Naegleria fowleri in India: a rare amoeba, a growing public-health signal

Primary amebic meningoencephalitis (PAM) caused by Naegleria fowleri is rare but highly lethal, warranting urgency in public-health and clinical response. PAM has been reported sporadically in India (including Kerala), often after freshwater exposure during hot months. In 2025, Kerala reports brought PAM into public discourse, renewing attention to environmental safety and health-system preparedness. Each case is a sentinel event that tests surveillance, diagnostic readiness, and risk communication. Since the 1960s, global case counts have remained low relative to other encephalitides, yet the case-fatality proportion is extraordinarily high. Early symptoms mimic bacterial or viral meningitis fever, severe headache, vomiting, and neck stiffness before rapid deterioration to seizures, coma, and death within days. Definitive diagnoses depend on molecular detection (PCR) on cerebrospinal fluid or tissue capacity typically limited to reference laboratories so delays in recognition and confirmation are common. Rapid clinical suspicions after compatible freshwater exposure is therefore pivotal.

There is no single curative therapy; survivors are rare and typically received early, aggressive, combination therapy plus advanced neurocritical care. Practice rec­ommendations include amphotericin B (intravenous ± intrathecal) with adjuncts such as miltefosine, azithro­mycin, fluconazole, and rifampin, together with mea­sures to control intracranial pressure; induced hypother­mia has featured in several survivor reports. Practical preparedness steps include maintaining ready access to miltefosine at tertiary centres, establishing fast referral pathways, and engaging national/reference laboratories at the point of suspicion.

Prevention is paramount. From a systems lens, PAM highlights gaps at the intersection of water safety, ur­ban recreation, and climate-sensitive infections. Exper­imental work has quantified disinfectant “Ct” require­ments for N. fowleri, including increased tolerance in biofilm-associated states underscoring the need for rou­tine monitoring, operator training, and enforcement in pools and splash-pads. Community-level advice should emphasize avoiding warm, stagnant freshwater; mini­mizing water entry into the nose (e.g., nose clips); and using sterile, distilled, or previously boiled water for na­sal rinses. Kerala’s 2025 experience with multiple con­firmed cases and deaths reported by state authorities and national media triggered stricter chlorination and en­forcement actions. Beyond immediate control, this is an opportunity to strengthen preparedness architecture: (i) integrate PAM into IDSP alerting (as a rare, climate-sen­sitive event), (ii) create fast lanes for state-level PCR confirmation, (iii) keep treatment algorithms and drug stocks visible and reachable, and (iv) run seasonal IEC with practical do’s and don’ts for freshwater recreation and nasal-rinse hygiene.

Although rare, Naegleria fowleri infections have dev-astating outcomes. India should approach PAM as a sentinel climate-linked threat: rare, but substantially preventable with disciplined water-safety management, rapid clinician recognition, and laboratory readiness. Even one averted death through anticipatory surveillance, enforcement of disinfection standards, and clear public messaging would be a meaningful win for health-system resilience.

Declaration of interests

None.