Dr KK
Aggarwal
This page will be daily
updated till the Nipah scare is over. Inputs invited in this white paper.
· Who
is a contact: any person having
history of contact with a case (person who is laboratory confirmed)
· Each
worker or person responsible for contact tracing should:
o Enlist all the contacts for
tracing
o Distribute Triple layer
surgical masks to each household and keep sufficient stock (but avoid
misuse/un-necessary use), as it may create fear/panic.
o IEC on Nipah virus (NiV)
infection, symptoms and importance of contact tracing and home
quarantine/isolation.
o Give his telephone number and
number of control room/nearest health facility
o Have location and details of
dedicated ambulance and availability of disinfectant
· Time/duration: when the case can transmit the disease:
development of first symptoms (which may be cough and/or fever with headache)
till 21 days have passed from the last contact.
· What
is to be done during contact tracing: Visit the person daily or ask him
telephonically and
o Ask him if had developed
any fever, cough, headache (and or other symptoms like altered sensorium,
shortness of breath etc.)
o Health education: about
keeping a self-watch on developments of symptoms and If anyone develops
symptoms, then he or she becomes a suspect case and thus suspect has to:
§ Immediately wear a triple
layer mask and put him under self-isolation (means should not go near/maintain
a distance of around 3 m) to any other person.
§ Inform concerned health worker
(and or nearby doctor) and not to move by himself (unless there is delay and
symptoms are getting worse).
§ Dedicated ambulance (with
driver and accompanying health staff having full protective gears) to be used
for transporting all such suspects
§ Enlist all possible contacts
since the time he/she has developed symptoms and inform health worker.
§ Health worker has to put all
such persons in contact list for further doing contact tracing for 21 days
since the time of last contact with a person having symptoms or till the time
the persons test for NiV comes negative.
(Source: National Center for
Disease Control, Recommended Community level Public Health Measures for Nipah
virus infection)
Time to Act and not React
There are two approaches to
resolve a problem: Action and reaction. This is also applicable to public
health problems.
The government often adopts
the “reaction” approach first, which is a denial mode.
No government would
acknowledge a public health problem, existing or impending, right away as it
could be perceived as tantamount to owning up to the inefficiency or
incompetency of health systems in place.
A terrorist attack does not
mean failure of the government. The Nipah virus can be likened to a
terrorist.
It’s time for action and not
reaction.
When the Zika epidemic
threatened Brazil in 2015-16, when the country was preparing to host the 2016
Olympic Games, the army was called into action and asked to join the efforts to
control the virus, which was made into a public movement.
· Public
health problems such as Nipah require a multilateral effort. Therefore, any
action taken involves education along with participation and involvement of all
stakeholders, including the general public.
· A
district, state, national and international plan of action should be in place.
· The
public health information should include standard relevant messages for
everyone and innovations in research. This information should include Dos and
Don’ts about eating pork, half-eaten fruits lying on the ground, consuming raw
date palm sap or toddy, handling bats, climbing fruit trees, etc.
· There
should be a uniform protocol for all systems of medicine.
· Doctors
from all systems of medicine should refrain from any claims of cure. If they
possess any such cure, it should be first submitted to the government for
review.
· The
primary source should be traced – pig, bat or human.
· There
should be guidelines and effective system for contact tracing and their management.
· There
should be a standard protocol for case handlers and probable case spreaders.
· National
surveillance in all cases of encephalitis for the cause, Nipah or any other.
· There
should be a protocol for spread of encephalitis to contacts.
· A
government advisory should be issued for handling of dead bodies of people who
die due to the infection.
· The
role of police, military and media should be well-defined.
Definitions
People often use the
term index case when they actually mean primary case. Both
terms are well-defined for outbreaks, and should not be confused.
The term primary case can only
apply to infectious diseases that spread from human to human, and refers to
the person who first brings a disease into a group of people—a school
class, community, or country.
The index case, however, is
the patient in an outbreak who is first noticed by the health authorities, and
who makes them aware that an outbreak might be emerging. Even outbreaks of disease
that is not spread from human to human, such as Legionnaire's disease, might
have an index case.
For many outbreaks, the
primary case will never be known—the worldwide HIV epidemic is one example.
In an outbreak that goes
unnoticed, no index case is present, but for all outbreaks that are discovered,
there will always be one (or more).
In the present Nipah case
in Kerala, we now have the index case, which led to notification. But
the primary case is yet to be diagnosed. The very fact more than 300 cases are
under surveillance means the government has no clue about the primary case.
The primary case may also
be the index case.
The first term is linked to
the basic epidemiology of the outbreak, the second rather to the surveillance
system and public health action.
Outbreaks
· Siliguri outbreak
in 2001: 45 deaths
· Nadia West
Bengal outbreak in 2007: 5 deaths
· Kerala
outbreak in 2018: 17 deaths
· Kerala
4th June 2019: 1 case
Nipah facts
· Incubation
period: 4-14 days (maximum 45 days)
· Spreads
by droplet infections, so unlikely to spread through air nuclei.
· Asymptomatic
subclinical infections: Yes
· Case
fatality 40-70%: last year 17 died so there might have been over 34 cases
· Suspect Nipah
in encephalitis cases with following epidemiological parameters:
o Encephalitis
cases from the areas reported NiVD in human population
o Area
with fruit bats showing presence of NiV
o Fever
with altered sensorium reported from health care personnel treating
patients with respiratory illness etc.
o In
any person who has recently visited the affected areas
· Reducing
the risk of bat-to-human transmission: 20% of bats in Kerala
have tested positive for Nipah
Efforts
to prevent transmission should first focus on decreasing bat access to date
palm sap and other fresh food products. Keeping bats away from sap collection
sites with protective coverings (such as bamboo sap skirts) may be helpful.
Freshly collected date palm juice should be boiled, and fruits should be
thoroughly washed and peeled before consumption. Fruits with sign of bat bites
should be discarded.
· Nipah
virus in domestic animals and reducing the risk of animal-to-human
transmission: Horses, goats, sheep, cats and dogs first reported
during the initial Malaysian outbreak in 1999. The virus is highly
contagious in pigs. Pigs are infectious during the incubation period, which
lasts from 4 to 14 days. An infected pig can exhibit no symptoms, but some
develop acute feverish illness, labored breathing, and neurological symptoms
such as trembling, twitching and muscle spasms. Nipah virus should be suspected
if pigs also have an unusual barking cough or if human cases of encephalitis
are present.
Gloves
and other protective clothing should be worn while handling sick animals or
their tissues, and during slaughtering and culling procedures. As much as
possible, people should avoid being in contact with infected pigs. In endemic
areas, when establishing new pig farms, considerations should be given to
presence of fruit bats in the area and in general, pig feed and pig shed should
be protected against bats when feasible.
· Reducing
the risk of human-to-human transmission: 75%
cases last year were in health care settings exposed to sick patients. Close
unprotected physical contact with Nipah virus-infected people should be
avoided. Regular hand washing should be carried out after caring for or
visiting sick people.
NiV
can persist on surfaces, posing risk for fomite-borne NiV transmission.
All
NiV case-patients with NiV RNA in their oral secretions died in
one study and those without NiV RNA survived suggesting virulence is
important. Human-to-human transmission results direct contact with respiratory
secretions of severely ill patients.
Only
7% of all Nipah patients are Nipah spreaders. Those with respiratory
involvement (difficulty breathing and cough) are more likely to become
Nipah spreaders. Bangladesh example: 16 Nipah patients; 12
laboratory-confirmed and 4 probables; of 12 lab confirmed cases 10 showed NiV
RNA in oral swab specimens. Surface swab samples for 6 Nipah patients; 5 had
evidence of NiV RNA on >1 surface: 4 patients contaminated towels, 3 bed
sheets, and 1 the bed rail. Patients with NiV RNA in oral swab samples were
significantly more likely than other Nipah patients to die.
· Phases
in prevention
o Investigation phase: immediate
investigations of exposed people, Notification circular
o Alert phase
1.
Prevention of spread
2. Identification of other possible foci
3. Reporting and dissemination of information
4. Quarantine of infected patient and observation of others
5. Inter-ministerial alert (vety, animal husbandry, health, army, wildlife
authorities)
6. Travel alert: whether patient from infected areas can move
to other districts or vice versa. It should also talk about local, state, inter
-state and International travel alerts if any from time to time.
o Operational phase: Public
awareness and education campaign and set up neighboring states and local
disease control centers.
o Stand-down phase: Last
phase after the disease is eradicated.
There is no National Program
for Surveillance of NiV. All these diseases are part of Integrated Disease
Surveillance Program (IDSP).
(Inputs: Dr A C Dhariwal, Dr
Shivlal)
Dr KK Aggarwal
Padma Shri
Awardee
President Elect Confederation of
Medical Associations in Asia and Oceania
(CMAAO)
Group
Editor-in-Chief IJCP Publications
President Heart
Care Foundation of India
Past National President
IMA
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