Battling Nipah: A month later, Kerala seems to be over the hump but officials can’t lower their guard

A month after the death of the first suspected victim, Kerala seems to be over the hump, having kept off a second wave of infection. But the 2,500 people in quarantine, doctors manning isolation wards, and officials can’t afford to lower their guard. The Indian Express reports from a state on high alert.

Written by Shaju Philip | Updated: June 26, 2018 11:48:47 am
Altogether, Nipah, that normally has a fatality rate of 70 per cent as per the WHO, has killed 16 (excluding Sabith) of 18 confirmed cases in Kerala. That works out to a mortality rate of 88.88 per cent. The two patients still undergoing treatment are out of danger.

On the evening of May 31, nurse Sindhu Baburaj says, she felt death creeping up. Sindhu had already been six days into isolation at her home after one of the patients she had nursed at government taluk hospital at Balussery, in Kozhikode district, died after testing positive for Nipah. A health worker for 18 years, Sindhu was one of the medical staff exposed to the patients infected with the deadly virus.

The hamlet of Lini Puthussery, the nurse who died after tending to one suspected Nipah patient, is merely 32 km away. Lini died on May 21.

When on May 31 came the news that B Rasin, 25, a native of Kottoor near Balussery had become the 17th victim of Nipah in Kerala, Sindhu thought it was the end. “The fear that death is inevitable in Nipah kept playing in my mind. The death of Lini had shattered us.”

On June 1, no shops opened in Balussery, theatres suspended shows, and buses kept off the roads. People remained indoors amid reports that Nipah may have come to Balussery from nearby town Perambra, to which the first death was traced.

It’s been more than a month now since that death, of Muhammed Sabith, suspected to be Patient No. 1. Since his samples were never sent for testing, it hasn’t been officially confirmed as a Nipah death, though with three of his family members later dying of the virus, Sabith is likely to have been the ‘index case’.

nipah outbreak in kerala Hospital staff at the isolation ward of Kozhikode Medical College Hospital. (Photo: PTI)

Read | Siliguri fever: When a town fled in fear

Altogether, Nipah, that normally has a fatality rate of 70 per cent as per the WHO, has killed 16 (excluding Sabith) of 18 confirmed cases in Kerala. That works out to a mortality rate of 88.88 per cent. The two patients still undergoing treatment are out of danger.

But Kerala may be over the hump. As on June 9, all the other 291 samples tested for Nipah had turned out negative. The number of suspected cases, hovering around two dozen last week, was down to 10 by Saturday.

What is left behind is the spectre of Nipah, from the empty wards at the Government Medical College Hospital in Kozhikode that is at the heart of the fight against the virus; the masks hiding faces on the streets of Kozhikode as well as Balussery and Perambra towns; among people scared of developing any kind of fever; in the fall in fruit exports from the state and in the tourist cancellations; in the closed educational institutions (shut till June 12, for now); among doctors unable to pinpoint the origin of the outbreak still; and among the 2,550 people in quarantine in their homes, waiting for the incubation period to get over.

Talking of life in isolation, nurse Baburaj says, “I can’t explain the trauma. I stayed in one room, keeping away from everyone. My daughters, aged 16 and 14, were told to keep away. I spent my time praying and calling up colleagues.”

Lini’s village Chembanoda struggled with its own fears. While no other case was reported, on June 5 when a ragpicker named Shekhar collapsed at the village junction, no one dared go near him for three hours.

“People looked on as he lay frothing from the mouth. Finally, an ambulance took him away,” says Semili Sunil, a member of the village panchayat.
The ragpicker was later found to have hypoglycemia (low blood glucose).

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Beeran Kutty, 52, of Changarothu village was put under watch on May 18, a day after three family members of fellow villager Sabith died of a mystery disease, that was till then undiagnosed. After his heartbeat was found to very high, Kutty was kept in isolation at the Kozhikode Medical College, where he spent three restless days there before testing negative for Nipah.

It has been nine days since R Rahul, 27, was asked to remain at home. A native of Kottoor village in Kozhikode district, Rahul is the first cousin of Rasin and was with him from 8 am till 11 am on May 31, the day the latter died of Nipah. He is among the five “close contacts” of Rasin under observation, Rahul says.

Read | Nipah virus outbreak in Kerala: All your questions answered

nipah outbreak in kerala What is left behind is the spectre of Nipah, from the empty wards at the Government Medical College Hospital in Kozhikode that is at the heart of the fight against the virus; the masks hiding faces on the streets of Kozhikode as well as Balussery and Perambra towns; among people scared of developing any kind of fever. (Photo: PTI)

While his observation period will end only on June 21, he had to step out of home on June 7. “I had to go to the Kozhikode Medical College and bring back Rasin’s parents Bhaskaran Nair and Indira, who were under observation at the isolation ward there since their son’s death. Others in the village would not have been willing to go. So I went,” says Rahul, a construction worker, adding that Rasin’s parents could not even conduct his final rites, which were performed by the corporation staff.

Recalling the days following Rasin’s death, Rahul says half a dozen neighbours left their homes in fear. “I don’t blame them.”

At dinner time these days, he is the first to eat. The rest have their meal after he has gone back to his room. And while his friends have started visiting him now, Rahul adds, he doesn’t allow them inside. “Wearing a mask, I stand on the verandah of the house. They too wear a mask.”

It’s difficult to pass the hours, the 27-year-old adds. As the family is in mourning, TV is not allowed. “While there is no strict direction to remain indoors, as people are scared, we have been advised not to venture out.”

With his work suffering, Rahul wonders how he would have been able to manage without the help of friends, village panchayat and political parties, who have been sending provisions.

Read | From the ground: How Kerala’s well-oiled health machinery helped cap Nipah spread

nipah outbreak in kerala While fruit bats are believed to spread the virus, after coming in close contact with a human, the two sets of bat samples collected from the premises of Sabith’s house and Changarothu have tested negative for Nipah. (Photo: PTI)

V Akhilesh, 30, of Punath in Kozhikode, is also under observation for contact with Rasin. He had visited Rasin, his neighbour and close relative, in hospital.

“I haven’t ventured out of the house since I was told by the Health Department that I was being monitored,” he says. Employee of a private firm, he worries he may be put in hospital over even a minor health problem.

With TV shut at his house too, Akhilesh whiles away time surfing the Internet. “My family members, parents and wife, are not so worried. But, for the sake of the neighbours, I am staying at home.” There are 56 persons under observation in Akhilesh’s panchayat, which has been providing all the necessary provisions, he says. “Relief committees of local masjids are also supplying cooked food.”

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Once the doctors decided it was Nipah, a list of people to be put under surveillance was drawn up by establishing a chain of contact or exposure with those who had tested positive. The number was narrowed down to 2,400 in Kozhikode and 150 in Malappuram district.

Officials say Health Department employees visited bereaved families to get the names, including of relatives who may have handled bodies of those who died of Nipah. Following Lini’s death, hospitals collected details of persons who had come to their inpatient and outpatient wings during the days of an infected person’s stay there. Chennai-based National Institute of Epidemiology helped trace the people.

Read | What is Nipah virus?

Kozhikode District Collector U V Jose says the quarantine period is 21 days. “This will be over for most of the contact persons in a couple of days. We wanted to monitor the contact persons at home so that they could be rushed to hospital in case they developed symptoms of Nipah. There was no strict instruction to stay at home.”

Director of State Health Services Dr R L Saritha says, “We found that most of those infected with Nipah had contracted the disease from either the Perambra taluk hospital or the Kozhikode Medical College Hospital, where the first victim (Sabith) had been admitted.”

A Nipah cell has been established, and it calls up those who are being monitored twice a day. People are asked if they are suffering from any uneasiness, fever, or discomfort. Besides, a junior health inspector or a junior public health nurse has been assigned to directly visit the “close contacts”. A 24×7 helpline in Kozhikode offers advice. The services of a mental health team have been hired to attend to general fears of the public.

Kozhikode Medical College Resident Medical Officer Dr R Sreejith says five ambulances have been positioned in affected areas to take patients directly to a special ward opened for suspected cases.

On June 4, after an all-party meeting to discuss the virus outbreak, the state government announced that it would reimburse the medical bills of all those undergoing treatment for Nipah. The families of the persons under surveillance have since been given free ration kits containing 10 kg rice, 1 kg sugar, salt, green gram, toor dal, tea and spices.

Dr Saritha says that in the initial days, the Nipah helpline was inundated with queries, even from the Gulf. “On June 4, the centre got 700 calls, which was down to 65 on June 8. This shows things have improved.”

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 Dr G Arunkumar, Director of the Department of Virus Research, Manipal, says Kerala did well with the early detection of Nipah, ensuring that the dreaded second wave of infection was staved off.

The virology lab in Manipal, funded by the Indian Council of Medical Research, has been researching Nipah since 2009. “A major challenge is identifying the Nipah virus,” Dr Arunkumar says, adding that the previous outbreaks, in Malaysia and later Bangladesh and West Bengal, helped them “get some data”. “Since August last year, the lab has been ready to do the Nipah virus test, in collaboration with the Centers for Disease Control and Prevention, Atlanta, US.”

It was to the Manipal lab that Kerala turned when it first encountered Nipah.

Read | Nipah virus lethal, but local: Why you needn’t panic

nipah outbreak in kerala The other effect of the scare can be seen in the fruit business, with the Nipah virus’s natural host being identified as the fruit bat. The sale of all fruits has dropped drastically in Kerala despite it being the month of Ramzan, a period of high demand.  (Photo: PTI)

On the morning of May 17, Muhammed Salih, 26, was brought to Baby Memorial Hospital in Kozhikode with symptoms resembling encephalitis. Dr Anoop Kumar, the head of the Critical Medicine Department at the hospital, says Salih’s situation deteriorated quickly. “His blood pressure and heartbeat were irregular and he was sweating. These symptoms were not of encephalitis.”

Then the doctors learnt that three weeks ago, on May 5, Salih’s brother Sabith, 23, had died of similar symptoms (cause of death was noted as ‘viral encephalitis’), and that the brothers’ father and an aunt were indisposed now. The father, Valachukettil Moosa, 62, and aunt Mariyam were brought to Baby Memorial Hospital, and the doctors alerted the Manipal lab.

Dr Arunkumar says Salih’s throat swab, urine and cerebral spinal fluid samples were rushed to Manipal by hand to cut delay. When he looked at the samples, he was surprised. “It was not encephalitis,” he says.

Sabith, it was later learnt, had died within five hours of being brought to Kozhikode Medical College. He had been referred there by government taluk hospital at Perambra, 5 km from his Changaroth village. The nurse Lini had tended to him at the taluk hospital.

On May 18, Salih too died. Mariyam died on May 19, and Moosa passed away five days later.

 

By May 19, Dr Arunkumar says, his lab knew the family had Nipah. This was officially declared after confirmation by the National Virology Institute and after the WHO’s consent.

More than a fortnight after Salih’s death, the outpatient and inpatient wings of the Kozhikode Medical College, which caters to five districts, wear a deserted look. Same is the situation at taluk hospitals in Balussery and Perambra. At the Institute of Maternal and Child Health attached to the medical hospital, for example, the outpatient department numbers are down from 2,500 daily to less than 1,000.

“Scheduled surgeries have been postponed as patients are not coming. However, we haven’t sent back any patient,” says Resident Medical Officer Sreejith.

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  The other effect of the scare can be seen in the fruit business, with the Nipah virus’s natural host being identified as the fruit bat. The sale of all fruits has dropped drastically in Kerala despite it being the month of Ramzan, a period of high demand.

P V Hamza of the All Kerala Fruits Merchants Association says, “Fruit sales have dropped 40 per cent across Kerala. In Kozhikode, the dip in sales is 75 per cent.”

Kerala Pineapple Growers’ Association president Baby John says both exports and domestic sales are hit. “Daily sales in the state have come down from 150 tonnes to 30 tonnes. In the last two weeks, we have suffered a loss of Rs 30 to Rs 35 crore.”

The government travel advisory to avoid Kozhikode and nearby hill station Wayanad has also hit tourism.

Read | Nipah virus infection: First-ever case, symptoms, treatment

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As the state government feels the worst is behind it, one house in Changarothu village that lost four members hopes it will have some answers before all is forgotten.

Health experts are yet to conclusively establish how Sabith, the suspected ‘index case’, contacted the virus. While fruit bats are believed to spread the virus, after coming in close contact with a human, the two sets of bat samples collected from the premises of Sabith’s house and Changarothu have tested negative for Nipah.

Villagers had earlier reported that Sabith and brother Salih had gone into a well to clean it and encountered bats there. But samples from the well were among those that tested negative.

There is another theory. Dr Arunkumar says his family had told him Sabith loved animals. “He might have picked up a baby bat carrying the virus.”

National Centre for Disease Control Deputy Director Dr Jay Kiran, whose team is analysing the infection, says they are also looking at a human-to-human infection. “No possibility can be ruled out,” he says.

And so, says Director of State Health Services Dr Saritha, on their radar are all the recent fever deaths in the state. Between January and May 31, Kozhikode district reported 1,07,386 fever cases and one death. The total fever deaths in Kerala during this period was 23.

While other families that fled Changarothu village after the Nipah deaths have returned, Mariyam, who lost sons Sabith and Salih and husband Moosa, continues to live with relatives in another village. “People blame us as if we spread the disease. There were fake reports that my son had gone to Malaysia and brought the virus from there,” she says over the phone.

Bewildered, she adds, “But I haven’t contacted the virus despite living with my sons who died.”

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