Following the human and material tragedy of the double earthquake in Central Nepal in April and May, which killed 8,700 people, displaced 90,000 and destroyed more than 500,000 houses and healthcare facilities, Nepal’s government and its partners have begun preparing for potential infectious disease outbreaks. With the monsoon comes an additional risk of outbreak and logistical challenges for any potential response.
Beyond the immediate fatalities and injuries, there has been a breakdown in hygiene and sanitation, as people seek refuge in relatives’ houses or in makeshift internally displaced people camps. Combined with insufficient vaccine coverage, this increases the risk of diseases such as cholera, typhoid fever or measles. The cholera outbreak that followed the 2010 Haiti earthquake − which affected over 700,000 people and killed almost 9,000 − exemplifies the type of situation Nepal might face without adequate preparedness and response capacity.
The risk of outbreak is amplified by two factors. First, the burden of infectious diseases in Nepal is high: The country has experienced cholera outbreaks almost every year in the last five years, affecting up to 70,000 in 2009. Second, the monsoon season, which traditionally starts at the end of June, will worsen living conditions and create an even more favourable environment for pathogens to thrive. The combination of earthquake-related landslides and the monsoon may cut off some of the most affected districts, complicating the response to any public health crisis. Small communities often live hours, sometimes days from the closest road or the closest health facility.
Preventing outbreaks from occurring or mitigating their impact in this context requires a four-pronged strategy:
- First, setting up a surveillance system that can detect any potential outbreak situation early, either through verifying rumours or through the quasi real-time collection and analysis of data on suspected cases of outbreak-prone diseases, followed by laboratory confirmation;
- Second, catch up vaccination campaigns for vaccine preventable diseases, especially measles;
- Third, preparedness plans for high impact scenarios such as a cholera outbreak: these should outline accountability and responsibilities across government and other partners such as the WHO, UNICEF and humanitarian agencies to streamline a swift response to any potential outbreak;
- Fourth, strengthening response capacity at the district level to ensure there is a timely first line of response if access to a specific area is compromised.
This strategy has started to be implemented: two months after the earthquake, the surveillance mechanisms are in place, and small scale clusters of disease are detected and investigated on a regular basis. In collaboration with the WHO, the Nepali government has set up a network of 40 health sites across the 14 affected districts, reporting daily on a number of outbreak-prone diseases through an early warning system via phone, email or SMS. Shortly after the first earthquake, the Nepali Ministry of Health, in collaboration with UNICEF, organized a measles vaccination campaign for more than 500,000 children in the earthquake affected districts. Training events on surveillance, as well as support missions to the districts have increased local capacity and a cholera preparedness plan involving relevant stakeholders is in development. The WHO has also deployed technical staff to each district to increase local surveillance and response capacity.
Limits to disease surveillance
The local capacity to confirm an outbreak and respond remains more limited, and outbreaks may still be detected late. The early warning system is largely hospital based, and may not detect outbreaks occurring in areas too far from these hospitals. In addition, none of the affected districts have the ability to confirm a cholera case. District level healthcare facilities can be limited, and the earthquakes have destroyed a high proportion of hospitals and health centres, further weakening the infrastructure. In addition, healthcare staff have sometimes left their post to tend to their affected families or properties. Despite foreign medical teams providing additional support, any large outbreaks will require transporting staff and equipment - which may be slow if only air access is possible.
Expanding the surveillance network, re-starting clinical services in areas where healthcare facilities are destroyed, ongoing staff training on disease surveillance and response and pre-positioning medical supplies where appropriate will help reduce the impact of potential outbreaks.
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