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, 2014Sep 12, 2014
On #Cholera #Nepal
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!!
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| 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.
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| 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.
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| 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:
- There are parents, family or community, who will walk for hours and hours to get their children vaccinated,
- There are parents, family or community, who wants to vaccinate their children but they are not aware “where and when” to vaccinate
- 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.
- 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
Aug 22, 2014
Aug 17, 2014
Dalit Reality - Poverty and Health
Dalit (दलित) = untouchable (अछुत )
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 !!
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| 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.
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| 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.
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
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| Photo - Anuj Bhattachan (verbal consent +) |
17 Aug, 2014
Jul 31, 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 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.
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:
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:
- WHO website - http://www.who.int/csr/don/archive/disease/ebola/en/
- CDC website - http://www.cdc.gov/vhf/ebola/outbreaks/guinea/
- PLOS Neglected Tropical dieases - http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003056
Jul 27, 2014
Jul 24, 2014
@WHO @Hep_Alliance sharing my story on viral #hepatitis #Nepal and want to contribute #ThinkHepatitis writing http://t.co/yywncaRfGP
— Anuj Bhattachan (@Yeti4mNepal) July 24, 2014Jul 22, 2014
Remembering Dengue Fever
True, Dengue is a fatal disease and can fetch you to intensive care unit in few days. This viral illness is spread by the bites of Aedes mosquito, particularly A. aegypti.The infected mosquito harbors Dengue virus (DENV). It is commonly reported that DENV consists of 4 stereotypes. However, there is a recent report of fifth serotype. Text book writes that the illness starts with fever, headache, muscle ache and joint pains, which is followed by "blue patches" suggestive of decrease in platelet counts. We need to remember that platelet is important for blood clotting process in the body, so its compromised number can lead to severe bleeding problem. Notoriously, we call this situation as Dengue Hemorrhagic fever (DHF), which can even take one's life if not treated timely or properly. Another remarkable feature of this disease is said to be the intensity of its pain so people have remembered it as "Break Bone Fever" in some community. These days, we have enough pain killers available in health post or clinics, so we may alleviate ourselves from this intense pain. However, I can imagine, there are still pockets of community in low income countries, where people are devoid of access to even paracetamol !!
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| Source: www.facebook.com [Yugesh Dhungana 22/July/2014 |
Those who have survived this disease truly know the suffering in and out - bed ridden, weak even to walk, dizziness, nausea and vomiting, bleeding from your orifices or impending fear of losing your life. For some of us, this may sound pontificating on your thoughts, but this is what a friend of mine has to say recalling his good memory intermixed with period of illness, diagnosed as suspected dengue fever. Here is how he reminisces the disease, " Today, I observed my profile picture keenly and discovered a lot of changes on me. This was the photograph of mine when I was on a first honeymoon trip to UK, India....from where I caught DENGUE (manifested, I would rather say)....a narrow escape from death with platelet count plummeting to 30,000. I look thin n young....subtle changes over four years has given a cumulative difference turning me more plethoric n wrinkled. Everyday, ageing engulfs us deducting each moment from life's tenure. That's why BHUPI ( Nepali poet) once told...HAR DIN JINDAGI CHHOTIDAICHHA YASARI NAI, TOOTH PASTE JASTAI..!!"
In Nepal, all 4 serotypes of DENV have been reported through government reports and journal publications. Therefore, Dengue is not anymore a new exotic disease in our part of the world. Yearly, we hear and read news reporting of suspected or confirmed outbreaks of Dengue fever in Terai (East to West). It is said, Dengue is related closely with urbanization and weather. So, we read that most of the outbreaks occurs in cities. Now, we also fear and already starting to hear the spread of DENV in hilly districts. Now, majority of the districts in Nepal are linked with roads, so there is easy mode of transportation within matter of hours. You can imagine, it used to take days and days to travel from hilly districts to Terai but now we can travel in a matter of hours. This expose us to importation of various diseases through person to person or through vector like mosquito. Another important global phenomenon that has contributed to the dynamic of vector borne diseases is climate changes - increasing temperature, further compounded by increasing population density and rapid urbanization. Therefore, we need to act fast reasonably and in SMART ways so we can do away with these emerging illnesses, which we can control and prevent, otherwise let me say - more of such stories where this disease will leave no one - rich or poor !! To end this short scribble on DENV, there are some encouraging news, we can hear that DENGUE Vaccine availability to the population is just few years away. There is a recent press release (11 July, 2014) that particularly says that clinical phase III trail on DENV vaccine has shown encouraging results.
Anuj Bhattachan
22/July/2014
Jul 16, 2014
I got INVITE to write !!
Now, I am back from 3 weeks of home leave. As always, I reached office early in the morning and checked e - mails. Hundreds of mails !! I patiently scrolled through all and responded to those urgent and organized the rest in files. Today, I am particularly interested in one mail sent by Linkedin .This is an invitation to write. Wah...For me this is so important that I am excited but whenever, i think of writing I go through a kind of "uneasiness" how to start and what to write? Nonetheless, I am getting a dominant positive thought that this must be the beginning and I should act on it. After all, each of us improve and start doing well only after continuous practice. There is no shortcut !!
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| Source: https://www.google.com.np |
To begin, I have to be honest, I am not a professional writer. However, one thing is common to everybody and that is, everybody has something to say - that is STORY of their own. Also, we have to start somewhere early in your career or late. It does not matter, how good or bad you write. My only intention here is to write, write and write. Nothing more, nothing less !! So let me start by saying that i am going to write whatever comes through my mind. After all, it will not be any worthless irrational thoughts.
Story begins. This time, I planned my leave in different in a way. I planned about it a month back. As always, early planning makes everything better in terms efficiency and it saves lot of time & of course, your money. Above all, one important feeling has taken over me and realized after returning back to Seoul that this trip is in a way spiritual journey. Seeing the dire situation of our country and all the cacophony that your hear has made me in thinking mode. What next?
To forget those noises and begin the journey of hope, let me briefly walk you through short reminiscence of my childhood and professional career that started from Nepal and now in Seoul. I come from a rural mountainous part of Nepal. Like any child, I had many dreams like joining British Gurkha army or be a trekking guide. As time progressed, I completed high school and lucky enough to enter a university in Kathmandu, where I got inspired to study science and dreamed of becoming a doctor. I studied hard day and night. Somebody rightly said that "luck favors those prepared mind". I was lucky because I prepared hard and entered a government medical college. It was here that I understood the value of health research in order to expand our limited knowledge.
On completion of med school, I worked in a hospital in eastern part of the country for a couple of years. Here, I come across face to face with various infectious diseases as a result of poor drinking water, sanitation and poverty like acute diarrhea, pneumonia, malaria, measles like illness, poliomyelitis, tetanus, rabies. During this period, I would say, I partially understood the nature of diseases of the impoverished, so I took up a jot at WHO – Program for Immunization Preventable Diseases, Nepal. As a surveillance medical officer, this job required application of core public health competencies, which is a combination of social skills and knowledge based on evidence. I had to manage Vaccine Preventable Diseases (VPDs) surveillance, conduct mass vaccination and investigate disease outbreaks & reports of adverse events following immunization. During this job, I realized, I need to develop myself further in the field of health research.
Fortunately, I got an opportunity to work for International Vaccine Institute (IVI) that requires skills and knowledge in clinical development of vaccines for fighting diseases that mostly affects children in the developing countries. To further my career, I have cherished a dream that I am able to master health research skills, so I can train more health professionals able to conduct quality health research in Nepal.
In tweetosphere
Our recently published study on #cholera in #nepal - epidemiology and #antibioticresistance of V.cholera. http://t.co/lZaEDf3LCb
— समीरमणि दीक्षित (@smadixit) July 15, 2014Jul 12, 2014
On Viral Hepatitis
The World Hepatitis Day is celebrated worldwide on 28th July, 2014. This day is organized by World Hepatitis Alliance. I would like to take part and contribute in whatsoever capacity I can in order to make this day meaningful. For me, this day is personal because I know what does it mean to suffer from viral hepatitis. Like me, millions of people even today suffers or have suffered from this preventable disease due to various reasons.
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| Courtesy http://www.worldhepatitisalliance.org |
First let me take you through my personal suffering as a result of viral hepatitis in early 1990s. At that time, I was studying in Kathmandu University, which was then located in Hadi Gaun in the valley. In the university, I was studying science (biology, chemistry and physics) aiming to be a doctor. It was in the second year, I caught jaundice and got confined to bed for almost 3 weeks. I was profusely vomiting and white of my both eyes became yellowish including skin. Commonly, people also call it as "Jaundice", where your white part of eye and even to some extent your skin turns yellow due to increase in "bilirubin" pigment in your body. I felt so weak and my appetite was so poor that I could not even tolerate the smell of food and walk few steps. During this illness, I took care of myself with pure restriction of those foods that were said not to be eaten or avoided, instead had to rely on boiled vegetables and glucose reach sugarcane juice or papaya fruit. Slowly, day by day, I recovered from this illness and regained my strength and started to visit university class again. Looking back, now I realize, what it means to suffer from this preventable illness. I also came to know that I did suffer from viral hepatitis, which may have been be either type A or E [ Note - Here, I have omitted anything about type B and C - this was not the type I contracted. However, I acknowledge that type B and C are even more notorious in its nature]. At that time, I was taken to local Vaidya (medicine man), who prescribed me herbal remedy. I took those remedy regularly with food supplementation. Now, I know that this viral illness is self limiting infection as a result of compromised water and sanitation. Somewhere in the chain of event, I must have got infected with this water borne illness. May be somewhere in the restaurant - where food hygiene must have been compromised.
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| Structure of Hepatitis E virus Courtesy http://www.medgadget.com/ |
Now, let me walk you through a public sphere and understand what happens when this same disease spreads in a community, where water and sanitation is compromised that is common in low income settings. In my last blog post May 2014, I wrote a briefly on "Increasing Reports of Enteric Diseases in Nepal". In that post, I stressed more on acute viral hepatitis outbreak that created news headline in national media. This outbreak was reported directly from Biratnagar, a city in Eastern part of Nepal. This outbreak created fear in the center of the city and caused huge toll of morbidity and some deaths. Some people said that whole town was frenzy due to this outbreak and everybody both rich and poor vulnerable to this illness. The sample tested were found to be hepatitis e virus. As per World Health Organization (WHO), this disease affects globally 20 millions of people every year, around 3 millions get acute hepatitis and - 56,600 hepatitis e related deaths. Apart from its morbid nature, this virus can sometime lead to acute fulminant hepatic failure, which can even take someone's life. It is reported that hepatitis e infection during pregnancy is the gravest danger posing threat to the mother's life. This illness is, as I already mentioned, more prevalent in low income setting like in South Asia or Sub Saharan countries. I therefore say that this is public health problem that we can do away with clean water, proper sanitation and health education. However, I see such improvement in providing clean water and improved sanitation takes time, given the current socio - economic landscape.
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| A child with jaundice Courtesy http://www.med4al.com/ |
Nonetheless, the best health policy is to impart people with health education on importance of hand washing, boiling water and visiting health professional if we get infected with this preventable illness. WHO also report that there is availability of vaccine against Hepatitis E & Hepatitis A. Vaccine against A is available. It is recommended to use in outbreak prevention in conjunction with improvement in water and sanitation. Regarding Hep E, China has produced and licensed the vaccine, but it is not widely available globally. There must be various reasons why this vaccine is not available in other countries. Finally, I feel, it is the common right of people living impoverished get safe, effective and affordable Hep E vaccine and this is what whole world is waiting for !!
Anuj Bhattachan
12 July 2014
Jul 9, 2014
@Africhol @NewIndianXpress thanks for sharing this success story on #cholera #vaccine & #Vaccineworks http://t.co/510xCNVUKs
— Anuj Bhattachan (@Yeti4mNepal) July 9, 2014Random thought - Global Health and Diseases of impoverished
We are living in
21st century, the age of supercomputers. Or you may call it - the age of big data. So, for some of us, diseases
related with poor water / food supply and sanitation may sound as a story of
medieval period. You may also say, "I read only in a book !!" However, it is a fact that millions of people are still living
with abject poverty and millions of children have to lose their life before
fifth birthday. Even if we go through
pages of our history, we have faced global pandemics that created havoc across
Europe to Asia. Millions of people lost their invaluable life to cholera, flu
pandemics, smallpox, tuberculosis, and thousands of children got handicapped
& live crippled life due to paralytic poliomyelitis. On positive note, to be fair, we have also successfully
controlled, eliminated or even eradicated many of these infectious diseases with
the use of vaccine and public health measures since science took its foothold
in the society from early 1900s. As an example, the greatest achievement in the
human history is the eradication of small pox so far. The last case of this
disease was detected in Ethiopia in 1980s. Now, we are almost nearing
poliomyelitis eradication from the globe. In the backdrop of this success
story, however, people in developing countries are still fighting death and illnesses
caused by waterborne, airborne and vector borne diseases (in whatever capacity
they can!!) through local and modern remedies available. But, the only challenge, this is further compounded by
increasing population density, deforestation, climate changes, increasing numbers
of multi – drug resistance bacteria, urbanization and poverty. It is reported that millions of children
still miss regular vaccination either zero dose or incomplete dose. The reasons are simply related with a big gap in access
and utilization of vaccines that are available through government health care
delivery services. This means that all these missed children are "at increased
risk" of vaccine preventable diseases and thus, outbreaks in the community.
These unfortunate missed children are usually from poor family, especially
tribal community or millions of so called "untouchables", who are pushed to the corner of social ladder always "under – privileged" and illiteracy rampant. So,
we have a mission to reach these "High Risk" populations and provide them access to safe, effective and affordable vaccine
against diseases of impoverished using science as its means. Our ultimate goal therefore should be to transcend vaccine science research from laboratory to the reach
of community in high risk areas of developing countries.
Anuj Bhattachan
9th July, 2014
Jul 5, 2014
Vaccine development: thinking out of the cold box http://t.co/6m0J5JL4uF via @guardian
— Anuj Bhattachan (@Yeti4mNepal) July 2, 2014Jul 1, 2014
28 July, 2014 - World Hepatitis Day
@IVIHeadquarters currently, there is a vaccine to prevent #hepatitis E, but it is not widely available, let us discuss more
— Anuj Bhattachan (@Yeti4mNepal) July 1, 2014May 31, 2014
Increasing reports of enteric diseases outbreaks in Nepal
These days, we are frequently hearing news related to outbreak of waterborne illness, particularly acute watery diarrhea (in short AWD). Among all acute diarrhea l illnesses, CHOLERA is notoriously known for its outbreak potential with high morbidity and mortality in the community. It is said to be the diseases of the impoverished, so this is more common in low income settings, where water and sanitation facilities are compromised. Notably, this disease is also common where there is natural disaster like earthquake & floods compromising the quality of drinking water e.g. Haiti. However, there is rise in outbreaks compounded by man made disasters like war leading to overwhelming refugees across borders e.g. South Sudan
All these news are very prominent in major international social media, but such similar outbreaks from Nepal does not get international coverage. There must be various reasons. I will not go into it. This year, there were many reporting of outbreaks related to enteric disease. One was from Biratnagar, eastern part of Nepal, where there was a large outbreak of viral hepatitis in the center of the city. This caused huge toll of morbidity and also some deaths. It is reported that the sample was confirmed to be hepatitis e virus (HEV). Similarly, another enteric illness has been reported from Rautahat and this is lab confirmed to be cholera. Few deaths have been reported with more than 600 people affected with the illness.
This shows that we have a long way to supply quality drinking water and better sanitation to the people. The provision of safe drinking water and sanitation is the basic human right. This is the duty of state. All these reflect poor governance and in nutshell, we can say "state has failed in providing basic amenities to the people". Irony, all these outbreaks are in majority, as of now, reported from cities, where these "untoward" public health disaster gets noticed by mainstream news media, (may be this can be generalized but, this is a general trend that i observe) while it is sad, these sort of outbreaks are rampant in rural parts of the country and gets rarely such coverage in the media. It is also the fact that rainy season has started, so we expect such public health occurrences will be more frequent in coming days. Therefore, it is the responsibility of the state mechanism to put an efficient surveillance system in place, so all diseases of outbreak potential can be detected early and appropriate action taken place before it takes the shape of an outbreak.
All these news are very prominent in major international social media, but such similar outbreaks from Nepal does not get international coverage. There must be various reasons. I will not go into it. This year, there were many reporting of outbreaks related to enteric disease. One was from Biratnagar, eastern part of Nepal, where there was a large outbreak of viral hepatitis in the center of the city. This caused huge toll of morbidity and also some deaths. It is reported that the sample was confirmed to be hepatitis e virus (HEV). Similarly, another enteric illness has been reported from Rautahat and this is lab confirmed to be cholera. Few deaths have been reported with more than 600 people affected with the illness.
This shows that we have a long way to supply quality drinking water and better sanitation to the people. The provision of safe drinking water and sanitation is the basic human right. This is the duty of state. All these reflect poor governance and in nutshell, we can say "state has failed in providing basic amenities to the people". Irony, all these outbreaks are in majority, as of now, reported from cities, where these "untoward" public health disaster gets noticed by mainstream news media, (may be this can be generalized but, this is a general trend that i observe) while it is sad, these sort of outbreaks are rampant in rural parts of the country and gets rarely such coverage in the media. It is also the fact that rainy season has started, so we expect such public health occurrences will be more frequent in coming days. Therefore, it is the responsibility of the state mechanism to put an efficient surveillance system in place, so all diseases of outbreak potential can be detected early and appropriate action taken place before it takes the shape of an outbreak.
May 20, 2014
My journey: learning to blog
Today, I would like to write on my own and take you through memory lane of blogging experience in science. Let me try to connect you to a recent event. A week back, i attended a course on vaccinology, which was a great learning experience for me. There were about 100 participants from Africa and Asia - Pacific regions. Apart from talks on serious science related to immunology and conduct of clinical trials in developing countries, I enjoyed the talks on the role of communication, vaccine hesitancy and social media. I also agree, the component of communication is either neglected or not in the picture in majority of project that i am aware of. Even if this important component that relates directly with how we communicate or inform community on essential key information comes to managers only when something error or events come to the notice of public purview through local newspapers. I did not realize that vaccine hesitancy is to such extent that it is a global public health problem. I also came to understand that the confidence level for vaccine is eroded due to various reasons.
The reason, i am sharing this experience is simply because it made me think, what is my real intent of blogging? Actually, i started blogging in Nepal since 2009. I came to know of blogging for the first time from a visitor to a organization that i was working with. Being a surveillance medical officer, i was assigned to accompany a CDC expert, whose role was to assess the surveillance ongoing in Nepal. We traveled, i guess, for a whole two weeks in hilly districts of Eastern Developmental Region. It was a great learning experience. We enjoyed as well as worked hard to perform what we were assigned for. After returning back to KTM, we shared our experiences and our expert shared his experience in a blog as a story with pictures taken during our visit. That was the first time i came across the idea of blogging. This opened me world of writing and sharing story. For a couple of months, i could post some pictures or short post, but I was not in a habit of writing regularly. Even now, i struggle a lot especially to write on some theme with story or message.
As years rolled passed, i tried hard to blog regularly. However, i was not able to perform well in terms of blogging effectively. Now, i realize that it was due to simply not planning well or writing regularly as I was supposed to do. Also, i was not telling my stories with message or sharing important public health events of public interest. After, I joined IVI in the year 2011, i started to regain the lost or little interest of active blogging. It was only after getting in touch with colleagues from communication or even serious writers, i came to realize that in order to survive in a world of academic i need to religiously start writing in whatever capacity i should. Over the months, the only problem with me was that idea was overwhelming that i need to write but in reality, i was not delivering in terms of original write ups to share. This is bad, as always, only thinking but not doing what i am supposed to be in deed.
I was struggling to be a blogger. Somewhere in the mid of 2013, there was a workshop on writing science organized by Communication & Advocacy team. The trainer was a senior science writer from BMJ. He was one guy who kindled the value of any thing written if you have story to tell in whatever form and size you are able to. This was a turning point that i started to seriously blog and became a bit regular posting anything i was able to. Over months, i came to realize out of complacency, i was just posting in a copy and paste fashion. This was not any original writing with story except some videos or events from other websites. I asked to myself, it is like plagiarism or something of sort like laziness? Deep down, i was not satisfied. However, one good thing that was on track was the number of visitors or number of flags suggesting there were visitors from various countries. One the other hand, i thought, am i doing justice to visitor, who spend few second of their time to explore what my blog has to offer !! It is also important that " First impression is the last impression". Now, I seriously understand the value of originality and story to tell that has message.
Finally, these days, i am enjoying writing and I am happy, i have managed to come to this stage to realize the value of writing and sharing stories of whatever event or accident or outbreak anywhere in my country.
Mantra:
The reason, i am sharing this experience is simply because it made me think, what is my real intent of blogging? Actually, i started blogging in Nepal since 2009. I came to know of blogging for the first time from a visitor to a organization that i was working with. Being a surveillance medical officer, i was assigned to accompany a CDC expert, whose role was to assess the surveillance ongoing in Nepal. We traveled, i guess, for a whole two weeks in hilly districts of Eastern Developmental Region. It was a great learning experience. We enjoyed as well as worked hard to perform what we were assigned for. After returning back to KTM, we shared our experiences and our expert shared his experience in a blog as a story with pictures taken during our visit. That was the first time i came across the idea of blogging. This opened me world of writing and sharing story. For a couple of months, i could post some pictures or short post, but I was not in a habit of writing regularly. Even now, i struggle a lot especially to write on some theme with story or message.
As years rolled passed, i tried hard to blog regularly. However, i was not able to perform well in terms of blogging effectively. Now, i realize that it was due to simply not planning well or writing regularly as I was supposed to do. Also, i was not telling my stories with message or sharing important public health events of public interest. After, I joined IVI in the year 2011, i started to regain the lost or little interest of active blogging. It was only after getting in touch with colleagues from communication or even serious writers, i came to realize that in order to survive in a world of academic i need to religiously start writing in whatever capacity i should. Over the months, the only problem with me was that idea was overwhelming that i need to write but in reality, i was not delivering in terms of original write ups to share. This is bad, as always, only thinking but not doing what i am supposed to be in deed.
I was struggling to be a blogger. Somewhere in the mid of 2013, there was a workshop on writing science organized by Communication & Advocacy team. The trainer was a senior science writer from BMJ. He was one guy who kindled the value of any thing written if you have story to tell in whatever form and size you are able to. This was a turning point that i started to seriously blog and became a bit regular posting anything i was able to. Over months, i came to realize out of complacency, i was just posting in a copy and paste fashion. This was not any original writing with story except some videos or events from other websites. I asked to myself, it is like plagiarism or something of sort like laziness? Deep down, i was not satisfied. However, one good thing that was on track was the number of visitors or number of flags suggesting there were visitors from various countries. One the other hand, i thought, am i doing justice to visitor, who spend few second of their time to explore what my blog has to offer !! It is also important that " First impression is the last impression". Now, I seriously understand the value of originality and story to tell that has message.
Finally, these days, i am enjoying writing and I am happy, i have managed to come to this stage to realize the value of writing and sharing stories of whatever event or accident or outbreak anywhere in my country.
Mantra:
- Write Write & Write
- Read Read & Read
- Collaborate Coordinate and Communicate
May 10, 2014
What is Viral Hepatitis?
Online Q&A
Q: What is hepatitis?
A: Hepatitis is an inflammation of the liver, most commonly caused by a viral infection. There are five main hepatitis viruses, referred to as types A, B, C, D and E. These five types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread. In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer.
Hepatitis A and E are typically caused by ingestion of contaminated food or water. Hepatitis B, C and D usually occur as a result of parenteral contact with infected body fluids. Common modes of transmission for these viruses include receipt of contaminated blood or blood products, invasive medical procedures using contaminated equipment and for hepatitis B transmission from mother to baby at birth, from family member to child, and also by sexual contact.
Acute infection may occur with limited or no symptoms, or may include symptoms such as jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.
Q: What are the different hepatitis viruses?
A: Scientists have identified five unique hepatitis viruses, identified by the letters A, B, C, D, and E. While all cause liver disease, they vary in important ways.
Hepatitis A virus (HAV) is present in the faeces of infected persons and is most often transmitted through consumption of contaminated water or food. Certain sex practices can also spread HAV. Infections are in many cases mild, with most people making a full recovery and remaining immune from further HAV infections. However, HAV infections can also be severe and life threatening. Most people in areas of the world with poor sanitation have been infected with this virus. Safe and effective vaccines are available to prevent HAV.
Hepatitis B virus (HBV) is transmitted through exposure to infective blood, semen, and other body fluids. HBV can be transmitted from infected mothers to infants at the time of birth or from family member to infant in early childhood. Transmission may also occur through transfusions of HBV-contaminated blood and blood products, contaminated injections during medical procedures, and through injection drug use. HBV also poses a risk to healthcare workers who sustain accidental needle stick injuries while caring for infected-HBV patients. A safe and effective vaccine is available to prevent HBV.
Hepatitis C virus (HCV) is mostly also transmitted through exposure to infective blood. This may happen through transfusions of HCV-contaminated blood and blood products, contaminated injections during medical procedures, and through injection drug use. Sexual transmission is also possible, but is much less common. There is no vaccine for HCV.
Hepatitis D virus (HDV) infections occur only in those who are infected with HBV. The dual infection of HDV and HBV can result in a more serious disease and worse outcome. Safe and effective hepatitis B vaccines provide protection from HDV infection.
Hepatitis E virus (HEV), like HAV, is mostly transmitted through consumption of contaminated water or food. HEV is a common cause of hepatitis outbreaks in developing parts of the world and is increasingly recognized as an important cause of disease in developed countries. Safe and effective vaccines to prevent HEV infection have been developed but are not widely available.
Source: http://www.who.int/features/qa/76/en/
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