Thiruvananthapuram/Ernakulam: When her phone rang a little past 11.45pm on 1 June (a Saturday), doctor Sreedevi knew something was wrong. On the other end, it was N.K. Kuttappan, chief medical officer of Kerala’s Ernakulam district. He wouldn’t have called so late unless a critical emergency was at hand.

Sreedevi is the public official responsible for initiating the government’s surveillance network in the district in case of an emergency epidemic outbreak. There was no way Kuttappan would call on a Saturday at close to midnight, unless there was bad news to share, she thought. It turned out to be about a suspected case of the dreaded virus, Nipah.

Two other people also got calls from Kuttappan in quick succession: K.K. Shylaja—a high school chemistry teacher-turned-politician, a third-time MLA, and Kerala’s health minister; and Rajan Khobragade— the civil servant who had just taken charge as principal secretary of the health department on 31 May.

What happened over the next few weeks under the watch of this small galaxy of early actors is a testament to the far-reaching value of a public health system that works, a rarity in the Indian context. The panic in the hurried phone calls of that Saturday night was palpable. After all, when the dreaded Nipah virus showed up in the southern state last year, 17 of the 18 infected patients had died.

However, a few weeks since, and in sharp contrast to the unfolding tragedy playing out in Bihar’s Muzaffarpur, where over 150 children have succumbed to acute encephalitis in recent weeks, Kerala has managed to close the book on its landmark fight against Nipah without a single death. While the precise nature of the illnesses may be different, Bihar’s handling of its public health crisis couldn’t have been more different from Kerala’s, another state within the same Union with a similar set of limitations.

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Unlike an encephalitis outbreak, which is an annual occurrence, Nipah is sort of like a new-age plague. It is caused by a deadly, brain-damaging virus of the same name that has made only rare appearances across the globe. It killed more than a hundred people when it first appeared in a Malaysian village called Sungai Nipah (hence the name) in 1998. While the treatment for encephalitis involves simple care such as providing glucose and ensuring a meal at night for the patient, Nipah has no known vaccine or cure. Protection, if any, comes from the person’s own immunity and a clampdown on the spread of the virus.

The previous time, in 2018, the virus supposedly jumped to humans via fruits infected by Nipah-carrying bats and then spread rapidly, with a fatality rate of over 70%. But the deaths were just the beginning of the damage. Most of those who died were from the two northern districts of Malappuram and Kozhikode. An outbound flight ban and a freeze on fruit and vegetable exports followed, which crippled several businesses. Tourism and the local economy briefly collapsed.

In its second coming, the virus managed to reach larger cities— Ernakulam, Thrissur, and Idukki district were under the scanner. The fight against Nipah represented a crucial test of Kerala’s substantial public healthcare system in a country that often neglects even basic hospital hygiene. But it also meant the state had an opportunity to lead the global response in fighting the outbreak.

Second coming

On 1 June, Shylaja was coming back to the state capital, Thiruvananthapuram, on a train. Khobragade was in Delhi on official work. They both immediately cancelled their schedule for the days ahead and reached Ernakulam. By then, Shylaja wanted one more person to be pulled into the team... someone who was seen internally as the crucial hand behind tackling Nipah last year: the just-retired additional chief secretary of health, Rajeev Sadanandan, a man who speaks as quickly as he does his work and not known to mince words with anybody. Several colleagues, in private, call him “arrogant". But, to his credit, Sadanandan had predicted a second outbreak nearly six months ago. And that farsightedness was going to help the state immensely in the tense few weeks that lay ahead.

Not many, except those in the upper echelons of Kerala’s health department knew this: while Nipah was waiting in the wings to strike again, Kerala was actively looking out for it too. The state had invested substantially in a network, whose task was to check nearly every newly admitted encephalitis patient— all so that the first case of Nipah (what is known in the medical world as the index case or “patient zero") could be identified as quickly as possible. The reason: the state was too late in catching the outbreak last year. By the time the public health response could kick in, the first patient had already transmitted the virus to a couple of others.

“We embraced the fact that there was a high probability for it to come back. The world across, it has mostly come back for a second time," said Rajeev Sadanandan.

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After last year’s outbreak, Kerala had estimated that 22% of the bats in Kerala are infected with Nipah. The virus can spread from bat to bat rapidly. But the bats won’t die since they are merely carriers. The threat begins once the transmission to the first human being happens. In November 2018, Rajeev had issued a circular asking people to be ready for a return of Nipah between December and June, when the chances of its return peaks.

“I said: there is a high probability, let’s get ready. That was the most important thing that saved us this time," Sadanandan said.

Top doctors, in both public and private hospitals, were asked to raise an alert in cases where people with an otherwise healthy immune system got admitted with pneumonia-like symptoms, the first signs of Nipah. An expert committee was set up to look at such suspicious cases. If suspected to be a Nipah or an Ebola case, it was decided samples would immediately be sent to the Pune-based National Institute for Virology (NID).

In the process, Kerala, in fact, sampled and examined nearly every encephalitis death over the last one year.

It even led to the identification of other rare diseases. When they were testing a patient in Malappuram district, he was found to have the rare West Nile virus.

“WHO (World Health Organisation) has identified nine emerging pathogens that are likely to be found anywhere in the world and there is a tenth one which is called disease X, which is a virus we don’t know yet. Post-Nipah, we have a policy of looking for this virus," said Rajeev.

In short, by the time the first Nipah patient was admitted to a hospital in Ernakulam this June, a system was already in place in Kerala to handle such an emergency public health crisis. But the real challenge began after the virus was confirmed.

The Ernakulam team

He liked mangoes; he ate them a lot; and there are a lot of bats around the house, told the Nipah-hit patient’s family, as Sreedevi looked at him lying down behind the glass doors of the isolation ward at Ernakulam-based hospital, Aster Medcity. The father, who works as a driver, was inconsolable. The mother, a pharmacist at a local hospital, was also struck by grief but understood the gravity of the situation and the potential for a contagious epidemic.

Sreedevi had reached the hospital early on the morning of 2 June, along with colleague and epidemiologist, Vinu. Nipah does not get transmitted via air, but through bodily fluids like cough and saliva. It was imperative for the state to draw up a list of people whom the patient could have been in contact with. Last year, the first patient had acute respiratory distress syndrome, which makes them cough uncontrollably and often. Several patients got Nipah from his cough. This time, the patient was not coughing, so the chance of spread must be lower, Sreedevi hoped. But no chances would be taken.

Sreedevi quickly learned from the patient’s parents that he is a 23-year old student hailing from Ernakulam, studying at a private college in Idukki, who had just returned from a training camp in Thrissur. People in three districts had to be scanned for sure, she thought.

Nearly 30 people were mobilized to launch a massive search for all those who might have come in contact with the patient. The group including Sreedevi, other health workers, collectorate staff, and youngsters from a volunteering group ‘Anpodu Kochi’ (who coordinated distress calls and distribute relief materials during Kerala floods of 2018) drew up a list of about 300 people who might have come in contact with the student within the previous 24 hours. Out of a control room opened with five telephone lines to each person, each one of them was contacted three times a day, routinely checking for fever-like symptoms, while asking them to stay indoors.

“It won’t take Nipah to kill you. If you get a call, you could die even by the whole anxiety about it," said a person whose relative got one such call. “But they were so calm on the call, spoke about the gravity of the situation, asked all members in the house to not move around for some days, and in case if it was needed, even arranged for food and hand gloves to be sent to the house," he said.

Meanwhile, the entire health department of the state had shifted its base to Kochi. Leading the fight was Shylaja, along with her senior aides— three of the top posts in the state’s healthcare system is held by women. There was no red tape for the ground staff to get approvals. They could just walk up and ask the minister who was right there in front of them.

“Something I can be proud of is the way our doctors behaved during the crisis last year and this year," Shylaja said in an interview. “Many of them, a lot of whom were youngsters too, were so driven by medical ethics that they tried their best to save lives, even as their lives were at risk by doing so. The nurses too should be saluted. I was so worried and anxious thinking about their lives," she said.

The game changer

The only thing Kerala lacked was testing facilities. Every time it needed to test a Nipah-suspected patient for final confirmation, the sample had to be flown to the NIV testing center in Pune. It would take 24 to 36 hours to get the results. On 6 June, something of a game changer happened.

“Rather than sending the sample and testing it in Pune, they allowed the whole set up to be shifted to Ernakulam. A lab was set up and we could get the results in three to four hours," said Rajan Khobragade. “The advantage is that the moment the news goes out that a sample has been sent to Pune, everybody in the state gets anxious. Many times, this has led to confusion in the public mind and in social media... that the results have arrived but the government is not disclosing details," he added.

The 23-year old student was eventually moved out of the isolation ward once his condition progressed over the weekend. The remaining people who were still under observation after having come into contact with the man in the last few weeks, along with the two nurses who treated him, were also cleared. However, some questions still remain, mostly hinging on the origin point of the latest outbreak and why it made an appearance in Kerala once again within such a short span of time.

The epicenter of Nipah in southeast Asia is in Bangladesh. Experts say that from Bangladesh the bats flew to West Bengal to spread the virus. But bats can usually fly only within a radius of about 50km. The distance between West Bengal and Kerala is more than 2,000km. Why has the virus not shown up in other places along the way? Or is Kerala’s virus coming from somewhere else? Or is it merely that other states have not picked it up? All those possibilities remain, until Nipah shows up again.

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