title: Investigating Rare Risk Factors for Nipah Virus in Bangladesh: 2001-2012.
abstract: Human Nipah encephalitis outbreaks have been identified almost yearly in Bangladesh since 2001. Though raw date palm sap consumption and person-to-person contact are recognized as major transmission pathways, alternative pathways of transmission are plausible and may not have been identified due to limited statistical power in each outbreak. We conducted a risk factor analysis using all 157 cases and 632 controls surveyed in previous investigations during 2004-2012 to identify exposures independently associated with Nipah, since date palm sap was first asked about as an exposure in 2004. To further explore possible rare exposures, we also conducted in-depth interviews with all cases, or proxies, since 2001 that reported no exposure to date palm sap or contact with another case. Cases were 4.9 (95% 3.2-7.7) times more likely to consume raw date palm sap and 7.3 (95% 4.0-13.4) times more likely to have contact with a Nipah case than controls. In-depth interviews revealed that 39/182 (21%) of Nipah cases reporting neither date palm sap consumption nor contact with another case were misclassified. Prevention efforts should be focused on interventions to interrupt transmission through date palm sap consumption and person-to-person contact. Furthermore, pooling outbreak investigation data is a good method for assessing rare exposures.
authors.affiliation: Centers for Disease Control and Prevention, Atlanta, Georgia, USA.|University of Michigan, Ann Arbor, Michigan, USA.
authors.forename: Sonia T
authors.initials: ST
authors.lastname: Hegde
authors.affiliation: icddr,b (formerly, International Center for Diarrheal Disease Research, Bangladesh), Centre for Communicable Diseases icddr,b, 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh.
authors.forename: Hossain M S
authors.initials: HM
authors.lastname: Sazzad
authors.affiliation: icddr,b (formerly, International Center for Diarrheal Disease Research, Bangladesh), Centre for Communicable Diseases icddr,b, 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh.|Medical Research Council Unit, Banjul, The Gambia.
authors.forename: M Jahangir
authors.initials: MJ
authors.lastname: Hossain
authors.affiliation: icddr,b (formerly, International Center for Diarrheal Disease Research, Bangladesh), Centre for Communicable Diseases icddr,b, 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh.
authors.forename: Mahbub-Ul
authors.initials: MU
authors.lastname: Alam
authors.affiliation: University of Florida, Florida, USA.
authors.forename: Eben
authors.initials: E
authors.lastname: Kenah
authors.affiliation: EcoHealth Alliance, New York, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Daszak
authors.affiliation: Centers for Disease Control and Prevention, Atlanta, Georgia, USA.
authors.forename: Pierre
authors.initials: P
authors.lastname: Rollin
authors.affiliation: Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh.
authors.forename: Mahmudur
authors.initials: M
authors.lastname: Rahman
authors.affiliation: Centers for Disease Control and Prevention, Atlanta, Georgia, USA.|Stanford University, Palo Alto, CA, USA.
authors.forename: Stephen P
authors.initials: SP
authors.lastname: Luby
authors.affiliation: icddr,b (formerly, International Center for Diarrheal Disease Research, Bangladesh), Centre for Communicable Diseases icddr,b, 68, Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka, 1212, Bangladesh. egurley@icddrb.org.
authors.forename: Emily S
authors.initials: ES
authors.lastname: Gurley
mesh_terms: D001459:Bangladesh / Q000453:epidemiology; D004196:Disease Outbreaks; D045464:Henipavirus Infections / Q000453:epidemiology*; D006801:Humans; D045405:Nipah Virus; D012307:Risk Factors
keywords: Bangladesh; Nipah virus; prevention; rare exposures; risk factors; zoonoses