Officials of the Health and Family Welfare Department in Karnataka's Shivamogga district are toiling to prevent another outbreak of a fatal viral infection - 'Kyasanur Forest Disease' (KFD) - popularly referred to as 'monkey fever' after the disease claimed the lives of five persons in the last two months. But questions have been raised against the department's efforts after it emerged that it did not follow the protocol in providing vaccination when it found evidence of a possible outbreak in January 2018.
Confirming the lapses by health officials, Shivanand Patil, Health and Family Welfare Minister of Karnataka said, "It has come to my notice that there have been lapses committed by the Health Department. An expert committee will be appointed and an internal enquiry will be conducted on this, which will include forest, health, rural development and the veterinary departments. The focus is on restricting the spread of the disease once again.”
What the protocol calls for
Since 1990, when a vaccine for KFD was first used, residents living within a 5 km radius of a suspected KFD case have been receiving vaccination. The radius was increased to cover 10 km in 2014 after researchers studying a suspected case of KFD in Kannangi in Thirthahalli taluk of Shivamooga found ticks and monkeys testing positive for the virus at a distance of 8 km and 10 km from the village.
Since then, the protocol has been to vaccinate residents living within a radius of 10 km whenever a suspected case of KFD is found. “It is also hard to predict where the disease will show up since it does not recur in the same villages every year,” says Dr Ravi Kumar, Deputy Director, Virus Diagnostic Laboratory, a specialist laboratory that was set up in Shivamogga in 1959 to carry out research on the disease.
However, in 2018, researchers at the VDL in Shivamogga found a tick that tested positive for the virus in Brahmana Ilakale, 8.6 km from Aralagodu in Sagar taluk of Shivamogga district, where the latest outbreak has occurred. “We began the vaccination process in the area for a radius of 5 km. Since Aralagodu is further than 5 km from Brahmana Ilakale, we did not vaccinate people in the area,” confirms Dr Ravikumar.
Aralagodu in Shivamogga where the latest outbreak of KFD has ocurred
Contrary to Ravikumar's claims, documents accessed by TNM show that the Commissioner of Health and Family Welfare Service had rejected a suggestion to reduce the vaccination radius from 10 km to 5 km in September 2016. In spite of that, vaccination was done in a 5 km radius following the most recent discovery of a tick which tested positive for the virus. If the vaccination was provided, per protocol, to the residents living in a 10 km radius, it would have covered the residents of Aralagodu, who are now facing the effects of the fatal disease.
“There is a provision to extend the radius to 10 km but at the time, officials did not do it because they had found only one case of the disease. If they had extended the vaccination to 10 km, it would have covered Aralagodu as well,” admits Dr Ravikumar.
The first case of suspected KFD in the latest outbreak came to light on November 24, 2018 from Aralagodu. Around 18 residents of the village are now suspected to have been affected by the virus and are currently being treated in McGann Hospital, Sagar General Hospital and Kasturba Hospital in Manipal.
Blood samples from the first suspected case of KFD in November were sent to the Kasturba Hospital in Manipal, which confirmed the fears of another KFD outbreak on December 27, 2018.
“We immediately informed our District Health Officer, who then took the details of the patients,” says Dr Avinash Shetty, Medical Superintendent at Kasturba Hospital, Manipal.
What next
Officials of the Health and Family Welfare Department in Shivamogga are now scrambling to ensure that the latest outbreak does not result in another string of casualties. The officials are also encouraging residents to report any cases of dead monkeys found near the village.
"Cases of monkey deaths act as an alarm bell for the disease but this time around, the first case of monkey death was reported in December after the first case of human infection came to light,” adds Dr Ravikumar.
The process of vaccinating nearby residents began at the end of November and has covered 2,000 residents in and around Aralagodu. “The response has been good. People are now coming forward for vaccination,” says Venkatesh, the District Health Officer for Shivamogga.
An ambulance arrives to carry a person suffering from high fever in Aralagodu in Shivamogga district
The vaccine needs two doses with a gap of one month, followed by a booster dose to have a complete effect. There have been cases in which people have been infected by the virus even after taking the two doses and the booster.
“For two months, we cannot confirm whether more people will die because the vaccination will only take effect after that time. After January, the immunity of people will be better to fight the disease,” says Dr Ravikumar.
But once the virus is detected, the vaccine is of little use, and the patient can only be treated for the symptoms of fever and dehydration on a case-by-case basis as well as to ensure that their blood reports are within normal range so that hemorrhagic tendencies do not occur.
How it spread from Karnataka to neighbouring states
Since 1957, when KFD was first discovered in Kyasanur forest of Shivamogga (formerly Shimoga) district, the disease used to recur every year during the summer months, taking lives from the communities that reside in the forest areas. For decades, the virus was confined to the forests of Shivamogga, which is located in the Western Ghat region of Karnataka.
However, in the last five years, the disease has spread along the forest to Karnataka's neighboring states. It was diagnosed in Wayanad district of Kerala in 2013 as well as in north Goa two years later. The virus has also been reported in the Sindhudurg district of Maharashtra, which borders Goa, in 2016.
The Virus Diagnostic Laboratory in Shivamogga conducts tests on ticks, monkeys and humans to detect the presence of the virus in them. Monkey Fever is transmitted to monkeys and humans through infected vectors, which are primarily fleas, ticks and mosquitoes.
Dr. Mangesh Gokhale, a researcher from National Institute of Virology (NIV), Pune drags a flag on the ground to collect ticks for testing in 2010.
During the monsoon season, the adult ticks mate and the female ticks lay as many as 3,000 eggs before dying. Larvae stick to the underside of leaves and rely on small mammals like squirrels for bloodmeals (the stomach contents of a bloodsucking insect). Generally, by the end of the monsoon season, the tick metamorphose into a nymph and can infect humans via sick or (recently) infected monkeys.
The symptoms of the viral infection include sudden onset of high-grade fever, nausea, vomitting, diarrhoea as well as haemorrhagic (bleeding) tendencies.
The disease has claimed the lives of more than 500 people in Shivamogga district since it was discovered in 1957. Furthermore, the Virus Diagnostic Laboratory in Shivamogga has reported 166 positive cases of KFD in 2014, 41 in 2015, 25 in 2016 and 49 in 2017. Around 30 blood samples collected in 2018 are currently being processed, of which three persons have died due to the disease.
Health department officials are keeping a close eye on cases of fever and dehydration being reported in hospitals in Sagar taluk. The VDL in Shivamogga is currently being stocked so that it is fully equipped. Meanwhile, residents of the villages along the forest areas are being urged to take 'monkey fever' seriously and get themselves vaccinated.
Dr Ravi adds, “We are hopeful that we can contain the cases that come up, before the immunity of people in the area improves with the two doses of vaccination, by the end of January.”