By Dr. George Jacob

Kochi: Kerala is also called ‘God’s own country.’ The state proudly flaunts this tagline, which was conferred on her because of, besides various other reasons, her enviable track record in the health front. Her health indices are comparable to, or even better than those of developed nations, including the Scandinavian nations-considered the healthiest in the world.

But, the state has had her share of fever epidemics denting her reputation as the healthiest Indian state.

The previous 3-5 years have had Kerala shivering to several of them. These epidemics have resulted in severe physical, financial and mental strain on the community and the government. Wailing from numerous households across the state, as the result of death and abject poverty these fevers banished them to, did not sit well on the state.

First half of 2018 saw Kerala reeling under various fevers. Around 150,000 people were affected by viral fevers in North Kerala, mainly caused by mosquito bite around the monsoons.

2017 was no better. As per official figures available with the Kerala Health Department, 1,468,281 individuals were afflicted with various communicable diseases until June 20, 2017. Fevers viz; Dengue, Malaria, Leptospirosis (rat fever), Hepatitis (A and B), diarrheal diseases including cholera, Chicken Pox, and H1N1 had claimed 114 lives in the state up to June 20 2017. Kerala’s population is 33387,677 as per the 2011 Census- which means one in every 23 residents was hit by a communicable disease.

Official data show 1,232,541 confirmed cases of fever up to June 20, 2017. The deadliest infection has been H1N1, with 806 confirmed cases and 53 deaths. There were 7,335 confirmed cases of Dengue with 13 deaths. The numbers for Leptospirosis were 660 and 9; and for Chicken Pox, 18,046 and 6 respectively.

Since the first half of 2018, there has been a lull on the ‘fever front.’

But recently, at the time of writing, Perambra, near Kozhikode (erstwhile Calicut) in North Kerala witnessed the death of 13 people, suspected to be caused by a contagious virus. This had hundreds of people with fever rushing to hospitals in panic, and forcing the Central government to send a team of experts to monitor and control the spread of infection. It almost looked certain to the panicky populace that the death dance Kerala had just witnessed had returned to haunt them again.

Meanwhile, the Pune-based National Institute of Virology confirmed four deaths from a same family as those caused by the Nipah Virus. A surviving member of the family was critical warranting ventilatory therapy in the ICU. The deadly virus also caused the death of a nurse who nursed one of the victims who succumbed to the deadly virus. This sent the health care personnel in Kerala to a state of extreme panic, expectedly.

This new villain which had Kerala shiver, both out of fear and uncertainty about the disease and to its manifestations, was an absolute stranger to the medical fraternity in this part of the world. The social media worked overtime to disseminate information about the new fever to have Malayalees shiver.

What is Nipah Virus?

Nipah Virus (NiV) infection is a newly emerging Zoonosis (an animal disease that can be transmitted to humans) that causes severe disease manifestations in animals and humans. The natural host of the virus is fruit bats belonging to the Pteropodidae family, Pteropus genus. NiV was first identified during an outbreak of the disease in Kampung Sungai Nipah, Malaysia in 1998 (hence its name).on that occasion, pigs were the intermediate hosts. About 100 perished then.

India witnessed two outbreaks among humans in 2001 and 2007 in West Bengal. Bangladesh was hit by an epidemic of NiV infection in 2004. On this occasion, humans were infected with NiV after consumption of date palm sap that had been contaminated by infected fruit bats. Human-to-human transmission has now been reported through the cases reported in Calicut, and during an outbreak in Siliguri, where 33 health workers and hospital visitors took ill after exposure to patients hospitalized with NiV infection.

These therefore exemplifies the modes of transmission of the deadly virus:

• Human-to-human, as in Siliguri and Calicut. Here people coming into contact with persons already harboring the virus or, with body fluids of those infected contract the infection. People who attended the funeral of those who perished in Calicut too were infected. They must have come in close contact with the bodies.
• Fruit bat-to-humans, by coming in contact with infected bats, or by consuming fruits and toddy being collected in pots atop palms, which might have been consumed by infected bats, or infected with excreta or body fluids from infected bats.
• From an intermediate host like pig. Pigs eat fruits partially consumed by infected bats. Humans later consume meat of infected pigs or come in close contact with them in pigsties, as in Nipah in Malaysia.
• Horses are believed to be another intermediate hosts, as observed in NiV outbreaks in Australia.
The virus has an incubation period (time interval between the instance a person actually is infected by the virus and appearance of symptoms) of 6-14 days. For people with good immunity, this could extend up to 21 days. As per established protocol, a person should be monitored for double the incubation period before declaring him/her ‘virus-free’, which implies that will have to wait for 42 days, before being declared cleared.

What are the manifestations of NiV infection?

• NiV infection can manifest with mild symptoms like fever, severe headache, body ache, weakness and cold as an ordinary flu, or,
• Develop altered mental status and seizures, indicating inflammation of the brain(encephalitis)
• Some develop severe breathlessness, cough and drop in oxygen levels in the blood, suggesting Acute Respiratory Distress Syndrome (ARDS) requiring ventilator therapy in an ICU.
• The latter two are the ones that kill. The case-fatality rate is 40-75%, and may even be 100%.

How is it diagnosed?

Diagnosis is made by establishing presence of the virus in the blood and body fluids through tests available in National institute of Virology in Pune.

How is it treated?

The treatment of NiV infection is supportive in an ICU. Cases of ARDS will require ventilatory therapy. There is no single medication available to cure the illness. Recently, an antiviral drug called Ribavarine is reported to be of use in treating NiV infection. There is no vaccine available against the deadly infection, which stresses the point that the only sensible option is to religiously observe stringent methods to prevent getting infected by the virus.

What are they?

• Prevent contact with bat excreta and consumption of fruits half eaten or bitten by fruit bats
• Always keep a minimum distance of 1 meter (one arm’s length) when visiting or coming in contact with patients or people suspected to be infected.
• Use personal masks and gloves when visiting patients in hospitals( as far as possible, try to avoid direct physical contact with them)
• Use soap and water to wash before and after meals, or after visiting patients.
• Use gloves and personal protection while handling excreta of domestic animals
• Avoid consuming toddy collected in open containers atop palms in areas with large bat population.
• Avoid close contact with domestic animals
• Avoid sharing utensils, clothes and bed linen used by persons suspected to be, or confirmed to be infected with NiV.
• Avoid close contact with mortal remains of those who died of NiV infection.
• Avoid touching the body with bare hands during funeral ceremonies.

Health care givers and institutions are advised to:

• Use personal protective equipment (PPE) and masks while interacting with patients.
• Sterilize non-disposable equipment.
• Use of PPEs by nurses and other caregivers while taking care of patients
• Carefully handle equipment while drawing body fluids for tests
• Enforce strict isolation, and to keep confirmed patients away from other patients, especially immune-compromised ones.
• Avoid careless disposal of surgical instruments after use
• Avoid crowding of ICUs and other treatment facilities within hospitals.
• Encourage use of disposable items in hospitals for suspected and confirmed cases of NiV.
• Avoid careless discarding of used gloves and gowns.
• Observe proper care while handling patients who succumbed to NiV. Extreme care must be observed while handling body fluids before the funeral.

Why is Kerala prone to develop fever epidemics, as the last two witnessed in 2017 and 2018?

• The numero uno culprit is improper, unscientific and often nonexistent, and careless waste disposal and management. People strew about waste most thoughtlessly and criminally along thoroughfares and vacant plots of land. NH47 in Kerala on Mondays stink of rotting meat and waste generated by culling birds and animals in markets during the busy weekend business. Certain stretches of the highway, especially around Trichur is rendered unfit for commutation, due to extreme stench of rotting animal waste.
• Stiff fines and other punishments must be enforced by the authorities on those throwing about waste. Even non-bailable arrest will not be out of place, as the situation is grave, and one which has assumed emergency proportions. People dare to and defy authorities by throwing waste even in public places under electronic surveillance.
• The second cause is the rampant, and increasing use of the non- degradable material-plastic. It is a usual criminal habit for citizens to throw away waste collected in plastic bags onto public roads and vacant plots. Waste thus thrown away includes food which feeds rodents, which spread leptospirosis (rat fever). Stray dogs and cats also live out of food in thrown away waste. These animals spread the dreaded rabies which has no treatment. Deadly Attack on humans including children playing in their own backyards by stray dogs is being witnessed in Kerala like never before. The dog is no more ‘man’s best friend’ in ‘God’s own country’! Plastic clogs drains and canals, forming ample breeding ground for mosquitoes.
• Disposable plastic plates, glasses and bottles are increasingly being used in Kerala for home parties and wedding receptions. These materials are dumped without second thoughts into public places. Water collects in plastic and also thermocol, used as packing material, which form microenvironment for various species of mosquitoes, which spread diseases like dengue, chikungunya, and malaria, which seems to have returned to Kerala.
• Lack of efficient waste collection and treatment procedures, especially in large cities which churn out waste by the ton. Though local governing bodies have succeeded in a large way to effectively collect waste from houses, their treatment still remains a challenge. The Brahmapuram Waste treatment facility near Kochi in Kerala only serves to spread nauseating stench even to places far away from the plant, than to actually bring it under control. Flies which breed in such facilities cause diarrheal diseases like Cholera. It’s indeed a crying shame that people in Kerala died of diarrhea, an eminently preventable disease at the height of fever epidemic of 2017.
• It is always easy to blame authorities. Citizens too have a responsibility to ensure scientific disposal of waste they generate in their homes. The government must encourage means and ways to encourage people dispose and decompose waste generated at homes in the space available within the compound. Use of Clean and less messy waste decomposing units within their own compound must be encouraged by the government through Incentives and subsidies.
• People must also ensure water does not collect around their homes, especially after the monsoon, which is traditionally copious in Kerala. It must be ensured that water does not collect inside Used tires and plastic plates placed beneath flower pots, and inside water-logged flowerpots. These ‘micro-water ‘bodies’ provide ample breeding ground for disease-spreading mosquitoes.
• The other cause contributing to fevers that spread like wildfire is inadequate health care facilities, especially in the public sector. There are only very few who can afford prohibitively expensive healthcare facilities in the private sector ‘for just a fever’! Overcrowding of public healthcare facilities, inadequate staff therein, and reluctance on the part of treating personnel to observe universal precautions at the height of epidemics, unavailability of disposable protective gear stand against containing them.
• Though people in Kerala are particular about personal hygiene, oversight of basic procedures like washing hands before eating at the height of fever epidemics too contribute to diseases, especially hepatitis and cholera, and other diarrheal diseases.
• Leaking pipes are not uncommon sight in the state. Leaking pipe ensures contamination of water meant for human consumption. Expeditious repair of leaking pipes, which can sometimes be seen to run through brackish drains must be ensured to contain diarrheal diseases and other gastrointestinal infections.
• Overcrowding of living spaces, though not as common or severe as in other Indian states is increasingly being encountered in Kerala, thanks to the increasing migrant workforce, who dwell in overpopulated slummy living conditions adding to epidemics like H1N1.