An Opportunity Not to be Missed: Vaccination as an Entry Point for Hygiene Promotion and Diarrhoeal Disease Reduction in Nepal

Abstract

Background: Diarrhoea remains a leading cause of under–five mortality, in part due to failures to increase access to safe water, improved sanitation and hygiene practices (WASH). Rotavirus vaccines have recently been recommended for introduction in low-income countries, but there has been little discussion on the delivery of such vaccines as part of a comprehensive package of interventions to reduce diarrhoea, including WASH. At the same time, immunization programmes could be a useful entry point for sanitation and hygiene promotion. Methods: Between April and May 2012 an exploratory study took place in Nepal to ascertain whether or not vaccination programmes offer a useful entry point for hygiene promotion and to define options for piloting and scaling up of a hygiene promotion intervention in Nepal. Focus group discussions were carried out in rural and urban areas of Kaski district with Female Community Health Volunteers and mothers/carers of infants vaccinated during the ongoing polio national immunization days. A further focus group discussion was conducted among ten members of a network of international non-governmental organizations (INGOs). Twenty-five stakeholders were interviewed including policy makers (state), non-state actors (donors, International NGOs), programme implementers and service providers at national (Kathmandu), regional (western region) and district (Kaski) level. Results: A high degree of trust in and respect for the volunteers was noted. FCHVs were mainly concerned about the need for further training on hygiene promotion. All mothers/guardians were highly motivated to vaccinate their children, despite of long distance and high cost. The concept of Integrating hygiene promotion and vaccination was acceptable to policy makers and program implementers. Concerns were raised about the availability and sustainability of financial resources for additional programming, as well as the effective mobilization of resources to ensure hygiene promotion is delivered consistently across the country. Likewise, other concerns were over-burdening of the FCHVs, availability of soap and water for demonstrations, and sustained practices and geographic and cultural variation in Nepal. Conclusions: As GoN decided to introduce the rotavirus vaccine into its routine immunization schedule in 2016, piloting should be undertaken in a variety of settings to reflect Nepal’s diverse culture, geography, sanitation coverage levels, and disease burden. At central level decision should be done at the central level how the pilot and subsequent program will be financed, to assign a responsible body to coordinate this initiative, to ensure commitment of key stakeholders, and to decide on and develop deliverables to which all collaborators can be held accountable. Keywords: diarrhoeal diseases; hygiene promotion; routine vaccination; rotavirus vaccines; vaccination.