The jabs and jabnots

A post-graduate student of mechanical engineering Samita Rimal is completing her 14-day quarantine in a hotel in Montreal. Despite being fully vaccinated with VeroCell in Nepal, she now has to take one of the four jabs recognised in Canada.

“I wish I had taken J&J before coming here, I just wasted time and money, others like me should really try to find out the exact requirements before leaving Nepal,” says 23-year-old Rimal.

Another student preparing to leave for Canada is in a dilemma: should she get a shot of the Johnson & Johnson (J&J) vaccine which is accepted in Canada, or face two weeks of quarantine and further restrictions because the Chinese vaccine VeroCell is not accepted by the Canadian government?

“People inoculated with vaccines other than those accepted there are treated as if they are not vaccinated and hence face additional restrictions. I probably won’t be able to attend in-person classes there,” says the 29-year-old.

Other students leaving Nepal are also confused because they do not know whether it is safe to mix vaccines accepted in Europe or North America on top of the Covishield or VeroCell vaccines they have taken earlier this year.

A year after the first Covid-19 jabs were developed, there are at least 11 different vaccines in use worldwide, and many more are in different phases of trials. Never before has there been as much effort and investment in vaccine development.

But this breakthrough in science is not accompanied by a fair distribution of vaccines around the world,  or within countries. It is usually those with access and reach who are fully vaccinated, and some are even getting booster shots already.

Nepal is currently using three different vaccines: AstraZeneca, VeroCell and J&J. While China is giving Nepal one million doses of its other Covid vaccine Sinovac, the government is set to receive 100,000 doses of Pfizer shots under WHO’s COVAX facility, which requires ultra-cold refrigeration.

There are two new jabs under trial in Nepal: a Chinese messenger RNA (mRNA) vaccine, and another developed by Sonafi, a partnership between a French company and UK’s GlaxoSmithKline.

Of these only AstraZeneca and J&J are widely accepted in Europe, the US, and the Gulf, which means Nepali students and migrant workers have to bear expensive hotel quarantine costs while missing out on university or work.

On the other hand, even as thousands of people get vaccinated each day, the vaccination drive has been concentrated in the urban centres. This is why it is not surprising that even as half of Kathmandu Valley residents is fully vaccinated, only 22% of Nepal’s total population has been inoculated.

Nepalis in the hinterland were already least prioritised by the state, for health, education and basic needs, but extreme climate events due to global warming has added to the pre-existing challenges.

“This week in a village in Kailali we met isolated pockets of Tharus and Dalits, most of them unvaccinated,” says epidemiologist Lhamo Yangchen Sherpa. “Because of flash floods, they had no access to healthcare, market or schools, the streets were all flooded and the river had swelled.”

Indeed, as Sherpa argues in her guest editorial, this monsoon rural Nepal was hit by triple disasters: historical state neglect, international apathy with rich countries stockpiling vaccines, and climate change.  All of this has further magnified the coronavirus crisis in the region least equipped with healthcare infrastructure, and vaccine inequity.

Elsewhere in Kathmandu, there is a false sense of security among people who think they are immune against Covid-19 with increasing vaccine coverage. The declining number of daily news cases and deaths have added to the complacency. However, many Kathmandu hospitals still report full ICUs -- mostly occupied but by referral patients from outside the Valley.

The misinterpretation of the recent sero-prevalence study conducted by WHO and the Health Ministry has added to the misconception. The sample survey found that 67% of Nepalis have natural immunity against the virus.

But virologists say the test used does not reveal the concentration of neutralising antibodies that fend off the virus in an individual. It does not detect memory T-cells either, which provide crucial immunity against foreign organisms in the body.

After six months of Nepal’s vaccination drive, about half of those who had been inoculated have started registering a decline in the level of antibodies. However, this does not always translate into individuals getting infected, as they might still have immunity afforded by memory T-cells.

“Given our vaccination coverage and natural immunity mostly against the Delta variant, we can say that there might not be an immediate large-scale surge unless there is a new strain,” says pulmonary specialist at Kathmandu’s HAMS hospital Raju Pangeni. “But we also know that even those vaccinated are not fully protected against the Delta variant which transmits much faster in enclosed spaces.”

With the Dasain festival starting this week, people are now leaving for their hometowns, and market places are crowded. Parties, meetings and seminars are being held in enclosed spaces, and unvaccinated students are packed into classes for lessons before the holidays begin.

During Dasain, children and the elderly are at the most risk of infection. While children are entirely unvaccinated, senior citizens even if fully inoculated have weaker antibody responses. This means the mobile younger population that have been vaccinated and hence are asymptomatic even if infected pose severe risks to the vulnerable groups.

“We must perform our rituals this Dasain keeping in mind the consequences of our actions, if we are not careful we will be jeopardising the health of our children and parents,” says Sherpa, who works with IPAS Nepal.

Experts have now shifted their focus to the post Dasain-Tihar festival season, and upcoming winter months when coronaviruses thrive. Children, elderly, people with co-morbidities, and immune-compromised individuals are at the higher risk.

Says Raju Pangeni: “Our priority now must be to vaccinate children across Nepal after the holidays. At the same time, we must also promote influenza vaccines in order to avoid the double whammy of Covid and flu.”