Clinical Protocol to Manage the Nipah Virus Disease
Prepared by Nipah Advisory Group, Kerala Health Services and approved by Additional Director of Health Services (Public Health Division)
Human Nipah virus (NiV) infection is an emerging zoonotic disease which was first recognized in a large outbreak of 276 reported cases in Malaysia and Singapore from September 1998 to May 1999.
In India, during 2001 and 2007 two outbreaks in human were reported from West Bengal and neighbouring Bangladesh. Large fruit bats of Pteropus genus are the natural reservoir of NiV. There is circumstantial evidence of human-to- human transmission in India in 2001.
During the outbreak in Siliguri, 33 health workers and hospital visitors became ill after exposure to patients hospitalized with Nipah virus illness, suggesting nosocomial infection. Nipah cases tend to occur in a cluster or as an outbreak.
Agent: NiV is a highly pathogenic paramyxovirus
Natural Reservoir: Large fruit bats of Pteropus genus are the natural reservoir of NiV. Presumably, pig may became infected after consumption of partially bat eaten fruits that dropped in pigsty.
Seasonality was strongly implicated in NiV outbreaks in Bangladesh and India. All of the outbreaks occurred during the months of winter to spring (December-May).
Incubation period: varies from 4-21 days.
Mode of Transmission: Transmission of Nipah virus to humans may occur after direct contact with in- fected bats, infected pigs, or from other Nipah virus infected people. Another route of transmission of Nipah virus has also been identified from its natural reservoir to human: drinking of raw date palm sap contaminated with NiV.
Laboratory diagnosis of a patient with a clinical history of NiV can be made during the acute and con-valescent phases of the disease by using a combination of tests. The designated Nipah virus testing facility for Kerala is MCVR Manipal. NIV Alappuzha also has the testing capacity, which may be utilised by Ernakulam/ Alleppey/ Idukki/ Kottayam districts. DSO will decide destination of samples based on updated communication from DHS office.
Fever, Altered mental status, Severe weakness, Head- ache, Respiratory distress, Cough, Vomiting, Muscle pain, Convulsion, Diarrhoea.
In infected people, Nipah virus causes severe illness characterized by inflammation of the brain (encephalitis) or respiratory diseases.
In general, the case–fatality rate is estimated at 40–75%; however, this rate can vary by outbreak and can be upto 100%.
Currently there is no known treatment or vaccine available for either human or animals. Intensive supportive care with treatment of symptoms is the main approach to managing the infection in people.
There is no proven treatment recommended for Nipah virus disease. Some observational data suggests that Ribavirin may be of use in reducing mortality among patients with encephalitis caused by Nipah virus disease. There is no data/evidence of its usefulness as a prophylactic drug
Intensive supportive care with treatment of symptoms is the main approach to managing the infection in people.
Suspect Nipah Case
Person from a area/ locality affected by a Nipah virus disease outbreak who has:
Acute Fever with new onset of altered mental status or seizure and/or
Acute Fever with severe headache and/or
Acute Fever with Cough or shortness of breath
Probable Nipah Case
Suspect case-patient/s who resided in the same village where suspect/confirmed case of NIPAH were living during the outbreak period and who died before complete diagnostic specimens could be collected.
Suspect case-patients who came in direct contact with confirmed case-patients in a hospital setting during the outbreak period and who died before complete diagnostic specimens could be collected.
Confirmed Nipah Case
Suspected case who has laboratory confirmation of Nipah virus infection either by:
Nipah virus RNA identified by PCR from respiratory secretions, urine, or cerebrospinal fluid.
Isolation of Nipah virus from respiratory secretions, urine or cerebrospinal fluid.
Definition of a Contact
A Close contact is defined as a patient or a person who came in contact with a Nipah case (confirmed or probable cases) in at least one of the following ways.
Was admitted simultaneously in a hospital ward/ shared room with a suspect/confirmed case of Nipah virus disease.
Has had direct close contact with the suspect/con- firmed case of Nipah virus disease during the illness including during transportation.
Has had direct close contact with the (deceased) suspect/confirmed case of Nipah virus disease at a funeral or during burial preparation rituals.
Has touched the blood or body fluids (saliva, urine, vomitus etc.) of a suspect/confirmed case of Nipah virus disease during their illness.
Has touched the clothes or linens of a suspect/con- firmed case of Nipah virus disease.
These contacts need to be followed up for appearance of symptoms of NiV for the longest incubation period (21 days), or preferably double incubation period, of 42 days.
Nipah virus disease: Guidelines for laboratory sample collection and diagnosis
Laboratory Diagnosis: Laboratory confirmation of a suspect/probable case can be made during the acute and convalescent phases of the disease by using a combination of tests. The designated Nipah virus testing facility for Kerala is MCVR Manipal.
Sample Collection and Transport Guidelines: Universal, standard droplet and bio-containment precautions should be followed during contact with excretions, secretions and body fluids of suspected patient for Nipah virus. Adequate bio-safety precautions should be adopted during collection/transport/ storage/ processing of suspected sample.
Sample collection: The samples should be collected as early as possible (preferably within 4 days) with all bio-safety precautions and accompanied with de- tailed history of patients on the proforma which can be obtained from the testing laboratory.
Sample collection should be done only after admission in an appropriately secure isolation facility, and ensuring that the staff member doing the collection is using adequate PPE.
During sample collection wear complete disposable Personal Protective Equipments (N 95 mask, double surgical gloves, gowns, goggles foot cover, etc). Wash hands with soap and water at least for 30 seconds and then clean hand using 1-2 ml alcohol based hand sanitizer before and after collection of samples.
The recommended samples are
Throat swab in viral transport medium
Urine 5 ml in universal sterile container
Blood in red vacutainer (5ml)
CSF (1-2 ml) in sterile container
Transportation and Storage of samples:
Samples should be safely packed in triple container packing and should be transported securely under cold chain (2-8°C) to the testing laboratory with prior intimation.
Sample containing vials, tightly closed, should be kept in good quality zip-lock bags wrapped with sufficient absorbent cotton padding so that inside material should not come out of bag if it leaks. The plastic bag should be kept in another Zip-lock bag similarly, which should be sealed with adhesive tape. This carrier should be placed in a hard container sealed with impermeable tape or plaster and placed in thermocol box /vaccine carrier containing ice packs. The case sheets with complete information should be placed in plastic bag and should be pasted outside the container.
Nipah Virus Disease: Advisory for health care personnel
1. Wash hands thoroughly with soap and water for 20 seconds after contact with a sick patient.
2. Use appropriate mask and gloves during history- taking, physical examination, sample collection and other care-giving to suspected Nipah cases.
3. Follow Standard precautions for infection control at hospital settings:
Use of PPE.
Use disposable items (NG tube, ET tube, oxygen mask) while handling the patient.
Safe waste disposal for potentially infected mate- rial including used PPE, linen, clothing of patient.
4. All suspect cases should be admitted to the designated isolation ward/ facility in the hospital prior to any sample taking. Once the case is suspected of Nipah, bystanders should not be permitted in the ward.
5. Segregate all suspect cases of Nipah from all patients in the isolation ward/ facility.
6. Avoid unnecessary contact with suspected Nipah cases or use barrier nursing Maintain bed spacing of 2 metres at least
7. Any spillage of body fluids in the OP/Ward should be managed as per infection control guidelines.
8. Immediately report admission of a suspected Nipah case to State Surveillance Officer and CSU (IDSP) in the prescribed daily report formats
9. Mortuary staff should wear PPE while handling a dead body. Designated sealed bag should be used for transportation of the dead body.
Draft /interim guidelines document prepared by Nipah Advisory Group, Kerala Health Services and approved for issue by Additional Director of Health Services (Public Health Division), Kerala, dt 02.06.2018
This version takes precedence over all earlier versions of the State Guidelines wef 02.6.2018
As the situation is still evolving, the matter contained in this guideline is subject to modification at regular intervals
Detailed reference documents to be read for addl information will be emailed to all DMOs and DSOs regularly
All are advised to check DHS website or contact your DSO for updates, regularly