Perennial impression of an emerging arbovirus on the epidemiology of rheumatic diseases in South India: Insights from the COPCORD study
A Rahim1, AJ Mathew2,
1 Department of Community Medicine, Medical College Hospital, Calicut, India
2 Division of Internal Medicine, Indian Institute of Diabetes, Trivandrum, Kerala, India
Department of Community Medicine, Medical College Hospital, Calicut
Are rheumatic musculoskeletal diseases (RMSD) given their due recognition by the medical fraternity and policy makers in India today? Focus on lifestyle diseases has taken away the importance of morbidity caused by musculoskeletal pain, which is one of the commonest ailments in the community. Poor awareness in general regarding the upcoming field of rheumatology and lack of proper data regarding these diseases in the country are the primary causes for this debacle. The epidemiology of RMSD in the country is fast changing, especially in the wake of viral epidemics, which leave their mark for months and years together. This view point emphasizes the burden of RMSD by highlighting the findings of two Community Oriented Programme for the Control of Rheumatic Diseases studies conducted to study the prevalence of RMSD in rural communities in the southern state of Kerala, which inadvertently captured the burden of RMSD following Chikungunya viral epidemics in the regions. Both the studies have reported a high prevalence of RMSD following the epidemics. The value of including RMSD in a national programme to combat the morbidity caused and to improve the health related quality of life of patients has been stressed upon, in the background of altering epidemiology of these disorders in the country.
|How to cite this article:|
Rahim A, Mathew A J. Perennial impression of an emerging arbovirus on the epidemiology of rheumatic diseases in South India: Insights from the COPCORD study.J Postgrad Med 2011;57:226-228
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Rahim A, Mathew A J. Perennial impression of an emerging arbovirus on the epidemiology of rheumatic diseases in South India: Insights from the COPCORD study. J Postgrad Med [serial online] 2011 [cited 2019 Dec 9 ];57:226-228
Available from: http://www.jpgmonline.com/text.asp?2011/57/3/226/85219
Emerging viral infections in the Indian subcontinent, of late, have been posing a daunting challenge for the clinicians.Chikungunya virus (CHIKV), a member of the genus Alphavirus of the Togaviridae family, transmitted to humans by Aedes aegypti and Aedes albopictus mosquitoes, is the latest among the lot. Following its initial report in India in 1963, CHIKV was thought to have disappeared from the subcontinent, until its invasion as an epidemic in 2005.  Kerala, a south-western state, has borne the brunt of its fury, with outbreaks in different parts, since 2006.  These outbreaks imposed a heavy epidemiological and financial burden on . CHIKV infection classically causes a highly infective, self-limiting febrile illness with fatigue, rash and incapacitating polyarthralgia, lasting 10 -12 days. Though there is a scarcity of follow-up data, persistent polyarthralgia, lasting for months to years, has been reported in the literature.  Other reported serious outcomes associated with CHIKV include meningoencephalitis,  myelopathy, peripheral neuropathy, myeloneuropathy and myopathy,  as well as cardiovascular, ocular and renal complications. , Studies have also reported likely fetal death in early gestation and severe neonatal infection following vertical transmission from mother to fetus. , There is also a report of 155 deaths, directly or indirectly caused by the virus. 
The Community Oriented Programme for Control of Rheumatic Diseases (COPCORD) was launched in 1981 to address the rising issue of rheumatic-musculoskeletal disorders (RMSD) in the rural economies of the developing world.  As part of the multicentric COPCORD project in India, funded by the Bone and Joint Decade (BJD)-India, two studies were conducted independently using a uniform methodology, with modified COPCORD Bhigwan model questionnaires,  in the southern (Trivandrum) and northern (Calicut) regions of Kerala. Both these rural community-based studies were done 8 months and 18 months following the 2007 and 2009 epidemics, respectively. Interestingly, during the 2007 epidemic, though the south was totally devastated, the northern part of the state was completely unaffected, and vice versa in the 2009 epidemic. These studies inadvertently captured the burden of post-CHIKV rheumatism in the respective regions.
Of the 10,286 subjects, above the age of 15 years, in both the centers together, 2900 (28.2%) individuals who had developed the infection during the epidemics were identified. The diagnosis of CHIKV was essentially clinical, using a standardized case definition, but in about 60%, was supported by serology in the acute phase (anti-CHIKV IgM antibodies). The proportion of subjects with persistent musculoskeletal pain during the surveys in both the centers together was 44.86%. In this group, 601 (46.2%) patients were naive to any musculoskeletal symptoms prior to the epidemics. This cohort was followed up for their clinical profile. Major self-reported sites of persistent pain in both the regions were knee, ankle, wrist and elbow. Higher age group (>45 years), lesser education, lower income, past history of joint pain, co-morbidities like diabetes and hypertension, type of occupation and longer duration of pain following the infection were some of the factors associated with persistent pain in this cohort. A validated, modified Indian Health Assessment Questionnaire  was administered to all subjects with persistent pain. Mild and moderately severe health assessment questionnaire scores were reported by 43.4% and 12.3%, respectively.
In the Calicut COPCORD study, prior to the 2009 epidemic, a point prevalence of RMSD in the community >15 years of age was noted to be 29%, which shot up to a staggering 47.2% in the aftermath of the epidemic, thereby changing the epidemiology of RMSD in the region. Another interesting observation was the increased incidence of inflammatory polyarthritis like rheumatoid arthritis, seronegative spondyloarthropathies, and soft tissue rheumatism following the epidemics in both the regions. Though a causal association could not be proved, this observation would set up a good platform for future studies for confirmation. There have been reports of rheumatoid arthritis and seronegative spondyloarthritis from North India and other parts of the world, following CHIKV infection. ,
The observations from these studies assume importance in the light of the heavy burden imposed by persistent arthropathy across India. Analysis of burden in relation to sequelae of this disease showed that acute episodes contributed only 7909 disability adjusted life years (30.9%), while persistent, incapacitating arthropathy accounted for the rest, thus indicating the major burden imposed by chronic CHIKV rheumatism.  Another study from Orissa has highlighted the disastrous health expenditure incurred by patients with chronic CHIKV rheumatism. 
National Program for RMSD - Need of the Hour
Planners and policy makers often tend to overlook the substantial morbidity and economic loss caused by these aches and pains, as they are rarely life threatening. Of late, the looming threat of non-communicable, lifestyle diseases in states like Kerala has given the thrust toward implementing the national program for control of diabetes, cardiovascular disorders and stroke (NPDCS) with vigor. The burden of RMSD in coexistence with diabetes, hypertension and emerging viral diseases too needs to be taken into account, thereby creating recognition of the need to include a national program for RMSD too. Recently, a study from Kerala has reported a high RMSD prevalence of 42.58% in patients with diabetes.  A national program will encourage many more such studies to look into the correlation of these disorders.
Disparities in health care quality occur across almost all areas of medicine. However, these are particularly underexplored in the area of RMSD, which are a substantial cause of morbidity worldwide. Until recently, disparities research primarily focused on acute disease and chronic diseases specifically targeted by national initiatives (e.g., cancer, diabetes, heart disease, and stroke). With our population growing older, more attention is being placed on disparities in chronic conditions that impact quality of life, such as arthritis and musculoskeletal diseases. In general, from a community-based perspective, RMSD show a prolonged nature resulting in large number of health care visits, profound health care cost and bulk loss of work time and earnings. A national program to address RMSD should therefore be designed to investigate plausible solutions to cut short the morbidity caused by these disorders.
In this context, the effort of the BJD-India to investigate the prevalence and incidence of RMSD across India and in particular sectors/groups is laudable. There is a need to explore further to improve our understanding of the risk factors for RMSD, their relative importance, and the interactions between them. There is dearth of encouraging studies into the patho-mechanisms and epidemiology of RMSD in the Indian context. The challenge in the domain of RMSD is to discover cost-effective methods to provide the right support to the right kind of people and in the most appropriate way. The WHO formulated the BJD (2000-2010) to see to it that musculoskeletal disorders are among the leading major health concerns in the minds and actions of opinion formers throughout the world and to fully realize the possibilities for prevention and treatment. The vision sought to ensure that prevention and treatment of people with RMSD is of high standards and consistently accessible, thus improving their health-related quality of life. To what extent this vision has been achieved in India with the added burden of RMSD inflicted and altered by the infectious as well as the non-communicable diseases is worth exploring. Observations from the COPCORD studies in Kerala matter in this context.
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