The return of communicable diseases

- Japanese Encephalitis has claimed 23 lives so far this year, and the monsoon is not even over yet. As of Thursday, there were 118 laboratory confirmed cases of this mosquito-borne infection across 36 districts with most patients in Lumbini.  

 - A cholera outbreak in Birganj last week claimed at least four lives, and 850 people were hospitalised in Parsa district alone. Cholera is caused by faecal-oral transmission, but the source of the contamination has not been determined.

- There was a resurgence of rabies infections with three fatalities in northern Dhading in July. Hundreds of others had come in contact with rabid dogs or infected persons amidst a shortage of anti-rabies vaccines.

 - This year’s dengue outbreak was not as serious as 2022 when at least 100 people died across Nepal from the virus spread by mosquito bites. Nearly 2,900 cases have been reported since January this year, mostly in Gandaki Province and Kathmandu Valley.

For some time now, many public health experts had thought that the burden of infectious diseases was going down in Nepal, and the bigger threat was chronic lifestyle-related ailments.

Indeed, communicable diseases were thought to be largely under control due to increased immunisation, better hygiene and sanitation as well as advances in healthcare. Deaths due to non-communicable diseases like cancers, cardio-vascular and respiratory diseases, and diabetes had increased from 31.3% of all hospital patients in 1990 to 71.1% in 2019.

The rise in chronic diseases is due to reduced physical activity as society urbanises, unhealthy diet, smoking, tobacco and alcohol use. While genetics is a factor, pollution and environment including climate breakdown have added to the challenge. Warming temperatures mean even vector-borne communicable infections such as dengue and malaria have moved up the mountains with the mosquitos.

Japanese encephalitis (JE) cases this year have surpassed last monsoon’s figures, and most of the deaths are of those above 15 years, meaning they were probably not vaccinated against the viral brain infection. Up until 2005, encephalitis killed up to 2,000 people every year, most of them in the Tarai, before the Chengdu vaccine was introduced.

“One-third of those who get JE don’t make it, one-third survive, and the rest survive but with neurological complications,” explains Buddha Basnyat, chair of the Oxford University Clinical Research Unit (OUCRU) in Kathmandu.

The Chengdu vaccine which was trialled in Nepal was first given to all populations of Banke, Bardia, Dang and Kailali districts which were most affected. The immunisation was later expanded to 19 districts with children under 15 inoculated.

Sher Bahadur Pun, virologist at Sukraraj Tropical and Infectious Disease Hospital, confirms that encephalitis is the biggest vector borne infection in Nepal right now. He adds, “Even as we were talking about dengue, for the past two years I have been concerned about JE since we started neglecting vaccination thinking that the threat was gone. That is why it has re-emerged.”

Nepal has frequent cholera outbreaks due to poor sanitation, and faecal contamination of piped water in cities. In most cases, it is dismissed as severe diarrhoea. A major outbreak of cholera in Haiti in 2010 killed 10,000 people with 820,000 cases recorded – it was traced to a camp housing Nepali peacekeeping troops who carried the Vibrio cholerae bacillus to a population that had not developed immunity against it.

A severe cholera outbreak in Jajarkot in 2009 killed 300 people, mostly children, and 40,000 cases were recorded. But cholera is now vaccine preventable, an Indian made Hillchol oral cholera vaccine being one of the jabs available.

Says Pun: “The fact that these biblical, easily preventable illnesses still kill people in Nepal is tragic. We need three things to fight communicable diseases: communication, hygiene and vaccines.”

The resurgence of rabies in Dhading and surrounding districts in July raised alarm bells, and public health experts worried that the vaccines had not reached the remote health posts. Rabies has a 100% fatality rate, but post-exposure prophylaxis, a standard 3-4 dose jabs administered after a dog bite can prevent it. The injections are supposed to be available for free in government hospitals.

An injection of rabies immune serum called immunoglobulin is also given if the risk is severe but it is expensive and available only in major hospitals. A pre-exposure prophylaxis is recommended to travellers in high-risk areas like Nepal.

Mary Warrell, world expert on rabies, says that no one who has had a course of pre-exposure vaccine has ever died of rabies. A small vial is sufficient for an entire family and would cost Rs700 at most. If bitten, a booster shot would be sufficient, and immune serum is not needed. 

“Unfortunately, even when you are bitten by a dog, rabies vaccination is still not a standard procedure in Nepal when you go to most pharmacies, they would rather give you a tetanus injection,” laments Basnyat. “Most people don’t even know you get a free post-exposure anti-rabies vaccine in Teku hospital in Kathmandu.”

Experts agree that the most effective antidote to tackle both communicable and non-communicable diseases should be awareness. This means communicating prevention options about how infections spread, as well as healthier habits to reduce risk from modern lifestyle-related maladies.   

Rakshya Pandey, pulmonary physician at HAMS Hospital, says most government budgets are spent on treating heart, kidney and neuro diseases, when the focus should be in delaying onset through awareness.

“We contract chronic illnesses just by breathing Kathmandu’s toxic air, there are children as young as 12 vaping and look at how easily accessible cigarettes are,” she says. “But most of the cost of treatment in Nepal is out of pocket.”

In addition, there is huge disparity between public and private healthcare. Government health centres are unreliable, underfunded and understaffed, while private hospitals are out of reach for most Nepalis. And now, with USAID’s health projects shut, the government’s dedicated health delivery programs will be affected.

Sixty percent of the money USAID was providing to Nepal was for the health sector, including paying for community mobilisers who are credited for successful immunisation and progress in maternal and child care in the country. Similarly, active case finding and contract tracing of tuberculosis which kills 6,000 people in Nepal every year was almost entirely funded by USAID.

“The wealth of a country is not measured in just income, but in the health and education of citizens,” says Pandey. “The health sector should not be politicised, and impacted every time there is a change in government.”

But since the problem is political malfunction, the solution lies in politics too. Policies such as taxation for tobacco, strictly enforcing mandatory vehicle emission tests, and reinvigorating vaccine programs and community healthcare would do much more to reduce the burden of both communicable and non-communicable diseases.  

Concludes Basnyat: “Communicable infections are whimsical in nature. They have not returned, they never went away from Nepal. Now, we also have to increasingly deal with chronic illnesses. It’s a double whammy, we have to recognise that and tackle them head-on simultaneously.”