Bangladesh's Nipah Virus Outbreak

News on Disease Outbreaks Virus

Overview of the Current Situation

In Bangladesh, outbreaks of NiV infection typically occur between December and April, coinciding with the collection and consumption of date palm sap. As of 9 February 2024, two confirmed instances of NiV have been reported in the Dhaka division, both of which resulted in fatalities. The World Health Organization has classified the national risk level as moderate due to the seriousness of the illness, the limited treatment options, the cohabitation of bats and potential zoonotic transmission, and the absence of approved vaccines for NiV prevention.

Overview of the Circumstances

Two cases of NiV infection were reported to the World Health Organization (WHO) by the Bangladesh National Focal Point (NFP) for the International Health Regulations (IHR) on 30 January and 7 February 2024. These cases were not linked epidemiologically.

The first case was officially reported on January 21, 2024.

A 38-year-old man from Manikganj district in Dhaka division was the initial patient. The man experienced a fever on 11 January 2024, which was followed by respiratory distress, restlessness, and insomnia. He was then admitted to a nearby hospital on 16 January and later transferred to the intensive care unit of a hospital in Dhaka City on 18 January. Due to deterioration of his symptoms, he had to be intubated.

Samples of blood and throat were obtained on 21 January and the patient’s results showed a positive outcome for NiV RNA through reverse transcription polymerase chain reaction (RT-PCR) on the throat sample. Additionally, enzyme-linked immunosorbent assay (ELISA) detected anti-NiV Immunoglobulin M (IgM) in the serum. The patient was subsequently moved to a hospital in Dhaka city on 27 January and passed away on 28 January.

On December 31, 2023, the individual in question had a past of consuming unpasteurized sap from date palms. By January 30, 2024, a sum of 91 individuals had been pinpointed as potential contacts, which included 11 relatives, 20 community members, and 60 healthcare workers from various hospitals. Nevertheless, none of these contacts were found to be positive for NiV through PCR testing or detection of anti-NiV IgM through ELISA.

On 31 January 2024, a second case was confirmed.

On January 30, 2024, a three-year-old girl from Shariatpur district, Dhaka division, was brought to a medical facility exhibiting symptoms of fever, altered consciousness, and seizures for the past two days. The diagnosis was encephalitis and shock, leading to the patient’s transfer to a different hospital in Dhaka city on the same day. Blood and throat samples were taken on January 30 and 31 for testing, which confirmed the presence of NiV infection through RT-PCR for throat sample and ELISA for anti-NiV IgM in the serum. Unfortunately, the patient passed away on the same day.

The individual in question had a habit of regularly consuming freshly extracted sap from date palm trees. As of February 7, 2024, a total of 67 people were identified as potential contacts, which included three relatives, 21 members of the community, and 46 healthcare workers from various hospitals. All of these individuals were tested for NiV using PCR or anti-NiV IgM ELISA, and the results came back negative.

According to the data, human infections have been documented regularly since the initial case was reported in 2001. The fatality rate for these cases has fluctuated between 25% (in 2009) and 92% (in 2005) (see Figure 1). The majority of clusters of cases have been identified in the central and northwest districts of the country.

Figure 1. The total reported cases and fatalities caused by Nipah virus in Bangladesh from 1 January 2001 to 9 February 2024.

Study of Disease Patterns and Prevention

The transmission of NiV infection occurs through contact with infected animals, such as bats or pigs, or through consumption of contaminated food that has come in contact with the saliva, urine, or excreta of these animals. While person-to-person transmission is less common, it can still occur through close contact with an infected individual. Nipah virus is primarily found in fruit bats, specifically the Pteropus species, which serve as the natural hosts for the virus.

The estimated incubation period is thought to be between 4 and 14 days, although there have been cases where it has been as long as 45 days. To diagnose a patient with NiV infection, a combination of tests can be utilized during both the acute and recovery stages of the illness. The primary methods used are RT-PCR testing on bodily fluids and detecting antibodies through ELISA.

The illness caused by NiV in humans can manifest in various forms, such as acute respiratory infection and deadly encephalitis. Additional details about NiV infection can be accessed at this link.

In Bangladesh, India, Malaysia, and Singapore, the rates of death in outbreaks usually vary from 40% to 100%, depending on the ability of the region to detect early and manage cases. Even though there are efforts to create antiviral treatments, there are currently no approved vaccines or therapies for preventing or treating NiV infections.

Response to Public Health

The Bangladesh government and WHO have put into action the following public health response:

Ongoing efforts are being made to increase awareness and educate the public about health issues through various media outlets, such as print and electronic media. This includes the distribution of posters and leaflets in areas that are affected by the disease. Additionally, activities are being carried out to communicate the risks associated with the disease, involving government officials, physicians, preachers, and farmers. These activities have been completed in several districts, including Rajshahi, Jashore, Madaripur, and Rajbari, as of January 31st.

WHO is collaborating with partners to enhance surveillance, infection control, risk communication, and the prompt diagnosis and treatment of infected patients. One Health Partners, including the Department of Livestock, Bangladesh Livestock Research Institute, Department of Forest, and icddr,b, have been informed and involved in these efforts. Printed materials containing health education messages have also been created.

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Risk Assessment by the World Health Organization (WHO)

According to WHO, the risk level at the national level is considered moderate for the following reasons:

The mortality rate caused by NiV infection is high. The initial symptoms of Nipah virus infection are not specific, making it difficult to diagnose the disease upon presentation. This can impede the accuracy of diagnosis and create challenges in detecting outbreaks, implementing effective infection control measures, and responding to outbreaks in a timely manner.
Despite being recognized as a priority disease by the WHO Research and Development Blueprint, there are currently no specific drugs or vaccines available for NiV infection. Treatment for severe respiratory and neurological complications usually involves intensive supportive care.
Despite efforts to communicate the risks and engage the community on food safety, the consumption of raw date palm sap continues within the community.
To combat these risks, strong public health measures have been implemented, including a hospital-based surveillance system for human NiV infection since 2006 and the use of National and Rapid Response Teams at both the central and district levels.

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The regional risk level has been evaluated as moderate by WHO. Despite being located near India and Myanmar, the affected districts in Bangladesh do not have a common land border. While there have been no reported cases of cross-border transmission in the past, there is still a possibility due to the presence of a shared ecological corridor for the natural host of the virus, Pteropus bats, and previous incidents among domestic animals and humans in both Bangladesh and India. However, India has experience in successfully managing previous outbreaks of NiV infection.

According to the World Health Organization, the risk of this particular situation is considered to be low on a global scale, since there have been no reported cases beyond Bangladesh, India, Malaysia, and Singapore.

Recommendations from the World Health Organization (WHO)

To effectively combat Nipah virus disease without a vaccine or approved treatment, it is crucial to prioritize early detection surveillance and contact tracing, as well as educate individuals on risk factors and provide support for reducing exposure to the NiV. Managing cases should involve providing prompt supportive care and utilizing a reliable laboratory system. For severe respiratory and neurologic complications, intensive supportive care is advised.

The primary emphasis of public health educational messages should be on:

Lowering the chances of bats infecting humans

To prevent transmission, the initial efforts should be directed towards reducing bat access to date palm sap and other fresh food items. Before consumption, freshly extracted date palm juice should be boiled, and fruits must be thoroughly washed and peeled. Any fruits that show signs of bat bites should be discarded. It is advisable to avoid areas where bats are known to roost.

Minimizing the possibility of animals transmitting diseases to humans

In animals, natural infection has been observed in pigs raised on farms, horses, and both domestic and feral cats. When dealing with sick animals or their tissues, it is recommended to wear gloves and other protective clothing. The same precaution should be taken during slaughtering and culling procedures. It is advised to minimize contact with infected pigs whenever possible. In regions where the disease is common, precautions should be taken when setting up new pig farms, taking into account the presence of fruit bats in the area. In general, measures should be taken to protect pig feed and sheds from bats, whenever possible.

Minimizing the potential for human-to-human transmission

It is important to avoid close physical contact with individuals who are infected with NiV. It is also recommended to regularly wash hands after taking care of or visiting sick individuals.

Preventing infection in healthcare facilities

Standard infection control precautions should always be implemented by healthcare workers who are caring for patients with suspected or confirmed infection or handling their specimens. Contact and droplet precautions, in addition to standard precautions, should be utilized due to reports of human-to-human transmission, especially in healthcare environments. In certain situations, airborne precautions may also be necessary. Trained personnel working in adequately equipped laboratories should handle samples from individuals and animals suspected of having NiV infection.

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Additional Details

Citable reference: World Health Organization (2024, February 27). Disease Outbreak News; Bangladesh reports Nipah virus infection. Retrieved from https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON508>

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