Molecular and Entomological Characterization of 2023 Dengue Outbreak in Dhading District, Central Nepal

In 2023, Nepal faced its second largest dengue outbreak ever, following a record-breaking number of dengue cases in 2022, characterized by the expansion of infections into areas of higher altitudes. However, the characteristics of the 2023 circulating dengue virus (DENV) and the vector density remain poorly understood. Therefore, we performed DENV serotyping, clinical and laboratory assessment, and entomological analysis of the 2023 outbreak in central Nepal. A total of 396 fever cases in Dhading hospital suspected of being DENV positive were enrolled, and blood samples were collected and tested by different techniques including PCR. Of these, 278 (70.2%) had confirmed DENV infection. Multiple serotypes (DENV-1, -2, and -3) were detected. DENV-2 (97.5%) re-emerged after six years in Dhading while DENV-3 was identified for the first time. Dengue inpatients had significantly higher frequency of anorexia, myalgia, rash, diarrhea, nausea, vomiting, abdominal pain, and thrombocytopenia (p < 0.05). In this area, Aedes mosquitoes largely predominated (90.7%) with the majority being A. aegypti (60.7%). We also found high levels of Aedes index (20.0%) and container index (16.7%). We confirmed multiple DENV serotype circulation with serotype re-emergence and new serotype introduction, and high vector density in 2023. These findings call for the urgent initiation and scaling up of DENV molecular surveillance in human and mosquito populations for dengue control and prevention in Nepal.

Possible high risk of transmission of the Nipah virus in South and South East Asia: a review

Nipah virus (NiV) is a zoonotic, single-stranded RNA virus from the family Paramyxoviridae, genus Henipavirus. NiV is a biosafety-level-4 pathogen that is mostly spread by Pteropus species, which serve as its natural reservoir host. NiV is one of the major public health challenges in South and South East Asia. However, few molecular studies have been conducted to characterise NiV in a specific region. The main objective of this review is to understand the epidemiology, pathogenesis, molecular surveillance, transmission dynamics, genetic diversity, reservoir host, clinical characteristics, and phylogenetics of NiV. South and South East Asian nations have experienced NiV outbreaks. Phylogenetic analysis confirmed that two primary clades of NiV are in circulation. In humans, NiV causes severe respiratory illness and/or deadly encephalitis. NiV is mainly diagnosed by ELISA along with PCR. Therefore, we recommend that the governments of the region support the One Health approach to reducing the risk of zoonotic disease transmission in their respective countries.

Co-Circulation of Dengue Virus Serotypes 1, 2, and 3 during the 2022 Dengue Outbreak in Nepal: A Cross-Sectional Study

The largest dengue outbreak in the history of Nepal occurred in 2022, with a significant number of casualties. It affected all 77 districts, with the nation's capital, Kathmandu (altitude 1300 m), being the hardest hit. However, the molecular epidemiology of this outbreak, including the dengue virus (DENV) serotype(s) responsible for this epidemic, remain unknown. Here, we report the epidemic trends, clinico-laboratory features, and virus serotypes and their viral load profiles that are associated with this outbreak in Nepal. Dengue-suspected febrile patients were investigated by routine laboratory, serological, and molecular tools, including a real-time quantitative polymerase chain reaction (qRT-PCR). Of the 538 dengue-suspected patients enrolled, 401 (74.5%) were diagnosed with dengue. Among these dengue cases, 129 (32.2%) patients who required hospital admission had significant associations with myalgia, rash, diarrhea, retro-orbital pain, bleeding, and abdominal pain. DENV-1, -2, and -3 were identified during the 2022 epidemic, with a predominance of DENV-1 (57.1%) and DENV-3 (32.1%), exhibiting a new serotype addition. We found that multiple serotypes circulated in 2022, with a higher frequency of hospitalizations, more severe dengue, and more deaths than in the past. Therefore, precise mapping of dengue and other related infections through integrated disease surveillance, evaluation of the dynamics of population-level immunity and virus evolution should be the urgent plans of action for evidence-based policy-making for dengue control and prevention in the country.

Forty years (1980-2019) of visceral leishmaniasis in Nepal: trends and elimination challenges

BACKGROUND

Visceral leishmaniasis (VL) is an important re-emerging neglected tropical disease associated with poverty. Despite the elimination initiative started in 2005, VL cases have been expanding into geographic areas in Nepal. The present study aims at exploring the trends of VL from 1980 to 2019.

METHODS

This retrospective analysis covers 40 y of VL cases reported by the Epidemiology Diseases Control Division, Nepal. Subgroup analyses for annual incidence were performed by age, sex, seasons, districts and provinces, and VL cases were visualized on in-country maps.

RESULTS

A total of 34 564 cases and 584 deaths of VL were reported during 1980-2019. VL persistently increased until 2006 and was reported from all seven provinces of the country. The highest number of confirmed cases (n=2229) was reported in 2003 and the lowest (n=60) in 1983. VL cases expanded from 12 to 23 endemic districts. The key components of the VL elimination program are early diagnosis; enhanced surveillance; integrated vector management; social mobilization; research and treatment.

CONCLUSIONS

Expansion of VL towards the hilly and mountain regions of Nepal has posed challenges to the elimination program. Urgent VL control measures are required to achieve the elimination goals.

Insights into transmission dynamics of Mycobacterium tuberculosis complex in Nepal

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis complex (MTBC) in humans and animals. Numbers of multi drug resistance TB (MDR-TB), extrapulmonary TB (EPTB) and zoonotic TB cases are increasingly being reported every year in Nepal posing a major public health problem. Therefore, the Government of Nepal should act immediately to strengthen the screening facilities across the country to be able to identify and treat the TB infected patients as well as detect zoonotic TB in animal species. Endorsement of One Health Act by the Government of Nepal is an opportunity to initiate the joint programs for TB surveillance among human and animal species using one health approach to reduce the TB burden in Nepal.

1219 Patient Satisfaction with Virtual Orthopaedic Clinics During the COVID-19 Pandemic

Background

The COVID-19 pandemic has elicited the need to deliver consultation appointments remotely due to social-distancing measures, as well as some individuals having to shield. Virtual clinics are not a familiar setting for orthopaedic surgeons or their patients, but it is a necessity in the current climate and potentially also in the future.

Aim

This study aims to determine patient satisfaction of virtual orthopaedic consultations, during the COVID-19 pandemic and for the future.

Method

A 10-question survey assessed the satisfaction level of both new and follow-up patients towards virtual clinics for consultations with orthopaedic surgeons.

Results

Based on 100 patients who completed the surveys in a 6-month study during the pandemic, it was found that a majority (90%) of patients reported being satisfied (either very satisfied or satisfied) with the telephone clinics and would be content on having virtual clinics in the future.

Conclusions

Many patients view virtual clinics as an acceptable substitute for face-to-face appointments, specifically during the pandemic. However, it was also reported that a majority of patients would still prefer a physical examination as well. If virtual consultations are to persist beyond the COVID-19 pandemic, further exploration would need to be carried out to determine the efficacy.

Molecular study of 2019 dengue fever outbreaks in Nepal

BACKGROUND

Dengue cases have been continuously reported in Nepal, including some large outbreaks, since its first introduction in 2004. The disease is now expanding towards newer locations above 1400 m high, especially the country's capital city, Kathmandu. In 2019, >14,000 dengue cases including six deaths were reported. This study was aimed at the detection and molecular characterization of dengue virus (DENV) in dengue patients.

METHODS

A total of 451 patients were enrolled in this study. Demographic, clinical and laboratory information was collected from dengue patients. Dengue infection was confirmed by antibody/antigen detection assays followed by RT-PCR analysis.

RESULTS

The DENV patients showed fever, body ache, headache, myalgia, retro-orbital pain and arthralgia. The platelets were decreased, serum liver enzymes were increased and leucopenia was seen. Out of 195 patients, 111 (57.0%) were positive for DENV RNA by consensus PCR. We found DENV-2, 70 (63.1%) as the predominant serotype responsible for the 2019 outbreak, while DENV-3 was detected in two patients.

CONCLUSION

Our findings suggest that DENV-2 was the major serotype causing the 2019 massive outbreak in Nepal. This information will help in disease control programs to understand the molecular epidemiology and its changing trend.

[Telemedicine in stroke-pertinent to stroke care in Germany]

BACKGROUND AND OBJECTIVE

Telemedical stroke networks improve stroke care and provide access to time-dependent acute stroke treatment in predominantly rural regions. The aim is a presentation of data on its utility and regional distribution.

METHODS

The working group on telemedical stroke care of the German Stroke Society performed a survey study among all telestroke networks.

RESULTS

Currently, 22 telemedical stroke networks including 43 centers (per network: median 1.5, interquartile range, IQR, 1-3) as well as 225 cooperating hospitals (per network: median 9, IQR 4-17) operate in Germany and contribute to acute stroke care delivery to 48 million people. In 2018, 38,211 teleconsultations (per network: median 1340, IQR 319-2758) were performed. The thrombolysis rate was 14.1% (95% confidence interval 13.6-14.7%) and transfer for thrombectomy was initiated in 7.9% (95% confidence interval 7.5-8.4%) of ischemic stroke patients. Financial reimbursement differs regionally with compensation for telemedical stroke care in only three federal states.

CONCLUSION

Telemedical stroke care is utilized in about 1 out of 10 stroke patients in Germany. Telemedical stroke networks achieve similar rates of thrombolysis and transfer for thrombectomy compared with neurological stroke units and contribute to stroke care in rural regions. Standardization of network structures, financial assurance and uniform quality measurements may further strengthen the importance of telestroke networks in the future.

The Double Burden of COVID-19 and Dengue in Nepal: The challenges ahead

Coronavirus disease 2019 (COVID-19) pandemic has caused significant impact on the health care system. As a consequence, diagnosis and treatment of vector borne diseases including dengue has been equally affected. Nepal is no exception to this, where COVID-19 cases is exponentially increased and all resources are concentrated on its prevention, control and management. Dengue, one of the major vector-borne diseases in Nepal, is apparently overlooked despite approaching the peak season of the disease. The aim of this paper is to describe the double burden of COVID-19 and dengue in Nepal, particularly highlighting the co-circulation and possible coinfections. This has posed higher risk of increased severity, more severe cases and deaths in Nepal. Moreover, potential misdiagnosis of these viral diseases may lead to delayed or, inappropriate treatment and poor allocation of resources.

Characterization of Mycobacterium tuberculosis genotypes and their correlation to multidrug resistance in Lusaka, Zambia

OBJECTIVES

The burden of multidrug-resistant tuberculosis (MDR-TB) has been reported to be increasing in Zambia. The reasons for the increase are still unclear. This study determined the diversity of Mycobacterium tuberculosis genotypes among isolates in Lusaka, the capital city, and investigated their association with MDR-TB.

METHODS

Spoligotyping, large sequence polymorphism (LSP) analysis, and sequencing of MDR associated genes were performed on a total of 274 M. tuberculosis clinical isolates stored at the University Teaching Hospital from 2013 to 2017. Of these, 134 were MDR-TB while 126 were pan-susceptible.

RESULTS

Spoligotyping showed the LAM family as the most predominant genotype (149/274, 54.4%) followed by the CAS family (44/274, 16.1%), T family (39/274, 14.2%), and minor proportions of X, S, Harleem, EAI and Beijing spoligofamilies were identified. Three M. bovis isolates were also observed. Among those, CAS1-Kili (SIT 21) and LAM1 (SIT 20) subfamilies showed a propensity for MDR-TB with p = 0.0001 and p = 0.001, respectively.

CONCLUSIONS

This phenomenon might explain the future increase in the MDR-TB burden caused by specific lineages in Zambia. Therefore, it is recommended that the National TB control program in the country complements conventional control strategies with molecular analysis for monitoring and surveillance of MDR-TB epidemiology.

Preparatory phase for clinical trials of COVID-19 vaccine in Nepal

Public health data suggested a rapid rise in COVID-19-confirmed cases in Nepal along with increased deaths. There has been a wide variation in clinical outcomes of this disease. Control of this pandemic depends on the availability of vaccines or drugs for SARS-CoV-2. Thus, viral and human genetics/genomics and immunology are necessary to understand whether these factors will affect clinical trials of vaccines in Nepal.

Genetic diversity of Mycobacterium tuberculosis Central Asian Strain isolates from Nepal and comparison with neighboring countries

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is an emerging threat for successful tuberculosis control worldwide. Central Asian Strain (CAS) has been reported as one of the dominant families contributing to MDR-TB in South Asia including Nepal, India and Pakistan. The aim of this study was to better understand the genetic characteristics of MDR-TB CAS family isolates circulating in Nepal and compare the results with neighboring countries.

METHODS

A total of 145 MDR-TB CAS family isolates collected in Nepal from 2008 to 2013 were analyzed by spoligotyping and mycobacterial interspersed repetitive units-variable number of tandem repeats (MIRU-VNTR) analysis. In addition, we compared these data with published data from India and Pakistan to investigate a possible epidemiological link via construction of a minimum spanning tree (MST).

RESULTS

Spoligotyping analysis exhibited CAS1_Delhi SIT26 (n=60) as the predominant lineage among the MDR-TB CAS family in all three countries. However, the combined analysis with spoligotyping and MIRU-VNTR further discriminated 60 isolates into 49 different types and 5 clusters. Each cluster was composed of 14 isolates with a clustering rate of 23.3%, suggesting ongoing transmissions. Based on MST data from neighboring countries, we elucidated an evolutionary relationship between the two countries, Nepal and India, which could be explained by their open border.

CONCLUSION

This study identified the evolutionary relationships among MDR-TB CAS1_Delhi subfamily isolates from Nepal and those from neighboring countries.

0923 Doxepin in Children and Adolescents With Symptoms of Insomnia: A Single Center Experience

Introduction

Pediatric insomnia is a widespread problem and especially difficult to manage in children with neurodevelopmental disorders. There are currently no FDA- approved medications for pediatric patients to use once first line therapy fails. Doxepin is FDA-approved at low doses for use in transient or chronic sleep maintenance insomnia in adults. The objective of this study is to determine the tolerability and efficacy of doxepin in the pediatric population.

Methods

This is a retrospective single center chart review of children and adolescents (2-17 years of age) whose sleep failed to improve with behavioral intervention and melatonin who were then trialed on doxepin. Treatment was initiated at a median starting dose of 2mg and slowly escalated to a median maintenance dose of 10mg. Improvement in sleep was recorded using a 4-point Likert scale reported by parents on follow up visits.

Results

Total of 29 patients were included in analysis. Mean follow-up duration was 6.5 months (±3.5). Out of 29 patients, 4 (13.8%) patients discontinued doxepin due to lack of efficacy or side effects. 8 (27.6%) patients showed significant improvement of their insomnia, 8 (27.6%) showed moderate, 10 (34.5%) showed mild and 3 (10.3%) showed minimal to no improvement on treatment with doxepin (P&lt;0.05) Only two patients (6.8%) experienced adverse effects in the form of behavioral side effects (aggression) and enuresis.

Conclusion

Our data suggests that doxepin is effective, safe and well-tolerated in the treatment of sleep initiation and maintenance insomnia as well as psychophysiological insomnia in child and adolescents with Ausitsm specutrm disorder, other neuro-developmental disorders and attention deficit hyperactivity disorder. It is also an effective, safe, and well-tolerated alternative in children suffering from chronic persistent insomnia. The results of this study suggests a promising emerging therapy for the treatment of insomnia in the pediatric population.

Support

None

Detection of virus-neutralising antibodies and associated factors against rabies in the vaccinated household dogs of Kathmandu Valley, Nepal

BACKGROUND

Rabies is a vaccine-preventable neglected tropical viral zoonosis. It occurs worldwide, creating a very heavy burden in many developing countries, including Nepal. Dogs are the principle vector for the transmission of this disease in urban areas. Vaccination is the most important preventive measure in areas where dogs are the principle source of infection. This study was conducted with the aim of detecting virus-neutralising antibodies and associated factors against rabies in vaccinated household dogs of Kathmandu valley.

METHODS

Blood samples were collected from 110 vaccinated pet dogs in Kathmandu, Bhaktapur, and Lalitpur districts of Nepal. The samples were taken to the laboratory of the National Zoonosis and Food Hygiene Research Center where serum was separated. An indirect immune-enzymatic assay (PlateliaTM Rabies II kit ad usum Veterinarium, Biorad, China) was used for the detection of rabies virus anti-glycoprotein antibodies in the dog serum samples following the manufacturer's recommendations and instructions. Optical density values for unknown samples were compared with the positive sera titers in quantification tests obtained after a direct reading on the standard curve. Results were expressed as equivalent units per ml (EU/ml).

FINDINGS

Of the total samples, 89.09% exceeded the required seroconversion level (≥ 0.5 EU/ml); another 9.09% did not reach the seroconversion level (0.125-0.5 EU/ml); and 1.81% had undetectable seroconversion levels (<0.125 EU/ml) suggesting that the animal had not seroconverted according to the PLATELIA™ RABIES II test. Only one factor, the condition under which the dog was kept, was significantly associated with the antibody titer level. No association was found for any of the other factors included in the study.

INTERPRETATION

Vaccination is the most effective measure for prevention and control of rabies. The locally manufactured brand of vaccine, which is available in Nepal, is potent enough to generate a sufficient amount of protective antibodies, equal to international brands.

Mutations in rpoB and katG genes and the inhA operon in multidrug-resistant Mycobacterium tuberculosis isolates from Zambia

OBJECTIVES

It is established that resistance to rifampicin (RIF) in 90% of RIF-resistant Mycobacterium tuberculosis isolates is attributable to point mutations in the rpoB gene, whilst 50-95% of M. tuberculosis resistance to isoniazid (INH) is caused by mutations in the katG gene. However, the patterns and frequencies of mutations vary by geographical region. In Zambia, the genetic mechanisms of resistance of M. tuberculosis to RIF and INH were unreported before this study.

METHODS

Using gene sequencing, the rpoB, katG and inhA genes of 99 multidrug-resistant M. tuberculosis (MDR-TB) and 49 pan-susceptible M. tuberculosis isolates stored at a tuberculosis reference laboratory from 2013 to 2016 were analysed and were compared with published profiles from other African countries.

RESULTS

Of the 99 MDR-TB isolates, 95 (96.0%) carried mutations in both rpoB and katG. No mutations were detected among the pan-susceptible isolates. The most common mutations among RIF- and INH-resistant isolates were in codon 531 of the rpoB gene (55.6%; 55/99) and codon 315 of the katG gene (94.9%; 94/99), respectively. Distinctly, katG mutations were predominantly high among Zambian isolates (96.0%) compared with other countries in the region.

CONCLUSION

Resistance-associated mutations to RIF and INH circulating in Zambia are similar to those reported globally, therefore these data validate the applicability of molecular diagnostic tools in Zambia. However, katG mutations were predominantly high among M. tuberculosis isolates in this study compared with other regional countries and might distinguish cross-boundary transmission of MDR-TB from other African nations.

Sero Prevalence of Virus-neutralizing Antibodies for Rabies in Street Dogs of Kathmandu Valley, Nepal

Introduction:

Rabies is a vaccine-preventable viral zoonotic disease that remains a serious global public health concern. Rabies vaccination with adequate coverage of the canine population has been shown to control rabies outbreaks among canines and to prevent the transmission of rabies from dogs to humans. As vaccination is the primary control measure for rabies, it is important to determine the level of anti-rabies antibodies in animals in order to determine the effectiveness of the control measures being implemented.

Materials & Methods:

Blood samples were collected from 50 street dogs (August 2016 to December 2016) in Kathmandu, Bhaktapur and Lalitpur districts. Rabies sero-conversion on the separated serum was quantified using PlateliaTM Rabies II Kit (Bio-Rad, China) according to the manufacturer’s recommendations.

Results:

Eighty percent (40/50) of the serum samples surpassed the requested level of rabies antibodies, suggesting good coverage of vaccination among street dogs.

Conclusion:

However, an active dog surveillance system with a dog registration process before and after vaccination campaigns, and a multi-dimensional approach including all stakeholders, are necessary to eradicate rabies from the canine population in Nepal.

Sero-prevalence of leptospirosis and differentiation in blood parameters between positive and negative cases in dogs of Kathmandu Valley

Background

Leptospirosis is a zoonotic disease with worldwide distribution. It affects both humans and animals. Dogs may serve as a sentinel as well as a potential carrier for Leptospira infection in human. This study was conducted with the aim of investigating the sero-prevalence of leptospirosis, and differentiation in blood parameters in positive and negative cases of dogs.

Methods

A cross-sectional study was carried out from August 2016 to December 2016 in Kathmandu valley. A total of 70 blood samples were collected from street dogs and tested against Leptospira infection using Immunocomb Canine Leptospira Antibody Test Kit.

Results

Out of 70 blood samples tested, eight samples (11.4%) were positive. The average mean and SD of total leucocyte count of positive and negative cases were 79 750±12 090/mm3 and 11 026.98±4316.742/mm3, respectively. Levels of blood parameters (total leukocyte count (TLC), blood glucose, serum glutamic pyruvic transaminase (SGPT), serum glutamic oxaloacetic transaminase (SGOT), and calcium and phosphorus) were found to be increased, and significant between positive and negative cases p<0.05, where blood urea and protein remained constant and non-significant.

Conclusion

Detection of Leptospira antibody in non-vaccinated dogs indicates a significant threat to human population and demand unique strategic action plan for the control and prevention of disease.

ABO-Incompatible Kidney Transplantation: Low Rates of Infectious Complications and Excellent Patient Survival

BACKGROUND

A significant gap exists between demand and supply of organs for patients with end-stage renal disease. To increase the donor pool, kidney transplantation is performed across ABO- and HLA-incompatible barriers. ABO-incompatible kidney transplant (ABOi-KT) recipients are at increased risk of antibody-mediated rejection, infection, and mortality. Hypogammaglobulinemia secondary to immunosuppression is highly prevalent after solid organ transplantation, and intravenous immunoglobulin (IVIG) has been reported to reduce the risks of infections in various settings. We use high-dose IVIG in ABOi-KT recipients perioperatively. We aimed to determine the rate of infectious complications along with graft and patient survival in our ABOi-KT recipients.

METHODS

We included all adult patients who underwent ABOi-KT from the year 2007 to 2016. Patients received rituximab, plasma exchange, and IVIG (2 g/kg body weight). Thymoglobulin and intravenous methylprednisolone were used as induction treatment. Oral prednisone, mycophenolate mofetil, and tacrolimus were used as maintenance therapy.

RESULTS

A total of 77 ABOi-KTs were performed, and the recipients were followed up for a median of 1557 days. Two patients were diagnosed as having BK nephropathy. No patients were diagnosed as having pneumocystis infection, cytomegalovirus disease, herpes simplex, varicella zoster, or fungal infection. One-year graft and patient survival was 94.8% and 100%, respectively.

CONCLUSIONS

In our series of ABOi-KTs, we observed a low risk of infectious complications and excellent patient survival. High-dose IVIG might have reduced infections.

Genetic diversity and distribution dynamics of multidrug-resistant Mycobacterium tuberculosis isolates in Nepal

Multidrug-resistant tuberculosis (MDR-TB) is an emerging public health problem in Nepal. Despite the implementation of a successful TB control program in Nepal, notifications of MDR-TB are increasing, yet the reasons are unknown. The objective of this study was to understand the genetic diversity and epidemiological characteristics of MDR-Mycobacterium tuberculosis (MTB) isolates in Nepal. We isolated and genotyped 498 MDR-MTB isolates collected from April 2009 to March 2013 and analyzed the patients' background information. Our results showed that the lineage 2 (Beijing family) was the most predominant lineage (n = 241; 48.4%), followed by lineage 3 (n = 153, 30.7%). Lineage 4 was the third most prevalent (n = 73, 14.5%) followed by lineage 1 (n = 32, 6.4%). The lineages were significantly associated with geographic region, ethnic group, age and sex of patients. The Beijing genotype was found to have an important role in transmitting MDR-TB in Nepal and was significantly associated with the eastern region, mongoloid ethnic group and younger age group. We conclude that early diagnosis and treatment including molecular-epidemiological surveillance of MDR-TB cases will help to control transmission of MDR-TB in Nepal.

Evidence of Chikungunya virus circulation in the Terai region of Nepal in 2014 and 2015

Background

Chikungunya virus (CHIKV) infection is an emerging viral disease in Nepal, with the reported by our laboratories in 2013. Because of the similarity in signs and symptoms to dengue virus (DENV) and misdiagnosis, the under-reporting of CHIKV infection in DENV-endemic areas of Nepal is very common. The aim of the present study is to identify CHIKV infection among patients with febrile illness during the 2014-2015 outbreaks.

Methods

A total of 219 serum samples were tested for CHIKV and DENV by using enzyme-linked immunosorbent assays (ELISAs) to detect immunoglobulin M (IgM) and IgG antibodies, with confirmation by a 50% focal reduction neutralization test (FRNT50).

Results

ELISA results demonstrated that for CHIKV and DENV, 20.5% and 14.2% of samples, respectively, were positive for IgG and/or IgM and 9.6% and 5.9% were positive for IgM alone. Further, FRNT50 results confirmed that 7.3% of samples possessed neutralizing anti-CHIKV antibodies.

Conclusion

We conclude that CHIKV infection is settling in Nepal as an endemic disease. It is highly recommended to strengthen the surveillance system for CHIKV and DENV to prevent possible outbreaks.

Segmental resection is a safe oncological alternative to total proctocolectomy in elderly patients with ulcerative colitis and malignancy

AIM

The standard approach for the surgical management of colorectal cancer (CRC) in the setting of ulcerative colitis (UC) involves total proctocolectomy (TPC). However, some patients also undergo a partial resection (PR). This may be an attractive option in older patients with a high risk for surgery. The aim of this study was to compare the risk of metachronous cancer after PR or TPC for CRC in the setting of UC.

METHOD

This was a retrospective cohort study conducted through the Nationwide Veterans Affairs Healthcare System (VA). Patients who had UC and underwent a PR or TPC for CRC were followed from the time of their surgery to their most recent clinical follow-up. The primary outcome was development of metachronous cancer in the PR group. Secondary outcomes included surgical and medical outcomes.

RESULTS

Fifty-nine patients were included: 24 (40.7%) underwent PR and 35 (59.3%) underwent TPC. The median age at cancer diagnosis was 73.0 and 61.7 years in PR and TPC groups, respectively (P < 0.0005). Amongst patients undergoing PR, 15 (60%) had no active UC at the time of surgery, whereas in patients undergoing TPC, at the time of surgery eight (23.5%) had no active UC (P = 0.005). No patient who underwent a partial colectomy developed a metachronous cancer in the retained colonic segment during the follow-up period (median 7 years).

CONCLUSION

Our study suggests that PR for CRC in the setting of UC may be a viable option in a selected cohort of patients, especially among the elderly.

Safety of herpes zoster vaccination among inflammatory bowel disease patients being treated with anti-TNF medications

BACKGROUND

The risk of herpes zoster (HZ) is elevated in inflammatory bowel disease (IBD) patients treated with anti-TNF medications. While it is optimal to give herpes zoster vaccine prior to initiation of therapy clinical circumstances may not always allow this.

AIM

To determine the safety of giving herpes zoster vaccine while patients are on anti-TNF therapy.

METHODS

We conducted a retrospective cohort study involving IBD patients who were followed in the Veterans Affairs (VA) healthcare system between 2001 and 2016. Patients who received herpes zoster vaccine while on anti-TNF medication were identified through vaccination codes and confirmed through individual chart review. Our outcome of interest was development of HZ between 0 and 42 days after herpes zoster vaccine administration.

RESULTS

Fifty-six thousand four hundred and seventeen patients with IBD were followed in the VA healthcare system. A total of 59 individuals were on anti-TNF medication when they were given herpes zoster vaccine, and amongst them, 12 (20%) were also taking a thiopurine. Median age at the time of herpes zoster vaccine was 64.9 years and 95% of patients had a Charlson Comorbidity Index of ≥2. Median number of encounters within 42 days after receiving herpes zoster vaccine was two. No case of HZ was found within 0-42 days of HZV administration.

CONCLUSION

Our data suggest that co-administering the herpes zoster vaccine to patients who are taking anti-TNF medications is relatively safe. This study significantly expands the evidence supporting the use of herpes zoster vaccine in this population, having included an elderly group of patients with a high Charlson Comorbidity Index who are likely at a much higher risk of developing HZ.

High diversity of multidrug-resistant Mycobacterium tuberculosis Central Asian Strain isolates in Nepal

OBJECTIVES

Tuberculosis (TB) caused by Mycobacterium tuberculosis (MTB) poses a major public health problem in Nepal. Although it has been reported as one of the dominant genotypes of MTB in Nepal, little information on the Central Asian Strain (CAS) family is available, especially isolates related to multidrug resistance (MDR) cases. This study aimed to elucidate the genetic and epidemiological characteristics of MDR CAS isolates in Nepal.

METHODS

A total of 145 MDR CAS isolates collected in Nepal from 2008 to 2013 were characterized by spoligotyping, mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR) analysis, and drug resistance-associated gene sequencing.

RESULTS

Spoligotyping analysis showed CAS1_Delhi SIT26 as predominant (60/145, 41.4%). However, by combining spoligotyping and MIRU-VNTR typing, it was possible to successfully discriminate all 145 isolates into 116 different types including 18 clusters with 47 isolates (clustering rate 32.4%). About a half of these clustered isolates shared the same genetic and geographical characteristics with other isolates in each cluster, and some of them shared rare point mutations in rpoB that are thought to be associated with rifampicin resistance.

CONCLUSIONS

Although the data obtained show little evidence that large outbreaks of MDR-TB caused by the CAS family have occurred in Nepal, they strongly suggest several MDR-MTB transmission cases.

Serological and Entomological Study of Dengue in Dang and Chitwan Districts of Nepal

A descriptive cross-sectional study was carried out among 264 suspected dengue patients in two districts (Dang and Chitwan) of Nepal from June 2013 to November 2013. The anti-dengue IgM positivity was found to be (51/264)19.31% by capture ELISA, of which 21 (41.2%) were male and 30 (58.8%) were female. Symptoms of seropositive cases were fever, anorexia, nausea, headache, retro-orbital pain, skin rashes, and myalgia. Hematological features like thrombocytopenia and leucopenia were found to be significantly associated with the dengue fever (DF). Discarded tires were found as the commonest breeding habitats for the dengue vectors. Higher sero-positivity was recorded from the area having higher Breteau index (BI). The pH, chloride ion concentration and the salinity of the water from breeding habitats were found to be ranging from 6.9±0.82 to 8, 103.33±17.52 mg/L to 140.65 mg/L, and 0.19±0.032 ppt to 0.25 ppt respectively. This study may be helpful for the health authorities and public health workers for early diagnosis of DF and for the improved preventive measures to be adopted in the epidemic and possible epidemic areas.

First insight into the genetic population structure of Mycobacterium tuberculosis isolated from pulmonary tuberculosis patients in Egypt

The present study aimed to assess the population structure of Mycobacterium tuberculosis (MTB) isolates from Egypt. A total of 230 MTB isolates were analysed using spoligotyping, large sequence polymorphism (LSPs), mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR) typing and multi-locus sequence typing (MLST). The majority of isolates (93.0%) belonged to lineage 4, including 44.3, 13.4 and 10.8% of the ill-defined T clade, LAM and Haarlem families, respectively, and lineage 3 was identified in 7.0% of the isolates. MIRU-VNTRs typing allowed efficient discrimination of the spoligotype-defined clusters, including spoligo-international types (SIT) 53, 34, and 4, into 56 patterns, including 13 clusters and 43 unique patterns. A new SNP at position 311614 was identified in all six isolates to form the biggest MIRU-VNTR cluster, which suggested a recent clonal expansion. This SNP could possibly be used as a genetic marker for robust discriminations of Egyptian MTB isolates belonging to SIT53. The combination of spoligotyping, 12 MIRU-VNTRs loci and MLST provided insight into the genetic diversity and transmission dynamics of the Egyptian MTB genotypes and could be a key to implementation of effective control measures by public health authorities.

Persistent dengue emergence: the 7 years surrounding the 2010 epidemic in Nepal

BACKGROUND

Dengue fever (DF) is an emerging public health problem in Nepal, and yet neither the magnitude of the DF burden or its epidemiological trends are well understood.

METHODS

We conducted a sero-epidemiological, seasonal trend and demographic analysis of the trends in DF in the Terai region of Nepal, from 2007 to 2013. In that period, 2002 serum samples were collected from febrile patients suspected of dengue virus infection. Samples were screened by IgM antibody ELISA analysis for the presence of anti-dengue IgM antibodies.

RESULTS

The overall prevalence of DF cases was found to range from 26.1 to 55.4%. Infection was found to be more common among adults and males. Seasonal trends revealed that cases peaked in October and November.

CONCLUSIONS

The study offers perspective on the dengue fever burden before, during and after a major epidemic and can now be used as a basis for formulating strategies by policy makers that will enhance and develop relevant control and preventive measures against dengue fever. The findings of this study reinforce the perceived need for urgent dengue virus surveillance to enhance dengue control strategies that need to be developed for future preparedness. In the light of the recent earthquakes, future major outbreaks of vector borne disease are likely to recur.

Regional variation in pig farmer awareness and actions regarding Japanese encephalitis in Nepal: implications for public health education

Japanese encephalitis (JE) is a mosquito-borne zoonotic disease that has pigs as the major amplifying hosts. It is the most important cause of viral encephalitis in people in Nepal and is spreading in its geographic distribution in that country. Pig farming is increasing in Nepal due to reducing cultural biases against pigs and government programs to support pig farming for poverty alleviation. Major strategies for JE prevention and control include education, vector control, and immunization of people and pigs. This study used a survey of 400 pig farmers in 4 areas of Nepal with different JE and pig farming histories to explore regional variations in farmer awareness and actions towards JE, the association of awareness and actions with farm and farmer variables, and the implications of these associations for public health education. Exposure to JE risk factors was common across pig farms and pig farming districts but there were significant district level differences in knowledge and practices related to on-farm JE risk reduction. Social factors such as literacy, gender, and cultural practices were associated with farmer attitudes, knowledge and practices for JE control. JE vaccine uptake was almost non-existent and mosquito control steps were inconsistently applied across all 4 districts. Income was not a determining factor of the differences, but all farmers were very poor. The low uptake of vaccine and lack of infrastructure or financial capacity to house pigs indoors or away from people suggest that farmer personal protection should be a priority target for education in Nepal. This study re-enforces the need to attack root causes of people's personal disease prevention behaviours and take into account local variation in needs and capacities when designing health or agriculture education programs.

Chlamydia trachomatis among HIV infected patients using PCR technique

Background and Objectives: Chlamydia trachomatis is a sexually transmitted organism and an important public health problem in the sexually active age group. Limited studies are found regarding the prevalence of Chlamydia trachomatis in Nepal. Moreover, no study in Nepal reports the association of Chlamydia and HIV infection. The current study attempts to determine the burden of Chlamydia on HIV positive patients. Material and Methods: A total of 117 HIV positive patients visiting a HIV clinic in Kathmandu, were screened for Chlamydia infection. For this, Urine samples were collected and analyzed using the Multiplex polymerase chain reaction technique (MPCR) and Agarose gel electrophoresis. DNA isolation was performed using QIAamp DNA and Blood mini kit handbook protocol. Results: C. trachomatis was detected in 4.27% of the total 117 HIV patients. Out of positive cases 60% were males and 40% were females. However, Chlamydia is found more prevalent among females (6.89%) than in males (3.4%). Eighty percent of positive cases were asymptomatic. Conclusion: Chlamydia infection was found less commonly among studied patients and most of those cases were asymptomatic. So there is difficulty in timely detection of C. trachomatis and track the clinical sequel, which might be devastating. Hence, routine checkup is recommended for all suspected cases for timely management of the disease Janaki Medical College Journal of Medical Sciences (2013) Vol. 1 (2): 3-10 DOI: http://dx.doi.org/10.3126/jmcjms.v1i2.9261

First isolation of dengue virus from the 2010 epidemic in Nepal

Dengue is an emerging disease in Nepal and was first observed as an outbreak in nine lowland districts in 2006. In 2010, however, a large epidemic of dengue occurred with 4,529 suspected and 917 serologically-confirmed cases and five deaths reported in government hospitals in Nepal. The collection of demographic information was performed along with an entomological survey and clinical evaluation of the patients. A total of 280 serum samples were collected from suspected dengue patients. These samples were subjected to routine laboratory investigations and IgM-capture ELISA for dengue serological identification, and 160 acute serum samples were used for virus isolation, RT-PCR, sequencing and phylogenetic analysis. The results showed that affected patients were predominately adults, and that 10% of the cases were classified as dengue haemorrhagic fever/ dengue shock syndrome. The genetic characterization of dengue viruses isolated from patients in four major outbreak areas of Nepal suggests that the DENV-1 strain was responsible for the 2010 epidemic. Entomological studies identified Aedes aegypti in all epidemic areas. All viruses belonged to a monophyletic single clade which is phylogenetically close to Indian viruses. The dengue epidemic started in the lowlands and expanded to the highland areas. To our knowledge, this is the first dengue isolation and genetic characterization reported from Nepal.

Study on the Prevalence of Beta Haemolytic Streptococcus Among School Children

Introduction: Βeta haemolytic streptococcal infections have a worldwide distribution among children and it poses an important health problem globally. So, a five months study was conducted to know the prevalence of beta haemolytic streptococci (BHS) in the throat of school children. Materials and Methods: Throat swabs from 200 school children of Kirtipur were collected, transported to the laboratory and were processed for BHS following standard microbiological procedures. Group A Streptococci (GAS) were identified by beta haemolytic colonies, bacitracin sensitivity and catalase negativity test. ASO test was also performed from serum samples. Result: Altogether 18 (9%) BHS isolates were identified from 200 samples, out of which 11 (5.5%) isolates were from males and 7 (3.5%) were from females. Among the 18 BHS isolates, 10 were identified as GAS isolates. The number of GAS presented only 5% of total sample. There was no significant sex difference in colonization of GAS (p> 0.05). Majority of cases were asymptomatic. All GABHS isolates were sensitive to Penicillin. In Serological examination, i.e. Antistreptolysin O (ASO) titre, all serum samples showed less than 200 IU ASO titre. Conclusion: This result highlights the current situation of GABHS throat infection in school children of Kirtipur. DOI: http://dx.doi.org/10.3126/jnps.v33i1.7004 J Nepal Paediatr Soc. 2013;33(1):45-47

Chlamydia trachomatis detection in HIV infected patients using polymerase chain reaction

Introduction: Chlamydia trachomatis is a sexually transmitted organism and causes important public health problem in the sexually active age group. Limited studies are found regarding the prevalence of C. trachomatis in Nepal. Moreover, currently there are no any study in Nepal reporting the association of chlamydia and HIV infection. This study attempts to determine the burden of chlamydia on HIV positive patients. Materials and Methods: A total of 117 HIV positive patients visiting a HIV clinic in Kathmandu, were screened for chlamydia infection. For this, urine samples were collected and analyzed using the Polymerase Chain Reaction Technique (PCR). Results: C. trachomatis was detected in 4.2% of the total 117 HIV patients. Out of positive cases 60% were males and 40% were females. However, chlamydia was found more prevalent among females (6.8%) than males (3.4%). Eighty percent of positive cases were asymptomatic. Conclusions: Although, the prevalence of chlamydia infection was found less HIV patients, most of those cases were asymptomatic. Therefore, routine checkup is recommended for all suspected cases for timely management of the disease. DOI: http://doi.dx.org/10.3126/ijim.v2i1.8003 Int J Infect Microbiol 2013;2(1):12-16

Dengue Virus Detection by Serological and Molecular Method in Different Hospitals of Nepal

Introduction: Dengue is an emerging mosquito-borne viral disease in the world and is the serious public health problem of Nepal. Methods: This study was designed to determine sero-epidemiology of dengue virus infection during the period (June-Nov) of 2010 among suspected patients with fever visiting Koshi Zonal Hospital (KZH), Biratnagar, Narayani sub-regional Hospital (NSH), Birgunj, Sukraraj Tropical and Infectious Disease Hospital (STIDH), Kathmandu and Dhading District Hospital (DDH), Dhadingbeshi. The sero-prevalence of anti-dengue IgM antibody was determined by enzyme linked immunosorbent assay (ELISA). Results: Among 271 serum samples tested, the anti-dengue IgM positivity was 14.4%. Sero-positivity in male was 10.7% of total and that in female was 3.7%.  Among different age groups, the highest positive cases 11.8% were from age group 15-50 years and found least among the age group above 50 years 0.4%. Out of 4 different hospitals, the highest positive positive cases from STIDH with 9.2% and the least positive cases were from DDH (0.4%). RT-PCR showed 4.7% positivity of 21 samples tested. Conclusions: Enzyme immunoassay and RT-PCR serological marker can be used to diagnose the acute patients of dengue during outbreaks.Medical Journal of Shree Birendra Hospital; July-December 2012/vol.11/Issue2/24-27 DOI: http://dx.doi.org/10.3126/mjsbh.v11i2.7905 

Prognostic value of rapid test for diagnosis of dengue in Nepalese patients during 2010 epidemic

BACKGROUND

Dengue is an emerging vector borne disease in Nepal and rapid diagnostic test is important for early diagnosis of the disease.

OBJECTIVES

The aim of the study was to evaluate the diagnostic accuracy of commonly used rapid immunochromatographic test kit in Nepal during 2010 dengue epidemic and to assess disease burden of dengue.

METHODS

A total of 131 acute and nonacute serum samples were collected during recent epidemic of dengue in 2010 from clinically suspected Nepalese patients of different hospitals. Rapid immunochromatographic test kit was used for early diagnosis and enzyme immunosorbent was chosen as a reference assay.

RESULTS

The sensitivity and specificity of rapid test was 70% and 76.54% respectively whereas the prevalence of the disease was 38.17%. The odds ratio for males was 1.8 however; the association with the disease was statistically not significant.

CONCLUSION

The diagnostic accuracy of rapid immunochromatographic test for dengue diagnosis was low (k=0.46). So, it should be substituted by highly sensitive test device for prompt diagnosis and health personnel should consider appropriate timing of sample collection for better performance of rapid test.

The burden of dengue infection in some vulnerable regions of Nepal

Dengue is an emerging mosquito borne disease of public health importance in Nepal. A descriptive cross sectional study was carried out to estimate sero-prevalence and distribution pattern of dengue in certain vulnerable regions of Nepal from June to September 2009. A total of 460 venous blood samples were collected from individuals experiencing a febrile illness clinically consistent with dengue infection visiting nearby hospitals of Kanchanpur, Kailali, Banke, Dang and Chitwan districts. The sero-prevalence of dengue virus specific IgM was determined by enzyme linked immunosorbent assay (ELISA) kit. The anti-dengue IgM positivity was found to be 12.17%. The higher frequency of positive cases (16.4%) were from age group 20-40 years followed by < 20 years age group with 9.7% and 5.3% from > 40 years age group. The association between dengue infection and age is found to be statistically significant (p < 0.05). The male:female ratio was determined as 1.3:1 in IgM positive population. Among sampling areas, Kanchanpur showed highest prevalence of dengue infection (15.5%) followed by Chitwan (11.7%), Kailai (11.1%), Banke (10.7%) and Dang (8.3%). Similarly, 94.6% of the positive cases were indigeneous and had no history of travel to other countries. Dengue is firmly established in terai region with increasing trends of infection and expansion into newer areas raising a public health threat. Regular epidemiological studies are suggested which could further reveal the contributing factors associated with dengue virus infection and help in formulating strategies in reducing the transmission rate and control of the infection.

Dengue in western Terai region of Nepal

BACKGROUND

Dengue Fever (DF) is an emerging mosquito-borne disease. It is a nagging public health problem in the low lands of Terai, expanding to new areas of Nepal in recent years.

METHODS

A cross-sectional study was conducted to determine anti-Dengue IgM positive rate in Mahendranagar, Dhangadi and Dang between August 2008 and November 2009. Serum samples were collected from 283 patients visiting hospitals with history of fever, headache and suspected DF. The samples were examined by ELISA.

RESULTS

The anti-Dengue IgM positivity was found to be 9.8 %. The positive rate was highest in Mahendranagar (13.3 %) followed by Dhangadi (9.8 %) (P<0.05). The Dengue positive cases were higher in female (10.9 %) than males (9.0 %). The positivity was higher in Ethnic group Brahman/Chherti (13.1%) as compared to Janajati (5.6 %). The highest positive cases (10.7 %) were from age group above 50 years. The highest numbers of Dengue positive cases were observed in occupation group of agriculture (18.2 %) (P>0.05).

CONCLUSIONS

Dengue has substantial expansion in Western and Far Western Terai region of Nepal which was limited to the middle Terai region in the past and mostly infects older people.