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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

May 17, 2015

A short report of suspected Enteric Perforation with localized peritonitis - Post Earthquake (April - May 2015)

On 9th May, 2015 - we went to inspect the temporary settlements in Kamal Binayak, Bhaktapur. We volunteered for few hours to soothe various ailments that local people living there in settlement had to go through. Among various complaints, some had diarrheal illnesses (some acute onset while some suggestive of dysentery), while some senior citizens complaints of joint pain aggravated by cold exposure. I think, there were around 100 to 150 people living there at the time, when we visited the settlement. During that period, we were a bit more concerned with two person who came to the temporary health center established there through District Public Health Office (DPHO), Bhaktapur. One was a middle aged women who was bitten by a local dog. We advised her to visit Sukra Raj Tropical Hospital and informed Dr. Sher Bahadur Pun, who is, I think, one of few passionate doctor in Kathmandu valley. Dr. Pun can be said without doubt one of  a leading infectious disease expert in Nepal. However, we found that she was not taken to Teku hospital for needful further. We know, sometime, local people have other priorities thought to be more important than to get vaccinated. But, we may land into an unfortunate event sometime - rabies is a deadly disease with 100 % fatality. This we know loud and clear! Hope she will be safe and healthy !! 

A child treated for enteric perforation, Bhaktapur (May 2015)
Photo Courtesy:Dr. Bhim Dhoubadel
Other visitor to the temporary clinic in the settlement was a female child of around 10 to 12 years of age. She was brought to the clinic by her parents. On seeing her, I immediately felt "a dead person walking" since she was profusely sweating with her face looking bland and i guess, she was in extreme agony. But she did not express it !! Now, i can realize how much suffering she must have faced hopping from one clinic to another with prescriptions that did not work. Fortunately, Dr, Bhim (Assocaite Professor at Nagasaki University, Japan and also a technical adviser in Sidhi Memorial Hospital in Bhaktapur) examined the child, then immediately diagnosed "intestinal perforation with localized peritonitis" and referred to Sidhi Hospital for surgical exploration. She was provided free care by the hospital and was surgically explored with Intensive Surgical Care. Later we came to know that the child had enteric perforation most probably due to typhoid fever with peritonitis with impending septic shock. She was given pints of blood transfusion. As of now, Dr. Bhim is waiting for reports of blood culture and sensitivity and also biopsy report for the final diagnosis. 

In retrospect, I can think the urgency of this public health problem of typhoid fever in Bhaktapur. We also know and we have been hearing in international forum that Kathmandu valley is considered and reported as "Capital of Typhoid fever". In order to say that there are enough studies to supplement the statement. The only contention that I have to be clear is whether this is exaggeration !! Nonetheless, it is right time that all those involved in the prevention and control of typhoid fever has an excellent opportunity to work in concerted effort to showcase an exemplary public health campaign so we could prevent this enteric illness through vaccination. In this effort to address possible typhoid fever outbreaks that may arise post Earthquake due to compromised water sanitation and hygiene, the Coalition Against Typhoid (CAT) local and international chapters have to act now. Never before has there come this opportunity to advocate typhoid and paratyphoid agenda to the international  fora as an global public health agenda !! I think and i believe, this is immense opportunity that we should not miss and erase once and for all from all literatures and even word of mouth the stigma of "Capital of Typhoid Fever" said for Kathmandu Valley, which is the national headquarter of Nepal. 

May 12, 2015

Some thoughts on Dr. Sack's important question on OCV delivery - Part 3 of 6 part series

Now, it is always in the best interest of community that we talk of the best available options like vaccination early rather than saying "Well this will complicate the situation without understanding the scientific facts as well as merits of vaccinating the most vulnerable during crisis situation. However, we also should acknowledge and prioritize (and can't undermine) WASH measures, which should be employed extensively in the backdrop of disease surveillance, which should be robust in its functioning . Few days ago I read Dr. Sack's blog post in ( ), the key message that I could get from the post is that efficient surveillance and rapid action are the two side of the same coin to stop cholera spreading in the community. This is what all of us emphasize during our conversation with public health colleague here in Nepal. When Dr. Sack says "efficient" surveillance, it also means that it should be equipped with stool sample collection, proper sample transportation, cold chain maintenance and  appropriate lab diagnostic test. In the field however we could use quick diagnostic test like modified rapid dipstick test. This can be supplemented with culture and sensitivity test. Therefore, this is one area, which interests me when assessing the risk of cholera outbreaks in the community and now especially in temporary shelters, where people directly or indirectly affected by Earthquake take refuge for safety. During this temporary stay, I would say children, senior citizens, pregnant women and weak / feeble are at high risk of exposure to various communicable diseases. 

This is so timely, therefore we discuss and put in place robust surveillance and use rapid diagnostic test in 14 affected districts. Once we assess the surveillance data along with risk assessment using appropriate tools available, we would be in a place to take evidence based informed decision. In this light, let me share recent experience of oral cholera vaccination in Malawi where thousands of people were displaced due to flooding. In collaboration with the International Vaccine Institute (IVI), the World Health Organization (WHO) implemented  Oral Cholera vaccination in response to reported and later lab confirmed cholera outbreaks in Psanje, southern part of Malawi . Specifically, WHO provided vaccines for 105000 people while the International Vaccine Institute provided vaccines for 55000 people. The World Health Organization is continuing to lead the monitoring, evaluation and documentation of the best practices in the introduction of the Oral Cholera Vaccine. Also, the mass preventive vaccination were carried out in Guinea, Ethiopia and Haiti.

These are exemplary collaborative efforts to address outbreak caused by neglected diseases that is related to water, sanitation and hygiene in the community. It is unfortunate that we are still lingering with basic necessity that a responsible state has to offer to its people. Because there is lack of such basic utility our people are victim to preventable diseases like cholera. This has become even more relevant when the globe has constricted with rapid transportation (both sea and land) within and outside our boundary. This is further compounded by changing population dynamics as well as climate changes, political instability and rising antibiotic resistance in the community.

While writing this blog, we felt another 7.4 Rector Scale Earthquake with epicenter in Everest region. We do not know as of now, how much it has damaged and loss of life / injuries. We therefore pray that we do not want another Haiti Situation, when cholera outbreak complicated the overall relief and rehabilitation of the state and its people, here in Nepal. We will work in that direction and we are united in this national endeavor. 


May 8, 2015

Post Earthquake Preparedness against possible Infectious Diseases Outbreaks in Nepal

Now I am in Nepal. Today is my 4th day here in Kathmandu. Over these days, I visited key government offices and expressed to directors, "how we can be of assistance to Government of Nepal (GoN)? Also, we stated our competencise, which can be used in case disease outbreaks should occur in Earhquake hit areas. After thorough discussion, my impression (as of now) is that GoN is working hard to address this emergency situation judiciously. The key aspect we need to understand is that the overall coordination of the relief work is being conducted through National Emergency Operation Centre (NEOC), while the health related activities are being coordinated through Health Emergency Operation Centre (HEOC), which are supported by all key international multilateral organizations like WHO, IVI, UNICEF and other UN organization, bilateral organization  and local NGOs and volunteer from many countries. HEOC is spearheaded by Ministry of Health along with other key departments and divisions. Special mention should be Epidemiology and Disease Control Division (EDCD), this division is working hard to control possible infectious diseases outbreaks like cholera, dengue, leptospirosis. To assist GoN, IVI along with WHO, UNICEF, CDC, JHU and GTA (group for technical assistance) is coordinating closely to tackle possible cholera outbreaks in affected districts in Nepal. Key activities that need to be done at the moment are assessment of cholera risk and then present the findings in Enteric Diseases Steering Committee under the leadership of Director General (DG), Department of Health Services. Surveillance is being strengthened and EDCD and WHO are working closely to pick possible outbreaks at the earliest. There is clear directive from the ministry of health to report all reportable infectious diseases SOS without hesitation. GON (at EDCD) along WHO / IVI / UNICEF / JHU / GTA will work hand in hand to mobilise WHO stockpile of cholera vaccine available. 

Key activities that I have been involved as of now:

Relief Camp in Bhaktapur (Photo courtesy Anuj Bhattachan)

5th May 2015: On this day, we had a meeting at EDCD (along with IVI / WHO /GTA). Also, visited WHO Program for Immunization Preventable Diseases (IPD) and Sukra Raj Tropical Hospital, Teku. I met Dr. Sher Bahadur Pun, Infectious Diseases Specialist, who shared his experiences and expressed opinion re: landscape of infectious diseases that report in the hospital. He says that yearly sporadic cases of cholera have been reported in KTM valley.

6th May, 2015: On this day, we had a meeting at Child Health Division (CHD) along with representatives from UNICEF, WHO. In the afternoon, I visited GTA office to prepare concept for tackling infectious diseases outbreaks which is highly possible aftermath of Earthquake in Nepal.

7th May 2015: I had meeting with Rotary Nepal to discuss on IVI Rotary Project that we have planned for Nepal. I also understand, we need to work hard to convince people from different background so we can immunize people from cholera or other vaccine preventable diseases (VPDs) in impoverished community. In the afternoon, we again had follow up meeting at GTA for the finalization of the concept note.

9th May, 2015: I visited Kamal Binayak Camp in Bhaktapur in response to possible cholera outbreak. The key issue after a preliminary report shared by one of senior epidemiologist has created noise among public health professionals involved in surveillance of reportable infectious diseases. The main concern is laboratory investigation of stool samples collected from those camps in the vicinity of Bhaktapur. We hope that the results of the stool examination will be openly shared and acted upon it.

May 3, 2015

3rd day update: 9th International Conference on Typhoid and Invasive NTS disease - Bali, Indonesia

The day started with a symposium on past experience from typhoid vaccine implementation: translating global policy to country use. This was moderated by Kim Mulholland, LSTM, UK. The talk started with Nepal Vi – ps introduction in Nepal. Dr. Pradhan urged international community to assist GON to introduce typhoid vaccine in its national EPI program. The second talk was given by Leon Ochai on vaccine introduction in Pakistan. There was also mention of DOMI program and its relation to assess vaccine effectiveness in the real public health situation with >60 % effectiveness > 5 years of age. It was introduced as school based vaccination. I could see that the coverage was average around 60 %. It was related with trust to the system, the reason for low coverage.
Where do we stand?

  •  Burden of TF – high along with MDR / age of infection as low as 6 months
  • Vaccine use: TF vaccination is efficacious and feasible / capability for vaccinating school children
  • National financial resources limited
  • Global agency financing will facilitate the vax introduction and help in controlling this disease
  • Sri Lankan experience: Jaffna (IDP camps) has the highest incidence of TF followed by Colombo (with highest population) in SL. Vaccine being given to outbreak situation / pilgrims / food handlers / close contact of patients / where water sanitation (poor)/health professional / armed forces / children with frequent of diarrhea. However, there is high literacy / improvement in WSH. There is also environmental surveillance.
  • surveillance – sentinel + lab surveillance
  •  Antibiotic monitoring
  •  Immunization in High risk areas

Conclusion: Government is willing to vaccinate and GAVI is also willing to finance this initiative. We should not hesitate to move forward. Also, we need environmental sampling + improvement in WASH

Integration of TF vaccine in NI Schedule: opportunities and challenges from industry (Bharat Biotech – India). There is higher disease burden in urban so urgent need for its control. (Ochiai + Florian’s paper) Typbar – tcv (6 months and above / single dose / IM – what r the key consideration (WHO ECBS guideline on Typhoid vaccine use)

  • Primary above 6 months / Single dose / at least 6 months of gap for boost / or school based booster
  • Current guidance available NIH efficacy studies
  • New Vaccine Introduction from WHO perspective (Principle, Practices and Realities) -
  • Moving fast

o   Measles vaccination
o   HiB introduction
o   Rubella vaccination
·                     Slow to medium progress
o   JE vaccine – regional vaccine
o   Pneumococccal
o   Rota Vaccine
o   HPV vaccination – cervical cancer

Various scenarios
·         Scenario A - ??
·         Scenario B – low income countries – GAVI funded / sustainability?
·         Scenario C – Gray area / prioritization

Key point to consider – decision making process

·         Burden of disease – various factors (eg incidence / mortality / DALY)
o   Accuracy of the burden studies (syndrome sx may overestimate)
·         Factoring in vaccine efficacy and its effectiveness – looks into overall effectiveness of the vaccine
o   Herd effect / impact
Key message
·         Vaccine effectiveness > efficacy
·         Vaccine factors – age / booster / dosing …..
·         Alternative ways to control also available but for example measles – vaccination is the only option
·         Cost – opportunity cost / cost benefit
·         its priority in government
·         Return on investment
·         Health budget
·         Global agenda (political / global initiative)
Question and answer session
·         what is the vaccine efficacy among 2 to 5 years of age
·         Some voice against using the word ‘alternative” in relation to vaccination e.g. HPV vaccination
·         Typhoid vaccination – John Crump interested with vaccination against frequent in acute diarrheal illness.
·         Breiman – 2 to 5 years of age  vaccine efficacy (factors like fear / poor acceptance might have influenced the low efficacy rate among 2 to 5 years)
·         The effect of taking consent may have an effect on low coverage
·         Dr. Bhutta gave a clear and succinct explanation of why low coverage in Pakistan.
Next symposium is on development of vaccines against typhoid, paratyphoid and NTS. This is the key area where I have an interest. This is moderated by Adwoa Bentsi Enchilli, WHO, Geneva, Switzerland
Ghananian proverb – lesson to be learnt from past
Typbar – TCV (Bharat Biotech, India)
·         Safety and immunogenicity in healthy infants, children and adults in endemic areas
·         control – Typbar (Vi – PS)
·         dose = 0.5 ml / cold chain needed
·         anti Vi igG 6 wks post vaccination – 1 endpoint
·         Safety across 6 months – 45 years
·         Results:
o   safe in all age group
o   Immunogenic (high IgG response) also in < 2 years
o   Persistent in immune response and also memory response
o   antibody avidity is important for qualitative assessment
o   Open label / controlled trial  - TypBar TCV / Typbar
§  Conclusion – safe / immunogenic / immune response persistent < 2 years / booster needed
§  Measles interference study underway
o   My question – Bharat Biotech is way ahead with their conjugate vaccine, how we are going to deal with it as we are working with Vi – DT vaccine

Vi - DT vaccine development – Bio Farma
§  our desire to move from medium > high priority in WHO list of vaccine
§  Target Product Profile (TPP)
§  Process development  / GMP process – master seed and working seed
§  Process flow (Vi Polysachharide)
§  ELISA / NMR /HPAEC method
§  WHO TRS 987 – requirement
§  Vi DT conjugation Process
o   Carrier protein prep
o   Vi PS preparation
o   Conjugation
o   Diafiltration
§  HPLC profile
§  Nonclinical immunogenicity studies (who guideline)
Vi CRM 197
o   CRN
o   Conjugation kinetics as a process map
o   Bulk conjugate vs. Formulated Bulk
o   Study plan – mice study
Live oral vaccine – M01ZH09 (from parent Ty21a with some changes) Ref: Waddington et al, J Infect 2013
o   Vax efficacy / correlates of protection
o   Vaccine efficacy – study design
o   blinded arm (Placebo vs M01ZH09)
o   Open arm (Ty21a)
o   LPS as surrogate of efficacy
o   Then challenge with TF bacteria / diagnosis after challenge (temperature or Blood C/S)
o   Dose escalation study
o   LPS vs. Flagellen vs. Vi
Bivalent Core and O PS (COPS) – flaggelin conjugate vaccine against iNTS and typhimurim infections
o   key - phase 1 flaggellin subunit serves as the carrier protein – target for immune response
Interesting discussion – I guess on emerging considerations for iNTS disease prevention moderated by John Crump, University of Otago, New Zealand
Typhoid conjugate vaccines for public use: overcoming barriers moderated by Zulfiqar Bhutta, University of Toronto, Canada
TF vaccine for public health use: overcoming barriers: moderated by Zulfiqar Bhhutta
o   Current WHO position of TF (2008) – recognition as serious health problem/significant public health burden/local epidemiology/high risk population must be the target/ there are also inadequate data on conjugate vaccine (t cell response / ? young age group)
§  national epidemiological data – rapid assessment tool to map the disease epidemiology (better describe the local epidemiology)
§  Lack of validated assay
o   GAVI – Vaccine Investment Strategy (VIS)
o   2008 HPV/JE / rubella, typhoid conjugate
o   2011 interest in typhoid conjugate
§  WHO PQ and recommendation
§  GAVI program window decision
§  Program implementation
§  Vaccine evaluation
·         vaccination scenarios
·         Demand forecast
·         Develop impact estimates
·         Develop cost estimates
·         Assess other disease / vaccine feature

o   International Vaccine Institute (IVI) -  landscape of what IVI is doing in Vi DT vaccine development
o   Gates Foundation - Stringent and focus / fulcrum of knowledge, innovation and technology / accelerate the product development program (PDP) / focus and ambitious / using the vaccine so we can eliminate it (nationally / regionally)/ integrate vaccine and WSH or other strategies necessary / engagement – innovation so we can address 
o   GAVI process / SAGE – uncertainties re: disease burden – magnitudes / distribution, target age group, strategy utilizing
o   micro planning of deployment – generate evidence / advocacy / once WHO pq we can use it also convince the investors / also generate demand – in direct communication with policy makers so we convince them, prepare ground for deployment of vaccine, guidance of regulatory authorities at country level
o   GAVI – key is evidence / disease burden data – matrix of investment
o   Immunization strategy need to be carved out and political will is also important / political commitment is always need – local champions and translating local data and connecting with policy groups through advocacy and communication
o   Need for efficacy data
o   Lack for good diagnostics so this could help surveillance
o   Transfer of plasmid is on threat??
o   Nepal could advocate strongly in WHA through executive body – how can we move forward???? / Position should focus on implementation part.
o   Global Typhoid Initiative – need

o   description, discovery, development, delivery

Anuj in Himalayas

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