Partnerships that contained Nipah

When the rare and lethal Nipah virus broke out in Kerala in May, many feared an epidemic on the scale of SARS in China or Ebola in West Africa. But, the authorities and the public swiftly controlled its spread. In the end, 19 people were infected, but the mortality rate was high, at 17 fatalities.

Health experts worldwide are rightly alarmed that we are unprepared for the next pandemic. What prevented the spread of the virus in Kerala was past investments in education and health services — and partnerships across states and among institutions.

Being infected by Nipah leads to acute respiratory problems, encephalitis and brain inflammation. The virus, against which there is no vaccine yet, was first identified among pig farmers in Malaysia, resulting in 265 suspected cases and over 100 fatalities in 1998-99. Cases now appear almost yearly in Bangladesh, and there were two previous occurrences in West Bengal. The Nipah strain found in Kerala was deadlier and more infectious than the one in Malaysia.

The key to its containment was the speed of detection, with cooperation across Kerala and Karnataka. With the second case, where the patient arrived at Kozhikode’s Baby Memorial Hospital on May 17, Dr Chellenton Jayakrishnan, the attending neurologist, quickly realised that the symptoms were unlike any encephalitis cases the team had ever seen, and reminiscent of the Nipah virus analysed in a recent neurology journal.

The patient’s samples were dispatched quickly to Karnataka’s Manipal Centre for Virus Research (MCVR) about 300 km from Kozhikode, which was equipped to detect Nipah as an international concern. The Centre made the detection in a day and got a medical team into the field within 24 hours for containment and surveillance, and to alert local communities. The head of MCVR, Dr Govindakarnavar Arunkumar stresses the importance of preparedness, capacity-building, and coordination with state, national and global organisations.

The MCVR team quickly got confirmation of the Nipah diagnosis from the National Institute of Virology in Pune before the Government of India apprised the World Health Organisation of the outbreak. Within hours of the patient’s arrival at Baby Memorial, Kozhikode’s district medical officer V. Jayashree put together a team of entomologists to initiate protective action at the patient’s home. Kerala Health Minister KK Shylaja took charge of directing teams on infection-control — isolating patients, using surgical masks and decontaminating surfaces.

One important contributor to preventing the spread of the virus is the relatively high proportion of doctors and nurses in Kerala’s population, and that private spending on healthcare is the highest in India in this state. Karnataka, too, stands out, with the highest number of medical colleges in the country, even as healthcare in the districts remains inadequate. Kerala has the highest literacy rate. Education has not had the expected economic payoffs, as unnecessarily restrictive regulations have stifled economic growth, but its contribution to healthcare comes through in this recent experience.

The equal presence of women in the workforce in Kerala enables drawing on the full potential of human capital in a society. India has the lowest female employment rate among major economies. In Kerala, however, girls are educated as much as boys and a girl born there can expect to live to 78 years, comparable to upper middle-income countries. It is striking that the line of command in the Nipah operation included both men and women not only in senior health management but also among doctors and paramedics.

Community spirit and societal resilience were key, underscored by a high degree of partnership between the government and the public. Kozhikode Medical College’s doctors, nurses and administrators went into high gear. Notable was the mutual trust and social cohesion beyond religious divides in India’s most religiously diverse state.

Against these positives is the worsening damage to the environment in Kerala, as in Karnataka and elsewhere, particularly uncontrolled garbage disposal in urban areas. Had the authorities not been able to quickly contain the virus, ecological factors would have spurred its spread. Environmental degradation was connected to outbreaks of the mosquito-borne Chikungunya virus in Kerala and the Zika virus in Brazil. In both instances, reckless deforestation played a role. Disease prevention, coupled with environmental protection, should be bigger priorities everywhere.

Nipah is on the World Health Organisation’s list of viruses most likely to set off a global pandemic. It is also on the priority list for developing a vaccine at the Coalition for Epidemic Preparedness Innovations, a new non-profit partnership. It has made a $25 million contract to Profectus BioSciences, a vaccine development company, and Emergent BioSolutions, a biopharmaceutical company, to develop a Nipah vaccine. Even so, the years taken for an effective vaccine for pathogens like Zika, Ebola and SARS highlight the urgency of national and global funding for a Nipah vaccine — and for all hands on deck to stave off the next pandemic.

(The writer is Visiting Professor, National University of Singapore, and former Senior Vice President, The World Bank)