over what the GOI reported and a
correlation of death with infection. Although the State
Governments of Andhra Pradesh, Karnataka, and Maharashtra
declared deaths and high numbers of infections, a senior MOH
official told Health Attach, "Kerala is our tourism
destination, and it would be a disaster if this state was
labeled as a place of infection." For its own political and
economic reasons, it seems the GOI is playing down the rate
of infection and deaths associated with the virus.

HUNT FOR CHIKUNGUNYA VACCINE ON
--------------


12. (U) In the late 1970s, US Army scientists at the Walter
Reed Army Institute of Research and the US Army Medical
Research Institute of Infectious Disease (USAMRIID) developed
the only known chikungunya vaccine tested on humans from a
live attenuated vaccine developed from a patient in Thailand.
The research stopped in 1997 due to difficulties with
funding and a &difficulty envisioning how final field
efficacy trials would be conducted due to the unpredictable
nature of chikungunya outbreaks.8 In September 2006, US
Embassy Paris announced a USG agreement to transfer research
records, vaccine supplies and seed stocks to the French, so
they could resume vaccine development. Scientists in France
have started laboratory safety testing of a chikungunya
vaccine. According to press reports, French scientists plan
to start clinical trials in September 2007.


13. (SBU) Hyderabad based Bharat Biotech India Ltd (BBIL),a
premier Indian biotech industry innovator, also has
development of a chikungunya vaccine in the pipeline. Though
BBIL met with a French delegation regarding a potential

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partnership at the end of 2006, nothing was agreed to. In
the end they realized they are working on different
methodologies for developing a vaccine.

COMMENT: A GLOBAL PROBLEM AND POTENTIAL BIOTERRORISM AGENT
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14.(SBU) The CDC already lists chikungunya (viral
encephalitis and alphaviruses) as a Category B Biological
Weapons Agent. Category B is the second highest priority for
defense because it is composed of agents that are easy to
disseminate, cause moderate morbidity, low mortality, and
would require enhancements of the US surveillance and
diagnostic capacity if there were an outbreak. In India, the
lack of disease surveillance and transparency in reporting
infections, insufficient testing laboratories, and the
dichotomy of statements between scientists, state authorities
and the policy makers in Delhi make India,s national health
structure particularly vulnerable.


15. (U) Mission will continue watching and reporting on
chikungunya and other emerging and reemerging infectious
diseases. HHS/CDC is engaged with the MOH on emerging and
re-emerging infectious diseases under the auspices of an
Indo-US bilateral agreement on Emerging and Reemerging
Infectious Diseases and Disease Surveillance (ERIDDS). This
interaction provides HHS staff at the Mission access to
unpublished data on disease surveillance and disease burden.
End Comment.
MULFORD