Book Call Girls in Kasavanahalli - 7001305949 with real photos and phone numbers
Nipah virus (ni v)
1. Nipah Virus (NiV)
Prof. Dr. Saad S Al Ani
Senior Pediatric Consultant
Head of Pediatric Department
Head of TDC
Khorfakkan Hospital
Sharjah, UAE
saad.alani@moh.gov.ae
2. Nipah virus (NiV) is a
paramyxovirus (genus Henipavirus)
Brainfeed Magazine
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 2
3. Its name originated from Sungai
Nipah, a village in the Malaysian
Peninsula where pig farmers became ill
with encephalitis in 1999
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 3
4. Three years later, a genetically distinct
NiV independently emerged in India as
well as in Bangladesh, where human
NiV outbreak events have been
reported nearly every year
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 4
5. A putative NiV also caused an outbreak
of disease in horses and people in the
Philippines in 2014.
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 5
6. To date, there is no reported evidence
of NiV outbreaks in humans emerging
in any other country than Malaysia,
Singapore, Bangladesh, India and
Philippines
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 6
8. In 19 May 2018, the Kerala Health Department
reported three deaths due to Nipah virus infection in
Chengaroth in Perambra block of
Kozhikode district in south Indian State
of Kerala: the 3 deaths occurred in family cluster and a fourth
death was subsequently reported in a health care worker caring for the
family.
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 8
9. As of 23 May 2018 and since the beginning of the
outbreak, following more investigations and contact tracing, a
total of 13 people have tested positive for NiV in
Kozhikode and Malappuram Districts
(Kerala State).
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 9
10. Of the 11 deaths reported so far, three
have been reported from Malappuram
district of Kerala and the others from
Kozhikode district
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 10
11. This is the first time of NiV infection
reported in Kerala State and third
known NiV outbreak in India. Last
outbreak was reported in 2007.
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 11
12. A total of 276 cases were reported with
106 fatalities (38%) in Malaysia,
Case fatalities in later outbreaks in India
and Bangladesh were associated with
significantly higher case fatality rates of
43 to 100%.
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 12
13. NiV infection in humans has a range of
clinical presentations, from :
asymptomatic infection to acute
respiratory syndrome and fatal
encephalitis
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 13
14. The natural reservoir of the virus
consists of the widely distributed fruit
bats from the Pteropodidae family
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 14
15. The fruit bats (Pteropodidae family,
Pteropus genus).
Grey-headed flying foxes
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 15
16. Virus transmission from bats to humans
occurs through:
• Inhalation
• Contact
• Consumption of NiV
contaminated foods.
06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 16
18. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 18
NiV is transmitted by:
• zoonotic :
from bats to humans
from bats to pigs and then to
humans
• Human-to-human routes.
20. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 20
Human-to-human transmission is
particularly notable in the outbreaks in
India and Bangladesh, where it has
been reported to account for 75% and
51% of cases, respectively.
21. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 21
The virus
NIV is an enveloped, negative-sense,
single-stranded RNA virus.
22. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 22
The Henipavirus genus in the subfamily
Paramyxovirinae (family
Paramyxoviridae) was then created for
these two pathogenic viruses, HeV and
NiV
23. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 23
Clinical disease
The incubation period of Nipah
5 days - 2 weeks
(In the majority of cases)
a maximum delay of 2 months between exposure and the
onset of illness had been reported during the outbreak
in Malaysia.
24. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 24
The majority of patients initially develop
influenza-like signs and symptoms,
including:
• Fever
• Headache
• Myalgia
• Vomiting
25. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 25
In general, the more severe clinical
features manifest as either:
• Acute encephalitic syndrome
• Pulmonary syndrome (less
frequently)
N.B. Considerable number of infections remain
asymptomatic
26. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 26
• In patients with reduced level of
consciousness:
Clinical signs such as:
• Areflexia/ hyporeflexia with hypotonia
• Pinpoint pupils with variable reactivity
• Tachycardia
• Hypertension
• Abnormal doll’s eye reflex
More frequently seen
27. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 27
Segmental myoclonus characterized by
focal, rhythmic jerking of the diaphragm
and muscles in the limbs, neck and
face was present in 32% of patients,
and may be unique to acute NiV
encephalitis.
28. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 28
Other clinical features :
• Meningism
• Generalized tonic-clonic
convulsions
• Nystagmus
• Cerebellar signs
were also observed
29. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 29
Pulmonary syndrome presented with:
• Cough
• Atypical pneumonia
• Acute respiratory distress syndrome
• Abnormal chest X-ray findings
30. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 30
Higher prevalence of respiratory
disease was observed during the
Bangladesh outbreaks with cases
experiencing atypical pneumonia and
developing an acute respiratory
distress syndrome.
31. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 31
In Bangladesh:
High prevalence of acute encephalitis:
• Altered mental status and/or
unconsciousness :>70%
• Severe weakness : 67%
• Areflexia/hyporeflexia : 65%
32. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 32
In Bangladesh, based on a review of
196 cases:
• Median duration from onset of
illness to death was 6 days
o (ranging from 1 to 47 days)
• Mortality was high, ranging from
about 40% to 100%.
33. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 33
• In a large cohort of patients who
survived
• the majority had no or few
sequelae.
• approximately 20% of patients
were reported to have :
Neurological deficits
Neuropsychiatric sequelae
Gait/movement disorders
34. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 34
The most intriguing complication of
Nipah is probably relapsing
encephalitis which may occur weeks to
years after symptomatic infection and
even after asymptomatic NiV infection.
So far, more than 20 cases of relapsing NiV encephalitis
have been reported, one of which occurred 11 years after
an asymptomatic infection
35. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 35
Relapsing NiV encephalitis
• Distinct clinical and radiological findings
• Brain MRI in relapsing encephalitis
shows :
more extensive and confluent hyperintense cortical lesions
• Virus could not be cultured from
samples collected
• No known risk factors nor for the
mechanisms for persistent
36. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 36
Pathological features
are characterized by:
disseminated, multi-organ vasculopathy
comprising :
• Endothelial infection/ulceration
• Vasculitis
• Vasculitis-induced thrombosis/occlusion
• Parenchymal ischemia/microinfarction
• Parenchymal cell infection
in CNS , lung, kidney and other major organs
38. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 38
Suspected case
1.A person fulfilling both of the following criteria is
defined as a suspected case:
Features of acute encephalitis as
demonstrated by:
- Acute onset of fever AND
- Evidence of acute brain dysfunction as
manifested by:
i. Altered mental status OR
ii. New onset of seizure OR
iii. Any other neurological deficit
39. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 39
Suspected case (cont.)
2.Epidemiological linkage
a.Drinking raw date palm sap OR
b.Occurring during Nipah season OR
c. Patient from Nipah endemic area
40. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 40
Probable case
A person with features of acute encephalitis :
During a Nipah outbreak in the area OR
With history of contact with confirmed Nipah
patient
41. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 41
In both suspected and probable cases,
the patient might present with
respiratory features with or without
encephalitis.
42. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 42
The respiratory features are
Illness < 7 days duration AND
Acute onset of fever AND
Severe shortness of breath, cough
AND
Chest radiograph showing diffuse
infiltrates
43. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 43
Confirmed case
A suspected or probable case with laboratory
confirmation of Nipah virus infection either by:
IgM antibody against Nipah virus by ELISA in
serum or cerebrospinal fluid
Nipah virus RNA identified by PCR from
respiratory secretions, urine, or
cerebrospinal fluid
44. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 44
Clinical features
• Symptoms
The following symptoms were observed
(in order of frequency in Bangladeshi cases)
1. Fever 6. Cough
2. Altered mental status 7. Vomiting
3. Severe weakness 8. Muscle pain
4. Headache 9. Convulsion
5. Respiratory distress 10. Diarrhea
45. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 45
Clinical features (Cont.)
• General Signs
• Reduced GCS score • Hypertension/Hypotension
• Raised temperature • Crepitations in lung
• Increased respiratory
rate
(Adult: ≥25/min;
Children of ≥ 12 months: ≥
40/min)
• Increased heart rate
(Adult: ≥100/min;
Children of ≥ 12 months: ≥
140/min)
46. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 46
Clinical features (Cont.)
• Neurological signs
i. Oculoparesis
ii. Pupillary abnormality
iii. Facial weakness
iv. Bulbar weakness
v. Limb weakness
vi. Reduced deep tendon reflexes
vii. Plantar-absent/extensor
47. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 47
Differential diagnosis
1. Other viral encephalitides e.g. Herpes
simplex encephalitis, Japanese B
Encephalitis (JBE)
2. Bacterial meningitis
3. Cerebral Malaria
48. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 48
Differential diagnosis of Nipah virus, Japanese encephalitis
and Herpes Simplex Encephalitis
49. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 49
Differential diagnosis of Nipah virus, Japanese encephalitis
and Herpes Simplex Encephalitis (Cont.)
50. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 50
Differential diagnosis of Nipah virus, Japanese encephalitis
and Herpes Simplex Encephalitis (Cont.)
51. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 51
Differential diagnosis of Nipah virus, Japanese encephalitis
and Herpes Simplex Encephalitis (Cont.)
52. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 52
Differential diagnosis of Nipah virus, Japanese encephalitis
and Herpes Simplex Encephalitis (Cont.)
53. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 53
Differential diagnosis of Nipah virus, Japanese encephalitis
and Herpes Simplex Encephalitis (Cont.)
54. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 54
Differential diagnosis of Nipah virus, Japanese encephalitis
and Herpes Simplex Encephalitis (Cont.)
55. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 55
Investigations
• Enzyme-linked immunoassay
Nipah IgM capture ELISA and an indirect
IgG ELISA have high specificity for the
diagnosis
• Polymerase chain reaction (PCR)
RT PCRs can be used for detection of viral
sequences in CSF, throat swab or urine
specimens.
56. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 56
Treatment
• Supportive/General Management
a. Isolation (preferably in a separate unit)
b. Barrier nursing e.g. personal protection
using masks, gloves, gowns, shoe covers
c. Hand washing with soap & water before
and after handling/visiting patients
• Symptomatic Treatment
• Other treatment: ribavirin ???
58. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 58
• There are different risk factors for transmission of
Nipah virus which are:
1. Ingestion of Raw date palm sap contaminated
by NiV
2. Person to person transmission of Nipah virus
3. From patient to care giver or contact
4. From patient to health care worker
5. Through objects used by patient
6. During handling deceased
59. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 59
Prevention and control of Nipah
transmission depends upon controlling these
risk factors
60. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 60
Standard precaution:
• Personal protection by practicing standard
precaution:
Hand hygiene: Hand washing /alcohol
based hand rub
Use personal protective equipment
(PPE)
Safe handling of patient, equipment
and linen
61. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 61
Also to follow
Barrier nursing (PPE use, Isolation)
Environmental cleaning and
decontamination
Safe waste disposal
62. 06/06/2018Nipah virus Prof. Dr. Saad S Al Ani 62
References
• WHO - NIPAH Baseline Situation Analysis - M. Denis, consultant - Draft, Jan 27 2018
http://www.who.int/blueprint/priority-diseases/key-
action/WHO_NIPAH_baseline_situation_analysis_27Jan2018.pdf?ua=1&ua=1
• Rahman SA. National Guideline for Management, Prevention and Control of Nipah Virus Infection including
Encephalitis http://www.iedcr.gov.bd/pdf/files/nipah/National_Nipah.pdf. 2011
• Broder CC. Henipavirus outbreaks to antivirals: the current status of potential therapeutics. Current Opinion Virology
2012;2(2):176-87.
• Rahman MA, Hossain MJ, Sultana S, et al. Date Palm Sap Linked to Nipah Virus Outbreak in Bangladesh, 2008.
Vector Borne and Zoonotic Disease 2012;12(1):65-73
• Rollin PE, Rota P, Zaki S, Ksiazek TG. Hendra and Nipah viruses. in: Versalovic J, Carroll KC, Funke G, Jorgensen
JH, Landry ML, Warnock DW, editors. Manual of Clinical Microbiology. 10th ed. Washington, DC: ASM Press; 2011;
p. 147987
• Chadha MS, Comer JA, Lowe L, et al. Nipah virus-associated encephalitis outbreak, Siliguri, India. Emerging
Infectious Disease 2006;12(2):235-40.
• Chua KB, Lam SK, Goh KJ, et al. The presence of Nipah virus in respiratory secretions and urine of patients during
an outbreak of Nipah virus encephalitis in Malaysia. Journal of Infection 2001;42(1):40-3.
• National Center for Emerging and Zoonotic Infectious Diseases Division of High-Consequence Pathogens and
Pathology (DHCPP)