The Jajarkot epidemic: Some crucial observations
Recently, Jajarkot district of Mid-Western Region of Nepal has become the headline news throughout the country as a result of spiralling cases of diarrhoea and dysentery. In this district alone, around 150 have died, with more than 250 deaths nationwide. The first case of diarrhoea related death was recorded four months ago, and finally, the concerned health authorities are now on high alert regarding the severity of the disease that has spread rapidly across Jajarkot and adjoining districts.
In recent days, not only the governmental health sector but also international organizations such as WHO, UNICEF, Red Cross are getting involved in controlling this epidemic. The question is, why did it take so long for all concerned to finally realize the seriousness of the situation? To find out the answer, as well as to assess the true situation in Jajarkot from an independent point of view, a team consisting of epidemiologist along with infectious disease research scientist was formed by Nepal Health Research Council (NHRC) and sent to the epicentre of the epidemic, Khalanga, the district headquarters of Jajarkot.
Dr. Gajanand Bhandari, Medical Epidemiologist, NHRC, Research Assistant Mr. Umesh Ghimire, and I had the opportunity to understand the ground reality of this outbreak. We assessed the situation from two different points of view- The collection and assessment of the epidemiological data in Khalanga and other VDCs; The collection of stool and water samples from those areas with assistance from a laboratory expert, Mr. Trivuwan Shah, sent by Nepal Public Health Laboratory, Kathmandu. This team spent over a week in the district carrying out planned activities with base set up at District Health Office in Khalanga.
In the process, data and samples were collected from both Khalanga and Khagenkot VDC, a nine hour walk each way from the district headquarters. Initially, 5 stool samples were collected from Khalanga and sent to Kathmandu as per request from World Health Organization, Nepal, with the remaining 10 brought back from Khagenkot to Kathmandu by our team.
Some of the issues as observed at Jajarkot during this visit are as follows:
Why was no effort made to identify the pathogen in question? While there is a possibility that other pathogens may also be involved in this outbreak, why was diagnosis or the pathogen overlooked in the last three months? As a result, up to three types of antibiotic were being, and are still being administrated to patients just to make sure all clinical symptoms are covered. Surprisingly, international organizations are being approached to help in diagnosis when this simple method is available right here in Nepal in both governmental and non-governmental laboratories. It is important to have a world class organization such as WHO validate results, but it is time that the government started to also trust and develop its own system of accurate diagnosis of pathogens involved in epidemics in collaboration with the private sector which also has high technology laboratories.
Why was the coordination mechanism still in its early stages in spite of the severity of the outbreak in recent months? Our team observed that the District Health Officer at Khalanga was having a hard time coordinating with the Chief District Officer of Jajarkot, the Army and the incoming teams of Doctors and Health Professionals. In one case, there were about 35 health professionals stuck at Chaurjhari (Rukum) airport where the Army was asked to drop the incoming support. From this place, on average, it took up to 6 hours walk to get to the district headquarters. We found out that those stuck at Chaurjhari didn’t have a clue as to where to go and what to do.
There is no doubt that Nepal Army has done a very good job at helping transport personnel and medications to different areas of Jajarkot and adjoining districts by its plane and helicopters. However, lack of coordination with the health authorities was evident - for example, instead of three antibiotics being sent, two were sent and the third left out. There were also complaints from the army pilots that in some instances, there was no one to receive the supplies at the point of medical drops.
Nepal Health Research Council took a timely decision to get involved in this national issue. For too long, research aspects into national epidemics have been missing completely from the governmental agenda. Too much focus has been given to control and treatment of diseases when those are seen, but hardly any effort has gone into prioritizing the epidemiology and diagnosis based research of the diseases. There is hardly any doubt that without proper research into epidemics, the scenario will repeat again in the coming years, with no efficient plan of action in place. The solution to the problem is not in simple medicative approach alone- this just enables temporary respite from the problem. The solution is in understanding the epidemics and their weaknesses, so that repeat epidemics are controlled much faster and more efficiently.
Dixit is Director, Centre for Molecular Dynamics Nepal (CMDN)