Tuesday, July 03, 2018

IJID: Enhancing Preparation For Large Nipah Outbreaks Beyond Bangladesh

Credit CDC


Until it finally happened in 2014, Ebola was thought unlikely to spark a large, urban  - or worse - regional epidemic.
The reasoning was simple if not ultimately flawed.
The Ebolavirus was considered too deadly, and it incapacitated its victims so quickly, that outbreaks seemed doomed to burn themselves out before they could spread beyond the remote, nearly inaccessible regions of Africa where it had been reported since the mid-1970s.

But over 40 years, new roads and railroads have been built, forests logged and jungles cleared, and millions more people (and goods) travel across interior Africa today than did two or three decades ago. 
Conditions that might have restricted the spread of Ebola 4 decades  ago, have changed.  And not just in Africa, theses sorts of changes are happening globally, and are accelerating.
Not quite a year ago (August-November 2017), Madagascar reported an urban outbreak of (mostly) Pneumonic plague (see WHO Disease Update: Plague In Madagascar), sickening more than 2,000 people.
While small epidemics of Bubonic plague are reported nearly every  year in the rural highlands of the island (above the 800 meter level), last year the epidemic moved into a number of densely populated urban areas, including Antananarivo and Toamasina.
According to the CDC: Between 1,000 and 2,000 cases each year are reported to the World Health Organization (WHO), though the true number is likely much higher.
Prior to 2017, the last really big plague outbreak was in India nearly 24 years ago (5150 suspected cases and 53 deaths).  This latest outbreak is a reminder that urban plague epidemics are not necessarily a thing of the past.
While novel influenza remains at the top of our pandemic worry list, and it is always possible we could be blindsided by something currently not on our radar, there are a number of non-influenza pandemic threats we follow closely.

Last March, in the WHO List Of Blueprint Priority Diseases, we looked at 8 disease threats in need of urgent accelerated research and development.   Among them is the Nipah virus.

List of Blueprint priority diseases
The second annual review occurred 6-7 February, 2018. Experts consider that given their potential to cause a public health emergency and the absence of efficacious drugs and/or vaccines, there is an urgent need for accelerated research and development for*:
  • Crimean-Congo haemorrhagic fever (CCHF)
  • Ebola virus disease and Marburg virus disease
  • Lassa fever
  • Middle East respiratory syndrome coronavirus (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS)
  • Nipah and henipaviral diseases
  • Rift Valley fever (RVF)
  • Zika
  • Disease X

The Nipah virus has been on our watch list for nearly two decades.
Nipah was first identified after hundreds of abattoir workers in Malaysia and Singapore were infected by pigs carrying the virus (see MMWR Update: Outbreak of Nipah Virus -- Malaysia and Singapore, 1999), killing more than 100.
While outbreaks thus far have been scattered, limited human-to-human transmission has been documented (see EID Journal Person-to-Person Transmission of Nipah Virus in a Bangladeshi Community), making Nipah a legitimate public health concern. 
Some of my earlier blogs on Nipah (and its Australian cousin Hendra, discovered in 1994) include: 
Indian Government Responds To Reported Nipah Outbreak In Kerala

Study: Hotspots For Bat To Human Disease Transmission
Research: Monoclonal Antibodies Against Nipah
Australia: Hendra Vaccine Hurdles
All of which brings us to a new open-access article that appears in the International Journal of Infectious Diseases, that discusses the potential of the Nipah virus producing a large urban epidemic, similar to what we saw in West Africa with Ebola in 2014. 
The full article is available, and it provides a detailed history of Nipah, along with recommendations on enhancing preparedness for large rural and/or urban Nipah outbreaks in the future.
After you return, I'll have a brief postscript.
Enhancing preparation for large Nipah outbreaks beyond Bangladesh: Preventing a tragedy like Ebola in West Africa
Halsie Donaldson,  Daniel LuceyCorrespondence information about the author Daniel LuceyEmail the author Daniel Lucey
Department of Medicine-Infectious Diseases, Georgetown University School of Medicine, 3800 Reservoir Road NW, Washington, DC, USA


  • Nipah epidemiology has differed in Malaysia, Bangladesh, and the Philippines.
  • Beyond Bangladesh, there is a need to enhance preparedness for large Nipah outbreaks.
  • Nipah epidemics beyond South Asia should be prevented to avoid a tragedy like Ebola in West Africa.


The Nipah virus has been transmitted from person-to-person via close contact in non-urban parts of India (including Kerala May 2018), Bangladesh, and the Philippines. It can cause encephalitis and pneumonia, and has a high case fatality rate. 

Nipah is a One Health zoonotic infectious disease linked to fruit bats, and sometimes pigs or horses. We advocate anticipating and preparing for urban and larger rural outbreaks of Nipah. 

Immediate enhanced preparations would include standardized guidance on infection prevention and control, and personal protective equipment, from the World Health Organization (WHO) on their OpenWHO website and 2018 “Managing Epidemics” handbook, along with adding best clinical practices by experts in countries with multiple outbreaks such as Bangladesh and India. 

Longer-term enhanced preparations include accelerating development of field diagnostics, antiviral drugs, immune-based therapies, and vaccines. WHO-coordinated multi-partner protocols to test investigational treatments, diagnostics, and vaccines are needed, by analogy to such protocols for Ebola during the unanticipated pan-epidemic in Guinea, Liberia, and Sierra Leone. 

Anticipating and preparing now for urban and rural Nipah outbreaks in nations with no experience with Nipah will help avoid the potential for what the United Nations 2016 report on Ebola in West Africa called a “preventable tragedy”.

Enhancement of preparedness measures for future urban Nipah outbreaks should include heightened surveillance, coordinated rapid diagnostic testing, training exercises including the use of and sufficient supplies of personal protective equipment (PPE), detailed isolation and quarantine protocols, clinical management protocols, and discussion of research protocols and their ethics for use of investigative therapies and vaccines. As with Ebola, Nipah virus has been reported to occur in healthcare facilities, including infection of health workers, and at burials from an infected corpse (Sazzad et al., 2013).
        (Continue . . . .)

The graphic above illustrates that the first two decades of the 21st century have been marred by a remarkable number of infectious disease outbreaks, with 9 of 11 of them kicking off in the past 10 years.
  • SARS
  • H5N1
  • H1N1 Pandemic
  • Cholera in Haiti
  • MERS-CoV
  • H7N9 in China
  • Ebola In West Africa
  • Zika in the Americas
  • Yellow Fever in Central Africa/Brazil
  • Cholera In Yemen
  • Plague in Madagascar
And these were just the major events; we could easily add Chikungunya in the Americas, Lassa Fever in West Africa, Monkeypox in Nigeria, EV-71 in China, and many, many others.
While our track record of predicting which emerging pathogen will spark the next big public health crisis has been less than stellar - the one thing you can count on is another one will arrive - and probably sooner rather than later. 
Although it is prudent for counties in the Nipah zone to prepare for Nipah, and countries in the Middle East to focus on MERS-CoV, the simple truth is that preparations designed to deal with one pathogen will often work for another.
Preparedness for one threat is preparedness for all, particularly if its focus is more on the impacts, and not the cause.
Whether the next `unprecedented' urban or regional outbreak turns out to be due to Nipah, Plague, Monkeypox, MERS-CoV, or disease X . . .  the outcome will depend, in large part, on what is done to prepare before the outbreak begins.

The only question is, how many times we will have to re-learn this lesson?

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