Punjab declares high alert as Nipah Virus threat looms large

The Punjab government has issued a high alert in response to growing concerns about the outbreak of the Nipah virus in the province, reported 24NewsHD TV channel.

The alert encompasses all areas of the province, including the capital city, Lahore, and marks a significant step in the battle against the virus.

The Punjab Health Department has taken swift action by disseminating guidelines to all Chief Executive Officers (CEOs) of Health, urging them to bolster preventive measures against Nipah infection. These precautionary measures are to be immediately implemented across all districts within the province.

One alarming fact emphasized in the issued letter is the high mortality rate associated with the Nipah virus, currently estimated at a staggering 74%. This underscores the urgency of the situation.

The circular further underscores the rapid spread of the Nipah virus in neighboring countries, raising fears of possible transmission to Pakistan. To counter this threat, the CEOs of Health have been instructed to promptly upload data on all suspected Nipah-affected patients to a centralized dashboard.

Moreover, it is imperative that both private and public sector hospitals adhere to the provided guidelines.

 A crucial aspect of the containment strategy is the monitoring of all potentially affected patients, who should be isolated based on suspicion. To expedite the diagnostic process, samples must be collected and promptly sent to the laboratory for PCR testing.

 The Nipah virus has demonstrated its ability to spread rapidly, both from animals to humans and from person to person. In a grim reality, there is currently no vaccine available for the virus. Hence, the only effective strategy against it remains timely diagnosis and treatment.

Past Outbreaks 

Nipah virus was first recognized in 1999 during an outbreak among pig farmers in, Malaysia. No new outbreaks have been reported in Malaysia since 1999. 

It was also recognized in Bangladesh in 2001, and nearly annual outbreaks have occurred in that country since. The disease has also been identified periodically in eastern India.

Other regions may be at risk for infection, as evidence of the virus has been found in the known natural reservoir (Pteropus bat species) and several other bat species in a number of countries, including Cambodia, Ghana, Indonesia, Madagascar, the Philippines, and Thailand.

Transmission

During the first recognized outbreak in Malaysia, which also affected Singapore, most human infections resulted from direct contact with sick pigs or their contaminated tissues. Transmission is thought to have occurred via unprotected exposure to secretions from the pigs, or unprotected contact with the tissue of a sick animal.

In subsequent outbreaks in Bangladesh and India, consumption of fruits or fruit products (such as raw date palm juice) contaminated with urine or saliva from infected fruit bats was the most likely source of infection.

There are currently no studies on viral persistence in bodily fluids or the environment including fruits.

Human-to-human transmission of Nipah virus has also been reported among family and care givers of infected patients.

During the later outbreaks in Bangladesh and India, Nipah virus spread directly from human-to-human through close contact with people's secretions and excretions. In Siliguri, India in 2001, transmission of the virus was also reported within a health-care setting, where 75% of cases occurred among hospital staff or visitors. From 2001 to 2008, around half of reported cases in Bangladesh were due to human-to-human transmission through providing care to infected patients.

Signs and symptoms

Human infections range from asymptomatic infection to acute respiratory infection (mild, severe), and fatal encephalitis.

Infected people initially develop symptoms including fever, headaches, myalgia (muscle pain), vomiting and sore throat. This can be followed by dizziness, drowsiness, altered consciousness, and neurological signs that indicate acute encephalitis. Some people can also experience atypical pneumonia and severe respiratory problems, including acute respiratory distress. Encephalitis and seizures occur in severe cases, progressing to coma within 24 to 48 hours. 

The incubation period (interval from infection to the onset of symptoms) is believed to range from 4 to 14 days. However, an incubation period as long as 45 days has been reported.

Most people who survive acute encephalitis make a full recovery, but long term neurologic conditions have been reported in survivors.  Approximately 20% of patients are left with residual neurological consequences such as seizure disorder and personality changes. A small number of people who recover subsequently relapse or develop delayed onset encephalitis.

The case fatality rate is estimated at 40% to 75%. This rate can vary by outbreak depending on local capabilities for epidemiological surveillance and clinical management.

Diagnosis

Initial signs and symptoms of Nipah virus infection are nonspecific, and the diagnosis is often not suspected at the time of presentation.  This can hinder accurate diagnosis and creates challenges in outbreak detection, effective and timely infection control measures, and outbreak response activities. 

In addition, the quality, quantity, type, timing of clinical sample collection and the time needed to transfer samples to the laboratory can affect the accuracy of laboratory results.

Nipah virus infection can be diagnosed with clinical history during the acute and convalescent phase of the disease. The main tests used are real time polymerase chain reaction (RT-PCR) from bodily fluids and antibody detection via enzyme-linked immunosorbent assay (ELISA). 

Other tests used include polymerase chain reaction (PCR) assay, and virus isolation by cell culture.

Treatment

There are currently no drugs or vaccines specific for Nipah virus infection although WHO has identified Nipah as a priority disease for the WHO Research and Development Blueprint.  Intensive supportive care is recommended to treat severe respiratory and neurologic complications.

Natural host: fruit bats

Fruit bats of the family Pteropodidae – particularly species belonging to the Pteropus genus – are the natural hosts for Nipah virus. There is no apparent disease in fruit bats.

It is assumed that the geographic distribution of Henipaviruses overlaps with that of Pteropus category. This hypothesis was reinforced with the evidence of Henipavirus infection in Pteropus bats from Australia, Bangladesh, Cambodia, China, India, Indonesia, Madagascar, Malaysia, Papua New Guinea, Thailand and Timor-Leste.

African fruit bats of the genus Eidolon, family Pteropodidae, were found positive for antibodies against Nipah and Hendra viruses, indicating that these viruses might be present within the geographic distribution of Pteropodidae bats in Africa.

Nipah virus in domestic animals

Outbreaks of the Nipah virus in pigs and other domestic animals such as horses, goats, sheep, cats and dogs were first reported during the initial Malaysian outbreak in 1999.

The virus is highly contagious in pigs. Pigs are infectious during the incubation period, which lasts from 4 to 14 days.

An infected pig can exhibit no symptoms, but some develop acute feverish illness, labored breathing, and neurological symptoms such as trembling, twitching and muscle spasms. Generally, mortality is low except in young piglets. These symptoms are not dramatically different from other respiratory and neurological illnesses of pigs. Nipah virus should be suspected if pigs also have an unusual barking cough or if human cases of encephalitis are present.

 

Prevention

Controlling Nipah virus in pigs

Currently, there are no vaccines available against Nipah virus. Based on the experience gained during the outbreak of Nipah involving pig farms in 1999, routine and thorough cleaning and disinfection of pig farms with appropriate detergents may be effective in preventing infection.

If an outbreak is suspected, the animal premises should be quarantined immediately.  Culling of infected animals – with close supervision of burial or incineration of carcasses – may be necessary to reduce the risk of transmission to people. Restricting or banning the movement of animals from infected farms to other areas can reduce the spread of the disease.

As Nipah virus outbreaks have involved pigs and/or fruit bats, establishing an animal health/wildlife surveillance system, using a One Health approach, to detect Nipah cases is essential in providing early warning for veterinary and human public health authorities.

Reducing the risk of infection in people

In the absence of a vaccine, the only way to reduce or prevent infection in people is by raising awareness of the risk factors and educating people about the measures they can take to reduce exposure to  the Nipah virus.

Public health educational messages should focus on:

• Reducing the risk of bat-to-human transmission.
  Efforts to prevent transmission should first focus on decreasing bat access to date palm sap and other fresh food products. Keeping bats away from sap collection sites with protective coverings (such as bamboo sap skirts) may be helpful. Freshly collected date palm juice should be boiled, and fruits should be thoroughly washed and peeled before consumption. Fruits with sign of bat bites should be discarded.
• Reducing the risk of animal-to-human transmission.
  Gloves and other protective clothing should be worn while handling sick animals or their tissues, and during slaughtering and culling procedures. As much as possible, people should avoid being in contact with infected pigs. In endemic areas, when establishing new pig farms, considerations should be given to presence of fruit bats in the area and in general, pig feed and pig shed should be protected against bats when feasible.
• Reducing the risk of human-to-human transmission.
  Close unprotected physical contact with Nipah virus-infected people should be avoided. Regular hand washing should be carried out after caring for or visiting sick people.

Reporter: Azmat Awan