<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110101156/636ccb019c7e80680e08bb9cjpeg.jpg" alt="Nepal Covid vaccine drive" width="1500" height="1000"/><figcaption>Photo: MONIKA DEUPALA</figcaption></figure><a href="https://www.nepalitimes.com/banner/nepal-begins-covid-19-vaccination-drive/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/nepal-begins-covid-19-vaccination-drive/&amp;source=gmail&amp;ust=1613056346323000&amp;usg=AFQjCNGRuyt2OfxCWKaKKLdw2TJG6SdtOw">Nepal was one of the first countries in the region to start</a> a mass Covid-19 vaccination drive two weeks ago, but less than half of the frontline workers and high-risk individuals prioritised by the government have chosen to inoculate themselves.Officials figures show that only 184,000 of the 430,000 people on the government’s list for the first phase opted for the jabs. India had donated 1 million doses of the <a href="https://www.nepalitimes.com/latest/jabs-and-jab-nots/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/jabs-and-jab-nots/&amp;source=gmail&amp;ust=1613056346323000&amp;usg=AFQjCNGbEytIydsDOvvzkqbOT7FXyhs-3Q">Astra Zeneca Covishield</a> vaccine made by Serum Institute of India.This means that the vaccines which were manufactured in October 2020 will expire by April, and the Nepal government is running out of time to use up the doses before another batch of 2.25 million Covishield doses under the WHO’s COVAX initiative arrive in Nepal.“It’s a new vaccine against a new disease, people are naturally concerned about taking it,” says Sher Bahadur Pun of the Sukraraj Tropical and Infectious Disease Hospital. “We should have promptly addressed safety concerns and about its minor side effects to curb any doubts.”Pun said even some of his doctors and nurse colleagues refused to take the vaccines, doubting their efficacy. The first phase of inoculations was being administered through 201 booths across 77 districts.Possibly because there are still so many doses left, the Ministry of Health has decided to ignore its own vaccination strategy and expand the first phase to also include civil servants, diplomats and journalists.“The first phase showed us that the vaccine is safe, there were no major side effects or deaths but our coverage was much lower than targeted,” admits Shyam Raj Upreti, head of government’s Covid Vaccine Strategy. “The vaccination campaign wasn’t as decentralised as we would have liked and weren’t able to reach as many people. We need to take vaccination booths to areas closed to the public, especially as we prepare to jab the elderly and those with morbidities in the second phase.”Quick, successive <a href="https://www.nepalitimes.com/here-now/when-will-nepals-covid-vaccine-turn-come/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/here-now/when-will-nepals-covid-vaccine-turn-come/&amp;source=gmail&amp;ust=1613056346323000&amp;usg=AFQjCNFs83cBekg92QnPuzJNNc2EvwI5zQ">vaccine development</a> also made many wary. Others in the priority list such as cleaners and security guards were suspicious of being turned into guinea pigs.“The government was unsuccessful in properly communicating the significance and efficacy of the vaccine and explain why certain groups of people are being prioritised for the vaccination,” says Ramesh Kant Adhikari of the National Immunisation Committee which oversees other vaccination programs in Nepal besides Covid-19.To be sure, vaccine hesitancy is not unique to Nepal. Several countries have deployed methods to increase vaccine acceptance among the masses: national leaders, politicians and celebrities were televised live being inoculated. Many influencers took to social media to share their experience of being vaccinated.India’s donation of 1 million Covishield vaccines to Nepal on 20 January has prompted China to now offer 500,000 doses of its own Sinopharm vaccines to Nepal even though it has not yet been certified by WHO. The Nepal government is reported to be reluctant to accept this gift because there might be even more public scepticism about it.Nepal is receiving 2.25 million more Covishield vaccines with a £550 million UK government support under the World Health Organisation (WHO) and the Global Vaccine Alliance (GAVI) <a href="https://www.nepalitimes.com/opinion/glimmers-of-hope-for-nepal-on-vaccine/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/glimmers-of-hope-for-nepal-on-vaccine/&amp;source=gmail&amp;ust=1613056346324000&amp;usg=AFQjCNFZN0apBpL_aFBCnwHDKiwmg_Ae-Q">COVAX initiative</a> by early March. Nepal will receive the rest of the vaccine it applied for 20% population later.But excluding people under 18 years of age, Nepal needs vaccines for 72% of its population. So in the meantime, the government is in talks with India to purchase another 2 million doses of Covidshield, which will arrive in a month.China’s promise of 500,000 doses of Sinopharm vaccine in March is up from 300,000 previously promised. India’s Bharat Biotech-manufactured Covaxin and <a href="https://www.nepalitimes.com/latest/sputnik-v-vaccine-mystery-in-nepal/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/sputnik-v-vaccine-mystery-in-nepal/&amp;source=gmail&amp;ust=1613056346324000&amp;usg=AFQjCNHBgDRzkXyVnFgFxxpCBi_0ZFm6Sw">Russian Sputnik V</a> are in a race to supply additional jabs for Nepalis.Earlier doubts about Russian and Chinese vaccines have been quelled with new findings and due to the limited manufacturing capacity of Covidshield, Moderna and Pfizer.A <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00191-4/fulltext" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00191-4/fulltext&amp;source=gmail&amp;ust=1613056346324000&amp;usg=AFQjCNGnOehxFhj9rk3WHLUe7xgfCoKJmQ">recent research paper</a> on the medical journal Lancet called Russian Sputnik V safe and effective (91.6%) based on interim results from its phase three trials. Sinopharm has had efficacy ranging from 86% to 79%.An <a href="https://www.nytimes.com/2021/02/05/opinion/covid-vaccines-china-russia.html" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nytimes.com/2021/02/05/opinion/covid-vaccines-china-russia.html&amp;source=gmail&amp;ust=1613056346324000&amp;usg=AFQjCNEmjmbcQ4Kmfsq2JtR_rbErtuXdGw">op-ed in the New York Times</a> last week explained that another Chinese vaccine Sinovac performed poorly (50.4%) in Brazil compared to Turkey (91%) because it was conducted exclusively among health workers in São Paulo who were at the highest risk, leading to much lower efficacy.But so far Covidsheild is the only Covid-19 vaccine registered at Nepal’s Drug Development Administration, even though South Africa has discontinued its use because it was found not to be effective against a new strain of coronavirus found there.“For us to administer Sinopharm and others, we need a different strategy, get an approval from a health authority in the manufacturing company and a study of its side effects in similar populations,” explains Adhikari.There is also an on-going debate about the use of different vaccines for the same individual. While experts agree on using the same vaccine for both the first and second dose as far as possible, a mix of two different shots is also being advocated given there is a limited stock of vaccines of one kind.Vaccines are here at a time when positivity and fatality rates are going down in Nepal and the region. Multiple factors have been credited to this: fewer tests and contact tracing, large chunks of the population developing immunity against SARS-CoV-2 after contracting it and the natural peak and fall cycle of infectious diseases.But one cannot ignore the possibility of another wave as seen frequently in the US and Europe and continue to <a href="https://www.nepalitimes.com/opinion/staying-safe-in-2021-and-beyond/" target="_blank" rel="noopener noreferrer" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/staying-safe-in-2021-and-beyond/&amp;source=gmail&amp;ust=1613056346324000&amp;usg=AFQjCNF6rm1nNlH54u3FDLQ2odstVqCvkQ">wear masks, maintain physical distance and practice handwashing</a>.Says Sher Bahadur Pun: “This is the right time to vaccinate and be better prepared for possible next wave by strengthening our health infrastructure and human resource while continuing to follow safety measures, we must use this period to the fullest.”

Sonia Awale

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Why is there vaccine hesitancy in Nepal?

<figure><img width="2048" height="1282" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181120/636be1af9c7e80680e083e61jpeg.jpg" alt=""/><figcaption>Photo: MONIKA DEUPALA</figcaption></figure>With the <a href="https://www.nepalitimes.com/latest/double-whammy-air-pollution-and-covid-19/">pre-winter resurgence of Covid-19</a> around the world and in Nepal, pressure is mounting on governments to procure vaccines to protect their populations.
Last week, the <a href="https://www.nepalitimes.com/latest/vax-populi/" target="_blank" rel="noopener noreferrer">Nepal government set up a committee</a> of secretaries of the Finance, Home, Health and Foreign Affairs ministries to study vaccines under development as well as procedures to procure them. But Nepal is far behind other countries, which have already ‘booked’ their future supplies.
On Wednesday President Bidya Devi Bhandari signed an ordinance empowering the government to import Covid-19 vaccines from international pharmaceutical companies, and to use them even if they are authorised only for emergency use.
<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/latest/vax-populi/" target="_blank" rel="noopener noreferrer">VAX POPULI</a>, Sonia Awale
However, there is no effective strategy to ensure vaccines for all as distribution in Nepal comes with the challenge of taking it to poor and remote corners of the country. Experts fear that even when the vaccines become available, the campaign will be plagued by the same socio-economic inequities that afflict the medical sector.
“We need to immediately start identifying vulnerable groups like <a href="https://www.nepalitimes.com/here-now/nepal-health-workers-battle-covid-19-but-also-stigma/" target="_blank" rel="noopener noreferrer">frontline health workers</a>, <a href="https://www.nepalitimes.com/here-now/spared-at-first-elderly-hit-hard-by-covid-19/" target="_blank" rel="noopener noreferrer">the elderly</a> or those with comorbidities to prioritise for immunisation,” says Bikash Gauchan, a physician at Bayalpata Hospital in the under-served western district of Achham.
“We also need to set up proper cold chain facilities across the country as soon as possible and have a well thought out distribution plan so that when the vaccine does arrive, we can hit the ground running,” he adds.
The silver lining is that Nepal already has a successful <a href="https://www.nepalitimes.com/banner/polio-hunt/" target="_blank" rel="noopener noreferrer">childhood immunisation</a> network that has successfully mobilised <a href="https://www.nepalitimes.com/latest/enlisting-female-health-volunteers-to-fight-covid-19/" target="_blank" rel="noopener noreferrer">Female Community Health Volunteers</a>, and they can deliver vaccines to the homes of the elderly who cannot make it to clinics. Monitoring the follow-up second dose for some of the vaccines will be crucial, although Nepal’s health system has experience with maintaining a cold chain for other campaigns.
<a href="https://www.nepalitimes.com/latest/nepali-diaspora-hit-by-covid-surge/">Nepali diaspora hit by Covid surge</a>, Nepali Times
Despite recent breakthroughs in trials (see box) public health experts stress the importance of exploring vaccine supply options closer to home. As of now, 11 vaccines developed in several parts of the world are in the third phase of <a href="https://www.nepalitimes.com/opinion/countries-cooperating-to-find-covid-19-cure/" target="_blank" rel="noopener noreferrer">clinical trials</a> with many of them expected to be as effective.
Neighbouring China and India are at the forefront. And Nepal should have begun its ‘vaccine diplomacy’ much before this to secure its supply of shots.
There is also the uncertainty of vaccine efficacy depending on the strain: the same vaccine could be highly effective against people in the West but not as much in South Asia where people suffer from chronic malnutrition and multiple infections.
“For a working vaccine to be made within a year is an amazing victory for science but we also need to know that these vaccines are designed for their population. So I’d want to know more about the vaccines in India and China,” says Sameer Mani Dixit of the Centre for Molecular Dynamics Nepal. “Particularly China, as it was where the pandemic started but <a href="https://www.nepalitimes.com/latest/what-nepal-can-learn-from-china-about-covid-19/" target="_blank" rel="noopener noreferrer">has since controlled it effectively</a> unlike rest of the world.”
<a href="https://www.nepalitimes.com/opinion/the-truth-about-the-chloroquine-scam/" target="_blank" style="font-size: 15px; letter-spacing: 0.01em;" rel="noopener noreferrer">Buddha Basnyat</a> of the Patan Academy of Health Sciences agrees. He says: “China looks at the reality in our backyard. So a more suitable vaccine for us could come from the Chinese, particularly because they have a track record of having developed better vaccine for this part of the world.”
Indeed, the JEVAX made by the researchers in Chengdu is now the most widely used jab against Japanese Encephalitis because it’s more cost effective compared to its western vaccines.
Nepal Health Research Council is once again considering conducting Phase III clinical trial of Coronavac by China’s Sinovac Biotech after an initial divided opinion over its safety. The vaccine has shown quick immune response in mid-stage trials in South America and parts of Asia.
In India, The Serum Institute has anticipated demand by already manufacturing 40 million doses of AstraZeneca’s potential Covid-19 vaccine. It will also soon manufacture Novavax.
Similarly, researchers at the Indian Institute of Science have designed a protein-based heat-tolerant vaccine that can stay stable for a month at 37°C, and could endure temperatures as high as 100°C if freeze dried, a feature that could be a game changer for mass vaccination campaigns in lower and middle income countries in Asia and Africa.
The other factor to consider will be the duration of the immunity after each vaccine shot, as well reinfection groups and if antibodies developed in the first episode helps fight the mutated forms of the virus.
With Covid-19 crisis continuing to spread rapidly across Nepal and at 10 fatalities per million population (same as Pakistan and much higher than China’s 3), it is not too early to start dialogue with Gavi, the vaccine alliance, COVAX and agencies like the World Bank and World Health Organisation to help procure the most cost effective approach to vaccines most suitable to Nepal’s conditions.
Alternatively, many pharmaceutical companies will want to play the field in order to boost their profile. In fact, embassies and foreign donors are already hard at work pushing for trails and deals.
“There is bound to be vaccine politics and it will mostly likely be ugly,” predicts Sher Bahadur Pun of the Health Ministry. “But we should not lose track of two things: efficacy of the vaccine against our population and its economic viability. If we do that we should be on the right path, more or less.”
In all this excitement, Nepal’s health authorities must also keep an eye on the plight of infected people and many more to come as <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/" target="_blank" rel="noopener noreferrer">they wait for a vaccine</a>. The results of current treatment regimens ranging from plasma therapy to administering Remdesivir have been patchy. And as scientists study the long-term impact of Covid-19 on patients even after they recover, making an optimal use of resources becomes even more significant.
So far, the government has been faulted for squandering months of lockdown, not carrying out sufficient tests and contact tracing, not increasing hospital capacity and equipment, and letting the people fend for themselves.  
The result is that Nepal is <a href="https://www.nepalitimes.com/banner/heat-map-of-nepals-covid-19-hotspots/" target="_blank" rel="noopener noreferrer">suffering a sustained surge</a>, with more than 1,400 new cases a day, over 60% of them in Kathmandu Valley alone and a quarter of those tested coming out positive. There is also a surge in symptomatic patients, even among those without pre-existing conditions, and those sick enough to require ICU and ventilator.
Even when the government does act, the <a href="https://www.nepalitimes.com/latest/coronavirus-coordination-committee-doesnt-coordinate/" target="_blank" rel="noopener noreferrer">priorities seem to be misplaced</a>. For instance, health experts say the emphasis in the past months should have been on high flow oxygen therapy or High Dependency Units rather than Intensive Care Units in hospitals.
“It would have been cheaper, it does not require highly trained staff or sophisticated equipment, and it would have freed up the ICUs for the really critical patients,” adds Pun, who himself is at the Health Ministry, and this possibly means his advice is not being taken.
Insiders say it will likely take upwards of six months for the first vaccines to arrive in Nepal, and there will be a rush by the rich, the powerful and those with political connections to get their shots. The marginalised, poor, those in remote areas will be the last to get their injections, unless the government has fair and effective rules in place and implements them.
Till then, there is little else to do than <a href="https://www.nepalitimes.com/opinion/silver-linings-in-the-covid-cloud/" target="_blank" rel="noopener noreferrer">keep masking up this winter, avoid large gatherings, keep distance and wash hands regularly</a>.
Says <a href="https://www.nepalitimes.com/opinion/a-covid-19-exit-strategy-for-nepal/" target="_blank" rel="noopener noreferrer">Buddha Basnyat</a>: “The mask is the best vaccine we have at the moment. These safety measures have largely reduced hospitalisation due to other infections in 2020, masks in particular will also protect us from winter pollution in the coming months.”<h2>The Vaccine Race</h2>The global resurgence of Covid-19 in the northern winter has coincided with breaking news every day of successful new vaccine trials.First the Russians announced a vaccine in September that is 92% potent against SARS-CoV-2.  Last week Pfizer unveiled a 90% effective vaccine, which on Wednesday was upgraded to 95% efficacy without side effects. Moderna was next with an efficacy of 95%, and not needing extreme refrigeration. More companies in China, India and Europe are conducting their own trials.Public health experts have hailed the developments, but warn that vaccines will not be universally available till late 2021 and even so will not provide full protection. They suggest continuing with masking up, keeping distance and avoiding crowded indoor places.Pfizer and its German partner BioNTech’s mRNA-based vaccine came out declaring over 90% effectiveness but only at -70°C ultra cold chain which will be a challenge even for countries with the best health facilities in the world.Massachusetts-based Moderna’s RNA shot has 94.5% efficacy, seems to also prevent severe infections and remains stable in medical and home refrigerators for up to 30 days, in freezers (-20°C) for up to six months, and at room temperature for up to 12 hours.Even so, poorer countries are unlikely to get coronavirus vaccine any time soon. Even the biggest pharmaceutical multinationals can only manufacture a limited quantity of the vaccine over the next year.Pfizer has capped its production at 1.4 billion for 2021, 80% of which has already been booked through advance purchase agreement by the US, UK, EU, Canada and Japan. Moderna expects to manufacture 20 million doses this year and up to one billion in 2021.On the other hand, <a href="https://www.nepalitimes.com/latest/sputnik-v-vaccine-mystery-in-nepal/" target="_blank" rel="noopener noreferrer">Russian’s Sputnik V</a> has been overshadowed by new developments, and due to lack of sufficient data to back up its claim of 92% efficacy. Although geopolitical rivalry with the West has given it negative publicity, some health agencies have not ruled it out.

When will Nepal’s Covid vaccine turn come?

<figure><img width="640" height="311" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109181120/636be1b29c7e80680e083e62jpeg.jpg" alt=""/><figcaption>Nepal Army special funeral team brings home the first fatality from Covid-19 in Bhojpur District. She was a 24-year-old woman. The government's challenge is to bring the Covid-19 vaccine to remote parts of Nepal like these. Photo: RSS</figcaption></figure>Nepal’s <a href="https://www.nepalitimes.com/banner/heat-map-of-nepals-covid-19-hotspots/" target="_blank" rel="noopener noreferrer">surge of Covid-19 continues unabate</a>d  with new hotspots, and because of inadequate testing, no one really knows how much and how fast the pandemic has spread.The government has left Nepalis to their own devices, only issuing guidelines on precautions, but stopping free testing and treatment. Meanwhile the daily positivity rate and fatalities have not come down. As of Thursday, out of the 9,805 people tested nationwide 2,103 were positive, which gives a very high positivity rate of 21.4%.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/when-will-nepals-covid-vaccine-turn-come/" target="_blank" rel="noopener noreferrer">When will Nepal's Covid vaccine turn come?</a>, Sonia Awale Nepal’s death rate from the coronavirus of 43 per million is much lower than India (93%), but much higher than China and Sri Lanka (3%). This points to poor prevention measures as well as inadequate or unaffordable hospital treatment. The only option for Nepal is to <a href="https://www.nepalitimes.com/here-now/when-will-nepals-covid-vaccine-turn-come/" target="_blank" rel="noopener noreferrer">wait for vaccines to be available</a>, but even on this it has moved too late. Many governments around the world have pre-booked vaccines from pharmaceutical companies like Pfizer and Moderna, and most countries will first prioritise their own citizens.Last week, the Nepal government finally set up a committee of secretaries of the Finance, Home, Health and Foreign Affairs ministries to study vaccines under development as well as procedures to procure them.On Wednesday President Bidya Devi Bhandari signed an ordinance empowering the government to import Covid-19 vaccines from international pharmaceutical companies, and to use them even if they are authorised only for emergency use.Despite this, Nepal will possibly be one of the last countries in the world to get a vaccine, and even when the first vials arrive perhaps by the middle of 2021, the poorest Nepalis living in the remotest areas will be the last in line to get them.The government, which has <a href="https://www.google.com/url?client=internal-element-cse&amp;cx=bead8272edd0f2143&amp;q=https://www.nepalitimes.com/here-now/kcs-fast-highlights-nepals-covid-19-failure/&amp;sa=U&amp;ved=2ahUKEwiSi7fx3pDtAhWlwjgGHWzzCnwQFjAAegQIBBAC&amp;usg=AOvVaw18PYxlijebm6Z8s6c8PcRX" target="_blank" rel="noopener noreferrer">failed all these years to make free health care accessible to all</a>, will have to prove that its vaccine distribution is fair, and the poor in remote areas of the country are not left out. Says Bikash Gauchan, a physician stationed in remote Achham district: “We need to immediately start identifying vulnerable groups like frontline health workers, the elderly or those with co-morbidities to prioritise for immunisation, and to have an effective distribution plan for remote areas.”Nepal is internationally recognised as a model low-income country with an effective vaccination programs against measles, <a href="https://www.nepalitimes.com/banner/polio-hunt/" target="_blank" rel="noopener noreferrer">polio</a> and other childhood killer diseases. It has valuable experience in deploying a nationwide network of <a href="https://www.google.com/url?client=internal-element-cse&amp;cx=bead8272edd0f2143&amp;q=https://www.nepalitimes.com/latest/enlisting-female-health-volunteers-to-fight-covid-19/&amp;sa=U&amp;ved=2ahUKEwjaqeaY35DtAhUSyzgGHYXhBtoQFjAAegQIAxAC&amp;usg=AOvVaw1_j5Qa_kWIBHLL5EZjqV1b" target="_blank" rel="noopener noreferrer">Female Community Health Volunteers</a>, and Nepal’s Covid-19 vaccine delivery will have to re-learn from its own best practices.Monitoring the follow-up vaccine dose can gain from Nepal’s acclaimed <a href="https://www.google.com/url?client=internal-element-cse&amp;cx=bead8272edd0f2143&amp;q=https://www.nepalitimes.com/banner/tb/&amp;sa=U&amp;ved=2ahUKEwjxlPay35DtAhWizDgGHd_SDB4QFjAFegQIBRAC&amp;usg=AOvVaw1d367zHYY84fBDOJyCB8HY" target="_blank" rel="noopener noreferrer">DOTS program</a> to deliver anti-tuberculosis therapies, and Nepal’s rural health care workers have experience in maintaining the cold chain from previous <a href="https://www.google.com/url?client=internal-element-cse&amp;cx=bead8272edd0f2143&amp;q=https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/&amp;sa=U&amp;ved=2ahUKEwj07oLT35DtAhW6yDgGHe6ZCsYQFjAAegQIABAC&amp;usg=AOvVaw2VfJkLuf5k3bEjPG4_59-X" target="_blank" rel="noopener noreferrer">vaccination programs</a>.  Despite recent breakthroughs in trials, public health experts say Nepal should be looking at neighbouring China and India and belatedly begin ‘vaccine diplomacy’ to secure its supply.Nepal Health Research Council is once again considering conducting Phase III clinical trial of Coronavac by China’s Sinovac Biotech after an initial divided opinion over its safety. The vaccine has shown quick immune response in mid-stage trials in South America and parts of Asia.In India, the Serum Institute has anticipated demand by already manufacturing 40 million doses of AstraZeneca’s potential Covid-19 vaccine. It will also soon manufacture Novavax.“There is bound to be vaccine politics and it will mostly likely be ugly,” predicts Sher Bahadur Pun of the Health Ministry. “But we should not lose track of two things: efficacy of the vaccine against our population and its economic viability. If we do that we should be on the right path, more or less.”

VAX POPULI

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101120/636b70d49c7e80680e06009bjpeg.jpg" alt="" width="1500" height="803"/><figcaption>Photo : UNICEF</figcaption></figure>Last month, the prestigious <a href="https://www.nejm.org/" target="_blank" rel="noopener">New England Journal of Medicine</a> published a study of the <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1905047" target="_blank" rel="noopener">successful trial of a new typhoid vaccine</a> that could prevent thedeaths of many children around the world. The vaccine research was conducted at Patan Hospital by a Nepali researcher.The randomised control trial of the typhoid conjugate vaccine (TCV) was conducted among more than 20,000 participants in Lalitpur district, and the efficacy of the new vaccine was found to be 81.6% -- a major improvement on previous vaccines. (See box below).The positive news from Nepal came as various parts of the world, including the US, Europe, Samoa and Africa, struggled to cope with the biggest measles outbreak in decades. Most of the cases have now been associated with people forgoing recommended preventive shots because of fears of side-effects fanned by social media.Fear of vaccination started ever since a paper in 1998 in the medical journal <a href="https://www.thelancet.com/" target="_blank" rel="noopener">The Lancet</a> cited a link between autism and the <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/maurice-hilleman-the-vaccine-man,1852" target="_blank" rel="noopener">measles, mumps, rubella (MMR) vaccine</a>. The research was later found to be fraudulent and retracted, but the anti-vaccine movement gained traction again in the past year after the rumours resurfaced on the Internet resulting in families rejecting early childhood immunisation against diseases like polio, rubella and measles.“The good news is that unlike in the rest of the world, people in Nepal demand vaccines. If we miss to vaccinate a child for any reason, parents come knocking, asking for the shots,” says Jhalak Gautam of the Family Welfare Division at Teku.Sameer Mani Dixit of The Centre for Molecular Dynamics Nepal concurs. “Entire communities actively participate in vaccination programs and are well aware of the benefits. Every mother in Nepal knows the immunisation schedule by heart.”The Centre for Molecular Dynamics Nepal has just completed a study on why the country has been so successful with its immunisation program, and the results will be published later this month. This study and similar studies underway in Senegal and Zambia are being conducted with  funding from the Bill and Melinda Gates Foundation, in an effort to analyse the success of vaccination programs in developing nations.Nepal’s national immunisation program started in 1988 and now vaccinates some 620,000 children under 15 months of age every year against 11 infectious diseases such as <a href="https://www.nepalitimes.com/banner/tb/">tuberculosis</a>, <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Bouncing-back-higher-wheelchair-basketball,3802" target="_blank" rel="noopener">polio</a>, pneumonia and measles.The last case of <a href="https://www.nepalitimes.com/banner/polio-hunt/" target="_blank" rel="noopener">polio</a> was detected in Rautahat district in 2010, and Nepal was declared polio free four years later. The country also eliminated maternal and neonatal tetanus in 2005. Similarly, Japanese encephalitis, diphtheria, pertussis and pneumonia have all been controlled, and there are regular vaccinations against congenital rubella syndrome and hepatitis B.Despite the high immunisation rate, thousands of Nepali children continue to die due to easily preventable and treatable communicable diseases <a href="https://archive.nepalitimes.com/news.php?id=16988#.XiBL7_4zaUk" target="_blank" rel="noopener">like diarrhoea</a> and according to Nepal Demographic Health Survey 2016, one in a hundred Nepali children have still not been vaccinated against any infectious diseases.Read also: <a href="https://www.nepalitimes.com/here-now/nepal-is-a-microcosm-of-all-of-the-changes-in-world-health/" target="_blank" rel="noopener">"Nepal is a microcosm of all the change in world health"</a>Immunisation coverage data from last year also shows a worryingly high dropout rate. While 93% of newborns received BCG jabs, the first in the national immunisation schedule, the coverage dropped to 73% by the time children received the last vaccine, an immunisation against measles and rubella, recommended at the age of 15 months.Several cases of <a href="http://archive.nepalitimes.com/news.php?id=186#.XiBGW_4zaUk" target="_blank" rel="noopener">measles</a> have been detected in Kapilvastu, Dang, Makwanpur, Sarlahi and Manang districts recently, and Nepal has not been able to meet its previously set target to eliminate measles and rubella by 2019. The new goal is to eliminate the diseases by 2023.“Dropout rate is a challenge, we have not been able to reach the remotest corners of the country, and children miss their shots because of migration,” says Jhalak Gautam. “We now have a strategy to identify missed pockets and deliver shots at home if required.”The Immunisation Section of the Ministry of Health is now gearing up for a nation-wide measles-rubella vaccination campaign aimed at those who might have missed routine shots. Three million children between the ages 9 months to 5 years are expected to participate in two phases of the campaign later this year.Polio drops will also be administered at the same time to 1.5 million children under five in 19 Tarai districts. The Immunisation Section is also introducing a new vaccine against rotavirus this June to reduce the prevalence of childhood diarrhoea.The new challenge to vaccination comes from an unlikely quarter: federalism. There is confusion about where the vaccines are sourced and who should pay for them. There is concern about the quality of vaccines, many of which need a cold chain with refrigeration to the point of delivery.Warns Patan Hospital physician Buddha Basnyat: “Nepal’s immunisation program is a model of success, but we cannot afford to be complacent.We have to introduce newer and more effective vaccines while also prioritising hygiene and <a href="https://www.nepalitimes.com/banner/toilet-trained/" target="_blank" rel="noopener">sanitation</a> simultaneously.”<h2>Successful trial of new typhoid vaccine</h2><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101120/636b70d79c7e80680e06009cjpeg.jpg" alt="" width="1500" height="1000">Over 20,000 children between 9 months and 16 years of age in Lalitpur district participated in the <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1905047" target="_blank" rel="noopener">first large-scale randomised controlled trial</a> of a new vaccine against <a href="http://archive.nepalitimes.com/news.php?id=17306#.XiBGav4zaUk" target="_blank" rel="noopener">typhoid</a>, a disease that affects millions across South Asia.Half of them received the vaccine and the other half received control shots. The efficacy of Typhoid Conjugate Vaccine (TCV) was found to be 81.6%, and the results were published last month in the prestigious New England Journal of Medicine.Prior to this, a small-scale TCV trial was conducted in Britain, and the World Health Organisation (WHO) has since strongly recommend the use of the vaccine for countries and regions where the water and food-borne infection is most common. "Pakistan has been able to control typhoid with this vaccine and <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(19)30320-1/fulltext" target="_blank" rel="noopener">Vietnam</a> has eliminated it," says lead author of the paper, Mila Shakya, "Administration of this new, effective vaccine by our government will help control the most common bacterial disease in Nepal and South Asia."<a href="http://archive.nepalitimes.com/news.php?id=12158#.XiBGbP4zaUk" target="_blank" rel="noopener">Typhoid</a> is a contagious infection caused by the bacteria Salmonella typhi, which is found in contaminated food and water and which causes fever, diarrhoea and vomiting. It can easily be prevented with awareness, safe drinking water and frequent hand-washing.The vaccine is useful because it is a prophylactic in places where preventive measures are taking time to implement. There are some 21 million typhoid cases and 161,000 typhoid-related deaths annually worldwide. South Asia has been often dubbed as the hub of typhoid and there are some 500 cases per 100,000 population in the region.“This study is Nepal taking a lead in preventing typhoid, after never having really prioritised it. It might not kill as many people as other diseases do, but it still affects thousands of school-going children,” says physician Buddha Basnyat at Patan Hospital.TCV is <a href="http://archive.nepalitimes.com/news.php?id=18178#.XiBGdP4zaUk" target="_blank" rel="noopener">not the first typhoid vaccine to be developed</a>. Currently there is an injectable unconjugated polysaccharide vaccine for persons aged two years and above, and an oral capsule for those over six years of age. But they do not work well on young children and they provide protection only for a few years. TCV on the other hand can be given to children below 2 years and the immunisation lasts up to five years.“A single dose of the new vaccine is safe, immunogenic, and effective, and the deployment of the vaccine will reduce the burden of <a href="https://www.nepalitimes.com/opinion/so-far-so-good/infectious-enthusiasm-for-travel/" target="_blank" rel="noopener">typhoid</a> in high-risk populations,” stated the interim analysis. “This new evidence of efficacy is especially timely with the recent spread of extensively drug resistant typhoid fever, which threatens child health in affected regions.”Pakistan, which has been struggling against an outbreak of drug resistant typhoid fever since 2016 is already using TCV with positive results and its Sindh province will become the first region in the world to include TCV in routine childhood immunisations.<a href="https://www.gavi.org/" target="_blank" rel="noopener">Gavi, the Vaccine Alliance</a>, which has earmarked $85 million to fund the introduction of the vaccine in the world’s poorest countries, is supporting the program. Nepal is also eligible for funding from the alliance.Says Basnyat: “We should take action before we are also hit, like Pakistan, by the drug-resistant typhoid. What are we waiting for, when Gavi is ready to fund the vaccination program for free and its benefits are so clear. This is a case of vaccine under-utilisation.”Sonia Awale

A shot in the arm for vaccines in Nepal

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