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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”

Jul 17, 2015

In Nepal: Earthquake, Cholera and Gorkha !!

Previous 3 months, I wrote and posted 6 parts series on cholera and one more post re: our experience with risk assessment in 14 earthquake affected districts. This is my mental exercise of expressing what I think and what I do. I know, sometime what I write and express may be immature or even out of context - well - so be it !! It is only through regular writing that we can refine how and what we write - this is so simple !! Key to success would be perseverance and consistency. So, I will be writing from now onward as a record of our "real" public health experiences in Kathmandu and some of the hilly districts we will be visiting for our challenging task - that is to prepare and conduct cholera vaccination. While, I can not tell you now what lies ahead but I am pretty sure this is going to be one of the most challenging public health campaign so far we have been involved. Why? Monsoon is already in the air !!

In Nepal (what I can tell from recent Gorkha and Dhading visit !!) as of today, we are under the spell of anything that moves could be Earthquake !! And you may be right most of the times, when we are experiencing minor jolts day and night. We have come to our homeland with our heart open to support at anything where we are able to contribute, while for me, being involved with clinical development of safe, affordable and effective "vaccine" against enteric diseases like cholera, typhoid fever and HEV - what else could I do? For me working together with epidemiology division along with other key organizations like WHO, UNICEF, Rotary, Red Cross is the best option available.

After 2 month long exercise of preparatory exercises, Nepal government firmly decided to go for preventive measures against acute water diarrhea including cholera. While, there  are  measures taken to strengthen the existing Early Warning and Reporting Network (EWARN) and additional support from WHO to enhance disease surveillance activities - it has been hard to reach remote hilly areas in the affected districts. So you may ask why??

Before answering WHY? First let us ask ourselves - Is it in the interest of few professionals interested in using vaccine or is it only for our academic voracity that we want to use oral cholera vaccine ? Definitely not !! Those who have seen in his or her clinical practice must have experienced the ferocity of acute diarrheal illnesses that may spread in the community. While those people who have experienced sickening experiences of getting loose watery diarrhea and getting weak "unable to walk even few feet away" would definitely know the importance of getting vaccinated and protected especially in places like remote villages like Lapu or Lapa villages. In these villages, if you get sick say viral hepatitis or even typhoid fever, you may have few days to get treated in the district headquarter or if you have enough money, then you could charter a helicopter, however this is not the usual situation. However, all residence in the community are not well off !! Especially, those people who are affected with outbreaks of infectious diseases are those low in the socioeconomic ladder. The main concerns that we have are about access to clean drinking water, health facilities in case you get sick and in particular vulnerable population - children, women, and senior citizens.

Another question that i would like to share for our intro inspection:

To understand more of Jajarkot outbreak - I suggest you to read the blog post:

18 July, 2015

Jul 9, 2015

Our experience with risk assessment of possible cholera outbreak in 14 earthquake affected districts in Nepal

In this post - I will share with you all our experience with risk assessment of possible cholera outbreak in 14 earthquake affected districts in Nepal. My intention of writing this experience is purely academic exercise as a part of documentation of following key points:
  • the need for the risk assessment post earthquake in Nepal
  • the approach to the risk assessment that we adapted according to the local situation, 
  • the process of the conduct of risk assessment and our field experience
  • some challenges that we had to negotiate through its content to create robustness and credibility in the assessment.
Before jumping into key points and provide you with explanation, I would like to walk you all through interesting reading that I have been able to re read again and get insight now. I think - this is the best of time to re think into how we have been able to fare with our effort to secure oral cholera vaccine to use in heavily affected districts of Nepal. One fact we all agree that methodical approach applying epidemiological tool for effective control and prevention of the disease under radar is the answer. This is well said in the blog post by Dr. Sack in Gates Foundation's Inpatient Optimist. In the same post, Dr. Sack also mention the importance of rapid diagnostic that is much improved in terms its ease of using in the real field situation. We therefore need to apply this available tools to the fullest. Hope we would be able to use them in Gorkha and other high risk districts this year. Another blog post in PLOS Speaking of Medicine by Lorenz Von Seidlein is a must read for those involved in relief work in Nepal. Dr. Lorenz writes passionately what he saw and what the risk assessment was all about and its implication. His blog also says a lot on our approach to assessment. The main goal of our risk assessment was to use the available tool in the "real" field situation and contribute to national effort in the infectious disease control and prevention. We were able to conduct the assessment within a week reaching every districts and some accessible villages and share the findings to "steering committee for enteric diseases" under the leadership of Directorate General, Department of Health Services, Ministry of Health and Population, Nepal. Based on this assessment, Government of Nepal firmly decided for preventive cholera vaccination in selected earthquake affected districts.

Also, while I am thinking and writing on risk assessment tool - I was following Tweeter for tweets related with cholera and its oral vaccine. One tweet caught my attention - it says "Promise is seen in an inexpensive oral cholera vaccine" posted through NYTTIMES, while Reuters US edition reports a trial recently conducted in Bangladesh - "Oral Cholera vaccine could speed control efforts" Reading all these reports, we can get a sense of urgency in terms of increasing cholera outbreaks across the globe and need for cholera vaccine in a situation as a result of either human created or natural disaster like Earthquake. On this background, we are cognizance of the importance of objective risk assessment in countries or areas at risk of acute watery diarrhea including cholera.

Now let us dive into our key points of discussion. First key point first, you may be still wondering what is this risk assessment of possible cholera outbreak? Well, this is a tool which tries to measure the risk of cholera in the communities using both objective and subjective questionnaire. The objective component of the assessment would be measurable through available data and some of those information can't be assessed objectively have to be collected through subjective methodology. Most importantly, this assessment was done within few days, so this has some limitations. However, the main objective of the assessment was to objectify the risk of possible cholera outbreak(s) in Earthquake affected districts, so that would assist key governmental  officials and donors in decision makings.

Now let us go one by one to the key points that I would like explain to all the readers. The point that we need to understand what was the need for the risk assessment post earthquake in Nepal? To answer this question I would like to share Sachin's (from ) famous phrase he used in recent conversation here in Nepal - " Earthquake was a big surprise to all of us, but monsoon is not !!" This is true - the recent Earthquake with first epicenter in Gorkha and second one in Dolkha affected millions of local people and thousands of them lost their precious life. Now, our people are very well coping with the adversaries and now rebuilding the villages and urban cities with their bare hands. On the other hand as a formidable challenges, monsoon has already started and there are every risks of infectious diseases outbreak(s). In particular, all the public health professionals are primarily concerned with water - borne illnesses in remote areas. In our conversation with senior managers in Epidemiology and Diseases Control Division (EDCD), they are concerned with possible outbreaks of cholera, which can cause deaths among vulnerable population (children, senior citizen, pregnant women, sick and infirm). And this cholera outbreak can be explosive in areas where the health care delivery + disease surveillance system is inadequate and where water sanitation and hygiene condition is poor. For example, we do not have to go far - Jajarjot cholera outbreak in 2009/10 took more than 500 life with thousands affected, It is therefore we do not want another Jajarkot tragedy. For this precautionary public health measure, we need to have risk assessment in the communities so we will be able to act rationally to carve out preventive measures in the high risk communities.

Another key point that we had to adapt according to the local situation was the approach to the risk assessment. In this assessment task, John Hopkins University (JHU) lead  in order to fine tune the tool available. In the tool, we made sure it covers all points that assess the infrastructure damages, the water sanitation and hygiene status, public health preparedness in terms of surveillance, disease reporting mechanism, case management capability and other environmental factors that may play role in the infectious diseases dynamic like population, transportation, weather patterns and health behaviors etc. The main strength of our assessment was that we visited most of the affected districts and interviewed key public health professionals, local health post in charges, nursing staffs, local people and volunteers. The only limitation was that we could not visit the most remote villages heavily affected by the earthquake due to geographical challenges in front of us. Once we finalized the tool, the risk assessment was conducted smoothly except in some districts where district public health officer in charge did not have time to listen to us and even did not want to hear the word "cholera vaccine" and in some places, WHO field staffs were a bit uncooperative in our field experience. This was completely opposite to what I had in my mind of WHO as an international organization with such a global visibility. Here I will not write about the bitter experiences, however I have convinced that it is people in the organization that my tarnish the image of the organization, not the organization itself.

Once we completed the assessment, the report writing was a group work and so much learning experience for us. Lorenze (representing JHU) guided us so well in the writing part, so we finally managed to share the findings at the task force meeting chaired by EDCD director. For the credibility of the assessment, we got it endorsed from the EDCD and its strength (along with WHO/UNICEF/IOM risk assessment report) we have been able to submit ICG application for oral cholera vaccine to be mobilized in the most affected high risk villages. They deserve to be protected using the fruits of scientific endeavor like vaccines and nobody should deny just because they lack public health sense of urgency and unaware of "equity" and "justice" they deserve in the remote parts where people are unaware what lies ahead !! So I would say - "No more Haiti situation in Nepal!!"

9th July 2015

Jun 26, 2015

Random thoughts on public health politics - Part 6 of 6 part series

In my previous post dated 21 June 2015, I expressed a deeper insight into what goes on and what we are not able to understand the web of public health politics. Here again, I would like re iterate that I am not able to say certainly what goes in the mind of decision makers at the international headquarters, but at least i can say - we understand the pulse of "what goes on" and "how it goes" in our local community !! Sometime, however - we are cognizance of the fact that we may subjectively feel that whatever we said and did should be right but we may not be up to the mark and fail to realize this fact !! It is therefore necessary that we need to analyse retrospectively what we do and how we think so we do not make the same mistake again and again. Time and then to keep us sane in times of confusion timely reading stories on infectious diseases gurus like Brad and David Sack encourages us to move forward in what we aspire to do. We also get encouraged to work hard and perspective in what we envision doing  in countries like Nepal.

Yesterday, I had to go through a psychological test (not in a psychiatrist or psychologist' chamber) at a personnel level. So you may ask what is this test and what does it have to do with public health politics. Well - it is about your ability to express your ideas (both at academic, programmatic or even anger or frustration)  in coherent manner. Sometime I have begun to question - does your language of expression to express your thought or ideas have any relation with public health politics or it is more than the language of expression - calculating the equation or even deciphering the intricacies in the relation that sometime exist beyond our knowledge? I know I am asking a very personal or even complex question. When in a national or even international forum - i had to face frequently the linguistic gap many of times. For example - my mother tongue is Thakali and all my childhood - i had to work hard to excel Nepali language and to be competent enough to understand science we had to learn English as one of the main foreign language. I do not want to each and every detail however I would be vocal and straight that we have to face challenges while writing and expressing our thoughts in the language other than our mother tongue !! Do you believe what I am saying? May be you may say - Oh this guy is being too emotional and ranting blah blah..... but this is one of my experience at deeper level after years year of trying to understand why we could not excel in some of the subjects that we had to learn in either Nepali or English !! I found the answer and this is definitely  language related competencies !! Along with it are its trailing competencies such as communication skills and also emotional or even social skills. And sometime - we get cornered just because we are not able to express what we think clearly in the language other than our own language. Do you agree with me?? Well, you do not have to agree with me but those who have to go through this subtle difficulties faced in their daily affairs may agree with me completely or partially. Again, you may ask, what does this language competencies or even communication skills have to do with public health politics? Well, this has a big role - and as I said I felt it acutely when approaching in such forum where you have to express your thoughts. 

Expressing all these thoughts at random - I would definitely say "Public Health Politics" has many dimensions and its equation has many variables. Among those variables - i would say language competency is the most important one. In some of the conference - we see those who can express their thoughts coherently, loud and vocal are able to bring their agenda in the forum and bring about impact in the conversation. This will, in turn, help them shape their idea through policy / decision bodies. That is why we have a Nepali proverb, " Those who speak loud and clear can sell even an item of no value, however those who do not speak can't even sell "rice" !!" With this proverb - let us start being vocal but also understand the landscape of public health politics, which is always fluid and changing within time and space - uncertain !! 

27th June 2015

Jun 20, 2015

Random thoughts on OCV delivery and public health politics in Nepal - Part 5 of 6 part series

By the time I am writing this blog post - my stay here in Kathmandu has crossed 45 days. The reason that I am here in Kathmandu was and is to be the part of greater Nepali family, which is what I have deeply felt from the beginning. I have never before felt this deep sense of solidarity than now to our own community, relatives, friends and people from all walks of life. This is an interesting "feeling" or "perception" which I need to fathom deeper and I guess, this is the kind of "togetherness" that we need to inculcate in our society.  Well, to put aside this soft feeling that I can hear and experience around us, we also have been the victim of "invisible hands" in what we do and what we want to do !! Myself, who was raised and brought up in rural community far away from "comforts" of urban city like Pokhara and Kathmandu, is not enough of "stories" to convince decision makers in the authority - it required more than that. "That" would be public health politics and we need to be master at it. 

Forget - big super cities !! We know how our people in the rural communities still have to suffer from malnutrition, worm infestation, common preventable diseases that have already been eliminated from high or even middle income countries. We know surveillance of these preventable diseases have to be robust supplemented by lab diagnostic facilities, while I am sorry this is still a challenge and too primitive in remote hard to reach areas of our country. Yes we know that there is such system in paper and public health leaders are cognizance of this scenario. It is not that they are unaware but these leadership are not able to enforce such surveillance in remote areas due to various bureaucratic red tape and of course, lack of "much needed" human as well as logistics resources. We also know that just observing and experiencing these diseases or even the systemic challenges in the community is not enough - what we need is evidence and that too in writing thoroughly supported by data available. However, I think - the availability of such data can be challenging in times of public health crisis or emergencies like Earthquake and Nepal's recent event is an example. 

Now, a little disconnection from above trail of thoughts - for me 45 days has been just like 5 to 15 days only - what a amazing experience so far !! Here I also like to share  - Nepal is a wonderful place to work and Nepalese are resilient people to be with. Also, I have to be straight and vocal - we are sometime disillusioned without clear goals and road map buried in our own mountain of problems created out of complacency or too many heads working like "too many cooks spoils the broth"!! Sometime in the future - I need to write this amazing experience in writing or at least as an essay.

Coming to back to topic of my post - during this 45 days period (my focused goal here in Nepal is to vaccinate the most vulnerable population) - I did not think in depth the complex processes that were in play when were working hard to mobilize oral cholera vaccine (OCV) in preparedness for preventive vaccination in heavily affected districts and that too not the whole districts but only selected villages at the highest risk. We are still trying to get the vaccine but we are not sure whether we will get the vaccine although we are prepared for the conduct of campaign. We are aware of the "seen" and "unseen" challenges that we have to face. We are prepared to accept a scenario where we are rejected from getting the vaccines. Another - to facilitate the process that we get the vaccines, we are doing our best to coordinate with all concerned and most of the partner organizations are positive except one or two organization who have reservation and we are trying our best to bring those organization on board. Somebody senior public health specialist, whom I respect a lot in his extra ordinary skill to make things happen, uses the term - "public health politics". I agree - it is more than just science and its technicality. It is however the "damn" shrewd coordination that works well if we are able to understand the "bigger picture" and landscape of interest groups in the picture. Our big picture that we know is " to protect the community through integrated preventive and control measures against enteric diseases like cholera, typhoid fever, HEV etc." As of now, our communities in the rural areas are coping well with the loss and structural damages while many children, women and weak and old are vulnerable to infectious diseases especially water borne illness, which could spread should there occur trigger factors of poor water, sanitation and hygiene. We also have to remember that Nepali humanitarian peace keeping forces were pointed out as the carrier of cholera bacterium in Haiti on record. It is therefore we want to prevent the possibility of cholera outbreak at the earliest before the monsoon starts. But we fear, time is the essence and my pnly question - are we entangled with unnecessary processes or "ego" or "arrogance" that emanates at personal level but not at organizational level? This is too tough to understand however the only caution that I am vocal about "No Jajarkot Cholera tragedy again!!" 

21 June 2015

May 25, 2015

Some thoughts on Dr. Sack's important question on OCV delivery - Part 4 of 6 part series

It is been complete 3 weeks. I came here soon after first big Earth quake hit Kathmandu valley and those Northern  as well Southern hill districts with huge loss of life and infrastructure damage. If we calculate these losses in terms of monetary value, then I think, never before in our history have we suffered so much like in 2015!! However, I found  that we Nepali people are sturdy on close observation. Also, one essence of goodness that we possess is acceptance of "what it is as it is". That means - we have a capacity to accept death and nature's brutality so comfortably. 

During this period of hardship, each of us have to contribute from our position at whatever capacity we possess at individual and professional level. We do understand, immediately aftermath of Earthquake - triage, safety, food, security, injury treatment and efficient management of relief task is always of highest priority, however once time moves forward and healing of acute trauma ensues then there is always our secondary priorities that relates to preparedness of possible infectious diseases outbreak. In this line - I have the same question as raised by Dr. Sher Bahadur Pun, "Are we prepared to respond to  possible outbreaks of infectious diseases?" I know this is such an important question that revolves and strikes different corners of the government mechanism and processes, while in this pertinent threat that Dr. Pun has timely raised also comes the important role of citizens, field of journalism, professionals, opinion leaders and of course - civil society to address and raise concern for preparedness and its action. In this preparatory effort - effective leadership is key so any action taken is timely, focused and evidence based rather than only political. In this light - a senior public health professional said in a casual talk - "You like it or not - public health politics is important and we have to learn to play the game judiciously so we know where we are going and where to act !!" I also think, this is important - key message would be "Politics for better or worse plays a crucial role in health affairs." This is relevant to the public health politics of cholera and its preventive measures. I know, this is a bit rash for some corners involved in this affair of public health policy of implementation and its administration. However, the ground truth is that we all linked up knowingly or unknowingly to web of interests that may be guided by true passion or just of the shake business. For me what count the most is passion of involvement. In this regard, I always stick and commit to the opinion that fruits of science like vaccine for cholera or typhoid fever that are purely developed for the benefit of humanity have to be available to the community. There should be fast track or expedited process for its use or even untangle the administrative web if its use is ethical based on comprehensive safety, efficacy and effectiveness data. 

Going back to the same question that Dr. Sack raised: "How to handle the mismatch between the actual needs and the use of tools available?" This is a challenge that I consider interesting since I foresee solution in near future and that will be based on efficient advocacy and concerted efforts that will bring local government, international partners and most important would be to bring local opinion leaders on board - this will include doctors, civil society and famous figures. Also, I have considered these challenges and mismatch as "a guru" for our learning to negotiate through the climate of uncertainties. Now in Nepal, we are working closely with government in preparedness to respond to possible outbreak should it occur in affected district post earthquake. We are of the same opinion like all learned personalities that Water Sanitation & Hygiene (WASH) strategy is the key approach to control and prevent possible outbreaks of diseases like cholera. However, should the threat outweighs and the risk of outbreak is extremely high in remote areas of the affected districts, then acting upon preemptive vaccination along with WASH measures should be highly considered. No one denies this universal fact and nobody has an intention to go against the prevailing wisdom.This consideration is aligned with the WHO cholera vaccine position paper (2010). Nonetheless, we strongly assert that there should not be any delay in the name of professional interest or I would call it in literal meaning "compartment syndrome" that we decide from here in the capital the fate of peoples living in extreme condition due to Earthquake and on top of that, people exposed to extremes of nature's cruelty - landslide, flooding, when monsoon is just a little more than a month away. Understanding the ground situation - myself who also survived cholera / viral hepatitis during younger days, I strongly urge all to think twice how we decide and act for common good at this hour of national distress. Most important point that we hear from everybody on close conversation is the "real" threat of acute diarrheal illness in the remote and high risk areas!! So the relevant question everybody is asking: "Will the outbreak be followed by cholera outbreak in Nepal given the situation that Vibrios cholerae are in circulation and reported in academic journals?" For details, we can read Dr. Lorenzo Von Seidlein, from the DOVE project ( in his PLOS blog post at

Anuj in Himalayas

Hi i am connecting disqus with my blog for healthy interaction and open dialogue