On September 10, 2023, four patients were admitted to the Aster MIMS hospital Kozhikode. Two minor siblings aged 9 and 4, their 22-year-old uncle and their 9-month-old cousin had fever. The minors were admitted to the pediatric departments while the uncle became an in-patient in the pulmonology department as he had breathing trouble and developed seizures. A team of multidisciplinary doctors led by Dr. Anoop Kumar AS, a Critical Care specialist, tested the four patients for common viruses to find out if they were infected by influenza, coronavirus or other such respiratory diseases. Dr Anoop, who was instrumental in detecting the Nipah virus outbreak in Kerala in 2018, says the team of doctors saw two red flags which eventually led them to detecting the latest outbreak of Nipah virus in the state.

While collecting the family history, the doctors discovered that the father of the two siblings, 49-year-old Mohammed Ali, had died on August 30. The doctors at Aster MIMS immediately got in touch with the private hospital where Ali was admitted. By then, the four patients at Aster MIMS had tested negative for any common virus. “We found that the father had died and he had bronchopneumonia. Though he died of multi-organ dysfunction, he had slurring of speech and diplopia. Diplopia is dual vision,” Dr Anoop says. Ali’s elder son, meanwhile, had severe breathing difficulties and had epileptic seizures and was shifted to the ICU.

This immediately triggered suspicion that the family could have been infected by the Nipah virus. Nipah is a zoonotic virus that is spread from animals such as infected pigs or bats to humans. It can also be transmitted through contaminated fruits (half-eaten fruits by fruit bats), and even by direct contact with sick persons. Symptoms include fever, headache, fainting and nausea. Some experience choking, stomach pain, vomiting, fatigue and blurred vision. The patient can possibly go into a coma just two days after the symptoms begin. The chance of contracting encephalitis or inflammation of the brain is also high.

The second red flag was where the family lived- the Maruthonkara grama panchayat in Kozhikode. “This was close to the 2018 epicenter of the Nipah virus outbreak. Fruit bats in a forest area nearby had tested positive for Nipah during the survey then,” Dr Anoop says. One thing became clear to Dr Anoop and others- there was an index patient and a cluster had formed.

The doctor directly spoke to state Health Minister Veena George alerting the government of the possibility of a Nipah virus outbreak. As the hospital was collecting blood samples to be sent to the National Institute of Virology in Pune, another patient was brought to Aster MIMS on the evening of September 11. A 40-year-old man who hails from Ayanchery in the Vadakara taluk of Kozhikode was first admitted to a private hospital in Vadakara with symptoms of pneumonia. Within a few minutes of shifting him to the emergency ward in Aster MIMS, the patient died of a cardiac arrest. “He too had a fever for three days, the disease had progressed rapidly unlike other viruses,” Dr Anoop says. Though the doctors immediately suspected Nipah, initial queries with the family showed no links between index patient Mohammad Ali and the new patient. While Muhammed Ali was from Maruthonkara Grama Panchayat, the other deceased person was from Ayancheri, which was 20 kilometers away.

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