Whispers of Peril: Kerala’s Struggle against the Nipah Menace
Dr. Manasa S R
Division of Veterinary Public Health and Epidemiology, Indian Veterinary Research Institute, Bareilly, Uttar Pradesh
The Kerala State Government announced on September 12, 2023, that six laboratory-confirmed cases of Nipah virus infection, including two fatalities, had been reported. The Kozhikode district of Kerala was the source of reports for all confirmed cases, which were all male and ranged in age from 9 to 45.
The first person was hospitalized in late August 2023 with pneumonia and acute respiratory distress syndrome (ARDS); the source of the infection is unknown. Soon after being admitted, he passed away. The other five confirmed cases were close associates of the initial case, including contacts at the hospital where the initial person was treated before passing away and two family members. An individual who was with another patient passed away in the second instance.
In response, the government established containment zones with movement limitations, social distancing, and mask wear requirements in public areas in nine villages inside the Kozhikode district. Major public activities in the Kozhikode district are prohibited by the government until October 1, 2023. States and neighboring districts received alerts for increased surveillance.
The virus discovered in Kerala has been named the Indian Genotype, or I-Genotype, and is comparable to the Nipah virus strain discovered in Bangladesh, according to the National Institute of Virology (NIV), Pune.
There have been reports of NiV outbreaks in Bangladesh, India, Malaysia, and Singapore. In the initial outbreak in Malaysia, the mode of infection was direct contact with sick pigs (1999). The ingestion of fresh date palm sap contaminated by fruit bats was identified as the cause of the epidemics in Bangladesh and India. In Siliguri, West Bengal, India, hospital visitors and healthcare professionals caught the infection after being exposed to patients in 2001, marking the first instance of human-to-human transmission in a healthcare setting. In Bangladesh, human-to-human transmission has also been reported (2004).
The third NiV epidemic in India, with the previous two occurring in Siliguri and Nadia, West Bengal (2007), happened in the Southern state of Kerala in May 2018. Reports of eighteen confirmed cases came from the districts of Kozhikode and Malappuram with high mortality and person-to-person transmission.
About the virus and the Disease
Nipah virus which is a zoonotic in nature carried by fruit bats and belongs to the Henipavirus genus which also contains the equine Hendra virus causes infection. People can contract the virus by eating raw date palm sap or fruit that has come into contact with bat secretions like urine or saliva. Direct contact with infected animal or bodily fluids can also result in transmission. Close contact with an individual infected with the Nipah virus or their bodily fluids, such as respiratory or nasal droplets, urine, or blood, can result in the virus spreading from person to person.
An infection with the Nipah virus can manifest clinically as anything from a minor respiratory infection, to an acute respiratory infection and deadly encephalitis. To detect possible infections, medical professionals should use a symptom and travel screen, though, as early symptoms could be non-specific.
The monoclonal antibody m102.4 has demonstrated promise in neutralizing Henipaviruses and has been used under compassionate use protocols for post-exposure prophylaxis for Hendra virus, despite the fact that there are currently no approved treatments for Nipah virus infection. Furthermore, with varying degrees of success, the antivirals ribavirin and remdesivir have also been used in outbreaks. The development of preventative vaccines is still a top priority.
Response of the state towards the outbreak
The Department of Health and Family Welfare, the Department of Health Research, and the Department of Animal Husbandry all organized many central multidisciplinary teams to assist the State and District administration with containment and mitigation efforts. Various response measures, such as surveillance, sample evaluation, tracking contacts, patient transportation, case oversight, logistics and supplies, training and capacity building, risk communication and community engagement, psychosocial support, and animal husbandry, were assigned to a total of 19 core committees. To coordinate the reaction actions, the district established a control facility with a phone center.
Surveillance and contact tracing: The district health authorities in the declared containment zones conducted active house-to-house surveillance as part of community-based surveillance activities. As of September 27, 2023, 53,708 houses had been surveyed in total. By September 27, 1288 contacts—including those deemed high-risk—had been identified, placed under quarantine, and were still undergoing follow-up activities. Every high-risk relationship was examined. Nine villages in the Kozhikode district were designated as containment zones, requiring people to wear masks in public areas, restricting their movement, and separating them from other people socially. Major public events in the Kozhikode district are prohibited by the government until October 1, 2023. States and neighboring districts have received alerts for increased surveillance.
Laboratory testing: The Regional Viral Research and Diagnostic Laboratory network lab at the Government Medical College (GMC), Kozhikode; the Indian Council of Medical Research (ICMR) Mobile BSL-3 lab; the Field unit of NIV at Alappuzha; and NIV, Pune are the labs where tests are carried out on environmental and animal samples, as well as suspected cases. Bats are among the animals and environmental samples that have not tested positive for the Nipah virus as of the 27th of September 2023.
Health facility readiness: Emergency rooms are outfitted with the tools necessary to manage any suspected instances and react to crises. When necessary, isolation facilities and intensive care units (ICUs) are kept prepared to handle suspected cases. When necessary, the government has ventilators, ICU beds, and isolation rooms set aside for mounting surge capacity. At specified medical facilities, cases that are both suspected and confirmed are being managed. Specialized the ambulances have been dispatched to transport patients.
Healthcare personnel are now receiving instruction on infection prevention and control (IPC) from the State Government. Health care personnel now have access to sufficient supplies of Personal Protective Equipment (PPEs), and IPC procedures are rigorously followed and audited.
Logistics management: The State Government provides sufficient supplies of medications, personal protective equipment, and other necessary supplies.
Dead body management: In accordance with standard procedure and IPC precautions, arrangements have also been made by the State Government for the transfer and management of dead bodies.
Risk communication and community engagement: Various modalities, such as regular press releases, have been used to start informational and communication campaigns. Expert doctors are also providing audio notices and video bytes. Strict measures are being taken against fake news while infodemic management strategies are being put into practice. The government of the state has also set up an on-call center to offer psychological assistance.
Animal Sector: A 300-acre (121-hectare) forest that is home to multiple bat species was sampled on September 15 from the village where the initial case resided. The samples included bats, animal droppings, and partially eaten fruits. The Nipah virus did not show up in any of the samples.
During Kerala state’s 2018 Nipah virus outbreak, public health response measures were carried out in compliance with the guidelines formulated by the State and Central governments, with assistance from WHO and other partners.
Kerala’s health authorities are working more closely with neighboring states such as Karnataka and Tamil Nadu to better monitor for possible cases and prevent cross-border transmission.
Prevention and Control
Patients suspected of having the Nipah virus should be isolated in well-ventilated individual rooms with dedicated individuals equipment and toileting; they should not be placed in cohort rooms. Healthcare personnel who provide care for patients suspected of having the Nipah virus should take contact and droplet precautions; these include placing the patient in an airborne isolation room when performing aerosol-generating medical procedures; if airborne isolation rooms are not available, the patient should be placed in a well-ventilated single room with windows open if using ventilation from the outdoors and doors to corridors closed.
Every surface in patient rooms containing suspected or confirmed Nipah virus cases should be cleaned and disinfected at least once every day. Following a soap and water cleaning, surfaces should be treated with a 0.5% sodium hypochlorite solution disinfectant and left untouched for five minutes. Anytime blood or bodily fluid spills, high touch surface cleaning and immediate cleaning and disinfection should be carried out. Improved water, sanitation, and hygiene services are necessary for health facilities to fulfill the requirements of employees, patients, and caregivers. Health care facilities should follow safe waste management procedures.
What to focus on in the future?
Prioritizing investigations and vaccine development will help ensure that funds are available for both the development of vaccines and antiviral drugs as well as for additional genetics research on NiV. Studies shed light on the virus’s behavior, dynamics of transmission, and possible therapeutics, while the creation of vaccines offers long-term defense against new outbreaks.
Capacity building is essential, requiring ongoing education for medical staff to guarantee that they can handle NiV cases in a safe and efficient manner. Clinical aspects, infection control strategies, coordination of outbreak response, and adherence to public health protocols are all covered in this training.
A key component of the One Health Approach is its emphasis on the connection between environmental, animal, and the well-being of people. This holistic approach acknowledges that human, animal, and the health of ecosystems are interdependent and that, in order to effectively prevent and manage outbreaks, solutions must take these interrelated factors into account.
The resurgence of NiV outbreaks in Kerala is a serious issue that needs to be addressed immediately with coordinated action. The ongoing need for research, preparation, and international cooperation in the face of infectious diseases with pandemic potential is highlighted by the fight against the NiV.
Conclusion
In conclusion, the recent Nipah virus outbreak in Kerala underscores the critical need for immediate and coordinated action. Prioritizing investigations, vaccine development, and embracing a One Health Approach that considers the interconnectedness of environmental, animal, and human well-being are keys to addressing and preventing the resurgence of such outbreaks. The absence of effective therapies or vaccines emphasizes the urgency in allocating resources for research, preparation, and international cooperation to effectively combat emerging infectious diseases like Nipah virus.
Reference
- Centre for Disease Control and Prevention., 2023 Nipah Virus Outbreak- India https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON490
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