Lessons in History The Nipah Story

Kerala with its experience of handling the 2018 Nipah outbreak and its high alert and proactive deployment of key resources in 2019 is best placed to share inputs for a draft national policy

It was on May 2nd 2018 when the first Index - Mohammed Sabith - was taken to a Kozhikode Sub divisional hospital and from where he was referred to the Kozhikode Medical College for better care. During the care process in the Casualty, CT room and ICU, the infection spread through direct contact to other people who later succumbed and took the final total death toll to 16. His brother Mohammed Salih who was the second case, was taken to the private Baby Memorial Hospital in the early hours of May 17th with symptoms of encephalitis. Due to the recent history of his brother’s demise from a similar condition about two weeks prior and three other close relatives exhibiting similar symptoms, clinical doubts arose that the treating medical team was not dealing with the usual case of encephalitis ; samples were initially sent to Manipal Institute of Virology and later to the National Institute of Virology.

The first positive identification came from Manipal on May 18th. It was at this time that the authorities at Kozhikode Medical College were notified and the state health machinery under the leadership of the Health Minister K.K Shailaja Teacher and then Additional Chief Secretary Rajeev Sadanandan rose up to the daunting challenge in isolating and containing the out- break to just two state districts -Kozhikode and Malappuram. A total of 18 people was infected of which 16 died and 2000 people who were in direct contact with the infected cases were kept under close observation and verified twice daily. Any person showing symptoms were immediately shifted in specially prepared ambulances to the specifically designated two buildings within the Kozhikode Medical College (away from regular Outpatient activities) where facilities for triaging, observation and isolation were created with clear segregation zones.

The deployed healthcare workers had under- gone an intense course in safe and protective handling procedures and the exact standards for Ebola cases were adopted. Finally, the State government declared the outbreak over on June 10, 2018. Subsequent studies by Indian Council of Medical Re- search (ICMR) showed that Fruit Bats at the Changorath village in Kozhikode district were found positive for Nipah.

It’s a myth that Nipah is seen only in Kerala. To date India had 3 outbreaks the first being in January and February 2001 at Siliguri, West Bengal causing 45 deaths and subsequently in 2007 at Nadia District causing 5 deaths. In 2001 the doctors at Siliguri were clueless as to what hit them, the infection initially was said to have spread from a nursing home through health care workers, patients and their relatives. Utter panic spread throughout the town and it was almost deserted. The state government had to deploy health care resources from Kolkatta to contain and isolate the outbreak. Later investigations by the National Institute of Virology showed a case fatality ratio of 74%.

Like mentioned before even in the first episode in Kerala, it was the clinical insight of the medical team at the private hospital that helped in the correct diagnosis. As per ICMR scientists about 20% of wild fruit bats are known to be carriers of Nipah virus and hence they are present across the country. Unfortunately, no proper epidemiological studies have been conducted at the annual seasonal fever related deaths nor do we have a national policy or guideline in the management of Nipah. The State of Kerala with its experience in handling the 2018 Nipah outbreak and its high alert and proactive deployment of key resources in 2019 is best placed to share inputs for a draft national policy. Interestingly the State government had to borrow the national guidelines of Bangladesh to manage the situation in 2018!

A combination of climate change and rapid urbanization is increasing the acceleration of bat- human interfaces, with the virus crossing from Bat to Human in the Index case and then spreading aggressively from human to human. The most effective way to control the spread and prevent future outbreaks is through widespread education and public health activities focussing on prevention. Once infected it is now known that hospitals both in public and private sector will play a key role in early diagnosis/ detection and isolation of cases.

Stringent adoption of infection control protocols, use of personal protection equipment (PPE’s) and setting up of fever clinics with triaging facilities specially during the times of seasonal outbreaks and immediate notification to public health authorities of suspected cases can go a long way to control outbreaks. It’s also essential to have low cost point of care PCR diagnostic kits made avail- able to designated nodal public hospitals. The clinical, epidemiological, administrative and political experiential learning that is currently available in Kerala needs to be documented and used in the preparation of the national guidelines.

The current index case was referred to Aster Medcity from a peripheral hospital with a history of fever since 10 days. He arrived early morning on May 30th at the emergency department with fever and showed all signs and symptoms of encephalitis including slurring of speech and altered sensorium. Further work up by the Consultant Neurologist including blood markers and a MRI Brain showed an atypical clinical picture for encephalitis that necessitated the dispatch of CSF sample to an NABL accredited lab for testing of a viral panel that included Nipah.

The Infectious Diseases Consultant was also notified who helped in analyzing the various differential diagnosis based on available clinical information. Within 48 hours of the arrival of the patient a positive result for Nipah was obtained that triggered the next chain of events. Immediately the patient was isolated to a negative pressure isolation room and all barrier precautions put in place. The District Medical Officer - DMO was notified and through him the District Collector and consequently the State Health Secretary and Health Minister. The rapid response of the public health authorities was remarkably quick and efficient and all possible support was given to the hospital in form of management guidelines, supply of anti- viral medicines. Further samples were taken and send to nodal labs at Allepey, Manipal and to the National Institute of Virology, Pune. The test results were all positive for Nipah and the rest as they say is history.

As I write this piece, the Index case is clinically stable and the 3 healthcare workers who were direct care givers and quarantined in the Government Medical College, Ernakulam have all tested negative for Nipah. It’s a much-needed good news to the entire hospital and also to the state at large and reflects strongly on the stringent infection control protocols practiced at Aster Medcity. The most important take away lessons from this experience is the critical importance of early diagnosis, isolation containment of the patient and the adoption of infection control norms by hospital workers. As seen in the two instances in Kerala, the initial clinical suspicion resulted due to the alertness and clinical acumen of consultants at private hospitals. This may also hold true for a large number of patients across India, hence it will be most help for the clinicians involved to publish their findings in peer reviewed journals so that the larger community of doctors especially the general practitioners have a good reference point to make an early diagnosis. Thankfully to date, unlike in 2018 even though the state is on full alert no fresh cases have turned positive.

The early governmental response, decisive leadership, quick mobilization of resources, active vigilance posture, coordinated communication to the public through all media channels and the highly mature and responsible actions by them have all resulted in a state of calm that is truly laudable. A large deployment of central and state teams are already at work to understand the how’s and why’s of transmission to the Index case and hopefully the country at large will be better prepared for handling any possible future events of a similar nature.

It will be most help for the clinicians involved to publish their findings in peer reviewed journals so that the larger community of doctors especially the general practitioners have a good reference point to make an early diagnosis.

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