Nipah virus

Epidemiology of Nipah Virus (NiV) infection
26-05-2018 Dr Tanveer Rehman PSM JIPMER

Geographical distribution of outbreaks of NiV infection in
Bangladesh and India

Morbidity and mortality due to Nipah in SEARO

Case definitions
1. Suspected (clinical) case:
Patient with an epidemiological link or from a community affected
by an outbreak who has fever with:
i) acute onset of altered mental status or seizure, and/or
ii) headache, and/or
iii) acute onset of cough with shortness of breath

Case definitions
2. Probable Nipah case:
Suspect cases who died before complete diagnostic specimens
could be collected and –
i. Resided in the same village where suspect/confirmed case of
NIPAH were living, OR
ii. Came in direct contact with confirmed cases in a hospital
setting

Case definitions
Confirmed Nipah case
Suspected case with laboratory confirmation of NiV infection either by:
i) IgM antibody against NiV identified in serum or CSF, or
ii) NiV RNA identified by RT-PCR from respiratory secretions, urine or
CSF, or
iii) isolation of NiV from respiratory secretions, urine or CSF or other
tissue specimens

Case definitions
Close contact
• A person who came in contact with a Nipah case (confirmed or
probable cases) AND stayed in the room or veranda or vehicle
for at least 15 minutes
• Contacts are to be followed up in case of occurrence of illness
(up to 18 days)

Nipah Contacts
1. Was admitted simultaneously in a hospital ward/ shared room with a
suspect/confirmed case
2. Has had direct close contact with the suspect/confirmed case during the
illness including during transportation.
3. Has had direct close contact with the (deceased) suspect/confirmed case at a
funeral or during burial preparation rituals
4. Has touched the blood or body fluids (saliva, urine, vomitus etc.) of a
suspect/confirmed case during their illness
5. Has touched the clothes or linens of a suspect/confirmed case

Natural history of Nipah Virus Infection

INFECTIOUS AGENT
• Family Paramyxoviridae
• Genus Henipavirus.
• The incubation period is from 4 to 18 days

ENVIRONMENT
1. The loss of natural habitat of bats
i. Stressed and hungry - immune system gets weaker- virus
load goes up and spills out in urine and saliva
ii. Nutritional stress - bats closer to urban areas
2. Strong seasonal pattern : Spring (December–May) - breeding
season of the bats - increased shedding of virus by bats
3. The date palm sap harvesting season

RESERVOIR
1. Five species of Bats (four species of fruit bats, including two flying fox species, and
one insectivorous species) of the genus Pteropus, family Pteropidae :
Asymptomatic carrier
2. Pigs – amplifying hosts - developed a febrile respiratory disease with a severe cough
and/or and neurologic syndrome - ‘‘barking pig syndrome’’, ‘‘one-mile cough”
3. Dogs, cats, horses and goats: dead-end hosts

Geographical distribution of fruit bats

Mode of transmission
• Malaysia and Singapore: No occurrence of person-to-person
transmission - consumption of raw date palm sap contaminated
with infectious bat saliva, urine and faeces
• Bangladesh and India: Person-to-person transmission is
regularly reported especially with body fluids - most commonly
family and caregivers of infected patients

Mode of transmission
• Direct as well as indirect
• The virus is readily identified in the saliva, urine of infected patients
and in cerebrospinal fluid (CSF) of encephalitic patients
• Respiratory secretions appear to be particularly important for
person-to-person transmission
• Highly contagious among pigs - spread by infected droplets

CLINICAL SPECTRUM
1. Asymptomatic and subclinical infection
2. Classical form of acute Nipah encephalitis
3. Relapsed encephalitis
4. Late-onset encephalitis

Asymptomatic and Subclinical infection
• No evidence of asymptomatic NiV infection
• Subclinical and mild diseases - Bangladesh and India :
Nonspecific - indistinguishable from flu-like symptoms and
included slightly raised temperature, malaise and body
aches

Classical presentation of NiV infection
1. Acute and rapidly progressive encephalitis with or without
respiratory involvement in all age groups
2. Presents with 3–14 days of fever and headache, followed by
drowsiness, disorientation and mental confusion
3. The acute encephalitis progresses then to coma within 24–48
hours, with high mortality rate

• Relapsed encephalitis: A case is considered to be relapsed
encephalitis if the neuro logical symptoms recur after recovery
from encephalitis
• Late-onset encephalitis: If the neurological signs and
symptoms of encephalitis develop after more than 10 weeks of
the initial exposure

Differential diagnosis
1. Japanese encephalitis (JE)
2. Measles
3. Cerebral malaria
4. Bacterial meningitis
5. Herpes simplex encephalitis

SOP for sample collection and transportation
1. Verbal consent from patient or patient’s family member
2. Using adequate PPE
3. 5 ml venous blood/ Throat swab / Urine 5 ml / CSF (1-2 ml) when
appropriate
4. Store the serum and CSF samples in liquid nitrogen if possible, or
−20°C freezer for short-term storage
5. Ship samples in liquid nitrogen tank or ice pack to assigned centre
for laboratory diagnosis;
6. Store samples in −70°C freezer for longer-term storage;
7. Laboratory diagnosis - BSL 4 facilities

BSL 1 BSL 2 BSL 3 BSL 4
Description Do not cause
disease in
healthy adult
humans
Disease is
treatable or
preventable
Serious disease in
humans.
Treatments and
vaccines for these
diseases may
exist.
Deadly disease in humans,
and they can easily travel
from one person to another.
No treatments or vaccines
exist for these diseases.
Examples E. coli ,
S. cerevisiae,
Lactobacillus,
B. subtilis
Streptococcus,
Herpes virus
Yersinia pestis,
HIV, SARS, TB,
Yellow Fever,
Chikungunya
Ebola virus, Nipah, crimean
congo HF, KFD, Marburg
virus, Lassa virus
Location NICD, NICED,
JALMA
High Security Animal
Disease Laboratory
(HSADL),
Centre for Cellular and
Molecular Biology,
Microbial Containment
Complex

Typical Laboratories

TREATMENT
1. Supportive care - immediately in all clinically suspected cases
2. Patient isolation (preferably in a separate ward/room).
3. The drug ribavirin - effective against the viruses in vitro, but
human investigations - inconclusive
4. Passive immunization using a human monoclonal antibody
targeting the Nipah G glycoprotein - benefit in the post-
exposure therapy in the ferrets

Preventive Measures

Caregivers or attendants
1. Follow instructions made in the local language/dialect;
2. Home isolation: keep the patient in a separate room. If not
possible, they should be maintained in a partitioned area.
3. Sleep in a separate bed or in the opposite direction
4. Maintaining more than at least two hands from patient’s face
while giving care face-to-face

Caregivers or attendants
5. Respiratory hygiene/cough etiquette for patients and other: Cover
mouth and nose with a napkin, piece of cloth or mask while talking
6. Practise minimum and essential handling of patients and equipment ;
Do not eat leftover food from the patient
7. Clean and disinfect used patient-care equipment properly; and
8. Wash hands with soap before eating and after cleaning and feeding
patients

HCW

Patients must:
• clean secretions and visible soiling with wet swabs frequently and
discard in designated covered waste bins and sanitize hand;
• be educated on hygienic use of toilets and other facilities;
• instructed to avoid unnecessary touching of objects within the
facility;
• • decontaminate used clothes; utensils and other belongings with
soap and
• water;
• restrict movement within and outside the facility

At community level
• Motivate people to stop drinking raw date palm juice.
• The date palm cultivators (known in Bangladesh as gachis) may be
requested to use some barriers such as bana, a locally produced jute-
sheet widely used in rural Bangladesh, to prevent bats from drinking
the date juice from the plants. Training programmes for this
•pig farmers and local livestock officials should be alerted about the
possibility of infection and precautions to be taken (personal hygiene
and good farming practices)

Nipah/Hendra virus outbreak in Siliguri, West
Bengal, India
in 2001

Outbreak was investigated by a team drawn from AIIMS, New Delhi;
National Institute of Communicable Diseases (NICD), Delhi; National
Institute of Virology (NIV), Indian Council of Medical Research, Pune
and WHO Country Office
• Any person with an acute onset of fever with altered sensorium of
unknown aetiology reporting to health facilities – case
• Four serum specimens from cases that tested positive for measles
IgM at the NIV,
• A total of 66 probable cases and 45 deaths were
• reported between January 31 and February 23, 2001.

• Four serum specimens from cases that tested
• positive for measles IgM at the NIV, Pune, four
• companion infected Vero cell culture lysates derived
• from the serum specimens, two case contact serum
• specimens (one reported as IgM positive, and one as
• IgM negative for measles at the NIV, Pune), four
• urine specimen, and one brain aspirate were sent to
• Centers for Disease Control and Prevention (CDC),
• Atlanta.

Possible epidemiological linkages amongst
cases.

Epidemic Bar graph showing the outbreak of
Nipah Virus in Siliguri, West Bengal, India, from
January through February 2001

• All the cases that could be interviewed had a definite history of
• exposure to a case. No association with factors like travel outside
• Siliguri, visit by guests from outside Siliguri, attending funeral,
• exposure to injections, contact with animals/birds including pigs,
• exposure to any new or old insecticide or homeopathic remedies
• during one month prior to date of onset in cases was found

• Entomological investigations did not reveal the presence of dengue or JE
• vector. Though initial laboratory investigations indicated the outbreak
• to be due to non- exanthematous measles, subsequent epidemiological
• and laboratory investigations including those conducted at CDC, Atlanta,
• where viral culture in Vero and B95a cell lines were negative for measles
• virus cytopathic effects as conveyed in its first report, did not support this
• diagnosis. In its second report, CDC reported that the outbreak may have
• been the result of Nipah / Hendra virus infection, or a closely related virus

• outbreak of Nipah virus occurred in India in Balachuapara village of
Nadia district in West Bengal

• The index case was a 35 year old male farmer who was addicted to
country liquor that is made from date palm juice [12]. A horde of bats
were observed hanging from the trees around his residence which
suggests direct contact of the liquor with bat fluids. The index case
then affected 3 of his relatives who showed symptoms within 12-14
days of contact and a man who collected his blood samples showed
symptoms 12 days after contact [12].
• From the two cases it can be concluded that the incubation period
can range from 4 to 20 days

Nipah outbreak investigation - Kerala

Verification of diagnosis
May 3: 26 year old Index case admitted MCH, Kozhikode
May 5: Index case died
May 17: 28 year old male dead (brother of index case)
May 18: 50 year old female dead (aunt of index case)
May 5 to 20: 13 more dead including Lini Puthussery, 31 a nurse in
Perambra Taluk Hospital in Kozhikode and Malappuram

Confirmation of existence of an epidemic
• Nipah outbreak - identification of at least one laboratory-confirmed
case.
• On May 20: NIV pune confirmed that three of the four samples from
the deceased to the institute tested positive
• A multisectorial team from the National Centre for Disease Control
(NCDC) arrived in Kozhikode. Headed by Dr Sujeet K Singh, director,
National Centre for Disease Control (NCDC), Dr S K Jain, chief,
department of epidemiology, NCDC; Dr P Raveendran, director,
department of Emegency Medicine relief emr, Dr Naveen Gupta,
director, department of Zoonosis, Dr Ashutosh Biswas, Professor of
Internl Medicine AIIMS, Dr Deepak Bhattacharya, Pulmonologist
Safdurjung, & an expert from animal husbandry department.

Confirmation of existence of an epidemic
• On May 20:
A district level special task force, headed by Kozhikode district collector,
UV Jose has been formed

Population at risk

NCDC team found many bats in a well from where
the index family took water. Some of bats caught
and sent to lab

Rapid search of all cases
• Serum specimens collected in case of symptom onset in high-risk
groups or in groups exposed to the source
• May 21: special medical camps at Changarothu in Kozhikode for active
and passive case-finding
• May 21 – 25: people are being kept under observation
• Five are undergoing treatment at the intensive care unit of the
Institute of Chest Disease at the Government Medical College
Hospital, Kozhikode, and one at the isolation ward of the hospital.
Two others are undergoing treatment at the Baby Memorial Hospital,
Kozhikode, and one at the Amrita Institute of Medical Sciences, Kochi

Dissemination information to community

• 24 x 7 NHM Health Services helpline DISHA on
•0471-2552056( Normal call, any line)
•1056(toll free from BSNL Reliance, TATA, Idea, JIO Lines)
• A control room has been opened at the District Medical Officer's
office, Calicut and the phone number is 0495-2376063
• Arogya jagrata

use of personal protective equipment

Is Jipmer Technically Equipped?
• Assess PPE in stock; central strores??
• Assess sample collection instruments; triple layer pack we have
• Evaluate laboratory capacity for NiV testing;
• Evaluate hospital capacities for isolation facilities and ability to treat
Nipah medicine SR?

• Hindu bats afforestation
• Siliguri slide
• BSL 3 Lab what needed Jipmer what lab
• Container
• Jipmer what plan they have? Transport kit available ppe available?
• Calicut migrants : none
• USHA how many ppe kits we have? Stocks count and keep. Check
expiry date

• Bsl 4 niv
• Presently bsl 2 we are going to bsl 3
• NIV must have done pcr
• Molecular test we can do but guidelines not saying RT PCR
• Sero surveillance antigen culture organism to be done, that not ready
jipmer.

• A nipah isolation ward opened O2 ward (behind EMS Casualty)
• Migrants or symptoms

THANK YOU

Nipah virus

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