Stumbling blocks on the path to measles-free Nepal: impact of the COVID-19 pandemic

Measles poses a significant global health threat, exacerbated by the COVID-19 pandemic. Despite the efficacy of two vaccine doses, under-5 mortality rates persist, with over 61 million delayed measles vaccinations worldwide. Nepal, striving to eliminate measles by 2023, faces a resurgence, attributing 1013 cases to inadequate vaccination and healthcare accessibility issues. Compounded by disruptions from the COVID-19 pandemic, the outbreak highlights the urgent need for vaccination promotion, improved healthcare access, and misinformation mitigation. This situation underscores the critical role of global collaboration and healthcare infrastructure investment to safeguard children's lives in Nepal and similar vulnerable regions.

COVID-19 mortality and its associated factors in Nepal: A cross-sectional study

Objectives

Reports from other countries have indicated that severe forms and fatal cases of COVID-19 in older adults and people with underlying comorbidities. The aim of this study was to assess the risk factors associated with COVID-19 mortality in Nepal.

Methods

A cross-sectional study was conducted from April 12 to July 23, 2021 to identify the underlying factors associated with COVID-19 deaths. Our sample included all cases diagnosed and registered as COVID-19-related deaths at 30 hospitals of Nepal.

Results

A total of 1459 COVID-19 hospital-based death records were collected from 30 hospitals. Mean age at death was 60.2 (±15.6) years. One-third of cases were admitted with fever, cough, and shortness of breath. The computerized tomography Severity Score showed that 7.3% of the individuals who underwent high-resolution computerized tomography chest had a severe form of lung involvement, and 3.6% had mild to moderate involvement. The most common comorbidities were hypertension (43.7%) followed by diabetes mellitus (25.8%). Among the deceased, 37.7% were diagnosed as cases of COVID-19 pneumonia. The most common recorded causes of death were respiratory failure followed by cardio-pulmonary arrest.

Conclusions

Individuals with comorbidities including hypertension and diabetes mellitus were at greater risk of developing complications and had a higher rate of mortality.

Physical, mental and social status after COVID-19 recovery in Nepal: A mixed method study

BACKGROUND

Nepal has been devastated by an unprecedented COVID-19 outbreak, affecting people emotionally, physically, and socially, resulting in significant morbidity and mortality. Approximately 10% of COVID-19 affected people have symptoms that last more than 3-4 weeks and experience numerous symptoms causing an impact on everyday functioning, social, and cognitive function. Thus, it is vital to know about the recovered patient's health status and undertake rigorous examinations to detect and treat infections. Hence, this study aims to assess the health status of COVID-19 post-recovery patients in Nepal.

METHOD

A descriptive cross-sectional mixed-method study was conducted in all seven provinces of Nepal. A total of 552 interviews were conducted for the quantitative study, and 25 in-depth interviews were conducted for the qualitative study among above 18 years COVID-19-recovered patients. The data was gathered over the phone through the purposive sampling method The results of a descriptive and thematic analysis were interpreted.

FINDING

The majority (more than 80%) of the recovered patients could routinely perform household duties, activities outside the home, and financial job accounting. However, a few of them required assistance in carrying out all of those tasks. Prior and then after COVID-19 infection, smoking habits reduced by about one-tenth and alcohol intake decreased by a twelve percent. A qualitative finding revealed that the majority of COVID-19 symptomatic patients experienced a variety of physical symptoms such as fever, headache, body pain, fatigue, tiredness, sore throat, cough, loss of taste, loss of smell, sneezing, loss of appetite, and difficulty breathing, while others felt completely fine after being recovered. Furthermore, there was no variation in the daily functional activities of the majority of the recovered patients, while a few were found conducting fewer activities than usual because they were concerned about their health. For social health, quantitative data indicated that more than half of the participants' social health was severely impacted. According to the IDI, the majority of the interviewees perceived society's ignorance and misbehavior. Family members were the most often solicited sources of support. Some participants got care and assistance, but the majority did not get affection or love from their relatives. Moreover, regarding mental health, 15 percent of participants had repeated disturbing and unwanted thoughts about COVID-19 after being recovered, 16 percent tried to avoid information on COVID-19 and 7 .7 percent of people had unfavorable ideas or sentiments about themselves. More than 16 percent of participants reported feeling some level of stress related to the workplace and home. While in-depth interviews participants revealed that COVID-infected patients who were asymptomatic didn't experience any emotional change in them but recovered patients who are symptomatic symptoms had anxiety and still being conscious of COVID-19 in fear of getting infected again Additionally, it was discovered that participants' mental health is influenced by ignorance of society, as well as by fake news posted to social media.

CONCLUSION

COVID-19 infection has had an impact on physical, mental, and social well-being. Hence, to aid in the early recovery of COVID-19 patients, provision of evaluating and reporting the clinical features, early detection and management of long COVID case is needed from the local and provincial and central government of Nepal.

Prevalence of Microalbuminuria in Non-diabetic Hypertensive Patients and its Correlation with Changes in Left Ventricular and Left Atrial Characteristics

BACKGROUND

Microalbuminuria is urinary albumin excretion in the range of 30-300 mg per 24 hours and is considered as an abnormal albumin excretion rate. Microalbuminuria is associated with epithelial dysfunction and have a high risk for target organ damage resulting in stroke, retinopathy and adverse cardiovascular events. The objective of the study was to determine the prevalence of microalbuminuria in non-diabetic hypertensive patients and its correlation with cardiovascular changes.

METHODS

A quantitative cross-sectional study was done in 107 participants diagnosed as non-diabetic hypertensive patients visiting to Manmohan Memorial medical college and Teaching hospital and Manmohan Cardio-thoracic Vascular and transplant Centre. The assessed parameters were basic metabolic profile, urine evaluation and Echocardiography.

RESULTS

The results showed microalbuminuria in 28 study participants and not seen in 79 participants. Similarly, microalbuminuria was observed more comparable in those with presence of left ventricular hypertrophy as compared to the absence of left ventricular hypertrophy (29.3% versus 22.8%) (p value 0.469); those with presence of left ventricular diastolic dysfunction as compared to the absence of left ventricular diastolic dysfunction (31.1% versus 19%) (p value 0.170) and those with dilated left atrium as compared to normal left atrium (26.7% versus 23.9%) (p value 0.820). In case of left ventricular ejection fraction, those with normal left ventricular ejection fraction (26.3%) had slightly higher proportion of micro-albuminuria than those with mild to moderate left ventricular systolic dysfunction (20%) (p value= 0.755) Conclusions: There was no significant difference in the level of micro-albuminuria between non-diabetics, hypertensive patients with cardio vascular changes compared to patients with no cardiovascular changes.

Assessment of quality of essential medicines in public health care facilities of Nepal: Findings of nationwide study

Essential medicines are those medicines that satisfy the primary health care needs of the citizens. Poor quality of essential medicines can have serious impact on public health. Thus, this study is aimed to assess the quality of essential medicines available in public health care facilities of Nepal. A cross sectional descriptive study was carried out in 62 health facilities across 21 districts, representing all seven provinces of Nepal and selected proportionately from all three ecological regions i.e. Terai, Hill and Mountain using lottery method. Health facilities in selected districts were chosen using random number generator. Face to face interview was taken with health facility in charge using structured questionnaire. All storage conditions information was recorded through observation checklists. Temperature and humidity were measured using a digital instrument. Similarly, 20 different generic medicines were collected for quality testing. The obtained data were entered in Epidata version 3.1, cleaned in Microsoft Excel 2007 and analyzed in SPSS version 16.0. Among 62 health facilities, only 13% of health facilities were found to follow the medicine storage guidelines, with temperature and humidity levels exceeding recommended limits. Out of 244 batches of 20 different generics of essential medicines, 37 batches were found to be substandard. These substandard medicines were- Ciprofloxacin hydrochloride eye/ear drop, Iron supplement tablets, Metformin Hydrochloric tablet, Metronidazole Tablets, Paracetamol Oral suspension, Paracetamol tablet and Povidone Iodine solution. The study recommends the urgent need for the Government of Nepal to prioritize ensuring the quality of essential medicines in the country.

Knowledge and attitude towards COVID-19 booster dose among healthcare professionals in Nepal: A cross-sectional study

Vaccination has become the most effective way to combat the coronavirus disease 2019 (COVID-19) pandemic. As there have been reports of a gradual decline in the protection it offers, many countries have decided to administer booster doses of the COVID-19 vaccine. In Nepal, booster doses have been introduced to frontline health workers as a priority group. Therefore, this study aims to assess the knowledge and attitude of health care professionals toward booster doses of COVID-19 vaccines in Nepal.

Methods

A cross-sectional study was conducted from December 2021 to January 2022 among health care professionals working at public health facilities in Nepal. Multivariable logistic regression was performed to identify predictors that correlate with knowledge and attitude toward COVID-19 booster dose. P value less than 0.05 was considered statistically significant.

Results

A total of 300 participants were included in the final analysis. Among the study participants, 68.0% and 78.6% had good knowledge and favorable attitude toward COVID-19 booster dose, respectively. Female health care workers and those who had received a single dose of COVID-19 vaccine had significantly lower odds of having good knowledge of COVID-19 booster dose. Similarly, participants with lower educational levels and those who had received a single dose of COVID-19 vaccination had an unfavorable attitude toward COVID-19 booster dose.

Conclusion

This study showed a satisfactory level of knowledge and attitude of health care professionals toward COVID-19 booster dose in Nepal. Health care professionals' positive attitude toward COVID-19 booster dose vaccine is key to the patient and community safety. Personalized education and risk communication can aid in improving overall awareness and attitudes toward COVID-19 booster dose in such populations.

Health Status and Management Practices of Home Isolated COVID-19 Adult Patients

BACKGROUND

The worldwide containment strategy for COVID-19 outbreak includes laboratory-confirmed cases, and their isolation and management in health care institutions or at home. The spread of the COVID-19 virus has mandated home isolation for mild cases, as recommended by the Government of Nepal. Isolation is a situation that can have a substantial influence on physical and mental health of isolated people. This study is aimed to assess physical and mental well-being of COVID-19 home isolated patients, and their home management practices.

METHODS

A descriptive cross-sectional research using quantitative methods was carried out. Purposive sampling was used to select COVID-19 patients. Total 536 COVID-19 home isolated patients were included in this study. Telephonic interview was conducted to obtain the data. Descriptive analysis was done and interpreted.

RESULTS

About 34 % of the participants were symptomatic. The most common symptoms experienced were fever (22.6%), followed by cough (19.4%) and cold (16.1%). About 20 % indicated having difficulties isolating at home due to lack of separate room. Furthermore, 4 percent of the participants didn't have anyone to take care of them at home. Also almost 2 percent of participants didn't get family support when infected. Moreover, majorities of individuals had normal stress, depression and anxiety level.

CONCLUSIONS

Most of the participants' physical and mental health was found to be normal though some of them experienced difficulties for management during home isolation. Hence, Interventions should focus resilience building by improving communication to address fears and concerns, encouraging routines and physical activities, and taking measures to reduce loneliness.

Nepal Urgently Needs a National Evidence Synthesis Centre

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Anticoagulation Strategies in Non-Critically Ill Patients with Covid-19

Anticoagulation in Non-Critically Ill Covid-19 PatientsMcQuilten et al. conducted a randomized clinical trial comparing low-dose, intermediate-dose, low-dose plus aspirin, and therapeutic-dose anticoagulation in patients with Covid-19 of diverse ethnicities in high-, low-, and middle-income countries.

Antibiotics Prescription, Dispensing Practices and Antibiotic Resistance Pattern in Common Pathogens in Nepal: A Narrative Review

Antimicrobial resistance (AMR) is increasing and it is a serious public health problem worldwide. Nepal is considered as one of the contributors for rising AMR due to the most prevalent irrational use of antibiotics. In this review, we have assessed the practices of antibiotic prescription and dispensing, and antibiotic resistance of commonly encountered bacteria in Nepal. There is exponential increase of therapeutic consumption of antibiotics either without clinician's prescription or irrational prescription. Almost half of the population in Nepal was found to purchase antibiotics easily from the nearby pharmacies without clinician's prescription. Irrational prescription is exceeded in remote areas which could be due to lack of access with health posts and hospitals. The third generation cephalosporins, which are considered as the last resort antibiotics were found to be relatively prescribed and dispensed higher as compared to other classes of antibiotics. Despite the existing limited functional surveillance system, antibiotic resistance among bacteria is increasing in Nepal because of irrational prescription, dispensing and consumption of antibiotics without prescription.

1779. An Assessment of Antibiotic Treatment Guideline Adherence for Common Infections in a Tertiary Care Hospital with an Established Antimicrobial Stewardship Program in Kathmandu, Nepal

Background

Antibiotic treatment guidelines have been increasingly recognized as an effective tool to guide appropriate prescriptions and help curtail antibiotic resistance. We aimed to assess the quality of inpatient antibiotic prescribing practices for common infections in a tertiary centre in Kathmandu.

Methods

We conducted a retrospective monocentric review of medical records of adult inpatients diagnosed with Urinary Tract Infection; Pneumonia; and Skin and soft tissue infection between January 2018 till December 2019. Adherence was defined as the prescription of antibiotics for mentioned infection fulfilling the correct choice, correct dose, and correct duration of therapy.

Flow diagram 1

Medical Records Review to assess adherence to guideline

Results

Clinical records of 354 inpatients were included in the analysis. Overall, 37.9% of antibiotic prescriptions were adherent to guideline recommendations. The non-adherent groups also had a higher proportion of patients in the age group between 45 and 60 years (66%, OR: 1.87, 95% CI: 1.09-3.21, p=0.2) and with the presence of co-morbidities (58%, OR: 0.44, 95% CI: 0.26-0.75, p< 0.1). The department categories, gender, number of comorbidities, infectious disease diagnosis, and history of antibiotic drug allergy had no significant effect reported on adherence. Incorrect selection (20%, or: 0.24, 95% CI: 0.07-0.79, p=0.19) and incorrect antibiotic dosage (21%, OR: 0.26, 95% CI: 0.08-0.82, p=0.02) were prescribed among patients diagnosed with urinary tract infection. Likewise, an incorrect dosage of antibiotics (40%, OR: 0.27, 95% CI: 0.07-0.97, p=0.05) was prescribed for patients with pneumonia. Pneumonia (52%) and urinary tract infection (32%, p< 0.01) had more de-escalations, while the antibiotic spectrum prescribed was significantly broad (81%, p< 0.001).

Study Schema

Conclusion

Our study revealed low adherence despite the availability of the updated guideline for an antibiotic prescription. These data demand an urgent need to confront the antibiotic prescription pattern in the tertiary care centres for tailored interventions to improve adherence to guidelines, particularly focusing on prescriptions of antibiotic types and in the elderly population. It is also an imperative to reduce the broad-spectrum antibiotic exposure to the patients with acute infections guided by the culture reports.

Disclosures

All Authors: No reported disclosures.

A clinical guideline-based management of type 2 diabetes by ayurvedic practitioners in Nepal: A feasibility cluster randomized controlled trial protocol

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a common chronic condition with significant health and socioeconomic consequences. In Nepal, T2DM is a common disease for which people consult ayurvedic (traditional medical system) practitioners and use ayurvedic medicines. Strong concerns remain about the suboptimal T2DM management of many patients by ayurvedic practitioners, and therefore, based on the best available scientific evidence, we have developed a clinical guideline for managing T2DM by ayurvedic practitioners. The research question to be addressed by a definitive cluster randomized controlled trial (RCT) is whether the introduction of a clinical guideline can improve the management of T2DM by ayurvedic practitioners in Nepal as compared to usual ayurvedic management (i.e., without any clinical guideline). In preparation for this future work, this current study aims to determine the feasibility of undertaking the definitive cluster RCT.

METHODS

This is a 2-arm, feasibility cluster RCT with a blinded outcome assessment and a qualitative evaluation. The study is conducted in 12 public and private ayurveda centers in and outside the Kathmandu Valley in Nepal (1:1 intervention:control). Eligible participants should be new T2DM adult patients (i.e., treatment naïve) - the glycated hemoglobin level should be 6.5% or above but less than 9%. At least 120 participants (60/group) will be recruited and followed up for 6 months. Important parameters, needed to design the definitive trial, will be estimated, such as the standard deviation of the outcome measure (i.e., glycated hemoglobin level at 6-month follow-up), intraclass correlation coefficient, cluster size, recruitment, the time needed to recruit participants, follow-up, and adherence to the recommended ayurvedic medicine. Semi-structured qualitative interviews will be conducted with around 20 to 30 participants and all the participating ayurvedic practitioners to explore their experiences and perspectives of taking part in the study and of the intervention and a sample of eligible people declining to participate in the study to explore the reasons behind nonparticipation.

DISCUSSION

We are now conducting a feasibility cluster RCT in Nepal to determine the feasibility of undertaking the definitive cluster trial. The first participant was recruited on 17 July 2022. If the feasibility is promising (such as recruitment, follow-up, and adherence to the recommended ayurvedic medicine), then the parameters estimated will be used to design the definitive cluster trial. Decisions over whether to modify the protocol will mainly be informed by the qualitative data.

Compliance with Social Distancing, Face Mask and Sanitizer Use Measures against COVID -19 in Kathmandu Valley

BACKGROUND

The novel coronavirus has caused significant global impacts and is still continuing. Social distancing, the use of face mask and sanitizer (SMS) measures have become the prominent security measures to diminish the COVID-19 transmission. Hence, this study aims to assess the general public's compliance towards SMS measures set by the Government of Nepal against COVID-19 in Kathmandu Valley.

METHODS

This cross-sectional study was conducted in selected public places of Kathmandu valley, Nepal employing an observational checklist from 5-6 August 2020. The practice of using facemask and its types were observed at the individual levels (malls, groceries, shops and 30 vehicles). The practice of SMS was studied in 23 public places that included banks, hospitals, vegetable markets, shopping malls, temples, restaurants and public buses.

RESULTS

A total of 23 public places and 4502 individuals were included in the study. More than two-third (72.6%) participants were observed using mask. Among the mask users, 27% did not follow the appropriate technique. Maintaining social distance of 2 meters was less followed by the people in the public places, hospitals and public vehicles. Only 37.5% institutions had set the marking of the social distance of 2 meters. Availability of hand washing facilities with soap or sanitizer was found less in the public places.

CONCLUSIONS

Overall, the compliance measures of SMS set by the Government of Nepal against COVID-19 were not followed appropriately. Efforts are needed to improve the proper practice of using the mask and conveying the SMS message by the Nepal Government which is important step for the prevention of COVID-19 in Nepal.

Advancing Health Policy and System Research: Lessons for Resilient Health System in Nepal

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Clinical Characteristics and outcome analysis of SARS-CoV-2 patients admitted to different Critical Care Units in Nepal

BACKGROUND

The clinical presentation, biochemical characteristics, and outcomes of patients infected with SARS-CoV-2 can vary in different populations. The purpose of the study is to assess the clinical presentation and identify predictors of mortality among patients with severe acute respiratory distress syndrome admitted to different critical care units in Nepal.

METHODS

An observational study was conducted among the confirmed SARS-CoV-2 patients admitted to different critical care units in seven provinces of Nepal. Retrospective data was collected for the period of three months (April 14, 2021 to July 15, 2021) in relation to the peak of the second wave of COVID-19 pandemic in Nepal. Clinical, biochemical and mortality data were collected from the admitted patients of different critical care units. Univariate logistic regression analysis was done among the selected variables at 5% significance. Final predictor variables were identified after multiple regression analysis.

RESULTS

Out of total of 646 patients admitted to critical care units of different provinces of Nepal, there was a male predominance 420 (65%). A total of 232(35.91 %) patients were non-survivors with the majority of mortality occurring in patients > 50 years of age. Cough (72.3 %), shortness of breath (70.9%) and fever (56 %) were the most common presenting clinical features. Increasing age, presence of comorbidity, critical COVID-19 cases, respiratory rate, temperature, serum urea and alanine aminotransferase were identified as predictors of mortality after multiple regression analysis.

CONCLUSIONS

Approximately 36 % of the confirmed SARS-CoV-2 patient admitted to critical care units did not survive. There was a male preponderance with most casualties occurring in patients more than 50 years of age. Cough, shortness of breath and fever were the most common presenting features. After multiple regression analysis of the identified clinical and biochemical factors, age, presence of comorbidity, respiratory rate, temperature, severity grade as per the World Health Organization classification, serum urea and alanine aminotransferase were identified as the predictors of mortality.

Prevalence and risk factors associated with chronic kidney disease in Nepal: evidence from a nationally representative population-based cross-sectional study

OBJECTIVE

This study aimed to determine population-based prevalence of chronic kidney disease (CKD) and its associated factors in Nepal.

STUDY DESIGN

The study was a nationwide population-based cross-sectional study.

SETTING AND PARTICIPANTS

Cross-sectional survey conducted in a nationally representative sample of 12 109 Nepalese adult from 2016 to 2018 on selected chronic non-communicable diseases was examined. Multistage cluster sampling with a mix of probability proportionate to size and systematic random sampling was used for the selection of individuals aged 20 years and above.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome in this study was population-based prevalence of CKD in Nepal. A participant was considered to have CKD if the urine albumin-to-creatinine ratio was greater than or equal to 30 mg/g and/or estimated glomerular filtration rate is less than 60 mL/min/1.73 m2 at baseline and in follow-up using modification of diet in renal disease study equations. The secondary outcome measure was factors associated with CKD in Nepal. The covariate adjusted association of risk factors and CKD was calculated using multivariable binary logistic regression.

RESULTS

The overall prevalence of CKD in Nepal was 6.0% (95% CI 5.5 to 6.6). Factors independently associated with CKD included older age (adjusted OR (AOR) 2.6, 95% CI 1.9 to 3.6), Dalit caste (AOR 1.6, 95% CI 1.1 to 2.3), hypertension (AOR 2.4, 95% CI 2.0 to 3.0), diabetes mellitus (AOR 3.2, 95% CI 2.5 to 4.1), raised total cholesterol (AOR 1.3, 95% CI 1.0 to 1.6) and increased waist-to-hip ratio (AOR 1.6, 95% CI 1.2 to 2.3).

CONCLUSION

This nationally representative study shows that the prevalence of CKD in the adult population of Nepal is substantial, and it is independently associated with several cardiometabolic traits. These findings warrant longitudinal studies to identify the causes of CKD in Nepal and effective strategies to prevent it.

A Nationwide Prevalence of Common Mental Disorders and Suicidality in Nepal: Evidence from National Mental Health Survey, 2019-2020

BACKGROUND

Mental disorders account for a large portion of burden of disease. In Nepal, the prevalence of mental disorders has been rising steadily, but national and province level prevalence is not available. This study aims to assess the prevalence of common mental disorders and suicidality in Nepal.

METHODS

We conducted nationwide descriptive cross-sectional community-based prevalence study of mental disorders and suicidality among adults (aged 18 years and above) and adolescents (aged 13 to 17 years) in Nepal. We included a total of 9200 adults and 5888 adolescents from seven provinces of Nepal by using a multistage Probability Proportionate to Size sampling technique. Mental disorders and suicidality were assessed using translated and adapted Nepalese version of Mini International Neuropsychiatric Interview (MINI) for disorders, English version 7.0.2 for Diagnostic and Statistical Manual of Mental disorders,5th Edition (DSM-5). Data were entered in CSPro v7.2. Weighted estimates for different mental disorders were calculated.

RESULTS

The overall weighted lifetime prevalence of any mental disorder among adults and adolescents was estimated at 10% and 5.2%, respectively. Suicidality was present among 7.2% of the adult and 4.1% of the adolescent participants. Among adult participants, the current prevalence of suicidal thoughts and lifetime suicidal attempts were found to be 6.5% and 1.1%, respectively.

CONCLUSIONS

This survey indicated that mental health problems are major public health concerns in Nepal that should not be overlooked. Hence, a multisectoral approach is needed to address the burden of mental health problems among adults and adolescents in Nepal.

Prevalence of diabetes mellitus and associated risk factors in Nepal: findings from a nationwide population-based survey

OBJECTIVES

The burden of diabetes mellitus (DM) has increased globally, particularly in low-income and middle-income countries, including Nepal. Population-based nationally representative data on the prevalence of DM is limited. This paper presents the prevalence of DM and its associated risk factors in Nepal.

RESEARCH DESIGNS AND METHODS

This population-based study sampled 13 200 participants aged 20 years and above in 400 clusters of 72 districts of Nepal. The study used a standardised questionnaire adapted from the WHO STEPwise approach to non-communicable disease risk factor surveillance instrument and digitalised in Android-compatible mobile phones. Fasting and 2 hours postprandial blood samples were taken to test various biochemical parameters. Descriptive followed by multivariate analyses were done to assess the association between explanatory variables and the outcome variable.

PRIMARY OUTCOME MEASURES

Prevalence of DM.

RESULTS

The prevalence of DM was found to be 8.5% (95% CI 7.8% to 9.3%). The odds of DM occurrence were higher in the upper age groups (40-59 years at adjusted OR (AOR) 3.1 (95% CI2.3 to 4.2) and 60+ years at AOR 4.7 (95% CI 3.3 to 6.6)), compared with the group aged 20-39 years. Men were found to have higher odds of DM (AOR 1.3, 95% CI 1.1 to 1.6) compared with women. Urban residents had almost twice higher odds of DM (AOR 1.7, 95% CI 1.4 to 2.2) compared with rural residents. Participants with raised blood pressure (BP) (AOR 2.2, 95% CI 1.8 to 2.7), those who were overweight and obese (AOR 2.0, 95% CI 1.6 to 2.4) and those who had high triglycride level (≥150 mg/dL) (AOR 2.1, 95% CI 1.8 to 2.6) also had twice higher odds of DM compared with those with normal BP, an average body mass index and normal triglyceride level, respectively.

CONCLUSIONS

Targeted interventions to higher risk groups as well as prevention and control of other associated biological risk factors might help to reduce the prevalence of DM in Nepal.

A Comparative Study on the Recording of Temperature by Thermo- Graphic Camera, Thermal Gun and Digital Clinical Thermometer in a Tertiary Hospital of Nepal

BACKGROUND

Body Temperature is one of the most common and an important sign of health and disease. Considering the need of keeping physical distance, newer methods have evolved such as; thermal imaging systems which have been used by several countries during epidemics. Therefore, the present study was conducted to compare body temperatures obtained with thermo graphic camera and commercially available thermal gun with reference to standard digital clinical thermometer.

METHODS

The study was comparative analytical in nature and quantitative method was used to collect data. Temperatures in degrees Fahrenheit were taken simultaneously using the three different thermometers in 101 patients at the outpatient fever screening clinic at Tribhuvan University Teaching Hospital, Kathmandu. The Bland Altman statistical test was used to assess the concordance by the 95% limits of agreement.

RESULTS

The thermo-graphic camera gave concordance (limits of agreement-0.0360 to 0.0440 °F) with standard digital clinical thermometer. Similarly, commercially available thermal gun gave the concordance (limits of agreement 0.0042 to 0.1293 °F) with standard digital clinical thermometer.

CONCLUSIONS

The results of the present study show that both thermo-graphic camera and thermal gun were found to be concordant compared to digital clinical thermometer. Therefore, it could be a preferable option for the screening of fever in mass number of individuals as part of an initial check at entry points.

Prevalence and factors associated with joint pain in Nepal: findings from a countrywide cross-sectional STEPS survey

OBJECTIVE

This study aims to determine the prevalence of joint pain and its association with demographic, socioeconomic and behavioural factors in Nepal.

DESIGN

The study was a national cross-sectional population-based study.

SETTING

We used the most recent nationally representative population-based cross-sectional health survey, The WHO STEPwise approach to surveillance (STEPS) survey, 2019 from all seven provinces of Nepal including both urban and rural areas.

PARTICIPANTS

The participants were men and women aged 15-69 years, who were usual residents of the households for at least 6 months and have stayed the night before the survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome in this study was prevalence of joint pain. The secondary outcome measure was factors associated with joint pain in Nepal. Joint pain in our study was based on any self-reported symptoms of joint pain, stiffness and swelling lasting for more than 1 month in the past 12 months. Data were weighted to generate national estimates.

RESULTS

The prevalence of self-reported joint pain in Nepal was 17% (95% CI 14.3% to 20.2%) with higher prevalence for older adults, females, ever married, none/less than primary education, smoker, lowest wealth quintile, homemaker, those with sufficient physical activity and those living in the Karnali province of Nepal. In multivariable analysis self-reported joint pain was found to be associated with advanced age (adjusted OR (AOR)=2.36; 95% CI 1.56 to 3.55), sex (AOR=1.47; 95% CI 1.19 to 1.82) and sufficient physical activity (AOR=0.40; 95% CI 0.25 to 0.65).

CONCLUSIONS

The results showed a high prevalence of joint pain in Nepal. Considering the process of ageing and rapid growth in non-communicable disease, this study warrants the need for health policies directed to prevention, treatment and rehabilitation for people affected by chronic musculoskeletal conditions addressing related disabilities and loss of work in Nepal.

Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Regularly updated data on stroke and its pathological types, including data on their incidence, prevalence, mortality, disability, risk factors, and epidemiological trends, are important for evidence-based stroke care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) aims to provide a standardised and comprehensive measurement of these metrics at global, regional, and national levels.

METHODS

We applied GBD 2019 analytical tools to calculate stroke incidence, prevalence, mortality, disability-adjusted life-years (DALYs), and the population attributable fraction (PAF) of DALYs (with corresponding 95% uncertainty intervals [UIs]) associated with 19 risk factors, for 204 countries and territories from 1990 to 2019. These estimates were provided for ischaemic stroke, intracerebral haemorrhage, subarachnoid haemorrhage, and all strokes combined, and stratified by sex, age group, and World Bank country income level.

FINDINGS

In 2019, there were 12·2 million (95% UI 11·0-13·6) incident cases of stroke, 101 million (93·2-111) prevalent cases of stroke, 143 million (133-153) DALYs due to stroke, and 6·55 million (6·00-7·02) deaths from stroke. Globally, stroke remained the second-leading cause of death (11·6% [10·8-12·2] of total deaths) and the third-leading cause of death and disability combined (5·7% [5·1-6·2] of total DALYs) in 2019. From 1990 to 2019, the absolute number of incident strokes increased by 70·0% (67·0-73·0), prevalent strokes increased by 85·0% (83·0-88·0), deaths from stroke increased by 43·0% (31·0-55·0), and DALYs due to stroke increased by 32·0% (22·0-42·0). During the same period, age-standardised rates of stroke incidence decreased by 17·0% (15·0-18·0), mortality decreased by 36·0% (31·0-42·0), prevalence decreased by 6·0% (5·0-7·0), and DALYs decreased by 36·0% (31·0-42·0). However, among people younger than 70 years, prevalence rates increased by 22·0% (21·0-24·0) and incidence rates increased by 15·0% (12·0-18·0). In 2019, the age-standardised stroke-related mortality rate was 3·6 (3·5-3·8) times higher in the World Bank low-income group than in the World Bank high-income group, and the age-standardised stroke-related DALY rate was 3·7 (3·5-3·9) times higher in the low-income group than the high-income group. Ischaemic stroke constituted 62·4% of all incident strokes in 2019 (7·63 million [6·57-8·96]), while intracerebral haemorrhage constituted 27·9% (3·41 million [2·97-3·91]) and subarachnoid haemorrhage constituted 9·7% (1·18 million [1·01-1·39]). In 2019, the five leading risk factors for stroke were high systolic blood pressure (contributing to 79·6 million [67·7-90·8] DALYs or 55·5% [48·2-62·0] of total stroke DALYs), high body-mass index (34·9 million [22·3-48·6] DALYs or 24·3% [15·7-33·2]), high fasting plasma glucose (28·9 million [19·8-41·5] DALYs or 20·2% [13·8-29·1]), ambient particulate matter pollution (28·7 million [23·4-33·4] DALYs or 20·1% [16·6-23·0]), and smoking (25·3 million [22·6-28·2] DALYs or 17·6% [16·4-19·0]).

INTERPRETATION

The annual number of strokes and deaths due to stroke increased substantially from 1990 to 2019, despite substantial reductions in age-standardised rates, particularly among people older than 70 years. The highest age-standardised stroke-related mortality and DALY rates were in the World Bank low-income group. The fastest-growing risk factor for stroke between 1990 and 2019 was high body-mass index. Without urgent implementation of effective primary prevention strategies, the stroke burden will probably continue to grow across the world, particularly in low-income countries.

FUNDING

Bill & Melinda Gates Foundation.

Experience of Treating COVID-19 With Remdesivir and Convalescent Plasma in a Resource-Limited Setting: A Prospective, Observational Study

Background

Convalescent plasma therapy (CPT) and remdesivir (REM) have been approved for investigational use to treat coronavirus disease 2019 (COVID-19) in Nepal.

Methods

In this prospective, multicentered study, we evaluated the safety and outcomes of treatment with CPT and/or REM in 1315 hospitalized COVID-19 patients over 18 years in 31 hospitals across Nepal. REM was administered to patients with moderate, severe, or life-threatening infection. CPT was administered to patients with severe to life-threatening infections who were at high risk for progression or clinical worsening despite REM. Clinical findings and outcomes were recorded until discharge or death.

Results

Patients were classified as having moderate (24.2%), severe (64%), or life-threatening (11.7%) COVID-19 infection. The majority of CPT and CPT + REM recipients had severe to life-threatening infections (CPT 98.3%; CPT + REM 92.1%) and were admitted to the intensive care unit (ICU; CPT 91.8%; CPT + REM 94.6%) compared with those who received REM alone (73.3% and 57.5%, respectively). Of 1083 patients with reported outcomes, 78.4% were discharged and 21.6% died. The discharge rate was 84% for REM (n = 910), 39% for CPT (n = 59), and 54.4% for CPT + REM (n = 114) recipients. In a logistic model comparing death vs discharge and adjusted for age, gender, steroid use, and severity, the predicted margin for discharge was higher for recipients of remdesivir alone (0.82; 95% CI, 0.79–0.84) compared with CPT (0.58; 95% CI, 0.47–0.70) and CPT + REM (0.67; 95% CI, 0.60–0.74) recipients. Adverse events of remdesivir and CPT were reported in <5% of patients.

Conclusions

This study demonstrates a safe rollout of CPT and REM in a resource-limited setting. Remdesivir recipients had less severe infection and better outcomes.

ClinicalTrials.gov identifier. NCT04570982.

Prevalence of non-communicable diseases risk factors and their determinants: Results from STEPS survey 2019, Nepal

Background

The World Health Organization (WHO) recommends ongoing surveillance of non-communicable diseases (NCDs) and their risk factors, using the WHO STEPwise approach to surveillance (STEPS). The aim of this study was to assess the distribution and determinants of NCD risk factors in Nepal, a low-income country, in which two-thirds (66%) of annual deaths are attributable to NCDs.

Methods

A nationally representative NCD risk factors STEPS survey (instrument version 3.2), was conducted between February and May 2019, among 6,475 eligible participants of age 15–69 years sampled from all 7 provinces through multistage sampling process. Data collection involved assessment of behavioral and biochemical risk factors. Complex survey analysis was completed in STATA 15, along with Poisson regression modelling to examine associations between covariates and risk factor prevalence.

Results

The most prevalent risk factor was consumption of less than five servings of fruit and vegetables a day (97%; 95% CI: 94.3–98.0). Out of total participants, 17% (95% CI: 15.1–19.1) were current smoker, 6.8% (95% CI: 5.3–8.2) were consuming ≥60g/month alcohol per month and 7.4% (95% CI:5.7–10.1) were having low level of physical activity. Approximately, 24.3% (95% CI: 21.6–27.2) were overweight or obese (BMI≥25kg/m²) while 24.5% (95% CI: 22.4–26.7) and 5.8% (95% CI: 4.3–7.3) had raised blood pressure (BP) and raised blood glucose respectively. Similarly, the prevalence of raised total cholesterol was 11% (95% CI: 9.6–12.6). Sex and education level of participants were statistically associated with smoking, harmful alcohol use and raised BP. Participants of age 30–44 years and 45–69 years were found to have increased risk of overweight, raised BP, raised blood sugar and raised blood cholesterol. Similarly, participants in richest wealth quintile had higher odds of insufficient physical inactivity, overweight and raised blood cholesterol. On average, each participant had 2 NCD related risk factors (2.04, 95% CI: 2.02–2.08).

Conclusion

A large portion of the Nepalese population are living with a variety of NCD risk factors. These surveillance data should be used to support and monitor province specific NCD prevention and control interventions throughout Nepal, supported by a multi-sectoral national coordination mechanism.

Pharmacological Treatment for the Management of COVID 19: A Narrative Review

Severe acute respiratory syndrome coronavirus 2 infections are alarming worldwide incurring tremendous loss of life and possession. Individuals are facing a terrible pandemic condition in the absence of appropriate medicines to combat severe acute respiratory syndrome coronavirus 2 infections. This review aimed to provide details on pharmacological treatment measures that were adopted to fight COVID 19 pandemic globally including Nepal. A massive review was performed including 110 articles from the relevant field. Preliminary results on the efficacy of some existing antiviral agents were found, however, promising data on effective treatment regimen for COVID 19 are yet to be obtained. This review examines various drugs, their mechanism of actions and vaccines which are currently being used in clinical trials or are recommended for use in COVID 19 infection.

Differences in cancer incidence and pattern between urban and rural Nepal: one-year experience from two population-based cancer registries

Variations in cancer incidence, mortality and pattern exist in rural and urban areas. Understanding these differences helps in developing targeted cancer prevention and control strategies. However, no previous studies have explored the differences in cancer demographics between the rural and urban areas of Nepal. The data of Kathmandu Valley (urban area) Population-Based Cancer Registry (PBCR) and Rukum (rural area) PBCR were analysed to identify the differences in cancer pattern in rural and urban areas. The age-adjusted incidence rate (AAR) in Kathmandu was higher than that in Rukum (1.6 times among males and 1.9 times among females). The top two leading sites in males were lungs and stomach in both the regions; however, the rates were higher in Kathmandu. The incidence rate for cancer of the urinary bladder among males in Kathmandu was particularly higher - 4.4 times that of Rukum. In females, the leading site of cancer in Kathmandu was breast, which was eight times higher compared to Rukum, whereas the incidence rate of cervix cancer in Kathmandu is 30% less than in Rukum. The incidence of tobacco-related cancer was found to be higher in Kathmandu compared to Rukum. These findings reveal the need for different policy priorities for cancer control in the urban versus rural regions of Nepal, based on the different demographics of cancer in the two areas. Similar studies from other regions of Nepal are needed to develop a targeted cancer control strategy.

Ethical Characteristics of Research Proposals Related to COVID-19 Pandemic in Nepal: A Retrospective Review

BACKGROUND

Public health emergency is vulnerable time where maintaining ethical principles is obligatory while doing research, on the other hand, it is the same time when breach in ethics is much likely whenever a researcher is unaware, unprepared or hastens to do research. The aim of this study was to assess ethical issues of the coronavirus disease 2019 (COVID-19) related research proposals submitted during the early stages of pandemic in Nepal.

METHODS

Retrospective analysis of COVID-19 related research proposals and their informed consent document submitted to the ethical review board at Nepal Health Research Council was done for the study. The analysis was done as per the National Ethical Guidelines, Standard Operating Procedure for Health Research in Nepal and World Health Organization guidelines for infectious disease outbreak, 2016 under ethically relevant headings. Descriptive data were analyzed in SPSS v24.

RESULTS

The major issues were observed in the informed consent documents where 55% were lacking principal investigator's contact information, 68% not having participant selection criteria, 70% without clear informed consent taking process, 57% without explanation of possible risks. Similarly, 68% of the interventional studies' consent form didn't mention possible adverse events and mitigation mechanisms.

CONCLUSIONS

Most of the research proposals related to COVID-19 were devoid of major ethical elements which took longer time for receiving approval and eventually delayed the opportunity for evidence generation in critical time. More attention is needed to increase awareness and to develop capacity of researchers, reviewers, ethics committees and relevant stakeholders at the time of health emergencies.

Assessment of Preparedness of Government of Nepal in COVID Designated Hospitals and Clinics for Pandemic Response

BACKGROUND

Preparedness, readiness, and response status of any country is integral in identifying, managing, and preventing COVID-19 pandemic. The objective of this study is to assess the status of the Government of Nepal designated COVID hospitals and COVID clinics to respond against COVID-19.

METHODS

A cross sectional study was conducted with the focal persons of COVID hospitals and COVID clinics using a semi-structured questionnaire from April 26, 2020 to May 27, 2020 via face to face interview with onsite observation and telephonic interview in few unreachable health facilities.  Results: Government of Nepal designated COVID hospitals and COVID clinics demonstrated efforts in establishing preparedness plans and committees such as COVID management core team (96.7% and 86%), provision of coordination with the government authority (both 100% ), preparedness response plan (93.3% and 84%), and infection prevention and control committee (63.3% and 65.6%) to respond to COVID-19 respectively. The participants reported differences in training provided to their health care workers with maximum COVID hospitals (80%) providing training on use of personal protective equipment and least (43.3%) on handling dead bodies. Only half of the COVID clinics (49.5%) had provision of triage systems.

CONCLUSIONS

COVID hospitals and COVID clinics in Nepal demonstrated different status of COVID pandemic preparedness and readiness. In case of surge, Nepalese hospitals would struggle due to lack of trained workforce and infrastructure.  Interdisciplinary, multi-sectoral collaboration with various focused strategies, including in-service training to staff, is paramount to increase preparedness and readiness.  Keywords: COVID-19; Nepal; preparedness; readiness.

Prescribers Perception on Drug Promotional Literatures in A Tertiary Care Hospital in Nepal

BACKGROUND

Drug promotional literatures can often be misleading and have biased information and can contribute to irrational use of medicines. Thus, it is necessary that prescribers critically analyze the drug promotional literatures presented to them. This study attempts to understand if the prescribers at Tribhuvan University Teaching Hospital are aware about the necessary information that should be present in a drug promotional literature.

METHODS

A descriptive cross-sectional study was conducted over six months in which prescribers at Tribhuvan University Teaching Hospital were provided with the self-administered questionnaire and were requested to submit the filled in questionnaire. Prescribers presently working at Tribhuvan University Teaching Hospital, attending out patient department services and had received drug promotional literatures within last six months were included in this study.

RESULTS

During the study, 163 of the received questionnaires met the inclusion criteria and were utilized for analysis. Advertisement, reminder items and others type of drug promotional literatures were commonly received by prescribers included in our study. Higher proportion of faculties (35.29%) preferred reprint type of drug promotional literatures. Most of the participants (47.85%) searched for 5-8 WHO-Ethical Criteria for Medicinal Drug Promotion criteria when referring a drug promotional literature. It was seen that 42.94% of prescribers realised that at least two out of four types of information related to negative attribute of the promoted medicines were missing.

CONCLUSIONS

The prescribers with least duration of clinical exposure are more likely to always prescribe the medicines promoted to them. Prescribers were more confident on claims made in drug promotional literatures if they were supported using scientific evidences.

Factors Associated with Chronic Obstructive Pulmonary Diseases in Nepal: Evidence from a Nationally Representative Population-Based Study

Background

The Global Burden of Diseases Study 2017 predicted that chronic obstructive pulmonary disease (COPD) is the second leading cause of death, the fourth leading cause of premature death, and the third cause for DALYs lost in Nepal. However, data on the population-based prevalence of COPD in Nepal are very limited. This study aims to assess the prevalence of COPD and factors associated with the occurrence of COPD in Nepal.

Methods

From a nationally representative, population-based cross-sectional study on chronic non-communicable diseases, the prevalence of COPD and its associated factors was determined. Of 12,557 participants aged over 20 years, 8945 participants completed a questionnaire and spirometry. Eligible participants were also asked to answer a COPD diagnostic questionnaire for screening COPD cases, and if needed underwent pre-bronchodilator and post-bronchodilator spirometry. COPD was defined as a post-bronchodilator FEV1/FVC (forced expiratory volume in 1 s/forced vital capacity) ratio of <0.70. Multivariate logistic regression was performed to identify factors associated with COPD. Sampling weights were used for all data analyses.

Results

The prevalence of COPD in Nepal was 11.7% (95% CI: 10.5% to 12.9 %), which increased with age, and higher in those with a low educational level, those who had smoked ≥50 pack-years, persons having a low body mass index (BMI), and residents of Karnali province. Multivariate analysis revealed that being aged 60 years and above, having a low BMI, low educational status, having smoked more than 50 pack-years, provincial distribution, and ethnicity were independent predictors of COPD.

Conclusion

COPD is a growing and serious public health issue in Nepal. Factor such as old age, cigarette smoking, low educational attainment, low BMI, ethnicity, and locality of residence (province-level variation) plays a vital role in the occurrence of COPD. Strategies aimed at targeting these risk factors through health promotion and education interventions are needed to decrease the burden of COPD.

Whole Genome Sequence Analysis to Identify SARS-CoV-2 Variant in Nepal

Background The spread of SARS-CoV-2 has become a global public health crisis. Nepal is facing the second wave of COVID-19 pandemic but, there is still a limited data on the genomic sequence of SARS-CoV-2 variants circulating in Nepal. Objective The objective of this study is to sequence the whole genome of SARS-CoV-2 in Nepal to detect possible mutation profiles and phylogenetic lineages of circulating SARSCoV-2 variants. Method In this study, swab samples tested positive for SARS-CoV-2 were investigated. After RNA extraction, the investigation was performed through real-time PCR followed by whole genome sequencing. The consensus genome sequences were, then, analyzed with appropriate bioinformatics tools. Result Sequence analysis of two SARS-CoV-2 genomes from patient without travel history (Patient A1 and A2) were found to be of lineage B.1.1. Similarly, among other four samples from subjects returning from the United Kingdom, genomes of two samples were of lineage B.1.36, and the other two were of lineage B.1.1.7 (Alpha Variant). The mutations in the consensus genomes contained the defining mutations of the respective lineages of SARS-CoV-2. Conclusion We confirmed two genomic sequences of variant of concern VOC-202012/01 in Nepal. Our study provides the concise genomic evidence for spread of different lineages of SARS-CoV-2 - B.1.1, B.1.36 and B.1.1.7 of SARS-CoV-2 in Nepal.

Combination of convalescent plasma therapy and repurposed drugs to treat severe COVID-19 patient with multimorbidity

Combination of convalescent plasma therapy and repurposed drugs such as dexamethasone and remdesivir could be beneficial for severe COVID-19 patients with obesity and chronic diseases such as diabetes and hypertension.

Quality of Drug in Health Facilities: A Cross-sectional Study

BACKGROUND

Poor quality drugs result minor to detrimental effect on human health. The drug should be of standard quality and should be used appropriately in order to meet its therapeutic efficacy. This study aims to assess the quality of drug in Nepal.

METHODS

A cross sectional study was conducted in randomly selected 88 health facilities in Nepal from 10th April to 30th June 2016. Selective medicines were collected from both private licensed pharmacies and selected public health facilities. Face to face interview with health facility in-charge of selected health facilities was carried out along with the direct observation of the medicine storage room. The collected medicine samples were dispatched to two laboratories for in-vitro analysis. The labels of the collected medicine were analyzed. The obtained data were entered in Epidata version 3.1, cleaned in Microsoft excel 2007 and analyzed in SPSS version 20.

RESULTS

Out of 172 brands, nine brands of medicines were found substandard. Information regarding storage conditions, direction for use and category of the drug were lacking in the label of some brands of medicines. Some selected health facilities were found not meeting major requirements for drug storage: protection from sunlight, moisture, heat, well ventilation and proper sanitation.

CONCLUSIONS

Few drugs were found to be substandard in Nepalese market from both public and private sectors. Adequate labeling and proper storage condition of medicines in health facilities were lacking.

Trend and Patterns of Research Proposals Submitted for Ethical Review in Nepal Health Research Council

BACKGROUND

The characteristics of research proposals submitted to the Nepal Health Research Council reflect the trend of health-related researches being conducted in Nepal. The objective of the study was to analyze research proposals submitted for the ethical review in Nepal Health Research Council from 2017 to 2019.

METHODS

A retrospective record review of research proposals received over three years from 2017 to 2019 were analyzed. A total of 2,305 research proposals was included in the study. The number of research studies per year, types of study design, priority area of research, and rejected proposal were the intended variables for the study.

RESULTS

91.45% (503), 92.19% (748), and 755 (80.1%) of received proposals were approved from Ethical Review Board in 2017, 2018 and 2019. The number of research proposals increased every year (550 in 2017, 812 in 2018, and 943 in 2019). Among the approved proposals non-communicable disease (n=150;15.90%) in 2019} was the topmost prioritized area in all three years followed by reproductive health [93 (9.86%) in 2019] and communicable disease [67 (7.10%) in 2019] respectively. Quantitative research was more than two-third in all the years. Among the approved proposals, more than half were for an academic purpose [610 (64.69%)]. The reason for the rejection of the proposal was the conduction of research before ethical approval [2 (0.36%) in 2017, 2 (0.25%) in 2018, and none in 2019].

CONCLUSIONS

There was a rising trend of research proposals for ethical clearance being submitted to the Nepal Health Research Council. Research related to non-communicable disease followed by reproductive health was the commonest one.

Barriers and facilitators to the implementation of a national multisectoral action plan for the prevention and control of noncommunicable diseases in Nepal: perspectives of stakeholders

BACKGROUND

Nepal adopted the Multisectoral Action Plan for the Prevention and Control of Non-Communicable Diseases (MSAP) in 2014. Implementation of the plan has been challenging, with limited participation from non-health sectors.

OBJECTIVES

The overall aim of the study was to gain the perspectives of key stakeholders involved in the Nepal MSAP on the barriers and facilitators to its implementation, through the participation of relevant sectors in the plan.

METHODS

We held face-to-face semi-structured interviews with 12 stakeholders working in sectors involved in the MSAP. These sectors included the Office of the Prime Minister and Council of Ministries; Ministry of Health and Population (MOHP); Ministry of Education, Science and Technology; Ministry of Forest and Environment; academia; and professional organizations. Thematic analysis of transcripts was used to identify themes on awareness of NCDs, awareness of the MSAP, and barriers and facilitators to participation in the MSAP.

RESULTS

Participants recognised NCDs as a growing and major burden in Nepal. However, a number of participants were not familiar with the MSAP, identifying a lack of leadership and poor dissemination. Political and systemic transformation, since the adoption of the MSAP, was seen as a key barrier to implementation. International commitments to develop multisectoral action made by the Government of Nepal were identified as drivers. The recent establishment of a separate section for NCDs and Mental Health within the Department of Health Services of MOHP and the promotion of a Health in All Policies (HiAP) approach in recent national documents, were both considered to support implementation.

CONCLUSIONS

The establishment of permanent multisectoral or multistakeholder mechanisms has been challenging despite strong political calls for their development. Moving beyond 2020, multisectoral action plans should engage with stakeholders from federal, provincial and local governments in order to develop costed action plans with specific roles and responsibilities for each sector.

Professional Quality of Life among Medical Doctors Working in Kathmandu: A Descriptive Cross-sectional Study

INTRODUCTION

The practice of medicine is an honorable profession besides being accompanied by a demanding environment. This study aimed to find out the professional quality of life of medical doctors working in Kathmandu valley.

METHODS

A descriptive cross-sectional study was conducted among 174 Nepalese medical doctors working in different hospitals of Kathmandu valley. Ethical approval was taken from the Ethical Review Board of the Nepal Health Research Council (Reference Number: 830). The data collection tool used in the study was WHO Professional Quality of Life Scale-5 to collect data about Compassion satisfaction, Burnout and Secondary traumatic stress among medical doctors working in Kathmandu valley. Data analysis was done in the Statistical Package for the Social Sciences version 16.0.

RESULTS

Out of 174 participants, 101 (58%), 126 (72.4%) and 135 (77.6%) were found to have moderate level of Compassion satisfaction, Burnout and Secondary Traumatic Stress respectively.

CONCLUSIONS

More than half, nearly two-third, and more than two-third participants had moderate levels of Compassion satisfaction, Burnout and Secondary Traumatic Stress respectively. The overall study findings reflected good balance between Compassion satisfaction and Compassion fatigue (burnout and secondary traumatic stress) among the Nepalese medical doctors. Further assessment of professional quality of life of doctors as well as other health care workers via Multifaceted and large-scale study is recommended.

Medicine Prescribing Pattern and Knowledge on Medicine Use at Different Level of Health Care Settings in Nepal

BACKGROUND

It is imperative to have adequate knowledge about medicines being used for their proper administration so as to obtain desirable therapeutics effects. This study aims to assess the medicine prescribing pattern and patients' knowledge about medicine use at different level of health care settings in Nepal.

METHODS

A cross sectional study was conducted in randomly selected 88 health facilities in Nepal. Altogether 2200 patients, taken randomly after the doctor visit, were interviewed and assessed for the prescription.

RESULTS

Out of total drugs prescribed from 88 health facilities (6,175), 68.91% were essential drugs, 23.74 % were antibiotics and 61 % of medicines were prescribed in generic names. And among patients receiving medicines, adequate response on medicine use was received on 49% of medicines out of 3,806 medicines dispensed.

CONCLUSIONS

Greater percentages of medicines were prescribed from essential drug list in health facilities. Knowledge on medicine use was poor among people.

Gender Disaggregation in COVID-19 and Increased Male Susceptibility

Novel coronavirus disease 2019 (COVID-19) is a growing public health crisis. Despite initial focus on the elderly population with comorbidities, it seems that large studies from the worst affected countries follow a sex-disaggregation pattern. Analysis of available data showed marked variations in reported cases between males and females among different countries with higher mortality in males.  At this early stage of the pandemic, medical datasets at the individual level are not available; therefore, it is challenging to conclude how different factors have impacted COVID-19 susceptibility. Thus, in the absence of patients' level data, we attempted to provide a theoretical description of how other determinants have affected COVID-19 susceptibility in males compared to females.  In this article, we have identified and discussed possible biological and behavioral factors that could be responsible for the increased male susceptibility. Biological factors include - an absence of X-chromosomes (a powerhouse for immune-related genes), a high level of testosterone that inhibits antibody production, and the presence of Angiotensin-converting enzyme 2 (ACE2) receptors that facilitate viral replication. Similarly, behavioral factors constitute - higher smoking and alcohol consumptions, low level of handwashing practices, and high-risk behavior like non-adherence to health services and reluctance to follow public health measures in males. Keywords: COVID-19; gender; males; sex disaggregation; susceptibility.

Research during COVID-19 Pandemic: Perspectives from the Ethics Committees of a Lower Middle Income Country

The pandemic of Coronavirus Disease 2019 (COVID-19) has created paradoxically a good opportunity globally to conduct research in the field of health and social science, and a Lower Middle-Income Country (LMIC) like Nepal is not an exception in this regard. During this ongoing pandemic, the Ethical Review Board (ERB) of Nepal Health Research Council (NHRC) has received numerous research proposals regarding COVID-19. As its main responsibility is to ensure participants' safety, at the same time maintaining the scientific standard of research, the ERB has meticulously gone through all the proposals received so far. During this situation of a health emergency, the ERB of NHRC has had a different experience compared to the usual time. Its strength, weakness, opportunities, and threats have been like never before.

Age and Gender Differences in COVID 19 Morbidity and Mortality in Nepal

Background The global health community has emphasized the importance of reporting epidemiological data by age and sex groups in the COVID-19 pandemic. However, age and sex disaggregated data of COVID-19 cases and deaths are rarely reported. Such data are very crucial for public to make truly informed choices about their own diseases risk and also for governments for public policy response. Objective To assess age and gender difference among COVID-19 cases and deaths in Nepal. Method This is a retrospective study which uses public data on COVID-19 cases and deaths released by Ministry of Health and Population, Government of Nepal from January to November, 2020. The data analysis was carried out using SPPS software version 26. Result Nepal reported 233,452 confirmed cases and 1,566 deaths of COVID-19 from 23 January 2020 to 30 November 2020. We found statistically significant differences on COVID-19 cases by age and gender in Nepal with higher number of cases among males of economically active age groups (20-60 years). Similarly, we found significant difference in COVID-19 mortality with more death occurred among male group compared to female group and with highest number of deaths among the people of above 60 years. Furthermore, we found differences in cases and deaths among provinces. Conclusion The age and gender differences in COVID cases and deaths in Nepal indicates needs of considering age and sex groups seriously while planning for testing, case management and vaccination against COVID-19 infections in Nepal.

Working Towards a Framework for Governing Health Research in Nepal

Health research activities have advanced considerably in Nepal over the past several years. However, stakeholders' confidence on scientific community is shaken as the latter failed occasionally in adhering to ethical principles. Nepal Health Research Council has exercised regulatory authority to control and support research works. However, much more is needed given the scale at which studies are being carried out. It is high time to conduct an analysis of the current situation followed by the development of an overarching framework to strengthen health research that facilitates a range of actions along the continuum of identifying information needs to translation of knowledge into policies and practices for ultimately improving people's health. Keywords: Ethics; health research systems; knowledge management; research regulation.

Safety and Efficacy of Different Therapeutic Interventions on Prevention and Treatment of COVID-19

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the strain of coronavirus that causes coronavirus disease 2019 (COVID-19), a respiratory illness. COVID-19 has now become a global public health crisis causing alarming numbers of morbidity and mortality. Ever since the COVID-19 pandemic started scientists, researchers, universities, companies, and institutions all around the world have been endeavoring to discover a potential treatment for COVID-19. Numerous studies and clinical trials on vaccines and drugs for the prevention and treatment of COVID-19 are underway across the world. However, the uncertainty around the efficacy and safety of various treatment regimens have become one of the biggest challenges in the battle against the SARS-CoV-2. This paper is a narrative review of articles regarding the various treatments and vaccines being tested for the SARS-CoV-2, available in the PubMed database along with Google Scholar. There are ongoing clinical trials on potential drugs such as remdesivir, favipiravir, lopinavir/ritonavir, chloroquine, and hydroxychloroquine, corticosteroids tocilizumab, azithromycin, anakinra, etc. and other therapeutic modalities like convalescent plasma therapy. Likewise, vaccines against SARS-CoV-2 are being developed and tested, including mRNA, non-replicating viral vector, DNA, protein subunit candidate vaccines, etc. Although some early-stage clinical trials and studies on these drugs and vaccines have shown positive results, definitive and conclusive results are yet to be obtained. Keywords: COVID-19; antiviral drugs; COVID-19 treatment; COVID-19 vaccine; SARS-CoV-2.

Addressing Emerging Public Health Issues through Interdisciplinary Research

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Let Us Fight Together against COVID-19 Pandemic

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Causality Assessment of Adverse Drug Reaction Using Naranjo Probability Scale: A Retrospective Study

Introduction: Globally, Adverse Drug Reaction (ADR) has been listed as the sixth leading causes of death. Recognition of ADR and establishment of relationship of drug with the symptom is the first step to the management of the problem. In this study, Naranjo algorithm has been used which is one of the most accepted tools for the assessment of causality of ADR with the suspected drug. Methods: A retrospective descriptive study was done which included 35 reported cases of ADRs in Drug Information Unit (DIU) in tertiary care teaching institute of Nepal from Dec 2015 to Oct 2016. Based on the information in the reported ADRs forms, categorisation was done using Naranjo’s ADR Probability scale. The data was analysed using SPSS version 16.0 and descriptive statistics was used. Results: It was seen that ADRs were more common in male (n=20) as compared to female (n=15). Amongst male, ADRs were more common in age group 50-75 years (n=8). ADRs were most commonly seen with antimicrobial agents (40%) followed by Non-Steroidal Anti-inflammatory Drugs (NSAIDs) (20%) and immunosuppressants (20%). Within the antimicrobial agents, anti-tubercular drugs (20%) contributed the most in ADRs and hepatotoxicity was the most common ADR seen. Majority of ADRs were categorised under possible (n=29) followed by probable (n=6). Conclusions: Naranjo algorithm could be a useful tool for causality assessment of ADR which can help physicians to guide the therapy.

Evaluation of aloe vera leaves extract in streptozotocin- induced diabetic nephropathy in rat

Having an anti-diabetic activity, Aloe Vera (Aloebarbadensis) has been used for medicinal purposes in several cultures for millennia. It has also been proved that aloe vera is having protective activity in nephrotoxic rats.The objective of the pres­ent study was to evaluate the effect of Aloe vera leaves extract on diabetic nephropathy in Streptozotocin-induced diabetic rat. Diabetes was induced by Streptozotocin(60 mg/kg-i.p.). Four weeks later rats were randomly selected and divided into 5 groups (n=6). Group I: normal control. Group II: diabetic nephropathy (DN) control. Group III: DN+AVE (250 mg/ kg). Group IV: DN+AVE (500 mg/kg). Group V: DN+AMG (1 mg/1ml in drinking water). The treatment was given for 8 weeks. Various parameters like physiological, antidiabetic, renal function, antioxidants and histopathology were measured. Administration of aloe vera extract showed significant decrease in body weight, food and water intake, kidney weight, blood glucose level, serum creatinine, BUN, protein in urine, serum uric acid and lipid peroxidation. It also significantly increases the plasma insulin level, liver glycogen content, urine volume, GFR, SOD, catalase, Reduced glutathione. Histopathologi­cal studies confirmed that administration of AVE prevented kidney damage, which provided structural support for the renal shielding effect. The significant effect of aloe vera extract on diabetic nephropathy could be due to the inherent antihy­perglycemic, antioxidant, improvement of renal function parameters. In the near future AVE could constitute a lead to the discovery of a novel drug for the treatment of diabetic nephropathy.

Surveillance of Quality of Medicines Available in the Nepalese Market: A Study from Kathmandu Valley

BACKGROUND

Many countries are having problem of substandard and counterfeit drugs which results in life threatening issues, financial loss of consumers and loss in trust on health system. This study is concerned with the assessment of drugs quality available in the Nepalese market.

METHODS

A cross sectional survey was carried out in Kathmandu valley. Five different brands from each eight molecules of drugs (Paracetamol tablet, Cloxacillin capsule, Amlodipine tablet, Metformin tablet, Losartan tablet, Cefixime tablet, Ofloxacin tablet, Carbamazepine tablet) were purposively selected. Registration compliance was verified from Department of Drug Administration (DDA) and laboratorial analysis was done in two different laboratories.

RESULTS

Out of 40 drug samples, 90% did not comply with the existing regulatory requirement on labeling and 42.5% brands did not mention about the pharmacopoeial standard. There was no uniformity in mentioning the selflife. Similarly, large variation was seen on price of same generic drugs. Laboratory analysis showed that 40% samples failed to meet the standard among domestic companies and 28% among imported brands. Altogether 32.5% samples were found to be of substandard quality. Only the result of one sample matched with both laboratories. This indicates that there was variation in the selected two laboratories.

CONCLUSIONS

The result of this survey indicates that, substandard medicines are available in Nepalese market. Moreover, there is weak regulation and no uniformity in similar pharmaceutical products. A larger study is required to access the quality of pharmaceutical products in the Nepalese market with testing of products in more than two independent laboratories.