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Revista de salud publica del Paraguay

versión impresa ISSN 2224-6193versión On-line ISSN 2307-3349

Rev. salud publica Parag. vol.14 no.1 Asunción abr. 2024 

Artículo original

Characteristics of acute chikungunya virus infection in children: an epidemiological study in the Department of Caaguazú, Paraguay

Características de la infección aguda por el virus chikungunya en niños: un estudio epidemiológico en el Departamento de Caaguazú, Paraguay

Gladys Estigarribia-Sanabria1

Carlos Miguel Rios-González2  3

Julio Torales3  4

Zoilo Morel4

Martín Agüero4

Gloria González-Vázquez5

Patricia Ríos-Mujica1

Analía Ortiz-Rolón1

Julieta Méndez-Romero1  2

Claudia Fox-Portillo1

Lourdes Dos Santos6

Iván Barios3  4

Gloria Aguilar2  3

1 Universidad Nacional de Caaguazú, Instituto Regional de Investigación en Salud, Coronel Oviedo, Paraguay.

2 Ministerio de Salud Pública y Bienestar Social, Instituto Nacional de Salud, Asunción, Paraguay.

3 Universidad Sudamericana, Facultad de Ciencias de la Salud, Pedro Juan Caballero, Paraguay.

4 Universidad Nacional de Asunción, Facultad de Ciencias Médicas, San Lorenzo, Paraguay.

5 Universidad Nacional de Caaguazú, Facultad de Ciencias de la Salud, Coronel Oviedo, Paraguay.

6 Universidad Nacional de Caaguazú, Facultad de Ciencias Médicas, Coronel Oviedo, Paraguay.



The rapid transmission and severe symptoms associated with acute chikungunya virus (CHIKV) infection in children make it a highly concerning health issue.


This study aimed to describe the characteristics of acute chikungunya virus infection in children from the Department of Caaguazú, Paraguay.

Material and Methods:

A retrospective observational study was conducted in the Department of Caaguazú, Paraguay, in 2023, with all patients who came to the Regional Hospital within 5 days of developing characteristic symptoms of acute CHIKV infection and tested positive for the virus by RT-PCR. Patients with Dengue or Zika infections were excluded. We collected data on clinical characteristics using a standardized case record form and created an electronic dataset for analysis.


A total of 461 children were included in the study. 51.6% were women. Cases were divided into groups based on pediatric age: infants (0-23 months, n=88, 19.1%), preschoolers (2-5 years, n=115, 24.9%), schoolchildren (6-11 years, n=163, 35.4%), and adolescents (12-17 years and 11 months, n=95, 20.6%). Schoolchildren and adolescents experienced a higher prevalence of myalgia (64.6%) and arthralgia (63.7%). Vomiting (89%), headache (89.4%), and retro-orbital pain (95%) were more common in preschoolers, schoolchildren, and adolescents, while rash (39.5%) and petechiae (18.5%) were more prevalent in infants. Four children died during the study period.


The 2023 CHIKV virus epidemic in Paraguay had different clinical presentations depending on the age of the affected children, with fatal outcomes occurring in a small percentage of cases.

Keywords: chikungunya; epidemic; childhood



La rápida transmisión y los síntomas graves asociados con la infección aguda por el virus de la chikungunya (CHIKV) en niños lo convierten en un problema de salud altamente preocupante.


Este estudio tuvo como objetivo describir las características de la infección aguda por el virus de la chikungunya en niños del Departamento de Caaguazú, Paraguay.

Materiales y métodos:

Un estudio retrospectivo fue realizado en el Departamento de Caaguazú, Paraguay, en 2023, con todos los pacientes que acudieron al Hospital Regional dentro de los 5 días posteriores al desarrollo de síntomas característicos de la infección aguda por CHIKV y que dieron positivo para el virus mediante RT-PCR. Pacientes con infecciones por Dengue o Zika fueron excluidos. Se recogieron datos sobre las características clínicas mediante un formulario normalizado de registro de casos y se creó un conjunto de datos electrónicos para su análisis.


Se incluyeron en el estudio un total de 461 niños. 51,6% eran mujeres. Los casos se dividieron en grupos según la edad pediátrica: lactantes (0-23 meses, n=88, 19,1 %), preescolares (2-5 años, n=115, 24,9%), escolares (6-11 años, n=163, 35.4%), and adolescentes (12-17 años and 11 meses, n=95, 20.6 %). La mialgia (64,6%) y la artralgia (63.7%) fueron más prevalentes en escolares y adolescentes. El vómito (89%), la cefalea (89,4%) y el dolor retroorbitario (95%) fueron más comunes en preescolares, escolares y adolescentes, mientras que la erupción cutánea (39,5%) y las petequias (18,5%) fueron más prevalentes en lactantes. Cuatro niños fallecieron durante el período de estudio.


La epidemia de virus de la CHIKV de 2023 en Paraguay tuvo diferentes presentaciones clínicas dependiendo de la edad de los niños afectados, con resultados fatales ocurriendo en un pequeño porcentaje de casos.

Palabras clave: CHIKV; epidemia; infancia


Children with acute chikungunya virus (CHIKV) infection are prone to experiencing severe symptoms due to its rapid transmission. While the majority of infected individuals develop symptoms, usually within 3-7 days of being bitten by an infected mosquito, children may be particularly vulnerable to the virus1. The most common symptoms of this infection include fever and joint pain; however, children may also experience headaches, muscle pain, joint swelling, or rash2,3. In addition, arthralgia and arthritis are reported to be the most debilitating symptoms, affecting 87% of adults and 30-50% of children during the acute stage of infection. Of these patients, 23-36% of pediatric patients and 53% of adults experience post-acute arthralgia4.

Individuals from all age groups are at risk of contracting the virus, but children tend to experience joint manifestations less frequently. In contrast, women appear to have a higher probability of developing debilitating symptoms5. However, severe neuroinvasive diseases related to infection can still occur in children. Additionally, people with existing comorbidities may experience atypical symptoms or even die because of the infection6,7,8,9,10.

In children, CHIKV disease can present with additional symptoms, such as respiratory difficulties, changes in skin color, and generalized weakness, which may necessitate immediate medical attention11. At present, there are no specific medications for treating CHIKV, making prevention and mosquito control crucial for preventing the spread of the disease12. However, in November 2023, the first vaccine against CHIKV, called VLA1553 and commercially known as Ixchiq®, was approved by the United States Food and Drug Administration (FDA) for adult use only13.

The situation is further complicated by the similarities between CHIKV's symptoms and those of other mosquito-borne diseases, such as dengue and Zika, which can lead to misdiagnoses and delay appropriate treatment5. Moreover, joint pain can be severe and debilitating, persisting for months, and can significantly impact a child's quality of life4,8. Although fatalities from CHIKV are rare, the disease can be more severe in children with concomitant health problems, neonates, or infants14,15,16.

Given these factors, this study aimed to describe the characteristics of acute CHIKV virus infection in children from the Department of Caaguazú, Paraguay, in 2023.


A study on children from Caaguazú was conducted in 2023. This was a retrospective observational study17, and the inclusion criteria were children who had developed symptoms of acute CHIKV infection within the past five days and had a fever of at least 38.5 °C. Children who had a positive antigen or serological test for dengue or zika were excluded.

Confirmed cases were defined as those with positive results by real-time RT-PCR analysis for CHIKV. In view of the possibility of coinfections, real-time RT-PCR was performed, which excluded possible coinfection with dengue or Zika viruses. We collected data on clinical characteristics using a standardized case record form and created an electronic dataset for analysis. The data were analyzed using Stata 14.0® Statistical Software. Pearson’s chi-squared test was performed to determine the association between categorical variables with a 95% confidence level.

This study adhered to the principles of bioethics and obtained approval from the National University of Caaguazú Ethics Committee.


A total of 461 children were enrolled in the study, 51.62% were women. The age groups included infants (0-23 months, n=88, 19.1%), preschoolers (2-5 years, n=115, 24.9%), schoolchildren (6-11 years, n=163, 35.4%), and adolescents (12-17 years and 11 months, n=95, 20.6%). School-aged children constituted the largest proportion of the cases (Figure 1). The female-to-male ratio was 1:1.067.

According to clinical characteristics, fever, headache, rash, myalgia, and arthralgia were more frequently reported. However, we observed variations in these manifestations based on age group. Specifically, school-aged children and adolescents experienced a higher incidence of myalgia (64.6% [p<0.001]) and arthralgia (63.7% [p<0.001]). In contrast, preschoolers, school-aged children, and adolescents were more likely to experience vomiting (89% [p<0.001]), headache (89.4% [p<0.001]), and retro-orbital pain (95% [p<0.001]). Additionally, while rash (39.5% [p<0.001]) and petechiae (18.5% [p<0.001]) were more common in infants, these symptoms were less frequently reported in other age groups (Table 1).

Four children died during the outbreak, including a neonate, two children aged two and three years, and an 8-year-old girl. None of the children had any underlying health condition (Table 2).

Figure 1 Notification curve of CHIKV in children of Paraguay. EW3 to EW22, 2023 (n=461) 

Table 1 Distribution of characteristics of children with CHIKV according to age group in Paraguay (n=461 

Characteristics Infants 0-23 months n (%) Preschoolers 2-5 years n (%) Shoolchildren 6-11 years n (%) Adolescents 12-17 years n (%) p
Male 37 (42.05) 57 (49.57) 82 (50.31) 47 (49.47) 0.623
Female 51 (57.95) 58 (50.43) 81 (49.69) 48 (50.53)
Fever 66 (98.51) 85 (97.70) 132(98.51) 76 (98.68) 0.944
Nausea 21 (25.93) 34 (33.33) 53 (34.64) 42 (47.73) 0.028
Vomiting 25 (30.86) 54 (52.94) 89 (58.17) 61 (69.32) 0.001
Rash 32 (39.51) 39 (38.24) 35 (22.88) 15 (17.05) 0.001
Headache 23 (28.40) 45 (44.12) 81 (52.94) 67 (76.14) 0.001
Retroorbital pain 5 (6.17) 25 (24.51) 35 (22.88) 37 (42.05) 0.001
Myalgia 32 (39.51) 49 (48.04) 84 (54.90) 64 (72.73) 0.001
Arthralgia 37 (45.68) 58 (56.86) 98 (64.05) 69 (78.41) 0.001
Petechiae 15 (18.52) 10 (9.80) 21 (13.73) 10 (11.36) 0.001
Leukopenia 1 (1.23) 3 (2.94) 1 (0.65) 1 (1.14) NA
Severe abdominal pain 1 (1.23) 3 (2.94) 1 (0.65) 1 (1.14) NA
Abdominal tenderness 0 (0.0) 0 (0.0) 0 (0.0) 1 (1.14) NA
Persistent vomiting 0 (0.0) 0 (0.0) 2 (1.31) 0 (0.0) NA
Mucosal bleeding 0 (0.0) 1 (0.98) 1 (0.65) 0 (0.0) NA
Irritability/drowsiness 2 (2.47) 0 (0.0) 0 (0.0) 0 (0.0) NA
Arthritis 8 (9.88) 21 (20.59) 31 (20.26 25 (28.41) 0.028
Skin eruption 39 (48.15) 38 (37.25) 44 (28.76) 16 (18.18) 0.001
Conjunctival hyperemia 1 (1.23) 0 (0.0) 0 (0.0) 0 (0.0) NA
Pruritus 3 (3.70) 8 (7.84) 6 (3.92) 3 (3.41) 0.468
Joint swelling 8 (9.88) 5 (4.90) 7 (4.58) 6 (6.82) 0.412

NA: not applicable

Table 2 Distribution of mortality and fatality rate of CHIKV in children according to age group in Paraguay (n=461) 

Characteristics 0-1 year n (%) 2-5 years n (%) 6-11 years n (%) 12-17 years n (%)
Mortality 1 (4.76) 2 (5.71) 1 (5.56) 0
Fatality rate 1.13 4.90 0.86 0


The symptoms of CHIKV infection in pediatric patients reported in our study are consistent with the common symptoms described in the literature. Fever, headache, rash, myalgia, and arthralgia are frequently observed in children with CHIKV infection, as reported in studies9,10,12,18,19,20. It is estimated that 70-93% of patients with CHIKV infection exhibit symptoms, with 3-25% of seropositive patients being asymptomatic and 2-7% experiencing atypical symptoms18. During the acute phase of human infection, CHIKV infection is characterized by a sudden onset of high fever, often accompanied by severe joint pain, headache, and rash20.

We found that school-age stage accounts for a disproportionately large number of cases. The school-age stage has been identified as a demographic group of great significance in contributing to a higher incidence of CHIKV cases, as reported in several studies21,22,23,24. These studies have demonstrated a negative correlation between age and the incidence of CHIKV infection, suggesting that the school-age population may be particularly vulnerable to CHIKV.

The importance of further exploring the disease in diverse age groups, particularly infants, has been highlighted by research findings. Robin et al.25 documented a retrospective hospital-based pediatric series revealing neurological manifestations of CHIKV in children, including encephalitis, febrile seizures, meningeal syndrome, and acute encephalopathy25. Janakiraman et al. discussed CHIKV in infants, challenging the previously held belief that cutaneous manifestations were benign26. Furthermore, Raju et al. 27 described varied clinical presentations and manifestations of CHIKV among different age groups in a case series27. These studies collectively contribute to the comprehension of the diverse clinical aspects of CHIKV infection in pediatric populations.

We found a higher prevalence of myalgias and arthralgias in school-age children and adolescents, a finding consistent with certain studies6,21. However, vomiting, headaches, and retro-orbital pain were less common in infants, although this data may be biased in underestimating pain in infants, as is often the case in clinical practice28. Skin lesions were more prevalent in infants, as reported in the literature10,29. Our results do not show re-hospitalizations, but four fatalities (0.87%) occurred without any underlying pathologies, indicating the potential for severe complications due to CHIKV15,16.

The study's limitations include its retrospective design and incomplete clinical records. Nonetheless, its strength lies in the insights it provides on the clinical presentation of CHIKV in various age groups.

In conclusion, the CHIKV virus outbreak in the Department of Caaguazú, Paraguay, displayed distinct clinical manifestations in children based on age, with fatal outcomes occurring in a small percentage of cases. Therefore, it is crucial to consider preventative measures such as vector control.


1. Imad HA, Phadungsombat J, Nakayama EE, Suzuki K, Ibrahim AM, Afaa A, et al. Clinical features of acute chikungunya virus infection in children and adults during an outbreak in the Maldives. Am J Trop Med Hyg. 2021;105(4):946-954. [ Links ]

2. Silva JVJ Jr, Ludwig-Begall LF, Oliveira-Filho EF, Oliveira RAS, Durães-Carvalho R, Lopes TRR, et al. A scoping review of CHIKV virus infection: epidemiology, clinical characteristics, viral co-circulation complications, and control. Acta Trop. 2018; 188:213-224. [ Links ]

3. Imad HA, Matsee W, Kludkleeb S, Asawapaithulsert P, Phadungsombat J, Nakayama EE, et al. Post-chikungunya virus infection musculoskeletal disorders: Syndromic Sequelae after an Outbreak. Trop Med Infect Dis. 2021;6(2):52. https://doi.10.3390/tropicalmed6020052. [ Links ]

4. Warnes CM, Carrillo FAB, Zambrana JV, Mercado BL, Arguello S, Ampié O, et al. Longitudinal analysis of the burden of post-acute chikungunya -associated arthralgia in children and adults: A Prospective Cohort Study in Managua, Nicaragua (2014-2019). Med Rxiv [Preprint]. 2023:2023.05.09.23289726. Update in: PLoS Negl Trop Dis. 2024;18(2): e0011948. [ Links ]

5. Pellot AS, Alessandri JL, Robin S, Sampériz S, Attali T, Brayer C, Pasquet M, Jaffar-Bandjee MC, Benhamou LS, Tiran-Rajaofera I, Ramful D. Infections graves a virus chikungunya en réanimation pédiatrique a l'ile de La Réunion [Severe forms of chikungunya virus infection in a pediatric intensive care unit on Reunion Island]. Med Trop (Mars). 2012;72 Spec No:88-93. [ Links ]

6. B SR, Patel AK, Kabra SK, Lodha R, Ratageri VH, Ray P. Virus load and clinical features during the acute phase of chikungunya infection in children. PLoS One. 2019; 14 (2): e0211036. [ Links ]

7. Ngwe Tun MM, Kyaw AK, Nwe KM, Myaing SS, Win YT, Inoue S, et al. Burden of chikungunya virus infection during an outbreak in Myanmar. Viruses. 2023;15(8):1734. [ Links ]

8. Khongwichit S, Chansaenroj J, Thongmee T, Benjamanukul S, Wanlapakorn N, Chirathaworn C, et al. Large-scale outbreak of chikungunya virus infection in Thailand, 2018-2019. PLoS One. 2021;16(3): e0247314. [ Links ]

9. Ritz N, Hufnagel M, Gérardin P. Chikungunya in Children. Pediatr Infect Dis J. 2015; 34(7):789-91. [ Links ]

10. Ward CE, Chapman JI. Chikungunya in Children: A Clinical Review. Pediatr Emerg Care. 2018; 34 (7): 510-515. [ Links ]

11. Kyaw AK, Tun MMN, Nabeshima T, Soe AM, Thida T, Aung TH, et al. Chikungunya Virus Infection in Blood Donors and Patients During Outbreak, Mandalay, Myanmar, 2019. Emerg Infect Dis. 2020;26(11):2741-2745. [ Links ]

12. Dhochak N, Kabra SK, Lodha R. Dengue and chikungunya Infections in Children: Guest Editor: Bhim S. Pandhi. Indian J Pediatr. 2019;86(3):287-295. [ Links ]

13. Wressnigg N, Hochreiter R, Zoihsl O, Fritzer A, Bézay N, Klingler A, et al. Single-shot live-attenuated chikungunya vaccine in healthy adults: a phase 1, randomised controlled trial. Lancet Infect Dis. 2020;20(10):1193-1203. [ Links ]

14. Samra JA, Hagood NL, Summer A, Medina MT, Holden KR. Clinical features and neurologic complications of children hospitalized with chikungunya virus in Honduras. J Child Neurol. 2017; 32 (8): 712-716. [ Links ]

15. Freitas ARR, Gérardin P, Kassar L, Donalisio MR. Excess deaths associated with the 2014 CHIKV epidemic in Jamaica. Pathog Glob Health. 2019;113(1):27-31. [ Links ]

16. Oliveira RMAB, Barreto FKA, Maia AMPC, Gomes IP, Simião AR, Barbosa RB, et al. Maternal and infant death after probable vertical transmission of chikungunya virus in Brazil-case report. BMC Infect Dis. 2018;18(1):333. [ Links ]

17. Torales J, Barrios I. Diseño de investigaciones: algoritmo de clasificación y características esenciales. Med. clín. soc. 2023; 7 (3): 210-235. [ Links ]

18. Sharif N, Sarkar M, Ferdous R, Ahmed S, Billah M, Talukder A, et al. Molecular epidemiology, evolution and reemergence of chikungunya virus in South Asia. Frontiers in Microbiology 2021;12. [ Links ]

19. Hertz J, Munishi O, Ooi E, Howe S, Lim W, Chow A, et al. CHIKV and dengue fever among hospitalized febrile patients in northern tanzania. American Journal of Tropical Medicine and Hygiene 2012;86(1):171-177. [ Links ]

20. Calvez E, Bounmany P, Somlor S, Xaybounsou T, Viengphouthong S, Keosenhom S, et al. Multiple chikungunya virus introductions in Lao PDR from 2014 to 2020. Plos One 2022; 17 (7): e0271439. [ Links ]

21. Raghavendhar BS, Ray P, Ratagiri VH, Sharma BS, Kabra SK, Lodha R. Evaluation of CHIKV virus infection in children from India during 2009-2010: A cross sectional observational study. J Med Virol. 2016 Jun;88(6):923-30. doi: 10.1002/jmv.24433. [ Links ]

22. Nyamwaya DK, Otiende M, Omuoyo DO, Githinji G, Karanja HK, Gitonga JN, et al. Endemic chikungunya fever in Kenyan children: a prospective cohort study. BMC Infect Dis. 2021;21(1):186. [ Links ]

23. Nyamwaya D, Otiende M, Mwango L, Kariuki S, Otieno B, Omuoyo D, et al. Incidence of CHIKV virus infections among kenyan children with neurological disease, 2014-2018: a cohort study. Plos Medicine 2022;19(5): e1003994. [ Links ]

24. Castellanos J, Jaimes N, Coronel-Ruiza C, Rojas J, Mejía L, Villarreal V, et al. Dengue-chikungunya coinfection outbreak in children from Cali, Colombia in 2018-2019. International Journal of Infectious Diseases 2021; 102: 97-102. [ Links ]

25. Robin S, Ramful D, Seach F, Jaffar-Bandjee M, Rigou G, Alessandri J. Neurologic manifestations of pediatric CHIKV infection. Journal of Child Neurology 2008;23(9):1028-1035. [ Links ]

26. Janakiraman L. and Bhimana V. Chikungunya in infants: a case series. Pediatric Infectious Disease 2021;3(2):77-78. [ Links ]

27. Raju P., Raju P., & Subramanian R. Varied clinical manifestations of chikungunya-a case series. Pediatric Infectious Disease 2020;2(2):64-66. [ Links ]

28. Ferrante P, Cuttini M, Zangardi T, Tomasello C, Messi G, Pirozzi N, et al. Pain management policies and practices in pediatric emergency care: a nationwide survey of Italian hospitals. BMC Pediatr. 2013; 13: 139. [ Links ]

29. Elenga N, Folin M, Vandamme YM, Cuadro-Alvarez E, Long L, Njuieyon F, et al. CHIKV Infection in Hospitalized Febrile Infants Younger Than 3 Months of Age. Pediatr Infect Dis J. 2017;36(8):736-740. [ Links ]

0Responsible editor: Silvia Araujo-Pino.

2Funding: This research was funded by the National Council of Science and Technology of Paraguay (ref. INVE 23-35, Resolution 264/2023).

4Statement: The views expressed in this manuscript are the responsibility of the authors, and do not necessarily reflect the views or policies of the RSPP and/or INS.

Received: March 25, 2024; Accepted: April 17, 2024

Corresponding author: Gloria Aguilar,

Conflict of Interests: The authors have no conflict of interests to declare.

Author’s contributions: GES, JT, GA: Conception and design of the study, analysis, and interpretation of results. ZM, MA, GGV: Manuscript drafting and literature search. PRM, AOR, JMR, IB: Critical revision of the manuscript. CFP, LDS: data curation. All authors: Final approval of the manuscript.

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