Prevention and Control Strategies for Nipah Virus Infection in India

This article discusses the prevention and control strategies used to manage Nipah virus infection in India. It covers basic prevention strategies, public awareness programs, government surveillance systems, environmental investigations, clinical supportive treatment, drug therapy, and the one health approach. The article also provides evidence-based recommendations to reduce the impact of Nipah virus on public health.

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HEALTH PROTECTION
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Introduction
Nipah viral infection is caused by the attack of Nipah virus (NiV) that is a type
of RNA virus identified in 1999 at an outbreak of the disease in Malaysia. The virus
was named after Sungai Nipah village in Malaysia. Even after 10 years of Nipah viral
identification still, there is no proper vaccination and treatment available for disease
as of 2018 (Chatterjee, 2018). The latest outbreak of viral infection was in
(Malappuram and Kozhikode) Kerala, India on 17th May 2018 where 17 people died.
Globally, 700 human cases were recorded with 60 to 70% of infected people were
reported dead due to Nipah viral infection in 2018. Hence, with such dangerous
mortality rate and no proper disease management, the Nipah virus infection is one of
the mysterious and complicated diseases of recent times (Baumgaertner, 2019).
The previous study conducted on the brutality of the Nipah Virus in the
geographical region of India indicates that Nipah disease is a deadly disease that
mostly impacts underdeveloped or developing countries like India, Bangladesh, and
Malaysia. The disease complications are severe mainly affecting the nervous and
respiratory system of the human body. The primary concern or risk is the mode of
disease transmission that is human-to-human, animal-to-animal and animal-to-human
contact through biological secretions. Further, no proper vaccination or treatment
available makes Nipah viral infection a deadly one. The health impact of Nipah Virus
in India and Bangladesh is the most severe one that makes these geographical regions
as one of the most important locations to study the impact of this disease. This study
focuses on the evaluation of applied prevention and control strategies followed by
suitable recommendations to manage Nipah disease in India.
Evaluating the prevention and control strategies used to manage the Nipah virus
in India
Basic prevention strategies
These were some of the basic prevention strategies suggested by experts to prevent
the outbreak or infection of Nipah virus in India. These strategies can help to control
and manage the disease at ground level for the safety of people.
 Avoiding physical contact with infected people, their secretions like saliva,
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blood, excretions etc.
 Wearing safety equipment’s like NH95 mask, covering the whole body
properly and covering household properly.
 Washing hands regularly and avoid eating partly eaten foods, fruits, and
unpasteurised liquid to avoid viral consumption.
 Boiling date palm juice before consumption
 Washing and disinfecting fruits before consumption
 The health care workers handling infected patient need to follow clinical
precautionary standards to ensure their personal safety
 Maintaining personal hygiene (Shapshak et al. 2015).
General public awareness programs
The Government of India and Bangladesh implement general awareness
programs that work to successful make people aware of every bit of details related to
Nipah virus and its pathogenicity (Clayton, 2017). The National Centre for Disease
Control in India sends a multi-disciplinary team to make public and officials aware
about Nipah Viral pathogenicity and get a control over the situation in India. The
information for the general public involves awareness about Nipah infection,
symptoms, high-risk areas, prevention measures and control. Further, the team
provides official and experts with reference materials and guidelines to manage an
infectious situation that involves case definitions, sample collection guidelines,
infection prevention guidelines, hospital infection prevention guidelines, clinical
management guidelines and safe disposal guidelines for handling infected dead bodies
(Chattu et al. 2018).
According to Sadanadan et al. (2018) studies, in 2018 Nipah Viral outbreak in
Kerala, National Centre for Disease Control make sure to deliver risk communication
message for public, community, stakeholders and partners as a new method of
awareness to control infection. Verma et al. (2018) conducted a survey to measure the
awareness about Nipah infection in the Malappuram district area. A questionnaire
survey with 200 MBBS students at the Medical college of Malappuram district was
done to understand the knowledge and attitude future doctor’s hold about this newly
introduced viral infection. As per survey findings, students hold good knowledge
about the disease and its serious impact through social media (40.5%), newspapers
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(34%), Internet (17.5%) and general awareness programs (8%).
Government Surveillance systems
The major goal of the surveillance system is to identify disease prevalence,
risk and transmission of disease in the vulnerable population (Human and animal).
These surveillance programs help to detect the victim in the most initial stage to get
control over infection with best possible measures (Shapshak et al. 2015). According
to Kumar and Kumar (2018) studies, in the 2018 Kerala Nipah outbreak, surveillance
team reported more than 2600 contacts cases. The syndromic surveillance was further
enhanced By National Centre for Disease Control in communities and hospitals to
confirm and control cases.
The strategies of surveillance system involve: -
 Hospital-based active and passive surveillance to detect “Nipah Belt” areas by
identification of Nipah cases in hospitals.
 The surveillance team suspects, identifies, confirm and report the Nipah cases
in a particular area. The government further takes initiates to manage the
condition as per reported cases by the surveillance team.
 The surveillance team performs outbreak investigations to detect the outbreak
situations increasing viral infection in a particular area. The multidimensional
factors that can lead to this outbreak are socio-cultural practices, animal
reservoirs, human-to-human transmission and food habits in out zone areas
like school, hospital etc. This is further reported to higher authorities
managing the disease.
 Lastly, surveillance in enhanced during most vulnerable disease seasons by the
formation of National and District based response teams to control infection in
the best possible manner (World Health Organization, 2019).
Environmental Investigations
The environmental investigations including zoonotic are conducted in India at
every Nipah outbreak season to control the spread of disease. This environmental
investigation involves testing primary environmental reservoirs like the zoo, animal
hubs etc. by taking the sample and investigating the area for any kind of
contamination (Lloyd-Smith et al. 2015). Verma et al. (2018) opine about the
environmental investigation conducted in India where date palm sap contaminated by
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bat urine was investigated for NiV infection. The sample was found for having
positive NiV contamination. This contamination can spread from the bat reservoir to
other peri-domestic and domestic animal. Therefore, team further investigated other
animals like cattle, dogs, cats, goat and pigs in the outbreak site. Therefore, this initial
environmental investigation helped to manage the spread of infection.
Clinical supportive treatment
There is no proper treatment or vaccination still available to cure Nipah infection yet
possible clinical and supportive treatment processes were involved in India to control
infection. This involves: -
 All the clinical suspected patients should be provided isolation, protection,
ABC (airway, breathing and circulation along with possible treatment.
 The professionals involved in treatment were provided with personal safety
equipment like masks, gowns, covers, personal hygiene instructions etc.
 The supportive treatment involved patient in drinking plenty of water,
maintaining electrolyte balance, nasogastric tube feeding, and nutrition
balance.
 Further, antibiotics were used to control fever that involved paracetamol,
aspirin etc.
 Patient with a serious complication like dyspnea, tachypnea, oxygen saturation
and respiratory distress were provided with best possible treatments like
oxygen therapy, endotracheal or oropharyngeal suction.
 The patient with severe respiratory failure and pneumonia were supported with
mechanical ventilation (Broder et al. 2013).
Drug therapy
There is no proper effective drug that directly treats Nipah infection till date
that makes treatment restricted to its prevention, control and supportive care
strategies. Yet, few drugs like ribavirin, anti-malaria drug etc. show possible passive
immunization to control viral infection symptoms (Angeletti et al. 2016). The
monoclonal antibodies target G glycoprotein of Nipah and anti-malaria drug
performed the function to stop the maturation of Nipah virus. However, their clinical
benefit is yet under observation. In 2013, this monoclonal antibody was used in
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Australia (Sivadas, 2019).
The Kerala Government approached the Australian Queensland Department to
secure and provide limited monoclonal antibody (m 102.4) to provide India in case of
emergency to control prophylaxis. Further, ribavirin was imported from Malaysia,
which is a suitable therapy for Nipah as per in vivo and in vitro investigations by Drug
Controller General of India (DCG (I)). Ribavirin was beneficial in Malaysia to control
36% of the mortality rate due to Nipah infection. However, it is not a proven therapy
for infection but still suitable to control Nipah fever as per WHO guidelines (Kumar
and Kumar, 2018). According to Verma et al. (2018) studies, some of the new
experimental drugs to control Nipah infection are under investigation in India.
Favipravir show effective results to control Nipah infection in animals.
One health approach
The government of India implemented One Health approach to manage Nipah
infection management as this strategy was observed to be successful in Bangladesh as
well. The one health approach involves collaborative work between government,
experts, scientist, media, communities and public to ensure precautions before the
disease outbreak. As Nipah viral infection is a zoonotic disease, primarily transmitted
by animals, therefore, the involvement of agricultural, livestock, local administration
and environment ministries in the primary step for one health approach. They are
involved in decision-making processes to implement public health interventions at
ground level. Further, experts, coordinator and scientist perform field investigations to
detect, check and report infections. Lastly, the media, journalist, community leaders,
social activist and other non-government organisations perform an active role in
public awareness to ensure the spread of information. In this manner, one-health
approach work effectively to prevent, control and manage Nipah infection (Yadav et
al. 2018).
Proposing evidence-based recommendations to reduce Nipah virus impact on
public health
Increasing ICU support services
The WHO recommendations favour the maximization of the Intensive Care
Unit and support services in hospitals to treat the severe neurological and respiratory
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complications caused by Nipah infection. The ICU support ensures good control over
severe infection symptoms and complications (Russo and Ancillotto, 2015).
According to Kumar and Kumar (2018) studies, In Bangladesh, the mortality rate
escalated up to 80% in settings without proper ICU support services which were
further minimized to 40% mortality rate after implementing ICU support in a timely
manner.
Satterfield, Dawes and Milligan (2016) studied that the ICU support services
in India is prominent in private healthcare hospitals but the public hospitals still lack
an effective number of ICU. The Government should take appropriate measures to
increase the number of ICU in public hospitals in time where Nipah infection is low
so that people get better care services in Nipah season outbreak.
Proper research and development
WHO suggest proper R&D, production, deployment and assessment as well as
preventative measures for India to develop in the country itself. As per suggestions,
the country needs to perform additional research in refining and standardizing animal
models, maintaining strain and dose of lethal virus and improve data management
related to disease (Cdc.gov, 2019). In the study, it is been notified that India imported
monoclonal antibodies from Australia in the 2018 Kerala outbreak to control Nipah
infection complications. This indicates the lacking resources within the country to
produce and supply sufficient drug therapy required to manage the disease. The
Indian Council for Medical Research (ICMR) requested Queensland with monoclonal
antibodies that were found workable to neutralise Nipah complications. However, this
medicine is a not a proper cure for viral infection but still, Government of India
should take initiatives to ensure the production and supply of this drug in the country
itself (Kumar and Kumar, 2018).
Filling the knowledge Gap
The Centres for Disease Control and Prevention (CDC) and Global Health
Security Agenda indicates the existence of the knowledge gap in India’s healthcare
system. The professionals lack proper knowledge about the viral infections especially
Nipah virus indicating the symptoms as “mystery fever”. As India is a developing
country with the most diversified environmental condition it is considered to be the
most vulnerable outburst of new viral infections and mystery fevers every year.
Filling this knowledge gap in their country, professional can surely uncover the
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mysteries behind these unknown symptoms to manage disease complications in a
more effective manner (Cdc.gov, 2019). For example- CDC introduced to AFI project
at Manipal Centre for Virus Research in 2014 to ensure proper knowledge and
guidance for professional related to complicated diseases. The project was successful
to let them provide knowledge about new threats, understand disease patterns and
disease treatments. Therefore, any such informative program related to Nipah virus
and many other mystery diseases would ensure proper control over the knowledge gap
in India (Lo Presti et al. 2016).
Conclusion
The prevention and control strategies employed in India to manage Nipah
infection involve basic prevention measures, public awareness programs, Government
surveillance system, environmental investigations, one health approach, clinical
supportive treatment and drug therapy to manage complications. All these strategies
are effective enough to manage the infection control for this deadly disease. Yet there
are certain loopholes in the country’s management system that requires suitable
recommendations. Firstly, increasing ICU support service shall improve the clinical
support system. Secondly, the country needs to improve its research and development
platform. Lastly, there is a huge knowledge gap in countries professional knowledge
and skill related to management of critical disease like Nipah infection that requires
an amendment of proper guidance to manage this deadly disease. As Nipah virus still
lacks proper vaccination or treatment, therefore proper prevention and control is a
must to avoid increased mortality rate due to this deadly infection in India.
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