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Feb 24, 2015

Viral Hepatitis E (HEV) series & Nepal - Vaccine in Demand !!! (Part 4)

Before we go into technical jargon or say business case that is required for HEV vaccine to make its place in WHO pq ed list so we can use this vaccine in public or get it enough in private market - let me walk you through noise of this disease and call for this vaccine in Nepal. Of other countries, I can not objectively tell or write now. But i can guess, same must be the case and scenario on other South Asian countries, where HEV outbreaks occurs yearly in impoverished population. 

I Google - ed "HEV in News in Nepal" - I came across pretty long list of online news or even oped pieces. One stand out among those i read  and is written by Dr. Buddha Basnyat in Nepali Times. This opinion piece (#Issue 591 - Feb 2012) strongly states on possible public health use of HEV vaccine  (in Nepal) comparing with SA 14 - 14 - 2, live attenuated vaccine against Japanese encephalitis (JE) also produced and licensed in China. This vaccine was also not WHO pq ed at the time when Nepalese health authority decided to use it country wide in endemic districts. This JE vaccination started in campaign mode and later introduced into routine immunization. This way, JE vaccination has been a successful program in controlling and preventing debilitating serious brain viral infection. Now, we see such a visible public health impact that anybody when travels to Terai districts can hear such stories of success. Myself  - I have been part of this public health activities initiated by government of Nepal along WHO - Nepal. The strength that lies hidden in this endeavor is the background surveillance of Acute Encephalitis Syndrome (AES), which provided clear picture as to the epidemiology of this disease, so policy makers were able to provide direction for the country. If so is the case for HEV vaccination in Nepal, my only question is " Do we have such robust background surveillance data to guide our policy makers so they can take policy decision?" Otherwise, i can agree to what Mr. Basnyat point of view, when another HEV vaccine which was tested in Nepalese population - why not make Hecolin (Chinese vaccine) available for public health use here in Nepal? 

Only constraint that I see personally is lack of comprehensive surveillance data to back up our argument for introducing HEV vaccine in the community especially vulnerable population. So, for me, I would love to see comprehensive epidemiological picture of HEV across the country. Therefore, one way would be to review all the literature so far published and use modelling tools, or conduct surveillance (active vs. passive) based on availability of budget aligning with interested parties to gauze and weigh the gravity of HEV problem in Nepal. Let us see how far does this go or else may be, there must be a way to extrapolate the findings of other country experience and create public demand for this vaccine. In that case, the recent outbreak of HEV in Biratnagar could be one scenario, we can build one, so what do you say??

Still, to be honest, i am clear on the gravity of HEV problem in terms of time, place and person, except I myself have suffered this HEV infection !! In science, your personal story may help you to connect with the wider audiences but i feel, we need evidence and solid network of those organizations who wants to contribute in this endeavor of prevention and control of this disease, which i call it - "Fire that catch up in the cliff, and spread through large geography without our knowing !!" 

Feb 17, 2015

Viral Hepatitis E (HEV) series & Nepal - Where are we in its vaccine development? (Part 3)

     As 6 part of  writing series on Viral Hepatitis E (HEV) and Nepal, I am now activating neurons in some part of neo cortex of my brain, so I can write meaningfully to understand better this HEV disease in particular. I am repeating again, why I am so interested to write about this infectious disease is because this is very personal to me !! In HEV series (Part 1), I wrote of myself getting to know  this disease closely. When I remember those days of extreme weakness with bouts of vomiting with incessant nausea that gripped your guts, I even now feel the suffering. In HEV seried (Part 2), i have tried to be more objective and I did pretty satisfying job in quickly reviewing all the papers so far published related to HEV in Nepal. It is comforting to know so much have been studied on HEV and now, we do know the basic epidemiology including the genotypic mapping of HEV circulating in Nepal. Notably, some of the human phase of clinical trials were also conducted in Kathmandu among Nepalese population. 
Source: (for purely academic purpose)

     However, there is only one voice that we have heard and now i have started to understand why the candidate vaccine meant for HEV is still not there in public health or even in private market arena? In this aspect, I read a short letter in response to a paper published in a leading science journal. Dr. Buddha Basnyat (a senior scientist seriously studying infectious diseases in Nepal) has raised a serious ethical question as to why vaccine industry or research organizations who have invested so much of their time and money to develop HEV vaccine and now, there is no vaccine when there is high demand in the community. In the letter titled Neglected HEV and Typhoid Vaccine, he raises a serious question, " These vaccines against hepatitis E.......are not available, despite their proven efficacy and safety. If GSK, Walter....were not going to develop these vacciness or make them available after their successful testing in Nepal and Vietnam, why were they tested? And if these organizations will not develop them further, is there a responsibility to make them available to others who might?"
    In response to this series question, where justice as a fairness so the fruits of science have to be available if they were tested in a population in its development. In next part, I will try to throw light in understanding what is the crux of delay in bringing out HEV vaccine in the community where it is needed the most. So the question comes, is it related with financing or business aspect of vaccine development? or is it related with regulatory or purely scientific challenges that have to be solved so that we can deliver safe, affordable and effective vaccine once and for all?

Feb 15, 2015

Short Note on Dengue in Nepal

Nepal is endemic for many vector-borne diseases, including malaria, kala-azar, Japanese encephalitis, and lymphatic filariasis. Diseases related with poverty are major public health problem. This is further compounded by deteriorating environmental conditions with tropical/sub-tropical climate. It is also aggravated by increased vector amplification and disease transmission due to urbanization, increasing population density and climate change effects. In recent years, there are increasing formal and informal reports of new emerging and re-emerging infectious diseases. Among those, Dengue fever (DF) which is proved to be associated with high morbidity and mortality, is posing increasing public health threat. This means that preventive and control measures against DF cannot be effective, if we lack good epidemiological understanding of the disease in question.
There was no documented indigenous case of dengue infection in Nepal until the Sept-Oct outbreak of 2006. During this outbreak, all Dengue serotypes were identified from few Hill (Kathmandu-no history of travel) and Terai districts (Banke, Parsa, Dhading, Jhapa, Rupendehi, Dang and Kapilbastu) of Nepal. (Malla S, Thakur GD, Shrestha SK, Banerjee MK, Thapa LB, Gongal G, Ghimire P, Upadhyay BP, Gautam P, Khanal S, Nisaluk A, Jerman RG, Gibbons RV. Identification of all Dengue serotypes in Nepal. Emerging Infectious Diseases 2008; 14 (10): 1669-70). The first report of dengue virus isolation was in 2008 involving a Japanese patient returning from Nepal in October 2004. According to genomic study, the virus was closest to a dengue virus from India. Basu Dev Pandey et al (August – November 2006) also reported serologically confirmed DF from Hill (Kathmandu and Sindhuli) and Terai districts (Bardiya, Salyan, Birgunj and Dang) among febrile patients. Only 1 case had travel history outside of their residence. Many entomological studies of mosquitoes carried since eighties to recent, have revealed the presence of dengue vectors in major urban areas of Hill and Terai districts. Previously no Aedes aegypti was recorded in Nepal. These evidences strongly suggest the existence of an epidemic cycle of Dengue in Nepal. 

However, there are few important points that need to be taken into consideration.
  • Inadequate evidence to explain actual burden and epidemiological characteristics of the dengue fever in the Nepal.
  • Health professionals do not usually consider dengue as a differential. There is also under or no reporting in the absence of diagnostic facilities at the field level. It may be reported as viral fever or pyrexia of unknown origin (PUO).
  • Nepal has no dengue surveillance programs, and lack effective preventive and control measures against DF. 
  • It is alarming situation that the DF is observed in patients from hilly districts with no travel history.

Jan 19, 2015

Viral Hepatitis E (HEV) series & Nepal - Where are we in its understanding? (Part 2)

Viral Hepatitis E (HEV) is a public health problem, which has caused havoc in many parts of the country. Among these, let me share with you two outbreaks that will provide clear perspective into the gravity of HEV problem in our country. One was the confirmed HEV outbreak in the premises of prime ministerial official residence in the year 2007, where then prime minister himself, cabinet minsters and other staffs caught this viral illness. The second HEV outbreak is very recent in the month of May and April, 2014, which occurred in the heart of Biratnagar municipality in eastern part of the country. This outbreak was national headline, where thousands of municipality residence were taken ill and some of them died. In both outbreaks, the root cause for the disease outbreak was found to be the fecal contamination of drinking water. These two recent examples could provide us with a sense of urgency as to the extent of public health problem in Nepal that need to be addressed with available preventive tools. 

Before going into preventive measures available for this illness, let us try to delve into following discussion. I did a quick review of paper in PubMed and was fortunate to find series studies re; to HEV in Nepal since early 1980s. For our convenience, let us try to dissect these studies as below:

  1. Literature pre - 2000: Almost all studies were conducted and reported from Kathmandu valley from early as 1980s. Majority of the studies are hospital based done among admitted inpatients supplemented with serological test for its diagnosis. Few studies are also conducted among travellers or expatriate in the valley, Nepalese army in UN mission - Haiti and notably among pregnant women. One study was non human done among local swines in the Kathmandu valley. The findings from these studies suggested that HEV is endemic in Kathmandu valley of significant public health importance and directly relates to poor water, sanitation and hygiene practices. Also, one study reports that local swine population is the host for this disease and suggest HEV as zoonotic illness. Another implication that these studies brings to our notice are that travellers / expatriates visiting Nepal are at risk, thereby this could affect tourism business. Also, there is every likely that the disease could spread to other geographical locations.
  2. Literature post - 2000: All the studies post 2000 add to HEV knowledge that have been gathered from studies in Kathmandu valley. What stands out in these studies is most of them are molecular in nature. These studies have clearly outlined the genotypic profile of HEV circulating in Kathmandu valley. Also, other studies done among pregnant women diagnosed with HEV infection adds to our knowledge that HEV remains serious threat to the health of mother and unborn child. Additionally, one study add that HEV has been detected to rodents in Kathmandu so adding to knowledge that some of the genotypes are zoonotic in origin, which later has implication in designing measures to control and prevention of this illness. Most important is that there was a conduct of HEV vaccine trial among Nepalese army. The vaccine tested in this controlled trial was Hecolin - which is licensed for use in China. 
One contention I would like to bring out and be vocal outright with this background of long history of HEV studies with yearly outbreaks in Nepal, how long do we have to wait for this HEV vaccine? This question will be discussed in next journal entry. Also, I will try to elaborate on following points:

  • Review data regarding the incidence and burden of disease caused by hepatitis E virus infection in Nepal.
  • Review issues related to hepatitis E surveillance and its diagnosis
19 Jan, 2015

Jan 10, 2015

Viral Hepatitis E (HEV) series & Nepal - My memory: Getting yellow with liver pain ( Part 1)

Let us welcome the year 2015 !! My only wish is to turn this year into a meaningful scientific discourse on what I want to learn more about in the field of infectious disease in Nepal. Last year was pretty meaningful that I regularly posted short write ups and sometime, referenced articles, which were related with Nepal. One aspect that I have learnt from blog writing is that we need to be regular and keep writing what pops up in our mind. You know, our mind is so beautiful which is a vessel filled with lots of ideas - interesting, funny, sometime negative silly thoughts. But to introspect the flow of our thoughts and trap those thoughts in black and white letters in a paper is so powerful. This is why writers are born, poets create masterpieces, great scientist work on their simple unique and bold idea passionately. I know, I learnt its value very late but to write with passion, there is no time boundary. You can write anything anywhere and anytime. Just you need to be habituated to carry your pen and a notebook all the time. This is so simple when I say or advise others, "You need to start writing regularly" but for me, this has been a long pause of learning, lots of time wasted just doing nothing. Now when I look back over time alleys, I can calculate the time wasted - now there is no time left to be wasted !!

This first quarter of the year, I have vowed to write about viral hepatitis (viral infection of your liver!!). You know this disease may be new to you and may be you may just brush aside saying, "Well, this is none of my business!!" If you are thinking in that line, wait a minute !! Let me share you my suffering from this disease and you know, you are also susceptible to this diseases. Why? This diseases is rampant in low income settings. Also, you may be avid hiker or trekker and you may have a plan to travel to these countries like Nepal, India. Pakistan. Here this disease is common. When you get infected, whatever a person with strength and stamina you may be, you will be bed ridden so quick that you have to get hospitalized for few weeks. During this illness, you feel so miserable that completely loose your appetite, lethargic, aversion to anything food or even its smell, and you turn yellow including your white of your eye bulb. Oh yes again, this disease is miserable, and it is said, this disease take hold in your body after you ingest food or drinks that are contaminated with human soils. This happens in places, where when there is poor water supply, sanitation and hygiene practices. Remember, this may take the form of outbreaks affecting hundreds and thousands of people. The worst part is if this disease affect pregnant women. There is high chance of loosing your pregnancy and even death of mothers due to liver complications that lead to fulminant hepatic failure and painful death. We know, this disease has not caught much of global attention like recent Ebola Virus Diseases, but remember, this disease is like a silent death that spread invisibly like bush fire with huge toll of illnesses and deaths in developing countries among impoverished population. And you know, I was one of the victim to this waterborne illness fortunate enough to write this piece of story, so if you want to know more of this disease, who could be seriously the best resource than me??

Jan 10, 2015

Dec 5, 2014

Writing plan for Year 2015


Two posts  per month (all together 24 posts in year 2015)


  • Viral Hepatitis E (6 posts)
  • Enteric fever (6 posts)
  • Neurocysticercosis (6 posts)
  • Cholera (6 posts)

  • Epidemiology
  • Diagnostic
  • Surveillance
  • Control and Prevention including vaccines
  • Global health issues 
  • Emerging themes 


  • HEV - Jan / Feb / March - 2015
  • Enteric fever - April, May, June - 2015
  • Neurocysticercosis - July, August, September - 2015
  • Cholera - October, November, December - 2015

Note: Subject to change.

Dec 3, 2014

A Review of my blog - Emerging Infectious Diseases in Nepal

I think, it is only 6 months back - an expert (in what she does) told me " If anything start with passion, that has a serious potential to grow !!" Since then, I am trying to understand what does it mean for me? Especially, my passion is to contribute in whatever capacity in the field of public health. So all those words still ring my head "...has potential to grow" and I have begun to see some glimpse of success for this blog if I seriously write and write for 10 years.

Again to begin from basic - let us start  by repeating the key words:  PUBLIC HEALTH. Well, you may say, this field is very broad and ask me " Where in this sea of unresolved suffering and challenges, which exist primarily because of poor governance or social / economical or political misfortunes brought on to people, is going to be addressed through this public health?" and somebody even dared to say just few days - "You are in the wrong fields !!" Well, to answer these serious questions  are too tough and I do not have a convincing answer at the moment. What I can tell to myself and well wishers that it is my passion that is driving me in this field. This is one thing certain and  rest is history in making. As a glimpse of hope and understanding - now I believe strongly more than ever that this is one area, where we try to deal with any challenges in a holistic approach. This approach believes in "root cause" analysis as it is said in Sanskrit Sloka that " कारणम: कारण", which means "there are reasons for every reason". Therefore, it suggests that we try to solve the root cause of any problem rather than just its symptoms or after we are with the problem(s). It also means, it is fine not to know all the answers, however, in not knowing we can explore for the answer in a systemic way applying the principles of problem solving.

For me, this mantra " कारणम: कारण" has been like a guiding star to move forward and a reason to dream and dare even to ask funny questions. Now, I believe strongly that is a good practice to write down whenever you come across any interesting questions and this can be archive for your future reference. This is the only reason why I have started to blog in my spare time. Here I try to try to organize and note down whatever thoughts or observations or questions related with public health issues come across my work. Also, I have to spell out here, it is tough to be regular and consistent in what you try do - somewhere Aristotle said, " Excellence is a habit". Now, I realize this is one simple truth, which we fail to recognize at earliest. So, I have to say that I tried to blog all the way from early 2009 but the momentum to note down your thoughts / ideas  into real writing took shape only in early 2014. Now, I am serious on writing but still,I am facing challenges when it comes to writing effectively and meaningfully.

Apart from my personal gibberish partly emotions sometime - I am so far happy that I started to blog. My focus in the posts so far published (in this blog) relates to infectious diseases that are rampant in Nepal. I think, I am only qualified to write or share some words or opinion of those infectious diseases which I have seen, experienced in its treatment and think are serious public health problem in Nepal. Say from examples scabies, other skin infections, worm infestation to diarrheal illnesses like cholera. That is why there is a saying in Nepali " दुखी को पिडा दुखिले बुझ्न सक्छ !!" which means the realms of suffering that people living with poverty have to deal with, can only be understood by those who have lived through the same situation. But when it comes to academics or public health delivery, I have to be strictly qualified enough to express my public health competencies that allow me use science along with social, emotional and communication skills.

From now onward, this blog will continue focusing its theme of writing in infectious diseases of public health importance still causing suffering among rural communities like cholera, enteric fever and viral hepatitis.

On Viral Hepatitis E - Part 2

      Causative Organism:
      It is a viral illness caused by hepatotropic (loves to infect liver) RNA virus.

Mode of transmission:

Faeco - oral transmission due to compromised water, sanitation and hygiene

Sign and symptoms:

Generalized weakness / lethargy / nausea and vomiting / Jaundice


Acute fulminant hepatic failure especially during pregnancy


  •          Clinical diagnosis
  •          Serological diagnosis

Preventive measures:
  •             Hygiene (hand washing,  clean water and proper sanitation)
  •             Control of patient, contacts and the immediate environment
  •       Epidemic measure through proper epi investigation
  •       Vaccination (still it needs more research / evidence  for justification to its use in the community)
      More on HEV in Nepal:


Nov 15, 2014

Communication for Development (C4D) - Just an organized thought for Nepal

Situational Description:

Nepal is a land-locked developing country in Southeast Asia with a population of approximately 29.8 million. Around the country, thousands of population still relies on unimproved sources for drinking water. It is reported that 49 % of the total population opt for open defecation, more so in the rural areas (57 %). Only 17 % of populations have sewage connection in urban areas, whereas it is almost non – existent in rural areas. One such district would be "Jajarkot" as an example.

“Tragedy called Jajarkot”

Jajarkot is one of the hilly districts of Bheri Zone in Mid-western Region of Nepal. Khalanga is it’s headquarter. It has 29 village development committee (VDCs). Each VDC has 9 wards which are the smallest geographical units. The total population was 1,34,868 (CBS 2001). Now, the expected population nears 1,51,511 (2009). This district is a confluence of people with different cultural background inter twined with various faiths from majority Hindu population to some who have faith in traditional healers. Jajarkot is also one of the districts in the bottom list with low Human Developmental Index in the country. The poorest people, considered “untouchables” often live in the worst environments, crowded together, lacking adequate shelter, do not have clean water or sanitation, and suffer malnutrition—ideal circumstances for infectious disease transmission. This is the district where thousands of people suffered from cholera outbreak and even hundreds of people died in the year 2009 and 2010.

Key problems to be addressed:

1.      Cholera along with other water borne illnesses is endemic in Nepal. Disease outbreaks 
      affect different parts of the country almost every year during August – October. 

2.   Since for example cholera has propensity to cause outbreaks and ability to rapidly lead to death, if therapy is not initiated immediately. This disease has caused fear in the communities that are and were affected in the past and present. While individual households are burdened by the costs of taking care of the sick, the impact of cholera and similar illnesses in the economy of the state is tremendous. Direct costs due to hospitalization and preventive care to be incurred by the state during epidemic would be huge in amount, while at the same time, it may hit hard the tourism and food industry.

The strategic approach & theoretical basis to solve the problem:

We may apply ecological model here. This model focuses on the individual and the socio - cultural surroundings and environmental factors as the targets for any interventions. People become proactive towards healthy behavior, provided environment and policy support healthy lifestyle. It usually takes the combination of both individual – level and environmental / policy – level interventions to achieve visible changes in health behavior.

Table. 1 An Ecological perspective: Levels of Influence on human behavior
Intrapersonal Level
Individual characteristics that influence behavior, such as knowledge, attitude, beliefs and personality traits
Interpersonal Level
Interpersonal processes and primary groups, including family, friends and peers that provide social identity, support and role definition
Community Level

Institutional factors
Rules, regulations, policies, and informal structures, which may constrain or promote recommended behaviors
Community factors
Social networks and norms, or standards, which exists as formal or informal among individuals, groups and organization
Public policy
Local. State and federal policies and laws that regulate or support healthy actions and practices for disease prevention, early detection, control and management
Source: Karen Glanz, Theory at Glance: A Guide for Health Education Practice, 2nd Edition

Oct 18, 2014

Listen to Whooping Cough

Free Source:

Death from Rabies - terrible death !!


Today, I read death of 13 individuals from RABIES in remote village in JAJARKOT, Nepal (Source; Nepali online news - SETOPATI) . It is said that it takes around 2 to 3 whole daysTo reach Majkot village from district headquarter - Khalanga. Here the whole day of walk on foot means, you need to walk uphill and down hill from early morning to evening till you reach a safe and comfortable village for night rest. Since I have traveled extensively in these part of the district including others like Humla, Dolpa, Mugu, Dailekh, I can say how tough it must have been for those unfortunate and family members when you have to face your loved ones die from this terrible disease, which is viral in origin. This diseases is almost 100 % fatal and there are only few individuals who have survived this disease only through intensive care in big hospitals in developed countries. Rabies is spread only through rabid dog. Even one case of rabies provides us picture of the dynamic of this disease in human and animal interface. While, there was 13 deaths and many other bitten, who were fortunate enough to go to neighboring towns to get vaccinated. Also, there were report of many cattle deaths.

For one health approach to Rabies, we can read an article published in PLOS Neglected Diseases

Sep 29, 2014

Tragedy called Jajarkot in Nepal

Tragedy due to Cholera Epidemic in Jajarkot, Nepal - 2009

Sep 28, 2014

Dissecting the cholera epidemic in Western Nepal

By: Dr. Partha Bhurtel and Dr. Santosh Dahal

Almost three months have passed since a diarrhoea outbreak was reported from Rokayagaun, Jajarkot on Baisakh 20, 2066 B.S. followed by the first death from nearby Sakala VDC on the 21st. The disease has covered the entire district and spread to the surrounding districts of Rukum, Salyan and Surkhet and has cost around 200 lives. Coming back home to Kathmandu after serving for two weeks in the field, we find rampant news in the media about the epidemic.

Things might appear simple from here in the capital city; but the situation out there is bewildering, and the challenges immense. We write this article to share our views and ideas and to give you a factual assessment of the ground realities. 

After more than a staggering 100 deaths and negligently late, cholera was identified as the possible cause of the outbreak. Caused by a bacterium called Vibrio cholera which is endemic to the Indian subcontinent, it is one of the most notorious killers known. The toxins from the bacterium cause the body to pump out water and electrolytes which results in sudden episodes of vomiting followed by severe diarrhoea classically described as rice water stool. Severe disease can be rapidly fatal with infected patients sometimes dying within three hours. Commonly, the disease progresses from the first liquid stool to shock in four to 12 hours, with death following in 18 hours to several days, unless oral rehydration therapy is provided. Numerous risk factors must come together for an epidemic to flourish. 

The source of the contamination is typically other cholera patients when their untreated diarrhea discharge is allowed to get into waterways or into the groundwater or drinking water supplies. In Jajarkot, lack of personal hygiene, proper sanitation and clean water supply, delayed medical care seeking behaviour, difficult terrain and lack of awareness serve as a fertile medium for the epidemic to flourish. 

People practice open-air defecation. Their faeces are washed into the drinking water sources by rain which further perpetuates the disease in the village and downstream areas. Interestingly in Jajarkot, the disease was initially concentrated in the hilly upstream northern and eastern areas of Rokayagaun, Sakala and Bhagwati which then shifted south and southwest to involve the entire district, Rukum, Salyan, Surkhet and Dailekh as the monsoon started. People do not wash their hands with soap after defecation, before eating or cooking; so a simple handshake or utensils often washed in the same contaminated water can be the source of infection. Daily travel by people among VDCs is also probably an important mode of transmission. 

People drink water from contaminated open water sources and rivers mostly without boiling or any sort of treatment. Even students of Class 12 who have been taught to drink water after boiling from childhood, fail to do so even in the midst of an epidemic as it is unpalatable due to a change in taste as per the people. In some areas, the only option is to drink water from the Bheri River containing human waste from upstream areas starting from Dolpa. As it is the peak planting season, farmers leave the sick alone at home or ignore a few episodes and work till cramps set in. By evening, the patient is already too sick to be rescued. Oral rehydration solution (ORS) is not available in villages outside health facilities and people do not buy ORS. Most people do not know how to make ORS. Often, you can see children licking it straight out of the packet or people boiling it. Steps to rehydrate are rarely taken due to complete lack of awareness, and the patients are severely dehydrated by the time they reach a health facility. Even if ORS is administered, as the water is contaminated all it does is increase the toxin load. Also, the fear of cholera is tremendous. People often abandon or lock patients in dark rooms to die fearing infection if they touch them. In this favorable interplay of factors for epidemic perpetuation, the government and various agencies are making a tremendous effort to fight it.

The government has deployed health personnel to provide curative services in most of the hotspots of the district. After initial hiccups, a system has come into place, and the work is running smoothly. The District Water and Sanitation Office along with UNICEF and locally active organizations is making an effort to supply chlorine tablets for water purification to households in the affected areas in Jajarkot. The government is campaigning through local FM radios and pamphlets to promote preventive practices. A few teams of health workers have set out on foot from the district headquarters for door-to-door campaigning. Meetings have been held for recruitment of locally available trained personnel and empowerment of Maternal and Child Health Workers and Female Health Volunteers for both treatment and prevention. The People's Liberation Army and the Nepal Army too are working together in the field. However, despite these efforts, the epidemic has not been brought under control due to a large number of factors.  

The most important area where we are lacking is expectant prevention in vulnerable areas most likely to be hit by the epidemic in the future. Our efforts seem to be concentrated not on the cause but on tackling the disease with curative services after it has already spread. It was surprising that even after nearly three months, there was no data on the number of cases of diarrhoea in the district, no epidemiological diagnosis, calculation of attack rates and case fatality ratios and no epidemic mapping. A simple mapping would have predicted that the disease would move into Rukum, Surkhet, Salyan and Dailekh more than a month ago. 

Tremendous efforts could have been put into awareness campaigns regarding hand washing, faeces management, handling of the sick and dead, constituting ORS solution and soap distribution and water purification campaigns to prevent its spread. It can still be done to prevent the epidemic from involving the entire mid-west. Without prevention, the epidemic will not stop till it takes its natural course as medical teams frantically try to save lives and we helplessly hear news of more people dying. Prevention itself will require huge mobilization of resources and it cannot be achieved without social mobilization, community participation and help from all sectors of society including political parties. For example, Jajarkot is a district with 32 VDCs with 35,000 households. The VDCs are large and require more than a day's walk to cover them. So, imagine the amount of human resources and medical supplies required to conduct a campaign in all the affected districts. 

Lack of coordination and clear channels between various government agencies slows all work and time is consumed in endless meetings. For example, the budget comes from Home Affairs, the medical personnel from the District Public Health Office (DPHO) and the helicopter from the army, each of which follows their own chain of command. The DPHO has already spent its disaster budget Rs. 1.5 lakhs in Baisakh itself and has no money left for the purpose. This should be solved by creating a decentralized Epidemic Response Unit with strong leadership, decision-making capacity, all necessary resources, clear organogram and efficient communication network with people in the field. A strong feedback system is needed so as to update the number of cases, identify key focus areas and drug and medical personnel requirements. Without a feedback system, all efforts will be like pouring water into sand.

A clear treatment protocol is lacking in the field. It is necessary in epidemic situations to ensure uniformity and adequacy of treatment. Its lack often leads to under or overuse of fluids as most health workers do not remember the exact formula for fluid calculation. The organisms serotype and antibiotic sensitivity is still unknown. This is a major deterrent in providing an antibiotic protocol. This is leading to over-prescription of antibiotics increasing the chances of emergence of resistance, which, if it occurs, will pose a problem beyond our imagination as we will be left without effective drugs to treat them. A single page protocol on use of fluids and antibiotics to all health workers would easily solve the problem. 

The management of medical supplies was seen lacking in the field. Since the boxes of drugs had come unlabelled from different sources, their content was not known. The distribution of resources was haphazard. Also, often the most important drugs like doxycycline, injectable ciprofloxacin and metronidazole were not present in required amounts. Lifesaving nasogastric tubes, which can be used to administer fluids even if no IV access is established, were altogether missing. After the prime minister's visit, all medicines have been flown to the District Hospital at Khalanga and are being distributed by medical personnel serving there, so we can hope for better distribution now.

The management of health professionals has been far from satisfactory. Most of them had left on an hour's notice from Kathmandu or Nepalgunj, some without any money, with the understanding that basic supplies would be provided in the field. However, they were dropped by helicopters virtually into the dark without any orientation about the district, treatment protocols, emergency survival kits, tools for communication and feedback, provisions for food, place to stay or any assurance of evacuation should they themselves fall ill. None were told that they would have to walk back for days to return. Some of the medical personnel from Nepalgunj and Kathmandu left as the government was unable to deploy them even after a frustrating wait of four-five days. Hats off to the medical teams working in the rugged villages, sometimes living in tents flooded by rain, fed by villagers who themselves depend on food supplied by the World Food Programme. 

One of our friends deployed at Archani VDC has been out of communication for days. The VDC has no modes of communication and is a two-day walk from the district headquarters. Some health workers had returned after controlling the disease in their area and often staying longer than they had promised. It is sad that instead of expressing gratitude and making provisions for their return, the health workers were said to have run away by the district officials to hide their inability to provide continuous recruitment of health professionals. The verbal diktat by the prime minister asking officials to prevent health workers from leaving did not help either. 

How humane is it to expect professionals with jobs and commitments to work in the district for months without any efforts to ensure the security of their lives? How difficult is it to carry a few bags of rice, lentils, blankets and provide a CDMA phone or police personnel with a radio with a solar charger to a health team being dropped by helicopter? Organizations are ready to provide a constant supply of personnel on a rotational basis. If manpower is needed on a long-term basis, there is a team of 150 doctors waiting for their Lok Sewa results which have been delayed for months. Why not bring out the results and recruit them for a liberal time period? However, the important fact is that no health personnel should be deployed without orientation, establishing the fact that he/she can walk, can survive on rotas and chillies, ensuring an emergency survival kit, food provisions and most importantly money and a means for communication so that they can provide constant feedback. A provision must be in place to arrange for their evacuation if they fall ill. Maybe the focus should shift to hiring locally available manpower, who can carry a few bottles of saline, IV lines, ORS, chlorine tablets and walk across the district giving initial treatment to the people, referring them to a health facility, and also conducting awareness campaigns along the way. 

The difficult terrain, sparsely scattered population and lack of roads is a big deterrent too. It is difficult for a health worker from Kathmandu or Nepalgunj to walk for hours on narrow, rocky, slippery tracks full of leeches in the rainy season. It is practically impossible for the government or the health workers to knock on each and every door to check for sick people without community participation. Most deaths have resulted in remote pockets of the district. The multiple deaths from a single family in Majkot occurred as the family lived at a distance of a six-hour climb from the nearest health facility.  
Despite all the shortcomings, we must appreciate that the people in the field are putting in their best efforts to fight it. It is very easy for us to sit in Kathmandu and say that Jeewan Jal, antibiotics and saline are all that are needed to control the epidemic. We need to wake up and realize that the challenges are immense, and working in the field is very difficult. It is extremely hard to reach a sick family on a hilltop which is a six-hour walk from the health facility or to change the lives and habits of people in days. This epidemic can be overcome only with Herculean efforts. We need to reassess our efforts, strategies, constantly evolve and move ahead. The focus should be on prevention. The media has played a huge role in generating awareness regarding the epidemic, it needs to play a greater role, the role of a leader, recruiter, and should provide information about ground realities. The entire nation should unite and take up the responsibility. In the end, a big dilemma is in front of us — whether to pray for the monsoon to stop which could help in halting the epidemic or pray for it as large swathes of the country lie barren. Whatever happens, let us all unite and contribute.

Fear of cholera

Dali. A women fell ill due to diarrhoea in a village six hours' walk from the Dali health post. Her daughter, who was working in the field, came back home due to diarrhoea and found that the mother was sick. None of the villagers helped to take her and her mother to the health facility. The mother died. The villagers locked the daughter in a dark room with husk and covered her with a blanket and took the mother to the river to perform the last rites, a two-hour walk from the village. Across the river lies Rari, Rukum where a health camp has been set up to tackle the epidemic. After the mother had been cremated, policemen saw the villagers putting out the fire. They asked them why they were putting out the fire. The villagers answered that they were saving wood as another person was ready to be cremated in the village. Luckily, the police rushed to the village and found the daughter in the dark room barely breathing and rescued her. While running to the health camp, the policemen said that the girl's blanket was drenched in stool which was falling in drops. The girl received treatment and survived.

Dhime. The team in Dhime heard that Gyanendra Sharma, a leper who had been previously kept at the District Hospital at Khalanga for one year to treat his rotting foot four years ago, was suffering from diarrhoea. On reaching the house to rescue the old man, volunteers saw no one in the house. They found the old man in a dark room, naked and covered in faeces. They asked the family to clean him up so that they could rescue him; the family refused and he died.


  1. The Kathmandu Post, August 2, 2009

Sep 18, 2014

Dhaka Declaration on control and elimination vector-borne diseases from WHO - SEARO region

This is one good news that I would like to share with all readers engaged with public health activities in South Asian countries. Recently, there was held (a) Thirty-second Meeting of Ministers of Health of WHO’s South-East Asia Region (b) Sixty-seventh Session of the Regional Committee for South-East Asia in Bangladesh on 9 - 12 Sept, 2014. This meeting is encouragement for all those professionals working in the field of vector diseases control and elimination in this area. It is reported in WHO - SEARO offical website: "Health Ministers commit to control and eliminate vector-borne diseases"

Link and source of information: 

Sep 12, 2014

On #Cholera #Nepal

Sep 11, 2014

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!!

Source: Anuj Bhattachan
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.

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

  1. There are parents, family or community,  who will walk for hours and hours to get their children vaccinated,
  2. There are parents, family or community, who wants to vaccinate their children but they are not aware “where and when” to vaccinate
  3. There are parents, family or community, who will vaccinate their children but are busy with family works because they have to worry about what to eat next day more than getting their child vaccinated.  
  4. There are some children, who are in the wild playing happily. Many of them are “Zero Dose” which means that they have not received even a single dose of vaccination.
There is another socio – economic aspect of a community which does affect the health of the family as well as to reach them. In South Asian society, there still exist millions of people considered “untouchables”. These people are perennially pushed at the lowest of low in the socio – economic strata. The children from these communities are usually those who are either “Zero Dose” or “incompletely” vaccinated. And it is in this community, where most of the disease outbreak occurs.

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

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

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

Anuj Bhattachan

12 Sept, 2014

Anuj in Himalayas

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