Here's how Kerala is responding to Nipah outbreak after teenaged boy loses life

Fourteen-year-old Ashmil Danish from Pandikkad, Malappuram, dreamt of being a footballer. He practiced regularly and was a decent player for his age group, even being named Player of the Month by his academy last September.

He chose Panthalloor HSS over the nearest school for his high schooling to pursue his career in football. Tragically, the deadly Nipah virus has violently tackled Danish's aspiration, abruptly ending his life at this tender age. Former India captain IM Vijayan has shared a touching video of Ashmil Danish practicing on a pitch, with the heartfelt message, "Condolences, dear son" on social media.

Danish succumbed to the virus, despite the doctors administering a monoclonal antibody, as a desperate life-saving measure authorised by the medical board. The antibody was procured from Australia by the Indian Council of Medical Research. “In his case, the deadline for the infusion of antibodies had passed. Still, the medical board authorised the administration as a desperate life-saving measure,” said Veena George, the state health minister.

Kerala records another death

Danish is the 21st victim of this lethal zoonotic virus in Kerala since it was first identified in Kozhikode in May, 2018. According to data from the WHO, there were 17 deaths and 18 confirmed cases in the initial outbreak (The patient zero, Sabith, died before he was tested, so the official death toll with the Government of Kerala would be 16, with two survivors, Ubeesh and Ajanya). A 23-year-old student who contracted the virus in 2019 managed to survive, though he has since developed severe health issues. Another three deaths were reported in 2021 and 2023. The effective intervention of Kerala’s renowned public health system is credited with the recovery of six patients who were laboratory-confirmed cases.

Nipah virus disease was first identified in Malaysia in 1998 and subsequently in Singapore. It then spread to Bangladesh and India, where it was first reported in Siliguri, West Bengal, in 2001. Since 1998, Nipah virus disease has affected around 700 people across various countries, with approximately 400 deaths. Nipah continues to be reported sporadically in Bangladesh, with 14 cases reported last year, 10 of which were fatal. The disease has also reemerged this year.

Fruit bats natural carriers

The fruit bats of the genus Pteropus, which feed on fruit, are natural carriers of the Nipah virus. The virus spreads through the bat's saliva, urine, faeces, and nasal secretions. It can also be transmitted to humans via the consumption of fruits that have been discarded by bats or through intermediate hosts that come into contact with these secretions. In Bangladesh, the virus reached humans through beverages made from contaminated palm sap.

Even though the efforts of the Kerala government and the health department —particularly KK Shailaja, the health minister in the first Pinarayi Vijayan cabinet, for her commendable handling of the situation — were widely appreciated internationally, the fact that the source of infection for the index cases remained unidentified was a cause for concern. In 2018, 2019, and the recent cases, it is still unknown how patient zero contracted the virus.

“While there was no way to establish with absolute certainty how he was infected, we were told by neighbours and friends that the young man was very outdoorsy, fond of animals and often took care of different creatures. One presumes that perhaps he picked up a little bat and thereby caught the infection. It is common for small bats in particular to fall off trees and it is humane to put them back. He couldn’t have imagined that his love for nature would prove so catastrophic,” Shailaja later wrote in her autobiography, ‘My Life as a Comrade’. In Danish’s case also the source of infection is yet to be ascertained.

Opportunity missed: WHO

According to the WHO’s health emergency information and risk assessment report, during the initial outbreaks “the opportunity was missed to prospectively and timely collect accurate data to further understand the epidemiology, clinical and virologic characteristics of NVD and make a timely introduction of emergency-driven clinical trials of various curative treatment options”.

The report further stated that technical shortfalls were compounded by a relatively inexperienced cadre of surveillance personnel who required additional training in field epidemiology and data analysis. Despite ongoing and close collaboration between India and WHO, data sharing regarding the extent of the outbreak response and its effectiveness was sparse.

“Nipah is a very rare disease, infecting individuals unexpectedly. It can be transmitted through handling fruit or other objects contaminated with bat saliva, urine, or other secretions. Identifying the exact source of the virus is extremely challenging. No similar virological situation has been identified anywhere else in the world. Despite knowing that almost 100% of these efforts have failed, we continue to persevere. To expedite our efforts, a specialised institute dedicated to Nipah research was established in Kozhikode in 2023 as part of the ‘One Health’ initiative. Kerala is likely the place with the highest number of natural objects tested for the Nipah virus. We will continue this work because finding an answer to this problem is crucial,” explains Kerala Health Minister Veena George.

Opposition slams govt

Now, the Opposition in the state is amplifying these points to hold the government accountable, arguing that the administration lacks the necessary data. Leader of Opposition VD Satheesan has stated that the death of a child due to Nipah virus infection is a dangerous sign that infectious diseases are still prevalent in Kerala. “It is unfortunate that a boy lost his life due to Nipah. This shows that infectious and communicable diseases are still present in the state. The Opposition raised the issue of the spread of epidemics and the deterioration of public health in the state Assembly, but the government has failed to address it," he said.

Dr SS Lal, a former WHO technical officer who unsuccessfully contested as a Congress candidate in the 2021 assembly polls, went a step further by accusing the government and the health minister of destabilising the entire department for the sake of ministerial one-man shows. “I am not calling for your immediate resignation. We need to use our existing resources to save lives. However, understand that the role of health minister is not suitable for you. Once this critical situation is resolved, you should request the chief minister to assign you to a less demanding department,” he wrote in an open letter to the minister.

Situation under scanner

With seasonal fever coupled with cases of amoebic meningitis, H1N1 fever, and now the reemergence of Nipah, the public health situation in the state is once again under scrutiny. There are increasing calls for a comprehensive overhaul from many quarters, including leftist circles.

“Based on recognised standards like infant mortality rate and life expectancy, Kerala is considered to be on par with developed countries in the health sector. However, it is notable that many infectious diseases, which have been eradicated or controlled in other developing countries excelling in healthcare like Cuba, Nicaragua, and Sri Lanka, are still present in Kerala. Considering the presence of these infectious diseases and applying negative weightage, Kerala may fall behind other countries in terms of healthcare excellence,” opined Dr B Ekbal, renowned neurosurgeon, public health activist and state planning board member.

“To address Kerala's health crises, it's crucial to enhance public health interventions alongside expanding treatment facilities. Despite the presence of numerous public health experts at various institutions, their expertise has not been fully utilised. More detailed studies and effective use of these experts are needed. Programs should be developed to collaborate with medical colleges, public health institutions, and local bodies to study regional health issues, propose solutions, and assist in creating health projects and initiatives,” suggested Dr Ekbal.