Health Horizons

The Epidemic That Wasn’t

Six months after Nepal’s earthquake, recognizing a global health innovation and victory.

Pasang Sherpa lives in a displaced persons’ camp under a plastic tent in Chabahil, Nepal. (Photo by M. Sophia Newman)

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Pasang Sherpa has enough problems without worrying about cholera.

Originally from the town of Nuwakot, Nepal, Sherpa now lives in the Kathmandu neighborhood of Chabahil. The area is pleasant enough, with bustling commerce, two Buddhist stupas, and a massive Hindu temple nearby. But his circumstances are less than ideal: Sherpa and his family moved to the area after losing their home in the massive earthquakes that shook Nepal in April and May, and they are among the unlucky few who remain homeless now. In Chabahil, they live in a displaced persons’ camp under a plastic tent.

Sherpa has a leg injury, and through an English-speaking cousin, he says his access to healthcare is insufficient. Living in a tent as the weather grows cold, he’s at risk for more illnesses too. Despite his troubles, there’s at least one potential health disaster he doesn’t have to fear: cholera. Through luck, work and an innovative oral cholera vaccine, Nepal has avoided an outbreak many feared.

Cholera is a waterborne, fecal-oral disease spread by the bacterium Vibrio cholera. By inducing severe diarrhea and dehydration, it can kill a person in as little as 12 hours — a short span that nonetheless permits the ill person to accidentally contaminate water sources and infect others. It spreads easily through populations without adequate water quality or sanitation.

The sanitation facilities at the displaced persons’ camp (Photo by M. Sophia Newman)

That situation describes Nepal now. The earthquake damaged water resources serving as many as 1.3 million people, and left up to 1.7 million without adequate sanitation. Within days of the quake came predictions that an enormous cholera outbreak would spread through the nation. “If the number of cases increases at an exponential rate, the containment of the outbreak is unlikely and a catastrophic outbreak … is the more likely scenario,” Public Library of Science Editor Lorenz von Seidlein wrote after a visit to Nepal in the spring. He didn’t have to reach far back for an example: Nepal occasionally suffers cholera outbreaks, and the last large one, in 2009, infected 30,000 people and ended 500 lives.

But there was no great cholera outbreak in 2015. The director of the government’s Epidemiology and Disease Control Division, Babu Ram Marasina, says the total infections in the Kathmandu area this year numbered just 82.

The reason isn’t health education alone. “We tried for the WASH intervention,” in some displaced persons’ camps, Marasina explains. WASH — water, sanitation and hygiene — is a category of public health interventions that includes educating communities on avoiding disease spread via dirty water or unsafe disposal of human waste. “We could not do it. It was very difficult.”

Luckily, another solution existed: “We decided to try for a cholera vaccine.”

The oral cholera vaccine, or OCV, is fairly new. An earlier epidemic that broke out in post-earthquake Haiti in 2010 — carried there, rather ironically, by a detachment of United Nations peacekeepers from Nepal — has infected over 750,000 people and killed 9,400. That outbreak prompted a final push to complete long-running vaccine development efforts. In 2010, the World Health Organization endorsed OCV as a means of controlling epidemics. As of 2013, they began stockpiling it, a necessary step to prompt manufacturers to make an adequate supply, and the Global Alliance for Vaccine Innovation has helped finance a store of two million doses, with plans to reach 20 million doses by 2018. It’s a drop in the bucket compared to the 1.5 billion people at cholera risk worldwide. But by mid-2015, when post-earthquake Nepal entered its cholera-prone monsoon season, deploying the vaccine was possible.

This August, Nepal obtained 18,000 doses of Shanchol, a vaccine made by the Indian pharmaceutical company Shantha Biotechnics. A two-dose regimen, the supply could cover 9,000 people, making each immune to cholera for five years.

What happened next was well-choreographed public health in action. With far fewer doses than at-risk Nepalis, Marasina led an effort to ensure that the doses reached the people most in need.

To select the spot was “not very scientific,” he admits. A team of public health professionals selected a slum area near a landfill and a single displaced persons camp in Kathmandu as the places to distribute the precious doses. Everyone offered the vaccine took the full dosage regimen. “To my knowledge, only 20 people have not taken the second dose,” Marasina says, a follow-up rate over 99 percent. Marasina says that public health officials closely monitored camps, testing water quality and carefully isolating and treating suspected cholera cases.

Although 82 cases amassed in Kathmandu, in nearby Lalitpur and Nuwakot (Pasang Sherpa’s hometown), the cases came in fits and starts, not in the steady flow of an epidemic. Marasina says that just one person died, a man already affected by an uncommonly poor health status. Prompt action by health teams ensured all other patients’ survival, a fact that clearly makes Marasina proud.

That said, the number of vaccinated people was much smaller than the millions of Nepalis at risk of contracting cholera. The hardest hit areas of the country, many of which are rural and high in the mountains, were beyond the reach of aid workers altogether.

Nonetheless, the deployment of the vaccine appears to have been a benefit. Marasina predicts the full post-earthquake rebuilding will take five years, and says he expects Nepal to remain vulnerable to a cholera outbreak for all that time. While he doubts vaccination for all Nepali people will happen in the near future, it’s clear his team has the means to distribute the vaccine in targeted populations again, for other outbreaks.

For now, a group of men at the displaced persons’ camp in Chabahil — not a camp where the vaccine was delivered — tell me they’ve never experienced any intervention against cholera. Yet despite living in tents with open-pit toilets, no showers and minimal hand-washing facilities, the residents say cholera isn’t a worry. They point out a safe water source just outside their camp.

Pausing in the midst of cooking lunch in a neatly organized communal kitchen, Pasang Sherpa shrugs at the mention of cholera. For all of the difficulties in his life, this is one, happily, he doesn’t have to face.

The “Health Horizons: Innovation and the Informal Economy” column is made possible with the support of the Rockefeller Foundation.

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M. Sophia Newman is a freelance writer and an editor with a substantial background in global health and health research. She wrote Next City's Health Horizons column from 2015 to 2016 and has reported from Bangladesh, India, Nepal, Kenya, Ghana, South Africa, and the United States on a wide range of topics. See more at​

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Tags: resilient citieshealthcarehealthdisaster planning

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