Written By: Dr. Nevethaa Natraj, PharmD
Medically Reviewed By: Dr. Seema Satbhai, BAMS, MPH, PhD-Public health
Kerala reports a rare outbreak of brain-eating amoeba (Naegleria fowleri), with 69 suspected cases and 19 deaths. Learn about symptoms, transmission, treatment, and public health measures to prevent Primary Amoebic Meningoencephalitis (PAM).
Kerala: An Epicenter of Naegleria fowleri Infection
Kerala has reported a bunch of rare but deadly brain infections caused by Naegleria fowleri, a free-living amoeba found in warm freshwater.
The organism enters the body through the nose and rapidly attacks the brain, leading to Primary Amoebic Meningoencephalitis (PAM).
As of mid-September 2025, health officials have confirmed 69 suspected cases and 19 deaths, prompting urgent containment efforts across affected districts.
The outbreak has raised serious concerns among clinicians and public health teams, who are working to limit exposure, improve early detection, and educate communities about water safety.
Naegleria fowleri Explained
Naegleria fowleri is a free-living amoeba commonly found in warm freshwater sources such as lakes, ponds, rivers, and untreated wells. It thrives in high temperatures and can also survive in soil. This organism is not harmful when swallowed, but it becomes deadly when it enters the body through the nose.
Once inside the nasal passages, Naegleria fowleri travels along the olfactory nerve to the brain. There, it causes a rare but aggressive infection known as Primary Amoebic Meningoencephalitis (PAM). The amoeba destroys brain tissue rapidly, leading to severe inflammation and neurological damage.
PAM has a fatality rate exceeding 95%, even with treatment. Survival depends on early detection and immediate administration of anti-parasitic drugs such as miltefosine, along with supportive care. However, access to timely diagnosis and treatment remains a challenge, especially in resource-limited settings.
Naegleria fowleri does not spread from person to person. It cannot infect through drinking water. The primary risk comes from water entering the nose during activities like swimming, bathing, or using contaminated water for nasal rinsing.
Symptoms and Diagnosis
Primary Amoebic Meningoencephalitis (PAM) caused by Naegleria fowleri progresses rapidly and often mimics common viral infections in its early stages. This makes timely recognition and diagnosis critical.
Initial symptoms typically appear within one to twelve days of exposure. Patients may report headache, fever, nausea, vomiting, and fatigue. These signs often resemble routine viral illnesses, which can delay clinical suspicion.
As the infection advances, neurological symptoms become more pronounced. These include stiff neck, confusion, altered mental status, seizures, hallucinations, and eventually coma. The disease can deteriorate within days, making early intervention essential.
Diagnosis requires a high index of suspicion, particularly in patients with recent exposure to untreated freshwater sources.
Confirmatory testing involves cerebrospinal fluid (CSF) analysis, where clinicians may detect the presence of Naegleria fowleri under microscopy or through molecular assays. However, access to rapid diagnostics remains limited in many settings.
Healthcare professionals are advised to consider PAM in any patient presenting with acute meningoencephalitis symptoms and a history of freshwater exposure.
Early empirical treatment may improve outcomes, though survival remains rare.
History & Timeline of the Outbreak
Primary Amoebic Meningoencephalitis (PAM) has been diagnosed in Kerala since 2016 but that cases were rare and sporadic. Only a few cases appeared before 2025, mostly in children.
The situation worsens in 2025. The infection spread to more districts. Unlike earlier years, the numbers rose sharply. By mid-September 2025, health officials had recorded 69 suspected cases and 19 deaths.
This rapid rise, along with the involvement of infants and young adults, has made the current outbreak Kerala’s most serious episode of PAM so far.
Kerala’s Current Situation and Containment Measures
Kerala has confirmed 69 suspected cases of Naegleria fowleri infection, with 19 reported deaths as of mid-September 2025. The outbreak has affected multiple districts, including Thiruvananthapuram, Kozhikode, and Malappuram.
Health officials have identified children and young adults as the most vulnerable, with recent fatalities including a 17-year-old boy and a three-month-old infant.
In response, the state government has launched urgent containment measures. Authorities have closed public swimming pools, initiated water quality testing in high-risk areas, and issued advisories against bathing in untreated water sources.
The Haritha Keralam Mission and local health teams are working to chlorinate wells and promote safe water practices across communities.
Kerala has released India’s first technical guidelines for diagnosis, treatment, and prevention of this infection. These include SOPs for hospitals and surveillance, and doctors have been advised to check all suspected meningitis cases for possible amoebic infection.
A molecular lab (PCR) has been set up in the State Public Health Lab (SPHL) to detect multiple amoebae (including Naegleria fowleri) locally. Medical college at Thiruvananthapuram and Kozhikode are being developed as specialized diagnostic centers.
Public health officials have also intensified awareness campaigns, urging residents to avoid nasal exposure to water during bathing and to seek immediate medical attention for symptoms such as headache, fever, or confusion.
Prevention and Public Health Advice
Preventing Naegleria fowleri infection starts with minimizing exposure to un-treated or stagnant freshwater sources. The amoeba enters the body only through the nose, so activities that involve nasal contact with contaminated water such as swimming, bathing, or nasal rinsing, carry the highest risk.
For the general public, health officials recommend the following precautions:
- Avoid swimming or bathing in warm, stagnant water bodies, especially during summer months.
- Use nose clips or keep your head above water when bathing in untreated sources.
- Ensure wells and tanks are properly chlorinated and cleaned.
- Refrain from using untreated water for nasal irrigation or religious cleansing rituals.
For healthcare professionals, early recognition and public education is a key:
- Maintain high clinical suspicion in patients presenting with acute neurological symptoms and recent freshwater exposure.
- Educate families about water safety, especially in high-risk districts.
- Support community outreach efforts that promote chlorination, hygiene, and prompt symptom reporting.
Treatment and Prognosis
Treating Naegleria fowleri infection remains one of the greatest challenges in neuroinfectious disease care. Once, symptoms of Primary Amoebic Meningoencephalitis (PAM) appear, the disease progresses rapidly, often leading to death within days.
Current treatment protocols involve a combination of anti-parasitic and antifungal medications. Miltefosine, originally developed for leishmaniasis, has shown promise when administered early.
Other agents include amphotericin B, fluconazole, and rifampicin, often used in aggressive, multi-drug regimens. Supportive care in intensive settings, such as managing intracranial pressure and seizures, is critical.
Despite these efforts, the prognosis remains poor. Most recoveries have occurred in cases where diagnosis was made within hours of symptom onset and treatment began immediately.
In Kerala, health authorities have urged clinicians to maintain high vigilance and initiate empirical therapy in suspected cases.
Conclusion and Call to Action
Kerala’s outbreak is the largest and most widespread episode of PAM ever seen in India. Sharp rise of cases in 2025, spreading to multiple districts of state and affecting from infants to young children make this outbreak a public health emergency. While treatment options remain limited and treatment success is rare, Kerala has taken proactive steps with new technical guidelines, diagnostic labs, and community water-safety initiatives. These measures, combined with strong public cooperation, can slow the spread and protect vulnerable groups. However these actions are only works if people take prevention seriously including avoiding untreated or stagnant freshwater, keeping wells chlorinated, and seeking care quickly for early symptoms are simple but life-saving actions.
As Kerala continues its containment efforts, Pharmacally will track developments and share verified updates. Whether you’re a clinician, caregiver, or concerned citizen, staying informed is the first step toward staying protected.
References
Surge in deadly ‘brain-eating’ amoeba cases causes alarm in India’s Kerala state, Reuters, 18 Sept 2025, https://www.reuters.com/business/healthcare-pharmaceuticals/surge-deadly-brain-eating-amoeba-cases-causes-alarm-indias-kerala-state-2025-09-18/
69 confirmed cases, 19 deaths in Kerala due to brain eating amoeba: Why this infection is challenging and requires caution, MSN News https://www.msn.com/en-in/health/health-news/69-confirmed-cases-19-deaths-in-kerala-due-to-brain-eating-amoeba-why-this-infection-is-challenging-and-requires-caution/ar-AA1MROmX
Regu K, Rajendran R, Bhaskaran K S, Rajendran A, Tamizharasu W. Primary Amoebic Meningoencephalitis in Kerala – An Emerging Public Health Concern. J Commun Dis. 2024; 56(1):25-35
Naseer MN, Subbaram K, Faiz R, Naher ZU, Manandhar PL, Ali S. Cases of brain eating amoeba in India: Primary amoebic meningoencephalitis clinical features and pathogenesis. New Microbes New Infect. 2024 Oct 2;62:101491. Doi: 10.1016/j.nmni.2024.101491. PMID: 39429729; PMCID: PMC11490792
Puthanpurayil SNT, Mukundan A, Nair SR, John AP, Thampi MR, John R, Sehgal R. Free-living amoebic encephalitis – Case series. Trop Parasitol. 2024 Jul-Dec;14(2):108-112. Doi: 10.4103/tp.tp_37_23. Epub 2024 Sep 3. PMID: 39411681; PMCID: PMC11473018
CDC – Naegleria fowleri Infection, CDC, https://www.cdc.gov/naegleria/about/?CDC_AAref_Val=https://www.cdc.gov/parasites/naegleria/index.html
Technical guidelines on prevention, diagnosis and treatment of amoebic meningoencephalitis in Kerala, HEALTH-F2/219/2024-HEALTH, Government of Kerala, https://kerala.gov.in/assets/ckupload/219%20Health_1721651318.pdf
New lab diagnoses amoebic brain fever, a first in state, 07 June 2025, Times of India, https://timesofindia.indiatimes.com/city/thiruvananthapuram/new-lab-diagnoses-amoebic-brain-fever-a-first-in-state/articleshow/121683557.cms
About Author
She wrote it what she wanted to convey !!
Nevethaa, a PharmD by profession and healthcare writer who believes that words can heal.
With a background in medical communication and a deep respect for the patient journey, She specialize in transforming clinical knowledge into language that feels clear, compassionate, and trustworthy. Every article she write is shaped by precision, empathy, and a quiet urgency because in healthcare, the right words at the right time can make all the difference.