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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chikungunya virus &#40;CHIKV&#41; was identified for the first time in Tanzania in 1952&#44; when it was isolated in humans and in <span class="elsevierStyleItalic">Aedes</span> mosquitos during an epidemic that had features compatible with dengue&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is classified as an arbovirus of the <span class="elsevierStyleItalic">Togaviridae</span> family&#44; genus <span class="elsevierStyleItalic">Alphavirus</span>&#44; a group that also includes other viruses such as Ross River&#44; O&#8217;nyong-nyong&#44; Barmah Forest and Mayaro&#44; which have been associated with the development of arthritis in humans&#46; It is considered to be endemic in large areas of Africa&#44; the Middle East&#44; India and Southeast Asia&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although the ecology of these agents differs&#44; morphologically and antigenically&#44; they are closely related&#59; moreover&#44; the diseases they cause are practically indistinguishable&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The term &#8220;chikungunya&#8221; is derived from the expression in the Makonde language for &#8220;that which bends up&#8221; or &#8220;bent over with pain&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The disease is a zoonosis transmitted by mosquitos of the <span class="elsevierStyleItalic">Aedes albopictus</span> and <span class="elsevierStyleItalic">Aedes aegypti</span> species&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It is important to point out that the <span class="elsevierStyleItalic">Aedes</span> mosquito is the vector of several arboviruses&#44; including dengue &#40;a flavivirus&#41;&#46; In countries in which both Aedes vectors are present and where the diagnostic facilities may be limited&#44; it would be difficult to distinguish between CHIKV and dengue&#44; especially in children&#44; since the symptoms and signs overlap&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Comparative studies have shown that characteristics like myalgia&#44; arthralgia and rash are particularly associated with CHIKV&#44; whereas thrombocytopenia is more is more frequently found in dengue&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">It is important to point out that the A226V mutation made it possible for the virus to adapt itself better to <span class="elsevierStyleItalic">Aedes albopictus</span>&#44; the only competent vector on Reunion Island&#44; a circumstance that also explains its unusual virulence in the last outbreak in 2005&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Chikungunya infection is thought to generate antibodies that protect individuals for life&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">With regard to the clinical signs&#44; more than 85&#37; of the patients had the typical symptoms of CHIKV infection&#58; sudden high fever &#40;&#62;38&#46;9<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; chills&#44; headache&#44; photophobia and an itchy petechial or maculopapular rash&#46; Most infected individuals complain of severe joint pain&#44; which is often disabling&#44; and edema in extremities&#59; there have also been cases of painful inguinal lymphadenopathy&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;13</span></a> ocular involvement&#44; most frequently anterior uveitis&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and gastrointestinal manifestations &#40;diarrhea and vomiting&#41;&#46; Reportedly&#44; 5&#8211;18&#37; of the infected patients are asymptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The acute phase typically has a duration of a few days to a couple of weeks&#44; although arthralgia and&#47;or myalgia can persist from weeks to months&#44; or even years&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Some patients develop an authentic chronic arthritic syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">17</span></a> which is usually symmetrical&#44; polyarticular and migratory&#44; predominantly affecting small joints of the hands&#44; wrists&#44; ankles and feet&#46; The large joints are less frequently involved&#46; Periarticular inflammation&#44; pain&#44; redness and limited mobility may be observed&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Persistent polyarthritis occurs in 30&#8211;40&#37; of the patients affected by the alphavirus&#44; and proinflammatory mediators&#44; such as interleukin 6 &#40;IL-6&#41;&#44; have been proposed as the cause&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Joint damage fluctuates over time&#44; but is always found in the same parts of the body&#44; mainly the extremities &#40;hands&#44; ankles and knuckles&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The percentage of affected individuals gradually decreases&#44; with recurrent joint pain persisting in at least 10&#37; to 20&#37; of the patients 1 year after acute infection&#44; and in up to 12&#37; at 3 and 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The mortality rate is low &#40;0&#46;4&#37;&#41;&#44; although it is higher among infants under 1 year of age &#40;2&#46;8&#37;&#41; and increases in older individuals with concurrent diseases &#40;cardiovascular&#44; neurological and respiratory tract disorders&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand&#44; there have been reports of patients with a post-CHIKV rheumatoid arthritis &#40;RA&#41;-like disorder&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> possibly due to the presence of the HLA-DRB1 gene&#44; which is associated with the development of RA&#44; a disease that would be triggered by the CHIKV infection&#46; The presence of progressive erosive arthritis has been reported&#46; However&#44; in contrast to what is known about RA&#44; high levels of rheumatoid factor and anti-cyclic citrullinated peptide were not detected&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">On 9 December 2013&#44; the Pan American Health Organization issued a regional alert on indigenous CHIKV transmission in the Americas for the first time&#46; This alert was released after the health authorities of the island of Saint Martin &#40;a French territory in the Caribbean&#41; confirmed 2 autochthonous cases in laboratory tests on 6 December 2013&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Up to 4 December 2013&#44; 1&#44;724&#44;759 suspected cases had been reported to the Pan American Health Organization&#44; as well as 59&#44;932 confirmed cases and 271 deaths related to the disease&#44; spread over 44 countries or territories in the Americas and the Caribbean&#44; including the United States and Brazil&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The real figures are much higher&#44; since the majority of the cases are not reported&#46; It was estimated that more than 60&#37; of the population of the Dominican Republic was affected&#44; out of a total of around 10 million inhabitants&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The phase of greatest transmission of CHIKV may be exponential and progress in very little time &#40;from 3 to 6 months&#41;&#44; as could be observed in the Dominican Republic&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">When documents on CHIKV epidemics are reviewed&#44; the high attack rate constitutes the major concern&#46; This rate is estimated to be between 30&#37; and 68&#37; of the population&#44; and is reached within short periods of time&#46; In the Dominican Republic&#44; it was predicted that the activity of that epidemic would be widespread&#44; as the scenario was a tropical&#44; densely populated country&#44; with a highly mobile population and the presence of the vector responsible for the transmission of the virus&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The infection is diagnosed on the basis of clinical&#44; epidemiological and laboratory criteria&#44; although it should be pointed out that there are no laboratory findings that are pathognomonic for the disease&#46; Signs like thrombocytopenia&#44; leukopenia&#44; abnormal liver function test results&#44; and elevated erythrocyte sedimentation rate and C-reactive protein have been observed&#46; To date&#44; a number of diagnostic tests have been developed to detect CHIKV infection in both the acute phase and late stage of the disease&#46; The majority of the epidemiological studies in the literature are based on IgM and IgG enzyme-linked immunosorbent assay &#40;ELISA&#41;&#44; a fact that demonstrates the importance of assays of this type&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">There is no specific treatment for CHIKV and&#44; moreover&#44; at the present time&#44; there is no available vaccine&#46; The disease is usually self-limiting and resolves over time&#46; Rest is indicated during the acute phase&#44; while there are joint symptoms&#46; Infected individuals should avoid exposing themselves to mosquitos &#40;remain indoors and&#47;or under a mosquito net&#41; during the first days of the disease so as not to contribute to the transmission cycle of the virus&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The main concern over the next few years could be that larger epidemics arise in recently affected regions&#44; like the Americas&#44; Europe and Oceania&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">29&#44;30</span></a> These regions comprise countries with na&#239;ve populations and well established <span class="elsevierStyleItalic">Aedes</span> vectors&#44; added to the fact that some have a relatively poor public health and diagnostic infrastructures&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">31</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">At this time&#44; it is not possible to determine whether CHIKV will become endemic in the Dominican Republic&#46; First&#44; the behavior of the epidemic should be observed over the next few years&#44; and systems of biosurveillance need to be implemented&#46; More than a year after the acute outbreak&#44; the patients continue to have musculoskeletal complaints of variable intensity that can be confused with the diagnosis of RA and spondyloarthritis&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Chikungunya virus has been added to the group of infectious diseases that are shared with Haiti&#44; a country with which the Dominican Republic will join forces to persevere in the efforts to control and eradicate these diseases&#44; with the same determination that has been&#44; and continues to be&#44; devoted to malaria&#44; cholera and lymphatic filariasis&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">32</span></a></p></span>"
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                      "autores" => array:1 [
                        0 => array:2 [
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                          "autores" => array:2 [
                            0 => "P&#46;J&#46; Mason"
                            1 => "A&#46;J&#46; Haddow"
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                        "tituloSerie" => "Trans R Soc Trop Med Hyg"
                        "fecha" => "1957"
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                        "paginaInicial" => "238"
                        "paginaFinal" => "240"
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                            "web" => "Medline"
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Chikungunya virus (CHIKV): What can be expected after the acute phase?
La enfermedad producida por el virus chikungunya. ¿Qué esperar luego del estadio agudo?
Vianna J. Khourya,
Corresponding author
viannakhoury@yahoo.com

Corresponding author.
, Pablo R. Camilob
a Pontificia Universidad Católica Madre y Maestra, FCS-Reumatología/Clínica Unión Medica del Norte/Hospital Regional Universitario Presidente Estrella Ureña, Santiago, Dominican Republic
b Clínica Corominas, Santiago, Dominican Republic
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    "titulo" => "Chikungunya virus &#40;CHIKV&#41;&#58; What can be expected after the acute phase&#63;"
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        "titulo" => "La enfermedad producida por el virus chikungunya&#46; &#191;Qu&#233; esperar luego del estadio agudo&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chikungunya virus &#40;CHIKV&#41; was identified for the first time in Tanzania in 1952&#44; when it was isolated in humans and in <span class="elsevierStyleItalic">Aedes</span> mosquitos during an epidemic that had features compatible with dengue&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is classified as an arbovirus of the <span class="elsevierStyleItalic">Togaviridae</span> family&#44; genus <span class="elsevierStyleItalic">Alphavirus</span>&#44; a group that also includes other viruses such as Ross River&#44; O&#8217;nyong-nyong&#44; Barmah Forest and Mayaro&#44; which have been associated with the development of arthritis in humans&#46; It is considered to be endemic in large areas of Africa&#44; the Middle East&#44; India and Southeast Asia&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Although the ecology of these agents differs&#44; morphologically and antigenically&#44; they are closely related&#59; moreover&#44; the diseases they cause are practically indistinguishable&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The term &#8220;chikungunya&#8221; is derived from the expression in the Makonde language for &#8220;that which bends up&#8221; or &#8220;bent over with pain&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The disease is a zoonosis transmitted by mosquitos of the <span class="elsevierStyleItalic">Aedes albopictus</span> and <span class="elsevierStyleItalic">Aedes aegypti</span> species&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> It is important to point out that the <span class="elsevierStyleItalic">Aedes</span> mosquito is the vector of several arboviruses&#44; including dengue &#40;a flavivirus&#41;&#46; In countries in which both Aedes vectors are present and where the diagnostic facilities may be limited&#44; it would be difficult to distinguish between CHIKV and dengue&#44; especially in children&#44; since the symptoms and signs overlap&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Comparative studies have shown that characteristics like myalgia&#44; arthralgia and rash are particularly associated with CHIKV&#44; whereas thrombocytopenia is more is more frequently found in dengue&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">It is important to point out that the A226V mutation made it possible for the virus to adapt itself better to <span class="elsevierStyleItalic">Aedes albopictus</span>&#44; the only competent vector on Reunion Island&#44; a circumstance that also explains its unusual virulence in the last outbreak in 2005&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Chikungunya infection is thought to generate antibodies that protect individuals for life&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">With regard to the clinical signs&#44; more than 85&#37; of the patients had the typical symptoms of CHIKV infection&#58; sudden high fever &#40;&#62;38&#46;9<span class="elsevierStyleHsp" style=""></span>&#176;C&#41;&#44; chills&#44; headache&#44; photophobia and an itchy petechial or maculopapular rash&#46; Most infected individuals complain of severe joint pain&#44; which is often disabling&#44; and edema in extremities&#59; there have also been cases of painful inguinal lymphadenopathy&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#8211;13</span></a> ocular involvement&#44; most frequently anterior uveitis&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and gastrointestinal manifestations &#40;diarrhea and vomiting&#41;&#46; Reportedly&#44; 5&#8211;18&#37; of the infected patients are asymptomatic&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The acute phase typically has a duration of a few days to a couple of weeks&#44; although arthralgia and&#47;or myalgia can persist from weeks to months&#44; or even years&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Some patients develop an authentic chronic arthritic syndrome&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">17</span></a> which is usually symmetrical&#44; polyarticular and migratory&#44; predominantly affecting small joints of the hands&#44; wrists&#44; ankles and feet&#46; The large joints are less frequently involved&#46; Periarticular inflammation&#44; pain&#44; redness and limited mobility may be observed&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Persistent polyarthritis occurs in 30&#8211;40&#37; of the patients affected by the alphavirus&#44; and proinflammatory mediators&#44; such as interleukin 6 &#40;IL-6&#41;&#44; have been proposed as the cause&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Joint damage fluctuates over time&#44; but is always found in the same parts of the body&#44; mainly the extremities &#40;hands&#44; ankles and knuckles&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The percentage of affected individuals gradually decreases&#44; with recurrent joint pain persisting in at least 10&#37; to 20&#37; of the patients 1 year after acute infection&#44; and in up to 12&#37; at 3 and 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The mortality rate is low &#40;0&#46;4&#37;&#41;&#44; although it is higher among infants under 1 year of age &#40;2&#46;8&#37;&#41; and increases in older individuals with concurrent diseases &#40;cardiovascular&#44; neurological and respiratory tract disorders&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">On the other hand&#44; there have been reports of patients with a post-CHIKV rheumatoid arthritis &#40;RA&#41;-like disorder&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> possibly due to the presence of the HLA-DRB1 gene&#44; which is associated with the development of RA&#44; a disease that would be triggered by the CHIKV infection&#46; The presence of progressive erosive arthritis has been reported&#46; However&#44; in contrast to what is known about RA&#44; high levels of rheumatoid factor and anti-cyclic citrullinated peptide were not detected&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">On 9 December 2013&#44; the Pan American Health Organization issued a regional alert on indigenous CHIKV transmission in the Americas for the first time&#46; This alert was released after the health authorities of the island of Saint Martin &#40;a French territory in the Caribbean&#41; confirmed 2 autochthonous cases in laboratory tests on 6 December 2013&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Up to 4 December 2013&#44; 1&#44;724&#44;759 suspected cases had been reported to the Pan American Health Organization&#44; as well as 59&#44;932 confirmed cases and 271 deaths related to the disease&#44; spread over 44 countries or territories in the Americas and the Caribbean&#44; including the United States and Brazil&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> The real figures are much higher&#44; since the majority of the cases are not reported&#46; It was estimated that more than 60&#37; of the population of the Dominican Republic was affected&#44; out of a total of around 10 million inhabitants&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The phase of greatest transmission of CHIKV may be exponential and progress in very little time &#40;from 3 to 6 months&#41;&#44; as could be observed in the Dominican Republic&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">When documents on CHIKV epidemics are reviewed&#44; the high attack rate constitutes the major concern&#46; This rate is estimated to be between 30&#37; and 68&#37; of the population&#44; and is reached within short periods of time&#46; In the Dominican Republic&#44; it was predicted that the activity of that epidemic would be widespread&#44; as the scenario was a tropical&#44; densely populated country&#44; with a highly mobile population and the presence of the vector responsible for the transmission of the virus&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The infection is diagnosed on the basis of clinical&#44; epidemiological and laboratory criteria&#44; although it should be pointed out that there are no laboratory findings that are pathognomonic for the disease&#46; Signs like thrombocytopenia&#44; leukopenia&#44; abnormal liver function test results&#44; and elevated erythrocyte sedimentation rate and C-reactive protein have been observed&#46; To date&#44; a number of diagnostic tests have been developed to detect CHIKV infection in both the acute phase and late stage of the disease&#46; The majority of the epidemiological studies in the literature are based on IgM and IgG enzyme-linked immunosorbent assay &#40;ELISA&#41;&#44; a fact that demonstrates the importance of assays of this type&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">There is no specific treatment for CHIKV and&#44; moreover&#44; at the present time&#44; there is no available vaccine&#46; The disease is usually self-limiting and resolves over time&#46; Rest is indicated during the acute phase&#44; while there are joint symptoms&#46; Infected individuals should avoid exposing themselves to mosquitos &#40;remain indoors and&#47;or under a mosquito net&#41; during the first days of the disease so as not to contribute to the transmission cycle of the virus&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The main concern over the next few years could be that larger epidemics arise in recently affected regions&#44; like the Americas&#44; Europe and Oceania&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">29&#44;30</span></a> These regions comprise countries with na&#239;ve populations and well established <span class="elsevierStyleItalic">Aedes</span> vectors&#44; added to the fact that some have a relatively poor public health and diagnostic infrastructures&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">31</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">At this time&#44; it is not possible to determine whether CHIKV will become endemic in the Dominican Republic&#46; First&#44; the behavior of the epidemic should be observed over the next few years&#44; and systems of biosurveillance need to be implemented&#46; More than a year after the acute outbreak&#44; the patients continue to have musculoskeletal complaints of variable intensity that can be confused with the diagnosis of RA and spondyloarthritis&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Chikungunya virus has been added to the group of infectious diseases that are shared with Haiti&#44; a country with which the Dominican Republic will join forces to persevere in the efforts to control and eradicate these diseases&#44; with the same determination that has been&#44; and continues to be&#44; devoted to malaria&#44; cholera and lymphatic filariasis&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">32</span></a></p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Khoury VJ&#44; Camilo PR&#46; La enfermedad producida por el virus chikungunya&#46; &#191;Qu&#233; esperar luego del estadio agudo&#63;&#46; Reumatol Clin&#46; 2016&#59;12&#58;1&#8211;3&#46;</p>"
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ISSN: 21735743
Original language: English
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