Health Action in

Health Newsletter Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division . World Health Organization-Emergency and Humanitarian Action - Issue V, January 2006

Highlights

v End of four months Mid -Western Region bilateral Ceasefire Nepal N v Beijing Declaration at HUMLA DARCHULA

the International Western RegionBAJHANG - MUGU BAITADI Western Region Pledging Conference on Far BAJURA

DADEL- JUMLA Avian and Human DHURA ACHHAM KALIKOT DOLPA

Pandemic Influenza MUSTANG KANCHAN - PUR DAILEKH JAJARKOT th KAILALI v 8 National RUKUM MANANG Central Region SURKHET MYAGDI SALYAN Earthquake Safety Day BARDIYA GORKHA ROLPA BA KASKI GL UN LAMJUNG Eastern Region G PARBAT RASUWA BANKE PYUT- v Special National HAN GULMI DANG ARGHAK SYANGJA TANAHU SINDHU - Immunization Day HACHI NUWAKOT PALCHOK PALPA DOLAKHA DHADING KATHM KAPIL - NAWAL SULUK- RUPAN- BHAK BASTU PARASI HUMBU (SNID) on 21-22 DEHI CHITWAN P SANKHUWA- A TAPLEJUNG MAKAWAN - LALIT KAVRE H SABA PUR H E C M A OKHAL- January in the Eastern, R PARSA DHUNGA SINDHULI KHOTANG T E R A I TERHA- A R BHOJ- THUM TH Central and Far BARA RAUT- E PUR C H AHAT DHAN - A SARLAHIMAHO- UDAYAPUR P H I L L KUTA TARI Western Regions of ILAM M O U N T A I N DHANUSA SIRAHA SUNSARI MORANG Nepal SAPTARI JHAPA

v A study of Measles Deaths in Nepal

\ News Update in EDCD in January 2006 24 Killed by Viral Influenza in Humla in the Mid Western EDCD News update

Region of Nepal v 24 killed by viral influenza in Humla in the Based on Media report s that 24 people died from viral influenza, the Ministry Mid Western Region of of Health and Population (MOHP), Department of Health Services (DHS), Nepal Epidemiology ad Disease Control Division (EDCD) sent two teams of health

v Investigation of reported workers to in the Mid-Western region of Nepal on Monday on th pneumonia Outbreak in the 16 of January in order to check the spread of influenza in villages of the Bajura District in the Far district. Severe cold has gripped some villages in the district, some 700 Western Region of Nepal kilometer west of which is also facing shortage of medicines, the report said. Heavy snowfall that occurred on Sunday on the 15th of January v Cold wave claims lives of affected day-to-day public life in the district and closed the government children, women and offices. Some air services were also suspended due to the snowfall. The aged people in the investigation on viral influenza outbreak in Humla is still on-going. Central Region of Nepal

v Epidemiological End of four months bilateral ceasefire Surveillance of A four month long unilateral ceasefire declared by the Maoists ended on 2 Lymphatic Filariasis in January 2006. Since then Nepal has seen a campaign of widespread bomb four districts attacks across the country targeting public offices. Clashes and cross fires v A Study Report on Post between security forces and Maoist have also increased considerably, Anti-Filarial Mass Drug including in the outskirts of Kathmandu Valley. Administration (MDA) 2005 by Active Both the Maoists and the coalition of the seven main opposition political Surveillance parties have expressed their intention to boycott and disrupt municipal elections scheduled for February 8. Mass gatherings, rallies and

demonstrations against the elections are taking place in most big cities. It is expected that the situation will remain tense with an increasing number of incidents leading up to the municipal elections.

Health Action in Nepal (Monthly Health News Letter, Issue V, January 2006) Page # 1 of 6

News Update in EDCD in January 2006 8th National Earthquake Safety Day Cold wave claims lives of children, women In commemoration of the 1934 Bihar earthquake, which had a and aged people in the devastating impact on large areas of Nepal, an annual National Central Region Earthquake Safety Day is celebrated on the 15 January. This year, the programme included a number of activities including a Local Media has reported that altogether symposium on Disaster Risk Management, an exhibition and 17 people died across the nation due to the several different types of mock drills and simulations. The entire severe cold wave, which gripped the programme was organized by the Department of Urban Planning country during January. According to and Building Construction and National Society of Earthquake reports, the cold wave claimed lives of Technology (NSET). The exhibition took place in Bhaktapur, children, women and aged people one of the cities most devastated by the 1934 earthquake. It was especially in five districts in terai belt inaugurated by Vice-Chair Mr.Kritinidhi Bista and attended by namely Dhanusha, Mohatari, Parsa, the Home Minister, Mr. Kamal Thapa. Organizations such as Sarlahi and Rauthat in the Central Region , NSET, the Scouts and Lutheran World of Nepal. Federation all made displays as did Nepal Army and Police and various Government Agencies. Epidemiology and Disease Out of total deaths, the cold wave claimed Control Division and WHO Emergency & Humanitarian Action lives of three people in Janakpur city in Programme made a display of the wide variety of activities Dhanusha and ten people in Mahottari focused on emergency preparedness and response, and the stall district. An old woman also died due to was well visited during the three days the exhibition lasted. cold wave in Birgunj city in Parsa and three in Rautahat.

As a result of the cold wave, a pneumonia epidemic has also gripped Mahottari. There is a surge of pneumonia patients at the district hospital, health posts and sub health post in Jaleshwor in in the Central Region

According to airport authorities, the cold wave and fog also affected flights. According to reports from Sarlahi, animals too were hit hard by the cold wave. “Even the bird have been affected due to the cold wave,” report quoted the head of the Veterinary office, Kanak Lal Shah as saying, “Also, as the grazing land is frost-laden, the cattle too have caught cold.” The cold wave also affected other districts of the terai as well.

Investigation of reported Pneumonia Outbreak in Bajura District in the Far Western Region of Nepal

Based on Media reports of outbreaks of pneumonia and common cold in the Far Western Region, a district Rapid Response Team (RRT) was sent to investigate. The team left for Bajura district on 4th January 2006 to investigate the problem of the Village Development Committee (VDC) and to provide necessary treatment. The team includes Ms. Luna Shrestha, Staff Nurse, Mr. Deepak Bahadur Shah, Auxilliary Health Worker (AHW) and Mr. Hemraj Budha (AHW) from District Health Office, Bajura.

The team investigated by visiting homes and meeting places and inquiring with people of the different wards of that particular VDC. They found that there was no outbreak of common cold and pneumonia nor were any deaths reported. The treatment team found that in the period of 9th to 31st December 2005, there were 7 deaths due to chronic diseases like arthritis, asthma, stomachache and complication after delivery.

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Beijing Declaration International technical agencies such as FAO, WHO and OIE have been

At the International playing a pivotal role in informing the response by developing global

[[ strategies to control avian influenza and prevent a human influenza Pledging Conference on

pandemic. The Secretary General’s Special Representative for

Avian and Human

coo rdinating the UN’s response to avian and pandemic influenza has

Pandemic Influenza, 17- made a substantial contribution in ensuring that all UN agencies are

18 January 2006, Beijing, working (maximally) to contribute to this effort.

China

Globally, the target of raising funds was 1.2 billion $ whereas 1.9 billion

$ was in fact raised in this conference. The following donor agencies and

The International Pledging conference on countries committed to support the global effort to contain the spread of Avian and Human Pandemic Influenza the highly pathogenic Avian Influenza epidemic, bring it under control, was convened in Beijing, China on 17-18 and stamp it out as soon as possible. January 2006 under the co-sponsorship of the Government of the People’ s Republic Donor Agencies and Countries Budget in $ of China, the European Commission and World Bank 500 million the World Bank and in close coordination United States of America 334 million with Food, and Agriculture Organization China 10 million (FAO) and World Organization for Asian Development Bank 468 million Animal Health (OIE). The conference was Australia 100 million attended by representatives of over 100 countries from around the world, Other 32 Donor Countries Necessary Funds will be representatives of international technical provided and financing agencies, organizations, and private sector and civil society. According to a World Bank Report, Nepal was considered as a low risk country for Avian and Human Pandemic Influenza. The State Thre e participants from Nepal Minister, Honorable Mr. Mani Lama, Ministry of Health and Population, participated in the conference. They were appealed to the World Bank to re-consider Nepal from a low risk to a honorable State Minister Mr. Mani Lama, high risk country due to the following reasons: Ministry of Health and Population 1. China has been adversely affected by avian influenza and India (MOHP), Chief Specialist Dr. Nirakarman is considered as a high risk country and Nepal lies between the Shrestha, MOHP and Director of Epidemiology and Disease Control two. 2. The boarder between Nepal and India is porous with people Division, Dr. Mahendra Bahadur Bista. from either country freely moving back and forth. 3. Nepal is located on major flyways of migratory birds from The world is face d with a re-emerging Russia, China and other countries. disease, avian influenza, which like SARS 4. Mixed farming practice such as poultry, ducks and pigeons in and HIV/AIDS respects no national different places in Nepal. boundaries. Avian Influenza has now spread from Asia to the Middle East and The team from Nepal distributed “National Avian Influenza and Europe with the prospect that the disease Influenza Pandemic Preparedness and Response Plan of Action” in the might also spread to Latin America, conference and presented a tentative budget plan for the prevention of Africa and elsewhere. Human casualties Avian Influenza for the period 2006-2008 with a total cost of $ have been confirmed and there is a real 15,133,000. The following are the main strategies and budget of the possibility that further genet ic changes in Contingency Plan as presented at the conference. the virus strain might result in sustained human-to-human transmission and a Strategies Budget in $ human influenza pandemic. Therefore the Planning and coordination 109,364.54 Conference aimed at achieving the Surveillance of human Influenza 634,113.71 following goals: Prevention and Control of Avian Influenza 10,068,561.87 Firstly, enhance cooperation and Pre-preparedness and management of Health 4,110,702.34 strengthen partnership by promoting Field extensive, in-depth and sustained global Information and Communication 45 ,150.50 cooperation. Capacity building of Health laboratory 225,752.50 Secondly, reaffirm commitment and deepen consensus. Total 15,183,612.04 Thirdly, evaluate needs and deliver funding pledges by specifying the sources of funding, principles for its use and (Source: MOHP/DHS/EDCD Director Dr. M.B. Bista) management and relevant procedures.

Health Action in Nepal (Monthly Health News Letter, Issue V, January 2006) Page # 3 of 6

A Study of Measles

Deaths in Nepal

Source : Dr. Thomas Wierzba Technical Officer, Programme for Immunization Preventable Diseases (IPD ), WHO

While there were an estimated 113,000 measles cases in Nepal in the year 2002, there was no accurate estimate of the number of deaths due to measles. In 2005, the World Health Organization (WHO) and Ministry of Health and Population (MoHP) decided to study the measles Case Fatality Ratio (CFR), that is, the number of children with measles who later died. To ascertain the CFR, a community-based retrospective study of a national, representative sample of measles outbreaks was conducted. Thirty-seven Monk–Apprehensively-Receiving Measles Vaccine outbreaks were investigated. Of these, 19 were from the hills and mountains and 18 were from the Terai. Five trained teams, one team for each development region conducted the survey using a structured, Measles CFR Study Districts, Nepal 2004 protested questionnaire. Before the interview, informed consent was obtained form each household head.

From the 37 outbreaks, 5303 persons with measles were interviewed. Forty-one percent of cases were from the hills and mountains and 59% from the Terai. Of t he Far-Western cases, 9%, 23%, 21%, 19, and 28% were Region from the Far-western, Mid-western, Mid-Western Western, Central, and Eastern Region

Development Regions. The mean age of Western Region cases was 6 years (range one month to 70 years) and females were 51% of cases. Central Region

The case fatality ratio was 9%, 3%, 1%, Eastern Region and 1% for infants, and persons aged 1 to 4 years, 5 to 14 years, and 15 years and above. Measles cases in the Far-western and Mid-Western Regions had the highest measles case fatality ratio with 2.5% and Case Fatality Ratio by Development 3.1% of children dying, respectively. The Western, Central, and Eastern Region in Nepal Regions had lower CFRs with 0.9, 0.8, and 0.3, respectively. 2.5 In conclusion, measles was found to cause deaths mainly among children with most 3.1 measles deaths occurring in infants and Far-Western children 1 to 4 years of age . Cases from Region 0.9 the Far and Mid-Western Development Mid -Western Regions were most likely to die. A Region 0.8 national measles campaign immunizing Western Region 0.3 all children nine to 14 years of age was conducted in year 2004 and 2005 in Himalayas (16 districts) Central Region Nepal. Since that campaign, there have Hills (39 districts) Eastern Region been few measles cases and no deaths Terai (20 districts) from measles.

Health Action in Nepal (Monthly Health News Letter, Issue V, January 2006) Page # 4 of 6

Special National Finally, despite the few problems of social mobilization altogether the program was Immunization Day (SNID) successful and able to visit the targeted areas. The monitor team hanged an held in the Eastern, Central immunization banner in the UN vehicle, which made it easier to visit the high -risk areas. and Far Western Regions of The presence of central level monitors enabled the spot monitoring and supervision Nepal from 21st to 22nd Jan 06 during the campaign. Visit ing in Kanchapur was useful in terms of joint supervision and

A Summary Report of Kanchanpur in sharing of feedback mutually.

the Far Western Region of Nepal The First Phase SNID Districts in the Eastern, (By PradeepAdhikar, CORE Co-ordinator, a nd Dr. Nabin Ghimire Surveillance Central and Far Western Region of Nepal Medical Officer (SMO)-Pokhara)

Due to the recent onset of wild poliovirus in Humla Nepal it has been difficult to eradicate polio Darchula in Nepal. A special national immunization Bajhang Baitadi Mugu KathmanduBhakta day was celebrated in 15 districts pur Bajura Jumla KaliKot Dolpa boardering India. Central level monitors Dadeldhura Doti Patan Dailekh Mustang visited . The main Kanchanpur Achham Jajarkot Kailali purpose of the visit was to assist planning, Surkhet Rukum Manang Myagdi Gorakha monitoring and supervision of the Bardiya Baglung Salyan Rolpa Kaski immunization program. In addition, the Bankey Gulmi Lamjung

Dang Pyuthan Parbat Rasuwa logistic arrangement, social mobilization Syanja Sindhu Tanahu Nuwakot Arghakhachi Palpa

Dhading activities and other accessories focused for Kapilvastu Rupandehi Dolakha Nawalparasi Makwanpur Kavre the program was closely observed. Chitwan Solukhumbu Sankhuwasabha Taplejung Ramechhap Okhaldhunga Sindhuli

21 January 2006 was the first day of the Parsa

Bara

Tehrathum

Khotang Bhojpur Bhojpur SNID Districts Udayapur Khotang

ahotari Dhankuta Panchthar

Rautahat program. All district supervisors had visited Sarlahi M Ilam Siraha to their assigned areas for monitoring and Dhanusa Saptari Jhapa Sunsari supervision of immunization program. Morang Though there was influence of the current tense security situation, the district level SNID held in Central Region security personnel supported well to the Reported by Dr. J.N. Giri, Immunization Coordinator, IPD/WHO SNID programme and alowed UN vehicles to visit different immunization booths in 1st round SNID has been completed in 15 districts. Observation made by the central different places ni Kanchanpur. It seems monitors is good. The monitors observed that those districts, which were previously that the security personnel were more aware weak, have improved. The difference in this SNID from previous SNID was that all of this programme than earlier. T he children had to be marked in the immunization booth centers on the first day, and on the second day every house was searched for left out children. immunization booth centers arranged in different wards of district were not affected The second most important event was the orientation to the FCHV, which certainly gave by the current situation. Because of that, a good impact on program for disseminating the message to the beneficiaries. approximately 70% of children already received polio vaccination by 2:00 pm of the first day. A Study Report on Post Anti-Filarial Mass Drug The social mobilization activities were not Administration (MDA) in Rupandehi and Parsa much effective in hard to reach areas. The people of that area had to depend on Districts, 2005 by Active Surveillance interpersonal communication. But it was not Under the programme to eliminate lymphatic filariasis, amass drug administration (MDA) completely effective to deliver the message campaign was launched in 5 dist ricts in the year 2005. They were Parsa, Makwanpur, towards the needy people. Interior parts of Chitwan, Rupendehi and Nawalparasi. The first three districts had previous programmes the communities still did not get whereas the other two were new additional districts in terms of programme information due to late orientation. The implementation. As per WHO strategy the last anti-filarial tablets were distributed to each contribution of Female Community Health eligible person present at home through trained local VHWs, MCHWs and volunteers on Volunteers (FCHVs) was highly the 24th September 2005. The reported coverage from those 5 districts was found to be encouraging. They were entirely committed over 90% on average. In order to understand the actual pills consumption rate, nature of to reach the polio vaccine to all the targeted adverse effects and reasons for non-acceptance of drug intake "active surveillance" – a < 5 children. study on post-MDA, was carried out in selected two districts, Parsa and Rupendehi within

22 Jan 06, the second day of the SNID, the 4 weeks after the drug administration. Japanese Encephalitis Support Group, a Kathmandu based NGO, did the study and submitted its report to EDCD/DHS in January, 2006. central level monitors visited a few suspected areas where there was a The study reports revealed that all together a total of 96% people in both the study districts possibility of missing children for ingested the pills with higher coverage ((98%) in Rupendehi district than in Parsa (94%). The adverse effects were three fold higher (5.64%) in Rupendehi district than in Parsa vaccination, which turned out to be true. A district (1.59%). Those who experienced adverse effects complained of dizziness, few children had in fact been missed out. headache, fever, vomiting and nausea in decreasing order. Among the non-acceptance, the But volunteers were alert to visit those majority put the reason for non-acceptance as "fear of side effects”. As compared to the places for household visit and provided average coverage rate (88%) among the other countries of MDA, the present study results polio vaccine to the children that had reveal a significant level of coverage on ingestion (>90%) of pills during the MDA in the missed out on the first day of the SNID. study districts in Nepal.

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News update in January 2006 The maximum study population (23.54%) belongs to age group 11-20 and the least (3.23%) above 70 years of age. Epidemiological Surveillance of Rupendehi Among the total 1040 night blood samples, microfilaria prevalence was found to Lymphatic Filariasis be 5.19% (54/1040) in Rupendehi district. Among them the highest prevalence in Four Districts (7.55%) was recorded in the Bisnupura sentinel site (40/530). Endemicity rate of the lymphatic filariasis includes the microfilaria positive cases with or without The Lymphatic filariasis elimination sign and symptoms as well as the crude disease rate which includes chronic programme has been in place in Nepal elephantiasis, limbs swelling, breast swelling, chyluria, skin thickness, since 2003 as called by World Health Organization (WHO) to eliminate the lymphoedema etc. Overall endemicity rate of lymphatic filariasis also showed disease by 2020 globally. very high in Rupendehi district i.e. 8.2% (85/1040)

Lymphatic filariasis is a parasitic disease Nawalparasi transmitted by mosquito bites. The A total of 1019 night blood samples were collected from the two sentinel sites of disease is an important cause of physical . Prevalence of microfilaria in this district is also found to be disability, social stigma and loss of lively high 4.9% (50/1019). Among the two sentinel sites higher prevalence of hood to affected individuals. It leads to microfilaria in the blood samples was found in Tharu gaun of the Kudia VDC significant economic loss to the country. than in Rani nagar of the Tribeni VDC. The crude disease rate was also found to The signs and symptoms of lymphatic be higher in Kudia VDC. Due to the large number of the crude disease rate, filariasis prevalently seen were particularly hydrocele and elephantiasis and chyluria, the endemicity rate of the elephantiasis, hydrocele, chyluria, lymphatic filariasis increased to 7.06%. lymphoedema, breast swelling, thick skin

etc. Under the implementation of the Chitwan programme, anti-filarial mass drug A total of 1006 night blood samples were collected from the two sentinel sites administration to each eligible person is of the , Bhandara and Ratna nagar. In comparison to the nedded once every year for 5 years to Rupendehi and Ratna nagar municipality microfilaria prevalence rate is found to bring down the filarial rate to one new be lower. Overall endemicity rate of lymphatic filariasis was about one percent case per 1000 susceptible individuals These findings would indicate the success of the first phase treatment against the during post treatment state. Microfilaria lymphatic filariasis before more than one year. prevalence and density, together with drug coverage are probably the best Makwanpur indicators for monitoring purposes. The A total of 1019 night blood samples were collected from the two sentinel sites of standard method of night blood survey of , Hatiya and Palung respectively. Microfilaria prevalence the entire sentinel site population is carried out for microfilaria prevalence. was found only in Hatiya i.e. 2.14% but nil in Daman VDC Palung. Makwanpur The measurement of the indicators in the district is also one of the district s where the first phase of the control programme sentinel sites serve as a baseline to follow had already been conducted before more than one year. Overall microfilaria the programme's impact from start to prevalence in Makwanpur district is 1.07% while the lymphatic filariasis finish. endemicity rate was 1.86% because of the high crude disease rate in both of the sentinel sites of this district.

Contacts for further information

Ministry of Health and Population Dr. M.B. Bista Department of Health Services Director

Epidemiology and Disease EDCD In this connection, epidemiological Control Division (EDCD) Department of Health Services surveillance of lymphatic filariasis in Teku, Kathmandu, Nepal Makwanpur and Chitwan. in the Central Tel: +977-1-4255796/4262268 Region and Rupendehi and Nawalparasi Fax: +977-1-4262268 in the Western Region of Nepal was conducted by central department of World Health Organization (WHO) Zoology (Parasitology) , Kathmandu. A total of 4084 community people were interviewed and Dr. Kan Tun Ms. Trine Ladegaard night blood samples were collected from WHO Representative Technical Officer two sentinel sites of each of the four World Health Organization World Health Organization districts. Among them 2007 (49.15%) were males and 2077 (50.85%) females. UN House, P.O. Box 108 UN House, P.O. Box 108 From each of the sentinel sites more than Pulchowk, Kathmandu, Nepal Pulchowk, Kathmandu, Nepal 500 community people were involved in Email: [email protected] Email: [email protected] the survey.

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