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6/29/2017

Vaccines Types and Storage

Type of vaccines

Currently available vaccines protect us from diseases caused by selective pathogens: bacteria and virus. Vaccines are usually categorized based on the constituents of the vaccines.

1. Inactivated/ killed vaccine: Those vaccines containing killed pathogens or particles are killed/Inactivated vaccines. Even though they are killed, they can trigger immune reactions, hence protects from the targeted diseases in the future. e.g. IPV

2. Live Vaccines: Vaccines consisting of live strain of pathogens are live vaccines, however, they are attenuated or weakened to reduce their virulence or infectivity. They are not capable enough to cause disease but triggers immune response for future protection.

3. Toxoid vaccines: Some of the disease conditions are caused by toxins produced by the microorganisms rather than pathogens themselves. Eg. The symptoms of tetanus is caused by the toxins such as tetanspasmin, produced by the clostridium tetani. Those toxoid vaccines contain the treated toxins of the disease causing pathogens which trigger the immune system to produce antitoxins.

4. Subunit and Conjugate vaccines: Subunit and Conjugate vaccines contain only the certain components of the pathogens, for example vaccine against Hepatitis B virus contains antigens (protein structure) of the hepatitis b virus that incite the immune reactions against Hepatitis B virus. Some Subunit vaccines are produced with genetic engineering. Conjugate vaccines are unique and effectively powerful as the part of the pathogens are combined with carrier protein making them more effective.

Vaccine Types and Storage
Vaccine Targeted disease Form Type Storage
Bacillus Calmatte Guerin (BCG) Tuberculosis Lyophilized powder , multi dose vial, requires reconstitution with diluent Live attenuated ( They are live but weakened to reduce their infectivity or virulence) 2 to 8 °C (As this is freeze-dried, hence recommended to store at -20C but no longer recommended)
DPT-HB-HIB Diphtheria, Pertussis,Tetanus, Haemophilus influenza, Hepatitis B Liquid, multi-dose vial Combination of diphtheria toxoid, inactivated pertussis, tetanus toxoid, Antigen (HBsAg) 2 to 8 °C (Don’t freeze)
OPV Polio Liquid, multi-dose vial Live attenuated vaccine Should be frozen at -14 °C in primary vaccine center but could be stored at 2 to 8 °C
IPV Polio Liquid, single dose vial/ multi-dose vial Inactivated vaccine store at 2 to 8 °C, don't freeze
Pneumococcal conjugate vaccine (PCV) Diseases caused by Streptococcus Pneumoniae Clear Liquid Suspension Conjugate vaccine store at 2 to 8 °C
MR (Measles-Rubella) Measles and Rubella Lyophilized powder, Requires reconstitution Live attenuated store at 2 to 8 °C
JE (Japanese Encephalitis)Vaccine Japanese Encephalitis Lyophilized powder, requires reconstitution, single-dose vial/ multi-dose vial Live attenuated (Chengdu SA-14-14-2 strain) store at 2 to 8 °C, should be used within 30 minutes of reconstitution
Td (Tetanus, diphtheria) Vaccine Tetanus and Diphtheria Liquid suspension Toxoid Vaccine store at 2 to 8 °C

BCG

BCG is the abbreviated form of Bacillus Calmette Guerin. This vaccine is given for developing immunity against tuberculosis. In this vaccine, the strain of tuberculosis bacteria is live and attenuated, hence they are harmless and doesn’t cause disease but are active enough to induce immune reactions. This produces necessary antibodies and memory cells to protect against future potential tuberculosis infection.

DPT-HB-Hib

DPT stands for diphtheria, pertussis, tetanus. Previously, DPT vaccine contained only the antigens for DPT that protects against diseases, diphtheria (known as “Bhyagute rog” in Nepali), pertussis (known as “Lahare khoki” in Nepali), tetanus (known as “Dhanustankar” in Nepali). However, the vaccine is now pentavalent and protects the five diseases including Haemophilus influenza type b and Hepatitis B. Haemophilus influenzae is one of the common causes of the pneumonia in children in Nepal. It can also cause ear infections, meningitis.

Polio vaccines

There are two types of polio vaccines: Oral polio vaccine (OPV) and Inactivated polio vaccine (IPV). Inactivated (Killed) polio vaccine (IPV), containing killed pathogens, is developed by Dr. Jonas Salk. Albert Sabin is the developer of non-killed i.e. live oral polio vaccine which contains strains of weakened live polio viruses. When I had confusion regarding name of developers of live and killed vaccines, I used to remember by the work ‘k’ in Salk so he is the developer of killed polio vaccine and IPV is given by intramuscular route whereas live vaccine is administered by oral route.

MR vaccine

MR stands for measles and rubella. Previously, only measles vaccine was given to the Nepalese children. Later, Rubella has also been added to the EPI schedule of Nepal and MR vaccine is given subcutaneously at the age of nine months. MR vaccines protects children from diseases Measles and Rubella.

Pneumococcal vaccine

Pneumococcal vaccine is given to develop immunity against infection of streptococcus Pneumoniae.

Td Vaccine

Recently, Td Vaccine is prescribed to prenatal mother in Nepal. Td stands for Tetanus and the diphtheria. This vaccine contains chemically treated toxoids of tetanus and diphtheria that triggers the immune system to prepare for future potential toxin exposure.

JE vaccine

JE vaccine is given against the Japanese encephalitis. Japanese encephalitis is a mosquito borne (spread by mosquito bite) viral disease caused by infection of JE virus. Live JE vaccine is given in Nepal at the age of 12 months

It is always essential to check the manufacturer’s guide about storage and transport. Even though all the vaccines provide some level of protection against specific diseases, they are not free of adverse reactions so, it’s very important to inform vaccine recipients of all the anticipated adverse reactions. Here in my experience in USA, when I had to take the vaccines for compliance of vaccination as recommended by the university, I was given pamphlets related to vaccines and its adverse reactions and consented for the vaccinations and their unwanted reactions (a part of defensive medicine.).
See the immunization schedule of Nepal

By Pramila Rai

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6/15/2017

Alcohol: A Neglected Threat

Factors affecting Alcohol Use in our society

  • In modern contemperory society!
    “We finished the exam. Let’s have a party!” a friend exclaims,
    “No Alcohol!” another friend exclaims,
    “Is that a party?” other friend yells,
    “Hey, just taste it. You’ll love it, a peg of alcohol is good for your health; you’ll not suffer from heart attack.”
    Other friend gives rationale, “You’ll forget all your pain at least for a while, it relaxes your mind.” the friend encourages,
  • In a traditional society!
    “It’s our culture, you need to drink it; It is sacred offering to our god and it's a Prasad from god.”
    “Your ancestor used to drink it, we drink and you can drink.”
    “Please, have some alcohol (the form could vary). You must be tired and hungry.”
    “When did you start drinking?”
    “I don’t remember at all, I used to drink since the day I know my existence”
    Those conversations clearly demonstrate the role of cultural practice, inadequate scientific knowledge, ignorance, peer pressure, adventure seeking habit in starting alcohol use.

Magnitude of Alcohol Use: Epidemic or Endemic?

The alcohol is one of the commonly used substances in our society but it is not tabooed or stigmatized like other substances such as heroin, opium at least in our society. Instead, alcohol has become an integral part of our culture. The alcohol use is pervasive in every society. Its use is highly contagious and endemic (not an infectious agent but the extent of its prevalence and incidence) especially among certain group of people in Nepal. "I recall my conversation with one of my students. He was a member of national level research on non-communicable diseases, he was astonished to see the people intoxicated with alcohol even during day time and they were even frightened to conduct interview itself in Dhankuta district, Nepal, where the majority belong to Matwali (Rai, Limbu, Magar, Yakkha) group (Population Monograph of Nepal, 2014)."
Belonging to an indigenous group that allow alcohol use and uses alcohol for sacred rituals, it is usual for me to see people, who used alcohol mildly, moderately to heavily. I saw many died with gastric bleeding, which was usually blamed for some witchcraft or god’s wrath sometimes. As the limited amount of alcohol has been further idolized as cardio-protective drink by modern science, this has been a most abused reasoning for the alcohol users lately.

Effect of Alcohol Use on Health

Physical Health: Many researches have accorded that alcohol can shrink the brain mass with regular and occasional heavy doses. It can cause alcohol related brain damage and dementia can occur as early as at the age of 40 to 50. Alcohol is metabolized in Liver so It also affects liver leading to Alcoholic liver diseases including Cirrhosis. Cirrhosis causes irreversible damage to liver cells and diminish the liver function. As it affects the liver, it can also lead to portal hypertension and further causing gastric bleeding. Many people die of untimely management of gastric bleeding. It also affects all other parts of the body. Heavy and regular drinkers also suffer from decrease in libido and other reproductive system dysfunction. Alcohol related cancers in esophagus, stomach, liver are also contributors of mortality and morbidity. Alcohol kills not only by deteriorating health of the people, it also causes mortality, disability and morbidity indirectly by road traffic accidents, homicides, injuries, violence.
Psychological Health: Just like other substances, alcohol causes physical and psychological dependency and its tolerance accelerates the amount of alcohol as the increased amount of alcohol is required to get the same level of effect. The alcohol becomes an eye opener for the alcohol-dependent people.
Social Impact: Alcohol overuse also impairs the family and social relationship. Even though occasional and scant drinking can be a mean of social interaction, the excessive use of alcohol brings strain in family as the uninhibited, incomprehensive, ineffective and offensive communication may prevail.
Economic Impact: Alcohol use directly impacts the economic status of the person by draining resources to purchase alcohol; those resources could have been used in other useful purposes such as nutrition, education, recreation of the family. Alcohol use can also affect the economic status of the family by reducing the working capacity and performance of the person.
Some beneficial effects of alcohol have been reported by researches especially congestive heart failure and diabetes mellitus but the negative effects offset the probable beneficial effects of it.

Control Measures

Formulation of laws and implementation: Strict implementation of National Alcohol Regulation and Control Policy - 2017 can successfully decrease the alcohol use. This policy reform increased the legal drinking age to 21 from 18, which is highly praiseworthy. Statutory and pictorial warning should be displayed in the alcohol containers. Just like control measures for smoking, the same graphic and text warnings encourage quitting of alcohol in alcohol users and discourage others to try alcohol. The policy has also bans the use of alcoholic beverages in public parties hosted by government institutions. This policy also bars of any form of advertisement about alcoholic beverages. Alcohols are restricted to sell in public places such as schools/colleges. The concept of dry days should also be added in the current policy as people are more likely to drink alcohol in certain occasions as in festivals.

Awareness Programs: Education is the key to success of any health programs. Education is aimed to impart the knowledge to modify the behavior and shape the perception about particular things. Substance abuse is manifestation of a behavior that can be modified by modification of existing knowledge. Awareness about negative impacts of alcohol will help in decrease in demand. Homemade alcohol is easy to find almost everywhere in the neighborhood of Nepalese community that can be overlooked by the existing laws making awareness programs more indispensable. Similarly, those neighborhoods whose economy depends on homemade alcohol should be provided with alternative vocational trainings and financing opportunities. Early education with integration in curriculum of schools can also be effective in shaping the attitudes of the future generation.
It is very essential to direct such awareness programs and other interventions to the most needy populations where the alcohol use is mostly concentrated such as aforementioned ethnic groups, rural area, community with low socio-economic status.

Some References

Paul CA, Au R, Fredman L, Massaro JM, Seshadri S, Decarli C, Wolf PA. Association of alcohol consumption with brain volume in the Framingham study. Arch Neurol. 2008 Oct;65(10):1363-7. doi: 10.1001/archneur.65.10.1363.
Walsh CR, Larson MG, Evans JC, Djousse L, Ellison RC, BASAN RS, Levy D. Alcohol consumption and risk for congestive heart failure in the Framingham Heart Study. Ann Intern Med. 2002 Feb 5;136(3):181-91.
Jason Andrade, Alcohol and the heart. BCMJ. 2009 June. 51(5)
Editorials: Alcohol consumption and brain health. BMJ. 2017.
Rehm J, Mathers C, Popova S, et. al. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. The Lancet. 2009. Vol. 373. Issue 9682.

By Pramila Rai

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6/02/2017

Top Ten Public Health Issues in Nepal

1. Childhood Diseases

Childhood diseases including diarrheal and acute respiratory diseases: The seasonal diarrheal diseases and respiratory diseases affect substantial number of children in Nepal leading to deaths and developmental delays. The malnourished and undernourished children are equally prevalent and Hence childhood diseases are still the number one priority in public health in Nepal. Neonatal mortality rate (21 per 1000), infant mortality rate (32 per 1000) and under 5 mortality rate (39 per 1000), are still high enough making it number one public health problem in Nepal.

2. Water and Sanitation

The timeline of health and longevity of the people in the developed countries can be traced back to sanitary reforms in those countries and the resulting long life expectancy and healthy life can be attributed to the adequate supply of potable water, appropriate sanitary facilities, waste management. However, Nepal and other developing countries are miles away to reach that level as the waste management and other sanitary reforms are at nascent phase, though progressive. There are 38% of households without improved sanitary facilities in Nepal.

3. Maternal and perinatal health problems

Still women in Nepal die during pregnancy and childbirth due to untimely management of complications such as antepartum hemorrhage, postpartum hemorrhage, pre-eclampsia, eclampsia. This is especially intensified by lack of adequate facilities and manpower in rural area of the country. Even though the tertiary level care facilities are available in major cities, many parts of the countries are devoid of such care and it takes several hours or days to reach to such care resulting in delays in care, subsequently fatal consequences to many women and children.

4. Sexual transmitted diseases and Other communicable diseases

Tuberculosis is endemic in Nepal. Vector borne diseases such as malaria, Leishmaniasis (Kala-azar), Dengue, are also endemic in certain tropical regions (plains) of the Nepal. sexually transmitted disease such as HIV/AIDS is present as concentrated epidemic in certain groups such as sex workers, intravenous drug users, migrant workers, wives of migrant workers.


5. Epidemics/Pandemics and zoonotic diseases

Every country is at risk of pandemics and epidemics due to increasing interconnectedness between different parts of the world/ globalization. Most of the pandemics are the zoonotic diseases; they contract human easily as they are novel and human are susceptible due to their inability to fight against new diseases as they lack antibodies and memory cells against such diseases. The recent phenomena of unregulated mass production of poultry and close living provision with the animals also leads to the zoonotic diseases.

6. Non-communicable diseases

The occurrence of the non-communicable diseases such as hypertension, coronary heart diseases and other cardiovascular diseases, diabetes mellitus, chronic kidney diseases have surged along with modernization in life style. They are leading reasons of mortality and burden of diseases. Epidemiologic transition is evident through increased incidence of non-communicable diseases, once supposedly diseases of wealthy.

7. Natural disaster and preparedness

Nepal is continuously at risk of natural disaster due to its topographical/geographical features. Nepal is at constant threat of earthquakes as this lies in the Himalayan range; the floods during the rainy seasons pose equal threat to the lives of the residents of Hills and plain. The massive earthquake in 2015, the frequent landslides and yearly floods in the major rivers of Nepal create a chaotic condition that requires immediate attention of every sectors including public health professionals. As people in such situations are at risk of so many health problems such as injuries, diarrheal disease epidemic, devoid of water and sanitation, food and security, they require immediate first aid, safe sanitation and water facilities, food, security, reproductive health services and mental health counselling and management. Disaster preparedness and effective communication channel are must have public health program in Nepal.

8. Substance use disorders

Drinking alcohol is a ritual by a certain group of people specifically indigenous groups traditionally categorized as ‘Matwalis’ of Nepal, includes Rai, Limbu, Newar, Gurung etc. Alcoholic dependence and liver diseases are very common in those people though they are under-focused by the current health system. Alcohol dependence not only affect the health of the sufferer, it also affects the social relationship, economy and family relationship. Tobacco use is also a common substance and its use is ubiquitous in the form of smoking, chewing form in Nepal; shisha hookah is established as recent trend among youth. Other substances like Marijuana, Heroine are also threatening public health concern to the youth of Nepal.

9. Disparity in Health system

This is a significant challenge that needs immediate attention from the government. Though the number of hospitals and number of health professionals are increased significantly in last two decades, people from the rural area and poor of urban areas don’t have adequate access to health care. Disparity in health care access is affected by different elements ranging from individual attributes such as ignorance fueled by low education, low income; to systematic biases created by the system and policies.

10. Mental health Problems

Mental health needs of the populations is recently recognized as vital after the decades of neglect in mental health domain. Mental health problems were accepted as the result of bad deeds in previous or present life, hence stigmatized. Professional growth and advocacies have highlighted the need of mental health treatment and management. The years long political conflicts, low economy, disasters, increasing social distances, individualistic life approach, high pressure for achievement, rapid urbanization, employment abroad etc. aggravate the mental health need of the population.

NOTE: The data have been extracted from NDHS 2016

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