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Sep 30, 2014

Tragedy called Jajarkot in Nepal

Tragedy due to Cholera Epidemic in Jajarkot, Nepal - 2009

Sep 29, 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

Anuj in Himalayas

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