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Dec 30, 2015

Review of 2015 - "Justice as fairness"

Let me start this post with the statement - "Justice is fairness". This will be the theme for the year 2016 in monthly posts, which will relate to global health agenda on the business delivering public health tools and utilities for vulnerable population in low income countries. Here I will not try to delve into detail of its definition for key words "justice" and "fairness" instead I would advice you to read Amartya Sen's thick book on justice - "An Idea of Justice" if ever you want get perspective on this topic.  However - it is still my responsibility to  elaborate a little on the context of this statement related with "justice", which could have both western and eastern meaning to it. Above all - again I would repeat "Justice is fairness" is the bottom line in my  discourse. Somebody said sometime "justice" could be  veiled in the  name of "just us" rather than truly believing in and practicing  fair treatment in our everyday life. In Nepali - Sanskrit - Hindi - we say "Nyaya" for the term "justice".  From my understanding - "justice" could be a vague word like "ethics" that relates to professional practice. It does have its meaning in our everyday only when it takes the shape of policy / law / statute or when  we truly practice what we believe. Otherwise - we can read and hear values such as fairness, transparency, respect for diversity in many organizations but do we really practice these values or we just preach for the shake of looking good?? I am asking this question to myself after years of observation and experiences at personal level at national and international fora and platforms. Sometime -  it takes lot of understanding, evidences and guts to  speak up against unfair treatment against any individual, community or citizens.
"Struggle against injustice should continue at any cost"

While writing this post - I am worried about our country and people when we are shaken terribly with recent earthquake and on  top of it - "undeclared & unofficial" blockade from our neighboring giant called India. This situation brings about serious discourse into the justice and fair treatment when such insane behavior sticking to the traditional practices like "big fish eats small fish" kind of wild justice. It is worrying that this should occur at diplomatic level when there definitely exist international understanding dealing with land locked country who is double hammered by earthquake of great magnitude and economic blockade. With current prevailing situation - I have firmly believed that unjust behavior occurs not only at person to person level but at the organizational and country to country level. All of us have become the witness to "insane" decision taken at diplomatic level. So what I am saying is all Nepali people are in a difficult situation that we did suffer after Maoist insurgency.
"Nepali people are going through an unprecedented magnitude of suffering  following Earthquake and blockade"


Now - back to reality - 2015 have been a mixed experiences while we all Nepali people are suffering hardship as I said earlier and also 2015 was fruitful when it comes to my writing journey through blogging. I wrote about cholera and vaccination in Nuwakot and viral hepatitis E in Nepal. Some of the posts were also wrote on ad hoc basis, while majority of the postings were as per plan. After all this writing experience - one theme that stands out would be global health issues related with health security, equity and of course politics. All these issues could be addressed through smart advocacy and evidence generation from the community. Therefore 2016 needs to be the year of revelation of our writing skills and test of perseverance. I know - 2016 would be challenging for me, but I have decided that it has to be fruitful in terms of writing notes on health agenda for Nepal that links to global health landscape. In order to write effectively - I need to read on such issues and I think the best authors to read would be Paul Farmer and  Jeffrey Sachs. Any way - I would start my new year by finishing a book on Elon Musk (how the billionaire CEO of Spacex and Tesla is shaping our future). Having started reading this book - in one of the chapter - he shares his revelation after reading one of his favorite book " The Hitchhiker's Guide to the Galaxy" where the author points out " one of the really tough things is figuring out what questions to ask". I can imagine - how lucky was Elon able to understand and get to read such books at such tender ages. We also remember that we used to come across books but never got attracted or even read such kind of books so seriously. Now I can feel how reading books at such tender age could engineer your though process and become well informed. For us - I think this is what we missed the most !!
"Narja and Thingan visit"
Another remarkable moment in the year 2015 has been our Narja Mandap (Nuwakot) and Thingan (Makwanpur) visit this month in December. The main objective of the visit was to monitor the mother and child health survey in Narja and the follow up visit of Thingan regarding cold chain project. This visit was also an opportunity to witness ongoing "real" public health work in Earthquake affected villages outside Kathmandu valley. Anybody could feel the warmth Narja locals showed to us despite the hardship and it was our luck that we met a wonderful being Mr. Gokarna in Narja. He took care of us without any irritation. He was able to treat us with warmth and hospitality in his temporary tin roofed shelter. We all slept well in that harsh winter at such altitude. Also, he was taking care of Octogenarian mother, who was still walking around helping with household chores. Even she prepared tea and served us after our day long visit for the survey. This should be the best tea that I relished in that climate of Narja. All the locals including female community health volunteers (FCHV) helped us in the task  of survey. Otherwise - it would have been very difficult to conduct such survey within 3 days. For this conduct - district health office fully supported this small mini project. Mainly - Mr. Bishworam and Pradip were wonderful  persons in helping out this survey. We look forward to a final report which will bring out the issues related with mother and child health in the village. We believe, this survey will also help the local health post in addressing the gaps that relates to the health care delivery at the door level in the community.
2016 should be challenging and transforming - it is only through struggle we rise above the common pitfalls. When we look at our fellow citizens - we need to work hard and of course from my side - we need read more and write more. In such positivity of our outlook - we can do away with any challenges that befall upon us. Therefore - 12 chapters needs to be written so what I read and write should go parallel and meaningful. Otherwise - time and moment wasted would get wasted !!
31 Dec, 2015

Dec 22, 2015

One Dose at a Time: Advancing Oral Cholera Vaccine Use Globally

[Note: This  write up  was published as  Partner News in Cholera Prevention  and Control (CCPC) Newsletter on 25 Nov 2015)
There were several milestones in 2015 for the oral cholera vaccine (OCV).  Originally based on a vaccine developed in Vietnam, the OCV was reformulated by the International Vaccine Institute (IVI) with support from the Bill & Melinda Gates Foundation, and the governments of Sweden and South Korea. Shanchol was finally WHO-prequalified in 2011 and is an example of successful international public-private partnership.
IVI continues to work on the cholera vaccine agenda by increasing the global supply of OCV and by increasing demand for OCV.  Among the 2015 highlights, IVI is partnering with additional manufacturers that include EuBiologics of South Korea and Incepta Vaccine of Bangladesh that will help ensure a sufficient supply of doses globally and for the stockpile. EuBiologics’ vaccine is expected to be WHO-prequalified by the year end.  Incepta’s vaccine, Cholvax, which is targeted for the domestic Bangladesh market, will be available by 2017.
IVI also contributed to the growing body of evidence on OCV use in real-life settings. In 2015, it provided technical and financial support to local governments to conduct pilot vaccination campaigns in Ethiopia, Malawi, and Nepal.  Each country had a different cholera scenario.  In rural Shashamene, Oromia Region, Ethiopia, cholera is endemic. Therefore, a preventive campaign was conducted in collaboration with the Ethiopian Public Health Institute, Oromia Regional Health Bureau, West Arsi Zone Health Department and LG Electronics. The campaign was conducted from February to March, vaccinating >40,000 people >one year old.  It was the first mass vaccination targeting people at risk for endemic cholera in Africa.
In Malawi, major floods struck the southern part of the country at the beginning of the year, resulting in cholera outbreaks in camps for people internally displaced by the floods and neighboring areas. To prevent the outbreak from spiraling out of control, an emergency vaccination campaign was implemented in Nsanje District from March to May.  With the Malawi Ministry of Health and Sanitation, WHO, JSI, Nsanje District Health Office and with funding from Kia Motors and South Korea’s Ministry of Foreign Affairs, approximately 160,000 people were vaccinated.  An additional 10,000 people in Chikwawa were vaccinated. With support from the Bill & Melinda Gates Foundation, IVI will conduct vaccine effectiveness and cost-of-illness studies in Nsanje to establish further evidence on the impact of vaccination.
Finally, following the devastating earthquakes that struck Nepal in April, the Epidemiology and Disease Control Division (EDCD) of the Nepali government called for preventive cholera vaccinations in selected villages of earthquake-affected districts due to concerns over possible outbreaks in high-risk areas, particularly rural, remote areas where infrastructure and health services were destroyed due to the earthquakes. A campaign was conducted by EDCD with support from IVI, UNICEF and GTA from August to September, vaccinating approximately 10, 486 people in Nuwakot District.  Coverage was high (100.5% during the first round and 96% during the second round).  Due to the success of the campaign, EDCD and IVI are under discussions to expand cholera control and prevention efforts next year through a possible collaboration with Rotary Club of Southwest Seoul and Rotary Club of Nagarjun Nepal.


Dec 5, 2015

Understanding Leptospirosis

Leptospirosis, also known as fall fever or mud fever, affects both animals and humans. This disease occurs worldwide, and the highest prevalence is in tropical climates and in warm and wet environments with poor sanitary conditions (6). Leptospirosis is an increasingly recognized cause of acute febrile illness throughout the tropical and sub-tropical regions of the world (2).Leptospirosis is presumed to be the most widespread zoonosis in the world; it is caused by pathogenic spirochaetes of the genus Leptospira (1–4). Humans are accidental hosts and usually become infected through contact with water or soil contaminated by the urine of infected animals such as rodents, dogs, cattle, and pigs. Exposure of skin or mucous membranes to leptospires can lead to infection. Clinical signs and symptoms are variable and range from subclinical to potentially fatal manifestations. Leptospirosis should be suspected in febrile children with contact with flood water (1). Interestingly, in this setting, many exposed people have asymptomatic seroconversion and some also undiagnosed fever; a small but important minority may develop severe disease. (3) The significant household clustering of Leptospira infection in slum communities, indicating that the household environment and related factors are important determinants for transmission of urban leptospirosis (4)

Leptospirosis is an emerging zoonosis that is often under-recognized in children and commonly confused with dengue in tropical settings. Unrecognized leptospirosis can be a significant cause of ‘‘dengue-like’’ febrile illness in children. Increased awareness of pediatric leptospirosis, and an enhanced ability to discriminate between leptospirosis and dengue early in illness, will help guide the appropriate use of healthcare resources in often resource-limited settings. In a semi-rural region of Thailand, leptospirosis accounted for 19% of the non-dengue acute febrile illnesses among children presenting during the rainy season. None of the children with leptospirosis were correctly diagnosed at the time of hospital discharge, and one third (33%) were erroneously diagnosed as dengue or scrub typhus (2)

Heavy rains were followed by an increase in laboratory-confirmed cases of Leptospirosis (5) Leptospirosis has become an urban health problem as slum settlements have expanded worldwide.  Deficiencies in the sanitation infrastructure where slum inhabitants reside were found to be environmental sources of Leptospira transmission (7)

This disease continues to have a major impact on people living in urban and rural areas of developing countries with inestimable morbidity and mortality.  It is widely recognized that the incidence of leptospirosis is remarkably underestimated and the disease underdiagnosed in endemic regions. Leptospirosis is estimated to affect tens of millions of humans annually with case fatality rates ranging from 5 to 25%. In endemic areas of leptospirosis, factors such as lack of sanitary conditions, mud flooring, together with rainy seasons and flooding catastrophes contribute to periodic outbreaks (3,8).

  1. S Karande, M Bhatt, A Kelkar, M Kulkarni, A De, A Varaiya : An observational study to detect leptospirosis in Mumbai, India, 2000: Arch Dis Child 2003;88:1070–1075
  2.  Libraty DH, Myint KSA, Murray CK, Gibbons RV, Mammen MP, et al. (2007) A Comparative Study of Leptospirosis and Dengue in Thai Children. PLoS Negl Trop Dis 1(3): e111 doi:10.1371/journal.pntd.0000111
  3. ER Cachay and JM Vinetz: A Global Research Agenda for Leptospirosis: J Postgrad Med. 2005 ; 51(3): 174–178
  4. Maciel EAP, de Carvalho ALF, Nascimento SF, de Matos RB, Gouveia EL, et al (2008) Household Transmission of Leptospira Infection in Urban Slum Communities. PLoS Negl Trop Dis 2(1): e154. doi:10.1371/journal.pntd.0000154
  5. Yu-Ling Chou, Chang-Shun Chen, and Cheng-Chung Liu : Leptospirosis in Taiwan, 2001–2006 : Emerging Infectious Diseases • • Vol. 14, No. 5, May 2008
  6. Ken Brown and John Prescott: Leptospirosis in the family dog: a public health perspective: CMAJ • February 12, 2008 • 178(4)
  7. Reis RB, Ribeiro GS, Felzemburgh RDM, Santana FS, Mohr S, et al. (2008) Impact of Environment and Social Gradient on Leptospira Infection in Urban Slums. PLoS Negl Trop Dis 2(4): e228. doi:10.1371/journal.pntd.0000228
  8. M J Pappachan, M Sheela, K P Aravindan : Relation of rainfall pattern and epidemic leptospirosis in the Indian state of Kerala: J Epidemiol Community Health 2004;58:1054–1055

Nov 30, 2015

Nepal Situation after Earthquake, New Constitution and Unofficial blockade

All of us have to be vocal in what you believe should be the norms and of course fair treatment, be it at personal, professional or international level. Here, I am referring to Nepal situation. Well, the year 2015 has been historical and will remain  in  our memory for centuries. In this time, all Nepalese must listen to this TED talk: 


Nov 19, 2015

Landscape of Viral Hepatitis E - local issues (Part III)

On 6 and 7 November, 2015 - Epidemiology and Disease Control Division (EDCD) under of Department of Health Services (DoHS), Ministry of Health and Population successfully hosted the first ever national symposium on Viral Hepatitis E in Nepal (Picture 1) The main objective of the symposium was to bring all key government officials, academicians, physicians and public health professionals into one forum and thereby share, discuss, reflect and question on the epidemiology, surveillance, diagnostics, clinical presentations and associated complications and preventive measures so far in Nepali soil by Nepali themselves. In this way, I would consider, the symposium had left a remarkable impression among delegates that we have so much resources and understanding about the diseases that we are able to do any complicated studies with our own resources.
Picture 1: Inauguration of the first HEV symposium in Nepal (6 Nov, 2015)
Photo Courtesy: @Yeti4mNepal
In this effort, as I mentioned in the earlier post, this symposium would not have been possible without the leadership of Dr. Baburam Marasini, current director of EDCD, Dr. Guna Nidhi Sharma, Deputy Health Administrator, Mr. Resham Lamichhane, Mr. Bhim Prasad Sapkota and many other important personalities from the team at EDCD. Not to forget, UNICEF country office - Nepal wholeheartedly supported this symposium along with International Vaccine Institute (IVI) and GTA - Nepal. There are other  important dignitaries who have supported this symposium - namely Drs. Sarala Malla (Ohm Hospital), Buddha Basnyat (PAHS), Shyam Raj Upreti (GTA), Ganesh Dangal (NESOG), Ananta Shrestha (Liver Clinic), Nabin Rayamajhi (PAHS), Mr. Deepak Bajracharya, Lenjana Jimi & Kshitij Karki (GTA). Other dignitaries from BPKHIS, Dhulikhel Hospital under Kathmandu University, Sukraj Tropical Hospital were also actively involved for the success of this symposium. I would also say that Dr. Samir Dixit (Center for Molecular Dynamic Nepal) was also our attraction among our delegates, who made the symposium lively with practical questions and suggestions to the speakers. Above all, the  group discussion was very fruitful in that it brought significant numbers of practical recommendations.

We strongly believe with local voices that represent the "real" public health need of curative and of course, effective preventive measures have to be elevated to new heights. When we say "new heights" - it  means that there is a strong need for applying the available public health tools or medicaments through the principle of equal access to vaccine or diagnostics at affordable prices in the community. The symposium has generated recommendations both  programmatic and academic so the moral responsibilities lie with us (including international organizations / research organizations / vaccine companies) to move forward  with concrete measures in HEV prevention and control in future.

Recommended reading:

1. Report on the International Symposium on HEV, Seoul, South Korea, 2010
2. Hepatitis E Epidemic, Biratnagar, Nepal, 2014

20 Nov, 2015

Oct 23, 2015

Landscape of Viral Hepatitis E in Nepal - let us explore what can we do to advocate for its control and prevention (Part 2)

In my previous blog post - I wrote briefly to understand the basics of Viral Hepatitis E (HEV), which is one of the basic requirements before we even contest ourselves in the business of prevention and control of HEV in Nepal or anywhere. Again to review what I remember - HEV is RNA virus single stranded and in particular - genotype 1 and 2 are related with outbreaks in human beings. This is considered neglected tropical diseases, however slowly - there is a growing interest in this disease because it has significant health impact among pregnant women. Well, now it is time for funders, governments and academicians to work and bring out preventive and control measures in the table for discussion. Otherwise - it will always be limited to news media !! Bottom line - it is time to act through something concrete for people to rely on when they are sick or even before they are sick !!

In this respect, Epidemiology and Disease Control Division (EDCD) under the leadership of Dr. Babu Ram Marasini, who is the current director with support from his staff teams like Dr. Guan Nidhi Sharma, Deputy Health Administrator has taken a bold step to convene HEV symposium in Kahtmandu in middle of chaos and uncertainty. We have to acknowledge this step taken since we know this initiative will lay foundation for future initiatives. Simply - we do not want to hear any more HEV outbreaks in our vicinity and of course in news media. It should be made history forever !! We can do it and we have human resource and tools for it. For you information - HEV symposium will be held on 6 to 7 Nov, 2015.


In this effort, we have seen a close collaboration between EDCD, UNICEF, WHO, IVI and GTA. We look forward to engaging fruitful discussion thereby will bring out recommendation to formulate national strategy in the control and prevention of HEV in Nepal.

    24 Oct, 2015
Seoul, South Korea

Oct 16, 2015

Landscape of Viral Hepatitis E in Nepal: Understanding the basics first (Part 1)

I am not an expert but out of curiosity - I am again writing on Viral Hepatitis E as a public health physician and also who understand this disease at personal level out of suffering. Please also read my previous summary post on Understanding HEV in Nepal.

Most of the time, the word "poor" is painful !! This is what  I feel - so why is it painful? Well, being "poor" is after all a package full of "suffering, hunger, diseases and  of course struggle". I am not in a position to ventilate every pains of being poor here, however I would like to bring one public health issue that has plagued our communities since centuries. In the business of being poor and others considering you poor - there is lots of differences and of course paradoxes. Sometime, I feel the concept of "poor" is more of psychological assessment of yourself rather than other labeling you a poor chap or even a poor country !! Here is one example: I meet many shepherds in highlands of Nepal, they do not consider them poor and they are the happiest individuals I have seen and come across. But in the index of modern socio economic scale, he will be considered poor; that's it !! This is one aspect of looking at being poor, however "poverty" is rather a more appropriate word when we correlate the factors associated with enteric disease that I am touching upon in this post. So I would use the word "poverty" more often trying to connect with enteric disease that inflict a community where there are perennial problem related with the provision of adequate water, sanitation and hygiene practices. But sometime, let me be a bit critical - people shades crocodile tear in the name of poor and poverty and do business for their benefit. I have come to realize this inconvenient truth late and of course out of humble understanding that everybody is honest in what they do and work for the noble cause to end the suffering of those in living in poverty stricken community. In this regard, I agree with some of our colleague that one who stays in 5 star hotel and wears a pencil healed shoes can't work for the poverty stricken community. This is another bitter truth !!

Now to the subject of the blog post for now. There are long list of enteric diseases that catches attention of any physician working in low income setting from enteric to vector borne illnesses that can inflict an individual from your head to toe. Here, I am writing few words on enteric disease that has outbreak potential and has been yearly headline in dailies in Nepal. Yes, your guess - viral hepatitis and in particular hepatitis E. Popularly, this enteric disease is known by the name of "viral jaundice" among health professional and layperson in the country.  For our knowledge, this viral hepatitis is a recent discovery in early 1980s in Kashmir, India. Back then, it was known by the name of "epidemic non - A, non - B hepatitis" or "enterically transmitted non - A, non - B hepatitis". However, this disease entity was genetically characterized in 1990s, thereafter named formally Viral Hepatitis E (HEV).
HEV is explained as a spherical, non enveloped virus with a single stranded, positive sense RNA genome. This is the only member of a new genus, Hepevirus, in a new virus family, Hepeviridae. There is a description of 5 genotypes (G). G1 and G2 have been recovered only from humans whereas G3 and G4 are recovered from both humans and swines. G5 is an avian virus. It is clinically difficult to differentiate with other viral hepatitis in terns of clinical presentation, however on careful history taking and examination we are able to delineate from hepatitis B and C. The incubation period (IP) of HEV can approximately of 40 days. It is also reported that HEV infection never progress to chronicity and can be diagnosed by detecting viral RNA (RT - PCR) in the serum and / or feces during IP or early acute phase of disease or can be diagnosed by demonstrating anti - HEV of the IgG class in the serum during late phase or convalescence period of the illness. As a common knowledge, this disease is self limiting illness so need to be treated symptomatically and there is no specific therapy as of now. However, we hear that antiviral drugs are in research phase.
The most dreaded part of HEV infection and why there is so much interest in the HEV vaccine development and its prevention is its grave complication that occur if infect pregnant women. There are numerous reports of maternal deaths with serious (fulminant) hepatic failure or in mild or moderate, it can cause loss of pregnancy. Therefore, HEV has serious public health importance in terms of maternal child health protection. Also, there are lots of other medical complications among those with chronic liver ailment or even other chronic illnesses.

From public health perspective, HEV and other enteric diseases like cholera have been relevant in the backdrop of increasing disaster situation that has led to public health disaster like situation. Name it - very current would our Nepal experiences, though fortunately we did not have major outbreaks but you never know what comes up there in coming days. Last year, there was HEV outbreak in Biratnagar and we all know well - how tough it can be when such outbreak occurs in the center of bustling  town. Much to worry, however, would be if such outbreaks occur in hard to reach areas of the country like the one that occurred in the year 2009/2010 where cholera outbreak took hundreds of lives untimely. It is therefore always in the best of investment that we work on the preparedness now, so we know what, how, where and who kinds of approach when such outbreaks occur in remotest part of the country.

17th Oct, 2015

Sep 14, 2015

Glimpse of Acute Watery Diarrhea (AWD) Surveillance in Kathmandu (Part 3)

[This is a personal log and does not represent any organizational position]

Dr. David Sack in his May post in stopcholera blog writes "quick, efficient and reliable surveillance that is supported with robust laboratory surveillance do save lives". This is a fact that nobody can deny, however conducting a surveillance in an efficient manner do cost a lot of money and above all - an efficient coordination and collaboration is the key deciding factor. In this post, I would like to dive into the actual functioning of the surveillance activities in Kathmandu valley. Also, i hear "surveillance" as a buzz words among all stakeholders involved in the business of communicable diseases prevention and control in Nepal.

Basic first: the meaning of surveillance is data collection, analysis and its interpretation for prompt public health action. In this respect, data is power. Some people even go further in saying that power is political so data is political !! I think - there is partial truth in this statement. The main objective of disease surveillance is to rapidly identify any re-portable epidemic potential infectious diseases [acute gastroenteritis (AGE) / acute watery diarrhea (AWD) / cholera].

Currently, there are several sentinel sites established and enhanced within Earthquake affected 14 districts of Nepal. This is a syndromic surveillance. Also, there exist Early Warning Reporting System (EWARS) which started with 6 re-portable diseases in early years of 1990s. There is also Vaccine Preventable Diseases (VPDs) surveillance in parallel that runs through Program for Immunization Preventable Diseases (IPD), which is a collaborative effort of child health division (CHD) and WHO country office Nepal. As of now, there are EWARs surveillance going on in 81 sentinel sites in 75 districts, which reports and  alerts on daily/weekly basis. The collection method of surveillance data are said to be conducted through informers or through mobile - text and paper form. Additional responsive activities  are daily situation report and weekly bulletin and also the situation of AGE and cholera in KTM valley.

Today, Dr, Marasini, Director of EDCD started the meeting with opening remarks "Cholera is a severe waterborne illness that kills within hours not days." Also, he added historical anecdotes where people in the rural areas had to be abandoned in rivers or even their home to die because of extreme fear that was associated with this diseases and even a Nepali queen then died due to this disease. He also said that "Cholera does not spread in a straight path that can be easily predicted !!. Most importantly, Dr. Marasini referred to the first scientific paper reporting cholera outbreak in KTM valley in the year of 1886 published in British Medical Journal (BMJ). With this background, Dr. Marasini concluded by stating that "Surveillance is the heart of any public health system and further added that this plays vital role to avert public health disaster. Therefore, surveillance has to be inbuilt system that should be robust able to detect any potential outbreak early"

The core activities that have been done and planned in order to strengthen the surveillance system in Kathmandu valley are as following:
  • Issue official letter from EDCD to support the surveillance activities
  • Visit all important health institutions in KTM valley
  • Coordination with NPHL / lab
  • Identify for surveillance gaps
  • Orientation & training if and when necessary
  • Logistics and swift management when and where required
  • Regular M & E
  • Data mx and analysis
  • Lab sample collection and transportation
  • Response and action 
Finally - I liked Dr, Marasini stressing a point very effectively saying "Cholera spread does not take straight path instead it takes zig zag path - very unpredictable, if we do not have a robust surveillance to detect early and response." Also,  "Poverty is humankind's greatest injustice" said Mahatma Gandhi while we know cholera is a disease of poverty. This means very  straight - detecting cholera outbreak in the community means there exist injustice but not sure who are responsible for such injustice. This remains a question for next write up !!

14th Sept 2015 

Aug 14, 2015

Reports of suspected and confirmed cholera cases from Teku Hospital in Kathmandu Valley - Nepal (Part 2)

                   [Personal opinion log and do not represent any organizational position

In the year of 1994, I visited Teku Hospital to get vaccinated against rabies. I had to take 10 shots of anti rabies vaccine around umblicus. Oh.....I still remember the "burning" pain once the needle penetrated my subcutaneous tissue and the vaccine released in the tissue  !! The reason for getting the shots was that "angry" monkey from Swayabhu Nath. The monkey robbed me of biscuit that I was carrying with me in the first place and bite me in my hand as a reward. Now, it is almost two decades later, I visit Teku Hospital again. This time not to get vaccinated but to inquire on the recent reports of suspected as well as culture confirmed cholera in Kathmandu valley. This is unfortunate that we have to deal with water borne illness like cholera in the center of capital even in the 21st century. To be honest, we feel sad to talk about cholera even now but the truth is bitter - just next to your door there may be cholera outbreak !! Who knows ?? However, there is one recent development that such infectious diseases in the community are no more problem of "low income countries" only. When I say such statement - it means neglected diseases are recently found to be "neglected" problem even in some corners of the developed countries where water, sanitation and hygiene practices are supposed to be highest standard. But this does not seem so when I read such in CNN which reports "neglected" diseases in Southern states of America, where people living with poverty have to face such diseases of tropical origin  !!

Now let us focus on Nepal. The king among waterborne illness - CHOLERA has been reported every year in Kathmandu valley and even this year 2015. Till the end of July - we did not hear of any report of cholera cases any where in the country. With the start of August - there begins the reports of suspected cholera cases from Teku Hospital, whose official name is actually Sukraj Tropical and Infectious Diseases Hospital (STIDH) which is located in Teku near the premises of Department of Health Services (DoHS) close to Epidemiology and Disease Control Division (EDCD), which is headed by Dr. Baburam Marasini, a veteran public health expert as well as senior clinician. Dr. Marasini told us that Teku Hospital used to be called Cholera Hospital when it started its service during Rana Regime. This hospital was established more than 60 years back to address yearly cholera outbreaks in Kathmandu valley. So long is its history in terms of its establishment and its service to the people of Kathmandu that STIDH deserves to be the center for excellence that can be a model for our country like International Center for Diarhheal Diseases Research (ICDDR) in Dhaka, Bangladesh.

Let me begin by saying"They like it hot !!" "They like it dirty !!" Here "they" means Vibrio cholerae. This microscopic organism said to be uni flagellated (with one long tail) and has darting movement when observed with "hanging drop preparation" under a microscope. This tiny invisible organism can create havoc in a community and even disrupt the socio - economic dynamics of the state if this gets uncontrolled by affecting the daily "bread and butter" activities of common people. It is sometime said - it does not need huge force to bring down thousands. Instead, it may be the might of invisible bugs that may bring down the whole contingents of army. That is what we have read in the history !! Now, with this in mind, everybody is talking about "cholera" in EDCD and at Teku Hospital. Then our common logic says, "Why shouldn't we talk about CHOLERA, when some cases are knocking just at our front door !!" Outside, the air is "hot" and even smell "putrid" when you go near Bishnumati bridge. We say Bishnumati a holy river but this has been turned into sanitation passage where you see anything from dead animals to mention it - you will get it there !! Also, these days - it is raining heavy usually in the evening and the so called rivers are flooded with dirty water filled and mixed with human night soils.

Much have been written on possible cholera outbreaks in Earthquake affected areas based on our read of outbreaks following natural disasters in Haiti (Earthquake) or Malawi (flooding) or even man made disaster like refugee situation in South Sudan. In all these situation - people are vulnerable to infectious diseases of outbreak potential. Among those diseases, cholera tops the list followed by viral hepatitis outbreaks. I have written on my previous 6 part series blog posts:
  1. My thoughts on business of cholera and impoverished community (Part 1 - April 18, 2015) - Here blogger writes that cholera is a recognized public health problem and we need to get prepared early in order to prevent and control otherwise even a single outbreaks may disrupt the socio-economic milieu of the community.
  2. Open talk on Dr. Sack's important question and Nepal  (Part 2 - May 02, 2015) - In this post - blogger tries to dig into a serious question - have we been successful in convincing the local governments to use Oral Cholera Vaccine (OCV) where it is needed the most? Well - blogger tries to balance the country's capacity post earthquake, the political / bureaucratic landscape as well as the need for close coordination between governmental, non governmental agencies as well as local partners for effective preventive measures.
  3. Open talk on Dr. Sack's important question on OCV delivery (Part 3 - May 12, 2015) - In this 3rd post, blogger touch upon surveillance as the foundation for prevention and control of cholera and any other infectious diseases. When we talk of surveillance - it means robust surveillance backed up by efficient laboratory diagnosis facilities which also include sample collection, transportation and its cold chain. In addition - another burning question would be introducing laboratory diagnostics (be it even hanging drop test or rapid serological diagnosis) in the ailing health system. Even in Kathmandu valley, I doubt each and every hospitals have efficient laboratory diagnostic facility for early diagnosis of cholera !!
  4. Open talk on Dr. Sack's important question on OCV delivery (Part 4 - May 25, 2015) - In this post - blogger is struggling to make sense of the chaos brought about by repeated tremors and preparatory dialogues / communications for preventive measure to curb possible cholera outbreaks that may follow once monsoon starts in the highly affected areas. Here - our team with government of Nepal on board were continuously stating that WASH measures are the key mantra to deal with possible waterborne illnesses in the community while we need to be prepared mobilizing oral cholera vaccine from WHO stockpile.  Now it seems what we thought and what we predicted has been true with recent cholera outbreaks in different locations of KTM and outside valley. What next is the question?
  5. Random thoughts on OCV delivery and public health politics in Nepal (Part 5 - June 20, 2015): In this post - blogger is reasserting his mission and specific objective to protect the vulnerable population from possible cholera outbreaks using vaccine on the foundation of key WASH measures in the community. Here - the blogger was particularly determined and at the same time asking how come we are rejected of our application to mobilize cholera vaccine to be used in the most vulnerable geography, where reaching once monsoon starts would be next to impossible !! Just few days early - we heard that there is an outbreak of viral hepatitis in Barpak, Gorkha and now it is difficult to reach there for investigation due to landslide aggravated by rainfall. 
  6. Random thoughts on public health politics (Part 6 - June 26, 2015): In this post - though not directly related to the business of cholera but this is a personnel feeling that sometime we come across working in the field of public health which is no more limited at national level. Instead, we have to keep up with newer innovations, concepts as well as updates and of course global health politics or equations that we may not be aware of and we are like puppets (unaware!!) who your master is or was !!
In addition to above posts at personal as well as professional level - Dr. Sher Bahadur Pun, Infectious diseases expert at Teku Hospital has written pretty good numbers of opinion pieces both in Nepali and English dailies in mainstream online dailies. Below are 2 opinion pieces that particularly may interest the readers of this blog (interested in infectious diseases of potential outbreaks in Nepal post Earthquake situation):
  1. Unprepared (Republica - 24 May 2015) - In this article, Dr. Pun urges all concerned public health authorities and equally the public, who have to bear all the onslaught of Earthquake and its aftermath of possible infectious diseases outbreak, to be on high alert !! In particular, Dr. Pun raised his concern about the preparedness and its (action oriented) responses should there be any outbreak(s) in already strained and ailing public health infrastructure.
  2. Stay Alert (Republica - 14 August 2015) - In this piece Dr. Pun write for public dissemination and education that residents from Kathmandu valley be aware of water borne illness and its preventive measures which are maintaining healthy & hygienic behavior that includes hand washing and boiling of waters. Also, Dr. Pun raises an important point based on laboratory finding and clinical presentation particularly of one case, which presented to hospital with severe diarrhea. The sample tested identified as Inaba rather than Ogawa. This Inaba serotype was detected after 8 years of gap in Kathmandu valley. His worry is that this serotype may spread to other areas where cholera may or may not have been reported especially Northern districts, where the population may be naive in terms of immunity against this new serotype too !! Additionally, Dr. Pun urges WHO Nepal to be proactive in the mobilization of oral cholera vaccines and should be used if the situation worsens or to prevent possible outbreak(s) among vulnerable population.
Also, there are 2 write ups published in reputed internationals journals. Notably, the first one was published by  Dr. Lorenz in PLOS Medical Journal's community blog immediately after our completion of joint risk assessment of possible cholera outbreaks in Earthquake affected Northern districts and another published on 14 August, 2015 in PLOS Neglected Tropical Diseases. 
  1. Nepal After Recent Earthquake:Reconstruction and Vaccine Preventable Diseases by Lorenz Von Seidlein: The risk assessment that is mentioned here in the blog was in addition to the "prior" risk assessment conducted by WHO-UNIECF-IOM, which was more of a desk based report. The risk assessment that we jointly conducted in close coordination with WHO country office Nepal was field based mobilizing doctors, and public health professionals in all affected districts. Dr. Lorenz strongly put forwards his arguments for preventive vaccination and also states clearly why would we need to mobilize WHO stockpile of cholera vaccine early rather than waiting for culture confirmed cholera cases to appear in the community.
  2. Is a cholera outbreak preventable in Post Earthquake Nepal by Eric J Nelson et. al: Reading this article shared in a tweet by Peter Hotez, President of Sabin Vaccine Institute was a timely read !! In this article, the authors walks us the real ground challenges in infectious diseases surveillance and also recommend the best use of limited and constrained public health system. More importantly,  the article also suggest how the mobile health can be utilized in the diseases surveillance for potential outbreak(s). Also, the authors touch upon both arguments for preemptive and "wait and see" strategy for oral cholera vaccination in high risk areas. In final note - the authors recommend WHO stockpile to listen to country's demand for cholera vaccine and also invest in stockpile rather than only sticking to logistics and who get what and how? of lengthy processes of the application, which needs to be adapted to evolving situation.  

Those who still doesn't believe that the "cholera" outbreak is already knocking at our neighborhood in and around Kathmandu valley and still adamant that the spread of cholera in Earthquake devastated Northern Hill districts is distant reality (or those who still believe that an innocent cat crossing brings bad omen !!) should read Drs. Partha Bhurtyal and Santosh Dahal's first hand story and experience dealing with cholera during Jajarkot outbreak in Nepal.

On final note: I would still patiently urge all involved that "time is essence here". This means that we need to "act" fast and mobilize oral cholera vaccine (OCV) while intensify the WASH measures hitting the target where there is an increased risk of possible cholera outbreaks. Here, I am not preaching for cholera vaccination only, instead I am trying to make a sense out of ongoing public health activities that we do not repeat "Haiti' situation here while forgetting tragedy called Jajarkot Cholera Outbreak !! In terms of clarity gauging the public health demands and its landscape - Government of Nepal has been very clear from the beginning regarding the need for preventive vaccination where it is needed the most while intensifying WASH measure as an integrated cholera and other enteric diseases prevention and control strategy in the Earthquake affected districts !!

15th August, 2015

Aug 11, 2015

Oral Cholera Vaccination in Nuwakot - First dose administration (Part 1)

[Personal opinion log and do not represent any organizational position

From 30th July 2015 onward, I will be writing real public health experiences at personal and professional level. This would be related to our preparatory activities and the actual conduct of Oral Cholera Vaccination in 6 selected villages of Nuwakot.  In this experiential log of what we believe, what we think and expect, our values and even work ethics will be under the radar of my observation and analysis.

First as any narrative - let me try to portray Nuwakot through what I see and saw in yesterday's trip to Bidur Municipality. By the way - Bidur is the district headquarter of Nuwakot, one of the northern adjoining district to Kathmandu valley in Bagmati zone. Earlier, I think, it was in the year of late 2010 / early 2011 - I used to travel from Nuwakot for regular Rasuwa visit. At that time, I used to work as a surveillance medical officer whose primary task was the surveillance of vaccine preventable diseases (VPDs) like paralytic polio, measles, neonatal tetanus and rubella. Those were the days of travel and of course - intense learning of applied epidemiology. Now, I think they were golden moments in my courier. Nuwakot has importance in the history of Nepal unification and I will not go into that part of writing. Whenever, I should write of infectious diseases of potential outbreak potential then definitely I can't write further without knowing the geography, the community, the local costumes, weather, flora & fauna and not to forget the local socio - economic dynamics.

Nuwakot is in the midhills and yesterday, I could the sense that the geography varies from few fertile valley to hill tops (that is why there is "kot" in its name "Nuwakot" - "nuwa" means nine while "kot" means castle). Through the heart of Bidur follows Trisuli river ("Trisul" means trident of Shiva), which seems to be "ferocious" in terns of force and its speed with dark muddy colored unlike its usual color, volume and speed !! Still - it was beautiful with lush green everywhere reminding me of our village during rainy season.

On 30 July 2015 -  In the first morning hours, our main goal was to conduct the district level planning meeting in Nuwakot. This meeting was lead by chief, District Health Office, Nuwakot in the presence of all the supervisors who will be involved in the vaccination campaign. The meeting went smoothly and agreed to the vaccination strategy with the final confirmation of the selected villages. While in the afternoon, we took an opportunity to visit some of the selected villages for cholera vaccination. As shown in one of the picture below, we visited Manakamana village development committee, where there were temporary settlements for displaced communities mostly Tamangs from Rasuwa and remote Nuwakots. One aspect we could observe during our visit were crowding and compromised water and sanitation status.

31 July 2015: On this day we primarily updated team members on our preparatory activities. We visited Epidemiology division, Department of Health Services and updated Dr. Marasini on our preparation and any challenges that needs to be addressed soon. The only concern was that there was also Measles and Rubella (MR) vaccination in 14 Earthquake affected districts. We managed to talk to WHO officers in the district along with EPI team and assured that this vaccination will not affect the MR campaign in any ways.

01 to 7 August 2015: The whole week was spent on close coordination between national and international organizations involved in  supporting this vaccination against cholera in the community. In this preparatory activities, Mr. Bishwo Ram Shrestha, district health officer and Mr. Pradeep Rijal, focal person for this vaccination have been dynamic and proactively supportive in every ways. The key activities done were as follows:
  • Line listing to get accurate number of target population. For this activity, female community volunteers (FCHV) were fully mobilized.
  • Vaccinator orientation and planning meeting for village level preparatory activities
  • Village level health facility management committee meetings
  • Social mobilization activities - FCHVs visited every home to invite community member during the vaccination days in the nearest booth.

First Dose OCV vaccination:

  • Inauguration - The OCV vaccination campaign was inaugurated by Mr. Khag Raj Adhikari, Honorable Health Minister, Minstry of Health and Population, Nepal along with Dr. Baburam Marasini, director  of EDCD in the presence of Mr, Bishwo Ram Shrestha, District Health Officer, Nuwakot, There was encouraging participation of the local community.

  • Vaccination - Our goal of this vaccination campaign is to achieve in aggregate at least 95 % coverage in first dose vaccination. The campaign was conducted smoothly without any significant challenges or problems. Our only concern was re: taste. There used to be "noise" that the taste of the vaccine is not "acceptable". In contrary, there was no significant complaints re: taste in the community instead local community got vaccinated in happy mood everywhere. There was a high rate of acceptance. In some places, we did not even had to offer water to drink except those who were vegetarian had to complain about its taste. However, people had a perception that medicine does not taste good either it should be bitter or taste horribly bad. After all, medicine is medicine - we need to take it - you like it or not !! 

In overall, the first dose vaccination has been overwhelmingly successful. Now remains our second dose vaccination. Soon we will have a review meeting in order for us to conduct second dose vaccination in equally successful manner. For now, this is all for first dose - the vaccination has been well received and accepted by the community. No issue with taste, no single report of adverse events. I will continue to write in the second dose vaccination  as well.

Aug 6, 2015

Following Social Media re: possible cholera outbreak in Nepal

In recent years, I have developed an addiction for scanning "tweets" on daily basis. My focus is always anything that relates to infectious diseases in Nepal. These days, in particular, there is increased vigilance for possible cholera outbreak in high risk areas. In this respect, I take interest some tweets like as follows by Dr. Sher Bahadur Pun, Medical Officer and Research Officer - Emerging and Re emerging Infectious Diseases at Sukraj Tropical Diseases Hospital, Teku, Nepal. In my opinion, Dr. Pun  is one of the most dedicated doctor in the study of infectious diseases in Nepal. Just few days back, there was a noise re: possible cholera outbreak in Kathmandu valley. Now, as of today, the sample tested have been proven to be culture confirmed cholera. This brings a question to each of us in particular involved in the control and prevention of cholera - what next ?? 

Some of the tweets from Dr. Pun in chronological order.

August 1

 August 2

August 3

August 4

August 5 & 6

Jul 28, 2015

Understanding Viral Hepatitis E (HEV) in Nepal - Getting yellow with liver pain

(This article is posted on the occasion of World Hepatitis Day - 28th July 2015. This is a summarized version of my previous 6 posts on viral hepatitis E. The author believes in the prevention of any enteric illness through comprehensive and integrated measures that is provision of Water Sanitation and Hygiene (WASH) in the community. However, there are times we have to act using available tools like vaccine in the situation of humanitarian crisis when we do not have option other than to act!!)


We are accustomed to hearing “Jaundice”, which is itself not a disease but one of the myriad manifestations of liver ailments. Among them, hepatitis of viral origin is what concerns me the most because I have myself been the victim of this preventive illness. The term “hepatitis” simply means the inflammation of the liver, which is considered body’s both storehouse and factory that produces essential biochemical essential for normal body functions. Among viral hepatitis E (in short HEV) may sound new for you.  You may even brush aside saying, "Well, this is none of my business!!" If you are thinking in that line, wait a minute!! Let me share you all our common suffering that we face every year in the name of viral jaundice. HEV is rampant in areas where water supply, sanitation and hygiene practices are compromised whereby drinking water gets contaminated with human soils. Once you become symptomatic, then you will be bed ridden for few weeks. During the illness, you feel so miserable and lethargic that you lose your appetite, complete aversion to anything called “food” or even its smell and white of your eye bulb turns yellow. Remember, this disease has potential for outbreaks that can affect thousands of people in the community. The worst and the most dreaded part is when it affects pregnant women, there is high chance losing your precious pregnancy and even death of mothers due to fulminant hepatic failure.

Where are we in its understanding?

HEV takes approximately 40 days from the time for infection to the start of illness. This is the most important cause of viral “Jaundice” among adults in the Indian Subcontinent. This is highly infectious and pregnant women are at special risk for severe liver complications in endemic regions like Nepal. HEV can be viewed like “bush fire” potential to inflict huge toll of sufferings and deaths in impoverished community. So saying, HEV is a public health problem in Nepal, would not be an over exaggeration. We know that viral Jaundice that includes HEV cause havoc in many parts of the country every year. For example, two outbreaks stand out and help us to understand the gravity of HEV problem in our country. One was in the premise of prime ministerial official residence in the year 2007, where then prime minister himself, some cabinet ministers along with other staffs caught this viral illness and bedridden for weeks, while the second is recent in the months of May and April in 2014. This outbreak occurred in the heart of Biratnagar,  where thousands of local residences were taken ill and some of them even died. Both outbreaks caught national and international headlines and the root cause was fecal contamination of municipality supplied drinking water. These examples definitely spark a sense of urgency demanding public health address with available effective preventive tools. 

Preventive measure 

Undoubtedly, the golden rule for its primordial and primary preventions would be health education, clean water and sanitation and hygiene practices. Sadly, this disease has not caught much of global attention unlike those of recent Ebola Virus Diseases outbreak, Tuberculosis, HIV and Malaria.  However, on positive note, we have safe and effective measure in our fight against this disease through vaccine along with preventive measures that adapted to the local situation. For this measure, HEV vaccine can be used as an effective public health measure to control its outbreaks in Nepal. To support his argument, he brings out the recent use of SA 14 - 14 - 2, a live attenuated vaccine against Japanese encephalitis (JE), which was used to effectively control and prevent JE in Nepal.  This vaccine was not then prequalified by World Health Organization (WHO). However, Nepalese health authority decided timely to use the available vaccine in endemic districts based on its public health merits. JE vaccination started in campaign mode and later introduced into routine immunization. Now, we see such a visible public health impact that anybody can hear such a dramatic success stories of JE prevention in the country. The key strength that lies hidden in this endeavor is the robust surveillance of Acute Encephalitis Syndrome (AES), which provided clear epidemiological picture of the disease, so policy makers were able to sketch pragmatic vaccination strategy in the country. This brings us to one pertinent question related to HEV vaccination “how long do we have to wait for HEV vaccine so people can get its benefit and get protected against this ailment? When I remember those days of extreme weakness, bouts of vomiting with incessant nausea that gripped your guts, I can even now feel the suffering. Nonetheless, it is comforting to know how much we understand the basic epidemiology including the genotypic distribution of HEV circulating in Nepal. Notably, some early human phases of HEV vaccine clinical trials were also conducted in Kathmandu among Nepalese population. We have to be honest, however that the concern raised by medical as well as public health fraternity, “why is HEV vaccine still not in public health use or even in private market?” is very relevant.

Final Thoughts

Viral hepatitis especially HEV is an area that is need of much advocacy from the community level in countries like Nepal / India / Ethiopia. We should also be able to advocate in the global health community. This means we should work simultaneously from both end - at international fora and also at the community level. Only then, we can reach a meeting point where funders and community health leaders can sit together and have a meaningful outcome from the entire penny invested in such studies related with HEV or any other vaccines. Whereas in Nepal, we should also be able to bring academician and public health professionals on board and educate the community well. Above all, the onus lies on us how efficiently we advocate on this issue at national or international level would be decisive and most important. Otherwise, we will always have to face the sad reality of yearly unexpected outbreaks in middle of some rainy seasons with national headlines as always – “Urban life disrupted with Viral Jaundice outbreak in the city”

Anuj Bhattachan

Jul 21, 2015

Glimpse of Vaccine Delivery in “Remote and High Altitude” areas of Nepal

“In remote of continents like Africa or Asia, a vaccine typically survives only five days before it spoils due to improper storage. This leaves millions of children without life-saving vaccines for preventable diseases.  In order for vaccines to stay fresh, they need to be kept between 0-8 degrees Celsius (32-46 degrees Fahrenheit).  That’s a hard thing to accomplish in warm, desert-like regions.  And it will be even harder if those places are remote and without electricity. Research organizations are working hard to figure out how to make a portable, sturdy and, most imperatively, reliable way to keep vaccines at that precise temperature.  To do that, researchers looked to a basic technology for inspiration.”

Today, I am going give you an overview of “Vaccine delivery” in remote high altitude areas of Nepal. As of now, I presume, each of us has received vaccination shots against common childhood illnesses. We must also remember that thousands and thousands of “unfortunate” children are still victim from infectious diseases at this very hour like measles, tetanus, cholera, which are otherwise easily preventable. My intention here is not to inspire or preach or convince you of what needs to be done. Instead, I am going to show you what I have personally observed and experienced the challenges while delivering vaccines in remote high altitude areas. First thing first, let me dedicate this blog post to those ladies, who are the foot soldiers for immunization in low income settings like Nepal. They are known as Female Community Health Volunteers (FCHV). They are directly involved in vaccinating the children in rural communities. Without them, immunization program would falter!!

The focus here would be on the challenges that we face delivering vaccines in remote and high altitude areas.   So, before jumping into vaccine delivery let me give you an overview of Nepal, which is a land locked country in South Asia. The estimated population is around 27 million. It is surrounded by two giants – China in the North and India in the East, West and South. It is divided administratively into 5 regions and 75 districts. It comprises 3 ecological zones that run from east to west – Southern Terai plain, Middle Hilly and High altitude Mountainous regions in the north. Altitude increases from south to north. There are 16 -districts in the mountain region. Among these 16 districts, my particular focus would a district named “Mugu” – this is one district which has the lowest human developmental index in Nepal. 

In Mugu, there is a district health office (DHO) at district head quarter. Its responsibilities lie in the provision of both curative as well as public health services. There is only one PHC below district level. And there are several health posts or sub health posts in every village development committee (VDC), which is the lowest government administrative unit. Under each health post or sub health post, there will be FCHVs, Outreach Clinic (ORC) clinics and Expanded Program on Immunization (EPI) ORC that function to provide public health services in the community. DHO is therefore a command centre for all public health activities. In remote districts like Mugu, the sustainability of energy requirement and transportation of health commodities are of the highest priority to the district management. Once we have commodities like vaccine or delivery kits, it cannot remain in district headquarter. These have to reach people and if it is vaccine in particular, then it has to reach the children at the earliest since it has to be kept cold within required temperature.

Energy is scarce in this part of the world. The basic source of energy here is firewood. This does not help them maintain cold chain temperature for vaccine. Next nearest energy source is kerosene, which is very expensive and it is difficult to sustain for the whole district. So the next reliable source would be either solar or wind or hydro energy. Here in Mugu DHO, the source of energy is only solar energy. There is no reliable electricity source as of now.

As we are aware by now, the cold chain maintenance of vaccine is of highest importance in vaccine delivery. If we fail maintain it properly due to various reasons – human or technical error, we are committing crime to humanity. You may ask,” Why is that?” It is primarily because vaccinating a child with “impotent” vaccine is as good as giving child a poison. Therefore, the continuous monitoring of temperature and documenting those numbers is very important. However, our experience based on field observation or monitoring visit tells that this is not always done. More than technical errors, we have observed that it is in majority of cases due to human factors and partly technical. This is one area many research organizations are utilizing their innovative ideas that can address and solve both human as well as technical limitations in the system.

The primary goal of EPI is to deliver safe and effective vaccine to the children of every country, every province, every district and every village. Apart from it, we also need to realize that getting vaccinated is the birth right of every children and delivering complete dose of vaccine thereby fully immunizing them. Therefore, reaching every child is has to be our mission and we all have a moral responsibility to achieve this mission.

But a very practical question comes to us, “Are we able to achieve these objectives?”  This is challenging but is also doable. Why sort of challenges do we have to face.  Sometime we come across vials of oral polio vaccine (OPV) given to protect child from “paralyzing” poliomyelitis. Unfortunately, we found in one of field inspection that many vaccine vials had to be discarded because Vaccine Vial Monitor (VVM) showed stage 4, which means they are damaged due to excessive temperature exposure.  So you may ask, “Why does it happen?” It has various reasons, as a result of human as well as technical limitation in those areas. One of the main reason, many of times, we find vaccine carriers – old, leaky and dilapidated conditions.

Another aspect of challenge in the delivery of vaccines is high drop out that leads to incomplete dose(s) of vaccine received by the child. In this, the role of mothers, health workers, community leaders, engineers, volunteers, teachers and students are vital.  Another important target for vaccination, which we tend to miss from getting them vaccinated, is all new borne babies. They are highly prone to infectious diseases. Many of times, thousands of babies are still home delivered in low income settings. Therefore, we need to serve these family and community living in hardest to reach area of any geography the most. This is one challenge that every government in low income setting are trying to solve to serve the most impoverished population and save children from preventable diseases.

To understand the real scenario from family and community perspective, “why many parents fail to vaccinate their children?” we have to understand the socio – economic dynamics of the community. These are some of the scenarios which we can observe or find in the community:

  1. There are parents, family or community,  who will walk for hours and hours to get their children vaccinated,
  2. There are parents, family or community, who wants to vaccinate their children but they are not aware “where and when” to vaccinate
  3. There are parents, family or community, who will vaccinate their children but are busy with family works because they have to worry about what to eat next day more than getting their child vaccinated. 
  4. There are some children, who are in the wild playing happily. Many of them are “Zero Dose” which means that they have not received even a single dose of vaccination.

There is another socio – economic aspect of a community which does affect the health of the family as well as to reach them. In South Asian society, there still exist millions of people considered “untouchables”. These people are perennially pushed at the lowest of low in the socio – economic strata. The children from these communities are usually those who are either “Zero Dose” or “incompletely” vaccinated. And it is in this community, where most of the disease outbreak occurs.

So as a vaccinator or local public health manager, s/he has to face a practical question – how do we reach these children and vaccinate them? Vaccinator has to think – how to reach there? She has to think – do I need to travel on foot or on horse and is “per diem” covered or am I insured? Many of times, these field level health workers have their own social responsibilities like we do.  I have to say, these are real public health dilemma that many of field level health workers have to go face because, on the other hand - if s/he does not carry out her duty well, then somewhere, an “unfortunate” child may get diseased or even lose his/her life!!  

In remote and high altitude areas, we need to walk for hours and hours to reach from one village to another. There is no other option. This is going to be your daily routine, if you decide to live there or serve these people.  Sometime, we have to risk our lives. Many health professionals have lost their life while in duty.  Therefore, most of the time, vaccine transportation is through human vehicle, walk for many hours to days even up to 10 days in some places. It is definitely heavy and painful, while paid less and walk for days to reach these children and vaccinate them. We have to acknowledge, the office helpers, who are indispensable in carrying out vaccination program in these remote high altitude areas. Sometime it is not easy to carry so they have devised a local method – carry it on your, shoulder, back or head. 

Finally, it is said, it takes a whole community to educate a child. In our case, it takes a whole district or country to vaccinate each and every child. However, there are challenges which we have to negotiate through, so we reach each child and vaccinate them.  So, let me conclude this post with wisdom, “The best way to escape from a problem is to solve it”

Anuj in Himalayas

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