On September 10, 2023, four patients were admitted to the Aster MIMS hospital Kozhikode. Two minor siblings aged 9 and 4, their 22-year-old uncle and their 9-month-old cousin had fever. The minors were admitted to the pediatric departments while the uncle became an in-patient in the pulmonology department as he had breathing trouble and developed seizures. A team of multidisciplinary doctors led by Dr. Anoop Kumar AS, a Critical Care specialist, tested the four patients for common viruses to find out if they were infected by influenza, coronavirus or other such respiratory diseases. Dr Anoop, who was instrumental in detecting the Nipah virus outbreak in Kerala in 2018, says the team of doctors saw two red flags which eventually led them to detecting the latest outbreak of Nipah virus in the state.
While collecting the family history, the doctors discovered that the father of the two siblings, 49-year-old Mohammed Ali, had died on August 30. The doctors at Aster MIMS immediately got in touch with the private hospital where Ali was admitted. By then, the four patients at Aster MIMS had tested negative for any common virus. “We found that the father had died and he had bronchopneumonia. Though he died of multi-organ dysfunction, he had slurring of speech and diplopia. Diplopia is dual vision,” Dr Anoop says. Ali’s elder son, meanwhile, had severe breathing difficulties and had epileptic seizures and was shifted to the ICU.
This immediately triggered suspicion that the family could have been infected by the Nipah virus. Nipah is a zoonotic virus that is spread from animals such as infected pigs or bats to humans. It can also be transmitted through contaminated fruits (half-eaten fruits by fruit bats), and even by direct contact with sick persons. Symptoms include fever, headache, fainting and nausea. Some experience choking, stomach pain, vomiting, fatigue and blurred vision. The patient can possibly go into a coma just two days after the symptoms begin. The chance of contracting encephalitis or inflammation of the brain is also high.
The second red flag was where the family lived- the Maruthonkara grama panchayat in Kozhikode. “This was close to the 2018 epicenter of the Nipah virus outbreak. Fruit bats in a forest area nearby had tested positive for Nipah during the survey then,” Dr Anoop says. One thing became clear to Dr Anoop and others- there was an index patient and a cluster had formed.
The doctor directly spoke to state Health Minister Veena George alerting the government of the possibility of a Nipah virus outbreak. As the hospital was collecting blood samples to be sent to the National Institute of Virology in Pune, another patient was brought to Aster MIMS on the evening of September 11. A 40-year-old man who hails from Ayanchery in the Vadakara taluk of Kozhikode was first admitted to a private hospital in Vadakara with symptoms of pneumonia. Within a few minutes of shifting him to the emergency ward in Aster MIMS, the patient died of a cardiac arrest. “He too had a fever for three days, the disease had progressed rapidly unlike other viruses,” Dr Anoop says. Though the doctors immediately suspected Nipah, initial queries with the family showed no links between index patient Mohammad Ali and the new patient. While Muhammed Ali was from Maruthonkara Grama Panchayat, the other deceased person was from Ayancheri, which was 20 kilometers away.
“We thought they were relatives, but both the families confirmed that wasn’t true. We then called the hospital in Vadakara and asked for the discharge summary. This patient had bronchopneumonia and low oxygen levels. Though the symptoms indicated Nipah virus, we had to find the connection between him and the index patient. Otherwise this could mean more than one index patient,” Dr Anoop recalls.
Conversations with the patient's family revealed that his father had been admitted to a private hospital in Kozhikode in the last week of August. This was the same hospital in which index patient Mohammed Ali had been taken to. “We then mapped the two admissions, and found that they were in the same ward at the same time. The second patient who had visited his father had interacted with the index patient. This is how he must have been infected with the virus,” Dr Anoop says.
Before the connection was established, as a precaution, Dr Anoop and others at the hospital told the second deceased patient’s family that the body could not be released as they suspected a serious virus infection. His blood samples too were sent to NIV in Pune.
On September 12, the Union Health Ministry confirmed four cases of Nipah virus, including the two deceased men. When asked if finding the index patient and tracing the contacts almost meant that doctors had to act like detectives, Dr Anoop says that his experience from 2018 has helped him. “We know that the symptoms for such patients can be different, and it becomes important to investigate family history thoroughly. This is the season when many people get influenza and pneumonia. It is not possible to test all of them for Nipah virus. It becomes important that we look at all clinical symptoms, even the blood work is important. For example, blood platelet count and total count is bound to be lower in such patients,” Dr Anoop says.
Eight panchayats in Kozhikode have been declared containment zones by the district administration. This includes nine wards of Ayancheri panchayat, nine wards of Maruthonkara Panchayat, three wards of Thiruvallur panchayat, eight wards of Kuttiadi panchayat, five wards of Kayakodi panchayat, three wards of Villyapalli, eight wards of Kavilumpara panchayat and one ward of Purameri panchayat.
Dr Anoop says this is not the time to panic. “We have dealt with such outbreaks and can do it again. People living in areas near the epicenter need to be cautious. Those with symptoms of fever need to be isolated and contact health authorities,” he says.
A lot of conversation in Kerala and outside is over why the outbreak of the disease has recurred in Kozhikode three times. Dr Anoop, however, brushes aside conspiracy theories.“Studies by NIV have shown the presence of the Nipah virus in fruit bats in almost every state in India. The Bangladesh strain of the Nipah virus spreads from person to person. Other places too must have had Nipah virus outbreaks and deaths, but since Nipah infected patients often die of encephalitis, these cases are not studied. Also, we need more awareness about how to be suspicious of certain clinical symptoms,” he points out.
Dr Ummer Karadan, Interventional Neurologist, at the Baby Memorial Hospital in Kozhikode points out that people are affected differently during a serious encephalitic disease. “For some it will affect only lungs, for some others it can affect heart, brain and lungs. So the symptoms can vary. Epilepsy can occur, blood pressure can increase along with fever and throat infections. We see many cases of encephalitis, epilepsy etc. There were cases where patients died without the disease even being diagnosed. Many think this is a normal disease, there were cases earlier we couldn't trace the reason. So Nipah may have occurred earlier too (before 2018).”