Impact of Interventions to Prevent Nipah Virus Infection

Investigate about the impact of different higher and lower intensity interventions that can prevent Nipah virus infection.

The following assignment focuses on the Nipah virus (NiV) outbreak and its transmission to humans in the state of Kerela, India that are traced to the fruit bats (Pteropus) localized in districts of Malappuram and Kozhikode. It claimed about 17 lives and this outbreak raised alarms among the individuals in the affected areas of Malabar region (1). People need to be aware of the deadly virus so that they can take precautions. Therefore, an annotated bibliography would be helpful in promoting health message to the population about the virus in terms of understanding its target population, symptoms, mode of transmission, awareness and prevention.

The paper is relevant for the target group as it investigates about the impact of different higher and lower intensity interventions that can prevent Nipah virus infection. The study aimed to reduce Nipah virus infection by using bamboo skirts to cover the sap stream of date palm and avoid the bat’s access to the sap to prevent risk of Nipah virus transmission. The main rationale for using this approach was that date palm sap collection is common in Bangladesh and bats visit the date palm trees during sap collection. Hence, bamboo skirts can be an effective physical barrier against bat. The main target population for this study was gacchis (date palm sap harvesters) as they were at higher risk of exposure to Nipah virus (2).

The effectiveness of the intervention was evaluated in four village of Bangladesh. As health promotion theory and practice is the main focus of the annotated bibliography, the study design and method of implementation of the intervention was analyzed.  Two types of intervention was implemented-low intensity and high intensity interventions. The difference in the method of implementation for both the intervention was that frequency of community meeting was higher and skirt making training was higher for high intensity intervention compared to low intensity intervention. In addition, half the time was spent in low intensity intervention compared to high intensity intervention. The meeting and training was necessary to raise awareness among gacchis regarding the transmission of infection through date palms. The effectiveness of both types of intervention is understood from the fact that 69% gacchis reported using skirts in high intensity intervention group compared to 35% gacchis in low intervention group (2). The approach taken for health promotion in this paper is in relevant with the health belief model of health promotion which states that understanding about individual beliefs related to health is important to predict health related behaviour and influence behaviours changes in a person (3). Hence, the community meeting and training was effective in raising awareness regarding the use of bamboo skirts. The strength of the study is that it proposed a noble way to reduce Nipah virus infection among high risk population such gacchis. However, the reliability of the intervention is low as the study evaluated the effectiveness of the intervention by use of skirts and making of skirts and these are poor indicators of Nipah virus prevention.

Evaluating Efficacy of Policy Options and Alternative Interventions

The intervention presented in this paper is relevant to the poster as the poster mentions about behavioural changes such as avoiding contact with infected bats and other living beings and the paper also reported about gives details regarding behavioural change intervention to reduce exposure to the Nipah virus.

This research article also discussed about focused intervention like use of skirts to bats prevents bats access to the sap stream. The paper targeted the population group of Bangladesh/India just like the 1^st paper. Both the papers used the same intervention. However, the first article used low intensity and high intervention by means of community meetings and providing skirt making training in target areas. In contrast, the second article focused on disseminating health message about not drinking date palm sap. The local non-governmental organization focused on providing appropriate health message by the implementation of a health campaign. They entered into collaboration with 281 opinion leaders to get adequate support for the ‘no raw sap’ campaign. The main elements of the campaigns were professionally developed public service announcements by use of short docudrama (4). The documentation indicated about the risk of raw date sap by providing an engaging story. This public service announcement was broadcasted in local cable network and posters were distributed in the villages. Considering the scale and nature of intervention, it can be said that the intervention proposed in this study had a wider reach compared to that proposed in paper 1. Campaigns are important part of health promotion practice and the advantage of mass media campaign is that it provides enough flexibility to plan methods of dissemination of interventions. Another advantage is that this form of campaigns can be disseminated to large audience and at a low cost (5).

The significance of this research is that the researcher used campaigns with engaging story and attractive poster as a health promotion method. However, desired results were not obtained as some residents from rural Bangladesh continued to drink raw date palm sap even after the delivery of campaigns. The next approach taken was to give the message to start drinking only after the sap is protected with a skirt. However, the study could not establish a larger effect because raw date palm sap because significant changes in the consumption of raw date palm was not achieved by the use of skirts.  Hence, there is a need to implement more studies in future to understand other ways to prevent Nipah virus infection. Review of several types of options that could prevent the outbreak is also important.

Health Promotion Strategies for Preventing Nipah Virus Outbreak

The paper selected is relevant to the poster as the articles discusses about the strategies to prevent Nipah virus infection and the intervention presented in this paper is similar to the preventive strategy of avoiding direct contact with humans and pigs as mentioned in the poster.

The significance of the paper implemented is that it used current policy in Bangladesh and evaluated the effect of interventions implemented using different modes to prevent Nipah virus infection. As per current policy, the Bangladesh government recommended against using raw DPS during outbreak season unless it was protected by bamboo skirts. The study proposed policy options and alternative interventions like integrated education and multi-species special surveillance program to increase public outreach and training and promote early identification and response to the epidemic. The study evaluated the efficacy of interventions options like education, surveillance, development of a human vaccine, habitat modification, infection control and quarantine (6). The intervention option that has been evaluated in this paper is in relevant to the five key actions areas mentioned in the Ottawa Charter of Health promotion. This included building healthy public policy, creating supportive environments, strengthening communication, developing personal skills and reorienting health care service. The first three actions can be fulfilled by education, surveillance and habitat modification intervention. Reorientation of health services can be done by development of human vaccine and infection control and quarantine (7).

In contrast to the other two papers, the study has the advantage of developing understanding regarding the advantages and disadvantages of various types of intervention options. The critical analysis and review of this paper would help to understand the best intervention that is needed for target population group as mentioned in the poster. For example, education is a cost effective way to spread awareness about Nipah, however changing age old beliefs is a challenging aspect of the intervention. Secondly, surveillance is beneficial in early detection of diseases. However, time constraint issues may hamper the purpose of intervention. Another option of developing and using vaccine is also labour intensive process (6). Hence, education is considered the most effective way. However, as the study lags behind in giving evidence regarding the method of implementation to prevent Nipah virus, there is need to review the method and content of such programs that would have maximum effect. The finding presented in this paper is also relevant to the poster as it discusses about different prevention methods.

Innovative Approaches to Communicate Information and Behavior Change Messages

The finding presented in this paper is very important as it reduces the gap found in paper 3 by suggesting about the best ways to disseminate Nipah Virus prevention message during an outbreak. As education and preventive message is found to the most cost-effective preventive methods, the study used a prevention strategy to reduce the gap between in content of health message related to the Nipah outbreak. The research explored health beliefs and perception about illness among research participants and the preventing message was implemented after an interactive strategy where photos were used as aid to display the type of contacts leading to Nipah virus infection (8). The approach of exploring health beliefs and perception is considered effective as it can enhance the likelihood of implementing culturally sensitive health promotion practices. This method can help to understand inherent beliefs. This is relevant to the health promotion theory of care seeking behaviours as it includes broader constructs such as norms, beliefs, external factors and socioeconomic factors to improve self-management skills of people and prevent progression of disease (9).

Another vital health promotion strategy shown by the researcher was that they used innovative approach to communicate information and behaviour change messages. The interactive strategy was to use information sequentially using lay language, examples and photographs.  Brief history about outbreak was explained and the photos related to sap collection pot were shown. In addition, pictorial communication messages like washing hands with soap before eating and after cleaning patient, sleeping in a separate bed and maintaining distance between patient and other persons were shown. The intervention helped to understand different types of spiritual beliefs related to Nipah Virus and its transmission. This also helped to adapt culture-centric solutions to manage risk of Nipah. The staffs used participatory approach to build rapport with clients and the use of culture-centred approach helps to develop a comfortable environment for the resident to express their concerns related to management of illness (9). Hence, this is by far the best intervention that has reported about the appropriate strategies needed to communicate health message to culturally diverse population group. The findings also give the implication to understand the role of multi-disciplinary team in effectively providing health message to target audience. Lack of follow-up participants was the limitation of the study which could be explored in future research.

This paper was also taken because it is relevant to the poster as it has used washing hands before a meal and wearing gloves in public as health message to communicate caring message to the participants. The effectiveness of the message was enhanced by adapting interactive strategy and culture centred strategy.

Conclusion

The paper published by Kulkarni et al. (2013) provides insight into the emergence and mode of transmission of Nipah virus into the human population. Compared to the other papers discussed so far, this paper gives information about the etiology and epidemiology of studies which has not discussed in detail in other papers. The importance of the paper is that it has given detailed understanding regarding the history of transmission, etiology of the disease, the host range, transmission route and diagnostic test (10).  The paper highlighted the mortality rate due to NiV and its transmission from pigs that acts as an intermediate host during outbreak in India and direct virus transfer from bats to human and further in the population. The article also highlighted the fact that as there are increased animal-human interactions along with inadequate sanitation, changing environment in India, it is one of the top hotspots for the livestock diseases like NiV (zoonotic diseases). However, major gaps found in this study are that the findings has been presented in a report form and it has not defined how the information was obtained. Conducting surveys and the method of implementation of survey would have enhanced the reliability of the research evidence.

Despite limitation, the information can be used to enhance policy directed actions and public health campaigns can benefits from the information as this would enhance participation of other stakeholders in the preventive effort. As increase in mortality and mortality is a threat to prevention, the message can used to promote behavioural change in patient. Health promotion campaigns are vital part of health promotion practice and evidence shows that valuable input from external experts improves the success of such programs (11).

The information is related to the poster because as the poster has used pictorial aids to give an idea regarding transmission of the infection and the paper also gives comprehensive details regarding the epidemiology of the disease in India. As the population of interest is India, reviewing the paper would help to develop in-depth understanding regarding the cause of Nipah virus outbreak. The content of the paper can be used to plan health message during health promotion activities.

The paper published by Verma et al. (2018) is an important and updated source of information on NiV infection spread, its signs and symptoms and prevention controls to create awareness and reduce the risk of infection spread in the states of India. The information is important as the target population group for poster is people living in Kerala India and the paper also reports about Nipah virus transmission in India. Compared to other papers which have used research methods to explore the impact of interventions to reduce infection, this paper gives an overview about distribution of infection (12).  The paper also highlighted signs and symptoms that were observed in humans during the early and advanced stages and the factors increasing the risk of exposure. The main limitation of the paper is that unlike other studies, it has not used experimental research design to explore the impact of any intervention of population group. However, the information is useful for framing health message while health promotion for Nipah virus. It is relevant to the communication theory of health promotion as it would help create message that are innovated and promote behaviour change initiatives.

Preventative strategies and treatment guidelines are also mentioned in the paper that is useful, valuable and can be shared with people to reduce risk of infection and its spread. This review provides spotlight on the infectious agent-NiV and indicates the urgency of multidisciplinary approach and government initiatives to insights into pathological process and virus transmission so that effective screening procedures, prevention measures, diagnosis and treatment options are developed to fight this deadly virus. The relevance of the paper in relation to the poster is that it has used similar information related to prevention, cause and method of Transmission.

The main rationale for selecting this research paper is that it gave special update regarding prevention strategies for Nipah virus with reference to India. Paper 1 to 4 discussed about prevention strategies, however these were not related to the Indian population context as the research was done in Bangladesh. However, as the target population for the poster is India, finding current update on prevention strategies are useful.

 The paper published by Ganguly et al. (2018) highlighted the fact that NiV is zoonotic in nature and spread through direct contact with infected sources. Few types of bats act as reservoir and its diagnosis is through laboratory testing. In India, the disease spread through consumption of toddy or raw date palm sap and materials contaminated with bats. The paper provided a detailed laboratory testing for NiV through reverse transcriptase polymerase chain reaction (RT-PCR) extracted from throat swabs, cerebrospinal fluid and urine. Compared to paper 5, diagnostic test mentioned in this paper is very specific to the Indian population. Paper reported about large number of diagnostic technique. However, all diagnostic test may not be relevant to the Indian context. The paper also recommended that the levels of IgM and IgG antibodies should be tested after recovery for confirming NiV. This article is also of immense significance as it provides an alternative approach to prevent infection as vaccines are not available. The strategies included avoidance of exposure to ill bats and pigs in endemic areas, avoid consumption of raw palm toddy or sap, fruits, drinking water from unsafe and open wells as those sources may be infested by colonies of bats. The most vital strategy was the use of subunit vaccine that provides protection against the Hendra virus was found to synthesize cross-protective antibodies against NiV using Hendra G protein has implications for future research contributing to effective prevention measure in humans as stated in the article (13). The interventions mentioned is in relevance with the theory of reasoned action as it is based on the assumption that people routinely consider the consequence of certain behaviours before engaging in it (14). Hence, the preventive message can be used to control behaviour of high risk group in India. No other research papers so far has reported about the use of Hendra G protein to fight against Nipah virus. Although the poster mentions about Hendra G protein, however this has not been mentioned in any one of preventive strategies explored so far.

The relevance of the paper is relation to the poster is that like the poster, it also reports about avoiding contact with pigs and bats and using Hendra G protein.

The paper published by Shameer et al. (2018) highlighted the major problem of new emerging diseases and resurging in aggressive forms. This is most advanced paper as it suggest the idea of preventing Nipah virus by transforming pharmaceutical production which has not been explored so far in any research paper. Pharmaceutical companies are facing challenges in drug development for endemic diseases constricted to certain regions or particular population. Considering this situation, in this article, the authors aimed at leveraging biomedical tools and data for analyzing available data on NiV infection. In this study, the application of chemogenomic enrichment analysis method and computational drug repositioning using host transcriptome data was used to match drugs that can reverse the action of virus-induced gene signature. The authors performed an analysis using two gene signature that comprised of gene signature (n=34) that was previously published and gene signature generation (n=5533) via characteristic direction method. The predictive framework used in the study suggested that FDA approved drugs like trihexyphenidyl, beclometasone, S-propranolol can be beneficial in modulating the induced gene signature by NiV infection in the endothelial cells. CXCL10, targeted specific analysis also indicates that potential application of drug in prevention (15). This source of information provided a proof-of-concept study highlighting the benefits of innovative translational bioinformatics methods that includes computational drug repositioning and gene expression analysis. The implications of the study is that it could pave for the epidemiological experiments in context to NiV infection, an emerging disease with no vaccine or effective treatment options.  This study has implications for future research in the field of clinical trials and biochemical assays for identifying effective therapies for future clinical use. The innovative application of translational bioinformatics and biomedical informatics highlighted in the source is useful in gaining an insight into molecular biology and facilitating therapeutic correlation in developing drugs against NiV infection. Therefore, translational bioinformatics may contribute to addressing of challenges that current healthcare delivery is facing in drug development against NiV infection.

The importance of the paper is that gives a critical review about different types of community based intervention that has been implemented to control zoonotic infectious disease like Nipah virus in South East Asia. Compared to the papers reviewed so far, this paper gives an understanding regarding evidence for best community based intervention that has been published in research studies so far. Unlike experiment based study, this paper can help to understand the utility of preventive interventions in research literature.

Although the paper reported about other types of zoonotic infections; however interventions targeting Nipah virus were only analyzed for this annotated bibliography. The intervention mainly included outbreak reports on illness and impact of the National Swine Surveillance Program in initiating control measures in Malaysia. This strategy is in relevance with the Ottawa Charter of Health promotion as it mentions changing the environment and reorienting health services (16). Hence, surveillance program could have been a useful approach to direct useful action to prevent the disease. However, the credibility of the finding was limited because of poor quality of outbreak reports and poor methodological quality of papers.  The sampling strategy for the program was discussed however no comment was made on the feasibility and sustainability of the program. This suggests the need for future studies to confirm the true effect of the health promotion intervention. The relevance of this to the poster is that it gives additional idea regarding ways to prevent contact with infectious agent.

This paper reported about the use of four types of physical barriers to prevent bats from gaining access to Nipah Virus. Compared to paper 1 to 4, the main significance of this paper is that it indicates about four types of barriers to prevent Nipah virus transmission which was not reported in the other four papers. In addition, the paper used randomized controlled trial as the study method which comes under top level in the hierarchy of research evidence.

The researcher used a cross over design to select date palm trees productivity. The tree was observed two nights, one night after the intervention and another night without the intervention. Apart from bamboo, similar types of observation were also done for other three types of barriers such as polythene skirts, the jute stick and dhoincha (local plant). Infrared camera was used to explore bat contact with the sap. The results of the study revealed that contact with bats occurred in 85% of observation. Another important conclusion from the study was that smaller skirts hampered the efficacy of the intervention. However, if size of the skirt was larger, no contact with bats were seen when the tree was compared with bamboo stick or dhoincha or polythene cover (17). However, contact was seen in some when jute stick skirt was taken. This evidence suggest that these intervention need to be tested in larger trials. The intervention is relevant to health promotion practice as it targets risk factors that lead to transmission of the disease. It is in relevant with the creating supportive environments elements of the Ottawa charter as it gives an idea to support population at risk to adapt elements that could help them achieve better outcome (7).

The paper is relevant to the poster as it suggest ways to prevent contact with bats as mentioned in the poster

References

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