Abhilasha Karkey: Infectious diseases in Nepal

I am Abhilasha Karkey, I head the Research Unit OUCRU-Nepal. I am a clinical microbiologist by training. The main objective is to have a significant, positive public health impact in Nepal, and not just in Nepal but in the whole South Asian region. Specifically talking about diseases, we focus on diarrheal diseases, that's always been our focus, specifically typhoid. Over the years antimicrobial resistance has become the next big thing, so in all areas especially hospital-acquired infections, and more recently dengue is a big problem for us and one of our main research focuses in the coming years.

I think the TCV typhoid vaccine has been one of our greatest success stories. Once we did the vaccination study, we realized a lot of things: first of all, we realised that we can do vaccine trials in Nepal on a world-class scale; second was we realised how important it is to work with policy makers. We'd been very focused on public engagement, communities, people that we involved and hospital management, but we actually previously had never worked together with policy makers. With the TCV vaccination trial, when we wanted to convince the government to put it on the immunisation level, we realized how important it was. Since then, we've started working really closely with policy makers. That's one big change we've had since then.

The other thing that the vaccine trial taught us was how important regional networking was. Pakistan and Bangladesh were part of the trial, so when going to policy makers it was easy to say: Bangladesh already has this on their immunisation schedule, we should do it too. It was just one more point to convince them. That's why another trial that we're doing looking at treatment for typhoid fever involves a regional collaboration between Pakistan, Bangladesh and Nepal, and hopefully in the future India as well. But it gave us an idea that you can't have a significant positive public health impact if you're not regionally connected, so that's another big lesson that we had.

The antimicrobial resistant research, to be honest, I think it's quite complex. In the past, we’ve focused purely on surveillance: trying to set up stewardship programmes, which was difficult because in Nepal we work with big government hospitals. They're extremely cash-strapped, nothing is digital, so you literally have doctors sitting and collecting data sets. What we've known now from our research in Nepal is what are the most common pathogens. The next focus for us is in the hospitals, carbapenem-resistant gram-negative pathogens are a huge concern, especially in the intensive care units. One of the things that we plan to do is have a randomised control trial looking at best treatment options for carbapenem-resistant pathogens. We're going to try and do control trials, looking at short course versus long course treatment for surgical patients.

I think in the future, my research on antimicrobial resistance will be more pathogen focused. We already know now, because of our surveillance data, what is the most common pathogens that affects our hospital: Klebsiella pneumoniae, enterobacters in the communities. I think my research will turn more focused. At the moment, all of my focus is actually on Salmonella. Extensively, drug-resistant Salmonella has become a huge problem in our region, and even though we haven't seen it in Nepal yet, we're still keeping our eye open for that. We're doing a regional surveillance on Salmonella.

Climate change is significantly affecting us. For example, dengue; we never had dengue in Kathmandu. You would see cases, but they would always be attached to a travel history to an endemic region. I think it was 2018-19 we started getting sporadic reports of a dengue case with no travel history, but you always thought: oh, they didn't take the history properly. In 2022, we had our biggest ever dengue outbreak in hospitals, and because it coincided with COVID, hospitals were just not prepared to take on the cases. And even we didn't know what to do. One of the good things that we realised about the (OUCRU) network was it was very easy to reach out to Vietnam, to the dengue group in Vietnam, and say what can we do. Now we've designed a very small surveillance study, just to know what variants are going around, together with the dengue team in Vietnam. I think these are effects of climate change. All of our disease research questions, we're just trying to make the research questions as objective as possible.

I've been in Nepal with the unit for 16 years now. There's been huge changes. The hospitals have started including us in infection prevention, control committees or antimicrobial stewardship programmes. We've now got a very good relationship with the community, so they understand if there's a question about any of the treatments that we're doing, or vaccines, they call us. There have been huge positive impacts on the medical community, as well as on the general community where we work. Globally a lot of people didn't even know that Nepal was doing all of this, and we've become more visible now which has attracted global collaborations, which is all good, especially for capacity strengthening the local clinicians and scientists, which is of course another one of our significant aims.

This interview was recorded in January 2024.