15-05-2025
The return of the dread
Sulaiman, a headload worker at Valanchery, had never missed the Workers' Day celebrations in over 20 years. But this May Day was different.
Instead of joining his co-workers, Sulaiman rushed his 42-year-old wife to clinics and hospitals, her health faltering with each passing moment. By midnight, she lay critically ill in the emergency wing of the EMS Memorial Cooperative Hospital at Perinthalmanna.
In the early hours of May 2, in the intensive care unit (ICU)'s sterile silence, she slipped into a coma. Her loved ones' world began shrinking to a terrifying reality as Sulaiman and their three children waited in frozen worry.
Their house at Thaniyappankunnu in Valanchery municipality stood still and silent, its doors locked since that fateful day. In the portico, two plastic chairs sat dusty and abandoned. Washed clothes flapped gently on a clothesline beneath a tarpaulin while Sulaiman's Hero bike lay idle behind the house. The 15-cent compound remained untouched. The locked house and its eerie compound provided a poignant reminder of life paused.
Nine wards within a three-kilometre radius of their house, encompassing areas of Valanchery municipality and the neighbouring panchayats of Marakkara, Edayur, and Athavanad, were declared containment zones on May 8, the day the woman tested positive for the deadly Nipah virus.
The State Health department sprang into action with Minister for Health Veena George herself rushing to Malappuram to formally announce the confirmation of the Nipah case.
Three cases in 10 months
Within 10 months since July last year, Malappuram reported three Nipah cases. A 14-year-old schoolboy succumbed to Nipah at Chembrassery, near Pandikkad, in July last year, followed by the death of a 24-year-old man from Naduvath, near Wandoor, in September. The Valanchery woman, the latest Nipah patient, fights for her life in the ICU with encephalitis having plunged her into a coma.
'We are all praying for her to come back,' say her neighbours K. Balakrishna and his wife Savithri. They appeared unfazed by Nipah. So was T. Bindu, another neighbour. 'It can affect anyone; it just happened to be her,' Balakrishna and Savithri add with a shrug.
They had not interacted with the woman since she fell ill with fever and headache on April 25. 'We may be close, but we don't visit like we used to. We would chat from across the tree-lined boundary of our homes,' Savithri explains.
Deepening mystery
The mystery surrounding the woman's Nipah infection deepens as her neighbours report that she rarely ventured out and mostly stayed indoors. 'Whenever she went out, she would be with her husband on his bike,' recounts Balakrishna. The source of her infection remains unknown.
'We know that days before falling ill, she had visited her siblings at Thiruvegapura in Palakkad district, where she exchanged fruits with them,' says Parassery Veerankutty, the municipal councillor representing Thaniyappankunnu ward.
He has been at the forefront to help the health and animal husbandry officials who conducted surveys in the area, and to spread awareness about the health protocols to be followed, including the isolation, and precautions against the spread of the virus.
'Masks are a must when we are among people. Better be safe than sorry,' Veerankutty cautions a small group of youngsters at Thaniyappankunnu, reminding them of the importance of following the guidelines issued by the health workers and taking the required precautions.
The Nipah-affected woman's house compound and surroundings were quintessential Malappuram with lush trees of different sizes thriving in the area. There were mango, jackfruit, papaya, guava, and bilimbi fruit trees aplenty. A small bilimbi tree laden with fruits stood sentinel at the front right corner of her house. Behind, an unused one-acre plot belonging to another joint family offered a veritable feast, overflowing with mangoes and jackfruits that likely drew fruit bats to the area.
'We strongly suspect a bat-bitten fruit as the source of her infection; but without evidence, it is hard to say for sure,' says C. Shubin, District Surveillance Officer, Malappuram.
Dr. Shubin, supported by District Medical Officer R. Renuka and her team, has been instrumental in detecting the three Nipah cases in Malappuram over the past 10 months. 'We ought to be prepared for further cases,' warns Dr. Renuka.
Dr. Renuka and the team had issued a pre-emptive warning against potential outbreaks of deadly diseases like Nipah before the summer peaked. They had advised the people against consuming fallen fruits, especially those bitten by birds and bats. People were also warned to maintain strict hygiene while dealing with domestic animals.
Surveillance of certain ailments, particularly encephalitic cases, has been ramped up in Malappuram since 2022. Apart from government hospitals, major tertiary hospitals in the district too have been trained to deal with encephalitic cases, especially with the Nipah risk in mind.
Nipah infection often progresses to Acute Encephalitis Syndrome (AES) after initial symptoms like fever, headache, and vomiting. Monitoring AES cases helps detect early warning signs of an outbreak, enabling timely treatment and interventions, according to medical experts.
'We identified all the three Nipah cases reported in Malappuram since last year through this surveillance. No AES or Acute Respiratory Distress Syndrome (ARDS) cases can go unreported under the current surveillance system, whether in private or government hospitals,' says Dr. Shubin. 'Our private hospitals are cooperative in promptly reporting the cases,' he adds.
Malappuram's major tertiary private hospitals are equipped with ICU isolation facilities, enabling them to effectively manage viral outbreaks like Nipah. 'Handling a Nipah suspect is no longer a cause for concern,' asserts Shubin.
Enhanced surveillance
Experts caution that eliminating Nipah may be impossible due to the complexity of factors leading to outbreaks. However, enhanced surveillance of AES cases can facilitate early detection and swift isolation of contacts, potentially preventing transmission, they say.
Research has identified fruit bats, specifically Pteropus species or flying foxes, as the natural reservoirs of Nipah virus. While the exact transmission route to humans remains unclear, it is suspected that contaminated fruits, bitten or licked by bats, may play a role in spreading the virus. The possibility of an intermediary host facilitating transmission is still being investigated.
Bat researcher Sreehari Raman, assistant professor at Kerala Agricultural University, who identified six fruit-eating bats among the 48 bat varieties found in Kerala, says that ectoparasites living on the body of bats may work like vectors. 'It is also a possibility apart from the transmission through fruits bitten by bats,' says Sreehari.
Another potential transmission route is through the consumption of bats, a practice still observed among some indigenous tribes in Kerala. 'I encountered several individuals who ate bats during my research, but the practice appears to have decreased following the Nipah outbreak and awareness campaigns,' he says.
Some unusual observations
His encounters with bats have led to unusual observations such as bats eating fruits stored in shops. 'I captured footage of bats feeding on bananas in a fruit shop. After showing the video to the shop owner, he promptly covered the potential entry points with a large net to prevent further access for the flying foxes,' he says.
Human activities such as urbanisation and deforestation are suspected to be a leading cause of virus spillover. According to studies, driving away bats by destroying roosting trees can cause changes in their habits. 'The viral load seems to be the highest during the breeding season. But this has to be studied to say for certain,' says Sreehari.
According to health officials, preventing bat virus spread requires a two-pronged approach: swift outbreak response and vigilant bat population monitoring. The World Health Organisation (WHO) has endorsed the One Health approach to integrate human, animal and environmental health as part of controlling zoonotic diseases like Nipah. 'It promotes a balanced relationship between humans, animals, and nature,' says Health Minister Veena George.
Deaths of cats, fowls
In Valanchery, animal husbandry officials joined the anti-Nipah drive by surveying within a 500-metre radius of the Nipah patient's house. They collected animal samples for antibody detection. The recent deaths of cats and fowls in the area are still a cause for concern amid intensified fever surveillance by health officials.
'We are doing a combined field investigation as part of the One Health concept. If the virus is traced early in animals, the spread can be contained easily,' says T.N. Anoop, district programme manager of the National Health Mission.
Research by the Indian Council for Medical Research's National Institute of Virology, Pune, found Nipah antibodies in bats across 10 States, including Kerala, Tamil Nadu and Maharashtra. However, Kerala, particularly Malabar, frequently reports Nipah outbreaks, sparking curiosity about the underlying reasons for this regional concentration.
According to A.S. Anoop Kumar, the critical care specialist who identified the deadly virus when Nipah broke out for the first time in Kerala in 2018, Nipah cases might be going undetected in other States due to limited testing. Kerala's frequent Nipah cases could be due to the State's enhanced vigil and routine screening, he feels.
Extent of virulence
The high mortality rate (70% and above) of Nipah virus makes it a matter of significant concern. Investigating whether the current strain retains the same virulence as the 2018 outbreak is crucial for understanding the outbreak's potential severity and guiding public health responses. 'I think it is less virulent now. That's why the rate of secondary infection went down in the latest incidence,' says Mohammed Ismail, former deputy district medical officer.
But Dr. Anoop disagrees. 'We have a solid surveillance system and a clear action plan. Unless studies prove it, we can't say the virus has lost its virulence,' he says.
As Sulaiman and his children are taking turns outside the ICU of the hospital all through the day hoping for her early return to normal life, medical experts are working overtime to help her battle the crisis. The villagers are also keeping her in their prayers to see her come back to a healthy life.
