Predictors of Chikungunya rheumatism: a prognostic survey ancillary to the TELECHIK cohort study
- Patrick Gérardin1, 2, 3Email author,
- Adrian Fianu1,
- Alain Michault†4,
- Corinne Mussard1,
- Karim Boussaïd1,
- Olivier Rollot1,
- Philippe Grivard4,
- Somar Kassab4, 5,
- Eric Bouquillard6,
- Gianandrea Borgherini7,
- Bernard-Alex Gaüzère8,
- Denis Malvy†9, 10,
- Gérard Bréart†3 and
- François Favier1
© Gérardin et al.; licensee BioMed Central Ltd. 2013
Received: 28 October 2012
Accepted: 4 January 2013
Published: 9 January 2013
Long-lasting relapsing or lingering rheumatic musculoskeletal pain (RMSP) is the hallmark of Chikungunya virus (CHIKV) rheumatism (CHIK-R). Little is known on their prognostic factors. The aim of this prognostic study was to search the determinants of lingering or relapsing RMSP indicative of CHIK-R.
Three hundred and forty-six infected adults (age ≥ 15 years) having declared RMSP at disease onset were extracted from the TELECHIK cohort study, Reunion island, and analyzed using a multinomial logistic regression model. We also searched for the predictors of CHIKV-specific IgG titres, assessed at the time of a serosurvey, using multiple linear regression analysis.
Of these, 111 (32.1%) reported relapsing RMSP, 150 (43.3%) lingering RMSP, and 85 (24.6%) had fully recovered (reference group) on average two years after acute infection. In the final model controlling for gender, the determinants of relapsing RMSP were the age 45-59 years (adjusted OR: 2.9, 95% CI: 1.0, 8.6) or greater or equal than 60 years (adjusted OR: 10.4, 95% CI: 3.5, 31.1), severe rheumatic involvement (fever, at least six joints plus four other symptoms) at presentation (adjusted OR: 3.6, 95% CI: 1.5, 8.2), and CHIKV-specific IgG titres (adjusted OR: 3.2, 95% CI: 1.8, 5.5, per one unit increase). Prognostic factors for lingering RMSP were age 45-59 years (adjusted OR: 6.4, 95% CI: 1.8, 22.1) or greater or equal than 60 years (adjusted OR: 22.3, 95% CI: 6.3, 78.1), severe initial rheumatic involvement (adjusted OR: 5.5, 95% CI: 2.2, 13.8) and CHIKV-specific IgG titres (adjusted OR: 6.2, 95% CI: 2.8, 13.2, per one unit increase). CHIKV specific IgG titres were positively correlated with age, female gender and the severity of initial rheumatic symptoms.
Our data support the roles of age, severity at presentation and CHIKV specific IgG titres for predicting CHIK-R. By identifying the prognostic value of the humoral immune response of the host, this work also suggest a significant contribution of the adaptive immune response to the physiopathology of CHIK-R and should help to reconsider the paradigm of this chronic infection primarily shifted towards the involvement of the innate immune response.
Chikungunya virus (CHIKV) is an enveloped RNA positive-strand alphavirus, transmitted by Aedes mosquitoes, belonging to the Togaviridae family and to the arthritogenic Semliki forest virus (SFV) serocomplex, which includes the well-studied Ross River virus (RRV) . CHIKV is now recognised to target human epithelial and endothelial cells, fibroblasts, dendritic cells, B cells and macrophages [2, 3], as well as human muscle satellite cells .
The virus is known to cause a wide range of acute manifestations combining fever, arthritis, arthralgias, myalgias, rash and fatigue [5, 6]. Furthermore, CHIKV infection often leads to prolonged joint pain, which may harbour two different tempos; either a continuous burden or relapse attacks that characterize the hallmark of Chikungunya rheumatism (CHIK-R) [6–9]. CHIKV might also trigger or reveal inflammatory rheumatic diseases (IRDs) such as rheumatoid-like arthritis (RA) or psoriatic arthritis (PsA) [10, 11]. In this context, routine biomarkers (C-reactive protein, CRP; erythrocyte sedimentation rate, ESR), rheumatoid factor, anti-cyclic citrullinated peptide antibodies, HLA-B27 expression, imaging features, or the need for upgraded treatment, usually enable accurate diagnosis. However, for the few CHIK-R patients matching the criteria for IRDs, the differential diagnosis and decision-making for treatment might be even more challenging [12–14].
Of note, the pathomechanisms underlying musculoskeletal pain and chronic arthritide after acute CHIKV infection are partially elucidated. It has been hypothesised that these symptoms may come from the early escape of CHIKV from blood monocytes  and its subsequent relocation and persistence in synovial macrophages rather than to an autoimmune process  as previously observed with RRV infection . This hypothesis is supported by a recent macaque model in which Chikungunya disease involves long-term viral persistence in macrophages of lymphoid, liver, joint and muscle tissues . Moreover, a positive association between high titres of CHIKV-specific IgG antibodies and long-lasting arthralgias has been observed contemporaneously from a pilot study by our group, and in an Italian cohort, without the pathophysiological significance or clinical impact of such relationship having been sought [18, 19].
To date, the predictors of the course of CHIK-R have so far been poorly investigated . According to Sissoko and coworkers, age over 45 years, severe initial joint pain and underlying osteoarthritis are independent indicators of non recovery . These findings are consistent with those reported in the seminal descriptions of CHIK-R [20, 21], or found in recent case series [22, 23], which showed a correlation between the age at disease onset and the duration of rheumatic symptoms.
Recently, we conducted the TELECHIK cohort study with the aim to address the topics of the burden of Chikungunya and perceived morbidity in the community after the 2005 to 2006 outbreak . In this context, we performed this ancillary study to search for prognostic factors of long-lasting rheumatic musculoskeletal pain (RMSP) indicative of CHIK-R. We took the opportunity of this research to test several hypotheses with regard to a putative involvement of the host immune response in the pathomechanism of CHIK-R. Long-lasting RMSP could be driven by either the initial viral load or by the intensity of viral exposure under the challenge of repeated infective bites and waves of CHIKV in La Réunion, or by ongoing antigenic stimulation due to the persistence of CHIKV in host sanctuaries, using the value of CHIKV-specific IgG antibody titre measured at plateau phase, at the time of the seroprevalence study , as a proxy.
Materials and methods
Setting and design
La Réunion is a French overseas department of 787,836 inhabitants (Insee census 2006), located on a volcanic island in the south-western part of the Indian Ocean. During the years 2005 to 2006, 300,000 of the inhabitants (38.2%) were considered to have been infected .
The present study is a prognostic survey of the predictors of CHIK-R from the TELECHIK cohort . Thus, it included all CHIKV seropositive adult participants (age ≥ 15 years) enrolled in the TELECHIK cohort, who had reported RMSP at disease onset.
Data collection and follow-up
Participants were interviewed by telephone. The questionnaire was administered by one investigator, blind to the serological status, to ensure the best possible reproducibility . It was composed of closed questions addressing the course of rheumatic manifestations in three consecutive time points (disease onset, one concomitant to the SEROCHIK study, and one for the TELECHIK inquiry). At disease onset, the questionnaire aimed to define the location of joint pain (hand, wrist, elbow, shoulder, neck, upper back, lower back, hip, knee, ankle, foot). At the TELECHIK time point, the questionnaire aimed to assess the clinical outcome, which was subsequently classified as recovery, relapsing, or lingering RMSP. Data on demographics, health status, knowledge of CHIKV transmission, habitat and environment were gathered from the SEROCHIK study .
Severe initial rheumatic involvement was defined as joint or muscle pain with fever and six or more painful sites among those listed above, and at least four other symptoms among the following: rash, headache, fatigue, mood or digestive disorders. Low to moderate rheumatic involvement was defined as RMSP with at most two of the preceding conditions.
Underlying comorbidities accounted for pre-existing metabolic syndrome (MetS), rheumatic disorders, and other chronic conditions (asthma, chronic obstructive pulmonary disease and cancer) . Rheumatic disorders included IRDs, that is, RA, ankylosing spondylitis (AS), PsA (axial PsA, or PsA with peripheral joint involvement), hip, knee and hand osteoarthritis, and gout [12–14]. MetS was defined by at least one of the following conditions: body mass index ≥ 30 kg/m2, type-2 diabetes mellitus, hypertension, or any type of dyslipidaemia. The individual exposure level was generated by the result of a scoring system deriving a probability of infection that was assumed to highlight the infection load. The characteristics of this scoring system of CHIKV exposure are depicted in the footnote of Additional file 2.
The values of total CHIKV-specific IgG antibodies were the ones provided by the SEROCHIK study. On this behalf, the option was assumed that post-epidemic IgG titre measured at the plateau phase might be an accurate proxy for the exposure level within successive immune boosts following repeated Ae. albopictus infective bites throughout the epidemic.
Total CHIKV-specific IgG antibodies were detected by direct ELISA, as established at the National Reference Centre (Pasteur Institute, Lyon, France). The technique was automated in an ETIMax 3000® apparatus (DiaSorin, Rome, Italy). Optical density thresholds were calculated from a series of 30 negative sera collected in 2004, before the epidemic .
Recovery was defined by RMSP at disease onset, absent at the two last follow up time points. CHIK-R was defined by long-lasting RMSP (> 3 months), relapsing RMSP (present at one to two time points with impossibility of a conclusion of recovery), or lingering RMSP (present at three time points), irrespective of pain and health-related quality of life .
Averages of age and CHIKV-specific IgG titres were compared between outcome categories using the Kruskal-Wallis and Cuzick tests, as appropriate. Predictors of long-lasting relapsing or lingering RMSP related to explanatory variables were assessed in bivariate analysis using recovery as the referent category. Weighted cumulative incidence rates (CIR) of RMSP were compared between categories of predictive variables using survey-adjusted Wald χ2 tests to account for the sampling scheme (1: probability of inclusion as sampling weight). Design-based crude odds ratios (ORs) and 95% CI were determined for each modality of significant variables and overall P-values were calculated using the χ2 likelihood ratio test.
At the first step of multivariate analysis, we fitted a full multinomial logistic regression model with age, gender, underlying comorbidity, exposure score, initial rheumatic involvement and CHIKV-specific IgG titres as explanatory variables, and relapsing or lingering RMSP as outcome variables with recovery as the referent category. From these covariates, we used a backward stepwise selection procedure to drop out non significant variables (output if P > 0.05). At the second step, we built in a minimal multinomial logistic regression model with all significant covariates from the precedent model plus gender. Indeed, we decided to force the gender because women are usually more susceptible to multiple musculoskeletal conditions . At the third step, in a sensitivity analysis we built up a Poisson regression model without an option for robust calculation of variance, predictive of lingering RMSP with the same covariates to better assess the incidence risk ratio (IRR) of the most pejorative outcome with recovery as reference. Independent predictors of CHIKV-specific IgG titres were subsequently searched using multiple linear regression analysis. Statistical significance was set at P = 0.05; analysis was performed using Stata 10® (StataCorp. 2008, Texas, USA).
The TELECHIK study had received approval from the ethical committee for studies with human subjects (CPP) of Bordeaux and the National Commission for Informatics and Liberty (CNIL), as ancillary research completing the SEROCHIK study [24, 28].
Among the 422 subjects included, 50 children (age < 15 years) and 26 adults were ruled out due to fear of poorly characterizing the course of CHIK-R, as well as to enhance benchmarking with some of the rare articles published in the field [6–8, 18–21, 30, 31]. The study participation profile is displayed in Figure 1.
Three hundred and forty-six subjects were analyzed for the determinants of CHIK-R on average two years after infection (range 15 to 34 months). The median age was 50 years (range 15 to 91 years). The sex ratio of men to women was 0.61 (131 to 215). All participants were assessed for the CHIK-V-specific IgG value on an average of 232 days (7.6 mo) after acute infection (range 1 to 18 mo).
Characteristics of 346 CHIKV-infected subjects ≥ 15 years of age assessed for Chikungunya rheumatism in the TELECHIK study, La Réunion, 2007 to 2008
15 to 29 yrs
30 to 44 yrs
45 to 59 yrs
≥ 60 yrs
Body mass index
< 25.0 kg/m2
25.0 to 29.9 kg/m2
≥ 30.0 kg/m2
Sites of arthralgia at disease onset
Sites of arthralgia at disease onset, n
2 to 5
Exposure score was not related to CHIK-R, making obsolete the hypothesis of a relationship between recurrent exposures and the expression of RMSP. On the other hand, there was a significant non linear positive association between CHIKV-specific IgG titres and the expression of CHIK-R. Thus, CHIKV-specific IgG level averages increased from the recovery, passing through the relapsing, to the lingering group (P < 0.001).
Predictors of Chikungunya rheumatism issues in subjects ≥ 15 years of age (full model) in the TELECHIK study, La Réunion, 2007 to 2008
Outcomes (versus recovery as reference)
Relapsing rheumatic musculoskeletal pain
Lingering rheumatic musculoskeletal pain
Adjusted odds ratio
Adjusted odds ratio
15 to 29 yrs
30 to 44 yrs
45 to 59 yrs
0.78 - 9.10
≥ 60 yrs
Metabolic syndrome without rheumatic disorders*
Rheumatic disorders with or without metabolic syndrome**
Initial rheumatic involvement
Low to moderate†
CHIKV-specific IgG titre (per one unit increase)
Exposure Score #
First quartile class (-2.526; -0.415)
Second quartile class (-0.400; 0.018)
Third quartile class (0.026; 0.432)
Fourth quartile class (0.433; 1.435)
Predictors of Chikungunya rheumatism issues in subjects ≥ 15 years (final model), TELECHIK study, La Réunion, 2007-2008
Outcomes (versus recovery as reference)
Relapsing rheumatic musculoskeletal pain
Lingering rheumatic musculoskeletal pain
15 to 29 yrs
30 to 44 yrs
45 to 59 yrs
≥ 60 yrs
Initial rheumatic involvement
Low to moderate†
CHIKV-specific IgG titre (per one unit increase)
Predictors of Chikungunya virus-specific IgG titres in subjects ≥ 15 years of age in the TELECHIK study, La Réunion, 2007 to 2008
Full multiple regression linear model of CHIKV-specific IgG titres (n= 309)
Estimated probability of infection #
Initial rheumatic involvement
Time elapsed between infection and test¶
Minimal multiple regression linear model of CHIKV-specific IgG titres ( n = 344)
Initial rheumatic involvement
Thus, CHIKV-specific IgG titres correlated with the intensity of CHIK-R but not to the infection load, which argues against the notion that the rise of CHIKV-specific IgG titres may be due to re-infection following new introduction and waves of CHIKV in La Réunion. In another manner, the sex and age-related discrepancies observed across the different clinical pictures at presentation do not favor major involvement of the viral load in the pathomechanism of CHIK-R. We conclude that the host humoral response to the persistence of ongoing antigenic stimulation is a plausible clue to long-lasting RMSP.
Here we report a prognostic survey of CHIK-R based on the subset of participants reporting RMSP at the onset of CHIKV infection, who were extracted from the TELECHIK cohort study, a population based-study aimed at assessing the disease burden and perceived morbidity in La Réunion island community after the 2005 to 2006 CHIKV outbreak . The major findings of our survey confirm the incidence at population level of CHIK-R across different variable categories, and the prognostic values of advanced age (≥ 45 years), severe initial rheumatic involvement at presentation, and rise in CHIKV-specific IgG titre through the recovery/chronic phases to predict the severity of CHIK-R over time. Thus, among previously uninfected individuals , the subjects ages 45 to 59 years and particularly the oldest subjects (≥ 60 years) were more likely to evolve towards relapsing and lingering chronic RMSP in an age-dependant dose-response manner. In addition, the risk estimate for severity of CHIK-R among the individuals in the 45-59 years age group was even increased towards the categories of outcome (that is, from the relapsing to the lingering feature group) in comparison with younger peers (aged 15 to 29 years). In the same way, the subjects who experienced severe initial rheumatic involvement (six or more painful sites with at least four other symptoms) at the acute stage of infection were more likely to exhibit chronic RMSP on follow up. Concurrently, the subjects who developed a strong CHIKV-specific IgG response shared a similar issue. These results were robust and were observed across different regression models controlling the exposure level to the infection (that is, the infection load) and major confounders such as female gender and underlying comorbidities. Likewise, these two factors have been previously recognized to be associated with poor health-related quality of life in people living with several musculoskeletal conditions, including IRDs, osteoarthritis, low back pain and soft tissue disorders, as reported in an Italian population .
It is noteworthy that in bivariate analysis female gender tended to be associated with lingering RMSP. Consistently, this finding has been previously reported for persistent arthralgias among CHIKV-infected subjects followed in the Italian cohort in the setting of the 2007 local CHIKV outbreak . Of note, the strength of this association was modulated in our cohort by the level of the humoral immune response, which was found to be much higher among female than male patients from both the Réunion (P < 0.001) and Italian Chikungunya cohorts (Figure 2a). Such a gender difference in the CHIKV-specific IgG level was found at the baseline and may be due to the natural estrogen-driven shift towards the Th2 cytokine profile for promoting antibody production in women, or to the inhibitory effect of dihydrotestosterone (DHS) on B cell functioning in men . On an other hand, it may also be due to higher production of immunosuppressive IL-10, which has been found to correlate positively with DHS and negatively with serum IgG3 titres in male patients with other viral infections [33, 34]. These same mechanisms may have driven the discrepancy between IgG titres following CHIKV infection in men and women. Interestingly, the isotypic switch observed in Singapore CHIKV-infected patients referred exclusively to the IgG3 subclass . Though we could not characterize the contribution of specific IgG isoforms, our results are consistent with those of the Italian cohort in which IL-10 levels decreased over time following the acute stage, in parallel with the rise in specific IgG level .
In the present study, more than 50% of the subjects ≥ 45 years of age at the time of infection still suffered from lingering RMSP on average two years after acute infection (Table 2). Other contributors have found a similar burden [6–8, 22, 23]. The prognostic value of advanced age as a harbinger of CHIK-R at disease onset has gained attention since the seminal description of CHIK-R [20, 21]. Consistently, the positive link between age and the duration of RMSP has been confirmed in recent years by several cohort studies [6, 8, 19, 23]. In line with these authors, we found a strong dose-response between increasing age over 45 years and the severity of CHIK-R, arguing for a causal relationship linking age to the duration and severity of CHIK-R. Moreover, a positive association between high titres of CHIKV-specific IgG in the plateau phase and long-lasting arthralgias has been observed contemporaneously from a pilot study by our group and in the Italian cohort [18, 19]. A possible mechanistic hypothesis may be that an imbalance towards B cell expansion and differentiation, in response to IL-6 secretion following the progression of both immunosenescence  and Chikungunya [35, 36, 38], is triggered by viral persistence in host sanctuaries [15, 17, 18].
The contribution of underlying comorbidity has long been considered a prerequisite to the subsequent expression of CHIK-R [5–8, 18–24, 31, 32], and a pre-existing rheumatic disorder was reported among 44% of the patients hospitalized after a CHIKV infection in La Réunion . A history of arthralgia before the outbreak was associated with persistent joint pain in the Italian cohort . Of the rheumatic disorders that could contribute to CHIK-R, RA [10, 11, 15], seronegative spondylarthritis [10, 31], soft tissue rheumatism , osteoarthritis [7, 8], and gout  have been reported to afflict CHIKV-infected patients. Previously, in the TELECHIK study, we were able to link osteoarthritis to long-lasting RMSP in the whole cohort , but failed to replicate this result in the subset of the arthralgic participants at disease onset. Indeed, rheumatic disorders were more likely to be associated with chronic RMSP when associated with one or more components of the MetS (that is, obesity, type-2 diabetes mellitus, hypertension or dyslipidaemia). However, this relationship did not resist to adjustment for age. Importantly, arterial hypertension and cumulative comorbidities have previously been associated with CHIK-R . Therefore, a high incidence of lingering RMSP was observed in MetS-positive subjects (53.8%). On the one hand, CHIKV has been suggested to trigger auto-immune IRDs such as RA or PsA [11, 12] and there is a growing body of evidence linking IRDs to MetS , especially RA or PsA . On the other hand, undifferentiated arthralgias according to rheumatologic guidelines [12–14], which represent the hallmark of CHIK-R, should be considered for specific involvement in systemic inflammation and enhancement of MetS, assuming these two risk factors are key issues in the increased incidence of cardiovascular diseases occurring among IRD patients . The issues should be considered of importance and deserve further studies to close a putative gap between Chikungunya and MetS.
The prognostic value of severe initial rheumatic involvement for predicting long-lasting RMSP is classical with alphaviruses, and encompasses most of the human pathogens included in the SFV serocomplex plus the Sindbis virus [1, 41, 42]. For CHIKV, it was first reported in La Réunion  and subsequently confirmed in other settings [19, 22, 23, 30]. The intensity of symptoms at disease onset has been linked to plasma viral load, CRP level, and Th1-driven cytokine traffic [3, 15, 41–44]. Indeed, in our study, a positive link between the intensity of symptoms at disease onset and the course of CHIK-R was found beyond the distribution of CHIKV-specific IgG titre values (Tables 2 and 3, and Additional file 3). Indeed, the relationship was found independent of IgG levels, while observing a correlation between the severity of the clinical picture and the IgG level (Table 4), highlighting a proper role of each of these factors on the outcome. This relationship may involve the pivotal action of IL-6 in the recovery phase of infection [35, 36, 38], which favours the switch from innate to adaptive immunity leading to B cell expansion and IgG3 production . Although controversial, IL-6 secretion at the acute stage may also explain the concomitant increase in CRP level [5, 43] and its predictive value for CHIK-R [15, 31].
In the absence of evidence of early-onset autoimmunity or circulating immune complexes , the proper role of IgG on CHIK-R remains elusive. From our study, the fact that non-linearity characterizes the positive association between CHIK-R and specific IgG levels argues for the contribution of other factors. The possibility of mixed cryoglobulinemia has been suggested  but not replicated in observational studies . Long-term persistence of IgM has been reported with CHIKV , sometimes associated with erosive arthritis , so that it is the timing of antibody commutation rather its significance (putative persistence of CHIKV antigens) that would be of critical importance.
We could not draw insights from the absence of a link between the exposure level and the course of CHIK-R, or between the infection load and CHIK-specific IgG titres. This could be due to the fact that our exposure scoring system did not capture the host behavior after infection throughout the epidemic, or that of the risk of being infected changed over time due to vector control measures. With the potential contribution of memory B cells to the level of CHIKV-specific IgG titres and subsequent related immunopathology, this negative finding does not imply failure to take care to prevent the burden of CHIK-R over the course of long-lasting CHIKV outbreaks. Indeed, the people at risk for CHIK-R should now be targeted using anti-Ae. albopictus saliva IgG abs .
This study has some strengths and limitations. The limitations inherent in the TELECHIK study have been reviewed extensively elsewhere . Regarding the rheumatologic aspects of Chikungunya, one of the main drawbacks to inference would be that in a declarative survey, patients were not examined physically by a clinician to rule out differential diagnoses and confirm the incapacity. However, we had previously demonstrated that the role of subjectivity was negligible in the TELECHIK study . Here, we have shown that the spectrum of early clinical manifestations declared at disease onset are slightly overestimated compared to those described in the setting of medicine or rheumatology clinics [5, 6]. This discrepancy could be explained in our study by the selection of more female and older participants, highly susceptible to CHIK-R, as well as by the enlargement of the window of disease onset due to the retrospective assessment of complaints, rather than to significant recall bias. Indeed, clinicians may also be inattentive to subtle complaints in the context of being overwhelmed by the number of consultations during epidemics. In that case, we also demonstrate in another sensitivity analysis that our findings are robust and valid for the most pejorative expression of CHIK-R (Additional file 3). Thus, we are confident that declaration bias was unlikely to have changed the scope of our findings.
The TELECHIK cohort study provides valuable clues in the field of rheumatology by contributing to strengthen the recognition and interpretation of the predictors of CHIK-R. Our findings also demonstrate the putative prognostic value of the IgG host level assessed in the recovery/chronic phase times. Thus, the standardized assessment of the engagement of the humoral response and the timing of production of neutralizing IgG3 might help to identify CHIKV patients at risk for long-lasting RMSP. This issue might also change the paradigm from almost exclusive interest in the innate immune response to adaptive immune trafficking, and thus pave the way to new avenues of research into Chikungunya [35, 36]. Consistently, these perspectives should focus on an integrative approach of exploring the timing of the IgG switch and B cell signalling, innate/adaptive collaborations, chronic infection and aging , or potential roads to late-onset autoimmunity  and lymphoproliferative disorders .
cumulative incidence rate
Commission Nationale Informatique et Libertés
Comité de Protection des Personnes
enzyme-linked immunosorbent assay
erythrocyte sedimentation rate
human leucocyte antigen
Institut National des Statistiques et des Etudes Economiques
inflammatory rheumatic disorders
incidence risk ratio
rheumatic musculoskeletal pain
Ross River virus
Semliki Forest virus.
We are indebted to the field workers of the SEROCHIK survey, the technicians of the CIC-EC of La Réunion who collected the sera samples, those of GHSR hospital who analyzed the sera. We also thank Professors Antoine Flahault and Philippe Gasque for helpful discussions and critical reading of the manuscript.
This study was funded by the Institut National de Santé Et de la Recherche Médicale.
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