Recent seasonal influenza outbreak in remote villages of Jajarkot district has become a major cause for concern. Laboratory investigation shows that the causative agent is Influenza A (H1N1), a type of virus that is currently circulating in South Asia. With over 25 deaths and over 3,000 possibly affected, there is a risk that this could spread into other districts, and cause further deaths. Although applying epidemiological tools allows us to calculate mortality—very low among currently infected population, similar to that for worldwide seasonal influenza deaths—this cannot be an excuse to downplay the risks posed to the affected population in this particular instance.
The cause for concern right now is that efforts being put in are clearly not enough. Granted, geographical difficulties are there, which make intervention activities difficult, but that cannot be a reason for not doing everything that we can do to mitigate the problem. Nepal is full of such places, and clearly, this particular instance gives us further reasons to realize that an outbreak response team for all of Nepal is need of the hour. We have had similar disease outbreaks in the past, and every time, the government has been slow to respond.
Jajarkot cholera outbreak IN 2009 is an event that the government found hard to handle, regarding intervention and control. What started as a simple diarrhoeal event from a VDC in Jajarkot evolved into a cholera outbreak, killing around 400 people and affecting most of the district and also adjoining districts. The response by MoHP at that time was anything but swift, effective and successful. To this day, there are questions as to why there was such delay in response by the Health Ministry at the time. The causes were linked to lack of health support services in the districts, access to affected areas, lack of adequate human resource, lack of medication (even Oral Rehydration Solution/ Jivan Jal) and in general, lack of coordination between the center and the district.
The scenario is once again repeating itself in the current influenza outbreak in the same district. How do we move forward? I put forward some immediate and some long-term solutions:
It is critical to immediately dispatch trained and experienced clinicians and support health professionals to affected sites along with required medications and other essential items. Experience from Jajarkot cholera outbreak would strongly suggest full involvement of country's security services, especially Nepal Army in this activity. Transport to and from the affected site by aerial route and further travel by foot should be considered for each group of health personnel sent from center (stationed for five-seven days maximum to ensure maximum efficacy).
It would also be important to understand the causes behind the motility. For example, there might by many cases of HIV, malaria, typhoid or other co-morbidities (diseases) present in those sites. At the same time, a person who might have certain health conditions (diabetes, cancer, etc) would also be more prone to fatal infection by the virus. It is accepted in scientific literature that having multiple illnesses can make human immune system weak. Thus, if someone is already affected with other infections and health conditions, this would pose a threat to them as compared to general population.
Our study on 2009 Jajarkot cholera epidemic showed multiple associations with other dangerous bacteria by Vibrio cholera bacteria, the causative agent of cholera. This led us to infer that the cholera outbreak was due to multiple infections in the population. Similar findings may be possible in current influenza outbreak in Jajarkot. H1N1 infection by itself is dangerous, but co-infection by other dangerous pathogens (virus, bacteria or parasite) may be fatal.
Migration by Nepali labor workers between Nepal and India through the Far West Nepal corridor is established cultural reality. Parts of India in January-February and thereafter Kathmandu and Chitwan in Nepal experienced H1N1 outbreak. Indian influenza strains were traced back to Mexican origin swine flu (novel H1N1) of 2009 which killed large number of people worldwide. Thus, the likelihood of the same strain having infected migrant workers returning to Nepal from India is high. Therefore, for this reason also, it is important to treat the current outbreak as that by a more virulent (stronger than usual) type of influenza virus. In order to ensure that the current viral strain does not show signs of further mutation, it is advisable to ensure that genetic analysis be carried out on all samples that are collected from the affected site. This is important for future preparedness.
This outbreak, like many others before it, will eventually subside, in a few weeks. However, rather than forgetting about it completely, lessons need to be learnt. A very important realization out of all this is that Nepali health sector needs to move from treatment guided policies to prevention guided intervention policies. History has given us enough evidence to show that focusing on interventions after an outbreak is not very effective and leads to loss of precious lives. Research and regular disease surveillance are tools for prevention based preparedness. We probably need a think tank of experts that can provide important advice to government and other stakeholders regarding outbreak mitigation. We must take important lessons from this outbreak and move towards mitigating this and future such outbreaks of infectious diseases.
The author is Director of Research at the Center for Molecular Dynamics Nepal
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