Dr G. Arun Kumar, currently heading Manipal Institute of Virology (MIV) under Manipal Academy of Higher Education (MAHE), is a renowned Indian microbiologist and virologist. He also heads the Regional Reference Laboratory for Influenza viruses established by Ministry of Health and Family Welfare, Government of India at Manipal and the ICMR Virology Network Laboratory (Grade-1) at Manipal. He is the pioneering scientist, who established the virology facility in Manipal with the support of the University and the Government. His research interests include viral diseases, epidemiology and diagnostic virology and public health response during infectious disease outbreaks. He led the team that was instrumental in containing the first Nipah Virus outbreak in South India. He is an expert member of several national and international committees pertinent to public health.
Dr G. Arun Kumar at Manipal Institute of Virology
How did you come to join Manipal Academy of Higher Education and how was the virology facility set up there?
I came to Manipal in 1994 to pursue MSc in Medical Microbiology after my BSc in Medical Laboratory Technology from Trivandrum Medical College. It was within a year since Manipal had become a deemed university. As soon as I finished MSc, I received the CSIR-JRF fellowship and went to the All India Institute of Medical Sciences (AIIMS), Delhi, to pursue my PhD in Virology.
About six months into AIIMS, as I was preparing to register for PhD there, my Professor from Manipal, Dr P G Shivananda MD, PhD., wrote to me asking me to join them. It was a difficult decision to take as Manipal did not have a virology lab at that time. The risk-benefit analysis showed that it was risky to move to Manipal. But my professor was insistent and promised me to provide a small facility for virology. I also discussed these things with my guide Dr Pradeep Seth, MD at AIIMS, New Delhi, and he also suggested taking up Manipal’s offer. I then thought that moving to Manipal was a challenge I had to take up – to initiate something that would have a lasting impact not only on me but also on the institution.
So, I joined Manipal as a lecturer in Nov 1997. I wrote a proposal to Prof. M. S. Valliathan, the then Vice-Chancellor of MAHE, through my professor, Dr P G Shivananda, to establish a virology laboratory. After a year, INR 500,000 was granted to set up a virology facility. That is how the virology lab was set up in Manipal and I came to be associated with it.
How did this facility grow to be an internationally renowned institute?
In May 1999, we set up a small lab with viral serology, tissue culture and virus isolation facility and started working on some clinically relevant viruses. We started the work with Respiratory Syncytial Virus (RSV) as I had worked on it in AIIMS and was familiar with it. I also started my PhD on RSV and completed it in 2002. By then we were actively working on 4 to 5 viruses and were providing diagnostics for it. This was also the time when we started attending conferences and people started noticing our work.
In 2003, there was a huge outbreak of SARS in Hong Kong. Government of India started looking at developing the capacity to detect and fight this virus. A review committee emphasized the requirement for more virology labs in India. The government also wanted to prepare the country for Avian Influenza (bird flu) Virus. Fortunately for us, without our knowledge, our facility was identified as a potential lab to be supported to work on these programs.
In 2007, we got a letter from the Indian Council of Medical Research (ICMR) asking if we were willing to develop the lab to a state-level virus diagnostic and research laboratory (VRDL). Following an expert site visit and a detailed project proposal review in 2010, they sanctioned a grant of INR 5 crore for a period of five years. Meanwhile National Centre for Diseases Control (NCDC), Delhi had included our lab under the network of regional influenza laboratories. This enabled our facility to be notified as a reference laboratory for influenza A H1N1 when the pandemic influenza arrived in India in 2009. The ICMR- VRDL facility was established in March 2010. Subsequently, realizing the potential of the lab, MAHE elevated it as a University department – Manipal Centre for Viral Research (MCVR). Now I had to report directly to the Pro-Vice-Chancellor of the university. This removed many hurdles and facilitated a faster decision-making process. We also moved into a new building with the support of the university. In this way, we grew in close association with the State and Central Health Services in India in the area of disease surveillance
In 2013, we had another quantum leap when we received a foreign grant from the Centre for Disease Control (CDC), USA as part of the global health security agenda (GHSA). We were awarded a sum of USD 250,000 to study emerging pathogens in the human-animal interface. We started the study in Shimoga, Karnataka. It progressed well and we received an upgrade of the award in 2015 to carry out the study in ten states in India. With that our funding had increased and our capacity grew tremendously. This enabled us to become a centre for excellence in disease surveillance and outbreak investigations.
In this way, we grew with the support of the university and the Government of India. We received several grants from the government and the university provided us with the infrastructural support. Manipal provided enormous support, space and freedom to grow and implement some of the dreams I had. The support has continued and now we have been elevated as independent institute – Manipal Institute of Virology (MIV) – under the university with higher containment labs and facilities.
MCVR (now MIV) did an excellent job in checking the Nipah virus outbreak. How did you go about detecting this rare virus?
Since 2009, we have been working very closely with Kerala on the detection of Pandemic Influenza. Besides the Influenza virus, we would also run diagnostic tests for other viruses in many cases. Gradually, many doctors of Kerala gained confidence in our viral detection tests and we developed a close relationship with the doctors. Baby Memorial Hospital at Calicut was one of the hospitals we had been closely working with.
In May 2018, a patient with symptoms of Encephalitis came to Dr Anoop Kumar at Baby Memorial Hospital. His brother had died with a similar illness 12 days earlier and two others in his family were also sick. This cluster of brain fever in a family raised an alarm. There were two possibilities viz., (i) Serial Poisoning (ii) An infection. When Dr Anoop called me around lunchtime on May 17, 2018, and explained the case, I sensed that it was a serious case. I directed him to collect multiple clinical samples and asked him to send it across quickly by hand. In a usual case, the samples are collected through a nodal officer at the district and are sent as a batch by train either daily or on alternate days.
In our primary investigation of this sample, in addition to the test for common Encephalitis agents like Herpes Simplex Virus and Japanese Encephalitis Virus, we tested for Nipah Virus as well. In the usual case of Encephalitis from Kerala of Karnataka, we would never consider testing for Nipah in the first set. But we considered it because of our understanding of Nipah epidemiology and knew that Nipah presents as a family cluster of encephalitis. Nipah virus testing was not new for us. In our fever study program in Assam and Tripura, we had tested samples for Nipah in the border areas close to Bangladesh (Bangladesh has been reporting Nipah cases every year since 2001) but didn’t detect any. That is why we considered it in our primary investigation and it turned out that the patient was positive for Nipah. But since this was from a different region, we were sceptical. We wanted to be sure. So we tested for about 30 other agents and by evening we were sure that it was Nipah only.
How did you tackle the situation when you realized that you were dealing with this deadly virus? What were the measures you took to rise to this public health challenge?
By the evening of May 17, 2018, we knew that we were dealing with Nipah. But you cannot announce it right away as it would have implications on national and international mobility. We also had to be absolutely sure of the agent. But the information had to be conveyed quickly to contain the virus and avoid transmission.
So immediately we sent the samples to National Institute of Virology (NIV), Pune, for a reconfirmation. In the meantime, we alerted the central and the state government authorities about the virus without naming it and urged the hospitals to isolate people who had come in contact with the patient.
Kerala responded to this situation in a very positive way. The health department instructed the hospitals about isolation procedures and patient care. The healthcare workers were pro-active, and the public also responded well.
The Hon. Health Minister of Kerala Smt. KK Shailaja teacher asked me to join them on the field as very little was known about this outbreak and had to be investigated. When we got there, we realized that there were several undiagnosed deaths in the medical college that week. Fortunately, the samples were preserved for few cases at least and they turned out to be positive for Nipah.
But these cases had no obvious connection to the first patient or the family. This was frightening. By this time the public and the government were growing restless and wanted to know what was happening. If these cases were not linked to the first cluster, we would have to consider the case of a biothreat. But Nipah is a difficult agent and is usually not used as a bioweapon. We launched a thorough epidemiological and virological investigation and traced those who had come in contact with the initial patients, isolated them and put them under surveillance. The health department of Kerala had already started isolation procedures on the night on May 18.
We then went into a detailed investigation of the first case, twelve days before the reported death. The patient was hospitalized in the Taluk hospital for one day and in the Medical College Hospital for another day. The Taluk hospital had already been evacuated, but the staff recreated the scene of the original patient in the ward. He had cough, vomiting, and irritability. His father and brother had attended to him and there were some deaths from the same ward because of human to human transmission. Nine cases were thus linked to this hospital.
When we tried to trace the other cases, we found an intriguing association with the radiology corridor of the Calicut medical college. Investigations revealed that the index case when admitted to Calicut medical college was subjected to a CT scanning on 5 May and most of the cases had exposure to index case that day. The index case was moved around the CT scan room and in the corridor for about four hours since it was difficult to get his scan due to his altered sensorium and irritability. CCTV footages helped trace this exposure. Once this link was established, we were relieved. Health department identified all contacts of these people and isolated all symptomatic cases and the situation came under control.
After this, the health department called for a meeting with News Editors and discussed the situation. We made them aware that Nipah is transmitted by droplets, where the person had to be within one-meter vicinity of the patient for it to be transmitted and not by aerosol (Airborne). At the start of the meeting, about 60% were wearing masks and at the end of it, no one was wearing a mask as the mask was required only for persons in close contact with the patient. This communication helped a lot to clear the public fear.
In retrospect, how do you view this achievement of Nipah intervention and what do you think about it?
Looking back, I think there were some critical junctures where important decisions had to be taken. The district administration was very supportive and was with the health team all the time. There was very good participation and intervention by the state and central health services. Hon. Health minister of Kerala Smt. KK Shailaja Teacher, The Additional Chief Secretary of Health department Sri. Rajeev Sadanandan and the Director of Health Services Dr RL Sarita has provided exceptional leadership. The Nipah emergency operation room at Calicut worked flawlessly in coordinating the response. It was a very good model and I am afraid if it can be replicated in other places.
Recently, Manipal Institute of Virology was added as a centre of Excellence within Global Virus Network (GVN). Could you please tell me a little bit about GVN and how you view this addition?
Global Virus Network (GVN) was founded by Robert Gallo, who won the second Lasker Award for the discovery of HIV, in conjunction with William Hall of University College London and Reinhard Kurth of the Robert Koch Institute. It is a Non-Government network that brings virologists and institutes together in a collaborative effort to fight viral infections.
The idea of the network is to develop expertise through centres for excellence and to exchange it among them to act quickly during an outbreak. The aims of the network include collaboration among virus scholars, expansion of virologist training programs, and evidence-based policy advocacy. The network also collaborates with WHO and gives expert opinion helping in framing evidence-driven policies.
I think our addition to the GVN will help us in building our capacity, be instrumental in framing evidence-based policies and to work on one health – a concept that tells that the health of people is connected to the health of animals and the environment, which is nascent in India. This collaboration is going to help us in the study of these aspects.
What is your vision for MIV for the next 10 years?
As we are transitioning from a centre to an Institute we are redefining our vision and goals. In the next ten years, we envisage transforming MIV to the most preferred place for infectious diseases researchers especially in the area of emerging and re-emerging diseases. We will enable and nurture basic, translational and public health virology research which is designed to contribute to achieving the sustainable developmental goals.
As a person who has been instrumental in building a centre of excellence in research, what is your advice for other academicians treading the path?
Three things are important to build a department or institution: (i) Your team: You need people who stay with you and understand your vision and philosophy (ii) An enabling leadership and environment (iii) Liaison with government systems and stakeholders.
It is also important that you grow in a niche area. For example, we specialized in disease surveillance, outbreak detection and pathogen detection, which requires quick mobilisation the team in the field.
However, it is important to periodically identify the strengths, weaknesses, opportunities and threats and strategize to reinvigorate the growth rate.