Expert Speak Health Express
Published on Jul 07, 2018
Timely interventions ensured prompt caring of the infected and prevented the spread.
Lessons from Kerala’s bold fight with Nipah

After tense weeks of waging war against Nipah, the deadly virus which claimed 17 lives, the government of Kerala has announced ‘Nipah-free Kerala’ on 30 June 2018. This has calmed the frayed nerves of the citizens and also energised them to dance to the video obituary “Bye Bye Nipah”, which has gained immense popularity on mobile phones in the state.

The efforts to overcome the outbreak of Nipah virus, which has surprise attack capabilities and abilities to survive across animal and human hosts causing brain fever in less than a day of infection, has thrown up opportunities for India to learn from Kerala’s experience. With the emerging threat of such biological outbreaks and no certainty that Nipah will not strike back, it is important that public, governments and other stakeholders — including social media — reflect on Kerala’s experience and carry their learnings into the future.

Having caused outbreaks earlier in Southeast Asia (Malaysia in 1999), India’s east (West Bengal 2001 and 2007), and in Bangladesh (2017), Nipah is a known but rare and dangerous zoonotic disease, surviving primarily among fruit bats and to some extent, also in pigs. It is currently among the World Health Organisation’s (WHO) list of high-priority diseases with ability to cause outbreaks of greater public health emergency. Research and development efforts by WHO and Coalition for Epidemic Preparedness Innovations (CEPI), are on to find a suitable vaccine in the next 3-4 years and hopefully, effective treatment as well.


With the emerging threat of such biological outbreaks and no certainty that Nipah will not strike back, it is important that public, governments and other stakeholders — including social media — reflect on Kerala’s experience and carry their learnings into the future.


However, until the arrival of vaccine or regimen to treat, it is critical to be abreast of what can be done and what needs to be done. Kerala’s Nipah experience has lessons for other States in the areas of coordination among responders, securing health information, proper communication of risk and ensuring timely interventions on the ground.

Systems that helped coordination

Right from the prompt setting up of coordination cells, camping of the State ministers for health and labour in the districts under attack to the parallel ongoing communications with the Government of India at the top and ground-level healthcare workers, the crises management was reflective of Kerala’s robust public health system. What mattered most was not the mere presence of health facilities but the significant long-term investments of political and administrative capital in the health affairs of the state.

Beyond the need to handle such health emergencies, it is vital to identify, nurture and strengthen the positions of the non-IAS technical leads among the public health cadres itself, especially since health is finding its due place among political priorities. Determined leadership of Health Secretary Rajiv Sadanandan going beyond his personal dedication to support public health officials take greater responsibilities is a lesson to build resilience in health systems though sustained technical capacity building of the state’s public health cadre.

Much before Nipah’s presence in Kozhikode district got flashed in the media on 21 May 2018, the virus had been identified by the health systems. Thanks to the timely suspicion and follow up of critical care specialists at Kozhikode’s Baby Memorial Hospital, the State put into place a spree of coordinated control actions. Treating doctors like Dr. Anop Kumar got suspicious when one of his young patients had rapid inflammation in brain and falling blood pressure. Realising that the patient had a family history of two recent deaths, Dr. Anop’s team referred the patient’s samples to Manipal Center for Viral Research (MCVR). MCVR, part of Manipal University in Karnataka, is a nodal center for viral research supported by ICMR, Government of India and Center for Disease Control (CDC, Atlanta). Headed by Dr. Arun Kumar, the centre was upgraded recently and was geared up to complement the surveillance drive – the litmus test in handling any outbreaks. The confirmation of deadly Nipah virus by MCVR within a day quickly steered the course of actions, paving way for an early end of the outbreak. Health cadres being well informed, laboratories equipped adequately, and a health force prepared to intervene quickly, are all vital links to arrest outbreaks, as much as their availability in the first place.


Much before Nipah’s presence in Kozhikode district got flashed in the media on 21 May 2018, the virus had been identified by the health systems.


Besides support from private university-based MCVR, importance of the private sector can also be inferred from the outreach done by the Chief Minster, who appealed for cooperation from private hospitals. Laudable voluntary service offered by the well-known Chennai-based Dr. Abdul Gafoor in Kozikode, also highlights the immense opportunities that can be unlocked, if public and private sectors work seamlessly to secure the health for all. At the same time, the tragic death of the public-sector nurse Ms. Leni, who cared for the Nipah-infected, and the ignorance of paramedics who were afraid of handling the bodies of the deceased, exposes the gaps in sensitisation and the lack of training as part of preparedness, which otherwise generally gets concentrated around doctors.

Effective countering of rumours

Immediately upon confirmation of diagnosis and the first death on 19 May, the State stepped up its public health control actions. It immediately informed the Centre, which, in turn, alerted the WHO. A team of experts from the National Centre for Disease Control (NCDC), New Delhi, supplemented the State’s efforts in quickly going behind the root cause, undertaking public outreach in parallel. Despite government setting up a 24-hour control room and releasing authentic public communiques, a section of the media went berserk reporting unscientific and exaggerated news. Social media, primarily WhatsApp, was flooded with rumours creating social panic. The rumour that Nipah was caused by fruits severely impacted the entire supply chain far beyond Kerala.

Rumour mongering in the Changaroth village, 45-km away from Kozhokode, drove the people to the edge, driving them away from their houses overnight and abandoning their affected ones owing to fear of contracting the disease. Perambra Taluka Hospital, which normally has up to 100 patients, overnight wore a deserted look, as most of the non-Nipah patients sought discharge out of fear.

Effective risk communication at three levels finally bore results. Fears among the villagers who were by then unnecessarily moving in masks, could be allayed when their panchayat leaders along with teams of doctors and personnel from Delhi reached out to them at their own houses with factual information and their assessment of the situation. Government administration at the district level was educating the general public on do’s and don’ts, while also addressing the needs of affected families including safe cremations for the deceased. At state level, political and administrative leadership were updating through frequent briefings to the media and reassuring the people on the overall situation with targeted messages. Health minister herself urged the citizens not to believe WhatApp rumors as a part of strong and effective counter-narrative to mitigate the fears.


Effective risk communication at three levels finally bore results. Fears among the villagers who were by then unnecessarily moving in masks, could be allayed when their panchayat leaders along with teams of doctors and personnel from Delhi reached out to them at their own houses with factual information and their assessment of the situation.


Timely interventions

Timely interventions ensured prompt caring of the infected and prevented the spread. Medical teams at the Kozhikode hospital made appropriate adjustments for handling the patients. While medical supplies like Antiviral Ribavirin tablets were mobilised internally within first week, more specific therapies for critically ill patients, like immunoglobulins were imported from Malaysia and Australia. Strict isolation of the Nipah infected, could be negotiated with their families along with tracing of all those who were in close contact with the infected.

The outbreak was kept restricted to two districts of Kozhikode and Mallapuram. More than 2,500 contacts have been screened, hundreds were quarantined, ultimately containing the outbreak and limiting the death toll 17, most of whom got affected in the early stages, even before the state sprang into action. Extensive search for confirming the source of infection, which involved veterinary personnel supported by the teams from National Institute of High Security Animal Diseases (NISHAD), Bhopal, confirmed fruit bats as the source for Nipah outbreak on 2 July.

The way forward

Kerala’s tryst with Nipah has several lessons for the rest of the States:

  • Overall, Kerala’s collaborative work across the public and private sectors, interdisciplinary coordination across human and veterinary sciences, and cooperation across all levels of governments has set the benchmark for all stakeholders to adhere to in the future as well. Central government, on its part, should focus on promoting seamless sharing of information and resources across the States. Understandably, this will be easier with less disparate, strategically prepared and confident health systems across all States. This can be achieved if India could successfully incorporate Universal Health Security in its journey towards Universal Health Coverage.
  • A robust health system, one which thrives on strong administrative and political commitment, adequate infrastructure and well-prepared workforce is vital to undertake the coordination efforts needed to avert the avoidable tragedies. Ability to promptly share health information across the state and national boundaries coupled with the effective risk communication will determine how quickly we can act holistically and minimise the outbreak’s overall socioeconomic impact. The ambitious Integrated Health Information Platform (IHIP) under deployment by Government of India could very well serve this cause as well.
  • Lacking a specific policy framework to ensure responsible reporting and to mitigate the undesirable consequences of the new social media and digital platforms, multiplies the risks on more fronts than what the outbreaks are themselves cable of. Government needs to promote self-regulation and surveillance mechanisms among new media, securing accountability from all platforms such as WhatsApp. Effective risk communication at all levels must be targeted to allay public fears and avert self-goals, reinforcing positive public perception of the state machinery.
  • Leveraging limited clinical information available, the sooner the governments can act, better the outcomes, while prior preparedness holds the key to holistic outbreak prevention as well as management.
  • There is a need to emulate the pioneering role of Kerala Veterinary and Animal Sciences University, for its advocacy of ‘One Health’ concept. One Health approach of addressing the zoonotic and emerging diseases through coordination among the animal, human health and environment personnel, sharing of surveillance and control mechanisms, needs to be institutionalised by all States. Unlike Swine Flu, which spreads through air, zoonotic diseases like Nipah spreads via direct contact from the infected (animals being the starting point) gives us the opportunity to limit its transmission through One Health approach.

Only when States are universally prepared, citizens can confidently rejoice to the ‘Goodbye Nipah’ track. Else it would only remain a momentary farewell at the border of Kerala before the virus strikes even more fatally in another State. This is exactly all stakeholders across all States should not let happen by choosing responsible preparedness over convenient complacency.

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