Coronavirus Outbreak: Monkey fever epidemic in Shivamogga district opens up two battlefronts for Karnataka
KFD Virus spreads primarily through forest ticks which are most active between November till the first weeks of monsoons.
In the quiet of a lockdown, healthcare workers and Panchayat officials in Aralagodu village in Karnataka’s Shivamogga district have their ears out for news of fresh cases of fevers.
Those who had returned from cities to the village before the declaration of the nationwide lockdown are under strict watch. Two hamlets have been completely sealed off, while an official order makes it illegal for villagers to go into forests that adjoin their households. Social distancing here is not only from people but also from the forest itself.
In this relatively-sparsely populated region nestled amid the lush forests and hilltops of the Western Ghats, the fear is less about COVID-19 which has dominated media and political narratives for over a month. After all, not one COVID-19 case has been detected in the district so far. Instead there is anxiety over the breakout of another zoonotic, viral infection: Kyasanur Forest Disease or, its popular moniker, monkey fever.
The disease, which spreads through tick bites, has seen over 225 positive cases and five deaths along the Western Ghats districts of Karnataka since the start of the year, reveals data collected by the state’s health department. Among them, 159 of these cases are in Shivamogga district, a traditional epicentre of the disease that was first discovered in 1957.
A shroud of fear hangs over Aralagodu village that bore the brunt of the disease last year. The small village and its neighbouring areas had recorded over 174 cases last year, and at least 22 deaths.
In February of this year, some 20-25 monkeys near the village were found dead – a sure sign that the viral disease is active in the forests. “People were scared. We didn’t want to go through this again,” said Chandraraju KS, a resident of Aralagodu and a member of its gram panchayat.
But, Aralagodu was better prepared this time around: nearly all villagers were administered three doses of vaccinations (only after the third dose, to be given six months after the first two doses do effectivity increase to 82.9 percent).
While Aralagodu’s residents had started their vaccinations late last year, those who arrived from the city to flee being stranded during the COVID-19 lockdown are unvaccinated.
“A lot of people from the village work in Bengaluru or study in cities outside. It is understandable that they want to come back here during these uncertain times. We are trying to track them to ensure they get at least one vaccination dose and to tell them to use tick-repellent oil if they choose to go out of the house,” says Chandraraju.
KFD Virus (KFDV) spreads primarily through forest ticks which are most active between November till the first weeks of monsoons. Within the closed systems of forests, it spreads from tick to hosts such as rodents, shrews and monkeys whose frequent deaths due to high viral load had led to the disease being popularly referred to as monkey fever. From these hosts, thousands of KFDV-carrying larval ticks infect other mammals in the vicinity including humans. The virus leads to fatal haemorrhagic fevers and has a mortality rate of nearly 10 percent -- significantly higher than coronavirus which has a mortality rate of 3 percent.
Tick bites are often undetected when walking through forests, and in villages like Aralagodu, nearly every house abuts a forest.
The people in-charge of KFD surveillance have flagged “lockdown” returnees as being susceptible to KFD. With COVID-19 -related lockdowns gaining acceptance among villagers, the deputy commissioner in Shivamogga declared nearly 31 KFD hotspots, primarily with these large pockets of unvaccinated returnees. Villagers have been barred from collecting dry leaves and firewood or graze their cows in forests or even from resuming plantation works here.
“People who’ve come from Bengaluru or other places are high-risk individuals when it comes to KFD. There is a tendency for them to treat this COVID-19 lockdown as a holiday and are spotted in forests or plantations which could instead be teeming with KFD,” says SK Kiran, Director of Viral Diagnostic Laboratory (VDL) in Shivamogga and the State’s KFD Special Officer.
Another unexpected impact of COVID-19 lockdown is the increased prevalence of KFD among children. Usually, children below the age of 18 years account for just 2-3 percent of KFD cases in a typical year. This year, however, they form nearly 8 percent of all reported cases.
“Schools (including boarding schools which is common for people of remote villages) have been closed for nearly two months now. The time they would spend at school is instead spent restlessly at home or in plantations increasing their risk of catching KFD,” he says.
The focus on COVID-19 and managing the subsequent lockdown has added layers of complication for KFD disease surveillance. In March, two BJP MLAs took on their own government angrily, accusing it of ignoring the epidemic and focusing its attention entirely on COVID-19 . Furthermore, until mid-April, VDL in Shivamogga, which has tested nearly 6,000 blood samples for KFD, was also tasked with additionally testing thousands of swab samples from across North Karnataka for COVID-19 .
The spectre of a pandemic at the time of an epidemic is stretching the grassroots health infrastructure. In Siddapur taluk of Uttara Kannada district, where 40 people have tested KFD positive including one death, local health workers had to do three rounds of door-to-door surveys for KFD and COVID-19 . In the absence of public transport, villagers with fevers can’t come to hospitals for tests, instead, doctors and health workers have to visit houses – further compounding the work a single health worker has to do in the hilly terrain pockmarked with remote hamlets.
“Day-by-day we are recording new cases, but the situation is under control. Along with our ASHA and ANM (Auxiliary Nurse Midwife) workers, we have asked PDO (Panchayat Development Officers) and Village Accountants to help identify people with fevers; while, our doctors and health workers do go to houses to collect samples for tests,” says Manjula Bhajantri, Tahsildar for Siddapur taluk.
On the flip side, the COVID-19 scare and its incessant messaging on televisions have led to an increased number of people reporting fevers — which are both a symptom for COVID-19 and KFD — to authorities, she says.
Learning lessons and lessons for the COVID-19 crisis
The outbreak of 2018-19 was, in part, blamed on a failure of the surveillance system that did not plan enough or vaccinate enough. This year, vaccinations had been more widespread, rate of sampling had been increased, surveillance in the form of door-to-door surveys had been strengthened.
“At the same time last year, we had double the cases and triple the number of deaths. We are more confident that things are under control,” says Kiran.
If a deadly outbreak brought about changes in processes for effective KFD management, perhaps, a post- COVID-19 world will being the bring back attention to zoonotics – which form nearly 60 percent of emerging diseases – and collaborative public health systems at large.
Helping officials this year are the predictive tools and decision support tools that have been developed under a multi-institutional collaborative project, Monkey Fever Risk project. And this ‘One Health’ approach (multi-disciplinary studies involving social scientists, epidemiologists, ecologists, virologists and others) may hold lessons for India’s response to its current COVID-19 crisis.
In many ways, KFD and coronavirus share similarities. Both are viral diseases, their emergence from species in the forests is still unsolved scientific questions. KFD’s spread may be limited by its reliance on ticks as carriers of the virus (unlike coronavirus that can spread through respiratory droplets), but it has been expanding its geographical range.
KFD was largely restricted to Shivamogga and parts of the Western Ghats till 2012. However, since then, it has been detected in Tamil Nadu, Goa, Kerala and Maharashtra. Since 1957, there have been more than 10,000 cases of KFD recorded in 16 districts of the country. This year, apart from Karnataka, over 13 cases and one death have been reported in Kerala.
The One Health Monkey Fever Risk project, which began in 2017, attempted to understand this spread better and to subsequently, predict the risk of spread of KFD in Shivamogga district. The project’s first scientific paper, published earlier this month, identifies high-risk areas as those with higher forest loss, higher proportion of plantations, closer to evergreen moist forests and with higher cattle densities (which is a blood source for ticks and is often grazed within KFDV-infected forests). The model’s prediction for hotspots in the 2019 correlated with the outbreak seen last year.
The risk map helped the KFD surveillance team pivot from being reactive, as was the established protocol, to being proactive in 2020.
“Generally, a monkey or human death would trigger vaccination drives in a 5-km radius around the infected spot. But, with this predictive information, we could ensure potential hotspots were vaccinated even before the detection of a single case,” says N Darshan from the Department of Health and Family Welfare, Karnataka and one of the authors of the paper.
Waiting for the rains
In parts of the country, state governments have begun strategies to remove lockdown restrictions, while uncertainty looms in the COVID-19 hotspots. However, in Shivamogga’s KFDV hotspots, restrictions in forest and plantation access depend entirely on monsoon rains.
“When the rains come, the ticks go away. Until then, hamlets in the hotspot will always carry the chance of contracting KFDV. We’ll try to enforce their lockdown restrictions as much as possible,” says Chandraraju.
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