Nipah virus (ni v)

Nipah Virus (NiV)
Prof. Dr. Saad S Al Ani
Senior Pediatric Consultant
Head of Pediatric Department
Head of TDC
Khorfakkan Hospital
Sharjah, UAE
saad.alani@moh.gov.ae

Nipah virus (NiV) is a
paramyxovirus (genus Henipavirus)
Brainfeed Magazine
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 2

Its name originated from Sungai
Nipah, a village in the Malaysian
Peninsula where pig farmers became ill
with encephalitis in 1999

Three years later, a genetically distinct
NiV independently emerged in India as
well as in Bangladesh, where human
NiV outbreak events have been
reported nearly every year

A putative NiV also caused an outbreak
of disease in horses and people in the
Philippines in 2014.

To date, there is no reported evidence
of NiV outbreaks in humans emerging
in any other country than Malaysia,
Singapore, Bangladesh, India and
Philippines

In 19 May 2018, the Kerala Health Department
reported three deaths due to Nipah virus infection in
Chengaroth in Perambra block of
Kozhikode district in south Indian State
of Kerala: the 3 deaths occurred in family cluster and a fourth
death was subsequently reported in a health care worker caring for the
family.

As of 23 May 2018 and since the beginning of the
outbreak, following more investigations and contact tracing, a
total of 13 people have tested positive for NiV in
Kozhikode and Malappuram Districts
(Kerala State).

Of the 11 deaths reported so far, three
have been reported from Malappuram
district of Kerala and the others from
Kozhikode district

This is the first time of NiV infection
reported in Kerala State and third
known NiV outbreak in India. Last
outbreak was reported in 2007.

A total of 276 cases were reported with
106 fatalities (38%) in Malaysia,
Case fatalities in later outbreaks in India
and Bangladesh were associated with
significantly higher case fatality rates of
43 to 100%.

NiV infection in humans has a range of
clinical presentations, from :
asymptomatic infection to acute
respiratory syndrome and fatal
encephalitis

The natural reservoir of the virus
consists of the widely distributed fruit
bats from the Pteropodidae family

The fruit bats (Pteropodidae family,
Pteropus genus).
Grey-headed flying foxes

Virus transmission from bats to humans
occurs through:
• Inhalation
• Contact
• Consumption of NiV
contaminated foods.

NiV is transmitted by:
• zoonotic :
from bats to humans
from bats to pigs and then to
humans
• Human-to-human routes.

Zovon.com

Human-to-human transmission is
particularly notable in the outbreaks in
India and Bangladesh, where it has
been reported to account for 75% and
51% of cases, respectively.

The virus
NIV is an enveloped, negative-sense,
single-stranded RNA virus.

The Henipavirus genus in the subfamily
Paramyxovirinae (family
Paramyxoviridae) was then created for
these two pathogenic viruses, HeV and
NiV

Clinical disease
The incubation period of Nipah
5 days - 2 weeks
(In the majority of cases)
a maximum delay of 2 months between exposure and the
onset of illness had been reported during the outbreak
in Malaysia.

The majority of patients initially develop
influenza-like signs and symptoms,
including:
• Fever
• Headache
• Myalgia
• Vomiting

In general, the more severe clinical
features manifest as either:
• Acute encephalitic syndrome
• Pulmonary syndrome (less
frequently)
N.B. Considerable number of infections remain
asymptomatic

• In patients with reduced level of
consciousness:
Clinical signs such as:
• Areflexia/ hyporeflexia with hypotonia
• Pinpoint pupils with variable reactivity
• Tachycardia
• Hypertension
• Abnormal doll’s eye reflex
More frequently seen

Segmental myoclonus characterized by
focal, rhythmic jerking of the diaphragm
and muscles in the limbs, neck and
face was present in 32% of patients,
and may be unique to acute NiV
encephalitis.

Other clinical features :
• Meningism
• Generalized tonic-clonic
convulsions
• Nystagmus
• Cerebellar signs
were also observed

Pulmonary syndrome presented with:
• Cough
• Atypical pneumonia
• Acute respiratory distress syndrome
• Abnormal chest X-ray findings

Higher prevalence of respiratory
disease was observed during the
Bangladesh outbreaks with cases
experiencing atypical pneumonia and
developing an acute respiratory
distress syndrome.

In Bangladesh:
High prevalence of acute encephalitis:
• Altered mental status and/or
unconsciousness :>70%
• Severe weakness : 67%
• Areflexia/hyporeflexia : 65%

In Bangladesh, based on a review of
196 cases:
• Median duration from onset of
illness to death was 6 days
o (ranging from 1 to 47 days)
• Mortality was high, ranging from
about 40% to 100%.

• In a large cohort of patients who
survived
• the majority had no or few
sequelae.
• approximately 20% of patients
were reported to have :
 Neurological deficits
 Neuropsychiatric sequelae
 Gait/movement disorders

The most intriguing complication of
Nipah is probably relapsing
encephalitis which may occur weeks to
years after symptomatic infection and
even after asymptomatic NiV infection.
So far, more than 20 cases of relapsing NiV encephalitis
have been reported, one of which occurred 11 years after
an asymptomatic infection

Relapsing NiV encephalitis
• Distinct clinical and radiological findings
• Brain MRI in relapsing encephalitis
shows :
more extensive and confluent hyperintense cortical lesions
• Virus could not be cultured from
samples collected
• No known risk factors nor for the
mechanisms for persistent

Pathological features
are characterized by:
disseminated, multi-organ vasculopathy
comprising :
• Endothelial infection/ulceration
• Vasculitis
• Vasculitis-induced thrombosis/occlusion
• Parenchymal ischemia/microinfarction
• Parenchymal cell infection
in CNS , lung, kidney and other major organs

Case definition of Nipah encephalitis

Suspected case
1.A person fulfilling both of the following criteria is
defined as a suspected case:
 Features of acute encephalitis as
demonstrated by:
- Acute onset of fever AND
- Evidence of acute brain dysfunction as
manifested by:
i. Altered mental status OR
ii. New onset of seizure OR
iii. Any other neurological deficit

Suspected case (cont.)
2.Epidemiological linkage
a.Drinking raw date palm sap OR
b.Occurring during Nipah season OR
c. Patient from Nipah endemic area

Probable case
A person with features of acute encephalitis :
 During a Nipah outbreak in the area OR
 With history of contact with confirmed Nipah
patient

In both suspected and probable cases,
the patient might present with
respiratory features with or without
encephalitis.

The respiratory features are
Illness < 7 days duration AND
Acute onset of fever AND
Severe shortness of breath, cough
AND
Chest radiograph showing diffuse
infiltrates

Confirmed case
A suspected or probable case with laboratory
confirmation of Nipah virus infection either by:
IgM antibody against Nipah virus by ELISA in
serum or cerebrospinal fluid
Nipah virus RNA identified by PCR from
respiratory secretions, urine, or
cerebrospinal fluid

Clinical features
• Symptoms
The following symptoms were observed
(in order of frequency in Bangladeshi cases)
1. Fever 6. Cough
2. Altered mental status 7. Vomiting
3. Severe weakness 8. Muscle pain
4. Headache 9. Convulsion
5. Respiratory distress 10. Diarrhea

Clinical features (Cont.)
• General Signs
• Reduced GCS score • Hypertension/Hypotension
• Raised temperature • Crepitations in lung
• Increased respiratory
rate
(Adult: ≥25/min;
Children of ≥ 12 months: ≥
40/min)
• Increased heart rate
(Adult: ≥100/min;
Children of ≥ 12 months: ≥
140/min)

Clinical features (Cont.)
• Neurological signs
i. Oculoparesis
ii. Pupillary abnormality
iii. Facial weakness
iv. Bulbar weakness
v. Limb weakness
vi. Reduced deep tendon reflexes
vii. Plantar-absent/extensor

Differential diagnosis
1. Other viral encephalitides e.g. Herpes
simplex encephalitis, Japanese B
Encephalitis (JBE)
2. Bacterial meningitis
3. Cerebral Malaria

Differential diagnosis of Nipah virus, Japanese encephalitis
and Herpes Simplex Encephalitis

and Herpes Simplex Encephalitis (Cont.)

Investigations
• Enzyme-linked immunoassay
Nipah IgM capture ELISA and an indirect
IgG ELISA have high specificity for the
diagnosis
• Polymerase chain reaction (PCR)
RT PCRs can be used for detection of viral
sequences in CSF, throat swab or urine
specimens.

Treatment
• Supportive/General Management
a. Isolation (preferably in a separate unit)
b. Barrier nursing e.g. personal protection
using masks, gloves, gowns, shoe covers
c. Hand washing with soap & water before
and after handling/visiting patients
• Symptomatic Treatment
• Other treatment: ribavirin ???

Prevention and control of Nipah
encephalitis

• There are different risk factors for transmission of
Nipah virus which are:
1. Ingestion of Raw date palm sap contaminated
by NiV
2. Person to person transmission of Nipah virus
3. From patient to care giver or contact
4. From patient to health care worker
5. Through objects used by patient
6. During handling deceased

Prevention and control of Nipah
transmission depends upon controlling these
risk factors

Standard precaution:
• Personal protection by practicing standard
precaution:
 Hand hygiene: Hand washing /alcohol
based hand rub
 Use personal protective equipment
(PPE)
 Safe handling of patient, equipment
and linen

Also to follow
 Barrier nursing (PPE use, Isolation)
 Environmental cleaning and
decontamination
 Safe waste disposal

References
• WHO - NIPAH Baseline Situation Analysis - M. Denis, consultant - Draft, Jan 27 2018
http://www.who.int/blueprint/priority-diseases/key-
action/WHO_NIPAH_baseline_situation_analysis_27Jan2018.pdf?ua=1&ua=1
• Rahman SA. National Guideline for Management, Prevention and Control of Nipah Virus Infection including
Encephalitis http://www.iedcr.gov.bd/pdf/files/nipah/National_Nipah.pdf. 2011
• Broder CC. Henipavirus outbreaks to antivirals: the current status of potential therapeutics. Current Opinion Virology
2012;2(2):176-87.
• Rahman MA, Hossain MJ, Sultana S, et al. Date Palm Sap Linked to Nipah Virus Outbreak in Bangladesh, 2008.
Vector Borne and Zoonotic Disease 2012;12(1):65-73
• Rollin PE, Rota P, Zaki S, Ksiazek TG. Hendra and Nipah viruses. in: Versalovic J, Carroll KC, Funke G, Jorgensen
JH, Landry ML, Warnock DW, editors. Manual of Clinical Microbiology. 10th ed. Washington, DC: ASM Press; 2011;
p. 147987
• Chadha MS, Comer JA, Lowe L, et al. Nipah virus-associated encephalitis outbreak, Siliguri, India. Emerging
Infectious Disease 2006;12(2):235-40.
• Chua KB, Lam SK, Goh KJ, et al. The presence of Nipah virus in respiratory secretions and urine of patients during
an outbreak of Nipah virus encephalitis in Malaysia. Journal of Infection 2001;42(1):40-3.
• National Center for Emerging and Zoonotic Infectious Diseases Division of High-Consequence Pathogens and
Pathology (DHCPP)

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