Nipah Virus: What Frontline Health Care Workers Need to Know

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What is Nipah Virus and How Does It Spread? 

Nipah virus infection is a viral zoonotic disease caused by the Nipah virus (NiV) from the genus Henipavirus. Fruit bats, also known as flying foxes, are the primary zoonotic host and can transmit the virus to humans and animals—particularly livestock such as pigs and horses. 

The virus can spread to people through consumption of raw date palm sap and fruit that has been contaminated with bat secretions (saliva, urine). Transmission can also occur through close contact with an infected animal or its bodily fluids. 

Once infected, person-to-person spread is possible with close contact and through nasal and respiratory secretions, blood, and urine.​ When person-to-person transmission occurs, it happens most commonly in health care settings or in caretakers of NiV-infected patients. Patients with respiratory symptoms are more likely to spread NiV. 

Nipah Virus Infection Outbreaks 

Nipah virus is named after the village in Malaysia where the first cases were identified in 1998. The outbreak resulted in more than 300 cases and 100 deaths in pig farm workers in Malaysia and Singapore. Since then, nearly annual outbreaks have occurred in Southeast Asia, primarily in Bangladesh and eastern India. 

Six cases have been reported in the Indian state of Kerala. As of September 29, 2023, four of those cases have recovered, with two deaths. This is the fourth outbreak of NiV in Kerala. 

Signs and Symptoms of Nipah Virus Infection 

Nipah virus infection can cause disease that ranges from mild to severe, including encephalitis, and potentially death.​ 

Symptoms typically appear within 4-14 days of exposure to the virus. Presenting symptoms may initially include one or more of the following:​ fever​, headache​, cough​, sore throat​, muscle pain, and vomiting.

Some people also have difficulty breathing, atypical pneumonia, and acute respiratory distress. Presenting symptoms can quickly be followed by dizziness, drowsiness, and altered mental status. Seizures and acute encephalitis can occur in severe cases and may proceed to coma within 1-2 days.​

Clinical Care for Patients Infected with Nipah Virus 

Diagnosis of Nipah virus infection can be difficult due to its non-specific early symptoms. NiV infection should be considered in people with symptoms of fever, headache, cough, vomiting, or severe illness who have been in areas where outbreaks are common (Bangladesh, India, Malaysia, Singapore); in those who report contact with raw date palm sap, fallen fruit, bats, livestock, or sick animals; or who have been in contact with someone suspected or confirmed to be infected with NiV. 

Early identification and vigilance at first health care contact are critical to increase chances of survival, prevent further transmission, and protect the safety of health care workers. Utilizing a universal symptom and travel screen can help identify people with potential infection.   

Treatment is mainly limited to supportive care, including rest, hydration, and treatment of symptoms as they occur.​ While there are no licensed treatments available for NiV infection, the monoclonal antibody m102.4 has undergone Phase 1 testing and has been used under compassionate care for individuals exposed to NiV and the related Hendra virus. The antiviral Veklury (remdesivir) has been shown to lessen disease severity in a non-human primate model of disease.  Learn more about treatment options. 

Case fatality rates in previous outbreaks range from 40-75 percent. Survivors of NiV infection may have recurrent seizures and personality changes. 

Are you prepared to treat a patient infected with NiV? NETEC’s free course “Special Pathogens of Concern,” designed for health care professionals and emergency responders, can help you to prepare for a special pathogen event.  Learn more and sign up now.  

Testing for Nipah Virus Infection 

Laboratory testing for Nipah virus is available through the CDC’s Viral Special Pathogen’s Branch. Pre-approval is required, so work with your local public health department to collect the appropriate specimen type. ​ 

Clinical specimens suspected of containing NiV are considered Category A when shipping. Appropriate training, as well as shipping containers and documentation are required.  

Clinical specimens suspected of containing NiV, including blood and spinal fluid, should be handled with enhanced precautions. Laboratory risk assessments should be completed to determine what tests can be carried out with minimal risk. Specimen collection, handling and processing should be done while using appropriate personal protective equipment (PPE) and engineering controls (e.g., biosafety cabinet). 

Recommended PPE 

If the patient is clinically stable without vomiting (and you suspect Nipah): gown, gloves, respirator, eye protection  

If the patient is clinically unstable (and you suspect Nipah) or confirmed to be infected with Nipah: follow the “wet” precautions you would use for Ebola: 

• Impermeable gown or coverall  
• PAPR or N95 respirator  
• Examination gloves with extended gloves  
• Boot covers (or shoe covers in combination with coverall with integrated socks)  
• Apron 

Place the patient in an Airborne Infection Isolation Room (AIIR), when available. 

Infection Control Measures for Nipah Virus Infection 

Because Nipah virus can spread from person-to-person, current recommendations are to place the patient in AIIR when available and to use contact, droplet, and airborne isolation to prevent hospital-acquired infections and safeguard staff. 

Like Ebola virus, NiV is an enveloped virus, that can be inactivated on surfaces using the appropriate disinfectant. To disinfect surfaces, refer to the EPA Q-List for recommended disinfectants. 

Waste generated in the care of patients with NiV infection, including laboratory waste and used PPE, is considered Category A waste, and should be handled in accordance with local, state, and federal guidelines. See the guidelines for managing solid waste contaminated with a Category A Infectious Substance. 

Additional Resources for Health Care Personnel

Nipah virus, an emerging zoonotic disease causing fatal encephalitis

Recent advances in combating Nipah virus