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Bhigwan (Pune District)   Bhigvan Photographs

COPCORD (Community Oriented Program for Control of Rheumatic Diseases) is a global initiative of the WHO/International League of Associations for Rheumatology (ILAR).

        Under the auspices of ILAR/APLAR, for the first time in India, a COPCORD (Community Oriented Program for control of rheumatic diseases) driven rural population survey was carried out in Village Bhigwan (Pune District) in 1996. The methodology used to extract information is presented, along with some general results. In Stage I Phase I, 6034 villagers (response rate 82%) were screened in 16 days by 21 trained village volunteers. Simultaneously, 774 patients (12.8%) identified completed Phase 2 questionnaire (symptoms and disability) prior to evaluation for diagnosis (Phase 3); limited laboratory workup was carried out. The entire cross-sectional survey was completed in 5 weeks. A pre-planned follow-up program was begun essentially to verify the survey diagnosis, identify new cases, impart health education (Stage II), and attempt control of risk factors (Stage III). A large community and patient data-base was created. As per phase I answers, musculoskeletal/rheumatic ailments were the commonest. The age and sex distribution of “pain at any site” and “symptoms” demonstrated preponderant problems in females, in the age group 25-54 years. In almost one-third of patients, a Symptom-Related-Diagnosis (34%) could be offered while degenerative (29%) and soft-tissue rheumatism disorders (20%) were commonly seen. Inflammatory arthritis (11%), Rheumatoid arthritis (4%) in particular, was seen in significant and unexpected proportions. Well defined reactive arthritis, tropical forms of arthritis (e.g. TB, Leprosy etc) and connective tissue disorders were not evident.

        The Indian COPCORD study is a “fast-track-model”. Unlike the previous COPCORD studies, this is an ongoing long term longitudinal observational study, and is in its tenth year running.

Using a similar model, a resurvey was completed in 1999 – 2000 to validate the initial survey results.
The Bhigwan data has been extensively presented and published.

Pune Pune Photographs
        The WHO – ILAR COPCORD Bhigwan (India) model has been adopted for the ‘Population Based Multiregional Urban Survey (2003-2004) for Rheumatic and other Musculoskeletal Disorders’ study, Sponsored and funded by the BJD-INDIA: NAN. The current model looks at several community issues including quality of life, socio economic impact, medical resources and health education.

        The urban study was begun in Jammu, Chennai and Pune in April 2004. In, Pune, the survey has been completed in the Narayan Peth locality in the heart of the city. Over 9000 population has been surveyed and 888 patients with different kinds of musculoskeletal rheumatic disorders identified.
Bavi Bavi Photographs
A rural population based study of Chikungunya infection with special reference to persistent ‘rheumatic musculoskeletal disorders
( An Indian Council of Medical Research, Govt. of India sponsored project)
Date of commencement : September 2006
Date of completion : June 2008
Chronic persistent RMSK is the most important sequel of CHIKV that leads to significant morbidity. In July-Sept 2006, several patients of chronic RMSK following CHIKV were referred to CRD, Pune, and the majority of these were inflammatory arthritis. A wide spectrum of inflammatory arthritis, ranging from RA like to seronegative spondyloarthritis (often HLA B 27 positive) was evaluated in CRD, Pune. This clinical expression of CHIKV led the investigators to speculate that CHIKV has a propensity to induce different types of rheumatic disorders. An important concern from the latter observation was whether ‘inflammatory arthritis’ following CHIKV was a frequent occurrence in the community. A population based study was required and this was a basis of the current CHIKV rural project. Village Bavi (District Sholapur), 200 km from Pune (population size ~2200) on the NH-4 highway to Sholapur was chosen as the study site. A house-to-house survey of an adult population of 1450 was conducted. Cases with persistent RMSK post CHIKV illness were followed up for 2 years till June 2008

In order to validate the observations of cases with persistent RMSK beyond one year following CHIKV illness a neighboring village (Modnimb, District Sholapur) population was selected; Modnimb is 6 km from village Bavi and 155 km from Pune. The Modnimb adult population (about 11000; the electoral list contained 9672 names) was screened for cases suffering from persistent RMSK following CHIKV illness, in December 2007.

As is known, and further shown by the data from this project, the CHIKV arboviral illness is relatively benign and resolves completely in over two thirds patients within one month. Over 90% of the remaining one third cases that continue to suffer from RMSK resolve within 16 weeks. At a community level, <12% cases and <5% population continue to suffer from RMSK for a year or so. More than 95% of the latter cases at one year suffer from non-specific arthralgias that need at its most symptomatic treatment, reassurance and follow up. Less than 0.2% cases at one year suffer from inflammatory arthritis which may be considered difficult to treat and is relatively a serious form of RMSK that can impact quality of life with a potential for physical deformities.

Persistent RMSK was the principle objective of the CHIKV project. The rural community data demonstrated that though non specific RMSK pain and disorders are common following CHIKV illness, inflammatory arthritis is an uncommon sequel.

A protocol driven program to compare oral chloroquin with oral meloxicam (a standard non-steroidal anti-inflammatory drug/NSAID) over 24 weeks of study period in patients with moderately severe RMSK pain following CHIKV illness was conducted.

This data showed that the predominant majority was relieved within 16 weeks and few required long term symptomatic care. At a community level, there was no evidence to prescribe oral choloroquin or steroids in any form for post CHIKV chronic RMSK, and symptomatic therapy with analgesics (paracetamol) and/or NSAID (diclofenac, meloxicam) as practiced in this study project, was sufficient.

List of Publications:
1.     We presented our preliminary results from village Bavi survey and the Pune rheumatology referral outpatient during the proceedings of the national conference on ‘Burden of rheumatic musculoskeletal disorders in India’ in Pune on 14-15 Oct 06.

2.     The preliminary observations on the referral cohort of patients was presented at the 1st National Conference of Infectious Diseases, Mumbai in 2007.

3.     The Chikungunya (CHIK) arthritis & rheumatism – an untold suffering. Arthritis & Rheumatism (Abstract) September 2007; Vol 56 9: 619-620.

4.     Chikungunya virus aches and pains: An emerging challenge
Arthritis & Rheumatism. 2008, Volume 58, Issue 9: 2921-2922.

5.     Acute Chikungunya Profile During The Indian Epidemic 2006 –Observation From Village Bavi (Dist. Sholapur) Indian Journal of Rheumatology 2008 November Volume 3, Number 3 (Suppl); pp. S42

6.     Chikungunya Related Persistent Musculoskeletal (MSK) Profile Following The Indian Epidemic 2006 –Observations From Village Bavi (Dist.) Indian Journal of Rheumatology 2008 November Volume 3, Number 3 (Suppl); pp. S42

7.     Chronic aches and pains following Chikungunya epidemic 2006 in Solapur (Maharashtra) : Observations from Modnimb Arthritis camps. Journal of Rheumatology 2008 November Volume 3, Number 3 (Suppl); pp. S26

8.     Does chloroquin work in chikungunya related musculoskeletal (MSK) pain and arthropathy? Results from the first community based controlled drug trial. Indian Journal of Rheumatology 2008 November Volume 3, Number 3 (Suppl); pp. S26
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