Research Article Asma M. Mukadam et al. / Journal of Pharmacy Research 2009, 2(9),1370-1372 ISSN: 0974-6943 Available online through http://jprsolutions.info Occurrence of chikungunya and prescribing patterns for its treatment in Maharshtra state Asma M. Mukadam*, Kanchan G. Chauhan, Sarfaraz Y. Topia, Kiran S. Bhise *Department of Pharmaceutical Chemistry, M.C.E. Society’s Allana College of Pharmacy,Azam Campus, Pune 411 001.Maharashtra. Received on: 20-05-2009; Accepted on:15-07-2009

ABSTRACT The objective of the present study was to survey the occurrence and prescribing pattern for Chikungunya. The study was carried out by surveying hundred patients between the age group 15- 45, undergoing treatment for Chikungunya in Buldhana district, (Maharashtra). The prescriptions, after the consent of the doctors and patients, were analyzed for prescribed drugs, and categorized. The results show that 50 % of the population suffering from Chikungunya was treated with the combination of an antipyretic, anti-inflammatory and antibiotic/antibac- terial; 38% of the prescriptions contained the combination of anti-inflammatory and antipyretics; 12 % of the total prescriptions contained only an antibiotic/antibacterial. In addition, supplementary treatment was also observed. About 80 % of suffered population was treated with IV fluids. Since a specific treatment is not available for Chikungunya, the patients were treated symptomatically. This survey highlights the demands for a more specific treatment, lest it leads to another epidemic break in the country.

Keywords: Chikungunya, Aedes aegypti, antipyretics, antibiotics, India

INTRODUCTION Chikungunya (pronounced as chik’-en-GUN-yah) fever is a viral dis- of India. It spread to other South Asian countries including Maldives ease transmitted to humans by the bite of infected mosquitoes Ades and Pakistan. The table I gives a brief account of the states affected aegypti. Chikungunya virus (CHIKV) is a member of the genus Alpha by Chikungunya in India, highlighting the incidence in Maharashtra virus, in the family Togaviridae. Aedes aegypti (the yellow fever mos- (5, 6). quito), a house hold container breeder and aggressive day time biter CHIKV infection can cause a debilitating illness, most often charac- which is attracted to humans, is the primary vector of CHIKV to terized by fever, headache, fatigue, nausea, vomiting, muscle pain, humans. Aedes albopictus (the Asian tiger mosquito) may also play a rash and joint pain. The incubation period can be 2-12 days, but is role in human transmission in Asia and Africa. The virus was first usually 3 to 7 days. ‘Silent’ CHIKV infections (infections without isolated from the blood of febrile patients in Tanzania in 1953 and has illness) do occur but how commonly this happens is not yet known. since been identified repeatedly in west central and southern Africa The prolonged joint pain associated with CHIKV is not typical of and many areas of Asia, and has been cited as the cause of numerous dengue. Co-circulation of dengue fever in many areas may mean that human epidemics in those areas since that time (1, 2). The term Chikungunya fever cases are sometimes clinically misdiagnosed as ‘Chikungunya’ is in Makonde language for ‘that which bends up’ (3). dengue infections, therefore the incidence of Chikungunya fever could This is a reference to the Chikungunya symptom where patients walk be much higher than what has been previously reported. No deaths, in a stooped posture due to joint pain. Chikungunya is also known as neuro invasive cases, or hemorrhagic cases related to CHIKV infec- Chicken guinea, Chicken gunaya and Chickengunya. The similarity tion have been conclusively documented in the scientific literature to the word “Chicken” has also lead to a lot of misconceptions about (7). the disease. Since 1952, Chikungunya showed cyclical outbreaks. MATERIALS AND METHOD Most number of Chikungunya cases was reported between 1960 and The present survey was carried out on prescribing pattern in Buldhana, 1982 in Africa and Asia .From 2003 onwards frequent outbreaks were district of Maharashtra, which was a highly prone to this epidemic. reported especially in South India. In 2005-2006, Chikungunya was The subjects of the study were infected males and females between reported in the Reunion Islands and about 200 people died due to the the age group of 15-45 years. The survey was carried out in the month disease. It was also widely reported from South Indian states namely of October-November, 2008.The prescriptions were obtained on the Kerala, Karnataka, Maharashtra, Tamil Nadu and Andhra Pradesh. consent of the physicians and the patients they had treated.6 general By 2007-2008, Chikungunya infection was reported from various parts practitioners were identified in the district and approached. From the Out Patient Department (OPD) book provided by the physicians, pa- *Corresponding author. tients were identified as infected and treated for the disease, all que- Tel.: + 91- ries posed to either the physician or the patient was strictly related to Telefax: +91- the survey. A 100 prescriptions were collected and a statistically ana- E-mail: [email protected] lyzed.

Journal of Pharmacy Research Vol.2.Issue 9.September 2009 1370-1372 Asma M. Mukadam et al. / Journal of Pharmacy Research 2009, 2(9),1370-1372 Table I: Chikungunya fever situation in India during 2006 (as on 11 October 2006) State No of Total fever/ No of No of Cases No of affected suspected samples sent to confirmed Deaths Districts Chikungunya laboratory fever Andhra Pradesh 22 7396 1224 248 0 Karnataka 27 758225 4944 294 0 Maharashtra 31 263268 5040 679 0 Tamil Nadu 35 62847 641 111 0 Madhya Pradesh 21 46407 669 62 0 Gujarat 25 71077 1023 145 0 Kerala 04 43148 0 38 0 Andaman and Nicoba 02 4462 0 0 0 NCT of Delhi 1 194 123 21 0 i Sixty five results awaited,ii The Kerala health minister differs on the number of deaths and has given a statement that the state witnessed 70 deaths caused by the disease Table 2: Data collected during the visit to the physicians in Figure I: Drugs used in chikungunya infection Buldhana, Maharashtra Asma M. Mukadam, Kanchan G. Chauhan, Topia Y. Sarfaraz Drugs used in CHIKV infection S.No No of Antibiotic with Antipyretic and Antibiotic prescriptions Antipyretic and Anti-inflammatory 100 collected Anti-inflammatory 80 1 39 19 17 03 60 40 88% 80% 2 20 07 09 04 P er c en ta ge 62% 20 3 10 08 - 02 0 4 17 10 04 03 Antibiotics Antipyretic+Anti- Supplementory 5 14 06 08 - inflammatory

Table 3: Table representing the % of patients prescribed antibiotic Drugs with antipyretic and anti-inflammatory, only antipyretic and anti-in- Percentage of drugs used in treatment of CHIKV infection flammatory, and only antibiotic respectivel Figure II: Antibiotics used in Chikungunya infection No of Antibiotic with Antipyretic and Antibiotic Asma M. Mukadam, Kanchan G. Chauhan, Topia Y. Sarfaraz prescriptions Antipyretic and Anti-inflammatory only Antibiotcs used in CHIKV infection collected Anti-inflammatory 100 50 38 12

Table IV: Drugs prescribed by the physicians for treatment of 31% 31% Chikungunya Cefixime Brand Name Content Quantity (mg) Ofloxacin Nise® Nimesulide 100 Emsulid® Nimesulide 100 Sparfloxacin Febrex-650® Paracetamol 650 Others Pyrigesic® Paracetamol 500 Emsulide-P® Nimesulide+ Paracetamol 110+325 15% Sumo® Nimesulide+ Paracetamol 100+500 23% Algiril® Nimesulide+ Paracetamol 100+350 Nimica plus® Nimesulide + Paracetamol 100+300 Percentage of Different Antibiotics used in treatment of Nobel plus® Nimesulide + Paracetamol 100+500 Nelsid-P® Nimesulide + Paracetamol 100+325 CHIKV infection Dolokind-P® Aceclofenac+Paracetamol 100+325 Acpara® Aceclofenac+Paracetamol 100+325 Figure III: percentage of Antipyretics and Anti-inflammatory used Zeredol-P® Aceclofenac+Paracetamol 100+500 Asma M. Mukadam, Kanchan G. Chauhan, Topia Y. Sarfaraz Ebugesic Plus® Ibuprofen+Paracetamol 100+400 % of Antipyretic & Anti Inflamatory Adiflam comp® Diclofenac Sodium+Paracetamol 50+500 Diclomol® Diclofenac +Paracetamol 50+500 used Voveran 50® Diclofenac Sodium 50 Doxy® Doxycyclin 200 13.63% Microdox® Doxycyclin 100 Ciplox500® Ciprofloxacin 500 Alcifro 500® Ciprofloxacin 500 Zoxan500® Ciprofloxacin 500 34.09% Nimesulide+Paracetamol ® Zenflox200 Ofloxacin 200 Aceclofenac+Paracetamo 15.9% Sparbact200® Sparfloxacin 200 l Oflomac 200® Ofloxacin 200 Nimesulide ® Mahacef200 Cefixime 200 Paracetamol Cefolac200® Cefixime 200 Zifi200® Cefixime 200 Megaflox500® Amoxicillin 500 Basmox500® Amoxicillin+Cloxacillin 250+250 22.72% Azithral500® Azithromycin 500 Zathru 500® Azithromycin 500 Percentage of Different Antipyretic and Anti-inflammatory used in Beplex fort® Vit B +B +B +Niacinamide 10+2+2+100 1 2 6 chikungunya Infection Journal of Pharmacy Research Vol.2.Issue 9.September 2009 1370-1372 Asma M. Mukadam et al. / Journal of Pharmacy Research 2009, 2(9),1370-1372 anti-inflammatory drugs, Chloroquine phosphate (250 mg/day) has RESULTS given promising results. Research by Italian scientist, Andrea From this survey we have concluded that, the most commonly used Savarino, and his colleagues in addition a French government press class of drugs was combination of antipyretic, anti-inflammatory with release in March 2006 have added more credence to the claim that antibiotics which contributed (50% of the prescriptions) and the most Chloroquine may be effective in treating Chikungunya (9). The CDC favored combinations were Nimesulide, Paracetamol with Cefixime, (Centres or Disease Control and Prevention) fact sheet on and second favoured combination was Aceclofenac, Paracetamol with Chikungunya advises against using Aspirin. Ibuprofen, Naproxen Cefixime. The physicians prescribed combination of anti-inflamma- and other non-steroidal anti-inflammatory drugs are recommended tory and antipyretics drugs to about 38% of population surveyed. for arthritic pain and fever. Currently there is no vaccination against The drugs mostly given in this combination were Nimesulide and Chikungunya. Research is ongoing on the development of DNA vac- Paracetamol or Aceclofenac and Paracetamol. Only 12 % of the pa- cination against Chikungunya. Usually the disease starts to decrease tients were prescribed with antibiotics and commonly used antibiot- in intensity after 3 days and it may take up to 2 weeks for recovery. ics were Cefixime or Azithromycin. In addition, the supplementary But in elderly the recovery is very slow and may take up to 3 months. treatment was observed. About 80% of patients were treated with In some cases the joint pain can last even up to a year. intravenous fluids and multivitamins. Since the specific treatment is not available for Chikungunya and On micro analysis of the treatments, the doctors favoured third gen- only patients were treated by symptomatic treatment, it demands there- eration antibiotic Cefixime (31%), and antibacterials such as Ofloxacin fore specific treatment. (31 %), Sparfloxacin (15 %) and other macrolides such as Azithromycin, As Chikungunya fever has spread very rapidly in last few months in or Benzyl Penicillin analogues such as Amoxicillin or Cloxacillin (15 India, The need for the preventive treatment of Chikungunya can %). never be sidelined; however this might take several years to come till The following tables (TableI, II, III and IV) and graphs (Graph I, II and a vaccine or medicine is developed. , thus the need arises to find a III) give a one glance summary of the survey analysis: symptomatic treatment the can give the best results, to overcome the From above information, the conclusion is made that chikungunya Chikungunya infection breaking into an epidemic again. Doctors and fever is a highly epidemised disease thus it requires an extensive pharmacists along with the help of patients can work in unison to preventive measures to avoid its spread. From this survey we have develop treatment that gives the best possible results. similar sur- concluded that, the most commonly used class of drugs was combi- veys can help trigger research work related to specific treatments nation of antipyretic , anti-inflammatory with antibiotics which con- and prevent another outbreak of the epidemic .Several areas on tributed 50% and the most favored combinations were Nimesulide + Chikungunya ever that merit future research include the reason(s) for Paracetamol with Cefixime, and second favoured combination was mysterious behavior of dramatic outbreaks interspersed by periods Aceclofenac + Paracetamol with Cefixime. The physicians were pre- of prolonged absence, development of an effective vaccine, afford- scribed combination of anti-inflammatory and antipyretics drugs to able, reliable and reproducible indigenously developed rapid serodi- about 38% of population suffered. The drugs mostly given in this agnostic useful in the field setting and a nation wide network of reli- combination were Nimesulide + Paracetamol, Aceclofenac + able, high quality or virology laboratories and developing a surveil- Paracetamol. The only antibiotic prescribed for about 12% popula- lance system for monitoring outbreaks of Chikungunya . A drastic tion suffered and commonly used antibiotics were Cefixime, change in the outlook of the community and public health authorities Azithromycin. In addition to the about, the supplementary treatment with regard to hygiene and mosquito control measures is essential to was observed. About 80% of suffered population was treated with IV fluids and multivitamins. stand a chance in the war against the mosquitoes (10). On micro analysis, the doctors most favored third generation antibi- REFERENCES: 1.Mohan A. Chikungunya fever: Clinical manifestations and management. In- otic was Cefixime (31%), and antibacterials such as Ofloxacin also (31 dian J Medical Res. 2006; 124: 471-474. %), Sparfloxacin (15 %), and other macrolides such as Azithromycin, 2.Mourya D. T, Yadav P. Vector biology of dengue and chikungunya viruses.Indian or benzyl penicillin analogues such as Amoxicillin and Cloxicillin (15 J medical Res, 2006; 124: 475-80. 3.Centres for disease control and prevention (CDC).Chikungunya fever diag- %). nosed among travelers-United States, 2005-2006.MMWR Morb Mortal Weekly In terms of anipyretics and anti-inflammatory drugs, the most pre- Rep. 2006; 55:1040-2. ferred combination was Nimesulide with Paracetamol (34.09%), fol- 4.Benjamin M. The internet living Swahili learning centre. Chikungunya is not lowed by Aceclofenac with Paracetamol (22.72 %), only Nimesulide a Swahili word. It is from Makonde language! Available at URL: Http: //research .yale .edu/Swahili/learn/q=en/chikungunya_makonde.Accessed on on 7 April, (15.9%), or only Paracetamol (18.63 %). 2009. DISCUSSION 5.India, Dengue and Chickungunya, Information bulletin no 1, 2006, Available There is no specific treatment for Chikungunya. Vaccine trials at URLhttp://www.ifrc.org/docs/appeals/rpts06/INdeng16100601.pdf.accessed on 7 April, 2009. were carried out in 2000, but funding for the project was discontinued 6.Government of India, Ministry of health and family welfare. update on and there is no vaccine currently available. No vaccine or specific chikungunya:13 October 2006.Available at URL:http://www.namp.gov.in/Doc/ antiviral treatment for Chikungunya fever is available. Treatment is Chikungunya%20-%20update.pdf.accessed on october28,2006 symptomatic—rest, fluids, and Ibuprofen, Naproxen, acetaminophen, 7.Prasanna N, Yergolkar, Babasaheb V. Tandale,et al. Chikungunya outbreaks caused by African genotype,India. Emerging Infectious Diseases 2006; 12: 1580- or Paracetamol may relieve symptoms of fever and aching. Aspirin 1583. should be avoided as it is known to cause the risk of bleeding (8). 8.World health organization,regional office of south east asia, Chikungunya Chloroquine is also gaining ground as a possible treatment for fever, factsheet. Available at URL:http://www.searo.who.int/en/Section10/ Section2246_13975.html.Accessed on 6 April,2009. the symptoms associated with Chikungunya and as an antiviral agent 9.Brighton SW. Chloroquine phosphate treatment of chronic Chikungunya to combat the Chikungunya virus. According to the University of arthritis.An opens pilot study. S Afr Med J 1984:66:217-8. Malaya, in unresolved arthritis refractory to aspirin and non steroidal 10.Ananthanarayan and Panikar’s, Textbook of Microbiology by R. Ananthanarayan and C.K. Jayaram Panikar, Seventh edition, 2005, 521- 525. Source of support: Nil, Conflict of interest: None Declared Journal of Pharmacy Research Vol.2.Issue 9.September 2009 1370-1372