28 November Monday

Kerala Thrice Defeated Nipah: How To Prevent A Fourth Outbreak ?

Aswathy JayasreeUpdated: Thursday Nov 25, 2021


Deadly Nipah virus struck India’s southern state of Kerala thrice in the past four years with each time the state fending off the attack in early stages and preventing a full-blown outbreak.  Even so, according to experts, threat of another  outbreak looms. And, the state is gearing up to combat that possibility  with  its One Health Approach.

Lini, the epitome of sacrifice, remains a fragmented memory in the hearts of Ridhul’s and Sidharth – her children who forever lives with the sorrow of not being able to see their mother one last time before the funeral. . Lini Puthusserry was the martyr of first Nipah outbreak in South India that occurred in 2018. Sidharth was a five-year-old boy then and Ridhul was just two. The whole state of Kerala was awestruck for three months, unable to comprehend the cause and nature of the endemic. The fright and anxiety elevated abruptly when the health sector confirmed it is Nipah, a deadly viral disease, that has unveiled in Perambra a rural village in Kozhikode. Mr.Sabith, from Sooppikkada Changorathu Panchayat, was the first Nipah patient. The term Nipah was alien to Kerala when was presented at Perambra Taluk Hospital with strange symptoms of severe fever and vomiting. Soon after Sabith’s demise, his brother Swalih, father Moosa Aliyar, and a distant relative Mariyam succumbed to Nipah. The whole state of Kerala was realizing the nature, dread, and terror of the endemic. Lini, who was a nurse at Perambra Taluk Hospital, got infected while treating Sabith. Even before understanding the precariousness of the disease, Lini lost her life. Her husband Sajeesh, a gulf returnee, got only a single moment to see her for one last time. In a span of three months, 18 people got affected with Nipah and almost 90% of people who got infected, died. The panic that lasted for three months ceased only in August 2018, after the Kerala Government’s official announcement that outbreak had been contained.

The Family Remembers
Sajeesh, Lini’s husband who was in Dubai when Lini contracted Nipah, boarded the next available flight to Kerala after learning about his wife’s condition. Even though Lini was conscious then, her oxygen level declined during midnight. It was the news of Lini’s demise that woke up Sajeesh on 21st May 2018. It still frightens him when he remembers the unforeseen dilemma he had to encounter that day, about what to do with Lini’s body, or where to go. The Department of Health and Social Welfare was still preparing the protocol and there was an air of fear all around. Even ambulance drivers were too scared to take the body.The entire district was vacant, not a single person left their homes for days. Soon after the Government announced the protocols, the peril unveiled before them: the body could not be shifted to either Sajeesh’s house in Vadakara or Lini’s house in Chembanod. In no time, her body was buried in the public cemetery, without giving a chance to her kids to see their mother’s face one last time. Seven days after Lini’s demise, symptoms of fever appeared in her children which created yet another period of dismay and social alienation for the family. Both the children were shifted to the isolation ward at Kozhikode Medical College at once who, fortunately tested negative for Nipah. But the mental trauma the family had to go through was unimaginable as even close relatives, acting out of fear, avoided them. In addition, the family had to deal with a lot of romour. ‘It still hurts to think that people said the kids and I were affected with Nipah,’ recalls Sajeesh. The compensation from the government was generous: although there was a promise to provide INR 5 Lakhs for relatives who lost their loved ones to Nipah, an amount of INR 10 Lakhs was deposited in Lini’s kids’ accounts and Sajeesh also got a government job.

മരിക്കുന്നതിന്‌ മുമ്പ്‌ ലിനി സജീഷിനെഴുതിയ കത്ത്‌ വീട്ടിൽ ഫ്രെയിം ചെയ്ത്‌ സൂക്ഷിച്ചിരിക്കുന്നു

മരിക്കുന്നതിന്‌ മുമ്പ്‌ ലിനി സജീഷിനെഴുതിയ കത്ത്‌ വീട്ടിൽ ഫ്രെയിം ചെയ്ത്‌ സൂക്ഷിച്ചിരിക്കുന്നു

50 phone calls a day
Soon after the outbreak was reported, the government launched an intensive contact-tracing through its newly set-up Nipah cell to co-ordinate the situation and to prepare contact history list of patients. “I received above 50 calls a day from the health department enquiring about my travel history and contacts,’ remembers Sajeesh. “I told them whatever I remembered. Lini had 16 primary contacts. The Nipah cell created a primary contact list for these 16 people and every single one was under minute observation for 21 days long incubation period”, says Sajeesh. “Local people were frightened yet helpful at the same time. The close neighbours cooked food for us and volunteers delivered essential items. The then health minister K K Shailaja teacher called frequently to ensure our well being”, Sajeesh added.

ലിനിയുടെ ഭർത്താവ്‌ സജീഷും മക്കളായ റിഥുലും സിദ്ധാർത്ഥും

ലിനിയുടെ ഭർത്താവ്‌ സജീഷും മക്കളായ റിഥുലും സിദ്ധാർത്ഥും

Bat, the Villain
The root cause of Nipah outbreak in Perambra that occurred in 2018 was assumed to be bats and even foreign scientists have considered the same. The virus presence was found in pteropus species, a species of fruit bat or flying foxes. The virus lives in the body of the bat which makes the mammal a ‘natural reservoir’ for the pathogen and spreads to people who come in close contact of a bat or its body fluids such as saliva, urine or dropping. Once transmitted, the ‘zoonotic’ virus -which means it originated in another mammal - becomes deadly for them since unlike bats, human bodies cannot co-exist with the virus naturally. The zoonotic origin of Nipah in Kerala was also highlighted in a study published by national institute of virology in 2019. The samples collected from 2018 patients and perambra bats had a compatibility of ‪99.7-100‬%. The test results from the samples collected from Kodiyathoor and Thamarasseri of Chathamangalam Panchayat in 2021 also elucidates the involvement of bats in Nipah outbreak. The antibody named IGG was found in the samples collected from a pterpous bat from Thamarasserry and Rositus bat from Kodiyathur. In the light of these, the government is preparing to conduct studies on that.

Severe Symptoms
Nipah shows severe symptoms which surface during the four to 14 days long incubation period. This can extend to 21 days. Fever, vomiting, headache, dizziness, unconsciousness etc are the symptoms. Rarely symptoms like cough, stomachache, nausea, blurred vision can appear. Patients can fall into a coma stage even just after two days of showing symptoms. It can affect the lungs or cause Encephalitis, a condition that affects the brain. The virus also spreads to anyone who comes in close contact of an infected person. This is what makes it a virus with ‘pandemic potential’ or a pathogen that can spread fast and cause mass infection. Experts advise that once someone has tested positive, the infected should be shifted to isolation wards. The number of health workers in the wards should be limited and level of oxygen in the patient’s body should be monitored frequently and accurately. Monoclonal antibody from Australia The primary factor that led the government to find a vaccine or medicine for Nipah was the fear of further spread, intractable deaths, and number of patients. Then they learned that a monoclonal antibody mixture that can be a shield against Nipah was available in Australia. With central government’s permission, the medicine was imported. But 16 people had already died before its arrival. Health condition of other patients improved with the use of Ribavirin, a medicine developed by Dr Christopher C Broader which can only be considered as an antibody.

Tracking  source is all-important
Changorathu Sooppikkada which is about 45 km north of Kozhikoze, is a dense forest area and is a natural habitat of bats. This place is assumed to be the source of first Nipah outbreak although it has not been proven officially. According to Beeran Kutty who travelled with Sabith on bike a few days before the Nipah outbreak, a bat fell down on Sabith’s bike during the travel and Sabith put it on the side of the road with his bare hands. However, Beeran Kutty himself tested negative. There is also no official explanation for the infection of first patient in all the three outbreaks. As a result, finding this source remains a task for the scientists and health workers till today.

One Health approach, The Remedy

According to Dr Prejith, Office in charge of Centre for One Health Education Advocacy Research (COHEART) in Wayanad, the ultimate solution for zoonotic diseases is to employ One Health approach. One health approach is a multidisciplinary vision that ensures comprehensive health and wellness through amalgamating environmental, veterinary, and human health. "Nothing can be done after a disease outbreak. So, samples should be tested for antibodies in regular intervals. The only way to understand these outbreaks is through an in-depth epidemiologic, environmental, virologic, and genomic research," he says.

Currently COHEART is closely working with the Department of Health and Social Welfare and Forest Department and has already initiated further research into Nipah virus. The institute is also planning to expand its scope of research by employing advanced lab facilities for further research. If a virus is confirmed in a region, its presence can never be erased completely, says Dr Prejith. It will be present in the animals and birds of that ecosystem. So, it is a tough task to control a viral disease. Activities like deforestation, which destroys the natural ecosystem, can be factors to stimulate them to excrete the virus. Since environment, weather fluctuations, vector population, animal health etc are inextricably linked to our health, significance of One Health approach is increasing,’ Dr. Prajith explains.

ഡോ. പ്രജിത്‌

ഡോ. പ്രജിത്‌

Contained but not Eliminated
Nipah has continued to resurface in Kerala. In 2019, an engineering student from Kochi got infected but a further spread was which was quickly contained. However, this year while Kerala was still combating the Covid pandemic, Nipah surfaced in Kozhikode which created a huge challenge for the government. 12-year-old Muhammad Hashim, a native of Chathamangalam panchayat died after testing positive of Nipah on September 5th which created a panic within the state. Almost 200 primary and secondary contacts of Hashim were under isolation. Fortunately, much to the relief of locals, none of these contacts tested positive.. according to the state’s health minister Veena George, in the light of frequent virus outbreaks the state has prepared a comprehensive plan to establish permanent isolation wards in every single hospital from community health centres to district level hospitals. Currently, all the medical college hospitals in the state are equipped with this facility. The Health department, which aims to provide fast and efficient treatment, has already prepared the action plan to tackle the next Nipah outbreak. It will be in force as early as possible, the minister says.

More Research Needed
‘After the Covid outbreak the need for One Health Approach is comprehended more,’ says Dr B Iqbal, Chairman of the State Covid expert committee and author of several books on viral diseases. According to him, Nipah has taught Kerala many a lesson, including the importance of using masks, sanitizer, quarantine, social distancing, and contract tracing which occurred even before Covid outbreak. As a result, state’s health infrastructure has been strengthened which helped containing both 2019 and 2020 outbreaks. But the virus’ continued resurfacing needs to be studied to determine if Nipah has turned into an endemic like H1N1 or rat fever. ‘As the disease spreads from bats, a thorough scientific research has to be carried out focusing on specific species in Kerala. A combined scientific approach by institutes like Kerala Veterinary University, Institute of Advanced Virology, Kerala Health University is needed,’ Dr Iqbal added. Currently the state depends on national institutes like Pune Virology institute and ICMR for viral investigations. To carry out researches and diagnostic services within the state, the government has established the Institute of Advanced Virology (IAV) in Thonnaykkal, Trivandrum. Currently, the institute is designing an in-depth research program for understanding the source of Nipah Virus, informs Dr. Mohanan  Valliyaveetil, Senio Principal Scientist at the IAV.

((This story was produced with the support of internews' Earth Journalism network)