<a href="https://www.nepalitimes.com/banner/dengue-days-are-here-to-stay">Dengue ravaged Nepal last monsoon</a>, with over 55,000 hospitalisations and 88 fatalities. But that is just the official count, and many who died from the mosquito borne virus that caused haemmorhagic fever were healthy adults. Public health experts had warned last year that the virus would strike again in the 2023 rainy season because the virus hibernated with the larvae of infected mosquitos. They say the larvae are just waiting for the puddles to hatch, and with it the virus can again spread exponentially. Waiting until the monsoon to target mosquito breeding areas will be too late. “Local government must start the search-and-destroy larvae campaign now, we cannot wait for the rains,” warns virologist Sher Bahadur Pun at Teku Hospital. “Dengue is a real public health crisis and we cannot prevent it without the government and the communities working together, individual precaution can only go so far.” The key is to raise awareness, preferably through school children so that we can reach their families and subsequently the community at large, about the nature of aedes mosquito that carries the dengue virus and the protective measures. Last year, almost every family in Kathmandu had multiple members suffering from <a href="https://www.nepalitimes.com/news/state-of-malaise">dengue</a>. Although 90% of patients were asymptomatic, they helped spread the virus.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230408040436_c88bd2e1183ab33f7763f64b18be6b6945cfae7fa1a6c1b793c9ffdeb3cf739f.jpg" data-media-id="editor_2" data-image-id="20230408040436_c88bd2e1183ab33f7763f64b18be6b6945cfae7fa1a6c1b793c9ffdeb3cf739f" data-rendition-name="original" width="5827" height="3885" loading="lazy" alt="dengue"> <figcaption>Photos: SUMAN NEPALI</figcaption> </figure>  Dengue patients generally have two weeks of high-grade fever accompanied by extreme muscle and joint aches, loss of appetite, nausea, and pain in the eye sockets. Many who had both dengue and Covid said dengue was much worse. <a href="https://nepalitimes.com/news/another-covid-wave-but-milder">Covid-19 is also back again</a>, possibly with a circulation of a new variant in the region. So all three levels of government must prepare for both outbreaks simultaneously. “Dengue is among the biggest public health challenges of the 21st century, given the disease burden and its socioeconomic impact in these parts of the world,” says Buddha Basnyat, physician at Patan Academy of Health Sciences. “And there is every potential of another outbreak given that we have not learned our lesson from previous outbreaks or taken any measures to prevent another one this year.” Indeed, Kathmandu had a major dengue outbreak in 2019, just before Covid-19 spread out of China in December of that year. There were over 17,000 official cases that monsoon but they were largely adult patients, most of which had milder symptoms and the fatality was very low. But <a href="https://www.nepalitimes.com/banner/as-covid-abates-nepal-sees-dengue-outbreak">last year’s outbreak</a> was much more widespread and serious. Although debilitating, fatality from dengue is rare but there were more complications and deaths. The mosquito eradication campaign came too late, and by that point dengue was out of control. We did not learn the lessons of 2019, and we haven’t learned the lessons of 2022. “How not to get dengue? It is simple, do not get bitten by a mosquito,” says Pun. “But preventing a mosquito bite is anything but simple because we do not do anything until it is too late.” Unlike the anopheles mosquito which carries the malaria parasite, aedes is active during the daytime, particularly in the early hours of the morning and evenings. This means avoiding the outdoors during these hours, if possible. So, mosquito net or coils at night do not help. Insect repellents should not be toxic, and contain the active ingredient that the aedes mosquito avoids. Full-sleeve clothes are always a better alternative.  <figure> <img src="https://publisher-publish.s3.eu-central-1.amazonaws.com/pb-nepalitimes/swp/asv65r/media/20230408040436_960e7fc347fa61878bfa623db07296c1e068a4c932f1257bbc43b70a56e7421b.jpg" data-media-id="editor_5" data-image-id="20230408040436_960e7fc347fa61878bfa623db07296c1e068a4c932f1257bbc43b70a56e7421b" data-rendition-name="original" width="1000" height="699" loading="lazy" alt="dengue"> </figure>  Also important is the knowledge of the breeding habits of aedes mosquito. Any pool of water is a fertile breeding ground, even egg shells and water bottle caps in garbage piles. &nbsp;Fumigation, as some Kathmandu wards did two months into the outbreak last year, was ineffective because the virus was already spreading from already-infected people. In short, destroying the larvae by removing possible breeding sites is the best preventive measures. “Every step that the government took last year after the onset of the pandemic, take them now. In fact, the people should pressure their local governments to do so right away,” adds Basnyat. Unlike Covid and most other infectious diseases, a dengue reinfection is even more dangerous and can be fatal. <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(20)30007-3/fulltext">Writing in the journal The Lancet</a> in 2020, authors Sudeep Adhikari, Buddha Basnyat and Kripa Maharjan explain: ‘Primary infection with any serotype in a non-immune population generally causes mild disease. When secondary infection with another serotype occurs in the same population, there is antibody-dependent enhancement, which usually causes severe dengue. Over time, this secondary infection might lead to a so-called explosion of the disease.’ Such an explosion occurred in 2022 in Nepal’s urban areas, affecting mostly children and young adults. Misdiagnosis also caused complications in patients. Hospitals were overwhelmed and many patients had to be turned away. There was rampant overtreatment, often with antibiotics which are ineffective against viruses. With global warming, disease vectors like mosquitos and the virus are also <a href="https://www.nepalitimes.com/news/nepal-s-dengue-outbreak-exposes-climate-risk">moving to higher altitudes</a> spreading not just dengue but malaria, kalazar and chikungunya. &nbsp; Additional reporting by Ritika Tewari.

Sonia Awale

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New dengue outbreak likely this monsoon

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204ac9c7e80680e0b2875jpeg.jpg" alt="" width="960" height="641"/><figcaption>Crowd of people lining up for Covid vaccination outside Teku Hospital on Tuesday. Photos: AMIT MACHAMASI</figcaption></figure>During the devastating second wave last year, hundreds of people were dying every day. Hospitals had <a href="https://www.nepalitimes.com/here-now/helping-nepalis-breathe-again/" target="_blank" rel="noopener noreferrer">run out of ICU beds and oxygen cylinders</a>.This time, hospitals are running out of medical staff.As elsewhere, <a href="https://www.nepalitimes.com/here-now/3rd-wave-in-2-years/" target="_blank" rel="noopener noreferrer">the third wave</a> in Nepal is infecting healthcare workers, endangering not only patients with Covid pneumonia, but also those suffering from pre-existing conditions like kidney failure, diabetes, cancers or cardio-vascular diseases.This acute shortage in medical staff across Nepal due to the rapid spread of Omicron has prompted the Ministry of Health to consider shortening the isolation period for doctors, nurses and paramedics to five days. The US and India have already done so.Hundreds of <a href="https://www.nepalitimes.com/here-now/nepal-health-workers-battle-covid-19-but-also-stigma/" target="_blank" rel="noopener noreferrer">health workers</a> are testing positive daily in hospitals all over the country, turning health facilities themselves into a hotbed of the virus.On Tuesday, there were 10,258 new cases out of 22,828 tested, bringing the positivity rate up to 45%. This is the highest ever daily new cases for Nepal and also the highest positivity rate.International airlines flying out of Kathmandu are reporting a sharp increase in the number of passengers who cannot fly because of the PCR positive test results. So far passengers on domestic flights are not required PCR tests, only vaccine cards from next week.“Omicron is spreading like wildfire through all hospitals, in ours alone we have 35 staff testing positive,” says <a href="https://www.nepalitimes.com/banner/nepals-far-sighted-eye-care/" target="_blank" rel="noopener noreferrer">Sanduk Ruit</a> of Tilganga Eye Hospital in Kathmandu.One of the bigger facilities in Kathmandu, HAMS Hospital, has 16 of its clinical staff in isolation after testing positive. On 17 January, 52 staff of the Trauma Centre Hospital tested positive in one day, affecting emergency care of accident victims.Teaching Hospital and Bir Hospital in the Valley also have a similarly high number of doctors and nurses infected and isolating.“Health workers in every ward are infected, Covid has now spread from the emergency to the general ward, the blood bank, physiotherapy, ICU and even the administration,” director of the Trauma Centre Pramod Joshi told Nepali Times.The hospital is now primarily treating patients that need emergency care and surgery. “The hospital is full of patients and the ICU is packed as it always is,” he said.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204ae9c7e80680e0b2876jpeg.jpg" alt="" width="1641" height="1000"><figcaption> </figcaption></figure>The third wave has now even affected hospitals outside Kathmandu, which are struggling to cope due to a shortage of staff.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/state-of-the-art-rural-hospital/" target="_blank" rel="noopener noreferrer">Bayalpata Hospital</a> in remote Achham district has curtailed some critical services like C-sections because of sick staff. Charikot hospital in Dolakha district which had finally stopped reporting new Covid infections only last month is back to caring for an increasing number of coronavirus patients but with fewer staff.“Some of us have mild but manageable symptoms but we are still working, we had a shortage of healthcare workers even before this third wave,” Binod Dangal of Charikot Hospital said. “In fact, we have fewer people than we had during the second wave, we have equipment but no trained staff. We are no better prepared than we were before.”The only respite during the third wave is that the new strain is much milder. Because Omicron’s impact is largely confined to the upper respiratory tract, physicians say their patients do not need as much oxygen or ventilator support as was the case with the Delta variant which primarily affected the lungs.Most doctors in and <a href="https://www.nepalitimes.com/here-now/at-the-covid-19-frontlines-in-rural-nepal/" target="_blank" rel="noopener noreferrer">outside Kathmandu</a> say they expect infected staff to be back at work in a week after another test. Even so, given Nepal’s largely unprepared and limited healthcare infrastructure which works on a shift basis, medical staff having to isolate just a few days can seriously disrupt medical care, especially in rural areas where hospitals and doctors were always few and far between.Indeed, this latest crisis reflects on a pre-existing chronic shortage of doctors, nurses and trained medical staff, says <a href="https://www.nepalitimes.com/opinion/diary-of-a-covid-frontline-worker-in-nepal/" target="_blank" rel="noopener noreferrer">Bikash Gauchan</a> of the Gandaki Province Infectious and Communicable Disease Hospital in Pokhara.“What we are experiencing now is both an acute and chronic shortage of healthcare workers, and this carries a lesson for our government, to strengthen and prepare its medical resources for future pandemics,” he adds.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/here-now/boosting-booster-jabs-against-omicron/" target="_blank" rel="noopener noreferrer">Booster shots for frontliners</a> including healthcare workers in Nepal  started this week, and the additional dose will provide much needed protection to doctors and nurses who work in close contact with possibly infected patients.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204b29c7e80680e0b2877jpeg.jpg" alt="" width="960" height="641"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204b49c7e80680e0b2878jpeg.jpg" alt="" width="960" height="641"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204b79c7e80680e0b2879jpeg.jpg" alt="" width="960" height="641"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022111410114/637204ba9c7e80680e0b287ajpeg.jpg" alt="" width="960" height="641">But crowded vaccination centres (pictured above) themselves risk being breeding grounds for infection. This time the queues are not just of the unvaccinated getting their first jabs, but also those waiting for boosters. Even if vaccinated, doctors say masks and physical distancing are mandatory.They warn the public <a href="https://www.nepalitimes.com/here-now/omicron-may-not-be-as-risky-but-take-care/" target="_blank" rel="noopener noreferrer">not to be complacent</a> because they are vaccinated and that Omicron is milder. Binod Dangal of Charikot Hospital says: “Most people are treating Omicron as a normal cold but it is very important for us to monitor the progress of the disease in the next few weeks, and prepare for adequate critical care.”At Nepal’s biggest infectious disease centre Teku Hospital, virologist Sher Bahadur Pun cites scientific studies to say that the shortage of healthcare workers will not persist, and the isolation period can be reduced. Nepal has likely passed the most infectious stage of <a href="https://www.nepalitimes.com/here-now/living-with-covid-in-2022/" target="_blank" rel="noopener noreferrer">Omicron spread</a> and it is now time to keep a close watch on people isolating at homes and in hospitals.Pun adds: “We must also investigate which strain is causing Covid deaths in Nepal because if Omicron had indeed replaced Delta, our figures for mortality should not be as consistent as it was before the third wave.”

3rd Covid wave infects Nepal’s frontliners

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111152/636b86709c7e80680e067854jpeg.jpg" alt="" width="1308" height="870"/><figcaption>Photos: AMIT MACHAMASI</figcaption></figure>The Covid-19 pandemic has already claimed the lives of 3.5 million people, worldwide, according to the World Health Organisation (WHO), although <a href="https://covid19.healthdata.org" target="_blank" rel="noopener noreferrer">Institute for Health Metrics and Evaluation</a> (IHME) puts the figure at an horrific 7.5 million -- projecting 9 million global deaths by September 2021.Waves of Covid-19 infections across the world have severely challenged health systems in the richest countries, but have been catastrophic for nations with more <a href="https://www.nepalitimes.com/here-now/protecting-those-who-protect-us-from-covid/" target="_blank" rel="noopener noreferrer">limited health infrastructure</a>. It is predominantly older adults and those with other health conditions who are most seriously affected by the virus, but the impact on health services indirectly affects those seeking help for other health problems, and the pandemic has further affected economic resilience of nations and families. Quite simply, <a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.facebook.com/the.university.of.oxford/posts/10165377035860107" target="_blank" rel="noopener noreferrer">we are all affected by the pandemic.</a>Against this backdrop, the wave of infections across South Asia this month is a cause for huge concern, with the reality of the pandemic being felt today so <a href="https://www.nepalitimes.com/here-now/its-an-emergency/" target="_blank" rel="noopener noreferrer">acutely by the people of Nepal</a>. It is a pain I have shared, having worked very closely for the past 16 years with a talented team of doctors and researchers at Patan Hospital, Lalitpur, (led by Dr Shrijana Shrestha and Dr Buddha Basnyat) researching infectious diseases and vaccines in children.Today, I feel so far away, more than 4,500 miles from Kathmandu, and rather helpless as the media vividly brings the news of Nepali political debates, lockdowns, individual suffering, <a href="https://www.nepalitimes.com/latest/why-is-there-still-an-oxygen-shortage/" target="_blank" rel="noopener noreferrer">oxygen shortages</a> and the selfless dedication of the hospital staff into my living room.In early 2020, I started work with other academics in Oxford on the development of the Oxford-AstraZeneca/Covishield vaccine. My role was leading clinical trials of the vaccine, starting on 23 April 2020, and eventually enrolling 24,000 volunteers in the UK, Brazil and South Africa during the course of the year.In the trials, half of the volunteers were given <a href="https://www.nepalitimes.com/banner/despite-doubts-nepal-sticks-with-astrazeneca-jabs/" target="_blank" rel="noopener noreferrer">the Oxford vaccine</a> and the other half received a ‘control’ vaccination which wasn’t designed to protect against coronavirus. We then compared the number of people who developed infection in the two groups and found that disease was reduced by around 70% in those who received the vaccine.Importantly, the vaccine prevented all hospitalisations and deaths. These amazing findings were recently confirmed in a trial of the vaccine in the United States. Our vaccine is remarkably effective. The trials also taught us that the vaccine had the potential to reduce the risk of transmission of the coronavirus by blocking infection and reducing the amount of virus in the throat of those who did catch it.Since 4 January 2021, the Oxford vaccine has been used in the UK, and the national rollout has shown how powerfully effective vaccines are in ‘real world’ use, with a recent analysis by Public Health England indicating that around 12,000 deaths, and 33,000 hospital admissions from Covid-19 have been averted by the vaccines in just a few months here in the UK.Our aim at Oxford University was to develop a vaccine that could be <a href="https://www.nepalitimes.com/latest/unicef-urges-g7-to-dispatch-vaccines/" target="_blank" rel="noopener noreferrer">distributed equitably</a>, and we hoped to achieve that through our partnership with AstraZeneca, who stepped up to help and have supported more than 20 vaccine manufacturing sites around the world (including Serum Institute of India, who make Covishield).They are working flat out to scale up manufacturing even more, and it is through their efforts that over 450 million doses have already been produced this year, and how the vaccine is being distributed to over 160 countries. This incredible progress in such a short period of time will save hundreds of thousands of lives. But making vaccines is hard, takes time, and there are still not enough doses for the world, even with many other developers producing vaccines too.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109111152/636b86739c7e80680e067855jpeg.jpg" alt="" width="1628" height="1062"><figcaption> </figcaption></figure>Covishield, made at the Serum Institute of India, was the version of the Oxford vaccine destined for Nepal, but the urgent need in India has delayed supply. The supply shortage has resulted in major concerns for countries with limited numbers of doses to decide what to do.Starting vaccinations programmes will have the greatest impact, with the first priority being getting a second dose to those left out, and the first dose to <a href="https://www.nepalitimes.com/here-now/spared-at-first-elderly-hit-hard-by-covid-19/" target="_blank" rel="noopener noreferrer">older adults</a>, those with other health conditions that make them more at risk of severe Covid-19, and health workers, as soon as possible.The WHO have issued guidance about each of the vaccines which have been reviewed by them, to help with policy decisions, and for the Oxford-AstraZeneca/Covishield vaccine we know that there is <a href="https://www.facebook.com/DHSCgovuk/posts/971145230300967" target="_blank" rel="noopener noreferrer">good protection for at least three months</a> after the first dose, with no sign of protection fading over that period.The immune system ‘remembers’ the first dose so that protection is boosted when the second dose is given. Where there are shortages of vaccine, longer delays will not compromise the booster response to the second dose. The main reason for giving a second dose is to increase the immune response, which might improve protection against variants, and will also extend the duration of protection.At this moment we do not have much information about mixed schedules where different vaccines are used for the first and second dose, although this is something that my colleagues here in Oxford are investigating. However, since all of the available vaccines use the coronavirus spike protein to stimulate the immune system, it is expected that there will be a response to a different vaccine for the second dose. Whilst we do need more data to confirm the best combinations, in the meantime, getting a first dose to those most at-risk people should be the absolute priority.While the vaccine roll out in high income countries is a remarkable success story measured in doses given, cases prevented, lives saved, and the green shoots of economic recovery, giving us hope for the future, it also reveals <a href="https://www.nepalitimes.com/here-now/nepal-needs-urgent-american-vaccine-support/" target="_blank" rel="noopener noreferrer">a serious concern</a> when looked at in the context of global equity.Some countries have vaccinated a high proportion of their citizens, while the pandemic continues to rage elsewhere. Many Nepalis have written to me asking why this situation is allowed to continue and asking what I am doing about it. Like you, I feel powerless.Since supply remains constrained, to save lives in the next few months, <a href="https://www.nepalitimes.com/here-now/aid-pours-into-nepal-but-where-be-vaccines/" target="_blank" rel="noopener noreferrer">vaccine doses</a> have to be redistributed to those at greatest risk, wherever they live. This can only be achieved if governments work together to prioritise their supplies in a global objective to protect lives, taking an international view rather than a domestic perspective.This year is the 30th anniversary of my first visit to Nepal, on that occasion as a mountaineer. With such a long connection to the country I felt so proud when I saw the <a href="https://www.nepalitimes.com/banner/nepal-begins-covid-19-vaccination-drive/" target="_blank" rel="noopener noreferrer">first doses of the Oxford vaccine being administered in Kathmandu</a>, and the hope that it brought to Nepalis, but I am now saddened to hear that further supply is delayed.Whilst the pandemic has brought us closer together in a shared suffering, it has also shown how far apart we are when it comes to sharing health.<a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.facebook.com/bbcnews/posts/10158299353147217" target="_blank" rel="noopener noreferrer">Professor Andrew J Pollard</a> is Director of the Oxford Vaccine Group, University of Oxford, UK.Read also: <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-Sci-Brief-ChAdOx1-S-recombinant-vaccine-Second-dose">WHO Technical Note on delayed shipments for vaccines: What are the implications for the administration of second doses? </a>

“I’m sad vaccines are delayed in Nepal”

<figure></figure> <img width="1500" height="1000" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba5129c7e80680e0736a1jpeg.jpg" alt=""/><figcaption>A woman with her mask down walks by Sneha Shrestha mural in Pimbahal, Patan this week. Photo: BIKRAM RAI</figcaption> Five months after the first COVID-19 case was detected in Kathmandu, and after many experts were puzzled about why the virus was not spreading as fast as elsewhere, parts of Nepal and Kathmandu city are now in the vortex of the pandemic.Hospitals in Tarai cities are fast filling up with symptomatic cases, and doctors say patients requiring ICU treatment and ventilator support are on the rise.On Thursday, Kathmandu Valley recorded its highest daily rise of 87 positive cases. All beds are occupied in hospitals with designated wards for coronavirus patients. Overwhelmed, doctors are sending asymptomatic patients to home isolation. Some were diverted to Kathmandu Medical College’s facility in Duwakot and Ayurveda Hospital in Kirtipur.<a href="https://www.nepalitimes.com/banner/experts-caution-against-extending-nepal-lockdown/" target="_blank" style="background-color: rgb(255, 255, 255); font-size: 15px; letter-spacing: 0.01em;" rel="noopener noreferrer">Experts caution against extending lockdown</a>, Sonia Awale<a href="https://www.nepalitimes.com/editorial/lockdown-may-be-over-but-pandemic-is-not/" target="_blank" style="background-color: rgb(255, 255, 255); font-size: 15px; letter-spacing: 0.01em;" rel="noopener noreferrer">Lockdown may be over, but pandemic is not</a>, EditorialThe government has approached private hospitals to start opening COVID-19 wards, and had set the maximum treatment charge per patient. However, private hospitals are balking, they say the fees are too low for the care needed.“Self-isolation at home has worked elsewhere but in Nepal where people don’t strictly follow safety measures, patients are ostracised, and there is a lack proper rescue mechanism, it might not be the best strategy,” cautions BaburamMarasini, former head of the Epidemiology and Disease Control Division. “It would be better to move asymptomatic cases to available government training centres, non-profit institutions, and if needed even hotels and hostels.” <figure></figure> <img width="955" height="594" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba5159c7e80680e0736a2jpeg.jpg" alt=""><figcaption> </figcaption> As of Thursday, Nepal has a total of 21,750 cases with 6,296 active. So far, 65 people have lost their lives, five of them on 6 August alone. Cases in Kathmandu Valley have reached 876, mostly in the capital city (see graphs). Eight people have been infected with coronavirus at the Ministry of Internal Affairs and Law and so has minister Gyanendra Kumar Yadav in Province 2.Says public health expert Sameer Dixit: “Local governments and security personnel should be facilitating self-isolation at homes. Admitting asymptomatic cases in hospitals depletes resources, as it exposes mildly infected patients to severe cases.”There are now 66 ICU cases across Nepal with 29 just in Bagmati Province (see map) where three patients are on ventilator support. Given the steep rise in symptomatic and severe COVID-19 cases, all 1,702 ICU beds nationwide and stock of 900 ventilators could be used up.“The rate of infection in Kathmandu is increasing, and this could lead to a shortage of hospital beds, equipment and heath workers,” warned Jageshwor Gautam of the Health Ministry, appealing to the public to remain at home and follow <a href="https://www.nepalitimes.com/opinion/prevention-while-searching-for-a-cure/" target="_blank" rel="noopener noreferrer">safety measures</a>. Several hundred traffic police in Kathmandu are in quarantine after the infections spread, and the Nepal Police headquarters was sealed this week after seven staff tested positive. <figure></figure> <img width="949" height="606" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba5189c7e80680e0736a3jpeg.jpg" alt=""><figcaption> </figcaption> Special attention should also be given to the fact the virus SARS-CoV-2 is airborne, which is why <a href="https://www.nepalitimes.com/banner/masks-unmasked/" target="_blank" rel="noopener noreferrer">wearing mask</a> should be mandatory, spitting prohibited and ensuring cross ventilation in workstations at all times.Finance Minister and government spokesperson Yubaraj Khatiwada says the government does not want to re-impose a nationwide lockdown, but says some restrictions may have to be put into place.District administrations of Kathmandu, Lalitpur and Bhaktapur districts met on Thursday to draw up a joint strategy for the Valley. Among the measures being discussed are: strict protocols for government offices, banks, markets, and public transport. They are worried most people are not following guidelines for masks and physical separation, and warn that they may have to resort to punitive measures and fines to enforce the rules.Health experts fault Khatiwada’s <a href="https://www.nepalitimes.com/latest/nepal-ends-covid-19-lockdown/" target="_blank" rel="noopener noreferrer">announcement on 21 July</a> in which he categorically stated that the “lockdown has been lifted” even though it had only been relaxed. They said this had given people a <a href="https://www.nepalitimes.com/editorial/lockdown-may-be-over-but-pandemic-is-not/" target="_blank" rel="noopener noreferrer">false sense of security</a>, and especially allowed Indian factory workers, vendors, barbers and drivers to stream back to Nepal <a href="https://www.nepalitimes.com/latest/heightened-covid-19-risk-at-india-nepal-border/" target="_blank" rel="noopener noreferrer">across the open border</a>. This is the reason the Tarai cities were the first to be hit, and the virus is spreading to Kathmandu from there.    The COVID-19 Crisis Management Centre (CCMC) is said to be discussing modalities for a ‘smart lockdown’, including isolating areas where there are outbreaks and stricter enforcement of mask and separation rules. It is also going to decide this weekend whether or not to re-open long distance buses, as well as regular domestic and international flights which were supposed to resume on 17 August.Says Buddha Basnyat, a physician at Patan Academy of Health Sciences: “We are seeing a worrying surge in typical COVID-19 symptoms with advanced pneumonia, unlike before when most cases were asymptomatic and had co-morbidity.” <figure></figure> <img width="516" height="655" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba51a9c7e80680e0736a4jpeg.jpg" alt=""><figcaption> </figcaption> Experts say the rise of symptomatic cases is also due to co-infection such as seasonal flu, typhoid and <a href="https://www.nepalitimes.com/opinion/the-dangers-of-the-dengue-virus/" target="_blank" rel="noopener noreferrer">dengue</a>, all infectious disease common during the monsoon. Some have pointed to high co-morbidity and delayed mass testing as  contributing factors to possible community transmission in the Tarai districts and Kathmandu.But despite the surge in symptomatic cases, health professionals have advised against re-imposing a blanket curfew, favouring a ‘<a href="https://www.nepalitimes.com/banner/experts-caution-against-extending-nepal-lockdown/" target="_blank" rel="noopener noreferrer">smart lockdown</a>’ where localities with cluster outbreaks are sealed off, and tested – while strictly enforcing masks in public places and preventing crowds.So far, shutdowns have been re-imposed in five Tarai districts, and semi-lockdowns in parts of nine others where there has been a surge in cases. <figure></figure> <img width="640" height="828" src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/2022110914110/636ba51d9c7e80680e0736a5jpeg.jpg" alt=""><figcaption> </figcaption> “We are already experiencing semi-lockdown of sorts because of floods and landslides. A lockdown now will cause more harm than good. The only way to fight this pandemic is <a href="https://www.nepalitimes.com/editorial/open-and-shut-case/" target="_blank" rel="noopener noreferrer">behavioural reform, surveillance and isolation</a>,” says Marasini.Indeed, most experts agree that a focus on the coronavirus should not shift attention away from more devastating conditions that can <a href="https://www.nepalitimes.com/banner/children-are-collateral-damage-in-nepal-lockdown/" target="_blank" rel="noopener noreferrer">affect people’s well-being</a> because of economic collapse.

Nepal’s virus vortex

<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/20221109121116/636b8c4d9c7e80680e06b2efjpeg.jpg" alt="" width="4096" height="2730"/><figcaption>Photo: BIKRAM RAI</figcaption></figure>With no proven <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNFhARSUb8HMQP_ZJgsaTmPoQDLWvA">cure or vaccine available yet for COVID-19</a>, various treatments with no proven benefits and potential deadly side-effects are being tried out on patients.One example of a desperate treatment measure is a New York City doctor carelessly declaring on primetime tv recently that COVID-19 pneumonia was similar to <a href="https://www.nepalitimes.com/latest/high-alert/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/high-alert/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGuDq-Ti_uWGlw-rY-q1PpyQQO54g">high altitude pulmonary edema (HAPE)</a>, and he recommended high altitude drugs like Diamox for the treatment of Covid-19.Trekkers in Nepal are familiar with <a href="http://archive.nepalitimes.com/news.php?id=19693#.Xp-oJy8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D19693%23.Xp-oJy8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGSLnJg3LMR2gIcZz9LMdKOvruqJA">Diamox</a>, a pill they take to acclimatise better when hiking at higher altitudes. There is no scientific basis that the drug will work, but this idea of very low oxygen (hypoxia) and pneumonia in both afflictions was appealing.To counter this some of us in Nepal and other countries have a forthcoming Opinion in the British Medical Journalcautioning against this rash treatment strategy using high altitude medicines. In medicine, doctors have to remember the maxim, Primum non nocere (‘above all do no harm’).But there are some silver linings <a href="https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/latest/nepal-must-hope-for-the-best-prepare-for-the-worst/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGtTkAInA3D5xIkzd65kTSfDvYESg">if Nepal escapes the worst of COVID-19</a>. <a href="https://www.nepalitimes.com/banner/tb/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/tb/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNGbOqrkOzN3uP_va7u0F-uhlxipaQ">Tuberculosis</a> rates, which are very high in South Asia (more than 400 per 100,000) could go down if people continue to use the masks since it will also mean that a tuberculosis patient will not spread the bacteria, not to mention other respiratory infections.Similarly, as more people get into the habit of washing hands with soap and water where available, the rates of diseases like typhoid and hepatitis A and E, caused by fecal oral transmission, will certainly be reduced.An average of <a href="https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/nepals-deadly-roads-take-their-toll/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNHn0HGje-Tq3pDeekYbQAbhZxJOwg">230 people used to be killed every month</a> on Nepal’s highways and streets. The lockdown has now lasted a month, and that is approximately the number of lives saved due to vehicles being off the roads.The importance of public health for both the rich and poor countries has been highlighted by the pandemic. Industrialised countries had thought they had been done with infectious diseases, except perhaps the odd HIV patient. This pandemic has given great pause to that argument. Developing countries which having tried to come to grips with pre-existing epidemics have used lessons learnt in dealing with coronavirus in prevention.The Indian state of Kerala for example, has done relatively better in dealing with COVID-19 partly because it utilised prior lessons from the Nipah outbreak a year ago. Other South Asian countries with robust public health infrastructure like Sri Lanka also have a better handle on the disease.They strengthened their public health system, and it has paid rich dividends. South Korea too had an outbreak of MERS Coronavirus in 2015 which was brought by a South Korean returning from Kuwait, but they were able to effectively control the spread, and have been dealing successfully (so far) with the novel coronavirus. Singapore had been doing well, but discovered last week that it had a blind spot in the migrant workers’ dormitories. It has now announced a ‘circuit breaker’ lockdown till 1 June.South Asian countries have had more time in preparing for the contagion, while they wait for a vaccine or drugs to treat COVID-19. Treatment trials are happening all over the world even as the patients and doctors await with bated breath (pardon the pun). In all likelihood, we will soon know if chloroquin works or not before we have a vaccine.Vaccines will be a game-changer against Covid-19, and competition is heating up because whoever makes this vaccine first will be the knight-in-shining armour. China, USA, UK are probably a few of the countries engaged in developing a vaccine, and among them are researchers at Oxford University Clinical Research Unit who <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNHKJgZ_d-vQIhZ5sdehQmMT7iWvHQ">collaborated closely with Patan Academy of Health Science</a> in a recent successful typhoid vaccine study.This Oxford University group lead by Professors Sarah Gilbert and Andrew Pollard are optimistic about producing a million doses of the vaccine by autumn. The vaccine will be eventually required not in the millions, but in billions of dosages. It also has to be affordable for countries like ours.For making vaccines promptly for neglected tropical illnesses, it is hard to beat the Chinese. When <a href="http://archive.nepalitimes.com/news.php?id=19220#.Xp-nMS8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D19220%23.Xp-nMS8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNEw-YGKhD3XomMEP736r5ileoWJ3g">Japanese Encephalitis (JE)</a> was raging in China and South Asia, it was the Chinese who tested, developed and made available the ‘Chengdu vaccine’ that revolutionised the prevention of the mosquito-borne disease. The earlier vaccine was expensive and only tourists in Nepal could afford it.Similarly, when <a href="http://archive.nepalitimes.com/news.php?id=18079#.Xp-m3S8w0Wo" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D18079%23.Xp-m3S8w0Wo&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNEndZvjwlu6D0uMBXFMGO9OgvSoXg">hepatitis E</a> was a scourge in China, the Xiamen Innovax Biotech came up with a vaccine in 2012 to protect vulnerable populations. Because there is no other commercial vaccine available against hepatitis E, it will be valuable in South Asia if the virus is rampant again and affect pregnant women with a fatal outcome.Nepal clearly needs to have a strong public health infrastructure in collaboration with a prestigious institute abroad to be able to tackle COVID-19 and other infections. Just like earthquakes, there will be more pandemics in future. Humanity needs to up its game in the control of emergent infectious diseases, and Nepal can make a small contribution by helping itself, especially by strengthening public health.Buddha Basnyat is a clinical researcher at Patan Academy of Health Sciences and a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1587612692665000&amp;usg=AFQjCNFhARSUb8HMQP_ZJgsaTmPoQDLWvA">frequent health columnist</a> for Nepali Times.Prevention while searching for a cur

Buddha Basnyat

Prevention while searching for a cure

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101156/636b79ac9c7e80680e064717jpeg.jpg" alt="" width="550" height="388"/><figcaption>American Red Cross volunteers carrying a Spanish Flu victim in 1919. Photo: RED CROSS</figcaption></figure>The <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1585031842556000&amp;usg=AFQjCNER7BK9EfiZTZ7HAcrRW7TMnI6jKg">current COVID-19 pandemic</a> has forced many to Google other historic outbreaks, and the search usually brings them to the 1918 influenza epidemic that killed between 20-40 million people – half of them in South Asia.Just over 100 years ago, as Europe was coming out of a ruinous four-year trench warfare, American soldiers brought the flu to the front lines from where it had spread like wildfire across Europe.Although it is called the ‘Spanish’ Flu, the virus first appeared in North America and crossed the Atlantic on US troopships bound for the front lines. It is called Spanish Flu because the virus was making people sick in the Pyrenees long after it had subsided elsewhere.After the war, British Army soldiers returning to India (some of them could very well have been Gurkhas) brought the virus to Bombay from where it spread along India’s vast railway network. 50 in every 1,000 Indians died of the virus.There were two waves of the influenza epidemic. It was probably transferred from returning migratory waterfowl to humans in Kansas in spring of 1918 before jumping across the Atlantic to Europe. The spread slowed over the summer, but returned with a vengeance in the autumn that year.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101156/636b79ae9c7e80680e064718jpeg.jpg" alt="" width="2400" height="1816"><figcaption> </figcaption></figure>Although there are many books about the Spanish Flu in Western literature, in South Asia there is no properly archived documentation about the tragic pandemic that took many lives.Even Mahatma Gandhi was stricken by the bug, and bodies were piled high along river banks in India as cremation sites ran out of firewood. Unlike COVID-19, the 1918 influenza virus struck people in the 20-40 age group.While it affected 28% of all Americans, killing 675,000 – of the US soldiers killed in World War I, half died of influenza. But surprisingly, the pandemic had very little effect on China.Many viruses have an animal reservoir, and the Spanish Flu was associated with ducks and pigs as is usual for influenza viruses. The <a href="https://www.cdc.gov/coronavirus/mers/index.html" data-saferedirecturl="https://www.google.com/url?q=https://www.cdc.gov/coronavirus/mers/index.html&amp;source=gmail&amp;ust=1585031842556000&amp;usg=AFQjCNE-MAzB2oWqzXngSV-qeu_vZW781w">MERS coronavirus</a> that affected the Gulf region in 2012 is associated with camels, and the <a href="http://archive.nepalitimes.com/news.php?id=2664" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D2664&amp;source=gmail&amp;ust=1585031842556000&amp;usg=AFQjCNFPL8LEypjMiL-Zq9OumVczJ63a9w">SARS coronavirus of 2003</a> transferred from civet cats. While the COVID-19 probably originated in bats like the other coronaviruses, its host is believed to be <a href="https://www.nepalitimes.com/banner/coronavirus-outbreak-may-curb-wildlife-trafficking/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/coronavirus-outbreak-may-curb-wildlife-trafficking/&amp;source=gmail&amp;ust=1585031842556000&amp;usg=AFQjCNGdAGDJ3BCYbsOftkHyaOipIJecdw">the pangolin</a>.As the ‘Spanish’ flu clearly showed, there is <a href="https://www.nepalitimes.com/opinion/covid-19-nepal-and-the-hygiene-hypothesis/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/covid-19-nepal-and-the-hygiene-hypothesis/&amp;source=gmail&amp;ust=1585031842556000&amp;usg=AFQjCNFhpeCjNw-lYwjui_QOmW3PKMnd3g">no evidence to show that we in South Asia have better immunity</a> towards the novel coronavirus COVID-19. So, what can be done?First thing is to increase tests for COVID-19 in suspected patients even without a travel history to affected areas. The more tests we do, the more we will know about the spread of  the actual disease.Read also: <a href="https://www.nepalitimes.com/editorial/this-is-a-test/" target="_blank" rel="noopener">This is a test</a>, EditorialIt is also crucial to do cross-sectional serological studies in communities to see if the virus has been introduced there. This test (unlike the RNA-based diagnostic test for a patient) can be done on asymptomatic people in the community to check for COVID-19 antibodies in the blood, and could give us an idea about the extent of the exposure to the community.Many of these antibody tests are new, and the Chinese have vast experience with them in treating COVID-19. The Nepali government would be well advised to seek Chinese help with antibody testing so that we are better prepared in the days and months ahead. Without more diagnostic and serological tests, we may continue to have a false sense of security as the virus continues to sneak up on us in South Asia.The silver lining (if there is one) in this unfolding COVID-19 pandemic is the attention that it has attracted to the importance of rapid diagnostic tests for other neglected infectious diseases in South Asia like <a href="https://www.nepalitimes.com/banner/tb/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/tb/&amp;source=gmail&amp;ust=1585031842556000&amp;usg=AFQjCNEq-c2ak8GqLj2idm1BOUPOOAk46A">tuberculosis</a>, <a href="http://archive.nepalitimes.com/news.php?id=18178#.XnhYpkAza70" data-saferedirecturl="https://www.google.com/url?q=http://archive.nepalitimes.com/news.php?id%3D18178%23.XnhYpkAza70&amp;source=gmail&amp;ust=1585031842556000&amp;usg=AFQjCNHZKfS0Lv_GE4wqJrQaZ6OSfqTgdg">typhoid</a>, typhus, or leptospirosis.The tests need to be accurate, simple, affordable, and quick. Rapid diagnostics will not just help find infected people, but also to decide on specific therapy so that unnecessary antibiotics and other treatment are not administered. Proper diagnosis will lead to control of antimicrobial resistance, another medical crisis affecting the world today.At present, diagnostic tests take many hours if not days, so hopefully, after the dust from COVID-19 settles, there will be more work on rapid tests for these still-rampant ‘biblical’ afflictions that plague us.<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101156/636b79b19c7e80680e064719jpeg.jpg" alt="" width="1500" height="803"><figcaption> </figcaption></figure>Another positive effect of the COVID-19 pandemic may be the restoration of <a href="https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/banner/a-shot-in-the-arm-for-vaccines-in-nepal/&amp;source=gmail&amp;ust=1585031842556000&amp;usg=AFQjCNEk_tK3eXW25A_sGyzoFrJsJEBxww">people’s faith in effective tried and tested vaccines</a> in the western world.Rumours about side-effects of vaccines going viral on social media have convinced many parents not to inoculate their children, leading to outbreaks of vaccine-preventable diseases like diphtheria, polio and whooping cough in the West. If successful, the COVID-19 vaccine would set the record straight for the proliferation of ‘anti-vaxxers’.Pandemics are like earthquakes, they cannot be wished away. It is best we prepare for a potential COVID-19 outbreak as best and resourcefully as we can. This is not optional, since there will be more pandemics in future.Buddha Basnyat is a clinical researcher at Patan Academy of Health Sciences and a <a href="https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/" data-saferedirecturl="https://www.google.com/url?q=https://www.nepalitimes.com/opinion/what-is-novel-about-the-novel-coronavirus/&amp;source=gmail&amp;ust=1585631034431000&amp;usg=AFQjCNE0aoyspsOeHIBjtexE2rB8xE3KOw">frequent health columnist</a> for Nepali Times.

Remembering a pandemic 100 years ago

<figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101132/636b742e9c7e80680e06237djpeg.jpg" alt="" width="1400" height="1050"/><figcaption>Pangolin that escaped from a community forest in Sankhuwasaba district in June 2019 rolls into its scales for safety before being released back into the wild. Pangolins are the world's most trafficked mammals and are also smuggled from Nepal to China across the Himalaya. Photo: SUJAN BAJRACHARYA/RSS</figcaption></figure>China is world's biggest market for the illegal trade in wildlife for food and traditional medicine, and its blanket ban announced this week may actually save some endangered species from extinction.The Chinese government said the ban on selling wild animal in markets would be in force ‘until the end of national epidemic’. However, conservationists including Chinese academics, are pushing for a permanent ban and believe the outbreak can be an opportunity to conserve endangered Asian and African wildlife.“A temporary ban does not address the larger problem, there will always be a risk of infections like coronavirus as long as there is demand for wildlife in China,” says Tulshi Laxmi Suwal of Nepal’s Small Mammal Conservation and Research Foundation who did her PhD on pangolins from National Pintung University in Taiwan.Read also: <a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/banner/why-nepal-must-watch-about-coronavirus-but-not-panic/" target="_blank" rel="noopener">Why Nepal must watch Coronavirus, but not panic</a>, Sameer M DixitEarly studies have pointed to bats as the source of the <a href="https://www.nepalitimes.com/banner/why-nepal-must-watch-about-coronavirus-but-not-panic/" target="_blank" rel="noopener">2019 novel coronavirus</a> -- now named Covid-19 -- and scientists are trying to figure out how it jumped from animals to humans. The origin of the epidemic has been traced to a seafood market in Wuhan that also sold wild animals.However, other Chinese researchers on Friday said that <a href="https://www.nepalitimes.com/banner/protecting-pangolins-from-being-eaten-to-extinction/" target="_blank" rel="noopener">pangolins</a>  the world's most trafficked mammal, might be the missing link between bats and humans.African and Asian <a href="https://www.nepalitimes.com/banner/lesser-known-endangered-species/" target="_blank" rel="noopener">pangolins</a> are hunted for the meat, considered a delicacy by locals. Its scales are used extensively as an ingredient in Chinese traditional medicine. All eight species of the mammals found in Asia and Africa are on the endangered list."Bats alone are known to carry anywhere between 40-200 different viruses. Eating meat of wild animals or close interaction with one can transmit the virus to humans," says Sanjan Thapa who is pursuing PhD on bats at China’s Quangchau University.Read also: <a style="font-size: 15px; letter-spacing: 0.01em;" href="https://www.nepalitimes.com/latest/a-nepali-in-beijing-during-coronavirus-scare/" target="_blank" rel="noopener">A Nepali in Beijing during coronavirus scare</a>, Rastraraj BhandariWhatever the mode of transmission, the latest outbreak has once again brought to the forefront the rise of zoonotic diseases and its critical association with flourishing illegal wildlife trade, especially in China.There is a fear that the Covid-19 epidemic will push many in China to resort to powdered rhino horn as a cure for the flu. Rhinos poaching in Africa and India already feeds the demand in traditional Chinese medicine.Covid-19 has killed at least 1,300 people as of Thursday, more than SARS in 2002-2003, despite its lower fatality rate of 2.2% against 9.6% for SARS. The newer virus, however, is the more contagious and has spread to 28 countries with over 60,000 confirmed cases.Before <a href="https://www.nepalitimes.com/latest/a-nepali-in-beijing-during-coronavirus-scare/" target="_blank" rel="noopener">the Covid-19 epidemic</a>, there were SARS and Middle East Respiratory Syndrome (MERS) that also originated from animals. The SARS virus moved from bats to civets and then to humans. Camels were the source of the MERS virus in 2012 in West Asia. Ebola outbreak (2013-2016) was also traced to bats.Experts believe that the coronavirus scare will also lead to decline in poaching and trafficking of wildlife in Nepal, which is on the traditional route for trafficking of endangered species from India to China and has <a href="https://www.nepalitimes.com/latest/better-nepal-china-connectivity-helps-wildlife-smugglers/" target="_blank" rel="noopener">flourished as a transit hub</a> for smuggling of pangolin scales, rhino horns, tiger and leopard skin and elephant tusks.“Once the demand in China goes down, poaching and smuggling here in Nepal will also decline. Conservation efforts in Nepal will gain a lot if a permanent ban on wildlife trade is placed in China,” adds Suwal. “This is also a good time to create awareness about the higher risk of zoonotic diseases on those involved in the illicit trade so that they are discouraged to continue.”According to District Forest Office Kathmandu, 1,798 body parts of 10 wildlife species destined for China were confiscated in the last eight years. Of those, 1,468 belonged to different species of birds, 94 to <a href="https://archive.nepalitimes.com/article/nation/city-for-transshipment-of-wildlife,3424" target="_blank" rel="noopener">red pandas</a>  92 to leopards and 42 to pangolins. Nepal Police has filed 880 cases against poachers in the past 18 years.Says Sindhu Dhungana of Ministry of Forest and Environment: “National and international coordination is essential to control wildlife crime and impossible to do so without a cross-border collaboration between Nepal, India and China.”With additional reporting by Mukesh Pokhrel.

Coronavirus outbreak may curb wildlife trafficking

<figure><a href="https://www.nepalitimes.com/wp-content/uploads/2020/01/Wuhan-coronavirus-spread-worldwide-in-map-NT.jpg" data-elementor-open-lightbox="yes"></a></figure><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101120/636b71a89c7e80680e0600e2jpeg.jpg" alt="" width="1456" height="793"/><figcaption>The worldwide spread of the Wuhan coronavirus as of 31 January 2020.</figcaption>The ongoing outbreak of the <a href="https://www.nepalitimes.com/latest/a-nepali-in-beijing-during-coronavirus-scare/" target="_blank" rel="noopener">2019 novel coronavirus in China</a>, also called the Wuhan coronavirus, has now affected at least 17 countries. Approximately 6,000 cases have been reported with the majority being diagnosed in China.The total fatalities have crossed 130, a majority of them in the Hubei Province in which Wuhan is located. Nepal has reported its first confirmed case: of a student studying in China who had been visiting Nepal when diagnosed.Read also: <a href="https://www.nepalitimes.com/latest/a-nepali-in-beijing-during-coronavirus-scare/" target="_blank" rel="noopener">A Nepali in Beijing during coronavirus scare</a>, Rastraraj BhandariViruses of the coronavirus family have historically caused diseases of the respiratory tract in human populations worldwide. Recent outbreaks included the <a href="http://archive.nepalitimes.com/news.php?id=2664#.XjFpRjIzaUk" target="_blank" rel="noopener">Severe Acute Respiratory Syndrome (SARS) in 2002</a> and the Middle Eastern Respiratory Syndrome (MERS) in 2012. Both affected thousands of people and were fatal in some cases.SARS killed 10% of infected individuals while MERS was fatal in 37% of the infected population. The current fatality rate due to the Wuhan Coronavirus is 2.2%. If we are to describe this statistic in reverse, about 98 percent of those infected with this virus do not die.The question then is, why is there so much concern regarding this outbreak, given the relatively low mortality rate in comparison to previous coronavirus outbreaks?The first reason is that the <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019" target="_blank" rel="noopener">Wuhan coronavirus is ‘novel’.</a> This term is used in viral epidemiology to indicate a new strain, one which has not been detected previously in the population. Scientists therefore do not have adequate information regarding the characteristics of the virus to provide evidence-informed public health instructions on containment and treatment.Second, unlike SARS and <a href="https://www.cdc.gov/coronavirus/mers/index.html" target="_blank" rel="noopener">MERS</a>, this virus has an incubation period of up to 14 days and asymptomatic infected individuals can transmit the disease to others during that time. Even infected individuals who show improvement can continue to transmit the virus.The R0 (pronounced ‘r naught’) value of this virus is estimated at 3, meaning that an infected person on average will transmit to three other persons. This is considered a high infectivity number, but still lower than that of SARS or MERS.The Chinese authorities have put in place <a href="https://www.bbc.com/news/world-asia-china-51236450" target="_blank" rel="noopener">strict measures in Wuhan</a> to try to contain the spread of the virus. However, this may not be enough as many infected individuals might have already traveled out of town by the time the measures were put in.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101120/636b71ab9c7e80680e0600e3jpeg.jpg" alt="" width="640" height="427"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101120/636b71ae9c7e80680e0600e4jpeg.jpg" alt="" width="640" height="427"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101124/636b71b29c7e80680e0600e5jpeg.jpg" alt="" width="640" height="427"><img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101124/636b71b69c7e80680e0600e6jpeg.jpg" alt="" width="640" height="427">                                              Photos: BIKRAM RAIWuhan has a population of 10 million, and many had begun to travel in advance of the Chinese New Year this week. Experts at Imperial College London have estimated infected population numbers to be already at around at 100,000.We can therefore expect more cases around the world as infected individuals travel and transmit the disease. However, once again, the question emerges of what the reported fatalities so far are among this large number of infected individuals. Could it be that the virus is spreading but not causing too many deaths?Nepal has seen regular outbreaks of respiratory diseases including seasonal influenza, ‘avian influenza’ and ‘swine flu’. The Nepali media often reports cases of ‘unknown viral disease’. The Nepal government had established screening centres for the coronavirus at airport and border checkpoints even before the first infected person was diagnosed in Tibet on Monday.The National Public Health Laboratory is working with private hospitals and laboratories to provide timely and accurate diagnostics of the Wuhan coronavirus with technical support from the World Health Organization (WHO).Cases are being referred to Sukraraj Tropical Infectious Diseases Hospital as the focal center and the Epidemiology and Disease Control Division is monitoring signs of possible outbreaks in country. The Ministry of Health and Population has directed all private hospitals around country to have ventilator supported ICUs to be on standby should those be required.The state mechanism appears to have learnt from weaknesses is showed during the SARS and H1N1 (swine flu) outbreaks of the past. However, accurate clinical diagnosis of this disease is going to be a challenge given the likelihood of infected individuals arriving at checkpoints showing no symptoms and because individuals infected with other viruses like influenza or other weaker strains may show similar symptoms as those infected by the Wuhan coronavirus.Screening is the only way of identifying the maximum number of cases entering the country and preventing those from infecting the population. There have been no further coronavirus infection cases reported in Nepal since 25 January. The first case, reported on that day, is so far the only one.Global media reporting of this outbreak has focused on fatality rather than recovery, and appears to have failed to notice that the WHO, with its expertise and access to data, has not yet declared the Wuhan coronavirus outbreak a public health emergency.The experience of having made the ‘premature and hasty’ decision to term the 2009 influenza A (H1N1) – or swine flu – outbreak a pandemic still being fresh, this time WHO has decided to monitor the situation closely before making any decision in this regard.The WHO has focused on China as a priority for action while observing rest of the world. This does not mean we can be complacent, as the threat of the virus mutating into a more severe form is real. However, it also does not help to panic. We need to look at the numbers, listen to experts in the field and move ahead accordingly.Sameer M Dixit is a public health research scientist at the <a href="http://www.cmdn.org.np/">Centre for Molecular Dynamics Nepal</a>.<img src="https://superdesk-pro-c.s3.amazonaws.com/sd-nepalitimes/20221109101124/636b71b99c7e80680e0600e7jpeg.jpg" alt="" width="126" height="145">

Why Nepal must watch Coronavirus, but not panic

<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

infectious-diseases