Cholera in Nepal

Introduction to Cholera 

Cholera is an infectious and often fatal bacterial disease that affects the small intestine, resulting from the bacterium Vibrio cholerae. Those infected primarily exhibit symptoms such as watery diarrhea, vomiting, and muscle cramps. In severe cases, these symptoms can escalate to intense dehydration, which, if left untreated, has the potential to be fatal.

Source:https://www.vinmec.com/en/news/health-news/general-health-check/characteristics-of-cholera-vibrio-cholerae/

Historical Context in Nepal

Cholera has been known in Nepal for centuries and has caused numerous epidemics. 

The 1960s Epidemics 

• Outbreak: Nepal experienced severe cholera epidemics during the 1960s, which were part of the seventh pandemic that originated in Indonesia in 1961. 
• Response: This era marked the beginning of international collaborations for cholera control in Nepal. The government collaborated with international organizations, such as the World Health Organization (WHO), to initiate containment and prevention measures.

History 

• 1823: The history of cholera in Nepal traces back to 1823 when the country recorded its first outbreak. This event marked the beginning of a tumultuous period for Nepal as it grappled with this new health threat. The specific regions affected and the exact response measures taken during this initial outbreak remain undocumented in the provided details.
• 1831, 1843, 1856, 1862, and 1887: The Kathmandu Valley became a focal point for cholera in the 19th century, witnessing a series of significant outbreaks. Epidemics hit the valley in 1831, 1843, 1856, 1862, and 1887. Each of these outbreaks posed unique challenges to the region, prompting local health authorities to potentially devise varied strategies for containment and care. The exact severity and response measures of these outbreaks, however, aren't clearly outlined in the available data.
• May 1886: A significant milestone in Nepal's public health documentation was reached in May 1886. During this time, the first scientific report on a cholera outbreak in the country was published. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2257173/pdf/brmedj04727-0005.pdf This report provided a vivid depiction, elaborating on the outbreak’s impact on the demography and geography of the affected areas. Additionally, it shed light on the sanitation and hygiene practices prevalent in Nepal at that time.
• Late 19th Century to Early 1990s: The close of the 19th century ushered in a period of silence in the public health history of Nepal, with cholera documentation nearly absent for close to a century. This gap can perhaps be attributed to the political turmoil and the Rana regime's trend of isolationism. As a result, many outbreaks might have gone unreported or under-documented during this period.
• Early 1990s: It wasn't until the early 1990s that Nepal saw a resurgence in cholera studies. These were primarily laboratory-based surveillance or outbreak reports. A notable revelation from these studies was the seasonal nature of cholera. Most cases were reported during Nepal's rainy or monsoon season, which typically stretches from June to October.
• 2009: The year 2009 was particularly alarming for Nepal's public health sector. Jajarkot, located in the mid-western region, experienced the largest cholera outbreak in the country’s history. The severity of this outbreak was unparalleled, with over 30,000 people affected and more than 500 individuals losing their lives. This outbreak likely required significant emergency response, although specific measures haven't been detailed.
• 2014: Cholera re-emerged in 2014, this time in Rautahat, situated in the Terai region adjacent to India. During the monsoon, more than 600 people were affected by the disease. The proximity to India might have necessitated cross-border collaborations and surveillance to manage the outbreak, but specifics regarding the response measures remain unspecified in the provided information.
• In 2015, Nepal was hit by two major earthquakes: a 7.8 magnitude on 25th April and a 7.3 magnitude on 12th May. These quakes, along with subsequent aftershocks, caused extensive damage to the Kathmandu Valley, particularly in the water and sanitation sector, amounting to NPR 11.4 billion in damages. Due to the poor hygiene conditions, especially in densely populated urban areas, there was a significant risk of waterborne diseases like cholera and diarrhea. 
• After the quakes, various WASH humanitarian agencies, anticipating an outbreak, promptly provided emergency interventions. While there were 76 reported cholera cases from August to September 2015, none were from urban Internally Displaced People (IDP) camps. However, 2016 was seen as a vital year concerning public health in the Kathmandu Valley. Under the district health and WASH agencies, and alongside partners like Nobel Compassionate Volunteers and Environment and Development Organization (NCV-ENDO), UNICEF Nepal played an instrumental role in planning, coordinating, and implementing crucial WASH activities. The first cholera case of 2016 was reported in early June, with Graph 1 detailing the cases from week 26 to week 36.
• In 2021, two significant cholera events were reported. In September, two imported cases were identified, prompting immediate surveillance and response activities; fortunately, no further cases were found. However, in October, a more severe outbreak occurred with over 1,500 cases first reported in a hospital in Kapilvastu District. This led to immediate epidemiological investigations initiated at both the local and district levels. As the number of cases grew, a joint team comprising members from the Provincial and Central Government's Epidemiology and Disease Control Division and the WHO Country office was formed to further investigate and respond. The WHO provided a Cholera Kit to the affected hospital to facilitate immediate response.
• Following an outbreak investigation in Kapilvastu District, a request for cholera vaccines was made to the International Coordinating Group and subsequently approved on November 3, 2021. Despite the ongoing COVID-19 response, the vaccination campaign has continued, and since its commencement, there have been no further cases of cholera reported in the district.

Source:https://www.gtfcc.org/wp-content/uploads/2022/04/9th-annual-meeting-gtfcc-2022-rajesh-pandav.pdf

 

• In June 2022, there were reported cases of a disease in the Kathmandu Valley, with 12 cases detected as of 27 June. The Epidemiology and Disease Control Division of the Ministry of Health and Population, in collaboration with District and Local Levels, initiated an investigation. A multi-sectoral strategy was adopted, under the technical guidance of the Ministry of Health and Population. This comprehensive approach involved various sectors, including local community engagement for risk communication, WASH initiatives, door-to-door activities, and ministerial-level involvement in water surveillance, food surveillance, and information dissemination.

Source: https://www.gtfcc.org/wp-content/uploads/2022/04/9th-annual-meeting-gtfcc-2022-rajesh-pandav.pdf 

 

Factors contributing to outbreaks

• Factors contributing to the outbreaks include floods, landslides, inadequate supplies of safe drinking water, high rates of open defecation, and the presence of drug-resistant Vibrio cholerae strains.
• Efforts by the government and international bodies to curb the spread: vaccination campaigns, awareness programs, and infrastructural development. The Ministry of Health and Population in Nepal has implemented a National Preparedness and Response Plan for acute gastroenteritis/cholera outbreaks. This plan aims to enhance Nepal's health status by decreasing cholera incidence nationwide. It specifically targets preventing cholera spread, minimizing mortality from the disease, fostering coordinated efforts during outbreaks, and ensuring a swift response mechanism to halt disease proliferation.

Source: https://www.researchgate.net/figure/The-framework-of-factors-associated-with-a-cholera-outbreak_fig1_325588763

• Since 2020, the Ministry of Health and Population has partnered with the International Vaccine Institute's Enhancing Cholera Control in Nepal (ECHO-N) initiative to combat cholera epidemics and bolster local public health services' capacity for sustainable cholera and diarrheal disease surveillance and control. This collaborative program has spearheaded a significant cholera prevention project in Nepal, integrating oral cholera vaccine (OCV) campaigns with Water, Sanitation, and Hygiene (WASH) initiatives, comprehensive disease surveillance, and the formulation and ratification of a National Cholera Control Plan.
• Nepal has established robust surveillance and laboratory networks under a newly federated governance structure, with local authorities taking the lead in response actions, community engagement, and sanitation. While the government is committed to cholera control, demonstrated by the National Preparedness and Response Plan, there's still a need for a clearer framework guiding the local level's responsibilities.
• For the year 2022-23, there are several key priorities set out. The Enhancing Cholera Control in Nepal (ECHO-N) project continues its research trajectory, with its findings to be instrumental in formulating a dedicated Cholera Control Plan. Concurrently, efforts are being directed towards bolstering Event-based surveillance, encompassing community-based surveillance efforts. Moreover, there's an agenda in place to train Rapid Response teams at the local level throughout 2022.

Vulnerable Areas 

• Nepal is particularly vulnerable to cholera, often due to factors like inadequate access to clean water, sanitation issues, and flooding. Certain regions in Nepal are especially susceptible to cholera due to factors like poor sanitation, lack of clean water access, and flooding. The Terai belt in southern Nepal faces regular floods, leading to water contamination. Kathmandu Valley, despite its urban status, struggles with outdated sewage systems and water contamination. The far-western and mid-western regions, due to their remote nature, lack adequate water and sanitation facilities. Additionally, temporary settlements and refugee camps, especially near the Nepal-India border, are vulnerable because of crowded conditions and limited sanitation. Natural disasters further heighten these risks by damaging infrastructure.

Urban vs. rural trends: 

• Urban: Overcrowded areas, especially slums, face heightened risks due to poor sanitation. Inadequate sewage and waste disposal systems can lead to water contamination. High mobility in urban centers can spread cholera quickly. 
• Rural: Reliance on natural water sources increases contamination risk. Limited access to healthcare can delay cholera diagnosis and treatment. Open defecation and poor sanitation practices enhance transmission. Less awareness about cholera due to educational gaps. Vulnerability to natural disasters, like flooding, can exacerbate contamination. In both areas, improving water and sanitation practices is key to reducing cholera risks.

Preventive Measures and Efforts 

• Role of national and local governments, and NGOs. 
• Policy formulation and resource allocation. 
• Ground-level operations and filling resource gaps.
• Importance of public awareness campaigns. 
• Educate about cholera's causes, prevention, and treatment.
• Cholera vaccination drives and their effectiveness. 
• Vital defense in high-risk areas; reduces disease severity.
• Infrastructure development, especially regarding clean water access and sanitation.
• Ensure access to clean drinking water. Build proper sewage and waste disposal systems; promote toilet use.
• A combination of government and NGO involvement, infrastructure development, public education, and vaccination is crucial for cholera prevention.

Global Perspective 

Source:https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON426

Fig 2: Incidence of Cholera cases per 100,000 population reported to WHO from 1 January to 30 November 2022

Comparison with Other Countries: 

• Nepal, like many countries in South Asia and sub-Saharan Africa, faces challenges with cholera primarily due to inadequate water and sanitation infrastructure. Countries like Bangladesh and India have similarly faced recurring cholera outbreaks, especially in densely populated areas or after natural disasters. 
• Contrastingly, countries in the West and some in Southeast Asia, like Singapore and Malaysia, see rare cholera cases mainly due to improved water, sanitation, and healthcare infrastructure. 

Lessons from Other Countries

Infrastructure Development: Countries that have successfully combated cholera prioritize water and sanitation infrastructure. Regular water quality checks and sewage system upgrades are essential. Vaccination Campaigns: Nations like Bangladesh have implemented large-scale oral cholera vaccination campaigns, significantly reducing incidence rates. 

Public Awareness: Education campaigns, as witnessed in many African nations, are vital. They not only raise awareness but also promote hygiene practices that prevent cholera. 

Rapid Response Teams: Countries that face natural disasters or are prone to outbreaks often have rapid response teams trained to handle cholera outbreaks, ensuring early detection and treatment. 

Collaboration with NGOs and International Bodies: Successful countries often collaborate with NGOs and international organizations like WHO for expertise, resources, and guidance in cholera control. 

Nepal can draw insights from these global successes, emphasizing infrastructure, public education, vaccination, and collaborations to effectively reduce cholera incidences.

The Way Forward 

Water Treatment: 

Upgrade purification systems and expand piped supply. 

Challenges: Funding, terrain, maintaining quality in remote areas. 

Community Education: 

Launch campaigns on water, sanitation, and hygiene. 

Challenges: Cultural practices, reaching remote areas, language diversity. 

Healthcare Infrastructure: 

Upgrade facilities, train professionals, and establish new centers. 

Challenges: Resource constraints, attracting talent to remote regions. 

Surveillance Systems: 

Implement comprehensive disease monitoring. 

Challenges: Real-time data collection, and technological limitations. 

NGO & International Collaboration: 

Partner for expertise and resources. 

Challenges: Bureaucracy, coordinating large-scale efforts. 

Infrastructure Development: 

Build sewage and waste disposal systems. 

Challenges: Urban expansion, costs, changing local norms. 

Vaccination: 

Organize regular vaccination drives. 

Challenges: Vaccine supply, community participation, record-keeping. 

A multifaceted approach, addressing these areas and their challenges, is essential to effectively reduce cholera in Nepal.

Conclusion 

Cholera remains a significant health challenge in Nepal, with factors like inadequate sanitation, water contamination, and lack of public awareness exacerbating its spread. However, with the combined efforts of the government, NGOs, and local communities, there's been notable progress in controlling its outbreaks and reducing its impact. While the strides made are commendable, continued vigilance is crucial. Enhanced infrastructure, consistent public education, and regular surveillance are imperative to ensure that the country stays ahead of potential outbreaks. With steadfast commitment and a holistic approach, there is a palpable hope that Nepal can envisage a future where cholera no longer poses a threat to its people, echoing the global aspiration of a cholera-free world.

Resources and Further Reading 

• https://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0003961
• https://www.unicef.org/rosa/media/12226/file/Wash_Field_Note_-_Evolution_of_the_Kathmandu_Valley_Cholera_Prevention_and_Preparedness_Programme.pdf
• https://english.onlinekhabar.com/cholera-epidemic-2022-nepal.html
• https://www.stopcholera.org/blog/understanding-cholera-nepal#:~:text=The%20first%20recorded%20cholera%20epidemic,May%20of%201886%20(2).
• https://www.youtube.com/watch?v=LAh4DO8Imlc