Lessons for Kerala from Nipah

Kerala is again bracing for disease outbreaks in the aftermath of massive rains and floods. It has been almost two months since the state, where Nipah infection killed 17 people in May 2018, was declared Nipah-free. A similar incident of Nipah in Siliguri in 2001 took 49 lives before it was contained. The quick reactions of the health care responders in Kerala limited the spread of this highly infectious disease. The mechanisms through which this swift response worked highlight the networks that underlie public health whilst also exposing crucial gaps in our public and private health care systems. This article studies Nipah containment in Kerala and suggests that in a resource-starved sector, improved diagnostic mechanisms should be prioritised over building tertiary care infrastructures.

The first victim of Nipah died undetected of the infection. However, the supervising doctor suspected an unidentified disease was at work when three of his family members also reported encephalitis-like symptoms. Normally encephalitis cases are sporadic and only one family member may get infected. But in this incident, all four family members in the house were showing the disease, indicating the presence of an infectious agent. The supervising doctor contacted Dr G Arunkumar at the Manipal Centre for Viral Research (MCVR) who advised on the various body fluids that should be tested. The state health department facilitated the transport of the body fluids and MCVR immediately subjected them to a variety of diagnostic tests.

MCVR was engaged in fever surveillance in Tripura and Assam and hence had the requisite diagnostic tests for detecting Nipah. Since Nipah infection results in encephalitis, the body fluids were tested for the virus and the results confirmed its presence. The doctors and state authorities were alerted and they promptly quarantined all affected patients and potential victims. Up to 2,600 people were kept under observation for the two weeks required for the disease to become symptomatic. No new cases were detected in June and the state was declared Nipah-free on June 30, 2018.

This incident underscores the importance of linkages between the various agencies involved in health care. Three pivotal points feature in the containment of the disease:

1. The contact made by the supervising doctor with MCVR

2. The presence of Nipah diagnostics at MCVR

3. The speed of the state health department in containing the outbreak by isolating cases, contact tracing and enhanced surveillance to identify potential cases once the disease was confirmed.

The Government of India, backed by World Bank, set up the Integrated Disease Surveillance Program (IDSP) to strengthen disease surveillance and expedite response rates. The system is for use by both private and public health care centres to send samples to MCVR. However, unlike Kozhikode, the system is underutilised by many practitioners. It is thus likely that the disease may have gone undetected for many days if it had stricken in another district which does not leverage the IDSP optimally.

In Siliguri, India’s first incident of Nipah in 2001, 49 of the 66 patients infected died. The disease was not diagnosed until after the spread was contained. Quarantine measures were set up fairly late and most of those infected came from the hospital where the index patients were treated. Even in Kerala, a government study has found that 17 of the 19 infected patients caught the disease from the index patient. Clearly, the swift diagnosis and quarantine measures were key to preventing a similar episode in Kerala.

This laudatory containment of Nipah however exposes major gaps in our existing health care processes. While developing infrastructure is resource intensive, developing networks between existing centres should be relatively straightforward. A World Bank report in 2012 suggests that there is a major shortage of trained individuals — microbiologists, epidemiologists and entomologists — to implement IDSP. Further, the number of districts providing timely surveillance reports was also less than the expected target of per cent.

In addition to increasing the scope of the programme, established protocols for prompt decision making — whom to call and when — need to be put in to ensure that state authorities and MCVR or national laboratories are immediately alerted to any suspect cases of unidentified or highly infectious diseases. Surveillance of febrile patients in public hospitals is already underway in many Indian states, but this network needs to cover private hospitals as well. Current estimates suggest that at 50 per cent of febrile cases can be easily diagnosed and accurate medical intervention can be started.

The dissemination of point-of-care diagnostic kits will bring down the costs and time of diagnosis, but would need time to set up and train resources. Investing in mobile diagnostic units or streamlining the supply chain to take the samples to established centres should be prioritised in the meantime. Availability of portable tests underpins the need for quick diagnosis and perhaps demand more focus than building new infrastructure.

The lessons from Nipah are clear — we need quick and efficient diagnosis to contain infectious diseases. Currently, Kerala is facing threats of disease outbreaks as the recent disastrous floods recede. The best way to contain these outbreaks is to catch them early. Arming doctors with effective point-of-care diagnostic tools would be the first step in creating a health care system that is responsive to the changing needs made from it.