<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

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It’s an Emergency

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101132/636b73f19c7e80680e062367jpeg.jpg" alt="" width="1500" height="1016"/><figcaption>Photo : MONIKA DEUPALA</figcaption></figure>Last November, a speeding bus in Argakanchi lost control and tumbled down a mountain, killing 19 and injuring 18 passengers. Three weeks later, another bus careened off a serpentine road in Sindhupalchok, killing 16 and wounding 18.Seven Nepalis die every day in <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" target="_blank" rel="noopener">road and highway accidents</a>. Shocking though that statistic might be, the number of injured is much higher. On average, 40 people are injured on roads across the country each day. Last year, there were nearly 13,000 road accidents in which 2,736 people lost their lives and 10,731 were seriously injured.Read also: <a href="https://www.nepalitimes.com/?p=40237&amp;preview_nonce=7ab9966f81&amp;preview=true" target="_blank" rel="noopener">It’s an emergency: Nepal needs to improve trauma care</a>, Sanghamitra Subba<a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/accident-prone-Mugling-Narayangadi-highway,3828" target="_blank" rel="noopener">Highway accidents</a> are now the biggest killer of young men and women in the country. The causes are usually carelessness and speeding, and poorly-maintained roads and vehicles. The number of accidents are rising faster than the increase in the number of vehicles.Those who survive often have traumatic brain and <a href="http://archive.nepalitimes.com/news.php?id=6946" target="_blank" rel="noopener">spinal cord injuries</a>, requiring long-term or life-long rehabilitative care. But the state of rehabilitation in Nepal is nearly non-existent. There is no government rehabilitation centre, and while some private hospitals do offer inpatient physiotherapy, none have dedicated acute rehabilitation units and none employ physical medicine and rehabilitation consultants.“Forget about prioritising it, rehabilitative medicine is not even included in the healthcare system of Nepal,” laments Raju Dhakal, the only physical medicine and rehabilitative doctor registered in Nepal. “Every hospital has a cardiology unit, intensive care unit and even physiotherapy but no rehabilitation unit. This should be integrated in the healthcare system rather than treated as a separate entity.”The <a href="https://www.facebook.com/SpinalNepal/" target="_blank" rel="noopener">Spinal Injury Rehabilitation Centre</a> (SIRC) in Sanga, founded in 2002, is Nepal’s largest inpatient rehabilitation centre and the only one specialised in spinal cord injury. The 51-bed hospital treats patients from all 77 districts and provides inpatient rehab for 300 individuals a year.It also conducts outpatient care, home follow-up visits, community outreach programs, and a residential vocational rehabilitation program to help people with disabilities integrate back into society and to better equip thier families to deal with their special needs.The only other facilities with dedicated inpatient rehabilitation beds are <a href="https://gphospital.org/" target="_blank" rel="noopener">Green Pastures Hospital</a> in Pokhara and the <a href="https://www.hrdcnepal.org/" target="_blank" rel="noopener">Hospital for Rehabilitation and Disabled Children</a> in Kavre.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101132/636b73f49c7e80680e062368jpeg.jpg" alt="" width="1500" height="1065"><figcaption> </figcaption></figure>“Usually two physical medicine and rehabilitation specialists are needed for every 100,000 people. This means we need 500 specialists in Nepal, and instead we have one,” says Manoj Sivan, associate professor of rehabilitative medicine at Leeds University in the UK, who says the gap in rehabilitative care can be bridged with telemedicine.“Tele-rehabilitation can link the people in the community with specialists to provide necessary interventions remotely, allowing them to the save time and money spent travelling to the centre,” adds Sivan, who was in Nepal last month with a team of researchers to launch a six-month pilot project called Tele-rehabilitation Nepal (TERN) in collaboration with SIRC (above).Unlike <a href="https://archive.nepalitimes.com/article/nation/long-distance-medicine-in-nepal,3521" target="_blank" rel="noopener">other telemedicine consultations</a> where a patient has to visit a health post to connect with doctors based in cities, in tele-rehab a social worker from SIRC visits patients, finds out their needs and then connects them with a specialist team that consists of a physician, physiotherapist, occupational therapist, nurse and  psychologist.Patients with long-term disabilities and their families learn about better management of bladder, bowel and pain, as well as exercise techniques to help mobility.The idea for e-rehab first came to Dhakal when a paraplegic patient from Surkhet visited SIRC and was unable to pay a minimal consultation fee. She had spent Rs45,000 to hire a jeep and had to pay for extended hotel stay for herself and two relatives. “It hit me hard,” Dhakal recalls. “This country’s topography makes accessing healthcare stressful for most Nepalis.”Besides those with <a href="http://archive.nepalitimes.com/article/Nepali-Times-Buzz/paraplegic-ram-bahadur-tamang-travels-from-namo-buddha-to-lumbini,1303" target="_blank" rel="noopener">spinal injuries</a> caused by highway accidents, tele-rehabilitation is useful for those recovering from other medical emergencies like strokes and also for general medicine.The Nepal Government’s 2016 Policy, Strategy, and Ten Year Action Plan on Disability Management plans for every province to have at least one fully equipped rehabilitation centre and established orthotics/prosthetics workshop in the next ten years. SIRC is also working with the Ministry of Health to develop another 100-bed hospital to provide specialised rehabilitation care.Added Dhakal: “Sooner or later the government has to take responsibility and decentralise rehabilitative care. This will allow us to train more people and supervise other centres to decentralise rehab.”<h2>Wheelchair doctor treats patients in wheelchairs</h2>As the only physical medicine and rehabilitation doctor in Nepal, Raju Dhakal (left) has a lot on his plate. His days are packed with back-to-back consultations with rehabilitation patients. The 37-year-old does this with ease as he moves about in his wheelchair greeting patients at Spinal Injury Rehabilitation Centre (SIRC) at Sanga, Kavre.Dhakal himself was diagnosed with poliomyelitis when he was two-and-half years old. Originally from Gorkha, he came to Kathmandu and lived in SOS Children’s Village while undergoing treatment. He started school at age seven, and learned to read and write at the same time as he learned to use crutches.Read also: <a href="https://www.nepalitimes.com/review/new-life-for-khagendra-b-basnyat/" target="_blank" rel="noopener">New life for Khagendra B Basnyat</a>, Sewa BhattaraiWith an MBBS from Kathmandu Medical College, Dhakal went on to receive an MD in Physical Medicine and Rehabilitation in Dhaka.“At daily rotations during my internship, there was one patient that every doctor skipped. He was undergoing rehabilitation after treatment for a spinal injury. No one could do anything for him so he remained there in a corner of that ward,” recalls Dhakal. “This opened my eyes to a gaping hole in medical care in Nepal.”Dhakal went on to become honorary clinical fellow at the Department of Rehabilitative Medicine at the <a href="https://medicine.unimelb.edu.au/research-groups/medicine-and-radiology-research/royal-melbourne-hospital" target="_blank" rel="noopener">Royal Melbourne Hospital</a> in Australia. He trained in Spinal Cord Medicine and Rehabilitation in Ireland, Canada and Switzerland.“In Nepal we are still very focussed on diagnosis and acute treatment. But what about residual paralysis in case of trauma, traumatic brain injuries and spinal injuries?” asks Dhakal. “Long-term rehabilitative care for patients with disabilities is severely lacking. We need more facilities for specialised rehabilitation care.”

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Injured use Internet to get rehab care

<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

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107171136/636934889c7e80680e03dfffjpeg.jpg" alt="" width="1400" height="700"/><figcaption>Photo: UNICEF</figcaption></figure>Polio eradication is one of the most ambitious public health initiatives undertaken in human history. Launched in 1988 by the World Health Organization (WHO) the campaign aimed to rid the world of the virus by 2000. But 30 years on and $15 billion later, even though polio cases worldwide have been reduced by 99%, there are still isolated pockets of the disease. And unless every last case is removed, there will always a chance that the infection will come back.Encouraged by the eradication of small pox, WHO launched the campaign in 1988. The organisation debated the wisdom of spending so much time and money to exterminate a disease when there were many other more pressing health concerns like <a href="http://malaria https://www.nepalitimes.com/here-now/the-mosquito-that-changed-nepals-history/" target="_blank" rel="noopener">malaria</a>, <a href="https://www.nepalitimes.com/banner/tb/ or diarrhoea" target="_blank" rel="noopener">TB</a> or diarrhoea that kill many more people.https://www.youtube.com/watch?v=KQd_-6W_9Gg&amp;feature=youtu.beThomas Abraham, a journalist who taught health reporting at the University of Hong Kong, has tried to answer this and other questions in his new book <a href="https://www.amazon.co.uk/Polio-Odyssey-Eradication-Thomas-Abraham/dp/1849049564" target="_blank" rel="noopener">Polio: The Odyssey of Eradication</a>. He says polio was held hostage by geopolitics, and traces the reason why countries opted for a weak vaccine against a strong virus. The author concludes that future global campaigns that zero in on just one disease must be weighed against the necessity of upgrading public health, especially in poorer countries.In Nepal, indigenous <a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Bouncing-back-higher-wheelchair-basketball,3802" target="_blank" rel="noopener">polio</a> was eliminated in 2000 after the country responded to WHO’s eradication goal by adding polio to its successful campaign of vaccination against other diseases. However, there were still polio cases in Nepal brought over the border from India. The last case of polio was detected in Rautahat district in 2010, and <a href="http://archive.nepalitimes.com/blogs/thebrief/2014/03/28/polio-free-nepal/" target="_blank" rel="noopener">Nepal was finally declared polio free</a> four years later.In response to a query from Nepali Times this week, however, Abraham said Nepal is not out of the woods yet. “If polio re-emerges in India, particularly UP and Bihar, this would be a major challenge to Nepal,” he said. “Also, if levels of routine childhood immunisation fall in Nepal there is a danger of outbreaks of vaccine derived polio, as we are seeing in a number of countries.”Even though polio has been largely removed, there are still cases in Pakistan, Afghanistan and Nigeria where vaccination campaigns have been thwarted by religious extremists. Ironically, enmity between India and Pakistan and the heavily guarded border between the two countries has minimised the risk of polio spreading via India to Nepal.Polio derived from oral vaccines has emerged as a new threat to the eradication campaign. By 2016, WHO deployed a combination of Inactivated Polio Virus (Salk vaccine) and bivalent oral vaccine to prevent further outbreaks.“Routine immunisation levels need to remain high in order to maintain Nepal’s polio-free status. Luckily, we have a strong disease surveillance system to detect any new polio cases,” said Jhalak Sharma Gautam of the Department of Health Services.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107171136/6369348b9c7e80680e03e000jpeg.jpg" alt="" width="640" height="869"><figcaption> </figcaption></figure><a style="background-color: #ffffff; font-size: 15px; letter-spacing: 0.01em;" href="http://archive.nepalitimes.com/news.php?id=16116#.W_aWJTgzaUk" target="_blank" rel="noopener">Polio</a> is one of the oldest diseases to afflict humans, but it wasn’t until the beginning of 20thcentury that there were outbreaks in Europe, North America and Australia. US President Franklin D Roosevelt was paralysed by poliomyelitis, and because of this the US threw considerable political influence and funds to back polio vaccine research.The first was the Salk vaccine that used inactivated poliovirus, and protected individuals injected with right dose, but it did not stop the transfer of the disease. The Sabin vaccine in 1961 employed a weakened poliovirus to be administered orally. It was cheaper and easier to use and protected individuals from paralysis as well as stopped polio transmission, which eventually led to it being chosen as a tool of eradication.Despite its success, the Global Polio Eradication campaign has been criticised for its huge cost and for widening the gap between local health needs and global health programs. In his book, Abraham puts his experience as a foreign correspondent to good use by visiting the frontlines of the battle against polio in Pakistan, India and Nigeria. He writes about the <a href="https://www.nytimes.com/2018/01/22/health/polio-pakistan-killing.html" target="_blank" rel="noopener">assassinations of polio vaccinators in Pakistan</a> and Afghanistan by the Taliban.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221107171136/6369348e9c7e80680e03e001jpeg.jpg" alt="" width="1250" height="441">A considerable portion of the book deals with a long-standing debate about whether targeting a single disease for eradication should take precedence over strengthening national health systems. This resonates with WHO’s own reluctance to endorse polio eradication for a long time in favour of a strong primary health care system.This book is a recommended read for public health professionals, but it has lessons for anyone who wants to better understand the inner workings of health systems, donor agency priorities, and what goes on behind the scenes in Geneva.Abraham is neither an epidemiologist nor a medical practitioner, he is a journalist with over 25 years of experience covering conflict, politics and health. Maybe that is why the book reads more like a thriller with an engaging real-life account of what goes right (and what can go wrong) in the fight against a disease-causing pathogen.Read also:<a href="https://archive.nepalitimes.com/article/Nepali-Times-Buzz/Bouncing-back-higher-wheelchair-basketball,3802" target="_blank" rel="noopener">Bouncing back</a>, Shreejana Shrestha<a href="http://archive.nepalitimes.com/news.php?id=16116#.W_aWJTgzaUk" target="_blank" rel="noopener">Laxmi dreams of flying</a>, Rupa Joshi

Polio hunt

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