On June 06, 2019, Directorate of Health Services, Kerala released the first of its kind interim guidelines on management of Nipah Virus (NiV) infection1. The guideline describes the disease epidemiology, clinical features, diagnosis, prevention and treatment of the disease. Moreover, it also explains the standard precautions to be followed by health care personnel during patient handling, diagnosis and treatment of disease. However, this is an interim guideline adapted from NCDC interim guidelines, and WHO Bulletins. The situation is still evolving, and the content of this guideline is subject to modifications at regular intervals.
NiV is a highly pathogenic paramyxovirus zoonotic disease where animals like large fruit bats/flying foxes are considered to be the natural reservoirs of NiV. The disease is transmitted by direct contact with infected bats, pigs or their partially consumed fruits, and human to human contact. Fever, inflammation of the brain (encephalitis), altered mental status, severe weakness, headache, respiratory distress, cough, vomiting, muscle pain, convulsion, and diarrhea are the common symptoms of NiV infection.
Challenges to the Indian health care facility
At present, there is no known treatment or vaccine available for humans or animals. Therefore, the disease management is limited to only symptomatic treatment and intensive supportive care of the patients. Some observational reports suggest that Ribavirin may be useful to reduce mortality among patients with encephalitis caused by NiV. Treatment unavailability is the biggest health care challenge and for the time being the focus is limited to preventive measures where bio-safety precautions seem the key to control the spread of the disease.
Strict Precautionary Measures
Standard droplet and bio-safety precautions should be followed by health care personnel during sample collection/transport/ storage/ processing of suspected cases. In addition, all suspect cases of NiV should be segregated from all other patients in an isolation ward/ facility for infection control. This again is a major challenge for Indian hospitals/health care units as most of these facilities are already overpopulated with patient visits where implementation of bio-safety precautions and usability of Personal Protective Equipment PPE(N 95 mask, double surgical gloves, gowns, goggles foot cover, etc.) appears long way to go.
Requirement of Isolated Facility
As per the guideline, the best preventive measure is to isolate the suspected case. It says, "Sample collection should be done only AFTER ADMISSION in an appropriately secure isolation facility, and ensuring that the staff member doing the collection is using adequate PPE." In addition, the guideline limits the movements of caretakers and even staff personnel of the hospital to the isolated ward and recommends to follow 'restriction for essential purposes' protocol. It means, the Indian health care facilities should upgrade their isolated ward/units not only in numbers but also biosafety standards as a single confirmed case of NiV can give rise to many suspected/probable cases of NiV, which may not be accommodated in few isolation wards.
Transportation and Storage of Samples
Nipah cases are only confirmed through laboratory tests of respiratory secretions, urine or cerebrospinal fluid using a combination of tests either by 1) Nipah virus RNA identification by PCR, or by 2) Isolation of Nipah virus from sample. For this the samples should be collected using adequate bio-safety precautions, then safely packed in triple container packing, and stored/transported under cold chain (2-8°C) condition to the testing laboratory within 24 hours with prior intimation of testing lab. The hospital facilities should be upgraded in such a manner that fulfills the requirement of cold chain storage and transportation of sample. In addition, the guidance demands countrywide establishment of additional laboratories for testing NiV as a preventive measure.
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