This page will be daily
updated till the Nipah scare is over. Inputs invited in this white paper.
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 owing 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 and made it 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
· Kerala
outbreak in 2001: 45 deaths
· Kerala
outbreak: 2007 5 deaths
· Kerala
outbreak 2018 17 deaths
· Kerala
4th June 2019: I case
· Others:
Siliguri area bordering with Bangladesh (most health care personnel suffered
and died) and West Bengal (Nadia District) also bordering with Bangladesh.
Nipah facts
· Incubation
period: 4-14 days (maximum 45 days)
· Spread
droplet infections, so unlikely to spread through air nuclei.
· Asymptomatic
sub clinical 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
are 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
neighbouring states and local disease control centres.
o Stand-down
phase: last phase after the disease is eradicated.
(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
