Indian Journal of Public Health

: 2019  |  Volume : 63  |  Issue : 3  |  Page : 261--264

Nipah outbreak in North Kerala – What worked? Insights for future response and recovery based on examination of various existing frameworks

Asma Ayesha Rahim1, Thomas V Chacko2,  
1 Professor, Department of Community Medicine, Government Medical College, Manjeri, Kerala, India
2 Professor, Department of Community Medicine, Believers Church Medical College and Hospital, Thiruvalla, Kerala, Director, PSG-FAIMER Regional Institute, Coimbatore, Tamil Nadu, India

Correspondence Address:
Thomas V Chacko
Department of Community Medicine, Believers Church Medical College and Hospital, St Thomas Nagar, Kuttapuzha, Thiruvalla - 689 103, Kerala


Asia Pacific region has been witnessing numerous public health emergencies in recent years with the Nipah outbreak in North Kerala (2018), India, needs special mention. Threats posed and experiences gained have compelled health systems to draft frameworks nationally and internationally for preparedness, outbreak response, and recovery. Our failure to obtain comprehensive guiding frameworks for application in the Indian context for Ebola, Severe Acute Respiratory Syndrome, Influenza A (H1N1), and Nipah outbreaks led us to the search outside India for frameworks that have worked in the past. A thorough review of the WHO, Centers for Disease Control and Prevention, and Malaysian framework was done to identify explicit components and replicable objectives to the national context. In the absence of a specific framework, Nipah recovery and response experience that worked in Kerala outbreak (2018) was compared against novel H1N1 (2015) guidelines at national level. This article provides the groundwork and insights as a value addition toward an India-specific framework of action for response and recovery for Nipah outbreaks in future.

How to cite this article:
Rahim AA, Chacko TV. Nipah outbreak in North Kerala – What worked? Insights for future response and recovery based on examination of various existing frameworks.Indian J Public Health 2019;63:261-264

How to cite this URL:
Rahim AA, Chacko TV. Nipah outbreak in North Kerala – What worked? Insights for future response and recovery based on examination of various existing frameworks. Indian J Public Health [serial online] 2019 [cited 2020 Aug 6 ];63:261-264
Available from:

Full Text


The Asia-Pacific region has experienced numerous public health emergencies in recent years arising from emerging and reemerging diseases such as Nipah virus (Niv), severe acute respiratory syndrome, avian influenza, and influenza A (H1N1).[1] Threats posed by these emerging diseases compel health systems and international health agencies to be constantly prepared and vigilant against the occurrence of these diseases. Experiences gained during these outbreaks have further strengthened national capacities to respond to such situations to protect the health of populations.[2] A number of frameworks and guidelines have been prepared at international and national levels for response and recovery from outbreaks and epidemics. Frameworks for Ebola virus response and recovery need special mention in this regard. Although Nipah outbreaks have occurred in India at Siliguri (2001) and Nadia (2007) in West Bengal, literature search and websites in India did not yield any standard operational guideline with focused components on outbreak response and recovery for the disease.

The closest available document in Southeast Asia in this regard is the detailed operational guidelines with WHO technical support from Bangladesh, and this could be explained by more Nipah outbreaks happening in Bangladesh than in India.[1]

Following the recent Nipah outbreak in May 2018, this gap in knowledge/lack of standard operational guidelines at national level led the authors to the search for articles and guidelines that already exist elsewhere outside India and have worked in the past in those settings. At the international level, agencies have drafted epidemic response and containment framework for Ebola, which appears to be the closest fit for Nipah and may be adapted for Nipah.[3],[4],[5] Nipah additionally shares the similarity in transmission with Ebola in that it is not transmitted through airborne spread like influenza, but rather from person-to-person, or animal-to-person, through direct contact with body fluids or blood. In this process, the authors tried to identify explicit components and replicable objectives for response and recovery suited to Nipah from these frameworks, particularly Ebola. Opportunity also presented to identify activities that worked in the widely appreciated Nipah control measures undertaken at the local level using action checklists adapted from two frameworks, namely Management Sciences for Health Framework checklist and WHO Framework for Ebola and Marburg outbreaks (2014).[4],[5]

This article presents our findings emerging from a focused study in response to the need for an appropriate response triggered by the Nipah outbreak by searching for comparable frameworks elsewhere with a best-fit framework for outbreak response and containment.

 The History of NIPAH

Niv infection was first recognized in peninsular Malaysia (September 1998–April 1999). The first identification of NiV as a cause of an outbreak of encephalitis was reported in 2001 (Bangladesh). Since then, outbreaks of NiV encephalitis have been reported almost every year from Bangladesh (2001–2012).[1],[6]

Description of the process from the genesis of the idea (the recent outbreak in Kerala) about the need for a guiding framework to development of framework for possible adoption by an expert committee

Treating physicians at an NABH-accredited private health facility at Kozhikode, where a 26-year-old male got admitted with clinical features of encephalitis noted tachycardia and hypertension, which is highly improbable in an encephalitis case. History of death of the patient's sibling 12 days ago at a Government health facility with an inconclusive diagnosis presented the leading clue. Symptoms of both siblings closely matched those of the patients affected in the NIPAH outbreak in Malaysia (1998). Diagnostic samples were dispatched to Manipal Centre for Virus Research (MCVR), a biosafety level-3 laboratory, and to NiV, Pune, for confirmation. Confirmation came out on May 20, 2018, from MCVR as the first NiV outbreak in South India. Outbreak left 17 dead out of the 19 confirmed cases as on June 1, 2018, and the two affected districts were Kozhikode and Malappuram. Majority of cases had a history of visiting or being admitted in the Government health facility. The outbreak was contained and declared over on June 10, 2018.

Against this background, the authors sought to explore if any particular framework or guideline has been followed at the regional and national level for rapid response and containment of Nipah outbreak. Applicability of each framework to Nipah outbreak was assessed based on the area of focus, theme, intended audience, and best practice principles [Table 1] and [Table 2].{Table 1}{Table 2}

Table 1 and Table 2 depicts existing frameworks and specific disease frameworks and guidelines at the global level.[2],[5],[7]

A search for best fit among existing national frameworks

A close scrutiny of the existing frameworks for diseases with similar epidemiology at the national level revealed three notable guidelines: (a) Ebola virus, (b) Influenza pandemic A H1N1 epidemic, and (c) Zika virus.[6],[8],[9]

Although Ebola virus guidelines issued by the Government of India, adapted from the WHO framework serves as a valuable document toward developing national framework for Nipah, existing H1N1 guideline has distinct components perfectly fitting to the outbreak containment actions carried out for Nipah.

Various frameworks as stated in [Table 1] and [Table 2] helped us to narrow down the goodness of fit of the key components as noted in the WHO Ebola and Marburg framework which may be successfully adapted for developing India-specific framework.[10]

 Emergence of Components of Proposed Framework

The first author had kept a record of timeline of events and actions at the state level, compiled the news clippings and tracked events, and being involved and entrusted with contact tracing operations. In the absence of an end-of-epidemic report for reference, these records served as a valuable tool for the present study. Using the existing national action plan for H1N1, Nipah response was assessed in some detail under three major subheadings, that is, “major components of the framework,” “lead agencies,” and “actions that worked.” A brief description of these based on the Kerala experience is given below so that they can lead to development of Nipah-specific national guidelines.

Component I: Institutional framework, planning, and coordination

Lead agencies: Ministry of Health and Family Welfare (MOHFW), National Institute for Communicable Diseases (NICD), and Director General of Health Services (DGHS) (Center) SG/district authorities (state)Actions that worked in Kerala: Political commitment, rapid response teams, urgent mobilization of manpower and materials, guidelines for clinical case management, and WHO assistanceInsights for future action (in alignment with the WHO framework): Develop national framework suited to local context incorporating lessons learnt from Nipah outbreaks in the years 2001, 2007, and 2018.

Component II: Surveillance and laboratory support

Lead agencies: DGHS, Indian Council of Medical Research/SG, and NICD/Integrated Disease Surveillance ProjectActions that worked: Clinicoepidemiological case investigations, framing case definitions, active surveillance, reporting, forecasting, targeted interventions among high-risk groups, animal surveillance and detection, medical follow-up of survivors, and monitoring recovering patientsInsights for future actionRapid diagnosis through the platform of multiplex polymerase chain reactionDiagnostic pathological autopsyInternational collaboration (candidate vaccine/laboratory diagnostics)Genomic studies and seroprevalence surveysEnhanced wildlife surveillance, veterinary surveillance, collaboration with animal health services, and prealert animal early warning.

Component III: Logistics

Lead agencies: MOHFW/SGActions that worked: Assessment of supplies and availability and drafting clinical management protocol. Ribavirin approved for the use by Drugs Controller General of India. Monoclonal antibodies procured. Suggestion to use of Favipiravir[3]Insights for future action: Research into candidate vaccines, drugs and evidence-based treatment, logistical support for field operations, and safety of response teams.

Component IV: Hospital systems

Lead agencies: MOHFW/DGHS/SGActions that worked: Surveillance protocol, additional surge capacities to cope morbidity in both government and private sector, review of clinical management protocols/infection control practices, and training and implementation as per the protocolInsights for future action-

Effective triage facilities in the casualty with optimal infection control and periodic reviewAccreditation of health-care institutions in the stateEthical issues related to protecting patients' rights in clinical research activities.

Component V: Communications

Actions that worked: Updated and reinforced key messages to health-care functionaries, regular updates to the WHO and other national partners, and dissemination of IEC materials through mass mediaInsights for future action: Newer tools for communications, dissemination of validated key messages through a centralized system, dissemination of end-of-epidemic report, and evaluation of the management of the epidemic.

Component VI: Regulatory framework

Lead agencies: MOHFW/WHO/SGActions that worked: Enforcement of social distancing measures by district collectorsInsights for future action: Drafting a comprehensive public health law as a notable absence of a regulatory framework exists, psychosocial support for families of victims, the community, and health-care workers.

Component VII: Community participation

Lead roles: Representatives from local bodies, humanitarian assistance organizations such as compassionate Kozhikode, religious organizations, and NGOs and INGOs operating in the area with special mention of Kerala Sasthra Sahithya ParishadActions that worked: Representation from as many as possible sectors toward spreading awareness on Nipah prevention, allaying fears, and anxiety of general public and humanitarian relief efforts to families of Nipah victims.

 Summary and Conclusions

This article sums up and depicts some of the relevant, available frameworks for infectious diseases, with special focus to Ebola, H1N1, and Nipah in India at the global and regional levels. Creation of a systematic guiding framework on similar lines suited to local context, helps to guide Nipah outbreak response in the future. In view of the high case-fatality rates of Nipah, the earlier this is done, it is better in terms of suspected cases being assessed with infection control measures applied to avert secondary infections to a large extent. The authors hope this article provides the groundwork and insights as a value addition in terms of processes followed for planning and developing frameworks and can inform policy-makers and national experts in India to frame an India-specific framework of action for response and recovery for Nipah outbreaks and epidemics in the future.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Guidelines for Surveillance, Diagnosis, Case Management, Prevention and Control of Nipah Virusencephalitis; 2011. Available from: [Last accessed on 2018 Jul 30].
2Malaysia Strategic Workplan for Emerging Diseases 2012-2015. Available from: [Last accessed on 2018 Aug 02].
3International Red Cross and Red Crescent Movement Ebola Strategic Framework; January 2015. Available from: [Last accessed on 2018 Aug 04].
4MSH Framework for Ebola Response and Recovery at the Local Level. Available from: [Last accessed on 2018 Aug 03].
5WHO. Ebola Response Phase 3: Framework for Achieving and Sustaining a Resilient Zero; 2018. Available from: [Last accessed on 2018 Aug 27].
6Guidelines for Ebola Virus Disease: National Centre for Disease Control. Ministry of Health and Family Welfare, Government of India; 2015. Available from: [Last accessed on 2018 Aug 24].
7Morbidity and mortality due to Nipah or Nipah-Like Virus Encephalitis in WHO South-East Asia Region, 2001-2018. Available from: [Last accessed on 2018 Aug 27].
8Influenza Pandemic Preparedness and Response Plan. Directorate General of Health Services. Ministry of Health and Family Welfare, Government of India. Available from: [Last accessed on 2018 Aug 24].
9National Guidelines for Zika Virus. MOHFW. Available from: ka-virus-disease. [Last accessed on 2018 Aug 24].
10WHO. Ebola and Marburg Virus Disease Epidemics: Preparedness, Alert, Control and Evaluation; 2014. Available from: [Last accessed on 2018 Aug 25].