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

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

Quality Of Life

Quality of life is one of the important indicators to measure overall population health or health status of the people living in any location. As the end expected outcome of any medical intervention, nursing intervention or any public health program is to improve the quality of life, health professionals at least once think about measuring Quality of life among their population of interest in their professional life.

What is quality of life?

Quality of life is a multidimensional concept and it involves subjective evaluations of various aspects of life. Human life has complicated structure physically and socially, as human can’t exist alone. They have body, which is further controlled by the mind, their mind is further affected their social, physical surrounding, system and significant others. Thus, quality of life is very difficult to measure. However, experts have developed definitions and tools to measure the quality of life of people.

WHO defines quality of life as “individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.”

Why do we use quality of life?

1. Comparison of people in different geographical region: people in different geographical area can be compared with this indicator. It will be easy to understand the reasons for the differences in Quality of life in those geographical region. Why do Swiss have better quality of life than Chinese or other countries?
2. Impact of any program or intervention or Policy: Quality of life indicator is the ultimate outcome of any interventions. The aim of smoking control and prevention program could be to reduce the number of people, who smoke, its effect could be seen as the change in quality of life in the targeted population. The improvement in relationship, self-esteem, improvement in physical health, improvement in environment, reduction in expenditure increases the quality of life of the people through the smoking prevention policies and programs. Depending on assessment of the quality of life, the policy, programs or interventions could be designed and modified so that they increase the quality of life of targeted population.
3. Health needs: Need of the population could be evaluated with this indicator. Lower quality of life indicates lack of good health or failings in other parameters and ultimately the shortcomings in the existing programs, and inadequate interventions to improve the quality of life.
4. Effect of chronic illness, short term or long term illness: We can also estimate impact of certain disease conditions on quality of life and to measure the ways to improve quality of life of the people living with such disease conditions.

Tools to measure the quality of life

• CDC HRQOL-4: Centre for disease control and prevention (CDC) uses 4 items questionnaire CDC HRQOL-4.
• CDC HRQOL-14 “Healthy days measure”: This is constructed by adding 10 more items in CDC HRQOL-4 tool.
• WHOQOL-100: This tool is developed by world health organization and it is elaborate. This includes 100 questionnaires from different aspects of life, that can affect the quality of life of a person.
• WHOQOL-BREF: It is abbreviated form of WHOQOL-100 and consists of 26 items only.

There are some tools such as SF 36, SF 12, which can be used to measure Health status of any population. They also used as quality of life indicators sometimes by some authors.

Difference between CDC Health related quality of life (HRQOL) and WHOQOL scale

The definition of health includes mental, physical, social and spiritual domains of life and HRQOL should measure all aspects of those domains. HRQOL tends to measure the quality of life that are directly related to health status of the people. HRQOL tool used by CDC contains items/ questions related to subjective perception of overall general health status, mental health, physical health and activity limitations. WHOQOL is more elaborate and includes health, psychology, level of independence, social relations, environment, spirituality/ religion/personal beliefs. WHOQOL-BREF is usually used in small scale studies. Authors need permission to use WHOQOL tools and required to abide by user agreement and researchers need approval if any modifications of the tool is required. WHOQOL have been adapted for certain diseases, for example, WHOQOL-HIV is constructed especially to assess quality of life of people with HIV.

- by Pramila Rai

Nutritional status of children and Anthropometric measurement!!

Background

Nutrition is key to life. “In fact people are pack of nutrients and they need all the nutrition since the formation of embryo to become a mature human. They need nutrition to keep on restoring depleted nutrition throughout the life.” This makes maternal, childhood, adult nutrition equally important throughout the life course of human.

How does Nutrition affect the Health?

If you don’t get adequate and essential nutrients, physical and mental growth will be delayed through various mechanisms, causes many diseases and even leads to death. The foremost mechanism is direct nutritional deficiency diseases such as deficiency of Vitamin A causes night blindness; imbalance of protein and carbohydrate results in PEM malnutrition, obesity; Iodine deficiency causes mental retardation, goiter. There are number of disease conditions that are directly related to the nutrition deficiencies. Such diseases are also responsible for other chronic disease such as cardiovascular diseases, diabetes.

Figure: Factors affecting Nutrition and its impact on health

Lack of nutrition also reduces immunity thereby making our body susceptible to many opportunistic infectious microorganisms. As for example, in a healthy people, tuberculosis could be in dormant phase but once the immunity or defense system of our body is disturbed, TB pathogen can become active and manifest TB disease. Viral infections are especially immunity relative and immunocompromised people suffer bouts of seasonal influenza or diarrheal diseases compared to people with strong immunity.

Anthropometric measures to measure the nutritional status of children

Anthropometry is the study of measurement of body parts. Nutritional status can be measured by various indicators such as mid arm circumference, BMI, height for age, weight for height, weight for age etc. However, the last three aforementioned indicators are used frequently.
Height for age: children should have comparable height for their age just like other children in their age group. If their height is below two standard deviations of that age group, then it is considered less height for age showing inadequate nutritional status. Having short gesture for age is also known as stunting. stunting is usually taken as sign of long term, chronic nutritional deprivation
Weight for height : Having short gesture or height for weight is also known as wasting. wasted children have short gesture for weight.If their weight for height is below two standard deviations of that age group, then it is considered less weight for height showing inadequate nutritional status. Low weight for height is an indicator of acute undernutrition
Weight for age : Similarly, this is one of the commonest and easiest way to measure the nutritional status of the children. children should have comparable weight for their age just like other children in their age group. If their weight is below two standard deviations of that age group, then it is considered low weight for age showing inadequate nutritional status. This combines information about linear growth retardation and weight for height

Indicators in NDHS Nepal Demographic and Health Survey 2016

According to NDHS 2016, 36 % of the children are stunted or have short gesture for that age group, 10% of the children are wasted or have lower weight for height and 27% under five children are underweight or have weight low for their age. These show Progress from the early years.

What are the reasons of Nutritional deficiency in Nepal?

I would like to describe the causes of nutritional deficiencies based on socio-ecological model.

• Policy: Certainly, Nepal is a developing country and significant fraction of people live under the poverty and very far from the light of development and education. The policy helps to shape the investment in different section of the programmes and population.
  
• Society, organization and culture: The culture, tradition and some taboos prevalent in the society, and organization equally affects the nutritional level of the population. Certain tradition like early weaning of female child, taboos prohibiting some foods during pregnancies, gender discrepancy in nutrition etc affect the nutrition of the children.
  
• Family level factors: socioeconomic status of the family, trade off of investment in other things vs nutrition also affects the family's importance in nutrition. This also depends upon the over all understanding of importance of nutrition.
  
• Individual level factors: Education of parents, other family members, occupation, knowledge about the nutrients, balanced diet and preparation, handling of the foods also affect the nutrition of the children
  
• International support: International support has tremendous influence over the policy and programmes and current programs like SUAAHARA project is funded by USAID. Many UNITED NATIONS organization have focussed in improving child nutrition in Nepal and all over the world affected by malnutrition.

By Pramila Rai

Gender Selective Abortion

Background

The most recent invisible phenomenon of modern day world in reproductive health is Gender selective abortion. Abortion is spontaneous, unintended and unfortunate event for some people whereas sometimes abortion is induced due to various reasons, mostly preclude the probable danger to the life of pregnant women. Nevertheless, this advancement of safe abortion in medical field has been also used as the sex selection tool for the birth of desired offspring aborting fetus of undesired sex.

This phenomenon has been observed especially in those countries, where the patriarchy prevails and the birth is restricted by law or societal pressures. Even though profound effect of this phenomenon, the intensity of this problem is difficult to measure. Measuring female to male ratio at the time of birth is one of the indirect methods of the underlying gender selective abortion. Direct measurement of gender selective abortion is particularly challenging because of its ethical, moral, legal and social ground. The secrets are guarded and the population scientists are unable to measure the depth of this problem.

The abortion policy in Nepal allows abortion up to 12 weeks of fetal age with the consent of pregnant woman unlike previous laws and only woman can decide whether to continue or discontinue the pregnancy. Although Nepal has engendered a very liberal abortion policy since 2002, to abort a fetus based on its sex is strictly illegal and considered criminal act in Nepal. So, many abortions might occur undercover. Hence, the indirect measurement of selective abortion such as sex ratio, population sex ratio, desired gender composition could be suitable tools to measure the gravity of sex selective abortion. Many researchers have figured out falling sex ratio at the time of birth as reflection of this phenomenon.

Factors of gender preference and sex selective abortion

Macro level Factors

Here I would like to focus on certain Macro level factors of sex selective abortion.

• Socio-Cultural dimension: Culture is important aspect of our life. We live and learn the culture from the day we are born. Similarly the perception that prefer sons over daughters has been passed down from one generation to another generation as an integral part of culture. Many of our countries in the world, the society is patriarchal and males are head of the households, they are the ones who forms social networking and maintains the boundary, integrity and function of the social net. Males are given higher position in that society and they are required for any ritual procedures during vital events like birth and death. I would like to particularly specify an example in Nepal. Couples are pressurized to have at least one son as they feel that if they are not given funeral pyre by their son, they wouldn't be able to go to heaven after life and daughters are not allowed to involve in such ritual. Though, many daughters have come forward to break this stereotype, It still is ingrained in minds of many people.
  
• Economic Transition:Our traditional society was agrarian where the larger number of offsprings would be desirable assets to the family. Sons were valued the most because of their high physical strength and utility compared to daughters. Yet, they could be help to the household chores and strengthening the family relationships. There was negligent concept of child health and care so the number of offsprings was not an issue of high concerns but with human civilization and modernization, child care and the number of children in the family have been central focus of the family now. Higher number of offsprings have also been stigmatized as a sign of ignorance. High investment in child care, concern about the number of children and fixed attitude towards gender; son as must-have offspring have led the many men and women taking such decisions.
  
• Technological advancement:Technological advancement has also been a contributing factor in sex selective abortion to some extent. Early detection of sex of the fetus with advanced ultrasonography and claimed safe abortion procedures serves to make decision for the trade for women health and the child of desired sex.
• Demographic transition and Policy: As the population growth rate and the fertility rate were high, the government in China came up with the "One child policy". Similarly, the government led family health programs in Nepal came up with the slogans of two children . These official and unofficial government policies have also fueled the limitation of birth and consequently, gender selective abortion in invisible way.

By Pramila Rai

Birth Preparedness and Complication readiness

Case Scenario

“In a rural area of Nepal, a woman is due to childbirth and she lives almost 5-6 hours far from the health care center. She belongs to low middle income socio-economic class. she is not aware of danger signs of pregnancy. Her family members think that childbirth is simply a natural process of giving birth and there is no necessity of special precaution because they gave birth to their children at home without anyone’s attendance from generation to generation. They know there is ambulance service but they don’t know the contact details of the ambulance service. The woman, her husband and other family members are not aware of any danger signs of childbirth. She starts getting contraction and pain but her mother in law is very sure that she delivers baby without any events. Her labor progresses, but instead of head, the cord prolapses. The outcome is yet unknown”

In above scenario, what are the conditions that can lead to adverse events of maternal and child morbidities, deaths?

1.  She is not institutionalized for the childbirth.
2.  They don’t have enough money saved for childbirth
3. They don’t have vehicle even if they want to take her to health care center in case of   emergency. She might reach the health center after golden hours.
4. They even don’t know when should they be contacting health care workers
5. They haven’t identified the people, who can donate blood if needed
6. They will take very long time to identify the complications, arrange money, vehicles and to decide which health center, they will be going.

What could have done to make sure healthy childbirth?

1. Birth Preparedness and complication readiness!!: definitely an answer among many others.

What is Birth Preparedness and complication readiness?

Whenever we study measures that effectively helped to reduce maternal mortalities and neonatal mortalities, we encounter the phrase ‘birth preparedness and complication readiness’. Birth preparedness package is simply a set of planning strategies that better assist the process of giving birth to a child to make child bearing process safe, appropriate, affordable, and accessible. Though birth preparedness is equally important to everyone, this concept is much more relevant and emergent for the developing world, where the childbirth is taken for granted and maternal death and newborn death during the child bearing process are high. It is proactive step to preclude maternal and newborn complications and mortalities. This strategy includes preparation of family, who are expecting child with counseling for preparing anticipated funds for delivery of baby, vehicles for transportation, probable hospital and health care providers, warm clothes for both baby and mother, blood donors in case of need, educational materials regarding danger signs of pregnancy, childbirth and postpartum period. In a birth preparedness package, counselling and educational materials are provided to the couple and family informing all the preparation.

How it impacts?

It helps in tackling three delays, identified to be main causes of maternal and newborn deaths. Birth preparedness obviates delay in seeking, delay in reaching and delay in receiving the care at the time of birth. For example, in the aforementioned case scenario, there is a high possibility that the family members would take a longer time to identify that the prolapse of cord is a danger sign of the childbirth that may cost child’s life and even if they identify the danger signs, they will take longer time to arrange money, vehicle or if they don’t have any transportation facilities, it will take even days to reach health care facility and health care providers. These delays may cause mother’s morbid conditions, death, and fetal death.

A woman or a family is considered to be prepared for birth and tackling tentative complications if they arrange estimated money, identify blood donors, transportation mechanism, know danger signs of pregnancy, childbirth and postpartum, identify health care providers and health care center.

Promoting Birth Preparedness and complication readiness is one of the three major strategies of safe motherhood and newborn health program of Nepal, others being Aama Surakshya Program and expansion of 24-hour emergency obstetric care services at public health facilities. These strategies have been successful in decreasing the maternal mortality rate of Nepal.

Let’s get into the Action: World Mental Health Day 2016: Psychological First Aid

7^th October, 2016: While I was coming out of the W.T. Young Library, University of Kentucky after short session of study, I was stopped by a girl. She politely asked me to fill up the form if I have time. I couldn’t decline it.

The form was standardized assessment tool for mental health status and when I completed filling up the form, the other girl immediately scored my test and referred me to a trainee consultant, who counseled me for short time. May be I didn’t require longer counseling based on my score and she informed me to come to the center if I need any help. They were providing psychological first aid. They were essentially working in response to World Mental health day 2016 with theme of Psychological first aid. That simple information actually helped me to find ways if I need any help in the future.

We are human and I feel human emotions are the most unpredictable things in the world and the distance between our normal mental status and abnormality is very thin. Anyone can switch over to other side at any moment. An instant of stress, anxiety, physical diseases, imbalance in the neurotransmitters could switch us to dark side of our mental health status. Especially when the world is turning competitive, eccentric, individualistic, we may suffer the things which we don’t want to. Even the healthiest looking human could be living with unseen turmoil and emotional disturbances around us.

A case of Nepal: Nepal was about to recoil from the wreckage of ten years long civil war (1996-2006) and was about to produce its precious new constitution. In April 2015, massive earthquake hit the Nepal and left many people bereaved due to loss of family, home, tangible and intangible valuables. Still many of us see its aftermath in shattered, cracked walls of home, teary eyes of the people who lost dear ones, mother, father, sisters, brothers, sons, daughter and other relatives, frustration because of amputated legs, nails and wires lingering in the bones, scarred skin and faces, frightful expression of kids and adults when something shakes the bed.

This is just an example of a disaster in Nepal. There are other several emergencies like war and violence in Syria and other countries, everyday hurdles, deadlines, and racing and fleeting lifestyle in which we have to fit ourselves for every new advances, we are in constant need of psychological assurance and social settings that pacify our emotional disturbances and racing hearts.

In such scenario, expert consultation from psychologists and psychiatrists is not available and accessible all the time due to their inadequate number and limited presence only at the tertiary level care centers and urban areas. We need someone by our side who can provide psychological first aid just the way a simple trained person can deliver cardio pulmonary resuscitation to a dying person with cardiac arrest. A person who can make someone accept the reality and help to find the ability to fight with the reality. A person who can arouse the passion for something in life, a person who find time to listen and create social environment that bind people together.

World Health Organization (WHO) is celebrating this mental world health day on October 10 with the slogan of Psychological First Aid. This harbinger is innovative and pragmatic way to achieve the holistic health as our current health system is mainly focused on physical symptoms and illness. This will surely sensitize our current health care service.

What can we do?

Most of the time, I see the trend of celebration of such important days with conferences and workshop where all the professionals and specialists gather up and share knowledge and stimulate each other. But we fall short in taking action, providing and continuing the services to the people in need. I hope psychologists, psychiatrists, mental health nurse experts, public health professionals, social workers would be leading this motto to action. Training and Preparing a bunch of people for first aid is only one aspect dealing with it. Other measures like formation of some form of society and communities such as literary clubs, professional’s clubs, youth clubs, mother’s group, Recreation group in the college, schools, villages with principles of inclusion, group work and cooperation would be equally helpful.