Expert Speak Health Express
Published on May 29, 2024

With shifting climate patterns, and rising viral transmissibility, the risk of Nipah outbreaks remains substantial, thus emphasising the need for ethical public health responses

Nipah virus: The need for contextually-situated public health responses

Source Image: NIAID

Nipah virus appeared in the news countless times in the recent past with four outbreaks reported in Kerala alone. Nipah virus is primarily transmitted to humans through animals but can also be transmitted through the consumption of fruit products contaminated with the urine or saliva of infected animals, and from infected humans. Clinical manifestations of the disease range from asymptomatic illness to respiratory infection to acute encephalitis. Although not as infectious as SARS-CoV2, the Nipah virus has a fatality rate of 40-75 percent, placing it at the centre of WHO’s priority diseases.

The latest outbreak was in the district of Kozhikode last year, where six laboratory-confirmed cases of Nipah virus, including two deaths, were reported. Kerala’s swift response lasted 21 days and was characterised by enhanced disease surveillance, restrictions on public movement, social distancing, and mandatory mask-wearing in public spaces. The policies implemented during this outbreak resemble the securitised responses that were undertaken during the COVID-19 pandemic. Presently, there are no preventative or therapeutic means to address the Nipah viral infection. This essay argues that responses towards Nipah outbreaks cannot be solely based on a COVID-19-like response as it requires a thorough understanding of Nipah-specific factors, including those that are responsible for its spillover into humans, its transmission dynamics, and the limitations of a securitised response. This essay argues the need for an ethically-driven public health response to address the next potential global health emergency.

Kerala’s swift response lasted 21 days and was characterised by enhanced disease surveillance, restrictions on public movement, social distancing, and mandatory mask-wearing in public spaces.

A securitised response 

Kerala’s securitised response to the Nipah virus may have had its benefits but it may not have been the most appropriate response. The government of Kerala and the Department of Health, actors in positions of authority, labelled the Nipah virus as a threat, placed the issue ‘above politics,’ and inducted the implementation of exceptional measures to manage the threat. The securitisation of infectious diseases is not new and aligns with the WHO’s mandate that ‘health is fundamental to the attainment of peace and security.’ Studies have pointed out that securitisation of infectious diseases is beneficial in increasing awareness of preventative public health measures and in increasing the allocation of funds for research and development activities. Notably, the exceptional measures implemented during the COVID-19 pandemic is an example of the securitisation of an infectious disease. While a securitised response is necessary to control outbreaks, what is less studied is the appropriateness of a securitised response to an outbreak. In the case of the Nipah virus, there is a need to focus on animal-human spillover events and transmission dynamics, which are factors that contribute to the nature of necessary public health responses. Excessively stringent preventative health measures are not necessary for the Nipah virus, instead the responses should be a context-dependent.

Virus-appropriate measures 

The public health measures applied in Kerala during the most recent 2023 outbreak were excessive as they did not consider the transmission dynamics of the Nipah virus, rendering these interventions ethically unjust. The measures mirrored those implemented during the COVID-19 pandemic and were also the first time that the lockdown measure was utilised to combat the Nipah virus. Researchers at the Ethox Centre of Oxford Population Health call for a different approach to managing the Nipah virus outbreaks, citing its transmission dynamics as the primary cause. Transmissibility occurs through consumption or contact with contaminated fruit products, or from infected humans in close clinical or household settings. This pattern is dissimilar to respiratory illnesses, where generalised community measures, such as social distancing, travel restrictions, lockdowns, and border screening are effective at reducing transmission levels. In the case of the Nipah virus, owing to its higher risk of transmissibility through close-contact settings, stay-at-home orders and quarantine measures may place individuals at greater risk of infection.

Transmissibility occurs through consumption or contact with contaminated fruit products, or from infected humans in close clinical or household settings.

Moreover, some measures, like, border testing mandates may not be sensitive enough to screen for rare cases of infection and may not be appropriate to manage outbreaks. In addition, owing to its high fatality rate, each case of the Nipah virus infection poses a severe risk to life, necessitating the need to limit each case of transmission. This indicates that extreme measures may not be appropriate or ethically justifiable to manage the Nipah virus outbreaks, instead concentrated efforts at limiting household or clinical spread should be the main focus. It should also be noted that Kerala’s response during the 2018 outbreak, which primarily centred on contact tracing, was effective and adequate in managing the outbreak. This demonstrates that the application of public health measures should be carried out reflexively as excessively restrictive measures may not aid in mitigating household or clinical occurrences of the disease, while measures such as contact tracing are beneficial.

Communicating health 

Proactive public communication about the Nipah virus remains crucial in outbreak management and in fostering public trust. Community case studies in Bangladesh have reported that medical understandings of the Nipah virus do not align with social understandings of the disease. Instead, religious and cultural factors contributed to misperceptions about infections and impeded the community’s ability to understand scientific causal factors of the disease and the utilitarian value of preventative measures, prolonging outbreaks. 

Furthermore, the Nipah virus is an example of the WHO’s One Health perspective, where economic practices, climate change, and biodiversity converge and affect viral transmission dynamics. In the case of Bangladesh and India, the source of spillover events from infected fruit bats to humans has been linked to seed collectors in plantations. Infected fruit bats typically bite the external shell of cashew nuts and areca nuts, causing them to fall on the ground in an undamaged condition. These nuts are typically picked up by plantation farmers, where the Nipah virus can potentially remain active on the surface of these fruit nuts for up to 30 hours serving as contact points for transmission.

Infected fruit bats typically bite the external shell of cashew nuts and areca nuts, causing them to fall on the ground in an undamaged condition.

Rational and informed understandings of health frameworks can lead to preventative behaviours, particularly in plantation communities. A lack of understanding of the link between the consumption of raw date palm sap and the occurrence of the Nipah virus on its surface was a key factor that stirred community mistrust in healthcare interventions in Bangladesh. In plantation areas, bats’ health is correlated to human health and demonstrates that transparency over practices that promote viral transmission can enhance awareness amongst the public, and can trigger them to adjust behaviours that facilitate transmission. For instance, limiting person-to-person transmission through strict home quarantine protocols, encouraging personal hygiene measures after the collection of date palm sap, and encouraging the use of bamboo skirts—which cover both the tree trunk and the sap collection pot where sap is stored during collection, thus impeding the ability of bats to access the sap. The onslaught of misinformation and disinformation campaigns, as evidenced during the COVID-19 and Ebola outbreaks, further underscores the importance of transparent communication, particularly since future outbreaks are likely to be marred by the same. This highlights the importance of transparent public communication to the public about the Nipah virus to ensure that an informed public can proactively contribute to mitigating disease outbreaks.

Contextually-driven public health responses  

In light of the WHO’s anticipation of a “serious international epidemic ... caused by a pathogen currently unknown to cause human disease” labelled as ‘Pandemic X,’ robust preparedness activities are underway. Accordingly, the WHO identified the Nipah virus as a priority candidate for the next global public health emergency.

Securitised responses may lead to unfair practices in vaccine and therapeutic allocation, surveillance under the guise of public health, and violations of privacy on health matters.

While deeply restrictive measures, like lockdowns, have been beneficial in reducing infection numbers and mortality rates, the negative consequences of securitised responses are clearly evident. Instances of violation of civil liberties, the cessation of social and economic activities, loss of livelihood, increase in the number of cases of domestic violence, increased incidence of mental health issues, are a few examples of the spillage of a public health emergency into other sectors. Further, securitised responses may lead to unfair practices in vaccine and therapeutic allocation, surveillance under the guise of public health, and violations of privacy on health matters. Moreover, studies have also demonstrated that prolonged and frequent lockdowns have generated mistrust in governments and their capacity to manage health crises. This indicates that health measures should be ethically minded to ensure that there is a context-based approach, one that does not overburden the healthcare system, does not spillover to other sectors, and does not infringe upon civil liberties to excess levels.

With changing climatic conditions, intensive land use, and increased viral transmissibility, the likelihood of future Nipah outbreaks remains high. This indicates that ethically-driven public health responses are the need of the hour.


Lakshmy Ramakrishnan recently earned her MA in International Relations from King's College London.

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Lakshmy Ramakrishnan

Lakshmy Ramakrishnan

Lakshmy Ramakrishnan recently earned her MA in International Relations from King's College London. Her MA dissertation delved into the role of political actors and the ...

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