Punjab government has issued guidelines for healthcare providers and public at large for prevention/control of Nipah Virus (NiV) infection after reporting of cases in the neighboring countries.

Director General Health Services Punjab has put Chief Executive Officers (CEOs) of District Health Authorities (DHAs) across the province on alert to prevent outbreak in their respective areas of jurisdictions.

“Ensure timely uploading of all suspected Nipah Virus cases on DSS, circulate NIH guidelines to all public and private sector hospitals and monitoring and isolation of patients with sign & symptoms. Ensure timely investigation, sample collection for PCR and transportation to laboratory”, reads a letter sent to the CEOs of DHAs.

Nipah Virus (NiV) Infection:

Nipah virus (NiV) infection is an emerging zoonosis that causes severe disease in both animals and humans and is endemic in South-East Asia Region. NiV was initially isolated and identified in 1999 in Malaysia and Singapore during an outbreak of encephalitis and respiratory illness among pig farmers and people with close contact with pigs.

In May 2018, confirmed cases of Nipah virus (NiV) infection including fatalities were reported in the southern state of Kerala, India.  As of 25 May 2018, a total of 36 confirmed cases including 11 deaths were reported.

Clinical Picture:

Infection with Nipah virus is associated with encephalitis. After exposure and an incubation period of 5 to 14 days, illness presents with 3-14 days of fever and headache, muscle pain, nausea and vomiting, followed by drowsiness, disorientation and mental confusion.

These signs and symptoms can progress to coma within 24-48 hours.

Some patients have a respiratory illness/influenza like illness (ILI). Long-term sequel following Nipah virus infection has been noted, including persistent convulsions and personality changes. It has 74% mortality rate.

Infectious Agent:

Nipah virus belongs to Henipavirus genus of Paramyxoviridae family.

Host! Reservoir:

Fruit bats of genus Pteropus, family Pteropodidae (also known as flying-foxes) are the natural hosts of the virus.

Mode of Transmission:

Nipah virus can be transmitted to humans from animals (bats, pigs) consumption of fruits contaminated with droppings/secretions and can also be transmitted directly from human to human.

Seasonality:

Outbreaks in South-East Asia occurred during winter and spring.

Suspected Case:

Respiratory features (cough, breathing difficulty) with acute encephalitis symptoms, acute onset of fever and altered mental status, seizure or any other neurological deficit.

Epidemiological linkage like drinking raw date, palm sap or travel to Nipah endemic areas.

Probable Case:

Any suspected case with epidemiological link or positive serological testing.

Confirmed Case:

Any suspected/probable case with laboratory confirmation of the disease

Lab Confirmation:

Procedures for the laboratory diagnosis of NiV include serology,histopathology, PCR and virus isolation. Specimens for virus isolation should be collected every second day of infection.

Treatment:

No vaccination for human use is available. Supportive care is recommended as no specific antiviral are available. Treatment is mostly focused on managing fever and the neurological symptoms.

Severely ill individuals need to be hospitalized and may require use of ventilator.

The clinical usefulness of ribavirin remains uncertain.

Risk Assessment in Pakistan:

The overall risk of disease occurrence in Pakistan is low.

Till date, there is no report of documented animal or human cases of NiV infection in.

However, there are several factors which could allow NiV emergence like evidences of the presence of Pteropus giganteus species of bats and having long border with India where outbreak has been documented.

Preventive Measures:

Eat fruits only after proper washing and improve public awareness.

Do not eat partly consumed fruits which may be contaminated with secretions from fruit bats.

Avoid exposure to sick pigs and bats in endemic areas.

Advice for Health Professionals:

Healthcare professionals should be aware of the signs and symptoms of NiV and obtain a travel history when assessing patients.

Health professionals caring for patients with suspected or confirmed NiV infection, or handling specimens from them, should implement standard infection control precautions at all times.

As human-to-human transmission, in particular hospital (nosocomial) transmission has been reported; contact and droplet precautions should be used in addition to standard precautions.

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