Nipah in the Time of Corona: How Kerala Is Handling the Double Crisis

Nipah virus threatens to destabilise the already-burdened health infrastructure of Kerala.

It may be recalled that in 2018 also, there was a Nipah outbreak in Kozhikode and Malappuram districts of Kerala.

(Photo: Kamran Akhter/ The Quint)

The death of a 12-year-old boy due to the Nipah virus infection at a hospital in Kerala has posed new challenges for the state that is already battling with a surge in coronavirus cases.

The Nipah virus is a zoonotic disease that can be transmitted by infected pigs, or by fruit bats and the incubation period of Nipah virus is typically from four to 14 days. One’s health condition can deteriorate quite quickly.

As the virus threatens to destabilise the already-burdened health infrastructure of the state, The Quint takes a look at Nipah and see if the state is prepared to handle the crisis.

Kozhikode: Epicentre of Nipah in 2018 as well

It may be recalled that in 2018 also, there was a Nipah outbreak in Kozhikode and Malappuram districts of Kerala. Over 18 confirmed cases were reported in May-June 2018, of which 17 resulted in death, including the index case which could not be confirmed by laboratory tests.

Nipah reappeared in 2019, this time in Ernakulam district. However, the infection was contained to just the lone index case, who survived the infection.

Kerala health department, then headed by KK Shailaja had received appreciation for containing the spread in 2018 and 2019, as the state had no past experience of handling a disease with such a high fatality rate. Kerala had then followed the protocol for Ebola Virus Disease (EVD), of tracing the contacts of the infected persons, putting them under room isolation for 21 days and identifying secondary and tertiary contacts.

At one point in June 2018, around 3,000 people were under quarantine in Kozhikode and Malappuram.

Nipah Strikes Kozhikode Again

On 5 September 2021, Kerala hit a 160-week high reporting a total of two lakh COVID cases. Among the 14 districts of the state, Kozhikode, which is the epicentre of the Nipah virus outbreak, has been reporting the highest number of coronavirus cases.

Dr Anoop Kumar A S of Critical Care Medicine department at Baby Memorial Institute, who attended to the first Nipah virus infected patient in 2018, told The Quint that while the pandemic does pose challenges, the health teams are better prepared to handle the crisis.

“The team that dealt with the crisis in 2018 and 2019 is the one handling the crisis today. What has helped prevent this from further spread is the already existing stringent COVID protocols. Kerala is also quite good at detecting COVID cases at the earliest. Since all hospitals and public spaces are strictly following the COVID protocols, it is unlikely that there will be an institutional outbreak. Kozhikode medical centre has been instituted as a separate centre for Nipah treatment,” he said.

Dr Swapneil Parikh, an internal medicine specialist in Mumbai flagged that many could mistake the symptoms of Nipah for COVID, which could result in a faster spread of the virus.

“This is the second time, in such a short period that, the same area in Kerala has been infected by Nipah. Also, the virus can sometimes present itself as encephalitis or as a respiratory illness. And this is concerning as people could get confused with the symptoms of COVID. Kerala’s resources are already strained with the pandemic.”

Dr Swapneil Parikh, Internal medicine specialist, Mumbai

The symptoms of Nipah include fever, headaches, myalgia (muscle pain), vomiting and sore throat, dizziness, drowsiness, altered consciousness and neurological signs that indicate acute encephalitis, the World Health Organisation noted.

Dr Parikh insisted that the state government closely monitor all districts and not just Kozhikode.

It is to be noted that 40-75% of Nipah cases can lead to death, according to the World Health Organisation (WHO). However, the fatality rate in the 2018 outbreak in Kozhikode was well over 90 per cent. Those who have survived the disease have reported long-term side effects, among them persistent convulsions and, in some cases, changes in personality.

‘Next Week is Critical’: Health Minister

The next seven days will be critical, said Health Minister Veena George. A point-of-care-testing facility will be set up at the Kozhikode medical college hospital on Monday with the help of experts from NIV.

In case of a positive test result, a confirmation test will be carried out at NIV, which has promised to make the result available in 12 hours, she said.

To show the preparedness, Dr Kumar said, “ The drugs that are used to treat Nipah are Remdesivir and others which were not available during 2018. But we have an added advantage now because this is already available due to COVID.”

The Indian Council of Medical Research (ICMR) has promised to make available monoclonal antibodies within a week, the Minister said.

All roads leading to Pazhoor ward under Chathamangalam have been blocked by police and movement of people has been completely restricted. The panchayat, which had 500 active Covid-19 cases on Saturday, has been a containment zone for the last six days.

A team of the National Centre for Disease Control was rushed to Kerala by the Central Government on Sunday to provide technical support.

The Ministry directed the Kerala public health department to closely monitor all those who had come in close contact with the child, survey areas in Malappuram district, especially clusters, active contact tracing for any contacts during the past 12 days, strict quarantine of the contacts and isolation of any suspects and collection and transportation of samples for lab testing.

'Trying to Determine Source of Infection'

Kerala Health Minister Veena George on Monday stressed that the Health department's priority is to strengthen contact tracing and determine the source of infection.

A total 188 persons who have been identified as having had contact with the infected boy, have been put in quarantine. Most of these individuals are healthcare workers at various hospitals in Kozhikode, where the boy had been treated or had consulted doctors from 29 August onwards. The parents had taken the child to a clinic first, then to a private hospital, then to the medical college and from there to another private hospital.

Twenty of these individuals have been identified as being in the high-risk category, and have been moved to an isolation ward at the Government Medical College in Kozhikode, the Minister said. The samples of seven people among the 20 high-risk contacts of the child have been sent to the Pune NIV for testing. Two of them, both healthcare workers, have developed symptoms of the infection.

"We are giving special training to our field workers. It is equally important to find the source of infection. Whether this child is the first to get infected or from where this child was infected. There can be more contacts. We are trying to locate everyone," she said.

Surveillance Stepped up at the Borders

Meanwhile, Tamil Nadu has stepped up measures to screen people coming from Kerala, to ensure the communicable disease does not spread to Tamil Nadu. Fever clinics and screening points have been set up in nine districts of Tamil Nadu bordering Kerala — Kanyakumari, Tirunelveli, Thenkasi, Virudhunagar, Theni, Dindigul, Tiruppur, Coimbatore and Nilgiris.

TN Health Minister Ma. Subramanian said on Sunday, “As soon as we received information about the boy affected by Nipah virus infection this morning, we informed health officials -- deputy directors and joint directors of health -- of nine districts sharing a border with Kerala.”

The minister has also issued a notice to all districts asking them to hold fever camps and take up testing in the border areas, even for those in two-wheelers or four-wheelers.

Health Secretary J. Radhakrishnan, in a message to Collectors and health teams, said that border districts, as part of fever surveillance, should cover all communicable diseases especially Zika and now, Nipah virus infection.