An update on Nipah Virus infection in context of recent outbreak in Kerala India.

1. Barking Pig Syndrome,
Porcine Respiratory and
Encephalitis Syndrome,
Porcine Respiratory and
Neurologic Syndrome
Nipah Virus
Dr. D. K. Niranjan
Infection Control Officer
Regency Healthcare Limited

2. Overview
 Organism
 History
 Epidemiology
 Transmission
 Disease in Humans
 Disease in Animals
 Prevention and Control
 Actions to Take

3. Agent
 Genus Henipavirus
 Virus discovered, 1999
 Related to Hendra virus
 Severe, rapidly progressive encephalitis in
humans
 High mortality rate
 Close contact with infected pigs
 Severe, respiratory disease in pigs

4. History

5. History
 1998-1999: Peninsular Malaysia
 Human febrile encephalitis, high mortality
 New virus discovered
 1999: Singapore
 Outbreak in abattoir workers
 Pigs imported from Malaysia
● Since 2001 – Bangladesh, India

7. Transmission

8. Reservoir
 Flying foxes (fruit bats)
 Carry the virus
 Are not affected
 Virus found in
 Urine
 Partially eaten fruit (saliva?)
 No known secondary host

9. Transmission
 Pigs in Malaysia
 Direct contact
 Contact with body fluids
 Aerosolization of respiratory or
urinary secretions
 Vertical transmission across the placenta?
 Semen and iatrogenic spread?

10. Transmission
 Person-to-person
 Not reported in Malaysia
 Likely in Bangladesh and India
 Nosocomial infections
 Bat-to-person
 Not reported in Malaysia
 Common in Bangladesh and India
 Contaminated fruit, unpasteurized date palm juice

11. 2018 India
 Closer home, in Kerala too, its being traced to a
well which had bats living in it.
 It correlates well with the season when young
bats leave the nest to fly (April- June with a peak
in May)!
 Once infection sets in, there is a human to human
spread.
 As the virus is found in blood, urine, saliva and
CSF, the spread happens when in contact with
these secretions.

12. Photo courtesy of James Roth, DVM, PhD, ISU
These are several of the hog confinement barns that were affected
during the Malaysia Nipah virus outbreak. The reservoir fruit bats live
in these caves and feed on the fruit trees that are in close proximity to
the hog confinement barns.

13. Photo courtesy of James Roth, DVM, PhD, ISU
hog confinement barns in Malaysia. There are many fruit trees and caves
close to this location.

14. Epidemiology

15. Epidemiology
 1998-1999: Malaysia
 265 persons hospitalized; 105 deaths
 Primarily adult males with swine contact
 Disease in swine
 Severe respiratory disease
 Transmitted by movement of infected pigs
 1.1 million pigs culled
 Great economic loss
 Surveillance and testing

16. Epidemiology
Center for Food Security and Public Health,
Iowa State University, 2011
 1999: Singapore
 22 seropositive persons (1.5%)
 All were male abattoir workers
 12 symptomatic
 Encephalitis, pneumonia, or both
 10 asymptomatic

17. Epidemiology
 2001: Siliguri, India
 Nosocomial transmission
 2004: Bangladesh
 34 cases; 26 deaths
 Transmission
 Close contact
 Exposure to common source

18. Epidemiology
 2005: Bangladesh
 44 cases; 12 deaths
 Contaminated palm fruit juice
 2007: Bangladesh
 7 cases; 3 deaths
 Person-to-person transmission

20. Disease in Humans

21. Human Illness
 Incubation period: 4 to 20 days
 Fever and headache
 Encephalitis
 Dizziness, drowsiness, vomiting
 Seizures
 Progresses to coma in 24-48 hours
 Respiratory difficulty
 Relapsing neurologic symptoms

22. Human Illness
 Complications (Malaysian outbreak)
 Septicemia (24%)
 GI bleeding (5%)
 Renal impairment (4%)
 Asymptomatic
 Relapse or late-onset encephalitis
 Residual neurological deficits

23. Case definition
 Suspected (clinical) Nipah case: Patient
coming from the community affected by an
outbreak and has: fever with acute onset of
altered mental status or seizure and/or fever with
headache and/or fever with acute onset of cough
with shortness of breath.
 Probable Nipah case: Suspect cases, and/or
who died before complete diagnostic specimens
could be collected.

24. Confirmed Nipah case
 Suspected/probable cases who have been
confirmed by tests from the laboratory, i.e. IgM
antibody (ELISA test) against NiV in serum or
CSF, or RT-PCR for NiV RNA from respiratory
secretions (throat swabs), urine or cerebrospinal
fluid, or Actual virus isolation from respiratory
secretions, urine or cerebrospinal fluid or other
tissue specimens.
(The tests are currently being done at National
Institute of Virology, Pune)

25. Disease in Animals

26. Disease in Animals
 Pigs
 Highly contagious
 May be asymptomatic
 Acute fever (>104°F)
 Severe respiratory disease
 Characteristic cough – harsh, “barking”
 Neurological changes
 Low mortality

27. Disease in Animals
 Dog
 Distemper-like signs
 Fever, respiratory distress
 Ocular and nasal discharge
 Cat
 Fever, depression
 Severe respiratory signs
 Horses
 Encephalitis

28. Sampling
 Before collecting or sending any samples, the
proper authorities should be contacted
 Samples should only be sent under secure
conditions and to authorized laboratories to
prevent the spread of the disease
 In India it is NIV Pune

29. Sample collection
 The samples should be collected as early as
possible (preferably within 4-5 days on onset of
illness.
 The samples may be as follows:
 Throat swab to be collected in viral transport
medium
 Urine approx 10 ml in universal sterile container
 Blood in plain vial (at least 5ml)
 CSF (at least 1 ml) in a sterile container

30. Transportation and Storage of
samples
 Samples should be safely packed in triple
container packing and should be transported
under cold chain (2-8°C) to the testing laboratory
with prior intimation.
 Before dispatching the sample, disinfect the outer
surface of container using 1:100 dilution of bleach
or 5% Lysol solution.

31. Diagnosis

32. Diagnosis
 Differentials for swine
 Classical swine fever, PRRS, pseudorabies, swine
enzootic pneumonia, porcine pleuropneumonia
 Diagnostic tests
 ELISA
 Immunohistochemistry
 PCR
 Virus isolation

33. Prevention and Control

34. Prevention is the ONLY cure
 Avoid exposure to infected patients and
animals (bats and pigs)
 Do not consume the sap of raw date palm
or unpasteurized fruit juices
 Practice hand washing and hygiene
 Cover your mouth, eyes and nose when
handling the patient
 Keep the patient’s items (clothes, utensils
etc.) separately
 NiV has been found in blood, urine, saliva
and CSF of the patients who have died from
it. Take utmost care while dealing with any
of these.

35. ADVISORY FOR HEALTH CARE
PERSONNEL
 Wash hands thoroughly with soap and water for
40 seconds after contact with a sick patient.
 While handling Nipah cases (suspected/
confirmed), standard precautions for infection
control should be practiced.
 For aerosol generating procedures, PPE such as
individual gowns (impermeable), gloves, masks
and goggles or face shields and shoe cover and
the procedure should be performed in airborne
isolation room.

36. ADVISORY FOR HEALTH CARE
PERSONNEL
 Dedicated medical equipment should be used
(preferably disposable whenever possible).
 All non-dedicated, non-disposable medical
equipment used for patient care should be
cleaned and disinfected as per manufacturer’s
instructions and hospital policies.
 Use of injections and sharps should be limited.

37. ADVISORY FOR HEALTH CARE
PERSONNEL
 If the use of sharp objects cannot be avoided, ensure
that the following precautions are observed:
 Never replace the cap on a used needle.
 Never direct the point of a used needle towards any part
of the body.
 Do not remove used needles from disposable syringes by
hand, and do not bend, break or otherwise manipulate
used needles by hand.
 Never re-use syringes or needles.
 Dispose of syringes, needles, scalpel blades and other
sharp objects in appropriate, puncture-resistant
containers.
 Ensure that containers for sharps objects are placed as

38. ADVISORY FOR HEALTH CARE
PERSONNEL
 Segregate all suspected cases of Nipah patients from
all patients in the isolation ward/ facility.
 Avoid unnecessary contact with suspected Nipah cases
or use barrier nursing.
 Any spillage of body fluids in the OP/Ward should be
managed as per Infection control guidelines.
 Mortuary staff should wear PPE while handling corpse
of Nipah.
 Air sealed bag should be used for transportation of the
dead body.

39. Treatment
 Limited to supportive care
 There are no vaccines or medicines available
right now though trials are on for both
 Animal trials are showing promise with an anti-
viral called favipiravir or ribavirin

40. Nipah as a
Biological Weapon
 CDC Category C Bioterrorism Agent (BSL-4)
 Emerging pathogen
 Potentially high morbidity
and mortality
 Major health impact
 Aerosolisation potential
 Economic impact
 Social disruption (fear, panic)