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7/22/2017

HPV vaccination: Primary prevention of cervical cancer

HPV vaccines

Human Papilloma vaccine (HPV) is a unique vaccine as this is intended against the virus amidst many available vaccines that are produced against bacteria. HPV, in abbreviated form, is given to develop immunity against the Human Papilloma virus. Available HPV vaccines are recombinant vaccines, which include genetically engineered HPV like virus particles.
Two doses of HPV vaccines at 6 months’ interval is recommended for girls of age 9 to 13 years by WHO. The age of the girls is specified to make sure that the girls get this vaccine before they contract HPV viruses by any means or sexual transmission.

Currently Available HPV vaccines

Ceravix : Effective against HPV STRAINS of 16, 18

Quadrivalent Gardasil: This is effective against HPV strains of 6,11, 16, 18

Gardasil 9: This includes antigens against 9 different strains of Human Papillomaviruses

All of these HPV vaccines are given intramuscularly.

Cervical cancer, caused by HPV, is one of the commonest cancers in women of developing countries. Thanks to human intelligence, this life threatening malignancy can be prevented by comprehensive implementation of preventive approaches, one of them being HPV vaccination.

Human Papilloma Virus

Human Papilloma virus infection leads to a range of manifestations from some epithelial lesions, warts to life threatening malignancies. Though Papillomavirus can cause other ano-genital, oropharyngeal cancers, cervical cancer has been extensively studied in relation to Human Papilloma virus because of its high magnitude among women especially in developing regions.
Most of the cancers of anal, oropharyngeal, cervix, are caused by human papilloma virus infection. These cancers are preventable if we could prevent and manage Human Papilloma Viruses infection.

Which Human Papilloma virus is responsible for cervical Cancer?

There are different strains of Human Papilloma viruses, however, mainly the strains HPV 16, 18 are attributed to cause cervical cancer. They can also cause premalignant genital lesions and other many strains cause genital warts, lesions of cervix, vulva, vagina.

What makes Nepalese women more vulnerable to HPV infection?

HPV infects not only women, rather it can affect both male too. However, the prevalence of high cervical cancers and susceptibility of women demands solemn attention.

Low awareness on HPV: women of this generation hardly knew about the relation of infection with human papillomavirus and cervical cancer. This lack of awareness prevented us from taking measures that would have helped in management of HPV infection. Nevertheless, upcoming new generation will be more aware and have means to prevent HPV infection

Reproductive health, hygiene and rights: Early marriage, sexual violence can lead to exposure to HPV viruses. Reproductive health especially sexual health is not much talked issue in developing countries due to stigma, hesitancy, and traditional mindsets. Sexual problems are like the iceberg in the sea, much of large chunk still under sea as people don’t want to expose about reproductive health problems and people are shielded from the right information on reproductive health.

HPV vaccination in Nepal

Government of Nepal has forwarded this important step with piloting of HPV vaccinations with support from GAVI alliance. This will be scaled up subsequently nationally. this vaccine is relatively novel and expensive vaccine. Hence, the feasibility of the sustainable inclusion in the national immunization program requires strong commitment from the government and generosity of the donors and International organizations.
Other primary preventive approaches such as sexuality education to both girls and boys, male circumcision, condom use, health information and warnings about tobacco use should be implemented effectively to curtail the cervical cancer burden.

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7/12/2017

“मेरो बर्ष २०७४: म स्वस्थ, मेरो देश स्वस्थ”

Healthy Year 2074: A New Start in Nepal's Health System

This is a promising start from health minister Mr. Gagan Thapa in Nepalese Public health sector. It triggered many of us; It impressed many forerunners in health profession. Indeed, we need something, be it some goals, deadlines or slogans to keep us moving. Let’s remember, we are so much driven by millennium development goals and sustainable development goals to meet their targets. So, this new campaign of “My Year 2074: I am Healthy, My country is healthy” (this is my unofficial translation of the slogan) will surely motivate us to remain committed for keeping ourselves and our people healthy.


Our health system was quite sensitive towards tobacco related products but the alcohol drinking was overlooked issue and this commitment is expected to aware people of harmful effects of alcohol resulting reduced consumption. Our country is being rapidly urbanized and many of us live sedentary lives in a chair so the slogan of remaining physically active will surely benefits many of us, who are living sedentary lives.

Another slogan refers to appropriate and right consumption of locally available healthy and balanced diet. As we say, ‘We are what we eat’, this will encourage us in supplementing the diet required for growth and development and regeneration of people in every age group. Regular health checkup screens diseases in its early phases making primordial, and primary prevention enough. This further reduces cost of individual and the health system. The fifth slogan tries to accommodate all the health issues related to family planning, child bearing and rearing, neonates, infants and children and old age people.

Some addition in set of commitments

If we critically see the slogans of this campaign, it is much oriented towards preventing the non-communicable diseases. It has proactively attempted to capture the transition of our communicable disease burden to non-communicable diseases. But, we still have pre-existing conditions that trigger the transmission of communicable diseases such as lack of improved sanitation and safe drinking water. This bothers us many of public health professionals including me, much than remaining physically active. Though, we have come in the 21st century, only the time passed, we are still far behind.
In some parts of the country, people live the lifestyle of early twentieth century and some live like in 21st century. Because of this vast differences in life styles, living standards, awareness level, I seriously want to include the components of waste management, personal hygiene, sanitation facilities, clean city and improved housing, improved drinking water in this slogan. Let’s quit the use of tobacco product and alcohol drinking; Let’s remain physically active; Let’s have healthy and balanced diet; Let’s perform regular health check up; Let’s spread awareness on Family and community health issues.

“My commitment to My Year 2074”


  • I will Commit to following points in Year 2074 and onwards..
      I will quit the use of tobacco product and alcohol drinking.
      I will remain physically active.
      I will have healthy and balanced diet.
      I will perform regular health check up.
      I will remain aware of Family and community health.

    Yes,

      I will keep personal hygiene.
      I will keep my house and city clean.
      I will have improved sanitation and safe drinking water.
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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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    4/23/2017

    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

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    3/31/2017

    Pandemics!



    When there was outbreak of SARS, Ebola, H1N1 influenza, HIV and other certain diseases in the past such as Cholera, Plague (Black death), everyone all around the world were concerned about those diseases.  They spread over many countries in a short span of time, claiming many lives, causing anxiety, panics, terrors and sufferings. Whereas, there are other diseases, which are contained within certain geographic spaces. 

    The recall of HIV/AIDS Pandemic as a child in rural Nepal

    The first pandemic I became aware of was HIV/AIDS. After its spread from one country after another country, it also invaded the border of Nepal along with identification of the first case of HIV in 1988. HIV contracted one after another since then fueled by stigma, scarce knowledge about disease pathology, lack of management facilities. I have vivid image of my childhood where HIV was so stigmatized and people's perception about its mode of transmission: the illicit sexual act. When I was in middle school, it became more apparent due to its coverage in news and media, educational forums, debates. As I saw the epidemic rise of HIV/AIDS during my childhood, this childhood memory of HIV/AIDS as fear producing factor always relates to subsequent pandemics. 


    Conditions favoring Pandemics


    1. New antigens or infectious diseases: as people are not immune to new antigens or infectious diseases, there is possibility. Sometimes, the diseases are under researched or so new that we become unaware of its route of transmission. As in case of HIV/AIDS, at first it was thought it was transmitted among gay men only. It took several years to identify the modes of disease transmission.
    2. Antigenic shift
    3. Globalization: global diffusion of SARS traces back to the visit of a case (from Guangdong China) of SARS in Hong Kong in 2003 thereby spreading SARS to other people staying in the same hotel. Then the infectious agents of SARS travelled to different countries along with those people.
    4. Bioterrorism: Use of biological agents as a means of war can bring pandemics.

    Disease outbreak Vs Epidemic Vs Pandemic

    Disease outbreak occurs when the disease occurs in many people at a time more than expected at that point of time or more than usual occurrence. However, sometimes there shouldn’t necessarily be occurrence in large number of people, a single disease case is still considered outbreak. For example, one case of yellow fever in Nepal is considered outbreak/epidemic as there is no occurrence of yellow fever in the past. Public health professionals and the disease surveillance system should be effective enough to identify such outbreaks to tackle its spread and management in time. Outbreak is usually used to refer to a small geographical region.

    Epidemic: If the disease outbreak is concentrated in a certain geography or within certain communities and if there is no possibility of spread in other regions or countries, then it is called disease epidemic.


    Pandemic: When the disease spreads over several countries, continents or all around the world, usually affecting large number of people, this is termed as Pandemics. 
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