jueves, 17 de julio de 2014

Ahead of Print -Preparedness for Threat of Chikungunya in the Pacific - Volume 20, Number 8—August 2014 - Emerging Infectious Disease journal - CDC

Ahead of Print -Preparedness for Threat of Chikungunya in the Pacific - Volume 20, Number 8—August 2014 - Emerging Infectious Disease journal - CDC


Volume 20, Number 8—August 2014

Online Report

Peer Reviewed Report Available Online Only

Preparedness for Threat of Chikungunya in the Pacific

Adam RothComments to Author , Damian Hoy, Paul F. Horwood, Berry Ropa, Thane Hancock, Laurent Guillaumot, Keith Rickart, Pascal Frison, Boris Pavlin, and Yvan Souares
Author affiliations: Secretariat of the Pacific Community, Noumea, New Caledonia (A. Roth, D. Hoy, P. Frison, Y. Souares)Papua New Guinea Institute of Medical Research, Goroka, Papua New Guinea (P.F. Horwood);National Department of Health, Port Moresby, Papua New Guinea (B. Ropa)Yap State Department of Health Services, Federated States of Micronesia (T. Hancock)Institut Pasteur, Noumea (L. Guillaumot)Queensland Health, Brisbane, Queensland, Australia (K. Rickart)World Health Organization, Port Moresby (B. Pavlin)


Chikungunya virus (CHIKV) caused significant outbreaks of illness during 2005–2007 in the Indian Ocean region. Chikungunya outbreaks have also occurred in the Pacific region, including in Papua New Guinea in 2012; New Caledonia in April 2013; and Yap State, Federated States of Micronesia, in August 2013. CHIKV is a threat in the Pacific, and the risk for further spread is high, given several similarities between the Pacific and Indian Ocean chikungunya outbreaks. Island health care systems have difficulties coping with high caseloads, which highlights the need for early multidisciplinary preparedness. The Pacific Public Health Surveillance Network has developed several strategies focusing on surveillance, case management, vector control, laboratory confirmation, and communication. The management of this CHIKV threat will likely have broad implications for global public health.
Chikungunya virus (CHIKV) is an alphavirus transmitted to humans by Aedes species mosquitoes, particularlyAedes aegypti and A. albopictus (1). It typically causes fever and severe and persistent joint pain (2). CHIKV was first recognized as a human pathogen in 1952 in Tanzania and, after several decades of little activity, has reemerged globally during the past decade (3). Chikungunya first appeared in the Pacific region in a small outbreak in New Caledonia in 2011 (1), but the virus is now a major threat in this reason. Outbreaks have been confirmed in Papua New Guinea (PNG) in June 2012 (4); New Caledonia in April 2013 (5); and Yap State, Federated States of Micronesia, in August 2013 (6). In this article, we give an overview of the virus, update the recent epidemiology of CHIKV, and assess the risk for CHIKV spread in the Pacific. We draw on lessons learned from the response efforts in the Indian Ocean, where the most devastating chikungunya epidemic so far caused havoc in a setting that is very similar to that of the Pacific Islands (7). We propose a series of public and clinical health measures to help Pacific Island countries and territories prepare for potential outbreaks of CHIKV infection.

Recent and Current Epidemiology of Chikungunya

Since 2000, chikungunya outbreaks have occurred in several regions of the world (3). Broadly speaking, the locations of these outbreaks appear to be moving in an easterly direction (3). Outbreaks occurred in the Democratic Republic of Congo in 2000 (8) and in Indonesia in 2001–2003 (9). In 2004, the virus appeared in Kenya; subsequently, a series of outbreaks occurred in the Indian Ocean during 2005–2007 (10). Affected locations included Seychelles (≈9,000 cases) (11), Comoros Islands (including 215,000 cases on Grande Comore) (12), Madagascar (12), Reunion Island (266,000 cases and 250 deaths) (12), Mauritius (≈6,000 cases) (11), and the Republic of the Maldives (13). During 2006–2007, outbreaks occurred in South and Southeast Asia (14). India reported 1.4 million cases (15), Sri Lanka 37,667 cases (15), and Malaysia 200 cases (15). Cases were also reported in Singapore in 2008 (16) and Thailand in 2008–2009 (17). The outbreaks in the Indian Ocean resulted in high attack rates, for example, 63% of the population in Grande Comore and 35% in Reunion Island (3,14,18).
Local chikungunya transmission had not been reported in the Pacific region until February 2011, when an autochthonous transmission of CHIKV was reported in New Caledonia (19). The first 2 cases were in persons who had recently returned from Indonesia; consistently, the virus was shown to belong to the Asian lineage. Only 33 cases were detected in total, and the outbreak was halted through aggressive case finding and vector control (1).
Thumbnail of Chikungunya epidemic in Papua New Guinea, 2012–2013. Colors denote the time for reports or rumors of emerging clinical disease. When such information was lacking, the date of laboratory confirmation of chikungunya virus infection determined the color coding. Solid colors indicate that cases were laboratory confirmed; striped colors indicate lack of laboratory confirmation.
Figure 1. Chikungunya epidemic in Papua New Guinea, 2012–2013Colors denote the time for reports or rumors of emerging clinical diseaseWhen such information was lacking, the date of laboratory confirmation of chikungunya virus infection...
In June 2012, a chikungunya outbreak started in West Sepik Province of PNG (20). In December, the PNG National Department of Health reported on PacNet, which is the Pacific Public Health Surveillance Network (PPHSN) early warning system (21), that similar but unconfirmed cases had been detected in Madang and East New Britain Provinces. Since then, investigations have made it apparent that CHIKV spread east through PNG (Figure 1Table 1) (4,22). In January 2013, confirmation of a case imported to Queensland, Australia, from PNG was reported (23). Since then, 10 more cases of chikungunya imported from PNG to Queensland have been reported (24).
At the end of April 2013, a chikungunya outbreak was confirmed in Noumea, the capital of New Caledonia (5). To date, 30 autochthonous cases have been confirmed, dating from early February through November 2013. The putative index case originated from the Indonesia, and the CHIKV was of the Asian lineage (data not shown).
In Yap State, an outbreak of chikungunya was reported in August 2013 (6). As of December 3, 2013, a total of 974 cases had been reported on Yap State and 128 cases on neighboring islands. The Yap State Department of Health Services posts weekly situational reports on PacNet to update the region. The path of introduction and the CHIKV genotype involved were not yet known at the time this article was prepared.

Risk for Further Spread of CHIKV in the Pacific

Thumbnail of Distribution of chikungunya vectors Aedes albopictus and Ae. aegypti mosquitos in the Pacific, 2013. Green outline indicates areas where Ae. albopictus mosquitos are confirmed or strongly suspected. Ae. aegypti mosquitos are found in most locations except New Zealand, Hawaii, Futuna, and some remote islands. Dotted lines indicate member countries of Pacific Public Health Surveillance Network.
Figure 2. Distribution of chikungunya vectors Aedes albopictus and Aeaegyptimosquitos in the Pacific, 2013Green outline indicates areas where Aealbopictusmosquitos are confirmed or strongly suspectedAeaegyptimosquitos are found in most locations except...
The CHIKV transmission cycle among humans can include Ae. aegypti or Ae. albopictus mosquitoes (25), both of which are widely spread in the Pacific region (Figure 2) (26). Some local Aedes mosquito species (e.g., Ae. polynesiensis) are also considered potential vectors. CHIKV has 3 genotypes, depending on its phylogenetic origins: West African, Asian, and East Central South African (ECSA) (27). The ECSA lineage may carry a point mutation in 1 gene of the E1 surface glycoprotein (E1:A226V), which greatly accelerates the replication cycle of the virus in the female Ae. albopictus mosquito, possibly from 5–7 days to 2–3 days (25). The ECSA virus strain was responsible for the largest documented epidemic of chikungunya in the Indian Ocean during 2005–2007 (28,29). CHIKV in PNG has been shown to be of the ECSA genotype and to carry this mutation (4). This genotype and mutation have also been confirmed in 4 of the recent cases imported to Queensland, Australia, from PNG (Forensic and Scientific Services, Department of Health, Queensland, Australia, pers. comm.). Furthermore, vector control measures in the Pacific may be hampered by pyrethroid resistance, which has already been described in Ae. aegypti mosquitoes in New Caledonia (1,30).
Thumbnail of Direct airline routes to Pacific region destinations from Papua New Guinea (Port Moresby), New Caledonia (Noumea), and Yap State, Federated States of Micronesia.
Figure 3. Direct airline routes to Pacific region destinations from Papua New Guinea (Port Moresby), New Caledonia (Noumea), and Yap State, Federated States of Micronesia.
Overall, the incidence of emerging diseases is increasing worldwide (31), partly because of population mobility and airline travel; >2 billion passengers take commercial flights every year (32). As demonstrated by outbreaks in Italy in 2007 and in France in 2010, both of which originated in India, CHIKV can spread by airline routes (33,34). Linking disease and vector distribution with air travel data is considered an important method for risk assessment of vector-borne disease spread (32). Considering the development of the situation in PNG, New Caledonia, and Yap State, the risk that cases of CHIKV infection will be imported to other Pacific Islands and is substantial, depending on travel patterns and numbers of airline passengers between countries and territories where CHIKV is circulating. The risk would be especially high for countries and territories with large numbers of air travelers to and from countries and territories with ongoing epidemics. Direct flights from PNG go to Fiji, Solomon Islands, Vanuatu, Australia, the Philippines, Hong Kong, Malaysia, Singapore, and Japan. From New Caledonia, direct flights go to Japan, South Korea, Australia, Fiji, Wallis Island, French Polynesia, and New Zealand; from Yap State, flights go to Guam and Palau (Figure 3).
Documentation on previous CHIKV circulation in the Pacific is scarce, but studies from PNG and Indonesia from the 1970s indicate a seroprevalence of CHIKV in the population of up to 30% (35,36). These results should be interpreted with caution because of known antigenic cross-reactivity of arboviruses, including CHIKV; however, these finding indicate that CHIKV could have circulated in the region and that there may be immunity among some populations.
Thus, similar to the situation in the Indian Ocean during the devastating chikungunya outbreaks in 2005–2007 (7), the risk of introduction of the virus to the Pacific region, followed by severe consequences for the area, is high because of virus strain, vector competence, and population mobility. The human population also likely has little or no immunity, making them susceptible to transmission, but this needs further study. However, differences between the Indian Ocean and the Pacific, particularly in population density, may decrease the risk of spread.

Lessons Learned from Recent Chikungunya Outbreaks in the Indian Ocean

Chikungunya had not previously been reported in Reunion Island, but during March 2005–April 2007, a total of 266,000 people—about one third of the population—were infected with CHIKV, and ≈250 people died (7,18). This outbreak resulted in a tremendous burden on the health system, peaking with >47,000 estimated cases in 1 week (7). The main risk factors for complications and death from CHIKV infection were age >65 years and preexisting diabetes and cardiovascular diseases (7,37). The economic costs of the epidemic were extreme, in large part because of absenteeism among both patients and caregivers, and the island economy had to be rescued by the central government of France under a specific crisis funding mechanism (38). Recurring and chronic joint pain affected one third of patients for 3 months to 1 year, and some case-patients have had these symptoms even longer (3), so that they are still affecting the health system and the socioeconomic well-being of the island’s population (38,39). Outbreaks of chikungunya and other diseases can also have a negative effect on tourism (40,41); the tourism industry is therefore a potentially important stakeholder to engage in prevention work.
The chikungunya outbreak in Reunion Island highlighted the importance of using a multidisciplinary approach to address medical and public health issues (42). Numerous teams in the arbovirus community rapidly focused their studies on CHIKV. One noticeable initiative was the creation of a CHIKV task force, comprising virologists, epidemiologists, entomologists, pathologists, immunologists, and clinicians working in Reunion Island (42,43).
Several lessons were learned from this experience. First and foremost were the limitations of island health care systems, which focus mainly on primary health care, to cope with so many cases of severe illness (44). The outbreak also emphasized the need for early preparedness to ensure the following: removal of potential vector-breeding sites; strengthening of vector control teams; efficient case management; adequate surveillance, case detection, and information and communication strategies; and the development of clear and consistent messages for behavior change campaigns (44,45).

Recommendations for Preparing for Chikungunya in the Pacific

To meet the need for early preparedness and consistent communication, the PPHSN has adopted an aggressive line of action in information dissemination. The PPHSN is a voluntary network of countries, territories, and organizations dedicated to the promotion of public health surveillance and appropriate response to the health emergencies for 22 Pacific Island countries and territories (Figure 2). The network was founded in 1996 under the auspices of the Secretariat of the Pacific Community and the World Health Organization (21).
The common surveillance system of the PPHSN is the Pacific Syndromic Surveillance System, which was introduced in October 2010 and implemented during the next 12 months in 20 of 22 Pacific Island countries and territories (46). This functional and timely regional infectious disease surveillance system tracks 4 core syndromes: acute fever and rash, diarrhea, influenza-like illness, and prolonged fever. Some countries also report the optional dengue-like illness. The frequency of syndromes is reported weekly to PPHSN partner World Health Organization in Suva, which prompts the countries and territories that there is an unexpected rise in a syndrome when the threshold of 90% of historically high reports is passed. The syndromes that would be expected to rise in frequency during dengue or chikungunya outbreaks are acute fever and rash, prolonged fever, and dengue-like illness (46,47). For confirmation testing of the causative agent of the outbreak, support is provided to Pacific Island countries and territories through the PPHSN laboratory referral network, LabNet (21).
In November 2012, a message was posted on PacNet relating that CHIKV infection occurred in PNG. In February 2013, a second communication was posted, relating to a case imported to Australia from PNG, including recommendations to the region (Table 2). The recommendations were derived through adapting international guidelines on preparedness for chikungunya outbreaks (4853) to the Pacific setting, on the basis of syndromic surveillance as the common surveillance system (Table 2) (46,47). After the issuance of these recommendations, the outbreak of CHIKV infection in Yap State was declared in August 2013 and reported in a timely manner on PacNet and elsewhere (6). The Yap State EpiNet team, the multidisciplinary national action team of PPHSN (21), has been effectively reporting weekly on PacNet on their efforts to map and control the outbreak. Regional assistance has been provided in the form of technical discussions and expertise in epidemiology and entomology from PPHSN partners. Furthermore, the Pacific Outbreak Manual (http://www.spc.int/phs/PPHSN/Surveillance/Syndromic/Pacific_Outbreak_Manual-version1-2.pdf) is being updated to include specific response guidelines for CHIKV outbreaks. PacNet has previously been shown to be sensitive in terms of number of messages on regional epidemics or on potential regional threats (21) and has continuously been used to update the region of the development of all the chikungunya outbreaks in PNG, New Caledonia, and Yap State.


CHIKV has reached the Pacific, with current chikungunya outbreaks occurring in PNG, Yap State, and New Caledonia. The threat of further spread is high. A large chikungunya outbreak in the Pacific would have severe effects on health care systems and public health infrastructure and would potentially affect general functions of society, as did the epidemic in the Indian Ocean region (7). Learning from previous experience is of the utmost importance, and governments and leaders in the region need to act in a timely manner and ensure balanced communication campaigns to inform and update public health professionals of the situation. In a region where many countries and territories struggle to meet International Health Regulation requirements, the management of the current threat of CHIKV in the Pacific is likely to also have implications for other parts of the world (33).
Dr Roth is a medical epidemiologist specializing in clinical microbiology. He currently serves as team leader for surveillance and operational research for the Secretariat of the Pacific Community. His research interests focus on infectious disease epidemiology and monitoring of vaccine and other health intervention effects.


We thank the Direction des Affaires Sanitaires et Sociales in New Caledonia for sharing prompt updates of the chikungunya epidemic in New Caledonia and Boris Colas for designing the figures in the manuscript.


  1. Dupont-Rouzeyrol MCaro VGuillaumot LVazeille MD’Ortenzio EThiberge JMchikungunya virus and the mosquito vector Aedes aegypti in New Caledonia (South Pacific Region). Vector Borne Zoonotic Dis2012;12:103641DOIPubMed
  2. Staples JEBreiman RFPowers AMChikungunya fever: an epidemiological review of a re-emerging infectious disease. Clin Infect Dis.2009;49:9428DOIPubMed
  3. Burt FJRolph MSRulli NEMahalingam SHeise MTChikungunya: a re-emerging virus. Lancet2012;379:66271DOIPubMed
  4. Horwood PFReimer LJDagina RSusapu MBande GKatusele MOutbreak of chikungunya virus infection, Vanimo, Papua New Guinea. Emerg Infect Dis2013;19:15358DOIPubMed
  5. Chikungunya (13): New Caledonia. ProMED. 2013 Apr 29 [cited 2013 Dec 3]. http://www.promedmail.org, archive no. 20130430.1681533.
  6. Chikungunya (47): Micronesia (Yap) alert. ProMED. 2013 Nov 11 [cited 2013 Dec 3]. http://www.promedmail.org, archive no. 20131114.2055640.
  7. Renault PSolet JLSissoko DBalleydier ELarrieu SFilleul LA major epidemic of chikungunya virus infection on Reunion Island, France, 2005–2006. Am J Trop Med Hyg2007;77:72731.PubMed
  8. Pastorino BMuyembe-Tamfum JJBessaud MTock FTolou HDurand JPEpidemic resurgence of chikungunya virus in Democratic Republic of the Congo: identification of a new central African strain. J Med Virol2004;74:27782DOIPubMed
  9. Porter KRTan RIstary YSuharyono WSutaryo Widjaja SA serological study of chikungunya virus transmission in Yogyakarta, Indonesia: evidence for the first outbreak since 1982. Southeast Asian J Trop Med Public Health2004;35:40815.PubMed
  10. Chretien JPAnyamba ABedno SABreiman RFSang RSergon KDrought-associated chikungunya emergence along coastal East Africa. Am J Trop Med Hyg2007;76:4057.PubMed
  11. Chikungunya and dengue, south-west Indian Ocean. Wkly Epidemiol Rec2006;81:1068.PubMed
  12. Renault PBalleydier ED’Ortenzio EBaville MFilleul LEpidemiology of chikungunya infection on Reunion Island, Mayotte, and neighboring countries. Med Mal Infect2012;42:93101DOIPubMed
  13. Chikungunya—Indian Ocean update (33): Maldives. ProMED. 2013 Dec 24 [cited 2012 Dec 3]. http://www.promedmail.org, archive no. 20061224.3598.
  14. Pulmanausahakul RRoytrakul SAuewarakul PSmith DRChikungunya in Southeast Asia: understanding the emergence and finding solutions. Int J Infect Dis2011;15:e6716DOIPubMed
  15. Outbreak and spread of chikungunya. Wkly Epidemiol Rec2007;82:40915.PubMed
  16. Leo YSChow ALTan LKLye DCLin LNg LCChikungunya outbreak, Singapore, 2008. Emerg Infect Dis2009;15:8367DOIPubMed
  17. Pongsiri PAuksornkitti VTheamboonlers ALuplertlop NRianthavorn PPoovorawan YEntire genome characterization of Chikungunya virus from the 2008–2009 outbreaks in Thailand. Trop Biomed2010;27:16776.PubMed
  18. Jansen KAThe 2005–2007 chikungunya epidemic in reunion: ambiguous etiologies, memories, and meaning-making. Med Anthropol.2013;32:17489DOIPubMed
  19. Alibert APfannstiel AGrangeon JP. Chikungunya outbreak in New Caledonia in 2011, Status report as at 22 August 2011. Inform’Action.2011;34:3–9 [cited 2013 Dec 3]http://www.spc.int/phs/english/publications/informaction/IA34/Chikungunya_outbreak_New_Caledonia_status_report_22August2011.pdf
  20. Pavlin B. Chikungunya (10)—Papua New Guinea response. ProMED. 2013 Mar 24 [cited 2013 Dec 3. http://www.promedmail.org, archive no. 20130325.1602542.
  21. Souarès YPacific Public Health Surveillance NetworkTelehealth and outbreak prevention and control: the foundations and advances of the Pacific Public Health Surveillance Network. Pac Health Dialog2000;7:1128.PubMed
  22. Horwood PBande GDagina RGuillaumot LAaskov JPavlin BThe threat of chikungunya in Oceania. Western Pac Surveill Response J.2013;4:810DOIPubMed
  23. Hide R. Chikungunya (12): Australia (Queensland) ex Papua New Guinea. 2013 Apr 27 [cited 2013 Dec 3]. http://www.promedmail.org, archive no. 20130427.1675486
  24. Queensland Health statewide weekly communicable diseases surveillance report, 25 November 2013 (for periods 18 November 2013–24 November 2013). 2013 Nov 25 [cited 2013 Dec 3]. http://www.health.qld.gov.au/ph/documents/cdb/weeklyrprt-131125.pdf
  25. Tsetsarkin KAVanlandingham DLMcGee CEHiggs SA single mutation in chikungunya virus affects vector specificity and epidemic potential.PLoS Pathog2007;3:e201DOIPubMed
  26. Guillaumot LOfanoa RSwillen LSingh NBossin HCSchaffner FDistribution of Aedes albopictus (Diptera, Culicidae) in southwestern Pacific countries, with a first report from the Kingdom of Tonga. Parasit Vectors2012;5:247DOIPubMed
  27. Powers AMLogue CHChanging patterns of chikungunya virus: re-emergence of a zoonotic arbovirus. J Gen Virol2007;88:236377.DOIPubMed
  28. de Lamballerie XLeroy ECharrel RNTtsetsarkin KHiggs SGould EAChikungunya virus adapts to tiger mosquito via evolutionary convergence: a sign of things to come? Virol J2008;5:33DOIPubMed
  29. Schuffenecker IIteman IMichault AMurri SFrangeul LVaney MCGenome microevolution of chikungunya viruses causing the Indian Ocean outbreak. PLoS Med2006;3:e263DOIPubMed
  30. Suivi de la resistance des moustiques aux insecticides. Noumea (New Caledonia): Institut Pasteur de Nouvelle-Caledonie; 2011.
  31. Jones KEPatel NGLevy MAStoreygard ABalk DGittleman JLGlobal trends in emerging infectious diseases. Nature2008;451:9903.DOIPubMed
  32. Tatem AJHuang ZDas AQi QRoth JQiu YAir travel and vector-borne disease movement. Parasitology2012;139:181630DOIPubMed
  33. Chretien JPLinthicum KJChikungunya in Europe: what’s next? Lancet2007;370:18056DOIPubMed
  34. Grandadam MCaro VPlumet SThiberge JMSouares YFailloux ABChikungunya virus, southeastern France. Emerg Infect Dis2011;17:9103.DOIPubMed
  35. Kanamitsu MTaniguchi KUrasawa SOgata TWada YWada YGeographic distribution of arbovirus antibodies in indigenous human populations in the Indo-Australian archipelago. Am J Trop Med Hyg1979;28:35163.PubMed
  36. Tesh RBGajdusek DCGarruto RMCross JHRosen LThe distribution and prevalence of group A arbovirus neutralizing antibodies among human populations in Southeast Asia and the Pacific islands. Am J Trop Med Hyg1975;24:66475.PubMed
  37. Borgherini GPoubeau PStaikowsky FLory MLe Moullec NBecquart JPOutbreak of chikungunya on Reunion Island: early clinical and laboratory features in 157 adult patients. Clin Infect Dis2007;44:14017DOIPubMed
  38. Lagacherie PCoverage of the chikungunya epidemic on Reunion Island in 2006 by the French healthcare system [in French]Med Trop (Mars).2012;72:978.PubMed
  39. Gérardin PFianu AMalvy DMussard CBoussaid KRollot OPerceived morbidity and community burden of chikungunya in La Reunion [in French]Med Trop (Mars)2012;72:7682.PubMed
  40. Flahault AAumont GBoisson Vde Lamballerie XFavier FFontenille DChikungunya, La Reunion and Mayotte, 2005–2006: an epidemic without a story? [in French]Sante Publique2007;19(Suppl 3):S16595.PubMed
  41. Malavankar DVPuwar TIMurtola TMVasan SS. Quantifying the impact of chikungunya and dengue on tourism revenues. Ahmedabad (India): Indian Institute of Management; 2009.
  42. Flahault AAumont GBoisson Vde Lamballerie XFavier FFontenille DAn interdisciplinary approach to controlling chikungunya outbreaks on French islands in the south-west Indian ocean. Med Trop (Mars)2012;72:6671.PubMed
  43. Schwartz OAlbert MLBiology and pathogenesis of chikungunya virus. Nat Rev Microbiol2010;8:491500DOIPubMed
  44. Gaüzère BAGerardin PVandroux DAubry PChikungunya virus infection in the Indian Ocean: lessons learned and perspectives [in French].Med Trop (Mars)2012;72:612.PubMed
  45. Bâville MDehecq JSReilhes OMargueron TPolycarpe DFilleul LNew vector control measures implemented between 2005 and 2011 on Reunion Island: lessons learned from chikungunya epidemic [in French]Med Trop (Mars)2012;72:436.PubMed
  46. Paterson BJKool JLDurrheim DNPavlin BSustaining surveillance: evaluating syndromic surveillance in the Pacific. Glob Public Health.2012;7:68294DOIPubMed
  47. Kool JLPaterson BPavlin BIDurrheim DMusto JKolbe APacific-wide simplified syndromic surveillance for early warning of outbreaks. Glob Public Health2012;7:67081DOIPubMed
  48. Centers for Disease Control and Prevention, Pan American Health Organization. Preparedness and response for chikungunya virus introduction in the Americas. Washington (DC): The Organization; 2011.
  49. Institut National de Prévention et d’Education pour la Santé. Dossier spécial chikungunya—point sur les connaissances et la conduite à tenir. Saint-Denis (France): Institut National de Prévention et d’Education pour la Santé (INPES); 2008 [cited 2013 May 10].http://www.inpes.sante.fr/CFESBases/catalogue/pdf/1085.pdf
  50. Programme de surveillance, d’alerte et de gestion du risque d’émergence du virus chikungunya dans les départements français d’Amérique. Prefecture de Martinique. Ministère de la Santé et des Soidarités—République Française; 2007 [cited 2013 May 10].http://opac.invs.sante.fr/doc_num.php?explnum_id=3518
  51. World Health Organization Regional Office for South-East Asia. Guidelines on clinical management of chikungunya fever. 2008 [cited 2013 May 10]. http://www.wpro.who.int/mvp/topics/ntd/Clinical_Mgnt_Chikungunya_WHO_SEARO.pdf
  52. Abeyewickreme WWickremasinghe ARKarunatilake KSommerfeld JAxel KCommunity mobilization and household level waste management for dengue vector control in Gampaha district of Sri Lanka; an intervention study. Pathog Glob Health2012;106:47987DOIPubMed
  53. Arunachalam NTyagi BKSamuel MKrishnamoorthi RManavalan RTewari SCCommunity-based control of Aedes aegypti by adoption of eco-health methods in Chennai City, India. Pathog Glob Health2012;106:48896DOIPubMed



Suggested citation for this article: Roth A, Hoy D, Horwood PF, Ropa B, Hancock T, Guillaumot L, et al. Preparedness for threat of chikungunya in the Pacific [online report]. Emerg Infect Dis [Internet]. 2014 Aug [date cited]. http://dx.doi.org/10.3201/eid2008.130696

DOI: 10.3201/eid2008.130696

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