NIPAH final.ppt epidemiology Managemant and prevention
- 1. NIPAH VIRUS INVESTIGATION STATE PEID CELL TEAM
- 2. INTRODUCTION • Newly emerging zoonosis • Natural host - Fruit bats, Pteropodidae Family, Pteropus genus • First identified – – outbreak in Sungai Nipah, Malaysia – pigs – intermediate hosts – September 1998 – April 1999 – 265 suspected cases • Singapore – March 1999 • No new outbreaks in Malaysia and Singapore since May 1999
- 3. • 16 outbreaks in Bangladesh and West Bengal • Siliguri and Nadia districts of West Bengal • No of confirmed cases – 1 to 66 • Case fatality rate from 45% to 100%
- 4. NIPAH BELT
- 5. PRESENT OUTBREAK • First NiV outbreak in South India • Affected districts – Calicut, Malappuram • Confirmed cases – 17 • Confirmed deaths –14 • First death - 5th May 2018
- 7. Center for Food Security and Public Health, Iowa State University, 2011
- 9. MODES OF TRANSMISSION IN PREVIOUS OUTBREAKS • Always bat to human - with or without intermediate host • Malaysia – Contact with infected pigs or close contact with infected patients • Singapore – Close contact with infected pigs from Malaysia • Bangladesh – – 5 – Drinking raw date palm juice – 4 – contact with a Nipah patient – 1 – contact with a sick cow – 1 – close proximity with pig herds • India – 2 outbreaks – Retrospective investigation nosocomial transmission
- 10. A walk through Nipah’s way Malaysia Bangladesh
- 11. KERALA
- 12. TEAM • State PEID cell team • 5 Experts • 6 Post graduates 1. Dr. Devadas 2. Dr. Indu P S 3. Dr. Tony Lawrence 4. Dr. Anish T S 5. Dr Chintha S
- 13. MAJOR ACTIVITIES • Contact tracing • Identification of potential points of contact • Recommendations and Action plan • Notification to be released to the public
- 14. Steps of epidemic investigation 1. Prepare for field work 2. Establish the existence of an outbreak 3. Verify the diagnosis 4. Define and identify cases 5. Perform descriptive epidemiology 6. Develop hypotheses 7. Evaluate hypotheses 8. Execute additional studies 9. Implement control and prevention measures 10. Communicate findings 11. Follow up recommendations
- 15. HOW WAS THIS OUTBREAK DETECTED • Surveillance data – PEID cell, IDSP • Medical Practitioner – Treating doctor – physician, critical care specialist, neurologist, microbiologist of BMH, MCH CLT • Affected persons/groups – similar presentations in family members and close contacts • Concerned citizens • Media - newspapers, news channels
- 16. WHY WAS AN INVESTIGATION ESSENTIAL • Immediate – to control spread from existing confirmed cases - to control spread of disease from contacts, if symptomatic • Program considerations – Isolation wards, Better diagnostic facilities Time when authorities are more receptive Lacunae in populations covered Failures in usual strategies (here, Universal health precautions, cough etiquette) Identify areas to focus on in later programs
- 17. RESEARCH OPPORTUNITIES • Recently recognised disease – emerging viral infections • Reasons for emergence • Describe and define natural history, epidemiological profile • Characterize population at risk • Identify risk factors • Assess and recommend control measures • Develop better, cost effective and accessible techniques for laboratory and epidemiological purposes
- 18. • TRAINING for post graduate students, health care workers in infection control measures • PUBLIC, POLITICAL AND LEGAL CONCERNS – responsible decision makers and Dresponsive authorities
- 19. CONTROL AND PREVENTIVE MEASURES QUESTIONS FACED • Cases still occuring? • Epidemiological patterns in cases • History of evolution of cases from index case • In which stage of epidemic presently • Duration of this phase • Expected duration of second phase • Population at risk
- 20. How was this outbreak established? • Comparison of data • Collection of data – from State PEID cell, IDSP (DHS) from the declaration of Nipah outbreak included hospital records, mortality data
- 21. HOW WAS DIAGNOSIS VERIFIED? • Proper diagnosis of reported cases – RNA PCR • review clinical findings – compare with existing literature • review laboratory results • summarize the clinical findings with frequency – yet to be done
- 22. HOW WERE CASES DEFINED? • Standard set of criteria for the health condition • Clinical criteria (signs and symptoms) • Restrictions by time, place and person
- 23. SUSPECT NIPAH CASE • Person from a community affected by a Nipah virus disease outbreak who has: Fever with new onset of altered mental status or seizure and/or Fever with headache and/or Fever with Cough or shortness of breath PROBABLE NIPAH CASE • Suspect case-patient/s who resided in the same village where suspect/confirmed case of NIPAH were living during the outbreak period and who died before complete diagnostic specimens could be collected. • OR • Suspect case-patients who came in direct contact with confirmed case-patients in a hospital setting during the outbreak period and who died before complete diagnostic specimens could be collected. CONFIRMED NIPAH CASE • Suspected case who has laboratory confirmation of Nipah virus infection either by: Nipah virus RNA identified by PCR from respiratory secretions, urine, or cerebrospinal fluid. Isolation of Nipah virus from respiratory secretions, urine or cerebrospinal fluid.
- 24. Definition of a Contact: • A Close contact is defined as a patient or a person who came in contact with a Nipah case (confirmed or probable cases) in at least one of the following ways. – Was admitted simultaneously in a hospital ward/ shared room with a suspect/confirmed case of NIPAH – Has had direct close contact with the suspect/confirmed case of NIPAH during the illness including during transportation. – Has had direct close contact with the (deceased) suspect/confirmed case of NIPAH at a funeral or during burial preparation rituals – has touched the blood or body fluids (saliva, urine, vomitus etc.) of a suspect/confirmed case of NIPAH during their illness – has touched the clothes or linens of a suspect/confirmed case of NIPAH • These contacts need to be followed up for appearance of symptoms of NiV for the longest incubation period (21 days).
- 25. IDENTIFY AND COUNT CASES • Basic information • Demographic information • Clinical information • Information about risk factors Already line list and detailed list of cases from PEID cell available
- 26. NIPAH DETAILS-2018(up to 24.05.2018) updated on 5.00 pm District Suspected Case Un confirmed Death Confirmed Case confirmed Death Trivandrum 1 Kollam Pathanamthitta Idukki Kottayam 2 Alappuzha Ernakulam 4 Trissur 1 Palakkad Malappauram 9 0 4 3 Kozhikkode 11 1 10 8 Wayanad 1 Kannur Kasaragode Total 29 1 14 11
- 27. DETAILS IN LINE LIST • Name, age, sex • Address, district of residence • Date of onset of symptoms • Date of admission • Name of hospital admitted • Provisional diagnosis – – Fever – Encephalitis – Meningitis – Meningo encephalitis – Fever, headache – Myalgia • Panchayat/ Municipality/ Corporation of patient • Details of lab confirmation – Negative, Awaiting, Positive • Date of confirmation, Date of death • Number of confirmed and suspected cases and deaths in each district
- 28. DESCRIPTIVE EPIDEMIOLOGY • Characterise the epidemic by Time, place and person
- 30. EPIDEMIC CURVE 0 1 2 3 4 5 6 7 8 1-May 2-May 3-May 4-May 5-May 6-May 7-May 8-May 9-May 10-May 11-May 12-May 13-May 14-May 15-May 16-May 17-May 18-May 19-May 20-May 21-May 22-May 23-May 24-May 25-May 26-May 27-May 28-May 29-May 30-May 31-May Nmber of cases Date of onset of symptoms No of cases
- 31. • Mean Incubation period – 10.3 days • Min incubation period – 8 days (Shijitha) • Max incubation period – 15 days (Ubeesh) Probable time of exposure taken as 4th May Epidemic curve – Common source epidemic point source epidemic
- 32. Mean no.of days from onset of symptoms to admission - 4.06 Mean no. of days from admission to death - 2.92 0 2 4 6 8 10 12 14 Patient name No of days from admission to death No of days from onset of symptoms to admission
- 33. • Earlier admission and intensive care support - prolonged lives
- 34. PLACE – SPOT MAP
- 35. Confirmed Nipah death Confirmed Nipah alive Suspected Nipah death Hospitals visited
- 36. • Index case – Sooppikkada, Chengaroth, Perambra • Later 3 more cases from the same family • Other places – Thiruvaode, Chembanoda, Cheruvannur, Koorachundu, Parakkadavu • 16 confirmed cases – 13 from Calicut and 3 from Malappuram
- 38. • Mean age of patients – 37 years • Minimum age - 19 years • Maximum age - 55 years
- 39. 8 8 Gender distribution Male Female 8 5 1 Religion distribution Hindu Muslim Christian 6 4 1 1 Hospital admitted MCH, CLT BMH THQH, Perambra MIMS 14 2 Outcome Dead Alive
- 41. CONTACT TRACING • Team made into groups of two • Telephonic conversations • Contacted close relatives or health inspectors • Detailed history of each case was obtained
- 42. • Questions asked included – Date of onset of symptoms – History of presenting illness – Health seeking behaviour of patient – Persons accompanied in each visit to hospital – Transport modalities used – Names and details of contacts at other points, like hospitals, vehicles, laboratories visited, guests visiting the patient at home and hospital, including health care workers – Date and Time of visit to above mentioned places – Date and time of death – Handling of dead body, funeral practices – Any caretakers developing symptoms – The caretaker’s perspective on how the patient contracted this disease
- 43. From the above information, potential points of contact along with the date and time were charted for each patient To identify and notify those who are at risk
- 44. SL NO NAME MODE OF CONTACT 1 SALIH BROTHER 2 MARIYAM AUNTY 3 ISMAYIL ADMITTED IN THQ HOSPITAL PERAMBRA WHEN SABITH WAS ADMITTED THERE 4 LINI STAFFNURSE WHO NURSED SABITH 5 JANAKI BYSTANDER OF A PATIENT AT THQ HOSPITAL,PERAMBRA WHEN SABITH WAS ADMITTED 6 RAJAN BYSTANDER OF HIS BROTHER WHEN SABITH WAS ADMITTED IN MCH,KOZHIKODE 7 ASOKAN HIS FATHER WAS ADMITTED IN MCH,WHEN SABITH WAS ADMITTED THERE 8 MOOSA FATHER OF SABITH
- 45. NO OF CONTACTS OF EACH PATIENT NAME OF THE NIPAH CONFIRMED CASE INDIVIDUAL NO OF CONTACTS SABITH,SALIH,MOOSA,MARIYAM 157 ISMAYIL 103 LINI 92 JANAKI 96 ASOKAN 74 RAJAN 23 AJANYA 44 ABIN 30 TOTAL NO OF CONTACTS TRACED FROM MALAPPURAM DISTRICT:137 TOTAL NO OF CONTACTS TRACED UPTIL 25/5/2018 IN STATE:753
- 46. SABITH THQH PERAMBRA MCH CLT – XRAY DEPT, CT SCAN LAB 77,78 CASUALTY ISMAIL (patient) LINI (staff nurse) JANAKI (by-stander) RAJAN (by-stander) ASOKAN (by-stander) VELAYUDHAN (patient) SHIJITHA ( by-stander) SINDHU (by-stander) UBEESH (patient) AJANYA (nursing std) HOUSEHOLD CONTACTS SALIH MOOSA MARIYAM KALYANI (patient) TH BALUSSERY RESIL MADHUSOODHANAN (by-st) SINDHU (Xray tech) ABIN (unknown) AKHIL MICU
- 47. SABITH Ambulance staff – 5th May SHIJITHA Burial – 5th May Dr Muthukoya clinic – 14th May MKH Hosp. Thirurangadi -16th-18th May Taxi, Ambulance – 19th May RAJAN Kottackal Arya Vaidyasala, Koorachundu – 14th May PHC Koorachundu – 16th -18th May EMS Hosp, Perambra – 18th May MCH Ambulance – 20th May Chest Hospital ICU – 20th May
- 48. SALIH BMH Emergency, Neurology dept – 17th May MCH – mortuary – 18th May Ambulance, Burial – 18th May MARIYAM Ambulance – 19th May Burial – 19th May SINDHU THQH, Thirurangadi – 16th May JANAKI Vadakkannoor MMC – 18th May MCH Ambulance – 19th May
- 49. ABIN CHC Olavanna – 15th, 16th May IQRA Hospital – 19th May LINI IQRA Hospital – 18th May Ambulance – 18th May VELAYUDHAN THQH PMNA-ward – 16th, 17th May
- 52. As informed by Janaki’s brother’s son Gireesh and her son-in-law Sreejith. Janaki s father-in-law go, 90 years of age, admitted in THQH, perambra on April28th, for the complaints of tooth pain. He was bedridden since 12 years and a patient of palliative care for complaints of decubitus ulcer following leg fracture. One week later, on May 9th, he died in THQH, Perambra. Janaki and her sister in law, Savithri were the by-standers. After 7 days of admission, on May 16th, her father-in-law expired, following which she developed headache on the same day, fever on the second day, and she was taken to THQH, Perambra, in a private bus, on May 17th, with her niece, Ponnu, 20 yrs, Female, at around 10 AM. Consulted doctor, and did blood tests in the same Hospital lab at about 11 AM. She was reassured and sent back home. The next day, she developed leg pain along with fever and headache, following which she was taken to Calicut MCH by 4 pm, in a jeep, driven by her brother’s son Gireesh. Her husband Venu, and daughter Babitha, also accompanied them. Blood tests were also done in the hospital lab by around 12 AM. Next day, she was again sent back home. CASE HISTORY OF JANAKI
- 53. At around 10 AM that day, on May 18th, her relatives found that she was very sick, and was taken to another nearby hospital, Vadakkannoor MMC, by around 10.30 AM, but the treating doctor was some doctor other than Dr.Muhammad. She was taken in a jeep, driven by a driver, name unknown, from around 5 kms away from their home, accompanied by her daughter Babitha, her son-in-low Sreejith, her relatives - Babu, Rajesh, and her sister-in-law Sarada. Further, by around 10-11 PM, referred to Calicut MCH Casualty – in a mobile ICU, accompanied by her relative Babu, a doctor and a nurse from Vadakkannur MMC. From there, she was referred to Chest Hospital, half a kilometers away, in ambulance from MCH, accompanied by driver, name unknown, husband Venu and other relatives. She was admitted to Chest Hospital ICU. Her by- standers in the Chest Hospital were her son-in-law , her sister- Santha and a relative- Babu. On May 20th, she was declared to be dead by 7 PM. Dead body was handled by son-in-law Sreejith, her brother Babu, brothers-in-law Shibu and Vinod. Janaki has only one daughter – Babitha. According to her relatives, Janaki was in THQH, Perambra, when Sabith was admitted there, during the days from April 28th to May 9th. Sabith was declared dead on May5th.
- 54. CASE HISTORY OF RAJAN • Mr Rajan 45 years male from Koorachand , who is coolie by occupation went to Kallode on 4/5/18,to stay with his uncle Mr Balan, k/c/o asthmatic for 15 years, admitted at Perambra Taluk hospital since 3/5/18. He reached the Taluk hospital by 3 pm , stayed with his uncle for a day at the hospital and returned on 5/5/18.After returning from Perambra Mr Rajan , a coolie by occupation was working along with other workers in building his new house. By 13/5/18 he developed fever but did not go to any hospital, being Sunday and took rest at home. Next day on 14/5/18, he was feeling more lethargic and went to Kotakyal Ayurvedashala at Koorachand and took some medicine . On 15/5/8 he had an episode of loss of consciousness and on 16/5/18 went to Koorachand PHC accompanied by his wife Mrs Sindhu 32 years, at about 10.00 am , doctor examined him and checked his platelet count and found it to be 1.7 lakhs/ml. As doctor’s advice Mr Rajan along with his wife went to PHC on 17/5/18 and 18/5/18 for monitoring the platelet count and found to be 88,000 and 84,000 respectively. Doctor referred Mr Rajan to Kallode Govt Hospital in view of thrombocytopenia. On 18/5/18, morning Mr Rajan along with his wife and elder daughter Sandra went to EMS private hospital where he was admitted, blood tests were done. His wife went for work and daughter stayed with him at the hospital. By evening 3.00pm, Mr Rajan developed altered sensorium and had an episode of loss of consciousness and was found to have hyponatremia . Sandra called her mother and informed about it .
- 55. • Mr Rajan was then referred to MCH , Kozhikode on 19/5/18 in view of altered sensorium and hyponatremia. Mr Rajan was then taken to MCH Kozhikode by car accompanied by his wife Mrs Sindhu , Sandra , Mr Ashokan ,Mr Gopalan ,Mrs Reji, Mr Subhash other than driver , reached MCH by 9.30 pm .He was then kept at casuality and on 20/5/18 morning ,went to coma and shifted to chest hospital ICU. On 22/5/18 ,Mr Rajan died and was taken to Mavoor crematorium with the help of Mr Gopalan , Mr Ashokan ,Mr Jithesh, Mr Mahesh .
- 60. • The above mentioned details were presented to the Director of Health Services • Informed about anticipating the second phase of the outbreak, lasting from May 25th to June 5th • Drafted the details of recommendations and notifications to be released if the second wave happens • Soon, informed of the death of a patient, who tested positive, and proved to be a case of the second phase
- 61. • The following steps were then taken – Arrangements for dedicated treatment facilities and laboratory facilities for patients tested positive – Arrangements for isolation of identified contacts – Arrangements for immediate reporting , if and when close contacts developed symptoms
- 62. An experience of immense educational and public health importance
- 64. THANK YOU