Kozhikode: Nipah – the two syllable virulence of a virus was doing what cruel tyrants had done - culling out lives at an unprecedented pace. At least 17 people have lost their lives to Nipah.
But like most dictators, the Nipah reign too was cut short by a set of valiant men and women who formed a crack team and stayed undaunted on the battle front. A nurse, Lini Puthuserry, lost her life tending to a Nipah-affected person. The state government honoured the doctors and nurses who were part of the anti-Nipah drive.
Ground zero
It was a month ago that Kozhikode became the epicentre of the Nipah outbreak. (The virus spreads through man-to-man fluid infusion/transfer). Fear was rife among local people and others as patients died as the viral disease with mysterious origins seemed to spare none. Though shaken initially, the health authorities soon rallied to tame the scourge effectively as people, officials, and agencies worked in tandem.
WHO, UN laud efforts
Health experts say diagnosis and containment of a disease like Nipah in a limited time was unprecedented. Global bodies like the United Nations (UN) and World Health Organisation (WHO) lauded the state government for this enviable feat and it seems the Kozhikode model can be adopted by even the developed countries.
Onmanorama tallies the efforts made by authorities to control the spread of Nipah fever from Kozhikode to other parts of the densely populated state even as it left behind a trail of death and fear psychosis.
Mysterious source
Ubeesh MP, 27, from Venniyur in Malappuram district, was the last and one of the only two survivors to leave the Nipah isolation ward at the Government Medical College Hospital (MCH). His wife, Shijitha, also fell victim to the disease. Today, Ubeesh is on a path of recovery and feels that he was more affected with the fake news that spread on his condition than the virus that attacked him.
“I was not severely affected as many reports said. I was knowing everything that was going around us, outside the isolation ward. Through my mobile, through social media, I was really updating myself on the disease and I was aware of the different stages of the disease, after attending to my wife in the same ward. Now, I am discharged and advised rest for two more weeks to regain my health,” he said.
The young man is positive enough to face life and live for the rest of his family. He could recollect the day he was injured in a bike accident and taken to the MCH for a broken forehead after a brief treatment at a private hospital in Malappuram. Unfortunately, he chose to visit the hospital again, for his scan results along with his wife, cousins, and friends. None of them (only Shijitha is not alive today) can recollect a coughing patient there who could have been infected with Nipah.
"Later, doctors were saying that we (he and wife) might have contracted the virus from the first patient, Sabith, who was brought for scanning at the specialty section on May 2, when we also went there. I can still remember many accident cases being brought there, but not someone who had been coughing throughout. The officials can check the CCTV cameras and confirm before coming to conclusions on how we contracted the disease. However, we are sure that, there were no other contacts other than those in the MCH,” Ubeesh added.
Early detection
While Ubeesh doesn't now from whom he contracted the disease, health experts are in the dark about the actual source of the virus. Anoop Kumar AS, consultant and chief of critical care medicine, Baby Memorial Hospital, said it was a mystery how the first patient (suspected to be Sabith) contracted the virus. His team had first suspected Nipah and had swiftly alerted the Manipal Centre for Virus Research. The tests there confirmed that the source of the virus was fruit bats.
History of outbreaks
Speaking on the past outbreaks elsewhere and responses to it, Dr Anoop Kumar said south-east nations like Singapore took a lot of time to identify the viral outbreak. “One has to compare this with the previous episodes across the world. Globally, so far only 269 patients have been recorded as having contracted the virus. There are two types of of virus – one is Hendra, other is Nipah. Together, they are called Henipavirus. Hendra, originally called equine morbillivirus, is transmitted through horse. Both have several similarities.
In Malaysia
In Malaysia, where it broke out between 1998 and 1999, pigs had eaten the fruits contaminated by the bats, and subsequently pig farmers got infected. All the cases there were pig-to-human transmission and no human-to-human transmission was recorded. They couldn't ascertain the cause of various deaths that occurred for nearly five months. Then it shifted to Singapore, because pigs were exported to that country. Ultimately, they took another four or five months to identify the reason. Though there was no man-to-man transmission, there was no chance of a rapid spread owing to low population. Still they took months and years to identify what was going on," Dr Anoop Kumar said.
India outbreak
The Kerala case was not unprecedented in India as West Bengal had reported it earlier, but there too there was no prompt redress. “In India, the first Nipah episode was reported in 2011 in Siliguri. There were 66 cases and 45 deaths. It was also reported from a small village and the population was very limited. There was no movement of population at all. There was a small hospital and the immediate contacts were contained within the village. There, 51% of the cases were from man to man. It was not a single-source epidemic. Still they took more time to identify the cause. In Kerala, the cause of the disease was diagnosed from the very second case," Dr Anoop Kumar said.
On the whole, Bangladesh and Siliguri had reported a mortality rate of 75 per cent as of the 280 patients 211 people died.
Prompt and coordinated action
Kerala's specific demographical profile posed a headache to authorities, but rapid, coordinated action made all the difference. Speaking further on these challenges they faced after the Kozhikode episode, Dr Anoop Kumar said: “The doctors were not sure if it was a single-point source. We are so thickly populated and we have a high floating population. The samples were collected from the suspected patients three times a day, and sent to virology institute. The results were ready in less than 24 hours and there was no delay in identifying a new case and taking decisions."
Dr Anoop Kumar lauded the governments, healthcare bodies and the local community. "The governments, both at the centre and in the state, acted hand in hand, and there was also no tiff with the opposition parties locally. This was a big achievement as never before had all the parties worked together without blaming each other. When a similar outbreak was reported elsewhere, the governments used to hide things and naturally people couldn't realise the gravity of the situation. Here, the state government took a brave decision to announce the virus, on May 18 evening. When the results from Manipal institute stated that the virus is highly infectious, the same was announced to the public. This was a great step in creating awareness and avoiding mass gatherings."
The response of the local community and the medical bodies elsewhere too proved decisive. "Religious communities, especially the Muslims, though it was a Ramadan month, cooperated well. The help from the National Centre for Disease Control and the Indian Council of Medical Research (ICMR) was immense. The public-private partnership in the fight against the disease was also exemplary and they worked together like never before," he noted.
Public restrictions
Upon realising that Nipah was contagious, Kozhikode district collector U V Jose requested the public to avoid public gatherings. But there was no ban as such on gatherings. Taking the cue, the public on their own, restricted their events and mass movements. Even religious ceremonies were cut down without any warnings. School opening was, meanwhile, postponed by the authorities.
“Kozhikode set an example to the world on staying united in calamities and sensibly handling the situation. The Nipah outbreak was not something to be handled by the health department alone. The duties were divided among the various departments, including the revenue authorities, and they accepted the challenge and worked non-stop till the situation was brought under control. Crisis always brings forth the goodness in people, their love for mankind and willingness to help each other. The health emergency was successfully handled with the involvement of representatives from all fields,” collector Jose said.
Even as the Nipah scare subsides, the vigil against the viral disease in Kozhikode district as well as at the MCH is on. Though classes had restarted at the medical college, infection control training would continue and instead of the one or two meetings, four to five meetings would be conducted at the medical college.
"Though no fresh Nipah cases have been reported, the isolation ward would stay for those affected with fever-related illness, said V R Rajendran, medical college principal. “As such, there are only 10 to 15 patients in need of the pay wards. So, instead of reconverting the ward, we are planning to keep this isolation ward for other fevers like dengue,” the collector added.
Isolation wards
The authorities at multiple levels have learned valuable lessons amid the Nipah crisis that gained global attention. And these are worth emulating if a similar tragedy happens anywhere.
During the Nipah outbreak, the pay wards at the medical college was converted into isolation wards. A separate outpatient (OP) wing was set up at the main OP for fever cases. The three storeys of the pay ward with 115 rooms were arranged in such a way that the ground floor was exclusively for the affected patients and those showing severe symptoms. Only 85 rooms had to be evacuated for the new ward, and of that, only 18 to 20 rooms were used. Those who were critical were kept in the ICU and others showing strong symptoms on the same floor. Seven rooms were converted into ICU at one stage. The first floor was for those showing symptoms but contact is not definite. The second floor was reserved for those who suspected to have contacted the patients, but not showing symptoms.
Setting up an isolation ward was also a challenge in a very crowded medical college. The first step was to suspend classes at the college and turn it completely into an isolation unit for fever-related illness and to train the staff, including the cleaning staff on the precautions to be taken while attending to a patient and handling things used by them.
Nipah had claimed its first likely victim on May 5. The first steps after realising that Nipah was very much in the district were crucial and the task was to rule out other diseases that affect the brain. The authorities had to ensure that the disease do not spread from person to person through contact. Four people from the same family had shown the same symptoms by then. When Nipah fever was confirmed on May 18, the health department was alerted to ensure maximum isolation possible and create awareness among the public, instead of panic.
The name of the virus was announced on May 20 and prior to that, isolation wards were set up to reduce the contact list of persons from the first set of patients who contracted the disease.
The turning point
Containing a serious virus outbreak in just 12 days would not have been possible with the initial and crucial support of that victim's family which agreed for tests, when they lost two sons. Ethnographic researches are on to find out from where the first victim had contracted the virus even as the vigil against Nipah is still on.
Dr Anoop Kumar patted the surviving members of the family that was worst hit by Nipah. “One family lost four people, including two sons, in the outbreak. Their third son had died in a motor accident a few years ago. The second son died on May 5 and the first son was admitted thereafter. After the latter's death, the family gave consent for a pathological autopsy. I had specifically told them that this was for the benefit of the public. If the disease was not diagnosed, the virus would create further havoc in the family, immediate contacts as well as the locality,” the doctor said.
The surviving kin also agreed for deep burial when the health officials insisted on it.
Model work
Dr Anoop Kumar claimed that the famed US body, Centers for Disease Control and Prevention should study what we have done here. Neither the Kozhikode doctors nor the Kerala government took its help despite a medical emergency that is notorious for high mortality rate.
“We do not have to depend on it as the CDC never detected any case in the second patient and they were never able to contain such outbreaks in such a densely populated place in a short time. We have all the infrastructure, all the intelligence here in India itself. We have to utilise that. Now we reached a situation where the CDC has to come to India," Dr Anoop Kumar claimed. His statement sums up the real significance of Kerala's success in controlling a major health scare.
