After the outbreak

Kerala’s health care system and social capital won the battle against Nipah, but it is important to review the lessons learnt in order to prepare for future invasions. It is also important that India develop a national policy on Nipah surveillance and management.

House surgeons at the triage section of the casualty wing of Government Medical College, Kozhikode, on June 9.

ON May 18, 2018, Dr G. Arunkumar of the Manipal Institute of Virology confirmed what clinicians and public health officials had been suspecting: there were patients in Kerala infected with the Nipah virus. That night, Kerala declared war on an enemy we knew very little about. By June 11, the outbreak was declared over.

The index case of the outbreak reported to a subdivisional hospital on May 2. He had also been to the casualty and CT scan units and the ICU of Government Medical College, Kozhikode, before he died at the Medical College Hospital. He passed the virus on to 16 persons at these places. Once the Health Department came to realise the magnitude of the challenge, an emergency response was put in place. A control room was set up under the District Collector, and the Director of Health Services was posted there until the crisis was over. The entire health machinery was engaged to follow up and quarantine every potential source of infection. Cases were picked up as and when they reported sick and shifted safely to the treatment centre at Government Medical College, Kozhikode. These measures ensured that the situation never got out of hand. Finally, 18 persons had been infected. Of them 16 died. We had prepared for at least four times that number.

Health Minister K.K.Shailaja (right) with Additional Chief Secretary (Health and Family Welfare) Rajeev Sadanandan (left) and Director of Health Services R.L. Saritha after a high-level review meeting on the Nipah outbreak, in Kozhikode on June 2.

The health system and social capital of the State won the battle, even though at a cost. However, the war will continue, as there is a strong possibility of the infection recurring. Therefore, it is important to review what we have learnt and how we can prepare for future invasions.

We need to institute good surveillance at hospitals and in the community. With the destruction of habitats and the impact of global warming, it is likely that many organisms that existed commensally with wild animals will cross over to humans. When a microbe moves from one species to another, it could become much more virulent than it was in the host animal. The reaction time for health or veterinary services would be very short. We have to be prepared for the unexpected and be vigilant for any emerging infections.

An alert team of doctors detected the second case in Kerala, saving many lives. However, had the first case, which had two interactions with the health system, been picked up in time, most of the deaths could have been avoided. In most of the other outbreaks, the infection was picked up much later. Our systems are designed to generate alerts when unusual episodes of sickness occur, and mostly they do. But Nipah has taught us that the margin for error is zero.

Universal precautions have to become standard practice in hospitals. A good health system has to have adequate precautions to protect workers and patients against any infection, known or unknown. This is more so in hospitals where infected persons come when they are sick and are therefore highly infectious. Many hospitals in India are inadequately equipped and the staff lack the needed knowledge and skills. Most of the infections in this outbreak occurred in hospital settings. While most of them could not have been prevented, Kerala will review infection prevention and control practices in hospitals.

The burial process could become a source of infection. In past outbreaks, such as HIV and Ebola, lack of precautions during burial rites had become an occasion for the spread of the virus. This happened in Kerala too. The National Centre for Disease Control has issued guidelines for burial. Bodies were not handed over to the families. The Municipal Health Officer of Kozhikode took over the task of safe burials, often conducting the last rites himself.

Religious and political leaders stepped in to convince families of the need to comply with burial guidelines. There was no spread from burials after the notification.

Making arrangements for providing quality care while ensuring the safety of health workers and preventing the spread is a challenge. On the basis of the experience of managing Ebola, guidelines have been developed for treating epidemics that are highly infectious and where mortality rates are high. Kerala adopted these in managing the epidemic. We kept more than 2,000 contacts under constant surveillance. All the contacts were verified twice daily and any case reporting positive was shifted to the dedicated treatment facility in specially equipped ambulances, which were on standby in strategic locations. This ensured that no infection occurred after the virus was notified.

Two existing buildings at the Government Medical College were evacuated and converted to triaging, observation and treatment areas, each firewalled from the other. All reported cases were driven straight there and moved from one segment to the next depending on the acuteness of their sickness and viral status. All walk-in patients who suspected they had symptoms were brought to an adjacent building, away from the main outpatient and casualty departments, to prevent infecting other patients. In many similar situations in the past, health workers, who face high risks, deserted their posts. But the staff of the Medical College Hospital, especially residents, nurses and cleaning staff, battling their fear (especially after we lost a nurse in the line of duty), provided standard care to all persons who were brought to the unit.

Health care workers are our most precious resource in times of an epidemic and must be protected and conserved. They operate in an atmosphere of fear and tension, wearing very uncomfortable protective gear. Burnout is usual in such situations. We reduced the normal working hours and kept additional personnel from other hospitals ready for deployment if needed so that the response was not short-handed and the entire health system was seen to be pulling together.

It is important for senior faculty and officers to be in constant interaction with front-line personnel to boost their morale. Some of the staff may try to avoid duty. These have to be firmly dealt with. Sourcing adequate Personal Protective Equipment (PPE) at short notice will be a challenge unless there is a procurement wing and it is given operational freedom.

A unified command structure is needed to win battles. When the infection involves multiple sectors such as wildlife, veterinary and human health and the response involves such areas as the police and transport, we are almost making the boat as we sail. A centralised command, with adequate financial and administrative powers, has to be established to manage the response. This has to be done as early as possible and all responses have to be coordinated from that centre only. In Kozhikode, this was set up under the leadership of the District Collector, with the Director of Health Services and the local Medical College providing the technical support. Given the political and media attention such episodes evoke, many agencies are likely to land up at the site, often trying to drive the response in contradictory directions. While inputs need to be taken, the final chain of command has to be clear. We had taken a stand that since health is a State subject, all agencies will operate only under the direction of the State government and under the control of the central unit that was established at ground zero. They were able to ensure that the same information and directions went to all participants.

At Olavanna in Kozhikode on May 27, when panchayat members stuck awareness posters on the virus.

The entire society needs to be mobilised. It would reinforce and in turn be reassured by the response of front-line workers. In Kozhikode, the Health Minister and the Labour Minister, who is also the local MLA, led the response from the front. In every affected panchayat, the presidents and members were in the forefront. Business houses donated services. When it heard that PPEs were in short supply, a Dubai-based hospital group flew in PPEs on a chartered plane. The modifications urgently required to equip the isolation ward were done overnight by an NGO (non-governmental organisation).

Support for the family of the deceased nurse flew in from the diaspora across the world. Such overt display of social capital kept the morale up when the extent of danger was unknown and the scenario was depressing.

Proper communication is an important requirement. In public health Kerala maintains transparency, which we followed in this case too. Every day the core group would review the data for the day and brief the press. The relationship between the Health Department and the press, sometimes antagonistic in normal times, turns collaborative in times of medical emergencies. This arrangement, built while combating HIV/AIDS, held during this epidemic too. The print and visual media were briefed by experts and they carried reports educating the public on the disease, prevention and mitigation strategies, what to do in different conditions, and a set of FAQs. They also lauded the warriors of the health sector when they were winning, thus keeping the morale of the team high.

Social media is a powerful player that did not exist in earlier occurrences of diseases. The Health Department operated Facebook and Twitter accounts and as a result its reach quadrupled during this period. However, some people on the Internet, looking for mischief and nursing their pet peeves, did a lot of damage, creating panic through false and forged news. The cyber cell of the Kerala Police registered six cases. Any management of such an epidemic in the future has to take into account rumours that could spread and create a strategy to counter them. Social media, mainstream media, pre-recorded audio and video messages, interactive platforms and modes of communication that may emerge and become popular by then have all to be factored in while developing the communication strategy, because mischief-makers will appear and try to create panic with false propaganda.

We had to be prepared for the worst. The course of an epidemic is unpredictable. One missed contact turning up infected will open up a new battlefront. More than one locus has been recorded in earlier epidemics. We have to identify additional facilities and resources (including back-up teams), and put them on standby. A new front is demoralising unless the team has been primed for it and is ready. The State may not have adequate resources and the Centre has to be kept alerted. While the possibility of further spread could lead to panic, it is better to alert the key influencers to the possibility so that it is not seen as a sign of incompetence of the team.

When the virus can move across territories, the response has to be global too . In a globalised world, diseases can cross boundaries quickly. India needs to have a mechanism for mounting a response, coordinating the best expertise sourced nationally or internationally. It is important to realise that an effective response to emerging viruses, for which India does not have the required expertise, needs international cooperation. When at a loss for remedies, Kerala reached out to all international contacts as was possible. One of them put us in touch with Prof. Christopher Broder, who had developed the cell line from which the monoclonal antibody was developed. He in turn liaised with the Queensland government, which had stockpiled this drug for compassionate use.

The Queensland government agreed to share the drug with the Government of India. The Indian Council for Medical Research (ICMR) and the Drug Controller General of India cut through red tape and obtained the experimental drug for use in Kerala. The Nipah Clinical Trials Group of the World Health Organisation (WHO) assembled a virtual group of experts to guide our clinicians on the use of the drug. Since the epidemic was controlled, the drug was finally not needed. But it is important to cut across national borders when responding to such a crisis. Going forward, the ICMR should assemble the best international expertise in epidemiological investigations and management protocols for Nipah.

The outbreak also underlines the need for continued research into emerging diseases. Considering that the first drug for HIV (which was discovered in 1981) hit the market in 1993, the progress on vaccine and drug development has been tardy for Nipah, a virus that was detected in 1998. Since the virulent version of the virus is confined to Asia, pharmaceutical companies have not invested in drug or vaccine development even though phase I trials were promising. It is gratifying that the interest generated by the Kerala episode has revived investment in this area. Prof. Broder’s company has been approved a $25-million grant by The Coalition for Epidemic Preparedness Innovations (CEPI) for vaccine development. The WHO Nipah Clinical Trials group has been reactivated. India has a substantial stake in developing a drug for Nipah infections and it should take the leadership in this area. The drive for further research should not slacken once the interest in the outbreak has worn off.

In any new epidemic the process and lessons learnt have to be documented for guidance in future. This is the third episode of Nipah infection in India. Since India had two episodes previously, the Ministry of Health should have developed its own guidelines and disseminated them to the States. In the absence of national guidelines, we used the ones issued by the Government of Bangladesh. We should develop the standard operating procedures for outbreak investigation, public health response and case management and make them available to all States. When such an incident occurs it is important to have proper documentation of the entire episode to understand the successes and failures and guide future responses. We are working on that now.

The probability of another Nipah outbreak at or near the site of past infections is high. Nipah has been added to the list of pathogens the State will watch out for, starting this year. We hope it will not recur. If it does, Kerala will be prepared to handle it again. But it could occur in any part of India. If it occurs in areas with high prevalence of other forms of encephalitis, the infection can easily be missed.

We have to be vigilant against its recurrence in any part of India. It is also important that India develop a national policy on Nipah surveillance, containment, case management and impact mitigation.

Rajeev Sadanandan is the Additional Chief Secretary in charge of Health in Kerala. Views expressed are personal.