<img width="1492" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221110151116/636d07e79c7e80680e0a5fe8jpeg.jpg" alt=""/>Twenty-three million children worldwide missed out on basic vaccines through routine immunisation services in 2020, 3.7 million more than in 2019, due to Covid induced global service disruptions, a <a href="https://www.who.int/data/immunization" target="_blank" rel="noopener noreferrer">latest survey by the WHO and UNICEF</a> has revealed.
Up to 17 million of these children likely did not receive a single vaccine during the year, widening already immense inequities in vaccine access. Most of these children live in communities affected by conflict and in under-served remote places with limited access to health facilities, food and hygiene.
“Even as countries clamour to get their hands on Covid-19 vaccines, we have gone backward on other vaccinations, leaving children at risk from devastating but preventable diseases like measles, polio or meningitis,” says Tedros Adhanom Ghebreyesus, WHO Director-General. 
He adds: “Multiple disease outbreaks would be catastrophic for communities and health systems already battling Covid-19, making it more urgent than ever to invest in childhood vaccination and ensure every child is reached.”
Disruptions in immunisation services were widespread in 2020, with the WHO Southeast Asian and Eastern Mediterranean Regions most affected. As compared with 2019, 3.5 million more children missed their first dose of diphtheria, tetanus and pertussis vaccine (DTP-1) while 3 million more children missed their first measles dose. 
During the first wave in 2020, villages in Nepal’s Dhading and Gorkha districts suffered outbreaks of measles because families were unable to vaccinate their children either because the health post was closed due to the pandemic, parents were concerned about Covid-19 transmission, or the lockdown prevented travel to health posts. 
“This evidence should be a clear warning. The Covid-19 pandemic and related disruptions cost us valuable ground we cannot afford to lose and the consequences will be paid in the lives and wellbeing of the most vulnerable,” says UNICEF Executive Director Henrietta Fore. 
She adds: “The pandemic has made a bad situation worse. With the equitable distribution of Covid-19 vaccines at the forefront of everyone’s minds, we must remember that vaccine distribution has always been inequitable, but it does not have to be.”
Even prior to the pandemic, global childhood vaccination rates against diphtheria, tetanus, pertussis, measles and polio had stalled for several years at around 86%. 
This rate is well below the 95% recommended by WHO to protect against measles, often the first disease to resurge when children are not reached with vaccines, and insufficient to stop other vaccine-preventable diseases. Just two years ago, there were widespread measles outbreaks.
“This is a wake-up call, we cannot allow a legacy of Covid-19 to be the resurgence of measles, polio and other killers,” says Seth Berkley, CEO of Gavi, the Vaccine Alliance. “We all need to work together to help countries both defeat Covid-19, by ensuring global, equitable access to vaccines, and get routine immunisation programs back on track.” 
School closures due to the pandemic have also affected vaccinations against human papillomavirus (HPV), which protect girls against cervical cancer later in life. Globally only 13% of girls were vaccinated against HPV, falling from 15% in 2019, which means 1.6 million missed out on the shot in 2020.
Nepal government had introduced the HPV vaccine for all girls aged between 11-13 years as part of the regular immunisation program in 2019.
The WHO, UNICEF and Gavi are working together to restore services and vaccination campaigns by ensuring that Covid-19 vaccine delivery is independently planned for and financed and that it occurs alongside, and not at the cost of childhood vaccination services while also strengthening immunisation systems as part of pandemic recovery efforts.
The Global Immunisation Agenda 2030 aims to achieve 90% coverage for essential childhood vaccines, halve the number of entirely unvaccinated children, and increase the uptake of newer lifesaving vaccines such as rotavirus or pneumococcus in low and middle-income countries.

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Pandemic hits non-Covid vaccines for children

<figure><img width="1236" height="856" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a09c7e80680e067804jpeg.jpg" alt=""/><figcaption>Photo: AMIT MACHAMASI</figcaption></figure><h2>1. Oxygen</h2> To save lives, Nepal’s most urgent need now is oxygen. Not just cylinders, but oxygen generators, concentrators and liquid oxygen. Most infected people are not succumbing to Covid-19, they are <a href="https://www.nepalitimes.com/here-now/helping-nepalis-breathe-again/" target="_blank" rel="noopener noreferrer">dying because of low oxygen saturation</a> in the blood, and lack of hospital beds -- patients who need not have died of coronavirus. Dire as the situation is in the cities, Nepal’s pandemic has now <a href="https://www.nepalitimes.com/editorial/nepals-humanitarian-emergency/" target="_blank" rel="noopener noreferrer">infiltrated the remotest villages</a> where there is no hospital care and no oxygen. The virus is preying on people already suffering malnutrition, previous ailments, and decades of structural state neglect. In Rolpa, Humla and other remote districts, between 80-90% of PCR tests are coming back positive, and it takes a week to get results. Patients are either not isolating, or not following precautions.Kathmandu's doctor-to-patient ratio is 1:850, but in rural Nepal it is one doctor for every 15,000 people, and hospitals and medical staff there <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/" target="_blank" rel="noopener noreferrer">are already overstretched</a>.Close to 60% of all swabs collected nationwide are from Bagmati Province, with nearly half of them in Kathmandu Valley, says epidemiologist Lhamu Yangchen Sherpa. She adds: “There just aren’t enough tests and contact tracing is minimal, official total cases and fatalities are grossly underestimated.” <figure><img width="1497" height="746" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a39c7e80680e067805jpeg.jpg" alt=""><figcaption> </figcaption></figure><figure><img width="984" height="519" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a69c7e80680e067806jpeg.jpg" alt=""><figcaption> </figcaption></figure>Hospitals in Kathmandu Valley with roof helipads have multiple daily rescue flights, but even these facilities are <a href="https://www.nepalitimes.com/banner/we-knew-the-tsunami-was-approaching/" target="_blank" rel="noopener noreferrer">at breaking point</a> with patients being turned away. Understaffed and under-equipped hospitals in the districts do not stand a chance. Even where hospitals exist, many families avoid them for fear of being infected and take wrong medication from pharmacies.Case in point are recent deaths due to misdiagnosis across the country. <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" target="_blank" rel="noopener noreferrer">Typhoid disease</a> simulates Covid-19 with similar symptoms, and the widespread Widal test is known to give false positives.“Covid patients are being prescribed antibiotics to fight typhoid, only to turn critically ill in a few days’ time,” says Buddha Basnyat of Patan Academy of Health Sciences. “This is the reason behind some of the latest Covid fatalities.” <figure><img width="1280" height="720" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85a89c7e80680e067807jpeg.jpg" alt=""><figcaption> </figcaption></figure>As in India, Nepal is beginning to see a slight bending of the curve for new infections, but health experts expect the fatality rate to remain high for some more time.  There were 190 Covid deaths in the past 24 hours and 6,543 recoveries. Of the total 8,305 new cases on Thursday, Kathmandu Valley accounts for 3,232 infections. 7,814 people are undergoing treatment in hospitals with 1,748 in ICU and 492 in ventilator support. “After the relentless patient pressure of the past month, we have seen a decline in those requiring admissions,” says virologist at Teku hospital Sher Bahadur Pun. “The virus has now infected a majority of people in the cities, and this combined with the lockdown means we may be getting to the halfway mark of the second wave.” <h2>2. Vaccines</h2> A prolonged lockdown is not the answer. If it was, the <a href="https://www.nepalitimes.com/latest/covid-19-numbers-slightly-down-in-nepal/" target="_blank" rel="noopener noreferrer">reduction in the number of cases and the positivity rate</a> this week would have been steeper. Even while the government tries to increase oxygen supply to hospitals, the only long-term strategy is to vaccinate at least 70% of Nepal’s eligible population.Doctors report a marked difference between the recovery of people who are vaccinated against those who are not. Says virologist Pun at Teku Hospital: “Except for a few rare cases, all patients in critical condition and those dying are the ones who for one reason or another had not been vaccinated.”But Nepal has run out of its vaccine stock, leaving 1.4 million people still waiting for their second dose of AstraZeneca Covishield in a lurch, after India banned its export, and the COVAX Facility could not supply its remaining 1.8 million vaccines to Nepal because of the global supply bottleneck.  <figure><img width="1440" height="1080" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85ac9c7e80680e067808jpeg.jpg" alt=""><figcaption> </figcaption></figure>The Nepal government and pressure groups in Nepal and the United States <a href="https://www.nepalitimes.com/here-now/nepal-needs-urgent-american-vaccine-support/" target="_blank" rel="noopener noreferrer">have strongly urged the Biden administration</a> to immediately rush some of its AstraZeneca doses to Nepal.Meanwhile, the UK, the US and Canada have authorised vaccines for use in children and adolescents, sparking outrage in the global public health community for prioritising an age group that is rarely critically affected by Covid-19. The World Health Organisation’s director-general Tedros Adhanom Ghebreyesus has urged rich countries to instead donate doses to the <a href="https://www.nepalitimes.com/latest/unicef-urges-g7-to-dispatch-vaccines/" target="_blank" rel="noopener noreferrer">COVAX Facility</a> for poorer states that have barely covered health workers and the most vulnerable groups. Speaking at the British Parliament last week, noted vaccinologist and the principal researcher of Oxford University’s AstraZeneca vaccine, Andrew Pollard, called the decision to inoculate children in wealthy nations ahead of high-risk groups in poorer countries “morally wrong.” Pollard has worked extensively in the region, leading research into the burden and transmission of typhoid in Nepal, Bangladesh and Malawi, and the impact of typhoid vaccine in these areas. He also runs surveillance for invasive bacterial diseases, and studies the impact of pneumococcal vaccines in children in Nepal.In Nepal, vaccination will grind to a halt this week after the current campaign to inoculate 300,000 people in the 18-59 age group with their second dose of the Chinese VeroCell ends.  <figure><img width="960" height="640" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85af9c7e80680e067809jpeg.jpg" alt=""><figcaption> </figcaption></figure><img width="960" height="640" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85b29c7e80680e06780ajpeg.jpg" alt=""><img width="960" height="639" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85b49c7e80680e06780bjpeg.jpg" alt="">Although <a href="https://www.nepalitimes.com/here-now/nepal-is-a-priority-for-vaccine-shipments/" target="_blank" rel="noopener noreferrer">Foreign Minister Pradeep Gyawali says</a> the government is in “final negotiations” for 2 million doses of Sinopharm VeroCell vaccines by June, there is no movement at the Ministry of Health. Ongoing talks to procure 8 million doses of <a href="https://www.nepalitimes.com/opinion/vaccine-geo-politics-and-sputnik-v/" target="_blank" rel="noopener noreferrer">the Sputnik V</a> have hit a production capacity snag in Russia. “We can implement lockdowns only for so long, the only exit strategy is vaccines. Science delivered, now our politicians must do the same,” says Buddha Basnyat, a physical at the Patan Academy of Health Sciences. “The Nepal government must procure vaccines using every diplomatic channel possible, and rich countries must realise that they are not safe until countries like Nepal are also vaccinated.” Activists have been trying to convince <a href="https://www.nepalitimes.com/latest/leading-public-figures-call-on-uk-government-for-oxygen-for-nepal/" target="_blank" rel="noopener noreferrer">the US government and Europeans</a> that Nepal has a lot of experience in successful vaccination campaigns against polio, smallpox, measles. It has over 50,000 female community health volunteers (FCHVs) reaching children with vaccines every year.  <figure><img width="1024" height="768" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85b79c7e80680e06780cjpeg.jpg" alt=""><figcaption> </figcaption></figure><img width="2048" height="943" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85ba9c7e80680e06780djpeg.jpg" alt=""><img width="1920" height="864" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111148/636b85bd9c7e80680e06780ejpeg.jpg" alt="">Similarly, Nepal’s health system has amassed vast experience in maintaining the vaccine cold chain even in the remote mountains. It also has trained human resource overseeing DOTS (Directly Observed Therapy, Short-course) for tuberculosis management all over the country who can lend a hand in equitable distribution of vaccines in <a href="https://www.nepalitimes.com/latest/rural-nepal-fights-back-covid-19/" target="_blank" rel="noopener noreferrer">rural Nepal</a>.Says epidemiologist Lhamo Yangchen Sherpa: “It’s not too late, we can still use existing resources like FCHVs to better mobilise vaccination, conduct contact tracing, dispel any remaining vaccine hesitancy, and use public health professionals in prevention.”

Sonia Awale

It’s an Emergency

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba4b39c7e80680e07367fjpeg.jpg" alt="" width="1500" height="1000"/><figcaption>Children in Gai Jatra procession in Kathmandu on Tuesday even as the risk of COVID-19 looms over the capital. Participants have however taken to wearing masks as mandated by the government while partaking in festivals. Photo: MONIKA DEUPALA</figcaption></figure>Prime Minister K P Oli held a meeting with 20 public health experts on Tuesday to discuss steps to deal with COVID-19, especially in <a href="https://www.nepalitimes.com/latest/heightened-covid-19-risk-at-india-nepal-border/" target="_blank" rel="noopener noreferrer">cities bordering India</a> – a sign that his government is taking a recent surge in cases seriously.The meeting came as Nepal reported 259 new cases on Tuesday, taking the total number so far to 21,009 and the number of fatalities up by one to 58. Kathmandu Valley detected 62 new cases and now has 727 confirmed cases (481 active) with 5 deaths.The government this week put six districts with over 200 cases (Kathmandu, Rautahat, Kailali, Mahottari, Parsa and Doti) in the Red Zone. (see map) In Kathmandu, 72 staff at Nepal Police Headquarters have tested positive and the premises are sealed off.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/editorial/lockdown-may-be-over-but-pandemic-is-not/" target="_blank" rel="noopener noreferrer">Lockdown may</a>be over, but pandemic is not, Editorial<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba4b69c7e80680e073680jpeg.jpg" alt="" width="1275" height="1650"><figcaption> </figcaption></figure>Speaking at the interaction, Prime Minister Oli said: “We must lower the infection rate to zero, and treat those who are sick. But as long as we keep the border open, there will be more cases ... so we have to test them before allowing them to travel to home districts.”Experts present noted that although the numbers are rising, the World Health Organisation (WHO) still puts Nepal in the ‘cluster spread’ stage, <a href="https://www.nepalitimes.com/editorial/lockdown-may-be-over-but-pandemic-is-not/" target="_blank" rel="noopener noreferrer">where the virus is not showing community transmission</a>. They advise the government against re-imposing a lockdown, saying it was not a long-term solution.Most public health experts favour a ‘smart lockdown’ where localities with cluster outbreaks are sealed off, and tested – while strictly enforcing masks in public places and preventing crowds.Since the lockdown was lifted on 21 July, the rate of infection has increased to 3.37%, indicating rapid spread in districts bordering India where all major cities like Birganj, Bitartnagar, Dhandagi, Nepalganj, Janakpur and Rajbiraj are under curfew.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba4b99c7e80680e073681jpeg.jpg" alt="" width="1265" height="822"><figcaption> </figcaption></figure>Officials in Kathmandu Valley are also said to be considering lockdown, but experts say it is more advisable to seal off neighbourhoods rather than a strict blanket closure.Medical experts fear that another shutdown is likely to kill more people than the disease it seeks to control, as people with non-coronavirus ailments cannot get to hospital for treatment, and the economy suffers even more, <a href="https://www.nepalitimes.com/latest/covid-19-leaves-millions-of-south-asian-children-hungry/" target="_blank" rel="noopener noreferrer">lowering nutrition levels</a> of people.Government figures show that there were <a href="https://www.nepalitimes.com/banner/children-are-collateral-damage-in-nepal-lockdown/" target="_blank" rel="noopener noreferrer">30% more child deaths in April-May</a> this year compared to last year. <a href="https://www.nepalitimes.com/here-now/birth-and-death-during-a-pandemic/" target="_blank" rel="noopener noreferrer">Maternal mortality has also gone up</a> because many more mothers gave birth at home instead of going to hospital. There has been a <a href="https://www.nepalitimes.com/here-now/meanwhile-a-measles-outbreak-in-nepal/" target="_blank" rel="noopener noreferrer">spike in measles</a> and other infections because of delays in vaccination campaigns.“A lockdown is not the solution to the coronavirus crisis. We must first analyse why we did not do the previous four months to take measures to control the spread,” says Sher Bahadur Pun of the Ministry of Health, “another lockdown will not make a difference.”Pun adds that uncontrolled movement of people across districts during the lockdown with thousands crossing the Indian border to reach their homes, led to the flare-up in the infection.“It is only going to get worse from here, especially as winter approaches,” predicts Buddha Basnyat of Patan Academy of Health Sciences. “We have to accept this and prepare for it, but another lockdown is only the last resort.”Basnyat says the government has to get on a war-footing to <a href="https://www.nepalitimes.com/editorial/open-and-shut-case/" target="_blank" rel="noopener noreferrer">increase testing in the Tarai districts</a> enforce mask-wearing and physical distancing, and as the number of severe cases rise, develop a treatment taskforce.Hospitals should be better equipped to handle the increase in symptomatic and severe coronavirus cases being seen now, with clear treatment guidelines identifying the most effective drugs and therapies for Nepalis, so there is no expensive over-prescription.As the ICUs get filled up, there is an urgent need for ventilators and oxygen concentrators, Basnyat adds. There are now 36 patients with COVID-19 across the country, with 23 in Bagmati Province, which includes Kathmandu Valley. Birganj is said to have reached saturation in ICU capacity, and hospitals in other Tarai cities are also filling up.Health experts say that while Nepal may not be able to build hospitals in a week like Wuhan did, the government can start mass testing in the high-risk zones, set up tents and ICU beds and stockpile life-saving drugs and medical equipment.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba4bd9c7e80680e073682jpeg.jpg" alt="" width="858" height="671"><figcaption> </figcaption></figure>Experts are also advocating for regular mass testing in cities with more movement of people. And if there is indeed another lockdown, they say testing in densely populated urban centres is a must.A recent surveillance based on swab samples of 10,000 of the people who entered Kathmandu Valley last week found that 0.7% of them tested positive for SARS-CoV-2. Despite this seemingly low positivity rate, health officials say that the finding is significant because those individuals would have been carriers in their families and communities.More worryingly, there is now a rise in cases with serious symptoms across Tarai districts, unlike in the past when most were asymptomatic or had co-morbidity. Hospitals in the Tarai are seeing a surge of typical COVID-19 symptoms with advanced pneumonia.“Most hospitals and doctors in Nepal are now starting to feel the devastation this virus can cause, as it did in Lombardy, New York and parts of India,” says Buddha Basnyat. “Which is why despite low fatality rate in this part of the world and the concept of herd immunity, there is no time to be complacent.”A rise in influenza in the rainy season could also be a reason for misdiagnosis because flu and COVID-19 have similar symptoms. Experts suggest flu to be tested with COVID-19, especially as winter approaches.But even with all the planning in the world, strategies, drugs and medical infrastructure, the most effective tools against the virus are the three <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/" target="_blank" rel="noopener noreferrer">simple safety measures</a>: physical distance, masks and hand hygiene.Says Sher Bahadur Pun: “Testing, tracing and treating are important. Government action is crucial. But how strictly Nepalis follow safety guidelines and adapt it into their everyday lives will make the most difference.”

Experts caution against extending Nepal lockdown

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141136/636badaf9c7e80680e077fabjpeg.jpg" alt="" width="1400" height="933"/><figcaption>Photo: GOPEN RAI</figcaption></figure>On Friday, it will be four months since Nepal closed the country down to prevent the spread of  SARS-CoV-2, the virus strain that causes COVID-19. Of the 40 who have died of the infection in Nepal, two are children below 5.But many more children have died during the four months of lockdown compared to the same period last year because of lack of access to health care due to the restriction on mobility, interrupted vaccination campaigns and the lack of medicines.However, the coronavirus grabs all the headlines. Mortality due to non-COVID-19 causes does not make the news – even though it is clear that a lockdown enforced to control one disease has caused far more deaths from other prevalent diseases, and threatens to undermine Nepal’s progress in infant and child survival over the past four decades.“The COVID-19 crisis and lockdown have pushed many families into poverty, many have lost their sources of income, l<a href="https://www.nepalitimes.com/latest/eu-unicef-support-child-nutrition-during-lockdown/" target="_blank" rel="noopener noreferrer">eading to malnourishment among children</a>,” says Jhalak Gautam of the Child Health Division at the Health Ministry. “Increased malnutrition means children are more susceptible not only to COVID-19 but to many other infectious diseases such as measles and diphtheria.”Under-5 child mortality rate in Nepal had declined substantially from 271 deaths per 1,000 live births in 1969 to 32 in 2018. Government figures show that since 17 July 2018-16 July 2019, a total of 1,357 children under 5 died of various infectious diseases all over the country. Preliminary figures for the same period 2019-2020 is 1,263 – even though only 78% of the data has been collected.Initial government figures also show that a total of 204 children under 5 have died across the country during the lockdown between 14 March-14 June. This number was at a much lower 151 during the same period last year.This data clearly show that the total child death numbers collected by Female Health Care Volunteers is higher this year — meaning they died at home. The number of those who have died at hospital in the same three months this year is lower than last year probably because parents are not taking children to hospital when they are sick during the lockdown.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141140/636badb39c7e80680e077facjpeg.jpg" alt="" width="1714" height="1210"><figcaption> </figcaption></figure>An expert at the Health Information Management System says when all the data for this year comes in, it is bound to be much higher than last year. This means the lockdown has pushed Nepal back in meeting its health targets under the United Nations’ SDGs (Sustainable Development Goals).Under the SDG target, Nepal is supposed to bring child mortality down further to 25 deaths per 1,000 live births by 2030. Persistent childhood malnutrition is a major reason for infant and child mortality remaining high despite dramatic progress in the 1990s. <a href="https://www.nepalitimes.com/banner/nearly-half-of-nepali-children-still-malnourished/" target="_blank" rel="noopener noreferrer">Figures for stunting, wasting and anaemia in Nepal have plateaued in the last decade</a>  Now, the lockdown has added to the challenge.Says Elke Wisch, UNICEF Representative to Nepal: “Progress made on children’s nutrition in the last decade is at risk of being reversed as rising numbers of children are facing malnutrition due to loss of household income and resulting food insecurity. The social and economic loss for Nepal resulting from the deterioration in children’s nutrition status will be felt long after the COVID 19 crisis is over.”The lockdown has also disrupted <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" target="_blank" rel="noopener noreferrer">vaccination campaigns</a> across the country, leading to <a href="https://www.nepalitimes.com/here-now/meanwhile-a-measles-outbreak-in-nepal/" target="_blank" rel="noopener noreferrer">measles outbreaks in Dhading and Gorkha</a> in April. Although regular immunisation services have now been restored in health facilities in all 77 districts, parents have been unable to take their children for shots because of restrictions on transportation and also because of the fear of COVID-19 transmission in health posts.In fact, the WHO and UNICEF earlier this week stated that preliminary data for the first four months of 2020 points to a <a href="https://www.who.int/news-room/detail/15-07-2020-who-and-unicef-warn-of-a-decline-in-vaccinations-during-covid-19" target="_blank" rel="noopener noreferrer">substantial drop in the number of children completing three doses of the vaccine</a> against diphtheria, tetanus and pertussis (DTP3), first time in 28 years. Moreover, at least 30 measles vaccination campaigns were or are at risk of being cancelled, which could result in further outbreaks in 2020 and beyond.“Vaccines are one of the most powerful tools in the history of public health, and more children are now being immunised than ever before,” said Tedros Adhanom Ghebreyesus, WHO Director-General. “But the pandemic has put those gains at risk. The avoidable suffering and death caused by children missing out on routine immunizations could be far greater than COVID-19 itself.”With schools closed for the past four months, children in many schools are also not getting their lunches. Domestic violence has also seen a spike during the lockdown, with many of the victims children. There is also evidence of a <a href="https://www.nepalitimes.com/latest/child-marriages-up-during-nepal-lockdown/" target="_blank" rel="noopener noreferrer">rise in child marriage</a>  anxiety, stress and <a href="https://www.nepalitimes.com/here-now/post-pandemic-mental-health-epidemic/" target="_blank" rel="noopener noreferrer">mental disorder</a>Nepal appears to be on track to proving correct the grim prediction in May by the Johns Hopkins Bloomberg School of Public Health that 1.2 million children worldwide could die from pre-existing diseases like malaria, pneumonia or diarrhoea in the next six months due to the disruption to health services and food supplies due to the lockdown. That makes <a href="https://www.nepalitimes.com/latest/pre-existing-diseases-may-kill-more-children/" target="_blank" rel="noopener noreferrer">6,000 fatalities a day</a> – a whopping 45% rise in child mortality.“Under a worst-case scenario, the global number of children dying before their fifth birthdays could increase for the first time in decades,” UNICEF Executive Director Henrietta Fore warned. “We must not let mothers and children become collateral damage in the fight against the virus. And we must not let decades of progress on reducing preventable child and maternal deaths be lost.”<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109141140/636badb69c7e80680e077fadjpeg.jpg" alt="" width="3600" height="2400"><figcaption> </figcaption></figure>Another aspect of the pandemic that Nepal has to be careful about is that while worldwide data show that children are relatively safe from contracting SARC CoV-2 which has mainly affected people above 70 years, in Nepal children also seem vulnerable.Health Ministry data show that the rate of infection among children below 5 is 2.2% and increasing – much higher than the global average. The infection rate among young children was at just 1% a month and a half ago.Many of the infected children belong to families who returned from India in the past three months, but children have also been infected by people who flouted lockdown rules and safety measures. This is why Far-west Province has the highest coronavirus infection rate among children at 5%.Nepal has also seen a <a href="https://www.nepalitimes.com/latest/why-are-younger-people-in-poor-countries-dying-of-covid-19/" target="_blank" rel="noopener noreferrer">disproportionate number of COVID-19 infections and mortality among a younger population</a>  Experts say this is mainly due to young returnee migrant workers from India, Malaysia and the Gulf, who make for the majority of the coronavirus cases in the country. Moreover, testing across the country so far has focused on returnees.“Unlike elsewhere, in Nepal people with co-morbidity have a higher risk of dying regardless of the age group, and this is worrying,” says epidemiologist Sher Bahadur Pun of the Health Ministry. “But we must widen our testing to come to a concrete conclusion about this. So, <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/" target="_blank" rel="noopener noreferrer">until we have a vaccine</a> we must wear masks, maintain physical distance and follow hand hygiene. This includes children.”

Children are collateral damage in Nepal lockdown

<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

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