Transactions of the Royal Society of Tropical Medicine and Hygiene (T ROY SOC TROP MED H)

Publications in this journal

• Article: The underlying aetiologies of coma in febrile Sudanese children.

  Eisa O El-Amin, Mohamed I Haj Elbashir, Osman E Elamin, Yousif Mukhtar, Hussein Abdo, Ismail Abdul-Rahman, Mohamed E El-Amin
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  ABSTRACT: Cerebral malaria, acute bacterial meningitis and viral encephalitis are the main causes of fever and altered consciousness in the tropics. In areas where reliable laboratory testing is unavailable, over diagnosis and misdiagnosis of these conditions is likely. In malaria endemic countries non-malarial contributors to coma may be overlooked, overburdening available resources. The aim of this study is to evaluate the underlying causes of altered mental state in children presenting with fever and coma to tertiary medical facilities in Sudan. Children over one month of age admitted to the emergency departments of three main hospitals in Khartoum with fever and coma were investigated for cerebral malaria, acute bacterial meningitis and Herpes simplex encephalitis during April to November 2011. One hundred and four children presenting with fever and coma were evaluated. Cerebral malaria was clinically suspected in 38 patients and 5 were confirmed. Acute bacterial meningitis was suspected in 63 patients and confirmed in 15. Herpes encephalitis was confirmed in only one case. There were five cases of mixed infection and the remainder were unknown. The clinical diagnoses of cerebral malaria, acute bacterial meningitis and viral encephalitis are unreliable. Further studies to evaluate the underlying causes of coma in febrile Sudanese children are warranted.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 05/2013; 107(5):307-12.
• Article: Plasmodium vivax malaria in Duffy-negative individuals from Ethiopia.

  Tamirat Gebru Woldearegai, Peter G Kremsner, Jürgen F J Kun, Benjamin Mordmüller
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  ABSTRACT: This study was conducted to estimate the prevalence of Plasmodium vivax and polymorphisms in the Duffy antigen receptor for chemokines (DARC) gene in patients with suspected malaria from eastern (Harar) and southwestern (Jimma) Ethiopia. Plasmodium presence and species was assessed by microscopy in 1304 and 627 febrile patients in Harar and Jimma, respectively, during October-November 2009. All microscopy-positive samples were confirmed by PCR. DARC gene polymorphisms were identified by DNA sequencing. Plasmodium vivax was the dominant species in Harar (74/98, 76%) and P. falciparum was more common in Jimma (70/107, 65%). We found 17/98 (17%) and 24/107 (22%) homozygous Duffy-negative patients in Harar and Jimma, respectively. Unexpectedly, three Duffy-negative patients from Harar had P. vivax malaria. This study documents the emergence of P. vivax malaria in Duffy-negative individuals in Ethiopia. The Duffy-negative blood group does not appear to provide absolute protection against P. vivax infection in this region.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 05/2013; 107(5):328-31.
• Article: Malaria burden in irregular migrants returning to Sri Lanka from human smuggling operations in West Africa and implications for a country reaching malaria elimination.

  K Wickramage, G N L Galappaththy
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  ABSTRACT: The number of malaria cases among irregular migrants returning to Sri Lanka has not been investigated. In the first 6 months of 2012 we screened 287 irregular migrants returning from seven West African nations to Sri Lanka for malaria to ascertain the risk of infection during migration. Four men were diagnosed as having malaria: three with Plasmodium falciparum had travelled to Togo and one with P. vivax had travelled to Guinea. The risk of contracting malaria was 14 cases per 1000. Facilitating a safe return with selective screening for at-risk inbound migrants flows is desirable as Sri Lanka advances towards its goal of malaria elimination.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 05/2013; 107(5):337-40.
• Article: Multicenter study of hypoxemia prevalence and quality of oxygen treatment for hospitalized Malawian children.

  Eric D McCollum, Erica Bjornstad, Geoffrey A Preidis, Mina C Hosseinipour, Norman Lufesi
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  ABSTRACT: Although hypoxemic children have high mortality, little is known about hypoxemia prevalence and oxygen administration in African hospitals. We aimed to determine the hypoxemia prevalence and quality of oxygen treatment by local clinicians for hospitalized Malawian children. The study was conducted in five Malawian hospitals during January-April 2011. We prospectively measured the peripheral oxygen saturation (SpO2) using pulse oximetry for all children <15 years old and also determined clinical eligibility for oxygen treatment using WHO criteria for children <5 years old. We determined oxygen treatment quality by Malawian clinicians by comparing their use of WHO criteria for patients <5 years old using two standards: hypoxemia (SpO2 <90%) and the use of WHO criteria by study staff. Forty of 761 (5.3%) hospitalized children <15 years old had SpO2 <90%. No hospital used pulse oximetry routinely, and only 9 of 40 (22.5%) patients <15 years old with SpO2 <90% were treated with oxygen by hospital staff. Study personnel using WHO criteria for children <5 years old achieved a higher sensitivity (40.0%) and lower specificity (82.7%) than Malawian clinicians (sensitivity 25.7%, specificity 94.1%). Although hypoxemia is common, the absence of routine pulse oximetry results in most hospitalized, hypoxemic Malawian children not receiving available oxygen treatment.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 05/2013; 107(5):285-92.
• Article: Comparison of three methods for the recovery of skin pathogens from impetigo swabs collected in a remote community of Northern Territory, Australia.

  Asha C Bowen, Steven Y C Tong, Mark D Chatfield, Ross M Andrews, Jonathan R Carapetis
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  ABSTRACT: BACKGROUND: Impetigo is a common infection in children living in remote areas. Immediate plating of impetigo swabs is the gold standard for bacterial recovery but is rarely feasible in remote regions. Bacterial culture increases our understanding of antibiotic resistance and strain diversity, which guides treatment protocols and epidemiological monitoring. METHODS: We investigated three practical alternatives for recovering Streptococcus pyogenes and Staphylococcus aureus from transported swabs: dry swabs transported at 4°C with desiccant and plated within 48 h; swabs inoculated into skim milk tryptone glucose glycerol broth (STGGB), transported at 4°C, stored at - 70°C and plated within 61 days; and ESwabs inoculated into Amies broth, transported at 4°C and plated within 48 h. Detection of Strep. pyogenes and Staph. aureus from simultaneously collected swabs was compared for the dry vs STGGB (36 sores) and the STGGB vs Amies (39 sores) methods. Swabs were collected from 43 children (75 sores sampled) in a remote community of Northern Territory, Australia in November 2011. The children had impetigo and were participating in the Skin Sore Trial [Australian Clinical Trials Registry ACTRN12609000858291]. RESULTS: Recovery of Strep. pyogenes for dry vs STGGB was 72% (26/36) and 92% (33/36) and for STGGB vs Amies was 92% (36/39) for both methods. Staphylococcus aureus recovery for dry vs STGGB was 69% (25/36) and 72% 26/36) and for STGGB vs Amies was 74% (29/39) and 85% (33/39). CONCLUSION: STGGB and Amies media provided higher recovery of Strep. pyogenes than dry swabs. These results and the opportunity to batch and store specimens for molecular studies support the use of STGGB transport media for future impetigo research.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 04/2013;
• Article: Clinical characteristics and outcome of 107 adult patients with chronic Chagas disease and parasitological cure criteria.

  Graciela L Bertocchi, Carlos A Vigliano, Bruno G Lococo, Marcos A Petti, Rodolfo J Viotti
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  ABSTRACT: BACKGROUND: The cure in adult patients with chronic Chagas disease and the relationship between parasitological and clinical evolution is still under debate. The aim of this study was to analyze the clinical, epidemiological and progression features of the disease in a patient population who became serologically negative either spontaneously or post-etiological treatment. METHODS: We included 107 patients over 20 years old with three different confirmed reactive anti-Trypanosoma cruzi serologic tests on admission, and a minimum of two years of follow-up. Patients were assigned to clinical groups according to Kuschnir. Change of clinical group was considered a heart disease progression criterion, and seronegative conversion of two or three as parasitological cure criterion. RESULTS: From 107 patients with parasitological cure, 82 had received treatment (77%) and 25 became spontaneously seronegative (23%). Forty-six (43%) and 61 (57%) patients had two and three negative serological tests, respectively. No differences in clinical groups, ECG, echocardiogram and heart disease progression were found in patients who became negative spontaneously or post-treatment. The clinical progression and ECG changes were observed in 5/107 (5%) and 11/107 (10%) respectively, in a mean of 10 years follow-up. CONCLUSIONS: Adults with chronic Chagas disease can cure, mostly post-etiological treatment, but also spontaneously, showing a favourable clinical outcome.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 04/2013;
• Article: Severe scorpion envenomation among children: does hydrocortisone improve outcome? A case-control study.

  Mabrouk Bahloul, Anis Chaari, Rania Ammar, Rania Allala, Hassen Dammak, Olfa Turki, Hedi Chelly, Chokri Ben Hamida, Mounir Bouaziz
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  ABSTRACT: BACKGROUND: To analyse the efficacy and safety of systemic infusion of hydrocortisone hemisuccinate in children admitted to the intensive care unit with severe scorpion envenomation, we assessed the impact on mortality and length of hospital stay. METHOD: We conducted a pair-wise, case-control study with 1:1 matching, reviewing records over a 13-year period (1990-2002) for the intensive care unit (ICU) of the Habib Bourguiba University Hospital, Sfax, Tunisia. A total of 184 children were included in the study (92 cases and 92 controls); cases received hydrocortisone hemisuccinate during hospitalization and controls received no steroids. Patients were matched according to age (±2 years), severity factors at admission (pulmonary edema and grades of severity of scorpion envenomation) and scorpion antivenom administration. RESULTS: Cases and controls did not differ significantly in age (4.9 ± 5.5 years vs 6.2 ± 3.8 years; p > 0.05), mean temperature on admission (37.2 ± 1.2 vs 37.2 ± 1.06; p = 0.99) or presence of systemic inflammatory response syndrome (SIRS) (77 vs 70; p = 0.198). The proportion of patients with pulmonary edema was similar in the two groups (77 vs 71; p > 0.05), and in each group 46 patients (50%) received scorpion antivenom (p > 0.05). The use of mechanical ventilation, ICU length of stay and ICU mortality was not significantly different between the studied groups. CONCLUSION: We detected no significant difference between patients receiving steroids and steroid-free patients in terms of mortality and ICU length of stay. The hydrocortisone hemisuccinate regimen described here had a limited effect in critically ill envenomated children and, therefore, we suggest that it should not be recommended.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 04/2013;
• Article: Low diversity of Leishmania parasites in sandflies and the absence of the great gerbil in foci of zoonotic cutaneous leishmaniasis in Fars province, southern Iran.

  P Parvizi, E Alaeenovin, P A Kazerooni, P D Ready
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  ABSTRACT: BACKGROUND: Fars province lies to the south of the main foci of zoonotic cutaneous leishmaniasis (ZCL) caused by Leishmania major in central and northern Iran, and its ZCL foci might have emerged more recently because of different transmission cycles. However, there have been limited studies of the parasites infecting the regional sandfly vectors. METHODS: The diversities of sandflies and the Leishmania parasites infecting female sandflies were assessed for different habitats in Fars ZCL foci, 2008-2009, using standardized sandfly trapping and characterization of ribosomal DNA haplotypes of parasites. RESULTS: Vector diversity was similar to that in the main Iran ZCL foci, but parasite diversity was lower. Only Le. major was detected in Fars sandflies. Most infections were found in the abundant vector Phlebotomus papatasi collected in rodent burrows. Infections were detected for the first time in Iran in the related P. bergeroti. CONCLUSIONS: The failure to detect other gerbil parasites (Le. turanica, Le. gerbilli) is explained by the absence of one reservoir host, the great gerbil Rhombomys opimus. Other gerbils (Meriones species) may be the regional reservoir hosts, but transmission modelling is required for a better understanding of the emergence and stability of ZCL foci in Fars and other Iranian provinces.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 04/2013;
• Article: No evidence for association of the CD40, CD40L and BLYS polymorphisms, B-cell co-stimulatory molecules, with Brazilian endemic Plasmodium vivax malaria.

  Marcela P Capobianco, Gustavo C Cassiano, Adriana A C Furini, Luciane M Storti-Melo, Erika C Pavarino, Ana L S Galbiatti, Valéria D Fraga, Luciana M Conceição, Vanja S C Couto, Alvaro A R A Couto, Ricardo L D Machado
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  ABSTRACT: BACKGROUND: Plasmodium vivax is the most prevalent malaria species in Brazil. The parasite-host coevolutionary process can be viewed as an 'arms race', in which adaptive genetic changes in one are eventually matched by alterations in the other. METHODS: Following the candidate gene approach we analyzed the CD40, CD40L and BLYS genes that participate in B-cell co-stimulation, for associations with P. vivax malaria. The study sample included 97 patients and 103 controls. We extracted DNA using the extraction and purification commercial kit and identified the following SNPs: -1C > T in the CD40 gene, -726T > C in the CD40L gene and the -871C > T in the BLyS gene using PCR-RFLP. We analyzed the genotype and allele frequencies by direct counting. We also compared the observed with the expected genotype frequencies using the Hardy-Weinberg equilibrium. RESULTS: The allele and genotype frequencies for these SNPs did not differ statistically between patient and control groups. Gene-gene interactions were not observed between the CD40 and BLYS and between the CD40L and BLYS genes. Overall, the genes were in Hardy-Weinberg equilibrium. Significant differences were not observed among the frequencies of antibody responses against P. vivax sporozoite and erythrocytic antigens and the CD40 and BLYS genotypes. CONCLUSIONS: The results of this study show that, although the investigated CD40, CD40L and BLYS alleles differ functionally, this variation does not alter the functionality of the molecules in a way that would interfere in susceptibility to the disease. The variants of these genes may influence the clinical course rather than simply increase or decrease susceptibility.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 04/2013;
• Article: Association between seropositivity for Toxoplasma gondii, scholastic development of children, and risk factors for T. gondii infection.

  Erika C Ferreira, Ariella A Marchioro, Terezinha A Guedes, Daniela C G A Mota, Ana L F Guilherme, Silvana M de Araújo
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  ABSTRACT: BACKGROUND: We evaluated the possible association of seropositivity for Toxoplasma gondii and certain risk factors for T. gondii infection with the scholastic development of children. METHOD: One hundred children aged 6-13 years attending the Hospital Municipal de Maringá Paranáa, Brazil, participated in the study. Serologic tests for IgG and IgM anti-T. gondii (indirect immunofluorescence (capture ELISA) were performed. The Scholastic Performance Test (SPT) for writing, mathematics and reading was applied to each child, and the result was classified as high, average or poor. The guardian of each child responded to a questionnaire about certain aspects of the child's living situation and diet. RESULTS: The prevalence of seropositivity for T. gondii was 8%. An association between seropositivity for T. gondii and scholastic development in the mathematics subtest and also consumption of fresh cheese were observed. Children with exposed soil, sand or grass lawn in their peridomicile were 9.116 times more likely to be infected by T. gondii. CONCLUSION: The findings showed the need to test school-age children for this parasite, educate families with T. gondii-positive children, provide training to educators, monitor recreation areas, and raise awareness of the need for care in handling food.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 04/2013;
• Article: Comparative efficacy of one versus two doses of praziquantel on cure rate of Schistosoma mansoni infection and re-infection in Mayuge District, Uganda.

  Edridah M Tukahebwa, Birgitte J Vennervald, Fred Nuwaha, Narcis B Kabatereine, Pascal Magnussen
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  ABSTRACT: BACKGROUND: The current recommended control strategy for schistosomiasis is annual treatment using 40 mg/kg of praziquantel. However, praziquantel is only effective on adult worms and giving a second dose may increase its efficacy. We assessed the effect of one versus two doses of praziquantel on cure rate and re-infection with Schistosoma mansoni in a high endemic community along Lake Victoria, Uganda. METHODOLOGY: To investigate the effect of the two regimens, 395 infected people were randomised into two groups; one received a single standard dose of praziquantel (Distocide® 600 mg, Shin Poong Pharmaceuticals, Seoul, Republic of Korea), 40mg/kg body weight, while the other group received a second dose 2 weeks later. Cure rate and infection intensity were assessed 9 weeks after the first treatment using standard parasitological procedures. Re-infection levels were monitored 8 and 24 months after treatment. RESULTS: Those who received two doses were more likely to be cured (69.7%) compared to those who received a single dose (47.9%) (χ(2) = 18.5, p < 0.001). Geometric mean intensity (GMI) of infection at 9 weeks (eggs per gram of faeces [epg]) was 12.0 epg (CI95: 8.9-16.1) for individuals who received 2 doses and 22.1 epg (CI95: 16.9-28.8) for those in the single dose arm. Eight months after treatment, prevalence of re-infection for individuals in the double dose arm (61.6%, CI95: 50.2-73.1) was not significantly different from that of those in a single dose arm (68.3%, CI95: 59.9-76.8). The difference in GMI of re-infection for individuals in the single dose arm (33.8 epg, CI95: 23.2-49.3) and those in the double dose arm (34.5 epg, CI95: 24.7-48.1) was not significant. Twenty four months after treatment, prevalence of re-infection was not significantly different. The difference in GMI of re-infection for those in the single dose arm (57.5 epg, CI95: 33.9-97.5) and those in the double dose arm (42.2 epg, CI95: 29.9-59.6) was also insignificant. CONCLUSION: Our results suggest that a second dose of praziquantel given 2 weeks after the first dose improves cure rate and reduces S. mansoni infection intensity. However, there is no added advantage on reduction of S. mansoni re-infection by administering two doses of praziquantel. CLINICAL TRIALS.GOV IDENTIFIER: NCT00215267.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 04/2013;
• Article: Laboratory diagnosis of malaria in the North West Region of Cameroon: analysis of limitations.

  Eric Ndofor, Tom van Gool, Henk Gillis
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  ABSTRACT: BACKGROUND: Malaria is still rife and perennial in Cameroon despite remarkable progress in controlling the disease. About 95% of the country is malaria endemic. Prompt and accurate diagnosis of malaria may lead to improved patient care and reduced morbidity. This paper analyses limitations in malaria diagnosis in the North West Region of Cameroon and opportunities for improvement. METHODS: The sample units were 40 laboratories in governmental health facilities (GHFs) selected by cluster (Health Districts) and stratified sampling. The three categories of GHFs in the Region - Hospitals, District Medical Centres (Centre Médical d'Arrondissement [CMAs]) and Integrated Health Centres (IHCs) - were strata in the sample. With pre-tested interviewer-administered structured questionnaires and visits to laboratories, mechanical and optical components of microscopes and malaria diagnostic techniques were studied systematically and in detail. RESULTS: The main finding was that locally prepared Giemsa-stained malaria smears were of unusable quality in 52 and 46% of GHFs for thick and thin smears respectively. Some loss of quality was observed in laboratories with good and moderate quality smears. CONCLUSION: The quality of malaria diagnosis was not optimal and GHFs did not have sufficient tools and resources to overcome loss of quality. Nonetheless, limitations in malaria diagnosis in the Region can be corrected.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 03/2013;
• Article: Assessment of the quality of life of patients with cutaneous leishmaniasis in Belo Horizonte, Brazil, 2009-2010. A pilot study.

  Antonio Carlos de Castro Toledo, Rosiana Estéfane da Silva, Rose Ferraz Carmo, Thaís Alves Amaral, Zélia Maria Profeta Luz, Ana Rabello
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  ABSTRACT: BACKGROUND: Cutaneous leishmaniasis (CL) may manifest as single or multiple skin lesions, causing significant aesthetic impact and affecting the patient's quality of life (QoL). The objective of this study was to assess the impact of CL on the QoL. METHODS: The QoL of 20 patients with CL was assessed by the Dermatology Life Quality Index (DLQI). RESULTS: For 70% of patients CL had a moderate/large impact on their QoL, with 'Work and School' being the most affected domain. This is the first study to use the DLQI to assess the impact of CL. CONCLUSION: CL has a moderate to large negative effect on QoL.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 03/2013;
• Article: Is mid-upper arm circumference alone sufficient for deciding admission to a nutritional programme for childhood severe acute malnutrition in Bangladesh?

  Engy Ali, Rony Zachariah, Zubair Shams, Lieven Vernaeve, Petra Alders, Flavio Salio, Marcel Manzi, Malik Allaouna, Bertrand Draguez, Pascale Delchevalerie, Anthony D Harries
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  ABSTRACT: OBJECTIVES: Mid-upper arm circumference (MUAC) and weight-for-height Z-score (WHZ) identify different populations of children with severe acute malnutrition (SAM) with only some degree of overlap. In an urban slum in Bangladesh, we conducted a prospective cohort study on children assessed as being severely malnourished by WHZ (<-3) but not by MUAC (>115 mm), to: 1. Assess their nutritional outcomes, and 2. Report on morbidity and mortality. METHODS: Children underwent 2-weekly prospective follow-up home visits for 3 months and their anthropometric evolution, morbidity and mortality were monitored. RESULTS: Of 158 children, 21 did not complete follow-up (six were lost to follow-up and 15 changed residence). Of the remaining 137 children, nine (7%) required admission to the nutrition programme because of: MUAC dropping to <115 mm (5/9 children), weight loss ≥10% (1/9 children) and severe medical complications (3/9 children, of whom one died). Of the remaining 128 children who completed follow-up, 91 (66%) improved in nutritional status while 37 (27%) maintained a WHZ of <-3. Cough was less frequent among those whose nutritional status improved. CONCLUSIONS: It seems acceptable to rely on MUAC as a single assessment tool for case finding and for admission of children with SAM to nutritional programmes.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 03/2013;
• Article: Markov model to forecast the change in prevalence of soil-transmitted helminths during a control programme: a case study in Vietnam.

  Antonio Montresor, Albis Francesco Gabrielli, Aya Yajima, Nam Lethanh, Beverley-Ann Biggs, Gerald J Casey, Ta Thi Tinh, Dirk Engels, Lorenzo Savioli
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  ABSTRACT: BACKGROUND: A mathematical model based on the Markov methodology to predict the change in prevalence of soil-transmitted helminth (STH) infections during public health control activities is not available, but would be an extremely efficient planning tool. METHOD: We used the parasitological data collected during a deworming and iron supplementation programme for women of child-bearing age conducted in Vietnam between 2006 and 2011 to develop a Markov transition probability model. The transition probabilities were calculated from the observed changes in prevalence in the different classes of intensity for each STH species during the first year of intervention. The model was then developed and used to estimate the prevalence in year 2, 3, 4 and 5 for each STH species and for 'any STH infection'. The prevalence predicted by the model was then compared with the prevalence observed at different times during programme implementation. RESULTS: The comparison between the model-predicted prevalence and the observed prevalence proved a good fit of the model. CONCLUSIONS: We consider the Markov transition probability model to be a promising method of predicting changes in STH prevalence during control efforts. Further research to validate the model with observed data in different geographical and epidemiological settings is suggested to refine the prediction model.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 03/2013;
• Article: Bloodfeeding patterns of sylvatic arbovirus vectors in southeastern Senegal.

  Diawo Diallo, Rubing Chen, Cheikh T Diagne, Yamar Ba, Ibrahima Dia, Amadou A Sall, Scott C Weaver, Mawlouth Diallo
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  ABSTRACT: Dengue (DENV), yellow fever (YFV) and chikungunya (CHIKV) viruses circulate in sylvatic, enzootic transmission cycles in southeastern Senegal, but understanding of the vector-host interactions involved is limited. The vertebrate hosts of several potential mosquito vectors of the three viruses were identified by PCR amplification and sequencing portions of the cytochrome b gene from bloodmeals of mosquitoes collected in Kedougou, Senegal, June 2010-January 2011. We identified the sources of 65 bloodmeals of 82 engorged mosquitoes. Aedes taylori was the only species that fed on monkeys (Chlorocebus sabaeus and Papio papio). The majority of the avian-derived bloodmeals were from the Western Plantain-eater (Crinifer piscator). These findings corroborate the importance of Ae. taylori and African monkeys in the sylvatic cycles of YFV, DENV and CHIKV and suggest the possible involvement of other vertebrates.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 03/2013; 107(3):200-3.