This page will be
regularly updated till the Nipah scare is over. Inputs invited in this white
paper.
Dr KK
Aggarwal
A team of doctors and
experts sent by the Union Health Ministry is investigating whether the
confirmed Nipah case in Kerala was caused by an infected guava that the patient
had consumed. The patient informed the doctors that he ate guava two weeks
before he was admitted to hospital (on June 3). The authorities have been
informed about this and asked to initiate surveillance, reported Indian Express
yesterday.
Fruit bats are the
carriers of the Nipah virus and their saliva transmits the infection.
So, what do fruit bats
eat? Fruit bats eat all types of fruits ranging from bananas, mangos, dates,
chickoos, avocados, wild dates and any type of pulpy fruit. They will avoid any
fruit that is very bright in color and has a strong smell. They can also
eat unripe, insect impacted fruit. Fruit bats do not eat the whole fruit;
they use their teeth to crush into the fruit and consume the pulp and the
juices. Hence, partially eaten fruits lying on the ground should be avoided (Source:
https://www.animalwised.com/what-do-fruit-bats-eat-1400.html).
No new Nipah cases in
Kerala
Union Minister of
Health and Family, Dr Harsh Vardhan has said that there have been no new cases
of Nipah virus disease and the clinical condition of Nipah positive patient is
improving further.
According to a Health
Ministry press release, as on Sunday, there are 8 patients in the isolation
ward and 7 of them were tested negative for the Nipah virus. The sample from
the 8th patient is being tested in the point of Care (POC) lab. Four other
patients from the isolation were discharged on Saturday as their clinical
condition improved.
National Institute of
Virology (NIV), Pune collected three blood samples from pigs and about 30
samples from bats from Thodupuzha (Idukki district)… (Source: Press Information
Bureau, Ministry of Health and Family Welfare, June 9, 2019)
Duration of contact
tracing
Duration of contact
tracing is 21 days from the time of last contact with a case.
Active fever surveillance
Area: within 5 km radius from the periphery of the affected area
(house/village of case/cases).
What has to be done?
· Enlist all
houses (and persons): Daily visits to each house and enquire about any person
developing any symptoms (like fever, cough, headache (and or other symptoms
like altered sensorium, shortness of breath etc.)
· In case of
a person developing symptom: follow steps as below “What is to be done
during contact tracing”
· Duration:
Up to 21 days from the last case in the area
· Daily
reporting: as per the format
Home Quarantine
Who has to be quarantined: all households and close contacts of a
suspect case.
· Till the
time test results of symptomatic comes negative or
· If the
test result comes positive then all such persons become contacts and have to be
put under contact tracing for next 21 days.
Isolation
· Temporary
can be in a room in the house or health facility till the time he/she is
shifted by the designated ambulance to the designated health facility.
· Following
shifting to health facility, place of temporary isolations needs to be
disinfected in accordance with prescribed SOPs by Lysol/5% sodium hypochlorite
or any disinfectant (if not available)
When the area/district/state can be declared free: 42 days
from the date of last positive case reported from the district/state
(Source: National
Center for Disease Control, Recommended Community level Public Health Measures
for Nipah virus infection)
Contact tracing
·
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 AC
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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