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Dr KK Aggarwal 10 June 2019
This page will be updated till the Nipah scare is over. Inputs invited in this white paper.
Dr KK Aggarwal
Union Minister of Health and Family, Dr Harsh Vardhan has said that there have been no new cases of Nipah virus disease and the clinical condition of Nipah positive patient is improving further.
According to a Health Ministry press release, as on Sunday, there are 8 patients in the isolation ward and 7 of them were tested negative for the Nipah virus. The sample from the 8th patient is being tested in the point of Care (POC) lab. Four other patients from the isolation were discharged on Saturday as their clinical condition improved.
National Institute of Virology (NIV), Pune collected three blood samples from pigs and about 30 samples from bats from Thodupuzha (Idukki district)… (Source: Press Information Bureau, Ministry of Health and Family Welfare, June 9, 2019)
Duration of contact tracing
Duration of contact tracing is 21 days from the time of last contact with a case.
Active fever surveillance
Area: within 5 km radius from the periphery of the affected area (house/village of case/cases).
What has to be done?
Home Quarantine
Who has to be quarantined: all households and close contacts of a suspect case.
Isolation
When the area/district/state can be declared free: 42 days from the date of last positive case reported from the district/state
(Source: National Center for Disease Control, Recommended Community level Public Health Measures for Nipah virus infection)
Contact tracing
o Enlist all the contacts for tracing
o Distribute Triple layer surgical masks to each household and keep sufficient stock (but avoid misuse/un-necessary use), as it may create fear/panic.
o IEC on Nipah virus (NiV) infection, symptoms and importance of contact tracing and home quarantine/isolation.
o Give his telephone number and number of control room/nearest health facility
o Have location and details of dedicated ambulance and availability of disinfectant
o Ask him if had developed any fever, cough, headache (and or other symptoms like altered sensorium, shortness of breath etc.)
o Health education: about keeping a self-watch on developments of symptoms and If anyone develops symptoms, then he or she becomes a suspect case and thus suspect has to:
(Source: National Center for Disease Control, Recommended Community level Public Health Measures for Nipah virus infection)
Time to Act and not React
There are two approaches to resolve a problem: Action and reaction. This is also applicable to public health problems.
The government often adopts the “reaction” approach first, which is a denial mode.
No government would acknowledge a public health problem, existing or impending, right away as it could be perceived as tantamount to owning up to the inefficiency or incompetency of health systems in place.
A terrorist attack does not mean failure of the government. The Nipah virus can be likened to a terrorist.
It’s time for action and not reaction.
When the Zika epidemic threatened Brazil in 2015-16, when the country was preparing to host the 2016 Olympic Games, the army was called into action and asked to join the efforts to control the virus, which was made into a public movement.
Definitions
People often use the term index case when they actually mean primary case. Both terms are well-defined for outbreaks, and should not be confused.
The term primary case can only apply to infectious diseases that spread from human to human, and refers to the person who first brings a disease into a group of people—a school class, community, or country.
The index case, however, is the patient in an outbreak who is first noticed by the health authorities, and who makes them aware that an outbreak might be emerging. Even outbreaks of disease that is not spread from human to human, such as Legionnaires disease, might have an index case.
For many outbreaks, the primary case will never be known—the worldwide HIV epidemic is one example.
In an outbreak that goes unnoticed, no index case is present, but for all outbreaks that are discovered, there will always be one (or more).
In the present Nipah case in Kerala, we now have the index case, which led to notification. But the primary case is yet to be diagnosed. The very fact more than 300 cases are under surveillance means the government has no clue about the primary case.
The primary case may also be the index case.
The first term is linked to the basic epidemiology of the outbreak, the second rather to the surveillance system and public health action.
Outbreaks
Nipah facts
o Encephalitis cases from the areas reported NiVD in human population
o Area with fruit bats showing presence of NiV
o Fever with altered sensorium reported from health care personnel treating patients with respiratory illness etc.
o In any person who has recently visited the affected areas
Efforts to prevent transmission should first focus on decreasing bat access to date palm sap and other fresh food products. Keeping bats away from sap collection sites with protective coverings (such as bamboo sap skirts) may be helpful. Freshly collected date palm juice should be boiled, and fruits should be thoroughly washed and peeled before consumption. Fruits with sign of bat bites should be discarded.
Gloves and other protective clothing should be worn while handling sick animals or their tissues, and during slaughtering and culling procedures. As much as possible, people should avoid being in contact with infected pigs. In endemic areas, when establishing new pig farms, considerations should be given to presence of fruit bats in the area and in general, pig feed and pig shed should be protected against bats when feasible.
NiV can persist on surfaces, posing risk for fomite-borne NiV transmission.
All NiV case-patients with NiV RNA in their oral secretions died in one study and those without NiV RNA survived suggesting virulence is important. Human-to-human transmission results direct contact with respiratory secretions of severely ill patients.
Only 7% of all Nipah patients are Nipah spreaders. Those with respiratory involvement (difficulty breathing and cough) are more likely to become Nipah spreaders. Bangladesh example: 16 Nipah patients; 12 laboratory-confirmed and 4 probables; of 12 lab confirmed cases 10 showed NiV RNA in oral swab specimens. Surface swab samples for 6 Nipah patients; 5 had evidence of NiV RNA on >1 surface: 4 patients contaminated towels, 3 bed sheets, and 1 the bed rail. Patients with NiV RNA in oral swab samples were significantly more likely than other Nipah patients to die.
o Investigation phase: immediate investigations of exposed people, Notification circular
o Alert phase
o Operational phase: Public awareness and education campaign and set up neighboring states and local disease control centers.
o Stand-down phase: Last phase after the disease is eradicated.
There is no National Program for Surveillance of NiV. All these diseases are part of Integrated Disease Surveillance Program (IDSP).
(Inputs: Dr AC Dhariwal, Dr Shivlal)
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA
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