Applying Evidence to Chikungunya 1

Running head: APPLYING EVIDENCE TO CHIKUNGUNYA

Applying Evidence to Screen for Chikungunya Virus

in Low Resource Settings

Michelle D. Kelly

University of San Francisco

 Applying Evidence to Chikungunya 2

Applying Evidence to Secondary Prevention Outbreaks of Chikungunya Virus

Mosquito-borne arboviral diseases, such as malaria and dengue, are well known and highly

studied, unlike the lesser-known chikungunya virus. Starting in 2003, reports of chikungunya

viral outbreaks have been published in reputable French and Indian scientific literature (Ministry

of Health [MOH] Malaysia, 2006; Pialoux, Gaüzère, Jauréguiberry & Strobel, 2007). Recent

outbreaks indicate that the chikungunya virus is exported and there is a lack of basic surveillance

and screening measures (Ledrans, Quatresous, Renault & Pierre, 2007; Ramchurn, Goorah,

Makhan & Moheeput, 2008). Chikungunya is transmitted by Aedes mosquitoes in temperate

regions and is most prevalent in areas of the world where only the most basic health services

exist (World Health Organization [WHO], 2008). The word chikungunya is Swahili, and it

means someone who bends inward because of a total body ache, and the person stooped over

graphically depicts the clinical representation of the viral infection’s characteristic arthralgia. In

a public health setting, diagnosis of chikungunya is a lengthy and inaccurate process based on

subjective symptoms.. Clinical manifestations of chikungunya are fever and rash, which are akin

to many other tropical diseases, like malaria (Ramchurn et al, 2008). Chikungunya has been

identified by the classic pattern of migratory arthralgia reported in over 90% of patients (MOH

Malaysia, 2008). However, the disease is only confirmed by the exclusion of other viral diseases

through a series of blood and diagnostic tests which, if available, only exist in hospitals in major

cities. A lack of sensitive, specific and timely methods to confirm a diagnosis of chikungunya
 Applying Evidence to Chikungunya 3

translates into high health care utilization and long inpatient or home stays. This deficiency can

lead to inaccurate, costly lab tests and potentially toxic pharmaceutical treatments (Pialoux, et al,

2007). Chikungunya is also spread from human to human and puts caregivers, health workers

and communities at risk (Pialoux et al., 2007; WHO, 2007).

Impact of Chikungunya and Significance to Nursing

Chikungunya epidemics debilitate populations and strip them of valuable health resources,

creating a burden comparable to rheumatoid arthritis in terms of disability-adjusted life years

(Krishnamoorthy, Harichandrakumar, Kumari, & Das, 2009). The poorest of the world’s

populations are more likely to become ill and die of preventable communicable diseases (WHO,

2005). Poor societies are particularly at risk for zoonotic diseases like chikungunya, which are

most prevalent in Africa and India where basic health services are lacking. These populations

suffer up to 30 times higher rates of morbidity and mortality than a non-vulnerable population

(Toole, 1992). Vulnerable populations are of particular concern by nurses, not only because of

their high risk factors, but because these groups are served by community health workers

(CHWs) who may have little to no formal education and few, if any, resources. Clinical trials to

research an effective chikungunya vaccine, provision of a rapid sensitive sero-test are far from

implementation as these results are not yet conclusive or acceptable for any clinical practice

(Pialoux et al., 2007).

Gap in Prevention Guidelines

In the low resource settings where chikungunya occurs, scarce resources must be targeted

on primary and secondary levels of prevention and, yet, current research and recommendations

are aimed at physicians in tertiary care setting, which are inaccessible to most vulnerable people.
 Applying Evidence to Chikungunya 4

Recent outbreaks have spurred a series of chikungunya guidelines from nation states, (EpiSante

in France and United States Center for Disease Control, regions (Eurosurveillence) and, to some

extent, global collaboration under the auspices of the WHO. Within the last five years, the

aforementioned governmental and international organizations have developed or revised

guidelines specifically designed to meet the needs of public health and medical staff at the

capital level for national surveillance and clinical management of chikungunya. These guidelines

are not of practical use to community-level health workers in low resource countries. The

Institute of Medicine (IOM) encourages that the use of established practice guidelines be

customized to where the greatest impact on health care is likely to occur (2001). Applying the

IOM’s strategy to chikungunya affected areas, the majority of health care is at the village level,

the most basic level of care, where advance practice nurses are needed to translate research into

field practice. In shaping guidelines, nurses are supporting CHWs and are able to contribute to

improving the health status of the world’s most vulnerable populations.

Need for Evidence-Based Screening

Evidence-based practice guidelines on screening for chikungunya and providing health

education in communities at risk for chikungunya are urgently needed. Specifically, there is a

need to identify public health screening tools for chikungunya in affected and at-risk populations.

This guideline for chikungunya screening must be both effective in, and appropriate for, CHW

practice in low resources settings. This paper describes and critically appraises the recent

literature on developments in chikungunya research and serves to formulate an evidence-based

guideline for CHWs in low resource regions of the world.

Literature Review
 Applying Evidence to Chikungunya 5

Description and Critique of the Literature

The majority of chikungunya research studies were found in peer-reviewed scholarly

journals, with a retrospective cohort study design initiated after the onset of a chikungunya

outbreak. Epidemiologists employ these types of studies, which are rapid and “designed to

inform without delay” (Merill & Timmreck, 2006). Burns describes the difficulty researchers

face in studying prevention as they are “measuring something that does not occur” (pp.X, 2009).

In the literature on chikungunya, three themes were identified: 1) The need for surveillance and

screening methods, 2) Capacity and quality of tools to confirm cases, 3) Estimating attack and

case fatalities rates. Studies of outbreaks dominated the research, as chikungunya had spread to

geographic locations that had not reported the disease in the past, and these populations are

immuno-naive. Some contributing factors to this dispersion of the virus are global warming,

increased travel and commercial trade (Donoso-Mantke & Niedrig, 2006). Scientists investigated

chikungunya outbreaks in La Reunion, a French territory east of Madagascar, as well as India

and Sri Lanka, where over one million people among the three areas were infected with

chikungunya since 2003 (Ramchurn, et al., 2008). The epidemics were studied with normal

international disease surveillance systems in place, and new tools were used after it was known

that chikungunya was involved.

Surveillance and Screening Methods

Depoortere and Coulombier (2006) studied retrospective chikungunya morbidity reports

from 10 countries to learn if an outbreak in La Reunion was moving into Europe. In their study,

chikungunya-risk assessment for Europe was based on recommendations in Eurosurveillance,

whose reputable and well published authors represented a recommendations task force from the
 Applying Evidence to Chikungunya 6

European Centre for Disease Prevention (ECDP). The researchers acknowledged that their data

was limited, as the Institut de Veille Sanitaire and Eurosurveillance editors solely provided their

data on morbidity. The data was analyzed to rapidly estimate the risks of human-to-human

transmission from travelers returning from La Reunion and other chikungunya epidemic areas

into Europe. The authors concluded the virus had been imported to Europe, the scope was not

known, and human-to-human transmission had not yet been identified. They emphasized that

their findings indicated the importance of secondary prevention by: 1) Improving surveillance of

chikungunya reporting, 2) Maintaining universal precautions, 3) Educating health staff, and 4)

Screening and providing chikungunya information pamphlets to travelers moving in and out of

known chikungunya epidemic areas.

The study design used by Depoortere and Coulombier (2006) was appropriate for real-

time epidemic investigation, however, there were significant gaps in the study’s explanation of

both the data collection methods and the criteria and rationale to determine which data sets were

included or excluded from their study. The researchers’ biases were not identified, and potential

financial or other gains from the study’s findings were not disclosed. The research article did not

provide information about the accuracy of the morbidity data or what classified a case as suspect

or confirmed chikungunya illness. It is not known if there had been an established case definition

in the regions submitting data to the ECDP and the ability of the various health staffs to reliably

use a chikungunya case definition tool in their practice. The data is not likely to be an accurate

representation of the epidemic in the entire population(s), as major variations of the aggregates’

access to care, active versus passive case findings by health staffs, and the sensitivity and

specificity of diagnostic and laboratory testing among the countries studied. These countries
 Applying Evidence to Chikungunya 7

included six each in the Indian Ocean and Asia, as well as the United Kingdom, Belgium, the

Czech Republic and Norway. Data from epidemic records from several points of care have very

limited comparability. Active case finding by community health workers recorded as suspect

chikungunya in morbidity registers are equated with the same level of diagnostic accuracy of an

advanced clinical practitioner in a hospital. Lastly, La Reunion and other tropical areas with

active chikungunya viral outbreaks are located in elite European tourist destination spots, where

the appearance of chikungunya cases has political and economic implications because those

communities rely on tourist dollars for their livelihoods. The extent of these influences on the

actual reporting of the disease is not known. Despite this study’s overall lack of rigor, unknown

bias and uncontrolled variables in the data, the ECDP’s four recommendations for secondary

prevention of chikungunya are advisable, as building solid reporting systems, following blood

precautions, and increasing awareness of health staff and the public are very acceptable

interventions, even with the limited evidence available in this study.

Capacity of Laboratories

The basics for the screening of any infection rely on the quality of the screening tool; an

accurate tool will report true cases screened as positive, which is of particular importance with

the chikungunya virus. In 2007, Donoso-Mantke and Niedrig implemented a landmark study out

of the Robert-Koch Center for Biological Studies in Berlin. The center was reputed as leading

European laboratories in setting high standards of quality, having successfully identified

laboratory capacities in Europe with West Nile virus in 2004. Given the occurrence of the exotic

chikungunya virus in several European countries, the Robert-Koch Center was a good candidate

for studying the quality of laboratory testing in Europe. The researchers utilized WHO to invite
 Applying Evidence to Chikungunya 8

its partners, as well as reference laboratories belonging to the European Commission, and held

registration in the European Network for Laboratory Diagnostics of Imported Viral Diseases

(ENIVD), a non-profit consumer protection organization.

Laboratories were invited to participate in the free, confidential external quality assurance

(EQA) study. The self-selected laboratories (n=24) represented 15 European nations, and a

majority of the sample was considered to be regional reference sites for specialized

communicable disease testing. Participants received 12 blinded samples of all known types of

chikungunya antibodies, as well as negative controls, without special education or procedures

mandated by the researchers. Researchers wanted to test the capacity of labs to diagnose

chikungunya with the procedures already in use, and the labs conducted testing with a variety of

methods, reagents and assays.

The EAQ findings show diagnostic accuracy of chikungunya was very limited in several

European reference labs. The labs had not detected the high viral loads, nor were they able to

discriminate among viral strains or conduct the test without the required reagent. The ENVID

acknowledged that this undertaking was the first quality testing of chikungunya in Europe, and

clearly even the reference laboratories were not at the industry standards. The ENVID added that

diagnostic capacity needed improvement.

Limitations of the study were the lack of descriptions in the methodology and analysis.

An explanation of how the blinded samples were coded and what was known about the level of

technical skills of the various laboratory staff were absent. Only a summary of the findings was

presented, and without statistical data. There was no mention of how the low diagnostic quality

of laboratory testing of chikungunya affects the reliability of surveillance data coming out of
 Applying Evidence to Chikungunya 9

Europe.

Estimating Morbidity and Mortality

Retrospective studies are operative ways to look at communicable disease patterns

(Merill & Timmreck, 2006). In 2008, researchers examined rates of mortality data pre-, during

and post-chikungunya epidemic in the nine districts of Mauritius to project case fatality rates

(CFR). Reporting accuracy for mortality rates is higher than that of morbidity data, thus

mortality rates are less likely to be skewed by effects of an epidemic (Ramchurn et al., 2008).

The researchers accessed six years of government mortality records to calculate average crude

mortality rates (CMR); these rates were compared to the mortality data during the chikungunya

outbreak. A p-value was used to identify statistical differences between the observed and

predicted CMRs, and a 2% assumed prevalence of chikungunya was used.

The study concluded that observed CMRs were a statistically sound means by which to

estimate chikungunya CFRs as rates of excess mortality, retrospectively correlated with the

reported CFRs in the nine districts. More explanation of confounding variables, such as deaths

due to pneumonia during colder seasons and nutrition-related morbidities likely in the pre-

harvest time of year. There are limits to using government data as the sole source of information

since very poor, marginalized or undocumented populations are often excluded.

Like Ramchurn et al. (2009), chikungunya research is also derived from public health

surveillance data. Ledrans, Quatresous, Renault and Pierre (2007) looked at mechanisms of

comprehensive epidemic monitoring and a means to estimate incidence. Their design is a

descriptive population-based study, which aimed to identify epidemic trends and used a

combination of case reports, as well as active and retrospective case-seeking by health staff from
 Applying Evidence to Chikungunya 10

cases reported by a vector team. Use of non-specific indicators by mortality surveillance to

predict normal mortality and estimated deaths due to the chikungunya virus.

The Ledrans et al. (2007) study had strong points, but there were also gaps in

methodology that lowered the quality of evidence provided. The sampling method employed in

this research was acceptable, as case finding is the most ethical way to locate positive cases in an

epidemic scenario. However, the actual diagnosis of chikungunya was made by health staff with

unknown abilities and without inter-rater reliability. No screening tool, such as a case definition,

was mentioned, and serological confirmation was not used. The unknown quality of the

screening tool(s) and screeners in this study makes the findings unreliable.

Summary of the Literature

The public health studies located on the topic of chikungunya lacked the rigor and

validity of multiple clinical trials. Expert opinion dominated the recent research and is

considered the lowest level of evidence in research, requiring further quantitative work to be

conducted to increase the results’ credibility (Craig & Smith, 2007). Recent guidelines on the

clinical management of chikungunya were not directly applicable to the majority of health

workers in low resource regions. Nonetheless, the available studies offer a basis of knowledge,

which could be applied to prevent chikungunya. The identified themes were surveillance and

screening methods, laboratory capacity to confirm cases, and forecasting epidemic rates with

retrospective data. The guidelines in Appendix A are for the secondary prevention of

chikungunya and aim to meet the needs of their intended audience, the community-based health

worker.

Implementation of the Guideline

 Applying Evidence to Chikungunya 11

Relationships are essential for the successful implementation of the Chikungunya

Awareness and Prevention Guideline for Community Level Health Workers. There are limits in

the rigor of evidence-based research on which this guideline is built; yet, the guideline is a pilot

and ready to be adapted to the needs and strengths of the community. The facilitators of the

implementation need to work hand-in-hand with stakeholders in developing a network of

working relationships with communities at risk for chikungunya. Parallel to the development of

community contacts, regional and international organizational networks are also needed for

financial and political support. Starting small with five to eight communities at risk for

chikungunya, the research must aim for close oversight in building models of community-based,

measurable and sustainable programs.

Implementation requires a three-pronged strategy: Assessment, monitoring and

evaluation of the guidelines’ impact. To begin, one must determine where the need is: Which

areas of Africa, India and Sri Lanka are predicted to face importation of the chikungunya virus in

the next rainy season? Epidemic forecasts of chikungunya are available through

Eurosurveillance, EpiSante and WHO. Once regions are mapped out, one assesses the level of

need in the community: How important is the prevention of chikungunya in the hierarchy of

needs in the community? If there are food gaps or major security issues, it is not likely these

communities will be able to afford the energy a chikungunya pilot would require. Just as

important is identifying all the stakeholders and the available materials.

Chikungunya affects working adults, and employers can be surveyed to assess possible

partnerships. It is also useful to coordinate with other prevention activities such as sanitation,

vector control and immunization. Bringing in a community-based worker with chikungunya

 Applying Evidence to Chikungunya 12

experience to work with a pilot program is useful, as is transplanting a CHW from an at-risk area

into an endemic area to be trained. The actual feasibility of implementation is reliant on several

factors being in place. There must be a functioning health information system, access to high-risk

groups, an understanding of population movements, funding for a minimum of two years,

availability of a trained workforce and material resources, and possibilities for supervision and

monitoring of activities. Many prospects for implementation exist; for example, community

awareness of chikungunya can be increased through dissemination of information by radio

stations, schools systems and newsletters.

Monitoring and evaluation require the development of objectives and metrics. What are we

measuring and how will we measure it? Outcome measures would be based on the severity of the

problem, available resources and the level of health care in the area or host country. The

effectiveness of this guideline is ultimately measured by a lack of predicted morbidity as

compared to a baseline prevalence and incidence of chikungunya.

Examples of prevention metrics:

• Number of communities informed of chikungunya risk

• Number of prevention activities carried out before rainy season

• Number of health workers attending the prevention workshop

• Number of health posts with chikungunya-case definition on site

• Number of presumed chikungunya cases identified

• Number of households at risk screened

Conclusion

Nursing and public health have an opportunity to take the most current research findings
 Applying Evidence to Chikungunya 13

into practice at the village level across the globe. Research proves that surveillance; screening

and community education are the most effective methods for health workers in low resources

areas to lessen the impact of chikungunya. However, reports illustrate that these methods are not

being utilized to nearly the degree that is necessary to manage the disease. In conclusion, these

appropriate guidelines for community-based health workers provide effective methods that will

significantly impact the spread and human cost of chikungunya.

References

Burns, N. & Grove, S. (2009). The Practice of Nursing Research: Conduct, Critique, &

Utilization (5th Ed). St. Louis, Elsevier Saunders.

Charrel N., de Lamballerie, X, Raoult D. (2007) Chikungunya outbreaks -- the globalization of

vectorborne diseases. N Engl J Med; 356(8): 769-71.

Craig, J. & Smyth, R., (2006) The Evidence-Based Practice Manual for Nurses (2nd Ed). St.

Louis,Churchill, Livingstone Elsevier.

 Applying Evidence to Chikungunya 14

Depoortere, E., & Coulombier, D. (2006). Chikungunya risk assessment for Europe:

recommendations for action. Eurosurveillance, 11(19):pii=2956. Retrived online on

April 15th 2009, from: http://www.eurosurveillance.org/viewarticle.aspx?articleid=2956

Donoso-Mantke O. & Niedrig M. (2007). Laboratory capacity for detection of chikungunya virus

infections in Europe. Eurosurveillance, 12(37): 3267.

Retrieved online on April 15th, 2009 from:

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3267

Institute of Medicine 2001 Report Brief. Crossing the Quality Chasm: A New Health System for

the 21st Century, 1-8. Retrieved online on April 9th, 2009 from:

http://www.iom.edu/report.asp?id=5432.

Krishnamoorthy, K., Harichandrakumar, K.T., Krishna Kumari, A., L.K. & Das, L.K.

(2009). The Burden of Chikungunya in India: Estimates of disability adjusted life years

(DALY) lost in 2006 epidemic. Journal of Vector Borne Diseases. 46(1), 26-35.

Retrieved online on April 2nd, 2009 from: http://www.doaj.org/doaj?

func=abstract&id=381588

Ledrans M, Quatresous I, Renault P. & Pierre V. (2007). Outbreak of Chikungunya in the French

Territories, 2006: Lessons learned. Eurosurveillance. 12(36), 3262. Retrieved online on

April 15th, 2009 from: http://www.eurosurveillance.org/ViewArticle.aspx?

ArticleId=3262Eurosurveillance

Merill, R.M. and Timmreck T. C. (2006). Introduction to epidemiology (4th Ed.). Sudbury, MA:

Jones and Bartlett

 Applying Evidence to Chikungunya 15

Ministry of Health Malaysia, (2006). Surveillance and Management of Chikungunya Disease.

Disease Control Division. 1-7.

Pialoux, G., Gaüzère, B., Jauréguiberry,S., & Strobel, M. (2007).

Chikungunya, an epidemic arbovirosis. The Lancet. 7(5), 319-327.

Ramchurn S, Goorah SS, Makhan M, Moheeput K.( 2008). Excess mortality as an epidemic

intelligence tool in chikungunya mapping. Eurosurveillance. 13(7), 8039. Retrieved

online on April 15th, 2009 from: http://www.eurosurveillance.org/ViewArticle.aspx?

ArticleId=8039

Toole. M., (1992). Centers for Disease Control. Famine-Affected, refugee, and displaced

populations: Recommendations for public health issues. MMWR. 41(No. RR-13), 164-

69.

Center for Disease Control (CDC) (2006). Chikungunya fever diagnosed among international

travelers: United States, 2005-2006. MMWR Morbidity and Mortality Weekly Report.

55(38), 1040-1042.

http://wonder.cdc.gov/wonder/prevguid/p0000113/p0000113.asp

World Health Organization. (2008). Guidelines on Clinical Management of Chikungunya Fever,

1- 18. Retrieved online on April 10th, 2009 from:

http://www.searo.who.int/en/showdetailsnew.asp?code=B3234

World Health Organization (2004). Malaria Epidemics: Forecasting, Prevention, Early

Detection and Control: From Policy to Practice 1-52. Retrieved online on April 10th,

2009 from:
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5000---50-about-0---01131-001-110utfZz-8-0-

0&a=d&c=who&cl=CL4&ld=Js13420e#selectedcldoc

World Health Organization (2005). Malaria Control in Complex Emergencies : An Inter-Agency

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Appendix a
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GUIDELINE TITLE
Chikungunya Awareness and Prevention Guideline for Community Level Health Workers

GUIDELINE STATUS
This is the first release of the guideline and submitted for review.

SCOPE
DISEASE/CONDITION
Chikungunya Virus

GUIDELINE CATEGORY
Communicable Disease:
Risk Assessment
Prevention, secondary

CLINICAL SPECIALTY
Public Health

INTENDED USERS
Community level health workers in low resource areas
Community Health Workers (CHW)
Health Educators
Nurses
Public Health staff

GUIDELINE OBJECTIVES
• Provide health workers chikungunya effective secondary prevention recommendations in
low resource practice settings
• Promote rationale use of material in low resource settings

TARGET POPULATION
Populations in Low Resource Areas
Impoverished and / or displaced populations in Africa, India, an Sri Lanka.

INTERVENTIONS AND PRACTICES CONSIDERED

Secondary Prevention of Chikungunya at the Village Level
Screen
Identify at risk groups
Use case definition
Maintain surveillance data and mapping
Test
Serological testing
 Applying Evidence to Chikungunya 18

Treat
Health education

MAJOR OUTCOMES CONSIDERED

Prevent Morbidity
Reduce burden of chikungunya disease on communities
Empower community level health workers

METHODOLOGY
METHODS USED TO COLLECT/SELECT EVIDENCE
Search of Electronic Databases April 2009

METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE

EVIDENCE
Weighting According to a Rating Scheme (Scheme Given)

RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Levels of Evidence
Level Ia: Evidence obtained from meta-analysis or systematic review of
randomized controlled trials
Level Ib: Evidence obtained from at least one randomized controlled trial
Level IIa: Evidence obtained from at least one well-designed controlled study
without randomization
Level IIb: Evidence obtained from at least one other type of well-designed quasi-
experimental study.
Level III: Evidence obtained from well-designed non-experimental descriptive
studies, such as comparative studies, correlation studies, and case studies
Level IV: Evidence obtained from expert committee reports or opinions and/or
clinical experiences of respected authorities

METHODS USED TO ANALYZE THE EVIDENCE

One expert review of published articles

METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Opinion

DESCRIPTION OF METHODS USED TO FORMULATE THE

RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS
Grades of Recommendations
A: There is good evidence to recommend the clinical preventive action.
B: There is fair evidence to recommend the clinical preventive action.
C: The existing evidence is conflicting and does not allow making a
 Applying Evidence to Chikungunya 19

recommendation for or against use of the clinical preventive action; however

other factors may influence decision-making.
D: There is fair evidence to recommend against the clinical preventive action.
E: There is good evidence to recommend against the clinical preventive action.
I: There is insufficient evidence (in quantity and/or quality) to make a
recommendation, however other factors may influence decision-making.

METHOD OF GUIDELINE VALIDATION -pending

External Peer Review

RECOMMENDATIONS
Secondary Prevention Practice Recommendations
1. Screen
Recommendation 1.0
Identify at risk groups, start 3 months before rainy season starts
(Level of Evidence = IV; Grade of Recommendation = B)

Intervention
Assess human migration and market movement patterns to and from known chikungunya risk
areas
Case finding in identified risk groups and geographic areas
(Level of Evidence = IV; Grade of Recommendation = B)

Recommendation 1.1
Screen suspect cases of chikungunya and populations from known chikungunya areas
(Level of Evidence = IV; Grade of Recommendation = B)

Intervention
Use case definition differentiating chikungunya from other diseases
(Level of Evidence = IV; Grade of Recommendation = B)

Recommendation 1.2
Maintain surveillance data and mapping
(Level of Evidence = III; Grade of Recommendation = B)

Intervention
Assure surveillance system is in place and working

Recommendation 1.3
Prevent human-to-human transmission
(Level of Evidence = III; Grade of Recommendation = B)
 Applying Evidence to Chikungunya 20

Intervention
Universal precautions for all persons at risk
Including health workers, birth attendants, caregivers

2. Test
Recommendation 2.0
No serological testing at village level
(Level of Evidence = IIA; Grade of Recommendation = B)

Interventions
Educate health staff on poor quality of testing
Re-enforce universal precautions

3. Treat
Recommendation 3.0
Health education
(Level of Evidence = IV; Grade of Recommendation = B)

Interventions
Increase Community Awareness
Health teaching for at risk and suspect cases will receive information on what chikungunya is
and how to prevent transmission

BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE

POTENTIAL BENEFITS
Promote existing or increase community health workers knowledge of and abilities to prevent
chikungunya
Prevent morbidity of chikungunya
Prevent human-human chikungunya transmission
Provide preventions strategies that are with in the resource and capacity means of low resource
regions.
Reduce chikungunya DALYs.

POTENTIAL HARMS
Invalidate or disrespect community health workers who have positive prevention strategies in
place.
Impose outside demands on health workers when they have other life sustaining priorities (for
example harvesting)
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