PPT about Nipah virus disease.It mentions about epidemiology Managemant and prevention

1. NIPAH VIRUS
INVESTIGATION
STATE PEID CELL TEAM

2. INTRODUCTION
• Newly emerging zoonosis
• Natural host - Fruit bats, Pteropodidae Family, Pteropus
genus
• First identified –
– outbreak in Sungai Nipah, Malaysia
– pigs – intermediate hosts
– September 1998 – April 1999
– 265 suspected cases
• Singapore
– March 1999
• No new outbreaks in Malaysia and Singapore since May
1999

3. • 16 outbreaks in Bangladesh and West Bengal
• Siliguri and Nadia districts of West Bengal
• No of confirmed cases – 1 to 66
• Case fatality rate from 45% to 100%

4. NIPAH BELT

5. PRESENT OUTBREAK
• First NiV outbreak in South India
• Affected districts – Calicut, Malappuram
• Confirmed cases – 17
• Confirmed deaths –14
• First death - 5th May 2018

7. Center for Food Security and Public Health, Iowa
State University, 2011

9. MODES OF TRANSMISSION IN
PREVIOUS OUTBREAKS
• Always bat to human - with or without intermediate host
• Malaysia – Contact with infected pigs or close contact with
infected patients
• Singapore – Close contact with infected pigs from Malaysia
• Bangladesh –
– 5 – Drinking raw date palm juice
– 4 – contact with a Nipah patient
– 1 – contact with a sick cow
– 1 – close proximity with pig herds
• India – 2 outbreaks – Retrospective investigation
nosocomial transmission

10. A walk through Nipah’s way
Malaysia Bangladesh

11. KERALA

12. TEAM
• State PEID cell team
• 5 Experts
• 6 Post graduates
1. Dr. Devadas
2. Dr. Indu P S
3. Dr. Tony Lawrence
4. Dr. Anish T S
5. Dr Chintha S

13. MAJOR ACTIVITIES
• Contact tracing
• Identification of potential points of contact
• Recommendations and Action plan
• Notification to be released to the public

14. Steps of epidemic investigation
1. Prepare for field work
2. Establish the existence of an outbreak
3. Verify the diagnosis
4. Define and identify cases
5. Perform descriptive epidemiology
6. Develop hypotheses
7. Evaluate hypotheses
8. Execute additional studies
9. Implement control and prevention measures
10. Communicate findings
11. Follow up recommendations

15. HOW WAS THIS OUTBREAK DETECTED
• Surveillance data – PEID cell, IDSP
• Medical Practitioner – Treating doctor –
physician, critical care specialist, neurologist,
microbiologist of BMH, MCH CLT
• Affected persons/groups – similar presentations
in family members and close contacts
• Concerned citizens
• Media - newspapers, news channels

16. WHY WAS AN INVESTIGATION ESSENTIAL
• Immediate
– to control spread from existing
confirmed cases
- to control spread of disease from
contacts, if symptomatic
• Program considerations – Isolation wards,
Better diagnostic facilities
Time when authorities are more receptive
Lacunae in populations covered
Failures in usual strategies (here, Universal
health precautions, cough etiquette)
Identify areas to focus on in later programs

17. RESEARCH OPPORTUNITIES
• Recently recognised disease – emerging viral infections
• Reasons for emergence
• Describe and define natural history, epidemiological
profile
• Characterize population at risk
• Identify risk factors
• Assess and recommend control measures
• Develop better, cost effective and accessible
techniques for laboratory and epidemiological
purposes

18. • TRAINING
for post graduate students,
health care workers in infection control
measures
• PUBLIC, POLITICAL AND LEGAL CONCERNS –
responsible decision makers and
Dresponsive authorities

19. CONTROL AND PREVENTIVE MEASURES
QUESTIONS FACED
• Cases still occuring?
• Epidemiological patterns in cases
• History of evolution of cases from index case
• In which stage of epidemic presently
• Duration of this phase
• Expected duration of second phase
• Population at risk

20. How was this outbreak established?
• Comparison of data
• Collection of data – from State PEID cell, IDSP
(DHS) from the declaration of Nipah outbreak
included hospital records, mortality data

21. HOW WAS DIAGNOSIS VERIFIED?
• Proper diagnosis of reported cases – RNA PCR
• review clinical findings – compare with
existing literature
• review laboratory results
• summarize the clinical findings with frequency
– yet to be done

22. HOW WERE CASES DEFINED?
• Standard set of criteria for the health
condition
• Clinical criteria (signs and symptoms)
• Restrictions by time, place and person

23. SUSPECT NIPAH CASE
• Person from a community affected by a Nipah virus disease outbreak who has:
Fever with new onset of altered mental status or seizure and/or
Fever with headache and/or
Fever with Cough or shortness of breath
PROBABLE NIPAH CASE
• Suspect case-patient/s who resided in the same village where suspect/confirmed
case of NIPAH were living during the outbreak period and who died before
complete diagnostic specimens could be collected.
• OR
• Suspect case-patients who came in direct contact with confirmed case-patients
in a hospital setting during the outbreak period and who died before complete
diagnostic specimens could be collected.
CONFIRMED NIPAH CASE
• Suspected case who has laboratory confirmation of Nipah virus infection either
by:
Nipah virus RNA identified by PCR from respiratory secretions, urine, or
cerebrospinal fluid.
Isolation of Nipah virus from respiratory secretions, urine or cerebrospinal
fluid.

24. Definition of a Contact:
• A Close contact is defined as a patient or a person who came in
contact with a Nipah case (confirmed or probable cases) in at least
one of the following ways.
– Was admitted simultaneously in a hospital ward/ shared room with a
suspect/confirmed case of NIPAH
– Has had direct close contact with the suspect/confirmed case of NIPAH
during the illness including during transportation.
– Has had direct close contact with the (deceased) suspect/confirmed
case of NIPAH at a funeral or during burial preparation rituals
– has touched the blood or body fluids (saliva, urine, vomitus etc.) of a
suspect/confirmed case of NIPAH during their illness
– has touched the clothes or linens of a suspect/confirmed case of
NIPAH
• These contacts need to be followed up for appearance of symptoms
of NiV for the longest incubation period (21 days).

25. IDENTIFY AND COUNT CASES
• Basic information
• Demographic information
• Clinical information
• Information about risk factors
Already line list and detailed list of cases from
PEID cell available

26. NIPAH DETAILS-2018(up to 24.05.2018)
updated on 5.00 pm
District Suspected Case Un confirmed Death
Confirmed
Case
confirmed
Death
Trivandrum 1
Kollam
Pathanamthitta
Idukki
Kottayam 2
Alappuzha
Ernakulam 4
Trissur 1
Palakkad
Malappauram 9 0 4 3
Kozhikkode 11 1 10 8
Wayanad 1
Kannur
Kasaragode
Total 29 1 14 11

27. DETAILS IN LINE LIST
• Name, age, sex
• Address, district of residence
• Date of onset of symptoms
• Date of admission
• Name of hospital admitted
• Provisional diagnosis –
– Fever
– Encephalitis
– Meningitis
– Meningo encephalitis
– Fever, headache
– Myalgia
• Panchayat/ Municipality/ Corporation of patient
• Details of lab confirmation – Negative, Awaiting, Positive
• Date of confirmation, Date of death
• Number of confirmed and suspected cases and deaths in each district

28. DESCRIPTIVE EPIDEMIOLOGY
• Characterise the epidemic by Time, place and
person

29. TIME DISTRIBUTION

30. EPIDEMIC CURVE
0
1
2
3
4
5
6
7
8
1-May
2-May
3-May
4-May
5-May
6-May
7-May
8-May
9-May
10-May
11-May
12-May
13-May
14-May
15-May
16-May
17-May
18-May
19-May
20-May
21-May
22-May
23-May
24-May
25-May
26-May
27-May
28-May
29-May
30-May
31-May
Nmber
of
cases
Date of onset of symptoms
No of cases

31. • Mean Incubation period – 10.3 days
• Min incubation period – 8 days (Shijitha)
• Max incubation period – 15 days (Ubeesh)
Probable time of exposure taken as 4th May
Epidemic curve – Common source epidemic
point source epidemic

32. Mean no.of days from onset of symptoms to admission - 4.06
Mean no. of days from admission to death - 2.92
0
2
4
6
8
10
12
14
Patient name
No of days from admission to
death
No of days from onset of
symptoms to admission

33. • Earlier admission and intensive care support -
prolonged lives

34. PLACE – SPOT MAP

35. Confirmed Nipah death Confirmed Nipah alive
Suspected Nipah death Hospitals visited

36. • Index case – Sooppikkada, Chengaroth,
Perambra
• Later 3 more cases from the same family
• Other places – Thiruvaode, Chembanoda,
Cheruvannur, Koorachundu, Parakkadavu
• 16 confirmed cases – 13 from Calicut and 3
from Malappuram

37. PERSON DISTRIBUTION

38. • Mean age of patients – 37 years
• Minimum age - 19 years
• Maximum age - 55 years

39. 8
8
Gender distribution
Male
Female 8
5
1
Religion distribution
Hindu
Muslim
Christian
6
4
1
1
Hospital admitted
MCH, CLT
BMH
THQH, Perambra
MIMS
14
2
Outcome
Dead
Alive

41. CONTACT TRACING
• Team made into groups of two
• Telephonic conversations
• Contacted close relatives or health inspectors
• Detailed history of each case was obtained

42. • Questions asked included
– Date of onset of symptoms
– History of presenting illness
– Health seeking behaviour of patient
– Persons accompanied in each visit to hospital
– Transport modalities used
– Names and details of contacts at other points, like hospitals, vehicles,
laboratories visited, guests visiting the patient at home and hospital,
including health care workers
– Date and Time of visit to above mentioned places
– Date and time of death
– Handling of dead body, funeral practices
– Any caretakers developing symptoms
– The caretaker’s perspective on how the patient contracted this disease

43. From the above information, potential points
of contact along with the date and time were
charted for each patient
To identify and notify those who are at risk

44. SL
NO
NAME MODE OF CONTACT
1 SALIH BROTHER
2 MARIYAM AUNTY
3 ISMAYIL ADMITTED IN THQ HOSPITAL PERAMBRA WHEN SABITH
WAS ADMITTED THERE
4 LINI STAFFNURSE WHO NURSED SABITH
5 JANAKI BYSTANDER OF A PATIENT AT THQ HOSPITAL,PERAMBRA
WHEN SABITH WAS ADMITTED
6 RAJAN BYSTANDER OF HIS BROTHER WHEN SABITH WAS ADMITTED
IN MCH,KOZHIKODE
7 ASOKAN HIS FATHER WAS ADMITTED IN MCH,WHEN SABITH WAS
ADMITTED THERE
8 MOOSA FATHER OF SABITH

45. NO OF CONTACTS OF EACH PATIENT
NAME OF THE NIPAH CONFIRMED CASE INDIVIDUAL NO OF CONTACTS
SABITH,SALIH,MOOSA,MARIYAM 157
ISMAYIL 103
LINI 92
JANAKI 96
ASOKAN 74
RAJAN 23
AJANYA 44
ABIN 30
TOTAL NO OF CONTACTS TRACED FROM MALAPPURAM DISTRICT:137
TOTAL NO OF CONTACTS TRACED UPTIL 25/5/2018 IN STATE:753

46. SABITH
THQH PERAMBRA
MCH CLT – XRAY DEPT,
CT SCAN
LAB 77,78
CASUALTY
ISMAIL (patient)
LINI (staff nurse)
JANAKI (by-stander)
RAJAN (by-stander)
ASOKAN (by-stander)
VELAYUDHAN (patient)
SHIJITHA ( by-stander)
SINDHU (by-stander)
UBEESH (patient)
AJANYA (nursing std)
HOUSEHOLD CONTACTS
SALIH
MOOSA
MARIYAM
KALYANI
(patient)
TH
BALUSSERY
RESIL MADHUSOODHANAN (by-st)
SINDHU (Xray tech)
ABIN (unknown)
AKHIL
MICU

47. SABITH
Ambulance staff – 5th May
SHIJITHA
Burial – 5th May
Dr Muthukoya clinic – 14th May
MKH Hosp. Thirurangadi -16th-18th May
Taxi, Ambulance – 19th May
RAJAN
Kottackal Arya Vaidyasala, Koorachundu – 14th May
PHC Koorachundu – 16th -18th May
EMS Hosp, Perambra – 18th May
MCH Ambulance – 20th May
Chest Hospital ICU – 20th May

48. SALIH
BMH Emergency, Neurology dept – 17th May
MCH – mortuary – 18th May
Ambulance, Burial – 18th May
MARIYAM
Ambulance – 19th May
Burial – 19th May
SINDHU THQH, Thirurangadi – 16th May
JANAKI
Vadakkannoor MMC – 18th May
MCH Ambulance – 19th May

49. ABIN
CHC Olavanna – 15th, 16th May
IQRA Hospital – 19th May
LINI
IQRA Hospital – 18th May
Ambulance – 18th May
VELAYUDHAN THQH PMNA-ward – 16th, 17th May

52. As informed by Janaki’s brother’s son Gireesh and her son-in-law Sreejith.
Janaki s father-in-law go, 90 years of age, admitted in THQH, perambra on April28th, for
the complaints of tooth pain. He was bedridden since 12 years and a patient of palliative
care for complaints of decubitus ulcer following leg fracture. One week later, on May 9th,
he died in THQH, Perambra. Janaki and her sister in law, Savithri were the by-standers.
After 7 days of admission, on May 16th, her father-in-law expired, following which she
developed headache on the same day, fever on the second day, and she was taken to
THQH, Perambra, in a private bus, on May 17th, with her niece, Ponnu, 20 yrs, Female, at
around 10 AM. Consulted doctor, and did blood tests in the same Hospital lab at about 11
AM. She was reassured and sent back home. The next day, she developed leg pain along
with fever and headache, following which she was taken to Calicut MCH by 4 pm, in a
jeep, driven by her brother’s son Gireesh. Her husband Venu, and daughter Babitha, also
accompanied them. Blood tests were also done in the hospital lab by around 12 AM. Next
day, she was again sent back home.
CASE HISTORY OF JANAKI

53. At around 10 AM that day, on May 18th, her relatives found that she was very sick, and
was taken to another nearby hospital, Vadakkannoor MMC, by around 10.30 AM, but the
treating doctor was some doctor other than Dr.Muhammad. She was taken in a jeep,
driven by a driver, name unknown, from around 5 kms away from their home,
accompanied by her daughter Babitha, her son-in-low Sreejith, her relatives - Babu,
Rajesh, and her sister-in-law Sarada. Further, by around 10-11 PM, referred to Calicut
MCH Casualty – in a mobile ICU, accompanied by her relative Babu, a doctor and a nurse
from Vadakkannur MMC. From there, she was referred to Chest Hospital, half a
kilometers away, in ambulance from MCH, accompanied by driver, name unknown,
husband Venu and other relatives. She was admitted to Chest Hospital ICU. Her by-
standers in the Chest Hospital were her son-in-law , her sister- Santha and a relative-
Babu. On May 20th, she was declared to be dead by 7 PM. Dead body was handled by
son-in-law Sreejith, her brother Babu, brothers-in-law Shibu and Vinod.
Janaki has only one daughter – Babitha.
According to her relatives, Janaki was in THQH, Perambra, when Sabith was admitted
there, during the days from April 28th to May 9th. Sabith was declared dead on May5th.

54. CASE HISTORY OF RAJAN
• Mr Rajan 45 years male from Koorachand , who is coolie by occupation went to
Kallode on 4/5/18,to stay with his uncle Mr Balan, k/c/o asthmatic for 15 years,
admitted at Perambra Taluk hospital since 3/5/18. He reached the Taluk hospital
by 3 pm , stayed with his uncle for a day at the hospital and returned on
5/5/18.After returning from Perambra Mr Rajan , a coolie by occupation was
working along with other workers in building his new house. By 13/5/18 he
developed fever but did not go to any hospital, being Sunday and took rest at
home. Next day on 14/5/18, he was feeling more lethargic and went to Kotakyal
Ayurvedashala at Koorachand and took some medicine . On 15/5/8 he had an
episode of loss of consciousness and on 16/5/18 went to Koorachand PHC
accompanied by his wife Mrs Sindhu 32 years, at about 10.00 am , doctor
examined him and checked his platelet count and found it to be 1.7 lakhs/ml. As
doctor’s advice Mr Rajan along with his wife went to PHC on 17/5/18 and 18/5/18
for monitoring the platelet count and found to be 88,000 and 84,000 respectively.
Doctor referred Mr Rajan to Kallode Govt Hospital in view of thrombocytopenia.
On 18/5/18, morning Mr Rajan along with his wife and elder daughter Sandra
went to EMS private hospital where he was admitted, blood tests were done. His
wife went for work and daughter stayed with him at the hospital. By evening
3.00pm, Mr Rajan developed altered sensorium and had an episode of loss of
consciousness and was found to have hyponatremia . Sandra called her mother
and informed about it .

55. • Mr Rajan was then referred to MCH , Kozhikode
on 19/5/18 in view of altered sensorium and
hyponatremia. Mr Rajan was then taken to MCH
Kozhikode by car accompanied by his wife Mrs
Sindhu , Sandra , Mr Ashokan ,Mr Gopalan ,Mrs
Reji, Mr Subhash other than driver , reached
MCH by 9.30 pm .He was then kept at casuality
and on 20/5/18 morning ,went to coma and
shifted to chest hospital ICU. On 22/5/18 ,Mr
Rajan died and was taken to Mavoor
crematorium with the help of Mr Gopalan , Mr
Ashokan ,Mr Jithesh, Mr Mahesh .

60. • The above mentioned details were presented to
the Director of Health Services
• Informed about anticipating the second phase of
the outbreak, lasting from May 25th to June 5th
• Drafted the details of recommendations and
notifications to be released if the second wave
happens
• Soon, informed of the death of a patient, who
tested positive, and proved to be a case of the
second phase

61. • The following steps were then taken
– Arrangements for dedicated treatment facilities
and laboratory facilities for patients tested
positive
– Arrangements for isolation of identified contacts
– Arrangements for immediate reporting , if and
when close contacts developed symptoms

62. An experience of immense educational
and public health importance

64. THANK YOU