The deadly Nipah virus is causing problems in Kerala, India, for the fourth time since 2018. Six confirmed cases—two of which resulted in fatalities—had been reported by the state as of September 15; the other patients were receiving treatment. For the third time since 2018, the zoonotic disease Nipah virus has returned to the Kozhikode district of North Kerala.
Kerala is prepared to face this virus due to the knowledge gained from earlier Nipah outbreaks and the difficulties of combating the COVID-19 pandemic in 2020 and 2021.
The state's health service was unprepared for the inaugural Nipah outbreak in 2018, which had a high death rate and little prior knowledge about the virus. Kerala adopted a plan to fight this foreign virus that was similar to the response to the Ebola virus disease (EVD), focusing on social seclusion, contact tracing, and isolation. In Kerala, it has become commonplace to see healthcare professionals wearing PPE kits.
Despite the scant information available during the initial outbreak, a coordinated attempt to restrict the virus was made. In order to discover contacts and promote self-reporting, the health department worked with the revenue district administration and a variety of partners to produce route maps of confirmed cases. Up to 3,000 people were under home quarantine in Kerala at one point, which was a revolutionary idea at the time. To offer psychological assistance to people under quarantine, a phone center was built in Kozhikode, and isolation wards were established at the government medical college hospital.
The health department established Nipah virus infection control recommendations in June 2019 after realizing the necessity for an organized strategy. This sets the stage for a methodical approach to dealing with epidemics in the future. Senior doctors who served as a resource group met to brainstorm and organize their efforts. Protocol development included participation from WHO members, and guidelines underwent two revisions to increase their efficacy.
When Kerala faced the COVID-19 pandemic in 2020, its management of the Nipah situation proved to be quite helpful. The response to COVID-19 easily included the Nipah standards, including contact tracking, disclosure of route maps, isolation, treatment, and containment.
In Kozhikode, India, a 12-year-old child passed away from Nipah in 2021, during the second wave of the COVID-19 epidemic. However, public acceptance of mask-wearing regulations and experience with quarantine and isolation protocols helped limit the spread of Nipah to a single case.
The ability to detect viruses has significantly improved since last year. In the beginning, Kerala lacked the lab resources to confirm Nipah, depending instead on other institutions like the Manipal Centre for Virus Research and NIV Pune. But over time, Kerala's government laboratories were modernized, and new tools, including POC micro-PCR tests and ELISA testing, were added.
With definitive confirmation coming from NIV Pune, which runs a biosafety level-4 lab, the most recent Nipah epidemic in 2023 was detected by a biosafety level-2 lab at the Government Medical College hospital in Kozhikode. In barely six hours, the Kozhikode government laboratory was able to identify the virus. In addition to a biosafety level-2 mobile lab in Thiruvananthapuram that can produce results in three hours, Kerala now has two additional virology labs in Alappuzha and Thiruvananthapuram.
The health department moved quickly to address the current outbreak after discovering Kozhikode's unusually high fever incidence. To contain the virus, a Nipah core committee was established, isolation rooms were set up, and numerous departments worked together.
Hospitals' involvement in the spread of Nipah has been one issue that has persisted. Healthcare settings were key to the propagation of the virus in both 2018 and 2023. Numerous healthcare-associated infections were caused by insufficient infection control measures in 2018, and a similar pattern emerged in 2023, with more than 150 health workers under surveillance.
Kerala's experience controlling Nipah epidemics shows its dedication to ensuring public health and safety. The state's capacity to adjust, pick up new skills, and put those skills to use in the face of ongoing difficulties demonstrates its adaptability and readiness to deal with developing diseases.
Kerala saw a second outbreak of the deadly Nipah virus in 2023, and the state's reaction showed its improved readiness and promptness. Kerala handled the problem as follows, in accordance with the 2021 guidelines.
On August 11, when unexpected fever cases were recorded in Kozhikode, the alarm was raised early in the morning. The state health department sprang into action right away, gathering information about fevers and starting surveillance. A local investigation was started, and the same day, samples were submitted to the lab in Kozhikode for analysis.
The health service took preemptive action by treating the patients as probable Nipah infections even before receiving confirmation from the lab. The Kozhikode lab verified the Nipah virus's presence in the samples on the evening of August 11. The samples were sent urgently via airplane from Kochi to the National Institute of Virology (NIV) in Pune.
By the morning of August 12, senior health department representatives, including Minister Veena George, had arrived in Kozhikode and were putting together an action plan and control measures. A control room and the Nipah core committee, which consists of 19 multidisciplinary teams, were established in accordance with the 2021 action plan.
The Kozhikode Medical College quickly set up 75 isolation rooms, each with plan A, B, and C to address different scenarios. In parallel, in the impacted areas, health department representatives and local panchayat leaders worked together to create a comprehensive action plan, including numerous departments, as contacts of probable cases were evaluated in a meeting.
The administrative apparatus of the administration was already running at full capacity by the evening of August 12, when NIV-Pune formally confirmed Nipah in Kozhikode.
Through phone counseling, the control room, which was open 24/7, gave those who were in isolation or in home quarantine vital psychological support. Accredited Social Health Activists (ASHA) workers and local health department representatives were vital in mapping fever cases in the villages where positive cases were reported. Additionally, representatives from the departments of animal agriculture and forestry were on the lookout for fruit bats, which are believed to be the virus's reservoirs.
Local self-government organizations recruited volunteers and rapid reaction teams to assist people in house quarantine, and nine panchayats were designated as containment zones. These volunteers, who had previously volunteered during the COVID-19 pandemic, made sure that individuals under quarantine had access to necessities and support.
The involvement of hospitals in the spread of the virus revealed a striking resemblance between the Nipah epidemics in 2018 and 2023. Epidemiological connections showed that the majority of cases in 2018 were contracted in healthcare facilities, mainly public hospitals and clinics, when the illness was well advanced. Unfortunately, insufficient infection control procedures in hospitals exposed countless medical personnel, and one nurse, Lini Puthussery, passed away while attending to a patient.
A similar pattern emerged in 2023. It was discovered that the second victim had interacted with the index case at a private hospital, leading to a cluster at the index case's residence. Currently, more than 150 healthcare staff are being monitored.
The Nipah outbreaks in Kerala serve as a reminder of the value of a well-planned and prompt response, particularly in healthcare settings. The fight against Nipah continues to test the state's resiliency and preparedness in the face of emerging infectious diseases, even if lessons have been learned and guidelines have been developed. (Rehash/Dr. Nithin GN)