Chikungunya virus: evidence for global policy, practice and research in disease management, surveillance, and mosquito control.

Abstract

Background: Chikungunya virus is a member of the mosquito-borne Alphaviruses accountable for the unexpected rise in crippling febrile arthralgia in the past decade. The continued increase in mortality and morbidity attributed to Chikungunya in at least 55 affected countries highlights uncertainty on the effectiveness of Chikungunya management strategies. Given that these strategies are included in numerous public health systems worldwide, it is necessary that an inaugural critical review of international evidence be conducted, resulting in research findings that can facilitate decision-making in practice and policy. Aims: This thesis specifically aims to conduct three comprehensive systematic reviews, to summarise evidence and to confirm the effectiveness of clinical manifestations management, early diagnosis of disease, disease education, public health surveillance systems and mosquito control strategies in Chikungunya. Thereafter, a content analysis involving the quality evaluation of existing Chikungunya management guidelines, and a cross-examination of guidelines and systematic reviews to formulate new graded evidence-based guideline recommendations is presented. Methods: The Joanna Briggs Institute model of evidence-based health care and its accompanying systematic methodology provided the main conceptual framework and steps to conduct the systematic reviews. In addition, the statement on Preferred Reporting Items for Systematic Reviews and Meta-analysis was followed for reporting purpose. For the content analysis, quality of guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation II instrument and the development of guideline recommendations was based on a comparative content-analytic approach. Results: Several therapeutics, surveillance and mosquito control interventions werefound to be effective in the management of Chikungunya. The combination therapy of prednisolone and acecylcofenac may be used to reduce inflammation, which in turn improves quality of life in Chikungunya patients with arthralgia. Chloroquine phosphate is recommended as an anti-viral agent option for Chikungunya-induced chronic arthritis, which was found to be effective in reducing joint pain and morning stiffness. Early diagnosis of Chikungunya can be beneficial to patients, suggesting the importance of Chikungunya early symptom control and disease management. Effective and rigorous surveillance systems are affirmed to play a vital role in reducing Chikungunya transmission, although high quality research findings are needed to support the finding. Single vector control interventions (such as fenitrothion, temephos, Bacillus thuringiensis israelensis, poecilia, pyriproxifen-treated bed nets and nighttime ultra-low volume adulticiding using DUET™) can be effective in short-term transitory control, to reduce the number of immature and adult mosquitoes Aedes aegypti and Aedes albopictus. Further, intensive mosquito control operations combining all chemical, biological and habitat control appeared to be effective in reducing Aedes albopictus eggs and adult populations. Existing Chikungunya guidelines were of low methodological quality and the rigour of development was the lowest-scoring domain. Twenty evidence-based guideline recommendations of grade B were carefully formulated. Research limitations included the paucity of high quality evidence from primary studies, small or inadequate samples sizes and poor reporting of interventions parameters. Conclusion: The call to increase and improve research on Chikungunya management interventions is reiterated. Clinicians and public health providers should consider new research evidence that clarifies the desirable and undesirable effects and be open to potential effective management strategies for utilisation in differing contexts.