An evaluation of global Chikungunya clinical management guidelines – a systematic review
Authors: Webb Eika , Michelen Melina , Rigby Ishmeala , Dagens Andrew , Dahmash Dania , Cheng Vincent , Joseph Reena , Lipworth Samuel , Harriss Eli , Cai Erhui , Nartowski Robert , Januraga Pande Putu , Gedela Keerti , Sukmaningrum Evi , Groves Helen , Hart Peter , Fletcher Tom , Blumberg Lucille , Horby Peter , Jacob Shevin T , Sigfrid Louise 
Published: February 2022

Background

Chikungunya virus (CHIKV) has expanded its geographical reach in recent decades and is an emerging global health threat. CHIKV can cause significant morbidity and lead to chronic, debilitating arthritis in up to 40% of infected individuals, impacting on livelihoods. Prevention, early identification, and clinical management are key for improving outcomes. This review aims to evaluate the availability of inclusive, evidence-based clinical management guidelines for CHIKV in a global context.

Methods

Six databases were searched systematically from inception to 14th October 2021 and complemented with a grey literature search until 16th September 2021. We included CMGs providing supportive care and treatment recommendations. Two reviewers independently screened records, extracted data and assessed quality using the AGREE II tool. Findings are presented in a narrative synthesis.

Results

Twenty-eight CMGs were included; most were of low-quality (median score 2 out of 7 (range 1-7)). None were produced specifically in a low-income country and 54% (15/28) were produced more than five years ago. There were variations in the CMGs’ guidance on the management of different at-risk populations, long-term sequelae, and the prevention of disease transmission in community and hospital settings. In the acute phase, 54% (15/28) recommended hospitalisation for severe cases, however only 39% (11/28) provided clinical management guidance for severe disease. Further, 46% (13/28) advocated for steroids in the chronic phase, yet 18% (5/28) advised against its use.

Conclusion

There was a lack of high-quality CMGs that provided supportive care and treatment guidance; this scarcity may impact patient care and outcomes. It is essential that existing guidelines are updated and adapted to provide detailed evidence-based treatment guidelines for different at-risk populations. This study also highlights a need for more research into the management of the acute and chronic phases of CHIKV infection to inform evidence-based care.

Systematic review registration: PROSPERO CRD42020167361

What was known before

CHIKV is endemic across most of the southern hemisphere, with risk of expansion into new regions driven by global travel, trade, and climate change.

Infection can result in severe illness with long-term sequelae, particularly in vulnerable groups. Chronic sequelae of CHIKV infection is a cause of significant debilitating morbidity affecting individual functionality and quality of life with wider health system and socio-economic impact.

There is no effective vaccine or targeted treatment against Chikungunya and supportive care is the mainstay of treatment.

Even with a limited evidence base, clinical management guidelines (CMGs) are key tools for standardising best available evidence-based care, and reduce inappropriate use of treatments, to reduce morbidity and improve patient outcomes.

What this study adds

This review highlights a global scarcity of CMGs for chikungunya providing detailed guidance on optimal supportive care and treatment for different at-risk populations and settings.

There was limited guidance available on care for severe cases, and available guidance was heterogenous and discordant (e.g., on use of analgesia, corticosteroids, and monitoring).

The limited availability of up-to-date CMGs and heterogenous recommendations identified is a concern, which may impact on equity in access to best available evidence-based care and patient outcomes.

Further research into access to and implementation of CMGs in different settings is needed, to ensure equitable access to best available care.

This study also highlights a need for further investment into research into supportive care and treatment for different at-risk populations, and new evidence incorporated into guidelines to reduce morbidity and improve long term outcomes for the people affected by and at risk of Chikungunya.