‘We Worked Like Detectives’: Kerala Doctor on How the Nipah Outbreak Was Spotted

It took rigorous investigation & timely action by a team of doctors in Kozhikode to identify and contain the virus.

(Photo: Critical Care specialist, Dr Anoop Kumar, Map of Kerala, and a positive Nipah virus test.)

(Photo: Aroop Mishra/ FIT)

Video Producer & Editor: Anoushka Rajesh

On 12 September, Kerala declared it's fourth outbreak of Nipah virus since 2018, after the death of two unrelated patients who were found to be positive for the virus was reported.

This was followed by swift containment measures put in place by the state health authorities to curb the spread of the virus.

However, it took presence of mind, and rigorous investigation by a team of doctors in Kozhikode district to spot the virus in time and keep the situation from getting out of hand.

Dr Anoop Kumar, Director, Critical Care Medicine, Astar MIMS Hospital, Calicut, tells FIT how his team identified the elusive virus.

Current Nipah Outbreak in Kerala: How It Unfolded

It all started when three children were admitted in the pediatrics department in Aster MIMS hospital, in Kozhikode on 10 September. At the same time, a 24-year-old man was also admitted there.

"All of them mainly had respiratory symptoms like high-grade fever and cough. They didn't have neurological symptoms."

However, the team of doctors treating them soon came to know that two of the children's father (also related to the other two patients) had died on 30 August in another hospital.

"We found out that the deceased man had slurring of speech and Diplopia (double vision) which then progressed to severe pneumonia, and then he finally died of multi-organ faliure."

Dr Anoop Kumar

He goes on to say, "At the same time, another patient, a 40-year-old man, admitted to a local hospital with three days of fever, cough, and symptoms of pneumonia, was referred to me."

"That patient unfortunately died soon after due to a cardiac arrest on 11 September. But at that point, we didn't have anything to connect him to the index case (the man who died on 30 August)," explains Dr Kumar.

"We told the family of the deceased that we have a suspicion of an unknown viral disease which is why we couldn't hand over his body to them. We took all precautions, covered the body in triple layer while we sent the samples for testing."

Dr Anoop Kumar

In 2018, when Nipah virus was first detected in Kerala Dr Anoop Kumar was leading the counter-action. "At the time I had treated five patients. So we already have experience dealing with it," he says.

The patients, they found out, were from Perambra, an area in Kozhikode which was previously an epicentre of Nipah virus

All these factors, Dr Kumar says, pointed to Nipah virus, but it took more investigating before they could confirm it.

Connecting the Dots: Tracing Contacts, Patient History

So we have a clustering of cases and one death that occurred two weeks before, hailing from a part of Kozhikode known to house Nipah virus-carrying fruit bats.

The symptoms, however, were unusual, says Dr Kumar.

"Nipah usually presents with encephalitis like symptoms. But this time it was progressing to pneumonia. So, the only thing that helped us was the clustering, contact tracing of the index case, and our past experience."

Dr Anoop Kumar

He says, "Like detectives," they set to work repeatedly taking the history of all the patients, including the deceased.

"When we got the index patient's medical history we found out that he was negative for other viral infections that could cause pneumonia like COVID, and influenza."

The patient who died on 11 September had a rapid progression of illness "which is also unusual for influenza-related pneumonia," he adds.

Furthermore, blood work also showed all these patients (including the children) had a slight drop in platelet count, and low White Blood Cell (WBC) count.

"Suprisingly, we also found out that the two patients that died were in the emergency room of the same hospital at the same time on the morning of 29 August."

Turns out, the patient who died on 11 September had accompanied a relative to the hospital where the index patient was admitted.

That established a history of contact with the index case.

Dr Anoop says, by this point, they had a strong index of suspicion and the samples were sent for testing immediately at midnight of 11 September. "I also informed the State Health Minister, Veena George about the situation."

'Not Their First Rodeo': How Past Experience Helped

"Only because we had experience in diagnosing and treating the patients, were we able to identify it quickly this time also," says Dr Kumar.

They were also able to prevent further spread and protect the healthcare workers involved by swiftly putting precautionary measures into action right when they had a suspicion of what they were dealing with.

"As soon as we identified the clustering, even before the samples were tested, we isolated the patients and took all contact precautions."

Dr Anoop Kumar

Right now, Dr Kumar says, two of the three patients are improving, and one of the children is on ventilator support.

One more healthcare worker who had treated the index case in the other hospital has tested positive. "But, he is also being treated and clinically stable," he adds.

Past experience is also why the health department was able to take quick action to contain the infection. Even before the test results came in, contacts of all these patients were traced,and categorized into high and low-risk contacts. 16 containment zones were made and movement in these areas was restricted.

Can Nipah Virus Lead to a Pandemic-Like Situation?

Dr Kumar says the situation is under control, all the preventive measures are in place, and they are not expecting it to cause a big outbreak.

He adds that Nipah virus in itself doesn't spread rapidly enough to cause a full-fledged outbreak. While it is a deadly virus, it isn't as infectious as, say, SARS-CoV-2

"The transmission rate (of the virus) is really low. That's why although it spreads from a primary source to a secondary host, transmission from secondary and tertiary infections is less likely."

Dr Anoop Kumar.

FIT has previously spoken to experts who have explained this in detail.

However, Dr Kumar says that continuing with protective measures is important.

The best way to protect yourself is to take appropriate safety measures.

• Mask up if you, or someone around you, have flu-like symptoms with high fever.

• If you live in an area that either has fruit bats, has had cases in the past, or is within a containment zone, avoid eating raw fruits, particularly those found on the ground or plucked from trees.

• Consult a doctor in case of suspicious or worsening symptoms.