Kinzel, Kasey

School of Public Health

MSPH

Nepal

Estimating the cost of illness for typhoid fever in Nepal: A sub-study of the Typhoid Vaccine Acceleration Consortium (TyVAC)

Typhoid fever represents a substantial epidemiologic and economic burden in Nepal, and while understanding of the disease burden is growing, data quantifying the economic burden is limited. The Typhoid Vaccine Acceleration Consortium Cost of Illness study (TyVAC-COI), led by Johns Hopkins Bloomberg School of Public Health International Vaccine Access Center as part of the broader TyVAC study led by University of Maryland and Oxford University, aims to generate new evidence on the economic burden of enteric fever (i.e., typhoid and paratyphoid fever) in Nepal. The study will estimate the cost of illness from the health care system and household perspectives and estimate the catastrophic impact on households through primary data collection. We are collecting data on health facility expenditures and utilization of health services for treating enteric fever from facility administrators, medical and non-medical staff, and laboratory technicians. We are also collecting out-of-pocket expenditures, productivity loss, and household impact data from patients with blood culture-confirmed typhoid and paratyphoid presenting to a participating study health facility using a facility-based cohort study design. This study is being conducted at two hospitals in Kathmandu (Patan Hospital and Kanti Children's Hospital), three public ward clinics, and one private clinic. Results from this study will be used to inform policy decisions on typhoid control interventions, including introducing the new Typbar typhoid conjugate vaccine.

This project is being conducted alongside a vaccine effectiveness trial, led by Oxford University.

PI Mentor: Cristina Garcia

I had the amazing opportunity to work with the International Vaccine Access Center (IVAC) on a study assessing the cost-effectiveness of the Typhoid Vaccine in Kathmandu, Nepal (TyVAC). In this study we collaborated with researchers from Oxford University and worked with two local hospitals, Kanti Children’s Hospital and Patan Hospital, along with several associated ward clinics. My role in this study was to create and prepare data collection materials as well as train data collectors. During this time, I also had the opportunity to see the beautiful country of Nepal as well as experience its rich culture, kind people, and incredible food. Altogether it was a wonderful experience and I am very grateful to GHEFP for allowing it to happen.

             As a person who grew up in a developing country and spent a good amount of time traveling, I felt decently prepared for this journey. However, I had never been anywhere in Asia and upon arrival I quickly realized just how little I knew about Nepali culture. I was initially very nervous, scared to accidentally offend someone or brand myself as a tourist. However, I was shocked by the kindness of the Nepali people. Everyone I met was so willing to help and so excited to show off their proud country. The culture was so relaxed and easygoing, it wasn’t hard to feel instantly comfortable and at home. It was so much easier to get around than I had anticipated as most everyone in the city spoke English in addition to Nepali. I had many opportunities to work remotely and travel to see some of the beautiful things Nepal had to offer.

            This project truly threw me into the world of global health. I learned very quickly that things hardly ever go as planned as it is often taught in an idealistic, classroom setting. I learned how much patience and flexibility a career in global health requires as study timelines continually shifted, and in-country partners would go weeks without responding to inquiries. I learned quickly how big of a role bureaucracy plays in developing country research as we patiently waited for approval from all levels of the Nepali government. I experienced the difference in work cultures from across the world as we spent many meetings trying to get on the same page with in-country partners. 

One thing that really surprised me was how difficult it was to work in this setting as a female. I had never before been in a setting where I felt my opinion mattered so little, just because I am a woman. As a female graduate student without the title of “Dr.” sitting alone in meetings with only male Nepali Doctors I often felt quite powerless. There were several meetings where some men would not even look me in the eye or respond to me when I spoke. However, there was nothing that could be done about this without offending or straying from cultural norms. This was something I had never experienced before and took a lot of getting used to. However, this did inspire me to consider looking into female health and women’s rights in developing countries as a future interest area or potential career path.         

My biggest piece of advice to future students planning for a similar experience is to stay flexible and patient. Try not to get overwhelmed when things don’t go according to plan (as they are almost guaranteed to change) and do your best to understand and accept the local workplace culture. I would also highly recommend making the most of any free time you are given by exploring the area and making local friends who can show you the non-tourist side of the country. 

Walk to the hospital past the temples of Patan Durbar Square

Data collector training presentation of monitoring activities

One-on-one practice during data collector training

View of Kathmandu from Swayambhunath Stupa (Monkey Temple)

View of the Annapurna mountain range in the Himalayas

People

Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...
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July 2020

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