The Nipah virus scare that shook India in May had all ingredients of an-edge-of-the-seat medical thriller like Outbreak: A country of 1.3 billion people and an encounter with one of the most lethal pathogens of our times.
But in the end the deadly virus inspired a singing, dancing Bollywood-style music video.
India's brush with Nipah can be traced to the small village of Soopikada in the region of Changaroth, says Dr. R. Gopakumar, the health officer at the Kozhikode Municipal Corporation, who led a task force charged with curbing the spread of the virus. It's 28 miles from Kozhikode, the third-largest city in the South Indian state of Kerala.
In an interview with NPR, Gopakumar describes the last few weeks in May as "the most challenging and heartbreaking days of his career" in public health. But the story of India's battle with Nipah is also a reflection of how well-prepared the public health establishment in Kerala was to take on the virus.
Nipah is a frightening disease to contend with because the virus attacks the brain and has the potential to send a healthy, young person into a coma within 24 hours. There's no vaccine or cure — just supportive treatment.
The World Health Organization (WHO) classified the Nipah virus as a "priority disease" in 2017, based on its potential to cause serious international outbreaks.
Nipah was first identified in Malaysia in 1999, when farmers were stricken by a mysterious illness transmitted via contact with the pigs they tended, which had in turn been infected by eating fruit contaminated by saliva and urine from bats, who are carriers of the virus. Nipah has little effect on bats. The virus can prove fatal for piglets and bring on severe symptoms in adult pigs.
People who contract the virus rapidly deteriorate, suffering acute respiratory distress syndrome and encephalitis, the latter causing brain inflammation, neurological symptoms, swelling and convulsions.
The Malaysian outbreak had a mortality rate of about 40 percent in humans. To stop Nipah in 1999, the government ordered the slaughter of more than one million pigs. Years later, fresh outbreaks resurfaced in India and Bangladesh — with a mortality rate around 70 percent.
India has had Nipah outbreaks at least twice before — both times in the eastern state of West Bengal in 2001 and 2007. Of the 71 people affected, 50 died.
The 2018 Nipah story begins when two young men fell ill. They were Muhammad Salih, 28, and Muhammad Sabith, 26, the sons of Valachuketti Moosa. Their father had recently purchased a home in Soopikada and neighbors reported that the two brothers had cleaned out an abandoned, bat-infested well in the compound. Both young men fell ill soon after.
Sabith died in Kozhikode Medical College Hospital (KMCH) on May 5. The cause of death was then unknown.
On the eve of May 17, Dr G. Arunkumar, a virologist and head of the department of microbiology at the Manipal Center For Virus Research, was working in his lab in the state of Karnataka, nearly 180 miles away, when he received a call from the doctor treating Salih.
Arunkumar had often provided treatment and analysis for public health emergencies in the past, and the local doctor wanted his advice. "[The treating doctor] was concerned because several members of a single family were affected," says Arunkumar. "And the clinical symptoms of his patient were unlike anything he had ever encountered before."
Salih, admitted to Baby Memorial, a private hospital in Kozhikode, showed signs of acute encephalitis — an inflammation of the brain caused by an infection or when the body's immune system begins to attack brain tissue. In patients with encephalitis, the blood pressure and heart rate are usually low, but Salih's blood pressure was very high and his pulse was fluctuating rapidly.
Arunkumar believed that it was critical to investigate quickly. He asked the team to hand-deliver the patient's cerebrospinal fluid, blood, urine and throat swabs to his lab. He received the samples on the morning of May 18. Salih died later that day.
Meanwhile, Kozhikode's District Medical Officer Dr. V. Jayasree accompanied a team of local epidemiologists to the family's home in Changaroth. "At first, we wondered if the mosquitoes were the cause of the infection," she says. "We examined the area, passed the bat-infested well, trapped mosquitoes and collected food and water samples for testing." But none of the tests turned up anything significant.
At the Manipal Center for Virus Research, Arunkumar was furiously running tests.
In 2014, as part of a training program initiated by the United State's Global Health Security Agenda the labs at the Manipal Center for Virus Research and the National Institute of Virology in Pune were prepared to identify outbreaks of Nipah. "That training really helped us," says Arunkumar. "I ruled out other causes of encephalitis and suspected it was Nipah right away." On the evening of May 18, less than 12 hours after he received the patient's tissue samples, his lab confirmed his suspicion.
The very next day, M. Miriyam, the boy's aunt, died.
"We were deeply worried," says Arunkumar. "You can contract [Nipah] from animals — with direct contact with the urine or saliva of bats or from direct contact with infected pigs as they did in Malaysia. In human-human transmission, it's via direct contact with bodily fluids. And isolation of patients in India's overcrowded hospitals would be a huge challenge."
Salih's tissue samples were sent to a second lab — the National Institute of Virology in Pune — to confirm the results.
Even before they received the confirmation, Kerala's public health services swung into action. They issued public-interest messages telling people with flu symptoms to report to the government-run KMCH for treatment. A helpline was set up so the public could call to report their symptoms.
"We didn't allow people suspected of Nipah to be treated in private hospitals. A separate ambulance was authorized to bring people to the KMCH and we ensured that there was complete isolation of even suspected cases," says Dr. Jayasree.
On May 20, the National Institute of Virology in Pune confirmed the diagnosis — but because of Arunkumar's foresight, measures to prevent its spread were already in place.
The next day, May 21, a 31-year-old nurse P. Lini, who tended to members of the infected family, died of Nipah. She was the mother of two sons, ages 5 and 2.
With every new casualty, health practitioners faced a difficult situation: How to handle the body of the deceased without exposing family members to bodily fluids, which could infect them with the virus.
The two brothers came from a Muslim family. According to Muslim tradition, bodies are washed and enshrouded in white. The head of the deceased is faced toward Mecca, a prayer is said and then burial takes place.
That had to change because of the risk of infection.
When Moosa, the boys' father, died on May 23, Gopakumar supervised the burial, performing the last rites and acting as one of the pallbearers. He and other personnel at the funeral were dressed in full protective gear — gloves, gowns, eye protection shields, masks and shoe covers.
"We followed the same protocol [used] for the Ebola outbreak," he says. The body, packed in two airtight plastic bags, was buried deeper than usual, lowered into a 10-foot pit filled with 11 pounds of bleaching powder.
Gopakumar supervised the funerals of 12 victims, performing the last rites and death rituals for two of them entirely on his own. One more Muslim patient was buried and the others were cremated as is Hindu norm. "We wanted the victims to have a dignified funeral," he says.
The case of 25-year-old B. Rasil weighed heavily on him. Rasil died while his mother was in a Nipah isolation ward. His father was too anguished to perform the last rites. "She couldn't even see him one last time. It was a tragic situation," he says.
Ever since the news that Salih had tested positive for Nipah was made public, rumors were spreading on whatsapp and social media.
As word spread about Nipah, the contagious — and deadly — nature of the disease meant that many people stayed indoors. While businesses still operated, schools were closed. For V. Jipsa, a 27-year-old nursing instructor who was visiting her mother, the sight of a deserted beach on a weekend in Kozhikode felt surreal. "I realized then how deep the fear ran," she says.
And the sale of fruits, even in neighboring states crashed — even though, as Kumar notes, "the only way to contract Nipah through fruit is if you consumed a fruit after a fruit bat bit into it, infecting it with its saliva — a rare occurrence."
Three weeks after Nipah had been identified as a cause of the outbreak, on June 10, Kerala's Minister for Health, K.K. Shylaja, declared that the state was Nipah-free. Of the 19 cases, two patients have recovered.
There have been no new cases since the last death — the 17th casualty — on May 30.
Statewide monitoring ended on June 30.
Investigators are currently testing bats from the well that the two brothers had cleaned to see if they harbor Nipah.
Arunkumar feels that heightened awareness and monitoring for encephalitis symptoms should continue among health-care practitioners in India. "There is a possibility that this can happen again," he says. "Fruit bats are endemic to India and other parts of Southeast Asia."
But along with the caution about the future there was a celebratory mood.
When the announcement was made that Kozhikode was Nipah-free, a group of musicians and filmmakers decided to make a video to celebrate.
On June 14, they released "Bye Bye Nipah."
"It was a labor of love," says music composer Sai Balan, who composed the tune for the video in an hour. "It's our way of saying that the anguish and suffering is behind us now."
"The song was an effort to reclaim and celebrate our public spaces after the threat of the epidemic almost shut the city down in fear," says A. Shaji Kumar, who wrote the lyrics. "We wanted to honor the effort and sacrifice of our healthcare professionals as well." The video shows smiling images of local doctors, nurses and health-care workers, giving a thumbs-up.
With scenes from malls, the beach, the emerald-green backwaters, the main streets and restaurants, the video is a slice of everyday life in Kozhikode. "We shot images of actual residents going about their day with health and hope," says Kumar.
"Don't forget that this is Kozhikode," say the lyrics. "We beat the contamination with strength and determination. We won't break down. We won't ever tire. Bye Bye Nipah!"
Kamala Thiagarajan is a freelance journalist based in Madurai, India, who has written for The International New York Times, BBC Travel and Forbes India. You can follow her @kamal_t.