547 पटक हेरिएको On July 7, two young people suffering from diarrhea were admitted to Shukraraj Tropical and Communicable Disease Hospital, Teku. Following a test at the National Public Health Laboratory, one of the individual was diagnosed with cholera, marking the first reported case of cholera this year. These individuals had come from the rehabilitation center located in Ward No. 14 of Godavari Municipality, Lalitpur.
According to the Epidemiology and Disease Control Division of the Health Service Department, 80 people have been diagnosed with cholera in Kathmandu, Lalitpur, Dhangadhi and Pyuthan, Makwapanpur, Sindhupalchok, Rolpa and Rupandehi within 45 days of first case been diagnosed.
Dr. Sher Bahadur Pun, the Coordinator of the Research Unit at Shukraraj Tropical and Communicable Disease Hospital, states that cholera is a highly contagious diarrheal disease caused by the bacterium “Vibrio cholerae”.
Cholera infection occurs when the bacteria from an infected person’s faeces enter the human intestine through various channels. The bacteria in the faeces of an infected person can easily enter the human body through our food, drinking water, vegetables, etc.
If left untreated, a cholera patient can die within hours. In previous years, there have been numerous deaths due to cholera infections. Dr. Pun emphasizes, “We should not neglect cholera.”
Faecal contamination – the primary cause of cholera
Health workers say, “As long as human faeces are not ingested by others, neither diarrhea nor cholera do occur.” This statement confirms that the main cause of cholera is the contamination of water with faecal matter.
According to the 2021 census results, 4.5% of the population still defecates in open areas. Even among the 95% of the population with access to toilets at home, proper management of feces is not ensured.
Er. Ram Kumar Shrestha, Director General of the Department of Drinking Water and Sanitation, reports that 11% of Nepal’s population is connected to sewer systems. Out of them, only 2.6% of human waste is properly treated, while 8.4% is discharged into open drains and rivers without treatment.
Open defecation, untreated sludge disposed into water bodies without any treatment and holding tanks – so called septic tank – often contaminate drinking water sources through runoff during the rainy season. This contamination can cause cholera outbreaks, as noted by Professor Sabitri Tripathi from Nepal Engineering College.
As per the government statistics, 61% of the population has access to safe sanitation services. However, this statistic is of those who have never emptied their septic tank. According to estimates, septic tank structures that fail to function properly can lead to underground water contamination, potentially allowing cholera bacteria to enter the human digestive system.
Nepal faces a shortage of adequate fecal sludge treatment centers. The existing centers often do not adhere to regulations, and there are no clear guidelines for the safe removal and transport of fecal sludge from septic tanks. Without proper safety protocols, the process of collecting, emptying, and transporting faecal sludge can facilitate the spread of cholera, leading to potential infections, as mentioned by experts.
Symptoms of Cholera
Cholera is a form of diarrhea that is highly contagious and spreads rapidly. Symptoms of cholera can appear within 5 days of infection. Among those infected, approximately 1% to 25% will exhibit symptoms, with 80% experiencing mild symptoms and about 20% showing severe symptoms. Cholera can affect both children and adults. The main symptoms of cholera include:
√ Watery, thin diarrhea resembling rice water
√ Nausea and vomiting
√ Severe dehydration
How to Identify Severe Dehydration?
Severe dehydration in cholera patients can be identified through certain symptoms. Dr. Sher Bahadur Pun outlines the following indicators of severe dehydration:
√ Sunken eyes
√ Dry mouth, tongue, and throat
√ Intense thirst and fatigue
√ Dry skin
√ Yellowish urine with reduced volume
√ Irritation
√ Low blood pressure
√ Irregular heartbeats
Series of Cholera Outbreak in Nepal
The largest cholera outbreak in the history of Nepal was recorded in 2009 in the Jajarkot district of Mid-Western Development Region. According to the operational guideline for cholera epidemic control and prevention and Vaccination Program 2078/79, published by the Ministry of Health and Population, Department of Health Services for the Control and Prevention of Cholera Epidemic, about 30,000 people were affected by the cholera outbreak and more than 100 people lost their lives. Earlier to this, the first scientific report on cholera in Nepal was published in May 1886.
Three years after the Jajarkot outbreak, cholera outbreak occurred in Doti and Dailekh in 2012, and in 2013, cases were reported in the Kathmandu Valley. Rautahat experienced another cholera outbreak in 2014. Subsequently, in 2016/17, 169 cases of cholera were confirmed within the Kathmandu Valley. Since then, cases of cholera have been reported annually in the Kathmandu Valley.
In 2021, a cholera outbreak in Kapilvastu, Lumbini Province, resulted in six deaths and over 1,350 infections. (awi.fwd.gov.np)
How to Prevent Cholera?
Since cholera is transmitted through contaminated water and food, ensuring access to safe drinking water and practicing good hygiene and sanitation are essentials for prevention. Essential practices include upholding personal hygiene, using clean toilets, regular hand washing, eating clean food, and ensuring that drinking water is purified. Dr. Mukesh Poudel, head of the Epidemiology and Disease Control Division, emphasizes that water from wells and streams is possibly contaminated and thus should be treated before drinking.
Dr. Poudel recommends the use of clean water for washing fruits and vegetables. He further advises boiling water prior drinking and urges water service providers to ensure that water is chlorinated before distribution.
Chlorination helps in making the water safe by destroying the harmful pathogenic microbes.
Experts further suggest implementing multidimensional means including robust monitoring systems, providing health education, encouraging improvements in hygiene practices, and managing clean water resources to mitigate cholera outbreaks and reduce related fatalities.
Response to Cholera Outbreak
In response to confirmed cholera cases in the Kathmandu Valley and other parts of the country, the Department of Water Supply and Sewerage Management, Water Quality Improvement and Service Regulation Section, and the Department of Health Services’ Epidemiology and Disease Control Division have been actively involved in addressing the outbreak.
Mr. Purna Prasad Upadhyaya, head of the Water Quality Improvement and Service Regulation Section, reported that mobile vans have been mobilized to test water quality in the affected areas. Chlorine has been distributed for water purification, and local communities have been oriented about its use through awareness programs.
The division has also tested water distributed by various water service providers in cholera-affected areas and provided results to relevant individuals and communities, advising them to consume only after treatment.
Additionally, experts emphasize that controlling cholera outbreaks and reducing fatalities involves establishing effective monitoring systems, providing health education, enhancing hygiene practices, and ensuring proper management of clean water resources.
Dr. Sagar Dahal, Senior Public Health Administrator at the Epidemiology and Disease Control Division, Surveillance and Research Branch, reported that awareness programs using information, education, and communication materials have been conducted in affected areas. He also highlighted that the quality of water distributed by service providers has been monitored, and potential risks of water contamination have been identified and communicated to the management.
Mr. Rajendra Shrestha, Program Director of the Environment and Public Health Organization (ENPHO) said that in coordination with the public health unit of Lalitpur Metropolitan Municipality, the volunteers have been oriented on the prevention of cholera, the importance of sanitation and the necessary measures to maintain hygiene in the community. The orientation was conducted in two phases to the ward health volunteers of the municipality.
According to him, the Kathmandu Metropolitan City and Gokarneshwar Municipality ward members, community leaders and representatives of the Health Promotion Center have been trained as trainers on drinking water, sanitation and hygiene and cholera prevention and control.
Program Director Shrestha said, “Hhealth volunteers, ward members and representatives of health promotion centers are given orientation on cholera prevention and control to ensure effective flow of message to the community people.”
Future Plans for Cholera Prevention
Since cholera is caused by contaminated water and poor hygiene practices, addressing these issues at their source is crucial. Authorities responsible for drinking water and sanitation must implement well-coordinated programs to tackle these problems.
What are the future plans for reducing cholera? According to Er. Ram Kumar Shrestha, Director General of the Department of Drinking Water and Sanitation, initiatives are in place to eliminate the direct discharge of wastewater from toilets connected to sewer systems into rivers. Treatment centers are being established in the Kathmandu Valley and other urban areas to address this issue.
Mr. Shrestha highlighted that large-capacity treatment centers are being constructed at various locations in the Kathmandu Valley, with completion expected within a few years. Once operational, these centers will ensure that wastewater is treated before discharge into the water bodies.
He further added that there is a focus on managing fecal sludge from septic tanks through the “one municipality, one fecal sludge treatment center” concept. Mr. Shrestha emphasized that treating both sewer wastewater and fecal sludge before disposal aims to effectively prevent cholera infections in the future.
Mr. Purna Prasad Upadhyaya, shared that various programs are being implemented to ensure the provision of safe drinking water. To improve water quality, old projects are being upgraded with new water treatment systems, and new water supply projects are required to include laboratory facilities.
He further added that the efforts are being made to empower drinking water consumer committees to water safety plans, strengthen their capacity for water purification, and establish laboratories for water testing. These activities are monitored by third parties. At the central level, the Drinking Water Quality Surveillance Committee, chaired by the Director of the Epidemiology and Disease Control Division, oversees water quality monitoring.
Similarly, at the provincial level, the Provincial Drinking Water and Quality Surveillance Committee has been formed which is led by the Director of the Health Directorate. At the local level, the committee is formed under the coordination of the head of the local hospital/primary health center or the health coordinator.
Mr. Upadhaya further adds, “Monitoring of drinking water quality detects contamination, thereby preventing and managing health risk. Surveillance system helps in identifying weaknesses and risks in the system and directs the measures to correct them. The water service providers should also distribute water only after testing the quality of water and meeting the prescribed standards.”
