Students are asked to authentically assess a strategy for treatment or prevention of global health disease, through adopting the role of a global health worker. As a global health

worker you choose ONE of five scenarios listed in this Guide and in the online Module supporting the assignment.

 

Each scenario is linked to a low income country or middle income country. Within each scenario you are presented a global health problem and your role is to propose an evidence-based strategy or program to improve the health of a specific population group in that country. Part of your role is to research best practice strategies/programs for preventing or treating this disease and propose a novel strategy/strategies or program which will improve the health of the population group you are working with. The proposed strategy will be based on credible evidence from academic  peer reviewed sources, recommended texts and readings, government and non-government organisation reports of global health organisations such as World Health Organisation (WHO) and the course text book.

The state of health in Chad is miserable; our country has one of the lowest life expectancies in the world at 51, and an even lower healthy life expectancy of 44. A vast majority of our health problems can be attributed to communicable diseases, which constitute 75% of Chad’s deaths and 77% of all DALYs. Specifically, diarrheal diseases, lower respiratory infections (LRIs), and HIV account for 34% of all deaths in Chad. Young, rural, and poor children are most at risk for diarrheal diseases and LRIs, while women and sex workers are the populations most affected by HIV. Risk factors vary greatly as many environmental and nutritional risk factors contribute to LRIs and diarrheal diseases. In contrast, risk factors such as having multiple partners, having unprotected sex, or having a sexually transmitted infection increase the risk of HIV. Consequences from these communicable diseases include the health impact on the infected individual, as well as the indirect economic and social consequences for Chad. As a global health worker, you need to develop a strategy or program to target prevention or control of a communicable disease in Chad. The program or strategy must accommodate the social, cultural and/orenvironmental factors contributing to the spread of this disease in Chad.

Nepal has the second highest prevalence of Japanese encephalitis (JE) in South East Asia. One in five cases of JE results in death and those who survive frequently suffer from residual neuropsychiatric disorders. Most cases occur in children ages 5-15 years living in rural plain areas of the western, mid-western, and far-western regions of Nepal that border India1 . Those not using insecticide treated bed nets (ITNs), living amongst animal reservoirs of the disease and practicing poor agricultural practices in JE-endemic areas are most at risk. No effective drug treatment for JE exists and few are aware of the JE vaccine. JE contributes to high levels of malnutrition, lack of education, and poverty. Despite  efforts from Government and non-government organizations, JEconstitutes a major cause of morbidity and mortality in our country and remains a priority for public health intervention. As a global health worker, you are to design a strategy or program that targets people living in rural areas and that accounts for the social, cultural and/or  environmental factors contributing to the spread of JE in rural areas of Nepal.

Introduction 

In the region of South East Asia, Nepal has the second highest prevalence rate of Japanese Encephalitis (JE). It is reported that, approximately one out of five people suffering from JE results in death and those who survive, may suffer from condition named residual neuropsychiatric disorders. However, it is reported that, most of  the cases, the children  under the age group of 5-15 years living in rural plain areas of the western, mid-western, and far-western regions of Nepal that border India. From the case study, it can be stated that, the people who are living in the JE endemic areas are at higher as they are not using insecticide treated bed nets (ITNs), living in the animal reservoirs of the disease and moreover, the people who are practicing poor agricultural practices are also have higher risks of developing the disease (Gao et al. 2014). However, it is reported that, most of the people are not aware about the vaccination process and the lack of education among the people is also associated with the poor awareness regarding the JE among the people (Pant et al. 2017). As a part of the governmental organization (NGO), the global health worker will help to improve the condition. Therefore, as a part of this, the global health worker will try to improve the disease condition of the people of Nepal.  While discussing about the intervention, it can be stated that vaccination along with the awareness program regarding the application of the vaccination will be implemented as intervention program.

Background and Risk factors 

According to the study of Lagarde et al.  (2014), it is reported that, JE is the disease caused by the virus named Japanese Encephalitis Virus (JEV), a single stranded RNA virus. In this study, it is stated that, JE is one  of the most  important endemic encephalitis around the different parts of  this world.  Specifically, in case of the Southern and Eastern Asia, approximately 50,000 cases of JE are reported and among them 15000 cases of deaths are reported. In Nepal, 24 districts of the country are suffering from this condition. The study result showed that, in case of sex-wise distribution of JE among the Nepalese children, approximately 593 cases were reported among the male children and in case of female children only 416 cases were reported (Khanal et al.2015). Among the overall affected male children 58 male children were seropositive and 49 females had seropositive result. In case of age specific rate of JE infection, it can be stated that in case of infants (less than 28 days age) only 46 cases were reported and among them 6.52 per cent was seropositive. In case of 1 month aged children 118 cases were reported and 3.39 per cent was seropositive.  Under the age group of 2-5 years children, 256 cases were reported and among them 30 children had seropositive result. In case of 6-10 years age group, total 349 cases were reported and only 43 patients had seropositive result (Khanal et al.2015).  In case of 11-15 years children, only 240 children are affected and 11.25 per cent of this age group had the seropositive result.  While discussing about the risk factors of JE in Nepal it can be said that, the natural reservoir of the disease is associated with the animals such as pigs, and birds such as pond herons, cattle egrets, poultry birds and ducks. However, the role of the bats and bovine is not at all established till date. Apart from the culex mosquitoes, many other species of mosquitoes are found to be positive in case of JE infection. The JEV may transmit to the cows, horses, men and pigs and as a result the circulation of the JEV in an enzootic cycle takes place. In case of Nepal, it can be observed that, presence of huge numbers of paddy fields in various region of Nepal is one of the most crucial risk factors of developing  JE infection among the country. According to the study of Pant et al. (2017), it is reported that, the prevalence of the JE infection in Nepal is not distributed equally in all  the regions of the country. Therefore, due to the high density of vectors, cultivated paddy fields in Southern Terai, the cases of JE infection are clustered in those areas. In those areas the rate of animal farming and paddy cultivation are very high and such conditions are favourable for the infection outbreak of the country. Along with this, lack of proper vaccination among the people and the children are also responsible for enhanced JE infection rate in the country. In this study, it is also reported that, poor agricultural practices among the farmers due to lack of education and awareness may also promote the JE infection cases in Nepal (Pant et al. 2017).

Determinants of Health

While discussing the social determinants of health in the context of high JE prevalence of the country, it can be said that, there are many factors that can impact the condition of JE infection among the Nepalese children.  Issue of this high prevalence in Nepalese children is one of the serious concerns of the Government of Nepal. While discussing the environmental factors contributing to the JE prevalence of  the country, it can be said  that, there are a few regions of the country that has a high prevalence of the  disease due to their geographical location (Dhimal,  Ahrens  and Kuch 2015).  The presence of favourable condition  in those areas,  the cases of JE infection   in those areas are very high. According to the study of  Pant et al. (2017), it is  reported that, the in between the time period of  2009 to 2015, the central Nepal region and southern Terai low plain area are mostly affected.  Within this time period, the district of Kailali has the highest prevalence rate of JE infection approximately 2.5 person per 100,000 person. The climatic natures of those areas are encouraging for the expansion of the JE infection in the country.  Another crucial factor that is associated with the political factor. As a part of this, it can be said that, use of vaccination is  the most effective preventive measure for JE infection. From multiple studies, it is observed that, although the government has taken vaccination strategy, they are not enough or not implemented in an effective manner (Upreti et al. 2013). According to World Health Organization, implementation of the proper JE vaccination among the community people can positively improve the condition of JE infection. Therefore, it can be said that, lack of poor implementation of the vaccination strategy in  those vulnerable areas has greatly promote the outbreak of JE vaccination among the children of Nepal. In most of the cases, it is observed that, vaccination during the childhood can reduce the overall disease burden in many other countries of the world. As a part of the social factors contributing towards the  disease prevalence in the country, it can be said that, education and health literacy is one of  the major contributors of this condition. According to the  study of Pathak  (2017), it is reported that, the health related education and overall literacy rate of Nepalese population is not at all satisfactory and as  result they are not aware about the vaccination process and other preventive measures for protecting themselves from JE infection. The poor socio-economic condition of the people also affect the health behaviour of the people in the country. According to the  study of Khanal et al (2015), it is reported that,  in the year of 2011, only 34.1 per cent of Nepalese people under the age  group of 5 years or above are literate and this shows the poor condition of the literacy in the country.  A huge portion of Nepalese people are still uneducated and thus it affects the health condition of the people. Another social factor that is affecting the health condition of the people is the poor housing that is most of the people are suffering from the problem of poor housing and as a result they are easily exposed to the mosquitoes capable of transmitting JEV (Joshi and Marg 2013).

Evaluation of Strategies

For improving the overall health condition of the Nepalese people regarding the JE infection condition a major action plan is definitely required so that the prevalence of the disease condition can be minimized. In many other countries of world, a JE vaccination strategy has taken in order to reduce the disease burden of JE (Rustagi,  Basu and Garg 2019). According to WHO, vaccination is the best strategy to prevent JE infection among the people.  As a part of this, such vaccination program must be run throughout the year in endemic regions.  Along with this, various developed countries in this world has improved this strategies to next level and as a part of this, they initiated vaccination program for the animals susceptible to JE infection. On the contrary, the developing countries like Bangladesh has initiated campaign for vaccination against the disease in order to reduce the overall disease burden of the country. It is reported that, JE immunization program in those areas has significantly improve the incidence of JE in those countries. The health care professionals, who are working in the endemic areas, should also be vaccinated to protect them from infection of JE. Another crucial strategy that is considered as an effective one is the up gradation of health care education and health care facilities in endemic region (Upreti et al. 2017). In India as a part of the JE prevention strategy, round the clock health care facilities in the endemic regions are used and as part of this, trained health care providers should be engaged in this process.  As a part of the awareness program, the people should be provided training regarding the importance of safe drinking water, housing, nutritional status, and sanitation in endemic regions and it helps to reduce the overall disease burden.

The Strategy or Program 

The present organization will work along with the other governmental and non-governmental organizations who are engaged in reducing the disease burden of the country. This organization will specifically work to deduce the infection rate of JE and as a result, the overall disease burden of the country will be reduced. Primarily this organization will emphasize on the vaccination policy and as a part of this accessibility of the JE vaccines must be enhanced so that all the people and children in the endemic region of Nepal can access the facility. Easy accessibility of the vaccination in all over the country along with the endemic regions  will encourage people to  immunize themselves. Along with this, the organization will promote the vaccination of the animals who are susceptible to JE infection and it is very crucial for the people of Nepal as the number of animal farming is increasing in Nepal day by day. The vaccination of animals will reduce the rate of infection from the animals to the humans. As a part of the educational program the organization will work to improve the literacy level of the people so that they can understand the importance of healthy living and importance of vaccination as well. As a part of this, the organization will organize awareness program to enhance the health literacy levels, healthy living practices, nutritional requirement of the people.  As the children are most vulnerable to JE infection,  it can be recommended that, children can be engaged in educational program regarding the preventive measures and as a part of this they should be given training on preventive measures from mosquito biting as they are one of  the major contributors of JE infection among the children.  Along with this, the present organization will also try to enhance the work forces for enhancing health care facilities to the endemic regions and along with this, the health care professionals must be immunized by using vaccines to prevent themselves from  infection. As a part of this , local work forces will be trained and it will be very helpful in reaching local people who are more exposed to the risks factors of JE infection. Involvement of local health care work force will help to reach more number of people in an easy manner and thereby the condition may improve.

References

Dhimal, M., Ahrens, B. and Kuch, U., 2015. Climate change and spatiotemporal distributions of vector-borne diseases in Nepal–a systematic synthesis of literature. PloS one, 10(6), p.e0129869.

Gao, X., Li, X., Li, M., Fu, S., Wang, H., Lu, Z., … & Gould, E. A., 2014. Vaccine strategies for the control and prevention of Japanese encephalitis in Mainland China, 1951–2011. PLoS neglected tropical diseases, 8(8), e3015.

Joshi, D.D. and Marg, J.S., 2013. Review on Japanese Encephalitis Outbreak Cases in Nepal During the Year 2011. In Encephalitis. IntechOpen.

Khanal, S., Ansari, S., Basnyat, S.R., Joshi, D., Adhikari, N., Shrestha, U.T., Acharya, D., Adhikari, P., Niraula, P.M. and Upadhyay, B.P., 2015. Sero-prevalence of Japanese Encephalitis (JE) among Nepalese Children. British Microbiology Research Journal, 6(3), p.126.

Lagarde, S., Lagier, J.C., Charrel, R., Querat, G., Vanhomwegen, J., Desprès, P., Pelletier, J. and Kaphan, E., 2014. Japanese encephalitis in a French traveler to Nepal. Journal of neurovirology, 20(1), pp.99-102.

Pant, D. K., Tenzin, T., Chand, R., Sharma, B. K., & Bist, P. R., 2017. Spatio-temporal epidemiology of Japanese encephalitis in Nepal, 2007-2015. PloS one, 12(7), e0180591.

Pathak, A., 2017. Socioeconomic determinants of child mortality: analysis of the 2011 nepal demographic and health survey. Finland: University of Eastern Finland.

Rustagi, R., Basu, S. and Garg, S., 2019. Japanese encephalitis: Strategies for prevention and control in India. Indian Journal of Medical Specialities, 10(1), p.12.

Upreti, S.R., Janusz, K.B., Schluter, W.W., Bichha, R.P., Shakya, G., Biggerstaff, B.J., Shrestha, M.M., Sedai, T.R., Fischer, M., Gibbons, R.V. and Shrestha, S.K., 2013. Estimation of the impact of a Japanese encephalitis immunization program with live, attenuated SA 14-14-2 vaccine in Nepal. The American journal of tropical medicine and hygiene, 88(3), pp.464-468.

Upreti, S.R., Lindsey, N.P., Bohara, R., Choudhary, G.R., Shakya, S., Gautam, M., Giri, J.N., Fischer, M. and Hills, S.L., 2017. Updated estimation of the impact of a Japanese encephalitis immunization program with live, attenuated SA 14-14-2 vaccine in Nepal. PLoS neglected tropical diseases, 11(9), p.e0005866.