Simple infection-control practices such as isolating sick patients and decongesting common areas in hospitals could have dramatically cut down the toll in the Nipah outbreak this year in Kerala, suggests a paper published in the Journal of Infectious Diseases last month. Though confined to the State, the outbreak in May-June, which claimed 21 lives, drew international interest and raised consternation in India on whether the country was prepared to deal with a novel, killer virus.
By reconstructing the sequence of infections through CCTV footage and interviews with patients, the authors of the paper have concluded that 18 of the 23 patients had caught the virus in two hospitals. Had health-care workers worn masks and gloves and friends and acquaintances been kept away from sick patients, more lives could have been saved, said Arunkumar Govindakarnavar, the lead author of the paper and head of Karnataka’s Manipal Centre for Virus Research. The findings have implications for managing other infectious diseases such as tuberculosis and influenza, because they too can spread through hospitals.
In the Nipah case, the first patient to contract the disease (possibly from fruit bats) was 27-year-old Mohammed Sabith, a resident of Changaroth village in Kozhikode. He was admitted to Perambra Taluk Hospital on May 3. The next day he developed a severe cough and began vomiting, which is when he became a “super-spreader” — a term for the small minority of patients in an outbreak who spread the infection to the rest. Sabith transmitted the infection to 19 others, while the second wave of cases (those who contracted the infection from him) infected 0-1 case each.
This was why it was important to restrict the first wave, but the lack of basic infection control played spoilsport. When Sabith was admitted to the male ward in the hospital, it had 10 patients. Alongside, 10 other people, including friends and health-care workers, entered the ward during the 24 hours he was there. Nine of those 20 succumbed after coming close to Sabith without protection.
Lini Puthussery, the nurse who attended to Sabith, was one of them. She used neither gloves nor a mask. Others, who barely knew Sabith, assisted him too. “In the ward, everyone was trying to help each other,” says Govindakarnavar. One of them, a fellow patient, attempted to feed Sabith. A family member accompanying another patient cleaned Sabith’s vomit. These well-meaning acts became death sentences. In contrast, patients who did not come into physical contact — those too sick to get up from their beds, for instance — did not contract the virus. Even a ward attendant who cleaned the patient’s vomit was unharmed as she had followed protocols by using a mask and gloves and disinfecting the floor.
‘Droplet transmission’
“This is a very clear case of droplet transmission. Only those within 1 metre could be reached by the large drops,” said Govindakarnavar.
The second transmission cluster occurred in the corridor outside the CT scan room at Kozhikode Medical College (KMC). When Sabith’s condition worsened, he was referred to the KMC’s emergency ward on May 5. However, within an hour of his admission, he was taken for a head CT scan because he was showing an altered sensorium, says Govindakarnavar. Altered sensorium is a symptom of brain inflammation in which the patient becomes confused or delirious. As a result, the CT lab personnel found it difficult to keep the patient steady, leading to a three-hour delay, during which the patient waited in the corridor. Over the course of three hours, CCTV footage showed over 100 people walking through the 2.5 m-wide space. This led to nine more getting infected, with eight of them succumbing to the infection.
According to Govindakarnavar, there are two takeaways from these findings. “First, basic infection-control practices could have saved lives. Also, hospitals should have case-management protocols for emergency cases.” In Sabith’s case, given his restless state, he should have been stabilised before the CT scan, Govindakarnavar has suggested. This would have protected others in the corridor. Also, there is a need in future to decongest common areas in hospitals by making sure that family and friends do not enter unnecessarily.
This is easier said than done given the overcrowding and understaffing in government hospitals. The KMC draws 6,000 outpatients a day and has 3,500 beds, said Dr. V.R. Rajendra, the principal of the medical college. Controlling crowds would be difficult without a government order, he added. However, according to him, the hospital had now put in place a triage system, which sends patients with severe symptoms to an isolation ward.
Today, in developing countries, poor infection control is a major driver of hospital-acquired infections. A Lancet meta-analysis in 2010 found that that for every 1,000 patient-days in developing countries, intensive-care units saw 47.9 infections, about four times the rate in the United States. The authors called such infections a hidden and serious burden, which could be tackled with low-cost measures such as hand-hygiene.
priyanka.pulla@thehindu.co.in
