Lesson learnt from diarrheal outbreak in Nepal

Lesson learnt from diarrheal outbreak edcd from DPNet

Writing plan for Year 2015

Goal: 

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

Focus:

Diseases

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

Area

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

Schedule

• 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.

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

Complications:

Acute fulminant hepatic failure especially during pregnancy

Diagnosis:

•          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:

      1. http://www.kumj.com.np/issue/16/530-544.pdf

      2. http://link.springer.com/chapter/10.1007%2F978-4-431-68255-4_104

Refer to Part 1: On viral hepatitis: http://anujinhimalayas.blogspot.kr/2014/07/on-viral-hepatitis.html

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
Concept	Definition
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

World Polio Day 2014

Listen to Whooping Cough

Free Source: www.youtube.com

Death from Rabies - terrible death !!

  Source: http://www.cdc.gov/rabies/resources

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
Link: http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0003270

What Will It Take to Achieve Both Healthy Children and Healthy Economies? - Webcast WBlive Source

Affordable Easy 2 Use Diagnostics are what we need !!

Great news - Vaccine against Hook worm !!

Spent a great day @sabinvaccine headquarters in Wash DC reviewing our phase 1 human hookworm vaccine trial results http://t.co/SKSxpalld4

— Dr. Peter J. Hotez (@PeterHotez) October 8, 2014

Tragedy called Jajarkot in Nepal

Tragedy due to Cholera Epidemic in Jajarkot, Nepal - 2009
Source: www.volunteernepal.com/blog

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.

Source: 

1. The Kathmandu Post, August 2, 2009
2. http://www.ngoforum.net/index.php?option=com_content&task=view&id=6867&Itemid=6

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: 

1. http://www.searo.who.int/mediacentre/releases/2014/pr1580/en/
2. http://www.searo.who.int/mediacentre/events/governance/rc/67session/en/

On #Cholera #Nepal

Control of #cholera in #Nepal is eminently possible w/ the tools, like #vaccine, & knowledge available today. Blog @ http://t.co/9nUOkTU5fn

— DOVE Project (@STOPCholera) September 9, 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.”

Source: http://www.wired.com/2013/06/how-to-design-a-life-saving-device/

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

Bat Flight and Ebola Connection

http://www2c.cdc.gov/podcasts/player.asp?f=8632573

Dalit Reality - Poverty and Health

Dalit (दलित) =  untouchable (अछुत )

Watching this video on Dalit reality, I am angry to what goes around us.

Yes, "anger" can be natural response to protect yourselves or even your family from  "outside" dangers or can be a plethora of emotional expressions that explodes out of an individual or a community !! Here, my "anger" is a symbolic representation of what is prevalent in our society as of this year 2014. I know, anger is said to be negative energy but how can you justify not to be angry, when some souls are treated less than animals !!  I am angry at this caste system, which has pushed certain segment of your community to the bottom pit of the socio - economic ladder. In this bottom pit of the social ladder, they have forgotten to even dream or even utter a word to express their pain and sufferings, because their mental process is so clouded with fear, everything seems impossible !!

Before proceeding further, let me be very clear upfront, the purpose of this 'anger" is not to point finger or muscle flex at anybody. This is simply to turn the negative energy (that boils in your psyche) to a positive outcome that benefits all of us. So, the best way is to write what comes in your mind and what you have seen in your community. This is what I am going to do. After all, writing is so powerful !!

Today, it is gloomy outside and is raining, so I have decided to write on this (un)social, unjust or even barbaric act that exist and still goes unnoticed in our South Asian society especially India and Nepal, where millions of socially marginalized people live in abject poverty to this day. To be a bit balanced or fair to all those social activists and government agencies, who are working or advocating  tirelessly in this area,  some of these practices may go noticed and treated lawfully but this is just a "centimeter" of journey, when we need to travel "kilometers" of proverbial rough road to eradicate such social practices. Therefore, I am pretty sure that i will not be overstating when I say, "The practice of untouchability is still rampant all over the country." This is what I can say of Nepal !! 

Photo - Anuj Bhattachan (verbal consent +)

As an example, let me share a story I usually come across in various parts of Nepal. Here, I would like to share an anecdote of a Dalit family (as shown in the picture above) that I had to come across in Sankhuwasabha in Eastern part of the country. This was in the year 2008, the month of rain. I had to visit one remote village since there was a report of measles like illness outbreak, so I had to travel all the way on foot for 2 whole days. Sometime, we had to walk for hours uphill and sometime, walk downhill for hours straight to river between a gorge. We had to cross the river in an old leaky boat. 

Once we reached the village and responded to the outbreak with necessary preventive measures including samples collected to confirm the diagnosis. The local office aid from the health post advised her to consult with me. The health professionals who were supposed to be serving this unfortunate people were on long leave, and the health care delivery was the mercy of the health aid. Utilizing his knowledge and experience, he did what was supposed to be done for any kind of illnesses. At least, he was there to be beside these people in their sickness. 

Photo - Anuj Bhattachan (verbal consent +)

On that day, I came across a young girl with a worried face in a dirty clothes covering her whole body (shown in above picture). From my cursory assessment, she was in a terrible situation and top of it, being a girl from a Dalit family. She was taken to local health post after everything done to cure this skin lesion failed. Her parent told me they applied all kind of herbal ointment suggested by locals. In the health post, there was not enough medication and trained health personal. The health aid was the only guy to dispense whatever medicine was there in their cubicle. When I asked them, " What is the white ointment applied in her weeping sore?" To my surprise, it was paracetamol (anti fever drug) applied in its powder form (after they grinded the tablet) !! No comment further, I carefully examined her and came in a conclusion that she was infested with scabies.  Once the disease was recognized, the girl including family members were advised what needs to be done. I knew, if i prescribe the anti scabies drug, it would be difficult for them to purchase it. So we arranged a way that she gets the drugs and all the members also gets necessary precautions.

Photo - Anuj Bhattachan (verbal consent +) 

What stands out from this story is social ills that keeps people perennially poor & illiterate. In this environment, we are bound to suffer from every kind of exploitation, so women suffers the most. If women suffer, their children also suffer. This is where every kind of diseases take root like scabies, tuberculosis, worm infestation, skin diseases, and many others - you name it and you will find it. Therefore, I am of the opinion, it is only through healthy dialogue and discourse that we can bring change in the society. The change that accommodates people's aspiration for equal opportunity and treatment. This is one of initiative to start dialogue and discourse in this area of social justice, which is root to any kind of disease dynamics. This is one of my realization over the years. Now, i think, i have matured enough to justify my graying of hair. May Wisdom Prevail !!

17 Aug, 2014

Let us know more of Ebola Virus Disease (EVD)

This year 2014 started with accidents or vanishing of Malaysian Airlines (no one knows where !!) and recent sinking of a ferry carrying school children heading for Jeju Island, South Korea. We were trying to forget this sad event, now we are bombarded with news about Ebola Outbreaks in some African countries, mainly Guinea, Sierra Leone and Liberia. I am particularly interested in this news because of my personal interest scanning anything that are emerging and re - emerging diseases in literature or social media.

Though we may think, these African countries are far  away from us, so we may plainly say, "Why do we have to worry about it?" On contrary, we need to get worried. First, humanity is suffering and dying from this disease. Second, we can not rule out that this disease may spread to other continent if ecology favors it circulation. I feel, therefore, the argument, " We are geographically distant so we are not at risk" no longer holds true !! To support my point, we can talk of recent cholera outbreak in Haiti that preceded a major earthquake that ravaged whole of the country in the year 2010. This was one of the worst disaster of massive scale that human kind has to face and deal with. This natural disaster affected thousands of family losing their near and dear with high death tolls.

Once Haiti was hit by cholera outbreak, the detailed epidemiological investigation(s) along with massive humanitarian relief activities was carried out by various international organizations and universities. It was reported that the bacterium was introduced into the country by those who actually came their for humanitarian assistance in the country. This brought about lots of academic as well as political debate, which is still haunting United Nations. Some academicians asserts that the organism was introduced in there from Nepal based on genotyping study.

Let us not go into dispute and argue who brought this bacterium or who did not and play political game. My main point here is - we are now living in a global village. Our travel time is much reduced, it is also said humorously that "Nowadays that we can have dinner in Asia and Toilet in Europe!!' Partly, this is a fact, we may like it or not !! Another popular saying that floats among disease detectives is that "lethal organisms do not need passport like we humans need!!" and to add some experts even say, " Some of them even evade immigration very easily" This two statements really stress that no body is out of danger. Infectious diseases can travel across continents in disguise.We have to be extra vigilant more than ever.

Ebola virus (source: commons.wikimedia.org)

Ebola Virus Disease (EVD) is caused by Ebola virus (EV). This virus is named after Ebola river in Zaire (now DRC) and first reported in 1976. There are five species of  EV and are named after their place of origin: BundiBugyo, Sudan, Reston, Ivory coast and Zaire. This disease spread through close contacts with
blood, secretions and other bodily fluids. It is said that EVD is highly contagious and fatal. This virus circulates in animals population - Bats and primates such as Chimpanzee and even deer. Human are accidental host. (Please look up at he EV Ecology below). There is no medicine or vaccines for this disease. Some experts say that this is the result of human economic activities interfering with natural habitats. So, this is unfortunate, the people have to face this deadly diseases on top of economic hardship in low economic setting. This outbreak this year has caught many international newspapers' headline, however, I am interested to understand the gravity of this disease outbreak myself.

Source: http://www.cdc.gov/vhf/ebola/resources/virus-ecology.html

Another thought that I am playing with for these few days -" What does this outbreak means to other countries in Indian subcontinent like Nepal?" As I read in MSF blogs, EV circulates in fruit bats as its natural host and these bats are found in this continent as well. As of now, we have no report of EVD here. We should remember, there are similar kind of viral illnesses linked with fruit bats that feeds on cell sap of a tree. This are Nipah and hendra virus. These viruses have been reported from Bangladesh (to my knowledge), which is just few km away from Eastern border of Nepal. Therefore, my only concern is whether this EV can get introduced in this geographical region? I need to better understand this disease through literature. My only wishful assumption is EVD  is still geographically at distance and may be, the ecosystem here in our continent does not favors for EVD to spread. To understand more of Ebola, please visit: 

1. WHO website - http://www.who.int/csr/don/archive/disease/ebola/en/
2. CDC website - http://www.cdc.gov/vhf/ebola/outbreaks/guinea/
3. PLOS Neglected Tropical dieases - http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003056